Skip to main content

Full text of "Medical jurisprudence, forensic medicine and toxicology"

See other formats






SJK!}£^. -:.',:::i;>^j -nv;-;,^!" 



< i 



'••y^ .-:'V.'":*i3:W 



hX-'^'" 



r.- 1 






f ■ i 










CORNE LL UNIV ERSITY 

.THE 

Sflouipt Hctcrtnatg Etbrary 

FOUNDED BY 

ROSWELL P. FLOWER 

for the use of the 
N Y. STATE VETERINARY COLLEGE 

1897 

This Volume is the Gift of 

pr,JLep.n....S......B.eardalejr 



Cornell University Library 
RA 1051.W83 1906 

V.3 



Medical 



I 



urisprudence, forensic medicine 




3 1924 000 293 245 




The original of tiiis book is in 
tine Cornell University Library. 

There are no known copyright restrictions in 
the United States on the use of the text. 



http://www.archive.org/cletails/cu31924000293245 



MEDICAL 
JURISPRUDENCE 

FORENSIC MEDICINE 

AND 

TOXICOLOGY 

BY 

R. A. WITTHAUS, A.M., M.D. 

Professor of Chemistry, Medical Jurisprudence, and Toxicology in Cornell University 

AND 

TRACY C. BECKER, A.B., LL.B. 

Counsellor at Law 
Professor of Criminal haw and Medical Jurisprudence in the University of Buffalo 

THUttb tbe Collaboration of 

August Becker, Esq.; A. L. Becker, Esq.; Chas. A. Boston, Esq.; Hon. Goodwin 

Brown; W. N. Bullard, M.D.; G. C. Cameron, M.D.; J. Clifton Edgar, M.D.; 

Jas. Ewing, M.D.; E. D. Fisher, M.D.; A. S. Geyser, M.D.; J. C. 

Johnson, M.D.; D. S. Lamb, M.D.; H. P. Looms, M.D.; W. B. 

OuTTEN, M.D.; RoswELL Park, M.D.; J. Parmenter, M.D.; 

Irving C. Rosse, M.D.; E. V. Stoddart, M.D.; 

George Woolsey, M.D.; J. H. Woodward, M.D, 



Secon& Ebitfon 



VOLUME THREE 



NEW YORK 

WILLIAM WOOD AND COMPANY 

MDCCCCIX 



Copyright, 1909, 
By WILLIAM WOOD AND COMPANY 



PRRS8 OF 

THE PUBLISHERS' PRINTING COMPANY 

419-421 LAFAYETTE ST. 

NEW YORK 



CONTENTS. 



PAGE 

Table of Cases, v 

Biological, 1 

Medico-legal Relations of Vision and Audition, and of Injuries to 

the Eye and Ear. J. H. Woodward, 3 

Medico-Legal Relations of Insurance. A. L. Becker, . . . 129 . 

Medical Aspects of Insanity in its Relations to Medical Jurispru- 
dence. Edward D. Fisher, . , 145 

Mental Unsoundness in its Legal Relations. Tracy C. Becker 

and Charles A. Boston, 347 

Care and Custody of Incompetent Persons and their Estates. 

Goodwin Brown, Second Edition revised by A. L. Becker, 677 

Medico-Legal Aspect of Marriage and Divorce. A. L. Becker, . 758 

Medico-Legal Relations of X-rays and Skiagraphs. Albert G. 

Geyser, 771 

Medico-Legal Examination of Blood anil other Stains and of the 

Hair. James Ewinq, . 807 

Index TO Vols. I., II., and III., 911 



TABLE OF CASES CITED m THIS VOLUME. 



PAGE 

A. V. A., 19 L. R. (Ireland), 403 . . 763 
A. V. B. and ano., 1 P. and D. (Eng.), 

559 766 

Abbott V. Commonwealth, 21 Ky. L. 

R., 1,372; 65S.W.R.,196...,502, 

513, 536 

Adams, In re, 10 Pa. Dist. R., 237. 

402, 519, 555 

Adams's Est., In re, 201 Pa. St., 502; 

51Atl. R.,368 565 

Adamsi;. State, 123 Ga., 500 456 

Adams v. State, 34 Tex. Cr., 470; 31 

S.W.Rep.,372 545 

Adams v. Thomas, 81 N. C, 296 . . 597 
Addington v. Wilson, 5 Ind., 137. . 399 
iBtna Life Ins. Co. v. Davey, 123 U. 

S., 739; 8 Sup. Ct., 331; 31 Law- 
yers' Ed., 315 139 

Mtna, Life Ins. Co. v. Fitzgerald, 165 

Ind., 317; 75 N. E. R., 262; 1 L. R. 

A.(N.S.),422 137 

Mtna, Life Ins. Co. v. Kaiser, 115 Ky., 

539 135 

jEtna Life Ins. Co. v. Sellers, 154 Ind., 

370; 56 N. E. R., 97 364, 368 

^tna Life Ins Co. v. Ward, 140 U. S., 

76; 11 Sup. Ct. R., 720; 35 Lawyers' 

Ed., 371 135, 136, 139 

Airington v. Airington, 32 Ark., 674. 

686 
Alabama & V. Ry. Co. v. Jones, 73 

Miss., 110; 19 So. R., 105 364 

Aldrich v. Steen, 98 N. W. R., 445; 

100 N. W R.. 311; 71 Neb., 33. 761 
Aldrich v. Superior Ct., 120 Cal., 140; 

62Pac. R., 148 592 

Allen ». Baker, 86 N. C, 91 768 



PAGE 

Allis V. Billings, 6 Mete. (Mass.), 415. 

364 
Allis V. Morton, 4 Gray (Mass.), 63. 586 
Allison's Est., In re, 104 Iowa, 130; 73 

N.W. R.,484 667 

Alvord V. Alvord, 109 Iowa, 113; 80 N. 

W. Rep., 306 537,543 

American Trust & Banking Co. v. 

Boone, 29 S. E. R., 182; 40 L. R. 

A., 250; 102 Ga., 202 370 

Ames V. Ames (Ore.), 67 Pac. R., 

737 526 

Anderson v. State, 43 Conn., 514; 21 

Am. Rep., 669 439, 460 

Anonymous, 35 Ala., 226 762, 

764, 765 
Anonymous, 89 Ala., 291; 7 So. R., 

100 762,763 

Anonymous, 21 Misc. (N. Y.), 765. 

766, 767 

Anonymous, 34 Misc. (N. Y.), 109; 

69Supp.,647 765 

Anonymous, 11 W. N. Cas., 479. .765 

Appleby v. Brock, 76 Mo.^ 314 636 

Argo V. Coffin, 32 N. E. Rep., 679; 

142 111., 368 362 

Arington v. Short, 3 Hanks (N. C), 

71 587 

Armstrong v. State, 30 Fla., 170; 11 

So. Rep., 618 532, 535, 542, 

652, 557, 569, 663 
Arnett's Com. v. Owens, 23 Ky. L. R., 

1409; 65 S. W. R., 161 364, 

368, 587 
Arnhout, In re, 1 Paige (N. Y.), 497. 

593 
Ashley v. Hohnan, 15 S. C, 97. .582 



VI 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Ashworth v. McNamee (Colo. App.), 

70 Pac. R., 156 516 

Ash's Case (Eng.), 1 Eq. Cas. Abr., 

278 762 

Asylum v. Craven, 17 Ky. L. R., 667; 

32 S. W. R., 291 383 

Aszman v. State, 123 Ind., 347; 24 

N. E. Rep., 123 487,493 

Atkinson v.. Medford, 46 Me., 510.761 
Attaway v. State (Tex. Cr. App.), 

55 S. W. Rep., 45 ..442 

Atwell V. Jenkins, 40 N. E. Rep., 178; 

163 Mass., 362 366 

Auilerson v. Auilerson, 42 Vt., 350. 

595 
Austen v. Graham,8Moore P. C, 493; 

1 Spinks, 357 398 

Autremont v. Fire Assn., 48 N. Y. St. 

Rep., 43; 65 Hun, 477; 20 N. Y. 

Supp.,345 437 

Averills' Est., In re, 133 Cal., 414; 

66 Pac. R., 14 382 

Avery v. Wilson , 20 Fed. R., 856 . . 425 
Ayers v. State, 26 S. W. R., 396. .490 
Aylward v. Briggs, 145 Mo., 604; 

47S. W. R., 510 517 

Ayres v. Russell, 50 Hun (N. Y.), 282. 

604 

B. m-se H. v. B. (1901), P 39. . .765 
Bacon v. Bacon (Mass.), 62 N. E. 

Rep., 990 417, 420, 565 

Bacon v. Bacon, 76 Miss., 458; 24 

So. Rep., 968 604 

Bacon v. United States Mut. Ace. 

Ass'n, 44 Hun (N. Y.), 599 141 

Bacon v. United States Mut. Ace. 

Ass'n, 123 N. Y., 304; 25 N. E. R., 

399; 20 Am. St. R., 748; 9L. R.A., 

617 136, 138 

Bageard v. Consolidated Traction Co. 

(N. J.), 45Atl. R.,620 428 

Bain v. Cline, 33 Pac. Rep.; 542; 24 

Or., 175 395,397,411 

Baird v. Howard, 36 N. E. Rep., 732; 

51 Ohio St., 57 376 

Balke v. Rerpass, 77 N. C, 193. . .684 



PAGE 

Baldwin v. Golde, 88 Hun, 115; 34 

N. Y. Supp., 687 366 

Baldwm v. State, 12 Mo., 233 . . .536 
Baldwin's Est., In re, 13 Wash., 366; 

43 Pac. R., 934 661, 566 

Ball V. Kane, 1 Penne. (Del.), 90; 39 

Atl. R.,778 413,503,516 

Ball V. Smith, 83 Hun (N. Y.), 438; 

23 N. Y. Supp., 54 361 

Ballard v. Chicago, etc., Ry. Co., 70 

Mo. App., 108 363,364 

Banker v. Banker, 63 N. Y., 409. 

367, 528, 666 

Banks v. Goodfellow, L. R., 6 Q. B., 

548 388,396,400 

Bannister v. Jackson, 46 N. J. Eq. 

(1 Dick.), 593, affirming 15 N. J. Eq. 

(18 Stew.), 702; 17 Atl., 692.. .414 
Baranoski's Case, 9 Pa. Co. Ct., 264. 

430 
Barber's Est., In re, 63 Conn., 393; 

27 Atl. R., 973 537,666 

Barbey v. Boardman, 202 Pa. St., 

185; 51 Atl. R. , 756 . . 392, 405, 408 
Barbineau's Will, In re, 27 Misc. R., 

417; 59 N. Y. Supp 408 

Barbour v. Moore, 4 App. D. C, 636. 

503, 604, 517, 520, 521, 566 

Barbour v. Moore, 10 App. D. C, 30. 

666 
Barker, In re, 2 Johns. Ch. (N. Y.), 

232 579 

Barkley v. Barkley Cemetery Assn., 

153 Mo., 300; 64 S. W. R., 482. 

656 
Barkman v. Richards (N. J. Pre.), 49 

Atl. R., 831 623 

Barlow v. Waters, 16 Ky. L. R., 426; 

28S.W.R.,786 419 

Barmley, Case of, 3 Atk., 173 679 

Barnesu. Hathaway, 66 Barb. (N. Y.), 

452 382 

Barnes v. State, 19 Conn., 398. . .482 
Barnett v. State (La.), 39 So. R., 

778 506 

Barnewall v. Murreil, 18 So. R., 831. 

667 



TABLE OF CASES CITED IN THIS VOLUME. 



Vll 



PAGE 

Barry v. United States Mut. Ace. 

Ass'n, 23 Fed., 712 141 

Barteline, In re, 34 Misc. R. (N. Y.), 

131; 9 N. Y. Ann.Cas., 448; 69 N. 

Y.Supp.,468 581 

Barth v. State, 46 S. W. R., 228; 39 

Tex. Cr., 381 604 

Bartholick, In re, 5 N. Y, Supp., 842. 

406 
Barton v. Goraa, 42 Hun (N. Y.), 

655 603 

Bascomb v. Bascomb, 25 N. H., 267. 

763, 764 

Bates V. Hyman (Miss.), 28 So. Rep., 

567 368 

Baxter v. Abbott, 7 Gray (Mass.), 71. 

531 
Baxter v. Baxter, 76 Hun (N. Y.), 

98; 27 Supp., 834 568, 576 

Baxter v. Earl Portsmouth, 7 D. and 

R.,614; 9 Alb. L. J., 30 354 

Baylies'!). Spaulding (Mass.), 6 N. E. 

Rep., 62; 1 N. E. Rep., 914. 399 
Beach, In re, 23 App. Div. (N. Y.), 

411; 48 N. Y. Supp., 437 399 

Beach v. Supreme Tent of K. of T. M. 

of the World, 177 N. Y., 100; 69 

N. E. R., 281 143 

Beall V. Stokes, 95 Ga., 375; 22 S. E. 

R., 637 581 

Beasley v. Beasley, 180 111., 163; 54 

N. E. R., 187 356, 369 

Beaubien i;.Cicot, 12 Mich., 459. .536 
Beaumont, Case of, 1 Wharton (Pa.), 

52 579 

Becket, Matter of, 103 N. Y., 167. 

410 

Beckwith, Matter of, 3 Hun, 443. 

367, 593 

Bedlow's Will, In re, 67 Hun (N. Y.), 

408; 22 N. Y. Supp. 290. . 397, 555 
Behrens v. McKenzie, 23 Iowa, 333; 

92 Am. Dec., 428 364, 425 

Behrensmeyer v. Kreitz (111.), 26 N. 

E., 704 587 

Bell V. McMaster, 29 Hun (N. Y.), 

272 ,...536 



PAGE 

Bellison v. Apland (Iowa), 89 N. W. 

Rep., 22 429 

Bennett, In re, 5 N. Y. Supp. 199. 

406 
Bennett v. Bennett (Neb.), 91 N. W. 

.R.,409 363 

Bennett v. Bennett (N. J. Pre. Ct.), 

26 Atl. Rep., 573; 50 N. J. Eq., 

439 384, 389, 392 

Bennett v. Hibbert, 88 Iowa, 154; 55 

N.W.,93 392,411 

Benton's Est., In re, 131 Cal., 472; 

63Pac. R., 775 421 

Benton's Estate, In re, 131 Cal., 472; 

63 Pac. R., 795 418 

Benton v. Boston City Hosp., 140 

Mass., 13; 1 N. E., 836 607 

Bentz V. Northwestern Aid Ass'n, 40 

Minn., 202; 41 N. W. R., 1037; 2 

L. R. A., 784 135 

Berdolt v. Berdolt, 56 Neb., 792; 77 

N. W. R., 399 764 

Beresford v. Stanley, 6 Ohio N. P., 38. 

403, 566 

Bernays v. United States Mut. Ace. 

Ass'n, 45 Fed., 455 139 

Berrien, In re, 5 N.Y. Supp., 37; 12 

id., 385 406 

Berry v. Safe Dep. & Tr. Co. (Md.), 

53 Atl. R., 720; see Safe Dep. & 

Tr. Co. V. Berry . . . .389, 508, 513 
Bernhardt v. State, 82 Wis., 23; 51 

N. W. Rep., 1009 487, 491, 

493, 494 
Betts V. Betts, 84 N. W. R., 975. .521 
Bevelot v. Lestrade, 153 111., 626; 38 

N. E. R., 1056 419 

Bever v. Spangler (Iowa), 61 N. W. 

Rep., 1072 410 

Bey, Succession of, 46 La. Am., 773; 

15 So. R., 297 669 

Bickwell v. Speer, 38 Misc. R. (N. Y.), 

389; 77 N. Y. Supp., 920. . . .356, 

366, 371, 381 

Billings V. Met. Ins. Co., 70 Vt., 477. 

140 
Bishop V. Commonwealth, 22 Ky. L., 



VUl 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

760; 58 S. W. R., 817; 22 Ky. L., 

1161; 60 S. W. R., 190.... 530, 

534 
Blackburn v. State, 23 Ohio St., 146. 

455 
Blackmann v. Edsall (Colo. App.), 

68Pac. R., 790 521 

Black's Est., In re, 132 Cal., 392; 64 

Pac. R., 695 418, 567 

Blair's Will", In re, 16 Daly (N. Y. 

Com. PL), 540 387 

Blakely's Will, Matter of, 48 Wis., 

294 531 

Blanchard v. Nestle, 3 Denio (N. Y;), 

47 385,580 

Bleecker v. Lynch, 1 Bradf. (N. Y.), 

458 402,411 

Blewitt, In re, 131 N. Y., 541 585 

Blewitt, In re, 138 N. Y., 148; 33 

N. E. Rep., 820 592 

Blinn, In re, 99 Cal., 216; 33 Pac. 

Rep., 841 424 

Blinn v. Schwartz, 63 App. Div., 25; 

71 N. Y. Supp., 343; afifd. 177 N. 

Y., 252 355,364,369 

Blough V. Parry, 144 Ind., 463; 43 N. 

E. R., 460 384, 567 

Blummer v. State (Ind.), 34 N. E. 

Rep., 968 559 

Boardman v. Woodman, 47 N. H., 

120 537 

Boggess V. Boggess, 29 S. W. Rep., 

1018; 127 Mo., 305 362 

Boggs V. Boggs (Neb.), 87 N. W. R., 

39 420 

Boisaubin v. Boisaubin, 51 N. J. Eq., 

252; 27 Atl. R., 624 523 

Bokemper v. Hazen, 96 Iowa, 221. 

366 
Boldman v. Leng's Est. (Mich.), 8 

Det. Leg. N., 175; 86 N. W. R., 

148 382 

Boiling V. State, 54 Ark., 588; 16 

S. W. R., 658 436, 457, 463, 

559, 585 
Boiling V. Turner, 6 Rand. (Va.), 584. 

595 



PAGB 

Bonard's Will, 16 Abb. Pr., N. S„ 128. 

398, 399 
Bond V. Neuschwander, 86 Wis., 391. 

380 
Bonnemort v. GiU, 165 Mass., 493; 

43 N. E. R., 299 519 

Bonner, In re, 33 Misc. (N. Y.), 9; 

67 Supp., 1117 555 

Booker v. State, 156 Ind., 435; 60 

N. E. R., 166; 54 L. R. A., 391. 

490, 493 

Boone v. Ritchie, 21 Ky. L. R., 864; 

53 S. W. R., 518 419, 567 

Boorman v. N. W. Mutual Relief 

Ass'n,90Wis.,144; 62N.W. Rep., 

924 543 

Bordeaux v. State, 51 Tex. Cr. Rep., 

37 482 

Borgasen v. Eklund, 96 111. App., 443. 

429 
Borum v. Bell, 31 So. R. (Ala.), 454. 

381 
Boswell V. State, 39 S. E. R., 897, 898; 

114Ga., 40 141 

Boughton V. Knight, L. R., 3 P. and 

D., 64, 72 387 

Bovard v. State, 30 Miss., 600 451 

Bowden v. People, 12 Hun (N. Y.), 

85 502 

Bower v. Bower, 142 Ind., 194; 41 

N. E. R., 523. .503, 614, 637, 544 
Bower v. Bower, 45 N. E. Rep., 

595; 146 Ind., 393 389 

Bowers, In re, 27 Pittsb. Leg. J. (N. 

S.), 237 r 411 

Bowman v. N. W. Mut. Relief Ass'n, 

90 Wis., 144; 62 N. W. Rep., 924. 

357 
Boydan v. Haberstumpf, 3 Det. Leg. 

N., 906; 88 N. W. R., 386 429 

Boyle V. Northwestern Mutual Life 

Ins. Co., 95 Wis., 312; 70 N. W. R., 

351 142 

Boynton v. Reese, 112 Ga., 354; 37 

S. E. R., 437 164 

Brackney v. Fogle, 156 Ind., 535; 60 

N. E. R.,303 512 



TABLE OF CASES CITED IN THIS VOLUME. 



IX 



PAGE 

Bradley v. Palmer, 193 111., 15, 61 

N. E. R.,856 516 

Bradley v. State, 31 Ind., 492 508 

Bradwell v. Pittsburgh & W. E. Pass. 

Ry. Co., 153 Pa. St., 105; 25 Atl. 

R.,623 429 

Brady v. McBride, 39 N.J. Eq., 495. 

525 
Brashears v. Frazier, 19 Ky. L. R., 

1248; 43S. W. R.,427....371,382 
Brashears v. Orme (Md.), 49 Atl. Rep., 

620 543 

Breed v. Glasgow Ins. Co., 92 Fed., 

760 136 

Breeding v. Jordan (Iowa), 88 N. W. 

R., 1090 429 

Breese, In re, 82 Iowa, 573 592 

Brennan v. People (Colo.), 86 Pac. 

R.,79.... 493 

Brick V. Brick, 66 N. Y., 149. . , .404 
Brigham v. Fayerweather, 144 Mass., 

48 364 

Broadstreet v. Broadstreet, 7 Mass., 

474 378 

Brock V. State, 22 Ohio Cir. Ct. R., 

364 430 

Brodrib v. Brodrib, 56 Cal., £63. .366 
Brommer's "Will, In re, 60 N. Y. St. 

Rep., 234 387 

Brooke v. Townsend, 7 Gill., 10. .536 
Brooks, Appeal of, 68 Conn., 294; 36 

Atl. R., 47 419 

Brooks V. Barrett, 7 Pick. (Mass.), 94. 

566 
Brooks V. Pratt, 118 Fed. R., 725 

(U. S. C. C. A., Mass.) 635 

Brothers v. Bank of Kaukauna, 84 

Wis., 381; 54 N. W., 786. .356, 

362 
Brotherton v. People, 75 N. Y., 159. 

557 
Brower v. Fisher, 4 Johns. N. Y. Ch., 

441 ; 410 

Brower v. Supreme Lodge, 74 Mo 

App.,490 373,374 

Brown v. Brown, 1 Hagg. Eccl., 16. 

764 



PAGE 

Brown v. Brown, 1 Hagg. Eccl. Rep., 

523 764 

Brown v. Brown, L. R., 1 P. and M., 

46 768 

Brown v. Commonwealth, 78 Pa. St., 

122 451 

Brown v. Cory (Kans. App.), 59 Pac. 

R., 1097 368 

Brown v. Ins. Co., 65 Mich., 306; 32 

N.W.R.,610 139 

Brown v. Miles, 61 Hun, 453 370 

Brown v. Mitchell, 26 S. W. R., 1059. 

518, 536, 540 

Brown v. Mitchell (Tex.), 31 S. W. 

Rep., 621 548 

Brown v. State, 40 Fla., 459; 25 So. 

Rep., 63 559 

Brown i;. Ward, 3o Am. R., 422, 426; 

53 Md., 377 398,399 

Brownlee v. Sweitzer, 49 Ind., 221. 

594 
Bruguier v. Pepin, 76 N. W. Rep., 

808; 106 Iowa, 432 362 

Brunor, In re, 21 App. Div., 259; 47 

N. Y. Supp., 681 503 

Brush, Case of Rodman A., 3 Abb. N. 

C. (N. Y.), 225 444 

Brush's Will, In re, 35 Misc. R. (N. 

Y.), 689; 72 N. Y. Supp., 421.. 396, 

399, 555 

Bryant v. Pierce, 95 Wis., 331; 70 N. 

W. R„297, 504 503 

Buchanan i;. Belsey,65 App. Div., 58; 

72 N. Y. Supp., 601... 386, 391, 396 
Buchanan v. Pierce, 54 Atl., 383; 205 

Pa., 123 399 

Buchan's Will, In re, 16 Misc. R. (N. 

Y.), 204; 38 N. Y. Supp., 1124. .402 
Buckey v. Buckey, 38 W. Va., 168; 

18 S. E. Rep., 383 361, 362. 

540, 564, 576 

Buckly 1). Rice, Plowd., 125 529 

Budlong, Matter of, 126 N. Y., 1423; 

s.c, 38 State Rep., 436 394 

Buffalo Loan, Trust and Safe Deposit 

Co V. Knights Templar and M. M. 

A. Ass'n, 126 N. Y., 450, 458; 27 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

N. E. R., 942; 122 Am. St. R., 839. 

135 
Bulger V. Ross, 12 So. Rep., 803; 

98 Ala., 267 389, 390, 523, 

544, 555 
Burdett v. Thompson, L. R., 3 P. & 

D.,72 384 

Bunn V. Postell, 33 S! E. Rep., 707; 

107 La., 490 366, 369 

Burford v. Deuthall, 2 Atk., 553. .582 
Burger v. HiU, 1 Bradf., 360. . . .385 
Burgh, In re, 61 How., 193 ... .593 
Burke, In re, 110 N. Y., Supp., 1004; 

125 App. Div., 889. . .581, 688, 594 
Burnett's Est., 201 Pa., 485; 51 Atl. 

R., 336; 10 Pa. Dist. R., 145. . .395 
Bumey v. Torrey, 100 Ala., 157; 14 

So. Rep., 685 389, 535, 537, 

540, 548 
Burns's Will, In re, 28 S. E. R., 519; 

121 N. C, 336 421,517, 

519, 567 
Burr, In re, 17 Barb. (N. Y.), 9 . . . 593 
Burritt v. Silliman, 16 Barb., 198; 

rev'd 13 N. Y., 93 413 

Burrows' Estate, In re, 11 Ohio S. & 

C. P. Dec., 229; 8 Ohio N. P., 358. 

353, 401 

Burt^). Burt, 46N. E. Rep.,622; 168 

Mass., 204 380 

Burt V. State, 38 Tex. Cr. App., 397; 

40 S. W. R., 1000; 43 S. W. R., 344; 

39 L. R. A., 305. . . .530, 531, 532, 

533, 545, 559, 561 

Burton v. State, 25 S. W. Rep., 782; 

33 Tex. Or., 138 433 

Bushi;. Delano, 113 Mich., 321; 'I 

N.W.R:,628 504,522 

Bueh V. Lisle, 89 Ky., 393; 12 S. W. 

Rep., 762 405 

Butler V. Ins. Co., 45 Iowa, 93. . .536 
Butler V. Michigan Mutual Life Ins. 

Co., 108 Fed., 487 134 

Butler?;. State, 102 Wis., 364; 78 N. 

W. R.,596 456 

Butler V. Comyns, 81 111. App., 418. 
381, 564 



PAGE 

Buys V. Buys, 99 Michigan 354; 58 
N. W. Rep., 331 642 

Caffey v. State (Miss.), 24 So. Rep., 

316 669 

Caffey v. State, 78 Miss., 645; 29 So. 

Rep., 396 430 

Cahn V. Cahn, 21 Misc. (N. Y.), 506; 

48 Supp., 173 765 

Calderon W.Martin, 50 La. Ann., 1153; 

23So. R. 909 .680 

Caldwell v. Anderson, 104 Pa. St., 

199 394 

CaUtins's Estate v. Calkins, 112 Cal., 

296; 44 Pac. R., 577. . . .520, 523 
Cameron's Estate, In re (Pa. Orph. 

Ct.), 14 Pa. Co. R., 247; 3 Pa. Dist. 

R., 101 389 

Campbell v. Barrera (Tex. Civ. App.), 

32 8. W. R., 724 417, 520, 621 

Campbell v. Campbell, 39 Ala., 312. 

582, 688 

Campbell v. Carlisle, 162 Mo., 634; 

63 S. W. R., 701 419, 420 

Campbell v. McQuiggan (N. J.), 34 

Atl. R., 383 419 

Cannon v. State (Tex.), 56 S. W. R., 

361 601 

Carlin v. Baird (Ky.), 13 S. W. Rep., 

434 408 

Carmichael, In re, 36 Ala., 614 .... 580 
Camagie v. Diven, 49 Pac. R., 891; 

31 Ore., 366 356, 362 

Carpenter v. Bailey, 94 Cal., 406. 
390, 546 
Carpenter v. Blake, 75 N. Y., 12.. 603 
Carpenter v. Calvert, 83 111., 62. . .666 
Carpenter v. Commonwealth, 92 Ky., 

452; 18S. W. R.,9 487 

Carpenter, In re, 41 Atl. Rep., 1042. 

482 
Carr v. State, 96 Ga., 284; 22 S. E. R., 

570 431 

Carr v. State, 98 Ga., 89; 27 S. E. 

Rep., 148 430 

Carson v. Metropolitan Life Ins. Co., 

1 Pa. Super. Ct., 572 142 



TABLE OF CASES CITED IN THIS VOLUME. 



XI 



PAGE 

Carter v. State, 12 Tex., 500; 62 Am. 

Dec, 539 450,457 

Carter v. Stewart (Tenn. Ch. App.), 

43S. W. R.,366 ...564 

Carter's Will, In re (N. J. Pre.), 51 

Atl. R., 65 411 

Carver's WiU (Surr. N. Y.), 3 Misc. 
Rep., 567; 23 N. Y. Supp., 753. 

411 

Casat V. State, 40 Ark., 511 493 

Case, In re (Conn.), 52 Atl. R., 403. 

412 
Castro V. Geil, 42 Pac. R., 804; 110 

Cal., 292 364 

Catlett V. State (Tex. Cr. App.), 61 

S. W. Rep.,485 549 

Cawley v. State (Ala.), 32 So. R., 

227 448,457 

Central Ky. Asylum v. Penick, 44 S. 
W. Rep., 92; 19 Ky. Law R., 1583. 

383 
Central Mutual L. I. Ass'n v. Hender- 
son, 195 111., 135; 62 N.E.R., 838. 

373 
Chambers v. Chambers, 61 App. Div., 

299; 70 N. Y. Supp., 483 .523 

Chamblee v. Broughton, 120 N. C, 

170; 27 S. E. Rep., Ill 380 

Chandler, In re, 45 La. Ann., 696; 12 

So. R. 884 430 

Chandler v. Jost, 96 Ala., 596; 11 So. 

R.,636 523,555 

Chapin v. Mitchell (Fla.), 32 So. R., 

875 515 

Chapline v. Stone, 77 Mo. App., 523. 

762 
Chappell V. Trent, 90 Va., 849; 19 S. 

E.R.,314 415 

Charter Oak Life Ins. Co. v. Rodell, 

95 U. S.,232 536 

Chase v. Pellerin, 16 La., 63 586 

Chase v. State (Tex. Cr. App.), 55 S. 

W. Rep., 833 430 

Chatham v. State, 92 Ala., 47; 9 S. R., 

607 490,492 

Cheney v. Price, 90 Hun, 238; 37 N. 
Y.Supp.,117 , 405 



PAGE 

Chesapeake & O. Ry. Co. v. Sauls- 
berry (Ky.), 66 8. W. R., 1,051. 

376 
Children's Aid Society of N. Y. v. 

Loveridge, 70 N. Y., 387 414 

Childs, Ex parte, 1 C. E. Green (N. J.), 

498 589 

Choice V. State, 31 Ga., 424 497, 

535 
Choice V. State, 66 Ind., 94; 32 Am. 

R.,99 457 

Chrisma,n v. State, 54 Ark., 283; 15 

S. W. R., 889 487, 490, 492 

Christensen's Estate, In re, 53 Pac. 

R., 1003; 17Utah, 412...536, 541 

Christie, In re, 5 Paige (N. Y.), 242. 

591 
Cicero, etc., v. Richter, 85 111. App., 

591 548 

City of Gallatin v. Tarwater, 44 S. 

W. Rep., 750; 143 Mo., 40 482 

City of Guthrie v. Shaffer (Okl.), 54 

Pac. R., 628 _. 421 

City of Richmond v. Long's Admrs., 

17Grat. (Va.), 375 607 

City of St. Joseph v. Harris, 59 Mo. 

App., 129 482 

Claffey v. Ledwith (N. J. Pre.), 38 
Atl. Rep., 433; 56 N. J. Eq., 333. 

386 
Clairty v. Sheridan, 91 Iowa, 304; 59 

N. W. R., 52 598 

Clapp V. Fullerton, 34 N. Y., 190. 

393, 404 

Clapp'sCase, 20 How. Pr. (N. Y.), 385. 

590 

Clark, Matter of, 5 Misc., 68 393 

Clark, Matter of, 175 N. Y., 139, 65 

N. E. R.,139 581, 588 

Clark V. Clark, 168 Mass., 523; 47 

N. E. Rep.,510 546,548 

Clark i; Fisher, 1 Paige, 171 392 

Clark V. Hill 69 Mo. App., 541 .. . 503 
Clark V. State, 12 Ohio, 483; 40 Am. 

Dec, 481 .636 

Clark's Will, In re, 5 Misc. Rep. (N. 
Y.), 68; 26 N. Y. Supp., 713. . .555 



Xll 



TABLE OF CASES CITED IN THIS VOLUME, 



PAGE 

Clarke v. Davis, 5 N. Y. Surr. (1 

Redf.), 249 393 

Clarke v. Eq. Life Ass., 118 Fed. R., 

374 (U. S. C. C. A., Md.) 374 

Clarke v. Irwin (Neb.), 88 N. W.Rep., 

783 542,547,564,598 

Clarke v. Sawyer, 2 N. Y. (2 Comst.), 

498 385 

Clarke v. Schell, 84 Hun (N. Y.), 28; 

31 N. Y. Supp. 1053 555 

Clary v. Clary, 2 Ired. L., 78. . . .536 
Claussenius v. Claussenius, 179 III., 

545; 53 N. E. R., 1006 419 

Claxton V. Commonwealth, 30 S. W. 

Ref., 228; 17 Ky. Law R., 284. . 433 

Clay V. Hammond, 199 111., 370; 65 N. 

E. R., 352 366, 371,592 

Cleland v. State, 65 S. W. R., 189. 

490 
Clements v. McGinn (Cal.), 33 Pac. 

Rep., 920 422, 504, 565 

Clifford, In re (N. J. Ch.), 41 Atl. R., 

356;57N.J._Eq.,14 433 

Cline V. Lindsay, 110 Ind., 337. . .389 

Clough V. Warsham, 32 Tex. Civ. 

App.,187; 74S.W.R.,350... .607 

Clum V. Barkly, 20 Wash., 103; 54 

Pac. Rep., 962 547 

Cochrane v. Amsden, 104 Ind., 282. 

580, 593 

Cockrill V. Cockrill, 79 Fed., 143; 92 

Fed.,811;34C. C.A.,254. 374,593 

Coffey V. Coffey, 74 111. App., 241. 

356 
Coffey v. Coffey, 179 111., 283; 53 N.E. 

R.,590 356 

CofRn V. Coffin, 23 N. Y., 9 393 

Coghill V. Kennedy, 119 Ala., 641; 24 

So. R., 459 416, 419, 519, 

620, 522, 555 

Coit V. Patchen, 77 N. Y. 539 554 

Colah, In re, 3 Daly (N. Y.), 529 . . 596 
Colby V. Jackson, 12 N. H., 526. .599 
Cole V. Cole, 5 Sneed (Tenn.), 57. 

762 

Cole's Trial, 7 Abb. Pr. N. S,, 321. 

439, 440, 442 



Colee V. State, 75 Ind., 511 536 

Coleman's Estate, In re, 6 Pa. Dist. 

R., 535 418 

Coleman v. Commissioners, 63 Mon. 

(Ky.),239 594 

Coles V. Jefferson Ins. Co., 4 W. Va., 

261;23S. E. R., 732.._ 132 

Colett V. CoUett, 1 Curt. Eccl. (Eng.), 

678; 1840 Wadd. Dig., 138. . . .768 

Collins V. People, 194 111., 506; 62 

N.E. Rep., 902. 541 

Collins V. Townley & Johnson, 21 N. 

J. Eq.,353 411,415 

Colvin's Case, 3 Md. Ch., 206 ... . 588, 

594, 597 

Commercial Travelers' Mut. Ace. Ass'n 

V. Springsteen, 23 Ind. App., 657; 

55 N. E. R., 973 143 

Commonwealth r;. Earner, 199 Pa. St., 

335; 49 Atl. R., 60 434,435, 

437, 451 
Commonwealth v. Berchine, 168 Pa. 

St., 603; 32 Atl. Rep., 109 557 

Commonwealth v. Brayman, 136 

Mass., 438 531, 546 

Commonwealth v. Brown, 193 Pa. St., 

507; 44 Atl. R., 497 542 

Commonwealth v. Buccieri, 153 Pa. 
St., 535; 26 Atl. R., 228; 32 W. N. 

C, 113 363, 430, 445, 502, 

531, 533 
Commonwealth v. Clark, 13 Pa. Co. Ct- 

Rep., 439 482 

Commonwealth v. Cloonen, 191 Pa. 

St., 605; 25 Atl. R., 145 524 

Commonwealth v. Cressinger, 193 Pa. 

St., 326; 44 Atl. R., 433 536 

Commonwealth v. Dorsey, 103 Mass., 

412 490,492 

Commonwealth v. Dudash, 204 Pa., 

124; 53 Atl. R., 756 491 

Commonwealth v. Fairbanks, 2 Allen 

(Mass.), 511 531 

Commonwealth v. Fritsch (Pa. O. & 

T.), 9 Pa. Co. Ct. R., 164 457 

Commonwealth v. Gerade, 145 Pa. 
St., 289 (Pa. O. and T.); 22 AtL 



TABLE Of CASES CiTED IN THIS VOLUME. 



XUl 



PAGE 

Rep., 464; 23 Pittsb. L. J., 117. 

436, 557, 559 

Commonwealth v. Gilbert, 165 Mass., 

45; 42 N. E. R., 226 481, 499 

Commonwealth, ex rel., v. Groh, 10 

Pa. Co. Ct., 557 586 

Commonwealth v. Hawkins, 3 Gray 

(Mass.), 463 492 

Commonwealth v. Hays, 195 Pa. St., 

270; 45 Atl. R., 728 580 

Commonwealth v. Heidler, 191 Pa. 

St., 375; 43 Atl. R., 211; 44 W. N. 

C, 310 557, 559, 560 

Commonwealth v. Hillman, 189 Pa. 

St., 548; 42 Atl. R., 196; 43 W. N. 

C.,356; 29 Pitts. L. J., 268.446,451 
Commonwealth v. Hollinger (Pa. O. 

& T.), 2 Dauph. Co. Rep., 13. . .435 
Commonwealth t>. Hollinger, 190 Pa. 

St., 155; 42 Atl. R., 548 560 

Commonwealth v. Kilpatrick (Pa.), 

53 Atl. R., 774 557 

Commonwealth ex rel. Kirkbride, 2 

Brewster (Pa.), 586 601 

Commonwealth ■!). Lutz, lOKulp (Pa.), 

234 439 

Commonwealth v. McMillan, 144 

Pa. St., 610; 22 Atl. Rep., 1029 . 484 
Commonwealth v. Metz, 2 Dauph. Co. 

R., 360 588 

Commonwealth v. Morrissey, 32 N. E. 

Rep., 664; 157 Mass., 471 482 

Commonwealth v. Mosler, 4 Pa. St., 

264 457 

Commonwealth v. Pomeroy, 117 

Mass., 143 506, 512, 513 

Commonwealth ■!). Preston, 188 Pa. St., 

429; 41 Atl. R., 534 563 

Commonwealth v. Rich, 14 Gray 

(Mass.), 345 534, 546 

Commonwealth v. Rogers, 7 Mete. 

(Mass.), 500; 4 Am. Dec, 458. 

451, 473, 534, 546 

Commonwealth v. Schmous, 162 Pa. 

St., 326; 29 Atl. R., 644. . .430, 433 
Commonwealth v. Wilson, 1 Gray 

(Mass.), 337 531 



PAGE 

Commonwealth v. Wireback, 190 Pa. 

St., 138; 42 Atl. R., 542; 43 W. N. 

C, 506. . . .436, 465, 466, 509, 510, 

534, 536,542,557,560,562 

Commonwealth v. Woodley, 166 Pa. 

St., 463; 31 Atl. R., 202.... 486, 

556, 575 

Conaty's Will, In re, 26 Misc. R., 104; 

56 N. Y. Supp., 854 535, 539 

Conley v. Com., 17 Ky. LawR., 678; 

32 S. W. R., 285 486,490 

Connecticut Gen. Life Ins. Co. v. 

McMurdy, 89 Pa., 363. . . . 133 

Connecticut Mut. L. Ins. Co. v. La- 

throp. Ill U.S., 612 531 

Connecticut Mut. Life Ins. Co. v. 

Union Trust Co., 112 U. S., 250; 

5 Sup. Ct., 119; 28 Lawyers' Ed., 

708 138 

Connor's Will, In re, 61 N. Y. Supp., 

910 535 

Continental Life Ins. Co. v. Young, 

113 Ind., 159; 15 N. E. R., 220; 

3 Am. St. R., 630 143 

Converse v. Converse, 21 Vt., 168. . 388 
Cook V. Standard Life and Ace. Ins. 

Co., 84 Mich., 12; 47 N. W.R., 568. 

135 
Cook V. State (Fla.), 35 So. R., 665. 

496 
Cook V. White, 167 N. Y., 588; 60 

N. E. R., 1109 576 

Coombe's Execr. v. Carthew, 43 Atl. 

R., 1057 (N. J.) 374 

Coop's Will, In re, 6 N. Y. Supp., 664. 

408 
Cooper, Matter of, 5 Law Bull., 338. 

590 
Coot V. Ionia Probate Judge, 93 

Mich., 304; 53 N. W., 395 592 

Copenroth v. Kienby, 83 Ind., 18. 

366 
Corbett v. St. Vincent's Industrial 

School, 177 N. Y., 16; 68 N. E. R., 

997 427, 607 

Corbli's Will, In re (N. J. Pre. Ct.), 52 

Atl. R., 996 420 



XIV 



Table of cases cited in this volume. 



PAGE 

Cornell v. State, 104 Wis., 527; 80 N. 

W. R., 745 530 

Cornell's Will, In re, 163 N. Y., 608; 

57N. E. R., 1007 555 

Corn well v. Riker, 2 Dem. ,354. 406 , 411 
Coryell v. Stone, 62 Ind., 307. . . .531 
Cotrell V. Com. (Ky.), 17 S. W. Rep., 

149 544 

Cottell V. State, 12 Ohio C. C. R., 467; 

1 Ohio C. D., 472 560 

Couch V. Gentry, 20 S. W. Rep., 89; 

113 Mo., 248 389 

Covenhoven's Case, Saxt. Ch. Cases 

(N. J.), 19 590 

Cowles V. Merchants, 140 Mass., 377. 

531 
Craig V. Southard, 148 111., 37; 35 N. 

E. Rep., 361 538 

Craig i;. 'Southard, 162 111., 209; 44 N. 

E. R., 393 566 

Cram v. Cram, 33 Vt., 15 536 

Crandall, Appeal of, 63 Conn., 365; 

28 Atl. R., 531 516, 521, 539 

Crane v. Crane, 62 N. J. Eq.,21; 49 

Atl., 734 767 

Cranmer, Ex parte, 12 Vesey, Jr., 454. 

580 
Crawford v. Christian, 102 Wis., 51; 

78 N. W Rep., 406 537, 546 

Crawford v. Thompson, 161 111., 161; 

43 N. E. Rep.. 617 381 

Creagh iJ.Tunstall (Ala.), 12 So. Rep., 

713 382 

Creekmore v. Baxter (N. C), 27 S. E. 

Rep., 994; 121 N. C, 31 368 

Crewt). State, 23 S. W. R., 14 490 

Critchfield v. Easterday, 26 App. D. 

C, 89 356 

Crockett v. Davis, 81 Md., 134; 31 Atl. 

R., 710 531 

Crosby v. People, 137 111., 325; 27 N. 

E. R., 49 490, 493 

Cross V. Kent, 32 Md., 581'. 425 

Crossan v. Crossan, 70 S. W. R., 136 

(Mo.) 388,504 

Oouzeilles, Succession of, 106 La., 

442; 31 So. Rep., 64 413 



PAGE 

Crowley v. Crowley, 19 Ky. Law Rep., 

285; 40 S. W. Rep., 380 379 

Cruger's Will, In re, 36 Misc. R., 477; 

73 N. Y. Supp., 812 405, 406, 

419, 555 
Cudney v. Cudney, 68 N. Y., 148 . . 404 
Cummins's Est., In re, 20 Pa. Co. Ct. 

R., 575; 7 Pa. Dist. R., 198. . . .421 
Cundell v. Haswell (R. I.), 51 Atl. R., 

426 365 

Cunningham v. State, 56 Miss., 269; 

31 Am. R., 360 450 

Curland, In re, 15 Misc. R., 355; 37 

N. Y. Supp., 922 416 

Cushman v. United States Life Ins. 

Co.,70N. Y., 72 ...138 

Cutler V. Cutler, 103 Wis., 258; 79 N. 

W. Rep., 240 393, 402, 420 

Cutler V. Zollinger, 22 S. W. Rep., 

895; 117 Mo., 92 358, 375 

Cutts V. Young, 147 Mo , 587; 49 S. 

W. Rep., 548 363 

Czynski Case, 14 Med. Leg. Jour., 150. 

481 

Daily Telegraph v. McLaughlin, 

(1904) App. Dec, 776; 73 Law J. P. 

C, 95; 91 Law T., 233; 20 Times 

Law R., 674 364, 365 

Daly V. Daly, 183 lU., 269; 55 N. E. 

R.,671 392 

Dandurand v. Kankakee Co., 96 111. 

App., 464; 63 N. E. Rep., 101; 

aff'd 196111., 537; 63 N. E.R., 1011. 

381, 382 

Darling, In re, 6 N. Y. Supp., 191. 

406 
Davenport v. Johnson (Mass.), 65 N. 

E.R.,392 522 

D'Avignon's Will, In re, 12 Colo.App., 

489; 55 Pac. Rep., 936. . .412, 539 
Davis V. Calvert, 18 Ky. L. R., 975; 

38S. W. R.,884 355 

Davis V. Com., 16 Va. L. J., 464; 15 

S. E. R., 388 487, 488, 491. , 

Davis V. Cox (Ky.), 67 S. W. R., 261. 

410 



TABLE OF Cases ^ited in this volume. 



XV 



PAGE 

Davis V. Denny, 94 Md., 390; 50 Atl. 

Rep., 1037 412 

Davis V. Latta, 94 Iowa, 727; 62 N. 

W. Rep., 17... 362 

Davis V. Merrill, 47 N. H., 208. . .599 

Davis V. State, 35 Ind., 496 531 

Davis V. State, 54 Neb., 177; 74 N. W. 

R., 599 661 

Davis V. State (Fla.), 32 So. R., 822. 

451, 560 

Davis V. U. S., 160 U. S., 469; 16 Sup. 

Ct. Dec, 353 549, 559 

Dean v. Dean, 27 Vt., 746 566 

Dean v. Phillips, 22 Ky. Law Rep., 

1621; 61 S. W. Rep., 10 384, 

391, 415 
Deane v. Aveling, 1 Rob. Eccl., 279, 

298 763 

Deas V. Wandell, 3 Supm. Ct. (T. & 

C), 128 (K. Y.) 442 

De Castro's Will, In re, 32 Misc. R. (N. 

Y.), 193; 66 Supp., 239 565 

Deck V. Deck, 106 Wis., 470; 82 N. W. 

R.,293 556 

Deer v. Clark, 3 Add. Ecc, 79 579 

Defoe V. Defoe, 144 Mo., 458; 46 S. 

W. R., 436 520 

De Hart V. Gondii, 51 N. J. Eq., 611; 

28 Atl., 607 591 

Deitzman v. MuUin, 108 Ky., 610; 67 

S. W. R., 210 761 

Dejarnette v. Commonwealth, 75 Va., 

867 455, 531 

Delafield v. Parish, 25 N. Y., 9. .386, 

403, 411, 565, 570 

Delaplain v. Grubb, 44 W. Va., 612; 

30 S. E. Rep., 201. ... : .362, 374, 

540, 550 

De Lesdemier v. De Lesdemier, 45 La. 

Ann., 1364; 14 So. Rep., 191. .380 
Delgado v. State, 29 S. W. R., 1070. 

490 
Demeet, In re, 27 Hun (N. Y.), 480. 

585 
Denning v. Butcher, 91 Iowa, 425; 

59 N. W. R., 69 521, 542, 

546, 548 



PAGE 

Dennis v. Dennis, 68 Conn., 186; 34 

L. R. A., 449; 36 Atl. Rep., 34.. 380 
Denver Life Ins. Co. v. Price, 18 Colo. 

App., 30; 69 Pac. R., 313 135 

Denver Tramway Co. v. Reid (Col), 

35 Pac. R., 269 428 

Des Moines, etc., v. Ohisholm, 71 Iowa, 

675 363 

De Treville v. Ellis, Bailey Eq. (S. 

C), 35; 21 Am. Dec, 519 597 

Devanbagh v. Devanbagh, 5 Paige (N. 

Y.),554 762, 763, 765 

Deveny v. State, 45 Ind., 208 482 

Dewey v. AUgire, 37 Neb., 6; 55 N. W. 

R., 276 357, 362, 364 

Dexter v. Hall, 15 Wall. (U. S.), 9. 

364, 531 

Dickerson v. N. W. Mut. L. I. Co., 

200 111., 270; 65 N. E. R., 694. 

374, 550 

Dickie, In re, 7 Abb. N. C. (N. Y.), 

417 589 

Dickson's Estate, In re, 20 Pa. Co. Ct. 

R., 152 504 

DieEfenbach v. Grece (N. J. Pre.), 39 

Atl. Rep., 536; 56 N., J. Eq., 365. 

407 
Dilleber v. Home Life Ins. Co., 69 N. 

Y., 256; 25 Am. Rep. 182. ... 135 
Di Lorenzo v. di Lorenzo, 71 App. Div. 

(N. Y.), 509, 519; 174 N. Y., 467. 

766 
Dimond's Est., In re (Orph. Ct.), 3 

Pa. Dist. Rep., 554 412 

Directors of Infirmary v. Merkle, 3 

OhioN. P., 169 382 

Dischner v. Piqua Mut. Aid Ass'n, 

14 S. D., 436; 85 N. W. R., 998. . 374 
Dixon's Will, In re, 42 App. Div. (N. 

Y.), 481; 59 N. Y. Supp., 421. 

406, 411 

Dobie V. Armstrong, 160 N. Y., 584; 

55 N. E. Rep., 302; affg 27 App. 

Div., 520; 50 N. Y. Supp., 801. 

396, 412, 565 

Dodge V. Cole (111.), 37 Am. Rep., 11. 

583 



XVI 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Doe V. Reagan, 5 Blackf., 217; 33 Am. 

Dec, 466 636 

Doe V. Roe, Edm. Sel. Cas. (N. Y.), ^ 

344 761 

Doheny v. Lacy, 168 N. Y., 213. 

553 
Dolbeer's Estate, In re (Cal.), 86 

Pac. R.,695 531, 536 

Dominick v. Randolph, 124 Ala., 567; 

27 So. Rep., 481 365, 

537, 642 
Donovan v. Bromley, 71 N. W. R., 

523 (Mich.) 555 

Dougherty v. People, 1 Colo., 514, 

519 141 

Douglass's Est., In re, 162 Pa. St., 

667; 29 Atl. Rep., 715. . . .390, 412 

Dove V. State, 3 Heisk., 348 636 

Dowdell, In re, 169 Mass., 387; 47 N. 

E. Rep., 1033 586, 666 

Dowling V. Merchants' Ins. Co., 168 

Pa., 234; 37 Atl. R., 988 133 

Downing v. Whitney, 46 App. Div., 

307; 61 N. Y. Supp., 640 698 

Downes?;. Harper Hospital, 101 Mich., 

565; 60 N. W. R., 42 427, 607 

Dozier v. Fidelity and Casualty Co., 

46 Fed., 446; 13 L. R. A., 114, 581; 

22 L. R. A., 620 137 

Drakeford v. Supreme Conclave K. of 

D., 61 S. C. 338; 39 S. E. R., 523. 

143 
Dreier v. Continental Life Ins. Co., 

24 Fed., 670 138 

Drew's Appeal, 57 New Hampshire, 

181 596 

Ducker v. Whitson, 16 S. E. Rep., 

854; 112 N. C, 44 363, 569 

Dudley v. Sautbine, 49 Iowa, 650; 

31 Am. Rep., 165 482 

DufEeld V. Morris, 2 Harr., 375. . .635 
Dugan's Est., 6 Pa. Dist. R., 222. 

413 
Dunahugh's Will (Iowa), 107 N. W. 

R., 925... 399 

Dunaway v. Smoot (Ky.), 67 S. W. 

R., 62 389,416,417 



PAGE 

Duncan v. Mason (Ky.), 20 S. W., 252. 

362 
Dunham's Appeal, 27 Conn., 192. 

635, 536 
Dunn V. Dunn, 114 Cal., 210; 46 Pac. 

Rep., 5 380 

Durcher v. Hill, 29 Mo., 271. . . .687 

Durham v. Durham, 10 P. D. (Eng.), 

80 762 

Eakin v. Hawkins, 37 S. E. Rep., 622 

(W. Va.) 367 

Ean V. Snyder, 46 Barb., 230 386 

Early v. Standard Life and Ace. Ins. 

Co., 113 Mich., 58; 71 N. W. R., 

500; 67 Am. St. Rep., 445 140 

Earp V. Edgington, 107 Tenn., 23; 

64 S. W. R., 40 520 

Ecksines' Estate, 1 Clark, 224 584 

Edgerly, In re, 84 N. W. Rep., 653. . 588 
Edgerly v. Union St. R. Co., 36 Atl. 

Rep., 558; 67 N. H., 312 376 

Edington v. Mutual Life Ins. Co., 67 

N. Y., 185 ...140 

Edson's Will, In re, 24 N. Y. Supp., 

711 566 

Edwards v. Davis (Ohio), 30 Wkly. 

Law Bull., 283 :397 

Edwards D. Millsaps (Tex. Civ. App.), 

70S. W. R., 357... .: 416 

Edwards v. Rives, 35 Fla., 89; 17 So. 

R.,416 .; 515 

Edwards v. State, 38 Tex. Cr., 386; 

43 S. W. R., 112; 39 L. R. A., 262. 

380, 501 

Edwards v. State (Tex.), 54 S. W. R., 

689 490,501 

Egbers v. Egbers, 177 111., 82; 52 N. 

E.R.,285 507 

Eggers V. Eggers, 57 Ind., 461 536 

Eisenberg, Matter of (U. S. Dist. Ct. 

S. D. of N. Y.), 8 Am. Bk'cy Rep., 

551 598 

Elder v. Schumacher, 18 Col., 433; 33 

Pac. R., 175 363,364 

Eldredge v. Palmer, 185 111., 618; 57 

N. E. Rep., 770 363, 368 



TABLE OF CASES CITED IN THIS VOLUME. 



XVU 



PAGE 

Elias V. Enterprise B. & L. Ass., 46 S. 

C, 188; 24S. E. R., 102 371 

Elliott V. Keith, 102 Ga., 117; 29 S. E. 

R., 155 515 

Elliott V. Wilby, 13 Mo. App., 19. 

566 
Ellis V. Ellis, 20 Ky. Law R., 438; 

46 S. W. Rep., 621 393 

Ellis V. State, 24 S. W. Rep., 894; 33 

Texas Or. App., 86 537 

Elwood V. O'Brien, 74 N. W. Rep., 

740; 105 Iowa, 239 355 

Ely's Est., In re, 16 Misc. Rep. (N. 

Y.), 228; 39 N. Y. Supp., 177. .413 
Elzey V. Elzey, 1 Houst. (Del.), 308. 

761, 762 
Emerick v. Emerick, 49 N. W. (Iowa), 

1017 580 

Emmerich v. Thoriey, 35 App. Div., 

452; 54 N. Y. Supp., 79 599 

Emswiler, In re, 8 Ohio N. P., 132; 

11 Ohio S. & C. P. Dec, 10. 

353, 580 

Endowment Rank K. of P. v. Allen, 

104 Tenn., 623; 58 S. W. R., 241. 

159 
Endowment Rank K. of P., v. Cog- 
bill, 99 Tenn., 28; 41 S. W. R., 340. 

134 
Englert v. Englert, 198 Pa. St., 326; 

47 Atl. R., 940 397, 537 

Entwistle v. Meikle, 180 111., 9; 54 N. 

E. Rep., 217. : 393,412 

Equitable Life Ins. Co. v. Hazlewood, 

75 Texas, 338; 12 S. W. R., 621; 

16 Am. St. Rep., 893; 7 L. R. A., 

217 133 

Eslava v. Lepretre, 21 Ala., 504. 

586, 597 
Ester V. Bridgforth, 114 Ala., 221; 

21 So. R., 512... 416, 523 

Ethridge v. Bennett's Exrs., 9 Hpust. 

(Del.), 295; 31 Atl. Rep., 813. ,541 
Evans' Estate, In re (Iowa), 86 N. W. 

R.,283 391, 517 

Evans' Will, In re, 37 Misc. R., 337; 

75 N. Y. Supp., 491 392 



PAGE 

Evans v. Johnson, 39 W. Va., 299; 
23 L. R. A., 137; 19 S. E. R., 623. 

586 
Evers v. State, 31 Tex. Cr. App., 318; 

20S. W. R., 744 490 

Eyre v. Shaftsbury, 2 P. Wms., 118. 

582 

F. I). D., 4 Swab, and T., 86 765 

F. V. P., orse ¥., 75 L. T., 192. . . .765 

Fain v. Com., 78 Ky., 183 480 

Fairchild v. Bascom, 35 Vt., 398 . . 531 
Falk V. Wettram, 120 Cal., 479; 52 

Pac. Rep., 707 356 

Farmer v. Farmer, 31 S. W. Rep., 926; 

129 Mo., 530 393 

Farnham v. Pierce, 141 Mass., 203. 

427 
Farnsworth v. Noffsinger, 33 S. E. 

Rep., 246; 46 W. Va., 410 356 

Farnum v. Boyd, 56 N. J. Eq., 766; 

41 Atl. R., 422 389 

FarreU v. State, 45 Ind., 371 482 

Farris v. Com., 1 S. W. R., 729. . .455 
Faulkner v. Territory, 6 New Mex., 

464; 30 Pac. R., 905 559, 577 

Feder v. Iowa State Trav. Men's 

Ass'n, 109 Iowa, 538; 78 N. W. R., 

252; 70 Am. St. Rep., 212; 43 L. R. 

A., 693 136, 137 

Feegan's Estate, 1 Myrick Prob. Rep. 

(Cal.), 10 595 

Feigenbaum v. Howe, 32 Misc. R., 

514; 66 N. Y. Supp., 378 368 

Feld V. Borodofski, 87 Misc., 72; 40 

So. R., 816 426 

Fenton's Will, In re, 97 Iowa, 192; 

66 N. W. R., 99 391, 514, 525, 

527, 544 

Ferrell v. State, 43 Tex., 503 488 

Ferris v. Ferris, 8 Conn., 166 762, 

764 
Fidelity & Casualty Co. v. Chambers 

(Va.), 24 S. E. R., 896 575 

Fidelity & Casualty Co. v. Johnson, 

72 Miss., 333; 17 So. R., 2, 3; 30 L. 

R. A., 206 136 



Xviii 



TABLE OP Cases cited in this voliime. 



Fidelity Trust Co., In re,. 27 Misc. (N. 

Y.), 118; 57 N. Y. Supp., 361. .354 
Fielbright v. Perry Co., 145 Mo., 432; 

43 S. W. R., 955 399 

Field V. Shorb, 99 Cal., 661; 34 Pac., 

504 365 

Finn, Matter of, 54 N. Y. State Rep., 

301 393 

Finn's Est., 1 Misc. (N. Y. Surr.), 280; 

22 N. Y. Supp., 1066 392 

Fire Ins. Patrol v. Boyd, 120 Pa. St., 

624 427 

First Nat. Bk. v. McGinity (Tex. Civ. 

App.), 69 S. W. R., 495. .. . 368, 537 
Fischer v. State, 30 Texas App., 502; 

18 S. W. Rep., 90 559, 560, 562 

Fitzgerald, In re, 3 Stewart, 59. .590 
Flach V. Gottschalk, 41 Atl. Rep., 

908; 88 Md., 368 365, 366 

Flanagan v. People, 52 N. Y., 467; 

10 Am. R., 731 431, 436, 440, 

448, 449 
Flanagan v. People, 86 N. Y., 559; 

13 Weekly Dig., 242 490, 499 

Flanagan v. State, 103 Ga., 619; 30 S. 

&. R., 550 455, 479, 503, 505 

Flanagan v. State, 106 Ga., 109; 32 

S. E. R., 80 532 

Flansburgh's WUl, In re, 82 Hun, 49; 

31 N. Y. Supp., 177 402, 410 

Flint's Estate, In re, 100 Cal., 391; 

34 Pac. R., 863 523 

Fluck V. Rea, 51 N. J. Eq., 233; 27 

Atl. Rep., 636 412, 414 

Fogarty v. State, 80 Ga., 450; 5 S. 

E. Rep., 782 445 

Folger, In re, 4 Johns. Ch., 169. .591 
Folt's Will, In re, 71 Hun (N. Y.), 

492; 24 N. Y. Supp. 1050 539 

Fonville v. State, 91 Ala., 39; 8 So. 

Rep., 688 487, 490, 495 

Foot V. Aetna Life Ins. Co., 61 N. Y., 

571 134 

Foran v. Healy (Kan.), 85 Pac. R., 

751 ; 525 

Forbell v. Denton, 53 App. Div., 402; 

65 N. Y. Supp., 1120 598 



Ford V. State, 71 Ala., 385 552 

Ford V. State, 73 Miss., 734; 19 So. R., 

665 431, 551, 652, 557, 

558, 564 
Foreman, Matter of, 54 Barb., 274, 

affirming 1 Tuck., 205. . . .394, 399 
Forman v. Forman (Super. Ct. of N. 

Y.), 24 N. Y. Supp., 91 -^ 376 

Fowler v. Ramsdell^ 4 Alb. L. J., 94. 

400 
France v. Frantz, 4 Ohio N. P., 278. 

580 
Francis v. Wilkinson, 147 111., 370; 

35 N. E. Rep., 150 361, 362, 

390 
Franklin Life Ins. Co. v. Galligan, 

71 Ark., 295; 73 S. W. R., 102; 100 

Am. St. R., 73 132 

Freeman v. Mercantile Ace. Ass'n, 

166 Mass., 351; 30 N. E. R., 1013; 

17L.R.A.,753 143 

French v. State, 85 Wis., 400; 55 N. 

W. Rep., 566 430, 433, 586 

French v. State., 93 Wis., 325; 67 N. 

W. Rep., 706 430, 483, 511, 

586 
French Lumbering Co. v. Theriault, 

107 Wis., 627; 83 N. W. R., 927; 

51 L. R. A., 910 364, 366, 381 

Fricke, Matter of, 19 N. Y. Supp., 

315 406 

Friery v. People, 54 Barb., 319; 2 

Keyes, 424 487 

Frost V. Redford, 54 Mo. App., 345. 

597 
Fulbright v. Perry Co., 145 Mo., 432; 

46 S. W. Rep., 955 539 

Fulton V. Umbehend (Mass.), 65 N. 

E. R., 829 670 

Funk, Inre, 101 Fed. Rep., 244. .598 
Furlong v. Carraher, 102 Iowa, 368; 

71 N. W. Rep., 210 643 

Furlong v. Carraher, 108 Iowa, 492; 

79 N. W. Rep., 277 640, 647 

G. V. G., L. R. 2 P. and D., 287; 46 
L. J. P. and M., 83; 25 L. T. Rep. 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

N. S., 610; 20 Weekly Rpt., 103. 

765 

G. t). G., 33 Md., 401 764 

G. V. G., 67 N. J. Eq., 30; 56 Atl. R., 

736 762,763,766 

Gable v. Rauch, 50 S. C., 95; 27 S. E. 

R., 555.. 387,417,584 

Gaines v. Fidelity and Casualty Co., 

Ill App. Div. (N. Y.), 386. . . .136 
Gale V. Mutual Aid and Ace. Ass'n, 

66 Hun (N. Y.), 600; 21 Supp., 

893 143 

Gait V. Provan, 79 N. W. Rep., 357; 

108 Iowa, 561 356 

Galveston, etc., Ry. Co. v. Harris, 

22 Tex. Civ. App., 16; 53 S. W. R., 

599 428 

Gamber v. Gamber, 24 App. Div., 446; 

48 N. Y. Supp., 501 515 

Gamble v. Gamble, 39 Barb., 373. 

392 
Gammon's WUl, In re, 2 Misc. Rep. 

(N. Y.), 329; 21 N. Y. Supp. 931. 

395, 397 

Gardner v. Arnett, 21 Ky. L. R., 1; 

50 S. W. R., 840 768 

Gardner v. Day, 95 Me., 558; 50 Atl. 

R., 892 429 

Gardner i). Gardner, 22 Wend. (N. Y.), 

526, rev'g 7 Paige, 112 413 

Gardner v. Jones, 126 Cal., 614; 59 

Pac. R., 126 592 

Garland v. Smith, 127 Mo., 567; 28 

S. W. R., 191; 29 S. W. R., 836. 

519 
Garley v. Park (Ind. Sup.), 35 N. E., 

279 407 

Garner v. State, 28 Fla., 113; 9 So. 

Rep., 835 487, 490, 493, 494 

Garretson v. Hubbard, 81 N. W, Rep., 

174 381 

Garrison v. Blauton, 48 Tex., 299 . 536 
Gate V. HOI, 46 La. Ann., 27; 14 So. 

R.,294 575 

Gates V. Bain, 2 Strick., 1104,.. 354 

Gatley's Est., In re, 16 Pa. Co. Ct. 

Rep., 69; 4 Pa. Dist. R., 52.. .402 



PAGE 

Gehrkei). State, 13 Tex., 568 532 

Geis V. Geis, 116 App. Div. (N. Y.), 

362; 101 Supp., 845 765 

Genl. Conv. of New Jerusalem Ch. v. 

Crocker, 7 O. Co. Ct., 327. . . .397 

Gensemer's Estate, In re, 170 Pa. St. 

96; 32 Atl. R., 561 528 

Genz V. State, 59 N. J. Law, 488; 
37 Atl. R., 69; 58 N. J. Law, 482; 

34 Atl. R., 816 431, 448, 450, 

536, 547, 561 
German Sav. & Loan Soc. v. De Lash- 
mutt, 67 Fed. R., 399 364 

Germon v. Dubois, 23 La. Ann., 26. 

586 

Gibson v. Gibson, 9 Yerg., 329.. .539 

Gihon's Will, In re, 44 App. Div. (N. 

Y.), 621; 60 N.Y. Supp. ,65... 401 

Giles, In re, 11 Paige (N. Y.), 243. 

591 

Gilgallon v. Bishop, 46 App. Div. (N. 

Y.), 350; 61 N. Y. Supp., 467. .368 

Gilhara's Estate, In re (N. J.), 52 

Atl. R., 690 413, 417 

Gillespie v. Gouly, 120 Cal., 515; 52 

Pac. Rep., 816 381 

Gillespie v. Thompson, 7 Ind., 353. 

591 
Gilman v. Ayer (N. J. Pre.), 47 Atl. 

R., 1049 396 

Ginrich v. Rogers, 96 N. W. R., 156 

(Neb.) 364 

Givin V. Givin (Idaho), 48 Pac. R., 295. 

398, 416, 520 

Glasscock v. Tate, 107 Tenn., 486; 64 

S. W. Rep., 715 381 

Glavin v. R. I. Hosp., 12 R. I., 411. 

607 
Glen, Ex parte, 4 Desauss. Eq. (S. C), 

546 761 

Glenn v. Glenn, 87 Mo. App., 377. 

482 
Goddard v. Westcott, 32 Mich., 180; 

46 N. W. R., 242 767, 768 

Goldsticker, Matter of, 192 N. Y., 35. 

392 
Goldthorp, In re, 94 Iowa, 336; 62 



XX 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

N. W. R., 845 503, 518, 

540, 548 
Goldthorp's Est., In re (Iowa), 88 N. 

W. R., 944 567 

Gombault v. Public Administrator, 4 

Bradf.,226..'. 410 

Gonzales v. State, 31 Tex. Cr. App., 

508; 21 S. W. R., 253 484, 

487, 490 
Goodbar v. Lidikay, 136 Ind., 1; 35 

N. E. R., 691..... 555 

Goodhart v. Speer, 7 Ohio Dec, 47. 

527 
Goodwin v. State, 96 Ind., 550. 

531 
Gordon v. Burns, 135 Mo., 223; 

54 S. W. R., 546 416 

Gordon v. Bums, 141 Mo., 602; 63 

S. W. R., 642 520 

Gordon's Est., In re, 28 Pittsb. L. 

