MEDICO-LEGAL AND MEDICO-SOCIAL DUTIES OF MEDICAL MEN 1. Taking the responsibility of advising the restriction of liberty, and placing cases under the care of attendants at home. 2. Signing medical certificates of insanity, in order to place patients in asylums and under care in private houses: (a) Is the patient insane? (b) If so, is he "a proper person to be detained under care and treatment?" (c) Why should he be placed in an asylum or sent from home? (d) Is there any legal risk to those who take the steps for asylum treatment? (e) Fill up even the formal part of the certificate up to "Facts" carefully; (f) "Facts indicating insanity ob- served by myself" the most important part of certificate-Delusions-Ap- pearance and manner of patient-Expression of face-Incoherence-Want of memory-Change from natural condition-Suicidal or homicidal expres- sions-Taciturnity-Quote words used-Put no redundancies-Cumulate facts-Use facts observed at other interviews; (g) "Facts communicated by others," corroborative-Attempts at suicide-Assaults-Paroxysmal aggravations; (h) Get the cue to delusions, etc., from others before you see patient; (i) Necessity for tact-Sometimes a little stratagem-Cunning and reticence of patients; (k) Cannot keep patients in private houses with- out certificate in England, or notice to Commissioners in Scotland. 3. Giving certificates of sanity-Need for care and caution. 4. Giving certificates as to the appointment of a curator bonis in Scotland, and making affidavits and giving evidence before a master in lunacy in England and Ireland when a commission de lunatico inquirendo is held by him. 5. Giving evidence as to the existence of mental disease or not in criminal cases, to enable the law to fix or absolve from responsibility, before higher and lower courts, and as adviser to procurator-fiscal in Scotland. Crimes most com- monly committed in Mania.-Epileptic, Alcoholic, Puerperal, and Simple. Melancholia.-Delusional. Dementia.-Impulsive violence. Impulsive Insanity. Homicidal, kleptomania, pyromania, animal impulse-Compli- cations of insanity with drunkenness-Somnambulism and allied states- Divergence of medical and legal views. Successive Legal Views.-Wild beast theory (Tracey)-Knowledge of right and wrong (Mansfield)— Knowledge of right and wrong as to the act (Twelve Judges)-Delusional test (Denman)-Habit and repute (Moncrieff)-Power of control (New Criminal Code, Stephen)-Difficulty of cases on the borderland-Necessity for caution, full knowledge of all the facts, and strict impartiality. 6. Will-making. Is he free from the influence of drink or drugs? Does he understand the nature of the act he is doing, and the effect of the document? Is the disposition of the property a natural one? Is it not influenced by insane delusion or insane state of mind? Is there no facility with undue influence being exerted? Can he tell twice over the disposition he wishes to make? Does he know how much property he has? Do not let a good motive sanction a bad will. 7. Detecting Feigned Insanity.-No general rule-Are the symptoms those of any known type of insanity? Is there any motive? Watch the patient when he thinks he is unobserved-Over- does his part-Power of endurance-Sleep-Sensibility-Sudden shocks, electric battery, etc.-Hysteria-Effect of drugs-Difficulty of this question -Imitations of aggravated insanity-Self-accusations of really insane people. 8. Giving confidential family advice as to such matters as engagements to marry, education, choice of profession, sudden changes of conduct and morals-Dreadful effect of helping to increase the neuroses, the insanity, and the idiocy in the world-On the other hand, Maudsley's opinion as to the genius that may result from neurotic marriages-Special mode of educa- APPENDIX. DESCRIPTION OF THE PLATES. PLATE I. (Frontispiece.) Appearance of the vertex of one hemisphere of the brain in a case of advanced General Paralysis. a, Skull-cap condensed. b, Anterior third of brain, as seen when dura mater was first raised, showing thickened milky arachnoid dotted over with small white spots, with the opaque turbid compensatory fluid under it, and the tortuous dilated veins, congested vessels, the convolutions showing dimly through. c, Middle third of brain, showing the appearance of the convolutions after the pia mater has been removed. They are congested, and the outer layers of gray substance have been torn away in irregular patches, from the most projecting part of many of the convolutions having adhered to the pia mater and been removed with it. The portions so removed have left ragged, eroded-looking spaces where the gray substance looks softened, while the outer layer looks hard and opaque on its surface. d, Shows the pia mater stripped from middle third of brain, hanging down, concealing posterior lobe of brain, and showing the appearance of its inner surface with the portions of the convolutions adhering to it. It is congested and thickened, so that, instead of being like the normal pia mater, a delicate, filmy, transparent membrane, it is a tough, spongy-looking texture. PLATE II. (Page 140.) Fac-simile of a letter written by a maniacal patient, showing incoherence, rapid change of ideas, delusions, hallucinations of sight, an insane association of ideas, and an insane symbolism. PLATE III. (Page 156.) The appearance of a section of the anterior lobe of the brain in a patient who had died of the exhaustion of acute mania. It shows-a, the congested gray substance of the convolutions; b, congested white substance near gray matter; c, an inner ring of still more intense congestion along the line of junction of the gray and white substances, and extending into the white substance; and d, limited areas of congestion in the white substance. This is a type of the irregular vascularity seen in the brain very commonly in insanity, indicating probably during