^{vjiîî-f rî»j»*"i -j^? »: : -,»:: \ î ; " î" :*j jj:; ::i t: :i ",: •- ^ ï- t~ *r»2 3^* >*>^' .1 ' : ? > : ■:;:* x ; : • ;' ït,r •* . ;:.: • "•i^v-r- ■ ':. -:i »-îîfî"î ■---.. • , .- v;;Ji; : ;.\;u ■. i NLN 000311^2 3 * *.* :t t l - < <* i I* ■■ * J> M 1} r « ^« r s* ; r if Sl{RGEON GENERAL'S OFFICE LIBRARY. Section No. 113, NO W.D.S.G.O. .ut&îrist U.S. NATIONAL LIBRARY OF MEDICINE ( a • * * V»T »* DUE TJ LAST DATE ÀU& 5 19K W «^ ^ r ; i * ** a'' t r , i r f * i <■ m 4 ' 1 C ♦ 7 .T «A. • j \ > * VI ^^^^^H 1 ^^H ?iP : SI \ > "* ■ ^ x ""3! '♦ * ' i s i .«f « < ï «s r * - > * ^» i \ \ C^P" Sp^ / 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. JAMES 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.GI3B, 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. McMURTRlE, 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 w Goo "H2ITs 1894- I * Copyriglit, by E. B. Treat, New York. 1894. Ail rigMs reserved. LIST OF COOTKIBIITOKS. VOLUME II. SIMEON E. BALDWIN, LL.D., one of the Judges of the Suprême Court of the State of Connecticut ; Prof essor in the Law Department of Yale Collège. LOUIS E. BINSSE, of the New York Bar. CHARLES GILBERT CHADDOCK, M.D., Professor of Diseases of the Nervous System, Marion-Sims Collège of Medicine, St. Louis, Mo. ; Neurologist to Rebekah Hospital ; f ormerly Assistant Médical 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 Médical School and in Dart- mouth Médical Collège; Visiting Physician to Bellevue Hospital; Neurologist to the Montefiore Home and to the Out-Patient Depart- ment, Bellevue Hospital ; Ex-President of the American Neurological Association and of the New York Neurological Society ; and Prési- dent of the Practitioners' Society of New York City. GEORGE RYERSON FOWLEÎ*, M.D., of Brooklyn, N. Y., Surgeon to the Methodist Episcopal Hospital ; to St. Mary's Hospital ; Consult- ing Surgeon to the Relief Hospital and to the Norwegian Hospital j Examiner in Surgery, State Board of Médical Examiners. LAWRENCE GODKIN, of the New York Bar. 5 6 LIST OF VUXTlilBL'IOUS. ALLAN McLANE HAMILTON, M.D., Consulting Physician to the In- sane Asylums 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 Collège Hospital; Président of the New York Obstétrical Society and Président of the Gynecologieal Society ; Corresponding Member of the British Gynecologieal Society. PHILIP COOMBS KNAPP, A.M., M.D., Instructor in Nervous Diseases at Harvard Médical School. CHARLES K. MILLS, A.M., M.D., Professor of Mental Diseases and of Médical 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 Suprême Court of the State of New York, and Lecturer upon Médical Jurisprudence at the Long Island Hospital Collège. 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 IL PAGE Duties and Responsibilities of Médical 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 CALYIN S. PRATT. Insanity and Crime......................................... 175 B. SACHS, A.M., M.D. On the Relations of Mental Defect and Disease to Crbiinal Responsibility........................................... 217 louis e. binsse. Aphasia and other Affections of Speech................... 259 CHARLES K. MILLS, M.D. The Traumatic Nécroses : beeng a Description of the Chronic Nervous Disorders that follow Shock and Injury....... 297 CHARLES L. DANA, A.M., M.D. The Effects of Electric Currents of High Power upon the Human Body............................................ 363 ALLAN McLANE HAMILTON, M.D., and GEORGE De FOREST SMITH, M.D. Accident Cases......................,...................... 377 lawrence godkin. Mental Distress as an Elément of Damage in Cases to Re- cover for Personal Injuries............................ 385 JOHN E. PAR SONS. 8 COXTLMi, 01' VOLUME IL PA(iE Feigned Diseases of the Mind and Nervous Svstem......... 391 philip coombs knapp, a.m., m.d. Birth, Sex, Pregnancy, and Delivery........................ 417 andrew f. currier, m.d. Abortion and Infanticide................................... 467 CHARLES JEWETT, A.M., M.D., Sc.D. Genito-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 Crimes............................................. 525 charles gilbert chaddock, m.d. Surgical Malpractice...................................... 573 GEORGE RYERSON FOWLER, M.D. Appendix................................................... 631 Index...................................................... 681 LIST OF ILLUSTRATIONS. VOLUME IL PLATES. PAGE I. Mieroscopic Appearance of Brain of Epileptic, showing Cellu- lar Degeneration...................................... 71 II. Criminals who hâve beeome Insane. Degenerate Type....... 183 III. Criminals by Reason of Insanity........................... 187 IV. Hvsterical Hemiplegia, showing the Peculiar Dragging of the Foot ................................................ 337 V. Maie Ilysteria, showing Characteristic Physiognomy......... 345 VI. Lungs and Intrathoracic Organs of New-born Child, a Victim of Infanticide......................................... 473 WOOD-CUTS AND HALF-TOXE ENGRAYINGS. FiG. 1. Skull of Tamping-iron Case........................... 21 Fies. 2-4. Diagrams illustrating the Rainifications of Fibers and the Location of the Basai Sensory Area of the Brain...... 22 Fig. 5. Diagram representing the Course of the Pyramidal Fibers.. 23 Fig. 6. Diagram representing the Topography of the Cortical Areas of the Left Hémisphère............................ 24 Figs. 7-10. Sections of the Cerebrum showing the Association Fiber System........................................... 25 Fig. 11. Arterial Supply at the Base of the Brain................ 26 9 10 LIST OF ILLUsTRATIOSS. PACK Fig. 12. Maie Sexual Pervert.................................. "'0 Fig. 13. Brain of Microcéphale................................ (>7 Fig. 14. Physiognomy of Chronic Excited Insane Patient......... 73 Fig. 15. Physiognomy of Chromo Depressed Insane Patient...... 74 Fig. 16. YVriting of a Paranoiac............................... "•» Fig. 17. Writing of an Educated Paretic Dément................ 76 Fig. 18. Writing showing Détérioration in Paretic Dementia...... 77 Fig. 19. Othamiatoma, or " Insane Ear "........................ 7lor and Form................................... 343 FiG. 59. Same for Left Eye................................... 343 FiGS. 60-62. Examples of Hermaphrodism.................. 420-422 Fig. 63. Diagram showing Relation of Parts in Hermaphrodism... 423 Fig. 64. Currier's Case of Enlarged Labia Minora................ 424 Fig. 65. Figure representing Female Organs of Génération....... 425 Fig. 66. Currier's Case of Double Utérus....................... 446 FiG. 67. Currier's Case of Tnbal Pregnancy..................... 448 Fig. 68. Diagram illustrating the Enlargement of the Utérus in Pregnancy........................................ 454 Fig. 69. Showing Annulai* 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, with Two Latéral Lacérations...................................___ 532 Fig. 77. Showing Circulai- Hymen, Torn in Several Places........ 532 Fie. 78. Showing Ruptured Hymen Sœptus..................... 533 DUTIES AND KESPONSIBILITIES OF MEDICAL EX- PERTS. BY WM. B. HORNBLOWER. One of the most important and striking developments of modem ju- risprudence is in the line of expert testimony. 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 peculiar meaning in such art or science. From this has developed the practice of calling ex- perts in mechanics to give opinions in patent cases, and experts in médical science to give opinions in cases involving médical questions. The most important class of cases in which médical experts are called to give testimony is that involving the issue of sanity or insanity. Many embarrassing difnculties hâve arisen in eases of this kind as to the examination of expert witnesses, and many well-founded objections hâve been made to the methods employed in such examination in the courts in this country and in England. Some of the most salient ob- jections are to the employing of persons as paid médical counsel by one side or the other ; the examination of the experts by hypothetical questions framed in the interest of one side or the other ; and the laying down of tests of sanity or insanity by the courts as matters of law, in- stead of treating the questions as purely médical ones to be decided by the weight of the expert testimony. Before considering any of thèse objections it is proper to state in a summary manner what is the gênerai practice prevailing in the courts of England and of this country. To cite authorities in illustration of the practice, or to endeavor to drfferentiate the practice of the various juris- dictions, or to state the limitations and exceptions to the rules laid down, woidd involve a treatise. My function is simply to give résulte and to state the practice in gênerai as it now exists. In the first place, it is a principle of oui* 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 médical experts. Again, the question of sanity or insanity présents itself in différent shape in différent forms of litigation, and the légal rules as to what constitutes sanity or insanity in the case before the court are laid down by the court for the guidance of the ex- perts as well as the guidance of the court itself or the jury. 13 14 A SYSTEM OF LEGAL MEDICINE. Thus, in criminal trials where the accused is defended on the ground of insanity, the courts hâve laid down certain rules of law as to what degree of mental or moral obliquity is sufficient to shield a man from punishment and to make him, in a légal sensé, irresponsible. The courts hâve differed widely as to thèse tests, and no rule of law with référence thereto is universally accepted even now • but nevertheless the courts assume the right to instruct the jury as to what does constitute sufficient insanity to be a défense. One of the tests laid down by some of the courts has been that défend- ant must hâve been so far under the influence of insane delusion at the moment of committing the act as not to be conscious of right or wrong. This test lias the sanction of the House of Lords. Another test laid down is that the défendant is responsible for Iris act if he had sufficient intelligence to know the physical conséquences of the act, and that it was a wrongful 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 déclare the rule and the jury are bound to accept it. Again, in the trial of will cases, the tests of competency to make a will are laid down by the courts. The most usual rule laid down is that the testator was compétent 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 though he may hâve been to some extent mentally unsound. Very severe criticism lias been indulged in by some médical men and alienists upon this practice of layingdown the test of criminal responsibility and testamentary capacity by the courts. It lias been urged that the ques- tion of insanity is one purely of médical 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. This objection assumes that the issue is purely one of sanity or insanity. There are, however, various degrees and phases of mental unsoundiiess. 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 consé- quences of criminal conduct. So, too, a man may hâve mental delusions or weaknesses, and yet not be incapable of disposing of his property. It would seem, therefore, proper that there should be some gênerai rules 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 différent classes of cases. At any rate, such is the practice. The rule is thus stated by an eminent authority (Wharton and Stillé's Médical Jurisprudence, sec. 193) : •' While experts may be called to testify as to states of mind and conditions of health, it is for the court to dé- clare whether such states and conditions constitute irresponsibility." Another well-settled rule is that médical-expert witnesses 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 conseiousness, appréhension, trutlifulness, etc. (See People vs. Barber, 115 N. Y. 475.) DUTIES AXD FESPOXSTBILITIES OF MEDICAL EXPEETS. 15 Again, another rule observed in the courts on the examination of ex- perts is that their opinion is to be asked, not upon the case as a whole, but upon hypothetical questions presented to them. 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 qiiestions framed by the respective counsel. The theory on which the experts are examined is that tliey are testifyiug to the rules of a participai* 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 sensés of sight and hearing. Thus the laws of ehemistry may be testified to by a chemical expert—the chemical effects of certain aci'ds, and the résulte of chemical analyses, for thèse are as much facts as is the label on a certain bottle, or the name of the apothecary from whom the bottle and its contents were purehased. The primary object, therefore, of expert testimony is, not to prove opinions, but facts in the shape of rules 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 differ in their views as to the rules ap- plicable to a given state of physical or mental phenomena presented to them ; hence cornes the sphère of what is called " opinion évidence." The object to be attained by the courts is to limit the opinion as much as possible, and to get as nearly 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 faets. This is the theory on which hypothetical questions are based. When an expert witness lias a hypothetical question put to him and is asked to give his opinion upon the state of facts presented, lie is in légal theory asked to state what he understands to be the fact with regard to the médical rules applicable to that set of circumstances. In criminal cases, or cases de Immtico inquirendo, it is, of course, feasi- ble for the expert witnesses to personally examine and observe the party, and they can thus form an opinion as to his mental condition at the tirne of such examination, which they can express in the shape of a conclusion, explaining the grounds on which the conclusion is based. In will con- teste, however, which form a.very large class of the eontroversies involv- ing the issue of mental competency, this is impossible. 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 faets 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 deeeased he would be in the judgment of the witness of sound and disposing mind and memory. Many forcible objections are urged against the use of the hypothetical question. It is claimed, and with too much truth, that this form of ques- tion assumes as proved whatever the counsel putting the question lias endeavored to prove, and combines insignificant with important circum- stances, and alleged faets, supported by slight and perhaps 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 be overwhelmingly established upon the other side : that this form of question is in effect nothing more nor less than a summing up by counsel, assuming ail the allégations of fact in his favor of which 16 A SYSTEM OF LEGAL MEDICIXE. there may be only a scintilla of proof, and omitting ail other facts, how- ever clearly established. Expert testimony based upon such one-sided hypothetical questions is almost of necessity favorable to the questioner, and the seeming inconsisteney of expert witnesses of equal abilitv and learning is very largely due to this mode of examination. In other words, expert witnesses who might agrée if the same hypothetical ques- tion were put to them almost of necessity disagree when directly op- posite hypothetical questions are put to them. Various remédies for this evil hâve been suggested, such as having the hypothetical questions framed by the court, based on the testimony of each side, and asking the witness to give his opinion on each theory. This practice, however, would only partially obviate the difficulty, unless the court should, in framing the question, assume to décide what facts had been established on either side. In will cases there seems to be no escape from the necessity of hypo- thetical questions in some form so long as the issue of sanity or insanity is to be decided by the court 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 décide the whole case, and nothing remains for the court or the jury to do except, perhaps, to décide between conflicting expert évidence ; and this, of course, is inconsistent with oui* whole theory of trial by court or jury. It might, perhaps, be feasible to hâve the court or the jury make find- ings of fact as to the évidence of conduct, character, and history, and then hâve a commission of experts décide whether, on such findings, the deceased was or was not insane. This, however, is also open to manifest objections, since it would in volve, in order to be of any value to the ex- perts, a multitude of findings involving minuti«> of conduct which would be almost hopelessly bewildering to a jury, and in a long trial, intoler- ably burdensome to the court. The true remedy for the evils that undoubtedly exist in the trial of cases involving the question of insanity is to hâve this question sepa- rately passed upon, as far as practicable, by a commission of experts. Législation in the State of New York has set an example in this direc- tion. By section 658 of the Code of Criminal Procédure of the State of New York, it is provided that when a défendant pleads insanity the court may appoint a commission to examine him and report to the court as to his sanity at the tirne of the commission of the crime. It is further pro- vided that if a défendant in confinement under indictment appears to lie at any time before or after conviction insane, the court mav, unless the défendant is under sentence of death (in which case powers are conferred by other statutes upon the govemor to examine into the question), ap- point a like commission to examine him and report to the court as to his sanity at the time of the examination. And if the commission find the défendant insane, the trial or judgment must be suspended until lie 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, and that upon his beeoming sane he be redelivered by the superintendent of the asylum to the sheriff, whereupon he must be brought to trial, judgment, or exécution, as the case may be, or be legally discharged. (Code of Criminal Procédure, secs. 659, 661.) DLTIES AXD EESI'OXSIBILITIES OF MEDICAL EXPEETS. 17 Thèse provisions of the Code of Criminal Procédure, enacted in 1881, supersede and enlarge the previous provisions of the Laws of 1874, chap- ter 44(5. That act, for some reason the propriety of which it is difficult to understand, restricted its provisions to the crimes of " arson or mur- der, 01* attempt at murder, or highway robbery," while the présent act extends to ail crimes. There are constitutional difficulties in the way of making the findings of the commission conclusive against the accused in criminal cases if they find him sane at the time of the alleged offense, since that would deprive him of his right 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 ail civil cases in which the issue of sanity arises that question 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 expédient, and would obviate many of the objections now existing in the trial of cases where expert évidence as to sanity is called for. There are certain cases in which expert évidence is frequently given where it would seem to be wholly inappropriate. Thus in murder cases the accused is very often defended on the ground of momentary or tem- porary insanity. This défense really amounts to little more than excus- able and uncontrollable anger. It is usually availed of in extrême cases, such as where the accused lias 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 reeeived from the deceased, readily avail themselves of the excuse offered by the défense of temporary insan- ity. Yet it is manifestly absurd, in such a case, to call médical 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 sensé a médical 01* scientific question, but a question of common sensé and common expérience which a judge 01* a jury are compétent to décide for themselves. Much criticism has been indulged in by the courts as to the value of expert évidence. Thus Lord Campbell's remark in the case of the Tracy Peerage, 10 Cl. & Fin. 191, has been often quoted to the effect that " skilled witnesses corne with such a bias on their minds to support the cause in which they are embarked that hardly any weight should be given to their évidence." This criticism is unduly severe. There can be 110 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 favor of having certain persons selected by the Suprême Court of the State from the médical 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 Vt dietn 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 calling them, which would tend to make them independent and impartial. 18 A SYSTEM OF LEGAL MEDICIXE. It is needless to urge the duty of médical experts to free themselves as far as possible from the bias of their rétamer. It should be the aim and pride of the médical expert to realize that lie is after ail not a counsel, but a witness called upon to testify to facts of médical science with which he is supposed to be familiar, and that those facts should be testified to fully, frankly, and fairly, 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 médical expert, especially when sub- jected to harassing and sometimes annoying and disrespectful oross-ex- ainmation. The obligation, however, to tell the truth, the whole truth, and nothing but the truth, should be constantly before the mind of the médical expert. It is not his function to carry on a dialectical warfare with opposing counsel or opposing experts, but to give a full and com- plète statement of the médical rules applicable to the case in hand, on the hypothetical questions put to him, without fear or favor. INSANITY IN ITS MEDICO-LEGAL BEARLNGS. BY ALLAN McLANE HAMILTON, M.D. Part I.—General Introduction. Mind is that manifestation of life which dépends upon the functional activity of the brain, and is expressed in the exercise of feeling, thought, and volition. In the light of modem 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 nietaphysicians and many theologians. It is my purpose to briefly consider normal and diseased function alone, referring my readers 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 ail mental activity, and through it he realizes the relations he bears to the external world, as well as the value of impressions which hâve been transformed into concepts, while previous expériences are stored up and form the basis of thought and action. The ou ter world bears an indirect relation toward him through external expérience. Ail of his ability for weighing, coordinating, and using his own internai formulated impressions (con- cepts), as well as of putting himself in every way in proper touch with outside things, dépends upon the faculty of attention (apperception). The power of attention and its connection with concept sélection déter- mines greatly the intricacy and degree of thought and action. The many steps of mental development hâve been traced by pains- taking observers whose results are incontrovertible, and in thèse days of progress we are furuished with indisputable facts which show how the mind may be partially or generally destroyed in a distinctly definite man- ner by morbid processes and focal disease. Extirpation of certain tracte or régions is followed by perversion or abolition, it being possible to repeat such expérimente over and over again if one chooses. We hâve been shown that ancephalous monsters exist, and modem localization has thoroughly changed oui* inexact and spéculative knowledge of brain function, which a quarter of a century a go partook largely of the nature of guess-work. It is, moreover, possible, after studying the questions of heredity and environment, to realize the influences that materially act in the geiiesis of mental development or deeay. The healthy play of hu- man passions and feelings dépends upon cérébral integrity, and possibly before long our knowledge and appréciation of the origin of many of the 19 20 A SYSTEM OE LEGAL MEDICIXE. higher attributes of mental function will hâve a material and salisfactory explanation. For the proper study of the mind in health and disease we must view the subject fh'st from the side of development and degenera- tion, and, agaiu, we must consider the coordination and mutual depend- ence of eellular functional activity and efferent and afférent perfeetness of communication. It is better to break away from the iron-clad so-called divisions of mind adoptedby the older metaphysicians and to consider the manifestations of brain action as not only extremely variable but eom- plex in their display. After ail, the power and extent of mental action dépend upon the capacity of the apparatus which gives birth to psychic activity. With the more primitive nervous organs we bave nothing hère to do, but the study of the mind of man is before us, and we shall proceed to the discussion of its inipairment. It may be assumed beyond doubt that the grouih of intelligence bears relation to the eomplcxity of the nervous organization or the évolu- tion of the highcr ganglia. It would be difficult to form any exact esti- mate of its extent, and the point to which it may be developed even in the lower animais, but it may be assumed that convolutionary perfection, completeness in the connection of cells and groups of cells, détermines the possibilités of mental growth. There is no absolute indication of intellectual power to be derived from the size of the brain or the shape of the head alone, except in a most gênerai way. Students of craniology hâve called attention to the asymmetry of the cranium and the irregu- larity and exaggeration of the fissures which divide the cérébral convo- lutions, but anything more than this is mère guess-work. Abundant statistics are on record to prove that the heaviest brains do not go with the grandes! intellects, but, on the contrary, thèse statistics indubitably show that some of the greatest minds are the product of insignificant brains so far as mère 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 noue at ail. Gratiolet {The Brain as an Organ of Mind, Bastian, p. 36) has fixed the lowest limit compatible with ordinary intelligence at 900 drams ; Broca at 907 for the female and 1049 for the maie. The aver- age weight of the human brain has been estimated by Sharpey as fol- lows : maximum weight of adult maie brain, 65 oz. ; average weight of adult maie brain, 49J oz. ; minimum weight of adult maie brain, 34 oz. ; maximum weight of adult female brain, 56 oz. ; average weight of adult female brain, 44 oz. ; minimum weight of adult female brain, 31 oz. Mor- ris lias reported the heaviest brain so far recorded, the weight being 67 oz. (Brit. 'Mrd. Jour., October 6, 1872). After ail, the true test of intelli- gence is that of gênerai structural development, and it is probable that, if the microscope could be brought to reveal the most délicate commissural connections, the brain nearest perfection would show a well-developed convolutionary surface, plentifully 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, show a flatness of the external surface, with imperfectly defined and sépara ted convolutions, a notable degree of flatness of thèse, as well as asymmetry or a distinct différence between the two hémisphères. At another part of this article thèse matters will be considered in extenso. The lessons of physiology and pathology throw much light upon the 1XSAX1TY IX ITS MEDICO-LEGAL BEA11IXGS. 21 functions of the brain and changes in the genesis of mental expression that follow its partial removal or impairment by disease. An experhnent often performed in the physiological laboratory consiste in the removal of the cerebrum from pigeons and frogs, resulting in the deprivation of ail mental control and the persistence only of reflex function and an autom- atism which foliows stimulation or suggestion and is shown in peculiar motor activity of one kind. Birds thrown in the air for a time fly, and swallow food only when it is placed so that the muscles of the throat are thus stimulated to reflex action, there being nothing volitional. The frog, if mutilated in this way, will only jump if pricked, and though when placed upon an inclined board it finds its way to the top, it is simply the resuit of a speeies of automatism which has no immédiate inteflectual connection, but is something acquired that has become habit. The. tolérance of the brain to injury is remarkable, for it may undergo very decided mutilation, even losing much of its substance, often with- out any considérable résultant impairment of function, and sometimes none whatever. Modem surgery has proved that ail sorts of operative procédures, which until recently were supposed to hâve no other résulte than those of a fatal character, are now not only proper and remédiai measures, but that the surgeon's knife can enter the brain in many places without any risk whatever to life. Hernia cerebri of magnitude often follows comminuted frontal fracture with loss of bone, and removal or necrosis of the cérébral tissue does not always mean any great impairment or abolition of mental function. The celebrated New England tamping-iron case is familiar to many people. The subject was a workman who was en- gaged in drilling a hole in the rock. Through a prématuré explosion the blast went off, blowing the tamping- iron, which was several feet long and at least one inch in diameter, through the anterior part of the head, it enter- ing below and passing ont above, cre- ating an opening of such size that much of the fore-brain was destroyed. (Fig. 1.) The immédiate effects were, considering the serious shock and loss of substance, comparatively insignif- icant, and he lived for many years, eventually dying of tuberculosis. Ex- cept for an irritability of temper there was little mental weakness. Large Fig. 1. tumors which may occupy the greater part of one hémisphère may exist for years, giving no indication of their présence- bony excrescences or spiculae may also make what must be considered dangerous pressure, and still the sites involved seem to be those without function, or at least tolerate the unusual violence. On the other hand, a very small lésion may create great mischief. This is especially true when it is situated at the ïower and posterior part of the brain, where nerve trunks and important nuclear centers exist. 22 A SYSTEM OF LEGAL MEDICIXE. Fig. 3. Fig. 4. Diagrams illustrating the ramifications of fibers and the location of the basai sensory area of the brain. (Testut and Meynert. ) Fig. 2.—Intracerebral fibers: a, anterior extremity of left hémisphère; h, its posterior ex - tremity; c, fissure of Sylvius; d, temporal lobe; e, splenius; 1, longitudinal fibers of the cingu- lum ; 2, long superior f asciculus (fasciculus arcuatus) ; 3, inferior longitudinal fibers ; 4, uncif orm fibers ; 5, 5, arched fibers. Fig. 3.— Diagram of arched fibers and those with close local connections: 1, short arched fibers going from one convohition to a neighboring one ; 2, long arched fibers going from one convolution to a more distant one. Fig. 4. —Diagram representing a vertico-lateral section of the left hémisphère, showing the sensory fibers and their irradiation toward the cortex: 1, optic thalamus; 2, geniculate bodies; 3, posterior extremity of hémisphère ; 4, fissure of Rolando ; 5, ascending frontal convolution ; 6, ascending pariétal convolution; 7, pyramidal (red), going to the motor zone; 8, sensory fibers (blue) ; 9, optic fibers ; 10, sensory decussation ; 11, vertical sensory fibers going to motor zone ; 12, horizontal sensory fibers going to the pariétal, temporal, and occiDital lobes. IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 23 Hère we find the origin of the cranial nerves, which play so important a part in spécial sensation, in respiration, the action of the heart, and digestion. Lésions at certain parts of the brain concerned in conduction, may wholly or partially involve the great bundle of nerve-fibers which descend or ascend, producing paralysis of sensation or motion, cutting off the centripetal impression or the centrifugal volitional flow. Above Fig. 5. Diagram representing the course of the pyramidal fibers between the cérébral cortex and the cord and anterior nerve roots. (Testut. ) tion of pyramids corresponding to the transverse axis X, X; 4, trunk of cervical cord seen anteriorly; 5, inferior part of the dorsal cord; 6, 6, anterior nerve roots of tlie right side; 6', 6', anterior nerve roots of the left side. " It is seen in this diagram that one side corresponds to the other: first, thecrossed pyramidal fibers entirely passmg over to the other side at tne root of decussation of the pyramids; second, the direct pyramidal fibers are crossed, bundle by bun- dle throughout the length of the cord ; in short, ail the motor fibers issuing from one hémi- sphère, that follow the course of crossed or direct fasoiculi, émerge from the cord as anterior nerve roots on the opposite side,1' 24 A SYSTEM OF LEGAL MEDICINE. Fig. 6. Diagram representing the topography of the cortical areas of the left hémisphère. (Testut.) (The method of division is that of Pitres.) a, a, Prefrontal section ; h, b, pediculo-frontal section ; c, c, frontal section ; d, d, pariétal section ; e, e, pediculo-parietal ; /, /, occipital section. The violet tinting indicates the psychic zone; Mue, the sensory; red, the motor; green, the geniculate centers (of face, and nerves con- cerned in mastication as well as the hypoglossal) ; yellow, the center of aphasia. I, Agraphic center; 77, aphasie center; 777, center of lower extremity ; IV, of superior extremity ; V, motor center of face; VI, center of word-blindness; V77, center of hemianopsia; V777, center of word-deafness. Besides thèse there is a center in the unciate gyrus, which probably controls the sensé of smell. INSANITY IN ITS MEDICO-LEGAL BEARINGS. 25 Fig. 7. Fig. 8. Fig. 9. Fig. 10. Sections of the cerebrum showing the association fiber System. (Testut.) Figs. 7 and 8.—Pediculo-frontal 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; 9, middle pediculo- frontal fibers; 10, inferior pediculo-frontal fibers; 11, orbital fibers; 12, corpus callosum; 13, cau- date nucleus; 14, internai capsule; 15, lenticular nucleus; 7, agraphic center; 77, aphasie center (see Mill's article); A, A, psychic fibers (violet); B, aphasie fibers (yellow) ; C, sensory fibers (blue). Figs. 9 and 10.—Frontal section of cerebrum: 1, ascending frontal convolution; 2, foot of ascending pariétal convolution; 3, island of Reil; 4, 4', 4", first, second, and third temporal convolutions; 5, superior frontal fibers; 6, middle frontal fibers; 7, inferior frontal fibers; 8, sphenoidal fibers; 9, corpus callosum; 10, caudate nucleus; 11, optic thalamus; 12, internai capsule; 13, lenticular nucleus; 14, external capsule; 15, claustrum; 777, motor center for in- ferior extremity ; 7F, 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. Fig. 11. Showing the arterial supply at the base of the brain. (Testut.) 1, Internai carotid artery, divided at the opening of the cavernous sinus ; 2, anterior céré- bral artery; 3, middle cérébral artery and Sylvian artery; 4, choroid artery; 5, anterior com- municating artery; 6, posterior communicating artery; 7, posterior cérébral 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, vertébral arte- ries; 13, inferior and posterior cerebellar arteries; 14, anterior spinal artery; a, anterior ex- tremity of inter-hemispherical fissure; h, its posterior extremity; c, olfactive bulbs; d, optic commissure ; e, pons ; /, bulb ; g, cerebellum. The left hémisphère of cerebellum and right temporo-sphenoidal lobe hâve been removed. INSANITY IN ITS MEDICO-LEGAL BEAlUNGS. 27 and in the cortex or investing gray matter we find the seat of that form of nervous action which is the direct output of cellular function. In some places are well-determined areas whose spécial office is to origïnate definite motor impulses. Thanks to Hitzig, Fritsch, Ferrier, and a host of other observers, we know that localized irritation of thèse will be fol- lowed by muscular contractions in distal parts, and that thèse are of a uniform character, as can be repeatedly proved. We know that poste- riorly in the occipital lobes are loeated centers for vision ; that above in the pariétal région is what is known as the angular gyrus, 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 resuit ; that at the base of the brain anteriorly is a center for smell. Thèse, as well as many others, hâve been loeated by experi- ment and proved to exist by the results of disease. What the exact location of the apparatus of mind is has always been a matter of active dispute, although the great mass of testimony goes to show that it is the fore-brain which is concerned. In the light of experi- ment and clinical observation this theory seems open to some question, and the views of Hughlings-Jackson and Exner are less conservative and more reasonable. I am therefore inclined to agrée with them that no one part of the gray matter is alone concerned, but rather that mental action is the resuit of gênerai and complex function. Figs. 2, 3, 4, 5, 6, 7, 8, 9, and 10, from Testut's admirable treatise ('Traité dWnatomie Hu- maine, etc., t. 2, Paris, 1893), 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 centrifugally. 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, diagrammatically illus- trate the course of thèse fibers. Figs. 6, 7, 8, 9, 10, indicate the gênerai connection of thèse with parts of the brain in which spécial functions are loeated ; Fig. 6 showing the entire latéral cortical surface of one hémi- sphère, with its function-zones mapped out and either represented in color or by limiting lines, and Figs. 7, 8, 9, and 10, the association Systems of the fore-brain. Fig. 11 shows the important basai arterial circulation of the brain, which is often subject to obstructive changes or other dis- ease, especially in those forms of dementia consécutive to thrombosis, embolism, or rupture from any other cause, the left middle cérébral artery being that most often involved. Kirchhoff (HandbooJc of Insanity, p. 9) formulâtes the status of knowl- edge of localization regarding the déductions 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 cerebellum 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 congénital absence of the cérébral hémisphères. 28 A SYSTEM OF LEGAL MEDICINE. 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 dépendent upon the frontal brain alone ; indeed, in thèse cases the occipital lobes are mainly atrophied. 4. " If the brain is imperfectly developed as a whole, as in some idiots, there can be no question of localization, nor is any further conclusion warranted from irregular development in the cortical layers, unless it is circumscribed." In illustration of this he alludes to the diseovery of only narrow py- ramidal cells in the frontal lobes of a few idiots, which were so irregularly distributed that it was almost impossible to distinguish the layers. Hère the imperfect mental development 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 well as their diverse nature, it is probable that they are stored up in no particular locality ; in fact, the pathology of dementia and its morbid anatomy présume a progressive and gênerai destructive change. MENTAL ELEMENTS—NORMAL AND DISEASED. Any extended considération of physiological psychology in a book of this kind would be out of place, but it will suffice to state that the divis- ions of mind are three in number: feeling, which includes sensibility and émotion ; thinhing, which implies intellection or thought ; and vol it ion, which is a resuit of the exercise of the first two. Thèse may be still fur- ther amplified and subdivided. In the older définitions of mind it was the custom to speak of judgment, reason, and memory, but, after ail, thèse may be better included under the head of •* thinking." In the study of the normal as well as of the diseased mind we are to consider perception, which implies the récognition and appréciation of the relations of sensation and the agencies which affect the same. This means the récognition of the part played by the organs of spécial sensé —the afférent nerves of conduction, the existence of groups of cells or nerve centers which receive the impressions from without, and the more important condition of consciousness. The kind of intelligence which is necessary for the mensuration of the form and physical attributes of objects must be taken into account, especially when we corne to consider the formation of hallucinations and illusions. When 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, a 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- tivity. Memory may be said to be of two kinds—that which consists in the rétention of perceptions or external impressions, and that which con- cerns the acknowledged récognition 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-appréciation. This latter form of memory, when affected, results in the change of the ego which is so INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 29 marked in some hallucinatory insanities. The grouping of concepts or ideas. and their association, constitutes reasoning and judgment, and précèdes volition, which may be the démonstrative active expression of their conclusion. The degree of this manifestation of course varies very much with the complexity and the extent of the mental opérations which ai-e behiud it ; and it differs from reflex action in the fact that the active démonstration is not govemed by thought in the latter, but is the resuit of a lively external impression, which is spinal in character, and the motor expression may or may not be attended by unconscious oere- bration. The simplest form of reflex action may be illustrated by the rapid withdrawal of the finger from a hot surface, which produces actual phys- ical pain, the cause or degré" of which is not weighed or estimated by the mind, and the act itself is also too rapid to be a volitional one. Then, a gain, there are so-called instinctive reflex acts, where previous associa- tions and expériences enter into the causation of particular museular contraction, and where no apparent conscious appréciation exists. The importance of the volitional act is, of course, gauged large]y by the par- ticipation of reason and judgment, as well as the concurrence of affective feeling ; and we are presented in health and disease with many gradations in the acts of will which begin as impulses and reach the dignity of elab- orate exercise of force after comparison, judgment, and discrimination hâve been operating. The capacity for inhibition, and, on the other hand, the influence of émotion 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 hâve resulted in the mental degeneration. We are also to compare his mental expressions ami conduct with that of others in the community in which he may be living, to consider his training and éducation, and to go back, if possible, into the remote past, to discover what influence, if any, has been exerted upon his development as a resuit 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 prédisposition or some long-existing cause, and in a very great many cases the process of mental dissolution is a slow one and the departure from mental health is prolonged. This should be borne in mind, especially in the considération of cases which form the subject of légal inquiry ; but the popular idea of insanity implies ail sorts of possibilités and improbabilities which do not stand the test of elinical expérience. Spécial Indications of Mental Weakness. Among the important évidences of mental détérioration are 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 A SYSTEM OF LIA;AL MED1CIXE. HALLUCINATIONS. 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 créa- tion of the latter consists in the distortion of an objective tîiing. Hallu- cinations are of three kinds : First. Those due to a defect of the peripheral perceptive organ. or of the afférent nerves and centripetal fil>ers. Second. The form which ineludes examples of disturbance of certain central organs. Third. Where the disorder is chien1 y confined to limited cortical areas. It has been held by some authors that it is possible to hâve hallucina- tions without any cérébral participation, or, in other words, any mental aberration, the organs of spécial sensé themselves possessing a certain local memory. This seems to me to be a nieretricious distinction and one wholly spéculative, for the reason that it is impossible to hâve an hallucination without a previously formed concept, no matter how an- cient. Persons who become blind after a time may bave visual halluci- nations, but those congenitally blind can, of course, hâve 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 spécial sensé themselves; and second, where they are centrally originated, as a resuit of an irrita- tion and stimulus of certain brain tracts where concepts bave been stored ulx The simples! form of hallucination is that due to some local irritation or disease of one of the perceptive organs, and the false images need not necessarily be insane; in fact, a variety of spurious sensory images, without objective basis, may be recognized by the individual as the re- suit of disease or temporary disturbances of the cérébral circulation, he being able to appreciate 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. Ail varieties of sensory impression are likely to be perverted by causes which it is not necessaiy to mention hère, except in a gênerai way; but we may consider the numerous factors that may pervert the innervation of the important organs which serve to keep us in relation with the outsi "e world. It is not difficult to explain by purely physi- cal agencies many startling varieties of disturbed spécial sensation. Hallucinations are divided into visual, audifory, olfactive, and cutaneous. Visual hallucinations are largely dépendent upon retinal phenom- ena, and are often connected with ischemia or disturbed circulation at the back of the eye. The pulsation of the central artery or variations in the retinal light may give rise to rings or disks of light, dark spots. fiashes, stars, or other scintilla, which may or not be used by a dis- eased brain as a basis for an elaborate morbid concept association. What other expansion there is of the mechanism which results in the misinterpretation of simple distal variations, I am unable to say. It would appear, however. that a very indiffèrent 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 INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 31 cortical layers are inactive, the mère flashing of a light before the eves of the sleeper is likely to produce complex dreams of tire and an unsvs- tematized comparison of concepts of some intricacy. There are some rides which govern the occurrence of peripheral visual hallucinations, and one is that they are more pronounced when the eyes are closed and in the dark, and they are more or less influenced by the condition of the ocular muscles generally. According to Kirc'hhoff loc. cit., p. 4S) : "If the sensorial déception develops in one eye alone, the possibility of distinguishing it from a unilatéral hallucination which has developed centrally is to be sought in the fact that the central devel- opment gives rise to much more complicated phenomena," The explana- tion of a unilatéral hallucination would naturally lead us to consider the physiological pathology, and to look for some affection of the occipital lobes. It bas been pointed ont that in paretic dementia in which the frontal lobes are most frequently affected, there are seldoni hallucina- tions; but in those cases where tins symptom bas oceurred the occipital lobes bave been found to be diseased. rnilateral hallucination of vision can be explained by 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 mistakes, are varied in their causation and occurrence. They perhaps more frequently bave a dceper and more alarming signifi- cauce than the others, are not so easily correeted, and are more gên- erai in occurrence than any other hallucinations. They usually consist of the récognition of the sound of imaginary voices and the répétition of many ordinary sounds. A distinctly insane hallucination of hearing has nearly always valuable diagnostic signiticance, for the reason that it in- dicates a more gênerai dérangement than those of the other sensés. A person may readily bave such a sane hallucination as hearing an imagi- nary voice, as the resuit, possibly, of an irritation of the middle ear ; but the insane individual expresses his fear of the sounds of voices speaking through a téléphone, the register, or cracks in his room ; or, in a more disorderly condition, it is the figures in the pictures upon the wall who are addressing him. Auditory hallucinations that convey 110 suggestion of insanity, like ail other ordinary false perceptions, are nearly always immediately re- moved, are récurrent in the original form, and, of course, are not associated with other évidences of dérangement. The auditory halluci- nations of the insane patient form the basis of communications from divine personages, from invisible friends or others, who eommand him to perform various acts, and he cannot be convineed of his error even when his environment is changed and certain objects are removed which facilitated the création of the hallucination itself. There is a, light grade of purely mental auditory hallucinatory disturbance that I bave seen, and it is in some measure hysterical, the full image being called up at will, and the patient's déclaration and be- havior doing away with any real supposition that the ear 01* eye is at fault. I bave reeently scvn a case of this kind, where the suspicion that an auditory hallucination existed was at first very strong, but fréquent interviews convineed 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 A SYSTEM OF LEGAL MEDICINE. eut conversation, in which the response to the imaginary mandate was prompted by a previous train of thought; and when I asked lier if the persons she addressed were near lier, she replied, "Xo.'' but that she was talking to them in the spirit. The conséquences of hallucinatory man- dates and subséquent delusions are apt to sometimes be serions, and those cases where patients refuse food and drink because they are told to do so by imaginary persons are often obliged to submit to compulsory feeding, oî*, if this is'not doue, death by starvation ensues. Hallucinatory voices may be bilatéral or unilatéral, external or inter- nai, 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, bave a local or a central basis. Perversions of both taste and smell, therefore, may resuit from some actual local condition, such as décomposition of epithelium in the mouth, bad taste, offensive discharges, etc. Sometimes thèse conditions lead to well-marked delusions, wilich are amplified usually in the direction of the horrible. The odor of decayed matter suggests that of a dead body, while re- fusai to eat is the resuit 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 olfactory nerve itself, or probably to the uncinate gyrus. Such a case I bave elsewhere reporte*], where oocasionally hallu- cinatory perception of the odor of smoke was a symptom, and a sub- séquent autopsy revealed extensive disease of the région above mentioned. However, the patient is nearly always able to recognize the source of his trouble ; but when lie does not, we may then account for such a perver- 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 viscéral organs, or an altération of what is known as the muscular sensé, are symptoms both of the lighter psychoses as well as of the graver forms of mental disease, and, like the other hallucinations previously mentioned, may not at times be attended by any considérable intellectual impair- ment. They play an important part in hypoehondriasis, and in that affection of limited intellectual disturbance known as paranoia, where one or two dominant illusions exist. Their range, however, is usually very Avide. Disturbances of muscular sensé lead to a variety of perverted percep- tions, individuals declaring that they hâve been deprived of certain mem- bers, or that one part of the body or the other is absent. A common ex- ample of this form of hallucination is that in which the individual who has undergone amputation déclares that he feels the présence of the lost limb. Sometimes thèse hallucinations are pleasurable and expansive, though very often they are associated with mental distress and not un- rarely lead to suicide. They very often cause the victini to déclare that lie 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 thèse eircumstances, the hallucination is the basis of a delusion. Sensorial hallucinations sometimes hâve 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 seXually de- INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 33 formed, as the resuit of sensorial hallucinations. I bave seen several men who through such a deranged mental state believed themselves pregnant. As before stated, the expression of hallucinations of ail kinds is very irregular, and does not necessarily indicate insanity. We find everywhere in literature instances of false perception, some of which are historical and familiar. Lombroso (The Man of Genius, London, 1S91, pp. 50, 57) lias ■eollected mimerons examples, as has also Brierre de Boismont. Brutus ( 'a'sar and Napoléon had simple hallucinations, those of the latter being evidently due to some circulatory disturbance incident to exhaustion. Shelley thought lie saw a child arise from the sea and clap its hands. Bunyàn heard voices. Byron imagined that he was haunted by a specter. Dr. Johnson distinctly lieard his mother call him "Samuel," although she was not présent, " Goethe saw his own image coming to meet him, and Van Helmont declared that lie had seen his own soûl in the form of a brilliant crystal. "When Oliver Cromwell was lying on his bed, kept awake by extrême fatigue, the curtain opened, and a woman of gigantic proportions appeared and anuounced that lie would be the greatest man in England." Some of thèse cases probably belonged to the condition of semi-consciousness or troubled sleep. Others were due to fatigue, and still others to genuine mental aberration. Dr. Johnson, as is well known, presented a form of mental disorder which is now recognized as folie du doute, which however is not usually aecompanied by hallucinations. The hallucinations of acute alco'holism, as well as those due to Canntdns Indica, opium, and numerous derivatives of the Solanacea—belladonna, hi/oscyamus, etc.—are examples of exhaustive or toxic causation. It is possible to induce various hallucinations by hypnotic suggestion, ami they are by no means uncommon accompaniments of those dramatie hvsterical states which are so eommonly witnessed in France. In women they not unrarelv hâve a sexual relation. Hallucinations are found Alone and Together.—It is rare for a ■single hallucination to last for any length of time, except possibly when it is of an auditory character, and in this case such an occurrence is rea- sonable when we consider how important and gênerai is the excitement which stimulâtes the word-symbol centers, that play so important a part in the opération of ail thought, So far as the connection of hallucina- tions with particular forms of insanity is concerned, it may be said that they are more frequently met with in acute mental disease. In primarv delusional insanity or paranoia, in confusional insanity, in conditions where the nerve centers are poisoned, especially in alcoholic insanity, in the insanity which is the resuit of levers, we find halluci- nations t<> be a common symptom, and they are always increased or developed by seclusion. Hallucinations are not only a common resuit of solitarv confinement, but are expressed at night, when the patient is alone and when sleep is fitful, and the insane person indulges m noisy outbreaks. As Lewis (A Text-bool; of Mental Diseases, p. 1G7) bas pomted ont such individuels are benefited by removal to an associate dormi tory. -Such hallucinations," savs he, "often peculiarly vivify and fascmate the mental vision, and, according to their nature, call forth correspond- ino- results. The patient may be passionate, wild, tlireatenmg, and défiant, shouting an alarm for suceor; joyous, exultant, or in a boisterous merriment Everv phase of emotional life may présent itself as the hal- lucinations vary and he enaets his little draina alone. ... In gênerai 34 A SYSTEM OF LEGAL MEDICINE. paralysis thèse nocturnal orgies are fréquent, noisy, restlcss, with or with- out hallucination, accomi)anving the latter stages of most cases." A table prepared by Dr. Edward B. Lane is reproduced, which will be of service in showing not only the kind and extent of hallucinations, but the forms of insanity in which they appear. (Boston Médical and Surgieal Journal, vol. cxxv., No. 11, p. 2(i8.) &X i < s ' s Paranoïa......................... 38 1 Acute melancholia................'< 312 i 5 mania..................... lf> i Paretic dementia.................! 9 ! 2 Post-paralytic insanity............i .. , 1 Other organic brain disease........| 3 1.. Epileptic insanity................j 4 4 Insanity of pubescence............! 4 .. Katatonia..................... Hysterical insanity............. Senile insanity................... G Alcoholic insanity.............. Récurrent mania............... Folie dit doute.................... Simple mania.................. " melancholia............. Folie circulaire................. Senile dementia................ IS 9 3 114 19 47 10 L'O 19 16 I '3 _ 10 7 6 3S 34 10 6 8 11 4 6- 29 3 4 1 2 10 7 6 1 105 301 The appearance of hallucinations in primary delusional insanity lias been ref'erred to, and in such a condition they are usually persistent, and form a basis of that varietv known as the sensorielle Verriichthcit, in which some delusions owe their origin to perverted perceptions originating in the skin or the viscéral organs. In other cases, delusions of persécution and suspicion spring directly from hallucinations of hearing and seeing. illusions. An illusion is a distorted perception of an objective reality ; in other words, it is the false perception 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 éléments of insanity they are by 110 means so important as the forms of false perception just described, which bave no objective basis. may originale more or less stubborn delusions, or, 011 the other hand, may often be easily corrected by their possessor. The distinction between an illusion and hallucination may be illus- * And touch. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 35 trated as follows : if a person looks at a tree and sees two, it is an illusion ; if he déclares that he sees a tree where none exists, it is an hallucination. If he misinterprets the sound of a ringing bell, it is an illusion ; if he says that he bears a bell when noue lias rung, it is an hallucination. Psycho- htoieallv, the processes consist in the inability to comprehend the nature of a phvsical impression, an imperfect concept being the resuit of a false perception upon which an imperfect judgment has been passed. In an hypnotic condition or one of exaggerated receptivity, an indi- vidual is very apt to make illusional mistakes in identity. which would be ont of the question under other circumstances; so that it is not un- usual for insane people to eventually bave distinct delusions of person- ality, which are due to their false appréciation of the figure and form of some person whom they bave possibly never seen before. Like hallucina- tions, illusions are common in alcoholic insanity, as well as in paranoia and eonfusional insanity, and sometimes exist as a symptom of paretic dementia. DELUSIONS. A delusion is a false belief, and may be regarded as sane and insane. Under the former head are groupent ail forms of erroneous or unusual beliefs which many individuals entertain whose mental integrity is un- questioned. Thèse latter may be simply the offspring of ignorance or préjudice or misinformation, and unless they be the fruit of religious or other dogmas may be easily removed by sufficient évidence. When be- liefs are held which to many seem unreasonable, but are nevertheless shared by a sufficient number of people to be simply matters of faith, they still need not be the product of diseased reasoning, though often- tim'es they are eccentric and troublesome to the world at large. No one would think of questioning the mental health of the large religious sects that believe in the iinmaculate conception or the miracles of Roman Catholicism, the doctrine of Swedenborgianism or spiritualism, any more than they would the sincerity of a great niajority who hold to any other faith the éléments of which are more or less inexplicable. It is, however, when extravagant belief obtains such complète possession, or is connected with clearly erratic behavior, that oui* doubts of the subject's sanitv arise. So long as the spiritualist bas or prétends to hâve com- munication with visible spirits, and so long as his hallucinations or illu- sions or delusions do not tincture bis conduct in a way that makes him a nuisance to his fellows, the law concerns itself but little; but when, as the resuit of a delusion, a crime is committed or a foolish business act is consummated, we more seriously question his responsibility. The law is exceedinglv merciful, if not lax, in its attitude toward such individ- uals, and is disposed to accept excuses that may be offered as a défense. I can reeall a case where a large ainount of money had been left by an eccentric Frenchmau to a philanthropie society for the suppression of cruelty to animais, and for the spécial eare of cats* His will was con- tested", and besides peculiarities of manner, it was the subject of contest by reason of this seeming mark of insanity. It, however, transpired that the testator had been for years a consistent believer in metempsychosis, and was, naturally, anxiou's that bis transferred soid should be well taken eare of after his démise. * The Bonard Will Case. 36 A SYSTEM OF LEGAL MEDKTXE. In Catholic countries, where large numbers of people believe in visions and miracles—such belief oftentimes being primarily based upon the doubtful testimony of a hvsterical girl or some equally unreliable ob- server—it does not do to too closely (piestion what most of the world would consider delusions. In a future time, when the study of the gen- esis of religious belief is more thorough than it now is, and when pathol- ogists and psychologists are brave enough to consider the subject from a material standpoint, much of the présent uncertainty will be removed, and it will be possible to estimate the mental integrity and illogïcal organization not only of many existing forms of faith, but of the new and hastily digested varieties of fashionable religion that crop to the surface from time to time and are little more than vents for those in search of notoriety or of emotional exeitement 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 expérience is shared by other students of mental medicine, namely, that much that is accepted by rep- résentative believers who are searcbing for sensations lias its origin in the insane asylums. In this connection I append the statement of a paranoiac patient, whose théories are explained by his disease. This man, like others, lived for some time in a communitv without attracting attention to his real state, and found sympathizers and believers. In accordance with }rour expressed wish that I write you a statement of events in my life which happened from the time of my return from Europe, February 7, 4 870, until the présent time, January 6, 187N, I proceed as follows. I will freshen your recol- lection by brief référence to the chief points of my éducation up to the beginning of this time. Early liome training and gênerai sehooling usual for Christian families. General university study. Graduation in----Médical Department. I went to----, opened an office in one of the best buildings there, lived at the best hôtel, 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 éducation, and my at least presumable professional attainments. I pursued the usual course among people— went to church, extended my acquaintance, did some professional business about the hôtel among Christians and Jews, had one or two misunderstandings on the matter of charges (very unpleasant to me). Received searcely any business from the city, though my card was very conspicuous in the city eolumn of the daily paper—simply narae, résidence, office, and téléphone number. I met several of the best citizens. At the hôtel at this time a gentleman, evidently one of the best citizens, was living. I saw him, and remember of thinking at the time, " Now, there is one of the best citizens ; he can appreciate my merits, so I will not crowd myself upon him." In the dining-room of the hôtel I happened to be seated fxill face to the enh'ance, but a goodly distance away. Times were active, and many people came in and out. One noon a young and stately lady came in, a young gentleman beside her (lier brother). I noticed strangely apparent évidences of her disposition for me—this upon several occasions—so much so that one day 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 type) ; then the gentleman mentioned before as a respectable citizen living at the hôtel was with her. It now became apparent they were ail of one family—father, mother, daughter, and two brothers. Of ail I liked the appearance and conduct. The young lady's expressions went on ; then I fell in love with lier. The passion grew upon me, possessed me, ran away with me. At approaching Christmas I sent her, before having met hei*, a large basket of flowers with my name dowrn in the middle of them. Thèse the mother returned, saying on a note she could not allow her daughter to receive présents from gentlemen with whom she was unacquainted. But before this I had met the father and asked him for an introduction to the family. I sent a card and called, met the mother and brothers, but a meeting with the daugliter wa'j prevented—evidently until they should satisfy themselves from others' say-so as to me : who, what, whenee, value, etc., etc. The girl seemed to me the en tire fui fi li- ment of ail my early-life impressions, and ail my desires might ask. I loved her in- INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 37 tensely. In this love my development was completed. I wrote the mother several tinx.'s to introduce us, but was not gratified. I thought, too, they favored our affec- tions, and I supposed their method would be their own ; and probably a party at their house, or at that of a friend's family also at that time at the hôtel, but presently to move into an home. The family with the young lady moved from the hôtel into their home in the city. We were thus estranged. Another family, friends of theirs. came to the hôtel, as I believed, to encourage me meeting them. This I would not do by any 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 ail sympathy with them at their inhuman conduct, but still loved the daughter. The season at----came on. I con- tinued my office in the city, and by appointment of the manager of the----Hôtel I kept hours there too, it being but a half-hour's nui between. At----another family, friends of the first, came to the lake. I met none of them as it happened. My young lady came out to visit them. I wrote lier, asking privilège to meet her ; got no reply. Asked an interview with the old lady she was visiting ; got it, explained the situation, and asked lier for an introduction to the young lady. She thought it wTould be wrong, as she was their guest. The next day they Avent boating ; came direct from the lake to their train, where the young lady's mother received lier and took her to the citj*. The old lady at the lake then advised me to see the young lady at lier home or write her, and to do so at once. Accordingly I wrote lier fully, the season at the lake being ended. I got no answer, but a brother came next day to the hôtel and dined with their friends. Next day the young lady came. By this time, the proceeds of business not having been up to expectations, I was being closed down upon by creditors. A friend upon whom I had relied came and helped me out, and refused to cooperate with me in any further opérations in----. I would not leave without an expression from this young lady. My friend went to the father for this, and brought me word that the young lady despised me. I then, much oppressée!, had nothing to do but to go away. I went to Jonestown. In Jonestown I opened an office, resolved now at ail hazards to be independent of any one. I was tliirty years of âge, and determined to make my profession support me now, or starve out of it into something else or into death. After so much éduca- 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 eonfirmed and verified themselves. I went on, managed to live also in my office—one room—reduced expenses to $4f> a month, went to church, and extended acquaintance. Notwithstand- ing ail 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 aecording to statutory requirenients and consistent with the understanding. 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 wras confident. However, a judgment was given against me—an unholy and an unright- «ous 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 up seventeen days head. so I was left in possession. I tried then to induce the owner not to insist on possession. I found him determined, and leai'ned that he was in a combination witli my neighbor, also a doctor, to give the latter my place, and it became apparent, beyond ail dispute, this doctor is an ignoble character. They kept on with their plot (every détail of which I can prove). I tried to obviate, circumvent, and even to allow them to exécute their judgment with failure to themselves, until I saw it wras abso- lutely impossible as by methods common among gentlemen. I saw they were deter- mined to carry out their exécution, which meant to me now a deprivation of business, office, home, and living, and I saw if they went on their way it meant a sacrifice of ail honor to me and manhood. I determined it could not end their way, for though they had the law and powrer I had right. I resolved it should end my wray ; accordingly, with my knowledge of man, I resolved on a gunpowder policy, and knew my expéri- ences would give me the nerve. I realized my good name would be put in hazard, and what I gained would be contestable ; but relative to the matter in hand I intended to apply my way, let corne what would : even death would hâve been préférable to re- signing every human feeling by running away from my defensible rights. Knowing the possibilitv of meeting death—for the proprietor had himself been, as lie from time ■to time had told me, a " Western tough "—I sat down the night before the day I in- tended to proceed, and wrote out my position, intention, and i*eferred to possible re- cuits, also stating my beliefs in religion, views on God, conclusions on my life up to 38 A SYSTEM OF LEGAL MEDICINE. this time, and changes in opinions on thèse snbjects I thought it désirable should be made. I outliued thèse only briefly, as I did not hâve time to elaborate, saying if I fell I might désire to see thèse things doue by others. If I died I knew this 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 proprietor of the building, on his desk in his office. Said I, "There is $20 and a receipt for it ; sign that." He took it, looked at it, and said, " Well, I don't hâve to if I don't want to." Said I, " Yes, you do," and "covered" his face with a liS-c.aliber revolver (S. & W.). He exclaimed, "Well ! " I saw lie hesitated, and I must minerve him. I raised the gun over his head and fired in the brick wall, high up. This brought him and two other men, who were in the office at the sanie time, to their feet. The two others came toward nie, and I supposed would seize me, so I "pulled down" on them, held them at bay, and announced, "He's got to sign that receipt." He, meantime. was exclaiming, " Fil sign it ! Fil sign it ! " and lie 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." "Fil sign it ! " he said. He did so. I then emptied the pistol in his walls, excepting one bail. Tins I did because I knew the facts would come out, and as an évidence of no more use for such forces ; to show only those ends may be attamcd by war which may be roached by peaceful, honorable means among fully accomplished men. The fifth and last bail I discharged at my office door, near my (lovely) neighbor, to show him ail the forces to be considered in such foui designs as his ; but while we had them we also knew how to control and direct 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. When I came to the street cries of " There he is ! take him ! kill him ! "" etc., etc., were expressed. I was arrested, taken to the police-station ; the proprietors 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, wliat's the matter?" This gentleman was a Mr. Z----, a Jew. The officers took me, locked me in a cell. Mr. Z----protested, and said he would go my bail. They fixed up the papers. I was taken to court. 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 writ for cjectment 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 dragged me from my office, thus using their exécution in spite of me. I was taken to the hospital, where I agreed to stay until the bond could be changed. This was extended indefinitely by Mr. Z---- signing a new bond to which my friend also affixed his signature, he having been sum- moned by wire. While at the hospital Easter Sunday I desired to go to chureh, but was not allowed to. By extension of the bond, and the déductions I wished to an- nounce from ail this treatment, I hâve come on to New York City. I shall return to Jonestown for my trial. My exécution in the writ 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 Jewish Sunday; refused attendance on chureh Easter Sunday. Yester- day I issued the following proclamation to the young ladies of Jonestown: "I call your attention to the treatment I hâve received at the hands of the Christians, and how differently the Jews hâve treated me. I call upon you to demand of your daily papers an open statement of the facts. I recommend you, unless the Jews are ad- mitted to full acknowledgment and given full and equal share in ail the joy of your coming Easter célébrations—I recommend you not to dance." (They are getting up an elaborate dance.) Now. you will notice the contrast of treatment which I hâve received from Jews and Christians—an equal stranger to both. Déductions : that defect of teaching in religion prevented me meeting the young lady of E----; thèse defects, as médical men, we know ; I refer to the technicalities and rites of the chureh—mystery of incarnation, résurrection, Adam and Eve, and such teachings out of harmony with nature and with fact, and wrong, leading us rapidly into dangers, if not national ca- lamity. Thèse dangers are not, of course, now particularly threatening. I tried Christianity under 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 187S years hâve held their position against the unnatural conception, and hâve been the victims of much persécution which the hypocrisies of Christianity as now interpreted are responsible for, and it is time thèse things stop. This virtually brings us about up to date, and the élaboration of the dé- tails respecting changes will be made in due time. When I left Jonestown I promised INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 39 to the Jews. through my friend Dr. R----, my body, soûl, and powers. I shall do- what I can to my purposes, and whether the Jews accept the offer or not remains to be seen. If so I shall unité the Jews with Christianity in flesh and blood under the new cross. As I told you, our name is Christians of the Starred Cross. I realize this- is but a beginning, but everything must start so and grow. Before this was written he had perfeeted a complète scheme of what he intended to do, had ordered spécial badges, one of which he wore, and perfeeted the détails of this new " Religion of the Starred Cross.'' The case is reproduced in full because I believe it shows most fully the gene- sis of a state characterized by significant erotic, persecutory, querulent, 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 éducation and ordinary behavior of the lunatic. Without pursuing this subject at length, I may refer to the teachings of Luther and Swedenborg and other fauatics, whose lives were filled with plentiful instances of the saine behavior. Insane delusions are those which concern us most directly. Au in- sane delusion implies the holding of a belief in something which bas no existence except in the discased imagination of a person, and which is not removable by satisfactory évidence of its falsity. Other définitions hâve been given, luit I think this will do for practical use. Spitzka (In- sanity, etc., p. *J-t) calls insane delusions "faulty ideas growing out of a perversion or weakening of the logical apparatus." Delusions are the outgrowth of a mental disorganization which is usually far-reaehing and implies a certain involution of the mental processes. They may be ec- centric and centric, depending in the first instance upon hallucinations or illusions or false appréciation of external object s, 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 expressed in speech or shown in man- ner, gesture, and dress. They may be logically manifested as the resuit of a more or less common train of reasoning with false premises (sys- temafized 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 demoralization. A systematized delusion has some basis, and the différence 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- sécution may pick out some particular person as his imaginary enemy, giving reasons for the alleged persécution—possibly Connecting the enemy with them—and is full of reasons for his mental attitude which are more or less plausible; while the possessor of the unsystematized delusion makes the vaguest and wildest accusations, complaining of per- sons concealed in the water-pipes, referring to the voices of imaginary enemies who are cursing him, and seems to hâve no basis whatever for his absurd belief. Systematized delusions are usually limited in number, and belong to 40 A SYSTEM OF LEGAL MEDICINE. the evolntional insanities, which include such affections as paranoia ; while unsystematized delusions are usually plentiful, and are very often acconipanied by the incohérence which belongs to the acquired and so- matic insanities or to the involutional psychoses, which include paresis, and dementia. The genesis of an insane delusion bears a proportionate relation to the failure of the object-consciousness, while the sulgect-consciousness is exerted; as Lewis (loc. cit., pp. 12G, 127) expresses it: "As sulgect-con- sciousness becomes more and more pronounced, with failure of object- consciousness, ail impressions alike, received from the non-ego, become the pabulum for the growth of an all-pervading egoisni. 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 part the origin of représentative cognitions of the outer cosmos, so out of this source there now arise falsifications of the environment. " We hâve been tracing in thèse mental opérations the transformation of the environment to the alien's mind : out of the old fissue, by a species of rearrangement and reconstruction, is woven a fabric representing to him the reality 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 concept is projeeted out as the actual cosmos, and since internai order must correspond to the external, so a transformation of the ego itself responds to this altered state—the former identity is lost and re- placed by the new. " And hère we hâve an explication of that newly acquired freedom which, at this juncture, appears 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 magie 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 présent. Self-ereations arise with wondrous célerity and of protean form ; and the morbid imagination con- jures up fantastic groupings utterly devoid of cohérence and objective reality. A feeling of new freedom replaces the old one of restriction and aggression by the environment, and the ego is consequently endowed with new faculties, new powers—becomes a mighty potentate or a god. Still the environment is indelibly stamped with 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 be too strongly held. It is the most conspicuous and least easily misunderstood embodiment of intellectual perversion, and therefore has been the strong- est élément in the formation of medieo-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. Ail other sorts of aberrations enter in its production, and it is active and rétro- active ; and it is only when the power to reeall concepts is destroyed that this impression of insanity is absent. Insane delusions are, as a rule, strengthened by false adductions of proof—the natural resuit of a disordered perception ; and their tendency INSANITY IN ITS MEDICO-LEGAL BEAEINGS. -11 is to become more and more unsystematized. Trivial and oftentimes ahsurd happenings will be seized upon by the patient and dignified to the position of corroborative proof. No better example of what I hâve said can be presented than the case of a patient who, while insane, came from Chicago to New York by rail, and whose journal thus graphically reproduces lier insane hallucinations, illusions, and delusions : Extract of Journal. Left Chicago by the 8.15 Grand Trunk Railway, telling Mrs. D----good-by, but adding that I did not meau to do so to the rest; that she would hear from me again, as but for her I would hâve enjoyed little rest at night—and so I do mean to write to her. On entering the car I immediately perceived one old man and one old woman, 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 jiaid. Hâve you gone through the other car?" "No," replied the woman. "Fil leave it to you to work through it—tliat's ail 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, conspicuously 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 Une with me, say : " That lady's head must 4>e aching—she has not changed her position from the time she entered the car." The man in front of me, who carried on the conversation before in German to the woman, said (he was not the same man who sat there first when I entered the car) : "You see, they're on the lookout. We'll get so and so to stand in front of her so she can't see lier, and a string of them to pass from the next car, and that'll make it ail right." And true enough a procession 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 obliged to sit with her until she left the ear, to which she kindly assented. The car was filled with a low lot of German emigrants and détectives 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. Rude glanées and smacks. Even while talking to lier, a woman deliberately knoeked me, and on entering the car at Suspension Bridge it took ail of my agility to évade 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 waitlng-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 détective 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 influence spread over ail the German emigrants who had accom- panied me from Chicago, and the vulgar woman and the wife of the old man said, " Of course she's got to pay—we'll make her ; we'll run her out of New York, just as they did out of Chicago ; ire work that game better than they do ; we've got some of their own men on our side." So, seeing a nice-looking lady behind me with a dog, I de- termined upon taking a palace-car, paying for my sleeper, but sitting in it, and fol- lowed the nice-looking lady in the palace-car, who was followed by an old gentleman who crossly insisted upon keeping her dog. The old gentleman left lier 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 awhile a viarked reserve and coolness which I had not observed before she spoke to the man. On the contrary; and her eyes were fixed toward a man, as several at the back of us, and I saw a forced manner in her toward me was the resuit, and I understood, by a glance to the man in a line with us, that they had struck a bargain. The porter came, and I told him I wislied to sit up ail night, and I would pay him for my berth, as I did not wish to enter the car with the 42 A SYSTEM OF LEGAL MEDICINE. low German emigrants. He said. "Ail the berths are taken." "Well," I said. "then find me a seat in"another car." " Well,'' was his reply, " we'll see what we can do for you," and off he went. The man on a line calls him : " Hère are hve dollars for you ! " "Yes, sir." The gentleman raised his finger : "Now you stick to it," and a nod ot assent, Up he cornes to me and asks for my ticket, i'gh'e it to him out of the bag, and instead of his returning it into my outstretched hand he puts it in my lap. Tlie nod previous had made me suspicions of him, and 1 thought of asking the lady to take the ticket, but thought, " Surely she will think me cranky." and picked it up, and at once sair the nod of assent on the lady opposite directed toward the gentleman who had paid the man the five dollars, and looking at him; he meant, "Noir you can say you saw her do it, and non-1 understand the whole business." The lady got up and changed her seat, and the porter, 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 through the whole business. He wislied my seven dollars to cover the man's five dollars 1o whom he winked, so I firmly said I had no idea of paying that—to take me to the other ■car at once ; and so I left, and he put me among the (ierman emigrants, saying I was "crazv." The fact is, lie was mad I had fooled them. and though I knew I would hâve a rough time of it, I determined to place myself in God's hands. After finding ont the lady who first spoke to me in the waiting'-room I asked lier 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 passed, just as they did when I left Chicago. The man cleared his throat, ail nodded in procession, and a low fellow in an impudent manner reclined on the side seat. I immédiately changed mine, and asked to occupy the one fac'nuj the lady, to which she assented. Immediately tire 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 présence of the lady, who told me she left in the Weisland; and my only salvation was in turning around, elosing my eyes, and saying, " Now I lay me down to sleep." What else could I do? Who else could help nie? Toward G a.m. the vulgar woman said in (ierman, "I trap geld"—it means fine, pay for punishment, ( >f course I riricked irp my ears. " We's got lier," said another. " Now we'll hâve her up and make her pay ;" and I saw two grim-looking men opposite me. They looked like farmers, very fieree. I thought to myself, "I'd like to see you dare lay your hands upon me ; I'd make it hot for some of you raseals." The manifestation of delusions, of course, bears a direct relation to the particular form of insanity, and their development is largely dépend- ent upon the habits of life, environment, and cause of the mental dis- ease, tis well as the emotional activity at the time. There are depressed, expansive, grandiose, erotic, religious, and hypochondriacal delusions, the latter being chiefiy subjective, 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 ebarac- ter, which is obstinât ely entertained and rarely changed in any way, and forming the conspicuous symptom of the insanity. What are known as concealed delusions are those which are sup- pressed. the lunatic preserving, when occasion requires, so much self-con- trol that it is impossible to extort from him his insane false belief, which, however, at other times he expresses very freely. It is very common, as I hâve said, for people with limited delusions to présent little or nothing which. draws attention to their real condition, such subjects being gen- erally well behaved. Tliese are the cases that lead to controversies in court and often end in the discomfitnre of the physician. With free- dom in view, the élever lunatic can be so aroused and on the alert as to deceive every one about him, and he is triumphantly discharged as au injured person. I can reeall many instances of this kind which are INSANITY IN FIS MEDICO-LEGAL BEAEINGS. 43 more or less dramatic, and one in particular where the delusion was of a religious charaeter, and though it was referred to a dozen times a day by the patient while in the asylum, it was found utterly impossible to get him in court to give any indication of his disease. Finally, after the man had undergone a trying and perfectly satisfactory examination in regard to his business capacity and abilitv to take eare of himself in ordinary way s, he was asked by the lawyer for the défense the question, l-Who are you F' and replied almost immediately, his manner changing to one of excitement, " I am the Lord Jésus Christ," It was subsequently easy to convince the jury that he had, as a resuit of this delusion, hi- dulged in threats which implied a use of his great imaginary personal power, and lie was returned to the eare of his custodians. Another case of the kind may be cited as an illustration—that of a. small merchant who inherited a moderate compétence. He had been more or less iden- tified with local charities and chureh affairs, but the accession of the new fortune proved too much for him, and, with other symptoms, he speedily derived the idea that he was a great reformer, and proceeded to put his théories in practice. Ile hired a floor in the Bowery, and invited the half-grown boys and girls of that questionable locality to make the rooms their headquarters and trysting-plaee. While his relations with them were exceedingly questionable for a long time, it was not until the dis- appearance of clothes from the lines of the neighboring tenement-houses, and the noise and disorder, that the attention of the police was attracted and the place was raided. After his arrest, his family, recognizing the change in his mental condition, had him examined by two physicians, who committed him to an asylum; but through the efforts of a spécu- lative lawyer a habeas corpus was procured and he was brought before the sheriff s jury. A long examination, which was chien1 y directed to show his ability to exécute business papers, compute interest, and to disavow that lie was insane, résultée! in his discharge, with a word or two of censure for the doetors. He, however, of his own volition went back to the asylum, where he stayed despite the efforts of the superin- tendent to get rid of him, and his behavior was clearly that of a lunatic, his delusions being freely expressed. He tbreatened to sue the physi- cians who committed him unless they gave him the opportunity to deliver his peculiar address before one or more médical bodies. I exam- ined him and found the well-marked symptoms of early paretic dementia. He had delusions of power, and a confidence in bis own capability as a reformer that was refreshing. His theory in regard to the immae- ulate conception was that it was through a kiss, and he proposed to do away with the ordinary method of intercourse and substitute a plan 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 movement 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 proceeded to issue bonds and bank-notes for its payment, which he made with a peu and whatever scraps of paper lie could lay his hands upon. This man has since committed suicide. Instances of tins kind could be multiplied, and thèse 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 prolongée! watch- 44 A SYSTEM OF LEGAL MEDICINE. ing and the application of tests which must be more satisfactory than those ordinarily employée!. Spitzka calls attention to the fact that the possessor of those systematizeel delusions which relate to social and polit- ie-al ambition, as a rule, possesses a higher intellectual activity than the holder of erotic and religious insane' faU* beliefs. It is certain that the former, who tire very numerous and usually behave themselves, conipar- atively, so well that* they keep outside of the walls of the asylums, are often simply recognized as ''cranks." The erotic ;mel religious delusions arc more apt to be manifested by the peissessors of acepiired acute insanity. Systematized erotic and relig- ious delusions are apt to be entertained by the same peTson, and spring more or less from eae-h other. The erotic belief is often pure and has relation to abstract things, and is not connectée! with emotional excite- ment of a physieal kind, though its genesis may dépend upon a local irri- tation, with indulgence in masturbation. INSISTENT AND IMPERATIVE CONCEPTS. Insistent and imperative concepts mark a speeies of mental weak- ness in which the patient's conduct is more or less strongly iuiruene-ed, 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 folio wed by subseepient repentance and distress. A number of mîmes hâve been applied to forms of mental disease of this kind, and they extend from the lower form, which may be called doubting insanity, or Griibelsucht, to serious reasoning and impulsive insanity. The impulse which one feels when tempted to jump from a height, or te> use some dangerous weapon that may be at hand, is an instance; of an imperative concept of a h>w order. Certain insane acts may lead to the commission of others by patients of this kind with imitative tendene-ies, and this explains the épi- démies of crime which oceasionally occur whenever some particularly dramatic or widely advertised horrible u sensation " has taken plae-e. Under this head we finel the crimes of instinctive criminals whose dis- order is manifested in such as kleptomania, pyromania, and other im- pulsive forms of dérangement, in which the dominant concept produces a physieal impression, etc., which is manifested in the exercise of ex- plosive motor activity, the offense against society possibly being the culmination of months or years of temptation and résistance, and pre- ceding well-developed and conspicuous insanity which has passed the bounds of inhibition. The dominance of the concept is rather constant, and is governed by the patient's surroundings and occupation. To the same extent its influ- ence may be antagonizeel by persistent exercise of wilhpower, by diver- sion and change in the mode of life. Intense concentration in one direction is apt to lead to the morbid exercise of activity and a fréquent 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 behavior. Where it exists there is nearly always inherited weakness, and often a remette history e>f alcoholism or epilepsy. The hvsterical woman is more subject to this INSANITY IN ITS MEDICO-LEGAL BEAE1NGS. 45 form of mental disorder than the maie, as she is in many wavs more subject to ideational activity than the latter. There may be a condition which is almost automatic, the concept being repeated over and over, and quite beyond the control of other inhibitory or restraining influences. So far as its connection with spécial forms of disease is concerned, we find that it is présent, as a rules in the depressed forms of insanity, as well as insanities with limited delusions, paranoïa being an instance. Cases of suicidai and homicidal insanity, where the act is the resuit of so-called morbid impulse, are explained by the présence of dominant imperative1 coimepts. Like delusions, thèse persistent concepts are often concealeel by the patient, who surprises her friends or the community by some unlooked-for act ; and my note-books eontain numerous observa- tions where people bave tbrown themselves from Windows, or attempted suicide in one way or another, not having displayed beforehand any con- spie'iious failure of mental health. Very often the explosion or giving way is folio wed 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 110 moral treatment is suggested. It may be stated that many of the cases of so-called moral insanity are, after ail, nothing but a disorder characterized by imperative and insist- ent concepts. A number of terms bave been applied by writers to the above-men- tioned forms of mental deigeneration, 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. Thèse consist in the fear of opem spaees—agoraphobia; fear of the stars; claustrophobia • fear of e-ontamination; 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, presentmg the stigmata of détective évolution. He was markedly dolichocephalic, his teeth were irregular, his forehead retreating, and his muscular motility impaired. His family history was essentially neurotic. His mother, after a life passée! as an extrême fanatic, ended her days in a lunatic asylum. His father drank immoderately and died in an asylum. One of his brothers was intemperate, and his sister was hystérie and neurasthénie, while one of bis maternai uncles was aise) a drunkard. He had for several years been a prominent figure in the town in which lie lived, and had devoted himself te) 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 teae-hings were bad, and marriage guide-s and books upon domestic medicine played a great part in shaping his home life. In spite of his peculiarities lie is a successful business man, and has saveel enough to live in comfort without helping his 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 indé- cision. There was much hésitation in telling his story, and in answering m v questions he repeated himself frequently. He fully appreciated his mental states and suffered very great agony of mind and want of faith in li i m self. His active mental unsoundness had lasteel for several years, and be-oan bv a graduai fear of défilement from contamination. It was rea- sonable enough at first, and simply followed acts that naturally required subséquent resort to soap and water. But this increased so that lie now 4G A SYSTEM OF LEGAL MEDICINE. washes his hands from thirty to forty times daily, and always does se) after handling money. The impulses that e-onqel him to calculate are sheiwn almost entirely in business matters, although bis habit is now to weigh ail coiu that lie receives or gives out, and this he bas donc for the past twe> years. The question of the honesty of others does not seem to figure largedy in this procédure, for he weigh s the money which he gives to them and counts the bills repeatedly, often foliowing the récipient several times in the day to know whether the amount he' bas paid is correct. He carries seales with him, not daring to trust himself without them, and while admitting the irksomeness of his bondage, suffers in- tensely if he forces himself to place them bevond his reach. In his efforts to esca])e the imperative impulse he often asks bis brothers to take ediarge of his business, and lie has finally been obliged to leave everything in their hands. Some time ago his imperative concepts took another form, which consistée! in the belief that paper, pièces of tin, scraps of iron, on the sidewalk, street, or elsewhere, would do in jury for which lie would be morally, if not legally, responsible if lie did not remove them. Paper upon the road that might frighten horses, serap-tin that might wound them, loose cobblestones, and other objects, lie would constantly gather and put out of harm's way. He was so dominated by lus morbid fears and the possible conséquences of neglect upon his part that lie refusée! to sell nails to his customers without removing the splints, and if the nuts upon the bolts he soie! were loose he would screw them up. lie' would question purchasers as te> the possible harm that might bave occurreel, and upon one occasion, when he went to Long Brandi for his vacation, after an boni* of anxiety and doubt upon the steamboat, he turned back at Sandy Heiok, to remove a banana-skin he had passée! without picking up on the sidewalk in New York. His morbid fears were excitée! by any object which might do harm, matches, combustibles, and sharp tools being induded, and he was finally obligée! to seek new employment, taking charge of the bill-collecting part of the business. There was not in his case anythiiig that might be regareled as a delu- sion. His relations with every one except the liquor-dealers were pleasant. He slept well, as a rule, and suffered from insomnia and disturbed diges- tion only when he underwent a peculiarly distressing period of doubt. AFFECTIONS OF MEMORY. An impairment of memory is an exceedingly common symptom of mental disease. It may consist in feeble receptivity—a condition of wliich implies something more than a failure of attention—which prevents the concept from retaining its place in the brain ; or it is due to a convohi- tional condition where the mental impressions are light or fugacious ; or it may arise from an epileptic condition, with temporary abolition of con- sciousness ; or in a graver form it signais a species of involutional degem- eration which follows or attains the actual destruction of the cells of the cérébral cortex. It is the ail-important symptom in dementia, and most of the disorderly expressions of that condition are directly traceable to mental disorganization. Xot only may a stage be reached where the individual stops storing up the freshly received impressions, but ulti- INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 47 matedy ail the concepts of previous periods are lost. It is distinct from eongenital weakness, which is manifeste'd in amentia, where perceptions are ne ver attended by lasting e'oncepts, the apparatus of réception and ap4>ropriation being undevelemeel. Loss of memory usually begins first in the direction of forgetfulness of substautives and proper names. "This," says James (Psychology, vol. i., p. 0S:i), " seems due to the fact that common qualities and names bave contracted an infinitely greater number of associations in our minds than the names of most of the persons whom we know. Their memory is better organized. Proper names as well organized as those of our family and friends are reeollected as well as those of any other objects. ' Organ- ization' means numerems associations; and the more numerous the asso- eiations, the greater the number of paths of reeall. For the same reason aeljectives, conjunctions, prépositions, and the cardinal verbs, those worels, in short, whieh form the grammatical f rame work of ail our speech, are the very last to decay." As Kussmaul says : " The concreter a cone;eption is, the sooner is its name forgotten. This is because our ideas of persons and things are less strongly bound up with their names than with such abstractions as their business, their circumstances, and their qualities." One of the primary indications of mental impairment is the inability to renew impressions and to recognize then* significances to arrange them and to apply them to e vents and things; and for tins purposes of course, consciousness is essential. There is a form of cérébral activity which consists in the voluntary birth of ideas that force them- selves to the surface without any effort, such a process being often in- stinctive. For the estimation of he>w far the memory is affected in mental dis- ease we must first test the patient's ability to reeall concepts and to fix their importance, to group the ideas and te) apply them to himself, and then détermine his ability to bring forward détails of the past, détermine his p«>wer of time, localization, and perception, and incidentally his idea of spaces With the enfeeblement of memory we find a certain degree of superficial adjustment which the patient uses to adapt himself to his surrounelings, and which is the result of his désire not to appear différent from others. Of course at a later stage this is lost, and the effort te) group and arrange facts leads to incohérence. What might be called the automatism of life is demonstrated in diseases where memory gradu- ally fails; the memory of recalled concepts, lasting Avhen others are for- gotten, showing that weak-mindedness of this eharacter, in its insielious advance, is attended by a certain kind of ability upon the part of the patient to reesill mental landmarks which he has referre d to habitually. Sonietimes this apparent integrity is sufficient to impress unthinking perse »ns. The minor grades of de génération are seen in a familiar disease known as aphasia, which is elescribed elsewhere ; but it is proper for me to refer to the disturbance of automatism, which is manifested in tricks of speech which sometimes are functional disorelers, or, on the other hand, foreshadow mental dissolution, which is not expressed until much later by unmistakable symptoms. Thèse cemsist in the transposition or substitution of syllables, stuttering, hésitation, and phonetic peculiarities, which may or may not betoken the coming of physieal as well as mental breaking down. 48 A SYSTEM OF LEGAL MEDICINE. DISTURBANOES OF VOLITION AND EMOTION. The various affections of will incident to mental disease may be con- sidered as those of an exaggerated or active character and those' of a depressed or passive charactvr. The first comprise those which are expressed as the dictate of an hallu- cination or delusion, or simply as an instinctive or purely impulsive act. or as the resuit of an imperative concept. To this class belenig the peculiar explosions of the epileptie and hystérie and maniac. The vio- lent acts of the former are usually suddèn, attended by apparent un- consciousness, and are not remembered afterwarel. Sometimes the patient while in a precursory attaek runs amuck, stabbing or otherwise assaulting those he may by chance meet. The outbreak is paroxysmal and the assault purposeless. The impulses of the insane' find expression in other ways : in destruc- tiveness, self-mutilation, suicide, inordinate eonsumption of food, the tak- ing of improper things into the stomach, perverted sexual acts, etc. It is no uncommon thing to find women with hysterical insanity or acute mania tearing their clothing or destroying various objects. Some- times the insanity of a patient wliose condition lias not attracted atten- tion is for the first time expressed in an impulse to destroy frail articles, This symptom is most often présent in mania and does not seem to be the resuit of delusion or hallucination, but is clearly an expression of continued and intense excitement. Various lunatics, under the force of dominant concepts, are likely to commit a destructive act of one kind whenever they get an opportunity. What are known as piquers in France are subjeets of this class. Some of them eut and slash the dresses of women, or pour vitriol or corrosive fluids thereon, while othe'rs surreptitiously clip oii the hair of young girls in the streets. This form of imperative concept is likely to go with sexual perversion. The chronic epileptie is quite likely to commit purposeless acts of destructive mischief—setting fire to buildings or willfully destroying property with apparently no object in view. At other times the impulse is to brutally murder some one. When arson is committed it is appar- ently motiveless, although the insane love of lire or a désire for notoriety may instigâte the act. Often the crime is repeated, and in one case that occurs to me the person, who was subsequently apprehended and tried,. was clearly dominated by an imperative concept. Self-mutilation or the mutilation of others is fréquent. In the former case it is sometimes sug- gested by an insane delusion, and the désire to commit a sacrifice may be apparent. Those who suffer from religious delusional insanity not unrarely eut off their right hand or pluck out their eyes as the resuit of a too literal interprétation of a scriptural command. Generally as a re- suit of sexual perversion the insane person will horribly mutilate the boelv of a person he has murdered, or sometimes he will obtain a sexual satisfaction by wounding the genitalia of young women or girls. This is known as sadism, and. was first practiced by the Marquis de Saelcr wliose insane orgies led to his appréhension by the French police. (Vide La Corruption fin de Siècle, Léo Taxtil.) Fantastic and ingeniously contrived suicides are often committed 1 >y the insane, either with delusional suggestion or impulsively. The para- INSANITY IN ITS MEDICO-LEGAL BEAEIXGS. 49 noiac not infrequently infuses into his taking off some élément that brings posthumous notoriety, and a crop of imitators repeat his widely advertised death. Kirchhoff has called attention to the fact that the impulsive suicide of the lunatic must be distinguished from that where lie jumps from the window or into a river to avoid an imaginary danger suggested by his hallucinations or delusions. The suicidai act is some- times wholly inexplicable except by inheritance, there being an apparent blind fatality, and no reeognizable immédiate disturbance of intellect to explain the self-destruction. The write'r bas had a family of this kind under observation for many years, and no less than six sons and daugh- ters bave attempted suicide, or hâve actually sueceeded in destroying themselves, at various times. As a rule the act was committed between the twentieth and thirtieth years, and in no instance was there the least apparent reason or motive. A meirbid propensity not only for the ingestion of large quantifies of food, but of foreign substances as well, symptomatizes an impulsive insanity, which may or not be connected with some perversion of the physioh)gical process which régulâtes the appetite. The tendency of hysterieal women to eat chalk or drink acids, the morbid désire for vari- ous essential oils and aromatic substances, are minor indications of gus- tatory and olfactory perversion e-emnecteel with impulsive acts; but there is an insane longïng for foui and répulsive substances, which is présent in the victims of evolutional as well as acquired insanity, which leads to the devouring of fseces. Another form of disgusting impulse finds vent in the eating of humaii flesh. The abstinence from food is usually the resuit of delusion 01* hallucination, so that in many asylums the necessity for forced feeding arise's, the patient refusing nourishment because he believes he bas been gifted with supernatural powers of endurance, or that lie is offeneling (Joël by eating. In other e-ases where sensorial de- lusions exist the patient refuses food because he déclares his stomach or intestine is tenanted by senne living animal. At times refusai of food depenels upon the fear of poisoning, such a delusion being one of the most fréquent and important of ail. Of course real disorders of the gastro-enteric tract will lead to a loss of appetite'. Sexual impulses of an unusual kind betoken the existence of mental degvneration. As a rule such perversion and loss of control belong to the possessor of the ••insane diathesis," the victini of evolutional insan- ity ; but the gênerai behavior of the sexual pervert need not be conspic- uous. Like the victim of imperative concepts, lie is in other wavs, as a rule, fairly strong intellectually although he may be the possessor of a congénital weakness which means a complète transposai of his normal appetite's and powers. Many individuals entertain sexual longings only for their own sex, and such find a form of gratification which it is not necessary to hère particularize (see Dr. Chaddoek's article). In many large cities the subjects of the contraiy sexual impulse form a class by the'inselves and are recognized by the police. The men bave their balls, where' they dress as women even to the détails of dainty unelerwear. (Fig. 12.) They adopt the names of women, and affect a féminine speech and manner, "falling in love" with each other, and writing amatory and obscène letters. In New York City alone there are not less than one hundred of thèse, who make a profession of maie prostitution, soliciting upon the streets and in parks when they get the opportunity. Physically, 50 A SYSTEM OF LEGAL MEDICINE. many of thèse men whom I bave examined présent the stigmata of de- generative insanity, or else physically approaeh the female types and hypo- and epispadias are common. The female pe'rvert or Lcshian rarely differs from others of lier sex, exeept that the ae-tive agent is gross, wears mannish attire, and cultivâtes masculine' hab- its* Other perverts enjoy sexual pleasure only when themse'lves subjeetcd to phys- ieal pain and dégradation; others dérive enjoyment solely from torturing the objects of their passion; while others alone gain satisfaction in act- ual contact with fétiches such as women's slioes and other articles of wear. In mania hvsteria and other expansive forms of insanity with exag- gerateel sexual activity, self- control is in part eu* totally lost, and we are presented with the conditions of nymph- oniania and satyriasis, as ap- plied to the' female and maie, which leael the patients to in- dulge in reckless exeesses, in- décent and sbameless proposais, and conduct wrhich is a complète de- parture from the normal state. A refined and high-bred woman will make aelvances to car-drivers, porters, or servants—black or white ; while the victini of satyriasis, who perhaps happens to be a elergyman or dignifieel banker, will expose bis person in public or court the notice of the police. False accusations of improper assault are common with thèse people, and often lead to unhappy lawsuits or criminal proceedings. The sexual excitement, it must be remembered, may be only a local prompting and bave no intellectual participation, and each case should be investigated carefully, with a view to the récognition of the person's ordinary mode of life, previous behavior, etc. As a rule there are con- comitant symptoms of insanity. The conversation of young women who suffer from hysterical insan- ity is quite apt to direct 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 duriug the early development of her insanity to catechising a mar- ried sister about copulation and pregnancy, and finally exteneled her in- quiries to the other female and maie members of the household. In this Fig. 12. — Maie Sexual Pervert. * The reader is referred to Krafft-Ebing's Tsuchopatliia Sexual is; TaxtiPs La Cor- ruption Fin de Siècle, and varions French romances, among them Mademoiselle du Mau- pin or Mademoiselle Giraud ma Femme. INSANITY IN ITS MEDICO-LEGAL BEAUIXG S. 51 case, as others, the interest in religious affairs becomes abnormally in- civaseel, ami may or not l)e accompanieel with a sensé of self-depreciation which eventually deepens into a delusion that the "unpardonable sin" bas been committed. Religious excitement and sexual irritation are the fruits of camp-meetings, revivais, and occasieuis when emotional activity is generatcd in e-rowds. It is not difficult to find examples of this ere- tlnsm among the African devotees who prae-tice the Assouia, the der- vishes, and in other times among the' flagellants. The subject of so-called religious insanity is epùte apt to beeome morbid, introspective, seclud- ing herself, mortifying the fiesh; then she becomes exalted, and has hallucinations and delusions of a semi-amorous or erotic nature, believ- ing herself te> be the bride of Christ or the agency of the immaculate conce'ption. Senne diseases are manifested by exaggeration of sexual vigor, and tins is marked in paivtie- dementia, in mania- and e'xcited forms of mental disorder. In cstablisheel involutional disease there is a decay not only of the se'xual appe'tite, but a shamelessness and a weakness of désire which, in senile dementia, manifests itself in indécent cxposure, urination in publie, indécent assaults upon children, and libidinous loquaciousness. Impaired or suspended volition charactcrizes conditions which may vary from ordinary feebleness to those which dénote 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, anel he does not realize the nature of his act unless attention is artificially directed. IIe>w far the ego and automatic sensé 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 persou commit a crime. The several indefinite conditions of semi-consciousness which consti- tute somnambulism, sleep-drunkenness, and dreaming, ail imply a partial inhibition of self-cognizane'e and ideation; and the diminished exercise of volition is the resuit of some automatic process or outside stimulation of subcortical fune'tion. The insane are apt to display an atonie indis- position. Tins ne>t only e*haracterize's the apathetic and stuporous vari- etie's of melancholia, but is a feature of quiet dementia. Fixed positions are adopted. muscular moveinent is slow and rarely made without sug- gestion, imnieibility is the rule, and at finies the muscular condition is one of a cataleptic character. Thei'e need not be the rigidity attended by amesthesia and loss of consciousness, characteristic of catalepsy proper, but in connee'tion with great intellectual torpor there is a dispeisition feu* the legs ov anus to remain in whatever position they may be placed. Récurrent attaeks of this condition e'haracterize a form of insanity known as lutatonia, in which a primary melancholia is folio wed by an excite'd delusional condition, with verbigeration, secondary inaction, and museuilar rigidity, and termination in dementia. The chronic insane are' sometimes exceedingly indiffèrent to external irritations or influences, especially when a condition of dementia has been re'ae-heel. This is due not only to the mental torpor, but to an actual amesthesia. Burns, the contact of irritating substances, 01* the bites of insocts, prove>ke 110 impression and 110 attempt at renmval. This in- différence imlicafe'S a suspension 01* impairment of consciousness which 52 A SYSTEM OF LEGAL MEDICIXE. is usually of slow duration, and divorces the' patient from the rest of the world. He is unable to weigh and separate' his concepts, or to estnnate and regulate their importance' or assoe.'iation. They cannot be volunta- rily summoned, and eventually it is impossible to cex'irdinate internai im- pre'ssions. Self is no longer recognized, and in the confusional condition a double personality may perhaps develop. DEFINITION AND CLASSIFICATION. The disorganization which results in the inharmonious opération of mental function must be considered as a graduai and intricate' disturb- ance of psyehie coordination. The comparatively ordeirly balancing and expression of feeling and thought that belong to sanity suffer a change, in which the conduct of the individual indie-ates a departure from a pre- viously existing normal standard. His new behavior places him at once in antagonism to the cemventions of the intelligent majority of his fellows. Sometimes he never reaches a point of ordinary mental integrity —he is the product of neurotic stock, the degenerate représentative of faulty reproduction. Under some circumstances lie is the weak-inindeel one—is the inventor "with a bec in his bonnet"—the "ne'er-do-well''— the "crank''—the reformer who suggests great issues and when pos- sesseel of misplaced power persécutes for trifles, always mingling with his work his own désire for notoriety. Should he pass through childhood possessing ordinary power, he may at puberty be subjeo.ted to the strain of d(welopment and go under, falling into the ranks of the incurably insane. Others of poor fiber are confrontée! at subséquent life epochs which they do not pass through safely, eleveloping evolutional and in- veilutional insanities. Some individuals whose weakness takes the form of moral degeneration may manifest sue-h slight intellectual al)erration, and be so much like ordinary depraved people, as to brin g them within the pale of the law, which is at times indisposée! to make allowance for theàr doubtful indications of insanity. To this class belong the mattoids described by Lombroso, whose unbalancing is a mixture of cleverness and dullness, and thèse are the eccentries, in whom the gap between sanity and insanity is a mère crack. Insanity is then usually a profound altération ; certainly it is not, as we are sometimes induced to believe, a condition that may originale in a day or two, exist for a few hours, and disappear as quickly, although occasionally an explosion which means a lapse of responsibility for a short time may occur in the course of an imperfectly recognized psychosis, which laymeu are apt to disregard. DEFINITION. It is an exceedingly difficult matter to give a perfectly satisfactory définition of insanity, or one that will meet the requirements of the law. In another place tins matter will be gone into ; it is sufficient hère for me to point out the radical différence 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 lias hitherto been gnided by the hard décisions of another day, when a lunatic was IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 53 considered as "a wild animal," and only excused for the commission of crime when he knew the abstraet différence between right and wrong. His standard of civil responsibility was only a slight grade higher. In a, ree-ent English case (Regina vs. Jhincan) an American expert* who ad- vance-el the rational theory of will enfeeblement effected a révolution in the légal practice of at least one part of Créât Britain; and only a few years ago the writer made in a New York court the distinction between the abstraet knowledge of right and wrong and the applied knowledge, which meant the internai power of discrimination, (l'eojtle vs. Liebluch- ner.) The médical idea is the outgrowth of actual familiarity and study of the' insane, which cannot be gained in any either way, and the conclu- sions that are drawn for the défense of the weak 01* eriïng are as firm as those of the clinician who estimâtes the significance of cough or rise of température in diseases the pathoh)gical nature of which is undisputed. There is, unfortunately, a group of lawyers and physicians (I am happy to say, of limitée! size) which advocates capital punishment for ail insane murderers—a proposition which can only be tolerated by those whose ideas of évolution and the survival of the fittest dwarf ail interest in humanity. Small wonder is it that the e'stimate of what constitutes insanity whie'h is held by many pe'ople is still unsettled—many technical write'rs even do not attempt to elefine it. Bucknill elefines insanity as "a disease of the brain (idiopathic or sympathetic), affecting the integrity of the mind, whether marked by intellectual en* emotional elisorde'r." Maudsley's définition is as follows : " Insanity is, in fact, disorder of brain, producing disorder of mine!; or, to elefine its nature in greater détail, it is a disorder of the' suprême nerve e-enters of the brain—the spécial organs of mind—producing de-rangement of thought, feeling, and aetion, together or separately, of such degree or kind as to incapacitate the individual for the relations of life. Mind may be defined physio- logically as a gênerai term denoting the sum total of those functions of the brain which are known as thought, feeling, and will. By disorder of the mind is meant dise>rder of thèse functions." It will be seen that Bucknill insists upon actual disease of the brain, while Maudsley rather leans to the view that the mind as a function is disordered, he makes the distinction, however, calling attention to the fact that numerous dis- eases of the brain are mit attentée! by insanity, but are attended by mental changes. Spitzka (Insanity: Its Classification, Diagnosis, and Treatment, New York, 18S3) formulâtes a définition that is an excellent though cum- bersemie one, but its length is justified by the merit of its comprehen- siveness: "Insanity is either the inability of the individual to correetly regïster and reproduce impressions (and conceptions based on thèse) in sufficient number and intensity to serve as guides to actions in harmony with the individual's âge, circumstances, and surroundings, and to limit himself to the registration as subjective realities of impressions trans- mitteel by the peripheral organs of sensation ; or the failure to properly eoordinate such impressions and to thereon frame logical conclusions and actiems; thèse inabilities and failures being in every instance considered as excluding the ordinary influences of sleep, trance, somnambulism, the common manifestations of the gênerai neuroses, such as epilepsy, hys- * Dr. Walter Kempster. 51 A SYSTEM OF LEGAL MEDIC1XE. teria, and e-lmrea of fébrile delirium, coma, acute' intoxications, intense mental préoccupation, and the ordinary immédiate effects of nervous shock and in jury." I bave for senne years adve>cated the use of a définition which, though inferior to others in fullm'ss e)f description, is e-onvenient be-cause it does not so directly draw the médical witness into a wrangh' with the e-ross- examining counsel. It is as tolhiws: "Insanity is a- condition due to diseuse of the brain, and ewpressed by impairment of feeling, thought, and volition." Such a condition must not be confused with the acute toxaunia of fevers, drugs, or other agents of the kind. I make this qualification because themgh akindof temporary aberratieui may resuit from alcohol,for instance, no one would think of applying the terni insanity tu a state that so directly implies cause and effect. Of course actual insanity commonly follows the protractcd use of aleohol and other agents of the kind, and after fevers or septic diseases we find prolongée! mental disease directly traceable to a défini te and adeepiate cause1. Dr." Ray adoptée! the use of the' qualifying word " prolonged," because '•there are many conditions in whie-h there are temporary departures from the normal standard of thinking, feeling, and acting, which are not called insanily," and in this I agrée with him ; but it is difficult some- times to fix the durâtiem of many conditions which produce temporary mental disturbance, or te) say when insanity really begins. The définition of insanity is, after ail, the province of the court, and by this is meant the légal définition which détermines the question at issue. It is the simple eluty of the médical witness to présent the facts of the case' in such a way as to make the dee-isiem of the court possible, and to enabh' the latter to arrive at a conclusion which will be pe)ssible under law. It is not even the jury's duty to décide the question of law ; in fact, they are not permitted to elo so ; they beàng incompete-nt so far as the affixing of précédents en* the détermination of definite rules is con- cerned. (Wharton and Stillé, vol. i., p. 114.) CLASSIFICATION. The changes incident to unsettled opinion and study stand in the way of makiug a classification which is entirely satisfactory or always faithful. In the early part of the century there was much confusion, although a very limited number of ternis were used ; and this disordered and imperfect understanding of the subject existed until about fifty years ago, when the school of alienists which included the late Forbes Winslow, Greisinger, Falret, and a few others, seriously attempted to bring order out of chaos, and to systematize the nosology of mental dis- ease. At this times and even until comparatively reeently, the conven- tional divisions of insanity were only four or five in number, and for the most part included idiocy, imbecility, mania, melancholia, and dementia. The varying anel relational expressiems of the excited or depressed states were not unelerstood, especially when they appeared alternately, and little or no atteuition was paie! to the mental expressions of coarse disease of the brain, ail such conditions being looked upon as " softening." The other school, while recognizing the existence of the forms of insanity just alluded to, still paid much attention and gave great weight to so-called iySANITY IN ITS MEDICO-LEGAL LEASINGS. 55 "moral insanity," which many of them believed could exist without any intellectual disturbance whatever. In the ranks of the latter belonged Ray and afterward Maudsley, but it was not until about a quarter of a century âge) that a greater advance was made, which had its birth in German y and has resulted in a very comprehensive and rational method of classification and study, its strongest exponents being Krafft-Ebing, Scbiile, Emminghaus Kirchhoff, and others. The basis of the German classification resteel upon the considération of the degenerative type. Much of the confusion that resulted from the descriptions of différent authorities has depended upon the coining of ternis, and from a degree of inexactness which has arisen from attempts to classify either from the somatic or epochal standpoint. In the various classifications the subject is approached from a num- ber of directions. The majority are based upon the clinical aspects of the disease, and the symptom-manifestations are alone regarded ; others incline to the adoption of terms relating to the epochs of life, e.g., ado- lescent and pubesceut insanities, the insanity of pregnancy, of lactation, etc., climacteric and senile insanities; other alienists give prominence to the somatic nature of the insanity or the etiological factors, Van der Kolk, Morel, Skae, Tuke, Clouston, and various English writers strongly ad- vocating and generally using such limited ternis—as examples may be mentioned n/asturbafic, ovarian, phthisiced, syphilitic, rheumatic, puerpéral insanities, etc. While the use of thèse terms is convenient and almost gênerai, it is sometimes open to confusion which is often to be deplored but not always avoidable. As has been said, the German school has made the greatest progress in the systematic and advanced study of psychopathol- ogy, Krafft-Ebing especially having recognized the importance of the underlying condition of heredity. He and his followers hâve rather con- sidérée! the matter with référence to whether there was a congénital influence, i.e., whether the insanity appeared in connection with an un- developed brain, or whether the insanity was an acquired one, the brain being of average development ; and incidentally whether it was curable or incurable. This seems a most rational and scientific theory. He classifies insanities as follows : A. Mental Diseases of the Developed Brain. I. Psychoxeuroses. 1. Primary curable conditions. a. Melancholia. j ^iS. , ^r . ( Exaltation. b. Mania, j Frenzy> c. Stupor or curable dementia. d. Wahnsin. 2. Secondary incurable states. a. Secondary monomonia. (Sccundàre Vcrrucktheit.) b. Terminal dementia. j ^ttetica. 56 A SYSTEM OF LEGAL MEDICINE. IL Psychical Degenerative States. a. Constitutional affective insanity. (Folie Eaisonante.) b. Moral insanity. c. Primary monomania. (Frimdre Vcm'icktheit.) Perseeutory, gran- diose, erotic, religious. d. With imperative conceptions. c. Insanities which are developed S jivsterical from constitutional neuroses. } Hypochondriacal. /. Periodical insanities. m. Cérébral Diseases, with Conspicuous Mental Symptoms. a. Paretic dementia. b. Lues cerebralis. c. Chronic alcoholism. d. Senile dementia. e. Acute delirium. B. Conditions op Mental Weaknesses with Arrested Development of the Cerebrum. a. Idiocy. b. Cretinism. This classification, which is practically that of Spitzka and Kirchhoff, as well as other psychiatrists who hâve recently written, has at least the merit of considering mental disease chiefly with référence to its expres- sion and form, while the question of cause, which is very often apt to create confusion, is left unmentioned. The writer has for some time been impressed with the possibility and convenience of classifying insanity with référence to development, believ- ing it possible to avoid the faults of various disputed schemes. With this object in view, bearing in mind the question of normal brain de- velopment, he has divided ail insanities into three classes : (1) those of évolution; (2) those oe'eurring in connection with normal development; (3) those of involution. The first group comprises insanities or conditions of mental weakness incident to the period when the brain has not reached its full develop- ment. Perhaps it lias suffered arrest ; perhaps a tax incident to a life- epoch which it cannot bear. This should include idiocy, imbecility— which comprises the forms of degenerative disease described by the Ger- man school, the primure Verriicldheit—the adolescent, circular, epileptie, hysterical insanities, etc. The second group includes those forms of mental disease which are quite likely to appear under ordinary circum- stances, disconnected with any hereditary etiological factor, the develop- ment of mind being unquestioned—the simple states of dépression and exaltation, the somatic disorders, whether caused by traumatism or gên- erai or spécial diseases; and the third those forms of mental disease where there is dissolution and a retrogression to amentia. Thèse three forms may for convenience be thus grouped : I. Evolutional Insanities. (Hereditary.) Idiocy; cretinism. Insanities with limited delusions. Insanities with prédominant moral weakness. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 57 Periodical and alternating insanities. Insanities with imperative concepts. Epileptie, hysterical, and periodical alcoholic insanities. Infantile paretic dementia of Clouston. Adolescent insanity—acute dementia of youth. IL Insanities of Normal Development. (Acquired.) Mania. ) Acute. Melancholia. i Chronic. Traumatic, toxic, and somatic insanities. III. Involutional Insanities. (Eetrogressive.) Terminal dementia. Consécutive dementia. Senile dementia. Paretic dementia. Maudsley's classification is as follows : I. Affective or Pathetic Insanity. 1. Maniacal perversion of the affective life. \ Man7ia sine x ( aelino. 2. Melancholia dépression without delusion. < -^^ \ y 3. Moral aliénation proper approaching this, but not reaching the degree of positive insanity in the insane tempérament. II. Ideational Insanity. 1. General. a. Mania. b. Melancholia. \ £®ute: ( Chronic. 2. Partial. a. Monomania. b. Melancholia. 3. Dementia. \ f"™^- ( becondary. 4. General paralysis. 5. Imbecility. This is open to the objection that so-called moral insanity is isolated and that so-called partial insanity is distinguished. As Wharton says, 11 The affective life is made independent of the mind, capable of being dis- eased when the mind is undiseased." The Causes of Insanity. Hereditary influence is undoubtedly the greatest factor in the pro- duction of insanity, at least forty percentum of ail cases being traceable to such taint, and some writers make a still greater claim. Clouston (Xeuroses of Development, p. 130), who is a close observer and conservative authority, says : '• There are two very gênerai laws or tendencies that prevail in différent families as to the neuroses. In one case nature tends to revert back to the normal and healthy type, and disease gets less in ÔS A SYSTEM OF LEGAL MEDICINE. intensity in différent générations, till it disappe'ars ; in others it gets aecentuated in each suce-essive génération—nervous instability or neural- gia or headaches in parents becoming hyste-ria and e'hore-a and asthnia in the children, epihq)sy in the graneh-hildren, melancholia in the great- grandchildren, and adolese-ent insanity, with its dementia or idioey, and extinction, in the next génération." So far as the rules which ^govern transmission are concerned we eannot speak with much positiveness. The transmission of the tendency is from maie to maie and female to female, though this rule bas its'exceptions. Actual insanity may not reappear in the progeny, but as se)ine other peculiarity. Of course if there be insanity on both sales the danger is greater than if on one only; and the existence of acquired insanity is h>ss potent in its evil effects than when the strain is a saturateel one. In courts of law, when dis- puted cpiestiems arise, it will make a great différence if the origin of the insanity of the parent is proved to hâve been at a period after the birth of the child. We must also remember that the inheritance of mental unsoundness oecurs, as Kirchhoff points out, first, in the majority of in- stances as variable symptom-complexes, such as inebriety, moral perver- sion, criminal impulses, their relations and transition being irregular ; second, a group which comprises the identieal form of insanity which existed in the progenitor, hereditary suicide being an example. Men of genius are apt to bave insane or feeble-minded ediildren, as are consumptives and inebriates. Historical instances of this are mimer- ons, and we either find criminality or the évidence of weak-mindedness. Scipio Afrie'anus, Petrarch, Mozart, Peter the Great, Tacitus, Mercadante, Thomas Campbell, Donizetti, Yolta, and Victor Hugo, ail had sons or daughters who were insane. The influence of drunkenness upon imprég- nation is generally admitted, and the writer can trace in more than one large family the mental weakness of certain children to the bad habits of the father during their procréation. The question is often asked, How soon after cure can persons who bave been insane run the risk of having children who are not liable to inherit the taint ! I think the answer can be, At no finie* after the existence of well-defined insanity which is not of a toxic or traumatic nature can the danger of hered- itary taint be saiel to be absolutely averted by treatment. This is said with the fact in mind that occasions do happen when the individual between attacks of insanity may produce children who are apparently vigorous both physically and mentally. Fleming and D émaux adduce statistics to incontestably prove that "even habitually sober parents who at the moment of conception are in a temporary state of drunkenness beget children who are epileptie or paralytic, idiotie or insane, very often microcephalic or with remarkable weakness of mind, which at the first favorable occasion is transformed into insanity. Thus a single em- brace, given in a moment of drunkenness, may be fatal to an entire génération." (Lombroso.) Lucas (Be l'Hérédité) refers to the fact that ail the descendants of a great soldier—a Hamburg noble—became insane at forty ; and Lom- broso speaks of a watchmaker who, having ree-overed from an attack of insanity, caused by the Révolution of 17S9, finally poisoned himself; later on his daughter became insane and fell into a state of dementia; one of his brothers stuck a knife into his own abdomen ; another became a drunkard and died from starvation ; his sister, who was of poor health, INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 59 had a son who was an epileptie lunatic, a daughter who became insane after her confinement and rejected food, an infant who refused to be sue-kleel, and two others who died of cérébral diseases. Berti has col- lected the records of one family, and during four générations there were eighty individuals descended from an insane melancholiae;, ten subject te> insanity (nearly always melancholia), nineteen who were neurotic, three who had spécial ability, and three with criminal tenelencies. The disorder was aggravated in the later générations and developed at an earlier âge. In the third and fourth branches the insane and neurotic appe-ared in every génération ; in the others the hereditaiy influence passed over one génération in the men and two in the women. So far as the heredity of the criminal instinct is concerned, there are numerous recorded examples where the progeny of illustrious men hâve gone to the bad or hâve shown a weak moral nature clearly due to dis- ease. It is a matter of easy ree'ognition that not only do habituai or in- stinctive criminals présent the stigmata of degvimration, but often be- come violently insane. The environment of the individual has much to do with the develop- ment of mental disease : thus we find that those in America who live in retired country places, with little chance for diversion or intellectual stimulation, more reaelily bee'ome insane than the inhabitants of great cities ; and this condition of affairs has its parallel in solitary prison con- finement, where absolute silence is impe)seel, and hallucinatory insanity develops. Rational eelue-ation prevents insanity or tends to regulate the disordered mind, while of course injudicious and tactless eare increases the weakness which tends to demoralization. This applies to the forcing of weak minds, punishment, and a neglect of the physieal neeels. Appli- cation and System operate against the develemment of insanity, and a sig- nificant proof of this is that busy merchants and students often undergo a mental break-down when they relinquish their active work and lose mental stimulation. According te) Kirchhoff, brain-workers are espe- cially endangered. This statement will bave to be takem with modifi- cations, and the writer is of the opinion that brain-work only of a dis- orderly or excessive character is that which is injurious. Under such eircumstances there is an implied irregularity, an excessive use of the émotions, and an eratput of force that brings exhaustion. Preelisposing diseases and bad habits of course bave much to do with the genesis of ail forms of mental disease, and thèse may be enumerateel as syi>hilis, the opium, cocaine, and the chloral habits, alcoholism, and dissipation generally. The e)ther causes of insanity may be divided into the direct physieal and the i indirect phi/sical and emotional causes. (Burr, Psychology and Mental Disease, Détroit, 1S94*) The former include in jury and its results, bodily disease—such as eane-er, pulmonary affections, Bright's disease, cardiac disease, rheuma- tism, utérine and ovarian disease, hemorrhoidal 01* other losses of blood —métairie and bisulphide-of-carbon poisoning, and sexual excitement, the * Burr estimâtes the frequency of cause as follows : Direct physieal, about 36 percent. Indirect pliysieal and emotional, about 14 percent. Vicions habits, about 2."> percent. Constitutional and evolutional causes, about 25 percent. 60 A SYSTEM OF LEGAL MEDICINE. effects of child-bearing (puerpéral insanity) and prolonged nursing (lacta- tional insanity). The resulting pathologie'al condition is one of exhaus- tion through shock, inflammation or depletion through drainage, poison- ing of the nervous substance, or various altérations in the integrity of centripetal sensory conduction. The somatic forms of insanity are not often rece>gnized by persons who are not careful, the mental disturbane-e overshadowing the' other organic disturbance. Phthisis sometimes produe-es in its last stages a dérangement attended by alternating depressiem and exaltation, in which delusions of a grandiose eharaeter are expressed. Asthma is sometimes likely to give rise to melancholia, but wliedher this is the resuit of the détective aération of the blood or the action of the remote hereditary predisposing cause that is usually behind the asthma itself it is difficult to say. La grippe, which in large measure may be said to be a disease of the respiratory organs, has playe'd a part of no small importance in the genesis not only of an ae-ute confusional insanity, but of occasioning a permanent delusiemal insanity. Cardiac lésions are at best only associated conditions, and are not important etiological facte>rs. In cérébral hyperaemia of the passive variety we are apt to hâve dépression, and the hypertrophy of the right ventricle with which it is often associated may possibly be regarded as a causative dément. •• It is a fact that patients suffering from ear- diac lésions are more likely to develop anxious and suspicious delusions than those of an opposite nature." (Spitzka.) Circulatory disorders, sue-h as exe>phthalmic goiter, which is most common in women, are atteneled by attacks of dépression often approaching simple melancholia in elegre-e. The fact should not be lost sight of that in secondary dementias due to cérébral thrombosis or embolism, the heart will probably show some évi- dence of disease. Rheumatism is an uncommon cause. Its pathological resuit is usually an irritation or actual inflammation of the cérébral méninges, with press- ure symptoms, a rise in température, headache, a confusional condition often aj)proaching delirium, which is less vie dent during the day. The prognosis is good, though dementia sometimes supervenes. Brighfs disease is an occasional cause of insanity. Utérine and ovarian diseases are, I am convineed, not nearly so impor- tant causes of insanity as is generally supposed. Especially is this the case when the utérus is displaced. It is true that in feeble-minded women the utérus is often found undeveloped, as are other organs ; and although many opérations of the most diverse eharaeter hâve been per- formed upon insane women, I do not believe the results are ever as satis- factory as might be inferred from the enthusiasm and reports of the operators. Personal expérience which has been recorded elsewhere per- mits me to speak authoritatively in regard to at least one gynecologieal procédure, that of oophorectomy. Pelvic disease attended by profuse hemorrhage is often, however, a cause of insanity, notably of the de- pressed form, and I hâve witnessed repeated cures when the loss was arrested and the drain stopped. Local excitement which is due to a variety of causes, such as mastur- bation or the irritation of vaginal discharges, is apt to resuit in a moral disturbance, introspective insanity, and hysteroid disorders under fitting circumstances. So far as the psychoses which dépend upon pregnancy [Xs.LV/7T IN ITS MEDICO-LEGAL BEAEIXGS. 61 anel delivery are concerned, there is much to be learned about their pathogeuiy. The gênerai disturbance of the sympathetic System during the nine months before delivery is in senne women a serions one, and the fax upon the vital powers is very great, se) that in women with a pre-elisposition te) mental tremble there often oe-e-urs a form of aberration of variable degree and continuanee. This is due sometimes to uraemia or othe'r forms of blood-poisoniug, to variations in the blood-pressure, and to moral causes. Illegitiniate pregnancy is, for the last reason, par- ticularly apt te) be attended by insanity. The insanities of a puerpéral nature', like those incident to prolonged lactation, are due either to septic poisoning, depletion after hemorrhage, or exhaustion. Climacteric in- sanity is due to the profound process which indicates the cemimencement of involution. This epoch pla3's the part, sometimes, of changing existing neuroses, transforming migraine into epiïepsy or epilepsy into insanity. Excessive sexual excitement is likely to enfeeble the central nervous System to an extent which leads to the production of mental impairment, though as a rule nature régulâtes eapaeity, and sexual appetite is sateel by exhaustion of the spinal centers and fatigue of the normal ideational cente'rs. Of course with unnatural abuses which are suggested by a cen- tral condition of existing mental disoreler, the individual may goad his wearied sexual apparatus. Those who resort to false means of gratifica- tiem not unrarely behuig to the class of moral perverts, and their vicious appetite is the product of a diseased imagination. In established insan- ity, especially dementia, the act of masturbation is the direct resuit of the insanity. Emotional causes, such as grief, shock, or fright, are alleged to bave much to do with the genesis of mental disease. Thèse influences, I think, are often exaggerated, the effect necessary to unbalance the mind depending upon the existemce of hereditary influence, or a previously exhausted nervous svstem which is due to brooding, insomnia, and irregularities. Kirclihoff looks upon psychie-al influences as important, espee'ially those which are concealed. " Constant gnawing fears, without actual material losses, may lead to the mental break-down. We always find two factors in thèse causes, viz., the repeated and constant occur- rence, and the painful dément of feeling. Both together prevent the inhibitory couuter-effects of other ideas." Overwork, anxiety without the prospect of affairs getting better, thwarted ambition, and fadure, ail under certain circumstances ae*t as causes. Disappointment in love and marital discord hâve, I believe, little to do with insanity, nor has re- ligious concentration, unless there is a degenerative basis. The feigning of insanity undoubtedly results, in some cases, in the establishment of a real psychosis. I know of two such cases, and there can be no doubt of its easy production in neurotic individuals who are long ine'are'crated, a laboriems effort at déception being maele which implies morbid concentration. The usually curable insanities due to fébrile disease are undoubtedly explained by microbic infection or exhaustion. The mental disorder ordinarilv follenvs the fébrile condition, and is characterized by a con- fuscel train of hallucinations, illusions, and delusions, with moments of apparent lucidity. Suicide is not uncommon. Injuries to the brain are apt to develop or cause insanities of a more or less constant and progressive nature, though sometimes a blow upon the 62 A SYSTEM OF LEGAL MEDICINE. head will modify or cure an existing insanity. Affections of the memory from shock are common and e>f sudden or rapid origin, or an inflam- matory e'ondition may be inaugurateel which is expresseel by the live- liest synqttoms, such as illusions, delusions, anel violence, which lead to outrageons assaults. A blow may effect, sennetinies, a complète transfor- mation in the individual, turning a peaceable, high-minded, honorable man into a lying, brutal thief. Intracranial disease, the most important etiologically being menin- gitis, not only effects a blight in development, but gives rise to varions psychoses, such as imbecility, epilepsy, hysterical insanity, delusional conditions, and Loss of memory, with ultimate dementia. The cutting off of the blood-supply, for example, through an occlusion of one of the middle cérébral arteries, is apt to lead to softening of a considérable cortical area, with dementia as a conséquence. The Course and Termination of Insanity. The course of insanity is nearly always downward and the proportion of real cures comparatively small. Statistics are apt to give false im- pressions, as they usually do, and the temptation to make good records has occasionally led the chronicler to amplify the list of recoveries. Earle (Curability of the Insane) cites the instance of one woman who was reportée! as eu red twenty-two times in twelve successive months, although the fact probably was that she had twenty-two paroxysms of mania during tins time. This careful observer collated the statistics of twenty American asylums and found the percentage of recoveries for five years to be 29.9, which is a much smaller number than it was during either of two periods of five years that preceded ; showing that there was a better System of reporting, or that the means of cure and treatment are more imperfect than in the past, which is improbable, or, what is more likely, that a mistake had been made. He appends another table, which includes the statistics for one y ear relative te> the insane in 58 American asylums: of 14,372, 27.88 percent, recovered, and 20.74 percent, died. The prognosis of insanby as a rule, therefore, is not good, and the outlook becomes more unfavorable as the time of improvement is prolonged. Blandford (Insanity and its Treatment, 3d éd., 188G, p. 249) présents a table showing the history of 244 insane persons who died at or after discharge from the York Retreat from 1796 to 1840, with the number who died during or after recovery from the first or subséquent attacks of mental disease : Recovered from the First Attack. Died Insane Recovery Per- Had Subséquent Attack. Cases followed through Life. during the Total. manent. First Attack. Lied Sane. Lied Sane. Lied Insane. Total. Maies ............ 113 55 58 21 6 31 37 Females.......... 131 58 73 24 14 35 49 Total........... 244 113 131 45 20 66 86 Thèse cases were well watched and recorded, and the déductions to be drawn are like those of Earle—neither favorable nor encouraging. The insane die most often from exhaustion. Sometimes the acute INSANITY IN ITS MEDICO-LEGAL EEAEINGS. 63 stage is fatal in a week or two after complète insomnia and refusai of food, although in most cases hypnotics and artificial feeding will keep many of tliese cases alive. Heart failure is, however, sometimes induced, espee-ially in cases wliose real condition has not been appreciated, and who bave been kept at home and permitted to exhaust themselves. Sometimes malpractice upon the part of an ignorant physician or nurse will resuit in the death of a patient from careless feeding. I was called to see a case where the liquid nourishment had been forced through a soft cathéter into the trachea, the patient being unconscious at the time. A resulting mechanically produced pneumonia proveel fatal in a few days. Death from exhaustion in acute case-s may be prolonged after a graduai and unpreventable waste of energy, and such an ending sometimes oc- curs in aenite mania, the brain after eieath presenting great hyperœmia or sometimes no gre>ss change whatever. Rapid exhaustion, with the de- velopment of unsystematized delusions and hallucinations, is a grave indication. Chronic cases show great vitality, occasionally physieal improvement, and a great accumulation of fat occurring after a time without any mental improvement. In fact this condition of affairs is always un- favorable. Acts of extravagance, so-called impulses of an immoral charae-ter, and sexual abuses in a patient with an insane family history are bad signs. Insanities expressed by ])eriodical attacks hâve a bad pre>gne>sis. Even though the interval of lucielitv may be marked it is unsafe after two attae'ks of mental aberration te> make favorable prédictions. Other exae-e-rbations are probable, and a termination at some later time in dementia is to be looked for, the intervais usually growing shorter in such cases. If the recover}^ from an attack of mental de'rangement be very rapid the indications are that there will be a récurrence. Curable cases of any kind as a rule présent a graduai elisappearance of symptoms ; the patient showing his favorable progress by anticipating the future, making plans, and analyzing his old elelusions after explaining them satisfaetorily. The gênerai physieal condition of the patient improves ; his skin becomes moist; sleep returns; and should the patient be a woman, sometimes the menstrual flow is reëstablished. One writer calls attention to the return of former ailments as a coïncident indication of commencing recovery. However, a cunning lunatic, seeing in what man- ner his false ideas impress others whose favor he seeks to obtain, will conceal and disguise his real delusions as far as lie can. This often oc- curs in connection with the désire for liberty. Sometimes he cannot thus dissemble, disedosing another delusion at the same time that he strives to control the one that lias gotten him into trouble. He may eleny his delu- sions to one person, but express them to others, or he may verbally dis- daim any mental infirmity or false belief while he still shows it in his manner anel dress, or in his unconscious actions. A fixed delusion may le'ad to exhaustion and starvation through refusai of food. The case of a patient oceuirs to the writer whose delusions were of a religious ediar- ae'ter. He would not ride on Sunday even to chureh, and displayeel a morbid eonscientiousness of an extrême kind. As his symptoms grew worse and insomnia could not be overcome by ordinary means he was sent to an asylum, where bis condition did not mend. He still mani- festée! a fear that he might do something to shock the Almightv, and 64 A SYSTEM OF LEGAL MEDICINE. absolutely refused to sit down. He stood so constantly that his fcet and ankles became œdematous and lie grew more and more weak, as coupled with this was a refusai to take food. It was finally found nec- essary to strap him in bed, but despite artiflcial feeding and enforced rest he failed 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 olfactive. In verbigeration or confused speech, the compoundhig of words attests an involved dissolution. Many forms of chronic insanity are characterized by periods of remission. Récurrent insanity, or folie circulaire, is one of such. In the intervais the patients are apparently se) much themse'lves that they are treated as sane persons. Paretic dementia, or gênerai 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 ami ending. This is true of the destruction of the e-ortex which belongs to paretic dementia, a disease of remarkably rapiel progress. With extrême exhaustion due to a continued light graele of exoitement we are apt to hâve an œdema of the brain, with collapse. Tins is par- ticularly true of anaemie cases. The prognosis of insanities due' to epilepsy, meningitis, sunstre>ke', in jury, and syphilis is bad ; and when lésions exist and produce progressive paralysis, convulsions, obstinate disorders of motility or ocular disease, we can ne ver take a favorable view of the patient's condition. The progressive appearance of symptoms in chddhood or advanced âge is bad. In the latter case an early fatal termination is to be feared, as the powers of résistance are feeble. The insanities of e'hildhood are usually due to hereditary influences ; and though the psychoses of puberty when acquired are favorable, the reverse is true where the insane dia- thesis exists. It is held that •• there is a différence, as regards prognosis, between hereditary psychoses whose outbreak is due to late accidentai causes, and those in which heredity lias produced a morbid development of eharaeter 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 greater prédisposition to relapses." (Kirchhoff.) The following table is presented, which is based upon the observations of Krafft-Ebing, Schiile, Spitzka, Kirchhoff, Clouston, Blandford, Savage, Stearns, and my own expérience, which indicates the gravity of symp- toms alone or associated : Unfarorablc Indications. Favorable or not absolutely Bad Indications. States characterized by slowly developing Eapidly developing unconsciousness, ex- loss of consciousness, indifférence, or cept in repeated attacks like epilepsy. hébétude, with staring. Loss of facial expression ; organic flatten- Return of harmonious play of facial mus- ing or change in shape of features. clés ; quick réflexes of emotional states. Moral indifférence ; degeneration shown Self-défilement in puerpéral condition or by impulsive criminal or destructive acute mania not necessarily bad ; incon- acts, including filthy practices, self- tinence in acute conditions compatible défilement ; protracted indifférence, with with recovery. involuntary discharges of contents of bladder and rectum. Protracted sexual excitement; manifest- INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 65 Unfavorable Indien fions. ation of sexual excitement or perver- sion in extrême youth or old âge. Loss of sleep, with exhaustion. Motiveless acts subsequently justified by patient. Imperative concepts of long duration and their results. Periodical attacks. ■Continued dépression and absorption, with picking of fingers and mucous membrane. Limited delusions constantly expressed. Tendoncy to homicide or suicide, with continued dépression. Auditory hallucinations. Unequal contraction or minute symmet- rical contraction of pupils. Verbigeration. Chrome alcoholism or coarse cérébral dis- ease. Congénital or other stigmata. Cutaneous ami'sthesia ; tremor, with paralj'sis ; ocular symptoms ; optic ncuritis ; absent or greatly increased tendinous réflexes. Catalepsy, with verbigeration. Constant drooling of saliva, with charac- teristic posture. Involuntary discharges as resuit of indif- erence, as in dementia. Favorable or not absolutely Bad Indications. Increase of weight, with corresponding mental broadening. Unconscious acts of violence in acute mania as resuit of transient delusion. Rapidly developing mania, with sudden change to dépression. Simple dépression, without fixation of ideas ; excitement ; irregularity. Confusional insanity. Visual hallucinations. An existing bodily condition such as anse- mia or a fébrile disease to account for the mental change. Dilatation of pupils. Temporary causes, such as the influences of pregnancy and the puerpéral state. Paroxysmal hysterical attacks; hyperres- thesia, with increased réflexes. Catalepsy, with simple or apathetic melancholia. Spitting as resuit of delusion. Involuntary discharges due to indiffér- ence, as in mania. Excitable forms of disease are more hopeful than those in which de- pression preelominates, and while an attack of acute mania may recover in two or three months, one of décidée! 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 inhérent weakness. The Morbid Anatomy of Insanity. In ail cases the configuration of the brain, its size, and the depth of the gray cortical substane-e, as well as the signs of récent disease, must be considered. If a small brain has an increased spécifie gravity which is disproportionate with its size, we shall probably detect the existence of sclerosis and atrophy. It lias been found that the weight of tins organ undergoes decided modifications in connection with insanity, and Clap- ham (West Biding Beports, vol. vi., p. 11) présents a table which includes twelve nundred cases of insanity. It would appear, according to this, that the brain-weight is greater in the insane, between the âges of forty and fiftv in women and between fifty and sixty in men, than at any other 66 A SYSTEM OF LEGAL MEDICINE. time; that in the maie the brain weighs more proportionately in idioev than it does in the female; that its average weight is greater in mania than melancholia, and in other forms of acute insanity than in senile or organic dementia, imbecility, or paretic dementia. Grammes. „. x, i 7 Cerebellum, Pons, An. Disease. Encephalon. and Medulla. Age' Idiocy............................. 1148.947 156.7 21.94 Imbecility......................... 12S5.009 174.6 36.2 Dementia (simple).................. 1310.956 169.7 49.132 Senile................... 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 paralvsis.................. 1270.271 174.0 41.610 Epileptie insanity.................. 1314.410 164.4 36.646 Chronic mania...................... 1327.267 171.9 46.863 Brain wasting...................... 1250.644 164.3 60.929 We are enabled to detee-t 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 graduated, 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 détermine, and removing a plug of white and gray matter. It will be found that the depth of the gray matter in certain forms of insanity bas undergone material diminution ; and in those where congénital deficiency is sus- pected we shall find that the proportion of the white and gray substances is very much changed, the latteT being îvduced. In measuring the depth of the gray substance of the convolutions it will be found that it is reduceel from eight one-hundredths of an inch to six or seven one-hun- dredths. Bucknill anel Tuke prêter measurements maele with a hair- divider, a variety of small compass, to the instrument invented by Herbert Major. Benedikt and other G-erman writers place great reliance upon pecul- iarities in the arrangements of the convolutions and sulci in the brains of insane criminals. While I do not believe that Benedikt's ideas are always susceptible of proof so far as it is possible to definitely connect gyral and fissurai anomalies with spécifie forms of moral departure, it is still a noteworthy fact that in the cerebrum of the congénital criminal there is givat coniplexity and irregularity in the arrangement of the con- volutional folds and fissures. In his boe)k upon the subject he présents a number of autopsies the subjen-ts of which were criminals, and in every instance there were certain peruliarities which he has minute-ly detailed,. and thèse ennsisted not only in the excessive fissure development, but in the repeated existence of asymmetries of the brain and the skull itself. The pariétal lobe was usually dwarfeel, the cerebellum was only partially covered by the occipital lob*1, 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 horizemtal and inter- parietal. Asymmetry of the two hémisphères and convolutional errors of development should always be noted. The brain in imbéciles and idiots présents malformations and arrest- ment of development which are quite characteristic. Thèse modifications INSANITY IN ITS MEDICO-LEGAL BEAEINGS. QJ take the form of atretphies of parts or groups of convolutions of the cortex ; and the partial atrophies are revealed by a thinning of the folds, and by a e'*>rrespondiiig enlargement and depth of certain fissures. Thèse are principally in the frontal convolutions, which présent irregularities of formation. Asymmetry is very noticeable in the brains of idiots, the two lobes often showing a want of corresponde'iice which is decided, as well as a poverty in the num- ber and depth of the sulci ; and convolutional flattening. Such brains are often exceedingly small and unformed. That pré- sentée! by Ireland is a good ex- ample (Fig. 13) of imperfect de- velopment. From a pathological point of view we finel arre'ste'd development de'pe'iiding upon de- fects in the' apparatus of nour- ishment in the cortical sub- stance. Luvs (Traité Clinique et Pra- tique des Maladies Mentales, 1881) has devoted much attention to the subjee't 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 Rolando is nearly normal, but its continuity is interrupted by irregularities which jut out from the marginal couve d ution s. Tins writer has collected pathological data of great interest, showing that certain definite convolutional changes are to be found in many cases of insanity. Aeren-ding to him, the most fréquent are those seen in the frontal convolutions, which are much more irregularlv disposed iu the right than in the left hémisphère. The first frontal, especially, is very frequently atrophied anel diminished in breadth. Luys has found in a case with well-marked hallucinatieuis that in the internai aspect of one cérébral hémisphère the paracentral lobule was prominent, the first frontal depressed, and the second frontal had undergone at its anterior part de- cieleel changes. Hère its continuity was broken up by a séries of second- ary multiple' folds having a vermiform appearance and bridges over the superior frontal fissure, which. was obliterate'd. In certain cases of chronic dementia the second frontal convolution becomes almost rudi- nientary. The third frontal convedution (the speech center) is rarely modified, except when there is aphasia. Luys lias found in three deaf- mute's that it was atrophied upon the left side1. The ascending frontal convolution often présents a change in its length anel continuity. At its union with the sevond frontal we find mi- merons variations, and a change is seen at the origin of the third frontal. The ascending pariétal is quite rarely affected, except in cases with para- Fig. 13.—Brain of Microcéphale (Ireland), showing the unfinished fissure occipitalis perpen- dicularis externa, the parallel fissure, the central fissure, which is incomplète, and the posterior branch of Sylvian fissure, a, The superior frontal gyrus; b, the inferior frontal gyrus; d, anterior central gyrus: rt1, posterior central gyrus; e, prœ- euneus; /, lobulus supra marginalis; a, gyrus angularis; i, cuneus; p, gyrus temporalis supe- rior ; o, gyrus temporalis médius. 68 A SYSTEM OF LEGAL MEDICINE. lytic symptoms. The angular gyrus is sometimes affected when there are auditory hallucinations. The paraeentral lobule is often the seat of pathological changes, on one siele or both, and in advanced cases of dementia both sieles will be affected. In the insane it will be found, espeeùally in forms of chronic mania, or where there has been excitement, that the; méninges are thie-kened, hyperamiic, or that there are haeniatonue. The dura mater is often ad- hèrent to the skull, and the other membranes show evidene-es of varions grades of inflammation, so that it is diflicnlt to remove the arachnoid and pia mater without tearing away more or less of the brain sub- stane-e. Lésions of the blood-vessels may be found whie-h vary from simple congestion to atheromatous degvneration or permanent dilata- tion, and thèse are either in the substance of the méninges or in the brain itself. The vascular e-enidition of the brain substance is either one of hyper- aemia or anamiia. Evidences of hyperannia are common in disease at- tended with excitement, such as mania or dementia paralytica. The gray substance is darker anel the white is more pink than in health. Minute extra vacations e>r local tracts of active congestion are found. In gênerai paresis thèse spe>ts of hyperaunia hâve been found to be more marked in the frontal région, though in tins disease it is common to find very gên- erai congestion. In melancholia we m cet with a pale condition of the tissues, with diminished caliber of vessels and perivascular accumulation of fluid, and the brain is blanched and soft. Territories of œde-matous brain are found in association with the plugging up of small vessels by an embolus, or as the resuit of thrombosis. There may be bony plates in the dura mater, which are very common in chronic insanity, or aelven- titious substane'es scattered over the surface of the brain, both at the convexity and the base. The brain itself présents certain changes in the appearance of its convolutions and deeper parts which are ejuite con- spicuous, and softening and sclerosis, giving rise to atrophy, dépression, and changes of color. The lining-membrane of the ventrich's is often thickened and the seat of a granular change ; and an accumulation of serous fluid, not only in thèse cavities but in the meshes of the arachnoid, both at the upper surface and at the base of the brain, is présent. The substance of the brain may be the seat of a diffused change, there being small collections of indurated tissue, which are so frequently présent in paretic dementia. In insanity produced by alcohol this appearance is partie-ularly notiee- able. In other cases we find collections of gummatous substance pecul- iar to syphilis. In still others, those with diseased vessels, there are eme or more partially organized blood-clots, anel perhaps some softening. In many brains we shall find a condition known as the état criblé, which consists in a number of small openings giving to the brain a porous appearance, and it is a resuit of a previous hyperaemia from probable exudation of sérum 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 boues in chronic insanity and the existence of bony spicula?. Greding présents 216 autopsies: 167 of thèse showed thickening, and 38 more or less thin- ness of the boues. IXSANITY IN ITS MEDICO-LEGAL BEAEINGS. G 9 In melancholia Luys lias found in several cases great hyperasmia of the gray substance of the third ventricle. The left optic thalamus pré- senter! on its internai face hyperaemic redness, which was also found in the third ventricle. The gray substance of the e-ortex of one of thèse patients was thin, and most of the convolutions appeared of a pale color, with irregular vascular arborizations irregularly disseniinated. It seems to be a peculiarity of this form of elisease that there is a gênerai ischemia, with localized spots of hyperaemia. In some cases of profound melancholia with stupor the brain was found to be completely exsanguinated, the white substance deprived of vessels, and an appearance of atrophy of the cortex and small vascular groups was presented (des petits bouquets vasculier dis- poser en ilôts). In cases of paretic dementia excessive and abundant prolifération of the neuroglia, with choking of the nerve cells, is apparent, the latter being diminished in number. The white substance as well as the gray présents the same appearane'e of sclere>sis ; the' nerve fibers appear as withered filaments, anel are torn and much reduceel in size ; and there are areolœ which indicate the disappearance of nervous déments. In acute mania evide-nces of active and violent hyperamiia in ail 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, witli dege'iie'ration of ail the nerve déments of this région. In another, an old foyer of softening, oceuipying the center of the pons, was found, the walls of whie;h were incrusted with coloring-matter, granular cor- puscles, and crystals of haunatoidin, which indicated the existence of prolonged e-ongestion, and which for some time had played the rôle in this région of a pathological point of irritation. The causation of meningval inflammation by bacteria has recently been fixed to a certainty by several observers. In acute delirium Rasori (Centralblatt fur Balrferiologie, etc., October 2, 1893, quoted by Potts) de- scribed a bacillus resembling the pneumonia coccus, and quite lately Potts (Philadelphia Médical Xews, June 30, 1894, p. 718) has reported a most earefully observed case which ended fatally. The température reached 108.2 just before death, which was pree'eded by a carbuncle, and later by acute delirium, insomnia, active delusions of persécution, and hallucina- tions of a lively nature which were chiefly visual. The autopsy was made about seventeen hours after death. The brain and méninges appeared to be normal, as were ail the other organs of the body. Some of the cere- bro-spinal fluid that had drained into the base of the skull was collected in a small bottle previemsly sterilized with boiling water, and from this cultures were made, with the resuit that the présence of a bacillus, an- swering to the description of the so-called Micrococcus lanceolatus or pneumonia e'e)ccus of Fraenkel and Weichselbaum, was demonstrated. The StapJiy/ococeHs pyogenes aureus and the Staphylococcus pyogenes albus were also présent.* The microscopic appearances of diseased nervous tissue are perhaps * Microscopic examination of the cérébral cortex showed the appearances described by Osier, i.e., perivascular dilatation and leucocytes in the lymph. sheaths and peri- gangliar spaces. 70 A SYSTEM OF LEGAL MEDICINE. of greater interest than any others, and in cases where no grave levions are presented the microse;ope will often reveal delie-ate changes, which consist most commonly in elegeneration of the nerve e-ells of the cortex, and vascular hypenemia and its conséquences. The large' cells of the cortical gray substane-e often break down, and leave in their places collections of granular matter, which may be either found in isolated masses or the cell wall may be intact and its contents entirely disen-gan- ized, there being disappearance of the nuclear déments. (Plate I.) We shall also find that the intercomnmnie'ating fibers and nerve-cell processes are broken off, and that the intercellular connectave tissue is increased, with prolifération of the neuroglia e-edls, and perhaps there may be the appearance of amyloid bodies. The blood-vessels are choked. There is >exudation of coloring-matter and infiltration. In hyperaemic states the vessels are dilated, their walls being covered by fat granules and haema- toidin crystals. Sometime's niasses of pigment are found. The vessels are varicose or disrupteel, 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 Meschéde lias found in paretic dementia that the increase is very decided. Luys, on the other hand, has found a réduction 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 resuit 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 eharaeter of the anatomical déments as to produce appearances in everjr respect resembling those of actual disease. Hard- ening in alcohol is quite likely, unless great eare be used, to hâve this resuit, 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 well to hâve our observations confirmed by another person. Physieal Signs of Insanity. The external évidences of existing mental disease are usually more or less pronounced. The objective évidences 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, as well as trophic defects of various kinds. Thèse blights may be recognized at an early âge or do not develop until later. Clouston aptly says : " It is a truism that each âge has its own beauty ; it is equally true that each âge has its own deformity. A beautifnl child may beconie an unprepossessing youth, because, through hereditary influences, the development of the countenance, the form, and the movements has not X 650 Microscopic appearance of brain of epileptie dément, showing cellular degeneration. (Clouston.) Fig. 1.— a. Nerve cell showing well-stained nucleus, with small amount of protoplasm round it ; h, nerve cell showing remains of apex process and granules of pigment in protoplasm : c, mass of cell protoplasm without nucleus; ri, nucleus of nerve cell, apparently destitute of protoplasm; c, nucleus of neuroglia cell. (X 3n the Unes that make for mature beauty. There has been a lack of harmonious progress ; the bodiïy idéal of the âge of adolescence has not been attained, through the working of an evil heredity. Some feat- ures hâve been retarded in growth, some distorted, some overgrown. It is beyemd a doubt in families with neurotic hereditary taint that we find marked ugliness, asymmetry, dwarfishness, hunchback, squint, un- gainly movements, bourse' laughing, hobbledehoyism, uncomfortable limbs, and such like departures from the anatomical and physiologïcal idéal." By far the most suggestive index of the insane tempérament is the misshapen head. While a large number of insane persons hâve the long or dolichocephalic head, such a cranial peculiarity has not the suggestive- ness 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 imbéciles are uneven, the incisors being sometimes crenateel; the cars 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 dépend very much upon his form of disease, as well as its stage and duration. It is always pe>ssible to witness a radical and progressive altération in cases that hâve become chronie?, a physieal change keeping pace with the mBiltal détérioration. Women who hâve been comely become ugly. E zpressieni alters, the Unes of the forehead and lower part of the face be eoming deepened, and the dominant affee'tive feeling leaving its im- p gss. The facial furrows that form are referred to by many as im- p rtant diagnostic marks in chronic insanity, especially the depressed e'< nditions such as hypeudiondriacal insanity and melancholia. In the latter there may be a elistinct transverse furrow, which sometimes exteiiels across the entire forehead or is again unilatéral, appear- ing over one eye. Through contraction of the frontal muse'les, the corrugator su- percilii, horizontal folds of the forehead and deep ver- tical folds extending up- warel from the root of the nose are produced. (Fig. 14.) As a result of the persistent and constant contraction of. other musede's, we find dre >e q)- ing of the lower lip and re- laxation of the muscles at the side of the face. In mania and other elateel eon- ditions there are no constant traces left except in chronic states, but the muscles being in lively play the expérience is one of pleasure and joy, or anger and excitement. Through trophic changes and muscular atony we find that the features Fig. 14. 74 A SYSTEM OF LEGAL MEDICINE. lose their eharaeter, the furrows disappearing, and the month beeoming changed in mobility. Blankne'ss eventually ce)ine's, with mental vacuity. (Fig.'15.) The attitude, ge'stures, locomot'um, ail undergo changes, anel the speech is hésitâting, ex- —] ph>sive, and embarrassée!, or the subje>e't indulges in verbigeration, which e'emsists in the répétition of worels in au irrelevant way, so that the résultant effe'e-t is a ro- domontaele of a meaningless j kind. New words are ooined, | and syllables joined incon- j gruously, so that the resuit ' is a e-ompouiid création I which usually eonveys a .} bombastic hint of the pa- I tient's grandiose delusions. .J The formation of new words is often the resuit 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 worels the things he imagines he hears. The words used are often most distorte'd and con- fused, and not only consist of those of his own language, but combined worels made by the conjune'tion of syllables from some foreign word with one of his own tongue. There is in excitent and confused patients a ten- deney to indulge in phrases that hâve a mystic signifieanee. Sometimes a repeated distortion of a syllable will be })ersisted 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. Echohdia is a term applied to the form of speech in which 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 lie is on his guard in other wavs, and I append the production of an insane subject, which illustrâtes a form of phrase répé- tition and extravagance of fantastic word use wilich chronic 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 OF MINNEHAHA AND COLUMBIA. Ordinarily quite Large White Silk for the whole of the background of Chureh Banner and a tinge off into blue as dark as perfect taste would allow for State Banner of United States of Minnehaha and Columbia including Mary Fidelia Bourne Stellar or Planetary TJniverse. State Flag of the United States near the top with either the full number of States and Territories or the Original Thirteen Meaning twelve originally ours and one great, Cruelty we adopt to protect in full natural color with Abraham Lincoln holding under- neath the Motto Malice toward none Charity for ail. And the Holy Dove above. Be- lowr on the Right Side an Orange Tree in full Bloom and délicate fruit in natural color with Justice written upon it. In the center lower than top 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 Siinto twining over it and perhaps grape INSANITY IN ITS MEDICO-LEGAL BEAEINGS. vine and by me held by me as Goddess of Liberty and America Benevolence and Truth written upon it at her feet coming up perhaps as far as the knees agricultural instru- ment with grapes in bloom or fruit over it on each side two well-known Monarch with weapons of defusive wrarfare and work One and Anstaradat as Peter Bowne the Great of Russia who no menial service honestly and noble performer 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 ôth of Twelth of Spain Conqueror of the Netherlands Prescott has a memoir highly interesting of him a Thorough pénitent with a well known face and ten Commandents in tablet form in Instrument of Agriculture with Laborore et Ovare and Return for Evil together Underneath Orange and Peach tree, a number of Irregular Lumps of Dirt and Stone with Tiger Lily very beautifnl and Dandelions and jealousy grass at the bottom over Lump of Dirt two skeltons Hands with know number of Stoned unjustly in America or its Représentation 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 Jésus name after as it brought a bad fate or to know the private affairs of Gods or Goddess and wislied to be impartial for that reason were probably starved by the cruel Création a number of Friends of Goddess of Liberty or America being among the num- ber several private friends ail 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 délicate 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 Tyranny Error False- hood Treachery Kindness in prosperity unkindness in adversity Uncleanness Lust. At the bottom underneath Jealousy grass and dandelion the Words Faith Hope and Charity on State Banner with perhaps the passage of Scripture. As I live south the Lord God I hâve no pleasure in the Death of the Wicked but rather that He may turn from his wickedness and live turn ye turn ye for why will ye die. D fiUHtj) KAMA^J^^M) TrJbur' f /Wt>^X^7 M^^o-^o^y^^ JuAt) W^UjO ï \p> Fig. 16.—Writing of a paranoiac. The handwriting itself undergoes a decided change in eharaeter, and is often feeble and uncertain or else suggests an exaggerated vigor and nervous force resulting in the production of bizarre scrolls, markings, anel interlineations. (Fig. 16.) Of course the disposition to write varies with 76 A SYSTEM OF LEGAL MEDICINE. the disease'd mental activity, those who are afemie or demente'el, writing but little, while the victini of chronic mania has a véritable cacodthes scri- bendi. This is especially the case in paranoia, the person of one- idea filling pages with diagrams, sketches, and symbolic referene'e's, often of a mathe- matical or religious eharaeter. 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 hâve been collected and published by Dr. Noyés. y * c Fig. 17.—Writing of an educated paretic dément ; 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 spécimens taken at différent times, when compared, show the degeneration ver)' beautifully. (Figs. 17 and 18.) The attitude of the lunatic is as a rule largely determined by the nature of his hallucinations, should they be présent, and he changes his position and behaves in a measure as he would if the impressions he re- ceived were real. Should he be the subject 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 atonie melancholia, where inaction character- izes the condition. The patient is listless, tacituru, absorbed, and will not usually move unless stimulated and urged. "When anxiety is a feat- ure we are presented with the expression we would find in a normal condition, only intensified. <^e^-o^ -£^ Fig. 18. Writing showing détérioration in paretic dementia. (Bacon.) a, b, Writing of educated man, with interval of several months; c, d, writing of unedu- cated man with commencing paretic dementia, c being written soon after admission to asy- lum, and ci his writing in health. 78 A SYSTEM OF LEGAL MEDKTNE. The existence of delusions is often reileeted in dress, and in asylums one or two patients are usually she>wn who décorât e themsedve's with ail the bits of bright métal anef gay colors they can find. This kind of adornment is usually associated witïi unsystematized delusions of power, the patient believing himself to be a pedentale. The .Ear.—Attention bas been called te) the misshapen ear, which is likely to be an index of a prolongeai dégénérât e condition. There.' is an- other deformity of the ear belonging to chronic insanity, and this con- sists in a striking deformity due at first te) impaired function of the sympathetic fibers anel a low condition of vitality of the organ, and to subséquent injury and inflammation anel ultimate contraction, so that there is a résultant change in shape and size which is coiispicuous. While the ear is congested, as is often the case in chronic insanity, it is liable to be injurcd or bruised, and lacération of small blood-vessels oc- curs, followed'by extravasation. The condition is known as othamatoma, or the " insane car." Othaunatoma may be associated with nearly every form of chronic insanity, and is usually of grave omen so far as complète 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. The Eye.—The pupils constantly présent 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 unequal 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 ail forms dilated. The dilated, mobile pupd of the epileptie is présent in about half 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. Thèse 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 with distinct organic causation, such as the syphilitic and alcoholic psychoses. The tendinous réflexes 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 Amesthesia.—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 with those qui- Fig. 19. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 70 escent states of will feebleness. Kirchhoff says : *• If there is very exten- sive diminution of sensibility the patient's feeling of his own personality may be extinguished and he may beheve himself dead. If the ames- thesia is confinée! to certain viscera—for example, if the ingestion of food takcs place without feeling—the patient believes that lie has 110 stomach." The sécrétion of tears is diminished in melancholia, but is abundant in paretic dementia and is apparently in 110 way connected with mental sufferi ng, the tears fiowing with the least excitement. The skin of the insane is apt to be dry and harsh, especially in the depressed forms ; but this is not necessarily a feature of ail insanities, as it is claimed. The violent muscular action incident to mania gives rise usually te- prof use sweating. The writer bas witnessed an oily condition of the skin in adolescent and evolutional insanities. The température in melancholia and dementia is, as a rule, lowered; the surface température, especially, is reduced, so that the skin is cool and clannny, and through sluggïshness of circulation is pale, dusky, or mottled. The subnormal température may be as low as 96.5° or less. In mania and other excitée! states the température does not rise, except when there is the condition known as typhomania, in which delirium is présent. In stuporous insanity and the apathetic forms, where great exhaustion exists, its extrême réduction usually foreshadows a fatal termination. Digestion atal appetite are likely to be more or less deranged in every form of acute insanity, but in mental disease of long standing the appe- tite and digestion are entirely unaffected. In melancholia there is a history of indigestion and détective assimilation—the urine is usually loaded with urates, except in cases where its sécrétion is abundant—the atonie examples. Thèse patients often suffer from diarrhœa and the passage of undigesteel food, which symptomatize the insufficienc}' of mastication. Constipation associated with tympanites belongs to the l^pochondriacal variety of melancholia, and the fecal matter is déficient in biliary coloring matter. The ravenous appetite of mania is largely psychical and not due to any actual craving for food. In hysterical and puerpéral subjects there is also an évidence of mental degeneration which consists in the craving for nauseous and indigestible substances. In paretic and other forms of dementia the patient is apt to eat too has- tily, thus producing gastric disorders ; or he may, through paralysis of the pharyngeal muscles and anaesthesia of the epiglottis and upper part of the larynx, be asphyxiated by the lodgment of a bolus of fooel or pièce of méat in the latter. Trophic disorders are likely to ensue in cases that hâve existed for an extended length of time. Cutaneous altérations, such as deposits of pigment, staining, changes in the growth and color of the hair, herpetic and other éruptions, are among thèse, as well as brittleness of the bones, fractures being very common among the chronic insane. Bed-sores usually attend the last stages of protracted insanity, and are common among déments or those who bave undergone very great exhaustion. The urine of the insane may présent the ordinary évidence of bodily waste', es]>ecially in mania or psychoses where great wear and tear exists. In agita teel conditions the quanti ty of urea is increased, and after epileptie paroxysnis it lias been found to contain albumin and even sugar. Some years a go the writer conducted a séries of experiments at the Hudson 80 A SYSTEM OF LEGAL MEDICINE. River Hospital for the Insane, which disclosed the fact that the appear- ance of sugar in the urine of paralytic déments was to be looked for at some time or other in most cases. Its présence has been détectée! in periodical mania. In alcoholic insanity it is quite natural to look not only for casts and other évidences of rénal disease, but albumin as well. Thèse évidences of increased blooelqtressure in connection with acute states are found not only after attacks of mania, but after the convul- sions occurring in the course of paretic dementia. The Insanities. I. IDIOCY. This term, as hère used, implies a congénital defect in both mental and physieal development, and differs from imbecility ("acquired idiocy" of some writers) in the fact that such defects, whatever they may be, are prénatal, and are due to causes which act directly through the parents. Injury inflicted during delivery—from forceps, pressure, and the like be- ing exceptions—for the true idiot possesses purely atypical defects due to détective organization. The remote influences causing the anomalies of development that belong to a feeble child of this kind are more apt to be alcoholism and syphiïis than any others, although sensitive people who désire to find a less degrading exjdanation are prone to assign the weaknesses of their off- spring to such traumatisms as falls, the carelessness of nurses, or actual injury inflicted by the forceps during delivery. Such causes are compar- atively unusual, as the study of the physieal aspects of the disease will prove. Idiocy is due much more often to the intempérance of the progenitors than to any other cause. Of 359 idiots seen by Dr. Howe, it was found that in 99 cases the parents were confirmed drunkards. Consanguineous marriages are believed by Maudsley to lead more often than is generally supposed to degeneracy, which is manifested in succeeding générations by idiocy. Exactly how much syphilis prédisposes to this condition it is difficult to say, for its manifestations are irregular. Not only can it resuit in late forms of degeneracy—in infantile gênerai paresis, as has been witnessed by Clouston—but it is ordinarily behind congénital feeble-mindedness, with associated epilepsy. The physieal peculiarities of idiots are varied and striking. The con- figuration of the cranium is one of thèse, and Broca has described several varieties, the most important of which is the microcephalous head. The diminutive head may hâve a circumference of but thirteen inches, and an exceedingly great facial angle. Broca holds that the possessor of a skull with an anteroposterior diameter of 148 millimeters is a micro- céphale. Of the two principal varieties, the dwarfed idiot and the idiot of ordinary height (les nains et les individus de taille ordinaire), the latter are almost always deprived of the faculty of language—sometimes they can pronounce a few words, without any appréciation of what is meant ; the cranium is larger than that of the first variety, and may be 140 to 145 millimeters in length, with possibly a circumference of 420 to 425 milli- meters and a capacity of from C00 to 700 cubic ceetimeters. INSANITY IN ITS MEDICO-LEGAL BEAEIXGS. 81 The greater number of microcephalous idiots are of the first variety (dwarfs) and rarely grow taller than a boy of eight years. (Broca.) Many always remain undeveloped, others are taught to talk, and but few ad- vance beyond the mental status of a child of two years. The antero- posterior diameter of the skull may be no more than over 10 to 13 centi- nieters, the horizontal circumference may be from 32 to 37 centimeters, and the capacity is always below 600, and may be no more than 300 cubic centimeters. The case of the microcéphale John Rouse is one well known in psychiatrical literature. He was under my eare for several years, and as a microcéphale ranks with the cases reported by Ireland. John Rouse is about fifty, weighs 72 pounds, is 4 feet 7£ niches high. The circumference of the head, taken at a point one inch above the root of the nose anteriorly and the occipital protubérance posteriorly, is 15 inches. The biaural arc is 8 inches, and the anteroposterior arc is 8 inches. Thèse measurements must be reduced about an inch by reason of the existence of thick, coarse hair. His teeth hâve disapi)eared, and he has a double cataract. The left ear is the seat of a haeniatoma. His intellect is almost nil. He can only say a few words, without any idea of their meaning. Broca also describes the demi-microcephale. Very often weak-minded children of this kind présent no diminution in the size of their crania ; in fact, I think the majority of my own cases were the possessors of un usually large heads. The scaphocepheùous deformity consists of an exaggeration of the vertical and longitudinal diameters ; the plagioeephalous or oblique-oval deformity, dépends upon prématuré oblitération of one of the branches of the coronal suture and of the lamb- doidal suture. In the platycephalous deformity the sinciput is flattened and the vertical diameter is diminished ; in the acrocephedous head, on the contrary, the sinciput is conical and there is an increase in the ver- tical diameter. Indication of prématuré closing of the sutures is often présent, and should be looked for. The height of the palatal arch has been referred to, anel an increase with basai narrowing is regarded by most authors as an invariable sign of détective development. I présent an excellent plate of Clouston, which enables the reader to compare several types 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 uneven or in a double row, and perhaps connected with fissuring of the hard palate ; harelip, or that projection of the lower jaw known as prognatliism, may be présent, and when it is, is highly characteristic. The features of the idiot are coarse. His vision is détective or he may be actually blind, 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 eye 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 work, as the muscular System is weak. Cutaneous sensibibty may be either elevated or depressed ; in the latter ease there is a remarkable tolérance of external disagreeable irritation. Sometimes there is loss of smell. The gait is often waddhng and unsteady, and the grasp weak. His habits are untidy and dis- gusting; he gorges himself with whatever may be placed before him, 82 A SYSTEM OF LEGAL MEDICINE. SECTIONS OF STANDARD PALATES. TYPICAL NEUROTIC. DEFORMED TRANSVERSE. LONGITUDINAL The Soft Palate Is represented by à dotted llne( Fig. 20.—Casts of vault of mouth showing defects in hard palate. (Clouston.) 1. TYPICAL. 2. NEUROTIC, 3. DEFORMED, &±* 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 hours at a time, in his mouth a bolus of fooel. Ile voids his urine and farces where ver he may be, and very often indulges in masturbation and objectionable amusements of a vile eharaeter. The idiot is either non compas, or his capacity is, as Pinel bas observée!, below that of another person of his own âge. In some cases the intelli- gence is even upon a par with that of some of the lower animais, and mental expression is chiefly emotional. He manifests feeble degrees of pleasure when shown bright objects, and indulges in fitful and short- lived gusts of passion without cause. He delights in rhythmical, musical sounds, or to indidge in automatic movements. His instincts are animal ; and without the restreint of judgment he gratifies every appetite, how- ever low. In completely idiotie persons there is no sign of récognition, no indication of memory, and the intellectual capacity is rudimentary. There is the absence of the primary mental apparatus, the absence prob- ably of a sufficient number of sensory cells and their Connecting fila- ments, and the resuit is the absence of mind. The gênerai conspicu- ous mental weakness of an idiot is the lost power of attention, and this accounts for most of the peculiarities. Nothing impresses him ; percep- tion is dulled, concepts are weak, and émotions are not, therefore, legiti- matdy aroused. The basis of mental expression is the bodily or instinc- tive feeling; the sensés of hunger, pain, satiety, comfort, and the like,. influence the conduct, and his outward manifestations are of a feeble nature and bear a close connection with the condition of the ego. The expressed feeling is unbalanceel, inharmonious, and is often evoked by unexpected or ordinarily ineffective stimidi. The speech of idiotie children has always been considered an inter- esting index of the mental failure. Its connection with the disorderly complexity of organized ideas, and the manifestations of its forms of impairment, perhaps point as fully as any other symptom to the degen- eracy. The defects of speech vary from absolute mutism to a state of apparent, though feeble, devehqnnent, where perhaps a free flow of words. exists, without systematized mental création or régulation. Many vaga- ries are found. Sometimes the vocabulary is very limited, being con- tined to a dozen or more words which the child invariably uses for the expression oj: 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 nurse, lier own name, those of various animais and objects,. as well as to convey information as to her needs. Such examples are common enough, and the simple words are curious, and frequently hâve no phonetic connection with any particular object. The range is rarely exteudeel, though occasionally skillful teaching may resuit in the use of new anel applicable expressions. The speech-defect is sometimes a gen- uine aphasia, and is associated with hemiplegia and epilepsy. Other children substitute consonants, using T for K, D for G, D for Z, etc. Echolalia, stammering, screaming, the utterance of rhythmical and monoto- nous sounds, the mimicry of the noises and cries of animais, are ail morbid expressions. There are many beautiful children who come into the world with an utter arrest of cérébral development, whose beautiful and expressive faces are strangely at variance with the paucity of mind. Cloustem, in detailing a case where there was an hereditary arrest of development of the mental cortex alone, the trophic, motor, and sensory centers acting INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 85 normally, while there was no émotion, reasoning power, no power of attention or speech, yet ''an exceptionally sweet face, fine, expressive eves, 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 thèse subjects are sometimes the seat of mal- formations, and monorchidism, hermaphrodism, and atypical errors are discloseel upon inspection. Their sexual appetite is perverted, and when any désire exists, which is not often the case, the adult idiot is apt to e-onimit 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 imbécile, 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 éducation—by an approach from without, that is to say, through an appeal to the sensés primarily, anel a removal, if pe>ssible, 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 endémie influences. It is common in southern Europe, especially in the Pyrénées, and seems to be rather a disease of high altitudes than elsewhere. The physieal and mental peculiarities of crétins consist in a dwarfing of stature ; imperfect development of the base of the skull ; a puffiness and swelling of the face, which is so marked in myxœdema, for, in fact, this disease belongs to the same group. The fingers are clubbed, and the tips spatulous ; the skin is of a dirty, waxy color; the surface tempér- ature is lowered ; the voice is high-pitched, raucous, or muffled ; the hearing is détective ; the mind is dull, and there is not so much motor activity as in ordinary idiocy. II. IMBECILITY AND KINDRED DEGENERATIVE STATES. Mental weaknesses beginning during the first 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 febriïe disease, or •■ brain-fever,'' or is associated with epilepsy. In other cases there is no such condition to explain its origin, anel, in fact, the mental weakness itself may not consist in any- thing more serions than a "queerness" and perversity, which causes the subject te» be looked upon as an unusually bad or an unusually élever child, or gains for it fréquent and useless punishment, or adulation or injudicious praise when it has performed some difficult feat of mathe- matics or memorized some very long verse or pièce of prose. To this tdass belong the musical and mathematical prodigies. Thèse children are usually correspondingly dull in other things, or grow up to be stupid men and women. The moral perversion which belongs to this kind of weakness is irregular in some wavs, entirely beyond control, and is fre- 86 A SYSTEM OF LEGAL MEDICINE. quently ineradicable. The boy commits a cruel act of some sort, tortur- ing dumb animais or even his own kind; again, as in the l'omeroy Case, he actually commits wanton murder. Lying, stealing, indecency, and purposeless, impulsive acts are cemimon. There is afteu-ward little remorse ; the child knowing the abstraet nature of its offense, ed'ten talk- ing about it, but feeling no shanie'. Oecasionally the subject is troubled by doubts and fears that constitute actual introspective insanity, and acts under the influence of imperative concepts ; but tins is not common. The mental after-life may be a continuation of that of childhood, and if the grade of degeneration be such as to permit 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 lie soon drops 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 people in the community who mingle freely with their fellows, anel wliose real eemdition is not recog- nized. They are one-sided, imitât ive, anel perform limited intellectual work where little inventive skill is ree|uireel. In some ways such people are decieleelly smart, and often indulge in feats of memorizing and tours de force which impress their friends. They are, however, without sufficient reasoning power, anel 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 soe-iety, with criminal instincts ; in fact, a very large number of instinctive criminals are but imbéciles. So far as the physieal make-up is concerned, we find peculiarities of head configuration—what is known as ""developmental ugliness"—stra- bismus, defects in the shape of the cars or teeth, eccentricity of dress, and tricks of manner and speech. The term eoined by Guiteau is most often applicable to thèse people, for they are often cranks in action and ap- pearance. An advanced grade of mental degeneration is manifested in disorders that run ail the way from " crankiness " or insane eccentricity to actual III. MONOMANIA OR PARANOÏA. The use of the word ■• monomania " by various authors has led to much confusion. It has been applied to forms of melancholia and mania, to intellectual insanity (Hammond), and by others to a number of widely differing psychoses. By some it has been considered synonymous with "partial insanity," that convenient légal excuse for "criminals whose alleged irresponsibility is connectée! with mental integrity in ail other directions save one. From the fact of its being an expression of initial degeneration it lias received the naine "primary delusional insanity." (Folsom.) Monomania or paranoia is an insanity in which the mental al terration consists in the existence of limited delusions that are either of a grand- iose or depressed or persecutorv nature. The gênerai mental health of the subjeed is not always bad ; in fact, sometimes the paranoiac, except for his own dominantly expressed delusion, may conduct himself with INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 87 considérable propriety, displaying a great deal of intelligence. Again, his prominent delusion is a central one, about which may be grouped others of a dépendent kind, with a growing mental dissolution which is finally clear to ail. A case of this kind has been referred to when describ- ing religious delusions. Hallucinations more rarelv occur, and when thev de» are limited like the delusions, and there is no incohérence ; like reason- ing insanity, the patient reaches conclusions from false premises. The émotions correspond with the delusions, and are relatively painful or liappy. Paranoïas may be divided into several varieties. The persecutory form, which is the most common, where the individ- ual entertains delusions of suspicion anel persécution, believing himself to be the object of attack or of a conspiracy, that he is deprived of his rights, that he is misunderstood anel misjudged. Possibly his delu- sion may be succeedeel by others—of power—he believing himself to be the inventor of some important and useful pièce of machinery or pro- cess, of which later on he says he has been or is to be robbed of. Some- times he is the great gênerai, reformer, or manager, and if he really bas had any offie-e or calling which he has improperly filled, lie refers his Avant of success to his imaginary enemies, who hâve plotted lus ruin. Persons who sit opposite to him in the e-ars are enemies anel détectives. At some time or other he misapplies quotations, both biblieal and otherwise, and invests himself with ne'w imaginary power. His delusions become un- systematized eventually, anel are accompanied by auditory hallucinations. He '-bas a mission to per- forai," and occasionally mur- de'rs senne one to further it, usually a président or sover- eign or public functionary. The reformatory paranoi- ac would regulate' soeùety ac- cording to his own methods or System. If lie occasion- ally has sufficient influene-e he gets himself appointeel or elccted as président of some society with a more or less noble aim, makes and en- forces persecutorv or non- sensical régulations, and his zeal is insane in its exhibi- tion, anel draws forth censure and newspaper abuse, no matter how sincère he may be. He may be and usually is ee'centrie' in dress, and should his delusions be of a Fig. 22.* grandiose eharaeter, déco- râtes himself with medals and décorations. In an extrême form, which lias received the naine mégalomanie from the French, we find the most ex- travagant delusions of power expressed. There is usually an expansive bien être and benevolence disjdayed which lead the individual to promise the * From the author's Types of Insanity, with kind permission of William Wood & Co. 88 A SYSTEM OF LEGAL MEDICINE. favors that only a king could confer. Ile is invulnérable and impervions to the bullets that may be fired at him ; he makes his attendant a gênerai or duke, or promises his visitor a million or two as a pleelge of his good- fellowship. He, too, is deeorated with shining bits e>f métal, buttons, featti- ers, boot-heels, and a thousand and one glittering gewgaws he has picked up or beggeel. (Fig. 22.) Should he be interviewée! in an asylum ward he calls attention to the fact that ail those about him are insane, and he alone is in possession of his fae-ulties, luit does not seem to wish to escape. In one case of which I know the patient called attention to his inven- tion of "painless death." The secret was "too dangerous to generally communicate," but he gave me the formula, which I produce. The pain- less death was to be produced by a blow with the fist, not in a vital spot, but anywhere. It was suggested for the exécution of criminals, but the secret " should not be imparted to persons likely to use it for revenge." About Painless Death formula, you multiply the weight of the man who strikes by the length of his extcndcd arm and by the length of the advance of his foot as he throws himself forward; the total divide by 2000 or 2lM:0 lbs., giving the energy in foot-pounds—generally H to 1-J tons. This should be verificd by actual test on scale registcr. Upon reminding him that blows of this kind rarely resulted in any serious injury though inflicted every day, he replied that " some of the conditions were absent." A class of paranoiacs infest the courts of law, bringing suits for ail sorts of imaginary injuries, and badgering and bothering judges and juries. This paranoia litigiosa, or que raient insanity, is common, and its victims are usually public nuisances who are always getting into trouble. An évidence of this form of disease is presented in the shape of the in- dorsement of a brief executed by a paranoiac who imagined himself perse •- cuted and deprived of his rights as a lawyer. The bombastic phraseology is highly characteristic. This paper consists of a légal form, which is ael- dressed to " the United States and whole world, as before the Court and Counsel, yet with this légal estoppel : et justicia ad infinit uni" and within : It appearing to my satisfaction that Mr. G. K. is the Chief of the Bar, and is clothed with ail rights, privilèges, honor, and justice, Ordercd that the Hon. J. S., Justice of said court, is in full sympathy with the said K., and that he lias sworn that his .obligation is in ail respects toward the said K., to do anything to his aid and advantage for the modification of 61 Barb. p. 573, even unto- death, as our inviolable rights and only légal settled citizen title, as registered in rem. J. S., Justice. On the back of the paper appears the following : TAKE NOTICE. To ail to ivhom it may Concern : That the within is a coi)y of an order this day filed in the Clerk's Office 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 ail religious dénominations and sects, and the various politi- cal parties and fractions and représentations. You will please restrain and hold over, and do the same by signing same. N. Y., May 9th, 1SS3. JOHN SMITH. Thèse and many others are familiar to the public through their ex- traordinarv behavior, accounts of which hâve found their way into the newspapers ; but the real condition, unless it is very pronounced, is rarely appreciated. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 89 The development of paranoia is slow, and, as it has a congénital, neu- rotic basis, we find a previous hfe characterized by some of the early peculiarities of conduct alluded to in describing imbecility. The down- ward progress of the disease is slow but sure, the patient entertaining a limited number of delusions for many years before lapsing into dementia. The subjects are tolerateel members of society, and not unrarely do much good in directions where their diseased intellect does not interfère. Para- noia is essentially a chronic disease, though lately a form has been de- scribed which is said to be acute. I am, however, disposed to believe that the very matter of time must exist to détermine the nature of the disease, for short-lived, single delusions, even with insane prédisposition, may be found under other circumstanees, and may symptomatize many ordinary acute insanities. It therefore does not do to speak of an acute paranoia. Suicide is not common, anel homicide is resorted to only when delusions of persécution or conspiraew exist, or when the person is being restrained or his acts controlled. A form known as Sensorielle Yerrncldheit exists when the limited de- lusion springs from some altération of sensation aud 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 wliose disease had had a hypochondriacal begïnning, and developed so that unsystematized delusions of persécution and conspiracy followed a period characterized by the existence of limited hallucinations and cor- poreal delusions relating to his own internai organs. He came from in- sane stock. The " Arenoughts " (Argonauts) were throughout respon- sible for his persécution. THE ARENOUGHTS. Mardi llth ISSti My Bowels Moved 3 times Before night parties or arenoughts, quite, quiat I com- menced Tacking the Medcson No 1862 . . . 3 11 86 Prescription from G R C---Hâve taken the first dost iu the evening 12th 1886 The parties threaton me with Blindness ; I hâve faith to Beleive G---D L---and J--- F F---; I Hâve ben threatond Several times before and a Blur Before my ejes Bowels Moved twice today now 8 Oclock at night I Beleive the parties Hâve power of My Mind and Brain and they hâve acnowladged thy hâve My papers and a Recept Book and a pair of Shomakers Pincers and Recepts of My Trade whitch I Hope and Pray May Be Restoared back to Me And they further Hâve acnowladged they hâve ben Pested by Myfolks and that they are going to Noculate Me the same This said tonight the Twelfth Whitch I think the Parties noculated M y 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 hâve claimed they are going to Mation Me for their Brother J---F---and ail My acts of Mine and J--- F---is not to Be found He J---F---■ agreed to Make Me clear of Debt if I would Stick to him until He got His Pention whitch I Did and the contract was never doue My Head and Cliest Bounced like ones Hart after running fast a long distance at Night the Parties notime letting up entirely 16 they Sometimes punch Me at the root of My Tongue and other times at My toes and other times at My Heals. The parties claim that 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 Hâve you and Me go to N Y city to a Mition Horsepittle or any Horseinttle and Hâve this Tested* Pleas Return this My Medeson 3 quorters used up * His urine. 90 A SYSTEM OF LEGAL MEDICINE. Mardi 20 1**0 The arenoughts Say this Morning that They wont come S----D----on Me for I liant the Money to buld'o/.e him backwards and forwards As i am thinking about a bill Dr L----ast Me to pay yesterday ; While I was talk- ing with L----the parties were operating on my Nurvs so i trembled allover ast ho I was as cold as could be without l'reezing; and they continue to opérâte on my cars daly; for thatmatter ail over Me from place to place; A L----Bill $10..10 cts; sur- vises lOth of Feb copy Mardi IS Thev 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 uurning Sulfor in My Durtcellar and get in the back side will it Harm me if I sit in the bottom at the back'side at the bottom My bowels scarcely any better Moving 3 or 4 times a day 2(1 while sitting in Sloats shop The parties up in The air said ; He wont 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 wi'tli 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 Bv it; It would be given back to My wife and if I dident Live with Hur They would Murder Me and Saying that Mis Wimon was diseased by them and They were going to Mation or Mil ion them and My Money Had to pay them for it & tonite They were operating on my body So I could hardly Breath Near my Nabol & felt as though it was Strained out; near the same as ones finger in a vice and turning Black with the preshure; Now as I am riting they say is lie arny worse of than he was & the other says He would if we wasent Afrade of Adams ; 22 Tonite The parties commenced punqùng 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 hâve seen My Head Move this doue after I got in bed ; Soon as I got up to rite this they let up after I again got in Ijed they commenced to operate again I was thinking about going up to The Justice of the Pièce and they said they would put me so low I couldent 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 runs 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 rcally begins. " Looking to the graduai development of mind up to puberty, and the enormous and rather sudden leap that is then taken toward the higher mental life of the adult, we must assume an almost completed apparatus lying ready to be brought into use, just as the centers of respiration are ready for their functions at birth ; and considering that the very highest mental and moral qualifies of ail, with the subtle differentiation between the maie and female mental types, are only fully seen between eighteen and twenty-five in the average human being, we must look still to the appa- ratus through which ail this is brought about in the brain cortex." (Clouston.) In children possessing the insane diathesis a very serious and often incurable psychosis develops, and is apt to afterward end in dementia. In those with unstable brains various forms 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, known as adolescent insanity, is. however, quite peculiar. It is symptomatized by excitement, irritability, and impulsive acts, though melancholia exists in a fair per- centage of cases. The moral sensé is blunted and sexual perversion is INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 91 common. The maie subject is insanely vain and conceited, bombastic, anel generally morbid. Some writers hâve describeel the disorder as mas- turbatic insanity, because the habit of onanism is supposed to précède anel cause the insanity. I do not think this terni 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 resembles folie circulaire. A large number bf cases recover wholly or partially, though about thirty percentum lapse into a profound dementia charac- terized by good physieal health (primary dementia of youth.) The affec- tion must always be considered as a developmental psychosis. V. PERIODICAL INSANITY. (Folie Circulaire; Alterntding Insanity.) The clinieal features of this form are recurring attacks of mania and melancholia, ordinarily in subjects with hereditary tendencies, though an acquired form is mentioned where states of dation or dépression may be repeated. The attacks are separated by intervais 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 internai causes, and are evidently the resuit of cumulative physieal dépression and mental disorder. The actual attacks of insanity tend to become more and more fréquent, and eventually run together, the resulting condition being a terminal chronic psychosis, though this is by no means an inévitable conséquence. Sometimes the attacks are always of melancholia or mania, or they alternate irregularby. 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 subséquent attacks the mental condition and power of attention is confused, as it is in old epdepsy, and the recol- lection dira. When the eharaeter of the disease is excitement, such excitement is apt to be of sudden occurrence and subsidence. There is great irritability, sharpness of memory, loquaciousness, self-aggrandize- ment, and morbid self-confidence ; incohérence 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 Belirio.) Many patients possess a remarkable ability to convince themselves, as well as others, as to the apparent consistency of more or less insane acts which they perform. This form of insanity, therefore, is one that 92 A SYSTEM OF LEGAL MEDICINE. is apt to be the basis of litigation, because of the apparent intellectual vigor of the subject. Its éléments are origïnally false promises, from which lie oftentimes reasons most logieally, arriving at a conclusion which may amount to a powerful imperative concept. In most ways his ordinary mental conduct may be ail that it shoulel be, but the false in- sane idea exists, and is defeuded and justifiée! with great vigor. Not unrarely the patient recognizes his weakness at some time or other, and undergoes great agony of mind. As the resuit of this dominating kind of thought lie makes purchases he can ill afford, or buys uselcss things, or is dangerous to Society. His aeds are often preposterous, but after their commission he is filleel with remorse and makes a manful effort to avoid the mandates of his specious conclusions. This disorder closely resembles the other affection which is e\|)ressed 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 élément or a history of alcoholism in other générations. The patients are usually adults. I hâve lately seen several children who, however, bave develeq)ed the psy- chosis. A few months ago a boy of fourteen Avas 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 détective organization. He studied hard and was ambitions, and, as a conséquence, hael developed headaches a year ago, with indigestion and gênerai ill health. Some months ago his mother noticed that lie washed bis hands more fre- quently than usual, anel that he would stand a long time before the basin in an apparently abstracted state; that he would spit in the coal-scuttle re'peatedly, and that he picked up pièces of straw and matches, which were always thrown into the coal-scuttle. Ile explained his actions by saying that the pièces of straw resembled crosses, anel lie could not show disresj)ect by carelessly stepping upon them. His habit of spitting, lie said, was due to the fear lest the saliva in bis mouth should interfère with the full effect of the communion-wine, and tins was carried still further by spitting in his handkerchief. Of late he occasionally bas de- lusions that his food is poisoned, but he dénies this to me. When he crosses the railroad tracks that run near his house he is impelled to pick up sternes 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 ail the distress of mind common to other sufferers from this form of trouble if lie neglects to follow his first impulses, and often returns to obey the dominant con- cept. He often remains for a long time* in the water-eloset, sometimes for ten or fifteen minutes, and when his mother enters to find the reason of his seclusion, she discovers that lie has littered the place with many pièces of discarded water-closet paper, refraining from elesecrating by use any pièce that contains creases that may bear any resemblance to* the com- mon symbol of Christianity; he examines each pièce earefully. He sleeps very badly and has nightmares, and grinds his teeth. His pockets, when examinée!, are often found to contain varions nails and sharp things that lie lias 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 INSANITY IN ITS MEDICO-LEGAL BEAELNGS. 93 thought it was poisoned as because it might in some way interfère with his religious professions and duties ; but from his mother's account he undoubtedly at other times has well-marked hallucinations and delu- sions. He expressed much distress in regard to his condition, and I think to some extent realized its hold over him. Upon interrogation I found that whenever he walked in the street he earefully put out of the way or picked up any object, especially pièces of straw, wood, or paper, that in any way in their arrangement bore the least resemblance to a cross, for fear that he might commit some act of sacrilège. After much questioning it turned out that he had received a deep mental impression from a story in a semi-religions school "reader," which was in use at the Ivoman Catholic school which he attended; and upon examining the book I found a highly colored romance which had evidently been préparée! for the purpose of appealing to impressible children of his particular faith. VIL EPILEPTIC AND HYSTERICAL INSANITY. Thèse forms are characterized by the primary existence of epilepsy, or a fundamental hysterical state which becomes more and more pro- nounced until the expressions of emotional excitement always rise to the surface anel give the mental disorder a distinct tinge. In the former the mental aberration is of irregular development. It is always heredi- tary, and may follow the occurrence of fréquent attacks of petit mal, when the type is that of mental feebleness, finally possibly amounting to dementia. In other varieties there may be attacks of excitement, which take the place of epileptie paroxysnis, during which the patient commits acts which he does not afterward remember. This form of dis- ease; must be distinguished from the epileptie manifestations of gênerai paresis, of embolism or coarse disease of the brain, where the attacks are generally symptomatic. Sometimes the insanity is expressed in melan- cholia, with delusions. The mental disturbance may be short-lived, tak- ing the place of or following a fit. There is great irregularity in the occurrence of the isolated attacks, and, in fact, in regard to the progress of the elisease. It rarely affects children, except as a symptomatic ex- pression, but often develops about the time of puberty. With the motor automatism which we often find the patient commits curious, purposeless acts which are so eccentric as to leave no doubt of mental unsoundness. One of my patients would disrobe wherever she happened to be. Others uneonsciously pursue the accomplishment of acts that were in process of commission before the seizure or lapse of conseiousness, of which they hâve no recollection. While the functional activity of the higher cortical centers is suspended, the patient may wander sometimes to a great distance, take railroad journeys, and travel with other people, who detect nothing unusual in his conduct. On his return he is often oblivious of any irregularity, or remembers nothing of where he lias been or what he has donc. The importance of such a state cannot be disregardeel as an dément of légal proceedings, when it is claimed that certain acts are not the product of the free will of the sub- ject. The relation of epilepsy to criminal responsibility will be later considérée!, but attention is hère directed to the possibilitv of the com- mission of an act by an epileptie with a niasked or aborted form of the 94 A SYSTEM OF LEGAL MEDICINE. disease, which would jeopardize his civil rights. Such a person might very readily make a civiï contract of which he would hâve no recollectiem subsequently, and which would not be approved by him in his normal state. The hysterieally insane are subjects of the neurotic tempérament, anel it is not difficult to' find some history of degeneration. They belong, as a rule, to families other members of which are alcoholics, insane, or in- stinctive criminals. The dation, vanity, irritability, and gênerai emo- tional instabilité of thèse patients lead to exaggeration, moral blunting, and conséquent impropriety of conduct, which is also expressed in alcoholic and epileptie insanity. The delusions and hallucinations are rarely ad- hered to, are échangeable, and are not always real, but arc due to what may be called a willful autohypnotism or voluntary indulgence in image- forming. So lively and absorbing is this process that a morbidly active woman may pass into an eestatic condition, examples of which are com- mon enough during times of religious revivais. Such patients are dis- posed to mutilate themselves for the purpose of gaining sympathy and notoriety, and are untruthful, sexually debased, and prone to make un- just charges against innocent people. Helen Miller, whose case is reported by Dr. Chaiming (Am. Journal of Insanity, January, 1878, p. 368), came under my observation some years ago. She had committed thefts from doctors' offices, and was arrested and sent to prison. While there she began to feign insanity and was sent to the Asylum for Insane Criminals. She had been of hysterical habits, had eaten opium, and was treated by one of the physi- cians she had robbed for dysmenorrhœa. Her first exploit in the asylum was to prick her gums, and the blood therefrom was mixed with urine and crumbled bread, so that an attack of hematemesis was suggested. She had several attaeks of hysterical dysmenorrhœa, was irritable, de- pressed, and had fits of temper. Then she began a System of self-muti- lation which was something extraordinary. At various times she thrust pièces of glass, splinters, and other things into various parts of her body ; eut herself with pièces of tin and a broken bottle. Upon one occasion she broke lier chamber over her head. Dr. Channing removed no less than ninety-four pièces of glass, thirty-four splinters of wood, two tacks, four shoe-nails, one pin, and one needle, at various times. In this case the woman's pride seemed to be that she was the object of sur- gical interest and of sympathy. I saw her after her transfer to the BlackwelPs Island Asylum, where she was sent after her second arrest for theft, as she had been discharged from the Auburn Asylum when lier first sentence had expired. She was hysterical, but I found no impress- ing intellectual dérangement, and I should not consider lier legally in- sane, though her psychosis was in some respects a grave one. Cases are detailed where women hâve set Are to buildings, or the clothing of children, and were unable to give any motive for the crime. There is another class of cases the subjects of which claim that they hâve been outraged or maltreated, and give the impression that self-inflicted wounds were made by their assailants, and as a resuit innocent persons are occasionally arrested. In such cases local examination will rarely reveal any indication of violence, but in cases of women of questionable purity it is a difficult matter to swear positively from any examination that their stories are not true. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 95 The papers were filled some years ago with the remarkable déclara- tions of a young woman, who lived in an inferior town in New York, and who claimed that while alone in the house she was surprised by the entrance of niasked robbers, who bound and gagged her, and applied chloroform upon a cloth to lier face, and after assaulting her brutally she became unceaise-ions. The story was se.) palpably fraudulent that it should bave received little or 110 récognition by those about her ; but, as in other cases of the kind, we find sympathetic friends and a sensational press ever ready to believe in and give publicity to the hysterical plaint of the impostor. In this case the ropes that bound her were evidently applied by herself, and the quantity of chloroform alleged to hâve been used, a small bottle having been found (wdiich it transpired she had bought herself), made her story appear at once manifestly absurd. This case is unlike the last in the superficial eharaeter of the disease. Hysterical insanity is occasionally épidémie, and may appear as the resuit of imitation. Folie à deux, which is generally consielered a more serions form of insanity, is, I believe, nearly always of hysterical origin. I bave 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 lier health, but no benefit was de- rived from the change, and she grew more violent and unreasemable. Her mother, and a sister very nearly her own âge, 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 véritable hysterical mania. They raved, and became so vio- lent that the hôtel 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 conelition being mistaken for drunkenness, they were arrested, but were finally released and again began their journey to New York, the mother being now in a partially responsible state, as she had been half crazed by the excitement and disgrâce. They finally reached New York and went to a hôtel, where they stayed for a night only, as one of the sisters tried to force her way through the fanlight over the door of her room, anel 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 responsibility is an interesting one, and it is évident that the final action of the Albany judge, who first thought the patients intoxicated and afterward sent them out of town, went to show that the behavior of the girls was not looked upon as criminal. VIII. ALCOHOLIC INSANITY, Or, more properly, the insanity of alcoholism, is an acute or chronic condition produced by the toxic use of alcohol in its various forms. Where the alcohol is fortified by an essential oil, as it is under the form of absinthe, the effects are corresjïondingly modified. Acute alcoholism, or delirium tremens, does not properly come under the head of insanity, 96 A SYSTEM OF LEGAL MEDICINE. and is not ordinarily so considered. Its fréquent présentation as an ex- cuse for crime meets with no favor, for the law usually very properly holds that when an irresponsible state is voluutarily proeluced, the indi- vidual is liable for his acts ; yet there are perie)die'al drinkers whose cul- pability is certainly deserving the leniency of juries. To this class belongs the dipsomaniac, whose excesses are separateel by periods during which his conduct is irre'proachable, and when he eloes lapse it is under the domi- nance of an insane appetite. The mental disturbance of acute alcoholism is the lively delirium, visual hallucinations and delusions, motor activity, and exhaustion. (■hronic alcoholic insanity is manifestée! by a train of progressive symp- toms of mental degeneration which vary greatly. The most important indication of the prolonged saturation of the nervous organs with alco- hol is an impairment and weakening of the mental functions, conspicuous among which is the moral enfeeblement. The familiar change of ehar- aeter is one that needs no description. Nervous irritability, the disregard of obligation, untidiness in dress, sexual perversion, lost sensé of honor, manifested in lying and other directions, indifferene'e as te> domestic and social duties, are ail every-day results of a prolongée! abandonment to drink. Advanced grades of détérioration 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 persécu- tion and suspicion. One quite charaederistic is that entertained by married men regarding the chastity of their wives. Persistent halluci- nations of hearing are also présent, are always of a distressing ehar- aeter, and the patient may be urged to suicide by imaginary voices; while sensory hallucinations which origin ate in the abdominal organs or those of génération 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 récurrent cases of the criminal insane collated by Lewis in which alcoholism largely figured. The visual and aurai in about the same proportion, and both associated in a few cases ; olfactory hallucinations or illusions were seldom notèd, 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 part of those around him. One patient receives a nightly 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 f rames into some idea of coming torture. Another patient, twenty-eight years of âge, addicted to intempérance in drink, and the subject of a serious cranial injury in youth, calls himself Sir Roger Tichborne, and accuses his relatives of filling his bedroom with the vapor of chloroform. 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 " (loc. cit., p. 215). Such physieal 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 IN ITS MEDICO-LEGAL BEAEINGS. 97 paralysis of the lower part of the body develops itself, and may be at- te-nded by cramps, deep pains, suggestive neuritis, or by an incoordina- tion, with plantai- amesthesia, which often leads to the mistaken diagneisis of locomotor ataxia. This anaesthesia is pretty gênerai, especially if the consumption of alcohol is constant, and points to a graduai inflammation not only of the large nerve trunks, but of the ultimate filaments as well. The skin of tlm legs is apt to be "shiny" anel smooth. Although some of thèse symptoms rnny improve 01* disappear if the alcohol be with- drawn, there can be only one ending as a resuit of continued indulgence. The " paresis " of alcohol is very much like classical paretic dementia, the delusiems of grandeur, perhaps, being more constant in the former, and the delusions of suspicion more systematized. The tremor is coarser anel more gênerai in alcoholic paresis. The gastritis of alcoholic paresis is of course not found in the other insanity, nor is the amesthesia or the fulgurating pains (except in the ascending form which follows tabès spinalis). Paretic dementia is not modified by treatment, as is the variety under considération* The medico-legal importance attached to ail forms of alcohohc insan- ity is fully proved by the freepiency of cases where it is the issue. It is allégée! as a cause of testamentary weakness, or in fact where the assump- tion of an improper obligation arises ; and the protection of the courts is often sought for individuals who are said to be incompétent. In ail of thèse cases the epiestion of the existence, degree, and duration of the * Alcoholic Insanitij complicated with Pa- ali/sis. Headache. Active hallucinations affeeting ail the sensés ; disordered vision (illusions). Délirions conceptions dei>ending upon hallucinations ; ideas of persécution, ten- dency to suicide, evil instincts, conscious- ness of dégradation. Embarrassed speech, depending sorne- 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. Amesthesia 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 éructations, voiniting of mucus in the morning. Diminution of the generative functions ; frigidité. lu adily cured or modified. Oecasional supervention of delirium tre- mens. Paretic Dementia. Generally no headache. Enfeeblement of the understanding ; rarely hallucinations. Ideas of grandeur and self-importance. Embarrassed speech, depending upon feebleness of the conceptions and paral- ysis of the muscles of the face. Feebleness of the inferior members, more marked generally upon one side than the other. Nothing appréciable in the superior limbs ; sometimes default of coordination. Pupils often unequal, 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 A SYSTEM OF LEGAL MEDICIXE. # cause is to be determined, as well as whether the allégée! irrespemsibility is due to a comparatively rapid toxic origin, or the mental distiirbaime mask.s a graduai and permanent disorganizatiem. The connection of alcoholism with insanity at Charenton has been studied by Thorneuf (Annales Medieo-Psychoîogique, 1S59, p. 365), who thus classifies alco- holism : 1. Acute alcoholic intoxication, in which the effect is always immedi- ately hnked to the cause, and the duration of which is dépendent upon the existence of the cause. 2. Subacute alcohoHc intoxication, supervcning to the immédiate action of the cause, usually melancholic in eharaeter. 3. Chrome alcediolic intoxication, which results in organic changes in the brain and nervous System, with accompanying insanity. Of 350 hmatics treated in Charenton, when Dr. Thorneuf was an in- terne, the insanity in 102 cases was due to alcohol : of thèse, 15 percent. were of delmum tremens ; 6 percent, were of drunken mania ; 1 percent. was of congestive mania ; 34 percent, were of paretic dementia ; 4 percent. were of folie circulaire ; 2 percent, were of dementia; and the remainder presented epileptiform convulsions and anomalous psychical symptoms. IX. MELANCHOLIA. This most familiar and common form of insanity is classified, with regard to its duration and clinical features, as acute and chronic, and clinically as simple melancholia; melancholia apathetica or atonita, or stuporous melancholia ; and melancholia agitata, or anxious melancholia. Simple melancholia is a state which is accompanied by intense de- pression, with painful delusions of a fixed but limited eharaeter, usually consisting of those which imply complète déjection and hopelessness, and may lead the person who entertains them to commit suicide. Through a condition of impaired 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 punishment. Such a form of melancholia is of slow development, and is précédée! by continued ill health, loss of appetite and insomnia, which becomes more and more profound unless rebeved. A naturally happy and joyous person becomes sad, reserved, and takes little interest in her surroundings. There may be an over-sensitiveness and a sensé of per- sonal shorteomings and a feeling of self-depreciation ; the patient is torturée! by doubts regarding her religious views aud 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, beheving her présence there will pollute those whom she may meet ; and one who has led a blameless and pure life may con- sider herself the lowest of women. In other cases the dépression exists in regard to more worldly things : the merchant will beheve that lie is bankrupt, that he is dishonest, or that he is the spécial object of con- tempt among his business associâtes. The patient is slow in his actions, and moves sluggishly and with. INSANITY IN ITS MEDICO-LEGAL BEAEIXGS. 99 reluctance. It is with difficulty that his attention can be aroused, and that his mind may be fixed for a short time upon some given subject. If an effort is made te> réassure him lie is incredulous and as dejected as ever. The appearance of melancholia of ail kinds is characteristic, and the physieal symptoms are those indicat- ing the existence of amenda (Fig. 23). The skin is often harsh, dry, anel pale, as are the mucous membranes. The white's of the eyeballs are of a dull, fiât white : the pupils are dilated and sluggish. 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-nads, which are due to détective nutrition and the constant habit of picking. The extremities are eold and clammy, with poor réaction to rubbing. The hair is damp and limp. Occasionally the patient will pluck out the eyelids or the hair from the head, with resulting deformity and highly characteristic change in appear- Fig. 23. (Shaw). ance. Respiration is apt to be slow, as is the puise. The patient may urinate copiously when excited or espe- cially anxious, and the excrétion will be of light color and lowr spécifie gravity. Constipation is also characteristic of melancholia. The surface and the eleep te-mperature are lowered, the latter being often subnormal for long perioels. Many patients complain of occipital or vertical pain and the sensé of pressure, which are probably due to cérébral anaemia. Hypochondriacal melancholia is a persistent form of disease which may be the outeome of ordinary hypochondriacal introspection ; the sub- ject ultimatdy believing that a serions and material altération lias taken place in his internai organs—that his brain has been removed, or that his bowels are impervious, that his food •• passes through him," that lus 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 dépression may be extrême in their depth. The patient can be aroused with the greatest difficulty, and im- mediately résumes his constrained, fixed position and absolute silence. He often sits for long periods, occasionally sighing, and lus external appear- ance is indicative of his mental torpor and bewdderment. Such patients will for hours retain morsels of food between their teeth and cheeks, being too indiffèrent to masticate or swallow; at times forcible feeding is absolutely necessary. Occasionally, especially in youthful subjects, there will be a tendeney to catalepsy, the muscles of the extremities being 100 A SYSTEM OF LEGAL MEDICINE. at times so rigid that it is possible to put the members in constraine-d positions which are maintaineel for a long time. The profound dépres- sion is sometimes varied by fitful flashes of intelhgence or some impulsive act, which is as likely as ne>t to be suicidai. Thèse patients upon ree-ove-ry are able to reeall the delusion, and its influence which bas possesseel 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 émotions. Restlessness, vie>lence, and often suicide or self-mutilation are exhibited or resorted to. The patient is active by day as well as night, can be taken eare of only with the great est difficulty, and wears himself out in useless effort. Delusions, hallucinations, and illusions are ever présent, and auditory hallucinations are the nmst torturing. The patient is told to do certain things by voie-es that come from water-pipes and holes in the wall. Visual and sensory hallucinations, too, adel to his mental terror. His bed swarms with im- aginary vermin. If he be suspicions that he has been poisoned, lie will make more or less successful 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 wavs the delirium of acute alcoholism is sometimes suggesteel, at others it approaches the excitement of mania; but in the former there are actual persécute>ry delusiems and in the lat- ter there is incohérence, due to the rapidity of outside stimulation, which reflects the elated and pleasurable state of the émotions. There is rarely auy disposition to the infliction of injury in melancholia, except se» far as suicidai attempts are concerned. Thèse are common, and the results of the hopeless delusions anel hallucinations. So far as the physieal disorders relate to the mental state it is the fact that there is much more gênerai constitutional disturbance with anxious melancholia than any other form. Some e>f it is due to want of sleep, and to the attempt at voluntary starvation which springs from the delusion. Chronic melancholia is the natural outeome of a continued dépres- sion which need not necessarily end in dementia. Sometimes, especially in the sexual forms in women, the chronicity is attended with a great deal of reasoning aeîuteness, and what Kirchhoff calls a folie raisonnante in a melancholic form, with alternate dépression and angry exe'itement. Melancholia is often curable. The first danger of exhaustion from star- vation is the only one likely to bring an early fatal termination, except it may be suicide or intercurrent disease. If the patients disease lasts one year it is apt to be permanent and incurable. When it originates at periods of sexual deveh>pment, such as puberty, at childbirth or the cli- macteric epoch, it is rather apt to be obstinate. This is especially true of the puerpéral form. x. MANIA. Mania, like melancholia, is an acquired insanity, though uneler certain conditions it may symptomatize both evolutional anel involutional insan- ities. So far as its duration is concerned, it, like the dejn-ession psyché>sis, may be either acute or chronic. The term subacute, 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 INSANITY IN FIS MEDICO-LEGAL BEAEIXGS. 101 e ontinuance. Like melancholia, it is apt if not cured to eud in terminal dementia. The emotional activity and intellectual exaltation are mani- fested in a rapid flow of ideas, which are not inhibited, and the resuit is incoherene-e. Acute mania is often of quite sudden development, though usually the way is paved by some dedine in the gênerai health. In the cases that usually eîome under notice a history of altération in mental health is evineed 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 spas- modic. His self-satisfaction and sensé of importance prompt him to enter into schemes more or less wild, his generosity is exubérant, and he makes the grandest promises, without any idea as to how he shall fulfill them. If lie is cre>ssed or doubted his anger is quickly aroused, but short-lived, anel the affront is forgotten immediately. His mind seems to be a kaleidose'eqie of evenz-ehanging ideas, which later become more and more e-onfuseel. He is restless, lorgets obligations and appoint- ments, sits up until late, and sleeps but for an hour or two, and after- warel not at ail. He gesticulâtes, and his manner is hurried and inipetuous. His letters refiect his topsjr-turvy state of mind and re- fer to his schemes. Thèse are often innumerable, and lie writes to every e>ne he has heard of. The télégraphie wire is kept busy with irrelevant or unnee'essary messages. His dress reflects his condition, for lie is slouchy, and his clotbes are carelessly put on anel often iinbuttoned. Some- times he orders and wears 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 fiushed, and his pupils are di- lated and mobile. The patient will busy himself doing and un- FiK. 24. (Dickson.) doing, fussing, and arranging and rearranging furniture, chdhes, or other things. Various moral changes appear in conversation and conduct. Thèse vary greatly, and the connnissiem of shanieless acts, the making of indécent proposais, or, at a later period, when the incohérence and confusion prevail, the défilement of himself with farces, are common évidences of loss of con- trol or évidences of sexual irritation. As the psychosis becomes more and more pronounced, the patient becomes more frivolous in dress or absolutely indiffèrent. He occasionally décorâtes himself with fantastic objects. ' One' of my patients, who was the subject of chronic mania and had acute exaeerbations, was in the habit of putting on a white satin 102 A SYSTEM OF LEGAL MEDICINE. ball-elress when she arose, and loading lier nee:k and wrists with dia- monds. She woidd give herself up to amorous thoughts and conversa- tion, and write erotic letters and poetry to men she knew but slightly or not at ail. So-called kleptomania is apt to be an incident of such develop- ment, and it differs from the kind due to imperative concepts by reason of the fact that in this disease the intellee-t is disordered. The thefts are of ail kinds, and bits of worthless rag, keys, bits of glass, or trifting objee-ts are stolen and secreted very much as a magpie would. The patient is also at times prone to indulge in low vitupération, 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 foui worels of the gutter and cannot be re- strained. When the disease lias increased to the point where the excitement is intense and the patient is incohérent, the hallucinations, illusions, and delusions are dominant and so ae-tive as to suggest delirium. Ail forms of intense motor activity 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. Sonietimes the patient deelaims energetically, flourishing his arms, and walks bombastic- ally up and down. Sometimes there is an exaggerated dramatic power of expression, a simple act being performed in a grandiloquent way. He décorâtes himself, as well as his rooni, with odd objects, mixes up his food in a disgusting mess, and eats ravenously. His hallucinations fol- low one another with great rapidity, and lie has freepient conversations with imaginary people he sees, which are not interrupteel by 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 démonstra- tions of the most marked kind. Local anaesthesia or hypera?sthesia, the former of which consists in in- sensibility to extrêmes of température, and the latter to headache and subjective discomfort, may be mentioned as symptoms. This heighten- ing of sensation maybe the origin of olfactive hallucinations, which are présent in about fifty percent, of ail cases. Fig. 24 represents very well the expression of exaltation so characteristic of this form of insanit}r. Mania is nearly always preceded by some dépression, and the activity of mental opérations which is sometimes evinced by a reviveel acuteness of memory must be looked upon with suspicion. After the continuance of the acute condition, which is expressed by the impulsive conduct and is variable in duration, we find convalescence and ultimate cure, or a chronic mania or terminal dementia. The duration of cases which are to get well 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 cemdusion, and a safe prédiction. When a case becomes chronic the mental condi- tion is often one of extraordinary evenness, though ail sorts of disorderly manifestations may occur from time to time. The chronic maniac of asylums is usually a moderately noisy, active patient, who always lias a collection of rather uniform 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 7VN.LV/Tr IN ITS MEDICO-LEGAL BEAEINGS. 103 and more disorganized and absurd, and whose incohérence is not con- fined to any part of the day or night. Some who présent the incurable form of this disease are harmless enough, and are capable enough to do farm-work requiring little or no ineiividual exercise of judgment. Ac- e-ording to the statistics of the Hartford Retreat it would appear that 52.1+ percent, of acute cases recovered and 20.2+ percent, were im- proved. Of the chronic cases 27.4+ percent, im proved or recovered. Of e-ourse the progression dépends upon the frequency and extensive vio- lence of the active congestion of the brain and the causation of organic changes. Typhomania (délire aigu) is a form of intense excitement of sudden origin, often due to shock or fright, and is characterized by a complète mental blotting out, or, as Lewis calls it, mental oblivion. There seem to be absolute incohcrence, babbling and confusion, and physieal signs of extrême exhaustion from which it gains its name : thèse are a rise of température, great exhaustion, sordes upon the teeth, scanty urine, a glazed or brown longue, involuntary stools, etc. The patient fads from the first, and usually succumbs in a short time. XI. PUERPERAL INSANITY. Puerpéral insanity is a psychosis of women, having relation to child-bearing, as its name implies, and is connected with the accom- plishment of delivery. It is sometimes dépendent upon exhaustion or septic poisoning, or both, and develops in from one to several weeks. The insanity of early appearance is usually maniacal. The patient does not siée}), but manifests great incohérence and violence. She smears her- self with fecal matter ; curses, and manifests great motor activity. Ex- haustion is rapid and great, and death may even follow in a week or two. A later form appears in a month or more, and is melancholic in eharaeter. The woman usually develops an indifférence or actual hatred toward lier child, which she may murder, while the tendeney to suicide is by no means unusual. Sennetimes there may be no indication of the real state until a crime of violence is 4>erpetrated. This is especially the case in remote and isolated régions of the country, where ail the subtle indica- tions of growing mental weakness are disregarded and looked upon as évidences of " ugliness." In this connection an abstraet from the con- fession of a puerpéral patient who killeel her child may be presented. This patient was tried for her life and sent to the Utica Asylum, nar- rowly escaping the penalty of the law. The case is suggestive, because it shows the existence of imperative concepts and perhaps auditory hal- lucinations. The subject was a young woman (see vol. i., p. 194, Figs. 36 and 37) who less than one year after her marriage killed her child. During her imprisonment she prepared the following statement. The first part, which is omitted, deals with her early married life and her disagreement with lier husband, Avho selfishly ignored her real state of mental dis- order : I did not want to live any longer; it seemed as if I had no friends, as if ail were against me. Through the summer tliese spells gained upon me ; would walk my room nights and cry as if my heart would break. M---- [the husband] would be angry with me for disturbing lus rest. He said at one time " he thought it very strange. Some- 104 A SYSTEM OF LEGAL MEDICINE. times I could not do enough for him, then at other times I acted as if I hated him." The 4th of July we went to O----. I proposée! going, as we had not been away from home but a few times since we were married ; told him I should enjoy the dance much more than ever before, to hâve him join, as it was no comfort for me to go when he played.* I gave him money enough to pay the bill, as he would not hâve went if he had had to pay. Mother had paid me at différent times for helping her, and out of this I gave him. I was not right for a few days before the dance. felt very strange, but thought I might feel better for going, but did not. It was a misérable night to me ; going home I wept, felt very badly ail that day and night. . . . After the baby was born it slept with me one or two nights. Then I rcmember Mrs. H----, my mother-in-law, came to my bed and took the child away from me, pretending that she was afraid M----or myself would accidentally hurt it, as we were not used to chil- dren. I was afraid of'lier, and dare not speak, and let the child go. I remember when my milk came she seemed determined not to hâve it nurse. Whenever Mrs. D----or Mrs. A----tried to hâve him nurse, she was as angry as could be, and said she thought they would kill the child. She never tried to hâve him nurse me. When- ever I would hold him and rock him, she always seemed displeased, and would say it would get him into bad notions ; so I dare not do anything with him—hardly hold him ; she seemed to want to take ail the eare of him. When he was about a week old A----H----and wife came one day, and as I was not able to do anything I held him most of the forenoon. Mrs. H----hinted about it several times, saying that was what spoiled him. A day or two after this I began to hâve such horrible feelings. It seemed that as if he or I could die it would be much better, as there was no comfort for me in the world. Something seemed to say to me, "It must be done." One day, as I was lying on the bed beside him, the thought suddenly came to me to strangle him by pressing the clothes tight about his neck. I did so, then got up and left him. Mrs. H----soon went after him to feed him. She thought he was dead ; she seemed much excited. I remember I was sitting by the stove as she brought him out, and remember her saying he was as limpsy as could be. Afterward she told the men that the clothes must hâve got over his face. About a week after I tried again, in my anguish and sorrow, to end his days by smothering, but, as before, he come to. It seemed as if it must be : something constantly seemed to say to me, " It must be done : lie must die or yourself." . . . A few days after I was confined Mr. H----came to the bedroom door and asked me what was the matter, as he had seen from the kitchen that I was crying. I don't know what rejdy I made. Before the E----dance, also the L----dance, I felt very strange and cried. M----said "I was only mad because he was going." The only objection I ever had to his playing was 1 never could go with him but there was trouble. He was jealous of me without any cause whatever. Pie told me before we were married that after we were married he never should play for another dance ; that he did not want to play and was not obliged to for a living, and wanted to give it up. The first I knew about that box of poison t M----called my attention to it when we were first there. It was in a small cupboard in the kitchen. He took it from the cupboard, saying S----'s folks had left it ; also said that a little of it would soon finish any one. From that moment the thought went with me that I could take a dose my- self, or give it to the baby, and we would be done suffering. I tried to drive this thought away, but could not. It did not seem wrong or as if it would be wicked. It seemed as if it must be : that voice or voices constantly seemed to say to me, "It must be done ; it must be done." One day when I was alone I had such horrible feelings ; that voice sounded so loud, saying those words, "It must be done," that I took the box, and was just going to take a dose myself when old Mrs. B----came in. I re- placed it, and talking with her seemed to arouse me. After she had gone I shuddered to think how near I had come to death ; went and put the box upon a high shelf in the pantry where I thought I would not be apt to get hold of it when I had those spells. Told M----when he came home that night where I had put the box, as I was afraid to leave it in its former place. We did not take the baby with us when we went to housekeeping. I did not want to take it. Mrs. H----seemed willing to take eare of it, and I was very willing she should. When at H----'s I preferred doing housework instead of taking eare of it or holding it. The Saturday before the lst of April, M----and myself went over to my father's. * The husband and wife were hop-pickers ; he played the violin at country dances. t Box of •■ Rough on Rats " with which she poisoned her child. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 105 as I had some machine-sewing to do. While there I began to hâve such horrible feel- ings—such a terrible feeling in my head—that I hardly knew anything. Mother fin- ished my sewing, as I could not. Ail I could think of was that poison. It seemed stamped upon my mind, and those voices repeated again and again those same never- ceasing words, "It must be done; it must be done." The last I can remember are tliose words ringing in my ears. From that time until the lst of June everything looks dark to me, and do not hâve a distinct remembrance of anything. During this time she actually forced rat-poison down her child's throat. After its death, even, lier conduct was looked upon as a display of simple perversity, and in most matters she behaved as she always had. XII. TRAUMATIC INSANITY. Considérable medico-legal importance is attached to tliose insanities that follow head and other injuries ; and suits for damages, though not so common as when spinal concussion is urged, are sometimes brought. As a result of a récent or ancient blow to the head, or other exhibition of force that may resuit in what is known as commotio cerebri, we are furnisheel with mental disorders of a more or less serions nature, the mode of causation of which lias been before alluded to. Such disturban ces of intellect are extremely variable, and may on the one hand consist in temporary confusion, or in much more grave and lasting psychoses due to degeneration. Ri gai (Annales d'Hygicn-e Publique, April, 1894, p. 340) lias recently written upon the. insanity due to cérébral commotion, and says that the impen-tant forms of aliénation are : (1) Reasoning insanity, whiedi Trélat calls/e//V lucide, because the intellectual faculties are gener- ally so active, but there is a peTversiem of the moral side ; (2) monomania (paranoia) of brusejue development, and rapidly ensuing dementia; (3) a confusional condition. In fact this author, as well as Magnan, Bail, and other French writers, believes that there is hardly a form of mental disease that under certain conditions cannot be pre>dueed by head-injury. Under some circumstances a sIoavIv forming organic insanity follows. whieh may resemble paralytic dementia. Spitzka is disposed to lay stress upon the fact that the subjects who are most likely to develop this kind of mental disease after injury présent the' •• traumatic neurosis," or preparatory basis. Sue'h a foundatiem exists in the cases where there is a hysterical tendeney, just as it does in "rallway spine," and a psychosis of an irregular nature follows, which is symptomatized by a sensory hyperresthesia and motor weakness. Intellectual changes of slow growth often follow slight shocks. Thèse manifest themselves in the departure from former habits and fastes ; moroseness or excitabilitv, immoral tendencies, and mental weakness are induced. Gall speaks of a man who was injured by a falling tile, which penetrated the brain. Before the accident lie was an amiable, steady man ; af terward he was quarrelsome, and fiew into a rage at little things. " W. H., about whom I was consulted some time ago, was a steady and respectable tradesman until he fell from some steps while cleaning a shelf in his own slmp, and was stunneel for a few seconds. From that time lie undcrwent a change. He no longer attended to business, to which lie had been formeilv deveded ; he speculated and lost his savings; he mani- fested antipathy toward his wife and two out of his five children, and 106 A SYSTEM OF LEGAL MEDICINE. saw his whole family reduced to penury through bis own rashness and neglect without displaying any compuncfions. When complète pecuniary ruin had been effected lie suddenly became himself again, and resunied industrious wavs, but ever since he bas had attacks of restless excitability, with hatred of bis wife and children, twice or thrice a year. He is at ail finies intelligent, rational, and free from delusions. anel when at his best ])eriod joins his relatives in deploring the sad visitât ions to which he is liable." (Browne.) Dr. Charles H. Hughes [American Journal of Insanity, 18) alludes to the peculiar nientarstate of duality which sometimes follows head in- juries—a condition in which one hémisphère appaivntly fills a vicarious office. He refers to a case presented by Joffe, and gives the main points of the history, which is the fohWing: "He was a married man, aged fifty-three, healthy in chiklhood and youth, in manhood had headache anel gïddiness ; 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 anel constipation for ten years. Disposition serious. His memory failing, he became unfit for service and was discharged in 1861. His pecuniary circunistances caused him great anxiety, and in the same year (1861) he exhibited unmistakable signs of mental disturbance. He continually employed the expression t we'—' we will go/ 'we will run,' ' we will do it,' etc. The 'other' man pulled his ear, plucked his arm, etc. His left arm had spasmodic twitch- ings. He invited himself to dine with his sister, saying that the 'other man' compelled him to be lier guest. While eating lie said, 'I bave eaten enough, but the other has not.' After the meal he ran out of the house ; when arrested said the 'other' was to blâme—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 gulter, thinking he was wrest ling with 'the other,' and finally attempted to commit suie-ide, imagining he was killing 'the other.' This brought him to the hospital. The con- formation of head was normal, pupils contractée! unequally, réaction to light in both limited. Hearing normal, but saw small animais, 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 dry, and température anel sensibility of body natural. Puise sev- enty-eight. Reflex movement to tickling soles of feet prompt. Xo 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 ail his misfortunes. He sometimes presented the picture of anxiety, dripping with sweat, and holding fast his shirt with both hands, in order, as lie said, to make himself stop. He had violent impulses to motion, lasting an hour or two, occurring several times in the course of six weeks, and which were probably epileptie or epileptoid seizures. After conversing some time, long enough probably to weary and morbidly disturb the sound hémisphère, his ideas grew confused, and it was impossible to gather any sensé 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 faix there was a lamina of bone half an inch long and a quarter of an inch broad. The membranes along the course of INSANITY IN ITS MEDICO-LEGAL LEASINGS. 107 the vessels were opaque, infiltrated with sérum, their veins quite full. Convolutions of the anterior lobes, especially the left lobe, very much thinned on the convexitv—left anterior lobe half an inch shorter than the right. Anterior half of ventricle of this side was adhèrent and hard. Optic thalamus and corpus striatum atrophied—especially the latter. Brain moist, anamiic, tough. Ependyma of the latéral ventricles thick- ened and granulated, corresponding to the thinned convolutions of the anterior lobe. The cortex was thinned, and the adjacent medulla was indurateel to the touch.' " The loss of memory that may occur after cérébral injury may or may not be connected with other symptoms of insanity. When we consider that the lésion may vary from a simple ischémie one, due to concussion, to a minute and gênerai disorganization of the brain substance, it is reasonable to expect widely varving symptoms. Bell arranges the de- fects that may follow a cérébral traumatism as : " 1. An instantaneous unconsciousness, that is to say, loss of récognition of one's individuality, folio wed by giddiness, stupidity, foolish talking, etc., which may pass off sooner or later, but still is in immédiate 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 innammatory changes in the cramai contents, feverishness, delirium, elreams, etc., passing off into fever or lapsing into coma, from compres- sion : if from hemiplegia thèse 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 eharaeter, beginning with structural changes in the cranial contents in the direction of atrophy or softening, where you may hâve 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 différent cases from minutes up to hours and even days, with ail its ae-fions, pains, and pleasures, before the accident hap- pened." A récognition of this condition of affairs is of immense impor- tance in those cases where testimony is given concerning the détails 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 injured, or bis behavior at the time ; and it may perhaps be insisted that he was drunk, when such was not the case. After surgical opérations of various kinds the subject may suddenly develop a confusional insanity, which is short-lived, and violent while it exists. Whether due to shock, loss of blood, or reaction following men- tal appreliension, it is difficult to say. It would appear that gynecologieal opérations in particular are those which are most frequently followed by the lighting up of mental symptoms. XIII. POST-FEBRILE INSANITIES. The fevers and other diseases in which exhaustion 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 A SYSTEM OF LEGAL MEDICINE. either at the turning-pomt in the particular affection or during conva- lescence. There is no régulai- expression of symptoms, and illusions, hallucinations, and delusions, which are generally unsystematized, are irregularlv expressed and are varied. Sometimes the condition, by rea- son "of its incohérence, is confused with delirium, but unlike the- latter is inconstant, and seems most pronounced in the night, the patient being fairlv in possession of bis faculties during the day time. The writer bas seen several cases of insanity after typhoid fever in which the symptoms appeared one or two weeks after the subsidence of the symptoms of the fever itself. In one of thèse cases there was wild incohérence, a rise of température, and refusai of food. A few of the cases beconie chronic or run into dementia, but as a rule they recover gradually, and sometimes suddenly. XIV. DEMENTIA. This degeneration, which when it occurs always implies the beginning of the vital end. may be the resuit of a continued simple (acquired) form of insanity, such as'melancholia or mania, when it is known as secoudary consécutive dementia ; a disease by itself, when it is known as primary de- mentia, paretic dementia, and senile dementia; or a resuit of destruction incident to such forms of coarse brain disease as hemorrhage, embolism, or thrombosis. AU forms of dementia dépend primarily upon the loss of stored-up impressions; in other words, an actual deprivation : in this respect de- mentia differs from amentia, where no development bas taken place. Its extent dépends upon the richness and variety of ste>red-up concepts, and its progress upon the acquired degree of automatism and the habituai régulation of concept stimulation and coordination. Memory is impaired proportionately with the degree of enfeeblement, and the involution, which keeps pace with the advance of the disease, implies, first, a loss of memory of substantives, a blotting out of récent impressions, and a ré- tention for a time of those acquired before the destructive effects of dis- ease had beguu to extensively make themselves felt. In comparatively récent cases old concepts are recognized, expressed, and acted upon, whde new percepts make fugae-ious impressions or none at ail. The business man will automatically follow out the routine work of years, while new créations are impossible and other forms of e'apae-ity may be lost. An isolateel instance of ability and shrewdness will be urged as an index of the mental health of the allégée! lunatic, when he occasionally correctly performs some long-learned and frequently prac- ticeel act. ITtimately everything goes, and the mind becomes a blank, and the dément is physically and mentally slow and inactive. He later becomes little more than a child, with ail of its weaknesses and silliness and irritability. He is occasionally pétulant, and sometimes violent in a weak way. When the disorganization has sufficiently advanced the patient sinks into a végétative state, disregarding the ordinary deeencies of life, urinating or defecating in his clothes, or masturbating publicly. The posture lie 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 vacancy, or they are averted, while the saliva drools from the corners of his mouth in a glairy stream. INSANITY IX ITS MEDICO-LEGAL BEAEIXGS. 