J. (N. S.), 78 555 

Gorkow's Est., 20 Wash., 563; 56 

Pac. R., 385 403 

Goucher v. Northwestern Traveling 

Men's Ass'n, 20 Fed., 596 143 

Goulds. Gould, 78 Conn., 242; 61 Atl., 

604 766,767 

Grand Lodge A. O. U. W. v. Jesse, 

50 111. App., 101 373 

Grand Lodge v. Wieting, 168 111., 408; 

48 N. E. Rep., 59 373, 541, 

542, 546 
Grand v. Thompson, 4 Conn., 203; 

10 Am. Dec, 119 531 

Grattan v. Metropolitan Life Ins. Co., 

92 N. Y., 274; 44 Am. Rep., 372. 

132, 138, 139 

Gray, In re, 5 N. Y. Supp., 464 . . 403, 

406 

Green, Matter of, 67 Hun, 527 393 

Green's Will, In re, 20 N. Y. Supp., 

538; id., 67 Hun, 527; 22 Supp. 

1112 519, 555 

Green v. Green, 145-111., 264; 33 N. 

E., 941 389, 390, 409 

Green v. State, 59 Ark., 246; 27 S. 

W. R., 5 511 



PAGE 

Green v. State, 64 Ark., 523; 43 S. W. 

R., 973 455, 505, 508, 529, 

548 
Greene v. Roworth, 113 N. Y., 470. 

553 
Green wade v. Green wade, 43 Md., 

313 580 

Greenwood v. Cline, 7 Or., 18 399 

Gregory's Estate, In re, 133 Cal., 131; 

65 Pac R., 315 520 

Gresh's Case (Pa. Quarter Sessions), 

12 Pa. Co. Ct. R., 295. 592 

Gress Lumber Co. v. Coody (Ga.), 27 

S. E. Rep., 169 547 

Gribbon v. Maxwell, 34 Kansas, 8. 

364, 366 
Gridley v. St. Francis Xavier College, 

137 N. Y., 327 585 

Griffeth v. Griffeth, 162 111., 368; 44 

N. E. R. 820; 55 111. App., 474. 

763, 765 

Griffin's Est., Inre, 9 Pa. Dist. R., 248; 

23 Pa. Co. Ct. R., 559 565 

Grimes v. Shaw, 2 Tex. Civ. App., 20; 

21 S. W. R., 718 528 

Gring v. Lerch, 112 Pa. St., 244; 

3 Atl., 841 768 

Gross, Inre, 14 State Rep., 429. .403 
Grover v. Zook, 44 Wash., 489; 87 

Pac, 638 768 

Guetig V. State, 66 Ind., 94; 32 Am. 

R., 99 456,514 

Guiteau Case, 10 Fed. Rep., 161. 

443, 475 
Gunn, Appeal of, 63 Conn., 254; 27 

Atl. R., 1113 519 

Gurley v. Park, 135 Md., 440; 35 

N. E. R., 279 523 

Gustavenson v. State (Wyo.), 68 Pac. 

R., 1006 491 

Guthrie's Appeal, 16 Penn. St., 321. 

584 

H. V. P. orse H., 3 P. and D., 126. 

763 

Hagan v. Sone, 68 App. Div., 60; 74 

N. Y. Supp., 109 535 



TABLE OF CASES CITED IN THIS VOLUME. 



XXI 



PAGE 

Hagan v. State, 5 Baxt. (Tenn.), 615. 

508 
Hailes, In re, 3 Johns. Ch. (N. Y.), 567. 

591 
Haines v. Hayden, 95 Mich., 332; 54 

N.W.R.,911 521,523 

Haines v. Scott, 35 App. Div. (N. Y.), 

515; 54 N. Y. Supp., 844 355, 

356, 366 
Halbert's Will, In re, 15 Misc. R., 308; 

37 N. Y. Supp., 757 399, 

414, 419 
Hale V. Sterp (Colo.), 42 Pac. Rep., 

598 376 

Hall V. Com. (Pa.), 12 Atl. Rep., 163. 

446 
Hall V. Perry, 87 Me., 569; 33 Atl. 

Rep., 160 393, 397 

Hall V. Wright, 1858, E. B. and E., 

746 / 767 

Hall's Will, In re (Surr.), 5 Misc. R. 
N. Y.), 461; 24 N. Y. Supp., 864. 

386 
Hallenbeck v. Cook, 180 111., 65; 54 

N. E. Rep., 154 392 

Hallet V. Patrick, 49 Cal., 690 684 

Hallett V. Hallett, 8 Ind. App., 305; 

34N.E.R.,740 383 

Hambleton's Appeal, 102 Pa. St., 5. 

696 
Hamilton v. Starr (Tex. Civ. App.), 

27 S. W. R., 587 515 

Hamilton v. Traher, 27 Atl., 229 

(Md.).... 683, 697 

Hamilton's Est., 4 Pa. Dist. R., 161; 

16 Pa. Co. Ct. R., 303 406 

Hampton v. Westoott, 49 N. J. Eq., 

622; 25 Atl. Rep., 254 389 

Hamrick v'. State, 34 N. E. Rep., 3; 

134 Ind., 324. . . .353, 647, 579, 680 
Hanbury v. Hanbury, Probate Div. 

(1892), 222 377,379 

Hanley v. Nat. Loan, etc., Co., 29 S. 

E. R., 1002; 44 W. Va., 450. . .365 
Hanna v. Connecticut Mutual Life 

Ins. Co., 150 N. Y., 526; 44 N. E. 

R., 1099 131, 135 



PAGE 

Hannon v. Hannon, 51 Fed. Rep., 

413 366 

Hansel! v. Hansell, 13 Pa. Co. Ct. R., 

514; 3 Pa. Dist. R., 734 378 

Hardy, In re, 26 App. Div., 164; 27 

N. Y. Civ. Pro. Rep., 174; 49 N. Y. 

Supp., 953 383 

Hardy v. Berger, 76 App. Div., 393; 

78 N. Y. Supp., 709 365, 367 

Hardy v. Merrill, 56 N. li., 227. .536 
Harmony Lodge, etc.. Appeal of, 127 

Pa. St., 269; 18 Atl. Rep., 10. .407 
Harp V. Parr, 168 III, 459; 48 N. E. 

Rep., 113 420, 618, 519, 

621, 661 
Harper, In re, 68 L. J. Prob. (Eng.), 

48 Prob., 69; 80 L. T. (N. S.), 468. 

698 
Harrigan v. Harrigan, 135 Cal., 397; 

67 Pac. R., 506 378 

Harris, In re (Del.), 28 AtL, 329 . . 584 
Harris v. Schlinke, 65 S. W. Rep., 

172 (Tex. Civ. App.) 380 

Harris v. State, 18 Tex. Cr. App., 287. 

451, 457 

Harris v. U. S., 8 App. D. C, 20. .488 

Harris's Will (Surr. N. Y.), In re, 19 

Misc. R., 388; 44 N. Y. Supp., 341. 

407 
Harrison v. Bishop, 131 Ind., 161; 

30N. E. R., 1,069 525 

Harrison v. Otley, 101 Iowa, 652; 70 

N. W. R., 724 366 

Harrison v. Rowan, 3 Wash. C. C, 

580 388 

Hart V. Deamer, 6 Wend., 497. . .367 
Hart V. MiUer (Ind. App.), 64 N. E. 

R.,239 382, 605 

Hartford Life and Aimuity Ins. Co., 

v. Gray, 91 111., 159 .....133 

Hartman v. Strickler, 82 Va., 225. 

418 
Hastings v. Rider, 99 Mass., 622. .531 
Hathaway, Matter of, 80 Hun, 186. 

696 
Hathaway v. Ins. Co., 48 Vt., 335. 

536 



xxu 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Hawe V. State, 11 Neb., 537; 38 Am. 

R., 375 439, 450 

Hawkins o. Grimes, 13 B. Monroe 

(Ky.), 257 566 

Hawley i.. Griffin (Iowa), 82 N. W. R., 

905 510, 537 

Hawley v. Griffin, 92 N. W. R., 113. 

381, 425 

Hawley v. Nat'l Loan, etc., Co., 44 

W. Va.,450; 29 S. E. R., 1022. .364 
Hay V. Miller, 48 Neb., 156; 66 N. W. 

R., 1115 357,363 

Hayes v. Candee (Conn.), 52 Atl. 

Rep., 826 547,548 

Hayes v. Kerr, 19 App. Div. (N. Y.), 

91; 45 N. Y. Supp., 1050 362 

Haynes v. Hayden (Mich.), 54 N. W. 

R., 911 395 

Hays V. Commonwealth (Ky.), 33 S. 

W. Rep., 1104; 17 Ky. Law R., 

1147 439 

Head v. State, 43 Neb., 30; 61 N. W. 

Rep., 494 492 

Heald v. Thing, 45 Me., 392 532 

Healy v. Mutual Ace. Ass'n, 133 111., 

556; 25 N. E. R., 52; 23 Am. St. 

R., 637; 9 L. R. A., 371 137 

Heath v. Koch, 74 App. Div. (N. Y.), 

338; 77 Supp., 513 555 

Heckman v. Adams, 50 Ohio St., 305; 

34 N. E. R., 155 586 

Heff V. Cox, 5 Ohio N. P., 413 ... . 381 
Hegney v. Head, 29 S. W. Rep., 587; 

126 Mo., 619 410, 556 

Hemingway's Est., Zra re (Orphs. Ct.), 

7 North. Co.R. 93; 195 Pa. St., 91; 

45 Atl. R., 726 395, 396, 397 

Hemlock Poor Dist. v. Hufford, 8 

Kulp (Pa.), 202 382 

Hempton v. State, 111 Wis., 127; 86 

N. W. R., 596 491, 514, 

526, 527, 536, 546, 552 
Hennell v. Board of Comrs., 132 Ind., 

32; 31 N. E. R., 462 425 

Hennessy's Heirs v. Woulfe, 49 La. 

Ann., 1376; 22 So. Rep., 394. 
412, 420 



PAGE 

Henrich v. Saier (Mich.), 82 N. W. R., 

879 394, 521 

Henrick v. Langford, 108 Cal., 608; 

41 Pac. R., 701 417, 419 

Henrizi v. Kehr, 90 Wis., 344; 63 

N. W. Rep., 285 362 

Henry v. Hall, 106 Ala., 84; 17 So. 

Rep, 187 405, 555 

Henry's Will (Surr. N. Y.), In re, 18 

Misc. Rep., 149; 41 N. Y. Supp., 

1096 411 

Hepler v. Hosack, 197 Pa. St., 631; 

47 Atl. Rep., 847 548 

Hemdon v. Vick, 18 Tex. Civ. App., 

583; 45 S. W. R., 852. . . .527, 551 
Herr v. Cent. Ky. Lun. Asyl., 17 Ky. 

L. R., 320; 30 S. W. R., 971 .. . .427 
Herster v. Herster, 122 Pa. St., 239; 

16 Atl. R., 342 503 

Hertrich v. Hertrich (Iowa), 87 N. 

W. R., 689 538,539 

Heseman v. Vogt, 181 111., 400; 55 N. 

E. R., 161 391, 392, 516, 518 

Hewitt's Will, In re, 31 Misc. R., 81; 

64 N. Y. Supp., 571 412, 535 

Hewitt V. Taunton St Ry. Co., 167 

Mass., 483; 46 N. E. Rep., 106. 

537, 548 

Hickman v. State, 38 Tex., 190. .532 

Hicks V. Marshall, 3 Hun, 327. .367 

Higbie v. Guardian Mut. Life Ins. Co., 

53 N. Y., 603, 605 143 

Higginbotham v. Higginbotham 

(Ala.), 17 So. R., 516 417 

Hildreth v. Marshall (N. J. Pre.), 51 

N. J. Eq., 241; 27 Atl. R., 465. .418 
Hill V. Bahrus, 158 111., 314; 41 N. E. 

R., 912 503, 519 

HiU V. Day, 34 N. J. Eq., 150 591 

Hill V. Fly (Tenn.), 52 S. W. Rep.,731. 

404 
Hill V. State, 42 Neb., 503; 160 N. W. 

R.,916 492 

Hinchman, Ex parte, 4 Clark (Pa.), 

184 586 

Hindman v. Hutchinson, 30 Pittsb. 

Leg. J. (N. S.), 422 604 



TABLE OF QASES CITED IN THIS VOLUME. 



XXlll 



PAGE 

Hindman v. Van Dyke, 1' .! Pa. St., 
243; 25 Atl, R., 772 519 

Hirley v. Kettle (Tex. Civ. App.), 65 
S. W. R., 48 482 

Hite V. Commonwealth, 31 S. E. 
Rep., 895; 96 Va., 489 484, 

536, 546 
Hoag, In re, 7 Paige (N. Y.), 312 . . 597 
Hobbs, In re, 73 Conn., 262; 47 Atl. 

R., 678 523 

Hobbs V. People, 183 111., 336; 55 N. 

E. Rep., 692 384 

Hoch V. Hoch, 197 Pa. St., 387; 47 

Atl. Rep., 351 363 

Hogmeir's Appeal, 108 Mich., 410; 

66N. W. R.,327 536 

Hohn V. Interstate Casualty Co. of N. 

Y., 115 Mich., 79; 72 N. W. R., 

1105 143 

Holcomb, In re (Iowa), 82 N. W. 

Rep., 1000 354 

Holcomb V. Holcomb, 95 N. Y., 316. 

546 

Holcomb V. State, 4 Tex. 125 536 

Holdom V. A. O. U. W., 159 111., 619; 

31 L. R. A., 67; 43 N. E. Rep., 772. 

374 
Holland v. Zolhier, 102 Cal., 633; 36 

Pac. Rep., 930 538 

Hollis V. Drew Theological Seminary, 

95 N. J., 166 393 

Holman's Estate, In re, 70 Pac. R., 

908 415 

Holmberg v. Phillips (Iowa), 78 N. W. 

Rep., 66 ...403 

Holtzman v. Hoy, 19 111. App., 459. 

603 
Homire v. Halfman, 156 Ind., 470; 

60 N. E. Rep., 154 429 

Hoope's Estate, In re, 174 Pa. St., 

373; 34 Atl. R., 603 526, 

537, 569 

Hoover, In re, 19 D. C, 495 390 

Hoover v. State, 48 Neb., 184; 66 N. 

W. Rep., 1117 537 

Hope V. Campbell, App. Cas. (1899), 
1 (Eng.), , ,, ,397 



PAGE 

Hopkins v. Wheeler, 21 R. I., 533; 

45 Atl. Rep., 551 548 

Hopps V. People, 31 111., 385; 83 Am. 

Dec, 231 437, 451 

Hopt V. People, 104 U. S., 631. 

490, 492 

Horn V. Pullman, 72 N. Y.,. 276. 

393, 403, 404, 406, 411 

Hornish v. People, 142 111., 620; 18 

L. R. A., 237; 32 N. E., 677. . .436 

Horton v. V. S., 15 App. D. C, 310. 

530, 534 

Hosier v. Beard, 54 Ohio St., 398. 

366 
Houston V. State, 26 Tex. App., 657; 

14 S. W. Rep., 352 487, 490 

Hovey v. Chase, 52 Maine, 304. .580 
Hovey v. Harmon, 49 Maine, 269. 

582 
Howard v. State, 36 S. W. Rep., 475; 

37 Tex. Cr. App., 494 552' 

Howat V. Howat's Exr., 41 S. W. 

Rep., 771; 19 Ky. Law R., 756. 

389, 419 

Howe V. Provident Fund Soc, 7 Ind. 

App., 586; 34 N. E. R., 830 132 

Howe V. Richards (Iowa), 83 N. W. 

Rep., 909 387, 389, 394, 

413, 517, 567 
Howell V. Taylor (N. J. Prerog. Ct.), 

50 N. J. Eq. (5 Dick.), 428; 26 Atl. 

566 389, 402 

Howes V. Colboum, 165 Mass., 385; 

43.N. E. R., 125 511 

Hoyt's Est., In re, 10 Kulp (Pa.), 166. 

384, 391, 551 

Hubbard v. Mutual Reserve Fund 

Life Ass'n, 100 Fed., 719; 40 C. 

C. A.,665 140 

Hudson V. Adam's Adm., 20 Ky. Law 

R., 1267; 49 S. W. Rep., 192. .537 
Hudson V. Hughan, 56 Kan., 152; 

42 Pac, 701 409 

Hudson V. Lynn & B. R. Co. (Mass.), 

59 N. E. Rep., 67 '.376 

Huff V. Sovereign Camp, 85 Mo. App., 

96 ,. .,,, .., 374 



XXIV 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Huggins V. Drury, 192 111., 528; 61 

N. E. K., 652 566 

Hughes V. Jones, 116 N. Y., 67. ,357, 

367, 369 
Hull's Will, In re (Iowa), 89 N. W. R., 

979 567 

Humboldt, In re, 12 Phila., 424. .592 
Humpeler v. People, 92 111., 400. 

482 
Hunt V. Rabitony, 7 Detroit Leg. 

News, 447; 84 N. W. R., 59. . .366 
Hunt V. Searcy (Mo.), 67 8. W. R., 

206 687 

Hunt V. State (Tex. Cr. App.), 28 

S. W. Rep., 206 559,564 

Hunteri). Edney orse H., 10 P. D., 93. 

762 
Hunter v. Talbard, 34 S. E. Rep. (W. 

Va.), 737 .• 375 

Hurlburt's Will, In re, 48 App. Div., 

91; 62 N. Y. Supp., 698 555 

Hurlbut, Matter of, 26 Misc., 461; 

57 N. Y. Supp., 648 412 

Hurst V. State (Tex. Cr. App.), 40 

S. W. R.,264 533,537 

Hurst V. State (Tex. Cr. App.), 50 S. 

W. R., 719 559,561 

Hutchinson v. Hutchinson, 152 111., 

347; 38 N. E. Rep., 926 402, 

410 
Hutts V. Hutts, 62 Ind., 214 585 

lago V. lago, 168 111., 339; 48 N. E. 

Rep., 30 378, 598 

Illinois Masons' Benefit Soc. v. Win- 

throp, 85 111., 537 142 

Imperial Loan Co. v. Stone, 1 Q. B., 

599 (Eng.) 365 

Inhabitants of Fayette v. Chesterville, 

77 Me., 28; 52 Am. Rep., 741 . . 532 
Inhab. of Kittery v. Dixon, 96 Me., 

368; 52 Atl. Rep., 799. . .382, 383 
Insurance Co. v. Hunt, 79 N. Y., 541. 

366 
![redale's Will, In re, 53 App. Div., 

45; 65 N. Y. Supp., 533.... 386, 
397, 403, 410, 533 



PAG« 

Irish V. Newell, 62 111., 196 566 

Isaacs V. Jones, 121 Cal., 257; 53 
Pac. R., 793 526 

Jackson v. Jackson, 39 N. Y., 153, 

reversing 1 Tuck., 259 392 

James White Memorial Home u.Haeg, 

68 N. E. R., 568; 204 111., 422. .391 
Jamison v. CuUigan, 151 Mo., 410; 

52 S. W. R., 224 364, 368 

Jamison v. People, 145 III., 357; 34 

N. E. R., 486 536, 557, 559 

Jaques v. Pub. Adm., 1 Bradf. Surr. 

(N. Y.), 499 762 

Jaroszewski v. Allen (Iowa), 91 N. W. 

R., 941 429 

Jenisch, Re Isabella, 3 Abb. N. C, 

200 430 

Jenkins ■;;. Hankins, 98 Tenn., 545; 

41 S. W. Rep., 1028 426 

Jenkins v. State, 93 Ga., 1; 18 S. E. 

R., 992 496 

Jennings v. Hennesy, 26 Misc. (N. 

Y.), 265; 55 Supp., 833 362 

Jewell V. Colby, 24 Atl., 902; 66 N. 

H., 399 425 

J. G. V. H. G., 33 Md., 401 763, 764 

John Hancock Mut. Life Ins. Co. v. 

Dick, 117 Mich., 518; 76 N. W. R., 

9; 44 L. R. A., 846. 135 

Johnson, In re, 57 Cal., 529 525 

Johnson's Will, In re (Surr.), 7 Misc. 

R. (N. Y.), 220; 27 N. Y. Supp., 

649 386, 519 

Johnson's Will, In re, 57 N. Y. State 

Rep., 846 413 

Johnson v. Armstrong (Ala.), 12 So. 

' R., 72 417,508 

Johnson v. Cochrane, 159 N. Y., 555; 

54 N. E. Rep., aff'g 91 Hun, 168; 

36 N. Y. Supp., 283 408, 

409, 546 
Johnson v. Commonwealth, 23 Ky. 

Law R., 856; 64 S. W. R., 467. 

424 
Johnson v. Johnson, 187 111., 86; 58 N. 

E. Rep., 237 553, 566 



TABLE OF CASES CITED IN THIS VOLUME. 



XXV 



PAGE 

Johnson v. Johnson, 45 Mo., 595. .762 
Jchnson v. Kincade, 37 N. C, 470. 

762 
Johnson v. State, 45 S. W. Rep., 436; 

100 Tenn., 254 436 

Johnson v. State (Tex. Cr. App.), 62 

S. W. Rep., 756 545, 549 

Johnson v. Stevens, 15 Ky. Law R., 

477; 23 S. W. R., 957 565 

Jones V. Angell, 95 Ind., 376 603 

Jones V. Collins, 9^ Md., 403; 51 Atl. 

R., 398 532, 538, 

545, 647, 548, 568, 569 
Jones V. Galbraith (Tenn. Ch. App.), 

59 S. W. Rep., 350 537 

Jones V. Grogan, 98 Ga., 552; 25 S. E. 

R., 590 520 

Jones V. Jones (N. Y.), 63 Hun, 630; 

17 N. Y. Supp., 905 552 

Jones V. Learned, 66 Pac. R., 1071 

(Colo. App.) 586 

Jones V. People, 23 Colo., 276; 47 

Pac. R., 275 509 

Jones V. Roberts, 37 Mo. App. , 165 . 503 
Jones V. Simpson, 171 Mass., 474; 50 

N. E.R.,940 416 

Jones's WiU, In re (Surr.), 5 Misc. R. 

(N. Y.), 199; 25 N. Y. Supp., 109. 

397, 403, 411, 412 

Jordan v. People, 19 Colo., 417; 36 

Pac. R., 218 529,531 

Joumeay's Will, In re, 15 App. Div. 

(N. Y.), 567; 44 N. Y. Supp., 548; 

aff'd 162 N. Y., 611, 646; 57 N. E. 

Rep., 1113 391, 419, 516 

Judd V. Gray, 156 Ind., 278; 59 N. E. 

R., 849 380 

Julke V. Adam, 1 Redf. Surr. (N. Y.), 

454 414 

Kaenders v. Montague, 180 III., 300; 

64 N. E. Rep., 321 : 394, 519 

Kaufman's Estate, In re, 117 Cal., 

288; 49 Pac. R., 192 393, 

418, 620, 523 
Kaufman v. Caughman, 49 S. C, 159; 

27 S. E. R., 16 516, 519, 538 



PAGE 

Kearney v. State, 68 Miss., 233; 8 So., 

292 436,532,559 

Kearney's Will, In re, 69 App. Div., 

481; 74 N. Y. Supp., 1045 535 

Keeffe v. Nat'l Ac„. Soc, 4 App. Div. 

(N. Y.), 392; 38 Supp., 854. .. . 140 
Keeler v. Keeler, 20 N. Y. State Rep., 

439 399 

Keeler's Will, In re, 3 N. Y. Supp., 

629 399 

K^enan v. Commonwealth, 44 Pa., 

55; 84 Am. Dec, 814 493 

Keener v. State, 24 S. E. R., 28; 97 

Ga., 388 560 

Keithley v. Stafford, 126 111., 507; 18 

N. E. Rep., 740 387, 409 

Keithley's Estate, In re, 134 Cal., 9; 

66 Pac. R., 5 638 

Kelch V. Slate (Ohio), 46 N. E. R., 6. 

660 
Kellogg V. Church Char. F., 128 

App. Div. (N. Y.), 214; 112 Supp., 

566 607 

Kellogg V. U. S., 43 C. C. A., 179; 

103 Fed., 200 552 

Kelly V. Burke (Ala.), 31 So. Rep., 

512 369 

Kelly V. Commonwealth, 1 Grant 

(Pa.) Cas., 484 492 

Kelly V. Kelly, 74 N. W. Rep., 899; 

72 Minn., 19 383 

Kelly V. Odell (111.), 48 N. E. R., 168. 

518 
Kelly V. Perrault (Idaho), 48 Pac. R., 

45 356 

Kelly V. State, 31 Tex. Crim. R., 216; 

20 S. W. Rep., 357 484, 487 

Kendrick's Estate, In re, 130 Cal., 

360; 62 Pac. R., 605 394, 395, 

396, 397, 398 

Kennedy i). Johnson, 65 Pa. St., 451. 

596, 597 

Kent V. Kent, 22 Misc. (N. Y.), 403; 

50 N. Y. Supp., 339 381 

Kent V. West, 33 App. Div., 112; 53 

N. Y. Supp., 244 382, 383 

Kenworth V, Williams, 5 Ind., 375. 580 



xxvi 



TABLE OF CASES CITED IN THIS VOLUME. 



Kenyon v. Knights Templar and M. 

M. A. Ass'n, 122 N. Y., 247. . .134 

Kem V. Kern, 51 N. J. Eq., 514; 26 

Atl.,831 376,761 

Ketteman v. Metsjger, 23 Ohio C. C. 

R., 61 389, 419, 508,521, 

543, 560 
Keystone Mut. Ben. Ass'n -o. Jones, 

72 Md., 363; 20 Atl. R., 195. .. . 133 
Kibler, Ex parte, 31 S. E. Rep., 274; 

53 S. C, 461 381 

Kiedaisch, Will of, 13 N. Y. Supp., 

255 404 

Kiehne v. Wessell, 53 Mo. App., 667. 

370, 592 
Kimball v. Baumgardner, 16 Ohio C. 

C, 587 370 

Kimball v. Fisk, 39 N. H., 110. . . .586 
Kimberly, Appeal of, 68 Conn., 428; 

36 Atl. R., 847; 37 L. R. A., 261. 
395, 398, 544 
King, see Rex. 
Kingt). Harvey and Chapman, 2 Bam. 

and Cress., 257 602 

King V. King, 42 S. W. Rep., 347; 19 

Ky. Law Rep., 868 389, 567 

King V. State, 90 Ala., 612; 8 So. R., 

856 490, 491, 493 

King V. State, 91 Tenn., 617; 20 S. W. 

Rep., 169 559 

King V. State, 64 S. W. R., 245. .490 
King's Will, In re, 29 Misc. R., 268; 

61 N. Y. Supp., 238 391, 512 

Kingsley v. Blanchard, 66 Barb. (N. 

Y.), 317 566 

Kingston v. Fort Wayne, etc., R. Co., 

112Mich.,40;70N.W.R.,315. .428 
Kirkpatrick v. Jenkins, 96 Tenn., 85; 

33 S. W. R., 819. . . .503, 519, 525 
Kischman v. Scott, 166 Mo., 214; 65 

S. W. R., 1031 390 

Kissam v. Kissam, 21 App. Div., 142; 

47 N. Y. Supp., 270 380 

Knight's Est., 167 Pa. St., 453; 31 

Atl. Rep., 682 403, 411 

Knights V. State, 58 Neb., 225; 78 N. 

W. R., 508 435,557 



Knights Templars' & Masons' Life 

Indemnity Co. v. Crayton, 209 111., 

550; 70 N. E. R., 1066 135 

Knights Templars' & Masons' Life 

Indemnity Co. v. Jamian, 104 Fed. 

R., 638; 44 C. C. A., 93; aff'd Supr. 

Ct. U. S., 187 U. S., 197; 23 Supr. 

Ct. R., 108 373 

Knox V. Knox, 95 Ala., 495; 11 So. 

R., 125 418 

Koegel V. Egner, 54 N. J. Eq., 623; 

35 Atl. Rep., 394 390, 552, 555 

Kolb's Est., In re, 6 Pa. Dist. Rep., 

543 382 

Kostelecky v. Scherhart, 99 Iowa, 120; 

68 N. W. R., 591 536, 544 

Kraus v. Kraus, 9 Ohio S. & C. P. 

Dec, 515; 6 Ohio N. P., 248. . .767 
Krause v. Stein, 173 Pa. St., 221; 

33 Atl. Rep., 1031 363 

Kroenung v. Goehri, 112 Mo., 641; 

20 S. W., 631 356,362 

Krom V. Schoonmaker, 3 Barb., 647. 

425 
Kuster v. Kuster, 37 Misc. (N. Y.), 

136; 74 N. Y. Supp., 853 379 

L. V. L., 7 P. D., 16 763, 765 

La Bau v. Vanderbilt, 3 Redf., 384, 

436 386 

Lack V. Brecht, 166 Mo., 242; 65 S. W. 

R., 976 368,371 

Lackey v. Lackey, 8 B. Mon., 107. 

585 
Lacky v. Cunningham, 56 Pa. St., 

373 591 

Lacy V. Mann, 59 Kan., 777; 53 Pac. 

Rep., 754 375 

Lacy V. State, 30 Tex. App., 119. 

562 

Lamb v. Lamb, 105 Ind., 456 394 

Lamb v. Lippincott, 115 Mich., 611; 

73 N. W. Rep., 887 542 

Lamb v. Lynch, 56 Neb., 135; 76 N. 

W. Rep., 428 537 

Lambert, In re, 134 Cal., 626; 66 Pac. 

R, 851; 55 L. R. A., 866- - ... ,587 



TABLE OF CASES CITED IN THIS VOLUME. 



XXVll 



PAGE 

Lamoree, In re, 32 Barb. (N. Y.), 122. 

594 
Lamoureaux v. Crosby, 2 Paige (N. 

Y.), 422 369 

Lancaster Co. Nat. Bk. v. Moore, 78 

Pa. St., 407 364 

Landfair v. Thompson, 112 Ga., 487; 

37 S. E. Rep., 717 362 

Lanckton v. U. S., 18 App. D. C, 348. 

448 
Lane v. Moore, 151 Mass., 87; 23 N. 

E. R., 387 503 

Lang V. liigalls Zinc Co. (Tenn. Ch. 

App.), 49 S. W. R., 288 575 

Lang's Will, 9 Misc. Rep. (N. Y.), 

521; 30 N. Y. Supp., 388. . .393, 395 
Langdon v. People, 133 III., 382; 24 

N. E. R., 874 552 

Lange v. Wiegand (Mich.), 85 N. W. 

R., 109; 7 Det. Leg. N., 673.. .512 
Lanier, In re, 170 N. Y., 7; 62 N. E. 

Rep., 761; 68 App. Div., 320; 

74 N. Y. S., 70 592 

Lanier, In re, 68 App. Div., 320; 

74 N. Y. Supp., 70; 170 N. Y., 7; 

62 N. E. Rep., 761 383 

Lantes v. Davidson, 60 Kan., 389; 

56 Pac. R., 745 551 

Lapey v. State, 29 Tex. App., 63; 14 

S. W. R., 398 494 

Lapham's Will, In re, 19 Misc. R. 

(N. Y.), 71; 44 N. Y. Supp., 90. 

397, 550, 569 

Laros v. Commonwealth, 84 Pa. St., 

200 508 

Lasher, In re, 2 Barb. Ch., 97 590 

Latimer v. Sovereign Camp Wood- 
men, 62 S. C, 145; 40 S. E. Rep., 

155 374 

Latimer v. State, 55 Neb., 609; 76 N. 

W. R., 207 492 

Lawrence's Will, In re, 27 Misc. R., 

473; 59 N. Y. Supp., 174; aff'd, 

48 App. Div., 83; 62 N. Y. Supp., 

673 535 

Lawson v. Hilton, 69 App. Div. (N. 

Y.), 303; 85 Supp., 863. .588, 594 



PAGE 

Layer v. Layer, 22 Ky. L~w Rep., 

1936; 62 S. W. Rep., 15. 

394, 398, 568 

Leache v. State, 22 Tex. Cr. App., 279; 

58 Am. Rep., 638; 3 S. W. R., 639. 

457, 652 

Leacocke, In re, Lloyd and Goold 

(Eng. Ch.), 498 696 

Leavell v. Western Ky. Asyl. for the 

Insane, 28 Ky. L. R., 1129; 91 S. 

W. R., 671; 4 L. R. A. (N. S.), 269. 

427, 607 

Le Barron v. Le Barron, 35 Vt., 365. 

765 
Le Donne, In re, 173 Mass., 560; 

64 N. E. R., 244 430, 587 

Ledwith v. Claffy, 18 App. Div., 115; 

46 N. Y. Supp., 612 386, 

416, 521, 523 
Lee V. State (Ga.), 42 S. E. R., 759. 

431 
Lee V. State (Tex. Cr. App.), 64 S. W. 

R., 1047 423 

Lenning's Est., In re, 4 Pa. Dist. Ct. 

R., 94; 36 W. N. C, 118 . .404, 411 
Lenno v. State (Tex. Cr. App.), 68 

S. W. Rep., 684 430 

Leonard v. State Mutual Life Ass. Co., 

24 R. I., 7; 51 Atl. R., 1049; 96 

Am. St. R., 698 133 

Leonard v. The Times, 51 111. App., 

427 381 

Leonard's Estate, In re (Mich.), 54 

N. W. R., 1082...: 353 

Levis's Estate, In re, 140 Pa., 179; 

21 Atl., 242 414 

Lewis, Matter of, 57 Misc. (N. Y.), 

670 590 

Lewis V. Hayward, 36 L. J. P. and 

M., 106 765 

Lewis V. Jones, 50 Barb., 645. . . .413 
Lewis V. Mason, 42 App. Div., 423; 69 

N. Y. Supp., 123 382 

Liddell v. Easton's Trustees, 9 F., 

154 768 

Lilly V. People, 148 111., 467; 36 N. E. 

R., 95 437, 461, 563 



XXVUl 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Lincoln, In re, 1 Brewster, 392. 

585, 589 

Lindberg v. Bavidson, 72 Minn., 49; 

74 N. W. Rep., 1018 355 

Lindsay v. White (Tex. Civ. App.), 

61S. W. R., 438 529,530 

Lindsey, In re, 44 N. J. Eq., 564; 

s. c, 15 Atl. 1 589 

Link V. Sheldon, 136 N. Y., 1 . . . . 531 
Linkmeyer v. Brandt, 107 Iowa, 750; 

77 N. W. R., 493 392,525 

Little V. Little, 13 Gray (Mass.), 264. 

761 
Little V. State, 61 S. W. R., 483. .490 
Litton V. Grand Lodge A. O. U. W., 

84 Mo. App., 208 581 

Livingston, /n re, 1 John. Ch. (N. Y.), 

436 594 

Livingston, In re, 9 Paige (N. Y.), 440. 

595, 597 

Livingston v. Livingston, 56 App. 

Div. (N. Y.), 484; 67 N. Y. Supp., 

789 381 

Livingston's Will (N. J.), In re, 37 

Atl. Rep., 770 390 

Lobdell V. Laboring Men's Mutual Aid 

Ass'n, 69 Minn. 14; 71 N. W. R., 

696; 65 Am. St. R., 542; 38 L. R. 

A., 537 143 

Loermecker's Will, In re, 112 Wis., 

461; 88 N. W. R., 215 503, 555 

Loeser's Est., In re, 3 Pa. Dist. Ct. R., 

817; 167 Pa. St. Rep., 498; 31 Atl. 

Rep., 732; 35 W. N. C, 543. 

411,412 

Loewenstein, Matter of, 2 Misc., 323; 

51 St. Rep., 423; 21 N. Y. Supp., 

231 409 

Loftus V. Mahoney, 89 Va., 576; 16 

S. E. R., 749 363 

Logan V. McGinnis, 12 Pa., 27. . . .539 
Logan V. State (Tex. Or. App.), 53 S. 

W., 694 549 

Logan's Estate, In re, 195 Pa. St., 

282; 45 Atl. R., 729 520, 555 

London iJ. Preferred Ace. Ins. Co., 43 

App. Div. (N. Y.),487 138 



PAGE 

Long V. Bowen, 94 Ky., 540; 23 S. W. 

Rep., 343 424 

Long V. Long, 2 Hawkes, 189 768 

Long V. Long, 9 Md., 348 364 

Longi). Morrison, 14 Ind., 695. . . .603 
Long Island State Hospital v. Stuart, 

22 Misc. R. (N. Y.), 48; 49 N. Y. 

Supp,, 372 382 

Longley v. Commonwealth, 2 Va. 

Supr. Ct. Rep., 600; 37 S. E. Rep., 

339 484 

Looby V. Redmond, 66 Conn., 444; 

34 Atl. Rep., 102 362 

Look V. Choate, 108 Mass., 116. .605 
Looneyi). State,10 Tex. Cr. App., 520; 

38 Am. Rep., 646 457 

Lopez V. State, 30 Tex. App., 487; 17 

S. W. R., 1058 423 

Lorenz v. Lorenz, 93 lU., 376 762, 

764 

Lott V. Sweet, 33 Mich., 308 599 

Loudoun V. 8th Avenue Railway Co., 

16 App. Div. (N. Y.), 152; 44 Supp., 

742 132 

Longhead v. Coombs Co., 2 Mo. App. 

Rep., 1017 375 

Loughney v. Loughney, 87 Wis., 92; 

58 N. W. Rep., 250 539 

Louis V. Corm. Mut. L. Ins. Co., 58 

App. Div. (N. Y.), 137 135 

Louisiana W. E. Ry. Co. v. Mc- 
Donald (Tex. Civ. App.), 52 S. W. 

Rep., 649 429 

Louisville & N. R. Co. v. Cummins' 

Admr., 23 Ky. L. R., 681; 63 S. W. 

R., 594 428 

Louisville etc. Ry. Co. v. Herr, 35 N. 

E. Rep., 556; 135 Ind., 591 367 

Lovegrove v. State, 31 Tex. Cr. R., 

491; 21 S. W. Rep., 191.... 436, 

445, 559, 560 

Lowe, In re, 64 Hun (N. Y.), 633; 

19 N. Y. Supp., 245 592 

Lower v. Schumaker, 61 Kan., 625; 

60 Pac. R., 538 376, 592 

Lucas V. Johnson (Tex. Civ. App.), 

64S.W.R.,823 429 



TABLE OF CASES CITED IN THIS VOLUME. 



XXIX 



PAGE 

Ludlow's Will, In re, 6 Ohio Dec, 344; 

4 Ohio N. R., 155 566 

Ludwick V. Commonwealth, 18 Pa. 

St., 175 591 

Luhrs V. Hancock, 181 U. S. , 567. . 364 
Lynch v. Doran, 96 Mich., 395; 54 N. 

W., 882 356,362 

Lyon V. Home, L. R. 6 Eq., 655. . 399 
Lyon V. Lyon, 230 111., 366; 82 N. E. 

R., 850 767 

M. V. B., 3 Swab and T., 650. . . .765 
M. V. H., 3 Swab, and T., 517. . . .765 
Maasv. Phillips (Okl.), 61 Pac. Rep., 

1057 430 

Maas V. Territory, 10 Okl., 714; 63 

Pac. R., 960; 53 L. R. A., 814. 

353, 436, 450, 560 

Mabie, Matter of, 5 Misc., 179; 24 N. 

Y. Supp., 855 402, 406 

Mackin v. State, 56 N. J. Law, 495; 

36 Atl. R., 1040 436 

Maddox v. Maddox, 21 S. W. Rep., 

499; 114 Mo., 35 389, 390, 555 

Mage V. State, 60 S. W. R., 55. . . . 524 
Makepeace v. Bronnenberg, 146 Ind., 

243; 45 N. E. R., 336 593 

Mallory v. The Travelers Ins. Co., 

47N. Y., 52 143 

Mallory v. Young, 94 Ga., 804; 22 S. 

E.R., 142 504 

Malone's App., 79 Pa. St., 481 593 

Manatt v. Scott, 106 Iowa, 203; 76 

N. W. Rep., 717 394, 409, 

503, 517, 521 
Mangrum v. Commonwealth, 39 S. 

W. Rep., 703; 19 Ky. Law R., 94. 

738 
Manhattan L. Ins. Co. v. Beard, 23 

Ky. L. R., 174; 66 S. W. R., 35. 

374 
Manhattan Life Ins. Co. v. Carder, 

82 Fed., 986; 27 C. C. A., 334. . 139 
Manley's Exrs. v. Staples (Vt.), 26 

Atl. R., 630 568 

Mann v. Keene Guaranty Sav. Bk., 

83 Fed., 51 356 



PAGE 

Manogue v. Hewell, 13 App. D. C, 

455 520 

Mapes V. People*, 69 111., 523. ...482 
Marceau v. Travellers Ins. Co., 101 
Cal., 338; 35 Pac. Rep., 856. 
433, 538 
Marons v. Marons, 86 111. App., 597 . 380 
Marston v. Kennebec Mut. Life Ins. 

Co., 89 Me., 266; 36 Atl. R., 389; 

56 Am. St. R., 412 132 

Martin, Matter of, 98 N. Y., 193. 

404, 554 

Martin D. Bowdoin, 158 Mo., 379; 59 

S. W. R., 227 394,522 

Martin v. Insurance Co., 57 N. J. Law, 

623; 31 Atl. R., 213 133 

Martin v. Martin, 54 W..Va., 301; 

46S. E. R., 120 767 

Martin v. Mottsinger (Ind.), 30 N. E., 

523 586 

Martin v. State, 119 Ala., 1; 25 So. 

R., 255 559 

Martin v. State of N. Y., 120 App. 

Div. (N. Y.), 633 427 

Martin v. Thayer, 37 W. Va., 38; 

16 8. E., 489 389,394,397 

Martinez v. Moll, 46 Fed. Rep., 724 

(U.S.Cir.Ct.La.) 365 

Marvin, In re, 1 Dill. , 178; 16 Fed. Cas., 

927 598 

Marvin v. Marvin, 3 Abb. N. Y. Ct. of 

App., 192 419 

Maryland Casualty Co. v. Hudgins, 97 

Tex., 124; 76 S. W. R., 145; 64 L. 

R.A.,349 141 

Marx V. McGlynn, 88 N.Y., 370. .393 
Mason, Matter of, 1 Barb. (N. Y.), 

936 590 

Massengale v. State (Tex.), 6 S. W. R., 

35 436 

Massie v. Commonwealth, 15 Ky. 

Law R., 562; 24 S. W. Rep., 611. 

536, 544 

Masters v. Jones (Ind.), 64 N. E. R., 

213 382 

Matchen v. Matchen, 6 Barr (Pa.). 
332, 378 



XXX 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Matthiessen & Weichers Ref. Co. v. 

McMahon, 38 N. J. L., 536. . . .364 

Mattson v. Mattson (Wash.), 69 Pac. 

R., 1,087 371,381 

Mattson v. Modern Samaritans, 

91Minn.,434;98N. W. R.,330..132 

May V. Bradlee, 127 Mass., 414. 

531, 546 

May V. May, 109 Mass., 252 595 

Maynard v. State (Tex. Cr. App.), 39 

S. W. R., 667 515 

Mayo V. Jones, 78 N. C, 402 566 

Mays V. Prewett, 98 Tenn., 474; 

40 S. W. R., 483 362 

McAffee v. Commonwealth, 3 B. 

Mon., 305 585 

McAnan v. Tiffin, 143 Mo., 667; 45 

S. W. R., 656 364 

McCabe, In re, 70 Vt., 155; 40 Atl. R., 

52 509, 537,547 

McCandless v. McWha, 22 Penn., 

261 603 

McCarthy, Matter of, 48 State Rep., 
315; 20 isr. Y. Supp., 581; 65 Am., 

624 408 

McCarthy v. Travelers Ins. Co., 8 
Bissel'sU. S. C. C. Rep., 362; Fed. 

Cas. No. 8682 137 

McCarty v. Commonwealth (Ky.), 

20 S. W. Rep., 229 487 

McClackey v. State, 5 Tex. App., 320. 

536 
McClary v. StuU, 62 N. W. Rep., 501; 

44 Neb., 175 392, 393, 400 

Mc Cleary v. Barcalow, 6 Ohio Circuit 

Ct.,481 370,379 

McCook V. State, 91 Ga., 740; 17 S. 

E. Rep., 1019 487,497 

McCormick v. McCormick (Iowa), 

81 N. W. R., 172 565 

McCoy V. Metropolitan Life Ins. Co., 

133 Mass., 82 133 

McCuUoch V. Campbell, 49 Ark., 367; 

5 S. W. R., 540 418 

McCury v. Hooper, 12 Ala., 823. .586 

McDonald v. Morton, 1 Mass., 543. 

591, 594 



PAGE 

McElroy's Case, 6 W. and S. (Pa.), 

451 580 

McFadin v. Catron, 120 Mo., 252; 

25 S. W. Rep., 506 412, 417, 

635, 578 
McFarland's Trial, 8 Abb. Pr. N. S., 

57 434 

McGarvan v. Brooks, 16 So. R., 936 

(Miss.) 374 

McGee v. Hayes, 127 Cal., 336; 59 

Pac. R., 767 626 

McGinnis v. Commonwealth, 74 Pa. 

St., 245 591 

McGinniss v. Dempsey, 27 Mich., 363. 

566 

McGlother v. Provident Mut. Ace. Co. 

of Phila., 89 Fed., 685; 32 C. C. A., 

318 140 

McGovern's Est., In re, 185 Pa. St., 

203; 39 Atl. Rep., 816 396 

McGraw v. McGraw, 50 N. E. R., 526. 

552 
McGraw's Will, In re, 9 App. Div., 

372; 41 N. Y. Supp., 481 408 

McHugh V. Fitzgerald (Mich.), 61 N. 

W. Rep., 354 648 

Mcllroy's Est., In re, 10 Pa. Dist. R., 

78 399 

Mcintosh V. Moore, 22 Tex. Civ. App., 

22; 53 S. W. R., 611 419, 603, 

611 
Mclntyre v. People, 38 111., 514. . .487 
Mclntyre v. Sholty, 121 111., 660; 13 

N. E. Rep., 239 425 

McKean's Will, Inre, 31 Misc. R., 703; 

66 N. Y. Supp., 44 534 

McKee's Admr. v. Pumell, 38 S. W. 
Rep., 705; 18 Ky. Law Rep., 879. 

367 
McKenzie v. Donnell, 151 Mo., 461; 

52 S. W. R., 222.... 368 

McKissock v. Groom, 148 Mo., 459; 50 

S. W. Rep., 115 362 

McLaughlin's Will, 2 Redf. (N. Y. 

Surr.), 504 393, 414 

McLean v. Breese, 109 N. C, 564. 

697 



TABLE OF CASES CITED IN THIS VOLUME. 



XXXI 



PAGE 

McLeod V. State, 31 Tex. Cr. R., 331; 

20 S. W. R., 749 531, 541, 562 

MoLeroy v. State, 120 Ala., 274; 25 

So. R., 247 491 

McMahon v. McMahon, 186 Pa. St., 

485; 40 Atl., 795 ,.767 

McMillin v. Wm. Deering Co., 38 

N. E. Rep., 398; 139 Fed., 70. .366 
McNaghten's Case, 10 Clark & F. H. 

L. Cas., 200; 1 Car. & K., 130. 

431, 435, 449, 460, 465, 467 

McNairy Co. v. McCoin, 45 S. W. Rep., 

1070; 101 Tenn., 74 383 

McNary v. Blackburn, 186 Mass., 141; 

61 N. E. Rep., 885 429 

McQueen v. Wilson, 31 So. R. (Ala.), 

94 555 

Mead v. Stegall, 77 111. App., 679 . . 366 
Mebany v. Mebany, 59 Ind., 257. 

591 
Medm V. Snyder, 61 Kan., 15; 58 Pac. 

R.,962 395 

Medlockv.Cogburn, Vol.B. Rich. Eq., 

477 585 

Medlock v. Merritt, 102 Ga., 212; 

29 S. E. Rep., 185 377 

Meehain v. Traders and Travelers 

Ace. Co., 34 Misc. (N. Y.), 158; 

68Supp.,821 141 

Meigs V. Dexter, 172 Mass., 217; 52 N. 

E. R., 75 357 

Meister v. Moore, 96 U. S., 76 761 

Memphis Nat. Bank v. Sneed, 97 

Tenn., 120; 36S. W. Rep., 716..365 
Mendenhall v. Tungate, 15 Ky. Law 

R., 639; 24 S. W. R., 431 , . 409, 575 
Menneily v. Employers' Liability 

Assur. Corp., 148 N. Y., 596; 43 

N. E. R., 54; 31 Am. St. R., 716; 

31 L. R. A., 686 139, 141 

Merriam, Matter of, 42 N. Y. State 

Rep., 619; 16 N. Y. Supp., 738. 

403, 406 

Merrill v. Merrill, 126 Mass., 228. 

763, 765 

Merriman, In re, 108 Mich., 454; 

66 N. W. R., 372 503 



PAGE 

Merriman v. Merriman, 153 Md., 631; 

55 N. E. R., 734 568 

Merritt v. Merritt, 43 App. Div. (N. 

Y.), 68; 59 N. Y. Supp., 357. .. . 371 
Merritt v. Merritt, 32 Misc. (N. Y.) 21; 

66 N. Y. Supp., 123, aff'd 62 App. 

Div., 617; 71 N. Y. Supp., 1142. 

356 
Merritt v. State, 39 Tex. Cr. App., 70; 

45 S. W. Rep., 21. . .464, 466, 515, 

541 
Merritt v. State, 40 Tex. Cr., 359; 

50 S. W. Rep., 384 542 

Messner v. Elliott, 184 Pa. St., 41; 

39 Atl. R., 46 415,507, 

518, 548, 551, 555 
Metcalf s Will, In re, 16 Misc. Rep. 

(N. Y.), 180; 38 N. Y. Supp., 1131. 

410, 520 

Metropolitan Life Ins. Co. v. Bergen, 

64 111. App., 685 142 

Meyer v. Meyer, 49 How. Pr., 311. 

767 
Meyer v. People, 156 111., 126; 40 N. 

E.R.,490 563 

Meyer v. St. Louis I. M. & S. Ry. Co., 

54 Fed. Rep., 116 426 

Michigan Mut. Life Ins. Co. v. Leon, 

135 Ind., 636; 37 N. E. R., 584. 

132 
Middleborough v. Rochester, 12 Mass., 

363 761 

Middleditch v. Williams, 45 N. J. Eq., 

726; 17 At., 826; 4 L. R. A., 783. 

400, 503 

Miles V. Treanor, 194 Pa. St., 430; 

45 Atl. Rep., 368 .555 

Mill V. Carr, 5 Ind. App., 491; 32 N. 

E. R., 591 536 

Miller v. Miller, 187 Pa. St., 572; 

41. Atl. Rep., 277; 43 W. N. C, 

84 549 

Miller v. Mut. Ben. Life Ins. Co., 31 

Iowa, 216; 7 Am. R., 122 170 

Miller v. Oestrich, 157 Pa. St., 264; 

27 Atl. Rep., 742 405,420 

Miller v. State, S Ohio St. , 275 .... 482 



XXXll 



TABLE OF CASES CITED IN THIS VOLUME. 



Miller v. State, 3 Wyo., 657; 29 Pac. 

R., 186 659, 562 

Miller's Est., In re, 179 Pa. St., 645; 

36 Atl. Rep., 139; 39 W. N. C, 397. 

407 
Miller's Lunacy, In re, Pa. Dist. R., 

269 592 

Milligan v. Pollard, 112 Ala., 465; 

20 So. Rep., 620 365, 367 

Mills V. Cook (Tex. Civ. App.), 56 S. 

W. Rep., 697 .548 

Mills V. Cook (Tex. Civ. App.). 57 S. 

W. Rep., 81 421, 548 

Minder v. State, 113 Ga., 772; 39 S. 

E. Rep., 284 446, 561 

Mitchell V. Copenning (N. C), 32 S. 

E. Rep., 798 403 

Mitchell V. Kingman (Mass.), 5 Pick- 
ering, 431 354 

Mitchell V. State (Fla.), 31 So. R., 

242 537 

Modawell v. Holmes, 40 Ala., 291. 583 
Modern Woodmen v. Kozak, 63 Neb., 

146; 88 N. W. R., 248 135 

Moett V. People, 85 N. Y., 379. .452 
Mohler v. Shank's Est., 61 N. W. R. 

(Iowa), 981 378 

Molton V. Henderson, 62 Ala., 426. 

586 
Moneypenny, Estate of, 1 Month. L. 

Bull., 7 414 

Montag V. People, 141 111., 75; 30 N. E. 

Rep., 887 445, 559 

Moore v. Commonwealth, 92 Ky., 630; 

18 S. W. Rep., 833 559 

Moore v. Cross, 87 Tex., 557; 29 S. W. 

R., 1051 .355 

Moore v. Gubbins, 54 111. App., 163. 

519 
Moore v. McDonald, 68 Md., 321; 

12 Atl. R., 117 503 

Morain v. Devlin, 132 Mass., 87; 42 

Am. Rep., 423 425 

Moran v. Moran, 106 Mich., 8; 63 N. 

W. R., 989 364 

Morgan, In re, 7 Paige (N. Y.), 236. 
367, 589 



PAGE 

Morgan's Case, 3 Blandf. Ch. (Md.), 

332 590 

Mormon Church v. U. S., 136 U. S., 1. 

582 
Morris v. Eighth Av. R. C, 68 Hun 

(N._Y.), 39; 22 Supp., 666 428 

Morris v. Gt. Northern Ry. Co. 

(Minn.), 69 N. W. Rep., 628. 

368, 369 

Morris v. Morton's Exrs., 14 Ky. Law 

R., 360; 20 S. W. Rep., 287.. .392 
Morse v. Crawford, 17 Vt., 499; 44 

Am. Dec, 349 425, 636 

Morton v. Sims, 64 Ga., 298 586 

Mott V. Mott, 49 N. J. Eq., 192. . .367 
Motz's Est., In re (Cal.), 69 Pac. R., 

294 567 

Moulor V. American Life Ins. Co. , 111 

U. S., 335; 4 Sup. Ct., 266; 28 

Lawyer's Ed., 447 138 

Mullen V. Dunn, 134 Cal., 247; 66 Pac. 

R., 209 598 

Munger, In re, 38 Misc.R., 268; 77 

N. Y. Supp., 648 504, 519 

Murphree v. Senn, 107 Ala., 424; 18 

So. R., 264 537, 552. 568 

Murphy, Matter of, 41 App. Div., 153. 

386, 411 
Murphy v. Commonwealth, 92 Ky., 

485; 18 S. W. R., 163. . . .508, 531 
Murphy's Exr. v. Murphy, 23 Ky. Law 

R., 1460; 65 S. W. R., 165. . . .384 
Murry v. Hennessy (Neb.), 67 N. W, 

R., 470 565 

Murtaugh v. City, 44 Mo., 479 607 

Mutual Benefit Ass. v. Nancarrow, 

71 Pac. R., 423; 18 Colo. App., 274. 

143 
Mutual Benefit Life Ins. Co. v. Wise, 

34 Md., 582 135 

Mutual Fire Ins. Co. v. Showalter, 

3 Pa. Super. Ct., 452; 40 N. W. E., 

80 426 

Mutual Life Ins. Co. v. Hunt, 79 N. 

Y., 541 367 

Mutual Life Ins. Co. v. Lothrop, 111 

U. S.,612 536 



TABLE OF CASES CITED I.V THFS VOLUME. 



Mutual Life Ins. Co. v. Selby, 72 Fed., 
980; 19 C. C. A., 331; 44 U. S. 
App., 282 133 

Mutual Life Ins. Co. v. Stibbe, 46 Md., 
302 135,139 

Mutual Life Ins. Co., r. Wiswall, 56 

Kan., 765; 44 Pae. R,, 996 527, 

569, 592 

Mutual Reserve Fund Life Ass'n v. 
Famer, 65 Ark., 581; 47 S. W. R., 
850 132,133 

Mutual Res. Fund Life Ass'n v. Sul- 
livan (Tex. Civ. App.), 29 S. W. 
R., 190 135 

Myer's Estate, 1 Myrick Prob. Rep. 
(Cal.), 178 .596 

Myers v. Knabe, 51 Kan., 720; 33 
Pac. R.,602 366 

Myers v. State (Tex. Cr. App.), 39 
S-W. Rep., HI 423 

Naanes v. State, 143 Md., 299; 42 N. 

E. R.,609 526 

Nailor v. Nailer, 4 Dana, 339 588 

National Fraternity v. Karns, 24 

Tex. Civ. App., 607; 60 S. W. R., 

576 134 

Needham v. Ide, 5 Pick. (Mass.), 510. 

.531 
Nelson's Est., In re. 132 Cal., 182; 

64 Pac. R.,294 .391,401, 

552, 555 
Nelson v. Equitable Life Ass'n Soo., 

73111. App., 133 374 

Nelson r. State (Tex. Cr. App.), 67 

S. W. R.,320 439 

Nesbitt, In re, 2 Phillips, 245 586 

Nevling v. Com., 98 Pa. .St., .323. 

496 
Newcomb's Exrs. v. Newcomb, 16 

Ky. Law R., 376; 27 S. W. Rep., 

997 544 

Newell V. Newell, 9 Paige (N. Y.), 25. 

762, 765 

New England Loan & Trust Co. v. 

Spitler, .54 Kan., 560; .38 Pac. R., 

799 ; ..370 



Newhou.se v. Godwin, 17 Barb., 236. 

385 
New York Life Ins. Co.»r. Fletcher, 

117 U. S., 519; 6 Sup. Ct. R., 837; 

29 Lawyers' Ed., 934 133 

Niskern v. United Brotherhood of C. 

and J. of A., 93 App. Div. (N. Y.), 

364 137 

Niven v. Boland, 177 Mass., 11; 58 

N.E. R.,2S2 580 

Nobles V. State of Georgia, 168 IJ. S., 

398 581, 586 

Noel 1). Modern Woodmen, 61 111. 

App., ,597 380 

Nonnemacher v. Nonnemacher, 159 

Pa. St., 634; 28 Atl. Rep., 439. 

376, 511, 564, 568, 761 

Norman v. Georgia Lock Co. (Ga.), 

18S. E. R.,27 370 

Norris v. State, 16 Ala., 776 535 

North V. Joslin, 59 Mich., 624 583 

Norton v. Moore, 3 Head., 482 ... . 536 
Norton ?•, Paxton, 110 Mo., 456. 

390 
Norton v. Seton, 3 Phill. Eccl., 147. 

763 
Nyce /'. Hamilton, 90 Ind., 417. 

585 

O. & W. Thum Co. v. Tloczynski, 
114 Mich,, 149; 72 N. W. R., 140. 

.369 
O.akes, In re, 8 Law Rep. (Mass.), 122. 

599 
Oberdorf's Est., In re, 2 Lack. Leg. 

N., 43 395, 418 

Oberdorfer v. Newberger (Ky.), 67 

S. W. R.,267 415,520 

O'Brien v. People, 36 N. Y., 276. 

532 

O'Connell v. Beecher, 21 App. Div. 

(N. Y.), 47 N. Y. Supp., 334. 

354, .502, 538 

O'Connell r. People, .S7 N. Y., 377, 

557 

O'Connors. Madison, 98 Mich., 183; 57 

N.W.Rep., 105..390, 410, 543, 546 



xxxiv 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

O'Dea's Will, 84 Hun (N. Y.), 591; 

33 N. Y. Supp., 463 394, 396 

Odell V. Moss, 130 Cal., 352; 62 Pac. 

R., 555 363 

O'Dwyer's Will, 61 N. Y. Supp., 903. 

410 
O'Gara v. Eisenlohr, 38 N. Y. . 296 . 761 
O'Grady r. State, 36 Neb., 320; 54 

N. W. R., .556 485, 487, 

491, 492 
Oil Co. V. Mclntire, 44 \\. Va,, 296; 

28 S. E. R., 922 586 

Olmstead v. Webb, 5 App. Div. (N. 

Y.), .38 520 

Omberg v. United States .Miit. Ass'n, 

101 Ky., 303; 40 S. W. R., 909; 

72 Am. St. R., 413 141 

Oneida Co. v. Bartholomew. 82 Hun 

(N. Y.), 80; 31 N. Y. Supp., 106. 

.382 
O'Neil V. Nolan, 66 Hun (N. Y.), 631; 

21 N. Y. Supp., 222 :«0 

Orchardson r. Cofield, 171 III, 14; 

41 N. E. R., 197; 40 L. R. A., 256. 

398, 399, 416 

O'Reilly v. Sweeney, 54 Misc. R., 408; 

105 N. Y. Supp., 1,033 525 

Orr V. Equitable Mtg. Co., 33 S. E. 

Rep., 708; 107 Ga., 499 .365 

Orth V. Orth (Ind.), 44 N. E. R.. 17. 

5.55 
Oster V. Meyer (Ky.), 67 S. W. R.. 

851 586, 587 

Osterhout v. Shoemaker, 3 Hill, 513. 
.367, 385 

Otis, In re, 101 N. Y., 580 370 

Otis's Will, In re. 1 Misc. R. (N. Y. 

Surr.), 2.58; 22 N. Y. Supp., 1,060. 

412 
Otte V. Hartford Life Ins. Co., 88 

Minn., 428; 93 N. W. R., 608; 97 

Am. St. R., 532 1,32, 133 

Otto V. Doty, 61 Iowa, 23; 15 N. W. 

R.,51S 400 

Ouachita Baptist College v. Scott, 64 

Ark., 349; 42 S. W. Rep., 536. 

390 



PAGE 

Overall v. Avant, 46 S. W. Rep., 1,031 

(Tenn. Ch. App.) 356 

Overall v. Bland, 11 Ky. L. R., 371; 

12 S. W. R., 273 418 

Overall v. State, 15 Lea., 672. . . .5.52 
Overing's Ca.se, 1 Blandf. Oh. (Md.), 

290 588 

Owens, In re. 47 How. Pr. (N. Y.), 

1.50 594 

P. V. L. or.se P., 3 P. D., 73 . . . 763, 765 

P. V. P., U Brit. Col., .369 763 

Packham ?■. Ludwig, 103 Md.. 416; 

03 Atl. R., 1,048 .537 

Page V. Kreky, 1.37 N. Y., 307 .375 

Page 7'. L. & N. R. Co. (Ala.), 29 So. 

R., 676 371 

Paige, In re. 7 Daly (N. Y.), 155. 

.594 
Paine v. Aldrich, 1.33 N. Y.. 544; 

30N. E. Rep., 725 .546 

Palmer v. Garland. 81 Va., 444. . .583 
Palmer v. Hudson River State Hos- 
pital (Kan.), 61 Pac. R., .506. 

382 
Parker v. Marco. 76 Fed. Rep., 510. 

.366, 375 
Parker v. Winona <t St. P. R. Co., 

83 Minn., 212: 86 X. W. Rep., 2. 

429 
Parsee Merchant's Case. 11 Abb. Pr. 

N. S. (N. Y.), 209. .. 598 

Parsons v. State, si Ala., 577; 7 Am. 

Crim. Rep., 889; 60 Am. R., 193. 
455, 456 
Patten v. Cilley, 67 N. H., 520; 42 Atl. / 

R., 427 517. 520, 541, 555 

Patterson, Matter of, 26 Abb. N. C, 

395; .36 State Rep., 813; 13 N. Y, 

Supp., 463 406 

Patterson r. Lamb, 21 Tex. Civ. App., 

512; 52 S. W. R.. 98 503, 518 

Patterson r. State, 86 Ga., 70; 12 S. 

E. R.,174 535 

Patton V. Thompson, 2 Jones Eq. 

(N. C), 441 596 

Paul V. Travelers' Ins, Co., 112 N. Y., 



TABLE OF CASES CITED IN THIS VOLUME. 



XXXV 



PAGE 

472; 20 N. E. R., 347; 8 Am. St. R., 

758; 3 L. R. A., 443 137, 139 

Payne 11. Burdette, 84 Mo. App., 332. 

364, 376 
Payne v. Payne, 46 Minn., 467. 

763 
Peabody v. Kendall (111. Sup.), 32 

N. E. Rep., 674 362 

Peacock v. New York Life Ins. Co., 

20N. Y., 293 142 

Pearson's Case (Eng.), 2 Lewin Cr. 

Cas., 144 497 

Peck, Matter of, 6 Dem. (N. Y.), 299. 

554 
Peck, Matter of, 42 State Rep., 898; 

17 N. Y. Supp., 248 412 

Peck?). Gary, 27N. Y.,9 411,413 

Peery v. Peery, 94 Tenn., 328; 29 

S. W. R., 1 503 

Peipho V. Peipho, 88 111., 438 . . .763 
Peninsular Trust Co. v. Barker 

(Mich.), 74 N. W. Rep., 508. ... 396 
People V. AUender, 48 Pac. Rep., 

1,014; 117 Cal., 81 433, 560 

People V. Barber, 115 N. Y., 475; 

26 N. E. R., 184 446 

People V. Barberi, 47 N. Y. Supp., 

168; 2 N. Y. Crim. R., 89 446 

People V. Barker (N. Y. Sup. Ct.), 

67 Hun, 649; 33 N. E. R., 745. .425 
People V. Barthleman, 52 Pac. R., 

112; 120 Cal., 7 538,559 

People V. Bawden, 90 Cal., 195; 27 

Pac. Rep., 204 559 

People t). Belencia, 21 Cal., 544. . .492 
People V. Bemmerly, 98 Cal., 299; 

33 Pac. Rep., 263 559, 560 

People V. Beno Ville, 3 Abb. N. C, 

195 430 

People V. Beverly (Mich.), 66 N. W. 

R., 379 431,436 

People V. Borgetto, 99 Mich., 336; 

58N. W. R., 328 536 

People V. Burgle, 55 Pac. R., 998; 

123 Cal., 303 435,502 

People V. Bums, 2 N. Y. Cr. R., 415. 

490 



PAGE 

People V. Carpenter, 102 N. Y., 250; 

4N. Y. Cr. R., 187 439, 

448, 452 

People V. Casey, 31 Hun, 158 452 

People V. Cassiano, 1 N. Y. Cr. R., 

505; 30 Hun, 388 490 

People V. Clendennin, 91 Cal., 35; 27 

Pac, 418 436 

People V. Coleman, 1 N. Y. Cr. R., 2. 

437, 452 

People exrel. Commissioners v. Smith, 

100 N. Y., 215 373 

People V. Conroy, 2 N. Y. Cr. R., 247; 

33 Hun, 119; aff'd 97 N. Y., 62. 

490 
People V. Corey, 148 N. Y., 505. .494 
People V. Creamer, 30 App. Div., 624. 

587 
People V. Crest, 168 N. Y., 19; 15 N. 

Y. Cr. R., 532; 60 N. E. R., 1,057. 

562 
People V. Davis (Cal.), 36 Pa'c. Rep., 

96 433 

People V. Dillon, 8 Utah, 92; 30 Pac. 

Rep., 150 559 

People I'. Ebanks, 117 Cal., 652; 

49 Pac. R.. 1,049; 46 L. R. A,, 269, 

481 
People V. Ellsworth, 127 Cal., 595; 60 

Pac. R., 161 538 

People V. Eubanks, 86 Cal., 295; 24 

Pac. Rep., 1,014 559 

People V. Fellows (Cal.), 54 Pac. R., 

830 483 

People V. Ferraro, 161 N. Y., 365; 

14 N. Y. Cr. R., 266; 55 N. E. Rep., 

931 466, 535, 562 

People V. Findley, 132 Cal., 301; 64 

Pac. R., 472 552 

People V. Finley, 38 Md., 482 450 

People V. Fish, 125 N, Y., 136. 

490, 494 

People V. Fogelsong (Mich.), 74 N. 

W. R., 730 532 

People V. Ford (Cal.), 70 Pac. R., 

1,075 436 

People r. Foy, 138 N. Y., 664; 53 



XXXVl 



TAPLE OF CASES flTED IX THIS VOLUME. 



N. Y. St. Rep., 26.5; 34 N. E. Rep., 

396 440 

People V. Francis, 38 Cal., 183. . .552 
People V. Gaynor, 33 App. Div., 98; 

53N. Y. Supp.,86 524 

People V. Geiger, 116 Cal., 440; 48 

Pac. Rep., 389 429, 430 

People V. Gilmore (Cal.), 53 Pac. R., 

806 489,524 

People V. Gordon, 103 Cal., 568; 37 

Pac. R., 574 489 

People V. Haight, 3 N. Y. Cr. R., 61; 

13 Abb. N. C, 198 439 

People V. Hall, 48 Mich., 482. . . .531 
People V. Hettich, 126 Cal., 425; 58 

Pac. R., 918 434, 5.57 

People V. Hill, 116 Cal., 562; 48 Pac. 