life a disturbed vaso-motor condition, which may be either the proximate cause, or a necessary accompaniment, or the effect of the mental disturbance. PLATE IV. (Page 187.) Great thickening of skull-cap anteriorly, with enormous deposits of new osseous tissue in an irregular nodulated way on the inner table of skull, in a case of alternating insanity of over twenty years' duration. This is an aggravated example and type of what is almost universal in chronic insanity with periods of excitement. It is a proof of the structural effects of such repeated congestions of the branches of the carotid artery, even in the hardest tissue, and may be fairly considered to be of the same nature as the brain changes in the same cases, which are not so evident, but are no doubt far more important. The atrophy of the anterior lobes of the brain that usually accompanies such bony thickenings and deposits probably helps the tendency, there being nothing but dura mater and cerebro-spinal fluid immediately under such growths. PLATE V. (Page 306.) A section through the brain of a man who had labored under syphilitic insanity (the third or vascular form), with slow arteritis affecting the vessels supplying the anterior and part of middle lobes of one hemisphere. This had caused slow starvation and absorption of nearly all the white substance in the centre of those lobes, leaving the gray matter of the gyri almost intact, so that there was a bag of fluid inside with the convolutions as its walls. The convolutions looked at from the inside are quite defined, and look as if the white substance had been carefully scraped off them. This illustrates the greater vascularity, and consequent greater vitality, of the gray matter as compared with the white, as well as the different sources of the chief blood-supply of each. PLATE VI. (Page 165.) A chart showing the relative prevalence of Melancholia (thin line), Mania (thick line), and General Paralysis (dotted line), in the Royal Edinburgh Asylum, and the ages at which those three conditions are most prevalent. The numbers per 1000 of the total admissions run along the sides, and the ages along the top and bottom of the chart. It is seen that most cases of melancholia occur between 35 and 40, while the highest number suffering from mania occurred between 20 and 25. The melancholic line keeps high all through the end of life. General paralysis is scarcely found at all before 25, reaches its acme between 40 and 45, and is not found at all after 57. While maniacal conditions rise highest as adolescence is completed, between 20 and 25, they rise very high again at the period when melancholic conditions prevail most, between 35 and 40; that is, when the mental and moral causes of insanity are most prevalent, when the business troubles, domestic worries, the afflictions, and the keen competitions of life are most common or most intensely felt. PLATE VII. (Page 83.) Five microscopic drawings. Fig. 1. Cells of semilunar abdominal ganglion of a very bad case of visceral melancholia, in a condition of atrophy, degeneration, and pigmentation. This patient had intense delusions that she had no stomach, and that her bowels were never moved. She had no appetite, and she obstinately refused food, and died of exhaustion, though regularly fed with the stomach-pump. Fig. 2. A marked apoplexy in a convolution, such as seen frequently in a lesser degree in acute mania, general paralysis, syphilitic insanity, senile insanity, and epileptic insanity (after Dr. J. J. Brown). Fig. 3. An epithelial granulation, from the floor of the fourth ventricle of a case of advanced general paralysis, showing the enormous proliferation of the epithelial cells. There is one or, at the most, two normal layers of delicate epithelial cells in this position; but as seen in the section they have increased a thousandfold, and have altered entirely in appearance. At the summit of the granulation they are round, at its base flattened, while under it we observe a sclerosed layer of nervous tissue, with the neuroglia enormously increased in volume. Fig. 4. The proliferated and much enlarged nuclei of the neuroglia, from a convolution of an acute case of general paralysis, who died of epileptiform convulsions. Those nuclei are seen to follow the course of the capillaries in some places, sometimes even taking their place, the vascular tissue having disappeared altogether. Fig. 5. A very interesting section of the outer part of a convolution of a case of general paralysis, as seen under a low power. The section had been forgotten in water, and had undergone partial maceration, so that the nerve cells and fibres had disappeared, leaving only at the free surface of the convolution the thickened pia mater full of nuclei, then under that the condensed and altered outer layer of gray substance, which is adherent to the pia mater in general paralysis, with few capillaries, then under this is seen the finer network of capillary vessels, and deeper still the more open network of vessels towards the white substance. All these vessels were seen under a high power to be congested, their coats thickened and covered with adventitious fibrous substance and proliferated nuclei. The actual space left for the nerve cells is much diminished in such a case. The gradually increasing fineness of the vascular reticulation in the gray substance of a brain convolution as we approach its peripheral surface, a fact to which there is little reference in works on histology, is here very well seen. A section of a normal convolution would not have held together at all under this treatment. PLATE VIII. (Page 306.) Fig. 1. A small artery in the brain, with all its coats enormously thickened, separated from each other, and its lumen almost obliterated, as found in cases of syphilitic insanity, senile insanity and other forms (after Dr. J. J. Brown). |