109 XV. SENILE DEMENTIA. This term has been applied to a variety of primary dementia occur - ring in aged people, the word primary being used to elenote an original condition, and not a disease which is a séquence of other morbid states. It is rare before sixty, and when it occurs later in life is difficult to dis- tinguish from the natural deeay of old âge. Its early symptoms may be dépression 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 persécution, and he is apt to believe that lie has been robbed. He conceals and hides his papers, or puts useless objects he may hâve hoarded in out-of-the-way places. He may tie a stone or cigar-end in his pocke't-handkerchief, or secrète bits of thread, buttons, etc., in his différent pockets. Ile 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 indécent advances to little girls or boys, exposing his genitals in the streets. In a more ad- vanced form he urinâtes publicly and ostentatiously ; is careless of his dress, leaving his trousers unbuttoned. He is vacillating, and apt to sepiander his money recklessly ; enters into absurd schemes, or gives his ]>re>perty away to persons who hâve no claim upon him whatever. He is the prey of sharpers or confidence men. His erotic excitement will often subject him to the arts of designing women, who for one purpose or another seek to gain control of his property. Such old men are apt to marry worneui many years their juniors, and to resent the interférence of their chddren, upon whom thew turn, often disinheriting them. In fact they are inconsiderate anel without affection. Sometimes their sexual weakness leads to the writing of love-sick letters to numerous women at the same time, the writer being unconsciems of the ludicrous position in which he has placed himself. The mind toward the end becomes more and me>re weakened, and the patient sinks into an exhausted condition and finally dies. XVI. PRIMARY DEMENTIA (OF YOUTH). Primary dementia, so called, is a somewhat misleading synonym for stuporous melancholia ending in dementia. It has by some been applied to the dementia of adolescent insanity. Spitzka classes this dementia and Hiat of senility together, very properly believing them both to be involutional degenerations—in which conclusion I am disposed to agrée. Acute dementia lias been spoken of, and has been used to designate that form of rapidly developing mental weakness so common sometimes in youth. Thèse patients, as a rule, manifest a dépression, with introspec- tion and silliness. The dépression deepens into a state of hébétude, with silence which is so pronounced that it is often impossible to draw forth any response. The young subject may be indiffèrent to his surroundings and to ail the demands of nature. Occasionally such dementia is pre- 110 A SYSTEM OF LEGAL MEDICIXE. ceded by an insanity which consists of dation, inordinate e-one-eit and vanity, religious doubts, and sexual aberration manifested by masturba- tion or onanistic hypochondriasis. A degree of forgetfulness and e-onfu- sion follows this. There are not necessarily hallucinations or delusions. XVII. PARETIC DEMENTIA. (General Paresis; General Paralysis; Dementia Paralytic.) This important disease is of a progressive nature, runs a compara- tively rapid course, and is symptomatized by important departures from the normal psychical and physieal condition. True paretic dementia is a disease of adult life, though exceptional cases hâve been recognized in childhood as a resuit of congénital 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 resembling it. One is " alco- holic gênerai paresis," which is an irregular form of chronic alcoholism ; the other " pseudo-general paresis," which is due to active coarse cérébro- spinal destruction, due to syphilitic infiltration, and the spinal symptoms are as important as the cérébral. Some writers hâve sought to make close differentiation of forms which hâve 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- ieal symptoms are presented. Beginning with slight altérations in man- ner, which are often disregarded or mistaken, and with very subtle physieal 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, hâve had much to do with the development not only of nervous diseases in gênerai, but paretic dementia in particular. The appearance of symptoms is some what irregular. In a large num- ber of cases we find a preliminary dépression which has a hypochondri- acal tinge, and this is common where there is early alcoholism, and is as- sociated with hopelessness and simple melancholia. In others the early active symptoms are expansive, and in a third class of cases shiftlessness 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 mère lying is followed by the wildest Munchausen braggadocio. He will perhaps tell you that he has horses which are f aster than any in the world ; that his diamonds exceed in value the crown jewels of ail the European courts ; or that he has made impe>s- 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 ail the great prima donne, and had built an opera-house ten IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. m miles long; another that he could speak ail the known languages, in- cluding Arabie, Sanskrit, and Hebrew, although lie was a printer with scare-ely any éducation of which to speak. Many paretics believe them- selves possessed of extraordinary physieal 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 excelled tliose be- longing to any of the personages of the Old Testament who possessed innumérable concubines. With this there is foolish extravagance and the purediase of useless things. One man will contract for property for which he cannot pay, or buy numberless pictures for which lie bas no use. Pie will order large quantifies of jewelry or precious stones. He resents interférence and the counsel of friends with violence, and plunges into the wildest excesses. He débauches 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 unequally dilated, one being larger than the other (usually the right), or that they are contracted to the size of pinheads. His tongue, when protruded, trembles slightly, the tremor being fine, and accompanied with sudden rétraction 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 mouth uneven. The speeeli is clumsy, and there is great difficulty in pronouncing the labials and lingual consonants. The mental state keeps pare, and the delusions are more marked—they are, however, occasion- ally concealed, but this is rare. It is common to fine! fits of viedence from time to time, and in thèse the patient may be aedually dangerous. Paretic dementia is characterized by periods of remission, which may last several weeks or sometimes much longer, during which the patient is appareuifly sane ; but they never continue for any great length of time, and the mental anel physieal symptoms reappear with great violence. As the malady becomes established there are changes in the gait, which is titubating and unsteady. The patient's ocular condition may vary, the pupils for a time becoming equal, and afterward unequal again. The température is elevated during the disease, more particularly throughout the late stages, anel generally after periods of excitement or convulsions. Thèse convulsions are not confinée! to any one stage, and they may even occur up to and into the state of established dementia. When they do occur they are a most striking symptom of the malady, and should settle our doubts. The writer lias reeently seen a patient whose early mental disturbance was very irregular, inasmuch as there was a condition of ex- trême excitement, violence, anel unsystematized delusions anel halluci- nations which were expressed. His state for weeks was one of absolute incohérence, and the diagnoses of acute mania and confusional insanities were suggested. The doubt of its being paresis was temporarily strength- ened by a rather rapid cessation of his excited state, and by considérable resolution of ail his symptoms ; but quite reeently a séries of convulsions, with slight facial hemiparesis and a return of the old expressions, has remeveel ail doubts. Dementia. finally cornes, anel with it an enfeeblement of ail the mental pe>wers take-s place. The disease is remarkably rapid in its downward pmgivss anel eommonlv ends fatally in three years; yet there are cases where it has lasted eight or ten years, but thèse are by no means com- 112 A SYSTEM OF LEGAL MEDICIXE. mon. The French authors are disposée! to consider the average duration of the affection to be less than twe) years, and some English writers fix it at twenty-two months. The duration of the remissiems is extremely variable. Baillarger bas reported nineteen cases, in which the period of remission varied from one month to two years. Legrand du Saulle has presented six cases, in which it varied from ten months to two years. Dagonet believes that during the rémission there is a state of mental feebleness quite incompatible with perfect responsibility. I bave known of one case where an apparent remission lasted for several years, but every indulgence in liquor, even to the extent of one or two ounces, immediately put the patient back for a month or two into bis mental slough. The early stages of paretic dementia are sometimes likely to be the subject of légal inquiry. In the beginning of the disease the individual's extravagant plans are apt to be looked upon by laymen as simply évi- dences of great business tact and energy, and sympathetic juries do not take the trouble te> ascertain whether the expenditures are in keeping with the means of the individual. So, too, during the apparent lucid intervais, légal steps may be taken which are not warranted by the history of the disease. The existence and manifestation of the irregular symptoms of paretic dementia continue, the physieal weakness advancing. Simple lowering of muscular tone and incoordination deepen into flatness of the face and a loss of expression. Local paralyses, especially of the face, actual hemiplegia, or complète loss of power supervenes, and the patient dies of exhaustion. Pulmonary tuberculosis is not uncommon. The emotional state from the first is disturbed, and the shedding of tears must not necessarily be looked upon as an index of feeling, but rather as a resuit of relaxation due to détective innervation. The paretic often cries without corresponding stimulation. Later he grows very ir- ritable and even violent, is noisy, salacious, extravagant in his gestures; or he may be amiability itself, making présents and wishing ail to enjoy his success. With this phase of feeling there is a sort of vanity which leads, as was the case in one of my patients, to freejuent visits to photog- raphers and the soliciting of newspaper puffs. Toward the end this ail changes, and actual indifférence and mental and physieal inaction reflect the establishment of the final mental decay. Part IL—The Influence of Mental Aberration upon the Capac- ity of the Individual. The attitude of the law in regard to insanity, as will be subsequently shown, is radically différent from that of medicine. The stern require- ments demanded for the protection of the individual and the community hâve necessitated the divorcement of sentiment from science, and the - drawing of Unes which sometimes, perhaps, seem unnecessarily narrow ; but the great result, after ail, adduces to the good of the many. Pos- sibly in time, when psychiatry has become more definite in its teachings. and there is less uncertainty regarding the significance of insane mani- festations and their course and termination, we may expect still fur- IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 113 ther advances in the acceptation and application of our exact find- ings, and greater liberality upon the part of the courts. The law often loe)ks askance at the terni "insanity" as used by the doctor, and prefers others of its own adoption, such as unsoundness of mind, or non compos mentis, etc. Unsoundness of mind is used in the most varied wavs to express con- ditions which incapacitate. By the older English jurists, idiocy, amen- tia, partial lunacy, furor, monomania, anel a number of other inexact appellations were supposed to constitute unsound mind. Coke discarded the term " lunatic," which, after ail, impbes a mental condition of the individual which is influenced by the changes of the moon. To-day many lawyers are inclined to look upon "unsoundness of mind" as a weak state which is not absolute insanity.* The term non compos mentis, however, is that in conventional use, and if this exists, and is determined by inquisition, it usually settles the mat- ter of incapacity in the eyes of the law, the fact of the incarcération in an asylum on proper affidavits of physicians or other persons not inter- fering with the civil rights of the individual. The law recognizes what are known as lueid intervais, believing that "no lunatic is wholly without reason," and satisfying itself that though his conduct may perhaps be scandalous, and most of his actions may be irrational, lie may stdl in some things be clear enough to intelligently and properly discharge the particular act which forms the subject of doubt.t How fully the opinion of expert witnesses is accepted, dépends upon the intelligence of judges and juries, who are sometimes disposed to cling to their preconceived ideas of what constitutes insanity, and to ignore the teachings of psychiatry and the évidence itself. It is to be regretted that what is sometimes accepted as an apparently normal display of in- telligence is, after ail, either a sudden flash in the intellectual pan or a misleading expression which only the studeut of mental disease can perfectly understand, and not always describe. " A luciel interval, in law, means a suspension of the active manifestations of mental disorders. . . . It only means restoration to the degree of enabling the party to judge soundly of the acit."| (Ordronaux.) Tins disposition to give value to iso- lated acts of insane people has led to the use of the term partial insanity. * Jf ail is vs. Lnhring, 134 Ind. 447. Action to contest the will of Catharine Wallis. Unsoundness of mind and undue influence alleged. The testimony showed that the deceased had been of unsound mind for some years before her death, although noue of the witnesses regardée! her as insane. No experts were called, but her family phy- sician testified that in his opinion " she was not fully sound in mind or body for sev- eral years before she died," although he did not consider her insane or crazy. The Trial Court refused to charge the jury that "unsoundness of mind, in law, means the same thing as insanity." The jury found for the contestants, and on appeal to the Suprême Court the judgment was affirmed. t Matter of Macpherson, 1 Connoly, 223. Mrs. Sara J. Macpherson, the testatrix, was in ill health and very excitable for some time prior to her death, and exhibiteei considérable antipathy to her relatives. " Thèse symptoms were chronic for some time, but at periods she iras in full possession of her faculties." The will was drawn in accord- ance with verbal instructions, which were afterward substantiated by a note of in- struction. At the time of its exécution she conversed rationally on the matters con- nected with the will. Probate aîlowed. t Bail vs. Warren, 9 Ves. 605; Boyd vs. Ehy, 8 Watts, 6G; Gombault vs. Pub. Adm., 4 Bradf. 22G. 114 A SYSTEM OF LEGAL M E TIC IX E. It is no more possible, in my opinion, for a partial diseuse of the mine! to exist than a partial variola or a partial phthisis. It is true that cer- tain insanities bave limited forms of expression, but I bave never seen a case, even of paranoia or some of its allied psychose's, or "meu-al im- becility," where sooner or later there were not more or less dévidée! in- dications of général and profound intellectual disturbance. It is at best a difficult thing sometimes for any one, no matter how compétent and expi-rienced lie may be, to say definitely how much the mind has escaped gênerai disorder, or, on the other hand, how potent is the exeirise of reason, judgment, and volition in insane persons whose disease is imper- fectly or not at ail rece>gnized by the world at large. Sir John Nicoll's view of lùcid intervais bas the ring of common sensé : " In cases of permanent, progressive insanity the proof of a lucid interval is a matter of extrême difficulty, as the court has often had oc- easieui to observe; and for this, among other reasons, namely, that the patient se» affected is not unfreepieutly rational to ail emtward appearances, without any real abatemeait of his malady ; so that, in truth and sub- stance, he is just as ins.inc in bis apparently rational intervais as he is in his visible raving fits." (lïrogden vs. lirown, 2 Add. 445.) The law iuq)oses rcspoiisibility upon the insane person wliose acts performed during the lucid intervais are the subject of question ; but the burelen of proof is upon those who seek to excuse or négative such acts. The fact of his being under restraint in an asylum at the time the act was committed is no excuse, for it is presumed that he may bave a lucid interval there as well as elsewhere. (f) Dow, Pr. C. 236.) This atti- tude of the law is to be borne in mind by those persons who obtain the signatures of patients to deeds, notes, chee;ks, or other instruments, either before actual commission or after incarcération. As has been before said,. nothing fixes the status of the insane person but a regular inquisition.* General Questions Relative to Capacity. The civil issues that occur where the question of responsibility arises are those which relate to the individual and his ability to eare for himself and his property, to understaiielingly enter into contracts, and to dispose of his possessions. Thèse are numerous and constantly occupying the attention of courts of law. It is the duty of the médical witness to eare- fully examine the person whose sanity is questioned, and to pass judg- ment upon his written and other productions ; to obtain a history of his conduct, and to form an intelligent opinion therefrom. It becomes nec- essai-y to discover, if possible, the existence of a delusion which will in- validate the particular act, as being a resuit of an insane exercise of judg- ment and reasoning power. The word " insane " is used in contradistinc- tiem to the cardess or conscious error which any normal individual may make, and which does not necessardy indicate impairment of responsibil- ity. If a business arrangement is entered into by a person who is non compos mentis and does not realize what may be the conséquence of his act, he is entitled to the protection of the law. We are to détermine just * Shelford on Lunacy, p. 340; Hix vs. Whittemore, 4 Metc. 545; Haden vs. Hayes, 9 Pa. 151; Jaclson vs. Van Duscu, 5 Johns. 144; Stcvens vs. Van Cleve, 4 Wash. C. C. 2G2. The author is indebted to Ordronaux for many of thèse citations. IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 115 what form of aberration incapacitates, although sometimes the gênerai showing that insanity exists will suffice. Careful judges require the exae-t estimation of mental disease that destroys responsibility, and how it does so, recetgnizing the fact that extensive disorder may exist which spares the individual so far as the ability to periorm certain acts is con- e-erned. Usually the conservation of the power to know the provisions and conseemences of the particular act, and the ability to exercise will- power, are sufficient to meet the demands of the law, no matter how de- ranged the |)erson may otherwise lie. This is shown in the admission of wills to probate which hâve been made by insane men who, so long as they were not subject to undue influences or laboring under a delusion touching the matter at issue, were considered compétent. The German law in regard to capacity differs but little from that of our own country in admitting that no matter what the condition of re- straint or gênerai state of a patient may be, the existence of testamentary -capacity must be specifically determined by his knowledge of the partic- ular act. In a récent case wilich was décidée! May 7, LSS9 (E)itscheidungen des Reichsgerichts in Civilsuchen, vol. xxhi., p. 140), it was held that though a man had been under the eare of a legally appointed guardian, anel had been déclarée! insane in 1885, the court, after an inquisition, cemsidered him in 1889 sane enough to make a will. The contesting parties alleged that a person under the eare of a trustée is incompétent to make' intelli- gent disposition of his or her }>roperty ; the will, however, was admitted to probate by reason of the assumed existence of a lucid interval. TESTAMENTARY CAPACITY. It would appear, then, as if the ability to legally dispose of one's prop- erty depended upon the possession of but a limited degree of intelli- gence, for the requirements are a knowledge of one's pe>ssessions and the obje'cts of one's bounty. Erskine's charge in the case of Harwood vs. Barber was as follows : " Their lordships are of opinion that in order to constitute a sound disposing mind a testator must not only be able to understand that he has by his will given the whole of his property to one object of his regard, but he must also bave capacity to comprehend the extent of his }>roperty and the nature of the daims of others whom by his will lie is excluding from ail participation in that property; and that the protection of the law is in no cases me)re needed than it is in those where the mind lias been too much enfeebled to comprehend more objects than one, and more especially where that object may be so forced upon the attention of the invalid as to shut out ail others that might re- quire considération." With regard to the proof of a disposing mind an English judge (Brett) said that " it was not sufficient for the testator to understand merely that he was making a will, but they [the jury] had to say whether, at the time the will was made, the testator had sufficient intelligence to understand substantially the state of his family and of his affairs, and the disposition of his property as made by the will ; and if he had sufficient power of mind to intend to make such disposition." We are to investigate the condition of the testator at the time lie makes his will, and décide whether his disposing capacity is affected in 116 A SYSTEM OF LEGAL MEDICINE. any way—either by the natural decay of old âge, by senile dementia, or by other kinds of insanity—or whether there exists a delusion which prevents him from intelligently disposing of his holdings. Wills made in Extremis. Wills made in extremis usually bave no value in the eyes of the lawr and thèse, as well as contracts, are often contested. Tardieu, Laségue, and other French writers hâve extensively written upon the mental condition of the individual during the last moments of life. They aunounce their belief that either as a resuit of gênerai disease or insanity the brain is always affected just before death, and intelligence obscured to some extent, so that the capacity for wdl-making is at least doubtful. There certainly can be no question as to the mental weakness that occurs when pulmonary decarbonization fails, and the brain is sup- plied with vitiated blood ; and there can be no doubt that just before death there must be a dissolution and incoordination of concept arrangement. The instances of hallucinatory disorders that are gravely presented in good faith by credulous people as death-bed utterances and prophecies are numerous and, after ail, significant indications of disorganization. It therefore cannot be denied that the last hours of life are frequently attended by mental obscuration or perversion, even when such does not appear to De the case to outsiders ; and a person with some assistance may be helped to sign and apparently understand a will. Some diseases, when the cause of death is toxannia or great exhaustion, must sometimes interfère with the clear exercise of judgment. An aged man wliose will was lately the subject of contest died after a week's illness, the nature of which was strangulated hernia and peritonitis. Shortly before death he was made to sign a will, notwithstanding the fact that soon after he was so délirions that it required the efforts of several men to hold him down, and he presented the signs of collapse ; yet he was pronounced by the Consulting physician in his case to be of sound mind. For obvious reasons it is impossible to fix a limit of time before death when a will should be rejected. Of course the particular circumstances shouid be determined and weighed. In a condition symptomatized by mental indécision due to weakness, especially where semi-consciousness is présent, the assertion that testamentary capacity exists should be re- ceived with some hésitation ; and where the person's condition is such that he lias to be supported and a pen held in his hand—the aid not be- ing alone requiree! because of existing parabysis—I think we cannot be too careful in sifting to the bottom the testimony that may be admitted. Old Age and Dementia. Much has been said about the distinction between the mental decay of simple old âge and the appearance of senile dementia, and it is impor- tant to make the distinction when we are called upon to testify. Dr. Ray says : " This form of the disorder, or senile dementia, is so often the subject of medico-legal inquiries, especially in connection with wdls, that it deserves particular attention. Senile dementia, it must be recollected, is something more than the mère loss of mental power which results INSANITY IX ITS MEDICO-LEGAL BEAELNGS. H7 from the natural decay of the faculties : it is not only feeble, but it is dérangée!. Were it not so every old man would labor under a certain degree of dementia." Senile dementia, as Pritchard has written, is not the lot of old persons universally, though it is a condition to which old tige has a tendeney, and to which the last stage of bodily decay approxi- mates. Extrême old âge sometimes prevents the testator from knowing the objects of his bounty, and from intelligently disposing of his estate. If his mind is so weak, either through disease or advanced years, that he may be tricked or swindled ; if his memory and perception are so blunted as to prevent him from knowing the extent or condition of his property or the persons to whom he wishes to give it—then true doubts arise in re- gard to his competene'.y. Simple old âge does not necessarily bring with it incapacity, for there are men who bave attained very great âge without any suspicion of mental unsoundness arising. In the Watson Case an old man of eighty-six was held to be compétent to make a will, and cases are on record «of wills made at ninety, or over, which stood.* The law is that " if man in his old âge becomes a very child again in his understand- ing, and is beconie so forgetful that he knows not his own name, he is then no more fit to make a testament than a natural fool, a child, or a lunatic." (Browne.) Lucy IL Eddy died in Rahway in 1879. She was a daughter of the late Thomas Eddy, of New York, who was distinguished for his public spirit and philanthropy, and inherited from him his strong mental quali- ties and convictions .of duty. She left a wiïl dated January 15,1875, and a codicil dated September 5, 1876. This will was contested in the Pré- rogative Court on the ground of lack of testamentary capacity. Deceased was eighty-three years old at the time she executed the will, and none of the witnesses for-contestants testified that deceased was of unsound mind, but only averred to weakness of memory regarding récent occurrences, which might be expected in a person of such advanced âge ; and some would not even say that she was unfit to make a will. On the other hand, it was shown that she read the classics and historiés, and would excite admiration by her able discussion of them ; that she seemed to re- member old events ; she answered questions intelligently ; knew what she was doing ; that she knew who her relations were ; that she used an old will as the basis of her will of 1875, and made ail the necessary mem- oranda thereon herself. Another point advanced by contestants was the confidence reposed by deceased in her attorneys, and lier indifférence to the fact that much more money had been expended on the building of a house for her than was at first contemplated, and it was claimed that this was évidence of the want of that capacity requisite to the making of a will ; but it was held that tins merely amounted to natural confidence in capable business men. Held, also, that mère forgetfulness of récent events is no évidence of incapacity to make a will. The will was there- * Bradi/ vs. McBride, 39 N. J. Eq. 495. The testatrix, Margaret Devine, executed her will February 24, 1 S7<>, at which time she was blind and over eighty years of âge. In October, 1S7S. a commission in lunacy found that she was of unsound mind and had been so more than three years past. There was much évidence that the testatrix was rational at and about the time of the exécution of the will, not only as to the dé- tails of the will but also as to her financial affairs and other matters. The will was admitted to probate, and on appeal judgment affirmed, the court holding that the finding of the commission in lunacy was not conclusive as to her mental condition at the time of the exécution of the will. 118 A SYSTEM OF LEGAL MEDICINE. fore admitted to probate. ('32 X. -T. Eq. 701.) In other cases the forget- fulness of récent events might lead to the disregard of those dépendent upon the testator as well as the condition of the estate. Influence of Delusions. The existence of delusions regarding the next of kin or others who hâve a daim upon the testator, or in regard to the condition of the property, or which in any way influence the judgment of the testator, is usually sufficient to invalidate the bequests that may be maele through such error. As has been stated, delusions of the most absurd nature may exist, but do not négative the existence of a disposing mind. Cock- burn held the following opinion (Banks vs. Goodfellow) : " No doubt, when the fact that the testator had been subject to any insane delusion is established, a will should be regarded with great distrust, and every pre- sumption should in the first instance be made against it. When in- sane delusions hâve once been shown to bave existed, it may be difficult to say whether the mental disorder may not possibly bave exteudeel beyonel the particular form or instance in which it bas manifested itself. It may be equally difficult to say he>w far the delusion may not bave in- fluenced the testator in the particular disposai of his property, and the presumption against a will made under such circumstances becomes additionally strong when the will is, to use the terni of the civilian, an insufficient one—that is to say, one in which natural affection and the daims of near relationship hâve been disregarded. But when, in the resuit, the jury are satisfied that the delusions hâve not affected the gên- erai faculties of the mind, and can hâve no effect upon the will, we see no sufficient reason why the testator should be held to bave lost his right to make a will, or why a will made under such circumstances should not be upheld." The celebrated Jumel Will Case was one in which the question of de- lusion arose. Madame Jumel died some years ago, leaving a large and valuable estate to différent religious and charitable institutions, cutting off lier family. It was shown that the testatrix, who was a very old woman when the will was made, was peculiar and crotchety, and that she labored under the delusion, among others, that she was the victim of a plot—that her relatives had attempted to poison her—and so deep- seate'd was her belief that she refusée! ail food until she procured it her- self. The case was tried in the Suprême Court of New York in 1866, and the court took the position that if she was insane because of thèse delusions, she was incompétent to make a will. The instances where insane delusions hâve interfered with testament- ary capacity are mimerons and bear a common relation, and the reader is referred to the comparativdv récent décisions in the cases of Merrill vs. Polston, 5 Redfield, 220 ; Mi'ller vs. White, 5 Redfield, :320 ; Dichie vs. Van Ylecl; 5 Redfield 284 ; Leslie vs. Leslie, 15 N. Y. Digest, 56. In ail of thèse cases the existence of delusions was urged.* The existence of * Also see American Bible Society vs. S forer, 12 X. Y. Weekly Digest, 213; Kings- bnri/ vs. Whital-er, 32 Louisiana Animal Keports, 1055; Cole Will Case, 49 Wiseonsin Reports, 179; Le Bau vs. Yanderhilt, 3 Redfield, 384. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. HÇJ insane delusions of a pertinent eharaeter is sometimes disregarded, the law preierring to believe that at some time the individual was able to dispense intelligently.* General Symptoms of Alleged Incapacitating Insanity. The suits brought by dissatisfied bénéficiaires to annul wdls that bave been maele by j>ersons who are alleged to be insane disclose peculiarities of conduct which often reach the dignity of mental disease, but more often are simply évidences of a purely eccentric naturel The drag-net which is hauled by every available hel|)er brings into court the thousand and one little weaknesses, the instances of moral delinquency, the moods and idiosyncrasies, which most men possess. Thèse are colored and tiuged by interesteel witnesses, persons with pliable memories, or those having ends in view or unredresseel wrongs. It may be the son or daughter wliose cupidity brings forgetfulness of a father's kindnesses, a discharged servant, or some stranger who solely desires the notoriety of appearing in court. Influence of Eccentricity. Mère dis})roportion in the division of property, or eccentricity, is not necessarily évidence of testamentary ineapae-ity ; and although the lawis very careful in regarel to the question of undue influence, great eare should be taken to distinguish cases in which the individual defers with pertect propriety te» the suggestions of intelligent and lifelong friends in- stead e>f bac! children who never bave shown any filial respect or interest in the testator until the epiestion of the division of property is raised. * Manlcifs Execntor vs. Staples (05 Vt. 370). This was a contest of the will of Madi- son S. Manley, by his daughter, Miriani A. Staples. The will was executed April 24, 1 Sss. and lie died July 4, 1888. Manley was a miserly and ignorant old man, and was infirm and almost helpless. Some years before his death his wife procured a divorce from him, with alimony amounting to over one half of his property, which, upon her death, previous to the exécution of Manley's will, she bequeathed to the contestant. For some years before his death Manley had an "insane delusion" concerning his wife and daughter, and accused them of being prostitutes and of conspiring to poison him. After the death of his wife he attempted to make a contract with contestant to take eare of him during his life, but failed. Afterward, on November 14, 1887, he made a contract with one Fisk for his eare during his life, and by the contract con- veyed most of his property to Fisk. He lived with Fisk until his death, and during that tirne was less eccentric than before. His will recited and confirmed the contract with Fisk, and bequeathed ail his property to Fisk, except some income which he be- queathed to two graudsons, who were sons of the contestant. The Probate Court sus- tained the will. The Suprême Court of Vermont, affirming the judgment, held that the fact that insanity existed for a number of years, while strong évidence of per- manency, was not conclusive of it : this was a question of fact for the jury. "That insanity continues is not a presumption of law, . . . but an inference of fact, varying with the circumstances of the case." There was no évidence that he entertained. an insane delusion concerning his daughter after lie went to live with Fisk and at the time he executed the will. Objection was made at the trial to Fisk as a witness be- cause he was a party to the contract mentioned in the will. The court held that as the contract was not in issue Fisk was compétent to testify to the exécution of the will. t Prcntis vs. Bâtes, SS Mich. 567; rehearing 93 Mich. 234. This case was a con- test of the will, dated July, 1SS(J, of Mrs. Adaline King, who died in Détroit in Novem- ber, 1SS6. There was testimony showing that Mrs. King, who was sixty-seven years 120 A SYSTEM OF LEGAL MEDICINE. When, on the other hand, a kind father, whose relations with his chil- dren are of the pleasantest kind, becomes, during the latter years of lifer morose, irritable, and shows unwarrantable dislike or neglect, with moral and intellectual weakness, grave doubts arise. Eccentricity should not be misunderstood and looked upon as disease, nor should superstitious belief, or the striking exaggeration of eharaeter of old âge we sometimes find, which, however, are perfectly consistent with mental integrity. The belief in spiritualism, or any other ism, which, perhaps, leads the testator to leave a legacy to some religious body, no matter how irregular, is not necessarily insanity, and should not be so considered. In courts of law it is often contended that because the individual wears certain loud colors and ungainly, conspicuous dress, or because he eats or drinks or walks or sleeps in an unusual way, he is of unsound mind. Not only lifelong ]>eculiarities, but personal traits which may be the offspring of ignorance or vanity or even vulgarity, may sometimes be sufficient in the eyes of snobbish or ungrateful children to stamp their parent as of unsound mind. In the case of Ilartwell vs. 2VMaster (4 Redfield, 38) it was shown that the deceased executed his wdl 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 testamentary capacity, and it was shown that he did not believe in the doctrine of the " real présence " or transub- stantiation, nor in the necessity of baptism in infancy; that he lived alone and locked himself in during his last illness ; that he had once disturbed a religious meeting by abusing the minister ; that he wished to attend a public school as a pupil; that when over sixty years old he fell in love with a girl of tw^elve. It was very properly held that thèse 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 cérébral symptoms of this old at the date of the will, was eccentric, 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 complained 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 dysentery. A post-mortem examination showed no chronic stomach disease. At one time Mrs. King Avas a patient at a sani- tarium. Dr. Gallagher, one of the attendant physicians, testified that he took pills to her; she would not take them—said they were Aies' heads. He then got a fiy's head and she took it. The probate of the will was disallowed, and on appeal the Suprême Court reversed and ordered a new trial (8.8 Mich. 567). On rehearing the judgment of reversai was upheld except as to costs (93 Mich. 234). IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 121 and other diseases, and their effect upon the conduct of the individual. Very often such petitioners are apt to formulate decidedlv original views regardmg the pathology 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- tability, stupidity, aphasia, and very rare epileptie conditions, nothing can be shown; but when we consider the rénal disease, with cardiac disease, as precursors of actual degeneration of the cérébral vessels, it has a decided importance. The démonstration of the connection between embolism or cardiac disease with cérébral softening and dementia, of syphilis with paretic dementia or epilepsy, is of the greatest moment. The distrust of the courts in considering such matters is often shown. When the will of the late Alexander D. Fraser, of Détroit, was contested, the issue was raised that his testamentary capacity had been destroyed by cancer. The will was dated May 17, 1877, and the évidence showed that the deceased was over eighty years old and had been sufïering for over twenty years from a cancer on the nose, which ultimatdy 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 lie had been very fond of soeiety, 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 exécution of the will appeared attired in a night-gown and Scotch cap. After the exécution 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 thèse facts five physicians believed him insane. On a trial before the jury a verdict was rendered sustaining the will, which verdict was, on appeal to the Suprême Court, affirmed. (42 Mich- igan Reports, 20G.)* Cases which are familiar, and where, as a rule, there is sufficient dis- ease of the structure of the brain to effectually weaken the mental powers to the degree of irresponsibility, 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 paroxysms of grief and crying. In April following she executed the will. In the summer of 1S76 she had another stroke of apoplexy, and on September 26th was sent to an insane asylum, where she died Mardi 10, 1877. In February, 1876, she wrote several clear and cohérent 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 lier, 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 see Mairs vs. Frccman, 3 Redfield, 181. 122 A SYSTEM OF LEGAL MEDIC1XE. ster, superintendent of the asylum in which deceased was confinée!, from an examination made in September, 1S76, believed lier to hâve been of unsound mind in April, 1876. (lUahdy Will, 48 V\ is. 294.) Seth H. Evitts died September 22, 18m, aged eighty years. On August 27, 1875, he executed a will, bequeathing to plaintiff ail his prop- erty with the exception of a few small items. Ou April 2, 1876, and September 22, 1876, lie maele two other wills, which were substantially the same as the will of 1875, the only change being in the minor be- quests. Thèse wills were severally offered for probate, but rejeeted on the ground that testator was not of sound mind when lie executed them, and thé will of 1875 was probated. On December 20, 1876, deceased exe- cuted a deed to défendants, transferring most e>f 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 theMaryland Court of Appeals said, in reviewing the évidence, that after the exécution of the will of September, 1876, the défendants, 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 ternis Avith plaintiff ; that there were no grounds for the delusion ; that he had several strokes of apoplexy in 1876, and was permanently paral- yzed ; became imbécile ; was childlike ; hael few ideas ; his mind became inert ; was easily controlled and influencée! ; his memory failed ; was un- able to walk without assistance and requiree! constant attendance; his hobby was politics. (Cherbonnier vs. Evitts, 56 Maryland Reports, 276.) Epilepsy.-—The' wills of epileptics are sometimes contestée!. In the case of Ross (12 N. Y. Weekly Digest, 34) the will was made in an inter- paroxysmal period anel was sustained. On April 29, 1879, the testator, who had been subject to attacks of acute mania, superinduced by epilep- tie convulsions, was committed to a lunatic asylum. lie was discharged May 12,1879. The superintendent of the asylum testified that testator's mental condition was then good, and that between the epileptie attacks he was of sufficient mental soundness to understand what he was doing. On May 21, 1879, testator executed his Avili. His family physician testi- fied that he was then of sound mind and memory, anel capable of making a will. Testator was again attacked with an epileptie 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 exécution of the will : Elizabeth M. Riggin was, on November 14, 1868, at the âge of sixty- two, attacked with an epileptie fit, and rendered unconscious ; an attack of pneumonia supervened the epileptie fit, accompanied with high fever anel 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 regardée! as a gifted and brilliant woman. Witnesses on 1 >oth sides, who were présent during her illness, stated that while occasionally out of lier mind, at other times she was rational and intelligent, her mental condition being clearly the resiilt 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 codieils testi- IXSAX1TY IX ITS MEDICO-LEGAL BEAEIXGS. 123 fied to the sanity and intelligence of deceased at the time of executing them. On the trial of the issues in the Circuit Court of St. Clair County, in Aprd, 187/, before a, jury, it was found that the will and codicils were not those of the testator, Elizabeth M. Riggin ; that is to say, that she was insane at the time she executed them, anel they were therefore mill and void. On appeal to the Suprême Court of Illinois this finding was reversée!. (Broivn vs. Riggin, 94 111. R. 560.) Alcoholism.—The will of a confirmed drunkard will stand in law, pro- vided the person who maele it is not in a condition to be so unreasonable and irratiemal as to be unable to exercise anything like healthy judgment. A man may be a hard drinker, and make the will after a debauch, but unless its eharaeter is so absurd as to betray mental unsoundness, he cannot be reasonably deenied irresponsible. In a récent case in which the writer appeared, the testator was a man of bad habits, who drank immoelerate'ly and steadily. Evidence was produced to prove that he had done ail manner of foolish things before and after the will was made, but no évidence was brought forward to show that at the time the paper was signée! the te'stator 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 degree of the drunkenness, the habits and physieal condition of the person. A case fell under the writer"s notice two or three years ago, the testator being a man of middle âge, 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, wras testified to by the con- testants, and one physician gravely asserted that a proof of the mental perversion consistée! in the irritability of the testator's throat during the time' lie' was making medicateel applications to the same. He was alleged to bave declared that "lie could not retain anything upon his stomach" ; that " he resorted to memoranda that he should not neglect bis engage- ments " ; that " he abused 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 havdng observed him drunk on several occasions; that "lie was extravagant, and bought large quantifies of oranges," whieh, how- ever, were for his sick wife ; and that he " talked wddly about his busi- ness." It appeared, on the other hand, that he was able to attend to his afïairs for some time before his death, whieh was not due to alcoholism ; that when lie made bis will it was at a time between two of bis sprees, and that there was no Avant of sagaeity or any irregularity sliOAvn in the disposition of his property. In this case, as in many others, the popular ideas of insanity are apt to be thoroughly ventilated, and it is strange that this 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 Avho is in no sensé insane. The "excitement" alluded to by interested Avitnesses is probably nothing more than a moderate emotional exhilaration, and the business schemes which attract the Avemderment of those who wish the will broken ordinarily display a mind of un usual shrewdness. The spéculations nearly always turn out well, anel the despondency does not rise above the dignity of an ordinary attack of the blues. In the above case the husband's dévotion to his 124 A SYSTEM OF LEGAL MEDICIXE. dying Avife seemed to hâve astonished those persons Avho appeared upon the side of the contestants; and tins peculiar behavior, Avhich was re- garded by them as évidence of mental unsoundness, consistée! in such kindly offices as removing lier to the AvindoAV, so that she might get the fresh air, and bringing lier fruit; and though bis exuberation of affec- tion might hâve been that which is so often intensified by occasional libations, it Avas in this case nothing unusual. It did not appear that there was anything in the eharaeter of the will that indicated insanity ; but that it was legally Avitnessed, and made at the time Avhen the indi- vidual was perfectly sober, and Avas therefore very properly admitted to probate. In another case of a différent kind the patient had for several years indulged in large quantifies of alcohol, and it Avas common for him to shut himself up in the room with a box of Champagne, and not leave until he had recovered from the effects of the intoxication produced by the dozen bottles he finished, one after the other, in rapid succession. This man, for several years before his death, drank ail kinds of liquors to excess, squandered his money, giving large amounts to persons who had little or no claim upon him, and betrayed a change in eharaeter which was remarkable when contrastée! Avith the regularity and sobriety of previous years. Within a short time before bis death he manifested .symptoms of the inévitable diseases which are due to excesses of this kind, and he finally succumbed to cirrhosis and died comatose. When supported in bed, and surrounded by those to Avhom he left his money, he made a Avili and died a few hours afterward. This will was very properly eontested by his brother, and it was admitted to probate by the surrogate, though the décision of the latter Avas subsequently reversed. It is quite likely hère that the man's mental condition was one which, even some time before his démise, would prevent him from properly reeognizing the objects of his bounty, and render him an easy prey to designing persons ; but a Avili made under more outrageons circumstances it is difficult to conceive of, for he Avas literally in a condition of extremis when his name Avas signed to the document. The following is a case of alcoholism where a mental disturbance ex- isted, with delusions, Avhich, however, were proved not to relate to the will itself or tliose Avho Avère to be benefited : Betsy Marsh died Aprd 7, 1876, aged sixty-five years. She was ec- centric in dress and coarse in language. Her death followed a short illness—undoubtedly a disease of the brain, which gave rise to fréquent delusions. Thèse delusions appeared only occasionally. On the 3d of April, 1876, she executed her will, and stated in answer to a question that she kneiv Avhat she Avas doing, and later in the same day sent for a Dr. Kinch, who had drawn her will, to make some altérations in it. Thèse altérations Avère ne\rer 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 Avas of sound mind at the time the wiïl was executed; that her delusions were only intermittent, resulting from her disease, and that they consisted of presentiments of death, and did not relate to any person Avho might hâve been an object of her bounty. The Avili was admitted in the Union County Orphans' Court, and on appeal to the Prérogative Court this action was attirai éd. IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 125 In chronic alcoholism AAuth organic brain diseases but no alleged insanity the question of responsibility naturally arises. In most cases of adA'anced structural disease the eharaeter of the testator undergoes a séries of changes which render him Aveak, vacillating, childish, and with- out vigorous memory. At such times it is extremdy probable that the person is a prey to elesigning relatives and suffers enfeeblement of the will. Care should be taken not to confuse the mental impairment of old âge or eccentricity with the peculiarities of disposition and habits result- ing from chronic alcoholism. (Lee vs. Slcudder, 31 N. J. Equity Reports, 633.) Undue Influence. A much-abused term, which, however, has an important légal value, is what is known as undue influence. Just how much pressure may be considered undue is of course a matter for judges and juries to décide ; yet it is a grave question whether any one is capable, without a deep in- sight into the eharaeter and mode of life of a particular individual, to estimate his susceptibility or powers of résistance, 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, présume the existence of individuals of varying mental attributes —some who receive suggestions more readily than others, and who lack individuality, others who shirk effort, and others whose susceptibility to emotional excitement anel 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. Médical 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, Avho may bave ends of their own to gain, and through the agency of undue influence may lead or force the person to dispose of bis property in a Avay 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 haA-e no doubt of the mental status of the testator, he is often bound by rules of évidence to answer a badly drawn hypothetical question which is unscientific anel négative. 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. Armstrong, 97 Ala. 731. John 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 conséquence his moral nature changed, and he took a woman, whom he claimed was his illegitimate daughter, 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 with the woman until he died, children being born to them. There was some évidence as to, acts and peeuliar conduct of deceased, quarrels with his children, his wife, and others. The probate of the will was refused by the Probate Court, and on appeal the Suprême Court reversed the judgment on the ground that undue influence hacl not been proved, and that there was not sufficient proof that Johnson was insane when the will was -executed, habituai and fixed insanity not having been proved. 126 A SYSTEM OF LEGAL MEDICIXE. by other people, or Avhere his Avill-poAver is so much impaired that he cannot resist Avell-directed and décisive demands of interesteel plotters. The suspieiousness and unreasonable delusions Avhich the insane man harbors toward those lie has ahvays loved are very often playe-d upon by iiiteresteel persons, and in certain stages of delusieuial insanity, as Avell as the first stage of dementia, it is possible to lead the insane indi- vidual to do many unjust acts, under the delusion that indignities bave been heaped upon him, anel that insults and slights bave been offered to him. It may readily be seen Iioav the subject of religions melancholia may be made to give ail bis money to the chureh, and instances of this kind are exe-eedingly common, especially Avhen the testator is a Avoman who is tortured with ideas of future unrest and punishment. The major- ity of eases Avhere undue influence is alleged to bave been exercised are those AAdiere there is a history of dementia in old people. The senile dément is prone to make f'oolish and trivial dispe>sition of his property, and particularly is tins the case' when he is aided by designing people who surround him; and the individual of this kind is very apt to be easily turned from bis original purpose by fresh suggestions or new influences. He is liable to imposition and injustifiable préjudice. In paretic dementia the viedim is very likely to squander his prop- erty anel to fall a prey to the many parasites Avho are ever ready to take advantage of his bonhomie and boastful good nature. In a récent case the paretic, whose illusions of grandeur Avère of the most magnificent eharaeter, became involved in a variety of schemes devised by ingénions sharpers, and when légal proceedings were instituteel it was found that he had gone so far as to buy for his new friends a cargo of bric-à-brac, and, to secure a place for the sale of the same, he had bought up the; stock of the occupant of the store, spending $30,000, so that his friends might take immédiate possession. In patients suffering fre)m the first stages of the disease it may readily be seen how any one, by judieious flattery and acquiescence in the startling projects and ideas of the indi- vidual, may wheedle him into parting Avith property. In other forms of organic/ insanity a condition of mental feebleness akin to dementia is manifested by irrésolution, irritability, or intellectual torpor. It will frequently be found that disease of the cérébral vessels, especially on the left side of the brain, is very apt to be followed, if at ail extensive, by degeneration of the mental faculties ; and if such degen- eration has an early fatal ending, and a biased and unjust will is made, even though there can be brought forward very few instances of mental irregularity, we should still question the ability of the patient to Avith- stand the arguments of interesteel friends. Softening is so common after accidents of the kind mentioned above, anel is so frequently symptom- atized by loss of memory, indécision, and childishness, that intellectual competency should ahvays be questioned. On October 12,1872, Mrs. Elizabeth Greenwood, then sixty-two years old, executed her will. She died August 9, 1875, leaving an estate worth $26,000. By the terms of lier Avili she bequeathed to two of her children, Eliza Smith and William GreenAvood (the contestants), $100 each, and the residue of her estate to Ohve Newsome, a granddaughter, and Mrs. Mary (line, lier remaining child. The will was contested on the grounel that the testator was of Aveak mind at the time it Avas executed, and un- duly influenced. It was not claimed, however, that she Avas incapable of IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 127 executing the will, but that she Avas laboring under a delusion Avith regard to contestants, brought about by the undue influence exercised upon lier weak and impaired mind by Mrs. Chue and Mrs. NeAvsome. Upon the trial of the issues in the County Court the will Avas rejected, the court holding that Avhile deceased had testamentary capacity, the will was executed under undue influence. On appeal to the Circuit Court this judgment Avas reversed, and contestants then appealed to the Suprême Court, who reversed the judgment of the Circuit Court and rejected the will, em the same ground taken by the County Court, and also sustained the daim of contestants that deceased Avas laboring under a delusion regarding them at the time she executed the Avili. The évidence, Avhich is voluminous, shows that deceased had a severe attack of paralysis in ls66, from the effects of Avhich she never recovered; that her memory became détective; she could not tell who was Avorking for her; would lease a pièce of land and forget it next day ; would ask the same question repeatedly. Tavo médical doctors who had knoAvn deceased testified that she Avas Aery despondent ; was différent from the majority of people ; at times exhibited mental obliquity ; her mental powers Avère impaired. Others testified that her eyes had a dead expression ; she sometimes acted like an intoxicated person ; in 1872 she Avas peculiar in her conversation ; Avould stop short Avhile making a remark, and faiï to finish it; was absent-minded ; while ill she imitated, with empty hands, the action of a persem breaking a pièce of quartz and examining for gold ; she very readily gave up her opinions, and Avould side with anybody who disputed them ; that Avhile going from Salem to HowelPs Prairie alone, she became turned around in the road and Avas coming back to Salem without knoAV- ing it ; that she did not appear cheerf ul, or laugh ; paid no attention to lier house work ; she was freejuently told that her mind Avas not right ; that on the day she executed her Avili 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 Avili ; that Mrs. Cline by means of a pretended communication from her deceased husband, obtained through a spiritual médium, stating that her son William was a rough eharaeter and Avould squander her property, and that she should get it ail out of his hands, produced a delusion in her mind regarding the eharaeter of her son. There Avas some évidence on behalf of proponents regarding the sanity of deceased, but as this was admitted it is not neces- sary to give a résumé of the évidence. The Avili Avas rejected on the ground of undue influence—that it Avas the offspring of a delusion re- garding the contestants. (Greenwood ats. Cline, 7 Oregon Reports, 17.) Hypnotism.—Since the revival of interest in hypnotic suggestion and the attention paid to the subject by the new^spapers, the claim has been frequently advanced in courts of hiw that certain unsatisfactory wills were made by decedents who Avère unduly influenced by hypnotism. After much research I am unable to find a single authenticated case of the kind, but, on the other hand, rather a great deal that shows how ignorance and préjudice flourish, as they did in what were supposed to be less enligbtened âges. As a rule no mention is made of hypnotic sug- gestion until after the Avili is found. That a person can be made to perforai an unjust act throilgh the suggestion of others is of course possible; but as a rule the suggestion must be an abstraet one, that is, provided the subject is pe>ssessed of ordinary mental health and normal 128 A SYSTEM OF LEGAL MEDICINE. independence of will. It is epiite possible that while actual hypnotic un- conse'iousness is not produced, an old person may make an unjust Avili through the constant suggestion of an idea by interested persons. Such acts are common with aged people Avho fall into the hands of sharpers, cure-ails, or disreputable exliortcrs. The experiments of investigators shoidd certainly go to shoAvthat it is impossible or extremdy difficult to make hypnotized subjects de) things that are naturally répugnant to them. The suggestion of disrobing Avas maele to a number of women, half of whom were of known immoral eharaeter. The virtuous women Avould not do so, but the others, without hésitation, took off their things. l\)ssibly a determined induction of hypnotism might throAv a testator into an irresponsible condition, Avhen his will Avould be subservient to that of another ; but lie would be Aery likely after ward to question and regret the nature of his act. It may be said that insane people are with difficulty hypnotized ; so if insanity is alleged as a contributory part of the incapacity it will be important to détermine the extent of attention possible. Suicide. The validity of the Avili of a suicide is sometimes questioned by reason of alleged insanity. The last hours of most suicides are, as a rule, marked by some expressiem which Avili enable one to détermine the probable mental state. De Boismont, Winslow, and others hâve collected an immense number of Avritten exjn-essioiis of suicides, anel the former has gotten together over three hundred and twenty letters Avhich show the most diverse forms of mental torture. Eighty-five wills were col- lected by this observer, the greater number showing clear and intelli- gent disposing poAver ; and it does not folioav that because a suicide lias probably shoAvn peculiarities of conduct before his death he bas lost the power to discriminate in the matter of choosing the objects of his bounty. On the other hand, there are many Avilis made by suicides that are irrational and absurd—some of which contain clearly insane directions in regard to the disposai of the body, the personal effects, etc. Thèse should always be received with 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 insanity of one of the parties it is necessary to examine not only 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 person to shirk a responsibility* In a récent case in Avhich the writer appeared, the qnes- * Lilly vs. Waggoncr, 27 111. 395. Bill to set aside conveyance of real estate, by George Waggoner, conservator of Elisha Waggoner. In 1851 Elisha Waggoner con- veyed real estate to A. Lilly. In 1858 an inquest declared Elisha insane, and George was appointed conservator 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 positive proof. On INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 129 tion of melancholia Avas urged, and it Avas averred that the plaintiff had maele a contract under the impression that his business was in a ruinons e'ondition, and that this Avas a delusion resulting from melancholia. In this case I was unable to find any characteristic intellectual dérangement, but only simple emotional disturbance of a depressing eharaeter. I found that his vieAv of the state of his affairs Avas perfectly in accordance Avith the real facts : that the contract Avas dictated by him and contained perti- nent marginal corrections and interlineations ; that his letters, written at the time, Avère intelligent; and that his motives in bringing the suit Avères to upset a bargain that did not bring him subsequently what he ceuisidered to be his proper share of the business he conducted with the ceuitracting parties. We must take cognizance of the fact, in such cases as this, as well as others, that no question of the insanity existed at the time of the alleged imposition ; that usually the friends of the person do not consider it necessary to seek légal advice, and it is not necessary to resort to an asylum or other means of protection. Casper relates a case of interest in this connection : " In a civil process the accused merchant, W., asserted that from his ailing condition lie Avas unable to pivpare a statement of his affairs and to confirm it by an oath. I had to satisfy myself in regard to this, and at the same time to give an opinion Avhether he could be arrested personally, if necessary. The investigation proved that W. certainly labored under the well-known disease called hypoehon- dria, which in itself could be regardée! as a mère simulation, though it could not be denieel that the manifold ailments alleged to exist were either intention a lly or unintentionally exaggerated. • (.Iranting, how- ever,' I said, 'that AV. is ill, nevertheless, since lie is not feverish nor con- fined to bed anel is of clear intellect, it is not easy to see why such an employaient as the one in ejuestion—the préparation of a statement of his affairs in his oavii apartments—should be impossible for him en- likely to be injurious. When he allèges that the mère addition of sums causes him anguish, such a statement is to be rejected as inconsistent with méd- ical expérience. Only if he were to be forcée! and hurried in the per- formance of such a work could there be a possibility of injury resulting.' Accordingly I déclarée! that W. was in a fit condition to prépare a state- ment of his affairs and to confirm it by oath, provided a few weeks Avère granted to him for this purpose, and that if necessary he might be per- sonally arrested. This opinion Avas commuuicated to W., and a state- ment of his affairs Avas very speedily thereafter handed in." William L. Rusk, avIio had previously been successful in business in the city of Baltimore, and was remarkable for his energy and industry and shreAvdness, was, on April 19, 1861, suddenly throAvn into a condi- tion of intense excitement, caused, it was believed, by the military prép- arations and excitements of those times. He remained in this condition for some time, and Avas removed to the résidence of his sister, and finally, the other hand, it was shown that Elisha had been engaged in numerous other trans- actions about 1851, in ail of which lie appeared rational; that lie "was about like the other AVaggoners—was always somewhat singular." One médical witness testified that "if there was reason for it, there would appear to be some marks of simulated in- sanity." The land had ris°n from four to twenty dollars per acre, and the court re- garded this as a reason. The Circuit Court decided that the deed was void, but on appeal the Suprême Court reversed the decree and dismissed the bill, holding that Elisha was not insane at the time of the conveyance. 130 A SYSTEM OF LEGAL MEDICINE. in the latter part of May, was admitted to bave been insane. His disease was declared to be a case of gênerai brain trouble, c-aused by the finan- cial excitement, etc., of that period. On December 2t, 1862, Avhile resid- ing with his sister, he executed a deed, for a nominal considération, of property valued at upward of $10,000, to Robert Turner, in trust for his mother, who Avas then seventy-five years old, and after her death abso- lutely to his sister. He left his sister's in 1861, anel lived with bis mother until 1875, when she died, and after her death the cestui que trust claimed the property named in the deed. He then brought suit to bave the deed set aside on the ground that he Avas not mentally capable of înaking a valid deed at the time it was executed, and the deed Avas declared voici. It Avas shown that although the property stood assesseel in his name no mention of the transfer had ever been made to him, and he claimed to hâve no recollection. It was also proved that lie was incapable of transae-ting business at the time of the exécution of the deed, and that he had not completely recovered from the effects of his attack in 1S61 until several years thereafter. On appeal to the Court of Appeals the judgment declaring the deed void was affirmed. (Turner vs. Rush, 53 Maryland Reports, 65.) The protection of persons Avho deal in good faith with lunatics has been assured * Avhen the contract has been équitable and there Avas nothing in the manner of the alleged lunatic to attract attention to his condition. Should the person take advantage of the supposed lunatic, he having been apjn'ised of his state of mind, of course the contract may be set aside. In fact, fraud of ail kinds, when proved, is a barrier to the claims of those who seek to avoid obbgations incurred with persons of weak mind. The Degree of Unsoundness.—The degree of unsoundness necessary to invalidate a contract as fixed by the law is uncertain and indefinite. The requirement of sufficient intelligence upon the part of the contracting party to know the nature of his act, however, no matter what may be the form of mental disease, is ail that is demanded. He may be an im- bécile or idiot, but unless the latter condition be an extrême one he does not escape the obligation incurred. His estate is liable for debts con- tracted to supply his immédiate needs, and he or bis administrator may be sued. He is also liable for debts contracted during his lucid inter- vais, but no inferred insanity, such as is urged in the fact of his having been in an asylum and discharged, is sufficient proof of his recovery. (Wharton and Stillé.) The contracts made by a lunatic during life are void; but the incapacity must be proved, for the obvions reason that there may hâve been only a partial incapacity during life.t In such cases the administrator may be held liable. There are décisions which hâve held that any contracts executed by lunatics are in themselves void.f * Jcnkius vs. Morris, L. R. 14 Ch. D. 674 ; Mitchell vs. Kingman, 5 Pieh. 431 ; etc. t Ducker vs. Whitson, 112 N. C. 44. This was an action brought against Wliitson as administrator of W. R. Mnrray, by heirs of said Murray, to whom he in his lifetime had executed notes, with a written agreement that they were to be paid out of his estate after his death. The défense was that at the time the notes were executed he was weak in body and mind, and not mentally capable of making a contract. There was évidence 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 détails of which are not stated in the report. Judgment for plaintiff affirmed. \ Curlis vs. Brownell, 42 Mich. 165. This was a bill to set aside a mortgage, on. IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 131 Marriage and Insanity. It sometimes happens that an attempt is made to invalidât e a mar- riage, one of the contracting parties being alleged insane. It may be that the person in Avhose aid the power of the courts may be exercised is at the time of marriage a declared lunatic, in Avhich case ail that is required is a sliOAving of the finding of a previous commission. More ■often the contracting party is one of Aveak mind, who has been entrapped by designing persons. The same influences that may hâve been brought into play to make a man link himself Avith some prostitute or adventu- ress may be brought to bear to make him an earnest défendant Avhen his family bring action to set aside the marriage. In such a case he is amply provided with friends and advdce, who supply the brains he un- fortunately does not possess. It will be readily seen that the sexual perversion inséparable 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 iiymphomania leads to impulsive acts Avhich the per- .sou, 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 évidence to be a friA'olous and Aveak- minded girl, Avhose éducation had been much neglected. She Avas a lady of fortune, and she ran away with and Avas married to a Mr. Newton. An application Avas maele by her family to dissoh^e the marriage on the ground that she Avas of unsound mind. Among other facts urged before the commission as proof of the allégation, it Avas mentioned that she Avas 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 Avas ignorant of arithmetic, and therefore incapable of taking eare of her property ; that she had some erotic tendeucies, Avhich Avère evinced b}' her Avant of Avomanly delicacy, and by lier having engaged herself, the ground of insanity of the mortgagor at the time of its exécution, to secure pay- ment for a set of mill machinery. The évidence showed that he had been engaged in business ail his life, and managed a farm and other interests. He had always been visionary and spéculative ; had various absurd schemes ; planned great improvements in his neighborhood ; had periods of exaltation, and of dépression, when he feared des- titution ; planned to manufacture pianos and furniture ; to build a town on an adja- cent farm, with a chureh and school ; claimed to hâve invented an excavating machine ; talked of setting up a woodyard in his village, and attempted 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. Laucaster County Bank vs. Moore, 78 Pa. St. 407. On December 30, 1871, George H. Moore, a man of property, about fifty-four years of âge, called at plaintiff's bank, and obtained the discount of two notes signed by him, amounting to $1000, the money being placed to his crédit and afterward checked out by him. This money he applied to the payment of a debt. There was nothing in his actions to warn the officers of the bank as to his mental condition. On June 5, 1872, de lunatico proceedings were in- stituted, and on August 10, 1872, inquisition returned that Moore was a lunatic, and had been for three years jiast. In this action to recover on the notes, Moore's insanity at the time the notes were executed was set up as a défense. There was no évidence of Moore's insanity beyond the record of the proceedings in lunacy and neighl)orhood reports, which latter it was held were not sufficient to constitute notice to the bank. Verdict for défendant, which was reversed, the Suprême Court holding that "the law 132 A SYSTEM OF LEGAL MEDICINE. Avith a view to marriage, to several individuals. On lier examination before the commissioners lier answers were intelligent, and her conduct in no Avay différent from that of ordinary individuals. Seven médical witnesses Avère summoned to support the commission, and each of them eh'posed that she Avas of unsound mind. The commissioners, however, had ree-ourse to Drs. Morrison and Haslam, avIio visited lier, and wlm came to the conclusion that she Avas neither imbécile nor idiotie:, and that lier inability to mariage her affairs arose from ignorance. She Avas aware of lier eleficiencies, anel deplored her ignorance of arithmetic, and explained it on the ground that lier 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 jury, by a majority of twenty to two, returned a A-erdict 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. ISingleton it Avas 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 Avas defended on the ground that at the time défendant had promised marriage he Avas advanced in life, viz., sixty years of âge ; and that before a reasonable time had elapsed from the request to marry, namely, in May, 180."), he Avas, by a " Visitation of God," attacked by a fit of apoplexy, since Avhich time he Avas in an infirm state and afflicted with softening of the brain, in conséquence of Avhich he could not perform his promise without putting his life in great péril and hastening his death. Evidence was called, on the part of the plaint- iff, to prove the engagement and to show that no apparent impairment of health or vigor remaineel after recovery from the attack. It Avas stated by defendant's counsel, Mr. Bail, that in 1849 he had suffered from dropsy and disease of the kidneys; that in 18Ô2 he had. an attack of apoplexy and congestion of the brain ; during the interval from that time until May last he had promised to marry the plaintiff ; but that in the latte t month he Avas afflicted Avith another attack of apoplexy, and Avas uoav suffering from paralysis and softening of the brain. The défense then called several médical men Avho had attended the défendant. They tes- tified that he had had apoplexy and Avas paralytic, Avas suffering from is well settled that persons who are not s ni juris, and hâve no gênerai capacity to contract debts, are nevertheless liable for their torts, and may bind themselves for nécessaires." The bank having acted in good faith and without notice, the estate of Moore was liable. Mutual Life lus Co. vs. Hunt, 79 N.Y. 541. Action for foreclosure of a mortgage executed by défendant April 23, 1870, for $4000 money loaned, payable September 1, 1871. Interest was paid to March, 1871, but in September, 1871, default was made. In December, 1871, défendant was adjudged a lunatic. At Spécial Term judgment was granted for plaintiffs, which was affirmed at General Term (14 Hun, lè9). The Court of Appeals sustained the judgment, holding that the fact that défendant was declared insane after the 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. INSANITY IX ITS MEDICO-LEGAL BEAEIXGS. 133 loss of memory and other mental symptoms, and that he was hable to another attack, and that any excitement Avould increase the tendeney to such attack, but would not say that he might not marry without imperil- ing his life. The jury returneel a verdict for the plaintiff of £300 damages and costs. The ground of this Arerdict, it is said, Avas that the jury con- sidered that an unreasonable time had elapsed between the date of the promise of marriage and the date of the last attack of apoplexy. Divorce, Annulment, Legitimacy, and Insanity. The plea of insanity is sometimes urged as a ground of divorce, and in one case which occurs to the Avriter the husband of an insane woman, whose disease developed after marriage, brought suit for séparation. In ordinary cases such inhumanity, in disregarding the existence of the af- fection as an unfortunate calaniity for Avhich the patient is no more re- sponsible than she Avould be for smallpox or typhoid fever, rarely finds favor in the eyes of the hnv; but it can be realized that in instances Avhen insanity lias existed before marriage, and when the husband or Avife has been kept in ignorance of the fact by the patient, or by his or her parents or nearrelatives, a délicate légal pe>int may arise* The attitude of the German courts regarding this question is most moderate. A late décision of the Reichsgericht (ato1. xxvii., p. 158) con- cerns a pétition 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 Avas brought to sIioav that the défendant had a he- reditary prédisposition and had been temporarily insane before as Avell as after her marriage. The plaintiff had married the défendant 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 Avas the subject of hereditary insanity, and that she had before marriage and afterward shown signs of Avliat lie claimed to be incurable insanity, and that lie was uuaAvare of this fact Avhen he married her. The défendant only admitted that she had been temporarily deranged after the birth of lier child, such insanity being puerpéral, and, moreover, that the plaintiff * Banker vs. Baukcr, 63 N. Y. 409. The défendant, Ellen M. Banker, and John Banker were married Ma.rch 8, 1869. In February, 1869, proceedings de lunatico in- ijuirendo were instituted, and on Mardi lOth, two days after the marriage, it was found that John Banker was a lunatic, and had been for six months previous. Mrs. Banker had notice of thèse 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 intervais, and affirmed his marriage after that date ; that lie was not insane at the time of his death ; and that Mrs. Banker had notice of the lunacy proceedings. Judgment was then entered dismissing the complaint, which the General Term affirmed. The Court of Appeals also affirmed the judgment, "the inquisition is conclusive against subsé- quent acts and dealings, and presumptive against prior ones," irrespective of notice. Eairdou vs. Eatcdon, '28 Ala. 565. This was a bill filed by Mrs. Elizabeth Rawdon for a divorce from her husband, Isaac Rawdon. It was alleged and proved that they were married ; that Isaac was insane at the time of marriage, and for some time after- ward, unknown to his wife. His insanity was caused by brain-fever. About the time of the marriage he had a lucid interval. but after the marriage she began to notice his strange conduct, although he was considered an intelligent man by many. About six years after marriage he developed religious mania, and his lucid intervals ceased en- 134 A SYSTEM OF LEGAL MEDICIXE. had been aAvare of her state of mind from lier very youth. The fact that the brother of the défendant had passée! tAvo years in a State luna- tic asylum in 1882 and had been elischarged uneured Avas admitted. The court decided against the plaintiff on the folloAving grounels : Tluit after its investigation, as Avell as upon the médical report of the direct»a- of the asylum, it Avas clear that the défendant, at the time of the set- tlement of her marriage, Avas not in a state of chronic mental disease, nor Avas she then suffering from eA'en a temporary attack of mental dis- turbance. It Avas determined that she Avas hereditarily afflicted and Avas thereby exposed to the danger of mental disease, and that twice in lier life, once before her marriage, at the occasion of the death of her sister, and again about six months after lier accouchement, she had suffered from attacks of acute mental disturbance in the form of passiA'e melan- cholia. It was the opinion of the court that no one had ever gone so far as to décide that a temporary disturbance of mind which Avas un- known to the other party, occurring before marriage, even if this disturb- ance reappeared after marriage, could seiwe as a cause for annulment, and, moreover, he was unaware of any précèdent for the annulment of a marriage because one of the contracting parties Avas hereditarily afflicted with a prédisposition, and a temporary dérangement had appeared after the consummation of marriage, such disorder being provoked by suffi- cient causes. In the case under considération the défendant recovered completely each time after a feAv Aveeks. It was also held that the de- fendant had no reason or cause, nor Avas she obliged in any way, to com- municate to the plaintiff the fact or nature of lier previous illness. It has also been held by the German courts that an innocently ac- quired insanity of husband or Avife does not constitute sufficient ground for divorce. (Ibid., vol. vii., p. 154.) The courts even go so far as to protect the insane défendant Avhose disease prevents the consummation of cer- tain customary habits of matrimony (sexual intercourse, etc.). The All- gemeine Protestantische Kirchen-Rceht ((Tcneral Protestant Chureh LaAv) considers wedlock as a communion standing above a common agreement and binding the AA'hole personality of the contracting parties in ail situa- tirely. During his paroxysms he frequently attempted to kill his negroes, and actually did kill their only child, erected a seaffold, and burned 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 ground that the marriage was contracted during a lucid interval ; and on appeal the Suprême Court affirmed this judgment on the grounds named above. The court also laid stress on the facts that the marriage was contracted in ISlifJ, in 1836 Rawdon developed insanity, and Mrs. Rawdon did not file her bill until 18-14. State ex rel Setter vs. Setzer, 97 N. C. 252. In August, 1859, Reuben Setzer and Sophronia Morcus were married, and lived together until 1862, when lie enlisted in the Confédérale 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 défend- ant, who administered the estate of Reuben Setzer on his bond for a share of the Personal estate. The défense was that Reuben had been an imbécile from his youth up, and was insane at the time the marriage was contracted. A jury declared that the intestate did not hâve mental capacity to contract the marriage, and judgment was rendered for défendant, which on appeal was reversed by the Suprême Court, the court holding that the question of the validity of a marriage 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 présent 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." IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 135 tions and possibilities of life until one or the other of the parties be- comes by his own fault umvorthy of the other. Unconsciously acquired madness, if developed after marriage, is therefore no ground for divorce. The German law (Allgemeiues Landrecht, sec. 6982), however, holds that rage, insane fury, and dangerous madness justify a divorce when such a dérangement has lasted for more than a year and there is no possible hope of recoArery. The fanions Mordaunt Divorce Case, in which the Prince of Wales fig- ured, is one in which puerpéral insanity Avas urged as the basis of irrespon- sibility. Lady Mordaunt, after her confinement, admitted that she had com- mitted adultery before the birth of lier child, and the évidence substanti- ■ating her story was seemingly very strong, for entries in lier diary a year before recorded the visits of a nobleman at an hour of the night inconsist- ent Avith 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 peculiar in the conduct of Lady Mordaunt either before or after lier dehvery, and this was in contradiction of those friends of the patient herself avIio asserted that lier cemfessioii Avas the resiilt of a delusion; for not only had the wife admitted improper relations Avith other men, but swore that the child Avas not lier husbaud's. The patient Avas delivered of lier ehild on the 2Sth of Eebruary, 1869, and a week or two later made her extraordinary admission. The physicians called by the plaintiff Avère inclined to think that she was not insane, and that there Avas nothing in lier conduct inconsistent with feigning. The reasons assigned .as e\ddences of her insanity Avère of the most extraordinary description, but they Avère met with much that was contradictory. It was shown that her habits had become fil thy, that she destroyed lier clothing and Avas unclean in her habits; and in 1870 she was demented and could not comprehend communications that Avère made to her. The jury and the judge took this latter view of the case, and it Avas decided that as early as the 30th of April the respondent had not sufficient capacity to briug 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 décide "Avliether she Avas or not in such a state of mental disorder as to prevent lier giving instructions." The case Avas afterward appealed and tried upon its inerits, the matter of insanity being left out of the question, the défendant being considered guilty of ■adultery, and the divorce Avas 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 Avhich seems to us far from being a safe one. In a case of murder the évidence of other persons or circumstantial évidence may be sufficient. In the relations of husband and Avife it seems hard to punish the Avife while she is unable to défend herself. At ail events, if the principle be admitted, it seems unjust that a poor laborer should bave to pay toAvard the support of an insane Avife in Colney Ilatch or Hanwell, and be liable to a prosecution for bigamy if he mar- ries again, while the wealthy baronet escapes almost scot-free and may marry again if he choose." Mai-iiages contractée! in extremis are usually A'ery apt to be dissolved by courts of law. Tidy refers to the case of Rochefort, who Avas married to his former mistress on her death-bed, lie being taken from prison for 136 A SYSTEM OF LEGAL MEDICIXE. the purpose. It appeared that the Avomau was in lier right mind, and consequently the marriage was held to be valid. But Avhere one of the parties is overa.Aved, or there is any évidence of mental perversion, the legality of the contract is properly questioned. A case showing that the alleged insanity must be that Avhich in itself Avili interfère with a proper understanding of the marriage contract is the following. In it " kleptomania " Avas urged as a ground for divorce. Lewis vs. Lewis, 44 Minn. 124. The parties to this action Avère mar- ried in 1882. At the time the défendant Avas insane, but this fact av;is concealed from plaintiff until lsSX. The plaintiff brought suit to annul the marriage on the ground of fraud in the concealment of defendant's insanity, and also that défendant Avas not compétent 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 défendant, which Avas affirmed by the Suprême Court, on the ground that the insanity proveel did not show that défendant was in- capable of understanding the marriage contract, and that the conceal- ment practiced was not sufficient to justify the court in ammlling the marriage. The plea of non-support by reason of insanity as a ground for divorce has not found favor with the courts* In the case of Baher vs. Baler, 82 Indiana Reports, 146, it was shown that plaintiff and défendant Were married in 1867. In 1874 défendant became insane, and was committed to an asylum, where he has since remained. Plaintiff instituted this suit for a divorce on the ground that défendant failed to support her. The Suprême Court on appeal held that this did not constitute sufficient ground for divorce ; that the statute providing for divorce AAdiere the husband fails to support 1ns wife does not apply when such failure is caused by mental or physieal disease. Another issue Avas raised in the case of Gerhold vs. Wyss, 12 North- western Reporter, 800. The plaintiff and défendant Avère married in "September or October, 1867." A few days thereafter plaintiff learned of defendant's insandy, but continued to live with her until September, 1881, Avhen a decree of séparation Avas made. He now sues for her sup- port during the time they lived together. The Suprême Court of Ne- braska held that as plaintiff knew of defendant's insanity, but continued to live with her, he Avas obligée! to support her. The existence of epileptie insanity or epilepsy may form the basis of légal proceedings, and the existence of epilepsy Avhich bas 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 Avas aroused at night by the restlessness of her husband, who violently at- tacked her, and she Avas obliged to call for assistance. This occiirred 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 claiming to be the wife of Jesse. The défense was that at the time of the pretended marriage Jesse was insane, and that she lived with him but a short time and then eloped with another man, with whom she lived for twelve years ; but the Trial Court refused to receive évidence in support of thèse facts, and ordered judgment for Mrs. Bennett. On appeal the Su- prême Court held that Bennett was insane at the time of the marriage, which was, therefore, void, and remained void till his death, and reversed the judgment. IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 137 midst of a severe epileptie attack, and he would again hâve doue violence if not restrained. In this case the patient had but an indistinct idea afterward of bis condition, but he admitted having had other attacks previous to his marriage, of a vertiginous eharaeter. Hence it seems to me there should be no reasonable excuse for denying a divorce, especially if the patient Avas cognizant of his previous disease and neglected to communicate his knoAvledge to his wife. BANKRUPTCY. A person who in the eyes of the law is non compos mentis cannot com- mit an act of bankruptey while his disability lasts, but if he has doue so previous to his lunacy, lie may be made the subject of a commission of bankriq>tcy.* (Ordronaux.) He cannot be arrested, and during the continuauee 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 lias been determined is of course incompétent, and lie 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 prévalence of in- sanity, the disturbance of their equipoise, the emotional excitability présent, and the underlying rapt us maniacus touching every faculty at some point ; remembering also that every human being is steeped in his own tempérament, wears the hvery of his ordinary mental states, and exhibits in his unguarded acts the complexion of his prédominant moral feelings—avc are forcée! to the conclusion that, e\'en outside of the sphère of delirium anel incohérence, the statements of one who is insane or bas been profounelly so, but is uoav recovered, need to be scrutinized from * Stock. N. C. :î8. In re Murpliy, 10 National Bankruptey Reg. 48. A pétition in bankruptc3r was filed against Alonzo Murphy by his ereditors, and on his failure to answer he was ad- juged a. bankrupt by défailli, and his property was turned over to the assignée. Be- fore distribution had been made Murphy appeared with an application alleging that he was non compos mentis at the time the debts were created and the bankruptey pro- ceedings instituted, and the court (United States District Court, Tennessee) opened the default. Subscquently a jury rendered a verdict of insanity, and the assignée was ordered to return the property to Murphy. /// re Weitzel, 7 Bissell, 289. This was an involuntary pétition in bankruptey. Insanity of bankrupt was pleaded as a défense. On demurrer to the answer the United States District Court for the Western District of Wiseonsin decided : First, That a lunatic can be adjudged a bankrupt against the consent of his guardian. Second, That an insane person cannot commit an act of bankruptey. In re Marvin, 1 Dillon, 178. William L. Marvin, a merchant, suspended payment on January 4, 1871, and did not thereafter résume, and his property was levied on shortly afterward. In February this pétition in bankruptey 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 bankruptey were committed. The District Court overruled a demurrer to the answer, and on appeal the Circuit Court affirmed the judgment, holding that a person who is "wholly incapable" can- not commit an act of bankruptey. 138 A SYSTEM OF LEGAL MEDICIXE. a standpoint not so much of veracity as of intellectual competency." (Orclronaux.) Authentic instances of a lunatic testifying are rare. In the case of Reejina vs. Hill, 2 Denis, C. C, 2Ô4, 1851, a lunatic, Donnelly, was permitted to testify in regard to an assault after haA'ing been ex- amined as to his competency. Although exceptions Avère taken, the ver- dict Avas sustained. As to matters of bare fact there can be no doubt that an insane per- son is often able to testify intelligently, but it is necessary to ascertain if a delusion or delusions exist, or if the person called entertains insane préjudice. 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 eare, especially in cases Avhere emotional states exist. Some authors hold that a person AA'ho has been insane and recovered should be permitted to testify to faets occurring during his insanity, provided the facts are •' objecti\rely 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 Avhile 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 laAvs governing the commitment of the insane vary greatly in detad. (See Appendix.) In some States the affidavit of one physician is sufficient, in others two, Avhile in others the alleged lunatic is to be brought before a jury, Avho pass upon his case. The appointaient of a commission is a more elaborate and satisfactory way of determining the incapacity of a person, if he be a lunatic or habituai drunkard ; and the eluty of such a body is to fix his status so far as his being a free agent is concerned, to inquire whether or not lie is able to manage his property, and, if necessary, to appoint a guardian of his estate and person. Upon the présentation of a pétition a judge of a court of record usually appoints three persons, one of whom is a physician, and another a laAvyer, and thèse conduct a hearing either in the présence of a sheriff s jury (New York) or a specially impaneled jury. Upou the finding of tins 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 eare of the property, and another for the person. If the patient demurs at the finding he has the right to a traverse, Avhich is granted if the appointing judge deems it wise, in vieAV 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 décide whether or not his déniai of the charge of insanity is well founded. The fullest inquiry should be made in such cases, although reform is needed in the admission 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 légal rules, hearsay and prejudiced testimony are admitted, some of which, even if subsequently discarded, influences the mind of the too sympathetic juryman. Great eare should be taken in giving or preparmg testimony, for it often happens that the reasons IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 139 assigned for the alleged insanity are of the most flimsy eharaeter, and may be trumped up by designing relatives and too readily accepted by cardess médical men. It should be ascertained Avhether the individual has been insanely extraA-agant ; or whether lie has been swindled repeat- ed ly or drawn into absurd spéculations. One old lady Avhom I examinée! invested two thirds of her small fortune in bogus mining companies Avithin a few months, and spent considérable sums of money in the most foolish Avays, Avhile before this time she Avas penurious and economical. It is often necessary to décide the question whether a person of weak mind should be detained in an asylum or placed iu 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 médical men who examined the patient considered her an insane person, their vieAv of the case was disregarded, and the late Judge Brady ordered Miss Dickie's discharge, but appointed a guardian. •'Miss Dickie Avas sent to Bloomingdale on the certificates of Dr, White, and of Dr. Alfred C. Post. She Avas accepted as a lunatic by Dr. Tilden Brown, and retained as such by Drs. Xicholl and McDonald, with the implied consent of her aged and imbécile father's physician and guardian, Dr. Ranney. " 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 Avas found to be diminutive in size, lame, and apparently deformed, hard of hearing, and Avith speech very indistinct and imperfect, from a very Avretched condition of her gums, teeth, and mouth. The latter, it was supposed, could easily hâve been relieved by careful rinsing and Avashing of the mouth. There Avère other signs of carelessness of person and dress which were not visible in the persons of the matron, attendants, and other patients who Avère 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 pull lier 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 thèse were served especially to annoy her. She stated that an effort was being made, with her consent and that of lier famdy, to remove lier from the asylum, and expressed a préférence to live in the city rather than in the e;ountry, with some slight hint which suggested that she did not like green things, but desired to visit shops, go to her oavh chureh, give money to it, and live by herself. She volunteered to say that she read the Sun and the Observer, and showed copies of them ; that she had a great impulse to improve her mind ; quoted some simple little niaxims at times, especially about not talking too much, when she Avas niemopedizing almost the whole conversation. As she occasionally quoted Sculpture, she Avas asked if she had a Bible ; it was then noticed that she seemed to keep almost ail her property under lock and key, but she quickly produeed her Bible from a locked drawer, and it Avas found not only filled with pened-marks from Genesis to Révélation, but many pages Avère folded in the most curious and complicated ways, as if to 140 A SYSTEM OF LEGAL MEDICIXE. mark spécial passages of great import to herself; but her visitor Avas surprised on unfolding thèse curiously doubled-up pages to find ne) pencil-marks whatever upon some of them, and she avoided answeriug Avhv she thus pointedly singled out particular liages. It is barely pos- sible that those Avère pages Avhich she did not wish to read, but nothing could be détectée! strikingly peculiar in the contents of tliose pages upon a short examination. "Her first visitor had been alone with lier for half an hour or more Avhen another physician came into the room, and was introduced by name and title as a second médical man Avho had come to see lier. She immé- diat ely Avent on conversing Avith him. His attention Avas attracted by hearing lier tell lier second visitor that there Avas a language of food as well as of floAvers, and Avhen asked for an illustration stated that c'offee was broAvn, broAvn Avas a Quaker color, a Quaker Avas a Friend, anel that hence cofïee meant friendship ; that if one person gave another a cup of codée, it Avas a sign of friendship, and if milk, which Avas white, was put into it, it Avas a sign of pure friendship, and the addition of sugar made it an indication of sweet friendship—in short, that coffee Avith milk and sugar in it Avas indicative of pure, sweet friendship. Then she volunteered to say that. bread represented a friend ; that a big pièce of bread Avas a sign of a large friend ; that butter signified refinement, and bread and butter a refined friend. She then epiie-kly said that cabbage was white on the insicle, and that signified purity, and gi-een on the outside ; but no questioning could make her say Avhat the green meant. She continued to say if one eut up the in side of cabbage and put it on a little plate, it Avould indicate purity and something else Avhich she AA^ould not disclose, possibly because it had référence to the green color. " Kepeateelly, Avhile this conversation was going on, lier visitors were Avarned not to speak loud, as persons were Avatching ail the time, up- stairs and doAvnstairs, through the register, pipes, etc., presumal)ly the Avaste, Avater, or gas pipes, none of Avhich, howeA'cr, could be seen on casual inspection. Thèse persons Avère also said to Avhisper to lier through the tubes. She declared that this food language was not peculiar to herself, but was knoAvn to and in constant use by ail the attendants and patients ; that her con\ersation anel letters Avère com- municated or perhaps telegraphed about the house, as she inferred, by single Avords, said by différent persons, in various places, in the midst of their conversation, and by putting thèse detached Avords together she found ont by something in her heart or chest—not in her head—that they had become acquainteel with the letters she had Avritten and the conATersations she had had with others and presumablv with herself. " It Avas very évident, said the judge, that Miss Dickie Avas of unsound and imperfect mind and understanding, yet for an hour and a half she had given no positive signs of absolute mental derangeunent, She kneAv who and Avhere she Avas, described the institution as a house of affliction, but she made no allusion or complaint of her felloAv-sufferers, or of any noises or annoyances except the imaginary Avbisperings through the tubes. She Avas conscious of her OAvn Aveakness and ignorance of many things ; seemed satisfied to bave as lier guardian a bank président, Avhom she named, as she Avas not accustomed to deal Avith large sums of money. In short, she presented the usual mixture of reason and uureason so common in many simple lunatics. Sometimes she exliibited a good deal IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. m of tact and cunning, at other times of extrême childishness and sim- plicity, mixed up Avith delusions, hallucinations, unfounded suspicions, extrême préjudice and hatred, great Christian piety, charity, and benevo- lence. " The only question that could arise was Avhether it was absolutely necessary to retain lier in the asylum. There seemed no objection to a trial elsewhere, provieled ail lier property should not pass into the hands of strangers and irresponsible persons ; that a proper résidence should be selected Avhere her peculiarities should not become the sport of the foolish and indiscreet; and that a compétent maid, nurse, assistant, or matron could be found, possessed of unmeasured patience, tact, and reso- lution." This action illustrâtes the conflict that frequently arises in cases where médical men bring to their aid their expérience in other cases. This patient Avas evidently a chronic delusional lunatic, and although her history had been a harmless one she evidently owed her improvement to the eare of an asylum, and Avas not there subjected to the disturbing irritation which she subseepiently would hâve been atïeeted by outside. Every one is familiar Avith the cases of so-called harmless lunatics who hâve been liberated. In many such instances the removal of ail restric- tion bas resulted in a train of disorderly conduct, extravagance, famdy quarrels based upon delusive ideas of persécution, 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 légal action may proA'e rather a curse than a blessing. The légal duty of commissions is to prove the gênerai existence of insanity, and for that reasem the courts are apt to ignore isolated or limitée! évidences unless they be especially dramatic; on the other hand, the désire to protect the patient is such that minor indications of es- tablished degenerative insanity are disregarded. For this reason the law, as will be shoAvn hereafter, looks Avith suspicion upon évidences of moral Aveakness, no matter how suggestive they may be of mental dis- organization* It was held in the case of Patterson (4 How. Pr. 34) that the rétro- spective finding of a jury regarding the acts of a lunatic or habituai drunkard is only presumptive anel not conclusive évidence of incapacity.f Ordronaux,! in commenting upon thèse cases and that of Wadsworth vs. Shetipsteen (14 Barb. 1C9 ; affirmed in 8 N. Y. 388), where the reverse Avas held, considers that a possible lucid interval was overlooked in the latter, and concludes: -'Legally considérée!, eA'ery form of lunacy implies the possibilitv of an intercurrent lucid interval; and until that possibility is juelicially declared never to bave borne fruit, the only proper infer- ence is that it may hâve done so ; and consequently that an inquisition which overlooks the question of lucid intervais is only presumptive and not conclusive eATidenc'e of past continuons inca]iacity." (Searles vs. Har- vey, 6 Hun, 658.) The finding of a commission that a person is insane is only prima facie évidence of business incapacity so far as a third per- son is concerned, nor are they compétent to dissolve a partnership. This * Titcomb vs. Yanti/le, 84 111. 371 ; Jacox vs. Jacox, 40 Mich. 473 ; Fentrus vs. Fentrus, 7 Heisk (Tenn.), 428 ; etc. t Van Deuscn vs. Sirect, 51 N. Y. 378. t Médical Jurisprudence of Insanity, p. 247. 142 A SYSTEM OF LEGAL MEDICIXE. must be determined by a judge, Avho takes into aecount ail the features. of the case, the degree of the unsoundness, and whether it is recover- able. TRAVERSE. If it is desired to tivaverse the finding of a commission, the lunatic, his friends, or any one legally empowered to act may make application. This includes those Avho may hâve had contracts with him, or Avho hâve been or are likely to suffer by his acts* The court Avili protect the in- terest s of the lunatic during the pending of the proceedings.! Applica- tion for a traverse should be accompanied by affidavits and the service of papers upon the opposing cemnsel. Suits may be brought in behalf of the committee of estate ; but should the complainant himself be a lunatic, the défendant may demur when it is the custom to appoint a guardian to appear in bis behalf. According to section 375 of the new Code of Civil Procédure, the limit of time in which a lunatic may bring action to recover real pre>perty, or enter a défense or counter-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 Baker vs. Baher,\ Avhere an action for divorce was brought against the lunatic's Avife, 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 défend or bring suit whenever it va&y 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 because of bis AÙolent acts, or that he may wander about and get into harm's way. To specify thèse would be to go over much of the ground we hâve traversed. It is clearly proper to send such a person to an asylum for treatment when the facilities for it elseAvhere are inadéquate ; and in the light of skilled expérience, isolation is deemed an early and important requirement 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 follow that he is to be incarcerated. The appréhension or removal of a patient from one State to another for the purpose of avoiding légal or other conséquences may be thwarted by the application for a commission ; in fact, persons who hâve so spirited lunatics away hâve been obliged to return them. (Wykeham, 1 Turn. & Russ. 537.) * Christie, 5 Paige, 242 ; Giles, 11 Paige, 243 ; Haie, 7 Ves. 261 ; Koberts, 3 Atk. 308. t Wendell, 1 Johns. Ch. 600 ; Eussell, 1 Barb. Ch. 42. f L. R. 5 P. D. 145. § Carter vs. Beckivith, 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, which failed, to supersede the commission and hâve his prop- erty restored to him. In 1875 the lunatic died, and plaintiff brought this action for his services against the administrators of said lunatic. Judgment for plaintiff was affirmed, the court holding that while a lunatic in the custody of a committee is in- capable of making a contract, and no claim thereunder could be enforced against his estate, at his death the claim must be adjusted and settled in like manner as other claims against the estate. IXSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. H3 TORTS. The responsibility of a lunatic for malicious acts dépends upon the extent of his direct participation and capacity, and his liability is thus limited. •• A lunatic is liable for bis torts so far as to subject his estate to a suit for damages reverted to others by his négligent management. On principle, howeA-er, he cannot be held liable for malicious acts in cases Avhere lie is not caput doli." (Wharton and Stillé.) The French courts in the case of Mariants vs. Bénard (Journal du Palais, 1882, vol. xchi., p. 678), held that the torts of lunatics when the insanity has bern the resiilt of debauch or the misuse of alcoholic liquors renders the individual civilly responsible. It has been held that the guardian of a deceased lunatic must recover for torts of the deceased from the administrator. This Avas held in the case of Brown vs. Howe, 9 (tray (Mass.), 84.* An action for trespass may be brought against the administrator of a deceased lunatic when his tort has resulted in the injury of others.t The liability of a lunatic for the carelessness and negle<;t of his guardian has been fixed in the case of Morain vs. Devliu, 132 Mass. 87 (1882)4 LIBELS AND SLANDERS. Thèse offenses, when committed by the insane, rarely form the basis of suits for damages, so clear is the disorderly mental condition of the offending party. Delusions of persécution and suspicion are so common as to tincture the speech and be manifestée! in the conduct of their possessor. Even when the ''partial insanity" of the law exists and the defendant's mind is normal in most matters, such a défense has often * Calvin G. Howe was appointed guardian of Daniel Saunders, an insane person. In the seulement his account contained this item : "For loss sustained by accountant by fire caused by want of eare on part of said Daniel Saunders, over and above amount îvcoived by insurance," which was allowed. Saunders having died, his administrator, Brown, appealed to the Massachusetts Suprême Court, who reversed the decree, hold- ing that a claim of this eharaeter, not arising from the trust, could not be made a part of the guardian's account. The trust being terminated by the death of Saunders, the guardian's only course was to sue the administrator for the damage sustained. t Mclntyre vs. sholty, 121 111. 660. In February, 1886, a man was discovered con- cealed in a barn on Levi Sholty's farm in McLean County, 111. After some efforts to induce the officers of the law to eject the man, Sholty, with several neighbors, gath- ered at the barn to drive out the person, who proved to be David Sholty, a brother of Levi Sholty, and who shot at them. Shortly after, the barn was discovered to be on fire, and David appeared at the door with a shot-gun and shot and killed Hannah, the wife of Levi Sholty, whom he had ordered to hait as she was passing by. Levi, as admin- istrator of his wife, brought action of trespass against Mclntyre as administrator of David Sholty, who perished in the burning barn, and recovered judgment. On appeal the judgment was affirmed. The appeal was taken on the refusai of the Trial Court to receive évidence of the insanity of David Sholty, which was the ground of défense. Held, no error. The Su- prême Court said that while a lunatic is not punishable criminally lie is liable civilly for a tort ; if otherwise, those interested in his estate might not take eare to prevent him from injuring others ; and "if parties can eseajie the conséquences of their injuri- ons acts upon the plea of lunacy, there will be a strong temptation to simulate insan- ity, with a view of masking the malice and revenge of an evil heart." t This was an action for personal injuries caused by a defect in a door-step of a building owned by défendant, who was at the time of the accident confined in an asy- 144 A SYSTEM OF LEGAL MEDICINE. been potent. (Rorner vs. Marshall, 5 Munf. 166; Abrams vs. Smith, 8 Blackf. 95.) The rétrospective finding of a commission will usually be a good dé- fense or will mitigate the damages after the actual suit has begun. "If the inquisition does not overreaeh the time of libel, then the subséquent insanity of the party can bave no bearing upon the question of the measure of damages, for a lunatic is civilly responsible for his torts wherever they may hâve been committed." (Ordronaux.) A case where the issue was the degree of insanity, and where it was held that though the défendant was so insane as to need a guardian, the weight of his slander and its conséquences dependeel upon the light de- gree of his mental unsoundness, was that of Dichinsou vs. Barber, 9 Mass. 225.* DISSOLUTION OF PARTNERSHIP BY REASON OF INSANITY. In the matter of business associations, especially Avhere the interest of one member is moneyed and that of the other is the expérience and "brains" he brings, lawsuits may arise and attempts at dissolution, growing ont of the insanity of one member of the firm and the consé- quent danger that mutual interests may be Avree'ked. The sane party may demand an inquisition upon proof of the insanity of the other, so that the copartnership may be dissolved. IMPEACHMENT BY REASON OF INSANITY. In the matter of guardianship, where the trust funds are being squan- dered, or where the protection of the ward so demands, steps may be taken for the déposition of the guardian. The most painful cases are those where the médical man is required to testify as to the incapacity from old âge or mental disease of an ofîicer holding a position of public trust. It cannot be denied that even learned judges whose long and honorable service has resulted in mental decay are able in a routine way to go through with familiar duties of the past, and in fact tliose mental opéra- tions which become automatic are apt to fail long after minor perver- sions hâve attracted the attention of his immédiate friends and family. lum, and had been for several years—since 1876, when a guardian had been appointed for lier. Verdict for plaintiff affirmed on appeal, the Suprême Court holding that an owner of real estate is liable for defects, eATen when caused by neglect of persons act- ing in his behalf, adding, "and there is no précèdent and no reason for holding that a lunatic, having the benefits, is exempt from the responsibilities, of ownership of real estate." * Action for slander. The complaint charged the défendant with having said that plaintiff had been criminally intiraate with his (defendant's) wife. LTpon the trial the défendant, by his guardian, submitted évidence, as a défense, that before and at the times the words were spoken he was insane, and still was délirions and insane. He also offered the dépositions of two physicians to prove that he was still insane, which dépositions the court excluded. The jury rendered a verdict for the plaintiff, which was affirmed by the Suprême Court, who held that where the insanity was notorious, so that the words could produce no effeet, no damage could be incurred; but where the insanity was slight, the slander might hâve its effect—thèse were questions of fact for the jury to détermine ; also that the rejection of the opinions of the physicians was proper, as they did not appear to be based on facts. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 145 In such cases the office of the médical man is a disagreeable one, and he should act Avith more than ordinary eare and prudence. No bloAv is so great as that inflicted upon a sensitive and high-minded person Avhen lie is made certain of his intellectual failure. The symptoms of ordinary disease or temporary manifestations of ovei-Avork should never form the basis for a hastily expressed opinion. INSANITY AND LIFE-INSURANCE. The question of insanity in relation to life-insurance occasionally arises, and is made the basis of refusai to pay the amount of the policy upon the part of the companies. (See Dr. Symond's article, vol. i.) It sometimes happens that an individual insures his life and fads to state that he has suffered from a nervous disease which is the precursor of a form of insanity. A case reportée! by Taylor and Tardieu * is that of a gentleman who insured his life, afterward becoming insane. The company refused payment, asserting that the insured was aware of his malady Avhen he applied for a policy, and refused to so state. The jury decided for the défendant, and the judge chargée! the jury that they must décide if the mental disease had a tendeney to shorten life, for in this case the dissimulation that had been proved Avas important; if the alién- ation had this tendeney they must décide in favor of the défendant. One of the oldest cases of this kind is that reported by Beck, and the high position of the insured party gives the case much interest : •• lu 1824 a policy was effected by the Baron von Lindenau on the life of Frederick IV., Duke of Saxe-Gotha and Altenburg, in the Atlas Insurance Company. The duke died on the llth of February, 1825, and the insurers refused to pay the sum insured for. •• On the trial it appeared that Lindenau had stated in his application that the duke was not gouty, asthmatic, or consumptive, or subject to fits ; that he had never had apoplexy, and that lie had no disease tending to shorten life. Tavo physicians of the duke certified that since the year 1809 lie had had a dimness of the sight from amaurosis in the left eye, and since 1819 had been •hindered' in his speech from having had an inflammation of the chest, of which lie had been perfectly cureel. In a communication from an agent in Germany it was mentioned that the duke had formerly led a dissolute life, by Avhich he had lost the use of his speech, and, according to some, that, also, of his mental faculties, which, hoAveA^er, is contradicted by the médical men. On this the com- pany, instead of asking an ordinary premium of £2 17s. percent, per annum, required £8 percent. It noAv, hoAvever, appeared that the duke had been afflicted Avith almost a total loss of speech from 1822 to the time of his death, which one of the physicians attributed to local paraly- sis ; and that lie had periodical catarrhal affections accompanied with fever. The Chamberlain of the duke, in his examination, mentioned that he had never complained of pain in his head. He ate, drank, and slept Avell, but could not speak. Dr. Dorl, physician to the duke, agreed that his intellectual faculties were impaired, although his boddy health was good. On examination after death, no chronic disease Avas dis- * Annales (VHygiène Publique, lxxvi., p. 152. 146 A SYSTEM OF LEGAL MEDICINE. covered in the viscera or any part of the trunk ; but in the head was found a large tumor six inches in length, tAvo iu breadth, and one in depth, Avhich not only pressed on the brain, but had depressed the skull at its base. It was inferred that this tumor had commenced in early life. The défense was that there had been a suppression of material facts. Dr. Green, an eminent English surgeon, gave it as his opinion that, from the history of the case merely, there Avère no symptoms of organic disease. He further thought that the tumor in the skull must, during hfe, hâve been in a passive state, and, from its appearance on dissection, that it must hâve been formed in early life. He was only willing to allow that the symptoms mentioned above would lead to a suspicion of disease in the head; and he Avas disposed to ascribe the difficulty of speech to want of volition, and not to tumor in the brain. In reply, hoAvever, to a question of Lord Tenterden, he answered : 'If I, as a médical man, were asked by an insurance company concerning the state of a man's health who was unwdling to move, who was subject to control upon his intellect, and who had lost his speech, I should not consider myself at liberty to forbear mentioning thèse circumstances.' Lord Ten- terden, who tried the cause, said this Avas sufficient, and that lie should charge the jury that if any material facts relative to the duke's health were concealed, then the policy Avas void. The plaintiff electeel to be nonsuited, and subsequently maele an effort to obtain a new trial, but it was refused." A French décision holds that if a person applies for a policy and with- holds the fact that he has been insane, or has a disease which may lead to insanity, his policy is null and void, and he cannot expeet the return of the premium, even though the person insured may die of some other disease. Paretic dementia may sometimes enter into the epiestion of life-insur- ance. A case is related by Legrand du Saulle which shows how one of the French companies was victimized. Two brothers went to the office of a Parisian alienist, and the elder had a private consultation, the residt being that he was informed that the other had the incipient signs of paretic dementia, and that death would occur in three or four years. They departed, and the resuit was that a policy of insurance was pro- cured for 100,000 francs. Three years afterward the elder brother quietly pocketed the results of the robbery. Another case is reported by Legrand du Saulle. A physician well known in science had for nine years before his death a life-policy for 100,000 francs. He suddenly presented the signs of great cérébral excitement, became boasting, and Avrote and spoke in an exaggerated manner. He again went to the companies and insured for 500,000 more. When the contract was prepared and ready for signature, the manner of the doctor Avas so véhément and excited that the agent be- lieved him to be drunk, and. under the pretext of having forgotten to insert an indispensable clause took back the policy. Upon the following day the médical man was sent to an asylum, and six months afterward died of paretic dementia. The company paid to the widow the 100,000 francs, and considered itself very fortunate in not having to add the half-million francs the husband desired to insure for. Henry C. Ross had effected an insurance on his hfe with défendant, and subsequently committed suicide by taking a dose of laudanum whde INSANITY IN FIS MEDICO-LEGAL BEAEINGS. 147 insane. In his application for a policy lie had stated that no member of his famdy had been afflicted Avith insanity or other hereditary disease, but admitted that his father had died of a brain disease caused by a hurt. •On the trial it was proved that his father had received an injury on his head in childhood, resulting in a Aveakening of his mental poAvers, and that at the âge of forty-seven lie Avas placée! in an insane asylum, and afterward died. On tins testimony plaintiff Avas nonsuited, but on appeal the Court of Appeals reversée! the judgment of nonsuit and ordered ab- sedute judgment for plaintiff. (Newton \-s. Mutual Boiefit Life Insurance Co., 76 N. Y. 426.) THE LIABILITY OF CUSTODIANS. The responsibility of the physician who shall receive into his asylum an insane patient extends only so far as the proper eare of such a patient is concerned. Under the kiws of New York, anel so far as this particular matter is concerned, the procédure is almost universal—the patient must be committed upon order of the court, upon proper médical affidavits. Under thèse circumstances the asylum physician is a mère custodian and can only discharge the patient upon recovery or upon the assump- tion of responsibility by the next of kin, provided, in lus judgment, he thinks it saf e to make others the caretakers of the patient. Under ail other circumstances the application of a writ of habeas corpus by the patient or bis friends is in order. If he is found to be improperly held lie is discharged. Until this time the asylum superintendent is prop- ■erhT the représentative of the court, who assumes the responsibility. The patient's rights to damages, if there be any, are to be determined by a suit against those upon Avhose recommendations he Avas committed by the court. Their défense must be that which is applicable in other professional matters, and must consist in évidence showing that they acteel in good faith and with an intelligent knowledge of the requirements of the profession* Maltreatment, of course, if proved, entitles the patient to damages. * Ayers vs. Eussell, 50 Hun, 282. On April 15, 1887, plaintiff was committed to an insane asylum in Albany, where he was kept until the 27th of April, on certificates of Drs. Selwyn A. Eussell and Daniel V. O'Leary that he was insane. On April 18th the plaintiff appealed from the commitment, and a jury was called who on the 27th of April declared him to be sane, and he was released. The plaintiff then brought this action against Drs. Eussell and O'Leary, and Anthony Gould as Eecorder of Albany, for false imprisonment. The défendants demurred, and the demurrer was sustained. On appeal to the General Term the judgment was affirmed as to Gould, and re- versed as to Russell and O'Leary, and the demurrer as to them overruled on the ground that as the complaint charged them with lack of ordinary eare and prudence, their demurrer (which was on the ground«that facts did not constitute cause of action) ad- mitted the allégations of the complaint. The court held that their certincate was not a privileged communication unless they had discharged their duty properly. Ilurlehy vs. Martine et al, 31 N. Y. State Reporter, 471 (Suprême Court, Third Dept., "M:\y 26, 181)0). In October, 1889, an inquisition was held as to plaintiffs lu- nacy, at which défendants, as physicians, made alleged false statements as to plaint- iff's puise, température, condition of mind, etc., and commitment was made to the Hudson River State Hospital, where she was confined for two years and fhTe months. The plaintiff brought this action after her release in 1888, for $20,000 damages, and on the trial a motion for nonsuit was granted on the ground that this was an action for false imprisonment, which, under section 384 of the Code of Civil Procédure, was limited to two years. On appeal to the General Term this décision was affirmed. 148 A SYSTEM OF LEGAL MEDICINE. MEDICAL WITNESSES. Attention has been elsewhere directed to the appearance of expert witnesses in courts of law, and the difficulties and abuses Avhich attend the introduction of this kind of testimony hâve been pointée! out. Jluch of the disrepute into Avhich hired testimony bas fallen is undoubtedly due to a kind of partisanship Avhich many men find it difficult to avoid, for the engagement of their seivices implies a bid for actual help in advancing a side by the building up of théories or reasons for the sup- port of a more or less tenable position. If the expert be cardess of his réputation, weak, or corrupt, lie will lend himself to the side of the case upon which lie has been retainod, and in reality he becomes a pleader, prostituting his knowledge, stretching a point, or burying his conscience. If he is not absolutely free his sympathies will be appealed to. It there- fore becomes him to avoid espousing the cause of any '• side " too ardently, or being actuated by a désire to "get back" at the cross-examiner. In other Avords, the médical Avitness who is called to give his opinion regard- ing the facts submitted to him should emulate the judge upon the bench in his impartiality. One of the unavoidable evils of the présent svstem is the hypothetical question, Avhich is supposée! to embody the facts of the case, but in reality is often distorted, disingenuous, and is roughly handled and more or less emasculated before the Avitness is finally allowed to pass judgment upon it. When the answer is given the médi- cal gentleman in the Avitness-chair is obliged to consider section by section, and an attempt is made to elicit a categorical ansAver, which is often impossible. What may constitute insanity as a Avhole may Avhen dissected mean nothing. By this means it is possible to get a truthful négative answer to many of the déments of real insanity. "Do you consider the fact that a man is slovenly in his habits an infallible sign of insanity?" may be asked, and the witness of course answers, "No "— while this very untidiness, taken with other indications, may be a very important dément of the mental disease. The médical man should therefore be.on his guard and refuse in such a case to give anything but a qualified answer. The Avitness can always avail himself of the privilège of qualifying his answers, for he cannot be made to demean himself by giving a nousensical définition which wdl stultify him as a scientific man. It is Aviser aud better for a physician to demand a person al examination, but in postbumous cases, of course, the hypothetical question is ail that is ayailable. Whether in civil or crimiiial cases, we are to détermine the influences that may destroy the responsibility of an individual, and it should always be borne in mind that the offices of the physician are onlythose in winch he is Avarranted in forming an opinion relative to the enfeeblement of mind through disease. Questions of law do not concern him, and the courts will not permit him to express more than what he knows regarding the médical aspects of the case. Xeither wdl he be permitted to testify to the légal meaning of the facts submitted to him, or their pertmency to the case. He shoidd ahvays remember the dignity of his calling and never lose his temper, no matter how much galled lie may be by the impertinence of the opposing counsel, Avho is not ahvavs a gentleman. He should, however, never be nurried, never give hurried answers, and should demand time for his fidl answer if "choked off" or INSANITY IN ITS MEDICO-LEGAL BEAEIXGS. 149 interrupted. He should never shoAV an eagerness to testify, or an argu- mentât ive spirit. His testimony should be given in a cool, impartial manner. He should be on the alert and avoid the peissibility of being trapped by lus ingenious légal opponent. He should avoid being drawn into discussions upon various other subjects which are foreign to the case in hand, and if thèse be not strictly médical, the witness may refuse te» answer—at least so far as he may be made to pose as an expert in some other field. This applies especially to abstraet theology, which may be a stumbling-block which it is well to avoid. An expert is received as such on his déclaration and upon présentation of qualifications or évidences of his expérience. A physician may avoid the obligation of giving spécial opinion by the avowal of non-expertism in the subject which forms the basis of the questions propounded to him. For exaniple, a surgeeui can properly disclaim being an expert in mental diseases, or a gênerai physician can properly refuse to pose as a spécial authority of any kind. " An expert cannot be exaniined as to a matter of common knowledge concerning Avhich a juror may form an independent opinion, nor as to a matter of mère mental or moral philosophy, or of domestic jurispru- dence." (Wharton and Stillé, section 262, p. 236.)* The relevancy of the matter which is to become the basis of an expert opinion is, of course, to be determined by the court. The offices of the médical Avitness are limited to the elucidation of such facts, so far as they constitute insanity, that will incapacitate, and he should be ready to gauge their importance and tell how they affect responsibility. It is not hère necessary to enter into a discussion of true and false experts, and of the value of their testimony. That there is need for reform is undeniable, and that the courts do not exercise sufficient eare in fixing the status of médical Avitnesses is equally true. The strictures of légal writers, courts, and others are just, so far as the existence of demoralization goes. As the laAV is administered, many persons can be found Avho are ready to arrogate knowledge anel position they do not deserve. The dignified alienist of expérience and réputation is con- fronted by the impostor, Avhose glib manner and bizarre "popular sci- ence " sometimes impresses the susceptible juryman as does the proprie- tary-medicilie advertisement, and Avhose expérience of medicine and its exponents is coufined to the epiack or cure-ail. The law is largely respon- sible for ail this. The use of books in court is not allowed where such authorities are intrexluced as évidence; but they may be read to a Avitness for the pur- pose of ascertaining how far they agrée with the opinion expressed by liim. Ile may be exaniined as to the standing of other experts or authorities, but should be careful in expressing his opinion of a personal nature. Under the laAvs 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 so to do. The compensation of •• expert" witnesses and alloAvance are usual when they give expressions of opinion, or Avhen time and labor hâve been expended in the préparation of the case. There is no impropriety in * Wharton on Evidence, section 434. 150 A SYSTEM OF LEGAL MEDICIXE. declaring the fact that compensation is expected ; and though bound to give médical testimony Avhich deals Avith matters of fae-t for no other compensation except the fées of ordinary witnesses, it does not appear that any opinions implying the exercise of spécial knowledge whieh has been gained at the cost of time and money should be given gratuitously. (See vol. i. p. 614.) It lias been held that the findings of a post-mortem examination do not constitute expert testimony, anel though the Avitness is entitled to pay for making such an examination, lie should be compelled to testify* The case of Dills vs. The State of Indiana, 1!) Ind, 1.1, is one Avhich altered the statutes of that State so that at présent the giving of expert testimony is compulsory. This is the case of Dr. Thomas J. Dills, avIio was committed for contempt in the Hamilton Case, Avith Dr. Buchanan. He refused to answer the questions referred to in the Buchanan Case, saying : " I did not offer my services hère any more than I do my pro- fessional services elseAvhere. I Avas sent for and bave come. M y time and my skill are my capital, and I cannot surrender them gratuitously to any but the poor, since it is by my professional opinion that I earn my living. There is a distinction betAveen a man Avho sees a fact, and is called to pixwe it in a court of justice, and a man avIio is selected to give his opinion on a matter with Avhich lie is peculiarly conversaut, from the nature of his employment in life. The former is bound, as a matter of public duty, to speak to a fact which happens to hâve fallen Avithin his knowledge ; without such testimony the course of justice would be stopped. The latter is under no such obligation. For the aboATe-named reasons I respectfully décline to give the opinion of an expert in the case now pending, except upon the payment of my fee in advance." In this case Biddle, C. J., Avrote an elaborate opinion for affirmance, which Avas, how- ever, dissented from by a majority of the judges, and the judgment Avas therefore reversed. EXAMINATION OF THE PATIENT. The duty of the physician is one implying a most serious responsi- bility, for upon his say largely dépend the freedom and peace of mind, the business interests, of a fellow-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 ail kinds, as well as a possible laAvsuit, It therefore becomes him to use the utmost eare 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 finding 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 court sustained him. Summers was eonvicted, and on appeal the refusai of Dr. Spohn to testify was noticed, the court saying: "The court may compel a phy- sician to testify as to the resuit of a post-mortem examination. . . . Dr. Spohn has doubtless been misled, in taking the position he did, by the misconceptions of cer- tain writ ers on médical jurisprudence. ... A médical 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 resuit of that exam- ination." INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 151 judgment in forming an opinion. He should put into opération a System of investigation by Avhich he can learn the patient's antécédent history, habits, feelings, associations, and conduct generally, and should déter- mine the time and manner of departure from ordinary mental health, .and the évidence of weakness. As many sources of information as possi- ble should be made use of, and the statements of interested persons be given their proper Aveight. Business papers and letters and other pro- ductions of the alleged lunatic Avritten, when not under observation or at s, time when he did not suspect he was watched, should be inspected, and will often give a edew to the nature of the disease. So far as the actual examination itself is concerned, I Avould 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 imfixed, he should be engagée! in conversation as a sound person. Such a conversation, if sufficiently extended, will nearly always resuit in the discovery of his delusion or other évidence of aberration. The first part of this article contains information that Avili serve as a hint to the examiner, but eA-ery case lias ifs oavh peculiarities, and the use of tact and patience wdl, with a knowledge of the features of mental dis- ease, help the physician more than anything else. Tardieu suggests the folloAving points : ••(c<) Mental State.—Three orders of facts should be investigated : 1. The intellectual troubles. 2. The perversion of the affective faculties and the instincts. 3. Altération of the sensorial functions. " The intellectual disorders consist in a gênerai dérangement, marked by delirious conceptions, with or Avithout complète abolition of judgment, memory, and conscience ; afterward commonly in a partial dérangement of understanding. From a medico-legal point of \dew the most direct and immédiate resuit of the disorder of the intellectual faculties is a peiwersion of Avili and a resulting impairment in action, either in an absence of control or purpose, or in action which bears the impress of incohérent or erroneous ideas. " Disorders of the affective faeuilties are constant in insanity. There is more or less altération of affections and instincts. The more natural sentiments are abolished or perverted, and the instinct is sometimes abolished as well. "The sensorial troubles are singular and characteristic in insanity, and hallucinations and illusions are the most important. . . . " (b) Somatic State.—The position, attitude, Avalk, gestures, the dress, malformation of head, physiognomy, expression. . . . The circulation and température are diminished in the inaction of melancholia and increased in the agitation of mania, The gênerai sensibility is exalted or perverted in monomania, or diminished to the point of analgesia in lypeinania. The spasms, the startings, the muscular twitchings, the partial paralyses of sensation and motion, indicate a grave altération of the nervous cen- ters. The embarrassaient of speech, the unequal dilatation of the pupds, the permanent déviation of the uvula, the ataxia of movement, suggest gênerai paresis. Finally we are to recognize ail the symptoms which are connected more or less directly Avith mental aliénation : vertigo, muscae volitantes, cutaneous and neuropathie manifestations, the mobility of the fougue, and scars which may be indicative of epilepsy, or traces of cica- trices Avhich may be the resuit of attempted suicide." 1.12 A SYSTEM OF LEGAL MEDICINE. " HABITUAL DRUNKARDS." It is an important matter to détermine what constitutes "habituai drunkenness," and courts of laAV take widely differing views. In the case of Blancy vs. Blancy, 126 Mass. Keports. 205, a décision was rendered in an action for divorce on the ground of habituai drunkenness. It was proved that défendant 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 eaeh time'; that when thèse spells came he Avas sent to an inebriate asylum, where lie remained until they passée!; that between the spells he'would drink nothing, but that any excitement would make him drink. Held, on appeal to the Suprême Court, that this was sufficient proof of habituai drunkenness. In the case of Wheeler vs. Wheeler, .13 la. 511, a divorce Avas granted the plaintiff, who was the victini 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 défendant Avère married in 1859, Previems to that finie défendant Avas addicted to liquor, and was fre- quently drunk. After bis marriage he became an habituai druukard, and his wife sued for a divorce on that ground, and also because of inhuman treatment. The divorce was granted. Although he was ahvays sober luring business hours, he was habitually drunk at other times, and when in that condition abusée! his wife, calling her vile names and openly charging her with unchastity. On appeal the Suprême Court affirmed the decree of divorce* The English Habituai Drunkards' Act of 1879 defines an " habituai drunkard" as a "person avIio, not being amenable to any juriseliction in lunacy, is, notAvithstanding, by reason of habituai 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 lier affairs." (Kerr.) In England such an habituai drunkard may be com- mitted toaretreat, either upon his own application or upon the affidavits of tAvo persons, for a period not exceeding twelve months. He is in ail 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 hâve an habituai drunkard secluded is through the interArention of the police—the occasion of some disorderly act being chosen for a com- plaint. If his habituai drunkenness is connectée! Avith symptoms of in- sanity, he may of course 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. IV. Goss (husband), 43 La. Ann. S6S. This was an action for séparation on the ground of habituai intempérance. The défendant owned a small store, of which his 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 ail 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 évidence that he had be- come wholly incapacitated for business. The decree was granted, and the Suprême Court affirmed the judgment. INSANITY IN ITS MEDICO-LEGAL BEAEINGS. 153 such subjects unless the departure from mental health be a prolongea and clear one. The use of the Avord " drunkenness '' does not include the intoxication produced by other agents, as Avas held in the case of Youngs vs. Youngs, 130 111. 230* The commitment of an inebriate may often lead to very disagreeable results—the médical men or the frienels being sometimes sued by the person coniniittccl. The case of Jason L. Blodgett, reported by Dr. Fisher (Boston Médical and Surgical Journal, June 6, 1881),.is so interest- ing that I may be pardoned for referring to it rather extensively, using the reporters' language. "A suit Avas brought tAvo years ago in the Massachusetts Suprême Court by Jason L. Blodgett against his divorcée! wife, Major Jones, uoav on the Board of Police Commissioners of Boston, and Drs. Fisher and Youngman for a conspiracy to imprison him in the Taunton Lunatic Hospital on the false charge of insanity ; also for assault and battery in causiug bis arrest ; and for taking his property, ruiuing his business, and causing great damage to his réputation and feelings ; for ail of Avhich damages to the extent of $15,000 were claimed. His légal adAÙser at first was Wilbam H. Toaviic, avIio aftei-Avard called to his assistance Ed- ward Avery. The défendants Avère represented by EdAvard P. Bi-oavu. At the first trial the plaintiffs pétition Avas dismissed for informality and illégal contents. Major Jones Avas excused, as having had nothing to do with the particular commitment complained of, the plaintiff having been sent to Taunton tAvice ; and Mrs. Blodgett, having been his Avife 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 Avas called again, unexpectedly, at the close of the summer vacation, when police officers, Avho Avère important Avitnesses, Avère absent. The Avife, wliose testimony Avas almost absolutely essential to the défense, had hiel- den herself from lier diArorced husband in the far West, and could not be compelled to attend or obtained as a Avitness Avithout great expense. The plaintiff told a story based on his confused recollection of eA'ents, and deliberately false in some parts, which Avas contradicted by the défend- ants, avIio offered to put in as the basis of their certificate information received ùpon ' due inquiry,' as Avell as the resiilt of personal examina- tion. This hearsay testimony, though requiree! by law as part of the foundation of the certificate, Avas not admitted in its support at this time, and the Avife beiug absent essential facts Avère kept out of évidence. The rulings of Judge Eudicott Avère in every other Avay favorable to the dé- fendants. The jury disagreed, as the foreman afterward stated to Major Jones, by permission of the court—nine for the défendants and three for the plaintiff, on the question of dack of due inquiry' only. Xo suspicion of a conspiracy Avas entertained by any juryman. "The case Avas again called last spring, the wife still being absent. The plaintiff, Avith one or tAvo unimportant exceptions, was his oavii Avit- ness, and made the same or sinidar false statements as before, showing * Plaintiff filed a bill for divorce, charging habituai drunkenness. There was proof of the excessive use of morphine by hypodermie injection, on which the charge of drunkenness was based. The bill was dismissed, and the Suj>reme Court affirmed the judgment. After reviewing the various définitions of the word " drunkenness " the court said: " It cannot be held to include intoxication produced by the hypodermie administration of morphine." 154 A SYSTEM OF LEGAL MEDICINE. clearly on the stand to médical observation the unreliable and irresponsi- ble nature of his mental opérations. The case was classified as dipso- mania on ail the certificates offered, of which there were three. The folioAving is a brief sketch of the plaintiffs history : " At the time of the trial he Avas a man about forty years of âge, of evidently neurotic constitution, impulsive, excitable, with a loose way of expressing hiniself, said to bave been characteristic of him from youth. One Avitness testified that he had ahvays been given to telling untruthful anel inconsistent stories. Ile Avas reported to bave had an aunt who was insane. His father Avas a clergyman, and both bis parents died in his early youth of consumption, leaving him in charge of his relatives. He was a bad and irregular scholar, though quick-witted enough for mis- cldef. At the âge of puberty lie showed a proneness to prématuré vicious conduct of various kinds. Ile is said to bave begun to drink by sprees at the âge of fifteen years. Ile had some good traits and impulses, but Avas early the slave of his appetites, anel Avas cursed Avith a craAdng for drink. His sister says lie Avas a good brother Avhen sober, but a 'perfect devil' Avhen drunk. " He Avas in fréquent trouble on account of bis scrapes, both in the country and in Boston, until the Avar broke out, when lie enlisted. Hav- ing previously lost the sight of one eye, it was still further injured by a thorn, and Avas enucleated. He Avas then put on an army freight-train as conductor or brakeman, and continued to serve until the close of the Avar. After the Avar he Avas 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 hâve reformed, and that lie Avas the possessor of a large sum of money. In this behef a widow of the former proprietor of certain Turkish baths in Boston—herself being the OAvner at that time—married him. His fortune proved mytbical, and his Avife Avas obliged to pay for his Avedding-suit and for the wedding-jour- ney; she gave him a gold wateh, and supported him ever afteiward, except for the small value of bis services in the baths. He obtained control of ail lier property, and in a very short time developed a tendeney to drink by sprees, in winch he Avas ugly, Adolent, and dangerous, threat- ening bis wife in particular. He was selelom seen drunk in the ordinary way, but Avas exalted and maniacal, acting mètre or less automatically, and failing to remember his conduct and coirversation aftei-Avard. It is but charitable to suppose that this accounted for his Avholesale déniai of mimerons facts testified to by a score of Avitnesses on the stand. In a year or two he had spent ail bis wife's property and destroyed her busi- ness by his drunk eu conduct. "My attention Avas first called to him October 12, 1875, by Dr. A. N. Blodgett, his Avife's physician, but not related to either party. Dr. Blod- gett, being in attendance on the wife, found the husband in a state of delirium from drink, in Avhich hallucinations of snakes in his bed were prominent. He thought he saAv the devd in the looking-glass ; threat- ened to kill his AA'if e : tbrew f urniture violently about the room ; and did not recognize Dr. Blodgett, but violently assaulted him several times. Policemen Avère called, and he Avas taken to the Tombs. The next morn- ing application Avas made by Dr. Blodgett to the Board of Directors for Public Institutions for his commitment to Taunton as insane. Ha\dng learned his previous history, I agreed that he might be a dipsomaniac, INSANITY IN ITS MEDICO-LEGAL BEAELNGS. 155 but, the présent attack resembling in some of its features delirium tre- mens, advised that lie should be sent to Deer Island. He did not hâve a perfect attack of that disease, and Avas discharged in tAvo or three days, apparently rational. " He was again arrested January 31, 1876, for violent conduct while drunk, and released on promise of good behaAÙor, but Avas rearrested the same day, fined three dollars and costs for being drunk, ten dollars and costs for assault on a female employée! at the baths, and was bound over for six months to keep the peace. Ile Avas sent to jail, and Major Jones, as bail eonimissioner, signed the bond on which he was released. June 24, 1876, he was arrested again, but let off on promise of good behaAÙor. Again, on NoA^ember 8, 1876, he was arrested as insane. Complaint having previously been made to the board of directors, I was sent Avith Dr. Youngman to intervieAv Blodgett. I learned that lie had been very Ado- lent at the baths, smashing up furniture and frightening bathers and employées. I found him at home, an officer bringing him up from the cellar, where lie had retreated, haviug an ax in his hand. His Avife had fied from the house, and the other inmates were locked in their room s. He was in a very ugly, sullen mood, having been drinking heavily. He denied, as was his custom, ever drinking to excess or using violence to any one. He had reeently had a spasm of religious interest ; Avent into a prayer-meeting at the Young Men's Christian Association and offered any brother tAventy-five dollars to coiwert him. A member went home anel prayeel with him, but Avas turned out by Blodgett because he • didn't pray Avorth a damned cent' ! No sign of delirium tremens was présent at this time, and it Avas determined to send him to Taunton as a dipso- maniac, with a AieAv to a sufficiently long détention for his improA'ement or cure. He made no objection and asked for no hearing, thus acquies- cing in his commitment. "Having remained at Taunton a few Aveeks, he was discharged on application of his counsel, Mr. Towne, and Avas sober and well behaved for a considérable period after it. He admitted, in an intervieAv with Major Jones, his irrésistible disposition to drink, and that he presumed the allégations of A'ioience Avère true, but that he did not remember Avbat < >ccurred at certain periods of his drinking-spells. He had also consulted a relative in référence to some cure for his entire loss of self-control in référence to drink. He joined the chureh of which his wife was a mem- ber, and behaved well till August, 1877. From August to December he had three sprees, in which his conduct was erratic and violent. For in- stance, lie would rush down Washington Street in the evening Avith a roll of bdls in his hand, flourishing them about, and followed by a crowd of men and boys. He Avould buy a pie, order a hack, and send the pie home alone in the back. On several occasions he used vulgar, profane, and threatening 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 boarding-house by Dr. Youngman and myself. We femnd him in bed, nervous and confused, as if from a prolonged debauch. I talked Avith him half an hour, explained to him my theory of his case, told him I thought nothing but prolonged détention Avould do him any good—that as lie had improved after a few Aveeks in Taunton, a year Avendd do him still more good. He denied drinking more than Avas good for him, but said he Avould stop at once if we would not certify in his 156 A SYSTEM OF LEGAL MEDICINE. case. I told him if lie aa-us arrested again for violent conduct I should certify. This intervieAv, he testified, Avas only a Icav minutes long, and he could remember but one thing that was said. Tavo days after, he Avas arrested at the baths for furious conduct toAvard his Avife and other ladies, and for trying to kick over a bot stov^e. Ile Avas sent to Taunton December 12,1877, and asked for no hearing at this time. " Kemainiug in Taunton about three months and a half, he was dis- charged Mardi 2(ith, and rearrested for throwing a bottle at some one at the baths Mardi 30th, four days after. The next morning he showed Acry little effect from liquor Avhen seen at the Tombs, the period of indulgence having been brief. He demandée! a hearing at once, and a certificate pro for nui having been signée! to bring his case before Judge McKim, be was released on promising good behavior. In April a libel for divorce was filed by his Avife, alleging brutal and violent conduct, Avith gross and fréquent intoxication. Blodgett appeared in the anteroom of the Su- prême Court in his usual peculiar condition, insulted several ladies there with obscène talk, imdertook to conduct his own défense, and haranguée! the court in such strange and familiar language that the judge told him he must be either drunk or erazy, and granted the divorce. His wife then left him for the West, in a penniless condition, and he soon found a laAvyer Avilliiig to take his suit against the alleged conspirators. This idea of a conspiracy Avas, I think, in part a vague delusion growing out of imaginary Avrongs, 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 feAv Aveeks before the final trial he was arrested for drunkenness in Waltham, and boasted, in his loose Avay, of the immense business he Avas doing, and the money he Avas going to make out of the doctors. " At the last trial before Judge Lord the preceding facts and many others of sinnlar import were proved. TAventy policemen testified to Blodgett's habits of drunkenness, eccentricity, and to bis AÙolent actions. They ail agreed that he Avas différent from ordinary drunkards in his talk and conduct, and Avas regarded as erazy and dangerous when in liquor. Tins opinion Avas sustained by many sober Avitnesses who knew him Avell, and by his own confessions to Major Jones, as Avell as his ap- pearance on the stand. He there denied in a Avholesale way ail excessive drinking and ail acts of violence, only to be contraclieted by many relia- ble witnesses. He might, perhaps, truly bave said that he remembered no acts of violence, as I bave no doubt his conduct Avas automatic. Judge Lord alloAveel 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 défense. Drs. Walker, BroAvn, Gage, Russell, Denny, Jelly, Folsom, Channing, Day, Blodgett, Fisher, and Youngman gave their définitions of dipsomania and testified to the propriety of treating it in hospitals for the insane, in the absence of other spécial institutions. Thèse 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 Avho on drinking a single glass must inevitably go on to complète intoxication. He thought Blodgett did not fall AAithin this définition. INSAXITY IX ITS MEDICO-LEGAL BEAEIXGS. 157 He was obliged to admit, boAvever, that he had reeently said that Blodgett Avas • erazy drunk' and properly sent to Taunton, but was kept too long ; and that he had certifiée! within three months in the case of a dangerous dipsomaniac committed to Dauvers. Dr. TreadAvell gave his views at length, anel thought the part of the testimony lie had heard did not warrant calling Blodgett a dipsomaniac. Dr. Chase's testimony I did not hear. "Judge Lord's charge to the jury Avas satisfactory in every way to the défense, and was an admirable statement of the rights and liabilities of physieians certifying in cases of insanity. It deserves reproduction as a whole, but I will give only a very brief abstraet of it. Judge Endi- -cott had said in substance at the previous trial that it was évident from the testimony that there was such a disease as dipsomania ; that the line between it anel ordinary vicious drinking was a narrow one, which only qualified médical 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 haATe 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 by ties of relationship or affection to the patient ; but they could not take sworn évidence in the case, and must act according to their best judgment upon the facts obtainable. Their certificate Avas not requireel 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 be shown that they Avillfully gave false testi- mony, or grossly and criminally negleeted to inquire into the facts of the case. In the words of the court : * If capable physicians should act reck- lessly, disregarding the rights of the party, and send him off to a hospital without any évidence at ail, then they would be responsible. But if on the other hand they made the inquiry AAdiicb the circumstances of the particular case called for, then, although subséquent events may shoAv that that inquiry might bave been pursued further if they acted in good faith, that is their protection. The jury rendered a verdict for the de- fendants." The same questions hère arise regarding the exécution of légal papers as do where there is no toxic causation of the unsoundness, and the issues are varied and ahvays interesting. The case of O'Conner vs. Rempjt, 29 N. J. Eq. 156, is one of a familiar kind where undue influence Avas evidently exerted. This was a bill to set aside a deed alleged to bave been executed while the plaintiff was in- toxicated and in a state of mental aberration. The plaintiff lodged at the house of the défendants on%Mardi 2, 1877. He had never met Mrs. Rempt, the grantee, before. He returned on the 4th of March and from that time until the 7th was secluded by them from his friends. He Avas drunk when lie returned on the 4th, had been on a drunken debauch for a month previously, and was delirious Avhen he left his home. The de- fendants admitted that O'Conner was not sober when he came to them, and they allenveel him to stay. The next morning he was sick, and was told to go to a hospital, but he asked to be alloAved to remain, saying, 158 A SYSTEM OE LEGAL MEDICINE. "You let me stay, and I Avili give you ail my properly, and you can: take eare of me as long as I live. I will make it ail right," On Mardi 7th the deed was executed, after three previous attempts to obtain his signature to it had failed, owing to the fact that he was in a stupor.. The deed was recorded on Mardi Si h, and a few days afterward he was removed from the défendants' bouse by the police, iu a state of mental and physieal prostration. On March 19th this bill was filed. The Court of Chancery declared the deed void, on the ground that "when the com- plainant Avent to the house of the défendants his mind was disordered ; that the day before the deed was executed lie was ail day in a state e)f drunken insensibility ; and that when he was rescued from the custody of the défendants he was suffering from delirium tremens." The case of Bliss vs. Cou n. d- Pas. Ri vers R. R. Co., 24 Vt. 424, is one in which the question of time-limit arose, and where the action of the Suprême Court Was extremdy merciful and protecting. The défendants took lands of the plaintiff for their use, and an award was made. Under the Vermont statute then in force (1852) an appeal from an aAvard must be made Avithin ninety days, except Avhere disabilities exist, when the appeal must be made within ninety days from the removal of the disabilities, Avhich are in the cases of "married Avomen, infants, idiots, or insane." The plaintiff for a long time was intemperate to such an extent as to unfit him for business, was out of his mind, required close watching, threatened to injure others, burn his buildings, etc. ; and during 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 ninety days had expired. Afterward with his consent the appeal Avas made, and was dismissed by the County Court on the ground that it had not been made within ninety days. The plaintiff then applied to the Suprême Court for a writ of certi- orari, which was granted, and the judgment of the County Court reversed, the court holding that the plaintiff was not capable of managing his affairs, and should be granted the benefits of the provision of the statute relating to disabibties of " insane," even though his disability was caused by his own excesses and misconduct. The subséquent ratification of a contract alleged to haA^e been made when the person is intoxieated has been held to make parts of the trans- action binding* THE CAPACITY 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 courts of law. How- ever, a much more intelligent view of the question of competency * Smith vs. Williamson, 8 Utah, 219. This was an action concerning a promissory note. It appears that the note was given, together with a Holstein bull, in exchange for a Durham bull. A few days afterward défendant returned the bull, and took in its place a Durham heifer, in pursuance of an agreement made at the time of the transaction. Défendant pleadeel that he was intoxieated at the time he signed the note. Judgment was rendered for défendant, but the Suprême Court reversed the judgment on the ground that even though défendant was intoxieated at the time the note was signed, his subséquent 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. INSANITY IN ITS MEDICO-LEGAL BE AFIN G S. 159 is now taken, and it is by no means the rule because certain chan- nels of expression which put the individual in communication Avith the world are eut off, that he is entirely deprived of intelligence. The law is disposed to approve of the actions of persons of this kind, provided they are in no other way mentally incapacitated. The mère deprivation of the sensés of hearing, sight, and speech does not imply weak-mindedness, although under the English law a deaf-mute is incom- pétent to give evidciie'e if lie is also blind. Disputée! Avilis (Jarm., Wills, 5th Am. éd., chap. iii.) of deaf-mute s lurve been allowed to stand. Those who offer such a will for probate must prove the intelligence and abil- ity that constitute testamentary capacity. Judge Redfield has decided that edue*ated deaf-mutes who make holographie wills or convey by gest- ures their intentions and Avishes should be adowed to do so, and that such wills should stand. The affliction of coïncident blmdness need not necessarily change the situation. It is, however, necessary to differentiate the mutism of simple accidentai deprivation or uncomplicated origin from that Avhich is a feature of imbecility. This question arises not only in will-making, but Avhere contracts of any kind are entered into. Dr. Peet, avIio lias had very wide expérience with the deaf and dumb, gives the following gênerai principles in regard to their rights and responsibilities : " A deaf-mute who bas no knoAvledge Avhatever of written languages may yet, if his dialect of gestures is sufficiently copious and précise, possess the intelligence necessary to manage his own affairs, to make ail civil contracts, to exécute a deed or a will, or to give évidence in a court of justice. But as the degree of intelligence and of moral development in uneducated mutes is very A~arious, some who haA^e been neglected in infancy being but a step above idiots, they should be earefully exaniined to ascertain Avhether they really possess the necessary degree of knowl- edge and intelligent Avili. With respect to the formalities used, it may be laid down as a gênerai rule that the deaf-mute who can read and write but imperfectly or not at ail should be regarded as in the position of a German or Frenchman whose ignorance of our language nécessi- tâtes the employaient of a sworn interpréter betAveen him and the court. But when the deaf-mute can read and Avrite 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 Avriting, 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 enaeted that a légal service, in the case of such persons, should consist in giving them a copy of the Avrit 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 but imperfectly, the reading may be accom- plished by the aie! of a compétent interpréter. Any légal oath or obligation may be taken or assumée! by a Avell-instructed deaf person by writing ont Avith his oavii hand the formula before witnesses, with such forms of solemnity as the occasion may 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 compétent interpréter. 160 A SYSTEM OF LEGAL MEDICINE. The matter of accident cases resulting in traumatic insanity has not been hère considered, but the reader is referred to subseepient articles by Dr. Dana and Mr. (lodkin Avhich eoATer the ground both as to the médical and légal points. BIBLIOGKAPHY. Thèse références, of course, include a small part of the literature of the subject ; but many of the works referred to hâve been used in the préparation of this article, and others are suggested for the aid of the reader. 1804. (1) Combe, A., "Practical Observations on Insanitv," etc. London. 7811. (2) Bcck, T. E., " On Insanity." New York. 1811. (3) Croiether, B., "Practical Remarks on Insanity," etc. London. 1812. (4) Bush, B., " Médical Inquiries and Observations upon the Diseases of the Mind." Philadelphia. 1814. (5) mil, G. N, "An Essay on the Prévention and Cure of Insanity/' etc. London. 1817. (6) Fodéré, '"Traité du Délire, Appliqué à la Médecine, à la Morale, et à la Législation." Paris. 1818. (7) Boehr, "Ist die von einem Wahnsinnigen in einem Lucido intervallo be- gangene Handlung zurechnungsfâhig oder nicht?" "Arch. f. med. Erfahr.," vol. i., pp. 429-469, Berlin. 1819. (8) Pincl, S., "Recherches sur Quelques Points de l'Aliénation Mentale." Paris. 1820. (9) Burroics, G. M., "An Inquiry into Cert. Errors Rel. to Insanity," etc. London. 1825. (10) Heinroth, J. C. A., "System der psychisch-gerichtlichen Medezin," etc. Leipzig. 1826. (11) Bonfils, J. L., "Sur la Jurisprudence Médicale Relative aux Aliénés." Paris. 1826. (12) Guislain, " Traité sur l'Aliénation Mentale," etc. Amsterdam. 1827. (13) Hoffbauer, J. C, "Médecine Légale Relative aux Aliénés et aux Sourds- muets," etc. Paris. 1827. (14) Brierre de Boismont, "La Médecine Légale des Aliénés." "Clin. d. Hop.," vol. i., No. So.3, Paris. 1829. (15) Marc, " Matériaux pour l'Histoire Méd.-Lég. de l'Aliénation Mentale." "Ann. d'Hyg.," vol. ii., p. 353, Paris. 1830. (17) Brierre de Boismont, "Considérations Médico-Légales sur l'Interdiction des Aliénés." "J. Hebd. de Méd.," vol. v., pp. 353-3*4, Paris. 830. (18) Marc (et al), "Rapports sur Quelques cas Contestés d'Aliénation Men- tale." "Ann. d'Hyg.," vol. iv., pp. 383-408, Paris. 1832. (19) Commission of Lunacy, Court of King's Bench, Bagster vs. Newton. "Lond. Med. Gaz.," vol. x., pp. 519-528. 1832. (20) Esquirol, J. E. D., "Aliénation Mentale," etc. Paris. 1832. (21? Fodéré, F. E., "Essai Médico-Légale sur les Diverses Espèces de Folie Vraie, Simulée et Raisonnée," etc. Strasbourg. 1833. (22) Friederich, J. B., "Die gerichtsàrztliche Ausmittlung der simulirten, u. s. w., psychischen Krankheiten. Wurzburg. "Mag. f. phil.-med. u. ger. Seelenk," 10. Heft., pp. 133-155. 1834. (23) Chelius, M. J., "Disseritur de alienationibus voluntatis, quatenus ad medicinam forensem spectant." Heidelberg. 1835. (24) Bonclet-Labcrnardie, L., "De l'Aliénation Mentale Considéré Médico- Légalement." Paris. 1836. (25) Testu, G, "Quelques Considérations sur les Causes et le Siège de l'Alié- nation Mentale." Paris. 1837. (26) Pritchard, J. C, "A Treatise on Insanitv and Other Disorders Affectinr- the Mind." Philadelphia. BLBLLOGEAPRY. 161 1838. (27) Morison, A., " The Physiognomy of Mental Diseases." London. 1838. (28) Es<] ni roi, "Des Maladies Mentales Considérées sous les Rapports Médical, Hygiénique, et Médico-Légale." Paris. 1840. (29) Marc, C. C. H., "De la Folie Considérée dans ses Rapports avec les Questions Médico-Judiciaires." Paris. 1842. (30) Pritchard, J. C, "On the Différent Forms of Insanity in Relation to Juris- prudence," etc. London. 1842. (31) Friederich, J. B., " System der gerichtlichen Psychologie." Leipzig. 1843. (32) Johnson, H., "On the Arrangement and Nomenclature of Mental Disor- ders." London. 1845. (33) Calmeil, "De la Folie, Considérée sous le Point de Vue Pathologique, Philosophique, Historique, et Judiciaire," etc. Paris. 1845. (34) Hohnbanm, C, " Psychische Gesundheit und Irreysen in ihren Ueber- gàngen," etc. Berlin. 1848. (35) Commission of Lunacy, on two sisters—Miss Maria Collins and Miss Amelia Maria Hortensia Collins. "London Med. Gaz.," vol. i., pp. 318, 482. 1851-52. (36) Eay, L, " Hints to the Médical Witness in Questions of Insanity." "Am. J. Insan.," vol. viii., pp. 53-67. 1852. (37) Eobinson, "On Some of the Vital Statistics of Insanity." "Med. Times," London, vol. v., p. 483. 1852. (38) Gait, J. M., " On the Medico-Legal Question of the Confinement of the Insane." "Am. J. Insan.," vol. ix., pp. 217-223. 1853. (39) Baillarger, J., "Recherches sur les Maladies Mentales," etc. Paris. 1853. (40) Winslow, Eorhes, "On Medico-Legal Evidence in Cases of Insanity." "Lancet," vol. i., pp. 47, 76, 101, 125. 1854. (41) Ott, "De la Folie Générale et de la Folie Partielle," etc. "Ann. Méd.- Psych.," 2. s., vol. vi., pp. 317-338, Paris. 1854. (42) Boileau de Castelnau, P., "Des Prodromes de la Folie Considérés au Point de Vue Médico-Légale." "Ann. Méd.-Psych.," vol. vi., pp. 392-412, Paris. 1854. (43) Falret, J. P., "Leçons Cliniques de Médecine Mentale," etc. Paris. 1S54. (44) Winslow, Forhes, " Lettsomian Lectures on Insanity." London. 1855. (45) Kriigelstein, "Ueber die Feststellung des Begriffs der fixen Idée," etc. "Deutsche Ztschr. f. d. Staatsarznk., n. F.," vol. v., pp. 160-181, Erlangen. 1855-56-57. (46) Monro, H., "On the Nomenclature of the Various Forms of In- sanity." London. "Asylum J. Ment, Se.," vol. ii., p. 28(3; vol. iii., p. 193. 1855-56-57. (47) Tuke, D. H., "On the Various Forms of Mental Disorder," Lon- don. "Asyl. J. Ment. Se," vol. ii., p. 445; vol. iii., pp. 81, 218. 335, 443. 1855. (48) Noble, D., "Eléments of Psychological Medicine," etc. London. 1855. (49) Piorry, P. A., "De la Folie et du Délire," etc. Paris. 1856-57. (50) Crawford, J., "Feigned Insanity," etc. " Glasgow M. J.," vol. iv., pp. 35-41. 1857. (51) Idelcr, K. W., " Lehrbuch der gerichtlichen Psychologie." Berlin. 1858. (52) Loeirenhardt, S. E., " Kritische Untersuchung iïber zwei Streitfragen aus dem Gebiete der gerichtlichen Psychologie," etc. Breslau. 1S58. (53) Bure/ess, J., " The Médical and Légal Relations of Madness," etc. London. 1858. (54) Bucknill, J. C, and Tuke, D. H., " A Manual of Psychol. Med.," and subsé- quent éditions. London. Philadelphia. 1858-59. (55) Conollu, J., "The Physiognomy of Insanitv." "Med. Times and Gazette," London, vol. xvi., pp. 2, 56, 134, 238, 314, 397, 498, 623 ; vol. xvii., pp. 81, 210, 367, 651; vol. xviii., p. 183. 1859. (56) Flemminses. be held to include every species of insanity or mental unsoundness in courts of e-iA-il jurisdiction. 169 170 A SYSTEM OF LEGAL MEDICINE. Cases involving questions of unsoundness of mind or insanitv in every form are divided into tAvo classes, civil and criminal: the first is one of capacity to do a particular act in questùm, such as making a <-<>n- tract or will ; the second is one of responsibility for an act or omission, such as an assault or homicide. Perhaps, as a gênerai rule, it may be stated that, in regard to contrae-ts generally and testamentary capae-ity, 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 Avhich is the subject of judicial considération." No such gênerai rule can be stated as applicable te> capacity and liability of insane persons in the criminal laAV, as the rule is not uniform in England or the various States of America, neither do the judges and médical ex- perts fully agrée as to a pre>per rule of responsibility. The rule in the State of NeAv York is in substance as folioavs: "Was the person Avhose act is in question laboring under such a disease of the mind as rendered hinl incapable of knowing the nature and quality of the act and that it was Avrong?" There are many distinguished experts who claim, Avith great force of reason—and the principle lias been held by many able judges—that another élément should be regarded as a valid exculpatory plea, to AAut, loss of self-control from any disease of the mind. The rule would then be stated as folloAvs : " Was the person whose act is in ques- tion able to understand the nature of the act anel pass a rational judg- ment on its conséquences to himself and others, and Avas he a f'ree agent so far as that act was concerned ? " and such AA'ill undoubtedly lie the rule in the near future. We wdl noAV examine the légal relations of insanity or unsoundness to certain spécifie issues relating to the folloAving subjects : Avilis, con- tracts, including contract of marriage, torts, and expert testimony. The medico-legal issue in cases regarding Avilis is whether at the time of making the will the testator possessed testamentary capacity. The rule upon this question may be tersely stated as folloAvs : " In order to make a valid Avili a testator must hâve sufficient capacity to comprehend the nature of the act he is performing ; he must understand the extent of the property of which. lie is disposing ; he must comprehend the rela- tion which he holds to those Avho hâve claims upon him, and be capable of making a rational sélection among them." (Am. & Enej. EncycUpadia of Lan; 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 considéra- tion. For example, Lord Coekburn, in the case of Banks 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 Avhich he ought to give effect, and, with a view to this effect, that no disorder of the mind shall poison the affection, pervert his sensé of right, or prevent the exer- cise of his natural faculties; that no insane delusion shall influence his will in disposing of his property, and bring about a disposai of it which, if the mind had been sound, Avould not hâve been made." The burden of proof is ahvays upon the party that propounds the will for probate to establish its validity. 1. He must prove that the statiitory requirements hâve been complied with. 2. That, by the subscribing witnesses, the testator appeared to under- MENTAL RESPONSIBILITY OF THE INSANE IN CIVIL CASES. \~\ stand the business in which lie Avas engagée!; but, in case the sub- scribing Avitnesses are deael or cannot be preuluced, the proponent of the will can rest upon the presumption that every man is presumed to be sane until some évidence to the contrary is offered. (63 N. Y. 409, 7 Pick. 94.) Where, hoAvever, a party has been proved to be insane, the presumption is that it continues, and the burden then shifts to the party aile gin g sanity (Am. d* Entj. Encyclopadio, vol. xi., p. 160), and he must prove that the Avili Avas exee-uted during a lucid interval. It Avili at once be perceived in this class of cases that a great many questions arise as to the kind and elegree of insanity, and how much 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 resuit of disease or accide-nt. It lias been held that extrême olel âge, excessi\re use of intoxicating liquor, strong beliefs, existence of mental delusions, licentiousness, and unreasonable préjudice against relatives are not necessarily incompatible with mental capacity or intelligence to make a will. (Same volume of Am. A Entj. En<-yclopt affect the subjee-t-matter of the contract." Where it clearly appears that a person lias married an insane person in ignen-ance of the fact, the contract Avili be declared void, for the con- tract if vend as to one party is as to ln>th (Am. A Eng. Encyelopadia, vol. xi., p. 140, notes 1, 2, 3) ; and any party interested may institute pro- ceedings to procure a decree of nullity. There is a sharp conflict of authorities in the Agirions States whether the marriage of an insane person is voie! etb initio, so that it may be im- peached collaterally. In Wightman vs. Wightman, Chancellor Kent held that such a marriage Avas absolutely void and no decree of nullity was necessary to set it aside. The e-ases that arise under this brandi of médical jurisprudence re- quire great eare and circumspection on the part of the médical expert. A majority of the cases arise from imbecility and epilepsy, and the great question relates to the degree of incapacity. (Am. A Eng. Encyclopadio, vol. xi., p. 141, note 1.) The history e>f the part}' up to the time of the marriage, the surrounding circumstances, are material considérations. A judge of the Suprême Court of Massachusetts trying such a case made the remark ••that the fact of a party's being able to go through the marriage ceremony with propriety Avas prima facie eAddence of suffi- cient capacity to make the contract." It Avili be at once recognized by the expert that such a rule is not of universal application. It is not a sufficient test of capacity that either a man or Avoman avIio lias been Avell brought up belurveel in company Avell for a short time, as such behavior may hâve become more or less automatic from habit. A careful per- sonal examination, if praeticable, should be had, and the eharaeter, dis- position, strengtli of Avili, should ail be taken into considération. In cases of Aveak-minded persons questions of force or unelue influence upon the Avili may also become important. Of course it is Avell known that any insanity or imbecility that has occiirred since the marriage furnishes no ground for a divorce. It Avas held by the Suprême Court of Yermont that insanity Avas a good défense to a libel or suit for divorce based upon a charge of adultery, the theory being that there is an ab- sence of a consenting Avili ; this doctrine has been disputed in some States, notably Pennsylvania ; but the weight of authority is that insanity fur- nishes a valid défense in such cases. (See Bradstreet vs. Bradstreet, 7 Mass. 471 ; Matcltin vs. Matehin, 6 Penn. 332.) A lunatic is liable civilly to make a compensation in damages to per- sons injured by his acts. Thus, for assaults, slander, or libel, an action can be maintained ; but the fact of insanity can be shoAvn in mitigation of damages in the two latter classes of cases on the ground that the words spoken or Avritten could not hâve an injurious effect of much consé- quence, varying according to the degree of insanity and the notoriety of the lunatics condition. In sueli cases it is for the jury to détermine ac- cording to the effect of the acts of the lunatic Avhat is a fair measure of damages. (Am. A Eng. Encyelopadia, vol. xi., p. 144, note, and cases there cited.) MENTAL RESPONSIBILITY OF THE INSANE IN CIVIL CASES. 173 A question often arises as.to the competency of an insane person to testify in court. It is a matter for the court to'détermine. The rule by which the court is guided is as follows : " In order to be compétent the person must be possessed of such an understanding as enables him to retain in memory the eArents of which he lias been a witness, and gives him a knoAvledge of right and wrong sufficient to appreciate the sanctity and binding force of an oath. (Am. A Eng. Encyclopœdia, vol. xi., p. 145, note, and cases cited.) INSANITY AS AFFECTING CONTRACTS. As a gênerai rule it requires a higher degree of capacity to make a contract than a will, depending someAvhat upon the nature of the trans- action, i.e., the complexity of the subject-matter. The most common 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 lias been appointed in whom his estate is vested. In ail other cases it is voidable. In order to inval- idate a deed of an insane person 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. A Eng. Encyclopœdia, vol. xi., p. 149.) Thèse rules apply to ail persons non compos mentis or labor* ing under delusions. Ail the authorities upon this subject, and upon ratification and executing contracts for the sale of land, are to be found in the same volume before 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 défense to an action upon the note by the payée or any persons haA'ing notice of such disability, or of such facts as Avould put a reasonable man upon inquiry as to the competency of the maker or indorser. But Avhere the insane party lias received full considération, and the note inured to his benefit, and it has passée! into the hands of a ~bona-fi.de purchaser Avithout notice, insanity is not a dé- fense to the note. It lias been held, however, that an accommodation in- dorser of a promissory note avIio receives no benefit therefrom, either to himself or his estate, may défend 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 knoAvledge of the indorser's insanity. (Am. A Eng. Encyclopœdia, vol. xi., p. 144.) INSANITY AND CRIME. BY B. SACHS, M.D. A few years ago the writer of this article was discussing with one of the learned judges of the Superior Court of New York the question of the responsibdity of the insane. The writer stated his opinion that up to the présent time the légal tests of insanity, as accepted in many of our States anel in England, were entirely unsatisfacteiry. The judge dissented from this view and thought the matter a very simple one. '-Ail Ave hâve to do," said lie, "is to détermine whether the accused at the time he committed the crime was able to distinguish between right and wrong, anel if he kne'AV that what lie had committed was Avrong he Avas as responsible for that crime as any sane person would be." Very f cav légal minds hâve been able to get beyond this antiquated view of the relation of insanity to crime. In Germany and France the more enlightened judges hâve been guieled by the e>4>inion of médical experts, but even there they are not in anywise bound by such an opin- ion, and it lias happened again and again that the judge, having asked for and receiA'ed the opinion of médical experts, has promptly set it aside and decided the question to the contrary. In England and in this country, unfortunately, the question of insan- ity, and of mental responsibility for crimes committed, is referred to a lay jury. Judges and laymen acquiesce in the belief that a body of twelve, often ignorant men, can décide the epiestion of mental responsi- bility, which under favorable circumstances may baffle the ingenuity of the most conscientious médical expert. England and America hâve been under the influence of the décision Avhich the English judges gave in answer to certain questions Avhich Avère propounded to them by the Ileuise of Lorels in 1843, after the atre)cious murder of Mr. Drummond by McNaughton. Maudsley, whom I folloAv in this matter, summa- rizes the answer as follenvs : "To establish a défense' on the grounds of insanity it must be e-le-arly proved that at the time of committing the act the party accused Avas laboring under such a defect of reason from elise'ase of the mind as not to know the nature and quality of the act lie was doing, or, if lie did kmnv it, that lie did not know he Avas doing Avhat Avas Avreuig." It will be seen from this quotatiem that the accused person Avas not expected to be able to distinguish betAveen right and Avreuig in gênerai, but that he' Avas at least to knoAV whether the spécial ae*t Avhich lie e-ommitted Avas right or Avrong, or that he was to be entirely ignorant of the nature of the crime e-ommitted. This "right" or "wrong" test has been the stumbling-block in the advance of 17.") 176 A SYSTEM OF LEGAL MEDICINE. légal psychiatry, and, as a matter of fae-t, if the tost hère mentioned Avère to be applied to the insane, nine ont of eve'iy teui lunatics Avould hâve to be dee-lareel sane, for most of them are perfectly aware of the nature- of the acts they commit. The majority of them knoAv that the-y are right or Avremg according to the ordinary standards, but they are impelled either by sudden influences or by sudden foi-cible delusions to the commission of acts Avhich they know to be Avrong, and Avhich, if sane, they Avould neA'er haA^e committed. We shall hâve occasion to refer to this qnestiem in détail; for the présent it suffices to point out the difficulties met with in determining the relation of insanity to crime. Thèse difficulties hâve been inereased by Avarions unfortunate circumstances: ftrst of ail, the plea of insanity lias be^en frequently used in cases in whieh there Avas not the least e'xcuse fer advancing it, and it Avas put forth simply in the hope of deluding the lay jury. The plea, therefore, has f ail en into discrédit, anel the sus- picion is entertaineel in almost every e-as<' in Avhie-h the plea is aelvanced, that it is simply a lawyer's trick and nothing more. Yet if one Avère to take the entire criminal history of this country into account, I feel satislieel that many more insane hâve been punished for crimes for which they were not responsible than sane peu-sons hâve eseaped the just. pemalty of their crimes on the plea of insanity. In this connection it is interesting to note' how much more fréquent insanity is in the criminal classes than in the normal population. Allow- ing for the number of case's brought on by imprisonment, the statistics still point to the close relationship betAveen insanity and crime. Accord- ing to Thomson, twelve percent, of prisoners in Scotland Avère insane. Of 5432 prisoners, 673 Avère insane ; of thèse 57 Avère imbéciles and 57 Avère epdeptics ; but of the total number only 53 were declared insane at the time they Avère sentenced. In England and Wales there is one luna- tic te> every 432 free inhabitants ; but among 664 accused of murder from 1857 to 1867, 108 were insane. (See Baer, I)er Verhreelier, 1893, p. 258.) In this country Dr. Robinson, physician to the Eastern State Peniten- tiary in Pennsylvania, states that in five ye'ars he has had to deal with about 3500 conviets for periods of one year to five years ; of thèse 245 Avère insane upon réception, 40 had insanity devedop during their incar- cération, and 20 Avère guilty of simulating insanity. In a paper read in Washington in 1892, Dr. Allison tabulâtes the crimes committed by 87 court cases now in the NeAv York State Asylum for Insane Criminals. Murder............................................................ 38 Assaults in the first clegree and attempts to kill....................... 18 Dangei-ous assaults................................................. 10 Arson and attempt at arson ......................................... s Burglary and larceny............................................... 10 Bigamy............................................................ 1 Horse-stealing............................... ...................... 1 Disorderly......................................................... 1 Total.......................................................... s; Another difficulty that besets the question is one that should be seri- ously considered. The layman argues that it is ail very well for médical men and for sentimentalists to excuse crime on the plea of insanity, but INSANITY AND CEI ME. 177 what is society to do in order to protect itself against the crimes of the insane ? As médical men Ave are bound to défend the rights of the in- sane, but as members of society Ave must acknowledge that the latter has full rights, and that it should enjoy immunity from crimes due to dis- eased minds. A remedy must be sought for the protection of society, and this remedy is not only the establishment of asylums for the criminal insane, but also the rétention of lunatics avIio hâve committed crimes in such asylums for years, if not for the remainder of their lives, or at least until the danger of their e-ommitting similar crimes has passed. In a récent trial in this city the experts did Avell who urged that a woman avIio Avas deelaivet innocent of the crime of murdering lier children should not be allô wed to go scot-free, but that she should be sent to an asylum and her mental condition earefully watched. Society must find some means of protecting itself, but it should not be guilty of juelicial murder. The national cemscience is no longer responsible for the exécution of Avitches, for the torture of those who were supposed to be possessed of the devil, but it has until récent years been responsible for the death of assassins Avhose deeds, as in the case of (luiteau, for instance, Avère clearly the resiilt of mental aberration. Let society procerd Avith ail due rigor against those avIio are the instigators of crime; lot, it adopt the most strenuous measures against anarchists and other enemies of socie'ty whose revoliitionary doctrines generally supply the torch that was needed to exe-ite Aveakened anel dise'ased minels to the e-omniission of outrageons crimes; but let the poeu* unfortuiiate lunatic or imbécile Avho has yielded to anarchistie'. preaediings or to the impulses of his morbid mind not suffer the penalty of a crime for Avhich he is not responsible. The question arises, When shall the plea of insanity be considered valid in exténuation of crime? The only proper ansAver to this question, in the light of the présent condition of psychiatry, is that no person shall be considered- guilty of a crime if, at the time the crime was committed, he iras suffering from any form of mental diseuse. The médical expert should be e',alleel upon to state Avhether the person accused is or Avas sane or insane, and if insane he should not be held responsible for his ae-ts. In several récent trials in this country the question has been put in this broad Avay, anel the ansAvers of the experts hâve been accepted Avith out any refeivnce to the oleler légal tests of responsibility. Let the médical mân's duties aise» end Avith the détermination of this purely médical ques- tion, and let the law and its exponents accept the responsibility for eveiything else. But in order that the question of sanity or insanity shall be justly derided, it is ne'cessary that the opinion shall be expressed by those avIio are truly qualified to give an opinion. Psye'hiatry is a veiy spee-ial brane-h of medicine. It does not con- stitute' part of the régulai* médical training in this country or in Europe ; yet in some of the most important trials of récent years any meelie-al man lias been ae'.cepted as expert, and his opinions hâve been held to be fully as valuable as those of a man who lias devoted years to the study and practie-e of this spécial brandi. There is no more reason to accept the opinions of a gynecologist in questions of insanity than tlu'i-e Avould be in ae-e-epting the opinions of an alienist on the feasibility of au opération upon the eye eu* the remen-al of an abdominal tumor. But if the expert lias been properly chosen another reform in the meth- od* of medico-legal procédure is urgently called for: the expert should 178 A SYSTEM OF LEGAL MEDICINE. not be maele a partisan to one side or the other, but the facts should be submitted to him as impartially as possible, and lie should détermine the ejuestion of sanity or insanity after considering such facts, and. if possible, after an unprejudiced examination of the supposée! criminal.* In spite of ail the defects of court procédure in the Uniteel States in matters affecting insanity, it is a satisfaction to knoAv that the rulings of the more enlightened judges in this country indicate a decided advance upe>n the principles laid down by the Enghsli courts. In the State1 e>f Ncav York the statutes simply state that "No act done by a perseui in a state of insanity can be punished as an offense." The humane spirit of this statute cannot be denied, and it Avili be neded that nothing is said in it of the responsibility of the criminal in case he was able to dee-ide between the right and the wrong of the act he committed, whe'ther he knew or did not know that it was contrary to the law of the lanel, 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 respemsible for the deed committed. The spirit of this statute throAvs greater respemsibility upon the médical expert. The principle of the statute of the State of New York is not yet adopted by ail other State's of the Union, and is very far from being adopted in England. We must therefore still discuss, though we may do it more brie'fly, the older tests of responsibility, and de-termine to what extent a person may be liable for acts he has committed.! In Germany the law revolves upon the point that the sane individual lias 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 décide simply upon the free détermination of the will involves a great many difficul- ties, above ail that of proving to judge and jury that the person in ques- tion could not exercise his own free Avili, and that such exercise was in any way influenced by the delusions or other symptoms exhibited by the accused. It leaves out of considération 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 ail others by ancient précèdent, and in spite of vigorous protests by eminent English jurists and many eminent médical 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 médical- expert testimony the reader is referred to a short article by the présent writer in the Médical Examiner for July, 1892. t The " right and the wrong " in law, the tolérant and the intolérant spirit, are well illustrated by two judges' charges. In the case of Sterens vs. State (see Lawson, pp. 8S et seq.). "If the jm-y believe from the évidence that the défendant knew the différence 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 narrow view the charge of Chief-Justice Perley, who instructed the jury " that the verdict should be not guilty by reason of insanitv, if the killing was the offspring orproduct of mental disease in the défendant; 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.'' INSANITY AND CRIME. 179 England than in any other country of the civilized Avorld* English judges and tliose who are inclinée! to follow them in this country—and many de>—still fall back upon the simple test of Avhether the accused at the time of committing the act was able te> distinguish betAveen the right and Avrong of it, and if he Avas so able to distinguish he is as responsible for the act as though lie were entirely sane. There are relatively few luna- tie-s who e'ommit viedent acts avIio are not aAvare at the time they commit the act that it is wremg, but their judgment is befogged for the time being, the motives which impel them are différent from those which guide the sane, their passiems are more uncontrollable, and they often aet in obédience to elelusiems Avhich impel them to e-emimit deeds which they knoAv to be Avremg, and Avhich may be as abhorrent to them as they are to others. Many an insane indiAddual has repented an atroeious crime the very next moment after lie had committed it. It Avas clear to the English judges that the "right" or *'Avremg" test could not be upheld in every instance, and for that reason further rulings Avère nee'essarily maele Avith référence to the influence of insane delusions, insane motiA^es and impulses ; and in making such rulings they hâve revealed a déplorable ignorance of the peculiar changes Avhich the mind undergoes in disease. Thus the judges déclare^, in ansAver to the question whether a person who, under an insane delusion as to existing facts, commits an offense in con- séquence 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 elelusion supposée! another man to be in the act of attempting to take his life, and kilh'el that man in self-défense, sue-h person would be exempt from punish- ment. But if lie Avas suffering from a delusion that another had inflicted serious injury to his e-harae-ter and fortune, and he killed him in revenge for such supposed injury, lie would be liable to punishment. Nothing more absurd than this has ever been written by a sane mind. A person who has an insane delusion is expee-teel to be able to reason regarding the facts of the delusion as every sane person Avould; he is expe'cted to be gnided by sane moti\res and to haA'e none but sane im- pulses with référence to his delusion. As Maudsley puts it, --He is ex- pected to be reasonable in his unreason, sane in his insanity." Tins doctrine is the outcome of the older théories of partial insanities, im- plying that a person could be sane in ail other respects while absolutely and hopelessly insane on some one single point of belief. Modem psy- chiatry lias taught us that this older doe-trine is wholly untenable, and that the mère continued existence of a single delusion, whatever its ehar- aeter may be, proves that the' entire mind is diseased—that the logical faculties, the judgment, and the reason of the person hâve been seriously impaired. If Ave consieler, furthermore, that any person afflicted with a single delusion is completely dominateel by it, the injustice of insisting that he shall be guided by ordinary reasoning will be évident at once. The theetrv of monomanias has done much mischief in psychiatry, but it lias doue infinitely more in médical jurisprudence. The English ïaw insisted that the criminal was responsible for his act if he knew that such act Avas contrary to the law of the land. This * According to the Lance!, influential sub-committees of the Br. Médical and of the Medico-Psychological Associations ha\'e been appointed to investigate and report upon this subject. ISO A SYSTEM OF LEGAL MEDICINE. was a departure from the strict "right" or "wrong" test, for in many an instance the insane are thoroughly cognizant of the Liav of the lanel anel yet hold a very différent opinion as to right and wrong in obediener to their own delusions. We need not enter into further argument regard- ing this older test. It is conceded on ail sides that the insane may hâve a perfee-t knowledge of right and wrong at the time a criminal ae-t is committed and yet not be responsible for the ae-t. The influene-e of de- lusiems is also liberally cone-eded, but much more difficulty is encountered in the attempt te) represent to judge and jury that the motive's of the insane are very différent from those of persons Avith healthy minds, and that sudden morbid impulses are responsible fe>r many acts of violence. Let us take up the matter of the medives of the insane as a guide to action. Persons in good mental health are expee-teel to be gnided by the exercise of their ernui judgments, by their oavh and the aecumulated ex- périence of e>thers, before pre)ceeding to any rash act; and in addition to this the fear of punishment is suppe>sed to exercise a very powerful, de- terring influence. A sane person is e-xe-used for au act of Aiolence only on the ground of self-defense, and self-défense only in case he is satis- fied that his life is being actually attempted. Feelings of reve'iige are not allô wed as an excuse for criminal ae-ts, and, abe>ve' ail, the sane' per- son in every civilize'd community is not allowed to take the huv inte) his own hands. The elise-aseel mind loses sight, however, of ail thèse restrain- ing influences ; the judgment of the insane individual becomes détective, and his reasoning is Avarped by the présence' of delusions anel by the change in his tempérament. There is little difficulty, as a rule, in exeus- ing crime that is the direct resiilt of a delusion. Any jury Avili exempt the accused person from punishment if his acts followed as naturally upon the delusion as they woulel in sane persems if the facts of the delu- sion were real. But trouble is certain to arise Avhenever the motives leael- ing to an insane ae-t are- iinknoAvn or do not appear to be the eliree-t resiilt of a delusion. There is the fanions story of the be>y avIio Avas extremely fond of windmills. He avms sent far away from his home for the improve- ment of his health ; Avhile aAvay he induceil a little girl to go Avith him to the wooels, 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 Avas one Avhich few would hâve surmised. Ile' Avas anxiems te> see the windmills, and he knew that after committing an act of this sort he Avould be returned to his oavh birthplace, Avhere his désire for windmills would be fully gratified. Could any sane mind hâve suspected such a motive? What an unbalancing of ail mental facul- ties this implies ! Take the case relateel by Dufour: A paranoiac was anxious to flee to America to escape from supposée! enemies. Having no money lie decieled to murder and rob a rich old couple. He bought a hammer, blackened his face, and bought a linen blouse to cover his clothes and keep them from becoming blood-stained. In this there Avas préméditation and a désire to conceal his person, also a knowledge of the wrong done; but marked insanity Avithal. Among jurists and médical men there has been some hésitation in allowing for the effect of sudden morbid impulses. The plea of insanity has in such instances been taken to be a mère subterfuge. It is claimed that even among the sane sudden impulses are eeunmon enough, and that if every sane individual Avère to act upon the numerous impulse-s starting INSANITY AND CRIME. 181 up Avithin him, he too might be guilty of criminal acts. The very sud- denne-ss of the impulses in the insane, the fact that the impulses cannot be subdued, that the perse >n must act upon it, constitute the strongest proof that such impulses are the offspring of a diseased mind. It is a mistake te) think, furthermore, that the insane yield to their impulses Avithout any attempt at self-restraint. Were this true we should hâve dozens of suicides and homicides for every one that actually occurs. I hâve ahvays felt how true Meynerfs remark Avas which he made verbally te» 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 outsiele of it." Every one of us has been witness to the struggle Avhich those who are perinanently or temporarily dérangée! havo made in order to resist the sudden impulses coming over them. At some finie a limit of endurance is reae-lieel, and, unfortuiiately, the insane' individual has to yield to the sudden impulses urging him on to commit every possible form of crime. The laity and many médical men may claim that since' the person in question and since others hâve been knoAvn at various times to resist morbid impulses, it Avas his duty on this spee-ial e>e-casiem again to resist. We may consider it unfortunate that he Avas not able to do so, but can surely not hold him responsible for yielding to impulses Avhich were so strong as to control his entire being. The criminal aet is the natural resiilt of his mental condition, the natural outcenne of mental disease, anel that must décide the lack of re- sponsibilitv, Avhile there is retenu for congratulation that the accused and others set often resist the sudden biddings of an impulse. I grant that there are great difficulties in the way of accepting this theory of morbid impulses as a défense for criminal acts. It may be urged that every act is the resuit of a sudden impulse, and that if we allmv the défense in one instance we must accept it in ail. To avoid this dilemma it is emly fair to expect that some other signs of mental dérangement shall be dise-ovored in a person avIio has yielded to a morbid impulse, or that proof shall be forthcoming that the person has had pré- vu >us impulses of this kind to Avhich lie has unfortuiiately yielded. If such évidence is not easy te> procure, further observation of the accuse-d individual should suppîy the ne'cessary évidence as to his mental condi- tion. It may be urged, on the other hand, that the impulse Avhich led to the commission of the crime Avas the first and only impulse of the sort ; that with the exception of this " temporary fit of insanity," as it is popu- larly called, the perse>n 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 de'se-ription are very rare indeed, anel if the person is kept under proper observation further évidence Avili surely be found. It is intere'sting to note the relation Avhich thèse 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 Avas not properly turned out and that the gas might be ese-apinu1. Ile ge-ts up, finds lie is mistaken, goes to bed, and after a feAV minutes may be startled again by the same fear. What has hap- pened to him is that a sudden morbid conception arises in lus minci as to the escape of gas, and he is not able to allay the fear by the methods Avhich ordinarily e-arry conviction. Keturning to one's de>or again and au-ain in order to make sure that it is properly lockeel ; the fear that the let ter which has just been mailed Avas not properly sealed; or the fear 182 A SYSTEM OF LEGAL MEDICINE. that one forgot to sign a letter or a check—ail such imperative concep- tions are of daily occurrence in the life of healthy individuals, are often regarded as annoying occurrene-es, but that is about ail. If we carry this physiological occurrence just one step further the morbid com-e'ptions may bee-emie permanentry lodged in the mind anel may lead te) morbid impulses. Who lias not felt when standing on a gidely height that lie Avould be suddenly draAvn inte> the abyss beletw, ami for fear that he might yield to this feeling has stepped bae-k a safe distance from the abyss f Others on board, a vessel hâve felt suddenly a peculiar sensation, as though they would be ineAitably dragged into the Avater; they step back unconsciously in order not to give Avay te) this spee-ial impulse. At the sight of a knife many a person has felt that he or she might do some harm with such a weapon. A few years ago an unhappy Avoman came to my clinic, and stated that Avhenever she sat down to table with her husband and lier fi\'e-year-old child, Avhom she dearly loved, she felt as though she Avould hâve to seize' the knife and kill the child. She stated that she passed through the most intense agonj^ for she would not Avdlingry harm a hair on the child's head. She came to me begging for adArice Avhat te) do. I told lier that she must, of course, control her- self under ail circumstances, but that it Avould be advisable for her to separate for some length of time from lier e'hild, to which she readily consented. A few weeks later she appeared again, stating that iioav that her child was away she had exactly the same feelings with regard to lier husband, and that unless she Avère plaerd under restraint she would some day kill him. Husband and wife too had to be se'jmrate'd, but Avheth- er they Avère eArer réunited, or Avhether the poor Avoman lias committed some act of violence in obe'eliene-e to lier impulses, I cannot say. Eew sane people would control themselves as this woman did had they similar impulses. Who would blâme such an unfortunate civature if at such times she had yielded to the promptings of lier diseased mind ? There is a story, also, of a nurse who was attending a child of Alexander a^ou Humboldt, who begged to be dismissed from service because every time she bathed the child and saw its pure-white skin she felt impelled to do it some harm. How cleisely akin to this state is the entirely normal con- dition of people avIio, 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 Avife as a resiilt of conceptions suggesting the need of the immédiate death of the life-partner. The important point to be remembered is that morbid impulses constitute a very grave séries of symptoms; that they occur in différent forms of in- sanity, as we shall see later ; and that far from being a mère subterfuge as a défense for crime they are too often the actual cause of the worst outrages. The criminal lunatic does not commit crimes merely as a resuit of delusions, hallucinations, or morbid impulses. He' may hâve inheriteel insane tendencies; his nature may be perverse, degenerate; he has been reared in crime, and his Avrong-doing is inévitable. This is particularly true' of those exhibiting marked moral defects. In thèse 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.* ^\ Fig. A. Fis- B. ,- 5* Fig. C. Fi::. D. CRIMINALS AVHO HAATE BECOME INSANE ("DEGENERATE TYPE"). Fig. A.—Aged 50 years; "Frenchy:" murder in the second degree; killed "Old Shake- speare" ; asymmetry of head and face ; deep orbital arch ; large ears. Became melancholy and emotional. Fig. B.—Aged 29 years ; "instinctive criminal :" several convictions; had strong delusions and hallucinations; assaulted fellow-convicts. Small head: large lower jaw. Fig. C.—Aged 21 years; murder in the first degree; said to hâve been insane previously; claims homicide in self-défense. Delusions of persécution. Dolichocephalus. Fig. 1).—Aged 31 years: repeated convictions for larceny a.nd assault. Has auditory and visual 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.] INSANITY AND CRIME. 1S3 question, endeavoring to pre)ATe, l)y careful craniometrical measurement, abnormalities of the criminal skull, of the fae-e, and of the entire organ- ism, that the criminal bears the distinct signs of déficient mental and physieal endoAvment. He is a degenerate individual, and if his degen- eracy is not the équivalent of insanity it is at least next of kin to it. The new school lias not adopted the phrenology of Gall, it lias not as- signed to \rarious parts of the skull the various peculiarities, vices, and virtues of the individual, but it lias endeavored to sIioav that the skull capacity as a whole is elefie-ient, or that the frontal région, Avhich is gen- erally considered to be the chief seat of intelligence', is déficient in the criminal classes. But this same région is déficient in other individuals avIio may lack intelligence but are not in any sensé 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 criminal, unless there be some further évidence of insanity in addition to the crime committed. Lombre>so in Italy and Benedikt in Vienna hâve been the chief stu- dents of cephalometric measiuvmeiits. I append one table taken from Lombroso's Ave>rk, shoAving the ATarying capacity of criminal skulls and tliose of insane or epileptie individuals. Skull Capacity. Murderers. Thieves. Sane. Insane. Epileptie. Cubic centimeters. ( ) ( ) Ci) (/.) CA 1101-1150 0 2.9 0 0 0.5 1151-1200 0 11.7 0.9 1 0 1201-1250 0 0 1.7 3 0 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 11.2 11 16.1 1601-1650 13.2 0 9.5 10 11.3 1651-1700 5.4 2.9 5.2 2 11.9 1701-1750 0 0 3.4 4 3.02 1751-1800 0 0 0.9 1 1.52 1801-2000 0 0 0 1 2.59 Lombroso draAvs 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 Avhich we might infer that murderers are more highly organized individuals than thieves. In skull measurenients the criminal (according to Lombroso) is nearer the insane than the healthy individual. But such statistics should not be overstateel ; the variations may indicate a generally détective organ- ism, and in the individual case variations from the average cannot be dependeel upon as eA'idences of an insane tempérament in its relation to the crime committed. Benedikt, avIio has examinée! a large number of German criminals, con éludes that in central Europe the army of criminals is recruited from the loAver anthropological order of the varions raves* * The présent writer has been tempted to enter upon the question of the degen- eracy of the " instinctive " criminal, but it would hâve been aside from the main sub- ject. AVliile there is little doubt that the Italian school lias exceeded the warrant of its facts in cstablishing varions criminal types and in attacliing undue importance to signs of degeneracv in the individual, it has established for ail times the intimate relations 1S4 A SYSTEM OF LEGAL MEDICINE. Without référence to conflicting théories it will be Avedl to study eare- fully and soberly the forms of insanity Avhich are knoAvn to lead fre- quently to the commissiem of crime. SPECIAL FORMS OF INSANITY IN THEIR RELATION TO CRIME* Crime may resiilt from defectÏA'c eleve'le>pment as Avell as from elise'ase of the mind. From a prae-tical stanelpoint it matters little Avhether the symptoms exhibiteel in a given case', or the actions e-ommitted, are due to improper growth of brain (and mind) or to ae-tual disease of a brain that Avas once normal. Both forms are morbid in the sensé that they indicate a departure from the normal. But as the brain and the men- tal fae-ulties are not fully developed until the âge of piùVrty lias been long passeel, we must aise) include the eeuiside-ration of those crimes Avhich are the resuit of unripe' judg- ment rather than of disease ; but as a matter of fae;t Arery few youthful persons are guilty of viedent or wrong acts unless they bear the germs of impending insanity or the traces of a tainted family record. iVrsems cannot be held respon- sible fe>r criminal acts— • 1. If they hâve not yet attained the âge at which they can be expeeted 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 évidence of ar- rested or de'fective development of the brain (idiocy and imbecility). 3. If they exhibit évidence of such disease of the mind as affects the fully deA-eloped brain, or of conelitions of degeneration that beconie apparent only after body and mind hâve 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. Fip. 25.— Ravachol : asymmetry of face, déviation of nose, slight growth of beard, and firmly set jaws. THE RESPONSIBILITY OF CHILDREN. The law of every land concèdes that a child cannot be held respon- sible for criminal actions: its judgment is détective, and it does not between the habituai criminal and the insane. The ann-exed faces will suffice to prove the existence of the insane type among criminals ; but if any reader will take the trouble to consult Byrncs's Professional Criminals of America, he will find that the majority of those habituai criminals exhibit few, if any, signs of degeneracy. For the présent there is still a wide gap between criminalitv and insanity. The èntire 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 eriticised in the work of Baer and in the monograph of Hirsch. * For a fuller account of each form the reader is referred to Dr. Hamilton's article in this volume. INSANITY AND CRIME. 135 realize its relations to the other éléments of the social organism; it may be able to discriminate between right and wrong in certain con- crète instances, but of the abstraet principle of right and Avrong it lias no conception. The early acquisition of such knowledge is, however, the main object of ail training. The limit of childhood is fixed differently in various countries. In this country responsibility begins with the fourteenth year. Lord Haie demanded that a normal individual should hâve the understanding '-as ordinarily a child of fourteen years hath." Austria adhères to the same limit, while Germany exacts fidl responsibility after the completion of the twelfth year ; in France there is no Avell-defined age-limit, and chil- dren under ten are not infrequently brought to court and sentenced. In ail civilized countries there is a tendenc}^ however, to extend the limit ; in France to the âge of sixteen years or thereabout, anel in other coun- tries eA^en up to the âge of eighteen years. This is quite in keeping with the efforts at criminal reform, and spécial reformatory institutions hâve been established at différent places for the eare and reform of youthful delinquents. Among the gênerai average of yemthful criminals not a few shoAV signs of a bad inheritance. The statistics of early crimes are quite appalling, shoAving the need of spécial legislatieui ; ae-cording to Krafft-Ebing the aATerage number of criminals under sixteen years in Prussia varies between ôOSÔ and 9225. A very feAv emly of thèse youthful criminals are examined Avith référence to their mental condition ; if such an examination were made it is safe to say that a very large number Avould give undoubted évidence of dé- tective inheritance, or of déficient 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 Rtd'ormatory haA^e be'en boys who were supposed to be of normal mental de'vedopment, CA'en bright ; yet their descent from hysterical and epileptie stock, and the poor training Avhich neurotic parents gave them, were 186 A SYSTEM OF LEGAL MEDICINE. Fig. 28. Fig. 29. Fig. 32. Fig. 33. Figs. 28 to 33.—Sélections from sketches made by Dr. Vaus 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 : horse- thief. Fig. 30.— Laborer, aged 21 : robbery with violence. Fig. 31.—Puddler, aged 21: wounding. Fig. 32.— Cook and steward: larceny. Fig. 33.—Age 25: robbery with violence. Ail but one (Fig. 31)'had been previously eonvicted. » PLATE III. Fig. A. Fig. B. / Fig. O Fig. I). CRIMINALS "BY REASON OF INSANITY. Fig. A.—Aged 37 years; killed Dr. Lloyd, asylum physician; in love with Mary Anderson: declared "insane and responsible "( !); life sentence. Characteristic pose of body. Fig. 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. Fig. C—Aged 26 years: murder in the first degree; sentence commuted to life imprison- ment; one term at reformatory; insane ancestry. Is depressed: delusions of persécution; massive jaws; dolichocephalic; exophthalmos ; coronal suture depressed. Fig. D.—Aged (?) ; shot at a female church-organist. Hallucinations of hearing caused act. Insanity not recognized on trial. Says he is "Duke of Sussex and Earl of Beauharnais.'1 INSANITY AND CRIME. 187 directly responsible for the wrongs they committed.* Growing up amid such surroundings they could not be expected to discriminate between right and Avrong in the abstraet, nor even between mine and thine. Consider in addition that the âge of puberty is attended by an awak- ening of the sexual sphère, with ail 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 âge ail the latent inheritance cornes into play, that the family ghosts (hysteria, epilepsy, insanity) hâve their say, and that the habit of masturbation is often engendered to intensifv latent defects or create new troubles : consider ail this and there will be little wonder that crime is so fréquent in early life. Chiïdren hâve committed many différent crimes. Murder, arson, and stealing are the commonest of thèse, ail of them the resuit of détective judgment or of détective training, or both. S., a lad of ten years, living in Alsace, had a companion who, as the son of Avealthy parents, wore fine clothes. S. was envious of thèse. 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 murder. He was discovered and tried. The jury found that he acted with •• discernment," and declared him guiïty, but recommended him to the mercy of the court ; he was sentenced to ten years in prison. (Mit- termaier, Friedreich's Blèitter, 1865, vol. v., quoted by Krafft-Ebing.) The jury were evielently guidedby the old principle that if the person knows the nature of the act lie must be guilty. This does not hold good with référence 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 aAvay from home and lived with one of his teachers. This Avas evidently not to his liking. One evening he asked to be allowed te) attend a '* caudy-pull." The teacher refused. Very soon thereafter the boy walked into his bedroom and deliberately set fire to the clothes in a closet. As soon as the smoke was noticed he conf essed what he had done and helped to extinguish the fiâmes. The examination of the boy brought out the fact that he was not very bright, 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 évidence of insanity or of viciousness. Still another case will illustrate the narrow line of demarkation be- tween sanity and insanity in children, as well as the effects of faulty training. A well-de3veloped girl of fourteen, the child of respectable and well-meaning parents, Avas referreel to me some time ago for an opinion as to her mental status. The child had become willfuï and unmanage- a.ble, had no regard for the truth, and at school had taken things out of other children's pockets. In addition to thèse unfortunate qualities she exhibited considérable sexual excitement and was anxious to obtain in- formation on sexual matters. By her relatives she was supposed to be precocious, Avhich she Avas not except as regards vicions habits. In former days physicians would hâve made a diagnosis of kleptomania, if * In this respect the meelical reports of the Elmira Eeformatory are of great in- terest. 188 A SYSTEM OF LEGAL MEDICINE. not of moral insanity • but the child, avIio Avas desceuided from a distinctly neurotic stock, Avas the victini of faulty training : in view of her siqtposed precocity she Avas encouraged in the idea that what she elesired sliemld be hors, that she was an unusiial child, etc. This young girl was placed in the charge of an intelligent, sober-minded teacher, who has studied her mental peculiarities anel lias suceeeded in changing the e-hild's point of vieAV. In this one instance the coopération of physician and teacher lias averted impending mise-hief ; but in dozeuis e)f other cases the se-ed that lias been soavii ripens, and ail sorts of crime resiilt in later years from faulty inheritance made Avorse by faulty training. The inference to be drawn from 'thèse iow examples is that even if insanity cannot be proved in a youthful criminal, the antécédent history and the early éducation of the child should be taken into account, and both thèse may discover extenuating circumstances. ARRESTED OR DEFECTIVE DEVELOPMENT OF THE BRAIN. Under this heading are to be included ail cases of insufficient devel- opment of the mind varying betAveen idiocy, imbecility, and nieu-e weak- mindedness. This is a différence in degree and not in kind ; a différence in the stage at winch cérébral development was arrested, or a différence in the extent to Avhich the de;velopment of an imperfectly organized brain has been carried. Idiocy or imbecility may be truly hereditary, or due to injury during labor, or to influences Avhich hâve been active during the earlier years of life. Idiocy from hereditary causes is most apt te» occur in the descend- ants of elistine-tlv neurotic stock, in faniilies in Avhich insanity has occurred in succeeeling gene-rations, or in those in Avhie-h epilepsy, chenva, hvsteria hâve been fréquent occurrences; often the parents the'inselves hâve bee-n thus affected. But tAve) conditions lead more freejuently than ail others to idiocy and imbecility in the descendants ; the first is alcoholism of either parent,* and the second is blood-relationship between man and Avife : if there be' the slightest taint in the family tins taint is greatly in- tensified by such a union. As there are feAv familles entirely free from such taints, the eA'il of intermarriages can be easily gaugeel. A A'ery considérable numbeu* of cases of idiocy are élue to difficulties during labe>r. To the study of this class of subjects the présent writer has devoteel much time and labor. The purely médical questions in- volved need not lie alluded to in this chapter, but from a forensic point of vieAV it is important to knoAV that prolongeel labor and the application of the forceps to the skull of the child often cause a hemorrhage OA'er one or both halves of the brain ; that this hemorrhage ultimately results in an atrophy of a considérable portion of the cortex ; and that this at- rophy may lead to détective development of the mind. Let me add at once that the laAvyer and médical man should not endeavor to prove too much by this, for in the A-ast majority of e-ases prolonged labor and in- strumental delivery do little harm; and if harm lias been done to the brain, epilepsy and paralysis (unilatéral or biïateral) ave frequently associ- ated with idiocy or imbecility. Ieliocy or imbecility may also be due to external injury (falls) to the skidl during the early years, or to the acute infections diseases so com- mon in childhood. Convulsions, whether of reflex origin or the precur- * Syphilis is also mentioned by many, 4mt I doubt its significance in this respect. INSANITY AND CRIME. 189 sors of an infections disease, may be the direct cause of arrest of brain develejpment. I hâve known children of two years and even older to beconie ceunplete idiots after the occurrence of such convulsions, although they Aveiv entirely normal before such coiiATidsie>ns had occiirred. Furthermore, Aveak-mindedness developing at about the âge of pu- berty may be the resuit of inheritance ; in thèse cases the brain has been capable of a certain amount of development, and the symptoms of imbe> cility hâve not become manifest untd the work of a normal adult brain lias be'en expected. The jurist and the medico-legal expert need take but little trouble to prove the existence of idiocy : the idiot, as a rule, speaks for himself ; but there are grades of imbecility which approximate so closely to the normal that it Avili require some skill to demonstrate Avherein the imbé- cile is déficient. The idiot is entirely incapable of utilizing impressions that lie has received ; there may be péremption, but not appereeptloii ; lie is restless, but restless Avithout a purpose ; lie is animal-like in his appetites, and the gratification of thèse is sought, at times, in bestial fashion. It is needless to aelel that the idiot exhibits no judgment and no memory, ex- cept that he is very apt to know whether his appedites hâve' been gratified in the usual Avay. The imbécile is elistinctly remoA'eel from this order of beings, yet re- lated to them clearly enough. He is e-apable of a feAv abstraet concep- tions, may learn to knoAv his relations, can be taught to avoid danger, to keep himself clean, to be quiet Avhen strangers are around, and so on ; but as he grenvs the delielency of his mental and moral make-up is evielene'eel in the excessiATe development of the animal appetites. The gratification of hunger and of the sexual appetite is his most important aim in life. EA'euy one bas knoAvn imbéciles avIio could be maele; happy by te)bacco or a feAv drops of Avhiskey. The sexual appetite is gratified by self-abuse, Avliie-h se)on ineivase's the imbecility, or by attempts at in- tere-ourse Avith ail sorts of persons—Avith children and old Avomen ; (liraud reports (Ann. Méd.-Psych., 1885, vo\. i.) the case of an idiot who attempted to râpe his oavii sister. A feeling of modesty or of shame is, as a rule, entirely Avanting. When ail symptoms are distinetly marked the task of diagnosticating imbecility is relatiATely easy. It is mue-h more difficult if the person in question exhibits only a moderate degree of imbecility; in such cases we must be gnided entirely by an examination with référence to the range of the person's mental horizon, anel by the account (ahvays valuable) of his behavior toAvard his relatives and in his home surrounelings. A com- parison with other subjects of the same âge is important, but individual différences must be allenveel for.* The ielied anel the imbécile hâve détective 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 déficient in the appli- * A few imbéciles hâve attained considérable skill in some one department, as me- clianics and even as artists ; through careful éducation the original imbecility may bc covered up. Sander reports the case of a young German who passed his first law examination who was pronounceel an imbécile. I knew a young chemist, an évident imbécile, who had suceeeded in 4>assing 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 such knoAvledge, for their judgment and déficient reasoning are easily overruled by their passions. Imbéciles hâve committed crimes not realizing the full ce>nseepie>iu-es of their actions, or from a mère désire te» gratify their passions and im- pulses. Casper reports the case- of au idiotie cannibal of forty years, Avho was in the habit of carrying abemt a nephew of two years. One day he failed to return home; lie Avas discovered in the avoocIs; lie had bit through the child's throat and gullet, had eaten its flesh and drank its blood. His only motive Avas that he wislied te> eat the child's flesh in order that lie might groAV tall—lie had no conception of the enormity of his e-rime. The annals of crime and of psychiatry are full of such cases—noue more horrible than that of Carlino Grandi, avIio burieel four children alive, and was discovered when lie attempted to bury a fifth. He Avas anxious to rid himself of boys A\lie> Avère poking fun at him, and thought it quite a proper Avay to proceed. Ile' thought that the four boys who Avère in Paradise Avère better off than he. He was sentene-ed to impris- onment for twonty years. Imbéciles hâve so frequently been guilty of incendiarism that they constitute a large pere-entage of pyre>maniacs. The incendiarism is some- times the me're resuit of a désire to see a grand spectacle, in other case-s of a désire to practice re venge upon a supposed rival, and sometimes arises from a mère spirit of restlessness and a désire to do something. Whatever the nature of the crime may be, it is the duty of the medie-al expert to prove by the history of the accuse'd, and by the resiilt of his examination, that he présents distinct symptoms of détective mental de- velopment. DEAF-MUTISM. No one would ordinarily think of classifying deaf-mutes with the insane ; but if they hâve not been trained in spécial schools they may re- main entirely devoid of ail moral concepts, and their social status may be not unlike that of the imbécile 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 responsibdity ; but a décision 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 Avrong. No one but an experienced deaf-mute instructor can be trusted to secure such évidence, or to déter- mine the exact condition of his mind. Under the influence of strong émotions during a fit of frenzy, deaf-mutes hâve set fire to houses and hâve committed murder. Casper (Vierteljahrsschr., vol. xxii., p. 136) tells of a deaf-mute twenty- four and a half years of âge AA~ho set fire to a stable after he had been strue-k by his father, who had been in the habit of abusing him. While the fire Avas raging lie clapped his hands Avith joy. On examination he Avas found to be weak-minded, his mental capacity not exceeding that of a boy of fourteen. It is e\ddent that deaf-mutism alone does not constitute an excuse feu- crime, but that if the person has not been properly trained his intellect and his moral make-up may be détective. It is therefore of the utmost INSANITY AND CRIME. 191 importance to détermine the exact mental condition independently of the deaf-mutism. The conelition of de^af-mutism may be simulated; if so, the folloAving tests should be' remembered : A deaf-mute perceives the vibrations of the' air causée! by loud clapping of the hands or by stamping the floor; a simulator will claim not to notice this, nor to perceive the vibrations of a tuning-fork placed between the teeth, which a deaf-mute perceives perfectly. Deaf-mutes spell correctly as a rule, as they hâve been eare- fully instructed; simulators often s}M'll incorreetly, perhaps intentionally se). Kraiît-Ebing refers to a metliod suggesteel to him by Predessor Kessel. The supposée! deaf-mute is to be placed in a room and given his meals at regular intervais. This is to be omitted for once, while in an adjoining room the sound of "forks anel knives" is to suggest that it is time for his meal to be brought : lie will, in ail probability, turn to the source of the ne>ise\ Tins is ingenious, but we doubt whether it Avdl prove successful in ail cases. MELANCHOLIA. Melane-holia is a well-recoguized form of insanity which may become the cause of crime. It is not to be confounded with simple melancholy dépression, Avhich may aecompany almost any form of mental disease. It is as natural for a lunatic avIio has delusions of persécution te> be de- pressed and melancholy as it would be for a sane person AArho found that everything and everybody were against him. In true melancholia the dépression is the primary condition. Without cause or reason the patient is in a state of intense dépression, ont of which he cannot be argued. Whatever his expériences may be, even though they might hâve beeui a source of pleasure to others, he is swayed by the eleqiresseel mood, and will look at the world only through the dark- ness of his own soûl. His feelings are smothered. He takes no pleasure in business or professional work ; mu sic lias lost its charm ; he grows indiffèrent to every one, cares not for Avife or child ; he is doomed to per- dition, and every one dear to him is to meet the same fate. A mother one-e devoteel to her children feels that ail maternai feelings hâve left her ; that she does not eare Avhether her children are dl or well, Avhether they are living or dead. Noue but sad thoughts pass through the mind, helping to intensify the original dépression. A total lack of energy charaeterize's such patients ; Avith this lack of energy goes the idea that there is no use' in trying to do anything, for it is bound to lead to evil and te» do harm in the end. The patient sometimes perceives the slug- gishness of mind and boelv Avhich is so characteristic of this state, and grows more and more morbid e>ver this altered state of feeling, broods ail day long, becennes silent and totally indiffèrent to everything. The physieal dépression, the loss of appetite and of sleep, chronic constipa- tion, soon affee-t his gênerai bodily health, and he becomes a pitiable physieal and mental Avree'k; but, fortunately, in many instances the Avre-e-k is not complète and reco\rery may set in. In melane-holy there is a distinct inhibition, a •• sloAving up " of ail men- tal anel physieal proce-sses, but the person thus afflicted is able for a time, at least, te» examine his reasoning poAvers, anel Avili naturally try to find senne cause for his depresseel feelings. As a rule the cause is supposed 192 A SYSTEM OF LEGAL MEDICINE. to be within himself : he has not done his duty to his next of kin, to his fellow-men; he feels that he is a misérable e-reature, that he lias been gudty of great sin, that lie does ne>t deserve to live, bringing misery only upon hiniself and his family. Medheu-s suffering from melanclmly ele- clare that they hâve not doue their full duty toward their children ; that they hâve been neglectful of their children's early éducation, or, as a patient of mine insisted, she did not prépare her daughter properly for the duties of married life, and in tins committed a graA-e offense—in short, naught but self-ae'cusation. To make the condition still more painful, delusions and hallucinations in keeping Avith the depressed émo- tions add to the anguish of the patient. For weeks and for months the patient may remain in tins condition of dépression, showing no signs of pliysieal or mental actiA'ity, often not uttering a Avord for days at a time, except possibly 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 committee! is often in direct proportion to the degree of former dépression. The patient breaks ail chains at once, as it were. The melancholiac is led to deeds of violence in order to put an end to his oavu sufferings, to avert impending danger for himself and others, or in obeelience to delusions and hallucinations. A sudden fear is very apt to seize him, and in tins condition he becomes thoroughly irrespon- sible. Suicide is the natural effort of the depressed patient to free himself from misery ; but on this act Ave need not dwell at any length, for it is not a crime in the eyes of the law, and the question of responsibiïity is not to be argued Avith regard to it. But cases of " indirect suicide '' hâve occurred which are- of the very greatest importance. Religious scruples hâve prevented many an individual who Avas so inclined from committing suicide, but as his only wish is to die he must merit death in some form, and so commits murder in order that lie may be put to death by the State. A young man twenty years of âge, without any knoAvn cause, stabbed a young Avoman sitting next to him in the theater ; she died instantly. To her husband he said, " I know neither you nor your wife. I do not know you." When cross-questioned he explained that he was tired of life, but preferred to die on the scaffold, as that would give him time to make his peace with God. He had thought of insulting an officer, of killing a priest, of assassinating the président of the French Republic, but ail thèse he did not Avish to kill ; as he entered the theater he saAv a young girl, but her life, too, he spared ; the married woman sitting next to him appeared to him to be the proper victini. (Gaz. des 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 Avould not hâve been suspected by any sane mind. The "désire to hang" is not ahvays the resuit of a tœdium vitie; it cornes 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 kdl some one : he followed a boy, Avho Avas the first person lie saw, to a convenient place, and murdered liim in cold blood, taking eAudent pleas- ure in the deed. He kneAv the boy had no ill feeling against him, " only I had maele up my mind to murder someboely." He did it because he wislied to be hanged. (Maudsley, p. 158.) The boy was executed, and INSANITY AND CRIME. 193 the juelge gave the opinion that he was thoroughly responsible, as lie Avas able to understand the nature and conséquences of his act, and that lie kneAV the punishment Avas capital. This the learned judge considered a deeper aggravation of the crime. But to return to melancholy. In a state of deep dépression a mother may suffoe-ate her child, either to end its misery or because the impulse suddenly cornes upon her to change her own condition ; she feels that she must do something in obeelience to an OArerpowering suggestion. Re- niorse and horror follow quickly upon the commission of the crime. Every one can reeall récent cases in which a mother has poisoneel her children to keep them out of misery, or has shot them to put them out of harm's Avay. 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-up feelings are finally let loose, and in a state of rttptus melemcholicus a horrible crime may be committed. From a f orensic point of view the question arises Avhether or not such persons should be permane-nfly condemned to an asylum. That the per- son is not responsible for deeels e-ommitted goes without saying ; but this is a euirable form of insanity, and for years and years not a sign of in- sanity need be exliibited. For a period of at least several years after the ceunniission of a crime the patient should be earefully guareled anel observed ; but after such a reasemable period it would seem just to giA'e such person full liberty, but as a further safeguard the lunatic should be placeîd under médical surveillance for a period of at least five years, and Avith the first indication of a relapse should be returned to the asylum for treatment and safe-keeping. MANIA. The term ••mania" is used to dénote a form of mental disease which is the direct opposite of melancholia. The sensé of the word was per- verted in the days of monomanias ; in modem psychiatry it represents the class of cases uoav to be described. In contra st to the inhibition and slowing up of ail cérébral and phys- ieal functions in melancholy, there is in mania a decided accélération of thèse functions, associated Avith a feeling of Avell-being. Far from being depressed and without energy, the maniac is in an exalted mooel, ready and able (so lie thinks) to do anything : to Avin in any struggle, to down ail enemies, anel to accomplish Avith ease Avhat the timid (the sane) dare not attempt. This exalted state of feelings leads to excesses and reckless- ne'ss : he is apt to be on the go, traveling from one place to another ; gen's about from club to club; indulges himself toexcess; drinks fre- epiently; and in the full vigor of manhood worships to excess at the shrine of Venus, and boasts of his sexual performances. The psye-hic processes being accelerated, or, rather, ail inhibition being remem'd, lie becomes fluent of speech; speaks ou every possible oe-casion, sometimes sensé, more often nemsense; the association of ideas is not under re-straint; he passes from one topic to another Avithout logi- e-al se'quence; like a child, mère sound is apt to suggest hcav lines, not of thought, but of talk, anel in many instances he begins to talk in rhyme. 191 A SYSTEM OF LEGAL MEDICINE. He mistakes his doggerel for true poetry, and recognizes his OAvn superior gifts. With the renmval of that inhibitory restraint which ke-eps us ail Avithin bounds, the maniac yields to every impulse, and will go to any length to satisfy his appetite or his ambitions. He Avili see'k the highesf pe>sition within the gift of the people, or Avili endeavor te) establish sexual relations Avith Avomen Avhom no one else Avould dare to approach (delu- sions of grandeur). If crossed in his plans he loses his temper, and often passes into a state of uncontrollable passion. His brain is in a constant turmoil ; he loses sleep and appetite, and soon becomes exhausted from physieal excesses, from emn-indulgence in sexual intercourse and in the use of tobacco and alcetholic drinks. The condition pictured above may last for years in a more or less pronounced fashieui ; such patients often pass for men of unusual activ- ity and capacity until the différence between intention and actual per- formance becomes apparent. If such a condition overtakes a man avIio was formerly slow to arrive at cemclusions, cautious and sober in his judgments, the change Avili be recognized by CA*ery one. At times this same patieuit Avili be able to give excellent motives for apparently rash acts, motives which the sane could not hâve advanced, and yet seem reasonable enough. (This spécial form is termed by the French writers folie raisonnante.) The exalted mood of mania may become intensified and will then lead to the state of frenzy, in which the person's will knows no restraint ; lie becomes AÙolent, elestroys everything, does bodily injury to himself, and Avili be hable to injure any one else avIio crosses his path Avhile lie is in tins state. The maniac cornes into conflict with the law by reason of his exalted mood and the extrême mental and physieal restlessness. At first lie in- dulges himself in private ; as the disease increases the maniac loses the ordinary regard for public morals, will attack the opposite sex on the street, wdl try to râpe young children or to masturbate in public. If opposed in the exécution of his plan he becomes quarrelsome and is only too quick in the use of firearms ; in the spirit of restlessness, and in obédience to transitory delusions or hallucinations, he will commit arson or murder. Mania as Avell as melancholy often represent the initial stages of more chronic forms of mental disease, and often, too, are entirely curable. The person who has been guilty of a criminal act during the period of exaltation or maniacal frenzy may hâve fully recovered by the time he is brought to trial. The physician 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- rary insanity is often advanced in cases in which there is insufficient rea- son for doing so. A distinction should be made between sudden extrême passion and maniacal frenzy. To prove the latter, évidence should be brought forward to prove dérangement before the commission of the criminal act, for maniacal frenzy is never developed with great sudden- ness, and he who knoAvs how to epiestion and examine the accused or his relatives will be able to proA*e the existence of insanity before the act, if any such existed. Such cases are, on the whole, easity recognized; a single example will suffice to illustrate its relation to crime : INSANITY AND CRIME. 195 Dr. Koster, in the Irrenfreund for 1875, relates the case of a man twenty-nine years of âge, who had an insane mother, and who had him- self always been distinctly neurotic. Marrying a Avoman much older than himself, lie Avas guyed by his neighbors, and became sensitive to their remarks. One ewening he was accused of not being the father of his e-hdd. This excite'el him intensely; lie Avas unable to Avork and be- caniei confused. Tavo days later lie paceel the floor until twelve o'clock at night, anel at two o'clock ran to his neighbors elivsse'd in his night- shirt, telling them that he had murelered his wife and child. He hael choked his wife anel eut the throat of the child. He sjioke in a confused manner of electricity, of satirical verses pointed at him, and was evi- dently subject. to deliria and hallucinations of a mild order. This con- dition lasted for nearly six months, when lie slowly regained his mental balance. This case proAres 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. paranoïa. The jurist's and the layman's aucav of insanity is represented best by paranoia. In this form of mental disease delusions and hallucinations play a very important part, Avhereas avc hâve hael little to say about them in the other forms previously mentioned. In paranoia the delusions and hallucinations are primary symptoms, and not engenelered on the soil of exaltée! or ele'presseel emotiems, as in mania and melancholia. Thèse delusions, '"fixeel ideas," be-e-ome systematized. They are the piATot about which the entire personality and the person's entire universe turn. They lead to the formation of an alter ego, altogether différent from the original ego. The delusions dominate the mental actiAuty to such an extent that they become the mainspring of ail action. The paranoiac is not annul- able to ordinary reasoning, anel his delusions cannot be dislodged by any power of logic. His mind is not susceptible to argument, for if it were, the elelusiem Avould of itself disappear, as the temporary delusions of the sane or of the curable insane do. Ile may hâve one sed of delusions, lie may haAre many : the pe-rsistence of one or of many pr<)Ares that the entire logical a.pparatus is out of gear. It is absurd, therefore, to e-laim that a person is insane on some one point, and one point only ; lie may sIioav liis insanity in one Avay onty, but his mental dérangement is as great as though he had dozens of fixed ideas. Paranoia is aise) the most typical form of insanity, inasmuch as it sIioavs most distinctly the effect of heredity. The first signs of the in- sane neurosis can, as a rule, be traced far back into chilelhood. The children avIio are exclusive, avIio never eare to play with other children, who are unusually irritable, avIio prêter to pray Avhen others go to play —thèse are the very ones avIio devehqi paranoia later in life. Moody, irritable, queer, anel " e-ranky," they go along Avell enough until they hâve to rub up against others in the struggle for existence', or until they are overcome by some seveu-e grief, by strong émotion, by politieal or relig- ions excitement (élection campaigns, revlval-meetings, and the like) ; and then delusions which may hâve been latent for a long time come to the ioreground. On further inepiiry into the antécédent history of the para noiac, lie Avdl be found to come of neurotic stock, in Avhich insanity 196 A SYSTEM OF LEGAL MEDICINE. hysteria, epilepsy, and chronic alcoholism hâve been common occurrences -, in other cases a fall early in life, a severe infectious disease, sue-h as typhoid fever or pneumonia, or masturbation, may appear to hâve been the direct exciting cause. Whde the disease begins in early life, the full- fleelgeel delusions do not, as a rule, appear until the âge of puberty, or possibly not untd the climacterium. The systematized delusions of paranoia may be (hvided into tAvo great groups: first, delusions of persécution; and secondly, delusions of grandeur; the latter may again be subdivided into religions, political, and erotic delusions. Paranoia with Delusions of Persécution.—The patient thus affected supposes himself to be the victini of circumstances, of an individual, or of a oorporate boelv. The essence of his belief is that he is made to suffer for Avrongs Avhich he lias committed, or for envy which others feel toward him. He has, as a rule, been morose, exclusive, and perhaps given to masturbation. He feels that lie is being observed by others; that they notice a peculiarity in him ; that they can read and control his thoughts; that the neAvspapers direct their flings at him—when they speak of rascals or of thieves they mean him. Before long he hears Aroices ; thèse are the voices of his enemies, who are tryiug te> ferret out his actions ; he stops up the keyholes and draAvs the blinds of his A\in- 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 pedson in his food, which he will refuse to take from that time on. He may be the victim of socialists, of the polie-e, of a definite religious sect, Avhe) Avili endeavor to influence him by eleedricity, through the téléphone, through hypnotism, or to kill him by causing him to inhale ail sorts of noxious vapors. An endless variety of delusions and of combinations of delusions and hallucinations may be the resiilt ; but the one feature of ail is that the patient is made the victim, the sufferer. A patient of mine, twenty-five years of âge, who had always been morose, was suddenly seized with the fancy that an intimate friend of his had gained full control over his mind and prevented the free exercise of his will. One day he bought a pistol, whieh he loaded and started out to find this friend and kill him ; but fortunately the friend was out of town. As a measure 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 regularly, which he did faithfully enough. After several months he remained away, when, to my chagrin, I discov- ered that he suspected his mother of being in conspiracy against himr and that he meant to " fix " her for it. He had to be removed to an asylum at once, where he will necessarily remain for a long period of time. It is easy to see that thèse 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 ail their misery, and against whom they may proceed with murderous intent. MoA-ed by their delusions, and regarding them as real, they act in self-défense ; for that reason they commit deeds of violence on the open highway, in public places, and in private houses ; they hâve no fear of the resuit, and often glory over their supposed victories. They discrim- INSANITY. AND CRIME. 197 inate between individuals, killing only those persons whom they suspect, while passing others by: the law, in its great Avisdom, considers this eAddenee of guilt, for it proves préméditation and a knowledge of the Avremg lie committed. The delusion of " marital infldelity " cornes under this heading, particu- larly if it occurs in a Aveiman, while suspicion of infldelity on the part of the wife is, as a rule, an accompaniment of chronic alcoholism in the husband. In the Avife such unfounded suspicions are the expressions of a paranoia persecutoria as it oe-curs during the climacterium. The dimi- nution of sexual concourse, the waning powers of fascination, naturally suggest that the husband or Avife seeks gratification elseAvhere. He be- trays his relations to other A\romen by the fact that he coughs when lie passes them on the street, The maid waiting at the table passes the dishes with spécial déférence to the master of the house. An old lady of sixty ae-cused her husband of nearly seventy of such illicit relations with the maid. The husband de-clared to me emphaticaUy that he desired no further intercourse with any one, and that ail he cared for was to go to sleep. But the delusion persisted, and for a time quiet was restored by banishing ail female help from the house except the cook, and the old lady guarded the kitchen very earefully. In other cases, again, thèse changes in the sexual sphère lead to the delusion that the person lias been raped in her sleep (Avhence false accu- sations), or that she lias been led to houses of prostitution and the like ; that othe-rs are spreading such reports for the purpose of defaming lier. Some feel called upon to prosecute the offenders in court as a matter of self-defense. Physicians play an unenviable rôle in some cases. A vaginal exam- ination is said to hâve terminated in sexual intercourse, or possibly to hâve been the e-ause of a change in sexual feelings. Physicians also play a part in many delusions of persécution ; above ail are they frequently supposée! to hâve gained complète mastery over the minds of the insane, and to be in a conspiracy against them. A patient of mine imagined that I hael been engagée! by the family to rid them of him, and that after his death I Avas to come in for a share of his fortune. Paranoia with Delusions of Grandeur.—In this form we may classify ail those cases in Avhich the subject imagines himself called upon to fui fi 11 some speedal missiem. It includes the class of insane political reformers, of religious fanatics, of emperors, kings, and présidents, and those bent on some spécial mission of love. In ail of thèse there is an exalted state of feeling sue'h as is charae-teristie- of delusions of grandeur. Those who find spécial pleasure in minute subdivisions may establish the following forms : paranoia reformatoria seu politica ; paranoia religiosa ; paranoia erotica. The political conditions of the présent day are such as to arouse the dissatisfae-tion of many living in monare-hical countries as well as in re- publics. The sane endeavor to right such defects by the ballot and other peaceful measures. The insane, avIio wish to bring about great reforms, to enfoive their oavii pet (generally foolish) schemes, are anxious to strike at once at Avhat they suppose to be the root of the evil, and therefore' aim at kings, présidents, prime ministers, and other high officiais. If their OAvn personal greed or désire for aelvancement has not been gratifiée!, thev hâve an additional incentive to acts of violence'. In this connection 198 A SYSTEM OF LEGAL MEDICINE. the case of Guiteau overshadoAvs ail others. If ever there was a pro- nounced lunatic it Avas he ; yet lie' Avas hanged to satisfy the public con- science'. The case is too well known to be giAren in eletail ; but let us pick out a feAv of the salient points which pro\ e his insanity. Guiteau Avas about forty years of âge at the time lie shot Garfield ; his father was an eccentric individual avIio believed in free love-, in me-s- merism, and believed himself to lie ordained by God to oxeuvise thèse functions ; an uncle Avas insane ; his mother had a brain trouble at the time of his birth; his sister suffered from opihq>sy and puerpéral mania. He had no sort of systematic éducation, but Avas fond of reading, and partieularly on religious subjects ; he masturbated at very early âge, and entered the Oneida Community at the âge- of nineteen. At the âge' e)f tAventy-four lie Avrites to his father, saying that he proposed to edit a journal for the spécial glory of Christ, anel that thereafter churehes would not be neeeled; that lie Avas emphyeel by Jésus Christ & (Jo. He endeavored to study hvw, but failed. At itlie âge of tAventy-eight he mar- ried a worthy Avoman, whom he abandoned after four years to live with a prostitute. At the age> of thirty-four he offered to secure the Presieleney for a foivigner, if that person Avould lend him $200,000. In this same year (1875) he attempted to kdl his sister, without any sufficient reason. He continued te) preaeh at religions meetings, anel denounced theaters. During the élection campaign lie Avrote a short article favoring Gar- field's élection, and imagined it to larve be-en chiefly instrumental in his élection. He felt, therefore, that he Avas entitled te» some offie-e ; aspired to the consulate at Paris, whie-h he anel the' rieh woman he Avas te> marry would represent Avorthily. Finding himself thwarted, he ceniceiveel the idea of murdering the Président, anel brooded over this (Avhich he' gradu- ai ly conceived to be a political necessity) for six Aveeks before proeeeding to the act ; lie borrowed the money to buy the pistol ; acteel Avith great délibération, and on one oce-asieui Avhen the Presideuit Avas Avith his wife desisted from shootiug, and waited lus eqtportunity until lie Avas able to find him alone. After the shootiug lie issueel a letter to General Sher- man, in which he tried to justify the murder from a sensé of duty toAvard the American people, and as a punishment for destroying the Republican party. His entire behavior on trial after he was pronoune-eel guilty and as he Avas led to the scaffold Avas that of a man Avho believed himself destined to fulfill a spécial political mission, avIio was morbidly conceited, and who reArenged himself for the neglect of his rightful ( ? ) claims. It was the cruel revenge of a confirmed lunatic, of a paraneuac Avith delu- sions of grandeur. (See Folsom, Boston Médical and /Surgirai Journal, February 16, 1882.) But the learned judge evidently thought otherwise and eharged ac- cordingly :* " If you find . . . that he had possession of his faculties, and the power to knoAv that his act Avas Avrong, and of his oavii free Avili de- liberately conceiAred, planned, and executed this homicide, then Avhether his motive Avas personal vindictiA'eness or peditical animosity, or a désire to avenge a supposed political Avrong, or a désire for notoriety, or fan- ciful ideas of patriotism or of the divine will, or you are unable to elis- eover any motive at ail, the act is simply murder, and it is your duty to find him guilty." The jury obeyed the charge, decided that Guiteau was * Lawson, p. 188. INSANITY AND CRIME. 199 in full possession of his faculties, and found him guilty. The judge thanked the jury, and modem psychiatry now records this case as fur- nishing the best possible évidence of the inability of judge and jury to recognize a diseased mind. EPILEPTIC INSANITY. Epilepsy is a well-known convulsive disorele-r characterized by seiz- ures of violent motor (elonic and tonic) contractions of some or ail of the muscles of the body. The attacks are of short duration, but extremely violent while they last ; betAveen the attacks there is a free interval of varying duration. The attacks may occur at intervais of months, Aveeks, days, or of hours only. The disease is a chronic one, beginning, as a rule, either in the earlier years of life or at the time of puberty up to the âges of twenty-five ov thirty years. Strictly speaking, epilepsy is not so much a disease per se as a group of symptoms resulting from many différent causes ; among thèse inheritance Avas formerly considered to play the most important part. While there is some elisagreement on this head, epilepsy in the ancestry, chrome; alcoholism of the parent, or even severe neuroses such as hysteria and chorea, are apt to lead to ejdlepsy in the descendants. Frequently enough the elisease is acquired in earlier years as a resuit of traumatism during labor, of early infantile diseases (such as scarlet fever, pneumonia, cerebrospinal meningitis, etc.), or of direct injury to skull and brain. Unfortuiiately the epileptie attacks, if long continued, become asso- ciateel with mental changes, chief among which are impulsive actieuis of great Adolence at about the time of an attack, or as an équivalent of a motor convulsion ; a psychic explosion may take the place of an ordinary motor elischarge. Such actions are often committed in a semi-conscious or Avholly unconscious state, and the epileptie who has committed an outrageons murder has been found asleej) by the side of his victim, or as the epileptie seizure passes aAvay awakens to a full sensé of the atro- cious crime he has committed. The act of the epileptie generally bears the imprint of a great sudden impulse. Lombroso has tabulated the records of 297 epileptie; prisoners, and of thèse 76 were imprisoned for murder. The statistie-s of Baer (p. 306) are much more favorable, but it is epiite evielent that relatively few epdeptics were turned OA^er to his institution. Epilepsy is uncommonly fréquent in criminals, and the reason is not far to seek : in the criminal classes there is a elistine-t tendeney to the severer neuroses, of Avhich epilepsy is one ; alcoholism is a powerful etio- logical faed.or, * and among thèse classes alcoholism is the rule ; and in- juries to the head are also fréquent enough as a resiilt of direct blows or of falls in childhood due to carelessness. The epileptie boy is unable to attenel school, cannot retain positions, and thus falls an easy victim to bad associâtes. But the criminal actions of an epileptie are not neces- sarilv the resuit of his disease, though the disease and the criminal tend- ene-ies may both resuit from faulty inheritance and faulty training. Crimes committed in an epileptie paroxysm are signalized by great sud- * Dejerine states that in 37.7 percent, of 350 epileptics the father was a drunkard. (L'Hérédité dans les Maladies du Sijstcme Nerveux, p. 115.) 200 A SYSTEM OF LEGAL MEDICINE. denness and Adolence of impulse ; their eharaeter suggests the équivalent or torce of a motor explosion. It is not an easy matter to prove epilepsy, for in nine cases out of ten the diagnosis rest s on hearsay eAudence. The attae-ks are extremely short, and the physician rarely enough (except in publie- institutions) sees the attae-ks ; lie has, therefore, to dépend upon the description given him by compétent attendants or observant laymen. In a genuine attack there are sudden loss of cenise-iousness ; the e-pileptic cry; convulsive movements of one or ail parts of the body ; biting of tongue, with bloody froth at mouth ; involuntary micturition ; relaxation of ail mus- cles, followed by sound sleep ; the entire convulsive period is of Aery short duration. There are but few tangible symptoms of the disease to be made out during the interval—the very time in Avhich it is often désirable to détermine whether or not a person has epilepsy. As slight évidence of the existence of this disease we may regard the trae-es of lacération of the tongue during the attack; but a feAv days after an attack thèse may not be visible. The évidences of bromism suggest that the drug may hâve been given for the disease', but such évidence must be accepted very guardedly. Moreener, the epileptie attack has been simu- lated so perfectly that the most careful observers hâve been deeeived* Sander (Geistesstorungn.Verorechen, p. 236) relates the mteresting case of an epdeptic aged twenty-nine, who was arrested several times in suc- cession for creating great disturbances on the streets of Berlin, of which he Avas only partly conscious, and for violence against policemen and others who attempted to subdue him—evidently a condition of epileptie mania. This same epileptie was charged by his mother with criminal viedence, breaking everything in the household that he could fasten upon, and assaulting his mother. When charged with this he was ignorant of much that had passed, and did not remember that a policeman was prés- ent in his mother's house. At a later period he attempted to choke his mother in a maniacal attack. Epdeptic violence and forgetfulness are Avell illustrated in this man. It is important to remember that if epilepsy is long continued a con- dition of mental imbecility or dementia is developed, during which im- moral or criminal actions are possible; furthermore, states of demble consciousness occur in epdeptics, not unlike the case of Dr. Jekyll and Mr. Hyde ; and for criminal acts committed during the states of altered consciousness the accused can hardly be held responsible. MORAL INSANITY. Alienists hâve waged a hot battle o\rer the question whether there is or is not such a disease as moral insanity.t That a condition exists in which defect or perversion of the moral sensé is the most prominent symptom there is no doubt, but the best authors of the présent day are agreed that there is no one disease characterized solely or even chiefly by the deficiency in the moral sphère without impairment of the inteî- * This is the famous case of the "dummy-chucker," who had studied epilepsy in prisons, and was able to imitate the epileptie attack perfectly. He would feign an epileptie attack on the streets, and while the crowd stood around, his boon com- panions were busy picking pockets. t For an explicit account of this struggle see Wharton and Stillé, p. 532. INSANITY AND CRIME. 201 lectual faculties as well. Maudsley (p. 58) not many years ago went out of his way to défend the rights of moral insanity. " It may be witnessed even in young children Avho, long before they hâve knoAvn Avhat vice meant, hâve eAunced an entire absence of moral feeling, with the active display of ail sorts of immoral tendencies—a genuine moral imbecility or insanity." But the author is compelled to add that " associated with this defect there is frequently more or less intellectual deficiency, but not always; it sometimes happens there is a remarkably acute intellect with no trace of moral feeling." The " acute intellects " are rare indeed among moral imbéciles, and such acuteness as there may be is overshad- owed by huge defects in other directions. Those who wish to establish moral insanity as a spécial form of men- tal dérangement claim that the moral sensé is distinctly hereditary. But this is scarcely conceivable. The moral sensé is the highest faculty of man ; it is not a quality inhérent in the brain of man, but is in reality a highly complicated concept resulting from the daily expériences and teachings of parents and teachers : if such teachings hâve not been given the moral sensé Avili be but poorly or not at ail deA^eloped ; if the teach- ings fall upon a déficient intellect, upon soil not fit to receive them, they will bear but little fruit, and the moral sensé will not be developed. Idiots and imbéciles are naturally afflicted with moral insanity and with much more in addition. Imbéciles of minor degree may conceal their intellectual defects, but the moral defect stands out prominently ; such imbéciles lack the power of absorbing those higher concepts which are essential to the eleArelopment of a high moral sensé. Meynert (Geliim u. Gesittnng, Vienna, 1889) was surely correct in his opinion that the seat of the moral sensé must be looked for in the entire hémisphères, in the mechanisms of association, the bearer of intelligence in gênerai. The moral sensé represents the highest function of the hu- man brain, and for that reason, on well-known principles of évolution and dissolution, it is the last (the most difficult) to be acquired and the first to be lost from disease. The loss of morality may therefore be notice- able before intellectual décadence has set in ; it often opens up the scène, but other symptoms Avili follow before the entire sad drama is enacted. As Lloyd (J. of N~erv. and Mental Disease, 1886, p. 681) puts it : " The doc- trine of * moral insanity ' proceeds upon an abstraction . . . that there is a moral • faculty ' . . . which may remain uneleveloped in a mind other- wise healthy, and may become diseased without at ail affecting the health of the other • faculties.'" Meynert (Psychiatry, trans. by Sachs) hits the nail on the head in saying, " It is taking altogether too simple a view of things to regard morality as one of man's talents, and as a definite psychiatrie property Avhich is présent in some persons and lacking in others ; " and lie quotes Weissmann, who holds that talents are the combi- nations e>f many and widely différent faculties. While the présent writer is thoroughly couAdnced that the defect in morality is to be ascribed primarily to an intellectual defect, it is but fair to say that opposing aucavs are held by many prominent authors : Lom- brose», Maudsley, and Hack-Tuke Avili not sacrifice "moral insanity" to any théories regarding the true nature of such defects ; and even Krafft- Ebing recognizes the propriety of adhering to the clinieal form* * In criminology moral insanity plays a very important part. 202 A SYSTEM OF LEGAL MEDICINE. The justice of the clinieal claim cannot well be denied—for cases do occur in Avhich the moral defect overlaps ail else—at least until a e-areful examination has established other mental detie-iene-ies. It is positive; that feAV médical authorities of the présent day will subscribe te> the doctrine of moral insanity as first established by Prite-hard ( Treatise on Insanity, 1842), and adopted later on b}' many French anel English authors. But if the term is to be used, it will be well to restrict it at least te> those cases in Avhich the defectiA-e moral sensé is the most striking symptom. Seune years ago I saw at a elinic a young man avIio had be'en arrested for an assault upon his mother, Avhom he hael faih'd te> kill. He Avas entirely indiffèrent to the charge brought against him, and when asked Avhether he thought it Avas proper to kill a mother, answered, •• You might as Avell kill your mother as any one else." On further examina- tion it Avas found that the man had received no intellectual or moral training, had received no religious instruction, had groAvn up among the most elegenerate of mankind, and had neAer receiA*ed the most ordinary moral teachings. Naturally the moral sensé Avas déficient. The case would fall easilv enough under Mendel's ("Moral Insanity," Eulen- burg's Real-Encyclop., 1S88) définition of moral insanity as that form of insanity Avhich is either congénital or acepiired in the earlier years of life, and is characterized by imbecility, associâtes! Avith a morbid tendeney to immoral actions. BinsAvanger's (YoTkmann Summlung, No. 299) view is unquestionably the nmst correct: that a number of mental diseases may lead to " moral idiocy.'7 A single example will illustrate the condition of moral insanity ; the case is reported by Krauss (FriedreicWs Bliitter, vol. xxx viii.) : " A girl twelve years old, daughter of a seamstress, stole the earrings of a eliild three and a half years old to buy sweetmeats Avith the proceeds of the sale, and threAV the child out of the window. The child died of fractured skull. The murderess seems mentally and physically the equal of children of her âge. The face has a distinct canine expression ; she Avas ahvays unemotional, lazy, and Avoidd steal sweets ; at the âge of four she Avemld pierce the eyes of rabbits, and Avould rip open their bel- lies. She knoAvs that it is Avrong to do certain things, but has no ethical feelings ; she felt no remorse over the murder of the child. The prose- cuting attorney inferred that she knew the nature of her crime and its penalty. The court sent lier to a reformatory for eight years, overruling the testimony of experts as to her détective moral condition." This was moral insanity if you choose, but it included a distinct defect of judg- ment and of ail the intellectual functions. PARETIC DEMENTIA, DEMENTIA PARALYTICA, OR GENERAL PARESIS OF THE INSANE. Considering the unusual and increasing frequency of dementia para- lytica, it leads less frequently to crimes than many other forms of in- sanity. This is accounted for by the rapid weakening of ail the faculties, which does not permit the lunatic to e-arry ont any Avell-designed plan of revenge or the like. Such acts as he commits are more apt to resuit from loss of reasoning, from carelessness. or from the exaggerated notion of his own prowess which the paretic entertains in the earlier stages of INSANITY AND CEIME. 