A child may be born alive, but may not be viable, by which is meant that it is not endowed with a capacity of maintaining its life. Speaking generally, 180 days represents the lowest limit at which a child is viable, but prolonged survival under these circumstances is the exception. Many cases, however, have been recorded in which children born at six months have been reared. The signs of immaturity and maturity may be thus tabulated:
| Immaturity. | Maturity. | |
| Centre of body high; head disproportionate in size; membrana pupillaris present; testicles undescended; deep red colour of parts of generation; intense red colour, mottled appearance, and downy covering, of skin; nails not formed; feeble movements; inability to suck; necessity for artificial heat; almost unbroken sleep; rare and imperfect discharges of urine and meconium; closed state of mouth, eyelids, and nostrils. | Strong movements and cries as soon as born; body clear, red colour, coated with sebaceous matter; mouth, nostrils, eyelids, and ears, open; skull somewhat firm, and fontanelles not far apart; hair, eyebrows, and nails, perfectly developed; testicles descended; free discharge of urine and meconium; power of suction, indicated by seizure on the nipple or a finger placed in the mouth. |
A child born in wedlock is presumed to have the mother's husband for its father. This may, however, be open to question upon the following grounds: Absence or death of the reputed father; impotence or disease in the husband preventing matrimonial intercourse; premature delivery in a newly-married woman; want of access; and the marriage of the woman again immediately on the death of her husband. In the last case, where either husband might have been the father, the child at the age of twenty-one is at liberty to select its father from the possible pair.
A child born of parents before marriage is in Scotland rendered legitimate by their subsequent marriage, but in England the offspring remains illegitimate whether the parents marry or not after its birth. The offspring of voidable or invalid marriages may be made legitimate by application to the courts.
There is a difference between being legitimate and lawfully begotten. A child born in wedlock is legitimate, but if the parents were married only a week previously it could not have been lawfully begotten.
The Acts and rulings relating to Marriage and Legitimacy are extremely complicated. It is not putting it too strongly to say that a very large number of people in this country who believe themselves to be legally married are not married at all, and that thousands of children who have not the slightest doubt as to their legitimacy are in the eyes of the law bastards.
By superfœtation is meant the conception, by a woman already pregnant, of a second embryo, resulting in the birth of two children at the same time, differing much in their degree of maturity, or in two separate births, with a considerable interval between. The possibility of the occurrence of superfœtation has been doubted, but there are well-authenticated cases which countenance the theory of a double conception. It has been shown that the os uteri is not closed, as was once supposed, immediately on conception. Should an ovum escape into the uterus, it may become impregnated a month or so after a previous conception. The most probable explanation is that the case has been one of twins, one being born prematurely; or, on the other hand, the uterus may have been double, and conception may have taken place in one cornu at a later period than in the other cornu.
In order to inherit, the child must be born alive, must be born during the lifetime of the mother, and must be born capable of inheriting—that is to say, monsters are incapable of inheriting. There is a mode of inheritance called 'tenancy by courtesy.' When a man marries a woman possessed of an estate or inheritance, and has, by her, issue born alive in her lifetime capable of inheriting her estate, in this case he shall, on the death of his wife, hold the lands for his life as tenant by the courtesy of England. The meaning of the words 'born alive' in this instance is not the same as in cases of infanticide. In Civil law any motion of the child's body, however slight, or the fact of it having been heard to cry by witnesses, is held to be sufficient proof of the child having been born alive. It may die immediately afterwards, and it is not necessary that the child be viable.
In the male, impotence may arise from physical or mental causes. The physical causes may be—too great or too tender an age; malformation of the genital organs; crypsorchides, defect or disease in the testicles; constitutional disease (diabetes, neurasthenia, etc.); or debility from acute disease, as mumps. Masturbation, and early and excessive sexual indulgence, are also causes. The mental causes include—passion, timidity, apprehension, aversion, and disgust. The case will be remembered of the man who was impotent unless the lady were attired in a black silk dress and high-heeled French kid boots.
If a man is impotent when he marries, the marriage may be set aside on the ground that it had never been consummated. The law requires that the impotency should have existed ab initio—that is, before marriage—and should be of a permanent or incurable nature; marriage, as far as the law goes, being regarded as a contract in which it is presupposed that both the contracting parties are capable of fulfilling all the objects of marriage. In the case of the Earl of Essex the defendant admitted the charge as regards the Countess, but pleaded that he was not impotent with others, as many of her waiting-maids could testify. When a man becomes impotent after marriage, his wife must accept the situation, and has no redress. A man may be sterile without being impotent, but the law will not take cognizance of that. The wife may be practically impotent, but the law will not assist the husband. He must continue to do his best under difficult circumstances. In former times in case of doubt a husband was permitted to demonstrate his competency in open court, but this custom is no longer regarded with favour by the judges.
The removal of the testicles does not of necessity render a man impotent, although it deprives him of his procreative power. Eunuchs are capable of affording illicit pleasure, whilst the male sopranos, or castrati, are often utilized for that purpose.
In the female, impotence may be caused by the narrowness of the vagina, adhesion of the vulva, absence of vagina, imperforate hymen, and tumours of the vagina.
Sterility in women may occur from the above-named causes of impotence, together with absence of the uterus and ovaries, or from great debility, syphilis, constant amenorrhœa, dysmenorrhœa, or menorrhagia.
Rape is the carnal knowledge of a woman by force and against her will. The resistance of the woman must be to the utmost of her power, but if she yield through fear or duress it is still rape. The woman is a competent witness, but her statements may be impugned on the ground of her previous bad character, and evidence may be called to substantiate the charge. The perpetrator must be above the age of fourteen years.