Rep., 711 5.38 

People V. Hill, 123 Cal., 47; 55 Pac. 

R., 692 524 

People V. Hoch, 150 N. Y., 291; 44 

N. E."R.,976 510,511 

People V. Holmes (Mich.), 69 N. W. 

R., 501 434 

People V. Hubert, 119 Cal., 216; 51 

Pac. R., 394, 684 450, 464, 466, 

515 

People V. Kleim, 1 Edm. (N. Y.), 13. 

439, 455 

People V. Kloss, 115 Cal., 567; 47 

Pac. Rep., 459.. .433, 486, 524, 575 

People V. Knott, 122 Cal., 410; 55 

Pac. Rep., 154 4.30 

People V. Koemer, 154 N. Y., 355; 

48N.E. R.,730 511,533 

People V. Lane, 100 Cal., 379; 34 Pac. 

Rep., 856 487, 489, 493, 563 

People V. Larrabee, 115 Cal., 1.58; 46 

Pac. Rep., 922., 433 

People i).Leary, 105 Cal., 486; 39 Pac. 

R., 24 4.39, 440, 499 

People V. Lee Fook, 85 Cal., 300; 24 

Pac. R.,654 430 

People V. Leonardi, 143 N. Y., 360; 

38 N. E. R., 372 490, 493, 494 

People V. Markell, 20 Misc. R. (N. Y.), 
149;45N, Y. Supp.,904 482 



PACE 

People r. Martin, 15 Mi.sc. R., 6; 36 

N. Y. Supp., 437 529 

People V. McCarthy, 115 Cal., 255; 

46 Pac. R., 1,073 433, 538, 

541, 557 
People 1'. McElvaine, 121 N. Y., 250. 

531 
People V. McElvaine, 125 N. Y., 

.596; 26 N. E. R., 929; 36 N. Y. St. 

Rep., 181 430,437 

People V. McNulty, 93 Cal., 4.37; 36 

Pac. Rep., 597 559 

People V. Methever, 132 Cal., 326; 64 

Pac. R., 481 480, 483, 489 

People V. Miller, 114 Cal., 10; 45 Pac. 

R.. 986 524 

People V. Mills, 98 N. Y., 176 490 

People V. Montgomery, 13 Abb. Pr. 

N. S., 207 (N. Y.); citing 4 Den., 9. 

435, 439 

People ex rel. Morrell i: Dold, 189 

N. Y., .546 587 

People V. Mulkins, 25 Misc. Rep. (N. 

Y.), 599; 54 N. Y. Supp., 414.. .482 
People ;-. Nino, 149 N. Y., 317; 43 N. 

E.R..853 532,559 

People r. Nolan, 7 X. Y. Cr. R., 134; 

aff'd 115 X. Y.. 660. 440 

People ex rel. Norton r. X. Y. Hospi- 
tal. 3 Abb. X. C, 229 421, 551 

People V. O'Connell, 62 How. Pr., 

436, abstr. s. c, 13 X. Y. "Weekly 

Dig., 95, .53(1 435, 483 

People r. Odell, 1 Dak., 197; 46 N. 

^Y. R., 601 489 

People r. Osmond, 138 X". Y., 80. 

442. 462, 563 

People r. (.)tto, 38 Hun. 99; 4 N. Y. 

Cr. R., 154.. 452,499 

People c. Owens. 56 Pac. R., 251. 450 
People V. Pekarz, 185 N. Y., 470. 489 

People r. Pine, 2 Barb., 566 435 

People r. Porter, 2 Park Cr. R., 14; 

Coke's Littleton. 247; Blackstone 

Comm., 26 487,488 

People r. Radley (Mich.), 8 Det. Leg. 

N., 467; 86 N. W. Rep., 1,029. .481 



TABLE OF CASES CITED IN THIS VOLIMB. 



xxxvu 



PAGE 

People 1'. Rhinelander, 2 N. V. Cr. R., 

340 439 

People V. Robinson, 2 Park Cr. R., 

235 497 

People V. Rogers, 18 N. Y., 9; citing 

Plowd.,19; 3T.Co,,46; 4Co.,125; 

Bac. Max., V., 7 Carr and P., 297, 

317; 5Mass.C.C. R.,28; 1 Curt. C. 

C.R., 1; 2 Park., 223,23.5. .487, 492 

People V. Sanford, 43 Cal., 29 535 

People V. St. Sav. San., 34 App. Div. 

(N. Y.),363 587 

People V. Schmitt, 106 Cal., 48; 39 

Pac. R.,204 564 

People I'. Schnyler, 106 N. Y., 298. 

531 
People V. Shattuck, 109 Cal., 673; 42 

Pac. R., 315 532 

People V. Silverman, 181 N. Y., 235. 

431,434,439 

People V. Slack, 90 Mich., 448; 51 

N. W. R., 533 481 

People V. Smiler, 125 N. Y,, 717; 26 

N. E. R., 812 531 

People V. Sprague, 2 Park. Cr. , 43 . . 435 
People V. Stratt, 148 N. Y., 566; 42 

N. E. R., 245 514, 532, 546 

People V. Taylor, .34 N. B. Rep., 275; 

138 N. Y.,398; 52 N. Y. St. R., 919. 
349, 352, 438, 444, 448, 452, 

460, 463, 467, 531, 546, 559, 562 
People V. Travers, 88 Cal., 233; 26 

Pac. R., 88 430, 483, 486, 560 

People u. Tuczkewitz, 149 N. Y., 

240; 43 N. E. R., 548 529 

People V. Vincent, 95 Cal., 425; 30 

Pac. Rep., 581 487, 489 

People V. Waltz, 50 How. Pr., 214. 

440, 449, 452 

People V. Walworth, 4 N. Y. Cr. Rep., 

355 452 

People V. Walworth, 4 N. Y. St. R,, 

717 448 

People i>. Ward, 105 Cal., 335; 38 Pac. 

R., 945 526, 557, 559, 560 

People D. Willey, 2 Park. Cr. R., 19. 

487 



PACK 

People V. Wood, 126 N. Y., 249; 36 

N. Y. St. R.,963 434. 448, 513 

People ('. Worthington, 105 Cal., 166; 

38 Pac. R., 689 481, 531 

People V. Wreden, ,59 Cal., 392 . . .535 
People V. Young, 102 ("al.. 411; 36 

Pac. Rep., 770 486 

People V. Youngs, 151 N. Y., 210; 45 

N. E. Rep., 460 546 

Perego, Matter of, 65 Hun, 478; 48 

State Rep., 496; 20 N. Y. Supp., 

394 410 

Pergason v. Etcherson, 91 Ga., 785; 18 

S. E. Rep., 29 394, 517 

Perkins v. Perkins (Iowa), 90 N. W. 

R., 55 389, 402, 

411,419,519 
Perkins v. Perkins, 39 N. H., 163. 

566 
Perret v. Perret, 184 Pa. St., 131; 

39Atl. R.,33 520 

Perry v. House of Refuge, 63 Md., 20. 

427 
Person v. Warren, 14 Barb., 488.385 
Petefish V. Becker, 176 111., 448; 52 

N. E. R.,71 389.511,537,548 

Peters, In re (Pa.), 10 Kulp., 93. 

424 
Peters v. Peters, .59 N. W. Rep., 609; 

101 Mich., 291 363 

Petersen v. Modern Brotherhood of 

Am., 125 Iowa, 562; 101 N. W. 

R., 289; 67 L. R. A., 631 1.38 

Petrie v. Shoemaker, 24 Wend,, 85. 

385 
Pettel, In re, 2 Paige (N. Y.), 174. 

586 

Pettit, In re, 2 Paige, 596 597 

Pflueger v. State, 46 Neb., 493; 64 N. 

W. R., 1,094 526, 544, 547 

Phelps V. Commonwealth, 17 Ky. 

Law R., 706; 32 S. W. R., 470. 

531,560 

Phelps V. Hartwell, 1 Mass., 71. .531 

Phenix Ins. Co. of Brooklyn v. Weeks, 

45 Kan., 751; 26 Pac, 410.. 132, 

133 



XXXVlll 



TABLE OF CASES CITED IX THIS VOLUME. 



PAGE 

Pidcock r. Porter, 08 Pa. Kt., 342; 

8 Am. Dec, 181 536 

Pienovi's Case, 3 City H. Rec. (N. Y.), 

123 440 

Pigman v. State, 14 Ohio, 555. . . , 492 
Pike V. Pike, 104 Ala., 642; 16 So. R. 

689 550 

Pile V. Pile, 94 Ky., 308; 22 S. W., 

215 377 

Pilkington v. Gray, 68 L. J. P. C, 63; 

(Eng.) App. Cases [1899], 401 . . 389 
Pinney's Will, 27 Minn., 280, , . .536 
Pirtle V. State, 9 Humph. (Tenn.), 

663 492 

Pitcairn r. Pitcaim, 201 Pa. St., 368; 

50 Atl. R., 963 377 

Pittard v. Foster, 12 111. App., 132. 

536 
Pitt's Estate, In re (Wis.), 55 N. W., 

149 389, 555 

Pittsburgh, etc., Ry. Co. v. Thompson, 

82 Fed. Rep., 720; 27 C. C. A., 333. 

421, 422 

Plake V. State, 121 Ind., 433; 23 N. 

E. R., 273; 16 Am. St. R., 408. 

455, 456 

Plank, Ex parte, 5 Clark (Pa.), 35. 

588, 589 

Plaster v. Rigney, 97 Fed. Rep., 12; 

38 C. C. A., 25 364, 371, 505 

Pohalski V. Mutual Life Ins. Co., 45 

How. Pr., 504; 36 N. Y. Super. Ct., 

234; 56 N. Y., 640 138, 139 

Polin V. State, 14 Neb., 540 536 

Pollard V. Nyborn, 1 Hagg. EccL, 

725 765 

Pollock V. Horn, 13 Wash., 626; 43 

Pac. R.,885 355,381 

Pollock V. U. S. Mut. Ace. Ass'n, 

102 Pa. St., 330 137 

Pones V. State (Tex. Cr. App.), 63 

S. W. Rep., 1,021 424 

Poole V. Richardson, 3 Mass., 330. 

531 
Pooler V. Cristman, 34 N. E. Rep., 

57; 145 111., 405 389,411, 

417, 512 



PAGE 

Porter, In re, 34 App. Div., 147; 54 

N. Y. Supp., 654; 28 Civ. Pro. R., 

405 354 

Porter v. Rich, 70 Conn., 235; 39 L. 

R. A., 353; 39 Atl. R«p., 169. 

586, 587 

Portwood V. Commonwealth, 20 Ky. 

L. R., 680; 47 S. W. R., 339. . . .559 

Post V. Mason, 91 N. Y., 539 554 

Potter's Will, In re, 161 N. Y., 84; 

55 N. E. R., 387; 17 App. Div., 

267; 45 N. Y. Supp., 563 503, 

504, 539 

Potter V. Jones, 20 Or., 239 390 

Potts r. House, 6 Ga., 324; 50 Am. 

Dec, 329 536, 539 

Pottsville Mut. Fire Ins. Co. v. 

Fromm, 100 Pa., 347 132 

Powell V. Powell, 18 Kan., 371. . .762 
Powell V. Smallwood, 37 S. E. Rep., 

551 425 

Powell V. State, 25 Ala., 28 535 

Powers V. Mass. Horn. Hosp., 109 Fed., 

294; 47 C. C. A., 122; 65 L. R. A., 

.372 607 

Powers' Exr. i'. Powers, 52 S. W. Rep., 

845; 21 Ky. Law, 597 396, 518 

Prather v. McClelland (Tex. Civ., 

App.). 26 S. W. R., 657 565 

Pratt, In re. 6 N. B. R., 276; Fed. Cas. 

11,371 598 

Preferred Ace Ins. Co. v. Robinson, 

33 So. R. (Fla.), 1,005; 61 L. R. A., 

145 141 

Prentiss v. Bates, 88 Mich., 567 .. . 390 
Prentiss v. Bates, 93 Mich., 234; 53 

N. W. Rep., 153 403, 508, 

532, 545 
Preston, Matter of, 43 Misc. (N. Y.), 

5.50 590 

Preston, Matter of, 113 App. Div. 

(N. Y.), 732 353,367 

Prine v. Prine, 36 Fla., 676; 18 So. 

R., 781 761, 762 

Pritchard v. Henderson, 3 Pennewill 

(Del.), 128; 50 Atl. R., 217 . . .389, 
391, 402, 403, 417 



TABLE OF CASES CITED IN THIS VOLUME. 



XX XIX 



PAOlv 

Providence Savings Life Ass. Soc. r. 

Reutlinger, 58 Ark., 528; 25 S. 

W. R., 835 132 

Prudential Ins. Co. v. Haley, 91 111. 

App., 363 133 

Pyle r. Pyle, 158 111., 289; 41 N. E. 

R.,999 516, 518 

Pyott V. Pyott, 90 111. App., 210; 

aff'd 191 111., 280; 61 N. E. Rep., 88. 
376, 379, 382, 762 

Quaifeu. Chicago, etc., R. Co., 48 Wis., 
513 ,531 

Quinn v. Metropolitan Life Ins. Co., 
10 App. Div. (N. Y.), 4S3; 41 
Supp., 1,060 1.33 

Ragland v. State, 125 Ala., 12; 27 

South., 938 536 

RailwayOfficials', etc.. Ass. f. Johnson, 

109 Ky., 261; 95 Am. St. R., :?70. 

1.37 
Rambler i;.Tryon, 7 S. & R. (Pa.), 90; 

10 \m. Dec., 444 .531, 536 

Ramsdell v. Ramsdell, 8 Det. Leg. 

New^s (Mich.), 541; 87 N. W. R., 81. 

355 
Ramsdell v. Streeter (N. J. Pre.), 48 

Atl. R., 575 ,523 

Rand's Will, In re, 28 Misc. (N. Y.), 

465; .59 Supp., 1,082 .555 

Rapplee'sWill, In re, 66 Hun, 5.58; 21 

N. Y. Supp., 801 402 

Rather v. State (Tex.), 9 S. W. Rep., 

69 487 

R,aub ?'. Carpenter, 187 U. S., 159. 

532 
Rawdon v. Rawdon, 28 Ala., 565. .762 
Rawles v. American Mutual Life Ins. 

Co., 27 N. Y., 287; 84 Am. Dec, 

280 135 

Raymond v. Wathen, 142 Ind., 367; 

41N. E.R.,815 .355,552 

Raynor, Matter of, 44 State Rep., 468; 

18 N. Y. Supp., 426 408, 

Rea V. Bishop (Neb.), 59 N. W. Rep., 

555 368 



PAGE 

Real V. People, 42 N. Y., 270 532 

Reason v. Jones, 119 Mich., 672; 78 

N. W. R., 899 366 

Redfield's Est., In re. 116 Cal., 637; 

48 Pac. R., 794 396 

Redmond v. Peterson, 102 Cal., .595. 

380 
Reed, Matter of, 20 N. Y. Supp., 91; 

2 Connolly, 403 413, 556 

Reed's Est. (Minn.), In re, 90 N. W. 

R., 319 389,411 

Reed's Will, In re, 20 N. Y. Supp., 91; 

2 Con. Surr., 403 413, 556 

Reed v. State, 62 Miss., 405 532 

Reese v. Reese, 89 Oa., 645; 15 S. E., 

846 370 

Regina v. Burton, 3 F. & F., 772. 

435, 439, 460, 463 

Regina v. Cooper, Mann's Forensic 

Med., 356 532 

Regina v. Davis (Eng.), 14 Cox C. C, 

563 486 

Regina v. Dodwell, C. C. C, 1878, 

Mann's Forensic Med., .3.57. . , .470 
Regina v. Doody, 6 Cox Cr. Cas., 463. 

500 
Regina v. Gamlin, 1 Post. & F., 90. 

500 
Regina v. Haynes, 1 Post, and F., 666. 

450 
Regina v. Oxford (Eng.), 9 Car. & P., 

525 455 

Regina r. Williams (Old Bailey, 

1886) 500 

Renfro v. City of Waco (Tex. Civ. 

App.), 33 S. W. R., 766 ,371 

Re voir v. State, 82 Wis., 295; .52 N. 

W., 84 4.34, 436, 559, 562 

Rex, see King. 

Rex)'. Thomas, 7 Car. & P., 820. 

500 
Rex V. Wright, R. and R. Crim. Cas., 

456 536 

Reynolds ;•. Equitable Ace. Ass'n, 

59 Hun (N. Y.), 13 140 

Reynolds v. Iowa and N. Ins. Co., 80 

Iowa, 563; 46 N. W. R., 159. . .133 



xl 



TABLE OF f'ASBS C:ITE7J IX THIS VOIArME. 



Reynolds v. Robinson, (i4 N. Y., 589. 

531 
Reynolds v. Root, 62 Barb,, 250. 

402 
Reynolds i'. I'nit ed States, 98 TJ. S. 

145 474 

Rhoades v. Fuller, 1.39 Mo., 179; 40 8. 

W. R;,760 366,527 

Rhode V. Rhode, 8 Ohio .S. & C. P. 

Dec, 684 378 

Rhyner v. Menasha, 73 N. W. Rep., 

41; 97 Wis., 523 429 

Rice !•. Peel, 15 Johns., .503 , . 354, 367 
Rice r. Rice, 50 Mich., 448; 15 N. \\. 

R., .')45 .525 

Richards, Kx jitirie. Brev. Vol. B. (S. 

C.),375 582,594 

Richardson's Will, Inre, 51 App. Div., 

637; 64 N. Y. Supp., 944 .396 

Richardson v. Adams, 110 Ga., 425; 

35S. E. R.,648 362 

Richardson v. Bly (Mass.), 63 N. E. 

R., 3 .555. 570 

Richardson v. Smart, 2 Mo. App., 

1,107 568 

Riggin V. Board of Trustees West- 
minister College, 160 Mo., .570; 61 

S. W. R.,803 410 

Riley v. Carter, 76 Md., 581; 25 Atl. 

R., 667; 19 L. R. A., 489 364 

Riley v. Riley, 73 Hun (N. Y.), 575. 

763 
Riley v. Sherwood, 144 Mo., 354; 45 

S.W. R., 1,077. .415, 416, 419, 420 
Riley r. State, 44 S. W. R., 498 

(Texas) 448 

Ring V. Lawless, 190 111.. 520; 60 N. E. 

Rep., 881 355, ;584, :588, 545 

Ring V. Ring, 112 Ga., 854; 38 S. E. 

Rep., 330 380 

Rintelen, In re, 37 Misc. R. (N. Y.). 

462; 75 Supp., 935 .565 

Rintelen. In re, 37 Misc. (N. Y.), .562; 

75 N. Y. Supp., 363; aff'd 78 N. Y. 

Supp., 1,092 414 

Ristine v. John.son, 143 Ind., 41: 42 

N. E. Rep., 310 425 



PAGE 

Roberson v. The Rochester Folding 

Box Co.. 171 N. Y., ,538 132 

Roberts, I'n re, 3 Johns. Ch., 43. 

595 
Roberts' Estate, In re, 197 Pa. St., 

621; 47 Atl. R., 987 593 

Roberts r. People, 19 Mich., 401. 

496, 497 
Robinson's Will, In re, 190 111., 95; 

60N. E. R., 194 516,539 

Robinson v. Adam's, 62 Me., 369; 

16 Am. Rep., 473. . . ..399, 400, 539 
Robinson v. Kidd, 59 Pac. R. (Kan.), 

863; 62 Pac. R., 705 364 

Robinson v. Robin.soii, 203 Pa. St., 

400; .53 Atl, R., 253 415, 417, 

419, 503, 520, 555 
Rookford Ins. Co. v. Nelson, 65 111., 

415 133 

Rodgers, In re. 9 Abb. N. C. (N. Y.), 

141 580,586 

Rodgers )■. Rodgers. 56 Kan. 483; 

43 Pac., 779 378 

Rodgers v. State (Tex. Cr. App.), 28 

S.W. Rep., 948 438 

Rodgers r. Walker. 6 Penn. St., 371. 

587 
Rogers, In re. 1 Halst. Ch. (N. J.), 

46 591,593 

Rogers, In re. 9 Abb. N. C. (N. Y.), 

141 590 

Rogers r. Armstrong Co. (Tex. Civ. 

App.), 30 S. W. R., 848 568 

Rogers v. State. :« Ind., 543. . . .497 
Rogers v. AV.ilker, 66 Pa. St., .371. 

591 
Rohe's Will, In re, 22 Misc. Rep. (N. 

Y.), 415: 50 N. Y. Supp., .399. .392 
Roller )'. Kling, 49 N. K. Rep., 748; 

1.50 Ind., 59 390, 507, 567 

Rollwagen r. Rollwagen, 3 Hun, 132; 

63 N. Y., 518 408 

Ronan r. Bluhm. 173 111., 277; 50 N. 

E. R.,694 368 

■ Ronker )■. St. John, 21 Ohio C. C, 

339 428 

Root. In re, S Paige (N. Y.), 625. . 593 



TABLE OF CASES CITED IN THIS VOLUME. 



xli 



PAGE 

Root V. London Guarantee and Ac- 
cident Co., 92 App. Div.. (N. Y.), 

518; 86 Supp., 1055 139 

Rorback v. Van Blarcoom, 20 N. J. 

Eq., 461.. .588 

Roseman v. Carolina Central R. Co., 

112 N. C, 709; 16 S. E. Rep., 766. 

376 
Rosenstein v. Staite (Ind.), 36 N. E. 

Rep., 652; 9 Ind. App., 290 482 

Ross V. jkyson, 160 111., 349; 43 N. E. 

Rep., 399 362 

Ross's Will; In re, 65 Hun, 626; 20 

N. Y. Supp., 520 519 

Rosselot V. State, 23 Ohio C. C, 370. 

430 
Rothrock v. Rothrock, 22 Or., 551; 

30Pao.,453 405 

Round's Will, In re, 25 Misfc. R. (N. 

Y.), 101: 54 N. Y. Supp., 710. 

409 
Rountree) Ex parte, 51 S. C, 405; 29 

S. E. Rep., 66 381 

Roush V. Wensel, 15 Ohio C. C. R., 

133 507,537,542 

Rowden v. Rowden, 28 Ala., 565. 

580 
Rowson's Est., In re, 4 Pa. Dist. Ct. 

Rep., 91 407,410 

Ruffino's Estate, In re, 116 Cal., 304; 

48 Pac. R., 127 394, 523 

Ruffijer V. Luther, 19 Pa. Co. Ct. R., 

349 505 

Rush, In re, 53 N. Y. Supp., 581. 

423, 580 

Rusk V. Fenton, 14 Bush, 490; 29 

Am. Rep., 413 (Ky.). 366 

Russell, In re, 1 Barb. Ch. (N. Y.), 38. 

585, 590 

Rustin V. Standard Life and Ace. Ins. 

Co., 58 Neb., 792; 79 N. W. R., 412; 

76 Am. St. R., 136; 46 L. R. A., 

253 140 

Ruter V. Mut. Life Ine. Co., 169 U. S., 

139; 18 Sup. Ct., 300; 70 Fed., 954; 

17C. C. A., 537. 501 

R itherford v. Morris, 77 111., 397 . . 536 



Ryan v. World Mut. Life Ins. Co., 
41 Conn., 168; 19 Am. Rep., 490, 

133 
Ryder v. Ryder, 66 Vt., 158; 28 

Atl., 1029 767 

Ryder v. State, 100 Ga., 528; 38 L. 
R. A., 721; 28 S. E. Rep., 246. 

559 

S. V. A., 3 P. D., 72. . 763, 764 

S. V. E., 3 Swab, and T., 240 765 

Sabalot ■!). Populus, 31 La. Ann., 854. 

762 
Safe Dep. & Trust Co. v. Berry (Md.), 

49 Atl. R., 401 . .530, 539, 

542, 548 
Saffer V. Mast, 79 N. E. R., 32; 223 

111., 108.. 363 

Sahsbury, In re, 3 Johns. Ch. (N. Y.), 

347 597 

Salter i;. Ely (N. J. Pre. Ct.), 56 N. J. 

Eq., 357; 39 Atl. R., 365 420 

Sampson, In re, 19 Pa. Co. Ct. R., 1; 

5 Pa. Dist. R., 717 375, 528 

Sanchez v. People, 22 N. Y., 147. 

514 
Sander v. Savage, 75 App. Di^'-., 333; 

78 N Y. Supp., 189. . .366, 368, 428 
Sanders v. Colman, 97 Va., 690; 39 

S. E.R.,621 768 

Sands v. Potter, 59 111. App., 206. 

355 
Sartain, In re, 14 Eq. (N. C), 231. 

597 

Sawyer v. State, 35 Md., 80 514 

Scattergood v. Kirt, 192 Pa. St., 263; 

43 Atl. R., 1030; 44 W. N. C.„ 313. 

555 
Schaeffer v. State, 61 Ark., 241; 32 

S. W. R., 679 508, 544 

Schaps V. Lehner, 54 Minn., 208. .366 
Scherar v. Prudential Ins. Co. (Neb.), 

88 N. W. R., 687 374 

Schieffelin v. Schieffelin (Ala.), 28 

So. R., 687. ... . .403, 416, 417, 505 

Schierbaum v. Schemme, 157 Mo., 1; 

57 S. W. R., 262 413, 520 



xlii 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Schiesler's Est., Inre, 198 Pa. St., 81; 

47 Atl. Rep., 966 712 

Schilling v. Kankakee County, 96 111. 

App., 432 383 

Schlencker v. State, 9 Neb., 241. 

536 
Schmidt V. Northern Life Ass'n, 83: 

N. W. R., 800 (Iowa); 51 L. R. A., 

141 ..374 

Schmidts. Ottmann, 46 La. Ann., 888; 

15 So., 310 366,373 

Schmittu. Michigan Mut. Life Ins. Co., 

101 App. Div. (N. Y.), 12 138 

Schreiber, Matter of, 22 State Rep., 

892 411 

Schrodt, In re, 32 Misc. Rep., 540; 

67N. Y. Supp., 244 353 

Schroter v. Schroter, 56 Misc. (N. Y.), 

169 763 

Schuettler v. Carman, 98 Iowa, 276; 

67 N. W. R., 249 357, 399 

Schultz V. State, 37 Neb., 481; 55 N. 

W. R., 1080 536 

Schuster's Est., In re, 198 Pa. St., 81; 

47 Atl. Rep., 966 414 

^chwabacher v. People, 165 111., 618; 

46 N. E. R., 809 .496 

Scott V. Bassett, 194 111., 602; 62 

N. E. R., 914 515, 598 

Scott V. McKee, 105 Ga., 256; 31 S. E. 

R., 183 538,539 

Scott V. State, 12 Tex. Cr. App., 31. 

490 
Scott's Est., In re, 128 Cal., 57; 60 

Pac. R., 527 396, 569 

Seagrist's Will, In re, 1 App. Div., 

615; 77 N. Y. Supp., 496 419 

Seagrist's Will,/ra re, 11 Misc. R. (N. 

Y.), 188; 32 N. Y. Supp., 1095. 

406 
Seamen's Friend Society v. Hopper; 

33N. Y.,619; affirming 4 Barb., 625. 

394 

Sears v. Shafer, 6 N. Y., 268 554 

Seawel v. Dirst, 70 Ark., 166; 66 S. 

W. R., 1058 .' 357 

Segur's Will (Vt.), 44 Atl. R., 342 . 398 



PAGS 

Sehr V. Lindeman, 153 Mo., 276; 

54 S. W. Rep., 537 406 

Serell v. Serell, 31 L. J. P. and M. 
55; 2 Swab, and T., 422. . . . . .764 

Shackleford v. Hamilton, 93 Ky., 80; 

19S. W. R., 5 768 

Shaffer v. List, 114 Pa. St., 486. 

598 
Shakespeare v. Markham, 72 N. Y., 

400 362 

Shanley's Appeal, 62 Conn., 325; 25 

Atl. Rep., 245 544 

Shannahan v. Com., 8 Bush (Ky.), 

463; 8 Am. R., 465 455 

Shapter v. Pillar, 63 Pac. R. (Colo.), 

302 580,581,582 

Sharkey v. State, 2 O. C. D., 443. 

530, 560 
Sharp V. Merriman (Mich.), 66 N. W. 

R., 372 392, 510, 542 

Sheanon v. Pacific Mut. Life Ins. Co., 
77 Wis., 618; 46 N. W. R., 799; 
20 Am. St. R., 151; 9 L. R. A., 685; 
s. c. 83 Wis., 507; 53 N. W. R., 878. 

140 
Sheehan v. Kearney (Miss.), 35 L. R. 

A., 102; 21 So. Rep., 41 503, 

504, 516, 519, 537, 565 
Shell, In re (Col.), 53 L. R. A., 387; 

63 Pac. R., 413 418, 523, 553 

Shelleig, In re, 11 Ohio S. & C. P.Dec., 

81 564 

Sherbero v. Miller, 65 Atl., 472 (N. J. 

Eq.) 355 

Sherboume v. Yuba Co., 21 Cal., 113. 

607 

Sherman, In re, 17 R. I., 356 592 

Shields v. Johnson, 47 S. W. Rep., 107. 

430 
Shirley v. State, 37 Tex. Cr. App., 

475; 36 S. W. R., 267 530 

ShotUff V. Modern Woodmen of Am., 
100 Mo. App., 138; 73 S. W. R., 

326 133 

Shreiner v. Shreiner, 178 Pa. St., 57; 

35 Atl. Rep., 974 397, 411 

Shufflin V. People, 62 N. Y., 229; 20 



TABLE OF CASES CITED IN THIS VOLUME. 



xliii 



PAGE 

Am. R,, 483, aff'g 4 Hun, 16; 6 

Supm. Ct. (T. & C), 215 442 

Shults V. State, 37 Neb., 481; 55 N. 

W. Rep., 1080 547 

Sibley v. Somers (N. J. Ch.), 50 Atl. 

R., 321 362 

Sickles's Will, In re (N. J. Pre.), 50 

Atl. R., 577 215 

Silverthorne, In re, 68 Wis., 372; 32 

N.W.Rep.,287 404 

Sim V. Russell, 90 Iowa, 656; 27 N. 

W. R., 601 394,517 

Simon v. Craft, 182 U. S., 427; 21 

Supr. Ct. R., 836 587 

Sims V. Sims, 121 N. C, 297; 28 S. E. 

R., 407; 40 L. R. A., 737 . . 376, 378, 

598, 762 

Sinclair v. Maritime Passenger Assur. 

, Co. (Eng.), 3 El. and El., 478; 4 L. 

T. (N. S.), 15; 30 L. J. (Q. B.), 77; 

7 Jur. (N. S.), 367 137 

Sindram v. People, 1 N. Y. Crim. 

Rep., 448; affirmed 88 N. Y., 196. 

439 
Sinnet v. Bowman, 37 N. E. Rep., 

885 389 

Sisson V. Supreme Court of Honor, 

104 Mo. App., 54; 78 S. W. R., 297. 

140 
Skaats's WiU, In re, 74 Hun (N. Y.), 

462; 26 N. Y. Supp., 494 .. . 392, 412 
Skinner v. Lewis (Or.), 67 Pac. R., 

951 394,406 

Slevin v. Board of Police Pension 

Fund Commr's, 123 Cal., 130; 55 

Pac. R., 785; 44 L. R. A., 114. . 140 
Slingloff V. Bruner, 174 111., 561; 51 N. 

E. Rep., 772 404, 505, 566 

Small V. Champeny, 102 Wis., 61; 78 

N.W.R.,407 525,552 

Smee v. Smee, L. R., 5 P. D., 84. 

566 
Smith, In re, 12 Pa. Supr. Ct., 649. 

580 
Smith V. Com., 1 Duv. (Ky.), 224.' 449 

Smith V. Com., 93 Ky., 318 434, 

436, 559 



Smith V. Day (Del.), 45 Atl. R., 396. 

391, 567 

Smith V. Henline, 174 111., 184; 51 

N. E. Rep., 227 406, 416 

Smith V. Kay (Eng.), 7 H. L. Cas., 

771 553 

Smith, Matter of, 95 N. Y., 516. 

404, 554 

Smith V. McClure, 146 Ind., 123; 

44 N. E. R., 1004 564 

Smith u.Morehead, 59 N.C., 360. 762 
Smith V. Pipkin, 77 N. C, 569. . .584 

Smith V. Ryan, 191 N. Y., 452 364 

Smith V. Smith, 171 Mass., 404; 50 

N. E. R., 933 546, 766, 767 

Smith V. Smith, 47 Miss., 211 761 

Smith V. Smith, 48 N. J. Eq., 566; 

25 Atl. Rep., 11 .396 

Smith V. State, 55 Ark., 259; 18 S. W., 

237 463,464 

Smith V. State, 31 Tex. App.; 19 S. 

W. Rep., 252 559 

Smith V. Williamson, 8 Utah, 219; 30 

Pac. Rep., 753 375 

Smith's Com., D. M., v. Forsythe, 90 

S.W. R., 1075; 28 Ky. L. R., 1034. 

366 
Smith's Will, In re (Surr.), 24 N. Y 

Supp., 928 394, 397 

Smith's Will, 52 Wis., 544; 38 Am. 

Rep., 756; 8 N. W. Rep., 616; 9 N. 

W. Rep., 665 399 

Sneck v. Travelers Ins. Co., 88 Hun 

(N. Y.), 94; 34 Supp., 545 140 

Snell V. U. S., 16 App. D. C, 501 . . 609 
Snelling, Matter of, 136 N. Y., 515; 

49 State Rep., 695; 32 N. E. R., 

1006 393,406,411,531 

Snellings' Will, In re (Surr.), 78 Hun 

(N. Y.), 211; 28 N. Y. Supp., 942. 

386 
Snider v. State, 56 Neb., 309; 76 

N.W.R.,574 542,560 

Snodgrass v. Knight, 43 W. Va., 294; 

27 S. E. R., 233 .■..550 

Snyder v. Sherman, 23 Hun, 139. 
386, 412 



xliv 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Snyder v. Snyder (111.), 31 N. E., 303. 

680 
Soberanes v. Soberanes, 106 Cal., 1; 

39 Pac. R., 39 355 

Soule, Matter of, 22 Abb. N. C, 236; 

19 State Rep., 532; 3 N. Y. Supp., 

259 386 

Soules V. Robinson (Ind.), 60 N. E. 

R. , 726; 62 N. E. R., 999 . . 625, 526, 

587 
Southard v. Railway Passengers' 

Ass. Co., 34 Conn., 574 137 

South Penn. Oil Co. v. Mclntire, 44 W. 

Va., 296; 28 S. E. Rep., 922. . . .586 
Sovereign Camp Woodmen of the 

World V. Woodruff, 80 Miss., 546; 

32 So. R., 4 143 

Spangler v. State, 55 S. W. Rep., 326. 

545 
Sparks's Will, In re, 51 Atl. R., 118 

(N.J. Pre.) 556 

Speiser v. Phoenix Mut. Life Ins. Co., 

119 Wis., 530; 97 N. W. R., 207 . 133 
Speller's Estate, In re (Pa. Co. Ct.), 2 

Pa. Dist. R., 513 403, 556 

Spencer v. State, 69 Md'., 28 450 

Spencer v. Terry's Est. (Mich.), 8 

Det. Leg. N., 392; 86 N. W. R., 

998 391 

Spencer's Estate, In re, 96 Cal., 448, 

31 Pac, 453 400,513 

Spinlock V. Noe (Ky.), 43 S. W. Rep., 

31 381 

Sporza V. German Savings Bk., 192 

N. Y.,8; 84N. E. R.,406 581, 

582, 587 
Springfield v. State, 96 Ala., 81; 11 

So. R., 250 487,490 

Spurgeon Yoimg Case (Chautauqua 

Co.,N. Y.), 14 Med. Leg. Jour., 529. 

481 
Squires v. State (Tex. Cr. App.), 54 

S. W. R., 770 630 

St. George v. Biddeford, 76 Me., 693. 

761 
St. Joseph's Convent v. Garner, 66 

Ark., 632; 53 S. W. Rep., 298. 543 



PAGE 

St. Lawrence Hospital v. Fowler, 16 
Misc. (N. Y), 165; 37 N. Y. Supp., 

16 382 

St. Louis Mut. L. Ins. Co. v. Graves, 

6 Bush (Ky.), 268 636 

St. Louis, etc., Ry. Co., v. Bradley, 13 

U.S. App., 68 532 

St. Louis, etc., Ry. Co. v. Shifflet 
(Tex. Civ. App.), 56 S. W. Rep., 

697 612,549 

Stafford V. Levinger (S. D.), 91 N. W. 

R., 462 .429 

Standard Life and Ace. Ins. Co. v. 
Schmaltz, 66 Ark., 588; 53 N. W. 

R., 49; 94 Am. St. R., 112 137 

Stannart v. Bams, 63 Vt., 244 382 

Stanton v. Weatherwax, 16 Barb. (N. 

Y.), 259 580 

Starr's Estate, In re, 10 Pa. Super.Ct., 

554 580 

State V. Agnew, 10 N. J. L. J., 165. 

484, 577 
State V. Alcom, 137 Mo., 121; 38 S. 

W. R., 548 524,652 

State V. Alexander, 30 S. C, 74. 

445, 464 
State V. Ashley, 45 La. Ann., 1036; 

13 So. Rep., 738 487 

State V. Barber, 74 Mo. ,292 631 

State V. Barry (N. D.), 92 N. W. R., 

809 434 

State V. Beard, 47 Mo., 301 584 

State V. Bell, 136 Mo., 120; 37 S. W. 

Rep., 823 560 

State V. Beuerman, 59 Kan., 586; 53 

Pac. R., 874 536 

State V. Billings, 55 Minn., 467; 67 N. 

W. Rep., 794 586, 672 

State V. Boyce, 24 Wash., 514; 64 Pac. 

R., 719 634 

State V. Bradley (La.), 45 So. R., 120. 

513 
State -v. Branton (Or.), 66 Pac. R., 

267 436 

State V. Bronstine, 147 Mo., 520; 49 

S. W. Rep., 612 544 

P*"'" V. Brooks, 67 Pac. R., 1,038; 



TABLE OF CASES CITED IN THIS VOLUME. 



xlv 



PAGE 

23 Mont., 146 440, 

557, 559 
State V. Brooks, 4 Wash. St., 328; 30 

Pac, 147 536, 562 

State V. Brown, 36 Atl. Rep., 458 . 421 

State V. Brown, 181 Mo., 192 487 

State V. Bruce, 48 Iowa, 536; 30 Am. 

Rep., 403 493 

State V. Callaway, 154 Mo., 91; 55 S. 

W. Rep., 444 442 

State V. Christmas, 6 Jones L. (N. C), 

471 508 

State V. Clarke, 47 S. W. Rep., 886; 

147 Mo., 20 445 

State V. Clements, 47 La. Ann., 1088; 

17 So. R., 502 ....557 

State V. Clevenger, 156 Mo., 190; 56 

S. W. Rep., 1078 484 

State V. Cole (Del.), 2 Penne., 344; 

45 Atl. R., 391 436, 557 

State V. Constantine (Wash.), 93 Pac. 

R., 317 ...504, 513 

State V. Crisp, 126 Mo., 606; 29 S. W. 

R.,699 433,531 

State V. Cross, 42 W. Va., 253; 24 S. 

E. Rep., 996 .487 

State V. Cunningham, 72 N. C, 469. 

508 
State ■!). Davis, 9 Houst. (Del), 407; 

33 Atl. R., 483, 487, 494 

State i;. Davis, 109 N. E., 780; 14 S. 

E., 55 436,559 

State V. Davis (W. Va.), 43 S. E. R., 

99 491 

State t). DeU Bello, 8 Oh. S. & C. 

P. Dec, 455 560 

State V. Donovan, 61 Iowa, 369; 16 

N.W.Rep.,206 487 

State V. Donovan, 10 N. D., 203; 

86 N. W. Rep., 709 482 

State V. Dom, 22 Ore., 591; 30 Pac. 

Rep., 317 ..559 

State V. Dreher, 137 Mo.-, 11; 38 S. W. 

R., 567 562 

State V. Duestrow,'137 Mo., 44; 38 S. 

W. R., 554... .661 

State i>.vBrb, 74 Mo., 199". . . .636 



State V. Faino (Del), 2 Hard., 153; 

1 Marv., 492; 41 Atl. R., 134. 

490, 524 

State V. Farr, 34 W. Va., 84; 11 S. E. 

Rep., 737 482 

State V. Feister, 50 Pac. Rep., 561 . 541 

State V. Felter, 25 Iowa, 67 465 

State V. Feltes, 51 Iowa, 495 531 

State V. Fiske, 63 Conn., 388; 28 

Atl. R., 672 486, 487, 490, 493 

State V. Ford (S. Dak.), 92 N. W. R., 

18 441,492 

State V. Geddis, 42 Iowa, 268 532 

State V. Gosnell, 74 Fed. Rep., 734. 

440, 442 

State V. Graves, 5 N. J. Law J., 64. 

577 
State V. Graviotte, 22 La. Ann., 587. 

513 
State V. Haab, 105 La., 230; 29 So. 

R.,726 497, 499 

State V. Hand, 2 Hardesty (Del.), 149; 

41 Atl. Rep., 192; 1 Marv., 545. 

483,597 

State V. Hansen, 25 Ore., 391; 36 

Pac. Rep., 296 489, 491, 

539, 559 
State V. Harrigan, 9 Houst. (Del.), 

369; 31 Atl. R., 1052 483, 511 

State V. Harrison, 36 W. Va., 729; 15 

S. E. R., 982; 18 L. R. A., 224. 
430, 448 

State V. Hayden, 51 Vt., 296 636 

State V. Hayward, 65 N. W. Rep., 63; 

62 Minn., 474 422 

State V. Heck, 23 Minn., 649 482 

State V. Helm, 69 Ark., 167; 61 S. W. 

Rep., 915 353 

State V. Hill, 46 La. Ann., 27; 14 So. 

Rep., 294 493, 559 

State V. HiU (N. J.), 47 Atl. R., 814. 

560 
State ■!). Hurst (Idaho), 39 Pac. Rep., 

554 536,640 

State V. Jack, 58 Atl. R., 833 455 

State V. Johnson, 40 Conn., 136. 
492, 497 



xlvi 



TABLE OF CASES CITED IN THIS VOLUME. 



State V. Jones, 50 N. H., 369 474 

State V. Judge 8th Jud. Dist., 48 

La. Ann., 503; 19 So. Rep., 475. 

430, 433, 586 

State V. Kalb, 7 Ohio N. P., 547; 5 

Ohio S. & C. P. Dec, 738. . 349, 353 
State V. Kale, 124 N. C, 816; 32 S. 

E. R.,892 431,488,496 

State V. Kavanaugh (Del.), 53 Atl. 

R., 335 483, 492, 576 

State V. Kelly, 32 Atl. R., 434. 

430, 455 

State V. Kindred, 148 Mo., 270; 49 

S. W. Rep., 845 487 

State V. Klinger, 46 Mo., 224. . . .536 
State V. Knight, 95 Me., 467; 50 

Atl. R., 276; 55 L. R. A., 373. 

448, 450 

State I). Kraemer, 49 La. Ann., 766; 

22 So. Rep., 254 483, 498 

State V. Larkins (Idaho), 47 Pac. Rep., 

945 559 

State V. Leehman, 2 S. D., 171; 49 N. 

W. R., 3 460,531,536 

State V. Leuth, 50 Ohio'C. C. R., 94. 

509 
State V. Levelle, 34 S. C, 126; 13 

S. E. R., 319 450 

State V. Lewis, 136 Mo., 84; 37 S. 

W. Rep., 806 480 

State V, Lewis, 20 Nev., 333: 22 Pac. 

R., 241 450,463 

State V. Lyons, 113 La., 959; 37 So. 

R.,890 448,457 

State V. McDaniel, 115 N. C, 807; 

20 S. E. Rep., 622 438, 499 

State V. Mcintosh, 40 S. C, 349; 17 

S. E., 446 436 

State V. McMurry, 61 Kan., 87; 58 

Pac. R., 961 526 

State V. Maier, 36 W. Va., 757; 15 S. 

E. R., 991 436, 448, 536 

State V. Marshall (Ore.), 57 Pac. R., 

902 514 

State V. Mewherter, 46 Iowa, 88. 

457 
State V. Miller, 7 Ohio N. P., 458; 5 



OhioS. &C. P. Dec, 703 434, 

466, 535, 550, 559, 561 
State V. Morgan, 40 S. C, 345; 18 

S.E.R.,937 491 

State V. Mowry, 15 Pac R., 282. 

450 
State V. Murphy, 118 Mo., 7; 26 S. W. 

Rep., 95 486 

State V. Newlin, 69 Ind., 108. . . .536 
State V. Newman, 57 Kan., 705; 47 

Pac R., 881 510 

State V. Novak (Iowa), 79 W. N. R., 

466 556, 557, 561 

State V. O'Grady, 3 Ohio N. P., 279. 

430 
State V. O'Neil, 51 Kan., 651; 33 Pac, 

287 436, 486, 487, 490, 491 

State V. O'Reilly, 126 Mo., 597; 29 S. 

W. R., 577 491 

State V. Paine, 49 La. Ann., 1092; 

22 So. Rep., 316 430 

State V. Palmer, 161 Mo., 152; 61 S. 

W. R., 651 , . 431, 439, 658, 563, 664 
State V. Parks, 93 Me., 208; 44 Atl. 

R., 899 560 

State V. Peel, 23 Mont., 358; 59 Pac. 

R., 169 455, 630, 545, 560 

State V. Pennington, 146 Mo., 27; 

47S.W.Rep.,799 430 

State V. Peterson, 129 N. C, 556; 

40 S. E. R., 9 491 

State V. Peterson, 60 Pac. R., 809. 

430 
State V. Pike, 49 N. H., 399; 6 Am. 

R.,633 465 

State V. Potts, 100 N. C, 467; 6 S. E. 

R., 657 460,483, 499 

State V. Probate Court Ramsey Co., 

83 Minn., 68; 85 N. W. Rep., 917. 

535 
State V. Punshon, 133 Mo., 44; 34 S. 

W. R., 26 514 

State V. Reddick, 7 Kansas, 143. 

552 
State V. Reidell, 9 Del., 470; 14 Atl. 

R., 550 461 

State V. Rigley, 62 Pac. R., 679. 484 



TABLE OF CASES CITED IN THIS VOLUME. 



xlvii 



PAGE 

State v.- Rippy, 104 N. C, 752; 10 S. 

E.R.,259 481 

State V. Robbins (Iowa), 80 N. W. 

Rep., 1061 545', 551, 560 

State V. Robinson, 12 Wash., 491; 

41 Pac. R., 884 529 

State V. Schaefer, 116 Mo., 96; 22 S. 

W.Rep.,447 436,448, 

559, 563, 577 
State V. Scott, 49 La. Ann., 253; 21 

So. R., 271 561,587 

State V. Scott, 41 Minn., 365; 43 N. 

W. R., 62 450 

State V. Seweli, 48 N. C, 245. . . .552 
State V. Shinn, 63 Kan., 638; 66 

Pac. R., 650 482 

State V. Smith, 26 Wash., 354; 67 

Pac. R., 70 422, 525 

State V. Sneed, 88 Mo., 138. . 491 

State V. Snow (Del.), 51 Atl. R., 607. 

492 
State V. Soper, 148 Mo., 217; 49 S. 

W. R., 1007 450,509, 

532, 541, 542, 547 
State V. Sweet, 21 R. I., 87; 41 Atl. 

Rep., 1011 382 

State V. Swift, 57 Conn., 496; 18 Atl. 

Rep., 664 444 

State V. Tincher (Ind.), 21 Ind. App., 

142; 51 N. E. Rep., 943 482 

State V. Truitt (Del.), 62 Atl. R., 790. 

496 
State V. Tyler, 7 Ohio N. P., 443; 5 

Ohio S. & C. P. Dec, 588. . . .349, 

431, 439 

State V. Van Tassel, 103 Iowa, 6; 72 

N. W. R., 497 508 

State V. Wade, 161 Mo., 441; 61 S. W. 

Rep., 800..... 434 

State V. Ward, 75 Iowa, 637; 36 N. 

W. Rep., 765 482 

State V. Weaver, 58 Pac. R., 109.' 489 
States. Welsh (Iowa), 79 N. W. Rep.," 

369 424 

State V. West, 157 Mo., 309; 57 S. W. 

R., 1071 491 

State V. Wilcox, 24 Minn., 143 , , . , 583 



PAGE 

State V. Williams, 149 Mo., 496; 51 

S. W. Rep.,88 384 

State V. Williamson, 106 Mo., 162; 

17S. W. R., 172 536 

State V. Wilner, 40 Wis., 304. . . .552 
State V. Wilson, 104 N. C, 868; 10 

S. E. Rep., 315 484, 487, 48 i 

State V. Wood (Iowa), 84 N. W. R., 

520 530 

State V. Wright (Iowa), 84 N. W. R., 

541 514, 530, 531, 

547, 564 

State V. Zorn, 22 Ore., 591 436, 

484, 494, 536, 562 
State Bank v. Norduff, 2 Kan. App., 

55; 43 Pac. Rep., 312 370 

State Hospital v. Fountain, 128 N. E., 

23; 38 S. E. Rep., 34; 129 N. C, 90; 

39S. E. R.,734 382 

Statham v. Blackford, 89 Va., 771; 

17 S. E. Rep., 233 592 

Steadman v. Steadman (Pa.), 14 Atl. 

R., 406 418 

Steele v. Helen, 2 Marv. (Del.), 237; 

43 Atl., 153 507,551 

Steinkuehler v. Wempner (Ind.), 81 

N. E. R.,482 399 

Sternaman v. Metropolitan Life In- 
surance Co., 170 N. Y., 13; 62 N. 

E. R., 763; 88 Am. St, Rep., 625; 

67L. R. A.,318 132,134 

Stevens v. Leonard, 154 Ind., 67; 

56 N. E. R., 27 401, 517, 539 

Stevenson v. Kingsley, 8 Pa. Dist. R., 

245 410 

Stevenson v. West Seattle L. & I. Co. 

(Wash.), 60 Pac. R., 51 376 

Stever v. People's Mut. Ace. Ins. 

Ass., 150 Pa., 132; 24 Atl. R., 662; 

16 L. R. A., 446 140 

Stewart, In re, 59 Hun, 618 411 

Stewart, Matter of, 15 N. Y. Supp., 

601 406 

Stewart v. Taylor, 23 Ky. L. R., 577; 

63S. W. R., 783 587 

Stewart v. Lispenard, 26 Wend., 255. 

38§ 



xlviii 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

Stillman, Matter of, 29 State Rep., 

213 ..410 

Stockmeyer v. Tobin, 139 IJ. S., 176. 

365 
Stout V. Rigney, 107 Fed., 545; 46 

C. C. A., 459 598 

Storey, In re, 20 111. App., 183 399 

Storms V. Allegan Circuit Judge 

(Mich.), 57 N. W. Rep., 1,074.592 
Stover V. Commonwealth, 92 Va., 780; 

• 22 S. E. R., 874...... 430 

Stuart V. State, 1 Baxt. (Tenn.); 178. 

559 

Stuckey v. Mathes, 24 Hun, 461. 

376, 378, 762 

Stufdevant Appeal, 71 Conn., 392; 

42 Atl., 70 388, 550, 567 

SuUings V. Shakespeare, 46 Mich., 408; 

41 Am. Rep., 166; 9 N. W. R., 451. 

132 
Sullivan, In re, 24 Misc. R. (N. Y.), 

357; 53 N. Y. Supp., 717 354 

Sullivan v. Foley (Mich.), 70 N. W. 

R., 322. 419, 

522,536 
Superintendents of the Poor v. Rab- 

bitt,57N.W. Rep., 1084; 99 Mich., 

60. 382 

Supreme Council Order of Chosen 

Friends v. Garrigus, 104 Ind., 133; 

3 N. E., 818; 54 Am. R., 298. 

136 
Supreme Court of Honor v. Peacock; 

91 111. App., 632 374 

Supreme Court of Honor v. Turner, 

99 111. App., 310 140 

Sutherland v. Hawkins, 56 Ind., 343. 

536 
Sutherland's Will, In re, 28 Misc. R., 

424; 59 N. Y: Supp., 989 414 

Suydam's Will, In re, 84 Hun, 514; 

23Supp.,449 395,555 

Swaink v. Swank, 61 Pac. R., 846 

(Ore.) 363 

Swartwood v. Chance, 131 Iowa, 714; 

109 N. W. R., 297 355 

Swenarton v. Hancock, 9 Abb. N. C, 



PAGE 

326; 84 N. Y., 653; 22 Hun, 38. 

387, 416 

Swenson v. Swenson, 178 N. Y., 54. 

767 
Swift V. Carpenter, 18 R. I., 645; 

28 Atl. R., 936.... 383 

Swope V. Donnelly, 7 Pa. Dist. R., 

448; 21 Pa. Co. Ct. R., 167. . . .503 
Swope V. Frazier, 18 Ky. L. R., 649; 

37 S. W. R., 495.. 586 

Sylvester v. Town«of Casey (Iowa), 81 

N. W. R., 455 428 

Tapp V. Hosmer, 14 Mich., 309. . .566 
Taylor, In re, 9 Paige (N. Y.), 611. 

594, 597 
Taylor v. Commonwealth, 90 Va., 

109; 19 S. E. R., 739 439, 562 

Taylor v. Levering (Mass.), 50 N. E. 

Rep., 612; 171 Mass., 303 381 

Taylor v. Moore, 23 Ky. L. R., 1572; 

65 S. W. R., 612 353, 580, 586 

Taylor v. Pegram, 151 111., 106; 37 

N. E. Rfip., 837 384, 390, 

618, 539, 569 
Taylor v. State, 105 Ga., 746; 31 S. E. 

Rep., 764 466,479 

Taylor v. U. S., 7 App. D. C, 27. 

510, 543, 553 

Tebout's Case, 9 Abb. Pr., 211. 

588, 690 
Teegarden v. Lewis, 35 N. E. R. (Ind.), 

24 355 

Ten Eyck v. Whitbeck, 156 N. Y., 

341,353 653 

TerreU v. State, 74 Wis., 278; 42 N. 

W. Rep., 243 484 

Territory v. Padilla, 8 N. Mex., 510; 

46 Pac. Rep., 346 516, 546 

Texas Pac. Ry. Co. v. Crow, 3 Tex. 
Civ. App., 266; 22 S. W. R., 928. 

364 

Thayer v. Standard Life and Ace. Ins. 

Co., 68 N. H., 577; 41 Atl. R., 182. 

139 

Thedford v. Reade, 26 Misc. (N. Y.), 

490; 54 N. Y. Supp., 1007, 382, 383 



TABLE OK CASES CITED IN THIS VOLUME. 



xlix 



PAGE 

Thomas v. Carter, 170 Pa. St., 272; 

33Atl. Rep.,81 , 398 

Thomas v. Commercial Unipn Ass. 

Co., 162 Mass., 29; 37 'N. E. R., 

672; .44 Am. St. R., 323 133 

Thomas v. Crawford, 118 Mich., 253; 

76 N. W. Rep., ,394. . . .362 

Thomas v. Hmisicker, 108 N. C, 720. 

380 
Thomas V. State (Fla.),. 36 So. .R., 

161 483 

Thompson, ■ Appeal of . (Pa'.>, 16 

Montg. Co. Law R., 102 565, 

'592 
Thompson v. Bennett, 194 111., 57; 

62 N. E. R., 321 521, 566 

Thompson. w. Hawks, 11 Biss., 440; 

14 .Fed. R., 902 399 

Thompson V. Thompson, 21 Barb., 

: 107 385 

Thomson, /re re, 92 Me., 563; 43 Atl. 

R,,511 ...551, 565 

Thorpe, In re, 64 Vt., 398; 24 Atl. 

Rep., 991 592 

Thorpe i!..Hanscom,; 66 N. W. R., 1; 

64 Minn., 201...... ...370 

Thurman i). State, ,32 N¥b.> 224^ 49 
. N. W. R., 338. .. . ... ,463, 464, 466 

Tibbett's • Estate, In re (Cal.), 69 

Pac. R.,978 523 

Tiffany v. Worthington,96 loWa, 566; 

65N.W.R.,817 ,....383 

Tilton v: Tilton, 16 Ky. Law Rep., 

538; 29 S. W. Rep., 290,, ... .379 
Titus V. Gage, 70 Vt., 13; 39 Atl. R., 

246 .515 

Tome V. Stump, 42 Atl. R., 902; 89 

Md., 264 .580 

Tomlinson v. Tomlinson, ,103 Iowa, 

740; 72 N. W. R., 664 362 

Toomes, Estate of, 54 Cal., .509; 35 

Am. Rep., 83. .,,, 533 

Topeka Water Supply Co. v',. Root, 

66 Kan., 187; 42 Pac. R., 715. 

370, 592 

Townsend v. PeppereU, 99 Mass:,. 40. 

531 



PAGE 

Townfiend v. Price, 53 Pac. Rep., 668; 

19 Wash. St., 415 381 

Townsend's Will, In re, 75 Hun (N. 

Y.), 593; 27 N. Y. Supp., 603. ■ • 386 

TowBon V. Moore, 11 App. D. C, 377. 

420, 503, 505, 553 

Tracy, Ex parte, 1 Paige (N. Y.), 580. 

582, 585, 590 

Tracy, Matter of, 11 State Rep., 103. 

411 
Tramwell v. Vaughn, 158 Mo., 214; 

59S. W. R., 79 ...768 

Traut V. Thompson, 4 Conn., 203. 

535 

Travelers Ins. Co. v. Dunlap, 160 111., 

642; 43 N. E. R., 765; 52 Am. St. 

Rep., 355 141 

Trezevant v. Rains, 85 Tex., 329; 19 

S. W., 567.... 390 

Trezevant v. Rains (Tex. Civ. App.), 

. 25 S. W. Rep., 1092. 392, 

420,523 
Tricb-'s Will, ,165 Pa. St., 586; 30 Atl. 

Rep., 1053., 392,398 

Trowbridge >. Stqne's Admr., 42 W. 

:Va.,454;26S.E. R.,363 515 

. True i;. Ranney, 21 N. H., 52 762 

Trumbull v. Erickson, 97 Fe^. Rep., 

891;38C. C. A., 536 428 

Trustees of Poor v. Jacobs, 6 Hbust. 

(Del.), 330 :..... 599 

. Tuckers. Hyatt, 51 N. E. Rep., 469; 

, 151Ind., 332. 437 

.TUcJser V. Roach, 139 Md., ?75; 38 

N. E. R., 822 ...522 

Tucker ij. Shaw, 158 111., 326; 41 N. 

E. Rep., 914 .....422 

TuUis D. Kidd, 12 Ala., 648 -.531 

Tunison u.Tunison, 4 Bradf., 138. 411 
Turner, Appeal of, 72 COiiTi., 305; 

44 Atl. Rep., 310 389, 417, 

419,537,544,549 
Turner v. Cook, 36 Md., 129. . i . .566 
;Turtier.i;. HoUpt, 53 N. J. Eq„ 526; 

, :33 . Atl. R., 28 356, 386 

.Turner "i!.i Meyers orse Turner, 1 
; . Hagg.Cons. (Eng.,).414. . .761, 762 



TABLE OF CASES CITED IN THIS VOLUME. 



Tilmer v. Rusk, 53 Md., 65 399 

Turner v. Territory, 82 Pac. R., 650. 

450 
Turner v. Union National Bank, 10 

Utah, 77; 37 Pac, 95 357 

Turner v. Utah Title Insurance and 

Trust Co., 10 Utah, 61; 37 Pac, 91. 

367, 363 

Turner v. Wells, Fargo & Co., 10 

Utah, 75; 37 Pac, 94 357 

Tutow V. Tutow, 54 Pa., 216; 93 Am. 

Dec, 691 539 

Tyler v. Gardiner, 36 N. Y., 659. 

554 

Ullrich V. N. Y. Press Co., 23 Misc., 

Rep. (N. Y.), 168; 50 K. Y. Supp., 

788 425 

Under^/ood v. Thurman, 111 Ga., 

325; 36 S. E. R., 788 520 

Union Casualty and Surety Co. v. 

Mondy, 18 Colo. App., 395; 71 

Pac R., 677 143 

Union Cent. Life Ins. Co. v. Hughes' 

Adm., 110 Ky., 26; 60 S. W. R., 

850 140 

Union Mutual Life Ins. Co. v. Payne, 

105 Fed., 172; 45 C. C. A., 193. 

374 
Union Pac. R. Co. v. Botsford, 141 

U.S., 250 765 

United States v. Chisholm, 153 Fed., 

808 606 

United States v. Drew, 6 Mas., 28. 

492 
United States v. Faulkner, 35 Fed. 

R., 730 451 

United States v. Frizzell, 19 App. (D. 

C.),48: 383 

United States v. German, 115 Fed. R. 

987 (Ky. Dist.) 430 

United States v. Guiteau, 3 Crim. 

Law Mag., 347 631 

United States v. McGlue, 1 Curt., 1; 

Fed. Cas., No. 15,670 492 

United States v. Shults, 6 McLean, 

121 606 



United States Mut. Ace. Ass'n v. 
Barry, 131 U. S., 100; 9 Sup. Ct., 
755; 33 Lawyers' Ed., 60 136 

United States Mut. Ace. Ass'n v. 
Newman, 84 Va., 52; 3 S. E. R., 
805 141 

Upstone V. People, 109 111., 169. 536 

Valentine v. Metropolitan Life Ins. 
Co., 106 App. Div. (N. Y.), 487. 

140 
Van Alst I). Hunter, 5 Johns. Ch., 148. 

411 
Van Auken's Case, 2 Stock. (N. J.), 

186 536,585 

Van Deusen v. Newcomer, 40 Mich., 

90 599,607 

Van Dusen v. Sweet, 51 N. Y., 378. 

367, 528 

Van Guysling v. Van Kuren, 36 

N. Y., 70 406,411 

Van Huss v. Rambolt, 2 Cold., 139. 

539 
Van Meter v. Darragh, 116 Mo., 163; 

22 S. W. R., 30 355 

Vanosdel v. Hyce, 46 La. Ann., 387; 

15 So., 19 362, 370, 568 

Van Wyck v. Brasher, 81 N. Y., 260. 

374 
Vamer v. Vamer, 16 Ohio C. C, 386. 

522 

Vedder, Matter of, 6 Dem., 92 401 

Vedder's Will, 14 N. Y. State Rep., 

470 399 

Village of Fairmount v. Meyer, 83 
Minn., 456; 86 N. W. Rep., 457. 

482 

Virginia Fire and Marine Ins. Co. v. 

Morgan, 90 Va., 290; 18 S. E. R., 

191 133 

Vivian, Appeal of, 74 Conn., 257; 50 

Atl. R., 797 503, 522, 538 

Vondal v. Vondal, 175 Mass., 383. 

766, 767 
Von de Veld v. Judy, 143 Mo., 348; 

44 S. W. R., 1117 389, 

391, 410, 652, 568 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

W. V. H., 2 Swab, and T., 240. . . .765 
Wabash Ry. Co. v. Monegan, 94 111. 

App., 82 428 

Wade V. Holbrook, 2 Redf. (N. Y.), 

378 403 

Wade V. State (Tex. Cr. App.), 63 

S. W. R., 878 560 

Wadsworth v. Sharpsteen, 8 N. Y., 

388 369 

Wager, In re, 6 Paige (N. Y.), 11. 

588 
Wp-ger V. Wagoner, 53 Neb., 511; 

73N. W. R.,937 364 

Wagner v. State, 116 Ind., 181. .484 
Wagner v. Stewart, 143 Ind., 78; 

42 N. E. Rep., 469 425 

Walker, In re, 57 App. Div., 1; 67 N. 

Y.Supp.,647 587 

Walker i). Coates, 5 Kan. App., 209; 

47 Eac. Rep., 158 592 

Walker v. People, 26 Hun, 67; 1 N. 

Y. Or. R., 7 457 

Walker v. Russell, 10 S. Car., 82. 

590, 731 

Walker 'v. State, 91 Ala., 76; 9 So. 

R., 87 490 

Walker v. State, 136 Ind., 663; 36 

N. E. Rep., 356 433 

Walker v. State, 46 Neb., 25; 64 N. 

W. Rep., 357 430 

Walker v. Walker, 14 Ga., 242 ... . 535 
Walker v. Winn, 39 So., 12 (Ala.). 

365 
Wallace v. Frey, 27 Misc. R., 29; 

56 N. Y. Supp., 1051 551 

Wallis V. Brown (N. J.), 52 Atl. R., 

475 581 

WaUis V. Luhring, 134 Md., 447; 34 

N. E., 231 390 

Walsh w. People, 88 N. Y., 458. '.445 
Walter v. Mitchell (Mont.), 65 Pac. 

R., 5 427 

Walts V. Walts (Mich.), 86 N. W. R., 

1032; 8 Det. Leg. N., 446. 521, 522 
Ward V. Chicago St. P., M. <«; O. Ry. 

Co., 85 Wis., 601; 55 N. W. R., 771. 

428 



PAGE 

Ward V. Conatsor, 4 Baxt. (Tenn.), 

64 425 

Ward V. State, 96 Ala., 100; 11 So. 

Rep., 217 433 

Warmsley v. Darraghj 12 Misc. (N. 

Y.), 199 366 

Warner v. State, 56 N. J. L., 686; 

29 Atl. R., 505 491 

Warren's Devisees v. O'Connell, 23 

Ky. Law R., 260; 62 S. W. R., 

890 392 

Washer v. Slater, 67 App. Div., 385; 

73 N. Y. Supp., 425 588, 605 

Waterman v. Whitney, 11 N. Y., 

157; 62 Am. Dec, 71 503, 505 

Waters v. Reed, 8 Detr. Leg. N. 

(Mich.), 899; 88 N. W. R., 394. 

556 
Watson, Matter of, 39 N. Y. State 

Rep., 42 411 

Watson V. Donnelly, 28 Barb., 653. 

392 
Waiters v. McGreavy, 82 N. W. R., 

949 515 

Waugh V. Moan, 200 111., 298; 65 

N. E. R., 713. . .384, 388, 390, 503 
Wax's Estate, In re, 106 Cal., 343; 

39 Pac. Rep., 624 538, 548 

Waxmuth v. McDonald, 96 lU. App., 

242 429 

Waymire v. Jetmore, 22 Ohio St., 

271 762 

Weaver v. Brenng-n, 146 Pa. St., 299. 

380 

Weaver's Appeal, 116 Pa. St., 225. 

590, 593 

Webb, In re, 2 Phillips, 10 594 

Webb V. State, 5 Tex. App., 596. 

536 
Webster v. Woodward, 3 Day, 90. 

354 
Weir V. Meyers, 34 Pa. St., 667. 

594 
Weis V. Ahrenbeck, 5 Tex. Civ. App., 

542; 24 S. W. Rep., 356 367 

Weitzel, In re, 14 N. B. R., 466; Fed. 

Cas. No. 17,365 598 



lii 



TABLE OF CASES CITED IN THIS VOLUME. 



PAGE 

• Welch, In re, 108 Wis., 387; 84 N. W. 

• R., 550... 564 

Welde V. Welde, 2 Lee's Eccl. Ca., 580. 

764 
Welford's Will, In re (N. J. Pre.), 51 

■ Atl. R., 501 556 

Wellman, In re, 3 Kan. App., 100; 

45Pac. R., 726 587 

Wells, Inre, 96 Me., 161; 51 Atl. Rep., 

868 551 

Wells, In re, 67 N. Y. Supp., 631. 

580 
Wendel v. Wendel, 30 App. Div. 

(N. Y.), 447 763 

Westcott V. Sheppard, 51 N. J. Eq. 

(6 Dick.), 315 390 

Westerfield v. Jackson, 3 N. Y. State 

Rep., 353 367 

Westerman's Will, In re, 29 Misc. (N. 

Y.), 409; 61 Supp., 1065 556 

Western State Hospital v. Conier, 99 
Va., 702; 40 S. E. R., 52; 3 Va. Sup. 

Ct. R., 539 382 

Wheatley v. State, 39 S. W. R., 67. 