203 the disease. He is met Avith more often in cIauI than in criminal courts. Sepiandering of money, neglee-t of Avife and children, false promises of marriage, lack of testamentary capacity, cause innumerable suits aud complications. Yet the incivased sexual appetite, the feeling of inordi- nate strength, maniacal excitement, leading to deeds of violence, often enough make the paretic a criminal. Crimes are perpetrated, as a rule, during the earliest period of the disease, at a time Avhen the gênerai symptoms may be so slight that eATen experts may differ as to the existence of the disease. It is therefore of spe'cial importance that the médical man and the lawyer understand the symptoms anel course of the disease, and, above ail, the signs of the pro- dromal period. The disease begins, as a rule, in a very insinuating fashion ; it attacks men more frequently than women, setting in, as a rule, between the âges of thirty-five and f orty-five years ; exceptionally it may begin much earlier. I hâve seen it begin at the âge of twenty-one years, anel one author has reporteel a typical case in a girl of sixteen. In a very large proportion of cases syphilitic infection has preceded, sometimes by many years, in other cases only by a few months or a year. Syphdis is the predispos- ing cause—not, as a rule, the direct exciting cause. The greater struggle for existence, the cares and responsibdities of business, Avorriment Avith overwork—not overwork alone—thèse are the chief causes that help to develop the disease. As men are more exposed to ail thèse influences, we can understand why gênerai paresis should be more fréquent in them, and why it should be more fréquent among negroes now than it was while they were in slaArery. A very slight e-hange in the eharaeter and morals of a person, in his business methods and habits, may be the first indication of paresis. The father of a family, always most correct in his habits, takes to drink, forms low associations, is found in houses of prostitution, gambles for high stakes. The merchant becomes careless in his accounts, in signing checks, in his treatment of his surroundings ; is unusually irascible to- ward his employées, or treats them with absurd considération. A patient of mine, who never bothered about the comfort of his factory-girls, or- dered ice-cream and lemonade every afternoon for the girls in his employ, and insisteel on their working only a very few hours each day. Such signs may appear tri\dal, but a change in a person's behavior without suffieieuit reason may be sufficient to justify the physician's fears. Before long the morbid eharaeter of the change will become apparent enough, as the disease is rapidly progressive. With the advance of the disease two distinct sets of symptoms are manifestée!. Thèse are partly psj^chic and partly physieal in nature. The psye-hic cemdition is characterized by a progressive weakening (de- mentia) of ail the faculties; memory and judgment become seriously impahvel ; the paretic may be in a melancholy, hypochondriacal mood, or in a e-ondition of exaltation with delusions of grandeur : he is the riche st man in the world ; owns ail the shops, every railroad in the coun- try ; lias innumerable mines, and is going to build houses—as an unfor- tunate' architect, a patient of mine, claimed—covered Avith gold, and con- taining diamond, not glass, Avindows. The delusions are not systematizeel. He says he is rie-h, but does not act the rich man. He is king, but does not exact homage from his subordinates. There is a progressive deteri- 201 A SYSTEM OF LEGAL MEDICINE. oration of ail the faculties until a complète dementia is developed, and the man, once intelligent, is nothing more than an animal organism ; animal-like in his appetites, and cemtenteel if thèse are satisfied. The physieal signs of gênerai paresis are inequality of the pupils ; failure of the pupils to react to light—sometimes both to light and dur- ing accommodatiem; tremor of the tongue and of the facial musch-s ; tremor of the hands ; awkAvardncss in ail movenu'iits ; great difficulty in buttoning clothes, in writing, in Avhistling, in playing of instruments. Spe'ee-h becomes tremulous, hesitating, anel defeediA'e ; words are slurrcd and run into each other; senteuices are begun and not finished ; in re- peating sentences A\rords are omitted; the legs groAV Aveak, and loce>me>- tion may become difficult or altogether impossible. Both the mental and physieal symptoms are progressive, and often in e-enirse of two or three years, during which time epileptie and apoplectic attacks may océan-, death ends the sad career. The physieal symptoms often précède the mental, and for this reason the greatest importance must be attached to them ; and during the earlier periods, too, excesses and crimes are apt to be committed in the feeling of exaltation or during a maniacal attack. The siUiness of the criminal act, the failure to conceal the deed, ofteui point to gênerai paresis. Magnan* refers to a paretic who asked two policemen to help him remove a full barrel of Aviné lying in front of a Avine-dealer's shop. If caught in the act and called to account, paretics either deny the theft or give some silly excuse, shoAving that they do not appreciate the gravity of the situation. They are apt'to pick up anything they can lay hands on, and in asylums either take things délib- érât ely from other patients, pick up paper and cigar-stumps, or peu-ket every sort of rubbish. At times thèse patients are tricky. A patient of Mendefs gave a "box of cigars" in payment of a debt ; instead of ci gars the box contained potato-peelings, which he claimed ged into the box in some Avay unknoAvn to him. Exposure of the person is a very fréquent occurrence; masturbation in public, particularly in the présence of women and children, is common enough. Westphal (Arch. f. Psych., vol. aul, p. 622) mentions a paretic forty years of âge Avho directed the attention of girls between the âges of eleven and thirteen years to his pénis, and used obscène language in doing so. A patient of mine invitée! the servant-girl into his bedroom at night, and attempted sexual inter- course Avith her in the présence of his Avife. Not a few hâve invited prostitutes to their oavu homes and introduced them into their families. Capital crimes are not freepient; if committed, the motives are either wanting altogether or extremely silly. A laborer aged forty-six years murelereel his wife because lie wished to enlarge his business and his wife was not his equal; he then wished to take his own life. After the mur- der he tells his neighbors that his wife died. He denied the murder at first, but later on became entirely indiffèrent. Thèse cases are sufficient to illustrate the importance of diagnosticat- ing the early stages of gênerai paresis. * Full literature to be found in Mendel's Monograph. INSANITY AND CEIME. 205 TOXIC INSANITIES. Alcohol, morphine, and cocaine are the three toxic substances Avhich, if taken in excess, produce serious disturbances of the central nervous system. Mental dérangement is a common effect of the long-continued use of thèse poisons, and crime is its mifortunate accemipaiiiment. Alcoholism.—The evil influence of (dcoholism is not sufficiently rec- ognized by the laity or the médical fraternity. Social custom has, in most countries, sanctioned the free use of alcohol ; the occasional drunk- ard is despised everywhere, but the man Avho poisons his system with alcohol day by day, without at any time putting his intoxication in évi- dence, is not censured for the habit, although he is even more certain than the occasional drunkard to develop the serious form of chronic alcoholism. In this country whiskey and rum are the deadly poisons, but Aviné and béer hâve their victims as well. A reaction, and a healthy one at that, is unquestionably setting in ; even in Germany the eAÙl effects of chronic alcoholism are now recognized and publicly discussed. Striimpell lias set forth the degenerating influences of alcohol upon the German people, and another physician lias asked the médical fraternity in Germany to set the example of absolute abstinence in order that others may take heart and free themselves from this overpenvering vice. This is not the proper place to décide whether total abstinence or moderate use of alcoholic liquors is in order ; we must, however, take into account the relation of crime to chronic alcoholism. In Germany, it is claimed, fully fifty percent, of ail crimes are com- mitted under the influence of alcoholic excesses ; in England and America the percentage is no doubt equally high. As ewery person is in a meas- ure responsible for the vice to which lie has fallen a victim, the question arises whether lie shall be declared responsible for deeds committed as a resiilt of such vice. The vice is so common among the sane criminal classes that to accept alcoholic intoxication as an excuse for crime Avoulel be placing a premium upon his misdeeels. Alcoholism can be an ex- cuse for crime only if it lias led to the deArelopment of an insanity, of a distinct form of mental dérangement ; and if so the alcoholist is as little responsible for his deeels as the paretic criminal is whose paresis is the resuit of syphilis. On the whole, the courts in various States of the Union hâve taken this view of the subjee-t : that intoxication is no excuse for crime, but that insanity resulting from long-continued drunkenness is an excuse for crime. (See Lawson, chap. iii.) The médical expert and the jurist shoulel therefore hâve a clear understanding of the symptoms of alcoholic insanity. The first and most prominent resuit of chronic alcoholic poisoning is a progressiA'ely increasing Aveakness of ail the psychic functions, a de- generation of the moral and intellectual facidties. The chronic drunk- ard becomes neglectful of his family and his business. Society despise's him, and he despise>s ail those avIio interfère Avith him ; he may lead his family to staivation, but he cares little as long as his morbid craving may be satisfieel ; he becomes irritable anel brutal, not only when under the immédiate influence of the drink, but particularly during a period (howcA-eu- short) of abstinence. In the early morning hours he is most apt to be irritable', ugly, and dangerous te) his surroundings. He endeav- 206 A SYSTEM OF LEGAL MEDICINE. ors to rid himself of the habit, but does not possess sufficient energy, and gives up the fight in despair. As the elise'ase or the habit takes a firmer hold he becomes stupid, Ave'ak-minded, obtuse ; his meunory for- sakes him, and he soon becomes thoroughly helpless. His sleep is restless, and both day and night he is troublée! by ail sorts of disagreeable visual hallucinations. He becomes suspicious of his surroundings, and devel- ops complète delusions of persécution. The delusion of marital infidelity is so common as to be Avell-nigh pathognomonic of this condition. There are physieal symptoms, also, Avhich are characteristic of the alco- hohY state : paiwsthesia and formie-ation in the extremities ; tremor and weakness of hands and legs. Tremor of the tongue and of the face- muscles appears quite early in the disease ; also fibrillary twitchings of the tongue and disturbances of speech. Among the later symptoms are loss of pupillary réflexes, loss of Ausion, and even e-pileptic seizures. The crimes of the chronic drunkard are either the resuit of his degen- erateel morals and of his gvneral intellectual weakening, or the resuit of uncontredlable passions and émotions. In some instances the delusions of infldelity and the delusions of persécution may lead te> ae-ts of re venge. Such delusions are occasionally developed after an acute intoxication. A patient of mine—a man of fine intellectual qualifies—celebrated the departure of a friend for Europe by an •• old-fashioned spree," as he called it. On his way to this city from Hedjoken he claimed he fell in with a woman who had a chdd with her. This child he had hurled into a stove in order that he might be alone with the woman, and he was cer- tain that the police were after him (as a matter of fact he was breuight home safely by an acquaintance). For a long time after this occur- rence lie was certain of the reality of his belief, for people on the elevated radway pointed at him with scorn anel made ail sorts of remarks about him : •• There he goes—the murderer," *' He is pretending to be a gentle- man," etc. It was very nearly a year before thèse delusions entirely dis- appeared. Such delusions as thèse may lead either to suicide or homi- cide (revenge for persécution). Krafft-Ebing (p. 188) records a Arery typical case, which I summarïze as follows : A locksmith thirty-six years of âge ; married nine years ; two children ; addicted to drink from early youth ; suspected his wife of in- fidelity ; neglected his work ; Avas irritable and brutal toAvard his wif e7 maltreated her, and on one occasion almost killed her in a fit of passion ; Avas sent to prison, but was not eonvicted, as he was declared insane. Three years later threatened his wife again, and was brought before court ; accused his wife of being a Xanthippe (particularly on Sundays, Avhen he was drunk), and of infidelity, which he was certain of because she was aAvay too long on errands, flirted Avith men, etc. ; but his wife Avas a décrépit, exhausted, but respectable woman. His wife removed him from the asylum ; in a fit of temper a few weeks later he smashed her skull and endeavored to kdl himself by ripping open his own belly ; lie showed no remorse for his deed, and excused himself on the plea of his wife's (supposed) infidelity and her quarrelsome disposition. During the period of abstinence crimes may be committed, as illus- trated by the following case : DreAv, the captain of the ship, had murdered the second mate. " It appeared that for a considérable time before the fatal act DreAv had been in . . . almost continuai drunkenness; that about five days before it INSANITY AND CEI ME. 207 took place lie ordered ail the liquor on board to be throAvn overboard, which Avas accordingly done ; . . . soon afterward became restless ; . . . expressed his fears that the creAV intended. to murder him, and com- plaineel of persons who were unseen . . . urging him to kill Clark. The night bcfetre the act he Avas more restless, seemed to be in great fear, and Avhenever lie lay down there were persons threatening to kill him if lie did ne>t kill the mate." (LaAvsem, p. 601.) Judge Story recognized the insanity in the case, and declared the act not to be that of a reasonable being. Criminal acts are alse> committed during the condition of delirium tremens, a condition of exhaustion Avith maniacal excitement in which the person is totally unconse-ious anel irresponsible for his actions. We need not give illustrative cases of tins condition, nor of the condition of alce)holic epiïe])sy, which oce-urs in almost ten percent, of ail chronic alco- holic cases. Like other epileqdic states, this one is attended by impulses of the most violent eharaeter, in whieh the alcoholist may kill wife or brother without being aAvare of the eharaeter of the deed. Crothers, of Hartford, has called spécial attention to the conditions of trance and som- nambulism in chronic ale-ediolists. Morphine Habit.—Morphine is not as powerful a poison as alcohol, and, fe>rtunately, the use of it is not as widespread as that of alcoholic stimulants. But it has fully as stroug a hold upon its victims, aud leads even more rapidly than alcohol does to a degeneration of the entire nerv- ous system and to mental imbecility. The habit is engendered in many différent way s. 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, anel the very craving establishes the pain. Druggists, phy- sicians, physicians' Avives, and nurses fall \dctims most easily to this scourge, because they can easily get as much of the drug as they wish. The system becomes accustemied rapidly to the drug, and huge quantifies can be taken without immédiate; danger to life, though many a morphine habitué lias met his death by an accidentai OA'erdose. The condition produced by excessive use of morphine varies in différ- ent individuals. As a rule there is at first great irritability of temper, excessive restlessness (allayeel for a time by each fresh dose), lack of energy anel application te> Avork, a distinct loss of memory, which may ultimately lead to complète apathy and imbecility. Early in the career of the morphine fiend a gênerai depra\dty is noticeable : he shows a dis- regard for truthfulness, and will resort to any subterfuge, even to steal- ing, to get his drug. Ne) trick is too despieable for the person who craves morphine and cannot get it. Even iu hospitals it is a common practice to bribe attendants—te> make the most extravagant promises if they will see-ure the deadly poison for them ; but when the physician questions the patient he is absolutely ignorant of any attempt at briberv. While eA'eiy person may be held responsible for the beginning of the habit, the continuance of the habit removes such responsibility. The misdeeels of a morphine habitué e-an, henvever, be attributed to the habit only if he e'xhibit distinct symptoms of morphine insanity. He must présent some such condition as Avas referred to aboA^e, and a few of the physieal symptoms; among thèse the most important are tremor, ataxia-, myosis, pred'usé sweating on the least exertion, nausea, and disgust for 208 A SYSTEM OF LEGAL MEDICINE. ail animal food. Furuncles in the skin and abscesses Avili give semie idea of the frequency of the practice. The Avorst crimes' are not often the resiilt of the morphine habit, but petty crimes are ail the more fréquent. Physicians avIio use morphine on their own persons in large quantifies bee-eune extremdy cardess in prescribing this aud other drugs for their patients. Ne> one av1h> use>s morphine habitually can be e-onsidered to be in a normal mental state-, for his condition varies Avith the quantity of morphine lie lias in his systeun. As soon as the period of abstinence is reached he is possessed by a spirit of restlessness Avhich makes him thoroughly irresponsible and incapable of sober reasoning. A common offense among morphine habitués is the forging of pre- scriptions calling for morphine, or the theft of morphine from the office of physicians or from the shelves of the druggist, Erlemneyer (p. 214) reports the case of a young woman avIio forged the prescription of a physician calling for 1.2 morph., which the patient changed to 6.2 ! adding the exclamation-mark which the German laAv demands in case of large' doses; the patient Avas sent to prison for ten days. Like alcohol, morphine leads to neglee-t of business, to loss of social position, and to poverty. In this condition a person who Avas once en- tirely honest Avili resort to petty thefts, perhaps to help his family, but more often to secure money enough to buy morphine for himself. The gênerai depravity of morals Avhich the morphine habit entails is the saddest symptom of ail. 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 the use of morphine'. He endeaATored to free himself from the- habit, but had not the moral courage to do so. In former days too proud to accept a f aAT>r of any one, lie allowed his relatives now to support him and his family. The mère use of morphine is not a sufficient excuse for crime unless the distinct symptoms of morphine psychosis are présent. 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 Avas twenty-nine years of âge, an illegitimate child; father unknoAvn ; history of insanity in mother's family. With exception of syphdis the prisoner had no illness ; did satisfactory work as hospital nurse during a period of fourteen months ; in this time practiced daily hypodermie injections of morphine, began to sleep poorly, Avas depressed (love-affair in addition), and Avas not quieted by morphine. September 12,1887, he was severely rebuked for his relations to a female nurse, anel discoArered that one A. had told on him. He desired to avenge him self at once, but took morphine injection instead ; the very next morning, how- ever, he stabbed A. while in bed and fired four bullets into his OAvn body. Immediately after the act he appeared normal, and exhibited no absti- nence symptoms on the absedute AvithdraAval of the drug—no physieal anomalies, and no stigmata of degeneration. The experts declared that morphine habitués must be diAdded into two catégories : in the one class we must place individuals Avith tainted ancestry and a tendeney to neu- roses, avIio are impelled to the use of Avarions poisons, such as morphine, alcohol, or cocaine ; the other class is made up of individuals avIio dis- cover the charms of morphine accidentally during a painfid illness and INSANITY AND CEIME. 209 then become addicted to it. In this spécial case the experts declared that the prisoner exliibited only slight symptoms of the morphine habit, that there Avas no trouble on withdraAving the drug, and that the use of morphine in his case did not in anywise affect the question of respon- sibility. He Avas found sane, and Avas cemdemned to five years at hard labor. (Contagne et Bernard, Archiv. de VAntliropol. Criminelles, vol. a\, No. 25.) The cocaine habit is the most récent affliction of man. It is en- gtuidered accidentally in the majority of cases. I hâve known it to re- siilt from the application of the drug to the nostrils, the patient continu- ing in private Avhat the physician practiced upon him in his office for the purpose of tr eating the membranes of the nose. The sensation of apply- ing it is distinctly disagreeable, but the habit is easdy deAxdoped Avhen once begun. Tliose who hâve been addicted to morphine or ale'ohol, 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 gênerai symptoms are very much the same as those of morphine insanity : horrible visual and auditory hallucinations, dedirium of persé- cution, visions of small animais. Intense restlessness and sleeplessness, nausea, and anorexia are the chief symptoms. In one case' of mine a patient who had passed with the usual success through a Keeley cure was alternately addicteel te> alcohol and cocaine ; he was unfitted for business, was constantly and naturaUy at loggerheads with his farnily, neglected Avife and children, and Avas a burden to his home untd he con- quered both habits, at least temporarily. It Avas my sad duty some years ago to treat a bredlier physician Avho had rid himself of the morphine habit and fell victini to e*ocaine, then lapsed into morphine again ; he con- tinued both drugs, was utterly unable to attend to his practice, became poverty-stricken, and finally committed suicide. The drug does not fascinate the individual as morphine does, nor lias it, te> the Avriter's knowledge, led to any serions e;rime as yet, except that of negleeting one's family and of leading to suicide ; but let it be con- tinuée!, and the danger of criminal acts on the part of the cocaine habitué becomes probable enough. HYSTERICAL INSANITY. In my lectures to physicians on nervous diseases, I am in the habit of saying that hysteria in this country is a rare form of disease. Startling as'this statement may seem, it is absolutely true if Ave restrict the term to the graver form of the disease, and de) 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 fréquent among the Russian, French, and Italian cléments of our mixed population. The aggravated forms of hysteria are most common in France, and ha\re been studied most earefully by French médical Avriters, aboATe ail by Charcot and his fol- loAvers. " They hâve created the modem conception of hysteria. Hysteria proper, la grande hystérie, the condition Avith which Ave are most 'concerned in tins article, is characterized by an unusual develop- nie'iit of the emotional facidties. The slightest cause is sufficient to 210 A SYSTEM OF LEGAL MEDICINE. produce great emotional disturbance ; there is a continuons alternation betAveen pleasurable and depressed moods, the latter prepemde-rating. Hypochondriacal tendencies are common. Every sensation, lmwever slight, is turned to account; danger and ill health are ahvays impending. By close observation of their own physieal condition, patients bee-ome egotistical and sedfish to an unusual degree. Ewry e»ne is maele to dance' attendance upon them, and from their oavu selflsh i>oint of view they are the pivot about which everything turns. They are ever mindful of themselves and culpably indiffèrent toAvard edhers. If the family groAv calions toward their sufferings, they exaggerate thèse, aud Avili simulât e ail sorts of conditions ; will run any and every risk (turn on the gas, swallow glass, needles), will do anything to attract attention ; will de- liberately commit suicide for the sake of a moments notoriety, in which they are often aided by our sensational press. If they fail in such efforts, hysterical indhdduals (men as well as women) become revenged'ul, and if the excitement increases (in women at the time of menstruation more particularly), deliria and delusions of persécution may be developed. The sexual sphère is frequently invoh^ed, and under the influene-e of erotic delusions respectable Avomen may prostitute themseh^es or imag- ine themselves the victims of man's sexual passion. False accusations and denunciations are the accompaniment of this condition. Mysteriems cases of râpe that hâve baffled the police hâve been explained as the re- suit of erotic delusions on an hysterical basis. In the condition of ex- haustion associated with severe hysteria, morbid impulses arise whieh may lead to offenses against the law. Hystérie;al Avomen, in their ego- tisni, learn to despise their offspring; one such mother told me that she hateel her child, and could kill it for the pain it gave her during laben*. The responsibility of an hysterical individual will hâve to be ded.er- mined in each individual case ; to say that a person is hysterical is surely no sufficient excuse for crime. In every case the évidence of severe hys- teria should be required. This can be accepted only if the person lias been subject to severe hysterical manifestations for a long period of time. Chief among thèse are : unusually violent anel sudden changes of moods ; hysterical fits and hysterical trance conditions provoked by pressure upon hysterogenic zones. And in addition there are a few physieal signs of importance : marked vasomotor disturbances, anaesthesia of one half of the body, with distinct involvement of ail the spécial sensés in that half, or patches of anœsthesia irregularly distributed over a large portion of the body. Thèse objective symptoms will prove to be of great Aralue in a given case. They will help us to differentiate between a mère " hys- terical" individual and one suffering from hysteria major. Hysteria of a grave order, hereditary hysteria in particular, is the mark of a gênerai psychic degeneration, and as such is often associated with more serious mental disturbance. The folloAving examples Avili suffice to illustrate the forensic importance of hysterical insanity : An unmarried woman thirty-eight years of âge accused her father that he alloAved another person to enter a room occupied by herself and sister, and that this person raped both of them; ''for two years she lias been pregnant by this man." She was not allowed to bring suit, se> she armed herself and meant to waylay the offender. She Avas sent to an asylum, where she improved. On her dismissal she met a laAvyer, who thought her sane and began suit against the father and the director of INSANITY AND CEIME. 211 the asylum for illégal détention ; but her insanity was recognized. (See also Mord, p. 687.) From Hammond I take the folloAving case: "In 1873, says M. Hu- chard, Mlle, de' M., aged eighteen years, accused the vicar of the parish of having e-ommitted a râpe upon lier. She stated that on such a day and at such an hour, Avhile she was saying lier prayers in chureh, the vicar, after having shut ail the doe>rs, approached lier and requesteel her to go Avith him into the sacristy. There lie hael maele, she declared, indécent proposais to lier, and, as she repelled him Avith indignation, he had pointed a dagger at her heart. She had fainted, and when she recovered her sensés she disceivered that she hael been violatod. During the trial of the accused jiriest the médical experts questioned her in regard to the modus fariendi, and as she answered by giving childish détails, she was submitted to physieal examination, with the resuit of ascertaining that she Avas a virgïn, and that there were no traces of violence." " Tardieu reters to a récent case, that of a young girl, an inmate of a coiiA'ent in Gase-ony, who persuaded her father that she had been made the a ie-tiin of ail kinds of tortures and unheard-of outrages. He, believ- ing what she said, Avent before' the authorities and elenounced the alleged perpetrators. Finding, hoAvever, that she had deceived him, not a word of her story being true, he took his life from chagrin and mortification." To the above might be added another case, also citeel by Hammond, in which the termination was sad enough : " The Marepiise de Prie, mistress of the Duke de Bourbon, was exilée! from court, and, of course, indifférence and neglect followed her in her retreat. She, hoAvever, resolved to regain, by a coup de théâtre, the favor she had lost. She aniiounceel that ou a certain day of the month, and at a certain hour, she would kill lieu-self. Every one was amazed at the déclaration that one so young, beautiful, and attached to life contem- plated suicide, and the hcavs Avas received Avith dérision. During the few days intervening, the marquise gave several fêtes, at which she danced, played, and aniused herself as in the days of lier highest favor. No one had ever seen her gayer, more spirited, more adorable. The hour arrived. She called the new loveu- she had chosen to lier side, and again announced her détermination. The e-ommunication was recehred 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, lie humored her so far as to give her, Avith his own hand, the draft she had pre- pared. It Avas in reality poison, and she died before assistance could be given." NEURASTHENIA. Neurastheuia is so common a disorder among men and women of our busy Avorld that it has become a AveU-recognized form of elisorder even among the laity, under the terms of nervous exhaustion, nervous prostra- tion, and the like. It Avould hâve little foreusic importance were it not for the- fact that it is freepiently the first sign of an inherited taint, and that it represents at times the first stages of more serious mental disturb- ances, such as hypoehondriasis, paranoia, and even dementia. In neuras- thenia, moreover, there are perieuls of excitement in AAdiich the individual is not fully responsible, and, aliène ail, morbid conceptions and morbid 212 A SYSTEM OF LEGAL MEDICINE. impulses are fréquent. Thèse hâve been fully deseribed in the intro- ductory pages of tins article. In former days, anel in many countries to this day, the kaw 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 resuit directly from such impulses, or the contin- uance of such morbid fears and impulses leads to a confusional condi- tion in which the sufferer becomes Avholly irresponsible. Spécial cases need not be cited, as the commission of crime is. after ail, rather rare, and neurasthenia should be ace-epted as an excuse for crime only if de- cided mental changes can be proved to hâve existed. HYPNOTISM. The discussions of hypnotism in the secular press are in inverse pro- portion to the impeu-tane-e attached to it by médical men the world over. Even in France, where the schools of Charcot in Paris and of Bernheim in Nancy hâve donc so much to popularize the subject, the médical men as a body hâve not faileel to ree;ognize the limitations of the subject. For the présent hypnotism is of greater theoretie-al than practical importance both from a médical and a foreusic point of view. Charcot, Kicher, and their folloAvers regard hypnotism as a cemdition similar to grand hysteria, whereas the foliowers of Bernheim hold that it is a cemdition proeluccd by mère suggestion, and that tins e-ondition can be exe-iteel in non-hys- terical as Avell as in hysterical subjects. The présent writer believes that ail " impressionable " indhdduals can be hypnotized. The novelists haAre maele much of thèse phenomena of hypnotism, both from an intrinsic psyediologic interest, and because it makes their task very much easier. It is fascinating, I am ce>rtain, to be able to change the characteristie's of one's hero at Avili, to subject him to ail sorts of occult influences, Avithout being called upon in the good old-fash- ioneel way to explain minutely how such changes were brought about. "Hypnotic influence" is a cemvenient subterfuge. In novels this influ- ence is generally exercised for evil, although Du Maurier, in the influence Avhich Svengali exercises over Trilby, makes an exception to this rule. 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, deprheel of his free will, Avould fortlr with proe-eeel to obey the suggestion. In médical circles sham murders (Avith wooden daggvrs) hâve been committed in obédience to such a sug- gestiem. The possibilitv of actual murder being committed cannot be denied. The practice should, therefore, be limited by law, and public exhibitions should be entirely prohibited. But, fortunately, no serious crime has as yet been committed, to my knowledge, in obédience to an hypnotic suggestion, and the efforts to proA~e hypnotic influences in récent French trials hâve faileel utterly. There is every probability, too, that the instigator to such a crime could be easily detected if the subject were rehypnotized by a compétent person or commission ap- pointée! for this purpose. In the hypnotic state information or hints would be given Avhich Avould lead te) the eliscovery; in the interval be- tAveen such states the subject would be ignorant of everything that had occurred. The suggestions made with evd intent during the waking INSANITY AND CEIME. 213 state are still of far greater importance than those issued to a hypno- tized individual. Before concluding this article, the Avriter Avishes to impress upon the médical man aud the jurist the following considérations : In determining the question of responsibility of an individual, the older tests of knoA\dedge of right and wrong, of free will, of prémédita- tion, should be disregarded altogether. The only duty the médical expert has is te) state and to prove whether the accused was or was not insane when the act was committed. To strengthen such évidence lie should be able to state the symptoms pointing to a spécial form of insan- ity, as he would be expecteel to state them in a case of pneumonia or any other purely physieal disease. Insanity should be a sufficient excuse for crime, Avhether or not a sane mind e-an f athom the relation between the insane condition and the criminal act. Crime committed by 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 référence to the proper method of examining in- sane criminals. The method employed should be very much the same as with other insane patients, bearing in mind that among the criminal classes, or those accused of crime, simidation is very much more fré- quent. But as simulation is discussed by another author I may disre- garel it altogether. lu examining a patient-or criminal, take note first of his surroundings, of his appearance, of his behavior before you enter, and whde you are Avith him. Note whether lie behaves under ex- amination as any other insane person Avould, and, above ail, a person with the same form of insanity. If the examiner has had considérable expérience in insanity it will be possible for him to speak very definitely on this point. A feAv years ago the Avriter Avas asked to see a prisoner who had en- tered the plea of insanity for his misdeeds in the commercial Avorld. He pretended te) be suffering from delusions of persécution, and refused to take the prison food. He insisted on cooking his oavh food, but took very freely senne medicine (an hypnotic) prescribed by the prison physi- cian—the A^ery last thing an insane individual woulel hâve done. Instead of referring to his persécutions, or of explaiuing why he should be persé- cutée!, he kept on saying that his head ached ; that " if lie could get down to Wall Street lie Avould make it ail right again." The man Avho spoke so freely under examination in private maintained absolute sdence and indifférence in e'emrt. The diseu-epaucy between his behaAior and that of the truly insane Avith such delusions was so différent that there was little doubt of simulation. It is best to enter upon the delusions of the insane, and to comrerse freely Avith them, as though the examiner Avère e-onvinceel of the truth of the premises. Avoid leading questions, but try to follow along the line of argument adopted by the insane, and in tins Avay the faulty rea- 211 A SYSTEM OF LEGAL MEDICINE. soning and faulty judgment will be' easily detee-te-d. It requires great patience on the part of the examiner, more' e-spe-e-ially in those e-ase-s in Avhich the person exaniined refuse-s to talk. As Avith the non-criminal in- sane, the conversation lias to be begun again aud again, or repcateel visits made, before a succe'ssful resuit is reaeheel. In some cases it may be necessary for the physician to disguise' his oavu person, orto appear under senne assumée! name' and in an assumed finie-tion, but the dignity of the professieui requires that this should be ave)ided whenever possible. Often, indeed, the very conduct of a peu-son knowing himself uneler examination gives the best clew to the actual mental condition. The crime of Avhie-h the person is accusée! should form the e-hief but not the sole topic of com-ersation, and the examiner must endeaA'or to get at the motives which inspirée! the criminal act ; also whether the accused feels any remorse, Avhether he Avould hâve the deed undone. And after this topic lias been exhausteel a gênerai examination should be made with the view of determining the person's mental capacity, his knowledge of other ewents, his memory, and his moral as well as religions vieAvs. The physieal examination is eepially important : the formation of the skull, his physiognomy, the action of the pupils, the présence or absence of tremor, his S4)eech, his writing, his gait, his heart, his gênerai physieal condition—ail thèse points should be earefully noted, and Avili help to form a definite opinion of the individual's mental status. But the sine qua non of a successful examination is that the examiner shoulel know what to look for, and that he should hâve had previous experieuce with the non-criminal insane. BIBLIOGRAPHE* Allison, "Am. Journal of Insanity," July, 1894. Baer, "Der Verbrecher in anthropologischer Beziehung." Leipzig, 1893. Benedikt, " Kraniometrie u. Kephalometrie." Lectures. Vienna, 1888. Benedikt, article on ''Cramai Measurements " in " Eulenburg's Encyklopâdie." Bucknill and Tuke, " Manual of Psychological Medicine." Caspcr-Liman, "Handbuch der gericbt. Med.," 7th éd. Charcot, " Maladies du Système Nerveux : Iconographie Salpetrière." Progrès médical of the last ten years—chiefly for hysteria and hypnotism. Clarke, "Heredity and Crime in Epileptie Criminal Brain," 1880. Contagne et Bernard, "Arch. de l'Anthropol. Crim.," vol. v., No. 25. Crothcrs, various articles in the "Journal of Inebriety," edited by him. Dcsjiinc, "Psychologie Naturelle." Paris, 1868-70. 3 vols. Dufour, " Virchow's Jahresschr," 1888, vol. i., p. 64. EUis, "The Criminal," "Contemporary Science Séries." Erlcnmeijer, " Morphiumsucht" (Morphine Habit). Monograph. 3d éd. Berlin, 1887. Esguiroi, "Malad. Mentales," 1838. Still worth Consulting. liricsiuger, "Pathologie u. Thérapie der Psychischenkrank.," 2d éd., 1861; Sydenham éd., 1867. Hack-Tuke. London, 1891. * This is not intended to be a complète list, but to include such works as hâve been eonsulted in the préparation of this article, and those which the alienist or the jurist would do well to consult in further studies on this subject. BIBLIOGRAPHY. 215 Hammond, "Treatise on Insanity," 1883. Hirsch, " Génie und Entartung." Berlin and Leipzig, 1894. Contains critieal studies in opposition to Lombroso's théories. Huchard, "Caractère, Moeurs, etc., du Hystériques." "Arch. d'Neurologie," March and April, 1882. Jolhj, article on "Hysteria" in "Ziemssen's Cyclopanlia." Kanc, "Alienist and Neurologist," July, 1882." Kirchhoff, "Lehrb. d'Psych.," 1892. Am. éd. by Wood & Co. Contains excellent photographie reproductions of insane faces. Kostcr, "Irrenfreund," 1875. Krafft-Ebing, " Gerichtliche Psychopathologie," 3d éd., 1892. A very full treatise, with ample références. See also communications in "Friederich's Blâtter," 187:2 and later years. Kurella, " Naturgeschichte des Verbrechers." Stuttgart, 1893. Lau-son, "Insanity as a Défense to Crime." St. Louis, 1884. An excellent légal summary. Legrand du Saulle, "La Folie." Legrand du Saulle, " Étude Méd.-Lég. sur l'Hystérie et sur le Degré de Responsabilité," etc. " Gaz. des Hôp.," 1859. Lloyd, "Journal of Nervous and Mental Dis.," 1886. Lombroso, " L'Uomo Delinquenti in Rapporto ail, Antropologia Giurisprudenza," etc., 3d éd., 1884. German translation by Fraenkel. Hamburg, 1887. Lombroso, " Neue Fortschritte," etc. German transi. Leipzig, 1894. Lowenfeld, "Neurasthénie u. Hystérie." Wiesbaden, 1894. Maudsley, "Responsibility in Mental Diseases," 4th éd. 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. Meynert, "Gehirnu. Gesittung." Vienna, 1889. Lecture. Also " Psychiatry " (transi. by Sachs), 1885. Moeli, " Ueber irre Verbrecher," 1888. More!, "Traité des Malad. Ment.," 1860. Nicol.son, "The Morbid Psychology of Criminals." "J. of Ment. Se," 1874, vol. xx. Prichard, " Treatise on Insanity," 1835. With especial référence to moral in- sanity. Ray, " Treatise on the Médical Jurisprudence of Insanity," 1860, 4th éd. Ro'binsou, TV. R., "Journal of Nervous and Mental Dis.," May, 1887. Rush, B., 5th éd., 1835. Sachs, B., "What the Law can Do to Mitigate the Evils of Médical-Expert Testi- mony." "N. Y. Med. Examiner," July, 1892. Sonder and Richter, " Geistesstorung u. Yerbrechen." Berlin, 1886. Schiile, "Psychiatrie," 1878. Smith, A., "On the Position of the Médical Fraternity with Référence to the Abuse of Alcohol." "Berl. Klin. Wochenschr.," 1894, No. 31. Sommer, "Beitràge zur Kenntniss der kriminellen Irren." "Allg. Zeitschr. f. Psych.," 1884, pp. 88 et seq. Sommer, " Ueber Trunksucht." Kônigsberg, 1888. Sj)it~ka, "Insanity: Its Classification," etc., 1883. Striinipell, "Die Alkoholfrage vom aerztlichen Standpunkte." "Berliner Kl. Woch- enschrift," 1893, No. 39. Taguet, "Du Suicide dans l'Hystérie." "Annales Méd.-Psychologiques," May, 1877. Tardicu, "Étude Méd.-Légale sur la Folie." Paris, 1892. Thompson, "Journal of Ment. Science," January, 1870. Thompson, "Psychology of Criminals." " J. of Ment. Se," vol. xvi. West)ihal, "Arch. f. Psychiatrie," vol. iii. and vol. vii. Wharton and Stiilé's "Med. Jurisprudence," 3d éd., 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 England recognized at an early day the existence of mental defect and disturbance, and in a rude and unscientific way attempted, according to the methods of the médical science of the time, a classification of its varieties and degrees. Coke, in the Commentary on Littleton (Co. Lit. 246b, 241a) and in Beverley's Case (d Co. Rep. 123&), makes the following distinctions: '• Hère Littleton explaineth a man of no sounel memorie to be non com- pos mentis. Many times (as it hère appeareth) the Latin word explain- eth the true sensé, and calleth him not amens, démens, furiosus, lunuticus, fatuus, stultus, or the like, for non compos mentis is most sure and legall. Non compos mentis is of four sorts: 1. Ideota, which from his nativitie, by a perpétuai! infirmitie, is non compos mentis. [Idiot or fool natural.] 2. Hee that by sicknesse, griefe, or other accident, Avholly loseth his memorie and understanding. [He who Avas of good and sound memory, and by the Adsitation of God has lost it.] 3. A lunatic that hath sorne- time his understanding and sometime not, aliquando gaudet lueidis inter- vallis, and therefore he is called non compos mentis so long as lie hath not understanding. [Luuatieas, qui gaudet lueidis interrallis, and some- times is of good anel sound memory, and sometimes non compos mentis.] 4. Lastly, hee that by his OAvne 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 Haie (Haie, P. C, chap. iv.) made a simi- lar but more eletailed classification. Mental defect and disease lie called dementia, the state of being out of one's mind. This lie divided into three great classes : I. Natural dementia, that is, idiocy, or fatuity from birth. II. Accidentai dementia or insanity. III. Voluntary dementia or drunkenness. In the se-cond' of thèse classes, that of insanity, he distinguished total from partial insanity ; the latter being partial in respect to its subjects, or partial in respect te) its degrees. Ile further took note that it was, as to its nature', at one time permanent, at another time e)ce-asioiial. The former he called phivne'sis or madness, the latter lunacy, from the con- temporaneous error that mental disease Avas influenced by the phases of 217 218 A SYSTEM OF LEGAL MEDICINE. the moon. In addition to the mère loss of the use or exercise' of reason, he recognized the further condition of a superaddeel state of violence or fury. This he called furor, rabies, or mania. However unacceptable thèse classifications may be to advane-ed médi- cal science (Prichard On the Différent Forms of Insanity, London, 1S42, p. 9), they form the necessary basis of any considération of the subjee-t from the légal point of vieAV, for, up te) the time of the answers given by the judges of England to the questions put them by the House of Lords in conséquence of the acquittai of Daniel McXaghten (10 Cl. & Fin. 200), the Avritings of Coke and Haie, together Avith the instructions given by judges in particular cases, constituteel the exclusive authorities on this subject. Although the law, speaking thus through its sages, lias attempted to classify according to the methods of médical science mental defect and disturbance in its varieties and degrees, it contemplâtes them from an altogether differing standpoint. Médical science deals with the causes of mental disease and seeks knoAvle-dgo ou the subject for a purely meeli- cal end. With it au inquiry as to the fact of insanity is an absolute and final one. The laAv, on the other hand, negleets the causes of insanity and deals exelusively Avith its conséquences, Avhich are evidenced by con- duct, the outward expressiem of the inner mental state. From this point of vieAV there are two forms of insanity—the one that causes a man to break the laAV, 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 inepiiry as to the fact of responsibility or punishabdity. Even in respect to this the two sciences hâve différent starting-points : the one, beginning with the fact of dis- ease, seeks to measure its disturbing influence on 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 ail men are sane, and consequently responsible for their acts until in individual cases they are proved not to be so. (Minshall, J., State, vs. Bowsher, 3 Cin. LaAV Bul. 187; Curtis, J., U. S. vs. McGlue, 1 Curtis, 1; " Responsibility in Criminal Cases," by David Nicholson, M.D., Jour, of Mental Hei., vol. xxiv., p. I; "On the Relation of Madness to Crime," by J. C. Bucknill, M.D., Am. Jour, of Insanity, vol. xl., p. 412.) In a criminal trial, Avhen mental defect or disease is pleaded as a défense, the question is " Avhether the accused be guiltv or not guilty." (Mr. Justice Manie, McNaghten's Case, supra.) In" this fact of gudt 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 mère interior intention, yet it is a fundamental maxim that '■ the act itself does not make a man guilty, unless his inten- tion AATere so." (3 Inst. 107.)t A criminal act is therefore complète only Avhen the evil mind concurs with the outward act ; and in the inquiry 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 lois ne se chargent de punir que les actions extérieures." t "Aetus non facit reum nisi mens sit rea." MENTAL RESPONSIBILITY IN CRIMINAL CASES. 219 (Stephen's General View of the Criminal Law of England, chap. iii., p. SG.) In nothing more than this has the laAv appreciated the futility anel péril of définition, the impossibility of defining or describing the dise'ase or of laying elenvn any test of its existence. (Lord Lyndliurst, Hansarel's Déliâtes, vol. lxvii., third séries, p. 716 ; Lord Denmau, liegina vs. (hford, 9 C. & P. 525.) It lias therefore refrained from making a spécial issue of the fact of insanity and has limitée! itself to the' estab- lishment of a canon of responsibility, légal insanity being commensu- rate Avith légal irresponsibility. " Oui* law Avas," says Erle, C. J., " that a ] man Avas respem.sible for his acts unless his mind was in a state which prevented him freun being responsible for his acts. If he was conscious I that he was doing wrong at the time when he committed the act then ' he Avas responsible. . . . The question Avas whether he was or Avas not responsible Avhen 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 undeflned. The issue was, whether or not when he did the act he Avas L'gally responsible—in other words, whether lie knew its nature, and knew that it Avas wrong." (Iîegina vs. Leiejh, 4 F. & F. 915.) The distinction thus made between insanity and responsibility marks the boimdaries of the separate and distinct provinces of laAV and medicine. The différence betvveeu mental health and disease is, and must remain, a \ fact of science entirely Avithin the purview of medicine. On the other hand, the eledermination of the relation of mental disease to guilt, and to the punishability of sue-h guilt, and of the point of séparation betAveen the conditiems of responsibility and irresponsibility, must be the exclusive function of the law. •• The question," says Sir J. F. J. Stephen, " What are the mental éléments of respeuisibility? is, and must be, a légal ques- tion. It cannot be anything else, for the meaning of responsibdity is liability to punishment, and if criminal law does not détermine avIio are to be punished under given circumstane-es it détermines nothing." (Stephen's History of the Criminal Law of England, chap. xix., p. 183.) From the nature of things, the law must détermine for itself, anel in the first place, whether or not the fact of insanity should exempt one at ail from the orelinary liability of the criminal law, and, having admitted the exemption, it must set and define the limits of such exemption. For in- stance, as a rule of policy, the laAV might détermine that no degree of madness should exempt, or that any degree of madness should so ex- empt ; or it might plae'.e the point of responsibility, as it does, sonieAvhere between thèse two extrêmes. The Suprême Court of New Hampshire j (State vs. Jones, 50 N. H. 369), which has gone to the extrême in its rejec- tion of the légal e-riterions of responsibility by leaving to the jury, as matters of fae-t, Avhether the accused had a mental disease, and Avhether the e>vert act Avas a product of such disease, impliedly laid down the cri- tcriem of légal responsibility that no man should be held aecountable, criminally for an ae-t the offspring or product of mental disease. Ac- cording to the German jurist Casper the term criminal responsibility is easily elefined, since it is based upon unchangeable natural psychological laws^ recognizeel by every man's conscience, and which may be compre- hendeel in the fedloAving simple elogmas: 1. Both a good and evil prin- ciple réside anel act in man. The récognition of this fae-t is coeval Avith the origin of man, and is expressed in the meist ancient religions. 2. This double principle itself, as well as the power of recognizing it, is born Avith 220 A SYSTEM OF LEGAL MEDICINE. every man, anel is firmly basée! in his conscieuice so long as lie remains in his natural condition. 3. Man in his normal condition is at pe-rfee-t liberty to permit himself to be gnided in his actions by either the goexl or the bad principle; "he has freedom of choice," according to others, "the poAver of spontaneous action," "moral freedom," or "the freedom of the Avili." 4. Every man knows, anel so long as lie continues in his normal condition must be presupposed to knoAV, that, in spite of his free- dom of choice, lie must alloAv himself to be guidée! in his actions by his good principle, and Avithstanel the allurements of his evil one. 5. And that when he acts reATersely he expe>ses himself to the punishment e»f his internai judge, his conscience, Avhich dAvells Avithin him as the natural guardian of the laAvs of morality. Thèse are eternal, inborn truths, the foundation-stones of the whole doctrine of criminal responsibility, to whieh the foUowing may be added, if, indeeel, they do not actually belong to the same category : every man living in the bonds of society, who has arrivée! at the normal development of his mental powers, lias experi- enced and knoAvs that society is not and cannot be satisfied by the pun- ishment inflicted by his internai monitor, but, in accordance with the re- quirements of the inborn laws of morality, has also laid down and put in exécution external punishments for any action opposée! to morality. In accordance Avith thèse hiAvs, therefore, he must be made responsible for every rash deed so long as he is in the uncloueled pe>ssession of his men- tal powers, sine-e, in such circumstances, he is in a position to foresee ail, even the catI results of his actions ; he is possesse-el of criminal responsi- bility. (Handbooli of the Practice of Foreusic Medicine, vol. v., part vi., chap. i., se'c. 58.) The laAV of England, in the same manner, places the femndatiem-stemes of criminal responsibility in the intuitions of conscience and the enact- ments of pe>sitive laAV, in relation to which it recognizes in the normal man a liberty of will, 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 (Haie, P. C, chap. ii.), it has assumed the truth of the corrélative proposition that Avhere there is an understanding sufficient to know the thing chosen, good and eAdl, the freedom of the Avili exists to the extent of conferring responsibility. It has placed, therefore, the capacity to form the caùI 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 "natural defect" of infancy (Haie, P. G, chap. iii.) as Avell as to the "accidentai defects" of idiocy and insanity— to those who are non compos mentis. "On the part of the défense, 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 wrong," or, in other words, " that from the effect of a diseased mind he did not know at the time that the act lie did was wrong." (Jîeqiua vs. Oxford, 9 C. & P. 525.) I. NATURAL DEMENTIA OR IDIOCY. Although Haie elaborately distinguishes idiocy from insanity, there would seem to be no sufficient légal reason for this elistinction, as the consequene-es of the knenvledge of the nature of an ae-t do not vary Avith causes purely physiologie-al in their différence, such as the différence in- MENTAL RESPONSIBILITY IN CRIMINAL CASES. 221 trmsically médical made between mental weakness and disease, and the différence of origin, whether it be congénital or otherwise. (Note 1 to Article 27, Stephen's Digest of the Criminal Law.) An idiot, " AAdiich from his nativitie, by a perpetuall infirmitie " (Co. Lit. 247*7), " being under a natural disability of distinguishing between good and evil, is not punishable by any criminal prosecution whatso- ever." (Hawk., P. G, vol. i., pp. 1,2.) As congénital mental defect varies infinitely from the condition where, " from an original malorganization, there is the human frame alone without the human capacity " (Erskine, Trial of James Hadfield, 27 How. St. Tr. 1312), through endless degrees of imbecility and mental weakness, tins doctrine in its generality must be limited to conditions of mind simdar to that set forth by Fitzherbert in his définition of " an idiot as such a person who cannot account or number twenty pence, nor can tell who was his father or mother, nor how old he is." (Fitzh. 6, N. B. 532.) Amid thèse degrees of imbecility and mental weakness, the point of responsibdity is found in the capacity of knowing good from evil. " The law will not measure the sizes of men's capacities, so as they be compos mentis," says Sir Joseph Jekyll in the Duchess of Cleveland's Case. (Erskine, Trial of Hadfield, supra ; Patterson vs. The People, 46 Barb. 625.) " The law does not undertake to measure the intellectual capacities of men," saj^s the Suprême Court of Indiana. (Wartena vs. The State, 105 Ind. 445.) "Imbecility of mind may be of such a degree as to constitute insanity in the eyes of the law, but mère mental weakness, the subject being of sound mind, is not insanity, and does not constitute a défense to crime. The law recognizes no standard of exemption from crime less than some degree of insanity or mental unsoundness. Immunity from crime cannot be predicated upon a merely weak or low order of intellect coupled with a sound mind." (Conway Ars. The State, 118 Ind. 482.) Sir James F. J. Stephen questions the responsibdity in law of one who, h knowing in a way the nature and quality of an act, and knowing that it / is wrong, yet through mental imbecility is unable to form such an esti- mate of its nature and conséquences as a person of ordinary intelligence would form. (Digest of the Criminal Law, Illustration 2, Artie-le 27.) In Connectie-ut one confessedly neither idiotie nor insane was tried for the burning of a barn. In charging as to his responsibibdy, the trial judge practically took the measure of his capacity, which he, the judge, likened to that of a veiy young child. Under thèse instructions, the accused was promptly acquitted. (State vs. Richards, 39 Conn. 591.) . Juries haA^e even gone bej^ond this point, and in the weighing of responsibility haA-e manifestly taken into account the weakness of the human intellect as contrasted with the force of human impulse or passion. At York, England, in the year 1859, one James Atkinson, aged twenty- four, was tried for the murder of a }Toung woman, whose throat he had eut, there being eight distinct wounds. There could be no question as to his appréciation of the nature of the act and its conséquences. After the commission of the deed lie hid the knife in a wall, washed his bloody hands in a pond, and on the folloAving day informed a brother that he had killed his sAveetheart. He could read and Avrite, and had done some arithmetic. Despite the instructions as to the e-riterion of responsibdity basent upon the knoAvleelge of right and Avrong, he was acquittée! by the jury on the ground of insanity, evidently on the médical testimony that 222 A SYSTEM OF LEGAL MEDICINE. being of weak intellect lie hael not reaseuiable control over his actions and could not be held responsible as other men. (" Insanity and Crime," by S. W. North, M.R.C.S., vol. xxxii., Journal of Mental Science, p. 163.) As the sensés are the avenues Avhereby ide-as are conveye'el to the mind, and speech is the ordinary faculty given feu- their expression, the condi- tion of deaf-mutism reverses the presumption of sanity, and casts upon the prosecution the burden of proving the responsibility of the accused. (The State vs. Draper, 1 Houst. Crim. Re-p. [Del.] 291.) H. ACCIDENTAL DEMENTIA OR INSANITY. (a) Total Insanity.—Like idiocy, a condition of total insanity is a complète bar to criminal responsibility. "Ile' that is non compos mentis and totally deprived of ail compassings and imaginations cannot com- mit high treason by compassing or imagining the death of the king ; for furiosus solo furore punitur; but it must be an absolute madness and a totall deprivation of memorie." (3 Inst. 6.) As cemcerning such condi- tions there can be but one judgment ; they need no extensive considéra- tion from médical jurisprudence. Even when the Liav, in its extrême rigidity, required that the insanity should extend to " the depriAration of ail compassings and imaginations," to the " state of total furiosity," it did not also require it to be continuons in respect of time. " The quality of the deed dépends entirely on the man's state of mind at the time he does it, so that whether his malady is constant and unremitting, or only re- turn at intervais, still his défense shall be equally available if he Avas then utterly furious and void of reason." (Hume's Commentaries on the Law of Scotland, chap. i., p. 39; Trial of Sir A. Kinloch, 25 Hoav. St. Tr. 891.) Lucid Intervais.—The truth of the converse of this doctrine Avould seem to be manifest. If an interAral of total madness should relieve from responsibility, an intermission or an interval of restoration to sanity should impose it. The fact of the occurrence of this intermission or inte^al of restoration, called a lucid interval, was, owing to détective médical knowledge, so embedded in the jurisprudence of the time that its existence marks, as has been shown, the légal distinction draAvn be- tween two classes of non competes mentis, and the différence between mad- ness and lunacy. OAving to this view that there was a particular form of insanity, the distinctive and essential characteristic of which was the occurrence of lucid intervais, in the early cases great stress was laid upon the mental state of the accused at the very occurrence of the act. In the case of Edward Arnold (16 How. St. Tr. 695), Sergeant Darnell for the Crown insisted that the insanity of the accused should be reck- oned at the time he did the deed : " If lie hath intervais and kills a man in those intervais, he is as much subject to the law as any other man." And with this was Justice Tracy agreed : " A man that is an idiot, that is born so, neA^er recovers, but a lunatic may, and hath his intervais • and they admit he Avas a lunatic. You are to consider what he Avas at this day when he committed this fact." In Hadfield's Case (supra), the attorney-general made the same contention, and the presiding justice, Lord Kenvon, at the conclusion of the trial, after admitting that the accused was insane both before and after the act, and that it Avas im- MENTAL RESPONSIBILITY IN CRIMINAL CASES. 22:1 probable that he had recovered his sensés in the intérim, declared that, were they to run into nicety, proof might be demandée! of his insanity at the pree-ise moment when the act was committed. (1 CoU. Lun., p. 488.) Sir James Mansfield charged the jury in Bellingham's Case (1 Coll. Lun., p. 636) that there Avas another species of madness, in which persons Avère subject to temporary paroxysms, in Avhich they Avère guilty of acts of extravagance, Avhich Avas called lunacy; that if thèse persons were to commit a crime Avhen they were not afflie-teel Avith the malady they Avould be to ail intents and purposes amenable to justice. As to this Haie Avas no less précise' and distinct : " Such persons as haA*e their lucid intervals (whie-h ordinarily happens between the full and change of the moon) in such intervals hâve usually at least a compétent use of reason, and crimes ceimmitte'el by theun in thèse intervals are of the same nature, and subject to the same punishment, as if they hael no sue-h deficiency." (Haie, P. C, chap. iv., p. 31.) That the occurrence of the lucid interval constituted in the mind of the law a reste> ration te) reason, or to the compétent use of it—in other Ave>rds, a temporary cure—seems plain from the authorities. Lord Thurlow (Attorney-General vs. Parnther, 3 Bro. Ch. 441) defined a perfect interval not to be a cooler moment, an abatement of pain or violence, or of a higher state of torture, a mind relieA^ed from excessive pressure, but an interval in which the mind, having thrown off the dis- ease, lias recovered its gênerai habit. And Baron Rolfe, in Iîegina vs. Layton (4 Cox, C. C. 149), instructed the jury "that such was the nature of the mind that it might be one minute sane and the next insane." If such Avère the real and essential eharaeter of a lucid interval, there could be no just criticism of the criterion of responsibility based upon its occur- rence; but the current légal view as to its intrinsic nature has been vehemently disputed by mental physie-ians, some of whom deny alto- gether its existe-ne-e, anel 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 Insanity, chap. xv.) The question, hoAvever, lias only a spéculative interest in forensic medi- cine. In the year 1816, at a Court e>f General Sessions held in the city of New York, one Clark was convie ted of petty larceny alleged to hâve been committed during a lucid interval (1 C. H. Rec. 176). This case, hoAvever, cannot be e-euisidered a précèdent, and it is authoritatively asserted that the books coi tain no other record of a similar conAuction. (Ray's Jurisprudence of Insanity, chap. xv., p. 427.) Casper testifies to a like expérience on the continent of Europe: "Expérience teaches us in regard to the Avhole epiestion of a lucid interval, what I hâve never seen stated, that practically speaking it is in so far of little importance that it is but seldom mentioned in foro. At least, of hundreds of criminal cases whie-h I hâve reported on, ï hâve never hael to do Avith one in which the question of a lucid interval came in question at ail." (Handbooh of Fo- rensic Medicine, vol. iv., part vi., chap. il, sec. 78.) Epilepsy.—The occurrence of the epdeptic paroxysm, whie-h, con- sidérée! as an interval, is the reverse of the one Ave hâve been consider- ing, e-annot be inferred from the fact that the accusée! was suffering from epîh'psy, a elisease' Avhiedi lias a tendeney to weaken the mind and to pre>- duce- insanity. In addition, proof must be given of the occurrence e>f the pare>xysni at the Aery time of the commission of the deed. (Common- wealth vs. Btu-cieri, 153 Pa. St. 535.) 224 A SYSTEM OF LEGAL MEDICINE. (b) Partial Insanity.—It has been contended, upon the theory of the essential unity and indivisibility of the human mind, that there is in fact no insanity which can witlisubstantial aceuracy be described as a partial one. (Wariug vs. ^Yuring, 6 Moore, P. C. 341.) In the crinnnal laAV, however, there eau be no doubt as to the authority of the distinc- tion made by Haie betAveen the conditions of total anel partial insan- }ity. The latter e-ondition, Avherein persons who labor under mental dis- ; ease with respect to one or more objee-ts, are entirely, or apparently entirely, rational Avith respee-t to others (Lord Lyndhurst, Hansard's Dé- butes, vol. lxvii., third séries, p. 712), forms the almost exclusive subject of inquiry and the exclusive difficulty when insanity is interposed as a défense in courts of laAV. Until the acquittai of James Hadfield (supra), a condition of partial insanity Avas, to the accused, no exonération. "This," says Halo (P. G, vol. i* p. 30), "is the condition of very many, especially melanchedy persons, who for the most part discover this defect in excessive fears and griefs, and yet are not Avholly destitute of the use- of reason; and tins partial insanity seems not to excuse them in the committing of any offense for its matter capital; for doubtless most per- sons that are félons of themselves and others are under a degree of partial insanity Avhen they commit thèse offenses." In the earliest cases the insanity that might acquit must extend to the total deprivation of "understanding and memory," se> that the ace-useel might "not knoAV what he was doing no more than an infant, than a brute or a wild beast." (Trial of EdAvard Arnold, supra.) This, derisively called the "Avild-beast theory," hael for its basis the fact of the comparative inelestructibility of the capacity to know good from evil; Avhich, not beung a process of thought, nor taking its eirigin in the intelligence, but much deeper in the mind, in the consciousness itself, insanity in its highest degree alone can obliterate. (Casper's Handbook of Foreusic Medicine, vol. iA\, part Ad., chap. i., sec. 63). " A child," argued the attorney-general in the case of Hadfield (supra), " cannot dispose of his property in any manner Avhat- ever, and no man Avould think lie had a capae-ity for that purpose ; but he lias sufficient capacity to be guilty of a crime. Why? Because there is a natural impression upon the mind of man of the distinction betAveen good and evil, which never entirely loses hold of the mind Avhile the mind has any capacity whatever to exert itself ; nothing but total and absolute debility deprives the mind of any màn of that." And with this the inductions of mental medicine are agréée! : " The sensé of duty, the feeling of right and AATong, 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- A'elopment, but is rendered an essential and uee-essary part of human nature. It seems needful to inquire to what extent this abstraet and necessary part of human nature becomes capable of being perverted or destroyed under the influence of cerebro-mental disease. It may be taken as an axiom that the innate and essential -principles of mind are ever présent where mind exists. It may aise) be asserted, as the resuit of obser- A'ation and expérience, that in ail lunatics, and even in the most degraded idiots, Avheuever manifestations of any mental action can be adduced, the feeling of right and Avrong may be proved to exist." (Bucknill on Crimi- nal Lunacy, p. 59.) The fact of the comparative indestructibility of the capacity of know- MENTAL RESPONSIBILITY IN CRIMINAL CASES. 225 ing goe>d from ev'û furnishes, as will be shown, the essential reason for the objections advanced against it as the exclusive criterion of légal re- sponsibility. From this standpoint, too, does the kiw consider mental ded'cet anel disease in the comparati\Te relations of " civd competency " and "criminal responsibility." An infant, aman incompétent for civd affairs en- the "constant duties of life," may, notAvithstanding, be crimi- nally responsible. (Attorney-General, Trial of Haelfiedd, supra.) Thomas Bowler, found guilty in the year 1812 of willfully and maliciously dis- e-harging a blunderbuss loaeled with bullets at one Burre)Avs, Avas after- Avard executed, although preAÙous to the commission of the deed he had been adjuelicated incompétent for the management of his affairs under an inquisition in lunacy. (1 Coll. Lun. 673.) A like doctrine, founded upon simdar reasons, is set forth by the Continental jurists: "The fact that the cemelitions of criminal responsibility are inborn in man and are consequently deeply rooted in the whole of his psychicàl organization, whde other psychicàl processes are the resuit of éducation, of mental cultivation, of indoctrination in the Avays of life, etc., produces another différence, and a most important one in medico-legal practice, betAveen ciAdl 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 denied. Of this a Avhole class of criminals affords an example ; I refer to tliose very youthful culprits avIio are in gênerai as yet incapable of exe-rcising the civil rights of life, anel consequently pe>ssess no civil respemsibility, while their illégal evil eleeds are e-arried out with the most perfect consciousness of their punishable eharaeter and witli ail the uiupiestionable criteria of freedom of AviU, 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 Avith them, this doctrine is assumed as indisputable." (Casper's Handbooh of Foreusic Medicine, vol. iv, part au., chap. i., sec. 58.) At the présent day, when the law no longer assumes the fact of the suiwival of the capacity of knoAving good from e\dl, and consequently that of responsibility, unless the mental wreck extend to a condition of total insanity the inquiry becomes more subtile and diffie-ult. An "in-i divisible line" may séparât e, as Haie says, the conditions of total and partial insanity, but the line is still more "indivisible" separating the \ partial insanity that does from the partial insanity that does not obscure this capacity, the obscuration being more complète and consequently more evideuit, in the night of total than in the clouds of partial insanity. ] For assuming that one partially insane is capable of a ci-iminal intent, / Avhat problem is more perplexing than the questiem Avhether the disease \ die! or did not affect the act ? (Maudsley's Responsibility iu Modal Dis- ease, p. 109), and the further question Avhether "ceuise-ious malice and mischief did mix Avith the insanity" î (Erskine, Trial of Hadfield, supra.) The application of the canon of criminal responsibility finds its most ordinary expression in the questiem left to the jury, "Whether at the time of the committing of the act the party accusée! Avas laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act lie Avas doing, or if he did knoAV it that he did not knoAV that he Avas doing Avhat Avas wrong?" (Me'Xaghten's Case, supra.) The same canon has found a variety of expressions, as the fol- lowing : " Did lie [the prisoner] knoAV when he committed the act Avhat 226 A SYSTEM OF LEGAL MEDICINE. the effect of it, if fatal, would be Avith referene-e to the crime of murder? Did he know that he Avas committing an offense against the' hnvs of God and nature ? " (Rex vs. Off or d, 5 G & P. 168.) " Whether the prisoneu- was laboring under that spe-cies of insanity Avhich satisfies you that lie' Avas quite unaAvare of the nature, eharaeter, and conseepience of the act he was committing, or, in other words, Avhether he Avas under the influence of a diseased mind and Avas really unconscious at the time he Avas com- mitting the act that it Avas a crime?" (Rigina Ars. Oxford, 9 G & P. 525.) " If, on the other hand, he [the accused] Avell knew that his act would take away life, that that act Avas contrary to the laAV of God and punish- able by the law of the land " (Regina vs. Townley, 3 F. & F. 839), " the sin- gle question Avas whether, when he [the accusée!J committed the offense chargeel upon him, he had sufficient understanding to distinguish good from evil, right from Avrong, and that murder Avas a crime» not only against the law of God but against the laAV 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. Spencer, 1 Zab. 196.) As to the first part of the canon, the knowledge of the nature and quality of the act, there can be little difficulty, as it contemplate\s a state of mind sufficiently obvious, one of complète overthrow, or of an illusion so complète 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 knoAV the nature and quality of the act Avhiedi she had committed. It was that of a maniacal woman who hael drowned her tAvo children in the Exeteu- 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 ple>ad. He sent for his brother judge from the Nisi Prius Court, and well I remem- ber seeing the twe> judges standing in their robes of différent color, and talking low to each other as they lookeel 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 taking any évidence, directed the jury to find a verdict of 'not guilty'' on the ground of insanity, and upon that verdict having been given lie ordered lier to be given to the eare 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- plète illusion in the mémorable debate on insanity and crime in the House of Lords (Mardi 13,1843, Hansard, vol. lxvii., third séries, p. 730) : "First of ail, did the unfortunate person know what he was about? Did he actually know he was killing a man "? Or did he think, peradvent- ure, lie was destroying some evil spirit, or some bird or beast ? If he did not know he was killing a human being—if he did not know what he was doing at ail—if he was so idiotie as to be utterly 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 Lyndhurst instanced as an example of this complète illusion a case taken from the Scotch reports, of a man tried for the murder of another by shooting him whde he was goinp- a cross a moor. MENTAL RESPONSIBILITY IN CRIMINAL CASES. 227 It had been claimed that the prisoner labored under the delusion that the man he shot Avas an evil spirit Avhom the Almighty had commanded him to kill. As to the second part of the canon, that relating to the consciousness of the différence' between right and wremg, good and eA'd, the judge-s in their instructions would seem to refer the question of re- sponsibility to the consciousness of the individual in respect to abstraet right and wrong ; the right and Avrong of the particular case ; the right and wrong of the moral law, the law of Ge>el, or the enactments of posi- tive law, the law of the land. By se>me it has been contended that the canon refers to the moral law alone (State vs. Spencer, supra); by others as strenuously, to the enactments of positiA'e law, the fact of pun- ishability. This latter vie-Av appeals most stremgly to those who seek in the laAV a précision perhaps unattainable ; for in relation to the conscious- ne'ss, the existeiu-e of a fact as that of punishment is, as it were, a fixed point, Avhen compared Avith the fluctuating conceptions of moral right and Avrong that may be entertained by individuals. " He [Lord Broug- hain] kneAv the learned judges used the phrase with référence to the e-ommands of the law. They could endy know one kind of right and Avrong; the right is when you act according to law, and the wrong is when you break it. . . . Distinguishing right from Avrong meant a kne>wle'dge that the act the peu-son was about to commit was punishable by the law." (Hansarel's Debate-s, vol. lxvii., p. 732.) Baron Bramwell strenuously maintained similar \deAvs before the sélect committee of the House of Commons upon the Homicide Law Amendment Act (Spécial Report of Select Cennmittce, vol. ix., p. 2G, 1874): "A erazy fellow knows it is forbidden by law to knock out my brains, but has a notion it is morally right because I once trieel a Fenian. Is it to be no crime? . . . He [Mr. Stephen, the author of the pre>posed act] says, ' I présume the notion arises from a disease affecting the erazy fellenv's mind, where- by he is preAenteel 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, bee-ause one of the conditions which law assumes in dealing with men is, that their moral feelings are on its side, to the extent, at ail events, of understanding that ae-t s of atrocious wickedness are atrete-iously wicked, and that a part from the law they ought not to do them ; and tins élément is wanting in the case suppe>sed.' He says further, * I do not believe in the peissibility of neglecting this considération in practice, as the following case will show.' . . . It is the case of a man [James Hadfielel] who sup- posed that if he could be put to death he would save the world, and then lie murelers 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, What rule are you te» lay doAvn ; are you to lay down a rule AA'hich would exeduele his being hung?) Hardly, I think; but if not, Avhy not? 'He not only knows Avhat he is doing, and that it is forbidden by law, but the fact that it is so forbidden is the \rery motiAe which makes him do it. . . . The man is under a monstrous delusion which prevents him from attending to or judging of the moral eharaeter of what lie does, and ought no more to be punished than a dreamer is blamed for what he does in his dreams.' I hâve put in ansAver to that, 'I would not Inrve a law to except this case, which would necessarily except others that ought not to be excepted.' 228 A 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 off being hung. but that he ought to be held guilty of murder I hâve no doubt ; whether I Avould hang him is another matter. And when Mr. Stephen says, ■ One of the conditions which law assumes in dealing with men is, that their moral feelings are on its side, to the extent, at ail events, of understanding that acts of atrocious Avickeelness are atrociously wicked, and that apart from the law they ought not to do them/ I deny that to my mind the law lias anything to do with it ; but it simply tends to terrify the man, te) threaten him; it cares not Avhat his views are on the subject, but says, 'That is a thing you should not do.' I do not quite understand that passage', and it Avould be very odd if it were true of moral and not of religious feel- ings ; which religious feelings hâve continually driven people into the commission of crime. . . . What you want to do is to frighten people, to terrify them, and the Avay to try who ought to be punished, to my mind, is to try avIio ought to be threatened with punishment ; . . . if you can find out Avhat man's mind is accessible to the influence of fear, you can find out the man you should punish, because those whom you threaten you ought to punish, that it may not be brutum fitlmen. You ought to threaten every man sensible to the effect of a threat, and if this erazy fellow knows that what he tliinks a A'irtuous or moral action is one which would cause him to be hung, I shall feel much more safety after having tried Fenians than I could otherwise feel." Sir James Mansfield instrue-te-d the jury in Bellingham's Case (supra) that there was a thirel species of insanity in which the patient f ancieel the existence of injury anel sought an opportunity of gratifying revenge by some hostile act. If such a person were capable iu other respects of distin- guishing right from Avrong, there was 110 excuse fe>r any act of atrocity which he might commit under this description of dérangement. This doc- trine placed obviously the criterion in the knowledge of right and wrong, good and evil, in the abstraet. The fallacy of this view became eAudent AAdien the case of James Hadfield (supra) had shown the necessary consid- ération of delusion as an élément in the criterion of responsibility. " Few men," says Alison, " are mad abôut others or things in gênerai ; many about themselves. Although, therefore, the panel [prisoner or accused] understands perfectly the distinction of right anel wrong, yet if he labors, as is generally the case, under an illusion and déception as to his own particular case, and is thereby disabled from applying it correctly to his own conduct, he is iu that state of mental aliénation which rentiers 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 thèse questions an authoritative resolution is found in the answers given by the judges of England (with the exception of Mr. Justice Maule) to the questions put them by the House of Lorels in conséquence of the acquittai of Daniel McXaghten, indicted for the murder of Mr. Drummond, secretary of Sir Robert Peel. (10 Cl. & F. 200.) Thèse judges, speaking through the Lord Chief-Jus- tice Tindal, gave the foUowing answers : " The first question proposed by your lordships is this : 'What is the law respecting alleged crimes com- mitted by persons afflicted with insane delusion in respect of one or more particular subjects or persons ; as, for instance, where at the finie of the commission of the alleged crime the accused knew he Avas acting contrary MENTAL RESPONSIBILITY IN CRIMINAL CASES. 229 to law, but did the act complained of with a vieAV, under the influence of insane delusion, of redressing or reArenging some supposed grievance or injury, or of producing some supposed public benefit?' In answer to Avhie-h epiestion, assuming that your lordships' inquiries are confined to those persons who labor under such partial delusions only and are not in other respee-ts insane, Ave are of opinion that, notwithstanding the party accusée! elid the act complained of with a vieAV, under the influence of insane delusion, of redressing or revenging some supposed grievance or injury, or of producing some public benefit, he is nevertheless punishable according to the nature of the crime committed, if lie knew at the time of committing such crime that lie Avas acting contrary to the law; by which expre'ssieui avc understand your lordships to mean the law of the land. Yemr lordships are pleaseel to inquire of us secondly, 'What are the proper questions to be submitted to the jury Avhere a person, alleged to be afflicted Avith insane delusion respecting one or more particular subjee-ts or perse>ns, is charged Avith the commission of a crime (murder, for exanqde), anel insanity is set up as a défense?' And thirdly, 'In what terms ought the question to be left to the jury as to the prisoner's state of mind at the time Avhen the- act Avas e-ommitted ?' And as thèse twe» epiestions appear to us to be more conveniently ansAvered together, we hâve to submit oui* opiniem to be, that the jurors ought to be told in ail 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, untd the con- trary be proved to their satisfactiem; anel that to establish a défense on the ground of insanity it must be clearly prêtée! that, at the time of the committing of the act, the party accusée! was laboring under such a de- fect of reason, from elisease of the mind, as not to knoAV the nature and quality of the act he Avas doing; or, if he did know it, that he did not knoAV lie Avas doing Avhat Avas wrong. The mode of putting the latter part of the epie'stion to the jury ou thèse occasions lias generally been, whether the ae-cuseel at the time of doing the act knew the (Différence between right and wrong ; Avhich mode, though rarely, if ever, leading to any mistake on the part of the jury, is not, as we ceuiceive, so accurate Avhen put gen- e-rally and in the abstraet as Avhen put Avith référence to the party's knowledge of right aud Avrong in respect to the very act with Avhich he is charged. If the question Avère te) be put as to the knowledge of the accused solely and exclusi\'ely Avith référence to the law of the land, it might tend to coiifound the jury, by inducing them to believe that an actual knowledge of the law of the land was essential in order to lead to a conviction; avIicréas the laAV is aelministered upon the principle that every one must be taken conclusively to know it, Avithout proof that he does knoAV it. If the ae'cused was cemscienis that the act was one which he ought not te) do, and if that act Avas at the same time contrary to the law of the land, lie is punishable ; aud the usual course, therefore, has been to leave the question to the jury, whether the party accused had a sufficient degree of reason to know that he Avas denng an act that was wrong; and tins ceuirse avc think is correct, accompanied Avith such ob- servations and explan a fions as the circumstances of each particular case may require. The fourth epiestion which your lordships hâve proposed to us is this: 'If a person under an insane delusion as to existing facts eeunniits an offense in conséquence thereof, is he thereby excused?7 To which question the ansAver must, of course, dépend on the nature of the 230 A SYSTEM OF LEGAL MEDICINE. delusion ; but, making the same assumptioil as Ave did before, namely, that lie labors under such partial delusion only, and is not in other re- speeds insane, Ave think lie must be considered in the same situation as te> responsibility as if the facts Avith respect to Avhich the elelusion exists were real. For example, if, under the influene-e of his dedusion, lie sup- poses another man to be in the act of attenipting to take away his life, and he kills that man, as he supposes, in self-dedense, lie Avoulel lie exempt from punishment. If his delusion Avas that the deceased had inflicted a serious injury to his eharaeter anel fortune and lie killed him in revenge for such supposed injury, he would be liable to punishment." The questions put to the judges Avère gênerai in their terms, having référence to the facts of no particular case, and Mr. Justice Maule ex- pressed a fear (p. 204) that the answers might, from their necessary gen- erality, prove an embarrassment in the administration of justice. There was also a question Avhether 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 laAV by the courts of THE UNITED STATES. U. S. vs. Holmes, 1 Clif. 98 ; U. S. vs. Nicholas Schultz, 6 MacL. 121 ; U. S. vs. Me Glus, 1 Curt. 1 ; as well as by the courts of the following of the United States of America : ARKANSAS. Casât vs. State, 40 Ark. 511. CALIFORNIA. People vs. Hobson, 17 Cal. 424 ; People vs. Coffman, 24 Cal. 230 ; People vs. MeDonneïï, 47 Cal. 134 ; People vs. Ferris, 55 Cal. 588 ; People vs. Pico, 62 Cal. 50; People vs. Hoin, 62 Cal. 120; People vs. Blale, 65 Cal. 275. DELAAVARE. State vs. Windsor, 5 Harr. (Del.) 512. GEORGIA. s Roberts vs. State, 3 Geo. 310 ; Loyd vs. State, 45 Geo. 57 ; BrinMey vs. State, 58 Geo. 296. IDAHO. People vs. Walter, 1 Ida. 386. KANSAS. State vs. Malin, 25 Kan. 182. MAINE. State vs. Lawrence, 57 Mai. 574. MASSACHUSETTS. Commonwecdth vs. Rogers, Jr., 7 Metc. 500. MENTAL RESPONSIBILITY IN CRIMINAL CASES. 231 MINNESOTA. State vs. Shippey, 10 Minn. 223 ; state vs. Out, 13 Minn. 341. MISSOURI. State vs. Huting, 21 Mo. 464 ; State vs. Redemeier, 71 Mo. 173 ; State vs. Erb, 74 Mo. 199 ; State vs. Kotovshy, 74 Mo. 247. NEBRASKA. Wright vs. IVo^e, 4 Neb. 407 ; Hawe vs. Peopte, 11 Neb. 537 : Hart vs. State, 14 Neb. 573. NEVADA. State vs. Zttm, 20 Nev. 333. NEW JERSEY. State vs. Spencer, 1 Zab. 196. NEAV YORK. Freeman vs. People, 4 Den. 9 ; 1J7///.V vs. People, 32 N. Y. 715 ; Flâna- (/an vs. Pecyjfc, 52 N. Y. 467 ; Moett vs. People of the State of New York, 85 N. Y. 373 ; Walher vs. People of the State of New Yorl; 88 N. Y. 81. NORTH CAROLINA. State vs. Brandon, 8 Jones (L.) 463 ; State vs. Ilayward, Phil. N. C. 376. OHIO. Clark vs. The State, 12 O. 483. OREGON. State of Oregon vs. Murray, 11 Or. 413. TENNESSEE. Dove vs. The State, 3 Heisk. 348. TEXAS. Thomas vs. State, 40 Tex. 60. THE DISTRICT OF COLUMBIA. U. S. vs. Guiteau, 1 Mackey, 498 ; U. S. vs. Lee, 4 Mackey, 489 ; U. S. vs. Cfr/rfa, 2 Craneh, D. G 158. Of an authority almost equal to thèse answers is the famous charge of Chief-Justice Shaw in the e-ase of Commonwealth vs. Rogers (supra), A\hich lias been repeated almost Verbatim in the instructions given to juries by the judges in many States of the American Union. The law, in its inquiry as to the fact of the existence of the capacity to knoAV right from wrong, good from evil, has given, as it were, a légal 232 -/ SYSTEM OF LEGAL MEDICINE. récognition to certain facts A\liich, as the indicia of the existence of this capacity, it regards as leading symptoms in the eliagiu>sis of criminal responsibility. As an all-controlling principle may be considered the dogma (Avliiedi is Avithout 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 charaete'r may support sue-h extrinsic proof of the fact of insanity. (Laros vs. CommonicealtJi, 84 Pa. St. 200.) 1. Evidences of Design and of the Adaptation of Means to an End. In the early cases givat stress is laid upon any fact or facts tending to show that the accused had a steady and resolute design and used ail proper me>ans to effect it. (Trial of Edward Arnold, supra ; Trial of Earl Ferrers, 19 Henv. St. Tr. 886 ; Trial of James Hadfield, supra.) At that time, Avhen the possession of any meunory and understanding of any of the minel's e'ssential e-emstituents argued the existence of the capacity to know right from wrong, good from evil, anel consequently that of resixmsibility, it was cemsidered an obvious e-onse-epience that the capacity to form a design, one of the most ordinary proofs of the pos- session of reason, should be considered a elecisive circumstance. At the présent day this same capacity is considered a contredling élément in the diagnosis of responsibility. In the case of The People vs. Henry (kernel, the défense being insanity, Mr. Justice Edmonds instructed the jury that the capacity to form an intention, and of deAÙsing the means of execut- ing it, Aveudd warrant a conviction. (2 Edm. Sel. Ca. 200.) The New York Cenirt of Appeals held in the récent case of The People vs. liarber (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 légal respeinsibility." Although abstraet and à priori 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 undisturbe'd, or one sufficiently so as to impose responsibility, a closer observation of the characteristics of insanily has had a tendeney to dis- crédit the so-caUed "method in madness." It lias been shown that cun- ning and contrivance are of the qualifies 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 A-aluable when it tends to indicate a condition of irresponsibility—"Avhen thèse plans and prép- arations themselves évince the stamp of a confused intellect, and betray the hazy consciousness, the mental darkness in which the culprit was in- volved." (Casper's Handbook of Foreusic Medicine, vol. iv., part Ad., chap. i., sec. 62 ; " Review of Mittermaier on the Excuse of Insanity," American Jurist, vol. xxii., p. 312.) 2. The Appréciation of the Nature of the Act and its Conséquences. From the earliest times the fact of responsibility has been inferred from any circumstance that might evielence the possession of the above capacity. Of this th^ fTTTo cases cited by Haie are examples—the one, " an MENTAL RESPONSIBILITY IN CRIMINAL CASES. 233 infant within âge that had killed his companion and hid himself was presently hanged, for it appeared by his hiding he could discern betAveen good and evil ; " the other, " an infant of the âge of nine years kdled an infant of the like âge ; he confessed the felony, and upon examination it was found he hiel the blood and the body; the justices held he ought to be hanged." (1 Haie, P. G, 26,27.) In the trial of Lord Ferrers (supra) the case of the Ciwvn, as set f orth by the solicitor-general, was mainly an appli- cation of this and the preceding criterion. As évidences of Lord Ferrers's knowledge of the conséquences of his act, the soliciter-gênerai 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 lie feared a prosecution, with the addition that if she would not prosecute him he woulel maintain her and her f amiïy ; his expression of fears as to being arrested for his act. This same appréciation may be manifested in many Avays, such as by the expression of the détermina- tion to be hanged (Regiua vs. Burton, 3 F. & F. 772), to be " electrocuted" (People vs. Taylor, 138 N. Y. 399) ; but the most common are the hiding or flight of the accused and the concealment of the corpus delieti. The défendant in the case of The People vs. Barber (supra) was indicted for the murder of one Ann Mason, the défense being that the act had been committed during an epileptie paroxysm. The accused, who had been on terms of intimacy with the Masons, an elderly couple, had, while on a visit to them, without any cause or apparent motive, assaulted them both with a billet of wood which he had taken from a woodpile on the premises. He then set fire to the house, in the ruins of which avciv found the remains of the woman Mason. The looking ont of the door by the accused before leaAÙng the house; his occasional answers to questions put him by Mason during the perpétration of the deed ; the absence of blood on his clothing, although Mason bled freely ; the discovery of the footprints of a No. 7 shoe in the snow, two days after the event, leading in a zigzag direction away from the house, anel occasionally turning as if the wearer were looking at the fire—Avère urged as facts tending to sup- port the theory of a knoAvledge of the nature of the act, and a désire to escape. (The Barber Case, American Journal of Insanity, vol. xlv., p. 360.) The New York Court of Appeals, in their reversai of the judgment of conviction, held that upon a neAv trial the above facts Avère factors of importance upon the question of the défendants responsibility. On the other hand, presumptions favorable to the accused hâve been drawn from the apparent want of this capacity of appréciation, such as the fact of the deed haAung been committed under circumstances winch rendered détection almost inévitable. (Regina vs. Layton, supra.) This criterion cannot, however, be taken as décisive. Inferences as to irresponsibility from the évident Avant of appréciation of the nature of the act and its conséquences can be drawn with greater certainty than the fact of re- sponsibility from the possession of this appréciation, for it seems to hâve been had by many lunatics of unqiiestioned irresponsibiïity. The artist Dadd, who murdered his father at Cobham Park, England, fied to France after the commission of the deed. Of this person's insanity, which hael manifested itself some time before the act, there could be no doubt. (Annual Register of August 31, 1843.) The books contain many similar instances. 234 A SYSTEM OF LEGAL MEDICINE. 3. The Existence or Absence of Motive. Evidence of the Avant of motive on the part of the accused for the perpétration of the deed is considered to be a strong corroboration of the fact of irresponsibility. "I do not say," says Chief-Justie-e- Hornblower (State vs. Spencer, supra), "that this absence of apparent medive iuvuri- ably exists in cases of homicide and other atrocious acts coniniitted by insane persons, but I say that it is generally the case, llene-e, if we wit- ness the perpétration of such an ae-t Avithout any apparent mettiA^e or object, but against every motive which Avould appear to be- naturally in- fluential with the persem committing it, Ave at once awake to the inquiry whether he Avas in his sound mind, and if avc can lay hold of any sufficient évidence that he Avas not so, this absence of apparent motive confirais us in the belief that lie was insane." (Legina vs. Lay ton, supra; People vs. Barber, supra ; Common wealth' vs. Iiuceieri, supra.) In the application of this criterion a distiiie-tion has been drawn between mère absence of évi- dence of the existence of motive and affirmatiAre eAudence of its non-exist- ence, thedatter 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 irrésistible impulse be made per viam exclusionis from the coiicurrene-e of the appaiviit absence of motive and the atrocity of the deed, for according to Baron Rolfe (Regina vs. Stokes, 3 C. & K. 185) 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 BraniAvell (Regina vs. Ha y nés, 1 F. & F. 666) motives exist unknoAvn and innumerable which might prompt the act. Any évidence as to the non-existence of motive has been held imma- terial when a knowdedge of the nature of the act is e-emph^d with évident intention to do it. (Regina vs. Dixon, 11 Cox, C. C. 341.) It lias been determined that évidence of the absence of motiA^e is an essential factor in considering the responsibility of epileptics (People vs. Barber, supra) ; but on the part of meelical science it has been maintained that evielence of the existence of such motive is not décisive. "Thèse patients," it is said, " are controUed in the midst of their passions by an appréciable motive, which has for them a reality ; but Ave should ask ourselves if in a state of sanity such a motive would arise, and, abo\re ail, if it would be prédominant enough to control reason. Thus the motive and prémédita- tion, which seem under such circumstances to hâve dictated the criminal act, are insufficient to establish peremptoriïy the integrity of free-Avill, anel consequently the existence of guilt." ("Criminal Responsibility of Epiïeptics as Iiïustrated by the Case of David Montgomery," by M. G. Echeverria, American Journcd of Insanity, vol. xxix., p. 341.) 4. The Acting upon Existing Facts, the Human Passion being Directed to its Proper Object. The considération 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 évidence of which MENTAL RESPONSIBILITY IN CRIMINAL CASES. 235 is the existence of one or more delusions, the acquittai of James Had- field (supra) gave a légal récognition to the theory that delusion, when there is no frenzy or ravin g madness, is of the very essence of insanity. In his mémorable défense Erskine maintained that the premises from whiedi such insane persons reason, when within the range of the malady, were uniformly false, not from any defect of knoAvledge or judgment, but bee-ause a delusive image, the inséparable companion of real insanity, was thrust upon the subjugated understanding, incapable of résistance 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. Thèse \dews, which are not consonant with the sci- ence of the day (" The Légal Doctrine of Responsibility in Cases of Insan- ity Connected with Alleged Criminal Acts," by Forbes Winslow, 1 Jurid- ical Society Papers, 595), reflected the médical ideas of the time, and above ail the metaphysical spéculations of Locke, the prédominant 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 extrême, for they do not appear to me to hâve lost the faculty of reasoning, but, having joined together some ideas very wrongly, they mistake them for truths, and they err as men do that argue right from wrong principles, for by the violence of their imaginations, haAÙng taken their fancies for realities, they make right déductions from them. Thus you shall find a distracted man fancying himself a king, with a right in- ference requiring suitable attendance, respect, obédience; others, who hâve thought themsel\res made of glass, hâve used the caution necessary to préserve such brittle bodies. Hence it cornes to pass that a man avIio is very se>ber, and of a right understanding in ail 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, incohérent ieleas hâve 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 différence between idiots and madmen : that madmen put wrong ideas together and so make wrong propositions, but argue and rea- son right from them ; but idiots make very few or no propositions, and reason scarce at ail." (Essay on the Human Understanding, book ii., chap. xi., sec. 13.) Thèse vieAvs hâve had a prédominant influence upon the law in ail its branches. In the leading case of Dew vs. Clark A Clark (3 Add. Ecc. 79), Sir John Nicholl held that the true criterion, the true test, of the absence or présence of insanity was the absence or présence of delu- sion. At a récent date, Lord Denman instructed a jury that to say a man was irresponsible without positive proof of any act to show that lie Ava.s laboring under some delusion seemed to him to be a presumption of knowle-dge which noue but the great Creator himself could possess. (Regina vs. Smith, "Plea of Insanity in Criminal Cases," 5 Journal of Psyehological Medicine and Mental Pathology, p. 103.) And Baron Martin, in Regina 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 Avhich did not exist, and acted thereupon. Upon this basis of delusion as the indispensable and essential characteristic of insanity, 236 A SYSTEM OF LEGAL MEDICINE. Erskine formulateel a criterion of responsibility (No. 4, supra) whieh, al- though it lias hael a certain Aveight, cannot be said to hâve suecessfully Avithstoetd the assaults of adverse criticism. "The principle contended for by tins eminent person is that Avhen a maniac conimits ae-rinie under the influence of an impression which is entirely visionary, anel purely the hallucination of insanity, he is not the object e»f punishment ; but that, though he may hâve shown insanity in other things, he is liable to pun- ishment if the'impressiem under Avhie-h he ae-teel Avas true, and the human passiem arising out of it was directed to its proper object, Ile illustrâtes this principle by contrasting the case of Hadfield Avith that of Lord Fcr- rers. Hadfield had taken a fane-y 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 Avhie-li Avère about to take place. Lord Ferrers, after shoAving variems indications of insanity, murdered a man against whom lie Avas knenvn to harbor deep-rooted resentment on ac- count of real transactions in Avhich 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 peu-son acting under the pure hallucination of insanity in regard to impressions which are entirely unfounded is not the object of punishment. But the converse does not seem to folloAv, namely, that the man becomes an object of pun- ishment merely because the impression Avas founeled e>u fact and because there was a human passion eiirected to its proper object. For it is among the characters of insanity not only to call up impressions which are entirely AÙsionary, but also to distort and exaggerate those which are true, anel to carry them to cemsequene-es whieh they do not warrant in the estimation of a sound mind. A person, for instance, who has suffercd. a loss in business whieh does not affect his circumstances in any important degree may imagine, under an influence of hallucination, that he is a ruined man anel that his family is reduced to beggarv. Now were a Avealthy man under the influence of such hallucinatiem to eiommit an outrage on a person avIio had defrauded him of a trifling sum, the case would afford the eharaeter mentioned by Erskine, namely, human pas- sion founded upon real e\Tents and directed to its proper objee-t ; but no one probably Avould doubt for a moment that the process was as much the resiilt of insanity as if the impression had been entirely visionary." (Abercrombie on The Intellectual Powers, part iii., see. iv., p. 265.) This is confirmed by the affirmation of médical science that it is one of the Avell-known characteristics of insanity tor persons te) labor under delu- sions connected Avith and originating in actual circumstances. ("The Légal Doctrine of Responsibility in Cases of Insanity Connectée! Avith AUeged Criminal Acts," by Forbes WinsloAv, 1 Juridieal Society Papers, 605.) It woidd seem, therefore, that in deciding a doubtful case a jury ought not to be guided by the circumstances of the case exclnsively, but by évidence of insanity in other things as Avell. This seems actually to be the rule, for maaiy A'erdicts given by juries iiiATolAre a practical rejec- tion of this criterion. The récent acquittai 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 strikina- instance among many. (" A Judicial Advance—the Daley Case," by W. W. Godding, M.D., Ameri- MENTAL RESPONSIBILLTY IN CRIMINAL CASES. 237 eau Journal of Insanity, vol. xlv., p. 191, October, 1888.) This case hael a twofold aspect: a delusion of poisoning and surveillance, and a real resentment founded upon existing facts. Daley, an Irishman of about fifty years of âge, had been a lay brother in a Cathedic collège. While an inmate there lie applied for médical ad vice to the elergyman in charge, avIio proe-ured medicine for him. From e-ertain circumstances he became convineed that the drug given him had been changée! by the priest in order to poison him and gvt thereby the possession of his money. While the amount of the drug taken had not been enough to kiïl him, it had undermined his health, producing a " gum exudation over his Avliole body," Avhich continued to the time of the murder, and his life Avas ruined in conséquence. On his leaving the collège, it Avas only to be shadowed by " détectives of the order," an order, apparently, of Catholic priests. He saw them Avhen lie visited Washington in 187S, and again in the fedloAving year. He made his home in Washington in the year 1882, and about that time cornes 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. The facts in regard to this transaction appear to hâve been : that the lot of land se) bought had again passed into the hands of Kennedy, he holding it in trust, Daley, Sr., had arranged in 1882 te) 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 settlenient, Kennedy, after examining his books, told him there Avas nothing due him. The lawyer whom Daley subsequently eon- sulted advised him to settle his claim for $100 if he could get it. Ken- nedy finally paid him $50 by a chee'k, taking Daley's receipt in full of ail demands. The books of the deceased, produced in court, showed a balance due the estate at that time. Kennedy subsequently sold this same lot in 1886 for more than the sum of $5000, as recorded. This latter fact probably came to the knoAvledge of Daley. It is certain that he always bedieved that Kennedy had "beat him" in the transaction, and, though he accepted the check for $50 iu fuU payment, doubtlessly consideu-eel he had been defrauded of money justly due him. Dalev, subsequently laboring under this delusion as to his persécution by the "detee-tive's of the order," purchased a pistol for the purpose of shooting one Elliott, an apothecary of Washington, whom he delusively imagined to bc one of those détectives. This pistol lie sold. At a later day meet- ing Elliott near the Capitol, he endeavored to strike him on the head Avith a stone, and failing in his attempt, he assaulted him with his fists. This led to his imprisonment. Upon his release, having met Ken- nedy 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 Avith 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 eonnect the homi- cide Avith the delusion of poisoning and surveiïlance that had prompted the assault on the apothecary EUiott, nor were they satisfied that his iele;as respecting the Avrong done him by Kennedy were dedusions in the same sensé as the aboA'e. The State practicaUy conceded the fact of the 238 A SYSTEM OF LFGAL MEDICINE. insanity, and gave the case to the jury on the failure to connect the homicide with the delusion, its theory being that the kiïling was founded upon a real resentment, the human passion being directed co its proper object, The jury, in their verdict of acquittai, were undoubtedly led to this conclusion by the évidence 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 sliemld 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." This doctrine as an abstraet proposi- tion may be beyond criticism, for medie-al science admits that "if the delusion be limited to one or to a few closely kindred subjee-ts, and if it be of long standing, it perhaps is possible for persons so afflicted to be capable of exercising their judgment upon matters not immediately con- nected with the delusion." ("An Address on the Présent Relation of Insanity to the Criminal Law of England," by W. Orange, M.D., British Médical Journal of October 20, 1887.) From this it would follow, as a légal conséquence, that the same rule prevailing in questions as to civil competency should be applied to criminal respemsibility (Banks vs. Goodfellow, L. R. 5 Q. B. 549)—that the mère existence of an insane delusion, which does not in fact influence particular parts of the conduct of the person afflicted by it, should hâve no effect upon their légal ehar- aeter. (Stephen's History of the Criminal Law of England, chap. xix., p. 162.) The connection, however, between the deïusiem 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 only be ascertained with e-ertainty through the statements of the accused himself ; 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 région of conjecture and probabihty." (The Address of Dr. Orange, supra.) As iïlustrations, 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 betAveen 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 three 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 police, saying 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 avms 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 conséquence Avith a revolver, Avhich he took to bed with him, intending, as he said, to shoot his persecutor Avhile actually m 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 his bed ; but before he could lay his hands on his revolver and take aim MENTAL RESPONSIBILITY IN CRIMINAL CASES. 239 lie' thought he saw the man pass out through the bedroom door. He followed as quickly as possible and fancied lie saw the- man on the stair- e-ase ; but again before lie coule! aim the man had, as he thought, passeel (Ioavu to the next flight. He still followed, and again he thought he should hâve been successful in slooting his persecutor at the front door, but again lie was too late. Still following the image that his delusion had ceuijured up, lie rapidly openeel the front door, and on the oppe>site side of the street he saw a man whom he imme-diately shot. In a case Avhich A\as tried at Maidstone in 1N75, and which obtained some notori- e'ty in cetuse-epience of the strong summing up of the judge in favor e>f a conviction, but in which the jury returned a verdict that the man Avas insane, there- Avas alse> a veuy edose connection between the man's delu- sions and his ae-t, although hère again the connee-tion Avas not clearly ascertained until after his trial. The man hael kided a fellow-workman at the Chatham Dockyard, by splitting his skull with an adze. After the man bee-ame an inmate e)f Broadmoor, he told me that some years before lie had ree-e'ive'd the Holy Ghost; that it had come to him like a flash; that his oavii eyes had been taken ont anel other eyes like balls of fire had been substituted. This, by the wa}T, Avas doubtless a slight epilepti- form seizure. He Avent eui to say that after this he was able to see peo- ple when they were not there, and that he could tell whether they wanted to 'make him go down to the grave.' He said he often felt very ill, as if he were losing his sensés, and that sometimes lie could tell who it was that made him feel so, anel sometimes lie could not. Upon the day when he killed his fellow-workman, he suddenly felt a severe pain in his head. His eyes told him that it Avas his mate avIio caused this, and lie struck him elead. Theu-e Avas no doubt Avhatever that the man was quite mad, and he is now steadily going on toAvarel a state of paralytic dementia. . . . It would appelai- from the cases just cited, and from numerous other similar e-ases Avhich might be adeluced if time permitted, that the absence of direct proed' of the connection between any delusion and any insane act ought by no means to be interpreted as being équivalent to évidence that no such e-emneetiou exists." The criterion contained in the fourth ansAver of the judges is an écho of the ingenieuis spee-ulations of the jurist Hoffbauer (Médecine légale relative aux aliénés et aux sourds muets, sec. 103): "In criminal kiw the dominant idea of an individual under the influence of a delusion should be consieh'ivd as true; that is to say, his actions should be judged as if he Avère actually under the conditions he believed himself to be when he e-ommitted the deed. If the circumstances do not change in any re- spect the nature of the crime, the responsibility anel culpability of the accusée! are establisheel ; if, on the other hand, they diminish or obliter- ate such culpability, the insane person cannot be considered guilty. At Brie-g a soldier killed a child because he believed he saw near him the Almightv, Avho commanded him to do the kiïling. In his report Dr. Glamvitz Avas of opinion that the man should be sent to an insane asylum." This e-riterion gives to a delusion the value of a mistake of fact, put- ting thus on the same plane, as far as they relate to the conséquences, a delusion, the resuit of disease, and a mistake of fact, the resiilt of acci- dent e>r circumstances like those narrateel in the case of William LeAre'tt (4 Cro. Car. 53S), avIio killed the friend of a servant concealed in a but- 240 A SYSTEM OF LEGAL MEDICINE. tery, he being of the impression that she Avas a burglar. (Commonwealtlt vs. Winnemore, 1 Brewst, 357.) From tins relative point of aùcav, that of the- circumstances delusively imagined to exist, the laAV judges the act, applying to it the criterion of the knoAvledge e>f right and Avrong. "It seems to us," says the Suprême Court of Mississippi, "only another method of stating that there eau be no crime Avhen the-re is a mental incapacity to distinguish between right and Avrong, for, though delusions as to particular matters frequently exist in minds which are perfectly ratienial upon ail other subjects, yet if the delusion be se> fixed and vivid as te) make the imaginary seem the real there must be' upon that subject a total incapae-ity to distinguish between right and Avremg, since, the entire relation between the victim of the delusieni and its unconscious subject being mentally perverte d, there can be no proper standpoint of right and wrong in the diseased mind. That which to the rest of the world seems right is to him the most fla- grant Avrong, and vice versa. If to his deluded imagination his best friend, or the Avife of his be>soin, seems a relentless toe bent upoii his destruc- tion, lie m-cessarily ae*ts upon the hallucination Avhich posse'sscs him ; and if his action is such as Avendd be justifiable or pre>per, if the reality Avas as lie supposes it to be, there can be no accountability, bee-ause there has been no conscious crime. If a erazy enthusiast violâtes the laAV, im])eUeel by madness which makes him deem it the inspirée! act of God, lie has endy done that Avhich his diseased and deluded imagination taught him was right; and if the aed would be proper in one so elivinely inspired, aud Avas the direct and necessary conséquence of the eledusion, there can be no punishment, because, hoAvever rational on other subjects, he Avas on that subject incapable of having a criminal intent." (Cuuuiugham vs. State, 56 Miss. 270.) The same e-riterion finds a shorter but sinidar ex- pressiem: "A simple and sound rule may be thus expressed—a man is not responsible for an act Avhen, by reason of involuntary insanity or de- lusion, lie is at the tirne incapable of perceiving that the act Avas either Avrong or unlaAvful." (People vs. Pine, 2 Barb. 566.) Au iïlustration of this eloctrine is the case of a man who might fancy himself a king, and those around him his subjee-ts. If such a person Avère to kill another under the supposition that lie Avas exercising his prerogatiATe as a king, and that he Avas called upon to exécute the other as a criminal, lie Avould not be deemed responsible for his act. (Regina vs. Toiodey, supra.) No less irresponsible are the many persons who imagine that they act under the direct command of God, Avhich supersedes ail human hiAvs and the laAvs e>f nature. (Commonwealtlt vs. Rogers, Jr., supra.) A récent case affords an illustration of the application of the criterion in a contrary sensé. (People vs. Taylor, 138 N. Y. 399.) The défendant Taylor Avas eonvicted of the murder of a fellow-comdct, committed in one of the prisons of the State of New York. After an assault upon a keeper of the prison, he had been transferred to the asylum for insane cornucts upon the report of the physician that he Avas suffering from insane melancholia Avith suicidai and homicidal tendencies. Upon his subséquent return to the prison, he hael been put to Avork in the broom-shop not far from the de- ceased, Avith Avhom he had been previously on very friendly ternis. After a time he exhibited without apparent cause a feeling of givat hostility to the deceased. The professée! occasion for this animosity was, as lie1 claimed, that he had been thwarted in a scheme whieh he had formed of MENTAL RESPONSIBILITY IN CRIMINAL CASTS. 241 making his escape by means of a gate-way, which was in process of con- struction, between the asylum and the prison grounds, and that the de- eeaseel had informed the prison authorities of his design and thus caused its failure. It Avould seem that his plan of escape Avas not a rational one if lie re-ally entertained it. It did not appear that he had eA'er confided it to the decease'd, or that the latter had informed any one in regard to it, or that any person had told the défendant that the deceased had given any such information. The défendant, having founel a convenient op- portunity, attacked the deceaseel with a knife which he had secreted, almost seA'ering his head from his body. After the commission of the dee'el lie informed one of the keepers that he had done it for the purpose of being eleedrocuted. The Court of Appeals, in its affirmance of the judgment of conviction, referred to the élément of delusiem (p. 406) : " Counsel relies Avith great confidence upon the proof of an insane delu- sion as to the part Avhich the deceased had taken in preventing the exé- cution of the defendant's plan of escape ; but this delusion, if established, would not of itself be a sufficient answer to the présent indictment. It may be that if the question of its existence Avère separately submitted to a jury, they might find, as Ave might be compelled to fine! if submitted te> us, that the Aveight of évidence seemed to indicate its existence. That fact, if conclusively proven, woidd faU far short of a elefense. An insane delusion with référence te the conduct and attitude of another cannot excuse' the criminal act of taking his life, unless it is of such a eharaeter that if it had been true it Avould hâve rendered the homicide excusable or justifiable. If the défendant had actually planned a mode of escape from prison, anel had confided this scheme to the deceased, and the latter had betrayed his confidence and informed the authorities of his purpose, and by means of such information it hael been frustrated, it would haAre a.ffordeel the dépendant no justification for his act, but would hâve aug- mentée! its enormity, because inspirent by the unholy moti\*e of revenge. How then can the false belief, standing by itself, that those things had happene'd, affeet the criminal nature of the dofenelant's wrong?" Thèse canons eleteraiiiiing the relations of delusion to e'riminal responsibility hâve found an acceptance even ampler than the principal one enunciated by the judges, for they are recognized as authoritative in States where the criterion of responsibility is not limited to the consciousness, to the poAver to discern between right and wrong, ge>oel and evil. (Peimsyl- vania: Commonwealth vs. Wiuuemore,su-pra,; Sai/res vs. Commonwealth, 88 Pa. St. 291; Taylor vs. The Commonwealth, 109 Pa. St. 262; IoAva: State vs. Stick/ey, 41 IoAva, 232; State vs. Mewherter, 46 IoAva, 88.) It is te) be noted that the ansAvers of the judges assume that the limits of the disease are found Avithin the delusion itself, and that the accused " is not in other respects insane." There can be no doubt as to the exist- ence of cases that the ansAvers of the judges Avould fully coA'er. If, on the other hand, a delusion considered as a symptom be évidence of mental disease- extending beyond the limits of the delusion, of the most e'xtensive mental dérangement, a case1 is presented not contemplated by the judges in their ansAvers. The question, hoAveA-eu-, as to the limits of the delusion, as to the insanity of the accused in other respects, like that of the connection between the delusion and the act, is a question of fact, not euie of laAV. 242 A SYSTEM OF LEGAL MEDICINE. THE EMOTIONS AND THE AVILL. The law of England, and of those American States that accept the an- swers in McNaghteu's Case, recognizes cerebro-mental disease' only in its effect upon the intellee't or the consciousness ; for, in the considération e)f responsibility, its disturbin g influence upon the- émotions and the Avili is utterly ignored. "Every man," says Baron Rolfe, " is held responsible for his acts by the laAV of this country [England] if lie can discern right from wrong. . . . It is true that learned speculaters in their writings hâve laie! it elown that meu Avith a consciousness that they Avère doing Avrong Avère irresistibly impelled to do some unlawful act. But who enabled them to dive into the human heart anel see the real motive that preunptcd the' commission of such deedsf " (Regina vs. Stokcs, 3 C. & K. 185.) If the intellect or consciousness, although dise-ase'd, be to that extent un- impaireel that it is able to pe'rceive that the act is unlawful or morally wrong, the insane man is in the eyes of the law a sane one, so far as the questiem of insanity may aftee-t the question of his responsibility. ( Willis vs. People, 32 N. Y. 715.) In such a case the laAV, ceuiclusiAely presuming the freedom of the will—the existence of a power of choice—considering the impulses of insanity as impulses not uncontrollable, but in fact un- controlled, exacts from the insane man a résistance to them similar to the insistance to human passion it requires from the sane euie. (People vs. Taylor, supra.) To this conclusion in a certain measure has the laAV been led by considérations of policy or convenience ; for in its estimate any further inquiry Avould be vague and uucertain, and a justification anel a cover for the commission of crime. (Flanagan vs. Veople, 52 N. Y. 467.) This vieAV is reflected in the report of the Re>val Commission on the Criminal Code Bill (1878-79) (vol. lxxiv, p. lf) : "The principal sub- stantial différence between Section 22 of the draft code anel the corre- sponding section of the biïl is, that the latter recognizes as an excuse the existence of an impulse to commit a crime so violent that the off en der would not be prevented from doing the act by knowing that the greatest punishment permitted by the law for the offense would be instantly in- flicted—the theory being that it is useless to threaten a person over Avhom by the supposition threats can exercise no influence. Tins proAÙs- ion of the biïl assumes that the accused . . . was, at the time he did the act, capable of appreciating its nature and quality, and knew that Avhat he was doing Avas wrong. The test proposed for distinguishing between such a state of mind and a criminal motive, the offspring of revenge, hatred, of ungoverned passion, appears on the whole not to be practicable or safe, and we are unable to suggest one which Avould satisfy thèse re;q- uisites and obviate the risk of a jury being misled by considérations of so metaphysical a eharaeter." Inasmue-h as every crime is committed under an impulse more or less irrésistible, and the object of the laAV is to control such impulses, it is considered to be a doctrine the most danger- ous to admit as a défense the fact of an impulse being uncontrollable, even though the impulse be the offspring of disease. (Regina vs. AJlnnt, Baron Rolfe, London Times, December 16, 1847; Regina vs. Brough. Erle, C. J., London Times, August 10, 1854 ; Regina vs. Barton, 3 Cox, Cr. Ca. 275.) "If an influence be so powerful as to be termed irrésistible," says Baron Bramwell, "so much the more reason is there Avhy we MENTAL RESPONSIBILITY IN CRIMINAL CASES. 243 should not Avithdraw any of the safeguards tending to counteract it. There' are three powerful restraints existing, aU tending to the assist- ance of the perse m Avho is suffering under such an influence—the re- straint of religion, the restraint of conscience, and the restraint of law. But if the influence itself be held a légal excuse, rendering the crime elis- punishable, you at once Avithdraw a most poAverful restraint—that for- bide! ing anel punishing its perpétration. We must therefore return to the simple question you hâve te) détermine—Did the prisoner know the nature'of the act he was doing, and diel lie knenv that he was doing what Avas Avrong?" (Regina vs. Hayues, 1 F. & F. 666.) This same judge em- phasizeel sinidar views before the sélect e-ommittee on the Homicide Law Amendment Act : " What is the meaning of a man being prevented from controlling his coneluct? When he is preventeel it is because the pivveutiug motives are strong enough. When he is not prevented it is because they are not strong enough. The effect of this [the proposed act] woulel be to lessen the preventing motiA'es. A Avishes to commit a râpe. Disease' of mind weakens his poAver of acting on motives of chas- tity, religion, morality, goodness, etc., but fear of the laAV addeel to thèse motives make's him able to resist. The proposai is to take away one of his ge>od motives. ... I tried a man named Doac many years ago tor murdering his wife. He called a number of witnesses for the pur- pose of proving that lie could not control his ae-tions. There was one of them who, to prove the state of this man's mind, proved that he shot a cat in the présence of his wife, or something of that sort, and this man graAi'lv said lie believeel it Avas an uncontrollable impulse. I put this question to him (I elid not let him see the difficulty it woidd lead him in ; 1 got his mind aAvay from the particular ansAver he had given): 'Noav, siqqtose a polieeman had been présent Avlie-n he shot that cat, de> you think lie Avould hâve been restrained?' And lie said, 'Yes!' 'WeU, then,' I said, 'according to venir vieAV an uncontrollable impulse is an impulse aeding upon a man Avhen a polieeman is not pre'sent.' It is obvious that what is called an uncontrollable impulse is one as to Avhichthe deterring or controlling motiA'es are not stremg enough. And this is a proposition in aU e^ase's to take away from a man, in a state of mind in which he is more likely to do mischief than anything else, a deterring motive." (Re- port of Select Committee, Minutes of Evidence, 1874, vol. ix., p. 26.) " The prisoner Avas prove-el to hâve been perfectly well aware," says Baron Alderson, " Avhat he hael done immeeliately afteiward, and in the inter- view Avhich he had since Avith one of the médical gentlemen he admitteel that lu- knew perfectly well what he had deme, and ascribed his conduct to senne momentary uncontrollable impulse. The laAV did not acknoAvl- edge such an impulse if the person was aware that it was a Avrong act he Avas about to commit, anel lie- Avas ansAverable for the conséquences. A man might say that lie pie-ke'd a pocket, from some uncontroiïable im- pulse, and in that case the hiAv would hâve an uncontroiïable impulse to punish him." (Regina vs. Pâte, London Times, July 12, 1850.) This e-euitemplation of insanity, as limited in its effects to the intellect anel consciousness, is as marked in the subordinate criteria as in the principal canon itself. In the distinction draAvn between an act the con- se'ejiie'iiee of a delusion, and an act founded upon a real eA^ent, the law, Aveighing the act in the scales of responsibility, takes no note of the insane émotion that may hâve distorted or exaggerated the event or fact 244 A SYSTEM OF LEGAL M El) ICI NT. giving rise te) the passion or émotion. To it delusions are e-sseutially ed an objective nature, mère errors as to existing facts (Regina vs. Burtou. 3 F. & F. 772), anel in the- considération of the-m the laAV utterly excludes the emedions as facte)rs of responsibility. For assuming a delusion to be that the accused had suffereel a Avrong at the hands of anetther, by arbitrardy ase'ribing the inspirât h >n of the act to the '•unholy passion of revenge- " (People vs. Taylor, supra), and by exacting from the insane man a sane' résistance to sue-h suppe>seel passion, the law totally excludes from its considération any disorder of the emotional nature' produced by the insanity of Avhich the delusion may only be a symptom. This légal vieAV* of insanity, Avhich interprets the ansAvers of the juelges in their natural and restrie-ted sensé, prevails, as has been said, in England and in the following of the United States of America : CALIFORNIA. People vs. Hoin, 62 Cal. 120. GEORGIA. Anderson vs. State, 42 Geo. 10. MINNESOTA. State vs. Scott, 41 Minn. 365. NEAV JERSEY. State vs. Graves, 5 N. J. L. J. 54. NEAV YORK. Walker vs. People, 88 N. Y. 82 ; People vs. Carpenter, 102 N. Y. 238. DISTRICT OF COLUMBIA. TJ. S. vs. Guiteau, 1 Mackey, 498. Having its foundation on metaphysical à priori reasoning this theory of insanity has met with the most relentless opposition from médical science, Avhich claims for its conclusions a weight due to exteudeel obser- vation and experiment. Inasmuch as the consciousness of right and wrong can be proved to exist in any condition of mind above that of " an infant, a brute, en* a Avild beast"; in any degree of insanity Avhich does not extend to the total deprivation of memory and understanding; and as this consciousness, as a criterion, could consequently only apply to the furions maniac, the confirmed idiot, or the actively delirious, anel Avould consequently include the greater number of the ordinary inmates of in- sane asylums, the majority of gênerai intellectual man'iacs. and a still larger proportion of partial intellectual maniae-s, médical science rejee-ts it as a true criterion of moral responsibility. In addition, the contem- plation of insanity as a disease' exclnsively affecting the inteiïect or the consciousness, thus ignoring the disordered émotions and the Aviiï as factors of responsibility, is said te) be oppeised to the essential pathole>gy of the disease, which is primarily a disorder of man's emotional nature. MENTAL RESPONSIBILITY IN CRIMINAL CASES. 245 " Responsibility dt pends upon power, not upon knowledge, still less upon feeling. A man is responsible to do that which he can do, not that which he feels or knows it right to do" (Bucknill on Criminal Lunacy, p. 59); a criminal being properly punishable, not because he knenvs good from evil, but because lie' veduntarily did the evil, having the poAver to choose the good. (Ogston's Lectures on Médical Jurisprudence, Lecture XXI. ; Buckndl and Tukc's Psychological Medicine,p. 269 ; Review of Dr. Jamiesem on "Criminal Responsibility of Iusane," 4 Psychological Journal, p. 187.) Many of the juriste of Englanel hâve borne testimony as to the diffi- culty of making the légal criterion a rule of uni versai appiïcation—a criterion emboelying such a définition of légal madness " that nobody is hardly ever really mad enough to be Avithin it," AAdiieh is the frank ad- mission of Baron BramAvell, who e-ertainly cannot be charged with sen- timental tenelerness toward the insane. (Repen-ts of Committees, Minutes of Evidence, 1S74, A'ol. ix., p. 27.) Redore the sélect committee on the Hennicide Law Amendment Act, Avhie-h, drafted by Sir J. F. J. Stephen, Avoulel hâve introduced into the- criterion of responsibility the additional élément, the prévention by any elise-ase affecting the mind of the power e)f ceuitrolling the conduct (Homicide Law Amendment Act, part ii., sec. 24e/), Mr. Justice Blackburn gave the following testimony: " We cannot fail to se'e1 that there are cases where the person is clearly not responsible and yet knew right from wrong. I can give ye>u an instance which shows Avhat I held deliberately ; it Avas in the case of that Avoman whom I Avas speaking of, avIio avus tried for wounding a girl with intent to murder. The facts Avère thèse : the Avoman had more than once been insane, insanity being principally brought on by suckling lier chiïd too long; that Avas the e-ause that had produced it before. She was living with lier husband, and had charge of this girl, a girl of about fifteen, an impotent girl avIio lay in bed ail day. She Avas Aery kind to her, and treated lier very Avell. They Avère miserably poor, and very much OAving to that she continued to nurse her be>y till he Avas nearly tAvo years old, anel suddenly, Avhen in this state, she one morning, about eleA^en o'e-loek, went to the child lying there in bed, ageel fifteen, and deliberately eut her throat, Then she Avent toAvard her own child, a girl of five or six ve'ars of âge, of Avhom she Avas exceedingly fond, and the girl hearing a ne use looked up and said, 'What are you doing?' 'I hâve kiïled Olivia, and I am going to kill you,' Avas the ansAver. The child, fortunately, in- stead of se-reaming, threw lier arms around her mother's neck and said, ' Ne>, I knoAV yeni would not hurt your elarling little Mopsy.' The Avoman dropped the child, Avent doAvnstairs and Avent into a neighbor's house, told lier Avhat she had donc, that she had killed OliA'ia and Avas going to kill Mary, but • Avhen the darling threw lier arms around my neck I had not the heart te) do it.' She clearly kneAV right from Avrong, and knew the eharaeter of her act, for senne little time after that she talkecl ration- ally enough; but before night she Avas sent to a lunatic asylum, raving mad, anel having recovered she Avas brought to be tried before me at a subséquent assize. On the définition in McNaghten's Case, she did 'know right from Avrong'; she did not [sir] kne»AV the quality of her act, and Avas epiite aAvare of Avhat she had done, but I felt it impossible to say that she should be punished. If I had read the définition in McNaghten's Case anel said, 'Do you bring lier within that?' the jury would hâve taken the bit in their oavii teeth and said, 'Not guilty on the ground of 246 A SYSTEM OF LEGAL MEDICINE. insanity.' I did not do that. I told tlieun that there were «'xe-eptional cases, and on that the jury found lier not guilty on the' grounel of in- sanity, and I think rightly. On this définition I think you Avemlel be- obliged to sa}T that Avoman Avas guilty." (Reports of Conimittees, Minutes of EAÙdence, 1874, vol. ix., p. 11.) Of similar ténor Avère the' vu-avs ex- pressed by the Lord Chief-Justice Ce>ckburn in a mémorandum submitted to this same committee : " As the laAV, as expounded by the judges in the House of Len-ds, ne>AV stands, it is only Avlieui mental elise'ase' proeluce's in- capacity to distinguish between right anel Avrong that ininninity from the pénal conseepiences of crime is admitted. The présent bill introduces a new élément, the absence of the power of self-control. I concur most cordially in the proposed alte-ratiem e)f the laAV, haAÙng always been strongly of opinion that, as the pathology of insanity abundantly estab- lishes, there are forms of mental disease in which, though the patient is quite aAvare that he is about to do Avrong, the Avili bee-omes overpowered by the force of irrésistible impulse-. The power of self-control, Avhen de- stroyeel or suspende-el by mental elise'ase, becemu-s, I think, an essential élément of respemsibility." (Reports of ( 'ommittees, Spécial Report Select Committee, No. 1, 1874, vol. ix., App. No. 1.) In a récent charge to the grand jury at the Shropshire Avinter assizes Mr. Justice Hawkins referred to the e-ase of one Anthony Ware, chargée! with the murder of one Smith at the Salop and Montgomery County Asylum, Bicton, near Shrewsbury. After the homicidal act was com- mitted, the patient Avas rememnl to Broaelmoor. Under thèse circum- stances, the finding of a true bill did not come under the e-onsideration of a jury. The judge, however, regarded the case as so very interesting that lie Avent out of his way to comment upem it to the grand jury. It appears that Ware had been for a e-onsielerable time a dangerems lunatic. Dr. Strange, the médical superhitenelent of the Bicton asylum, stated that Avhile he had been a patient at the County Asylum lie had com- mitted several murderous assaults upem patients, and in one instance upon an attendant. On the fatal elay this homicidal patient hael been out for an airing with another dangerems lunatic nameel Smith. Indeed there seemed to be some fifteen or sixteen patients of the class together. On returning to the asylum, Ware prendded himself Avith an iron bar from a bedstead, and was seen by the- attendant in charge to strike the deceased (Smith) upon the head with it. From the Avounels thus received the latter quickly died. As Ware threateneel to murder every one who approache'd him, prompt assistance coule! not be renelered to save Smith's life. Having called attention to the ansAvers of the judges, his lordship requested the jury to apply them to the case in question, in Avhich no one, lawyer or layman, would A-enture to say that the Avretched man is responsible for the act he committed; yet, although he Avas a confirmed lunatic, lie Avas perfectly aAvare, according to the dépositions, of the nature of the act. It was quite cl ear, from Avhat lie himself had said, that lie had kiiïed some one, and that lie Avas alse> aware that Avhat he had done was Avrong; for lie extraeted a promise that lie should not be punished if he gave up the iron bar that he had in his possession. " This being so, it would be impossible to say that Ware did not know that he had killed a man, because he said himself that lie had; anel it would bc impossible for anybody to urge that he did not knoAV it Avas wrong, for lie Avanted a promise that lie should not be punished ; but unless one put MENTAL RESPONSIBILITY IN CRIMINAL CASES. 247 a totally différent construction on the laAV, that Avoulel haA-e to be proved; although no man in his sensés Avould suppose that any juiy Avould find Ware responsible for what he had done." Mr. Justice Hawkins stated in additiem that he had not only spoken his own views upon the matter, for more than one of the judges had expressed the désire that the law upem the subject should be reAÏsed and a little more definite understand- ing arrivée! at. (Mr. Justice Hawkins on " The Plea of Insanity iu Crim- inal Cases," Journal of Mental Science, vol. xxxi., p. 64.) Expressions of opinion as to the incompletene-ss or inadequaey of the criterion are not confined to the judges of England. The trial ed' Andréav Kleim Avas hael before Mr. Justice Edmonds of the Suprême Court of the State of NeAV York. The prisoner had been indie-ted for the Aviiïful murder of one Catharine Hanlon. The deceased, Avith her husband and children, re- sieleel in a Ave>e>den shanty or dwelling, the only door of which was in the front, abenit five yarels from the prisoner's résidence;. One morning, be- tAveen six and seven o'clock, the prisoner came out of his house and piled Avoeiel-shavings and straAv at the door of the dee-easeel's résidence, to Avhich he then se't fire. The deeeaseel attempted to escape through the door, but was forcibly thrust back by the prisoner, who stabbed lier in the thigh Avith a sharp instrument attaelied te» a stick. She Avent to a window with her son, a bey of about thirteen years of âge, when the' prisoner threateneel to eut lier throat; she them swooned away and became sense- less. The ded'ense Avas insanity, anel upon a preliminary inquiry the jury found that the prisoner Avas not then insane. Upon the subséquent trial upon the main issue1, the jury returned a A'erdie-t of " not guilty " upon the ground of insanity. "The first case of insanity that came before me as juelge," says Mr. Justice Edmonds, "Avas this e'ase of Kleim. In the pre- liminary inepiiry into présent insanity, I followed tins rule (McNaghten's Case), and the verdict of the jury at once satisfied me that it had misled them, for lie Avas not totalfy but only ' partially insane,' and he did know that it Avas Avreuig to shut that woman and her children in their hut and burn them to death ; yet there Avas no doubt of his insanity, and in less than a year lie became a mère didveling idiot, and so died. He knew the ae-t Avas wrong, yet he Avas insane. The act of piling up sliaAÙngs, fasten- ing the woman in lier hut, anel forcing lier back into the fiâmes, Avas not an • involuntary act of the body without the concurrence of a mind diree-ting it,'* yet he Avas insane. He kneAV the 'act was contrary to the plain dictâtes of justice and right, injurious to others, and a violation of the dictâtes of duty,'t yet he Avas insane. He knew 'he was acting con- trary te> law,' yet lie' Avas insane. He knew the act Avas 'one he ought not to do,' vet he Avas insane." (Note to People vs. Andrew Kleim, 1 Edm. Sel. t'a. 28.') A ree-ent case trie-el at the Taunton assizes, England, affords a striking proof of the possible coexistence of extraordinary insanity and aiï the conditions that might bring an accused Avithin the letter of McNaghten's Case. (uRegina vs. Hitchens" by Charles M ère der, Laneet, Mardi 3,1888.) The prisoner, a lad of twenty-one, had suffered for many years from epi- lepsy, Avhich hael been getting more sewere. His mother had been on two eice-asions insane, the second occasion being shortly before the birth of the prisoner. One morning, before he Avas fuiïy dressed, the prisoner * Sliaw, C. J., Commonwealth vs. Rogers, Jr., supra. t Ibid. -^ A SYSTEM OF LEGAL MEDICINE. went into the bedroom of his eldest sister, who was in bed, and blew her brains out with one discharge from a double-barreled gun. Ile then fired two shots from the same gain at his own head, but oïdv slightlv wounded himself. He then rushed out of the room anel plunge-el hea'd-foremost down a flight of stairs. He did not slip or faiï down, but threw himself down with his hands up, as if diving into wator. After this he got up and threw himself in the' same way down a second flight of stairs. Ile ao-ain got up and threw hiniself in tlu- same way into a fireplaee. Being taken and put to bed, he told his father to look into the pocke-ts of a e-oat that was hanging in his room. There the father found the following letter : " I leave everything that belongs to me to my dear mother. I hâve been treated so badly by that beast, my sister Constance, that I must put an enel to her hfe by shooting ; anel knowing that I should hâve to die for it, I also shoot myself. Good-by to ail ! Hoping von will hâve a haï m v time of it, good-by, dear father and mother ! " The prisoner subsequently said several limes to différent people that his sister had been verv unkind to him, and had been a bad eme to him. It did not appear at the trial, however, that he had previously shown animosity toward her beyond that usually displayed in mère children's squabbles, and the onlv com- plamts he had ever maele against her were that she had not given him a neAvspaper when he asked for it, and that she hael passed hiin in the street without speaking. The prisoner, at the instance of the Crown had been examined previously to the trial by médical experts, who at the trial itself gave testimony for the défense under circumstances of great difficulty, owing to the rulings of the trial judge. It appeared in évi- dence that the epilepsy to which the accused was subject included both forms of epileptie paroxysm, namely, le haut and le petit mal, and in addition physieal symptoms proved to the médical mind at least 'the tact of the- pnsoner's extrême insanity. The summing up of the judo-e (Mr. Justice Field) was very strong against the prisoner. He declared that ail the conversations narrated and ail the acts of the prisoner were perfectly rational. He took the letter written by the prisoner, and read- ing it sentence by sentence, asked if each sentence was not a rational one. He told the jury that the question for them was, " Did the prisoner knoAV the nature and quality of the act he had committed ; that it was con- demned by the laws of God and man, and if he committed it that lie would hâve to suffer death for it ? " The judge further charged the jury that even if they were satisfied that the prisoner was insane at the time ot the crime, they could not return a verdie-t of "guiltv " but "insane " unless they found that lie was suffering from such a delusion that, if the tacts really had been as he deludedly beiïeved them to be, he could hâve legaiïy committed the act for which lie was tried. After a short absence the jury returned a verdict, according to the récent statute, of " o-uiltv but insane at the time the act was committed." The repeated occurrence of thèse "exceptions! cases " referred to by Mr. Justice Blackburn—cases where palpable irresponsibility coexiste with an évident knowledge of the différence between right and wrong—has compelled the judges, to avoid the commission of the most manifest injustice, to départ from the- crite- rion. thèse facts furmsh a very strong practical argument against the criterion as being a rule complète in itself. At the trial of Joseph Giiï, at the Leeds assizes, in April, 1S83 Mr Justice Ray charged the jury that "the most important question Va s MENTAL RESPONSIBILITY IN CRIMINAL CASES. 249 Were they dealing with a sane man ? Judges had said over and o\rer again that a man could not be considered insane merely because he did a criminal act, and the importance of that vie-Av could not be etveresti- mated. Nevertheless, he did not agrée Avith the learneel counsel avIio put it that ' it Avas necessary te prove that a man did not knoAV the différ- ence' betwenui right and Avrong in order to show that he Avas insane.' If a nian's mind Avas in suedi a diseased condition that he Avas subject to uncontroiïable impulse', they Avould lie justified in finding him irresponsi- ble for his actions. What the jury had to ask tliemsedves Avas, Was the prisemer's mind subject to an uncontrollable impulse over Avhich his Avili hael no power? If se), they must ae-epiit him on the ground of insanity." (Itevie-Avof " History of the Criminal LaAvof England," by Stephen, Jour- nal of Mental Science, vol. xxix., p. 258.) So also in a récent case, Mr. Jus- tice Lawre-nce put thus the epiestiem to the jury: "Was the priseuier un- able to control his actieuis in conséquence of disordered mind?" (The Duncan Case, Journal of Mental Science, vol. xxxvii., p. 5G2.) As the lead- ing canon, so hâve the subordinate criteria in relation to delusions met with adveu-se- anel, destructive criticism. As lias been said, thèse answers of the judges haA^e for their basis the assumption that the aeeuse-el is " not in other respects insane " ; that the effect of the delusion is to produce an intellectual en-en- as to an existing fact, the limits of Avhich are found within the delusion itself. It is held by the most distinguished authority that the fact of an illégal act being committed from the point of aùcav of a fixed delusion is in itself a prend' that the reason of the ace-used has lost control of the fixée! idea, and that the elelusion itself has e'eascd to be a limited one. (Casper's Handbook of Foreusic Medicine, part vi., vol. iv., chap. ii., sec. 80.) Be this as it may. the ansAvers, even upon their as- sumption of a partial or limited delusion, hâve not met Avitli 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; the at- tributing to madiie'ss the delusive imaginary fact, and to sanity the émotion or passion arising out of that fact; the judgment of thèse émotions or passions from a standpoint of sanity, by the exaction from the accused of a sane- conduct in référence to them, thus eliminating any influence of the disease upon the émotions and the Aviïl. • (State vs. Joues, 60 N. H. 369 ; Parsons vs. State, 81 Ala. 577.) This élimination, it is claimed, essentially e'ontradie-ts the pathology of delusions as symp- toms of mental dérangement. Médical science assures us that " a delu- sion . . . never, or hardly ever, stands alone, but is in ail cases the resuit of a disease of the brain, Avhich interfères more or less Avith every function of the mind, Avhich falsifies aiï the émotions, alters in an unaccountable Avay the natural Avcight of motives of conduct, Aveakens the Aviïl, and soinetimes, Avithout giAÙng the patient false impressiems of external facts, se> enfeebles every part of his mind that lie sees aud feels and acts Avith re'gard to real things as a sane man does with regard to what he sup- pe»se-s himself to see in a dream. . . . Suppose, for instance, that by rea- sem of the elise'ase e>f the brain a man's mine! is filled Avith delusions Avhich, if true, would not justify or excuse his proposed act, but which in them- selves are so Avild aud astonishing as to make it impossible for him to reasem about them calmly, or to reason calmly upon matters connected Avith them. Suppose, too, that the succession of insane thoughts of one 250 A SYSTEM OF TE G AL MEDICINE. kind and another is so rapid as to confuse him ; and finally suppe>se' that his Aviiï is Aveakened by his disease, that he is unequal te) the effort of calm sustained thought upon any subject, and especially upon subjects connected Avith his delusion—can he be said to knoAV or bave- a e-apacby of knowing that the act Avhich lie proposes to do is Avrong?" (Stephen's History of the Criminal Lan- of England, vol. ii., chap. xix., pp. 157, 164.) As a solution, Sir J. F. J. Stephen Avemld construe the answeu-s of the judges in a broader anel, as it Avère, a "non-natural" sensé-: the word "know" including, in his opinion, not knowledge only, but the power of cenitrolling the conduct as Avell: "Knowledge and power are the constit- uent éléments of ail voluntaiy action, and if either is seriously impaired the other is disabled. It is as true that a man avIio cannot control him- self does not know the nature of his acts as that a man Avho does not knoAV the' nature of his acts is incapable of sedf-control." His proposition is, "that, if it is not, it ought te) be the law of England that no act is a crime if the person Avho does it is at the time Avhen it is done prevented either by détective mental poAver or by any disease affectinr his minel from controiïing his own conduct, unless the absence; of the poAver of self-control lias been produced by lus own default." (Stephen's History of the Criminal Law of England, vol. ii., chap. xix., p. 168.) In the opinion of the Lord Chief-Justice Cockburn, the doubts and difficulties suggested by the answe-rs of the judges liave been due to a construction too wide and gênerai, and to their not having been applienl strie-tly with référencer to the questions put: "Among the functions e>f the human minel liable to be ;)erATerted by disease is, as ail scientific writ ers on insanity are- agreed, the human Avili; Avhich sometimes becomes the slave of maniacal impulses, Avhich it is unable to resist. Among the différent forms of madness by Avhie-h the Avili is hable to be thus affected is that which is knoAvn by the name of homicidal mania, e>r AA'hen it compels a person to self-destruction, suicidai mania. That the Aviiï is liable to be thus maniac- ally affected, and so to be SAvayed by impulses Avhich it is unable to resist, is a point on which Avriters on mental pathology are agreed. Instances lnave been known in which lunatic patients ba\re been periodically thus affected, and, conscious of the approach of the maniacal condition, hâve recpiesteel to be phu-e'd under restraint. Murders for which no motive could be suggested, sometimes of childreji by their own mother, self-mur- der, equally Avithout adéquate motive, by men of religious eharaeter, can often only be thus ae-e-ounted for. Ought persons, avIio, thus afflicted, commit crimes, te) be punished as though they Avère of sound mind and capable of the self-restraint Avhicli the sensé of moral right and wrong or the fear of the kvw imposes upon others more happily constituted ? The point cannot as yet be said to hâve been authoritatively determined. The language of the judges in the House of Lords has, no doubt, been repeated as of gênerai application, but erroneously. Their ansAvers had référence to the spécifie questions put them by the House, the language of aa Inch was in thèse terms : ' What is the laAV respecting aiïeged crimes committed by persons afflicted with insane delusions in respect of one or more particular subjee-ts or persons?' The ansAver is restricted to the spécifie question so put. 'Assuming,' it begins, 'that your inquiries are confinée! to tliose persons Avho labor under such partial delusion only and are not in other respects insane, Ave are of opinion,' etc.—the ansAver thus excluding any other form of insanity save that of partial delusion, MENTAL RESPONSIBILITY IN CRIMINAL CASES. 251 anel consequently not touching the case of mania, to Avhich I am at prés- ent diree-ting attention. Further questions are put as to the questions to be put to the jury when a person haAÙng insane delusions is charged Avith crime, and insanity is set up as a défense, anel the answers, as be- fore, hâve référence only to the questions put, that is to say, as to the effect of iusaue delusions as a défense. The point has not come under juclicial discussion in a case Avhich really raised the question. The near- est approach to it Avas in the case of Regina vs. Burton, reported in 3 F. & F. 772, where the prisoner, a lad of eighteen, had murdered a boy, con- fessing the fact afterward, and accounting for it by saying 'lie had made up his mind to murder some one, as he was tired of life.' There Avas insanity in the boy's family, his mother having been twice confined in a lunatic asylum, but the défense set up being homicidal mania and the want of self-control, there was no évidence of the latter in anything but the fact itself. The summing up of the learned judge, Mr. Justice Wight- man, cannot, I think, be considérée! as satisfactory. Whde depreciating the doctrine of homicidal mania as a highly dangerous doctrine, lie went the length of saying, founding himself upon the supposed doctrine of the judge's, which lie 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 défense was not submitted to the judges or in\Tolved in their answers. The question whether under the influence of mental disease the human Aviïl may become subject to impulses which it is unable to resist, and upon which even the fear of death will not eqier- ate as a restraint, is not one for hiwyers to dispose of dogmatically, as they often do, but one which, as a question of pathological science, it is for men conversant with that science to décide. If the fact is estab- lished, as I beheve it to be, it is for the enlightene-d and philosophie law- giver, in the interest of justice and humanity on the one hand and of so- ciety on the other, to détermine 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 thèse latter views are the Continental jurists agreed. With them the " faculty of choosing betAveen good and evil," or "the power to act with freedom," is not necessarily included in the capacity to know right from Avrong; 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 f acultjr of choosing between them. (Review of Mittermaier on "The Excuse of Insanity," American Jurist, vol. xxii., pp. 312, 313; Casper's Handbook of Forensic Medicine, vol. iv., part vi., chap. ii., sec. 80.) The effect of mental disease upon the émotions and the will, and the conséquent poAver of controlling the conduct, are recognized as essential éléments of responsibiïity in ALABAMA. By the loss of the power of choosing between right and wrong through the duress of mental disease. Parsons vs. State, 81 Ala. 577. CONNECTICUT. Bv the irrésistible impulse arising from disease. State vs. Johnson, 40 Conn. 136. 252 A SYSTEM OF LEGAL MEDICINE. ILLINOIS. By an uncontrollable impulse- to do the act chargée!, which deprives the accused of the power to choose between the right and the wrong. Hopps vs. People, 31 111. 385. INDIANA. Bv the loss of the poAver of self-control through mental disease. Sterens vs. State, 31 Ind. 485; Bradley vs. State, 31 Ind. 492; Conway vs. State, 118 Ind. 482. IOAVA. By an uncontroiïable and irrésistible impulse arising from mental disease. State vs. Felter, 25 Iowa, 67 ; State vs. Mewherter, 46 Iowa, 88. MICHIGAN. By the loss from insanity of the poAver 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, e-ontrol the will, and render it impossible to do otherwise than yield thereto." Taylor vs. Commonwealth, 109 Pa. St. 262; Commouweedth vs. Winnemore, 1 Brewst. 356; Ortivein vs. Common- wealth, 76 Pa. St. 414; Brown vs. Commonwealth, 78 Pa. St. 122. MORAL INSANITY. The impulses hitherto referred to hâve been of two kinds. The one, overwhelming the reason, conscience, and judgment, oblitérâtes or ob- scures the capacity to distinguish between right and wrong. (Common- wealth vs. Rogers, Jr., 7 Metc. 500; Cuuningham vs. State, 56 Miss. 269; People vs. Sprague, 2 Park, C. R. Cases, 43; Regina vs. Bartou, 3 C. C. 277.) The other, irrespective of its influence upon this same capacity, so subjugates the Aviiï 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 dérangement—of intellectual insanity— a récognition of it as an élément of responsibility does not involve as a necessary conséquence an acquiescence in the theory of the so-caiïed " moral or emotional insanity." This theory, having its origin in a sup- posed lésion of the Avili, apart from that of the understanding, in the pre- sumed existence of an instinctive and abstraet rage or mania Avithout delirium, "un emportement maniaque sans délire," was extended by other theorists to the disc-OArery and description of a disorder called " moral in- sanity," of which the symptoms Avère only displayeel in the state of the feelings, affections, temper, anel in the habits aud conduct of the indi- vidual, or in the exercise of the>se mental faculties AAdiich are termed the; active and moral powers of the mind. In this alleged disoreler it Avas assumed that there Avas no discoA*erable iïlusion or hallucination, or MENTAL RESPONSIBILITY IN CRIMINAL CASES. 253 any symptom characteristic of monomania or intellectual insanity—in a word, that "an insanity in conduct" existed séparât ely and distine-t from the insanity in ideas. (Prie-harers Forms of Insanity, sec. v.) Dr. Mauds- ' ley, recognizing this alleged form under the gênerai name of "affective insanity"—that is, insanity Avithout delusion, or insanity of feeling anel ae-tion—subdivides it into the two classes of impulsive and menai insan- ity ; the former being mental disease whereby the sufferer, Avithout pas- sion, delusion, or motive-, is driven independently of the Avili by blind1 instinctive impulses; the latter a disorder of the mind Avithout illusion, delusion, or hallucination, the symptoms of Avhich being mainly exliibited' in a perve-rsion of those limitai faculties which are usuaiïy called the act-j ive and moral poAvers. (Responsibility in Mental Disease, chap. v.) Dr.' Ray anel othe-rs, insisting upon the existence of a moral mania as contra- distinguished from the intellectual form, distinguished betAveen gênerai moral mania and partial moral manias, the latter being evidenceel by spé- cifie morbid impulses which are in thèse cases presumably the e-xe-iusive' and essential symptoms of the existing insanity : such as kleptomania, an irrésistible impulse to steal ; pjn-omania, an irrésistible impulse to burn and destroy ; erotomania and nymphomania, irre-sistible impulses to sexual excess; homicidal mania, an irrésistible impulse to kill; suicidai mania, an irrésistible impulse to self-destruedieui. (Ray's Médical Juris- prudence of Insanity, chap. vii.) As in the opinion of the médical experts there Avère évidences of mental dérangement in the e-ase of Charles P. Huntington, avIio Avas tried for forgery at the General Sessions of the county of New York in the year 1856, the dise'ased tendeney to " make paper," that is, forge» commercial pape-r, may not perhaps be» considérée! an addition to the above classifications. (Trial of Charles P. Hunting- ton, Testimony of Willarel Parker, M.D., p. 253.) It is olmous that thèse théories, the " excuse of an irrésistible impulse coexisting with the full possessiem of reasoning poAvers " (Baron Parke, Regina vs. Barton, supra), e-an find no countenance in the law of England, which does not admit into its criterion of responsibility the élément of impulse, even though that impulse be the» undoubted offspring of intellect- ual dérangement. A récognition no more ample is given by the courts of those Amerie-an States that admit an impairment by elisease of the freedom of the will, the elisease being presumably a form of intellectual insanity. (l'arsons vs. State, supra.) Some few cases Avhich cannot be consielereel as authorities hâve gone' a step beyonel. At an early day in Pennsylvania Chief-Justice Gibson affirmed (Commonwealth vs. Mosler, 4 Pa. St. 264) that insanity Avas either mental or moral, the latter consist- ing of an irrésistible impulse to kill or commit some other offense. The Suprême Court of Conne-cticut, speaking through Mr. Justice C arpenter, helel that a elerangeune'nt of the moral faculties is in itself a particular form of insanity, Avhie'h is divieleel into tAvo kinds, gênerai and partial; the» former ceuisisting in a gênerai exaltation, perversion, or dérangement of function of ail the affective or moral poAvers ; the latter of particular ! morbid impulses, such as kleptomania, or propensity to steal ; pyromania, or pre>pemsity te» destroy by fire; and homie-idal mania. (Andersen vs. state, 43 Conn. 514.) So also the Suprême Court of Kentucky : "The common law progresses Avith ail other se-ie»iice AAuth which it is affiliated as a groAving and consistent Avhole. Anel, consequently, as the science of man's moral nature has eleweloped the phenomena of insane affections. 254 A SYSTEM OF LEGAL MEDICINE. émotions, and passions, Avhich either neutralize or subjugate the will, médical jurisprudence recognizes this morbid and overwhelniing influ- ence as moral insanity, anel preniounces it as exculpatory as tic other form caiïeel intellectual insanity. No enlightened jurist no\v doubts the existence of such a type of moral, e-ontraelistinguished from intellee-tual, insanity, as homicidal mania, or morbid and uncontreiiïa.ble appetite for man-killing, and pyromauia, or the like passiem for house-buriiing, and kleptomania, or an irrésistible inclination to steal. In each of thèse cases and others of a kindreel eharaeter, Avhether the unnatlirai passion be congénital or only the offspring of some supereniinent cause, moral unhingement and a subjugateel and subsidized Avili are the invariable cliaracteristie-s. Tins is elisease, and the man thus doomed to the anarchy of morbid and ungovernable passions is, in laAV as Avell as in fae-t, insane ; and to the extent of the opération of that blind and brutal influence he may be no more responsible than a tiger or other brute." (Smith vs. Commonwealth, 1 Duv. [Ky.J 224.) The reproach of Lord Cliief-Justice Cockburn e-an with sufficient rea- son be adelressed to courts which would affirm, as matter of laAV, that which it is not the province of law either to affirm or eleny, especially when doctrines most dangerems hâve been laid down dogmatically in the name of advanced science. The 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 dérangement, are questions of mental pathology, anel as such do not come Avithin a considération of insanity from the légal point of view. In this connection it suffices to affirm that their existene-e» is not an admitted fact of science, but a the- ory, the subject even at the présent day of dispute and controArersv. ("Menai Insanity—What is It?" by J. Workman, M.D., American Jour- nal of Insanity, vol. xxxix., p. 334 ; "Intempérance and Insanity," by Dr. Chipley, American Journal of Insanity, vol. xxiii., p. 1; "Report of the Animal Meeting of the Association of Me-dical 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 "Ulteriori Conside'rationi sull Argomento délia Cosi detta Pazzia Morale," by Dr. C. Bonfigli, American Journal of Insanity, Arol. xxxaù., pp. 224, 476 ; " Kleptomania," by Dr. J. C. Buckniiï, Journal of Mental Science, vol. viii., July, 1862 ; Caspe-r's Handbook of Foreusic Medicine, vol. iv., part vi., chap. ii., sec. 75, 76, 88, 89, 91, 93.) The problem anel difficulty presented to médical jurisprudence by the theory of affective or moral insanity would not lie in the abstraet (Ques- tion as to its existene-e, which is one of fact and one for mental science alone to décide, but in thé proof of its actual existence when pleadeel 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 fort h by Mr. Justice Allen in his charge to the jury in the case of Wiïliam Speirs, who was tried at Rome, N. Y., in the year 1858, for having Avill- fully set fire to the State Lunatic Asylum at Utica, the défense being insanity in the spécial form of a morbid pretpensity for " fire-raising." " The défense was made to rest mainly upon the ground of moral insan- ity, so called, whieh under that name had but reeently found a place in any of the classifications or diAdsions of insanity. That the moral affec- tions might be, and frequently were, perverted or impaired by the same MENTAL RESPONSIBILITY IN CRIMINAL CASES. 255 diseases, or other causes, Avhich affected or impaired the reasoning fae'- ulties and the memory, Avas not donbteel. But 'moral insanity,' as a distinct manifestation apart from any dérangement of the intellectual faculties or any elisease affecting the mind, had not been and could not be Avith safety recognized by the laAV as exempting its subjects from pun- ishment for their unlawful acts. Certainly this could not be done until science should be able to do Avhat it lias not yet done—elescribe its char- acteristics and manifestations, and define its eviele-nces anel the rules by Avhie-h its existence coule! be ascertameel and known. It should be capa- ble of being distinguished from moral depravity. Me-n of science, for the conve-niene-e of inve-stigation and dise-ussion, might subdivide and e-lassify thèse subjects as they pleased, and distinguish their divisions. by any nomenclature Avhich might be convenient, and no harm could e-nsiu' ; but when courts and juries Avère caiïed upon to apply the princi- ples anel déductions of science in the process of judicial investigation, it Avas indispensable that their tests should be such as were capable of being appreciated and judged with some approximation to certainty ; that is, the déductions anel e-onclusions of science which are to control judicial action anel be influential in the administration of justie-e should be the» ascertained results anel conseepienees of facts pixwed, judged, anel applie'd, according to the Avell-e'stablished principles of the particular sci- ence involved. Senne of the Avitnesses had spoken of a moral mania, of Avhich an ineliAÙdual might be the subject, and by Avhich he might be im- pelled to the commission of crime ; but juries coule! not, Avith any safety, regard a maniacal impulse of this dese-ription as absolving from the con- seque'iices of crime, in the absence of any eAÙdence of a lésion of the intellect aud reasoning powers, or of some dérangement or disease affect- ing the mind and judgment—and for the best of ail reasons, that there could not, in the nature of things, be any satisfactory évidence of any disease or dérangement of the functions of the individual Avhich could coiiAunce a jury that the act Avas not the deliberate and \Toluntary act of the party, his mind assenting to it. The existence of the impulsive mania could only be proveel by the commission of the acts which it was sought to excuse-, which Avould be no évidence at ail; and the jury could never knenv, even should it be concédée! that such a 'moral mania' might and did exist, Avhether in a particular case the acts were the results of this impulse or the fruits of a Avicked and depraved mind. Courts and jurie's, in the attempt to détermine the existence of 'moral mania' or irrésistible impulse, apart from mental disturbance and dérangement, as evidenceel by the Avcll-knoAvn symptoms of mental disease, as an excuse for crime, Avould become bewildere'el and lost in the labyrinth of scien- tific niceties and fanciful théories. But when called upon to consider the subject of insanity, regarded as a dérangement of the intellect, a mental dise-ase, or the manifestations of elise'ase affecting the mind, whether the moral penvers Avère or were not impaired or perverted, they Ave-re not entirely Avithout the» means of arriving at a satisfactory conclu- sion Avith the aid of intelligent and experienced men and the exercise of their geiod judgment." (" The Case of William Spcirs," American Journal of Insanity, Arol. xv., p. 200.) It is insisteel, hoAvever, that the difficulty presented to forensic medi- cine does not end Avith the disproof or réfutation of the theory of a purely emotional or moral insanity-, that cases ex-cur where the disen-ders 250 A SYSTEM OF LEGAL MEDICINE. i \ in the emotional or moral nature are the prédominant symptoms, the intellectual lésion being niasked e>r obscure, thèse symptoms marking ; the early stage of what Avili eventuaiïy pre>ve to be an undoubted case of intellectual insanity. It is insisted, further, that under thèse condi- tions a e-riine may be committed, the produe-t of e-erebro-niental disease. (" The Moral Phenomena of Insanity and Ee-centricity," by Thomas Maye>, M.D., The Médical and l'syehologieal Critie, vol. i., p. 173; Bucknill and Tuke, Psychological Medicine, p. 25S.) Of this, the case of the boy Wil- liam NeAvton Allnut, tried at the G-ntral Criminal Court for the murder of his grandfather by poiseming, furnishes us, according to the médical Avitnesses in that case, a practical example; the accuse'd being, in their opinion, in an early stage of insanity, Avhich affected his moral seuitiments and interfered Avith his notions of right and Avrong, but which did not then affect his intellect in any marked degree. (Trial of William Newton Allnut, Testimony of Dr. Densbury anel Dr. Conolly, London Times, De- cember 16, 1847.) The difficulty thus presemted is obvious even to those avIio hâve sug- gested it, and senne hâve attempted its solution. "The vicions act or crime is," says Dr. Maudsley, "not in itself proof of insanity. it must, in order to êstablish moral insanity, be tracée! from disease through a proper train of symptoms, just as the acts of a sane» man are deduced from his motives, and the évidence of elisease Aviiï be found in the entire' histery of the case. What we shall often obseiwe is this, that after some great moral shock, or some severe physieal disturbane-e, in a person A\dio has a distinct hereditary predispe>sition to insanity, there' lias been a marked change of e-haracter ; lie bee-omes ' much différent from the man , he Avas' in feelings, tempe»!-, habits, and conduct. We ediserve, in fact, that after a sufficie»nt and Avell-ree-ognized cause of mental dérangement —a combination of preilispe)sing and exciting e-auses which are dady pro- ducing it—a person exhibits symptoms Avhich are strangely ineonsistent with his previous eharaeter, but which are consistent Avith moral insanity. Or it may appear that there lias been an attack of paralysis or epilepsy, or a seA'eu-e feA'er, and that the change of eharaeter and the symptoms of moral aliénation lnive folloAved one of thèse physieal causes. In ail cases, as Dr. Prichard, avIio was the first to describe the disease, has remarked, there has been an altération in the temper anel habits, in conséquence of , disease or of a sufficient cause of elisease. Perhaps the strongest e\ddence of the nature of moral insanity as a disease of the brain is furnished by the fact that its symptoms sennetimes précède for a time the symptoms of inteiïeetual dérangement in a severe ease of undoubted insanity, as, for example, a case of acute mania, or of gênerai paralysis, or of senile dementia. It is interesting, indeed, to notice that at least one of Dr. Prichard's cases, on Avhich he foundeel lus description of the disease. Avas reaiïy a ease of gênerai paralysis—a disease not specially recognized in his day, but the best knoAvn noAV of aiï the forms of mental dérange- ment. Surely, then, Avhen a person is subject to a sufficient cause of in- sanity, exhibits thereupon a great change of eharaeter, and finally passes into acute mania or gênerai paralysis, avc cannot fairly be asked to ree-- ognize the adéquate cause of the disease and the intellectual disorder as disease, and at the same time to eleny the eharaeter of disease to the in- termediate symptoms." (Responsibility in Mental I>iseas«, pp. 173, 174.") MENTAL RESrONSIBIIITY IN CRIMINAL CASES. 257 According to Dr. Ray, if moral insanity be pleaded in défense, proof of the fact must be found in the antécédents of the prisoner, the manner of committing the crime, his mental or bodily condition, aiï the circum- stances, in fact, connected with the act. (" An Examination of the Objec- tions to the Doctrine of 'Moral Insanity,'" by Isaac Ray, M.D., American Journal of Insanity, A'ol. xA'iii., p. 112.) Dr. Tuke, admitting that ne» absolute rule can be laid doAvn to differ- )! entiate moral insanity from moral depravity, insists that each case must bc décidée! in relation to the individual himself, his antécédents, his edu-; cation, surroundings, and social status, the nature' of certain acts, and! the mode in Avhich they are performed, along with other circumstances' fairly raising the suspicion that they are not under his control. In no, other form of insanity is it so necessary to study the individual, his natural eharaeter, 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 défense has generally been presented under the form of the se>-called "mania transitoria," an instantaneous tempo-. rary madness Avhich begins "in the eve of the criminal act and ends Avhen it is consummated." (Depue, J., State vs. Grave, 5 N. J. L. J. 54.) The acceptance* of this theory by juries as an exculpation of the accused may be regarded in certain cases at least as a proof of their sympathy Avith him, and of their conséquent détermination to acquit. ("The Case of People vs. .E rat us F. Pierre," American Journal of Insanitu, vol. xxviii., p. 399 ; Cole's Trial, 7 Abb. Pr., N. S., 321.) The utterances of the law on tins subject, so replète with difficulty, cannot receive a complète acquiescence on the part of the» jurist. An unwilliiigne'ss to admit that the facts of insanity were to be learned from science and learned opinion, rather thau from ordinary évidence, like an ordinary fact (Lord Chaneellor Wcstbury, Debate of March 11, 1862, Hansard's Déliâtes, third serie's, vol. clxv., p. 1297), has, as an error, its parallel in the intrusion made by the laAV into the domain of mental pathology itself. The writings of the earliest authorities and some of the juelieial utterances of later days, by their attempted classifications of mental disease, anel dogmatism as to its essential nature and character- istics, hâve, under the name of the kiw, perpetuated or giATen longer life te) scientific errors or the imperfect science of the time, as Avitness the description drawn betAveen madness and lunacy, the imputing to insanity delusion as its essential and necessary eharaeteristie'., and the draAving of fixée! légal consequene-e's from the fact of delusion itself. It is submitted that Avith the particular forms of insanity and its essential characteris- tics as a elisease the law has nothing Avhateve'r to do. The effects of the Aurions manias, of epilepsy, the probable limit and effect of delusions, the relation of the insane impulses to the human will, the question as to the» existene-e and nature of an insanity purely emotional and moral, are, and must remain, facts of mental pathole>gy to be preiveel or disproved as facts, and not to be dogmaticaiïy affirmée! or denied. and to be A'ieAve'd only in relation to the h'gai question of responsibility. As to this it may fairly be asked whether the action of the House of Lords in relation to McNaghten's Case lias not justifiée! the npprehensiems of Mr. Justice Maule, in ulsettling rather than settling, the law by the suggestion of 258 A SYSTEM OF LEGAL MEDICINE. doubts rather than the solution of theni, thus affording matter for bit- terest controverse between the professions of laAV and medicine, a con- trovei-sy that extends even to the présent time. A complète and unas- sailable canon of responsibiïify 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 OTHER AFFECTIONS OF SPEECH. BY CHARLES K. MILLS, M.D. HISTORY AND LITERATURE. The medico-legal aspects of aphasia and other affections of speech hâve not escaped investigation and discussion, but they hâve received little attention from English and American Avriters, and, compared with the immense literature of the gênerai subject of aphasia, but little from Avriters of other nations. Much of the work published has been in the nature of records, Avith comments on particular cases which hâve come before a court or other tribunal ; and in fcav, if any, of thèse contributions has any systematic effort been made to classify for médical ;)iirposes the noAV Avell-recognized forms of aphasia. In papers deaiïng with the gên- erai phenomena and mechanism of speech, important medico-legal points are eleveloped in a casual and incidental manner, as in the writings of J. Hughlings Jackson,* Charcot,! Lichtheim,i and Ross •§ and to some of thèse références wiïl be made in the course of this article. In the sec- ond édition of Bateman's treatise on aphasia,|| a new chapter on the jurisprudence of aphasia is introduced, in which some original observa- tions are giAren, and références are maele to the work of French and Ger- man authors. Bateman <| cites some cases of interest. In 1743, for example, a rési- dent of Miinden, Hanover, applied to the government for permission to make a Avili by signs in favor of his Avife, and the court acknowledged the validity of the act. Another aphasie for five years discharged the functions of may or and municipal eouncilor, by writing his name to nec- essary documents with his left hand. In the same way he also Avrote a holographie Avili, Avhich was sustained. Thèse and other cases are referred to by Legrand du Saulle. Bateman refers to several cases in Avhich the Avilis of deaf-mutes were recognized as valid by the court because it was proved that they understood the contents of the wiiï, either through gest- ure and pantomime alone, or by thèse anel written language combined. He also records the case of a man, sixtj'-three years old, who Avas engaged * Hughlings Jackson, Brain, October, 1878, and July and October, 1879. t Charcot, Le Prog. Méd., 1SS4. and Médical Press and Circulai-, London, 1884. f Lichtheiin, Brain, January, 1885. § Ross. Aphasia, etc., London, 1887; New York, 1890. || Bateman, Aphasia, etc., London, 1890. H Ibid. 260 A SYSTEM OF LEGAL MEDICINE. to be married and was suddenly seized with right hemiplegia and apha- sia, and Avished to make a will in favor of the lady whom he intended to make his wife. The document Avas Avritten by one of his médical attend- ants. The testator's mark Avas made and the will attestée! by Avitnesse's. He communicated his wishes by making signs for Avriting material s. His Avishes Avère then interpreted by means of signs and written doAvn on a card. He held up his hand, extended his five fingers, and he was asked if lie meant " thenisand " ; lie be>Aved assent. He then closed his hand anel opened it the same Avay, implying ten ; this opération Avas repeated until it amounted to thirty, the-u he elropped his arm down. Testator Avas then asked whether he Avished Miss K. to hâve £30,000, and he nodded his head. When aske-d if Miss R, Avas to hâve tins sum absolutely, he signified dissent; but on being asked if it Avas to be hers for life and afteiward to revert to his family, lie boAved his head. Unfortuiiately the testater's mark Avas made in the middle of the card instead of at the bottom en- foot, and so did not satisfy the provisions of the statutes rclat- ing to Avilis, aud the testament Avas therefore refused probate. In Dumas s Couut of Moute-Christo is an interview with a motor aphasie which might hâve ansAvereel as testimony in court in a case in which the emestiem Avas that of testamentary capae-ity. The old Bonapartist, Noir- tier, pa.ralyzed and profouiidly aphasie-, angereel at his son and daughter- in-laAV, détermines to change his will. His son, his granddaughter, and his old seivant could understand and communicate with him through an arranged system of signs—by his closing his eyes for "yes," by Avinking them Avhen lie meant "no," and when lie had some désire or teeling to expre'ss, by looking upward. He signifies his désire for a notary by indicating to his granddaughter, avIio recites to him ail the letters eif the alphabet, that lie wishes "n" and "o" in succession; then Avith a dic- tionary lie picks ont the word "notary.1' Two notariés are brought and read the formai copy of the Avili, and then test Noirtier by much the same method as Bateman relates Avas employed in the case above e-ited. Several sums are named before the aphasie, who signs " no " until the question is asked, " Do you possess 900,000 francs ? " In answer to this lie closes his eyes in assent. He finally succeeds in making a will, of the validity of which the notariés are thoroughly satisfied, although other characters in the story are not equally satisfied with its contents. At the meeting of the British Médical Association, 1889,* Dr. Drys- dale, of London, cited the case of a celebrated civil engineer avIio had right motor paralysis and aphasia, but avIio wrote his OAvn checks, copy- ing them from a former signature of his owu, and who for maiiA' years was a senior partner of the tirai. His partners, however, did aïl the Avork. In this case the gentleman retained enough inteiïigence to play whist with the cards spread out before him, and left a Avili which was not contested. Professor Gairdner, at a former meeting of the British Médical Association, had mentioned the case of a Scoftish judge affected with aphasia AAdio had continued in office for some years, and sat on the bench while suffering from a form of this malady. Legrand du Saulle t has extensively discussed the subject of aphasia * Neir Yorl- Médical Record, September 28, 1889. p. 360. f Legrand du Saulle, Gazette des Hôpitaux, June and July, 1868 ; and ibid., vol. Iv., 1S82. In this séries of lectures other références are as follows : Ch. Sazie, Troubles Intellectuels dans VAphasie, Paris, 1879; Finance, État Mentale des Aphasiques: Con- APHASIA AND OTHER AFFECTIONS OF SPEECH. 261 and aphasies considérée! from the medico-legal and other points of view. He holds that Avhen the lésion of aphasia is confined exclusively to the third left frontal convolution, intellectual disturbance is slight; but ace-ording as it lias extended to the motor zone, or to the prefrontal région, Avili paralysis or disorders of the mteiïigence appear ; also that most aphasies hâve a certain measure of dementia as Avell as of paralysis, but that the intellectual disorder observed iu aphasies is most variable, sometimes not interfering Avith the important eArents of life, at others so Avrecking the intellectual faculties as to cause mental incapacity and irre- sponsibility. Among aphasies impatience aud anger are common; their moeids are very changeable : Avant of attention is one of their most marked traits -, memory and recoiïection are less alert, some aphasies exhibiting decided loss of memory. He insiste that aphasia is compatible Avith in- telligence, but that this is ahvays more or le»ss Aveakened by the loss of language. If the brain lésions are extended and multiple, pronounced Aveakening and even abolition of memory may be observed. Incohérence of ideas when présent is not by any means on a par with incohérence of language. To lésions of the prefrontal régions he relates the loss of memory and attention, the incohérence, hallucinatienis, and delirium— probably only a partial truth. He speaks of haiïuciuations as fréquent among aphasies, the most common being tliose of hearing and sight; semietimes thèse hallucinatienis are of a charae-ter that may lead to crime, or may make the aphasie suspicious of others. He admits three caté- gorie-s of aphasies—those in Avhom intelligence is intact, but slightly touched ; tliose in whom it is manifestly changed : and those in whom it is entirely abolisheel. A physician called to gh'e an opinion on an apha- sie should give attention to the smalh'st particulars. He has need also to use ail his eare and knoAvleelge in scrupulously reviewing every one of the différent forms of language employée! by an aphasie. It is always avcII to make the patient count, to ask his âge, to test him Avith money, etc. Gallard,* in a A'olume of clinieal lectures delivered at La Pitié, lias one chapter on aphasia and aphasie:s discussed from the medico-legal point of AdeAV. His com-lusiems with référence to the interdiction of aphasies are : (1) If the inteUigenee of the aphasie is completely obliter- ated, or if in preserving his lucidity lie cannot manifest it by Avritten language, pantomime, or speech, lie should be interdicted ; (2) if the in- telligence of the aphasie, not being completely aliéna ted, has not aiï its brightiiess, and can only be im-ompletely manifestée!, lie should be pro- vieleel with a judicial couusel ; (3) if the aphasie possesses his intelligence, anel if he can manife-st it sufficiently, Avhether by Aven-el, by Avriting, or by signs, lie has no need of judicial protection, and should be free to man- age himself anel his affairs. The Parish Avili case is perhaps the most famous American medico- legal e-ase' in Avhich the mental poAver of an aphasie Avas the main point at issue. Henry Parish made his first Aviïl when fifty-four years of âge, sidéra lions Médico-légales, Paris, 1878; Legrand du Saulle, Etude Médico-Légale sur l'Interdiction des Aliènes et sur le Conseil Judiciaire, Paris, 1881, p. 212; J. Lefort, "Remarques sur l'Interdiction des Aphasiques," Bulletin de la Société de Médecine de Fronce. * Gallard, Clinique Médicale de La Pitié ; analyzed in Le Journal de Médecine et de Chirurgie Pratiques, vol. xlviii., pp. o77-380. 2G2 A SYSTEM OF LEGAL MEDICINE. and the next year had a slight apoplectic attack, from Avliieh he soon recovered. SeA'en years after making his will he had another severe apoplexy, which left him for the rest of his life, about seAren yoars in ail, paralyzed in his right limbs and Avith the poAver of articulation lost. After this second seizure lie also had at intervais epileptie fits. The codicils to his Avili Avère contested. The first Avas maele about six Aveeks and executed about five months after the severe apoplee-tic attack ; about four years later a second ce>elieil, and about ihre years after this a third, Ave-re made. The surrogate admitted the first eodicil and excludeel the others. The Suprême Court and the Court of Appeals decided against aiï three. The trial of this case Avas a notable one and eminent physi- cians were employed on both sides. Dr. Isaac Kay, avIio Avas one of the médical experts, testified in oppe>sition to Mr. Parish's testamentary capac- ity, and lias contributed a Aaluable papeu- on the case.* The Beven case is another of interest, repen-ted by Dr. C. H. Hughes, t Mr. Beven had been stricken Avith right hemiplegia and aphasia, probably due to embolism, as lie had a e'areliae'-Aalvular lésion. He became défend- ant in a suit for the recoAery of nieuiey on a deed of trust signed by himself with his left hand when he Avas aphasie, four months after his first apo- plectic seizure, in 1873. Dr. Hughes, three years after the attack, found that he Avas suffering from ine-omplete paralysis of motion on the right side and gênerai amesthesia; that lie fully understood oral signs, and Avritten ones tardily and impertectly; that lie re»ce>gnized the doctors name anel Avrote cIoavii his own name and that of his attorney and of the doctor; that he either had or feigne-d détective vision, and also impaired hearing in the left ear. He had had three paralytic strokes altogether, but hael groAvn steadily better. Dr. Hughes ana±yze»d the various fae-ts whie-h Avère brought foi-Avare! as evide-ne-es of his insanity, and decided in favor of his competency. Dr. Hughes i lias also Avritten a paper on the medico-legal aspect of cérébral le>calization anel aphasia, This article revieAvs the varieties of aphasia, with some considération of the lésions causing them, and also considers to some extent the eftee-t of simple and complicated aphasia on the judging, comparing, expressing, and other faculties of the mind, citing varie>us authorities in support of his posi- tions. The Fillmore Aviiï case, reported by Dr. Landon C. Gray,§ lias at- tained considérable 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, Avidow of the ex-President of the United States, in 1877, three years after the latter's death, began to sIioav changes in her eharaeter, soon becoming coarse, profane, suspicions, and delusional. She was stricken Avith hemiplegia. She made Iavo Avilis, the first eighteen months after the changes in lier eharaeter were first noted, anel nine months before the paralysis; the second Avili or eodicil was maele five months before the stroke. She developed a form of aphasia and showed not only this speech disturbance, but a combination of svmp- toms of gênerai mental impairment, Dr. Gray and others testified' that Aie Avas insane anel incompétent. * Ray, Contributions to Mo/fol Pathology. t Hughes. American Journal of Insanity, vol. xxxv., January. 1879, p. 410. f Hughes. Alienist and Neurologist, vol. i., April and July, l's.SO. § Gray, American Journal of Nonology and Psychiatry. vol. iii., p. 549. APHASIA AND OTHER AFFECTIONS OF SPEECH. 2G3 Ray,* in his text-book, as well as in the monograph on the Parish case, lias given some attention to the médical jurisprudence of aphasia, relating seAreral interesting cases. Diiïer t lias also discussed the medieo-le'gal aspects of aphasia, and gives notes of two cases. One Avas a retired physician, sixty years old, Avho had a hémiplégie and aphasie attack, after whie-h he e;e)uducted a large busi- ness. An effort Avas made te) break his wdl on the grounds that lie had progressively de'teriorated mentally anel physically, and that his will Avas made a few months before his death, Avhen lie Avas technically insane anel incompétent. A w ill Avhich hael been made senne ye'ars before his attack of aphasia, and Avhich almost tallied Avith the contested Aviïl, Avas sprung in court and caused a hasty terniination of the proceedings. The secenid was a case of right hemiplegia and almost complète motor aphasia in a lady of sixty-five years. She coniprehended and expressed clearly enough e-ertain ideas, and just as clearly failed to express certain others. He finaiïy conclueled that she Avas incompétent to enter into ■chdl contracts anel in a technical sensé insane, but Avas aille to delegate to lier children powe»r of attorney. He believed that she would be able to gi\re inteiïigent assent to any single business proposition, but that she Avas ine-nmpeteiit to recehTe anel pay ont money constantly, as her busi- ness required. My OAvn expérience Avith other cases ace-ords with this conclusion. Diller he)lds in considering the medico-legal problems that may arise in any given case of aphasia that it is emly nee'essary to déter- mine, first, Avhether the peu-son is sane ; secoue!, Avhethe»r iele'as may be con- veyed to him; and third, Avhether lie can convey his ideas to others. Clark | has recorded a case in Avhich the question was whether a hemi- ph'gic who alse> suffered Avith aphasia Avas compétent to exee-ute a will. After his attack lie had ree-overeel largely and had gone on with his busi- ness. He holds that it Avould not do to déclare a man incompétent simply because of his aphasia. MEDICO-LEGAL QUESTIONS AVHICH MAY AEISE IN CONNECTION AVITH APHASICS. It will be seen from this hasty glanée at the meager literature of the subject that the medico-legal questions Avliieli may arise in connection with the study of aphasies are someAvhat îiumerous, although aiï are by no means embraced in this revieAv. They include many of those which the insane présent for solution, but also others especially belonging to aphasia. At the outset it sliemld be borne in mind that avc are not deal- ing with some clearly defined entity caiïeel " aphasia." It is not possible to fix upon any gênerai standard of capacity or responsibiïify for one suffering freim an affection simply labeled "aphasia." Even correctly labeling an individual as insane does not décide as to his right to hâve certain privilèges, or his capacity to do e>r not to do e'ertain acts, as, for example, to hâve his personal liberty or the e-ontrol of his estate, to get married, or to make a will. In a practical as well as a philosophical .sensé, questions of sanity and insanity are relative, and so likewise are * Eav, Médical Jurisprudence of Insanity. t Diller, Journal of Nervous and Mental Disease, May, 1894, p. 292. f Clark, American Journal of Insanity, vol. xlix., 1892-93, p. 291. 2G4 A SYSTEM OF LEGAL MEDICINE. those présentée! by aphasies. They v ill dépend not only on the torm of the disoreler, but also upon its degree and spécial characteristics in a par- ticular case. " The affections of sjieech met with are very différent in degree and kind," says Hughlings Jackson,* "for the simple reason that the exact position of elisease of the brain and its gravity differ in différent case-s ; différent amounts of ne-rvous arrangements in différent pentions are ele-streyed Avith différent rapidity in différent persons. There is, then, no single, well-defined 'entity'—le>ss of speech or aphasia—and thus to state the matter for a practie-al purpose, such a question as, 'Can an aphasie make a wiïlf cannot be ansAvered any more than the epiestion, 'Will a pièce- of string reach ae-ross this room?' can be answered. The question sliemld bc, 'Can this or that aphasie person make a wiiï?'" Thèse medico-le'gal questions may be either criminal or civil, although they are much more fre-epienfly the latter. Legrand du Saulle says truly that it is rare for aphasie-s to be implicateel in major crimes, being to a certain extent savecl from them by their habituai infirmity ; but aphasies are much given to impatience anel anger, and their moods are uncertain and e-hangeable anel oe-casionally dangerems. They haAre been chargée! Avith thefts, and hâve been implicatod in other crimes. One remarkable e-ase is referred to by Legrand du Saulle. An aphasie and hémiplégie Ava.s charged Avith killing his wife, and the e-ase», had not only this crimi- nal aspect, but later a eiviï question, that of the disposai of his and of his wife's property, arose. The parties had been married Avithout a con- tract, anel hael no children, and each had left to the survivor the whole of his or her property. Attempts Avère made to nullify the donation of the Avife on account of ingratitude, as shown by the assassination, but against this it Avas urged that as the man had been pronounced irre- sponsible he could not be an ingrate. In the end, however, the donation Avas aniiulh'd and Avent to the wife's heirs. Evidently Avhether or not an aphasie should be exonerateel from the conse»<|uenees of a crime is a Autal matter, and in some cases the question should be decided on the same principles that would govern the décision in a case of alleged insanity; but thèse might not always suffiee, and the présence of the aphasia, and its form, might need to be particularly con- sidered in arriving at a correct conclusion. Many aphasies suffer to a greater or less extent from variems spécial forms of mental diseases, the degree of Avhich may be dépendent somewhat on the location of the lésion causing the speech disturbane-e, or on the extent to which the aphasie lésion has extended beyond the speech centers, or, again, it may be en- tirely independent of the aphasia, The lésion which causes aphasia, as is well known, in addition usually produces a certain and it ma}' be a large degree of paralysis, and less frequently also various sensenv dis- orders. The greater the aecompanying disease, even though it be of a physieal 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 whieh the lésion has taken. M. Sazie tells of an aphasie who had amesthesia of his limbs, anel who believed that his legs had been ampu- tated ; and Legrand du Saulle speaks of monomania, melancholia, hvpo- chondria, and of impulses to drunkenness, suicide, or even homicide, * Hughliugs Jackson, Brain, October, 187,8, p. 314. APHASIA AND OTHER AFFECTIONS OF SPEECH. 265 among aphasies. Every one A\dio has had much expérience Avith aphasies can reeall such cases, but we must remember that thèse are disorders occurring among aphasies, not a part of the aphasia. Recognizing the importance of such facts as thèse, and remembering also that aphasie-s avIu) are not in any just sensé insane are often greatly misunclerstood, it follows that the committal of an aphasie to an insane asylum may some- times be a serions epiestion for décision, and might eventually lead to a criminal or civil suit. Kussmaul* refers to the fact that the Avord-eleaf, possessing at the same time abiïity to express themselves in words, but misplacing and often distorting them, leave the impression that they are crazed ; and lie warns the observer to avoid this error, and also the greater one of re- garding the patient as be>th deaf and demented. He cites several inter- esting cases—one reportée! by Baillarger, avIio demonstrated that a Avoman Avho had been regarded as both deaf and demented Avas reaiïy neither one nor the other; and another of a paraphasie; patient of \Yer- nicke's, at first supposed to be deaf and erazy. An interesting case of aphasia complicated Avith insanity has been reported by Bancrof t, t Among the civil questions which arise in connection with aphasies, perhaps the first in importance is that of testamentary capacity, anel such aiïied epiestions as their competency to make cleeds of trust or comvèy- ance, to sign powers of attorney, promisseny notes, due biïls or checks, to make contracts, or to manage any business ordinarily involving speak- ing or writing. The marriage of aphasies may hâve to be consietered. According to French law—and the laws of other nations are mue-li the same—dementia is the only thing that interdicts marriage. Aphasia is not sufficient to preArent it. Signs are recognized as available to signify consent ; but it may be necessary to décide as to the true signification of the pantomime anel gestures empleyeel by the aphasie. The question is, Avhether the husbanel e>r Avife at the time of the marriage had a sufficient degree of intelligence to realize the act, and AAliether it Avas of his or lier own Avili. An interesting case is given by Legrand du Saulle of an aged aphasie and hémiplégie- Avidenv avIio, having fallen out Avith her daughter, contracted a second marriage against the Avishes of her family. I once testified before a register e>f Avilis regarding a man Avhom I hael seen in consultation several Aveeks before his death. This man had lived for many years Avith a Avoman avIio was not his Avife, but by whom he had several children. By many lie was supposée! to be legally married to the Avoman. He Avas stricken Avith right-sided pai-alysis and partial aphasia ; but I found him capable of ansAvering questions and of read- ing a little consecutively. I saw him tAvice before his death, and be- tween my tAvei Ausits lie was married to the Avoman Avith whom he had been living. The granting letters of administration to his wAe was ré- sistée! by senne of his relatives, who claimed that undue influence had been used, and also that he Avas not in a state of mind to know Avhat. he Avas doing A\dien he Avas married. After hearing the testimony the reg- ister ga\re letters of administration to the Avife and the case was dropped. The question of interdiction may come up for décision AAdien an * Kussmaul, Zicmsseiés Cyclojyœdia of Practical Medicine (American édition), vol. xiv., 4>. 77."1. t Bancroft, Boston Médical and Surgical Journal, vol. civ., Xo. 21, May 26, 1881, p. 483. 2GG ^ SYSTEM OF LEGAL MEDICINE. aphasie is aiïeged to be insane; and the décision, as in the case- of the' insane not aphasie, may resuit in the patient going to an insane hospital, or simply being put under the control of a committee or of a guardian. Another epiestion may be of the aiïeged malingering of deaf ness or of deaf-mutism by a criminal, a soldier, or an employée wishing to shirk duty ; and still another Avhether an apparent, aphasia. is one of the phases of alleged hysteria. Occasionally aphasia, the resuit of traumatisni, may hâve a dee-ided medico-legal importance, as in litigation, because of injuries resulting in aphasias ; or when the ability of au aphasie, who lias been injured with criminal intent, to recognize an alle-ged assailant is questioned. In various AveU-known forms of insanity, as paretic dementia, monomania, katatonia, confusional insanity, mania, or melan- cholia, the peculiarities of the speech disorde'rs belonging to the affections may assist in the early or late diagnosis of such cases, and may thus haATe a bearing upon sueh légal matters as necessity of restraint, relief from responsibility, or discharge after recovery. It is not possible to establish rules by Avliich the capacity, compe- tency, or responsibiïify of aphasies can be measured. This, in given cases, is largely a matter for judicial décision and technical interpréta- tion of the laAV. In ail chdlized countries, and in différent States of a country like our oavu, the administration of the kiw with référence to such matters as Aviiïs, deeds of trust, civil contracts, restraint in asylums, and particular crimes, Avhether relating to aphasie-s or others, is basée! upon précédents, and upon législative and other enactments. Thèse may sometimes be at variance Avith what is just and équitable from a médical point of vievr. The object of a paper like the présent is chiefly to sIioav the methods of gauging the mental status of those affected with disorders of speech, Avhich mental status, from the médical point of view, Avould be the criterion of competency and responsibility; but such studies might lead to a conclusion that a testator in a certain case was compétent to make a valid Aviïl, although his testament might not be sustained by a court because of a technical violation of a pre>vision of the law. The French hiAv recognizes three kinds of Aviiïs : that by public act before notariés and Avitnesses ; the holographie Avili, or that Avritten by the testator's oavu hand unguided by another; and the secret Avili (testament mystique). _ The secret will may be written entirely by the hand of the testator, like the holographie will, or be written by another person and only signed by him. It is then given in charge of a notary in présence of a stated number of Avitnesses, who countersign the envelope, and by whom it is closed and sealed ; and upon this the testator Avrites, or causes to be written, that this is his will duly signed by him. Thus, if the writ- ing and signing of the will are iïlegible or difficult to read, this act acquires the value even of a holographie Aviiï. (Gallard.) Under even thèse or similar laws, an aphasie who, medicaiïy speak- ing, might be entirely compétent to do certain acts, as could be deter- mined by careful médical 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 Sauiïe and others. APHASIA AND OTHER AFFECTIONS OF SPEECH. 267 DEFINITIONS AND TERMIXOLOGY—VARIETIES OF APHASIA. It wiïl be necessary to define certain terms and to give a few of the most important facts Avith référence to the nature and mechanism of speee-h and its disorelers, and also regarding the sites of lésions produc- ing aphasias. While it is impossible to make explicit statements Avith référence to the mental status—or légal status, Avhich is sometimes a very différent matter—of aphasies, basing such statements upon the loca- tion of a h>siem 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 influenced by the site of a lésion which causes an aphasia. Before the term aphasia, which means "loss of speech," was fuiïy grafted upon médical nomenclature, and to some extent since, numerous other terms hâve been used to describe disorders of speech from cérébral elise'ase. A lalia was employed by Lordat in the same gênerai sensé 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 inabiïity to utter artic- ulate sounds, ranking it uneler the heads of losses and defects of enun- ciation. Aphemia has also been used by Broca and others for cérébral speech disturbances in gênerai. 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 be confined in its définition to elefects of speech from lésions of those fibers which connect the motor, or, as he Avould say, " kinesthetic " e-enters 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 displaee the word " aphasia," which wiïl be used in this paper in its commonly accepted and gênerai sensé to indi- cate cérébral loss or defect in both language and signs. Formerly the terms a taxi c aphasia and amnésie aphasia were em- ployed almost uniA^ersally, and thèse expressions are retained by high authorities. Ataxia aphasia lias been used to describe the aphasia of com- mon type resulting from lésions of Broca's convolution and the immedi- ately adjacent région, on the supposition that the affection of speech is an inability or incapacity for the motor coordination of words ; but as it is a matter of dispute Avhether 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 amnésie aphasia is the term AAdiich lias been applied to those affections of speech which are the resuit of lésions on the sensory or réceptive side of the brain. Kussmaul defines amnésie aphasia as the incapacity for the recollection e)f words as acoustic aggregates of sound ; but objections, based upon theoretical considérations, hâve also been urged to this term. Disregareling for the présent différences of opinion of almost equally high authorities, the best practical subdivision of the aphasias is into sensory or reeejdive, and motor or emissive. Foiïowing such authorities as Kussmaul, Charcot, Broadbent, and Ross, under the gênerai term sensory aphasia I include those affections of speech which are dépendent upon elisease loeated in the receiving part of the brain. Sensory aphasia has, therefore, necessarily several varieties, as word-deetfness and ivord- 2G8 A SYSTEM OF LEGAL MEDICINE. blindness, terms Avhich define themselves; and apraxia, sometimes e-alle-d soul-blindness, mind-blindness, or objeet-blindness, AAdiieh is defineel by Kussmaul as an affection in Avhich the memory for the use-s of things is lost, as Aveiï as the understanding for the signs for Avhieh the things are ex- pressed. To test for apraxia, as suggested by Starr,* it is only nece'ssary to présent various objects to a person in various wavs and notice» whether he gives évidences of récognition ; to hâve him Avatcheel by his friends, AAdie) Avili be able to tell whether he still choose»s his articles of food atthe table intelligently ; Avhether he still knows Iioav to put on his clothes ; to use various toilet articles ; te) scav, knit, or embroider if the patieuit is a lady ; or to admire pictures or floAvers or perfumes, as before the illness began. Motor aphasia includes the common form of disorder of speech some- times known as Bioca's aphasia, and in addition agraphia, or loss of the power of A\rriting, when this is due to disease of the graphie centers of tracts in the motor cortex. Other affections may resuit from the breaking through of the com- missures or lines of connection betAveen the various centers. Thèse give us AA'hat are knoAvn in gênerai ternis as paraphasias or conduction aphasias, which may be of as many types as there are commissures. Sensory and motor centers and commissures may aiï be» affected at the same time, and this gives the total aphasia of some Avriters, or AAdiat is perhaps better calletl b}' Ross combined sensory and motor aphasia, or by others mixed aphasia. Other terms in use are those elescriptive of the peculiarities of symptom a t oh )gy exliibited by the différent \Tarieties of aphasia to which référence has bee»n made, as alexia, dyslexia, and paralexia. Some of the symptoms thus designated may be produced by either sensory, motor, or conduction disease, or by eombinations of thèse. Alexia is abedition of the penver of reading, as agraphia is that of AA'riting; dyslexia refers to difficulty or fatigue in reading; paralexia 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 kiiOAAm as verbal amuesia or the aphasia of recollection. Those suffering from tins 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 Avith other forms of aphasia. Pure verbal amnesia is inability to reeall the name of an object, quality, or eArent, al- though the conception or idea of it is présent in ceuisciousness. This loss of word memory may be almost 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 revi\red in the memory, although the person or thing is absolutely heard or seen, and is recognized. Xouns, and especially proper or gênerai 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 hâve been reported by Avriters. Besides word-deafness and word-blindness, disorders known as psy- chicàl deaf ness and psychicàl blindness occur from cérébral disease; the Avord disturbances are perhaps best regarded as degrees or varieties of the more comprehensive psychicàl affections. A case of psychicàl deafness, however, may in addition to word-deafness, or perhaps inde- * Starr, New York Médical Record, Oetober 27, 1888. APHASIA AND OTHER AFFECTIONS OF SPEECH. 209 pendently of it, haA*e lost gênerai auditory memory for objects and for sounds of delinite import. In psye-liical blindness the \dsual memory of forms and e-olors, and of things in gênerai, may be lost, or the poAver of recognizing by sight the spee-ial properties of objects may be impaired or de'strevyed ; although even such patients may préserve sight of a lower kind, that, for instance, Avhich would enable them to aA'oid obstacles place-el in their path, as the psychicaiïy deaf may also by loAver centers appree-iate vibration or noise. Apraxia, ahvady defined as the inabiïity to recognize the use or meaning of objects, it Avili be seen might be the resuit either of psychic- àl blindness or psychicàl deafness, or of both. Apraxia and verbal amnesia are not necessarily présent 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 revive in memory. CEREBRAL CENTERS AND TRACTS CONCERNED IN THE MECHANISM OF SPEECH. Various schemes and diagrams of the centers and tracts of speech, and of their possible lésions, hâve been suggested, and almost any one of thèse might answer for the séparation of aphasias in a study of them for medico-legal or other practical purposes. Lichtheim * indicates at least seven loe-aiïties for diagnostically separable lésions, without includ- ing the visual or conce-pt centers, or some of the hypothetical inner com- missures ; and thèse might be readily increased to ten or more locations. The principal brain centers or areas cone-emed Avith the phenomena and mechanism of speech are : (1) auditory (center of auditory images) ; (2) visual (center of visual images); (3) concept; (4) propositionizing (center of motor images) ; (5) utterance; (G) graphie or writing; (7) in- hibitory (higher prefrontal centers). Of rece>ptive centers I hâve mentioned only the auditory and Adsual for the sake of simpiïcity, although, of course, impressions r(»cei\Ted by the cérébral centers for toueh, taste, and smell, and particularly by those for toueh, may sometimes enter into the mechanism of speee-h. The chief cérébral tracts and commissures concerned with speech are : (1) the entering auditory tract, Avhicli couveys impressions to the auditory center; (2) the entering Ansual tract; (3) the commissures be- tween the auditory and concept centers; (4) the commissures between the Ausual and concept centers ; (5) the commissures between the auditory and visual centers ; (6) the commissures betAveen the concept and prop- 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 anel graphie or writing centers ; (10) the direct tract, sometimes used, from the Adsual sensory center to the motor graphie or Avriting center; (11) the tract or tracts Connecting the medor cortical centers concerned Avith speech and writing with the centers in the bulb and spinal e-ord. * Lichtheim, Brain, vol. vii., January, 1885. 270 A SYSTEM OF LEGAL MEDICINE. PARTICULAR FORMS OF SPEECH DISORDER PRODUCED BY LOCALIZED LEsieixs. Restricting ourselves to this number and arrangement of cérébral speech centers and patlnvays, the first cérébral tract involved in spoken anel Avritten language Avould be the entering auelitery tract—the path between the primary auditory centers in the bulb and the cortical center for words, which is situated in the posterior thirels of the first and second temporal convolutions. Lichtheim lias placée! 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 lésion of this entering patlnvay, as it Avould be also of a lésion of the auditory center itsedf, but in the latter case paraphasia and paralexia Avould be also présent, as the patient Avould be unable to verify the correetness of his spoken words by hearing. The entering tract for vision passes by way of the optic radiations of Gratiolet, Avhich are chie'fly 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 région. Word-blindness would be caused either by lésion of this entering tract or of the visual center feu- words. Expérience shows that other symptoms, such as mind-blindness and hemianopsia, are often associated with word-blindness, because the tracts and centers concerned Avith the functions of sight impaired in the latter disorders are closely associated with those which take part in Avord 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 présent in cases of word-blindness produced by lésions thus situated ; but it must be remembered that the word-blind can sometimes Avrite from dictation or spontaneously, largely by the aid of tactile or muscular sensé, and that they can also sometimes copy printed or Avritten text Avhich they may not be able to read or un- derstand, probably as they would copy a geometrical or other figure. Récent authorities are generaiïy agreed as to the necessity of some area and mechanism on the sensory or réceptive side of the brain, or in- termediate between it and the motor cerebrum, for a higher intellectual process than the mère registration of auditory and visual impressions— for the formation of concepts in contradistinction to percepts which are represented in the true cérébral centers of hearing and sight, for the or- ganization in consciousness of definite ideas and the identifying of thèse Avith names. As to the existence of topographically separated centers or régions for this higher process, considérable différence exists. Some ad- A'ocate a spécial naming, idea, or concept center. Others do not consider that a center for the élaboration of concepts is localized in any particular spot or area of the brain, but that this process is rather the resuit of the combined action of the Avhole sensorial sphère, and that the commissures betAveen the sensory and motor speech centers and this conceptual sphère consist of convergïng radiations from various parts of the cortex to the réceptive 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 neAV centers introduced, but only APHASIA AND OTHER AFFECTIONS OF SPEECH. 271 complication upon complication of one perceptive center. Broadbent,* on the other hand, believes that a certain convolutional area, which might be calle-el the "idea center" or "uaming center," exists on the sensory or upAvarel side of the nervous system, anel e-onjectures that it is situe ted on the under-surfae-e of the temporosphenoidal lobe near its j miction with the occipital lobe, as it seems to him that fibers from aiï the convolutions in Avhich perceptive centers hâve been placed converge to and end in the gray e-nrtcx of this région. Itoseuithal, AAdio is cited by Ross, lias recorded a case of verbal am- nesia without Avord-deafness in a patient suffering from gênerai paralysis, Avhie-h defect of spe-ech was ushered in by an apoplectrform attack, and persiste-el michanged for upward of t\ve> ye»ars. At the autopsy, besides évidence of a chronic leptomeniugitis, an oldfocus of softening Avas found in the secemd anel third tempeu-osphenoidal convolutions, the first tem- porosplu-noidal convolution being quite free from disease. After ail, the existence of a spécial development or organization of the cortex for thinking by concepts and for the clothing of ideas in names is ree-ognizeel by authorities like Re>ss, Bastian, and others, who differ from Broadbent, Charcot, and Kussmaul, and the school of believers in se-parate ceuicept centers, only in not restricting this organization to an area absolutely set apart. It is neither improbable nor unphiïosoph- ical that a région conveniently intermediate between ail réceptive and emissive- centers concerned in the mechanism of speech may constitute a spee-ial, but not narrowly limited, area of the cortex, which is the ana- tomie-al substratum for concepts and the names which they awaken. The chief affections of speech anel of thought due to lésion of this nam- ing en- concept cortex, whether it is regardée! as an isolated area or as a coniplie-ation of centers and paths spread over the whole sensorial sphère, are varieties en° A'erbal amnesia or the aphasia of recollection, Avith usu- ally additional symptoms, such as lenss of understanding of spoken or Avritten language, or of Aolitional spe»ech or Avriting, because of the al- most ne-cessary iiiA'olvement of commissures to other sensory and motor centers. Various affections of hearing and speech, or of vision and speech, may be due to lesiems of the inner commissures between the auditory ami visual e-e-nters, or betAveen thèse and the concept centers, and like- Avise Avarions degrees of disturbance of thought and speech from lésions of the paths between thèse concept centers and the motor régions for speech ; anel thèse disorders Avili par take of the rece'ptive or sensor ehar- aeter on the one hand, or of the emissive or medor eharaeter on the other, according as the lésion is respect!vely toAvard the sensory or the motor side of the brain. Isedated word-blindness, according to Lichtheim and other obse-rven-s, is the resiilt of a break between the visual anel auditory centers of Avord représentation. Paraphasia and paragraphia, en- disturb- ane-es in speaking and writing shown in the misuse and jumbiïng of sounds and Avords, resuit from interruption in the commissure betAveen the auditory and motor speech centers, or in the arc which unités visual, auditory, anel motor centers. If we acknoAvledge the existence of concept areas as practically dis- tinct centers or régions, or even if Ave take the view that they exist as * Broadbent, Brain, vol. i., January, 1887. 272 A SYSTEM OF LEGAL MEDICINE. complications or elaborations of the true auditory and visual anel other i-eeeptive centers, then lésions of thèse higher ce-11 clusters, partie-ularly if exteiish'e, might of course give rise to coneeptual disorders of speech and thought. SeArerance of association tracts between the ceuu-ept and the perceptive centers may, henvever, often be the cause of différent A'arieties of thèse psychicàl disorders, according to the tracts disseA'ered. To give a simple illustration, one of my patients, avIio Avas both objee-t- blind anel word-blind, could not recognize a purse by sight, but on hanel- ling it, examining its clasp, etc., she at e)iiee named it eorrectly ; probably the tracts between the AÙsual perceptive and higher visual areas Avère de- streycd, as well as the Ave)rd centers, A\diile the tae-tual centers and lines of communication from them to the conceqit région Avère unaffected. Dyslexia is probable most frequently due to a partial break or lésion in the commissures betAveen the visual aud the motor aphasie centers, although imperfect destruction of the commissure betAveen the au suai and auditory centers, e>r between tlmse for Aven-d hearing and Broca's convo- lution, might cause some degree of tins disorder. Paralexia, like para- phasia, may be due to severance of the communications betAveen either the auditory or visual centers and the motor speech régions. The purest forms of motor speech defect Avili, of course, be due to an isolated lésion either of Broca's convolution, Avhich 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, luwe been reported ; senne Avhich are Avell known in the litera- ture of aphasia seem to clearly prove that the loss of propositionizing poAver is présent only when the lésion is absolutely limited to Broca's conA'olution. While it is true that the power of building and rehearsing in the minci a phrase or sentence and the poAver of uttering it are commonly lost together, stiiï such a combination does not always exist in aphasie cases. Doubtless two processes of this kind, which are so intimately connected and so often jointly lost, hâve their anatomical substrata in closely ad- joining localities, and one so-called center might be considered, after the manner of Ross, simply as a complication or extension of the other ; but still the more elaborateel area is separated, even if it be only the shortest distance, from the other. Aphasia 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 poAver of repeating and of reading aloud should also be lost. Spoken anel Avritten words, however, could be understood, and the faculty of copying retained. The destruction of the short commissures between propositionizing and graphie centers must nearly ahvays take place in lésion of Broca's con- volution and its subcortex, and hence give motor aphasia and agraphia. In a case recorded by the writer 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 Sytoian surfaces, and a spot one-half inch in diameter about the middle of the internai portion of the island of Reil, utterance was largely abolished, whde 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 lésions, commis- APHASIA AND OTHER AFFECTIONS OF SPEECH. 273 sures of some kind must be involved, and henee varieties of commissural or conduction aphasia are nearly ahvays blendeel Avith motor disorders, but thèse are often recovered from in part or Avhole. Agraphia, or the leiss of poAver of Avriting, Avhich may, of course, be of the highest importance in medico-legal directions, may be due to lésions variously situated. I hâve alreaely spoken of Avhat might be fermée! the sensory tonus of agraphia due to lésions of the \dsual centers or of the entering visual tracts, but even motor agraphia is of several kinds. The patient, for example, may be unable to Avrite spontaneously, although he can from dictation, and he may at the same time be able te) copy either written or printed text ; or, again, he may not hâve the ability to Avrite either from dictation or by copying. Lésions situated in several places may give rise to motor agraphia ; for instance, in the first place», in the spécial motor centers concernée! Avith writing. Agraphia may again be dépendent upon lésions of the tract uuiting the concept Avith the speech and Avriting centers, and if a direct sépara te tract exists between the visual and the graphie centers, the poAver of copying may in such case be retained. As propositionizing is as necessary to volitional Avriting as to volitional speech, destruction of the third left frontal AAuiï cause more or less agraphia as well as aphasia. " The same resuit," says GoAvers, " folioavs an isolating lésion just beneath the cortical center, and henee the» path to the arm center must be by the ' associating fibers ' of the sub- jacent white substance, anel not the gray matter of the cortex. But it is conceivable that a subcortical lésion may be so placed as to interrupt the paths te> the internai capsule and to the opposite hémisphère, and not that te> 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 actually been observed." THE MENTAL STATUS OF SENSORY APHASICS. In gênerai terms it is doubtless true that mental capacity and its manifestations are impaired most in tliose forms of amnesia or aphasia Avhich are the resuit of lésions on the sensory side of the brain, that is, in Avord-deafness, word-blindness, in the various forms of apraxia or mind-blindness, and in those combined forms of speech and pantomimic disturbance Avhich are due to lésions of the réceptive or impressive mechanism of speech. Words seen or heard faiï to revive the ordinarily appropriate ideas in memory. Mind-blindness is not always associated Avith word-blindness, nor psychicàl deafness with word-eleafness, but Avhen such an associatieui is présent it Avould require the closest scrutin y of the particulars of a e-ase of alleged capacity or incapacity to détermine the true status of the individual, and the presumption Avould be rather against than in favor of the préservation of mental power for definite purpe>ses. More commeuily than otherAvise, Avorel-blindness and Avord- deafness are présent in the same case, and quite often the more serious psychicàl disorelers are also associated. While, liOAvtwer, aiï this is true, it is not correct that Aveirel-deafness or Avord-biïndness, or eA'en mind- blindness or psychicàl deafness, necessarily destreiys mental integrity to such an extent as to shut out testamentary capacity, the ability to makecon- trae-ts, to testify as a Avitness, or to take eare of one's person or property. 274 A SYSTEM OF LEGAL MEDICINE. MENTAL STATUS IN AVORD-DEAFNESS. What is the mental status of a ease of word-deafness ? With what voluntary acts would such an affection interfère ? First in importance cornes the question of testamentary capacity anel simiïar exercises of men- tal power in assenting or dissenting to légal papers. Gowers says that Avord-deafness is ine-ompatible Avith Avill-making, because it is impossible to knoAV Avhether the testator really understands Avhat is said to him ; but tins is putting the matter too strongly. If lie is only word-eleaf from lésion of either the entering auditory tracts or of the auditory center, but still pré- serves full cérébral visual poAver, and intact lines of communie-ation be- tAveen the AÙsual center aud the motor areas for speech and Avriting, a will might be made, or other légal papers might express his real intentions. It ought not to be necessary, in other words, for competency that the per- son should be responsfve by every channel of communication. This, as in so many other cases of the kind we are discussing, should be studied on its oavu merits, and testimony as to how the disputed act Avas done should be clear and immistakable. Evidently a completely Avord-deaf patient coidd not express either assent or dissent by hearing, and pecul- iar statutes might hâve some bearing on the capacity of a case of word- deafness; for instance, if it Avère required by statute that the testator should be addressed by spoken Avords. If he Avas capable of assenting or dissenting Avith certainty by any of the legitimate or légal means of communication, he might be compétent. Some word-deaf patients are or become able to communicate in spoken or written language, but if the lésion is complète the interférence with aiï methods of communication Avili also be nearly complète until new centers are educateel and new lines of communication opened, or compensation takes place through the other hémisphère. Complète word-deafness is therefore a serious affection in its direct effects on thought aud its expression, and also because of the conditions Avith which it is likely to be complicated. Bastian says that a totaiïy word-deaf patient might perhaps not understand written lan- guage, but acknowledges that this ability might persist to some extent through the action of the opposite hémisphère. In spite of the serious- ness of word-deafness, it is a mistake to conclude too hastily that the in- dividual is either incompétent or in any technical sensé 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 occur. In a number of the cases of combined sensory and motor aphasia observed at the Philadelphia Hospital, word-deafness, at an early period almost complète, rapidly or gradually disappeared, but not ahvays fuiïy. Many of the patients responded to the last Avith difficulty or sloAA-ness to spoken words. In the considération of the medico-legal as- pects of Avord-deafness the fact that patients improve or recover should be constantly borne in mind. The most conflicting testimony might be truthfully given about the condition and the competency and responsi- bility of an individual, if such testimony were based upon observations maele 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 f eA*er he suddenly lost his powers of speech, and Avas Avord-deaf—words APHASIA AND OTHER AFFECTIONS OF SPEECH. 275 feiï unrecognized upon his ear ; but after many Aveeks he recoA'ered, re- sumed his professional work, and AA'rote a Aaluable analysis of his oavu case». Schmidt's e-ase, quoteel by Kussmaul, is interesting as showing the e-harae-teristic symptoms in a Avord-deaf case, and also iiïustrates the fact that word-deafness and high grades of verbal amnesia may in large part disappear. RecoArery took place» sloAvly. She did not understand short sentences until after a lapse of half a year, and then only when the»y Avère pronounced slowly anel distinctly. Even to the last there re- mained some difficulty in speaking. A Avord-deaf patient might be able to Avrite a wiïl understandingly ; lie might retain or soon acquire sufficient powers in speaking to give as- sent or dissent, en- even to express an opinion; he might retain certain powers of pantomime, visual centers and Connecting tracts remaining undiseaseel and perAÙous, and the motor areas for pantomimic speech not being destroy éd. 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, Avho had Avith the aid of Aision trained himself in the use aud compréhension of sign language. Although secondary atrophy of hearing or speech <-euters etce-urs in cases of peripheral deaf- ness, a disturbane-e of mental equilibrium occurs, and to some extent persiste, in cases of cérébral deafness Avhich is not présent in the ordi- nary deaf and dumb. Cere;bral centers and lines of communication are at first untoucheel in the latter cases, and the Ausual and manual training which is pursued takes pe>ssession of and utilizes everything possible. Lichtheim records a valuable case of Avord-deafness from lésion of the eeivbral auditory tract, a rare form of recordeel lésion. This patient, al- though Avord-ele-af, differed iu striking particulars from a case of Avord- ele'afness or speech-deafness from lésion of the center for auditory images. While, for example, he could not understand spoken language, had lost the faculty of repeating, and that of Avriting from dictation, he préservée! intact volitional speech and Avriting, the understanding of writing, the ability to eeqry Avords, and finally the faculty of reading aloud properly, thèse last being lost in cases of auditory-center deafness. He had neither paraphasia nor paragraphia, because the arc uniting auditory, concept, and motor centers Avas unbroken. This man's available mental power Avas greater than that of an ordinary case of word-deafness. He was, in fact, a teacher anel a journalist, and continued Avith success the business of Avriting articles for the newspapers. He could understand noises and other sounds of definite import, but not speech. He spoke with absolute aecuracy, but with a. slight drawl ; he could find substantives, even com- plex ones, and proper names. He copied an I O U Avritten by Lichtheim, and gave it to his Avife, remarking, " You see, you hâve money." MENTAL STATUS IN WORD-BLINDNESS. .V 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, psychicàl blindness or deafness, verbal amnesia, or paralexia. I hâve already stated, for instance, that the word-blind can sometimes write spontaneously or from dictation, or even copy writing which they do not understand. Such matters as the simple 27(1 A SYSTEM OF LEGAL MEDICINE. signing of a name to a check, to a will, or other document, are often points in dispute, and yet the ability to do this is retained in many case-s where the patient is not only Avord-blind, but se> completely so as to be able to Avrite nothing but his autograph. Letters may be understood Avhen Avords are not. The understanding for figures may be lost or re- tained. A patient repen-ted by Broadbenfj—a case which, after a time, fell into my oavu hands—cemld not at first tell how many tAvo and two maele', but in two weeks learned to add together tAvo Ioav figures, and rapidly thereafter gained iu his understanding of figures. Trousseau has recorded the case of an ace-e mutant avIio could read off the sum 7GG figure for figure, but did not knenv Avhat the figure 7 meant before» the tAvo 6's. Proust, cited by Kussmaul, records another aphasie avIio, al- though lie could no longer count in Avords, could add and subtract on paper, and even multiply pretty well. That an inchvidual is not able either to read or to Avrite because of worel-blindness should not absolutely invalidate the Avriting or signing of a wiiï or other document, although such patient is not exactly in the same condition as one avIio has never been educated to read or write, or has lost sight through extra-cerebral disease. The gênerai nie-ntal impairment, the pe>ssibility of the existence of hallucinations or delusions, and the disturbance of the equilibriuin of thought processes, must ail be taken into considération. Cases of interest in connection Avith the discussion oî word-blind- ness and of agraphia are mentioned by Legrand du Saulle and Bate- man. An aphasie, fifty years old, wislu-d to make a will, and elesired to leave an old domestic a remembrance of some importance. He made the most strenuous efforts to get together Avords and expivss on paper his Aviiï in the matter, but the Aveu-ds would not form an intelligible sentence, and the Avriting was ine-eu-ree-t and in some places undecipher- able. This defect of coordinatieui of the will and of movement could not be overcome, and he died before lie could make the will he so much desired, to the grief of the testatrix. Boucher tells of a hémiplégie affected Avith word-amnesia, avIio Avished te) make a Aviiï and give a certain sum of money to a relative who had taken great eare of him. In spite of the most expressive gestures and pantomime he had great difficulty in making himself understood. He suceeeded, hoAvever, and, the clew found, he was able to carry out his Avishes. The proof of testamentary capacity of a word-blind patient, or the validity of a written instrument alleged to hâve been prepared by or for him and having his signature, would hâve to dépend largely upon col- latéral évidence. If it could be shown that such a patient had Avritten a short contract, wiiï, or other document, and then had had it read to him, and had signified his assent to its contents, and if the évidence Avas in favor of his gênerai mental stability, his testamentary and gênerai mental capacity should be sustained. If it should be attempted to prove that such a patient had read a document in question, anel therebv as- sented to it before signature, the évidence would be against its validitv and his capacity. A word-blind patient recognizing his defect, but not being word-deaf, and in possession of his gênerai mental faculties, might hâve a wiiï or other légal paper written for him, and then read to him, and signify his assent to its contents by gesture, by his autograph, or APHASIA AND OTHER AFFECTIONS OF SPEECH. 077 by his mark. The possibilitv of déception having been practiceel upon the- Avriter en- testator in such a case should, of course, be taken into con- sidération and eliminateel. Word-blindness, like Avord-deafness, often improves so as to change the AÙsual recepthre powers, and possibly the capacity and e-ennpetency of the patieuit. The following case Aviiï serve to illustrate some of the points likely to arise- in the settlement of problems assex-iated Avith conditions of Avord- blindness anel A~erbal amnesia. The patient Avas a married Avoman sixty- six ye-ars old, who had had an attack of hemiparesis. Examination sheiAved that she had right latéral hemianopsia Avithout Wernicke's pupd- lary inaefion. Testing lier in a variety of Avays it was found that she ceudd îve-ognize obje'cts seen, heard, felt, smelled, or tastecl. Until a short time betore examination she had been able to recognize persons on the street, although she could not name them ; but this power of réc- ognition of pe-rsems Avas leaving lier. She understood what was said to her. She had four sons, and evidently could tell one from the other, but could not correctly name them, just as likely as not calling one by anothe-rs name. She understood Avhat Avas read to her, but cemld not re-ad, as she die! not understand printed or Avritten words. She could sign lier name and write a few short words at dictation, although the writing, except lier name, was so imperfect as to be almost illegible, ex- cept in the case of a small worel like " cat." She e-ould recognize au ob- ject by sight, hearing, or toueh ; she could not name it correctly from seeing it, but could do so from toueh ; 01* after it was told to lier she would indicate that she knew the name but coidd not reeall it. She called a stamp held before lier a "ticket" or a "letter," and said she knew what it Avas but coule! not name it. She caiïed pills "pencils," but knew Avhat they Avère used for although she nameel them Avrongly. When a paste-bottle was held up before lier she named it correctly, but called a pe>stal card a. "stamp," although she kneAV what it Avas. She calice! a Avatch a "key," and said it looked like a key. When some keys Avère held up before lier she said they Avère "locks," and evidently knew their uses. On holding a pocket-book before lier she could not name it, but did this quickly Avhen she took it in lier hand. MENTAL STATUS IN VERBAL AMNESIA. The medico-legal bearings, civil anel criminal, of verbal amnesia, or the- aphasia of recollection, open an interesting field, and one not alto- gether unexplored by Avriters ou disorders anel disturbances of speech. It is rarely an iselafeel symptom. It is frequently associated Avith aprax- ia in some of its forms, 01* with Avord-blindness or Avord-cleafuess, or both ; it may, indeed, be eennbined in the same case Avith almost aiï other aphasie affections. Me»st commonly, as Avould be expected, it is combined Avith sensen-ial aphasias and apraxia s. I hâve already discussed the questieui of spécial naniing 01* concept centers, leaning to the aucavs of the)se Avhe) hold to the aggregatie)ii of thèse concept centers into a more or less isolated field or zone, but that this concept field is probably not limitée! to one spot in the sensorial sphère. When more perfect knowledge of localization is attained, it Avili probably be found that the concept région of the brain is a comparatively large but connected area, 278 A SYSTEM OF LEGAL MEDICINE. interlacmg among various centers for percepts in sue-h a Avay as to make certain portions of it eonveniently intermediate anatomieally between particular percept centers and the spécial motor or eiuissive centers with which they are most intimately correlated. Lesienis somewhat variously distributed and extended Avili, therefore, give rise to forms of amnesia and apraxia; and strange symptom-pictuivs, difficult to analyze and to refe'i- to thèse lésions, Avili sometimes be prese'iited to the clinician and meelie-al jurist. The loss of the faculty of recalling words must interfère to some ex- tent Avith the acts of thinking as Avell as with expression. Kussmaul holds, and doubtless correctly, that amnésie aphasia in its most severe forms must reuder 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 tins, important as it may be, but should, in studying individual cases, separate the varieties of verbal amnesia and apraxia into classes, based upou a study of the relations of the symptoms présentée! to the sites and extensions of the lésions on which thèse symptoms are dependeut. Those» deep disturbances of speech and thought Avhich are» dépendent upon large lésions destroying and disrupting various percept anel cone-ept ce-nters, and the lines of communication between them, must so Aveaken and confuse the mental poAvers 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 fréquent associations hâve been recorded in the classical treatises on aphasia, and hère and there in journal s anel text-books, but I will only refer to two or three. Kussmaul cites Bergmann's ease, in which nouns had disap- peared from the patient's ve>eabulary, but lie still had eommand of the verbs. A pair of scissors lie calle-d that with Avhich one cuts; the win- doAV, that through Avhich one see»s, through Avhich the room is iiïumined, etc. The same author also gives the well-knoAvn case reported by Hun of Albany of a farrier avIio understood Avhat Avas said to him, but al- though his tongue Avas freely moAable lie could not find words and had to make himself understood by signs. If the Avord Avas Avritten out for him he Avas able to spell it, and could pronounce it after a feAv attempts. When lie Avas able to pronounce a Avord lie Avas aise) able to write it. Bateman* records the ease of a merchant avIio seemed to understand everything that Avas said, but had to a certain extent lost the memory of Avorels, and would call things by their Avrong names ; for instance, when the fire Avas burning particularly brightly he said, " How bright the poker le>e)ks ! " Some one said, " You mean the fire ? " " Yes," he said, " I mean the fire." Lichtheim reports a case of lésion of the paths betAveen both the auditory and the visual centers and the concept sphère, with an interest- ing medico-legal experiment. Such a break should ghre us, according to his analvsis, loss of understanding of spoken and AA'ritten language, with the préservation of volitional speech, Avhich would, however, be para- phasic, and of volitional Avriting, which Avould be similarly paragraphic ; ,-dso Avith rétention of the faculty of repeating Avords, of reading aloud, of * Bateman, Aphasia, etc., p. 169. APHASIA AND OTHER AFFECTIONS OF SPEECH. 279 Avriting from dictation, and of copying words, Avith, hoAveA'er, a loss of in- telligence for Avhat is repeated, read aleuid, or Avritten from dictation. The case bears out fully this analvsis. Verbal deafness Avas présent, but Avith little or no deficiency in the man's vocabulary, although he Avas in great difficulty when lie had to name objects shown to him ; lie could repeat Avhat Avas said te) him Avithout understanding; lie understood nothing printed eu- hand-Avritten ; lie could make up letters into Avords and ceuild read aloud by spelling, but the sensé of the Avorels remained closed to him. His other h)sses and préservations Avère in accordance» with the ■analvsis just given. Word-deafness, paraphasia, paragraphia, and in- telligent compréhension changée! markedly for the better ; but eA'en after much improvement writing to dictation remained obscure. Lichtheim die-tateel to him an I 0 U for 20,000 francs, Avhich the patient allowed the tor aphasies, howeA'er, gênerai conclusions are neit sufficient, as such e-ases separate themseh'es into several classes ae-e-ording to the site and extent of the brain disease producing them. A sharp distinction must be made with référence te) ail aphasies, but par- tie-ularly those in which the motor type prédominâtes, betAveen having * Starr, New York Médical Record, Oetober 27, 1888. •JSO A SYSTEM OF LEGAL MEDICINE. mental power and being able to make known tins possession to othe-rs ; between the capacity to Avish and will certain things and the- ability by speech, writing, or pantomime to show the désire and intention. In pure motor aphasia, due either to lésion 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 anel purpe)se-s known. Usually such aphasia is asse>ciated with agraphia., but exjiressiA'e panto- mime is likely to remain in senne degree, se> that the patieuit can often communicate intelligibly Avith others. The impressive and concept sphères of language are not interfered with, and if any clear means of expression and communication remain, the capacity and competency of such a patient Avili be scarcely questiemeel. Cases Avhich illustra te this standpoint are to be found in ail articles and treatises on aphasia, and neeel not be quoted. Even cases of pure» motor aphasia may be some- times misunderstoe)d. if eare is not taken in communicating with them. Bastian* says that in pure agraphia thought is least of ail interfered Avith, while in pure aphasia it is more e>r less hampered, because the non- revival of glossokinesthe'tic impressions seems to interfère somewhat Avith the free and thorough revh'al of words in other functionally related word centers, even during the prex-ess of siïent thought. Motor agraphia is usually associated with aphasia of the motor type, anel, like the latter, is also A'ariously combinée! Avith conduction en- even conceptual and sensorial affections, and its importane-e Avili of course dépend 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 anel agraphia combined Avith types of conduction aphasia and well-marked hemiplegia. Thèse hémiplégie aphasies easily separate inte three edasses with référence to the présence and persistence of the aphasia: (1) those in which aphasia, cennplete or nearly complète at first, in the course of days, Aveeks, or months totally or ahnetst totally elisappears; (2) those in which aphasia is nearly or quite absolute anel remains pernumently ; (3) those AA'hich improve slowly, and largely through a tedious process of training and rééducation. The nervous warels of the Philadelphia Hospital almost always contain some cases of thèse différent types. When the hemiplegia persiste although the aphasia passes aAvay, the lésions are most probably of the internai capsule, e-ompressing 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 integrity of patients of this class after the apoplectic period is ahvays retained, and is, as a rule, soon easy of détermination. The ability to write and to express thought by pamte- mime is fully preserved on the non-paralyzed side, and to some extent, when the paralysis is not absolute, the paralyzed limbs may be made to do servie-e in expression. In hémiplégie aphasies, in Avhich the aphasia remains nearly or quite absolute anel permanent, the détermination of the mental status of the crippled indh-idual is often a matter of great difficulty. Generaiïy the lésion is one of large size, involving anel destroying both internai and * Bastian, British Médical Journal, vol. ii., 1887, p. 93-4. APHASIA AND OTHER AFFECTIONS OF SPEECH. 281 external capsules, and to a greater or less extent both striate bodies and the insula ; in other words, one Avhich, according to oui* best lights, disrupts entirely the internuncial tract for speech and also largely the commissures, both direct and indirect, betAveen the sensorial and motor e-e-nters or between the latter and the center for concepts. The lésion, moreover, is often se) close to the cortex for speech as to destroy the commissures which would otherwise connect the left hémisphère with the right through the callosum. Although motor aphasia and motor paralysis of face and limbs are prominent, the case is in reality one of baelly mixed type, and présents phenomena at first sight as confusing to the iiiA'estigator as the disturbances of thought and speech are to the suffering patient. It is in such a case particularly that a A'ast différence exists between the possession of thinking power and the ability to com- municate Avith others. As a rule writing and pantomime are lost in equal degrees Avith speech ; but every means should be exhausted and every channel of communication tested. Some knoAvledge of the most fréquent methods of combination in the mixed aphasias Avili be of service in attempts at the solution of the medico-legal problems of speech. Brain lésions, usually A'ascular, are likely to extend over areas and tracts Avhich are associated in function- ing, and hâve, in accordance with a gênerai laAV, a more or less common source of blooel-supply. Différent varieties of psychicàl blindness and de»afne»ss, partial or complète, may occur together; motor aphasia, agraphia, and amimia, partial or complète, are usually associated Avith paraphasias ; and frequently partial Avord-deafness is found in conjunc- tion Avith one or se»veral of the A'arieties of motor defect in expression. Total sensory and motor aphasia is sometimes obseived, and is of course accompanied by the e-ompletest form of speech, graphie, and pantomimic disorder—complète aphasia, agraphia, and amimia. Close studies of thèse compound cases Avili doubtless better enable us after a time to se-parate them into différent classes, gnided by localiza- tion facts and théories ; to distinguish cases in Avhich either the direct sensorimotor or the concept-motor commissures, or both, or the hemi- spheric commissures, are daniaged at the same time that the lésion at- tacks e-ortical centers and e*ortico-bulbar tracts. The path from concept lo motor, or from auelitory te) motor, centers is certainly frequently broken, and probably most frequently near the motor end of the fine. Pure en- almost pure cases of concept-motor aphasia haA'e been reported in considérable number. PSEUDOBULBAR AND BULBAR AFFECTIONS OF SPEECH. The form of infracortical affection of speech which results from lésion of the tract or tracts Connecting the cortical centers with the nuclei of the bulb and spinal cord is of considérable importance because of the fréquent disturbance either by pressure or destruction of this portion of the cerebrum. In many cases of hemiplegia, aphasia, at first Aery promi- nent and peisitive, after a time disappears in large part or eA'en almost entirely, the paralysis of the leg and arm remaining A'cry pronounceel. Some of thèse» cases are to be explained by the fact that the intra cérébral facial tracts are only affected by pressure, and in others, eAren Avhen they oc;o A SYSTEM OF LEGAL MEDICINE. are more or less destroyed, the opposite hémisphère assumes the Avork of both. The common view is that the bilatéral movements Avhich occur during speech may be innervated from each hémisphère. More or tess complète destruction of the fibers whieh connee-t 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 speoeh, which has been variously described as pseudobulbar paralysis, labio-glos- sopharvngeal paralysis of cérébral origin, aphemia, etc., and e-ases haA'e been reported by Kirchoff, Ross, Hobson, Bastian, the Avriter, and others. Tavo such cases Avili be given in the section on pantomime. Thèse patients articulate AA'ith difficulty ; paresis en- paralysis of the tongue is présent ; labials and gutturals and linguals may ail be- troublesome te) pronounce ; draAving of the face will usually be présent ; swallowing may be difficult ; the movements of the jaw may be impaired ; anel drooling is a fréquent symptom. In such e-ases interférence with speech is sometimes extrême, amounting almost to complète speechlessness. While such a train of symptoms usually accompanies a generalized hemiplegia, it is occasion- aiïy observed unconnected with paralysis in parts other than the face. This pseudobulbar paralysis is a more décidée! and permanent affec- tion when the resuit of bilatéral disease, but a form of it can oe-cur from a deep-seated lésion confined to the left hémisphère. Strictly speaking, Broca's conA'olution is not directly connected Avith the basai nuclei, but indiree-tly it is through the utterance or glosso-labio-pharyngolaryngeal cortical centers, and the larger portion of the fibers whie-h go down from thèse centers te) the bulb pass by Avay of the left hémisphère, although a partial decussation probably takes place. If a commissure connects the spe>ech or utterance régions of the two hémisphères, it must be compara- tively close to the ce>rtex, and its destruction, as Avell as of the fascicu- lus to the bulb, would ae-count for some of the infracortical speech or articulatory disturbance-s. Ace-ording to Lichtheim* Ave are compelled to assume that only a short extent of the efterent tract from Broca's centers is so constructed as to give rise, e>n being injured, to real aphasie disturbances; and we shall therefore hâve to look also for the lésion of aphasia Avithout agraphia in the Avhite matter of the hémisphères. Anarthria, or disturbance in articulation, rather than a genuine apha- sia, accompanies pseudobulbar or labio-glossopharyngeal paralysis of céré- bral origin. The most marked examples are due to bilatéral lésions or degenerations. Whether unilatéral or bilatéral, ail cérébral centers and commissural channels are undisturbed ; volitional speech, Avord répétition, and reading aloud are lost or greatly impaired simply because of inter- ruption to speech impulses in the outgoing roadways beloAv the cortex. Mental capacity and competency need not be in the least diminished, as the patient préserves his réceptive and conceptive faculties and large poAvers of communication by means of pantomime and Avriting unless paralysis of face and limbs accompany the aphasia. In true bulbar paralysis, in Avhich the changes in articulation are sometimes slight and at others so complète as to almost abolish articu- late speech, mental soundness, if the cases are uncomplicated, is ind in any degree impaired, and A'arious methocls of expression and communi- * Lichtkeim, Brain, January, 18S5, pp. 481, 482. APHASIA AND OTHER AFFECTIONS OF SPEECH. 283 cation remain. " As in the course of thèse degenerative changes one ganglioii-cell after another is slowly destroyed in the bulbar nuclei," says Kussmaul,* " we perceh'e consonants and a'oavcIs successively cruinbling aAvay, as it were, from the patieut's speech, Avhiïe his intellectual poAvers may be perfectly retained." The A'ariems but alliée! forms of speech disturbance which resuit from insular sclerosis and focal lésions of other sort in the intracerebral tracts are not necessarily accompanied with any loss of mental strength or clear- ness, although, as is Avell known, mental changes are somewhat common in this affection because of its diffuse and destructive eharaeter. It is searcely necessary to refer to the peculiar varieties of speech defect found in this well-known disease, which hâve been well described under a A-ari- ety of names such as draAvling, sjdlabic, scanning, staccato, and hesitating. SPEECH DISTURBANCES ASSOCIATED AA'ITH INSANITY. The study of speech disturbances which are associated Avith varions forms of insanity would need an article of considérable length for their full discussion. I can searcely more than refer to them. As has been said by Dr. Hughes, aphasia dissociated from marked mental impairment is of more fréquent occurrence than in association with évident insanity ; se) that in a case of suspected mental disease the burden of proof wiiï fall on those who might maintain the coexistence of mental aberration, and the légal 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 obseiwed in an institution deve)ted to the treatment of mental disease, and not a feAv of the recen-ded cases hâve been observée! in hospitals for the insane. Every physician in charge of an institution of this eharaeter should earefully inquire into the history and symptomatology of cases shenving spécial forms of speech disturbance. The tAvo cases referred to by Kuss- maul wiiï 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 décisive importance in the détermination of questions of e-ennpetency. In mania, melancholia, paranœa, katatonia, idiocy, and imbecility the peculiarities of speech might hâve some bear- ings upon medico-legal problems in connection with the diagnosis of the nature, depth, or stage oî the affection. About the hallucinations and delusions of aphasies much of interest might be written. The haiïucinations are usually of hearing and sight, and may in not a few cases be dépendent upon irritation of senseny cen- ters ; Avliile A'arious delusional states may hâve their origin in disease of both senseny anel concept centers, or in the disruption of various lines of communie-ation between the différent areas of the brain concerned with speech. A considération might be hère in place of the inhibitory speech cen- * Kussmaul, op. cit., p. 654. 2S4 A SYSTEM OF LEGAL MEDICINE. ters, or centers for abstraet thinking, which I hâve included in the list of centers taking part in the phenomena of speech, but Avhich are not usually so inclmled. They are probably loeated in the prefrontal région. Hughlings Jackson * Mercier, and others hold that anterior to the Kolandiciinotor région are the highest motor centers, and that thèse with corresponding sensory centers make up the highest level of the- central nervous system. Jackson contends that the-se higher centers repivsent ail parts of the boelv ; and Mercier that the highest nerve processes which form the substrata of the most elaborate mental e)perations reqn-esent at the same time not only the most elaborate forms of conduct and mus- cular movements, but also cA-ery part of the organism to some degree. Aceepting such doctrines, speech, like every other function of the body, must, of course, lie influenced by anything AA'hich affects thèse highest centers. Affections of speech due to lésions of thèse prefrontal areas are a part of the gênerai mental impairment which goes with the destruction of this région ; and the mental status of the individual wiïl 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 epileptie or epileptiform aphasia without spasm—or at least Avithout the usual type of convulsion Avith unconsciousness—may haA^e important medico-legal bearings. Disturbances of speech in connec- tion with epiïeptic attacks are, of course, very common, and may occur before or after or even during a fit, when loss of consciousness is not profound. Sometimes a seizure is preceded by muttering or confusion of si)eech, by " thickness of tongue," by utterance of ce-rtain expressions, by an unusual talkativeness, or by an absolute inability to talk. The aura of the attack may be a speech disorder. It is not worth while to go into de-tails as to the numerous perversions of speech and thought Avhich so evidently foiïoAV epileptie attacks ; they are simply the eAÙdences of exhaustion of the cérébral mechanism Avhich lias resulted from a ter- rible explosion of nervous energy which had occurred during the fit. In addition to thèse affections of speech, however, are others of rarer occur- rence and of spécial interest. In some of thèse the aphasia itself is the fit, just as avc may hâve instead of a motor paroxysm, Avhich is the usual epileptie manifestation, a substitutional attack of mania, of vertigo, of pain, of running, or other automatism. The présence or absence of speech disturbances with conscious epilep- tie automatism—A\diich is perhaps a somewhat contradictory expression —may hâve some medico-legal importance. Stevens and Hughes t hâve reported such a case, and many more as similar are to be found in books and journals. This patient, a physician, on several occasions got up in the night, dressed himself, and Avent out-of-doors to look at his stock, or perhaps simply without any purpose. During part of the time at least he realized that lie was doing something which he should not. He had had many real epileptie seizures preceding thèse attacks. He was put * Hughlings Jackson, New York Médical Record, vol. xxxvi., August 31, 1889, pp. 227, 228. t SteArens and Hughes, Alienist and Neurologist, April, 18S0. APHASIA AND OTHER AFFECTIONS OF SPEECH. 2S") uneter treatment and greatly improAed, but on another occasion in a similar seizure he Avas asked a question which he understood perfectly but could ne>t answe»r, although he continued te) talk for about twenty minutes attempting to explain Avhat lie Avas trving to say. The night foUoAving this incideuit lie had a severe epiïeptie attack. He aftei-Avard could reeall much of Avhat he had said and elone AA'hen in this confused automatic state. The reporters of the case ask what Avould hâve been the resuit hael some acts been done by this patient during his apparently consedous sonmambulism, 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 neurologist of expérience lias seen similar cases. SDIULATED, MTMETIC, AND MISCELLANEOUS AFFECTIONS OF SPEECH. The nature of some cases of sudden loss or abrupt disturbance of speech is sometimes obscure and ueeds careful investigation. The affec- tion might be absolutely assumée! or malingered, as, for instance, where it is part of a scheme for dissimulation of insanity, or where it is shammed to présent 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 Avoman who had suddenly beconie perfectly speechless, causing great consternation to her lover and the other résidents of the house. No facial or limb paralysis could be made out, and she had noue of the usuaiïy associated phenomena of either an apoplectic or an epileptie attack. Tins abrupt loss of speech had come on after a quarrel with her lover, in which both lie and she had exhibited violent rage, although no physieal force had been used. This case Avas probably one of hysterical aphasia, the resiilt of neivous excitement attendant upon the quarrel. The patient recov- ereel as abruptly as she had been attacked. A form of mutism is, as is weiï known, quite common as a phase of hysteria, but the cases hère referred to are those in which the loss of speech cornes on as a sudden attack. The simulation of dumbness by criminals or others should not be over- looked, as it is iu fact a simulation of aphasia or in some cases e»f both aphonia and aphasia. It may be resorted to by criminals feigning to be insane in order to escape the conséquences of their crimes, or by prison- ers te» avoid duties and punishments. Ray* mentions the case of aman who had eut off his wife's head and had or assumed the demeanor of an imbécile. Among other manifestations he carried a pièce of wood about with him, which he represented by signs to be a sword. He would not speak or ansAver any questions except by now and then repeating the word " cabbage " without any meaning. Another French homicide, who was adjudicated insane, would not answer questiems, although he heard and understood them. Jean Gérard murdered a woman at Lyons in ]S29, and immediately after his arrest ceasecl to speak altogether and appeared to be in a state of fatuity. The use of the actual eautery for several days brought him to terms, and after some urging he spoke, * Ray, Médical Jurisprudence of Insanity. 286 A SYSTEM OF LEGAL MEDICINE. declaring his innocence of the crime with Avhich he Avas charged. An Italian criminal became insane soon after he had been betrayeel by his accennplices, and to any question Avhatever he merely uttered the worels '•priest, book, crown, crucifix." Many détails are connected Avith tins case, but it was finaiïy decided that lie Avas insane. It is not impeissible that he may hâve been insane and also simulated some of his symptoms. In suspected shamming of dumbness or of aphasia the gnnuineness of the phenomena should be patiently tested from the standpoint that the defect oî speech might be (lue 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 détermination of the présence of insanity or its simulation should be applied as far as possible, resorting to surprises, strategy, and perhaps even in some cases to anaesthesia or to stern methods. The apparent aphasia or apraxia should also be tested and studied as is any ordinary case of this affec- tion in the sane. Word-deafness, Ave>rel-blindness, alexia, dyslexia, motor aphasia, and agraphia should, if possible, be» iiwestigated and included or excluded ; and the existene-e or non-existence of accompanying paralysis, anœsthesia, hemianopsia, etc., should be giveni full Aveight. The disease known as echolalia or coprolalia, and by various other names, might hâve some medico-legal importance. This is an affection in which convulsive or choreic menements are associated with a sudelen explosion of speech. The patient, with a grimace, contention, or violent movement of some kind, suddenly bursts into an obscène, profane, or absurd expression. This expression may be the écho of something over- heard—henee the name echolalia—or it may be a spontaneous outery. It is conceivable that such a patient might be arrested for the use of obscène or insiilting language in the présence of others, and physicians and jurists should therefore bear in mind that such a disease exists, and that the impulse to burst forth iu this way is sometimes irrésistible. It is not simply an hysterical affection, controiïable and curable, but is a true monomania, the affection of speech being beyond the patients voli- tion. One patient of mine, a boy about twelve years of âge, would at times Avithout warning, in a street-car or other public places, as Avell as in private, suddenly give utterance to a filthy expression tAvo or three times, accompanying it with a violent movement of the head and shoul- ders and one arm. Another patient, a lady of good éducation and fine personal appearance, would in the midst of a conversation, or on intro- duction to another, or at any most inopportune time, suddenly with vio- lent gesticulation shout, " Damn it ! Damn it ! " Gilles de la Tourette, Dana, Seguin, and others hâve reportée! numerous cases of this kind, and the affection certainly has a pe>ssible medico-legal aspect. The foiïowing quotation from Hughes* may serve to cover some points with référence to the medico-legal aspects of affection of speech not otherAA'ise included in the présent paper : " The hysterical, the choreic, the cataleptic, the emotional, the hyper- emic, and reflex forms of speech failure hâve neither distinct clinieal sig- nificance, nor are they likely often to hâve medico-legal importance sep- arate from the diseases with which they may be associated. They need not, therefore, be considered hère, and we mention them mainly to ex- * Hughes, Alienist and Neurologist, vol. i., No. 3, July, 1880, pp. 315, 316. APHASIA AND OTHER AFFECTIONS OF SPEECH. 