The definition of rape which we have given is not altogether satisfactory. Take, for example, the case of a woman who goes to bed expecting her husband to return at a certain hour. The lodger, let us say, takes advantage of this fact, and, getting into bed, has connection with her, she not resisting, assuming all the while that it is her husband. This is rape, but it is not 'by force,' and it is not 'against her will,' but it is 'without her consent,' as she has not been fully informed as to all the circumstances of the case.
In all cases of rape in which there is no actual resistance or objection, consent may be assumed. It is not essential that the woman should state in so many words that she does not object. The force used may be moral and not physical—e.g., threats, fear, horror, syncope.
By 48 and 49 Vict., c. 49, the carnal knowledge of a girl under thirteen is technically rape. The consent of the girl makes no difference, since she is not of an age to become a consenting party.
An attempt at carnal knowledge of a girl under thirteen is a misdemeanour. Her consent makes no difference, and even the solicitation of the act on the part of the child will not exonerate the accused.
Intercourse with a girl between thirteen and sixteen, even with her consent, is a misdemeanour.
This Act is a favourite with the blackmailer. The child is sent out to solicit, dressed like a woman, but appears in the witness-box in a much more juvenile costume.
To constitute rape there must be penetration, but this may be of the slightest. There may be a sufficient degree of penetration to constitute rape without rupturing the hymen. Proof of actual emission is now unnecessary.
The subject of carnal knowledge (C.K.) or its attempt may be summed up as follows:
| Under thirteen | C.K. | Felony. |
| Under thirteen | Attempt | Misdemeanour. |
| Consent no defence. | ||
| From thirteen to sixteen | C.K. | Misdemeanour. |
| From thirteen to sixteen | Attempt | Misdemeanour. |
| Consent and even solicitation no defence. | ||
| Reasonable cause to believe the girl over sixteen is a good defence. | ||
| Charge must be brought within three months. | ||
| Over sixteen | C.K. with consent | Nil. |
| Subject to civil action for loss of girl's services by father. | ||
| Idiot or imbecile | C.K. with violence | Rape. |
| Idiot or imbecile | C.K. without violence | Misdemeanour. |
| Personation of husband | Rape. | |
| Tacit consent no defence, for obtained by fraud. | ||
| Married woman | C.K. with consent | Adultery. |
| Mother, sister, daughter, grand-daughter | C.K. consent immaterial; born in wedlock or not | Incest. |
| Females | Indecent assaults | Misdemeanour. |
It is a misdemeanour to give to a woman any drug so as to stupefy her, and so enable any person to have unlawful connection with her.
False charges of rape are very often made. The motive may be to extort blackmail, revenge, or mere delusion. On examining such cases bruises are seldom found, but scratches which the woman has made on the front of her body may be discovered, and the local injuries to the generative organs are slight, if present at all.
Physical Signs.—In the adult the hymen may be ruptured, the fourchette lacerated, and blood found on the parts, together with scratches and other marks and signs of a struggle. In the child there may be no hæmorrhage, but there will be indications of bruising on the external organs, with probably considerable laceration of the hymen, the laceration in some cases extending into the rectum. Severe hæmorrhage, and even death, may follow the rape of a young child. The patient will have difficulty in walking, and in passing water and fæces. After some hours the parts are very tender and swollen, and a sticky greenish-yellow discharge is present. These signs last longer in children than in adults; but as a rule—in the adult, at least—all signs of rape disappear in three or four days. Young and delicate children may suffer from a vaginal discharge, with swelling of the external genitals, simulating an attempt at rape. Infantile leucorrhœa is common, and many innocent people have been exposed to danger from false charges of rape on children, instituted as a means of levying blackmail. A knowledge of these facts suggests the necessity of giving a guarded opinion when children are brought for examination in suspected cases. Pregnancy may follow rape.
Seminal stains render the clothing stiff and greyish-yellow in colour, with translucent edges. On being moistened they give the characteristic seminal odour.
Semen may be found on the linen of the woman and man, and will be recognized under the microscope by the presence in it of spermatozoa, minute filamentary bodies with a pear-shaped head; but it must not be forgotten that the non-detection of spermatozoa is no proof of absence of sexual intercourse, for these bodies are not always present in the semen of even healthy adult young men. Spermatozoa must not be mistaken for the Trichomonas vaginæ found in the vaginæ of some women. The latter have cilia surrounding the head, which is globular.
Florence's Micro-Chemical Test for Spermatic Fluid.—If a drop of the fluid obtained by wetting a supposed spermatic stain be mixed with a drop of the following solution (KI, parts 1.65; pure iodine, 2.54; distilled water, 30) in a watch-glass, brownish-red pointed crystals resembling hæmin crystals are obtained.
Barberio's Test.—Mix a drop of the spermatic stain with a drop of a saturated solution of picric acid, when needle-shaped yellow rhombic crystals are formed.
Gonorrhœal Stains.—A cover-glass preparation stained with methylene blue reveals the gonococci lying in pairs within the leucocytes.
Trials for sodomy and bestiality are common at the assizes, but, as they are rarely reported, they fail to attract attention. Sodomy is a crime both in the active and passive agent, unless the latter is a non-consenting party. The evidence of either associated may be received as against his colleague. If the crime is committed on a boy under fourteen, it is a felony in the active agent only. As in cases of rape, emission is not essential, and penetration, however slight, answers all practical purposes.