559 

Wheeler, Matter of, 5 Misc., 279. 

411, 412, 555 

Wheeler v. Grand Trunk R. Co., 70 

N. Y., 607; 50 Atl. R., 103; 54 L. 

R. A., 955 428 

Wheeler v. State, 34 Ohio St., 394. 

582 
Wheeler's Will, In re, 56 N. Y. State 

Rep., 709 387 

Wheeler's Will, In re, 5 Misc. R. (N. 

Y. Suit.), 279; 25 Supp., 421. 

411, 412, 555 

Wheelock V. Godfrey, 100 Cal., 578, 

35 Pac. R., 317 538 

Whipple D. Eddy, 161 111., 114; 43 N. 

E. Rep., 789 '. .400 

Whitaker v. Hamilton, 126 N.C., 

465; 35 S. E. Rep., 815 544, 548 

Whitcomb v. Hardy, 73 Minn., 285; 

76N. W. Rep., 29... 369 

White, In re, 1 Barb. Ch. (N. Y.), 43. 

. 595. 



PAGE 

White, In re, 2 C. E. Green (N. 3.), 

247 593 

White V. Davis, 62 Hun, 622; 17 N. Y. 

Supp., 548 356,546 

White V. Farley, 81 Ala., 563; 8 So. 

Rep., 215 425 

White V. Hinton, 3 Wyo.,.753; 30 

Pac. Rep., 953 380 

White V. Ross, 48 State RepT, 599; 

20 N. Y. Supp., 521. 386 

White V. State, 30 S. W. R., 556. 

490 

Whitelaw's Adm. v. Whitelaw's Admr. 

96 Va., 712; 32 S. E. R., 458. 

507, 517 

Whitelaw's Exr. v. Simes, 90 Va., 588; 

19 S. E. Rep., 113 546, 555 

Whiteman v. Whiteman, 152 Ind., 

263; 53 N. E. Rep., 225 402 

Whitman v. Morey, 63 N. H., 448; 

2Atl. R., 899 .503 

Whitney v. Twombly, 136 Mass., 145. 

389 
Whitten v. State, 22 So. R., 483. 

489, 493 
Widmayer, In re, 74 App. Div. (N. Y.), 

336; 77 Supp., 665 565, 569 

Widmayer's Will, In re, 34 Misc. R., 

439; 69 N. Y. Supp., 1014 391, 

412 
Wightman v. Wightman, 4 Johns. Ch. 

(N. Y.), 343 762 

Wilcox v. State, 94 Tenn., 106; 28 S. 

W. R.,312 450,491,493 

Wilde's WiU, In re, 38 Misc. R. (N.), 

149; 77 N. Y. Supp., 315. . . 404, 407 

Wilder v. Weakley, 34 Ind., 181. 

364 
Wilkins v. Wilkitis, 35 Neb., 212; 52 

N. W. R.. 1109 366 

Wilkinson v. Pearson, 23 Pa. St., 117. 

536 
Wilkinson v. Wilkinson, 129 Ala., 279. 

364 

Wilkinson, Gaddis & Co. v. Markert 

(N. J.), 47 Atl. R., 488; 65 N. J. L.,. 

618 381 



TABLE OF CASES CITED IN THIS VOLUME. 



liii 



Will's Estate, In re, 67 Minn., 335; 

69N. W. R., 1,090 522 

Wille V. Wille, 57 S. C, 413; 35 S.E. 

Rep., 804 362 

Williams, In re, 24 App. Div., 247; 

48 N. Y. Supp., 475; aff'd 157 N. 

Y., 704; 52 N. E. R., 1126. . . .581 
WiUiams, Matter of, 40 N. Y. State 

Rep., 356; 2 Connolly, 579; 15 N 

Y. Supp., 828, aff'd 46 State Rep. 

791; 19 N. Y. Supp., 778 393 

403, 406, 410 
Williams v. Haid, 118 N. C, 481 

24 S. E. Rep., 217 553 

WiUiams v. Hays, 143 N. Y., 442 

38 N. E. R., 449; 26 L. R. A., 153 

426 
Williams v. Hays, 157 N. Y., 541 

52N.E.Rep.,589 426 

Williams v. Lee, 47 Md., 321 539 

Williams v. Robinson, 39 Vt., 267. 

525 
Williams v. Sapieha, 94 Tex., 430; 

61 S. W. R., 115 364, 368 

Williams v. State, 48 Ind., 306. . .482 
Williams v. State (Tex. Cr. App.), 53 

S.W. R.,859 530,540 

Williams v. State, 37 Tex. Cr. App., 

348; 39 S. W. Rep., 687 .. . 537, 559, 

561 
Williams v. Williams, 2 Hun (N. Y.), 

Ill 599 

Williams v. Williams (Ky.), 23 S. W. 

R., 789 399 

Willis V. Lewis, 5 Ired. (N. C), 14. 

594 
Willis V. People, 32 N. Y., 715; aff'g 

5 Park Cr., 621 440, 448, 452 

Willis V. Willis, 12 Penn. St., 459. 

587 
Willoughby, In re, 11 Paige (N. Y.), 

257 596 

Wilsey v. Ellis, 89 111. App., 632. 

534 
Wilson V. Hay's Exr., 22 Ky. Law 

Rep., 897; 58 S. W. Rep., 773. 

392 



PAGE 

Wilson V. State, 60 N. J. Law, 171; 

37Atl. R.,954 491 

Wilson's Est., In re, 117 Cal. R., 262; 

49 Pac. Rep., 172 407, 517 

Winslow V. Troy, 97 Me., 130, 133; 

53 Atl., 1008 762 

Winspear v. The Accident Ins. Co. 

(Eng.), L. R., 6 Q. B. D., 42. . .138 
Wisdom V. Shanklin, 74 Mo. App., 

428 380 

Wiser v. Lockwood, 42 Vt., 720. . .762 
Withrow V. Smith, 37 W. Va., 757; 

17 S: E. Rep., 316 380 

Wolcott V. Conn. Gen. L. I. Co., 100 

N. W. R., 569; 11 Det. Leg. N., 346. 

364 
Wolcott V. United Life and Ace. Ins. 

Ass., 55 Hun (N. Y.), 98; 8 Supp., 

263 143 

Wolf, In re, 9 Kulp., 523 425 

Wolf, In re, 10 Kulp., 112 588 

Wolf, In re Solomon, 195 Pa. St., 438; 

46 Atl. R., 72 588 

Wolf V. Edwards, 106 La., 477; 31 So. 

Rep., 58 365 

Wood V. Carpenter, 166 Mo., 465; 

66S. W. R., 172 507 

Wood V. Lane, 29 S. E. Rep., 180; 102 

Ga., 199 402 

Wood V. State, 58 Miss., 741 536 

Wood V. Zibble (Mich.), 92 N. W. R., 

348; 9 Det. Leg. N., 489 521 

Woodford v. Buckner, 32 Ky. L. R., 

627; 63 S. W. R., 617 567, 568 

Woodward's Will, In re, 167 N. Y., 

28; 60 N. E. R., 233 503, 521 

Woolsey's Will, In re, 17 Misc. R. (N. 

Y.), 547; 41 Supp., 263 575 

Wray v. Wray, 19 Ala., 522 378 

Wright V. Southern Exp. Co., 80 

Fed. Rep., 85 421 

Wright V. State, 37 Tex. Cr. App., 

627;40S.W. R.,491 . .490,493,524 
Wright V. Waller (Ala.), 29 So. Rep., 

57 376 

Wright V. Wright, 139 Mass., 177; 

29N. E., 380 356 



liv ' TABLE OF CASES CITED IN THIS VOLUME. 

PAGE PAGE 

Wright's Est. (Pa.), In re, 51 Atl. R., Young v. Miller, 145 Ind., 652; 44 

1031 389, 535 N. E. Rep., 757 390, 569 

Wurster v. Amifield, 67 App. Div., Young v. Stevens, 48 N. H., 133. 

158; 73 N. Y. Supp., 609 355 366 

Wyman v. Gould, 47 Me., 159. . . . 531 Young v. Travelers Ins. Co , 80 Me., 

Wyse V. Wyse, 155 N. Y., 367; 49 244; 13 Atl. R., 896 143 

N. E. Rep., 942 546 Yturburru's Est., In re, 134 Cal., 567; 

66Pac. R., 729 382 

Yarbrough v. State, 105 Ala., 43; 16 

So. Rep., 758 537 Zeltner v. Bodman Home, 1 Ohio S. 

Yarrow v. Yarrow, Probate Div. & C. P. Dec, 306 363 

(Eng.), 92 377 Zerega v. Percival (La.), 15 So. R., 

Yorke's Estate, In re, 6 Pa. Dist. R., 471 419 

321 507, 555 Ziegler's Will, In re, 65 Hun, 621; 19 

Youn V. Lamont, 56 Minn., 216; N. Y. Supp., 747 397 

57 N. W. R., 478 375, 543, Zirkle v. Leonard, 61 Kansas, 636; 

564 60Pae.R., 318 537,543 



FORENSIC MEDICINE. 



BIOLOGICAL. 



THE MEDICO-LEGAL EELATIONS 



OF 



VISION AND AUDITION, 



AND OF 



INJURIES TO THE EYE AND EAR. 



BY 



J. H. WOODWARD, B.S., M.D., 

Surgeon to the Metropolitan Throat Hospital, and to the New York Throat 
and Nose Hospital, New YorTi City. 



VISIOI^ AND ATJDITIOIT AI^D II^JUEIES 
TO THE EYE AND EAE. 

CHAPTER I. 

ON THE ACUTENESS OF VISION. 

The acuteness of vision of an eye-witness may have an im- 
portant bearing upon the credibility of his testimony. It may 
have an important bearing on those cases of alleged direct or 
indirect injury to the visual apparatus, in which the simulating 
plaintiff is actuated by revengeful motives, or by a dishonest 
desire for pecuniary remuneration for his alleged hurt. It must 
be taken into, consideration likewise in those cases of actual in- 
jury, direct or indirect, to the visual apparatus, in which justice 
would naturally side with the injured party, to the end that the 
degree of his incapacity may be correctly determined. 

The visual apparatus comprises the eyeball together with its 
extrinsic muscles, the optic nerves, the chiasm, the optic tracts, 
and the centres of visual perception in the brain. Acuteness 
of vision depends upon the integrity of these structures. The 
eyeball is really a living camera. Upon its retina is projected 
an instantaneous and transient photograph of the objects seen. 
By virtue of the transmission of such impressions upon the 
retina to the centres of vision in the occipital lobes, by the optic 
nerves, the chiasm, the optic tracts, and the prolongations of the 
optic tracts, the retinal image of the object under observation 
is perceived. If the retinal images be true and if impressions 
of them be properly transmitted to a normal visual centre, the 
perceptions of the object will be correct, so far as concerns the 
visual apparatus. It often happens, however, that the retinal 
images are not clear and distinct; under certain conditions they 
do not represent the thing as it is. The reason for this must 
often be sought in the state of the refraction of the eye. 

By refraction of the eye is signified "the influence of the 



6 VISION AND AUDITION — WOODWARD. 

ocular media upon a cone or beam of light, whereby a normal 
or emmetropic eye produces a proper image of the object upon 
the retina. " ' The ocular media which cause such a deviation 
of a cone or a beam of light are the cornea, the aqueous humor, 
the crystalline lens, and the vitreous humor. They are spoken 
of as the " dioptric system" of the eye. These media together 
constitute a lens which, in the normal, emmetropic or ideal eye, 
cause parallel rays of light (i.e., rays derived from infinitely 
distant objects) to unite at a focus in the retina.'' "From near 
objects, the rays proceed in a diverging direction, and their 
point of union in the normal eye, consequently, lies behind the 
retina, and yet the organ is capable of perceiving near objects 
also accurately. It has, therefore, the further power of bringing 
divergent rays into union on the retina. Now this power of 
bringing at will rays of different direction into union on the 
retina is the power of accommodation of the eye. . . . The 
change consists in an alteration of the form of the lens ; above 
all, its anterior surface becomes more convex and approaches 
the cornea." ' This alteration in the form of the lens is brought 
about by contraction of the ciliary muscle by which the zone of 
Zinn, or the suspensory ligament of the lens, is relaxed, when, 
by virtue of its own elasticity, the lens becomes more refract- 
ing. The accommodation is all positive. If we paralyze the 
ciliary muscle with atropine, for example, we can then accu- 
rately measure the refraction of the eye; the dioptric system is 
then adjusted for its far point. 

The emmetropic, or normal, eye is not often seen. Emme- 
tropic eyes are eyes in which, when they are at rest, parallel 
rays of light, that is, rays of light proceeding from infinitely 
distant objects, are brought to a focus on the retina; and in 
which the power to adjust the eye for near objects remains 
sufficiently good to enable the eye to read type as small as 
Jaeger No. 1, at 32 centimetres distance, until the patient is 
forty or forty-five years old. Such an eye is endowed with nor- 
mal refraction and accommodation. And, inasmuch as emme- 
ti;opia is relatively uncommon, there are deviations from the 
normal refraction. The varieties of abnormal refraction, or 
ametropia, are hypermetropia, astigmatism, and myopia, and 

^ Gould '8 " Medical Dictionary. " ■' Dondeis : " Ref laction and Ac- 

■'"*"• commodation, " p. 8. 



ON THE ACUTENESS OF VISION. 7 

various combinations of astigmatism with hypermetropia and 
myopia. 

The greatest number of eyes are hypermetropic. The antero- 
posterior diameter of such eyes is shorter than that of emme- 
tropic eyes. In technical terms, the " retina is situated between 
the dioptric system and the principal focus of the eye." ' Very 
many eyes are astigmatic. By astigmatism we mean a " state 
of irregular refraction of an eye, usually congenital, in which 
the rays of light diverging from a single point cannot be brought 
to a focus at a point on the retina ; an asymmetrical condition 
of the refraction of different meridians of the eye." " " Regular 
astigmatism is that error of refraction which is due to a differ- 
ence in the focal distance of the two principal meridians, and 
depends mainly on the curvature of the cornea." ' Simple hy- 
permetropic astigmatism is that variety of astigmatism in 
which one of the meridians of the cornea is emmetropic and the 
other is hypermetropic in their effect upon the refraction of 
light. Simple myopic astigmatism is that variety of astigma- 
tism in which one of the meridians of the cornea is emmetropic 
and the other myopic in their effect upon the refraction of light. 
Compound hypermetropic astigmatism is simple hypermetropic 
astigmatism plus hypermetropia. Compound myopic astigma- 
tism is simple myopic astigmatism plus myopia. Mixed astig- 
matism is that variety of astigmatism in which one of the 
principal meridians of Ihe cornea is hypermetropic and the other 
myopic in its effect upon the refraction of light. Astigmatism 
of these varieties is regular. It may be irregular. Irregular 
astigmatism may be normal or abnormal. " Normal irregular 
astigmatism is due to irregularity in the structure and density 
of the crystalline lens, so that an aberration of the rays occurs 
as they traverse the different sectors, in consequence of which 
there is an imperfect coincidence of the images of the different 
sectors. Its chief symptom is polyopia." * " Abnormal irregu- 
lar astigmatism is due to some defect in the curvature of the 
cornea, or to some irr0gula,rity in the structure or position of 
the crystalline lens." ' Astigmatism may be acquired, and then 
it is " dependent on flattening of the cornea from inflammatory 

' Landolt : " Traite complet d ' Oph- ' Ibid. 

thalmologie, " iii., p. 136. * Ibid. 

'Foster's "Encyclop. Med. Die." ^ Ibid. 



SNELLEN'S TEST TYPES. 
CO. 

60 M. 



r 



T 



,4.. 
i 



C. 

30 M. 



i 


■ 


^^^^^^^1 


■ 






ll 


ri 











LXX. 

30 M. 



L. 

15 M. 



1 

— ,_ 
i 


w 


■ 


m ! 



XL. 

13 M. 




XXX. 

9M. 




^m I" 

^H , I 







^ 



XX. 



ffi ^ ^ ^ ^ 



10 VISION AND AUDITION— WOODWARD. 

changes or irregular apposition of the flaps after a cataract ex- 
traction, or in dislocation of the crystalline lens." ' Any wound, 
or other solution of continuity, of the cornea may cause astig- 
matism. Myopia, or "short sight," is that state of the refrac- 
tion of the eye, in which, in the great majority of instances, the 
antero-posterior diameter is longer than in emmetropia. This 
is axial myopia. The most comprehensive definition of myopia 
is that state of refraction in which the retina lies beyond the 
focus of the dioptric system." 

The acuteness of vision of any eye is measured by testing 
the reading power of each eye separately. Charts of test 
types are used, and that devised by Snellen, based upon the 
deduction that the minimum visual angle is one minute, has 
been generally adopted by ophthalmologists. The chart is 
hung upon the wall in a good light — not direct sunlight — at 
20 feet, or 6 metres from the patient. A screen is then placed 
before one eye, and, with both eyes open, the patient is directed 
to begin at the top and read as many letters upon the chart as 
he can. 

If he is able to distinguish only the first letter, A, of the 
test types with either eye, the acuteness of vision of each eye is 

^, or — f V = ^) °^ 60 )■ ^^ ^^ ^^^ ^^^^ *^® following 

two letters, but none below that line, then V = q-» or — . 
That is to say, the patient at 20 feet can read only those letters 
of the test types which he should be able to read at 300 feet 
and 100 feet respectively, if his vision were normal. The 
numerator of the fraction always denotes the distance between 
the patient and the test types, and the denominator denotes the 
lowest line of type that he is able to read with each eye 
separately. The same fraction may stand for the acuteness of 
vision of both eyes ; but frequently the vision of one eye is more 
acute than that of the other, 
on (\ 

When V = — — , or — , it is normal ; that is, the patient 

must be able to read at 20 feet letters analogous to those in the 

20 
^QT line of the chart used in the test. A person having nor- 

' Foster's "Encyclop. Med. Die." « Landolt, I.e., p. 118. 



ON THE ACUTENESS OF VISION. 11 

mal vision may read also the letters in the lowest line and even 
still smaller type; but vision is not normal unless in a good 

light one can read at 30 feet the letters in the ^^ line at least. 

XX. 

"When vision is not normal, the cause for it may be found in 
some failure of transparency of the refracting media, or in 
some morbid state of the cornea, aqueous, iris, crystalline lens, 
vitreous, ciliary bodies, retina, choroid, or optic discs. The 
ophthalmoscope will inform an experienced person whether one, 
or more, of those structures is in a morbid state. Vision is 
below normal also when the retro-bulbar portion of the optic 
nerves, the chiasm, the optic tracts, and the cerebral centres from 
which the nerve fibres composing the optic tracts are derived, 
are diseased or injured. The ophthalmoscope may not reveal 
anything denoting the condition of those deeply seated struc- 
tures until some weeks or months have passed ; in certain cases 
no morbid changes in the ophthalmoscopic image are ever ob- 
served. 

When the visual apparatus is in a healthy condition, acute- 
ness of vision depends upon the refrac+ion of the eye. Emme- 
tropic eyes have normal vision. Hypermetropic eyes may 
have normal vision, and they may not. In order that an hy- 
permetropic eye may have normal vision, a contraction of the 
ciliarj' muscle must take place to increase the sphericity of the- 
crystalline lens enough to compensate for the shortness of the 
antero-posterior diameter of the eyeball, by advancing the focus 
of the dioptric system until it lies in the retina. So long as the 
ciliary muscle is able to accomplish this fact, the hypermetropic 
eye will have normal vision. 

Low degrees of regular hypermetropic astigmatism may be 
overcome by an analogous process ; but, in general, the acute- 
ness of vision in astigmatic eyes is below normal. Irregular 
astigmatism always reduces the acuteness of vision to a marked 
degree. Myopic eyes never have normal acuteness of vision (30 
feet test) . 

Recognition of things by sight depends not only upon the 
size of the object, but also, to a certain extent, upon the observ- 
er's familiarity with the general aspect of the object, and upon 
the brilliancy of the object. It is well known that persons 
whose vision is imperfect are able to recognize things lying 



13 VISION AND AUDITION — WOODWABD. 

beyond their range of distinct vision by virtue of their familiarity 
with the general characteristics of those things. A woman is 
thus distinguished from a man by her dress. And a near- 
sighted person will recognize an acquaintance by his walk, by 
some peculiarity of dress, or by some other mark of individuality, 
notwithstanding that the person's features are absolutely indis- 
tinguishable to the observer at such a distance. 

Brilliant objects, such as stars, flames, polished surfaces, etc., 
are visible at much greater distances than other objects having 
the same size and form. 

To ascertain- whether failure in acuteness of vision be due to 
an error of refraction or not, ophthalmologists employ four 
methods : 

1. Ophthalmoscopic examination. The ophthalmoscope 
will reveal the existence of morbid changes in the structures 
of the eyeball which take part in the visual act. It may be 
used to objectively determine the refraction of the dioptric 
system. The accommodation (ciliary muscle) of the patient 
must be paralyzed, and the accommodation of the observer re- 
laxed, to make this method of observation reliable ; and, even 
under such conditions, the error will amount to 0.50 or 0.75 of 
a diopter. 

2. The fundus-reflex test, or retinoscopy. This is an objec- 
tive method of determining the state of the refraction. Unless 
the patient's accommodation be paralyzed, the results of this 
examination are not to be relied upon, in many cases. The 
error, when the accommodation is paralyzed, will be 0.35 of a 
diopter at least, and it may be 0.75 D. 

3. Javal's ophthalmometer is used to measure astigmatism 
objectively. It gives an approximately accurate idea of the 
curvature of the cornea, from which is derived a probable diag- 
nosis of the amount and of the axis of the astigmatism. It is, 
in general, the more useful the greater the astigmatic error. 
But the ophthalmometer does not inform us whether the astig- 
matism is hypermetropic, or myopic, or mixed. It reveals ir-' 
regular corneal astigmatism with great certainty. 

4. The refraction is measured alsabythe subjective method. 
The patient is required to read with each eye separately the 
chart of test types as far as he is able. Then convex (+) spher- 
ical lenses are placed before the eye under examination, begin- 



ON THE ACUTENBS8 OF VISION. 13 

ning with a weak lens. The strongest convex lens through 
which the eye can read clearly the |i line of types is the meas- 
ure of its manifest hypermetropia. An emmetropic eye will re- 
ject -h glasses. When hypermetropia is all latent, the eye may 
reject glasses. By paralyzing the ciliary muscle with atropine, 
the total hypermetropia will be revealed and may then be meas- 
ured. An emmetropic eye, while under the influence of atro- 
pine, should read clearly the ||^ line of types. Should the pa- 
tient fail to read the normal line of types with the convex spher- 
ical lenses, convex cylindrical lenses should be tried ; and the 
strongest convex cylinder through which he can read the normal 
line of types is the measure of his manifest hypermetropic astig- 
matism. Should neither the convex spherical nor the convex 
cylindrical lenses alone give him the proper acuteness of vision, 
combinations of them may do so ; and the strongest combination 
of such lenses is the measure of the manifest compound hyper- 
metropic astigmatism. These various errors may be absolutely 
measured by the same method, while the patient's accommoda- 
tion is paralyzed by atropine. 

Should the patient reject convex lenses of all varieties and 
strengths, the eye may be tested with concave (— ) lenses; and 
the weakest concave lens with which the normal line is clearly 
read is the measure of the myopia. Concave cylinders should 
be tried, and the weakest of them that gives normal vision is the 
measure of the myopic astigmatism. Combinations of concave 
spherical with concave cylindrical lenses may be required to 
raise vision to normal, and the weakest combination is the meas' 
ure of the compound myopic astigmatism. In myopia and my- 
opic astigmatism, the accommodation may be in a state of 
spasm. This will exaggerate the error of refraction. To obvi- 
ate this source of error, atropine should be used until the ciliary 
muscle is paralyzed. 

The diagnosis of astigmatism is not completed, however, 
until the eye can see the test dial correctly at twenty feet. The 
test dial is a chart made like a clock-face with three parallel 
black lines running from each hour toward the centre. A clear 
space is left about the centre to avoid confusing the patient. 
The width of each line is such as to subtend a visual angle of 
one minute. 

It is by no means always possible to raise the acuteness of 



Vi 



VISION AND AUDITION — WOODWARD. 



vision to normal with glasses, even though the visual apparatus 
be perfectly healthy. Very many hypermetropic, myopic, and 
astigmatic eyes fall into this category. Nevertheless a combi- 
nation of the four methods of examination will reveal the state 
of the refraction of any eye. If the error of refraction be con- 
siderable, and the acuteness of vision be not raised to normal, 
or if it be not materially improved by correcting lenses, it is 
highly probable that the dulness of sight is a consequence of the 
error of refraction and nothing else. The burden of proof that 
it is due to something else should always rest upon those who 
entertain that proposition. 

Having measured the acuteness of vision for distant objects, 
the power of the eye to see objects close at hand must be tested. 

Jaeger No. 1. 

A Fox ImId; etagbt in » tnp, wu gl^d to compound for bia neck bf leaving bb tall beblod bim; bnt upon. coming ibroid Into 
the world> hs began to be bo sensible of the disgraoe suob a defect would bring upon bim, that be almost wiabed he bad died 
rather- than oome away vltbout it. HoveTer, resolving to main the beat of a bad matter, be called a meeting of the rest of the 
.Foxcs,'Ud proposed that all should fallow bU example. "Tou bavo no nodon," said b^ "of the ease and comfort irith Irbicb 
I nilv more aboat: X oould never bare believed it if I bad not tried it toyself ; but xeallj when one comes to reason upon it, a 
tail Is fuob an ugly, inconvenient, unnecessary appendage, that the only wonder is that, as Foxes, we ooold bare put up with it ao 
long. I propose, therefore, mj worthy brethren, that yon all profit by tb« experience that I am moat williog to afford you, and 
flu* lU Poxea from tbia d^ forvaid cot off their tails." Upoa tbia oat of tlie oldest stepped forward, a&d a&id, "I rather tiiink. 

Jaeger No. 2. 

ay Mend, that yoa would not faave advised us to part \ritb our tails, if €bsre were any chanoe of 
reoorering yoar ofm." A Man vrho bad been bitten by a Dog was going about asking who conld care 
bim. One that met him said, " Sir, if joa -would -be cured, take a bit of bread and dip It In the blood of 
the woQDd, and give It to tbe dog that bit jou." The maif smiled, and' said, "If I were to follow yoor 
advice, I should be bitten by all tbe-dogs in the city." He who p^roclaims himself ready to buy up Uq 
enemies will never want a supply of them. A certain man had the good fortune to possess a Oobse that 
laid him a Golden Egg every day.. But dissatisQed with so slow an income, and thinking to seize the 
Whole treasure at once, he killed tbe Goose , and cutting her opea foand her— goBt what an^ other goose 

Snellen D — 0,5, 



The Gallic tribes fell off, and sned for peaee. Even 
the Batavians became weary of the hopeless contest, 
while fortune, after much capricious hovering, settled 
at last npon the Etoman side. Had Clvllis been sue- 
cessfal, he would baf e been deified; but his misfortunes, 
at last, made him odious In spite of his heroism. Bnt 



tbe Batavlan was not a man to beornshed, nor haA 
be lived so long in the Boman service to be oot- 
matched in politics by the barbarons Germans. 
He was not to be sacrificed as a peace-offering t4> 
revengefDl Borne. Watohlng hvm beyond the Bhlne 
the progress of defection and the dec^ of national 



Snellen D = 0,6, 

mthufliasm, he determined to be beforehand with those who were now his enemies. H* 
accepted the offer of negotiation from Cerialia., The Soman general was eager to grant a 
fall pardon, and to re-enlist so brave a soldier in the service of the empire. A colloquy was 
agreed npon. The bridge across the Nabalia was broken asunder in the middle, and Cerialia 
and Cirilis met upon the severed sides. The placid stream hy which Roman enterprise had 
«onpa<ri«d tbe waters of the Rhine with tbe lake of Flevo, flowed between the imperial 



ON THE ACUTENESS OF VISION. 15 

This power depends upon the state of the accommodation. A 
normal, emmetropic eye should be able to read fine print, Jae- 
ger No. 1 or Snellen i^, as near as 8 inches, or 22 centimeters, 
from the eye. 

The error of refraction being corrected, nearly all hyperme- 
tropic and astigmatic eyes (irregular astigmatism excepted) 
will be able to do the same. Myopic eyes, in which the error 
is not excessive, will be able to read as well, either without or 
with correcting lenses. These statements will hold good until 
the patient has passed his fortieth year. All eyes then begin 
to experience the results of the change in accommodation power 
known as presbyopia, or "old sight." This is a normal physio- 
logical change, which makes it difficult, or impossible, for the 
patient to read fine type or to distinguish small objects at 8 
inches, or 33 centimetres, from his eye. He holds his work far- 
ther from his eye, and places the lamp between his eye and the 
book or paper. But sometimes the ciliary muscle is strong 
enough and the lens is elastic enough to enable the patient to 
overcome the effects of this physiological alteration in his vis- 
ual apparatus, even until he is forty-eight or fifty years old. 
His eye is presbyopic, nevertheless. Now and then such eyes 
suddenlj' lose their power to read newspaper type at any dis- 
tance without the aid of convex lenses. In many cases, no very 
definite reason can be given for this sudden failure of the 
accommodation . 

Presbyopia develops regularly in every eye. At forty-five 
years it amounts to S+1 D. ; at fifty years it is S+3 D ; at fifty- 
five years, 8+3 D; at sixty years, S+4 D. In practice it is 
found that after sixty years the presbyopia does not increase 
with regularity. 

The acuteness of vision for near work, therefore, undergoes a 
physiological modification. An emmetrope, for example, in 
order to see small print as well at fifty years of age as he did at 
forty, must use a spherical convex lens of 3 D. His presbyo- 
pia must be corrected. The same is true of those whose eyes 
are hypermetropic or astigmatic. , The amount of the presbyo- 
pia must be added to the patient's distance glasses to give him 
the correcting glass for near work. Myopes may not experience 
any of the effects of presbyopia until later in life; because myo- 
pia compensates for equal amounts of presbyopia. A myope. 



16 VISION AND AUDITION — WOODWARD. 

fifty years of age, wearing a spherical — 2D. would read Jaeger 
No. 1 easily at 32 cm. without glasses. But at fifty-five years 
the same person would require S+1 D. to enable him to see as 
well." 

The extrinsic muscles of the eyeball play an important role 
in the visual act. The acuteness of binocular vision is dimin- 
ished whenever these muscles are not suflQciently balanced to 
adjust both eyes properly for the object under observation. If 
the image of the object do not fall upon corresponding portions 
of the fundus of the two eyes, the object will not be seen clearly 
(contours blurred), or it will be seen double (diplopia). This 
condition is often more distressing to the patient than failure of 
vision due to an error of refraction. It is probable that the nor- 
mal power of the internal recti is sufficient to overcome the effect 
of from 30 to 40 prism degrees ; that the normal power of the 
external recti is about 8 prism degrees; that that of the superior 
and inferior recti ranges from 1 to 4 prism degrees. 

When the external recti are relatively weak and the internal 
recti are strong, there is a tendency of the visual lines to 
meet before they should — esophoria; when the interni are 
weak and the externi relatively stronger than they should 
be, there is a tendency to divergence of the visual lines — 
exophoria. When a superior or an inferior rectus muscle is 
relatively weaker than its antagonist, there is developed a.ten- 
dency of one visual line to rise above the other — hyperphoria, 
which may be either right or left, according to the case. These 
conditions are grouped under the term heterophoria. When the 
deviations are more marked ; that is, when there is an obvious 
turning of the eye, we have, for those cases in which the eye 
turns in, the term esotropia (internal strabismus) ; for those in 
which the eye turns out, esotropia; for those in which the eye 
turns up, hypertropia ; or in which it turns down, hypotropia. 
These conditions are designated as cases of heterotropia. 

To measure heterophoria, prisms are used, by means of which 
lateral or vertical diplopia is produced at will by the observer. 
Having developed the diplopia, the amoimt of deviation of the 
images from the normal position is measured by the number of 

' For th ose who cannot read, charts and for near-testing the patient may 
of numbers, or charts of peculiar be required to designate small dots, 
figures, are used for the 20 feet test ; or to thread needles, etc. 



ON THE ACUTENESS OF VISION. 17 

prism degrees required to restore the images to a proper relation, 
one to another. Heterotropia may be measured in prism de- 
grees also in a similar manner when it is possible to develop 
diplopia. It is not always possible to develop diplopia in these 
cases. When the heterotropia is due to recent paralysis of one of 
the extrinsic ocular muscles, diplopia is always present, if the 
vision of each eye is fairly good. The patient may learn to sup- 
press the false image. A red glass placed before one of the eyes 
will enable the observer to distinguish the image projected upon 
that eye, so that the deviation of the lines of vision may be 
measured. 

The subjective symptoms commonly associated with errors 
of refraction and heterophoria are indistinct vision, blurring of 
vision, pain in the eyes, pain in the orbit behind the eyes; 
frontal and temporal headache, which may be more marked on 
one side than the other; general headache; "sick" headache; 
"sun" headache; "blind" headache; occipital headache; pain 
in the back of the neck ; confusion of mind ; blind spells ; and 
vertigo. Stevens and other writers have claimed that chorea 
and epilepsy are caused by errors of refraction and by hetero- 
phoria. It must be recollected that, at the time of testing the 
patient's eyes, vision may be normal, and the patient honestly 
unconscious that his eyes are the cause of his symptoms. Fre- 
,quently it may be impossible to state positively that the symp- 
toms are due to eye-strain. Then, in order to make a positive 
proof of the matter, the ocular errors must be corrected, and, 
if they have caused the disturbances, the symptoms will disap- 
pear after a few weeks or a few months. 

Hypermetropia, and astigmatism not due to lesions of the 
cornea, are congenital. They do not change materially during 
life. Latent hypermetropia and latent astigmatism may become 
manifest and so give rise to the idea that the error of refraction 
has increased.' 

Myopia is seldom congenital, but generally develops in early 
childhood. The development of it is favored by school work, 
and other severe usage of the eyes at short range, by the diseases 
of childhood, and by anything that undermines the bodily vigor. 

' In a few cases that have come tain, that an astigmatic error has 
under the writer's observation it has actually increased, 
seemed highly probable, if not cer- 
III.— 3 



18 VISION AND AUDITION— WOODWARD. 

All cases are more or less progressive; but the progress of the 
trouble in the majority of cases ceases spontaneously, or may be 
made to cease. Oases of myopia must be divided into two cate- 
gories : the malignant and the non-malignant. Non-malignant 
myopia of low degree may be a positive advantage to one whose 
business calls for continuous use of the eyes at short range. 
Malignant myopia, on the contrary, is a condition involving 
great danger of ultimate blindness. The eye is not healthy; 
the myopia becomes more and more marked until it is excessive ; 
the range of vision becomes progressively smaller. Injuries 
affect such eyes much more seriously than others. Even slight 
contusions may accelerate the increase of the myopia, or dislo- 
cate the lens, or cause hemorrhage into the vitreous, or precipi- 
tate a detachment of the retina. 

The muscle of accommodation of one, or of both eyes may 
suffer from paresis or paralysis. The eye will then be adjusted 
for its far point. Both eyes will not work in harmony and the 
patient may be greatly annoyed by his condition. On testing 
such an eye it will be found that the power to adjust the eye for 
objects at varying distances is gone. The causes of this condition 
are as follows : Diphtheria, typhoid fever, articular rheumatism, 
syphilis, diabetes, parasitic diseases, poisoning by raw sausages 
and tainted meat, lesions of the central nervous system involv- 
ing the nuclei or trunk of the third nerve, and vascular disturb- 
ances in the same region, digestive troubles, fracture of the 
skull, locomotor ataxia, anything that weakens bodily vigor, 
e.g., essential anaemia, and anaemia developed by acute diseases, 
lactation, alcoholism, venereal excesses, masturbation, uterine 
lesions, abundant hemorrhages, etc., herpes zoster ophthalmi- 
cus, traumatisms of the eye or orbital region, sympathetic oph- 
thalmia, glaucoma, and neuralgia of the dental branches of the 
fifth nerve, atropine and other mydriatics.' 

' Landolt : " Refraction and Accommodation, " translated by Culver, 
1886, p. 551 et seq. 



CHAPTER II. 

SIMULATED BLINDNESS. 

A PERSON may claim that he is partially or totally blind in 
^ne or in both eyes in consequence of some injury. If ophthal- 
moscopic evidence of a lesion in the visual apparatus sufficient 
to materially weaken or totally abolish the function of the eye 
or the eyes be found, the patient's statement regarding his 
abiUty to see may be accepted. But when no ophthalmoscopic 
evidence of a lesion is manifest, doubt of the truth of the patient's 
statement should be entertained. 

By amblyopia is signified partial blindness, where there are 
no lesions demonstrable with the ophthalmoscope; by amauro- 
sis is signified total blindness where there are no lesions demon- 
strable with the ophthalmoscope. In this connection, then, we 
have to deal with simulated amblyopia of one, or of both eyes; 
and simulated amaurosis of one, or of both eyes. 

Monocular amblyopia or amaurosis is simulated most fre- 
quently. The problem that confronts the examiner in such cases 
is to prove that the malingerer actually uses the eye which he 
claims is amblyopic or amaurotic. The objective evidence bear- 
ing upon the question is as follows : The pupil of a healthy eye 
contracts in response to the stimulus of light ; also when the eye 
accommodates, and during the act of convergence of the visual 
lines. It does not necessarily follow, however, that the exis- 
tence of these reactions is proof positive that the eye is not af- 
fected. The converse proposition, however, is often true. The 
pupil of myopes is generally large (semi-dilated). The pupil is 
dilated when the light is faint, during and after great muscular 
exertion, and in real amaurosis. ' Some persons can dilate or con- 
tract their pupils at will. In old age, in hypermetropia, in near 
vision and in strong light, the pupil is contracted. Observation 
of the tendency to fixation of the eye in monocular and in binoc- 
ular vision will afford useful evidence regarding the function 
of the organ. Place a screen before the eye in question and in- 

' Vide p. 27. 
19 



20 VISION AND AUDITION — WOODWARD. 

struct the patient to look at an object, which is caused to move 
toward and recede from the eye; if, when the screen is removed, 
the affected eye fixes the object, it is probable that the eye is a use- 
ful one. The same is true when a prism of 8 or 10 degrees base 
out is placed before the eye. If, under such conditions, the eye 
turn so as to overcome the action of the prism, while the sound 
eye fixes a given object, it is probable that the eye is a useful one. 

One may cover the sound eye and attempt to surprise the 
patient by thrusting a finger toward the eye said to be affected. 
Should the patient wink or cringe, the eye is not blind. 

The examiner may seem to devote his whole attention to the 
sound eye, determining its acuteness of vision, its refraction, 
and its range of accommodation. The patient's attention is 
thus diverted from the alleged amaurotic eye. He is then to 
read fine print ; both with and without glasses. Finally, with- 
out exciting his suspicion, a strong convex glass (6 D.) is set 
before the sound eye, while the type is held at the usual distance 
for reading, i.e., beyond the focus of the convex lens. If the 
patient still reads the type, he reads with the eye said to be 
affected. 

Among the tests for detecting simulated monocular amblyo- 
pia and amaurosis are those in which prisms are used to pro- 
duce double vision. If a prism be placed before one eye and the 
patient see two images, for example of a candle, he must have 
used both eyes. The experiment may be modified to confuse a 
person acquainted with the test. Thus, exclude the eye in ques- 
tion from vision, and place a prism over the sound eye so that 
the edge shall bisect the pupil. This will cause monocular di- 
plopia. Then, without attracting the patient's attention, remove 
the screen from the other eye, at the same time moving the prism 
so as to cover the pupil of the sound eye completely. Should 
the patient still see double, he is using both eyes. 

In some respects the stereoscope is one of the most useful 
agents employed in detecting simulated blindness. Prisms are 
an essential part of the construction of this instrument. The 
following from Kugel ' indicates the method of its use : 

" Vieusse gives the following method: Two wafers of dif- 
ferent color, whose distance from one another is a centimetre, are 

'"Ueber die Diagnose von Simu- opie, " Wiener med. Wochenschrift, 
lation der Amaurose und Ambly- 1889. 



SIMULATED BLINDNESS 21 

brought under the stereoscope. With this small distance of one 
from the other, the one lying on the right hand of the person 
examined appears on the left side and the other appears on the 
right side. Suppose there were a red wafer on the right and 
a blue wafer on the left, then the blue wafer will appear on the 
right side, and the red wafer on the left side. If, for example, we 
have to do with an individual who pretends left-sided amauro- 
sis, the case can be of two sorts : either the person admits that 
he sees both the wafers; then the simulation is eo ipso proved; 
or, he admits that he sees 'only one wafer. In the latter case he 
would naturally confess to seeing the blue wafer, since this is on 
that side which corresponds to the professedly strong eye, viz., 
the right side, and he betrays himself thereby, so to speak, 
through a double lie. He denies the existence of the red wafer 
which he must see with the professedly strong-sided eye, but 
on the other side he professes to see the blue wafer which he 
can see only with the professedly amaurotic eye. 

" In order to determine, by this method, even the degree of 
the sharpness of vision, I have with advantage employed two 
short words, as for example herz-mein. The pretender has 
either read mein-herz, or asserts that he sees only one of these 
words, the very one indeed which he could have seen only with 
the professedly bad eye." 

Baudry ' gives the following : " Our test is designed to de- 
termine the visual acuteness of the amblyopic eye or the one 
that is supposed to be so. We accomplish this with typo- 
graphical characters disposed as wiU be stated. Let us suppose 
that upon each half of a card like those which are employed for 
stereoscopic tests one has commenced by tracing the same let- 
ters arranged identically in the same way and separated by per- 
fectly equal intervals in the two tests, in such a manner that the 
latter shall be a faithful fac-simile one of the other without the 
least difference of stereoscopic parallels. Let us imagine, finally, 
that one suppresses upon each portion a certain number of letters 
or entire words taken by chance, or a combination of forms of 
letters, having care always that the suppressions made upon 
each of the lists shall not be reproduced upon the other. The 
place of the suppressed parts should be left blank. One may 

' " Simulation de 1' Amaurose et de yens de la devoiler, " Bull, scient. du 
I'Amblyopie, des principaux mo- Department du Nord, Nos. 8,9, 1883. 



23 VISION AND AUDITION — WOODWARD. 

prepare in the same way ten cards of which the characters 
shall have progressively increasing dimensions calculated 
in a manner to represent ten numbers of the typographical 
decimal scale, so that they may be made to serve as a measure of 
the acuteness of vision in tenths. Several numbers may be 
grouped on the same card. These cards being placed in 
turn in the stereoscope, the simulator is invited to read the 
words or to pick out the letters which he sees, commencing 
with the last number — that corresponds to V=0.1. "When 
he can read only the characters traced upon one of the halves 
of the card, the test will be ended, and the number of the 
last character which he shall have been able to read at one time 
upon the two halves of the card will measure the visual acuteness 
of the amblyopic eye. ... It is convenient to have, moreover, 
a card both halves of which are perfectly identical and to make 
that the first test, in order that the person submitted to this mode 
of examination shall not suspect the trick which is used for the 
purpose of unmasking the fraud." 

Another series of tests are based upon the principle of sup- 
pression of color by colored glasses. Kugel,' in his exhaustive 
article, writes as follows : " Snellen ' gives the following very 
practical method. Eed and green letters are viewed binocularly 
while the strong eye is furnished either with a red or with a 
green glass. As is well known, translucent ' green letters are 
seen indistinctly through a red glass, while translucent ' red 
letters are seen indistinctly through a green glass. If, now, in 
our case, both green and red letters are seen plainly, the person 
examined is caught. 

" Let us take the case of left-sided amaurosis : then holding 
a red glass before the right eye, only the red letters are recog- 
nized. The reverse must be the case if a green glass be held 
before this eye. If both green and red letters are seen at the 
same time— a thing that can happen only by the help of the 
professedly amaurotic or amblyopic eye — ^the pretender is un- 
masked." 

Bravais* gives the following test: "For cases where the 
prism test has failed, or the observer does not possess the double 
prism of Monoyer, and does not possess the scale of Snellen, or 
the tables of Stilling, the author suggests the following : Writ- 

'iofl. cit. "Bulletin et Memoires de la Soc. 

■'Zehender s Klin. Monatsch. fur Francaise d'Ophthalmologie 1883- 

AuRenheilkunde, 1877. 84. 
' Woodward. 



SIMULATED BLINDNESS. 23 

ing with a red pencil disappears when viewed through a red 
glass. Write a word in two colors, alternately red and blue let- 
ters, e.g., the word noir. If the o and r are in red, the eye 
covered by a red glass will see only ni. If the patient read the 
word noir the eye covered by the dark glass is not blind. One 
may write two isolated words, one to be written in red, the 
other in blue. Or an entire phrase may be written in which 
certain words are in red, e.g., Je ne vois pas bien clairj the 
words ne, pas and clair in red. 

" One may have cards half blue and half red. It suffices to 
write with a black pencil "upon the two colors. With the col- 
ored glasses the writing upon the blue ground is not read through 
the red glass and the writing upon the red ground is not read 
through the blue glass ; as with the scales of Snellen, each eye 
sees only certain characters. With this card one can vary the 
tests ; write words of different or of the same size, place them 
one above the other, or one to the right, the other to the left. " 

Michaud' gives the following: "It is known that marks 
with the red pencil traced upon a piece of white paper are not 
visible through a red glass. Therefore in the case of amaurosis 
or monocular amblyopia one places a red glass before the healthy 
eye. The patient ought not to see any of the characters. If 
the red characters are seen it will be by the alleged amaurotic 
eye. The patient, however, may be posted respecting the test 
and declare that he sees nothing. To eliminate as far as pos- 
sible this chance of error we have recourse to the following 
artifice. It is sufficient to remove from letters of simple form 
one or two parts to change at once the aspect and value. For 
example, from the letter E it is easy to make I, F, or L. If then 
we trace upon paper an E of which the horizontal lines are red, 
and if we cause this letter to be seen with a red glass, the pa- 
tient will not see an E but an I. Several letters thus modified 
in a word may compose a new word, and if one may admit that 
a badly seen E maybe confounded with I or L, it is impossible 
to pretend that the word TETE could be taken for the word 
FILLE. In the same way the word MEOTANE, having no 
sense, could become VICINAL. 

" Now, in reading the reader does not habitually look at each 
letter forming a word. It is the general appearance of the writ- 
' Archiv. de Medecine et de Pharmacie Militaires, 1888. 



24 VISION AND AUDITION — WOODWARD. 

ing which fixes in his mind the thought corresponding to the 
word. By suppressing such and such a word representing an 
idea a change may be made to another word representing another 
idea. Thus let us present to the simulator the word EPONGE 
made in red and black. After having put a red glass before 
the good eye, the alleged amaurotic eye which is uncovered will 
see the word EPOISTGE. The idea corresponding to this word 
is fixed in the mind of the patient, and it will be difficult for 
him to substitute for it the idea LION by the mental sub- 
traction of that which is marked in red. The simulator, urged 
to read quickly in a loud voice without time for reflection, will 
surely read EPONGE. If the uncovered eye is really amauro- 
tic, the red glass does its work of effacement for the healthy eye, 
all that traced in red disappears, and the patient reads the word 
LION as quickly as he reads EPONGE without the interposi- 
tion of the red glass. 

" To render more difficult for the simulator the mental sub- 
traction of the red, one may employ other colors in tracing the 
parts of the letters so as to make them polychromatic. Yellow 
should be avoided, as it is difficult to see it at a certain distance, 
and the perception of it is annihilated by the red glass. 

" Finally, if one wishes to disturb stiU more the simulator, one 
may, while placing the red glass before the good eye, place a 
glass strongly tinted in green before the suspected eye. If bi- 
nocular vision is preserved, the word will be read in its entirety. 

" It is not sufficient for the military surgeon to be able to 
affirm that an eye pretended amaurotic or strongly amblyopic 
is not so ; it is necessary that he may be able to say whether 
the acuteness of vision of that eye is superior or inferior to i for 
the right eye, and ^ for the left eye. Nothing is easier than to 
give to the characters in color dimensions clearly defined and 
fit to serve for the determination of the acuteness of vision. 
We make use of a red glass, a green glass, and small tablets. 
Our red glass is rectangular in shape, 10X5 cm. We recom- 
mend a glass of an intense red and of demi-double quality as 
we find it at all glaziers'. Same dimensions and recommenda- 
tions for the green glass. Our tablets have the dimensions of 
loto cards, which renders them easy to carry. The characters 
which we have adopted are those of the type of the scales of 
Snellen ; they have among other advantages that of being easy 



SIMULATED BLINDNESS. 25 

to trace with brush and water-color upon paper ruled in milli- 
metres, i.e., architect's paper. Take the paper of which the 
ruling is brownish-red in preference to that of which the ruling 
is in blue. Avoid tracing in pencil the contour of the letters, 
above all in the parts which ought to be tinted red. Do not 
make use of carmine, but of vermilion or cinnabar. 

" We confine ourselves to characters of 3, 4, and 5 mm. in 
size, which are visible to the normal eye at 6.66 m., 13.33 m., 
and 16.66 m. ; and consequently at 1.66 m., 3.33 m., and 4.16 
m. by an eye of which the vision is reduced to i, and at 0.55 
m., 1.11 m., and 1.38 m. by an eye of which the vision is re- 
duced to ■^. 

" For the illiterate we substitute for letters, points, marks, 
crosses, which may become themselves points, and horizontal 
or vertical marks ; figures of playing cards, etc. 

" We advise placing the tablets well in front of the light to 
avoid the chances of error which might come from the reflec- 
tions and dulness given to the characters by the colored glasses 
employed. As an example of the results to which we may come 
by the use of glasses and colored characters we consider it of 
some interest to give the following observation : It was concern- 
ing a young soldier of our regiment who for three weeks declared 
to his immediate superiors that he did not see with his right 
eye. This man, endowed with a subtle intelligence, had taken 
care to prepare the way by saj'ing in his company that he had 
dissimulated his infirmity at the conseil de revision, and since 
his enlistment, in order not to be exempted or invalidated. 
He wished to avoid marriage, and, moreover, he desired to satisfy 
his military obligations. But he had not counted on target 
practice, and in fact, to his great regret, he could not dissemble 
any longer. 

" This good apostle, to whom nothing was wanting, not even 
a contusion of the superciliary arch from the kick of a horse, 
was submitted to an examination. We proceeded to our exam- 
ination with the aid of M. Maupetit, surgeon-major. 

" Nothing was found with the ophthalmoscope — the fundus 
was normal. 

" Our man could read well with the left eye, but with the 
right eye he did not distinguish the A from Z, whatever the 
size of the letters. 



26 VISION AND AUDITION — WOODWARD. 

" We place a red glass before his left eye, leaving the other 
uncovered, and the reading of the black characters is quite easy. 
Nothing surprising thus far. But behold, when we substitute 
colored characters for black characters, the vision is declared 
abolished for both eyes ! The presontation of colored letters had 
aroused the suspicion of our man, his strange reply aroused ours. 
The idea occurred to us to let him understand that this was not 
really extraordinary and that it could be dependent upon trouble 
with the sight of the right eye (the eye said to be amaurotic). 
We cover that eye with the palm of the hand, and the left eye 
recovers its function ! The colored characters are read through 
the red glass ! We substitute a green glass for the palm of the 
hand placed before the right eye, at the same time a red glass 
is placed before the left eye; and we present another table. 
This table is read in detail as if nothing had been traced upon 
it in red. The fraud was thenceforth manifest. 

" A final test showed us to what degree of skill our simulator 
pretended. We place a red glass before the eye declared good, 
we leave uncovered the eye declared amaurotic, and we present 
some lines of writing of a yellow color. The man sees nothing 
and cannot read. Arguing then as before that the vision may 
be affected by the trouble in the right eye, we cover the right 
eye and the reading goes freely. That was an irreparable dis- 
aster for the pretended sincerity of the simulator in question ; 
for with the right eye covered, and the left eye concealed behind 
a red glass, he ought to see absolutely nothing (we have said 
above that red glasses prevent the perception of clear yellow). 
How then could he read? He did not read, he recited from 
memory what he had had time to learn before we had closed 
the right eye. Moreover, all that had been read had been read 
under conditions which enabled us to declare that his vision was 
normal." 

Many other tests for the detection of simulated blindness 
have been devised. The reader is referred for a description of 
them to the writings of Kugel,' Baudry,^ Bravais,' and Nieden.' 

' " Uebei- die Diagnose von Simu- lateral par les Verres colorees de 

lation der Amaurose und Ambly- Snellen, " Bull, et Mem. de la Soc. 

opie," Wiener med. Wochen., 1889. Fran?. d'Ophthal., 1883-84. 

'^ " Simulation de 1' Amaurose et ^ "Ueber die Simulation von 

del'Arablyopie," Paris, 1889. Augenleiden und die Mittel ilirer 

' " Simulation de 1' Amaurose uni- Entdeckung, " Wiesbaden, 1893. 



SIMULATED BLINDNESS. 27 

Congenital amaurosis and congenital amblyopia are not un- 
common. And amaurosis and amblyopia ex anopsia are not 
uncommon. The anatomical structure and the physiological 
function of such eyes are normal so far as we can discern, ex- 
cepting that the vision is very much reduced. Strabismus, 
convergent or divergent, is often associated with such an amau- 
rosis or amblyopia. A difference in the refraction of the 
eyes is, however, much more regularly found. As a rule, 
the refraction is hypermetropic, or an astigmatism of high 
degree is found, or a combination of the two exists. The dif- 
ference in the refraction of the two eyes is such that the patient 
will use the one that gives him least strain (smaller error of re- 
fraction). Inasmuch as the condition is one of long-standing 
— from birth or early childhood — the patient has never enjoyed 
perfect binocular vision. Experience has taught him to see 
everything with one eye. But a person who has enjoyed clear 
binocular vision is very much disturbed for some weeks or 
months after losing one of his eyes. Appreciation of perspec- 
tive is practically suspended for some time, and obliteration of 
so large a section of the field of binocular vision causes at first an 
awkwardness and a hesitation in the patient's movements, that 
is not observed in one whose eye has been amaurotic or am- 
blyopic from birth or early childhood. 

Monocular amaurosis or amblyopia may be innocently 
claimed by children, or even by older patients. Association 
with one who has some marked ocular abnormality may sug- 
gest to a child the existence of some trouble with one of its own 
eyes. Or, the statement that one of its eyes is blind will some- 
times lead a child to insist positively and persistently that it is 
so. There is no difficulty in proving the truth in these cases. 
On the part of the patient there is no desire to deceive, and when 
it is proven to him that he sees with the eye supposed to be blind, 
the trouble is at an end. Why older subjects should experience 
this sort of amblyopia and amaurosis, it would be difiScult to 
explain. I have never observed it in a patient more than twenty 
years of age. 

True amblyopia and amaurosis may be due to traumatism, 
lightning stroke, local or general hemorrhages, toxic substances 
in the blood, ursemia, diabetes, hysteria, migraine, reflex action, 
and lesions in the brain and spinal cord. 



28 VISION AND AUDITION— WOODWARD. 

Simulated amaurosis of both eyes will be detected only by 
watching the patient and by surprising him into some action 
that will reveal the fraud. General anaesthesia might be tried. 
While recovering from the ansesthetic, the patient would be ofp 
his guard and might then be entrapped. 

Simulated amblyopia of both eyes might be detected by ob- 
serving the variations in the vision from time to time, and al- 
ways under similar conditions of light, etc. If the acuteness of 
vision do not vary, and if it be not possible to detect any evi- 
dence of simulation by watching the patient or by surprises, 
true amblyopia may exist. 

AFFECTIONS OF THE EYE INTENTIONAI.LY PRODUCED. 

Such ocular disturbances are especially common in those 
countries in which military service is compulsory. Conjunc- 
tivitis, keratitis, cataract and mydriasis are the affections com- 
monly observed. In general, the right eye only is attacked. 
A variety of things have been introduced into the eye to pro- 
duce conjunctivitis, e.g., cigar ashes, tobacco, snuff, the seed 
of various kinds of grain, pepper, spirit of wine, brandy, soap, 
common salt, blue vitriol, lunar caustic, plaster, cantharides, 
pus from purulent ophthalmia, pus from a suppurating lachry- 
mal sac, etc. A great variety of foreign bodies have been in- 
serted into the eye for similar purposes. Inflammation of the 
cornea sometimes complicates such attacks of conjunctivitis, 
and patients have occasionally resorted to rubbing the cornea 
with lunar caustic in order to inflame its tissues. Cataract 
has been intentionally produced by thrusting a needle or a knife 
blade through the cornea into the crystalline lens. 

Foreign bodies in the conjunctiva may be buried in granu- 
lation tissue and escape detection. When they lie in the superior 
fornix, they are not easily found. They may lodge there 
for a long time without exciting more than a slight catarrh. 

Artificially induced conjunctivitis is most intense, as a gen- 
eral rule, over the lower eyelid and lower portion of the bulbar 
conjunctiva. Croupous conjunctivitis is excited by caustic sub- 
stances. An eroded spot will be found in the palpebral con- 
junctiva and a corresponding erosion on the opposing bulbar 
conjunctival surface. The course run by artificial conjunctivi- 



AFFECTIONS OF THE EYE INTENTIONALLY PRODUCED. 29 

tis differs from that of other varieties in that it is especially 
obstinate in yielding to treatment. After having brought about 
a considerable improvement in the eye's condition, at the next 
visit one may find that the disease has broken out afresh.' More 
of the exciting cause had been introduced into the eye. In 
order to cure such cases and unmask the malingerer, absolute 
control over the patient is a necessity. When it is no longer 
possible for him to keep up the irritation, the inflammation 
may be caused to subside. 

Solutions of atropine and ointment of belladonna are the prep- 
arations employed to cause mydriasis. The full effect of these 
preparations is maximum dilatation of the pupil and complete 
paralysis of the muscle of accommodation. From one to two 
weeks elapse after discontinuing the applications before the 
effects entirely disappear. 

The differential diagnosis of mydriasis induced by a drug, 
from that due to trauma, glaucoma, or real amaurosis is estab- 
lished by virtue of the following : The pupil is more widely 
dilated ; ruptures of the sphincter of the iris, which are present 
in cases of marked traumatic dilatation, are wanting ; ophthal- 
moscopic evidence of glaucoma does not exist; the accommo- 
dation is paralyzed either partially or completely. Moreover, 
illumination of the sound eye causes consensual contraction 
of the pupil in an amaurotic eye ; on the contrary, however, 
illumination of an amaurotic eye does not cause consensual 
contraction of the pupil of the sound eye ; and illumination of 
an amblyopic eye causes slow and weak contraction of the pupil 
of its fellow. Slight inequality of the pupils without paralysis 
of the accommodation may be due to pathological changes in 
the brain or spinal cord, or to a difference in the refraction of 
the eyes.' 

'Nieden: "Ueber die Simulation von Augenleiden," etc., 1893, p. 245. 



CHAPTER III. 
INJURIES or THE ORBIT. 

Contusions op the Margins op the Orbit. 

Contusions of the margins of the orbit may excite periosti- 
tis, caries or necrosis of the bones at the site of the injury in 
scrofulous and badly nourished persons, especially children, 
whether extravasation have occurred or not. Such injuries are 
among the most frequent causes of those diseases in that class 
of patients.' The inflammation of the periosteum may termi- 
nate in resolution ; but, as a rule, suppuration with the forma- 
tion of an abscess takes place. Death of the bony structure 
may follow. The process may run an acute or a chronic course. 
It may be circumscribed, or it may extend to the adjacent orbi- 
tal walls. 

Especially when the inflammation runs a chronic course, the 
cicatricial tissue resulting therefrom will cause ectropium, or 
lagophthalmus, or it may restrict the movements of the eyeball. 
This may be the end of an acute attack as well. Periostitis, 
with or without caries or necrosis, may be complicated by a 
severe attack of orbital cellulitis resulting in the formation of an 
abscess in the orbital cellular tissue. The consequence of this 
may be inflammation and atrophy of the optic nerve, and con- 
sequent partial or complete blindness ; or the patient may die 
from extension of the morbid process to the brain or its mem- 
branes. 

When the inflammatory process involves the roof of the 
orbit, meningitis, or abscess in the frontal lobes of the brain, 
may set in and terminate life. 

Contusions of the margins of the orbit may be productive of 
a lesion having clean-cut edges and resembling very closely an 
incised wound. Its usual site is near the superior margin of 

'Berlin: " Graefe-Saemisch Handbuch d. ges. Augenheilkunde, " ri., 
pp. 530, 581. . 

30 



INDIRECT FRACTURE OF THE ROOF OF THE ORBIT. 31 

the orbit, but it has been observed over the inferior margin. 
The wound extends to the bone, the sharp edge of which severs 
the soft parts as they are driven upon it by the contusing force. 
For this reason, the superficial wound is less extensive than 
the subcutaneous wound. Beneath the integument, the soft 
parts are lacerated and separated to a greater or less extent 
from the subjacent bone. Such lesions are apt to suppurate.' 

Fracture of the Margins of the Orbit. 

Contusions may result in fracture of the margins of the orbit 
on which they impinge. The force of the blow is generally 
sufficient to produce a compound fracture, but the fracture may 
be a simple one. Owing to its more exposed situation, the supe- 
rior margin is most frequently affected. 

An excessive force may fracture or dislocate the malar bone. 
This will be evident from the deformity. Moreover, if anaes- 
thesia involving the area supplied by the infra-orbital nerve be 
noted, it is probable that the inferior margin of the orbit has 
been fractured. 

Uncomplicated fractures of the orbital margins, as a rule, 
lead to deformity only. Berlin cites a case of fracture of the 
infra-orbital margin from a stone bruise which terminated 
fatally by tetanus.^ A compound fracture may inflame, suppu- 
rate, and endanger the patient's life as well as his eye. 

When a compound fracture of the orbital margin is compli- 
cated by fissure of the roof of the orbit, the gravity of the in- 
jury is intensified. Meningitis, or abscess of the brain, may 
develop, and carry off the patient. Such fractures of the vault 
of the orbit are less dangerous than direct fractures in which 
the orbital margin is not involved. 

Indirect Fracture of the Roof of the Orbit. 

Injuries productive of fracture of the base of the skull fre- 
quently cause fracture of the roof of the orbit. The fracture in 
such cases is one in continuity. According to Berlin,' Prescott- 
Hewitt's statistics from St. George's Hospital give 23 cases of 
fracture of the roof of the orbit in 68 fractures of the base of 

' For medico-legal case, see Ber- ^ Loc. cit. , vi. , p. 584. 
lin, I.e., p. 582. =" Loe. cit., p. 604. 



32 VISION AND AUDITION— WOODWAED. 

the skull. Von Holder ' found in 124 cases of fracture of the 
base of the skull, that in 79 the roof of the orbit was also frac- 
tured. These lesions belong especially to the domain of general 
surgery. When, as sometimes happens, the victim of such a 
casualty survives, coincident and consecutive alterations in the 
function of his visual apparatus may become a subject for med- 
ico-legal investigation. 

Immediately on recovering consciousness, the patient may 
complain of blindness of one or of both eyes. Failure of vision 
may be owing to lesion of both optic nerves or of the chiasm, 
by fragments of bone. Hemorrhage at the base of the brain 
may impair the function of the optic nerves, or of the optic 
tracts. Blood may be extravasated into the sheaths of the optic 
nerves and cause blindness. When the optic nerves, the chiasm, 
or the optic tracts are lacerated by spiculee of bone, the resulting 
disturbance of function will be permanent. When hemorrhage 
interferes with the conductivity of those structures, the loss of 
function may be transient. The differential diagnosis between 
these sets of cases may be established only by the conditions 
observed after some weeks have passed. Restoration of sight 
would imply that the conducting apparatus had not been torn 
by fragments of bone. 

Failure of vision may supervene not as an immediate conse- 
quence of the traumatism, but as a result of consecutive inflam- 
mation of the membranes of the brain, or of the brain tissue itself. 

Indirect violence may fracture the roof of the orbit alone. 
Berlin " collected 27 cases of this description. In 1890, KoUer 
reported 2 cases,' and, in 1893, Callan* reported 8 cases of the 
same nature. Similar cases have come under the writer's ob- 
servation. The clinical picture of such accidents is a clear one. 
The patient receives a blow from a club, a stone, or the fist, in 
the orbital region, or he falls from a height (15 to 30 feet) or is 
thrown from a carriage or other rapidly moving vehicle (tobog- 
gan) and receives a contusion near the eye, or his head may be 
compressed under a wagon-wheel or a horse's hoof. One of 
Callan's patients fell down three steps of a stairway, struck the 
edge of an open door, and was wounded above his left eye. 

• " Graef e-Saemisch Handbuch d. ' N. Y. Med. Jour. , April 12th, 1890. 

ges. Augenheilkunde," vi., p. 604. * N. Y. Eye and Ear Infirmary 

2 Loc. cit. Reports, vol. i., p. 1, 1893. 



INDIRECT FRACTURE OP THE ROOF OF THE ORBIT. 33 

Symptoms of concussion of the brain are more or less marked. 
The patient may fall to the ground unconscious and remain in 
that state for many hours. Two or three days may pass before 
memory is restored. Or, the patient may not become uncon- 
scious, but complain of dizziness and faintness. Bleeding at 
the nose and vomiting of blood are common symptoms. On 
recovering consciousness, the patient may call attention to blind- 
ness on the injured side. Or, as happened in Callan's second 
case, the patient, whose consciousness is not suspended by the 
injury, may assert positively that blindness immediately fol- 
lowed the blow. The eyelids on the injured side will be discol- 
ored and cedematous. Subconjunctival extravasation and even 
exophthalmus may be present. Deviation of the eye inward, 
or more frequently outward, or even ophthalmoplegia may be 
found. 

Ophthalmoscopic examination will give a negative result 
immediately after the injury. Nothing will be found in the 
eye to account for the blindness, excepting in cases where there 
has been a contusion, or other direct injurj' of the eyeball. 
Vieusse reported the occurrence of complete optic atrophy 
twenty-four hours after the injury, but Berlin ' regarded it as an 
example of ischsemia of the optic nerve and retina. Callan ^ 
observed atrophy of the optic nerve one week after the injury. 
The appearance of the change may be delayed until the fifth 
week.' 

In all of Callan's cases, atrophy of the optic nerve on the 
injured side was observed. Berlin refers to the fact that among 
27 cases, in which visible traces of injury to the forehead and 
orbital margin of the right side were found, only one showed 
blindness of the opposite (left) eye. 

Only one case of one-sided amaurosis in Berlin's statistics re- 
covered, and two improved. In 10 cases, the vision of both eyes 
was affected; in some amblyopia, in others amaurosis. Five 
recovered, or improved. In 1 case, one eye remained blind, 
in 2 cases, both eyes remained blind, in the remaining cases the 
result was not known. Eecovery was not noted in the other 
cases referred to. 

The lesions in the class of injuries under consideration are 
believed to be fracture of the roof of the orbit involving the 
' Loc. (At. ^ Loo. cit. ' Berlin, I.e. 

III.— 8 



34 VISION AND AUDITION — WOODWARD. 

optic foramen, laceration of the optic nerve, and hemorrhage into 
its sheath. Direct proof that it is so, is, obviously, not obtain- 
able ; for the injury is seldom, if ever, fatal. 

Direct Fracture of the Roof of the Orbit, Not 
Involving the Margin. 

These fractures are compound. They are caused by direct 
violence, e.g., thrusts of pointed instruments into the orbit (hay- 
fork, rapier, foil, sword, umbrella, walking-stick, knife, pointed 
sticks, etc.) or falls upon similar things (pencil-holders, etc.), or 
gunshot wounds, — even the missile from a blow-gun has frac- 
tured the roof of the orbit. Owing to the fragile nature of the 
bone in this region, a pointed weapon driven with moderate 
force into the orbit in an upward and backward direction will 
cause a fracture. The extreme gravity of the lesion depends 
upon three things: the violence inflicted upon the brain; the 
occurrence of intracranial hemorrhage; and the development 
of abscess of the brain or of meningitis. 

Berlin' collected 53 examples of this lesion: 41, or 79 
per cent, died ; of these, 34 per cent died from the immediate 
effects of the injury; 11, or 21 per cent, recovered more or less 
completely — 3 had hemiplegia, 1 suffered from headache, and 1 
was weak-minded. 