2S7 élude them, as Ave likewise do the speechlessness of îiightmare. Marc anel others, however, hâve' noted the temporary impairment of the mental faculties in chorea, and the defect in the speech poAver in this disorder is probably as much dependeut on cérébral disorder implicating the speech center along Avith other portions of the cortex as on disturbances of the motor area for the organs of articulation. There are circumstances, too, under Avhich aphasia occurring in the course of cérébral hyperemia might hâve ceu-reiborative significance in a question of doubtful sanity. "The occasional aphasia of drunkenness lias neA'er been pathologic- ally defined with sufficient distinctness. It is often, no doubt, a sort of incomplète and transient glossolabial paralysis, like the other forms of ine-oorelmation seen in inebriates, or the peculiar and more permanent defee-ts of speee-h displayed by gênerai paralytics. This latter form of s|M'ee-h defe'ct, aise», need not be considered apart from the graver disease Avith Avhich it is assex-iated, and which has other characteristic signs. Nor need we note any of the glossoplegias causing speech defect. " The momentary speee-hlessiiess sometimes occurring in persons over- e-onie Avith f right or profound surprise at being the uinvilling or unex- pected Avitnesses of some horrible tragedy might possibly be considered Avhere an innocent perse>n is indicted as partieeps eriminis from the fact of lus being présent and uttering no prétest or cry of alarm ; but in such e-ases the proper explanation, I believe, lias always bee»n and is stiïl likely to be made and received, so well understood is the fae-t by the common mind that intense fear may for a time paralyze the power of speech as weiï as motion." DISORDERS OF PANTOMIME OCCURRING AMONG APHASICS. In seA'eral places in this chapter the subject of pantomime has been referre-el to incidentally, but it is of such great importance medico-legaiïy and it has received se> little attention from Avriters that it has seemed best to consider it in a separate see-tion. Pantomime is the représentation of ideas by action and movement ; it is an intellectual act ; according to Hughlings Jackson it differs from gesticulation as a propeisition does from an oath, although the terms gesture and pantomime are frequently used almost interchangeably. Amimia and paramimia are terms Avhie-h hâve a corresponding import, as regards pantomime, te) aphasia, paraphasia, paralexia, etc., with référ- ence to speee-h. We may hâve a jargon of signs and motions as weiï as of wen-ds and of sounds ; avc may hâve a sensory or réceptive and a motor or emissh'e amimia ; sensory amimia is in fae-t a form of apraxia. Pan- tomimio elisorders may be mixed, combined, or associated; Ave may hâve ail blendings of them just as avc haA'e the ordinary speech disturbances. A study of the losses and disorders of pantomime will often be of great assistance to the physician in diagnosis, and in some medico-legal cases décision will largely liinge upon the considération of the présence, absence, or disturbance e>f intelligent pantomime. Différent and conflicting inter- prétations are too often given to pantomime observed among aphasies ; e'very case of aphasia should be studied for itself as to pantomime. Loss or impairment of pantomime is in many cases proportionate to the dis- turbane-e in speee-h, but the two do not ahvays go hand in hand, and some patients recover pantomimio poAver more speediïy than ordinary 288 A SYSTEM OF LEGAL MEDICINE. speech. If the AÙsual centers or entering visual tracts are destroyed, the patient Aviiï not be able to use sight in the exécution of manual or other forms of pantomime in so far as they may be de-pendent upon vision. E\'en impairment or destriu-tiem of the entering auditory tracts, or of the centers for auditory images, might impair pantomime Avhie-h would other Avise be called out in response to sounds and Avords heard. The most distinctive interférence Avith pantomime will, ho avc ver, be from destruction of the center for propositionizing and of the tracts Connect- ing it Avith the concept centers on the one side or the centers for move- ments of the limbs or face on the other, or from the destruction of the e-oncept areas and their commissures. Some of the most interesting cases of aphasia associated with impairment or destruction of pantomimic or gesticulatory speech indicate différences both in the form of the disorder and in the site and extension of the lésion e-ausing them. In an aphasie Avhe> nodded affirmatively Avith the head when she wished to ansAver in the négative, and used two Angers to express four, and maele similar mistakes of pantomime, a cyst Avas found destroying a great part of the third left frontal convolution, the entire left island, and the neighboring meduiïary substance and anterior third of the corpus striatum* This patient knew that she expressed herself Avrongly, and the disorder Avas therefore not amnésie; but many amnésie- cases haAre been reported. In nine cases of aphasia or pseudo-aphasia Avhich were inA'estigated by me, notable différences and pecuiïarities in pantomime were presented by the patients. In one case of brachiocrural monoplegia almost complète motor apha- sia with marked préservation of pantomime was présent ; in a hémiplégie 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 complète aphasia chiefly of the motor type, the pantomime was varied and uncertain ; a fourth case was one of right hemiplegia with marked contractures, complète aphasia of the mixed type with a single recurring utterance, and almost complète 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 graduai development, Avith motor aphasia and anarthria, only a slight degree of loss of pantomime was shoAvn ; whiïe case seven, one of right-sided pseudobulbar paralysis, with anarthria and préservation of writing abiïity with the left hand, exhibited also full préservation of pantomime. Case eight was an ex- ample of right-sided pseudobulbar paralysis and ophthalmoplegia, with anarthria, marked orolingual paresis, and full préservation of pantomime, nut Avith considérable mental apathy. The ninth and last case recorded was one of double hemiplegia from successive lésions 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 fixing subcortical lésions, and particularly the position of a subcortical lésion with référence to its distance from the cortex. Some of the cases detaiïed showed that when the lésion was entirely in the straits between the ganglia, pantomime was either not lost or soon entirely regained. * Perroud, cited by Kussmaul in Ziemssen's Cyclopœdia. APHASIA AND OTHER AFFECTIONS OF SPEECH. 289 The speech defect, as has been stated, is of the nature of an anarthria or pseudobulbar affection, and a diagnostic point is the ability of such patients to throw CA'en into the paralyzed members some volition, as in the two following cases : Right-sided Pseudobulbar Paralysis—Anarthria—Préservation of Writing Ability with the Left Hand—Préservation of Pantomime. F. G., aged thirty-five years, a salesman, after an attack of the grippe in 1889, on awaking one morning found that he was paralyzed in the right leg, arm, and face, anel Avas nearly speechless. He continued in this condition for four months, during which time he was only able to say " }^es." S])e»ech steadily improved after this. He was admitted to the Philadelphia Hospital in September, 1891. His paralysis had remained about the same, but his speech had gradually improved, and when he was admitted to the hospital lie could speak as well as usual ; but about three Aveeks after admission his speech again suddenly became impaired, and at the same time he complained that his jaw felt stiff. He talked in a slow, calculating, hesitating manner, as though it was difficult to articu- lat.e and enunciate the words he kneAv. A few days later tins disorder of speech cleared up some what, but shortly afterAvard became pronounced, anel has remained. His condition as to speech, when examined by me October 28th, was as follows : He understood words spoken or read to him, also printed or Avritten 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 tdlked. He had no paresis in the upper distribution of the facial nerve. Ile could not draAV up the right side of the mouth, and could not elevate or depress the right lip as Avell as the left; the platysma movements of the right side were also impaired. The tongue showed inefficienc3r and want of rapidity and strength in its movements. When thrust out it went a little to the left, arching slightly, the convexity of the curve being upward and a little to the left ; the inner half of the right side of the tongue was arched, whiïe the outer was depressed. The right side of the tongue seemed to be someAvhat atrophied, and in conséquence of tins 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 réflexes were exaggerateel, and front tap was présent. Marked ankle-clonus Avas elicited when obtained with the leg extended. The tendon and muscle jerks were well marked in the left leg, but no clonus Avas présent. He hael no sensory losses or disturbances anyAvhere. Before he Avas paralyzed he wrote with his right hand ; since his attack he had taught himself to Avrite very well Avith 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 Avas very decided, but not as complète as in the upper, and, like that in the upper, it Avas of the distal rather than of the proximal type. The movements beloAv the knee Avère totally paralyzed, as was also the sar- torius incrément, or if any poAver Avas retained in the sartorius it Avas 290 A SYSTEM OF LEGAL MEDICINE. very slight. Above the knee power Avas retained in the reverse order from the proximal to the distal portion of the thigh, the bip and pelvis movements being much better preseiweel than those at the knee. A study Avas made of the poAver of pantomime, both Avith the para- lyzed and unparalyzed limbs. With the latter pantomime Avas entirely preserved for ail practical purposes, such as beckoning, signing away, pointing to attract attention, emphasizing his meaning, etc. He could also use his badly paralyzed arm to a considérable extent for expresstee» purposes. On asking him to indicate his âge with this arm, he did so by striking with the paralyzed hand on his knee se\'en times, lifting the limb chiefly with trunk muscles, showing thereby that he meant his An- gers multipled by seven, namely, thirty-five years. He Avas 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 parabyzed member just as far as its loss of motor power would permit. Right-sided Pseudobulbar Paralysis and Ophthalmoplegiei—Anarthria— Marked Orolingual Paresis—Full Préservation of Pantomime, but Con- sidérable Mentcd Apathy. J. K., aged thirty-five, white, clerk, was admitted to the Philadelphia Hospital in October, 1887. He had a history of syphilis. 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 drew 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 fiât. The right upper extremity was strongly contractured at the shoulder and elbow, so that the arm was draAvn Avith great 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 contracture was présent at the knee and some at the hip, but he had slight use of the quadriceps and some ability 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, probably the less power over abduction and extension. The gênerai conclusion as to the loAver extremity was that paralysis was comparatively complète, and nearly equal for proximal and distal portions, but probably greater in the proximal. Knee-jerk was increased on the right, but no ankle-clonus was présent. Sensation was unaffectecl. G. E. de Schweinitz, ophthalmologist to the hospital, reported as fol- lows : vision about one fifth of normal ; pupiïs unequal—right, non-re- sponsive to light ; left responds to light anel shade. Oculomotor palsy of the right side, with iïmitations of the movements of aiï 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 atrophie. Marked eccentric narroAving of the fields of vision, the tem- poral fields being correspondingly narrower, but no true hemianopsia. APHASIA AND OTHER AFFECTIONS OF SPEECH. 291 This man's speech trouble Avas distinctly an anarthria. He under- stood everything that was said to him ; he Avas neither mind-blind nor word-blind. He could speak voluntarily ; evidently rehearsed phrases and sentences properly in his mind ; and, incleed, he formed and uttered A\e>rds ce>rreetly, although he sometimes mispronounced them. His de- fe'ct of speech was clearly due to deficiency in phonating, articulating, and euiunciating. He spoke AA'ith closed mouth aud feeble movements of the tongue and lips ; his speee-h Avas Ioav and muffled—it Avas Avanting in feu-ce, tone, and emphasis. Pantomime was practicaiïy unaffected so far as his left limbs and his head, face, and trunk Avère concernée!. Marked différences in the disorders of pantomime Aviïl be found in cases of paralysis and of motor and mixed aphasia which are apparently ielentie-al, or at least very similar, in eharaeter, which identity or close simdarity, liOAveA'er, will often be found to be apparent rather than real; for investigations will show in many cases différences in degree and ehar- aeter of the motor paralysis, senseny symptoms, and aphasia, A\rhich are suffie'ie-nt to separate the pantomimic disorders into classes. The medico-legal investigator, eA'en Avithout any appréciation of the nature, extent, and loe-ation of the lésions, Avould recognize important dif- férences betAveen thèse patients—differene-es both in speech and panto- mime, which make it essential for just décisions to earefully study both. The "yes" and "no" of an aphasie are Aveiï knoAvn to hâve very diverse degrees of value. One of thèse two words may be used to ex- press both assent and dissent, or with its propeu* meaning; or to express asseut Avhen dissent is meant, or simply as an emotional, interjectional, or ae'cidental expression. In like manner, the usual pantomimic methocl of expressing asseut by the forward nod or bowing of the head, and of indicatiug dissent by shakes or half-rotations of the head, or any other movements apparently meaning "yes" or "no," will be found in aphasies to hâve as many interprétations as the articulated "yes"or "no." The certainty and uniformity Avith Avhich an aphasie expresses even simple» assent and dissent by Avord or gesture, Avhen questioned with réf- érence to his Avishes or with référence to facts, must be taken into full considération. Some cases of aphasia, Avhich Avère certainly not word- deaf, or only partially so, Avère earefully tested at the Philadelphia Hos- pital Avith référence to their ability to certainly and consistently exhibit assent or dissent to questions relating to matters easy of comprehen- sieui. The results Avère A-ariable, and sometimes contradictory, puzzling, en- amusing. One patient, Avhose only A-ocabulary was the word "no," evidently used this Avord to express both assent aud dissent, but accom- panied its use with such an appearane-e of countenance and such gesticu- lation as tel make it impossible to décide as to her real intention. Some- times she seemed to instantly and clearly comprehend what Avas asked, and sliOAved this by her countenance, but oftener her look Avas one of annoyauce, e-onfusiem, or impatience, rather than of either assent or dis- sent. Another patient seemed to understand most of Avhat Avas said to her, particularly at first, but after a few quelles she became emotional, exe-ited, confused, and decidedly impatient of investigation. A third, Avhose' ae-companying paralysis Avas less complète than that of the other two, but wliose A'oeabulary Avas chiefly confined to the Avord " no," as- sented or dissented by means of facial expression, nodding her head, and 292 A SYSTEM OF LEGAL MEDICINE. pantomime of fair correctness, and yet on continuing the examination frequently maele foolish and absurd assents and disscnts. A fourth patient possessed expressive gesture and pantomime in a much higher degree. She not only understood aiï that was said to her, but, within the" limits of her original capacity, éducation, and expérience, could, so far as her unparalyzed members would permit, express lier mean- ing clearly and distinctly by the most significant pantomime. With the instruments which nature had left unimpaired she coidd promptly indi- cate what she wished to convey, and yet she was tremendously crippled so far as ordinary speeedi was concerned, and had as a most common method of vocal reply a routine, recurring utterance, " come-on-to-nong." lier pantomime hael high prope)sitional value. In studying her panto- mimic powers, for instance, I asked her âge, and with lier unparalyze'd left hand she openeel 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 Avhen I said to her, "You mean you are seventy years old?" she nodded her head "yes" in a most emphatic manner. I asked her how long she had been sick, and with lier hand she promptly told me fifteen years. I said to lier, " You mean tAventy." She shook her head " no," and again opened and shut her hand three times to indicate fifteen. Great eare should be taken not to misinterpret the emotional mani- festations of an aphasie. The gestures and appe-arances of the face indicative of displeasure, anger, obstinae-y, irritability, etc., are often strongly suggestive of dissent ; while, on the other hand, tlmse which merely indicate pleasure, amusement, or playfuluess 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 unaffceded in aphasies, but it would not be correct to say that it is entirely unaf- fected. The expression of the émotions, Avhile frequently correct, some- times energetic, and often violent, is in serious cases of disturbance of intellectual pantomime not uniform and under control. In many nor- mal individuals emotional manifestations may be instantly controlled at any stage ; and, in accordance with varying inhibitory powers in différ- ent individuals, weeping can be turned to laughing, a smiïe to a froAvn, the sounds of lamentation to those of rejoicing, by the trained and skiïl- ful actor, and in Ararying degree this power of control is preserved in aiï normal individuals. In aphasies with serions disturbances of pantomime, the losses, AA'hen in the emotional side, are seen in meaningless continua- tions or répétitions, slow transitions, and in undue excitement. The folloAving are the notes in détail of two of the nine cases sum- marized above (p. 30) : Right Hemiplegia—N~early Complète Aphasia Chiefly of Motor Type— Varying Conditions of Pantomime. R. E., aged fifty-four, white, has been in the Avards and out-wards of the Philadelphia Hospital most of the time for twenty years, haAing first entered the institution because of an attack of apoplexy AA'hich occurred during labor and left her aphasie and paralyzed on the left side. She APHASIA AND OTHER AFFECTIONS OF SPEECH. 293 soon, however, became able to Avalk. Nine or ten years after the first attack she had a fit, and about three years ago she probably had a sec- ond apoplectic attack or seizure, falling in the out-Avards of the hospital. Since this fall she had complained of much pain in the right thigh and had not been able to Avalk. This patient shcnved a curious confusion both of speech and panto- mime'. She apparently understood aiï or almost ail that was said to her, but seemed te) take in Avhat Avas said Avith great slowness. She conA'eyed the impression of one who required a sharp and strong mental stimulus to Avhip her cérébral centers into activity. She assented by " yes " and disscnted by " no," and oftener than not correctly ; nevertheless her " yes " and " no " could not by any means be relied on—she evidently used some- times one for the other, and presented a différence from the last patient in never correcting herself. While apparently answering properly to some easily understood query, in other cases her assent or dissent by speech Avas foolish or absurd. When asked, for example, if her name Avas Smith she ansAvered " yes ;" BroAAii ? " Yes ;" Jones ? " Yes," etc. She coidd not or Avould uot repeat anything from dictation. Her pantomime was much affected, and, like her speech, of a conf using va rie ty. Frequently, for instance, she usée! the forward nod for assent appropriatelv, and simiïarly the sidewise shake or rotation of the head for " no." Now and then, however, she eAudently nodded " yes " AA'hen she meant " no " ; and this pantomime, like her speech, was never correct spon- taneously. She neA'er used or could be induced to use her unparalyzed hand and arm to enforce anything she said. In attempting conversations Avith her she usually made good use of lier face for emotional expression ; smiling Avhen pleased, froAvning when angered or displeased, etc. To the little speee-h anel pantomime this patient had, the word "unre- liability " Avas particularly applicable. Right Hemiplegia With Marked Contractures—Complète Aphasia of the Mixed Type—A Single Recurring Utterance—Almost Complète Amimia. J. R., aged f en-ty, had had two paralytic attacks. The first had caused moderate loss of poAver 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 few months later, three years before the examination hère eïe'taiïed was made, she hael a second and more severe apoplectic seizure, which caused pro- found right-sided paralysis and aphasia. The right loAver extremity was entirely helpless and showeel some permanent flexure at the knee, the toes exteneled anel the foot slightly fiexecl ; the right upper extremity was also totally paralyzed, the» wrist and elbow in a permanent position of slight flexure; the fingers Avère extended and somewhat approximated 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 protrudeel and deviated to the right. In voli- tional niOA7ements of the mouth and lips—as in an attempt to display the teeth—the face, or more correctlv the angle of the mouth, Avas drawn to the left. Sensation was apparently unimpaired, but the examination could not be thoroughly made. The right knee-jerk Avas quite spastic, but no ankle- clonus Avas clicited. A tap on the right pateiïar tendon was followed by 294 A SYSTEM OF LEGAL MEDICINE. visible and palpable contraction of the quadriceps muscle and tendon. but, probably OAving to the partial fixation of the knee-joint, the leg Avas not propelled. At rest the tocs of the left foot coule! be seeui in regular, rather fine moA'ement. The hyperirritability of nerve, perhaps aise) of muscle, Avas also illustrated in the right upper extremities. Wln-n the dorsum of the Avrist Avas tapped, a feeble but distinct elemus bee-ame ap- parent, and gentle taps on the other tendons or muscles—triceps, deltoid, biceqts, ete-.—caused contractions. Whether or not tins woman Avas word-blind I coulcl not détermine without a knowledge of lier previous history. She Avas not Avord-deaf, at least. not completely so. She impressed me as one of those aphasie- patients AA'ho having first been Avord-eleaf, or largely thus affected, had gradually regained some pe»Ave»r of understanding spoken words. She Avas certainly not psychically bliud. She could close the eyes, protrude the tongue, etc., when thèse or similar performances Avère gone through before her ; she could also protrude the tongue on command, close the eyes, anel lift up the left hand, but searcely more- than this. Her speee-h and pantomime might be said to be summed up in lier "la-la" and laugh, and a much less fréquent expression of anger or dis- pleasure, which was usually accompanieel by a movement of coA'ering lier mouth Avith lier hand. The appearance of her face could not be said to be without expression, but like lier recurring utterance, it Avas an appear- ance nearly always the same. It might mean that she Avas pleased, it might signify assent or dissent, it might mean nothing at ail. Some- times the "la-la" and the laugh became loueler and more emphatic, but that AA'as aiï. She never nodded the head in the usual manner for "yes" or for "no." Only two différences could be made out in the study of lier case : one, that her usual utterance and grimace were at times more démonstrative or even more \dolent 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 tins kind Avould rank in gênerai terms as one of mixed con- cept-motor aphasia. Using the ordinary terms, her loss of pantomime and her loss of speech were both amnésie and aphasie, the former largely predominating. She seemed to be totally unal de to conceive» or reeall either proper words or mo\rements. The lésion was of such a eharaeter as to ha\re prohibited any éducation of lier right hémisphère for thèse purposes. It probably destroyed not only both capsules, but also the internai commissures for speech. The following quotation from Kussmaul is of interest in connection with the report of this and the preceding case» : " A woman was paralyzed on the left half of her body and aphasie from apoplexy. She stiiï had at her disposition only the following little phrases, which she uttered Avith interjectional sprightliness : ' Oui, par- bleu ! ' ' Tiens ! ' and ' Vous comprenez ! ' When asked if she Avished to eat, she ansAvered, ' Oui, parbleu ! ' What Avas her name f ' Oui, par- bleu ! ' or also ' Tiens ! ' in a mocking, snappish tone. She se»emed per- suadée! that lier ansAvers Avère to the point. She often added, 'Vous comprenez ! ' in a tone in AA'hich a person would use it AA'ho thinks he lias convineed the person speaking Avith him. She often maele use» of gest- ures, AA'hich Avère as useless and limitée! as lier eliscourse petered out. Hère were amnésie or combined amnésie and ataxic dérangements." APHASIA AND OTHER AFFECTIONS 01 SPEECH. 295 I append notes of an interesting case kindly furnished me by the late Dr. J. A. Jeffries, of Boston : Motor Aphasia—Only Affirmative aud Xegative Pantomime—Sometimes Confused Contraction of Visual Fields. The patient, a woman fifty-five years old, married, first came under observation July 7, 1S91, Avith a report that she had been struck dumb. Her history, as gathered from her sister, and later from herself, Avas as follows: On the afternoon of the 4th of July, Avhile celebrating Avith some friends, she tripped on a rocking-chair and feiï to the ground. She Avas not stunned, got up by herself, and e-ontinued 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 she rejoined the company and began to speak, but stopped short in the middle of a sentence, unable to say a word. She had no pain, vertigo, ov other symptoms. She had never been pregnant. She was a strong, straight, healthy-looking woman with an inteiïi- gent cast of countenance. Examination of heart, lungs, and abdominal organs Avas négative. Urine 1017, acid, free from albumin, sugar, bile, and abnormal sédiment. No atheroma. A large black-and-blue spot Avas présent about the left eye, extending into the temple. Her eyes moved freely in aiï directions, either open or with one» ce)vereel ; no dip- lopia; pupiïs of normal size, respondecl promptly to the light, to near vision, and on irritation of the skin. No ptosis of the right eye; the left lid drooped, but Avas much swollen. No différence between the two sieles of the face in mime-tic meiA'ements or in expre-ssion of émotion. Tongue exteneled straight; could be moved freely and rapidly in every direction, and restée! symmetricaiïy in the mouth. Fauces symmetrical ; no difficulty in SAA'allowing. Yoe-al cords moved well in respiration and in laughing ; sneezed with explosion. No paresis of neck or of body or legs. Right arm not so strong as the left, but both Avère fairly strong and freely moved. Tendon réflexes normal, the saine on both sides. There Avas possibly some blunting of the sensé of contact in the right arm and face, but the faintest toueli was perceived the same as on the left side. Spe-ech Avas absent. On effort to speak there Avère a f cav slight motions of the tongue and lips, and at times a slight inarticulate sound. The voavcI sounds Avère more pronounceel, a and e being recognizable. Could not repeat or read aloud ; could uot Avrite alone from dictation or copy— in ail efforts to do so the hand Avas A'ery clumsy. She could, however, draw at recpiest 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 ceniA'eying ideas seemed to be by nodding or shaking the head. She use-el no e»ther form of pantomime. When asked a question she assented or dissenteel Avith the head, but frequently after a nod would contraelict or e-euree-t herself by a violent, shake, so that after each ques- tion I was obliged to wait for what might come after. Objects were recognized properly, and her observation was good. There was no deaf- ness. The patient Avas formerly an habituai reader of the papers, and occasionally wrote a letter. 296 A SYSTEM OF LEGAL MEDICINE. There Avère no signs of alopecia, no se»abs in the mouth or on the- skin, no enlarged lymphatics, aud the tibial and other long boues Avère» smooth. In the course of the next two Ave»e-ks there Avas considérable improve- ment in the power of speech. The poAver of repeating first returned little by little, and by the time she coukd repeat sight-wen-els, "yes" and "ne>" returned. She could sign her name, Avrite a few letters from copy, but could not complète " Boston " or write offhand. At this time I found her visual field reduced te) about thirteen degrees ail the Avay round in both eyes, and that she had lost ail arithmetical power. As the power of speech came back the paresis of the lips became apparent. Thèse in speaking moved sIoavIv and clumsily, as if cold, Avhiïe in other motions they were steady and offered nothing peculiar. By the end of August the patient had made material progress and was if anything better than when last seen in December. The grip of the right hand was one hundred, of the left eighty-four ; there was but the barest trace of the former immobiïny of the lips during speech. This was quite free and spontaneous, the vocabulary good, and the use of the words good. At times she would hesitate for a Avord, but would not use a wrong one. There was, however, a period, when speech was first return- ing, AA'hen Avrong words were used frequently, but corrected. The power of reading was very limited ; at times she could get through a few fines correctly, but as a rule she " forgot what the first part of the word was before she got to the end." Writing was confined to her name. Ail forms of testing gave néga- tive results. Hearing was normal, also the power to understand Avords. The power to count and do simple sums was very imperfect. She could count ont loud correctly, but if given a few piïes of matches, she would make some wrong counts, seA'en for eight, or the like. She could not make change, but could name the coins. The visual field was ample, and the récognition of objects normal. Lastly, as speech returned there was a time when she filled out her imperfect language by pantomime, which often enabled me to give her the right word. THE TRAUMATIC NEUROSES: BEING A DESCRIP- TION OF THE CHRONIC NERVOUS DISORDERS THAT FOLLOW SHOCK AND INJURY. BY CHARLES L. DANA, A.M., M.D. Synonyms.—Concussion of the spine, raiïway spine, railway brainr traumatic neurasthenia, traumatic hysteria, hystero-traumatic disorders, traumatie hystero-neurasthenia. This article wiiï include a description of concussion and shock, but not of traumatic insanity, or of the gross lésions of the nervous system caused by injury. Définitions—As my article may be sometimes referred to by per- sons not familiar with ail the technical words used in neurological medi- cine', I propose to give hère brief définitions and descriptions of some of the terms employed. A neurosis is a morbid nervous state, and the Avord is practically syn- onymous Avith a nervous disease. When the neurosis occurs Avithout any change in the structure of the nervous tissues it is called a functional or non-organic neurosis. When it is due to some structural change, such as inflammation or softening of the nervous tissues, then it is called an organic neurosis. A psychosis is a morbid mental state. The différent forms of insanity are calleel psychoses. There may, however, be morbid mental states which are not true insanities, such, for example, as decided mental de- pression, a tendeney to fixed ideas, and hypochrondriacal states. Hys- teria is sometimes e-lassed under the head of the psychoses. Shock is a sudden dépression of the vital functions, especiaiïy of the circulation, due to the nervous exhaustion foiïowing an injury or a sud- den Auolent émotion, and resulting either in immédiate death or in pro- longea prostration. (Foster.) Shock is spoken of as being either corpo- real or psychic. Corporeal shock is that form in which the dépression of the vital poAvers is produced by a violent injury or a sudden loss of blood. Psychic shock is that form in Avhich the dépression is produced by an émotion. Often shock involves both thèse éléments. So far as I can learn there is no way by Avhich the two conditions can be distin- guisheel, apart from the history of the case ; in other Avords, a severe bodily injury and a violent depressing émotion may produce exactly the same neiwous results. Concussion is a Avord which has been much twisted out of its original 297 298 A SYSTEM OF LEGAL MEDICINE. meaning. Properly speaking, the term should lie applied only to the act itself in Avhich the body receives a severe jar. Practically, cone-nssion means almost ahvays concussion of the brain. Concussion of the brain is a jarring of the brain substance» Avithout lacération of its tissue, or with only microscopic lacération. (Foster.) It is characterized by partial or complète loss of e-onsciousness, with feebleness of puise, coldness of the extremities, pallor, anel dilatation of the pupiïs, followed by vomitiug, moaning, restlessness, jactitation, and somnolence, with warmth of the skin, a full, relaxée! puise, and sometimes irregular contraction of the pupils. The state Avhich folioavs directly upon concussion, and Avhich lias just been described, is spoken of as col- lapse. The after-effeets of concussion of the brain liave been described by earlier Avriters under the name of raihvay spine, or spinal concussion. This, however, as avc shall show, is a misuse of the term, and the word should only be applied to the e'ondition I hâve described. Concussion of the spinal cord is a condition Avhich, in my opinion, prac- tically never oecurs. As the term Avas formerly used, he>AveA"er, it meant a condition of the spinal cord produced by a violent shock, such as that which Avould resuit by falling from a height, by a severe blow on the back, or by a raihvay collision or similar accident. A condition of more or less collapse Avith partial suspension or perversion of the function of the spinal cord Avas belieAa»d to folloAV such accidents. It is the présent opinion, however, that thèse conditions are due to concussion of the brain and nervous shock, together with, in some cases, lacérations of ligaments and perhaps structural injury of the spinal cord. Neurasthenia is the term used to indicate a condition of nervous ex- haustion or nervous Aveakness Avith irritability. Trauma means, strictly speaking, a avouucI. The term is used gener- ally as synonymous with an injury. Keuralgia means pain in the course of nerves. Paralysis is the term used to indicate a loss of power of muscular movement. When the paralysis is incomplète it is called peu-e sis ; paral- ysis affecting one half of the body is called hemiplegia ; when it affects the two loAve-r extremities it is caiïed paraplegia ; and when it affects only one limb it is called monoplegia. Ancesthesia means a loss of the sensé of feeling. When there is a loss of the feeling of toueh it is caiïed tactile anœsthesia, and Avhen there is a loss of sensation of pain it is called pain anaesthesia, or analgesia. Tremor is the name given to the condition in which there is a vibra- tory motion of the extremities or of the muscles of the body. It is due to an alternate contraction and relaxation of muscular fibers. Thèse contractions are rhythmical, and occur at a rate of from three to twelve per second. History.—It has been knoAvn since ihe beginnings of medicine that injuries AA'ould cause différent forms of insanity, and Avould give rise to epilepsy and St. Yitus's dance, and Avould excite hysterical attacks. The facts AA'ith regard to AAdiat is known as concussion of the brain hâve also been long famiïiar to surgical AATiters. In the early part of tins e-entury the French and English surgeons reportée! anel studied cases of what they termed " concussion of the spine." Their vieAvs at this time were that as the resuit of bloAvs upon the body, anel particularly upon the back, or as the resiilt of faiïs or other forms of injury, the functions of THE TRAUMATIC NEVROSES. 299 the.' spinal cord might be temporarily perverted or suspended, causing pains, paralysis, and other symptoms. The theory Avas that the action of a severe injury or concussion upon the spine was analogous to that of a bloAV upon the head: just as the latter injury would produce con- cussion and a suspension of cérébral function, so it was thought a bloAV upon the spine Avould cause a functional disorder of the spinal cord. Thèse views Avère basée! largely upon historiés of cases in Avhich after a seve»re injury paraplegia ensued, which paraplegia in the course of a few weeks or months entirely disappeared. Cases illustrating this aùcav Avère reported by Boyer (2),* Bell (3), Sir Astley Cooper (6), Abercrombie (8), Maye> (9), Ollivier (10), and Lidell (11). The earlier Avriters also studieei the effects of injurie»s iu the production of chronic nervous disorders due to actual injury to the cord or brain, particularly the former, and cases of traumatic myelitis and traumatic meningitis were put in eAddence. Maty (1), Girard (4), and Lideiï (11) were among tliose Avho 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, foiïowing injury. We find in the writings of Girard (4), Peronne (12), Weir Mitcheiï (14), and Lockhart Clarke (15) contributions to the subject of injuries of the ne-rves and to the development of organic disease of the central nervous system after injury. We find much also in thèse earlier Avriters upon the gênerai subjects of concussion and shock. It Avas not, howeA'er, until the appearance of Erichsen's book (13) in 1866 that the study of the functional nervous affections following injury Avas reaiïy begun, and ail crédit must be paid to this observant surgeon for the epoch-making work which he did at this time. Erichsen's teaching Avas that injuries Avould produce at times an actual cemcussion of the spine, in the sensé that it temporarily suspendeel the functions of that organ anel perhaps for senne time disturbed its normal Avorkings. He also taught that injuries Avhich did not ae-tually fracture the spine or produce gross lésions of the cord and membrane-s Avemld lead to Avarions grades of chronic spinal menin- gitis, and finally he taught that folloAving thèse injuries there sometimes eleveloped peculiar chronic nervous disorders, to Avhich he gave the name "concussion of the spine," or raihvay spine. Thèse disorders he consid- érée! to be due sometimes to spinal anaunia, sometimes to spinal hyper- aemia, and at other finies to meningitis. The authority of Erichsen's teae-hings remained but little questioned for a good many years. Yari- ous further contributions to this subject were made by Buzzard (16), Fletcher (17), Webber (21), and others. In systematic treatises such as those of Erb (29) and Leyden (26, 31) "spinal concussion" was discussed as though it were a recognized clinieal entity. In 1878 Charcot, reviving the observations of Brodie, caiïed attention te» the fact that traumatisms sometimes develop local hvsterical phenom- ena. Esmarch (1872), Shaffer (1880), Ketch (1887), Mitehell (1885) hâve also ceuitributed to this same subject. A good many German and a few French Avriters meanwhile reported various cases of concussion of the spine», and most of them accepted more or less fuiïy the views enun- ciatecl by Erichsen. * The spécial articles by thèse writers will be found arrangée! chronologically under the bibliography at the end of this article. 300 A SYSTEM OF LEGAL MEDICINE. In 1882 a new stimulus was given by Mr. Herbert W. Page, who pub- lished a work entitled Injuries of the Spine and Sjdnal Cord (51), in which lie sharply eriticised the aùcavs taken by Erichsen. He denied the exist- ence of spinal concussion, and she>Aved that many of the cases of suppose»el raihvay spine Avère nothing but cases of a tempe>rary nervous disturb- ance, or of hysteria or simulation. Shortly before this, Dr. K, M. Hexlges (47) had published a séries of e-ases in which he also disputée! the seri- ous eharaeter of the so-caiïed e-emeussion symptoms. From this time on, the critieal study of the traumatic neuroses may be said to hâve begun. Contributions bearing upon it poured in Avith great rapidity from Ger- man, French, aud American observers. In this country Drs. G. L. Wal- ton (55), J. J. Putnam (60), Hamiïton (57), Dana (64), Johnson (66), Knapp (117), and Dercum Avrote spécial articles upon the subject. To Dis. Wal- ton and Putnam in particular, crédit is élue for showing that some of the cases that hâve been known as raihvay spine Avère cases of major hysteria. In France, Charcot (1887) (89) and his pupils, Berbez (124), Terriiïon (68), and Guinon (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 bave begun in 1884, when a séries of articles was published by Thomsen and Oppenheim, and later by Oppenheim (74) alone. The teaching of Oppenheim was that as a resuit of injuries there developed a séries of chronic nervous symptoms which had a rather definite eharaeter, so much so that the spécial name of "traumatic neurosis" might be applied to it. Oppen- heim's Avork caiïed out a great many articles of a e-ontrove-rsial eharaeter, in AA'hich it was asserted that the élément of malingering had been Ae-ry much overlooked by the writer 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 acknoAvledged to exist in the traumatic nervous disturbances. Dr. William Thorburn (105), in his work entitled A Contribution to the Surgery of the Spinal Cord, presented the question systematically and clearly to English readers. This brings the question down to the présent time. It Avili be seen that at first the whole matter was in the surgeon's hands, and was studied from a surgeon's standpoint. Erichsen, A\iio first suggested the nervous side of the case, Avas 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 clinieal 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 still earlier by others. The spécifie neurosis theory advanced by Oppenheim never secured much of a foothold. The advances being made iioav are largely in the direction of closer clinieal observation and more exact methods of diagnosis, and in pathology and pathological anatomy. Mooted Points.—The points about which présent 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 anœsthesias and paralyses; fourth, the question of the existence of a spécial class of nervous symptoms folloAving an injury and due entirely THE TRAUMATIC NEUROSES. 301 to 'it ; fifth, the question of the existence of objective signs in thèse dis- orders by Avhich one can test the reality of the alleged nervous phenom- ena ; sixth, the existence and significance of local nervous phenomena, such as hysterical joints and local hysterical symptoms of a spasmodic or paralytic eharaeter. Upon tliese various points the amount of literature that has accumu- lated is simply enormous. I haAre ventured to collect this and présent it in cemnection with my article, the matters being arranged first chron- ologically and next in ae'cordance with the différent subjects discussed. In the se'cond arrangemeuit I hâve not included ail 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 hâve appeared from writers in ail parts of the civil- ized world. Germany has been most prolific ; after this xVmerica, then France and Great B ri tain. English, 27 ; French, 51 ; German, 118 ; American, 64 ; Italian, 6 ; Scandinavian, 2; Swiss, 3; Belgian, 2; Dutch, 2; Russian, 4: total, 278. It is obviously impossible that any one man should famiïiarize him- self with ail thèse articles; but I hâve studied the more important ones, and I am led to the e-onclusion, from their perusal and from my own personal expérience, that many of the mooted questions above referred to are rapidly reaching a satisfactory solution. Among American neu- rologists of to-day I do not think that there is any great différence 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 believe that the answer is practicaiïy a négative one. It is perhaps not impossible that a severe blow, prop- erly direrted, may cause a temporary paralysis of the spinal cord due to simply the molecular AÙbration 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 hâve been brought in évidence by Drs. Hnnt 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 hâve been called such hâve been undoubtedly cases of hemor- rhage either external to the dura or internai to it, generaiïy the former. The reader must bear in mind, however, that the term " concussion of the spine " is hère used in its strictly technical sensé. Through the writ- ings of Erichsen and others immediately following him the term was so transposée! as to mean not strictly concussion, but the chronic nervous symptoms following it, and often in ordinary médical usage this meaning still obtains. Few careful AA'riters, 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 lésion if there is any, such as " traumatic myelitis." Sometimes, after an injury, the symptoms of a chronic myelitis slowly develop. This is considérée! by Knapp a proof that the spinal cord has been "concussed." It rather indicates that some slight lacération of ves- sels or nerve tissues occurs, from AA'hich reaeth'e inflammatory changes, gliosis, or most often syphilitic exudates develop. One sees exact copies of this kind of traumatic myelitis occur Avithout trauma. With regard to the second peiint, that of the importance of the élément 302 A SYSTEM OF LEGAL MEDICINE. of malingering. there is perhaps not quite so much harmony of opinion. Tins is particularly the case among the German writers, where a great number of articles upon the subject of simulation hâve been written. There has been, howeA-er, in my opinion, a large personal élément in this discussion, and a perusal of it leads me to think that most of the < ier- mans avIio haA'e written regarding simulation ha\'e not been praetically famiïiar Avith functional neuroses, such as neurasthenia, to anyAvhere near the extent that American neurole>gists are. It woulel certainly bave been impossible for any such lengthy ae-rinionious and stérile de- bates as hâve occurred in Germany to hâve taken place in America, and in this country there is, I feel assùred, no great différence of opinion as to the actual existence and the at times serions nature of the traumatic neuroses. We recognize, of course, the impendanee, and I might add the relative frequency, of deceit, exaggeratiem, and imposture; also the fact that the process of litigation often aggravâtes and adds to the nervous condition. But Ave do, I beheve, with great uniformity agrée upon the fact that functional nervous conditions of a chronic and sometimes in- tractable eharaeter are produced by trauma. With regard to the third point, that of the existence of a traumatic hysteria, there has been, I beheve, no great amount of controversy. It is acknoAvledged that the major forms of hysteria as weiï as the minor forms may folloAV trauma. The investigations of late years hâve been more in the hue of studying the frequency, the clinieal charâcteristics, and ultimate course of thèse disorders. In France, if Ave may judge from the médical literature of that country, trauma, Avhen it is folloAved by any functional nervous disturbance, is foiïoAved oftenest by hysteria. In tins country traumatic hysteria is relatively rarer, yet it is by no means very infrequeut. With regard to the fourth point, that of the existence of a spécial form of functional neurosis due to injury, aùz., the traumatic neurosis, agreement lias also been reached. In the A'ast majority of cases the nervous symptoms foiïoAving injury, when not due to organic lésion, take the form of a neurasthénie condition, and this neurasthénie condi- tion differs but little from that which is brought about by other causes. Traumatic neurasthenia symptomatologicaiïy resembles ordinary neu- rasthenia plus symptoms élue to local injury, such as sprains, and wdth the addition of a rather larger amount than usual of pain in the back and tendeney to exaggeration. In very rare cases, hoAveAer, there does develop after a time a chronic nervous disorder, of whose spécial ehar- aeter I will speak later, which lias symptoms that are to a certain extent peculiar to itself, though resembling multiple sclerosis. To this rare type of disorder the name of " the graA-e traumatic neurosis " might per- haps be given ; for the eAddence at the présent time goes to show that a certain amount of incurable organic disease exists hère. As to the fifth point, the question of the existence of objecth'e signs in the traumatic neuroses, a great deal has been written and a great deal claimed. Many peculiar symptoms haA^e been elicited and a spécial symp- tomatological value attributed to them. My own vieAvs upon their A'alue wiiï be stated in greater détail later. It Aviiï be sufficient to say ne>w that we hâve a sufficient number of objective tests to render it impos- sible in almost ail cases for a patient to deceive a skilled observer. As to the sixth point, the existence of local hysterical disorders, there THE TRAUMATIC NEVROSES. 303 lias not yet been very much Avritten, and the subject is in a someAvhat unsatisfactory state. It lias been shown, heiAvever, that arthralgias, local spasms, paralyses, and tremors may resuit from injury, and that thèse may exist and be of a purely functional eharaeter. The epiestion of the amount and importane-e of associated hysterical or neurasthénie stigmata bas, hoAve\rer, yet to be worked out. Such, in brief, is the history of the rise and development of our knoAvleelge of the functional îiervons disorders followiug injuries. Classification.—It is hardly to be expected that perfect agreement can yet be reached upon the subject of classif}dng the functional nervous disorelers that follow injury and shock. A classification suggested by Dr. E. C. Seguin in 1889 (Annual of the Uni versai Médical Sciences, vol. iii.,, No. 3), modified somewhat in aee-eu-dance with the advances made since that time, Aviiï be used as a guiele hère. CLASSIFICATION OF NERVOUS DISORDERS FOLLOAVING INJURY. f Shock, Immédiate Symptoms : \\- in rhythm. The extremities are cedd, the face» is pale, the skin often covered with moisture. If the patient dies in this state of collapse, post-mortem examination may reveal a localized bloexl-clot or a slight amount of lae-e-ration of the brain substance under the point of injury or at the opposite pôle of the brain. In senne cases minute heni- orrhages are found throughout the substance of the brain, in other cases no e-hange AvhateA'er is found except perhaps a cenigestion of the vessels of the pia mater. A number of théories hâve been put forth to explain the profound effects produced by blows which are not associated with any gross lésions of the brain, but Avhich yet produce most serious effee-ts upon the ner- vous centers. The preA^alent theory is that of Duret, that the effects are produee»el mainly through the sudden driving of the cerebro-spinal fluid from the subarachnoid space through the îdramen Magendie into the fourth ventricle and thence into the central canal of the spinal cord, and through the aqueduct of Sylvius into the ventricular cavities. The fatal objection to this theory is that, as shown by Kocher and Ferrari, pressure in the intracranial e-avity is transmitted in ail directions, as in a fluid, so that the pressure in the ventricles can never be any less than that outi side the A^entricles. The theory which appears most to satisfy the re- quirements is that which lias been reeently worked ont by Mr. Victor Horsley, and AA'hich has been described with great clearness'by Dr. S. B. Kr-imer, of Cincinnati* It is based on a number of expérimente 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 upon the skull there was an immédiate and sudden rise of intracranial tension ; in other words, the sudden blow compressée! 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 (Adamkiewicz), but, as thèse expérimenta sIioav, a slight amount of compression can be made, and the force of the blow produces this effect. The compression oxerts its force mainly upon the soft-walled blood-vessels, that is, the capiiïaries. The blood is driven out into the veins and thence into the extracranial circulation. As a resuit, therefore, of this sudden compres- sion and rise of intracranial tension there is an extrême though very brief anaemia of the brain produced. This amenda affects the parts sup- plied by the capiiïaries, 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 resuit of this their functions are suspended. In the process of restora- tion of their 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. 305 -disturbance is accompanied perhaps Avith dilatation and rupture of smaiï vessels. After concussion there arise sometimes a long train of neivous symptoms, AA'hich I shall elescribe later. SPECIAL DESCRIPTION OF THE TRAUMATIC NEUROSES, IN- CLUDING TRAUMATIC NEURASTHENIA, MIXED TYPES, TRAUMATIC NEUROSIS OF GRAVE TYPE, AND TRAUMATIC HYSTERIA. The effects of concussion and shock haAÙng in a measure passed away, the patient sometimes develops some form of chronic functional nervous disorder, to Avhich the gênerai term -'traumatic neurosis" is applied; or Avithout concussion, and with only some slight psychic shock and physieal injury, similar symptoms may arise. It is this class of disorders which I shall hoav specifically describe. yEtiology.—While the exeiting cause of the traumatic neuroses is always trauma, there are many conditions which prépare and ripen the system for a nervous disease, and thèse causes Avili be considered first. Age.—The period of life most susceptible to the traumatic neuroses is that between the twentieth aud fortieth year; that is to say, the most active years of our existence. The cases occur oftenest in the décade twe»nty-one to thirty, next, thirty-one to forty. Practically no cases occur after the sixtieth and very feAv before the twentieth year. This is shown in the following table of cases of traumatic neurasthenia, hys- teria, and hystero-neurasthenia, compilée! from cases reported by Erich- sen, Page, Berbez, Oppenheim, Weill, Knapp, Dercum, Bremer, Clevenger, and myself. Ages. Ail Cases. American 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 faiï on the head. (Weiiï.) The average âge of the French hysterie'al cases (Berbez) is twenty-five years, the maie cases being the elder. The ordinary neurasthénie cases are more fréquent between the âges of thirty and forty. The fact that people between the âges of tAventy and forty travel more and are more eiposed to injuries has something to do with the prevalence at this period. Still, the first two décades of life enjoy a great though not abso- lute immunity. In this country the neurasthénie cases occur more fre- quently in the earlier décades. This is a peculiarity which I hâve noticed of other neuroses, such as megrim, chorea, and epilepsy. Sex.—Traumatic neuroses occur in men oftener than in women, in the proportion of 3 to 1 (144 to .12). Traumatic neurasthenia occurs relatiA'ely oftener in men (2 to 1). This relative e»xce»ss of the maie is due partly perhaps to the greater frequency with Avhich men travel and are exposed 306 A SYSTEM OF LEGAL MEDICINE. to accidents; perhaps also to some extent to the great readiuess of men to resent injury and to attempt litigation. Still the same' excess exists in neurasthenia due to other causes. The German statistics give a much larger percentage of maies. Among 33 cases of Oppenheim's only 2 were Avomen. Previous Condition of Health.—There is a very firm convie-tiem among most neurologists that a neurotic constitution or some condition of ill-ïiealth exists in a large proportion of the genuine cases of traumatie- neuroses. This is certainly true for some type»s of hysteria, and to a less extent, in my expérience, in neurasthenia. Those cases Avhich develop degenerative diseases of the central nervous system haA'e in some e-ases been infected with syphilis, or hâve been accustomed to excesses in alco- hol and venery, or hâve been subject to strain and privation. Sexual excess stands in especially important relation Avith hysteria. I hâve known slight trauma to bring out an attack of nervous syphilis, and to cause its exacerbation in quiescent cases. I bave known aise) trauma to excite chorea and afterward hysteria in a patient who had Brights dis- ease. This factor of previous condition of health and personal prédis- position to nervous disease ought to be very carefuiïy considered in esti- mating the responsibility of a person or corporation for injury. Rigler thinks that railway officiais are predisposed to traumatic neu- roses, on account of the irritation of the nervous centers from the con- tinuai A'ibration. This may be true of locomotive engineers, avIio espe- cially suffer from concussion, and avIio are also subject to much mental strain. Statistics show that it is not true of other employe-es, and there are not enough facts at hand to enable me to speak positiA-ely about the engineers. They sometimes develop neurasthénie conditions simply from the nature of their work, just as other peoph' clo. Concentration of Population.—Dr. W. B. Outen, chief surgeon of the Missouri Pacific Raiïroad Company, finds that traumatic neuroses develop much more frequentty in the neighborhood of populous cities. Thus, among 814 injuries to passengers occurring at points remote from cities, only 6 cases of traumatic neurosis developed, while among 30 passengers injured on suburban trains there were 5 cases of traumatic neurosis. Furthermore, among 18,275 injured employées only 8 were credited with traumatic neuroses, 4 of whom recovered. There Avère, however, 767 injuries to the back of various kinds. Among injured passengers there was 1 neurosis to 76-&; among employées, 1 in 2248g. The employées Avère ail taken, however, and promptly treated in the company's hospitals. Dr. Outen's view that many of the cases of neu- rosis were the resuit of suggestion and litigation is no doubt in a measure true. It may be said, however, that people hVing 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, attoriiev for the New York Central and Hudson River Railroad Company, tells me that very few cases of traumatic neuroses occur, in his expérience, on that company's lines. Condition at Time of Injury.—There is no doubt that persons who are injured while asleep or intoxieated are less liable to severe neuroses. This is partly due to the fact that the élément of fright and psychicàl shock is, in a measure, eliminated in thèse cases, and partly to the re- laxée! condition of the body, which renders the physieal shock less violent. THE TRAUMATIC NEUROSES. 307 Persons avIio are accustomed to travel, and, like old soldiers, are some- what inured to the possibilities of ae-e-idents, are less likely te) be injured than inexperienced travelers, avIio are full of appréhensions at every sug- gestion of danger. Condition Subséquent to Injury.—Persons avIio are promptly and properly e-areel for after accidents are less liable to bee-ome nervous. The immédiate' resuniption of se»vere work and the careless use of stimulants anel narcotics no doubt favor the development of nervenis synqdoms, if such Avère destinée! to appear. More than aiï this, however, is the effect upon the' patient of the attentions of laAvyers and umvise physicians who are trying to make out a case. The worriment of litigation naturaiïy brings out and intensifies many symptoms. On the other hand, many typie*al cases of traumatic neurosis oce-ur when no litigation exists; and the attempt to put down eA'en the majority of e-ases of traumatic neuroses to suggestion and litigation is quite un justifiable* _ The foregoing description of the causes of the traumatic neuroses ap- plies to ail forms of the functional nervous troubles. In undertaking to describe the symptoms, however, it is necessary to make certain clinieal types, anel describe thèse separately. As I hâve studied thèse neuroses they can be mostly grouped under the head of : 1. Traumatic Neurasthenia. (a) Mixed Ta'pes. 2. Traumatic Neurosis of Grave Type. 3. Traumatic Hysteria. Symptoms of Traumatic Neurasthenia (Railway Spine).—The ner- vous symptoms Avhich follow shoe-k and injury, and which take the neu- rasthénie type, are not ahvays alike, though they bear a gênerai resem- blaime to each other and to neurasthénie states from other causes. The most cennmon séries of phenomena is that Avhich may be grouped under the heael of a simple traumatic neurasthenia. The history of a patient is something like the folloAving: After re»e-e»iving an injury Avhich is often but sligl.it, but Avhich is usually accompanied Avith a great deal of fright and emotional disturbane-e, 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 ave 175,233 miles of railroads in the United States, and in the year 1892, 575,7(i!).(i78 passengers were carried. One person is killed yearly out of every 3,800,000 imssenger 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 4£ times greater than that in the United Kingdom. This is due to the fact that our railroads are more cheaply built and more numerous, and that there is proportionately a greater amount of travel upon them. Collisions are the cause of nearly one half of the train accidents, and thèse accidents are due in ten percent, of cases to road defects and in about fifty l>ercent. of cases to négligence. (H. G. Prout, North American Rerieir and Poor's Man nul.) As showing the frequency of accidents in a large city, I hâve obtained, through 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 this city. Deatlis caused by street accidents in New York City in the year 1892 : elevated rail- roads, S j other steam railroads, 56 • street railroads, 49 ; other vehicles, 73 : total, 186. 308 A SYSTEM OF LEGAL MEDICINE. the next mwning, feehng not quite as Avell as usual. but congratnlating himsedf, perhaps, on having gotten off se> easily. Ile résumes his Avork and finds that lie eau do it,"~though with not quite se) much ease as usual, aud he very likely suffers from some pain due to a strain or bruise that he lias ree-èived. In a feAv days, almeist ahvays Avithin a Aveek, lie begins te) notice that lie is more nervous than usual, that little things irrita te him Avhich did not do so before, that his head seems sonie-what e-euifuseel, and that the effort to work is Avearying. His sleep is disturbed, and he Avakes up in the morning unrefreshed by his night's repose. He beceunes somewhat despoiiclent over his condition, and thouglits of paralysis or some other serions aliment annoy him. His head aedies, the pain being more or less constant anel diffusée!, aud loeated usually over the forehead or at the bae'k of the neck. He has uiipleasant sensations in the head, such as that of constriction or pressure or scalding feelings. His back also is continually painful, and Avalking increases it. His nervemsness becomes more marked, and close examination sIioavs a little fine tremor in the hands. He has also sometimes creeping sensations e>ver the body or numb feelings in the extremities. He» tires very easily. He is emo- tional, and becomes more despondeiit as the days go on. Sometimes lie lias spots before his eyes, noises in his head, or ringing in the ears. Reading is laborious and increases his headache ; so aise» does attention to work. His appetite becomes eapricious and his boAvels are cemstipated. He suffers semiewhat from flatulene-y and elyspepsia. His heart palpitâtes easily, and the puise is a little accelerated. Seunetinies for a feAv days there is a little Aveakness about the bladder or irritability of that viseus. His sexual poAver is diminished; his circulation seems rather pooivr than usual. Very slight excitement procluces sweating e>f the hands or colel- ness of the extremities. Hc loses a little flesh. Thèse symptoms may be seA-eral Aveeks in developing, and during tins time lie may perhaps cousult a lawyer about his e-ase. If so, the anxietie-s of litigation begin to add to and intensif y his troubles. Ile e-emsults a physician, and the physician finds the subjective symptoms that I haA'e mentioned. ObjectiArely, Avlien examined, the physician will diseover that the muscular poAver is somewhat Aveakened, that there is a certain amount of fine tremor, perhaps in his hands. The knee-jerks and elbow- jerks are exaggerated ; there are teneler points along the spine and upon the head. On making him stand Avith his eyes closed there is a et»rtain amount of static ataxia discovered. The pupiïs are often dilated aud mobile, and examination of the A'isual field shows seunetimes a slight con- traction, at other times the "shifting type," to be described later. In many cases a, degree of peripheral retinal amesthesia Avili be discovered. The puise Avili be found accelerateel, and pressure on a tender point will send it up A'ery rapidry ; a slight exertion wiiï also ae-celerate it. There wiiï be something apparent in the physieignomy of the case Avhich sIioavs the man te be in a nervous and asthénie condition. Sometimes the pains from which the patient suffers in the back and the Aveariness in the limbs are so great that he remains a good deal of the time in bed. In ail cases he Aviiï assert most positi\'ely that lie is unable to work or to take that interest in his affairs that lie has previously done. In a ge>od many cases there wiïl be added to the foregoing picture a number of symptoms due to some local injury : for example, the arm may hâve been wrenched or bruised, and the resuit may be a certain amount of neuritis THE TRAUMATIC NEUROSES. 309 and Aveakness or pain in that member ; in other cases the back may hâve been se» severely spraineel that the typical symptoms of spinal irritation ensue, and this is particularly apt to be the case when Avomen are injured. In other e-ases, again, the legs may haA'e been hurt to such an extent that a seiatica or some other form of neuralgia develops. The foregoing symptoms, A'arying in amount and degree, wiiï last, Avith little change, for a very long period of time. If the e-ase goes into litigation, there is added the Avorriment oceasioned by having to go through the disturbing expériences of trial by jury. In many cases, after the trial lias been settled and damages aAvarded or otherwise, the patient begins to mend, and in a certain proportion of cases he gets com- pletely Avell. This is not by any means invariably the rule; it may be saiel, on the contrary, that as a gênerai thing a person avIio receives a se-riems shex-k to his nervous centers, resulting in a genuine and grave neu- rasthenia, is rarely entirely the same afterAvareî. HoAveA'er, after a varia- ble period of months or years most cases get into a state of at least comparative health. Their nervousness graclually diminishes, their sleep improves, the pains successively lessen, the appetite is restored, the flesh is regaiued, the power of work and enjoyment in hfe come back. MIXED TYPES. Traumatic Spinal Irritation.—Besicles the foregoing gênerai and common symptoms of traumatic neurasthenia, it sometimes affects per- seuis in other anel spécial modes. For example, the symptoms of spinal irritation may predominate. Thèse fe>rm the cases AA'hich Avère described by Erichsen under the head of spinal anamiia and hyperamiia. Their symptoms eliffer little from those described in systematic Avorks upon spi- nal irritation. Thèse patients are usually Avomen. After receiA'ing an injury Avhie-h may hâve been slight and Avhich may not necessarily haA'e directly injured the spine, they A'ery soon eomplain of pains in the back and particularly the lower end of the spine and in the back of the neck. Thèse pains are so severe that they soon give up attemptingto Avalk about, and finding that they ged some relief and comfort in bed they go there and there remain. V\ nile keeping perfectly quiet the back gi\Tes them comparatively little» discomfort, but attempts to sit up for a long time, to ride, or to Avalk, cause such distress that they are speeclily abandoned. The paius are of a heavy, aching eharaeter, increased until they become A'ery sharp when attempts at movement of the trunk are made. There is a great deal of ten- elerness te > pressure along the sjiinal processes, someof thèse processes being mue-li more sensitiA'e than others. The most sensitive points are usually the back of the neck anel the upper dorsal A^ertebra?, and doAvn in the lum- bar région. There is some pain also upon pressure alongsiele of the spinal processe's. Painful points often A'ary, anel even in a single examination the patient may eomplain, and eomplain honestly, of différent sensitive veTtebra1. They suffer much from headaches. The arms are often Aveak, so that attempting to scav or Avrite or hold a book causes pain in the neede and shoulders. The» legs are also Aveak and the e-irculatioii poor. There is sometimes palpitation of the heart and precordial distivss. A certain amount of dyspepsia is ahvays présent, anel constipation is the rule. The patients often hâve attacks of voiuiting, and attempts to feed them re- quire much eare. The menstrnal functions become irregular, and if it 310 A SYSTEM OF LEGAL MEDICINE. be a maie the génital functions are weak. The knee-jerks are exagger- ated, but there is never any true ankle-clonus. There is no nmesthesin of the skin, and avc rarelv detee-t any amesthesias of the spécial sensés. I bave never been able to find contraction of the visual field or of the aurai field, nor do, in tins country, the amesthetic stigmate of hysteria présent themselves. The patients are mentally very emotional and de- pressed. They eomplain much about their pains ; they are irritable and exae-ting; their sleep is very poor and often requires hypnotics. They hâve fréquent intense headaches, Avhich are usually of a e-emgestive ehar- aeter—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 hâve become thoroughly bedridden, their symptoms are ex- tremely apt to become chronic, and they form a very difficult class to deal with. After a time the legs Avaste ceuisiderably, and there may be even a e-ertain 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. Elee-trical examinations, hoAvever, never show any of the évidences of degenerative reaction. Cases of this kind may con- tinue for two or three years, their symptoms then gradually ameliorate, and, as a rule, they get "better, if not entirely avcII. A feAv cases continue Avith more or less painful spines and Aveak extremities for a great many years* Hypochondriacal Neuroses.—There is another form of traumatic neu- rosis, which is, strictly speaking, a psychicàl disorder or form of hysteria. It is characterized by the existene-e of certain fixed ideas or a fixed idea regarding some morbid condition of the body. The spécial direction or point toward which the mine! is fixed varies somewhat, being often de- termined in a measure bj^ the original injury. Sennetimes it is sinqdy a painful spot iu certain parts of the body, sue-h as the back or the head ; or it may be a painful joint, and develop into a so-e-alle-d " hysterical joint" ; sometimes it is a morbid condition of the stomach or of the sexual func- tions Avhich alarm s and de-presses the iiatient. The spécial symptom about which the patients mind is centered is the only prominent trouble that he has, but it is generally associateel Avith a certain amount of dyspepsia * Traumatic Functional Paralyses.—There seems to be no doubt that occasionally patients suffer from functional paraplegia, which is essentially of spinal origin rather than cérébral. The cases resemble in many respects those just 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 gênerai neurasthénie state. Thèse cases hâve often been described under the heads of spinal aniemia and of hysterical paraplegia. Bastian, in his work on Hysterical or Functional Paralysis, believes them to be due to a functional disorder of the anterior cornual cells or of the pyramidal tracts in connection with the anterior horns. 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 injury. In some there is a history of tubereulosis. The onset of the trouble is usually graduai. The patients suffer from a progressive enfeeblement of the lower limbs, associated with pains in the back and a sensé of heaviness and weariness in the affected extremities. The circulation of the lower limbs is somewhat feeble, and the skin looks white and feels cool and clammy. There is no decided muscular atrophy, and there are no qualitative changes in the electrical reactions. The knee-jerks and skin réflexes are usually ex- aggerated. No spécial group of muscles is affected more than othei's. There may be a little bladder weakness, but it is not serious or permanent. There is rarely any ,ana?sthesia, and if présent it is only very slight in gradé. There is pain in the back THE TRAUMATIC NEUROSES. 311 and constipation, Avith a condition of impaired nutrition, gênerai weak- ness, a good deal of mental irritability, and always with mental dépres- sion. The most searching examination of the bodily functions faits to discover any sign of organic disease or any évidence of serious disturb- ance of the nervous function ; yet despite» tins the patient incessantly com- plains and talks continually about his sufferings. This immense dispro- portion between the subjective suffering e)f the patient and the objective symptoms constitutes the characteristic feature of* the disorder. It is not ace-oiupanied, I should add, Avith those stigmata which are associated with dee-ieled forms of neurasthenia. Tins neurosis, Avhich is also called hypochondriasis, usualto occurs in persons avIio hâve a psyclmpathic histery—i.e., in persons Avho hâve always been self-centered anel of a neurotic tempérament. Cases of traumatic arthralgia and se)-called topoalgia belong to tins class. In connection with trauma true hypoe-hondriases and arthralgias are in my expérience rare ; though thèse conditions not infrequently complicate genuine neu- rasthénie states. A somewhat typicalcase of this form of disorder is the folloAving : J. K., aged twenty-eight; natiA'ity, United States; single; occupa- tion, bartender. The patient gives a family history AA'hich is compar- atively fre-e from neurotic ine-icle-nts. His father suffered from chronic headache, but Avas otherwise healthy. There is no tuberculosis in the family. He himself hael always been a fairly healthy man, though of a nerve) us and somewhat irritable tempera nient. He had înegrainous liead- aches, beginning at about the âge of twenty-tAvo. Three and a half years before I saAv him lie had a fall through a trap-eloor. He got no severe injury anel Avas not stunned. He got up and Avent about his work as usual. In the course of six or eight Aveeks lie began to notice a pain developing in the back between the shoulder-blades, which he put into relation Avith the strain experieneed during the fall. This pain was of a dull, aching charae-ter; it did not pass around the chest, but was con- fined to an area about the level of the fourth dorsal vertebra on the left side, betwetm the vertebra and the scapula. The pain Avas constant, neA'er disappearing during the elay-time, not improved by posture, not sometimes, but not in the legs. The paralysis may be incomplète, the patient being able to stand and take a few stejts ; sometimes, however, it is so severe that the patient is bedridden, although she never loses entirely the jjower of moving the lower limbs while lying in bed. After a time contractures take place in some cases and the legs are drawn up. Along with this a considérable amount of wasting occurs, but there are still no electrical changes characteristic of degeneration. The S4)ine is tender to pressure, and the patient often suffers great distress iu the back, particularly in the lower part and in the cervical région. The arms are usually unaffected. The patient présents absolutely none of the characteristic hysterical stigmata, such as anœsthesias of glove and stocking type, contracted visual field, pharyngeal ana?sthesia, disturbance of smell aud taste, and hysterical crises. In fact, the pictui-e of the case is very much like that which I hâve described under the head of spinal irritation ; the différence being only that the dominant symptom in this class of cases is the paraplegia, while the sjnnal and other 4)ains are simply associated with it. The patients often take a fair amount of food, though they are subject to digestive disturbances and attacks of vomiting. They hâve severe headaches at times. The 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 ffve years. As a rule the patients get well, and an active, vigorous treatment is an extremely important factor in securing this end. In fact, the ju-ognosis is vastly changed in accordance with the eharaeter of the therapeutic measures which the patient receives. 312 A SYSTEM OF LEGAL MEDICINE. increased by moA'ement or Avork, anel not relieve'el by rest. At times there Avère exaecrbations of it, se) severe as to reuder him idterly mis- érable, though they never incapae-itated him for his Avork. His gênerai health continueel getod. Ile Avas able te) eat and digest his food, to sleep, and to perform his daily work. His habits Avère good; he neither drank nor snioked, except in great modération. Ne) form of treatment produced the slightest effect upon the suffering, and at the end of three and a half years he was brought to nie for examination. Ile' Avas a man e>f stremg and muse'ular build, some Avhat thin in figure, but not emaciateel in any degree. He presented some symptoms of a catarrhal dyspepsia, but other than that the»re Avère absedutely no object- ive symptoms, nor Ave»re there any of the marks of hysteria. On ex- amining the painful area I diseewered it to be loeated about as stated, betAveen the third and fourth dorsal spines, covering an area of abenit twe) inches in diameter between thèse spines anel the inner border of the scapula. Hère there Avas some hypenesthesia to te)iie-h anel senne tender- ness on pressure. The pressure and manipulation of the spine produced no pain, nor coule! pain be eliciteel by any movements of the trunk or shoulders. The pain Avas relieveel only temporarily by injections of co- caine. It was not hel})ed by cauterization, blisters, or counter-irritants of any kind. In fact, no local application or any internai médication did the slightest good. EXUSUAL TYPES. There are certain peculiar forms of traumatic neurosis AA'hich cannot be classée! strictly under any of the foregoing heads. Thèse atypical forms of traumatic neurosis hâve not been observed in sufficient number as yet to enable us to make of them a type. I shall therefore ne>t at- tempt a systematic description of them, but shaiï place on record a e-ase which iiïustrates very Avell the class of injury te Avhich I refer, adding that in atypical forms the probability of simulation or exaggeration is ahvays very great. A. D., aged forty-five, married, had ahvays been a strong, hard-work- ing, vigorous man of temperate habits, and Avithout any history of alco- holism or syphilis or previous nervous disorder. In Âpril, 1892, while standing in a car, lie Avas throAvn doAvn in the aisle by the force of a col- lision. He Avas temporarily stunned, but got up, sat in his seat very much frightened, but unconscious of much injury. He got to his dépôt in fifteen or twenty minutes, then found he could not Avalk, and had to be iïfted to a carnage Avhich coiiA-eyed him to his home. His physician, avIio was then called, found that lie had a cemtusion of the right pariétal 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 weakness of the legs anel of the right arm. Tremor*was also observed in the two upper extremities. The température was ninety- seven degrees. Xo bladder or rectal troubles. He suffered considérable pain in the bae-k and in the leg. He Avas placed in bed, and continued in about the same condition for a week or two. then gradually improA^ed so that lie coule! sit up and walk a little. During this time lie had chok- ing sensations at times. He slept and ate pretty Aveiï, but Avas nervous. THE TRAUMATIC NEUROSES. 313 depressed, emotional, aud irritable. He had during this time a shght attack of herpès zoster over the course of the right tAvelfth dorsal nerve. He was seen by me about six months after the injury. The physieal examination at that time shoAved him to be a man of good color, not anaemic, weiï nourished. He Avalked sloAvly, using a cane, and spreading his feet apart. He was unable to stand with eyes closed. There was no atrophy of any muscular groups in any of the extremities. He had a fine tremor of considérable amplitude, continuons in eharaeter, increased on extension of the arm, and slightly on A'olitional movement. There was senne tremor in the legs and a very little in the face and tongue. On making him shut his eyes and sIioav his teeth a peculiar sharp con- traction of the platysma myencles was produced (perhaps natural to him). The tactile, température, and pain sensations Avère aiï normal. There was a slight degree of ataxia in the legs, but noue in the arms. There was a slight amount of tenderness about the région of the third and fourth lumbar vertebrœ. Pressure and the application of heat produced some wincing and reflex contraction of muscles near the spinous pro- cesses. He could move the bae-k and trunk in ail directions. Pushhig on his legs caused pain in the bae-k. This lumbar pain never radiated around the waist 01* darted denvn the legs. There appeared to be consid- érable Aveakness in both legs, more in the right, and there was some weakness in the right arm as compared with the left. No fibriïlary con- tractiems. The knee-jerks were exaggerated slightly, but there was no clonus. There was also exagge'i-ation of the elbow-jerks. Electrical ré- actions of the leg and arm muscles were normal or slightly increased. There was 110 hyperœsthesia or tenderness except in the back. The spécial sensés of smell anel taste were normal. The hearing Avas normal except in the left ear, Avhere he Avas deaf to high notes, bone and aëiïal conduction being good. The pupils Avère smaiï, equal, reactec! to light and accommodation. Vision Avas good, and there was no contraction of the visual fields. The pidse Avas seventy-two anel the heart actieni normal. The pharyngeal reflex Avas normal, anel the choking-attacks which he had once suffered from had ceasecl. The urine Avas normal. He suffered from cold feet and some eA'idenees of A'asomedor weakness. The diagnosis at the time Avas a traumatic neurasthénie condition, plus some local injury to the s|>inal ligaments and to some of the nerA'es issuiug between the tAvelfth detrsal and first lumbar, and between the third and fourth lumbar on the left side. This case, Avhiïe to a large extent functional, Avas perhaps compiïcated with a certain amount of injury to spinal nerves, and certainly with much exaggeration. The patient got practically well. Spécial Symptoms.—Having gone over the symptoms of the vari- ous types of traumatic neuroses anel given some iiïustrative cases, I pro- pense now to discuss some of the spécial symptoms AA'hich we find in thèse cases, anel Avhich are more or less characteristic. First of aiï, I shall take up those symptoms Avhich belong to the psy- chicàl sphère, and Avhich include mental irritability and dépression, lack of attention, lack of poAver of concentrating the attention, feebleness of nu-meu-y, anel Aveakness of A'olitional poAver. Associated vvitli thèse may lie- e-lassed the headaches, verfigo, para»stlie'sia of the head, including suedi symptoms as insomnia, head-pressure,feelings of constriction and fullness. (if thèse symptoms the insomnia is one which is perhaps most characteris- 314 A SYSTEM OF LEGAL MEDICINE. r j<- :v "Y- O Diagrams showing in Figs. 34 and 35 the area over which a cutaneous irritation causes a reflex contraction of cremaster; showing in Fig. 36 the areas over which a slight blow produces a knee-jerk. From a patient with a traumatic neurosis. THE TRAUMATIC NEUROSES. 315 fie, and AA'hich may be looked upon to a certain extent as a symptom of an objective eharaeter. Sleep is usuaiïy very much disturbed by bad dreams, and it is characterized especiaiïy by the fact that Avhen the patients wake in the morning they hâve noue of the sensation of restfidness that cornes from healthful slumber. The emotion- ality and irritabiïity of patients are also things which are usuaiïy noticed by others, and are in a measure objective. Little things, which never before annoyed the patient, now are become a source of con- stant annoyance ; they get angry at slight provocation, and become very disagree- able persons to live with. 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 stimulants and narcotics. The Muscular and Motor Symptoms.— Tremor is a symptom which is A'ery fre- quently présent. It is fine in eharaeter and vibratory, and brought ont best by making the patient extend the hands and fingers. It is increased readiïy by a shght 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 physieal work. There is usu- Fig. 37. Eyes closed. Fig. 38. Eyes open. Ataxiagram showing swaying of body. aUy a certain amount of wasting of muscles, but this wasting is gênerai, and does not affect spécial groups. Questions as to the normal différence 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 cases, and that the right is larger than the left in about 31G A SYSTEM OF LEGAL MEDICINE. one third, while the left is larger than the right in somewhat less than one fourth of the e-ases. The différences never excee'd five eighths of an inch, and rarely reach that extent. ( \Valton.) The differ<»nces in the size of the arms are more considérable relatively, depending upon the e)ccupation and habits of the indiAddual, so that the exact figures cannot be given. TAvitching motions of the face and a slight amount of fibrillary contraction take place. In thèse cases there is no loe-omotor or motor ataxia, but there is ahvays in my expérience a consielerable degree of static ataxia, varying Avith the nervous dépression and irritability of the patient. This test for static ataxia I consieler an objective one of considérable value. It must be maele, however, by means of instruments of précision, Avliich record accurately the amount of sAvaying of the patient with the eyes closed and Avith the eyes open. (See Figs. 37 and 38.) Something further Avili be said upon this point in connection with the diagnosis. The ten- don-réflexes are, as a rule, considerably exaggerated. This exaggeration is shown by the quick and extensiAre movement of the feet on striking the pateiïar 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 quaelriceps muscle above for a considérable extent. This extensive area over Avhich a blow will bring out a reflex contraction is an objective indication of nervous irri- tability of A'alue in diagnosis. There is also an increase in the activity and extent over AA'hich the skin-reflexes e-an be brought out. This is particularly weiï studied in connection Avith the cremasteric reflex. (See Figs. 34, 35, and 36, on page 314.) In the sensory sphère there are a number of symptoms which caiï for spécial study. In traumatic neurasthenia there is no anassthesia of the skin unless some complicating organic injury or some hysterical process be présent. In this statement I knoAV that I am at variance with the teachings of some of the German neurologists. Oppenheim in particular lay s stress upon the fae-t that in traumatic neuroses there are conditions of slightly diminished cutaneous sensibiïity as well as genuine anaesthesia. This diminished sensibiïity or hypaesthesia is, hoAvever, one I hâve never been able to satisfactorily demonstrate in any except patients who pre- sented distinct hysterical marks of other kinds or in cases of organic neurosis, and the difficulties in the Avay of establishing a diminished sen- sibiïity which may be considered pathological are so great that the symp- tom is, in my opinion, even if présent, one of little importance. There is a good deal of tenderness along the spine (in sixty to seA'enty-five per- cent, of cases) at varions points ; also upon the scalp, particularly at the sutures of the bones ; and sometimes in other portions of the body. This tenderness on pressure is looked upon as an objective symptom, and is, I believe, admitted as such in courts of laAV. When the test is properly applied it has a certain amount of value, because the patient will not aï- Avays wince properly if he is pressed unexpecteciïy on points that are not really tender, and because, on the other hand, the skillful application of sudden pressure will bring out certain genuine manifestatiems of pain. In addition to that, there is in some cases a rather sudden accélération of the puise AA'hen a tender point is pressed. Tins symptom Avas first described by Mannkopf in 1885 and is called after his name. Its prés- ence indicates an undue irritability of nerve centers and lias objective importance, though it does not show the existence necessarily of a trau- matic or other neurosis. 27CT iw Left Eye. Right Eye. Fig. 39, showing limitation of visual field in a patient with a traumatic neurosis. co h-1 -a 318 A SYSTEM OF LEGAL MEDICINE. Visual Troubles.—In traumatic neureises Avithout hysterical compli- cations there is, as a ride, no concentric limitatieui of the visual field. Still, slight Hmitation occurs in a minority of e-ases, and in nearly ail in- stances in which the symptoms are of a severe type there is évidence of a certain amount of fatigability of the Aisual field. I mean by this that there are évidences of a A'ery easy tiring of the periphery of retina. The existence of this condition has been pretty Avell established by the labeu-s of Fôrster, Kônig, and others. My own expérience is that in at- tempts to map out the AÙsual field in thèse 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, shoAving that their power of attention Fig. 40, showing Fôrster s 'shifting-type" in a case of traumatic neurosis. The contin- uous line represents the field of vision 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 poAver of perception weakens along with it. In some cases one finds a gênerai 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 Fôrster and Kônig, and is known as the Fôrster shifting-type (Schiebungstypus). 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 AÙsion toward the periphery. If, for example, an object is placed to the temporal side of the right eye and gradually brought forward until it coin es into the field of vision, it wiiï be seen, we wiiï say, at eighty-five degrees. The object is then brought graduaiïy forvvard 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 moveel back it Avili be lost to view, we wiïl say, at eighty degrees. The object is then moA'eel in the same Avay on the nasal side, and above and beleiw, Avith the same resiilt. An example of tins is shoAvn in the diagram appended hère. (See Fig. 40.) Tliere is sometimes a disturb- ance in the coter sensé in thèse conditions, and avc often find évidence of muscular asthenopia, especially loss of poAverof convergence. (Huebscher.) Other symptoms are a visual Aveakness, Avith at times spots before the eyes, and pain anel tenderness in the eyeballs aud about the brow. Patients often eomplain of total inability to reael for any but a very short time. Attempts to read produce headache, mental confusion, and a sensé of prostration.* The sensé of smell is sometimes found to be impaired or abolished after injuries of the head. It is, hoAvever, in most cases, if not aiï, an évidence of local disorder or of some actual organic disease. Thus, among twenty-two cases of head injury Avhich Avère followed by anosmia, Von Bergmann found évidence of fracture of the base of the skuiï in ten. It is to be re»membered, also, that anosmia is sometimes a symptom in tabès dorsalis, and is sometimes produced by syphiïis. Disturbances in the sensé of taste are A'ery common in hysteria, but not in traumatic neurasthénie conditions. In this latter class of cases there may be- an undue irritability of tins sensé or some perversion due to local conditions or digestive troubles, but that is aiï. The disturbances of the spécial sensé of hearing consist of noises in the ear, hyperacusis, and sometimes siïght deafness. Baginsky lias de- se-ribed a deafness occurring in traumatic neurasthenia, and due to con- cussion of the labyrinth. It is associated with noises in the head and sometimes Avith Arertigo. It oce-urs especially after a physieal injury. Sometiine's A'crtigo oce-urs and becomes extremely annoying, and cases hâve' been described in which the dizziness Avas so severe as to produce a condition resembling Ménière's disease. In my own expérience I haA'e found ringing in the ear to be the most distressing and common symp- tom. This ringing is generally cemtinuous, not much modified by post- ure, and not of the pulsating eharaeter, but rather continuons and per- sistent. There is no limitation of the field of hearing—that is to say, patients can hear veiy high notes and A'ery low notes—but in a considér- able number of neurasthénies one finds a slight amount of deafness of boue conduction, generally, however, in only one ear. Laryugeal Symptoms.—Benno Holz reports two cases of aphonia neiv- e>sa élue te trauma and associated Avith paresis of the abductors. Paresis of this kind is rare, but does occur. Paralysis of the dilators of the larynx, hoAveA'er, has never been described and probably never occurs. (IL Burger.) Vtisomotor Disturbances.—In a large proportion of traumatic neu- rose-s one finds évidences of vasomotor weakness. Tins is shown in the cold hands and feet, the tendeney to perspire easiïy, and sensations of heat and flushing. Tliere is also in many cases a considérable degree of derineigraphy. On draAving a dull-pointed instrument over the skin of the back or chest a broad red line wiiï soon develop, which lasts some- * AA'ilbrand finds often some CL V Field in neurasthenia, but most others disagree (Koniy, Hochwardt, Topolanski). There is, however, not rarely a limitation of color field, especially for blue. (Neur. Centralbh, 1893, p. 584.) 320 A SYSTEM OF LEGAL MEDICINE. times for half an hour, and is much more marked than in normal persons. This vasomotor disturbance, hoAvever, is often found in healthy people, and may dépend upon other things than a neurasthénie state.* There .sonietimes develops a local cvanosis of the extremities, so that the Angers or the toes become cold and Avhite, and resemble the condition knoAvn as Raynaud's elisease. A few cases hâve been reported in which a local edematous sAvelling developed in différent parts of the body after trauma. Thèse local swellings are known as angïoneurotic edema. They do not occur necessarily near the part injured. They develop rather suddenly in the form of circuniscribed SAvellings, which arc» usuaiïy somewhat pale, though they may hâve a redelish tinge, and the»y do not pit on pressure. They may last for a feAv hours or days and then disappear.t Traumatic neurasthénies are often liable to perspire excessively. This tendeney to sweat is, hoAvever, not a uniform symptom, and at times there may be only a local sweating. Thus the patient complains of an area of profuse perspi ration in the small of the back, or on the legs, or perhaps only on one side of the body. Urticaria and éruptions of a sim- ilar eharaeter sometimes deA^elop. (Kriege.) A case of bloody SAveating has been reportée! by Ehrig. It ex-curred in a trapèze performer, avIio f eiï and struck his head. The local bloody SAveat took place on the head, and was accompanied by no other sign of SAveating. The bodily température has been found at times subnormal, while others hâve described attacks of feverish eharaeter. In my oavu expéri- ence I hâve found no marked or important changes in bodily température unless tliere AA'as an hysterical factor in the case. It is Aveiï to bear in mind, hoAvever, the expérimente of Lehmann (Ceutralblatt f. Aerveuheilk., May, 1890), AA'ho found that, by clirecting attention to the subject of bodiïy température, indiAÙduals who were not preAÙously hypnotized could raise the température as much as half a degree Fahrenheit. The puise is often abnormally fréquent in the traumatic neuroses, ranging from 90 to 100, and if not fréquent it is apt to be irritable, so that slight physieal exertion and shght mental excitement accelerate the beat of the heart greatly. This increased pulse-frequency and abnormal irritabiïity of the heart constitute objective symptoms AA'hich may be considered to hâve much positive value in diagnosis. The average puise in fifty-nine cases, as determined by Walton, was for maies 90.5, and for females 90.75. This rapidity of puise is a symptom on whieh German writers lay much stress, and Oppenheim has noted some cases in whie-h as a result of persistent rapid heart-beat some dilatation and compensa- tory hypertrophy of the heart took place. The increased puise-rate when pressure is made on a tender point has already been referred to. The condition of the urine in traumatic neurasthénies is also some- what characteristic. It is apt to vary much in quantity, sometimes the patients suffering from polyuria and again from a rather condensed urine. There is at times an irritable bladder and tendeney to fréquent * Ludwig Man (Berlin Klin.Wochenschr., July, 1893) finds a lessened electrieal ré- sistance of the head in traumatic neuroses. He uses small électrodes and weak cur- rents (3 éléments). He puts one électrode on the neck, the other on the forehead. He finds the normal résistance 4000 to 6000 ohms ; in neuroses, 1500 to 2500. Eulenberg, using larger électrodes, fix 12 ctm. and 10 éléments, finds the normal only 1200 to 1600. t Guiuon reports a case of blue edema with ansesthesia after a fall. (Op. cit.) THE TRAUMATIC NEVROSES. 321 mie-turition. The urine in most cases présents a relative excess of phos- phates, and the earthy phosphates in particular are increased dispropor- tionately. Methods of Examination and Diagnosis.—I hâve not space to go over in deta.il aiï the methods which are required in a thorough exami- nation of a case of traumatic neurosis or traumatic neurasthenia. The détails of thèse methods are given in text-books on nervous diseases. It Avili be sufficient for my purpose noAV to give simply an outiïne of the geimral plan to be pursued, and then to e-aiï attention to e-ertain spécial methods Avhich are of importance in the détermination of objective symp- toms and iu the détection of simulation. The physician who is examin- ing a patient should proceed in a certain régulai- and systematic way. An outline of the plan to be foiïoAved is given in the accompanying scheme : 1. Preliminary facts : name, âge, sex, condition, nationality, occupa- tion. 2. Family history. 3. Personal history. 4. History and causes of présent disease. 5. Physieignomy of case. General appearance, nutrition, abnormalities, gait, etc. 6. Disorders, if any, outside of nervous sphère. Digestion, heart, lungs. Température, respiration, puise, urine. 7. Psychicàl sphère : mental condition; sleep, etc. 8. Motor sphère : paralysis ; tremor ; abnormal movements ; atrophy ; electrical and mee-hanical réactions of muscle and nerve ; speech. 9. Sensory sphère. General sensations : vertigo ; pain ; paraesthesia. S4)ecial sensations : tactile, température, pain, muscular (ataxia) ; vision ; hearing, taste, smell. 10. Réflexes superficial, deep, organic. 11. Trophic, vasomotor, and secrète >ry disturbances. The examiner should bear in mind the importance of weighing aiï the évidence as impartially as possible ; of aiïowing only the proper weight to the statements of the patient ; of securing eAÙdences of organic disease, évidences of conditions which the patient cannot simulate; and he should bear in mind also that Avhiïe the patient may be perfectly sincère lie lias so much at stake that lie wiiï often exaggerate. It is well to secure a careful history of aiï the détails of the accident, and to hâve the history corroborated from several sources. The facts with regard to the condition of the patient subséquent to the injury should also be gathered with the greatest eare. The physician must in aiï cases assume an attitude AA'hich is not syinpathetic but critie*al ; he must, even, perhaps, at the expense of a certain apparent unkindness, investigate every statement and every phenomenon that is présentée! in connection Avith the case. Ile should also take espeedal pains to inquire into the previous health of the patient. It has been found by Walton that in seventeen out of a hundred cases tliere Avas some nervous or organic disease before the injury occurred, and investigations by other authorities bave led to similar results. Having secured a full and complète history of the case, the physician pre>eeeds to the direct physieal examination of his patient, For the purpose of carrying out such an examination in aiï 322 / SYSTEM OF LEGAL MEDICINE. its détails a considérable number of appliances are necessary m many cases. The following list may be perhaps of senne use to those Avho de- sire to equip themselves for this kind of work: a stéthoscope»; appliance-s for examining the urine ; a galvanic and faradic battery with milham- peremeter, sponge électrodes, and a wire brush Avith interrupting-handle ; a dynamometer, esthe'siometer, and ophthalniose-ope; a penmeter; a Gal- ton's whistle; a tuning-fork ; a percussion-hammer ; and matenals fe>r te»sting the sensés of smell and taste. In addition to thèse one may sometimes bave use for a sphygmograph, and in my oavu Aven-k I am ac- customed also to use spécial' dynamometers for the legs and extensor muscles of the arms ; a concealeel needle for testing the sensé of pain ; métal tubes one centimeter in diameter, which are use»d in testing the cold and heat sensé according to Goldscheider's method; weights for testing the muscular sensé; 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. Anatomicul— Preliminary to a detaiïed description of methods of examination, I hâve thought that it would be helpful to the reader to in- sert some anatomical diagrams Avhich could be referred to in the course of an examination or in préparation for it. Fig. 41 iiïustrates the com- parative size and relations of the brain aud 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. 4:> shem's the points of exit of the cutaneous branches of the spinal nerves. Fig. 44 shows the positions of the spinous processes of the vertebraa (indicated by the squares), the point of exit of the spinal nerves (indie-ated by the horizontal lines), and the relation of the points of origin of the spinal nerve roots (indicated by the dot ted lines) to the spinous proccsse»s. 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 ont the dis- tribution of anaesthesia, and in determining whether this corresponds to the area of any given nerve or nerves. Such facts are of importance both in localizing lésions and in questions of diagnosis between organic and hysterical troubles. (Se-e 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 hère with regard to this matter. Tests of Heart Action.—I bave already referred to the fact that the heart-beat is sometimes abnormally rapid, and to the fact that pressure upon a tender point, particularly one near the spine, wiïl produce an ac- célération of the puise-rate. According to Mannkopf such pressure Aviiï raise the puise from 84 to 92 or from 100 to 120, and this accélération lasts for two or more minutes ; the puise also gets smaller. This test is known as the neuralgic cardiac reaction. In examining the puise it is im- portant to feel the two radial arteries or the two carotids or the tAvo femorals at the same time, the physician placing a finger of each hand upon the tAvo arteries. In this way he can détermine whether the puise on the two sides is synchronous, and may possibly detect the présence of an aneurism. The sphygmograph wiiï in my expérience usuaiïy give a curve of low tension and one that is somewhat characteristic of the neu- rasthénie heart. I hâve taken the tracings of twelve typical cases of ^^V3 Fig. 41, illustrating the comparativo size and relations of the brain and spinal cord as they appear when removed together from the body. CO to co Fig. 43, showing the relations of the brain and cord in their normal position in the body. 324 A SYSTEM OF LEGAL MEDICINE. neurasthenia and superimposed them, producing as a resiilt a sphygmo- gram, which may be considered to represent the neurasthénie- type-. The eharacters of the urine in traumatic neurasthenia I hâve îvterred to already under the head of Symptoms. Tests for phosphates, both earthy anel alkaline, for al- bumin, e-asts, sugar, uric acid, and indican should be made. Tests for Motor Xerves and the Muscles.—The existence of tremor or spasm is of course easily determine-d. It is very important, henvever, to study earefully the ehar- aeter of thèse disturbances. The tremen* is usually of a fine and vibratory eharaeter, the rate of A'ibration being about ten per second. It is best produe-.ed by making the patient extend the hand and spread out the Angers. It does not increase on A'edun- tary motiem, and i s A'ery slight when the patient's extremi- ties are relaxée! and quiet. The heael is not affected, anel when the-re do occur some osciiïatory or nodding mo- tions of the heael it is sig- nificant of some hysterical condition or some serious neurosis. Slight muscular twitchings of the face anel extremities are not at ail rare symptoms, and are of some importance as indicating motor irritability. When a paralysis exists it is of ex- trême importance to déter- mine Avhether it be of a func- tional or organic eharaeter. The points for determining this are given in détail also in standard Avorks on neu- rology, and they cannot be entered upon fully hère. It is important, however, to bear in mind that in functional palsies tliere is little or no atrophy, and that the same faed applies to palsies due te) brain disease, except in children. A certain amount of wasting occurs in the limbs from disuse, but in my own expérience this Fig. 43, showing the points of exit of the cutaneous branches of the spinal nerves. (Van Gehuchten.) Fig. 44, showing the position of the spinous processes (indicated by the squares), the points of exit of the spinal nerves (indicated by the continuous lines), and the points of origin of each nerve (indicated by the dotted lines). Thus the nfth lumbar nerve originates at a point be- tween the eleventh and twelfth dorsal spines. Drawn from a photograph of a man on whonx thèse points had been mapped out. ,>|- 32G A SYSTEM OF LEGAL MEDICINE. rarely exceeds half an inch for the leg, and hardly as niue-h for the arm. (See p. 316.) The most important means of deternihiing the organic ehar- aeter of a paralysis is by the use of electricity. I feel very confident that I am correct in stating that degene»ration reactiems are never found Avhen the paralysis is of a functional type, and that they do not en-e-nr in hys- teria uncomplicated with organie- elisease. By a " ctegeneration réaction " I mean a diminution in the e-oiitraetility of the muse-le to the faradic car- rent, Avith a peculiar sluggïshness of réaction Avhen the eurrent is passed through the muscle. Sometimes there are changes in the relative exeita- bility to the two pôles, se> that the pe>sitive pôle on cleising the eurrent gives a stronger reaction than the négative ; and sometimes the contrac- tion is not only sluggish but diffuses over the Avhole boelv of the muscle. 'There are, I believe, some elee-trical change-s which to a certain extent are ■characteristic of a neurasthénie state—that is, of a state of irritability and weakness of the nervous centers. I think, however, avc cannot yet posi- tively formulate Avhat thèse» are». Eumpf bas laid down three tests for the traumatic neuroses : first, pivssmv on painful points, giving rise to accél- ération of the puise (Mannkopfs symptom) ; second, a quantitative réduc- tion in galvanic irritability of motor nerves; third, a fibriiïary contrac- tion of the muse-les, AA'hich lasts sometimes after the eurrent has passeel through them, and Avhich extends into adjoining muscular groups. This he calls the traumatic retalion. The second symptom occurs only late in the disease, that is to say, one or two years after its ine-eption. He finds, for example, that in the normal iilnar and peroneal nerve the Ka C 0 (négative pôle closure-eontraction) is produced by £ to 2 milliamperes, in a traumatic neurosis by 4 to 10 millianiperes ; the normal Ka C Te (négative pôle closure-tetanus) is produceel by 4 to 11 milliamperes, that in the traumatic neurosis by 20 to 25 miiïiamperes. Tliere is in the traumatic neuroses an abnormal degree of muscular Aveakness ; the patients tire easily and are incapable of their ordinary amount of physieal Avork. This symptom, of course, is easily simulated, and is one that is almost ahvays complained of by malingerers. A test for the genuiiieness 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 différent groups, and oblig- ing him to go through various exercises. He is Avatched while tins is done, and the records that he is able to make are compared Avith the normal. The observation of the patient at this time is also often help- ful ; for a genuine neurasthénie avIio Avants to get well will do his best at the Avork laid down for him, AA'hiïe the Simulator is constantly groan- ing and complaining at the distress that eAery effort causes him. Tests for Sensory Symptoms.—The subjective complainte of pain and of tenderness are ahvays A'ery great and prominent symptoms. The method of testing it by the " traumatic cardiac reaction," or Mannkopfs symptom, has already been described. Pain along the back occurs in about tAvo thirds of the cases, and is ahvays a matter of especial cone-ern to the patient. The physician in examining the patient finds tender spots along the spine, and thèse spots Avili sometimes vary even during the single examination. This variability of tenderness used to be considérée! a sign of malingering, but I do not belieAre it ahvays is, since it Avili be noted in neurasthénies aaIio bave no object for dee-eit. However, very gross and persistent changes in the location of pain may be considered THE TRAUMATIC NEUROSES. 327 •J2S A SYSTEM OF LEGAL MEDICINE. suspie-ious; so also is the absolute anel imiterai localization of pain- ful spots on the same vertebra at différent examiiiations. In testing for painful spots the physician should, however, always make it a point to distract the patients" attention, for if he finds that a place which was asserted to be extremely sensitive on pressure can be vigorouslv punched when the patients attention is distracted, it is usually an évidence of either malingering or senne very hysterie-al state. The tenderness of the skin and of the parts beneath sliemld be» separately exaniined. Amesthe- sia of the skin in its différent degrees should be testée! by means of the sesthesiometer, by Avhich tactile and pain sensés are determined, and with hot and cold tubes, by which the température sensé is determined. In Fig. 47. Fig. 48. Fig. 49. Fig. 50. Fig. 51. Fig. 52. testing for aneesthesia to pain (analgesia) it is not sufficient to use simple pricking-instruments, but the strong faradie brush should be employed. It is sometimes a good plan also to use a large wire brush, one part of which is laid over an aiïeged anaesthetic area, the other extending over the non-anœsthetic area. The eurrent being turned on, the brush can be tiïted so that at one time it touches the amesthetic part and at another time not, and in this way malingering can sometimes be détectée!. In testing the sensé of cold and beat Goldselieieler's method may be at times employed to adAantage, and objective symptoms eau in this way be de- termined. The test of the cold sensé is made Avith métal cyhnders at THE TRAUMATIC NEUROSES. 329 from 59° to 63° F., that of the hot sensé with cylinders at from 113° to 12(3° F., the patients eyes being closed. Tiring and cooling of the skin affect the results. The latter Aviiï correspond most closely Avith Gold- selieieler's normal tables AA'hen the cutaneous température in the first in- terosseous spaee of the hand or foot is from 85° to 86° F. The examina- tion begins with the test of the cold sensé, a maximal point being tested. If the patient feels no température, but merely a sensation of pressure, then there is amesthesia of the cold sensé, Avhose limit and intensity must be determined. The intensity is testée! by maximal température irrita- tions. Feu- the cold sensé a température of the métal cylinders of 50° F. suffices. But Avhen the cylinder placée! on the maximal point produces a sensation of température, the question is Avhether it is normal or weaker. Therefore the minimal point is next tested, and if this is likewise given correctly the sensé of température is normal. But if disturbance is found—diminution (hypa-sthesia), hypera»sthesia being very rare aceend- ing to Ge)lelse-heider—its degree must lie ascertained by comparison with symmetrical points or Avith eqmvalent other points of the table.* Visual Tests.—It is of course best in many cases to hâve the eye eare- fully exaniined by a compétent ophthalmologist ; the neurologist, hoAv- ever, in particular détermines the condition of the muscles and of the visual field and alse> the A'isual acuity. As already stated, there is often a consielerable degree of Aveakness of the adduetor muscles. This is tested with prisais and colored glasses, and by nie-aus of them often the efforts of the patient to dece-ive may be détectée!, particularly if this patient f eigns serious disturbances of A'ision, such as diplopia or amblyopia. The dé- termination of the A'isual field is made by means of the perimeter accord- ing to the methods ordinarily describeel in the text-books. In my ex- periene-e' there is no contraction of the visual field in ordinary cases of traumatic neurasthenia ; but there is, as I haA^e already stated, some de- gree of retinal hypaesthesia 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 and Fôrster with regard to the existene-e of the shifting-type in traumatic neuroses, as de- scribed above. (See Fig. 40.) It is not présent, however, in ail 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 AA'ith objects at a considérable distance. In this way attempts at simulation may be dé- tectée!. With regard to the other spécial sensés I haA'e already said sufficient under the head of Symptoms. The testing of the réflexes and of the muscular irritability is a matter of much impeu'tance. As a rule, the dee»p réflexes are exaggerated ; AA'hen they are- not, I haA'e generally found that there was either a history of alcoholism or some infections disease. The skin-reflexes also are apt to be exaggerated, anel the peeuiliar enlarged area over Avhich the cremasteric re-de'x can be clicited lias 1 >een already descril »ed. (See Figs.34, 35, and 3G.) In intercostal neuralgia it is stated by Seeligmiiïler that the abdominal reflex on the affectée! side is exaggerated. In testing for ataxia one should try to détermine the power of the * Goldschoider's table and figures are published in the Archiv. fur Psychiatrie, vol. xviii., 1SS7. 330 A SYSTEM OF LEGAL MEDICINE. patient to stand steadily Avith the eyes open anel then witli the eye-s e-losed, the heels and toes being placed together. The patient should also be tested as to his power to place the extremities in différent pe>sitienis, touching différent parts of the body Avith the eyes closed, and as to his knowledge of the position of his limbs when the eyes are ch>sed, and also as to his ability to détermine différent Aveights. The- epiestion now cennes finally as to Avhether there are any single objective symptoms by means of Avhich avc can say that the patient lias a traumatic neurasthenia. My oavii belief is that tlie-re» are objective sjnnptoms whose existence sIioavs that the patient is not simulating, but has some real morbid condition. Tliere is, heiAA'ever, no single objee-tive symptom upon whieh avc can alone rely.* The aggregation of aiï the objective symptoms does not preve that the patient lias a traumatic neu- rasthenia, but does proAe that he has some morbid condition Avhose exact nature must be determined by the history of the case. Practically the object of the examinations in most cases is to détermine, first, whether the patient is simulating, and next whether lie bas organie- or functional disease», and finaiïy, if he lias only functional disease, Avhat the exact nature of that trouble is. Now, as to the last point, we e-an say that it is traumatic neurasthenia. We fine! that the patient suffers from the pe- culiar psychicàl anomalies referred to,the subjective sensory disturbances, the insomnia and cérébral para»sthesia, and such objective symptoms as muscular weakness and irritability, tremor, static ataxia, exaggerated réflexes, aecelerated puise and cardiac irritability, vasomotor disturbances, disturbance's of the A'isual field and aurai field. I do not mean to say that it is necessary that the patient hâve ail of thèse symptoms, and it must be left to the expérience and judgment of the physician to déter- 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 knoAvn as traumatic neurasthenia. It appears to be a condition in Avhich there is an excessive weakness and irritability of the cells of the central nervous system ; those groups of ceiïs controlling and regulating the circulation of blood—that is to say, the vasomotor system—being particularly affected. There hâve been up to the présent time but feAv cases of post-mortem examinations made in traumatic neuroses. In 1875 Wiiïigk reported the case of a be>y of nine who had a fall and received a severe injury upon the head. He developed some symptoms of a neuras- thénie and hysterical eharaeter. He died, and the post-mortem showed some softening in the pons. The case is evidently not one in point, though often quoted under the head of the pathology of traumatic neu- roses. Oppenheim (23) in 1SSS reported an autopsy ùpon one case. He found no lésion, but there was no microscopical examination made. In 1889 Sperling and Kronthal reported a e-ase of a man AA'ho at the âge of forty-two received a shght injury in a railroad collision, followed at once by symptoms of traumatic neurasthenia. The man gave no history of syphilis or alcoholism. The history, hoAvever, of his symptoms 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 puise, 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 Avère found in ail parts of the white matter of the cord, Avith degeneration of ganglion cells in a small area in the loAver dorsal région, including Clarke's columns. There Avas a small hemorrhage in the middle of the densal cord. Bernhardt and Kronthal report a case of a man aged thirty-three who was struck in the epigastrium by a horse's hoof. He suffered from a seA^ere degree of hystero-neurasthenia for three years, and finaiïy hung himself. The cord only Avas examined. Some slight ai-terial thickening and mimerons patches of sclerosis Avère discoA'ered in the white matter of the spinal cord. The patient had passed bloocl and vomited it, but there was no lésion found in the stomach or intestines. Se-hmauss lias repented the case of a man aged twenty-nine who fellfrom a ladder and gradually deA'eloped the symptoms of a combined systemic degeneration of the spinal cord. There was, however, an imperfect his- tory of the case. Schmauss also reports the results of some expérimente upon animais, which do not throw very much light on the pathology of the traumatic neurosis. Friedmann in 1890 reported two cases of head injury, occurring in a man of tAventy-seven and a woman of thirty. The injuries were occasioned by falls, and were followed by symptoms of meningeal irritation, with paroxysms of excitability. In the first case there was a paralysis of one of the cranial neiwes. After deatli no gross le-sion Avas discovered in either case, although it had been supposed tliere was some pachymeningitis. The microscopical examination Avas made in one case only. The blood-vessels were found to be distended and sacculated in places, and filled with blood. The perivascular spaces Avère dilated, and there Avère blood pigment and round cells in them. There Avas also found a hyaline degeneration of the walls of the blood-vessels— in fact, the lecord is suggestive of a syphilitic process. THE GRAVE TRAUMATIC NEUROSIS. In some rare cases severe traumatism may be followed by the produc- tion of a séries of symptoms which partake partly of the nature of neuras- thénie or hysterical disorder and partly of the nature of organic disease. The neurasthénie and hysterical symptoms are much like tliose observed in the trauniatie' neuroses of other types. The additional symptoms, Avhich suggest the existence of actual organic lésions, are such as haAre been observée! in the condition knoAvn as disseminated sclerosis of the brain and cord. The exact nature of thèse cases has yet to be definitely settled. There is a steady and even gradation between cases of severe traumatic neurasthenia, traumatic hysteria, and the grave traumatic neurosis sclerosis; just as it is often exceedingly difficult to draw a sharp line between the very exaggerated type of traumatic hysteria and a e-ase- of Avhat seems to be a disseininateel sclerosis. Thèse cases, hoAV- eA'er, are extremely rare, at least in this country. In my own expe- riene-e I hâve» seen but a feAv. The causes of the development of this form of trouble are traumatism s which are particularly severe and in whieh the head lias been also injured. I do not believe that such a diseu-eler can be produced by psychicàl shock alone. The trouble seems to aftect men oftener than Avomen, just, as is the case with major hysteria, and it occurs usually in persons avIio hâve reached the third or fourth 332 A SYSTEM OF LEGAL MEDICINE. décades of life. The symptoms develop in some cases A'ery rapidly after the injury is received. The patient suffers from headache and verfigo ; mentally he is de»pressed, irritable, hypochondriacal, although this mental state I do not find ahvays to exist. Sometime's the patie-nt is rather hopeful, but is at the same time emotional and perhaps a little childish. The mental power in eae-h case is lessened. Either soon after the at- tack or some months later he de»ve»lops tremors of the extremities and tongue, speech becoming somewhat thick or syiïabic. Nystagmus may be présent. The tremor is ce>arse and jerky in charactei-, large- in range, and increases on \roluntary effort; in other words, it resembles that ob- served in multiple sclerosis and also in some forais of hysteria major. There is exaggeration of réflexes, as a rule ; no paralyses, however, occur. There may be some incoordination and some cutaneous anaesthesia, Avhich is usuaiïy not hmited to one side of the body. The visual fields are limited, and oe-casionally tliere is optic atre>phy. There is also at times limitation of the auditory field and disturbance of the sensé of taste. Sometimes tliere is laek of control over the bladder, and the patient may suffer from pain anel stiffness in the back. Thèse» symptoms progress until they reach the stage Avhie-h practically incapac- itates the patient from work, although he is not ahvays bedridden, and finally he présents the picture A'ery much of a case of disseminated scle- rosis. The organic changes underlying the trouble are tliose of minute speds of sclerosis in the brain and cord. My oavii eqdnion is that at présent avc must consider thèse cases as belonging to the type of multiple sclerosis described in systematic Avorks. It Avili be founel that very fVav e-ases of this disorder occur which are not precedeel either by an infective fever or by some se\'ere trauma. A good illustration of a traumatic neurosis of this type is the folloAving. The history of the case has been kindly prepared for me by Dr. Joseph Cedlins, under whose eare the patient is. F. M., aged fif ty-seA'en ; boni in Ireland; laborer. Family History.—Xo phthisis, rheumatism, insanity, epiïepsy, nor hereelitary prédisposition. Previous Iiïness.—With exception of a fever when a young man, has never been ill; lias ahvays been as sound as a "paving-stone." Hygiène and Habits.—Has been twice married, children healthy. Has never had venereal elisease. Alcoholic in a moderato Avay aiï his life. Présent Iiïness.—Tavo years age>, Avhile riding on a load of hay, feiï, struck on head, Avas carried to St. Vincent's Hospital, remained uncon- scious for tAvo days, and Avhen 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 tliere he was weak and " shaky." He was unable to go to his ordinary occupation, but got light Avork about a stable. In less than a month after leaving the hospital he noticed that his hands were very unsteady and that it Avas necessary to use both of them to carry a cup or glass to the mouth. The shaking and Aveakness Avère more iii the left hand and arm than in the right. At tins time he noticed aise» that his hearing was gradually becoming impaired, and this impairment steadily became AA'orse. He remarked also (one month after the injury) that tliere was some impediment in speech ; the Avords did not come regu- larly, as before. Thèse symptoms, particularly the shaking e>f the hands and the trembling of the voice, he noticed Avère considerably increased by THE TRAUMATIC NEUROSES. 500 000 excitement, and less so by fatigue. At this time very little continuons effort caused fatigue. Ahvays in cold weather he felt Avorse. Although the appetite remained good, and bowels and bladeler régulai*, he could not gain strength. He die! not suffer headache, dizziness, 01* pains. He lias noticed that it is A'ery difficult to make him perspire. When he takes alcohol (Avhich he does biit rarely, on account of being in hospital) lie feels better, and the tremor is not so marked. Examination—Appearance.—Poorly nourished. Face ahvays the seat of a passive, elark, sluggish flush. Countenance not expresstee. Station aud Gait.—Both good. Does not hâve tendeney to fall. Tremor.—Slenv, 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 se» on fatigue and on voluntary effort. Both upper extremities are affected, left sicle considerably more than rigl.it. In lower extremities mostly in left. Moderate tremor of head, which does not reach noelding. Réflexes—Knee-jerks.—Both lively. Left very moderately increased. Slight aukle-clonus of left ankle. Eyes.-—No nystagmus, either on movement or rest. Slight arcus senilis. Flecks of degenerative arcus irregularly distributed throughout cornea. Meibility of eyeballs not impaired. Pupils smaiï, area of mo- bility small. React to light and ae-e'ommodation. Pupils remain regular on accommodation. Consielerable contraediem of visual field of both eyes. Sensation.—Bluiiting of cutaneous tactile sensibiïity ; a sharp pencil feels like the finger, and lie says lie cannot elistinguish the contact of e-ot- ton from contact of pièce of soft rubber. Pain conduction not delayed nor diminished. Discrimination of various tactile irritations A'ery poor. No hype>raesthesia. Subjectivedy has paraesthesia in extremities at times. Hearing.—Can just hear tick of Avate-h AA'hen brought in contact Avith left ear, but not in right ear. Bone conduction apparently diminished. Puise.—Régulai*, 78 ; moderate capacity, slight increased tension. Temjterature.—Slightly subnormal, 98° F. Speech.—Markedly scanning, and biting of syllables. Tongue not partieuilarly jerky. Has trouble in sterling speech. Mental.—Itopeful, never complains ; satisfied and complacent ; mem- ory détective. Physieal.—Extremities rather Aveak, poor grip, and weak résistance of extensors and flexeirs. Diagnosis.—The physician avIio is called upon to examine cases of this kind must détermine whether they are cases of hysteria major, paralysis agitans, disseminated sclerosis, or are simulators. The exist- ence of hysteria major must be tested by the rules AA'hich Aviïl be laid denvn later. Paralysis agitans is in some instances caused by shock or injury ; its characters, hoAvever, are sufficiently definite to enable us ahvays to distinguish it. The tremor is segmentai, anel is most marked during rest. It involves one side of the body more than the other, and rarely the face. There is 110 speech-disturbance and no nystagmus. There is a graduai de»Arelopment of muscular rigidity Avith the tremor. The patients also suffer much from sensory disturbances, such as pains along the course of the nerves, sensations of heat, and numbness or prickling. The voie-e of the patient becomes feeble, high-pitched, 01* seniïe in ehar- aeter. There is a peculiar flush of the face due to vasomotor paralysis. 334 A SYSTEM OF LEGAL MEDICINE. The détection of simulation must be maele out by the methods described later. It Avould be very difficult for a patient successfully to simulât e» 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 themseh'es. They do not suffer much pain, anel some- times are hopeful and cheerful. Reaching this chronic stage, the elisease progresses very slightly, anel they may live for many years ; but recovery is extreniely rare, and if it occurred avc should be obligée! to consider that a large part of the symptoms were hysterical. Pathology.—It is becoming more and more my conviction that ail cases of multiple se-lerosis are eithe-r traumatic neuroses or are the re- siilt of acute infectious diseases. The pathology, therefore, of the grave traumatic neurosis would be nothing différent from that Avhich is usu- ally described as the pathology of disseminated sclerosis due to other causes. If anjr aedual organic elisease exists in this class of cases it must be one that is produced by small multiple hemorrhages Avhich set up foci of softening, folleiAved by a reparatiAre process that le ad s to the develop- ment of smaiï connee-tive-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 folloAvs infections 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 the»re seems to be the same tendeney for the nodules of sclerosis to be situated most frequently in the white matter, especiaiïy in that of the pons, internai capsule, and centrum ovale. The cranial nerve roots are sometimes affected anel also the spinal cord, but the diseased process is essentially a cérébral 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 présent. There are two forms of hysteria, the hysteria minor and hysteria major. Hysteria minor is that form of the morbid condition whie-h is generally meant by the term hysteria. It is the hysteria of popular conception and of gênerai médical parlance. In hysteria minor there is simply an exaggeration of the emotional side, together with outbreaks of A'arious kinds, sue-h as crying or laughing, fainting-attacks or convulsions. This minor hysterical condition is prés- ent in men and the great majority of Avomen, anel it is not ahvays 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, cpiite différent in its essential characters from that malady which is popularly understood as hysteria. In hysteria major there is a decided and serions disturbance of certain spécial functions of THE TRAUMATIC NEUROSES. 33,5 the brain. As a resiilt of this avc bave severe crises or attacks, during which the patients exhibit coiivulsh'e» or other explosiA'e phenomena, and Ave haA'e between thèse paroxysnis A'ery striking symptoms, consisting of amesthesia, paralyse-s, contractures, tremen-s, peculiar mental conditions, and even vasomoter anel trophic disturbances. Traumatic hysteria major is essentially the same elisease as hysteria major due to other causes. In making a stuely of the ana-sthesias of tAvelve cases of major hys- teria some years ago I found that four of them Avère of traumatic origin, and the clinieal history of thèse four cases was not essentiaiïy différent from that of the other eight. In a dese-ription of traumatic hysteria, therefore, I shall bave to go over, to a certain extent, the same grounel that Avendel be taken in the systematic description of this disease. Let me say uoav that in usiug the term hysteria in this connection I shaiï mean, unless I specify otherAvise, hysteria major. Age.—The traumatic form of hysteria occurs chiefly in middle life. Berbez found the average âge of 21 cases to be 25 years, the range being 19 and 56. Thorburn found the aAerage âge to be 31 among 17 cases, being 281 in the female and 35 in the maie ; the range Avas from 18 to 42. Amemg 10 of my oavu cases the average âge was 33, the range being from 14 to 54. The âge of the female cases is younger than that of the maie. Sex.—The disease occurs oftener in men than in women. This is the expérience of Berbez, who found 14 maies to 7 females, and in my own cases, Avhe're there Avère 11 maies to 5 females among 16 cases. Thorburn Avould explain this on the ground that more men are injured than women in raihvay accidents. Few of my cases, howe\'er, were raihvay cases, but were injured by electric shocks, by falls, or bloAvs. Thorburn states, however, that ameuig 228 persons injureel in raih\'ay accidents there Avère 157 mules anel 71 females. Among the former there were 10, among the latter 13 e-ases of hysteria-, so that lie estimâtes that the probabilities of a raihvay acculent being follenved by hysteria are three times as great in the» female as in the maie. Thorburn probably uses the term hysteria in a le»ss definite sensé than I do. In my expérience hysteria major is rarely found in Avomen who hâve suffered from raiïAvay accidents. They more frequently el<»ve»leq) spinal irritations, functional spinal palsies, and hysteria minor or neurasthenia. Marriage lias no effect upon maies, but unmarried Avomen are perhaps somewhat more susceptible than the married. Race.—Hysteria of the major type is apparently 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 neureisis. In tins country traumatic hysteria is less freepient than traumatic neurasthenia. In Walton's expérience the per- centage of hysterical cases Avas 17 ; in Knapp's, 15. In my oavu expérience I hâve had an apparently unusual percentage of hysteria, for I found that among 33 earefully ree-oreled cases of traumatic neuroses 16 were cases of Irysteria. About one third of thèse were of German or of Russian origin, one fourth of Irish, and the rest Avère of American parentage. Chronic alcoholism preelis]>e>ses to a elevelopment of traumatic hysteria. Every year I find in the alcoholic cells at BelleAuie one or two cases of typical hysteria oe-curring in chronic ale-e>holics avIio hâve been subjected perhaps to some btew or shock. Traumatic hysteria, however, occurs in persons of perfcctlA' temperate habits, and in most of my traumatic cases 336 A SYSTEM OF LEGAL MEDICINE. no history of alcoholism Avas noted. Traumatic hysteria occurs more freepiently among men of the Ioavci- seu-ial class—that is to say, among laboring-inen and meehanics anel men AA'ho are- subjected to hard work and privation. The influence of heredity has been much dAvelt upon by French Avriters. Charcot maintains that there is ahvays or nearly ahvays some hereditary taint. The German writers do not take this vieAV, and in my oavu cases tliere is no évidence that heredity plays any important part; certainly in nom- of my cases Avas there disceiverable any serious neurosis or psye-hosis in the family. The patients, hoAvever, Avère many of them of a neurotic tempérament, but perhaps no more so than many other persons Avho ha\re not been vlctims of major hysteria. The exciting cause is the injury. In my expérience an elee-trical shock has a particularly powerful effect in producing traumatic hysteria. Three of my sixteen cases deA'eloped hysteria in this Avay. In one case, hoAveA'er, the patient did not actuaiïy 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. HoAvever, 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 kne>AV of any case in which a person got hysteria if he was injured Avliile intoxieated or asleep. Direct injury to a nerve is said by Thorburn to be a potent cause of producing hysteria. The climate and season of the year seem to bave no spécial effect upon the disorder, other than that hysteria is more prévalent in temperate chmates and in large and popu- lous cities. The person's state of mind previous to the injury prépares the Avay for the development of the neureisis. Thus if a person traA^els with a mind fuiï of alarm and agitation over some possible calamity, the hysteria would be more likely to develop should such an accident actually occur. This is Avell illustrated in the case of a patient of mine avIio had read of the killing of a man by an electric wire. A few days after lie was Avalking along the street, when suddenly a dead Avire fell and struck him on the head. The blow was not very severe, nor was there any electrical eurrent passing through the wire, but the man feiï unconscious, and when he Avas aroused he Avas found to hâve a typical hysterical hemiplegia with hemianœsthesia. The fact may Avell be borne in mind that traumatic hysteria may be produced by surgical opérations, and especiaiïy, in my expérience, by minor opérations conducted under cocaine rather than under ether. Opérations upon the nose and throat and minor opérations upon the utérus are not infrequently foiïoAved by nervous and hysterical disorders. Symptoms.—The disease develops in différent way s ; it may be either graduai or sudden. In some cases the patient receives an injury or fright, and at once becomes excessively excited, and perhaps even deiïri- ous for a feAv 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 sensibiïity upon this same side, and that aiï the classical symp- toms of a hysterical hemiplegia hâve 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 maele. After emerging from this attack he is found to be suffering from some form of hysterical paralysis. In stiiï other cases a PLATE IV. 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 résumes his work. In the course of a feAv days lie notices that lie suffers from headaches and sleeplessness ; that he is irritable anel easily excited, and is entirely unlike himself. After a few weeks he perhaps gives up his Avork, and during this time he lias attacks of SAvooning or of cataleptic or convulsive eharaeter. Thèse attacks are alarming, but they pass away and he continues to be simply suffering from a nervous irritability and dépression, Avith more or less vague pains about the head and back. The picture, in other words, is much like that of a traumatic ne-urosis. In the course, hoAvever, of a few Aveeks, or per- haps even months, there develop symptoms of* a much more severe ehar- aeter. The patient is found to lose the power of one side of the body, or perhaps to be gradually becoming paraplégie ; and associated with this condition of paralysis are found disorders of sensation and other symp- toms of the hysterical condition. In a typical case of traumatic hys- teria the symptoms may be described very much as folloAvs : The patient is usually a man of middle âge. 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 ne»ver absolute. The patient can move the arm a little and can draAV up the leg and often can walk about, though with some difficulty. The hemiplegia is of a flacciel type—that is to say, there is none of the rigidity asse>eiated with hemiplegia due to organic lésion. The réflexes at the knee are, if anything, diminished, though sometimes slightly exaggerated, but tliere is no ankle-clonus. The gait of the pa- tient Avith 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 Une, the toe scraping the floor. (See PI. IL) 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 ont 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 Avith 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- aiïy of the tremor of a multiple sclerosis, though it is often even more exaggerated and jerky. The tremor ceases when the hand is quiet ; it begins AA'hen voluntary motion is made, and it becomes very 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 excited man. There is no nystagmus, nor is there usuaiïy much tremor of the face, though this may be slightly prés- ent. The tremor as I hâve described it is often not very much marked, and it may be even practicaiïy absent. There is no atrophy of the mus- e-les of the affected side, nor'are there any electrical degenerative reac- tions. Vigouroux at one time stated that there was an increase in the résistance of the paralyzed limb to the electrical eurrent 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 Avith a paralysis on one side of the» body, but with an amesthesia of the skin upon this side». This cutaneous ames- thesia in some instances involves the whole of the paralyzed side of the body from heael to foot, stopping sharply, however, anel absolutely, at the middle line. Sue-li extensive amesthesia 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, anel the side of the' head ; in other words, it has what Charcot lias called the gauntiet and stocking type. (See Fig. 03.) Fig. 53, showing the différent modes of hysterical anaesthesia. The dark spots indicate hysterogenic zones. The anaesthesia may extend, however, to the other side, so that there is a bilatéral anaesthesia. This is extremely rare, especially in traumatic cases. The anœsthesia may occur in zones or patches on the surface of the limbs or the head. Thèse zones or patches do not correspond with the distri- bution of any nerves, and in this respect they are characteristic of a hysterical condition. The anaesthesia much more frequently affects the arm, leg, and face together ; next in frequency the arm and leg ; then come the irregular types that I hâve spoken of. In some instances the anaesthesia may be crossed—that is to say, there is anaesthesia on one side of the face and on the opposite side of the body. The anaesthesia as well as the paralysis is usually found to be on the same side as the injiuy, 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 eharaeter this xvill occur on the same side as the external lésion. Regarding the eharaeter of the cutaneous anaesthesia I haA'e made a number of observations.* I hâve found that the toueh sensé was the least affected, whiïe the reaction to painful sensations was most frequently and * "A Study of the Ansesthesias of Hysteria," Amer. Jour. Med. Sciences, October, 1890. THE TRAUMATIC NEUROSES. 341 most extensively abedished. BetAveen thèse two came the température amesthesia. I found also that there Avas very rarely any anaesthesia of the muscular sensé' or articulai' sensé except Avhen the paralysis was very predonne!. Tins latter cone-lusion is at variance with the théories of Dr. Bastian and with senne of the data whieh he lias collectée!. HoAvever, 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 sensation ; e-ertainly this is the expérience in a number of A'ery earefully obse-rveel e-ase-s of m y own. When, henvever, the paralysis is absedute, there' is undoubtedly, in most cases, if not aiï, muscular anaesthesia also. (See Figs. 54, 55, 56, aud 57.) Fig. 54. Fig. 55. Fig. 56. Figs. 54 to 57 show by contrast the distribution of anaesthesia in lésions of the cauda equina (Figs. 54. 55. 56) and in myelitis Fig. 57, on next page), as compared with that in hys- teria (Fig. 5o). Beside's the cutaneous anaesthesia there is an anaesthesia of the spécial sense's—e>f sight, he-aring, faste, anel smell—upon the- affee-teel 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 cone-entiic limitation of the» A'isual tie'ld. With this phenomenoii tliere is at times a change in the color sensé» anel in the color fields. In some cases the only trouble cenisists in a dise>rder of the color fields, and in some cases there is an actual loss of cedeir sensé altogether. I haA'e observée! this in Iavo cases. Drs. Mitehell and De ScliAveinitz, who hâve made a study of this subject, faileel to fine! it in a se»ries of twenty-fivo cases, not, however, of traumatic eharaeter.* The green field is relatively more and more often contracted * ComTdete studies of this subject hâve been made by Pansiea (Ocular Manifesta- tions of Hysteria, Paris, ISOi'), by Wildbrand and Sânger, by Fraenkel, Hopevart, and Topolanski, by "Wilhelm Kënig, and A'ery reeently by Mitehell and De Schweinitz (Journal of Nerrons and Men lai Dispose, January, 1894), who give a full bibliography. Tliese latter authors give spécifie directions for testing the concentric limitation of the visual field. Their tests were made by means of the perimeter. The test-objects were white and colored cards ï-\ cm. in diameter. The patient is placed in a good light, and the test must be made in several différent wavs. 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 the others. (See Figs. 58 and 59.) Itoversal in the normal séquence of the cedors, so that red is the largest field, is usually présent, the normal order being blue, red, anel green. The» fielel of vision is contracted in both eves, but more on the affected side. The contraction is ahvays more or less concentric, and does not présent the characters of a hemiane>psia— that is to say, the visual field is e-em- tracted at aiï points of its e-ire-uinfer- ence, and there is no halfddindness, either horizontal or vertie-al. Te> tins rule Mitehell and De Se-bwelnitz hâve reported an apparent exe-e-ption (loc. cit.). The hearing on the affected sub- is sometimes much impaired, and is almost uniformly affected in some way or other. The most fre-epieuit disturbance is a diminution of hear- ing or absolute eleafness to boue condue-tiem, Avliile hearing is fairly good te> aërial conduction. Loss of the poAver of hearing high notos and very low notes is aise» a freqiu-ntly observed phenomenon. The deaf- ness to high neitos oe-eurs almost Avithout exception, as testée! by a Gai ton Avhistle. Deafness to low notes I bave found in only two en* three cases. In thèse the patients were unable to hear a note made by the bass string oî a viol giving vibrations of about 34 or 68 peu- sec- ond. The sensés of smell anel of taste are abolished on the affected side. The most striking symptoms of hysteria major are those that I bave just described—paralysis and ames- thesia. The distribution of the-se symptoms, hoAvever, is not always hémiplégie. Sometimes a patient suffers from simply a paralysis of one arm or of a leg, or of both legs. An hysterical parai) sis of au arm is the more common. Hysterical paraplegia is relatively rare, particularly the cases Avhiedi can be spoken of as in a true sensé hysterical, that is, of cérébral origin. When the patient suf- fers from an hysterical arm-palsy he lias, along Avith the palsy, Avhich is flaccid in type, ansesthesias of the skin and perhaps of the muscles, and he has at the same time some of the anaethesias of the A'isual, 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 procédure once or twiee. If tliere is ground for suspecting simulation the test must then be repeateel 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 physiologieal limits of the fielel for- form and for blue, red, anel green. (Fig. 58, p. 343, also Fig. 59.) THE TRAUMATIC NEUROSES. 343 and other spécial sensés. If a person suffers from hysterical paraplegia of a type that is truly hysterical, he wiïl, I am convineed, hâve along Avith this paraplegia some elisturb- ance of cutaneous sensation of the affected parts. Tliere wiiï be also some eAndences of disturbance of the spécial sensés, and often tliere occur certain disorders of motor cranial nerves, more e'speciaiïy a lingual spasm. In hysterie'al paraplegia the-re is some exagge-ration, as a rule, of knee-jerks, anel after a long jieriocl of time there may be e-eiutraetures. There are», however, in the early stages no muse-ular atrophies and no changes to the electrical e-urrents. There may be a slight disturbance of the bladder for a time, but no persist- ent impairment of its function. I am convineed, with Dr. Bastian, that as Ave become more familial* Avith the ehar- acters of thèse paraplegias we shall be less inclinée! to consider them ail as of cérébral or hysterical origin, but rather to place some among the functional paralyses of spinal eharaeter. Fig. 58. Diagram of the normal field of vision of the right eye for blue, 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 Mitehell.) Fig. 59. Diagram of the normal field of vision of left eye for form blue, red, and green. (Landolt.) Besides the symptoms of hemiplegia and sensory disorders there are other troubles from whieh thèse patients suffer. As a rule, the patient is very 344 A SYSTEM OF LEGAL MEDICINE. much depressed mentaiïy and discouraged about himself. (See PI. Y ) He suffers a great deal from pains in the back and limbs and bip, and is apt to be of a very complaining habit. Ile- is usually emotienial, and e-ries easily. He is persistent in his expressiems of a désire to get Avell, anel wiiï usuaiïy carry out A'ery faithfuliy the dire-ctions given to him by his physician. He lias at times hysterical attacks or crises. In men thèse attae-ks seem to take more often the eharaeter of simple comatose or lé- thargie stages, the patient passing off for a few minutes or hours, or cacu days, into a state of what resembles hypnotic sleep or lethargy • at other times the patients haAre emotional anel almost maniacal attae-ks or décidée! ceuivulsive seizures, and more rarely go through the characteristic hys- tero-epileptic phenomena. I bave never, however, in this country, seen the typical hystero-epileptic attae-ks develop in maies Avith hysteria of traumatic origin. Again, the patients may suffer from A'iolent and obsti- nate attacks of ATomiting. Xe»arly ail the curions anel weird manifes- tations of hysteria may be exliibited by thèse patients—the cutaneous éruptions, the edematous swellings, the anuria, the viscéral 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 dé- tails of this eharaeter, because the symptoms are those Avhich wiiï be found described under the head of major hysteria in spécial treatises. I bave found in my expe-rience that in young women the interpar- oxysmal marks of hysteria, sue-h as the anœsthesias and paralyses, are less common, while contractures and tremors of various kinds and pain- ful neuralgic disorders are more fivepiently observée!. In traumatic hys- teria in women also crises of A'arious kinds, more particularly convulsive attacks, are much more fréquent, 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 Avho iiïustrated in a classical way the ordinary symptoms of traumatic hysteri- cal hemiplegia. The second e-ase illustrâtes a somewhat irregular type of this disorder, occurring also in a man. The third case illustrâtes the de- velopment of traumatic hysteria in a young Avoman. Case I. Traumatic Hysteria.—B. N., aged fifty ; married ; Moravian by birth ; clerk. Mr. N. states that he has always been Avell, is of temperate habits, lias had no venereal disease, has a famiïy of five children, ail healthy. He was Avalking along the street September, 1889, at the time of the great excitement about street currents, when he saw a wire from an electric-light pôle falling toward him. The wire struck him aeross the head, making a welt on his derby hat ; he seized it in his right hand. He does not remember any more until lie came to in New York Hospital. He is said to hâve faiïen clown, then to bave been helped up, and to hâve walked Avith some assistance. When struck, he saAv a bright light, but felt no peculiar sensations of any kind. \Vhen admitted to the hospital lie Avas conscious and soon able to talk, losing his amnesia except, as he says, of the events just after the blow. There Avas a black stain on his right hand, but no burn. His right arm and hand and leg Avère paralyzed, the leg almost completely, < CL THE TRAUMATIC NEUROSES. 347 so that lie could not walk. The face or tongue Avas not involved. There Avas complète hemiamesthesia of the right side of the body. The bladder was normal. The mental condition good, though he did not sleep weiï for -a few nights. The abdominal and thoraeic A'iscera seemed to lie normal. Through the kindness of the A'isitmg-physician, Dr. Wiïliam Cl. Thomp- son, and the house physician, Dr. Cobb, I Avas enabled to make an exam- ination of the patient, September 24th. He Avas then able to Avalk slenvly anel to use his right arm fairly well. He seemed to be an intelligent man, someAVhat emotional, but anxious to tell the truth about his symp- toms and to get weiï and back to his work. His mind Avas clear, and he suffered from no emotional dépression or crises. He Avas sleeping well. His puise was quite rapid (120) under my examination, but it had been normal, as were the température aud respiration. The face showed no paralysis, the tongue Avas protruded straight, and thè pharyngeal arch was even. The right arm Avas Aveak, but he could exécute ail movements with it exce»pt raisin g it directly over his head. Dynamometer : right hand, 2ô ; left hand, 40. Tliere Avas a tremor in the arm and hand and occasionally in the leg. This tremor Avas rapid, but of rather large excursion, and increased on A'oluntary movement, or on directing attention to it. It Avas an *-intention" and ''attention" tremor. It did not affect the face or tongue. Speech was (dear and dég- lutition normal. The leg Avas much more paretic than the arm. The foot and toes could barely be moved, the leg could be flexeel and extended but partially. The tendon réflexes of arm and leg Avère présent, but not ■exaggerated. The skin réflexes were well marked. Tliere was anass- thesia in varying degree over the right side of the body. It was most marked in the Ioavci- limb, AA'here it extended diffusely up to about Pou- part's ligament in front anel the gluteal fold behind. lu the arm the anaesthesia was more marked over the area of the ulnar, but it was prés- ent in a degree over the whole extremity. Around the shoulder and neck it became less. It Avas présent oA'er the right half of the face, including the tongue, but Avas less marked hère than on the extremities. The anaes- thesia was most marked for cold sensations, we»ll marked for pain, and less marked for tactile sensé. There AA'as no muscular anaesthesia or loss of coordination as testée! by weights and by touching the nose and postur- ing the limbs. The spécial sensés showed peculiar conditions. The pupils Avère nor- mal, even, and reae-ted to iïght and ae'e-ommodation. There was no color- blindness. The man Avas presbyopic, but since his admission he had been unable to read Aveiï. (He had broken his glasses.) His right eye sheiAved décidée! limitation of visual field, the left very much less, though some Avas présent. No différence in visual 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 bone conduction. A large tuning-fork A'ibrating on the mastoid was not heard ; and Anbrating on the teeth was heard only by left ear. Testée! by Galton's whistle, the left ear slmwed a decided loss of hearing of high notes; the right still more. I had never met before a person so deaf to so great a range of tin» upper notes, though it is not very uncommon to find shght degrees of this deafness in the aged. The man had evidently a limitation of the .auditory field comparable to that of the visual field. 348 A SYSTEM OF LEGAL MEDICINE. There Avas an almost complète loss of smell in the right nostril, and a complète loss of taste on the right side of the tongue. There Avas alse> absence of pharyngeal reflex Avhen the finger Avas thrust into the bae-k of the throat. There Avère no manifest secretory or trophic disturbances of the af- fected side. The man complained of A'ery little pain. The electrical ré- actions were not taken. We bave hère a case of traumatic hysteria of the type described by Charced, Guinon, and the French Avriters. The points are so marked and characteristie.', that a discussion as to diagnosis would be supereroga- tory. A\Te hâve the (1) hemiplegia not involving the face ; (2) the ana»s- thesia distributed in the '• gauntiet" shape, i.e., not following nerve tracts but mvolving mainly the limbs, anel covering them like a stocking or glove ; (3) we hâve the peculiar limitation of visual field (4) and auditory fielel, the bone-deafness, (5) the ageusia and anosmia, and (6) pharyngeal ana'sthesia. Three years after tins accident, the patient was much improved but far from Avell. Case in litigation and not settled. The auditory phenomena are particularly interesting, as they hâve not been iiiA-estigated with as much eare as the visual, and are in my expérience rarer. The loss of smell on the right side is confirmatory 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 oleteetery nerves do not decussate, anel henee that hysterical hemiageusia is only apparent and due to trigeminal ana'sthesia. This would not explain the présent case. For the trigemi- nal anœsthesia Avas very shght and the ageusia almost complète. Case II. Traumatic Hysteria with Violent Tremor.—Mr. X., aged fifty-four; of American birth and parentage ; married ; business man. The family his- tory is good in every way so far as any détails can be obtained. The patient himself had always been an active business man, traveling a good deal. There is no history of syphilis or alcoholic excesses ; he lias, how- ever, been somewhat excessive in sexual indulgence. He had never suf- ered from any serious disease or injury, and was perfectly well at the time of his accident. He Avas riding on a horse-car when this occurred. There Avas a cedlision ; his car was suddenly stopped, and he was throAvn violently against another person, being struck on the side of the head. He Avas not knocked cIoavii, but was very much confused. He went home, hoAvever, being at the time somewhat excited and nervous over the acci- dent, and in a feAv hours passée! into a partially comatose state, which lastecl for two days. This ended in a violent hysterical outbreak of a maniacal or delirious eharaeter. This had subsided in the course of a week, and he Avas then found to be unable to use the left arm or le»'. One month later muscular twitching and tremor began in the left ami. This tremor extended and soon involved the right arm and the muscles of the neck aud head. About this time there was found to be also a left hemiana»sthesia. He complained ail the time of pains in the neck and head while thèse various phenomena were developed. The pains in the THE TRAUMATIC NEUROSES. 349 head anel neck and the tremor were found to be somewhat relieved by pulling on the head, so that his physician constructed for him a jury- mast by which permanent support was given, and AA-hile wearing this lie stated that he felt more comfortable. He Avas able to Avalk about, though not without much difficulty. The patient was brought to me by his phy- sician, Dr. Gray, for examination while in this condition, some six months after the accident. I found him to be a Avell-nourished man, not at ail aneemic, but having a de-pressed and distressed look. He walkecl Avith a dragging of the foe>t on the paralyzed side, in a manner that was perfectly typical of hysterical hemiplegia. His face Avas not hwolved by either paralysis or spasm. The tongue turned slightly toward the left. The left arm and leg Avère nearly powerless. He could flex, extend, preinate, and supinate the fore- arm and hand, but his upper arm Avas weaker ; lie could only partly con- tract the biceps and could barely raise the arm out from his siele a few inches. He could not keep the arm up Avhen held. He showed the same gênerai weakness in the leg, though this was relatively less paralyzed. He could stand and drag the leg along ; he could extend and flex the foot ; he could do ail movements, though feebly. The paralysis of both arm and leg was of the flaccid type, and there Avas no rigidity or spasm. The knee-jerks Avère normal on the left, somewhat exaggerated on the right ; the elbow-jerks the same. The arm was affectent with a marked tremor, which was coarse in eharaeter, and clic! not increase with Aroluntary move- ment, but continuée! active. On resting the arm the tremor ceaseel. 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- terien- oscillation or tremor of the head; this Avas lessened and almost stopped by taking hold of the heael with the hands and pulling upward. There was no notable tremor of the legs. There Avas some cutaneous anaesthesia on the left side, iin'olving especially the arm, the shoulder, uppe-r part of the trunk, and to a less extent the leg. The face Avas not involved. There was no ataxia. There Avas a vasomotor paresis of the left hanel and arm, which Avère reddened and felt colder than the right. There Avas a slight atrophy of the left arm, the left forearm measuring 8f, the right forearm 9£ inches. The electrical reactions shoAveel a slight lessening of gatoanic and faradic irritability. Electric sensibiïity Avas lessened in the left arm. The pupils were normal in reaction, and not dilated. Some visual weakness in the left eye ; cemeentric hmitation of the visual field ; no re- versai of the color fields, but the green field Avas very much contracted. The ears shenved a h>ss of hearing to high notes, especiaiïy in the left ear, with a lessening of bone conduction in that ear. Tliere 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 Avas no évidence of amesthesia of the cutaneous surface of the face. The patient was a man of fair mteiïigence. He Avas suffering a good deal from pain in the head and mental dépression, and from the incon- A'enience of his tremor and paralysis. He had no conAuilsive attacks or crises of any kind after the first Aveek folloAving the accident. The case Avas settled out of court and lost sight of by me. 350 A SYSTEM OF LEGAL MEDICINE. Case III. Traumatic Hysteria in a Woman-ctitaleptie.—K. C, female; aged twenty-two, single; nativity and parentage, Anierie-an; oe-cupation, sah-s- Aveunan. Famiïy history absolutely négative, parents and bredhers and siste»rs Avère aiï healthy. The patient used to be a Avell, strong, and healthy girl, said not to bave been of a nervous tempérament. She had clone lier wen-k regularly as salesAvennan for several years, and Avas intelligent and compétent. * On December 11, .1892, she was struck on the top of lier heael b}' an iron instrument Avhich fell from a shelf upon lier. It knockeel lier cIoavh and she was made senseless, and shortly after Avent into convulsiems the eharaeter of Avhich I do not knoAV. She Avas revived and walked home two hours later. There Avas a eut found upon the head when she Avas exaniined by the physician that day. She Avent to lied and slept that night, anel stayed at home for the next three days, suffering from headache and koss of appetite. Then she Avent to Avork, but suffered continually from headache, loss of appetite, and a feeling of Aveariness anel exbaustieni. At times she had to gei home from lier Avork before the day Avas ove-r. She menstruated re;gularly. She gradually lost flesh, but kept up lier Aven-k until the early part of Mardi, 1893, three months after the accident. She then hael an at- tack of convulsions again, Avithout any known cause. Tliere hael been meaiiAvhile no attempts at litigation on lier part. The coiivulsieuis con- tinuée! elaiïy after this time ; she Avould bave them several times in the course of the twenty-four hours. She woulel fall back on the bed appar- ently unconscious and become perfectly rigiel, then she Avould go thremgh A'arious coôrdinated 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 thèse states of unconsciousness Avith rigidity, about a month after the e'onvulsions began. I made the diagnosis of traumatic hysteria, prescribed for her some A'ale-rianate of zinc with tonics, and advised, if possible, a removal from home. After my visit the attacks became somewhat lighter and consisted simply of fainting-spells, during Avhich she became unconscious and someAvhat rigid for about half an hour. She would haA^e several of thèse weekly. Dur- ing the next six months thèse attacks grew still lighter anel more infre- quent. The patient gained some strength, though she Avas still weak and pale, and in aiï 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 spécial motor-disturbance except a gênerai Aveakness. There was some exaggeration of the knee-jerks, how- ever, and of the elboAA'-jerks. There was no cutaneous or muscular an- aesthesia. Examination showed a very decided eoneenti-ic limitation of the A'isual fields. This was almost equally marked for ail colors in the right eye, but only a hmitation by the rule for ail colors in the left eye. There Avas no loss of color sensé and no reversai of the blue and red fields in either eye. The AÙsion of the right eye was someAvhat weaker, apart from limitation of the field, and she had decided amesthesia of the right nostril both to ammonia and to odors. There Avas also some pharyngeal anaesthesia and some disturbance of taste on the right side of the tongue, so that bitter was tasted as sait. The hearing in both ears THE TRAUMATIC NEUROSES. 351 was good as to range and conduction and acuity. The patient has con- tinued to improve, and I bave since lost sight of her. Prognosis.—It is difficult to make a gênerai statement with regard to the progimsis of traumatic hysteria. There are cases which are well in a few Ave»e»ks from the onset of the symptoms ; there are others in Avhich the dise»ase lasts for three or four years, and I haA'e known cases in Avhich the duration was very much longer. Charcot gives a rather imfavorable prognosis feu* cases of hysteria major Avhere the symptoms haA'e become fixed, Avhether this be e>f traumatic or other origin. Thorburn speaks more- hopef ully of such cases, and believes that if they are treated promptly and if there is no complicating élément of physieal injury or litigation, patients ought to get Avell in a feAv months at least. My own expérience is that in traumatic cases the patients may ail be said in a gênerai Avay to be curable, but that e\-en under good conditions they may suffer for several years and are liable to a relapse after recovery has taken place. There are many cases, hoAvever, in Avhich complète recovery lias taken place within a few months. Tliere is no doubt that the fact of a litiga- tion anel 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 Aveighs upon them. The coexistence of a physieal in- jury, such as a severe sprain or an injury to a nerve or a bac! contusion of the head, makes the prognosis less favorable. The prognosis is less favorable in middle-aged maies than in young men, and it is usually more favorable in women than in men. The présence of chronic alcoholism, of sexual abuse, of a decided neurotic tendeney, aiï make the prognosis less favorable. The marked fluctuation in the symptoms, such as trans- ference of the anaesthesia or partial disappearance of it under m étals, make-s the progneisis more favorable. Finally, it must be remembered that severe types of hysteria major appear in rare instances to be asso- ciateel Avith the development of organic changes in the nervous centers. Pathology.—The preAalent view with regard to the nature of major hysteria is that Avhich lias been so earefully elaben-ateel 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 resuit of this lias paralysis Avhich is strictly comparable with that artificially produced by hypnotism ; in other words, traumatic hysteria major is a condition of auto-suggestion in which the anaesthesia., paralysis, tremors, contraction of the visual field, and other symptoms are the resiilt of a violent excite- ment of the imagination, Avith an accompanying loss of A-olitional and inhibitory poAver. ttoeluced to non-technical language, this theory is that traumatic hysteria. is ail a fancy. Such Auew is entirely insufficient, in my opinion, to explain the symptomatology of the disease. No person Avho had not received some previous suggestion could by any exercise of his imagination think himself suffering from loss of smell, taste, vision, hearing, and tactile sensé on one side of the body alone, for such complex of symptoms is entirely unknown to the laity. There must be, therefore, something more than this postulated in order to explain thèse curions phenomena. This further élément in the theory of the condition is as- su nied by others to be a vascular spasm, it being thought that by the influence of a ner\rous shock there can be produced a spasm of ce»rtain Aascular areas which nourish the posterior parts of the internai capsule 3Ô2 A SYSTEM OF LEGAL MEDICINE. and perhaps the sensori-motor areas of one side» of the brain. Dr. Bas- tian seems to think that the A-ascular theory isdhe essential and perhaps the efficient one. For my own part, it seems to me avc are» at présent quite unable to explain the phenomena of major hysteria A\ith 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 thèse severer types of hysteria that there should not be some organic e-hange under- lying it. The fact that there is no such change, however, lias been dem- onstrated : first, by the historiés of cases in AA'hich sudden cure lias taken place even Avhen the paralysis and amesthesia were most complète ; and secondly, post-mortems by Pell, Oppenheim, and others on cases of trau- matic hysteria hâve demonstrated that tliere are no lésions appréciable to the naked eye or through ordinary microscopical research. BIBLIOGRAPHE 1766. (1) Maty, "Médical Observations." A palsy attended by uncommon symp- toms. A case cited by Erichsen as illustrating spinal meningitis the resuit of concussion. 1815. (2) Boyer, "Maladies Chirurgicales," vol. iii., p. 135. Two cases of concus- sion with paraplegia, autopsy showing no lésion. 1816. (3) Bell, Sir Ch., '-Surgieal Observations." 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"St.Thomas's Hosp. Reports," vol. xviii. 1890. (184) Brcmer, "Cincinnati Med. News," February, 1890. "Traum. Hysteria," March. 1890. (185) Bruuelli, " Reforma Medica," Naples, July Ist. Traumatic hysteria case. Very rare in Italy. 1800. (186) Clcvcnger, "Boston Med. and Surg. Jour.," September 4th. "Erichsen's Disease." 1S90. (187) Fracnkel, "Inter. Klin. Rund," July 20th. Simulation. 1890. (188) Knapp, "Boston Med. and Surg. Jour.," December 26th. Simulation. 358 A SYSTEM OF LEGAL MEDICINE. 1890. (189) 1890. (190) 1890. (191) 1891. (192) 1891. (193) 1891. (194) 1891. (195) 1891. (196) 1891. (197) 1891. (198) 1891. (199) 1891. (200) 1891. (201) 1891. (202) 1891. (203) 1891. (204) 1891. (205) 1891. (206) 1891. (207) 1891. (208) 1891. (209) 1891. (210) 1891. (211) 1891. (212) 1891. (213) 1891. (214) 1891. (215) 1891. (216) 1891. (217) 1891. (218) 1891. (219) 1891. (220) 1891. (221) 1891. (222) 1891. (223) 1891. (224) "Meditsina," St. Pe- Nederl. Tijdschr. V 1891. (225) Donath, "Wien. Med. Woch.," September 27th. Simulation rare. Barbon r, J. F., two cases of traumatic neuroses. "Progress," vol. iv., p. 697, 1890. Bobrotf, A. A., "Traumatic Tropho-Neuroses of the Lower Extremities." "Laitop. Khirurg. Obsch. v. Mosk.," 1890, vol. ix., p. 2(i0. Hermanu, O., "Notes on the Traumatic Neuroses." Wurzburg, 8vo, 1891. Thesis. Selenski, " Case of Traumatic Neuroses in a Child." tersburg, 1801, vol. iii., p. 60. Stephan, "Nervous Disturbances after Trauma." ' Gen.," vol. xxvii., p. 625. Carter, A., "Traumatism and Neuropathy." "Med. Mod.," Paris, 1891, vol. ii., p. 117. Cullerre, A., "Neuroses Consécutive to Accidents." "Ann. Med. Psy- cholog.," Paris, 1891, vol. xiii., p. 261. Dcbove and Remond, " Hvstero-Traumatic Accidents following Sudden In- jury." "Bull. Soc. Med. de Hôp. de Paris," 1891, vol. viii., p. 273. Wolff, R., "Neurasthenia Cerebralis Traumatica." Dunin, Th., "Some Notes on the so-called Traumatic Neuroses." "Deut. Arch. f. Klin. Med.," Bd. lxvii., p. 532. Brainerd, "Médical Standard," March, 1891. Experiments on dogs by Watson. Hun, "Traumatic Hysteria." "N. Y. Med. Jour.," February 7, 1891. Putnam, "Buffalo Med. and Surg. Jour.," October, 1891. Three cases of traumatic hysteria cured. Dercum, "N. Y. Med. Jour.," June 6, 1891. Litigation symptoms and prognosis. Freund, C. S., and Kayscr, S., "Ein Fall von Schreckneurosen mit Gehors- anomalien." "Deut. Med. Wochen.," No. 31. Freund, C. S., "Démonstration Einiger Falle von sog. traum. Neurose." "Centralbl. f. Nervenheilk. und Psych.," July, 1891. Roth, four cases of traumatic neuroses, with notes upon the same. "Ber- lin. Klin. Wochenschr.," No. 9. Seelir/m iillcr, " Further Notes on the Traumatic Neuroses and the Question of Simulation." "Deut. Med. Woch.," Nos. 31, 32, 33, 34. Dubois, "The Traumatic Neuroses." "Correspondsbl. f. Schweitzer Aerzt," No. 17, 1891, p. 530. Sérieux, P., "Arch. de Neurol.,"vol. xxii., p. 48, 1891. Hystero-traumatic paralysis ; loss of faradic excitability. Dercum, "The Back in Railway Spine." "Jour, of Nervous and Mental Diseases," July, 1892. Sepclli, "Revista Sperimenta di Frenat.," January 11, 1891. Review. Schultzc, Fr., "Deut. Med. Woch.," July 2, 1891. "Visual Fields and Anaesthesia." Also "Munch. Med. Woch.," June 9th. Hitzig, "Deut. Med. Woch.," July 30, 1891. Controversial. Collins, Joseph, "Journal of Nervous and Mental Diseases," November, 1891. Truamatic hysteria. A case cured by hypnotism. Seguin, "Annual Univer. Med. Sci.," vol. iii. Simulation. Mobius, "Munch. Med. Woch.," September 29th. Hoffmann, A., "Die traumatische Neurosen u. Unfaffversicherungs Ge- setz." Volkmann's " Vortrâge," No. 17. Nature and pathology. Oppenheim, H., "Weitere Mittheilungen in Bezug auf die traum. Neu- roses." Simulation. Fricdmann, M., "Study of the Sequelœ of Brain Concussion." "Deut. Med. Woch.," 1891, No. 39. Autopsy. Bruns, T., "Bibliography." "Schmidt's Jahrb.," 1891, Bd. ccxxx., p. 81. Kriege, "Vasomotor Disturbances of the Skin in Traumatic Neuroses." "Arch. f. Psych.," vol. xxii. Kônig, "An Objective Symptom in the Traumatic Neuroses." "Berlin. Klin. Woch.," No. 31, p. 774, 1891. Elzholz, " The Traumatic Neuroses." "Wien. Med. Presse," No. 48, 1891. Immermann, "A Case of Traumatic Neurosis." "Correspon. Bl'att. f. Schw. Aerzt," No. 17, 1891. Benedict, "The Traumatic Neuroses." "Wien. Med. Presse," No. 48. 1891. BIBLIOGRAPHY. 359 1891. (226) Lewck, S., "The Traumatic Neuroses." 1892. (227) Kiihucr, "The Traumatic Neuroses." "Viertiljahrsch. f. gericht Med.," vol. iii., 4). 340. 1892. (228) Wilbraud, " (Jhanges in the Visual Field in the Traumatic Neuroses." "Deut. Med. Woch.," 1892, vol. xviii., p. 379. 1892. (229) Panas, "The Ocular Stigmata of Traumatic Hvsteria." "Reforma Med.," Naples, 1892, vol. viii., p. 531. ' 1892. (230) Prince, M., "Traumatic Hysteria. A Contribution to Prognosis." "Amer. Jour. Med. Sci.," 1892, vol. civ., p. 63. 1892. (231) Rosenbach, "Study on Traumatic Neuroses." Vratch, 1892, vol. xiii., p. 173. 1892. (232) Roseubaum, G., two cases of local traumatic neuroses and their course. "Therapeutic Monat.," Berlin, 1892. 1892. (233) Gillct de Grand mont, "Traumatic Neurasthenia and Ocular Accidents." "Bull. Soc. de Med. Prat. de Paris," 1892, p. 244. 1892. (234) Horwitz, "Neurotic (Edema following Trauma." "Med. News," 1892, vol. Ix., p. 432. 1892. (235) Lyman,H. M., "Traumatic Paralysis Agitans." "Chicago Clinic Review," 1892, vol. i., p. 42. 1892. (236) Muilier, "Observations on Traumatic Neurosis." "Arch. Med. Belg.," 1892, vol. xlii., p. 242. 1892. (237) Bach, J., "Klinischer Beitrag liber Traumatic Hysteria." 8vo, Breslau, 1892. Thesis. 1892. (238) Bcrmaiiu, E., "Ueber Traumatische Neurosen." 8vo, Strassburg, Ist éd., 1892. Thesis. 1892. (239) Butz, E., " Storungen der Sensibilitât dureh Traumen." 8vo, Wurzburg, 1892. Thesis. 1892. (240) Bernheim, "Traumatic Neurosis of the Nuclme." "Rev. Med. de l'Est.," 1892, vol. xxiv., p. 439. 1892. (241) Bure/er, "Laryngoscopic Findings in Traumatic Neuroses." "Berlin. Klin. Woch.," 1892, vol. xxix., p. 1197. 1892. (242) Eisenlohr and Ueinhard, "Neurolog. Centralbl.," February 15, 1892. Simu- lation. 1892. (243) Oppenheim, "Die Traumatische Neurosen." Second édition. Simulation. Spécial eharaeter and symptoms of traumatic neuroses. "Arch. f. Psvch.," vol. xxv., p. 248. Simulation. 1892. (244) Schullzc, "Deut. Zeitsch. f. Nervenheilk.," vol. i., p. 445. Simulation. 1892. (245) Freund, C. S., "Ein Ueberlick ueber den gegenwârtigen Stand der Frage von den Sogenannten traum. Neuroses." Volkmann's "Vortrâge." 1892. (246) Dercum, "Journal of Nervous and Mental Diseases," January. Cases not in litigation. 1892. (247) Nonne, A., "Deut. Med. Woch.," July 7th. Visual fields, etc. 1892. (248) Schmidt-Rimpler, "Deut. Med. Woch." Visual fields, etc. 1892. (249) Huebscher, "Deut, Med. Woch.," April 28th. Muscular asthenopia as an objective symptom. 1892. (250) Lauenstein, "Deut, Med. Woch.," April 14th. Chloroform narcosis for simulators. 1892. (251) Rumpf gives three objective tests : pressure on painful points ; quanti- tative réduction of galvanic irritation; faradization of nerve-trunk, causing fibrillary contractions. 1892. (252) Ncumaun, A., "Inter. Klin. Rundschau," August 14th. Case of traumatic hysteria. 1892. (253) Charcot, "Clinique des Mal. du Syst, Nerv.," Tom. i., 1892, pp. 29, 117. Hystero-traumatism. Prognosis. 1892. (254) Bencdict, "Ueber Hypereesthesien der Kopfknochen (Nahtneuralgien)." "Internat. Klin. Rundschau," No. 1. 1892. (255) Friedmann, upon a peculiar form of sequel to brain concussion and the vasomotor symptom complex of it. "Arch. f. Psych.," vol. xxiii. ; aise " Neurolog. Centralbl.," April 14, 1892. Local neurosis and simulation question. 1892. (256) Tliicm, C, "Notes on Treatment and Care of Traumatic Cases." Berlin 1892. 1892. (257) Wichmann, on the value of the symptoms of the traumatic neuroses Braunschweig, 1892. 1892. (258) Goldschcider, "Neurolog. Centralbl.," August, 1S02. Tests of analgesia 360 A SYSTEM OF LEGAL MEDICINE. 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 °82 28.3 284 Elzholz, "Wien. Klin. Woch.," February 18th. Case of traumatic hys- teria. Also "AA'ien. Med. Doct. Coll.," 1801. Knapp, P. G, "Boston Med. and Surg. Jour.," September Ist. Classifi- cation. Bcard, Minneapolis. Review. Mickle, J., Brain, Spring No. Effects of concussion. Cocstcr, "Berlin. Klin. Woch.," No. 31. Case of traumatic hysteria. Hainaut, M., "Neurose Traumatique." "Arch. Méd. Belges," October, 1892. Strauss, A., on the value of Mannkopffs symptom in traumatic nervous diseases. "Berlin. Klin. Woch.," November 28, 1892, shows that it and Rumpf's symptoms are not always présent. Miles. "Cérébral <'oncussion." "Boston Med. and Surg. Jour." The- oretical and expérimental. Wcill, E., "Slight Traumatisms of the Head in Infants." "Lyon Médi- cal," November, 1893. Knajip, P. C, "Simulation in Traumatic Nervous Diseases." "Boston Med. and Surg. Jour.," September 28, 1893. Dubois, "Correspond, fur Schweizer Aerzt," September Ist. Simulation, against. Striimpell, "Neurolog. Centralbl.," May Ist. Text-book, seventh édition. Simulation. Wcrnickc, "Neurolog. Centralbl.," May Ist. Simulation. Bremcr, L., a case of hysterical astasia-abasia, suing for damages. Hys- terical paraplegia. "Journal of Nervous and Mental Diseases," Jan- uary, 1893. rcl, " Traumatic Hysteria, with Autopsy." "Berlin. Klin. Woch.," 24, vol. xxx., June 12, 1893. Millard, Ferry H., "Some Critieal Observations U4)on Certain Forms of Spinal Injury." "Annals of Surgery," 1893, 41. 546. Bremcr, L., "Traumatic Neuroses in Court." "Médical Review," No- vember 11, 1893. Outen, W. B., "Injuries to the Nervous System without Evident Gross Lé- sion." " Médical Mirror," November, 1893. Dana, C. L., "Text-bo.ok of Nervous Diseases." Article, Traumatic Neu- roses. Reed, R. Harrei/, "Railway Surgerv, its Présent Status and Importance." "The Times and Register," October 7, 1893. Morton, Tlios. G., "Medico-Legal Expériences in Railway Cases." "Jour. of Amer. Med. Assoc," October 7, 1893. Wilmaers, M., "Hystero-Epilepsie Traumatique." Hypnotism. "Arch. Med. Belges," 1893, p. 153. Blum, A., "Hystero-Neurasthenie Traumatique." "Arch. Gen. de Med.," 1893, p. 458 sqq. Critieal review and cases. Bauer, L., "St. Louis Clinique." Barlow, "Casuistik zur Traumatisch. Neur. Mûnehen." Lehmann. Hochwardt and Topolanski, " Neur. Centralbl.," 1893, p. 584. Visual fields in traumatic neuroses. IXDEX. Autopsies and Pathology, 23, 127, 139, 147, 166, 173, 194, 213, 268. See also case by Oppenheim, of hysteria. Classification, 60, 152, 154, 253. Concussion of Spine and Brain, 3, 5, 7, S. 9, 10, 27. 50.-59, 78, 89, 105, 155. Constitutional Nécroses following Trauma or Shock. 84. 276. Hysteria, 17, 18, 30, 51, 56, 64, 68, 75, 76, 80, 81, 83, 85, 86, 91, 95. 101, 102, 103, 107, 110, 119, 120, 122, 123, 124, 129, 135, 137, 138. 140, 152, 156, 170, 178, 179, 189, 195, 196, 203, 207, 231, 246, 247, 253, 257, 267, 277. INDEX. 361 Local Nécroses : (a) Arthralgias, 4, 36, 39, 68, 111 ; also in Oppenheim, Tr. Neuroses case 31. (b) Paralysis and Spasm, 13, 18, 22, 95, 203. (c) Vasomotor Disorders, 158, 165, 215, 228, 249. (d) Other forms, 17, 25, 30, 46, 191, 226, 234, 235. Medico-Legal, 130, 270, 275. Organic Diseases following Trauma and Shock, 49, 58, 114, 174, 229. Prognosis, 21, 44, 90, 153, 196, 197, 208, 224. Shock, 19, 26, 38, 41, 42, 67, 141. Simulation, 30, 44, 63, 126, 128, 131, 133, 161, 162, 168, 181, 182, 183, 201, 209, 212, 236, 237, 238, 240, 244, 262, 263, 266. Spécial Symptoms : (a) Visual Disorders, 117, 206, 216, 222, 223, 227, 241, 242, 251. (b) Aurai, 118. (c) Cutaneous, 233, 252. (d) Throat, 235. (e) In children, 185, 261. Symptoms and Diagnosis, 28, 40, 43, 57, 60, 70, 74, 109, 112, 136, 142, 143, 144, 145, 167, 169, 175, 176, 216, 233, 242, 244, 245, 248, 251, 252, 259. Treatment, 141, 208, 250. t THE EFFECTS OF ELECTRIC CURRENTS OF HIGH POWER UPON THE HUMAN BODY. BY ALLAN McLANE HAMILTON, M.D., and GEORGE DE FOREST SMITH, M.D. The utilization of electricity nowadays is too gênerai and familiar to need extended comment ; suffie-e it to say that an agent that until a quar- ter of a century ago was used only for the opération of the telegrajih, in electrometallurgy and other chemical proe-esses, and in medicine, to-day provides a large part of the me)tive power, light, and heat of towns and cities throughout the civilized world, Avhile in our own country the small- est villages are equipped Avith electric-light anel street-e-ar plants, and before another décade is finished electricity is likely to find its way into every household for some économie purpose. Incident to its adoption it is natural that the use of so potent and dangerous an agent should hâve been attended by accidents more or less grave, duc sometimes to want of familiarity upon the part of those who were engaged in providing it, or in its application, and of consumers who were for the most part entirely ignorant of its properties or manipu- lation. Thèse accidents hâve so far not found their way into courts as the basis of litigation except to a limited degree, though there is no reason why the responsibilities of electric corporations differ from others where injury or death lias been the resiilt of négligence. The dé- termination of culpability is, however, much more difficult, and contribu- tory négligence is naturally claimed with some reason Avliere the régula- tions and instructions are not complied with, or where the bodily harm is the» resuit of foolhardiness upon the part of the injured person. The properties of electric currents should by this time be Ave»ll enough known to fix the blâme AArhere it belongs—either upon the victim, the power-providing or subway companies, or those AA'ho supply or maintain imperfect apparatus or poorly insulated conductors, or exact dangerous servie-es from their employées, or in any Avay expose others to risk of life or limb. The mechanical causation of ae-cidents is a subject that is fully gone inte> bvwriters upon electricity, and it is only necessary to say that where more or less serienis harm has résultée! it has been through imperfect condue-tors or insulations, when the person places himself in the circuit, receiAÙng a much more powerful eurrent than he expected, or where as the» resuit of underground leakage a eurrent of high voltage» has been turned where it does not belong, either traversing Avires designed for 363 364 A SYSTEM OF LEGAL MEDICINE. currents of leiwer voltage or finding escape through iron water or gas pipes w'hich the A'ie-tim grasps. Again, tlie person places himself in the circuit of a eurrent of great amperage, se> that he is burned. The effects of the passage of an electric eurrent of high penve-r through the human body are exccedingly variable and uncertain. It sometimes proeluces instant death and again no resiilt AvhateA'er. As will be seen later, neiwous shock, more or less severe burns and a Aariety of minor nervous disorders may follow. Modifying Conditions.—What is a eurrent of high poteiitialhVv and AA'hat are the conditions A\rhieh antagonize its effects? The voltage suffi- cient to produe-e death is eommonly fixed at 1500 A'eilts, yet cases are re- ported where A'ery much more» Avas received Avithout fatal conséquences, but in thèse cases it is probable that the entire eurrent did not enter the beuly. In the détermination of the strength of the eurrent we are to consider the élément of surface résistance, remembering Ohm's law that the intensity varies chiefly Avith the ele-ctromotive force and inversely Avith the résistance. The conditions of moisture and the pressure of mctal fastenings increase the danger, Avhile it is likely that it is some- Avhat diminished by the dryness of the hands or the interposition of non- conelucting substance. Gaertner and Edison found the résistance of the body when the sur- face was denuded to be from 1600 to 2000 ohms, but this is probably much greater. The effects of the alternating and direct differ greatly, a voltage of from 250 to 800 of the alternating killing a dog which Avithstood a continuous eurrent of 1000 to 1400. The rapidity of the alternations also increases the fatality. It Avould seem that sudden in- terruptions hâve much te> do Avith the serious effects, for a sudden break of the continuous eurrent, say of 500 ve>lts, is likely to produce much more decided effects than Avhere no break is produced. •• The problem of the elee-tr'omotive fore-e is by no means so simple as it Avould appear from the ordinary statement that the eurrent used avus one of 500 or of 2000 volts. In the early days of Faraday's researclies he was asked Avhy a shock Avas felt Avhen a circuit containing an electromag- net was broken, and Avhy no shock Avas felt Avhen the circuit contained neither electromagnet nor wire coil. This led Faraday to study what he called extra currents, but Avhich are now spoken of as currents of self- induction or inductance.* If the circuit contains a coil of wire it is found that on making closure a eurrent of brief duration is induced in that wire, which runs in the opposite direction to the steady eurrent. . On opening the circuit another eurrent, running in the same direction, is in- duced in the circuit. Thèse extra currents, or currents of self-induction, were earefully studied by Blaserna,t who found that the extra eurrent of opening was of shorter luration but much more intense than the extra eurrent of closing, Xow every elynanio-current necessarily contains a coil in its circuit, and consequentiv must présent the phenomena of in- ductance. Henee when a person receives a shock from a dynamo-cur- rent he must also get, when the eurrent is broken, a self-induced or extra eurrent of opening, of great intensity but short duration. The strength of this extra eurrent dépends on so many factors that it is not easy to * Fleming, The Altcrnate-Current Transformer, pp. 37 et seq. London, 1889. t Blaserna, Giornale di Science Naturali cd Economiche, Arol. vi., p. 22, 1870. EFFECTS OF ELECTRIC CURRENTS. 365 calemlate, but I understand that with a eurrent of 500 volts it may reach 2000 or 3000 volts. " It folle >avs, then, that where the factors in the problem are so variable we cannot make any positive assertions and say that because A received a shock from a 2000-volt eurrent without harm it must be harmless to B, when avc know neither the body résistance of A or B, nor Avhat part of the eurrent A received. As well say that because A SAvalloAvs ten grains of morphine and survives, ten grains is a safe dose to give to B." (Knapp.) Effects of Discharges that do not Kill.—Slight shocks may resuit in pains, numbness, paresis, or swelling of an extremity ; headache, ver- tigo, insomnia, and disturbed vision. Of course ail such cases must be studied by themselves, for the temptation to exaggerate some of the subjective symptoms is A'ery great. Persons who hâve been subjected to shock are sometimes avoi-sc during electrie-al atmospherical disturbances, their aches and pains and nervousness being exaggerated by a thunder- storm. Thèse symptoms are usually recoverable, though there may be a variety of residual shock, with deep-seateel nervous disturbance of an emotional kind, Avhich obstinately persists. Dana is of the opinion that electrical currents when they do not kill produce no permanent harm, but this, we belieA'e, is not aiAvays the case. The immédiate effects of a strong non-fatal eurrent (300 to 1000 volts) are temporary tetanus, the victim falling, with préservation of consciousness, but a sensé of terror and pain which disappears with the rigidity. Of course the unexpected play s a part in the demoralization. A large number of residual con- ditions are left after electric shock. Thèse A'ary from nervrosism and the conelition which is known as the traumatic neurosis (see Dana's arti- cle) to light hysteria. The demoralization that remains after railway accidents is sometimes witnessed in thèse cases, and the resemblance to this kind of disorder is very close. In hypochondriacal persons the nervous excitement is extrême, and an excellent case of Knapp's may be used in illustration to show how powerfully the imagination may be excited AA'hen there is no actual injury but simply fright : '* I Avas asked by Dr. D. W. Cheever to see Geeu-ge L., forty-two, mar- ried, a coachman, Avho was said to be suffering from an electric shock. I saw him on April 14, 1889, and obtained the following history of his accident : He had ahvays been well and strong, although slightly hypo- chondriacal ; had used alcohol pretty regularly, although never to excess. He had been in one or tAvo serious run away accidents, and had conducted himself with marked coe)lness, judgment, and courage. Five days ago, on the 9th, a Avet day, he Avas driving a span of horses attached to a coupé, anel about 10.30 a.m. one or both of the horses steppeel on the conduit of the West End Street Railway, Avhich, from some defect in con- struction, had become chargée! Avith the electric eurrent used in running the cars, claimed to be 500 ve)lts, but probably greater. The horses got a shoe-k, dropped, and lay squealing and struggling for a moment. As the»y fell, the driver, aa'Iio was sitting on the box holding the reins, says that his hands felt numb and queer, and prickled and tickled. He jumped eloAvn, and tliinks he steppeel on the conduit; at any rate he felt a shock and a prickling sensation like needles in his legs, which was worse than in his arms, but neither shock was painful. He wore ordinary se»wed single-soled shoes, Avith iron nails only in the heels. He thought he did 366 ^ SYSTEM OF LEGAL MEDICINE. not toueh the conduit Avith his hands, but he may hâve touched the tire of the wheels, although he felt no further shock ; he cannot say whether lie knelt on the conduit. He saw no sparks before his eyes and had no queer taste in his mouth. He sprang to the coupé, after alighting, and got the horses loose, and they started and ran to the stable. A frienel Avho helped him move the carnage felt a slight shock, Avhich Avas not painful. L. was very much excited and felt that lie could not go after the» horses. He did go to a house some two blocks away to tell his em- ployer of the accident. In eloing so he had te> take a friend's arm, as he hael severe pain in the knees, especially in the knee-caps. He then re- turned to the scène of the accident, where he met the stable-keeper, who had come in a buggy to see Avhat the matter was. L. got into the buggy, helped take the coupé to the stable, and then went home. Since that time he has stayed in the house most of the time, being unable to do anything. He has been extremely nervous and apprehensive, and for two days had the feeling of pins and needles in his feet, and cramps in the calves of his legs at night, with occasional pain in the knees ; but he lias had no pain in the knees since the 12th. He has occasionally an aching pain in the back. He lias a gênerai shivery feeling, but does not feel cold or sick. He had a little headache on the 9th and the 13th, but not enough to amount to anj'thing. He feels a little dizzy on stretching. There is no trouble with vision. Sleep has been very poor until last night, when he slept pretty well under thirty grains of bromiele». He has been kept awake by a neivous feeling, and when he did fall aslee»p would start. Night before last he shook ail night. To-day he has a slight pain across the epigastrium. He has had no sexual désire since the accident. Since his accident lie has had a constant tremor, most marked in the hands • this is rather better to-day. When he came home he could not put his toes down to the floor very well. The calves now feel a little stiff. " L. is stout, ruddy, and the picture of vigorous health. He is very nervous, apprehensive, and restless, constantly rubbing his hands to- gether. He fears that lie will never be able to work again or be the man he was before. There is a tremor of the head and limbs, most marked in the hands ; this tremor is slightly increased in the arms on in- tended movements. The gi-ip is not very strong, but there is no ataxia or Romberg's symptom, and he walks well. The tactile sensibiïity seems a trifle blunted ail over the body, possibly more on the left side of the face than on the right, but there is no distinct line of division and no true hemianaesthesia to toueh. The field of vision, as tested by fingers, seemed slightly contracted on the right. Ail movements were well per- formed. There was slight tenderness over the calves and the fourth dorsal vertebra, and rather more tenderness over the upper lumbar ver- tèbres. The knee-jerks were exaggerated ; there was front tap contraction, and a tendeney to a pateiïar clonus. There Avas no real clonus either at the patella or ankle, but a tap caused several contractions and a gênerai muscular spasm. Examination of chest négative ; puise 106. No elec- trical tests Avère made. '* April 16. Sleeping better ; tremor almost gone. Complains of sore- ness in the back. Goes out a little, but is unable to do any Avork. '• May 30. Getting on well. Still has a slight tremor in the right hand. Knee-jerks normal. Says he is not the same man, and is rather despond- EFFECTS OF ELECTRIC CURRENTS. 367 ent and anxious. Nervous; gets out of breath easily; arms give out on carrying anything. u Soon after he went with his employer to the sea-shore, and resumed his work." Jackson reports a case where the shock was severe but the consé- quences not fatal : R. R., aged twenty-two, well developed and muscular, Avas driving, and the feet of his horses became entangled in a live electrie- light wire. R., in his attempts to remove the wire, probably took hold of some unprotectcd spot and was throAvn to a distance of twelve feet against a curl>stone and then instantly to the middle of the street again, swaying back three or four times. His hands were in contact with the wire about three minutes, when from some unknown cause the eurrent broke and lie dropped to the ground unconscious, remaining so abenit ten minutes ; then in a semi-conscious state Avas taken to the office of the writer. Two hours after was first seen by Dr. Jackson ; then the puise Avas 100, strong and bounding ; température 100° ; pupils dilated ; headache, and Avas nervous and irritable ; réflexes increased. The headache, accom- panied by insomnia, continued three days, then rapidly disappeared, and he resumed his work as se-ctiem-hand without inconvenience», none the Avorse for the shock. His hands were blackened from the finger-tips to midway between the elbow and wrist. The eurrent was from a fifty- light Thomson & Houston arc-machine, ampere-current 6.8, voltage 2100. ° Donnellan (Médical News, August 4,1894, p. 126) reports a case where the subject received 1000 volts and ree-e>veivd after remaining comatose for some hours : " On the 20th of April, 1894, J. R,, aged forty-four years, while engagée! in repairing broken wires for the Bell Téléphone Com- pany, grasped the ends of a wire that had crossed an electric-light Avire e-emveying 1000 volts. He received the full force of the eurrent through his boelv, and Avas immediately renelered unconscious. He Avas threnvii violently to the ground, and could not be released until the eurrent was broken by a felloAv-lineman, who eut the Avires apart Avith a hatchet. The man Vas brought to St. Mary's Hospital at 11 a.m., within half an hour of the accident, and I saAv him a few minutes after his admission. He Avas in preifemnd coma, with pupils widely dilated and irrespemsive to light, breathing stertorous, face pale and bathed in perspiration. About ten minute»s later he vomite-el, and then became wildly delirious, so that it required the combined efforts of three men to keep him in bed. He meianed and criée! incohérent!}', and tonic and clonic convulsions of a severe tvpe suceeeded each other with great rapidity. At this time we AA-ere unable to take his température on account of his extrême restless- ness, but to the hand it appeared about normal. His respirations now lost'their ste»rte)rous eharaeter and became more of the Cheyne-Steikes varietv, averagmg about ton per minute for two hours after his admis- sion. ' The puise Avas 80 per minute», of high tension. v At 11.40 a.m. the man was given morphine, gr. J, by hypodermie injection, and as the de- lirium anel convulsions elid not abate the injection was repeated at 12.10, and soon afterward lie gradually quieted doAvn. About 1.30 P.M., as his respirations were alarminglv feeble, he was given strychnine, gr. ■&>, bv hvnodermic injection, with excellent effect. At 2 p.m. he fell into aiï apiiarently normal sleep, from which he awoke four hours later, con- scious but slightlv dazed, and feeling, as he expressed it, 'tirée! anel sore ail over.' On my visit to the hospital next morning I found that he 368 A SYSTEM OF LEGAL MEDICINE. had slept well during the night ; his température was 98.8°, his puise 72, his respiration 18. He complained of pain from a number of severe burns that lie received during his contact with the wire. Thèse burns Ave-re distributed irregularlv in lines over the back, arms, and legs, and evidently were caused by the intensity of the eurrent, as the e-lothing wïiich coAH-ivel the- affected areas shoAved no signs of having be-en scorched. On epiestioning the patient as to the nature of the accide-nl, lie remembered pe»rfee-t!y ail of the incidents of his morning s work up to the time when he gràsped the Avire that eemveyed the shock through his boely. After that moment lie had not the slightest knoAvledge of what had occurred, and did not suffer the least pain until he aAvoke at 6 p.m., as already stated, to fine! hinise-lf in bed in the hospital." Death from electricity is, as a rule, sudden and aceennpanied by ap- pearances which hâve been more or less earefully observed at the varions electrical e-xecutions that hâve occurred in the State of Ne»AV York. Those of an objective eharaeter consist of the immédiate production of a gên- erai tétanie state Avith current-closure, which disappeared Avith current- opening. There were also in some cases clonic muscular spasm of the thorax, immédiate loss of consciousness, a slight escape of mucus from the mouth, pallor, facial petechiae, dilatation of the pupils, dininess of the cornea, and extinction of the puise. In tAvo or three cases the causation of death Avas evidently not immédiate—notably in that of Kemmler. One of the e-ondemned—the most horrible case of ail—Avas first actually anaesthetized after being removed from the " electrical chair," and Avhen rendered insensible was finally put to death by a second turn- ing on of the eurrent. William G. Taylor (Brown, J. W., " The hntest Electrocution," Médical Record,New Yorkj 1893, vol. xliv., p. 222) was electroe-uteel at Auburn, July 27, 1893. A eurrent of 1260 voltage Avas •turned on at a given signal, and Avith a e-rash the legs shot forward and upAvard, tearing the standard and entire front from the chair. For exae-tly 52 seconds this e-ondition Avas sustained and then the eurrent Avas shut off. The condemned now pitched forAvard and Avould hâve fallen upon his face had he not been restrained by straps. For 20 seconds lie remained apparently dead, a slight froth oozing from the mouth below the mask ; then gasped. An attempt Avas made to again turn on the eurrent, but this faileel. Puise could not be felt. Thirty seconds later puise was slight and thready, respiration 6 per minute. He was unbound and placed on a cot and remoA^ed to adjoining room ; respiration ne>Av 12 to 13, puise 100 and full, breathing stertorous, and features possessing the idiotie expression seen in apoplectic seizures. Breathing continued labored, but increasing in frequency, and at half an hour after contact was 18 and puise 120 anel full. He now made the first movement of left foot and in a very I'cav moments became restless, moving legs and arms and rolling frenn side to side. He was noAv gi\Ten, hypodermically, f gr. morphia. After 15 minutes, no appréciable effect being produced, a cône Avas saturate»d Avith ^ chloroform and f ether and applied. He opened his eyes and trieel to e>bject to this. Forty-eight minutes after contact puise was 130, full and vigorous. Readily responded to the anaesthetic and was again placed in the chair and a second contact made and continued 40 seconds ; an examination proved him dead from a voltage of 1220. Autopsy 1 hemr and 34 minutes later: no rigor mortis, slight esehar on temple, exten- EFFECTS OF ELECTRIC CURRENTS. 369 sive one on right leg, slight congestion of peritoneum, lungs slightly congested at apex, one ouuce sérum in pericardium, otherwise normal oonelitiems, blood fluid throughemt. This case and another quite reeently reported in France by ArsonA'al raise a grave question of Iioav electricity kills, anel Avhether the production of asphyxia is not what really takes place. The subject eif the French case was a workman avIio rece»h'ed 5000 A'olts ( ! ) in some way, and was re- stoivel tolife by artiflcial respiration and other means. Again and again cases " struck " by lightning haA'e, though apparently some time deael, been resuscitated, and it certainly is a grave questiem whether post- mortem examinations should not ahvays be délayée! until the matter of death is indisputably settled. Buchanan (London Lancet, 1892, Arol. i., p. 629) reports a fatal case of a man who received a eurrent of 2400 volts. He was seen ten minutes after the accident. His face Avas livid, lips congested, pupils dilated, bloody mucus oozed from the nares, hands almost clenched; he Avas lying on his back inclined to the right side. Artiflcial respiration Avas resorted to ; he respired three times, anel then dieel in four minutes, epiite rigid. There were no marks on the heael or body, but a dirty spot on the right hand, which was probably the japan from an iron bar held in the hand, he having struck at the induction-Avire AA'hile the insulating india-rubber was fusing. After having struck at the Avire lie fell back Avith a cry for help and was then carried aAvay insensible. Post-mortem 31 hours after death: rigidity e-euispicuous; no signs of violence; lividity marked; supe-rficial intestines slightly congested; deeper abdominal con- tents highh congested (hypostatic) ; urinary bladder congested; spleen enlargeel and eleeply congested, and adhèrent to posterior parts by bands of adhésions ; stomach e\'ielence»el olel inflammation ; heart normal ; su- pe-rficial veins congested ; right auricle distended ; right ventricle flaccid ; left ventricle firni anel solid; left auricle containing from one to twe> ounces of liquid blood; right lung firmly anel universally adhèrent ; both lungs congested, right more than left, tarry blood and air exudeel on pressure, floated in water, and absence of disease ; epiglottis, larynx, and trachea deeply congested, otherwise normal ; brain anel spinal cord con- gested, otherwise normal ; death evidently by asphyxia. One of the earefully detaiïed autopsies (that of Jugigo) made by Van Giesen maA' be presented (The Infiiction of the Death Penalti; by Means of Electricity, by G. F. Macdonald, M.D., New York, 1892, D. Àppleton & (Jo.), and fully describes the appearances found in other cases : " The post-mortem examination was held four hours after death. The pupils were alike and moderately contracted. The body Avas well nourished and unusually well developed. The anterior epithelial cells of the cornea had desquamated from the central portion by the action of heat. There was a bulging forward of the sciera of the left eye at the left sclero-corneal junction. Conjunctiva anaemic. The scalp and the skin covering the neck had a dull, purplish hue. The skin of the anterior surface of the body was not discolored or ecchymosed. At the flexure of both elbows Avère a number of symmetrical linear ecchymoses, which were more marked on the right side ; also a curved, narrow ecchymotic line just be'loAv the outside of the right nipple. Thèse probably were caused by the straps. At the posterior surface of the right knee-joint, and on the posterior and inner and upper surface of the calf, the epidermis was 370 A SYSTEM OF LEGAL MEDICINE. raised, wrinkled, and folded. At the flexure of the knee-joint the epider- mis had been torn away to the extent of about an inch in diameter. The right lower extremity was fle»xeel and lient more to the médian line than its fellow. There av;is a slight discharge of thin, milky fluid from the» urethra and some still remaining in the canal. A sample of this fluid Avas taken for microse-eipical examination. Post-mortem rigieiity well marked, except in the arms, where it Avas only slight. The whole pe>steiïen' sur- face of neck, trunk, arms, and lenver extremities Avas of a dull, purplish hue. Tliere were a feAv shght blisters on both temples and both cheeks and eyelids. There Avère raised Avhitish streaks on both sidos of the nee-k, just below the angle of the jaw. The trunk Avas opene-d by a straight incision from the top of the sternum to the pubes. The fat Avas an inch thick over the abdomen. Muscles red and firm. Diaphragm at left side was found at the level of the sixth intercostal spacc, and on the right side at the fifth intercostal spae-e. Portions of small intestines were taken for microscopic al examination. Examination of heart : auricle-s and ventricles flaccid and in diastole and filled with fluid blood. The larger vessels were tied and the heart removed. The left ventricle was Ave»îl filled with fluid blood but no clots. The auricles Avère the same». The blood Avas of the same color in the left ventricle as in the right. Valves normal. On opening the vessels a large quantity of dark-colored liepiid blood escaped, half filling the pleural cavity. There were no pleural adhésions. Lungs perfectly healthy, but slightly congested. The spleen was found to be of normal size, the capsule smooth, pulp firm and uniformly filled Avith blood, and the arrangement of the Mal- pighian bodies and splenic connective tissue entirely normal. The pan- créas Avas perfectly normal and a portion reme>ved for micreiscopical ex- amination. Liver entirely m>rmal, and a portion was also removed for microse-opical examination. The gall-bladder was filled AA'ith bile. Left kidney : the capsule was non-adhereiit. It Avas rather large and the cor- tex of normal thickness. The kidney Avas uniformly injected, and the markings in the cortex Avère normal as to number anel arrangement. The right kidney was in the same condition. The stomach Avas empty, the mucous membrane pale ; the rugae were well marked and perfectly healthy. The intestines were healthy. The small intestines were filled Avith semi-fluid fa-ces. The large intestines showed the same condition. The urinary bladder was normal and half full. Examination of brain : The brain was exposed by a straight incision of scalp e>ver the vertex from ear to ear, and saw cuts through the skull at a slight angle and at the level of the eyebrows. The scalp showed several old scars, and Avas slightly less adhèrent under those portions where the électrode was attached. The skull was symmetrical. The dura mater Avas normal and the vessels moderately dilated. The longitudinal sinus was found to be normal and contained some fluid blood. The brain was remoA'ed in the usual Avay. The pia mater was uniformly thin and transparent ; the vessels in a médium state of congestion ; subpial fluid small in amount. The blood was everyAvhere fluid in the meshes of the pia mater. There Avas no apparent différence in that portion which the e\ee- trode covered. The A^essels at the base were perfectly normal. The ven- tricles contained a small amount of clear fluiei. The roof and floor of the latéral ventricles Avère normal. The ependyma was smooth and trans- parent. White substance Arm. Gray matter normal in every respect. EFFECTS OF ELECTRIC CURRENTS. 371 Floor of the fourth ventricle at the upper half contained some dilated vessels, and on the left side there Avère a number of minute, radiating petechial spots from one to twe> millimeters in diameter. The spinal cord was exposed in the usual manner. The external appearance of both e-en-d anel menibrane»s Avas entirely normal, and the vessels contained if anything, e-ve-n less blood than usual, due, probably, to the short time that had elapseel betwe-en the occurre-nce of death and the holding e>f the autopsy. Sections half an inch apart showed nothing abnormal. A portion of both se-iatic nerves Avas taken for microscopical examination. OAving to the great length of time ne-e-essary to make this autopsy as compie-tely and minutely as Avas donc, and the subséquent careful mie-niscopical examinations, it Avas not considered necessary to examine the brain and spinal cord in the other cases, espe-oially as nothing of any importance had been observed in thèse organs in this ease. The micro- scopical examinations shoAved no recognizable changes in the tissues or organs of the body.' Falls and Other Injuries.—As a resiilt of falls which follow the receipt of a shock by the victim, who may be engaged in a high place in repair- ing Avires or doing some other Aven-k, there may of course be almost any kind of other injury, which varies from simple concussion to fracture of the skull ov spine ; but thèse do not cone-ern us except so far as they are the resiilt of an initial shock, the mode of receipt of Avhich is to be determined, as well as wlie-ther the contact Avas due to the victim's care- lessness, or Avhether lie Avas mmecessarily subjected to danger through the fault of others. In NeAv York City and elsewhere there are any number of " dead " Avires, which become, by crossing, the conveyers of fatal currents, and thèse are» often responsible for such accidents. Electric Burning.—Case»s of another kind are tliose in which the electric eurrent produe-es burns of greater or less gravity. Nankevell re-ports the case of an elee-trie-light trimmer avIio received accidentally the full pressure of 2400 volts through his left hand, which held the Avire. He was rendered insensible; his legs Avère draAArn up to the trunk. This brought his full weight on the wire, which then broke and released him. He» Avas taken to the hospital and there recovered con- sciousness, and, though exe-ited, gave an account of the accident. The thumb and forefinger Avère blae-k and charred, and an eschar was perceived Avhie-h extended on the dorsum of the hand to the end of the ulna, the tract being burned to the bone. The burned parts Avère insensible, but there Avas intense», pain in parts not burned. On removal to bed four toes of the left foot were found burned on the palmar surface, each eschar being about the size of a threepenny pièce. Tliere was no mark on the boot. He1 recovered in the cemrse e)f a few Aveeks. The following fatal case of burning, which was earefully observed by Dr. Galvin at the Boston City Hospital, is cited : " Electric shock. Fall from pôle. Severe burns from electric-light Avire. Sloughing of burns, graduai failure, and death. " Peter K., nineteen, single, boni in Ireland, a lineman. Some alcohol ; dénies syphilis. At 2 p.m. on November 17, 1SS6, while on a pôle trim- ming aii electric light, Avas severe-ly burned, anel fell about twenty fëet, Has no recollection of the fall, or Ïioav he struck. Considérable shock. Well developed and nourished. Right Avrist burned superfie-ially over a space about three inches each way. Right thenar eminence burned through. 372 A SYSTEM OF LEGAL MEDLCLNE. to the muscles, and adductor pollicis laid bare over a space the size- of a quarter of a dollar. Middle finger burned to the boue over a space- about tAvo inches long, beginning at tip e>f finger, and on the back of it. Third finger burned over a space about one inch long on the back. Little finger burned the same as the third. Tavo middle tocs on right foot burned a little. Poultices to burns. Two wounds of forehead over right eye-, e-ae-h about three (juarters of an inch long, and one» of them just over the- border of the orbit. Large subeeuijune-tivaï hemorrhage in left eye. Both wounds stitehed with catgut, anel sealed up with absorbent cotton and compemnd tincture of benzoin, after being pe melereel AA'ithiodof orm. Brandy, ,rl xxv, and Magendie's solution, ÏÏL v, subcutaneously ; heaters. November 19th. On dangerous list. Poultiee has made burns much less painful. 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. Arm swelled to elboAv. To-niglit he feels miserably, and says he felt a répétition 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 list. November 25th. Has been délirions for some days. Puise anel température up. Very sick to-day, and failing fast. This afternoon Avas constantly muttering to himself. Puise getting weaker and weaker. Takes brandy, a teaspoonful at a time. Sloughs on right hand very deep anel foul-smelling. Little finger of left hand entirely dead. Died at 4.45 p.m." The burns are chiefly about the hands, and dépend in severity A'ery much upon the dry ness of the skin ; a moist skin conducting more freely, though there are e-ase-s where the eurrent is so strong and the contact so perfect under ail conditions that the inévitable resuit is a bad burn or séries of burns. Thèse are deep and do not heal quickly, are attended by sloughing, but not necessarily by much surgieal shock. Many of the burns are se-ve-re» as the victim is unable to let go or because he is entangled with wires so that the contact is prolonged. Sometimes an- aesthesia. and paralysis of the forearm or arm follows the receipt of such a shock. Médical Electricity.—Accidents in connection with the médical use of electricity are rare, and arise from the incautious application of cur- rents of high tension to the head, especially when the subject is a person of advanced âge, and when there is latent cérébral disease. The too early use of electrical currents after cérébral hemorrhage, or when in- flammation of the nei'A'ous structures is concerned, is prone to retard the cure or precipitate fresh trouble. In certain peripheral paralyses ex- cessive electrical stimulation may do much harm, but in such cases AA'hat the electrical reactions were before treatment must be determined, and the nature of the particular disease settled. Vertigo and transitory losses of consciousness hâve been observed by the writers as sequelhe of cérébral disturbance due to galvanic currents of high potentiality. Static electricity may, through a careless use of Leyden jars and con- nections, produce a shock of considérable A'iolence ; and a case is known to one of us where the transmission of a six-inch spark through the head produced a temporary unconsciousness, and great subséquent weakness. Induced currents from ordinary médical apparatus are not dangerous. EFFECTS OF ELECTRIC CURRENTS. 373 Late Légal Décisions.—Some récent medico-legal cases are cited in illustration of the issues that may arise. An interesting case is that of the tioutluvestern Telegraph and Téléphone Company vs. Robinson, 2 U. S. App. 205, in Avhich it avus decided that though the injury AA'as inflicted in a manner that the téléphone company could not prevent, they Avère liable. On the afternoon e>f Oetenber 29,1889, J. B. Robinson Avas traveling on horseback on the Dallas and McKinney HigliAvay, Texas, during a heavy thiuider-sten-m, and came in contact with one of the téléphone company's Avires, AA'hich had fallen and was suspended Avithin a feAv feet from the ground, and, the Avire being heavily charged, he was knocked from his horse and seriously injured. The jury returned a verdict for $2500, which the United States Circuit Court of Appeals for the Fifth Circuit affirmed. The téléphone company claimed that the electricity by Avhich the injury was caused was produced by the heavy thunder-storm AA'hich was raging at the time. In answer to this the court said : "If the electric fluid with which the wire of the téléphone company was charged at the time was an élément, or the main élément, in the production of the injuries to the défendant in error, still it is clear that the displaced Avire furnisheel the means of the communication of the dangerous force which resulted in the injury to him." An ordinary and clear case of negbgence is the case of Cléments vs. Louisiana Electric Light Co., 44 La. Ann. 692. Joseph Cléments, avIio AA'as a tinsmith, Avas killed on October 4,1890, by a eurrent from the wires of the Louisiana Electric Light Company, while repairing the roof of a gal- le-ry in New Orléans. The Avires were fastened to a •• house" on the gal- lery. They Avère insulated and appeared to be safe. While cleaning the gutter of the roof he came in contact with two AAÙres and was immedi- ately kille'el. After the accident the insulation on the wires Avas discovere-d to be much Avorn by exjnisure. This action was brought by the parents of Cléments for damages, and the jury awardeel them $5000. The Su- prême Ce>urt of Louisiana affirmed the judgment, holding that the de- fendants were négligent in not properly insulating the Avires, but regarded the verdict as excessiA'e, and reducad it to $2000. An important case is that of Burt vs. Douglas County Street-Railway, 83 Wis. 229, Avhere suit was brought by Burt, Avho received a shock in the manner below stated. The défense was contributory negbgence, which, heiwever, Avas not entertained. The défendants operate a street- railway in Superior City, Wis. On December 23, 1890, they ran two cars attached together. Each car was built Avith a platform at each end, guarded by a dash-board, Avith an iron handle attached. The plaintiff got upon the first of thèse cars, but, finding it cold, attempted to go to the other, AAdiere there was a fire, while the cars were moArmg, 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 properly insulated, and the elec- tricity escaped, the» handles becoming heavily charged with it, unknown to plaintiff, and Avhen lie took hold of them he received a severe shock and was badly injured, being dragged a considérable distance by the cars, because he Avas unable to loosen his hold of the handles. He brought suit against the railway company for damages and received a verdict for $1500, which the Suprême Court of Wiseonsin affirmed, holding that the company was chargeable with notice of the détective condition of their ap- 374 A SYSTEM OF LEGAL MEDICINE. paratus, and that it was not négligence for the plaintiff to pass from one car to the other Avhile in motion. In the case of the Colorado Electric Co. vs. Lubbers, 11 Colo. 505, the action was defeated on the score that the person was injured at a time when lie should not hâve been Avorking at the wires and had been so forbidden to do ; but a verdict for the défendant was reA^ersed on error. Charles Lubbers was employed by the Ceilorado Electric Company as a carpenter to assist in taking eare of its light-teiAve-rs. At 3.30 o'clex-k in the afternoon of December 17,1881, he was sent by the superintendent to remove a lamp and connect the Avires with the circuit. The usual time for turning on the eurrent at that time was from 4.30 to 4.45 o'cle>ck. This was outside of his duties and he was not experienced in the Avork. While Connecting the wires after removing the lamp the eurrent was turned on and he was shocked and thrown to the ground and seriously injured. Lubbers sued the company for damages and received a ver- dict. On appeal the Suprême Court of Colorado held that the question of contributory négligence, which was the only défense urged, was a matter of fact for the jury. But the Trial Court admitted, under objec- tion, évidence that after the accident the company put up notices in its Avorks warning ail employées to quit work at four o'clock and not to con- tinue without notifying the office»rs. The court held that this was error, and on this ground reversed the judgment. A case resembling the last, in the question of the élément of time, was that of Kraatz vs. Brush Electric Light Co., 82 Mich. 457. This was an action for damages caused by négligence brought by Almeron Kraatz against the Brush Electric Light Company, by whom he was employed as a trimmer. On August 19, 1886, at nine o'clock in the morning, he was trimming lamps on an electric tower in Détroit, Avhen he received a shock and was seriously injured by the contact of a day-wire which Avas in opération Avith the wire upon which he was working, which was " dead " at the time. There was a verdict for the plaintiff, which was affirmed by the Suprême Court, reciting the above facts. One of the grounds of défense was that the injuries had been caused by a stroke of paralysis, but this being a matter for the jury the court refused to go into it, the jury having decided the question. The défense of trespassing was made in the case of Sullivan vs. Boston A A. R. R. Co., 156 Mass. 378. Daniel Sullivan and another boy were playing bail near a coal-shed of the défendant, on Lehigh Street, Boston. The bail was batted and fell on the coal-shed, and Sullivan went up and recovered the bail. He then came into contact with two naked copper wires on the roof, which were used by the défendant to conduct electricity, and received injuries resulting in his death. Charles Sullivan, as ad- ministrator, then brought this action against the railroad company for damages for his death, and on the trial the court ordered judgment for the défendant. The Suprême Judicial Court of Massachusetts, on appeal, affirmed the judgment on the ground that the wire was a lawful a.ppa- ratus, and not a trap, and that décèdent, if not a trespasser, was only a licensee, and that therefore the company Avas not liable. A case in which the injured man was hurt by the wires 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 défense of très- EFFECTS OF ELECTRIC CURRENTS. 375 passing Avas advanced. Andrews was employed by a téléphone company in Augusta, Ga., to put up wires. On the same pôles on which thèse were to be placed were wires of the Augusta Fire Department and the Augusta Raihvay Company. While» attempting to place the telephone- Avireï over the fire-alarm wire he recehreel a shock which threw him to the ground anel seriously in jurée! him. He brought suit against the railway company for damages, charging negligene-e» in the opération of their " feed- Avire " in alloAving it to come into contact with the fire-alarm wire at the intersection e)f twe) streets, anel that the contact of the two wires produe-ed the (uirrent which causée! his injuries. The A'erdict was for the plaintiff, but on appeal the Suprême Court of Ge-en-gia reversed the judgment, holding that the railroad company Avas under no duty to protect him, that lie had not been grante-el permission to climb the pôles and thus became a trespasser, and that therefore lie could not recover. In the case of Ri ed m ont Electric Illuminating Co. vs. Patteson''s Admiuist. the issue» dependeel upon détective apparatus provided by the défendant. Miles Patteson, a negro, about thirty years of âge, uneducated, but noted as a cautions man, had been in the emph)y of the illuminating company as a elay-trimmer e)f street electric lights in Lynchburg for about four months at intervais. About eight o'clock on the night of Mardi 23, 1SS6, it was discovered that one of the circuits was open, and Patteson anel several others Avère» sent out to repair the trouble, each taking with him a •* shunt " cord or switch. The shunt cord which Patteson took was visibly détective and absolutely Ave>rthlcss. Soon after they started to work the broken line lit up Avith a flash, and Patteson was discovered ban gin g at the top of a lamp-pole deael. He had founil the break, anel in trying to turn on the eurrent grasped the shunt cord at its détective end with one hand and put his other on a lh'e Avire. His two hanels were seve-rely burned and the insulation of his shunt cord was burned off at both ends, one end being entirely broken off, showing that his death was cause^d by the eurrent passing through his body by reason of the détective shunt cord while fixing the lamp. The company proved that Patteson had received erroneous instructions from another negro, under whom lie had been placed when he entered their employ, as to the disadvantage of the shunt cord ; also that the circuit coule! hâve been tested Avithout turning on the eurrent. Patteson's Avidow, as administratrix, brought suit against the e-ompany for damages for his death, and the jury ren- dered a A'erdict for $3000, which, on appeal, the Suprême Court of Appeals of Virginia reversed, saying: "The plaintiffs own testimony f ails to prove négligence on the part of the défendant company unmixed by the concurring cooperating négligence of the décèdent, but for which the accident e-ould not hâve occurred." A négligence case where damages were obtained for the loss of a horse is that of the Electric Railway Co. vs. Shelton, 89 Tenn. 423. This Avas an action by C. F. Shelton against the Union Electric Railway Company and the Cumberland Téléphone and Telegraph Company for damages. During a fire the Avall of the burning building fell and broke a pôle of the telegraph company, which in faïling broke the wires at se'Aeral points ; one of thèse Avires fell across the trolley-wire of the rail- Avay company, and while resting on it Shelton's horse came in contact with it and Avas killed. The trolley-wire was not guarded. The Circuit 376 A SYSTEM OF LEGAL MEDICINE. Court gave judgment for plaintiff, which was affirmed by the Suprême Court of Tennessee, who held that both companies were négligent in not properly protecting their wires from contact in case the telephone- Avire fell. BIBLIOGRAPHY J. H. Knapp, "Arch. f. path. Anat,," vol. xv., p. 378. Strickcr, ''Arch. fiir path. Anat.," vol. xx., p. 45. Sesticr, "De la Foudre," etc. Paris. Morgan, "Electrotherapeutics." New York. Bornes, "Med. Times aud Gazette," January 20th. Richardsou, "Med. Times and Gazette," May 15th, June 5th, August 14thr Charcot, "Leçons du Mardi," vol. xi., No. 19. Clowes, "London Lancet," vol. ii. Gartner, " Medizinische Jahrbiicher," p. 519. Joli y, " Untersuchungen iiber den elektrischen Leitungswiderstand des mens. Kôrp." Ktrassburg. Grange, "Annales d'Hygiène," etc., January and April. Shcilil and Dclcpinc, "British Médical Journal," March 14th. Hummcl, "Philadelphia Médical Bulletin," April. Buchanan, "London Lancet," February 13th. Robert, "St. Louis Courier of Medicine," November. Moycr, "Chicago Médical Journal and Examiner," November. DÀrsonral, "Comptes Rendus," etc., 8th séries, tome iv., p. 95. Tcrry, "No. Am. Jour, of Homeopathy," December. Brown, " The Comparative Danger to Life of the Alternating and Con- tinuous Currents." "Occidental Med. Times," October, p. 562. Petersen, "New York Med. Record," November 2d. Brown, "Novtli American Review," November. Petersen, " Report of Committee of New York Medico-Legal Society." Edison, " North American Review," November. Westingliousc, "North American Review," December. Dana, " New York Médical Record," November 2d. ISiggs, "New York Médical Record," November 2d. Tain m, " New York Médical Journal," February 22d. " Boston Médical and Surgieal Journal," vol. cxxv., p. 270. 30) '• Medico-Legal Journal." Knapp, " Accidents from the Electrical Current." ""Boston Med. and Surgieal Journal," April 17th and 24th. Collins, " New York Med. Journal," p. 664. 33) White, A.. "Monoplegia from Passage of Electric Current." "Univ. M. Mag.," Philadelphia, vol. iv., p. 822. Nankcrillc, "Br. Med. Journal," vol. ii. Clowes, H. A., "Death from Electricity." -"Lancet," vol. ii. Birand, Francis, "La Mort et les Accidents Causé par les Courants Élec- triques de Haute Tension." Lyon, p. 80. 37) Crossland, J. C, "Death by Electricity; Post-Mortem Findings." "Columbus M. J.," vol. xi., pp. 204-207. Brown, J. W., « The Latest Electrocution." "Med. Record," New York, vol. xliv., p. 222. ACCIDENT CASES. BY LAWRENCE GODKIN, Esq. The term " accident cases " is the colloquial légal expression for actions brought to recover damages for personal injuries Avhich it is claimed Avère the resuit of the defendant's négligence. The greater number of thèse actions are brought against coinmon-carrier corporations or the owners or occupants of premises upon Avhich the ace-ident occurred. When 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 persemal inju- ries resulting from alh-ged négligence, and that in almost ail such ac- tions one or more médical experts are called to testify in regard to the plaintiffs injuries, it is appaivnt what an important part médical testiniemy must play in this large field of litigation. Médical experts in thèse e-ases are generally called to testify as to the probable effect of Avemnels and injuries in respect to their duration, extent, and resiilt upon the gênerai health or e-apae-ity for mental or physieal work, of the injured person; and in some jurisdictions the services of the ex- perts may be called upon, by légal proe-edure, before the trial. One of the meixt interesting questions Avhich this class of cases has created lias had public attention reeently directed to it by the passage of a statute of the State of Ne»AV York (L. 1893, chap. 721) pre>viding that in an action for personal injuries the court may, aud in certain cases must, grant an orele-r compelling the plaintiff to submit, before trial, to a physieal ex- amination by one or more physicians or surgeons. It is left to the dis- crétion of the court Avhether or not to grant such an examination, unless the défendant shall présent fe> the court satisfactory eA'idence -'that lie is ignorant of the nature and extent of the injuries complained of." This statute has cenne up for construction seAreral times during the past year aud has been the cause of much discussion ; aud in a récent case in Avhich a female infant sued the Manhattan Elevated Raihvay in the City of New York, and an order was obtained for her examination by a physi- cian before trial, the statute was sharply attacked as an unconstitutional invasion of personal rights and the sanctity of the person, and was an- imaelverteel upon bythe court; but its constitutionality has been thus far uphelel. According te) the procédure under the New York statute the physician asks questions of the plaintiff, makes a physieal examination, and reports his e-onclusion in Avriting. This report is filed and may be useel by either party on the trial. It certainly seems as if this statute Avould 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 A SYSTEM OF LEGAL MEDICINE. But the right to such an examination has been held by the Suprême ( 'eiurt of the United States not to exist at common laAV, and Mr. Justice Cray, in his opinion in the case of the Union Pacific Raihvay Co. vs. Ilots fard, 141 U. S. 250, says : " The inviolability of the person is as much invaded by a compulsory stripping and exposure as by a bloAV. To ceunpel any one, and especially a Avennau, to lay bare the body, or to submit it to the toue-h e>f a stranger, Avithout hiAvful authority, is an indignity, an assault, and a trespass." The rule Avas the same in Ncav York previous to the passage of the statute above» mentioned.* But in the States of Iowa, Ohio, Kansas, Wiseonsin, Minnesota., Nebraska, Missouri, Arkansas, Texas, Geen-gia, and Alabama it has been the practie'e of the court to grant or- ders cennpelling the plaintiff to submit to a physieal examination before trial. It is probable that in those State»s the plaintiff would also be com- pelled te) submit to a physieal examination at the trial. But in Ncav York, even since the passage of the act of 1893 before alluded te), such an examination cannot be eompe»lleel at the trial. The plaintiff may be reque-stcel to submit te» such an examination, and if he refuse his refusai may be considered by the jury as bearing on his good faith, but he can- not be compelled to undergo it. In the Union Pacific Raihvay case before cited Justices BreAver and Brown dissented vigorously from the e-onclu- sion reae-lied by the majority of the court, and enunciated by Justice Cray, and saiel : u It seems strange that a plaintiff may, in the présence of a jury, be permitted to roll up his sleeve and diselose on his arm a wounel of which he testifies ; but Avhen he testifies as te) the existence of such a Avound the court, though persuadée! 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 arm to the inspection of surgeons. It is said that there is a sanctity of the person Avhich may ne>t be outraged. We believe that truth and justice are more sacred than any personal considération ; and if in other cases, in the interests of justice or from considérations of merey, the courts may, as they often do, require such personal examination, Avhy should they not exercise the same poAver in cases like this, to preA'ent wrong and injustice?" An analogy to the case of compelling an examination of the person of the plaintiff in actions for personal injuries is te> be found in the law of divorce. In actions for a divorce 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, AA'here the évi- dence is necessary, and can be obtained in no e>the»r way, for the court to order an inspection of the person by médical experts. The same ob- jections hâve been urged in divorce cases to such inspections as hâve been urged to an examination in actions for damages for personal inju- ries, anel as far as the A-iolation of the sanctity of the person is concerned the objection to an examination in divorce cases is more weighty, for the reason that the intrusion and violation of the subject's modesty are greater. But the necessity, it may be said, is also greater. " It has been said," remarked Lord StoAvell, " that thèse modes resorted to for proof on thèse occasions are offensive to natural modesty. But nature has pro- * McQuigan vs. D., L. j- W. R. R. Co., 129 N. Y. 50. ACCIDENT CASES. 379 vided no other means ; anel Ave must be under the necessity of saying that ail relief is denied e>r of applying the means within oui* power. The court must not sacrifice justice to notions of its oavu." * Even in a case where a husband sued for divorce on the ground of the physieal incapacity of lus wife, and his bill Avas taken for confessed, that is to say, the Avife.» interposed no défense, Chancellor Walworth of New York ordered an examination of the défendant by surgeons anel matrons, and a report to the court. And that learneel jurist, in discussing the application, said : " Investigations of the kind are always indélicate, anel the mode of proof to Avhich resort must of necessity be had must frequently be very distressing to the feelings of parties. This court, he> we ver, is not at liberty to elee'line jurisdiction in such a case, but must proceed to the examination and décision thereof in the mauner required by law, if the injured party thinks proper to insist upon his légal rights." t In many actions for personal injuries the plaintiff greatly exaggerates his injuries, even if he does not pe»rjure himself about them, and a médi- cal examination, conducteel under proper safeguards and restrictions, would seem a wise check upon the te»inptation to such exaggerations or perjuries. And in connection Avith the natural anxiety of the plaintiff to make his condition ont as bael as possible, a story is told of an action for personal injuries in the New York courts, in AA'hich the plaintiff tes- tified that his right arm had been so injured that he was unable to raise it any longer to a horizontal peisition. Upon cross-examination the de- fendant's counsel asked him to inelie-ate Iioav high lie could now raise his arm. •• Only so high," replie»d the witness, lifting his arm with apparent difficulty a few inches from his side. " And how high could you raise it before this uiifortunate occurrence f " said the laAvyer suddenly. " So high," replied the witness, raising this same injured arm above his head with ease. When it cornes to the actual trial of actions for personal injuries there are two difficult questions, to the solution of AA'hich the testimony of the médical expert may be directed. One of thèse is Iioav far the defendant's négligence is responsible for some subsequently deAreloped infirmity or disease, or, in other Avords, hoAv far a given injury may be said to be the natural and proximate cause of a subsequently developed condition, and therefore reuder the défendant liable for that condition. The gênerai rule is easily stated—to AA'it, if the subséquent disease or infirmity is one Avliich would occur as the natural resiilt of the injury, and it is not shown that any other independent cause existed of which it might hâve been the resiilt, then the author of the original injury is liable for the subsé- quent disease or infirmity. But, like ail gênerai rules of Liav, the difficulty of this rule lies in applying it to particular states of facts. Some illustra- tions majr be useful. The question has freepiently arisen where, in the case of Avomen, it is claimed that a miscarriage is the ultimate resuit of the shock of an accident, though not of any direct physieal injury. A pregnant Avoman was driving with her brother o\rer a détective 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 * Briggs vs. Morgan, 3 Phillim, 325. f Devanbagh vs. Dcranbagh, 5 Paige, 554. 380 J SYSTEM OF LEGAL MEDICINE. jury to say whether the accident was the natural and proximate cause of the miscarriage* And so where a raihvay train Avas backed off the rails through a fence and into the plaintiffs porch—she being upstairs in the house at the time—and tAvo days later she had a miscarriage, it was held that it was proper to leave it te') the jury to say Avhether there was a suf- ficient proximate connection betAveen the accident and the miscarriage to warrant a recovery.t Thèse cases are also illustrations of the rule that it is not necessary, to warrant a recovery, that the disease or infirmity should hâve been the resiilt of actual physieal contact Avith the médium of the négligence. But an instance in which it was sought to carry this liability for miscarriage a little too far is to be found in a case in Illinois, where the defendantNvent to his neighbor's house and used violent, threatening, and abusive language to the plaintiff's husband in the hear- ing, but not in sight, of the plaintiff, as a resiilt of whieh, through fright, the plaintiff had a miscarriage. The court very properly, it would seem, held that the injury in epiestion, not being one AA'hich the défendant could reasonably be expected te) anticipate as likely to ensue from his e-onduct, could not, therefore, be regarded as the natural conséquence thereof, for which the» défendant could be» held responsible. In a case in Avhich a boy sued the city of Ripon, Wis., for damages for falling on a détective sideAvalk and injuring his arm it Avas shown that the ultimate resiilt to the arm Avas that the humérus Avas in a necrosed condition nearly its Avhole length, and that there was a running sore on the arm. It Avas also sIioaaui that the boy Avas scrofulous, and it AA'as con- tended for tlie défense that the damage to the arm was principally the resuit of the plaintiff's condition at the time of the accident, and that the defendant's négligence Avas not, therefore, the proximate cause of the whole injury for AA'hich the plaintiff recovered. The court, liOAveA'er, held in effect that the sidewalks of a city are for the use of the scrofulous as Avell as the sound, anel that if a sick person falls on a defecthe sideAvalk so much the worse for the city, and upheld the plaintiff's contention that the négligence of the défendant Avas the proximate cause of the AA'hole in- jury for which the plaintiff recovered damages.t The other difficult question, which is, in a sensé, the corn-erse of the foregoing, is how far the defendant's négligence is responsible for an existing condition where a disease or injury existed previous to the négligence complained of, and is claimed to hâve been aggravated by that négligence. For instance, the fact that a person suffering injuries from the négligence of a railroad company is afflicted Avith a disease of which he must ultimately die, Avili not relieve the railroad company of responsibility for injuries AA'hich hasten his death.§ Anel the fact that a person was suffering from Bright's disease at the time he was injured does not prevent his recovery, although the injury was aggravated by the disease.|| And if the plaintiff hael a tendeney or prédisposition to can- cer this will not reheve the défendant from liability for a cancer which develops as the resuit of an injury.|f So a person predisposed to mala- * Oliver vs. Town of Lavalle, 36 "Wis. 592. t Chicago <}• Northwestern Ry. Co. vs. Hunerbcrg, 16 Bradwell, 387. t Stewartvs. City of Ripon, 38 Wis. 5S4. § Louisville meuts AA'hich the jury may consider in determining the amount of damages are the impaired capae-ity of the plaintiff to earn money, the cost of his cure, and his physieal and mental pain anel suffer- ing. In ail thèse matters the testimony of physicians may be material. In estimating the loss of earning poAver, just as in determining how far the elefendant's négligence is responsible for suliseepiently developed in- firmity, the rules of common sensé must be applied, and the decrease iu earning penver for whieh there may be a recovery must be such as is reasonabîy certain to residt from the injury in ordinary course of nature, and not such as may be the possible conséquence of the injury. In a leading case in NeAv York, Dr. Spitzka, who had examined the plaintiff, who was a boy who had been injured in a railway accident, Avas asked as to the permaneney of this condition of the plaintiff, and he answered that it was very likely to be permanent. He also stated that the plaintiff was liable to retain the greater part of the symptoms which he had, if he did not develop worse signs. He Avas then asked Avhat lie referred to by his statement that the boy's condition might develop into worse signs or con- ditions, and he answered, " A patient sustaining such injuries and pre- senting such premonitory signs may develop traumatic insanity or men- ingitis or progressive dementia or epilepsy, Avith its results." The question Avas objectée! to as spéculative and hypothe-tical, but was allowed, and the Court of Appeals, in reversing the judgment and ordering a new trial, said: "The door AA'as opened for the jury, in estimating the damages, to include compensation for the mère hazard to AA'hich the plaintiff Avas claimeel to be exposed of being afflicted AAith the terrible disorders, or some of them, enumerated in the ansAver," and " to entitle a plaintiff to * Stover vs. Bluehill, 51 Me. 442. ACCIDENT CASES. 383 recover présent damages for apprehended future conséquences there must be such a degree of probability of their occurring as amounts to a reason- able certainty that they will resuit from the original injury."* There is an English case, illustrating some of the rules of law by Avhich the jury are to be guidée! in deciding upon the amount of damages for personal injuries, which may hâve a peculiar interest to members of the médical profession, owing to the fact that the plaintiff Avas himself an eminent London physician. To lawyers the case is of importance because it is a leading English case on the subject, and was twiee tried before a jury and tAvice appealed, and the principles involved were A'ery thoroughly discussed by the appellate courts. The plaintiff, Dr. Phillips, was an eminent London physician of middle âge 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 Cockburn put it, Avas 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 médical at- tenelance to still more, and the latter was likely to be for a long time necessary. He had already lost his income for the period of sixteen months which hael elapsed between the time of the accident and the trial. On the first trial the jury gave him £7000 damages. The Court of Queen's Bench reversed the judgment and ordered a new trial on the ground of the insufficiency of the verdict, and this reversai Avas affirmed by the Court of Appeal. Lord Cockburn said : " But Ave think that a jury cannot be said to take a reasonable view of the case unless they consider and take into account ail the heaels of damage in respect of which a plaintiff complaining of a personal injury is entitle-d to compensation. Thèse are the bodily injury sustained; the pain uudergone ; the effect on the health of the sufferer, according to its degrees and its probable duration as Hkely to be temporary or permanent ; the e-xpenses incidental to attempts te) 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 eharaeter or may be such as te> incapacitate the party for the remain der of his life. If a jury hâve taken ail thèse éléments of damage into con- sidération, and hâve awarded what they deemed to be fair and reasonable compensation under ail 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 présent case it seems to us that the jury must bave omitted te> take into account some of the heads of damage which Avère properly involved in the plaintiff's claim." t On the second trial, before Lord Chief-Justice Coleridge, the jury found a verdict for £16,000. This time the défendant appealed and the case again went to the Court of Appeal, but the judgment was affirmed. On the secenid appeal, in discussing the évidence 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 défendants that * Strohm vs. N. Y., L. E. # W. R. R. Co., 96 N. Y. 305. t Phillips vs. Southwestern Ry. Co., 4 Q. B. D. 406. 381 A SYSTEM OF LEGAL MEDICINE. the amount of the income at the time of the aceiele»nt ought not te> be taken into acceumt. This suggestion seems to me to be erroneous. . . . If no accident had happened, nevertheless many cire-unistanees might hâve happened te> preA'ent the plaintiff from earning his professional income. lie- may be disabled by illness, lie is subject to the ordinary ae-e-ielents and vicissitueles of life, and if ail those circumstances of Avhich no évidence can be given are looked at it Avould be impeissible to exactly estimate them. Yet if the jury Avholly pass etver them they AA'ill go AA'rong, because those accidents and vie-issitudes 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 ahvays recover the cost of médical attention, nursing, and ail ordinary and reasonable expenses which he has incurred by reason of his sickness, and it lias been held to be no défense to a recovery for money paid to a nurse that the plaintiff had a family capable of taking eare of him. This last défense in thèse days of trained nursing strikes one as being a little strained, and eAÙdently struck the court so* It has even been held that a plaintiff may recover the value of médical services gratuitously rendered, the reason being that thèse seiwiees were rendered for the benefit of the plaintiff and not for the benefit of the défendant, and the défendant should not, therefore, be alloAveel to profit by them. In one of the cases in which this rule was eniinciated the plaintiff was a physician, and it was sought to prove that it Avas a uni versai custom among physicians and surgeons not to charge members of the profession for services rendered, but the e\ddence was held inadmissible as immate- rial.t The term "médical services and expenses" does not merely in- clude doctors' bills, medicines, and nursing, but covers also reasonable, necessary, and judicious trips to health-resorts ; as, for instance, Avhere a person injured in a raihvay accident went to the Electric Wells in Geor- gia and the G-lenn's Springs in South Carolina for treatme-nt, he Avas alloAved to prove the expense of thèse trips as part of his e-laim.f But where a parent sues for the loss of serrées of a child as the resuit of an accident, lie can recover as expenses for médical 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. City of Albia, Iowa Suprême Court, October 27, 1887. t Citii of Indianapolis vs. Gaston, 58 Ind. 224. t Hart vs. Charlotte R. Co., 32 S. C. 427. § Jones vs. Chamberlain, 109 N. Y. 100. MENTAL DISTBESS AS AN ELEMENT OF DAMAGE IN CASES TO EECOVER FOR PERSONAL INJURIES. By JOHN E. PARSONS, Esq. It is common expérience that anguish of mind, lacération of feeling, a sensé of shame, of indignation, or of humiliation, anxiety, distress of a sentimental eharaeter, are often more difficult to bear than bodily hurt. Where such injury has been occasiemed by the fault of another, the ques- tion arises whether in every case the hiAv affords redress. The maxim of the law is that for every Avrong there is a sufficient remedy. Does tins maxim hold true in ail e'ases of the eharaeter referred to? The gênerai principle is well established that in actions of tort, where for the Avrong there is a right to recover damages, mental distress may be taken into considération in fixing the amount. But the Aveight of authority seems te) e»stablish that when the injury consists in distre»ss of mind alone, or Avhere the mental distress is separate from and independent of the Avrong, it does not constitute an clément of damage and may not be considered in determining the amount of a recovery. In support of the gênerai proposition, Mclntyre vs. Giblin, 131 U. S. 174, is a récent authority. This Avas a suit to recover damages for the careless shooting and Avounding of Giblin by Melntyre. On the trial the court charged the jury that in Computing the damages they might take into considération "a, fair compensation for the» physieal and mental suf- fering caused by the injury." The United States Suprême Court, Chief- Justice Waite ele»livering the opinion, held that there AA'as no error in permitting a recovery for mental suffering. The court said that the effect of the instruction was no more than to alloAv the jury to give com- pensation for the personal suffering of the plaintiff caused by the injury. 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 refusai to pay his fare a second time, that the injury to his feelings might be taken into considération by the jury and a suitable récompense given therefor. In Hamilton vs. Eno, 81 N. Y. 116, the same court affirmed the décision of the» General Term of the Suprême Court (Hamilton vs. Eno, 16 Hun, 599), heilding in an action for libel that, in a case where damage had been she mm, injuiy to feelings might be treated as a proper subject for con- sidération. Other illustrations of the gênerai rule will be found in cases decided 385 386 A SYSTEM OF LEGAL MEDICINE. bv the English courts and bv the courts e>f many of the States. Thus in Blake vs. Midland Railway '('o., 18 Q. B. 93, Coleridge, J., said: <■ When an action is brought by an individual for a personal wrong, the» jury, in assessing the damages,*can Avith little difficulty award him a solatium fe»r his mental sufferings alone, with au indemnity for his pecuniary loss." Godeau vs. Blood, 52 Vt. 251, was a case where a child Avas bit ten by a vicious dog. Redfield, J., said that the appréhension of poison from the bite of the dog, and the fear and solicitude as to evil results therefrom, were proper matters for considération by the jury in estimating the dam- ages. In Heddles vs. Railway Co., 77 Wis. 228, it appeared that one of the defendant's engines ran over a boy and crushe»d be>th his legs. It Avas held on appeal that damages might be awarded for the "mortifica- tion and anguish of mind wliich he bas suffered anel will suffer in the future by reason of the mutilation of his body and the fact that lie may become an object of curiosity anel ridicule among his felloAvs." Seger vs. Town of Barhhamstead, 22 Conn. 290; Shenvood 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 employée e>f the défend- ant, fell several stories and Avas killed. TÏie fall Avas due te» a détective floor. When lie struck the ground he became unconscious and remained so until death. This action Avas brought by his administratrix. At nisi prius the mental sufferings of the deceased during the fall Avère allenveel as an élément of damage. Morton, J., on appeal, said : " It may be true, as an abstraet proposition of laAV, that if a man is precipitated from a height by the négligence of another, and is injured, lie may recover, as one élément of his damages, for any mental suffering lie ma)' prove he endured during his fall." Damages were refused simply because, Ken- nedy having remained unconscious till death, tliere was no way of prov- ing mental suffering. The cases ail 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 injury to person or ehar- aeter. Some go to an extrême length iu permitting a recovery where it is wounded feeling, mortification, indignity, or a sensé of humiliât!em in AA'hich consists substantially the entire injury. Thus in Craher vs. Rail- way Co., 36 Wis. 657, it was held that a female passenger on a raihvay- train could recover for the sensé of shame and personal affront Avhich accompanied the act of the coneluctor of the train in placing his arm around her against her protest, and kissing her. Obviously 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 Avhich courts hâve 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», 415, and Railway Co. vs. Williams, 55 111. 185, Avère suits brought by female colored passengers avIio Avère not permitted to sit in cars reserved for ladies. In the first case the Suprême 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 app*»al that a verdict of $200 was not excesshe, Scott, J., saying: "We appre- hend that if the act is AA*rongfully and wantonly committed the party MENTAL DISTRESS. 3S7 may îveoA'er, in addition to the actual damages, something for the indig- nity, ve'xation, anel disgrâce to Avhich the party has been subjecteel." In Anonymous, Milieu- (Ala.), 52, it appeared that one broke into the heiuse e)f anothe'i- Avithout a warrant, under prêteuse- e)f searching for stolen money. The cenirt said: "He [plaintiff] may bave sustained no pecuniary h>ss, but the injury fixes on him the eye of public suspiciem, inflicts a rankling Ave>und on his feelings, anel tends to prostrate his eharaeter.'' It was helel that for sudi injury to his feelings the plaintiff might rce-over. In Cumming vs. Inhabitants of Williamsburg, 1 Cushing, 451, Mete-alf, J., said: "Though that beidily injury may bave been A'ery small, yet if it Avas a ground of ae-tion Avithin the statute, anel caused mental suffering te> the plaintiff, that suffering Avas a part of the injury for Avhich lie Avas e-ntitled to damages." (Yide,slso, Curtis vs. Railway Co., Suprême Court of loAA'a (1893), 54 NorthAvestern Reporter, 339 ; Will- sou vs. Railroad Co., 5 Wasli. 621 (1893) ; Chicago, etc., R. R. Co. vs. Con- hy, 6 Indiana Appe'llate Court Reports, 9 (1892) ; Shepard vs. Raihvay Co.. 77 Iowa, 54 (1SS9) ; The Lake Erie, etc., Raihvay Co. vs. Fix, 88 Ind. 381 (1882) ; Chicago, etc., R. R. Co. vs. Flagg, 43 111. 364 (1867).) What remains te) consieler is the right to recover for mère mental elistress conseepient upem the négligence en* misconduct of another. Upon tins subject an interesting and instructive case is Lynch vs. Kniejht, 9 H. of L. Cas. 598. The case came to the House of Leirds from the Irish Cenirt of lAcheque-r Chamber. It was heard just before the death of Lord Campbell. He left a written décision which, Avith comments by Avay of ])artial dissent, Avas read by bis successor, Lord Brougham. The ele-fendant had impugne-el the e-hastity of the plaintiff's wife in terms Avhieh av<»iv not actionable per se. The husband sued in his own right, joining his wife, anel ree-.oA'ered £150 for the deprhation of lier society, lie having sent her home te> lier parents in conséquence of the imputation upon her conduct. Ail the judges agreed, there being no évidence of spécial damage», that a recovery for mental suffering could not be sus- taine»d. H y ait vs. Adams, 16 Mich. 180, is te) the same effee-t. The action AA'as bremght te> receler damages sustalne-d by the plaintiff b}^ reaseni of malpractice resulting in the» death of his Avife. The plaintiff claimed damages for his mental agony on ae-count of his Avife's sufferings for the three days prior to her death. Christianey, J., in overruling the charge of the judge beh)AV, speaks e)f "the propriety and good sensé of the rule Avhich restrie-ts the right of action for mental suffering to the person Avho lias receiveel the physie-al injury." Counell vs. Western Union Telegraph Co., 116 Mo. 34, deals Avith the gênerai subject in a very able Avay. The case was elaborateby dise-ussed, ail the le»ading authorities upon the sub- ject being referred to. The actiem Avas te> recover damages for the négli- gence of the défendant in failing to deliver to the plaintiff the following télégraphie message sent to him by his wife : " Sedalia, Mo., December 13,1889. To Matt. Connell, Soldiers' Home, Leavenworth, Kansas. Your chilel is dying. Mary." The chilel died on December 24, 1889. The plaintiff, claiming that the elefendant had negligently failed to deliver the message, and that in cemsequence he had been unable to attend the funeral of his child, brought suit to recover among e>ther things for the mental anguish and prostra- tion Avhiem lie had suffered. The court helel that lie could not ree-ove-r, the mental distivss not having attended upon or been accompanied by 388 A SYSTEM OF LEGAL MEDICINE. physieal injure. The same principle AA'as dee-ided in Wilcox vs. Richmond A D. R. Co., 52 Fédéral Reporter, 264. The complaint alleged that the plaintiff, being informed by telegraph of the dangerous illness of his father, engaged défendant to convey him to Ce.lumbia, S. C, Avhere bis father Avas, in a fixée! finie, paying t'en* the service $195. The plaintiff charged that the défendant refused to perforai its agreement, and that as a conséquence he suffered great distress of mind, anxiety, mortifica- tion, anel suspense, for which lie 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 Circuit Court of the United States for the District of South Caroliua, Cliie4:'-Justice Fuller sitting with the Circuit Juelge and District Juelge, affirmed a décision by which it Avas held, on the authority of Lynch vs. Knight, that for mental pain alone, unatteiided by injure "to the person, caused by simple négligence, an action could not be sustaineel. Victoria Railway Commission vs. Conltas, L. R,, 13 App. Cas. 222 (1888), privy council on appe»al from Suprême Court of Yie-toiïa, is a récent case»" A female cre>ssing a railroad track in a Avagon just ese-aped being dashed into by a passing train, in consequene-e of the negligene-e of an employée. She received a severe nervous shock from fright, and the con- seepience of the fright Avas an attack of illness. On appeal it was held that for this she» could not recover, the damages being too remote. Sir Rie-hard Cerne-h, in delivering the opinion of the court, said : " Damages arising from mère sudden terror unacconipaiiiëd by any actual physieal injury, but occasioning a iier\'Oiis e>r mental shock, cannot under such circumstances, their lordships think, be cemsidered a conséquence which in the ordinary course of things Avould Aoav from the négligence of the gate-keeper." To the same effee-t are Ewing vs. Railway Co., 147 Pa. St., 40; City of Satina vs. Trosper, 27 Kan. 544; Wyman vs. Leavitt, 71 Me». 227. In Railroad Co. vs. Stables, 62 111. 313, it appeared that Stables, AA'hile crossing a railroad track, Avas struck by a passing train. His Avagon Avas broken and lie was severely injured. The court held that for his mental sufferings Stables coule! ree-over, saying.- " The mental anguish whieh Avouhl not be proper to be considered is where it is not connected with the bodily injury, but Avas caused by some mental con- ception not arising freun the physieal injury." It is proper to state that although the cases cited and others seem to settle the rule that for mère mental distress there can be no recovery, their authority bas not gone unquestioned. In Bell vs. The Great Xorih- ern Railway Co., 26 L. R., Ireland, 428 (1890), the court expressly refused to follow Victoria Raihvay Commission vs. Coultas. The plaintiff was put in great fright by the anticipation of a collision. She suffered from nervous shock and ill health in conséquence. She sustained no bodily injury. It Avas held on appeal that, since the fright was the direct consé- quence of the occurrence and the plaintiff's ill health the conséquence of the fright, damages might be recovered for impairment of health. And in some of the States it bas been stoutly maintained that there - might be a rece)A'ery for nervous shock or mental distress where there was no bodily or pecuniary loss. Haie vs. Bonner, 82 Tex. 33, was such a case. The plaintiff sued to recover damages for breach of contract on the part of the défendant in failing to elelher promptly the body of her deceased husband. The contract Avas for carnage from San Antonio to MENTAL DISTRESS. 389 Jefferson. _ When the train arrived at Jefferson, where many friends Aveu-e Avaiting to ae-company the body home, it AA'as not on board, to plaint- iff's great distress of mind. When the body did arriAe» it Avas in an advanced stage of décomposition, which caused the plaintiff additional pain of mind. A demurrer Avas sustained in the court below. On appeal the judgment entered on the demurrer was reversed. Western Union Telegraph Co. vs. Xewhouse, 6 Indiana Appellate Court Reports, 422 (1892), is a. e-ase in AA'hich a plaintiff was permitted to recover because» lie faileel to see his mother before her death in conséquence of the failure of the défendant to deliver a telegram. Womack vs. The Western Union Tele- graph Co., 22 SoutliAvestern Reporter, 417 (1893), Court of Civil Appeals of Texas, is to the same effect. Thèse anel numerous other cases are reA'ieAved with great ability by Garnit, P. J., in Connellvs. Western Union Telegraph Ce, previously cited. He said : " We are fully aware that the plaintiff's claim appeals strongly to the sensibilities ; but to adopt that view Ave must either be guilty of adopting one rule of damages for one class of common carriers, and the breach of their contract, or we must conclude that ail of oui* predecessors in the great common-law courts were at fault, and henceforth repudiate not only their utterances but our own on this subject, and this we hâve no inclination to do. We prêter to travel yet aAvliile super autiquas vias. If, in the évolution of society and. the laAAr, this innovation sliemld be eleeine'd nee-essary, the législature can be safely trustée! to intrexlue-e it, AA-ith tliose limitations and safeguards which wiïl be absolutely necessary, judging from the variety of cases that hâve sprung up since the promul- gation of the Texas e-ase." This may be accepted as an accurate statement of the présent state oî the law upon the subject. FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. BY PHILIP COOMBS KNAPP, A.M., M.D. There are two great motives which incite a man to feign disease— the désire to escape from something unpleasant, and the désire 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 prison life, or even obtain a pardon. The criminal and the loafer in our pub- lic institutions by simulating disease can often escape from the hated work and perhaps obtain the more agreeable diet of a hospital. In mil- itary life the illnesses Avhich develop just before a battle hâve caused "sogering" to become synonymous with malingering, and in countries where compulsory military service exists, numerous déviées are reported as practiced by those AA'ho désire to escape conscription. The second motive for feigning disease is the one which will most likely be met with by the physician in ordinary practice. There are many ways in modem life in which a man, although in the exercise of due eare, may suffer personal injury by another's négligence ; and, consequently, the dockets of oui* courts are filled with suits for damages, and railway corporations are compelled to pay large sums for such purposes, a single corporation in Boston paying annually on an average over $150,000. Such acci- dents also lead te) claims against insurance companies and charitable associations. In other cases, the désire for a pensiem may be the cause which leads the claimant to feign disease. Considering, therefore, the large number of persons whose moral sensé is, to say the least, defective, it Avould 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 clinieal rcsearch it is obA'ious that the difficulty of simulation is enor- mously increased. Only tliose affections the symptoms of which are subjective e-an be suceessfully feigned. The stéthoscope, the ophthalmo- scope, and the microscope give us testimony which the malingerer can- not counterfeit ; consequently the majority of surgieal affections, together with most of the diseases of the lungs, heart, and kidney, which présent symptoms clearly objective, cannot be simulated so as to deceive the trained physie-ian. It is in the domain of the nervous system that the majoritv of cases of alleged simulation occur. Many phvsicians are 391 392 A SYSTEM OF LEGAL MEDICINE. unfamiliar with the rarer forms of nervous disease anel Avith the ne»Ave»r methods of diagnosis, and many of the symptoms are purely subjecthe. The feigning of a broken leg is practically unheard of ; the feigning of the varions conditions classed as traumatic neuroses is claimed to be ex- tremely common. Statistics as to the frequency of feigning are someAvhat uncertain, and sIioav great variations. My personal belief is that simulation in any form is rare, and that suce-essful simulation, if the examining physician be compétent, is CA'en rarer. Ont of 23,903 surgieal cases admitted to the Boston City Hospital in ten years, the diagnosis of malingering Avas made in two, and in 30,639 médical cases the diagnosis was made in fif- teen. As might naturally be expected, malingering is more fréquent in the office of the admitting physician of the hospital, Avhere a considérable number of the simulators are detected and turne»d away. In addition to the cases Avhich were admitted to the hospital in the ten years, there were 15,957 rejee-tions, and of thèse 511 were refused admission, the cause being assignée! "no disease and malingering." Of thèse 511 rejec- tions, the admitting physicians considered about one fourth were e;ascs of malingerers who Avère anxious to get the shelter and food of the hospital; the other three fourths were uot suffering from any disease. Thèse latter figures, lunve-A'er, show merely the number of reje-e-tions, and not the number of persons, for it has sometimes happened that a. nialin- ge»rer has been turned aAvay eight or ten times in the cemrse of a ye»ar. In pénal institutions malingering seems to be distinctly more com- mon, but its frequency seems te> dépend somewhat upem the strietness of the prisem discipline. A considérable number of prisoners will report to the physician at sick-call in the morning for the sake of eseaping from Avork for a time, or in the hope of being admitted to the prisem hospital ; but such cases are usually readily detected, and they seldom attempt such a proe-ee-ding except upon a neAV physician Avhom tïie»y think is inexpérience-et. In my e>Avn expérience and in that of my colleagues at the Suffolk County House of Correction in Boston, there Ave»re many cases who, we thought, came to sick-call when there Avas no real disease ; but the physicians who bave been in charge at the House of Correction in récent years agrée that there bave been very few cases of deliberate and persistent simulation of any form of disease or of insanity. Dr. W. B. Bancroff, the présent physician, has informed me that, in his opinion, simulation was distinctly rare ; that in five years fifty prisoners bave been committed to insane asylums, and that there were only three cases where insanity was deliberately feigned. Dr. G. F. Jelly, the examiner in lunacy for the public institutions, coincides in this opinion, and adds that cer- tain cases, Avhich were believed to bave feigned insanitv, gave évidence of genuine insanity after admission to an asylum. At the Massachusetts Reformatory Prison at Concord Dr. G. E. Titcomb writes that there is little simulation ; however, the men hâve 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, malinger- ing becomes much more fréquent. Dr. C. D. Sawin writes me that at the Massachusetts State-prison at Charlestown, AAmere the discipline has been very lax, feigning lias been extremely common, but usually it bas been readily detected. Statistics from the pension offices as to simulation are not easilv to FEIGNED DISEASES OF THE MIND AND NERTOUS SYSTEM. 393 be obtained in sufficient numbers to give a definite opinion, but the im- pression of several of the examiners seems to be that dehberate, conscious simulation is rare. The epiestion as to the frequency of simulation has been most dis- cusseid Avith referene-e to the claims for damages for personal injuries, and hère opinions vary very greatly. Hodges (Boston Med. and Surg. Journal, April, 1SS1) believed that out of 21 e-ases lie had seenr10 were fraudulent and 6 Ave»re doubtful. Rigler (Revue Médicale, January, 1879, Ueber die Folgeu der Verletzungen auf Eisenbahnen) out of 28 cases thought 7 were fraudulent and 13 doubtful. Page (Injuries of the Spine and Sjii- ual Cord) in 234 cases considered simulation or gross exaggeration to be A'e-rv common. Te> thèse figures, hoAvever, the objection may at once be raiseel that they are the opinions of surgeons accustenue-el to deal with objective» symptemis, and uiifamiliar Avith the subtler and more obscure phenomena found in neuvenis eliseases. It is obvious that only a man Avith long e-xperience» in the observation of patients Avith mental and nerv- ems diseases can juelge ceu-rectly of the reality of nervous symptoms. It is only within a A'ery I'cav years that neurologists hâve brought forward statistics shoAving the fr«»epieney of simulatieui. In 1890 J.H. Hoffmann (lïerliu. klin. Wochensch)-., July, 1890) started a discussion upon this sub- je»ct, Avhich Avas carried on at the Berlin International Médical Congress in the same year by Schultze (Sammlung klin. Vortrage, No. 14, 1890), Seeligmuller (Deutsche med. Wochenschr., Oe-tober, 1890), Mendel, and others (Verhand. des X. internat, med. Congress, B. iv., Ab. ix.). The Avriters mentioned e-laimed that in the so-called traumatic neu- roses simulation AA'as extivmely common, existing in from one fourth to one third of ail the cases. The cases AA'hich they published in support of their opinions are not, hoAveA'er, absolutely conclusive; the variable charae-ter of symptoms often observée! in hysteria and neurasthenia, and some eif the subtler peculiarities in those symptoms, seem to bave been <>A'e»rlooked, and in more than one instane-e the destructive criticism of Dubois (Corr.