There can be no doubt that in the majority of these cases there exists a congenitally abnormal condition of the sexual instinct, these individuals from their childhood manifesting a perverted sexual instinct. The man is physically a man, but psychically a woman, and vice versâ. The tendency nowadays is not to charge these people with the more serious offence, but to deal with them under Section 11 of the Criminal Law Amendment Act, 1885 (48 and 49 Vict., c. 69). This section, which is sufficiently comprehensive, runs as follows: 'Any male person who in public or private commits or is a party to the commission, or attempts to procure the commission by any male person, of any act of gross indecency with another male person, shall be guilty of a misdemeanour.' The penalty is imprisonment for two years, with or without hard labour. It is provided by Section 4 of the same Act that a boy under sixteen may be whipped.
Incest.—This crime is dealt with under the Punishment of Incest Act, 1908 (8 Edward VII., c. 45). Carnal knowledge with mother, sister, daughter, or grand-daughter, is a misdemeanour, provided the relationship is known. It also applies to the half-brother and half-sister. It is equally an offence whether the relationship can or cannot be traced through lawful wedlock. Consent is no defence. A woman may be charged under the Act if she, being above the age of sixteen, with consent permits her grandfather, father, brother, or son, to have carnal knowledge of her.
There are in London and every large city scores of men and women who live by blackmailing or chantage. There are many different forms of this industry. There is the man who knows something about your past life, which he threatens to reveal to your friends or colleagues unless you buy him off. There is the breach-of-promise blackmailer, and there is the female patient, who threatens to charge you with improper conduct or indecent assault. Medical men from their position are often selected as victims. The introduction of corridor carriages on many of our railways has done much to stamp out one particular form of blackmailing, but public urinals are still a source of danger.
It is the worst possible policy to temporize with a blackmailer. If you give him a single penny, you are his for life. It is as well to remember that it is just as criminal to attempt to extract money from a guilty as from an innocent person. It is of no use attempting to deal with these cases single-handed. You must not only deny the allegation, but 'spurn the allegator.' Put the matter into the hands of a good sharp criminal solicitor, and instruct him to rid you of the nuisance by taking criminal proceedings.
Marriage may be accomplished in many ways: (1) By the publication of banns; (2) by an ordinary licence; (3) by a special licence; (4) by the Superintendent-Registrar's licence; (5) by a special licence granted by the Archbishop of Canterbury in consideration of the payment of the sum of £25. Then, for persons having a domicile in Scotland, there is the marriage by repute. The consent of the parties, which is the essence of the contract, may be expressed before witnesses, and it is not requisite that a clergyman should assist, but it is essential that the expressions of consent must be for a matrimonial intent. 'Habit and repute' constitute good evidence, but the repute must be the general, constant, and unvarying belief of friends and neighbours. The cohabitation must be in Scotland.
Any irregularity in the marriage ceremony or the non-observance of any formality will not invalidate the marriage, unless it were known to both the contracting parties. If a man were married in a wrong name the contract would still be valid if the wife were unacquainted with the deception at the time. If the person who officiated were a bogus clergyman, the marriage would hold good if the contracting parties supposed him to be a properly ordained priest. In a case in which a marriage was solemnized in a building near the church at a time when the church was undergoing repairs, and where during such alterations Divine service had been performed, it was held that the ceremony was good. To all intents and purposes marriage comes under the 'Law of Contract' (see Anson, W.R., Bart.), and the law looks to the intention rather than to the actual details. All marriages between persons within the prohibited degrees of consanguinity or affinity are null and void. This prohibition extends both to the illegitimate as well as the legitimate children of the late wife's or husband's parents. A marriage with a deceased wife's sister is now legal in Great Britain and the Colonies, and is recognized in most foreign countries. A common device with people within the prohibited degrees is to get married abroad, but such marriage is strictly speaking inoperative, and the children of such union are illegitimate. Practically, however, it is a matter of no importance, for when people live together and say they are married, they are accepted at their own estimate.
A man can obtain a divorce from his wife if he can prove that she has been guilty of adultery since her marriage. This may be established by inference. Obviously, it is difficult in the majority of cases to establish by ocular demonstration that adultery has been committed. But given evidence of familiarity and affection with opportunity and suspicious conduct, a jury will commonly infer it.
A woman cannot obtain a divorce from her husband for adultery alone. She must prove adultery plus cruelty, or adultery plus desertion without reasonable cause. Failing this, she may be able to prove either bigamy or incestuous adultery. Legal cruelty is a very comprehensive term, and does not of necessity mean physical violence. If the husband as the result of his infidelity were to give his wife a contagious disease, that would constitute cruelty. Taking a more extreme case, if a husband were to have connection in her house with his wife's maid, that would probably be held to constitute cruelty, as it would tend to lower her in the eyes of her servants.
A wife can obtain a judicial separation if she can prove (1) adultery, (2) cruelty, or (3) desertion without reasonable cause for two years. If a husband is away on his business, as, for example, the case of an officer ordered abroad, that is not desertion. For a woman to get a judicial separation, it is sufficient if she can prove one variety of matrimonial offence, but for a divorce she requires more than one.
The jury may find that Mrs. A. has committed adultery with Mr. B., but that Mr. B. has not committed adultery with Mrs. A. The explanation is, that a wife's confession is evidence against herself, but not against another person. You can confess your own sins, but not another's.
The Divorce Law of Scotland differs materially from that of England. In Scotland there is no decree nisi, no decree absolute, and no intervention by the King's Proctor. Instead there is a single and final judgment, and when a decree of divorce is pronounced the successful litigant at once succeeds to all rights, legal and conventional, that would have come to him or her on the death of the losing party. If the husband is the offender, the wife in such circumstances may claim her right to one-third of his real estate; and if there are children, to one-third of his personal property, and to one-half if there are none.