Oallan reports one case of direct fracture of the roof of the 
orbit following the thrust of a foil between the nose and the eye- " 
ball. His patient recovered with atrophy of the optic nerve 
and divergent strabismus. 

The upper eyelid, especially near the inner angle of the eye, 
is commonly punctured. Occasionally the weapon enters be- 
tween the open eyelids and passes through the conjunctiva into 
the orbit. When this happens the existence of a wound may 
be overlooked. The eyeball is seldom injured. Having trans- 
fixed the integument of the eyelid and the conjunctiva, the 
weapon passes through the orbital cellular tissue, reaches the 
bone, fractures it, and may then lacerate the substance of the 
brain and even rupture one of the large blood-vessels. Frag- 
ments of bone may be driven into the brain, and a foreign body 
{e.g., the ferule of an umbrella) may be lodged in the brain or 

' Loa. cit. , p. 603. 



DIRECT FRACTURE OF THE ROOF OP THE ORBIT. 35 

in the fracture when the weapon is withdrawn, thus projecting 
into both the orbit and the pranial cavity. The course of the 
wound is not easy to follow through the soft parts. For, as 
the blow is delivered, the eyeball rolls upward and is pushed 
before the weapon. When the weapon is withdrawn the globe 
resumes its usual position, and thus the tract of the wound may 
be so distorted that a probe could not be made to follow it. 
Moreover, probing of such wounds must be done with caution 
lest further injury to the cerebral tissue be inflicted. 

Hemorrhage from the wound and into the orbit, prolapse 
of orbital fat, and the appearance of cerebral tissue in the dis- 
charges, are indications respecting the depth to which the weap- 
on may have penetrated. Among the cerebral symptoms, sudden 
loss of consciousness is noted in a large number of cases. The 
patient may die unconscious. After recovering consciousness, 
the patient's symptoms range from headache, vertigo, weakness 
of intellect, and prostration, to paralysis, unconsciousness, and 
coma, ending in death. The symptoms are those of intra-cra- 
nial hemorrhage, of injury to the brain substance, of cerebral 
abscess, or of meningitis. 

Not all persons injured in this way suffer from cerebral 
symptoms immediately after the injury. A certain number do 
not have cerebral symptoms. According to Berlin,' the num- 
ber of such cases is relatively large ; he refers to 14. Both phy- 
sician and patient may be disposed to consider the injury a 
trivial one, owing to the apparently insignificant wound and 
the general condition of the patient; while, later on, stupor, 
vertigo, convulsions, unconsciousness, sopor, and a febrile move- 
ment may develop and kill the patient, or he may die suddenly. 
The following cases illustrating various phases of this class of 
injuries are cited by Mackenzie." 

" Case 14. — Euysch relates the case of a man who was wounded in 
the left orbit with the end of a stick, not particularly sharp. The injury 
appeared of little importance, yet the patient died soon after receiving 
the wound. The magistrates appointed Euysch to examine the body, 
in order to discover the cause of sudden death. Externally, he observed 
a slight degree of ecchymosis at the upper part of the eye, but on re- 
moving the calvaria, he found that the wound had penetrated to a con- 
siderable depth into the brain. 

'ioc.cif., p. 603. Mackenzie :" Dis- ^ Loe. cit., p. 53 et seq. 
eases of Eye," Phil., 1855, p. 60. 



36 VISION AND AUDITION — WOODWARD. 

" Case 15. — Peter Borel mentions a still more remarkable case of a 
man who was wounded with a sword in the left orbit. Thinking the 
wound had not penetrated deep, he merely covered it with plaster, after 
which he walked two leagues, and ate and drank heartily with his com- 
panions, exactly as if he had been well, being affected with no pain. 
Next morning he was found dead. The skull was opened, when the 
wound was found to have penetrated the cerebellum. 

"Case 16.— A man was brought into the London Hospital, April 
12th, 1832, with a lacerated wound of the right upper eyelid. He stated 
that, while working on board ship discharging coals, a hook used for 
raising the coals caught him by the eye, so that he was elevated to the 
height of several feet. His companions, observing what had happened, 
suddenly let go the rope, so that the poor fellow fell heavily on the 
deck. He immediately withdrew the hook himself. On his admission 
to the hospital, he did not appear to be suffering from any serious 
injury. The eyeball was uninjured, and no fracture could be detected; 
his respiration was natural; his pulse 76, fuU, but not more than 
might have been expected in a robust man; pupils obedient to the Ught; 
no pain in the head. . . . He passed a quiet night. . . . The next morn- 
ing he had verylittle pain in the head. . . . Symptoms of compression 
of the brain came on very suddenly in the evening. His breathing 
became stertorous; his pupils contracted and insensible to the stimu- 
lus of light; pulse 52, and laboring; he could not be roused by any 
noise. At this time a quantity of blood, mixed apparently with cere- 
bral substance, to the amount of about two ounces, escaped from the 
wound. . . . He lingered in this state until two o'clock the next morn- 
ing, when he died. 

" The orbitary plate of the frontal bone was found to be completely 
smashed, and a considerable portion of the anterior lobe of the right 
hemisphere of the brain wanting, it having escaped through the wound. 

"Case 17. — A countryman, about 55 years of age, was asked by 
one who met him to step out of the way; but as he was carrying a 
heavy burden at the time he could not do so, and therefore refused. 
The other, provoked at this, struck the countryman violently over the 
shoulders with a whip, and when the whip broke thrust the sharp 
end of the broken shaft of the whip in the countrjrman's face. Not appre- 
hending any dangerous effects from the blows which he had received, 
the countryman, with his burden on his back, trudged along after his 
cart, which was loaded with wood, for nearly a quarter of a mile, till 
he arrived at the wood-market, when he instantly dropped down dead. 

' ' Schmid was appointed to inspect the body. On examining the 
head externally he found that the sharp end of the stick had penetrated 
at the inner canthus of the right eye. He endeavored to ascertain 
with the probe whether the wound had reached the brain; but he could 
not on account of the narrowness of the wound. Having opened the 



DIRECT FRACTURE OP THE ROOF OF THE ORBIT. 37 

cranium, the brain and' its membranes at first view appeared sound; 
but, on raising the anterior part of the cerebrum, the nasal extremity 
of the falx was observed to be injured, and it was found that the wound 
had penetrated into the third ventricle, in which lay a considerable 
quantity of clotted blood. 

"Case 18. — A man, standing at the head of a horse which had fall- 
en in the street, was suddenly struck in the face, upon the animal 
raising itself unexpectedly. The blow was so violent that he was 
thrown down by it, but not stunned. He was of the opinion that it 
was not the head of the hoi'se, but some part of the harness, that had 
struck him. There was a bleeding wound between the left eye and the 
nose, about an inch long, dividing the lachrymal canal and the pal- 
pebral tendon. A probe was introduced to the depth of three-quarters 
of an inch into the wound, in the direction of the inner wall of the 
orbit, but without the bone being felt. The left eye was uninjured. The 
right eye, without any perceptible injury, had entirely lost the power of 
vision. Its pupil was dilated to the utmost; and, although its common 
sensibility, as well as its different motions, was perfect, a lighted 
candle held close before it caused no contraction of the pupil, nor any 
sensation of light. The patient answered questions promptly and 
clearly, and evinced no symptoms of injury extending to the brain, ex- 
cept that he complained of a little headache. The bones of the nose were 
examined, but no crepitus could be felt; neither was there any ecchymo- 
sis to indicate injury on the right side. Delirium, however, and stupor 
supervened on the following day. ... In the evening convulsions 
came on; the left arm and leg were stiff and contracted, while the right 
extremities were in constant motion. The pupil of the right eye was 
now found to be contracted. . . . The left side and extremities sub- 
sequently became paralytic, while the right was tranquil. He died 
convulsed on the fifth day after the accident. 

"On dissection, the brain and its membranes were found loaded 
with vessels, and there was a copious deposit of lymph between the 
arachnoid and the pia mater, over both hemispheres. A large accumu- 
lation of serum, with purulent matter di£f used in it, was present in both 
lateral ventricles. The whole lower surface of the anterior lobes was 
adherent to the dura mater, by means of coagulable lymph. The optic 
nerves being exposed, the right was seen to be torn completely through 
or its ends joined only by delicate membrane close to the foramen opti- 
cum. The base of the brain, from the medulla oblongata to the chiasma, 
was thickly covered with a layer of lymph, which obscured the roots of 
the nerves. In the posterior part of the right anterior lobe, close to the 
injured part of the optic nerve, and approaching to the anterior cornu 
of the lateral ventricle, the brain was bruised, softened, and ecchymosed. 
The cause of the laceration of the brain and tearing across of the optic 
nerve was found to be a fracture of the cerebral plate orf the ethmoid 



38 VISION AND AUDITION— WOODWARD. 

bone, with part of the sphenoid forming the roof of the foramen opti- 
cum. The fractured fragment of bone was found loosely attached by 
dura mater to the forepart of the sella turcica, above the right cavernous 
sinus. On introducing a probe into the external wound, it could be 
made to pass, by a slight degree of management, into the crushed part 
of the ethmoid, and to appear within the skull. . . . 

" Case 21.— A soldier was brought to the hospital at Brest, at eleven 
o'clock in the evening, having been wounded with a pitchfork at the 
middle of the left upper eyelid. The wound was oblique, about three 
lines in length, and appeared to implicate only the skin and orbicu- 
laris palpebrarum; there was very little blood discharged; the eyelid was 
distended and the conjunctiva inflamed. The apparent simplicity of 
the wound, the goodness of the pulse, and the free exercise of all func- 
tions, led to a favorable prognosis; the patient asserted that he had 
experienced nothing particular at the moment of the injury, and had 
scarcely been stupefied by it. . . . The patient rested during the night; 
next day he was quite lively, walking about the wards, complaining 
only of slight pain Ln the wound, and even eating with appetite. The 
same day, at seven in the evening, he was seized with convulsions, 
which were supposed by his attendants to be epileptic. The day after, 
he was kept from food, and bled at the arm; the convulsions returned, 
and he was bled at the foot. Vomiting, uneasiness, agitation, and 
delirium came on; the pulse became smaller and contracted; cold 
sweats succeeded, and the patient died at two o'clock next morning. 

"On dissection, the eyelids were found oedematous, and the wound 
had already closed. On cutting through the upper eyelid and orbicu- 
laris palpebrarum, a circumscribed collection of pus was found in the 
orbit between its roof and the levator palpebrse superioris. This col- 
lection of pus communicated with the cranium through the orbitary 
plate of the frontal bone, which had been penetrated by one of the 
prongs of the fork. After removing the eyeball, the inferior wall of 
the orbit was found fractured, and depressed almost completely into 
the maxillary sinus. This fracture is compared by M. Massot, the 
narrator of the case, to the depression which might be produced on the 
surface of an egg, by pressing it inward with the thumb. On remov- 
ing the calvaria, the dura mater appeared in a morbid state at that 
place, the anterior fossae of the base of the cranium were covered with 
pus, the anterior lobes of the cerebrum were in a state of suppuration, and 
the rest of the brain healthy. M. Massot thinks it probable that, when 
the fork was pushed through the orbit into the cranium, the eyeball 
being fixed and violently pressed between the fork and the floor of the 
orbit, the thin plate of the superior maxillary bone could not resist this 
pressure, but sank by continued action of the fork upon the eyeball. 

"Case 31. — A lieutenant in a Highland regiment, running on a 
dark night to escape a shower of rain, came in contact with an irritable 



DIRECT FRACTURE OP THE ROOF OF THE ORBIT. 39 

old man, who made a thrust at him with an umbrella, the point of 
which struck him immediately beneath the left eyebrow. The wound 
was attended with so little pain or shock to the system, that the gentle ■ 
man walked a distance of at least half a mile, to Sir Philip Crampton's 
house; and having mentioned the occurrence as one to which, how- 
ever, he attached no importance, begged Sir P. to look at the wound 
on the eyelid, which still continued to bleed slightly. Sir P. found a 
wound of about three-fourths of an inch in length in the upper eye- 
lid, exactly in the seat of the fold formed in this part by the action of 
opening the eye, on looking up. When the eyeball was so turned, 
there was no appearance of wound; but when the eyelid was drawn 
downward, the wound gaped and showed the conjunctiva, which 
still completely covered the upper portion of the ball of the eye. 
Vision was quite unimpaired. The wound having been united by two 
points of suture, the patient took his leave and walked home. Sir P. 
called on him next morning, and found him at breakfast, making no 
complaint, but of some stiffness in the eyelid. Next morning at seven 
o'clock, Sir P. was called to him in a hurry, and found him in so strong 
convulsions that it was with difficulty two persons were able to keep 
him from working himself out of bed. The convulsions continued, 
with short intervals of coma, till eight or nine o'clock in the evening, 
when he expired. 

"At the post-mortem examination it was found that the brass fer- 
rule of the umbrella, nearly two inches long, had penetrated the orbi- 
tal plate of the frontal bone, and was lodged in the substance of the 
left hemisphere of the brain; it was imbedded in a thin coagulum of 
blood, which extended into the left lateral ventricle; both ventricles 
contained a small quantity of bloody serosity. 

" Case 25. — A laborer thrust a long lath, with great violence, into 
the inner canthus of the left eye of another laborer. It broke o£f quite 
short, so that a piece nearly two inches and a half long, half an inch 
wide, and above a quarter of an inch thick, remained in his head, and 
was so deeply buried that it could scarcely be seen or laid hold of. 

' ' He rode with the piece of lath in him above a mile, to Barnet, where 
Mr. Morse extracted it with difficulty, it sticking so hard that others 
had been baffled in attempting to remove it. The man continued dan- 
gerously ill for a long time; at last he recovered entirely, with the 
sight of the eye and the use of its muscles; but, even after he seemed 
well, upon leaning forward he felt great pain in his head. 

"Case 26. — Percy had under his care a fencing-master, who in an 
assault received so furious a thrust from a foil on the right eye, that 
the weapon penetrated nearly half a foot into the head, and broke 
short. The man fell down in a state of insensibility, and very soon 
the supervening swelling was so great as to conceal the foreign body. 
In order to lay hold of it, Percy opened and evacuated the contents of 



40 VISION AND AUDITION — WOODWARD. 

the eyeball. His forceps not being strong enough, he sent to a clock- 
maker in the neighborhood, and borrowed from him a pair of screw 
pincers, with which he laid hold of the broken end of the foil, and 
thus succeeded in extracting it. The fencing-master died some weeks 
after, more from the consequence of intemperance than of the injury. 
"Case 33. — Mr. White relates the case of a person, to whom it hap- 
pened that, as he sat in company, the small end of a tobacco-pipe was 
thrust through the middle of the lower eyelid. It passed between the 
globe of the eye and the inferior and external circumference of the 
orbit, and was forced through that portion of the os maxillare which con- 
stitutes the lower and internal part of the orbit. The pipe was broken 
in the wound, and the part broken off, which, from the examination 
of the remainder, appeared to be above three inches, was quite out 
of sight or feeling, nor could the patient give any account of what had 
become of it. The eye was dislocated upward, pressing the upper eyelid 
against the superior part of the orbit; the pupil pointed perpendicularly 
upward, the depressor oculi was upon the full stretch, and the patient 
could see none with that eye. Mr. White applied one thumb above 
and the other below the eye, and after a few attempts at reduction it 
suddenly slipped into its socket. The man instantly recovered perfect 
sight, and suffered no other inconvenience than that of a constant 
smell of tobacco-smoke in his nose, for a long time after, for, as he in- 
formed Mr. White, the pipe had just been used before the accident. 
About two years afterward he called upon Mr. White, to acquaint him 
that he had, that morning, in a fit of coughing, thrown out of his 
throat a piece of tobacco-pipe, measuring two inches, which was dis- 
charged with such violence as to be thrown seven yards from the place 
where he stood. In about six weeks he threw out another piece, meas- 
uring an inch, in the same manner, and never afterward felt the least 
inconvenience. 

"Case 34. — A boy of 14 years of age was struck by an arrow, while 
amusing himself in his playground. It stuck fast in the orbit; but the 
boy pulled it out, and threw it on the ground. A surgeon arrived, to 
whom the playfellows of the boy who was wounded showed the arrow, 
deprived of its iron point. With a probe the surgeon attempted to 
examine the wound; but, on the boy fainting, he desisted, so that the 
iron point was left in the orbit. The external wound healed, and the 
boy recovered; the eye remained clear and movable, but deprived of 
sight. This happened in the beginning of August, 1594, and not hing 
more was heard of the iron point till October, 1624; when, after an 
attack of fever and catarrh, with a great deal of sneezing it descended 
into the left nostril, whence, taking the way of the fauces, it came into 
the mouth and was discharged. During the whole thirty years and 
three months that it had remained in the head, it had not been produc- 
tive of any pain. 



FRACTURE OF THE INNER WALL OF THE ORBIT. 41 

"Case 22.— The son of General E., a student at the Polytechnic 
School in Paris, received, in fencing, the end of the foil through the 
roof of the orbit, and became hemiplegic on the opposite side of the body. 
The eye was saved. 

"Case 23. — Thomas Hale, aged 35, was assisting in hay-making. 
A scaffolding had been erected at the side of the hayrick; and while 
his companion, a' man named Joslyn, was in the act of throwing some 
hay upon it, the pitchfork missed the hay, and struck Hale in the right 
eyebrow. Instead of drawing the pitchfork out, Joslyn, under the im- 
pression that he had caught the hay, thrust it farther in, the one prong 
entering Hale's orbit, while the other glanced over the outside of his 
head. 

"When the prong was withdrawn, which was accomplished with 
diflBculty, Hale turned to leave the field, having the impression that 
his eye had been driven out of his head; but he had not proceeded more 
than five or six yards before he fell, his left side crippling under him. 
In other respects he recoveredj but the palsy continued, the fingers of 
the left hand being contracted, and the left foot swinging about, 
although he became able, in the course of some months, to walk at the 
rate of a mile in thirty minutes. Dr. Eoe, who published the case, 
had given a trial to strychnia internally, and to electro-magnetism, 
without any very striking improvement. Hale continued to taste, 
smell, and see as well as ever." 

Fracture of the Inner Wall of the Orbit. 

These fractures may be either direct or indirect. When di- 
rect they are due to gunshot wounds, blows from umbrella han- 
dles, etc., falls upon iron hooks, etc., injury bj' the calks of 
horseshoes, etc. Indirect fractures may be due to falls, blow 
of fist, etc. Direct fractures are compound, and may be recog- 
nized, as a rule, without much difficulty. The diagnosis of indi- 
rect fracture is indicated by hemorrhage from the nose and em- 
physema of the orbit. Emphysema of the orbit is a crepitating 
swelling produced by the entrance of air into the areolar tissue 
through the fracture, when the patient blows his nose or sneezes. 
It may occur in fracture of the roof of the orbit, the air enter- 
ing the areolar tissue by way of the frontal sinus. This is un- 
common. It may occur also in fracture of the floor of the orbit ; 
then the antrum is the avenue by which the air reaches the site 
of the lesion. Emphysema of the orbit is, however, generally 
due to fracture of the inner wall. These lesions may be com- 
plicated by fracture of the roof of the orbit. Ordinarily they 



42 VISION AND AUDITION — WOODWARD. 

do not threaten the patient's life. Deformity may result from 
them. 

Fracture op the Floor op the Orbit. 

They may be gunshot fractures, or they may be due to heavy 
blows upon the face, or they may be caused by a force pushing 
the eyeball through the bone. 

Fracture of the External Wall op the Orbit. 

Considerable violence is necessary to cause these fractures. 
They are usually compound fractures and occur most commonly 
in gunshot wounds. Extensive fractures of this wall may open 
the cranial cavity, and endanger life. Fissures extending along 
the base of the skull may occur as a complication. Some de- 
formity of the face remains. 

Wounds op the Soft Parts op the Orbit, Not In- 
cluding Injuries to the Eyeball. 

Sword-thrusts, thrusts of pointed sticks, canes, umbrella 
handles, knife blades, etc., or missiles like fragments of iron, 
copper, or stone, bird-shot, bullets, etc., sometimes wound the 
soft parts in the orbital cavity without injuring the eyeball. 
The anatomical structures involved in these traumatisms are 
the cellular tissue, the blood-vessels, the ocular muscles, the 
nerves supplying those muscles, the branches of the fifth nerve 
supplying sensation to the cornea, and the optic nerve. In cer- 
tain cases, fracture of one of the walls of the orbit exists as a 
complication: when thereof of the orbit is involved, the gravity 
of the injury is greatly magnified. A weapon or a missile per- 
forates the eyelid, the conjunctiva, and the septum orbitce 
before it wounds the soft parts of the orbit. The blow may 
fall, however, when the eye is open, and then the eyelids may 
escape injury. In general, the blow is delivered point-blank, 
or nearly so, and the weapon commonly enters the orbit to the 
nasal side of the eyeball. 

Merkel found the depth of the orbit to be in men 43 mm., in 
women 40.5 mm. These figures are approximately correct for 
adults. Children's orbits are much shallower; according to 
Lushka, in one instance the measurement was 26 to 27 mm. 



WOUNDS OF THE SOFT PARTS OF THE ORBIT. 43 

After one of these injuries, a foreign body may or may not 
remain lodged in the orbit. Certain effects are observed to fol- 
low traumatisms of the soft parts of the orbit irrespective of the 
lodgment of a foreign body therein. Thus, laceration of the blood- 
vessels is an accompaniment of every wound. The hemorrhage 
is intra-orbital ; its volume depending upon the number and the 
size of the vessels injured (especially arteries) . The bulk of the 
extravasation accumulates in the orbit and only a relatively 
small portion escapes by the wound, which is usually of restricted 
calibre. Accumulation of blood in the orbit displaces the eye- 
ball forward (exophthalmus) toward the point of least resistance, 
and possibly in a vertical or a lateral direction, according to 
the position of the principal bleeding point. Exophthalmus 
may be so marked that the eyelids cannot close over the cornea. 
This state may excite inflammation and ulceration of the cornea 
and terminate in destruction of the eye.' Vision, in average 
cases, may not be affected or it may be very much impaired, 
presumably by virtue of pressure upon the optic nerve by the 
extravasation, or by virtue of the tension of the optic nerve due 
to the altered position of the eyeball, or perhaps by both condi- 
tions working together. In nearly all cases, no ophthalmoscopic 
explanation of the amblyopia or amaurosis will be found. Un- 
less the acuteness of vision is very much reduced, the patient 
will complain of diplopia. 

Eesorption of the extravasated blood, return of the globe to 
its normal position, and restoration of function may, in gene- 
ral, be prognosticated. Still, recovery may not be complete. 
Amaurosis or amblyopia may become permanent, if the resorp- 
tion take place slowly ; or the eyeball may become phthisical by 
virtue of an excessive exophthalmus, as in Berlin's cases. 

The ocular muscles may be injured. According to Berlin," 
the ocular muscles, as regards frequency of the occurrence, are 
injured in the order in which they are named as follows : rectus 
internus, rectus inferior, levator palpehrce superioris, rec- 
tus superior, rectus externus, obliquus superior, obliquus in- 
ferior. The levator palpebrae superioris, as its name signifies, 
simply elevates the upper eyelid, and does not affect the move- 
ments of the eyeball. Division of its fibres gives rise to trau- 
matic ptosis. Partial or complete division of one, or of any 
' Berlin, Z.c, p. 576. ^ Loc. cit. 



44 VISION AND AUDITION — WOODWARD. 

combination of the ocular muscles, will disturb the movements 
of the eyeball and alter the direction of the visual line of the 
affected eye. It is conceivable that bruising of the muscles, 
without division of their fibres, may produce the same conditions. 
While it may be expected that bruising will impair the use- 
fulness of a muscle for a brief period only, both partial and 
complete division of its fibres will produce a permanent impair- 
ment of function, unless operative interference be successful in 
repairing the rent. 

Such lesions cause diplopia with strabismus, or diplopia 
without apparent deviation of the line of sight, according to 
the extent of injury to the muscles. Diplopia will not be pres- 
ent when vision is very much affected, and may not be com- 
plained of when the strabismus is excessive, owing to great 
separation of the images. Strabismus in these patients possesses 
the characteristics of the paralytic varieties. The diplopia like- 
wise is characteristic. Careful observation of the behavior of 
the double images will reveal which muscles are affected, even 
when the injury is a minor one. Malingerers may pretend that 
they see double in consequence of an accident to an eye, or to the 
head. Children sometimes, without intending to deceive, com- 
plain of the same symptom. Such frauds may be detected by 
observing the relations maintained toward each other by the 
double images, since it is not possible for a patient to avoid giv- 
ing answers that do not radically conflict with one another, un- 
less diplopia be really present. Convergence of both eyes and 
diplopia may be produced by voluntary effort, and maintained 
for a few moments at a time. It is also possible to wilfully 
cause convergence of one eye only. A person of my acquaint- 
ance was able to do this ; he could also rotate one or the other 
eye upward at will. Such control of the ocular muscles is very 
exceptional. 

Diplopia with slight rotation of the eyeball is more trouble- 
some to patients than diplopia with marked strabismus ; for, in 
the former, the double images are near together and both are 
constantly seen, while in the latter they may be widely sepa- 
rated and only one of them lie in the field of fixation. Double 
vision is suflicient to incapacitate one for all kinds of work. It 
may endanger life indirectly, by exposing the patient to mishaps 
in the street, or in going up and down stairs, etc. Patients are 



WOUNDS OF THE SOFT PARTS OP THE ORBIT. 45 

obliged to close the affected eye to get about, or they hold their 
heads in strained and peculiar positions to suppress the false 
image. The false image is suppressed at the expense of vision 
in one part of the field. Sense of perspective is wanting. 

Careful suturing of the divided muscle will restore the bal- 
ance of the ocular muscles, in the more simple cases. Unless 
operative interference succeed in this line, the diplopia will be 
permanent. But, after weeks or months, the patient will be able 
to suppress the false image, and learn to compensate for his 
sense of perspective, to some extent. When more than one mus- 
cle is involved in the injury, less benefit may be anticipated 
from operative interference. 

Paralytic strabismus and diplopia are likewise the conse- 
quence of intraorbital lesion of the nerves supplying the ocular 
muscles. These lesions are rare and incurable. 

Intra-orbital branches of the fifth nerve supplying the cornea 
with sensation have been wounded. Resulting ansesthesia of 
the cornea predisposes to ulceration of that structure and hence 
to destruction of the eyeball by inflammation. 

A weapon or missile penetrating deeply into the orbit may 
wound the optic nerve. The central artery of the retina enters 
the optic nerve about 10 mm. behind the eyeball. Division of 
the nerve may be partial or complete, and may occur between 
the point of entrance of the central artery and the eyeball, or be- 
hind that point. Blindness, either partial or complete, is the 
immediate consequence. If the wound lie between the entrance 
of the artery and the globe, the ophthalmoscopic appearances, 
in the early stages, will be similar to those observed in cases of 
embolism of the central artery of the retina. Subsequently the 
nerve atrophies. Division of the central artery before it enters 
the sheath of the nerve will cause similar disturbances. When 
the lesion in the optic nerve lies behind the entrance of the 
artery, the ophthalmoscopic appearances are normal in the early 
days.' After two or more weeks, atrophy of the nerve is ob- 
served. When the atrophy is partial, it is probable that the 
optic fibres were not severed completelj'. 

Fragments of iron, copper, stone, etc., missiles from pistols, 
rifles or shot-guns, pieces of wood, twigs of trees, ferules from 
umbrella-handles or walking-sticks, knife-blades, needles, and 
other bodies may effect a lodgment in the orbital cavity. They 



46 VISION AND AUDITION— WOODWARD. 

may be located in the soft parts, or they may become embedded 
in one of the bony walls and project into the orbit. Foreign 
bodies lodged in the orbit may be large enough to displace the 
eyeball and restrict its movements. The displacement may 
amount to dislocation of the eyeball. When resorption of the 
extravasated blood has taken place, the eyeball will still remain 
displaced, if a large body be lodged in the orbit, and, similarly, 
restriction of the movements of the globe will persist until the 
obstruction is removed. Vision may be destroyed while the 
globe is displaced, but it may return when the foreign body is 
removed and the eye restored to its normal position. When 
the injury is fresh the foreign body may be seen if the wound 
be large, or it may be felt with the probe if the body be not too 
small. Probing, under antiseptic precautions, is advised when 
there is reason to suppose that a foreign body has lodged in the 
orbit. It is the most fruitful means of diagnosis in these cases, 
but it does not always give accurate information.' 

Wounds of the orbit heal promptly, as a rule. Orbital cellu- 
litis and abscess are seldom observed unless the wounds have 
been infected. Even when foreign bodies are lodged in the 
orbit, unless they are of large size or carry the germs of infec- 
tion, the wounds close in a short time. Small bodies like bird- 
shot and bullets of small calibre, and other aseptic or nearly asep- 
tic substances, frequently become encapsulated, and may not give 
rise to any further disturbance. 

The wound may close over the foreign substance, and subse- 
quently open, leaving a discharging sinus. Or the wound 
may not heal, but continue to discharge. Both circmnstances 
are indicative of the presence of extraneous matter in the 
tissues. In such cases, an attempt to find the foreign body 
should be made. In fresh cases, when the position of the body 
is located, it should be removed : a possible exception may be 
made when the foreign body is imbedded in the bony walls at 
the apex, or in the roof of the orbit. The propriety of removing 
foreign bodies imbedded in those portions of the walls of the 
orbit may be questioned. Surgical interference in such injuries 
may sacrifice the patient's life by causing intra-cranial hemor- 
rhage, or inflammation of the brain. Expectant treatment may 
also expose the patient to fatal complications within the cranial 
' See cases cited under direct fractures of roof of orbit, pp. 33-39. 



WOUNDS OF THE SOFT PARTS OF THE ORBIT. 47 

cavity. Between these alternatives, the choice may very prop- 
erly be given to operative interference conducted cautiously by 
the principles of the antiseptic method, as afiEording the patient 
the best chance for his life. If, however, the foreign body have 
become encapsulated and its presence be not causing any serious 
disturbance, no attempt at removal of it should be made, even 
though it be imbedded in the bones separating the orbital from 
the cranial cavity and project into the cerebral substance. 
Operations upon such cases have proved fatal at the hands of 
the best operators.' 

The following case cited by Mackenzie shows the dangers 
encountered in operations on these cases : 

"Case 29. — A girl, 10 years of age, playing along with other chil- 
dren, near a cotton-spinning machine, fell upon one of the pointed 
iron spikes, five or six inches long, on which the bobbin is placed. 
This instrument penetrated to the depth of about two inches into the 
orbit, between the inner wall and globe of the eye, and then broke 
across, so that 3 or 3 lines' length of it projected above the level of the 
skin. Attempts were made to remove it; but so much difficulty 
was experienced that these attempts were not persisted in. Ten days 
afterward, the piece of iron was found protruded to the length of 9 or 
10 lines; a month afterward, it was still more protruded; in fact, it 
now held apparently so slightly, that it was laid hold of with the fingers 
and extracted. Scarcely had this been done, when the child was seized 
with convulsions, and died in a quarter of an hour. The sight had not 
been affected during the residence of the foreign body in the orbit, nor 
had its presence there excited any very marked symptoms. The child 
had always been able to go about." 

The following cases are cited by the same author, and are 
evidence that removal of foreign bodies wedged in the roof of 
the orbit and injuring the cerebral substance is followed by a 
favorable result, in some severe cases : " 

" Case 37.— Sabatier notices an instance of wound with a knif«, 
through an upper eyelid, with injury of the neighboring edge of the 
frontal bone. It was not, he says, till after four hours' work, that the 
surgeon succeeded, by means of a hand- vice, in tearing away the por- 
tion of the knife-blade which remained in the orbit, on account of its 
projectmg so little from the wound. The patient complained of severe 

' Pagenstecher's case, vide " Traite ^ For other similar cases see arti- 

complet d'Ophthalmologie," t. iv., cle on direct fractures roof of orbit, 
p. 800. PP- 33-39- 



48 VISION AND AUDITION— WOODWAKD. 

pain, as if one had been tearing out his eye. No ill consequence fol- 
lowed; the cure was speedy, and without any affection of sight. 

"Case 28.— A laborer, aged 51 years, while cutting wood in a forest, 
stumbled over the root of a tree, and with the whole weight of his body 
drove the end of a file, which he held in his hand, against his left eye. 
The file broke across, and a portion of it remained in the orbit. The 
patient was carried, in a state of insensibility, to a small town some 
miles off, where three surgeons tried by turns, but in vain, to extract 
the foreign body, which, with the probe and the forceps, they felt dis- 
tinctly, through the wound, beneath the middle of the eyebrow. They 
enlarged the wound with the knife, and during three days made re- 
iterated attempts at extraction; but the foreign body continued immov- 
able. On the fourth day, the patient was brought to the surgical clinic 
at Prague. The eyelid was greatly swollen, and in the middle of it there 
was a triangular wound, with inverted edges. The eyeball was motion- 
less, and was so pushed downward and outward that it almost lay 
on the cheek, carrying the lower eyelid before it. The cornea pre- 
sented more than an ordinary degree of lustre. The patient was nearly 
comatose. Fritz endeavored, by means of strong pincers and polypus- 
forceps, to withdraw the foreign body, but these instruments bent 
under the pressure. At last, with a pair of small but very strong lith- 
otomy-forceps, which he grasped with both his hands, he succeeded in 
extracting the piece of the file. 

"It was triangular, measured an inch and a half in length, and was 
denticulated to its point, which was blunt. The patient answered ques- 
tions very slowly, or not at all; his face was pale and sunk, his eyes 
were shut, and he lay motionless, except that he often raised his left 
hand to the left side of his head. Respiration slow; pulse oppressed 
and hard. The wound gaped widely; the eyelid, almost completely 
divided into lateral halves, was of a dark red color, and so much 
swollen as to allow only a small portion of the displaced eyeball to be 
seen. 

"Notwithstanding the repeated use of venesection and of leeches 
and constant cold applications to the eyes, the cornea filled with pus, 
and giving way about the twelfth day, allowed the iris to protrude. 
The cornea was ultimately left in an opaque and atrophied state. The 
wound suppurated abundantly, and for some time a probe could be 
passed along it, in a direction backward and inward, beneath and 
through the orbitary portion of the frontal bone, to the depth of five 
inches, without causing pain. At length the wound closed, the upper 
eyelid remaining palsied. The patient's general health was perfectly 
restored. 

"Case 33. — Marchetti had under his care a beggar, who, asking 
charity rather importunately one summer's day from a Paduan noble- 
man, this testy personage struck the beggar with the handle of his fan, 



TRAUMATIC ENOPHTHALMUS. 49 

in the inner angle of the eye, and with so much force that a portion of 
the fan, three inches long, broke through the orbit, and sank out of 
sight in the direction of the palate. When the man came to the hos- 
pital, Marchetti removed some small bits, which he found sticking in 
the angle of the eye, combated the inflammation, allowed the wound 
to close, and dismissed the patient as cured. In three months he re- 
turned with a large swelling in the palate. When Marcetti cut into 
it, his knife struck upon the handle of the fan, which he immediately 
extracted with a pair of forceps. The patient speedily recovered." 



Traumatic Enophthalmus. 

Traumatic enophthalmus is an uncommon condition in which 
the eyeball sinks into the orbit, in consequence of wounds or 
contusions of the region of the eye. Beer has collected fifteen 
cases that constitute the data of his dissertation, a translation 
of which may be found in Knapp-Schweigger's Archives of 
Ophthalmology.^ The force required to produce enophthal- 
mus is a heavy blow or a severe wound, such, for example, as 
would be inflicted by the horn of a cow. 

In one case (Schapringer's) the enophthalmus disappeared 
after three days. It was permanent in the remaining cases. 
The affected eye was found to lie from 3 to 8 mm. deeper in the 
orbit than its fellow. Vision and mobility of the eye remained 
normal in some of the cases. No cicatrices existed in the re- 
gion of the eye. In other cases wounds of the soft parts, even 
deeply penetrating wounds of the orbit, complicated by fracture 
of the orbital walls, were present. Vision was impaired in these 
cases. 

One case became totally blind : " a soldier whose right eye 
was injured by a falling stick of wood. The sight at once be- 
gan to fail and there was periodic pain above the eye. Seven 
months after the injury, the right lids were retracted as in 
phthisis bulbi, and the palpebral fissure was decreased in size. 
When the upper lid was elevated the ball rolled upward. Pupil 
and fundus normal. In the right eye, there was no vision ; in 
the left, fingers were counted at 10 feet. A pulsating pain in 
the region of the eye, temples, and ears, particularly at night. 
After some months there was complete blindness, while the pain 
and retraction of the ball remained as before. The right globe 
' Vol. xxii. , 1, pp. 98-106. 
, III.— 4 



50 VISION AND AUDITION — WOODWARD. 

lay six lines behind the superior margin of the orbit, the left 
four and one-half lines." 

In most of the cases, the movements of the globe were re- 
stricted by paralysis of the muscles or by cicatricial tissue. 
Homonymous diplopia occurred in one case. 

Pulsating Exophthalmus. 

Protrusion of the eyeball with exaggerated pulsation in the 
orbit, depending upon an aneurismal condition of the blood-ves- 
sels (aneurism by anastomosis (?), arterio- venous aneurism (?), 
diffuse aneurism, aneurism of the ophthalmic artery, rupture of 
the carotid into the cavernous sinus) , may be either traumatic or 
idiopathic. The recorded traumatic cases show that the follow- 
ing injuries may operate as the exciting cause : a penetrating 
wound of the orbit made by an umbrella-handle, by a fork-like 
ornament of a parasol, by a knitting-needle, by a fall upon a stick, 
and by bird-shot. A discharge of shot received in the left orbit 
has caused pulsating exophthalmus of the right eye. And a 
wound through the left lower eyelid by the handle of an umbrella 
has caused pulsating exophthalmus of the opposite (right) side. 
One patient was wounded at the inner side of the left upper eye- 
lid by the bursting of a soda-water bottle, and a pulsating tumor 
developed at the site of injury. Among the indirect causes 
capable of producing this disease are cited falls upon the head, 
blows upon the temple, blows upon the back of the head, blows 
upon the nape of the neck, blows upon the forehead, and blows 
in the region of the eye. The blow must be a severe one, but 
unconsciousness does not necessarily follow. In one recorded 
case a knock-down blow with the fist in the temple was fol- 
lowed by pulsating exophthalmus. And a blow upon the nape 
of the neck from the fist of a very muscular man has caused 
bilateral pulsating exophthalmus. 

The condition is confined to one side, in nearly all cases. In 
penetrating wounds of the orbit it may occur on the opposite 
side. Bilateral pulsating exophthalmus has been observed in a 
few cases. 

Idiopathic cases begin commonly with a noise in the head; 
the exophthalmus develops later on. In traumatic cases, the 
symptoms are developed, as a general rule, within nine months 



PULSATING EXOPHTHALMUS. 51 

of the accident preceding the affection. "More than half the 
■cases," cited by Rivington,' "exhibited all the symptoms within 
two months. Some of the cases were not seen till a much later 
period, but from the history it is clear that all the symptoms 
were well established a few weeks after the injury. In two 
cases only was there an interval of years." It is probable that 
in most of the traumatic cases there was a fracture of the base 
of the skull. 

According to Eivington," "the typical symptoms of the so- 
called ' intra-orbital aneurism ' are exophthalmus, a chemosed 
pad of conjunctiva concealing the lower lid, pain, paralysis of 
orbital muscles and iris, with or without anaesthesia, pulsation 
of the eyeball, a pulsating tumor above the eye beneath the in- 
ner part of the orbital arch, distention of conjunctival vessels, 
obliteration of the hollow beneath the orbital arch, bruit and 
noises in the head. Pulsation of the eyeball, a pulsating tumor, 
•and paralysis of ocular muscles may be absent without contra- 
indicating the diagnosis of aneurism ; but I do not think that 
any case should be regarded as aneurismal in which a bruit can- 
not be heard, or be placed under the head of 'intra-orbital an- 
eurism' unless, in the absence of pulsation, exophthalmus and 
congestion of conjunctiva accompany the bruit." 

It is not possible to differentiate the traumatic from the idio- 
pathic cases by studying the aneurismal conditions alone. The 
history of the case must, in certain instances, be positively for- 
mulated before such differentiation may be made. A trauma- 
tism which subsequently results in pulsating exophthalmus may 
leave no other evidence that it has been received. Even pene- 
trating wounds of the orbit {e.g., puncture made by a knitting- 
needle) may leave no discoverable cicatrix, yet such lesions may 
be succeeded by pulsating exophthalmus. Traumatic cases are 
more common than idiopathic; they are much more common in 
men than in women; while, on the contrary, idiopathic cases 
are much more common in women than in men. 

Spontaneous recoveries are recorded, but such cases are un- 
common. Traumatic cases may have a fatal termination 
through secondary hemorrhage. Not only the danger to life, 
but the deformity, the disturbance of vision, and the distress 

' Medico-Chirurgical Transactions ' Ibid. , p. 313. 
(London), vol. Iviii., p. 311. 



52 VISION AND AUDITION — WOODWARD. 

occasioned by the noises in the head must be considered, while 
estimating the effect of this affection upon the welfare of the 
patient. The deformity is unsightly. Vision of the affected 
eye may be totally destroyed by the injury, or, subsequently, 
by the exophthalmus, by pressure upon the optic nerves, by 
changes in the retinal vessels, or by ulceration of the cornea. 
The latter may or may not end in perforation and panophthal- 
mitis. Sometimes diplopia exists in a troublesome degree. 

Again, it is likewise important to take into consideration 
the dangers incident to the treatment of this affection, while 
estimating the importance of it. For, inasmuch as ligation of 
the common carotid is the treatment most productive of favor- 
able results, it is the method of cure to be selected in preference 
to others, and in itself it involves a certain risk to the patient's 
life (8 deaths in 63 operations).' Even that operation has failed 
to cure in 17 out of 55 cases, collected by Sattler.' 

' Sattler :"Graefe-Saemisch discussion of this affection, consult 
Handbuoh," vol. vi., p. 933. Rivington, op. dt., and Sattler, op. 

^ Ibid., p. 927. For exhaustive cit. 



CHAPTER IV. 
injuries and wounds of the eyelids. 

Contusions. 

Contusions of the eyelids are followed by subcutaneous 
extravasation of blood (ecchymosis, suggillation, "black eye"). 
The extravasation may be small, or it may be great enough to 
close the eye. After a severe contusion, the ecchymosis gen- 
erally appears immediately ; after milder injuries, it may not 
become visible for some hours. 

Subcutaneous extravasations of blood in the eyelids are not 
always a consequence of direct violence. They may occur spon- 
taneously in persons having a tendency to cerebral apoplexy. 
They have been observed, in rare cases, as a symptom of disease, 
e.g., purpura hcemorrhagica. They have been caused by 
straining in whooping-cough. They occur in nearly all cases 
of fracture of the vault of the orbit, whether the fracture be the 
result of direct violence or not. Fissures in the vault of the 
orbit may not extend beyond the frontal bone, or they may be 
continuous with a fracture of the base of the skull. Palpebral 
ecchymosis may be due also to fracture of the bones composing 
the lateral walls, or the floor of the orbit. 

When ecchymosis of the eyelids originates in fracture of the 
bones of the orbit, subconjunctival extravasation is observed 
as a precedent symptom. In cases of this nature, the extrava- 
sated blood infiltrates the deeper tissues of the orbit, spreads 
forward under the conjunctiva of the eyeball, and appears be- 
neath the integument of the eyelids. Such palpebral extravasa- 
tions may appear first near the inner canthus ; and eighteen or 
twenty -four hours may pass after the injury before any discol- 
oration of the eyelids becomes manifest. 

Palpebral ecchymoses have been observed after contusions of 
the abdomen and of the thorax. They may be produced by 

53 



54 VISION AND AUDITION — WOODWARD. 

strangulation. Such extravasations have the same aspects as 
if they originated in fracture of the base of the skull. 

Ammon described a "sympathetic suggillation," by which he 
meant an ecchymosis appearing in corresponding parts of the 
face about both eyes. Fracture of the skull involving the walls 
of both orbits may be the causal lesion in such cases. But the 
condition has been observed, without fracture, after enucleation 
of the eyeball. 

Cases of amblyopia and amaurosis supposed to arise by reflex 
action from contusions of the supra-orbital or of the infra-orbital 
nerve have been reported.' The only cases of this description, 
which I have seen in recent literature, are those reported by 
Dunn." He gives the history of two attacks of amblyopia oc- 
curring in the same patient, following a contusion of the right 
and subsequently a contusion of the left supra-orbital nerve. 
Both attacks were apparently cut short by section of the injured 
nerve. 

Whenever it is alleged that impairment of vision is due to 
injury of one of these nerves, the case should be subjected to 
especially careful scrutiny ; for it is not intrinsically probable 
that amblyopia or amaurosis ever depends upon these compara- 
tively simple lesions. If, after a contusion or other injury of 
the supra-orbital or the infra-orbital nerve, the patient com- 
plain that vision in the eye of the injured side has become de- 
fective, one of the following explanations of the phenomena 
may obtain, — viz., that the optic nerve has been injured by frac- 
ture of the orbital bones, or that the defect in the eye antedates 
the injury, or that the disturbance in the eye is a coincidence, 
not a consequence, of the traumatism; or that the patient is 
malingering. In the more obscure cases, judgment should be 
reserved until sufficient time have elapsed for the ophthalmo- 
scopic signs of pathological changes in the fundus to become 
manifest. The appearance of such signs may be delayed. 

Wounds of the Eyelids. 

The eyelids may be the site of all sorts of wounds— incised, 
punctured, lacerated, and contused wounds. They may be either 

' Mackenzie: "Dis; of the Eye," » New York Med. Journal, Aug- 

Philadelphia, 1855, p. 150 et seq. ust 9tli, 1890 ; May 30th, 1891. 



WOUNDS OF THE EYELIDS. 55 

superficial or deep. The whole eyelid may be torn ofE, or so 
extensively lacerated as to slough away, leaving the cornea ex- 
posed to the atmosphere. They may be confiued to the struc- 
tures of the eyelids, or they may involve neighboring structures. 
They may be either infected or non-infected. 

The course of the wound is important. When it is parallel, 
or nearly parallel, with the free margin of the lid, the scar will 
be less conspicuous and the deformity much less marked than 
if the wound were oblique or vertical. Incised wounds parallel 
with the free margin of the lid may heal without noticeable 
scar or deformity. When they pass through the levator palpe- 
brsB superioris, however, the patient will not be able to open his 
eye; he will suffer from traumatic ptosis. Careful suture of 
the divided muscle wiU restore its usefulness, but it may be an- 
ticipated that evidence of the traumatism, in the line of deform- 
ity or in restricted action of the muscle, will remain after the 
most skilful handling. The most favorable time for operation 
in such cases is immediately after the injury. Green made a 
successful operation two years after the muscle was divided. 

A wound near the inner can thus may divide the canaliculi. 
Cicatricial tissue may occlude the lumen of the tube, causing 
epiphora, or weeping of the eye. Epiphora is an annoying con- 
dition that disturbs the function of the eye by virtue of accumu- 
lation of tears in the conjunctival sac. 

Wounds parallel with and near the margin of the lids, pass- 
ing through the tarsus in the region of the Meibomian ducts, 
will result in formation of cysts of the Meibomian glands, 
through cicatricial occlusion of their ducts. 

Wounds dividing the eyelids in an oblique or a vertical di- 
rection will cause deformity. Incised wounds of the lid margin 
and tarsal cartilage, even though they may have been promptly 
and accurately united by a suture, may heal with permanent 
deformity (traumatic coloboma). The eyelashes about the 
wound may be turned toward the eyeball by the cicatrix, so 
that they constantly irritate the cornea. When this takes 
place, the patient is very uncomfortable; his eye may be con- 
stantly inflamed, and its function may be impaired by loss of 
transparency of the superficial strata of the cornea. 

Lacerated and contused wounds resulting in loss of tissue 
are productive of greater evils. Such wounds, even when su- 



56 VISION AND AUDITION — WOODWARD. 

perficial, will leave a noticeable scar, and, when the loss of tissue 
extends over a sufficient area, the cicatrix will prevent complete 
closure of the eye (lagophthalmus) . In order that the lagoph- 
thalmus may be permanent, considerable loss of tissue is neces- 
sary, owing to the elasticity of the integument of the eyelids. 
Lacerated wounds having a vertical or an oblique direction are, 
more frequently than others, productive of lagophthalmus and 
coloboma. Lacerations of the eyelids may destroy sufficient 
tissue to uncover the cornea permanently. Unless relieved by 
surgical treatment, the eye will remain open. Sooner or later 
the drying effect of the atmosphere and the dust in the air, 
lodging upon its surface, will set up a persistent inflammation 
of the cornea, which will destroy the eye. The most successful 
treatment cannot efface the deformity. 

Lacerated and contused wounds of the eyelids may be suc- 
ceeded by eversion of the lid margins (traumatic ectropium). 
This is more commonly due to wounds of the lower than to those 
of the upper lid. The deformity is unsightly. When the inner 
portion of the lower lid is everted, the eye will weep constantly. 
Punctured wounds of the eyelids, when they extend into the 
orbit, may result in eversion of the lid margin, by virtue of 
cicatricial contraction. 

Incised wounds of the eyelids heal promptly. Lacerated 
and contused wounds, when infected, or when they occur in 
persons whose health is depraved, heal slowly and usually sup- 
purate. Such wounds may be attacked by erysipelas. This 
may endanger the patient's life, and it may extend to the orbital 
cellular tissue, causing atrophy of the optic nerve, or ulceration 
of the cornea. Under such conditions, the latter would run a 
very destructive course. Punctured wounds made by an in- 
fected instrument may be followed by similar results. 

Burns of the Eye. 

The eyelids may be burned by fire, by explosions, and by 
corrosive agents. The burns may be superficial or deep. They 
may totally destroy the eyelids. Burns of the first degree heal 
without leaving any trace behind. Deeper burns are followed 
by scarring; such scars contract so as to give the eyelids a false 
position. Thus, the several conditions, ectropiimi, even to com- 



BURNS OF THE EYE. 57 

plete eversion of the eyelids and exposure of the cornea, lagoph- 
thalmus, and anchyloblepharon, may be caused by contraction 
of such cicatrices in the eyelids. The deformity is sometimes 
very repulsive. Operative interference will relieve that feature 
to a considerable extent, but vfell-marked traces of the casualty 
will persist in the more severe cases, notwithstanding the most 
skilful management. 

Burns of the eyelids are associated, in many cases, with a 
more serious corrosion of the conjunctiva and eyeball. But burns 
of the latter may not be complicated by burns of the eyelids. 
Quicklime and acids (vitriol) are the corrosive agents that most 
frequently enter the eye. Flames from gunpowder and other 
quickly inflammable substances may scorch or severely burn 
the eyeball. Corrosion of the conjunctiva causes ulceration. 
When the palpebral and the opposing bulbar conjunctiva are 
involved in the same ulcerative process, symblepharon, or ad- 
hesion of the eyelid to the eyeball, ensues. Such adhesion may 
prove to be a serious impediment to the performance of the 
functions of the eye. Symblepharon may attain such degree 
that the palpebral conjunctiva is adherent to the cornea. When 
this is the case vision is very much impaired or destroyed. 

Burns of the cornea may be either superficial or deep. A 
superficial burn may destroy the epithelial layer only. Such 
an example came under the writer's observation. Both cornese 
of a boy were burned to this degree while he was examining a 
burning paper that contained gunpowder. The flame destroj'ed 
the whole epithelial layer of both cornese. Both eyes recovered 
perfectly without a trace of the injury. Explosions of blasts 
and accidents with fire-arms are not uncommonly followed by 
burns of the cornea and lodgment of grains of powder therein. 
In general, the cornea recovers its transparency, notwithstand- 
ing the retention of the powder-grains in its substance. Burns 
of the cornea may be sufficiently deep to open the anterior cham- 
ber at once, or the ulceration following them may perforate the 
cornea subsequently. Such injuries destroy vision in the in- 
jured eye and lead to sympathetic inflammation of the fellow- 
eye. An example of the latter came under the writer's observa- 
tion. The right eye of a man was corroded by quicklime. 
The anterior chamber was opened. Some years later, the eye 
appeared as if an iridectomy outward had been performed. The 



58 yiSION AND AUDITION— WOODWARD. 

uninjured eye was blind, owing to unmistakable sympathetic 
inflammation. 

The dangers of burns of the cornea are, then : 1, immediate de- 
struction of the eye by extensive corrosion ; 2, in less severe cases, 
perforating ulcer of the cornea, leading sometimes to sympa- 
thetic inflammation; 3, cloudiness of the cornea, following 
ulceration or severe keratitis ; and 4, symblepharon. 

Burns of the sclera may destroy the eye by perforating the 
organ, when sympathetic disease may supervene and destroy 
its fellow; or by exciting violent inflammation of the uveal 
tract. They injure the usefulness of the organ in other cases, 
by virtue of the symblepharon, which almost invariably suc- 
ceeds them. 



CHAPTEE V. 
injuries and woxtnds of the eteball. 

Dislocation op the Eyeball. 

The eyeball may be dislocated by blunt objects thrust into 
the orbit. " Gouging" is a practice which consists in thrusting 
a thumb or a finger into the victim's orbit between the eyeball 
and the bony wall. This forces the globe from its bed sufl&- 
ciently for the eyelids to slip behind it. Injuries of this charac- 
ter may rupture one or more of the ocular muscles. They cause 
severe contusion of the eyeball, in a certain number of cases. 
"While the eye is dislocated its vision is suspended, but normal 
vision may return when the dislocation is reduced. A progno- 
sis of the ultimate effects of the injury, however, cannot be 
made early; for, subsequently, destructive inflammation may 
supervene. Hemorrhage into the vitreous, dislocation of the 
lens, detachment of the retina, rupture of the choroid, and rup- 
ture of the sclera occur as complications, which terminate the 
usefulness of the organ. 

Dislocation of the eyeball may be due to blows upon the eye. 
Noyes relates a case caused by falling down-stairs and striking 
the head against the banister. ' Prominent eyes in shallow sock- 
ets are more easily dislocated than others. 

Dislocation of the eyeball into the maxillary antrum has 
been described. A remarkable case of this nature was observed 
by Langenbeck. The patient was struck on the right side of 
his face by a locomotive. Eight days later the eyeball was 
found projecting into the antrum, through the floor of the orbit. 
When replaced, it was found to be uninjured and its acuteness 
of vision normal. Four months after, an ulcer appeared in the 
cornea and the eye became shrunken.'' 

' "Dis. of Bye," 1890, p. 447. 2 Archives of Ophthalmology, N. 

Y. , vol. xxii., 1, abstract. 

59 



60 VISION AND AUDITION — WOODWARD, 



Evulsion op the Eyeball. 

The eyeball may be torn from its socket by accident. Mac- 
kenzie' cites the following case : While intoxicated a man fell 
against the ring of a key which was in the lock of the door. 
The ring divided the upper eyelid and, penetrating into the orbit, 
scooped the eyeball out so that it fell upon the floor. The man, 
being too drunk to realize the extent of his injury, went to bed 
and was found in the morning covered with blood. Under 
simple treatment he made a speedj' recovery. 

Mackenzie refers also to a case in which the eyeball was torn 
from its socket by a cart-wheel passing over the side of the pa- 
tient's head." 

Contusions op the Eyeball. 

The damage accruing from contusions of the eyeball will 
vary with the amount of force and the direction of the blow. 
The bony margins of the orbit are arranged in a way to protect 
the globe against blows directed from points not immediately 
in front of the eye. Large blunt objects, like the clenched hand, 
striking point-blank, would generally be arrested by the bony 
margins of the orbit and cause only trifling, if any, injury to 
the eyeball. If, however, the eyeball were prominent and the 
orbit shallow, or if the assailant's knuckles were large, and if 
they were armed with a metallic reinforcement, a point-blank 
blow might cause a severe contusion, resulting even in rupture 
of the eyeball and destruction of the eye. Contusions of the 
globe are more likely to ensue from the impact of small blunt 
objects. They may be received at the hands of an adversary, 
who viciously attempts to gouge the eye from its bed. 

Rupture of the sclera, due to contusion, is, almost without 
exception, observed in the anterior portion of the eyeball, pass- 
ing through the ciliary region. Bowman reported one case of 
rupture of the posterior portion of the sclera. Ruptures of the 
sclera may be either partial or complete. They are more or 
less concentric with the cornea, and are found, as a rule, above 
the cornea. The rent in the sclera lies near the cornea, on the 

^ Loc. eit., p. 417, from "Annales '' Loc. cit., p. 417, from Graefe 
d'Oculistique," t. xxvi., p. 99. and Walther's Journal, vol. i. 



CONTUSIONS OF THE EYEBALL. 61 

side opposite to that receiving the contusing force. A blow 
from in front will rupture the sclera above the cornea; for the 
patient will roll his eyes upward instinctively to protect them 
from injury, and the blow will strike below the cornea. Blows 
delivered upon the upper and outer portion of the globe will 
rupture the sclera on the opposite side of the cornea — that is, 
downward and inward. Blows upon the temporal side of the 
cornea will rupture the sclera on the nasal side ; and blows re- 
ceived above the cornea will rupture the sclera below the cor- 
nea, and vice versa.^ 

Large complete rents in the sclera are associated with loss 
of vitreous, collapse of the eyeball, and immediate destruction 
of the organ. Smaller complete ruptures may be complicated 
by prolapse of the iris, ciliary body, choroid, and vitreous, and by 
extrusion of the crystalline lens. At the same time, the con- 
junctiva is often torn, so that there is direct communication be- 
tween the contents of the eyeball and the external world. When 
this occurs, the wound will generally become infected by micro- 
organisms; irido-cyclitis will follow, and may lead to an attack 
of sympathetic inflammation in the fellow-eye. Or, purulent 
panophthalmitis may invade the injured organ and destroy it. 

The scleral rupture in other cases may exist without lesion 
of the conjunctiva. So long as the conjunctiva is not torn, the 
danger of infection by micro-organisms and the subsequent dis- 
asters supposed to be due to them is very much diminished. 

Loss of vitreous, and prolapse of the iris and of the choroid, 
are always serious complications. Even a moderate loss of 
vitreous is sometimes followed by detachment of the retina. 
This may not supervene until some weeks or months have 
elapsed; that is, until the cicatrices which form in the chamber 
of the vitreous have begun to contract. It is possible for the 
patient to recover from the immediate efEects of the injury 
with useful vision in the eye; but this may be destroyed sub- 
sequently by detachment of the retina. Attempts made to re- 
duce prolapsed portions of the iris, ciliary body, or choroid, 
will not commonly prove entirely successful. Some incarcera- 
tion of the stump of the abscised prolapsed structures will 
persist in the scar. It must follow, in most cases of that 
nature, when the cicatrices contract, that irritation, or a low 
' Alt : Wiener med. Wochenschrift, 1874, pp. 230, 231. 



62 VISION AND AUDITION — WOODWARD. 

grade of inflammation, will keep the eye tender and menacing 
to its fellow. The comfort of the patient will be seriously 
disturbed, the usefulness of both eyes greatly impaired, and, 
subsequently, an attack of sympathetic inflammation may 
cause blindness of both eyes. 

Judged from the standpoint of the rupture alone, contusions 
of the eyeball sufficiently severe to produce such a lesion are 
among the most serious injuries that befall the eye. 

Moreover, such contusions may cause hemorrhage into the 
anterior and the posterior chambers, and into the chamber of 
the vitreous ; they may cause partial or complete luxation of the 
lens, or even extrusion of the lens from the eyeball ; they may 
be complicated by irido-dialysis, or by retroversion of the iris, by 
rupture of the choroid or the retina, or by detachment of those 
structures; and they may be complicated by fracture of the 
walls of the orbit. An eye subjected to such an injury is, there- 
fore, often destroyed at once. 

Contusions of the Cornea. 

The cornea may be contused by a force applied to the closed 
eyelids, or by one striking the cornea directly. Unless the blow 
is delivered with great velocity, the eyelids will close before 
the eyeball is struck. In this manner, the organ is protected 
in many instances against accidents that would otherwise pro- 
duce serious results. Evidence of contusion of the eyelids will 
be present when the injury has been received by them. 

Contusions of the cornea may be the cause of inflammation 
of that structure, and the inflammation may be superficial, or it 
may involve the deeper layers. The cornea will lose much of 
its transparency and vision may be considerably below normal. 
But complete resolution of the morbid process may be antici- 
pated in most cases, under appropriate treatment. 

When the blow of a blunt object falls directly upon the cor- 
neal tissue, an abrasion of the epithelium,or even a deeper wound, 
may be the result. Such solutions of continuity may ulcerate. 
Then destruction of tissue maj^ be sufficient to ruin the eye. 
Abrasions of the cornea may heal without leaving a trace of 
their existence. They may be converted into ulcerations, if in- 
fective material come in contact with them. The sources of 



CONTUSIONS OF THE CORNEA. 63 

such infection are commonly a purulent discharge from the con- 
junctiva, a purulent discharge from the lachrymal sac, a dirty 
body causing the contusion, rubbing the eye with dirty fingers 
or a dirty handkerchief, or carelessness on the part of the at- 
tending physician. Ulceration may appear first as an abrasion, 
and, without the intervention of infection, necrosis of the cornea 
may supervene in consequence of the violence of the blow. The 
corneal tissue, in such a case, is killed by the traumatism, and 
the dead part is separated and thrown off from the living by the 
process of ulceration. 

Contused wounds of the cornea amounting to more than an 
abrasion of the epithelium heal by cicatrization. The tissue 
composing the scar is opaque. If the loss of substance extend 
over more than a very limited area, the scar will be a notice- 
able deformity. Sometimes small ulcerated spots heal without 
the development of opaque scar tissue. The spot appears, when 
healed, as a small pit or facet in the surface of the cornea, and 
it is apparently covered with epithelium as transparent as that 
which extends over the adjacent normal tissue. Delicate scars 
are developed from superficial ulcerations. They may be almost 
or quite invisible to the unpractised observer. 

Whether these traces of the pre-existing loss of substance 
be marked or insignificant, their chief importance, as regards 
the function of the eye, depends upon the position occupied by 
them. When they invade the region through which the visual 
line should pass, they always impair the acuteness of vision. 
A large opaque scar located over the pupil will produce blind- 
ness. A delicate nebula in the same position will destroy read- 
ing vision. In such cases, loss of normal transparency of the 
cornea will explain the effect upon sight. When a facet of the 
cornea lies over the pupil, the acuteness of vision is also seriously 
impaired. For the surface of the cornea is no longer regular, 
and, in the affected region, the rays of light passing into the eye 
are irregularly refracted (irregular astigmatism). Hence the 
retina does not receive a perfectly formed image of the object 
looked at. Distortion of the retinal image in some of these 
cases is so marked that the usefulness of the eye is destroyed. 

Eventually external strabismus may supervene, in conse- 
quence of disuse of the affected eye. 

Inflammation, abscess, and ulceration of the cornea result- 



Gi VISION AND AUDITION — WOODWARD. 

ing from contusions are more prone to follow such injuries in 
patients who are old or badly nourished.' 

Kupture of the cornea alone has been observed. De Wecker ' 
refers to two cases that occurred in his own practice. In one, 
the lesion was due to a violent blow of the fist ; in the other, it 
was due to gouging, the assailant's thumb being thrust between 
the inner wall of the orbit and the eyeball. 

Contusions sufficiently forcible to rupture the cornea would, 
in most cases, cause other severe injuries of the eye. The rent 
may extend into the sclera, and would then involve the ciliary 
region. The iris would be prolapsed. The lens might be dislo- 
cated or even extruded. Rupture of the choroid, detachment 
of the retina, or loss of vitreous may also complicate the case. 

Simple rupture of the cornea, in the most favorable cases, 
would endanger the preservation of the eyeball; for it is a 
penetrating injury. Iritis of a severe type may be expected. 
Purulent panophthalmitis may ensue, and removal of the eye 
become a necessity. 

But, even though the rupture be uncomplicated by injury of 
other structures, and the healing be prompt and uneventful, the 
function of the eye will be seriously impaired or perhaps totally 
destroyed. For, in the first place, the line of union may cross 
the pupil and mechanically interfere with the passage of light 
into the eye ; and, in the second place, the union will result in 
irregularity of the cornea, and, therefore, irregular astigmatism 
and its consequences. 

Ruptures of the cornea, or of the cornea and sclera together, 
may be followed by chronic iritis or chronic irido-cyclitis. The 
eye will remain tender and irritable after the wounds have 
healed, and, subsequently, the fellow-eye maybe invaded by an 
attack of sympathetic infiammation. 

Affections of the Iris, due to Contusions of the 

Eyeball. 

Contusions of the eyeball often separate the iris to a certain 
extent from its peripheral attachments. That condition is 
known as irido-dialysis — the iris retracts toward the pupil at 

'Alt: Wiener med. Woohen- « "Traite complet d'Ophthalmo- 
schrift, 1874, p. 231. logie," 1886, p. 216. 



AFFECTIONS OF THE IRIS DUE TO CONTUSIONS. G5 

the site of the detachment, thus forming an aperture by the cor- 
neal margin, through which the fundus-reflex may be seen, 
when the eye is illuminated with the ophthalmoscopic mirror. 
The aperture may be large enough to permit an ophthalmoscopic 
examination of the fundus through it. The pupil will not 
maintain its normal roundness, and does not respond properly 
to the stimulus of light. In fresh cases, blood will be found 
in the anterior chamber, but it soon undergoes resorption. 
Hemorrhage into the vitreous and traumatic cataract occur as 
the more common complications, together with transient loss of 
transparency of the cornea. 

Cases are observed in which the eye is inflamed and painful 
for a number of months, especially when the contusion has in- 
jured the deeper structures, causing profuse hemorrhage into 
the vitreous. As a rule, however, all irritation subsides after 
a few days or a few weeks. Transparency of the media may 
become normal, with normal vision in the eye. A partial opac- 
ity in the posterior capsule of the lens, with diminished vision, 
occurred in two cases under my observation. The vitreous in 
both cases contained a few particles of extravasated blood, which 
soon disappeared, leaving the media clear in every part except- 
ing the small area of the posterior capsule. One of these pa- 
tients was injured nearly four years ago, but no extension of 
the area of opacity was visible at a recent examination. The 
eye had not been troublesome after the primary irritation sub- 
sided, although the boy had attended school regularly. 

Irido-dialysis may be sufficiently marked to excite comment 
from casual observers. Its situation and size may cause mon- 
ocular diplopia. Another patient was annoyed by this symp- 
tom, until he learned to disregard the false image. He can still 
see through the false pupil, however, by directing his attention 
to it. The glare of light may dazzle such eyes; for, owing 
to the imperfect movements of the pupil and the fault in the 
periphery of the iris, the eye receives more light than an unin- 
jured eye. "Vision may, also, be imperfect on dark days, bj' 
virtue of an imperfect dilation of the pupil. 

Rents in the substance of the iris may be due to contusions. 
De Wecker ' cites a case from Lawson, in which the rent occurred 
above and near the pupil. The appearance was that of a large 
' "Graefe-Saemisch Handbuch," 4, p. 536. 
III.— 5 



66 VISION AND AUDITION — WOODWARD. 

pupil divided transversely by a narrow band of iris-fibres. 
Vision was quite imperfect. If vision through either aperture 
alone had been normal, it would, nevertheless, have been con- 
fused when both were uncovered. The force of a blow suflScient 
to cause a rent in the substance of the iris may be expected to 
injure other structures (lens, choroid, retina), so as to perma- 
nently depreciate the acuteness of vision, if not to destroy use- 
ful sight. 

Severe contusions cause absolute dilatation of the pupil. 
Blows upon the eye may, rarely, produce either complete or par- 
tial retroversion of the iris. Complete retroversion resembles 
both absolute dilatation of the pupil, and absence of the iris. 
Partial retroversion resembles coloboma of the iris. Congenital 
coloboma always occurs downward, or downward and inward, 
and is generally binocular." When the iris is retroverted in 
any case, ophthalmoscopic examination of the ciliary processes 
is not possible. This fact does not obtain in dilatation of the 
pupil, or in aniridia, or in coloboma. Traumatic and post-opera- 
tive colobomata of the iris are associated with scarring of the 
cornea. 

These conditions are permanent, almost without exception. 
An instance, however, of healing in a case of irido-dialysis fol- 
lowing a " combined extraction " of cataract has come under my 
observation. Berry refers to a case of recovery, recorded from 
the Dublin Eye Hospital.' 

Affections of the Crystalline Lens, due to Con- 
tusions OP THE Eyeball. 