-Iil. f. sclnveiz. Aerzte, Se»ptember, 1893), Mobius (Miincli. med. Wochenschr., Se»ptember, 1891), Oppenheim (Weitere Mittheïlungen in Bczug auf die traum. Xeurosen), anel others, has shem-ii that the accusation of simulation Avas not substantiated. Indeed, in a later communication, Schultze (Deutsche Zeitschr. f. Xervenheilk., vol. i., p. 445) found only ten percent, of simulation instead of thirty, as in his preA'ious séries. It is clear that simulation ought frequently to be seen in the claiin- agent's room more than in the office of the neurologist, anel claim-agents, corporation laAvyers, anel raihvay surgeons are fond of saying that the vast majority of cases are frauds. The- more pronounced cases of simulation are receignized at once, anel only the doubtful cases run the gauntiet successfully anel are subjected to the expert judgment of the neurolo- gist. Even in the AA'hole mass of cases that come to the daim-agents office, hoAvever, the amemnt of deliberate simulation seems to be small. Dr. M. D. Fielel (Trans. Am. Xeur. Assoc, 1893; Joum. Xerv. aud Meut. Dis.. March, 1894), the examining surgeon of the Manhattan Ehwated Raihvay, bas stated that deliberate simulation is seen only in a very small pe-iventage of the cases, and that in such cases it is so manifest and the symptoms are so grossly e»xaggerated as to be at once recognized bv a trained observer. Other examining physicians bave expressee! te) me similar opinions. My own personal expérience coïncides fully AAuth 394 A SYSTEM OF LEGAL MEDICINE. thèse A'ieAvs. In less than four pe»revnt, of the cases that hâve come under my oavu obse-rvatiem Avas simulation at ail probable, ami I bave .suceeeded in demenistratiiig the gcuuineness e>f the symptoms in some cases where simulation Avas claimeel by good obse-ive-rs, and i baye also known some suspecte-d cases to terminate fatally. Exagge-ration of symptoms is more common, but it must be remembered that exagge-ra- tion is a common feature- in ail sorts of nervous disease-s, Avhere intre»- spcctive-ness, hypex-hondriasis, and fear lead the patient, to make much of minor ailments. The possibilitv of the successful simulation of the varions fen-ms of nervous disease» is not great, provided the investigator be familiar Avith the clinieal manifestations. The simulator s task is not easy. Ile must be as familiar with ail the» symptoms of the feigned disease as the» phy- sician is, lie must be» pivpared for ail the forms and variations of tests ■employed in a clinieal examination, anel lie must be constantly on his guard'lest lie betray himself by some unguardcd admission. It is clear that such knowledge and such skill are be-yond the grasp of the average patient. Many of the minor symptoms of nervems disease and the» more exact and elaborate uu»the>ds employed in their diagnosis are uuknoAvn even to the ave»rage physie-ian, anel the patient cannot learn of some of them unless lie is able to read a foreign language. Granting that lie could acquire this knoAvleelge, or that he could find a physician suffi- ciently expert to eoae-h him, another difficulty stands in the way: lie must simulate ail thèse symptoms accurafely before a physician at least as Avell acquainted Avith them as bis coach, familiar Avith ail the» symptoms of the disease feigned, aud reaely at any mistake te) catch him off his guarel. Re»e-e»nt psyché)logieal iiiA'estigations, hoAveve-r, haAre shown that a man can kee-p lus mind fixed upon any spécial topic only for a short time. Henee most persons, even if they knenv the particular movement which constitutes the "trie-k" of a sleight-of-hand performance, Avili fail to note it because the performer choe>ses the one moment to make that movement AA'hen their attention is distracted. The simulator must be préparée! to feign a dozen symptoms at the same time, so that his task becomes much more formidable, and a siie-cessful examiner can readily take him off his guard by the application of some unexpee'ted test. This has been clearly shoAvn by Pitres (Leçons cliniques sur l'hystérie, vol. i., p. 79), who had a remarkably good opportunity to prove it. A man had for seA'eral years taken the part of the amesthetic man in a s1k>av, en- during pricks, cuts, ete-., Avithout the slightest manifestation en0 pain. In order to eùbtain the shelter of hospital life this man feigned a disease, one symptom of AA'hich Avas anaesthesia; but AA'hen he AA'as subjecteel to the unexpected application of painful stimuli Pitres proved at once that the anaesthesia Avas feigned. One of the striking characteristics of the average simulator is that his symptoms are usually pronounced, and are ahvays made prominent in the clinieal picture. There is paralysis, not Aveakness; anaesthesia. not diminished sensibiïity; A'iolent pain, not aching. He calls attention to his symptoms; they do not bave to be sought for by spécial te»sts in a clinieal examination. Suedi symptoms as a moderate e-oiitraetion of the A'isual field, a diminished sensibiïity to pain or température. AA'itb normal se»nsibility to toueh, or the quibblings e>r questionings of insanity of doubt, haA'e nothing to do with his complaints. The exaggvration of FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 395 symptoms, the manner of thrusting them before the examiner, the ab- sence of any shading 01* qualifie-ation, the total absence of objective phe- nomena, the détection of false statements with regard to certain symp- toms of a partly objective eharaeter, and the like, render the détection of fraud easy. It must be borne in mind, hoAvever, that e-emtradictory statements and cA'en conflicting data from examinations are» by no means absolute proof of simulation. A very limited acquaintance Avith patients suffer- ing from actual elisease will pre>ve he>Av contraelie-tory their statements seunetinies may be, and, in neivous troubles e-sjiecially, Iioav their eeuidi- tion may A'ary from one hour to the next; Avhat an influence expectant attention has upon their symptoms ; and Iioav suggestible they may be to the slightest influence. Certain conditions, too, may seem absolutely contradieteu-y, and may, to the inexperieneed, seem absolute proof of the unreality e>f aU the patient's complaints. Thus, tenderness se> extre»me that the slightest toueh cannot be borne ma}' be associated with com- parative insensibility to deep pre-ssure ; hysterical amblyopia may be shenvn to be really psye-hical, anel to exist only on monocular Ansion ; comple-te inability to stanel or Avalk, as in astasia-abasia, may be associ- ate-el Avith normal stivngth anel pe)Aver of e-oordination in the legs, anel the like ; so that, Avithout knenvledge of such conditions, the diagnosis of simulation is often incorrectly maele. In the» de»tee'tion of attempts te» feign disease certain gênerai rules are to be borne in mind. Whe»never it is possible, cemfirmatory évidence should be sought from disinte-resteel persons in regard to the patient's condition. Then the history should be obtained from the patient him- self. Careful inquiry should be made in regarel to ail the bodily func- tiems, and detaiïed inquiries in regard to ail his complaints. The simu- lator usually proclaims ail bis sufferings loudly, but the genuine sufferer may often require close e-re)ss-exainiiiatiou to elicit the whole story. It is well to return after an inte-rval to certain symptoms in order to see whether the patient's sten-y is consistent or ne>t, and to ask if he has ever hael certain symptoms, either impossible in themselves or inconsistent with the type of elisease» lie présents. It must bc remembered that many people are incapable of telling a e-onnected ste>ry or of ghing an aecurate account of real sufferings, that many affections she>w pronounced Aaria- tions, aud that sometime»s the claim that the symptoms ahvays remain the same, or of the same severity, may of itself be suspicious. During the process of taking the h i sten-y, the patient should be quietly and un- ■obtrusively Avatched, and it may be that he will be detected in performing senne ae-t Avhich he lias just announced himself incapable of performing. The taking of the case history should be followed by a thorough and comple-te physieal examination, paying especial attention to the motor fune-tions, sensation (including sensibiïity to pain and température as well as to toueh), the spee-ial sensés (ahvays including examination with the ophthalmoseope and perimeter'), nutrition, the electrical réactions, the renVxes, and the condition of the internai organs. It is safe to say that if there be any real disease of the nervous system such a comple-te ex- amination Avili reveal some symptoms AA'hich it is either impossible or extre-mely improbable for the patient to feign. Among the symptoms Avhich cannot be feigned are optie- neuritis and atrophy, Ai'gyll-Re>bertson pupils, nystagmus, muscular atrophy, réactions of degeneration, loss of 396 A SYSTEM OF LEGAL MEDICINE. knee-jerk, ankle clonus, and a différence in the activity eif the skin and tendon réflexes on the twe) sides. After this the physie-ian will probably be in a position to give» a definite opinion. Sometimes repeated exami- nerions Avili be necessai-A-, and in rare cases it may be necessary to apply the crucial test of protracted observation in a hospital. Seeligmiiïler {Art cit.; Verhandl. des X. Internat. Med. Congress, B. iv., Al), ix.) bas urged this, and tliinks it advisable to establish observation hospitals where patients who claim damages ou account of traumatic nervous affections may be sent. In very few e-ases, however, would such hospitals be re- quired. Until the physician be absolutely convineed, after a thorough exami- nation, that the patient is feigning, it is important not to treat him as a malingerer. Such a course will directly antngeniize the patient and his friends, and the e-ases of deliberate feigning are too feAv to just if y it. The suggestion maele long ago by Casper (Haudb. d. Gerichtl. 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 thau good, anel this, and similar proceedings, will seldom be found necessary. With a thorough knowledge of modem methods of clinieal research, the old brutal methods of ignorance must be abaiidoned. Flagellations, douches, and the cautery may injure one who is really suffering, anel they give no help to the scientific observer. Even the so-calleel crucial ex- periment of etherization Avili rarely be necessary. It is of legitimate use in the diagnosis of certain affee-tioiis, as is Ave»ll knoAvn ; but it is not Avholly devoid of danger, and it shoulel be employed in suspectée! simula- tion only in cases where Ave might legitimately employ it in ordinary diagnosis. Many Avriters point ont the danger to the malingerer of feigning dis- ease. By persistent]y feigning e'ertain symptoms there is danger that a morbid habit may be established, anel the feigned disease may be-ceunc real. Tins is helel to be especially true of attempts te) feign insanity. I hâve seen one case AA'here, in order to obtain a pardon, a prisoner at first deliberately induced vomiting, but finally the A'enniting got beyond bis control, and although lie became alarmed at his condition anel Avanted to stop, lie Avas for some time unable to control the vomiting. In many cases, lioAveA'er, alloAvance must be made for the mistakes of the physi- cian, who regards the early symptoms of mental or nervous discase as feigned, only to find ont later that there is really trouble. I hâve spoken thus far of the debberate feigning of disca.se. There are, lioAveve-r, four conditions to be borne in mind by the physician in examining the ordinary cases : first, cases where no disease exists and ail the symptoms are deliberately feigned ; second, Avhere there is some disease, but the symptoms are greatly exaggerated and additional symp- toms perhaps feigned ; third, AA'here certain morbid conditions are delib- erately produced by the patient, such as conjunctivitis, skin affections,. and the like ; fourth. AA'here the symptoms, although genuine, are ne>f due to the alleged cause but bave existeel long before. Although deliberate simulation is, in my opinion, rare», and is usually easily to be detected, it is a harder matter to détermine, when there is genuine disease», Iioav far the complaints arc exaggerateel. In many cases exaggeration is in itself a symptetm of nervous disturbance; introspecth'eness, hypochondria,. FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 397 and exagge-ration are characteristics of the mental condition of many nervems patients. To appreciate thèse conditions justly requires long familiarity with nervous patients and nervous affections ; and, as a rule, the physician and the friends are too apt to undervalue their complaints. Feu- the détection of exaggeration 110 definite rules can be given ; the physician must be guided by his knowledge of nervous disease in gênerai, by his personal estiniate of the individual case, and by his gênerai knowl- edge of human nature. He may be aided in some cases by the lack of ceuTe-spondence between the complaints and the symptoms revealed by an e-xamination, and by the statements of the patient's friends and ac- quaintanees, especially by disinterested observers. The chances of error in damage suits from the statements of interested friends are too obvions te> need. mention. It is well to bear in mind a source of error on the other side in the fréquent tendeney among the laity to make light of ail nervous troubles and to regard them as imaginary. In cases of the third e-lass, where morbid conditions are deliberately produced by the act of the patient, we are seldom in a position to defect this by the symptoms alone, and in such cases Ave must be guided by the évidence brought forAvard to show such facts. In cases of the fourth class also the physie-ian is rarely in a position to testify as to the exact relation between the alleged cause and the synqtteuus. The symptoms may be wholly due to preëxisting disease, or the aee-ident may bave aggravated some of the symptoms of such a disease. In some cases indications of previous trouble may be elicited on e-lose inquiry; the patient may admit, for instance, the existence of rheumatic pains for years before an accident, anel thèse pains may hâve been the early symptoms of a tabès which bas been referred to the acci- dent. Such epiestions are often not a matter of expert opinion but a matter to be dete-rmined by ordinary évidence, and the only position Avhich the physician can take is to state that the existing conelition may well hâve been due to such an accident as the patient is said to bave suf- fered. Whether the disease existed before the accident, or whether the patient ever e-xperieheed an accident, are alike questions of évidence Avhich the jury must détermine. Having thus cliscusseel the gênerai conditions relative to the feigning of disease, it remains to consider the possibilities of feigning the varions symptoms of nervous elisease, since the considération of feigning in spé- cial cases can be more succinctly and clearly treated in this Avay than by the attempt to discuss the simulation of inelividual types of disease. The feigning of insanity, hoAvever, can better be considered under a separate heading. MOTOR SYMPTOMS. Paralysis.—Paralysis, being one of the most sfriking symptoms of motor disturbance, is, next to convulsions, the symptom most likely te) be feigned. Certain assoe-iateel symptoms, hoAvever, Avhen présent, render it exceedingly improbable that the paralysis is feigned. Thus, if paralysis be assex-iateel with muscular atrophy, especially with degenerative atro- phy, Avith contracture, vasomotor disturbances, or changes in the ré- flexes (sympte)ms which of themseh'es cannot be feigned), the paralysis is also, in ail probability, genuine. If there be anaesthesia, AA'hich, as will be shoAvn later, is hard to feign, the probability that the paralysis is 398 A SYSTEM OF LEGAL MEDICINE. feigned becomes distinctly small. If the paralysis be limited to the dis- tribution of a peripheral nerve or a spinal segment, it is highly improb- able that the patient bas knowledge sufficient to make the attempt to simulate such a condition, and it is often impossible for him to bave such control of the muscles as to suce-eed in his attempt. Furthermore, the voluntarv control over some of the muscles, such as the ocular muse-les, the upper facial muse-les, and the Uke, is not sufficient in most e-ases for the patient to feign paralyses of them. Most paralyses of long standing show simple atrophv of the muscles from disust—the limb is smaller, and the muscles feel" softer and flabbier. It is therefore évident that the question of simulation is likely to arise only when tliere is a récent flac- e-id paralysis, Avithout anaesthesia and without degenerative reactions and atre>phy.' In such cases it may be possible to deteet the fraud by notic- ing movements in the limb claimed to be paralyze-el, when the patient is off his guard, or is attempting to do some ordinary ae-t such as taking off bis clothes ; by finding that when the patient stoops the limb is held rigidly to the side and does not follow the action of gravity ; that passive movements are iiiu-euisciously resisted, and the like. In feigned hemi- plegia the characteristic droop of the shoulder, the eircumcluction and dragging of the toe of the paralyzed leg, the greater degre»e of paralysis in the arm and in the distal joints, and like symptoms, may be absent. The shoe may not show the wear upon the inner and anterior portion of the sole that it would if the foot were persistently dragge-d. If the paralyzed limb be held up for a time anel the support, suddenly removed, it may not fall immediately. In hysterical paralysis, however, many of thèse characteristics may be absent. Thus, in hysterical hemiple-gia there is not the circumduotion of the leg, the proximal joints may be as much paralyzed as the distal, anel the influence of suggestion may keep the paralyzed limb extended Avhen the support has been take-n away. In such cases the détection of hysterical stigmata may enable the physician to make an accurate diagimsis and to détermine that the paralysis is gen- uine. With a flace'id paralysis, without any stigmata, where the patient makes none of the errors just mentioned, it may be necessary to subject him to a more protracted observation. In such cases the application of poAverful faradic currents may, on account of the pain which they cause, lead the patient to make voluntary movements ; and during the period of excitement at the first administration of ether, on recovery from ether- ization, on waking from sleep, or when under the influence of alcohol, the alleged paralyzed limb AA'ill often be moved. Paralyses of the sphincters, which often occur especially in spinal paralyses, can readily be detected. If the patient has been subjected to a long examination, without an opportunity of passing water, and at the end of that time the clothing be still dry, his complaints of incontinence lack credibility. In true incontinence the characteristic odor and the reddened, irritated condition of the skin will indicate that the cloth- ing is constantly wet. Wichmann (Der Werth der Symptôme der soejen. traum. Xeurose, p. 15) has suggested that in alle»geeï incontinence the nicatus be earefully dried with absorbent cotton ; if, afte-r that, the urine be found oozing from it, it is proof that the incontinence is genuine, since the urine cannot be voided in this way A'oluntarily. Paralysis of the sphincter ani can lie readily recognized from the patulous condition of the anus on inserting the finger. FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 399 In e-onditions of paresis the détection of simulation is not so easy. Oppenheim (Die traumatische Xeurosen, p. 119, 2 a»//.) has stated that in some cases of traumatic nervous affection the patient makes apparently gre-at effort and calls many muscles into play, without aceeuiiplishing any great resuit, the memeny of the muscular effort required being lost. Such a cemdïtion may give rise unjustly to the suspicion of simulation. In most case»s Ave must be aided by other associated symptoms. Wich- mann (op. cit., p. 56) bas suggested a method of testing the muscular strength by the dynamometer in alleged paretic conditions, the A'alue of which 1 bave been able to corroborate by personal experiment. The pa- tient is blindfolded and told to squeeze the dynamometer to the extent of his strength. If he does so, the index will reach A'ery nearly the same point each time», although after several trials the strength begins to dimin- ish. If the patient does not exert his full strength he Avili not squeeze to the same point each time, but there will be quite distinct variations. This test may be applied to the muscles of the leg by means of the appa- ratus ree-enfly described by Krauss (Trans. Am. Xeur. Assoc, 1893). Convulsions.—Epilepsy, the chief convulsive disorder, is the form of nervous disease most frequently feigned. The epileptie seizure is so striking, and the disease itself is so common and is so well recognized as a grave» disorder which may lead to serious mental disease, that malin- gere»rs are especially apt to feign it. It is one of the commoner forms of nervous disease feigned by criminals, either in the hope of escaping work, or of being sent to a hospital or an asylum. There is aise) a spécial class of criminals who feign epileptie attacks ("chuck a dummy") in public places to attrae-t a croAvd, the performer obtaining alms from the benevolent e>n account of bis malady, while his accomplices pick the pex-kets of the by-standers. It is a point in faAor of the genuineness of the disorder if it can be pi*OAren that the patient has had such attacks since childhood. Attacks coming on in adult life AA'here there is a powerful motive for simulation may be regardée! with suspicion. The average simulator has his attacks only when he thinks he is observed; lie seldom falls so as to hurt him- self ; he is not likely to pass urine or faeces in his clotbing ; the move- ments are more exaggerated than are usual in epilepsy ; they may not be at ail like the epileptie movements, and they are often limited to the ex- tremities ; the tongue is less apt to be bitten ; the simulator seldom speaks of the aura, and he may omit the characteristic cry. Other symptoms are more difficult to feign. During a genuine attack the patient is un- conscious and anaesthetic, the pupils are often dilated and almost ahvays immobile», and the conjunctivae are anaesthetic ; the epileptie is often pale at the on set of the attack, and becomes cyanotic if the convulsion be severe ; after a severe convulsion there is profound sopor. Opisthotonos anel the short contractions of the spinal muscles can lie feigned only with great difficulty. Heller (Simnlationen und ihre Behandlung, p. 35) has suggesteel that during a suspicious attack firm pressure be made by the hand on some group of muscles, such as the thigh muscles; after a time the-se muscles will relax ; if then an attempt be made to flex the limb the simulaten* will contra<»t the muscles again. If the chuiched hand b<» opened during a genuine attack it will not be closed again—a simu- lator is apt to close it, After a severe attack, as Avas first pointée! ont by Hughlings Jackson (Médical Times and Gazette, February, 1881), and 400 A SYSTEM OF LEGAL MEDICINE. as I hâve myself seen in several cases, there may be ankle clonus or loss of knee-jerk, symptoms AA'hich cannot be feigned. Afte-r a successiem of fits the température rises, iu extrême e-ases reaching 40° C. or more {104° or 105° F.). The confirmed epileptie has a characteristic facial ex- pression, familiar to ail AA'ho hâve seen many cases; bis face is often dis- figured by the bromide-acne, and the tongue, head, and body often bear scars from the injuries received in the attae-ks. The simulator of epilepsy can be unmasked in A'arious ways. West- phal (Berlin, klin. Wochenschr., No. 40,1873) and Winkler (Heller, op. cit., p. 33) hâve both detected cases by saying in the patient's presene-e that certain movements, such as no c»i)ilep)tic perfen-ms (for instaiieH», exte-nding the arm and spreading the Angers), ought to be performed in the attack, and the simulator in his next attack pertormed them. Tamassia (Rivista sper. di freniatria, vol. xviii., p. 140) reports a case of a woman who feigned symptoms of insanity anel epilepsy. He found that she remembered what happened during her attacks, and, after she had overheard his in- quiries as to whether she had certain symptoms in her attacks, she pro- truded her tongue to the left during an attack, vomited, contracted lier fiiigers in a eurious Avay, cried out in a way unlike the epileptie cry, kept the left arm rigid and the right arm flaccid, protruded the tongue when asked to do so, and finally had an attack Avhen the ceiwical vertebrœ were pressed upon—none of which symptoms had she sIioavii before they were spoken of in her présence. A prisoner at the Massachusetts State-prisem ceased his convulsion when it was proposed to give him ether, of whie-h he stooel in great dread. Given a motive for feigning, it is ground for suspicion when a patient lias a fit in the physician's présence. Ont of ninety cases of epilepsy in patients who were able to come to see me I ree-all but three who bave; ever had fits during such a visit, and it is often difficult to get the oppor- tunity of observing a fit from its beginning when the patient is in the wards 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 Surg. Jour., December, 1880) was able to un- mask the " dummy-chucker " Clegg, who had baffled many prison officiais and physicians, 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 stuelv and observation, had learned to imitate fits very accurately. In an attack lie made no mani- festation of feeling when pins wen-e thrust under his nails or when the cornea was touched ; he turned livid, bloody 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 with 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 e-alling attention. Knowing that simulators rarely fall so as to hurt themselve»s, he once had a fit in the gallery of the prison and rolled off thirty fee»t to the pavement beneath, breaking one or two bones. The reasons which led to the détection of his simulation were the definite motive he had for feigning, the fact that he had a fit on the physician's first visit, the way he called attention to his trouble and his scars, the change from the epileptie to a natural expression Avhen he thought no one saw him, the FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 401 fact that in the fit the fingers were not closed over the thumb, the nails Avère not livid, the rigidity could be easily overcome, the hands closed again after they Avère once opened, the sphincters Avère not relaxed, and finally, that there were no ecchymoses, extra va sations, or petechiae on his person. There is another form of convulsive seizure, however, which some- times rese'inbles epilepsy, yet in which many of the phenomena which in epilepsy suggest simulation may actually occur. In hysterical attacks the patient may hâve a seizure at such a time as strongly to suggest the de-sire for display, consciousness is not wholly lost, the patient seldom falls so as to burt himself, and the sphincters are not relaxed. The grand attack of hysteria is rare in America, and its stages of epileptiform con- vulsions, contractions and grand movements, plastic poses anel passion- ate attitudes, and delirium, demand such great knoAvledge, such mimetic penver, and such extraordinary muscular control that it e'an seldom be successfully counterfeited. In lesser attacks avc must rely for the dém- onstration of the reality of the affection partly upon the e-areful observa- tion of the attack, but chiefly upon the discovery of other symptoms of hysteria. In some cases we may find régions AA'here1 pressure Avili pro- voke an attack—hysterogenous zones—or régions Avhere pressure Avili 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 nutrition dans Vhystérie) h&ve found that the amount of urine Avas someAvhat decreased for the ensuing twenty-four hemrs, that the soliel constituents (urea anel phosphates) were one third less, and that the ratio betAveen the earthy and alkaline phosphates, which is normally from one to three, rose to from one to two or even to equal- ity. Where there are no attacks the urine is usually normal. It is important also to de»termine the genuineness of the post-epileptic unconsciousness, as well as unconsciousness arising from any other cause. If firm pressure bc exerted upon the supra-orbital nerve as it émerges from the notch, the pain soon becomes too great for the simulator to bear. Similar results may be obtained by the faraelie brush or by the needle-pe)int électrode AA'ith a very strong faradic current. Contracture.—In certain forms of paralysis contracture of the affectée! limb becomes an important symptom, but it is impossible to feign it successfully. On passive motion the physician can at once detect the différence between the tonic rigidity of true contracture, the limb being absolutely stiff anel yielding gradually a trifle to pressure, and the active résistance of voluntary muscular contraction where the résistance is more irregular. The attempt voluntarily to resist passive movements will also be indicated by an increase in the puise and respiration, flushing of the face, and, if more strength be applied, by the active résistance of other muscles of the body. In contracture, too, there is often an increase in the tendon réflexes in the affected part. In catalepsy the contracture of the muscles is of a différent type, the limb is perfectly flexible and remains in whatever position it is put, sIoavIv and gradually falling after some time by the action of graAdty. The old experiment of Hunter (Wichmann, op. cit., p. 54) may detect any simulation. Hunter hung a Aveight to the arm of a supposed cataleptie by means of a tape : the Aveight dreAV the limb down very sloAvly and gradually, he suddenly eut the tape, the weight fell, and the limb flew up 402 A SYSTEM OF LEGAL MEDICINE. AA'hen the résistance to the voluntary eontrae-tiem Avas suddenly re»niove»d7 shoAving that. the catalepsy was feigned. Charcot (Leçons sur les mala- dies du système nerveux, vol. iii., p. 17) has demonstu-ate-el by means of a re-gistering apparatus that if a cataleptie limb be put in any position it will gradually fall by the action of gravity, and that the curve of descent will be a perfectly even aud regular line. In feigned catalepsy, however, the curve of descent will be very irregular, the limb sinking and then being brought back again by a sudden voluntary effort, shoAving many oscillations ; the simulator, too, will, after keeping a limb in a given posi- tion Avithout support for a certain length of time, give evidene-e of his effort by an increase in the puise anel respiration. Other forms of spasm are more rarely simulated. The feigning of tonic spasm may be detee-ted in much the same Avay as the feigning of eemtrae-ture. The A'arious forms of clonic spasm, sue-li as tic, respiratory spasm, and the like, are to be detected by protrae-te-el observation of the patient AA'hen lie thinks himself un observed, or by determining Avlie»ther the affected muscles are such as are normally capable of such action voluntarily. Tremor.—Although tremor is a comparatively common symptom of nervous disease, its simulation is not an easy matter. Walton (Jour. Xerv. and Ment. Dis., 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 AA'ithout fatigue. Other observers hâve shoAvn that tremor of the feet or hands can some- times be kept up by supporting some part of the foot or hand against the Avall, the bed, or a table. Such obvious methoels of feigning should elevehe no one. Honig (Ueber Simulation und Uebertreibung, 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 aAvay. Seeligmiiïler (Lehrbuch cl. Krankheiten des Riiekenmarks, p. 673) bas suggested a method for de- tecting feigning in such cases. The patient is. put upon his belly and his feet are concealed from his sight ; if he can press the- toes against the bedclothes or the foot of the bed he can in this 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 Seeligmiiïler claims that the tremor will cease and will not begin again until the toes can once more be touched to some rough surface 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 artiflcial. Real tremor cannot be feigned persistently. After a very short time the rhythm of the tremor becomes irregular, the excursions vary A'ery much, and as fatigue cornes on the effort to continue the tremor manifests itself in the puise and respiration. Tracings of a simulated tremor Avould easily show the irregularity. 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 ail. Ataxia, Choreic Movements, etc.—The various disordered move- ments, such as ataxia and chorea, can quite easily be feigned, but, when genuine, they are usually associated with definite objee-tive symptoms. A simulator can feign the ataxia and the gait of tabès, but he cannot feign FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 4Q3 the i-ondition of the pupils or the loss of the knee-jerk. The diagnosis of any condition will rarely dépend upon thèse symptoms alone, and the- only e-ertain method of testing their genuineness is by protracted obser- vation. SENSORY SYMPTOMS. Anaesthesia.—The successful feigning of anaesthesia is easy when the patient e-an see Avhat he is about and knoAvs that the tests are to be applie'd. Under suem circumstane-es many persons bave nerve enough to permit the ce>rnea or the conjunctiva \o be touched Avithout winking, to endure needle-thrusts, strong elee-trical e-urrents, or even the hot iron. Me>st schoolbe>ys bave driven pins into themselves up to the head Avith- out any manifestation of pain. It is another matter, hoAvever, when the tests are applied unexpectedly. Hère-, if powerful stimuli be used, the patient Avili almost invariably start or make some manifestation of sensi- biïity. Thus Honig (op. cit., p. 27) observed a simulator who made no manifestation of pain at a ele»e»4> prick of a needle when lie knew that the test Avas going to be appliee! ; but the next day, when a needle Avas stue-k into him Avithout his knowing it, he at once maele- an outcry. In a case of feigned insanity, Field (Jour. Xerv. and Ment Dis., June, 1890) saw no signs of sensibiïity when lie sjnïnkled e-old water on the patient while standing in front of him, but the man started AA'hen it Avas unexpectedly sprinkled on him from behind. Gray (Treatise on Xervous and Mental Diseases, ]). 14G) has suggested accidentally spilling very he>t water on the alleged ana-sthetic spot. Pitres' case cited above shows the practical impossibility of feigning amesthesia AA'hen the tests are applied unex- pecte-elly. In ail cases where the sensibiïity is to be tested the patient should be blindfolded. If, after the ordinary testing with the tip of a finger or a eainefs-hair brush, the patient claims e-omplete anaesthesia, the best test for demonstrating the reality of the ainvstliesia is the unexpected applica- tion of a powerful faradic e'urrent through a sharp-pointed électrode ; this can be deme most easily AA'liile te»sting the ordinary electrical reactions of the muscles. An ordinary testing électrode being attached to one cord of the battery, a pin or a needle may be thrust through the cord between this électrode and. the battery, and concealed by the hand. A large indif- fèrent électrode shoulel be attached to the other cord. A faradic battery capable of giving a Ae»ry 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 question as to his sensibiïity. While doing this the current can suddenly be turned on to its full strength, and instead of applying the électrode, the pin may be appliee! te> the anaesthetic spot. The pain of such an application is so great that if it be unexpectedly applied the patient cannot refrain from manife-sting bis sensation. If the hand or foot be anaesthetic, a pin or some other sharp instrument may be pressée! down under the nail toward the matrix. If the anaesthesia be feigned the malingerer will give some inelie-atiem of bis pain, either by muscular contrae-tion, an outcry, or, at any rate, by an ine-re-ase in the rapidity of the puise. If the amesthe-sia be limited to a definite part of the body it is j r -- sumptioii in faveu* of its genuineness if it be limited to a definite periph- • 401 A SYSTEM OF LEGAL MEDICINE. eral nerve distribution or te) the area of any of the spinal segments, since the average simulator knows too little of such distributions of an- a'sthesia to be likely te> feign them. If the boundary betAveen the anaesthesia and the sensitive régions be sharply defined the test becomes casier. The boundary should be marked out AAith a colored e-rayon before the patient is blindfolded. Then, after lie is blindfolded, tlie skin on the sensitive siele should be lightly touched at some distance from the line, and the touches repeated, gradually approaching the line, until the patient says lie no longer feels them. The point where he ceases to feel the toueh should be» indicated by a e-rayon mark of another coh>r, and the test repeateel. After a ucav boundary line has been established in this Avay, the skin on the anaes- thetic side of the line should be touched in the same way, the touches approaching the boundary until a point is reached AA'here the patient says he feels the toueh ; this should be marked Avith a crayon of a third color until a boundary line» is again established. If possible, the part should be covered and examination of other parts be unelertaken, and thèse tests be repeated after au interval. If the three lines agrée the ana'sthesia is undoubtedly genuine, for no one can ahvays say ce>rree-tly on which side of an imaginary line lie is touched, Avhen lie is touched close to the line. Some people can tell with considérable accuracy whether a toueh is on one siele or the other of the médian line, but they cannot tell in regard to lines elseAvhere, espee-ially the curions boundary lines of the geometri- cal anaesthesias eiccasionally seen in hysteria or of the anaesthesias from a peripheral nerve lésion or from the lésion of a spinal segment. If this boundary line pass threiugh one of the le»ss sensitive régions of the skin its genuineness is still more probable, for it is still harder to say on which side of an imaginary line a toueh is made in such régions. Burghardt {Rraktische Diagnostik der Simulatiouen der Gefithlslâlimung, Schwerhorig- keit, und Schwaehsiehtigkeit) bas suggesteel that Avhen the boundary lines are found to elisagree they be sIioavii to the patient and a neAv test made, but the advautage of this is not apparent. Burghardt lias also suggesteel that the patient be told to indicate by raising the finger whenever lie is touched, claiming that, if the touches be rapidly made, the malingerer will sometimes indicate when the anaesthetic région is touched. In most cases, however, it is difficult to get an ordinary patient to lift the finger quickly enough to make this test very practical. The compassés may be useful in testing the relative sensibiïity of two différent parts of the body, but their use requires very much time, and, as a rule, the results obtained by them are hardly Avorth the trouble. Goldseheider has sug- gested another method of testing the genuineness of anaesthesia AA'hen its boundary is sharply defined. A Avire brush électrode or Erb's farado- cutaneous électrode is placed on the boundary Une and the faradic current passed through it. When evenly pressed upon the body the patient will •of course feel the current in the sensitive région, but if it be slightly tipped it may be made to rest almost wholly on the anaesthetic territory without the patient observing it has been tipped. If then he states that he still feels the current the probabilities are that his anaesthesia is feigned. In most cases of anaesthesia the skin réflexes are lost or diminished in the affected part. In hysterical conditions, too, some of the réflexes from the mucous membranes may disappear ; a loss of the pharyngeal reflex is especially common. FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 4Q5 While thèse tests are sufficient to demonstrate clearly the genuine- ness of anaesthesia, Ave cannot ahvays say, if the tests fail, that the an- aesthesia is feigned ; for in hysteria, as is Avell known, the boundaries of the anaesthetic région may shift rapidly, and in certain forms of anaes- 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 influence of suggestion may sometimes be so great that under ex- amination the anaesthesia may increase, diminish, or perhaps be trans- ferreel to the other side. Furthermore, it is now recognized that hyster- ical amesthesia is distinctly of psychicàl origin, that the patient actually feels a toueh or a prick in the anaesthetic hmb, and that by hypnotism, or in other Avays, the patient may be made to state definitely Avhere and how many times lie lias been touched. Ail thèse facts, therefore, must be duly considered before we state positively that an anaesthesia is feigned. Of other forms of anaesthesia it is not necessary to speak in much détail. The tests already mentioned will reveal any analgesia, which may occur with normal sensibiïity to toueh. Few simulators are likely to know enough to feign thermanaesthesia. If the température sensé be earefully tested by métal rods of différent température, according to the method described by Goldscheider (Diagnostik der Xerveukrankheiten, p. 33), and there be a distinct diminution to either heat or cold in one région as compared Avith that of the opposite side, the symptom is very apt to be genuine, although, of course, the success of such a test is not an absolute proof. The unexpected applie-ation of very cold or very hot Avaler Avili usually elicit signs of sensibiïity if the thermanaesthesia be feigned. Fcav patients, too, bave sufficient knewledge to feign disturb- ances of the muscular sensé, and, if they should, it is usually possible, on protracte-d obseivation, 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 anaesthesia can be temporarily produced by the application of belladonna, cocaine, and other drugs. If, however, the area of the anaesthesia 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 anaesthesia of such an extent, there would, in ail probability, be pronounced signs of their physiologieal 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 malin ger- ers. Of the truth or falsehood of such a complaint we hâve no absolute method of judging, but in many cases we can find some confirmatory évidence from other symptoms to aid us in forming an opinion. If, for instance, the patient complains of lancinating pains, and we find object- ive signs of tabès, or if the pain be referred to a given nerve distribution, and we find Valleix's tender points or changes in the réflexes, we can assume the pain to be real. In cases, however, where there is no other évidence of elisease, we cannot come to a definite conclusion, excepting that if the patient's claim of severe, extrême, and continued pain be true it will often be manifested by disturbed sleep and impaired nutrition. With regard to tenderness, however, Mannkopf and Rumpf (Centralbl. f. Xervenheilk., No. 12, 1889) hâve suggested a procédure which often enables us to say definitely that the tenderness is real. If firm pressure be made upon a tender spot, the pain Avili often cause an increase in the 40G A SYSTEM OF LEGAL MEDICINE. puise rate, sometimes as much as tAventy beats a minute. In seune» cases there» may be, in adelition to, or insteael e)f, an ine-rease in the rapidity en0 the puise, a Aveakening of the puise, a flushing of the fae-e, eu- an oiitburst of sweat on the forehead. If there be no increase in the puise, ho avc ver, we cannot say that there is no tenderness, for in cases of real dise-ase the puise is sometimes unaffected, especially if the tenelerness be slight. In many cases, hoAvever, I hâve been able to demonstrate the reality of ten- derness by this means. It is needless to say that the patient should bave no idea of the test to be applied, and it is also better that he should be blindfolded. SPECIAL SENSES. Vision.—The détection of feigned visual disturbances is a compar- atively easy matter. The feigning of complète blindness of both eyes demands great persévérance and unusual skill in order to counterfeit the gênerai demeanor of a blind person and the rigid, unaltered look to the eyes, which does not vary at any visual impression. Few hâve sufficient control to remain unmoved when objects are closely approximated te) the eyes. If a large object, however, be suddenly brought before the eyes even of a blind man, the current of air engendered by the movement may cause him to make some motion of défense. 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 Avhich indicates that he sees. Protracted observation will also show that he has not the characteristic habits of a blind man, and that lie is governed by his eyesight when lie is moving about a room and thinks himself unobserved. Burghardt (op. cit.) has suggested a method of detecting feigned blind- ness. The patient is asked to put out one finger and then to toueh it with the other. A person who is actually blind can do this perfectly well ; the simulator is very apt to overact the part and not to toueh it correctly. Burghardt then had an attendant, with bandaged eyes, do it m the présence of a simulator, and the next day the snnulator suceeeded m doing it perfectly well. Arlt (Heller, op. cit., p. 73) has pointed out that m feigned blindness, 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 now. In such a case we might properly suspect there was percep- tion of hght. 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 may arise. Such experiments, however, are seldom necessary. There are very few cases of blindness in which the ophthalmoscope wili not reveal definite structural changes in the optic nerve, the retina, or the conducting média. If the eye be normal in an ophthalmoscopic'ex- amination, and if there be no rénal disease, our suspicions may properly be awakened. In a few cases of optic neuritis, or of optic atrophy, blind- ness may_ précède any changes in the eye itself. Von Graefe (Heller, op. éd., 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 considérable visual poAver is still re- tained, and in cases of atrophy peripheral hmitation of the visual field may précède the visible signs in the retina. Heller (op. cit., p. 74) claims that the simidation of unilatéral blindness FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 407 is much more common than that of complète blindness, as it is naturally much less unpleasant for the simulator. Even in such a case simulation is exceedingly improbable, since changes would, in ail probability, be found by the ophthalmoscope in the blind eye. If blindness of one eye be feigned, however, it can usually be quite readily detected by means of prisms or by similar tests. The simplest method is that proposée! by Von Graefe (Archiv f. Ophth., vol. ii., p. 266). The prism, of from six to twelve degrees, Avith its base turned upA\*ard or downward, is placed before the healthy eye. If the name of a candie, en* a small dot or a fine line upon a paper, be seen double», the simulation is at once proAren. We may also try whether the double image moves during the rotation of the prism, or whether the double image disappears upon the reëstablishment of binocular vision by turning the base of the prism outward. If the simulator be sbrewd enough to know that one of thèse images belongs to the pretended blind eye, Ave may hold a prism AA'hich refracts vertically before the normal eye so that its refracted angle will bisect the pupil. In this Avay, when the alleged blind eye is covered, monocular diplopia may be produced : if the simulator deny this eliplopia, tliere is good reason to doubt bis state- ments ; if he admits it, it can very easily be made into binocular diplopia by uncovering the pretended blind eye anel moving the prism slightly so that it shall ce >ver the whole pupil. Feigned blindness of one eye can also be dete-e-teel by the stéréoscope. As is AArell knoAvn, in binocular A'ision through the stéréoscope the fields of the two eye>s are united into one. Ixabl-liuckhard (Deutsche militdr-arztl. Zeitsehr., 1874) has recom- mended that we should put into the stéréoscope a figure which should haAre a circle in each field ; in normal vision through the stéréoscope the tAvo cire-les Avould blend into one, forming a single object, Avhich may serve as a fixation point. By arranging the cards so that other figures can be me>veel about in the field in A'arying 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 Avhether he see-s it with the right eye or Avith the left. It must be borne in mind, hoAvever, 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 (op. cit., vol. i., p. 103) states that an oculist once said to him that every case of hysterical blindness was fraud- ulent. Pitres himself demonstrated the plausibility 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 Avas closed the patient could see with the right eye only the letters to the right of the se-reen ; when the right eye Avas closed no letters at ail Avère pere-ehee! ; Avhen both eyes Avère 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, shoAving conclusively that the letters Avère perceived with the left eye. This agrées with the conditions which hâve been spoken of under anaes- thesia, AA'here it has been sIioaati that the patient actually feels a toueh in some e>f 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, avc must consider, as Pitres does, that in hysterie-al blindness of one eye the blindness exists only with monocular vision. In such cases the other symptoms of hysteria will usually be présent, so that we can make an accurate diagnosis. 408 A SYSTEM OF LEGAL MEDICINE. The détection of poor \nsion is somewhat more difficult. In most cases, hoAvever, tliere are distinct physieal cemditions in the eye to ac- count for such AÙsion. Possibly in such conditions there may be senne corneal opaeities, retinitis pigmentosa, etc., or else the failure of visieui may be élue te> erreirs of refraction. In the latter case the-se» errors can be readily dete»rinined. If the patient makes false state-ments in re-garel to the ordina.ry test Avith lenses, a degree of refractive error, aniounting from one half to one diopte-r, eau be determined by a skilled obseive-r Avith an ophthalnmsceqie, or by the shaelenv test, if the patients accom- modation be paralyzed by atropine, and réfraction errors of less than one diopter cannot haAe» a A'ery markeel effect upon the A'ision. Ilcmeralopia is sometimes feigned by se)ldiers. In e-xamining tins ceuielition the patient is made to look into a dark e-hamber at A'arious ol)jects. By means of a sliding shutter, the ehamber can be more and more illuminatcd, and the degree of light gradually increased until the patient says he can see the e/bjects upon the» test-card. A simulator can selelom ghe consistent and accurate statements. Feigning of eolen'-blindness can usually be ele-tecteel by the ordinary worsted test. Unless the patient be thoremghly experience»d in the mis- takes AA'hich the color-blind make, lie Avili put together worsteds of coloi-s which no color-blind person would confuse. In many cases of alleged elefective A'ision A'ery much can be learned by a careful examination of the fielel e>f visieui. Various iiiA'cstigations in hysteria and the so-calle-el traumatic neure)ses bave giA'en aelele-el weight te) the changes in the visual fielel. No satisfactory results, hoAvever, can be obtained without a careful investigation by meaus of the perimeter, and in many cases the field should be tested not only for form but also for coleir. If there be hemianopsia there Avili usually be other symptenns to confirm the diagnosis, such as amesthesia, paralysis, or the heinieqn'c pupil reaction. In many forms of disease, including the initial stages of optic atrophy, hysterical amblyopia, and other affections, there will be a concentric Hmitation of the field. If the perimeter be placed so that the light cornes from behind the patient's back, and the patient be facing a uniform dark surface, it is impossible for him to feign successfully the concentric limitation as tested on the perimeter. The outline of a feigned contracted field, as Oppenheim (Weitere Mittheilungen in Bezug auf die Traumatisehen Xeuivsen, p. 43) has shown, will be irregular, and much greater in some meridians than others. Furthermore, on repeated tests the simulator cannot feign the same contraction. Should doubt arise, avc may adopt the method suggested by Wilbrand and Saenger (Ueber Sehstorungen bei funetiouellen Xerveuleiden, p. 189), and test the field bv périme fers of différent diameters. This renders it practically impossible to simulate repeateelly a contracted field which shall bave the same ex- tent and outline. Hearing.—In the great majority of cases of actual deafness a careful examination of the ear by means of the aurai spéculum will reveal the cause, unless the deafness be due to lésion in the auditorv nerve or the labyrinth. Should there be a motive for simulation, and should any changes be found on examination, deafness may usually be detected by protracted observation. The simulator seldom'knows enough to distin- guish betAveen the vibratory sensations which are conveyed to his sensé of feeling by loud noises aud those which are conveyed to the sensé of FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 409 hearing by the saine noises, and lie Avili often deny any sensation Avhat- ever. The simulator may also start at unexpee-ted noises, and may be aremsed from sleep liy a loue! noise, or Avhen drunk or under the influence of an amesthetic he may ansAver questions that are put to him. Heller (op. cit., p. 103) lias suggested that simulated deaf-dumbness may bc de-tecteel by a perse)n aa'Iio is genuinely deaf and dumb, eu- by a teacher of the deaf and dumb, owing to the failure of the simulator ac- e-urately te> feign the belnwior of a genuine deaf-dumb person. Further- niorc, if the simulator lie uiiedueated, and attempt to AA'rite, he Avili not sptïll his Avords corree-tly, but Avili be apt to spell them as they are pro- nounce-el, whereas the deaf and dumb pe-rsoii will not be guided by the sonne! of the» Avord, but will spell it as lie has been taught. Absolute deafness, henvever, is not so likely to be feigned as par- tial ele»afness, and it is a well-known fact that in partial deafness the poAver of hearing may A'ary very greatly from time to time. In gen- uine cases of partial eleafne»ss there are usually definite changes in the ear. The simulator often fails to imitate the e-harae-teristic expression of a deaf person. Casper lemg ago suggested a method of examination which is of senne value. A se-ntence should be begun in a very loud A'e>ice, and the voice gradually leiAvered. The simulator will often be con- fuscel by this simple experiment. Burghardt (op. cit.) lias suggested another method of senne value. One ear is cleised anel the patient is put at such a distance that he cannot, as he claims, bear the ordinary spoken A'oice, the» eyes being blindfolded ; a tube is put in the affected ear, through which the patient can still bear. If iioav the tube be closed suddenly, AA'ithout the patient hearing it, and lie still hears the spoken word, lie hears it through the air, anel his previous statement Avas incorrect. Unilate»ral deafness is aise) occasionally feigned. If tliere are no changes to lie found in the ear itself, this may be detected in various Avays. Erhardt (Deutsche militar-drzt Zeitsehr., 1872) has pointed out that the sound of a repeater may be heard, CA'en when the ear is closed by the finger, at a distane-e» perhaps of ten feet. If the repeater be held six or eight feet in front of the sound ear the patient naturally hears it perfe-ctly Avell ; if that be closed anel it be brought within four feet of the ear Avhich is saie! to be deaf, anel the simulaten- says he no longer hears it, the chane-es are that his stateme»nts are incorrect. The best method of detecting simulation of one-sided deafness, hoAvever, is a modification of the expe-riment described by Ooggin (Zeitsehr. f. Ohrenheilk., vol. viii.). Coggiu suggests that the ordinary binaural stéthoscope be used. By this means the objee-t is brought rather too near the ears for careful testing, aud the experime»nt shoulel lie» modified so that the binaural stetho- sce>pe e-an be» usée! Avith much longer tubes, the patient sitting several feet away from the testing-eibjeet. With the stéthoscope placed in the ears it may then be possible, without the patient's knoAvledge, te) close one or the other of the conductiiig-tubes ; the sound is conveyed either to the sound car or to the allégée! deaf ear at the will of the examiner,, Avithout the patient's knoAvledge, and the simulator can in this way be readily led to make contradictory statements. Disturbances of smell aiid taste are of extremely slight importance», and we bave no absolute means of testing them apart from 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 absolute dumbness. Genuine acemired dumbness occurs only in hysterical mutisni, AA'here the patie'rtt is un- able to make any sound whatever. In the loss e>f speech of aphasia the patient makes varions inarticulate sounds. True aphasie disturb- ances, sue-h as AA'ord-blindness, Avord-deafness, motor aphasia, and para- phasia demand extrême skill upon the part of the simulator, anel in the vast majorité of cases they are associated witli hemiplegia. Feigned mutism is occasiemally seen as one of the symptoms of feigne»el insanity, but in tliese cases protracted observation will usually give the opportu- nity for revealing the patient's déception, and lead him into making some nnguarded remark. FEIGNED INSANITY. From the old statement of Zacchias, " Xidlus morbus facilius et fré- quent i as simulari solet quant iusania," to that of Kiihn (Archiv f. Psychia- trie, vol. xxii., p. 649), that the number of simulants of insanity are in inverse ratio to the physician's psychiatrie knowledge, is a long step, but it sIioavs both the increase in oui* knoAvledge of iusanity and the change of médical opinion in regard to feigning. Even at the présent time, however, although ail physie-ians regard feigned insanity as rare, there is not gênerai harmony as to its absolute fréquence. Thus Se-hule, in the second édition of bis Klinisehe Psychiatrie, stated that lie had never seen a case. Fritsch (Jahrbiicher fi Psychiatrie, vol. viii., p. 115) saAv but one case out of 3800 in Meynert's clinic,and Me>eli (Ueber irren Verbrecher) and Sander and Richter (Die Beziehuugeu zwischen Geistesstorung und Ver- brechen) hâve ail considered feigning as e»xtremely rare. It may be said, heiAvever, that thèse figures are taken chiefly from the statements in regard to gênerai insane asylums and the ordinary clinics for mental disease ; but Fûrstner (Arch. fi. Psych., vol. xix., p. 601) bas urged that if statistics were taken from criminal asylums, or from the cases of alleged insanity among criminals, it Avenile! be found that feigned insanity was not se) A-ery uncommon. Fiirstne-r himself found 12 e-ases ont of 25. Holmboe (Xorsk Magaziu fi. Laegevidensk, Xe>. 2, 1893) found 1 case in 21. Snell (Allg. Zeitsehr. f. Psych., vol. xlhr., p. 4) considered feigning not rare, and BinsAvanger (cited by Fiirstner) found 21 cases out of 73. Kiihn (art. cit., p. 650), on the e-ontrary, Avho had the opportunity of observing over 10,000 criminals, and had iiivestigated nearly 150 cases of insanity occur- ring among them, saw but two avIio had simulated. The figures already given from Massachusetts prisons would indicate that feigning of insan- ity by criminals was distinctly rare. It must, henvever, be» again noted that at the CharlestoAAii Stateqirison there were many attempts at feigning, which Avère readily detected by the prison physician Avithout the need of calling in a spee-ial examiner in lunacy. In the vast majority of e-ase-s insanity avuT be simulateel only by the criminal, although Xie'hols (Boston Med. anel Surg. Journal, April, 1891) has reportée! one e-ase of a boy AA'he» simulated dementia in the hope of obtaining damages on account of a rail- way accident. It must, hoAvever, be borne in mind that the pereentage of FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 4H actual insanity among criminals is probably much greater than it is in the community at large. Not only is the criminal more exposed to the various acquired injurious factors AA'hich may produce insanity, but often, as is well knoAvn, he is himself degenerate and cornes of a bad heredity. Even if we do not accept the théories of Lombroso that the actual crim- inal must be regarded as mentally diseased, the évidence in favor of bis degeneracy is too great to be absolutely neglected; and this is often shoAvn, not only in bis mental characteristie's, but aise) in many of the physie-al characteristics. More than one case indeed is upon record AA'here a criminal avIio already had one form of insanity simulateel another form ; and many A\n*iters agrée Avith Fritsch that the simulation of mental disturbance is very rarely seen in healthy individuals, and that, in gên- erai, the hypothesis is not unjustifiable that simulation points Avith some probability to a coexisting neuropathic disposition or psychopathic taint, or that it may be brought into relation Avith previous conditions of so-calleel degeneration. Sander aud Bichter (op. cit.) hâve 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 their nature and their perioelicity, anel are marked by irregularity and lack of harmony in the symptoms. Fritse-h has pointed out that much may seem simulated which. really is not so, anel cites the case of a young man who was repeatedly arrested for various crimes, who presented a peculiar com- bination of symptoms, characterized, first, b}^ a peculiar gait and ges- ticulations, Avith periods of silence, then by various delusions of a hypochondriacal type, Avhich were not at ail in harmony with one another, ami gave rise to much suspicion of malingering; yet pro- tracted observation finally shoAved a distinct underlying condition of paranoia. We must consider, therefore, that even the attempted simu- lation of insanity is rare, and that in feAv cases, if the physician bave any expérience, is it ever successful. In many cases it is difficult to make an absolute diagnosis of insanity from a single examination, and Avhen there is reason to suspect simulation a period of protracted obser- vation in an asylum may be necessary. From what bas already been said the difficulty of simulation is appar- ent. Krafft-Ebing (Lehrbuch d. gerichtl. Psycliopetthologie, p. 42) lias em- phasized this. The simulator is in some respects like an actor ; but, unlike an actor, lie must be an author as well, and lie must also constantly be an improviser ; bis acting, moreover, must be incessant, even if he thinks hiinself unobserved. A simulator must also act before an audience of trained critics who cannot be diverted from his performance ; conse- quently, lie must bee-ome exhausted after a few hours, and the mental strain of such a performance may in itself be a cause of mental break- dOAVll. The absurd attempts to depict insanity in the majority of novels well show the false ideas which are usually helel in regard to mental diseases. The lunatic, according to popular belief, is either raving or so demented that he is incapable of any sensible act or Avord. In a few cases, of course, the simulator may bave had the opportunity of associating with the insane and of studying their symptoms Avith eare. In such cases the portrayal of insanity may sometimes be sufficiently realistie-, as te) cause considérable doubt as to the actual condition. In ordb 41*> A SYSTEM OF LEGAL MEDICINE. nary cases, hoAvever, where tins opportunity for spee-ial study is absent,. the'simulation is so grossly exaggerated, and se» entiivly 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 insanitv beuin suddenly, de vêle') ping upon a pe»riod of apparent mental health ■ the slight prodromal stages, whieh can usually be clicited 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 démonstrative, or else, less freepiently, they began by some lase-ivious act, such as exposure of the person. The simulator usually greiAVS worse under examination, and at other times lie Avatches the acts of the physi- cians and attendants in a way whieh is seldom seen except in some e-ases of paranoia. He also fears to be too reasonable ; lie has no memory of anything ; he is never cohérent ; in the quiet periods of his insanity lie knoAvs nothing; lie manifests no logieiil reasoning and no assex-iation of ideas. The case of a man repen-te-d by Krafft-Ebing (Jahrbiicher fi. Psy- chiatrie, vol. viii., p. 293) avIio simulated dementia, deafm-ss, and dumb- ness, sIioavs some of thèse peculiarities. The patient suddenly became demented, deaf, dumb, aud did not react at ail to external processes. Previous te> that time lie had been sane». Such a condition naturally coule! resuit emly from some seA'e»re psychicàl shock or acute brain dis- ease leading to profound mental disorganization, yet, although apparently so demented, lie shoAved himself capable of varions acts requiring consid- érable mental poAver. When given a Avritten eu-der to perform certain acts he responeleel by Avriting A'ariems letters in a discoimeeted manner. He had apparently lost ail idea of the movements for feeding himself, yet he acquired them at eniee Avlien shown how to eat. Unlike a dément, he became violent Avhen deprived of food. Another patient, who feigned acute hailucinateu-y e-onfusional insanity, Avas apparently anaesthetic to a pin-prick Avhen he kneAV Avhat Avas being done», but responded Avhen he Avas unexpectedly pricked. His delirium Avas not continuous, but he was forced to break off until he could think of new material for his delirium, anel fill the inteival by singing a song or repeating some steree>type»el phrase, and Avhen the symptoms which lie at first presented failed to Avin confieleiice other symptoms were added. The simulator, men-eeiver, may assume certain symptoms AA'hich are suggested to him. A shreAvd feigner might naturally be upon his guard if the physie-ian Avère to make use of the phrase AA'hich Avas once advised, that if the patient Avère insane lie would présent such and such symp- toms ; but lie Avould often be taken off his guard if the remark be maele that such symptoms, if présent, Avould indicate a particular type of dis- ease ; or if careful inquiry Avère maele Avhether such symptoms, which Avère characteristie' of the dise-ase, were pre-se-nt. Thus, in the e-ase already cited, reportée! by Tamassia, the patie-nt manifested a feehng of cold in the ear, and a live»ly pain on pressure over the left clavicle, on overhearing the remark that in the type of disease which she exhibited tliose symptoms were ahvays présent ; later, after another suggestion, pressure over the third cervical vertebra caused extension of the great toe. Simulators often manifest a letss of memory, Avhich is so great as to render it practically impossible that it should be real. As a rule, if an insane person can be made to respond to any questions lie re tains some memory of familiar FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 41g facts ; but a simulator whose case was reported by Bernardini and Petraz- zani (Iîivista sper. di fireniatria, vol. xix., p. 696) could not remember his own name or that of his father, did not know in what toAvn he Avas, Avas ignorant of the motives for which he 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 Aveek, that four and five made six, and that three times four were five. Another patient when asked to mention the names of the days of the week left out Tuesday. When the insane answer questions at ail they usually answer with some degree of sensé. Thus, if an insane person be asked his âge, he may not give a correct answer, but his answer will ahvays hâve some definite relation to the question put, and not be something entirely différent. He will never say, as did Derozier (Spitzka, Insanity, p. 355), "245 francs, 35 centimes, 124 carriages te> carry it." Spitzka (op. cit., p. 364) has mentioned various spécial signs which just if y suspie-ion of simulation. The simulator Avili demonstratively avoid looking the physician in the face, which the patient in stuporous conditions neAer does. He will give extravagant, absurd ansAve»rs to simple questions ; he will often be very slow in answering and yet not présent the appearances of depressed states. He will be watchful to see whether an eibseiwer is approaching. He may recollect his acts and ex- pressions during a feigned epileptie state ; he may make various strange, rhythmical movements which hâve no analogy with any form of insanity ; he may eomplain more of strange feelings and pain in the head than the insane usually do. He may, if lie 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 (Dietiouary 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 Avith the workings of the paranoiac mind the détection of simulation becomes easy. FeAv simulators could ever feign the logical reasoning of the paranoiac on the subject of his delusions, his facial expression and actions. His delusions are highly systematized and workeel into every act and thought of his daily life, and traces of them may be found in hundreds of trivial matters. The shreAvdness and logical reasoning by which every event of the day is brought into train with the gênerai ideas of persécution is something that no one is able to counterfeit without unusual opportu- nities for study. In paranoia, too, there Avili be the history of a bad he- redity or of mental peculiarities beginning in early life and of a graduai development of the symptoms. The feigning of other forms of insanity is distinctly less common. Paretic dementia in its advanced stages présents certain well-known physieal signs of the disorder, so that it cannot be simulated ; but Fiïrst- nei- (art. cit.) bas reported one case of a man who had formerly spent se'vcral Aveeks with a paralytic, AA'ho feigned the dementia, the delusions of grandeur, the speech, the uncleanliness, and even the attacks. Spitzka (op. cit., p. 354) lias cited the case of a man who feigned, with considér- able skill, the prodromal symptoms, and Norman (art. cit.) has mentioned another case. Fiirstner (art cit.) states that most frequently the simulator présents 414 A SYSTEM OF LEGAL MEDICINE. the picture of dementia, with coexisting apathy or mutism, or with strik- ing contradie-tions of speech, writing, and actions. Next in frequency cornes a condition of clouding or loss of consciousness, which is claimed to hâve occurred at the time of the criminal act and is usually accom- panied with hallucinations. In the third group the symptoms are vari- able, irregular, and confused. The fourth group présents conditions of excitement, with confused, senseless utterances, and a tendeney to violent acts. Ail thèse forms, however, présent symptoms not unlike those seen in acute hallucinatory confusional insanity (Acute halluciuatorische Ver- wirrtheit, Amodia of Meynert), the form of insanity whieh probably is the least readily re-etognizeel by alienists in this country. In this form of insanity the* simuîaten* usually misses the pe-culiar confused condi- tion. He is too incohérent, and eloes not manifest the occasional intelli- gent association of ideas seen in the-se confused states; lie does not give the sensible answers whie-h patients e-an sometimes be roused into giving. Such patients, moreover, Avili often manifest sensé enough te) ansAver in regard to familiar matters of life, to tell their name, to re- member people, to state the days of the week, to count, or to do simple sums. Most cases of tins condition, too, show distinct physieal changes, a sluggish circulation, cold anel congé-sted extremities, and a marked loss of weight ; they also shoAV occasional A'iolent outbursts and distinct de- lusions. In ail the acute psychoses tliere are usually distinct ]>hysie-al conditions coexisting witli the mental disease AA'hich point elefinitely to a morbid state, such as the increaseel puise, insomnia, leiss of appetite, loss in weight, détective circulation, and \-arious conditions of the skin, especially cedd- ness and cyanosis. The simulator Avili sometimes cease his actions if he thinks himself unobserved. A simulator at Charlestown was extremely noisy when anybody Avas about, but lie Avas very quiet when lie supposed the officers Ave»re out of hearing. Occasionally the simulator Avili 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 démonstrative, and tore ail her clothing to pièces, and was found in her cell stark naked ; yet, A\rhen the officers came to the cell, she turned her back to them, which no maniac as violent as that woulel hâve done. In rare cases, especially AA'here the simulator has had opportunities for studying or observing insanity, the skill in feigning is sometimes extremely great, and shows Avonderful powers of endurance. A simu- lator at the Suffolk County House of Correction went so far as to daub himself and his cell Avith excrément, and finally to eat his oavu faeces. In regard to the feigning of the différent types of insanity the forms which can be most successfully feigned are those Avhich présent the type 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 (cul. cit.) has reported such a case, where a man for Aveeks Avould not utter a word. Careful observation faileel to show that lie moved during the night, and in passing through a low doorAvay he Avould strike his head unless the attendants took pains to push the head doAvn low enough for him to go under. In this way he received several pretty severe bloAVS. He would not take food, even if it were left beside FEIGNED DISEASES OF THE MIND AND NERVOUS SYSTEM. 415 him, although he Avould swallow when food Avas put into his mouth. He did, hoAvever, respond when cold water was sprinkleel upon him unex- pecteelly, anel he finally escaped from the prison. One of his fellow-pris- oners afterward cemfesseel 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 dépression of simple melancholia, or convalescence from thèse conditions, with a certain amount of success ; but no patient has the physieal endurance to feign the excitement and violent actions of ordinary mania, and although he can assume incohérence for a time, lie cannot keep up the incessant flow of incohérent plirases ; after a time nature must assert itself and fatigue will be manifested. Insomnia, rapid loss of weight, and loss of appetite, are ail beyond his control. The same may be said of the feigning of acute melancholia. Although for a time he may assume the dépression, he cannot keep up the psychicàl anaesthesia, the profound dépression, the manifestations of grief, the self- absorption ; nor can he feign the insomnia, the cold and clammy extrem- ities, the weak puise, the loss of appetite, the constipation, and the various other physieal symptoms so often seen. In conclusion, it may be said that in the majority of cases where simu- lation is suspected there may be symptoms présent upon examination which will prove that our suspicions are in part gronndless ; but it must also be borne in mind that the failure to find such symptoms as hâve already been described, or even the détection of symptoms which are apparently contradictory, is not absolute proof that the disorder is simulated. BIRTH, SEX, PREGNANCY, AND DELIVERY. BY ANDREW F. CURRIER, M.D. I. BIRTH. Légal Obligation of Physicians with Référence to the Recording of Births —Détermination of the Period of Development in Xeiv-boru Infants, especially in the Stiïl-born, with Evidence Relating to the Viability of the Latter. The importance of correct and accurate vital statistics both to the lawyer and the physician is self-evident. Indeed it is a matter in which the entire commiinity is interested, for in the absence of accurate records of this eharaeter how can the status of a community as to population be asce»rtaineel ? But there are other considérations Avhich are of much greater significance in this connection—considérations which affect the material welfare of large numbers of indhiduals, anel Avhich dépend in no small degree upon the faithfulness with Avhich thèse records are made. The responsibility of physicians is, therefore, direct and decided in this matter, and should be appreciated from the very beginning of their career. The state rather than the chureh should be the custodian of such records, at any rate in so far as the material interests of the individual are con- cernée!. The récognition of this fact has doubtless been an important factor in the formation and development of bureaus of vital statistics in connection with the systematic régulation of ail matters which pertain to the public hygiène. One of the decided eAudences of advaucing civili- zation consists in the verj'- gênerai establishment of boards of health, and the development of sanitary science in ail parts of the world. With in- ■creasing expérience the work of such bodies is yearly becoming more perfect and A'aluable. It will continue in this direction, pari passa, with the importance which physicians attach to it, and the heartiness and in- telligence of their coopération. In New York the law requires the return of a birth-certificate to the local board of health or other officiai 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 fulfill this requirement. This is the duty of the physician if he were in attendance at a given birth ; otherwise the return must be made by the midwife or other person who assisted when the birth took place. The importance of this subjee-t should be emphasized by those AA'ho serve as instructors in 418 A SYSTEM OF LEGAL MEDICINE. médical collèges, and in the examinations which e-andidates for license to practice are compelled to pass. lu France the folloAving sections from the Civil Code appertain to the registre of births : "Art. 55. Déclarations of birth must be maele Avithin three days of accouchement to the preiper civil officer ; the chilel shall be sIioaaii to him. "Art. 56. The birth of a child shall be declared by its father, or, in default of the father, by the physician, surgeem, niiehvifc, offie-e-r of health, or other perse>n avIio assisted at the aceemclie-ment, and if the mother Ave-re confined aAvay from her oavu home by the person at whose house she Avas delivered. The fact of the birth shall be stated in proper légal form in the présence of tAvo Avitnesses. " Art. 57. The return of a birth shall specify the day, hour, and plae-e of birth, the sex of the child and the names lie lias re-e-e-iveel, the first and second names, occupation, and résidence of the father, mother, and wit- nesses." " Pénal C<3DE, Art. 346. Every person assisting at au ae-e-oue-hement Avho shall fail to make the déclaration as prese-ribeel in Art. 56 of the Civil Code and in Art. 55 of the same Ce nie 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 présent at the time ; otherwise upon the physician, if one were présent, devolves this obligation, if he assisted efficiently in the accouchement. The duty devolves upon him though the child is born upon bis arrivai, if it is still united by the cord to its mother and the placenta is still in utero or in vagiua. The same obligation holds for still-born infants if they bave passed the fourth month of fetal life. (Vibert, Précis de Médecine Légale, Paris, 1886, p. 645.) The détermination of the period of development Avhich bas been reached by a new-born infant, Avhether it is mature or prématuré, whether it was living and \dable at birth, are ail matters of the greatest importance, and can usually be decided with a considérable degree of précision. Thèse subjects are elaborated in the article upon Infanticide (q.v.). n. SEX. Hermaphrodism—Defective and Rudimentary Organs of the Génital Ap- petratus, and the Bearing of the same upon Matrimouy and Fertility —Détermination of Sex—Puberty and its Attendant Phénomènes Menstruation, Xormal and Abnormal—The Ménopause. Hermaphrodism or hermaphroditism is a condition AA'hich has elicited a great deal of attention from the earliest times and has given rise» to a great variety of opinions and spéculation. The work of Klebs upon this subject is scholarly and rational, but that of Pozzi in his Traité de Gyné- cologie, vol. ii., p. 1069, is more récent, and will be frequently referred to in this article. To go to the root of the matter in defining the term, Ave must hâve in a true hermaphrexiite, as Pozzi correctly states, a being AA'ho has the génital organs of both sexes, with the possibilité of functional activity of both sets of organs. The testicles and oA'aries are the essen- tial organs of reproduction in the maie and female sexes respectively. BIRTH, SEN, PREGNANCY, AND DELL VERY. 4.19 A true hermaphre)dite must bave organs Avith the anatomical peculiari- ties of both o\'aries and testicles. Pozzi déclares that there does not exist a single incontestable example in which tins condition bas be-e-n realized; but lie, as Ave-11 as Kicks, has evidently OA'erlooked the case of He»ppne»r (quoted by (larrigues in Haiin's System of Gyuecology, vol. i., p. 26!)), Avhich Avas that of a e-hild Avhich dieel at the âge of twe> months and Avas found by post-mortem examination to bave a hypospadiac pénis or e-nlarge-el clitoris, a cleft scrotum, a sinus urogenitalis and Rosenmuller's organ repre-senting parovarium anel epididymis, a prostate gland, both testicles, vagina, utérus, Fallopian tubes, both ewaries, round and broad ligaments. The e>va.ries e-ontained (h'aafian follicles witli ova, and the testie-les hael séminal canals. Among plants and many of the hnver orders e>f in vertébrale; animais the condition of true hermaphrodism is common enough. Bland Sutton states (Transactions London Pathological Society, 1S85, pp. 509, 510) that among the vertébrales it occurs in the coel and herring, and that an ove)-testis is ve-ry common in the te>ad anel frog. Hermaphrodism is usually e-lassified as true aud spurious, the former of which must be exce»eeïingly rare, making due allowance for any case»s Avhich may not haA'e been reporte»d. Pozzi bas exaniined many spécimens Avhich hâve been regarded as examples of herniaphrexlism in the Musée Dupuvtren anel elseAA'here, as Avell as the available literature, and bas founel the-ni ail spurious.* Inste-ael eif true and spurious hermaphrodites it Avould seem more practical to foUow Pozzi in classifying them as gynanders and androgyns, accen-eling as the peculiaritie»s of the female or the maie sex predominate. In gynanders there may be menstruation, Avell-developed mammae, utérus and ovaries, and the possibility of imprégnation. In androgyns menstru- ation is absent, the bivasts are» of the maie type, utérus anel ovaries are absent, anel there is a possibility that they may beget offspring. In both * Plenty of cases are recorded in légal anel médical literature as véritable instances of hermai>hrodism. Lukoinsky's case (quoted by K. Guiteras in Morrow's System of Gcnito-itrinari/ Discaxcs, Si/iiliilnlor/;/, and Dermatohxjy, vol. i., p. 50) was that of an individual thirty years of âge, with }ienis two inches long, without urethra, below which was a scrotum with two testicles. Below the scrotum was a normal vulva, with labia majora., labia minora, and. clitoris, the urethral opening being below the clitoris. The vagina was three inches in depth and terminated in a normal utérus. The patient had never menstruated. When coitus was practiced with a female a whitish fluid was ejected through the vaginal slit. Whether ovaries were présent is not known ; henee the évidence is inconclusive. Wharton and Stillé (Médical Jurisprudence, 1SS4, vol. iii., p. 140) narrate several cases of varying degrees of importance and authenticity, including the following : Kiwisch's case was thirty-three years of âge, had a normal pénis, with rugose but enipty scrotum, a normal utérus in proper position, a rudimentary vagina opening into the prostatic portion of the urethra, Fallopian tubes, three and three-quarter inches long, with imperfect fimbriae, normal round ligaments, no ovaries, testicles with epielidymis and efferent duct leading to the inguinal ring and finally opening into the prostate gland, the latter being of normal size and provided with vesieula? séminales on either side. Ackley and Blnckman's case was twenty-six years of âge, with the gênerai appear- ance of a man, but with very broad hips. Painful discharge of blood had occurred from the pénis at monthly intervais. Tliere was a large pénis, also an empty scrotum, pervious Fallopian tubes, ovaries, testicle on each side above the ovary, with exci-"- tory ducts leading from them, vagina opening into the neck of the bladder, and pros- tate gland. The inner surface of the vagina was covered with blood when examined post mortem. The same spécimen was examined by J. B. S. Jackson, who found 110 trace of the os externum uteri, 110 vaginal portion of the cervix uteri, and a vagina only 420 ^ SYSTEM OF LEGAL MEDICINE. Fig. 60.—c, Clitoris; b, Connecting bridge from Fig. 61.— c. Clitoris; ov, orifieium clitoris to meatus urinarius ; mu, meatus urinarius ; ov, vaginse. (Pozzi. ) orifieium vagina;. (Pozzi.) in some cases, but the common observation is that they are stérile ; in fact but tAvo cases occur to the writer in the literature of the subject in four or five lines in circumference. No true ovarian structure was found. The testi- cles were normal in size and structure, but there were no vasa deferentia, vesiculae séminales, or prostate gland. Among reeently reported cases may be mentioned one of Mr. Edgar Willett's, reported at the meeting of the London Pathological Society, February 6, 1894. The spécimens presented were from a man who died, at the âge of forty-four, of cérébral hemorrhage. The testicles were undescended ; there was a well-developed utérus 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 pénis was well developed. The man wore a beard, was married, and had two children. The testicles were provided with vasa deferentia, which passed down by the side of the vagina toward the prostatic division of the urethra. The vagina nar- rowed as it perforated the prostate gland, and opened in the usual situation of the utérus masculinus. A closed Fallopian tube proceeded from the utérus on either side, terminating above the globus major of the epididymis in a body representing the usual hydatid of Morgagni. Mr. Stonham reported a similar case to the society a few years ago. BIRTH, SEN, PREGNANCY, AND DELIVERY. 421 which they Avère observed to be fertile. (Cases are reported in which hermaphrodites bave discharged semen containing living spermate>zoa, while others haA'e had ovaries in whieh were Graafian follicles and e>va.) They must necessarily hold a peculiar position before the law. Their right of holding property and \roting might be called in questiem. If they mar- ried the marriage might be annulled on account of their physieal defects, and yet the laAV deies not forbid their marrying. They ma}' hâve inordinate or détective sexual désire. In the cases AA'hie'h one finds re-corded, tliose AA'ho resemble females are in some instances excessh'ely libidinous. This may be élue to the exubérance of erectile tissue in the preteriiaturally enlarged clitoris, and the irritation to Avhich that sensitive organ is continually exposée!. In tliose avIio resemble maies, on the other hand, an aA'ersion to Avomen and to the sexual act is sometimes reported. The absence of well-marked peculiarities AArhich are common in the physieal deA'elopment of well-formed spécimens of either sex is to be expected in individuals of such doubtful or blended sex as are hermaphrodites, but one doe»s not see, in actual expérience, the grotesque characteristics AA'ith which Avriters bave» been prone to clothe thèse unfortunates. One should not expect to find, on the one hand, a strong A'eùce anel a manly beard, or, on the other, well-roundeel limbs and womanly breasts—thèse are the attributes of persons avIio are not physically eh'fecthe; but one may sometimes see individuals AA'ith imperfee-t ge-nera.th'e organs of one sex and Avell-marked pee-uliarities of figure and habit of the other. The précise détermination of the sex in such cases is not easy. Hermaphrodites are not the only ones aaIio possess peculiarities of the génital organs, but such peculiari- ties are often their chief distinguishing feature, and they Avili now be considered in détail, together with similar or related peculiarities in individuals about Avhom the sex is not doubtful. The génital organs of the maie are the pénis and scrotum externally, the latter containing the testicles Avith their appendages, the epididy- mides, and the spermatic cords, which ceuinect the testicles with the séminal ve»siclcs, the latter lying at the base of the bladder and serving as re-serA'oirs for the semen. This fluid is conveyed from the testicles, Avlie-rc it is see-reted, through the vas deferens, a tube contained in the spermatie- cord, to the séminal vesicle, whence it is discharged in the act of copulation into a short tube called the ejaculatory duct, and thence into the urethra, the canal AA'hich extends through the entire length of the pénis, terminating in the bladder, the réservoir of the urine. The pénis 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 thèse structures is not essential in this connec- tion. The testicles are developed in the early months of fetal life on either side of the loAver (lumbar) segment of the spinal column, from which position they gradually descend into the pehis or bony basin which connects the body or trunk AA'ith the lower limbs. During the seventh month each testicle leaves the pehds, passing down a canal in the antei-ior and lowermost portion of the abdomen known as the in- guinal 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 hair), and the labia majora, the latter presenting an elliptical appear- 422 A SYSTEM OF LEGAL MEDICINE. ance, lying under the mons Veneris and being partly cemccaled from vieAV on account of the inclination of the pelvis Avhen a Avoman is in the erect position. Within the dépression at the inner aspceit of the labia majora and including its upper two thirds are the labia. minora or nymphae, and at their apex is the clitoris. BeloAv the clitoris is the opening of the urethra, the lat- ter terminating in the bladder, and beloAV this opening the entrance or introitus of the va- gina, which in the virgin is usu- ally shielded by a membranous structure, the hymen. The va- gina is a tube about three inches long AA'hich terminâtes in the utérus or Avomb, a portion of its neck being within the vagina, while the remainder of the neck and the entire body are above the vagina and in the cavity of the pelvis. The utérus 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 utérine end by a ligament an inch or an inch and a half long, is the ovary, an ovoid structure about as large normally as a small English wa.lnut. It is also attached to the fringed extrem- ity of the tube by a single stalk or pedicle of very délicate 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 utérus. On its way through the tube or within the utérus it is met by the spermatozoon, union of the two éléments and conception taking place ; or if this does not occur the ovum is cast out of the utérus as inert matter. The pénis may be abnormally large or abnormally small. It may be so small as to simulate an enlarged chtoris and perhaps cause uncertainty Fig. 62.—Example of hermaphrodism. (Pozzi.) c, Clitoris. BIRTH, SEN, PREGNANCY, AND DELIVERY. 423 as to the sex of the indiAddual. If the organ in question has a canal and this canal terminâtes in the bladder, the organ must be a pénis and the individual a maie, no matter what other defects may exist. An imper- fect urethra AA'ith an opening on the loAver surface of the pénis (hypo- Fig. 63.—p, Hypospadic pénis; s, symphysis pubis; t, testicle; v, bladder; v.p, pseudovagina; r, 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 tliere is no doubt in regard to sex. Such a deformity often prevents fruitful sexual intercourse. Absence of the pénis may resiilt from elisease or injury ; congénital absence of the organ is of very rare occurrence. The scrotum may be clef t or bifid, suggesting the labia majora of the female, and tins is common in hermaphrodites. It may be empt}', that is, Avithout testicles, or it may hâve a single testi- cle, neither of them, or only one, having descended during fetal life. It may hâve a smooth surface like the labia majora, or the wrinkles and creases which are normal to it. The development of the testicles may bave been arrested, or they may hâve Avithered (atrophied) and disap- peared. If the testicles lnive descended only partially they may be found thus dislocated post mortem, and give rise to uncertahity as to whether they are oA'aries or testicles. Absence of the testicles may be due to disease or injury. In eunuchs the testicles alone may hâve been removed, or the testicles and pénis. Disease of the other organs of the maie genito-urinary apparatus may haAre an important bearing upon the question of proe-realhe ]>ower anel sexual capacity, though it might not cause» difficuhy in the détermination of sex. In the female the appearance of the labia majora might suggest a détective scrotum, especially if one or both 0Araries had descended into 421 A SYSTEM OF LEGAL MEDICINE. them; an accident which has seimetimes occurred, though in an extensive expérience during many years the» Avriter has neAer se-e-n it. The e-lite>ris is normallv half an inch te> an inch in length, only its minute e-xtremity being usually visible, but it may be enlargeel to a length of thre-e, fe)in*,. or eA'en five inches. (See Wharton and Stille'», vol. iii., p. ll-'l.) It is sus- ceptible of érection, and when greatly enlarged may perform the' same function as the pénis in the copulathe act ; but it has no canal, en- 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—especially if the clitoris is greatly enlarged. In adult life they may becenne large aud prominent; in the Hottentots they are» enor- mously enlarged and pendent. They are» often enlarged as the resiilt of masturbation, and sennetimes as the resiilt 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 eharaeter which has been under the writer's eare. The patient is a large, well-developed woman, twenty-four years of âge, a prostitute, a syphilitic for three years, an opium-smoker for a vear. 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. BIRTH, SEN, PREGNANCY, AND DELIVERY. 425 suse-e-ptible of cemsiderable dilatation. In hermaphrodites and those A\rho Avère otherwise deformed, it lias sometimes been mistaken for the A^agïna anel lias been used in the copulative act, of course to the great détriment of the indiAddual. The hymen may be rudimentary and présent no obstruction to coitus, or it may be se) thick and firm that coitus Avili be impossible until it bas been incisée! eu- entirely removed. In such cases serious difficulty may Fig. 65.—Figure representing the female organs of génération. (D. Berry Hart.) F, Ovary ; G, par ovarium ; H, round ligament ; O, broad ligament ; N, entrance to vagina ; L, labium minus; K, labium majus; M, clitoris; P, vagina; A, os uteri; B, body of utérus; C, f undus uteri ; D, Fallopian tube ; E, fimbriated extremity of tube. arise on account of the rétention of the menstrnal fluid. A large ab- dominal tumor may thus be formed, anel the issue may be a fatal one. The vagina may be» rudimentary or entirely wanting.* If the» vagina is rudimentary it is often possible that it may be so developed as to accom- plish ail the necessary functional purposes. The utérus is seleleun entirely Avanting. I. E. Taylor bas reportée! two cases in AA'hich post-mortem examination reArealeel no trace of the organ. It is very frequently rudimentary. Peaslee has reported a case in Avhich it Avas a mère band of tissue of no functioual importance. (Mann's System of Gynecology, A'ol. i., p. 269, quoted by Garrigues.) The Avriter bas seen many cases in Avhich it Avas very small and insignificant. In hermaphrodites it is usually rudimentary. Such a condition may * An interesting case of this eharaeter was under the writer's eare reeently. The patient was a girl, sixteen years old, with no vagina, ail the other organs being well developed. Inability to discharge the menstrual fluid had led to the formation of a large abdominal tumor. This was openeel and evacuated through the rectum. A false opening was then made where the vagina should hâve been, but after two months her physician unfortunately allowed it to close. The menstrual fluid then reaccumulated, and the writer found it necessary to open the abdomen and remove the ovaries, thus bringing menstruation to an end. In view of the possibility of matrimony a vagina was then made by cutting, tearing, and dilating, the opération requiring several months for its conipletion. This vagina might serve the purpose of copulation, but could not be expected to answer for the safe passage of a fétus ; henee the necessity of sterilizing the patient to anticipate a possible calamity. The patient was at last accounts entirely well. 42G A SYSTEM OF LEGAL MEDICINE. effectually prevent imprégnation, but it is astonishing te> what an extent such an organ may be developed by suitable gyneceilogical treatment or by the stimulus of coitus. If impre»gnation takes place se»rious results may occur, on account of the imperfee-t eharaeter of the tissue; either abortion or rupture of the organ, usually Avith fatal resuit, being the eeuisequence. The Fallopian tubes are» essential organs in the female repreKluetive» apparatus, forming the emly médium of eeminiunicntion betAveen the utérus and the ovarie»s, anel unless they are in proper func- tional anel strue-tural condition the passage of ova to the utérus and the» acconiplishmeiit of imprégnation be-e-ome impossible. The tubes arc not essential to menstruatiem, as senne Avriters bave affirmed, fe>r menstrua- tion bas bee»n known to continue after they haA'e been renmved, more or less of the ovarian structure having been retained. Their importance as OA'iducts is suprême, and for this function there can be no substitute. The»y may be rudimentary, mère impervious cords, and they are suscep- tible of A'arious forms of elisease at ail pe-riods of life. Disease of the tubes may be curable spontane-emsly or as the resuit of surgieal treat- ment, or it may be incurable. It may be of a malignant eharaeter (sar- coma, carcinoma), or inflamniateiry, the resiilt of gonorrhea, abortion, or labor at term ; it may be due to infection from unclean hands or instru- nie-nts, the infee-tious preu-ess having extended from the vagina or utérus ; or it may be an élément in an infections elisease such as tube-rculosis or syphilis. In the great majen-ity of e-ases the» discase» is due te> gonorrhea or abortion, the ultimate e-ause- being an infective bacte-rium. It is one of the most common forms of disease peculiar to Avomen, and its im- portance in a medico-legal sensé, especially with référence to the respon- sibility of the gynecologist in its récognition and treatme'iit, is great. It bas heretofore escaped récognition in medico-legal works, principally for the re»aseui that until A'ery reeently e-orre»ct knowledge of the subject was possessed by A'ery few. In hermaphrodites the Fallopian tubes are often AA'iinting or rudimentary. The ovaries are the distinguishing sexual organs of the female as the testicles are of the maie, anel the absence of them renders the individual absolutely incapable of conception. They control the function of ovula- tion and bave a A-eiy decided influence upon menstruation. In cases in AA'hich they bave been removeel menstruation usually ceases at once or within a short time, but it has been known to continue for many months afte»r their removal, thus supporting the statement of Arthur Johnstone that the menstrual function is cemtrolled by a nerve» in the broad liga- ment contiguous to the utérus, and that this nerve bas not been eut Avhen the ovaries are removed should menstruation persist, The ovarie»s may be e-enigenitally absent or they may be very small and defee-tive in struct- ure. Like the Fallopian tubes, they are extremely susceptible to dis- ease, and the elisease may begin in fetal life or it may be de-ferred until advanced âge. There is perhaps no organ of the boely AA'hich is subject to disease in a greate»r variety of forms, and perhaps neuie» which is at- tacked more frequently. It further resembles disease of the Fallopian tubes in that it may lie recovered from spontaneously, it may make the patient an in valid for life, it may be fatal AA'ithout a timely surgieal opération, or it may be inévitable 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 glory BIRTH, SEX, PREGNANCY, AND DELIVERY. 427 of modem gynecologieal surgery that it has found a remedy for the disease in thousands of cases AA'hich formerly Avère doomed to certain death. The medico-legal importance of ovarian discase, like that of tubal disease, bas but lately been ree-e)gnized. In hermaphrodites ques- tions relating to the ovaries are ahvays of great significance, and the sex of an indiAddual under e-onsideration may require for its détermination an abdominal opération, inspection of the pelvic organs, and differentia- tion Avith the aie! of the micmsceipe e>f ovaries from testicles. Unde- si-eneled testie-les may be mistaken by outward examination of the body for e>varies, the gênerai contour of the persons frame and the appearance of the external gvnitals may still leave one in eloubt as to the» question of sex, but the structure of the e>rgan as revealed by the microscope Avili usually set doubt at rest* Pozzi bas analyzed three remarkable e-ases reportée! by excellent German authorities, Avliie-h Avère regarded as illustrations of the coexistene-c in the same person of te»sticles and ovaries. He e-emcludes that the propositions advaiiceel haA'e not been pioved. The condition of the breasts in hermaplirodites or those aa'Iio are of doubtful sex may prove of great A'alue» in deciding the question of sex. In some e-ase»s in AA'hich the external genitals are of the female type», the breasts Avili be flat, the nipple poorly deve'loped, and the mammary gland rudimentary. This bas bee-n the history in a number of recorded cases of hermaphrodites of gynander Arariety, but other cases are recorded in which the resemblane-e to the- female type of breast is unmistakable.t In ree-vut years, that is, since the era of abdominal surgery began, and in Avhich the number of opérations upon the essential organs of généra- tion in the female has multiplied, feAver cases of doubtful sex hâve been reportée!. Should they be necessary, exploratory opérations may be îvsorted to in case-s of doubtful sex, AA'ithout Avaiting for the décision of the post-mortem table. The bearing of the foregoing pages upon the questions of fertility and matrimony is direct and important. Marriage being a contract in the eye of the laAV, and one Avhich may be dissolved under certain adéquate e-onelitions, it folhovs that beith parties to the contract hâve a right to knoAV beforehanel AA'hether each. is in such physieal coneiition that the marriage relation e-an be properly ceinsummated. It is assumed that such knoAvledge is lawful, because a dheu-ce is granted in cases in Avhich physieal defects prevent the consummation of the marriage relation. The family is the unit in civilized seie'iety ; it is essential to the stability of se)ciety that the» propagation of species should be effected under the safeguards of the family ; the love» of offspring is innate, and should be» encoursgeel within reasonable limits, and is one of the bulwarks of soe-iety : therefore, Avhatever our AÙews as to the morality orimmorality of divorce may be, A\re must admit that society can protect itself only * The writer is aware that Zweifel has stated that the ovary and testicle in early infancy closely resemble each other in their anatomical structure, and that differen- tiation of them may be an extremely difficult and délicate task. (Pozzi, loc. cit., p. 11)7!).) t In Von Franqué's case (quoted by Garrigues, Mann's Si/slan of Gynecology, p. 2G9 et seq.), the individual whose picture is given has a strongly marked female face, broad hijis and back, long hair, and finely developed breasts. She lived as a woman until her forty-sixth year; then, as the maie organ of copulation was strongly devel- oped, and as a whitish fluid was discharged from it during coitus, she assumed maie attire, married, and lived as a man the rest of her life. 428 -4 SYSTEM OF LEGAL MEDICINE. bv the marriage of men anel Avomen in whom the reproductive ap- paratus is ne>t impotent. This is fundamental for se>ciety at large, and if true for the mass it should be true for the individual. But absence e>f offspring does not necessarily imply absolute impedence or even defe-ct of the reproductive apparatus in either a husband or a Avife ; ail the organs may be structurally sufficient for the proper performance- of copu- lation, the désire for offspring may be intense, anel yet the désire is not gratified. It has often happened that in senne of thèse cases the adop- tion of suitable médical or surgieal measures brings the desired end; in eithers the husband or Avife, by marriage Avith some other persem, demon- strates by the présence- of offspring after a suitable period the fae-t of bis or lier ability te) beget or to conceive. Divorce in such e-ases must be for seune etther cause than physieal defect, otherAvise husband or wife might be the victim of grave injustice. What, then, are the conelitions pertaiuing to the reproductive apparatus AA'hich reuder marriage in valid bee-ause necessarily infertile f Plainly, the absence of those organs which are essential to the marriage ae-t and to the begetting or bearing of offspring. A man avIio Avas Avithout testie-les at the time of his mar- riage» Avoulel be absolutely unable te> beget offspring. But a man Avithout a pénis, wtith one Avhich is rudimentary, or AA'ith only a stump resulting from disease or injuiy, may accomplish the sexual ae-t, though imper- fectly, and may beget offspring. It would therefore be a question whether a Avoman Avhom lie may bave marrieel e-ould secure a divorce from him on the ground of his imperfectieni* Eunuchs are incapable of begetting offspring bee-ause deprh'ed of testicles. This ele)es not signify that they are alAvays Avithout sexual désire, and it is said that in e-ase-s in AA'hich the pénis has not been removeel the sexual act is not unusual. If a female is Avithout a vagina sexual iiitercourse anel conception are both impossible, though ail the either génital organs are présent and AA'ell eleveleiped. If in such a case the abdomen Avère opened, the utérus, ovaries, and tubes found Avell developed and Avithout apparent dise-ase, and a pseudoAagiua Avère maele, conception might be possible anel no ground for divorce fe>r absolute deformity be tenable ; though it might be urged Avith justice that the Avennan Avas physically defee-tive, for the delivery of a full-term e-hild by such an uimatural passage, if pe)ssible> at all,»Avould almost certainly resiilt in the death of the mother and proba- bly in that of the child as Avell. The only alternative te> tins hazardous method of delivery Avould be the Ca»sarean section. Readily as such opérations may uoav be performed, and Avilling as the writerVemld be on ail suitable occasions to perforai them, lie Avould in no instance feel justifiée!, nor deem it justifiable in another, to deliberately bring about by opération upon a woman such conditions as would expose her to such great risk to lier hfe. There are many Avomen who express a Avilling- ness to take such a risk, or any other \vhich would offer to them the * A ease in point is that of a man of robust physieal development and détective moral sensé, who copulated not only with his wife but with numerous other women. Cancer attacked his pénis and it was amputated, only a stump of insignificant propor- tions remaining. His sexual appetite remained, and he continued to hâve indiscrim- inate sexual intercourse. He stated upon inquiry that none of the women with whom he cohabited experienced any différence of sensation at the change in his condition. Whether any of the women were impregnated after his opération is not known, but the essential éléments in his procreative power were said to hâve remained. BIRTH, SEN, PREGNANCY, AND DELIVERY. 429 pe>ssibility of maternité, so strong is the maternai sensé Avith some Avomen ; but the AA'riter must leave to others the coopération iu ail such cases, which to his mind is entirely unAvarrantable. The A'aghia may be normal and coitus be readily accomplished, but if the utérus is absent or extremely rudimentary, conception Avili be impossible. The conditieni of the utérus can usually be ascertaineel by a careful examination, especially if the tissues are thoroughly relaxed by the administration of an ana?s- thetic. In some cases a décision can be reached only by incision of the abelomen and direct inspection of the pelvic organs. In hundreds of case-s the utérus has been remoAred for serious disease, the disease being of such a eharaeter as to reuder conceptiem improbable or impossible. It bas frequently been successfully removed by the writer uneler such conditions. Absence or rudimentary condition of the Fallopain tubes rend ers conception impossible. Such a condition resulting from congénital fault is rare, but disease of thèse organs not infrequently occurs before marriage, rendering the woman hopelessly stérile, and the situation is équivalent to that in which they hâve been removed by the surgeon's knife. Absence or rudimentary condition of the ovaries places a Acoman in a condition similar to that which obtains when the tubes are absent or rudimentary. Disease in the tubes anel the ovaries A^ery often coexists, and a condition AA'hich demands remoA^al of the tubes demands equally the removal of the ovaries. There is no laAV Avhich forbids hermaphro- dites to marry, but as marriage Avith such individuals is almost certain to be unfruitful and resiilt in discontent and unhappiness, and as, more- o\Ter, there is in most cases légal ground for dhorce, such unions are always to be discouraged. The period AA'hich is known as that of puberty marks one of the most important and critieal eras in the life of every individual, whether maie or female. The e-hanges which then take place are marked and promi- nent, anel are indicative of a decided transformation in the physieal con- dition. Ri|)eness 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 bas been observe»d in this countiy, quickness of perception reaches its acme at puberty, intellectual 4)i*ogress thenceforvvard being relatively sIoav. From the perioel of puberty, at AA'hatever âge it may occur, the maturity of the reproductive apparatus begins, and in this respect the individual is as completely equipped functionally as lie will e\'er be. Puberty means, therefore, ripeness of the procreative power, ability to beget or to e-emeerve, the culmiiiation of childhood, and immergence into physieal 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 génital s, the sexual appetite is aroused. In girls, similar phenom- ena upon the skin are apparent, the breasts enlarge, the curées of the be>dv formed bythe development of the muscles and fat are acceiituated, anel the important function of menstruation is established. This func- tion is peculiar, ne>t only on account of its régulai- récurrences, its sus- pensiem under certain Avell-recognized conditions, notably the conditieni of pregnancy, but also from the fact that it is the visible expre»ssion and announcement to the individual that the period of puberty with ail its possibilities lias arrh'ed. Xo wonder that among primitive people aa'Iio 430 A SYSTEM OF LEGAL MEDICINE. were in the least obseiwant the appearance of menstruatiem should be the occasion for the performance of appropriate rites anel ce-rememies.* There are numerous factors Avhich détermine the time and the man- ner of the establishment of puberty. While thèse factors are influential for both sexes they are especially so for the female, inasmuch as the female is usually more sensithely "organized than the maie. They may lie regarded as subjective and objective: among the former are race and family peculiarities, gênerai physieal condition, tempérament, etc. ; among the latter are climate, occupation, altitude, personal habits, e-te. (Sec the Avriters "Disorelers of Menstruation," Trams. X. Y. State Médical Society, 1889, p. 151.) In gênerai it may be said that puberty occurs one or two years earlier in girls than in boys, earlier in Avarm than in e-old climates, earlier at the sea-level than at high altitudes, earlier among tliose who are healthy than among the sickly and. délicate, earlier among sav- ages than' among the civilized. In boys puberty is most frequently reached between the thirteeuth and sixt<»enth years. In girls the limits are farther apart: it may occur as early as the eighth or as late as the tAventieth year. The latter limit is not at ail unusual in very cold cli- mates, Avhile in the tropics menstruation at ten ye»ars of âge is not pré- cédons. Even in oui* OAvn climate maturity may occur A'ery early, the writer being familial* Avith a number of instances in which pregnancy occurreel betAveen the tAvelfth anel fourteenth years. A question which is often. a very important one relates to the e-oin- eidence or Avant of coinciden.ee of menstruation ami ovulatieui. Some writers are of the opinion that ovulation may begin almost at birth. HoAvever this may be, it is certain that conception does not usually eie-cur until menstruation has been establishe-el. On the other hand, menstrua- tion often occurs with considérable regnlarity when the ovaries are abse»nt. The establishment of menstruation is often a sIoav process—a discharge of blood may take place from the genitals, Avith the attendant phenomena of the nervous system, an interval of several months may folle>av, then another discharge of blood lasting several days, then per- haps a less prolonged interval before another ree-urrene-e, and finally, after a year or so, the re-currences may be at stated monthly periods ; or the function may assume full-fledged peculiarities from the start. The discharge of bloody fluiel continues from one to six or seven days, grad- ually increasing in quaiitity until the maximum is reached, anâ then as gradually receding and disappearing. There may be no acceniqmnying phenomena Avhich are worthy of note, or there may be pain in the back, headache, and gênerai discomfort ; anel thèse symptoms vary within very Avide limits, so that the period of menstruation is justly looked upon as one of the most important in the functional life of a Avennan. It is one which often calls for the most careful attention on the part of the physi- cian. It may demand examination of the génital organs, and surgieal treatment for the rebef of faults which are funelamental to the menstrual disender, which if unrelieved make life a burden during a not inconsid- erable portion of every month. Rarely does a boy require the same * Among the American Indians at the Quapaw (Ind. Terr.), Round Valley (Cal.), and Neah Bay ( AA'ash.) réservations such célébrations are ol)served. The cérémonies are somewhat disgusting to the civilized mind. (See the writer's investigations rela- tive to the functions of the reproductive apparatus in American Indian women, Trans. Amer. Gyn. Soc, vol. xvi., p. 272.) BIRTH, SEX, PREGNANCY, AND DELIVERY. 431 careful and prolongée! supervision as a girl while puberty is being estab- lished. Ile certainly should be instructed during or before that period con- cerning the control of his sexual appetite and the eare of the sexual organs, negle'cte-d though this duty usually is ; but lie suffers far less frequently than the girl from defects and disorders of bis sexual organs, anel far less freepiently does his future Avelfare dépend upon the Avise counsel anel treatment of his physician at tins time. Gyrnece>le>gy, the science Avhich deals particularly with the diseases peculiar to Avenneu, has done very much to mitigate the ills and twils of the period of puberty, as well as of subséquent periods ; and if it bas sometimes shenvn excess of zeal in the treatment of such conditions, which call fe>r the highest manifestations of tact, skill, moelesty, anel con- seientiousne-ss, it still has a proud record in the relief of présent eliseom- fort and the Avisdom with AA'hich it has frequently aiiticipated trouble which was impending. The influences of climate, altitude, and the gên- erai condition of the indiAddual bave been referred to as factors in deter- mining the early or late appearance of puberty, and we haA'e also seen that in some e-ases it Avas established without disturbance while in others it was atteneleel by perlurbatienis or storms, repeatedly recurring, until the system had aeljusteel itself, as it were, to the new conditions. In boys, if they bave been the victims of nervous disease, such as epilepsy or chorea, the disease may disappear at puberty; or, on the other hancl, it may be exaggerated, especially if the subjects are masturbators. The same is true Avith regard to girls, and it is at this time, also, that the hys- terical tempérament is Avont to become apparent. It may be added that this is aise) the» best time to bring it under control. Insanity develops at this period of life AA'ith far less freepiency than at the period AA'hich ushers in old âge Avith its ele'gvnerative tendencies and processes. Malignant elisease, AA'hich is also fivepiently associateel Avith the period of senility and decay, seldom makes its attacks at puberty. Certain serions consti- tutional diseas<»s, such as pulmonary consumption, frequently beconie ex- aggerated at this time, but it is not clear that this is necessarily due to any influence pce-ubar to puberty. Ou the AA'hole it may be said that this period should be as conducive torobustness of physieal condition as any period of life, for it is the time of youth aud exubérant physieal activity. Consequently there is seldom anything in the expérience of puberty to impair the légal accoimtability of the indiAddual in so far as a stage of légal accouiitability has been reached at that epoch of moral and intel- lectual elevehqiment. Menstruation or the menstrual floAvis a discharge of blood and other material AA'hich is de'rh'eel from the utérus, ovaries, and Fallopian tubes. It recurs with conside-rable regularity each lunar month in females avIio haA'e» attaineel the âge of puberty, if they are not pregnant anel are not suffering Avith any wasting disease. It continues, as we hâve already seen, under normal e-euiditions, from one to six or seven days. It is composed not only e)f blood but of glandular sécrétions and degenerafed tissue-material, and, unlike the blood under its ordinary conditions, does ne>t coagiilate» or clôt e»xcept AA'hen the circumstances attending its dis- charge are unusual or pathological. A somewhat analogous discharge is eibseiveel among many of the lower animais, and in the apes anel monkeys it bas decided resemblances to the monthly flow of Aveimen. With the animais the floAV coïncides Avith the rut, or period of heat, that Y.\2 ^ SYSTEM OF LEGAL MEDICINE. is, the period of aethe sexual désire, AA'hich is the natural expression of functieuial activity of the reproductive' apparatus. It is not improbable that the function of menstruation is an outgroAvtli or e-volutiemary pro- cess of the e'ondition AA'hich bas been referred to in animais. Its nidi- fications and varying effects are apparent enough as Avoman aelvauce-s in the se-ale of chilization and intellectual development. One of the e-har- acteristic features of the menstrual fune-tion is the increase in the tension of the ble>od-vessels, especially in theise Avhich supply the génital organs. The te-usion being greater than the resistane-e of the superficial vesse-ls in those organs, rupture and hemorrhage resuit, When me-nstruation is performed under normal conditiems it giA'e»s rise te) no particular disturb- ance, Avith the exception of the annoyance from a moist and sometimes malodorous dischai-ge, anel even this annoyance may be entirely eiA'e-r- come by the use of suitable means. Like ail the othe»r functions of the boelv, it is painless AA'hen it is normally performed. The most reasonable theory in re»g;ird to its obje-ct, and the one Avhich comports most with the analeigems function in the lower animais, is that it se-rves as the expression of the fact that a membrane or decielua lias been formed in the utérus feu* the re-e-eptlon of an ovum, such a membrane being an indispensable nee-essity should insémination of the ovum and conception occur. Should such a resiilt not occur the unfertilizeel ovum passes ont of the utérus, and the dee-idua, Avith the small vesst»ls AA'hich it e-euitains, breaks down anel is Avashed aAvay by the blood-current, the latter forming one of the phenomena of menstruation. Should this phenomenem fail to make its appearance at the customary time, it is often, but not ahvays, the sign that Conception lias taken place. The abnen-malitie-s of the menstrual function are many. In e-ivilized life, especially in the» cities and among those» Avhose» manner of living is artificial and higlily irregular, there are more women aa'Iio expérience pain anel ammyancè with menstruation than there are of tlmse avIio pass through it unconsciously and naturally. This might be regardée!, from one point of vieAV, as an argument that chilization had ae-te-d unfavorably upon the physieal condition of woman. The fault, however, is not exactly that of civilization, but of its accom- pauiments of Avealth and poverty, vices and excesses, neglect to incule-ate in the young the importance of hygienic laws anel précautions. Among savages and barbarians the abnormalities in question are of rare occur- rence. The following digressions from normal conditions are often observed : 1. Painful menstruation, or dysmenorrhea. 2. Profuse menstruation, or polymenorrhea. 3. Scanty menstruation, or oligomenorrhea. 4. Absence of menstruation, or amenorrhea. 5. Irregular or substitutional menstruation, or atopomenorrhea. The first of thèse abnormal conditions, ahvays 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 expérience in the*observa- tion of many cases in which menstruation was absolutely unaceompanieel Avith pain, and because it would hardly be fair to assume that so impor- tant a function was an exception to ail the other functions of the bodv in being normally painful. With many women pain is a symptom of menstruation only during the earlier years of life. nerhaps until thev BIRTH, SEN, PREGNANCY, AND DELIVERY. 433 bave borne one 01* more children ; but Avith others it is a customarv and expected and trying symptom during the entire period of life in Avhich menstruation occurs. It is most frequently loeated in some portion of the head and in the lumbar région of the back. Very often it is also in the thighs and legs anel the muscular system in gênerai. It may be prese'iit during the entire menstrual period, eu- during the day 01* two preceeling it, en- it may not occur until the blood begins to Aoav, this form be-ing less common than the others. Pain may also be présent in the stennach anel bowels, Avith or Avithout nausea and A'omiting, and in the- utérus itself in the form of cramps or contractions, comparable to the pains e)f labor, and often due to the blood AA'hich bas accumulateel in the organ, AA'hich it takes this method to expel. Young anel immarried Avomen are the greatest sufferers from this disorder, but the married oncs and those avIio hâve borne children are by 110 means exempt. The effect of thèse repeated attacks upon the mental condition, especially in tlmse who are predisposed to mental disturbance, is sometimes A'ery pronounced, many of the inmates 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 AA'ith respect to her me-nstrual function. Profuse hemorrhage during the menstrual permet is sufficiently com- mon, but less so than dysmenorrhea, the condition just elescribeel. Its cause is often apparent enough when there are tumors in the utérine structure or Avhen the mucous membrane of the utérus is diseased from other causes, but frequently the cause is e>bscure. It is a common occur- rence in young gn-ls who are anémie but Avithout perceptible disease in the wotnl) itself, the hemorrhage reducing their strength and sometimes bringing them te) the verge of e-e>llapse. It is common in prostitute-s and others avIio bave abused the sexual act, in those avIio hâve suffered abor- tion Avhich bas been imperfectly or improperly treate'd, anel occurs almost invariably in tliose avIio suffer Avith malignant disease of the Avomb or its appcndage's. The hemorrhage may appear in gushes, in cle>ts, or in a continuous leakage lasting many days. In some cases a Avoman has barely time te> rally from one attack before she is seized with another. Unle»ss the re>ot of the matter can be quickly reached such Avomen be- come hopeless invalids, dying from exhaustion or becoming an easy prey to disease» of some other eharaeter. Scaiity menstruation may be an indication of a depraved gênerai condition or of some disturbance loeated in the génital organs. The menstrual period may last only a feAv hours or it may extend over seAeral days, the quantity of blood lost each day being insufficient to relieve the tensiem in the blood-vessels and ghe the woman a sensé of relief. It may be due to a sudden checking of the menstrual flow causée! hy low température, a high wind, a cold bath, or a profound mental émotion. It is often accompanied Avith severe pain (dysmenorrhea) ; the blood itself may be pale and watery, with an unusually small proportion of the ■constituent* (especially the red corpuscles) of healthy blood. The con- dition is usually amenable to relief, either by measures directed to the gênerai condition or by treatment of the génital organs themselves ; but it is far less frequently an expression of organic disease than is profuse me-nstruation, and far less ealeulated to cause alarm on the patient's behalf. 134 A SYSTEM OF LEGAL MEDICINE. Absence of menstruation, or amenorrhea, is relatively an infrequent condition, those cases being excluded, of course-, in AA'hich it is an ace-enn- paniment of the pregnant state. The cause' is sometimes quite beyond the existing state of our knowledge, but at others a rational explanation is entirely possible. It sometime>s oce-urs in Avomen Avho are suffering Avith seA'ere Avasting elise'ase, sue'h as pulmeniary tubercuhisis, chreuiie- Bright's disease, or diabètes. It may ex-e-ur in e-onnee-tion AA'ith an océan A'e>yage or re-sielence by the sea. Many of the young immigrants to this country suffer in this Avay for months, if the-y remain at the- sea-coast; but it usually disappears, leaving no bael e-ffce-ts, after the-y lniA'c be-come accustemied te> the e-limate. It is sometimes observée! in women aa'Iio are Avell deAelojted, but aa'Iio in early life haA'e suffered Avith chorea, epilepsy, or some other disease of the neivous system. Very fat avoid en oe-ca- sionally suffer in this Avay. It is suggesthe of pregnane-y, anel Avomen aa'Iio are thus affectée! frequently consult a physie-ian in great alarm, fearing pregnancy, espe'cialty if they are single anel bave good reason for fearing that such a condition might exist. It is a common superstition that it may cause eu* lead to consumption. This it never eloe-s in anel of itself. It is often a conservative proe-e-ss on the part of nature AA'hen the Aveunan is too Aveak to bear Avithout détriment the» loss e>f even a small quantité of blood ; and this is a most inipen-tant point for the médical jurist. The supe»rstition alluded to is probably attributable to the fae-t ab-eady men- tioned, that it may be an incident in the cemrse of the wasting diseases. In such cases it is both post hoc and propter hoc. At the présent finie, AA'hen the removal of the e>varies is of such fréquent occurrence, it is an almost inévitable resiilt, and is a matter of daily observation. It is reme- diable in many Avays—by removal of the résidence from a moist to a dry climate, by imprcvement of the gênerai condition, and by renie)val of ex- isting causes in the génital organs. It is irrémédiable if due te> the renie)val of the ovaries, or the utérus and ovaries, or if the patient is suf- fering Avith the incurable diseases such as Avère mentioned as its causes. Irregular or displaced or substitution al menstruation is the variety AA'hich bas often been called vicarious menstruation, a term Avhich is mis- leading and objectionable. The someAvhat clumsy term atopomenorrhea is suggested as a substitute which is correct etymoleigie-ally and explicit. It is a substitute for menstruation of the ordinary type or it mav be a sort of addendum to it. One variety of whieh the writer bas seen several instances consists in spots or patches of a dark-red color upon the skin, known by dermatologists as purpura. Thèse spots are causée! bv exuda- tions of blood from the vessels beneath the surface of the skin. Xa»vi or birth-marks are usually swollen and darker in color than usual during menstruation. The blood or blood-serum may even exude through the skin bke a bloody SAveat, and cases of tins eharaeter hâve sometimes been used to impose upon the minds of the superstitions and the credulous. In women who hâve ulcers or open sores the diseharge therefrom is more abundant during the menstrual period than at other times, on account of the rise of the blood-pressnre which then obtains. Other varieties of atopomenorrhea are bloody diarrhea, bleeding from the gums, the nose, the anterior chamber of the eve, vomiting of blood from the stomach. Malingerers bave been knoAvn 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 notorietv. BIRTH, SEX, PREGNANCY, AND DELIVERY. 435 In ail thèse e-ases it becomes the duty of the physician to ascertain Avlietlie-r the fluid ejected is a natural product 01* Avhether it is the resiilt of fraud on the part of the individual, the opportunities for deceit and imposition being abundant. Concerning the relation of menstruation to gestation, the menstrual floAV and its attendant phenomena are ordinarily absent during gesta- tion, and the explanation appears in the theory of menstruation Avhich has been given. But this is not ahvays the e-ase : some Avomen menstru- atc regularly AAdiile pregnant the same as in the unimpregnated state. In the dangerems condition known as placenta, prawia, in AA'hich the pla- ce-nta is implanted diree-tly over the internai opening of the Avomb, a dis- charge of blood oce-urs every month and may resiilt in abortion or even in fatal ceuiseepiences. If nialignant elisease e-e>exists AA'ith pregnane-y, hem- orrhage may take place either at the customary finie of menstruation or at irregular intervals. In ail cases of pregnancy in AA'hich hemorrhage takes plae-e», Avhether at régulai* or irregular intervals, it is very désirable to ascertain its cause, for serienis cemsequences may thereby be averted. If the menstrual Hoav ex-e-urs in any other than the normal manner—if it is too abundant 01* too se'anty, if it continues te)o lemg, at too fréquent en* at too infrequeiit intervals—its cause should be ascertained as promptly as possible. It luis been shown that such irregularity may be assex-iated Avith disease of the utérus, the Fallopian tubes, or the ovaries, and the bearing of any such possible conditions must be earefully determined. (fonorrhea invedving any of the génital organs may produce a bloody discharge; also syphilis, abscess e>f the pelvis, or pelvie- congestion from any other cause. Certain diseases of the bladder aud urethra are aise» accompanieel Avith hemorrhage, and such a diseharge must not be mis- taken for the menstrual Aoav. Bloody discharges frémi the rectum and anus must also be carcfullv referred to their proper origin and not be hastiiy regarded as an evielence of abnormal menstruation. It Avili there- fore be apparent that ail dise-barges of blood from the female génital organs are of very decided signifie-ance, and only by careful attention can their true nature be determined. The ménopause, or change of life as it is commonly e-alled. marks one of the important eras in the life of a Aveunan. Puberty aimounces the initiation of the child-bearing period, the ménopause its terminatiou. By this term is meant primarily the cessation of the menstrual function. In temperate climates it ex-curs, in"the great majority of instances, be- tAveen the fortie»th anel fiftieth years* In very Avarm anel in very cold climates it ofton occurs prior to the fortieth year. Those whe> reach puberty early frequently reach the ménopause late in life. Tliose AA'ho bear many children in rapid sue-cession, aise) tliose avIio are very fat, usually cea.se nienstruating early. The same is true of those Avho suffer Avith the Avasting and exhausting diseases : as Avas remarked in a previous part of tins artie-le, the limit of the reproductive force has been reached, and is evielently depe»ndent upon the gênerai condition of nutrition of the body. Those Avhose ovaries bave been removed expérience the méno- pause as the direct conséquence of such an opération. * This rule is very far from universal in its application. The writer has known many instances in which menstruation lias occurred as late as the hfty-fourth year Avithout interruption. Very late occurrence of the ménopause is a noteworthy char- acteristic in many families. 436 A SYSTEM OF LEGAL MEDICINE. The menstrual function may terminate abruptly or gradually, the interval betAveen the permets gradually lengthening until they cease alto- gether. If a bloody diseharge from the genitals recurs after the méno- pause bas taken place it may be regarded as an unfailing évidence of discase, and it is usually an* évidence of serious disease. Xo one of expérience, nowadays, A\'ould think of attributiug to menstruation a hemorrhage or séries of hemorrhages occurring five or ten years or even longer after the disappearance of the menstrual function, though such diagneises Avère common enough in the practice of a generatieui âge» and earlier. The ménopause marks not. only the cessation of menstruation and the e-hild-bearing function, but tlie advent of diminished resisting power of the tissues and en-gans to disease processes. Kepair iioav takes place less readily than in tlie previous years of life, and the individual is more susceptible to disease». Cancer and other inalignant and degenerative processes are proue to deA'elop, aise) insanity and other diseases of the nervous system. Women aa'Iio are passiug through the ménopause are often troubled with sudden flashes of heat upon the surface of the body, especially about the face and head, which appear AA'ithout warning and \-anish as mysteriously ; they may suffer with unace-ountable attacks of hysteria, with dise>rder of the stomach, liver, and bowels, e>r Avith great irritation of the kidneys and bladder. In fae-t, if the ménopause is a storniy one, as it very often is, they are to be judged by a différent standard of phys- ieal condition and behavior from that which is applicable to younger women or to tliose aa'Iio are fortunate in getting through it Avithout particular perturbation. In considération of the many possibilities of discomfort of this period a grave responsibility is laid upon the gyneeo- logïe-al surgeon AA'ho may be called upon to perform an opération AA'hich Avili precipitate it. The frequency with AA'hich this opération is done sometimes gives rise te» the suspicion that thèse possibilities ha\re not been Aveighed with sufficient eare. The subject is certain to require more profounel and extensive considération at the hands of the jurist than it bas heretofore recched.* In women who are the victims of fibroid tumor of the utérus the ménopause usually cornes later than with tliose who are free from such disease. Schorler (see CnisseroAv, Xeubildungen des Utérus, p. 28) found the aA'erage âge of the ménopause in women AA'ithout tumors to be 47.13 ye-ars. Of those who had tumors the average of 29 in private practice Avas 49.14 years, and of 23 in hospital practice 48 years. In GusseroAv's investigations menstruation persisted at 50 years in 5.4 percent, of ail cases of fibroid tumor of the utérus in private practice, and in 7.7 per- cent, in hospital practice. The teaching that fibroid tumors of the utérus are quiescent and harmless after the ménopause is frequently erroneous. The Avriter reeently removed the utérus with a large fibroid tumor whieh was firmly fixed in the pelvis and acthely growing from a woman who had passed the ménopause tAvo years preA'iemsly. The tumor was abun- dantly nourished by the adhésions in AA'hich it Avas ensheathed. * In this connection see a timely article by Goodell, " The Effect of Castration on Women, and other Problems in Gynecology," Annals of Gynecology, January, 1891, p. 1(JS. BIRTH, SEN, PREGNANCY, AND DELIVERY. 437 III. PREGNANCY. Alarriage and Conception—Sterility—Evidences of Pregnancy in its Early Stages, also in its Later Stages—Conditions which Simulate Pregnancy —Superfetation—Complieated Preguaneies—Age-limits within whieh Pregnancy is Possible—Can Pregnancy Exist aud the Mother be Igno- rant of the Fact?—Viability—Duration of Gestedion under Ordinary aud Extraordinary Conditions—Détermination of the Period ivhieh Pregnancy has Reached in a Given Case—Légal Questions Relating to the Foregoing. Marriage implies the possibility of sexual intercourse ; sexual inter- course during the child-beariug period implies the possibility of concep- tion : judging from analogy in many of the lower animais, that is its physiologieal object and not solely the gratification of the sexual appe- tite. If conception does not take place after sexual intercourse it is because the ce nidifions as to OA'ulation are unfavorable, or bee-ause of physieal disability on the part of the man or the woman, 01* because of mechanical iiite'rfere'nce» in some Avay or other. This statement is com- prehensive enough to ansAver and explain many facts and questions. It explains the failure of countless Aveunen to become pregnant though they and their husbands long for children Avith earnest longing. It explains the failure of other Avomen te) becenne pregnant who would not submit to prcgnancy and labor if tliere Avère an}' possible way of avoiding it. It also suggests the explanation of pregnancy Avhen it occurs against the Avili of the pregnant, and AA'hen they Avère under the impression that they had used ail the means AA'hich Avère necessary to prevent conception. It is not affirmed by the writer that abseilute non-interference prior to con- ception is the proper and only line of conduct to be followed. In this respect lie is well aware that ail of his médical brethren will not agrée with him. It seems to him that there are cases in which interférence to prevent conception is désirable and just, anel not injurious to the physieal cemdition of either the husband or the AA'ife. Inebscriminate intercourse between those AA'ho are not married to each other is excluded as at ail times immoral, unnecessary, and improper. That men and women are often very badly mated is abundantly shown by the hideous mental, physie-al, and moral monstrositics and deformities which resiilt from such unions. It Avould be avcII for the world if the reproductive power of many individuals Avère termiuated. A stock-raiser avIio should breeel his animais with 110 more eare and thoughtfuhiess than is exercised by the average of human beings Avoulel soon be compelled to go out of the business. Greater A\dsdom in the pairing of men and women, wisdom and judgment in the getting and rearing of offspring, may resuit in feAver children, but they will be better than the présent average, and marriage will hâve less misery and bitterness connected with it. After conception lias taken place, to interrupt it is to destroy life, anel this is rarely warrantable. In many years of city practice the Avriter has seen but tAve) cases in which such practice seemed to him jus- tifiable. In one the mother Avas redneeel by persistent A'omiting to such a deiii-ce of exhaustion that longer delay would almost certainly hâve re-siiïted in death. The case was seen in consultation and its gravity 43S A SYSTEM OF LEGAL MEDICINE. appreciated, but the opération was not performed until the patient had been seen bv an obstctrician of great emmenée and wisdoiu, who e-on- curi-ed in its propriety. In the other case the alternative would bave been a serious cuttmg opération at or near the conclusion of pregnancy. Such an alternative would at the présent time be adopted, at least in the majorité of cases, but at that earlier period it would not bave been deemed advisable. Sterility is the term which is commonly applied to the condition of uiifruitfuliiess iu a married woman. But a man may be stérile» as well as a woman, and this condition, Avhether in man or in woman, may be relative or absolute». The resuit of the marriage» of Napoléon I. and Joséphine was sterility and divorce, though the latter as Joséphine Beau- harnais had borne two children prior to her marriage AA'ith Napoléon, anel lie was subsequently a father by Marie of Austria, This familiar example has had maiiy'cemnterparts. Absolute sterility is nee-e'sxarily présent AA'hen those organs which are essential to reproduction are want- ing. Tins matter lias been elaborateel at sufficient length in the section relatin g to hermaphrodism and rudimentary and détective organs. Relative sterility refers not merely to the incompatibility of a given man and woman for each other with référence to having offspring, but also to the inabihty of either to perforai the ne»cessary part in the e»xpe- riences connected with reproduction during a prolongée! period of time». Thus a Avoman who lias no children, after having had one or more, during flve or ten successive years is relatively stérile. Or the relative sterility may be due to some physieal defect in the man or the Aveunan or both Avhich in time is remédiée! and they ultiniately bave offspring. In the man the condition of epispadias or hype>spadias, or a defect of senne other eharaeter in the organ of copulation, may prevent insémination of his wife though his testicles and their sécrétion may be normal. Or, on the other hand, the semen may be lacking in vitality, the spermatozoa being few or inactive. Such a condition is frequently remediable by such measures as careful diet, stimulating exercise, or tonic drugs. In any case it must be remembered that it is prématuré to pronounce a woman stérile until the condition of the génital organs and the sécré- tions of her husband bas been ascertained, and this may nee-essitate one or more microscopical examinations of the semen, the examinations being maele» with the greatest eare and delicacy immediately after the semen bas been discharged. A great variety of conditions in Avennen, in addi- tion te> those Avhich bave been mentioned as causing absolute sterility, may preArent conception. A thickened and nearly impervious hymen may prevent effective access of the spermatozoa to the utérus;* an abun- dant anel acrid vaginal sécrétion may destroy the vitality of the sperma- tozoa; and equally effective causes of sterility may consist. in induratmn of the A'aginal portion of the cervix uteri, Avith very minute external open- ing of the same, catarrhal inflammation of the lining membrane of the Avomb, also acute anterior or posterior displacement of the womb. Ail thèse morbid conditions are usually remediable by proper surgie-al pro- cédures, and if the other necessary prerequisites to conception are prese-nt * Such an obstruction is not always efficient. Grandin reports a case (Nor York Journal of Gynecology and Obstctrics, November, 1893) in which imprégnation occurred, the évidence being conclusive that introduction of the pénis was impossible. BIRTH, SEX, PREGNANCY, AND DELIVERY. 439 the case cannot be regarded as one of absolute sterility. In not a feAv instances the AA'riter has had the satisfaction of a practical acquaintance Avith Avomen in aaIioui the difficulties AA'hich hâve been alludeel to hâve been everceune ; anel to a Avoman AA'ith AA'hom the maternai sensé is strong there» is no greater boon than the satisfaction of that sensé. More diffi- cult of treatment than any Avith such abnormabties as bave been men- tioned are theise cases in AA'hich the sterility dépends upon serions disease of one or both of the o Avaries or the Fallopian tubes. In such cases entire organs or parts of organs must be removed, and the parts Avhich are retamed must be brought into such relations as to functionate as nearly as possible like the organs in their natural condition. To over- come such obstacles anel thus facilitate a succeeding pregnancy is a triumph of surgieal art.* A method of e)A*ercoming sterility Avhich was ardently advocated by the elder Sims and practiced by him as Avell as by other gynece>logists, especially by those of the French school, consists in artiflcial insémination, the semen being collectée! from the A^agina and introduced into the ute»rus by means of a clean glass tube as soon as possible afte»r it bas been de»posited in the vagina, Tins method is attended Avith many difficulties and bas been so seldom successful that it bas not been generally adoptée! by the profession.! The questiem e>f overcoming sterility is often an important one in connee-tion AA'ith the inheritance of estâtes. It is, of course, justifiable and pre>per to use ail available means for the attainment of this end. It is useless te> attempt it in cases in whie-h absolute sterility is présent, anel suspicion must necessarily be» aroused in such case»s if a child is brought foi-Avard as a claimant for property. If the condition is one of relative sterility it is proper to extend the hope that the difficulties may be over- come- and a child obtained, eA'en though a long course of médical or surgieal treatment, perhaps continuing for years, be necessary for its acconiplishment. This resiilt will seldom be accomplisheel by artificial insémination, though the trial of such a method aauII be Avarranted, espee.'ially if other measures bave been tried Avithout success. * A case of this eharaeter has occurred in the writer's practice, and is so unusual in its particulars that he feels justified in narrating it at some length. The patient was a young Irishwoman, twenty-three years of âge, who was first seen October 20, 1SXS, eighteen months after her marriage. She had never been pregnant, though in- tensely désirons of offspring. Her womb was retroflexed and fixed by firm adhésions. After various attempts to relieve her by mild measures, which were entirely unsuc- eessful, she consented to hâve the abdomen opened and a radical opération performed. The womb was foreibly detached from its improper position, brought forward, and secured by silver wires passed through each horn to the abdominal wall (January 8, 1S91). Both ovaries were diseased. The right one was as large as a man's fist, and with its corresponding Fallopian tube was removed. The left ovary was enlarged to the size of a hen's egg, but contained a certain portion of tissue whieh seemed to be normal. The diseased tissue was eut away, the remaining fragment properly stitehed and brought into relatively normal relations with its tube, and the abdominal wound closed. The opération resulted in recovery and in great improvement in the gênerai condition. After ten months she became pregnant, and at the proper time (September S. 1S!)2) was delivered by the writer of a fine, large female child. t Personal communication with Dr. Harry Marion Sims in regard to the expérience of his father with the subject of artificial insémination revealed the fact that this method is not only a very troublesome but a very unsatisfactory one. The elder Sims practiced it in fifteen cases, and in only one did pregnancy resuit, and then it occurred only after sixteen opérations. Dr. Harry Marion Sims has also tried the method in eight cases, and in none of them did his efforts resuit in pregnancy. If the method fails in such skillful hands others may well despair. 440 A SYSTEM OF LEGAL MEDICINE. Gestation or pregnancy is that physmlogie-al condition in the female Avhich is essential te) the reproduction of spee-ies. It implies the effective union of spermatozoon and ovum aud their subséquent development, It does not imply anything in regard to the resiilt of the process. It implies the existence of the essential génital organs—the vagina, utérus. Fallopian tubes, and ovaries. When the condition proceeds neirnially the products of conception are in the cavity of the utérus—that is the normal nidus of the human OA'iim. There are many instances, however, in Avhich pregnancy bas taken place outside the utérus, in some» e-ases proceodinir without interruption to the end of the period which is neces- sary for the full development of the fétus, in others suffering interrup- tion at an earh stage, with conséquent destruction of the fétus, and often Avith fatal resuit te) the mother as well. The greater number of thèse extra-uteriue or ectopic pregnancies undoubtedly take place in some portion of the Fallopian tulies. Some Avriters of the highest authority deny that they can eve-r take place anyAvhere else, but it does not se»em to the» Avriter impossible that spermatozoa should Avork their Avay through a tube- and meet an eivum just as it Avas extruded from a ruptured Oraafian follicle. Should that occur anel union of the tAvo éléments take place, it would seem quite possible that development of the fructified ovum might take place upon the ovary or even within the free abdominal e-avity. A number of e-ases are recorded in AA'hich it bas been asserted that true ovarian pregnane-y Avas présent ; also a number of e-ases, including one of the Avriters, in AA'hich the pregnane-y seemed to bave been limited to the abdominal caA'ity.* Some of the spe-cimens of thèse e-ases are preserved in médical muséums, and the-y bave been exam- ined by various experts, senne of whom admit, while others deny, that they represent etvarian en- abdominal pregnancy. The su!) j cet is still in dispute». It is much casier to believe that imprégnation takes place, in thèse extra-uteriue cases, in some portion of the tube rather than upon the ovary or intestine or other portion of the surface» of the peritoneum, and it is quite possible that au ovum inseminated at the fringed extrem- ity of the Fallopian tube might, after a short time, fall or drop from its primary place e»f attachment and loeate itself ane»Av on the surface of the ovary or elseAvliere. In the unmistakable tubal pregnancies the tumor may develeqi in any portion of tlie tube and the remaining portion may pivsent a normal appearance. In the great majority of cases the tubal tumor ruptures from the sixth to the teiitb Aveek of gestation, the open- ing being into the free peritoneal caA'ity or into the folds of the broad ligament Avhich lie under the tumor. In the former case the fétus may be» precipitated into the free abdominal e-avity, usually dying, but in rare cases retainiug its life anel developing in this strange situation. Such cases are often fatal to the mothers from hemorrhage. In the latter e-ase a roomv pouch is found. to which the fétus adapts itself, and deA'elop- ment may continue» in tins situation until the child has reached maturity. From this pe»sition it can be extricated only as it is remoA'ed through an incision in the abdomen or the A'agina, or after the slenv process of dé- composition has taken place, the boues and other solid tissues ulcerating * In the writer's case a fétus of the fifth month or possibly later was found in the mother's abdomen after death. So far as could be judged at the time, from the con- dition of the utérus, tubes, and ovaries, none of thèse organs had been at any time the seat of this pregnancy. BIRTH, SEX, TREGNANCY, AND DELIVERY. 141 their Avay through the rectum, bladder, vagina, e>r abdominal Avall. Very feAv Avomen are able to endure the strain of such a terrible proce-ss. Ex- tra-uteriue pregnancy occurs much more frequently than Avas formerly supposed, but it Avould probably be much more fréquent still if imprég- nation began, as is niaintained by many Avriters, in the Fallopian tubes, the ovum then descending into the utérus. It would seem more reason- able te) believe that the sperm and germ cells meet and imite in some portion of the utérine e-avity, and that. Avlien this does not take plae-e- it is lie-cause of some abnorniality in the utérus, the tubes, or the ovaries. A number of cases of tubal pregnancy in the writoi-'s knoAvh'dge, in winch such abnormalities bave been présent, bave confirmée! his vicAvs in regard to the correetness of thèse statements. The ovum anel spermatozoon having uuiteel, conception becomes a fact, the ovum becoming imbedded or implantée! in the utérine mucous mem- brane, and developing in accordance Avith physiologieal laws which haA'e beeui e-arefully inve»stigated anel clearly determined, and whieh are embod- ieel in the beautiful scie-nce of embryology. If pregnancy prex-eeds normally the first évidence or intimation of its présence to the vomaii eeuisists in the absence of the menstrual flenv Avhen the time for its appearane-e has arrivée!. At this early stage of gestation the ovum may be» rcaelily dis- lodged, and many abortions are produceel by the drastic remédies Avhich are taken by Avennen avIio are alarmed because their "sickness" does not appear. If the ovum is not disturbed and the time feu* the menstrual floAV reeurs again Avith e-xperience similar te) that of the preceding month the hope or suspicion of pregnancy AA'hich Avas entertaiiied by the woman will, in most e-ases, haA'e elevelopeel into a certainty. If the Avoman is pre-gnant for the first time she Avili usually be a sufferer Avith nausea and A'oiniting, espe-cially in the e»arly hours of the day (morning sickness) ; lier breasts will begin to enlarge, anel perhaps be painful. In a certain num- be-r of cases tliere Avili be milk in the breasts, but this is by no means a customarv occurrence». The changing e-ontour of the abdomen Avili cenn- 4>i»l the Avoman to loosen he-r clothes about he»r Avaist. ( Ymstipatioii Avili freepiently be a troublesome symptom, also au abundant leucorrheal dis- charge from the vagina. The appetite may be increased, anel the strug- gle between incivase of the appetite and inability to retain the food Avhich is taken is often A'ery distressing. Such are the principal sub- jective symptoms during the first two months of pregnancy. If a phy- sician is called eni ace-ount e>f the non-ap])e»arane'e of the menstrual Aoav at the custeunary time lie may be assistée! in his diagnosis by the state- ments of the patient, ov the-y may be intended to mislead and deceive him; he should therefore be» on his guard against elece-ption and dépend upon objeethe rather than subjectiA'e symptoms. He should refrain from introducing instruments into the utérus, as lie might inadvertently puncture the ovum, produce an abortion, and thus aeceunplish the A'ery end Avhich his patient desired, though she may not hâve expressed such a désire». If the pregnancy bas not advanced beyond the fourth or fifth Ave»ek a ]>ositiA'e diagimsis of the condition may be A'ery difficult or even inipe>ssibl<\ An examiiiation AA'ith the finger will usually reveal a soft- ness of the A'aginal portion e>f the neck of the utérus, which is suggestive of pregnancy- and the bimanual examination wnll sIioav that the utérus is larger anel semieAvhat more globular than in the uninipregnated state: but there are no unfailing signs AA'hich will indicate Avith absolute accu- 442 -J SYSTEM OF LEGAL MEDICINE. racy that pivgnaney exists; the symptoms mentione-d may ail be due to other e-auses, and both physician and patient may be compelled te) a wait further developments before arriving at a conclusion* A sign, e-alled after its dise-e>verer Ilegar's sign, and e-onsisting in a boggiuess and resiliency of the Ioaa'ci- segment of the body of the utérus, is discernible from the fifth to the seventh week, but it is not_ constant anel is mit universally ree-eignizeel as a sign of value. The sign upon Avhich the writ en- places greatest dependene-e be-tAve-en the fifth and tenth weeks is the discoloratioii of the» mucous membrane of the vulva anel vestibule. This varies from a pale purple to a pale violet, in plae-e- of the light-pink hue of the unimprcgnated state». It implies e>bstructiem of the- venons circulation of the tissue inveilved, and, Avliile it may bc an indication of obstruction from some e-ause apart from pregnancy, it is of great A-alue in ele'termining a diagnosis Avhen taken in ce>njmiction with the other early signs of the pregnant state. It is the first sign AA'hich arrest s the attention of the practiced eye in making an inspee-tion of the genitals. It bas been obse-rveel by the Avriter in lmndreds of in- stances anel bas rarely proveel misleading. From the seee)iiel month of pregnancy onward the signs may still be considered AA'ith advantage from a subjective and an objective stand- point, the former be-ing first e-onsiele»reel. The menses continue to be wanting; the breasts e-oiitinue to enlarge», and ghe rise to more or less pain anel soreness ; nausea and vomiting persist until the fifth or sixth month anel gradually disnppear as the Avomb rises from the pelvis into the more capacious abdominal caA'ity, though in some cases they con- tinue until the eue! of pregnancy. The- patient bas uncontrollable drow- siness and sleeps much of the time, alse> backache, vaginal leucen-rhea, fréquent inclination to urinate, aud other anneççances ; or, on the other hand, the latter portion of pregnancy may be free from diseomfort, or even attended by a greater elegree» of comfort than is customarv in the unimpregnated state. One of the meist important of the subjective s}'mpte>ms of pregnancy is quickening, which is a peculiar sensation, some- times cemipared to the fluttering of a bird, cause»el by the moAcments of the fétus Avithin the womb, and the first intimation te> the mother that she is carrying in lier body a lhing, moA'ing being. Of the objet-the signs the discohn-ation of the A'iilvar mucous mem- brane becomes more and more marked as ge»station progresses, until, during the last month, the color may be almost black. In some e-ases the veins of this région are much enlarged and resemble bunches or * Dickinson (New York Journal of Gynecology and Obsfetrics, November, 1893, p. 0S."> ) offers the following scheme concerning the early signs of pregnancy, which is the most récent contribution to the subject : Six signs of early pregnancy obtained by the bimanual examination : 1. Bellying or bulging out of the body of the utérus. "1 2. Elasticitv or bogginess of the body of the utérus. A, , „ . , 3. Compressibility of the lower utérine segment. \ About four to S1X weeks" 4. The transverse fold. J 5. The longitudinal fold or furrow. ) ., ... . , , , 6. The denser spot. S About S1X to ei^ht weeks" "Dickinson thinks that in farorahle cotes the présence or absence of pregnancy may be determined between the second and sixth week after coitus, or between the third and eighth after the beginning of the last menstruation. BIRTH, SEX, PREGNANCY, AND DELIVERY. 443 clusters of Ave>rnis. The softness e>f the vagina and vaginal portion of the neck of the Avomb also becomes more pronounced ; the cervical canal be-comes patulems, readily admitting the end of the index-finger as the time for labor approaches. The enlargement and ascent of the utérus progress, pari passa, with the de'A'elopment of gestation. Tliere is little différence of elescriptiou among the best obstetric Avriters concerning the relations of the utérus te> its surroundings during the différent months of prceiianev. We» shall folioav the description of Winckel (Text-book of Ob tctrics, 1S{)0, p. 79 et seq.) : At the end of the second month the fundus of the utérus can be felt by the examining hand behind the symphysis pubis. At the third month the utérus is as large as a man's fist, and the ab- domen begins to be prominent. At the fourth month the fundus of the utérus has risen out of the pelvis. At the fifth month the fundus is miehvay betAveen the sympliysis and the navel. Stria» begin to appear upon the surface of the abdomen, anel the linea alla assumes a more pigmented appearance. During this month the sound of the fetal heart may be ele-teete'el in many cases. At the sixth month the fundus rises to a point about two Angers' breadth below the navel, and its loAve»r half becomes flatter. At the seve'iith month the fundus is two fiiigers' breadth aboA^e the navel, and during this month the h)Ave»r pôle e)f the fétus may usually be felt through the vagina, though the fétus 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 latéral expansion of the utérus is considérable, and the movements of the child are A'ery vigorous and can readily be felt when the hand is placed upon the abdomen. During the» ninth month the fundus nearly reaches the epigastrium, continues to expanel laterally, and in the elosing Weeks of pregnancy the prese-nting portion of the fétus descends into the pehis, preparatory to its exit from the birth canal. In additiem to the graduai enlargement, hardness, anel soreness of the breasts during pregnancy, an important point to be obserA'ed iu making a diagnosis is the enlargement of the papillae or sebaceous glands sur- rouiiding the nipple, aise) the greater prominence» of the nipple, the in- crease in the elepe>sit of pigment in the colored areola around the nipple, and the dcA-e-lopment of a secemdary areola around the first, AA'hich is lighter in e-olor anel îiarrenver than the first, and does not appear until the later months of pregnancy. Among the objective signs of preg- nane-y which Avère formerly more frequently alluded to than they are at the- présent time may lie mentioned kiestein and ballottement. The former was first brought te) the attention of the profession by Nauche, who asserteel that its pre-sence in the urine AA'as a certain sign of pregnancy; it e-onsists simply of triple phosphates and Ioav forms of life—but it is aise» found in the urine of maies (Wine-kel, loc. cit.). It has frequently be-en referred to in Avorks on médical jurisprudence as a diagnostic sign. Ballottement AA'hich e-onsists in pressing smartly upon the fétus with a finge»r in the vagina, the bail of the finger being applied to the anterior vaginal Avall, the pressure causing the fétus to rise in the fluid in which 111 A SYSTEM OF LEGAL MEDICINE. it is immersed anel then rebound against the fingen-, is a good enough sign, but not ahvays prae-tieable nor easily accomplishetl. f'esides, it is unnecessary because there are- so many other means of determining pregnancy which are easier of applie-ation anel just as reliablc. The condition e)f the kidneys must not be eiA-erlookeel iu determining preg- nane-y. especially if there is any .suspicion that disease of thèse organs existed prior te) pregnancy. Fréquent e-xaminations of the urine should be» made, especially Avith referene-e to the preseue-e of albumin. A trace of albumin during the earlier months need not cause alarm, but if, after the sixth month, AA'hen there is more or less pressure from the utérus upon the kidneys, there is albumin to any considérable extent in the urine, the e-ondition becomes one of grave iinpeirtance aud calls for the me>st careful Avatchfulness aud Avisdom e>n the part of the physician. Eclampsia or concisions is sometimes associated Avith rénal disease during the latter portion of pregnane-y, and constitutes one of the most dangerous complications of the-pregnant, parturient, en* puerpéral state». There are no peculiar conditions of the heart, lungs, intestines, or other A'isce-ra during pregnancy AA'hich call for particular attention in a book of this eharaeter. The systematic treatises eui obstetrics may be eonsulted in regard to ail such unusual incidents. It is a Avell-known fact that deceit is often practiced by those Avho désire to be pregnant, as Avell as by those avIio désire te> be relieA'ed of pregnane-y, the physician being often imposée! upon by both. Erroneous diagneises are maele by physi- cians through ignorance», Avant of discrimination, and sometimes on ac- count of difficulties which reuder error quite pardonable. Mistakes of this kind are far less freepient than formerly, for the gênerai diffusion of gynecologieal knowledge bas informed the profession at large con- cerning the anatomy of the peh'is to a far greater extent than ever before. Cases AA'hich simulate pregnancy may be divided into two groups, in the first of AA'hich enlargement of the abdomen will be the chief symp- tom, AA'hile in the second tins symptom may or may not be pre-sent, other noteAvortby symptoms being prominent, According te» this classification individuals e>f the first-meiitioiied A'ariety and their friends may be de- cehed by the situation, but the physician usually will not be. * In the second case the physician also may be the A'ie-tim of déception. The most eonsph-iious menibe-rs of the first group include those women Avith Avhom the great object and désire of life is te> become preg- nant. This group also includes cases AA'hich are interesting and impor- tant, and in AA'hich the entail of an estate dépends upon the birth of an heir. The intense désire of thèse Avomen to hâve children very often leads them to imagine that they are pregnant whether there is any ground for it or not, A fanions illustration of this group Avas Queen Mary of England, wife of Philip IL of Spain, who was continually report- ing herself pregnant. and even appointing the time for her accouchement. The enlargement of the abdomen in thèse cases is usually due to ferment- athe changes in the intestines, with resulting accumulation of gas and such gastric and intestinal disturbane-e 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 avIio is thus affected may readily deceh'e herself with the thought that she is pregnant, especially if she BIRTH, SEX, PREGNANCY, AND DELIVERY. 445 happens to be A'ery anxious to become so ; anel the déception is fostered by sympathizing friends who haA'e hael a somcAvliat similar expérience in connection Avith their oavu pivgnancies. A condition of this charae-ter should never mislead a physician, because he can détermine by examina- tion, with the aid of an anesthetic if necessary, whether the distention is gaseous or due to an enlargement of the utérus, 01* to the two causes combinée!. Collections of fluid in the abdomen may simulate pregnancy. Such collections occur in connection AA'ith malignant disease of the ab- dominal viscera or with tuberculosis of the peritoneum. This conditieni sometimes occurs in young unmarrieel Avomen, and the unjust suspicion Avhich is aroused is peculiarly cruel by adding te) the hardships of a dis- ease which, in malignant cases at least, is hopele»ssly incurable. Enlarge»- ment of the abdomen due to the présence of an unusually abundant depeisit of fat in its Avall, or to solid or fluid tumors in its eaAdty, may simulate pregnancy. The first of thèse statements need not seem in- credible, since a laver of abdominal fat three 01* four inches in depth is not uncominon. The tunmrs referred to hâve many times been mistaken by the uninitiated as évidence of pregnancy, to the great détriment and unhappiness of those Avho suffer with them.* Before the time AA-hen ovarian tumors were well understood, those who had them were often accused of pregnancy. The injustice of such accusations Avas in some notable instances demonstrated by the removal of the tumors after death. Happily such growths are now removed with such facility and comparative safety that an innocent woman need no longer suffer sue*h aspersions until her veracity can be attestée! by a post-mortem e'xamination. But in the second group of cases mentioned the conditions Avhich simulate pregnane-y may be of such a charae-ter as to deceive even the ex- peu*t diagnostician : first, when the utérus alone is affected ; second, when the difficulties iirveihe other organs of the génital apparatus. The utérus may enlarge slowly and synimetrically 011 account of the présence of a fibroid, a fibrocystic, or a purely 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 en° affairs, and it may be necessary to repeat the examination seweral times at short intervals. A spurious pregnane-y in the form of a mole or a hydatiel tumor of the utérus may also prewe misleading. Cessation of the mense»s from any of the causes mentioned in the remarks concerning menstruation (q.v.) may also misleael be>th the patient and the physician. The présence of milk in the breasts is ahvays suggesthe of the pregnant state, but it may be an isolated symptom.f Softness and SAvelling of the vagina and cervix anel external genitals, and discoloration of the vulvar * It must be remembered that tliese tumors may coexist with pregnancy, intro- ducing an élément of gravity which may be very serious. t A particularly noteworthy case was seen by the writer in 1891. The patient was an Irishwomau, thirty-one years of âge, who had been pregnant but once, having borne a child when sixteen years of âge. For several years prior to 1891 there was milk in her breasts, and for the two years immediately preceding it was constantly présent, as much as a tablespoonful being frequently removed at once. She had suf- fered six years with disease of the pelvie organs, but the exact relation of this to the active condition of her mammary glands could not be ascertained. 446 A SYSTEM OF LEGAL MEDICINE. mucous membrane caused by interférence Avith the circulation on account of neoplasms in the pelvis, may make it difficult or impossible to affirm or deny the existence of pregnancy. Multiple pregnancy, in Avhich tAA'o oreAren three fetuses are developed simultaneously, is sumciently Avell known as a physiologieal fact. King (Manued of Obstetrics, 1892, p. oil) states that twin pregnancies occur once in seAreuty-five cases, triplets once in five thousand, anel that quatl- ruplets and quintuplets are extremely rare. Winckel believes that five is the largest number of fetuses that a AA'ennan can sustain in her utérus at once, and that the statements, cspee-ially in ancient literature1, con- cerning Avomen avIio bave had more than fhe infants at a birth are fabu- leras. Well-authentieated reports of epiadruplet and epaintuplet birtbs are to be found in récent literature. (Winckel, op. cit., p. 111.) The-se multiple pregnancies ma}' resiilt from one ovum AA'hich bas undergone subdivisiem, ov each fétus may be the product of a se?parate ovum. Superfetation, or the condition in AA'hich fecundation of an ovum lias take-n place after eleA'elopment has begun in an ovum in the same utérus whieh has been fecundateel at an earlier period, is considered a possibil- ity, but one which bas uot }-et been proved. In the condition AA'hich is Fig. 66.—Author's case of double utérus (utérus bicornis unicollis). known as double utérus (see figures and history*), in which there are two distinct utérine bodies, union of the tAvo having faileel to take place during fetal Hfe in accordance with the usual course of development, there may be simultaneous or nearly simultaneous imprégnation in each * Author's Case of Double Utérus.—The patient was an Irishwoman, twenty-five years of âge, first seen August 15, 1889. She had borne five children within a period of five years, ail the labors having been tedious, and the last three of them breech présentations. 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 utérus retroflexed and adhèrent. There were large external hemorrhoids and fissure of the anus. Thèse latter difiiculties were first operated upon ; then Emmet's opération was performed upon the cervix, the opération not resulting satisfactorily. Subsequently the cervix was amputated and the ruptured perineum closed, the resuit being good. A month later the abdomen was opened to relieve the adhèrent utérus, and the condition found which is represented in the picture. The round ligament of each utérus was shortened, the organ being thereby brought into its normal relations. The patient recovered without mishap. This anomalous condi- tion is termed by Kussmaul utérus bicornis unicollis. BIRTH, SEX, PREGNANCY, AND DELLVERY. 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 might be born days 01* Aveeks before the other. It is e\'en possible in a normal utérus in Avhich there is a twin pregnancy that development may not proceed absolutely pari passa, and that one fétus may mature and be delivered someAvhat 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 reports a case in Avhich a woman gave birth to a child freun one born of a double utérus July 10,1855, and to another from the other horn Se'ptember 22, 1855. Cases are recorded in which black Avomen bave borne twiiis, one of them being black and the other white. This is probably due», as Lusk has suggested, to the detachment of two OA'a 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 utérus. The same writer thinks that imprégnation at Iavo periods of time remote from each other, in the same utérus, must be regarded as inadmissible until physiologists shall succeed in demonstrating in a single instance, by the présence of corpora lutea in différent stages of development, that ovulation ever occurs during pregnancy* In addition te> the peculiarities which are iiiA'olved in that form of pregnancy which bas just been considérée! the pregnant state is suscepti- ble of others of a most interesting though usually A'e»iy grave e-haracter. Allusion is made to the so-called ectopic pregnancy, in AA'hich the ovum is implanted outsiele the cavity of the utérus and usually in some portion of the Fallopian tube (see illustration of the authen-'s case of tubal preg- nancy, Avith ae-conqmnying histeuyt). The principal facts in regarel to this most undesirable method of fetal deve»lopment hâve already been given in an earlier part of tins article, and need not be repeated. A number of cases haAre been reporte»el in Avhie'h living children bave been removeel through an incision in the abdomen after having deA'eloped in this abnormal manner ; but they hâve been elef ecthe and short-lived in almost ail cases. What is still more strange, there are cases 011 rece>rd in which tAvo fetuses hâve been found in the same tube, in différent stages e>f deA'elopment ; also cases Avith one fétus in each tube, and others Avith enie fétus in a tube and another Avhere it belonged, in the cavity of the utérus. Such facts are quite in the realm of the marvelous, and impress us Avith wonder at the ecceiitricities of Avhich nature is capable. The adA^ent of puberty iu the female is, as Ave hâve seen, usually re- gareled as the announccnieiit that conception is now a possibility. The âge at Avhich this occ.urs, as well as the âge when the child-bearing func- * Obstetricians of the highest authority admit the existence of superfetation in animais. Sehroeder narrâtes a number of such cases (Lchrlmch der Gcburlslriilfe, 1SS0, p. 76) ; but the same high authority, with Kleinwàchter, Leishman, Scanzoni, Wagner, h'amsbotham, and Churchill, ail concur in denying the existence of any reliable évi- dence, thus far, that superfetation ever occurs in women. t A récent case of the writer's, a drawing of which is given herewith, illustrâtes in a gênerai way the condition of tubal pregnancy. This case was that of a negro woman thirty-threo years of âge, who had given birth to one child twelve years ago (1SS-J). She had been complaining for some weeks prior to opération, which was performed February 112, 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 intimately associated AA'ith the tumor II, both tumors containing much blood and blood-clot. No 418 A SYSTEM OF LEGAL MEDICINE. tiem ceases, is, as Ave haA'e also seen, variable, depending upon chmate, race anel family peculiarities, and other well-knoAvn conditiems. In tem- perate» climates pregnane-y rarely eiccurs earlier than the sixte-e-nth or later than the forty-fifth year. In tropical climates Avomen mature early Fig. 67.—Author's case of tubal pregnancy. The structures are seen in front or face view. V. A'afdna; A, a, left Fallopian tube, with tumor of pregnancy at ^1,- B, tumor of left ovary; F, normal right Fallopian tube; O, normal right ovary. and the child-bearing function cease»s early. Among the savages of New Mexico and Arizona (Meijaves, Apaches) complète womanly development is often seen as early as the twelfth year. Among the Arabs of the désert the child-bearing period is said to end frequently as early as the twentieth year or soon thereafter. lu cold climates puberty is delayed. Among the Esquimaux, as Avell 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 extrême, fétus was found in tumor A, but placental structure was shown by microscopical ex- amination made by three expert microscopists. The fétus probably died at a very early period and was quickly absorbed, the other structures retaining their vitalitv, and hemorrhage had probably taken place on several occasions. Both ovaries and tubes were removed, the woman making an uneventful recovery. BIRTH, SEX, PREGNANCY, AND DELLVERY. 449 Barker has seen a first pregnancy as late as the fifty-second year, fol- loAve'd by a second and a third in the same person at the fifty-tîiird and fifty-fifth years. Ile thinks this the latest period of which there is any autheiitic record of sue-h an etccurrence, AA'ith the» exe-eption of that of Sarah Avhich is mentioned in the Book of Genesis* (Transactions Amer- ican Gynecologieal Society, 1NS8, p. 301.) Legrand du Saulle (Médecine Légale, second édition) states, without referring to particular cases, that prcgnane-y may oe-e-ur as late as the seventietli year. The questiem as to the pe)ssible existence of pregnancy AA'ithout the knoAvledge e>r consciousness of the AA'oman may be regarded from différ- ent standpoints. We must consider not only the fae-ts relating to the wennan's physieal e-ondition, but also the very impentant question of lier truthfulness. It is undeniable that many women, especially the young and unniarried, uublushingly refuse to admit the pe)ssibility of* preg- nancy from its beginning to its termination, and it may be impossible to décide whether this is due to then* untruthfulness e>r to their unconse-ious- ness of their condition. The déception or attempt to deceive must ulti- mately be expeised. In other cases, in which conception has taken place Avithout the introductiem of the pénis into the vagina,-in AA'hich the hymen is practie-all}' intact, it is easy te) understand the unwillingness on the part of the woman to belieA'e that she can be pregnant. In cases in which coitus has taken plae-e during sleep or intoxication or the hypnotic state, self-dee-eptiou is also pe>ssible. There is also the class of cases asseiciated with utérine 01* ovarian tumors, in whie-h pregnancy lias super- ve-ne'd after the existence of the tumor was recognized. The writer has seen such a case in which pregnancy was unsuspee-teel until labor actually began. Again, tliere is the entire class of extra-uterine pregnancies, in Avliie-h the condition may not be suspected until the abdomen is opened by the surgeon for the purpose of remening a tumor the charae-ter of Avhich lie might be quite unable to détermine in advance or until the situation is determined by auteipsy. In a case which has been reported by the writer, a Avoman Avas under the constant supervision of an acute and unusually intelligent physician for Aveeks before her death. The latter event took place sudelenly, after symptoms of great abdominal dis- turbance accompanied Avith agonizing pain. An a/utopsy Avas made, and when the abdomen Avas opened an infant, nearly full-groAvn, Avas found lying free in the abdominal cavity, where it hael developeel entirely out- side the utérus. Normal pregnancy has many times been mistaken even by the expert gynecedeigist for a tumor AA'hich required remoA'al, the true situation becoming known only when the abdomen was opened.t From * The writer has been informed of a case which was known to one of his associâtes (Dr. G. W. Small wood), in which delivery of a living child took place when the mother was sixty years of âge, fourteen years after the ménopause was supposed to hâve oc- curred. Such cases demonstrate the persistency of ovulation beyond the limit which has usually been fixed for that event. t Three such cases hâve occurred in the writer's practice in récent years. In one, the wife of a physician, long under the writer's observation, presented ail the char- acteristic symptoms of tubal pregnancy. The writer's diagnosis was concurred in by a colleague of great expérience. The abdomen was opened and the utérus found dis- placed, but with the fétus within it and not outside of it. An abortion followed on the third day, and death from peritonitis several days later. In the second case there was disease of the ovaries, but the pregnancy was not recognized until the abdomen was opened. The patient recovered without abortion. In the third case, a Syrian 150 A SYSTEM OF LEGAL MEDICINE. the foregoing it A\'ill be évident that it is epiite possible» fe>r a woman to be ignorant of the fact that she is pregnant, or te) be conscious that she is pregnant aud be able to succe-ssfully elece-ive the physician without disparagement to his skill and discrimination. Viabilité is the term which is applied to the susceptibility of an in- fant te> sustain existence outside its medher's womb. It implies a elegree of development sufficiently advanced to sustain such an existence. A child is not mature or ripe until the normal termina tion of pregnancy, but it is freepiently capable of living and developing though boni prier to maturity. Prématuré childreii-are of course more sensitive and deli- e-ate than tlmse AA'ho bave reached full maturity, but there» are countle-ss instances in which such children hâve surmounted such adverse e-ondi- tions and live»d to adult life or old âge. The seventh month bas usually been regarded as the earliest limit of fetal viability, and many who are boni at that early period quickly succumb. The vital organs are suffi- ciently developed to permit the e-ontinuance of life, but unless the sur- rouneiings are unusually favorable attempts to re-ar such feeble» infants are usually futile». In ree-ent years, anel espee-ially in France, the use of the couveuse or incubator lias resulted in the saving of many prématuré or immature children. The» nanns of Tarnier anel Auvarel are- promi- nently identified with this important Avork, and Auvard believes that by the judicious use of the incubator the limit of viability may be set back as early as the end of the sixth month. The question of successfully continuing existence is quite différent from that of merely showing signs of animation, such as gasping, moving the limbs eu- even the body. Children aaIio give such signs of life are quick or living, in distinction from the still-born, avIio ghe no eAudence Avbatever of life. Signs of life, though few and feeble, may be of the greatest importance frémi a légal stanelpoint. Cases are mit infrequent, espee-ially in the gynecedogical literature of the» past feAv years, in AA'hich signs of Ufe bave been sIioavii at-the sixth, fifth, or even fourth month* The absolute duration of gestation—that is, the exact time from con- ception to delivery—is, for many reasons, a difficult matter to détermine in the great majority of instances. If a woman experie»nces sexual inter- course every day or nearly every day it will be almost impe>ssible in case of pregnancy to décide just when conception occurred. If sexual inter- unable to speak English, the tumor was supposed to be one requiring extirpation of the utérus. The pregnancy was recognized when the abdomen was opened, and the • patient promptly recovered, also without abortion. In another case known to the writer a surgeon of great expérience opened the ab- domen on account of supposed ovarian tumor, mistook the pregnant utérus 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 reeently reported, is a verv remarkable one. The fétus 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." (Transactions American Gynecologieal Society, 1893, 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 mother's abdomen. It was between eleven and twelve inches in length, weighed twenty-four 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 still distinct. The nails did not reach to the tips of the fiiigers. (Trans. Amer. Gyn. Soc, ÎS'J.'J. p. 263.) BIRTH, SEX, PREGNANCY, AND DELIVERY. 451 course occurs only at considérable inteivals the date of conception may be nmre nearly approximatif!. If ovulation invariable coincided with menstruation, and occurred at no e>ther time, the selution of the question Avould be facilitated. Some AA'riters are» of the opinion that ovulation may oe-e-ur at any and ail times, irrespe»ctive of menstruation : if this is correct the habit of dating conception from the last menstruation is un- reliable». Ea'cii if the last coitus for a long period of time were assumed to be the fruitf ul ont- tliere would still be a chance of error, for the reasem that a previous coitus might bave been the fruitful one. If the last coitus Avère fruitful the exact date would still be uncertain, on account of the une'ertainty as to the eiecurrenee of ovulation, and also as to the activity anel vitality of the spermatozoa. The microscope has sIioaa'U that this vitality may continue as many as eight days, and as long as active mo- tieui is apparent they are capable of performing their function in fructi- fying the ova. None knoAV better than the obstetrician that the habit of fixing elates for conception and labor is untrustAvorthy, for none suffer more anneiyance and inconvenience as the resuit of such miscalculatieui. It is merely a method of guessing, for the premises upon AA'hich to base mathematie-ally accurate calculât ions are wauting. The development of the fétus in utero may be influenced by the same causes which influence puberty anel menstruation, though of course not to the same extent. Sue-h conditions are climate, race and family peculiarities, the gênerai state of body and mind of the mother during the period of gestation, etc. The statements which women make ceme-e-rning the data of their preg- nane-ies are» not always to be relied upon, however truthful the intention of the individual may be. J. Veit (quoted by Winckel, loc. cit.) observée! the folloAving variations in the duration of pregnancies in the same séries of women : In 7 cases the variation was less than 10 days. " 4 " " " from 10 to 20 " " 7 " " " from 20 to 40 " " 2 " " " more than 40 " " 1 case " ■" 64 " Schlichting, also quoted by Winckel, observed in 456 cases that the dura- tion of pregnancy varied from 210 to 334 days. Of several observers AA'ho hâve started from a common basis, their in- formation being assumed to be reliable, and the basis being that the ovum of the last menstruation is impregnated, the duration of pregnancy being ealeulated from the first day of that period : Mattei found the average duration....................265 days. Schlichting found the average duration................273.1 " Matthews Duncan found the average duration.........278 •■ Wachs, Jr., found the average duration...............279.87 " Lowenhardt-Ahlfeld found thè average duration.......281.6 " Winckel (op. cit., p. 01) made a careful study of more than 5000 cases of pregnancy in order to give expert testimony in regard to its duration before a < fermai! court. In 70 of thèse cases the duration exceeded 300 davs, and in 47 it exe-eeded 302. In one it Avas 314, and in another 318, elavs from the day of the presumably effective coitus to the day of de- liA'ery. The conclusion of Winckel is in the folloAving words: "The 152 A SYSTEM OF LEGAL MEDICINE. average duration of pregnancy is about 280 days; it may vary, however, from 210 to 320, and perhaps even exee-ed this latter limit, which is by no means se) rare as Avas formerly supposed, for in (i.S percent, the dura- tion is over 300 elavs." Schroeder Aviseïy says that a very large child, with évidences of un- usual development/vigorous A'oice, large franic, long hair, etc., does not necessarily mean an unusually prolongée! gestation, for ail thèse phe- nome-na may be seen in immature children. Winckel narrâtes a case» in which 310 days interveneel betAveen the last coitus and the birth of the child. The mother hael been divorced from her husband on account of adultery, anel additional punishment was sought by the husband by civil process. The possibility that the dura- tion of pregnane-y, under'lawful conditions, Avas 310 days could not be disproved, and this fact, together AA'ith the ver}' large size of the child, led to the mother's acquittai. Protracted gestation exceeding even the limit mentioned in the fore- going statements may occur either in the intra-ute-rine or extra-uterine variety. In the former variety some unusual conditions may bave caused the delay, such as abnormal rigidity of the utérus, undue absence of irritability i'11 the utérus, absorption of the liquor amnii, or disease and death of the fétus. If labor does not occur Avithin a short time» after the fétus bas reached maturity its death must follow as a conséquence', and in this condition it is possible that it might be retained Ave»eks or months, perhaps undergoing décomposition, or AA'ithering and sliriveling Avithout décomposition, or becoming converteel into a hard, stone-like mass, called lithe>pa»dion from the abundant deposit of lime salts within its tissues. An inert mass of this eharaeter may be carried by a Avoman in lier utérus 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-mentioued cemrse is alAvays 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 fétus is perfectly mature, false labor-pains may be experienced at that time. They are false because they do not occur in a utérus AA'hich is pregnant, and because delivery by the natural avenues and means is impeissible. Death of the mother may resuit from hemorrhage, or from septicamiia (bloeid-poisoning) in connection Avith the décomposition of tlie child, or she may bave vitality sufficient to Avith- stand thèse or any other accidents in this connection and die eveutually from some entirely différent cause. The child may be coiiA'erteel into a lithopœdion, AA'hich Avas described in the preceding paragraph -, it may elecompose and the firmer tissues eventually be discharged after ulcéra- tion into the rectum, the vagina, or the bladder ; or it may be removed from the abdomen by surgieal opération. Cases which illustrate- ail thèse possible conséquences are recorded in récent gynecologieal lit- erature. The duration of pregnancy is insufficient AA'hen labor occurs before the fétus lias reached maturity. This does not imply that a living child may not be born and be susceptible of deA'elopment though it may be imma- ture in many respects. The facts Avhich relate to this phase of the ques- tion haA^e been ceuisidered in connection with viability, and the subject will be further discusseel in the article on Abortion (q.v.). BIRTH, SEN, PREGNANCY, AND DELIVERY. 453 The détermination of the period of pregnancy which lias been reached in such cases is by referene-e to the last menstruation or by inspection of the fétus itself. The question of légitimacy of offspring must in many cases hinge upon the supposed duration of pregnancy, and it lias been sIioavii that this is a subject in which error is very liable to occur. Many States bave fixed légal limits to the duration of pregnancy, but it must be évident from the testimony Avhich has been adduced that such limits are A'ery fallible, anel that adhérence to them pre>vides the oppeutunity for possible injus- tice. By Scoftish law anel by the French Coele 300 days is the légal limit allowed foi- pregnancy; by Prussian law the limit is 301 days (note as exce-ptiem the case quoted by Winckel in a previous paragraph). By English law no time-limit for pregnancy is fixed, cases being decided in accordance Avith the évidence of meelical experts and the moral and col- latéral aspects of each case. In this country great latitude is allowed. Two cases are quoted by Taylen*, in both of which legitimacy was ad- mitted, the duration of pregnancy, counting from the last ceiitus, being 313 days in one and 317 in the other. (See Leishman's System of Mid- wifiery, 1875, p. 181.) As it bas been shown to be impossible to eleter- mine with accuracy the exact duration of complétée! pregnancy in any ghen case, this being a A-ariable quantité, it may be sIioaati to be equally impe>ssible to state Avith exactness the point or extent of development AArhich has been reached in any given e-ase of incomplète pregnancy. It is quite» peissible, lioAvever, to answer such a question approximately, and thus satisf'y ail légal requirements. Referene-e to the last menstruation will usuaily be regarded as the most impen-tant limit from Avhie-li to make the necessary ealeulatioiis. The size of the utérus Avili also be of assistance in such e-ale-ulations, and Ave may add, upon this point, to the suggestions already given, the commentent statements of Lusk, which are as folloAvs : In the second month the utérus 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 heael and can be felt aboA'e the symphysis pubis ; in the fifth the fundus is mid- way between the symphysis anel navel ; in the sixth it bas reached the navel; in the seventh it is two fiiigers' breadth above the navel; in the eighth it is half-Avay between the navel and the epigastrium ; in the ninth it reaches the epigastrium ; in the tenth (lunar months are e-onsidered) it sinks until its upper level corresponds AA'ith the situation at the eighth. (See eut from Lusk's Science aud Art of Midwifery, p. 113.) As the naArel is not a fixed point and A'aries considerably in différent Avomen in its distance from the symphysis, Spiegelberg suggests that measurements be made from the symphysis as a constant limit. Lusk adds, however, that it must be remembered that the utérus is subject to variations ac- cording to the size of the child and the quantity of amniotic fluid. Spie- gelberg's measurements from the SA'mphysis to the fundus at différent periods are as follows : From the 22d to the 26th week........ 8| inches. From the 22d to the 28th week........10£ " From the 22d to the 30th week........11 " From the 22d to the 32d and33d week.. 111 " From the 22d to the 34th week........12 " From the 22d to the 35th and 36th week 12£ " From the 22d to the 37th and 3Sth week 13 " From the 22d to the 39th and 40th week 13J " 454 A SYSTEM OF LEGAL MEDICINE. Alilfeld, whose Avork on the détermination of the size and âge of the fétus prior to birth (Archiv fur Gyndkologie, Baud ii., p. 353) is authority with the best récent obstétrical authors (Schroeder, "Winckel, Lusk, et al), adopts methods which are rather complicated for gênerai use, and Lusk's Fig. 68.— Schultze's diagram, illustrating schematically the enlargement of the utérus during the successive months of pregnancy. (Lusk.) criticism of them is that they show such variations in the size of children boni in the same week of pregnancy as to somewhat impair their prac- tical A-alue. Adelitional assistance in determining the period of gestation may be derived by référence to the date of quickening. This is said to occur usually at the eighteenth week of pregnancy, but allowance must ahvays be made for variations from that limit. The measurements of Farre are regarded by many as very valuable, and differ from those which hâve been given by Spiegelberg. They would, perhaps, be seldom applicable upon the kving subject; neverthe- less they demonstrate the impossibility, even on the part of compétent anatomists, of arriving at identical results upon such a epiestion as this. The following are Farre's measurements of the pregnant utérus : BIRTH, SEX, PREGNANCY, AND DELIVERY. 455 Length, Width, Inches. Inches. End of 3d month 4£ to 5 4 " 4th " 5£ " 6 5 " 5th " 6 " 7 5i " 6th " 8 " 9 6| " 7th " 10 7i " 8th "11 8 " 9th " 12 9 If after the foregoing rules bave been applied the utmost limit of ges- tation bas been reached and 110 signs of labor are apparent, the suspicion will be Avarrantable that there is extra-uterine gestation, or that there is intra-uterine gestation and that the fétus bas died. The former supposi- tion Avili be warrantable if a sound intrenluced into the utérus shows that the organ is only slightly enlarged if enlarged at ail. If the latter suppositiem is the correct eme tliere Avili be absence of fetal movement; palpation of the utérus will show want of resiliene-y in the organ, anel a sensatiem of boggïness or doughiiiess, while the patient will be conscious of «111 uneomfortable feeling of Aveight or chilliness in the utérus, which is very différent from the sensation AA'hich is produced by the présence of a living child. IV. DELIArERY. Delivery and the Puerpéral State—The Condition of the Génital Organs at the Time of Delivery, together with Evidences in General of Récent De- livery—Loch i al and Lucteul Sécrétions—Sujtposititious aud Sujgnrssed Children—Feigned Delivery—Duties of the Physician when the Consé- quences of Labor are Likely to Prove Serious to Mother or Child—Inter- vals between Successive Dreguaneies—Evidences that Pregnancy has Existed at any Time—The Injuries of Parturition, their Frequency, Extent, and Possible Conséquences—Duty of the Obstetrician iu Recog- nizing and Treating Them—Responsibility of the Patient when the Physi- cian's Advieeis not Heeded—Questions Concerning the Duties of Physicians in the Présence of Conditions which Call for the Major Opérations in Obstetric Surgery. IVlhery 01* labor or parturition includes the phenomena associated Avith the extrusion of the fétus and the structures appertaining to it through the birth canal. It is dhisible into three distinct stages or peri- ods, the first being concernée! Avith the softening and dilatation of the tissues through Avhich the fétus is to pass, the second with the passage outward of the fétus, anel the third with the expulsion of the placenta or fleshy structure AA'hich bas been the bond of union betAveen the mother and the child, the médium through which the vital current, AA'ith its nutrient éléments, has been communicated from the one to the other. With the placenta are also expelled the membranes 01* envelopes in whie-h the fétus has been surrounded. Delivery at term signifiVs conipletion of development—the fruit, being ripe, drops, having 110 furtheu- necessity for attae-hment to the parent stem. If laben- occurs before the fétus has matured it means, as in the 456 A SYSTEM OF LEGAL MEDICINE. analogems condition in A'egetable life, miripeness anel imperfection, Avith possible harm to the stem from AA'hich it bas been separateel. Delivei-y, like pregnancy, is a normal function, anel AA'hen ace-oinplisheel in a perfectly normal manner shoulel give rise to no se-riems disturbance-. Among many of oui* native Intlian tribe»s the pain and disceunfbrt asse>- e-iateel Avith labor are insignificant. A Avoman may fall in labor while e>n the mardi : she steips aAvhile until the child is born, Avashes it in the- near- est streani, straps it on her back, and then hurries forward to rejoin lier comrades, avIio hâve not Avaiteel for her. In e-ivilized life the besf-con- ditioned, best-deve»loped Avomen bear children Avithout great disceunfbrt, though there are feAv Avho are» entirely insensithe to the pain which ac- companies childbirth, especially AA'hen they expérience it for the» first time. Others AAdio are Aveak aud badly formée! fine! the pangs of labor almost insupportable, and there are many AA'hom de-ath woulel e-laim as its A'ictinis, on ae-count of absolute inability te) bring forth their cliilelivn, if art did not intervene and remeely nature's ele-ficicne-ie-s. The obstetrie art is essentially life-conse-rving; it is more than that—it is life-giving; and it was never practiced with such skill and succe-ss and discrimina- tion in any previous âge of the Avorld, by the profession at large, as are exere-iseel now. To conduct a labor to a suce-e»ssful issue the physie-ian must détermine with reasonable ae-eurae-y the folleiAving facts : that the vitality of the mother is not being seriously encroae-lieel upon by the pain which she is suffering; that the birth canal of the nmther is of ample dimensions to permit the extrusieni of the e»hilel at the proper time; or, if the fon-geùng conditions are not satisfied, that the prope-r iiistrumentalities are at hand to reinforce the vitality of the mother, and to furnish a safe delivery, and, if peissible, the safe delivery of the chilel as Avell. A physician is négligent who trusts to the unaided efforts of nature te) effect delivery Avhen it is évident te) one of ordinary perception and expérience that na- ture unaided cannot deliver, or can do so only at the grave»st 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 négligent, when operative measures are required, aa'Iio does not call to his aid skill superior to his oavu for the performance of such operative measures, if his own skill and expérience are insufficient, if such superior skill is available. Except under extraordinary conditions, a woman should not be allowed to die undelivered. Except under extraordinary circumstances, the life of a child should not be deliberately sae-rificed by operathe measures. A physician should, in the great maj'ority of cases, be able to discriminate whether the interests of mother and child are best subserved by the opération of version or by the use of the obstetrie forceps. A physician should be aide to discriminate, with the assistance of counsel if necessary and available, Avhether the interests of mother and child may not be best subserved by the performance of symphyseeit- omy or Ca»sarean section. In view of aU the rcsoure-es Avhie-h modem obstetrics places at the command of the physician, including the practice of rigid asepsis, which is only another terni for cleanlmess, tiierc are few complications which place any case of midwifery beyond the reach of efficient relief. After labor is concluded the puerpéral state begins. It usuallv contin- ues four to six weeks, and is a period of very great importance," for it is. BIRTH, SEN, rREGNANCY, AND DELIVERY. 457 the period in which the» utérus undergoes involution by means of contrac- tion and fatty de-ge-ne-ratieui of its muscular fibers, the placental site be- coming oblitéra ted, and by AA'hich restitution to the condition which it sustained prior to pregnane-y is established. This condition is, however, never pree-isely identie-al Avith the condition of a utérus Avhich lias never been impreguated, the contour of* the organ being someAAdiat more rotunel, Avhile its external orifice almost invariably déclares to the prac- tice-el eye or finger that the AÙrgin state 110 lemger exists. While the preu-e-ss in question is going on, e-specially in its early stages, the condi- tieui of the Avennan is a very sensitive one. Within the utérus, and some- times in other portions e>f the birth canal if the labor bas been a severe one, there is an exte-nsive rave surface through which poisonous germs may be absorbée! Avith great facility. It is the period in which the drcaded and dreadful puerpéral fever, which sometimes SAveeps through eommuiiities like a pe»stilence, is a possible contingency. Only since the self-denying labors and sae-rifices of the lamentée! Semmelweiss bas it been appree-iateel that this elisease is preventable if the labor has been prope»rly conducted anel strict cleanliness observed iu ail the surround- ings of the patient. This elisease is practically unknown among savages and others who lead an out-of-door life. This is not, however, 011 ac- count of superior cleanliness or caution 011 their part, but because of the bénéficiai effects of an out-of-door life. In many maternity hospitals in which puerpéral fever once raged Avith terribly destructive effects it is now almost unknoAA'ii. It is proper to reiterate the statement that a physie-ian is négligent who does îmt obser\Te the most scrupulous cleanli- ness in ail bis dealings Avith puerpéral women. In alme)st ail labeu-s, espe-e-ially the first AA'hich women expérience, the strain upou the tissues as the child leaA^es the birth canal is such that more or less tearing of them occurs. Such injuries are ordinarily most marked at its outlet, and careful inspection Avili usually reA'eal their loca- tion and extent. Their importance cannot be exaggerated if we remem- ber that they often f uriiish. the opportunity for septie infection ; henee the necessity of treating them by means of suitable ligature material as soon as possible after they bave occurred, thus anticipating any further injury from such a source. The tissues iu question may be toru in any diree-tion, the mucous membrane of the vagina being terni longitudinally, transversely, or obliquely, or the mucous membrane of the vulva may be involved, or the» injury may extenel outAvarel to the skin, 01* through skin, mucous membrane, fascia, and muscle, finally going through the rectum, or it may exte-nd upAvard and invade the bladder. The injury may resiilt in the detachnient of the fascia by which the vagina is supported, without any apparent nrvolvement at the surface. The utérus may be wounded to any extent, from a simple fissure at its external orifice to complète» rupture of the organ and delivery of the child into the abdom- inal cavity. It must therefore be plain that the ae-coucheur's duty has not endeel Avhen the fétus and its attachments hâve passée! out of the mother's body and into the Avorld. He should acquaint himself at the earliest possible moment after the conclusion of labor Avith the condition of the mate-mal tissues AA'hich ha\re been subjected to such a severe strain. If this AAere ahvays done as a matter of routine, much tremble Avould be obviate-el feir patient, and physician, and there would be fewer invalids from such a cause. lu adelition to the évidences of récent delivery from 458 A SYSTEM OF LEGAL MEDICINE. the injuries AA'hich haA'e been alludeel to, one may also observe swelling and discoloration of the vagina and vulva, enlargement e>f the veins of the A'iilva and anus, and more or less prolapsus of one or be>th lips of the» c-ei-A'ix uteri. In many cases there Avili also be paralysis of the bladder anel e-onseepient inability to pass the urine, AA'hich may e-euitinue several days after delivery. As soon as the contents of the utérus bave been expelled there is im- médiate slirinkage or contraction of the organ if the course of events is the natural one, anel insteael of e»xcending far above the navel it does not extend much higher than the symphysis pubis, its size being quickly re- duce'd to that of a small coe-eianut. Theneeforward during the puerpéral state or puerperium it e-ontinues to contract, as we bave already remarked, until the normal unimpregnateel size bas been reached. In some cases the contrae-tieui is so excessive that a e-ondition of atrophy is reached, the organ becoming reduced to the size of a seckel-pear. This is the condi- tion AA'hich is knoAvn as superinvolution, and it is usually folloAved by ii-remediable sterility and the ménopause. It is a rare condition, the Avriter having seen not more than four or five cases. In other e-ases tlie contraction is imperfect : the organ remains nearly as large as a base-bail for months, and is more or less boggy to the toueh. 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 conebtion will prove a very troublesome one. This is the con- dition Avhich is known as subinvolution, and is a very common one. The abdomen, which bas been greatly stretched during gestation, be- comes relaxed anel flabby, and the more mimerons 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 sherws furrenvs and stria» and more or less pigmentation in testimony of the pregnancv which has reeently occurred. The breasts SAvell and harden, and by the third day after delivery lactation is usually established. The Aveniderful sensitiveness of the mammary glands and the intense sympathy which they share with the rest of the génital apparatus, and espee-ially with the nerveuis system, are seen m the frequency with which they become inflamed after delivery in response to any disturbance in the parts with which they are in sym- pathy. Lochial and lacteal sécrétions are necessary concomitants of the puerpéral state in normal cases, and, converselv, Avîie-n they are observed the obvious mference must be that the pregnant state bas reeently ex- isted. But it must not be forgotten that a bloody diseharge from the vagina and milk m the breasts may occur independently of pregnancv Avhde it is also possible that both may lie absent though pregnancv and delivery hâve been récent. The lochial discharge is composed of blood and broken-down tissue, and implies that the usual degenerative chaînas in the utérus are progressing. It usually continues three or four weeks gradually becoming less abundant and more watery in eharaeter It is a very important index to the physician of the situation within the uté- rus, and if it suddenly ceases or becomes unusually abundant or very offensive it is a Avarning that the situation within 'the utérus is not a désirable or proper one, and a plain indication that interférence is neces- sary. The lacteal sécrétion is susceptible of great variation as to quan- BIRTH, SEN, PREGNANCY, AND DELLVERY. 459 tity and quality, and tlie physician should be alert to discover the first évidence of disturbance in this direction, for it is then that the trouble may be averted or ininimized. The suppositition or substitution of a child for fraudulent purposes is, of eenirse, petssible, especially if there has been collusion on the part of the physician 01* midwife. Cases are recorded in aa hich such a fraud bas been practiced for the purpose of securing an inheritance (see Wharton and Stillé, \rol. iii., see'. 37) ; but détection canuot be avoided if the sigus of récent pregnancy anel delivery are AA'anting in the supposed mother. There is 110 Avay of counterfeiting such signs, taken as a Avhole, Avhich is knoAvn te> the writer. The same may be said in regard to feigned delivery. Many AA^omen hâve deceived themselves anel their attendants, either Avill- fully or unconsciously, during their supposed pregnancy, and haA'e finally taken their beds in expectation of delivery. The possibility of such occurrences demonstrates the necessity of diagnosticating the condition of a woman by means of a careful examination and not by the statements which may be made, if one would préserve his réputation and his self- respect. Suppression of a child after it bas been delivered is possible either through accident 01* by design on the part of the mother. Cases are suf- ficiently mimerons in which the mother bas been suddenly taken in labor anel bas gone to stool apparently for the purpose of emptying her bowels : the child has been born and has perished from expetsure, the mother returning to lier household duties as if nothing had happened. It is pe>ssible to conceive that such cases and others of similar precipitate labor may occur without criminal intent on the part of the mother, but the inference «in most cases will be that criminal intention was présent. The obstetrie art bas made a distinct adA^ance in the last décade in the treatment of cases in Avhich labor was likely, according to former meth- ods of treatment, to prove serious or even fatal to the mother or the child, or to both. Unfortuiiately there are many women who are so de- formed as to their pelves, that it woulel seem impossible that they could be debvered of living full-term children by the natural process, if indeed they could be de»livered of them at ail. The alternatives are the destruc- tion of the child, with dismemberment if necessary, and delivery through the contracted natural passage, the induction of labor at the seventh month or subsequently in the hope of obtaining a living child, or the ivmoval of the child at maturity through an opening in the mother's .abdomen and utérus (Caesarean see-tiem), or the division of the boues at the symphysis (symphyse*ttomy). If the child is dead when the obste- trician takes charge of a given case it has 110 rights Avhich are to be re- garded, and it should be delivered in such a manner as will offer the highest degree of safety and c*)mfort to the mother, Avhether with instru- ments or Avithout them. But if the child is living it bas natural and le»gal rights AA'hich must not be ignored. The Roman Catholic Chureh forbiels the deliberate sacrifice of the child, even though the hfe of the mother may, in ail probability, be saved thereby. Tliere are certain con- tingene-ies in which the mandate of that chureh Avould be disregarded, especially if the obstetrician were not of that faith. If a child were manifestly feeble or defeirmed, or so constituteel that it could not accord- ing to human judgment, survive, the obstetrician Avould be dereliet if be hiu A SYSTEM OF LEGAL MEDICINE. allowed its useless existence to jeopardize the life of its mother. But mère disproportion betAveen 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 tlie'chilel of life. If the mother is alreaely in a dyiug condition Avhen the obstetrician arrives upon the se-ene, anel the child is vigorous in its movements aud bas a vigorously acting heart, the epie»s- tion of quickly removing it by Ca»sarean section becomes pertinent. Sue-h an eiperation has been done AA'ith the resiilt of obtaining a living child. Of course it requires not a little fortitude to undertake such an ope-ration. The chane-es of eibtaining a living child are diminished if Ca»sare»an section is déferrée! until the mother bas expired. Such opéra- tions hâve also been performed: they are usually unsuccessful, for the vitality of the child is dépendent upon \dtality in the mother. The induction of prématuré labor at the seventh month, when the birth canal of the mother is not suffie-iently capacious to allow the pas- sage of a fully grovvn child, is a procédure which is directed chiefly in the mothe-r's interests. A seven months' child, as we haA^e alreaely stated, lias not the vitality eu- the development of a full-term child, and there is not only the risk that a child thus prematurely delivered may not be lh- ing when delivered, but that attempts te) rear it, if living, may be futile. The homes of the poor and careless, where such children most frequently come, are illy equippeel for the painstaking efforts which are required by such feeble infants. The mother suffers less risk by such a procédure than by aity other which has thus far been devised, and no unusual skill is required of the obstetrician for its performance. Of the two remaining measures suggested for the rebef 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 ail directions, but particularly in its transverse diameter, through which 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 beconie sufficiently spacious for the passage of the child, symphyse*>te>my should be the opération of choice or élection. The opération consists in dhid- ing the tissues which cover the joint formed by the union of the two pubic bones, and then dividing the structures which hold the bones to- gether. The pressure of the child upon the structures of the pelvis being constant, as soon as the bones are» divided the pelvis expands like a hoop which has been eut 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 the child. Even when this has been done delivery is not always accom- plished by the unaided efforts of nature, but a Avay has been opened so that if further use of instruments becomes nece-ssary they can be employed with greater aelvantage than before the opération. If the utmost space that cemld be gained by such a procédure still leaves the conditions unf a vend- able for delivery the alternative must be Ca-sarean section, which signi- fies an incision in the abdennen of the mother, another in lier utérus, and removal of the child through the Iavo openings thus maele. The expéri- ences of the past ten years ha\'e made this opération relatively safe in- stead of almost uniformly fatal as was formerly the case. It is the last resort, with its modifications, of obstetrie surgery, and if performee! upon a woman AA'ho bas not been exhausted by ineffectuai attempts at delivery BIRTH, SEX, PREGNANCY, AND DELIVERY. 461 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 AA'hen labor bas commenced—the chances for success for both mother and child are-, as a rule, very good. A certain amount of skill is required in the performance of either symphyseotomy or Ca?sarean section, anel this fact see'ins te> be e>A'erle>okeel by many writers. It does not folloAV that one who is cleA'er in the use of the obstetrie forceps or in the perform- ane-e» e>f manual version Avould be equally successful in performing sym- physe* >t*)my or Ca»sarean section; henee such opérations will ahvays ap- pertain to the specialist rather than to the gênerai practitioner. A more exae-t définition of the scope of thèse opérations is not appropriate» to a Aveu-k of this charae-ter. Their history has been very gratifyiiig, since it includes the restoration to health and usefulness of many mothers and the rescue from certain death of many children. Not a few instances are on rccord in Avhich Ca'sarean section has been repeatedly performed upon the same woman, the- boon of hving children being thus accorded to many who could bave» them in no other way. The number of children which a woman may haA^e or should bave is a question which cannot be answered in a gênerai Avay. Conditions of laAV, physiology, and easuistry may ail be invohed in its consieleration anel may ail eonflict with one another. It is not generally appreciated that an enormous number of the cases in Avhich pregnane-y occurs are abortive». Tins fact has its favorable and its unfavorable aspects. If ail pregnancies resulted in the birth of living children it would be almost inévitable that OA'erpopulation would quickly stare many communitie-s in the face* On the other hand, multitudes of fetuses are like blighted fruit, not having sufficient vitality to mature ; other multitudes are killed, murelereel in utero, and in the vast majority of cases neither those avIio commit the crimes nor their accomplices are eA'er brought before courts of justice, the rights of the murdered children being absolutely ignorée!. It was contended in ancient médical tradition that the pregnant state Avas the normal one for Avomen, and certainly the anatomy of the endo- me»trium, with its dcAelopment and degeneration during each menstrual cycle, Avendd seem to sustain such a supposition. But it must never be forge)tten that a pregnant woman lias two existences to provide for—lier own anel that of the fétus AA'hich she is carrying ; and if her stock of vitality is insufficient to properly sustain herself, it is manifestly unjust te> lier to impose upon lier the burelen of sustaining herself and another : it is also unfair, or at least unfortunate, to her offspring that it should come into the world handie-apped with an inheritance of physieal debility. This is no plea for criminal abortion, but a protest against ill-assorted marri âges, unrestrained sexual indulgence, and failure to guard against * This statement is made with due caution and réservation because of the per- fectly obvions fact that in many parts of tlie world conditions of climate, race, etc., are unfavorable to fecundity. even though abortion never occurred. Dr. F. A. Cook, ethnologist to the first Peai-y North-Greenland expédition, states that among the Esquimaux, with whom the impulses of nature are followed without restraint, abortion seldom occurs (though some of the women are stérile, and death during labor is an occasional occurrence). During the fifty years or more that thèse people hâve been under observation, though living under natural conditions and in surroundings to which they hâve become habituated, they hâve increased in numbers very slowly. It must he added that overpopulation is effectually prevented by their custom of kill- ing the helplessly aged, and infants whose mothers hâve died. 4Gl_' A SYSTEM OF LEGAL MEDICINE. imprégnation when enfeebled and diseased offspring must be au inévi- table conseejuence. After imprégnation lias taken place the attitude AA'hich the physie-ian should take toAvard the mother and lier unborn offspring should be- a e-eniservathe one. He cannot tamper AA'ith life. Those cases only are excepte-d in which failure to terminât*» the pregnancy prematurely Avould almost certainly resiilt speedily in the death of the mother, and, of course, of the child also. In the case of Aveimen aa-Iio are suffering Avith serious e-onstitutienial disease», including pulmonary phthisis, chronic nephritis, syphilis, and diabètes mellitus, it is believed that pregnancy should be prevented if pe>ssible. It is hard thus te) décide for those Avith AA'hom the maternai instinct is strong, but it is better to suppre-ss natural tendencies or self- loAe- than-to work lasting injustice to e)the»rs. If a Avoman is not debili- tated by disease and is of suitable physique for the requirements of pregnancy, parturition, and lactatieui, she Avili usually be benefited rather than harme-d by imprégnation occurring as frequently as it may oe-cur naturally in the ordinary course of temperate married life. It will be understood that thèse statements refer only to the physieal side of AA'oman's life ; their bearing in other directions is not under eemsideration. Among our native American population, espe-cially among those who are provident and temperate, the number of e-hildren Avhicli a Avoman bears rarely exceeds six ; usually it is unde-r rather than oa'it this number. Who can say that it is not better to raise and train earefully a small number of children, both Avith regard to the interests of the individuals themselves and tliose of the state, than to breed mimoderately, AA'ith re- sulting détérioration of the offspring and détective bringing 114) 1 Six pregnancies at intervals of two or three years Avili consume as much vitality as the average American Avoman can spare for such pur- pe)ses and at the same time de> justice to the other duties of life. Hoav- ever natural it may be for a healthy woman to bear children—and that is conceded—it e-e»rtainly is not the first and only duty which she has to consider. There are many indications or signs which déclare to the eye of an observant physician that pregnancy is présent or has been présent in a given case. In the absence of thèse signs it is not well to affirm too positively that it bas not been présent, A woman's statements that preg- nancy has or has not existed at a préviens time are useful only as they are confirmatory of a diagnosis Avhich must be based essentially on the sight and toueh of the physician. The facial expression of a Avoman Avho has borne children is entirely différent from that of one who lias not. It is frequently alluded to as the matronly or the maternai 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 benignaney of expression AA'hich is entirely sui gêner is—the radiancy of maternity AAhich the old Italian mas- ters incorporated in senne of their madonnas. The breasts of one who has borne children are usually well developed, especially if the children hâve been nursed. Fuiietionaf aeth-ity tends to the enlargement of thèse glands as it does to that of any others •' but if the BIRTH, SEX, PREGNANCY, AND DELIVERY. 463 quantity of fat associated Avith the glands is small the breasts may not be conspicuously large, though serving sufficiently well the object of lac- tatieni. The pax>illa3 of the areola» of the breasts, also the nipples, are suggestive by their prominenee and enlargement that pregnancy has ex- isted ; but the évidence derived from the breasts may be misleading, and it is chiefly of value when cemibined AA'ith other évidence. The scars, the folds, and the pigmentatieni of the skin upon the abdomen are also sug- gestive. They are sometimes lacking in distinctness, especially if a Avoman lias borne but one child, or if the nutrition of her body is unusually goe>d ; but they tell an almost unmistakable story in women who hâve been pregnant several times, repeated stretching having destroyed the natural appe-arance of the skin and the ordinary contractile force of ail the tissues of the anterior abdominal wall. With regard to the évidence furnisheel by the appearance of the external genitals there may be little that is suggesthe» if pregnaney neA'er proceeded to term, but if it had so proceeded the stretching anel tearing associated with the delhery of the chilel Avould almost certainly leave behind some évidence as to the fact, If, however, the Avounds which Avère made hâve been skillfully closed, détermination as to the preA'ious existence of pregnancjr may be almost impossible. The vaginal mucous membrane of one who has borne chil- dren is smoother, less rugose than it is in the A/irgin, the folds having been stretched or spread out. The vaginal portion of the cerA'ix in the parons woman présents decided points of dissimilarity from the condi- tions in the virgin : it is larger, its extremity suggests the section of a cylinder insteael of a cône (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 lias heretofore been considered a diagnostic point of unfailing accuracy in differentiating those who hâve been pregnant from those avIio bave not. Since the eiperation of trachelorraphy lias come into vogue, hoAveA^er, it bas frequently been found difficult to dé- cide from this sign alone in regard to the question of a previous imprég- nation. From the foregoing statements it will be e\ndent that the cases Avili be rare and infrequent in which it will not be possible for a physi- cian of expérience, cspe-e-ially if he has devoted considérable attention to the practie-e of obstetrics and gynecology, te> state Avitli considérable pré- cision whether pregnancy bas ever existed in a given case. If opérations hâve been performed upon the pelvic organs the inferences therefrom will sometimes be of value and sometimes they will not. The scar of an incision upon the abdomen may be an indication that Csesarean section bas been performed, but it may also indicate that an opération for dis- ease- of the e)Araries lias been performed, and if those organs were removeel subse-epient pregnancy Avould be impossible. The scar might also indi- cate that an opération hael been performed for appe»ndicitis or any other disease of the abdominal A'isc*»ra entirely distinct from disease of the génital organs. Scars upon the vagina or utérus might also signify the performance e>f opérations AA'hich had no relation to pregnancy. Testi- mony e>f this eharaeter is therefore necessarily inconclusive and indirect, anel should ne)t be acceptée! by a court of justice as évidence per se that pre-gnancy has existed. Obstetrics or miehvifery is indeed a Avell-nigh perfect art, A correct appre-ciatiem e)f its principles is more generally diffused than ever before, and tliere is searcely a complication AA'hich can arise which is not suseep- 401 A SYSTEM OF LEGAL MEDICINE. tible of successful treatment by those who are masters of the art. The number of those avIio bave acquired this mastery is ine-rcasing year by year. The obstetrician avIio practices in the cities is espe'e-ially conscious of thèse facts, because to the city hospitals the greater numbe-r of those avIio suffer from the accidents of parturition are brought for reparathe treatment. The number of those AA'ho suffer from certain forms of thèse accidents is far less than it was a few years ago. Take, for example, the accident of vesie-ovaginal fistula, one of the most distressing in the e-ntire category of parturition injuries, resulting from a severe or a badly man- age»d labor. A feAV years ago oui* spécial Imspitals Avère filled Avith such sufferers: uoav they*are rarely seen. This must prove that midwifery and its sister-art, surgieal gynecology, are more intelligently and more successfully practiced than formerly. The question then arises, Why is it that se> many women still continue te) présent themselves for relief from the» accidents "of labor? To this epiestion several answers are possible. First, th<»re are certain cases in whie-h, enving to serious faults and defects of structure, injury cannot be prevented, no matter how skillful or in- telligent the obstetrician may be. Again, the labor may hâve been prop- erly conducted and terminated, but subséquent carelessness or injudicious conduct on the part of the patient may hâve led te> conditions which could only be relieAeel by surgieal measures ; or an unskillful michvife or e\'en an uuskillfid or badly equipped obstetrician may haA'e» been responsible for the injury; or, finally, bad results may hâve come about through no apparent error on the part of the physician or the patient, for reasons Avhich cannot be explained. Unavoidable accidents from first labeirs are still quite fréquent and probably ahvays Avili be AA'hen the tissues hâve a tendeney te) fear rather than to stretch, as is so frequently the case Avhen Avomen do not become pregnant until after they hâve passed their thirtie-th year. The particular forms which thèse injuries may take bave alreaely been noted. It is Avell to réitérât e the necessity that the obstetrician care-fully examine his patient after labor bas been e-*mcluded and at once repair the damage as ace-urately and completely as possible. Tliere are cases in AA'hich the excuse for not following so vigorous and thorough a line of treatment seems entirely valid : the labor may hâve occurred at night, anel in the imperfect light which Avas available an injury may hâve been o\'erlooked ; or the eramped and contracted limits and appliances of a tenement-house may bave furnished obstacles which at the moment seemed insuperable ; or the patient may hâve been so exhausted by her sufferings that additional exposure and pain even for a feAv minutes Avould bave seemed imwarrantable. But whatever the excuse, whether valid or iuvalid, it often happens that neglect to take the précautions mentioned results in infection through the wounded tissues, with subsé- quent scarring and contraction, or in inflammatory elisease of the utérus, Avith subséquent involvement of the oviducts and o varies. If the patient leaves her bed too soon, or is exposed to cold, or is not kept sufficiently clean, evil results may follow for which the physician is iu no Avay responsible, for he Avould not hâve allowed the imprudence en* the exposure if lie could hâve prevented it, The mother of a familv among the poor is often compelled by stern necessity to take risks after her labor AA'hich a woman in more* eomfortable 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 BIRTH, SEN, PREGNANCY, AND DELLVERY. 4G5 penalty in many cases is a very severe one. Finally, no matter Iioav skill- ful or intelligent the physie-ian or the midwife may be, no matter hoAV careful or he>AV clean in their treatment, there is a e-ertain number of cases which go Avrong from the beginning, not only among the ignorant, the poor, and the careless, but among the Avell-to-do anel the careful. In addition totbe mischievems results of severe labor upem the structure of the génital and urinary organs, there are other morbid conditions affect- ing Avomen avIio bave been pregnant, which are sometimes secondary to and eh'pe'iident upon the>se injuries Avhich they bave received, and some- times occur independently of or in the absence of such injuries. Malig- nant disease of any part of the body, AA'hich may ha\'e been quiescent during pregnancy (though it frequently preigresses pari passa with the pregnancy), may assume a dangvrous aspect and progress rapielly to a fatal issue as soon as pregnancy bas terminated. The same is true of tubercular disease of the différent parts of the body, alse> of the chronic inflammatory diseases of the kidneys, etc. One e»f the most important groups of the morbid sequels of parturition includes the mental disorders, and thèse may occur with or Avithout the surgieal injuries before men- tioned. The mental dérangement may take the A'iolent form of mania in its varying grades, or the subdued form of melancholia, also of vary- ing degree. In a gênerai Avay it may be sait! 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 preëxisting tendeney to mental disease, which matures either into occasienial attacks of mania or into a prolonged period of melancholia within a few days or weeks after pre»gnaiicy is over ; or by septic influences or material operat- ing during the period of pregnancy through the médium of the blood and lymph currents, or after labor lias terminated. The subject of légal procédures against physicians in cases in AA'hich parturition bas resulted unfavorably iu one way e>r another is an interest- ing and most important one. Siie-h procédures are usually most annoy- ing anel vexatious, involving much time and expense, and, it may be, the Arery possibility to the physician of hving and working at his calling in the commimity AA'here ail his interests are loeated. Such interests may bave been built up by the laborious AA'ork of many years, and it not in- frequently happens that they are jeopardized by tliose who should be attached to the physician by ail the claims of gratitude and humanity. Let us see for a moment AA'hat are the phases of obstétrical practice. In the majority of cases it e-euisists mainly in cleanliness on the part of ail aa'Iio are in any way concerned, in not being meddlesome, and in " ghing nature a chance.'' Such cases may be handled by intelligent midwives Avith perfect propriety. Other e-ases demand the exercise of geiod judg- ment, common sensé, and a reasonable degree of mechanical skill ; they are beyond the sphère of the midAvife, anel shoidd be attended by physi- cians of at least the average intelligence. The remaining minority of cases require the highest qualifies of judgment and the highest degree of intelligence and mechanical skill—quabties AA'hich are possessed by but A'ery ft-AV. The» average physician, who has had no opportunity or train- ing iu spécial lines of work, should not be held accountable for injuries resulting from suprême difficulties, nor for injuries which hâve resulted from the- carelessness or imprudence of the patient, nor for those which bave résultée! from lier failure or unAvillingness to comply AA'ith conditions 466 A SYSTEM OF LEGAL MEDICINE. which he or one of greater expérience and skill has deenied essential te> lier Avelfare. The laAV, which recognizes the physician's Avork as largely one of hu- mane-effort, AA'hich exempts him from jury duty and other duties whie-h are incumbent upon the ordinary citizen, should shield him also from the attacks of niischievous anel irresponsible persons in the matter of the diseharge of bis duty in behalf of parturient Avomen. In e-euisideration e>f the présent status of the science and art of obstetrics, and of the oppor- tunities whie-h are uoav Avidely diffused for obtaining the necessary infor- mation and experiene-e in this direction, it may be boldly said that no one who practices in this department should offer the plea of inability to per- forai the opérations AA'hich are îiecessitateel by the lesser ae-cidents Avhich are incidental thereto. CVrtainly one avIio is incompétent to do such opérations is uot a proper person to practice obstetrics, for we haA'e' seen hoAV important is their hearing 1141011 the future welfare of the individual- Besides, in ise)lated e-ommunities and sennetimes even in the cities, the services of the skilled specialist are often quite unavailable, and unless the opérations in question are performed at the finie the injuries are re- ceived they are either not done at ail, to the possible détriment of the indi- vidual, or they entail 110 little expense and ammyance by being elone at a subséquent period, perhaps necessitating a prolonged absene-e from home. In the présence of the serious complie-ations of midwifery—for ex- ample, such as require the opening of the abdomen, and incision, repair,. or removal of the utérus 01* other important structure—what is the duty of the average obstetrician with but little surgieal expérience 01* skill and no expérience at ail in such suprême emergenciesf The supposition is, furthermore, that he is unable to call to his aid the skilled assistance necessary for such an occasion. The condition is a dilemma either horn of which is disagreeable enough to take. Either he must attempt a seri- ous, délicate, and difficult opération for which he has neither expérience 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 properly, or he must fold his hands and do nothing except enforce cleanliness and drainage, with the possibility that nature may furnish the one chance in the pa- tient's favor which is necessary to overcome the situation. The lesser evil would seem to the Avriter to be inveilved in the expectant or do-noth- ing plan, and he Avould therefore counsel against the performance of the opérations in question by the inexperienced. There is no chance of suc- cess in ignorant and haphazard rushing into such serious situations for the sake of doing something, the most that can be accomplished being to bring the operative measures into discrédit. It is better to do nothing than to do something rashly and unwisely. It is better to hâve the con- sciousness that a patient died because one did not know how to relieve her than to feel certain that she died because of the injudicious violence which Avas inflicted upon her. The performance of thèse major obstétri- cal opérations must ever be limited to the comparatively few, and the part of prudence and wisdom will consist rather in anticipating and pro- viding for thèse evils than in abortive attempts to remedy them Avith means which are almost certain to prove ineffectuai and disastrous. ABOETION AXD INFANTICIDE. BY CHARLES JEWETT, A.M., M.D., Sc.D. ABORTION. By the term abortion, or miscarriage, as used in criminal laAV, is under- stood the unlaAvful termination of pregnancy at any period of gestation. The distinction observed in medicine between the terms abortion and pré- maturé labor is not recognized in law. An abortion is said to be com- plet*» when the entire product of conception is expelled ; incomplète AA'hen a portion of the ovum is retaineel in utero after the expulsion of the fétus. For the purpose of this discussion the subject of abeirtion présents two gênerai subdiAÙsions, non-induced and induced abortion, and under the latter head must be distiuguished legitimate and criminal abortion. 1. NON-INDUCED OR SPONTANEOUS ABORTION. The frequency Avith which miscarriage occurs from innocent causes is variously estiniateel at from one in five to one in ten pregnancies. The causes of spontaneous abortion may be dhdded into two groups : 1. Those which act by first causing the death of the fétus ; 2. Those which act independently of the death of the fétus. By far the larger proportion of cases are included under the first head. The fétus may die in conséquence of malformation, disease, me- chanical violence—as falls or blows—maternai toxemia (e.g., carbonic- acid poisoning, saturnism, alcoholism, mercurialism, iodism, etc.), excess- ive anémia, ])athological conditions of the chorion, the amnion, the cord, or the decidua. Old âge or disease in the father is an occasional cause. On the death of the fétus the ovum shrinks, and, as a rule, is expelled within a ft»AV days or weeks as a foreign body. Under the second head are included reflex irritation of the utérus (as by stimulating rectal injections, h'ritatieui of the mammary glands, and the like), emotional excitement, placenta prœvia, epileptiform convulsions from uremia or other cause, carbonic-acid poisoning, hemorrhages into the plae-enta, détention of the utérus in the pelvis by adhésions, dis- placements of the utérus, utérine carcinoma, hyelramnie>s. multiple preg- nancy, falls, or blows. Congestion of the pehic organs due to circulatory obstruction in the» lungs or liver, or to heart disease, A'iolent muscular effort, exe-e»ssive coitus, etc., may resuit in hemorrhage into the placenta and conséquent abortion. The-se causes operate primarily to excite con- tractions of the utérus and thus the ultimate expulsion of its contents. 467 468 A SYSTEM OF LEGAL MEDICINE. 2. INDUCED ABORTION. (a) Legitimate Abortion.—Under certain conditions it becomes the duty of the obstetrician to terminate the pregnane-y. As a gênerai 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 imcontrollable vomiting of pregnancy. In extrême contractiem of the pelvis, and in certain e-ases of marked atresia of the soft parts of the parturient canal, the évacuation of the utérus in the early months of pregnancy is permissible, on élection of the mother, Avliere a Ca»sarean operatiem Avould otherwise be necessi- tated if the case were allowed to go to term. It may also be called for in placenta praevia. The induction of abortion, AA'hen required for scientific reasons, should be uiidertaken only AA'ith the formai assent of another practitioner. The physician should ahvays, for his oavu protection, associate Avith himself a compétent consultant in the management of the e-ase. Various measures bave been used for provoking abortion. Among them may be mentioned the puncture of the membranes and the partial séparation of the ovum by means of a utérine sound. Thèse 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 utérine Avall, are recognized methods. Repeated strong applications of faradism or galvanism through the utérus will usually provoke abor- tion at any stage of pregnancy. In the first two or three months a good method in experienced hands is the dilatation of the cervix and the évacuation of the contents AA'ith a curette and utérine forceps. A skilled operator can easily empty the gravid utérus in this manner in fifteen to tAventy minutes. (b) Criminal Abortion.—The measures employed to procure illegiti- mate abortion are of two kinds, médicinal and mechanical. Médicinal Measures.—Abortifacient drugs act by directly or indirectlv exciting utérine contractions. Among the reputed abortifacients are ergot, borax, cimicifuga (blacksnake-root), extract of cottonwood, savin, rue, tansy, vorcuwood, apiol, yeAv, pennyroyal, digitalis, squills, quinine, belladonna, pilocarpine, sarsaparilla, hellébore, laburnum, grains of para- dise, guaiacum, sodium salicylate, oil of amber, phosphorus, strvchnine, broom-fern, lignum vita, hoarhound, camomile, mugwort, cantharide-s, Juniper, juice of bamboo leaves, milk-hedge, and other euphorbiaceous plants, chiretta, 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, hierapicra, and pilaeotia ; carbonic dioxide, bisulphide of carbon, and illuminating gas, by inhalation, are also recognized abortives. Some of thèse préparations act directly to induce contractions of the utérine mus- cular fibers; such agents are kne>Avn as ecbolics. Others act on the vascular system. With very few exceptions, thèse drugs are capable of causing abortion only when the ovum has an insecure attachment, if at ail. When they operate promptly, at least in ordinary doses, it is to be presumed that there was a prédisposition te> miscarry. Of the foregoing agents only a few require spécial mention. ABORTION AND INFANTICIDE. 4G9 Ergot.—This substance is a morbid growth sometimes found on the seed of rye and certain other grasses. The ergot of rye (Secale cornutum) is that most commoiily employed. Ergot has the power to intensity utérine contractions already begun. That it eau originale them de novo, during the first half of pregnancy, is considered doubtful ; yet I hâve occasionally seen évidence of its influence as an abortifae-ient, eA^en in the early months of gestation. The dose of the crude drug is from one- half to two drains, of the fluid extract, from one to two fluid drams, three times elaily. In extrême doses ergot gives rise to toxic effects. A sensé of beat and elryness of the throat, pains in the stomach and boAvels, nausea, and sometimes diarrhea are the principal symptoms. Occasion- ally tliere is marked retardation of the cardiac movements, with headache and vertigo, delirium and coma. The pupils are usually dilated. Ergot in powder has a faint, fishy odor which is especially eleA-eloped by rubbing Avith a solution of potassic hydrate. The same odor is mani- fest on mixing the caustic potash solution Avith 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 intestines. Tansy (Tanaeetum vulgare).—In our oavu country, especially, this agent has a popular réputation as an abortive. The oil and the infusion are the pre»parations most frequently useel. Fatal results hâve followeel the ingestion of a half-ounce of the oil, and eA'en smaller quantifies. In a case mentioned in the Uniteel States Dispensatory, death resulted from a large dose of the infusion taken interiially. The tuxic sA'mptoms con- sist of irregular respiration and extrême» cardiac de»pression, AA'ith, finally, viole>nt coiiA'ulsions and coma. Abortion does not necessarily occur. Cotton-root (root of the Gossypium herbaeeum, or common cotton- plant).—The tincture or décoction of the bark of the root has acquired the réputation of an abortifacient, anel is saiel to be used feu* this purpose among the colored race of the Southern States. The latter statement, boAvever, lias been denied on the authority of reputable Southern practi- tioners. Savin (the tops of the Juniperus satina).—The oil is the most active préparation. The fluid extract is nearly as effecthe. The poAvdered leaf is sometimes employed, as are also the infusion, the décoction, and the tincture. The médicinal dose of the poAvdered leaf as an emmenagogue is ten te) fifteen grains, of the tincture one-half to one drain, and of the oil five mininis. The toxic effects are severe pain, caused by its irritant action upem the steunach and intestines, Avith A'omiting and diarrhea, and finally colic and convulsions. Salivation and hematuria are aise) com- mon results of tlie ingestion of teixic doses. Its action upon the utérus is probably secenidary to its violent systemic effects, and the drug is ace-orelingly an excceelingly dangerous agent when used in quantifies suflicient to produce abortion. It can be said to bave no spécifie power as an aborthe agent. The oil is ree-e)gnized by its yelloAvish color and the characteristic odor of the plant. It is soluble in ether, anel may be recovered from the con- tents of the stomach by shaking them in a fiask Avith this agent. After death by savin-poisoning the odor of the drug is sometimes perceptible in the tissues of the body. 170 A SYSTEM OF LEGAL MEDICINE. Rue (Ruta cjraveolens).—Préparations of rue bave a decided action upon the utérus. Most used are the powdered leaf, the essential oil, and the infusion. The médicinal dose is one-half to one drain of the powder, from one to five minims of the oil, and from five to thirty grains of the leaf in infusion. In toxic doses it produces vertigo and is a power- ful vascular depressant, The tongue becomes sAvollen and the patient suffers from salivation, nausea, severe pain in the stomach, jactitation, stupor, and chills. The abortive effects of the drug are usually developed only after marked systemic disturbance. The contents of the utérus are-, as a rule, expelled on the second day after the onset of the toxic symp- toms. Yew (Taxus baccata).—Abortive properties hâve been attributed to the fruit of the ycAV-tree, but in ail recorded instances of its use for the purpose», death has taken place without évacuation of the utérus. Saffron (Crocus sali vus).—The stigmas of the saffron flowers are a popular abortifaeient; but their réputation as a utérine excitant appears to hâve no foundation in fact, Pennyroyal (Hedeoma puleejioides).—The warm infusion, peimyroyal tea, is a "much-used emmenagogue in domestic practice. Its réputation, however, as a means of provoking the menstrual flow is not Avell foundeel. Its mention hère woidd be unnecessary but for the fact that active aborti- faeient properties hâve been erroneously attributed to it in a noted case in the criminal e*ourts of Great Britain. Drastic Cathartics.—Aloes, croton-oil, elaterium, colete-ynth, and other violent purgatives may act as reflex utérine e»xeitants. Hiera-picra (a combination of cane»lla bark, one part, and aloes, four parts) and pilacettia (a mixture of colex-ynth and aloes) are sometimes enqile-yed as abortive»s. This class of agents are of little effect as abortifacients except in condi- tions Avhich prédispose to miscarriage. Apiol is an emmenagogue of undoubted poAver. It exerts a direct effect upon the circulation of the utérus. It is therefore capable of ex- citing abortion under favorable e-ircumstances. The tincture of the chloride of iron has been given in large doses with the intent of producing abortion. While it is capable of deleterious effects upon the gênerai health when used in large quantifies, it has no spécifie action as an abortifaeient. Mechanical Measures.—Mechanical measures are far more effectuai abortives than drugs. Thèse means may, after the first tAvo or three months of gestation, be such as act by first causing the death of the fétus. Thus the child may be killed by blows upon the mother's ab- domen. Generally direct violence to the abdomen produces abortion by disturbing primarily the relation of the ovum te) the utérus. The at- tachment of the ovum to the utérine wall is partially broken up, AA'ith the e'ffecf to bring on expulsive efforts of the utérus. Under this head are included blows on the abdomen, intentional falls anel niuse-ular strains, carriage-riding over rough roads, bareback riding, long AAalks, tight-lacing, vaginal or utérine tlouches, and direct interfe-r- ence by other means AA'ithin the utérus. Tents of sponge, sea-tanglc, or similar material are probably seldom used by criminal abortionists. Thèse instruments consist of small, compact pencils of sponge of avoo<1 about tAvo inches in length, which possess the property of ex]ianeling when moist. Placed in the canal of the utérine neck they absorb Avater ABORTION AND INFANTICIDE. 471 from the surrounding structures, and, SAvelling, they dilate the cervix. The ovum is partially separated from its attaclmients at the lower seg- ment of the utérus, and becoming in part a foreign body, the utérus con- tiacts to expel it, The methods most empleiyed are some forms of direct interférence. The» ovum may be partially detached from the Ioaa'ci* utérine segment by nu-ans of a sound or probe, or it may be perforated. In the first method the curve-el utérine sound is passed betwee-n the membranes and the uté- rine» Avall, anel the membranes peeleel up by sweeping the point of the sound around the e-iivle. Utérine contractions may thus be set up gen- erally Avithin a feAv hours. When abortion is ineluceel by penetrating the' membranes a blunt probe or pointée! instrument is passed through the neck of the utérus anel tlie membranes perforated. This opération is dénie by the professhmal abeu-tionist and sometimes by the patient her- self. The attempt is less likely to be succe'ssful in proportion as the stage of gestation is early and the ovum small. Among the instruments that hâve been used for tins purpose by the Avoman herse-lf may be men- tioned knitting-iiee-dles, piee-es of Avire or whalebone, stiletteis, hairpins, penholders, bemgies or e-atheters, and Avooden skcAvers; sometimes the finger. The professional abortionist generally emph>ys a utérine semnd or some similar appliance» as a perforator. On puncture of the mem- branes the liquid contents of the omm escape anel the OA'iim collapses, the utérus retracts, partially se»parating the product of conception from its attachments to the» utérine wall, anel a greater or less amount of hem- orrhage- occurs. The embryo or fétus elles from beginning interruption of the uteroplacental circulation and other e-auses, and the utérine» con- tents be-come a foreign beiely. As a rule contractions of the utérus are seion established, and it expels its contents generally Avithin a few days. The final expulsion of the ovum may, hoAvever, be delayed for a Avee»k or more. Frequently the case terminâtes fatally by peritonitis or gênerai sepsis. While in properly conducted abortion the death-rate is practically nil, the mortalité of criminal abortion is A'ery great. This is du*» to tlie fact that in abentiem donc by the Avemian herself or by an unskille»el abentiemist portions of the product of conception are usually left to putrefy in the utérine cavity. Often, too, the Avoman is infected primarily by unelean instruments anel methods of operating. MoreoA't-r, unnecessary A'iolence is frequently done to the utérine walls. The point of infeetiou is often a Avound of the utérus made by the instrument. Many cases bave been reported in which the woman, in her desperate dé- termination to put an endto the pregnancy, had passed a kiiitting-neeelle or similar appliance through the posterior vaginal fornix or the utérus into the peritoneal cavity. Bodies of this description haA'e slipped Avholly into the e-avity of the abdeunen and been subsequeiitly removed by abdom- inal section. Such injuries to the peritoneum usually resuit in death by peritonitis. Me>re scientific methods sometimes resorted to by expert abortionists are intra-uterine injections 01* the mechanical dilatation of the e-ei'A'ix uteri. The galvanic 01* faraeiic current is sometimes employed to excite ex- pulsive efforts. Tins method is frequently effectuai when strong currents are» passe'd directly through the utérus. One électrode is placed in the vagina against the cervix or is passed Avithin the utérus, and. the other rests on the Ioavci- abdomen or back. Thèse agents act by inducing ute- ±-o A SYSTEM OF LEGAL MEDICINE. rine contractions, or possibly, when heavy currents are» employed, by first causing the death of the fétus. CLINICAL EVIDENCE OF RECENT ABORTION. The amount and eharaeter of the médical évidence on which the proof of abortion dépends differ with the stage of gestation, and with the time that bas elapsed since the utérus was emptieel. Génital Discharges.—For at least one or two weeks after miscarriage at any stage of pregnancy there is a more or less abundant lochial Aoav. Flooding or the existence of a fetid, bloody vaginal discharge should arouse suspicion. Thèse signs, however, in the living subject, disappear within a short time after abortion in the early months of gestation, and are rarely sufficiently marked, after one or two weeks bave elapsed, to be of much'value as évidence that pregnancy has existed. When the» product of miscarriage, or any portion of it, is available for examination the question présents little or no difficulty. Blood-clots which hâve been expelled from the utérus in the early months of sup- posed pregnancv should be broken up under water and careful search made for shreds of fetal membraues and fragments of placental tissue. The gross characters of the product of conception are usually sufficient for its identification. When doubt exists, if the spécimen bas not been too much altérée! by décomposition, examination by the microscope will décide. The discovery of fetal villosities in the material e-ast off by the utérus is conclusive eA'idence that the case Avas ont» of pivgnancy. In the first two months the embryo is seldom found. It is either lost in the dis- charges or lias disappeared by absen-ption before expulsion of the utérine contents. Its tissues at this' early stage of development are se) soft that they are rapidly broken down after its death, and are promptly abse>rbeel or Àvashed aAvay in the discharges. Even AA'hen the ovum has be»en ex- pelled and lost, chorial A'illosities may usually be obtained by curetting the utérine cavity within a I'cav days after the abortion. By the end of a Aveek after the expulsion of the utérine contents the search for fetal structures in the ute»rus Avili seldom be successful. At the third month, and later, the development of the fétus is such that it constitutes a con- spicuous part of the product of conception. Condition of the Utero vaginal Tract.— The utérus remains some- what enlarged for at least tvvo or three Aveeks after abortion at any stage of pregnancy, and its structure is for a time somewhat less dense than is normal to the 11011-graA'id utérus. The cervical canal, too, is more patulous. The groAvth of the utérus is greater Avith each suceeeeling month of gestation, and its involution after labeir in advanced pregnancy e>e-cu- pies a greater length of time than after abortion in the earlier months. For two or three Aveeks after delivery at or near term, the vagina remains enlarged and relaxed, and more or less extensive tears are to be found about the vaginal orifice. Thèse injuries are more cenispie-uoiis in primi- parae than in multipare. The stage of repair will correspond with the length of time that has elapsed since the birth. Abortion in the early months leavesno similar traces in the loAver portion of the génital tract. Other Changes in the Maternai Organism During Pregnancy.— Before the end of the third month of gestation the changes which take place in other than the pelvic organs in conséquence of pregnancy are Plate WÊi VI Fi9B^ &9-c* 'o:<*fe#?%--9'*°* ^--v-^-.'iO, Fig. A—Lungs and intrathoracic organs of a new born child at term, having lived and respired, who was the victim of infanticide by suffocation. C Fig. •—Spot of Meconium. found on cloth. B Fig. (i—Spot of Fœtal Coating (enduit fœtal Tardieu). ABORTION AND INFANTICIDE. 475 fe-Av and imperfectly deA'eloped, and they recède more 01* less within a few days after miscarriage. They are of practically no diagneistic value in pregnancies subséquent to tlie first, since many of the changes induced by pregnancy remain in a measure permanent. The size and firmness of the mammary glands Avili be found increased from the end of the second month of gestation. The increased pigmentation of the mammary areola?, and the» pigmented line extending from the pubes to the umbilieus, ex- cept in light-complexioned subjects, are perceptible by the second month. By this time, too, the veins eiver the surface of the breasts bave beconie turgid, and by.e-lose inspection may be seen coursing across the primary areola?. After the third month a milky sérum may generally be pressed from the nipples. Practically ail thèse changes may occur as the resiilt of pelvic disease, Avhich, therefore, must be excluded. Evidence Afforded by Stains upon the Bedding or Clothing.— Blood discharged from a Avoman in case of abortion is practically indis- tinguisliable from human blooel eleriveel from other sources. Meconium stains présent certain distinctive characters by which they may usually be identifiée!. This material is a dark-greenish, viscous liquid yielding the reae-tion of bile to the nitric-acid test. With tincture of iodine a green coloration is produced. Among its microscopical éléments 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 patients linen or bed-linen. This material may be identified by its microscopic and chemical characters. The microscope reveal s epidermic scales and lanugo. The présence of fatty matter is elemonstrateel bv shaking up the particles with ether, which extracts the fat. (Plate YL, Fig. B.) POST-MORTEM SIGNS OF RECENT DELIVERY. Ail the changes in the maternai organism Avhich may resuit from pregnancy should be looked for. The évidence of récent delhery, how- ever, is to be found mainly in the e-ondition of the A'agina and the utérus. The vagina is increased in size, and, after delivery in the later months of pregnancy, its outlet présents the wounds or cicatrices characteristic of récent childbirth. The utérus is enlarged according to the stage of gestation AA'hich had been reached and the degree of involution which had taken place. Immediately after delivery at term the utérus measures externally 7 01* 8 inches in length, and 4 or 5 in width at the level of the Fal- lopian tubes. The thickness of the Avalls is about 1J inches. The depth of the e-avity is at the close of labor 6 inches ; at the end of the first week about 1£ inches ; at the enel of the second week 3£ inches ; and about 3J inches at the expiration of a month. The fundus uteri, shortly after labor, lies at the level of the umbilieus ; by the tenth day at the pelvic brim. The average» Aveight of the utérus at the close of a full-term labor is 35 ounces ; at the end of the first week, 16 ounces ; at the end of the seeeuul week, 12 ounces; end of the third week, 8 ounces. The utérus doe-s not usually fully regain its normal dimensions for nearly tAvo months. The régressive process is somewhat slower in multipara? than after first labors. The cervix remains relaxed and soft after labor, begin- 47G A SYSTEM OF LEGAL MEDICINE. ning to regain its form aud ceuisistence after about twelve hours ; Iavo fingvrs can be passed through the os iiiternum at the end of twenty-fbur hours. At the expiration of a Aveek the cervical canal admits one finger. Directly after delivery the cavity e>f the utérus is still lined with the» outer laver of de»cidua and Avith shreds of the inner laver. The place-ntal site présents a slightly elevated and uneven surface studded Avith thrombi lying in the months of the uteroplacental vessels, which bave been torn acreiss by the se»j)aration of the placenta. Men-e or less fluid and e-lotted bloe)d is preseuit in the caA'ity. The muse-ular fibers of the full-tenn utérus are from seven to eleven times longer than in the normal state of the nem-gravid organ, and are increaseel in thickness. Thèse changes in the utérus Avili bave recedeel in proportion te» the> length of time that has elapsed since» confinement, and Avili vary, too, ivith the degree of pre- maturity of the birth. The présence of a corpus luteum in the oA^ary is not distinctive of pre-gnancy. A corpus luteum is found whenever an ovum bas been reeently discharged from the ovary. It is always to be observed during the first two or three weeks after menstruation. It reaches a higher degree of development during pregnaney anel does not disappear for several Aveeks after childbirth. The absence of the usual corpus luteum of menstruation in its récent state would be évidence that a period of at least many weeks had elapsed since the last menstrual flow. AT AVHAT STAGE OF GESTATION HAS THE ABORTION TAKEN PLACE ? The stage of pregnancy at which abortion has taken place must be estimated from the measurements of the utérus, and from the size and development of the fétus Avhen the latter is available for examination. The following table sIioavs the dimensions of the utérus while it still contains the living ovum, at différent periods of gestation : SIZE OF THE UTERUS. Stage of Gestation. Length. Aid th. 3d month. 5 inches. 4 inches, 4th it 6 a 5 " 5th a 7 a 6 " 6th it 8* a 6i " 7th ii 10 a 7 " 8th it Hi tt 8 " 9th it 13 a 9 " lOth il 14 il 10 " The measurements of the utérus are considerably diminished after ex- pulsion of its contents, yet the foregoing figures may serve as a guide in estimating the period of pregnaney atwhich a miscarriage has taken place. The nuUiparous utérus is nearly 1 inch in thickness, H inches in AA'idth at the fundus, and 2£ in length ; it weighs about 1 oïince. The parons utérus in the non-graAÙd subject is approximately 1 inch thick, 2 inches wiele, and 3 inches long, and its Aveight is 1J ounces. The utérus at the close of labor at term weighs about 35 ounces. ABORTION AND INFANTICIDE. 477 Development of the Fétus.—The length, Aveight, and development of the fétus at différent stages of gestation are as folloAvs : At the end of the first limai* month the diameter of the ovum is f of an inch. The chorial villi are developed OA'er the entire surface of the ovum. The embrye) measures £ of an inch in length and Aveighs 15 grams. The nose and mouth form one cavity, the abdomen is still e)peu, the umbilical A'esicle persistent, and the members are indicateel by mère- papillae. At the entl of the second month the ovum is 2.J inches in diameter; the chorionic villosities haA'e begun to disappear over tAvo thirds of its surface. The length e>f the embiyo is 1J inches, and its average weight is 1 dram. The mouth and nose are separate anel the abdomen closed. The umbilical vesicle disappears. The members are formed, but the fiiigers and toes are Avebbed. Ossification is beginning in the inferior maxilla anel in the clavicle. At the end e>f the third month the diameter of the ovum is 4 inches. The placenta is formed. The embryo is 3| inches in length anel weighs 1 ounce. The finge-rs and toes are» separatetl ; the sex is discernible. Tliere are points of ossification in the bernes of the skull and the limbs. The length of the umbilical e-ord is 2^ inches. At the end of the fourth month the fétus measures 5 inches in length and weighs about 3 ounce-s. Hair begins to appear; the sex is clearly apparent ; nails begin to be formée!. At the end of the fifth month the length of the fétus is 9 inches, and its average weight 9.V ounces. The umbilical corel is about 1 foot in length; its point of insertion, insteael of being at the symphysis as it is till the fourth month, begins to move upward. Mecoiiiuni is présent in the intestines. Vernix caseosa appears for the first time. Ossification begins in the ischium. At the enel of the sixth month the fétus is 12 inches in length and Aveighs about 23 ounces. The cord measures 14 i inches. Ossification begins in the pubic bones. At the end of the seventh month the fétus is 14 inches long and Aveighs about 21 pounds. The average length of the cord is 161 inches. Ossification lias begun iu the astragalus. EA'IDENCE OF CRIMINAL ABORTION. It Avili seldom be possible to détermine by examination of the pelvic organs, the fétus, 01* its appendages AA'hether the abortion bas been spon- taneeuis 01* the resiilt of criminal interférence. When the opération bas been clumsily done the marks of violence may be suffjciently obvions in the living patient, aud especially on examination after death, to estab- lish the fact that criminal nmasures hâve been employed. The obvions présence of disease in the membranes or placenta Avemld point to the probability that fin» abortion Avas spontaneous. In criminal abortion the product of conception is more likely te) be mutilated than entire. The history of the Avoman's illness should be earefully analyzeel for the» toxic symptoms of the médicinal agents commonly employed for producing abortion. In post-mortem cases the contents of the stomach .anel boAvels should be examined for e»vide»nee of the présence of abortive 478 A SYSTEM OF LEGAL MEDICINE. drugs. The abortive agents of this class which are usually empleyed are generally capable of récognition by their microscopic or chemical char- acters or by experiments upon animais. EVIDENCE THAT CONFINEMENT HAS AT SOME TIME TAKEN PLACE. It may devolve upon the médical Avitness to distinguish between the pa- rous anel'the niilliparous condition—in other words, to détermine whether the woman has ever been confined. The signs are gênerai and local. The pigmeiitary changes which take place upon the breasts and abdo- men during the first pregnancy remain in a measure permanent. They are usually well marked in briiuettes, but not so in women of light com- plexion. Moree>ver, they art» not wholly reliable as évidence of pregnancy, since similar e-hanges may occur as a resiilt of pe»hic elisease. The irreg- ular whitish, pinkish, or bluish lines which are developed over the lower half of the abelomen afte>r the sixth month of prcgnaney, one-c formed, are never effacée!. They are also produced by abde mimai enlargement to the same degree from other causes, yet this source of error may be easily eliminated. The principal signs are to be sougbt in the condition of the organs immediately concerned in the pregnancy and the birth. Cie-atrices of old lae-erations may be found about the A'idvar orifice. The présence of true caruncula? multiformes may be taken as évidence of childbirth. This condition must be distinguished, hoAvever, from mère rupture e>f the hymen. The caruncula? consist of four or five small, fleshy exe-resce-nces skirting the vaginal orifice, and which rcpresent the remains of the hymen torn by the birth of the child. After delivery during the first half of pregnancy the condition of the hymen would not be sufficiently char- acteristic to be of value as évidence that confinement had taken place. The vulva and vagina are more relaxed in the parous than in the nulliparous woman. Vaginal cicatrices may resiilt from labor. Reliable CA'idence of pre\dous childbirth is usually afforded by the condition of the cervix uteri. The lower border of the utérine neck is always more or less notched, and sometimes deeply fissured, after labor at or Avithin tAvei or three months of term. The utérus remains permanently larger. Whether the number of confinements which hâve taken place is one or more cannot be determined by the physieal signs. It is seldom possible to décide whether an abortion has at any remote time occurred in the early months of pregnancy. The signs are fewer and less perfectly 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 purpose of incriminating others a woman may simulate abor- tion. Taylor relates a case in which a woman in Guy's Hospital accused a polieeman, who, she alleged, had ravished her, of haAdng procured an abortion by means of drugs which he had administered anel by the use of local mechanical measures. On examination by a médical expert, tAvo months after the alleged miscarriage, no eA-idence Avas found that she had ABORTION AND INFANTICIDE. 4713, ever been pregnant. Primarily grave doubt, as the author observes, is east upon a charge of this kind Avhen so long delayed after the alleged fact. Of interest in connee-fion with tins subject is a case of assumed abortion which was reeently brought to public notice in Brooklyn. A gynecologist of recognized ability and unblemished réputation Avas ar- rested on the charge of criminal abortion. The Avoman, aaIio had beconie ill during his treatment, joined in the accusation, under the belief, Avhich was shared by her usual médical attendant, that she had miscarrieel anel Avas about to die of peritonitis. On examination by the Avriter she Avas found to be still pregnant, at about the second month, Avith no évidence that violent measures had been employed. On investigation before the coroner the gynecologist, whose treatment was shown to hâve been en- tirely innocent and proper, was fully exonerated. INFANTICIDE. The term infanticide as used in médical jurisprudence applies to the murder of a new-born child. In the vast majority of cases the crime is committed at birth or directly after. It is immaterial, however, whether tlie âge 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 bas been completely born as it would be feloniously to kill an adult." Nor is it necessary that the child shall bave reached the full term of intra-uterine development, provided it has lived after its birth. It must, however, bave been fully expelled in a living condition. It does not matter Avhether the cord bas been di vidée! or not ; the child is born AA'hen it bas been completely expelle-el from the maternai passages even though the cord be» still intact. Il may hâve 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 utero 01* in course of birth is not infan- ticide. The law assumes that every neAA'-born child bas been born dead until the contrary is preived. The burden of proof that the life of the child has been willfully destroy ce! is cast upon the prosecution. This is a benefi- cent provisieui of the law to prevent unjust conviction, and is rendered nee-essa.ry by the fae-t that a large number of children are at birth dead or non-viable. It will thus be seen that the problem presented to the médical jurist in a case of alleged infanticide is by no means a simple on*» ; sennetimes it is be»yond the reach of médical évidence. Adopting the scheme of Ogston, the questions which confront the expert are the feillenving : 1. Has the prisoner been reeently delivered? 2. Was the child mature ? 3. Was it the child of the prisoner ? 1. Was it dead or alive at its birth? 5. If alive, what was the cause of its death ? 480 A SYSTEM OF LEGAL MEDICINE. 1. HAS THE PRISONER BEEN RECENTLY DELIVERED ? The facts upon AA'hich the solution of tins question Avili dépend bave been alreadv e-euisidered under Abortion. The question mav arise in this connection whether a Avoman who has just been confined could be ignorant of the fact. That a a\ ennan may give birth to a child Avithout knowing it and Avithout having recognized the existence of pregnancy is searcely 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 terminatiem of the birth is frequently abrupt : the' child is sometimes expelled from the utérus into the Avoiïd in a single pain. This is more likely to occur if the wom- an is in an upright posture. A child expelled Avhile the mother is in a standing or sitting position may sustain serious injury by précipitation upon the floor or into a Avater-closet. Yet simple falls are seldom fatal : the distance is short and the fall may be partly broken by the cord. Unintentional précipitation of the child into a Avater-closet or privy vault may easily happen and is not an extremely rare occurrence. The pressure e>f the presenting part of the fétus in the lower peirtion of the birth canal usually gives rise to a violent rectal tenesmus. The sensa- tion is mistake-ii for an urgent demand for stool. h'espondhig to the seeming necessity, the upright position of the parturient, and the strain- ing, help to precipitate the birth, anel in this Avay it can happen that the chilel may be dropped into a water-closet e-onsistently with the entire in- nocence of the mother. Unconscious delivery is of course possible in eclampsia, in coma from whatever cause, and under amesthesia. 