Voidable Marriages.—If a man and woman go through the marriage ceremony, such a contract is null and void under the following circumstances: (1) Where bigamy has been committed; (2) if one of the parties were insane at the time of marriage; (3) where the plaintiff is under sixteen years of age; (4) when the marriage has not been consummated or followed by cohabitation; (5) when one of the parties was incapable of performing the marital act (impotent, and such not known by the other at the time); (6) when drunkenness had been induced so as to obtain consent; (7) concealment of pregnancy at the time of marriage.
Malingering in its various forms is by no means uncommon, and by many is regarded as a disease in itself. It is necessary, however, to distinguish between those cases in which it is feigned for some definite purpose—for example, to escape punishment or avoid public service—and those in which there is adequate motive, and the patient shams simply with the view of exciting sympathy, or from the mere delight of giving trouble. It is not uncommon for individuals summoned on a jury, or to give evidence in the law courts, to apply to their doctor for a certificate, assigning as a cause of exemption neuralgia, or some similar complaint unattended with objective symptoms. In such cases it is well to remind the patient that in most courts such certificates are received with suspicion, and are often rejected, and that the personal attendance of the medical man is required to endorse his certificate on oath.
Malingering has become much more common since the National Health Insurance Act has been passed. The possibility of obtaining a fair sum each week without the necessity of working for it induces many persons either to feign disease or to make recovery from actual disease or accident much more tedious than it ought really to be.
The feasibility of successfully malingering is greatly enhanced by the possession of some chronic organic disease. An old mitral regurgitant murmur is useful for this purpose.
It is not flattering to one's vanity to overlook a case of malingering, but should this occur little harm is done. It is a much more serious matter to accuse a person of malingering when in reality he may be suffering from an organic disease.
Here are some of the diseases which are most frequently feigned:
Nervous Diseases, as headache, vertigo, paralysis of limbs, vomiting, sciatica, or incontinence or suppression of urine, spitting of blood; others, again, simulate hysteria, epilepsy, or insanity.
On the other hand, the malingerer may actually produce injuries on his person either to excite commiseration or to escape from work. Thus, the beggar produces ulcers on his legs by binding a penny-piece tightly on for some days; the hospital patient, in order to escape discharge, produces factitious skin diseases by the application of irritants or caustics.
It is much more difficult to decide whether certain symptoms are due to a real disease which is present, or whether they are merely exaggerations of slight symptoms or simulations of past ones. The miner, after an injury to his back, recovers very slowly, if at all. He is suffering from 'traumatic neurasthenia'—a condition only too often simulated, and a disease very difficult to diagnose accurately. The miner takes advantage of our ignorance, and continues to draw his compensation. A workman during his work receives a fracture; instead of being able to resume work in six weeks, he asserts that the pain and stiffness prevent him, and this disability may persist for months. Such cases as these frequently come before the courts when the employer has discontinued to pay the weekly compensation for the injury. Medical men are called to give evidence for or against the injured workman.
Epilepsy is often simulated. The foaming at the mouth is produced by a piece of soap between the gums and the cheek. The true epileptic, especially if he suspects that a fit is imminent, takes his walks abroad in some secluded spot, whilst the impostor selects a crowded locality for his exertions. The epileptic often injures himself in falling, his imitator never; one bites his tongue, but the other carefully refrains from doing so. The skin of an epileptic during an attack is cold and pallid, but that of the exhibitor is covered with sweat as the result of his exertions. In epilepsy the urine and fæces are passed involuntarily, but his colleague rarely considers it necessary to carry his deception to this extent. In true epilepsy the eyes are partly open, with the eyeballs rolling and distorted, whilst the pupils are dilated and do not contract to light; the impostor keeps his eyes closed, and he cannot prevent the iris from contracting when a bicycle-lamp is flashed across his face. A useful test is to give the impostor a pinch of snuff, which promptly brings the entertainment to an end.
Lumbago is often feigned, and the imposture should be suspected when there is a motive, and when physical signs, such as nodes and tender spots, are absent. A simple test is to inadvertently drop a shilling in front of him, when he will promptly stoop and pick it up. The same principles apply to spurious sciatica.
Hæmorrhages purporting to come from the lungs, stomach, or bowels, rarely present much difficulty. The microscope is of use in all cases of bleeding. Possibly the gums or the inside of the cheeks may have been scratched or abraded with a pin.
Skin Diseases are excited artificially, especially those which may be produced by mechanical and chemical irritants. The most commonly employed are vinegar, acetic acid, carbolic acid, nitric acid, and carbonate of sodium; but tramps frequently use sorrel and various species of ranunculus. The lesions simulated are usually inflammatory in character, such as erythema, vesicular and bullous eruptions, and ulceration of the skin. They may be complicated by the presence of pediculi and other animal and vegetable parasites. Chromidrosis of the lower eyelids in young women often owes its origin to a box of paints. Factitious skin diseases are seen most commonly on the face and extremities, especially on the left side—in other words, on the most accessible parts of the body.
Feigned menstruation, pregnancy, abortion, and recent delivery are common, and should give rise to no difficulty. The same may be said of feigned insanity, aphonia, deaf-mutism, and loss of memory.
The following hints may be useful to a medical man when called to a supposed case of malingering: Do not be satisfied with one visit, but go again and unexpectedly; see that the patient is watched between the visits; make an objective examination, compare the indications with the statements of the patient, noting especially any discrepancies between his account of his symptoms and the real symptoms of disease; ask questions the reverse of the patient's statements, or take them for granted, and he will often be found to contradict himself; have all dressings and bandages removed; suggest, in the hearing of the patient, some heroic methods of treatment—the actual cautery, or severe surgical operation, for example; finally, chloroform will be found of great use in the detection of many sham diseases.
The presumption in law is in favour of a person's sanity, even though he may be deaf, dumb, or blind.