Traumatic Cataract. — Cataract maybe the principal re- 
sult of a contusion of the eyeball. Changes in the transparency 
of the lens may not be observed until weeks or months have 
passed. When the opacity begins, it generally becomes com- 
plete and reduces the visual power to perception of light. Evi- 
dence of the existence of any other lesion may be wanting. It 
is supposed that the anterior capsule is ruptured in most of the 
cases, and that cloudiness of tlie lens is due to the action of the 
aqueous humor, which is admitted to the lens tissue through 
the rent in the capsule. But in other instances the existence 
' Berry : "Dis. of Eye," p. 270. « Loc. dt., p. 269. 



TRAUMAIIC CATARACT. 67 

of a rent in the capsule cannot be made out. When the capsule 
is ruptured, the incipient stage of traumatic cataract ought to 
become visible in a few hours, or a few days. When the cap- 
sule is not ruptured, the cataractous degeneration of the lens 
ought to be developed much more tardily. At all events, after 
contusions of the eyeball, cataract may develop, whether the in- 
jury does or does not appear to be serious, when the patient is first 
examined. Liegey ' reported such a case. A man was struck 
in the face with a whip-stock. The right side of the face, when 
the first examination occurred, was smeared with blood, which 
still flowed from a small, clean Avound 1| cm. long, situated at 
the base of the lower eyelid, but not penetrating to the bone. 
The lower eyelid was swollen and ecchymosed. The superior 
lid was slightly swollen and ecchymosed. The palpebral and 
bulbar conjunctiva was injected with blood; there was slight 
chemosis; media clear, fundus normal, as seen with the oph- 
thalmoscope. Patient avowed that he could see light only. 
Liegey did not think that the eye had been seriously injured, 
and gave a favorable prognosis. About five weeks later the 
man returned to him saying that the eye was entirely blind. 
Iris was immobile and pupil dilated. No physical signs of the 
injury. Media still clear and fundus appeared normal. The 
diagnosis at this time was incomplete traumatic amaurosis, 
which may or may not continue and may become total. Two 
weeks later, no especial change' had taken place. Five weeks 
after this visit Liegey examined the ej'e again and found signs 
of cataractous degeneration of the lens. The court allowed the 
plaintiff damages. 

In every case, traumatic cataract permanently injures the 
eye. The cataract may be extracted, or its solution may be 
effected by operation. In either case, the images of objects 
may be formed upon the retina again, as soon as the obstruc- 
tion is removed. But a cataract glass must be fitted to the 
eye in order that vision may be distinct. With glasses, how- 
ever, the patient will not be able to adjust his eye for objects at 
variable distances. The power of accommodation is wanting; 
and the injured eye cannot work harmoniously with the sound 
eye. For this reason, patients soon abandon attempts to use 
both eyes again, for such attempts always prove abortive. 
> Journal de Medecine, 1871, p. 496. 



G8 VISION AND AUDITION — WOODWARD. 

Traumatic cataract is a noticeable deformity. The white 
pupil attracts attention ; and, therefore, it is a source of annoy- 
ance to the patient. Eventually, the injured eye turns outward ; 
thus, divergent strabismus is added to the disfigurement already 
present. Operation upon these cataracts improves the appear- 
ance of the eye, and restores sufficient vision to improve slightly 
the sense of perspective, even without glasses. When the pa- 
tient has only one eye, or when the fellow-eye does not retain 
sufficient visual power, operations on these cataracts will restore 
useful vision. 

Traumatic cataracts may, in some cases, undergo complete 
solution, without operative interference. The pupil may thus 
become clear and black, and the eye may appear perfectly nor- 
mal to the casual observer. In many cases, however, the solu- 
tion is not complete, or the capsule of the lens subsequeatly 
becomes cloudy and the pupil remains white, or, after a variable 
period, becomes white, and the eye has an unsightly appear- 
ance. Operation (discission) will often clear the pupil in these 
cases. 

Dislocation of the Liens. — Contusions of the eyeball may 
cause dislocation of the lens. The dislocation may be either 
partial or complete. The suspensory ligament, or zone of Zinn, 
is ruptured. The lens may be expelled from the eyeball and 
lodge under the conjunctiva, or it may be extruded from the eye 
altogether. Complete dislocation of the lens is spoken of as 
luxation of the lens ; partial dislocation as subluxation of the 
lens. 

Luxation of the Lens. — The lens may be dislocated into 
the vitreous, and will be found lying below the pupil. If the 
vitreous be fluid, the lens will change position when the eye or 
head is moved in certain directions. It may remain clear for 
some time, but will finally become opaque. After the primary 
irritation subsides, the eye may remain quiet during a number 
of years ; or the eye may continue irritable and become very 
painful. This happened in the case of a patient who consulted 
me about eight months after the accident. She had attempted 
to break a stick of kindling-wood with an axe. The stick flew 
against her right eye, striking it with considerable force. 
Vision was immediately impaired. There was no laceration or 
other wound of the eye. Severe inflammation followed. The 



SUBLUXATION OF THE LENS. 09 

eye continued painful for months, in spite of the treatment ad- 
vised by her physician. Owing to excessive pain, she acquired 
the morphine habit. When I saw her, the eyeball was enlarged, 
hard, and tender to pressure. The pupil was semi-dilated. 
Ciliary staphylomata were present. Tjie lens was dislocated 
downward into the vitreous. Vision was perception of light 
only. Her general health was very much shattered. The case 
was one of luxation of the lens, followed by secondary glaucoma. 
Enucleation was imperative. 

The lens may be dislocated into the anterior chamber by 
contusions of the eyeball. The luxated lens appears trans- 
parent, like a drop of oil. By oblique illumination its pecu- 
liar structure may be discerned. The lens may remain clear 
for some weeks, but eventually it becomes opaque ; in certain 
cases, opacity of the lens is noted soon after the injury. An 
opaque lens in the anterior chamber resembles in appearance 
a collection of thick pus. In every case vision is very much 
impaired. 

A lens dislocated into the anterior chamber, and lying in 
contact with the cornea, will very often excite inflammation of 
that structure, which may terminate in a perforating ulceration 
of the cornea, expulsion of the lens, and phthisis bulbi. On the 
other hand, in some instances, a dislocated lens may lie in the 
anterior chamber for months without exciting much irritation. 
Very frequently, however, secondary glaucoma supervenes, 
causing excruciating distress. The lens may lodge in the pupil. 
When this occurs, secondary glaucoma is inevitable. 

Dislocation of the lens under the conjunctiva occurs only 
when the tunics of the eyeball have been ruptured by the blow. 
Immediately after the injury the diagnosis may be obscured 
by the presence of extravasated blood. Subsequently, resorption 
of the blood will enable the attendant to detect the lens in its 
false position. A contusion which gives rise to such an injury 
as this must necessarily be a severe one. 

Subluxation of the Lens. — Subluxation of the lens de- 
pends upon a partial rupture of the zone of Zinn. The free 
margin of the lens, when the zone is torn, may fall away from 
the iris, while the opposite edge of the lens advances toward the 
anterior chamber. Hence, the lens lies in an oblique position 
in the pupil. Such a condition will cause irregular lenticular 



70 VISION AND AUDITION— WOODWARD. 

astigmatism. This is not always easy to diagnosticate. But 
it may be presumed to exist, when, in an eye the refraction of 
which was previously known, irregular astigmatism is detected 
for the first time after an injury, the media being clear and the 
fundus normal. The ophthalmometer will assist in making the 
differential diagnosis between corneal and lenticular astigma- 
tism. The depth of the anterior chamber will not be the same 
at all points, and the iris will be tremulous, where it is not 
supported by the lens. Glasses will not improve the vision 
much. 

When tilting of the lens is more marked, its free margin may 
be seen in the pupillary space. So long as the lens remains 
clear the patient may complain of monocular diplopia. 

Lateral, or vertical, displacement of the lens is revealed by 
the presence of the margin of the lens in the pupillary space: it 
appears as a dark crescentic line. When the lens is displaced, 
the iris is no longer supported and trembles when the eye is 
moved quickly. The power of accommodation is wanting ; and 
while the lens remains clear and its edge passes through the 
pupillary space, the patient may complain of monocular 
diplopia. 

Monocular diplopia exists in these cases because the light 
entering the pupil passes in part through the lens and in part 
through the space from which the lens has moved. The rays 
of light passing through these two regions wiU be refracted 
differently, and two imperfect images of the same object will 
be formed upon different portions of the retina at the same time. 
Both images may be perceived by the patient. On account of 
this, the usefulness of the eye will be destroyed, unless the pa- 
tient learn to suppress the less distinct image. 

Subluxation ends sooner or later in complete dislocation. In 
time, the lens becomes cataractous. And, owing to the changes 
of position which some of these lenses undergo when the con- 
ditions are favorable, the eye may be irritated and cychtis, 
choroiditis, or secondary glaucoma may supervene to destroy 
the eye definitively. 

Dislocation of the lens of any sort always permanently in- 
jures the function of the eye. Nothing can be done to restore 
the lens to its normal position, nor is it possible to prevent the 
cataractous degeneration that is certain to ensue sooner or later. 



SUBLUXATION OF THE LENS. 71 

When the eye becomes irritable, or when cyclitis, choroiditis, or 
secondary glaucoma develops, in a certain number of cases, the 
lens may be removed, and the necessity for enucleation of the 
eyeball obviated. Operations upon these lenses are most diffi- 
cult when the dislocation is into the vitreous. In every case, 
the operation is a delicate one. It is least difficult when the lens 
lies under the conjunctiva. Glasses may improve the vision 
very much, but the disparity between the eyes (supposing the 
fellow-organ to have ordinary visual power), is such that, in 
general, patients are not as comfortable with as without them. 
A dislocated lens may excite irido-cyclitis, and some ophthal- 
mologists believe that it is one cause of sympathetic inflam- 
mation. 

Not all dislocations of the crystalline lens are traumatic. 
Congenital dislocation, or ectopia lentis, is a well-known de- 
formity of the eye. In such cases both eyes are affected, and 
generally the lenses are partially dislocated in an upward and 
outward direction. Such lenses are smaller than normal. The 
anomaly is symmetrical.' "Ectopia lentis occurs mostly up- 
ward, or upward and inward, and upward and outward. It 
is often met with in several members of the same family, and 
is hereditary. ... It probably always occurs in both eyes 
and is frequently associated with a defect in the power of con- 
vergence." ° According to De Schweinitz, "complete congeni- 
tal luxation is also described." ' 

Spontaneous dislocation of the lens into the anterior chamber 
or into the vitreous may occur, especially in cases of fluid vitre- 
ous, in myopia of high degree, and in cases of choroiditis. Hy- 
permature cataracts may become spontaneously dislocated. 

I have observed a case of subluxation of the lens, toward 
the nasal side into the chamber of the vitreous, in an eye which 
had been destroyed years before by a burn of the cornea. The 
cornea had been perforated, the iris had prolapsed, the pupil 
was irregular and presented the appearance which a large iri- 
dectomy would leave. There was absolutely no history of con- 
tusion of the eyeball. No operation had been performed upon 
the eye. 

'Becker: " Graefe - Saemisch = Berry : " Dis. of Eye, " 1893, pp. 

Handbuch," 5, p. 286. 180, 181. 

8 "Dis. of Bye, "p. 403. 



73 vision and audition— woodward. 

Rupture of the Choroid and Detachment op the 

Retina. 

Profuse hemorrhage into the vitreous arises from severe con- 
tusions of the eyeball. Until resorption of the blood has taken 
place, it is not possible to examine the fundus. When the 
media have become clear, a rupture of the choroid, or a de- 
tachment of the retina may be found. Ruptures of the choroid 
are situated between the macula and the optic disc, and are 
more or less concentric with the latter. They appear at first as 
a yellowish stripe, sometimes branched, becoming pale later on, 
with pigment deposits along the margins. Choroidal rupture 
has been observed near the equator of the eyeball. 

Vision is commonly very much disturbed : in rare cases the 
eye may still retain useful vision. After resorption of the blood 
has become complete and the eye has become perfectly quiet, 
no further improvement in function may be expected. 

Traumatic detachment of the retina may be diagnosticated 
only after the extravasation has been resorbed. It may be par- 
tial or complete. Partial detachments become complete sooner 
or later. The lesion is most easily produced in myopic eyes. 
The ophthalmoscopic appearances are characteristic. Useful 
vision is permanently destroyed in every case. 

WOUNDS OF THE EYEBALL. 

Wounds of the eyeball may be incised, punctured, lacerated, 
or contused. Lacerated and contused wounds differ from others 
especially in that the injured tissues are so torn and bruised 
that primary union is not possible, healing is prolonged, and 
danger of infection is correspondingly increased. Moreover, 
inasmuch as they are due to impact of blunt weapons, the force 
required to produce them is sufficient to cause a contusion, as 
well as a laceration of the eyeball. 

Wounds of the eyeball may be infected or non-infected: 
that is to say, some wounds are contaminated by pathogenic 
microbes, and others are not. Such contamination may be due 
to an unclean instrument or weapon, to a pre-existing purulent 
inflammation of the conjunctiva, or the lachrymal sac, or to 
carelessness on the part of the patient or his attending physi- 



WOUNDS OF THE CORNEA. 73 

cian. Non-infected, or aseptic, wounds heal with little or no 
inflammatory reaction, provided that close apposition of their 
edges may be maintained. Infected, or septic, wounds, even 
though trifling in appearance, heal slowly, and the consecutive 
inflammation often invades the whole eye and destroys it. Dis- 
infection of wounds of the eyeball is much less readily accom- 
plished than is the case with wounds of other parts of the body. 
Strong antiseptic solutions irritate the deUcate structures of that 
organ and may seriously injure them. Moreover, the deeper 
parts of the wound are comparatively inaccessible. Hence it 
follows, that when infection of these lesions occurs, the conse- 
quences of them are much more disastrous than the nature of 
the injury would, at first sight, appear to warrant. 

Wounds op the Cornea. 

Wounds of the cornea may be either superficial or perforat- 
ing. Perforating wounds open the anterior chamber. Wounds 
of the cornea heal by the formation of an opaque cicatrix. The 
cicatrix of an incised or a punctured wound is much less notice- 
able than that of a lacerated or a contused wound having the 
same linear measurement. 

Both superficial and perforating wounds of the cornea cause 
distortion of its surface, resulting in irregular astigmatism, 
which may be only partially corrected by glasses. Vision is 
permanently impaired. The function of the eye is more dis- 
turbed when the cicatrix crosses the pupil than when it does 
not. In the former case, vision is impaired by the opaque scar 
and by the irregular astigmatism ; in the latter, the uncorrect- 
able astigmatism is responsible for the disturbance of sight. 

Perforating wounds of the cornea, moreover, are frequently 
complicated by prolapse of the iris, which is washed into the 
wound by the flood of outpouring aqueous humor. Speaking 
generally, loss of the aqueous is not a serious accident, for it is 
reproduced within twenty -four hours. Sudden loss of a volume 
of aqueous, however, through a large wound in the cornea, 
may be followed by dislocation of the crystalline lens into the 
anterior chamber. Prolapsed iris commonly heals in the scar 
(anterior synechia), and the pupil is distorted. Dilatation and 
contraction of such pupils go on under the varying intensities 



74 VISION AND AUDITION — WOODWAED. 

of light, and dragging upon the adhesion is the consequence. 
In many cases, this irritates the eye and may excite sympa- 
thetic irritation, or sympathetic inflammation. Or, if sympa- 
thetic disease be due to transmission of microbes, the entrance 
of the pathogenic germs into the exciting eye may be facilitated 
by the presence of iris-tissue in the corneal wound. 

Wounds of the cornea may be so destructive in themselves 
that enucleation of the eyeball should be performed at once. 
And when they are followed by plastic irido-cyclitis, removal 
of the eye may be indicated to terminate the patient's suffering 
and to prevent an outbreak of sympathetic inflammation. 

Wound's of the Ciliary Body. 

Penetrating wounds of the eyeball, involving the circum- 
comeal zone, injure the ciliary body. When the wound is 
large, prolapse of the ciliary body may follow. This is always 
a serious complication ; for it is not always advisable to abscise 
the prolapsed tissues, and incarceration of the ciliary body in 
the scar will rarely fail to excite a persistent cyclitis which 
will endanger the fellow-eye. Wounds of the ciliary body 
are universally regarded as among the most serious, if not actu- 
ally the most dangerous, injuries that befall the eye. Even 
when the wound is aseptic and the healing is prompt, subse- 
quent contraction of the scar is likely to result in chronic irri- 
tation, with great disturbance of vision, and may become the 
exciting cause of sympathetic disease. Septic wounds in this 
region are followed by violent inflammation, suppuration in the 
vitreous, and loss of the eyeball ; or they may be followed by a 
less severe attack of cyclitis, which runs a chronic course, even- 
tually blinding the eye and possibly exciting sympathetic dis- 
ease. Profuse hemorrhage into the vitreous may occur with 
wounds of the ciliary body. 

Wounds of the Lens. 

Penetrating wounds frequently injure the crystalline lens or 
its capsule. Contused and lacerated wounds may be compli- 
cated by dislocation, or by extrusion, of the lens. When the 
capsule or the lens tissue is wounded, traumatic cataract sub- 
sequently develops. In the great majority of cases, the anterior 



WOUNDS OF THE IKIS. 75 

capsule is injured, — then the aqueous humor is admitted to the 
lens tissue. The lens becomes opaque, and, if the wound in the 
capsule do not heal too rapidly, solution of its tissue is effected 
by the aqueous. Solution of the lens may be complete after 
several weeks, when the pupil will become black and clear; or 
the solution may be incomplete, when opaque lens tissue will 
give a white appearance to the pupil and obstruct the passage 
of light. In the former set of cases, evidence of the lesion is 
not obvious to the casual observer, provided that the corneal 
wound have healed, leaving a narrow linear cicatrix. Subse- 
quently the capsule, which remains unabsorbed, may become 
opaque and white. After complete solution of the traumatic 
cataract, before opacity of the capsule sets in, vision of the eye 
may be normal with proper lenses. But, power of accommoda- 
tion is wanting in such eyes, the sense of perspective is impaired, 
the eyes cannot work harmoniously, and the patient is not able 
to perform work requiring correct binocular vision. When the 
rent in the capsule is large and the substance of the lens is much 
torn, it may swell so rapidly as to fill the anterior chamber ; se- 
vere iritis may then set in, or secondary glaucoma may destroy 
the sight of the eye permanently. If solution of the lens be 
partial, or if, after complete solution, the capsule become 
opaque, vision is very much impaired, and the appearance of 
the eye is not pleasing. Divergent strabismus usually super- 
venes after a few weeks or a few months. 

Wounds of the Iris. 

Wounds of the cornea and wounds of the lens may be com- 
plicated by wounds of the iris. Hemorrhage into the anterior 
and the posterior chambers occurs at once, and may fill those 
chambers so that inspection of the structures behind the cornea 
cannot be made. Resorption of blood in the anterior or the 
posterior chamber takes place in a few days or a few weeks. 
The wound may have excited such an attack of plastic iritis 
that when the transparency of the aqueous is restored, the 
pupil may be found closed by an organized exudate. Plastic 
iritis and occlusion of the pupil are the great dangers to be 
met in wounds of the iris. Exclusion of the pupil (complete 
attachment of the margin of the pupil to the anterior cap- 



ij'Q VISION AND AUDITION— WOODWABD. 

sule of the lens) may supervene. This condition, as well as 
occlusion of the pupil, is productive of secondary glaucoma, 
unless relieved by a successful iridectomy. Naturally, septic 
wounds of the iris are followed by greater reaction than are 
aseptic wounds. The inflammatory reaction in the latter may 
be trifling; in the former, it will be intense and will extend to 
other portions of the uveal tract, viz., the ciliary body and the 
choroid. 

Wounds of the Eyeball Opening the Chamber of the 

Vitreous. 

Penetrating wounds of the eyebaU may open the chamber 
of the vitreous and allow more or less of that tissue to escape. 
Loss of a small amount of vitreous may not prove harmful. 
Greater losses are followed eventually by detachment of the 
retina and blindness. When large losses of vitreous occur, the 
globe collapses and the eye is immediately destroyed. Prolapse 
of vitreous will be greatest, other things being equal, when the 
wound in the sclera runs at right angles to an antero-posterior 
meridian of the eyeball. Such wounds gape more than others 
and heal more slowly on that account. Profuse hemorrhage 
into the vitreous may occur in such injuries, and may destroy 
the visual power of the eye. Aseptic wounds entering the 
vitreous and parallel with the antero-posterior meridian of the 
globe, even when they are not trifling in extent, may not be com- 
plicated by dangerous prolapse of vitreous or profuse hemorrhage, 
and they may heal kindly, leaving the eye in a condition of 
usefulness. But, in general, such large wounds let out so much 
vitreous, cause so great intra-ocular hemorrhage, and injure the 
choroid and retina to such an extent, that the visual power of 
the eye is lost, although in some cases the eyeball may be pre- 
served. Such eyes, however, generally become shrunken after 
a few weeks, or a few months. Septic wounds of the vitreous, 
both small and large, are followed by suppurative inflamma- 
tion. Then the patient's suffering may be severe. Unrelieved 
by surgical interference, the ocular inflammation may possibly 
threaten his life by extending to the brain. Enucleation of eyes 
which were the seat of suppurative panophthalmitis has been 
followed by metastatic meningitis and death. Such eyes may 
be eviscerated without incurring such risks. 



CHAPTEE VI. 
FOREIGN BODIES IN THE EYES. 

Foreign bodies in great variety effect a lodgment in the eye. 
They may enter in consequence of an accident, or they may be 
introduced by an adversary, or, in rare cases, the patient may 
introduce them into his own eye. In the last set of cases, 
introduction of foreign bodies into an eye Jby the patient is 
the product of a desire to keep up an irritation of the organ 
for the purpose of gain, or of an hysterical condition of the 
nervous system that thrives upon the interest and sympathy 
which the " peculiar " case excites. Foreign bodies may tra- 
verse the eyelid on their way to the eyeball, or they enter 
through the palpebral slit. They may reach the eyeball after 
traversing one of the bony walls of the orbit. In gunshot 
wounds, splinters of bone maj^ be forced into the eyeball. 

Foreign Bodies in the Eyelids. 

When the foreign body is diminutive, the wound of entrance 
may be so small that the existence of a corpus alienum in the 
eyelid may not be suspected. Even a moderately large fragment 
of metal may lodge in the eyelid without making a wound suffi- 
cient to attract much attention, if the wound of entrance be 
linear and parallel to the margin of the eyelids, and, especially, 
if several days have elapsed before the wound is carefully ex- 
amined. 

Lodgment of foreign bodies in the eyelids may result in ab- 
scess, after which cicatricial contraction may lead to deformity 
of the lid. Occasionally, a foreign body remains quiescent in 
the eyelid for a number of years, possibly becoming encapsulated, 
and does not excite any further reaction, or occasion anj symp- 
toms whatever. A body which has been lodged in this way 
for a long time may, for one reason or another, set up an attack 
of inflammation in the eyelid, and be eventually extruded from 

77 



78 VISION AND AUDITION — WOODWARD. 

the tissues altogether. Septic bodies cause suppurative inflam- 
mation, which may be followed by an attack of erysipelas, 
unless the offending substance be removed and the wound be 
thoroughly disinfected. Erysipelatous inflammation of the 
eyelids may extend to the orbital cellular tissue. Notwith- 
standing the indication that a septic foreign body is lodged in 
the eyelid which is given by the history of the injury and the 
symptoms immediately following, it is not possible to locate and 
remove the foreign body in every case. It is even possible that 
a comparatively large body may escape detection, especially 
when it is lodged in a swollen eyelid. 

A foreign body may lodge in the eyelid in such position that 
it perforates the conjunctival surface and irritates the eyeball. 
It is conceivable that in such a case the swollen conjunctiva may 
envelop and conceal the foreign body. A severe grade of in- 
flammation of the globe would doubtless ensue. Sooner or later 
the foreign body will be expelled, and then the inflammation . 
subsides. 

Foreign Bodies in the Conjunctiva. 

Foreign bodies frequently lodge in the bulbar or palpebral 
conjunctiva. A favorite site for them is the under surface 
of the superior eyelid. Minute particles of metal are not readily 
discovered. And even large bodies lodged in the superior retro- 
tarsal fold are sometimes found only after prolonged search. A 
foreign body in the conjunctiva excites inflammation. It may 
scratch the cornea, and, unless removed, set up a keratitis. The 
conjunctiva becomes swollen and may enclose the body and 
conceal it from discovery. As a rule, the offending substance 
is extruded from the conjunctival sac after a longer or shorter 
period of inflammation. In some instances, encapsulation oc- 
curs, or the foreign body remains lodged in the mucous mem- 
brane without exciting any secondary' reaction. The latter is 
observed most frequently in case of powder-grains blown into 
the eye. 

Foreign Bodies in the Cornea. 

Foreign bodies may lodge in any part of the cornea; they 
may be imbedded in the superflcial layers, or they may lie in 



POEEIGN BODIES IN THE CORNEA. 79 

the deeper layers, and they may project into the anterior cham- 
ber. Large bodies may lacerate the cornea so extensively that 
vision is destroyed by the resulting cicatrix, the appearance of 
vrhich is not pleasing. Small bodies, unless very superficially 
imbedded, leave a small scar. When the epithelial layer only 
is wounded, healing wiU. not leave a scar. Minute scars in 
the cornea are most certainly detected by oblique illumination. 
The location of them is important ; for when they lie in that 
region of the cornea through which the visual line passes, ir- 
remediable dimness of vision will be noted; whereas, if they 
be laterally located, they do no harm whatever. If small bodies 
in the epithelial layers even of the cornea are not removed 
promptly, inflammation with ulceration is most likely to ensue, 
and the resultant cicatrix is correspondingly increased in size. 
This will hold true in the case of more deeply imbedded bodies. 
A minute septic foreign body, even though very superficially 
lodged in the cornea, excites destructive ulceration, leading to 
loss of the eye, by perforation of the cornea, or by the presence 
of a large cicatrix formed in the process of repair. 

Deeply imbedded foreign bodies excite inflammatory reac- 
tions and lead to results similar to those alreadj- mentioned. 
Septic bodies deeply lodged excite very serious inflammation, 
which may extend to the uveal tract. Hypopyon, plastic iritis, 
and even cyclitis may follow in the train of such injuries. The 
offending substance may work its way to the surface and be 
extruded, or it may ulcerate through the posterior layers and 
drop into the anterior chamber. The latter event is a decisive 
catastrophe. 

In certain uncommon cases, the corneal wound may close 
over the foreign body which may remain imbedded, either 
encapsulated or not, without exciting secondary reaction, 
through a period of years. But it is not uncommon to observe 
powder-grains in the cornea which have been lodged there many 
years without causing any irritation. 

The presence of a foreign body in the cornea is not always 
easy to detect. This is true of the following sets of cases : those 
appearing for examination after an intense keratitis has set in ; 
those in which awkward and unsuccessful attempts have been 
made to extract the foreign body ; those in which the foreign 
body has lodged deeply, and the adjacent cornea has become 



80 VISION AND AUDITION — WOODWARD. 

opaque. Under such circumstances it may be impossible to 
detect the foreign body. But the attending physician should 
assume that a corpus alienum has lodged in the eye, whether 
he can find it or not, provided that the circumstances under 
which the accident occurred, together with the symptoms ob- 
served in the case, create a strong probability that a missile has 
entered the eye. 

Foreign bodies in the cornea should be removed as soon as 
possible. Fragments of metal often enter the cornea in a heated 
state. The only disadvantage arising from this circumstance 
is that they adhere very firmly to their bed, and are therefore 
more difficult of removal. Deeply lodged bodies may drop into 
the anterior chamber during attempts to extract them. The 
eyeball must then be opened. Vegetable substances may be 
broken during attempts to extract them, and a small fragment 
be retained in the eye undetected. In still other cases, it may 
not be possible to remove the foreign body from the cornea. 

Foreign Bodies in the Iris, the Anterior and the 
Posterior Chamber, and in the Ciliary Body. 

Foreign bodies obtain access to the iris by passing through 
the cornea, or by penetrating the deeper regions behind the iris. 
As a rule, they enter through the cornea. They may lodge at 
any point on the surface of the iris; they may penetrate its 
tissues, they may perforate the iris and pass on to the lens or 
the ciliary body. The propulsive force may drive the body so 
that it simply impinges upon the anterior surface of the iris, 
from which it falls into the anterior chamber; or the force 
drives the bodj' through the iris and it falls into the posterior 
chamber, where it may lie so as to persistently irritate the 
ciliary processes. 

Aseptic foreign bodies may lodge in the iris or in the an- 
terior or the posterior chamber, and remain there without doing 
much, if any harm, provided that they are of small size and 
their chemical composition is not deleterious. Small particles 
of iron or glass, in especial, may lodge in this way. They may 
become encapsulated. But these cases are exceptional. Septic 
bodies lodged in these regions excite violent suppurative irido- 
cyclitis, which will prove fatal to the eye, and endanger its 



FOREIGN BODIES IN THE IRIS. 81 

fellow. Whether the foreign body be septic or aseptic, the 
mechanical injury to the iris may be followed by plastic iritis, 
resulting in a more or less permanent injury to the eye. 

Foreign bodies in the iris, or the anterior chamber, are, as a 
rule, open to detection in recent injuries, unless considerable 
effusion of blood into the anterior chamber have occurred. After 
inflammation has set in, cloudiness of the cornea, swelling and 
discoloration of the iris, turbidity of the aqueous humor, a col- 
lection of blood or pus in the anterior chamber, may so obscure 
the view that the foreign body may not be found. A probable 
diagnosis of the presence of a foreign body in these regions of 
the eye may be based upon the history of the injury, the exist- 
ence of a perforating wound of the cornea, the presence of blood 
or pus in the anterior chamber, irregularity of the pupil, and 
the existence of synechiae, especially anterior synechia. It 
should be assumed that a foreign body has entered these regions, 
if the probability is strong that one has so entered. A few eyes 
may be sacrificed, perhaps, unnecessarily, by adhering to such 
a rule of action ; but the danger of subsequent sympathetic dis- 
ease and total blindness is sufficient reason for keeping on the 
safest side in all cases. 

Mauthner ' cites the following experience, which illustrates 
very forcibly the obscurity which enshrouds some of these in- 
juries : " The patient had severely wounded his right eye while 
discharging a musket. He avowed with the utmost confidence 
that no foreign body was lodged in the eye. But it was evident 
that a perforation, located in the centre of the cornea, ha.d been 
made by a bit of an exploded percussion-cap. Had the frag- 
ment rebounded from the capsule of the lens, or had it, per- 
chance, penetrated the lens itself? These points could not be 
then determined, for a large amount of pus occupied the anterior 
chamber and concealed the pupil. The iris was prolapsed into 
a puncture, which had been made in the lower border of the 
cornea for the purpose of evacuating the pus. It was in this 
condition that I first saw the patient. It was impossible, at 
that time, to decide whether the purulent masses which still 
occupied the pupil were nodules of exudation upon the anterior 
capsule, or were swollen and suppurating fragments of the 
wounded lens; the latter condition, however, seemed the more 
' "Sympath. Dis. of Eye," pp. 18, 19, 20. 
III.— 6 



82 VISION AND AUDITION— WOODWARD. 

probable. Nevertheless, the pus gradually disappeared, and 
although the pupillary border of the iris was found extensively 
adherent to the anterior capsule, neither the latter nor the lens 
had been wounded.' The eye continued to improve, but, along 
with some lachrymation and pain, a slight conjunctival injec- 
tion persisted around the dark-colored spot where the iris had 
prolapsed. One day, while examining the eye more carefully, 
in order to discover the cause of the obstinate irritation, I no- 
ticed that the dark, prolapsed iris had a distinct metallic lustre, 
so that I at once suspected the presence of a piece of metal. 
With a pair of fine forceps I extracted, f roin a small excavation 
in the corneal edge of the sclerotica, where it lay imbedded, a 
roUed-up piece of copper cap, 4 mm. long and 2i mm. wide. 
All the signs of irritation now disappeared in a short time. A 
fortunate accident had saved the wounded eye and its mate. 
The piece of metal had penetrated the cornea, struck the anterior 
capsule of the lens without opening it, and had then rebounded 
to the bottom of the posterior chamber, where it lay directly 
upon the ciliary body and excited a severe inflammation of the 
whole anterior part of the eyeball. The puncture of the cornea 
which had been made for the removal of pus from the anterior 
chamber having luckily been unskilfully performed, a portion 
of the iris fell through the incision, and into the pocket-like 
duplication thus made the piece of metal was received. After 
necrosis of the prolapsed iris the metal lay freely exposed at the 
edge of the cornea. Had the operation been made according to 
rule the iris would not have prolapsed, and the foreign body 
left within the globe would, in all probability, have produced a 
dangerous cyclitis, with the chance of involving the second eye."' 
Disappearance, by chemical action, of small particles of iron, 
and copper, which had lodged in the iris, has been reported. 
Such occurrences, and also examples of encapsulation or of innoc- 
uous lodgment of foreign bodies in the iris, or anterior chamber, 
are observed so exceptionally, the onset of dangerotis irido- 
cyclitis being quite common to these injuries, it follows that 
the only safe rule to adopt for the management of the cases 
is to remove the foreign body as soon as possible. In the great 
majority of cases, so long as a foreign body remains lodged in 
the anterior chamber, the iris, the posterior chamber, or the 
ciliary body, so long is the eye in a dangerous state, both as 



FOREIGN BODIES IN THE CRYSTALLINE LENS. 83 

regards its own integrity, as well as that of its fellow, by 
virtue of the pathogenic, the mechanical, or the chemical in- 
fluences exerted by the foreign body. No certainty exists, in 
any case, that an encapsulated foreign body will always be 
innocuous. It may subsequently excite a violent secondary re- 
action, precluding the possibility of saving the vision of 
either ej'e. 

Foreign bodies enter the ciliary body through the cornea and 
iris, or through the sclera. In the most common cases, the 
wound of entrance is near the sclero- corneal junction. As a 
rule, severe cyclitis immediately supervenes. The inflamma- 
tory process extends forward to the iris and backward to the 
choroid. Suppuration may occur in the vitreous. The dangers 
incident to wounds of the ciliary body, referred to in a preced- 
ing section, are intensified when the injury is complicated by 
lodgment of a foreign body in that region. Unless removed, 
the foreign body in the ciliary region will almost certainly 
destroy the eye and excite a fatal sympathetic inflammation in 
the uninjured eye. After removal of the foreign bod}', the eye 
may become quiescent and remain so, or a chronic cyclitis may 
persist and obstinately threaten the fellow-eye, while it destroys 
the usefulness of the injured organ. A foreign body lodged in 
the ciliary region may, however, in very rare cases, remain there, 
doing comparatively little harm, after the primary reaction has 
subsided. Years afterward, relapses of the cyclitis may set 
in and the foreign body be expelled. After this has occurred, 
the eye may remain quiescent for the remainder of the patient's 
life, or relapses of cyclitis may recur, owing to the irritation 
incident to contraction of the cicatrices, and sympathetic in- 
flammation may eventually break out in the sound eye. 

Foreign Bodies in the Crystalline Lens. 

The lens may be invaded from in front or from behind. The 
foreign body, in nearly all cases, penetrates the cornea before 
striking the lens. It may, or may not, wound the iris. It may 
lodge near the anterior capsule, or it may penetrate more deeply 
into the substance of the lens. Foreign bodies entering the 
lens from any direction wound the capsule. Either the aque- 
ous or the vitreous then comes in contact with the lens tissue. 



84 VISION AND AUDITION — WOODWARD. 

and a traumatic cataract will be developed. Lesions of the 
anterior capsule admit the aqueous humor to the lens. When 
the rent in the capsule is small, it may heal promptly, leaving 
the foreign body imbedded in the traumatic cataract, where it 
may remain for years without originating further irritation. 
Vision is obscured by the cataract. Large rents in the anterior 
capsule do not heal quickly enough to prevent solution of the 
cortex of the lens by the aqueous humor. The cases run the 
same course as that already described for wounds of the lens. 
When solution has advanced a certain stage, the foreign body 
may become loose in the capsule and excite a persistent irrita- 
tion, leading to irido-cyclitis, and, possibly, sympathetic oph- 
thalmia; or the foreign body may still be firmly attached in 
such position that it does not irritate the eye. As solution of 
the cataract progresses, vision of the eye improves, until even- 
tually the media may be clear again, leaving the sight good 
with cataract glasses. The usefulness of the organ is impaired, 
however, as explained when discussing wounds of the lens. 

It may be predicted as true of nearly all cases that small 
fragments of metal or stone lodged in a lens, which becomes 
cataractous but does not undergo solution, will remain imbedded 
for many years, without exciting secondary irritation of the eye 
and without predisposing to sympathetic inflammation. Bodies 
in a septic state, however, will excite suppuration and its at- 
tendant dangers. Whenever, therefore, a small fragment of 
metal has entered the lens, the eye may be kept under observa- 
tion for a time before any surgical interference is undertaken. 
This is especially applicable to cases injured by fragments of 
iron, copper, stone, or glass, the temperature of which had been 
elevated immediately before entering the eye ; for the elevation 
of temperature will more or less completely disinfect the foreign 
body. Should the primary irritation be moderate in severity 
and show a tendency to subside promptly, the foreign body may 
be allowed to remain in the eye. It may be extracted subse- 
quently with the cataractous lens, if secondary irritation super- 
vene, or if the patient desire the operation for cosmetic effect. 
If, however, the primary irritation become severe and threaten 
the eye by irido-cyclitis, an attempt must be made to remove 
the offending substance, lest the inflammatory reaction advance 
beyond control. Panophthalmitis and loss of the eyeball may 



FOREIGN BODIES IN THE VITREOUS. 85 

result, and the danger of sympathetic ophthalmia must be kept 
constantly in mind. 

Larger bodies cause larger rents in the capsule, through 
which the aqueous reaches the lens and may cause so rapid 
swelling of it that iritis, or secondary glaucoma, may supervene. 
Moreover, such bodies excite greater reaction in the eye by vir- 
tue of mechanical irritation and the septic material borne into 
the eye by them. It may be possible to combat such conditions 
successfully, and the foreign body may become encapsulated in 
such a position that secondary irritation may not arise. But, 
while attempts are being made to attain this result, the patient 
is exposed to a greater danger than that incident to an operation 
for the removal of the foreign body. No guarantee may be 
given that the foreign body will become encapsulated; it is 
much more probable that it wiU sink into the ciliary region and 
cause a very dangerous irido-cyclitis, or it may fall into the 
vitreous and set up inflammation there. In either contingency, 
an outbreak of sympathetic ophthalmia may be anticipated. 
On the whole, therefore, extraction of such large bodies should 
be undertaken at the very beginning. Removal of the foreign 
body may not be accomplished in some cases, even by compe- 
tent ophthalmic surgeons. Then the question of enucleation of 
the eyeball must be entertained. 

Foreign Bodies in the Vitreous. 

A foreign body may penetrate the cornea with sufficient 
force to pass on through the iris and lens into the vitreous. 
More frequently, foreign bodies enter the vitreous by perfo- 
rating the sclera. When they pass through the circum-corneal 
zone, in their transit to the vitreous, they must penetrate the 
ciliary body. Foreign bodies may lodge in the scleral wound 
or in the ciliary body. They may have been propelled by a 
force just sufficient to drive them through the tunics of the 
. eyeball (sclera, choroid, retina), when they will drop into the 
vitreous ; or they may traverse the vitreous, impinge upon the op- 
posite side and drop back, and sink to the bottom of the eye. Or, 
they may become imbedded in the retina, choroid, or sclera, on 
the opposite side of the eye. Cases showing that foreign 
bodies may be imbedded in the optic disc are on record. A 



8(5 VISION AND AUDITION— WOODWARD. 

foreign body (e.g., bird-shot) may perforate the eyeball and 
lodge in the tissues of the orbit. Splinters of wood, thorns, etc., 
may transfix the eyeball. 

When a foreign body enters the vitreous by way of the cor- 
nea, the danger incident to the presence of the body in the vitre- 
ous is complicated by the perforating wound of the cornea, iris,' 
lens, and probably of. the ciliary body. Other things being 
equal, such lesions are the most dangerous of this class of 
injuries. 

When a foreign body enters the vitreous by way of the cili- 
ary region, the case is complicated by wound of the ciliary 
body, often resulting in a destructive inflammation of the whole 
uveal tract. 

The simplest cases of entrance of foreign bodies into the 
vitreous are those not complicated by traumatism of the ciliary 
body, lens, iris, or cornea. In these simpler lesions, much de- 
pends upon the size of the foreign body. Large fragments of 
stone, metal, glass, etc., rend the sclera so widely that a large 
prolapse of vitreous takes place immediately, the eye will fill 
with blood, and these two effects sufl&ce to destroy the eye at 
once. The presence of a large body in the vitreous will me- 
chanically excite so much inflammation that no hope may be 
entertained of preserving the function of the eye. Smaller 
bodies may enter the vitreous after slitting the sclera by strik- 
ing it in an oblique direction and cause a fatal prolapse of 
vitreous. 

Even large bodies may lodge in the vitreous chamber, and 
after the initial inflammation has subsided, the shrunken and 
useless globe may remain free from irritation for a number of 
years. Eventually, however, the inflammation will recur, and 
may subside again. Such recurrent inflammatory outbreaks will 
be noted from time to time until eventually the other eye may 
be sympathetically diseased. The resulting blindness will then 
be a consequence of an injury sustained many years before. In 
some cases, the eyeball opens during one of the relapses of in- 
flammation, and the foreign body is expelled, thus greatly di- 
minishing the danger of sympathetic disease. Fragments of 
glass seem to be better tolerated in the vitreous chamber than 
other large foreign bodies. 

' Ixis may escape injury. 



FOREIGN BODIES IN THE VITREOUS. 87 

Small particles of metal entering the vitreous may lodge in 
the retina, choroid, or optic nerve. They may fall to the bottom 
of the eye, where they may become encapsulated. They may 
lodge in the retina, choroid, or nerve, where they may become 
encapsulated, or they may not. It is not a very uncommon ex- 
perience to observe small particles of metal lodged in the retina 
or choroid (apparently not encapsulated), which have remained 
in the eye for a nuniber of years without destroying the useful- 
ness of the organ and without endangering the fellow-eye. 

In Hirschberg's Clinic, the writer saw a patient in whose 
retina a fragment of iron could be seen perfectly distinctly with 
the ophthalmoscope ; the iron had entered the eye twenty years 
earlier and had neither destroyed vision, nor endangered the 
fellow-eye since the primary effects of the injury had subsided. 
Since then I have seen cases of a similar nature. One of them 
was a man whose right eye was useless, owing to a wound of 
the cornea received when he was a child. While driving nails, 
a fragment of iron penetrated his sound eye. The fragment 
made a very small wound in the conjunctiva and sclera about 
one centimetre from the nasal margin of the cornea. Vision 
was much blurred by hemorrhage into the vitreous. About one 
week after the accident he came under my observation. The 
track of the missile through the anterior portion of the vitreous 
was then visible ; but the position of the missile could not be lo- 
cated. Subsequently, however, the vitreous cleared up and the 
fragment of iron was seen lodged in the retina below the optic 
nerve. Inflammatory reaction subsided in a few weeks, and 
the patient returned to work, with glasses for his hypermetropia 
and as a protection against further accident. Three years later, 
he called to inquire about his glasses. The fraginent of iron 
was still in the retina, but appeared to be smaller. It had not 
given him any trouble, and he had worked as usual. He was 
enjoined to return if the eye troubled him. I have not seen him 
since, five years after the injury. Eecently I have seen another 
case in which a fragment of iron or steel has been lodged in the 
retina for seven years (after perforating the sclera), without in- 
juring the usefulness of the eye. The missile is still readily 
detected with the ophthalmoscope. 

The favorable course observed in cases of this nature is de- 
pendent upon the following conditions, namely: The small size 



88 VISION AND AUDITION— WOODWARD. 

of the foreign body, freedom from septic infection, the compara- 
tively trifling hemorrhage into the vitreous, fixation of the 
missile, and the material of which it is composed. Attention 
has been directed to the effect that may be expected when large 
bodies enter the eye. Small foreign bodies generally make 
small wounds; prolapse of vitreous, therefore, either does not 
occur, or it is very trifling in amount. Other things being 
equal, small bodies are less likely to carry septic infection than 
large bodies. In a large number of cases, the small foreign 
body is a fragment of iron or steel, the temperature of which 
had been raised immediately before it entered the eye. Such 
missiles are aseptic, or nearly so. Missiles, such as bird- 
shot and heated fragments of glass are likewise aseptic. Par- 
ticles of copper may enter the eye in an aseptic state. But 
fragments of stone and vegetable substances, for example, 
twigs, pieces of bark, etc., are never in an aseptic condition. 
Not all particles of iron or steel, or glass, or copper, or gunshot 
missiles enter the eye in an aseptic state. When they carry 
septic infection into the vitreous, suppurative panophthalmitis 
will follow and destroy the eye. Hemorrhage into the vitreous 
occurs when foreign bodies penetrate into that tissue. Large 
hemorrhages in themselves destroy, or seriously injure vision 
permanently. Small hemorrhages may be resorbed, leaving the 
vitreous clear. 

Aseptic particles of iron, steel, or glass lodged in the interior 
of the eye, and immovably fixed by encapsulation or otherwise, 
may not cause very serious injury. But foreign bodies of any 
variety that are not fixed in the eye, but change their position 
from time to time, are exciters of destructive inflammation of 
the uveal tract, and of sympathetic ophthalmia. A foreign body 
having remained fixed for a number of years, may subsequently 
beconie movable. When this occurs, the eye, which had been 
free from irritation and perhaps as useful as its fellow, is at- 
tacked by an inflammation that may exist a few weeks and then 
subside, leaving the sight more or less impaired. Relapses re- 
cur at variable intervals, until the sight is lost, the globe shrinks, 
and sympathetic disease of the other eye sets in. In other cases, 
the inflammation does not subside imtil these effects have taken 
place. The patient may thus become blind in consequence of 
the primary inflammation, aggravated by the existence of a 



FOREIGN BODIES IN THE VITREOUS. 89 

movable foreign body in the chamber of the vitreous. A foreign 
body, that may at first have been movable, may become fixed by 
the products of inflammation, and the eye may recover with 
more or less vision, or the globe may be preserved, though 
sightless. 

Vegetable substances, copper, and mercury are not tolerated 
in the eye. Copper and mercury excite chemical reactions, that 
in turn excite destructive inflammation. 

The treatment of one of these cases may be the subject of a 
medico-legal investigation. And the question arises, what con- 
stitutes an appropriate treatment of a case of foreign body in 
the vitreous? Obviously, no hard and fast rules may be laid 
down for the surgeon's guidance. In general, it may be said 
that the body should be extracted as soon as possible. The cases 
cited show that this rule should not be applied to all eyes con- 
taining foreign bodies. When the scleral wound is large and 
the loss of vitreous is great, no hope should be fostered that con- 
servative measures will give a favorable issue ; then, the eyeball 
should be removed to prevent suffering, and to obviate danger 
to the fellow-eye. Chronic inflammation of the uveal tract, or 
relapsing inflammation of the uveal tract, in eyes that contain 
a foreign body, must be treated by removal of the foreign body, 
or by enucleation of the eye ; for by such management only may 
an attack of sympathetic disease be prevented. 



CHAPTER VII. 

SYMPATHETIC DISEASES OP THE EYE. 

I. Sympathetic Irritation.— II. Sympathetic Inflam- 
mation. 

Syn. — Sympathetic Ophthalmia; Sympathetic Ophthalmi- 
tis; Ophthalmia Sympathica ; Irido-Cyclitis Sym- 
pathetica. 

When a morbid state of one eye depends for its existence 
upon a pre-existing disturbance of the other, the ej'e is said to 
be sympathetically affected. We have to consider sympathetic 
irritation and sympathetic inflammation. In both, the eye 
first affected is the exciting eye, or exciter, and the eye secon- 
darily diseased is the sympathizing eye, or sympathizer. In 
the former, the changes in the sympathizer are not structural, 
but have the nature of a functional disturbance. In the latter, 
the sympathizer exhibits the lesions of an inflammatory process 
involving a greater or less extent of the uveal tract. The former 
is a disease which responds promptly to treatment; the latter 
is a very grave malady, difficult to handle, ending, in the 
majority of cases, in blindness. 

I. SYMPATHETIC IRRITATION. 

Symptoms in the Exciting Eye.— They are attacks of 
ciliary injection, tenderness in the ciliary region, pain, photo- 
phobia, and lachrymation. Vision is more or less impaired; 
the eye may be blind. Objectively, inflammatory changes may 
be readily discovered, although in some they may be so incon- 
spicuous as to be overlooked. The subjective symptoms may 
subside and recur from time to time. 

The Symptoms in the Sympathizing Eye.— The eye 
is weak and easily fatigued. The acuteness of vision is usuaUy 



SYMPATHETIC IRRITATION. 91 

impaired, but it maj be normal. Photophobia, lachrymation, 
and pericorneal injection are more or less marked. The ciliary- 
region may be tender to pressure at a point corresponding to the 
region of greatest tenderness in the exciter. Ciliary neuralgia 
may become a prominent symptom. Blepharospasm, photopsia, 
and contraction of the field of vision have been observed. 

The symptoms of sympathetic irritation usually come on 
immediately after the outbreak of the disturbahce in the ex- 
citer, or their appearance may be delayed a few days or a few 
weeks. The attacks may come and go at irregular intervals 
for months and years. That sympathetic irritation may pass 
into sympathetic inflammation is denied by Swanzy,' Meyer," 
and D'Oench.' But Fuchs,' Nettleship," Juler," Mauthner,' 
and De Schweinitz * are of the opinion that, in some cases, sym- 
pathetic irritation is the premonitory stage of sympathetic in- 
flammation. Rossander ° holds that sympathetic inflammation 
may succeed sympathetic irritation, and accounts for the infre- 
quent occurrence of such a change by the fact that competent 
surgeons resort to the preventive treatment early in the case. 
According to Lawson," "sympathetic irritation is closely allied 
to sympathetic ophthalmia, and although it presents features 
different from sympathetic inflammation, yet it may and fre- 
quently does drift into it. . . . " In the report of the committee 
on sympathetic ophthalmitis," Cases 2 and 40 in the tables are 
examples of irritation- passing into, or succeeded by inflamma- 
tion, after excision of the exciter. 

Sympathetic irritation may run a course of a few days or a 
few weeks and terminate in permanent recovery ; or the recov- 
ery may be temporary, and the symptoms may recur again and 
again at irregular intervals for years, without change in the 
character of the malady ; or, in one of the attacks, the sympa- 
thizer may become the seat of true sympathetic inflammation. 

' " Dis. of the Eye, " 1890, p. 255. ' " Sympathetic Diseases of the 

2 "A Practical Treatise on Dis. of Eye," New York, 1881, pp. 68, 69. 
Eye," 1887, p. 216 ' "Diseases of the Eye," 1892, p. 

* Archives of Ophthalmology, New 337. 

York, 1887, p. 201, vol. xvi. « Annales d'Oculistique, 1876, p. 

* " Lehrbuch der Augenheil- 301 et seq. , abstract. 

kunde," 1891, pp. 320, 321. '"Royal London Oph. Hosp. Ee- 

5 "Dis. of the Eye," 1890, p. 173. ports, vol. x., 1880, p. 2. 

""Handbook of Oph. Science " Tr. Ophth. Soc. Unit. King., 

and Practice, " 1884, p. 162. vol. vi. 



92 VISION AND AUDITION — WOODWARD. 



II. SYMPATHETIC INFLAMMATION. 

Sympathetic inflammation has no typical form ; it has no 
character sui generis which differentiates it from other cases 
of irido-choroiditis, whether they be serous or plastic' To this 
opinion of De Wecker's there can be no valid objection ; and it 
follows that by the objective symptoms alone a diagnosis of the 
sympathetic nature of the disease cannot be sustained. 

Symptoms in the Exciter. — There is, commonly, well- 
marked objective evidence of inflammation in t^e uveal tract, 
but the lesions may be indistinct and unnoticed. " An inflamma- 
tion in the uveal tract of the exciting eye is a necessary factor in 
the production of sympathetic inflammation." ' Vision may be 
good ; commonly it is seriously impaired, and often it is totally 
destroyed. Pain, photophobia, lachrymation, ciliary injection, 
and tenderness are usually present. In some cases, however, 
the exciter may be quiet, that is, it may give no signs of irrita- 
tion, when sympathetic inflammation breaks out in the sympa- 
thizer.' Tenderness in the ciliary region, causing the patient 
to shrink away in a significant manner when that point is 
touched gently through the closed eyelid, is often marked. But 
that does not necessarily imply that an attack of sympathetic 
inflammation is imminent.* 

Symptoms in the Sympathizer.— They depend in some 
measure upon the form of the disease. Sympathetic inflamma- 
tion may present a variety of lesions. The greater number of 
the cases are examples of plastic irido-cyclitis and plastic irido- 
choroiditis.' A certain number of cases are instances of plastic 
iritis only. Frequently the sympathetic inflammation exhibits 
the characteristics of serous iritis and serous irido-choroiditis. 
Swanzy and others ' believe that the serous form of inflamma- 

•De Wecker: Annales d'Oculis- Brailey, W. Adams Frost, R. Mar- 

tique, June, 1893, p. 413. cus Gunn, Wm. Lang, J. B. Law- 

« Schirmer : Ophthalmic Review, ford, E. Nettleship. 

London, vol. xii., March, 1893, p. -• Swanzy, op. cit., p. 256. 

89; » " Graefe-Saemisch Handbuch d. 

"Tr. Ophth. Soc. Unit. King., Augenheilkunde," 4, p. 520. 

vol. vi. Tables of 211 cases of ^ Op. cit., p. 256; De Wecker, 

sympathetic ophthalmia. The com- "Traite complet d'Ophthal.," tome 

mittee making the report was ii., Paris, 1886, p. 321. Milles, 

composed of the following oph- Brailey, Royal London Oph. Hos. 

thalmologists : John Couper, W. A. Rep., vol. x. 



SYMPATHETIC INFLAMMATION. 93 

tion is the first stage of nearly all cases of sympathetic ophthal- 
mitis, which as a rule passes into the plastic variety. This 
opinion should be accepted with some reserve. Admitting that 
the presence of "keratitis punctata" is presumptive evidence 
that severe inflammation is present in the uveal tract, I exam- 
ined the histories of the 211 cases of sympathetic ophthalmitis in 
the report ' already alluded to, and found " keratitis punctata" 
mentioned in only 36 cases. After making due allowance for 
the unavoidable imperfections in the histories, this finding still 
casts a measure of doubt upon the accuracy of Swanzy's ob- 
servation. ° 

Neuro-retinitis, in rare cases, is the form of the sympathetic 
disease.' Schirmer thinks there is "ample evidence that there 
is such a condition as a primary sympathetic papillo-retinitis." 
It is a benign affection, cured by enucleation, and depends upon 
the transmission of bacterial products from the exciter.* 

Exceptional cases of sympathetic conjunctivitis and sympa- 
thetic keratitis are mentioned by Noyes and others.'' 

The disease may come on insidiously and pass beyond the 
initial stages before the patient's attention is attracted. Law- 
son ' says : " The disease usually commences without pain as a 
warning, though it is commonly preceded by a certain amount 
of irritation, slight photophobia, impairment of accommodation 
sufificient to give rise to fatigue of the eye, and lachrymation. 
One or all of these symptoms may be present, and in an adult 
would probably draw attention to the state of the eye, but in a 
child they are not, as a rule, suflScient to lead him to make 
complaint, so that in children the disease is not infrequently far 
advanced before it is detected." In 40 of the 211 cases already 
referred to, the sympathetic disease began insidiously. In 36 

' Tr. Oph. Soc. Unit. King. , vol. " Ophthalmic Review, vol. xii. , 

vi. March, 1893. 

2 Compare Mauthner, " Sympathe- ^ Noyes, " Dis. of the Eye, " 1890, p. 
tic Diseases of the Eye, p. 81 etseq., 493 ; G. L. Johnson, Archivesd'Oph- 
and p. 168. In same line is the thalmologie, Jan., 1893, p. 53, case 
evidence in Gunn's cases, B. L. of sympathetic keratitis. Forcriti- 
Ophth. Hosp. Rep., xi., 1886-87. cism of recorded cases of sympathe- 

3 Tr. Oph. Soc. Unit. King. ; Alt, tie conjunctivitis, and sympathetic 
Archives of Oph. and Otol., New keratitis, see Deutschmann, "Oph- 
York, vol. V. ; Deutschmann, "Oph- thalmia Migratoria," pp. 108-116, 
thalmia Migratoria," gives many also Schirmer, Ophthalmic Review, 
references to cases of this nature, March, 1893, pp. 91-93. 

pp. 117-119. * R- L- Oph. Hosp. Reports, 1880, 

vol. X., p. 1. 



94 VISION AND AUDITION — WOODWARD. 

of these both eyes were not painful, or were quiet. In 2 of the 
remaining 4, the exciter was quiet, while the sympathizer was 
painful; and in 2 the sympathizer was quiet, while the exciter 
was painful. 

In the plastic form of inflammation in the sympathizer, 
ciliary injection and tenderness are usually well marked, the 
pupil is contracted, and numerous synechise quickly attach the 
pupillary margin of the iris to the capsule of the lens. The 
posterior synechiae may be complete, shutting off all communi- 
cation through the pupil between the anterior and the posterior 
chambers. The pupillary space may be filled with a plastic 
exudate, which may also fill the posterior chamber and invade 
the ciliary body. In rare cases, pus and blood may be found in 
the anterior chamber. The choroid may be invaded by the 
plastic inflammation. The vitreous becomes turbid with parti- 
cles of plastic material. Thus, the eye may be the seat of plastic 
iritis, plastic cyclitis, and plastic choroiditis at the same time. 
Early in the disease, the intra-ocular tension may rise, but 
eventually, in severe cases, the eyeball becomes soft and atrophic. 

The subjective symptoms are ciliary neuralgia, photophobia, 
lachrymation and impairment of vision, amounting to absolute 
blindness in the worst cases. The neuralgic pains may be very 
severe in the eye, and in bad cases they may extend to branches 
of the fifth nerve, other than the ophthalmic. 

Both the objective and the subjective symptoms vary greatly 
in severity in the different cases. The symptoms may amelior- 
ate and the eye may return to a state of usefulness, though gen- 
erally it still exhibits some sequelae of its hazardous experience. 
Exceptional cases have been observed in which there has been 
a single attack of sympathetic inflammation, resulting in recov- 
ery with a useful eye. As a rule, the course is less favorable. 
After a period of quiescence, a relapse occurs, and after one or 
more relapses the eye is destroyed. The severest cases are the 
more common and end in blindness.' 

In the serous variety of inflammation in the sympathizer, 
the circumcorneal injection is not very marked; the iris is dis- 
colored, the pupil is small; there may be a few posterior syn- 
echiae; the anterior chamber is deep; the aqueous humor is 

' Fuchs, op. eit., p. 313; Schirmer, Ophthalmic Review, vol. xii., 
March, 1893, p. 94. 



SYMPATHETIC INFLAMMATION. 95 

cloudy. Small grayish-white dots in variable numbers are 
found on the posterior surface of the cornea— this is "keratitis 
punctata." The vitreous is turbid, and chorio-retinitis or pa- 
pillitis may be noted, if the media are sufficiently clear. Vision 
is impaired. Photophobia, lachrymation, and mild attacks of 
pain complete the list of symptoms. 

The disease may run a chronic course, and, in exceptional 
cases, terminate in recovery with a useful organ, without opera- 
tive interference directed to the exciter. ' Other cases make a 
less complete recovery and are subject to relapses. Still other 
cases, the greater number, end in blindness. The serous vari- 
ety of sympathetic inflammation is considered the benign form 
of the disease, whereas the plastic variety is justly regarded as 
the malignant form. 

Etiology. — Syrapathetic irritation may appear in conse- 
qence of a variety of injuries and diseases of the eye. The cau- 
sation of sympathetic inflammation has been held to be the 
same. But the more thoroughly the matter is sifted the clearer 
does it appear that in order that sympathetic inflammation may 
break out in the fellow-eye, it is necessary that inflammation of 
the iris and ciliary body in the exciter shall be present. An 
irido-cyclitis not due to a perforating lesion of the tunics of the 
eyeball is very exceptionally the cause of sympathetic inflam- 
mation. The committee on sympathetic ophthalmitis were 
of the opinion that "' sympathetic ophthalmitis occurring with- 
out a perforating lesion of the exciting eye is, if not unknown, 
at any rate extremely rare." ' The perforating lesions that may 
be followed by irido-cyclitis are wounds of all varieties — lace- 
rated, contused, incised, punctured, accidental, and operative. 
The wound is most dangerous when it involves the ciliary re- 
gion. This is the general opinion of ophthalmic surgeons. 
The strongest objection ^o this view of the matter is that made 
by Alt. Having critically examined 110 eyes enucleated for 
sympathetic ophthalmia, Alt reports the following conclusion 
bearing upon this question : " Cicatrices and foreign bodies in 
the ciliary body or incarceration of it— which are usually looked 
upon as the most important factor in sympathetic affections — 
appear in only 17^ per cent, while the affections of the ciliary 
body all together amount to 76^ per cent. The iris is changed in 
' Noyes, op. cit, p. 490. ' Tr. Oph. Soc. U. K., vol. vi., p. 179. 



96 VISION AND AUDITION— WOODWARD. 

but 68 per cent, and the choroid in 73 per cent, thus showing 
about the same number of changes in each of the parts of the 
uveal tract, with only a slight percentage in favor of the ciliary 
body." ' Gunn found that "as regards the accidental wounds, 
the mere position of the injury did not seem to influence the 
character of the inflammation or the result ; wounds of the cili- 
ary region had as low a percentage of severity as those confined 
to the cornea with implication of the iris. Similarly the nature 
of the instrument appeared to make no difference in this re- 
spect."" 

The entrance of foreign bodies into the eye must cause a 
penetrating lesion. Such injuries may be the initial stage in 
the etiology of sympathetic inflammation. "When the foreign 
body has lodged in the tissues of the eyeball in such a position 
that extraction of it is impossible, the gravity of the case is 
aggravated. Randolph thinks that "by far the greater num- 
ber of sympathetic eye-troubles are caused by the entrance of 
foreign bodies. Clinical experience shows us every day that 
wounds resulting from infectious foreign bodies cause the most 
violent inflammations, and, on the contrary, wounds caused by 
aseptic matter result in comparatively little disturbance. "° Schir- 
mer's conclusions are doubtless nearer the truth. He is of the 
opinion that "it is the inflammation which follows a perforating 
wound, and not the wound itself, which threatens the fellow- 
eye, and such inflammation is usually due to infection through 
the wound. The danger attaching to the presence of a foreign 
body in the interior of the eye has probably been somewhat 
overrated, for there is no evidence that aseptic foreign bodies 
can cause sympathetic inflammation, even though, as in the 
case of fragments of copper, they may by chemical action dam- 
age the injured eye. The danger lies in the fact that very 
many foreign bodies carry infective organisms with them into 
the eye. The only cases in which a foreign body was supposed 
to affect the fellow-eye without the intervention of uveitis in 
the injured eye, were cases of sympathetic irritation only. The 
most dangerous cases are those in which the injured eye seems 

' " Anat. Causes of Sympathetic ' " Pathogenesis of Sympathetic 
Ophthalmia, " Archives of Ophthal- Ophthalmia," Archives of Ophthal- 
mology, N, Y., vol. V. niology, N. Y., vol. xvii., 1888, p. 

^ Royal London Oph. Hosp. Re- 193. 
ports, vol. XV., 1886-87, p. 316. 



SYMPATHETIC INFLAMMATION. 97 

at first to tend toward recovery, but nevertheless remains more 
or less injected and tender on pressure. This tenderness is the 
expression of a persistent cyclitis, and is a most important in- 
dication. Its absence cannot, unfortunately, be taken as a proof 
that there is no cyclitis, for a slight cyclitis does not always re- 
veal itself by tenderness on pressure." ' Hirschberg finds that 
a foreign body lodged in the eye may excite destructive inflam- 
mation even though it may not have been infected." 

Perforating ulcers of the cornea maybe succeeded by relaps- 
ing irido-cyclitis and lead to sympathetic inflammation of the 
fellow-eye. 

Burns of the cornea and symblepharon are given as causes 
of sympathetic inflammation. It is altogether improbable that 
such could be the cause unless perforation of the cornea had 
occurred. 

Panas has reported two cases of sympathetic irido-cyclitis 
following tattooing of the cornea.' 

Intra-ocular tumors are said to cause sympathetic inflam- 
mation. Schirmer, after a careful search, found " twenty-eight 
cases attributed to sarcoma of the choroid and two to glioma of 
the retina. The analysis of these shows that nine were cases 
of sympathetic irritation; that some others were of doubtful 
character ; and that in several more a perforation of the excit- 
ing eye had occurred either spontaneously or by operation. Ex- 
cluding these, there remain at least three cases in which a cho- 
roidal sarcoma, with no perforation of the tunics, appeared to 
cause a true sympathetic inflammation in the fellow-eye. In 
these three cases the exciting eye presented in addition to the 
tumor a well-marked irido-cyclitis, and this complication was 
present also in some of the more doubtful cases just referred to. 
It appears, therefore, that a choroidal sarcoma can only cause 
sympathetic inflammation when it is associated with irido-cy- 
clitis, and seeing that only a small minority of such tumors are 
complicated in this way, the irido-cyclitis and not the tumor 
must be regarded as the chief agent." ' 

Intra-ocular cysticercus is mentioned as a cause of sympa- 

' Ophthalmic Eeview, vol. xii., ■* Oph. Eeview, vol. xii., March, 

March, 1893, pp. 87. 88. 1893, p. 85. See also Report of 

" Graefe's Archiv ftlr Ophthal. Cora. Symp. Ophthalmitis, op. cit., 

5 Cited in "Ophthalmia Migrate- for similar criticism. 
ria,"p. 87. 

III. -7 



03 VISION AND AUDITION — WOODWARD. 

thetic imiim Illation. Deutschmann could not find such a case 
in literature, but Schirmer found one case of mild sympathetic 
irritation due to that cause. 

Irritation due to wearing an artificial eye is also given as a 
cause of sympathetic inflammation. Such might be the conse- 
quence of wearing an artificial eye over a phthisical globe, for 
that might excite a relapse of irido-cyclitis in the degenerated 
eye. But it is highly improbable that an artificial eye ever ex- 
cites sympathetic inflammation under other circumstances. 

Incubation. — The onset of sympathetic inflammation occurs 
generally in from three to twelve weeks after the injury to the 
exciter. The shortest interval between the injury to the exciter 
and the outbreak of sympathetic inflammation, according to the 
Committee of the Ophthalmological Society of the United King- 
dom,* was three days in Case 134, but this record is not above 
suspicion. In Case 95, the interval was only three or four days, 
but may have been much longer. De Schweinitz states that it 
occurs exceptionally as early as the seventh day.'' According to 
Fuchs, ° the shortest period is two weeks. Deutschmann ' asserts 
that the shortest interval recorded in literature is ten days, in 
the case described by O. Becker. In his monograph on " The 
Sympathetic Diseases of the Eye,"" Mauthner says: "I must 
emphasize the fact that, in my own experience, I know of no 
case in which I ever saw sympathetic ophthalmia appear sooner 
than in four weeks after the injury. I grant, indeed, that this 
period of four weeks might be somewhat shortened, in occasional 
cases, but I will not grant that the necessary period can be re- 
duced to a few days, as is alleged to have been observed by 
several authors." 

There is no definite limit to the period during which an at- 
tack of sympathetic ophthalmia may occur. Oases observed 
twenty, thirty, forty, and even sixty years after the injury to 
the exciter are on record. According to Fuchs," " so long as an 
eye destroyed by injury remains free from inflammation and 
tenderness it is not liable to excite sympathetic inflammation. 
But if such an eye become irritable and inflamed, which it is 
apt to do if there be a foreign body lodged in it, the danger of 

'g^^- OP*i- See. U. K., vol. yi., * "Ophthalmia Migratoria," p. 

^ Op. cit. , p. 338. 6 p ;i43 

. ' Op. cit., p. 833. 6 Op cil, pp. 331, 333. 