2. AA'AS THE CHILD MATURE? The probability of natural death in the neAV-born is greater in propor- tion to the prematurity of the birth. The médical witness Avili therefore be required to testify to the probable stage of intra-uterine development which the child had reached. The folloAving are the data upon which an approximate estimate may be given in the last three months of fetal development, Fe n- the rate of fetal growth in the precetUng months the reader is referred to page 477. At the eighth lunar month the average fétus measures 16 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 fétus is, approximately, 17 inches in length, and its weight about 4 pounds. Lanugo is beginning to dis- appear from the body. The ossifie nucleus in the lower fémoral epiph- ysis first becomes visible. At the tenth lunew month, the period of full maturity, the height of the child is from 18 to 20 inches. The measure is to be taken from the vertex to the lower border of the calcaneum. The average» weight is 7 pounds. The principal head diameters, subject to certain modifications due to molding when measured shortly after birth, are as folloAvs : The bipari- ABORTION AND INFANTICIDE. 481 étal, measured through the pariétal emmenées, 3f inches ; the fronto-men- tal, from the sunimit of the forehead te» the center of the lower margin of the e-hin, 3£ inches ; the occipito-frontal, from the tip of the occipital protuberane-e to the root of the nose, 4J inches ; the occipito-mental, from the tip of the oce-ipital protubérance to the center of the lower margin of the chin, n j- inches ; the suboccipito-bregmatic, from the jnnction of the nuelia and occiput to the center of the bregma, 3^ inches ; the bitemporal, the distance be'tAveen the lower extremities of the coronal sutures, 3£ inches ; the bimastoid, the greatest distance between the mastoid apophy- ses, 23 inche»s. The length of foot is 3£ inches. The» average weight of the new-born child is from 7 to 7^ pounds. Both weight and measurement are slightly greater in maie than in female births. The face and Ixxly are plump. The child suckles and cries lustily. Vernix casée>s;i is présent chiefly on the child's back and on the flexor surfaces of the limbs. The skin lies in deep folds at the flexor surfaces of the joints. Portions of the integumeiit, especially about the shoulders, are thickly covered with lanugo. In f ull-term children the skin is Avhiter than in those prematurcly boni. The epidermis begins to be throAvn off on the second day. The exfoliation commences on the abdomen, sprcads over the body and lower part of chest, aud is complète in about tAvo weeks. The location of the umbilieus is above the center of length of the child's body. If the child bas breatlied, the thorax is arched and the diaphragm de-pre-sseel ; if respiration bas not taken place, or only imper- fee-tly, the chest is fiât, The finger-nails project beyond the finger-tips^ the toe-nails to the end of the bed of the nail. The cartilages of the nose anel of the ear are firm. The cramai bones are hard, the sutures and the fontaiielhs small. Ossificatieui is beginning in the upper epiphysis of the tibia and in the cuboid boue. The ossifie nucleus in the lower end of the fémur bas reached the diameter of nearly or quite ^ of an inch. Ossification to this extent in the loAVt-r epiphysis of the fémur may be taken as conclu- siA'e évidence of term-deve»lopment. This bony nucleus appears as a small, distinctly marked, bright-red spot in the white cartilage. It may be much smaller or entirely Avanting even in term-births. Hartmann failed to find it in 12 e-ase»s out of 102. The examination of the epiphysis for determining the stage of ossifi- cation shoultl be eemelucted as folloAvs : The knee is slightly flexed and the joint laid open. Seve-ral horizontal sections are then made through the epiphysis. The dimensions of the bony nucleus may thus be» readily de-termine-el. Its greatest diameter at term, which is the trans\'erse, is from 2 to ."> mm. (£ inch). When only portions of a tlismembered body are at the disposai of the expe-rt, bis conclusion must be basée! ou the évidence of development affeu-eleel bv the bones. Heasurements of the bones are liable to be mis- leading, A-et may fnrnish presumptive évidence. The stage of ossification is more conclusive. The fémur and the inferior maxilla, as AA'e bave already seen, afford valuable data. Not only the» ossifie nuclei but the papillae of the molars should be exaniined. The latter become croAvned in the last Aveeks of fetal devel- opment. The germs of the teeth do not solidify during intra-uterine life. 4-S2 A SYSTEM OF LEGAL MEDICINE. The measurement and Aveight of certain portions of the body and the weight of viscera afford useful guides for determining the» stage e)f de- velopment. The following figures are given on the authority of Letour- nean : 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 internai condyle of the fémur is 2 inches ; from the latter point to the lower border of the calcaneum, 4£ inches. The distance from the acro- mion process to the epicondyle of the humérus is 3£ inches; from the latter point to the styloid process of the radius, 2j£ inches. The weiglit of the right lung is f ice. The frozen organs should be immersed in Avarm Avaler until they hâve cennpletely thawed. Pulmonary Docimasia by the Microscope.—This method of exam- ining the state of the lungs in suspectée! infanticide Avas proposed by Bouelmt. Under a magnifying power of five or ten diameters the eut surface of a lung which bas not breathed présents tlie appearance of solid tissue. It sIioavs reticulation, but no air-vesicles. On the other hand, the pulmonary structure, after respiration has taken place, exhibits initier the magnifier agglomérations of air-cells. By its aid imperfect expansion of pulmonary lobules is readily recognized. If respiration has not been fully established a portion of the alveoli is seen te> be undilated. The inflated air-vesicles do not disappear under pressure with the Angers, as do the» gaseous bubbles in the intercellular tissues. Morcno preiposes that the smallest bronchioles be examined. The dil- atée! epithelium passes into cubical, and by expansion of the alveoli in inspiration becomes squamous. The method is searcely practicable for gvneral use, sine'e» only after examining the entire lung coidd partial e'xpansiem be excluded. Has the Child Cried ?—The only médical eviehnee on this question is to be» seuight in the condition of the lungs. Full inflation of the air- cells may gem»rally be taken as proof that the child has e-ried. On the either hand, it is improbable that it had utte»red any sound if the lungs are found in the fetal state. Imperfee-t dilatation of the pulmonary le>l>- uh-s is not inconsistent Avith the allégation that the child cried feebly. 48G A SYSTEM OF LEGAL MEDICINE. The fact that it had done so. hoAvever, is not évidence of living birth, since the child may cry before it is completely boni. The possibility of an intra-uterine cry (vagit us uteri nus) is well recog- nized. This can occur, obA'iously, only'after the rupture of the mem- branes, and AA'ith such accident or manipulation as may admit air into the utero-vaginal tract. The child cannot cry AA'ithout air. In gênerai it must be remembered that the présence of air in the lungs, however demonstrated, Avhile it is usually to be taken as proof of life during birth, is not eA'idence of living birth. The lungs may be partially inflated in a child that bat! died before it Avas completely boni. Air in the Alimentary Canal.—Before birth no air is contained in the stomach or intestines. Air gains access to the steunae-h and the deeper portions of the digestive tract directly after birth in the bving child. This occurs either by aspiration or by the act of swalhnving. Its prés- ence, therefore, as indicated by flotation of thèse organs Avlien placed in water, is generally an indication that the child Avas boni alive, anel the inference is the stronger in proportion as the air is found in larger quantifies and at a lower point in the bowel. To apply this test the stomach must be ligateel at each end before it is opened, and the section of intestine must be tied in like manner on opening the abdomen. It must not be forgotten, however, that air may be introduced into the stomach and intestinal canal during attempts at insufflation of the lungs, and that the gases iu the stomach and boAvels may be the product of putrefactive décomposition. Merkel found air in the digesthe tract of the neAv-born child only after thirty Schultze swings, never after other methods of insufflation. The mouth-to-inouth method he probably did uot use. Cardiac Movements.— As bas been alreaely stated, life terminâtes Avith the cessation of the heart-beats. If on auscultation over the chest the heart-souiids are heard after bh*th, or if cardiac movements can be felt by pressing the Angers up under the inferieu- costal border on the left side, or if the umbilical stump puisâtes, the child is bving, even in the absence of respiration. Wreden's Test.—Wretlen lias called attention to the fact that at birth the middle ear is filled with epithelial cells and mucus, and that in the living child thèse substances are absorbed within a short time after birth. The présence of a cavity in the middle ear is therefore to be taken as évidence that the child had survived its birth. Docimasia of the Circulation.—Coagulability is the property of living blood. The blood does not eoagulate in tlie dead body. Henee ecchymoses or blood-coagula in the tissues of the body are proof that the chilel was living at the time the injury Avas inflicted, irrespective of the state of the lungs. How Long did the Child Live ?—It is not ahvays possible to déter- mine the length of time the child lived. The question, as a rule, can be only approximately decided. The facts which bear on its solution art» the following: The skin sheds its superfieial epithelium in the first day or two after birth, and remains red for a week or tAvo. After this length of time it assumes a whiter appearance. The caput sue-eedaneum subsides AA'ithin from twenty-four to forty-eight hours after birth. Its persistence after death may be regarded as évidence that the child did not sui-A'h'e the birth for more than a few hours at the most. A blood-tumor (cephal- ABORTION AND INFANTICIDE. 487 haematoma) must not be mistaken, however, for the mère edematous swell- ing of the caput succedaneum. Thèse bloody effusions usually persist for tAve» en- there months. The umbilical stump, when exposed to the air, or if loosely covered with a dry dressing, remains in a fresh state for only a short time, be- coming dark-colored and shriveled by the second day. In the course of two or three days more it assumes a horay consistency, and generally falls off by the end of the fifth day. Yet in exceptional instances the cord may not separate for a Aveek or me ire-. It must be borne in mind that changes simulating those which occur in the living infant may take place after death, and that the séparation of the cord may occur from putrefactive causes after the child is dead. The» wound Avliich it leaves in the living child usually heals in the course of four or fh'e days after the cord sépa- râtes, yet complète cicatrization may be delaye'd for a variable period. Oblitération of the umbilical vessels is eennplete in from six to seven days after birth. The umbiïical arteries are closed Avithin t\vo days ; the umbilical vein, ductus venosus, and the foramen ovale in the course of six or seven days. Yet thèse periods are subject to some variation, and it is not an uncommon expérience in post-mortem examinations te> find the foramen ovale persistent in the adult. The ductus arteriosus is obliter- ateel in from ten to fifteen days. The examination of the lungs will sIioav Avhether respiratiem bas been established. If the lungs are found in the fe-tal state the chilel bas died either before or eliree-tly after the birth. Yet a condition of partial ate»- lectasis, as bas been seen, is not inconsistent Avith hfe for a feAv hours or eA'en days. A frothy condition of the fluid contained in the stomach is évi- dence that the child breathed and e-ontinued to lhe for at least several minutes—long enough to bave sAvallowed fluid material AA'hich had been mixe-d with air in the mouth. The présence in the stomach of lanugo and particles of veruix casée isa from SAvalleiAved liquor amnii Avould indicate that the child had probably died Avithin two or three days after birth, before thèse substances could be passeel off. This ceme-lusion Avould be borne enit by the présence of meconium in the intestinal tract. On the other hand, if the stomach contains food and the meconium lias been Avholly evacuated from the boAvels and replacée! by féculent material, the child bas liveel for at least three or four days. Among the substances that should be looked for in the stomach are milk, blood, sugar, anel starcly material. Milk anel blooel can usually be ielentified by the niie-reise-ope. The iodine test should be used for starch; Fehling's or the fermentation test for the sugar of milk or grape-sugar. If the» precautieni lie taken to boil a portion of the stomach contents be- fore te-sting, Avith dilute hydrocliloric acid, any cane-sugar that may be présent Avili be e-emverted into grape-sugar. Atti-ntion bas been called to the bony nucleus in the Ioavci* epiphysis of the fémur, as proof of full-term development. GroAvth of this ossifie center be-yonel the maximum size at term Avould indicate that the chilel had liveel for at least several days. The extent of ossifie devele'qmient in other bones should also be noteel. How Long has the Child been Dead ?—The décision of this question is more difficult the longer the time that bas elapsed after death. An appre>ximate estimate is generally possible AA'hen the examination is held 488 A SYSTEM OF LEGAL MEDICINE. within a Aveek or little more post-morte»m. The only médical evidene'e» is afforded by the stage of deconqiosition. The rapidity of the putrefactiA *» changes, hoAvever, AA'ill obviously dépend on the température and humidity of the» air anel other physie-al conditious to Avhich the body bas been ex- pose-*l. They go on more rapielly in tbe air than in other média. As bas been already stated, peist-niortem changes begin at a later period in the lungs than in most either structures of the boelv. Marked putréfaction in thèse» organs is therefore proof that the body bas been dead for a consid- érable length of time. 5. AVHAT AA'AS THE CAUSE OF THE CHILD'S DEATH? The essential question to be decided by tbe médical évidence in a case of alleged infanticide is the cause of death. Nearly tAventy percent. of ail children die be'fore or shortly after birth from other causes than criminal violence. In prématuré births the death-rate is still greater, anel is larger in proportion to the degree of prematurity. Maie children are me>re liable to die during labeu- than female, OAving to the somewhat larger size of the former anel the greater difficulty of birth. So, too, children die in larger nunibers in first than in subséquent labors of the mother, the proportion being one to e»leve-n in the former and one to thirty-one in tbe latter. Thèse facts must be taken into account in estimating the» probability of death from natural causes. It is therefore necessary that the médical witness be familiar with the natural causes of death in the neAAr-born. NATURAL CAUSES OP DEATH IN NEAV-BORN CHILDREN. The fétus may die in utero or shortly after birth in conséquence of malformations, asphyxia, operative or accidentai violence, or from fetal or maternai disease. Malformation—Congénital defects are frequently met with. They may be found in any organ of the body and they seldom occur single. Death from this cause takes place oftener after than before birth. Amenig the faults of development which are inconsistent with extra-uterine life are anencephalus, exencephalus, spina bifida with ulcération of the tumor, acardia, and certain other malformations of the heart, The heart may consist of but one auricle and one ventricle. The aorta and pulmonary artery are, in rare instances, transposed, the former coming from the right, the latter from the left ventricle. Atresia of the esophagus, imperforate rectum incapable of surgieal rebef, and marked ectopia of tbe abdominal or tlioraeic viscera are necessarily fatal. Under this heael, too, are in- cluded malformations of the respirateuy tract, which prevent free ace-ess of air to the alveoli of the lungs. Contraction of the conus arteriosus, and other malformations of the heart or large vessels which permit mixing of the venons with the arterial blood, are usually inconsistent with extra- uterine hfe for more than a limited period at most. On the other hand, moderate microcephalus or hvdrocephalus, spina bifida when not ulcerated, dislocation of the heart, valvular cardiac dis- ease, persistence of the foramen ovale, transposition of the stomach or other viscera, exstrophy of the bladder, and intra-uterine amputation of limbs, do ABORTION AND INFANTICIDE. 189 not usually cause death. In occasional instances the subjects of moderate hydrocephalus lhe to an advanced âge. Spina bifida is much more fatal when situated in the cei-rical région than in the lower portion of the spine. Monsters, iu a large proportion of cases, die soon after birth. Fetal Disease.—Congénital disease» is an infreque»nt cause of death in the new-born. Among the diseases which are pe>ssible during intra- uterine life are cardiac affections, rheumatisni, rickets, leucemia, gênerai dropsy, seirrhus, and probably ail iufectieuis diseases. Examples of the latter whie-h ace knoAvn te) oce-ur iu the fétus are syphilis, searlet feA'er, measles, sniall|)<>x, chole-ra, tvphoid fever, yellenv fever, pneumonia, tu- be-re-ulosis, eiysipelas, and septicannia. Other causes of death in tbe child are», metallic imprégnation, parents te>o young or too old, the effects eif alcoholism and certain other chronic diseases iu one or both parents, nephritis, diabètes, and feeble fetal development. Syphilis is responsible for more deaths in utero or soon after birth than any other fetal malady. It may be either of maternai eu- of paternal or- igin. When the mother is syphilitic every ovum cast off from the ovary is probably affected with the disease, ami the child winch is developed from such an ovum is syphilitic. If the father be syphilitic it is believed by many authorities that the spermatozoa contain the- acthe cause of the elisease anel convey syphilis to the ova Avhic.h they impregnate. When the mother is hifected at the time of the fruitful coitus, or shortly be-fbre, tbe child is invariable syphilitic. Frequently, though not uniformly, it develeqis the disease Avlien the materna! infection is cemtractcd during the pregnancy. In something less than fifty pe-reent. of syphilitic cases the pregnaney terminâtes in abortion. A large proportion of the children die in utero in the later months of gestation. Only a small pereentage of those born alive long survive the birth. In e-hildren boni dead from tins e-ause, the récognition of the disease is usually not difficult. Among the most conspicuous lésions of fetal syph- ilis are e>ste<>chondritis betAveen the head anel shaft of the fémur and either long bones, and enlargement of the liver and spleen. On examining the cartilage AA'hich séparâtes the diaphysis from epiphysis in the long bones and espeedally at the» leover end of the fémur, the line betAveen bone and e-artilage, instead of being narroAv, e-lean-e-ut, and sharply defined, as in health, is found Avide anel 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 prématuré attempts at pulmemary respiration. It is to be remembered that during intra-uterine life the respiratiny function is per- formed by the placenta, after birth by the lungs. So long as the placental functions are perfectly performee!, tbe» child lias no need of pulmonary respiration, and makes'no effort to breathe. If the placental functions are wholly or partially suspended, respiratory movements are provoked by the air-hunger thus developed. This may occur before birth from com- pression of the umbilical cord, prématuré detachment of the placenta, partial or complète, profuse hemorrhage, and from undue compression of the placenta by violent and persistent utérine contractions. If the first' attempts at respiration take place in the absence of air Avhile the head is still in the birth canal, usually liquor amnii, blood, vao'inal mucus, or meconium is draAvn into the trachea and bronchi. 490 A SYSTEM OF LEGAL MEDICINE. Access of air to the aheob and the lungs may thus be preventeel afte-r birth. The essential élément in the asphyctic condition is the A'eneuis stasis superinduced in the thoracic circulation by prématuré resjurateny efforts. On expansion of the thorax in the first respirateny niOA'ements the capil- laries of the lungs art» filled by f en-ce of aspiratiem. In the absence- of air, bleiod stasis is deAeloped aud congestion of the entire intrathoracic A'eneuis circulation. A secenidary venous congestieni is frequently deA'eloped in the gênerai circulation. Prolongée! compressiem of the brain during spontaneous labor in narroAv pehis, or by 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 pneumeigastric neive. For a full expo- sition of tbe pathology of asphyxia neonatorum the reader is referred to Lusk's Science aud Art of Midwifery. The appearances found after death by asphyxia are tlescribed under Infanticide by Suffeication. Accidents and Injuries.—The new-born chilel may dit» from accidentai injuries sustained at the time of birth or seieui after. Cases are frequently reported in AA'hich oAving to uuexpected delivery the child has fall en upon the floor or lias been expelled into a Avater-cleiset, Injuries sustaineel by falls owing to suelden expulsion of the child in dangerous places, as bas been already stated, are- not often severe enough to be fatal. Précipitation into a privy vault exposes the child not only to mechanical injuries but to the daugers of elroAvning, or of suffeication by noxious gases. In laeeratiem of the umbilical e-orel death may take plae-e from hemorrhage. Bouchut cites a ease in Avliich a stout e-en-eï hael parted during delivery by forceps and the child had bled to death before» birth. Yet the division of the cord AA'ithout ligature is by uo means necessarily folloAved by much bleeding. The funic stump is less likely to bleed when torn than Avhen eut. Umbilical or other hemorrhages may occur with a fatal resuit from other causes than non-ligation of the cord. Even when the funis is securely ligateel, persistent and uncontrollable hemorrhage may take place from tbe umbilieus and from other régions of the body, owing to hem- ophilia ov other causes. In hemorrhage due to placenta prœvia, or prématuré séparation of a normally placed placenta, the child is frequently born dead or in a non- viable condition from asphyxia. In difficult breech extraction fatal injury may be done te) the cervical portion of the spinal cord. In instrumental labors the fetal mortality is increased. Intracranial injuries mav arise from compression of the heael in difficult spontaneous births, especially in narroAv pehes. In delivery in the absence of the physician the child is sometimes suf- foeated from lying with its face in a pool of blood and liquor amnii. In very rare instances the child is boni with the membranes unbrokem Tins occurrence is much less fréquent at tenu than in prématuré de- livery. Though alive at birth, Avithout interférence tbe 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 overlving are occa- sionally reported, the mother rolling over unconsciously lîpon the» child in her si ce»]). It is the duty, therefore, of the médical jurist in passing upon a case ABORTION AND INFANTICIDE. 491 of alleged e-hild-murder to examine the child for marks of violence at- tributable tei the birth, and for other accidentai causes of death, as Avell as for the évidence of crime. Maternai Disease.—Many acute diseases of tbe mother are liable to rcsult in the death and prématuré expulsion of the fétus. The child may die by the direct influence of the elisease poison, by the effects of the dis- ease upon the maternai pelvic circulation, or from exe-essively high tem- pérature. In case of the death of the mother during gestation the child dies in utero. In protracted sickness the death of the fétus usually piv- e-ede-s that of tbe mother. Whe-n the mother dies suddenly, the chilel gen- erally survives lier by a pt»i*iod seldom exceeding five or six minutes. It is the duty of the physician Avhen jn-esent at the death of the mother during pregnane-y to hmnediately extract the child if it gives évidence of being alive and Adable. Post-mortem delix'ery may be rapidly aeeompbshed by deep cervical incisions and extraction Avith the forceps or by the feet. A post-mortem Ca»sarean section, however, if the consent of the friends can be had, is the préférable method. Delivery by abdominal incision is more rapid than is ordinarily possible by the natural passages, and the child is less exposed to injury. The opération must generally be done within six minutes after the death of the mother ; yet cases hâve been re- ported in which the child lived four or five hours after the mother's death, and living deliveries hâve been aeeompbshed after an interval of thirty minutes. Pathological conditions of the placenta liable to resiilt in the death of the fétus by interruption of its nutrition are degeneration of the chorial villi, apoplexy, thrombosis, and retro-placental hemorrhage. Exception- ally, hytiraiimios is attended with intra-uterine death of the child. CKDIINAL CAUSES OF DEATH. Infanticide by Suffocation.—A common method of infanticide is by suffocation. A handkerchief or cloth may be thrust into the mouth either before or after the establishment of respiration, or the nose and mouth may be forcibly held till death ensues. Cotton, feathers, and either similar material s, and even liquid substances, bave been used for the purpose of obstructing the respiratory passages. The child may be smothered by covering it closely under the bedclothes. The vapors of chloroform, illuminating gas, and other poisonous gases hâve been ad- ministered by inhalation Avith criminal intent. Tbe post-mortem appearances after fatal suffocation are tbe same in the neAv-born as in adults. Tbe skin is of a gênerai bvid color and studded Avith ecchymotic patches, the face is swollen, and the superficial veins turgid. The conjunctiva? are injected and the eyeballs protruding, yet the fullness of the superficial blood-vessels subsides in great measure within a few hours after death. If the child bat! breathed, blood and frothy mucus exude from the mouth and nostrils. Ecchymose-s and imprints of the Angers or nails on the nose and mouth may be présent, The présence of poisonous gases in the respi- ratory tract is usually betrayed by their odor. 492 A SYSTEM OF LEGAL MEDICINE. In fatal asphyxia by smothering under the bedclothing it is rare to find other than internai lésions. Foreign bodies should be looked for in the air-passages. The blood is generally fluid. The principal viscera are more or less hypera-mic. The lungs usually présent the marks of blood stasis. A fairly e-onstant condition is the presemce of small subpleural hemorrhages. They may be few in number or may be thickly diffusée! over the surface- of the lungs. They occur most frequently at the root and loAver border of the lungs. (Plate- VI., Fig. A.) Similar hemorrhages are found in the thymus gland, the pericardium, endocardium, anel in the pericranial cellular structure. Yet subpleural ecchymoses are of common ex-currence in death from other e-auses than suffocation. They are sigiiificant of death by violence only AA'hen the ehild bas breathed, since they are sometimes found when the» lungs are still in the fetal state. They occur in death during birth, from compression of the umbilical cord. They are to be attributed te) efforts made to breath e. They are of A'alue as indicating the mode of death only AA'hen taken iu connection Avith other post-mortem findings. The ecchymotic spots of suffocation must be distinguished from those of choiera, purpura, and grave forms of eruptive fevers. In the former the ee-chvnmses présent a dotted appearance, and the spots are rounded, clear-e-ut, and distinctly circumscribeel. In the latter they are irregular effusions of a purplish color, anel are associated with the characteristic lésions of the disease. In poisoning by phosphorus, strychnine, or prussic acid, ecchymoses are found resembling tliose last eleseribed, and the présence of the toxic substance is reA'ealed by chemical analyses. If it is claimed by the défense that the child AA'as suffocated during the birth then httle or no air should be found in the lungs. EAddence that respiration had taken place increases the probability of death from homi- cidal causes. A child may be buried alive, the mother claiming that it was buried after death. In asphyxia by burying the characteristic lésions of suffo- cation are observed, and portions of the same kind of material that sur- rounds the body Avili generally be found in the esophagus and stomach. After death, it may get into tïie mouth or throat but no farther. Infanticide by Strangulation—Among the différent methods most frequently employed for the destruction of new-born infants is stran- gulation. The neck is constricted by ligature en* by manual compression. Cases haA-e been recorded in which the fatal ligation was accomplished by tying the umbilical cord about the throat. The most conclusive signs of death by strangulation are the appear- ances at the site of ligation. The mark of eemstriction is frequently ap- parent, and the superficial structures above and beloAV are ecchymosed and edematous. The imprints of the Angers and nails may be perceptible. When great violence has been used, the skin at the seat of constriction may be abraded and torn and the muscular structures confused and laeerated. The face is usually congested and edematous and tbe eyes protruded. Ecchymotic spots are présent upon the conjunctiva» ; they are seen, how- ever, after death from other causes than strangulation. " Extravasations of blood are frequently found in the deeper structure-s on dissection, when not A-isible to any extent upon the surface. There is usually great vascular engorgement in the lungs, though in a certain proportion of cases thèse ABORTION AND INFANTICIDE. 193 organs présent a normal appearance. Emphysematous areas in the lungs aud pulmonary apoplexies are frequently obseiwed. The brain and mén- inges are violently congested. In gênerai tlie post-mortem findings are the» same as in the atlidt after death by strangiilation. The lésions of strangulation, however, are not easil}' differentiated from those of suffo- cation. Little confusion need arise from the existence of other marks upon the body resembling those of strangulation. The mottling of the skin Avhich is common after death from other causes is not attended Avith ece'hymoses. The absence of edema and venous engorgement in suffoca- tion serves to distinguish it from strangulation. If it be urged that the injuries sustained Avère imiocently inflicted by the mother in attempts to deliver herself, the ansAver Avili be that at the time Avhen such efforts would be required, Avhile the body of the child Avas still partly in the utérus, the respiratory function would bave been maintained through the placenta, and strangulation Avould at that time be impossible. Again, if the child had died in the act of birth little or no air Avould be found in the lungs by the usual test. Nearly the same ar- gument Avould apply in réfutation of the claim that the child had died during birth from the winding of the cord about the neck. Furthermore», it is very rarely that the coiling around the neck, when accidentai, is suf- ficiently tight to strangulate the cord. Infanticide by Précipitation into a Privy Vault.—Infanticide by précipitation into the vault of a privy must be distinguished from cases in which the body bas been deposited in the privy after death for the pur- pose of concealment The présence of night-soil in the air-passages and stomach may generally be regarded as évidence that the child Avas living Avlien it was placed in the A'ault. If it be claimed that the woman, un- a.Avare tlîat the birth Avas so near conipletion, had innocently expelled the child into the Avater-closet, the médical facts should accord Avith this explanation. If, for example, the cord be found to bave been eut instead of torn the défense Avili be discredited. In some instances a close inspec- tion of the ends of the divitled cord may be required to détermine Avhether it Avas sundered by incision or by lacération. The post-mortem appearances usually présent after death by droAvning should be looked for. Infanticide by Drowning.—The methods of child-murder most com- monly employed are tliose 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 lier child by getting into the bath-tub partially filled Avith water, as the birth AA'as about to be completed, and forcibly holding the beat! under Avater. Accidentai drowning, as already stated, may resuit from sudden and unexpected delivery, bythe expulsion of the child into a privy vault. Not uncommonly the body of the child, after destruction by otlier means, is throAvn into the water for the purpose of concealing the évidence of crime. In ail cases of drowning it is extremely difficult to détermine bythe médical eA'ideuce alone whether death Avas due to accidentai or criminal causes. In ease of alleged drowning careful search should be made for marks of violence such as obtain in other homicidal methods. The body should be examined for proofs of suffocation or strangiilation, and for other évidence of violence, accidentai or criminal. The fauces and 4D4 .1 SYSTEM OF LEGAL MEDICINE. traehea should be searclied for obstmcting material which may bave* b*-eii placée! there Avith criminal intent, as wt-U as for the usual causes ot asphyxia bv accident in the new-born. The présence in the stomach ot liquid or other material like that contained in the» vault would be» prool positive that the child was living Avhen thrown into it. Thèse substances could bave gained access te) the stomach only by the ae-t of swalhrvving. In the dead body they could go no farther than the mouth aud naivs. _ Infanticide by Wounds.—When wounds are found on the body m cases of alleged infanticide, the médical Avitness will be called upon to testify whether or not the existing wounds were compétent to cause death, anel whether thev were inflicted upon the living child or were post-mortem injuries. The first epiestion will be» determined on gênerai médical grounds by the location and extent of the injury. To answer the second is some- times difficult. Dise-* doive! patches upon the skin should bedissected ta distinguish ecchymoses from the simple blue coloration which is commonly seen about the lips and nose of the new-born after death. Wounds re- sulting from labor usuallv oe-ciipy the» presenting part of the fétus. Yet the death of the child may resuit from luxation of the cervical vertebne in imskillful delivery. Abrasions, ecchymoses, and even lacérations of the skin, are frequently found after difficult births, even in the absence of instrumental interférence. Wounds inflicted during life are usually distinguished by the t-A-idence of hemorrhage, and, if the child lives sufficiently long after the infliction of the injury, by signs of repair or of inflammatory action. Apparently insignificant Avounels, and even so small as to escape any but the closest scrutiny, may be fatal where vital organs are involved. The wound may pass uiidetec'tce! Avhen the puncture is maele through the mouth, the navel,. the orbital cavities, or other natural openings. Thèse cavities, as well as the fontanelles and the surfaces overlying other vital organs of the body, should be earefully scrutinized. In death by e»xtcnsive wounds the boelv may présent the marks of extrême anémia from acute hemorrhage. In case of suspectée! complicity of the médical attendant in the crime, the fétus and the pelvis should be examined for évidence of any condition that may hâve justifiée! the mutilation of the child. Fractures of the Skull.—Fractures of the skull in the new-born are not necessarily twidence of homicidal Anolence. They sometimes occur from accidents of difficult or precipitate labor. It is not ahvays possible' to distinguish fractures produced after from those occurring before death. A distinguishing mark in post-mortem fractures is the almost complète absence of bloody effusion. This is ahvays présent in such injuries when sustained during life. '' ExtraA'asation indicates movement of the blood toAvard the part affected."' In case of Avounds inflicted a sufficient le-ngth of time before death, the signs of inflammation will be observed. Fract- ures from the pre-ssure of the pelvic Avalls upon the head during the birth are of extremely rare occurrence. Such e-ases, howeA^er, hâve been re- corded. De»pressions of the skull by the sacro-vertebral promontiny in deformed pelvis are situated ou the anterior part *>f one pariétal bone en- on the frontal or the temporal near the pariétal. They are seldom fatal. Skull fracture in the neAv-born from other causes than criminal, as has been seen, may resiilt from unexpected delivery while the Avoman is in the standing posture. A full history of the confinement Avili obviously ABORTION AND INFANTICIDE. 495 form an essential part of the data upon which the conclusions of the expert are to be based. Infanticide by Neglect.—Under tins head are to be mentioned expos- ure to cold, starvation from willful omission to feed, and purposely neg- lected accidents. Examination after death resulting from exposure to cold will reA-eal nothing pointing specifically to the fatal injury, yet it will be important for the purpose of deciding whether or not an explanation of the death may be founded 011 other grounds. In death from this cause the lungs contain air, showing that the child had breathed. The body présents 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 f unis from the neck ; it may purposely be allowed to lie with its face in a pool of liquids discharged from the birth canal ; or umbiïical hemorrhage may proceed to a fatal termination in conséquence of omission to tie the cord. Even the failure to obtain médical aie! in asphyxia, con- vrdsions, 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-URINARY AND VENEREAL AFFECTIONS IN THEIR MEDICO-LEGAL RELATIONS. BY F. R. STUEGIS, M.D. In the article which bas been assigned to me I propose to consider the affections of the genito-urinary organs in men and women in their bearing upon the marital relation, and the results which venereal diseases —and by thèse I mean gonorrhea and syphilis—hâve upon the bearers of the diseases as well as upon their offspring. To properly discuss the effects of thèse diseases iu their medico-legal relations I propose to divide them into the following groups: First. Impotence in the maie. Second. Impotence in the female. Third. Sterility in the maie. Fourth. Sterility in the female. Fifth. The effects of gonorrhea in its sexual relations ; and Sixth. The effects of syphilis upon the bearers of the disease and upon the children which may be born to them. My portion of this article will be entirely confined to the médical side of thèse affe»ctions. Impotence in the Maie.—Tins affection is due to two causes, one physieal, the other psychicàl, the first having its origin entirely in some physieal malformatiein or physiologieal perversion, congénital or other- wise, and the other depending upon mental disturbances or impressions, whether originating from without or within the patient's mind. The physieal causes are the ones AA'hich I shall first examine, and those of the pénis are the foremost to invite attention. Sometimes there is a congénital absence of the \drile organ, while ail the other parts are more or less perfect (entirely apart from any ques- tion of hermaphroditism), the man being in perfect health, with ail the exte»rnal symptoms of virility such as are apparent in the face and in the contour and shape of the body. The scrotum is présent, with the testes in their normal place, but at the spot Avhere the pénis should be nothing is apparent. The urethra, in thèse conditions, usually opens behind the seredum, in the perineum, as a small opening concealed by a fold of skin, sonie-fimes se»ate»d behind a little excrescence, looking like a cockscomb, and commun ie-a tes directly Avith the bladder, simulating somewhat the appearance of the female meatus. It Avili be noted that in this ease there can be no question of hermaphroditism. There is no appearance 497 498 A SYSTEM OF LEGAL MEDICINE. or simulation of any of the female genitalia, the subject being, to ail intents and purposes, a man, except that he has no pénis. Sometimes, however, the condition of things does not go quite so far as entire absence. In this case the malformation may be simply in the diminutive size of the pénis, which varies from half an inch to two inches in length, and is capable of more or less complète érection, unless it be tightly bound to the scrotum. Under such circumstances the subject need not necessarily be impotent. He is capable of intromission within a cer- tain distance, and, providing the ejaculation of the spermatic fluid be com- plète, the man may be the father of a family. Excessive smallness of the pénis is not, therefore, a bar to the completion of the sexual act nor to the exercise of marital duties ; but the condition is différent in tliose cases known as a palmate pénis—that is to say, where the pénis is adhèr- ent to the anterior raphe of the scrotum and Avhere it is then bound down, mechanically, during any attempts at érection. This condition of affairs is, however, easily remedied by freeing the pénis, when the physi- ologieal functions of the organ are restored to their normal condition. The opposite condition may also act as a bar to the sexual act, where the pénis is inordinately large—and I do not mean enlarged from ele- phantiasis, but where the Avhole organ seems to be abnormally and equally developed, and where intromission into any ordinary vagina is impossible. Under thèse circumstances the man, although capable of complète érection and of the performance of the sexual act, is impotent from the disparity betAveen his genitals and those of the average woman. Anotht»r cause of masculine impotence is due to the fact that the pénis is sometimes double for a greater or h-ss extent of its length, eae-h organ having its oavu urethra. Thèse imite posteriori y into one canal anel one pénis, finding their termination in a single bladder, both organs freun their point of bifurcation emitting tAvo streams of equal size during micturition and being capable of double séminal émission. Under such e-ircumstances it is peissible that a man may haA'e connection, as is noted in the case of a patient reported by Isidor Geoffroy St. Hilaire. This man, it is stated in the report, never engendered anything but twins. This last statement I do not claim to pass judgment upon, as it seems to me, unless two ova were deposited in the utérus at the same time for fecundation, that it would make little différence hoAV many virile organs entered the Avoman at the same connection. Another reason for the non-performance of the sexual act is due to a curions malformation AA'hich bas been noted by many writers, A-iz., that at some portion of the pénis a deposit occurs in the 'corpora cavernosa which prevents the complète distention of the organ. Sometimes this results from cale-areous deposits, from inflammation (gonorrheal or sim- ple), or from an injury done to the organ by " breaking a chordee,"' as it is called, and sometimes from syphilitic exuclations. " Where it results from gonorrhea or syphilis it is, as a ride, curable, but where it is caused by violence or injury done to the canal, or where it occurs idiopathie-allv, little can be done by treatment, although some cases are reported to bave recovered spontaneously. Under thèse circumstances the pénis is turned either to one side or the other, or, as I bave seen it in one instance, where the exudation was annulai-, one half of the pénis remained entirely flac- eid Avhile the posterior half was erect. Intromission and sexual inter- course are usually impossible, although if the peuis be merely twisted, GENITO-URINARY AND VENEREAL AFFECTLONS. 499 Avhile érection is complète, coitus, with a little management, may be aeeompbshed. Again, besides thèse pathological causes there may be complète tor- sion of the pénis upon its axis during érection, as is noted in the ease reported by Guerlain (Bulletin de la Société Anatomique, 1859, 2e série, t. iv., p. 27), in Avhich the pénis, during érection, Avas completely rotated in such a manner that the dorsum of the pénis became the under-surface, looking backwarel toward the scrotum, while the urethral aspect Avas turned uppermost and a little to the left. Sometimes the corpora cavernosa présent anomalies, either being atrophied or even going so far as to be completely absent. Such a -case is reported by Delbarier (Annales de la Médecine Belge, 1842, Mai, 5e Cahier, p. 10). In most of the malformations considered above, it is apparent that the patient would be impotent from purely physieal causes, Avithout the mind exercising any influence as regards the sexual act. Another vari- ety of physieal deformity which sometimes acts as a bar to complète «oitus is seen in cases of hypospadias. Epispadiaes, as a rule, are capa- ble of copulating properly, notwithstanding that their sexual organs may not be perfectly normal, and the same is true, to a certain extent, among hype)spaeliae-s. Proviele»d that the hype>s})adias be in the anterieu- portion of the urethra, in such a position that during émission the semen can be ejaculated with in the labia majora, coitus will be successful; but where the hypospadias is far back, say at the penoscrotal or behind the perineoserotal angles, the émission AA'hich takes place of course does not reach the vagina, nor even probably the external vulvar lips in the female, and therefore becomes of 110 effect. Sometimes thèse cases are remedia- ble, in eithers not; and of course when the latter condition obtains, the patient will bave to be classée! among those who are physically inq)e)tint. Phimosis, particularly if congénital and adhèrent to the surface of the glaus pénis, or Avhere the orifice is exceedingly small, may sometimes be the cause of impotence in the maie, by preA-enting the émission of the semen into the vagina, the entire charge being pocketed in the elongated and diste-nded prépuce and only being evacuateel by the m annal interfer- ence of the patient. In the majenity of instances, unless the adhésions are exceedingly firm and extensive, the evil may be remedied by circum- cision. Stricture of the urethra, when seated far back and AA'hen tight, often- times acts as a bar toward the conipletion of the sexual act, and I hâve seen e-ases in which the stricture Avas so tight that during the excitement and turgescence conséquent upon the copulation the entire séminal dis- charge Avas forced backward into the bladder, but a few drops escaping per urethra m during the act. The first micturition after the act showed the urine full of spermatozoa. The patients in thèse e-ases ahvays eom- plain of a great fullness in the perineum, sometimes accompanied Avith a momentary sensation of sharp pain, probably due to the enormous elis- te»ntion of the urethra at a point where the obstruction Avas présent, and AA'hich Avas relieved as soon as the semen found its Avay backward.. Anomalies of the testicle are another cause of impotence, and in thèse instances they may be sue-h as to lead to a condition of azodspermatism in which healthy spermatozoa are not secreted. This is espee-ially noticed in the case of monorchids in whom the testicle is retained in the abdo- 500 A SYSTEM OF LEGAL MEDICINE. men or at the inguinal ring. Whe»re this oce-urs the patient is not only stérile, but he also is impotent: the érections are ine-omplete or evane-s- cent, and Avhateve»r séminal discharge tliere is, ejaeulation ex-curs so pre- maturely that frequently the patients bave finished the sexual act before gaining entrance into the AA'oman. Sometimes the testes are found te) be e-ongenitally atrophied. In an interesting case given by Roubaud (Traité de l'Impuissance et de la Stéri- lité, p. 161), the patient, twe-nty years e>f âge», shenveel a pénis AA'hich, on ere-c- tion, Avas about the size of a penvupine's quill and only tAvo inches in length, and in whom the testes had only attained the size of a hazelnut ; and thèse latter, upon contracta>n of the scrotum, Avould disappear entirely into the inguinal eanals. Atrophy may also resiilt as a conséquence» of gonorrheal epididymitis, varicoe-e-le, and sjqihilitic orchitis, and in ail three affections the atrophy is usually permanent and past cure. The question of hermaphroditism naturally présents itself in thèse cases of sexual perve»rsi*>n, but so far as their sexual aspects are con- cerned they neeel not cenu-em the surgeon, for the simple reason that in nearly ail instances the hermaphrodite may be classée! as e»ither maie or female, and a careful examination should enable the surgeon te) place the hermaphrodite as either a man or woman. The crucial tests in thèse cases are the présence or absence of the catamenia and the prese-nce or absence of the sexual émissions ; and where one or the other of thèse functions can be shoAvn to exist the establishment of the patient's sex folloAvs as a natural conséquence. Some cases are spoken of as being neuters, in whom the sexual condition seems to be so evenly divided as to make it difficult of décision ; but such cases are very rare in deed, and I am myself strongly disposed to doubt their existence. Oe-casionally, in the» case of female hermaphrodites, the surgeon Avillbe sometimes puzzled by being told that the catamenia hâve never appeared ; but upon careful examination in thèse instances, where ail other indications point toAvard the féminine sex of the patient, the monthly discharge of blood will be found to issue from some portion of the body outside of the sexual organ—in other words, they are cases of vicarious menstruation. Besides the physieal causes for impotence in the maie just enumer- ated, the mental condition of the patient sometimes opérâtes to prevent normal coitus. Those who hâve much to do with the treatment of sexual disorders in the maie hâve been struck with the curions phases which this mental condition sometimes assumes. For example, some men avIio are perfectly well formed, vigorous, healthy, and capable, as has been shown by expérience, of performing the sexual act, are rendered com- pletely impotent unless the usual conditions to which they are accustomed are ail fulfilled at the time of connection. One most curious instance of this mental condition is given by Roubaud (op. cit., p. 439 et seq.), in Avhich the patient, when a boy of fburteen years of âge, was seduced bv a female friend older than himself, a member of bis family. The girl herself was a pronounced blonde, Avore ringlets, and inasmuch as the forbidden pleasure had to be done by stealth their amorous relations were aeeompbshed AA'hen both Avère fully dressed. Thèse relations lasted for some time, and the young man finally left home and went into the army. Upon trying subsequently to perforai the sexual act, he found to bis extrême astonishment that every Avoman was répugnant to him un- GENITO-URINARY AND VENEREAL AFFECTIONS. 501 less she Avas a blonde, AA'ore her hair in ringlets, and Avas fully di'esseel. Under thèse circumstances he could perforai the sexual act Avith vigor and complète satisfaction, but for another kind of a Avoinan, brunettes especially, and under any other conditions, as, for example, when un- dressed and in beel, he had such an aversion that lie Avas practie-ally impotent. Such Avas the force of imagination and of habit upon bis sexual poAvers. Now the seepiel is just as curious. With the perversity of human nature, he fell in love AA'ith a brunette, and it was this unfortunate condition of affairs that induced him to consult Roubaud, aa'Iio gave him a potion which he told him to take, and bade him make an attenqit at coitus Avith the brunette two hours after its ingestion, assuring him of success. The draft was taken, the man Ave>nt to bed, and although no coitus was attempted at that time» the patient had during the whole night a violent érection, AA'ith strong sexual désire. Apparently, from the history of the ease, the reason Avhy coitus was not attempted Avas from the» fear that it Avould prt>Are a failure. However, the next day he consultée! M. Roubaud again and Avisheel to know if he might use the draft a se-conel time. Inasmuch as it e-ontaineel a large de>se of can- tliarieles, M. Roubaud refusée! to give his permission, but substitut et! another one in which the amount of cantharides was very much redueîed, and told the patient te) take that. The man, having been convineed that he had at last obtained an agent which Avould at least overcome the physieal results of his aversion to brunettes, took the second draft, and going to bed Avith the woman the see-euid night accomplished his pur- pose and thus conepiered his curious and seemingly irrational aversion to brunettes or to attempting the sexual act except when fully dressée!. This is an extrême instance of AA'hat mental impressions Avili do in causing perversion of the sexual functions ; but not infrequently surge-ons are eonsulted by patie»nts aa'Iio state that, Avhile the sexual désire is strong up to the» point of going to bed, the moment coitus is attempted the érection disappe»ars anel Avith it ail possibility of intercourse. The same condition often ensues from the unreasonable fear that the attempted connection will enel in failure. There is no physieal reason for this dread : the patient is perfee-tly capable of performing the sexual act ; and yet when he is with the Avoman lie is perfectly useless as a bedfelhnv; and oftentimes the mère dread of failure, if failure has once occurred on attempting coitus, puts an end te) ail future attempts. There is often a physieal cause for this mental disturbance, such, for instance, as hyper- a?sthesia of the deep portions of the urethra, slight and irritable urethral strictures, hemorrhoids, fissures of the anus and rectum, or a subacute inflammation of the neck of the bladder ; and the well-informed surgeem Avili earefully search, in such cases, for any physieal cause to account for the patients sexual condition, and if such exists, by removing the physieal cause cure the» sexual disturbance. Çlyeosuria is another of the causes which are mentioned as a possible source of impotence in the maie, particularly in the latter stages, when ail sexual désire and ail sexual ])OAver seem to be either in abeyance or else e-e>mpletely l*>st, and in addition there also appears to be a diminu- tion in the amount of the semen secreted. Reniai diseases, especially that condition of the kidneys known as atrophy, inflammation of the prostate-, e»specially AA'hen associated AA'ith marke-el hypertreiphy, and affections of the nee-k of the bladder, coexist- 502 A SYSTEM OF LEGAL MEDICINE. ing or associated AA'ith the prostatie hypertrophy, may ail be causes of impotence in the maie and interfère materially with sexual désire as well as AA'ith érection. Eversion of the bladder is another cause of impotence, not so much on account of the protrusion and eversion of this A'iscus, but from the fact that, associated with it, tliere is very often a malformation of the pénis, usually either complète hypospadias or epispadias. In one instance Avhich I bave seen lately, the patient was entirely epispadiac, the lower portion of the pénis beiiig fairly well formed, but the upper portion Avas entirely Avanting. The urine was se-creteel by the bladder and ran into a gutter Avliich Avas formed of the inferior portion of the urethra. The e-orpora cavernosa Avère imperfect, and lie never had any ereetiems, al- though he stated that he occasionally had sexual desires, but, of course, without any possibility of gratifying them. Soinetinies the lack of érection appears due to an impe»rfee-t circula- tion of the blood in the pénis, and I am of the opinion that it is generally associateel with some cenigestion of the deeper portion e>f the» urethra (usually pre)static), with preistatic enlargement or Avith some inflamma- tion e>f the neck of the bladder. Sexual debility and impotence bave often been ascribed to masturba- tion, aud undoubtedly, if the habit be resorted to intemperately, it may Aveakeu the sexual poAver ■ but I am by no means in accord Avith those Avriters avIio regard the masturbation of early youth, as generally prac- ticed by beys and aeledescents, as a e-ause of serious sexual disorder later in life. A great deal of the functional disturbane-e AA'hich occurs in thèse cases is due to the mental impressions made- by reading the A'arious books and articles Avliich describe, in gloAving anel fearful ternis, the sexual penalties Avhich the masturbator pays for his trifling amusement, and to the fact that masturbators A'ery frequentiy suffer from deep- seated urethral inflammations, situated about the bulbus urethra», and from tliere extending backAA'ard buvard the blaelder. Thèse disorders are purely functional and generally yield to appropriate and rational treatment; though evaneseent in eharaeter, they nevertheless arc, te» ail intents and purposes, while they last, as serious a cause of impotence as though tins latter was due to some organic defect. Impotence in the Female.—The female being a passive agent in the copulative act, impotence in her plays a minor part as compared Avith that of lier more active partner. The principal causes of impotence in the female are those of an organic nature, as, for example, AA'here the vulva is absent, AA'here the vagina is absent, or AA'here the vagina ends, as it does in some instances, either in the bladder or in the rectum, consti- tuting a vesicovaginal and recto vaginal malformation. Impotence, there- fore, is partial or complète according to the nature of the organic lésion, being complète where tliere is absence of the Aiilva or vagina, and in- complète if the vagina be moderately developed—that is to say, if it be tAvo inches in length ; and instances haA'e been known where coition lias been complète in still more undeveloped vagina». Of course connection is more complète in the instances where the vagina is more nearly normal in length, but ends, perhaps, in the bladder or rectum. Absence of the utérus woidd not constitute a bar to perfect coitus so far as the female is concerned, but Avould constitute another kind of trouble Avhich I shall consider Avhen I speak of sterility. GENITO-URINARY AND VENEREAL AFFECTIONS. 503 In the Avemian, as in the man, extroversion of the bladder would also be a bar to intercemrse, especially if, as is sometimes the e*ase, there is an extroversion of the anterior vaginal wall, what would be the posterior wall of the bladder forming the anterior wall of the vagina ; and in thèse cases very often there is an absence of the utérus, so that the canal is practically undeveloped. Besides thèse causes of impotence in the female, the question arises how far an imperforate hymen may act as a bar to coitus. This mem- brane has been supposed to stand as the symbol of virginity, and its absence to be suspicions of antenuptial impurity; but such is by no means the ease. Hymens differ very much with regard to their tough- ncss and the completeness with which they protect the vaginal opening. Some are verjr slight, trifling bands of tissue placed at the entrance of the vagina, and are easily broken by an accident, such as a sudden fall, violent and excesshe horseback-riding, physieal exercise, etc. ; others, again, are exceedingly tough and résistant, so much so that when the time arrives for the final consummation of the marriage the man finds himself baffled in every attempt to gain entrance. This résistance may be so marked that nothing short of a surgieal opération will remeiA'e the difficulty, and it is mentioned hère as it has occasionally been maele the starting-point of proceedings for dissolving a marriage. But, fortu- nately, it need not proceeel to this, because a simple surgieal opération will usually suffice to obA'iate the difficulty. Another symptom, which is more serions and important, is that which is knoAvn as A'aginismus, a peculiarly irritable condition of the vulva and the introitus Araginae, Avliich causes in the Avoman extrême pain upon every attempt at coitus, and this pain is sometimes so excesshe as to induce a. pe-rfect horror at the idea of sexual intercourse, and terror at the approach of lier husband. Under such circumstances, if the case, as occasionally happens, is incurable, the question might arise whether the man might not be justified in seeking a divorce on tlie ground of the wife's incapacity for carrying out the marital contract, and cases are on record in which such a view bas been sustained. Another curions malformation, AA'hich, however, need not necessarily be a bar to the complète consummation of the marriage, is that in some Avomen the Aragina and utérus are double, sometimes the vulva also ; but in ail thèse instances one of thèse passages seems to be more used than the other, sometimes entirely so, and the woman may even haA-e children under tlmse circumstances. Each vagina and each utérus seems to be perfect in itse-lf, anel appears to be» analogous in the female to what a double peuis is in the maie, only that in the female there is less impedi- ment to the sexual act. There are occasional instances where hysteria, pure and simple, seems to play a part in preventing e-eiitus, AA'hich are analogous to the psychicàl impotence of the maie. Sue-.h cases, where unassociated with any phys- ieal defee-t or deformity in the female», are rare. They are usually con- joined Avith the condition of affairs Avhich has been described under the heael of vaginisinus, and in many instances a cure of the physieal defect is a key to the remedy of the entire trouble. Sterility in the Maie.—This occurs in ail affections of the testes in AA'hich the sécrétion or élimination of the spermatozoa is interfered AA'ith. It mav be due to the absence of thèse bodies, either congénital or aeci- 501 A SYSTEM OF LEGAL MEDICINE. dental (from injury or from ablation) ; but tliere» are cause»s Avliich inter- fère Avith the transmission of the fully formed spermatozoa from the testicle to the vesicuke séminales, although the testes may be, to ail outAvard appearances, perfectly sound and healthy, this interfere-ncc being due to a blocking up of the vasa deferentia from the following causes : 1. The most fréquent is gonorrheal epididymitis. 2. Syphilitic epididymitis. 3. Tubercular epididymitis. 1. Syphilitie' orchitis. 5. Tubercular orchitis. 6. Cancerous or sarcomatous orchitis. 7. Atrophy from an injury or a blow; and 8. Atrophy from a long-standing varicocele. In addition, I think that varicoe-ele, except in its earlier stages, inter- fères very markedly with the ae-t of coition, and that it finally results in the production of both impotence and sterility ; and I beg the reaele»r to note—what perhaps I hâve not said in so many words—that there is a différence between impotence and sterility. A man may be impedent anel yet perfectly fruitful, and, on the other hand, a man may be per- fectly potent and yet unfruitful. Sterility is entirely separate from the question of impotence, anel depe»nds upon any cause, whateve»r its origin, which interfères either with the sécrétion of the spermatozoa or with their transmission from the testes to the natural réceptacle for their storage. Ste-rility may be temporary, as, for example, in cases AA'here men in- dulge excessively in either masturbation or in venery, and in thèse cases the semen, if examined, will be found to become gradually diminished in quantity and less endowed with spermatozoa. Thèse bodies are imper- fectly formed and are oftentimes broken, and in cases where the debility is extrême the semen is composeel of a thin, viseid fluid filled with colloid bodies and exhibiting no spermatozoa at ail. This condition, unless the disorder is deep-seated, is usually amenable to treatment and one from which the patient, in time, recovers. Such cases need not hâve any important bearing so far as the medico-legal aspect of the case is con- cerned. Sterility in the Female.—One of the chief factors of sterility in the female is absence of the ovaries, either congénital or acquired—that is to say, due to a surgieal opération. Under such circumstances, of course, a Avoman is no longer fruitful and is incapable of bearing children. Other causes of sterility in the female are extrême version or flexion of the utérus, iu which the cer\dcal canal is so much occluded that the spermatozoa are prevented from entering the utérine cavity. Another source of sterihty in the female seems to be due to an ex- ceedingly acid condition of the utérine and vaginal sécrétions, in Avhich the spermatozoa are killed almost immediately or shortly after being deposited in the vagina and in the cervical canal, and so fail either to find their way into the body of the utérus, or else, if they do find a lodg- ment there, practically arrive in a dead or dying condition. In thèse cases, both of impotence and sterility in the two sexes, some would undoubtedly, in a medico-legal sensé, be a bar to any question of matrimony, and perhaps might be a just reason for divorce, where the GENITO-URINARY AND VENEREAL AFFECTIONS. 505 impotence» or sterility Avas dépendent upon causes impossible of remoA'al. But in many e-ases thèse* affections are remediable, and a return to health A\'ould ensue not only if thèse conditions supervene after marriage, but even if they are ceuncident with matrimony, particularly where the cause is complicateel with sexual or nervous disturbance—I am getting more and more to regard thèse cases of mental disturbance as dépendent upon a physie-al basis—anel it then becomes a niée questiem to décide how far the surgeon is justified in advising matrimony as an assistance to the cure», anel Iioav far lie is properly bound to counsel bis patient against matrimony in order to prevent unhappiness to both parties to the marital contrae-t. Venereal Diseases of Both Sexes, in Adults and Children.—For the purposes of this artie-le I shall consiehr only two A'enereal diseases, gonorrhea and syphilis ; and I shall take up first the considération of the disease as it appears in the maie, and its cemsecpieiices ; next, the malady as it appe-ars in the female, and its conséquences ; and lastly, the results upon their offspring. (fonorrhea, or, as it is freepiently called, urethritis, whieh is perhaps a better name, is simply a catarrhal inflammation of the urethral mucous membrane in the maie and the urethral and vaginal mucous membranes in the female. Since the discovery, by Neisser, of the gonoeoccus which goes by his name, it lias been believed by many writers upon venereal diseases that the»se bacteria are the cause of gonorrhea, anel that where thèse microscopic bodies are absent the disease is not gonorrhea, but a simple urethritis. I am not ready to fully accept such a conclusion, as I bave seen instane-e-s in Avhich the gonococci Avère absent and yet the elisease ran, to ail intents and purposes, the same course precisely as an ordinary clap. I will, hoAvever, admit that, given the présence of the gonoeoccus of Neisser in the urethral or vaginal discharges, it Avould go far to prove the existence of gonorrheal infection and that the elisease Avas not simply catarrhal in nature ; but the absence of thèse gonococci in any given spécimen of the so-called gonorrheal pus Avould not, I believe, authorize tlie surgeon to say that the disease Avas simply a catarrhal affee-tion. The logical séquence of such an opinion Avemhl be disastrous, inasmuch as lie would permit his patient to haAre intercourse Avith inno- cent people, to their détriment. The existence of thèse bodies, therefore, is of value only when they are présent ; but the reverse, that is to say AA'hen they are absent, does not prove that the eharaeter of the discharge is non-infections. Now as to the modes of infection. The time-honored and customary manner is by cohabitation Avith a gonorrheal persem, be the same maie or female». But there are other wavs of catching a clap. Nearly ail surgeons admit that the leuce>rrheal diseharge in the female, ai>art from the question of gonorrhea, Avili A'ery frequently produce an irritation in the maie urethra AA'hich, call it Avhat you like, is, to ail intents and pur- pose-s, a chip, anel the same is also admitted, within certain limits of re- se»rve, as possibly occurring from the menstrual discharge of a woman, particularly if the man hâve connection AA'ith the Avoman just before or after her flow. Of course every vaginal discharge in a woman is not necessarily gonorrheal, and it often becomes a nice question to décide Avhether any given sécrétion from a Avoman, AA'hich is saie! to bave been the cause of disease in the maie, is benign or otherwise. If the discharge 50G A SYSTEM OF LEGAL MEDICINE. from the woman should be found full of gonococci, or if the sécrétion Avhie-h tomes from the A'agina can also be pressed ont of the urethra, the A'er- dict woidd be rather against the woman, as I knoAV of no disease e»xe-ept gonorrhea AA'hich will produce a purulent diseharge from the latte-r canal in the female. But if no gonococci are found the woman should iv- ceive the benefit of the doubt and be considérée! as oue of those un- happy persons whose A'aginal secretiems are a staneling menace to e A'ery maie-—no, not every maie, bee-ause most men beceime accusteune-el to the vaginal sécrétions of their Avives or mistresses anel suffer no injury, Avhere others who poaeh upon forbidden ground are the Avorse for it. To quote Rieord's famous dictum, the husbands are •'acclimatée!.'' Paradoxical as it may sound, it is possible for a man to contrae-t an urethral discharge from a Avoman aa'Iio absolutely sIioavs no signs of dise»ase. The man is the cause of bis oaaui clap. Many men, after inter- course, are straightway filled with a dread e>f impe-neling infeedion and repair to the elruggist for an injection ••against chip." This they imme- diately use with assiduité, to find out, alas ! that things are not what they seem ; instead of preventing the clap, they havt; brought it on. Forth- AA'ith the old cry : " The woman did tempt me ; " but when the woman is examined she is found to be entirely sound. If the man had Avaited to find out whether he really had a clap he might bave escaped the nee-.essity of treating one. There is an unique case given by Anmdée Latour in a footnote to Rieord's Lettres sur la Syphilis, \). 51, in whieh a edap was state-d to bave been caught AA'ithout intercourse AA'ith any female. AViu-real sur- geons are asked to belieAre many curious statements, butl frankly déclare that if a patient offered such a story to me as the e>st*»nsible cause of his clap I should doubt him. The case is that of a young man who, from 10 a.m. to 7 p.m., Avas engaged in the délectable occupation of attempting to overcome a young woman's virtue. She proved the vie-tin- in the en- counter, and the unfortuiiate man, having suffered violently from priap- ism during the time thus spent, later on nurseel a seve»re clap AA'hich lasted for forty days. He is said to hâve been continent for six weeks preA'iemsly. I must mention one other source of contagion which is often pre- sented to the surgeon's attention. A man cornes to him and says that he has a discharge, Avhich, upon examination, proves to be an active and healthy gonorrhea. The surgeon so informs him, when the patient hastens to assure him that it cannot be, for he bas had no intercourse, and then with an air of innocence inquires if it be possible to catch it m the water-closet, I know of no better reply to make than the time- honored gag that it is possible, but it is a nasty place to take a woman. Such a plea the surgeon may listen to from politeness, but be never seriously entertains the idea that a clap e-an be» taken from the water- closet seat, any more than it can be derived from a pair of trousers borroweel from a friend " who had a running," which has been gravely advanced to me as the explanation for the existence of a edap. There is really but one way of catching it—per eoitum gonorrha fit; but AA'hen we come to speak of syphilis I shall show that it is possible to contract that disease in other Avays besides copulation. An interesting point cornes up as to how far a clap is contagious in the maie; that is, up to what stage in the course of the disease he is capable of conveying gonorrhea. Broadly speaking, probably as long as GENITO-URINARY AND VENEREAL AFFECTIONS. 507 lu» bas any discharge ; most certainly as long as lie lias any purulent élise-barge, or as long as there are any gonococci te» be found in the diseharge. Many a man, after bis clap bas lasted for several Aveeks, has nothing te» sIioav except a little mucus or a slightly purulent discharge in the morning. During the daytime nothiug is apparent and tliere seems to be no tremble Avliatever. Sexual connection, if moderately in- dulged in, seems te) produce A'ery little disturbance. The partner of bis amorous joys is free» from disease until the man, excited perhaps AA'ith Aviue or from Avliatever (.-anse, e>\'erdoes the business, couverts what Avas a e-omparatively innocuous discharge and mucous in eharaeter into an ae-tive and purulent one, and then the Avoman suffers. It is just such instances as this AA'hich make it difficult for the surgeon to détermine Iioaa' soon a man may résume bis marital duties Avith safety to his wife, the patient being iniportunate in that respect in order to avert suspicions Avliich perhaps bave already been excited by his abstinence from bis duties. Under thèse circumstances, it becomes exceedingly difficult, suppeising that the AA'ife contracts some disease, to be able ahvays to détermine as to Avhether its origin be leucorrheal or simply goneu'i-heal ; first, because so many Avomen suffer Avith " AA'hites," and secondly, because the diseharge in the patient may be of the A'ery slightest aud apparently mildest eharaeter. It is under thèse conditions that the microscopic examination for the gonococci becomes of importance and will go far toward establishing the verdict against the man ; but it sometimes hap- pens that goiioe'oe-e'i are not detee-ted, and then there is nothing left but the Scotch A'erdict of " non-proven." The results of gonorrhea in both maie and female play a direct part in the medico-legal relations of the sexes during marriage. The most notable of thèse in the maie is the inflammation of the epididymes, which produces blocking up and occlusion of the vasa deferentia, which lead from the testes into the urethra, and of Avhich I hâve already made men- tion when speaking of sterility in the maie. This inflammation does not lead to any différence» Avliatever in the inan's power or capacity for copu- lation, and se> far as bis sexual strength is concerned neither he nor his wife can se»e any différence; the only thing, perhaps, which attracts attention is that Avhereas, antécédent to his gonorrhea, lie Avas fruitful and capable of impregnating his AA'ife, after his attack no children are born. This statement must, hoAvever, be modifiée! by the proviso that for complète sterility to ensue the epididymitis must hâve been double, that is te» say, both testicle»s must hâve been attacked. If one only is at- tacked and the other one is sound, the man is still fruitful, but of course he is injured iii se) far as lie has only one sound testicle insteael of two. Prostatie hypertrophy, if it be chronic and continuous, may produce sterilitv by compressing the ducts which lead into the urethra from the te'stes. but this condition is more likely to occur late in life and is asso- ciated Avith the chronic hypertremhy which is met with in elderly men. Inflammation of the vesicub séminales, if it bas gone on to suppura- tion and destrue-tion of both vesiculi, will also produce sterility from the fact that the reserve >irs intended for the réception of the séminal fluiel are no longvr présent, and there is an obstruction in the course of the passage betAveen the testes and the urethra ; but unless destruction of thèse organs occur the patient is usually not much the Avorse for his in- flammation. 508 A SYSTEM OF LEGAL MEDICINE. Strictures of the urethra, as the resuit of gonorrhea, I bave already spoken of, but it is only rarely that strie-turcs become so extremely tight as to cause régurgitation of the séminal fluid into the bladder, instead of anteriorly through tlie meatus. When this occurs the man is, to ail in- tents anel purposes, as stérile as though bis vasa deferentia were blocked and no semen passed into the canal. For the woman the results of gonorrhea may be also disastrous. I by no means share the views of those gynecologïsts who consider that every Avoman AA'ho bas had a clap is stérile, iu conséquence of inflamma- tion *of the Fallopian tubes or of the ovaries ; but I think there is reason- able ground for believing that a certain proportion of women are ren- dered stérile in conseepieuie-e of an inflammation of the ovaries, and in tliose Avomeu Ave often times find great menstrual disturbance in the shape of diminished sécrétion of the catamenia, marked pain during the menstrual molimen, and perhaps the e-jee-tion of immature or undeveloped OA'a. I do not believe, hoAvever, that clap ever produces as bad results in the woman, or that she suffers as severely as the man in cases of gonorrheal infection. Sometimes gonorrhea may produce so much inflammation as to cause a partial stenosis of the ceivical canal, AA'hich Avould bave an effect in a twofold way—first, in preventing the natural outfloAv of the catamenia, and see-ond, in obstructing the passage of the spermatozoa into the utérine cavity; but this conelition is usually easily remedied by an opération, anel cannot be regarded as any serions dérangement te) the marital relations. As regards the effect of gonorrlma upon the offspring, it may be said to be almost nil. The only Avay in which the child suffers is from a form of ophthalmia kiioAAii as eiphthalmia neonatorum ; but inasmuch as any vaginal discharge will proeluce the same inflammation, and inas- much as many children ae-epiire an ophthalmia from discharges entirely free from suspicion of gonorrhea, the resiilt upon children need not occupy attention. A question hère cornes up upon AA'hich the surgeon is not infrequently eonsulted. A man desires te) marry, and in the course of bis confessions admits that he has had repeated attacks of clap and still is occasionally liable to some slight discharge, Avhie-h, although not constant, is apt to appear if he over-indulges in the pleasures of the table, or drinks a little more wine than usual, or if he cohabits Avith a Aveunan. This, the patient assures the surgeon, gives him no uneasiiiess physically; there is no im- pediment to the stream of urine ; but the patient, knowing that it is not an entirely normal condition of things, Avishes the surgeon's opinion before consummating his marriage. The surgeon examines his patieuit earefully and finds, in the majority of instances, a stricture of the ure- thra or granulations in the canal which keep up more or less irritation, not sufficiently so to produce a steady or constant discharge, and yet enough, on excitation, to cause a slight sécrétion. He then examines the sécrétion to find if there be any pus or any of the alreaely mentioned gonoe-occi in the discharge. If lie finds thèse latter, as a prudent surgeon he counsels no marriage until they disappear, although he remembers this fae-t, that more women give claps than get them. The chance of a woman being infeeted under thèse circumstances perhaps is slight, but Avith e\'en that in the man's favor the surgeon has no right to counsel matrimony until the man is physically fit. GENITO-URINARY AND VENEREAL AFFECTIONS. 509 But suppose he finds no gonococci and but very little pus, Avhat shall he say? Some surgeons perhaps might say ''Marry." I tïiink that a prudent surgeon had better say "Don't," because by giving bis assent he assumes a tremeiidous respemsibibty. Suppose any accident should hap- pen, although it is quite likely that noue Avould, ht» Avould be responsible for it ; tlieivfore the best plan for the surgeon to adopt is to recommenel treatment until the patient is entirely Avell, befen-e ghing his formai consent te) the marriage. In many instances, probably the majority of them, his advice Avili not be followed, the marriage will take place, and no accident happen ; but if any ill results should folloAv lie bas perhaps the satisfaction of knem'ing not only that he hael no hand in bringing it about, but had done bis best to prevent it. It is better, therefore, to err on the siele of prudence, and to regard any dise-harge from the urethra, unless it can be clearly demonstrated to be innocuous, as a possible source of danger and n bar to marriage. Syphilis.—We now come to the most important of ail diseases of a venereal ov sexual nature : first, because it is capable of producing so much mischief and misery in the unfortunate bearers of the disease; see-emd, because it is e-apable of producing prématuré death or a misér- able and iinhealthy life in the unfortunate offspring of the syphilitic parents.; and third, because it can be contracte-d iu such uiiexpee-ted and apparently innocent Avays that oftentimes a person AAdio Avould not Avit- tingly contaminate another is }7et the unconsciems instrument of spread- ing Avhat may become a horrible disease. Of e'eiurse the commonest way of contracting the elise-ase is by copulation, but apart from that method it can be coiweyeel without any improper or immoral conduct in either the giver or the ree-eiver. This elisease differs from ail the other A'enereal affections in being constitutional and in tbe fact that the sécrétions of home of the lésions Avhich appear subséquent to the chancre aaIH produce the infection almost as certainly as the chancre itself. I refer to the mucous patches and to the blood during the earlier stages of syphilis, both of AAdiich are capable of conveyiug the elisease. Almost eArery surgeon bas seen cases of young Avomen, inneu-e-nt and virtuous in every sensé of the Avord, AA'ho bave been brought for an opinion as to the nature of a peculiar lésion of the bp, the eharaeter of AA'hich is without question, AA'hich lias been coiiA'eyed through the médium of a perfectly innocent and proper kiss by men avIio Avère the subject of mucous patches of the lips and tongue, the nature of which they Avère ignorant of, or Avhich, OAving to improper aehie-e, they eonceiveel to be innocuous and incapable of coiiA'tying tlie infection. But a short time since a young man Avas sent to me for cemsultation about the nature of some peculiar lésions of the bps and on the siele of the tongue Avhich lie Avas inclined to attribute to smoking. He was paying attention to a young lady, and he-r father', AAdio Avas a jiIia sie-ian, having been cemsulteel by this young man for thèse lésions, Avas suspicious anel sent him to me for my opinion. There Avas no doubt as to the eharaeter of the lésions, and I so reported te> the young man and to the gentleman avIio sent him. The young man himself Avas niue-h astonished, as he hael been continent for some time; but unfortuiiately he elid not appreciate the fact that there Avas a long period of incubation between the time of the infection and the appear- ance- of the first symptom—a period often of thirty days, usually, how- ever, not se) long. ' This Avas an instance» in Avliich trouble Avas averted. 510 A SYSTEM OF LEGAL MEDICINE. But suppose the circumstances had been such that the prospective father- in-law, knoAving nothing about thèse things, and naturally being unsus- picious, should give bis consent to the engagement. The man would he accepted as the girls suit en-, and claiming the innocent privilège of an accepted hiver, Avould cenivey by a kiss a disease Avhich might produce untolel misery and ill health to his future Avife, aud the sequel of im- mature and rotten abortieuis as offspring. Under thèse circumstances, be>w far would the man hiinself be responsible for having contaminated his fiancée f Ht» might bave done it unwittingly and without any knoAvl- edge Avliatever of bis disease», and yet the results would be just as bad. In addition to the possibility of this method of infection by direct contact, tliere is very good évidence to sIioav that it may be contracted indirectly, through the médium of inanimate thiiigs, such as spoons, drinking-eups, pipes, and the like ; and in factories, such as glass-bloAving factories, Avhere the blenvpipe is haneled from one Aveirkman to another in a gang, a syphilitic subject, the bearer of mucous patches, has been known to infect several of bis fellow-Avorkmen. Rollet ghes an instance in Avhich a Avoman Avas contaminated by her cook, the mistrcss being in the habit of going downstairs to assist in the cooking and tasting of the dishes with the same spoon that the cook used, aa'Iio, without the knowl- edge of her unfortunate mistress, was the possessor of mucous patches of the mouth. Again, in former days, when vaccination was practiced from arm to arm and when as much e-are was not exercised as at présent, the scab or crust taken from the syphihtic baby or pe»rson bas been the means of infecting an entire community, and the mischief, being started, was con- tinued in various Avays, by the contamination from the babies' bps to women suckling them, and from thèse women to their husbands or to their oavu babies, until, in this community of whieh I write (in Italy), the infection spread through the entire village and there were very feAV of the inhabitants but shenved some manifestations of syphilis. Nor are the symptoms in the acquired form the only ones which are con- tagious. In the con génital variety the mucous patches of the baby, notably of its mouth, are capable of conveying the disease to those persons about it who are free from syphilis, either by the process of suckling or by kiss- ing ; and nurses are not infrequently contaminated by giving the breast to children who may be, to ail outAvard appearances, fairly healthy, and yet be syphilitic. In some instances the syphilitic baby is born appar- ently healthy, fairly well nourished, and free from any sign of syphilis. Shortly after birth manifestations of the disease appear upon itwhich, although not apparent to the impractie-ed eye, are highly contagious and capable of infecting sound persons. Now in cases where both baby and nurse are undoubtedly syphilitic, the question often arises whether the baby has been the cause of the nurse's infection or AA'hether the nurse has given the child the disease. The story usually told the surgeon is as folloAvs : That the baby, apparently well at first, was put to the nurse's breast; that it gradually lost health and strength, and became, from a healthy child, a weak, puny, misérable brat. The nurse then exposes to the surgeon a breast the nipple of which is fissurée! and cracked, perhaps bearing upon its surface an ulcération, seated upon a raised base, in- durated; and showing glandular indurations in the axilla. The nurse accuses the child of giving lier the disease, the parents, on the other GENITO-URINARY AND VENEREAL AFFECTIONS. 5H hand, accuse the nurse, anel the surgeon is called in to settle the question. The first glanée tells him that the baby is the probable source of the trouble, for the reason that aU cases of syphilis in Avhich tlie elisease is acquired, Avhether in the adult or in the infant, begin with an initial lésion (chaimre) ; the only variety which is devoid of initial lésions, so far as knoAvn, is the congénital form. Mucous patches belong to a subséquent stage and do uot appear until after a period of incubation varying from six to ten weeks. If, therefore, the nurse had been the source ofthe syphilis of the child, it is the child who should sIioav an initial lésion and not the nurse. In addition, the nurse would probably show senne éruption on the body, gênerai induration of the glands ail ove»r the» body, mucous patches of the mouth and elsewhere—in short, the usual symptoms of the so-called seeondary stage, or the stage» Avhich follows the outbreak of the initial lésion. But instead of that it is the baby who shows tlie»se symptoms, symptenns Avhich occur at a period later than the nurse's lésion, and winch she, in turn, will show as the disease progresses in her. It is therefore the baby which is at fault and not the nurse, and it is important for the surgeon in ail cases of syphilis to bear in mind the question of dates and what lésions are hkely to oe-e-ur in regular séquence ; for unless thèse points are Avell borne in mind, error and confusiem are» apt to ensue. Then, again, the baby may show other symptoms of disease which woultl prove it to be of congénital origin, such as the bullas of pemphi- gus, with macération and desquamation of the skin, thèse two latter being almost pathognomonic of congénital syphilis. It would also pre- sent the evielence of trouble in its throat, tlie hoarsc, squeaking cry, the présence of ulcérations in the interior of the mouth, with fissures of the lips, and the emaeiaceel, puny, Aveazened look which syphilitic babies show when profounelly poisoned. Under such conditions, when it is clearly the child which is at fault, it is the duty of the surgeon, AA'hen lie is obliged to call in a wet-nurse for a syphilitic baby, to inform the pro- spective f oster-mother of the child's condition. No matter what his rela- tions to the parents may be, no surgeon should ever knowingly permit himself to be made the means of conveying the disease from the baby to the healthy woman, Avhose health is often the only thing she has to rely upon for a livelihood ; it is far better that such a baby should die than that any woman should be exposed to the slightest risk so far as syphibs is concerned. But notAvitlistanding ail admonition, it is exceedingly difficult to im- press people AA'ith the danger anel the risk that they run in playing with or in fondling syphilitie- children. Many women and guis are singularly fond of kissing every baby they come across, without taking into the slightest considération the possibility of the child being disease»d, and the only Avemeler is that more mischief does not ensue from tins indis- criininate fondling of children. I reeall one instance in which a small boy, three years of âge, Avas sent to me for a diagnosis. This, oddly enough, was a case of acepiired syphilis, the initial lésion (chancre) being seatetl on the inside of the lenver eyeliel. How the boy got it I never e-ould find out. His father anel mother anel his immédiate relathms de-nieel having the disease (the immédiate relations consistée! of his father anel mother and a young aunt). The father and mother I examined, and could find nothing the matter with them ; the young aunt I did not see ; 512 A SYSTEM OF LEGAL MEDICINE. but at any rate the fact existed—the boy hael acquired syphilis. When the time arrheel for subséquent lésions te) make their appe'aranee I eau- tioned the mother that ail the family Avère in peissible danger of con- tracting the disease. Inasmuch as it Avas not a congénital disease, she Avas just as much exposed to danger as the rest, and I particularly eau- tioned lier not to let him play AA'ith or kiss lus little sister, a girl betAveen five and six years of âge, avIio Avas ve-ry fond of him, and, like ail little sisters, played Avith and kisseel lier baby brotber. I thought I hael im- pressed upon lier mind the importance of my advice, when, te) my aston- ishment, a ft»Av weeks later she brought the girl te> see me with a beauti- ful chane-re» on the cheek, and the history Avas that the chilel hael a httle scratch on the chee»k, they Avère alloAved te) play together as the-y formerly had been, the httle boy hael probably kisseel bis sister the-re, and the residt Avas a fine chancre of the cheek. Both of them Avent through the subséquent lésions of syphilis, the lie y slightly, the girl more se-ve-rely. The question may arise, Hoav far are the symptenns of sjqihilis conta- gions ? or, iu other worels, Is syphilis during its entire duration capable of being inoculated from one person to another? It is one of the pecu- liarities of tins disease that the physiologieal sécrétions, the tears, the SAA-eat, the milk, are incapable of conveying the elisease, even though theA' be directly inoculated upon healthy people. The only exception which has been claimed to the rule that syphilis is mit communi cable through a physiologieal see-retiem is in the supposed cases of the infection of the Avife by the se-men. I am myself a elisbebever in this me»thod of conveying syphilis, but for the information of my readers let me» explain in a few Avords what the supposée! modus operandi of infection is in thèse cases. A previemsly syphilitic man marries a healthy woman, who remains seemingly healthy throughout lier married life, provided no e-hildren are born. Suppose the Avennan becomes pregnant : straight way she begins to show symptoms of the disease. The baby, in due course of time, cornes into the Avenld with manifest •syphilitic lésions. Query—How did the woman get her syphilis? The believers in the indirect method claim that the semen of the father is capable of conveying the disease through the ovum, which, becoming infected, is the focus of infection for the mother, who, contracting it through the utérine anel placental vessels, for the first time becomes inocidated. Tins is Avhat Rieen-d ealls infection from choc en retour. The father himself may show no symptoms Avliat- ever of the disease, nor perhaps has he during his entire married hfe, and yet both mother and child are palpably syphilitic. Tliere is nothing harder in the practice of venereal medicine than to establish the origin of such a Avoman's syphilis. Women often acquire syphilis in a most mysterious manner, and of course, unless absolutely obbged to, they seldom AA'ill confess even to then* médical attendant the fact that they bave ever had the disease. Many of them in perfectly good faith mislead the attending surgeon by positively declaring that they hâve never been exposed to contagion, anel yet instances are not Avanting whei-e women bave had the disease previous to marriage, hâve apparently entirely recoA-ered from it, anel show no subséquent évidences of their former syphilis, even at the time of the child's birth. A notable and most curions instance of this kind lias been îiarrated by Dr. Keyes (Venereal Diseasis, p. 71), in AAdiich a lady was under his eare for a very mild and trifling GENITO-URINARY AND VENEREAL AFFECTLONS. 513 syphilis, apparently not contracted from lier husband. Like most women, she» Avas e-areless in pursuing treatment and seemingly entirely recovered. About that time she gave birth to a syphilitic child, Avhich died. The father became syphibtic, and in the report of the case it is stated that the father's syphibs Avas claimed to bave been derived from tlie child, AA'ho was saie! to hâve been poisoned by its Avet-nurse. Matters went on in this Avay for some time until the Avoman became again pregnant in an- other city. She gave birth to an apparently healthy child, avIio aajis put by the attending physie-ian under the eare of a wet-nurse. The nurse shortly acquired a sore upon lier nipple which turneel out to be syphilis, and the baby also presentt»d évidences of the same disease». The nurse was accused of having poisoned the child with syphilis and AA'as dis- charge»d. The child Avas put under treatment, another nurse Avas ob- tained for it, and in due course of time this second nurse also deA'eloped a chancre on the nipple. The family shortly before that had returneel to New York, and came again under the eare of Dr. Keyes. The mother seemed to be perfectly well and presented no traces of syphilis; the father, em the other hand, still shenved eAidences of the disease. A third pregnancy folle)Ave'd ; the Avoman still remained apparently perfectly AA'ell, and, although advised to follow treatment, neglected to clo so. A still- ben-n child was the resuit, which apparently had be»en dead for some time. The mother still showed no évidences of the disease. Hère is an instance where, if Dr. Keyes hael not had the opportunity of seeing the Avoman in the early stage when she had the symptoms of lier syphilis—milel, it is true—he would very easily hâve been misled into cemsidering this as an instance of infecfio per jxttris seminem. But besieles that, it shows that a woman may for years enjoy good health, shoAving no erideiice of the fact that she has been syphibtic, and still she can give birth during that finie to syphilitic children. Grefsberg (Yierteljeihresschrift fur Dermatologie, 1879, p. 102) gives a case of a woman who for two years suffered from syphibs, from whie-h she apparently recovered. A year after recovery and three years after lier attack she married a man avIio was not syphilitic, and in ten years of married life she had eleven miscarriages. At the twelfth pregnancy, thirteen and a half years after the initial lésion, she went to full term and was delivered of a syphilitic child. In this instance the period of apparent immunity Avas even longer than in that of Dr. Keyes, being praetically eleven years in which the Avoman had seen no eA'idence of the syphilis, and yet there is no reason to doubt that lier offspring were diseased or that the abortion s which she had were due to her old trouble. It will be noted in this case that the father claims never to bave contracted syphilis. In the course of syphilis there are many periods, varying from a feny Aveeks to many months, in AA'hich there is an entire absence of any syphi- btic lésions—there» is a lu 11 in the activity of the elisease. The patient is outAvardly well, and, indeed, so far as can be told by any examination AA'liaetver, is avcII ; and yet this seeming immunity is no guaranty that syphilis will not crop out in the children. Many cases are found in venereal literature in support of this proposition. The question might arise whether sue-h a condition of affairs would be sufficient ground for a divorce. That aspect of the case, of course, I haAe nothing to do AA'ith, and I instance thèse cases merely to illustrate 511 A SYSTEM OF LEGAL MEDICINE. the importance of the surgeon being upon his guard, when he is called upon for an opinion in cases of apparent immunity on the Avoman's side from syphilis, not to make too hasty a judgment that because nothing is apparent tliere is no danger of syphilis—a reversai of the aelage that as to those things which are not apparent and tliose things which do not exist, the reasoning is the same. Is there no Avay in which the surgeon can tell ? I know none in which the point can be decided positively, but it may be decided inferentially in tins manner: Continued and repeated abortions should ahvays excite; suspieùem of syphilis, no matter AA'ho the parties may be. Syphilis is no respee-ter of pe-rsons, and, like the pale Death of the poet, invades both the palace of the rich and the cabin of the poor; so that where repeated miscarriages take place, the surgeem should bear in mind that one of the likeliest causes of the trouble is syi>hilis. Of course, with regard to historiés, if neither man nor Avoman présent any évidence of disease, it is heipeless to expect to get anything definite, and an examination of either one or both of the»m may end perfectly negathely, because a per- son can haA'e had a mild form of syphilis, recover entirely from it, and présent no évidences as te) its prcAÙous existence. There is one peculiar point—a curious fact, known as Colles's law— which is that the seemingly non-syphilitic mother cannot be infected by her syphilitic child extra uterum. The child may be a source of danger to everybocly else around it Avho has not been protected by a preAdous attack of syphilis, but the mother may kiss lier diseased offspring, suckle it, and permit the most intimate relations, Avithout suffering in the slight- est degree. And another singular thing is that such a Avoman is exempt from any attempt to inoculate her with the e-ontagious sécrétions of syphilis. Such lias been tried by Caspary of Berlin (Vierteljahresschrift fur Dermatologie, 1875, p. 137), Avith a negathe resiilt. Another of the singular features about syphilis is that the disease does not pursue a continuous course ; the appearances of the lésions are interrupte-d by periods AA'hen the patient feels and is practically as well as he» ever was. Thèse intervals are called the periods of repose. Sup- pose a man were to marry in this interval, when ail symptoms were absent, when he believed himself in good faith to be entirely well, Iioav far would the appearance of subséquent symptoms later on be a ground for marital séparation ? And again, suppose that in this interval of re- pose a man engages himself to a woman, and before the marriage takes place finds that he is not entirely well and that symptoms of the" disease are presenting themselves, how far would such a man be justified in breaking his engagement ? I know of no cases bearing upon the first point, but on the second a case reeently occurred which was tried in Kentucky and Avas finally decided in the Court of Appeals of that State in favor of the défendant, who was a man. The circumstances, as nar- rateel to me by the physician who attended the man, were thèse • X con- tracted syphilis, from which lie believed he was entirely well, anel in this period of apparent recovery engaged himself to a young'woman. Before the marriage took place he broke out with later symptoms of the disease, and, under the circumstances, broke off his enganvment to the young woman, explaining, as I understand, to her lawyeAhe condition of affairs. The statement Avas not. accepted anel a suit followed. After being tried in the minor courts it went to the Court of Appeals in Ken- GENITO-URINARY AND VENEREAL AFFECTIONS. 515 tueky and was decided in the man's favor on the ground that, although at the time of his engagement he honestly bebeved himself to be well, on finding out his mistake later on, as an honorable man, rather than bring misery upon his future wife, he decided to break the engagement. The plaintiff's side attempted to show that the mère fact of his having thèse late lésions was no bar to his marriage, because they were probably not infections, and quoted varions authorities to show why the man should bave carried out bis contract ; but the court decided otherwise, stating that, as long as there was a question, the man Avas justified in breaking off his engagement.* A syphilitic patient, having run through the earlier manifestations of his disease, marries during an interval of repose, or during a period in the course of his disease Avhen he believes himself to be perfectly well, and later on during the course of his married life shows symptoms of late or so-ealled tertiary syphilis. The questiou then arises whether tliere is any likelihood of thèse lésions proving contagious and capable of in- fecting either the wife or future children. The gênerai opinion among venereal surgeons is that the late stages—so-caUed tertiary stages—of syphilis are not contagions nor capable of communicating the disease, and yet the surgeon may be confronted with cases Avhich will put his belief te) a severe test and may perhaps induce him to change his opinion as to the non-inoculability of the late lésions of syphilis. The difficulties in such a case as this are so A'ery Avell exemplified in a case Avhich is given by Dr. F. N. Otis (Clinieal Lectures on Physiologieal Pathology, and Treat- ment of Syphilis, p. 107) that it may serve as an example, in the first place, of the difficulty in obtaining testimony, anel, in the second place, of the danger of making up an opinion hurriedly and in the face of what would appear, perhaps, good évidence. The case Avas that of a yemng man who Avas under Dr. Ôtis's eare for early syphilis, and after treatment appar- ently recovered entirely from bis disease. The treatment was continued for about twe) years, and at the eue! of that time the patient, bebeving him- self AA'ell, marrie-d. The Avife gave birth to a chilel which Avas perfectly healthy and remained so 114) to its third year, Avhen he died of tubercular meningitis, following scarlet fever, there not being then or previously any manifestations of syphibs. Later on the patient had a gummous periostitis of his right tibia, for which he Avas treated and which tlisap- peared entirely within a month. From that time, for nearly a year, both husband and wife were healthy, Avhen one morning the husband came te> announce that bis Avife had trouble in lier mouth which looked like Avhat lie bad had during his early syphibs. Dr. Otis doubted if it was syphilis, because the Avife's eharaeter Avas above suspicion, and lie did not believe that the late lésions of syphibs could convey the disease. The woman Avas sent to see him, and, to his utter astonishment, he found that she had syphilis, as Avas shown by mucous patches in lier mouth, together Avith mucous tubercles on the inner border of the thigh and the right labium majus. Hère AA-as the question : Was Dr. Otis wrong ? Can syphibs be con- v(»yed by the late» lésions ? Or Avas Dr. Otis right ? and if so, then the woman contracted lier syphibs from some one who had a récent syphibs, * Shacl-lcford vs. Hamilton. The Soutirwestern Eeporter, Vol. 19, No. 1, May 2, 1892, p. 5. 51(3 A SYSTEM OF LEGAL MEDICINE. evidently not her husband. The husband was-allowed to believe that he AA'as the source of the trouble, but the doctor kept his oavu counsel and at the right time asking pe»rmission of the husband te> tell the Avit'e what the matter was with lier, after a little fencing and hard pushing, got from her a confession that a yachting excursion, an unexpected night at se-a, exposure with an old lover three months betbre lier outbreak, Avère the causes of her trouble; and the truth of this Avas substantiated by a letter received from the source of the tremble, stating that he had discoA'ered himself to be syphilitic, expressing great regret, and inquiring if she hael been lucky enough to hâve ese-aped the infection. I think the e-ase hardly needs comment ; it is pecuharly instruethe and only shenvs how nece-ssary it is for the surgeon, even at the risk of being considered cynical anel suspie-ious, to suspect everybody connectée! with a case of syphilis, particularly if the history of the case requires acceptai!ce of what is liighly improbable or AA'hat is not in accordance Avith our présent knowl- edge of the disease. The surgeem, of course, should not be dogmatic in his opinion ; he should always remember that it is the unexpected that happens ; but, on the other hand, he should earefully consider the fact that syphibs is a disease full of most unpleasant surprises, and that vene- real patients, particularly Avhen it cornes to a question of expert employ- ment, will tell the most unconscionable and unblushing falsehoods, and perhaps not unnaturally, for the reason that no person is bound to crimi- nate himself, and it is for the doctor to find out how far they are telling the truth ; and, though perhaps it may sound bitter, the surgeon should further remember that people who come into court with their venereal or sexual troubles hâve usually said good-by to both their réputation and to their capacity for truth-telbng. MARRIAGE AND DIVORCE. BY SIMEON E. BALDWIN, LL.D. MARRIAGE. Définition of Marriage—Scope of this Article.—Marriage is a con- tract betAveen persons of a différent sex for cohabitation as man and wife, during their joint lives. whereby a new social relation is created betAveen them, and a new légal status acquired by the woman. It is an institution of society in which the whole community hâve an interest, and which is everywhere regulated to some extent by positive laAV. It is the object of tins article to treat of marriage and its dissolution solely with référence to such points as may be of common interest both tei the physician and the lawyer. Statutory Régulation.—Each of the United States has its own law upon this subject, as to marriages contracted within its jurisdiction, or Avith a A'iew ti> future résidence there, though contracted elseAA'here. The United States, as such, bave no law as to marriage which is oper- ative within any State. Ceuigress bas made régulations "with referene-e to tliose celebrated in the District of Columbia, in the several Territories of the United States, and abroad. Tliose of the latter class can be entered into betAveen any persons avIio would be compétent to marry if residing in the District of Columbia, before any Consular officer of the United States in any foreign country. By an act of Congress passée! in 1887, marriage is prohibited in any e>f the Territories between persons relatée! Avithin and not including the fourth degree of consanguinité, computed according to the rules of the civil law (of the old lîennan Empire). Bigamy and polygamy are also prohibited in the Territories. Age of Consent.—The âge which must hâve been attained by the parties to a marriage is in most of the older States (following both the civil and the common laAv) fourteen for maies and twelve for females. In the Middle and many of the Western States it is higher ; often eight- een for maies and fourteen for females; in some cases sixteen for females.* Marriages of those under the prescribed âge can be disaffirmed by either as soon as it is reached, or annulled by the courts prior to that time. It is of no importance Avhether the parties were or were not, whem * Vide Indécent Assault Upon Children, vol. i., and Râpe, vol. ii. 517 518 A SYSTEM OF LEGAL MEDICINE. married, physically capable of sexual intercourse. If they or either of them were not of the légal âge for consent the marriage can be set aside. Capacity to Consent—Insanity.—The parties to the marriage con- tract must not only be of sufficient âge, but of sufficient mental capac- ity, in fact, to understand the gênerai nature and conséquences of the ae-t. Insanity or idiocy at the time of marriage is ahvays and everywhere a légal impediment. Supervenient insanity was not a cause of divorce at common law, nor is it one under the statutes of most of our States. It is occasionaby made the ground of a spécial act of divorce, granted by the législature ; but such a power is not vesteel in the législatures of ail the States. It does generally belong to the Territorial législatures, under the laws of the United States. Monomania or delusions, which do not disqualify a person for enter- ing into the gênerai transactions of life, and managing bis affairs with ordinary prudence and skill, and do not affect bis understanding of the marriage contract, or bis ability to perforai its obligations, will not de- feat its validity. Seated insanity defeats a marriage with the insane person, although it Avas celebrated during a lucid interval. On the other hand, a sane person may avoid a marriage contractée! during temporary insanity, even if produced by drunkenness. A marriage contracted while insane may be confirmed by the party wliose mind was so affected, should he regain his reason, anel such confirmation may be established by continued co- habitation. In such a case no neAV célébration of the marriage is neces- sary. The original marriage will be treated as voidable, not void.* Capacity to Consummate the Marriage.—Although the parties bave reached the proper âge and are of sufficient mental capacity, the-y cannot marry unless physically capable of sexual intercourse. This does not mean that the man must be able to beget children and the Avoman to conceive and bear them. It is enough if the physieal condition of each at the time of marriage is such as to fulfill the conditions of copu- lation, though not of procréation.! This much each party may insist upon, as essential to the validity of the marriage, notAvithstanding the woman was, at the time of its célébration, beyond the âge of child-bear- ing. The right, hoAvever, is oue which may be waived, and is Avahed AA'hen marriage is knowingly contracted with an impotent person, or one of so advanced an âge that impotence might naturally be expected to exist. Impotence, as above explained, while a cause of divorce in ail oui* States, does not in most of them render the marriage absolutely void from the beginning. If it is due to a temporary cause, and is curable, it is no légal impediment to the marriage, unless after marriage the party refuses to submit, within a reasonable time, to the proper treatment for its removal. A refusai on the part of either to participate in sexual intercourse, within a reasonable time after marriage, if unexplained, raises a presump- tion of incapacity. If, while sexual intercourse is not physically impossible, it is practic- ally so, because possible only under coneiitions to which the other party * Colc vs. Cole, 5 Sneed's Tenn. Rep. 57 ; 70 Am. Dec. 275. t Schouler on Husband and Wife, § 23; J. G. va. H. G., 33 Ind. Rep. 401. MARRIAGE AND DIVORCE. 519 ought not to lie expected to submit, tlie case would be one of légal im- potence, fiirnishing a sufficient ground for divorce. Impotence is, in some States, made a cause of divorce on the ground of a fraud in inducing the petitioner to contract the marriage. It is generally restée!, however, on the foundation of the Avant of capacity to conclude the contract ; nor is the ignorance of the impotent party that impotence exists anywhere received as a défense. If, hoAvever, impotence exists, and is known to the party disabled by it, it may be an actual fraud in such party to contract marriage without disclosing the fact to the other party. Thus, if a Aveunan, while of an âge for child-bearing, should be rendered barren by submitting to the opération of ovariotomy, it would be a fraud on her part not to disclose the results of the opération to the intended husband. Disqualifications from Relationship.—Blood relationship generally disqualifies those within the thircl degree, inclusive, computed according to the civil law; that is, those nearer to each other than first cousins, whether by the whole blood or half blood, by legitimate or illegitimate connection. Some States also prohibit marriages between those connected by affinity, within certain degrees. Effect of Disqualifications.—By the common law, canonical disabil- ities rendered a marriage Aroidable only ; civil disabilities might render it voit!.* In the several State»s of the United States it is generally held that marriages by persons under any disability are simply voidable, and that the proper mode of avoiding them is by an application for a divorce. In senne, howeA'er, the common law rule is still recognized.f Paternity of Children.—A child boni in Avedlock is legally presumed to be legitimate. This presumption is not overcome by proof of adultery on the part of the AA'ife at about the time of conception, unless it is also proved that the husband hael no opportunities of intercourse with lier at or about the same time. Such proof must be so strong as to put it beyond ail reasonable doubt that the husband could not hâve been the father .J That the child must hâve been begotten before the marriage does not affect the question of its legitimacy. DIA^ORCE. Divorce Procédure.—Divorces are of tAvo kinds, a vineulo matrimonii, or from the bond of matrimony, and a mensa et thoro, or from bed anel board. In some States both thèse kinds of divorce are granted; in others, only the former. A séparation is also not infrequently aeeom- pbshed by mutual consent, u]>on terms and settlements arranged through the médium of trustées for the Avife. Divorces in the United States generally are granted only under con- ditions and for causes determined by the statute law of the State or Territeny AA'here one or both of the parties are domiciled. Some States, hoAvever, hâve entertained équitable proceeeiings to déclare a marriage * 2 Kent's Coramenfaries, 95. t Harrison vs. The State, 22 Maryland Rep. 468; 85 Am. Dec. 658; Browne's Digest^ of Divorce Lairs, 57. f Phillips vs. Allen, 2 Allen's Rep. 454. 520 A SYSTEM OF LEGAL MEDICINE. null because the parties were not of sufficient capacity to contract, or for frauel in procuring it. Législative divorces, by a spécial statute passée! to meet the particular case, are alse> granted by some States in exceptional instances, for othe-r than the orelinarv statutory e»auses.* The United States hâve no hiAvs regulating dhorees, except as to ]>er- sons belonging to the District of Columbia. In some States proA'ision is made by law for the intervention of a publie-, prosecuting offieer to make défense in une-ontested divorce suits, when lie thinks such a course demanded by the pubbc interests. Causes of Divorce Antécédent to the Marriage.—Want of sufficient âge, or of mental or physieal capacity, or relationship Avithin the ]>rohib- iteel degrees, are causes of dhoree antécédent to the marriage. So also is fraud in procuring the contract. The term **frauelulent contract77 is sennetimes used to dénote only marriages where one of the parties is im- potent, thus defrauding the other of one of the expected aeh'antages of the union ; or where both are so relatée! as to make the contract one in fraud of the law.t But Avhile thèse are cases of eonstrue-tive fraud, tliere may also be those of actual fraud. To constitute a e-ause of divorce for actual fraud, the fraud must be plain and the proof clear. Fraud is never presumed. An unchaste woman commits no légal fraud in marrying a man Avho is ignorant of her eharaeter. If, lienvc-A-er, she marries Avhen actually preg- nant by another man, and the husband was ignorant of her e-onditiem and belie\reel her chaste, ht» e-au claim a divorce on the ground of her fraud4 It is otherwise if he knew that she Avas unchaste, though he did not know that she AAras AA'ith child.§ Should she, be>Aveve»r, while in tins condition, under false représentations 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 afterAvard claiming a divorce, because he would then hâve marrie»d her knoAving by his oavii act that she Avas unchaste, sue-b active fraud on her part, coupled with her pregnancy, would be sufficient 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 défendant to submit to a surgieal examination, unless this has been done before the institution of the» action, and the resuit 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 knoAA'ledge, and a Avant of reasonable dibgence in seeking to obtain it.** * Maijnard vs. Hill, 125 U. S. Rep. 190 ; Starr vs. Pease, 8 Conn. Rep. 541. t Bcnton vs. Ben ton, 1 Day's Rep. 114. t Scott vs. Shvfclt, 5 Paige's Rep. 43. § Crchore vs. Crchore, 97 Mass. Rep. 330. || Seilhcimer vs. Seilhcimcr, 40 N. J. Eq. Rep. 412 ; 2 Atl. Rep. 376. H Devcnbaghvs. Dcvcuhagh, 5 Paige's Chan. Rep. 554 ; LeBarron vs. LeBarron, 35 Vt. 365. ** Newell vs. Nciccll, 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 ail women. It is enough to estai»lish its existence so far as the intercourse with the petit!oner is e-oncerned. A failure to consummate the marriage after three» years of e-ohabitation is presumptive évidence of impotence.* Causes of Divorce Arising after the Marriage—Insanity—Cruelty. —We» hâve already seen that loss of physieal power, occurring after the marriage', is no ground for a divorce. The same is true in most States as to loss of reason, even if a permanent affection, though this is some- times. in such jurisdietions, made the subject of a divorce by a spécial ae-t of the législature.! It is not a e-ause of divorce on the ground of "intolérable cruelty" that a husband insists on sexual intercourse against the wishes and re- memstrances of the wife, although, in conséquence of lier physieal con- dition, this is indelie-ate, improper, unreasonable, and injurions to lier health, unless he knew that lier condition and health were such as to make the act unreasonable.f If he had such knoAvledge, bis acts would violate bis marital obligations. There is a duty of forbearance on the part of the husband at the reasonable request of the AA'ife, as well as a duty of subniission on lier part at his reasonable request.§ The Avillful conimunieatiem of venereal disease by one party to the otbe-r may amount to such an act of e-ruelty as to justify a divorce ; anel knoAA'ledge of the existence of the disease on the part of the party affected may be inferred from the mère fact of its existence. It is not " cruel and abusive treatment77 within the meaning of divorce statutes for a Avife to refuse for years, without e-ause, to hâve any sexual intercemrse Avith lier husband.|| The old laAV of England gave a remedy in such a ease, 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 refusai be continued after a judgment in favor of the petitioner ; but this proceeding Avas founded on principles of eccle- siastie-al laAV, applie-able to courts having in vieAV the préservation of the morals of the parties before them, and acting pro sainte aninm. Divorces for IIl=treatment Injuring Health or Endangering Rea- son.—In some States divorces are granted for acts which, though not amounting to extrême cruelty in the légal sensé, yet are such as seriously to injure the health or endanger the reason of the other party. In applying such laAvs the tempérament 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-treatinent as would hâve bttle or no effect on a healtliier subject. Divorce is not intended as a pun- ishme-nt of the offemler, but as a relief to the party against whom the offense is committed.^ If a man compels his wife to submit to sexual intercourse so fre- quently as to inqiair lier health, it will be a sufficient ground of divorce, under a laAV of this eharaeter.** * Anonymous, 22 Eng. Law and Eq. Rep. 637. t See Cooley's édition of Blackstone's Commentaries, vol. i., p. 441, note 23. { Shaw vs. Shaw, 17 Oonn. Rep. 189. § Mai/hew vs. Mai/heir. 61 Conn. Rep. 235. || Cowlcs vs. Coules, 112 Mass. Rep. 298. II Robinson vs. Robinson, (New Hampshire) 23 Atl. Rep. 362. ** Mclvin vs. Mclrin, 58 X. H. Rep. 5G9 ; Grant vs. Grant, (Minnesota) 54 Northwest. Rep. 1059. 522 A SYSTEM OF LEGAL MEDICINE. Divorces on Account of Loathsome Disease.—In some States it is a ground of divorce if either party Avas affected at the time of marriage with a loatiisenne and incurable disease (such as leprosy or syphilis), and failcd to inform the other party of this fact,* If the knowledge of the disease, when gained, brought such mental anguish as to e-ndange-r health or e-reate a reasonable appréhension of such danger, tbe ae-t of concealment may be considered as such "cruel and abusive treatment" as to justify a divorce, under a statute embracing that as a sufficient cause.! Divorces for Adultery.—To constitute adultery ' tliere must be a wrongful intent. If the woman is violateel by force, or submits to sexual intercourse AA'hile insane», or with one Avhom she supposes to be her hus- band, there is no ground for a divorce.! It is, however, held in some States that insanity is no answer to a libel for adultery, and that the conséquences of the a et are to be regardée!, rather than the guilty pur- pose of the Avife.§ In no State would nympheimania be any excuse. Proof that the husband lias the ve»nereal elisease, and that it first lu- carne apparent some time after marriage, does not slie»Av that it Avas not contracted before the marriage, and is therefore not sufficient proof of the commission of adultery. Divorces for Habituai Drunkenness.—Proof of ocasional intoxica- tion does not suffice to sIioav habituai drunkenness. hidulgene-e- in the use of chloroform, ov of morphine by hypodermie injections or other- Avisc, though habituai anel carried to exce-ss, is not drunkenness. Intoxi- cation by the immoderate and habituai use of " iiitoxieating liquors" as a beverage must be estai>lished.|| Divorces for Désertion.—The refusai of a wife to permit sexual in- tercemrse, though unreasonably continued for a e-emsiderable period of years, does not constitute ehsertion of her husband, so long as she re- mains a member of bis household and under bis roof.fl Divorces where One Party is Insane.—A pétition for a divorce may be brought by an insane husband or Avife, suing by a guardian or a committee appointed by a proper court ;** and against an insane hus- band or Avife, for an offense committed while sane, or for insanity exist- ing at the date of the marriage. Such a pétition is not supportée! by proof of the existence of temporary paroxysms of insanity before mar- riage, e>f which the petitioner had no knowledge, even though after mar- riage permanent insanity ensued.tt Divorces by Consent.—Any ordinary contract, as it is made by the mutiial consent of the parties to it, can be also reseineleel by their mutual consent, Marriage being, as alreaely stated, something more than a contract, is not thus dissoluble. On the contrary, courts look Avith suspicion on any divorce proceeding, though gooel cause be shoAvn, where there is ground for believing that both parties are Avilling that * See Mai/nard vs. Hill, 125 U. S. Rep. 205. t Leach vs. Lcach, (Maine) 8 Atl. Rep. 349. t Schouler on Husband and Wife. § 504. ft Machin vs. Machin, G Ban-'s Penn. Rep. 332. || Youngs vs. Youngs, 130 111. Rep. 230 ; 22 Northeast. Rep. 806. il Soutlncick vs. So/ithwick. 97 Mass. Reji. 327. ' ■ Cowan vs. Coiran, 139 Mass. Rej). 377. tt Ilamakcr vs. Hainakcr, 1S IU. Rep. 137 ; 65 Am. Dec. 705. MARRIAGE AND DIVORCE. 523 the pétition should be granted ; and if such Avillingness amounts to col- lusion, a divorce will usually be refused.* Récrimination as a Défense.—A pétition grounded on adultery may be defeated by proof of adultery ou the part of the petitioiier. Déniai by the Avife of sexual intercourse, though long continued and Avithout justification, is not a défense to a pétition by her for a divorce on the ground eif adultery. It lias been held no défense to her pétition grounded on désertion, and, ou the other hand, désertion b}rthe AAÙfe has been held a sufficient ansAve»r to lier pétition groundeel on adulteiy.t Extrême cruelty, if a statutory ground of divorce, may be shoAvn, in most States, to defeat a pétition brought for the cause of adultery.! Condonation as a Défense.—If either party to the marriage has a cause of divorce arising from the misconduct of the other, it can be Avaived or condoneel by forgiveness. Occupying the same sleeping-apart- nient 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 évidence to the contrary. Condonation is less readily presumed on the part of the Avif e, since she is the weaker party, and in a position of greater dependence. Testimony in Divorce Suits.—The rules of évidence 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 proceedings, 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 Avitness.]] The results of any physieal examination made by experts must, in this country, be given by the examiners, testifying as witnesses under oath. We bave not adopted the English practice of accepting a certifi- cate of the result from officiai inspectors. * Danforth vs. Danforth, 105 111. Rep. 603. t Schouler on Husband and Wife, *J 536. f Chureh vs. Chureh, 16 Rhode Island Rep. 667; 19 Atl. Rep. 244. § Rogers vs. Rogers, 122 Mass. Rep. 423. || Lucas vs. Brooks, 18 Wallace's U. S. Rep. 436. If 2 Bishop on Marriage and Divorce, § 287. SEXUAL CRIMES. BY CHARLES GILBERT CHADDOCK, M.D. RAPE. Légal Considérations.—Râpe constitutes an offense in common law, but its légal définition varies in the statutes and codes of various States, particularly with respe»e-t to the bearing of the âge of consent upon the crime. Râpe is carnal knowledge of a woman by a man, unlawfully and by means of force, against the will and without the consent of the AA'oman. On the points of " Avili7' and •• consent " there hâve been décis- ions in Arkansas, Florida, Michigan, Nevada, and Wiscemsin. Thus râpe may be committed when, iu sensu strictiori, the AA'ennan shenvs no will at ail ; as Avhen she is narcotized, or in a state of non compos mentis. Carnal knowledge may also be râpe AA'here it takes place AA'ith consent that has been obtained through ft-ar or fraud. Absence of consent is interpreted as eepiivalent to being against the Avili of the Avoman, in later English laAV. Râpe is possible only in case of physieal capacity in the direct maie perpetrator; but impotence is no défense for intent to commit râpe where it cannot be shown that the perpetrator Avas aware of his sexual inca- pacity. The âge of the maie, in its effect upon capacity to commit râpe, may be of importance in determining the conditions constituting the crime. A maie under the âge of fourteen cannot commit râpe, accord- ing to English law ; but in the United States a feAv courts hâve held that there is no conclusive presumption of incapacity determined by âge.* The crime of râpe may be perpetrated upon the person of any female, no matter what her âge, eharaeter, or capacity. Since the questiem of eemsent is of primary importance in its bearing upon the crime, the âge of the female», as affecting her légal capacity to give consent to sexual intercourse, is of the greatest importance. In common laAV, a chilel that has not attained the âge» of ten years is pre- sumed to be incapable» of giving consent. Therefore, in gênerai, carnal knoAvleelge of such a child is felony. But statutes in England and in many of the United States make carnal knowledge of a chilel betAveen the âges of t*-n and twelve a misdemeanor. If, under such circumstances, the child consents, the offense is a misdemeanor, not an assault. The âge of consent, in a majority of the States is fourteen years. A Ncav York statute makes it râpe for a man to haA'e sexual intercourse AA'ith a female to Avhom lie is not married AA'ho is under the âge of sixteen. It is felony * New York, Ohio, Tennessee, Kentucky. 525 526 A SYSTEM OF LEGAL MEDICINE. for a man to hâve carnal knoAA'ledge of a child who is under the âge- of ten, in Arkansas, Miehigan, Mississippi, Xorth Carohna, "Wiseonsin, and Texas. Intercourse with a child under the âge of twelve» ye-ars is râpe; under the Code of Louisiana. The âge of consent is fixée! at fifteen years in Xebraska ; at thirteen in IoAva ; at sixteen in Pennsyhania ; at eigliteen in Wyoming and Kansas. In Ohio, decisiems bave been less stringent; the knowledge of the child has been taken into considér- ation. Actual carnal knowledge must be shown by direct or indirect évi- dence, in order to establish the crime of râpe. Pénétration, in the least extent, of the female genitals by the maie organ, constitutes carnal knoAvl- edge. Force, actual or its équivalent, is necessary to the commission of râpe ; and the force must hâve been sufficient to accomplish the purpose. Submission obtained by means of fear or terre >r ineluceel by tbreats or otherwise, is construed as the resuit of moral force eepiivalent to a com- pelling degree of physie-al force. In laAV, intercourse ace-eimplisheel by means of fraud, where there was no intent to use A'iolence, is not râpe. Within the âge of consent, Avhere consent is given, no matter how re- luctaiitly, tliere can be no râpe. The female must bave offered ail pos- sible insistance, eu* résistance must bave been made impossible by ternir or either means. Commonly, eonnee-tion with a woman AA'hile she is un- consedous, as during sleep or insensibility occasioned by alcohol or other narcotics, is râpe ; and the same is true in cases of idiocy and imbecility, though in Xew York tins is merely a crime against the person. The prose-cutrix in a trial for râpe is a ceunpetent witness ; but in case the défendant dénies guilt, lier testimony must be corroborated as to mate»rial fae-ts, though the fae-t of the râpe need not be proved by other AA'itnesses. Tlie foregoing paragraph shenvs that there aauII be many cases of the crime of rapt» in AA'hich no technical médical testimony will be reepiired; but freepiently médical eAÙdence Avili be called for—not in any se»nse to define legally an act of sexual congress, but to assist in the détermina- tion of the questiem Avhether sexual contact has taken place or not. The physician may be required to give évidence concerning facts which indi- cate Avhether coitus bas taken place or not; or he may be asked to give testimony concerning any eA'idences of physieal force used in the accom- plishment of sexual intercourse. Conditions that Indicate that Coitus has Taken Place.—Physio- logically, coitus consists of immissio pénis and emissio seminis ; but the latter is not essential to the crime of râpe. Meueover, immissio pénis need not hâve been complète, the slightest pénétration of the female genitals by the maie organ being sufficient in the légal sensé. For the purposes of diagnosis, attention must, of course, be directed to the female ; for examination of the maie can reveal nothing, save in those cases AA'here the démonstration in him of venereal elisease or of marks on his person indicative of résistance offered by the female is of importance. Examination of the female will hâve for its object the détermination of the existence of anatomical conditions or changes affecting her geni- tals that indicate Avhether coitus bas taken place or not; whether there are eA'idences of the ejaculation of semen in or about lier genitals and clothing: Avhether her person présents signs of violence ; and whether there is any existing venereal disease or évidence of its previous existence. SEXUAL CRIMES. 527 The Anatomical Changes of the Female Genitals Induced by the First Act of Coitus.—In females that hâve had coitus many times, and in those that hâve borne children, the changes that hâve taken place in the form and condition of the genitals are necessarily of such a nature that a single aet of normal coition would leave no immédiate anatomical évidence of its occurrence. The répétition of the act of sexual inter- course, and, much more, the occurrence of labor, enlarge the génital passage anel render its tissues yielding, so that the single act of e-entus takes place Avithout leaA'ing a change in the parts. Still, even under thèse circumstances, tlie act may be done AAÙth such brutality as to leave marks in the form of abrasions and lacérations. In the vast majority of instances of râpe, hoAAever, the crime is committed on virgins ; and often in such cases the questions the physician may be called upon to ansAver are : (1) Is the alleged victim a virgin? (2) Do the genitals présent évi- dence of récent or remote défloration ? In a virgin, as a rule, the labia majora are firm, large, and Avell- rounded, their edges lying in intimate contact in the médian line», and completely covering the labia minora ; the labia minora présent a bright red color ; the vestibule is narrow ; the hymen is intact ; the vagina is narrow, and présents prominent folds of its walls. While the state of the labia majora mentioned usually accompanies virginity, it is not a sign of much determinate value. The size and posi- tion of the labia AA'ith relation to each other dépend in great measure upon the eharaeter and amount of subeutaneous adipose tissue in the parts. In healthy virgins tliere is usually an abundance of subeutaneous fat, and in conséquence, the labia are full, well-rounded, and in close contact. Even in such instances, howeA'er, the labia readily separate with sépara- tion of the thighs, and this must be remembered in any conclusions draAAii from examination of the labia. Anything that leads to deficiency of sub- eutaneous adipose tissue may alter the relations of the labia and cause them to separate more or less completely. In thin subjects, whether chddren or virgins, the examiner must expect to find more or less defi- ciency of médian contact of the labia ; but, on the other hand, if a female is AA'ell-nourished and youthful, the labia may still be in close contact, even though coitus has been performed many times. Again, as âge ad- vances the subeutaneous areolar tissue loses that firmness characteristic of youth, and in eonse-epience, though well-nourished and a virgin, a fe- male be}7ond the years of youth may show marked séparation of the labia. Frenn thèse facts it aaIII be seen that the conditions and relations of the labia dépend more upon the gênerai condition of health and âge than upon Avhether centus has taken place or not. The condition of the labia minora dépends largely upon the condition of the labia majora. As long as the nymphae are covered by the latter, the membrane covering them retains its original charaeteristics ; it is moist, and ]>resents a rosy tint. After altération of the position of the labia majora induces ceuistant expeisure of the nymphae, the mucous mem- brane covering them undergoes changes AA'hich 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 mint)i*a upon the condition of the labia majora allenvs no absolute value to attaclt to the condition of the nymphae in determining the question of A'irginity. The condition of the hymen is of much greater value as évidence of 32$ A SYSTEM OF LEGAL MEDICINE. virginity or défloration. But even the state of this membrane Avili not ahvavs save from an erroneous conclusion. The hymen is not ahvays ruptured in the first coitus; it bas been found intact even after labor. Moreover, the hymen may be altered by other means than the pénétra- tion of the maie organ. The hymen frequently présents anomabes and defects, as well as variations' of form of slighter degree ; and an understanding of thèse possibilities is of great importance for a correct appréciation of the changes in the hymen induceel by coitus. The hymen is commonly regarded as merely a fold of mucous mem- brane closing, more or less perfectly, the entrance of the vagina ; but Pozzi* bas shoAvn it to be a structure of much more definite morphology. The hymen makes its appearance somewhat late iu fetal life, for it can- not be distinguished until after the fourth month, when the differentia- tion of the génital organs bas become epiite complète. At first it is seen as two folds AA'hich appear, one on each side, at the opening of the uro- genital sinus. Advaiicing in development, thèse two folds meet and fuse in the médian Une, leaving at the vaginal orifice the hymeneal opening. The primitive folds of the hymen extend forward from the ostium vagina» to the base of the clitoris, forming a circular fold about the orifice of the urethra, and uniting in the médian bne of the vestibule to form the frenum masculinum. Thus, morphologicaUy, the hymen is the repré- sentative of the maie corpus spongiosum, and it is to be regarded as an organ modified by arrest of development. In the infant the hymeneal folds are Avell developed and prominent, but the vestibule lies deeply betAveen the labia. It is pointed out by Pozzi t that AA'hen the hymen has the labiated form (two latéral folds), in the infant it might be mistaken for the nymphse, oAving to the considérable 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 birth, owing to the depth of the vestibule, the hymen is more deeply placed than later in life. However, this infantile peculiarity may pe-rsist in youth and be found even in adult life. Turnipseedt. states that in the negro race this peculiarity is very marked. Such a deep situation of the hymen, espe- cially in adults, might lead to the erroneous conclusion that it is absent, Congénital absence of the hymen is certainly very rare. Modem .observers are in accord in stating that they hâve never met with an in- stance of it. The cases of it reported by older Avriters are probably ex- amples of erroneous conclusions due to a Avant of knowledge of the possible variations in form and situation to which the hymen is now known to be subject. In structure the hymen is usually thin and membraniform. It is made up of the folds previously mentioned, which lie in apposition. Thèse latéral folds may remain perfectly distinct ; but usually they are fused together more or less perfectly, commonly lea\dng a single opening into the entrance of the A'agina. In some cases, hoAve\*er, there are marked déviations from the oreiinary structural characteristie-s. The * S. Pozzi: "De la Bride Masc.," etc., Bull, et Mon. Soc. Biolog., January 2G and February 16, 1SS4. * Gynecologn, vol. ii., p. 443. \ Am. Jour, of Obstet., 1877, Arol. x. SEXUAL CRIMES. 529 hymen may be found thick and fleshy ; or it may be so dense and inelas- ti<* as to présent an obstacle to normal coitus AA'liicli the maie organ can- not overcome. On tbe other hand, the hymen may be so elastic and yielding as to survive uninjureel the strain of coitus, or eA'en that of labor. However, instances of the latter kind must be exceedingly rare. The condition of an uninjured hymen might be of some value in de- termining the question of coitus. A dense, unyieldiiig hymen would positively exclut!e complète pénétration, providing its opening were suifi- clently small to prevent immissio pénis. On the contrary, an uninjureel hymen of exceptional elasticity AA'emld not prove that the act of coition hael not been performed. It should also be remembered that it is pos- sible to dilate the hymeneal orifice graduaUy without gross injury to its tissues. By this means rupture of the hymen is avoided in the gynecei- logical treatment of virgins. Exee»ptioiially, the hymen is exceedingly vascular, and in such cases its rupture may be attended with alarming and even fatal hemorrhage. Cases of multiple hymen hâve been re- ported ; but ail such instances are to be explained as the results of path- ological adhésion of the vaginal walls. Such adhésions. usually occur early in life, if at ail, and they may persist up to adult âge. Since the hymen is developed from two latéral lamina?, as might be expected, in cbildhood it is usually found in the labiated form. Gradu- ally thèse original laminae be- e-e>me fused in varions way s, lead- ing to a great variety of forms of the fully-developed hymen. In the adult the hymen is most com- monly annulai- in form (Fig. 69) ; but this type has received vari- ons names in accordance with the variations of form produceel by variatieuis of the position of the hymeneal orifice. Infrequently tlu- opening is found occupying a central îiositioii in the mem- brane. More commonly the ori- fice lies in the anterior half of the membrane. The shape of the hymen varies also in accordance with tbe size and form of the opening. The hymeneal aper- ture may be circulai*, but more ceunniemly it is oval, AA'ith its long diaine-ter lying antero-pos- teriorly. The diameter of the opening varies Avidely. It may be so nar- re )av, both in children and adidts, as merely to alloAV the passage of an ordinary sound (1.0 mm.) ; or it may be so large that the hymen forms searcely any obstruction at. the entrance of the vagina. Imperforate hymen, while occasionally observed, is certainly a rare condition; more e-ommeuily the- atresia of the vagina, presumed to be due to imperforate hymen, is due to an imperforate condition of the vaginal canal itself. Under such circumstances, the hymen is found in close contact Avith the imperforate membrane derived from the fusion of the vaginal walls, the Fig. 69.—Annular hymen. (Aftef Hofmann.) 5'JO A SYSTEM OF LEGAL MEDICINE. hymen presenting its normal perforation. When the hymeneal opening is comparatively large, and anteriorly situated, the hymen has the cres- centic form (also called falcifonn). (Figs. 70 and 71.) A e-re-scentic hymen with the orifice lying posteriorly, and the membrane anteriorly, is un- 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 praeticaUy made up of two symmetrical latéral halves, and the hymen is then said to be labiated—a, persistence of the common infantile form. Fig. 72.-Hymen fimbriatus, intact. (After Fig. 73.-Ruptured hymen fimbriatus. Hofmann.) (After Hofmann. ) The free edge of the hymen bounding its orifice is subject to much variation m form, and this occasions a variety of forms of hymens. In many cases, when the membrane is made tense, its free margin mav be traced as an unbroken line, forming a ring or semicircle, as the case may be. Aside from variation in gênerai outline, hoAvever, the free edge SENUAL CRIMES. 531 may présent various irregularities. It is frequently found notched. Thèse indentations of the free margin may be situated anteriorly or posterienly, but their most common seat is in the anterior part of the membrane. Usually the membrane is nedcheel symmetrically on each side. The notches vary in depth, from a slight irregularity of the edge of the membrane to division of the membrane deiAAii to the vaginal wall. Thus two deep notches symmetrically placed, one on each side, may divide the hymen into four parts. Tliere may be an anterior and a posterior note-li on each side. Thèse natural irregularities of the free margin of the hymen, Avhen présent, are of some medico-legal importance. Careless e>l iser Aation might mistake them for artificial tears that bat! healed. Cletse examination of such natural notches will shenv the absence of cicatri- e-ial tissue and the integrity of the mucous membrane covering them. In rare instances the free edge of the hymen présents a large number of shal- low notches ; anel still more rarely it may be fringed (hymen fimbriatus, Figs. 72 and 73). The hymeneal orifice may be found divided by a narrow band of membrane (hymen steptus). The membranous septum dividing the orifice usually exteiiels antero-posteriorly, either in the médian line or somewhat obbquely. The two hymeneal openings, uuder such circum- stances, may be approximately eepial, or very unequal, in size ; commonly they are manifestly unequal. (Fig. 71.) The hymen sœptus has been looked upon as a proof of the origin of the hymen in the Miillerian structures ; but, as previously shoAvn, other considérations must cause the abandonnant of Fig. 71.—Hymen sseptus, with unequal open- Fig. 75.—Hymen with posterior rudimentary. ings. (After Hofmann.) septum. (After Hofmann.) this A/iew. In some instances but one latéral hymeneal orifice is found, 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 hymen présents a large number of small perforations, constituting the variety called cribriform. In the normal, unstraineel position of the genitals, the hymen does not présent at the opening of the vagina as a tense membrane ; rather it 5;jL> A SYSTEM OF LEGAL MEDICINE. is seen folded on itself. The manner in AA'hich the hymen is foldetl, under such circumstances, varies somewhat in accordance Avith its form. The crescentic hymen présents a médian antero-pe>sterior fold, resem- bling a raphé ; the eelge of the circular hymen is folded in such a Avay as to form the wrinkled apex of a e'one directe*! exterually. With Aviele séparation of the thiglis and labia, thèse conditions are- altérée! ; the mem- brane becomes more en- less tense. This is more especially true in adults ; in children séparation of the thiglis and labia does not so readily affee-t the state of the hymen, because, in early years, it is of greater area than the introitus A'agina». The présence of an uninjured anel intact hymen is in itself strong presumptive proof that the normal anel complète act of coitus bas never taken place. Such a hymen does not, however, exclude, in any ease, the possibility that partial pénétration, as into the recess between the labia and into the A'estibule, bas taken place. Furthermore, notwithstaiiding the intact condition of the hymen, its physieal peculiarities are of importance, as bas been previously mentioned. An uninjured hymen might exhibit such a marked degive of elasticity as te) raise the question of its possible distention Avithout rupture in the act of coitus. Again, the size of the hymeneal orifice might haA'e some bearing upon tins point : an opening unusually large woidd require less elasticity in the narrow membrane to permit pénétration by the maie organ without rupture ; an opening of small diameter would speak against the possibility of complète pénétra- tion without rupture, notwithstanding marked elasticity of the hymen. Of course, in ail questions on thèse points the size of the maie organ must be considered. Fig. 76.—Ruptured crescentic hymen, with two Fig.77.—Circular hymen, torn in several places. latéral lascerations. (After Hofmann.) (After Hofmann.) As a rule the hymen is torn more or less in the first act of coitus. The resulting lacérations of the membrane vary in eharaeter, in part owing to the variations in its form and structural eharaeter. Usually SEXUAL C TIMES. 533 such lacérations start from the free margin of the hymen and extend through the membrane to its junction Avith the vaginal tissues. Usually the labiatetl hymen is found torn posteriorly in the médian line, the tear dividing the hymen into tAvo perfectly distinct latéral valves. The cres- centic hymen commonly tears on each side in such a way as to leave» an approximately triangular médian valve attachée! along the posterior edge of the A'aginal entrance. (Fig. 76.) The circulai' or annulai* hymen tears in four or more places, dividing the hymen into several vahular remuants. (Fig.77.) The structure of the hymen may détermine dc-partures from thèse rules. Relative weakness of one part may iuflueiie-e the direction and e»xtent of the lacération. The hymen saqitus is peculiar in this respect, that lae'eration of but euie siele may take place, the sep- tum anel opposite side remaining intae-t. In re'cent cases it cannot be difficult to ree-ognize that rup- ture of the hymen has taken plae-e. There Avili be the his- tory of hemorrhage, and perhaps the eA'iele'ne-es of it. The mem- brane will présent tlie unhealed edges of the lacérations ; and the remaining ■ tissue of the hymen aaHI probably sIioav some degree of inflammatory hyperaemia and sAvelling. As a rule hemorrhage is insignificaiit AA'here the lacéra- tion is confined to the hymen itse-lf, but it may be, as already mentieuied, so considérable» as to call for surgieal interférence. Profuse hemorrhage folloAving a first coitus, or, more especially, an at- tempt at râpe, is usually élue to lacération of other parts than the hymen, either directly or by extension of the lacération of the hymen into the A'aginal Avall. Repair t)f the orelinary lacérations of the hymen takes place in tAA-o or three elays, but the severer anel more extensive tears may require a con- siderabh» period te> complète healing. The presene'e of inflammatory red- ness and swelling and exudation about the edges of the Avemnds e)f the hymen make»s the diagnosis of récent hymeneal rupture easy. Te) recog- nize that the hymen bas at one time been lacerated, after repair has been completed, is much more difficult in some cases. If the lacération has been extensive, with conséquent imperfectieni of repair, the case présents no difficulty. It is otherAvise, however, AA'here tlu» lacérations hâve iiiA-olved merely the free eelge of the hymen. In such a case repair may bave left nothing more than slight notehing of the margin of the membrane, and verv careful examination may be necessary to differentiate between cieatrieial anel natural notehing of the free edge of the membrane. Marked cicatrices resuit only Avhere the lacération bas been considér- able. The slighter artificial notehing may be distinguished from that Fig. 78. -Ruptured hymen sœptus (after Hofmann). 5ol A SYSTEM OF LEGAL MEDICINE. normally présent in some cases by the superficial deficiency of the mu- cous membrane ; by the peculiarity of the outline of the edge of the notches, irregularity being characteristic of those due to lacération ; aiul by the présence of cicatricial tissue. The examination of the hymen for lae-eratiou must be A'ery earefully conducted, espee-ially in children, with a A'ieAv to the avoidance of injury to it at the hands of the examiner ; foi- an injury inflicted in this Avay might mislead at a subséquent examination. Coitus, though the conimonest, is but one of many Avays in AA'hich injury of the hymen may originate» ; anel in any case it may become im- pentant to exclude en- establish the influence of other causes than coitus to AA'hich an existing injury of the hymen might be attributable. Injury of the hymen by forcible séparation of the thigh s is searcely possible, saA'e as a feature of a lacération of the perineal structures, which could occur only as the residt of force sufficient te) aceoniplish dismembe-rment. In children the most extrême séparation of the thighs e-ompatible with integrity of tlie limbs and perineum would stib bave no lacerating effect on the hymen, OAving to the fact that the infantile hymen is of givater ex- tent than tlie dilatée! introitus vagina?. Falls on the perineum, AA'ith im- pact upon objects capable of exerting localizetl pressure and partial péné- tration dn-ectly betAA'een the labia, or of drhing the soft parts upAvard into the pehic outlet, might lacerate the hymen ; but isolated rupture of the hymen by accident of this nature Avould be possible only under most pecul- iar circumstances. It is thought that the practice of masturbation com- monly leads to injury or altération of the hymen ; this may be true in youthful aud mature females, but quite the contrary is the* fact in the case of young children. Undoubtedly manustupration is a very common practice among female e-hildren, as it is among boys ; but the manipula- tions are usually confined to friction and titillation of the clitoris and inner surfaces of the labia. Thèse parts early ha\Te an erogenous power, AA'hile the introitus vaginae and other parts do not become erogenous until quite late ; n*>t until puberty, and in senne cases not until after the first act of coitus. In children it is common to find that attempts bave been made to pass objects into the urethra. In case the finger or other objects hâve been passed into the vagina, tbe insertion has been gradu- ally ae-eompbshed and the hymeneal orifice dilated rather than the mem- brane ruptured. Pruritus from any cause in children might occasion so severe rubbing and seratching as to lead to injury of the hymen. This is a more fréquent cause of injury to the hymen in children than simple manustupration. Cicatrices may be found on the hvmen that bave resulted from disease-processes * like diphtheria, noma*, and smallpox; but in such cases the eharaeter of the scars and the history Avili usually make the diagnosis of then* nature easy. Venereal disease mav also give rise to cicatrices on the hymen, and that too when no rupture of the membrane has taken place. The first coitus may occasion injury of other parts besides the hvmen. The fourchette is, with the hymen, the part most frequently involved ; but lacération of the nymphee and even rupture of the perineam havé been knoAvn to residt from it, However, such injmies are unusual, and could but seldom be caused by simple coitus in a fullv deA-eloped female. In children it is otherwise. Forcible pénétration *of the adult maie organ into the vagina of a child or immature girl might cause rupture of the fourchette, the perineum, and eA-en the A'agina. The cases reported SEXUAL CRIMES. 535 in AA'hich such extensive injury was inflicted are, for the most part, those of children under the âge of* fourteen. Where such extensive lacéra- tions are présent, especially in mature females, there is ahA'ays great probability that they hâve been brought about by other means than the pénis. Insertion of the finger is capable of occasioning rupture of the hymen like that due to pénétration of the pénis, but the finger may inflict much greater injury than the maie organ, if usée! with any great force or misdirection. Lacération of other parts than tlie hymen, eA'en in small children, is more frequently due to attempts at manual dilata- tion on the part of the rapist than to forcible attempts to introduce the pénis. Injury of the vestibule and urethra, under such circumstances, is almost iii\rariably due to manual effort. The state of the vaginal wall and mucous membrane in themseh'es in mature females, aside from gross injury, can afford no e\ridenee as to whether primary centus has taken place or not; in children, lie>Ave»A'er, the vaginal passage, which is narrow, nui}', after distentieui by an adult pénis, présent évidence of its having been dilatée!. On tlie other hand, habituai répétition of the act of coitus doe»s induce quite characteristic altérations of the vagina ; it loses the folds charae-te-ristic of its virgin state, and the mucous membrane loses its primitive delicacy of structure ; and the tissues and muscles about the introitus vagirne become relaxed. Thèse changes, secondary to repeated coitus anel labor, are of interest hère only as circumstances Avhich render impossible anything like ana- tomical evielence of the single act of normal coitus. Proof of the présence of semen in or about the genitals of tbe female, or on lier clothing, may be e»f great importance in some e-ases of alleged râpe. The sécrétions found in the vagina and utérus a short time afte-r the alleged perpétration of râpe may afford incontestible proof of sexual contact. For jnirposes of examination, a small quantity of the sécrétions should be taken from the parts and preserved between glass slides or otliei'Avise for microscopical examination. Dried sécrétions found on the external genitals or génital hair may afford the same proof of malt» con- tact en- proximity. Such dried sécrétions should be earefully seraped from the parts, or remoA^ed by severing the hair to which they are found attached, anel earefully preserved. Stains found upon the linen should also be taken for microscopie- examination. Stains may be préservée! for examination by cutting out the parts of the garments that présent them. When possible, such spécimens should be submitted to an expert microscopist for examination and report ; but it may be necessary for the examining physician to give his opinion upon the nature of such findings. The only distinctly characteristic constituent of semen is the sper- matozoon ; ail other organic beidies found in the séminal fluid are of too little definiteness of form to permit a just conclusion as to the nature of a spécimen in whie-h spermatozoa are not found. On the other hand, failure to find spermatozoa in suspectée! fluid or stains is not proof that they are not of séminal origin. Spermatozoa are not infrequently ab- sent from the semen of men given to sexual excesses, and of those that hâve suffered AA'ith epididymitis. The examination of a fluid suspectée! to e»ontain spermatozoa is sim- ple. A drop of the fluid placée! on a glass slide is covered vrith a eever- glass and examined through a lens of high power. If the spécimen 5;](j . A SYSTEM OF LEG.IL MEDICINE. contain living spermatozoa they Avili be seen nioving about in the» fielel as eell-like objects, tlie tail-like processes, OAving to their rapid vibrateuy movement, being ail but invisible. When the spermatozoa are lifeless the processes are readily distinguished. To prépare a spécimen of dried sécrétions for examination, a drop of distilled Avaler is plae-ed on a glass slitle and a particle of the dried matter dropped in it. As the particle imbibes Avaler it should be gently teasetl AA'ith needles until it is quite broken up anel diffused. CoA'ereel Avith a glass, the spe-cimen is then ready for examination. For examination of a stain on linen, a peution of the stained fabric should be soakedin a drop or tAvo of distilled Avater, and the resulting solution may then be examinée! in tlie manner de-- scribeel. It is remarkable Iioav long, under favoring circumstances, sperm- atozoa. retain their charaet<»ristic form. Thty bave been demonstrated in sécrétions that bave remained elesiccated many months, catii years. Water quickly kills sperniate>zoa ; therefore, to demonstrate their cenn- paratively récent déposition in the female genitals by finding them at-the, it is ne>e-essary to examine sécrétions almost immediately afte-r their re- me)val, and that without tlie addition of water to them. Forme»rly e-ertain pee-uliarities of séminal stains Avère held te» be characteristic; but their prese-ne-e could establish nothing more than a presumption that the stains AAere of séminal origin in the absence of microscopic démonstration.* Venereal disease frequently plays an important part in cases of alleged râpe», as evieleuce that sexual contact or coitus bas taken place. In a nie-elicodegal ease Avliere the question of the existence e>f venereal disease in the plaintiff calls for an ansAA'e-r, the greatest eare and accurae-y in diagimsis are demanded of the médical Avitness called upon to ansAver the questiem. Fortunately, in the case of gonorrhea, the bacteriologie;al examination is capable of ghing positive évidence of the nature of a génital discharge in certain cases. The gonoeoccus, when found, is an absedute démon- stration of the venereal nature of a génital catarrh ; its absence, or fail- ure to find it, however, does not constitute négative evidene-e of like value. It is mainly in the acute stage of gonorrhea that the présence of the gonoeoccus is easily demonstrable in the discharge. At an acute stage, it will be found in the vaginal secretieuis, and, in children espe- cially, in the moist seeretiem bathing the mucous surfaces of the vulva. In the chronic stages of the disease it is less apt to be discovered in the vaginal sécrétion, but may still be found in the cervie-al mucus, and in the sécrétions expressed from the urethra, whieh is the preferred habitat of the spécifie microorganism. What is true of the gonoeoccus in the female is also applicable to the maie. It is found easily in the diseharge from the maie urethra during the acute stage of gonorrhea ; in a chrome stage its habitat is the deeper portion e)f the urethra, and it is difficult to demonstrate its présence in the gleety discharge. With référence» to the value of the bacteriological examination of dise-barges suspectée! to be gonorrheal, it may be said that the diseovery of the gonoeoccus is an absolute démonstration of the venereal nature of a diseharge ; that failure to find it in the discharge from an acutely inflamed génital surface con- stitutes presumptive évidence that the inflammation is non-venereal in nature; that failure to find it in a discharge of a chronic eharaeter is of no value as an aid in the détermination of the real nature of the disease. * Cf. Séminal Stains, vol. i., p. 184. SEXUAL CRIMES. 5o7 There is neither space nor need hère to give the technical détails of the bacteriological examination for the détermination of the spécifie nature of discharges ; such an examination, for medicodegal purposes, must needs be made by an expert bacteriologist. The necessity for accurate détermination of the nature of a malady affecting the female genitals is shown especially in those cases where the existence of the disease constitutes the basis for the institution of criminal preie-ee-dings ; and such cases bave not been rare, especially in Europe. Tliere is a belief more or less prévalent among semie of the more ignorant peasautry of Europe that obstinate gonorrhea in the maie is to be cured by sexual intercourse Avith a A'irgin—henee, AA'ith a child. This leads, not infrequently, to the allegatieni that a simple A^aginal eatarrh in a child is the resiilt of infection at the hands of some infe-cted m aie. Such a belief is îioAvliere prévalent in the United States; but, OAving to the immigration of the pe-asant classes of Europe, the pe>ssible opération of such an idea in the production of sexual assault on children, and in the préféraient of charges of râpe, basée! upon simple génital dise»ase in them, should lie: kept in mind. Important as the proof e>f venereal disease is as an évidence of sexual contact, it is never oî abseilute A'alue in itself. The genitals may become infee-ted with venereal disease in many other ways. A case* is eut record Avhere two female children were» infected Avith gonorrhea by means of a sponge used in tbe» bath, the sponge haAdng been previously used by a man suffering AA'itb the disease. Génital infection might be brought about by the liant! of an infected manustuprator ; or a child might in- fect its oavii genitals AAdth its own hands, after manipulation of the dis- easeel genitals of another person. Again, one infee-ted female might infect another, Avère mutual génital manipulation, or génital contact, te) be prac- ticed. The latter possibility Avili seem less improbable if it is remembered that there is a ree-orel of the transference of séminal fluid from one female te» another, resulting in the pregnancy of a Avoman who had never knoAvn maie contact. It is also concehable that a female presenting signs of the seconelary stage of syphilis might make them the basis of criminal accusa- tion. With syphilis, as'with gonorrhea, the possibilities of infection are not exclnsively génital. Kissing is a very fréquent manner of communi- cating the disease- ; and génital oscillation, or cunnibngus, is another possible source e>f gvnital infection. A génital discharge due to simple inflammation of some portion of the genito-urinary tract of females, both adults and children, may be élue to a A'ariety of causes. It is very common for tbe virgin to haA'e a simple leucorrhea; and the existence of it may prédispose to the development of an intense muco-purulent inflammation im- mediately upon the performance of the first coitus ; and that without spe-cific infection of any kind. This possibility is capable of raising more than one important medico-legal question. A bride lias been known to sue for dhorce on the ground that she had been infected by her neAvly made husband, when the disease Avas due only to the mechan- ical irritation of the first coitus. Again, in females that hâve been raped, it is common to fine! such a non-specific discharge from the genitals Avhen they are examined shortly after the crime ; and it is important not * Ryan, cited by Hofmann, Gerichtliche Med., p. 137. 538 A SYSTEM OF LEGAL MEDICINE. te> mistake this for gonorrhea. For gonorrhea may not be found m the alleged ravisher, and thus a false ground for défense might be estai hshed. Among the more common causes of niueo-puruleut génital di sel larges in females are disordered menstruation; masturbation, however prac- ticed ; skin eliseases ; oxyuris vermicidaris, alone» or in eonjunction Avith manual irritation. Génital catarrh may also be an accompaniment of a gênerai enfecbled state of the orgauism, as in tuberculosis and chlorosis. Vulvo-A-aginal eatarrb sometimes occurs in an épidémie forai. The pos- sibility of diphtheritic inflammation of the génital mucous membrane is also to lie remembered. The close resemblance of venereal inflammation to simple inflamma- tion of the génital mucous membrane bas led designing mothers to excite the» latter in their young elaughters, by mechanical means, for the purpose of blaekmail or revenge. In a given case it may become essential to détermine the relation be- tAveen the alleged time of infection with spécifie venereal elisease 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 eare must be exercised in giving medico-legal opinions concerning ulcerative processes affecting the female genitals. The differentiation of such processes from syphilitic sores does not présent much difficulty ; but errors may be made if it is iiotreinem- bered thatulcers of other kinds may simulate the hard e-hane-re, owing to some induration of their bases; that syphilitie-, induration is not ahvays typical. The diagnosis is not to be maele until after thorough considera- tion of aU the CA'idence. The diagnosis of soft chancre» is to be made nuire especially from its course than from its eharaeter and seat. To be sure», soft chancre can be diagnostie-ated by inoculation on the person affe-e-teel, but such a means AA'ill rarely be expédient. It may be necessary to distin- guish soft ediancre from herpès. Ulcerative and gangrenous proe-esses of varions kinds affecting the genitals may be mistaken for venereal affee- tions ; more espe-cially noma and diphtheritic ulcération, which some-tinie-s affect the genitals of female ediildren after se-arlet fever, typhoid fever, and measles. For the expression of a medico-legal opinion in case»s where the question of venereal elisease is a matter for décision, it will be seen that a thorough acquaintance Avith ail the characteristies of the venereal affections is esse-ntial; hoAve\7e»r, such kneiAvledge is to be gained best in works deA'oted specially to them, and it does not fall properly Avithin tlie scope of tins article to enumerate diagnostic criteria. In any case AA'here the existence of venereal disease is ae-cesseny évi- dence of râpe, examination of the person of the accused will give addi- tiemal évidence of great importance. It is impossible to do this, heov- eA'er, Avithout the consent of the accused. The présence of similar disease in the person accused becomes strong circumstantial eA'itle-iie-e against him. It is to be remembered hoAv chronic gonorrhea in the maie may easily escape observation, and précautions are to be taken to guard against such an error. The urethra is to be examined some hours after the last act of urination. A gleet, while on the Avhole less infectious than a gonorrhea in its acthe stage, may infect, and that the men-e- reaelily in e-ase of génital contact AA'ith Aurgins and children. On the other hand, the existence of elisease in the female anel its absence in fie- maie accused is CA'idence of his innocence and of lier leAvdness. Still, SEXUAL CRIMES. 539 there may be sexual contact under such drcumstances without infection. However, a diseased prostitute accusing a man of râpe Avould with diffi- culty sustain her charge in case the accused Avère free from infection. Again, the absence of disease in the accusiug female and its présence in the accused maie would constitute strong évidence that sexual contact had not taken place, especially were the female a virgin or a child, and the elisease gonorrhea; at the same time, thèse conditions Avould not actually disprove sexual contact. The Physieal Evidences of Force.—Since there can be no râpe where there bas been no force, actual or constructive, it may become the duty of the meelie-al Avitness in a trial for râpe to give testimony concern- ing tangible iwidence of the use of pliysieal force. Severe injuries, such as might residt from blows, choking, brutal violence to the genitals, etc., do not présent any difficulties ; Avhere injuries are slighter, the question of their self-iuflictiem by the alleged victim must be considered. Signs of force may speak as well for the degree of résistance of the victim. The old question whether it is peissible for a single man to force a woman of good physieal development, Avliile in full possession of her sensés, to' submit to coitus, is quite beside the mark in cases of actual râpe. Un- der such circumstances, though a woman might appear to be physically capable of suce-essfully resisting the sexual appremeh of a man, lier failure to do so woulel be no eAddence that she had not offered ail the résistance peissible for lier at the time. Even though the man Avère proportionately Aveaker than the Avoman tlie same Avemld hold true ; for the psychicàl excitement induced in the woman by the attack might be sufficient to make her physieal résistance less effectuai than it would otherwise be. When a Avennan is attacked by a man with intent to compel her sub- niission to coitus, no matter Avhat her pliysieal strength, the initial ener- getic résistance she.offers will probably groAV less under the influence of pain inflicted by the ravisher in bis efforts, and as a resuit of the wom- an's psychicàl excitement aud fear that the greatest bodily harm may be inflicted. The Avemian's mental conelitioii may, through appréhension, finally beconie such as to make physieal résistance no longer possible. HoAvever, renienibering the frequency with which false charges of râpe are made, it may become necessary to consider the comparative strength of accusée! and a*-e',use»r. In case it seems that the woman were capable of offering effectuai physieal resistiince, it is proper te> direct attention to the discovery of conditions that may hâve preArented its exercise. Where strenuous résistance has been offereel by a woman, physieal eAddences of the force used by the man Avili rarely be wanting ; ahvays provide»d that they are sought before sufficient time bas elapsed to allow their removal by natural processes. The physieal évidences of ftnve Avili be» the more obvious the more strenuous and hmg-continued résistance bas bee-n. Scratches, bruises, anel more serious injuries on the pe'i-son of the Avennan may be in évidence. Thèse injuries may be fourni em almost any part of the body, but they are most frequently seateel on the limbs, especially the thiglis. The external genitals often pre-se'iit évidence of violent treatment. Senne caution is necessary in determining the nature of marks pre- sumed to be» the évidence of the infbction of violence. Natural pigmen- tations of the» skin bave been mistaken for suggillations. Self-inflicted marks and injuries are usually slight, and to be found only on parts of 510 A SYSTEM OF LEGAL MEDICINE. the person easily reached by the hands. The genitals are usually the parts chosen for injury by a Avennan seeking to deceive. In any case, injuries presented as CA'idence of force used in the accomplishnient of râpe are to be considered with respect to the relatieuis their aspect at the time of examination bears to the time they are asserted to bave been inflicted. The person of the accused may also give evidene-e of a physi- eal kind of the résistance offered by the A'ictim. Se-rate-hes, bruises, anel wounds made by biting, may be fourni. Injuries of the malt» genitals are neit unusual. Moral Force.—When coitus is accomplished by means of threats of violence, the résistance of the female being thus precluded by fear, tlie act is none the less râpe; but under such circumstances the eA'ide-nce that résistance was thus obvia teel requires no médical interprétation. The threats used may be directed against the woman's oavii person or against others. Thus, a mother might be forced to submit to coitus by threats diree-teel against lier children. Kesistance to sexual attack may be precluded by physieal or mental conditions. A female in an invalitl condition might be incapable of offering any physieal résistance. Fraud.—In laAV, intercoiirse aeeompbshed through fraud, AA'ithout intention to use violence, is not râpe ; but unlaAvful connection with a woman Avhile she is asleep, unconscious, or insensible as a resuit of in- toxication by alcohol or other narcotics, is commonly râpe. Where co- itus is aeeompbshed upon a Avoman by a man aa'Iio takes advantage of circumstances—darkness, etc.—to bave himself mistaken by lier for her husband, the act is oue of fraud; and if there Avère no intention on the part of the man to use violence, such a crime coidd not be legally held to be râpe. At the same time, a sensé of strict justice could but regard such a crime as much a râpe as coitus performed with a female whose sensés ha\-e been befogged by intoxie-ants. Again, for example, coitus performed by a physician with a patient on the pretext that the act is a necessary part of médical treatment is not râpe, but fraud ; though it is possible that such a crime could be made râpe in laAV by proving the imbecility of the victim; or her Avant of adéquate knoAvledge of the nature of the act, if such could be shown, should establish the same de- gree of irresponsibility for consent that obtains in cases of children. ^ States of Unconsciousness.—It bas been amooted question whether coitus could be performed on a female sleeping normally without awak- ening her. That such a thing is possible must be adniitted ; but tliere would needs be a rare combination of circumstances te) make the possi- bibty an actuality. A married female might be subject*»el to the sexual act Avithout rousing from slumber; but a female who had never per- formed coitus would certainly be awakened from anv normal sleep by the unusual manipulations and pain necessarily attendant upon the act, Sleep and a favoring position, with absence of impeding garments, might make the commission of râpe easier, and permit the perpetrator to gain such advantage that the female, on awaking, would find ail lier résistive efforts futile. States of unconsciousness differing from that of normal sleep, in that they are deeper anel less easily overcome, may be used as aids in the performance of unlawful coitus. Such unconscious conditions may be purposely induced for an ultimate sexual object; or being présent, they may be utilized for such a purpose. A Avoinan might be purposely in- SEXUAL CRIMES. 511 duced to take alcohol to intoxication, and her condition utilized for a sexual purpose. If, while intoxieated in this Avay, a Avoman still offered résistance to the sexual approach, or if she were so far unconscious as to knoAV or remember nothing of the ae-t, the crime Avould be râpe. Hem'- ever, if under such circumstances a Avoman Avère to give consent, the criminal sexual act would not be râpe, notwithstanding the contributing effect of the intoxie-unt, unless uncemsciousness of the acepiiescence could be proveel. In such a case, AA'here an aelult female is concerned, it Avoulel be assumée! that she Avère more or less acquainted AA'ith the effects of alcohol, and that she knoAvingly took that AAdiich Aveuild lenver lier moral résistive poAver. With a youthful female unaeepiaiiited AA'ith the effects of alcohol in the ordinary forais in which it is taken, the case Avoulel be quite différent ; and consent under such circumstances might not, or should not, qualify the crime. Other narcotics might be purposely or secretly administered for the purpose of removing the possibility of résistance te» sexual approaches. The» most important of thèse are chloroform, ether, nitrous oxieie, opium anel its alkaloiels, and chleiral hydrate ; but there are many other sub- stances that might eventually be usée! te> serve such a purpose. Tlu-re are but very feAv cases on re-corel in AA'hich the more poAverful narcotics and aimesthetics bave be-e-n used primarily Avith the purpose to indue e» a conelition that AA'enild render résistance to coitus impossible; but there bave been numerous instane-es in which the effects of tliese agents hav- ing been induceel for other purposes, the opportunity has been used for sexual approach. This is e's|K>e-ially true of anaesthetics administered for surgieal procédures. X*>t infrequently the complaint is made that un- consciousness has been suddenly inelueed by the sudden and unexpected use of chloroform or similar age-nts. Such statements are to be accepted only Avith the greatest e-aution ; for such substances do not produce im- meeliate unconsciousness. The question of the peissibility of chloroforming a sleeping person without disturbiug the slumber may call for an answer. Expérimenta- tion to test this problem bas sIioavu that it is possible to induce ana's- thesia with tdiloraform AA'ithout interrupthig normal sleep ; but te) do this successfully, kneiAvleelge of chloroform and skill in its administra- tion are requiree! ; and even with every scientific précaution the chance of failure is as good as that of success. Therefore, the probabilities are much against tlie success of an attempt by an miskilled operator to chloroform a sleeping person AA'ithout breakiug the sleep. Where other narcotics are in question, an appeal to knoAvn physiologieal ae-tions will often pro\'e valuable in dete»rmining the nature of testimony. Other states of temporary unconsciousness seldom afford detect maUngering; but it may be impossible to show that she was 512 A SYSTEM OF LEGAL MEDICINE. in an hypnotic state at the time of the alleged sexual assault. In the eases of this kind thus far reported, the females bave been invanably hysterical. Again, the hypnotic state is in itself an abnormal state of consciousness, and any statements based upon perceptions of t-A-ents had during such a condition should be accepted only with a full under- standing of that fact. Tlie hypnotic state is one preëminently hallu- cinatory, and therefore proue to originate false ideas, especially in the hysterical subject. For this reason, there eau be no excuse for the in- duction of the hypnotic state in a female by a man without the présence of AAutnesses. Certain autohypnotic or cataleptie states that sometimes occur in hysterical females might be used for sexual purposes ; but hère, as in states of hypnosis induced by a second person, testimony given by the subject should be corremorated by more objective évidence than alleged pe-rce-ptiems of events during such an abnormal state of consciousness. False Accusations.—Women frequently accuse physicians and den- tists of having taken improper bberties with them while under the influence of an anaesthetic. Expérience teaches that such accusations are to be taken only with the greatest caution. In the majorité of such eases, the state- ments are the outeome of illusions or hallucinations to which the female Avas subject during tlie period of temporary une-onsciousness. Usually the alleged A'ictim asserts that unconsciousness was incomplète ; that Avhile robbed of ail power to make any résistance, there Avas still con- sciousness of aU that Avas taking place. Where testimony of this ehar- aeter is offered, it should never be given weight without other independent évidence; for it is testimony cemeerning eA'ents confessetlly experienced or observed during an abnormal state of conse-iousness. This considér- ation alone should be sufficient to exclude it as trustworthy testimony. The best proof of the justification of this pétition with regard to sue-li testimony is offered by the mimerons cases in which such accusations hâve been made in the face of the contrary testimony of other persenis aa'Iio were présent at the time of the allégée! sexual assault—eA'en of the parents of the accusing female. In the face of the frequency Avith AA'hich such accusations are made, no circumstances can justify the administration of an anaesthetic to a female by a physician Avithout the présence of others. Accusations of a sexual nature against physicians and others are frequently made as a resuit of more obvious mental anomalies in the accusers ; but in such cases, the A'ery nature of the accusations, with other évidences of mental disturbance, are usually sufficient to establish their true eharaeter. Designing females haAre taken advantage of the physie-ian for purpeises of blackmail, by lodging accusations of improper relations at tunes of consultation in the absence of Avitnesses. The fré- quent necessity for umvvitnessed conférence betAveen physician and patient affords excellent oppeirtunity for a designing woman. Tbe possibility of trouble of this kind is so great that the physician jealous of his re»pu- tation cannot afford to take risks, more especially in the practice of gynecology ; it is his duty to himself, as to his patient, to hâve a female Avitness at hand in ail cases of génital examination, etc. False accusations founded upon génital disease in children, and upon such elisease induced for the purpose of blackmail, hâve been already alluded to in preceding pages. SEXUAL CRIMES. 513 States of Non Compos Mentis.—UnlaAA'ful intercourse with a female idiot or imbécile, or AA'ith an insane female, is commonly râpe. In such a case résistance and force may bave been in play, as in any other; but, under such circumstances, ordinarily the question of the crime of râpe hangs upon the irre»sponsibility of the female for the assent she may bave accordée!. The proof of the mental condition of the prosecutrix then beceunes indispensable; and this must follow on gênerai psyehi- atrieal lines. At the same finie, in case consent has been given by an irresponsible female, it woidd also be obligatory on the part of the pre>secution to sIioav that the» accused Avas aware of the irresponsibility of the female, in order to bring the crime within the légal définition of râpe. Actual and Apparent Age.—Sexual intercourse with a female under the âge of consentis, under ail circumstances, râpe. It would seem, Iioav- ever, that where the âge of consent is high (fourteen years) there might be conditions which would mitigate» the crime. Though under the âge of consent, a girl might be so fully developed as to make her appear much older ; aud lier consent to a sexual approach, or iiiA'itation of one, should then, in the ignorance of the man, be given the Aveight of the consent of one of the âge which she appears. Such a case is considered by the Austrian laAV. Sexual Assault of Children.—Râpe of children is the most fréquent form of sexual crime. The majority of children thus abused are of tender years ; even babyhood is not exempt. The âge in recorded cases ranges from eight months upAvard. There are no statistics showing the num- ber of e-ases of râpe and the proportion of children concerned in America, but statistics sboAvthat in France from 1851 te> 1875 inclusive tliere Avère 22,017 cases of râpe brought to trial. Of this number, but 4360 e-on- ce»rned adult females ; tlie remainder, children. (Tardieu.) Of 40G cases of alleged râpe examined by Casper and Liman, 81 pere-ent. of tlie females were under the âge of fourteen, and 70 percent. beloAv the âge of tAvelve ; anel in 218 cases reported by Maschka, the âge was below fourteen in 171 instane-es. It is but natural to seek 'soem reason for the great prépondérance of such sexual assaults of children. The superstitious ignorance which fosters a belief that gonorrhea is cured by intercourse Avith a virgin or child would hâve an influence to increase sexual assaults on children where it prevailed. Many times children are approached because they eau be pe»rsuaeled more readily than others to submit to embraces of the nature of which the}^ are ignorant ; or because, if need be, their résist- ance can be easily overcome. Similarly, old women may become A'ie-tims bv reason of their présumée! lae-k of power to offer physieal résistance». iii some» instances children fall victiins to men aa'Iio haA'e not the courage (fear of impotence) to attempt intercourse with adult females. Through fear of possible failure with an adult, and conséquent ridicule, a young man may first essay sexual contact AA'ith a child. Intercourse may be attempted AA'ith a chilel with the thought to seek a new stimulus to sexual poAver exbausteel in sexual debauchery AA'ith women. Sexual assaults upon children by aged men are especially fréquent. In such cases, in the maie there» is usually a coincidence of impotence and libido : sexual désire prennpts to the sexual act; but consciousness of impotence, and the impossibility of gaining the consent of an adult to sexual approachr 511 A SYSTEM OF LEGAL MEDICINE. cause such old men to seek children, in Avhose ignorance they would conceal theh* deficiency. In such men mental failure is an inA'ariable accompaniment of such acts. Sexual perversion (erotic fetichism) might lead to an unnatural préférence for children. Finally, in a certain pro- portion of cases, children fall victims to the sexual appetite eif maies through the accidentai coincidence of asseie-iation, inordinate» passion in the maie, and favoring circumstances. In cases of alleged rapt» of children, considération of tlie physie-al condition of the genitals of both parties becomes very important. The yenmger and more undeveloped the child, tlie smaller the possibility of actual pénétration by the adult maie organ. As a rule, owing to the common disproportion of size. the sexual contact is confined to the vul- var fissure. Where this (lispre)portion exists, and the foreed entrance of the peuis is attempted, laeeu*ation of the child's genitals is almost inévi- table, OAA'ing to the delieaey of the infantile tissues. Still, Avhere lacéra- tions of a child's genitals are fouud, the question arises at once whether they coidd hâve been causée! b}' the erecteel maie organ. OAving to tbe Hmited power of the pénis to overcome résistance, Avhere serious or exten- sive lacérations of a child's genitals are found they are to be attributed to brutal attempts to bring about dilatation by the fiiigers or other un- yielding object. It should be remembered that eA^en a child's génital passage may be enormemsly dilated ly persistent gentle efforts, Avithout tlie» production of lésions; and marked dispreiportion betAveen the âge and the size of the génital passage of a child should be given weight as évidence that she has been used for sexual purposes.* Secondary Conséquences.—Medico-legal questions may arise con- cerning the idtimate conséquences of rapt» to the victim. Imprégnation may result, and place additional liability on the raA'isher. Injuries inflicted by the râpe may, aside from tlie effects of venereal infection, seriously affect the health of the female ; and sueli injuries may even e-ause death, as numeroiis cases reportée! by Tardieu, Taylor, Casper, and others attest. Such cases show that death, under such circumstances, may resuit early or late, in accordance AA'ith the immédiate cause. Thus it 'may be due to shock, hemorrhage, sepsis through wounds inflicted in the immédiate sexual act, and to hemorrhages into the central nervous system. Géni- tal wounds may directly or indirectly implicate the peritoneal cavity and lead to a fatal peritonitis. Sinee sepsis may play a very impentant part in thèse cases, it becomes of the greatest importance that the physician examining such an injured female exclude by the most rigid asepsis in his examination the possibility of a défense based on the assumption that he made secondary sepsis possible by his manipulations and in- struments. Râpe of Maie Children.—The English common law does not recog- nize râpe of maie children by mature females, but such an offense is recognized by the laAV of some Continental nations. In the United States such crimes are punishable under the laws of some» States, as indécent assault. The most serious conséquences to such children is venereal dis- ease, aside from moral injury, and cases of this kind are not of great rarity. * Cf. Indécent Assault upon Children, vol. i., p. 649. SEXUAL CRIMES. 545 SEXUAL ABUSE OF CHILDREN.* Ch)sely related to the crime of râpe, but widely separated from it in a légal sensé, is sexual abuse of children. The common law does not recognize sexual abuse of this nature as such, but such immoral acts may becenne the basis of légal proceedings, and various medico-legal questions may be raised in such cases. Sexual abuse, in the sensé in which it is hère employed, signifie»s se»x- ual manipulations Avhich are unrelated to the normal sexual act. Man- ustupration may lie practiced upon the person e)f a maie or female child by a man or Aveiman ; en- children may be induced to perforai such an act on one another as an exhibition ; or, again, they may be persuadée! to manipulate the genitals of the seducer, maie or female. Feir the most part, the e-ases of this kind that hâve the greatest medico-legal importance are those in which female children are abusée! by me»n. In such cases, questions arise similar to those that are of such importance in instances of râpe under like circumstances. The âge of the alleged victim would be determinate. It would be essential to e'on- sider any évidences the female genitals might afford of the nature of abuse. The présence of coarse anatomical changes will dépend, of course, upon the force or brutality of the manipulations to Avhich the parts hâve been subjected, and as aatII upon the fre-epiency Avitli which the»y bave been repeated. Merely gentle titillation would leaA'e no sign behind, unless frequently repeated; and it would be necessary to em- phasize the impossibility of distinguishing a condition of irritation induceel at the hands of a second person from that due to self-abuse. At the same time, the child is apt to confine her manipulations te) the A'csfibule ; a second person of maturer years Avould be almost certain to attempt to enter the vagina. The state of the hymen and the hymeneal eqie'iiing, as Ave»ll as the capacity of the vagina, might give e.AÙdence of lacération eu- dilatation. Where gross anatomical changes of the geni- tals of a female e-hild are found, the question of râpe arises ; but it must be remembered that such changes are much more commonly the resuit of manipulations made preparatory to an attempt to introduce the pénis than the resuit of the primary introduction of that organ. Too, injuries may be found which coule! not possibly hâve been induced by the maie organ. Other forms of sexual abuse of children can seldom afford physieal évidence of their practice in effects left in the genitals. Medico-legal questions in relation to sue'h crimes AA'ill oftenest arise in respect to the mental condition of the perpetrators. SODOMY. In English common laAV, sodomy is a very broad term, covering ped- erasty, buggery, and bestiality. The common law defines sodomy as carnal knenvleelge committed against the common order of nature by man with man, or AA'ith woman ; or by man or woman Avith a beast. In early times in England the offense AA'as regarded as highly pénal. Grael- ually it came to be looked upon as less heinous, until by statute it was * Loc. cit. 546 A SYSTEM OF LEGAL MEDICINE. again déclarée! tobe a felony in the reign of Henry VIII. This statute Avas repealed and again revived in the time of Elizabeth. Thus, by the common law of the States sodomy is an offense ; but Avhether it is a crime or a misdemeanor is uncertain. In England it Avas formerly the custom to burn or bury the offemler alive. In the reign of Richarel I. it Avas customary to hang a man aud droAvn a woman proved guilty of the crime. The punishment now in England is pénal servitude for ten years or more. With sodoniy, as with râpe, it is nee-essary to haA'e proof e>f pénétra- tion in order to establish the fact of carnal intere-ourse. The» évidence of a proseeuiting Avitness, if an accomplice, is not alone sufficient. The English common law takes no cognizance of the common form in which eoitus is imitated by maies betAveen the thiglis—coitus inter femora ; and it makes no référence to an unnatural sexual act that women indulge in— namely, Lesbian loA'e, or tribadism. Pederasty in laAV is the act of immissio pénis in anum. Both parties to the act, where both are A-oluntary participants, and both hâve reached the âge or condition of légal responsibility, are punishable. As indie-ateel by the légal understanding of the te»rm, pederasty may be aeeompbshed by maie with maie or female. Peelerasty is both active and passive. The active part is always taken by a maie; the passhe rôle may be en acted by a maie or female. The active party may perforai the act upon the person of the passive party by force and Avithout the consent of the latter ; and under such circumstances pederasty becomes similar to râpe. 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 le-gally irresponsible active party to the crime. However, tbe majority of the instances of the crime are cases where there lias been mutuâl e-onsent of both parties, with mutual responsibility, and consent of the passhe party, AAdth légal irresponsibility. Forcible performance of tbe act by the active party without the consent and against the will of the passive party is rare. As in râpe, so in pederasty, owing to the paramount importance of physieal évidence, there has been a persistent effort made to discover pathognomonic physieal signs left after performance of the act. Many such signs hâve been described by various observera, but they are of no trnstAvorthy diagnostic value. They call for notice hère, if for no other reason than to hâve their worthlessness pointed out. It is clear that the person of the active pederast could offer no unequivocal évidence that he had performed pederasty. Tardieu thought, however, that habituai indulgence in the act led to a change in the form of the glans pénis, at least in some instances. In some pederasts he found the organ pointed. Such a peculiarity of form, however, could be justly attributed only to a developmental defect. The same may be said of constriction of * the body of the pénis 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 party to the act. Abrasions of the pénis might resuit from its forcible introduction into the anus, but such signs could, of course, hâve no diagnostic A'alue. Passive pederasty would seem capable of indueing more eieterminate anatomical changes in the person given to it ; but practically such pos- SEXUAL CRIMES. 517 sible altérations are of little positive A-alue save in a feAv instances. Where the immissio pénis in anum has been forced, especially in children, abrasions, lacérations of the mucous membrane, and even more extensive tears, Avith accompanying signs of inflammation, might resiilt; but in such cases, even more than in cases of râpe, tliere would be the presump- tion that such Avounds Avère caused by a more unyielding object than the pcnis. In adults the spliincter ani is more readily capable of dilatation than in children ; and for this reason, Avhere an adult permitted the act of peelerasty, tliere might be no évidence of it found in tbe subséquent condition of the tissues abemt the anus. There are certain conditions of the anus and surrounding parts that bave been consielered diagnostic of habituai passive pederasty since the time of the Romans. Considéra- tion of tliese signs will sIioav, heiAvever, that they are ne>t of unequivocal significance. Relaxation of the tissues about the anus, Avith conical deepening of the normal anal dépression ; dilatation of the anal orifice ; relaxation of the sphincter ani ; oblitération of the créa ses of the mu- cous membrane and skin which usually radiate from the anus ; anel hypertrophie growths of tlie mucous membrane, are some of the signs of passive pederasty enumerateel by observées. Their slight independent importance as signs of pederasty is at once apparent ; and the same is true of the various forms of proctitis that might be caused by the A'ice. Démonstration of the présence of spermatozoa in the person of the passive party might afford A^aluable e\'ielence. Should they be found in the rectum, the proof would be conclusive ; found elsewhere about the person, they would be of no A'alue as eAddence, save in cases where the maie individuals concerned were demonstrably below the âge of puberty. Yemereal diseases might be communicated by peelerasty. Where such disease is seated in the rectum anel about the anus exclusively, it is of some value as indicating tlie vie-e ; but it is to be remembered that such parts may become the seats of venereal eliseases communicated in other Avays than by means of pederasty. Bestiality cannot well afford anatomical évidences of its practice as far as the maie or female criminal is concerned ; but under favorable circumstances, the animais made use of by maies may présent signs about the genitals of the treatment to which they hâve been subjected, and human spermatozoa might be demonstrateel in the génital passages or in the dried accretions about the genitals of the animal. Tribadism, immissio clitoridis in vaginam, likewise leaves no distinctive évidence behind. Though such a vice, lemg practiced, would ultiniateby lead to more or less change about tbe female genitals, thèse altérations would not necessarily be différent from those that follow repeated man- ual irritation. In females given to the practice of tribadism an enlarged clitoris is usually found ; but enlargement of the clitoris in itself could indicate nothing with regard to such an unnatural vice. Its medico- legal importance is slight. The psychicàl aspect of pederasty and other unnatural sexual acts is considered under Sexual Perversion. INCEST. Incest is tlie carnal copulation of a man and a woman related to each other in any of the degrees within which marriage is prohibited by law. 548 A SYSTEM OF LEGAL MEDICINE. This offense is unknown to the common laAV, and is merely a statutory cri nie. By most of the States it is punished as felony. In some cases of ine-est, questions might arise for solution not unlike tliose met in cases of râpe of children, AA'here» the se»xual act might be performed under such cn-cumstanees as to constitute at once the crimes of iiice»st and râpe. The crime of incest, in its most aggravated forais, as betAveen parent and e-hild or brother and sister, is so répugnant to the nuirai sensé that it is difficult to conceive it as occurring save as an expression of a psychopathological state; and in many recordeel instances of ine-est it has been possible to establish the influence of such a factor in its causation. In relation to the pe>ssible rôle of an anomalous psychicàl state in the e-ausation of this répugnant crime, it is of interest to note the source of the uni versai aversion tliere is among mankind to the marriage of blood ivhitions. Von Krafft-Ebing* says that " the préservation of the moral purity of family life is one of the fruits eif development in e-ulture (cul- tur-entwichlunej)." Ile regards it as a product of evolutional develequiu-nt. In the sensé in AAdiich this is meant, it does not ae-count for the fact. Eth- nologists hâve aelA'ane-eel many ingénions théories to account for this feeling of aversion to sexual relatienis with near kindred, which is Avell- nigh uni versai among mankind, savage as well as civilized ; but ail thèse explanatiems résolve themselves into the statement that incest is avoided as a resiilt of teaching. When a phenomenon like this is practically of universal manifestation, its occurrence must ele-pe»nd upon something more fixée! and unalterable than accielental instruction, or a geiu-ral réc- ognition of the evil effects of consanguineous marriages; it must arise from some inhérent psychophysiological peculiarity common to the race. This inhérent aversion te) marriage Avith a relation, it may be said, is an instinct, but this does not explain the matter. The origin of the in- stinct must still be explained. Tliere is no inhérent répugnance to mar- riage witli a relation dépendent upon the mère fact of consaiiguinity ; the aversion exists to sexual union of maies and females that hâve liveel in the edosest and most intimate association from early ediildhood. This aversion has been naturally extended by analogy to include répugnance to marriage between persons of the same blootî. What we hâve to ac- count for, then, is ne>t aversion to marriage of relations per se, but the répugnance to mutiial sexual congress there is in those that hâve devel- oped in intimate association. The origin of this instinctive aversion to incest is to be found in a study of the psychology of sexual development. Normally, in human beings, sexaiality is acquired late ; the child passes through along period of development before the distinctive sexual characteristies make their appearance. During the primary period of asexual life the most inti- mate and definite mental associations are formed, and thèse are relatée! to those persons with Avhom the child is in constant social (family) con- tact, In the nature of normal circumstances, the child must first acquire a fixed asexual relationship to those in the intimate society of whom it develops. With the oncoming of puberty, emotional longings of a new and unknown eharaeter are experieneed by the individual which are * Psychopathia Scxualis, p. 431. SEXUAL CRIMES. 519 directed normally toAvard persons of the opposite sex ; this, Ave believe, largely, if not exclnsively, by reason of suggestion and example made operative before sexuality bas asserted itself. But tliose of the opposite sex in the same family (mother, sisters), standing as they do in tlie précèdent fixed mental relation to the developing yenith, and being sub- jectively in a mental attitude identical Avith his oavu, are the last persons toAvard Avhom thèse new émotions e-an be directed. Those of the oppo- site se-x that bave been reared Avith the înaturing individual bave so long occupied an asexual place in bis thought that they naturally fail to enter into assetciatiem with the hcav expérience. The ik-av longings—incom- préhensible and indefinite at first—beconie by A'ery necessity diree-ted toAvarel persons avIio, by virtue of their being comparative or absolute strangers, are the more re-adily brought into a causal relationship with the strange- emotienis. Or, to state the matter in a différent Avay, the sexual feelings, under normal circumstances, are directed toward com- parative strangers bee-ause intimate associâtes (in the family) through infancy and ehildhood bave filled up the measure of the individual's mental associations possible in relation to them. Under normal circum- stances, then, neAV anel strange» sexual feelings, when arising spontane- ously, are elirected, ae-cording to an évident psychophysiological law, te)Avard tliose persems that bave not impressed the developing child in the Avays necessarily attendant upon prolonged primary intimacy. Though oftentimes arising spontaneously, the primary sexual émotions are ordi- narily excited into activity through the influence of external impressions. Assoe-iation with the members of a family, however, is attended by the ultimate devehqnneiit of certain fixed forms of intellectual and emotional réaction in the child; so that persons aa'Iio, by association with an indi- Addual through the asexual period of dewelopment, bat! come to exert certain fixée! influences, Avoulel be tlie less e-apable of exciting new émo- tions ; impressions made by them Avould excite the accustomed paths of neuropsychie'al association ; and AA'hen that period of life in which sexual stimuli become effectuai had been re-ae-heel, they would necessarily be derhed from an individual Avho had stood in no intimate and fixed rela- tion to the child. The manner of the first sexual stimulation is largely determinate for the future direction of sexual désire. Once projected outside the family circle», it is never changed save in obetlience to anoma- lous circumstances. As sexuality develops, it cornes to exercise the most powerful influ- ences over the inelhiclual, finally leading to the seA'erance of the asseicia- tious of ehildhood through tlie establishment of sexual relations with the person avIio has exe-iteel sexual feeling of sufficient intensity te> over- e-ome primary ties of intimacy. As a resiilt of jieculiar or anomalous e-ircumstane'es, like those of comparative isolation of a family, ineestuous relations wouhl almost certainly arise; or too early anel too intense development of the sexual instinct might preclude the deA'edopment, or acepiisifieni, of the normal (or usual) psychophysiological aversion, and lead to incestuems instinct anel practice; again, the aversion primarily ae-epiired might be lost as a re-sult of mental disease, or temporarily suppressed b}^ the dominance of pathological hyperexcitation of sexual désire. It might be urgvel that to prove the validity of this explanation of tlie uiihersal prevalenee of human aversion to ineestuous relations, it 550 A SYSTEM OF LEGAL MEDICINE. would be necessary to sIioav the opération of sue-h a tendeney in the lower orders of animais. We should expeet to fine! sue-h a psychosexual law operative only in lower animais having a long period of asexual de- velopment and presenting a great variety of psye-lieisocial associations other than those of a true sexual eharaeter. Such a law could be opera- tive only in animais manifest ing the beghmings, at least, of the more complicateel ps3'chosocial relatiems. Thèse considérations plaee the normal aversion to incest upon a psychophysiological basis, and emphasize the need there is to investigate tlie mental condition of the criminal in ail aggravated cases of this crime. EXHIBITION—INDECENT EXPOSURE. Indécent exposure is such intentional exhibition, in a public xilace, of the naked human body, or such exposure of the private members, as is ealeulated to shoek the feelings of chastity or corrupt tlie morals of those who Avitness it. This offense"must be committed in a public plaee and in the sight of more than one person in order to be punishable under the common laAV. HoAvever, the statutory provisions of various States are broader. The chief medico-legal interest that attaches to this minor sex- ual e-rirne is in regard to the mental condition of the perpétra tors of it. There is nothing in the crime that precludes the possibility of its being committed by normal individuals, but under ail circumstances the act of génital exposure is in itself so obviously silly and purposeless that it cannot fail to give rise to the presumption of the influence of anomalous mental factors in its causation. The records of cases that bave come to trial bear out this view. Indeed it is seldom that the crime is not the residt of congénital mental deficiency or acquired insanity ; and this fae-t should be clearly understood and ghen weight in trials for such a crime. SEXUAL PERVERSION. The sexual crimes hâve been considered chiefly AA'ith respect to the évidence that might be invoked to establish the fact of the perpétration of them ; hère the purpose is to examine a psychicàl factor which frequently becomes the cause of A'arious criminal sexual acts—namely, sexued per- version. To Westphal,* Tarnowsky,! von Krafft-Ebing,! and Moll § we are in- debted for a systematic study of the psychosexual anomalies; but von Krafft-Ebing bas done by far the most toward elucidating them. Hère nothing more than a résumé oî the estabbshed facts and prévalent théories can be attempted. Ail manifestations of the sexual instinct that are not in accord, directly or indirectly, AA'ith the physiologieal proAdsions of nature for the propaga- tion of the race may justly be regarded as anomalous, as perversions ; but * Archivf. Psi/chiatrie, vol. i., p. 651. t Die kraukliaften Erscheinungcn des Geschleelitssiiuies, Berlin, 1886. t Psjfchopathia Scxualis, Philadelphia, 1892. § Coutràre Sexualempfindung. SEXUAL CRIMES. 551 it becomes of the greatest importance to détermine in how far such phe- nomena are due to disease, or to what extent they are the resiilt of A'ice. For a correct compréhension of the various déviations to which the sexual instinct is subject a thorough knowledge of the normal sexual manifestations is necessary. Psychosexual Development.—Owing to the fact that the majority of maies feel sexually attracted by females, and vice versa, it is concluded that the expression of this désire is the normal manifestation : more than this, it is assumed that this désire of each sex for the other is inhérent and con- ditioned by the anatomical peculiarities which détermine sex ; that when an indiAdelual is ghen distincthe sexual organs there are simultaiieously implanted the germs of corresponding psychosexual characteristies AAdiich subsequently, in spite of any external influence, Avili distinguish the in- dividual as a sexual being. FolloAving this method of reasoning, in cases which présent a déviation from this normal relation of anatomical and psychicàl endowment the peculiar phenomenon is explained by the as- sumption that the want e>f e-orrespondenee is due to the congénital im- plantation of an inappropriate sexual instinct; or the Avant of normal correspondence between instinct and sex is regareled as due to external influences that hâve disturbed the once normal relation—that is, the sexual perversion is an acquired characteristic. Thus there are theoretically two catégories of sexual peiwersiem—the congénital and the acquired. It is still an eqien epiestion Avhether Ave are justified in making a hard-and-fast bue of demarkation betAveen thèse psychosexual anomalies ; certain it is that with our présent means of differential diagnosis we are often left in doubt as to Avhether a given e-ase is to be placed in one or the other of thèse catégories. The many sources of error inhérent in the diagnosis of such anomalies are due in tbe main te> the subjective nature of the data upon AA'hich the physician must dépend for information and ultimate judgment. Anatomical differentiation of the sexes preceded the development of the eomplementary sexual instincts characteristic of the t\vo sexes. Sexual désire, whether ultimately arising from the primitive sensé of hunger or not, sprang directly from pleasurable sensation experieneed under cir- cumstances of peculiar contact of two organisms. Such contact could be essentially peculiar only after the development of organs possessed of pe»culiar sensibiïity. With the attainment of this stage of eArolutional de- velopment the contact (conjugation) of organisms of eomplementary sex is the only contact that could be influential in the further development and differentiation of the sexes ; for the conjugation of organisms of like sex could but haA'e been devoid of results beyond the immédiate influence exerted by it upon the organisms concerned. With the limitation of fruitfulness to the conjugation of organisms mutually eomplementary arose the conditions for a more distinct differentiation of sexual organs, and the acquisition of the psychicàl suppléments of sexual differentiation ; that is, the intuitive récognition of sex, which comprises self-récognition sexually and its complément, and the intuitive impulse to a definite form of action and sensory stimulation. The anatomical and functional différ- ences AA'hich accompanied sexual differentiation were determinate in sup- plving the conditions necessary for the origin and development of dis- tincthe psychosexual characteristies, which in their turn served to rentier sexual différentes in gênerai more marked. Thus the conditions that must bave» attended the graduai évolution of the sexes anatomically, and 552 A SYSTEM OF LEGAL MEDICINE. the graduai acquisition of a sexual instinct appropriate to each sex, were such that though the instinct must hâve reached full development seconel- arilv to the evolveinent of eomplementary generative: organs. the fully de- veloped désire for the opposite sex Avas but remotely connected with the sexual organs per se. In its primitive nature the sexual instinct or désire must hâve been an impulse to a stimulus arising from the mechanical irritation of contact of the sexual organs with AA'hich the organism was endowed. The fact that only the.se organisms that had found contact Avith their sexual compléments would lie instrumental in propagation must necessarily hâve ultiniately evolved the see-ondary psychosexual character- isties of sexual instinct ; that is, sexual désire for the opposite sex. The fully developed sexual désire for the oppe>site sex is thus exclusively a secondary évolution from the primithe sexual impulse to mère contact. Necessarily eomparatively a longer period of evolutional dt-A^elopment would be required for its perfection than for the development of that part of the instinct directly connected with the sexual organs. Owing to the nature of this désire "for union with the opposite sex—its iudepenelent e-liarae-ter—AA'hen evolved to its highest development it is purely psyc-bical, and therefore quite independeut of the sexual organs per se. ^ Once de- veloped to this degree of comparative independence the sexual instinct lie- ce unes capable of hereditary transmission quite independently of the an- atomical nature of the sexual organs of the inheriting organism. In higher organisms, Avhere psychicàl eharaeter is transmitted inelependently of physieal pecubarities, we thus find that there may be lack of harmony betAveen the fundamental and the secondary or psychicàl éléments of the sexual instinct. Commonly the funelamental éléments of sexual désire, including especially the impulse to stimulation of the sexual organs, are infinitely more poAverful than the secondary psychicàl éléments, because they are dépendent upon lower nervous centers, and they are manifested much eariier in the lif e of the organism. An inherited psychicàl instinct for union Avith the opposite sex cannot attain expression until deAelop- ment has taken place to a degree that permits récognition of sexual différ- ence ; it is therefore of secondary anel subséquent development Avith re- spect to the fundamental éléments of sexual désire. Anomabes of the fundamental élément of sexual désire (impulse to génital stimulation) occur only Avliere tliere are also marked anomalies of physieal (peripheral) and nervous organization ; but the see-ondary cléments (psychicàl), owing to their dépendent-!» upon the higher nervous en-ganization (cérébral cortex), are, in a sensé, less definite in e-haracter. Purely psychicàl characteristies in higher animais, and especially in man, are commonly less truly and perfectly reproduced in offspring by inherit- ance than are the more definite organic characteristies; andby reason of this imperfection or variation of psychicàl inheritance, éducation becomes of prime importance in determining the psychicàl characteristies which distinguish the mature indiAddual. In the nature of things, since the higher psychicàl characteristies are of graduai development in the lifetime of the individual organism, they are the more subject to favorable or un- favorable influence from without, and thus such inherited potentialities might be emphasized, altered, or obscured. Such considérations as thèse should lead us to expect tbe fundamental élément of sexual désire to be a fairly constant quantitA' in inheritance in the physically normal man ; on the other hand, we should expect more SENUAL CRIMES. 553 variation in the secondary or psychicàl élément. Relativelyindependent of the sexual organs as Ave hâve seen tins secondary élément to be, Ave can concehe that it might be well developed in an individual AAdiose genitals Avère so markedly détective as to be incapable of normal functions. The rule is, of e-ourse, the transmission of distinetive sexual organs, AA'ith the virtual transmission of an appropriate sexual instinct ; but remembering the independene-e of the psychicàl élément of sexual appetite, and ahA'ays the possibibties of inheritance from the maie aud female, theoretically Ave should expect, also, the occasional transmission of definite sexual organs together Avith an inappropriate or oppe)site sexual instinct. In such a case the inappropriate sexual instinct might be as strong as in e-ase»s Avliere it and génital conformation Avère entirely in harmony. Betwt't'ii thèse two possible extrêmes there may be ail degre»es of varia- tion in the perfection of the transniitteel psyehie-al instinct. In the extrême e-ase e)f either kind the inherited insthie-t Avemld attain its predestined ex- jn-essiem iu spite of ail opposing influence exerted freun Avithout; but in the cases betAveen the extrêmes the final expression of the se»xual impulse Avoulel be determined me>re or less by external circumstane-e-s—in other Avords, influenced by éducation. Thus, if the inherited instinct feir the opposite sex Avère weak, it might be strengthened by appropriate éduca- tion; on the other hand, it might be perverted by circumstances exerting an opposite influence. And the same Avould be true of cases in which the sexual organs and sexual inedinations were ont of harmony. The incon- gru* >us or inverted sexual impulse might be so strong as to reach its pré- destinée! e'xpression in spite of ail opposing influences; or, less strongly implanted, it might be altered in direction by force of educating influ- ences. Such considérations but lead us to a récognition of the fact that the primary or fundamental sexual instinct is not determinate in its direction toward sex; that the secondary or higher psye-liical élément is the deter-. mining factor ; and that since tlie latter is psychicàl, it is subject to wider variations Avithin ordinarily normal limits than the former. The trans- mission of the higher psychicàl éléments of sexual instinct must be subject to Avieh'i* variations, aise), for the reason that the inheritance of a definite sexual inclination must take place from one of two parents rather than from two ; for the necessary ce ni jnnction of possible inheritance of opposite sexual inclinations from both parents Avould necessarily Aveaken the prob- abilité of direct inheritance from one parent of a definite sexual incbna- tion for one or tbe other sex. We know that anatomically each sex has in embrye) the morpliological possibility of representing the opposite sex ; and likewise each individual must haA'e Avithin bis organization the possi- bility of the ultimate devehipment of the two secondary (psychicàl) in- stine-ts. Anatomically, ordinarily one set of generathe organs attains complète deA'elopment, AA'ith dAvarfing of the eomplementary set, and thus renders the sex definite. This process takes place as a resuit of hidden organic causes, though tliese causes are probably intimately connected Avith the process of nutrition. With the psychicàl side of sexuality the case is soine-AA'hat différent. As has been shown, there are maivy possible sources of variation in the deA'elopment of the sexual instinct; and more than that, actual observation bas disclose'd the fact that in the human rae-e the» development of the psyediical part of sexuality is profounelly in- fluenced by a definite éducation, which is usually in harmony with the / 551 A SYSTEM OF LEGAL MEDICINE. anatomical sex. With the récognition of a e-liild's sex this sexual éduca- tion begins, and under normal circumstances it is ahvays in harmony Avith the sex represented by the child. Moreover, that the educational factor is of vast nnportance in determining an abnormal direction of sexual inclination is abundantly shown by many reported cases. AlloAving the importance of éducation in determining the charac- ter of the developed sexual instinct, we may consider tlie manner in which its influence is exerted. A long period of the life of the human being i s nor- mally asexual. During this asexual period the developing child learns the outward distiiiguishing marks of the two sexes ; this the more perf e-ctly the less sexual concealment there is. Thus, in a saA-age state the human being, learniug at once the sexual (anatomical) distinction of the persons around him, and recognizing his oavii classification, would almost inevitably con- form to tlie manner of his sex. The only exceptiem to this is Avhere cultha- tion at the hands of others brings about a deA'iation. And the comparative- ease with whieh such a deviatiou can be brought about by directed effort in early years but emphasizes the fact that tliere tlie inheritance is usually only of the primitive sexual instinct (for contact). In a higher state of chiliza- tion the distinctions between the sexes are less obvions physically,'and more obvious in dress and occupation. Under such circumstances the- child learns only comparatively late to classify himself sexually ; and, in conséquence, the possibility e>f sexual perversion is increased. A maie child thus might early sIioav a préférence for féminine dress and féminine play. This tendeney would bave in itself no sexual meaning ; but the proclivity might take so strong a hold of the mind as to be determinate and serve in itself to pervert (or prevent the normal expression of) the sexual inclination. There Avould be sexual désire, 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 AA'hich direct the development of the child's minel, and its tastes are determined thus before puberty has awakened sexual feelings. Since éducation, example, and imitation develop in us ail the secondary and higher characteristies of sexuality appropriate to each sex, it would seem that the term congénital as applied to sexual perversions should be used sparingly. However, the accepted classification of psychosexual anomalies, in its séparation of so-called congénital and acquired cases, justly recognizes an important distinction, namely, the séparation of cases datiiig back to ehildhood from those of later origin. The importance of this differentia- tion dépends upon the fact that a tendeney arising and developing in ehild- hood is aptto become so strong and unaïterable that it persists as a domi- nant characteristic throughout life, in spite of ail artificial efforts to correct or aller it after maturity. This is especially true of the sexual tendeney. Should a child develop any kind of sexual perversion, aside from the inhér- ent tendeney for it to persist, circumstances would favor its continuance. Thus the modesty of cultivated society prevents the récognition of such an anomaly early ; the affected child goes on in the perverse tiirectioii un- enlightened ; at last, with expérience 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 experieneed in perverse sexual indulgence, and they make no impression on the individual. On the other hand, a sexual perversion acquhed late is far more subject to change. SEXUAL CRLMES. 990 In such a ease normal sexual inclinations hâve been primarily exercised, and they continue the stronger ; perversion has taken place under pecul- iar <*ircumstances, and with a restoration of normal circumstances the normal inclination reasserts itself. Another important fact in psycho- sexual pathology is the relation of sexual perversion to neuropsychiced de- g<' ueracy. Observation sIioavs that for the most part psychosexual anom- alies are developed upon a degenerate constitution Avhie-li may commonly be traced to a neuropathic disposition inherited from ancestors. This relation must be given due considération in estimating the significance of any psychosexual abnormality. Para'sthesi.a sexualis is a gênerai désignation covering ail cases of gen- uine sexual perversion. It signifies a de»parture from tlie normal direction of sexual feeling, and as a gênerai term it includes several distinct varie- ties of sexual perversiem, namely, stalism, passivism, fetichism, and contrary sexual instinct in ail its varieties. Paraesthesia sexualis is frequently asso- e-iateel Avith other anomalies of sexual feeling, especially hypereesthesia sexualis ; and for the sake of ceimple-teness, before considération of para?s- thesia sexualis in détail, Ave may briefly review thèse relatée! sexual anom- alies, which, in accordane'e Avith the classification of von Krafft-Ebing,, may be divided into sexual paradoxia, sexued amesthesia, and sexual hyper- asthesiet. Sexual Paradoxia.—Like ail thèse anomalies, paradoxia sexualis is referable to a cérébral neurosis. The term ce>vers those manifestations of sexual désire Avhich occur during periods of life when sexual inclina- tion is normally absent; ie., when reproductive poAver has not been at- taineel, or has be-en extinguished as a resiilt of advanced years. Tlie paradoxieal expression of sexual appetite in ehildhood is chiefly of médical interest, espee-ially in its relation to neuropsycliopathic disposi- tion and the psycheisexual anomalies of maturity ; its immédiate medico- legal importance is small, eiAving to its association Avith moral and légal irresponsibility. Paradoxia sexualis manifesteel during senility, after the sexual glands and organs bave become functionless, isapsychopathologi- e-al pheimmenon of great medico-legal interest. It is the most fréquent motive feir the commission of sexual crimes by old men, and in ail cases of this eharaeter the perpetrator should be given the justice of a psychi- atrical examination. Sexual désire in old men is not in itself a pathological phenomenon. There are many instances of the rétention of procreative poAver by men up to a very advanced âge ; but where sexual power and désire haA-e once been extinguished in the course of advancing years, and sexual désire is reawakened anel manifested in Avays unknown to the indiAddual during his period of virility, tliere is at once a presumption that this change is the resuit of pathological causes. Accompanying senile sexual désire there is, if the intellect be not too seriemsly impaired, récognition of the absene'e of jxiAA'er to perforai normal sexual acts, and such vietims of senile eleerepitude- arc therefore elrhen to the performance of varieras acts as équivalents. In the impossibibty of obtaining the consent of mature iudhieluals te> the performance of perverse acts with them, they are forced to avail themsehres of others AA'hom, through ignorance or innocene-e, they are able te> influence or fore-e» into submission. In this way children fre- quently become their vietims. Still sue-h indiA'iduals are not incapable of a formai sexual assault upon more mature females. 556 A SYSTEM OF LEGAL MEDICINE. Thèse anomalous psyclmsexual phenomena are e-ennmonly manifested after other obvions mental symptoms of senile organic changes in the» brain bave become apparent, and under such circumstances tbe diagneisis is sufficiently easy; but in many cases the paraeloxical sexual désire is apparent before tliere are any marked signs of intellectual decay. Ea'cîi hère it will not be difficult to establish the pathological eharaeter of the sexual impulse upon careful examination. It will usually be found that the man's moral charae'ter bas been undergoing a more or less marked détérioration, as indicated by changes of occupation, manner, and thought, and by unAvemted irritability and lack of sympathy—a marked intensifica- tion of selfishness. Before dementia has become pronounceel there may be sufficient mine! to allow récognition of the necessity for priva*y in sexual acts, but Avith increasing mental decay ail restraining ideas are lost, and im- moral acts are performed inqmlsively and Avithout the slightest considéra- tion of conséquences. In such a condition, Avith the total lack of power to perforai coitus, psychosexual excitement is sure to lead to perverse acts as substitutes. The sexual crimes possible under such circumstances are very numerous. Râpe may be attempteid anel carried out; exhibition is very frequently indulged in ; and tbe various forms of sexual abuse of children, aside from râpe, are very fréquent. Indécent acts of various kinds not sexual in themselves may be performed as équivalents, and eve»n acts of cruelty may thus residt. Tliere may be formai perversion or inversion of the sexual désire, leading to sodomy, ov to pederasty, active or passhe. This paradoxical manifestation of sexual impulse may also arise in aged women, but in them it is less freepient and of less medico-legal importance. The following ease illustrâtes a senile attempt at râpe : X, aged sixty, Avife living, and father of grown children, preA'iously moral, Avas ceuiA'icted of an attempt at râpe on the person of a girl aged eighteen, and sentenced to imprisonment. Examiiiatiem showed him to be décrépit both physically and mentally. He looked te»n years older than his âge. In confinement he was given to religions enthusiasm and a demented remorse for bis crime. The edrcumstances under AA'hich the attempt Avas made clearly showed the demented lack of appréciation of the certainty of conviction for the assault. A psychiatrical examination was not alloAved before e-ouA'iction. The folloAA'ing case is one of senile exhibition : * X, aged sixty, widower, and father of a family. He repeatedly ex- liibited his genitals at his windenv to a little girl living opposite. Ile ac- knowledged the depraAdty of his actions, but could offer no excuse. He died in a year of cérébral disease. Often the sexual offense of senile dementia consists of génital manipu- lations. Children are thus abused, or induced to fondle the genitals of the sedueer in varions disgusting Avays. Senile sexual excitement may find satisfaction in the infliction of pain (vide Sadism), and thus seek ex- pression in flagellation and even lust-murcler (q.Ar.). A case reported by Tarnowsky illustrâtes the possibility of tlie» most disgusting équivalents for the sexual act. An aged man seized an eipportunity to defecate on the expe)se-d bosom of a AA'ennan. During the act lie experieneed a feeling of ejaculation. The possibility of senile sexual inversion is illustrated by the following case reported 1 y von Krafft-Ebing ; t ■* Lasèuge, Union Médicale, May, 1877. t Psycopathia Scrnulis, p. 41. SEXUAL CRIMES. 557 X, maie, aged eighty. For fourteen months it had been noticed that he manifestée! affection for maie servants, especially for a boy. He would surfeit his favorite with favors, and cominand that lie be sIioavh the greatest respect. The acts practiced with the boy and other maie servants Avère exhibition, génital manipulations, and mutual masturba- tion. X was devoid of ail inclination toward the opposite sex. Sexual Anaesthesia.—Absence of sexual inclination occurs as au orig- inal and an acquired anomale. The original form is exceedingly rare. It is represented by the entire failure to eleveleip sexual désire in tlie présence of sexual en-gans normal in structure and function. In itself it is a sign of imperfect development of cérébral funetiem. It may be présent Avithout other indications of psychicàl defect, or it maybe accompanied by various degrees of mental im perfection up to idieie-y. Some deficiency is more common than total ab- sence, and it is much more freepiently observed in women than iu men. Its direct medico-legal importance is small, but it is a fréquent cause of marital uiihappiness. Ne>t infrequently Avive's manifesting sexual anaes- thesia are also subject to dee'ided psychopathic tendencies. Acquired sexual amesthesia is, as an isolate-el condition, of slight medico- legal interest ; but as a f ae-tor in cases of sexual perversion its relation to the latter should be unde'rstood. XormaUy, libido sexualis is diminished temporarily after the sexual act, and it déchues gradually as âge ad- vances. Libido is more or le»ss closely related to the functional acthity of the generative glands (maie and female) ; in exe'i»}itional cases, hoAvever, désire outlasts the functiemal life of thèse organs ; for example, some women retain lhely sexual désire after the climacteric, and some eunuchs bave been known to manifest sexual appetite. The common peripheral causes of acquired amesthesia sexualis are castration, degeneration of the o A'aries aud testes, gênerai Avasting, chronic intoxications, and sexual exe-e-sses iu the normal manner or in masturbation. Sexual excess in onanism is perhaps the most fréquent cause ; and in cases where mastur- bation bas induced anasthi-sia for normal sexual stimub it is not infre- epient to hâve the sexual impulse fine! some perverted manner of expres- sion and lead to acts AA'hich become of medicodegal importance. Indeed it may be said that masturbation is one of the most potent causes of sexual perversion, anel that through its effect to induce psychicàl anaes- thesia for ail normal sexual stimuli. Sexual anaesthesia acquired early is often associated Avith mental discase, where any acts to which it might lead, in case they Avère of a criminal nature, Avould call for investigation on the basis of tlie accompanying mental anomaly. Sexual Hyperaesthesia.—This tenu signifies a pathological intensifi- cation of sexual désire. In the mileler degrees of intensification of tlie sexual inclination it is always difficult and often impossible ti> satisfac- torily détermine Avhether the phenomenon is pathological or not ; in its more marked degrees, however, Ave haA'e no trouble in recognizing its pathological eharaeter. In estimating the intensity of sexual inclination it must be remembered that it A'aries much in intliAdduals as Avell as in the- sexes. It may lie said that sexual appetite is usually proportionate to the gênerai physieal deA'elopment, but there are many exceptions to tins. Normally, women manifest much less intensity of sexual inclina- tion than do men; anel therefore when a woman shows a prédominant sexual inclination the suspicion that it is pathological is at once excited. 558 A SYSTEM OF LEGAL MEDICINE. Observation sIioavs that in both sexes hypera»sth<»sia sexualis is fre- quently manifestée! by perSons having a neuropatbie cemstitution ; this symptomatic manifestation may be, indeed, the most edndous sign of such a constitutional eleficiency. Von Krafft-Ebing points ont very justly that in such indiA'iduals satisfae-tion of the sexual impulse may become an organic necessity and thus endanger responsibility. In females sexual désire is temporarily intensified immediately after menstruation, and in neuropatbie Avomen this normal intensification frequently reaches a pathological degree. Pathological intensification of libido sexualis may be brought about by peripheral or central causes, the former being more frequently operative. Certain drugs, as cantharides, are capable» of ex- citing it. The period of the climacteric iii females is one in AA'hich hyper- aesthe'sia sexualis may be markedly exhibited, especially in those of neu- ropatbie constitution. Sexual hyperaesthesia of central (cérébral) origin is meist frequently observe'd in neurotic individuals, and is frequently associated Avith lysteria and states of gênerai mental exaltation. Where there is hyperasthesia sexualis tliere is an impulse» to indulge in some sexual act, and if the impulse be powerful enough, en- if there is a simultaneous removal of inhibitory influences, it finds expression. The sexual acts possible under such circumstances are coitus—which may take the form of râpe—masturbation, peelerasty, anel bestiality. The spécial form of sexual indulgence practiced will, of e-ourse, dépend upon sur- rounding circumstances, previous habits, and the indivielual's moral sensé and possible moral self-control. As a rule, hyperaesthesia se-xualis is a condition accompanying the various forms of sexual perversion, and its manifestation will be best illustrated in such cases ; henveA-er, Ave may hère cite briefly simple cases of it which will make its independent medicei-legal bearing clear. The following case is given by von Krafft-Ebing : * C. Avas arrested for an attempt to râpe a Avoman aged seventy, whom he found alone. Examination of the culprit slunveel him to be in a state of high nervous excitement, and he gave the impression of one in the incipient stage of alcoholic insanity. There were still signs of sexual excitement. He made a statement to the effect that his criminal act Avas the resuit of an uncontrollable impulse to sexual indulgence; and in substantiation of his assertion he gave the following history; lie Avas forty-five years old ; at the âge of seven he had develope^d a peculiar par- tiality for men, and lie fell in love with certain men. He began to mas- turbate at the âge of fourteen; first intercourse at seventeen. Then his earher tendeney to sexual inversion disappeared. At that time he passed through a peculiar psychopathic state. He developed hemor- rhoids at fifteen. He Avas at this time in a state of constant sexual ex- citement, which wras temporarily relieved by the occasional occurrence of profuse hemorrhoidal hemorrhage. His sexual excitement he satis- fied in onanism and coitus. Every woman lie met excited him ; even with his female relatives he was unable to control his impulse, and thus often breuight disgrâce on himself. He married at thirty-six, and be- came a burden to his wife because of his sexual needs. Three years later he had an attack of mania, and he Avas treated in asylums until his forty-second year. His mental symptoms were those of récurrent mania * Loc. cit., p. 51, SEXUAL CRIMES. 559 Avith great sexual excitement. After his recovery he still suffered Avith inordinate sexual désire, and at the heiglit of sexual excitement lie Avas indiffèrent as to AAdiether it was satisfied with human being or beast. His last sexual attack had followed sexual abstinence, and lie Avas at the time on bis way to join his wife in Vienna. In his excitement and con- fusion he had left the train, and meeting a woman had exposed himself and sought to embrace lier. Sexual hyperaesthesia may also be manifested intermittently or period- ically, and then it is either a neurosis per se or the symptom of gênerai mental excitement. (Von Krafft-Ebing.) The folioAA'ing case, which von Krafft-Ebing* takes from Trélat's Folie Lucide, is of great interest as illustrating pure sexual hyperœsthesia : Mrs. V. had ahvays hael a passion fe>r men. She Avas Avell-bretl, pleas- ant, and modest, but a terror to lier family from ehildhood on account of lier sexual inchiiatioiis. She could not be left alone Avith a man, because of her passion to haA'e sexual relations AA'ith every one she met. Nothing cured lier of this. Marriage Avas of no avail. When a grand- motlier she attempted to seduce a boy. Confinement iu a couvent did no good saAre during the time of her détention. Banished by her family, she earned money to purchase hivers. She Avas finally placed in an asy- lum, Avhere she elied in lier seventy-third year. During lier treatment there she showed no sign of mental abnormality, but her uncontrollable sexual impulse Avas manifested shortly before she died. Sexual Parsesthesia.—This term covers those cases in which the sexual feeling and inclination are more or less ont of harmony Avith the natural purpose of the sexual instinct. As already note»d, sexual hypeiwsthesia is a fréquent accompaniment of sexual panesthesia, and it then becomes the active factor in inducing the affected individual to indulge in per- verse sexual acts. The sexual acts prompted by the association of thèse two pathological conditions are the most important of ail sexual crimes, from a medico-legal standpoint■; and it becomes of the greatest im- portance to détermine in how far such crimes are the results of disease or vice. The récent estabbshment of parœsthesia sexualis on a pathological foundation makes it imperative to take this aspect of the matter into considération. It may be said at the outset of such inquiries that the question of the pathological basis of a perverse sexual act can in no case be determined by the act per se; no more than can a case of insanity be diagnosticated scientifically by means of some isolated mental symptom. The sexual acts springing frenn disease and tliose prompted by \dce may be in many cases iclentical. The distinction betAveen pathological anel vicions sexual acts is to be made only upon a thorough understanding of the nature of the motive of which the speedfie sexual act is the <»xpres- sion; and this can only be accomplished by a thorough investigation of the Iii story and tlie physieal anel mental peculiarities of the individual —an inquiry which must often be extended to eelucational influences that may bave been effective, and to ancestry, just as in ail cases of neurei- psvchie-al maladies. The normal direction of sexual feeling is toAvard the opposite ; but sexual désire may be so altered in direction that the sexual inclination is * Loc. cit., p. 55. 5C0 A SYSTEM OF LEGAL MEDICINE. actually iuverted and becomes directed tinvarel the same sex. Such an altération of sexual feeling is a variety of sexual panestliesia, a sexual perversion ; but oAA'ing te> its distinctness, and to separate it from other varieties of perversion, it is best to desiguate it as sexual inversion eir contrary sexual instinct. Moreover it is found that contrary sexual in- stinct is subject te) various perversions, like the normal sexual instinct. Where sexual feeling is normal in direction it is called heterosexual ; Avhere it is directed tenvard the saine se»x it is called honmsexual. For convenience avc may consider the sexual perversions that occur apart from sexual inversion, remembering that thèse anoinabes may occur in eoujunction Avith the latter. Sudism is the terni applied to sexual lust that finds expressieui in the inflietion of cruelty on others. This Avord is derived from the name of a writer of obse-ene fiction, the Marquis de Sade, AA'lmse thème was lust and cruelty. A synonym for sadism, proposed by von Schrenck-Xotz- ing* is active algolagny, AA'hich is dérivée! from Greek Avords signifying love of pain. The perverse sexual gratification in the inflietion of cruelty may affect maie or female, but it is far more commonly observed in maies. This pathological association of sexual lust and pleasure in tlie inflietion of pain, Avith its prédominance in maies, is to be understood only by means of psychophysiologie;al asse>e-iations. Psychosexual émotion anel the émotion (anger) which normally impels to injury of another are alike in their objective direction and in their de-pendence upon intense exe-ite- ment of the psychomotor sphère. OAving to this common characteristic and this common depentlence, there is a A'ery close association betAveen the ae-ts of love at its greatest intensity and the acts of anger. Within physiologieal limits intense excitement during the sexual act is thus apt to lead to the performance of acts Avliie-h are ordinarily expressive of anger ; and, on the other hand, the objective acthity of angry émotion is apt t<> excite lustful feeling. The maie sexual rle is the aggressive one, and maie sexual excitement is more intense than that of the fe- male ; henee the greater frequency of sadism in the maie. This psycho- physiological association reaches patlie)h)gical intensity and then finds expression in acts of cruelty of varions degrees up to the commission of murder. It is not ahvays necessary that actual pain be inflicted; often an act symbobe of cruelty is sufficient to satisfy the individual. Saelistic acts also vary in their relation to the sexual act. They may be indulged in at the height of sexual excitement during the sexual act; after the sexual act, when tins has not diminished the primary psychosexual excitement ; before the sexual act as a stimulus to viriïity, AA'hen A'irile power is diminished ; and to induce ejaculation, AA'hen this is impossible in coitus. Sexual hyperœsthesia is ahvays the basis upon which sadistic ae-ts rest, Practically it is found that most persons manifesting sadism are originally more or less psychopathic. Yon Krafft-Ebing is inclined to be- lieve that this perversion is always congénital; but such an assumption does not seem necessary. In psychopathic individuals, Avliere there is frequently a hypersensitive nervous organization, psychicàl associations are most readily formed, and substitution, primarily at least, most read- ily occurs ; henee in such persons there Avould be spécial proclivity to the * Suggestions hy. Thérapie, 1892. SEXUAL CRIMES. 561 development of an intense and lasting association of lust with acts of cruelty, to Avhicli they are predisposed by the readiness with AA'hich they react Avith intense psychomotor excitement to stimub normally inadé- quate. HeiAvever avc seek to explain this association of lust and cruelty theoretically, the actual associatiem is most clearly sIioavu by recorded cases, and the monstrous crimes it leads to make tins particular form of sexual perversion of the greatest medico-legal interest. Lust=murder.—Only murder committed in association with sexual exe-ite»ment or for sexual gratification is preiperly lust-murder. The lust may aise) lead to horrible mutilation of tlie body after the death of the victim. Lombroso* reports the ease of a man nanieel Grassi, aa'Iio Avas suddenly seized Avith a sexual désire for a relative. When she resisted he stabbed lier several times with a knife, and also lier father and uncle, who sought to restrain him. He then repaired to a prostitute to cool bis sexual désire ; returning, lie killed his father and slaughtered several oxen in their stalls. The case of Andréas Bichel, reported by Feuerbach, is also instructive. He killed and dissected prostitutes. Concerning one of bis A'ictims be said : " I openeel lier breast and eut through the fleshy parts of lier bod}^ Avith a knife. I then arranged lier body as a butcher does a beef. . . . While opening the body I was so greedy that I trem- bled anel could haAre eut out a pièce and eaten it." Another case is that of a man who was examined by Lasègut», Brouardel, and Motet, and exe- e-uted : Menesclou, aged tAventy, murdered a girl aged four. One of lier forearms was found in his pocket. The beat! and entrails, in a half- burneel state, were taken from the stoA^e, and other parts of the body were found in the water-closet, but the genitals could not be found. M. became embarrassed Avhen questioned about the latter. His sexual his- tory was to the effeet that he did not indulge in intercourse with women, but practice»d masturbation and sodomy. His mother and an uncle Avère insane. M.'s OAvn history was othei-Avise that of a psychopath. How unbridled lust may lead to antlireq)ophagy is shown by the following case, reported by Gorget: L., aged twenty-four, caught a girl of tAvelve in the woods anel violated lier. He mutilated her genitals, tore out her heart and ate of it, drank her blood, and buried the remains. He confessed his crime and avus executed. In some cases sexual violation is omitted, the mutilation of the A-ic- tim being a full sexual équivalent. The case of Yerzeni, reported by Lombre)so, wras such an one. He made several unsuccessful attempts to strangle Avomen, and in the same way murdered three young women. The ceniiession of this degenerate créature is especially iuteresting for the lhlit it throAvs upon this association of lust and cruelty. The com- mission of the murders by strangulation gave him an intense lustful pleasure, ae-companied by érection and ejaculation. He experieneed sexual pleasure immediately upon grasping the neck of his victim. Ordinarih', merely choking bis victim was sufficient to induce sexual pleasure ;' but if the orgasm were de»layed lie continued the strangulation until eleath ensued. In one instance he had found great satisfaction in sucking his victinis blood, and he tore out a pièce of the calf to roast and cat at home, but hid it. He delighted in smelhng and touching the clothes and intestines. While in the act he was in a perfect furor of * The Criminal. Ô62 A SYSTEM OF LEGAL MEDICINE. excitement and oblhious to everything else. The female genitals Avère a matter of indifférence to him, and lie never had inclination for normal sexual indulgence. His perverse inclination Avas first shown in bis tAvelfth year, Avhen lie experieneed a peculiar feeling e>f pleasure AA'hile wringing the necks of ehickens. He did this frequently AA'ith no other purpose than the induction of sexual excitement, and the early accidentai asso- ciation remained determinate and became an uncontrollable impulse. He was sentene-ed for life. Mutilation of the dead body out of lust is allied to actual lust-murde-r in that the mère act of mutilation of a corpse affords the sexual gratifi- cation that in lust-murder is attendant upon the actual inflietion of* pain. It is an act of symbolic sadism, performed by a sadistic individual whose moral sensé is still strong enough to re strain him from doing violence to the bving female. This form of sadism may be combined with an inclination to actual sexual gratification with the body. The case of Sergeant Bertrand is a celebrated instance. He was of délicate consti- tution and peculiar eharaeter. At the âge of thirteen his sexual désire became manifest and he began to practice masturbation, in the act sur- rounding himself AA'ith imaginary Avomen. He would fancy haA'ing in- tercourse Avith them and then kiïling them ; then lie Avould think of violating the eorpses. At last he experieneed the désire to make his fancies actual. First he made use of the bodies of animais, opening the abdomen and tearing out the entrails while masturbating ; next lie killed and mutilated dogs; and finally he came to exhume female eorpses to mutilate them and masturbate. On three occasions he first performed the sexual act on the bodies of females, but he never omitted'subseepie-nt mutilation, AA'hich AA'as the only act that gave complète» gratification. Allied to this symbolic sadism is true necrophilia, in which a female corpse is preferred to a living Avoman for the performance of coitus. In such cases there is not pure sadism, but it Avould seem that the idea of féminine submission, which is so strong a sexual stimulus for the maie, becomes so intensified as to see its objective perfection only Avhere there is no possibility of résistance, as in death. Still such cases may also be dépendent upon fetichism (q.v.), i.e., pathological association of first sex- ual'excitement and the ielea 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 experieneed in the mère inflietion of pain or at the sight of blood. The Marquis de Sade took pleasure in coitus only when he could draAv 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 hâve been a pure case of fetichism originatiug in an early coitus Avith a menstruating Avoman. The slighter bodily injuries inflicted on women by sadists for the purpose of sexual gratification vary. It is fréquent to observe a désire to draAv blood ; but flagellation of the female often suffices. It is to be noted that in ail the cases of sadism reportée! in literature the subjects hâve been more or less markedly psychopathic ; tliere bas always been observée! a basis of hyperasthesia, upon AA'hich the perver- sion has been deA-eloped by accidentai association of ideas. The varia- tions in the manner of expression of the sadistic impulse show hoAv much it is determined by accident of expérience. With an original psycho- SEXUAL CRIMES. 5G3 pathic basis and sexual hyperaesthesia the conditions are favorable for the development of sadism, as they are for the deA'elopment of aU other forms of psychosexual perversion. The e;ase of a young man reported by von Krafft-Ebing illustrâtes lust- ful pleasure at the sight of blood. The patient remembered his lustful de- light at the sight of blood as early as his tenth year. He eut and pricked himself to gain this pleasure. The sight of the bleeding finger of a female gave his impulse objective direction, and he masturbated Avhde reveliug in the fancy of bleeding girls. Finally his sadistic faney extended to the most horrible slaughter of human beings. The act of masturbation banished such ideas. He was always able to keep himself from attempt- ing to make his fancies actual. Neuropatbie though lie was, his sadistic ideas Avère 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. His satisfaction was intensi- fied by the sight of blood on the blade. A similar case» is reported from Augsburg. The offender had stabbed about fifty girls, but Avas always careful to avoid doing serious injury. He also found sexual gratification in looking at bis collection of knives, swords, etc. A case reported by Dr. Moll is an instance in which flagellation of the female nates and humiliation of the female Avère substitute s for the sexual act. The sadistic impulse may be directed only to humiliation of the female, and thus find e»xpression in acts of défilement of the female per- son. Frequently this défilement is of the most disgusting eharaeter— with urine, faeces, etc. It seems highly probable that the motive which leads to the défilement of women by ink, etc., is a sadistic impulse ; at least ail such cases should hereafter be examined Avith a vieAV te> discover any peissible sexual factor where the.perpetrators are men and their vie- tims women. The cutting off of womeiis hair by force or stealth ma}' possibly hâve some relation to sadism, but more frequently it is to be referred to erotic fetichism, whieh is de»scribed later. The literature shows that there ma}' be merely a symbolic satisfaction of the sadistic impulse. Thus the sexual gratification sought may be found in acts and situations which suggest the inflietion of pain or hu- miliation, but in which there is no actual suffering. In such e-ases the mère idea of suffering endurée! by the passive person, suggesteel by a situation artificially created, suffices to give sexual satisfaction. Cases of this kind can seldom ghe cause for medico-legal investigation, but where such situations Avère forced on a person légal questions might arise, as in a case reported by von Krafft-Ebing, where a certain Aus- trian count Avas eonvicted of giving public offense by forcing a young girl Avho accompanied him into a public garden to kneel doAvn, implore him with foldeel hands, and bck his boots, at the same time demanding that she actually kiss him ad nates. The sadistic inclination may be directed toward any living object, Avhether the affected individual is aAvare of its sexual coloring or not. Thus there hâve been many cases of sadistic Avhipping of children by maie teachers; and the torture of animais has not infrequently been found to dépend upon sexual gratification experieneed in this wanton inflietion of cruelty. In young perseuis innoc*»nt of knowledge of the sexual relations the latter tendeney may be indulged with unconscious- 504 A SYSTEM OF LEGAL MEDICINE. ness of its true significance : in more experieneed men it may be practiced as a substitute for the satisfaction experienceel in e-ruelty practiced e>n females. Yon Krafft-Ebing regards e-ases in AA'hich the mère sight of blood, death, etc., excites sexual feeding as instane-es of such original cem- stitution of the vita sexualis that the relation between thèse impressions and lustful feeling is a direct or immédiate one ; but to exclude patho- logical association, even in thèse cases, is impossible; anel it see-ms su- perfluous to assume the existence of an unne-cessary factor to explain the phenomenon. Though sadism is distinctly foreign to the psychicàl charae-ter of Avemien, it is oce-asionally observed in them. The tendeney of Avomen to bite at the heiglit of sexual excitement is Ave-11 known, and that this may bee-ome intensified to a pathologic.d degree is illustrated by the case re- portée! by Moll, AA'here a young wife found her most intense pleasure in biting her husband until the blood came, and aa'Iio was best satisfied if she bit her husband and he bit her. As von Krafft-Ebing points ont, many of the Messalinas of history were celebrateel for their lust and crue-ity ; and in some of thèse instances the conditions suggest that there Avas complète inversion of the féminine eharaeter, Avith excessive deA'elop- ment of the sexual charaeteristie's normal to men. In order to prove the sadistic nature of acts of cruelty it is always necessary to demonstrate distinctly their association with true sexual excitement. We knoAV that cruelty is a very fréquent manifestation, and that it is ordinarily an independent psychological phenomenon ; there- fore it cannot be presumed that the sexual factor is operathe, sa\re in those cases where peculiar circumstances indicate the existence of this remarkable pathological association. Where atrocious or peculiar acts of cruelty can be explained upon no ground of sane motive, and the in- dividual is to aU intents sane, there would be some reason to suspect the hidtlen influence of a sexual impulse, more especially if the acts were in any way related to sexual ideas. Passivism.—This term is applied to a psychosexual condition that is the counterpart of sadism : sexual gratification is sought and experieneed in suffering personal pain or violence, or their psychological équivalents, at the hands of a person of the opposite 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 entire exclusion of ail normal stimuli. Where this subjection is experieneed, 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 psychicàl characteristies of women, wliose sexual rôle is physiologically a passive one, with Avhich the idea of sub- jection to the masculine will is a natural psychicàl association. Daily expérience is sufficient to show that Avoman finds her completest sexual satiety in being subjected to the masculine sexual domination, and the degree to which this characteristic is exhibiteil by females within reason- able limits may be taken as a measure of their femininity. Sue-h a char- acteristic manifestée! by a man, however, is strikingly abnormal, anel it can but be regarded as one variety of perversion on the Avay to complète psychosexual inversion. However, the many cases thus far observed in men hâve been but infrequently assoe-iated^vith fully developed sexual inversion ; as a rule, men thus affected expérience a désire for subjection, SEXUAL CRIMES. 505 humiliation, and abuse, going to the extent of violence and cruelty, at the hands of Avomen. With this tliere may be varions degrees of impair- ment of vh-ibty up to complète psychicuî impotence. The satisfaction of tins strange sexual inclination is usually sought by inducing Avomen to pe»rform the part necessary te> insure satisfaction: prostitutes are hired to perforai flagellation or te» e-arry out A'arious comédies in AA'hich the individual is placed in the rôle of ont» subjected to the grosses! violence and indeceiicies, or one lmmiliated by a mistress to an extrême degree. Yon Krafft-Ebingre-gards case»s of passivism as psyediologically distinct from cases e)f so-called simple flagellation. Pleasure in being flagellated may be something quite differe-nt from passivism. Passivism is essen- tially a psychosexual anomaly of early origin in the bfe of the indiAdd- ual ; ple-asure in being flagellated may arise secondarily as a resuit of eultivatioii, through expérience of its reflex effect or as a stimulus to sex- ual poAvers weakened by prolonged exe-esses in normal venery or onan- ism. Cases of passhism thus far reported lead to the conclusion that this psye-hical pecubarity is a congénital characteristic in a certain num- ber of instances. This conclusion is reached mainly through a study of the facts presented by the autobiographies of such individuals ; but it must ahvays be remembered that statements made by mature individuals e-oncerning events of their early ehildhood can but rarely, if at aU, be freeel from unconscious errors of memory ; and it would seem that to preive the congénital origin of such an anomaly merely by statements which are so confesseelly open to the possibibty of being uiiintentionally erroneous, especially in the face of so many cases where such anomalies can be sliOAvn to be acquired, is far from being strictly scientific. Further- more, in many cases of pure passhism the anomaly is purely psychicàl, and finds its field of activity only in the imagination, reabzation of the imagined situation, Avitli suffering of punishment, being attended only with pain and no sexual satisfaction whatever. To account for such cases by assuming an inborn idea, or material substratum for the spon- taneous origin of such an idea, independently of expérience, is to do A'io- lence to scientific methods of observation and advance into the realm of pure and improfitable spéculation. Passivism often occurs in association Avith sachsm, and évidence of its existence in a given case might be of value as indicative of the exist- ene-e of suspected sadism AA'here the latter might be of medico-legal im- portance. Passivism is of much less direct medico-legal interest than sadism, for, in the nature of its tendencies, it can seldom lead to acts that Avili bring the affected indhidual within the vit'Av of the law. How- ever, there are several possible results to which passivism may lead that may e-all for medico-legal inA'estigations. Thus it is e-emceivalde that a passivist might cause himself to be subjecteel to A'iolence that might resuit in his serious injury or death, and that through accident or unin- tendeel stwerity in the active party; or, eoncealing his anomaly, he might seek légal damages at the hands of the person he had hired to maltreat him. That serious accidentai injury might occur in this way wdl be un- elerstoetd AA'hen it is remembereel that this pleasure in pain, punishment, aud abuse» is satisfied in many A'iolent procédures. Thus a passivist may fine! satisfaction in having his naked person flageUated Avith a heavy Avhip ; in being troel upon by poAverf ul AAromen wearing heaAy shoes ; in being hanged in farce, etc. 5GG J SYSTEM OF LEGAL MEDICINE. Passhism is frequently combined with some variety of fetichism, especiallv that whie-h bas for its object female shoes. In some cases the individuals are affected with larvateel passivism. Hère tbe idea ot hu- miliation is satisfied in personal subjection te) the most disgusting and indécent treatment at the hands of women. Thèse cases are- a cemnter- part of svmbolic sadists. The most disgusting class of tins variety find satisfaction in being defiled in various way s by féminine excrément, et*- Erotic Fetichism.—lust as sadism and passivism can be- regarded as pathological exaggerations of psychicàl characteristies normal to the majority of persons, so can the relationship of erotic fetichism be trae-ed back to'normal or physiologieal sexual préférences. In any case of elis- ease it is well-nigh impossible to establish the dividing-line that marks the departure from health ; so in erotic fetichism it is sometimes difficult to détermine AA'here phvsiological phenomena of sexual préférence bave become pathological erotic fetichism. Technie-ally, erotic fetichism sig- nifies a psychosexual peculiarity by virtue of which the individual exhib- iting it finds sexual satisfaction more or le»ss complète» in objects whieh under physiologieal conditions are incapable of affording sexual gratifi- catiem. Phvsiologically, the characteristic marks, physieal, mental, and arti- ficial, ôf each se-x come to bave a psychosexual meaning for the opposite sex, and on this basis is developed that endless variety of individual sex- ual préférences which avc observe in men and women. When this sexual préférence bas attained such force or particularité of expression as to be in any degree exe-lusively directed toAvard an obje-e-t AA'hich can normally serve as merely a step "in the play of sexual attraction, and when this affords complète sexual satisfaction by the side or to the exclusion of the normal means of sexual satiety, the préférence bas become a patho- logical phenomenon and is an example of erotic fetichism. This display of sexual préférence may hâve for its object the pliysieal (corporeal) charae-teristics of the opposite sex or objects artificially associated Avith them by custom, such as articles of Avearing-apparel ; in still other e-ases the object ghing erotic pleasure may hâve no relation to the opposite sex. Erotic fetichism is regarded by ail authorities as an acquired anom- aly ; but it, bke ail the sexual perversions, is closely related to a psy- chopathic constitution, and for the most part this constitutional weak- ness is inheriteel. Erotic fetichism may arise in cases of mental disease. Owing to this relation to a constitutional psychopathic deficiency, erotic fetichism is often but one of Aarienis sexual anomalies exhibited by the individual ; thus it occurs with saelism, passivism, and contrary sexual- ity. The explanation offered for the origin of erotic fetichism is that of early psychicàl association. Where sexual feeling is exclusively directed toward some object normally incapable of exciting lustful pleasure, it is presumed that the primary expérience of lustful feeling has occurred simultaneously Avith some strong mental impression of that particular object, and that this initial association remained determinate for tbe future vita sexualis. In many recorded cases it has been possible to demonstrate this mode of origin beyond ail doubt; its frequency in neuropathic persons is accounted for by the fact that in such individuals the awakening of sexual instinct is frequently early, and thus associations are formed which hâve but imperfect relation to normal sexual activities SEXUAL CRIMES. 5G7 because the child is more or less ignorant of the true sexual relations. The persistence of such an early association is in great measure dépend- ent upon the fact that early psychicàl associations are the deepest and most enduring. Erotic fetichism may lead to the commission of crime, and therefore it is of much medico-legal interest. The recorded cases of er*)tic fetichism are in maies, though the possibility of female fetich- ism is to be remembered. Body=fetichism.—It is convenient to consider under this term those cases of erotic fetichism where the object afford in g sexual gratification is some physieal peculiarity of the female. Nemnally men are sexually attracted by féminine peculiarities of person, such as the eyes, the hands, the fee-t, the hair, the bust, and other sexual marks of feminmity ; and any of tliese may become the particular pathological fetich. The déter- mination Avhether such a sexual préférence is reaUy pathological is to be made by its relation to the activity of the sexual functions. If the ob- ject of erotic fetichism constitutes a sine qua non in some relation for normal sexual gratification, the case may be unhesitatingly pronounced pathological ; and there can be no doubt of the pathological nature of cases in which the eibject giving sexual pleasure occupies the sexual attention entirely to the exclusion of ail other sexual ideas. In cases of the latter kind, woman sinks to insignificîince as a représentative of sex, and the sexual ae-t loses or has no meaning, while sexual pleasure is found only in some physieal or idéal relation Avith the particular object. It is the comparative or absolute exclusion of the action of normal sexual stimuli by the particular object of sexual désire that is the» measure of disease. The female hand is frequently the object of sexual préférence, but hand-fetichists are seldom led to acts Avhich attain medico-legal importance. The concentration of sexual interest on the féminine hand is entirely like that manifested in other cases of AAdiich illustrations feillow. The greatest medico-legal interest attaches to those e-ases of body-fetichism in AA'hich the particular object of sexual interest is capable of easy removal, like the hair. It is conceivable, how- ever, that cases might arise in Avhich for the sake of entire possession of the hand, the foot, etc., of a female, the fetichist might resort to acts of a criminal nature ; for example, a combination of hand-fetichism and sadism might lead to murder, or to the mutilation of eorpses, for the possession of the member. The following case, reported in the Annales d'Hygiène, April, 1890, and cited by von Krafft-Ebing,* will clearly illustrate the nature of erotic fetichism and the nature of the crimes to which it may lead : August 28, 1889, P. was arrested at the Trocadéro, Paris, in the act of robbing a young girl of her hair by cutting it from lier head. He hael the hair in his hand and also the scissors with which he had eut it off. He explained his act by asserting that he Avas at the moment men- tally confused and had acted in obédience to an irrésistible impulse born of an unfortunate passieni lie had for women's hair. He confessed that he had eut off hair many times before. He took great delight in keep- ing lus booty at home. On examination of his apartments sixty-five sAvitches and locks of hair were found assorted in packets. It was ascer- tained that he had been'arrested on a similar charge three years before, Op. cit., p. 163. 