The terms 'insanity,' 'lunacy,' 'unsoundness of mind,' 'mental derangement,' 'madness,' and 'mental alienation or aberration,' are indifferently applied to those states of disordered mind in which the person loses the power of regulating his actions and conduct according to the ordinary rules of society. The reasoning power is lost or perverted, and he is no longer fitted to discharge those duties which his social position demands. In some cases of insanity, as in confirmed idiocy, there is no evidence of the exercise of the intellectual faculties. It is probable that no standard of sanity as fixed by nature can be said to exist. The medical witness should decline to commit himself to any definition of insanity. There is no practical advantage in attempting to classify the different forms of insanity.
According to English law, madness absolves from all guilt, but in order to excuse from punishment on this ground it must be proved that the individual was not capable of distinguishing right from wrong in relation to the particular act of which he is accused, and that he did not know at the time of committing the crime that the offence was against the laws of God and nature.
Lunatics are competent witnesses in relation to testimony, as in relation to crime, if they understand the nature of an oath and the character of the proceedings in which they are engaged. The judge, as in the case of children, examines the lunatic tendered as a witness as to his knowledge of the nature and obligation of an oath, and, if satisfied, he allows him to be sworn.
A person, if suffering from such a state of mental unsoundness as to be unable to take care of his property, may be placed under the care of the Court of Chancery. The Court then administers his property, and otherwise allows him entire freedom of action.
With regard to the care of lunatics, no person is allowed to receive more than one lunatic into his house unless such house is licensed and the proper certificates have been signed. One patient may be taken without the house being licensed, but the usual certificates must in all cases be signed, and the Lunacy Commissioners communicated with. If a person receives another not of unsound mind into his house, and such person becomes subsequently insane, the person so keeping him renders himself liable to heavy penalties, unless the legal certificates are at once procured and the Commissioners of Lunacy communicated with.
At common law it appears that a lunatic cannot be placed in an asylum unless dangerous to himself or to others, but under the Lunacy Acts the placing of a madman in an asylum is considered as a part of the treatment with a view to the cure of the patient.
Idiocy is not a disease, but a congenital condition in which the intellectual faculties are either never manifested or have not been sufficiently developed to enable the idiot to acquire an amount of knowledge equal to that acquired by other persons of his own age and in similar circumstances with himself. Idiots, as a rule, are deformed in body as well as deficient in mind. Their heads are generally small and badly-shaped, and their features ill-formed and distorted. The teeth are few in number and very irregular. The hard palate has a very deep arch, or may even be cleft. The complexion is sallow and unhealthy, the limbs imperfectly developed, and the gait is awkward, shambling, and unsteady. In his legal relations an absolute idiot is civilly disabled and irresponsible, but in regard to crime, or as a witness, see remarks made above.
Imbecility is a form of mental defect not usually congenital, but commencing in infancy or in early life. The line of demarcation between the imbecile and the idiot may be found in the possession by the former of the faculty of speech, in distinction from the mere parrot-like utterance of a few words which can be taught the idiot. Imbecility may be intellectual, moral, or general. Questions frequently arise as to their responsibility for actions done by them, or as to their ability to manage their own affairs.
Cretinism is a form of amentia, which is endemic in certain districts, especially in some of the valleys of Switzerland, Savoy, and France. The malady is not congenital, but its symptoms usually appear within a few months of birth. The characteristics of this form of idiocy are an enlarged thyroid gland constituting a goitre or bronchocele, a high-arched palate, dwarfed stature, squinting eyes, sallow complexion, small legs, conical head, large mouth, and indistinct speech.
Feeble-Minded.—These are persons who are capable of earning a living under favourable circumstances, but are incapable, from mental defect which has existed from birth or from an early age, of (a) competing on equal terms with their normal fellows, or (b) of managing themselves and their affairs with ordinary prudence. Feeble-mindedness may affect the moral nature only, rendering the person selfish, untruthful, obscene, or unemployable. The Act of 1899 controls feeble-minded children; many such become paupers, criminals, prostitutes, etc.
Mental Deficiency and Lunacy Act, 1913.—Those included under this Act are idiots, imbeciles, feeble-minded persons, and moral imbeciles. The parents or guardians of such children between the ages of five and sixteen years must provide for them education and proper care. If they are unable to do so, the School Boards or Parish Councils must do so.
In dementia the mental aberration does not occur until the mind has become fully developed, thus differing from amentia, which is congenital or comes on very early in life.
Acute Dementia.—This is a condition of profound melancholy or stupor, which arises from sudden mental shock, the mind being, as it were, arrested and fixed in abstraction on the event.
Chronic Dementia is generally caused by the gradual action on the mind of grief or anxiety, by severe pain, mania, apoplexy, paralysis, or repeated attacks of epilepsy.
Senile Dementia is a form which is incidental to aged persons, and commences gradually with such symptoms as loss of memory for recent events, dulness of perception, and inability to fix the attention. Later on the reasoning powers begin to fail, and finally, memory, reason, and power of attention, are quite lost, the muscular power and force remaining intact. In the last stage there is simply bare physical existence.
General Paralysis of the Insane, Paralytic Dementia.—This is a most interesting form of dementia. It is closely allied to, if not identical with, locomotor ataxy. Its most prominent and characteristic symptom consists in delusions of great power, exalted position, and unlimited wealth—megalomania. The exaltation is universal, and the patient may maintain at one and the same time that he is running a theatrical company, that he is the Prince of Wales, and that he is the Almighty. Moral perversion is a common symptom, and the patient is often guilty of criminal assaults, indecent exposures, bigamous marriages, and the like. It is accompanied with progressive bodily and mental decay. Women are comparatively rarely affected by it, and it generally commences in men about middle age, and its duration is from a few months to three years. It is commonly parasyphilitic in origin. Paralytic symptoms first appear in the tongue, lips, and face; the speech becomes thick and hesitating. The paralytic symptoms gradually go on increasing, the sphincters refuse to act, and death may occur from suffocation and choking. Sometimes, during the earlier stages especially, there may be maniacal paroxysms or epileptic fits. The delusions remain the same throughout, the patient always expresses himself as being happy, and his last words will probably have reference to money and other absurd delusions.