SYMPATHETIC INFLAMMATION. 99 

sympathetic inflammation again appears. An eye destroyed 
by a traumatism is a standing menace to its fellow. The dan- 
ger of sympathetic inflammation is greatest during the most 
active stage of irido-cyclitis in the exciting eye." This accords 
with the experience of ophthalmic surgeons in general. 

Frequency of Occurrence.— As a contribution to this part 
of the subject the following facts are offered. They will give 
an approximately correct idea of the matter. Among the in- 
mates of asylums for the blind, about 4.6 per cent lost their 
vision by sympathetic ophthalmia.' Among 637 blind inmates 
of the Hospice des Quinze Vingts, Paris, Trousseau ' found that 
14, or 2. 3 per cent of the number, became blind in consequence 
of sympathetic ophthalmia. Out of 500 enucleations of the eye 
in the practice of Knapp,' 51 eyes were removed for sympathetic 
irritation and 21 were removed for genuine sympathetic oph- 
thalmia. Among the 360 enucleations made by Becker,* the 
eye was removed for irido-cyclitis with sympathetic disease in 
10 cases. From the practice of Roosa, 131 cases of enucleation 
are reported ; ^ among them were 35 cases of sympathetic oph- 
thalmia and 15 cases of sympathetic irritation. 

Diagnosis. — Ordinarily it is not difficult to detect inflam- 
matory changes in the uveal tract. But there are cases of sym- 
pathetic ophthalmia which, in the early stages dt least, may 
deceive the observer. The diagnosis of papillitis, neuro-retini- 
tis, and chorio-retinitis, when the changes are inconspicuous, 
will be more difficult to establish, should the refraction of the 
eye present a high degree of hypermetropia or astigmatism, es- 
pecially if the observer be not on his guard. In obscure cases 
of sympathetic ophthalmia, atropine may be used to facilitate 
the ophthalmoscopic examination and to reveal inflammatory 
lesions that might otherwise pass unnoticed. Especial attention 
should be given to the cornea and iris, for the existence of kera- 
titis punctata and slight posterior synechia may be overlooked 
unless the examination be thorough. 

Having noted the presence of a lesion in the fellow-eye, the 

question arises, Is that lesion due to the presence of disease in 

the eye primarily affected; in other words, have we to deal with 

' Noyes, op. cii. , p. 698 e* seg-. « Augenklinik in Heidelberg, 

'"Hygiteedel'CEil," p. 16. 1888, p. 93. 

' Archives of Ophthalmology, N. ' ' N. Y. Med. Record, Oct. 15th, 

Y., vol. xvi., p. 201. 1893, pp. 445, 446. 



100 VISION AND AUDITION — WOODWARD. 

a case of sympathetic trouble? The differential diagnosis is 
very important, and, in certain cases, is surrounded by great 
difficulties. For, lesions undistinguishable from those observed 
in sympathetic inflammation are the effect of a variety of causes. 
Inflammations of the uveal tract dependent upon constitutional 
causes may first appear in one eye and subsequently break out 
in the other, but it cannot be said of such cases that the disease 
has been transmitted from one eye to the other. In both in- 
stances the cause of the disease is a constitutional one. Thus, 
inflammations of the cornea, iris, ciliary body, and choroid may 
be due to syphilis, scrofula, rheumatism, diabetes, gonorrhoea, 
acute febrile diseases, and traumatisms, or they may be idio- 
pathic. Inflammation of the choroid may be due also to anae- 
mia, chlorosis, septic emboli, meningitis and cerebro-spinal 
meningitis, orbital abscess, and thrombosis of the orbital veins. 
Inflammations of the retina may be due to syphilis, nephritis, 
diabetes, leukaemia, or they may be idiopathic. Inflammations 
of the optic nerve may be due to syphilis, scrofula, nephritis, 
diabetes, cerebral disease, acute febrile diseases, severe hemor- 
rhages, menstrual disorders, pregnancy, childbirth, lead poi- 
soning, prolonged exposure to cold, inflammation and tumors 
of the orbit, and heredity.' The presence of any of those con- 
ditions and their etiological bearing upon the case under con- 
sideration must be ascertained before a correct opinion respect- 
ing the sympathetic nature of the disease may be formulated. 
Primary glaucoma also must be excluded. 

The nature of the injury and the condition of the eye first 
affected will throw some light on the differential diagnosis. 
Severe injuries resulting in penetration of the eyeball and lesion 
of the ciliary body, especially when they are followed by a 
chronic irido-cyclitis showing marked and persistent tenderness 
in the ciliary region, are very dangerous. Foreign bodies re- 
maining in the eye, especially fragments of stone, copper, and 
lead, and infected bodies of all kinds are very prone to excite 
sympathetic ophthalmia sooner or later. On the other hand, 
eyes in the condition of purulent panophthalmitis are compara- 
tively infrequently exciters of sympathetic disease. Sympa- 
thetic disease does occur, however, when the exciter is in a state 
of panophthalmitis." 

' Fuchs, op. cit. , pp. 316, 347, 353, 446, 479, 480. ' Alt, op. dt. 



SYMPATHETIC INFLAMMATION. 101 

Should the inflammation in the second eye begin in from 
three to twelve weeks after the injury to the first eye, or after an 
outbreak of cyclitis in an eye disorganized by a penetrating 
wound received months or years before, a suspicion that the 
disease is sympathetic must be entertained. But should the 
disease break but in the second eye after a much shorter or a 
much longer interval, the opinion that the disease is sympa- 
thetic should be accepted with greater reserve. 

If the injured eye be enucleated and the disease in the fellow- 
eye promptly abate, the second eye was probably sympatheti- 
cally aflEected. On the contrary, should inflammation in the 
second eye remain unchanged after excision of the first, or should 
the disease increase in severity, it cannot be said that the sec- 
ond eye was not sympathetically diseased; for, after sympa- 
thetic inflammation has appeared, enucleation of the exciter may 
not produce any effect upon it. 

Prognosis. — In addition to what has preceded, it may be 
stated that sympathetic irritation, although it may have re- 
curred again and again, is very amenable to treatment. Meyer ' 
says : " The prognosis may be regarded as very good in sympa- 
thetic irritation, favorable in serous iritis, very bad for plastic 
irido-cyclitis, for useful vision is rarely preserved." According 
to Swanzy,^ "the vast majority of cases of sympathetic inflam- 
mation end in blindness." Nettleship ' remarks : " When once 
sympathetic inflammation has begun we can do little to modify 
its course." De Schweinitz * says : " The prognosis of sympa- 
thetic ophthalmitis is usually grave. In some cases recovery 
occurs ; this has been seen in those cases in which neuro-retini- 
tis is present. More frequently, especially in the forms which 
appear as an irido-cyclitis or irido-choroiditis, the sight of the 
eye is lost, and the organ shrinks. The varieties which appear 
as a serous iritis give the greatest hope of a good result. It is. 
extremely important to warn patients of the grave nature of 
this malady, and if an attempt is made to save an eye injured 
in the way already described, it must be done with the full un- 
derstanding of the serious risks which are undertaken." 

Eeferring again to the report of the committee on sympa- 
thetic ophthalmitis,' we find that of 211 cases the details of the 

' Op. eit., p. 217. ■* Op. cit, pp. 341, 342. 

^ Op. cit., p. 258. *Tr. Oph. Soc. U. K., vol. vi., 

3 Op. cit. , p. 175. P- 173. 



103 VISION AND AUDITION— WOODWARD. 

treatment were given in 90 ; of these 50 recovered completely. 
Taking 303 of these cases for the basis of calculation, I found 
that about 26 per cent were totally lost, about 23 per cent re- 
covered with V=fg-, and about 50 per cent partially recovered. 
It should be noted that a reasonable doubt may be entertained 
respecting the sympathetic nature of the inflammation in a 
few of the cases ; and that in others the records were very im- 
perfect. Eyes reported as having recovered may have been de- 
stroyed subsequently by a relapse of the inflammation. The 
committee were of the opinion that " the prognosis in sympa- 
thetic ophthalmitis is, on the whole, more favorable if the dis- 
ease comes on after a short than after a long interval." ' 

Gunn," in a carefuUy prepared paper, reported 47 cases of 
sympathetic ophthalmia in which the final condition of the pa- 
tient is given as follows : " In 34 cases the exciting eye was 
lost; in 30 of these it was excised. In 3 cases the exciter al- 
though not really lost was excised. In 6 cases the exciter re- 
tained useful vision, although the sympathizer was lost in 5 and 
greatly damaged in the sixth." " In 5 cases the final condition 
of the sympathizing eye was good, i.e., retained at least f of 
normal vision ; in 12 the result was moderate (able to get about) ; 
in 25 cases the sympathizer was known to have been rendered 
useless. In 8 of the 12 cases in which the result was "moder- 
ate," a progressive degeneration was noticeable. 

Propagation of the Sympathetic Diseases. — It is gen- 
erally believed that sympathetic irritation is due to reflex action 
through the ciliary nerves. But the raison d^etre of sympa- 
thetic inflammation is still under discussion. Mackenzie,' in 
the earliest systematic description of the disease, speaking of 
the ratio symptoinatum, oiiered the conjecture that the blood- 
vessels, the ciliary nerves, and especially the optic nerves may 
be the various channels by which the morbid process is trans- 
mitted from one eye to the other. In 1858, Miiller enunciated 
the theory that the disease is propagated by reflex action through 
the ciliary nerves. This theory has been supported by various 
eminent observers and still claims many partisans. Deutsch- 
mann * opposes that theory and has undertaken to prove, by ex- 

'Tr. Oph. Soc. U. K., vol. vi., » "Diseases of the Eye," 1844. 

p. 189. * "Ophthalmia Migratoria," 1889. 

^ R. L. Oph. Hosp. Reports, vol. 
xi., 1886-87. 



SYMPATHETIC INFLAMMATION. 103 

periments on animals and by pathological and bacteriological 
examinations of human eyes, that sympathetic ophthalmia is 
due to the action of micro-organisms and is propagated from 
the exciter to the sympathizer by the lymph channels of the 
optic nerves. This theory has excited much discussion. It has 
been provisionally accepted by many competent ophthalmologists 
and totally repudiated by as many others. At the present time, 
the most that can be said of this matter is that no theory pre- 
tending to explain the propagation of sympathetic ophthalmia 
has withstood the assaults of adverse criticism. 

Treatment. I. The Preventive Treatment, when 
THE Exciter is Destroyed.— The surest prophylaxis of sym- 
pathetic inflammation consists in enucleation of the exciter. 
The operation is indicated when useful vision has been destroyed 
by a penetrating injury or by disease of the cornea, resulting in 
perforation of that structure, if the eye be painful or tender to 
pressure, and especially if it contain or may be supposed to con- 
tain a foreign body. Enucleation should be more urgently ad- 
vised, when the symptoms of sympathetic irritation have become 
manifest in the fellow-eye. Globes in the state of phthisis 
bulbi, and stumps of the optic nerve, when tender to pressure, 
should be removed, and especially if the other eye show any 
signs of sympathetic disturbance.' It is the duty of the phy- 
sician in charge of such cases to warn the patient against the 
dangers of sympathetic inflammation. And too much faith 
should not be put in the patient's ability to note the first sign 
of disturbance in the healthy eye, which shall bring him to an 
operation for excision of the injured organ. The disease some- 
times begins insidiously and its existence may not be suspected 
until well -marked structural changes are developed ; this is es- 
pecially true of children and ignorant persons. But not all such 
eyes, or stumps of eyes, are exciters of sympathetic inflamma- 
tion or even sympathetic irritation, although they may be pain- 
ful and tender and contain a foreign body. Just how many, 
or which one, will cause sympathetic disease cannot be predicted 
with certainty. Some latitude, therefore, must be allowed to 

•Compare Fuchs, op. cit., pp. 218 ; Juler, op. wY., p. 164; Noyes, 

328, 329 ; Graefe-Saemisch, op. cit. , op. dt. , p. 494 ; De Schweinitz, c^. 

4, p. 520; Lawson, op. cit, p. 130; cit, p. 340; Warloment, Annales 

Nettleship, op.cit, p. 175; Swanzy, d'Oculistique, 1876, t. Ixxv., p. 53; 

op. cit., p. 259; Meyer, op. cit, p. Eossander, ibid., p. 305, abstract. 



104 VISION AND AUDITION — WOODWARD. 

the judgment of the attendant in a given case respecting the 
time when an excision of the eye should be performed, but 
the patient must be made to understand that attempts to save 
the injured eye are fraught with more or less danger to the 
other. Should the patient wish that every possible precaution 
be taken against the outbreak of disease in his remaining 
eye, the injured organ should be enucleated without further 
delay. 

So far as regards sympathetic irritation, excision of the ex- 
citer is an almost absolutely certain preventive, and is curative 
in nearly all cases even after the disease has broken out. Rhein- 
dorf, in 1865, collected 75 cases of sympathetic disease, 55 of 
which were treated by enucleation. Of these, 28 were cases of 
sympathetic irritation, in 27 the result was cure or improve- 
ment, and in one the disease was said to have been aggravated 
by the operation. Mooren, in 1869, published a series of 35 
cases of sympathetic ophthalmia treated by enucleation. Of 
these, 16 were cases of sympathetic irritation, and all were 
cured. In 1876, Rossander published 117 enucleations for di- 
verse causes: in 68 the disease was sympathetic ophthalmia. 
Of these, 33 were cases of sympathetic irritation, and aU were 
cured. Vignaux, in 1877, published 48 cases of sympathetic 
irritation treated by enucleation; complete cure in 43, cure 
incomplete or disease stationary in 3, and in 2 the treatment 
failed. In 16 cases in which the appearance of sympathetic 
inflammation was imminent at the moment of enucleation, he 
was able to determine in all cases the persistence of the normal 
state after a period of one to four and one-half years. D'Oench, 
1887, reports from Knapp's practice 51 enucleations, for sym- 
pathetic irritation, with a speedy cure in every case, although 
in some the symptoms had existed for a long time. 

In a certain number of cases of sympathetic inflammation, 
neither enucleation of the exciter nor any other treatment will 
prevent an outbreak of the disease. The report on sympathetic 
ophthalmitis ' gives " three cases in which the damaged eye was 
excised almost immediately after the injury and yet iritis after- 
ward occurred in the other. We think it well to quote these 
cases without expressing an opinion as to their nature, pointing 
out, however, that the attack in each case differed materially 
' Tr. Oph Soc. U. K., toI. vi., pp. 193-194. 



SYMPATHETIC INFLAMMATION. 105 

from common sympathetic ophthalmitis, and that in each case 
the damaged exciting eye had been ruptured by a severe blow. 

" In Case 48, a woman, sst. 45, had her left eye ruptured by a blow, 
on January 15th, 1884. It was excised by Dr. Little, of Manchester, on 
the same day. The other (right) eye seemed healthy at the date of excis- 
ion. On the 20th there was slight muco-puruleut conjunctivitis, but 
pupU was clear and active. On the 23d, chemosis, pupil sluggish, acting 
imperfectly to atropine. 24th, distinct iritis with lymph in iris and 
pupil, severe congestion and pain, conjunctival discharge nearly 
stopped. 25th, iritis worse, no keratitis punctata could be made out; there 
was marked congestion at the limbus cornese. From this time rapid 
improvement, and by February 20th the eye was practically well, free 
from synechiae and V. perfect. There was no history or evidence of 
syphUis and no other apparent cause for the iritis. 

" Case 112. — Man, aged about 20, left eye hurt by a blow on Janu- 
ary 22d, 1883, and excised the next day. The socket healed well and re- 
mained free from irritation. A glass shell worn after two weeks. 
Seven weeks after excision acute iritis with ciliary congestion and pain 
set in in the other (right) eye. The attack not severe, and was well in 
a few days, vision not being affected. It remained well for seven 
months, when a relapse occurred with more synechiae. This attack 
lasted nearly two months, but the eye recovered with V=U. No kera- 
titis punctata was observed. None of the ordinary causes of iritis 
noted." 

"Case 109. — An engine-driver, set. 41, had his right eye smashed 
and orbital tissue much bruised in a railway accident. The eye was 
excised within forty-eight hours. The tissues healed tardily and dis- 
charged more than usual. From four to six weeks later severe acute 
iritis came on in the other (left) eye. The attack lasted about a month. 
Then the eye became quiet and sight improved somewhat, but a few 
days before admission, six months after the accident, a tolerably severe 
relapse took place, vision not 20 Jaeger, Tn. Eapid improvement. 
Five weeks later V=f§, numerous synechiae, thin membrane in the 
pupil, iris texture natural. The eye remained quiet for the few follow- 
ing weeks, during which he remained under notice. Chronic articular 
rheumatism in hip, knee, and elbow, on same side as the iritis, four 
years previously; but no inflammation of the eye then; no syphilis." 

It may be assumed that these three cases belong to the mild 
grade of sympathetic inflammation. As such they are abso- 
lutely exceptional; and, if it be admitted that they are genuine 
cases of sympathetic inflammation, the cause of the outbreak of 
the sympathetic disease, after the prompt excision of the injured 
organ, may be sought in the bruising of the tissues of the orbit. 



lOG VISION AND AUDITION— WOODWAKD. 

On the other hand, sympathetic inflammation may occur 
after excision of the exciter, when the operation is performed 
after a longer delay. Mauthner ' has claimed that in some of 
those cases the operation was the starting-point of the sympa- 
thetic disease. He cites two cases of neuro-retinitis published 
from Mooren's practice, and another case of " hypersesthesia 
ciliaris" also Mooren's, all of which, he claims, were produced 
by the enucleation. Davis' has reported from the practice of 
Roosa two cases of sympathetic inflammation occurring after 
enucleation of the exciter. In the first, enucleation of an atro- 
phied globe, resulting from an accident after a cataract extrac- 
tion two months earlier, was performed, June 7th, 1890. On July 
16th, 1890, the patient returned with sympathetic irido-cyclitis 
in the remaining (right) eye. Removal of the stump of left eye on 
the following day. Other treatment immediately inaugurated. 
Finally the eye became soft and V=pl (?). The second case 
was one of injury and traumatic cataract, seen August 5th, 1890. 
Cataract removed, iridectomy performed ; eye remained painful 
and was enucleated, November 30th, 1890. Good recovery, no 
sympathetic irritation when discharged. December 20th, 1890, 
patient returned with sympathetic irido-cyclitis. Patient had 
noticed for a week that he could not see distinctly. In June, 
1892, V^-j'tnr; patient gets about with difficulty. "The plastic 
irido-cyclitis is slowly destroying his sight." 

Referring again to the Report on Sympathetic Ophthalmitis' 
for further information regarding this question, we find that 
there were " 30 cases of genuine sympathetic ophthalmitis set- 
ting in after enucleation of the exciter, and 6 others the sympa- 
thetic nature of Avhich is doubtful. Taking the 30 true cases 
we find that 18 recovered completely, 3 partially, and 9 were lost. 

" The first subject of inquiry in this group is whether the 
sympathetic disease is caused by the injured eye or by the ope- 
ration for its removal. If the disease were due to the excision 
we should expect to meet occasionally with cases coming on a 
long time afterward . We find the following four cases in which 
such is said to be the case : 

"Case 1. — A young woman lost the left eye from spontaneous 
irido-choroiditis. Many years after, at the age of 30, it was excised on 

' "Symp. Dis. of the Eye," p. 153. ^ Tv. Oph. Soc. U. K, vol. vi., 

' N. Y. Med. Rec.Oct. 15th, 1893. pp. 190-193. 



SYMPATHETIC INFLAMMATION. 107 

account of irritation in the right. This ceased after excision, but twelve 
months after the operation the right eye passed through a painless 
attack of iritis with keratitis punctata and opacities in the vitreous. It 
improved for a time, but four years later the disease was still active 
and vision very bad. Other possible causes of iritis not mentioned. 
(Cant, Case 1, unpublished.) 

"Case 191.— A woman lost her left eye by sloughing of the cornea 
in gonorrhceal ophthalmia at 36. After being quiet ten years it became 
painful, and was excised. A year afterward, at the age of 47, there 
was pain in this orbit with puckering around the end of the optic nerve. 
At the same time acute iritis came on in the other (right) eye. The 
stump of the left optic nerve was cut out, and under treatment the 
right rapidly and completely recovered, and did not relapse. There is 
no note as to syphilis or gonorrhceal rheumatism. (Ayres, Knapp's 
Archives, XI., 199.) 

"Case 199. — The left eye of a man, set. 30, was excised, reason not 
stated. He wore an artificial eye without trouble for the next fifteen 
years, when, on getting a new eye, much irritation of the conjunctiva 
came on. Two and one-half weeks after beginning the use of this eye, 
well-marked p] astic iritis with much effusion began in the other (right) 
eye. It recovered perfectly under the usual measures, including mer- 
cury and removal of the artificial eye. Three months later vision per- 
fect. No history of rheumatism or syphilis. (Culbertson, Amer. Jour. 
Ophfh., I., 161.) 

"Case 200. — A man, set. 23. Blow on right eye with a small piece 
of wood, probably causing rupture. Excised seven months later for 
irritation in the left. All irritation ceased, and for nearly nine years 
he could see as well as ever he did in his life. Then (nine years after 
excision) slight pain in the eye and progressive failure of sight. When 
seen twelve months later, very severe plastic iritis with ciliary staphy- 
lomata, T slightly +, severe pain, V= p. 1. in the outer part of the 
field. After sclerotomy, pain subsided, but the eye became soft. Other 
possible causes of iritis not mentioned. (Lawson, O. H. R., X., p. 3.) 

"Another case by Colsmann (Case 207) may be mentioned, in which 
the interval was six months, but as the disease in the second eye took 
the form of neuro-retinitis only, the sympathetic nature of the attack 
is very doubtful. 

" The only two of these cases which are at all convincing are 
Cases 1 and 200, and to them we do not see that any exception 
can be taken, unless it be assumed that the disease in the sec- 
ond eye was spontaneous. 

" Again if the sympathetic disease were due to the excision, 
we should expect to meet with it sometimes after the removal 
of eyes which, had they been left, would not have produced it. 



108 VISION AND AUDITION — WOODWARD. 

But in turning to the cases we find only a single instance, an 
that one already quoted as doubtful (Case 1 above) , in whic 
the exciter was lost by spontaneous inflammation. In all tb 
others there had been a complicated wound, operation, or pei 
f orating ulcer. 

" Assume then that sympathetic disease beginning after ea 
cision is due to the eye and not to the operation for its removal 
we may next ask: What is the interval that may elapse be 
tween removal of exciter and the onset of the sympathetic ir 
flammation? We find that this (the 'second interval') was be 
tween two and five days in 11 cases; between one and two week 
in 7 cases; about three weeks in 6 cases; and from one montl 
to eight weeks in 5 cases. The 5 cases just quoted in whicl 
the interval was extraordinary in length are not here included 
Although the length of the 'second interval ' ' thus varied fron 
two or three days to seven or eight weeks, the sum of the firs 
and second intervals showed a much smaller range, viz., fron 
four to eight weeks, only exceeding the latter in two cases 
Now, from four to eight weeks is a common interval betweei 
injury and sympathetic disease, but the second interval slom 
was, as the above figures show, usually too short to permit ol 
our assuming the excision to have been the cause. It may fur- 
ther be observed that in none of these cases was the eye excisec 
promptly; ample time was always allowed for traumatic in- 
flammation to set in. In fact the 'first interval' alone was 
nearly always of sufficient length to account for the occurrence." 

Such is the nature of the evidence both for and against the 
opinion that enucleation may excite sympathetic inflammation. 
In conclusion, it may be said that while the possibility that 
the operation may be the starting-point of sympathetic disease 
cannot be denied absolutely, still the burden of proof remains 
with those who maintain that in a given case it has excited an 
attack of sympathetic inflammation. 

II. The Preventive Treatment, when the Exciter 
IS Not Destroyed. — Traumatisms may destroy an eyedirectly 
and immediately, or indirectly through the consecutive inflam- 
mation. It follows, in some instances, that an injured eye may, 

' "First interval" equals time in- time intervening between the ex- 
tervening between the lesion and the cision and occurrence of sympa- 
excision ; " second interval" equals thetic ophthalmia. 



SYMPATHETIC INFLAMMATION. 109 

in the early days, retain a fair amount of vision, which later on 
is destroyed more or less thoroughly by the inflammatory process. 
Hence, in coming to a decision regarding the treatment to be 
adopted in a case of injury, it is necessary to consider both the 
immediate and the remote effects of the accident upon the use- 
fulness of the organ. Should the eye still retain fair vision, and, 
after a few days' observation of the case, should it appear highly 
probable that the function of the eye will be permanently de- 
stroyed by the inflammatory process, enucleation may be ad- 
vised as a protective measure against sympathetic ophthalmia. 

If, after an accident which has not totally destroyed the use- 
fulness of an eye, the symptoms of sympathetic irritation ap- 
pear in the fellow-eye, the injured organ may be removed ; and 
it is not advisable to delay the radical treatment when the sym- 
toms of irritation are intense enough to excite apprehension 
that the other eye may experience an outbreak of sympathetic 
inflammation.' 

As a general rule, to which there are exceptions, it may be 
advised that all eyes in a state of chronic irido-cyclitis, which 
contain foreign bodies that cannot be removed, should be enu- 
cleated to prevent sympathetic ophthalmia, even though they 
may retain useful vision." 

In many cases, when the exciter retains considerable visual 
power, it is difficult to decide upon the best treatment to adopt. 
The dangers incident to an attempt to save some of these eye- 
balls should be fully and fairly explained to the patient and his 
family. Should they leave the attendant untrammelled in his 
management of the case, he should adopt the surest method of 
saving his patient's vision, even at the expense of an eye which 
may still retain considerable visual acuteness. On the other 
hand, the patient or his family may interdict operative inter- 
ference, and it is then the surgeon's duty to do as well as possi- 
ble under the circumstances, in which contingency he should 
not be held responsible for a disastrous termination of the 
case. 

III. CUKATIVE TKEATMBNT, WHEN THE EXCITER IS DE- 
STROYED .— Should enucleation of the exciter be performed after 
sympathetic inflammation has broken out? The strongest ob- 

'Mauthner, "Sympath. Dis. of « Swanzy, op. ctt, 1890, p. 259. 

the Eye, "p. 167. 



110 VISION AND AUDITION — WOODWARD. 

jection to tiiat practice is raised by Mauthner/ who says: "In 
my opinion, there cannot be the least doubt that iritis serosa 
may become transfored into iritis maligna by the operation 
of enucleating the other eye."' Enucleation "may cause sym- 
pathetic inflammation in a previously healthy eye, as well as 
increase a mild inflammation to the most severe. Enucleation 
is of no benefit whatever in genuine iritis maligna, but occa- 
sionally, when the sympathizer is extremely irritated, does 
harm." This opinion is defended by the citations of a few un- 
decisive cases. Opposed to Mauthner stands the report of the 
committee on sympathetic ophthalmitis." In it we find the fol- 
lowing: "When sympathetic inflammation has begun does ex- 
cision of the exciting eye influence its progress? ... Of our 
total (about 200) we find 4 cases in which the exciter was re- 
moved within a short time of the outset of sympathetic inflam- 
mation (that is, within three weeks of the outbreak of the symp- 
toms of structural disease in the sympathizing eye) and of these 
the sympathizing eye was known to be lost in only 8. In an 
almost identical number (65) , the exciter was either not removed 
at all, or not till long after the sympathetic disease had set in, 
and in no less than 26 of these the sympathizer was lost. . . . 
Whether early removal of the exciting eye be positively useful 
in staying the disease or no, it is certainly not injurious, as no 
less an authority than Mauthner has asserted that it is when 
sympathetic disease is of the 'serous form.' . . . Eecovery 
of the sympathizer after early removal of the exciter may be in 
part ascribed to the natural mildness of the disease (in both 
eyes). . . . Loss of the sympathizer when exciter is not re- 
moved may in part be ascribed to the natural severity of the 
disease (in both eyes) . On the other hand the fact that sym- 
pathetic ophthalmitis, when it sets in after enucleation of the 
exciting eye, is usually mild seems to show that early removal 
of the cause does in some degree check the disease." 

Schirmer entertains a similar opinion. He says : " If sym- 
pathetic inflammation has already broken out, the exciting eye, 
if blind, should be removed. The removal of the exciting eye 
has never been proved to have an ill effect on the sympathetic 
inflammation, but has on the other hand appeared in many 

'"Sympath. Dis. of the Eye, " pn. « Ti-. Oph. Soo. U. K., vol. vi., 

157, 159. *^' pp. I7i-i?3. 



SYMPATHETIC INFLAMMATION. Ill 

cases to act beneficially in this respect, although the improve- 
ment may not be permanent. It is rational to remove the 
source of the infection, and thereby to obviate the chance of a 
further migration of germs from one eye to the other ; moreover, 
the enucleation cuts short any sympathetic irritation which 
may be present, and thereby, in all probability, favors the sub- 
sidence of the inflammation." ' 

IV. Curative Treatment, when the Exciter is not 
Destroyed. — Given a case of sympathetic inflammation in 
which the exciter retains useful vision, should enucleation be 
performed? Mauthner " replies : " Every one will admit that it 
is a crime, in a case of pronounced sympathetic irido-cyclitis, 
to enucleate an eye which still possesses vision, or in which 
vision might at a later date be restored." Swanzy'says: "I 
would not enucleate the exciting eye, if sympathetic ophthalmitis 
had already appeared, should the vision of the exciting eye be 
fairly good. For it often occurs that the process in the sympa- 
thizing eye is not arrested by the proceeding, and that, when 
the latter is not undertaken, the exciting eye turns out in the 
end to be the organ with the better vision." 

Nettleship * advises as follows : " The exciting eye, if quite 
blind or so seriously damaged as to be for practical purposes 
certainly useless, is to be excised at once, though the evidence 
of benefit from this course is slender. But it is not to be re- 
moved if there is reason to hope for restoration of useful sight 
in it ; if there is simply a moderate degree of subacute iritis, 
with or without traumatic cataract, and with sight proportion- 
ate to the state of the lens, the eye is to be carefully treated, 
since it may very probably in the end be the better of the two." 

Finally, Lawson ' makes the following observation : " On 
several occasions, when the injured eye has retained some sight, 
I have seen the opposite eye destroyed by sympathetic ophthal- 
mia,' while the injured eye so recovered that useful sight has 
been restored, and the patient has been able to get about without 
assistance. ... If sympathetic ophthalmia be established, the 
injured eye should not be removed if it retains any sight." 
When the sympathizer is lost, it may be enucleated if the exciter 

' Ophthalmic Review, London, * Op. cit. , p. 360. 
March, 1893, pp. 97, 98. ^ Op. dt, p. 176. 

= Op. cit., p. 169. ^ B- L- Oph. Hosp. Rep., vol. x., p. 5. 



112 VISION AND AUDITION— WOODWARD. 

retain some vision. For, according to Berry,' "cases hav 
been met with when there seems to have been good reason t( 
think it has reacted on the first or original exciter." 

In the present state of our knowledge, enucleation must bi 
ranked superior to any of its substitutes in sympathetic disease 
The most noteworthy of the substitutes are evisceration, Mules 
operation, and optico-ciliary neurectomy. Evisceration is es 
pecially favored by Graefe of Halle. The objections to it are, 
the wound heals more slowly than in the case after enucleation, 
and the local reaction is more intense. Moreover, the posterioi 
one-half of the sclera of the displaced organ is permitted to re- 
main to form the stump. The operation of inserting a glass sphere 
into the scooped-out sclera (Mules' operation) is open to the same 
criticism. Optico-ciliary neurectomy, championed by DeWecker 
and performed also by Schweigger, consists in the abscission of 
a segment of the optic and ciliary nerves, leaving the eyeball in 
the orbit. The focus of the exciting cause therefore is not re- 
moved; and, since the mode of propagation of the sympathetic 
disease is still unknown, this operation should not be as favor- 
ably regarded as the others. " Undoubtedly there are cases suita- 
ble for each of these operations. The question whether, in a 
given case, one or the other should have been performed can be 
answered only after consideration of the circumstances which 
confronted the surgeon. When such heroic measures are indi- 
cated, enucleation will give the patient the best chance of a fa- 
vorable result; and an operator, who elects a procedure other 
than that in a case of sympathetic inflammation, should be pre- 
pared to give a sufficient reason for his choice. 

' "Dis. of the Eye," 1893, p. 348. « Compare Berry, op. cit, p. 350. 



CHAPTER VIII. 
injuries of the ear. 

Injuries of the External Ear. 

Contusions, contused wounds, incised, punctured, and lac- 
erated wounds, gunshot wounds, and burns of the external ear 
are occasionally observed. The cartilages may be fractured by 
a contusion. Destruction of tissue by wounds may be extensive 
or it may be trifling ; it may be an immediate consequence of 
the injury, or the greatest loss of tissue may ensue from inflam- 
mation and gangrene of the affected structures. The auricle 
has been completely severed from the head. 

Even severe wounds of the auricle show a marked tendency 
to heal kindly. Completelj'^ severed parts will occasionally 
unite if brought into proper coaptation with the wounded mem- 
ber and held there by sutures and carefully applied dressings. 
Of course this extraordinary result will not be attained if the 
wound be not thoroughly disinfected and the entrance of mi- 
crobes into it be not prevented by appropria'te antiseptic precau- 
tions. On the other hand, not all wounds of the auricle run a 
favorable course. Inflammation with suppuration sometimes 
sets in, causing swelling of the ear and adjacent parts, destroy- 
ing the cartilages to a greater or less extent, and resulting in 
prolonged annoyance and permanent deformity. 

Contusions of the auricle give rise to inflammation of the 
investing membrane of the cartilages, — the perichondrium. 
Such inflammation may be productive of abscess and subse- 
quent deformity of the ear. In other cases, contusions are fol- 
lowed by the appearance of a blood tumor of the auricle, known 
as othcematoma. This tumor is due to extravasation of blood 
between the perichondrium and the cartilage, or between the 
perichondrium and the skin, or to extravasations into the sub- 
stance of the cartilage. Experiments on animals ' indicate that 

' Hilttig, Viertelsjahrsschrift ftir gericht. Med. u. oflentlich. Sanitats- 
wesen, Oct., 1893, 321. 

III. -8 113 



114 VISION AND AUDITION — WOODWARD. 

the extravasation may not set in for twenty-four hours, or a 
longer time. Othsematoma occurs also as a spontaneous or 
idiopathic affection. In both the traumatic and the idiopathic 
cases, the left ear is commonly the site of the trouble ; and in both, 
the tumor is observed almost invariably upon the anterior aspect 
of the concha. But it has been found on the back side of the ex- 
ternal ear. Idiopathic cases are observed among the insane; 
rare exceptions to this rule have been reported as occurring in 
sane, but debilitated subjects. 

Gruber ' describes the appearance of idiopathic othsematoma 
as follows : It " commences most commonly in the upper part, 
in the fossa triangularis (fork of the antihelix) , or in the upper 
half of the concha ; appearing as a larger or smaller, more or 
less distinctly fluctuating, circumscribed tumor ; the skin cov- 
ering it being either normal or of a livid red color. The sur- 
face is regular and smooth, if the blood has been effused into the 
subcutaneous areolar tissue; or if, as is often the case, the ex- 
travasation has taken place into the substance of the cartilage 
itself, or between this and the perichondrium, the external sur- 
face exhibits more or less definitely the ordinary elevations and 
depressions of the auricle. " In traumatic cases there is no char- 
acteristic hemorrhage, but the appearances may be identical 
with those of the idiopathic variety. Other evidence of injury 
may be found. Fracture of the cartilages may be noted. But, 
inasmuch as the cartilages are softened in some idiopathic cases, 
and fragments of them may be felt beneath the fluctuating 
swelling, the signs of fracture of the cartilages do not necessa- 
rily indicate the nature of the cause of the extravasation. 

The subjective symptoms of idiopathic otheematoma are a 
feeling of fulness and burning in the auricle. Traumatic cases 
may give more marked symptoms, especially pain, tenderness, 
and heat. An abscess forms occasionally. Should the tumor 
rupture, septiceemia may follow. Cases of that nature have 
been reported. Both traumatic and idiopathic othsematomata 
cause permanent, unsightly deformity of the auricle. 

Bums of the external ear by heat or corrosive agents present 

considerable variety as regards the extent of surface involved 

and the degree of destruction of tissue. Superficial burns of the 

auricle heal very satisfactorily, leaving inconspicuous traces 

' "Dis. of the Ear," N. Y., 1890, p. 221. 



INJURIES OF THE EXTERNAL AUDITORY CANAL. 115 

behind. Deep burns, however, deform the auricle. The entire 
external ear maj- be burned away. When the burn involves 
the parts surrounding the orifice of the external auditory canal, 
the resulting cicatrix will close the ear. Such a result will 
cause deafness. Considerable difficulty would be experienced 
in attempting to re-establish the opening of the external audi- 
tory canal if the cicatrix were not very thin. In some cases, 
failure would follow every such attempt. 

Spontaneous gangrene of the auricle has been observed by 
Eitelberg,' who has reported two cases of it: that of a boy thir- 
teen months old, who suffered also from suppuration of the mid- 
dle ear and died on the fifth day of exhaustion ; and that of a 
badly nourished girl, three weeks old, in whom the lobule and 
concha became dark brown, shrunken, and cold (a similar 
spot was found at the umbilicus) . 

Injuries of the External Auditory Canal. 

The external auditory canal is anatomically divided into two 
portions, a cartilaginous and a bony. Either, or both, may be 
injured by direct violence. Lesions of the cartilaginous por- 
tion of the canal are of minor importance. They may excite 
inflammation which will temporarily diminish the acuteness of 
hearing. Healing occurs, however, in the greater number of 
cases, with no permanent impairment of the organ. Burns 
may close the canal permanently by cicatricial contraction, if 
the lesion be a severe one. Knapp " has reported one such case 
from sulphuric acid. Permanent atresia resulted. 

Lesions of the bony portion of the external auditory canal 
are the- result of either direct or of indirect violence. They may 
be complicated by direct injury to the drum -head and middle 
ear. Or, injury to the canal may excite an inflammation of the 
drum-head which will lead to perforation of the latter and sup- 
puration in the middle ear. Hiittig ' asserts that this result is 
most common after injury to the superior wall of the canal. 
The mastoid process may be invaded by inflammation, which 
sometimes extends to the drum, when the posterior or posterior- 
superior wall is injured. When the anterior wall is injured, 
the parotid gland may become inflamed. 
' Huttig, op. cit., p. 221. « Ibid., p. 224. » Ibid., p. 223. 



IIG VISION AND AUDITION— WOODWARD. 

Diffuse inflammation of the canal occurs in consequence of 
direct injury ; but, in general, resolution is perfect, leaving no 
permanent effects. In other cases, subjective noises and deaf- 
ness remain. In still other cases, the canal is partially or com- 
pletely closed by the results of the inflammatory process, there- 
by affecting the hearing to a marked degree. 

Intense inflammation of the external auditory canal has been 
excited by introducing into it cotton moistened with creosote. 
Trautmann' reported two such cases; in both hearing was 
temporarily affected. Christinneck ^ reported a case of inflam- 
mation following the introduction of concentrated carbolic acid 
into the canal; healing was complete in two weeks. 

Injuries of the external auditory canal occur in consequence 
of indirect violence. The soft parts have been injured by pull- 
ing the ears. The bony walls have been fractured by a blow or 
a fall upon the head, or by a blow, or a faU upon the chin or 
lower jaw. When the force is transmitted through the lower 
jaw, the anterior wall of the canal is fractured, and the lesion 
may occur in both ears at the same time. Baudrimont' ob- 
served such a case in which the lower jaw was dislocated back- 
ward. After the dislocation was reduced the right drum-head 
was found badly lacerated ; some splinters of the anterior wall 
were removed, and recovery took place. 

When the fracture of the bony walls is simple, hemorrhage 
takes place beneath the soft parts, and blood does not come from 
the ear. A subcutaneous blood-tumor may form and close the 
canal. In the case of compound fracture of the bony walls the 
ear bleeds. The hemorrhage may be moderately copious, but 
soon ceases spontaneously. If, however, there is also a fracture 
of the base of the skull, the hemorrhage is more persistent, and 
may become serious enough to require treatment. The jugular 
vein and the carotid artery may be injured by the fracture. In 
such cases the bleeding is profuse. When the hemorrhage 
comes from the carotid, it wiU prove fatal. 

In compound fractures, the lesion may be diagnosticated 
with the sound before inflammation and swelling set in. Mas- 
tication will be painful or impossible in fractures of the anterior 
wall of the canal. 

' "Handbuch der gerichtlichen ^^ Htittig, op. (At., p. 224; Arcbiv 

Medicin," von Dr. J. Maschka, f. Ohrenheilk., Bd. 18, S. 291. 
Tubingen, 1881, i., 386. » Huttig, op. dt., 227. 



INJURIES OF THE DRUM-tlEAD. 117 

Uncomplicated fractures of the canal do not, in general, 
leave any permanent evil consequences. Protracted inflamma- 
tion, or caries or necrosis of the bones ensues, in a certain num- 
ber of cases. 

Injuries op the Drum-Head. 

Ruptures or perforations of the drum-head are caused by 
direct or by indirect violence. Direct violence to the drum-head 
is done by penetration of objects thrust into the ear ; by shot 
wounds ; by violently syringing the ear ; by surf bathing ; by 
entrance into the ear of molten metals, steam, scalding water, or 
corrosive agents. Indirect violence to the drum-head is caused by 
blows upon the ear with the open hand, fist, or missiles; by 
falls upon the ear; by severe concussion transmitted through 
the bones of the skull; by intense sounds (explosion of projec- 
tiles, great guns, long-continued musketry fire, machine guns, 
steam whistles, loud voice) ; by violent traction on the auricle ; 
by sudden condensation of air in the drum as when the ear ia 
inflated with the air douche; by rarefaction of air external to 
the drum-head as in diving ; by entering caissons ; by fracture 
of the temporal bone. ' 

A great variety of things may be thrust into the ear and 
perforate -or rupture the membrana tympani. The membrana 
may be simply contused by such foreign bodies, and subse- 
quently a perforation result from the inflammation excited 
thereby. 

Destruction of the membrana tympani, together with other 
serious lesions in the auditory apparatus, has been criminally pro- 
duced by pouring corrosive liquids or molten metal into the ex- 
ternal auditory canal. Even the entrance of cold water into the 
external auditory canal may excite inflammation and consecutive 
perforation of the membrana and suppuration in the middle ear. 

Indirect violence by blows upon the ear with the open hand 
or fist has often resulted in rupture of the membrana tympani. 
Trautmann" cites 11 such cases; Sexton' refers to 51 cases 
among his records; other writers refer to similar cases. The 
violence may be comparatively slight and yet cause rupture of 

' Vide Sexton, "The Ear and its ^ Op. cit., p. 400 et seq. 

Diseases," 1888, p. 176; also Traui- ^ Op. cit., p. 177. 

mann, op. cit., 1, p. 393. , 



118 VISION AND AUDITION — WOODWARD. 

the drum-head. Gruber ' refers to two cases observed by him 
in which the rupture was caused by a kiss on the ear (rarefac- 
tion of the air in the external auditory canal) . 
The following cases are cited from Sexton:" 

"That of a young man, aged 22, whose father had given him a 
blow upon the left ear six years previously. Severe inflammation of 
the middle ear followed, lasting for two years, during which time the 
air whistled through a perforation in the drum-head whenever he blew 
his nose. When seen the drum-head was found thickened, irregular, . 
and otherwise changed almost beyond recognition. Hearing very 
much impaired. 

" A young man was slapped upon the left ear by his father. There 
was immediate pain and deafness, followed in a few hours by a 
watery discharge, which afterward was tinged with blood. Two days 
after the boxing, a perforation in the lower segments of the drum-head 
was giving vent to a free discharge and the middle-ear inflammation 
was complicated with periostitis externa — the mastoid cortex being 
swollen, red, and tender to the touch. Autophonia, noises in the head, 
and pain occurred at the beginning, and were very distressing for a 
long time, recovery not taking place for three months. 

' ' The grave consequences of pounding the ear are well shown in 
the case of a woman addicted to drink, aged 38, who was struck 
violently by a man upon the right ear. The immediate result was 
severe dizziness, and she had to hold on to a stair-railing to keep from 
falling. Vertiginous symptoms became more severe, and the pain and 
autophonia with this alarmed her very much. She was taken to a 
dispensary, where an energetic attendant, feeling that something must 
be done, vigorously inflated the ear by Politzer's method, causing 
extreme pain in the ear, and afterward introduced some irritating medic- 
ament on cotton-wool with instructions to keep it in the ear. After 
this the pain became more severe, and she came to the Eye and Ear 
Infirmary, where the drum-head was examined. This was found to 
be ruptured. An enormous quantity of serous fluid was escaping from 
the ear, which was believed to consist largely of the water of the 
labyrinth, thus indicating that the round window had also been rup- 
tured by the blow. She had now become extremely nervous and ex- 
perienced insane hallucinations, as was confirmed by the physician 
who saw the case. She was admitted to the wards of the infirmary, 
and purulent inflammation of the middle ear soon set in. The cerebral 
symptoms— pain, vertigo, hallucinations, etc. — became more grave. 
They seemed due in part to the concussion of the blow; but on review- 
ing the case the author is convinced that there was also transmission 
of a septic irritant through the cerebro-spinal fluid into the cranial 
' Op. cit, 257. s Op. dt, pp. 178, 179. 



INJURIES OF THE DRUM-HEAD. 119 

cavity, inducing leptomeningitis. The patient left the infirmary be- 
fore she was well, and when last heard from, a month after the injury, 
had not recovered." 

Falls upon the ear and blows upon the ear with missiles pro- 
duce ruptures of the membrana similar to those caused by box- 
ing the ears. 

Pulling the ears in a violent manner has ruptured the drum- 
head. The following cases are quoted from Sexton : ' 

' ' Female, 11 years of age. "While playing with some other children 
in front of a shop, the proprietor ran out and seized the patient by the 
left auricle, and, during her struggles to escape, the organ was vio- 
lently wrung and pulled. She cried out with pain, which continued 
for some time; a discharge appeared the next day, and she was brought 
a few days afterward, July 14th, 1884, to the New York Eye and Ear 
Infirmary for relief. An examination of the ear showed that the 
integument covering the superior wall of the canal and the upper por- 
tion of the drum-head was inflamed and exfoliating, and, furthermore, 
that the membrane was lacerated in several places about the umbo. 
There was a discharge through the perforations from the drum; also 
deafness and autophonia. 

"The patient was under observation for about seven weeks, after 
which she failed to return. The drum-head had not then healed, and a 
purulent discharge from the ear still existed. There was also consid- 
erable deafness. On December 4th, 1887, three and a half years after 
the injury, this patient called on the author, stating that for two or three 
weeks she had had a good deal of pain and discharge in the right ear. 
On examining the left (injured) ear, it was found that the drum-head was 
adherent to the inner wall of the drum; furthermore, that a white cica- 
trix was present behind the handle of the hammer, which was drawn 
backward somewhat. The malleus was displaced downward. Ante- 
riorly the drum-head had a little brilliancy. Loud ordinary voice could 
be heard in the left ear at twenty feet distance. She stated that the 
left ear had discharged off and on until four months ago; that there 
was tinnitus resembling musical sounds and intermittent pain in the 
same ear. She left off going to school six months since, as she was so 
deaf that she could not understand what the teacher said to her. 
Patient has many decayed teeth. She works at present in a cigarette 
factory. 

"Male, aged 14 years. Three months ago his brother caught him 
by the lobule of the left ear, pulling it until some blood escaped from 
the canal. The ear has discharged ever since, and he only hears 
shouting voice in that ear. The left drum-head is hypersemic; the 

' Op. cit., p. 233. 



120 VISION AND AUDITION — WOODWARD. 

inner end of the canal, which is large, is red, dry, and exfoliating. A 
month later, when patient was last seen, the drum-head had healed. 

"Male, 23 years old. Two days ago left aaricle was seized hy the 
teeth of a man during a fight. The lobule was much torn, and the 
traction made on the auricle lacerated the superior membranous wall 
of the canal, where it enters the bony portion. The membrana fiaccida 
was also lacerated at its anterior insertion. The parts were still bleed- 
ing, and the neighborhood very much injected. There was no deaf- 
ness. Patient seen but once." 

The following case quoted from Gruber' exhibits other 
consequences of a blow upon the ear than rupture of the drum- 
head: 

"As an example of injury to the ear from a blow, without rupture 
of the drum-head resulting, a case of Biirkner's ^ may be cited. The 
patient was knocked down and rendered senseless by a blow from the 
flst over the ear. On recovering consciousness, two hours later, he 
had a loud buzzing in the ear, with pain on moving his head to the 
same side, uncertainty in walking, and dizziness, increased on closure 
of the meatus. The tympanic membrane was depressed, but otherwise 
uninjured. All the symptoms disappeared in ten days under treatment 
by the Politzer process. Biirkner ascribes the symptoms to displace- 
ment inward of the membrane and auditory ossicles, especially the 
stapes, subsequently remedied by inflation." 

The following case of rupture of the drum-head by contre- 
coup is taken from Gruber : ° 

"Ruptures of the membrane, brought about by so-called contre- 
coup, are particularly noteworthy. The author has seen several such 
cases in Vienna. A young lady, leaving the room, struck her fore- 
head against the door-post, and ruptured her left tympanic membrane ; 
it healed in the course of a week. A young man, while diving, struck 
his forehead against the bottom of the bath, and ruptured the left drum- 
head ; a severe inflammation was set up, and it was some weeks before 
it had quite disappeared. Williams ^ oberved a fracture through the 
external auditory canal, with rupture of the membrane, in a boy who 
fell on the back of his head. Eitelberg ' reports a case in which a per- 
foration below the malleus, with fracture of its handle, were said to 

' Op. cit. , p. 258. seren Gehorganges durch Contre- 

'Zur Casuistik der traumati- coup mit Zerreissung des Trommel- 

schen und entztindlichen Mittel- felles," Zeitschrift fur Ohrenheil- 

ohraflfectionen, " Archiv ftir Ohren- kunde, Bd. xiv. 

heilkunde, Bd. xv. ' " Bruch des HammergriflEesdurch 

Op- ci<., p. 359. Schlag auf s Ohr," Separatabdruck 



4 " 



Eiii Fall von Fractur des aus- aus der "Wiener med. Presse. 



INJURIES OP THE DRUM-HEAD. 121 

have resulted from a blow upon the ear with the fist; both lesions 
healed. Kirchner' saw several cases of this kind. In a man of 60, 
who fell with the side of his head against a beam, fracture of the 
osseous portion of the auditory canal, with rupture of the membrane 
and fracture of the handle of the malleus, took place. In another case 
there was fracture of the temporal bone and of the hammer ; in this 
instance the patient had been run over by an engine. He also observed 
a case where the os tympanicum was broken by the force of the lower 
jaw in a fall from a considerable height. On recovery, a deep furrow 
was seen on the anterior and lower surface of the osseous part of the 
auditory canal, extending as far as the membrane, and a fissure on the 
posterior wall 11 mm. long; the membrane also was ruptured. Kra- 
kauer saw a fracture of the handle of the malleus which was due to 
examination of the ear with a sound under a bad light. In the author's 
collection is a preparation in which, besides a fissure parallel to the 
long axis of the petrous bone through the whole of the tegmen tympani, 
there is a tear through the tympanic membrane, with fracture of the 
handle of the malleus; the head of the malleus is likewise dislocated 
frora the crown of the incus, the latter being untouched. The case 
was that of a man who fell upon his head from a third-floor flat." 

Objective Symptoms. — The position and form of the rup- 
ture produced by direct violence vary with the shape and size of 
the offending body and the direction it takes in traversing the 
external auditory canal. Punctures and small vpounds may not 
be visible, only a scanty extravasation of blood being found at 
the site of the lesion. In other cases of direct violence to the 
drum-head a more or less ragged aperture will be found, having, 
according to circumstances, greater or less dimensions, and 
either free or filled with coagulated blood. Fissures resulting 
from indirect violence have, as a rule, smooth margins and their 
form is more or less oval. Their edges are white or covered 
with coagulated blood. After twenty-four hours, the margins 
become red and swollen, thus narrowing the aperture. 

Hemorrhage in these cases is very slight— a few drops only 
of blood being the limit. If more copious hemorrhage occur, 
other parts have probably been invaded by the traumatism. 
Copious hemorrhage is a rare incident. 

Air may be forced through the fissure by the Valsalvian 
method with a sharp piping sound. A snapping noise is heard 

1 Jahresbericht der Wurzburger Section der 59 Versamlung deut- 
otiatrlschen Poliklinik, 1884-85; scher Naturforscher und Aerzte, 
ferner, Bericht aus der otiatrischen Berlin, 1886. 



123 VISION AND AUDITION — WOODWARD. 

at the time of injury when the membrana tympani is broken 
through by direct violence. 

Subjective Symptoms. — Pain, especially severe in cases 
of direct injury, is usually experienced, but it may not be noted. 
As a rule, it subsides in a few hours, but will continue if in- 
flammation supervene. Loss of consciousness for a few minutes 
commonly ensues from direct violence. Attacks of fainting 
maybe repeated; and convulsions sometimes occur. Vertigo, 
autophonia, tinnitus aurium, and deafness are quite constant. 
Hearing, instead of being dulled, may be rendered abnormally 
acute, so that certain sounds are distressing to the patient. The 
perception of the direction of sounds is lost. The tuning-fork 
is heard best by bone conduction on the injured side. 

Healing of uncomplicated fissures, due to indirect violence, 
occurs early — in from three to seventeen days, but may be pro- 
longed to six weeks.' Those due to direct violence heal more 
slowly, according to the size and characteristics of the rupture. 
According to Trautmann, fissures do not leave a visible scar. 
Inflammation, suppuration in the lesion, and invasion of the 
middle ear by suppurative inflammation complicate some cases. 
The shape of the fissure will become more rounded if suppuration 
occur. Syringing and inflating such injured ears will retard the 
reparative process, and excite suppurative inflammation. Cold 
air blowing into the ear will produce the same effect. The aper- 
ture does not always close ; especially is this true if suppurative 
inflammation have occurred. Relapses of this inflammation 
are often observed. And so long as the ear is discharging pus, 
the life of the patient is endangered, by virtue of the possible 
occurrence of meningitis, or of abscess of the brain, or of septic 
thrombosis of one of the sinuses. 

Hearing is commonly restored when healing is complete; 
but in some cases it remains more or less impaired. An aper- 
ture through the drum-head does not necessarily diminish the 
acuteness of hearing. 

Imprudence on the part of the patient will have an evil 
influence on the healing of the injured drum-head. And pre- 
existing disease of the ear will operate as a predisposition to 
protracted healing and complicating inflammatory distur- 
bances. 

• Trautmann, op. cit. 



INJURIES OF THE DRUM. 123 

The question arises, naturally, whether the rupture of the 
drum-head or the suppurative inflammation of the middle 
ear is due to traumatism or not. It is well known that both 
occur without injury of any sort. As regards the causation 
of rupture, it can only be certainly attributed to injury 
when extravasations of blood are discovered in the drum-head, 
or when there is found evidence of hemorrhage in the mar- 
gins of the fissure or in their immediate vicinity.' A prob- 
able diagnosis of the causation of the conditions may be 
made, however, in other cases. The relationship between an 
injury and suppurative inflammation involving the middle ear 
may be pronounced upon with certainty only, when the de- 
velopment of the various stages of the ear trouble has taken 
place under the eye of a competent observer. If the examina- 
tion have been made first after the suppuration has set in, and 
if other traces of an injury be discovered, it is probable that the 
injury was the cause of the ear disease, and, indirectly, of the 
death of the patient. If, however, other traces of injury are 
wanting, it is not possible, after suppuration has set in, to state 
positively, on the strength of the objective evidence, that trauma 
and suppuration bear to one another the relationship of cause 
and effect." 

Injuries of the Drum. 

The structures in the middle ear, e. g. , the ossicles of the ear, 
the chorda tympani and the facial nerve, the intrinsic muscles 
of the ear, the mucous lining of the cavities and their bony 
walls, may be directly injured by the entrance of such objects 
as have caused rupture of the drum-head by direct violence. 
Being the most exposed of the ossicles, the malleus, especially 
the handle of the malleus, is most frequently injured. Frac- 
ture of the handle of the malleus has been reported by a num- 
ber of observers. In Meniere's case ° the twig of a tree entered 
the external auditory canal, ruptured the membrana and frac- 
tured the malleus. Healing occurred without treatment. Von 
Troltsch * saw the case reported by him after the fracture had 
united. The injury was done by a penholder which was driven 

• Htlttis o». dt., p. 43. •" Trautmann, i&id. ; vonT.,"Lehr- 

i'ibid., p. 303. buch derOhrenheilkunde,"1877, p. 

2 Trautmann, op. eit., 405, M. 149. 
Gaz. medicale de Paris, 1856, No. 50. 



124 VISION AND AUDITION — WOODWARD. 

into the ear acidentally. Hearing was blunted and the patient 
complained of noises in the ear. In Weir's case, the fracture 
of the handle of the malleus had not united four months after 
injury. The patient gave a history of having fallen into an 
open areaway about fifteen feet. He was unconscious about 
sixteen hours. He had been informed that the right ear had 
bled for about an hour. He experienced pain in the right ear, 
forehead, and other ear for about a month; and great tinnitus, 
which remained unabated since the injury. There was no his- 
tory of entrance of a foreign body into the ear. The watch was 
heard on affected side when pressed upon the ear. The drum- 
head was normal in color; there was an irregularity in the 
handle of the malleus. The bone was found to be fractured a 
short distance below the short process. The broken ends were 
completely and transversely displaced. Reposition of the ends 
of the fragments took place when the ear was inflated by Val- 
salva's method, but soon became displaced again. Two of Dr. 
Weir's colleagues were of the opinion that a faint, whitish line 
posterior to the malleus might be a cicatrix from a laceration 
of the drum-head. Patient was not seen again. ' Hepburn re- 
ported a case of rupture of the drum-head and of fracture of the 
handle of the malleus due to thrusting a hair-pin into the ear. 
Hearing-distance, watch, one-half inch. Seven months later, 
necrosis of the fragments was observed." 

Severe injury to the ear, and other more serious consequences, 
have been produced by pouring corrosive liquids and molten 
metals into the ear. Trautmann ' cites the following cases of 
that nature : 

Morrison's ' case, of a man who poured nitric acid into his 
wife's right ear while she was lying in a drunken slumber. 
Hemorrhage, violent inflammation, paralysis of the right side 
of the body, and death in six weeks, M'ere the consequences. 
Caries of the petrous portion of the temporal bone and menin- 
gitis were found at the autopsy. 

Rau's " case, in which melted lead was poured into the right 
ear of a drunken man; causing deafness, purulent discharge, 

' Roosa, "Dis. of the Ear, " N. Y., = Op. cit, p. 387. 

1891, p. 277. 4 Dublin Journal of Medical Sci- 

''Burnett, "Dis. Ear, Nose, and ence, vol. ix., No. 15. 

Throat," vol. i., p. 266; Trans. ' Med. -chirurg. Zeitung, 1853, 39. 
Amer. Otol. Soc, vol. i., 1870. 



INJURIES OP THE DRUM. 125 

paralysis of the corresponding half of the face. The lead was 
so firmly embedded that seventeen months later it could not be 
removed. 

Ostander's ' case, of an English woman who murdered six 
husbands by pouring molten lead into the ear. She was de- 
tected in the seventh attempt. 

Taylor's ' case, in which a mother poured molten metal (seven 
parts tin and three parts lead) into the right ear of her idiotic 
son to destroy his life. Violent pain and great inflammation en- 
sued, but finally recovery took place. 

Toynbee's ' case exhibits the results of a traumatism of the 
middle ear involving the chorda tympani. The twig of a tree 
penetrated the patient's right ear. There was very severe pain, 
some bleeding (blood is said to have run from the ear) , subjective 
noises, deafness, and, when the ear was inflated by the Valsal- 
vian method, air passed through the drum-head. Seven days 
later some clotted blood was found in the external auditory 
canal. A fissure was found in the drum -head behind and par- 
allel with the handle of the malleus. Its margins were red and 
swollen. Nine days later the fissure was healed, the subjective 
noises had diminished, and, the hearing had improved. Four 
days after the injury the patient had the feeling that a cold 
body had been rubbed over the right half of his tongue, and the 
sense of taste was diminished on the affected side. Klaatsch 
had also observed the sensation of cold in the tip of the tongue. 

Commenting on this case Trautmann states that " patients in 
whom he has accidentally severed the chorda tympani in punc- 
turing the drum-head give different replies: some state that 
they experience a sticking, prickling sensation with a metallic 
or sour taste on the affected half of the tongue, especially along 
its edge. Von Troltsch, Neumann, and others have noted the 
prickling sensation on the edge of the tongue. In another 
case a sense of smoothness on the affected half of the tongue 
lasted six days. The sensation had been experienced imme- 
diately after division of the nerve, and disappeared absolutely, 
leaving nothing abnormal behind. Blunting of the sense of 
taste and anomalies of the secretion of saliva are frequently ob- 

> "UeberdenSelbstmord," S. 395. » Xrautmann, pp. ct7., 405, "Die 

'"Med. Jurisprudence," London, Krankheiten des Gehororgans, " 
1861. ubers. von Moss, 1863, S. 180. 



126 VISION AND ATTDITION— WOODWARD. 

served. In many cases, these characteristic symptoms of in- 
jury to the chorda tympani were accompanied by a sudden, al- 
most lightning-like movement of the head, mouth, and tongue. 
The head, affected as it were by electric shocks, is drawn slightly 
toward the affected side, as are also the corner of the mouth and 
the tongue, which is slightly protruded. In large perforations 
of the membrana which lay bare the chorda tympani, these 
symptoms may be induced by touching the nerve with a sound." 

Direct violence to the middle ear has been done by the at- 
tending physician in attempting to extract a foreign body from 
the external auditory canal. The foreign body has been forced 
into the middle ear through a drum-head lacerated by the un- 
skilful manipulation.^!. A foreign body lodged in the middle 
ear causes suppurative inflammation, and may excite grave com- 
plications in the brain — meningitis, abscess, and thrombosis of 
the sinuses. Headache, vertigo, epilepsy, and mental disturb- 
ances of a serious nature sometimes occur in the non-fatal cases. 
Not only have foreign bodies lodged in the external auditory 
canal been forced into the middle ear, but methods adopted for 
their extraction have led to perforation of the skull, laceration 
of the brain, and death of the victim. Worse than this has hap- 
pened. Misguided by the statements of the patient or his 
friends regarding the presence of a foreign body in the external 
auditory canal, physicians have searched so unskilfully that 
not only has the drum-head been lacerated and removed, but 
the ossicles of the ear have been torn out, and even the walls 
of the middle ear have been perforated and the brain injured in 
the vain hunt for a thing that did not exist. Ordinarily, re- 
moval of foreign bodies from the ear may be accomplished with- 
out injury to the organ, by simply syringing the ear. When- 
ever it becomes necessary to resort to other measures than that, 
it is best for the patient that the case be referred to a competent 
specialist in aural surgery, or that the foreign body be allowed 
to remain in the ear. In a certain number of cases it may do 
no harm if allowed to remain in its bed unmolested. 

Injury to the middle ear by indirect violence occurs by 
virtue of shocks to, or blows upon, the head, falls upon the knees, 
gunshot wounds in the immediate vicinity of the ear, violent 
vomiting and coughing, forcible inflation of the ear, and falls 
upon the chin. In consequence of such injuries, hemorrhage 



INJURIES OF THE DRUM. 127 

into the drum has taken place to an extent sufficient to cause 
deafness, noises and pressure sensations in the ear, and vertigo. 
Loss of consciousness and vomiting signify the coexistence of 
concussion of the brain. Eventually — after some weeks or 
months — the effused blood will be absorbed and the function of 
the organ restored. Sometimes suppuration, with perforation 
of the drum-head, occurs. In other cases, inflammation of the 
middle ear without suppuration ensues. When inflammation 
of the middle ear ensues, whether suppuration occur or no+, the 
probability that the function of the organ will ever be restored 
is proportionately lessened; but it is not always impossible to 
restore such organs to their normal function. 

The drum is injured indirectly by such causes as effect a 
fracture of the base of the skull. Tlie characteristic symptoms 
are those of fracture of the base of the skull, viz. , marked hem- 
orrhage from the ear, escape of cerebro-spinal fluid from the 
ear, and, in exceptional cases, escape of brain matter through 
the external auditory canal. Even in such cases, death is not 
inevitable. 

The mastoid process is occasionally injured by heavy blows 
and gunshot wounds. Dupuytren ' reported a case in which the 
mastoid was torn away from the skull. As a rule, the injuries 
cause fissure or splintering of the bone. They heal kindly, in 
some cases ; in others, necrosis of the bone occurs ; in still other 
cases, death follows from consecutive meningitis. 

"In gunshot wounds, which involve the mastoid only, or 
the adjacent bones and soft parts also, the ball may become 
encapsulated and excite no further disturbance; yet in other 
cases, if the missile press upon the sterno-cleido muscle, neu- 
ralgia and interference with the movements of the neck may 
bother the patient." " Absolute deafness is the consequence cf 
gunshot wounds of this region, in nearly all cases. 

Injuries of the internal ear and auditory nerve are due 
either to direct or to indirect violence. In the former set of cases, 
the direct injury involves, almost without exception, other 
structures within the cranium and terminates fatally. In the 
latter, when the internal ear and the auditory nerve only are 
indirectly injured, the objective symptoms are not sufficiently 
positive to base a diagnosis upon them. Thus is afforded a 
• HUttig, op. cit., Jan., 1894, p. 25. ' Ibid., p. 25. 



138 VISION AND AUDITION — WOODWARD. 

favorable opportunity for malingering. And, inasmuch as it 
is not possible objectively to differentiate between a malingerer 
and a truthful patient in this class of cases, on account of the 
absence of objective evidence, discussion of the subject is post- 
poned until our knowledge of these injuries is more satisfactory. 
The reader is referred, however, to the writings of Trautmann 
and Hiittig for a discussion of that class of injuries. 



THE MEDIOO-LEGAL EELATIOlfS 

OF 

BY 
ALFRED L. BECKER, A.B., LL.B., 

Of the Buffalo, N. F., Bar. 



III.- 



THE MEDICO-LEGAL EELATIONS 
OF lE'SUEAE'OE. 

Scope of the Article.— Only a small number of questions 
in distinctive insurance law involve any essential relation to medi- 
cine, and these concern exclusively life, health, and accident in- 
surance. The following subjects will be treated in this article: 
Powers and Duties of Medical Examiners for Life Insurance ; 
Proofs of Death ; Definitions of Terms of Medico-legal Signifi- 
cance Used in Insurance Policies. 

The trials of insurance causes frequently require expert med- 
ical testimony. The subject of medical expert testimony in gen- 
eral is considered elsewhere in this treatise.' For discussions of 
the causes of death, often an issue in insurance cases, and for 
the effects of insanity on insurance, consult the respective arti- 
cles in this work.^ 

POWEBS AND DUTIES OF MEDICAL EXAMINERS FOE, LIFE 

INSURANCE. 

The universal life insurance practice requires an examination 
of the person of an applicant for insurance by a physician em- 
ployed by the insurer. Generally the medical examiner also 
puts to the applicant certain questions contained in a blank form 
furnished by the company, designed to test the applicant's de- 
sirability as a risk, and he records the answers on the blank, 
which the applicant signs. Very frequently these answers are 
made a part of the policy and declared to be warranties, and the 
courts construe them as having the force of warranties, for the 
truth of which the insured is wholly responsible.' 

'Vol. I., pages 49-72. insurance cases; also the Effects of 

' Medico-Legal Autopsies, Vol. I., Insanity on Insurance, Vol. III., page 

page 831; Personal Identity, Vol. I., 373; and the subject of Poisons, 

page 865; Determination of the treated in Vol. IV. 
Time of Death, Vol. I., page 919; ' See the excellent discussion of 

Death by Heat and Cold, Vol. I., this subject in Cooley's Briefs on the 

page 939; Death from Starvation, Lawof Insurance, Vol. III., pp. 1931- 

Vol. I., page 975; etc., etc., all of 1963. It falls outside the scope of 

which may be of great assistance in this treatise. 