5G8 A SYSTEM OF LEGAL MEDICINE. but had been dismissed for lack of evide-n*-*-. He Avas aged forty ; bis father had been tenipen-arily insane and his mother was A'ery nervems. P. (h>veloped Avell and Avas inte'lligent, but lie early exhibited tics and imperative ideas. He had never practiced onanism. His sexual in- clination had been rather Platonic; he had had sexual relations with prostitutes, but very infrequently, and had never experieneed any real pleasure in coitus. Three years previously financial ruin had come, and this was followed by a fébrile disease attended with delirium. Since that time lie had been subject to anxiety when alone in bis room at night, and at such times he felt an impulse te> fondle female hair. When he could toueh a girFs hair he became greatly excited sexu- ally, and had érection and ejaculation without other contact with lier person. Tins pleasure grew to be more and more intense, and pre- vious sexual intercourse had never given him any such pleasure. At last he could not resist the impulse to eut off a girls hair and take it home to fondle. Hère lie repeated the process of inducing sexual or- gasm : he rubbed his person Avith the hair, etc. After this lie could not trust himself to venture out for several days. After some months he was again unable to resist a new impulse to repeat his expérience. Driven by this impulse he went out to possess hiinself of some giri's hair. This was frequently repeated until he had a collection of paekets of hair. If he were unsuccessful in an attempt to get a new lot of hair, lie would hurry home anel revel in bis possessions there. He was ace-ustometl to comb and fondle it and simnltaneously practice masturbation. Hair ex- posed for sale had no effect on him ; he was excited only by that hanging from a woman s head. When he touched the hair with the scissors it induced érection, and ejaculation took place at the instant of cutting it. The opinion of the medico-legal examiners (Voisin, Socquet, Motet) was to the effect that P. was a psychopathic person subject to imperative impulses, of Avhich his impulse to steal hair was one accompanied with a simultaneous excitation of sexual feehng of abnormal eharaeter and in- tensity. He was sent to an asylum. A similar case is reported by Magnan,* in AAdiich it was possible to trace the origin of the impulse to association of the sight of a woman combing her hair with a primary expérience of spontaneous sexual ex- eite-ment. When some particular part of the female person is the object of erotic interest, the fetichist may be driven to illégal measures to satisfy his désire. Thus the roundeel hips of a woman possess such attraction for some men that they seek te> place themselves in contact with women secretly in crowds. Such indécent acts hâve frequently been the subject of légal investigation. Dress=fetichism.—By a kind of psychological substitution, or through pathological association, material objects may come to be the erogemous fétiches. The process of substitution is for the most part effectuai Avith articles of female wearing-apparel : from enthusiasm for a part of the female person the corresponding customary covering may become the cause of erotic excitement. Thus the hand-fetichist might develop a love of female gloA^es ; or the foot-fetichist, of female shoes. Often the fetich is some particular costume or some spécial article of * Psychopatliia Sexualis, p. 165. SEXUAL CRIMES. 569 attire. In thèse cases, as Avell as frequently in those where a possibility of transference of original sexual interest in parts of the female person is suggested, psychological association of primary sexual excitement with the particular objee-t is the only possible explanation of the origin of the pathole>gïe-al manifestation. The more the object of erotic excitement is foreign to the normal sexual stimulus the more serions is its pathological significance. The limits of tins article Avili not permit détails of illustrative cases. The articles most likely to become the objects of exclusive erotic interest are shoes, gloves, petticoats and other female imder-garmeiits, and hand- kercliiefs. The possibilities of patholeigical association are such that any object of female dress may eventuaUy become a fetich. When such ob- jects are erotic fétiches they may lead the individuals to commit theft to obtain them. The following case, reported by Zippe,* illustrâtes this tenelency : X, ageel thirty-tAvo, Avas arrested for stealing a handkerchief from a lady. lie- cemfesse-el that lie had stolen a great number, but that it was not for gain that he took them. He cared only for handkerchiefs be- longing to ladies that attracted him. He showed markeel mental Aveak- ness. The act of stealing the handkerchief AA'as accompanied by true sexual satisfaction, and tins gave him more pleasure than normal sexual congress. He looked upon this theft as an équivalent for coitus. The following case by Lombroso, cited by A'em Krafft-Ebing,! is an example of shoe-fetichism combinée! with passivism and sadism : X, maie, aged twenty-six. He is sexually excited by nothing but the shoes of the opposite sex. The shoes must be handsome, of black leather, and bave» high heels. The shoes alone suffice. This peculiarity had existed from e-hildhood. X is potent, but the female during the act must haA'e on dainty shoes. At the height of sensual excitement he has cruel thoughts connected with tbe shoes : he thinks of the death-agony of the animal from Avhich the leather came. At times lie takes animais (ehick- ens) to haA'e his consort tread on them with her shoes ; at other times he has the Avoman Avalk on him with the sheies. Caressing of women's shoes cause»d eive-tion and ejae-ulation. Erotic fetichism may hâve for its ob- ject some sjiee-ial material such as fur and velvet. The cases of this eharaeter are usually examples of association independently of the rela- tion of the spécial material to the opposite sex. In such cases there is expérience of primary sexual excitement when handbng velvet, for ex- ample, anel thereafter this association is maintained. A partiality for furs might arise from expérience of sexual excitement when fondling furry animais. Contrary Sexuality or Sexual Inversion.—The cases of sexual per- version falling under this head, as previously indicated, are divided by von Krafft Ebing into tAvo classes, namely, acquired and congénital. We bave seen, hoAvever, 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 late (acquired) and early (congénital) ■cases, in acee>rdance with the period of the first manifestation of the in- version. * Wiener Med. Wochenschr if t, 1879, No. 23; Psychopathia Sexualis, p. 172. t Op. cit., p. 131. 570 A SYSTEM OF LEGAL MEDICINE. Ail observers agrée in the conclusion that a neuropatbie nervous system, congénital or acquired, is a prerequisite for the development ot sexual instinct feu* the same sex (homeisexuality). To tins predisposing neuropatliic condition some exciting cause is added. The most impor- tant exciting or coiitributing causes are excessive masturbation, fe-ar e>t preguaucv, and venereal infection. According to von Krafft-Ebing, the signs of a neuropatliic constitution which may lead to sexual inversion are prématuré development of sexual désire ; sexual hyperaesthesia ; func- tional and anatomical signs of degeneration; neuroses (hysteria neuras- thenia, epileptoid symptoms) ; psychicàl anomalies even to degrees of Aveak-mindedness and moral insanity; neuroses and psychoses in pro- géniture. The same author differentiates four degrees in the develop- ment of the inversion, appbcable alike to early and late cases : 1. With predominating homosexual feeling there is a trace of feeling (heterosex- ual) for the opposite sex (psychosexual hermaphroditism) ; 2. Exclusive homosexuality limited to the vita sexualis; 3. The whole eharaeter corresponds with the incongruous sexual feeling; 1. The form of the body, aside from the genitals, corresponds with tbe» anomalous sexual inclination. Since in any case sexual inversion is but a phenomenon arising from a îieureqisye-heipathic condition, as previously indicated, it is selehnn au isolated manifestation, but is most frequently observed in conibination -with other sexual perversions. In accordance with this, tbe medico- legal questions arising in se-xual inversion may be identical with theise; raised in the sexual perversions previously considere-d. The further pos- sibilities of a criminal.eharaeter are related to the crimes of pede-rasty. The individual affected with contrary sexuality satisfies himself with men by means of passive or mutual onanism, ov by coitus-like acts (coitus interfemora); if active peelerasty is performed, it is only as a resuit of intense sexual désire, or ont of Avish 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 entirely in the fémi- nine rôle». To distinguish such cases from pederasty not dépendent 114)011 a pathological condition, it is but necessary to exclude the existence- eif psychosexual mversion, 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 opportunity for natural satisfactiem, and as a new means e)f sexual gratification A\There natural methods of sexual 4>leasure hâve been exhausted by excess. Nem-pathological passive- pederasty is prac- ticed only for gain. The following unpublished autobiography will illustrate a case of sexual inversion of early eleve-hqnnent : " From my earliest ehildhood I bave exhibited an abnormal sexual tendeney. I haA'e never love il a Avennan—never experieneed a trace e»f sexual feeling for a woman. Yet I cannot say that I haA'e a horror femi- narum. I elo not associate with ladies, not because I dread them, but knowing my condition I feel so inexpressibly imhappy by reason of it that I avoid their society. I bave never attempteel coitus Avith a woman, because I haA-e no désire, and then again I know it would be impossible. Xeither elo I consort criminally Avith men. My desires are for men ex- clnsively, but they hâve neA'er yet been so strong that I was unable- to control my actions. Of course I avoid temptation. In ail my thoughts SEXUAL CRIMES. 571 (sexually) I regard myself in a passive rôle. I am effeminate in action and appearance, though I am told I am less so than formerly. My voice is a good baritenie, bearel abundant, height five feet six inches, weight one hundred and seventy-twe> pounds, genitals well formed (as far as I can judge), but someAvhat under size, and as far as I knoAV they are in a healthy state. I do not practice masturbation, and bave no désire to do so. I did practice masturbation for many years—probably as early as my tenth year, and from that time more or less frequently until I left the university in my twenty-third year. I dei not think I ever practiced it oftener than once in four ov five days. Xoav, hewever, I bave aban- doned the habit and neveu- feel any inclination to reneAv it. Intleed I never think of it, and it seems incompréhensible to me that any one should eare to indulge in it, I seldom bave nocturnal émissions—per- haps euice; a month—but they are always accompanied by lascivious dreams in whiedi men are substituted for women. I am inclined to be- lieve» that my condition is congénital, although my early practice of mas- turbation may be responsible for it. I ahvays as a child was fond of dolls and seAving and other féminine things. This Avas eA'en prior to forming the habit of masturbation. I do not think either of my parents: had any abnormal sexual feelings. My mother died AA'hen I Avas thirteen years old, of asthma—nervems asthma, I think. My father still survives. My father never seemed to me to eare for ladies' society. I never knew him to A'isit a lady unless on business, and his réputation for morality is of the highest. Neither eloes lie ever toue-h liquor or even smoke. If my failing is inherited it must be from my father, and that I cannot be- lieve». My mother's family are ail men-e or less nervous, but are cemsitl- e-retl very bright mentally. Henvever that may be, I bave this abnormal teiiele-iiey—eu- rather not tendeney, but appetite; for it is more than a tendeney—and the kiioAvledge that I ani so unlike others makes me A'ery misérable. I form no acepiaintances outside of business, keep mostly to myself, and, as I sait! before, do not indulge my sexual feelings. I am at times exceedingly melancholy, OAving, I suppose, to my unhappy con- dition and the great différence between myself and others. Whenever I go into society this différence is im pressed upem me, and causes me such deep distress that I do not go more than I can help. I do not Avant to create the impression that my feelings for my oavu sex are weak, for they are strong ; but I bave heretofore had sufficient Avill-power to restrain them. On one occasion, some three or four years ago, I permitted a yeumg man to take a liberty Avith me, at his request, not because I coule! not resist or because the felloAv had any attraction for me, but merely out of curieisity, as I wanted to see Avhat he would do. I took no lib- erty with him and mere-ly submitted to him while lie put my pénis in os suum. The Avhole thing was unpleasant to me and I bave never re- peated it. I haA'e ahvady stated that I do not indulge in sexual impro- prietie-s. My désire in this matter lias always been to handle the genitals of tliose for whom I feel affection and to ha\'e them do the same to me. I am therefore someAA'hat uncertaiii as to Avhether I should consider niv- se»lf in an active or passhe reîle, but probably passive. This, with em- brae-es, seems te) be the extent e)f my désire. But the most serious feature to my minel is the total anel utter absene-e of any feeling for Avomen. I die! once dream of ha\dng connection Avith a woman—neit a woman I had ever seen, but an imaginary créature—and my recollection is that I had ;y72 A SYSTEM OE LEGAL MEDICINE. an émission at that time. This dre-am, I think, was caused by my firm resolution made about that finie- te) try te) concentrate my mind em Avomen to the» exe-lusion of men. But never hâve I had such a thought aAvake, anel never sine-e Avhe'ii asleep." The following abrielged auteibiography illustrâtes a late case- m which there are distinct évidences of psychosexual hermaphreielitisni : " I am tAve-nty-nine, and born of healthy parents. My sister and broth- ers are normal." As far bae-k as I can 'remember I masturbateel—long before I reached pubcrtv. I practiced nnitual masturbation with but three men, ail older than myself—this before I Avas eighte-en. Since then I bave- masturbated alenie. I praetic*»*! self-abuse very frequently until e-ightee-n ; from that finie until my twenty-fifth year abemt one-e a month ;' since then but. three» finies in ali I bave freepient polbitieuis at night, anel 1 occasionally awake to fine! myself masturbating. With thèse emissiems I mostly bave men eiomie-cte-d in my divanis—oce-asiemally, hoAvever, Avome-n. From my earliest rcc*)ll<'<'tion I bave» hael sexual thoughts of nie-n and also of* women. From fourteen to eighteen I had coitus occasionally, AA'hich I enjoye-d, but not so much as the pleasure in onanism. I ahvays t*>t)k men for my object Avhile masturbating. Men of fine figure exe-rt a great sexual effe-e-t on me. I bave» never yielde-d to this te-neiency. My attempts at centus for senne years haA'e been ve»ry un- satisfaetory.' I fe-a.r I am impotent with women, but I hâve no trouble» in having an érection at the thought of men. There are times AA'hen this love of men is absolutely obnoxious to me, but, alas ! they are only too infrequent." Responsibility.—Since ail forms of sexual pei-A'ersiem may lead to criminal acts, the most important epiestieni from a medico-legal stand- point is that AA'hich concerns respemsibility. On this peiint it may be said that the fact that an individual is subject te) a perversion of the sexual instinct is ne>t sufficient to establish p*»rsonal irresponsibility. Many persons—in fact, the majority—thus affectée! are able to control their abnormal se-xual impulses. When such a persem has committed a crime AA'hich can be shown to be the expression of his peculiar anomaly, in or- der to justify a judgment of irresponsibility it is necessary to sIioav that tlie crime Avas the resiilt of organic necessity ; that owing to a neuropsy- ehical constitution the individual was incapable of eleveh>ping or acquir- ing ideas and feelings Avhich act in opposition to animal impulses ; or, thèse haring been developed or acquired, that pathological conditions bave been influential in overcoming them. Thus the question of re- sponsibibty for crimes committed by sexual perverts falls ■within the lines which guide in the détermination of responsibility in gênerai. STJKGICAL MALPRACTICE. BY GEORGE RYERSON FOWLER, M.D. Définition.—Malpractice is defined as bad or unskillful practice on the part of a medie-al attendant, whereby the results are such as to in- jure the health of the patient ov elestrey bis life. The administration of me-dieines or the performance of an opération AA'hich the practitioner knoAvs or expects will residt in damage to the» patient's health, needlessly endanger his life, en* e-ause his death, is defined as AA'illful malpractice, Avhile négligent malprae'tice incbides those instane-es in Avhich a criminal or dishonest object or intention is absent, but in AA'hich there» is gross négligence or failure to render that attention to the patient AA'hich the exigencies of his illness re>epiire. The administration of medie-ines or the performance» of an opération if the médical attendant is incapable of properly appreciating its effects, either in regard te> the medicine or the operative procédure», through any fault of bis own—such as Avould exist, for instance, AA'hen lie Avas in a state of intoxication—the effect being to inflict injury rather than to benefit the patient, woidd come under the latter head. Ignorant malprae'tice, on the other hand, consists in the administration of medicines or tlie performance of opérations AA'hich do harm, anel AA'hich a Avell-eelucated anel se-ientific metlie-al practitioner would recognize as inappropriate in the» e-ase and likely to be followed by injuri- ous conséquences. The passhe malpractice involved in alloAving a patient to bleed to death AA'ithout ascertaining the source of the hemorrhage or taking proper measure-s to arrest it is quite as reprehensible, eateris paribus, as the act- ive malpractice involveel in causing a dangerous hemorrhage for want of prope-r e-are. Errors of omission. lienveA'e-r, are» of as great importance as tliose* of commission, yet the former are apt to be judged less harshlv than the latter. But it would be better, viewing the matter from a purely professiemal and scientific standpoint, to rejee-t ail artificial distinctiems, and consider only the behavior of the surgeon AA'ith relation to the nature of the disease», tlie condition of the patient, anel the particular procédure claim*»*! to be at fault. Measure of Responsibility.—It is extremely difficult to accurately estimate the measure of the surgeon's responsibility at aU times and under ail e-ircumstance-s. This has varied greatly in times past and among différent nations. In the days AA'hen priests assumed the func- tions of medie-al pra édition ers and performed surgieal opérations, their knowledge-, being then considered as de-rive-d from (iod, AA'as looked upon 571 A SYSTEM OF LEGAL MEDICINE. as infallible. On the other hand, among the Egyptians the surgeon who ventured beyond the» bemntlaries of the» rules whieh were- regarded a s established was liable to suffer corporal punishment, even though his practice was successful. In Koumania the mère fact that a physician s ov a suruvon's efforts were unsucce-ssful maele him responsible at law for pecuniarv damages. Among the western Goths the unsuccessful niniis- trations 'of the surgeon, if resulting in death, were followed bythe turn- ing over of the latter to the vengeance of the- relatives of the deceased patient. In Germanv, at tlie présent day, both the» Civil and Criminal Code hold t*. a strict accôuntability ail those whose office, profession, calling. or trade demands the e»xe-rcise»'of eare, in case death or injury results from the» Avant of proper precauthonary measures. In England there are- no spécial statutorv provisions laid down defining malpractice, and no e-rimi- nal hnv bearing upon the subject save the common law. Ail cases of this eharaeter are treated in pioe-esses before» jurors. The latter course is like- wise pursued in the United Stales, as regards both <-ivil anel criminal processes; but in this country there is a statutory provision on the sub- je-e-t of criminal liability for' neglige-nce» or miscenidue-t. In Germany, Austria, and Franc*» the»'trial process is not had before jurors. In Grerniany tlu» superior courts hold to the principle that every médical prae-titioner Avlie», by a culpable Avant of attention and eare», or by the» absence of a compétent degree of skill anel knowledge, causes injury to a patient is liable to a civil ae-tiem for damages, e»ven AA'here the patient either empleyed him or agree-d to pay him, unless the patient bas by bis oavii carelessness diivctly contributed to such injury. A surgeeui does not stipulate to perforai a e-ure, ne-ither does lie untler- take te> use the highest possible elegree» of skill, but he does undertake to bring a fair anel reasonably compétent degree of skill anel knenvh-dge te> bis aie! in the e-ase-. In an action brought to recover damages tlie que-stiem is Avhether the injury is to be referre-d to the Avant e>f a proper de»gree of skill and car*- on the part of the défendant or not. A médical man avIio is guilty of grass ne»gbgence or évinces a gross Avant of knowl- edge of bis profession is criminally responsible, but he is not liable to criminal investigation for eve-ry instane-e in AA'hich an unfortunate termi- nation of the case folio av s his efforts. The distinction be»tAve»en ae-tiemable and criminal neglige»nce cannot be de»fineel, except so far as to sa}' that to constitute the latter tlie»re» must be such a elegree of complète négli- gence as tlie laAV means by the word •* félonie us." The American e-ourts hold similar vie'Avs, except that the responsibility of pliysicians and sur- geons is not to be measured by the same ruh-s that apply te> meehanics and artisans. Malpractie-e, therefore, bas come to be an offense punishable by fine and imprisonment as Avell as financial loss to the défendant from ae;tions brought by patients or their légal represe-ntatives. Under the common law.the latter cannot receiver in e-ase of death, inasmuedi as the act of malpractice constitutes a tort, unless some pmperty interest is involveel. That exact justice demands that physicians and surgeons should be held responsible for their actions as Avell as their omissions, both morally and legally, sliemld untoward results follow their willful ae-ts as Avell as their failure to act promptly under cireumistances demanding such action and the intelligent application of ordinary skill and car*», there can searcely be two opinions. But the fae-t should not be lost sight of that SURGICAL MALPRACTICE. 575 members of the profession of heabng should not be restricted in the sélec- tion of what may seem to them the proper procédure in a given case, lest the development and progress of then* liumane science be unnecessarily restricted or repressed. To the fair and impartial mind it is easily apparent that, until medi- cine becomes an exact science, in a certain proportion of cases failure must follow the efforts of the best-informed men, the failure being attributable to the conditions for which the treatment was applied as well as to errors of judgment on the part of the practitioner. The errors, however, need not necessarily be culpable à priori, as surgeons are but human, and are liable to error in common with others of the race. The public at large can searcely be justified in requiring from every individual surge-on tbe highest grade of knoAvledge and ability, but, rather, a gênerai average must be struck, this average being employed with whatever especial eare, précaution, and attention are required by the partieuilar case iu hand. Médical knowledge advances by stages, and besides the improvements which each décade brings to the profession, one individual member thereby, either because of especial opportunities for observation, the possession of a gift of genius, or as the residt of an e-xceptionally large expérience in a particular field of work, may outstrip his feUows and attain a degree of proficiency AA'hich, if established as a standard, it would be impossible for the majority of his professional brethren to reach. The Principles of the Art of Surgery.—The gênerai truths and maxims Avhich authority has established constitute the principles of an art ; but thèse can neA'er become permanently fixed in the art of surgery, with its constant aelvance in methods and scientific improvements. Un- td the changes, therefore, Avliich necessarily foIIoav upon the latter recelée the sanction of recognized authority they cannot attain the Aveight and importance of principles, and henee changes in established principles e>ccur but ver}' sloAvly. A sufficient knoAvledge of the principles upon Avhich the practice of the art of surgery is grounded, and an intelligent apphcatioii of those principles, therefore, becomes the standard by means of which a judicial estimate of the responsibiliti.es anel obligations of the surgieal practitioner may be arrhed at. Opinions of Experts.—In an art like that of the operative portion of surgery, the principles of which are undergohig constant improvements, and which are susceptible of still further improvements, in order to de- te»rmine the civil eibligations of the surgeon, and form a judicial estimate as to how far he bas availed himself of trustworthy knowledge upon the subject and diligently and intelligently applied the same, it is necessary to obtain the opinions of the ackiienvledged exponents of the science and art whose practice and expérience extend over the particular period of time under reA'ieAA'. Unexpected and Unfortunate Results of Opérations.—Although the operating surgeon may perform the most difficult and extensive opéra- tions many times aud AA'ith quite a uniform degree of success, and those of considerably less magnitude will occasionally be followed by unfortu- nate and unexpected results from causes not easily foreseen or guarded against, it is neverthe-less true that the results of opérations generally dépend upon the qualifications of the operator. From the judicial stanel- point, therefore, tlie surgeon avIio undertakes to perform an opération 576 A SYSTEM OF LEGAL MEDICINE. assumes an obligation which, though only implied, has ail the force of a formai contract drawn and signed in the présence of witnesses. And further, this légal construction of the obligation requires that the» sur- geem shall possess ordinary skill aud that eïegre*» of knoAA'le»dge» AA'hich is the common property of those AA'ho practice» the same art and science, intelligently apply tîiose principles which are deemed essential, under the circumstances, by the leaders of the profession, and for the» best interests of the patient, and employ a reasonable de-grec of e-are and judgment in tlie exere-ise of bis skill aud in the application of the prin- cipes to AA'hich allusion has been made* The Criteria of Malpractice.—Speaking in a gênerai Avay, it may be stated that the three criteria of malpractie-e, and upem the establishment of Avliich actions at law must dépend in en-der to be sue-e-essful, are em- braced in the following questions : First, lias injury be-en inflicted or has death been caused by the act of the surgeon ? See-ond, Die! the attendant in bis treatment of the case exhibit a Avant of knoAvledge of tliose rules Avhich are the common property of the profession, or Avhich bave been sufficiently long established to beconie knoAvn to him Avith ordinary watch- fulness of the advances of his art on his part ? Third, Die! the attend- ant départ from the established rule-s bearing upon the particular case in an un justifiable or extra ordinary degree? In other Avorels, did he omit, either through carelessness or ignorance, to do that Avhich might hâve been of benefit or haA'e saveel the life of the patient; or die! lie aebninis- ter a remedy or perform an opération AA'hich resulted in injury or death, without sufficient reason for se) doing, from the scientific standpoint as judged by his peers in the profession ? Errors in Diagnosis.—The particular dire-e-tion AA'hich the; error e-om- mitted takes should also haA'e some bearing upon the case. For instance», a diagnostic error in an obscure case, tbe treatment being properly basée! upon such error, should be deemed less culpable than either Avrenig or correct diagnosis foUoAvetl by treatment e-alculated to be of no service or absolutely harmf ul in either case. Diagimstic mistakes ha\re been made by the most eminent practition- ers and consultants, and upon his ability as a diagnostician the entire réputation of a surgeon frequently dépends. An error in diagnosis, therefore, should be A'ieAveel in a more charitable light by bis confrères, and also by the community, than errors in treatment which e-aused dis- aster. This is fortunate for the practitioner, for the reason that when a correct récognition of the case on bis part has been proved it is difficult to prove that a AA-rong treatment has been pursued ; and from the further fact that the diagnosis in a large number of instances can only be clear*-d up by observing the results of treatment. Under thèse circumstances, therefore, the treatment must be largely expérimental and consequently more or less at variance Avith any set of bare! and fast rules Avhich miglit be urged as applicable to the case. Errors of Judgment.—While the surgeon is bound to give his patients the benefit of his best judgment, lie is not liable for a mère error of judg- ment, unless it can be sIioavii that the latter is so gross as to be incon- sistent AA'ith reasonable eare, skill, and diligence, t * 14 Am. & Eng. Encycl.' of Law, 76. t West vs. Martin, 31 Mo. 37ô ; Howard vs. Grover, 28 Me. 97. SURGICAL MALPRACTICE. 577 Unusual and Extraordinary Emergencies and Surroundings.—The surgeon is compelled occasionally to act under circumstances of the most trying and extraordinary e-haraeter. His own safety may be imperiled at the ve»ry mennent lie is calh»d upon to act in behalf of another. The surroundings upon a battle-field or a railroad Avreck are not conducive to an cacii balance of mind, or ealeulated to assist in bringing a cool and e-alm judgment of the necessities of the ease to the ait! of the attendant. Local, temporal, aud external conditions of varions 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 improvised charae-ter and ill-adajiteel to the emergency, may prevent the surgeon from making use of knoAvledge' which lie really possesses, or from showing that ability Avhich under more faven-able circumstances lie would exhibit. Moreover, the necessity at times for the rapiel performance of an opération, as, for instance, tracheotomy, or the prompt application of a remedy in an einergency, may be absolutely incompatible with the exercise of due eare and précaution against accident. In addition, the importunities or expostulations of the patient or bis friends may serve to bias, or at ail 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 AA'here tliere exist no extenuating circumstances such as bave been already chvelt upon, the surgeon, in the performance- of ail surgieal ope-rations, is bound to bring at least the ordinary eare and skill possesseel by tliose aa'Iio practice in the same locality or bave aee-ess to the same» sources of information which he can avail himself of.* He must peissess and exercise in an intelligent and practical manner that degree and amount of knowledge and science which the best authorities bave declared to be the resiilt of their observation, expérience, or re- search, up to Avithin a reasonable time of the date of the error of com- mission or omission which is at issue.! Response to a Call and Duration of Attendance.—Reproach is some- times cast upon the surgeon for failure to respond to a call for profes- sional services in urgent cases. It is bis implied duty, if lie 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 formai 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 eare is necessary. It is also Avithin his province to détermine when attendance may be safely and properly discontinued, but the same rule in regard to the exercise of ordinary eare and skill likewise holds good in this connection. Spécial contracts may be math», hoAvever, betAveen 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.J * Gramm vs. Boencr, 56 Ind. 497; Eelsey vs. Haij, 84 Ind. 189. t Elwell on Malpractice; Am. Law Reg. (N. S.) 774; 8 East (Eng.), 347; 1 H. Bl. (Eng.) 61 ; McCaudlcss vs. McWha, 22 Pa. St. 261; 27 N. H. 460; 13 B. Mon. 219; Sliearman & Redfield, § 440 ; McLalon vs. Adams, 19 Pick. (Mass.) 333 ; Carpenter vs. Elakc, 60 Barb. 448 ; Tatten vs. Wiggin, 51 Me. 594 ; Rex vs. Long, 4 C. & P. (Eng.) 423 ; Slatcr vs. Baker, 2 Willes (Eng.),' 259. t See Ballon vs. Prescott, 64 Me. 305 ; Todd vs. Meycrs, 40 Cal. 357. 57S A SYSTEM OF LEGAT MEDICINE. No Implied Warranty to Cure—Express Stipulation.—The» nie-re employment of a surgeon does not, in the légal se-nse, imply a e-ontract to cure-,* although the surgeon may, at his discrétion, contract te) per- forai a cure absolutely, in AA'hich e-ase he eau be held as a guarantor of success.! The professa ni, hoAvt'A'er, lias ahvays loeikeel upon such bargains with disfavor. Tlie surgeon, when lie enfers upon the charge e>f a e-ase Avith dignity and a due regard for his professional standing, is not in any sensé supposed t*> insure a cure, and henee is not to be- tried for the îvsult of his efforts, providing he treafs the case Avith rea- sonable» eliligence, eare, anel skill. More than this may be e'xpecte-d anel demaneled if an express stipulatiem exists, pree-isely as in common con- tracts betwe-en individuals in commercial life. The mère fae-t that the surgeem attends for a fee simply inqdie-s that be shall exercise- e-are», elili- ge»ne-e, and skill in ail his ae-ts, and that thèse shall be such as are best e-ale-ulated to restenv the patient to health, and least likely to injuriemsly aff'ect him. Equal Amount of Time and Attention.—The surgeon is not ahvays bound to bestoAV au equal amount of time en- de-gree- of attention anel skill upon ail Avhe> come under his eare», much less is il necessary that lie» should e-arry thèse», to the same» exte»nt as senne other meelical man might bave donc. In oreler te) render him liable it must be sIioavii that damage bas been inflicted and that there bas been a Avant of compétent and ordi- nary e'are or skill, en* an indifférence to the patient's best. interests. Eve-n an admission on the part of the- surgeem himself that there bas been a lack of eare» on his part does not altcr the e-ase- so far as is concerned the nee'essity of pmving that there» Avas such lae-k e>f eare, and that the patient suffered in conséquence thereof. The proposition that the» surgeon is not bonne! to give» the same or equal e-are and attention to ail e-ases is based upon tlie fact that each e-ase is te) be individualizeel, and that the» peculiar mental qualities of eme patient, although ne>t A'ery ill, Avili demand more attention than required by another aa'Iio is more seriously ill, ye-t not so profoundly iiupressed mentally as te) require oft-repeatcel assurances of continuée!" Avell-being. So many factors may emter into the considération of the e-ase in this con- nection that it Avoulel be absurel to permit a standard to be set up base-d upon the patient's oavu préférences. It is not sufficient that the patient asse»rts that he die! not get as much eare as lie desired : he must show that he was damaged by insufficient eare or in efficient treatment, and that thèse Avère a voidable on the part of the attendant. Qratuitous Services.—Tlie fact that a surgeon rend ers services gra- tuitously does not affect his duty to exercise reasonable and ordinary eare, skill, and diligence.!. Treating a patient gratuitouslv does not give the surgeon license to treat him other than in a scientific and careful manner and AA'ith due regard to his best interests. In fact, failure on the part of a surgeon to render a bill or make some claim for'compensa- * Teft vs. Wilcox, 6 Kan. 44fi ; Hcese vs. Enippel, 1 Mich. X. P. 109 • Gctchcl vs mil, 21 Minn. 464 ; O'Hara vs. Wells, 14 Neb. 403 ; Leiqhton vs. Sargent, °7 X H 4d> ■ Craig vs. Chambers, 17 Ohio St. 2Ô3 ; Bliss vs. Long, Wright (Ohio), 351 ; Griudlc vs' Rush, 7 Ohio, pi. 2, 123. t Elu vs. Tr»76«»-f 49 X. J. L. 6S.A ; Gallaher vs. Thompson, Wright (Ohio), 466; Smith vs. Ili/dc, 19 Vf. 54. j McNerins vs. Loire, 40 III. 209. SURGICAL MALPRACTICE. 579 tion feir the treatment of a case, and the inability on his part to explain this othe*rAvise than upon the ground that the patient AA'as a hospital or dispensai-}' patient cast» Avhich came under bis eare as such, might, in an action for malpractice, and espee-ially in a doubtful or balaneed case, be urged Avith great force as in the nature of an admission of neglect or want of skill on the part of the surgeon—as e»A'iele»nce of a consciousness that he Avas ne>t entitled to pay for bis services, and that the latter Avère Avorthless.* Expérience and Instruction Will Vary.—The law does not demand the most thorough educatieni or the most extensive expérience on the liait of the surgeon—evidently it cannot, because expérience and instruc- tion Avili vary—but it will not e-ountenance quackery. An unedue-ated or ignorant person avIio attempts, under prêteuse of being a qualifiée! me-die-al prae'titioner, to perforai surgieal ope-rations is to be held aeeount- able, both criminally and civilly, for the results of his actions. If, how- ever, there is an understanding between the pat nuit and the surgeon, aa'Iio frankly confesses bis Avant of skill, or even if the patient is made fuUy aware in some other Avay of the lack of knoAA'ledge and ability on the part of the practitioner, lie cannot eomplain of the bad resuit, since this dépends upon the lae-k of those qualifies which lie Avas informée! did not exist.! Effects of Locality upon Standard of Care and Skill.—The stand- ard of skill may not only vary under the Aaiying circumstances already mentioned, but it may differ in différent portions of the same country or even State. Thus, for instance, médical practitioners in rural districts, or even in towns of considérable size remote» from médical centers, al- though Avell read and grounded in the theory of tlie profession, are com- parative-ly seldom e-alled upon to assume charge of graA't» surgieal con- ditions or perforai difficult opérations. Thèse men do not enjoy the opportun!fies Avliich the more fortunate city practitioner ele>es, of daily observation and more or less of constant practice, and it Avould be most unreasonable to ileniand from them the same» degree of skill Avhich hos- pital practice or daily work in a largvr field, AA'itb the opportunities for cenisultation with recognizeel authoritie's and of listening te> or participat- ing in discussions at tbe médical societies upon subjects in AA'hich tliose aa'Iio take part are particularly interesteel and bave therefore studied Avith particular eare, would imply. The Surgeon is Bound to Use the Best that he can Command.— Peculiarities of environment may demand of a surgeon, although eom- parathely unlearneel, unskillful, or inexperienced, in an émergence, or Avliere the» patient cannot, from one reason or another, be transportée! to a hospital or médical center, or pay a skibful surgeon to visit him, the rendering of such service-s as he may be able to give. Under such circum- stances lie may undertake an opération AA'hich lie bas never seen per- formed, or the appbcation of apparatus Avith the mechanism or rationale * 14 Am. & Eng. Encycl. of Law, 81 ; Baird vs. Gillette, 47 X. Y. 18G. t Sheannan & Bedfield on Négligence, §v\ 433-435; Lcighton vs. Sargent, 27 Me. (7 Fost.) 4(>S; Rci/nolds vs. Graves, 3 Wis. 416; Carpcnter vs. Blake, 60 Barb. (X. Y.) ISS; Patten vs. li'iggin, 51 Me. 594; Briggs vs. Taglor, 2S Yt. 180; Landon vs. Huni- phrei/, 9 Oonn. 209; McNerin vs. Loire, 40 111. 209; S mothers vs. Hanks, 34 la. 286; Tcft'vfi. Wilcox, 6 Kan. 46; Howard vs. Grgrer, 28 Me. 97; Long vs. Morrison, 14 Ind. ~><>r>; 11 Am. Rep. 363. 580 A SYSTEM OT LEGAL MEDICINE. of Avhich he is uufamiliar or unacquainted, anel yet be perfectly justifie! in giving such aid as lie can. Ail that the law requires in this connec- tion is that he shall use the best that he bas at bis eommanel, Avhether of knoAvledge as to what to do, skill in doing it, or of apparatus or in- struments. Expérimental Surgery.—The question of expérimental surgery as appliee! te) human beings is one of much hnp*>rtane-e. The buv is rather explicit on the subject, and décisions hâve agreed that a médical man cannot experiment upon his patients Avithout liability to damages, should injury or death f(dlow, and be élue to sue-h expe-riment* It Avould be a question for care-ful cemside-ration em the» part e>f a jury Avhether or not the experiment, under the circumstances, AA'as a justifiable- euie. Feir in- stance, in a condition Avliich would ordinarily be e»asily cured by simple means, and Avhich, if une-ured, AA'ould not give- rise to great dise-omfort, disabilify, eu- danger, it would follow that tlie» application of a dangerous or heretofore mitried remedy or opération AA'hich left the patient in a Avorse» conditieni than before», or resulted in his de-ath, would be folloAved by severe e-ondemnation, ca en Avith a jury en0 médical men. On tbe other hand, Avith a patient suffering from an incurable anel necessarily fatal malaelv, and in whom ail knoAvn remédies ha\'e failed to bring relief, a much Avider latitude of actiem may be permitted the prae-titienie-r. Expérimental Treatment not Necessarily Culpable.—Oeuidemna- tion of expérimental treatment, strictly speaking (for ail treatment is more or h»ss expérimental in a gênerai sensé), may be» carried so far as to ceuistitute a serions bar to progress in médical se-ience». An experi- ment is not ahvays to be regarded as culpable of itself, for the reason that there is not, nor can the-re eA'er be, a légal code containing the rules of médical science. On the cemtrary, the thonghtful and scientific phy- sie-ian Avili ahvays endeavor to individualize each case in its treatment, and preiceed in accordance» Avith the dictâtes of his own judgment. He is therefore often justified in acting in opposition to established rules. Progress in médical science dépends upon independent rese»are-h and the free sélection of methods of procédure. Therefore not even an untoward resuit of a course of treatment differing from that which is ordinarily pursued need necessarily, as has been assumed, be construed as mal- practice. Even good results do not ahvays protect the surgeon against reproach. A new and, therefore, untried procédure may, despite the fact that the patient died in conséquence of its employment, be regarded as rea- sonable and justifiable. This is just as true as the proposition that a standard operative procédure in which ail the rules laid down by author- ities are folloAA-ed frequently fails to save the patient, and may even be directly held responsible for his death. If the surgeon is able to give such reasons for his course as are satisfactory to scientific men, and lias employed the new procédure with eare and 'due attention to ail of the possibilities in the case, and in good faith, then he is not to be mulcted in damages because of an unfortunate outcome of his effort to improve upon older, and probably not more satisfactory, methods. Improper Introduction of Non=Professional Persons into a Case.__ The introduction of a non-professional person into a case, and in whieh * Pattcn vs. Wiggin, 51 Me. 594. 6'URGICAL MALPRACTICE. Ob'î no necessity exists for his présence or assistance, may render the prac- titienier and the intruder liable for AAliatever damages may haA'e been sustained by the patient. In the recorded instances in which the parties committing the offense Avère held liable, the patients were women in con- finement. The offense Avas not mitigated nor the right to recoA'er al- lée-teel by the fact that both the patient and lier husband supposed the intrude»r to be a médical man and therefore made no objection to his présence.* The fact that the intruder Avas an unmarried as well as a nonqu'ofessional man seems to bave affected the que»stie)ii, so far as the cases eiteel are conce-rne'd. But tliere are other considérations aside from tlieise of shanie anel modesty whie-h Aveiuld serve as a basis for a suit for damage's, such, for instance, as those relating to privdeged communica- tions, the présence of venereal éruptions upon the skin, etc. Burden of Proof and Matters in Défense.—As to the burden of proof, this fedlows a gênerai rule with Avhich attorneys are famibar, and AAdiich need only be casually alluded to in this connection: "As to the order of the production of évidence, it is held that the burden of proving any fae-t lies upon the party who substantially asserts the affirmative of the issue."! Where the surge-on is put upon the defenshe and enters a de»nial of the claim for damages, the plaintiff must prove in an affirma- tive manner ail of the essential and material éléments entering into the négligence as specifically charged. Not only this, but tliere must be a prépondérance of évidence, not only in thèse respects, but particularly where Avant of skill or knoAA'ledge is charged, before the verdict of a jury can be claimed. in favor of the plaintiff. Most especially is it necessary for the plaintiff to estabbsh an exact etiological relation between the resiilt of the alleged malpractice and the négligent, careless, or willful maltreatment. In addition to this it falls Avithin the province of the inepiiry whether there are not causes other than those relating to the procédure e-emiplained of which may be held partly or wholly responsible for the failure of tlie tivatment. Furthermore, the question arises as to Avhether or not the methods employed and alleged to be faulty hâve been folhiAved by successful results in analogous cases. Finally, the justifia- bility of the procédure, providing it be a neAv one, should be discussed upon a purely scientific basis, the question as to the propriety of its employment depending largely upon whether or not its rationale can be explained upon scientific principles, or appeals to the unprejudiced minds of s*-ie»ntific men. Contributory Négligence.—It is a Avell-defined principle of laAV that upon each person devolves the élut}' of exercising reaseniable eare, dili- gence, and prudence in avoiding personal injuries as avcII as damages or losses resulting from the- Avrongfid ae-ts of others. Perse m s who are ill and under the eare of a professional attendant can no more ese-ape the respemsibility arising from failure to observe this rule than he who Avalks the street. ïlence it folloAvs that if there is shown any Avant of ordinary and 4)1-04)1-1- eare and diligence on the part of the patient to avoid the conseque-ne-es Avhich may arise from malpractie-e, he may be chargeable with e-ontributeny négligence, and this plea may be set up in défense of the action 01* in mitigation of the damages claimed. The plaintiff, if this * De Mail vs. Robcrts, 46 Mich. 160; 41 Am. Eep. 154. t Field'sAlcdico-Lcgal Guide, p. 218; Field's Bricfs, § 310. 5S2 A SYSTEM OF LEGAL MEDICINE. contributory négligence on his part is proved—and the burden of proof of this is upon the défendant*—will be debarre-d from receivering, or, at the most, it will be found that lie e-an reeoA'er only to a limitée! extent. The bmit to be placée! upon the amount AA'hich he will be» able» te) re-cover will be governed by the extent to AA'hich it Avas iu his power to prevent the damage inflicted, by the» exere-ise of ordinary and reasonable e-are and diligence, t Therefore, AA'hile a surgeon is liable for any injury caused the patient by the Avant of that ordinary skill and diligence AA'hich an intelligent and reputable member of the profession would use under the same circumstances, and Avhich the laws of the country require, yet if the patient neglects or refuses to make use of the remédies prescribed, or deediiies to permit a necessary opération to be performeel, it goes without saying that he thereby absolves the attending surgeon from ail responsibility for any injurious conséquences that may oce-ur, if such neglect or refusai can be shown to be a proximate cause of tlie injury ; eA'en though the surgeon may bave failed to enqdoy that degré*» of ordi- nary skill and diligence which is demandée! under the hnv, still, if the patient contributes to the injury by any failure on his oavu part or on that of his attendants to properly ce)é)pe»rate with the médical attendant, it has been held that he cannot recover damages for such injury. $ The proposition last stated does not hold good in mitigation of dam- ages where one person bas received a personal injury from négligence on the part of another ; in other words, the ordinary personal-damage suits of the courts are not criteria in thèse cases. Under thèse circum- stances the claim for damages on the part of the plaintiff cannot be offset or the amount reduced by reason of bis failure to secure the most skillful professional aid, providing lie lias used reasonable and ordinary eare. § Eléments of Pecuniary Damages.—The éléments of the pecuniary damages which may be sustained in any given case hâve been classified as : (1) loss of time and labor arising from the injury sustained by the malpractice ; (2) the reasonable expenses incurred for surgieal, médical, and other attendance ; (3) diminished capacity to work at the trade or business of the injured party in conséquence thereof; (4) bodily pain and mental anguish in conséquence thereeif. In addition to thèse a jury may take into considération the fact of permanent disability and proba- ble future disability and suffering, the principle hère being the same as that which is applied in estimating damages for personal injury. || In fact, when the éléments of fraud, malice, gross négligence, or oppression are introduced into the controversy the case permits the jury to give punitive, \dndictive, or exemplary damages, fl The plaintiff in an action for malpractice is not entitled to, nor should he be permitted to recover, damages on account of the pain and suffering * Gramm vs. Boener, 56 Ind. 497. A contrary rule is adopted in Iowa : Baird vs Morford, 29 la., 531. t Field's Latrgcrs' Bricfs, $§ 445, 446; Field's Medico-Legal Guide, p. 221. f Geiselman vs. Scott, 25 Ohio St. 86; Lower vs. Tranks, *115 Ind. 334; Chamberlain vs. Porter, 9 Minn. 260 ; Hibbard vs. Thompson, 109 Mass. 286 ; 36 Am. Rep 668 ■ Botter vs. Warner, 91 Pa. St. 362 ; West vs. Martin, 31 Mo. 375 ; Jones vs. Anàell Q<ï Ind. 376; O'Hara vs. Wells, 14 Neb. 403. ' J ' V° § 32 la. 324 ; 7 Am. Rep. 200. || Field's Medico-Legal Guide, p. 225. f Seg. on Damages, p. 38; Field on Damages, § 26; Brooke vs. Clarke, 57 Tex 105. S UR G ICA L MA LPRA CTICE. 583 resulting from the disease itself. Thèse are to be limitée! to the addi- tional pain and suffering caused by the négligence or Avant of proper eare and skill on the part of the défendant.* Partnership Liability.—In case two or more surgeons are assoe-iateel together in practice as partners aU are liable for malpractice by any member of the firm.t Action Barred by Recovery for Services.—A receivery by a surgeon for his services will bar a future action for malpractice-, as a rule. Ex- ceptiems to this will be found in some States Avliere it is held that if the recovery be by confession or default it is not a bar. f CRIMINAL LIABILITY FOR NEGLIGENCE OR MISCONDUCT l'XDER SPECIAL STATUTORY PROVISIONS. As previously stated, in the United States there are pénal statutes, differing somewhat in the différent States, Avhich provide for the pun- ishment of médical practitioners for negligene-e or misconduct, in their professional capacity or in the course of their emphyment or business, Avhich causes eleath. The law is held to apply, in some States, to dealers in drugs and medicines avIio by carelessly labeling a tleadly poison as a harmless medicine inflie-t an injury or damage to persons without fault on their part. The folloAving extracts bear upon the point of criminal liability for négligence» : ** A person Avho, bv any act of négligence or misconduct in a business or empleyment in Avhich he is engageel, ... or by any unlaAvful, négli- gent, or reckless act, . . . occasions the death of a human being, i s guilty of manslaughter in the second degree." The abo\re paragraph has been held to apply to druggists as well as to practitioners. § ** A physie-ian or surgeon, or person practicing as such, who, being in a state» of inteixication, 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 guilty of man- slaughter in the second degree." || GENERAL CRIMINAL LIABILITY AT COMMON LAAV. Under the common law, as well as under spécial statutory enactments, a physician or surgeon avIio, by his culpable négligence, causes the death of his patient is guilt}' of manslaughter. A person AA'ho unlawfully en- gages in the practice of the profession of medicine and causes death by the application of means which he may even believe will be of benefit to * Wenger vs. Cahier, 78 111. 275. t Hi/ruevs. Eririn, 27 S. C. 226; 55 Am. Rep. 15; Whittakcr vs. Collins, 34 Minn. 299. f L'esseguie vs. Bi/crs, 52 Wis. 650 ; 38 Am. Rep. 775 ; Ski/es vs. Bonner, 1 Cin. Sup. Ct. 464; Goble vs. Dillon, 86 Ind. 327; 44 Am. Rep. 308; 14 Am. and Eng. Encycl. of Law, 83. § Pénal Code of New York, § 195; Thomas vs. Winchester, 6 N. Y. 397. H Pénal Code, § 200. 5S4 I SYSTEM OF LEGAL MEDICINE. the patient, would be- guiltv of manslaughter* Gross ignorance», gross care-lessuess, rashne-ss, or Avant of proper précaution on the part ol sue-h a pretender cemstitutes manslaughter at common law.t A person who mav assume» to act as a physician or surgeon is not criminally liable for'the death of a patient caused by the meeliciiu-s Avhich headministers, provided he acts in good faith and to the best of his abilities, and does not prétend to be a physician, and is known not to be such.l In the absence- of statutory provisions upon the subject, the gênerai rule applies. Under this a ivgularly epialified physician and surgeon le-o-allv authorized to practice his profession cannot bc held criminally responsible for an honest error of judgment in the treatment of his patient, although sue-h treatment may e-ause» bis death.§ Failure» on lus part, he>Aveve»r, to nie-e-t the requirements of ordinary skill and diligence, the death of the- patient resulting from bis gross ignorance, inattention, or e-are-lessness, or from criminal mise-onduct, being sbeiAvn, lie Avould lie held guiltv of manslaughte-r 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 spécial statutory enactments or at common law, tins does not constitute a bar to a civil action which the patient may bring against him for damages arising from such malpractie-e». The fae-t that the défendant had already suffered punishment for the offense Avould not eve»n affect the rights of the plaintiff in such an action in recovering punitive damages, where, under the circumstances, such damages are allowable.fl THE MISHAPS OF SURGICAL PRACTICE. GENERAL CONSIDERATIONS. There are certain accidents occurring after injuries and opérations which may be looked upon as unavoidable to a great extent. Among thèse are to be included traumatic debrium, debrium tremens, fat em- beilism, and intoxication by fibrinous ferments. Among the accidents Avliich 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 anaesthetics. Traumatic Delirium.—Traumatic debrium may attack old and en- feebled patients as Avell as those who were in perfect health prior to the occurrence of the accident. It may resemble the somewhat peculiar form of debrium Avhich attacks drunkards following an injury, the symp- * Marsh vs. Daridsou, 9 Paige (N. Y.), 579. t 1 Haies, P. C. (Eng.) 429 ; 4 Bl. Corn. 197 ; Rex vs. St. John Long, 4 C. & P. (Eng.)- 432 ; Rex vs. Van Butchel, 3 C. & P. 333 ; Rex vs. Ellis, 2 C. & K. Eng. 479 ; Rex vs. Spiller, 5 C. & P. 333; Rex vs. Williams, 3 C. & P. 633. f State vs. Shultz, 55 la. 628; 39 Am. Rep. 187. § Field's Medico-Legal Guide, p. 192. || Wheeler's Criminal Reports (N. Y.), p. 312; Commonwealth vs. Thompson, 6 Mass. 134: 11 Am. Rep. 122. f, Hendrickson vs. Eingsburg, 21 la. 379; Coririn vs. Walton, 18 Mo. 71; Hadley vs. Watson. 45 Yt. 289; Roberts vs. Mason, 10 Ohio St. 277; Childs vs. Drake, 2 Met. (Kv.) 146; Field on Damages, §§ 436-139. SURGICAL MALPRACTICE. 585 toms of inability to sleep, anorexia, and delusions being présent in both. Prominent among the latter may be mentioned the grasping at imagi- nary small animais and attempts to escape from imaginary dangers. The latter are much more pronounced in delirium tremens, hoAvever, than in traumatic delirium. Fat Embolism.—Fat embolism occurs probably in almost aU fract- ures to a greater or lesser extent ; in addition it may occur where there is injury to the stomach or boAvels while fat which is undergoing digestion forais a portion of the contents of the latter. In the case of fractures the fat is derived mainly from the medullary cavity, and in addition to tins source it may be derived, to a certain extent, from the subcutaiieous 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 aa'Iio die almost immediately following injuries involving fracture of bones, the drops of fat may be demonstrate*! in the lungs by post-mor- tem examination. The particles of fat are broken up as they pass through the capiiïaries, becoming reunited in the larger trunks, until at last they are» excrétée! by the kidneys. (Mansell Moulin.) While in the vast majority of cases no symptoms may arise, it occasionally happens that collapse cornes on, too late to be attributed to shock, but superven- ing after an interval of several hours. Dyspnœa and syncope, with rapid fall of température, are the characteristic symptoms. Intoxication from Fibrin Ferment.—The causes of intoxication from fibrin ferment are obscure. This is looked upon as one of the feA'erqiroducing agents not necessarily of a septic eharaeter in the sensé that they dépend upon an infective organism. The source of the fibrin ferment is the broken-down blood-clot following hemorrhages. It follows subeutaneous injuries in which décomposition in the sensé of putrefac- thm does not take place. It produees one of the varieties of traumatic fever, the température rising in proportion to the amount of the extrav- asation. It is more than probable that other substances, set free from crushed and braisée! tissues, likewise give rise to traumatic fever. The heiglit of the fever is reached in about tAventy-four hours ; its duration dépends upon the amount of irritant material présent anel the extent of its absorption. In the average cases the fever subsides in about forty- eight hours, but it may last for a Aveek or more, the fever, howeA'er, steadily falling after the first twenty-four to thirty-six hours. It may assume a rémittent type. Tetanus occurs most frequently in wounds accidentally inflicted, par- ticularly in punctured and penetrating wounds, and in those in which a foreign body remains behind. Its existence is now believed to dépend upon the présence of a spécial organism, the Beu-illus tetani. A variable length of time is occupied in the period of incubation, according to the number of bacilli introduced ( Watson Cheyne), the location of the point of infection, the anatomical characteristies of the surrounding tissues, and the capacity of the différent tissues to yield the ptomaïnes under the influence of the bacillus. It is also probable that the degree of viru- lence gOA'erns, to a certain extent, both the duration of the stage of incu- bation and the seAerity of the attack. The» questiem is sometimes raised as to the propriety of remoAÙng foreign botlies AA'hich hâve remainee! in situ for perhaps months in those patients in Avhom thèse bodies are supposed to be the cause of the dis- 58xvge-n in order te> groAV, it is evielent that a puneduivel wemnd epiieklv closed offers just the conditions appropriate for the reproduction of "the gerin, if it bas been introduced into tbe depths of the avouikI. In wounds of this eharaeter, particularly if they hâve» been received in a hx-ality where te-tanus frequently follows trivial wounds, as on the south siele» of Long Island, the wound should be well cleanseel, anel enlarged if necessary for this purpose, anel tre-ated with tampons of gauze wrung out of a 1-1000 bichloride-of-merc,ury solu- tion, and healing by granulation ene'ouraged, rather than union by first intention. Uncontrollable Hemorrhage.—Tins is among the most unfortunate accidents of surgery. Rigidity and brittleness of an artery, or its retrac- tion beyond oui* reach, in spite of dilatation or eve-n enlargement e>f the Avound, may bring about this resiilt. Ilemorrhage-s from large venons trunks are the most dangerous. Before the fae-t that hemorrhage- from a large» ve-in could be- influenc*-*l by ligature of the eorrespemding artery Avas established, ble»eding from the- internai jugular en- fémoral veins aa.is consielcred as almost necessarily fatal. In henmphiliacs the slightest opération may cause an almost uncon- trollable hemorrhage. The application of the actual cautery is most usc- ful, and e'emqiression is sennetimes efficient. If the compressing meelium is such as te> imitate the finger, i.e., imperméable, elastic, and easily cleanseel, a great adA'antage may be gained by its use. A buncb of cot- ton or a soft sponge1, Avrappeel in î-ubber tissue, the layers of the latter being gummeel together by moistening their edges Avith chloroform and pivssing the moistened surfaces firmly upon each other, ansAvers an excel- lent purpose. Such a tampon, if kept applied so as to make firm com- pression anel to dam back the Aoav of blood from the point at which it escapes, Avili be found an efficient means in a e;e-rtain preqxn-tion of case-s. The most rapidly fatal cases of hemorrhage are those» in AA'hich septie; processes—gangrené, etc.—invade the structures of the A'essels them- selves. The opération of transfusion of blood requires, in order to carry ont the necessary précautions and technique, the eonsumption of se) mue-h time that surgeons are coming to bave less and less confidene-e in this procédure as an available means of combating the eA/il results of excess- ive loss of bloe>d. Without due préparation and the employment of proper instruments, ande\Ten AA'ith ail thèse conditions fulfilled, the-re? xvill occasionally ex-cur such accidents as the- injection of coagula or of air Avith the transfusée! blood. While the» firsf-named may be aA'oided in sabne infusion, AA'ithout due eare the second may occur. As to hoAv much SURGICAL MALPRACTICE. 5fc>7 benefit may lie derived from transfusion of blood, or saline infusion in a given ease, en- Iioav much the surge-ou may be held responsible from the scie-ntific standpoint for failure to employ it in fatal cases, is yet a matter of doubt. As far as my own experie-ne-e goes I bave never seen a case of acute anamiia benefite-el by either of thèse procédures that, in ail prob- ability, Avould not hâve donc Avell without such interférence. Certainly a much larger pereentage of re-cove»ries in extrême cases must be recorded before a surgeon can be justly blamed for omitting to use them. Sepsis.—Within the last quarter of a eentury tliere hâve been dis- e-em-ries made and principles established in the treatment of so-called wounel eliseases, or sequehc of avouikIs, AA'hich bave almost completely changed the science and art of surgery, and increased the responsibility of the surgeem to an extraordinary degree. Diseeiveries in the treatment of internai diseases, or e)f methods of preve-nting them, can never bring to the medie-al practitioner that degree» e>f increased respemsibility AA'hich bas characterized the introduction of those ik-av principles in the treat- ment of Avounds to Avhich I refer. The reason for this is obvious : the médical practitioner never produces the conditions AA'hich render jiossible the présence of the disease AA'hich lie bas been called upon to treat, and henee his measure of responsibility deies not extend, to an extrême de- gree, te) the prévention of the disease. The only exception to this, per- haps, wdl be found in those comparât!vely rare instances in which, dur- ing the prevalenee of an épidémies, such a demand is made upon the nie-elical man. But, as a rule, lie finels the enemy already présent and iiitrenehed, perhaps, behind what may seem an impregnable line of dé- fenses, and, feeling no resjxuisibility for his présence there, his duty is simply te» dislodge him. The saine remarks might apply to the surgieal practitioner in his rela- tion to Avemnd treatment if it Avère» a fact that the wounds AA'hich he is called upon to treat Avère the residt of accident, or were made by others than hiinself. But, as a matter of fact, tAvei thirds of the wounds which come under the eare of operating surgeons are maele by the surgeons themselves, and henee his responsibility for their treatment. Fiuther than this, it lias been de-monstrateel that almost ail disturbances of the repair of the Avound itself, anel in addition tliose of the gênerai system with their dread results, knoAvn under the gênerai term of blood-poison- ing, are due te» putrefacthe prex-e-sses AA'hich bave their origin in ferment- ative conditions AA'hich hâve been familiar to us for many years. With the dise-e>very of this fact, and the means of preventing the occurrence of the train of events leading up to its full development, began neAV obligations and îrspousibilitie-s. From the» earliest times, AA'ithout exactly knowing why, surgeons prac- tieeel occlusion of Aveumds, and in true emphïcal fashion lauded first this and then that ointment or lotion, ahA'ays, however, clinging to the idea that the» latter must ceiver the parts and " protect " them. When the idea that contae-t Avith the air causée! mischief in the Avenmd Avas thought of, the température of the air Avas generally considered to be the origin of the trouble ; and even iioav, among the laity, it Avili he found, as the resiilt of the teachings of earher authorities, that any niishap, such as erysipelas, occurring in a wound is attributed to "catching cold."' Ambroise Paré aelde-el to the theory of cedel the belit»f that the air e-arrieel AA'ith it e-ertain miasms ; and Benjamin BeU, in late-r times, taught that gases, mingied 588 A SYSTEM OF LEGAL MEDICINE. with the air. Avère a potent source of evil. Undoubtedly the large anel varied expériences of thèse older surgeons led them to plan and adopt many methods which in the light of our présent knowledge would pass fairly well for autiseptic procédures; aud without doubt tlieuse- of aviiu-, turpentine, brandy, aluni, commun sait, etc.. relatively efficient antisep- th-s in their Avay, was by them considered the essential portions of the balsams and ointments then in use, although they searcely dared to omit Avhat avc» now regard as the- superstitions anel ridiculems éléments of thèse conqxnmds, such as serpents, eartliAven-ms, hunian fat, ete-. In the earbest times one thing seems to bave been entirely lost sight of, namely, the intrinsic tendeney on the part of wounds to heal if left alone! Xo one dared trust anything to nature, and, in the absence of the usual and popular measures directed toward making the flesh groAV and the Avound e-icatrize, it Avas imagined that aU sorts of evil would cer- tainly occur, and that healing would not take- place. In those times, like- wise,'there seems to bave been a dread of healing by first intention or immédiate union. Tents or pledgets of but were croAvded constantly into wounds to keep their edge-s apart, for fear of pent-up humen-s giv- ing rise» to e-onstitutional disturbance—fever, etc. Thus it will bc seen that the importance of drainage to the parts Avas not overlooked. Among the common jn-e^de of senne country districts, it is considere-d a great advantage to hâve a Avemnd ''heal from the bottom," as they express it. At the présent day the putréfaction of discharges in avouihIs consti- tutes AA'hat is knoAvn as a septic e-enidition of a AA'ound. This putréfaction depe'iuls upon a fermentation, AA'hich may or may not be accompanied by the deA'elopment of off en she odors." Fermentation, according to Fownes, may be defined as a "iic-av arrangement of the éléments of an organic compouiid, and the conséquent formation of new prexliu-ts." Changes coming under the head of this définition are known as the resiilt of Avhat is ternied catalysis. Ferments are elhdeled into two classes, ont» recehing the name of -'chemical ferments/' AA'hile the term " A'ital " is usually applied to the other. In the catalytic change knoAvn as e-hemie-al fermentation the décom- position of one boelv is effected by the mère présence of another, the latter remaining unchanged. Thèse ferments, as bas be-en again and again demonstrated, bave not the power of self-multiplie-ation. Familiar examples of chemical fermentation may lie e-iteel in the action of the pepsin of ga strie juice, the ptyaline of saliva, etc. On the other hand, the ferments knoAvn as vital ferments possess the power of self-multi- plie-ation in a remarkable and unlimited degree. The yeast-plant is the most familiar example of tins last-mentioned class. In ls:;i Braconnet advanced the opinion that microorganisms acted as vital ferments, or that they produced in the process of self-multiplication virulent prin- ciples which acted as such, although this had been suggested in the beginning of this century. In the next fhe years followed Doaviics's discoAcry of the presene-e of microscopic organisms in the see-retions of certain \-enereal sores, and during the folioAving fifteen years Fuehs anel Pollender demonstrated the 4>ivscne-e of bacteria in the blood of some of the loAver animais suffering AA'ith septic diseases, notably of cattle dying of the disease» knoAvn as charbon. But it Avas reserved for Louis Pasteur, in l^fil, to bring ont from the mass of imperfect knowledge of the sub- SURGICAL MALPRACTICE. 589 ject at that time available, and to add tliere to as the resuit of his own brilliant Avork, facts which led at once to a proper conception of the rôle played by thèse microorganisins in the production of elisease. The theory of the relation of putréfaction to fermentathe proe-esses was naturally applied to pathological conditions at once, and the genius of Lister applied the principle to the explanation of certain phenomena folloAving Avounds iiivohdng the surface of the body. The beautiful and simple experiment of Tyndall of iinprisoning in a glass tube dust from the atmosphère, anel shoAving its prese»nce by the aiel e>f a fugitive sun- beam impressed into the» serA'ie-e for the time being, suggested the source of the putrefactive agents. Thus Avas started a train of scientific re- seareh which has almost completely reA'olutionizeel the surgieal world. The literature of the last t\venty years has been literally teeming AA'ith the results of experiments, until there bas sprung up a class of speeual workers knoAvn as bacteriologists, Avheise further researches, by means of positive methods and instruments of tlie greatest précision, bave ail teneled to confirm the principle laid down by Lister, and upon AA'hich is founded the modem tivatment of Avounds. Accessory Wound Diseases.—A number of ce nidifions may be grouped together under the head of ae-e'essory wound diseases, any one of Avhich may occur as a e-omplication folloAving the inflietion of a Avound. In this grouping together of thèse disen-ders it Avili be understood that, as a rule, they haA'e nothing in common except the fact that the»}' are due to the presene-e of mie-roorganisms. As before stated, thèse micro- organisins play the» part of the ferment, and set up changes resulting in putréfaction ; a multiplication of the original ferment, or, in other Avords, an increase of the microbes, occurring at the same time. To tins putrefae-tion or groAA'th of baederia are due the much-dreaded diseases erysipelas, pya?mia, septicœmia, hospital gangrené, etc. Starting Avith the pr*q)ositions that subeuitane-ous injuries rarely suppurait», and likeAvise»^ that they heal rapidly compared to open AA'ounds, that putre- fae-tive changes in wounds ahvays retarel their healing, and that it lias been sIioavii by care-fully e-onducted experiments that the injection of putrid fluitls into the blood of healthy animais will produce symptoms AA'hich e-an only be compared to tliose pathognomonic of septic in- fection as we meet it in wound diseases, thèse conchtions led Lister to apply the knoAvledge thus placed at his disposai to the elevelopuunt of the» method of Avound preitee-tieni AA'hich bears his name. His distinct aim, as shoAvn by bis earliest writings upon the subject, AA'as to plaee a barrier against tlie- entrance of grrms, from whatever source, including the air, into and about wounds, and his avci-c the first systematic attempts to formulate aud put into practice a method of Avound treatment based upon the germ theory of the origin of wound eliseases. True, carbolic acid, AA'hich he first empleyed for the purpose of destroying the germs, as Avell as other substances noAv knoAvn to be» aiitiseptic agents, were in use in the treatment of Avounds, but not as germicides. Lister's first attempt simply brought ridicule upon him from his col- lcagues ; he worked steadily oii, however, modifying and perfecting his plans, making use of common putty mixed with carbolized oil as a dress- ing, and operating under the inadéquate protection of a large carbolized sponge, until at last he arrivée! at the procédure now generally known as the Listerian. Less cumbrous dressings aud tremblesome détails haA'e 590 A SYSTEM OF LEGAL MEDICINE. made antiseptic and aseptic surgery a less formidable unde-rtaking than in the past, vet the îrsults obtained by those avIio followed rigorously his teachings nave brought us well beyond the threshold of a new era in surgery. A point wortiiy of note in this connection relates to thy exist- ence of microbes upon and about the Avound and its dise-barges, inspit*- of the application of antiseptic elressings, and, coincidently, an uninter- rupted course of healing em the- part of tlie wound. Cheyne, who biought out tins point verv fully, seems to regard thèse- microbes as innocent, so long as they belong euily te> a certain class. Certain it is that fermenta- tion leading to putréfaction does not ahvays folioav upon the» présence of microbrganisms. There can be ne) reasonable doubt that the- inve-sti- gateu- of the future-, with improved means of investigation, will demon- strate as many points of différence betAveen thèse- minute organisms as are uoav knoAAii to exist, bctw*»e»n vertébrale animais. If they Avère ail equally harmless no amount e>f expeisure» t)f AA'ound surfae-e» to their influ- ence could be productive of evil; while, em the other hand, if they were ail equally hurtful, noue- Avemld be found in the aseptic wounds. The surgeon of bygone times performed the- needful opérations as skillfully, perhaps, as it could be done to-day, but lie thereafter relied for the final îrcovery of the patie-nt mainly upon good fortune» and means Avhich Ave iioav look upon as inefficie-nt, if not positively h arm fui. As a resiilt the measure of his sue-cess Avas tex) often Ixyenid his con- trol anel iiidependent of his own e-ffeuts. Tbe surgeon of to-day, ht)AV- ever, assumes, in the main, the- ivsponsibility for the after-e-euirse of the Avound lie inflicts : the occurremee of any ae-cident having its origin in the Avound, and the residt of thèse disease»s, may be found to be du*» to coneiitions to a great extent within his control. The development dur- ing the- past twenty ye-ars of the» modus operandi of a successful method of Avound treatment, based upon a principle AA'hich preA'ious to that time had never entered into the history of surgery, has arrive-d at such a state of perfection that in most case-s of earefully planned and pirmeditated opération a fatal resuit should not occur, dire-eth traceable to the Avound itself. Most surgeons AA'ill agrée that, provhled a Avound does not in- vohe some organ of vital importance, anel de)es not preive fatal from shock or hemorrhage, and is treated with rigiel regard to tbe exclusion of gérais, a favorable imme-diate resiilt ma}- be expected. Its edges are not inflamed and the surrounding parts are» not greatly swollen nor infil- trateel. The discharge is slight and is ge-nerally the» oozing of a clear or but slightly turbid fluid, for the appearance of pus containing bae-teria indicates that it is not strictly antiseptic. Provided the edges of the wound are Avell coaptated immédiate union will folio av, unless the sur- rounding parts are bruised, or the vessels supplying the parts prevented from performing their function, thèse latter e-onditions favoring death of the tissues or sloughing. The aphorisms of aseptic and antiseptic surgery bave been generalh' approved and acce-epte-d ly ail the leaders of surgieal thought—in other words, the authorities of the présent day. They, therefore, must be re- garded as principles of practice firmly established, and be respected as such until new théories and procédures are advanced and accepted regard- ing the undoubted favorable influene-es AA'hich ase-ptie- measures and anti- septic agents exert OA'er the process of Avound healing. From the first moment that a surgieal operative case involving the production of a SURGICAL MALPRACTICE. 591 Avound e-omes under the eare of the surgeon until the case is coneluded and tbe last pièce of bandage is removed, thèse principles of aseptic and antiseptic surgery should govern the action of the surgeon. Not only Avili the»y contred the question as to the justifiability of operating at ail, butas to the particular kind of opération best adaptée! to main tain a proper condition of the Avound as regards protection and drainage, as well as the methods to be pursued in tbe conduct of the opération itself. In explanation of tlie asse-rtion that thèse principles should control the ques- tion of the justifiability, or otherwise, of operating at ail, it may be said that opérations are now suecessfully performed which heretofore Avère either unknoAvn or condemned almost in the same breath in Avhich they Avère suggested. Surgieal diseases and the results of injuries, as a con- seepience of the development of the principles of aseptic and antiseptic surgery, are now ame-nable te) operative procédures which formerly A\'ere considered as eminently of a fatal eharaeter, or which doomed their sub- jects to lifeloug invalielism. The surgeon avIio fails to resort to thèse ne»AV opérations because» of their danger when performed according to the older methods to which lie» still adhères, or who, performing them, fails to give» his patient the advantage-s of the prote-e-tion from suppuration and its eoiisequene'es AA'hich the proper carrying ont of aseptic me-asures, antiseptic précautions and treatment assures, as Avell as ail other recog- nized means at his command for the furtherane'e» of his patients interests, cannot escape the responsibibty feu any ill results that may follow. The surgeon AA'ho fails to give his patient the benefit of the immunity from danger which the asi'4>tic and antiseptic methods secure is certainly re- sponsible for AA'hat folh)Ws. The responsibility is growing year by year, as evinced by the uttereel opinion of one of the first surgieal authorities of Eurape», the late Professor Billroth, of Vienna, who has saie! that fail- ures in the treatment of wounds at a AveU-ordered surgieal clinic bave beconie as rare as accidents on a well-managed railway. The Surgeon's Responsibility for Failure when Aseptic and Anti= septic Principles are Violated.—The rule that the surgeon is in a great measure responsible for the evil results due to a failure to apply the aseptic and antisiqitic principles to the treatment of the wounds made by himself will not be invalidatetl by the asse-rtion occasionally made, that tlie-re are still surgeons aa'Iio do not subscribe to the claims made on behalf of aseptic or antiseptic prine-iples, nor use methods of any kinel based thereon, anel who, nevertheless, obtain quite as gooel results as do those avIio claim to folloAV thèse rigidly. A study of the methods employée! by thèse surgeons will frequently reveal the fact that they are most scrupulously clean and e'areful in ail their procédures, in striking contrast to tliose pursued before the» advent of antiseptic surgery. The plentiful use of soap and water to cleanse the parts to be operated upon and the instruments employed, as well as the eare of the surroundings generally, eA'ince a bebef, if it is not definitely expressed, in the impor- tance of excluding noxious matters from the possibibty of contact Avith Avound surfaces. XotAvithstanding their disclaimers, thèse surgeons \dr- tually practice aseptie' surgery. Those exceptional instances in which the utter disregarel of the employment of antiseptics is noticeable occur in the» praedice of certain specialists in abdominal surgery; anel it is in the e-lass of cases coming under the eare of thèse most expert and rapid opéra tors, in which cleanliness is assumed, and Avound surfae-es are 592 A SYSTEM OF LEGAL MEDICINE. exposed but for a comparativelv short time to the action of ge-rms, that most phénoménal sut-cesses occur. But that this will folloAV in gênerai surgery and among gênerai surgieal practitioiiers it Avould be most absurd to claim; and until singeons avIio pursue the course of simple e-le-an- liness shall estabbsh tins or some e>tln»r iirocedure as the saf'e-st te» pur- sue iu the différent branches of surgieal art, the antiseptic as Avell as aseptic principles of wound treatment, established by the sanction and practice of the highest authorities iu the world, must remain, as they do to-day, the prope»r basis of a judicial estimation of the extent of the re- sponsibibty anel chil obligation of the operating surgeon. Nothing can lessen the force of the» civil obligation, or re-lh'A'e the responsibility of the practitioner who, either through Avant of famibar- ity Avith the principh-s and practice of the method, or a failure te> supply himself with the necessary appliane-es, fails to give te> every 4)atient com- mitted to his eare, to be-e-ome the subject of an opération, if ever so tri- fling, the benefit of the greatest measure of sue-ce-ss AA'hich is possible. Tliere is searcely any condition in life, or any circumstances, under whie-h the application of thèse prine-iples is not possible, |>roA~ide-d they are thoroughly understood. Certainly in opérations Avhie-h are eleliberate-ly planneel tliere can be no question about the truth of this state-ment. Only in the case of wounds ace-identally reerhed e-an exerption b*» taken to this ride. Difficulties of technique», cumbersoiueness of materials, and the possible harm to the patient from the use of the poisonous antiseptic agents employed, bave ail been urged as reasons for not adopting the antis*»ptic treatment, in addition te> the expressed disbelief in its aeh'ant- ages and in the truth of the statements made by its advoe'ate-s. But complicate-d typical Lister dressings bave been replaeed by much simpler means, Avithout losing any of the advantages to be derived from the original methods, anel antiseptics of a nem-poisonous nature are available to tliose who fear to use the more powerful germie-ides. In shent, the rules are so simple and concise, and the prinedple so easily applied, that no surgeon, loeated eA'en at a point remote from the sources of supph of the dressings themselves, can bave any valid excuse for failing te) follow them, even if it involves the improvising of dressings from sucli crade materials as can be readily obtained in the humbles t abodes of the poor. It is, therefore, the duty of every surgeon, AA'hen treatiiig a wound or performing an opération, to use a rigorous aseptic procédure, i.e., to prevent sepsis, and employ antiseptic measures in addition, in e-ases in AA'hich septic conditions already exist. The sélection of* the methods to be employed in individual cases must be left to his oavu discrétion, how- ever, and this will be directed by his own se-ientifie convictions, and also, perhaps, to some extent, by accidentai surrounding circumstances arising from peculiarities.of environment of the patient. The Surgeon is not Bound to Follow any Specially Planned Pro= cedure.—The principles being established, no spécial procédure can be insisted upon. The mère covering of a wound with a pièce of protective or a laver of antiseptic gauze does not constitute an aseptic or au antisep- tic procédure, however, if the surgeon does not use them correctly. The sélection of a recognized method and its application in such a manner as to offer a bander against infection AAdll protect the surgeon from re- proach and punishment in case of failure. In protesting against holding the surgeon responsible in case he does SURGICAL MALPRACTICE. 593 not feilloAv a specially planned method which has given apparently per- fect results in the hands of other surgeons, no more forcible argument can be employed than that AA'hich calls attention to the personal-equation factors as they relate to the operator as well as to the individuality of the e-ase itself. In the refinements of art the artist, individually, takes the prominent part himself—" Si duo faci unit, idem non est idem.'11 Circumstances may arise which render a perfect aseptic or antiseptic procédure impossible, such, for instance, as the occurrence of a severe hemeirrhage or a dangerous narcosis, where ail other cemsiderations must be laiel asiele» in oreler to meet the existing exigencies and saA'e the patient from the inimediate-ly threatening dangers. Accidentai Wounds.—In the case of accidentai wounds alreaely in- flicted, and at a depth which would necessitate a grave operative procéd- ure in order to insure complète disinfection, the question of the justifia- bility of carrying this out must be left to the surgeon. In compound fractures, for instance, with but a small wound forming a communica- tion be-tAvee-u the external air and the injury to the boue and surrounding soft parts, it is often a very serions question Avhether the effort to reach the eleqdhs of the wound may not open up new channels of infection and inflict new damage upon structures wliose vital résistance, without the inflietion of this added traumatism, might be able to withstand the effects of already existing infection. The question becomes a still more impor- tant one Avhen the problem is presented of opening into important cavities of the bexly, such as the cranial or thoracic, thus mvading and jeopar- dizing vital organs. Aseptic Precautionary Measures.—Aside from thèse extrême in- stances, hoAvever, the duty of the surgeon is plain. To cleanse with soap and water, to shave and even scrub the parts surrounding the Avound, is his bounde»n duty. That lie shall apply dressings Avhich are free from ail suspicion of infection is but an additional reasonable demand. With the e-xpenditure of a little time and slight pains the first requirement, i.e., the cleansing, can be aeeompbshed. Water, with the addition of a tea- spoonful of common sait to eae-h pint, will thoroughly sterilize dressing materials after ten minutes' boiling, if thèse be only strips of domestic cotton eir linen articles torn up for the purpose. Where, however, trust- Avorthy antiseptic agents are at hand or obtainable, they are désirable, in addition, when cleansing the wound. Failure to employ the latter, how- ever, may not necessarily lead to infection, for the reason that ail acci- dentally inflicted Avounds, even when exposed for a time to accidentai influences, are not necessarily infected wounds. The infection is a mat- ter of pure accident, and even when it exists the tissues may be in a con- dition to resist its evil influence. Again, Schimmelbusch has shown that once a wound has become invaded by microorganisms, it becomes, not a question of getting rid of them, but rather of preventing the occur- rence of further infection. The getting rid of such culture material as the accumulated wound sécrétions furnish, by means of proper drainage, and thus preA-enting the prolifération of noxious agents, constitutes a means to this end, in addition to taking such précautions to prevent further infection from Avithout as are comprehended in proper cleansing of the surrounding parts and the applicatiem of stérile dressings. Anaesthesia.—Fréquent attempts to punish surgeons for deaths occur- ring Avhile an aneesthetic is being administered tend to damage, not only 594 A SYSTEM OF LEGAL MEDICINE. the profession, but society at large. The great benefit which humanity has received from the use of thèse- agents bas been in danger of being nullified by fear on the part of the administrator, not only of damage te» his professional réputation, but of being punished as avi»U. Given a case in Avhich a pure article of chloroform or ether was employed, and it would be difficult, in view of the fact that différences of opinion exist as to the exact manner in which amesthetics ae-t, to state the précise mechanism of the fatal issue, and henee» the extent of the responsibility of the sur- geon. Nélaton e-ven advised, iu vicav of the difficulties involved in de-- termining beforehand the conditiems under Avhich the administration of anaestheties e-eiuld be safely undertaken, in e-ase surgeons were mulcted in civil praee-sses under e-ire-umstance-s Avhere the amusthetic agent Avas of good quality and properly employed, that they should ceunbine to renounce the use of amesthetics altogether. Velpe-au declared that to abandon the use of amesthetics Avould injuriously affeet society at large- more than it Avould the surgeons. An Anaesthetic should not be Administered without an Assistant. —An anaesthetic should not be administered Avithout an assistant except under circumstane-es of emergency. When the» operaten- is compelled to accept the service-s of a non-professional person lie must take» the entire responsibility of the administration. When the assistant administering the amesthetic is a regularly qualified practitioner, the responsibility, from the professional standpoint, shoulel be shared by both. If, hoAveA'er, the operating surgeon can be justly accused of sélect ing an assistant who bas not had sufficient expérience to enable him to give the amesthetic properly, and was so engaged in the opération as to be unable to person- ally supervise the administration, then, in case of acculent, he could be helel liable under the gênerai rule. AVhere malpractice is charged because» of death under an anaesthetic, the fae-t should be borne in mind that, before the discovery of amesthetic agents, patients suddenly perished just before or during operative pro- cédures. Thèse deaths bave been attributed to A'arious causes. When no other cause could be assigned it Avas said that the patie-nt died from fear if death took place before the open-ation had really commencée!. Of those deaths whieh haA'e occurred during or soon after the opération, the entrance of air into a vein, exhaustion, the resiilt of debilitating diseases or great loss of blood, and shock are to be held -accountable. The élé- ment of fear may bave also entered largely into the last-named class of cases, before the introduction of chloroform or ether. It cannot be denied that some of those eases which bave perished almost in the very commencement of the administration of an anaesthetic, and before a suffi- cient amount had been inhaled te) reasonably account for the sudden lethal exit, may hâve been unfavorably influenced by the same causes. Those AA'ho bave had a large expérience in the use of anaestheties believe that, under thèse circumstances, the amesthetic failed to prevent the death of the patient, rather than produced it. In the présent era of amemic and nerA-ous Avomen such instances are not as infrequent as one Avouhl suppose ; yet, occurring under such circumstances, the almost unive-rsal verdict, in the popular mind, is that the case is one of death from the» amesthetic. Dupuytren, the fanions French surgeon, lost no less than nine patients during opérations Avithout the use of anaestheties. and Nuss- baum, of Munich, lost two patients just prior to the intended opération. S UR G IL A L MA LPRA CTICE. 595 One died from suffocation. If tins had happened during the anaesthetiza- thm it Avould bave been very difficult to conA'ince a jury of laymen that the death was not due to the anaesthetic. A collapse» of the thinned carti- lages of the trachea AA'as the cause of the suffocation. Xussbaum relates an instance in Avhich a professional friend essayed to examine a strong country Avoman Avith the utérine sound. She closed lier eyes and AA'as found to be dead. A curions instance is related of a dentist who in- tended to administer an anaesthetic to a patient for the extraction of a tooth. This was so loosely attached that an amesthetic was not thought to bc nece-ssary. He helel a cupping-glass under lier nose with the prê- teuse that it was an aiiaesthetizing apparatus, anel after a moment pro- ceeded tej remove the tooth. As bis hand approached her mouth she Avas found to. be dead. Witnesses to Ansesthetization of Female Patients.—The necessity of ahvays having Avitnesses at hand when anaesthetics are administereei to female patients has been more than once insisteel upon. Expérience sIioavs that yenmg Avomen often hâve A'oluptuous sensations AA'hile under the influence' of an ainesthetie-, during which time their clothing may become soiled AA'ith mucus. Upon awakening they Avili affirm, Avith the greatest positiveness, that they hâve been violateel sexually during the anaesthesia. This may arise in part from the fact that Avome-n fear that the person administering the anaesthetic might take advantage of their helplessness. The impression may continue after awakening, the fear being changed into a belief of the impirssiem as a reality. The importance of ednser varions upon this point is apparent when the fact is borne in mind that more than a few persons thus ace-used bave suf- fered punishment, although in the light of subséquent events it was deemed more than probable» that they Avère innocent. Cause of Death Difficult to Establish when Anaesthetics are Em= ployed.—Owing to the difficulties of excluding other causes of death in a particular case, fatal anaesthesia narcosis is not easy to estabbsh. This is particularly true AA'here the opération has advanced sufficiently far to allow the élément of shock to enter into the ease. Reflex irritation of the cardiac centers, giving rise to lessene-el force combined AA'ith accél- ération and intermittene-y, this iwentuating iu the arrest of tlie heart's action, eie-euirs, especially AA'hen chloroform is administered. The sudden breaking up of adhésions Avithin a joint, or dilatatieui of the anal sphinc- ters, has, not infrequently, been followed by the development of dan- gerous symptoms. In the case of the latter it is adA'ised to AvithdraAV the anaesthetic beforehand, in order that the few spasmodic iiis4)b'ations AA'hich the patient takes immediately following the forcible stretching of the sjdiincter may not carry into the circulation through the vessels of the pulmonary system a sudden and e verAA'helming dose of the anaesthetic. Where the clément of shock enfers largely into the condition tliere can be no question as to the freedom of the surgeon from responsibility in the sudden collapse. Reflex paralysis of the respiratory or cardiac centers, the first from ether and the second from chloroform, has been thought to be produced b}' hritation, primarily, of the distribution of the trigeminous and pneumogastric nerves, particularly when large quan- tifies of the amesthetic hâve been employed at the very commencement of the administration. In vieAvof the fact that the use of an anaesthetic in a hurried manner, or " crowding the anaesthetic," as it is called, at the 596 A SYSTEM OF LEGAL MEDICINE. very commencement, is but rarely called for, the responsibility of lie- surgeon is greater if death follows such a method. The drop-by-drop method insures, to a great extent at least, immunity from danger from thèse sources, Inflietion of Pain when Patient is but Partially Anaesthetized.— While profound narcosis is n*>t deemed e»sscntial for e'A'ery opération, notably those of eomparative-ly short duration, yet the sudden inflietion of great pain, the patient being but slightly under the influence of the amesthetie-, bas resulted in the sudden supervention of reflex cardiac paralysis. This is more apt to oce-ur Avhen chloroform insteael of ether is used. This bas likewise been considered a cause of death, even Avhen the patient lias been, te» ail appearane-es, completely under the influence of the amesthetic. It must appear at a glane-r that the surgeon could searcely be held accountable under such circumstances. Post=mortem Appearances in Fatal Chloroform Narcosis.—Among the» causes of death Avliich are said to be elememstrable anatomically in those avIio haA'e perished from alleged eivereloses of chloroform that of fatty degeneration of the heart is most prominent, yet cacii hère there is room for reasonable doubt. Patients haA'e taken amesthetics e-ven under thèse circumstances, and during the folloAving fortnight died of he-art faiïure due to an apparently slight but sudden movement of the body. Indirect Causes of Death from Anœsthetics.—The indirect causes of death in fatal narcosis from chloroform or ether are somewhat nume-rous. Aspiration of vomited material or blood-coagula, in opérations about the mouth and throat, thèse finding their way into the air-passages, may resiilt in suffocation. Thèse do not properly belong in the category (A cases of fatal narcosis, yet the question may arise as to whether or not proper précautions in the way of having ordered that no food be taken for a sufficient length of time beforehand, and in how far a proper position of the head (Rose's dt'i>endent head position), or the aid of compétent assistants in keeping the glottis clear of blood-clot by spong- ing, or the performance of preliminary tracheotomy, might hâve averted the catastrophe. Unless the person engagée! for the administration of the anaesthetic has been likewise intrusted with the proper préparation of the patient, the surgeon can searcely be held négligent if death be due to the aspiration of vomitted material. The operator himself must see to it that the passage of blood coagula into the larynx is avoided, if possible. In neither case can the manner or method employed in administering the anaesthetic be held responsible, although it is true that patients will hâve violent retching attacks Avlien coming out from under the ether ; henee by keeping them Avell under the anaesthetic influence thèse retching efforts AA-ill be avoided. Thèse latter, unless there is food in the patient's stomach, wiïl do but little harm beyond embarrassing the operator in his work. The respirations may faiï from convulsive closure of the glottis, from falling backward of the tongue during profound narcosis, or from the latter being drawn convulsively backward. Spasmodic closure of the lips and jaAvs must also be guarded against, and should not escape the attention of the anaesthetizer, as asphyxia may resuit from this want of précaution. Cases of fatal suffocation by artificial teeth, chewing-tobacco, and even mucus hâve been reported. An inflammatory swelling, following the passage of a portion of the anaesthetic in a liquid state into the re- spiratory passages, flexion of the trachea from torsion of the neck, and SURGICAL MALPRACTICE. 597 mechanical pressure upon the thorax or abdomen may likewise cause asphyxia. Death under Anaesthesia Following Severe Traumatism or during a Chronic Disease.—A fatal resiilt occurring in connection Avith a severe traumatism, as, for instance, a severe head injury, rupture of intestine, intraperitoneal hemorrhage, or a neglectetl intestinal obstruction, the strength of tbe patient being already greatly dee-reased—even though he pe-rishes almost immediately after anaesthesia is established—the surgeon is not te> be helel responsible». On the other hand, a patient suffering from a chronic elisease, as, for instance, phthisis puhnonalis, and to AA'hom an amesthetic is give»n, say, for the réduction of a dislocation, if a fatal resiilt fedlenv immediately upon the administration lie must be considered as having died from the effee-ts of the anaesthetic, although the operator may be held blameless. Direct Cause of Death in Chloroform Narcosis.—The direct cause of death AA'hen chloroform is empleyeel as an anaesthetic is paralysis of the lie-art AA'ith subséquent asphyxia, and anaemia of the brain. In addi- tion te> the sudden paralysis of the heart, occurring with or Avithout the common degenerative changes, long-continued narcosis with chloroform may induce degenerative changes in the heart muscle. Furthermore,, repeateel chloroformization has been accused of producing fatty degen- eration of the heart muscle. In tliose suffering preriously from pulmo- nary affections, bronchopneumonia may deA'elop from détective heart action; circulatory disturbances, edema, and inabibty te» rid the bronchi of ace-umulateel sécrétions contributing thereto. Ether as well as chloro- form may tenel to produce this conelition, the former, in addition, lead- ing to increased sécrétion along the respiratory tract. Effects of Anaesthetics upon the Kidneys.—Rénal affections may re- siilt from either chloroform or ether. Contrary to AA'hat has been gener- ally supposed, Wunderlich* has shown that the latter agent is not alone in its supposed damaging effects upon the kidneys. From his extended ohseu-vations of the effects of the two anaesthetics upon the rénal organs, he makes the following deelue-tions : (1) An already existing albuminuria is ofte-n increased by etherization. (2) Albuminuria can be caused by nar- cotizatioii with both chloroform aud ether, but more frequently Avith chloroform. With the latter this resulted in 11.5 percent, of the cases ; with ether it occurred in only 6.9 percent. (3) Casts appeared in tbe urine after both chloroform and ether, but more frequently folioAving the former. This occurred after chloroform in 34.8 percent, of the e-ases, anel folioAved ether in 24.G percent, of the eases. (4) When casts are al- reaely pre-sent, both ether and chloroform bave the effect of increasing the number. It folhnvs, therefore», that both anaesthetics must be used cautiously, as both hâve the poAver of setting up degenerathe changes in the irnal epithelia. Anaesthetics in gênerai anel chloroform in particular should be aA'oideel in persons aa-Iio turn suddenly pale, AA'ith dilated pupils, or who are e-xcessivelytimid and faint easily. According to Bardeleben, exe-ite-ment and fear before and during the administration of the anaes- thetic eh> more harm than the latter, whatever its nature. Respiratory and Cardiac Indications.—As far as the respiratory and cardiaeï indications are concerned, Kocher recommends to employ ether * Beitràge zur Idinischen Chirurgie, Band xi. 598 A SYSTEM OF LEGAL MEDICINE. exclusivelv in cases of affections of the heart not combined with respira- tory disturbances, and chloroform in affections of the» respiratory organs with hype-raernia of the trachéal and branchial mucous membranes, or other obstacles to respiration. Every sue-h contraindicatieni, however, is only relative, each <-ase being earefully considered in relation te) the spécial conditions présent. In urgent cases, such, for instance, as straiigulated hernia, it may occur that either one en* the other may be employed from force- of e-ircuin- stances. While the question of proper sélection of the amesthetic may be of importance from the scientific standpoint, its relations to possible charges of négligence, in the présent state of our knowledge, e-an searcely enter into the e-euitioversy. Chloroform Idiosyncrasy.—There is a condition knoAvn as the chl*>- roform idiosyncrasy, which, henvever, can only be ree-ognized during the attempt to administer this anaesthetic. Sexm after the» first inspira- tion the patient beconies pule and springs from the table Avith terror anel great anxiety, declaring that ht» is suffocating. Almost immedi- ately lie passes into a saa'oou, from AA'hich lie is aroused AA'ith difficulty. At the same time the pupils bee-ome dilated, and strabismus may occur, with clonic convulsions of the uppe-r and loAver extremities. On the other band, some patients exhibit a sent of chloroform or ether hun- ger, inhaling immense quanti tics in a short time by means of extraordi- narily A'igorous îvspirateny efforts. Both e>f tliese classes of cases require careful Avatching on the part e>f the anaesthe-tizer. In the first the» anaes- thetic agent sliemld be changed to ether, and it may be necessary to abandon for the time being ail efforts at anaestlietization. Patients should be» Avatched earefully for seA'eral hours after anaes- thetization, particularly AA'hen chloroform bas been employed. Dyspnœa anel cardiac failure may elemand attention. Quantity of Anaesthetic Employed.—When accusations are made that unusually large quantifies of the anaesthetic agent bave been used, it would be well to bear in mind Mair's* statements bearing upon tins point. This author states that patients haA'e inhaled 160 grams of chloro- form in seven hours ; 1023 grams in tAveiity-four hours in another case ; in another, suffering from tetanus, 700 grams in tAventy-four hours ; in another, 1000 grams in twehe hours ; a Avoman in the puerpéral state remained chloroformed for thirteen hours, 200 grams be-ing used. In- stances are recorded where patients habitually took 500 grams daily for five or six days AA'ithout injury. A e-ase is related by Xussbaum in whieh this surgeon anaesthetizetl with chloroform a patient fifty-three finies for the purpose of passing urethral sounds. This patient succumbed to the fifty-fourth anaestlietization. Upon this occasion laughing-gas Avas employed. The post-mortem examination shoAved disintegration of tbe blood-corpuscles, etc. Methods of Anœsthetization—As to methods of anaesthetization by means of chloroform, authorities are agreed that this agent should be given largely diluted Avith atmospheric air, and that it should never be poured but ahvays tlropped upon the napkin or mask. The puise should be earefully watched, and note made of any change of color in the face, the occurrence of superficial breathing, or the superventiou of loud snor- * Gerichtlich-medicinische Casuistic der Kunstfehler. SURGICA L MALPRACTICE. 599 ing. If the puise becomes weak, the respirations shallow or stertorous, or the color pale or bvid, the chloroform must be at once withdraAvn. Complète narcosis is announced by relaxation of the muscles and the absence of ocular reflex. Precautionary Measures.—Précautionary measures consist in plac- ing the patient in the horizontal position ; by some surgeons it is even required that the head lie lowered, the body assuming au angle of forty- five degrees. The précaution relating to an empty condition of the stom- ach has already been alluded to. Obstructions to full respiration, such as the présence of a collai-, or a eravat, or a tight neck-band of the shirt, etc., should be removeel or loosened. Treatment of Dangerous Chloroform Narcosis.—In eases of danger- ous narcosis from chloroform the air is to be permitted to 41ass freely about the patient, AA'ho should also be \dolently shaken and perhaps Nélatonizetl (suspended by the feet) ; Avater dashed into the face ; artifi- cial respiration instituted ; perhaps a cathéter iutroduced into the larynx, or a tracheotomy performed ; mouth-to-mouth breathing practiced : the phrenic nerve faradized, one pôle being placed over the scaleni, lenv doAvn in the neck, and the other at the lower costal margin ; the heart stiniu- lateel by means of bot cloths, and perhaps acupuncture ; inhalation of oxygen. In order to permit the free access of air, the pharynx is to be cleaned and the tongue draAvn forvvard by means of a tongue-forceps. A latéral gag in the mouth is useful in addition. In Koenig's clinic at G-dttingen, in cases of chloroform syncope, sim- ple compression of the cardiae; région is employed in place of the eirdinary artificial respiration. Maas* reports tAvo A'ery striking case»s illustrative of this methexl of treatment. In both the respiration hael e-eased, the raelial puise Avas absent, and the pupiïs were Arieiely dilated. The move- ments Avère continued for oati- an hour. The compression is maele by placing the foot upon the patients left thorax and making quick move- ments of pressure oA'er the eartliac région 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 Anaesthetic.—The after-vomit- ing may prove a dangerous sequel to the administration of an amesthetic, and should receive attention at the surgeon's hands. The taste of the anaesthetic increases the flow of saliva, and as the expelled air contains more or less of the anaesthetic agent for some time afterward, the sécré- tions of the mouth, loaded Avith this, are SAvallowed and, irritating the gastric mucous me-mbrane, provoke intense nausea and persistent A'omit- ing. The patient should be encouraged to eject the accumulations in the mouth. LaA'age AA'ith a one-half to two percent, carbonate-of-soda solu- tion is frequently effectuai in affording relief. The Use of Chloroform at Night.—The use of chloroform at night is to be aveiided as much as possible. It is a common expérience under thèse e-ircumstane-es to observe some peculiar effects, such as a tendeney to A'omit, an irritathe cough Avith subséquent deA'elopment of bronchitis and severe catarrhal pneumonia. Thèse are supposée! to be due to com- binations betAveen the A'apor of the chloroform and the products of combustion. * Bcrlincr Klin. Wochenschrift, No. 12, 1892. 600 A SYSTEM OF LEGAL MEDICINE. The Administration of an Anaesthetic to Pregnant Women.—The administration of an amesthetic te) pregnant women, for opérations of convenience, or for such opérations as can be readily performed without an amesthetic, as the opening of an abscess or the extrae-tieui of a tooth, has been the subject of inquiry. In the opinion of some» authorities the production of abortion, or the induction of prématuré labor, in this con- nection may resuit, even though the narcosis is of but short duration ; Avliiïe others are equally confident that the anaesthetization has nothing whatever to do Avith the untoward resiilt, if any such follow, but that the latter is either a coincidence, or can be more properly attributed to the operathe procédure. Tliere are many diffie-ulties in the way e»f de- citling tins question, inasmuch as amesthesia is iuduced under conditions where some operative prex-eelure is to be performed, and in patients peculiarl y susceptible to mental influences ; the anxieties incident to the administration of the amusthetie, as Avell as tlieise arising from fear as to the outcome of the opération, to sa}' nothing of the fear of an interrup- tion of the normal gestation, may aiï combine to bring about an unfor- tunate resiilt, irrespective of the effects of the anaesthetic itself. The surgeon eau bave uo choice but to subject the patient te> the risks of the anaesthetic just as he Avould to the other risks of the opération, where this is one of necessity and involving great suffering should its perform- ance be undertaken Avithout an anaesthetic. Unusually Prolonged Anaesthesia.—The possibiïity of an unusually prolonged anaesthetic effect cannot be denied, especially in the case of chloroform. Thèse cases seem to resemble those in which the extrême effects of carbon dioxide hâve been suffered from. They are character- ized by slow and incomplète return to consciousness and sensibiïity after from forty-eight hours to three days. Convulsions may occur. In cases of chronic alcohobsm, in AA'hich paralysis and extrême nerve exhaustion contribute largely to produce the fatal resuit, the latter may enter in such a manner as to simulate death from the protracted effects of chloroform. Objections to Ether.—Ether, particularly if a pure article is not used, produces irritation of the mucous membrane of the respiratory passages to an extent sufficient to cause bronchitis or catarrhal pneumonia. As has been already shoAvn by Wunderlich's studies, its influence upon the rénal organs has been greatly eiverestimated in the past. The inflamma- bility of the vapor of this anaesthetic agent introduces an élément of danger when the opération is performed near an open flame, or where the thermocautery is employed in opérations about the head. Occasional Similarity of Dangerous Symptoms in Chloroform and Ether Narcoses.—The causes of death from chloroform are, to a certain extent, the same as tliose from ether. Distinctions hâve been made as to the manner in which the alarming symptoms enter, as well as the vital organs first affected. While in gênerai it is true that heart failure eharacterizes dangerous chloroform narcosis, and failure of the respira- tory function that from ether, yet the fact remains that in many cases patients wiiï cease to breathe under chloroform while the heart is in no Avise disturbed in either its force or frequency, on the one hand, while, on the other, it is not infrequently observed that patients under ether Avili suffer from faiïure of the cardiac impulse while the respiratory move- ments are but sbghtly, if at ail, affected. If the person administering SURGICAL MALPRACTICE. 601 the anaesthetic Avère to wait for the paiïor of the surface which is sup- posed to be the signal of danger in chloroform narcosis, he Avould be 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 much more likely to exhibit the appearances of carbon-dioxide in- toxication, with somewhat pronounced cyanosis, than the symptom of pallor. In gênerai terms, however, it may be stated that Avhiïe the symptom of cyanosis is présent in both cases, in so far as oui* présent knoAA'ledge of the action of thèse agents goes, in chloroform narcosis this dépends upon déficient oxygénation of the blood from stasis, whiïe with ether it is de-pendent upon true asphyxia from respiratory obstruction or failure. That there are numerous exceptions to this rule, however, as before stated, there eau be no epiestion. The fact nevertheless remains that, Avhile this cyanosis occurring in the course of the administration of ether cornes on graduai!}', it is epiite readily remedied by the free access of air for a short time, and is not an alarming symptom unless it persists in spite of the removal of the anaesthetic. If it becomes a pronounced symptom in chloroform narcosis, the patient is usually beyond hope of resuscitatiou. As lemg as the heart's action is sufficient to carry the blood-current to the important cérébral centers an extrême cyanosis is not incompatible with prompt resuse-itation. No amount of forcing of air into the lungs, ho Aviver, eau bring about this resuit if the carbon-dioxide accumulation is the resuit of cardiac failure. Ether the Anaesthetic of Choice.—We mustbe forced to the conclu- sion, in making sélection of an anaesthetic, that ether, AA'here it can be employed, is the amesthetic of choice. Since Wunderiich lias shown that the immunity from rénal sequelae formerly supposed to exist in chloro- form narcosis has no foundation in fact, the last argument in favor of the employment of chloroform in place of ether, when the latter is not positively contraindicated—as, for instance, by actually existing pulmo- nary conditions or in intracranial opérations, in AAdiich class of cases ether seems to increase, whiïe chloroform decreases, the cérébral congestion; and in certain opérations about the mouth and face where the gah'ano- or thermocautery must be used or the mask frequently removed in the progress of the Avork—falls to the ground, when statistics showing the unquestioned safety of this anaesthetic agent as compared Avith chloro- form are considered. A collection of yearly reports * of narcosis covering 62 reports, mak- ing a total of 61,526 cases, shows, after the déduction of 11,464 cases of nitrous-oxide anaesthesia, that there AA'ere 11 deaths in the remaining 50,062, or one in 4551 cases. The number of cases of anaesthesia coiïected during the past three years amounts to 161,800, in AA'hich number there were 52 fatal cases, or one death in 3111 cases. Of 133,729 cases of chloroform anaesthesia there were 46 deaths, or one in 2907 cases. In 14,646 cases of ether nar- cosis there was not a single death. Of mixtures of chloroform and ether tliere were 4118 cases, AA'ith one fatal case. Mixtures of chloroform, ether, and alcohol (Billroth's) show in 3440 cases no fatabty. In 4555 cases of * Gm-lt, " Bericliterstattung iiber die Sammelforschung zur Narkotisirungsstatis- tik," Ccutralblatt fiir Chirurgie, No. 30, 1893. 602 A SYSTEM OF LEGAL MEDICINE. bromide-of-ethyl anaesthesia there occurred one death. Of 597 cases of pental anaesthesia 3 Avère fatal. To sum up, therefore, it may be said that every patient to whom an anasthetic is administered takes thereby some risk, but that this risk is less in ether than in chloroform narcosis. Each possesses especial aehant- ages, but tliose edaimed for chloroform relate chiefly to convenience, AA'hile those claimed for ether relate to comparative safety. The warn- ing signais of approae'hing danger in ether can be recognized before tlie patient is beyond reeall ; in chloroform he is frequently already within the vaiïey of the shatloAv of death before the anaesthetizer is aware that anything- is wrong. The surgeon, therefore, aa-Iio at the» présent day sélects chloroform as the anaesthetic of choice Avould do weiï te> fort if y himself with facts to sIioav that ether is e-ontrainelie-ated in the particu- lar case; othei-AA'ise the ae-e-usatioii may be made that an unnecessary risk Avas assumed in employing chloroform rather than ether, the patient dying from indubitable chloroform narcosis. More skiiï is required to proeluce» ether narcosis than chloroform nar- cosis ; more skill is required, also, to preA'ent the patient from dying from chloroform than from ether. An indiffèrent!}- skiiïful anaesthetizer can easily kiïl a patient Avith chloroform, but lie wiïl not be able to ana-sthe- tize properly with ether, much less destroy the patient Avithout some Avarn- ing AA'hich the operator himself Avould be likely to observe. With blood before him of a healthy hue, and the rhvthm of regular and full respira- tions in lus ears, the latter will feel safe» as he proceeds in bis work, if ether is used. Either of thèse» fail in g, a Avorel of caution to the anaesthe- tizer suffices to correct the unelesirable condition. But if chloroform is employed the experiencetl operator knoAvs only too Aveiï that the dark blood and absence of respiration mean that the heart has faileel in its aetieni, perhaps for seA'eral seconds or a considérable fraction of a minute, before the dark blood and failing respiration occurred, and from tins time on the most vigorous efforts must be made, with the chances greatly against him, to rescue the patie-nt from death. Failure to Produce Anaesthesia.—Occasionally it occurs that the attempt to etherize a patient faiïs, and chloroform is substituted. It is more than probable that in the great majority of cases the fault lies Avith the anaesthetizer, and not AA'ith the patient or the anaesthetic. In tlie rare instances in AA'hich, either from the extraordinarily excited condition of the patient, or the occurrence of convulsive or eA'en tétanie respirateny movements, there is a faiïure to anaesthetize ref érable to the agent selected, it Aviiï be found that the patient bas been in the habit of indulging largely in alcoholic stimulants. A e-hange to chloroform is hère indicated, the ether, hoAvever, being résumée! AA'hen narcosis bas been established. Protection of the Patient's Face.—Complaints of négligence may be made AA'here the anaesthetizer fails to protect the patients face from con- tact Avith the anaesthetic by the application of some unctuous mate-rial. Vaseline ansAvers the purpose very well and is usually employed. Move- ments of the patient's head may lead to the accidentai entrance of ether or chloroform into the patients eyes, but beyond the temporary burning sensation no harm usuaiïy results from this. It should be provided against by placing a folded toAvel or napkin over the eyes. SURGICAL MALPRACTICE. 603 Hydrobromic ether (bromide of ethyl) bas been employed to some extent for shen-t opérations. It Avould seem, hem'eA'er, that this agent is not altogether free from danger.* From 5 to 10 grams usuaiïy suffice for ce impiété narcosis, although from 15 to 20 grams may be used. In eme ease 40 and iu another 50 grams Avère employed Avith fatal results in healthy persons. It is a, dangerous agent to employ for long ope-rations, profound narce>sis leading te) destruction of the blood-cor- puscles, Avith bh)ody diarrhœa. It is particularly contraindicated in amende and hysterical Avomen. In one instance of tins kind 7.5 grams 4>roved fatal. There AA'as no eyanosis, but the respirations failed com- pletely. only Iavo in effectuai respiratory efforts bedng made after narcosis Avas established, AA'hen death took place. In Biiïroth's clinic 400 anaes- tlietizatieuis Ave»re> made AA'ith bromide of ethyl; in one case a fatal residt folioAveel the sudden élévation of the patient to the upright position for the purposes of the dressing. In this ease cyanosis AA'as obse-rved after some seconds. Three minutes after the establishment of the narcosis both heart aud respiration had failed. The post-mortem sliOAved degen- erative changes in both the heart and rénal organs. It is iioav generally agreed that bromide of ethyl is less dangerous than chloroform, but that AA'hile it peisse'sses some advantages as to con- venience, etc.—patients eoming ont from under its influence very much as from nitrous oxitle orlaughing-gas—yet it mustbe used cautiously as regards the quantity employed. The stage of excitement occurring in e-onnecthui with its use ce)rresponds closely to the amount used. The quantity to be used in a given case is poured upon a cône simiïar to that usée! for ether and covercel AA'ith a napkin. Pental lias reeently been introduced as an anaesthetic agent. Expéri- ence with it has been thus far too limited to admit of any definite opinion as to its merits. The stage of exe-itement is said to be very short ; in aleoholics, hoAveA'er, it may be longer. From 10 to 20 grams are needed. The effect is sait! not to be unpleasant, and patients do not struggle against its administration as Avith other anaesthetics. Sensibiï- ity is abolished after about 50 seconds, and the stage of deep analgesia is reached after from 10 te) 20 seconds longer, this lasting for a further 50 seconds. The vapor of pental is easily inflammable, and the same précautions are requisite in this respect as during the administration of ether. The patient e-omes ont from under its influence sloAvly. Branchial and cardiac affections contraiudicate its use. A peculiar odor, compara- ble to that of asafetida, pe»rA'ades the room after its use. Nitrous Oxide.—Probably the safest of ail gênerai anaesthetics is nitrogen monoxide, or laughing-gas. Its use is greatly restricted, how- eA'er, by the fact that under ordinary circumstane-es an anaesthetic effect of but short duration is obtained, although Dr. Gr. 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 anel forty minutes.! Spee-ial skill, however, arising from a long expérience AA'ith the agent is necessary in order to suceessfully aecomplish such a resiilt. Bert's method involves the use of a specially constnicted inhalation chamber, * Miinchen. Mcdic. Wocheuschrifl, No. 15, 1S00, p. 267; 1891, p. 544. t American Journal of the Médical Sciences, October, 1889. 604 A SYSTEM OF LEGAL MEDICINE. and is not applicable for gênerai use. It would appear that this chamber is not at ail necessary for the purpose. Matters in Défense in Cases of Fatal Narcosis.—The difficulties in the way of exactly regulating the dose, bee-ause of the fact that ail gên- erai anaesthetics are exhibited in the form of gas or vapor, bas not be-e»n overcome by any of the so-called safe inhalation apparatus introduced for this purpose.' And even if tins were not true the maximum dose for anaesthetic agents bas not as yet been established, as in the case of other poAverful drugs. The quantity to be employed in any given case, there- fore, must dépend entirely upon the surgeon's subjective judgment. What is more than ail other things necessary, therefore, is that tbe sur- geon must be familiar AA'ith the particular agent AA'hich he is using, and, especially in the case of chlore >fe>rm, AA'ith the détériorations which this agent is subjected to Avhen ke»pt for a long time and exposed to influ- ences, such as sunlight, that tend to al ter its physieal qualifies. For such changes occurring prior to the chloroform coming into the hands of the surgeon the manufacturer ov dealer is to be held responsible. He must likeAvise be familiar Avith and bave at hand approved means of resuscitation, as Avell as drugs of an antidotal eharaeter, such as stiych- nia, tincture of digitalis, amyl nitrite, etc., to administer should danger threaten the patient. With thèse conditions fulfilled, and no easily dem- onstrable conditions présent to contrainelicate its employment, gênerai an- aesthesia may be established even for the performance of unimportant or slight opérations. The omission to at least auscult the patient's chest beforehand would be considered culpable négligence, even when such auscultation, if employed, bas demonstrated the présence of a heart murnrar, in a case in which it is absedutedy necessary that the anaes- tlietization be proceeded AA'ith. The information acquired, although per- haps it Avould not preA-ent the use of the» anaesthetic, Avould tend to in- duce a measure of Avatchfulness and caution AA'hich, it might be claimed, Avould not otherwise be employée!. Examination of the chest organs, hoAvever, does not always afford trnstAvorthy data, but this does not ex- cuse the omission of this précaution, except in tbe face of graA^e emer- gencies. On the other hand, as before stated, the indubitable évidences of existing disease, the circumstances of the case requiring the use of the anaesthetic, may permit this within proper limits, and AA'ith the usually employed restoratives at hand. It Avili usually be sufficient for the sur- geon's protection (1) that the use of the anaesthetic was necessary ; (2) that the agent employed was adapted to the particular case ; (3) that a Avatchful eare was exercised during the administration ; (4) that the usual restoratives were at hand, and that thèse were intelligently applied if they were required. SPECIAL OR REGIONAL CONSIDERATIONS. In reviewing the accidentai complications and unfortunate sequelae which may occur in surgieal opérations and affections, it is to be observed that tliere is searcely any procédure 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 aA'oida- bility or otherwise of the unfortunate termination. SURGICAL MALPRACTICE. 605 Opening an Abscess.—Even opening an abscess has been the occasion of accidentaiïy wounding an important A'essel. Aneurisms bave been mistake'ii for abscesses and opened AA'ith fatal results from hemorrhage. Venesection.—This opération is now rarely performed, but this very fae-t tends to lessen our estimate of the importance of carrying out the proe-edure in a proper manner. The médian cephalic vein, selected for the purpose, is sometimes perforated completely, and the adjacent artery is injureel as Aveiï. The artery should be accurately loeated before placing the constrie-ting band upon the arm. The surgeon recognizes the occurrence of tins accident by the simultaneous steady fle>Av of dark A'enous 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 AA'hich is established be- tAveen the artery anel the vein, and takes immédiate 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 Avili resuit. Embolism from Injection of Vascular Tumors, Varices, etc.—At- tempts to obliterate vascular tumors anel varices by the injection of cer- tain substances, such as ferrie cldoriele, carbolic acid, etc., hâve 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 oblitération of the enlarged A'es- sels by coagulating the blood. The prématuré remoA'al of one of the bandages, particularly that one betAveen the seat of coagulation and the heart, has resulted in the occurrence of coagulation in the vessels Avithin the thorax, and rapid death. Aneurism.—Aneurism may at times présent the most difficult prob- lem in the art of diagnosis. This is due to the fact that the disease is marked by varying conditions and instability of symptoms, as a resuit of the différent varieties and particular stages of each variety, as weiï as to the fact thafc the contents may be entirely fluid, semi-fluid, or nearly or quite solid. Any or ail of the symptoms may be misleading and bring the surgeon into disrepute because of failure to recognize an aneurism when présent, or of mistaking another form of tumor for aneurism and instituting danger- ous measures of treatment, such as incision, ligature of the main A'essel of an extremity, the application of continuous pressure, etc. For instance : (a) every tumor situated in the course of an artery is not an aneurism ; (b) pulsation may be absent AA'hen an aneurism is présent, and expansive pulsation may be présent in an abscess surrounding an artery ; (c) the pulsation may cease in a tumor or SAvelling situated upon or in the neigh- borhood of an artery Avhen compression is made upon the cardiac side, on the one hand, Avhiïe, on the other, subsidence of the swelling may not occur and yet an aneurism be présent ; (d) a bruit may be absent in aneurism and be présent in the case of an abscess or tumor surrounding or situated upon a vessel ; (e) even exploratory puncture may residt in the AA'ithdrawal of liright arterial blood in several A'arieties 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 earefully in- ■quire into the early symptoms, the length of time of their existence, etc. GOG A SYSTEM OF LEGAL MEDICINE. Under thèse circumstances the practitioner may be justly regarded as having been culpably négligent. The most eminent surgeons, ho avc ver,. bave faileel to make a correct diagnosis, even when the history has been taken into account, the symptoms methodically studied, anel the value of the latter earefully Aveighed in the partie-ular case. Many instances are recorded in which an aneurism existed when the history and symptoms indicateel an abscess. (Sir Charles Beiï, Dupuy- tren, Cooper.*) Again, the early history may indie-ate an aneurism, ail the symptoms pointing to the existence of au abscess. Finaiïy, an aneurism and abscess may coexist. The former may follow and be dépendent upon the latter, in Avliich case the early history and symptoms point to abscess, while the later ones indicate the existence of an aneurism. Or the aneu- rism may occur first, fedloAved by inflammation in the connective tissue about the tumor, terminating in suppuration. (Deschamps.) Under thèse circumstances the early histeny is thatof aneurism, the later symptoms those of abscess. The symptoms of aneurism, however, continue to be the more prominent., as a rule, and errors of diagnosis are not necessarily of a serious eharaeter, for the reason that the careful anel intelligent sur- geon AA'iiï ahvays take into account the symptom of pulsation and apply such scientific tests as may serve to clear up the diagnosis. If be is finally impeiïed to incise the SAveiïing he will do so Avith sue-h precaution- ary measures as Avili permit him to either re-trace his steps before great harm has been done, or operate for the cure of the aneurism. Puncturing an aneurism by mistake for an abse-ess has not infrequently occurred. Thèse are among the most serious of the mishaps of surgieal practice, and if expansive pulsation is présent, they are certainly among the most inexcusable. Tavo sue-h e-ase-s came under the e-are of Mr. Erichsen, and both succunibed to the operathe procédure instituted to correct the mistakes of the practitioners who were guiïty of the errors. In a third case there Avas senne excuse for the error for the reason that the symptoms of popliteal aneurism Avère not Avedl defined. (Lancet, 1858.) The error of mistaking an abscess for an aneurism in a locaiïty Avhere, if the latter existed, it Avould be almost necessarily incurable, while an abscess would imperatively demand operative interférence, is sometimes made. The foiïoAving e»ase is offered in illustration : Miss B., of Rock ville Center, L. L, 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 tAve> months, foiïoAving which swelling eje-e-urred, and fever of an intermittent type. There had been no symptoms of car- diac disturbance, no dyspnœa, nor bat! the présent tumor, the size of a fist, been preceded in its development by the usual extrême pains incident to the progress, in an outward direction, of then-acic aneurism. Before presenting to me the letter of introduction from her physician she visitée! some friends in the city, avIio persuaded her to consult two other sur- geons. The first of thèse introduced an exploring needle and Avithdrew a small quantity of blood. She then eonsulted the other surgeon, avIio pronounced the case to be one of aneurism and strongly advised her not to permit, under any circumstances, any surgeon to interfère with the * Stephen Smith, American Journal of the Médical Sciences, April, 1873. SURGICAL MALPRACTICE. (jQ7 tumor, but to proceed at once to her parents' home in western Xcav York, there to a Avait her inévitable fate. Upon examining the tumor I found it to be the site of a weiï-marked but mit expansive pulsation. There Avas no bruit présent, The skin over the tumor Avas reddened and tender. The âge of the patient, the history of the development of the tumor, and the accompanying fébrile symptoms ail impelled me to the diagnosis of abscess, and I proposed to lier to enter the Metheidist Episcopal Hospital for exploration at least. S*) inipressed was she, hoAvever, by the Avarning of the gentleman AAdio hael pronounced the case to be one of aneurism that she decided to go home to die. Six months later I learned from the physician avIio had referred her te> me that the local practitioner aa'Iio had he-r in charge at her parents' home had become convineed that she was suffering from an abscess, and bat! persuaded her to permit a surgeon from a neighboring city to oper- ate. More than a epiart of pus Avas evacuated, and extensive necrosis of the chest Avaiï discovered. No aneurism Avas présent. Gunshot Injuries.—The greatest. possible diversity will be found to exist in différent cases of gunshot injuries. Différences in velocity, }>ro- jeetile force, angle, articles p*»rforated before the bail reaches the bexly, and tissues traversed, ail bave an influence in determining the eharaeter of the injury. A bail may strike a bone, glance off, aud bury itself into the surrounding structures. Although the injury to the soft parts, to- gether with its sequela», Avili occupy the attention of the surgeon, the fact is not to be lost sight of that certain changes may take place in the bone itself, such, t'en- instance, as infections periostitis and ostitis, the infec- tion finding its Avay into thèse structures either directly from foreign sub- stances carried in AA'ith the bail itself, or from suppurative processes hav- ing their point of commencement in the soft parts and subsequently exteneling to the bony structures. The immédiate complications most to be dreaded in gunshot injuries relate to important vessels and nerves. While hemorrhage from vessels in the torn and lacerated muscular structures may be at first prof'use, the irritability of the latter, producing involuntary muscular contrac- tions, together with the tendeney on the part of the bruised and irregu- larly divided Avalls of the vessels to favor coagulation, lead to rather prompt arrest of the bleeding. But the surgeon should not OA'erlook the possibiïity of a contusion of the waiï of a large vessel having occurred, Avhich may lead in the course of a Aveek or ten days to a most profuse and dangerous secondary hemorrhage. Failure to proride against the possibility of this accident may beconie a source of reproach to the attend- ant, or even liée*mie the basis for a suit for malpractice. More or less damage to important nerve structures may occur in gun- shot injuries, AA'hich in the excitement of the moment may be overlooked. Such injuries are most frequently found where the extremities are in- volveel, either from the direct blow of the baiï, by force transmitted through the médium of a fragment of bone, or by muscular contraction forcing pointed or sharp-edged spiculae against the nerve trunk. Injury to important nerves, when suificiently severe, leads at once to complète parai}'sis of their peripheral distribution. In addition, injury to large nerves greatly incmise-s the surgieal shock, AA'hich may become so pro- found as te) bring about fatal inhibition of vital functions. 608 A SYSTEM OF LEGAL MEDICINE. If a fracture has taken place as the resiilt of a gunshot injury, the bone may be completely shattered, and the resulting deformity Aviiï be» at once apparent. But if a portion of bone has been simply carrie-d away by the baiï in its passage, nothing short of an exploration, and this preferably with the surgeon's finger, properly eleansed and disinfected for the purpose, aatII suffice in establishing the diagnosis. Neglect of this in the case of a gunshot wound of an extremity, or in fact in ail portions of the body, with the exception of penetrating Avounds of the great caA'ities, may lead to e-rror as to the extent of the injury inflicted. The surgeem's" first investigation wiiï be directed as to whethe»r the missile is still loeated in the tissues or not. He will therefore se»ek to ascertain if there is présent a wound e>f exit as well as one of entrance. Several faiïacies may enter at this point, against Avliie-h the surgeon must be on his guard. The existence of but one wound does not ahvays dé- termine the question affirmatively, any more than the présence of tAvo AA'ouiuls ean eleeide it negatively. In tlie first instance the bail may bave dropped out in transporting the patient, or may haA'e been dragged out in undressing the patient by a portion of clothiug AA'hich was carried into the Avound Avith the bail. An accurate inspection of the surroundings, including the chithing of the patient, should therefore be made, in order that needless injury be not inflicted in an uunecessary probing of the wound in searching for the bail. Failing to thus find the bail, attention should be directed to the possibility of the bail being superficially loeated. To this end every portion of the adjacent and even remote parts which could ha\'e peissibly been in the line of the projectile is to be earefully examined. Next, the p*)ssibility of the bail having been deviateel from its course by contact Avith bone or by dense planes of intermuscular ajio- neurotic structures afte»r its force Avas partially spent should be taken into account. Careful palpation should be performed, in order to be certain that the missile does not he directly beneath the skin at some point easily accessible for purposes of removal, before instituting a formai aud perhaps dangerous exploration or extensive dissection for its removal. Ail suspicious élévations of the skin should be earefully examined by the surgeon, and failing to thus locate the buiïet the question as to whether further search should be instituted or not should be discussed. In cases in which Iavo wounds exist, one representing the point of entry and the other that at which the bail left the body, there may still exist a doubt as to the absence or présence of the missile, or at least a portion thereof, in the tissues. The Avisdom of examining the clothing is hère again manifest. A bail may hâve been split or divided by contact with a sharp bony edge, and in its further passage a portion may bave left the body by the wound of exit, whiïe the rest still remained lodged in the tissues. The portion which escaped ma}'sometimes be found in the clothing, and, its dhided condition being apparent, form the basis for further search. The justifiability of risking injury to important parts in attempting to remove the bail, after having loeated the latter, should be decided only AAdth référence to the patients OAvn interests. The dangers to be feared from its présence in the tissues should be weigheel against the risks at- tending its removal. It is a grave error to mutilafe a limb or to invade one of the great caAnties of the body in the search feir or removal of a bail whose présence Avould, in aiï probability, do less harm than the operathe procédure itself. Where, however, as for instance in the péri- SURGICAL MALPRACTICE. G09 toneal e-avity, serious eompbcations may arise—not necessariïy from the continued présence of the bail, but rather from damage done to impor- tant structures by the escape of fecal matter from the intestinal canal, hemorrhage, etc.— explorative operative procédures are not only Avar- rantt'd but imperathely demandée!. Under thèse circumstances merely tentathe measures sue-h as probing are not only contraindicated, but are apt to do more harm than good. The passage of a probe cannot give trnstAvorthy information as to Avhether intestine has been wounded or hemorrhage is going on in the abdominal cavity, any more than it can détermine the probable course of the bail beyond its passage through the abdominal parietes. On the other hantl, probing may carry infec- tion Jinto the peritoneal ca\dty, or, if it chance to pass into a perforation of intestine, may, in withdrawing, smear fecal matter upon the peritoneal surfaces. In gunshot Avounds of the head meddlesome surgery is always bad surgery. Whiïe turning back a flap of the scalp in order to détermine whether or ne>t the bail lias entered the cavity of the skniï, and the inci- dental removal of ae»cessible spicula» of bone which haA'e been driven into the e-ere»bral tissues, are proper procédures in selected cases, failure to institute further interférence than tins Aviiï ne»A'er bring reproach to the surge»em. Under thèse circumstances his cemservatisni Aviïl be com- meneleel by his professional brethren. Aimless probing, on the other hand, will be almost certain to inflict further damage. THE HEAD AND NECK. Atheroma of the Scalp—Thèse so-caiïed "wens" are frequently re- gareled as simple affairs, and operated upon by those who hâve had but slight expérience in surgieal operative work. Whiïe the opération is usually a simple one, this very fact sometimes leads to a neglect of précautions Avhich Avould be taken in more serious opérations. In pre- antiseptic times many of thèse cases perished from erysipelatous inflam- mation, to AA'hich the région of the face and scalp seems to be especially prone. Patients, especially women, wiïl frequently object to the removal of the hair necessary to a complète aseptic course of technique, and the surgeon Aviiï be incbned to listen to their entreaties. If the practitioner has a due regard for the patient's best interests as well as for his OAvn réputation he will insist upon the necessary steps of préparation, or dé- cline the responsibility of the opération. Trephining.—This opération has not infrequently been performed AA'ith the expectation of finding an abscess of the brain, or a coagulum, AA'hen neither Avas found. Exploratoire trephining in cases diagnosticated as hemorrhage from the middle meningeal artery is foiïowed, eA'en in the best of hands, by the discovery that the blood is furnished, not by the artery, but by one of the sinusesof the dura mater. Opérations for Harelip.—Fcav realize the intrinsic dangers of the operative procédure for the correction of this congénital deformity. It is estimated that fully one third of the cases submitted to the opération elie (Nussbaum), as an immédiate resuit from suffocation conséquent upon the enforced e-h)sure of the mouth. Foiïowing the loss of consielerable blood, the little patients easiïy succumb to sbght causes. The infec- 610 A SYSTEM OF LEGAL MEDICINE. tion of a suture track, due to the neglect of aseptic précautions, leads tei erysipelatous inflammation, which in its turn produces pain and rest- lessness. Fear of failure of the opération leads to the administratiem of opium, AA'hich the little patients bear badly in their Aveakened condition. Without the administratiem of opium the continued acts of crying lead to straining upon and finally the tearing out of the sutures. The deformity is thus frequently made Avorse than at first. The cosmetic residt in eases of harelip is frequently unfavorable even after tlie best-eonducted antiseptic procédures, for the reason that the operator does not fully appreciate the necessity of a decided projection upon the vermillon border at the point AA'here the incision terminâtes, te) aiïoAvfor subséquent contraction of the cicatrix AA'hen perfectly healed. This contraction may go on for a long time, and unless the précaution alluded to is observed an unsightly notch AA'ill appear at the point where, at first, the lip Avas perfectly symmetrical. A further unsightliness fol- io AA'ing the opération results from the injudicious remoA'al of the promi- nent intermaxillary bone. A comparison of the faces of tAve> persons operated upon in early life for harelip, in one of whom the intermaxiiïary bone was removed, AA'hile in the other it Avas alloAved to remain, sIioavs such striking différences as to stamp the former procédure as most un jus- tifiable and cruel. The sélection of the proper âge for the opération is of importance. While single harebp may be operated upon at almost any time, in double harelip it is better to postpone the opération until the se>e-oiiel year of life. Cleft Palate.—In cleft-palate opérations the same dangers threaten the chiïd as in harelip, but to a greater degree. Yery young ehiïdren de) not bear the loss of blood at ail weiï, and therefore it is better to defer interférence until they arrhe at an âge AA'hen they e-an untlergo the neces- sarily extensive operative procédures with less fear of an immediately fatal resiilt. The mortality in early infancy is almost fifty percent. The most favorable period for the opération so far as danger to life is con- cerned is at the fifth year. (Schede.) On account of the extent to which uranoplasty interfères with the deA'elopment of the arch of the palate, it may be postponed until the period of the second dentition, or between the tenth anel tAvelfth years. (Ehrmaim.) Faiïure in the immédiate residt is less frequently due to an insuffi- ciency of blood-supply from injury to the arterial branches than to the fact that too few veins are présent in the pedicles to maintain the return- circulation. The cieatricial tissue left, hoAvever, after the mucoperios- teal flaps hâve sloughed aAvay, can frequently be utiïized for a second opération. Faiïure in the functional residt is more fréquent and important. The voice is not greatly, if at aiï, improved, and the surgeon is frequently blamed because of the disappointment in this respect by both the patient, AA'hen old enough to realize the extent of his misfortune, and by the friends. In undertaking an opération of this kind the surgeon should bear in mind that a congénital cleft in the palate is not merely a slit in the parts, but that an actual deficiency of tissue exists. Henee even after a most skillfully performed opération for closure» of the cleft the vélum still remain s as a tight eurtain stretched ae-rass betAveen the oral and pharyngeal cavities anel the posterior mires, which is too short to reach the posterior pharyngeal waiï, and past which the air rushes SURGICAL MALPRACTICE. Cil from the pharynx through the posterior nares ; the peculiar nasal twang is, therefore, still présent. While certain vocal exercises are not AA'ith- out value in oliviating this, a perfect production of normal voice and speee-h has probably never been produced by uranoplasty aud staphylor- rhaphy. The Teeth—The accidentai extraction of the Avrong tooth has some- times brought repraach upon the operator. This eiccurs more frequently since the introduction of anaesthetics. The patient Aviïl not ahvays be able to point out the tooth AA'hich is at fault, anel even if able te) ideutify it lie may plaee his finger upon tvvo or even three in the attempt to indicate the one whieh causes the difficulty. Again, two teeth may be so closely attachée! as to make it impossible to remove one Avithout the other. Luxa- tion of the lower jaw has occurred when great force lias been îiecessary in the extractiem. Fracture of the jaAv, considérable portions of the alveolar prae*-ess being brought away AA'ith the tooth, has been the basis of malpractie-e suifs. Such accidents will occur in the most skillful hands, but if the mouth be earefully kept clean and septic complications avoided, the patient can searcely bave been sufficiently damaged to Avarrant a suit. While replae-ing the braken-off part may sennetimes be followed by com- plète union, yet the pressure of a loose and perhaps pointée! or sharp- edged pièce of bone in the oral cavity invites dangers from irritation of the adjoining cheek and tongue AA'hich far outweigh any advantages to be derived from the replacement and union of the bone itself. Hemorrhage following the extraction may be alarmiug, anel require the employnu»nt of the therraocautery for its an-est. When dentures are attached to the patient's envn teeth the latter may become worn at the point Avhere the meta! clasps are applied, with the resiilt of alloAving the plate and artificial teeth to fall back into the pharynx or esophagus. Cases are recorded (Nussbaum) in which a dent- ure has been lodgetl in thèse positions for months Avithout giving rise to dangerous conséquences. Under tlu-se» circumstances, for tlie reason that the treatment of a condition sliemld not be more dangerous than the condition itself, surgeem s haA'e generaiïy not adA'iseel interférence before some direct indication had existed for this. Tonsilotomy.—Several accidents may foiïow this apparently simple opération, for which the surgeon may he blamed. The slice of tonsil removed has fallen 1141011 the glottic opening and caused suffocation. With the modem tonsil guillotine the risks of this ae'cielent are reduced to a minimum. The instrument also guards against injury of the larger A'essels, which may occur when an irdinary scalpel is used. The présence of a e-alculus in the tonsil may prevent the use of the guillotine, and even break it, and necessitate the use of the scalpel 01* bistoury te) dis- entangle the broken instrument, as Avell as to remove the tonsil. The surgeon may be compelled to adopt the use of the scalpel by force of circumstance»s. Hemorrhage foiïoAving the opération of tonsiïotomv lias given rise to great anxiety, as regards both the patient and the surgeon's réputation. While ligature of the external earotiel artery has been re- sorted to in this complication, the nee-essity for this must be exceptional. Tlie application of the thermocautery or pure spirits of turpentine is fre- quently sufficient. Thèse faiïing, suturing together of the pillars of the fanées over the bleeding stump of the tonsil will almost certainly arrest the hemorrhage. 61*2 A SYSTEM OF LEGAL MEDICINE. Retropharyngeal Tumors.—In the ostéoplastie résection e>f the upper jaAv suggesteel by Langenbeck for the removal of retropharyngeal tumors, portions of the growth may become detached from the remainder and fall upon the glottic opening, producing death by suffocation. Catheterization of the Eustachian Tube.—Fatal phlegmon of the neck has followed attempts at catheterization and inflation of the Eusta- chian tube, the air being forced into the cellular tissue of the neck. Mastoid Disease.—in cases of suppurative disease of the middle ear the surgeon avIio fails to take note of the supervention of mastoid dis- ease», when such weiï-marked eA'idences of tins condition are présent as are furnished bythe occurrence of sAvelling and tenderne-ss over the mas- toid région, commits a serienis error. The occurrence of gastric irrita- tion in thèse cases should also arouse suspicion. The proximity of the cerebrum to the labyrinth, only a thin lameiïa of boue intervening, and the dangers of infection of the cerebellum through phlebitis of the latéral sinus, should be borne in mind. It is not a serious mistake to trephine the mastoid process and not find pus ; but it is a most grave error to fail to apply sue-h a comparativelv simple procédure in cases in whieh the patients life dépends upon its performance. Injury of the latéral sinus is a not infrequent ae-e-ielent in trephining the mastedd process. An excceelingly threatening or even fatal hemor- rhage may folloAV. In performing this opération the surgeon should bear in mind the importance of not carrying the perforation of the bone, or the clearing out of the abscess cavity by means of the sharp spoon, too great a distance from the immédiate neighborhood of the hebx. Tracheotomy.—St-Aeral accidents may occur in the course of a trache- otomy. There may be an alarming hemorrhage from the engorged ves- sels in the neck. The opening of the trachea, particularly if the case is an urgent one, need not be de»layed until this has been arrested. The application of a few hemostatic forceps, anel relief of the dyspncea by the introduction of the cannula, wiiï be almost always foiïowed by an im- provement. The trachea may élude 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 latéral surface, great difficulty being experieneed in the introduction of the cannida. Thèse difficulties and accidents may usually be avoided by inserting a tenaculum into the trachea and steaeïying the latter while the incision into the anterior wall is deliberately made. The hold which the tenacu- lum has upon the trachea should not be relinquished until the cannula is in position and ail hemorrhage arrested. In the absence of the surgeon a pièce of false membrane may become loosened and block up the cannula. Those left in charge of the patient must be instructed under thèse circumstances to remove the cannula entirely, rather than risk the delay incident to efforts at clearing its lumen. If the loosened pièce is engaged in the tube it will probably come ont 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- cédure itself—involving as it does extensive dissections in the neighbor- hood of important vessels and nerves, during which accidentai injury to «URGICAL MALPRACTICE. 613 thèse may resuit in destruction of the patient—and those arising from sudden bending of a trachea which bas become thinned and flattened by pressure (seabbard trachea), in a certain proportion of cases a peculiar cachexia (e-achexia strumiprha) supervenes in a feAv Aveeks or months. The affection is charae-teu-izetl by certain psychicàl and physieal disturb- ances which e'en-respond A'ery e-losely to those in the idiopathic condition knoAvn as niyxedema. A more acute form is knoAvn as tetany, a spas- modie- affection someAvhat ivsembling tetanus, but in AA'hich, hoAA'ever, there» is ne) underlying infection. OAving to the» freepient occurrence of the unfortunate eompbcations and seepielae just alluded to, goitres are not to be totally removed. EA'en Avhen the vital indications are présent for operathe interférence, smaiï portions may be left attachée! to the trae-hea, or even but one lobe re- moveel. Cachexia strumipriva is thus aA'oided. Expérience likewise te-aehes that the remoA'al of a comparatively small portion of a thyroid tumor is sometimes folhnved 1 y degenerative changes in the remainder. Incisions in the Neck for Suppurative Conditions.—Fear of injur- ing the larger vessels in the neck frequently impels the praeditioner to delay opening foci of suppuration in this neighborhood, such delay resulting in serious conse-eruences. This, as Avell as undue risk to im- portant structures, may be avoided by simply incising the skin and then completing the search for the pus cavity Avith a blunt dressing-forceps. The track thus made anel leading to the purulent collection may be dilated sufficiently by spreading the blaeles of the forceps so as to permit the introduction of a drainage-tube. The blunt extremity of the forceps Aviiï not injure the vessels under ordinary circumstances. Tumors in the Région of the Neck.—In addition to the accidents AA'hich may arise in the course of opérations for the removal of tumors of the nee'k relating to injurie>s of the nerves and vessels, aspiration of air iu Avounds of the larger vessels, etc., the surgeon may be blamed for the neetlless inflietion of deforming e-icatrices in the case of young females. Lines of incision may be so planned as to turn back the over- lying skin Avithout bringing the resulting eicatrix into prominence and renelering this région unsightly. An ine-ision AA'ith beveled edges, carrieel along the natural line of either the» anterior or peisterien* border of the sternomastoid, is much less notieeable and henee less objectionable than incisions e-arried either directly across or in a vertical direction. Ine-ishms commencing somewhat posteriorly and curving doAvnward anel foi-Avartl, anel then carried along the line e»f the claA'icle, in the great majority of cases Aviiï uhcoaci- tumors Ioav doAvn in the ceiwical région; anel the incision along one or the other margin of the sternomastoiel, if combined Avith an additional incision carrieel either anteriorly or pos- teriorly, as the e-ase» may be, will give ready aee-ess to those in the upper latéral"cervical région. The maximum amount of room for the operathe prae'e'dure, with the minimum of ultimate unsightliness, Avili be obtained by thèse bues of incision. THE THORAX. Amputation of the Breast.—An error may be charged against the surgeon in case-s in AA'hich récurrence of carcinoma after amputation of tbe breast takes plae-e. While every careful surgeon Avili see to it that 614 A SYSTEM OF LEGAL MEDICINE. no suspicions indurations remain, and that the axillary caA'ity is opened up freely and ail glandular tissues that eau be identified as such are removed, yet it will not be possible for him to positively state, even after aiï of thèse precautionary measures, that eve-ry vestige of the disease is extirpated. In order to still further insure against possible infection through the médium of the pectoral fascia, with its rich supply of lymph- channels having free communication with the lymph-channels of the mammary glaneï, an additional précaution cemsists in remoA'al of a por- tion or even ail of the pe-edoral muscles of the e-orresponding siele-. In- fected lymphatie glane Is are sometimes disclose-d Avhich Avithout total remeivaî of both the pectoralis major and minor muse-h-s would bave eseaped détection and leel to so-caiïed régional récurrence. Lacteal Fistula.—The occurrence of a miïk fistula following incis- ion for abscess of the female breast may be a source of reproach te> the surgeon aa'Iio OA'erlooks the anatomical arrangement of the lactiferous tubules, anel insteael of making the ine-ision parallel with thèse, crosses them to a greater or lesser extent. The resulting fistula is a source of extrême annoyance anel is frequently difficult to cure. Empyema.—Consielerable anxiety is sometimes caused by the ace-i- dental disappearance of .a rubber drainage-tube within the pleural cavity during the treatment of a case of empyema. Systematic dilatation of the original wound track by means of sponge-tents or laminaria digitata, and subséquent vigorous flushing of the cavity by copions injections, Avili frequently resuit in floating out the tube without instituting a formai operative procédure and thus greatly alarming the patient. THE EXTREMITIES. Fractures.—There are numerous eompbcations and sequelae which may occur in the course of the treatment of fractures, due to circum- stances entirely beyond the control of the surgeon, but which are at- tributed by the patient and his friends to the unskiiïful treatment of the attendant. The existence of syphilis or some other disease may prevent the formation of proper callus, and an incomplète union, due to tbe for- mation of a cicatricial mass of conneetive-tissue origin, take place, or even a pseudarthrosis resuit. While the surgeon cannot be held responsible for the existence of the dyscrasia, yet he cannot be held entirely blame- less if the dyscrasia is of such a eharaeter as to hâve been amenable to treatment. The interposition of the soft parts about the site of the fracture is frequently the occasion of non-union in fractures. Hère the surgeon is more at fault than in the former instance, particularly if he has not in- vestigated the conditions and taken pains to provide against the possi- bility of tins compbcation. Deformity Following Fracture.—One of the most damaging sequelae (to the surgeon's réputation, at least) of fractures is the occurrence of deformity folioAving the union of a fracture, and the existence of short- ening as compared AAdth the opposite limb. A palpable bend or boAV in an extremity is a constant reproach to the surgeon's art, sometimes un- avoidable, it is true, so far as the surgeon is concerned, but, alas ! too frequently the resiiït of faiïure on his part to bear in mind the golden SURGICAL MALPRACTLCE. 615 rule never to permit the first dressing to remain during the entire process of repair, but to remove tins at least once, and perhaps oftener, and that at a period of time sufficiently early to permit of correction of any exist- ing malposition. Inspection of the injured parts at the " half -healing point " Aviiï save many erooked limbs, as well as regrets on the part 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 Humérus.—The mistake of diagnosing a fracture of the neck of the humérus as a dislocation is not infrequently made. The differential diagnosis is not ahvays easily made, particularly where considérable sweiïing exists. The careful surgeon, in case of doubt, Aviiï prêter to delay his attempt at réduction until after tlie swell- ing has subsided, rather than risk the inflietion of further damage by his manipulations. The combination of a fracture of the neck of the humérus and a dis- location is sometimes observed. Even when this e-emiplicated condition is eliagnosticated the surgeon is at a loss to décide upon the proper meth- ods of procédure. If he delays interférence until complète solidification at the seat of the fracture» is effee-teel, the difficulties of reducing the dis- location are greatly increased over those eneountered in uncomplicated dislocations. The method of McBurney, of exposing the head of the bone, driiïing the latter, aud inserting a traction-hook by means of which the displaced portion is raplaced by diree-tly appbed 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 AA'hich this nerve takes around the neck of the humérus, as Avell as its re»lations to the shoulder-joint, render it especiaiïy liable te> injury from 1)1oavs or falls upon the shoulder. Dislocations of the humérus 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 invohed in a neuritic process. As a result of interférence AA'ith the supply of the circumflex nerve there is a noticeable Avasting of the structures which cleithe the joint; and suits for malpractice, based upon thèse appearaiie'es and a failure on the part of the surgeon to discover and reduce a supposed dislocation of the shoulder, hâve resulted. With extrême atrophy of the deltoid muscle there is a marked prominence at the aeromion process and a decided groove per- ceptible through the atrophied muscle between the head of the humérus and the articulai- surface of the scapula. Under thèse circumstances the resemblance to a disloe'ation is striking, until manipulation discloses the real condition. Fractures near the Elbow=joint.—Fractures in the neighborhood of or invoh'ing the ellxov-joint are apt to give rise to contractures and anchylosis in this articulation, from inflammatory conditions the resuit of the injury. While thèse are frequently unavoidable, and no one may know beforeband in the indhddual case to what extent thèse may impair the usefulness of the arm, the extent of the loss of function, Avhen it does occur, Aviiï dépend, in great measure, on the eare which the surgeon exer- eises in placing the member under conditions in which, should anchylosis folioAV, the patient may be able to perform certain needful movements. An arm anchylosed in the straight position, or nearly so, will be prae-ti- eally useless, and one sharply flexed Avili be nearly so. With the forearm C1G A SYSTEM OF LEGAL MEDICINE. at right angles to the arm, a compensa tory increase of the range of mo- tion at the shoulder occurs, and the patient will be able to exécute move- ments Avith the extremity to a surprising extent, While the treatment" of a fracture of the arm in this locality in the straight or extended position (anchylosis not occurring) gives a me»re» symmetrically perfect arm, for the reason that the normal angle which tîie radius and ulna bear to the humeras is preserved and with it the so- caiïed carrying function, yet, as before stated, no one may know Ix-fbre- hand whether or not the inflammatory changes will be such as to prevent free motion at the elbow-joint. Henee, in order to prevent this undesir- abh- complication, the» surgeon wiiï do well to earefully study each case-, and endeavor, in the event of the probability of anchylosis, as évincée! by the présence of severe injury te) the joint and extensive extravasation in the soft parts, to obtain early passive moveme-nts. The arm is to be retain*»el at a right angle to the forearm in the intervais, if thèse move- ments produce increase in the inflammatory conditions to the extent to indie-ate their elise-ontinuance. In other words, although rest is indicated AA'hen the inflammatory process is intra-artie-ular 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 first-named, rest is indicated; but this prolonged to the period sometimes necessary to bring about complète restoration of the joint wiiï lead to eeuitracture of the muscular and tendinous structures and restriction of motion ; at the same time adhésions will form within the joint itself. It woulel se»ein that compromise measures, consisting of fixation of the joint at a right angle in the intervals by means of a splint, and the application of massage, serve best in thèse cases. It is also to be noteel that after the intra-articidar inflammation has subsided anel some range of movement is aeeompbshed, this is generaiïy increased by the patient's OAvn voluntary movements. This is particularly true in the ease of young chiïeiren. The surgeon may remove the bandages and splints at the end of a Aveek or ten days from the date of the injury, and practice massage him- self. The application of this A'aluable therapeutic measure should ne>t be intrusted to a lay person, or even a professional masseur, at this time, for the reason that an intelligent reapplication of the splint and band- ages following the massage is necessary. Later on, when consolidation has pragressed suificiently far and improvement in the intra-articular in- flammation wiiï warrant it, passive movements are to be added. Should the latter increase the inflammatory action, they must be abandoned for the time being. Ail this requires the personal supervision of the sur- geon, and failure to give this to the case may bring him reproach. He cannot be held responsible for anchylosis resulting from vicious câlins. Fractures at the Lower End of the Radius.—Impairment of func- tion folioAving fractures at the lower end of the radius results (1) from failure to properly disentangle the small portion of bone torn off by for- cible extension of the hand, and which occurs because of the tough and unyielding eharaeter of the anterior radiocarpal ligament, or (2) the swelling and congestion conséquent upon the injury inflicted upon tbe surrounding soft parts may pass from the stage of active hyperaemia to inflammation, and this, involring the atljoining muscular aponeuroses and tendinous sheaths, produce fixation of thèse. This is particularly SURGICAL MALPRACTICE. 617 true if a spbnt apparatus that extends from the upper portion of the forearm to the finger-ti})s is employed and permitted to remain undis- turbed during the entire period of repan*. In the majority of cases very slight if any retentive apparatus Aviïl be necessary from the first. The surgeon aa'Iio e nuits to apply any apparatus whatever will be less frequently reproached than he avIio applies a fixation splint and removes it after the end of three or four Aveeks for the first time. In the first instance the normal movements of the Avrist and finger joints are more quickly restored, and inflammatory adhésions are not so apt to binel down muscular and tendinous structures. In the second the parts are held rigidly in a position to faA'or contracture of the muscles and tendons as Avell as the occurrence of fibrous adhésions within and upon the sheaths of the latter. Where the use of a simple roller-bandage does not suffice for sup- port, a splint AA'hich shall hold the liant! in the position of slight palmar flexion may be used. But AA'hether the hand and forearm be envelopeel in a simple roller bandage or supported upon a splint, the important point in the treatine-nt is to avoid the impairment of function due to fix- ation e>f the tendons anel to adhésions Avithin the joints. The means best ealeulated to ae-e-omplish this is by the early and persistent use of daily massage and passhe movements. As in the case of the elboAv-joint, the surge-on should perform thèse for the first three weeks himself, at the end of Avhich time he may intrust them to a professional masseur. Gangrené of the Hand Following Fracture of the Radius.—Espe- cial eare should be exercised in the aiijdication of a plaster-of-Paris band- age» to the forearm in fractures of this part which resuit from direct or indirect force. Surgeons, as a rule, aA'oid, as far as possible, such appli- cation, on account of the liabiïity of the occurrence of rapid swelling and the danger of gangrené. The occurrence of blood stasis, as eA'inced by the failure of the blood to refill the vessels beneath the finger-nails promptly after it bas been forced ont by pressure, is an early and infal- lible test. The nail remains white ; even if the color eA'entuaiïy returns, if it is délayée! 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 bandages. Malposition of the fragments in fracture of the radius may produce gangrené of the hand where no bandage whatever has been applied, through pressure upon the blood-vessels. Changes in the Avalls of the blooel-A'essels may lead to thrombostasis, this extending to the eapillary area. Gangrené Following Fracture of a Lower Extremity.—This is an extremely unfortunate complication. With the rare exception of the cases in AA'hich the gangrené results from simultaneous contusion of the blood-A'essels or pressure from displaced fragments, gangrené of a loAver extremity, the site e>f a simple fracture, is due, in tins class of cases, to the te>e> early appbca.tieni of a fixed dressing, such as plaster-of-Paris, sili- cate of sexla, or starch. It may also arise from the application of an or- dinary splint, The occurrence of pain, with appeals on the part of the patient to remove the bandages, if unheeded, may lead to the most dis- astrous conséquences. Under such circumstances the surgeon wiiï be held responsible for the loss of the limb, which is the inévitable resiilt, The fact should never be lost sight of that the faiïure to apply any Gis A SYSTEM OF LEGAL MEDICINE. sort of apparatus for the first ten days, save a piïhnv support, can neA'er residt in harm to the injured member. At the end of this time the sAvelling. AA'hich is the cause of the mise-bief, Avili bave reached its maxi- mum. Correction of malposition, anel the application of fixed dressing or retentive apparatus, may noAv be enqdtyed. In about ten days from this time Avhateve»r sAvelbng stiiï remains AA'ill bave subsieled, and the dress- ings may be remoA'eel and appbed. This wiiï aise) afford an opportunité to inspect the» parts and correct any undesirable e'onditiems Avhich may be prese»nt. Thèse remarks are particularly applicable to frae-ture-s Avhich are the resiiït of direct force.* Injuries to the Hip=joint.—This articulatioii is deeply placed, sur- rounded by large masses of muscular tissue, and is capable normally of a great variety of moA'einents. In the young both the aponeurotic and ligamentous structures in and about the joint yield considerably, AA'hile the bony structures are in a condition to withstand e-on sidéral de for*-*; before giving Avay. Later in hfe the fibrous structures become tough anel unyielding, Avhiïe the bone, owing to rarefying processes, is more or less brittle and easily broken. Henee it foiïoAvs that in early and middle life disloe-ations occur most frequently, while in the later years of life frae-tures oce-ur more commonly. The points in the differential diagnosis of thèse two great classes of injury are easily made out in typie-al cases. Henee the error of mistak- ing a dislex-ation for a fracture, and vice versa, is not frequently made». In a given e-ase of injury to the bip-joint, hoAvever, in AA'hich the existence of a dislocation can be taken out of the considération, there may still be an absence of the usual signs of fracture, and the surgeon beled into error. Tins arises from the fact that a large proportion of cases occur from faiïs upon the trochanter, the effect of Avhich is to force the distal into the proximal fragment, Avith conséquent impaction. Under thèse circumstances the cliaraeteristic shortening and preternatural mobility will be absent. Crepitus Avili bkewise be absent, although this symptom is of less value in the diagnosis of frae-tures in gênerai, and particularly those in the neighborhood of the hip-joint, than is generaiïy supposed. It cannot be obtained when impaction is présent, and any attempt to elie-it it by manipulation may residt in breaking loose the impaction and producing a worse conditieni than previously existed. The occurrence of impaction wiïl dépend to some extent upon the location of the fine of fracture. This will most frequently be» présent 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 Avriters. Impaction is rarely présent 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 Avhich there is loss of function, as shoAvn by mabiïity on the part of the patient to raise the limb from the level of the body while lying upon the back, slight shortening-, and eversion of the foot which cannot be converted into a complète inversion, in the great majority of cases is an impacted fracture of the base of the neck of the fémur. If the patient is past middle life and a woman the chances are stiiï greater of this condition being présent. * Nussbaum, Acrztl. Central Anzciger, 1887, No. 18. SURGICAL MALPRACTICE. 619 The e»version of the limb présent in impacted fracture of the base of the neck is usually comparât! vely slight, Avliile that présent in îion-im- pacted fracture is greater. This is also true of the shortening. The en- tanglement of the fractured surfaces will limit the shortening, while the fae-t that tbe posterior surface of the neck is impacted to a greater extent than in front ace-ounts for the partial but quite constant eA'ersion, as avcII as the difficulty iu overcoming the latter. Therefore slight shortening (le-ss than an inch), combined AA'ith slight or only partial eversion, should aAvaken suspicion of this injury, and manipulation should be very eare- fully maele. On the other hand, the présence of considérable shorten- ing, together Avith th'cieled or complète eve-rsion, Avili suggest a fracture of the smaller portion of the neck of the- fémur. Thèse tAvo points, namely, the amount of shortening and the extent of the eversion, should be ase-er- taineel before manipulation of the limb for diagnostic purposes is made. Failure of union in fracture» of the neck of the fémur will occur in a certain proportion of e-ases. This is more likely to be présent in cases in Avhich the fracture is at the narroAv portion of the neck (intracapsular), for the reason that the nutrition of the proximal fragment is generally so interfered Avith as to prevent repair. In some instances the peri- osteum is not torn completely aerass and union foiïoAvs. In frae-tures at the base of the neck (extracapsular) non-union may follow from tliose e-auses Avhich produce the same conditions else-Avlie-re, namely, failure to see-ure or maiutaiu proper appositiem of the broken surfaces, rarefying pracesses either pree-e-ding or folloAving the injury, or arrest of the eA'olu- tion of the câlins before it has entered upon the stage of ossification. Fracture of the neck of the fémur bas occurre-d during attempts at réduction of a dislocation. This is an unfortunate accident, inasmuch as it renders réduction practie-ally impossible, and if intracapsular, is likely to be followed by necrosis of the head, for the reason that, the liga- mentum teres being separated by the dislocation, the nutrition of bone at this point is de'stroyeel. Hip Disease in Children.—The importance of an early diagnosis of morbus coxarius can scarcedy be overesthnated. There are seA'eral con- ditions whie-h may simulate this elisease more or less edosely, and AA'hich it behcoves the surgeem to keep before him in examining cases in which the sympteuns point te» disease of the coxed'emoral articulation. In the first place, it is not an infrequent expérience in the metropolis to bave children suffering from hip disease brought to the surgeon's of- fice Avith a knee-joint painted Avith tincture of iodine or marked by the pce-uliar discoloration following a blister, in AA'hich the diseased condition really exists in the hip-joint. The patient's complaints refer the pain t*) the région of the inside of the thigh just above the knee-joint, or even at the knee-joint itself. The explanation of this is furnished by the inti- mate relations and anastomoses of the sciatic, obturator, and anterior crural nerves. An injury of the hip-joint in a chiïd may give rise to synovitis without necessarily being folloAA'eel by true hip disease. While it is désirable to make a proper diagnosis whenever possible, the error indicated is of but minor importane-e» compared to some others that will be mentioned, pro- videel the- synovitis is treated properly, for the reason that this will in- volve rest, e-euinter-irritation, and the other measures applicable to bip disease in its earliest stage. G20 A SYSTEM OF LEGAL MEDICINE. Congénital dislocation of the hip is a more common condition than is usually considered, and may be mistaken by a careless observer for hip- joint disease. During the year ending September, 1891, tAventy-five» e-ase-s were i>resented at the XeAv'York Hospital for Ruptured and Crippled, or more than one for every ten e-ases of tubercular disease of the bip. A care- ful inquiry AA'iiï usually elicit the fact that the child limpetl from the time that it began to Avalk, and exaniination will disdose the following ob- jective symptoms : (1) a peculiar Avaddling gait in connection with the limp ; (2) a shortening of a half-ineh or more» ; (3) élévation of the tro- chaiiter (in fat children this is not ahvays easily defined) ; (4) the limited motion is mechanical, and arise»s from the relations of the head of the» fémur to the rim of the acetabulum, and is not due to muscular spasm as in hip elisease. In addition there will be absence of tenderness. Children AA'ith hip disease are not infrequently treated for rheuntaiism. The careful practitioner will not fail to suspee-t the true nature of the affection at hand if ht» Avili but bear in mind that mon articulai* rheuma- tism in ehiïdren is a very rare disease, and that tlie 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 elisease». Surgie-al should replace purely médical treatment in a very feAv days, if decided improvement does not promptly folloAV the latter. Inflamed ingainai glands, élue either to tubercular infection or the ac- cumulation of subpreputial sécrétions, may cause a limp and limitation of the moA'ements of the joint. The error of mistaking this for hip dis- ease is not a A'ery serions one» fretin the medico-legal standpoint, and shoidd not continue longer than necessary to make a local exami- nation. Limitation of the movements of extension and cemsequent limp may be early symptoms in osteitis ov Pott's disease in the hembar région, and lead the surgeon into error. Every endea\'or should be made to recog- nize and treat Pott's elisease of the spine early in the affection, for the reason that if this be deferred until a protubérance appears, the elisease wiiï be Aveiï advanced, AA'itb no possible hope of oA'ercoming the existing deformity, to say nothing of the dangers arising from the destructhe bone-lesion. SaA'e in tliose instane-es in which rest in the recumbent position is employed, as advoeated by some surgeons in the treatment of early hip disease, the mistake of treating a case of Ioav Pott's disease for hip disease Avould be a serions one, and likely to delay the proper treatment until either deformity or tubercular abscess, or both, e-ompli- cate the case. If flexion, AA'hich is normal, be first employed in order to completely relax the psoas muscle, ail other movements of the hip-joint Avili be found to be easily performed. Irritation of the psems by any diseased condition of the lumbar vertebra wiïl cause rigidity of this région instead of increased flexibiïity, as found upon attempts to produce com- plète extension of the thigh in bip disease* Resection of the Knee.—After exposure of the joint surfaces the popliteal artery may be wounded either AA'hile the surgeon is in the aet of dhiding the crucial ligaments or while remoring the articulai* surfaces. The occurrence of this accident is most unfortunate. for the reason that, following as it does the division of the freely anastoinosing articulai* ar- * Dr. "ATalter C. Wooel, Brooklyn Médical Journal, July, 1804. SURGICAL MALPRACTICE. G21 teries, the emly channel of supply to the leg is destroy ed, and amputation is the only resource left in order to save the patient, In résection of the knee-joint the operator should bear in mind the necessity of sparing tbe epiphysis AvheneA'er possible. In case of injury te) this important structure, particularly in groAving chiïdren, the limb becomes relatively shorter on account of the diminished rate of growth as e-ompared with that of the opposite limb. Tenotomies and Myotomies.—Thèse bave- been the occasion of grave accidents. The deep peroneal ne»i-ve has been injured in tenoteuny of the biceps femoris, anel hemorrhage from the.posterior tibial artery is a not infreepient accident occurring in connection with the common opération of the division of the tendo Achillis. In the dhision of the groups of muse-les that movi» the head, for Avrym-ck, it is ofte-n extremely difficult to détermine just Avliich musch-s are at fault, and the operator may find himself in the position of having divided a number of thèse mmeeessarily before he finally sueceeds in rectifying the position of the heael, if, in- oleed, he does not fail in ae-eomplishing his object altogether, even after extensive mutilation. Contracture and Anchylosis.—Accidents are» likely to happen in the attempt to apply brisement forcé for oA'ercoming anchylosis. Failure to diviele muscular contractions prelimiiiarily may resiilt in the ruptur- ing of thèse in localities in Avhich harm may arise or eA'en considérable damage be inflicted. An unfortunate circumstance occurring AA'hile attempting to break up a bony anchylosis consists in an ace-ielental fracture of the bone at some point in the diapliysis, insteael of giving Avay at its aelventitious attaclnue-nts in the joint. A wen-se condition than that for AA'hich the opération Avas undertaken follows. Henee» the importance of the précau- tion so rigidly insisted upon by some authorities to first forcibly flex the joint, thus break in g up adhésions by nioA'e»ments in a direction the least ealeulated to do harm, before attempting the more dangerous movements of extension. An important artery may be embedeled in the rigid mass of exuda- tion about the jennt, and this being ruptured, an enormous subeutaneous hemorrhage may occur, necessitating immédiate amputation. The press- ure of the surrounding mass may mask tins symptom, aud the surgeon be not aAvare of its présence until loss of sensation and natural Avarmth, and finally gangrené of the periphery of the limb, lead to an hiATstigation. Amputations.—In amputations the flaps may not be made sufficiently long, and an exe-eeelingly sensithe condition of the stump arises from a tii>'htly elraAvn line of e-ie-atrix, AA'hich may be the occasion of great suffer- ing to the patient for the remainder of his life. The» neglect to draAv doAvn and divide the larger nerve truuks upon a higher leA'el than the flaps frequently re-sults in their imprisonment in the eicatricial tissue. The most exe-ruciating pains, referable to the area of former distribution or the site of the neive stumps themselve»s, may follow. It Avoulel seem to be almost impossible that an accident such as the amputation of the wrong foot could occur, but this is said to hâve hap- ])eneel at a clinic in Europe» during the» last century. A man Avas suffer- ing from extenshe ulce-ratieui of both feet, one of Avhich Avas condemned foi* amputation, Avhih- the other Avas deemed to be annulable to treatment, Both feet Avère bandaged. The bandages were removed from one foot, G22 A SYSTEM OF LEGAL MEDICINE. and this was amputated. Upon removing the dressings from the other foot it AA-as discovered that the one whieh had been thought to be curable had been removed, AA'hile that which had been regarded as incurable re- mained. The surgeon made every effort to cure the foot, and finaiïy suce-eeded. The late Dr. Daniel Ayres. of Brooklyn, related te) the writer that he once witnessed an amputation of the hip-joint upon the battle-field during the late war, in Avhich the operator, in the excitement of the moment. eut the flaps from the parts above the line of section of the muscular structures, and consequently removed them Avith the amputated bmb. THE ABDOMINAL AND PELVIC CAVITTES. The Diagnosis of Tumors of the Abdomen and Pelvis.—Some of the most serions mishaps in surgieal practice haA'e otvurred in connection Avith the differential diagnosis of abdominal and pelvic tumors. To enumerate aiï of the errars inte) Avhieh the surgeon may fall without due eare would be impossible in this connection. Hysterical contrae-tioiis of isolated juntions of the muscular wall of the abdomen may simulate a tumor, and repeated examinations may be necessary in order to escape this error. Once, hoAvever, the fact of the existence of a tumor has been established, many difficulties arise to baffle the surgeon iu his attempts to differentiate betAveen the A'arious neoplasms AA'hich occur in those regiems. For instance, an ascites having its origin in tubercular peritonitis, AA'ith aellusions of the intestines to the neigh- borhood of the A'ertebral colunm and the utérus fixed high up at the pehic brim, A'ery ch)selv resembh's, in its objeethe symptoms, an OA'arian cyst. Instead of the intestines floating upon the surface of the fluid aud the utérus forced thnviiAvard, the reverse obtains; a flat percussion-note exists anteriorly, and the tympan itic note, due to tbe présence of tbe in- testines, is heard posteriorly, as in *>A-arian eystoma. Simpson mentions six cases in which the abdomen AA'as opened and only a tympanitic condition of the bowels found. The writings of Mai- sonneuve, Lizars, King, Smith, Ah-Dowel, and Dolhof contain many simi- lar operative errors* An hour-glass contraction of a distended uriiiary bladder has been mistaken for a cyst of ilie ovary; the eliagnosis AA'as only established by keeping up steady pressure upon the loAver portion of the abdomen dur- ing catheterization. In another instance an ovarian cyst existed in con- junction with an hour-glass contraction of the bladder. (Xussbaum.) The operator in this case did not discover the true state of affairs until the bladder had been wounded. Differentiation betAveen a neoplasm and pregnancy, either normal or extra-uterine, is sometimes extremely difficult, Xo less an authority than Sir Spencer Wells once opened the abdomen for a supposed ovarian eys- toma, and even proceeded so far as to puncture the utérus. He was eompeiïed to empty the latter at once by reason of the protrusion of the fétus through the opening made by the large troe-ar. Attempts to force the contents of the utérus back through the opening only resulted in * Spiegelberg, Die Diagnosc der Eicrstocks-Tumoren, etc. S Ti? G K A L MALPRA CTLCE. 623 rupture of its Avalls. Two similar cases, ending fatally, are recorded by Hegar and Kaltenbach. A ease is recorded in Avhich a tubal pregnancy was mistaken for a rétroA'ersion of tbe utérus. Réduction Avas attempted, and Avas folloAA'ed by death frémi peritonitis. Hugier once diagnostieateel an extra-uterine pregnancy, and brought the case- before the Academy of Medicine in Paris. A commission nr>- pointed te) investigate the case agreed Avith Hugier. Dubois. hoAveA'er, suggest*»*! the possibility of normal pregnancy. With the occurrence of labor abdominal section AA'as déterminée! upon. While the préparations for the opération Avère being made, Roux made an examination and found the head engaged. The child Avas born per vias naturales. I ha\'e twiee seen the pregnant utérus remeiveel together Avith large utérine fibromata. Upon incising the tumor and utérus a three months' fétus Avas discloseel. Some exceedingly sad instances hâve occurred in whie-h, an abdominal tumor being présent, unmarried patients bave been accused of pregnancy. Paracentesis Abdominis.—Tins opération, is frequently performed by the)se who bave very little expérience in opérations in gênerai, and avIio fail utterly to appreciate the fact that there are (-eu-tain précautions to be ol)se»rA't»el in sjiite of the apparent simplie-ily oî the opération. The AvithdraAval of the entire (piantity of ascitic finie! e-ause»s the A'essels Avith- in the abdominal cavity to beconie overfilled in the attempt on the part of the circulating fluid to fill the vacuum. This may lead to rupture of some of thèse A'essels, or to dangerous cere-bral amenda. Where the abdominal walls are thick and e-elematous (combination of ascites and anasarca), the e-annula may fail to reach the ascitic fluid ; yet the escape of a small quantity of fluid from the connective tissue of the abdominal Avall at first misleads the practitioner, and he is very much perplexed at the situation. He fails to realize that the cannula has not entered the peritoneum, and is led to believe either that a Avrong diag- nosis has been made or that a loop of intestine has faiïen across the open- ing of the cannula. This will lead to either fruitless efforts to clear the cannula or an abandonnant of the opération altogether. Replacing the trocar and making deeper pénétration wiïl clear up the mystery. Intestinal Obstruction and Hernia.—Abdominal section not infre- queiitly fails to disclose the cause of acute obstruction ; not only this, but the manipulation of the intestines in the search sometimes removes the obstacle. Again, it sometimes happens that the obstacle is found but cannot be relieA'ed, or, being relieved, as, for instance, a torsion in the long axis of the bowel, it ree-urs as soon as the restraining hand is re- moved. Under thèse eircunistances an enterotomy is préférable, if the opération bas been greatly prolongée! iu the seare-h for and attempts at remoA'al of the obstae-lc, to immédiate», resection or latéral anastomosis. The latter proceelure may be instituteel later on. The mistaking e>f an inflamed strangulateel hernia for an inguinal abse-e-ss may do incalculable harm and lead to most disastrous consé- quences; mistaking suppurating inguinal glands for hernia Avili searcely resuit in damage to the patient. The attempt to reduce the inflamed mass by taxis in the latter ease must soon be abandoned, anel the careful dissce-tion, laver by laver, of the tumor until an abscess cavity is reached is far préférable to thrusting a knife into the mass and being greeted (J24 A SYSTEM OF LEGAL MEDICINE. with gas of intestinal origin, further investigation revealing the présence of a loop of intestine. FolloAving falls from a heiglit, sAveiïings in the groins haA-e been mistaken for hematocele, when hernia bas been présent anel the residt of the accident, To earefully disseet down upon a hemat- ocele under the impression that it is a hernia is an innocent mistake» ; to incise at a single stroke a hernia in the belief that it is a hematocele is a most grievous error. Before" the days of aseptic aud antiseptic surgery it was the rule in performing herniotomy to endeavor to relieve tbe obstaede» to réduction Avithout opening the sac, on ae-e-ount of the dangers whieh the- peritoneal section then involved. Sometimes the redue-tieni en niasse resulted in a failure to relieve the strangulation whie-h still existed within the sue. Réduction by taxis likewise involves this danger, as Avell as the possibil- ity of forcing the herniated mass between the abdominal walls, or of riipturing the gut at the point Avhere» the strangulation existed, fatal peri- tonitis resulting. When the slight risks of a properly organized and conducted aseptic herniotomy, on the one hand, are Aveigheel against the dangers of pro- longvd taxis on the other, the argument is in favor of a complète herni- otomy. When the advauta.ges of a raelie-al cure of the hernia are» added to the herniotomy of necessity, there can se-are-ely be t.Avo opinions re- garding the greater desirability of the cutting ope»ration. During herniotomy the 1>oaat1 bas freepiently been mistaken for the hernial sac, and ine-ised. In order to clear up any doubt upon tins point the surgeon may press aside the prese-nting surface with the blunt enel of a probe or grooved director. If the bmvel is presenting, the probe will easily enter the peritoneal caA'ity; but if it is the hernial sac the probe AA'ill be arrested by the neck of the sac at the constricting ring, or at Poupart's ligament, and cannot be made te) advance farther AA'ithout the employment of considérable force. The difficulties of distinguishing the sac in umbilical hernia are very greatly increased by the fact that this structure is exceedingly thin and quite frequently firmly attached to the overlying skin. Hysterical Atony Simulating Intestinal Obstruction.—A case of this kind oce-urred in my service at the Methodist Episcopal Hospital in Brooklyn. The patient, a neurotic female of forty years of âge, had been the subject of inereasing difficulty of obtaining movements for a year and a half. Thèse- were only finally obtained by attacliing a rub- ber injection-tube to the house fauce-t, connected with one of the gênerai city réservoirs, and turning the full force of the pressure on, whiedi was estimated as not less than twenty pounds to the square inch. This was continued upon repeated occasions until the entire intestinal canal was force»el full of Avaler. The method finally failed altogether, and she Avas admitte»d to the hospital Avith the abdomen enormously distended. An abdominal section shoAved that no obstruction Avas présent; the entire intestinal tube Avas distended to an enormous extent. The Cure of Hernia by Subeutaneous Injection.—Heaton, Daven- port, and Warren hâve attempted the radical cure of hernia. without the necessity of an operative procédure, save that involved in the subeutane»- ous injection of fluid extracts of AA'hite-oak bark. For the same purpose ScliAvalbe bas recommended the injection of alcohol. Great car*», how- ever, is necessary not to pass the point of the injecting-needle into a vein. SURGICAL MALPRACTLCE. 625 A glass-barreled syringe should be used. This may be partially filled Avith the solution to be injectée!, and introduced to the desired extent. The piston may lie slightly with drawn, when examination of tbe contents of the barre-1 Aviïl discoA'er if a flow of blood lias rushed into the syringe to fill the vacuum. Or the operator may pause for a full minute after introducing the needle, to see if there is a marked flow of blood along- side the syringe-point indicating that a Aein lias been Avounded, before making the injection. Disturbances of Function Following Opérations about the Lower Bowel and Anus.—Thèse disturbane-es may consist in either inconti- nence of faeces and gas from inability to contract the sphincter, or in the présence of a strii'ture. The action of the sphincter may be entirely lost from multiple incis- ions across its substance in fistula opérations, or from failure of the reparative process in tuberculous patients AA'here but a single incision has been maele. The process of stretching the sphincter, employed as a preliminary step in opérations for the removal of hemorrhoidal tumors, may also be folloAveel by degenerathe changes and a more or less per- manent Aveakening of the muscle. In addition to the stretching the sur- geon may do still further damage by including portions of the muscular structure in the clamp or ligature, or by dissee-ting it away in the opéra- tion knoAvn as Whitehead's, or senne of its modificatiems. Stricture of the rectum may resiilt from a too free application of the cautery in the clamp and cautery opération for the removal of hemor- rhoiels. In both this anel the ligature opération the surgeon should be careful to leave Avell-defined areas of mucous membrane betAveen the portions subjected to eauterization or included in the ligature. In the Whitchead opération, in which the attempt is made to excise the entire so-calleel pile-bearing area of the rectum, failure of union if the opération is not properly performed, as well as too great an encroaehment upon the cutaneous surface of the anus, wiiï resiilt in stricture of the rectum. Ventral Hernia.—Large Avounds of the abdominal wall, whether op- erathe or otherwise, are very liable to become subsequently the seat of a ventral hernia, anel reflect upon the eare and skill of the surgeon. In the prévention of tins distressing condition it is necessary to obtain primary union of ail of the divided structures, the différent layers being unitetl either by buried sutures, or some form of suture that Avili aecom- plish the same residt and still be capable of removal* When the latter is enqdeyeel it should be allowed to remain in situ for at least three Aveeks. Whatever method is used the patient should not leave the re- cumbent position for four Aveeks at the earliest, some form of external bandage to support the weakened abdominal wall should be worn, and the patieeait cautioned not to engage in any violent exercise for several months. THE GENITO-URINARY ORGANS. In no one of the régions of the body occur so many surgieal mis- haps or complications, and unfortunate sequelae to injuries and opéra- tions, as in the genito-urinary system of the maie. Almost any accidentai * S*»o article on the "crossed suture," by the writer, in the Annals of Surgery, vol. xv., p. 351. G2G A SYSTEM OF LEGAL MEDICINE. injury or operative procédure is accompanied by accidents, both avend- able and unavoidable, anel the careful practitioner who has much to do Avith the surgery of thèse parts must necessarily be constantly watcbful, lest his patient's life and his own réputation are lost at one and the same time. Catheterization.—The failure to thoroughly disinfect a cathéter be- fore using it is a most inexcusable error, and can only be committed by an ignorant or criminally careless surgeon. The contention of the great French surgeon Civiale,'remarkable from the fact that it Avas made long before the introduction of antiseptics, that no person ever suffered from e-atarrhal cystitis in wliose bladeler a foreign body had not been intro- duced, shoîdtl be weiï considered in this connection. The making of a false» passage by the unskillful or forcible use of a métal cathéter or sound, in the présence of strictures or enlarged pros- tate, is one of the most common as well as most culpable mistakes iu surgery. Even when the prostate lias been safely reached an attempt to bore through the enlarged middle lobe is sometimes made, and profuse hemorrhage, and eventually abscess, is the resiilt. The young and inexperienced surgeon Avili sometimes fail in a case of rétention-to empty the bladder because tbe instrument employed Avas blocked up by a dried blood-elot or some débris resulting from its last previous use.' Doubt then ai-ise»s in the mind of the operator as to, first, whether or not the instrument is in the bladder at ail, and secondly, whether the bladder contains any urine. To guard against tbe possi- bility of such mistakes the» cathéter should be thoroughly cleansed and cleared, and the suprapubic région pereussed prior to the attempted catheterization. In parai}.'tic e-ases the urine Avili sometimes refuse to floAV, and in atony of the bladder Avalls from prolonged distention the same effect will be observed. Under thèse circumstauces the doubt as to whether or not the e-atheter has been properly passed Avili be cleared up by making pressure Avith the hand over the région of the bladder. Warnings against the use of cheap rubber cathéters cannot be too often repeated. Again and again calculi hâve been removed from the bladder having as nuclei pièces of a broken-off cathéter. Even a Avhole soft rubber cathéter lias been found in the bladder, AA'hich had slipped in AA'hen the patient had fallen asleep after haAdng passed the cathéter in the early hours of the morning and retired again. Subséquent search failed to discover the Avfiereabouts of the instrument until symptoms of the présence of a calculus explaineel the mystery. In speaking of forced catheterization and the production of false passages, it Avas not intended to convey the impression that in compétent hands it is possible to reae-li the bladder in aiï cases, and Avithout acci- dent. It is true that if the skillful surgeon were to persist he Avemld do as much harm as the novice. The former, however, will generally per- ceive AA'hen an unjustifiable degree of force is being employe-d, and desist, haAdng at bis command other means for accomplishing the desired object. The ignorant and careless practitioner, hoAvever, believing that he must enter the bladder with the cathéter whether or no, proeeeds to plow bis Avay through Avith a métal instrument, regardless of conséquences. Other Methods of Emptying the Bladder.—When the difficulties in the» way of emptying the bladder, in a case of retentieni of urine, are sue-h as demand of the prudent surgeon the substitution of other means than SURGICAL MALPRACTICE. 627 those haA'ing 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 bladeler will arise. Without doubt the first choice at this perioel Avili be the method of aspiration. It should be borne in mind in this connection that relief of the over-distendeel viscus by aspiration will frequently permit of the subséquent e-mptying of the latter by means of a cathéter through the natural ehaniiel. The opération may be done above the pubes Avithout injury to the pe»ritoneum, and may lie repeated two or three times in tAve-nty-four hours, thus giving the' patient relief until catheterization is 4»e)ssible or other measures are deA'ised for his permanent rebef. The préférence for aspiration over suprapubic puiicture by a large trocar and cannula is base-d upon the fact that, Avith the latter, urinary infiltration of the abdominal Avalls may occur anel lead to serious phleg- monous inflammation of thèse» structures. Incision aboA'e the pubes may be done if the external AA'ound be» made sufficie»ntly large- to permit of ready escape of the urine ; but this is an opération rarely performed for rétention. Permanent Catheterization—The permanent rétention of a cathéter AA'hen once the bladder has been reached through the natural route also has its dangers. A me»tal instrument will rarely be tolerated for more than a ft»AV hours, and a soft rubber cathéter cannot, as a rule, be em- ployed in difficult catheterization. Whate-ver instrument is used, the concentrated eharaeter of the urine in thèse cases produces rapid in- crustation from the deposit of the salts, and thèse, becoming displacetl, form nuclei for vesie-al calculi. Circumcision.—Both hemorrhage and sepsis foiïow tins opération. In the ritual opération the» mohl or rabbi not infrequently removes a slice of the glans alse>. In later life the» scar resulting from this accident may be mistaken for that AA'hich has folloAved a e-lianere, the patient being Avrongfully accused bee-ause of its présence. In tbe ritual opération the internai or mucous-niembraiie surface of the prépuce is torn insteael of being inciseel, and the rent thus made may extend. beyond the corona glandis upon the dorsum of the pénis. In France the prese»nee of a sur- geon is required by law at ail ritual circumeisions. Failure to keep the prépuce Avell retracted after the opération may lead to the formation of a cicatricial ring of the mucocutaneous tissues about the glans beyond the corona glandis and necessitate a second opération. Tins mishap may also resiilt from the removal of an insuffi- cient portion of the prépuce. Inexperienced operators sometimes become alarmed at the swelling along the suture-line, and make the attempt to remove still more of the prépuce afte»r two or three days. The resiilt of thèse attempts is usuaiïy such as to leave the parts in a. much worse condition than before. Hydrocele.—In the opération of tapping a hydrocele the most com- mon accident consists of an injury to the testicle. Hematocele, orchitis, or even abscess, may residt. Another accident is the slipping of the oannula from the sac of the tunica vaginalis, thus aiïoAving the contents of the latter to Aoav into the cellular tissue, where it may cause a phleg- mon or even te-rminate in gangrené of the entire scrotum. The first-named accidents arise from a failure on the part of the oper- ator tei bear in mind that the testicle lies behind and upward, AA'here, 628 A SYSTEM OF LEGAL MEDICINE. under ordinary circumstances, with proper eare it may abnost ahvays be avoided. It bas happened more than once that the practitioner who is little accustomed to operating and to the e-are of instruments cleanses the troear after an opération and puts it away, overlooking the cannula. When next it is needed the troear alone is plunged into the hydroe-ele. Again, it may happen that he negh-e-ts te) ascertain if the troear e-an be Avitlidrawii from the cannula. After the pimcture he» essay s to de) so, but finds it so thoroughly fasteneel by corrosion or rust to the cannula that they cannot be separated. Abscess of the Testicle.—Prolapse of the semiuiferous tubules is an accident occurriiig in the e-ourse of an abse-ess of the testicle. An ugly, grayish-looking mass is seen projecting from the abscess cavity, AA'hich the inexperienced practitioner may mistake for an ordinary slough, and attempt to remove it AA'ith the dressing-fore-eps ; ivme>ving thus meter after meter of the tubules until several or even aiï of tbe lobuli testes are evacuateel, the effect being the same as castration. Cauterization of the prolapse-d mass and crowding it by me-ans of the dre-ssings as much as possible into the lobule from which it projee-ts, is the prope-r treatment. Castration.—Separate ligature of the vessels e)f tbe corel, although apparently a typie-al prex-edure», is less tei be relied upon than ligature en masse, then Avith the latter nie»thod, unless the operator is careful to dhide the structures of the cord for at least three fourths of an inch aAvay from the point of ligature, the action of the cremaster may so re- tract the A'essels as to cause troublesoine hemorrhage. The vas deferens need not be included in the ligature. In malignant disease of the tes- ticle and cord this extends along the séminal duct proper, and récurrence takes place sooner or later, as a rule. Avulsion of the vas deferens should be done in order to guard as much as possible against this resiilt, the vas being twisted and Avitbdrawn at the same time. In this manner the entire vas deferens, from the point where it joins the ejaculatory duct of the corresponding vesicula seminalis at the base of the prostate to the internai abdominal ring, may be removed. Opérations for Vesical Calcul us.—Ail of the 04)*-rations for the re- lief of stone in the bladder are liable to some mishap or accident. While the opération 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 edosed at once. If it is left open there is less risk of infiltration, although im- munity from this cannot be assured 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, unfortunately, this opération 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 faciïitate the ele\ration of the bladder, are to be noted. In my oavu expérience the use of the Petersen rubber baiïoon résultée! in a rupt- ure of the anterior wall of the rectum, although but eight ounces of fluid were used to distend it. (Annals of Surgery, vol. xii.,1890, p. 129.) Two other cases are reported (Cadge, Proe. Royal Med. and Chir. Soc, London, 1886, p. 97; Nicaise, quoted by Keyes in Annual of rnirersal Médical Sciences, 1888, Section C, p. 27.) Médian perineal lithotomy, on the other hand, admits of the removal of moderate-sized calculi only, and SURGICAL MALPRACTICE. 629 henee its application in the treatment of calculous disease is limitée!. The combination of perineal section and lithotrity (perineal lithotrity : Nussbaum of Munich, Dolbeau of Paris) offers some advantages, but is limited in its application. Latéral lithotomy, whiïe it admits of the re- moval of a rather larger stone than the médian opération, has been ac- cused of causing sterility because of injury to the séminal vesicles or to the ejaculatory ducts. Again, the rectum is more apt to be injureel in latéral lithotomy, particularly if tenesmus and prolapse of the bowel bave been prominent features in the history of the case». Urethro-rectal fistula results. In lithotomy in a number of sittings, as practiced previous to the introduction of Bigelow's method of lithotomy at a single sitting and complète évacuation' of the fragments through a large urethral tube (litholapaxy), it sometimes happened that pointed fragments remaiued in the bladder to forment the patient in the intervais between the séances. In addition to this the surgeon could never be sure that ail of the small fragments had been passed, and patients bave frequently returned Avith from four to eight stone-s, smaiï fragments which had been left having served as nuclei of new stones. Although thèse mishaps are prevented to a great extent by the method of litholapaxy, together with the use of BigeloAv's large evacuating-tubes anel force-pump apparatus for removing ail fragments from the bladeler, yet there is one accident which may occur in inexperienced hands in both lithotrity and litholapaxy. This is the eatching of a fold of the mucous membrane lining the bladder betAveen the blades of the crushing instru- ment, and conséquent injury to this structure. In order to avoid this the surgeon should never forget, after having seized the calculus, to ratate the instrument in order to ascertain whether or not it moves freely in the bladder. A stone nia}- be previously detected anel its présence verified by the surgeon's colleagues, and yet not be diseoverable at the time of the opér- ation. This is due to the fact that the stone is small and faiïs into a recess of the bladder, the AA'aiïs of the latter closing over it. In order to a\Toid this awkAvarel predicament it is advisable for the surgeon to make sure fhat the stone is Avithin reach just prior to the administration of the anaesthetic at the time of opération. Extravasation of Urine.—This accident may foiïow the giving AA'ay of the urethra at a point behind an old stricture, from long-continued pressure and the changes which the mucous membrane undergoes in con- séquence- ; or it may resuit from injuries to the canal, occurring from the injudie-ious use of métal instruments in attempts at forced catheteri- zation, and also from laeerated and confused Avemnds of the perineum from Avithout. Crush injuries of the pelvis, with fracture of the bones of the latter, may also be eomplicated Avith rupture of the urethra and urinary extravasation. Fracture of the corpora cavernosa during érec- tion, e-ither frenn a sudden bending of the pénis by the grasp of the hand or violent coitus, likewise gives rise to this condition. Failure to recognize the oceurrence of extravasation is a grave error, and is likely te) re-sult in most serious conséquences. In case the solu- tion of continuité is behind the bulb this will lead to infiltration of the scrotum, from which locality the extravasation will be directed between the spine of the pubes and the symphysis, finaiïy reaching the abdo- 630 A SYSTEM OF LEGAL MEDLCLNE. men. In the peniïe urethra the rupture wiïl be followed by a sAvelliug of the peuis, Avhich reaches its maximum in the neighborhood of the point of e-scape. At the membranous urethra the extraA'asatetl urine is confined betAveen the hivers of the triangular ligament, from which it subsequently escapes by processes of sloughing and suppui-ation. At the prostatie urethra, i.e, behind the posterior laver of the triangular liga- ment, the extravasation may find its Avay to the anal région in the peri- neum by foiïowing the course of the rectum : or the thin pelvie- fascia may give Avay at its thiimest point near the puboprastatic ligament, thus permitting the extraA'asation to spread through the subperitoneal con- nective tissue. In AA'hatever direction the urine finds its way, its présence in the tis- sues gives rise, unless speedy measures of rebef by free midtiple incisions and thorough disinfeetion of the infected parts are instituted, to rapid sloughing of the connective tissue, gangrené, gênerai sepsis, and death. APPEITOIX.* EXTRACTS FROM THE LAWS OF THE DIFFERENT STATES AND TERRI- TORIES OF THE UNITED STATES WHICH RELATE TO THE GENERAL CARE OF THE INSANE. The following pages relate more particularly to the duties and responsibilities of physicians and officers of the law in référence to committing insane persons to insti- tutions for eare and treatment, their gênerai management while under treatment, and their discharge from institutions. As the laws of the States differ very considerably in référence to the form of pro- ceeding necessary to be followed in thèse several respects, it is thought désirable that from the great body of statutes relating to the management of the insane such extracts as relate to the duties of physicians should be compiled and made easy for référence. It is believed that the following arrangement will prove to be of service, especially to gênerai practitioners. Acts of 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 fit subject for eare and treatment in the hospital for the insane ; pro- vided, that no person idiot or imbécile from birth, or whose mental development was arrested by disease or physieal injury prior to the âge of puberty, or any person who is afflicted with simple epilepsy, shall be regarded as insane, unless the manifestation of abnormal disability, violence, homicidal or suicidai impulses are such as to render his confinement in the hospital a proper protection to prevent him from injuring him- self or others. Sec. 2.—Be it further enacted that authority to discharge patients from the hos- pital is vested in the trustées, and may be delegated by them to the superintendent under such régulations as they may see proper to adopt. . . . Sec. 3.—Be it further enacted that the superintendent of the hospital has author- ity to furlough, 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 be borne by the parties. Sec. 4.—Be it further enacted that 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. IL P. Stearns, and is used with his kind permission. 631 632 APPENDIN. Reatsed Code of Alabama, 1886-87. Sec. 1237.—Order of Admission. In order of admission the indigent insane must hâve precedence of the rich, and récent cases of both classes must bave precedence over those of long standing. The paying patients from other States may be received into the hospital should vacancies occur unclaimed by natives or résidents of Alabama. Sec. 1241.—Investigation of Insanity and Admission to Hospital 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 résides, and such judge must without delay make appli- cation to the superintendent of the hospital for his admission. . . . When informed that the applicant can be received the judge must call one respectable physician and other trustworthy witnesses and fully investigate the facts in the case, and either with or without the verdict of a jury, at his discrétion, must décide the case as to insanity and indigence ; and if the judge believe that satisfactory évidence has been adduced showing the patient to be insane, and his estate insufficient to support him and his family (or himself alone, if he has no family) under 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 requiree! to keep the vacancy for a period of thirty days after the date of notice that patient can be received. The judge in ail such cases shall hâve the requisite power to compel the attendance of witnesses and jurors, and must file the certificate of the physician and other papers relating to the case, with a report of the proceedings and décision. 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 hâve precedence over other claims, and be repaid promptly, by the commissioners of the county from which the patient cornes, 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 gênerai conduct of the accused upon which «uch charge of insanity is based; and shall also cause to appear before him one or more graduâtes of medicine, and known to be reputable practi- tioners thereof, who shall be présent 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 book 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 APPEND1N. G33 person to be conveyed to the Territorial Insane Asylum, and shall présent for the safe confinement and eare of such person suitable place in such asylum, and shall draw their warrants in payment of proper costs and charges therefor upon the county treasury ; and the county treasury shall pay such warrants out of the gênerai fund, as other warrants are paid from such fund ; provided, that such insane person shall bave no money or property from which said cost and charges may be paid, according to the provision of this act. Acts of Arkansas, 1889. Sec. 1.—Female Attendant to be Provided. That ail females who hâve 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 maie attendants for the same service. Act II. Sec. 1.—Privilèges of Inmates in Correspondent. 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 lie or she desires, and over thèse letters to this individual there shall be no censorship exercised or allowed by any of the asylum officiais or em- ployées, but their post-office rights, so far as this one individual is concerned, shall be as free and unrestrained as are those of any other résident or citizen of the United States, and shall be under the protection of the same postal laws ; and each and every inmate shall hâve the right to make a choice of the individual party every three months, if he or she so désire to do. And it is hère 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 ail 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 ail patients ; the attendant is required in ail 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 disposai ; and the contents of thèse boxes must be collectée! 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 Superintendent. That it is hereby made the duty of the superintendent to keep registered and posted, in some public 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 this individual ; and ail thèse 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 médication, in which case the letter shall be required to be opened in the présence of a compétent witness, and this substance shall be delivered as directed. Sec. 3.—Violation of the Act by Persons Connected irith Asylums a Misdemeanor. That any person refusing or neglecting to comply with, or willfully and knowingly violating, any of thèse provisions of this act shall be guilty of a misdemeanor, and upon conviction thereof shall be punished as the Civic ('ode of the State of Arkansas describes for misdemeanor, and by ineligibility to any office in the asylum afterward. 634 APPENDIN. Sec. 4.—Copy of this Act to be Postcd 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 of 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 eare he may be, and who is bound to provide for his support, to confine him in some suitable place until the next term of the Probate Court for his county, which shall make such order for the restraint, support, and safe-keeping 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 having 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 court shall make further order thereon, as in the preceeling section specified. Sec. 3814.—Tus/me Persons Found at Large. Insane persons found at large and not in the eare of some discreet person shall be arrested by any peace officer and taken before a magistrats 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 service, a warrant directing that such person be arrested and taken before any judge of court of record within the county for examination. Sec. 2211.—Two Witnesses. When the person is taken before the judge he must issue subpœnas to two or more witnesses best acquainted with such insane person, to appear and testify before him at such examination. Sec. 2212.—Two Physicians. The judge will also issue subpœnas for at least two graduâtes of medicine to appear and attend such examination. Sec. 2214.— Duty of Physician. Th'e 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. APPENDIN. 035 Second, The premonitory symptoms, apparent cause, the class of insanity, the duration and condition of disease. Third, The nativity. âge, résidence, occupation, and previous habits of the person. Fourth, The place from whence the person came, and the length of his résidence in this State. Sec. 2217.—Duty of the Judge and Clcrk on Commitment of Insane. 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 property, must make an order that he be confined in the insane asylum. A copy of such order shall be filed with a record by the clerk of the county. The clerk shall also keep in convenient form an index-book showing name, âge, 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 fées shall be charged by the clerk for performing any duties provided for by this section. Sec. 2222.—Fccs of Physicians. The physicians attending#such examination of an insane person are allowed five dollars, which are to be paid by the treasurer of the county where the examination was had, on the order of the supervisors. Code of Colorado, 1883. 2281—Sec. 28.—(2) Arrest of Varions Lunatics—Inquest—Verdict—Commitment —Custody. AA7henever 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 property, or the person or proi>erty of any other or others, if allowed to go at large, the county court, 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 appréhen- sion of such alleged insane person, which order may be executed by any sheriff or con- stable of said county, or by any person especially appointed by said court to exécute the same ; provided, 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 arrested 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 détermination 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.—Définition 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 intempérance or any disorder, or unsoundness of mind, shall be incapable of managing and caring for his own estate. Sec. 2241.—Superintendent and Commissioners to Report Annually. 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, âge, sex, occupation, and résidence, treatment and state of reform of persons admitted, from the date of opening of the asylum or from the date of the last report, together with such other facts as their expérience and observation may approve and may deem in the interest of the public ; the governor shall cause such reports to be published, and he shall présent them to the next gênerai assembly. . . . 636 APPENDIN. Acts of Connecticut, 1889. Chapter 162, Section 1.—In this act the words and expressions following shall hâve the several meanings hereby assigned to them, unless there is something in the subject or context répugnant 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 anv State-prison, county jail, or poorhouse, nor any public reformatory or pénal in- stitution of this State. "Insane person" means and shall include every idiot, non compos, lunatic, insane, and distracted person. " Patient " means any person detained and taken cave of as an insane person. The words "keeper of an asylum" mean any person, body of persons, or corporation who hâve the immédiate superintendence, charge, management, and control of an asylum and the patients therein. Words im- porting the masculine gender may be applied to females. Sko. 2.—Any judge of a Probate Court, within his probate district, shall hâve power to commit any insane person residing in said district to an asylum in this State, in the manner hereinafter provided. Sko. 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.—AAIienever any person in this State shall be insane, or shall 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 réside, 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 may adjourn saiel hear- ing from time to time for cause. Said judge may issue a warrant for the appréhension and bringing before him of said person complained of, and shall see and examine said person, if in his judgment the condition or conduct of such person renders it necessary and proper so to do, or state in his final order why 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 tAvo physi- cians, each of whom is a graduate of some legally organized médical 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 hâve 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 asylum ; 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 he so finds, and commanding some proper officer, or any 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 détention, not an asylum, in such manner as said judge shall order. . . . Sec. 16.—AU insane persons confined in any asylum in this State shall be entitled to the benefits of the writ 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 décide that the person is insane, such décision 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 insane per- son, or on his behalf by any relative or friend, or person interested in his welfare. Sec. 17.—The provisions of this act shall not extend to nor affect in any way the cases of persons eonvicted of or charged with crime, as provided for in the following AP PEND IN. 637 sections of the General Statutes—to wit, sections 1600, 1601, 1602, 1603, 33S5, 3386, 3615, 3617, 3618, 3619, 3620, and 3621 ; nor shall they be construed as repealing sec- tions 487, 3683, and 3684 of said General Statutes. Sec. 18.—The keeper of any asylum in this State may receive and detain therein, as a patient, any person who is desirous of submitting himself to treatment and makes written application therefor, but whose mental condition is not such as to ren- der it légal to grant an order of commitment as an insane person in his case, under the provisions of this act. No such patient shall be detaiued for more than three days after having given notice in writing of his intention or désire to leave said asylum. Sec. 19.—An attorney at law regularly retained by, or on behalf of, any patient in an asylum, or any médical practitioner designated by such patient, or by any member of his family, or by some relative or friend of such patient, shall be admitted to visit such patient at ail reasonable hours, if in the opinion of the keeper of said asylum such visit would not be injurious to said patient, or if a judge of the Superior Court first orders in writing that such visit be allowed. Sec. 20.—Ail persons detained as insane shall at ail times be furnished with materials for communicating with any suitable person without the asylum, and such communications shall be stamped and mailed daily. Should the patient désire it, ail rational communications shall be written at his dictation and duly mailed to any rela- tive or person named by the patient. Sec. 22.—Ail asylums in this State shall be subject to the inspection and Visita- tion of the State Board of Charities, and shall be so visited and inspeeted at least once in six months in each year. Sec. 23.—Every person who willfully conspires 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 punished 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 provis- 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 discrétion of the court. Sec. 25.—Ail acts or parts of acts inconsistent herewith are hereby repealed. Laws of Dakota Territora', 1887. Sec. 2179.—Appointmcnt of Commissioners 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 their Power. The said commissioners shall hâve eognizance of ail applications for admission to the hospital, or for the safe-keeping otherwise of insane persons within their respect- ive counties, except in cases otherwise specially provided for. For the purpose of discharging the duties required of them they shall hâve the power to issue subpœnas and compel obédience thereto, to demonstrate this and any act of the court necessary and proper in the premises. Sec. 2183.—Application for Admission to the Hospital. Application for admission to the hospital must be made in writing, in the nature of an information, verified by affidavit. Such information must allège that the person on wliose behalf application is made is believed by the informant to be insane, and a fit subject for custody and treatment in the hospital ; if such person is found in the county and has a légal 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. 638 APPENDIN. Sec. 2184.—Investigation by Commissioners as to the Alleged Insanity—Physicicni'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 lus or her présence, and they may issue their war- rant therefor and provide for the suitable custody of such person until their investiga- tion shall be coneluded. . . . Any citizen of the county, or any friend of the person alleged to be insane, mav appear and resist the application, and the parties may ap- pear by counsel if they èlect. The commissioners, whether they décide to dispense with the présence 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 allégations in the information touching the actual condition of such person, and forthwith report 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 appointaient, 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 propounded in such cases, and such interrogations and answers shall be attached to this certificate. Sec. 2185.—How Patients should bc Sent to tlie Hospital. On the return of the physician's certificate the commissioners shall, as soon as 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 find such j)er- 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 duplieate 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 tlie hospital to reçoive and keep such person therein. Such warrant and duplieate, with the finding and certifi- cate of the physician, shall be delivered to the sheriff of the county, who shall exécute the same by conveying such person to the hospital and delivering him or her, with the duplieate of the physician's certificate and finding, to the superintendent thereof. The superintendent, over his officiai signature, shall acknowledge such delivery on the original warrant, which the sheriff shall return to the clerk of the commissioners, with his cost and expenses indorsed thereon. . . . Sec. 2190.—Penalty for Cruelty to the Insane. Any person having eare 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 Privilèges 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 thèse letters to this individual there shall be no censorship exercised or allowed by any asylum officiai or employée, but their post-office rights, so far as this one indi- vidual is concerne*!, shall be as free and unrestricted as are those of any other rési- 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 hâve 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 the superintendent to furnish each and every inmate of the insane asylum in this Territory, either public or private, with suitable material for APPENDIN. 639 writing, inclosing, sealing, stamping, and mailing letters, sufficient at least for the writing of one letter a week, providing they request tlie same, unless they are other- wise furnished with such material, and ail such letters shall be dropped by the writers thereof, accompanied by the attendant when necessary, into a post-office box provided at the insane asylum and kept in some place easy of access to ail patients ; the attend- ant is required in ail 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 disposai of the superintendent ; and the contents of this box shall be collected once every week by an authorized person of the Post-office Department, and by him placed in the hands of the United States mail for delivery. Laws of 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 pétition, together with the certificate of two practicing physi- cians of the county wherein such lunatic or insane person shall réside, 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 médical treatment in such case than can be afforded in the almshouse wherein such lunatic or insane person may réside, the chancellor shall, if satisfied with the proofs offered of such lunacy or insanity, refer such applications to the trustées 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 ; provided, 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 trustées 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 spécial treatment. Sec. 3.— When Indigent Lunatics may be Returned. That whenever the principal physician of the Insane Department of the New Castle County Almshouse shall represent to the trustées of the poor of the county from which said indigent lunatic or insane person may hâve 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 résidence in said Insane Depart- ment unnecessary, or that the said person is, after full and sufficient opportunity, 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 ail cases of application for the commitment of an insane person to the hospital the évidence 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 trustées or chancellor, as provided in section 6 of this act. Digest, Laws of Florida, 1881. Chapter 147.—Lunatics. Sec. 3.—Duty of the Circuit Judge. Whenever it shall be suggested, by pétition or otherwise, to any judge 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 own affairs, or of 040 APPENDIN. taking eare of himself or herself. it shall be the duty of said judge to issue a writ to the sheriff of the county wherem 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 be Taken to the Asylum—Order for Private Cave of Lunatic. If it shall appear that said lunatic or insane person is destitute, then the judge shall draw an oreier that the sheriff shall transport such lunatic or insane person to the Asylum for the Indigent Lunatics of the State of Florida, and there deliver the lunatic or insane person to the officer having charge of same, for the purpose of his eare, custody, and treatment ; provided, however, that the judge may, in his discrétion, direct the said lunatic or insane person to be delivered to any other person for his eare, 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 eare, 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 bythe Board of Commissioners of State Institu- tions, to receive into said asylum any lunatic, idiot, or insane person whose friends, parents, or guardians are able and willing to pay for the eare and custody and main- tenance of said lunatic, idiot, or insane person. Sec. 13.—Attention, etc. Such lunatic, idiot, or insane person shall receive aU care, food, clothing, and médical attention as he or she may demand and require, from the physician and other employées of the asylum. Sec. 17.—Powers. The physician of the asylum shall hâve sole supervision of and immédiate 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 Florida, 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 under 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, législative committees, and aU others interested. Acts of 1883. Chapter 3444, Section Y—Fee and Mileage. That hereafter any practicing physician who shall be called in by the circuit judo-e 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 APPENDIN. 641 per mile by the State, out of appropriations for the maintenance of indigent lunatics and insane persons ; the same shall be audited by the comptroller on the approval of the circuit judge, and paid by the treasurer on the comptroller's warrant. Code of State of Georgia, 1882. Sec. 331 (5).—The State asylum is intended for the care of lunatics, idiots, epi- leptics, or demented inebriates. Inmates are divided into four classes : (1) Pay or pauper patients, résidents of the State. (2) Pay-patlents who are non-residents. (3) Insane penitentiary convicts. (4) Insane negroes, in certain cases. Citizens of Georgia hâve a préférence over non-residents. Résident pay-patients are admitted upon authentic évidence of lunacy according to law, or by a certificate of three respectable physicians and two respectable citi- zens. . . . Laws of 1889, Providing for the Appointment of Guardian or Commitment to Lunatic Asylum. Sec. 1.—To hâve Guardian Appointed or Subject Committed to Lunatic Asylum. Upon the pétition of a person on oath, setting forth that another is liable to hâve a guardian appointed under the provision of this act (or is subject to be committed to the lunatic asylum of this State), the ordinary, upon the proof, if ten days' notice of such application has been given to the three nearest adult relatives of such person, or if there is no such relative within this State, shall issue a commission direct to any eighteen discreet and proper persons, one of whom shall be a physician, requiring any twelve of them, including the physician, to examine by inspection the person for whom guardianship (or commitment to asylum) is sought, and to hear and examine witnesses on oath, to make return of such examination and inquiry to said ordinary, specifying in such ^return under which such classes they found said person to come ; such commission shall be sworn by any of the officers of this State authorized by the laws of this State to administor an oath, "well" and truly to exécute said commission, to the best of their skill and " ability," which oath shall be returned with their verdict. Statutes of Idaho, 1887. Sec. 750.—The Idaho Insane Asylum, loeated at Blackfoot, is under the man- agement and control of a Board of Directors, consisting of three persons. . . . Sec. 756.—The médical superintendent must be a graduate of medicine, and must hâve practiced in his profession five years after date of his diploma. Sec. 757.—Must Réside at and Give his Entire Time to the Asylum. He must réside at the asylum and give his entire time and attention to promote the best interests of the patients. His duties not specified in this chapter must be prescribed by the Board of Directors' by-laws. Sec. 758.—General Powers. He is the chief executive officer of the asylum, with powers and duties as follows : To control the patients, prescribe the treatment, and prescribe and enforce the sundry régulations of the asylum. Sec. 764.—Discharge. Any person received in the asylum must, upon recovery, be discharged therefrom. Sec. 767.—Not Eligible for Admission. No person laboring under any contagious or infectious disease must be admitted into the asylum as a patient. Sec. 769.—Examination before Whom. When it appears by affidavit, to the satisfaction of a magistrate of a county, that any person within the county is so far disordered as to endanger health, person, or 642 APPENDIN. propertv, he must issue and deliver to some peace officer, for service, a warrant directing that such person be arrested and taken before any judge of a court of record within the county for examination. Sec. 771.—One Physician. The judge may also issue subpœnas for at least one graduate of medicine to appear and attend such examination. Sec. 773.—Duty of Physician. The physician must hear such testimony and must make a personal examination of the alleged insane person. Sec. 774.—Certificate of Physician. The physician, after hearing the testimony and making the examination, must, if he believes the person to be dangerously insane, make a certificate in his own hand- writing, showing, as near as possible : (1) That such person is so far disordered in his mind as to endanger health, per- son, and property. (2) The premonitory symptoms, apparent cause or class of insanity, and the con- dition of the disease. (3) The nativity, âge, résidence, occupation, and previous habits of the person. (4) The place from whence the person came and the length of his résidence in this Territory. Sec. 776.— Order of the Judge. The judge, after such examination and certificate made, if he believes the person so far disordered in his mind as to endanger health, person, and property, must make an order that he shall be confined in the insane asylum. Sec. 778.—Money Found on Insane Persons must be Delivered to the Asylum. Any money found on the person of an insane person at the time of the arrest must be certified to by the judge, and sent with such person to the asylum, there to be delivered to the médical superintendent, who must deliver the same to the Terri- torial treasurer. If the sum exceed one hundred dollars the excess must be applied to the payment of expenses of such person while in the asylum, and delivered to the person when discharged, or applied to the payment of funeral expenses if the person dies at the asylum. Sec. 781.—Fcc of Physician. The physician attending each examination of an insane person is allowed five dollars, to be paid by the county treasurer of the county where the examination was had, on the order of the Board of County Commissioners. Statutes of Illinois, 1881. Chapter 85, page 950.—Lunatics. Sec. Y—Pétition. That when a person is supposed to be insane or distracted, any near relative, or, in case there be none, any respectable person residing in the county, may pétition the judge of the County Court for proceedings to inquire into the alleged insanity or distraction. For the hearing of such applications and proceedings thereof the County Court shall be considered as always open. Sec. 2. — Writ Service. Upon the filing of such pétition the judge shall order the clerk of the court to issue a writ, directed to the sheriff or any constable, or the person having custody of the alleged insane or distracted person, unless he shall be brought before the court with- out such writ, requiring the alleged insane or distracted person to be brought before him at a time and place to be appointed for the hearing of the matter. It shall be the APPENDIN. 643 duty of the officer or person to whom the writ is directed to exécute and return the same and bring the alleged insane person before the court as directed in the writ. Sec. 4.—Jury Trial. At the time fixed for the trial a jury of six persons, one of whom shall be a phy- sician, shall be impaneled to try the case. The case shall be tried in the présence of the person alleged to be insane, who shall hâve the right to be assisted by counsel, and may challenge the jurors as in civil cases ; the court may for good cause continue the case from time to time. Sec. 5.—Verdict. After hearing the évidence the jury shall render their verdict in writing, signed by them, which shall embody the substantial views shown by the évidence. Sec. 6.— Verdict Recorded—Order of Committal—Application. Upon the return of the verdict the same shall be recorded at large by the clerk, and if it appears that the person is insane, and is a fit person to be sent to the State Hospital for the Insane, the court shall enter an order that the insane person be com- mitted to the State Hospital for the Insane ; and thereupon it shall be the duty of the elerk of the court to make application to the superintendent of some of the State hos- pitals for the insane for the admission of such person. Sec. 8.— Warrant to Commit. Upon receiving notice at what time the patient will be received, the clerk shall, in due season for the conveyance of the person to the hospital by the appointed time, issue a warrant directed to the sheriff or any other suitable person, preferring some relative of the insane person when desired, commanding him to arrest such person and convey him to the hospital ; and if the clerk is satisfied that it is necessary, he may authorize an assistant to be employed. Sec. 18.—Discharge of Patients—Notice—Removal. Whenever the trustées shall order any patients discharged the superintendent shall at once notify the clerk of the County Court of the proper county thereof (if the patient is a pauper [and if not, shall notify ail the persons who signed the bonds re- quired in section 15 of this act], and request the removal of the patient). If such patient be not removed within thirty days after such notice is received, then the superintend- ant may return him to the place from whence he came, and the reasonable expense thereof may be recovered by suit on the bond, or, in case of the pauper, shall be paid by the profit paid to the county. Sec. 20.—Restoration to Reason—Discharge. When any patient shall be restored to reason he shall hâve the right to leave the hospital at any time, and if detained therein contrary to his wishes after such restora- tion, shall hâve the privilège and right of habeas corpus at ail times, either on his application or that of any other person in his behalf. If the patient is discharged on such writ, and if it shall appear that the superintendent has acted in bad faith or neg- ligently, the superintendent shall pay ail the costs of the proceedings. Such superin- tendent shall, moreover, be liable to civil action for false imprisonment. Sec. 22.—Trial by Jury Necessary. No superintendent or other officer, or person connected with either of the State hospitals for the insane, or with any other hospital or asylum for the insane or dis- tracted persons in this State, shall receive, detain, or keep in custody at such hospital or asylum any person who shall not hâve been declared insane by the verdict of a jury, and authorize*! to be confined by the order of a court of compétent jurisdiction ; and no trial sliall be had, questioning the sanity or insanity of any person before any judge or court, without the person being présent alleged to be insane. 644 APPENDIN. Acts of Indiana, 1881. Sec. 2835.—Duties of the Trustées. The trustées shall be intrusted with the gênerai control and management of the hospital. . . . Sec. 2837.—Proceedings. The trustées shall keep a full account of their proceedings in a book to be pro- vided for that purpose. The officers of the institution shall make reports to the trustées as they may from time to time require. The superintendent and treasurer shall severally make full reports to be submitted at their annual meetings. Sec. 2840.—Powers and Duties. The superintendent shall be the chief executive officer of the hospital, and shall hâve the care and control of everything connected therewith. He shall see that the several officers of tlie institution faithfully and diligently discharge their respective duties. He shall employ such attendants, nurses, servants, and other ])ei-sons he may think proper, and assign them to their duties, and may at pleasure discharge them. He shall receive from the i>roper persons the patients entitled to admission in the hospital, and when cured discharge them. In ail cases, however, he shall be subject to the control of the trustées. Sec. 2841.—Reports. The superintendent shall make reports to the trustées as required by section 2837. Sec. 2842.—Admission of Patients. Ail insane persons residing in the State of Indiana, and having légal settlement in any county therein, shall be entitled to be maintained and receive médical treatment in the Indiana Hospital for the Insane at the expense of the State. . . . Sec. 2844.—Examination. The justice of the peace with whom said statements shall hâve been filed, together with another justice of the peace and a respectable practicing physician other than the médical attendant of the person alleged to be insane, who shall be elected by the aforesaid justice of the peace, and who shall réside in the proper county, shall imme- diately thereupon visit and examine the person alleged to be insane, in relation to his mental condition. Sec. 2847.—Médical Certificate. They shall require the médical attendant to make, on oath, a written statement of the médical history and treatment given to the case. Sec. 2852.—Superintcndent's Duties. Upon receiving said application and transcribed statements and certificates, the superintendent of the hospital for the insane shall immediately, upon the information therein contained, détermine whether the case is récent and presumably curable, or chronic and less curable, of idiotie and incurable. If the case be récent and curable, the superintendent shall at once notify the proper clerk of the acceptance of thé application for admission. If the case be chronic, whether curable or incurable, an acceptance shall issue as above, provided that there be room in the hospital for more patients than are at présent résident therein, together with those reeently accepted but not admitted ; otherwise the application shall be rejected. In the sélection of chronic cases for admission, each county shall be entitled to a just proportion, accord- ing to its population, and priority of application shall hâve récognition. Sec. 2862.—Récurrence of Insanity. Any person who has ever been adjudged insane according to law, within the State of Indiana, and has been formally discharged from any hospital or asylum for APPENDIN. 645 the insane within the State, shall not again be admitted to any such hospital or asy- lum, "except upon the affidavit of a respectable practicing physician of the county where the patient résides, that he knows the patient, that he has been adjudged insane, that he has been in a hospital, that he is insane and a proper subject for treatment." He must state the reasons of his opinion. Sec. 2863.— Diseharge. Any patient may be discharged from the hospital by the superintendent upon restoration to health ; and incurable and harmless patients shall be discharged when- ever it is necessary to make room for récent cases. Ail dangerous patients shall be retained in the hospital. Code of Iowa, 1889. Sec. 1395.—In each county there shall be a board of three Commissioners of Insanity ; the clerk of the Circuit Court shall be a member of such board and clerk of the same ; the other members shall be appointed by the judge of said court. One of them shall be a respectable practicing physician, and the other a respectable prac- ticing lawyer. . . . Sec. 1399.—Application for admission to the hospital must be made in the form of information, verified by affidavit, alleging that the i>erson in whose behalf the appli- cation is made is believed by 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 a légal 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 has advice on the subject. Sec. 1400.—On the filing of such information the commissioners may examine the informant under oath, and if satisfied there is reasonable cause therefor shall investi- gate the ground thereof, and for this purpose they may require that the person for whom admission is sought be brought before them and that the examination be had in his présence ; and they may issue their warrant therefor, and provide for the suit- able custody of such person until their investigation shall be coneluded. Such war- rant may be executed by the sheriff or any constable of the county ; or if they shall be of the opinion from such preliminary inquiries as they may make—and in making which they shall take the testimony of the informant, if they deem it necessary or désirable, 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 person. In their examination they shall hear testimony for and against such applica- tion, if any is offered. Any citizen of the county, or any relative of the person alleged to be insane, may appear and resist the application, and the parties may appear by counsel if they elect. The commissioners, whether they dispense with the présence 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 thereon. 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 has in pursuance 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 physi- cian shall endeavor 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 propounded in such cases ; such interrogatories and answers to be attached to his certificate. Sec. 1401.—On return of the physician's certificate the commissioners shall, as soon as practicable, conclude their investigation, and shall find whether 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 their county, where it is, if ascertained. If they find that such person is not insane they shall order his immédiate discharge, if in custody. If they find such person insane and a fit subject. for custody and treatment in the hospital (they shall 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] sliall appeal from the finding of the said commissioners) they shall forthwith issue their warrant and a duplieate thereof, 646 A PREND IN. stating such finding, with the settlement of the person, if found ; and, if not fourni, their information, if any, in regard thereto, authorizing the superintendent ot the hospital to receive and keep such person as a patient therein: such warrant and duplieate, with the certificate and finding of the physician, shall be delivered to the sheriff of the countv, who shall exécute tlie same by conveying such person Jo the hospital. and delivering him, with such duplieate and physician's certificate and find- ing, to the superintendent thereof. ... Sec. 1424.—Anv patient who is cured shall be immediately discharged by the superintendent. Upon such discharge the superintendent shall furnish the patient, unless otherwise supplied, with suitable clothing and a sum of money not exceeding twentv dollars, which shall be charged with the other expenses in the hospital of such patient, The relatives of anv patient not susceptible of cure by remédiai treatment in the hospital, and not dangerous to be at large, shall hâve the right to take charge of or remove such patient on consent of the Board of Trustées. In the mtermediate meetings of the board the consent of two trustées shall be sufficient. General Statutes of Kansas, 1889. Sec. 260 (63 80).—Government. The government of insane asylums of the State shall be vested in the Board of Trustées of the institutions for . . . insane. Sec. 261 (6187).—Application. The Board of Trustées shall designate the superintendent of one of the insane asylums, to whom ail applications for the admission of insane persons shall be made, and who, under such rules as may be made by the Board of Trustées, shall designate to which asylum each applicant shall be admitted. . . . Sec. 263 (6189).— Médical aud Executive Officer. The superintendent shall be the executive officer of the asylum and shall hâve control of ail the affairs of the asylum, subject to the direction of the Board of Trus- tées. . . . He shall make to the Board of Trustées at least semi-annual reports show- ing the movements of the population and the opérations of the asylum during the period embraced therein ; and at the close of the biennial period he shall report in détail the conditions of the asylum and ail of its concerns. Sec. 266 (6192).— Abstraet of Corrcspondcnce. A full abstraet of ail correspondence relating to the admission of patients, their treatment, and ail other matters of an officiai nature and the replies thereto, shall be kept by the superintendent. He shall also cause to be kept a complète record of each case 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 full knowledge of ail prescriptions and business of the médical department. State of Kentucky, Statutes, 1881. Chapter 73, Section 4.—Officers of the Asylum. There shall be for each asylum a médical 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. Thèse officers shall réside in the asylum. . . . Sec. 5.—Duties of Médical Superintendent. A médical superintendent shall hâve gênerai management, supervision, and con- trol of patients and the asylum, subject to the régulations of the Board of Commis. sioners, and shall dévote his entire time thereto. He shall keep a register of ail APPENDIN. 647 patients, showing their names, âges, résidences, dates of réception and discharge or death, by whose authority received, and whether they are pay-jiatieuts or paupers. The superintendent shall appoint ail such other inferior officers and employées (not otherwise provided for in this act) as he may deem necessary for the proper management of the institution ; and he may remove any of them at pleasure and fill their jilaces with others. Sec. 9.—Présence of the Person Necessary. No inquest shall be held unless the person charged to be of unsound mind is in the court and personally in the présence of a jury. The personal présence of the person charged shall not be dispensed with unless it shall appear by the oath or affidavit of two physicians that they made personal examination of the individual charged to be of imsouiid mind, and that they verily believe him to be an idiot or lunatic, as the case 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 hâve 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 cured pauper before being discharged shall hâve a good suit of clothes and be furnished with money enough to pay his traveling expenses back home, not exceeding twenty dollars. Sec. 20.—Report of Superintendent and Board. The superintendent and the Board of Commissioners shall, on or before the Ist 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 j)atients 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 législature at its next regular session. Statutes of Louisiana, 1876. Sec. 1768.—Lunatics—How Admitted. Whenever it shall be known to the judge of a district or parish court, by the péti- tion on oath of any individual, that any lunatic or insane person 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 issue a warrant to bring before him said lunatic or in- sane person, and after inquiry into ail the facts and circumstances of the case, if in his opinion lie ought to be sent or confined in said asylum, he shall make out his war- rant to the sheriff of the parish, commanding him to convey the lunatic or insane person to the insane asylum. . . . Sec. 1776.—Examination by Physician. The physician of the asylum shall professionally examine the lunatic 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 président of said board shall cause said person feigning insanity, and who had been previousl.v committed to prison for a crime, to be confined in the parish jail, and shall immediately inform the président of the police of the parish, or a proper author- itv in the parish of Orléans, 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 recoA'er and become sane in said asylum. 648 ArPENDIN. Acts of Louisiana, 1888. Sec. 1.—Postal Rights of Inmates. Be it enacted by the 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 thèse letters to this individual there shall be no censorship exercised or allowed by any of the asylum officiais or employées, but their post-office privilèges shall, so far as this one individual is concerned, be as free and unrestricted as are those of any other résident or citizen of the State of Louisiana, and shall be under the protection of the same postal laws ; and each and every inmate shall hâve the right to make a new choice of this individual every three months if he or she so desires. And it is hère made the duty of the superintendent to furnish each and every inmate of every insane asylum in this State, either public or 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 ail 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 ail 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 trustées, one of whom shall be a woman. . . . Sec. 4.—The Trustées may Examine and Discharge Patients. There shall be a thorough examination of the hospital monthly by two of the trustées, quarterly by three, and annually by a majority of the fui! board ; and at anv 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 trustées, 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 public no longer require his confinement. . . . Sec. 7.—Duties and Powers of the Superintendent. The superintendent shall be the physician, réside constantly at the hospital, hâve gênerai superintendence of the hospital and grounds, receive ail patients legally sent to the hospital, unless the number exceeds its accommodation, and hâve charge of them, and control of ail persons therein, subject to the régulations of the Board of Trustées ; and annually on the last day of November report to the trustées the condi- tion and prospects of the institution, with such remarks and suggestions relative to its management and the gênerai 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 prmted cards containing the rules prescribed for the government of the attendants in charge of patients. Sec. M.—Certificate of Physicians. In the case of preliminary proceedings for the commitment of an insane person to the hospital, the évidence and certificate of at least two respectable phvsicians, based upon due inquiry and personal examination of the person to whom 'insanity is im- puted, shall be required to establish the fact of insanitv, and a certified copy of the physicians' certificate shall accompany the person to be committed. APPEND1N. 649 Sec. 36.—Postal Rights of the Inmates. The names of the Committee of Examiners and the post-office address of each shall be kept posted in every ward of the hospital, and every inmate shall be allowed to write when and whatever he pleases to them, or either of them, unless otherwise ordered by a majority of the committee in writing, which order shall continue in force until countermanded in writing by said committee. For this purpose every patient not otherwise orderetl as aforesaid shall be furnished by the superintendent, on re- quest, with suitable materials for writing, inclosing, and sealing letters. The super- intendent shall provide, at the expense of the State, securely locked letter-boxes, easily accessible to ail inmates, to be placed in the hospital, into which such letters can be dropped by the writer. No officer, attendant, or employée of the hospital shall hâve the means of reaching the contents of thèse boxes, but the letters in them shall be 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 Maryland, 1888. Sec. 1.—When any person is alleged to be a lunatic or insane, the Circuit Court of the county in which such person may réside, or a criminal court of Baltimore (if such person réside in the city of Baltimore), shall cause a jury of twelve good and lawful men to be impaneled forthwith, and shall charge the said jury to inquire whether such person 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 confined 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, publie, corporate, or private, or almshouse, where the insane may be kept, shall be required to keep a record of ail patients in such form as the commissioners shall direct ; also a record in which shall be entered the incidents and accidents that may occur ; also the number and kinds of restraints used, with détails 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 in custody any insane person in accordance with the law, may appoint one or more attendants or other employées of such places, as polieeman 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 person shall be put or confined as a patient in any institution, pub- lic, corporate, or private, or almshouse, or other house for the care and custody of the insane or idiotie, except ujion the rendering of a certificate of two qualified physicians, made within one week after the examination by them of said alleged lunatic, 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 réception 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 confine*! in such place as hereinbefore mentioned shall be furnished at ail times with paper, envelopes, stamps, pen and ink, or pencil ; shall at ail times hâve access for correspondence with the Lunacy Commission, and some one other person whom such lunatic may designate every month, under seal, which com- munication shall be forwarded by the officer, superintendent, or keeper who may be in charge of such person or place. . . . Acts of Massachusetts, 1882. Chapter 87, Section 11.—Judges may Commit Insane Persons to the State Hospital. A judge of the Suprême Judicial Court or Superior Court of any county, or a judge of a probate court, or of a police or district or municipal court within this 650 APPENDIN. county, may commit to either of the State lunatic asylums any insane person, when residing or being in said county, who in his opinion is a proper subject for its treat- ment or custody. Sec. 12.— No Person to be Committed to any Hospital without Order of the Judge. Except when otherwise si>ecially provided, no person shall be committed to the lunatic hospital or other réceptacle for the insane, public or private, without the order or certificate therefor signed by one of the judges named in the preceding sec- tion, said person residing or being within the county as herein provided. 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 Physicians. No person shall be committed unless, in addition to the formai testimony, there has been filed with the judge a certificate signed by two physicians, each one of whom is a graduate of some legally organized médical collège and lias 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 hâve personally examined the j)erson alleged to be insane within five days of signing the certificate, and each shall certify that in his opinion said person is insane and a proper 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 officer 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 with 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 application, within ten days after the commitment or admission, a statement in respect to such person, showing, as near as can be ascertained, his âge, birthplace, exact condition, place, and occupation ; the supposed cause and duration and eharaeter of his condition, whether mild, violent, dangerous, homicidal, suicidai, paralytic, apoplectic ; the présent symirioms of insanity in the person or his family ; his habits in regard to tem- pérance ; whether he has been in a lunatic 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 birth 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 âge, 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 lie 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 writing, 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 be Received at the Hospital without Warrant of Commitment. The superintendent or keeper of a hospital, including the McLean Asylum at Somerville, 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 résides or is found, shall be left with the superintendent of the hospital or asylum in which the insane person is APPENDIN. 6Ô1 received, and such application shall contain the statement in respect to such insane person which is required by section 15, and a further statement that the case is one of violent and dangerous insanity. Sec. 29.—Notice to bc Given to the Board of Health, Lunacy, and Charity. AA'hen the patient is received into such hospital upon his own application or under the provisions of section 26, the superintendent thereof shall give immédiate notice of such réception to the State Board of Health, Lunacy, and Charity, stating ail the particulars, including the légal settlement of the person so received, if known; the State board shall immediately cause such cases to be investigated and a record be made of ail the facts pertaining thereto. Sec. 35.—Certain Privilèges of Patients in Hospitcds. An attorney regularly retained by or on behalf of any person committed to a lunatic hospital, asylum, or réceptacle for the insane shall be admitted to visit such client at aU reasonable times, if, in the opinion of the superintending officers of such hospital, asylum, or réceptacle, such visit would not be injurions to such person, or if a judge of tlie Suprême Judicial Court, Superior Court, or Probate Court in any county first orders, in writing, that such visits be allowed. Sec. 36.—Postal Privilèges of Patients. The patients in the lunatic hospital, asylum, or réceptacle for the insane shall be allowed to write monthly to the superintendent or to the State board, and they shall be furnished by the suiierintendent with ail materials necessary for such correspond- ence ; and a letter-box shall be placed in each ward, in which each writer may deposit his letters, and the box shall be opened and the letters distributed monthly by the said board. Acts of Massachusetts, 1883. Sec. 1.—Diseharge of Inmates from Lunatic Asylum by Superintendent. The Board of Trustées of the State lunatic asylums, or of the Massachusetts Gen- eral Hospital, may by vote confer on the superintendent of the hospital or asylum under their control authority to discharge therefrom any inmate thereof committed thereto as an insane person, provided due written notice of intention so to discharge shall be sent by said superintendent to the person or persons who originally sent the pétition for the commitment of such inmate. Sec. 2.—Temporary Absence from the Hospital by the Permission of the Superintendent. Said superintendent may also, when he shall deem it advisable, permit any such inmate to leave the hospital or asylum temporarily, in charge of his guardian, rela- tives, or friends, for the period not exceeding sixty days, and receive him when returned by such guardian, relatives, or friends within such period without further order. Public Acts of Michigan, 1885. gEC> i.— . . . The asylums for the insane of the State of Michigan shall be under the control of separate boards of trustées. Sec. 5.—Appointaient of the Superintendent, . . . Steward, and Assistant Médical Superintendent. . . . The Board of Trustées shall severally appoint a médical superintendent, who shall be a well-educated physician, experieneed in the treatment of the insane, and a treasurer, not one of their number, who shall give bonds for the performance of his trust, in such sum and with such sureties as the director-general of the State shall approve. They shall also appoint, upon the nomination of the médical superintend- ent, a steward' and a chaplain; and also. in a like manner, an assistant médical superintendent and necessary assistant physicians. Ail médical officers shall réside at the asylum. . . . 052 AFP END IN. Sec. 12.