When a person of hitherto blameless life is charged with an act of indecency, he should be examined for G.P.I. The condition of his prostate should also be investigated. He may be suffering from either mental or physical disease, or both (see p. 59).
Under the term 'mania' are included all those forms of mental unsoundness in which there is undue excitement. It is divided into general, intellectual, and moral, and each of the two latter classes again into general and partial.
General Mania affects the intellect as well as the passions and emotions. Mania is usually preceded by an incubative period in which the patient's general health is affected. The duration of this period may vary from a few days to fifteen or twenty years. When the disease is established, the patient has paroxysms of violence directed against himself as well as others. He tears his clothes to pieces, either abstains from food and drink or eats voraciously, and sustains immense muscular exertion without apparent fatigue. The face becomes flushed, the eye wild and sparkling; there is pain, weight, and giddiness in the head, with restlessness.
General Intellectual Mania, attacking the intellect alone, is rare; but some one emotion or passion, as pride, vanity, or love of gain, may obtain ascendancy, and fill the mind with intellectual delusions.
A delusion may be defined as a perversion of the judgment, a chimerical thought; an illusion, an incorrect impression of the senses, counterfeit appearances; hence we speak of a delusion of the mind, an illusion of the senses. Lawyers lay great stress on the presence of delusions as indicative of insanity. An hallucination is a sensation which is supposed by the patient to be produced by external impressions, although no material object acts upon his senses at the time.
Partial Intellectual Mania, or Monomania, also called Melancholia, is a form of the disease in which the patient becomes possessed of some single notion, contradictory alike to common-sense and his own experience.
General Moral Mania.—This is a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the intellect, or knowing and reasoning faculties, and particularly without any insane illusion or hallucination. It is often difficult to distinguish this form of mania from the moral depravity which we associate with the criminal classes.
Partial Moral Mania—Paranoia—Delusional Insanity.—In this form one or two only of the moral powers are perverted. Delusions are always present, and very frequently are those of persecution. The patient's conduct is dominated by his delusion; thus murder and suicide may be committed. There are several forms:
Kleptomania, a propensity to theft; common in women in easy circumstances. Dipsomania, or Oinomania, an insatiable desire for drink. Morphinomania, a craving for morphine or its preparations. Erotomania, or amorous madness. When occurring in women this is also called Nymphomania, and in men Satyriasis. It consists in an uncontrollable desire for sexual intercourse. Pyromania, an insane impulse to set fire to everything. Homicidal mania, a propensity to murder. Suicidal mania, a propensity to self-destruction. Some consider suicide as always a manifestation of insanity.
Insanity of Pregnancy.—This may show itself after the third month of pregnancy in the form of melancholia. It is not recovered from until after delivery.
Puerperal Mania.—This form of mania attacks women soon after childbirth. There is in many cases a strong homicidal tendency against the child.
Insanity of Lactation comes on four to eight months after parturition, either as mania or melancholia. The mother may repeatedly attempt suicide.
Mania with Lucid Intervals.—In many cases mania is intermittent or recurrent in its nature, the patient in the interval being in his right mind. The question of the presence or absence of a lucid interval frequently occurs where attempts are made to set aside wills made by persons having property. In these cases the law, from the reasonableness of the provisions of the will, may assume the existence of the lucid interval. A will made during a lucid interval is valid. When an attempt is made to set aside the provisions of a will on the ground of insanity in a person not previously judged insane, the plaintiff must show that the testator was mad; when the provisions of the will of a lunatic are attempted to be upheld, the plaintiff must show that the will was made during a lucid interval.
A testator is capable of making a valid will when he has (1) a knowledge of his property and of his kindred; (2) memory sufficient to recognize his proper relations to those about him; (3) freedom from delusions affecting his property and his friends; and (4) sufficient physical and mental power to resist undue influence. The fact of a man being subject to delusions may not affect his testamentary capacity. He may believe himself to be a tea-kettle, and yet be sufficiently sound mentally to make a valid will.
Undue Influence.—Persons of weak mind or those suffering from senile dementia are often said to have been unduly influenced in making their wills, and subsequently their dispositions are disputed in court. Before witnessing the will made by such a person, the medical man should satisfy himself that the testator is of a 'sound disposing mind.' This he will do by questioning, and his knowledge of the home-life of the patient will either confirm or set aside the idea of influence.
A person who is aphasic may be competent to make a will. He may not be able to speak, but may understand what is said to him, and may be able to indicate his wishes by nods and shakes of the head. Ask him if he wishes to make a will, then inquire if he has £10,000 to leave, then if he has £100, and in this way arrive approximately at the sum. Then ask him if he wishes to leave it all to one person. If he nods assent, ask if it be to his wife or some other likely person. If he wishes to divide it, ascertain his intention by definite questions, and, having ascertained his views, commit them to writing, read the document over to him, and ask if it expresses his intentions. That being settled, a mark which he acknowledges in the presence of two witnesses, preferably men of standing, will constitute a valid document.
In certain forms of neurasthenia, the 'phobias' are common, but must not be regarded as evidence of insanity. 'Agoraphobia' is the fear of crossing an open space, 'batophobia' is the fear that high things will fall, 'siderophobia' is the fear of thunder and lightning, 'pathophobia' is the fear of disease, whilst 'pantophobia' is the fear of everything and everybody.
