Aids To Forensic Medicine And Toxicology Part 9

=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.

XLII.--DEMENTIA: ACUTE, CHRONIC, SENILE, AND PARALYTIC

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 a.s.saults, 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).

XLIII.--MANIA

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 cla.s.ses again into general and partial.

=General Mania= affects the intellect as well as the pa.s.sions 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 pa.s.sion, 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 a.s.sociate with the criminal cla.s.ses.

=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 circ.u.mstances. _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 s.e.xual 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 a.s.sume 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 a.s.sent, 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 doc.u.ment 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 const.i.tute a valid doc.u.ment.

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 s.p.a.ce, '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 pa.s.sion; 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 pet.i.t 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:

1. _Acute Alcoholic Delirium_ (_mania a potu_), due to excessive amount of alcohol consumed.

2. _Delirium Tremens_, due to long-continued over-drinking. The patient suffers from horrible dreams, illusions, and suspicions, which may lead him to attack people or commit suicide.

3. _Chronic Alcoholic Insanity._ Loss of memory is the chief symptom, with paralysis of motion, hallucinations and delusions of persecution.

=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.'

XLIV.--EXAMINATION OF PERSONS OF UNSOUND MIND

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, appet.i.te, 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 Pet.i.tion_ 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 pract.i.tioner 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 pract.i.tioner must exercise that amount of care and skill which he may reasonably be expected to possess.

XLV.--THE INEBRIATES ACTS

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.