—Powers and Duties of the Médical Superintendent. The médical superintendent shall be the chief executive officer of the asylum. He shall hâve the gênerai superintendence of the buildings, grounds, and farm, together with the furniture, fixtures, and stock ; and the direction and control of ail persons therein, subject to the by-laws and régulations established by the trustées. He shall daily ascertain the condition of ail patients, and prescribe for their treatment in the manner directed in the by-laws. He shall hâve the nomination of his eo-resi- dent officers, with power to as'sign them to their resjiective duties, subject to the by-laws ; also to appoint, with the approval of the trustées, such and so many 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 trustées, their compensation, and to discharge any of them at his will and discrétion ; but in every case of diseharge he shall forthwith record the saine, with the reasons of discharge, under a proper head in one of the 4)ooks of the asylum. He shall also bave the power to suspend until the next meeting of the trustées, for good and sufficient cause, a résident officer ; but in such case he shall forthwith give written notice of the fact, with its cause and cir- cumstances, to one of the trustées, whose duty thereupon shall be to call a spécial meeting of the board to provide for the exigency. lie shall also, from time to time, give such orders and instructions as he may judge best ealeulated to insure good conduct, fidelity, and economy in every department of labor and expense ; and he is authorized and enjoined to maintain well-directed discipline among ail who are em- ployed by the institution, and to enforce direct compliance with such instructions and uniform obédience to ail rules and régulations of the asylum. He is authorized anel directed to use every proper means to furnish employnient to such j)atients as may be benefited by regular labor suited to their capacity and strength. He shall further cause full and fair accounts and records of ail his doings and the entire imsiness anel opérations of the institution to be kept regularly from day to day, in books provided for that purpose, in the manner and to the extent prescribed in the by-laws ; and he shall see that ail such accounts are fully made up to the last day of September imme- diately preceding the meeting of the législature, and that the principal facts and results, with his reports thereon, be at the time presented to the trustées. It shall be the duty of the médical superintendent to admit any member of the Board of Trustées in every part of the asylum, and to exhibit to him or them on demand ail the books, papers, and accounts and writings belonging to the institution or pertaining to its business, management, discipline, or government ; also to furnish copies of abstracts and reports whenever required by the board. The médical superintendent shall make, in a book kept for that purpose, at the time of réception, a minute with date of same, the name, résidence, office, and occupation of the person, by whom and by whose authority each insane person is brought to the asylum ; and shall hâve ail the orders, warrants, requests, certificates, and other papers*accompanying him forth- with filed. The assistant médical superintendent shall perform the duties and be sub- ject to the responsibility of the médical superintendent in his sickness or absence. Laavs of 1889. Sec. 21.—Certificate of Admission of Patients— . . . Duty of Médical 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 under oath, appointed by the judge of Probate Court where such alleged insane person résides to conduct an examination, and an order from the said judge of the Probate Court 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 such asylum or institution for more than fourteen days without such certificate or order. Sec. 22.—Qualifications of Physicians Certify ing to Insanity, etc. It shall not be lawful for any physician to certify to the insanitv of any person for the purpose of securing his admission to an asyhim,'unless such physician be of repu- table eharaeter and graduate of some incorporated médical collège, a permanent resi- APPENDIN. 653 dent of the State, registered according to law, not related by blood or marriage to the alleged insane person nor to the person applying for such certificate, and shall hâve been in actual practice of his profession for at least three years ; and such qualifica- tion shall be certified to by the clerk of the county in which such physician résides. No certificate of insanity shall be made except under the personal examination of the party alleged to be insane ; and it shall not be lawful for any physician to certify to the insanity of any person for the purpose of committing him to an asylum for which the said physician is either a trustée or a superintendent, proprietor, an officer, or a regular professional attendant. . . . Sec. 37.— . . . Report by the Médical Superintendent of the Insane Asylum. . . . . . . The médical superintendents of the several insane asylums shall report quarterly to the secretary of the Board of Corrections and Charities the names and âges of ail patients supported at State or county charge ; . . . and shall also report to the secretary of the Boai-d of Corrections and Charities the date and circumstances attending the diseharge, removal, elopement, or death of ail insane persons received, aided, or supported at county or State charge. . . . Sec. 38.— ... Préférence in Admission, etc., u-hen Lack of Room for AU. ... In case the superintendents of the asylums find it impossible to receive ail patients for whom application is made, they may, at their discrétion, give préférence to those for whom, in their judgment, treatment is most urgently necessary. To make room for urgent cases they are also authorized to order the removal from the asylum to his home and friends, or to the superintendent of the poor of the county whence he came, of any patient that in their judgment may safely réside outside of the institu- tion. Sec. 47.—Définition of Terms "Insane" and "Insane Persons." The terms "insane" or "insane persons," as used in this act, include every spe- cies of insanity and extend to every dérangement of persons and to ail of unsound mind other than idiots. . . . General Acts, Minnesota, 1887. Chapter 146, Section 1.—Postal Rights of Insane Persons. That henceforth each and every inmate of each and every insane asylum, both public and private, in the State of Minnesota, shall be allowed to choose one indi- vidual from the outside world to whom he or she may write when and whatever he or she may désire, and over thèse letters to the individual there shall be no censorship exercised or allowed by any of the asylum officiais or employées, but their postal rights, so far as this one individual is concerned, shall be as free and unrestricted as are those of any résident or citizen of the State of Minnesota, and shall be under the protection of the same postal laws ; and each and every inmate shall hâve the right to make a new choice of his individual party every three months if he or she so désires to do ; and ail such letters shall be dropped by the writer thereof, accompanied by an attendant when necessary, into a post-office box provided by the State at the insane asylum and kept in some place easy of access to ail the patients ; the attendant is required, when necessary, 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 superintendent's disposai ; and the contents of the box shall be collected once every week by the author- ized person from the Post-office Department, and by him placed into the hands of the United States mail for delivery. Sec. 2.—Duties of the Superintendent of the Insane Asylum. That it is hereby made the duty of the superintendent to keep registered and posted in some public place at the insane asylum a copy of the names of every indi- vidual 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 named 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 this individual inmate ; and ail thèse letters bearing the individual writer's name on the outside lie is requested to deliver, or cause to be delivered, any letter or writing to him or her 654 APPENDIN. directed, without opening or reading the same, or allowing it to be opened or read, unless there is reason for believing the letter contains some foreign substance which may be used for médication, in which case the letter shall be required to be opened in the présence of a compétent witness, and this substance shall be delivered to the superintendent, to be used at his discrétion. Sec. 4.—Superintendent to Provide Registers and Stationcry. 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 e 'orrections and Charities may prescribe, and to keep on hand some envelopes, paper, and postal cards, which shall be used for each correspondent. Such registers and stationery shall be furnished on réquisition 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 deliver the same to the inmate to whom it is addressed, without unnecessary delay, taking the receipt of said inmate therefor. Sec. 6.— The Superintendent to Mail and Délirer 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 under 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 saiel 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 case 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 written by a corre- spondent 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 with the Governor and the Secretary of the State Board of Corrections and Charity. . . . Each and every inmate of any hospital for the insane in the State shall lîave the privilège of communicating in writing with the governor and the secretary of the State Board of Corrections and Charities, in the same manner, under the same régu- 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 county in which such warrant was issued a certificate signed by him, stating that the person has been discharged from such hospital, and the date of such discharge, which certificate shall be filed in the Probate Court. Code of Mississippi, 1880. Sec. 665.—The médical superintendent shall hâve power to appoint and re- move ail subordinate officers and employées allowed by the trustées, and he shall make, in a book kept for that purpose, at the time of réception, a minute with the APPENDIN. 655 date of réception, with name, âge, sex, résidence, office or occupation of the person, and by whom and by whose authority each insane person is brought to the asylum, and hâve ail orders, warrants, réquisitions, certificates, and other papers accompany- ing him or her earefully filed, and hâve them copied in said book. . . . He shall ascertain the condition of the patients, and prescribe their treatment. in the manner prescribed in the said by-laws ; and he shall also be required to see that ail the rules and régulations for the discipline and good government of the institution are properly obeyed and enforced. Sec. 659.—Any person being a lunatic and résident of the State of Mississippi shall be admitted into the asylum free of charge. . . . Sec. 660.—It shall be the duty of the superintendent to admit into the asylum ail 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 présentation of a duly certi- fied copy of such order under the seal of Chancery Court, showing thereby admission of the patient to the asylum. Sec. 661.—On application in behalf of any person being a lunatic and a résident of this State, for his or her admission into the asylum, the superintendent and Board of Trustées 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 hâve 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 réside 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 county in which such lunatic is going at large, to make inquisition thereto on oath, and the resuit of such inquisition to be returned to the said court forthwith ; and if the person said to be a lunatic shall be adjudged by suçb inquest, or a majority of them, to be insane, and one who should be confined therein, the said clerk shall order said sheriff 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 lunatic 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 hâve expérience 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 ail other business, dévote himself to the supervision and care of the asylum and its inmates. Before entering on the duties of his office he shall take an oath or affirmation that he will diligently, faithfully, and impartially discharge ail the duties required of him by the law. Sec. 473.—Patients—Hoir Admitted and Discharged. Persons afflicted with any form of insanity may be admitted into the asylum when the superintendent deems it probable that their condition can be improved by the care and treatment of the institution; and any person may be discharged 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.—Pay-patients—Hoir Admitted. Pay-patients, or those not sent to the asylum by order of the court, 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 his âge and place of nativity, if known, his Chris- tian and surname, place of résidence, occupation, and degree of relationship, ^r any 656 APPENDIN. circumstances of connection between him and the person requesting his admission; and a certificate . . . dated within two months, under oath, signed by two physicians, of the fact of his being insane. Such person signing such request or certificate shall annex to his name his profession or occupation, and the township, county, and State of résidence, unless thèse appear on the face of the document. Before any probate patient shall be received into the asylum tliere shall be proeluced 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 obligées to secure the payment of the charges incurred in behalf, on account, of said patient. . . . No board constituting thirty days' payment shall be refunded 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 writing be given to the Probate Court that any person in its county is an idiot, lunatic, or person of unsound mind, and incapable of managing his affairs, and pray that an inquiry thereinto be had, the court, if satisfied that there is good cause for the exercise of its jurisdiction, shall cause the facts to be inquired into by a jury. Sec. 5550.—To be Discharged—When. If it be found that such person has been restored to his right mind, he shall be discharged from the care and custody, and the guardian shall immediately settle his accounts and restore to his person the things remaining 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 discrétion of the court, be required to pay the cost of proceeding. Statutes of Montana, 1887. Sec. 1215.—Examination of Person Alleged to be Insane. From and after the passage of this article it shall be the duty of the probate judge, or, in his absence or incapability to act, the chairman of the Board of County Commissioners of the several counties 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 under mental dérangement, 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 jury of three persons of his county, one of whom shall be a licensed practicing physician, 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 such person by reason of insanity is unsafe to' be at large, or is incompétent to provide for his or her own proper care and support, 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, living within the Territory, of suffi- cient means and ability to provide for such care and maintenance, or if he or she hâve kindred within the Territory and such kindred fail or refuse to properly care for and maintain such insane person, such judge or county commissioner shall make out a duplieate warrant reciting such facts, and place it in the hands of the sheriff of said county, who shall immediately, in compliance therewith, hâve 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 may be Discharged upon Ileport of Physician. The governor shall direct and hâve discharged from the insane asvlum anv of the inmates thereof at any time when, from the written report to him bv the physicians in charge of said asylum, or either of them, or from any phvsician who' shall be'appointed to visit and examine said institution, he believes such discharge should be granted- provided that the report upon which lie may act shall be filed and kept in his hands ' APPENDIX. 657 Sec. 1230.—Inmates of an Asylum may Choosc Confidential Correspondent. . . . Each and every inmate of each and every asylum, both public and private, shall be allowed to choose one individual from the outsiele world, to whom he or she may write when and whatever he or she desires, and over thèse letters to this indi- vidual there shall be no censorship exercised or allowed by any one of the asylum officiais or employées, but their post-office rights so far as this one individual is con- cerned shall be as free and unrestricted as those of any other résident or citizen of the Territory of Montana, and shall be under the protection of the same postal laws ; and each and every inmate shall hâve the right to make a new choice of this individual party every three months if he or she desires to do so. And it is hère made the duty 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, inelos- 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 ail such letters shall be dropped by the writers thereof, accompanied by an attendant, into the post-office box provided by the départaient at the insane asylum and kept in some place easy of access to ail the patients ; the attendant is required in ail 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 disposai ; and the contents of this box shall be collected once every week by an authorized person 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 be Registered and Posted. That it is hereby made the duty of the superintendent 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 write his or her name on the outside of the envelope of every letter he or she writes to this individual inmate ; and ail thèse 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 médication, in which case the letter shall be required to be opened in the présence of compétent witnesses, and this substance shall be delivered to the superintendent, to be used at his discrétion. Nebraska Compiled Statutes, 1887. Sec. 2.—Post-office Privilèges 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 résident 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 Power of the Superintendent. The superintendent of said institution shall be a physician of acknowledged skill and ability in his profession, and be a graduate of a regular médical collège. He shall be the chief executive officer of the hospital, and shall hold his office for the term of six vears, 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 65s APPENDIN. attendance at the 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 hâve the entire control of the médical, 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.—Application for Admission to the Hospital. Application for admission to the hospital must be made in writing in the nature of information validified by affidavit ; such information must allège that the person in whose behalf the application is made is believed by 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 the 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 require that the person for whom such admission is sought be brought before them, and that the examination be had in his or her présence. . . . The commission- ers, whether they décide to dispense with the présence 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 allégation in the information, and adjudge the actual condition of such person, and forthwith report to them thereon ; 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 pur- suance of his appointaient, 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 of Nevada, 1889. Chapter 39, Section 1.—"V-Thenever by reason of absence of the district judge of the county an insane person 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 diseharge such person 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, upon application under oath, setting forth that a person by reason of insanitv is dangerous to be at large, cause any person to be brought before him, and he shall summon to appear, at the same time and place, two or more witnesses having had fréquent intercourse with the accused during the time of alleged insanity, who shall certify under oath as to conversation, manners, and gênerai conduct upon whieh said charge of insanity is based; and he shall also cause to appear before him at the same time and place two graduâtes 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 insane person the said physicians shall certify on oath that the case is of récent or curable eharaeter, or that the said insane person is of a homicidal. suicidai, or ineendiary APPENDIN. 659 ■disposition, or if from any other violent symptoms the said insane person would be dangerous to his or her own life, or to the lives and property of the community in which he or she may live ; and if said physicians shall also certify to the naine, âge, nativity, résidence, occupation, length of time in this State, apparent cause and class of insanity, duration of disease, and présent condition as nearly as can be ascertained by inquiry and examination ; and if the district judge shall be satisfied that the facts in the examination establish the existence of insanity in the person of the accused, of a récent or curable nature, or of a homicidal, suicidai, or ineendiary eharaeter, or from the violent symptoms the said insane person would be dangerous to his or her own life, or to the lives and property of others, to be at large, he shall direct the sheriff or some suitable person to convey to the capitol of the State and place such insane person in charge of the secretary of the State, and shall transmit duplieate copies of complaint and commitment and physicians' 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.—Only Pauper Insane iu County Asylums—Reports of County Superintendent. No person other 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 purpose ; and the said superin- tendent shall at al! times furnish such information regarding the insane in his charge as the State board may request. 1878.—Chapter 10, Section 12.—Persons Dangerous to bc Committed to the Asylum. If any person is in such condition as to render it dangerous that he should be at large, the judge of probate, upon pétition 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 pétition 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 two Physicians Required 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 Suprême 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 Stationcry, Papier, and Transmit Letters to Trustées. It shall be the duty of the superintendent to furnish stationery to any patient who may désire it, and transmit any letter such patient may address to the Board of Trus- tées to such member as said board shall bave designated to receive such correspond- ence, and ail such letters shall be promptly transmitted without interception. Laws of 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 Freeholders 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 «•iving the names of ail patients at said asylum at the expense of the county for whieh 660 APPENDIN. said statement is made, who hâve been at said asylum during the last preceding quar- ter, which statement shall also contain the dates of admission of the respeetive patients, the township from which they came, the days of discharge of any who bave been discharged, the date of death of any who hâve died, and the dates between which they hâve been away on a visit or otherwise during the quarter. Trenton Asylum, 1886. Sec. 1.—Admission of Patients. ... No person shall be admitted into the asylum as a patient except upon Ihe order of some court or judge authorized 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 âge and place of nativity, if known, his Christian and surname, place of résidence, occupation, and degree of relationship, and other circumstances of connection between him and the person requesting his aelmission ; 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 such request or certificate shall annex to his name his profession or occupation, and the township and county and State of his résidence, unless thèse facts appear on the face of the documents. Sec. 7.—Duties and Powers of Physician. The superintendent shall be the chief executive officer of the asylum. He shall hâve the gênerai superintendence of ail the buildings, grounds, and farm, with their furniture, fixtures, stock, and the direction and control of ail persons therein, subject to the laws and régulations 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 discrétion ; but in every case of discharge he shall forthwith record the same, with the reasons, under the proper heading in one of the books of the asylum. He shall also bave the power to suspend until the next meeting (monthly) of the managers, for good and sufficient cause, any résident 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 spécial meeting of the board to provide for the exigency. fie shall also, from time to time, give such orders and in- structions as he may judge best ealeulated to insure good conduct, fidelity, and econ- omy in every department of labor and expense ; and he is authorized and enjoined to maintain salutary discipline among ail who are employed by the institution, and to enforce strict compliance with such instructions and uniform obédience to ail rules and régulations of the asylum. He shall cause a full and fair account and record of ail his doings, and of the entire business and opérations 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 ail 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 présentée! to the managers imme- diately thereafter. The assistant physician shall perform 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 complète recovery, may discharge any patient 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 eomfortable 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 eomfortable maintenance without further public charge. APPENDIN. G6I Sec. 21.—Proceedings when Lunatics are Dangerous if at Large. That it shall be and may be lawful for any two justices of the peace of the county in which any lunatic, furions, mad, or dangerous, if permitted to go at large, shall be found, by warrant under their hands and seals, to direct the Overseers or Overseer of the Poor of the city or township in which such lunatic or mad person may be found, to cause such person to be apprehended and kept safely locked up, and chained if necessary, in some secure place within such city or township or within the county within which said city or township shall be situated, as such justices shall by their warrant appoint, in case the légal 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 lunatico inquirendo, to inquire into the lunacy or habituai drunkenness of any person within this Territory, or having real or personal estate therein. Such commission shall issue in the county wherein lie last had his résidence, 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 exécution of the commission to the party with respect to whom such commission shall be issued, or to some of his 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.—Inquisition—When 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 sufficient to justify the expense of a com- mission and tlie proceedings under it, the judge thereof, in person, shall hold said commission during the term of the court, anel shall direct an inquest to be impaneled from the jurors attending said court, and which proceeding shall hâve 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 shall be the duty of the jailer or keeper of the prison forth- with to give notice of the fact to two justices of the peace, who shall within five days attend at the prison, and, upon the oath or affirmation of such persons as they shall think fit to examine, proceed to inquire into the state of mind of such prisoner, and if they shall find 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 the care and treatment of insane, except upon the certificate of two physicians, under 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 approved by a judge or justice of a court of record of the county or district in which the alleged 662 APPENDIN. lunatic résides ; and such judge or justice may institute inquiry and make proofs as to the fact of alleged lunacy before approving or disapproving such certificate ; and such judge or justice may in Lis discrétion call a jury in each case to détermine the ques- tion oflunacy. Sec. 2.—It shall not be lawful for any physician to certify to the insanity of any person for the purpose of securing their commitment, unless the physician be of reputable eharaeter and a graduate of some incorporated médical collège, a permanent résident of the State, and shall bave been in actual practice of his profession for at least three years ; and such qualifications shall be certified to by a judge of any court of record. No certificate of insanity shall be made except after the personal exam- ination of the party alleged to be insane, and according to the forms prescribed by the SI ate Commissioner of Lunacy, and every such certificate shall bear a date not more than ten days prior to such commitment. Sec. 3.—It shall not be lawful for any physician to certify to the insanity of any person for the purpose of committing him to an asylum of whieh the said physician is either superintendent, 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 three days after the réception of any patient, make, or cause to be made, a description of such case, entered in a book exclnsively set apart for that purpose, and shall also make entries from time to time mentioning state, bodily condition, and médical 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 case-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 discrétion of the court before which the conviction shall be had. Sec. 33.—When any person confined under the indictments of arson, murder or attempt to murder, or highway robbery, or who has been acquitted thereof on the ground 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 superintendent 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 officiai hand and seal, to a justice of the Su- prême Court of the district in which such asylum is situated, who shall thereupon and upon such other facts as may be proven before him détermine whether it is safe, légal, 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 complète recoA'ery, 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 asylum 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 further treat- ment in the asylum, or when the asylum is full, upon a like certificate that he or she is manifestly incurable and can probably be rendered eomfortable at the poorhouse, so that the préférence may be given, in the admission of patients, to récent 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 friends who will undertake, with good and approved sureties, for his peaceable be- havior, safe custody, and eomfortable maintenance without further public charge. And such sureties shall be approved by the county judge of the county from whieh said patient was sent. . . . Upon the présentation of acertified copy thereof the man- agers may discharge such patient. APPENDIX. 663 Code of North Carolina, 1883. Sec. 2249.—Superintendent—Qualifications. . . . He shall be a skillful physician, educated to his profession, of good moral ■eharaeter, of prompt business habits, and of kindly disposition. He shall hold his office for six years from and after his appointaient, unless sooner removed . . . for infidelity to his trust, gross immorality, or incompetency to discharge the 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 appointaient, 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 ail subor- dinate officers and employées engaged in the service and labors of his asylum, and lie may discharge such as hâve been employed by himself or his predecessor, and shall report to the Board of Directors of the asylum the misconduct of ail other subordinates. 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 with, the justice of the peace of the county, an affidavit. . . . 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 seeurity 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 sheriff 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 tlie Superintendent in Doubtful Cases. Whenever an insane person shall be conveyed to any asylum, 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 décide 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 seeurity to maintain and take care of him in the same manner as he might hâve become bound uneler the surety of the justice of the peace. Sec. 2200.—Discharge of the Cured—Removal of the Incurables. Any three of the Board of Directors of any asylum, 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 found 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 the county of his settlement on probatlon, when in tlie opinion of the said superintendent it will not be injurious to himself or dan"-erous to the community; anel said board may discharge or remove such person 664 APPENDIX. upon other sufficient cause appearing to them ; and whenever any such person ad- mitted as indigent may be so discharged 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, 1888. Sec. 1.—Application for Admission to the Asylum. Be it enacted by the General Assembly of the State of Ohio that section 705 of the Kevised Statutes of Ohio be amended so as to read as follows : Probate judge upon receiving certificate of médical witnesses . . . shall forthwith apply to the superintendent of the hospital for the insane situated in rhe district in which the patient résides ; he shall at the same time transmit copies under his officiai seal of the certificate of the médical 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 advised 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.—Diseharge of Patients from the Insane Asylum. ... On consent and adviee of the trustées 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 suicidai propensities shall be discharged without a bond in the sum of one thousand dollars, with two or more sureties, 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 county ; and no patient with known homicidal or suicidai 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 such 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 furnish 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 Médical 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 médical 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 asylum 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 récurrence of the disease, and such other facts relating thereto as he deems proper, the probate judge shall forthwith transmit a copy of such affidavit, authenticated by his officiai seal, to the superintendent of the proper asylum; and thereupon the same APPENDIX. 665 proceeding shall be had as proA'ided in this chapter for persons found to be insane upon inquest for that purpose. Sec. 715.— When Patient Dies, Relatives shall be 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 notify the probate judge of the county from which such patient was sent, who shall forthwith cause a notice of his death to be printed in two of the leading papers published in the county. Sec. 736.—Qualifications for Admission. The asylum shall be open for admission of ail persons over seven yea^s having a légal settlement in the county of Hamilton ; but no person shall be entitled to admis- sion unless he become insane after acquiring a légal settlement therein. Sec. 740.—Examination—Physician's Certificate. At the time appointed (unless for good cause the investigation is adjourned) the judge shall proceed to examine the witnesses in attendance, and if upon the hearing of the testimony such judge is satisfied that the person so charged is insane, and is included in the class enumerated in this chapter, he shall cause a certificate to be made out by the physician, setting forth the name, âge, résidence of patient, with a concise history of the case, médical treatment pursued, supposed cause of disease, and such other information as is deemed useful. Sec. 741.—Patient shall be Taken to the Asylum. The probate judge, upon receiving the certificate aforesaid, shall forthwith trans- mit a copy thereof, and his finding in the case, under his officiai seal, to some suitable person (giving the relatives of the insane person the préférence), who shall imme- diately take charge of and convey such patient to the asylum, and return therefor to the probate judge a receipt of the superintendent, to be filed with the other papers in the case. Laws of Oregon, 1887. Sec. 3555.—Superintendent to Make Pay-rolls of the Employées. At the end of each month the superintendent shall cause a pay-roll to be made, on which is written the name of each person employed in or about the asylum, giving the capacity in which each is employed, the rate of salary or wages, and the amount due each. Upon receiving this pay-roll, duly receipted by the superintendent and audited by the board, the secretary of the State shall draw his warrant on the treasury in payment of the several amounts audited and allowed by the board, and in favor of the person to whom the same is allowed, in a like manner as their warrants are drawn for the payment of claims against the State. Sec. 3557.—Judge of the County to Hear and Détermine Complaint of Insanity. The county judge of any county in this State shall, upon application stated in writing, setting forth that any person or persons, by reason of insanity or idiocy, is suffering from neglect, exposure, or otherwise is unsafe to be at large, or is suffering under mental dérangement, shall cause such person or persons to be brought before him at such time and place as he may direct ; and the said county judge shall also cause to appear at the same time and place one or more compétent physicians, who shall proceed to examine the person or persons alleged to be insane or idiotie ; and if said physician or physicians, after careful examination, shall certify upon oath that such person or persons are insane or idiotie, as the case may be, then such judge shall cause the said insane or idiotie person to be conveyed to and placed in the Insane Asylum of the State of Oregon. . . . Sec. 3553.—Superintendent as the Executive Officer. The superintendent shall be the executive officer of the asylum under the régula- tions and by-laws of the Board of Trustées. He shall hâve control of the patients, 66G APPENDIN. prescribe their treatment, adopt necessary measures for their welfare, and discharge such as in his opinion hâve permanently recovered their reason, or such other patients as the best interests of the State and the institution require. He shall mamtain dis- cipline among the subordinate officers and employées, and enforce obédience to the laws, rules, and régulations adopted for the government of the institution ; and is empowered to discharge anv employée or attendant for violation of the laws or rules of tlie asvlum, and submit the same to the Board of Trustées immediately for then- approval.* He shall remit to the Board of Trustées a report of the amount, kind, and quantity of furniture and household furnishing goods, provisions, fuel, forage, cloth, and other material required for six months ending on the first day of June and Decem- ber of each vear, and the trustées shall then advertise, when practicable, for four successive wèeks, for contracts for furnishing said supplies, or so much thereof as they deem necessary. . . . Necessary expenditures other than for provisions, fuel, forage, clothing, and furniture and household furnishing goods may be made by the superintendent subject to the approval of the board. . . . Sec. 3554.—Superintendent to Keep Accurate Accounts and Make Monthly Reports. The superintendent shall cause accurate and careful accounts to be kept of the daily expenditures of ail classes of stores and property placed in his charge, and shall at the end of each month submit the same to the trustées for their inspection, and on each daily report shall be shown the number of persons having lodging in the asylum, whether as officer, employée, or patient. . . . Laws of Pennsylvania, 1873. Sec. 1.—On what Evidence Insane Persons may be Placed in an Asylum. Insane persons may be placed in a hospital for the insane by their légal guardians, ... or by their relatives or friends in case they hâve no guardians, but not without the certificate of two or more reputable physicians under a personal examination made within one week of the date thereof ; and this certificate to be duly acknowledged and sworn to or affirmed before some magistrate or judicial officer, who shall certify to the genuineness of the signatures and to the responsibility of the signers. Sec. 13.—Philadelphia State Lunatic Asylum Physician. . . . The trustées shall hâve charge of the gênerai interests of the institution ; they shall appoint a superintendent who shall be a skillful physician, subject to removal or réélection no oftener than the period of ten years, except by infidelity to the trust reposed in him, or for incompetency ; said physician shall also réside in the asylum, and shall be a married man, and his family shall réside with him. . . . Sec. 14.—Powers of the Supcrintcnding Physician. The superintending physician shall appoint and exercise entire control- over sub- ordinate officers and assistants in the institution, and shall hâve entire discrétion of the duties of the same. Laws of Pennsylvania, 1883. Sec. 19.—Time within icldch Certificate must be Made. The certificate above provided for shall hâve been made out within one week of the examination of the patient, and within two weeks of the time of the admission of the patient, and shall be duly sworn to or affirmed before a judge or magistrate of this commonwealth and of the county where such person has been examined, who shall certify to the genuineness of the signatures and to standing and good repute of ail the signers ; and any person falsely certifying as aforesaid shall be guilty of misde- meanor and also liable. Sec. 23.—Duty of Médical Attendant. ... The regular médical attendant of the house shall, within twenty-four hours after the réception of any patient, examine such patient and reduce to writing the APPENDIN. 667 results of such an examination, and enter the same upon the book to be kept for the purpose, with the opinion formed from such examination and from the documents received with the patient. Sec. 24.— When Détention Unneccssary, Notice to bc Given. In case the said médical attendant is of the opinion that détention is not necessary for the benefit of the patient, he shall notify the person or persons at whose instance the patient is detained, and unless such a person shall without a delay not exceeding seven days exhibit satisfactory proof of such necessity, the patient shall be discharged from the house and restored to his family or friends. Sec. 25.—Interviews Allowed. At the time of such examination the médical attendant shall himself cause the patient strictly to understand, if he or she is capable of doing so, that if he or she desires to see or otherwise communicate 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 hâve a full unrestrained interview with the patient. Sec. 26.—Reports to bc Made by the Médical Attendant. The statement furnished at the time of the réception of the patient (and of the examination of the patient by the médical 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 réception 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 médical 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 Correspondance, etc. Ail persons detained as insane shall be furnished with materials and reasonable opportunity, under the discrétion of the superintendent or manager, for communicat- ing, under seal, without the building, and such communication shall be stamped and mailed. They shall bave the unrestrained privilège of addressing communications, if they so désire, not oftener than once a month, to any member of the Committee on Lunacy. Sec. 31.—Persons Restored to Reason to be Forthwith Discharged. Ail persons that hâve been detained as insane (other than criminal insane duly eonvicted and sentenced by a court) shall, as soon as they are restored to reason and are compétent to act for themselves, in the opinion of the médical attendant of the house, be forthwith discharged ; and any person so detained shall at ail times be en- titled to a writ of habeas corpus for the détermination 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 bc Nofificd of Discharges. The Committee on Lunacy shall be notified of ail discharges within seven days thereafter, and a record of same shall be kept by the committee. Sec. 36.— Postal Privilèges 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 employée of any insane asylum, to intercept, delay, or interfère with, in any manner whatsoever, the transmission of any letter or other written communication addressed by an inmate of any insane asylum to his or lier counsel residing in the county in which the home of the patient is, or the State or county in which the asylum is loeated," is hereby amended so that the same shall extend to superintendonts, 668 A P PEND IN. officers, servants, or other employées of ail hospitals, houses, or places which are sub- ject to the provision of this act. Statutes of Ehode Island, Maa', 1884—January, 1885. Chapter 479.—Apportionment of Insane l'aupersat the Butler Hospital or other Curative Hospitals. AA'lienever 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 governor, 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 Khode Island, 1882. Chapter 74, Section 1.—AA'lienever 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 furiouslymad 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 deputy 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 on Return of the Warrant and Commitment of the Mad Person. If the court on such examination shall adjudge such complaint to be true, it shall, unless a recognizance satisfactory to said court 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 under 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 aud examination, be declared to be restored to soundness of mind, or to be no longer under the necessity of restraint, or until recognizance as aforesaid, satis- factory to such court, shall be given. Sec. 10.— When a Person Committed may be Discharged though not Cured. Any person committed to any such institution under the previous proceedings of the fourth section may, although not restored to sanity, be discharged therefrom upon the written recommendation of the trustées and superintendent thereof, or an order of any justice of the Suprême Court, to be made in his discrétion. 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 hospital 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 Receive and Dctain 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 bv his keeper and servants, until discharged by any one of the modes herein provided ; and no super- intendent, his keepers or servants, nor the trustées or agents of same, shall be liable, civilly or criminally, for receiving or detaining such person so committed or detained! APPENDIX. 66g Sec. 14.—Superintendent may Discharge—When. The superintendent of such institution for the insane within the State may, on the application of any relative or friend, with the proper approval in writing of the visiting committee or trustées, discharge from such institution anj' patient 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 discrétion 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 from in any way or manner interfering, hindering, or preventing any person so confined from com- municating at ail times, in manner as aforesaid, with 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 bis 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 tlie said commission without delay. Laws of South Carolina, 1884. Act 508, Sec. 1.—Certificate of Physicians. . . . Physicians examining summoned persons alleged to be insane for admission to a lunatic asylum shall certify under oath that they are registered in accordance with the State law, that they hâve 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 their médical 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 be Sait unless Violent. Physicians giving certificates recommending commitment to the asylum of a per- son who is simply idiotie, epileptie, physically infirm, or mentally imbécile, unless such person is violent or dangerous, shall be deemed guilty of a misdemeanor, and upon conviction thereof shall be fined by the District Court. Laws of 1882. Act 121, Sec. 1.—Tenus and Conditions upon which Patients may be Admitted into the Asylum. . The superintendent and régents of the State Lunatic Asylum shall not re- ceive into said institution any beneficiary patient unless the order consigning such person to the asylum is accompanied by report from the County Commissioners of the county from which such person is sent, certifying that they bave earefully 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, 1S81-82. Chapter 646, Sec. 1.—How Lunatics are to be Sent to the Asylum. Ail 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 APPENDIN. of the Board of Countv Commissioners, or the clerk of such board, that such person should be sent to the lunatic asylum, having first had such lunatic, if of a dangerou- or violent eharaeter, so secured as not to do any damage or injury. . . . Sec. 1586.—Hoir to be Admitted to the Asylum. It shall be the dutv of the regenev to admit as subjects of the institution ail idiots, lunatics, and epileptics, under the statutes of this State and subject to the following conditions, that is to sav: ... (3) ail 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 tlie Count v e Commissioners wherein such pauper has a légal 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 ôf the idiot, lunatic, or epileptie. Sec. 1588.—Judges may Direct Inquisition. Whenever a judge of probate or a judge of the Circuit Court shall direct an order to any trial justice to inquire as to the idiocy, lunacy, or epilepsy of any person, or when information on oath shall be given to any trial justice that a person is an idiot, lunatic, or epileptie, and is chargeable for his support on the county, it shall be the duty of said triai justice forthwith to call to his assistance two licensed practicing physicians, and examine such person as to évidence of his or her idiocy, lunacy, or epilepsy ; and if after full examination they shall find such person an idiot, lunatic, or epileptie, they shall certify to said judge or Board of County Commissioners whether in their opinion such person is curable or incurable, 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 discrétion may make an order that the said person shall be sent to the lunatic asylum. Sec. 1594.—Discharge of Lunatics. Whenever any lunatic or epileptie shall hâve recovered, it shall be the duty of the régents to discharge him from the asylum. Sec. 1596.—III Treatment of Patients by Employées. It shall be the duty of the régents to remove from office and cause to be indieted any person employed in said institutions who shall assault any idiot, lunatic, or epileptie with any other or greater violence than may be necessary for his or her restraint, government, or cure. Code of Tennessee, 1884, Article 2, Section 2027.—Qualifications of Superintendent. The superintendent of the hospital shall be appointed by the Board of Trustées, and shall be a skillful physician, of unblemished moral eharaeter, of enlightened anel thorough professional éducation, of prompt business habits, and of humane and kind disposition. Sec. 2028.—Résidence, etc. He shall be a married man, and with his family shall réside 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- tées for infidelity to his trust or incompetency fully shown and declared. Sec. 2030.— Powers over Officers. He shall exercise entire control over ail subordinate officers and assistants in the hospital, and shall hâve entire direction of the duties of same, he himself being accountable to the Board of Trustées for their good eharaeter and fidelity in the dis- charge of their duties. APPENDIN. 671 Sec. 2036.—Duties. It shall be the duty of the superintendent, under the orders of the Board of Trus- tées : First, to exercise a gênerai superintendency over ail matters relating to the hospital. Second, to visit the patients therein at least twiee a week, or oftener if necessary. Third, to call meetings of extraordinary importance of the Board when- ever he may deem it necessary. Fourth, to report to the trustées immediately before each gênerai 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 bave been affected before admission ; fifth, the profession, occupation, âge, and habits of each patient, and whether married or single ; sixth, the names of those discharged, and the condition of each when discharged ; seventh, and such other particulars as he may deem necessary to further action and législation thereon. Sec. 2037.—In Référence to Removal of Patients. The superintendent, by authority of the résident Board of Trustées or a majority of them, shall hâve 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, Eevised Statutes of Texas, 1879. Article 67.—Board of Managers. The gênerai 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.—Monthly Inspection. 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 advice 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 appointaient shall be only for the expiring term, aud the term of such officer shall, in any event, expire with the term of the governor making the appointaient. Art. 76.—Qualifications of the Superintendent. The superintendent shall be a married man, and also of expérience in the treat- ment of insanity. He shall réside in the hospital with his family, and shall dévote 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, médical, and disbursing officer of the institution, and subject to the by-laws, but shall hâve gênerai 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 ail employées connected therewith diligently and faithfully perform duties as- signed to them. Art. 81.—Tlie superintendent shall also, with the consent of the Board of Mana- gers, employ 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 ail moneys intrusted to him are judiciously and economically ex- pended. Art. 82.—The superintendent shall keep also an accurate and detaiïed account of aU moneys received and expended by him, certifying the source from which such moneys were received. and to which and on what account to be used ; and on the first day of July of each year lie shall report the same under oath to the governor. 672 APPENDIX. Art. 83.—The superintendent shall also keep and register patients received into the asylum and discharged therefrom, together with a full record of ail the opérations of the institution, and on the first day of November of each year he shall report such opérations in full to the governor, accompanied with such suggestions and recom- mendations concerning the management and opérations 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 ail the personal property belonging to the asylum to be prepared, in which inven- tory an estimated value shall be set beside each article, and shall submit the same to the Board of Managers. Art. 92.—Before any person can be received as a patient . . . the parent or légal guardian of such person, or, in case he has no parent or guardian, then some near relative or other person interested in him, must présent a written request to the super- intendent for his admission, setting forth the name, âge, résidence of the lunatic, 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 résides, that the physician 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 county. Art. 99.—Discharge of Patients. Any patient, except such as are charged with or eonvicted of some offense and hâve been adjudged insane in accordance with the provisions of the Code of Criminal Procédure, 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.—No 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 friends, or to the eounty from which he was sent. Art. 106.—Appréhension of Lunatics. Ii information written under oath be given to any county judge that any person in his county is a lunatic or non conqws mentis, and that the welfare of himself or of others requires 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 appréhension of such person, and shall fix a day for the hearing and détermination of the matter. Art. 120.— Suitable Clothing to be Provided. Before sending any patient to the asylum the county 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 Médical Superintendent and his Duties. The médical superintendent shall be well educated, an experieneed physician, and a regular graduate in medicine, and shall hâve practiced at least five years from the date of his diploma. He shall bave the gênera! superintendence of 'the buildings APPENDIX. 673 grounds, and property thereof, subject to the laws and régulations of the directors. He shall bave control of the patients, prescribe their treatment, adopt sanitary meas- ures for their welfare, and discharge such as in his opinion bave permanently recovered their reasou. He shall appoint, with the approval of the directors, as many attendants as may lie necessary for the efficient and économie care and management of the asylum, anel, with the consent of the Board of Directors, fix their compensation and discharge any of them. He shall prescribe the duties of the subordinate officers, maintâin dis- cipline among them, and enforce obédience to the laws, rules, and régulations adopted for the government of the institution. He shall estimate quarterly, in advance, the probable expenses of the asylum, and submit the same to the Board of Directors at their regular meeting preceding the commencement of such quarter, for their approval. . . . The médical superintendent shall cause to be kept full and accurate accounts and records of his officiai transactions from day to day, in books provided for that purpose, in the mode prescribed in the by-laws. He shall see that his accounts are fully made up to the 3Ist 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 président of the Board of Directors, in which event the assistant physician shall discharge his duties. . . . Sec. 16.—Judge of Probate may, if Found Necessary, Direct that Insane Persons be 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, cause 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 shall testify, under oath, as to the conversation, manners, and gênerai talk upon whieh 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 case 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 récent or curable eharaeter, or that the insane person is of homicidal, suicidai, 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, âge, nativity, résidence, occupa- tion, length of time in tlie Territory, State, or county last from, previous habits, pre- monitory symptoms, apparent cause, and class of insanity, duration of the disease, and présent 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 récent or curable nature, or of homi- cidal, suicidai, or incendiary eharaeter, or that from the violence of the symptoms the said insane person 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 médical superintendent of said asylum. . . . Vermont, 1884. Act No. 52, Section 1.—It is hereby enacted by the gênerai assembly of the State of Vermont, that section 2898 of the Revised 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 discrétion ; 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 physieal and mental con- dition, and médical treatment; form a careful opinion of the patients, apart from the officers and keepers, and investigate the cases that in their judgment require spécial investigation, and particularly ascertain whether persons are confined in such asylum or other place-s who ought to be discharged. They shall hâve the gênerai supervision of the insane of the State not in confinement, so far as it concerns their physieal and 674 A PREND IN. mental condition, their care, management, and médical treatment ; and also those who are discharged from such asylum or place of confinement by authority under section 4 of the act approved November 28, 18s2. and shall make such order therein as such case requires. Revised Statutes, 1880. Chapter 139, Section 2897.—Supcrvisors. The gênerai 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 vaeancies of the board during the term. Two of said supervisors shall be physicians, and none of them shall be a trustée, superintendent, employée, or other officer of an insane asylum in the State. Sec. 2900.—Powers of the Supervisors. The supervisors may administer oaths, summon witnesses before them in any case under investigation, and discharge by their orders in Avriting 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 warrant discharge. But conviets 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 supervisors shall order their return to the Prison or House of Correction. In no case shall the super- visors order the diseharge of a patient without giving the superintendent of the asylum an opportunity to be heard. Sec. 2905.—Fine for not Dischar ging Patient after Recovery. If a trustée, superintendent, employée, or other officer of any asylum for the insane willfully and knowiugly neglects or refuses to diseharge a patient after such patient has become sane, or after the supervisors hâve ordered his discharge, such trustée, superintendent, employée, or other officer shall be fined not more than five hundred dollars. Se*'. 2906.—Ptiysiciaus' Certificate Required. No person, except as hereinafter provided, shall be admitted or detained in an in- sane asylum as a patient or inmate except upon the certificate of such person's insanity, made by two physicians of unquestioned integrity and skill, residing in the probate district in which such insane person résides, or, if such insane person is not a résident of the State, in the probate district in which the asylum is situated ; or if such insane person is a convict in the State Prison or House of Correction, such physicians may be résidents of the probate district in which such place of confinement is situated. Sec. 2907.—Certificate— When to be Made. Such certificate shall lie made not more than ten days previous to the admission of such insane person, and, with the certificate of the judge of probate of the district in which the physicians réside that such physicians are of unquestioned integrity 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 Examination. The certificate of the physicians shall be given only after a careful examination of the supposed insane person, made not more than five days previous to the giving of the certificate ; and the physician who signs the certificate without making such previous examination shall, if the person is admitted to any asylum under the certificate be fined not less than fifty dollars and not more than one hundred dollars. Code of Virginia, 1887. Sec. 1668.—Annual Reports. The board of each asylum shall annually before the first day of November report to the governor, for the information of the gênerai assembly, the condition of the asylum APPENDIN. 675 and an account of ail sums received and disbursed, with a list of the patients desig- nated by name or otherwise in the asylum during the preceding year, showing their âge and sex, place of résidence, and civil condition, deaths, and discharges, and con- dition when discharged, and any statistics and remarks as to the management of insane and the subject of insanity which in their judgment may be useful. Sec. 1669.—Any justice who suspects any person in his county or corporation to be a lunatic shall issue his warrant ordering such person to be brought before him. He and two other justices shall inquire whether such person be a lunatic, and for that purpose summon his physician (if any) and any other witnesses. . . . Sec. 1670.—If the justices décide that the person is a lunatic and ought to be con- fined in an asylum—unless some person (to whom the justices, in their discrétion, may deliver such lunatic) will give bond, with sufficient seeurity, to be approved 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 empower any person of responsibility and eharaeter 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 arrangements 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.—Discharge of other Reêtored Lunatics. When any other person confined in an asylum or jail as a lunatic shall be restored to sanity, the superintendent or the court, as the case may be, shall discharge him and give him a certificate thereof. Code of Washington, 1881. Sec. 2251.—Appointment and Qualifications of Superintendent. The superintendent shall be a skillful practicing physician, and shall réside upon the hospital grounds ; he shall hold his office for such time as the trustées may deem wise and for the efficiency and economy of the institution ; he shall hâve entire control of the médical, moral, and dietetic treatment of the patients, and, so far as is not in- «onsistent with the by-laws and régulations of the hospital, of ail other internai 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 prescribe, appoint ail sub- ordinate employées, and shall hâve entire direction of them in their duties. Sec. 2260.—No Person Laboring under Contagions Disease Admitted. No person laboring under any contagious or infectious disease shall be admitted in said hospital as a patient. Sec. 2264.—When and How Patients may be Discharged. Any patient may be discharged from the hospital when in the judgment of the superintendent it may be expédient. 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 county unattended by any person, 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 an*! care, without endangering the health of such patient, is through or by any reason un fit 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 APTENDIX. shall immediately upon receipt of the notice issue his warrant to the sheriff, command- ing him to remove the patient and return 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 tbe time being, be retained in said hospital at the expense of the county from which he or she was so committed. Sec. 22G7.—The Superintendent shall Ascertain History of each 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 Trustées, whe shall use efficient means for the collection of ail sums due the institution from those who are able to pay for such care. Sec. 2273.—Correspondence of Patients Free from Censorship. 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 unrestraineel as are those of any other résident 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 public and private, in the Territory of Washing- ton, with suitable material for writing, inclosing, sealing, stamping, and mailing letters sufficient for writing of one four-paged letter a week, provided they request the same, unless they are otherwise furnished with it; and ail thèse letters shall be dropped by the writers 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 ail the patients ; and the contents of thèse 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 superintendent of every insane asylum in the Territory of Washington, both public and private, to deliver or cause to be delivered to said person any letter or writing 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 nnist Give Certificate, Stating Name of Patient and County. Whenever any patient is delivered at the asylum under the provisions 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 person under oath, setting forth that any person by reason of insanity is unsafe to be at large or is suffering under mental dérangement, shall cause such person 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 under oath, in writing, give their opinion of the case, which opinions shall be earefully 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 court or judge that such is the fact, said court or judge shall cause such insane or idiotie 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 décide 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 désire to take charge of such insane or idiotie person the court or judge may so order, if they shall give bonds, to be approved by said judge, conditioned that such insane or idiotie person shall be well and securely kept. APTENDIX. 677 Amended Code of West Virginia, 1884. Chapter 58, Section 7.— West Virginia Hospital for the Insane. A superintendent and as mauy assistants as may be necessary, who shall be physicians, and other officers, shall be appointed by the board, and shall receive such compensation as the board may prescribe. The board may also appoint an executive committee, and may authorize the superintendent to employ as many nurses and attendants as may be necessary, and also diseharge them, or any of them, and em- ploy others, but 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 persons brought to the asylum as lunatics, and order those found to1 be such to be received. Sec. 11 (Acts of 1882, p. 133).—Any justice who shall suspect any person in bis. county to be a lunatic shall issue his warrant, ordering such person to be brought before him. 1 le shall inquire whether sirbh person be a lunatic, and for that purpose summon a physician and other witnesses. In addition to any other questions he may propound as many of the following as may be applicable to the case : 1. AA'liat is the patient's âge, and where boni? 2. Is he marrieel ; if so, how many children has he? 3. \Arhat are his habits arrd occupation? 4. How long since indications of insanity ap- peared? 5. AA'hat were they? 6. Does the disease appear to increase? 7. Are there periodical exacerbations ; any lucid intervals, and of what duration ? 8. Is his dérange- ment evinced on one or on several subjects ; what are they? 9. AA'hat is the supposed cause of his disease ? 10. AA'hat change is there in his bodily condition since the attack? 11. Has Ihere been a former attack ; when, and of what duration? 12. Has he shown any disposition to commit violence to himself or others? 13. Whether any, anel what restraint has been imposed on him? 14. If any, what connections of his bave been insane. Were his parents or grandparents blood relations; if so, in what degree? 15. Has he any bodily disease from suppression of évacuations, éruptions, sores, injuries, or the like, and what is its history? What curative means bave been pursued and their effect, and especially if depleting remédies, and to what extent, hâve been used? Sec. 12.—Lf the said justice décide 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 discrétion, may deliver such lunatic, will give bond, with sufficient seeurity, tobe approved bysaid justice, payable to the State, with condition to restrain and take proper 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 according to law—the said justice shall order him to be removed to the hospital and received, if there be room therein. Sec. 23.— When Persons may bc Discharged from Hospital. Except in the case of a person charged with crime and subject to be tried therefor, or eonvicted 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 court of any county, may deliver any lunatic confined in the hospital or in the jail of such county to any friend who will give bond with seeurity, with the condition mentioned in the twelfth section of this chapter ; anel 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 willing and, in the opinion of the board, able to take care of him. Sec. 50.—Genercd Provisions. If any director of the hospital, justice, clerk of a court, or other officers shall fail to perform any duty required of him in the chapter, or shall offend against any prohibi- tion contained herein, he shall forfeit not less than fifty nor more than one hundred Sec. 51.__The word " lunatic," whenever it occurs in this chapter, shall be construed to include every insane person who is not an idiot. % C78 APPENDIX. Rea7ised Statutes of Wisconsin, 1879-1883. Chapter 32, Section 588.—Duties of the Superintendent. The superintendent of each hospital shall, before entering upon the duties of his office, take and subscribe an oath faithfully and diligently to diseharge the duties re- quired of him by law and the by-laws of the Board of Trustées. Ile shall be chief executive officer of the hospital, and shall dévote ail his time and attention to his duties ; he shall exercise entire control over ail the subordinate officers ; he shall employ aU employées 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- ployée at will, being responsible to the Board of Trustées for the proper exercise of that duty in regard to officers. The superintendent shall not be compelled to obey the subpœna of any court in any case, civil or criminal, if lie shall file with the magistrate or clerk his affidavit that to obey the same would be seriously detrimental and hazarel- 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 juelge shall make a spécial order therefor, and the subpœna, with a mémorandum thereof indorsed thereon, be served one week before the time when he shall be required to appear ; provided, however, that no person shall be entitled, in any case, to make and file such affidavit, exempting him from subpœnas as aforesaid, who shall upon tender of the usual fées of witnesses, in courts of record, refuse to be présent and to give his déposition at his office or usual place of business, or, instead thereof, at his house or usual place of abode ; provided further, that any person so présent and giving his déposition at lus office or usual plaee of business, or, instead thereof, at his house or usual place of abode, who shall be de- tained four hours from the time fixed for the taking of such déposition, or from the time to which the taking of the same may hâve been aeljourned, may make affidavit that further détention would be seriously detrimental or hazardous 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 déposition is given, shall thereupon adjourn further proceedings thereon to a future day. Sec. 593.—Proceedings to Détermine Insanity—Examination by Physicians. Whenever any résident of this State, or any person from therein whose résidence cannot be ascertained, shall be or be supposed to be insane, application may 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 résides, or, in case his résidence 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 sliall be in writing and shall specify whether or not a trial by jury is desired by applicant. On receipt of said pétition the judge to whom it is addressed shall appoint two disinterested physicians, of good réputé for médical skill and moral integrity, to visit and examine the person alleged to be insane ; and such physicians shall proceed without unnecessary delay to the résidence of the person supposed to be insane, and shall by personal examination and inquiries satisf v themselves fully as to his condition and report the resuit of their examination to th*e judge. . . . . . . Upon the receipt of the report of the examining physicians the judge may, if no demand bas been made for a jury, make and enter his order of commitment to the hospital or asylum of the district to whieh the county belongs, or, if not fully satisfied, he 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, he, or any relative or friend acting in his behalf, shall hâve 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 case a trial by jury is demanded, the forms of procédure shall be the same as in trials by jury in justices' courts, and the trial shall be in the présence of the person sup- posed to be insane, and his counsel and immédiate friends and the médical wit- nesses. . . . County Judge may Order Insane Persons Confined. On receipt by the county judge of the pétition provided for bv section 1 of chapter 266 of the General Laws of 1880, such judge may, if in his opinion the public safety AFP EN DIX. 679 requires it, deliver to the sheriff of his county an order in writing requiring him forth- with to take and confine such insane or supposed insane person in some place to be specified, until further order of the judge ; and after the receipt by such judge of the report of the examining physicians provided for in said chapter, such judge may, in his discrétion, deliver to such officer such order in writing requiring him forthwith to take such person into custody and keep him in some place to be specified, until the further order of such judge. The examining physicians provided for by said section 1 of said chapter 266, 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 your opinion is he insane? ... If any relative or friend—being of a légal âge and compétent to perform 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 paid his necessary expenses, not exceeding the fées 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. Rea'ised Statutes of Wyoming, 1887. Sec. 2287.—Application for Inquisition. If information in writing be given to the probate judge that any person in the county is an idiot, lunatic, or person of unsound mind, or an habituai drunkard, or incapable 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 jurisdiction, shall cause the facts to be inquired info by a jury. Sec. 2288.—Court may Act in Vacation. Such information may also be given in the vacation of said court, to the judge therefor, in which event he shall call a spécial term of the court for the purpose of holding an inquiry whether tlie person mentioned in such information be of unsound mind or an habituai drunkard, or not. Sec. 2289.—Person may be Brought into Court. In proceeding under this chapter the Probate Court may, in its discrétion, cause the person alleged to be of unsound mind or habituai drunkard to be brought before the court. Sec. 2290.—AA'lienever any judge of the Probate Court, justice of the peace, sheriff, coroner, or constable, shall discover any person résident of his county to be of unsound mind or an habituai drunkard, 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 bave been completed and accepted by the Board of Commis- sioners the board shall serve notice in writing upon the Boards of County Commis- sioners of ail the différent counties in tins Territory, which notice shall state that the asylum for insane at Evanston is now completed and ready for the réception and care of insane persons. Each Board of County Commissioners shall, after the receipt of such notice cause ail persons adjudged to be insane, and whose care shall bave been thrown upon the county, to be sent as patients to the Insane Asylum at Evanston, there to be kept and cared for at the expense of said county. And ail insane persons liavin» been sent to asylums outside of this Territory shall, upon the completion of said asylum 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 EA'anston. 680 APPENDIX. Sec. 3764 (1887).—Superintendent of Asylums—Qualifications and Duties. The Board of Commissioners shall elect one résident physician, who shall be the gênerai superintendent of the insane asylum herein provided for, subject at ail times to the order and duties of said board, which shall hâve power at any time, whenever in their judgment it shall be deemed proper and for the best interests of the Territory, to discharge and remove such superintendent. The superintendent so electee! shall réside 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 ail his doings and the actual business and opéra- tions of the institution, and submit a monthly report to the Board of Commissioners. The superintendent shall employ ail 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 hâve 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 ail re- spects receive the same médical care and treatment, and be given as wholesome foodr as is given to paying patients. I3STDEX. PAGE Aberration, mental, influence of, upon capacity of individual..............II. 112 Abortion, clinieal évidences of : changes in maternai organism during preg- nancy, condition of utero-vaginal tract, génital discharges..........IL 472 stains upon beelding or clothing.....................................IL 475 criminally induced...................................................II. 468 (a) médicinal measures : ergot, tansy, cotton-root, savin, rue, yew, saf- fron, pennyroyal, cathartics, apiol, chloride of iron............IL 469, 470 (b) mechanical measures : blows, jolts, douches, tents, etc............IL 470 defined.............................................................IL 467 direct, interférence to produce : detachment of ovum, perforation of fétus, galvanic current.................................................IL 471 évidences of criminal................................................IL 477 that confinement has occurred..............................IL 478 feigned.............................................................IL 478 infanticide..........................................................IL 479 legitimately induced.................................................IL 468 non-induced or spontaneous..........................................IL 467 post-mortem signs of.................................................IL 475 relations of physicians, etc., to the patients in cases of.................I. 638 size of utérus and development of fétus...............................IL 477 stage of gestation when abortion took place...........................IL 476 Abscess of testicle.......................................................IL 628 Abuse, sexual, of children ; manustupration...............................IL 545 Accident, death by drowning............................................ L 128 hanging or strangulation.............................. I. 120 suffocation........................................... I. 111 disease the resuit of, in relation to insurance..........................I. 585 in relation to insurance.............................................. L 583 Accident Cases, damages for loss of income..............................IL 383 defined.............................................................H. 377 inviolability of the person............................................IL 378 négligence of injured party...........................................II. 380 physieal examination before trial.....................................IL 377 questions for médical expert..........................................IL 379 recovery of cost of médical attention..................................IL 384 ultimate and direct results of injuries.................................IL 380 Accident Insurance (see Insurance).................................I. 493, 583 Acetic Acid............................................................I- 490 681 682 INDEX. pxe.v, Acids, boracic, boric, chromic, chromic anhydride, potassic dichromate...... I. 332 I 3»>9 hvdrochloric, muriatic................................................. ,................. I. 326 minerai...................................................... „ ,. „....... I. 330 mtric, aqua fortis............................................°....... sulphuric, oil of vitriol................................................ Aconite, aconitin, aconitine, aconitia, aconitina...........................I- 4-' ACQUETTA DI PeRUGIA................................................... I# TT 'M Action, reflex...........................................................l TT 95 Acute Alcoholism......................................................iJ- Acute Dementia........................................................H- 10** Adipocere............................................................... I- Adolescent Insanity...................................................H- 90 Affections of Memory.................................................H- 46 Age, détermination of the- indications of................................... 1- ^^ as determined by skeleton........................................... I- °" Age of consent.............................................I- 651; IL 517, 525 Agoraphobia...........................................................H- 45 Agraphia...............................................................H- 268 Alalia.................................................................H. 267 Alcohol, insanity due to................................................II- 205 Alcoholic gênerai paresis...............................................II- 9? insanity.............................................................H- 9î>' hallucinations in.............................................H- 96 Alcoholism.....................................................II- 59, 123, 205 habituai drunkards..................................................II- 1 °- Alkaloidal and other Organic Poisons (see Poisons)......................I. 415 Alkaloids, animal (see Poisons).........................................I- 475 mydriatic........................................................... I- 427 Ammonia................................................................ I- ^-4 Amnesic Aphasia.......................................................II. 267 Amputations (see Surgery)..............................................IL 621 Anaesthesia, cutaneous, in traumatic neuroses............................IL 339 feigned.............................................................IL 403 sexualis.............................................................IL 557 Anaesthetics, administration of..........................................IL 598 never without assistant....................IL 594 to pregnant women........................IL 600 with witnesses, with female patients........IL 595 bromide of ethyl, hydrobromic ether..................................IL 603 cause of death.......................................................IL 595 chloroform, fatal narcosis............................................IL 596 idiosyncrasy.............................................IL 598 dangerous narcosis, treatment of......................................IL 599 death under.........................................................IL 594 by suffocation from....................................... I. 113 indirect causes of.........................................IL 596 effect of, upon kidneys...............................................IL 597 ether, objections to..................................................IL 600 failure of, to produce results.........................................IL 602 nitrous oxide........................................................IL 603- statistics, reports, and cases..........................................IL 601 INDEX. G83 TAGE Analvsis, spectrum, of blood-stains.......................................L 142 Anchylosis.............................................................IL 621 Aneurism. case of mistaken..............................................IL 606 diagnosis of.........................................................IL <>05 surgieal malpractice in treating.......................................IL 605 Angular Garus of the brain.............................................IL 27 Antimony, antimony chloride, antimoniureted hydrogen, butter of antimony. I. 341 Aphasia, agraphia.......................................................IL 268 amnésie and ataxic..................................................IL 267 apraxia.............................................................IL 269» bulbar and pseudobulbar affections of speech..........................IL 281 cases of : Beven, Fillmore will........................................IL 262 Parish will.................................................IL 261 cérébral centers in mechanism of speech..............................IL 269 disorders of pantomime in............................................IL 287 cases...................................IL 289-296 dyslexia............................................................IL 272: forms of speech disorders produced by lésions..........................IL 270' history and literature of..............................................IL 2591 interdiction of aphasies..............................................IL 261 measure of capacity.................................................IL 266 medico-legal aspects of...............................................IL 259 questions in connection with.............................IL 263 mental disturbance in................................................IL 261 status of motor aphasies.......................................IL 279» of sensory aphasies.....................................IL 273 in verbal amnesia.......................................IL 277 in word-blindness.......................................IL 275 in word-deafness........................................IL 274 motor or emissive....................................................IL 267 paraphasias or conduction aphasias...................................IL 268 psychicàl blindness and deafness......................................IL 268 sensory or réceptive..................................................IL 267 simulated, mimetic, etc., affections of speech..........................IL 285 speech disturbances, associated with insanity and epilepsy.........IL 283, 284 in (bearing on insanity)..........................IL 47 testamentary capacity in.............................................H- 265 total................................................................II- 268 verbal amnesia......................................................H- 268 Aphemia................................................................II- 267 Apperception of the mind...............................................II- 19 Apraxia................................................................H- 269 Aqua Toffana......................................................I- 350, 490 Arsenic, arsenic acid, arsenates, arsine, arseniureted hydrogen, sulphides... L 380 arsenious acid, arsenious oxide, white arsenic.......................... L 356 eating, Maybrick case................................................ I- 369 metallic............................................................. I- 355 Aseaiasia................................................................II- 267 Aseptic and antiseptic surgery...........................................II. 590 Asphyxia, dynamical....................................................L 113 in drowning.........................................................I- 120 C84 INDEX. PAGE Assaults, criminal (see Post-mortem Examinations)....................... I- 33 indécent, upon children......................................I- "49 ; 11. <>_.> Association, benefit (see Insurance)...................................... I- 49,! Asyluai Phvsician, a mère eustodian.....................................H- 141 Ataxia, ataxic aphasia..................................................H- -'' ' feigned..............................................................H- 402 Ataxiagram............................................................II- 315 Atheroma of the scalp...................................................H- *>09 Atropine, atropin, atropia............................................... I- 424 Autopsy (see Post-mortem Examinations)...............................I- 25, 57 government régulation of............................................ I- " ' 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- 18G effects of electric currents............................................H- 376 insanity and crime...................................................II- 214 insanity in its medico-legal relations..................................H- ICO traumatic n euroses...................................................H- 3e2 Birth, child, number a woman may or should hâve........................IL 461 substitution and suppression of..............................IL 459 viability of.................................................H- 450 delivery, Cœsarean section.......................................IL 456, 459 duties of physicians in...................................IL 456, 466 prématuré labor, induction of................................IL 460 symphyseotomy.............................................IL 459 lactation............................................................IL 458 légal obligations of physician in recording.............................IL 417 French Civil Code..................................................IL 418 légal procédure against physicians....................................IL 465 obstetrics.......................................................IL 459, 463 pregnancy, artificial insémination.....................................IL 439 conception, marriage and conception, interférence to pre- vent conception........................................IL 437 duration of gestation, its bearing on legitimacy.........IL 450, 453 extra-uterine.............................................IL 440 laws of différent countries regarding.......................IL 453 multiple.................................................IL 446 past or présent condition of...............................IL 402 signs of..................................................IL 441 Hegar's................................................IL 442 kiestein, ballottement...................................IL 443 simulation of.............................................IL 444 sterility, relative and absolute.............................IL 439 superfetation.............................................IL 446 puerpéral fever, local injuries........................................IL 457 state.....................................................IL 456 Blindness, feigned......................................................IL 406 Blood, arterial, A-enous, menstrual.......................................I. 179 INDEX. 685 PAGE Blood, chemical composition of..........................................I. 140 corpuscles...................................................I. 150, 171, 173 distinctions between human and other................................I. 172 fluidity of, after death................................................I. 99 gravitation of, in capiiïaries after death...............................I. 96 tests for........................................................I. 157-162 transfusion of.......................................................IL 586 Blood-stains (see AArounds and Post-mortem 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 guaiacum.........:...................I. 150 water...................................................... I. 149 âge of...............................................................I. 179 bibliography of......................................................I. 186 blood, chemical and physieal properties of.............................I. 139 chemical composition of.......................................I. 140 color of....................................................... I. 139 distinction between human and other...........................I. 172 Alley case..................................................I. 179 dried.........................................................I. 141 menstrual, arterial, and venous................................. L 179 "blood-coloring matter................................................ I. 140 blood-corpuscles, measurements of..........................L 150, 171, 173 crystalline bodies obtained from....................................I. 147 haematin..........................................................L 141 hsemoglobin.......................................................L 140 crystals................................................L 148 spectroscopic appearances of............................L 144 Stokes' band...........................................I. 147 optical properties of...............................................L 142 red corpuscles, comparative study of................................ L 150 number of..........................................L 151 epithelium from vaginœ..............................................L 180 illustrative cases of..................................................I. 180 xnicroscopical examination of.....................................L 167, 169 attempted distinction between blood of man and cow................. I. 180 man and duck ; man and sheep I. 181 blood-clots........................................................ I- 168 cases : Commonwealth vs. Piper, State of Connecticut vs. Hayden.....I. 169 illustrative cases................................................... I- 170 materials found associated with blood............................... L 171 spores of porphyridium............................................ I. 170 microspectroscope................................................... I- 143 examination by....................................................I- 144 séminal stains....................................................... I- 184 spermatozoa.......................................................I- 185 trichimonas vagina?................................................I- 185 spectrum analvsis of.................................................I- 142 testing of suspected stains...........................................L 152 appearance 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 tanuing materials, grease or tar, red paint, vegetable stains......................................................... L 157 preliminary examination.........................................• • I- 10_J tests, chemical...................................................... I- guaiacum......................................................I- 1 ' 1 hœmin........................................................L ]:,s- W'2 histological........................................................ I- microspectroscope................................................. I- 1 ()4 spectroscope......................................................I- 1 substances producing blue color....................................I- 1"! Brain, anatomy of......................................................H- --' arrested development of, idiocy.......................................II- 188 arterial supply to base of...........................•.................H- 26 centers : psychic, sensory, motor, geniculate, aphasie ; agraphic, aphasie, of lower extremity, of superior extremity ; motor, of face, of word- blindness, of hemianopsia, of word-deafness, of unciate gyrus.......IL 24 cortical centers, angular gyrus........................................II- 27 fibers, association of.................................................II- 22 course of pyramidal...........................................H- 23 mind, its dependence on activity of (see Mind)........................IL 19 tolérance of, to injury.............................................H- 19, 21 New England blasting case.........................................IL 21 weight of, Broca and Gratiolet.........'...............................IL 20 Bright's Disease. as a cause of insanity..................................IL 60 as affecting insurance................................................L 537 Bromide of Ethyl, hydrobromic ether (see Anaesthetics)..................IL 603 Bromine, potassium bromide............................................. L 334 Brucine, brucin, brucia.................................................. L 460 Bulbar and pseudobulbar affections of speech............................IL 2X1 Bullets (see Wounds)................................................... L 726 Burns (see Wounds)..................................................... L 288 Cesakean Section..............................'...............IL 456. 459, 460 Calculas, vesieal.......................................................IL 628 Calojiel, mercuric and mercurous chloride, mercuric bichloride............ I. 400 Camphor............................................................... I. 472 Cancroin .............................................................. I. 492 Cannabis Indica........................................................IL 33 Cantharides, Spanish fly............................................... I. 472 Capacity, mental.......................................................IL 114 testamentary.......................................................IL 115 Carbolic Acid......................................................... I. 469 Carbonic Acid, death from suffocation by................................ L 115 Cases : alcoholism (Von Krafft-Ebing's)......................................IL 206 Alley (Leavitt), blood-stains......................................... I. 179 aphasie affections...............................................IL 2*9-296 Ayer vs. Eussell, insanity and false imprisonment......................IL 147 Baker vs. Baker, insanity and divorce.................................IL 142 Banker vs. Banker, insanity and divorce..............................IL 133 Banks vs. Goodfellow, insanity and will...........................IL 118, 170 INDEX 6S7 PAGE Cases : Bell vs. Bennett, insanity and annulment of marriage..................IL 136 Bellingham, right and wrong test.....................................IL 228 beneficiary on life-insurance policy...............................L 507 5(>8 Beven, contract with aphasie.........................................IL 262 Billings. gunshot wounds............................................L 263 Blakely, insanity and will............................................II. 121 Bliss vs. C. & P. R. R. R., habituai drunkard..........................IL 15S Blodgett, habituai drunkard..........................................IL 153 Boyd vs. Eby, lucid interval and insanity..............................IL 113 Brady vs. McBride, insanity and will..................................IL 117 brain, tolérance to injury, New England blasting case.................IL 21 Briggs, gunshot wounds.............................................L 262 Brown vs. Howe, insanity and torts...................................IL 143 Brown vs. Riggin, insanity and will...................................IL 122 Bruin, wounds, self-inflicted.........................................I. 281 Budge, Mrs., knife-wounds..............................I. 249, 259, 273, 277 Carter vs. Beckwith, claim against lunatic.............................IL 142 Cherbonnier vs. Evitts. insanity and will..............................IL 122 Colvocoresses. Captain, suicide.......................................I. 282 Commonwealth vs. Piper, blood-stains................................I. 169 Cramer, Jennie, poisoning, arsenic................................... I. 381 death under ana»sthetic..............................................IL 594 delusions, insane................................................IL 235-241 of râpe...................................................IL 211 Dickie, commissioner in lunacy.......................................IL 139 Dickinson vs. Barber, degree of insanity..............................IL 144 Dills vs. State of Indiana, compulsory expert testimony................IL 150 Ducker vs. Whitson, contract with lunatic.............................IL 130 Eddy, insanity and will..............................................IL 117 electric currents, burning............................................IL 371 damages for injury or death and loss of income.... IL 378-383 death from.....................................IL 368, 369 effects of.......................................IL 373-375 injuries from...................................IL 365, 367 Erdmann's blood-stains..............................................I. 170 feigned diseases.....................................................IL 399 insanity.....................................................IL 410 Fillmore, aphasia and testamentary capacity..........................IL 262 Fort Edwards, wounds, confused..................................... I. 269 Garfield (Président), post-mortem examination........................I. 43 Gerhold vs. Wyss, insanity and divorce................................IL 136 German courts, attitude regarding divorce, etc., and insanity.......IL 133, 134 Greenwood vs. Klein, insanity and undue influence....................IL 126 Guiteau, insanity and crime..........................................IL 198 Gumbault vs. Public Administrator, lucid interval......................IL 113 Hall vs. Warren, lucid interval.......................................II. 113 hallucinations, historical.............................................IL 33 Hamilton vs. Third Avenue R. R., damages for mental distress.........IL 385 Harford vs. Singleton, insanity and breach of promise..................IL 132 Harris (Carlvle), professional confidences of physicians................ I. 625 688 INDEX. page Cases : Hartwell vs. McMaster, eccentricity and will..........................IL 120 Heigham, wounds, gunshot.......................................... I- 254 hermaphrodites.....................................................H- 419 historical, of hereditary insanity....................................-LL 58 Howe, insanity and torts.............................................II- 143 Hughes, wounds, incised............................................. L 270 Hurlehy vs. Martine, false imprisonment and insanity..................IL 147 hysterical ..........................................................IL 21.1 illustrating blood-stains..........................................L 170-182 imperative concepts..................................................IL 45 insane motives......................................................IL 180 insurance—warranties and représentations........................ I. 499-504 Johnson vs. Armstrong, insanity, undue influence, and testamentary ca- pacity ..........................................................II. 125 Jumel will, delusions and testamentary capacity.......................IL 118 Kennedy vs. Standard Sugar Refining Co., damages for mental distress. . .11. 386 Klock, wounds, gunshot.............................................I. 268 Lancaster Co. Bank vs. Moore, contracts and insanity..................IL 131 Lee vs. Scudder, alcoholism and testamentary capacity.................IL 125 Lewis vs. Lewis, insanity and annulment of marriage..................IL 136 lif e-insurance policy on lunatic; recovery on......................IL 145, 146 Lilly vs. Waggoner, contracts and insanity............................IL 128 Lynch vs. Knight, damages for mental distress.........................IL 387 Mclntyre vs. Giblin, damages for mental distress......................IL 385 Mclntyre vs. Sholty, torts and insanity................................IL 143 McNaughton, "right or wrong" test, crime and insanity............IL 175, 218 McPherson, insanity and testamentary capacity.......................IL 113 Mallon, wounds, gunshot............................................L 271 Manley's Executor vs. Staples, delusions and testamentary capacity......IL 119 Marsh, alcoholism and testamentary capacity..........................IL 124 Marvin, bankruptey and insanity.....................................IL 137 Maybrick, Mrs., poisoning, arsenic................................I. 357, 369 Mechanicsville, wound, confused, and fracture........................ I. 268 mental distress, damages for.........................................IL 385 mère distress.....................................................n, 337 sensé of shame....................................................H_ 3gg mistaken diagnosis..................................................H, qqq Mordaunt, puerpéral insanity and divorce.............................IL 135 Murphy, bankruptey and insanity....................................II, 137 Newton vs. Mutual Benefit Life Insurance Company, insanity and insur- ance ...........................................................II 247 O'Connor vs. Rempt, habituai drunkard...............................H, 157 O'Shea, wounds, confused........................................1 251 paranoiac delusions...............................................U gp, Parish, aphasia and testamentary capacity...........................IL 261 Patterson, habituai drunkard.......................................H 141 People vs. Barber, mental responsibility and crime.....................IL 233 Piper, blood-stains............................................ I ^gg Pomeroy, imbecility and crime.....................................H gg Prentis vs. Bâtes, eccentricity and testamentary capacity...............IL 119 INDEX. 680 PAGE Cases : Pritchard, poisoning, antimony.......................................I. 343 puerpéral insanity and crime.........................................IL 103 râpe, senile attempt at..............................................IL 556 Ravachol, insanity and crime........................................IL 184 Rawdon vs. Rawdon, insanity and divorce.............................IL 133 Riddle, Mrs., poisoning, arsenic......................................I. ;j8Q Riggin, delirium and testamentary capacity...........................IL 122 Rusk, contracts and insanity.........................................IL 129 sexual perversion...................................................IL 556 contrary sexuality.................................................IL 570 fetichism, body...................................................IL 557 dress...................................................IL 569 hyperaesthesia sexualis............................................IL 558 lust-murder.......................................................IL 561 Shattuek, wounds, gunshot...........................................L 281 Sherman, Mrs., poisoning, arsenic....................................I. 350 Smith vs. Williamson, habituai drunkard..............................IL 158 State ex rel. Setzer vs. Setzer, insanity and legitimacy.................IL 133 State of Connecticut vs. Hayden, blood-stains......................... I. 169 Steenbergh, wounds, confused.......................................I. 275 Summers vs. State of Texas, power to compel expert testimony.........IL 150 Thompson, wounds, contused and laeerated...........................I. 278 Tichborne, identity..............................................I. 71, 192 traumatic hysteria..................................................IL 344 Underwood vs. Wiug, survivorship....................................I. 236 Victoria Railway Commission vs. Coultas, damages for mental distress.. .IL 388 Wallis vs. Luhring, undue influence and testamentary capacity.........IL 113 Watson, extrême âge................................................IL 117 Weitzel, insanity and bankruptey.....................................IL 137 Welsh "fasting girl"................................................I. 137 Weston, wounds, incised.............................................L 260 Wharton, poisoning, antimony.......................................L 347 Whitechapel murders, identity of dead body.........................L 61, 75 Wightman vs. Wightman, insanity and validity of marriage.............IL 172 Williams vs. Goss, habituai drunkard.................................IL 152 Young vs. Young, alcoholism and divorce.............................IL 153 Castration............................................................IL 628 Catalepsy..............................................................IL 51 feigned.............................................................IL 401 Causes of insanity......................................................IL 57 Children (see Birth, Pregnancy, Sexual Perversion, etc.). âge of consent...............................................L 651 ; IL 525 indécent assault upon........................................L 649 ; IL 525 limit of ehildhood...................................................IL 185 responsibility of, for crime...........................................IL 184 substitution of, at birth..............................................IL 459 suppression of, after birth............................................IL 459 Chloral, chloral hydrate.................................................L 468 chloral habit, a cause of insanity......................................IL 59 Ciilorine, potassic chlorate...............................................I. 333 C90 INDEX. PAGE Chloroform (see Anaesthetics)...................................I. 466 ; IL 596 Cholin................................................................. I. 492 Chorea, feigned.........................................................IL 402 Cicatrices, identification by............................................L 72, 201 Circcaicision (see Genito-urinary)........................................IL 627 Claustrophobia (see Insanity)...........................................IL 45 Cleft Palate (see Surgieal Practice)....................................IL 610 Cocaïne.................................................................I. 428 insanity due to cocaine habit..................................IL 59, 205, 209 Cocatinnic Acid.........................................................I. 428 Coce'ULrs Indicus, picrotoxin.............................................I. 473 Codéine.................................................................I. 439 Colchicum, colchicine, eolchicin, colchicia, colchicina......................I. 430 Cold as affecting insurance................................................I. 540 COLICA PlCTORUM........................................................I. 394 Color-blindness, feigned................................................IL 408 Commission in lunacy...................................................IL 138 application for......................................................IL 142 traverse in finding of.................................................IL 142 Commitment of the insane...............................................IL 138 Committee of estate, in lunacy...........................................IL 142 Compensation of expert witness.........................................IL 149 Competency of the insane to testify.......................................IL 173 Concepts, agoraphobia and claustrophobia................................IL 45 insistent and imperative..............................................IL 44 case of imperative concepts........................................IL 45 mental.............................................................IL 28 normal and diseased.................................................IL 28 Concussion (see Wounds)................................................L 287 of the brain and of the spinal cord....................................IL 298 Coniine, conium, coniin, conine, conia, conicine, conicina..................I. 432 Consumption as affecting insurance.......................................L 529 Contagious Diseases, duties of physicians and surgeons as to...............I. 633 Contracts, in légal relations of physicians and surgeons....................I. 604 insanity as affecting.................................................H_ 173 Contracture (see Surgieal Practice).....................................IL g2i Contusions (see Post-mortem Examination and Wounds).................I. 32 244 Convulsions (see Epilepsy)..............................................II, 223 f eigned.............................................................II. 399 Copper, cupric sulphate..................................................1 494 Coroner's Inquest (see Post-mortem Examination)........................L 57 Corpse, identity of (see Identity) .*........................................I. ;.>•> Corrosive Peiisoxs (see Poisons and Post-mortem Examination)............L 33 Corrosive Sublimate..................................................1 400 Courts of Laav, rulings of (see Laws, Cases, etc.). capacity to know right from wrong, charge of Chief-Justice Shaw.......IL 231 décisions recognizing mental disease..................................IL 251 delusions as a défense for crime......................................IL 230 légal views of State courts regarding impulse..........................IL 244 Craniology............................................................II 73 of criminals.......................................................H_ ig3 INDEX. 691 PAGE Cretinisai..............................................................IL 85 Crime, deaf-mutism and.................................................IL 190 imbecility and.......................................................IL 189 inherited and insane tendencies.......................................IL 182 insane impulses toward..............................................IL 48 intoxication as an excuse for.........................................IL 205 responsibility of children for.........................................IL 184 sexual..............................................................IL 525 signs of degeneracy..................................................IL 184 Criminal, âge of........................................................IL 185 assaults.............................................................I. 33 craniology and skull capacity of......................................IL 183 légal relations of physicians and surgeons to...........................I. 636 lunatic.............................................................IL 182 Criminal Responsibility (see Responsibility).............................IL 217 Croton Oil.............................................................I. 471 Cutaneous Anjesthesia.................................................IL 339 Daravinian Tubercle...........................................I. 70 ; IL 73 Datura Straaionium.....................................................L 427 Deadly Nightshade.....................................................L 424 Deaf-mutes, mental capacity of..........................................IL l->^ deaf-mutism and crime...............................................IL 190 feigned deafness.....................................................IL 408 Death, autopsies, government régulation of................................L 57 causes of, médical 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 décomposition and putréfaction.......................................I- 99 adipocere, formation of.............................................I- 1 ()4 chronological order of..............................................I- 115 external appearances of.............................................I- 107 mummification and saponification...................................I- 105 détermination of......................................................I- ;)8 drowning, death by...................................................I- 8h appearance of mucous membrane....................................I- 102 asphyxiation.......................................................I- 1-0 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- 1°2 effect of température on décomposition...............................L 103 effusion of fluid into cavities........................................I- 102 fluidity of the blood after death.....................................I- 99 injuries to body in running water....................................I- ! 29 internai examination...............................................I- 123 nature and depth of fluid............................................I- l30 paleness of the body................................................I- 121 pulmonary apoplexy and neuro-paralysis.............................L 121 putréfaction, pressure of gases evolved in............................L 100 putréfaction after drowning.......................................L 99 692 INDEX. PAGE Death by drowning, relation to life insurance..............................I. 586 situation of the tongue..............................................I- 122 water in lungs and stomach.....................................I. 100, 126 whether the resuit of accident, suicide, or homicide...................I. 128 due to violence.......................................................L ~>* electricity, death by..................................................I. 134 frost erythema.......................................................L 97 gravitation of blood in capiiïaries after.................................I. 96 hanging aiul strangulation, death by...................................I. 116 accidentai..........................................................I. 120 appearance of body..'...............................................I. 118 occurring before or after death......................................I. 117 suicidai............................................................I. 116 beat or cold, death by................................................ I. 131 burning, conséquences 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 accidentai or voluntary altérations...............................I. 193-196 âge..............................................................I. 64-66 anthropological aids...............................................L 59 cases, Whitechapel murders......................................L 61, 75 Tichborne claimant..........................................L 71 cicatrices......................................................... I. 72 Darwinian tubercle................................................ L 70 deformities........................................................ L 72 features, gnathic index.......................................... L 60 70 hair, color and eharaeter of........................................L 70 diameter of.................................................. L 74 human and animal............................................ L 74 nose..............................................................L 61 occupation during life.............................................. I_ 73 photography, value of................_..............................I 59 race characteristies.............................................. I gg scars..........................................................I -1 sex, of mutilated or decomposed bodies............................. L gi of skeleton............................................... j g^ stature................................................... I gg and size of races...................................... I gQ figure carré for determining.......................... I gg length of fémur as determining......................... j q$ Orfila's and Sue's tables.................................1 68 69 tables of détails to be noted in identification......................... L 75 teeth, development of................................ j gy tattoo marks......•.................................. t -o medico-legal aspects of................................ j ^- period at which occurred.............................. j gg poisoning, death from, by illuminating-gas.................... .1, 97 INDEX. 693 PAGE Death, septica?mia, death from........................................... I. 9u sign* of...........................................................I. 87, 91 changes in the eye ................................................I. 92 from narcotic poisoning............................................L 95 rigor mortis ................................................. L 93-95, 991 softening of muscles and tissues....................................L 93; starvation, death by.................................................L 134, baby-farming...................................................... L 137 faciès hippoeratiea................................................. L 137 Welsh "fasting girl "............................................... L 137 suffocation, death by, manner produced...............................I. 108 accidentai......................................................... L \\\ amesthetics, by....................................................I. 113; carbonic acid, by..................................................L 115. dynamical asphyxia by noxious gases...............................I. 113 homicide by...................................................L 111, 112 internai occlusion of air-passages................................... I. 111 post-mortem appearances of........................................I. 109 sewer-gas and sulphureted hydrogen................................ L 115 smoke, by........................................................ L 113 smothering, by.................................................... I. 111 vitiated air, by....................................................I. 112 suicide by carbone acid.............................................. I. S8 suspended animation, by........................................... L 88, 89 suspension of respiration, by.....................................I. 88 syncope, by.........................................................I. 88 tests showing.......................................................I. 95 Dewmposition (see Death and Post-mortem Examination).................I. 35 effects of température upon.......................................... I. 99 Delirium (see Insanity), acute...........................................IL 103 tremens.............................................................IL 95 Delusions (see Insanity).................................................IL 35 as a défense for crime...............................................IL 230 as betrayed in dress.................................................IL 39 as symptoms of insanity..............................................IL 40 associated with hallucinations........................................IL 39 ease of, in paranoia..................................................IL 36 concealed...........................................................IL 42 définition of.........................................................IL 35 erotic...............................................................II. 44 fixed................................................................II. 42 formation of........................................................II- 39 genesis of...........................................................IL 40 persecutory.........................................................IL 41 religious............................................................II- 35 case of............................................................IL 43 sane or insane...................................................IL 35, 234 Swedenborg's and Luther's...........................................IL 39 systematizeel or unsystematized.......................................IL 39 Dementia f see Insanity).................................................IL 46 acute...............................................................IL 10» 094 INDEX. PAGE Dementia, forms of.....................................................II- 1'ls paretic..............................................................IL H" illusions due to paretic dementia....................................IL 3.) primary.............................................................IL 109 senile..............................................................H- 109 Dentists, professional standing of, before the law.........................I. 643 1 )etection of metallic poisons............................................ L 54 Deatelopmental Ugliness...............................................IL 86 Diathesis, insane.......................................................IL 49 Digitalis, digitalin, digitonin, digitoxin, digitalein........................ I. 463 Diploma as showing qualification of physicians and surgeons............... I. 637 Disease. Bright's........................................................ L 537 cold................................................................ L 540 consumption........................................................ I. ~>'-■ ' elyspepsia........................................................... L 534 eye, diseases of the.................................................. I. 539 fits.................................................................L 534 headaches........................................................... I. 540 heart disease.............................'........................... I. 535 hemoptysis.......................................................... I. 532 in relation to life insurance (see Insurance)............................ I. 493 liver, disease of the.................................................. I. 53s mastoid............................................................IL 612 narcotics............................................................ I. 551 opium.............................................................. I. 551 rheumatisni......................................................... I. 536 the resuit of accident................................................ I. 5S5 tonsilitis............................................................ I. 53* Dislocations (see Wounds).............................................. I. 294 Distress (see Mental Distress)...........................................IL 3*5 Divorce (see Marriage and, Insanity and). by consent..........................................................IL 522 causes for, adultery..................................................IL 522 arising after marriage..............................................H, 521 before marriage............................................IL 520 cruelty............................................................IL 521 désertion..........................................................IL 522 habituai drunkenness..............................................IL 522 ill treatment.....................................................IL 52 ] impotence................................................IL -497-503, 520 insanity......................................................IL 133, 521 cases of....................................................IL 133-136 loathsome diseases.................................................II. 522 gonorrhea ......................................................II. 505 syphilis.........................................................IL 509 conelonation and récrimination as défenses............................IL 523 procédure...........................................................H. 519 testimony in divorce suits............................................U. 523 Dreaming..............................................................II. 51 Drowning (see Death)................................................... I h> Drunkards, habituai (see Insanity)......................................H. 150 INDEX. 693 PAGE DrTY of médical examiners for insurance companies ...................... I. 509 of physicians and surgeons as to contagious diseases................... I. 633 gonorrheal disease....................IL 508 Dyslexia.............................................................H 272 Da'Spepsia as affecting insurance.......................................... I. 534 Eating of human flesh (see Insanity).....................................IL 49 JOccentuicity as affecting testamentary capacity...........................IL 119 Kcciiymosis (see Post-mortem Examinations and Wounds)..............I. 35, 244 Echolalia (see Insanity)................................................II. 74 Electric Curkents of high power........................................II. 363 bibliography.........................................................H. 37g death from.................................................I. 134 . n. 367 autopsies.........................................................II. 309 cases........................................................II. ;ir)s, 3G9 effects of, upon the human body..................................... IL 304 charges that do not kill............................................IL 305 cases.......................................................II. 3G5-367 electric burning and case of. ,........................................IL 371 falls and other injuries due to........................................IL 371 médical electricity, accidents from....................................IL 372 récent légal décisions................................................IL 373 Augusta Railway Co. vs. Andrews..................................IL 374 Burt vs. Douglas County Street Railway ............................IL 373 Cléments vs. Louisiana Electric Light Co............................IL 373 ( 'olorado Electric Co. vs. Lubbers..................................IL 374 Electric Raihvay Co. vs. Shelton....................................II. 375 Krantz vs. Brush Electric Light Co..................................IL 374 Piedmont Electric Illuminating Co. vs. Patteson's Administrator.....IL 375 Southwestern Telegraph and Téléphone Co. vs. Robinson............II. 373 Embalming as affecting putréfaction..................................... I. 104 Eaibolism, fat, as a mishap of surgieal practice........................IL 585, 605 Emotion, disturbances of................................................IL 4.8 Empyema..............................................................IL 014 Epididymitis and crime................................................IL 199 and idiocy..........................................................TI. 188 aiul imbecility......................................................IL 200 and violence........................................................IL 200 as a cause ôf sterility................................................IL 504 defined.............................................................IL 199 epileptie insanity...................................................IL 93 feigned ........................................................IL 200, 399 morbid states after convulsions.......................................IL 93 Epilepsy..............................................................IL 223 and aphasia.........................................................IL 284 Epithelrai from vagina (see Blood-stains)...............................I. 180 Erythema, frost (see Death anel Post-mortem Examination)................I. 97 Erythroxylon Coca...................................................I. 428 Ether, hydrobromic (see AiiEesthetics anel Surgieal Practice)...............II. 603 Ethylidendiamin and ethylendiamin.....................................I. 491 ErsTACiitAN Tube, catheterization of.....................................IL 612 Examtnation, expert................................... ................I. 591 696 INDEX. PAG F, Examination, expert, in indécent assault.................................I- 6->o of insane criminals..................................................II- 213 physieal, in accident cases..........................•.................II- 377 post-mortem........................................................!• -' Examining Boards, diplomas of physicians and sm-geons from.............I. 598 Excise Laws. relations of physicians and surgeons to...................... L 638 Experiaients on effects of ptomaïnes..................................... I- 485. Experts, médical....................................................... IL 13 avowal of non-expertism.............................................II- 14s compensation of............................................L 614 ; IL 149 criminal cases or de lunatico inquirendo............................II- 15, 148 duties and responsibilities of......................................II- 13, 148 English laws regarding..............................................H- 13 évidence, in surgery cases...........................................H- 574 value of...................................................II- 1 " examination of applicants for insurance...............................I- 591 plaintiff in accident cases.............................IL 377 hypothetical questions............................................IL 15, 148 impartiality of......................................................IL 148 qualifications of................................................IL 148, 177 questions for, in accident cases......................................IL 377 infanticide cases.......................................IL 479= use of books in court................................................IL 149- Extraa'asation (see Wounds)............................................I. 298 E\'E, diseases of, as affecting insurance.................................... I. 539- feigned............................................................IL 406 hysterical blindness................................................IL 407 Faciès Hippocratica................................................... I. 137 Fées, of médical experts.........................................I. 614 ; IL 149 of physicians and surgeons...................................I. 604, 608, 614 Feigned Diseases of the mind and nervous system........................IL 391 insanity............................................................IL 410 difficulty of feigning...............................................IL 411 spécial signs justifring suspicion...................................IL 413 instruments for deteeting............................................IL 391 manlingering.......................................................IL 392 danger to manlingerer........................:....................IL 39g motives for, and frequency of....................................IL 39l? 392 paranoia, paretic dementia, and dementia........................IL 413, 414 pension-office statistics..............................................IL 392 rules for deteeting..................................................IL 395 simulated motor symptoms and methods of détection, paralysis.........IL 397 convulsions, epilepsy..............................................II. 399 contracture, catalepsy.............................................IL 401 tremor, ataxia, chorea.............................................IL 402 simulated sensory symptoms and methods of détection, anaesthesia......IL 403 blindness, hysterical blindness.................................U. 406 407 hemeralopia, color-blindness........................................II. 408 hyperœsthesia and pain............................................jj. 405 speech disturbances...............................................IL 410 symptoms most easily feigned........................................IL 414 INDEX. 697 PAGE Feigned Diseases, etc., symptoms impossible to feign......................IL 395 deliberately produced...................IL 396 genuine, cause feigned..................IL 396 Fetichism, body, and cases...............................................II. 567 ^'ess...............................................................II. 568 cases.............................................................II. 569 erotic ..............................................................IL 566 Fibers (see Hairs)...................................................... I. ; *7 Finger marks (see Post-mortem Examination)............................I. 32 impressions (see Identity)............................................ I. 534 Fistula, lacteal........................................................IL 614 Fits as affecting insurance...............................................L 534 Folie à Deux...........................................................IL 95 Folie Circulaire.......................................................IL 91 FOXGLOA'E...............................................................I. 463 Fractures (see Wounds and Surgieal Practice)............................IL 573 amputations........................................................IL 621 anchylosis..........................................................II. 621 contractures........................................................ IL 621 deformities following................................................IL 614 extremities..........................................................IL 614 gangrené following..................................................H. 617 hip disease in children...............................................IL 619 injuries of hip-joint..................................................IL 618 lower end of radius..................................................IL 616 near elbow..........................................................IL 615 neck of humérus....................................................IL 615 resection of knee....................................................IL 620 tenotomies and myotomies...........................................IL 621 wounds and fractures................................................ I. 290 Frost Erythema....................................................... I. 97 Fugin..................................................................I. 492 Gadinine................................................................I. 492 Gelsemium, gelsemine, gelsemic acid, gelsemin, gelsemia...................I. 434 General Paresis, alcoholic (see Paretic Dementia)........................IL 97 Genito-urinary and venereal affections...................................IL 497 gonorrhea, urethritis.................................................IL 505 duty of physician advising marriage................................IL 508 effects of, in producing sterility....................................IL 508 upon offspring...........................................IL 508 upon relations of sexes during marriage....................IL 507 gonoeoccus.......................................................IL 505 modes of infection.................................................IL 505 impotence in the maie................................................IL 497 diseases of the kidneys, bladder, etc.................................IL 502 glycosuria.........................................................IL 501 malformations.....................................................IL 498 masturbation......................................................IL 502 mental conditions.................................................IL 500 impotence in the female..............................................IL 502 hvsteria..........................................................IL 503 698 INDEX. r.\<;K CENrro-riiiNAUY, etc., impotence in the female, imperforate hymen.........IL 503 malformations....................................................II- '">"- vaginisinus........................................................H- ;)0-> sterility in the maie..................................................II- •),,-> blocking of vasa deferentia.........................................H- ;^"4 epididymitis......................................................II- 504 sterility in the female................................................II- ;)01 absence of ovaries.................................................II- ;)"1 acidity of sécrétions...............................................II- •~)^'v surgieal practice and malpractice.....................................IL 62.> abscess of testicle.................................................IL 628 castration........................................................II. 628 catheterization and other methods...................................II. 62f> permanent.........................................IL 627 circumeision.......................................................IL 627 hydrocele.........................................................IL 627 vesical calculus.................................................. IL 62* syphilis.............................................................IL 509 Colles's law.......................................................IL 514 congénital and acquired...........................................IL 510 ground for divorce................................................IL 513 infection from choc en retour....................................... IL 512 intermittence of lésions............................................IL 514 niiscarriages as évidence of.........................................II. 514 modes of infection.................................................IL 509 GoNococcrs............................................................IL 505 présence of, in objects of râpe.......................................IL 536 Gonorrhea (see Genito-urinary and Venereal Affections)..................IL 505 Grtbelsucht (see Insanity).............................................IL 44 GrxsiiOT AAtounds (see Wounds and Surgieal Practice)............I. 252 ; IL 607 Habitual Drunkards, mental capacity of................................IL 152 cases...........................................................II. ] 52-158 H.ematin ... .......................................................... I. 141 H.k.min.............................................................L 158, 162 ILe.moglobin...................'......................................... I. 140 Hairs and Fibers..............................................I. 70-74, 195, 196. body, hair from human.............................................. I. i sy diameters and markings of....................................... I. 187-189 found upon weapons................................................. I. 1x7 microscopical appearance of..........................................I. i ys silk, wool, fiax....................................................... I. i ^9 Hallucinations......................................................II. 30 auditory............................................................H. 31 définition of............................................. .........II. 3(1 due to alcohol, belladonna, Cannabis Indica, hypnotic suggestion......IL 33 solitarv confinement..........................................H. 33 forms of insanity in which hallucinations appear ......................IL 34 found alone and together ...........................................H. 33 historical examples of...............................................H. 33 mechanism of.......................................................H. 30 of feeling.........................................................H. 30 INDEX. 699 PAGE Hallucinations, olfactive...............................................H. 32 sensorial disturbances...............................................IL 32 unilatéral...........................................................IL 31 visual..............................................................IL 30 Halogens, the.......................................................... I. 333 Handwiuting, insane, change in eharaeter of............................IL 74 Hanging (see Death by Hanging)......................................... I. 116 Harelip (see Surgieal Practice).................^........................IL 609 Headache as affecting insurance......................................... I. 540 Health, in relation to insurance ................................... I. 511-51 > family record....................................................... I. 554 habits as affecting................................................... I. 541 occupation as affecting.............................................. I. 556 sound............................................................. I. 519 tables of mortality, etc.........................I. 511, 512, 530, 550, 551, 557 wholly disabled..................................................... I. 587 Hellébore............................................................. I. 460 Heaieralopia, feigned..................................................IL 408 Hemlock............................................................... L 432 Hemophiliacs..........................................................IL ô^\ Hemoptysis as affecting insurance........................................ L 532 Hemorrhage as a mishap in surgieal practice..............................IL 580 Henbane...............................................................L 427 Heredity, as a cause of insanity.........................................IL 58 of criminal instinct..................................................IL 59 Hermaphrodite........................................................IL 41 s Hernia (see Surgieal Practice)............■...............................IL 623 cure of..............................................................IL 624 disturbances following opérations....................................IL 625 hysterical atony simulating..........................................IL 624 Hip Disease in children.................................................II. 619 History of life insurance.............................................. I- 493 Homicide (see Death, Post-mortem Examinations, Wounds, etc.). by drowning....................................................... I- 128 suffocation...................................................I- 1H,H2 defined............................................................. I- 243 Ha-drocele............................................................II- 621 Hydroparacumaric Acid..............................................• L 4*9 Hymen, anatomical changes induced by coitus............................IL 52.8 imperforate, as cause of impotence...................................IL 503 Hyoscyamus, hyoscyamine, hyoscine..................................... L 427 Hyperaesthesia Sexualis..............................................II- 55~ Hypnosis and auto-hypnosis in cases of râpe..............................IL 541 hallucinations due to................................................II- 33 hypnotic influence...................................................II- 212 illusions due to......................................................H- 35 Ha'pothetical Question (see Expert)....................................II- 14s HYSTERIA (see Insanity).................................................H- 93 II 211 cases ............................................................... hysterical atonv simulating hernia....................................H- 624 insanity..................................................H- 209 700 INDEX. PAGE Hysteria, mercurial.................................................... I- ^99 responsibility.......................................................II- 210 Identity op the Dead Body (see Death)..............................L 32, 59 détermination of..................................................I- 60- < 3 Identity op the Living................................................ I- ] !>1 accidentai or voluntary altérations in appearance.....................I- 1 93 âge, détermination of...........................................I- 64, 194 ■cicatrices.....................................................I- 171, 193 deformities.....................................................I- 72, 193 disease, effects of..............................................I- 193, 194 finger-nails........................................................ I- 196 hair, changes in.................................................. I- 195 classification of.............................................. L 196 décoloration of............................................... L 196 head, configuration of............................................. I- 19.) insanity, results of................................................ L 193 labor, manual or other, signs of.................................... I. 193 loss of limbs, teeth, or hair........................................ I. 193 pigment bleaching.................................................. I. 193 teeth............................................................. L 195 trophic changes................................................... I. 193 finger and foot impressions.......................................... I. 2<)4 Galton's method................................................... I. 206 right- and left-handedness......................................... I. 207 significance of footprints................. ........................ I. 2u0 gênerai appearance.................................................. I. 21s handwriting, identification by means of............................... I. 203 history and expériences.............................................. I. 228 iiicriminating circumstances......................................... I. 228 mental traits....................................................... I. 226 mistaken identity..............................,..................I. 30, 191 récognition by pistol-flash.......................................... L 191 physieal peculiarities................................................ L 221 skin lésions and their results......................................... I. 200 cicatrices.......................................................L 72, 201 âge of................................................... I. 202 diseases, évidences of............................................. I. 200 indelibility of marks.............................................. I. 2o2 tattooing.......................................................L 72, 2* i2 stigmata of occupation............................................I. 73( ] 97 hands............................................................. L ] 9s récognition of changes due to occupation............................ L 19s suggestions as to examination........................................ L 207 Bertillon's methods................................................ L 208 Smart's and Greenleaf's methods................................... I. 211 unreliability of évidence............................................. L 192 Tichborne case.................................................I. 71 ; 190 Idiocy, acquired.........................................................IL su and alcoholism......................................................II. su and epilepsy, and paralysis...........................................IL 1 s.s and heredity........................................................IL LS8 INDEX. 701 PAGE Idiots, basis of mental expression of..........___........................IL 84 craniology of........................................................IL 81 defective brain development of.......................................IL 188 mental capacity of...................................................IL 84 microcephalous......................................................IL 80 palatal arch, deformity of............................................IL 81 physieal peculiarities of..............................................IL 80 prognathism........................................................IL 81 sexual anomalies in..................................................IL 85 speech of...........................................................IL 84 suture, prématuré closing of..........................................II. 81 Illusions (see Insanity).................................................II. 34 définition of........................................................II. 34 differentiation of....................................................II. 34 due to alcohol.......................................................IL 35 confusional insanity...........................................IL 35 hypnotic suggestion............................................IL 35 paranoïa IL 35 paretic dementia.............................................IL 35 Imbecility (see Insanity)................................................IL 85 Imperative Concepts (see Insanity, Morbid Impulses).....................IL 44 cases of ...........................................................IL 45 Iaipotence (see Genito-urinary)..........................................IL 497 Impulse (see Insanity). maniacal.......................................................... H- *-ou morbid.............................................................H- 49 cp'vili^l ...«.....................,.«•••••>••..............-L.L. *x*J uncontrollable..........................................H. 44, 188, 191, 243 Incest (see Sexual Crimes)..............................................IL 547 anomalous psychicàl state leading to..................................H- ;)48 defined.............................................................IL 547 origin of aversion to...............................................H- 54° punishment of.....................................................H- o4" Indécent Assault upon children.........................................I- 649 accused (the) of.................................................._■ ■ ■ L 652_ âge of consent..............................................L 651 ; IL 52o définition of......................................................... L 649 examination......................................................... • "•>•> false accusations....................................................I- 6o3 légal aspect of...................................................... L 649 penalty for.................................'•...........'............L 6yl F .; , .............. I. 653 seventy ot................................................. ... » ...... .........I. 651 varieties ot............................................. Indécent Exposure (see Sexual Crimes)..................................H- 5o° T 489 INDIGO-BLUE.............................................................1- *°^ Indol, indoxyl, indirubin................................................ I- 4^' Infanticide (see Abortion).........................................H- 467> 4'9 criminal causes of death............................................H- drowning.........................................................IL 493 fracture of skull...................................................IL 494 , . .......................IL 495 neglect. . •■............................................... 702 INDEX. PAGK Infanticide. Criminal causes of death : précipitation into a vault...........................................IL 493 strangulation....................................................IL 492 suffocation.......................................................IL 491 wounding.........................................................IL 494 defined.............................................................IL 479 natural causes of death in new-born...................................IL 48s accidents and injuries..............................................IL 490 asphyxia..........................................................IL 48!) fetal disease.......................................................IL 4S9 malformation......................................................IL 4ss maternai disease...................................................IL 491 questions for expert..................................................IL 479 air in alimentary canal.............................................IL 486 artificial insufflation...............................................IL 484 atelectasis........................................................IL 485 cardiac movements................................................IL 4S6 child, cause of death...............................................IL 488 has it cried..................................................IL 485 how long been dead..........................................IL 487 how long did it live..........................................IL 480 was it dead or alive at birth..................................IL 482 was it mature...............................................IL 480 was it prisoner's.............................................IL 482 hydrostatic test....................................................IL 483 prisoner, has she been reeently delivered............................IL 480 pulmonary docimasia..............................................IL 485 putréfaction.......................................................IL 4S4 solidification......................................................II. 485 Wreden's test.....................................................IL 486 Inherited insane tendencies (see Insanity)................................IL ] so Inorganic Poisons (see Poisons).........................................I. 322 Insane, the. appearance and conduct of...........................................IL 73. appréciation of nature of act, etc., by.................................IL 232 appréhension or removal of...........................................IL 142 as witnesses.........................................................H. ] 37 attitude of..........................................................H 7g. capacity of, gênerai questions relative to..............................II. 114 bankruptey.......................................................H 137 cases...........................................................IL 137 breach of promise.................................................II 132 contracts.....................................................II. 128 172 cases...........................................................II 129 deaf-mutes........................................................H 15s delusions..........................................................H j ] s cases...........................................................II us disease...........................................................H J20 cases.......................................................U. 121-125 divorce and annulment.............................................H 133 eases.......................................................IL 134-136 INDEX. 7s Blodgett, habituai drunkard........................................H- 1°-' Boyd vs. Eby, medico-legal ; lucid interval..........................II- H •' Brady will........................................................IL 1] 7 brain tolérance to injury, New England blasting.....................H- 21 Brown vs. Howe, torts.............................................H- '* ' Brown vs. Riggin, will.............................................H- 1-2 Carter vs. Beckwith, contract.......................................H- 142 Cherbonnier vs. Evitts, will.........................................II- 122 delusions, insane..............................................II- 23.)-l41 Dickie, commission in lunacy.......................................II- 1-19 Dickinson vs. Barber, degree.....................................•.. IL 144 Dills vs. State of Indiana, expert fées...............................IL l->6 Ducker vs. Whitson, contract.......................................IL 130 Eddy will.........................................................H- 117 Fillmore, testamentary capacity....................................IL 262 Gerhold vs. Wyss, divorce..........................................IL 136 German courts, divorce........................................IL 133, 134 Gombault vs. Public Administrator, medico-legal ; lucid interval......IL 113 Greenwood vs. Klein, undue influence...............................IL 126 Guiteau, crime....................................................IL 198 hallucinations.....................................................IL 33 Hartwell vs. M'Master, testamentary capacity........................IL 120 historical heredity.................................................IL 58 Howe, torts.......................................................IL 143 Hurlehy vs. Martine, false imprisonment............................IL 147 hysterical.........................................................IL 211 imperative concepts................................................IL 45 insane motives....................................................IL 180 Johnson vs. Armstrong, testamentary capacity.......................IL 125 Jumel will, testamentary capacity..................................IL 118 Lancaster County Bank vs. Moore, contract..........................IL 131 Lee vs. Scudder, testamentary capacity..............................IL 125 Lewis vs. Lewis, annulment of marriage.............................IL 136 life insurance, recovery of.....................................IL 145, 146 Lilly vs. Waggoner, contract........................................IL 128 Mclntyre vs. Sholty, torts..........................................IL 143 McNaughton, " right or wrong " test............................IL 175, 218 McPherson, testamentary capacity..................................IL 113 INDEX. 705 PAGE Insanitv, cases bearing on : Manley's Executor vs. Staples, testamentary capacity.................IL 119 Marsh, testamentary capacity......................................IL 124 Marvin, bankruptey...............................................IL 137 Mordaunt, divorce................................................. IL 135 Murphy, bankruptey................................................IL 137 Newton vs. Mutual Benefit Life Insurance Co., insurance.............IL 147 O'Connor vs. Rempt, habituai drunkard.............................IL 157 paranoiac delusions................................................IL 89 Parish, testamentary capacity......................................IL 261 Patterson, habituai drunkard.......................................IL 141 People vs. Barber, mental responsibility.............................IL 233 Pomeroy, crime...................................................IL 86 Prentis vs. Bâtes, testamentary capacity.............................IL 119 puerpéral, and crime...............................................IL 103 Ravachol, crime...................................................IL 184 Rawdon vs. Rawdon, divorce.......................................IL 133 Riggin, testamentary capacity......................................IL 122 Rusk, contract....................................................IL 129 Setzer vs. Setzer, legitimacy........................................IL 133 Smith vs. Williamson, habituai drunkard............................IL 158 Summers vs. State of Texas, expert fées.............................IL 150 Wallis vs. Luhring, undue influence.................................IL 113 Watson, testamentary capacity.....................................IL 117 Weitzel, bankruptey...............................................IL 137 Wightman vs. Wightman, marriage.................................IL 172 Williams vs. Goss, habituai drunkard................................IL 152 Young vs. Young, divorce..........................................IL 153 causes of: alcoholism........................................................II. 59 Bright's disease....................................................IL 60 cardiac lésions....................................................IL 60 child-bearing and illegitimate pregnancy..........................IL 60, 61 cocaine, chloral, or opium habits...................................IL 59 depletion.........................................................IL 60 direct and indirect.................................................IL 59 emotional.........................................................IL 59 environment......................................................IL 59 excessive sexual excitement........................................IL 61 feigning..........................................................II- - 61 fright.............................................................IL 61 grief..............................................................n- 61 heredity. historieal cases...........................................IL ->8 injuries to the brain...............................................IL 61 intracranial discase................................................IL 62 la grippe..........................................................IL 60 masturbation......................................................H- 60 overwork.........................................................H- 59 phthisis...........................................................H- 60 predisposing...............................•......................II- 59 rheumatisni.......................................................II- 60 70G INDEX. PAGE Insanity, causes of : septic poisoning...................................................IL 61 shock.............................................................II. 61 syphilis...........................................................IL 59 utérine and ovarian disease........................................IL 60 classification of......................................................IL 54 convulsions in.......................................................IL 78 course and termination of............................................IL 62 craniology of........................................................IL 73 curability of.........................................................IL 62 cutaneous anaesthesia in.............................................IL 7H death from exhaustion in.............................................IL 02 y> définitions of, légal...............................................IL 53, 178 médical, by Bucknill...............................................IL 53 Hamilton...........................................H. 'A, 5(5 Maudsley...........................................IL 53, 57 Spitzka...............................................II. 53 Von Krafft-Ebing......................................IL 55 delusional (primary)..................................................IL 86 drunkards, habituai..................................................II. ; ,->2 epileptie.........................................................IL 93, 223 epochal.............................................................H -,-, expert witnesses................................................H. 113j ]48 case, Dills vs. State of Indiana......................................H. 150 feigned.............................................................n. 410 hallucinations.......................................................U. 30 heart failure in......................................................H (53 heredity as a cause of................................................H 5s inherited tendencies...............................................H. ; ^>> of criminal instinct.............................................jj gg homicidal...................................................... jj 45 hypnotism..........................................................TT 2l 2 hallucinations due to........................................... jj 00 illusions due to......................................... jt 3- hysterical.................................................n. 4S -)()< 9;j 2(l!) la grande hystérie....................................... jj rmo responsibility of hystérie................................... jt 01 n insane tendencies in...................................... jt , kq intellectual............................................. jj sf. lucid intervals in...................................... jj 00„ mania.......................................................... IL 93, ÏÔÔ mattoids............................................ jj -., medico-legal aspects of.................................. jj -,() commission on \ commitment of (see Insane). committee of estate of * légal définitions ; gênerai................................ jj 53 1 -s degree of insanity................................ j j ' , ,, English décisions....................................... jj j-0 German décisions.................................... jj -, -^ judge's charge................................... jj -, _s INDEX. 707 PAGE Insanity. Légal définitions, etc. : of lucid intervais, non compos mentis,unsoundness of mind..........IL 113 province of the court............................................IL 54 médical définitions............................................. IL 53-57 médical expert....................................................IL ] 13 megalomania........................................................H. s7 melancholia..................................................U. 69, 98, 191 memory, affections of..............................................IL 40, 47 monomania.........................................................II. $q moral..........................................................H 200 252 morbid desires....................................................IL 49 50 morbid impulses............................................II. 180 191 242 imperative concepts...............................................IL 44 cases of.........................................................IL 45 neurasthenia........................................................IL 211 paranoia............................................................H. s0 paretic dementia.....................................................IL 69 partial..........................................................II. 113, 224 periodical...........................................................IL 91 physieal signs of :...................................................IL 70 bones, brittleness of...............................................IL 79 brain, appearance of convolutions of................................IL 67 asymmetry of....................................................IL 67 atrophy of.......................................................II. os configuration of..................................................IL 65 hypersemia of...................................................IL 68 increase in size of...............................................IL 68 lésions of the blood-vessels of....................................IL 68 meningeal inflammation..........................................IL 69 microcephalous (Ireland).........................................IL 67 morbid anatomy of, in acute mania, melancholia, and paretic de- mentia .......................................................IL 69 spécifie gravity of...............................................IL 65 weight of.......................................................IL 05 in imbéciles and idiots.................................IL 66 digestion and appetite.............................................IL 79 ear...............................................................IL 78 eye...............................................................IL "8 sécrétion of tears................................................IL 79 face, expression and furrows in.....................................IL 73 skin in............................................................IL 97 teeth in...........................................................IL 73 température in....................................................IL 7!) tendinous réflexes in...............................................IL "8 microscopic appearances of nervous tissue........................IL 69 trophic disorders in................................................IL 79 urine in...........................................................IL 79 post-febrile.........................................................IL 107 after typhoid......................................................IL 108 prognosis of.........................................................IL 63 puerpéral, and cases.................................................IL 103 708 INDEX. PAGK TT 88 Insanity, querulent..................................................... reasoning............................................................ somatic............................................................. ,>,) speech disturbances associated with aphasia...........................IL -s-> suicidai............................................................. symptoms of, favorable and unfavorable (tabulated).................IL 64, 6o J V > ' TT <>9<) total................................................................u- "- traumatic...........................................................IL 10^ after surgieal opérations...........................................H- 1°' due to slight shocks................................................n- 10^ loss of memory in.................................................IL I" ' traverse IL 142 application for....................................................H- *■'*'* case, Baker es. Baker..............................................II- 1"*- ('erriiektheit, primare................................................LL °6 sensorielle.........................................................IL 34 Insanity and Annulment of Marriage (sec Insane, capacity of)...........IL 135 marriages contracted in extremis......................................H- 13.) cases, Lewis vs. Lewis.............................................IL 135 Bell vs. Bennett.............................................LL 136 Insanity and Bankruptcy (see Insane, capacity of).......................IL 137 cases, Marvin, Murphy, Weitzel......................................II- 137 Insanity and Breach of Promise........................................IL 132 case, Harford ?\s-. Singleton...........................................H- 132 Insanity and Crime (see Crime and Responsibility)...................IL 175, 217 bibliography of......................................................II. 214 examination of insane criminals......................................IL 213 expert testimony regarding...........................................IL 177 heredity of criminal instinct.......................................IL .>8, 59 individual responsibility.............................................IL 213 insane criminals.....................................................IL 182 relationship between.................................................IL 1 76 spécial forms of insanity in relation to crime..........................IL 184 alcoholism................................................IL 59, 123, 205 epileptie insanity..................................................IL 199 Guiteau case......................................................IL 198 moral insanity....................................................IL 200 paretic dementia..................................................IL 202 toxic insanity.....................................................IL 205 Insanity and Divorce..............................................IL 133, 521 cases : Banker vs. Banker............................................IL 133 Gerhold r*. Wyss..............................................IL 136 Lewis vs. Lewis...............................................IL 136 Mordaunt.....................................................IL 135 Rawdon vs. Rawdon...........................................IL 133 Setzer vs. Setzer..............................................IL 134 décisions of German courts regarding.............................IL 133, 134 innocently acquired insanity..........................................IL 134 laws of German Protestant Chureh....................................IL 134 plea of non-support..................................................IL 136 Insanity and Legitimacy...............................................IL 133 INDEX. 709 PAGE Insanity and Life Insurance...........................................IL 145 cases : Baron von Lindenau..........................................IL 145 Legrand du Saulle's...........................................H. ]4<; Newton vs. Mutual Benefit Life Insurance Co....................IL 147 Insanity and Marriage.................................................II. 131 capacity to consent to marriage.......................................IL 518 Inspection, medicodegal (see Post-mortem Examination).................. I. 25> Insurance : accident insurance and benefit associations............................I. 583S " accident " defined................................................I. 5s:; bénéficiai societies.................................................I. 5x7 spécial statutes regarding them...................................L 588 death from drowning as an accident................................. L 586 disease the resuit of an accident.................................... I. 5S5 injury without visible sign.......................................... I. 5S7 négligence........................................................I. 5x7 poison............................................................I. 5sg " wholly disabled ''.................................................L 587 life insurance....................................................... I. 493. history of........................................................ I. 493 (a) légal features.................................................. I. 49s answers, incomplète and omitted.................................. L 504 superfluous................................................... I. 506 beneficiary...................................................... I. 506 cases.....................................................I. 507, 508 warranties and représentations................................... I. 498 cases.....................................................I. 499-504 (b) medico-legal relations to........................................ I. 509 disease, freedom from............................................ L 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 rheumatisni...................................................I. 53G tonsilitis...................................................... I. 538. family record.................................................... I. 554 habits.......................................................... L 541 médical attendance.............................................. I. 514 médical examiner................................................ I. 510 mortality (see Tables)...........................................I. 511 narcot i es........................................................I. 556 opium habit..................................................... L 551 other insurance................................................. I. 562 710 INDEX. PAGE Insurance. Life insurance, medico-legal relations to : prior rejection................................................... I- ;)04 résidence.......................................................L -"'60 sound health.................................................... L 519 suicide......................................................... L •),) » (c) obligations of insured and insurer............................... L <>91 causes of death, inquiry into...................................... L ')(,3 expert examination.............................................. L ^ 1 relation of médical profession to insurance companies.............. I. ->91 (d) tables of actual and eomjnited rates of mortality................. L 511 of comparative mortality in tubercular and heart diseases . . I. 512 of deaths from consunqition.............................. L i>30 of mortality in différent occupations....................... I. 557 of relative mortality of intemperate persons................ I. 550 Intelligence, test of....................................................IL 20 Intoxication (see Alcoholism. Insanity)..................................IL 205 from fibrin ferment (see Surgieal Practice)............................IL 58.1 Iodine. potassium iodide.................................................I. 335 Iron, ferrie chloride. ferrons sulphate..................................... I. 413 Irregular Practitioner, disabilities of.................................. I. 602 Irritation, sexual......................................................IL 51 Isoamylamine.......................................................... I. 491 Jasmine, yellow......................................................... I. 434 Jervine................................................................ L 460 Katatonia.............................................................IL 51 Kleptomania...........................................................IL 102 Laws (see Courts and Cases). affecting benefit insurance coinj)anies................................. L 5ss autopsies, laws regulating............................................ I. 27 French and German Systems....................................... I. 57 capacity to know right from wrong...........................IL 178, 179, 231 charge of Chief-Justice Shaw.......................................IL 231 criminal liability for surgieal maljiractiee..............................IL 583 criminal, responsibility of............................................IL 217 defining insanity, unsoundness of mind, non compos mentis, lucid inter- vals...............................................II. 113, H4. 217, 222 Sir John Nicoll's opinion of lucid intervais...........................IL 114 divorce.............................................................IL 519 English. on médical exjiert...........................................IL 13 on sodomy.................................................II. 545 excise, relation of physicians and surgeons to.......................... L 63S expert testimony....................................................H. 14 French, on wills and testamentary capacity............................IL 266 German, on insanity and divorce......................................IL 133 German Protestant Chureh, on divorce................................II. 134 indécent assault..................................................... I. 64(1 légal procédures against surgeon, in eases of pregnancy, delivery, etc___IL 465 in commitment, etc., of insane.............................IL 138-142, 147 légal relations of physieians and surgeons to their patients and to one another......................................................... I. 595 abortion.......................................................... L (33-3 INDEX. 711 PAGE Laws. Légal relations of physicians and surgeons, etc. : a«ents............................................................ I. 611 contract and fées.................................................. I. 604 criminal offenses.................................... .1. 636 dentist, standing of................................................ I. 643 diploma, proof of.................................................. I. 637 duty as to contagions diseases...................................... I. 633 examining boards................................................. I. 59s excise laws................................................ . i. qs$ fées, contingent................................................... I 615 expert witness.................................................. I 614 who is liable for................................................. I. 608 grateful patients.................................................. I. 6.3,8 irregular practitioners, disabilities of............................... I. 596 législative restrictions............................................. I. 595 libel.............................................................. I. 640 license laws, médical, theory of..................................... I. 596 licenses........................................................ I. 59s malpractice (see Surgieal Practice).................................IL 583 médical societies.................................................. L 639 obligation to obey a call........................................... L 606 to record births.........................................IL 417 partnerships...................................................... L 635 pharmaeists, standing of........................................... I. 646 practice of medicine, what is proof of............................... I. 602 prescription, ownership of......................................... I. 636 professional confidences............................................ L 616 Carlyle Harris case.............................................. L 625 registration....................................................... L 600 sanctity of the patient's person..................................... I. 632 slander........................................................... I. 640 unprofessional conduct............................................ I. 599 waiver............................................................ I. 626 license laws, médical, theory and constitutionality of.................. I. 596 life insurance....................................................... I. 498 marriage............................................................IL 517 râpe.................................................................IL 525 Lead................................................................... I. 391 Lesbian................................1................................IL 50 Liability of custodians of the insane.....................................IL 147 Libel on physicians and surgeons........................................ I. 640 Licenses (see Examining Boards)........................................ I. 598 Life, accepted period of (see Death)...................................... I. 58 Life Insurance (see Insurance).......................................... I. 493 Lithotomy.............................................................IL 629 Liver, diseases of, as affecting insurance.................................I. 538 Lucid Intervals (see Insanity).....................................IL 113, 222 Sir John Xieoll's opinion of..........................................IL 114 Lust-murder..................................................•........IL 561 Magendie's Solution (see Morphine).................................... I. 440 Malingering (see Feigned Diseases).....................................IL 392 712 INDEX. PAG h Maltreatment of (he insane.............................................LL 1-*' Mania (see Insanitv)................................................H- 100> m acute........."......................................................H- 10(> chronic.........................................................H- 100, 102 course of............................................................H- 1 - defined.............................................................n- 193 recoveries in, j)ercentage of..........................................LL 103 removal of iiihibitory restraint........................................II- 1 •** sudden passion and frenzy in.........................................IL 19-1 synqdoms of........................................................IL 101 Manustupration.......................................................IL 0^'y Marriage, âge of consent...................................I- 651 ; IL 51 i, 525 capacity to consent..................................................II- 518 consummate...............................................II- 518 contracted in extremis.................................................IL 13o définition of.........................................................H- 517 disqualification from relationship.....................................H- 519 effect of disqualifications.............................................IL 519 paternity of children.................................................IL 519 physieal conditions rendering marriage invalid........................IL 427 imjjotence and sterility........................................IL 497, 504 in females..................................................IL 428-431 in maies........................................................IL 427 Mastoid Disease........................................................IL 612 Meadow Saffron....................................................... I. 430 Meconic Acid........................................................... I. 440 Médical, attendance in insurance cases................................... I. 514 case of Price vs. Life Insurance Co.................................. I. 514 compensation............................................... I. 614 ; IL 149 examiner in relation to insurance..................................... I. 510 attendance........................................................ I. 514 duties of.......................................................... I. 509 expert (see Expert)...............................................IL 13, 148 profession (see Laws, Légal Relations.of Physicians and Surgeons)......I. 595 relations to insurance.............................................. I. 591 societies............................................................ I. 639 testimony (see Expert)............................................IL 13, 148 as to cause of death in insurance cases.............................. I. 593 Medico-legal (see Laws)................................................ I. 595 aspects of death.....................................................L 57 inspection........................................................ I. 25 relations in insanity.................................................IL 19 in life insurance............................................ I. 509 MegaloMxVNIa ..........................................................IL 87 Melancholia (see Insanity)..............................................IL 98 agitata..............................................................IL 99 chronic.............................................................H. 100 crimes of............................................................IL 193 defined..........................................................IL 98, 191 delusions in.........................................................IL 100 dépression in........................................................IL 191 INDEX. 713 PAGE Melancholia, "désire tohang"..........................................IL 192 feigned.............................................................IL 410 hypochondriacal.....................................................IL 99 simple..............................................................IL 98 stuporous...........................................................IL 99 symptoms of.....................................................IL 98, 191 uncontrollable impulse in............................................IL 192 ■Memory (see Mind)......................................................IL 47 Ménopause.........................................................IL 418, 435 Menstruation......................................................IL 418, 431 menstrual blood-stains...............................................I. 179 Mental Defect and Disease in relation to criminal responsibility (see Re- sponsibility).....................................................IL 217 Mental Distress as an élément of damage................................IL 385 cases : Hamilton vs. Third Avenue R. R................................IL 385 Kennedy vs. Standard Sugar-refining Co.........................II. 386 Mclntyre vs. Giblin............................................IL 385 mère mental distress, cases...........................................IL 387 Lynch vs. Knight..................................................IL 387 Victoria Railway Commission vs. Coultas............................IL 388 sensé of shame......................................................IL 386 Mercury...............................................................L 396 Methylguanidine....................................................... L 491 Microorganisms in wound diseases (see Surgieal Practice)..................IL 589 Microscope, microscopic appearances of diseased nervous tissue in in- sanity.......................................................... IL 69 microscopic appearances of hairs and fibers...........................L 188 examination of blood-stains..............................I- 167 Microspectroscope (see Spectroscope)...................................L 143 Mind (see Insane, etc.)................................................II- 19; 28 apparatus of........................................................H- - ' localization of.....................................................II- - ' apperception of......................................................IL 1^ TT OQ concepts............................................................iX- delusions............................................................IL 30 feeling..............................................................TL L'S hallucinations.......................................................H- 30 TT °8 ideation.............................................................±Ll illusions............................................................IL 34 judgment...........................................................*L j* memory, affections of................................................lL 4b forgetfulness of substantives and proper names......................IL 47 lossof..............................................;.............IL 47 mental aberration, influence of, upon capacity of the individual.........IL 112 éléments, normal and diseased......................................IL 28 weakness.........................................................IL 29 relation of intelligence to complexity of nervous system................IL 20 sensation............................................................IL 28 TT ''8 thinking.............•......-...............#........................1X- unsoundness of......................................................H- -! volition.............................................................IL L'8 714 INDEX. pagi: Mistaken Identity (see Identity)..................................... I- 30, 191 Monk's-hood............................................................ I- Monomania (see Insanity)...............................................H- 's<) Moral Insanity (see Insanity).......................................IL -00. '-•>- defined.............................................................H- -m doctrine of..........................................................H- - * moral sensé.........................................................H- -01 Morbid Desires (see Insanity).................................'..........H- 4!l contrary sexuality. Lesbians, sexual pervert s, nymphomania, satyriiisis. .IL 50' eating human fiesh and fa-ces.. ;......................................H- 49 fear of poisoning.....................................................LL "*-' Morbid Impulses (see Insanity)..................................II- 1 ^°. 19L -"'- imperative concepts..................................................II- ^^ cases of.............................................•..............H- 4r> Morphine.............................................................. I- 4-l(-> habit...............................................................II- -°T insanity due to.............................>........................II- -05 Mortality (see Insurance).............................................. L ;,11 MUMMIFICATION......................................................... L 105 Murder (see Blood-stains, Crime, Death). cases : Billings, gunshot.............................................. L 263 Briggs, gunshot............................................... L 262 Budge (Mrs.), knife...............................L 249, 259, 273, 277 ( 'onimonwealth vs. Piper....................................... I. 169 Cramer (Jennie). arsenic....................................... I. 381 Grarfield, post-mortem examination.............................. I. 43 Guiteau, murder...............................................IL 198 Harris (Carlvle), professional confidences....................... I. 625 Heigham, shooting............................................ I. 254 Hughes, stabbing.............................................. I. 270 Klock, shooting............................................... I. 268 McXaughton, murder......................................IL 175. 218 Mallon, shooting.............................................. I. 271 Maybrick (Mrs.), poisoning................................ I. 357, 369 Mechanicsville, skull fracture.................................. I. 268 O'Shea. cutting................................................ I. 251 Pritchard, poisoning........................................... I. 343 Ravachol, murder..............................................IL 1 .-4 Riddle (Mrs.), poisoning....................................... I. 381) Shattuek, shooting...................................*......... I. 28 ] Sherman (Mrs. ), poisoning....................................L 3501 Steenbergh, contusions........................................ I. 275 Thompson, contusions......................................... I. -J7S Weston, cutting............................................... I. 260 Wharton, poisoning............................................ L 347 Whitechapel. identity of bodies...............................L 61, 75 Muscular Sexse, disturbance of.........................................IL 32 Mutism, feigned (see Deaf-mutism).......................................IL 409 Mydaleine............................................................. L 492 Mydatoxine............................................................ I. 492 Mydriatic Alkaloids.................................................. I. 421 INDEX. 715 PAGE Myotomi es.............................................................IL 621 Mytilotoxine.......................................................... I. 492 Narceine............................................................... I. 440 Narcotics as affecting insurance.......................................... I. 551 Narcotine.............................................................. I. 439 Nasal Index (see Identity).............................................. L 61 Négligence as affecting insurance........................................ I. 587 Neurasthenia..........................................................IL 211 as an excuse for crime............................................... I. 212 Neurine................................................................ I. 492 Nicotine, nicotin, nicotia, nicotina, Nicotiana Tabac u m..................... I. 437 Nitrous Oxide (see Aiuestheties and Surgieal Practice)...................IL 603 Non Compos Mentis (see Insanity, medico-legal)..........................IL 113 Nux Vomica...........:................................................ I. 447 Nymphomania...........................................................IL 50 Obligations, of insured and insurer......................................I. 591 of physician and surgeon to obey a call............................... 1. 606 Obstetrics (see Birth, Pregnancy, and Surgieal Practice)..............IL 459, 463 Ciesarean section...........................................IL 456, 459, 460 Occupation, as affecting insurance....................................... I. 556 as a due to identity...............................................I. 73, 197 Oil of Vitriol......................................................... L 329 Opium.................................................................. L 439 habit, as affecting insurance......................................... L 551 as cause of insanity............................................IL 59 Organic Poisons (see Poisons).......................................... L 415 Orpiment............................................................... L 387 Othjematoma...........................................................H- "^ Para, parakresol........................................................ I- 490 Paracentesis abdominis.................................................H- 623 Paradoxia sexualis......................................................II- 5o5 Par.esthesia sexualis.............................................. H- 5.)5, 559 Paralysis, feigned......................................................II- 397 Paranoïa, monomania, intellectual insanity, partial insanity, primary delu- sional insanity (see Insanity).................................IL 86, 195 and crime...........................................................IL 1^" east.s..............................................................IL 88-90 Guiteau...........................................................n- 198 defined.................•...........................................IL 19^ delusions (with).....................................................n- SJ_ of grandeur.................................•..............LL 197 of infidelity................................................n- 197 of persécution..........................................H- K~- I96 development of.................................-.....................H- s!) feigned............................................................. H. 413 hallucinations in.....................................................H- K[ illusions due to---,.................................................H- ,3° litigiosa, or querulent insanity........................................IL *% megalomania........................................................H- '_ reformatory.........................................................H- s ' sensorielle Verriicktheit.............................................H- S(J 71G INDEX. PAGE Paranoïa, monomania, etc., symptoms of................................IL s,) violence in..............................................»...........H- 1 ■' ' Paraphasias............................................................IL -()S Paretic Dementia, gênerai paresis, gênerai paralysis. paralytic dementia (see Insanity)....................'...........................H- HO. 2<)2 and crime...........................................................II- -°- apparent lucid intervals in...........................................H- 11 - ■convulsions in.......................................................II- Hl dementia in.........................................................H- 111 duration of..........................................................H- 11 - emotional state in...................................................IL m feigned.............................................................IL 413 moral weakness in...................................................IL 111 periods of remission in...............................'................IL 111 symptoms of....................................................IL HO, 2<»3 delusions of grandeur in...........................................IL 110 extravagance in....................................................IL 111 gait in............................................................IL 111 illusions in........................................................IL 35 pupils unequally dilated in.........................................IL 111 silliness in.......................................................IL 204 speech clumsy in..................................................IL 111 tremor in.........................................................IL 204 Partnership between practitioners....................................... I. 635 dissolution of, by reason of insanity..................................IL 144 Passivism and sexual perversion.........................................IL 564 Patoammine............................................................ I. 491 Pellagra.............................................................. I. 4SI i Pénis, rétraction of, in drowning......................................... I. 122 Periodical Insanity, folie circulaire, alternating insanity (see Insanity)___IL 91 Pharmacists, professional standing of.................................... I. 646 Phénol, phenyl hydrate................................................. I. 469 oxyphenyl-acetic acid................................................ I. 499 Phosphorus............................................................ I. 336 Piquers................................................................IL 4s Poison, by illuminating gas.............................................. I. 97 définition of......................................................... I. 321 as affecting insurance.............................................. I. 586 effects of a poison---,............................................ I. 321 true poisons....................................................... L 321 fear of (see Insanity)............................................;... H. 49 narcotic, signs of death in............................................ I. 95 Poisons, Inorganic..................................................... I. 30 ] alkalies and their salts............................................... I. 322 ammonia.......................................................... I. 324 analysis of...................................................... I. 326 caustic effects of................................................. I. 325 cérébral effects of............................................... I. 325 chemical analyses of............................................. I. 324 fatal doses of.................................................... I. 323 post-mortem appearances........................................ I. 323 INDEX. 717 PAGE Poisons, Inorganic. Alkalies and their salts : potash and soda.................................................I. 322 symptoms.......................................................I. 322 time of death....................................................I. 323 treatment....................................................... I. 323 antimony...........................................................I. 341 antimoniureted hydrogen........................................... I. 349 antimony chloride, butter of antimony.............................. I. 348 history of......................................................... L 341 préparation and properties of....................................... I. 342 séparation from organic material................................... I. 347 tests..............................................................I. 346 Wharton case.....................................................L 347 arsenic............................................................. L 349 amount necessary to prove poisoning................................L 381 amounts of, found in body.......................................... L 380 Jennie Cramer case..............................................I. 381 Riddle case..................................................... I. 380 détection after long periods........................................ I. 383 distribution in the body............................................I. 378 élimination....................................................... I. 382 examination of drugs, food, vomit, etc.............................. I. 377 history...................................................;....... 1. 349 aqua toffana................................................I. 350, 490 Sherman case...................................................I. 350 ice-cream poisoning................................................ I. 355 metallic arsenic................................................... I. 355 modem statistics regarding........................................ I. 351 accidentai deaths, New York City.................................I. 352 deaths from poisoning and from arsenical poisoning................ I. 351 occurrence in nature...............................................L 352 in the arts......................................... L 353, 388 possibility of distinguishing ante- from post-mortem arsenic.......... I. 385 séparation of, from the tissues...................................... L 377 soluble salts, Paris and Schweinfurth greens........................ I. 388 tests : for arsenic in pure solutions..................................I. 373 for arsenic in complex solutions..............................L 374 for solid arsenic.............................................L 372 arsenic acid, arsenates, arsine, arseniureted hydrogen, sulphides........ I. 386 arsenic in graveyards.............................................. L 353 in wall-papers and other fabrics.........................L 354, 388 arsenical poisoning................................................ L 361 acute and sub-acute.............................................. L 358 appearance of first symptoms..................................... I. 359 arsenic eating...................................................I- 368 Maybrick case................................................. L 369 cérébral or narcotic..............................................L 361 chronic cases of................................................. L 362 chronic symptoms after large doses and peculiar lésions............I. 365 dangerous and fatal doses........................................ I. 367 disturbances of sensation and of motion........................... I. 364 718 INDEX. PAliK. Poisons, Inorganic. Arsenical poisoning : illustrative cases................................................ L 30O poisoning by external application................................. L 367 post-mortem appearances of body................................. L 3 < 1 of organs............................... I. 3 < 1 prognosis and treatment......................................... L 367 symptoms....................................................... I. 36.J time of death................................................... L 359 treatment and antidotes......................................... L 370 trouble with digestion........................................... L 363 arsenious acid, " Rough on Rats "................................... I. 356 arsenious oxide, white arsenic..............,....................... L 356 poisonous symptoms............................................. I. 357 Maybrick case............................................ I. 357, 369 properties of.................................................... I. 356 copper.............................................................. I. 404 antidotes and treatment............................................ I. 407 eooking utensils of................................................ I. 404 cupric sulphate....................................................I. 406 dangerous and fatal closes.........................................I. 407 extraction of, from the tissues......................................I. 408 occurrence of, in nature........................................... I. 404 properties of...................................................... L 404 tests..............................................................I. 407 toxicology........................................................I. 404 verdigris..........................................................I. 407 halogens and their salts.............................................. L 333 bromine.......................................................... I. 334 potassium bromide.............................................. I. 334 chlorine.......................................................... I. 333 potassic chlorate................................................L 333 symptoms.......................................................I. 333 iodine............................................................ I. 335 potassium iodide................................................ I. 33g "'on................................................................I. 413 ferrie chloride..................................................... I. 413. effects upon man................................................ I. 413 fatal dose....................................................... I 4} 3 post-mortem appearances......................................... I. 443 ferrons sulphate, green vitriol...................................... I. 413. tests for iron......................................................I 444 lead................................................................ I. 391 acute poisoning....................................................I. 392 post-mortem appearances.........................................I 393 symptoms.......................................................I. 393 time of death...................................................j 303 treatment....................................................... I 393 cause of death.................................................... I 39g chronic poisoning..................................................I 394 blue line on gums................................................ I. 394 intestinal pains, colica pictorum..................................I. 394 INDEX. 719 PAGE sons, Inorganic. Lead, chronic poisoning : symptoms.......................................................I 394 excrétion of lead..................................................I. 395 how introduced into system.........................................L 391 location in tissue..................................................I. 395 properties as a poison..............................................L 391 separating lead from tissues........................................L 396 tests...............•..............................................I. 395 mereury............................................................I. 396 calomel, mercurous chloride........................................ L 400 chloride and bichloride............................................I. 400 fatal dose of.................................................... i. 401 post-mortem appearances........................................L 401 time of death....................................................L 401 treatment for................................................... I. 401 chronic poisoning.................................................. I. 39g corrosive sublimate, mercuric........................................ I. 400 effects, physiologieal and poisonous................................. I. 397 élimination of poison..............................................I. 400 external poisoning................................................. I. 402 mercurial hysteria................................................. I. 399 other irritant eompounds of........................................ I. 401 séparation from the tissues.........................................I. 403 tests for..........................................................I. 402 minerai acids.......................................................I. 330 aqua fortis........................................................I. 330 boracic and boric acid.............................................I. 332 chromic acid, chromic anhydride......................,.............I. 331 potassic dichromate..............................................I. 332 hydrocliloric acid.................................................. I. 329 distinction from other acids...................................... I. 330 muriatic acid......................................................I. 329 nitric acid........................................................ I. 330- poisoning by fumes of........................................... L 331 oil of vitriol.......................................................L 329 sulphuric acid..................................................... I. 326 external application.............................................I. 328 post-mortem examination........................................I. 328 symptoms.......................................................L 327 tests............................................................L 328 treatment....................................................... L 327 phosphorus.........................................................L 336 dangerous and fatal doses..........................................I. 339 poisoning by vapor of.............................................. L 339 neerosis of jaw from..................................... I. 339 vs. atrophy of liver.......................................I. 338 post-mortem changes..............................................I. 338 properties, physiologieal...........................................I. 336 poisonous....................................................... I- 337 symptoms......................................................... I- 337 tests.............................................................. L 340 700 INDEX. PAOK Poisons, Inorganic. Phosphorus : time of death...................................................... 1- '',,s treatment and antidotes............................................ I- ^)S dlver................. argentic nitrate...... chronic poisoning by. tests................ I. 411 I. 412 I. 412 I. 412 tartar emetic........................................................ x- °~f- chronic cases of poisoning by....................................... I- -!~H dangerous and fatal doses.......................................... I- 344 élimination of..................................................... I- °^') physiologieal effects, external...................................... I- 342 infernal............................................. I- 343 poisonous effects of ............................................... I- 343 post-mortem appearances........................................... I- 344 Pritchard case..................................................... I- 343 prognosis......................................................... I- 344 symptoms......................................................... I- 343 times of death..................................................... L 34.) zinc................................................................ I- 409 chloride.......................................................... L 4S physiologieal.................................................. I- 43.) treatment ...................................................... I- 438 veratrum, veratrine, and jervine.................................... I- 460 active principle of hellébore ..................................... I- 462 détection of the poison........................................... L 462 in contents of stomach........................................L 462 in tissues.............................^......................L 463 fatal dose...................................................... L 461 period when fatal............................................... L 461 post-mortem appearances......................................... L 461 properties of the alkaloid......................................... L 461 symptoms of poisoning by........................................ L 461 tests for jervine.................................................. L 462 tests for veratrine................................................ I. 462 hydrocliloric acid..............................................I. 462 physiologieal..................................................I. 462: sulphuric acid.................................................I. 4(32 treatment.......................................................I. 461 not alkaloidal....................................................... I. 463 camphor.......................................................... I. 472 post-mortem appearances........................................ L 473 symptoms....................................................... I. 472 treatment....................................................... L 473 cantharides or Spanish fly..........................................L 472 détection of poison............................................... I. 472 post-mortem appearances........................................ L 472 symptoms....................................................... L 472 treatment....................................................... I. 472 earbolic acid (synonyms, phénol, phenyl hydrate).................... I. 469 détection of poison..............................................I. 472 fatal quantity....................................................L 472 period when fatal................................................I. 472 post-mortem appearances.........................................L 472 symptoms....................................................... I. 479 tests, bromine................................................... I. 471 ferrie chloride.................................................I 471 hypochlorite..................................................I. 471^ chloral, chloral hydrate............................................ I. 45g détection of poison.............................................. I 45g fatal period..................................................... I 469 fatal quantity................................................... I 4(59 post-mortem appearances......................................... I. 469 résistance to décomposition...................................... L 4691 IXDEX. 725 P -VGR Poisons, Organic Not alkaloidal, chloral, chloral hydrate : symptoms....................................................... L 4(JS tests.......................................................'....'. L 469 treatment................................... T 459. chloroform.....................,................ j ±qq détection of poison......................................... . 1. 4,3^ résistance to décomposition............'........................ I 46g, (a) taken as a liquid by the mouth............................... L 466. fatal quantity.................................... j ±qq, period when fatal.............................................. I 46g. post-mortem appearances.......................................I. 467 symptoms.......................................;.............1 46Q treatment.....................................................I ±qq (b) taken as a vapor by the lungs.................................I. 467 fatal period...................................................I 467 fatal quantity.................................................t. 467 post-mortem appearances......................................I. 467 symptoms.....................................................I. 467 treatment.....................................................I. 467 tests............................................................I. 467 Cocculus Indiens...................................................I. 473 détection of the poison........................................... I. 473 picrotoxin.......................................................I. 473 post-mortem appearances......................................... L 473 symptoms.......................................................I. 473 treatment.......................................................L 473 croton oil.........................................................L 471 détection of the poison...........................................L 471 post-mortem appearances.........................................I. 471 symptoms.......................................................I. 471 treatment.......................................................I. 471 digitalis, foxglove (synonyms, digitalin, digitonin, digitoxin, digitalein, toxiresin).....................................................I. 463 détection of the poison...........................................I. 465 fatal quantity....................................................I. 464 period when fatal................................................I. 464 post-mortem appearances.........................................I. 464 résistance to putréfaction........................................1. 465 symptoms.......................................................L 463 tests : Grandeau's.......................'.........................I. 464 Lafon's...................................................L 465 treatment....................................................... L 475 Poisons, Ptoma'ines, and other putrefactive products......................I. 475 animal alkaloids..................................................... L 475 distinctive color-reactions............................................I. 487 poisons formed during putréfaction...................................I. 491 cancroin..........................................................L 492 cholin...........................................................L 492 ethylendiamin and ethylidendiamin.................................L 491 fugin.............................................................L 492 gadinine..........................................................L 492 72G ixdex. P.VOE Poisons. Ptomaïnes, etc. Poisons formed during putréfaction : isoamylamine............ .................................; ;......L 4. l methylguanidine................................................... L 491 mydaleine......................................................... 1- mydatoxine....................................................... 1- 4- - mytilotoxine..................................................... L "^■,- T 4(t2 neurine.......................................................... A- ^- - patoammine....................................................... I- ^Jl T 49'' ptomo-muscarines................................................ x- *•'-' susotoxine........................................................ 1- 49- tetanine, tetanotoxine, spasinotoxine, and tetanus toxalbumins........ I. 491 trimethylendiainin................................................. I- 491 typhotoxine.......................................................I- 492 tyrotoxicon........................................................L 4. L poisons formed in decomposing tissue in the présence of arsenic.........I. 490 aequetta di Perugia................................................ I- 49(1 aqua toffana........................................................ L 490 purity of reagents...................................................L 476 putrefactive products................................................ L 487 hydroparacumaric acid (para-oxyphenyl-propionic acid).............. I. 4*9 indol, indoxyl (indirubin and indigo-blue)........................... L 4s9 parakresol......................................................... L 490 para-oxyphenyl-acetie acid......................................... L 490 phénol............................................................ L 490 skatol (methyl indol), skatol-acetic acid..................'........... I. 489 putrefactive products resembling the vegetable alkaloids............... I. 477 colchieine-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 strychnine-like products........................................... I. 48(j pellagra......................................................... I. 4S0 veratrine-like products............................................. I. 4 s ] tests for (see under each poison). Poppy, papaverine, papaver somniferum................................L 439, 44'» Porphyridium, spores of. in microscopical examination of blood-stains......I. 170 Post-mortem Examinations.......................................... L 25, 57 accepted period of life............................................... I. 5s authorities.......................................................... I. 57 autopsies and coroners' inquests....................................I. 27, 57 blood (of)......................................................L 37, 43, s s blood-stains (of)..................................................... L 29 contusions (of).......................................................L 32 criminal assaults.................................................... I. 33 râpe followed by murder........................................... L 2!) séminal stains.................................................. I. 99 décomposition and putréfaction (see Death).....................L 35, 99-107 détermination of âge............................................L 50. 64, 66 IXDEX. 727 page t-mortem Examinations. Détermination of âge : anthropological aids to.........................................___L 59 as determined by skeleton .......................................I. 50, (}S détermination of identity (see Death and Identity)................I. 30, 32, 59 cases of mistaken identity.......................................... I. 30 Tichborne claimant.............................................. I. 71 Whitechapel murders..........................................I. 61, 75 détermination of manner of death (see Death) ...................... I. 26, 58 by asphyxiation.................................................... I. 120 drowning...................................................... I. S8 electricity...................................................... I. 134 hanging and strangulation....................................I. 33, 110 poison.......................................................I. 33, 97 starvation...................................................... L 134 suicide.......................................................L 32, ss violence..................................................I. 32, 47, 58 finger-marks......................................................... I. 32 government régulation of..........................................I. 27,57 in France and Germany............................................ I. 57 need of reform.................................................... I. 26 injuries on genitalia................................................ L 33 contusions and iividities.........................................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.................................IL 596 bodies advanced in putréfaction.....................................I. 53 of children................................................. I. 51 examination of abdomen........................................... I. 42 bladder........................................... I. 4.8 bones.............................................. I. or> brain............................................ L 39, 40 female organs...................................... I. 48 signs of abortion.................................IL 475 heart.............................................. L 44 kidneys and spleen................................... I. 48 liver............................................L 50 spinal cord......................................... I. 40 stomach and duodénum............................ I. 49 thorax...........................................L 42, 43 external examination of body..................................... L 32 contusions, finger-marks, wounds...............................I. 32, 33 identity of body.................................................. L 30 inspection of natural orifices...................................... L 33 corrosive poisons, strangulation, epilepsy, criminal assaults........ I. 33 internai examination..........................•................... L 35 instruments, proper time for................................... I. 36 is life extinct?.................................................. L 27 position of body.................................................. L 29 728 ixdex. PAGE Post-mortem Examinations. Order of : post-mortem lividities, ecchymoses, and décomposition............... I. 35- surrounding circumstances and objects.............................. L 28 suspended animation.............................................. L 88 température of body............................................ I- 34, 90- purpose of.......................................................... L --> safeguards to be observed............................................ I- 26 tables : of détails to be noted......................................... I- "•) of hair...................................................... L "4 of skeleton................................................ L 64, 68 of teeth...................................................... L 67 of weights of organs.......................................... L 50" wounds............................................................L 32, 71 edges of.......................................................... L 33 gunshot, search for bullet.......................................... L 47 Garfield case.................................................... L 47 inflicted during life................................................ I. 33 of the neck....................................................... I. 32 penetrating....................................................... I. 32 suicidai................................................ .......... I. 32 Potash................................................................. I. 322 Practice of Medicine, what constitutes proof of......................... I. 602 Prescription, ownership of.............................................. I. 636 Primary Dementia (see Insanity)........................................IL 109 Professional Confidences of physicians and surgeons.................... I. 616 Carlyle Harris case.................................................. I. 625- Progeny of the insane (see Insanity and Heredity).........................IL 58 Psychiatry.............................................................IL 177 Psychicàl deafness and blindness........................................IL 268 Ptomo-muscarines...................................................... I. 492 Puerpéral Fever.......................................................IL 457 Puerpéral Insanity (see Insanity).......................................IL . 103 Putréfaction (see Death and Post-mortem Examinations)...............I. 99, 475 Railway Spine.........................................................IL 397 Râpe...................................................................IL 525 actual and apparent âge..............................................IL 543 âge of consent...............................................I. 651 ; IL 525 coitus, anatomical changes induced by, in labia, in hymen..........H. 527, 528 conditions indicating...............................................jt_ -^q génital discharges.................................................H 537 proof of présence of semen..........................................H .53.-5 state.of vaginal wall and mucous membrane.........................IL 535 venereal diseases communicated in..................................U 535 causes of infection other than sexual contact......................II. 537 gonorrhea, présence of gonococci................................II. 536 false accusations of................................................H 549 for blackmail...................................................H .340 the resuit of illusions, cases....................................H. oj 1 540 followed by murder............................................ . j 99 force, moral.........................................................U 540 physieal évidences of..........................................H 539 INDEX. 729 PAGE Râpe, fraud, intercourse accomplished through............................IL 540 légal considérations..................................................IL 525 secondary conséquences of...........................................IL 544 sexual assault, on children...................................I. 649 ; IL 543 on maie children...................................................H. 544 states of hypnosis and autohypnosis...................................IL 541 non compos mentis................................................IL 543 unconsciousness, facilitating.......................................IL 540 Raptus Melancholicus.................................................IL 193 Realgar................................................................I. 387 Reflex Action (see Insanity)..........................................IL 21, 29 Registration of physicians and surgeons.................................L 600 Relations of médical profession to life insurance......................I. 514, 591 Religious Excitement (see Insanity).....................................IL 51 Représentations in relation to insurance................................L 498 Résidence in relation to insurance........................................L 560 Responsibility, Criminal.......................................IL 213, 217, 245 appréciation of nature of acts.........................................IL 232 case of People vs. Barber...........................................IL 233 criminal-law définitions of.......................................IL 217-220 Coke, Haie........................................................IL 217 McNaghten case...................................................IL 218 delusions as a défense for crime..................................IL 230, 234 e;lses.........................................................IL 235-241 dementia (accidentai) or insanity.....................................H- 222 epilepsy...........................................................IL 2-3 lucid intervais.....................................................II- 222 (natural) or idiocy.................................................II- 220 cases..........'.................................................II- "21 partial insanity....................................................H- 2'_4 total insanity.....................................................-1X- -— cases.......................................................H- 225-231 effects of mental disease upon émotions and will...................IL 242, 251 cases.........................................................IL 243-253 évidences of design..................................................H- 232 impulse, maniacal...................................................H- 250 uncontrollable.........................................IL 44.180,191,243 cases.......................................................H- 245-251 moral insanity.......................................................H- *-°- cases...................................•.....................IL 253"258 motive or absence of.................................................H- 234 " right or wrong " test................................................H- 228 Responsibility in Civil Cases..........................................IL 169 of children..........................................................IL L^ of surgeon for malpractice............................................IL 5/3 of the insane (see Insanity)..........................................IL 170 Rheumatism as affecting insurance....................................... L 536 Rigor Mortis (see Death)................................................ L 93 Rough on Rats........................................................ I- 356 Sadism.................................................................IL 560 Sanctity of the Person of patients.................................... L 632 7:50 INDEX. PAOE Saponification (see Death)...........................'................... L 105 Satyriasis..............................................................IL 50 Scalds (see Wounds).................................................... L 2>s Scalp, atheroma of......................................................IL <>n9 Sklf-Mutilation (see Insane Impulse)...................................IL 4> Séminal Stains.............................................I. 29. 184; IL 536 Senile Dementia........................................................IL 1(|9 Sensorielle Verrucktheit..............................................IL 34 Sepsis. septicamiia...............................................L 90 : IL 587 Sex, détective sexual organs.........................................IL 418, 422 medico-legal importance of diseases of sexual organs.............IL 425, 426 détermination of.....................................................IL 41 8 hermaphrodism.................................................IL 418.419 cases of.......................................................IL 419-425 gynanders and androgyns..........................................IL 419 ménopause..........................................................IL 435 menstruation, normal and abnormal...................................IL 431 puberty and attendant phenomena....................................IL 429 Sexual Impulses (see Insanity)..........................................IL 49 Sexual Irritation (see Insanity)........................................IL 51 Sexual Perversion..................................................IL 48, 55o anomalies, congénital and acquired...............................IL 552, 554 bestiality...........................................................IL 547 contrary sexuality...................................................IL 569 cases of...........................................................IL 570 éducation, influence of, upon.........................................IL 554 psychosexual development..........................................IL 551 erotic fetichism......................................................IL 566 body fetichism, and cases of........................................IL 567 dress fetichism, and cases of...................................IL 56S, 569 Lesbians............................................................IL 59 lust-murder........... .............................................H. 561 nymphomania........................................•...............n. 59 passivism............................................................H. .-,94 pederasty............................................................IL -)46 pathognomonic signs of............................................H 549 responsibility oî perverts........................................H. ,-,4.-5 572 sadism..............................................................II. 560 satyriasis...........................................................IL 5(> senile attempt at râpe, and cases of...................................II ,-,-,] dementia, abnormal sexuality in...............................jj ]()9 sexual anaesthesia...................................................U --,7 hyperaesthesia, and eases of................................H -,.-,7 ^-^ paradoxia................................................ jt 55 -. para»sthesia...............................................H -,-,.-; --y sodomy.............................................................IL 545 English common law on....................................... jt 545 tribadism...................................................... jt 54- Sexual Vigor. exaggeration of (see Insanity)............................H 5] Shock ( see Traumatic Neuroses)............................... . jj 097 393 Silver, argentic nitrate........................................... j 411 INDEX. 731 PAGE Mmi Lation (see Feigned Diseases).......................................IL 444 Slander of médical practitioners......................................... I. 640 Sleep. condition of semi-consciousness....................................IL 51 dreaming...........................................................n 51 drunkenness................................... H 31 V'A\W in.............................................................IL 540 somnambulism.............................................. jt .-,]_ Soda...................................................................j ^ Sodomy (see Sexual Perversion)..........................................II. 545 Somnambulism........................................ jj 51 Spanish Fly................................................ j 470 Spasmotoxine......................................................... I. 492 Spectroscope, for determining blood-stains............................... I. 142 for determining hœmoglobin.......................................... L ] 44 stokes' band........................................................ I. 147 Speech Centers.....................................................H. 24, 269 Speech Disturbances...................................................II. 270 feigned.............................................................II. 410 in aphasia......................................................IL 259-296 verbigeration........................................................IL 74 Spermatozoa (see Séminal Stains)....................................... I. 185 Spontaneous Combustion...............................................L 133 Stains, blood ; see Blood-stains)................. .................... I. 29, 139 séminal (see Séminal Stains)......................................I. 29, 184 Staphis Agria..........................................................I. 4S2 Starvation, death by....................................................L ]34 baby-farming........................................................ I. ] 37 Welsh fasting girl....................-............................... I. 137 Sterility (see Genito-urinary Diseases)..................................IL 503 Stokes' Band (see Spectroscope).........................................I. 147 Stramonium, Datera................................................... 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. 108-115 and insanity........................................................IL 45 and melancholia.....................................................IL 192 Suicide (see Wounds)...................................................I. 280 as affecting insurance............................................... I. 565 as affecting testamentary capacity....................................IL 128 by earbolic acid.....................................................I. 88 by drowning.............•.......................................... L 128 by hanging or strangulation.......................................... I. 116 fantastic............................................................IL 48 statistics of, in New York for 1891.................................... L 352 Surgeon, measure of responsibility of.....................................IL 573 partnership liability.................................................IL 583 punishment of..................................................IL 574. 582 Suegical Practice and Malpractice : accessory wound diseases............................................IL 589 amputations.........................................................IL 621 anaesthetics, administration of........................................IL 594 7-2 INDEX PAGE Surgical Practice, etc. Amesthetics, administration of : administration of, to pregnant women...............................II- GuO bromide of ethyl (hydrobromic ether)...............................II- G03 cause of death from, direct and indirect.........................IL •)-)-1- -"^G chloroform idiosyncrasy............................................IL i)!'s dangerous or fatal narcosis, treatment of............................IL ;)i,!' défense in.......................................................IL 604 ■death from........................................................II- ~>-^ post-mortem appearances........................................H- ;)')() effects of, upon kidneys............................................II- ;)>'~ ether, objections to................................................IL 600 failure to produce results...........................................IL 602 nitrous oxide........................,.............................IL 603 aseptic and antiseptic treatment......................................IL 590 accidentai wounds.................................................IL 593 microôrganisms.................................................: Al. 589 précautions.......................................................IL 593 procédure.........................................................IL 592 common mishaps in, spécial or régional considérations : 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, thyroidectomy, tonsilotomy, tracheotomy, traumatic delirium, trephining, tumors........................IL 584-614 fractures of extremities..............................................IL 614 contracture and anchylosis.........................................IL 621 deformities following................................'..............IL 614 gangrené following.................................................IL 617 hip-joint injuries and disease...................................IL 618, 619 resection..........................................................IL 620 tenotomies and myotomies.........................................IL 621 genito-urinary organs................................................IL 625 abscess of testicle, castration, catheterization, circumcision, extrava- sation of urine, hernia, hydrocele, hysterical atony, lithotomy, vesical calculus....................................................IL 625-629 improper introduction of non-professional into case....................IL 580 malpractice, burden of proof of.......................................IL 581 contributory négligence in.........................................IL 5S1 criteria of.........................................................IL 579 défense in........................................................IL 5s ] définition of.......................................................II. 5713 errors in diagnosis and of judgment.................................II. 576 expérimental surgery..............................................H 539 gratuitous services.................................................H. 57s latest methods and appliances......................................II. 577 liability (criminal), action barred by recovery for services............II. 583 common-law provisions..........................................II. 5S3 measure of responsibility..........................................II. 573 when aseptic principles are violated..............................IL 591 partnership liability...............................................II. 5S3 IXDEX. 783 PAGE Surgical Practice, etc. Malpractice, burden of proof of, etc. : pecuniary damages.................................................IL 582 unexpected and unfortunate results of opérations....................IL 575 unusual emergencies...............................................IL 577 opérations, abdomen and pelvis.......................................IL 622 disturbances following.............................................IL 625 procédure not restricted..............................................IL 592 response to call......................................................IL 577 warranty to cure.....................................................IL 578 Survi vorship...........................................................L 234 case of Underwood vs. Wing..........................................I. 236 SUSOTOXINE.............................................................L 492 Suspended Animation................................................... I. 88 Symphyseotomy.........................................................II. 459 Syncope.................................................................I. 88 Syphilis................................................................IL 509 Tables and Statistics : accidentai deaths in New York City, 1870-91...........................I. 352 anaesthetics, mortality from use of................................IL 379, 601 Balch, experiments on effects of gunshot wounds.......................I. 254 blood-corpuscles, measurements of....................................I. 173 comparative actual and computed rates of mortality....................I. 511 mortality 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 détails to be noted in examining into identity..........................L 75 hair, according to race characteristies.................................L 196 insanity, classification of, by Hamilton................................IL 56 Maudsley................................IL 57 Von Krafft-Ebing.........................IL 55 extent of hallucinations, etc.................................IL 34 symptoms favorable and the reverse.........................IL 64 mortality in différent occupations.....................................L 557 (relative) of intemperate persons............................I. 550 railroad accidents....................................................IL 307 stature : Orfila's- method..............................................L 68 Sue's method................................................L 69 suicides in New York City in 1891.....................................L 352 teeth........'.......................................................I- 67 weights of organs of human body.....................................L 50 Tartar Emetic.........................................................L 342 Tattooing........................................................• • I- 72> 202 Teeth, extraction of, mishaps occurring in.................................IL 611 identification by.................:...................................L 195 post-mortem examination of........................................L 56, 67 Température of body at time of death....................................I. 34 Tenotomies.............................................................IL 621 Tests for blood......................................................L 157, 162 signs of death....................................................... L 9ô 734 ixdex. PAGE Tests for blood, suspected blood-stains................................I. 152, Lx aconitc, etc....................................................• • • • I- 423 antimony......................................................... I- 347 arsenic....................................................... L 372. 374 belladonna and atropine with.......................................L 425 Vitali's method.................................................. L 426 Wormley's method............................................... L 426 earbolic acid with bromine, ferrie chloride, hypochlorite.............. L 471 chloral............................................................ L 469 chloroform........................................................ L 469 cocaine with ferrie chloride, odor, permanganate, physiologieal.......I. 429 colchicum with Mandelin's, nitric acid, physiologieal, Zeisel's......I. 431, 432 coniine with alloxan, butyric acid, hydrocliloric acid, odor........ I. 433. 434 copper............................................................ L 407 digitalis with Grandeau's, Lafon's..................•................. I. 465 gelsemic acid with ammonia, fluorescence, nitric acid, sulphuric acid.. I. 43(5 gelsemine with nitric acid, oxidation................................ I. 451 iron.............................................................. I. 414 jervine............................................................ I. 462 lead.............................................................. I. 395 meconic acid with ferrie chloride, lead acétate....................... I. 443 mercury.......................................................... I. 402 nicotine with hydrocliloric acid, iodine, mercuric chloride, physiolog- ieal ....................................................... L 438. 439 opium and morphine with ferrie chloride, iodic acid, nitric acid, sulpho- molybdic acid................................................... I. 442 silver............................................................. L 412 strychnine with color, crystals of strychnine chromate, physiologieal, taste........................................................... L 451 veratrine with hydrocliloric acid, physiologieal, sulphuric acid........ I. 462 zinc.............................................................. I. 499 Testamentary Capacity................................................IL 115 as affected by alcoholism..............'................................n. 123 delusions..............................................IL Ils dementia..............................................H. 1 ig disease................................................H j2() eccentricity............................................H 149 epilepsy...............................................H J22 hypnotism.............................................H j 07 old-Age............................................II. 116) 117 senile dementia........................................H j ] q suicide................................................H ] ■>,. proof of a disposing mind..........................................H 1^5 German décisions regarding......................................U j 1 ^ what constitutes................................................ H j 15. Tetanine, tetanotoxine, spasmotoxine, tetanus toxalbumins................ I. 491 Tetanus as a mishap in surgieal practice.................................H -,^5 Thebaine............................................................... j 440 Theory (légal) of criminal responsibility..................................jj. 217 Thyroidectomy.........................................................II 612 Tobacco............................................................... j 437 index. 735 PAGE Tonsilitis as affecting insurance........................................ I. 538 Torts by the insane......................................................IL 143 Toxic Insanity........................................................IL 205 ^ alcoholism.........................................................IL 205 cases.............................................................IL 206 offenses due to.................................■...................IL 205 physieal and psychic symptoms................................IL 205, 206 cocaine habit........................................................IL 209 morphine habit......................................................IL 207 offenses due to....................................................IL 208 symptoms of.......................................................IL 207 Toxiresin.............................................................. I. 463 Tracheotomy...........................................................IL 612 Traumatic Delirium as a mishap in surgieal practice......................IL 584 Traumatic Insanity (see Insanity)......................................IL 105 Traumatic Neuroses...................................................IL 297 setiology.............................................................IL 305 âge when most liable to.............................................IL 305 ataxiagram.........................................................IL 315 bibliography and index.........................................IL 352-360 classification of disorders following injury.............................IL 303 concentration of population as affecting...............................IL 306 condition at time of injury.........................................."IL 306 subséquent to injury........................................IL 307 définitions and synonyms...........................................IL 297 diagnosis and prognosis.........................................IL 333, 334 feigned.............................................................H- 402 grave traumatic neurosis, and cases of............................IL 331, 332 history of...........................................................H- 298 hysteria (traumatic).............................................II- 305, 334 cases of, in a woman cataleptie.....................................IL 350 with violent tremor.............................................IL 348 pathology of......................................................IL 351 prognosis of............................................•'..........L.- ^50 susceptibility in âge, race, and sex................■.................IL 335 symptoms of......................................................H- 336 methods of examination and diagnosis............................IL 321, 322 mooted points.......................................................n- 3°0 neurasthenia (traumatic).............................................II- 305 pathology of....................................................H. 330,334 previous condition of health..........................................IL 306 sex most liable to...................................................n- 305 shock and concussion................................................H- 303 statistics of railroad accidents.......................................IL 307 svmptoms...........................................................II- 307 * neurasthenia (railway spine), spinal irritation, hypochondriacal neu- roses, unusual, spécial, muscular and motor, sensory, visual, hear- ing laryngeal, vasomotor, puise, bladder and kidneys..........IL 307-320 . . , ' ° ...............................................IL 322 tests................... for nerves and muscles, traumatic reaction, sensory and visual symp- toms IL 322-329 PAGE IL 402 IL 609 730 INDEX- Tremor, feigned.................................................. Trephining...................................................... .11. o4< Tribadism....................................................• • ' Trichomonas Vagins.................................................. ' ,'',' „, .........I. 491 Trimethylendiamin................................................ . _, . ,, , .............IL 013 Tumors m the neck.............................................. o of abdomen and pelvis............................................... t , , .........IL 612 retropharyngeal.............................................. F J 5 .........IL 103 Typhomania....................................................... I 49" Typhotoxine............................................................ I 492 Tyrotoxicon............................................................. Uncontrollable Impulse (see Insanity).................................II- - - views of the courts in regard to......................................H- ~44 TT 1°5 Undue Influence.......................................................XXm ' T 599 Unprofessional C onduct............................................... *' TT 113 Unsoundness of Mind..................................................■"■• ±1,J degree of...........................................................IL 13° Urethritis.............................................................H- 50° Vasa Deferentia.......................................................H- ^04 Veratrum, veratrine.................................................... I- 4"° Verbigeration. Verdigris....., IL 74 . I. 407 Verrucktheit......................................•.................II- 34, S9 Vitriol, green.......................................................... I- 413 oilof...............................................................I- 329 throwing............................................................I- 2l">-' white............................;.................................. L 409 Volition.............................................................H- -s disturbances of.....................................................H- 48 suspended..........................................................H- ;)1 Waiver in professional relations of physicians and surgeons............... I. 626 Warranties in relation to insurance............................•.......... I. 498 Weapons (see Wounds).................................................. L 275 Weight of brain........................................................ L 20 Wills (see Testamentary Capacity). French laws regarding...............................................IL 266 made in extremis....................................................IL 116 of drunkards........................................................IL 123 insane...........................................................IL 170 suicides..........................................................IL 128 Witnesses, the insane as................................................IL 137 Wolp's-bane........................................................... I. 421 Wounds (see Blood-stains, Death, and Post-mortem Examinations). affecting spécial 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 IXDEX. 737 Wounds. Affecting spécial parts : head..............................................................I heart.............................................................I intestines........................................................I involving cavities.................................................. I kidneys........................................................... I liver............................................................. I neck..............................................................I spine............................................................I fractures of.....................................................I injuries to spinal cord...........................................I stomach.......................................................... I vertébrée, dislocation of............................................I blood upon weapons.................................................I Steenbergh case ..................................................I blood-stains, évidence from........................................... I bullets, shot, or other substances in wounds........................... I burns and scàlds..........................,..........................I as cover for crime.................................................. I blisters........................................................... I bodies destroyed by fire............................................I boiling oil and sugar...............................................I boiling water......................................................I electricity by............................................-........H contusions and ecchymoses........................................... I concussion........................................................I discolorations.....................................................I extravasation.....................................................I from sand-bags.................................................... I of abdomen.......................................................I of head...........................................................I on living or dead body.............................................I pseudo-ecchymosis................................................. I corrosive liquids..................................................... I danger of........................................................... defined ............................................................. dirt, grass, and similar substances in............ •'....................I dislocations....................... ................................. effusion from violence or disease...................................... 1 évidence of weapons and other articles................................ I Billings case ..................................................... Briggs case........................................................ Budgecase............................................ I- 249,259,27 did person move after............................................. Fort Edwards case................................................. from blood-stains.................................................. Hughes case...................................................... Klock case........................................................ Mallon case....................................................... manner in which blood flows.......................................I Mechanicsville case................................................I 296 307 310 258 310 309 304 300 302 302 310 301 275 275 274 276 288 287 288 289 287 288 371 244 287 247 298 245 245 297 245 246 289 25,8 243 277 294 299 259 263 2<32 3, 277 295 269 272 270 268 271- 273 268 73S 1XDEX. PAGE Wounds. Evidence of, etc : position of body................................................... I- 294 Weston case...................................................... I. 200 extravasation of blood from a blow................................... L 298 fractures............................................................L -•',l cause of........................................................... L 291 from blows........................................................L 241 of bones of skull................................................... L 293 of ribs............................................................ L 292 of spine...........................................................L 302 spontaneous....................................................... L 291 gunshot (see Bullets)................................................ L 252 experiments by Dr. Balch.............................L 254, 257, 266, 267 Heigham case....... ............................................. L 254 loss of lead by bail................................................. I 252 made by shot-guns................................................. L 253 marks of diseharge................................................I. 254 self-inflicted....................................................... I. 25s incised by cutting instruments........................................I. 247 blood-marks from..................................................L 248 Budge case...........................................I. 249, 259, 273, 277 made immediately after death...................................... I. 249 signs of healing....................................................I. 24s laeerated........................................................... L 250 ( CShea case....................................................... I. 251 position of weapon, clothes, or body.................................. I. 277 post-mortem examination of........................................ I. 32-47 relation of médical witness........................................... I. 315 severity of.......................................................... I. 25s suicide.............................................................. L 280 Captain Colvocoresses case......................................... L 282 détermination between suicide and accident........................ I. 284 weapons, blood upon................................................ I. 275 Budge case............................................I. 249, 259, 273, 277 évidence of....................................................... I. 24!) hair upon......................................................... I 276 position of........................................................ I. 277 Thompson case.................................................... I 278 where more than one................................................ I. 079 Bruin case........................................................ I 2sl Shattuek case..................................................... j 281 wound diseases, accessory........................................jt -$# microorganisms................................................... jj ggg Zinc, zinc chloride................................................... j 4Qg >>2 \ f ii t > * . i. *. **.* ^r -\ * y } » m 11 % > > > • J 9 HIHl: p M -m X M * > r i\ \ NLM000311923