Epilepsy in Relation to Insanity.—The subjects of this disease are often subject to sudden fits of uncontrollable passion; their conduct is sometimes brutal, ferocious, and often very immoral. As the fits increase in number, the intellect deteriorates and chronic dementia or delusional insanity may supervene. (1) Before a fit the patient may develop paroxysms of rage with brutal impulses (preparoxysmal insanity), and may commit crimes such as rape or murder. (2) Instead of the usual epileptic fit, the patient may have a violent maniacal attack (masked epilepsy, epileptic equivalent, psychic form of epilepsy). (3) After the fit the patient may perform various automatic actions (post-epileptic automatism) of which he has no subsequent recollection. Thus the patient may urinate or undress in a public place, and may be arrested for indecent exposure. Epileptics who suffer from both petit and grand mal attacks are specially liable to maniacal attacks. Such insanity differs from ordinary insanity in its sudden onset, intensity of symptoms, short duration and abrupt ending. To establish a plea of epilepsy in cases of crime, one must show that the individual really did suffer from true epilepsy, and that the crime was committed at a period having a definite relation to the epileptic seizure.
Alcoholic Insanity.—This may occur in three forms:
Responsibility for Criminal Acts.—To establish a defence on the ground of insanity, it must be proved that the prisoner at the time when the crime was committed did not know the nature and quality of the act he was committing, and did not know that it was wrong. At the present time, however, the power of controlling his actions is usually made the test.
The plea of insanity is brought forward, as a rule, only in capital charges, so that the prisoner, if found guilty, will escape hanging. If proved 'guilty, but insane,' the person is sentenced to be kept in a criminal lunatic asylum 'during His Majesty's pleasure.'
The following hints with regard to the examination of patients supposed to be insane will be useful: The general appearance and shape of head, complexion, and expression of countenance, gait, movements, and speech, should be noted; the state of the general health, appetite, bowels, tongue, skin, and pulse, should be inquired into; and in women the state of the menstrual function should be ascertained. The family history must be traced out, and the personal history taken with care, especially as to whether the unsoundness came on late in life or followed any physical cause. Ascertain whether it is a first attack, whether the patient has suffered from epilepsy, has squandered his money, grown restless, has absurd delusions, etc. In order to ascertain the capacity of the mind, questions should be asked with regard to age, birthplace, profession, number of family, and common events, such as the day of week, month, and year. The power of performing simple arithmetical operations may be tested. It may be necessary to pay more than one visit. The examiner should be careful to ask questions adapted to the station of life of the supposed lunatic; a man is not necessarily mad because he cannot perform simple arithmetical operations, or does not know about things with which his questioner is well acquainted. The opinion of a supposed lunatic that his examiner's feet were large was not considered by the Commissioners among the facts indicating insanity, yet statements quite as absurd are made by medical men as 'facts of insanity' observed by themselves. 'Reads his Bible and is anxious about the salvation of his soul' is another example of a bad certificate. Some well-marked delusion should be recorded.
For a lunacy certificate (Reception Order on Petition or Judicial Reception Order), except in the case of a pauper patient, there are required the signatures of two independent medical men and of a relation or friend. The medical men must not be in partnership or in any way interested in the patient; they must make separate visits at different times, and write on the proper forms the facts observed by themselves and those observed by others, giving the name of the informer. A certificate is valid only for seven days. In very urgent non-pauper cases the signature of one medical man is sufficient, but such certificate (Emergency Certificate or Urgency Order) is only valid for two days, and, as the patient can only be detained in the asylum under this order for seven days in England or three in Scotland, it must be supplemented by another signed as above directed. The medical certificate must contain a statement that it is expedient for the alleged lunatic to be placed forthwith under care, with reasons for making such statement. The certifying medical practitioner must have personally examined the patient not more than two clear days before his reception. In London and other large towns, where an expert opinion is readily obtainable, it is not expedient to resort to such urgency orders. Medical men should be careful how they sign certificates of insanity. No medical man is bound to certify, but if he does so he must be prepared to take the responsibility of his acts. There must be no reasonable ground for alleging want of 'good faith' or 'reasonable care.' The practitioner must exercise that amount of care and skill which he may reasonably be expected to possess.
It is somewhat difficult to define an inebriate, but for the moment the following will suffice, and will ultimately, in all probability, be officially adopted:
An inebriate is a person who habitually takes or uses any intoxicating thing or things, and while under the influence of such thing or things, or in consequence of the effects thereof, is—(a) dangerous to himself or others; or (b) a cause of harm or serious annoyance to his family or others; or (c) incapable of managing himself or his affairs, or of ordinary proper conduct.
Under the provisions of the Habitual Drunkards Acts (42 and 43 Vict., c. 19, and 51 and 52 Vict., c. 19), any habitual drunkard may voluntarily place himself under restraint. He must make an application to the owner of a licensed retreat, stating the time during which he undertakes to remain. His application must be accompanied by a statutory declaration of two persons stating that they knew the applicant to be a confirmed drunkard. Without this testimony as to moral character his application cannot be entertained. His signature must also be attested by two justices, who must state that he understands the effect of his application, and that it has been explained to him. The limit to the term of restraint is twelve months, after which he must resume his former habits if he wishes to qualify for another period. The Act works automatically, and, when it has been set for a certain time, the patient cannot release himself until the period has expired. The Inebriates' Retreat must be duly licensed, and the licensee incurs distinct obligation in return for the powers entrusted to him. It is an offence against the Act to assist any habitual drunkard to escape from his retreat, and should he succeed in effecting his escape he may be arrested on a warrant. A drunkard who does not obey orders and conform to the rules of the establishment may be sent to prison for seven days. It may be as well to mention that it is an offence to supply any drunkard under the Act with any intoxicating drink or sedative or stimulant drug without authority, and that the penalty is a fine of £20 or three months' imprisonment. The Act is a good one, but might be carried farther with advantage. It has been ruled that a crime committed during drunkenness is as much a crime as if committed during sobriety. A person is supposed to know the effect of drink, and if he takes away his senses by drink it is no excuse. He is held answerable both for being under the influence of alcohol or of any other drug, and for the acts such influence induces.
Inebriates Act (1898-1900).—If an habitual drunkard be sentenced to imprisonment or penal servitude for an offence committed during drunkenness, or if he has been convicted four times in one year, the court may order him to be detained for a term not exceeding three years in an inebriate reformatory.
Though the law does not define in definite terms what a poison really is, it lays stress on the malicious intention in giving a drug or other substance to an individual. It is a felony to administer, or cause to be administered, any poison or other destructive thing with intent to murder, or with the intention of stupefying or overpowering an individual so that any indictable offence may be committed. It is a misdemeanour to administer any poison, or destructive or noxious thing, merely to aggrieve, injure, or annoy an individual. For a working definition we may state that a poison is a substance which, when introduced into or applied to the body, is capable of injuring health or destroying life. A poison may therefore be swallowed, applied to the skin, injected into the tissues, or introduced into any orifice of the body.
The sale of poisons is regulated by various Acts, but chiefly by the Pharmacy Act, 1868, and by the Poisons and Pharmacy Act, 1908. Only registered medical practitioners and legally qualified druggists are permitted to dispense and sell scheduled poisons. They are responsible for any errors which may be committed in the sale of poisons. If a druggist knows that a drug in a prescription is to be used for an improper purpose, he may refuse to dispense it. The practitioner who carelessly prescribes a drug in a poisonous dose is not held responsible, but the dispenser would be if he dispensed it and harmful or fatal consequences followed on its being swallowed. When a dispenser finds an error in a prescription, it is his duty to communicate with the prescriber privately pointing out the mistake.
A great responsibility rests on the medical man who does his own dispensing, as there is no one to check his work.
If a doctor prescribes a drug with the intention of curing or preventing a disease, but that, contrary to expectation and general experience, it causes illness or even death, no responsibility can rest with the prescriber. It has to be proved that actual injury has been sustained by the complainant before an action for damages can be commenced, and that the plaintiff was free from all contributory negligence.
Scheduled Poisons.—By the Pharmacy Act of 1868 two groups of poisons are scheduled. Part I. contains a list of those which are considered very active poisons—e.g., arsenic, alkaloids, belladonna, cantharides, coca (if containing more than 1 per cent. alkaloids), corrosive sublimate, diachylon, cyanides, tartar emetic, ergot, nux vomica, laudanum, opium, savin, picrotoxin, veronal and all poisonous urethanes, prussic acid, vermin killers, etc. Such poisons must not be sold to strangers, but only to persons known to or introduced by someone known to the druggist. If sold, the latter must enter into the 'Poison Register' the name of the poison, the name of the person to whom it is sold, the quantity and purpose for which it is to be used, and date of sale. The entry must be signed by the purchaser and by the introducer. The word 'Poison' must be affixed to the bottle or package, and also the name and address of the seller.
Part II. contains a list of poisons supposed to be less active. These may only be sold if on the bottle, box, or package there is affixed a label with the name of the article, the word 'Poison,' and the name and address of the seller. It is not necessary to enter the transaction in a register.
Chemists are required to keep poisons in specially distinguishable bottles, and these in a special room or locked cupboard.
Dangerous Drugs Act, 1920.—The regulations restrict the manufacture and sale of opium, morphine, cocaine, and heroin so as to prevent their abuse. Preparations containing less than 1/5 per cent. of the first two or less than 1/10 per cent. of the last two are excluded. Prescriptions containing the above drugs must be dated and signed with the full name and address of the prescriber, and must have also those of the patient. The total amount of the drug to be supplied must be stated, and it must not be dispensed more than once; the dispenser retains the prescription. Special books must be kept recording the purchase and sale of these drugs.
Proprietary Medicines Bill (introduced in 1920, and likely soon to become law).—The sale of any unregistered proprietary medicine purporting to cure certain diseases or produce abortion is made an offence. A register of proprietary medicines, etc., is established. The object is to protect the public against quack remedies.
Notification of Poisoning.—Every case of poisoning which occurs in any industry (lead, arsenic, anthrax, etc.) must be notified by the medical attendant to the Chief Inspector of Factories (Factory and Workshops Act, 1895).
Action of Poisons.—They may act either locally or only after absorption into the system.
Age, idiosyncrasy, tolerance, and disease, all exert modifying influences on the action of a poison. The form in which the poison is swallowed and the quantity also determine its action. In the gaseous form, poisons act most rapidly and fatally. When in solution and injected hypodermically, they also act very rapidly. In the solid form they act as a rule slowly, and may even set up vomiting, and so may be entirely ejected by vomiting. Poisons act most energetically when the stomach is empty. If taken when the stomach already contains food, solution and absorption may be greatly delayed.
Some poisons are cumulative in their action, and thus, even if infinitesimal doses be swallowed each day, there is a certain amount of storage in the tissues (though a certain percentage of the poison is being constantly eliminated), and at last symptoms of poisoning show themselves.
Classification of Poisons.—As an aid to memory, the following classification is perhaps the best:
| 1. Irritant | { | Animal—venomous bites, food poisoning, cantharides. Vegetable—all strong purgatives, hellebores, savin, yew, ergot, hemlock, laburnum, bryony, etc. |