131 



132 INSURANCE— A. L. BECKER. 

The relation of physician and patient of course does not arise 
between the medical examiner and the applicant for insurance. 
Hence no legal privilege or rule of confidential communications 
binds the examiner not to testify as to facts learned from 
the examination. Sound professional ethics doub'tless incul- 
cates, however, discreet silence as to the circumstances of an 
examination for insurance ; they should remain confidential with 
the physician, the insured, and the insuring company. ^ 

Medical Examiner the Agent of the Insurer.— In 
the very nature of things ^ the medical examiner is the agent of 
the insurer. 

The fact that he has been employed by the company to make 
the examination and to take down the answers to the questions 
controls the legal relations between him, the company, and the 
applicant.^ Some companies in drawing their policies have in- 
cluded a stipulation, repeated in the application, that for the 
purpose of recording the answers the medical examiner shall be 
the agent of the insured. But the courts have held quite uni- 
formly to what may be called a doctrine of immutable agency. 
Such a stipulation is of no effect because it agrees to a legal 
impossibility ; the facts unalterably establish an agency between 
the company and the examiner.* 

It follows from such agency that the company is responsible 
for the acts of its medical examiner in taking down the answers 
of the applicant, and if a mistake, misinterpretation, or inten- 
tional error be made in recording them, provided the insured 
stated the truth ^ and did not read over the answers as written, 
thus making the misstatement his own," the policy issued is 

' Cf. Sullings V. Shakespeare, 46 * Cases last cited; also Providence 

Mich., 408, 41 Am. Rep., 166, 9 N. W. Savings Life As. Soc. v. ReutUnger, 

R. 451; Loudoun v. 8th Avenue 58 Ark., 528, 25 S. W. R., 835. 

Railway Co., 16 App. Div. (N. Y.), » Mutual Reserve Fund Life Ass'n 

152, 44 Supp., 742; Roberson v. u Farner, 65 Ark., 581; 47 S. W. R., 

The Rochester Folding Box Co., 171 850; Michigan Mut. Life Ins. Co. % 

N. Y., 538. Leon, 138 Ind., 636; 37 N. E. R., 

btemaman v. MetropoUtan Life 584; Marston v. Kennebec Mut. 

Insurance Co., 170 N. Y., 13, 62 N. E. Life Ins. Co., 89 Me., 266, 36 Atl. R, 

R., 763, 88 Am. St. Rep., 625, 67 389, 56 Am. St. R., 412; Otte v. 

L.R.A., 318; Franklin Life Ins. Co. Hartford Life Ins. Co., 88 Minn., 423, 

?Xo ^Inf""/ ^^ ^'■'^■'295, 73 S. W. R., 93 N. W. R., 608, 97 Am. St. R., 532; 

102 100 Am. St. R., 73. Grattan v. Metropolitan Life Ins. 

Sternaman v. MetropoUtan L. I. Co., 92 N. Y., 274, 44 Am. Rep., 372. 

Ui., supra; Howe i). Provident Fund "Pottsville Mut. Fire Ins. Co. v. 

o?n' 'rJ?^- ^PP-' ^^^' ^^ ^- ^- ^■' Fromm, 100 Pa., 347; Mattson v. 

830; Coles w Jefferson Ins. Co., 4 Modern Samaritans, 91 Minn., 434, 

W. Va., 261, 23 S. E. R., 732. 98 N. W. R., 330; but see Phenix 



MEDICAL, EXAMINERS. 133 

nevertheless binding on tlie company. ^ Decisions vary as to the 
degree of care required of the insured to see that his answers 
are correctly set down. ^ But it seems to be well settled that 
where the applicant is not required to read over the blank when 
filled out, and merely signs it, he is not bound by inaccarate 
transcriptions of his truthful answers ; at least, not unless the 
errors are afterward included in the policy when delivered, 
and moreover are in some sufadent manner called to his atten- 
tion.' It will thus be seen that the law fastens complete respon- 
sibility upon the medical examiner to state fairly and accurately 
the substance of an applicant's statements concerning his health 
and health history. If, however, the insured connives with the 
examiner to make an untrue report of his answers, this fraud is 
of course a defence to an action on the policy.'' 

Another question which sometimes arises concerns the effect 
of knowledge on the part of the company's agent, as its medical 
examiner, that statements contained in an application are un- 
true. If these statements are in a given case mere representa- 
tions and the medical examiner knows facts to the contrary of 
them, there is no doubt that the company waives the untruth of 

Ins. Co. of Brooklyn v. Weeks, 45 an action in equity, Martin v. In- 

Kan., 751, 26 Pac, 410. surance Co., 57 N. J. Law, 623, 31 

' Cases cited in last three notes; Atl. R., 213. 

also Leonardo. State Mutual Life ' Ryan «. World Mut. Life Ins. Co., 

Ins. Co., 24 R. I., 7, 51 At. R., 1049, 41 Conn., 168, 19 Am. Rep., 490; 

96 Am. St. Rep., 698; Mut. Life Otte v. Hartford Life Ins. Co., 88 

Ins. Co. V. Selby, 72 Fed., 980, 19 Minn., 423, 93 N. W. R., 608, 97 Am. 

C. C. A., 331, 44 U. S. App., 282; St. Rep., 532; Dowling v. Merchants' 

Mutual Reserve Fund Life Ass. Co. v. Ins. Co., 168 Pa., 234, 37 Atl. R., 

Farner, 65 Ark., 581, 47 S. W. R., 988; Hartford Life and Annuity 

850; Prudential Ins. Co. v. Haley, Ins. Co. v. Gray, 91 111., 159; Quinn 

91 111. App., 363; Shotliff v. Modern v. Metropolitan Life Ins. Co., 10 App. 

Woodmenof Am., lOOMo.App.,138, Div. (N. Y.), 483, 41 Supp., 1060; 

73 S. W. R., 326; Connecticut Gen. Keystone Mut. Ben. Ass'n v. Jones, 

Life Ins. Co. v. McMurdy, 89 Pa., 72 Md., 363, 20 Atl. R., 196; Vir- 

363; Equitable Life Ins. Co. v. ginia Fire and Marine Ins. Co. v. 

Hazlewood, 75 Texas, 338, 12 S. W. R., Morgan, 90 Va., 290, 18 S. E. R., 191. 

621, 16 Am. St. Rep., 893, 7 L. R. A., ' New YorkLife Ins. Co. v. Fletcher, 

217. But see, holding that parol 117 U. S., 519, 6 Sup. Ct. R., 837, 

evidence is not admissible, that the 29 Lawyers' Ed., 934; Leonard v. 

apphcation, made part of the con- State Mutual Life Ass. Co., 24 R. I., 

tract, does not correctly show the 7, 51 Atl. R., 1049, 96 Am. St. R., 

answers, McCoy v. Metropolitan 698. 

Life Ins. Co., 133 Mass., 82; Thomas * Reynolds v. Iowa and N. Ins. Co., 

V. Commercial Union Ass. Co., 162 80 Iowa 563, 46 N. W. R., 159; 

Mass., 29, 37 N. E. R., 672, 44 Am. Speiser v. Phoenix Mut. Life Ins. Co., 

St. Rep., 323; and holding that the 119 Wis., 530, 97 N. W. R., 207; 

application, when made part of the Rockford Ins. Co. v. Nelson, 65 111., 

contract, must first be reformed in 415. 



134 



INSURANCE— A. L. BECKBK. 



the statements. It cannot be said tliat it relies on them, and 
hence their falsity will be no defence to the policy.^ When the 
statements, by the clear intention of the contract, amount to war- 
ranties, a more diflBicult question arises ; on the whole, the weight 
of authority appears to be that the same rule does not apply. A 
company can accept the premium payment from an applicant 
for insurance and insure him without waiving the defence of 
false warranty, although its agent knows the falsity of the war- 
ranty at the time.^ And such knowledge is not in any case im- 
putable to the company unless it exists at the time in the mind 
of the particular agent whose business it is to obtain the war- 
ranties or to deliver the policy. "It is a fundamental principle 
in the law of agency that for information given an agent to be 
attributable to his principal the information must be imparted 
to the agent in the course of his agency. " ' 

The medical examiner must, if the questions on the applica- 
tion blank are worded inadequately to draw out all the informa- 
tion desired, supplement them with further inquiries. Thus 



' Endowment Rank, K. of P., v. 
Cogbill, 99 Tenn., 28, 41 S. W. R., 
340; National Fraternity v. Karnes, 
24 Tex. Civ. App., 607, 60 S. W. R., 
576 (only facts learned on the 
examination). 

^ Any discussion of the nature of 
warranties in insurance lies beyond 
the scope of this article. The state- 
ment in the text is borne out by: 
Kenyon v. Knights Templar and 
M. M. A. Ass;n, 122 N. Y., 247, 257: 
"The cases in which knowledge of 
the agent through whom insurance 
is taken may operate to defeat the 
right of the company to avail itself 
of the fact so known, at the time it 
is taken, are those in which there is 
no application (warranty) signed by 
the assured stating to the contrary 
of such existing fact, but rests upon 
a condition expressed in the policy 
merely. Then it may be presumed 
that the statement of it in the policy 
as required by the condition was 
omitted by mistake or waived." 
And see Foot v. Aetna Life Ins. Co., 
61 N. Y., 571. But the following 
language from Sternaman ■;;. Metro- 
politan Life Ins. Co., 170 N. Y., 13, 
23, 62 N. E. R., 763, 88 Am. St. R., 
626, 67 L. R. A., 318, a case relating 



to statements negligently taken 
down by the medical examiner, 
certainly is broad enough to cover 
knowledge contrary to a warranty: 
[The Company] "could not take the 
money of the insured while he lived, 
and, when he was dead, claim a 
forfeiture on account of what it 
knew at the time it made the con- 
tract of insurance, for that would be 
fraud." And indeed, if knowledge 
of the medical examiner or other 
agent is ever to be imputed to the 
company at all, it would seem that 
it ought to be imputed in the con- 
ceivable case where a medical ex- 
aminer knows facts about the appli- 
cant's health directly contrary to his 
innocently made warranties. Pei^ 
haps the law will be held ultimately 
to be that where a warranty is inno- 
cently false, the agent's knowledge 
wai be imputed; but if knowingly 
false, the courts will not aid the 
insured even though the agent knew 
its falsity; collusion of the agent 
with the insured might then almost 
be presumed. 

* Butler V. Michigan Mutual Life 
Ins. Co., 184 N. Y., 337, 340; Caru- 
thers V. Kansas Mutual Life Ins. 
Co., 108 Fed., 487. 



PROOFS OP DEATH. 135 

where the question was asked whether the applicant had had any 
sickness or disease during the last ten years and he replied that 
he had had typhoid fever nine years before, it was held that if 
information of other diseases or of all the diseases from which 
the applicant had suffered was desired, the medical examiner 
was bound to ask for it.^ The duty of the applicant is in gen- 
eral satisfied by his giving frank answers to the questions as put 
to him.^ 

PROOFS OF DEATH. 

The physician who attended the last illness of a person de- 
ceased frequently is called upon to make proof of the death, in 
the form of an afi&davit or certificate to be submitted to the in- 
surance company, or in the form of testimony on the trial of a 
contested insurance case. The method of making proof to be 
submitted to the insurer is ordinarily determined by the policy 
itself, which should always be consulted. Proofs of death so 
prepared in accordance with the policy are admissible on the 
trial of a case as some evidence of the cause of death, but they 
are not conclusive.^ As a rule the beneficiary may on the trial 
show by parol testimony that the proofs submitted were erro- 
neous.* 

The famUy physician's certificate of death, adhered to by 
him in his testimony, is entitled to just the weight which the 
jury concludes should be given to the opinion of a learned phy- 
sician, who saw deceased shortly before his death, and had per- 
sonal knowledge of him for some time before.* 

' Dilleber v. Home Life Insurance missible in behalf of beneficiary in 

Co., 69 N. Y., 256, 25 Am. Rep., 182; Aetna Life Ins. Co. v. Kaiser, 115 

Mutual Res. Fund Life Asso. v. SvilU- Ky., 539; Cook v. Standard Life and 

van (Tex. Civ. App.),29 S. W. R., 190. Ace. Ins. Co., 84 Mich., 12, 47 N. W. 

' Mutual Benefit Life Ins. Co. v. R., 568. Otherwise as to the vital 

Wise, 34 Md., 582; Rawls v. Ameri- statistics of the Board of Health, 

can Mutual Life Ins. Co., 27 N. Y., Buffalo Loan, Trust and Safe Deposit 

287 84 Am. Dec, 280. Co. v. Knights Templar and M. M. A. 

' Hanna v. Connecticut Mutual Ass'n, 126 N. Y., 450, 458, 27 N. E. 

Life Ins. Co., 150 N. Y., 526, 44 N. E. R., 942, 22 Am. St. R., 839; or the 

R., 1099; Knights Templars and minutes of a coroner's inquest, Louis 

Masoiiic Life Indemnity Co. v. Cray- v. Conn. Mut. L. Ins. Co., 58 App. 

ton, 209 111., 550, 70 N. E. R., 1066; Div. (N. Y.), 137. , ^ , ^^ 

Mutual Life Ins. Co. v. Stibbe, 46 ^ Cases cited and John Hancock 

Md 302- Modern Woodmen v. Mut. Life Ins. Co. v. Dick, 117 Mich., 

Koz'ak, 63 Neb., 146, 88 N. W. R., 518, 76 N W. R., 9, 44 L. R A., 846; 

248- Bentz v. Northwestern Aid Denver Life Ins. Co. v. i^rice, 1» 

Ass'n, 40 Minn., 202, 41 N. W. R., Colo App 30 69 Pac. R. 313, 

1037, 2 L. R. A., 784. Held inad- 'Aetna Life Ins. Co. v. Ward, 140 



136 INSURANCE — A. L. BECKER. 

DEFINITIONS OF TEBIUS OF MEDICO-LEGAL SICrNIFICANCE 
USED IN INSURANCE POLICIES. 

Determinations by courts of law of such purely diagnostical 
questions as what is pneumonia, or what is a disease of the res- 
piratory organs, made upon the trial of insurance causes, need 
not be collated in this article. Some other terms, however, have 
a more distinctively medico-legal character, either in view of the 
context in which they are employed in policies of insurance, or 
by reason of the fact that their definition involves questions 
which while demanding medical knowledge do not arise except 
in connection with the law of insurance. Policies of life and 
accident insurance frequently exempt the insurer from liability 
for death of the insured from certain excepted causes, and assume 
liability for certain specified risks. Life policies are also invari- 
ably issued upon the applicant's representations or warranties as 
to his health. The terms defined below are mainly of these 
classes. The citation of cases is intended to be illustrative and 
not exhaustive.' 

Accident. — Usually employed in accident policies in the 
phrase, death or injury "by external, violent, and accidental 
means. " The term is to be construed as meaning an event which 
takes place without one's foresight or expectation.^ Unforeseen, 
unexpected, and unthought-of occurrences are accidents.' "An 
injury may be said objectively to be accidental, though subject- 
ively it is not, and if it occurs without the agency of the in- 
sured, it may logically be termed ''accidental,' though it was 
brought about designedly by another person."* The term acci- 
dent itself imports an external, violent agency. ° Injury result- 
ing naturally from usual and ordinary acts of the insured is not 
an accident; e.g., rupture from closing a window;' rupture of a 

U. S., 76, 11 Sup. Ct. R., 720, 35 * Fidelity and Casualty Co. v. 

Lawyers' Ed., 371. Johnson, 72 Miss., 333, 17 So. R., 2, 

' See the excellent encyclopaedia 3, 30 L. R. A., 206, citing Biddle on 

"Words and Phrases Judicially De- Ins., Vol. 2, p. 780. But see Gaines 

fined," for numerous citations of v. Fidelity and Casualty Co., Ill App. 

cases. Div. (N. Y.), 386. 

'' Supreme Council Order of Chosen ' Bacon v. United States Mutual 

Friends v. Garrigus, 104 Ind., 133, Ace. Ass'n, 123 N. Y., 304, 25 N E. 

3 N. E., 818, 54 Am. R., 298. R., 399, 20 Am. St. R., 748, 9 L. R. 

' Breed v. Glasgow Ins. Co., 92 A., 617. 

Fed., 760, 764; cf. United States ' Feder v. Iowa State Trav. Men's 

Mut. Ace. Ass'n v. Barry, 131 U. S., Ass'n, 107 Iowa, 538, 78 N. W. E., 

100, 9 Sup. Ct., 755, 33 Lawyers' Ed., 252, 70 Am. St. R., 212, 43 L. R. A., 

60. 693. 



DEFINITIONS. 137 

blood vessel affected with arterial sclerosis caused by regular 
work at the trade of carpenter ; ^ hemorrhage of a consumptive 
caused by the exertion of closing a railway car window. ^ Sun- 
stroke is not an accident, for it is not really a "stroke" at all 
but a disease of the brain. In a leading English case so decid- 
ing, Cockburn, C. J., well said:* "It is difficult to define the 
term 'accident, ' as used in a policy of this nature, so as to draw 
with perfect accuracy a boundary-line between injury or death 
from accident, and injury or death from natural causes, such as 
shall be of universal application. At the same time we think 
we may safely assume that in the term accident as so used, some 
violence, casualty, or vis major is necessarily involved. We 
cannot think disease produced by the action of a known cause 
can be considered as accidental."* The distinction is clearly 
brought out in a border-line case in the United States Circuit 
Court, ^ in which death resulted from the bursting of a blood-vessel 
during exercise with Indian clubs, and the court laid down as 
the law of the case that if the deceased had used the clubs in the 
ordinary way and there had been no unusual circumstances, it 
was not an accident ; but if there occurred any unforeseen, ab- 
normal, or involuntary movement or torsion of the body, then 
the injury was an accident. In a singular case it was held that 
inadvertently resting the head upon the hand while sleeping, in 
such a way as to cause serious inflammation of the periosteum 
of the metacarpal bones, was an accidental injury. ° Poisoning 
inadvertently, as by swallowing or inhaling a toxic substance, 
has been held to be, and not to be, by external, violent, and acci- 
dental means.' So also death by drowning is by such means.' 

'Niskern v. United Brotherhood Co., 46 Fed., 446, 13 L. R. A., 114, 

of C. and J. of A., 93 App. Div. 581, 22 L. R. A., 620; Railway 

(N. Y.), 364. See also Southard v. Officials', etc., Asso. v. Johnson, 109 

Railway Passengers' Ass'n Co., 34 Ky., 261, 96 Am. St. R., 370. 

Conn., 574. ° McCarthy v. Travelers' Ins. Co., 

' Feder v. Iowa State Traveling 8 Bissel's U. S. C. C. Rep., 362, Fed. 

Men's Asso., 107 Iowa, 538, 78 N. W. Cas. No. 8,682. 

R., 252, 70 Am. St. R., 212, 43 L. R. " Aetna Life Ins Co. v. Fitzgerald, 

A., 693. But see Standard Life and 165 Ind., 317, 75 N. E. R., 262, 1 L. 

Acc.Ins. Co. V. Schmaltz, 66 Ark., 688, R. A. (N. S.), 422. 

53 N. W. R., 49, 74 Am. St. R., ' Healey v. Mutual Ace. Assn., 133 

112. III., 656, 25 N. E. R., 52, 23 Am. St. 



'Sinclair v. Maritime Passenger R., 637, 9 L. R. A., 371; Paul v. 

Assur. Co. (Eng.), 3 El. and El., 478, Travelers' Ins. Co., 112 N. Y., 472; 

4 L. T. (N. S.), 15, 30 L. J. (Q. B.), contra, Pollock v. U. S. Mut. Ace. 

77, 7 Jur. (N. S.), 367. Assn., 102 Pa. St., 330. 

*Dozier v. Fidelity and Casualty » Winspear v. The Accident Ins. 



138 INSURANCE — A. L. BECKER. 

On the other hand, death from contact with putrid substances 
containing virulent bacilli was held to be from disease and not 
from accident.' 

Aflfection. — See Disease. 

Attendance by Physician. — See Medical Treatment. 

Breaking of Limb. — This has been judicially defined to 
mean any actual fracture. Where a policy allowed a benefit for 
the breaking of the shafts of both bones between the knee and 
ankle-joints, it was held not to include thereby "Pott's frac- 
ture," i.e., the breaking of one bone between the knee and ankle 
and the dislocation of the other. ^ 

Disease.— One of the required representations or warranties 
in a life policy is whether the insured has had certain kinds of 
diseases. By this term mere temporary ailments are not in- 
tended.' For example, "spitting of blood " means the complaint 
of spitting blood, not a mere isolated instance.* Even when a 
warranty is made that the insured has not had certain diseases, 
it usually means, according to the strongest authority, not to his 
knowledge, and does not include an obscure disease undiscover- 
able even by medical diagnosis.^ For the distinction between 
accident and disease as a cause of death, see Accident. 

Epidemics. — Where a policy excluded the risk of death 
from an epidemic, the word was held to have "its plain, ordi- 
nary, and popular sense as a familiar word in our language," 
and not the technical medical meaning laid down in Copeland's 
Medical Dictionary, title, "Epidemics." The court adopted the 
Webster definition— a disease generally prevailing, affecting 
great numbers. And it was held that the yellow fever was not 
epidemic in Havana when there were only the usual number of 
cases, viz., 500 to 1,000 deaths annually.* 

External, Violent, and Accidental Means. — See Ac- 
cident. 

Co. (Eng.), L. R. 6 Q. B. D., 42; Co., 24 Fed., 670; Sehmitt v. Michi- 

London v. Preferred Ace. Ins. Co., gan Mut. Life Ins. Co., 101 App. Div. 

43 App. Div. (N. Y.), 487. (N. Y.), 12. Cf. Connecticut Mut. 

' Bacon v. United States Mut. Ace. Life Ins. Co. v. Union Trust Co., 112 

Ass'n,123 N.Y., 304, 25 N. E. R., 399, U. S., 250, 5 Sup. Ct., 119, 28 Law- 

20 Am. St. R., 748, 9 L. R. A., 617. yers' Ed., 708. 

^ Petersen v. Modem Brotherhood ' Moulor v. American Life Ins. Co., 

of Am., 125 Iowa, 562, 101 N. W. R., Ill U. S., 335, 4 Sup. Ct., 266, 28 

289, 67 L. R. A., 631. Lawyers' Ed., 447; Grattan v. Metro- 

' Cushman v. United States Life politan Life Ins. Co., 92 N. Y., 275, 

Ins. Co., 70 N. Y., 72. 280. 

* Dreier v. Continental Life Ins. ' Pohalski v. Mutual Life Ins. Co., 



DEFINITIONS. 139 

External and Visible Sign of Injury.— When this 
sign has been required as the condition of liability under a policy 
the courts have been inclined to construe slight signs as suffi- 
cient. The requirement is satisfied by the death of the insured ; ' 
and by pallor ; ^ by discoloration of a member, showing within a 
reasonable time after the accident ; ' by an emanation of gas from 
the lungs of a person killed by the inhalation of illuminating- 
gas.* Cf. Visible Sign of Injury. 

Habits. — Policies sometimes require the insured to state 
whether he has habits of using intoxicants or narcotics, and 
sometimes also restrict the liability of the insurer if the insured 
shall thereafter acquire such habits. Habitually excessive or 
intemperate use of an intoxicant or drug means uncontrolled 
use, daily or often;* but not under advice of a physician for 
medical reasons.® 

Health. — See Disease. If the insured states that he is in 
good or sound health, this means free from any substantial or 
chronic malady having a direct bearing on the general health, 
expectation of life, and hence on the risk,' 

Intemperance, Death. Caused by. — "Where this risk is 
excepted it has been held to include death caused by the exces- 
sive use of liquor for a short period of time only.* 

Intoxicating Liquor or Narcotics, Death from 

Use of. — Where this risk is excepted it has been held to intend 

voluntary use, not when prescribed by a physician." And it 

must be the proximate cause of death. If it be such cause it 

need not be immoderate or intemperate use to fall within the 

exception of such a risk in a policy.*" 

46 How. Pr., 504, 36 N. Y. Super. U. S., 739, 8 Sup. Ct., 331, 31 Law- 

Ct., 234, afE'd on opinion below, 56 yers' Ed., 315. 

N. Y. 640. " Aetna Life Ins. Co. v. Ward, 140 

' Paul v. Travelers' Ins. Co., 112 U. S., 76, 11 Sup. Ct., 720, 35 Law- 

N. Y., 472, 20 N. E. R., 347, 8 Am. yers' Ed., 371. 

St. R., 768, 3 L. R. A., 443; Bernays ' Manhattan Life Ins. Co. v. 

V. United States Mutual Aec. Ass'n, Carder, 82 Fed., 986, 27 C. C. A., 

45 Fed., 455. 334; Brown v. Ins. Co., 65 Mich., 

^ Root 11. London Guarantee and 306, 32 N. W. R., 610; Grattan v. 

, Accident Co., 92 App. Div. (N. Y.), Metropolitan Life Ins. Co., 92 N. Y., 

578, 86 Supp., 1055. 274, 44 Am. R., 372. 

3 Thayer v. Standard Life and Ace. ' Aetna Life Ins. Co. v. Davey, 123 

Ins.Co.,68N.H.,677,41Atl.R. 182. U. S., 739, 8 Sup. Ct. R., 331, 31 

* Menneily v. Employers' Liability Lawyers' Ed., 315. 

Assur. Corp., 148 N. Y., 596, 43 N. "Endowment Rank K. of P. v. 

E. R., 54, 51 Am. St. R., 716, 31 L. Allen, 104 Tenn., 623, 58 S. W. R., 

R A 686 241. 

" Aetna Life Ins. Co., v. Davey, 123 '° Mutual Life Ins. Co. v. Stibbe, 



140 INSURANCE— A. L. BECKER. 

Loss of a Member. — Where an accident benefit is pro- 
vided for the loss of a member, the question has arisen whether 
only the complete and actual amputation of the member is 
meant. By the weight of authority, if the testimony shows that 
the insured has completely and permanently lost the use of a 
limb, as by paralysis, he has suffered the "loss " of it within the 
meaning of the policy.' 

Medical Treatment.— Where a policy requires the in- 
sured to state whether he has received medical treatment within 
a given time, a physician's attention for some actual disease is 
intended, not for some trifling or imaginary disorder.^ 

Natural Causes, X>eath from. — Where liability was 
measured by natural causes of death, it was held that intentional 
or accidental killing was excluded thereby.^ 

Over-Exertion. — Where an accident policy excludes the 
risk of death or injury from over-exertion, the term has been 
defined to mean a voluntary and unnecessary over-exertion, not 
one put forth in an emergency of danger to save oneself from 
injury, as from being crushed by a great weight.* And what is 
over-exertion for one man may not be for another ; thus, riding 
a bicycle race,^ or lifting a 300-pound weight a short distance by 
a strong man accustomed to such exertion." 

Poison. — When liability under a policy -is exempted for 
death or injury from poisoning, or contact with poisonous sub- 
stances, both unintentional and intentional poisoning are in- 
cluded.' But when the exemption is from liability for deatli 

46 Md., 302; Hanna v. Conn. Mut. 477; Edington v. Mutual Life Ins. 

Life Ins. Co., 8 Misc. (N. Y.), 431, Co., 67 N. Y., 185; Valentine v. 

28 Supp., 661; c/. Miller v. Mut. Metropolitan Life Ins. Co., 106 App. 

Ben. Life Ins. Co., 31 Iowa, 216, 7 Div. (N. Y.), 487; Hubbard v. 

Am. R., 122; Union Cent. Life Ins. Mutual Reserve Fund Life Ass'n, 

Co. V. Hughes, Adm., 110 Ky., 26 100 Fed., 719, 40 C. C A., 665. 

60 S. W. R., 850. 3 Slevin v. Board of PoUce Pension 

' Sheanon v. Pacifio Mut. Life Ins. Fund Commr's, 123 Cal, 130, 55 

Co., 77 Wis., 618, 46 N. W. R., 799, Pac. R., 785, 44 L. R. A., 114. 

20 Am. St. R., 151, 9 L. R. A., 685, * Reynolds v. Equitable Aec. Ass'n, 

S.C. 83 Wis., 507, 63 N. W. R., 878; 59 Hun (N. Y.), 13. 

Sneck v. Travelers' Ins. Co., 88 Hun ° Keeffe v. Nat'l Ace. Soc, 4 App. 

(N. Y.), 94, 34 Supp., 545; Supreme Div. (N. Y.), 392, 38 Supp., 854. 

Court of Honor v. Turner, 99 111. » Rustin v. Standard Life and Ace. 

App., 310, Sisson v. Supreme Court Ins. Co., 58 Neb., 792, 79 N. W. R., 

of Honor, 104 Mo. App., 54, 78 S. W. 412, 76 Am. St. R., 136, 46 L. R. A., 

R., 297; contra (?), Stever v. People's 253. 

Mut. Ace. Ins. Asso., 150 Pa., 132, ' McGlother v. Provident Mut. 

24 Atl. R., 662; 16 L. R. A., 446. Ace. Co. of Phila., 89 Fed., 685, 32 

^ Billings V. Met. Ins. Co., 70 Vt., C. C. A., 318; Early v. Standard 



DEFINITIONS. 141 

caused by taking poison or inhaling poisonous gases it seems to 
be well established that only a voluntary taking is meant. ^ The 
question often arises as to what are poisons, and it usually in- 
volves expert medical or chemical testimony. For the general 
classification of poisons and also the essential differences between 
toxicological, i.e., chemical, action of substances upon the body, 
and purely mechanical action, such as burning, suffocation, or 
drowning, see Vol. IV. of this work generally. ^ The following 
have been held not "poisons " : Substances not ordinarily poison- 
ous, e.g. , oysters ; ^ putrid animal matter ; * sting of insect.^ But 
carbolic acid thrown in the face is " contact with a poisonous 
substance, " " and contact with poison-ivy has been held the same.' 
Whether inhaling coal-gas is poisoning was determined in an 
interesting case as a question of fact depending upon the weight 
to be given by the jury to conflicting expert testimony. As a 
matter of curious, rather than scientific interest, it may be noted 
that the jury found that the result was suffocation, not poison- 
ing. » 

Proximate Cause of Death. — Medical testimony is often 
requisite to enable the court to determine whether the injury of 
an insured was the proximate, or only the remote cause of death. 
The questions of law in cases where proximate cause is at issue 
have been so varied and have involved so many subtle distinc- 
tions that it is impracticable to examine them adequately in this 
article. Any standard work on accident insurance discusses a 
multitude of such cases. A charge of United States District 
Judge Dyer to the jury ° states the law in a typical case succinctly 
and accurately. The policy in suit required that the accident 

Life and Ace. Ins. Co., 113 Mich., 58, 97 Tex., 124, 76 S. W. R., 745, 64 

71 N. W. R., 500, 67 Am. St. Rep., L. R. A., 349. 

445, and cases cited. ^ Bacon v. United States Mut. 

' Travelers' Ins. Co. v. Dunlap, Ace. Ass'n, 44 Hun (N. Y.), 599. 

160 111., 642, 43 N. E. R., 765, 52 Am. ^ Omberg v. United States Mut. 

St. R., 355; Menneily v. Employers' Ass'n, 101 Ky., 303, 40 S. W. R., 

Liability Assur. Corp., 148 N. Y., 909, 72 Am. St. R., 413. 

596, 43 N. E. R., 54, 51 Am. St. R., ° Meehan v. Traders' and Travelers' 

716, 31 L. R. A., 686. Ace. Co., 34 Misc. (N. Y.), 158, 68 

' Cf. on this point, Boswell v. Supp., 821. 

State, 39 S. E. R., 897, 898, 114 Ga., ' Preferred Ace. Ins. Co. v. Robm- 

40; Dougherty v. People, 1 Colo., son, .33 So. R. (Fla.), 1005, 61 L. R. 

514, 519; United States Mutual Ace. A., 145. 

Ass'n V. Newman, 84 Va., 52, 3 * United Stsites Mut. Ace. Ass'n v. 

S. E. R., 805. Newman, 84 Va., 52, 3 S. E. R., 805. 

' Maryland Casualty Co. v. Hudgins, " Barry v. United States Mut. Ace. 

•^ Ass'n, 23 Fed., 712. 



142 INSURANCE — A. L. BECKER. 

should be the proximate and sole cause of death. Judge Dyer 
charged: "Interpreting and enforcing the policy according to its 
letter and spirit, it must be held that if any other cause than the 
alleged injury produced death, there can be no recovery. In 
short, to entitle the plaintiff to recover you must be satisfied that 
the alleged injury was the proximate cause of death. Whether 
a cause is proximate or remote does not depend alone upon the 
closeness in the order of time in which certain things occur. An 
efScient, adequate cause being found, must be deemed the true 
cause, unless some other cause, not incidental to it, but inde- 
pendent of it, is shown to have intervened between it and the 
result. If, for example, the deceased suffered injury to an in- 
ternal organ, and that necessarily produced inflammation, and 
that produced a disordered condition of the injured part whereby 
other organs of the body could not perform their natural and 
usual functions, and in consequence the injured person died, the 
death could be properly attributed to the original injury. In 
other words, if these results follow the injury as its necessary 
consequence and would not have taken place had it not been for 
the injury, then I think the injury could be said to be the prox- 
imate or sole cause of death ; but if an independent disease or 
disorder supervened upon the injury, ... I mean a disease or 
derangement of parts not necessarily produced by the injury,, 
or if the alleged injury merely brought into activity a then exist- 
ing but dormant disorder or disease, and the death of the deceased 
resulted wholly or in part from such disease, then it could not be 
said that the injury was the sole or proximate cause of death." 

Pulmonary Disease.- vvhere an insured warranted that 
he had had no pulmonary dis; ase, it was held to mean no chronic 
disease, and the question did not require him to state that he had 
had pneumonia.' This seems a doubtful decision. Of. Disease. 

Serious Illness. — When an applicant for insurance is re- 
quired to state whether he has had a serious illness, only those 
illnesses which commonly affect the risk, by permanently injur- 
ing the system and tending to shorten life, are meant. It is not 
necessary that they should have been dangerous illnesses.^ 

' Metropolitan Life Ins. Co. v. Co., 20 N. Y., 293; Boyle v. North- 

Bergen, 64 111. App., 685; Carson western Mutual Life Ins. Co., 95 

V. Metropolitan Life Ins. Co., 1 Pa. Wis., 312, 70 N. W. R., 351; Illinois 

Super. Ct., 572. Masons' Benefit Soe. v. Winthrop, 85 

^Peacock v. New York Life Ins. 111., 637; Continental Life Ins. Co. 



DEFINITIONS. 143 

Spitting Blood.— See Disease. 

Suicide.— Seethe article in this volume on the Medico-Legal 
Eelations of Insanity, Effect of Insanity on Insurance, Vol. III., 
page 373. "When a person is found drowned, there is in general 
a presumption of fact that he did not commit suicide, based on 
the principle that every man tends to obey the instinct of self- 
preservation.^ 

Sunstroke. — See Accident. 

Total Disability. — Incapacity for work or business is gen- 
erally the test of total disability within the meaning of accident 
policies.^ The phrase must be given a reasonable meaning, and 
if what the insured is able to do is only a small and unsubstan- 
tial part of his usual work, he is totally disabled.' 

Vaccination, Successful. — Where made a condition of 
the policy being valid, successful vaccination was held not to 
require vaccination producing absolute immunity from small- 
pox, 'but merely producing the ordinary symptoms; it was suf- 
ficient if the vaccination "took."* 

Visible Marks upon the Body. — See External and Visible 
Sign of Injury. When an accident policy requires as a condi- 
tion of a recovery under it that there shall be a visible mark 
upon the body merely, it is sufficient if some internal sign is 
found, as a localized redness of the tissues of the brain shown by 
an autopsy.^ And it has been held that the mark need not be 
visible to the eye ; if a physician can perceive it by the sense of 
feeling the mark is sufficient to satisfy the requirement of the 
policy.' 

V. Young, 113 Ind., 159, 15 N. E. R., Ace. Ins. Asso., 55 Hun (N. Y.), 

220, 3 Am. St. R., 630; Drakeford 98, 8 Supp., 263; Commercial Trav- 

V. Supreme Conclave K. of D., 61 S. elers' Mut. Ace. Asso. v. Springsteen, 

C, 338, 39 S. E. R., 523; Goucher v. 23 Ind. App., 657, 55 N. E. R., 973; 

Northwestern Traveling Men's Asso., Young v. Travelers' Ins. Co., 80 Me., 

20 Fed., 596; Higbie v. Guardian 244, 13 Atl. R., 896; Hohn v. Inter- 

Mut. Life Ins. Co., 53 N. Y., 603, state Casualty Co. of N. Y., 115 

605. Mich., 79, 72 N. W. R., 1105. 

■ Mallory v. The Travelers' Ins. * Sovereign Camp Woodmen of 

Co., 47 N. Y., 52. the World v. Woodruff, 80 Miss., 

^ Mutual Benefit Asso. v. Nan- 546, 32 So. R., 4. 

carrow, 71 Pac. R., 423, 18 Colo. ° Freeman v. Mercantile Ace. Ass'n, 

App., 274, Lobdell v. Laboring Men's 156 Mass., 351, 30 N. E. R., 1013, 17 

Mut. Aid. Ass'n, 69 Minn., 14, 71 N. L. R. A., 753; Union Casualty and 

W. R., 696, 65 Am. St. R., 542, 38 Surety Co. v. Mondy, 18 Colo. App., 

L. R. A., 637; Beach v. Supreme 395, 71 Pac. R., 677. 

Tent of K. of T. M. of the World, 177 ° Gale v. Mutual Aid and Ace. 

N. Y., 100, 69 N. E. R., 281. Ass'n, 66 Hun (N. Y.), 600, 21 

' Wolcott V. United Life and Supp., 893 



MEDICAL ASPECTS 

OF 

INSANITY 

IN ITS 

RELATIONS TO MEDICAL JURISPRUDENCE. 



BY 

EDWAED D. FISHEE, M.D., 

Professor of Mental and Nervous Diseases, University of the City of New York^ Medical 
Department; Consulting Physician to the Neio York City Insane Asylum; Neuro- 
logist to Hospital for Incurables^ B. I. ; Visiting Physician to Hospital 
for Nervous Diseases; Assistant Visiting Physician to Belle- 
vue Hospital; President of the New York Neurological 
Society, etc, etc. 



II^SAIiflTT IIT ITS RELATIOI^S TO 
MEDJOAL JURISPRUDENCE. 

introduction. 

Difficulties of the Subject. 

An introduction to a subject of this nature is at once difSS- 
cult and yet important. It is but natural that diflSculties should 
surround it, as the action of the mind in its normal condition is 
as yet but partly understood. The position of the public to this 
subject has, however, materially changed from that which it 
occupied even a quarter of a century ago. The idea of disease 
of the brain as associated with mental derangement has done 
much to remove the horror and mystery associated with mental 
disease. In the early centuries physicians had associated in- 
sanity with disease of the brain, and all through the literature 
of this period we find descriptions of cases of insanity ; but in 
the Middle Ages superstition and ignorance again held swaj', 
and the intelligent and more or less scientific opinions of the 
past were lost sight of. Under the direction of the priest, the 
insane were regarded as possessed by spirits or under the dis- 
pleasure of God. The consideration that morbid changes in 
the organ of the mind, the brain, as in other organs of the 
body, must necessarily interfere with its functional activity, 
provides a material basis for the consideration of the subject, 
which alike to the professional and lay mind has had the effect 
of removing the stigma from those who are so unfortunately 
affected. This conception also suggests the idea that, as in 
other diseases, we may have acute and chronic, curable and 
incurahle forms, so in mental disease, like conditions may exist, 
opening up in this way a solution of many questions of the re- 
lation of the insane to their surroundings. 

The study of psychology from a physiological standpoint 
has done much to bring about this improved condition. It is 

147 



148 INSANITY — FISHER. 

not possible at present, and probably never will be, to establish 
a material basis for thought, nor in my opinion would much be 
gained thereby; but it is of great importance to have arrived 
at a definite conclusion as to the method of study of thought or 
mental action. Proceeding from this we can see that to under- 
stand insanity we must hold some conception of sanity. No 
definition can be made to apply to all civilizations. The nor- 
mal mind expresses itself through the feelings, thought, and 
volition, in accordance with the accepted customs and rulings 
of its surroundings, and departure from this recognized order 
of action constitutes just so far a d.eparture from the normal. 
The legal aspect of the question only arises where the welfare 
of the individual or community is affected. One can well 
understand that acts by savages, cruel and inhuman though 
they may be, cannot be ascribed to mental disease, though they 
would be classified as insane acts in a civilized nation. The 
great advance of modern times, then, is the consideration of 
insanity or mental derangement as a disease of the brain. 
The term "partial insanity" is a poor one and open to criti- 
cism, for, as has been truly said, the person must be either sane 
or insane; and yet as all the other organs of the body may be 
more or less completely disorganized and still functionate, al- 
though imperfectly, so the mind may be able to act although 
imperfectly. The principle here laid down is of great impor- 
tance, and if applied would do away with much of the contra- 
diction of expert testimony ; for, after all, it is not the question 
of insanity that is most often in dispute, but the question of 
responsibility for the act committed, which must depend on the 
form and degree of mental impairment. The absurd travesty 
of justice and common sense is seen too often in our courts, by 
which persons are declared insane and irresponsible at the time 
of the act, although sane at the time of and following the trial. 
Such conditions lead juries, from fear of allowing the dangerous 
if not insane man his liberty, to discard the plea of insanity. 
The commission of certain acts, which are held to be those of 
an irresponsible person, usually also mark that person as one 
who should remain in the custody of the State. The fact that 
he has at one time been capa.blc of irresponsible action of a 
serious character makes it possible, if not probable, that he will 
again be subject to a like impulse. We should estimate his 



DIFFICULTIES OF THE SUBJECT. 149 

condition from his past history as well as from his present 
apparent state. 

Cullen ' discusses the subject of partial responsibility or 
partial insanity very fully. He says in substance as fol- 
lows : 

Considering the profouYid and complex modifications which 
the moral organism of the individiial is subject to, it is very 
difficult for the physician to define the limits within which 
moral liberty remains intact. The doctrine, however, of partial 
or attenuate responsibility is admitted by a certain number of 
physicians and legal writers. 

Casper, at a period still recent, "considered that any one, 
the subject of a delusion, should be held responsible, if the act 
was not committed under the influence of that delusion." This 
is the generally accepted ruling in civil and criminal procedure. 
Legrand du SauUe " admits total irresponsibilitj' only in cases of 
general insanity. In cases of partial alienation (a term unten- 
able from a medical point of view) the individual "should not 
be held responsible when he has acted under the influence of the 
delusion, but should be so considered, when the impulse under 
which he acted is foreign to the sphere of his maniacal concep- 
tions." 

These opinions, however, have as a foundation psychologi- 
cal considerations not consistent ivith medical views and 
contrar}'- to clinical observation. For admitting them, it is 
necessary to deny the solidarity of the faculties which compose 
the human intelligence and to admit, for instance, that the in- 
dividual possessed by a fixed idea is suflBciently master of his 
reason to resist all other impulses. To-daj^, however, there 
can scarcely be found a clinical expert, who does not admit 
that, " however limited the circle in which the delusion moves, 
the intelligence is altered in its totality, and that morbid ideas 
can germinate and develop only on a territory previously mor- 
bid ; that insanity, if different in its manifestations, is a unit 
in its nature, and that monomaniacs present in the course of 
their existence several different monomanias, not constituting, 
however, different forms of insanity but different symptoms of 
one disease." 

'"Maladies Mentales."3d part: « "Traite de Medecine Legale, " 
Legal Medicine and Legislation. Paris, 1886. 



150 INSANITY — FISHER. 

" How can it be affirmed," says J. Falret,' "that a given act, 
accomplished at a certain moment, is totally foreign to the 
maniacal conceptions of the individual, while another act, com- 
mitted at the same moment, must be ascribed to a morbid im- 
pulse?" 

The whole question often hinges on the idea so common, 
with judge and jury, that insane persons must at all times 
show evidence of insanity, so that, if they exhibit any natu- 
ral desires and motives, or show any lucidity in their speech 
and actions, it is assumed at once that they are of sound 
mind and responsible for their acts. This is especially seen 
where the person after the act uses methods to escape the result 
of his act, or has shown skill in planning its accomplishment. 
Another element, which, while of great importance indeed in 
deciding these questions, namely, that of a motive for the deed, 
is given too great weight, for motive is often present in the 
insane. A delusion, perhaps a concealed one, may be back 
of it, but except in the violently maniacal cases, where great , 
mental confusion exists, there is frequently a motive, more or 
less well defined, present. 

The tendency of modern times to give more weight to the 
testimony of physicians, trained in mental diseases and accus- 
tomed to observe the method of thought in the insane, is to be 
encouraged. The two aspects of view, i.e., the medical and 
legal, are necessarily different, but at the same time cannot be 
absolutely divorced. It cannot be the province of the expert to 
render a decision as to the responsibility of the person in ques- 
tion, nor can he define insanity in a way which can always be 
of practical use for the courts, but he can and should state how 
far the mental condition depends on disease and to what extent 
the individual has been deprived of the free exercise and con- 
trol of his will, either by reason of overpowering false ideas or 
by general impairment of his mental faculties. 

The object of all law is the protection of the public. 
Punishment of the criminal is only a means to that end. 
In the principle, laid down by all civilized nations, for the 
protection of those who are considered mentally unsound, from 
the consequences of their acts, this idea is present. Any diffi- 
culty in this respect arises only where the question of fact as 
' " Diet. Enoyclop. des Sciences Medicales, " 3' serie, t. ill. 



DIFFICULTIES OF THE SUBJECT. 151 

to the insanity of the accused exists, especially in the so-called 
borderland cases or when again the mental disorder manifests 
itself either intermittently or periodically. 

Practically, however, another phase of the question arises, 
especially in criminal cases — that is, whether the mental disor- 
der is of such a character as to deprive the individual of the 
knowledge of the moral character of his acts, as to whether they 
are right or wrong, and as to whether he knew they were con- 
trary also to the law of the land. A person mignt understand 
the character of his acts, while from a medical standpoint he 
might be considered insane. The English and American law 
follows this method of procedure, while the German courts 
give greater weight to the medical testimony, and have special, 
so-called court physicians, who are called upon to state the 
mental condition of tlie accused. As a result there is more 
frequently partial responsibility for the act allowed than with 
us. The question of partial insanity can in this way be eluded. 
Casper, the great German authority, in the last edition by Li- 
man takes this ground very positively. 

While agreeing with most of the authorities, as Griesinger, 
Krafft-Ebing, Kirchhoff, and others, that we must regard the 
mind as a whole, and not as consisting of independent fac- 
ulties, or functions, which can be individually and indepen- 
dently diseased, he holds for this very reason that disease espe- 
cially affecting one of these divisions of the mind must involve 
the integrity of the whole. If these views can be accepted, it 
is reasonable to consider degrees of responsibility — without ac- 
cepting the idea of partial insanity. 

A delusion which does not affect the act committed or has 
no bearing on it, or again if true would not justify the act in a 
sane person, is not accepted by the courts as a defence. While 
this is right in so far as it should not preclude the accused from 
all responsibility for his act, the fact that the individual is so 
far mentally affected that he has delusions, should have its 
weight in respect to the kind of punishment to be meted out. 

These remarks have especially to do with criminal cases. 
In civil cases, indeed, as in matter of contracts, wills, torts, etc., 
the presence of delusions having no bearing on the subject- 
matter are justly excluded from rendering the acts void. 

In no waj" can the great difference between the medical and 
III.— 13 



152 INSANITY — FISHER. 

legal estimate of the fact of insanity and its relations be better 
shown than in the degree of responsibility ascribed to those of 
unsound mind, in civil or criminal procedure. 

An individual might be held responsible for his civil act, 
who, however, would not be held criminally responsible. 

It is impossible, therefore, for the law ever to establish 
lasting or permanent principles. Each case must be studied 
by itself, and changes in opinions on social questions wiU always 
modify with time present rtdings. 

Mechanism op Thought, or the Science of Mind. 

In order to properly consider the subject of mental disease, 
we must in a brief manner consider the subject of the mind 
itself. Mind is represented by mental action, which is only 
the psychical function of the brain, as distinguished from 
its physical function. Mental action can only be understood or 
appreciated by its expression in the feelings generally and their 
subdivisions, the various emotions ; and by thought, which is 
represented by perceptions dependent in every case on the spe- 
cial sense impressions received into consciousness. Under the 
head of thought, therefore, must come ideation, which depends 
on the reception of perceptions, their retention or memory, and 
their comparison and association, or judgment. The knowledge 
whether or not thought exists in the individual depends on its 
expression, either in language or action, in other words in 
volition. The combination of the three general faculties of 
the mind constitutes the psychical function of the brain. Voli- 
tion must, therefore, represent thought, as action must be pur- 
posive in normal mental function. It is under this considera- 
tion that we are able to recognize the great difference between 
sanity and insanity. 

In considering the various faculties of the mind, their activ- 
ity implies consciousness on the part of the individual — a spe- 
cial consciousness, in which the individual or Ego is cognizant 
of the impressions which are being perceived. 

We have to do with, in fact, self -consciousness, which has 
been defined as the recognition of one's own personality. Self- 
consciousness differs from consciousness in general; it is 
what makes the individual. 



MECHANISM OF THOUGHT. I53 

111 a child impressions are received, painful ones resulting in 
reflex expressions of painful feeling or emotion, and vice versa. 
Mere excitation of the special senses of sight or hearing are 
usually pleasurable. Repetition of these impressions creates 
permanent mental perceptions, which are recalled by similar 
impressions, by which means memory, so-called, is established. 
At first a new impression of a similar character is required to 
recall the former perception ; later this may arise of itself. The 
comparison of these various perceptions results in an idea or 
conception ; this implies memory, that is, the recalling of former 
perceptions, or, as it is called, apperception. It is now that a 
higher grade of feeling manifests itself in the form of desire ; 
this is not at first present, all the responses of the cerebro-spinal 
system being reflex. Following close upon ideation and desire 
comes judgment or comparison of the various conceptions, and 
this is associated with volition. It is some time before the in- 
fant can dissociate himself from his environment, or in other 
words establish the Ego as distinct frotn his surroundings ; self- 
consciousness is not acquired until that is accomplished. 

In our brief study of the development of mind in the infant, 
the close and almost indissoluble relation or connection of the 
three faculties of mind is plainly seen. Another fact should be 
commented on, and that is, that the first evidence of mental 
function is in the field of the feelings. This seems the first to 
be evolved and in fact always accompanies the further devel- 
opment of the mental function. As it is the first to appear in 
the evolution of the mind, so, following a well-observed law 
of the nervous system, it is the first to be affected in its dis- 
solution. 

It is only with the evolution of the Ego into the con- 
sciousness, that desire can be said to be fully established and 
that the individual is able to discriminate what is for his own 
personal good or injury. Up to this point none of the higher 
qualities of man have shown themselves. The ethical side has 
not been developed; his relations have only been those which 
have concerned his own good or pleasure — the last stone to be 
laid on the edifice is regard for the good of others, under which 
head comes love of family, of country, and as the top stone love 
of mankind. 

Feelings, as we have said, represent the emotions. In gen- 



154: INSANITY — FISHER. 

eral they are divided into pleasurable and painful. All mental 
action is accompanied by one or the other in some degree. 

Subdivisions or forms of emotion are joy, sorrow, anger, 
fear, etc. 

Perceptions are received through the special senses of sight, 
hearing, taste, and smell and general sensibility, under which 
we will include touch, pain, and temperature. 

The intensity of these perceptions depends on the character 
of the irritation of the special sense and on the manner of re- 
ception into the sentient consciousness, that is, on the degree of 
attention. On these two conditions will depend the ability to 
correctly recall the perception. It is imperfect recollection in 
this regard which leads to phantasy. Where the attention has 
not been intense or active, or in cases where several impressions 
or presentations are taking place at the same time, or again 
where the impression in itself is not sharp and defined, eri-one- 
ous perceptions may result; this is recognized in the form of 
hallucinations or illusions, or again in delusion. 

A certain duration of time is also necessary for the com- 
plete recognition or reception of impressions ; there must also be 
a certain degree of feeling accompanying it, else no attention is 
given. When impressions are rapidly received, there is usu- 
ally a pleasurable condition resulting; when, however, one per- 
ception remains long in the consciousness, a sense of fatigue or 
pain results. 

Intellection or thought implies the presence of perceptions, 
which by association of previous perceptions has led to a com- 
parison of the various attributes of an object as received 
through the special senses. This recalling of former perceptions 
is memory, and any defect in it interferes with ideation or 
thought. 

This can be studied from a psychological standpoint very well 
in the insane, where either a false perception, or the failure to 
recall all in regard to an object, results in a delusion or wrong 
conception. 

In judgment we have the same mental process going on, 
only now conceptions or ideas are reached by memory and com- 
pared, their resemblances and differences noted. Here again, 
attention is of great importance, associated as it is also with 
feeling. 



MEDICO-LEGAL ASPECT. 255 

There cannot be thought or intellection without its expres- 
sion in action or speech; in fact, speech is, probably, the agent 
or means by which thought takes place. 

Speech was no doubt later evolved; nevertheless, by long 
hereditary influences, it has become a part of ratiocination. 
I do not mean by this that speech is necessarily articulate in 
the mental process. In our consideration so far we see the close 
relation of the various processes employed in mental action. It 
seems psychologically impossible to consider one as being af- 
fected, without involving the action of the others. Excessive 
pain or sorrow, pleasure or joy, can entirely prevent thought 
from taking place; again, the continued presence of certain 
ideas which cannot be removed can establish emotional condi- 
tions of pleasure or pain. 

Just such conditions occur in the insane ; the self-conscious- 
ness or the Ego being so changed or affected that the usual 
response to impressions no longer takes place, leading thus in a 
logical way to abnormal feeling, thought, and volition. 

Medico-Legal Aspect. 

Our conception of mental disease depends entirely on whether 
we look at it from a medical or legal standpoint. Ordroneaux, 
quoting Eay, says: "Insanity in medicine has to do with a 
prolonged departure of the individual from his natural mental 
state arising from bodily disease. " " Insanity in law covers 
nothing more than the relation of the person and the particular 
act which is the subject of judicial investigation. The legal 
problem must resolve itself into the inquiry, whether there 
was mental capacity and moral freedom to do or abstain from 
doing the particular act." 

Legally, the question of civil and criminal responsibility 
arises, making it necessary that we should consider not so much 
the form and character of the disease, as the mental soundness 
of the person affected, and also as to whether there can be any 
motive for simulation. 

All countries agree in absolving from responsibility for 
criminal acts any one who is mentally unsound. According to 
the German law, a crime is not counted such when the doer at 
the time is unconscious, or is deprived of his free will by disease 



156 INSANITY— PISHBE. 

of the mind. Austrian law defines an act as not criminal when 
the doer is unconscious or when his will is affected, or the char- 
acter of the act not perceived. The French law is virtually the 
same. ' 

What is Insanity ? 

Synonyms. — Insania, Folie, Alienation mentale, Insania 
Folia, Irrsinn, Irresein, Wahnsinn, Verrilcktheit. It is 
hardly possible to give a succinct definition of insanity. So long 
as the mental processes arise from natural causes and correspond 
to the condition of the surroundings, so long is the mind sound; 
when the feelings, ideas, and acts arise without cause, but 
rather from cerebral disease, we have the reverse. Mental dis- 
ease is brain disease, but the reverse is not true. The organ of 
the mind has its basis in the cortex of the brain. ^ " Insanity is 
a matter of fact, and is not amenable to any legal test. It is 
for the jury or experts to determine the fact of insanity; for 
the courts to determine its effect on civil rights." The general 
meaning of insanity at laiv is "' a permanently disordered state 
of the mind beyond the control of the individual, produced by 
disease. This must be proved, the burden of proof resting on 
the party alleging it. As mind is represented by feeling, 
thought, and volition, any departure from their normal relation 
must represent mental disorder. Persons may, however, be in- 
sane medically, but not in the eye of the law, and vice versa." ' 

" It is a trite but a most important observation, that in the 
question of what constitutes insanity, the members of the two 
great and learned professions of law and medicine entertain 
essentially different and seemingly irreconcilable views, and 
that on the question of the irresponsibility of criminals, who 
are supposed to be insane, there is still a wide chasm of differ- 
ence of opinion between them. To a certain extent this is true, 
and perhaps inevitable, and the reason of it is not difiScult to 
find — that the two professions have to regard insanity and to 
deal with the insane with different aims and purposes. The 
physician has to prevent or cure it, and to him, therefore, the 
whole and especially the early history of the patient, embracing 
the causes and the development of the changes, bodily and men- 

' Kiafft - Ebing : "Geiichtliche ^ Ibid. 
Psycho-Pathologie, " edition of 1875. » Ordionaux. 



WHAT IS INSANITY? 157 

tal, and affording perhaps some insight into the pathology, is 
of preponderating importance. With him the main (question is 
to prevent its interference with the enjoyment and duration of 
the life of the patient. 

" To the lawyer it matters not how the seed of insanity was 
sown, nor the growth of the plant, except as confirmatory evi- 
dence that the plant is there. With him the sole question is, 
its existence, its degree, and its influence on the conduct, not 
therefore a medical but a moral one ; and if the same mental 
states were capable of being produced by other conditions than 
disease, the same amount of irresponsibility would, I think, 
be recognized, as indeed is the case for children under seven 
years of age, in whom the law refuses to recognize the responsi- 
ble knowledge of right and wrong." ' 

While indeed, as the writer just quoted states, the standpoint 
of law and medicine is different in the view of what insanity 
is, there are many points which they must investigate in com- 
mon, especially hereditj', injuries, etc., as causative agents, and 
again "the bodily and mental changes" are fully as important 
for the lawj'er to study as for the physician. In fact it is 
impossible for the law to do without the knoioledge which 
belongs to the medical expert, for the question of responsibility 
is determined by the fact, whether or not the disease of the 
brain is of such a character as to fall under the rulings of the 
courts, as to what constitutes insanity. This cannot be left to 
laymen to decide, and therefore, despite the somewhat con- 
temptuous reference to medical experts by some judges, they 
are forced to make use of their knowledge. 

" No doubt the extension of the meaning of insanity, as un- 
derstood by medical men, has been due in a great measure to 
more laborious and accurate methods of observation, resulting 
in actual discovery and increase of knowledge, and also to a 
more enlightened estimate of the correlation of insanity with 
other nervous diseases ; but also it seems to me it has gained an 
impulse from the adoption of hypotheses which have no direct 
relation with the actual existence of mental disease, and which, 
however useful and admissible in the theoretical conception 
and in the practical study of other causation of insanity, are 
completely out of place in the investigation of such practical 
' Buoknill : "Insanity in its Legal Relations." 



158 INSANITY — FISHER. 

questions as whether a criminal is or is not insane. As a type 
of this kind of hypothesis I may cite what is called the insane 
neurosis, being, if I understand it aright, the condition of a 
man who is more liable than other men to become insane, but 
who has hitherto shown no signs of the presence of the disease 
itself. No doubt there is such a condition as an insane neuro- 
sis. And there is also such a condition as a criminal neurosis. 
It is the Hegelian theory of becoming, and we are all becoming, 
something which we are not. But the inquiries of criminal 
courts are restricted to actual events of the past ; and if these 
forty-fold forms of insanity, this tendency, to comprehend all 
nervous disease within the pale of insanity, these speculative 
views as to the existence of inherited insanity which shows no 
signs, are in any way reflected in the evidence of medical wit- 
nesses, no wonder if our legal fellow-laborers, in the interest of 
truth and justice and the welfare of society, should take a stand 
which may be nothing more than the conservatism of common 
sense." ' 

One observes perhaps primarily, in all mental disease, 
a change in the feelings or the emotions, and therefore in 
the personality. There may be excitement or apathy, but in 
either case a concentration upon the ego or individual who be- 
comes the central figure amid disordered perceptions and con- 
ceptions. As all mental action is carried on through perception, 
we expect and find disorders of the various perceptions, as rep- 
resented in Jiallucinations and illusions. While these latter 
conditions are not necessary for our diagnosis of insanity, still 
in conjunction with other symptoms they are perhaps the 
strongest and most common evidence we have of mental dis- 
ease. Delusions, either primary or secondary to hallucination 
and illusion, are the best proof we possess of mental aberration, 
but they are not absolutely necessary, and in many cases are 
not present in well-recognized forms of insanity. As a neces- 
sary part of the normal mental activity, consciousness must be 
present, and the recognition of one's own personality, by which 
we mean self-consciousness. We observe then, in the insane, 
first some change in this entity — self-consciousness. 

J. Battey Tuke defined insanity as consisting " in morbid 
conditions of the brain, the result of defective formation or 
' Bucknill ; "Insanity in its Legal Relations." 



WHAT IS INSANITY? I59 

altered nutrition of its substance, induced by local or gen- 
eral morbid processes, and characterized especially by non- 
development, obliteration, impairment, or perversion of one 
or more of its psychological functions." Bucknill ' defines 
insanity as " a condition of the mind in which a false action of 
perception or judgment, a defective power of the will, or an un- 
controllable violence of the emotions and instincts have sepa- 
rately or conjointly been produced by disease." The legal 
question must always involve the extent of impairment of the 
will, and the consequent irresponsibility. As Eay has well 
said, " certain it is that as we have become better acquainted 
with the anatomy of the brain, and have become more thor- 
ough and persevering in our examinations, the more rarely do 
we find a case of insanity presenting no organic changes after 
death." 

Clinically, insanity is a disturbance of self-consciousness, 
and is dependent upon disease of the cerebro-spinal system . The 
object of the study of insanity is to discover the conditions 
under which psychical function or mental action departs from 
the normal, and to learn the method by which this function 
may be restored. 

Brain affections with predominating disturbance of mental 
function are called diseases of the mind. The question neces- 
sarily arises, however, as to where the seat of the psychical or 
mental function lies. The cortex of the cerebrum is the organ 
of all mentality, the rest of the nervous system acting only as a 
conductor. Here are grouped the result of former feelings, per- 
ception, and volition. Mental action springs from, and depends 
upon, conscious perception in the cortex. There alone is the 
seat of thought. By comparative study of the hemispheres of 
the various grades of mammalians it is noted that the anterior 
brain, and the convolutions around the fissure of Sylvius, which 
pathology and physiology designate as the centre for speech, 
are especially developed in man. The significance of the an- 
terior brain for the intellect is also shown by its proportionate in- 
crease in the more intelligent races, its loss in weight (Meynert) 
in mental disease. The convolutions become more complicated 
and increase as we ascend in the species. The significance of 
these fissures and convolutions lies in the fact of the increased 
1 "Unsoundness of Mind in Relation to Criminal Acts." 



160 INSANITY — FISHER. 

surface they present for the gray matter, which is proportional 
to the intelligence. 

Mental action consists in perceptions and their action one 
on the other. In general, the three principal functions or 
faculties of the mind — the feelings, thoughts, and will— must 
act in harmony. We cannot separate them before the law. 
The fact of mental unsoundness is the important thing.' Men- 
tal disease must then affect these different factors of the mind, 
manifesting itself by anomalies of the feelings, and disturbances 
of the perceptions and conceptions. 

" Any one or more of numerous causes may produce disease 
of the brain or nervous system, which interferes more or less 
with the feeling, will, or intellect of the person affected. Com- 
monly the disease, if it runs its full course, affects the emo- 
tions first, and afterward the intellect and the will. It may 
affect the emotions, either by producing morbid depression, 
or by producing morbid excitement or feeling. In the first, 
which is much the commoner of the two cases, it is called 
melancholia, and in the second mania. Melancholia often 
passes into mania. Both melancholia and mania commonly 
cause false opinions as to existing facts, which suggest them- 
selves to the mind of the sufferer as explanations of its mor- 
bid feelings. These delusions are often accompanied by hallu- 
cinations which are deceptions of the senses. Melancholia, 
mania, and the delusions arising from them often supply 
powerful motives to do destructive and mischievous acts, 
and cases occur in which an earnest and passionate desire to do 
such acts is the first and perhaps the only marked symptom of 
mental disease. It is probable that in such cases some morbid 
state of the brain produces a vague craving for a relief by some 
form of passionate action, the special form of which is deter- 
mined by accidental circumstances, so that such impulses may 
differ in their nature and mode of operation from the motives 
which operate on the sane and insane persons alike. The differ- 
ence may be compared to the differejQce between hunger prompt- 
ing a man to eat, and the impulse which, when he suffers 
violent pain, prompts him to relieve himself by screaming. In- 
sanity affecting the emotions in the forms of melancholia and 
mania is often succeeded by insanity affecting the intellect and 
' Neuman's "Lehrbuch der Psychiatrie." 



ANALOGOUS CONDITION IN HEALTH. 161 

the will. In this stage of the disease, the characteristic symp- 
tom is the existence of permanent incurable delusions, commonly 
called monomania. The existence of any such delusion indi- 
cates disorganization of all the mental powers, not only the 
power of thinking correctly, but the power of keeping before 
the mind and applying to particular cases the general principles 
of conduct. The last stage of insanity is one of utter feeble- 
ness, in which all the intellectual powers are so much prostrated 
as to reduce the sufferer to a state of imbecility. Lastly, paral- 
ysis and epilepsy are so closely allied with insanity, that insan- 
ity frequently forms a symptom of each. In all the cases above 
referred to, the sufferer is supposed to have been originally sane, 
but sanity may never be enjoyed at all. This happens in cases 
of idiocy." ' 

English law recognizes two states of mental disease : (1) De- 
mentia naturalis; and (2) dementia adventitia, under which 
general insanity is included. To this the term " lunacy" is usu- 
ally applied. In New York, Massachusetts, and several other 
of the States statutes have been passed defining the term " in- 
sane person," "lunatic," "non compos," and "insane," so as to 
embrace all forms of insanity except idiocy. In many of the 
States, the law has made the words "lunatic," "insane," and 
"non compos m,entis" synonymous and convertible terms.'' 
There is no distinction between the terms insanity and un- 
soundness of mind. 

ANALOGOUS CONDITION IN HEALTH. 

Mental disturbance as represented by hallucinations, illu- 
sions, and delusions is not confined to the insane, but analo- 
gous conditions are not infrequently seen in health and in vari- 
ous diseases, or in persons under the influence of drugs, such as 
alcohol, morphine, hasheesh, etc. A most typical example of 
this is seen in delirium tremens, which may be taken as a fair 
representation of mania. In it we find great excitement, hal- 
lucinations, especially of sight and hearing, marked volubility, 
and the accompanying mental confusion which is usually pres- 
ent to a greater or less degree in all mania. The distinction, 

' Stephen's "History of Criminal ^ Taylor's "Medical Jurispru- 
Law of England, " vol. ii. dence." 



1(53 INSANITY — FISHER. 

however, is easily made between this condition and mental 
disease, in that we are acquainted with its cause and also with 
the fact that clinically we can define its course and duration. 
But even in* these cases, the truth of its close alliance with 
mental aberration is proven by the fact that in chronic alco- 
holism we have a well-defined chronic, and generally incurable, 
form of insanity. 

With morphine, we find hallucinations and delusions, usu- 
ally of a pleasant character, which, however, the subject is able, 
when aroused to full consciousness, to recognize as merely 
such, giving therefore one of the cardinal distinctions between 
the so-called hallucinations of the insane and of the sane. The 
brief duration of these conditions also, of whatever nature, is 
opposed to the idea of their dependence upon disease of the brain 
structure. 

We find in the dreams accompanying sleep an almost typical 
reproduction of the mental condition of the insane, as in both 
instances self -consciousness is never fully in the ascendency. 
In both cases, not infrequently, a dual existence may be par- 
tially recognized; or, again, the two existences, accompanied 
frequently by a change of personality, remain distinct and apart, 
so that in the insane, at least, acts committed or persons met 
during one state are not recollected in the other. 

Kraflft-Ebing puts this very clearly : 

The physiological function of the brain, on its mental 
side, is the production of feelings, thought, and volition. 

The spontaneous origin of mental action without adequate 
cause is, in general, a sign of internal irritative processes, 
its pathological nature manifesting itself by its duration, in- 
tensity, and general disproportion. Only when we know the 
source and motive of the mental action, can we decide whether 
it is that of a sane or insane person. In the majority of cases, 
in the early stages of insanity, the most marked symptom is 
emotional, not intellectual, and apparently has arisen without 
cause. It is similar, however, to the normal physiological 
reaction ; the course of the feelings can be tumultuous or de- 
pressive, corresponding to melancholia or mania. If we com- 
pare physiological or normal depression with melancholia we 
notice no substantial difference; in both individuals there is 
evidence of psychical pain, both are depressed, and given over 



ETIOLOGY. 163 

to their painful impressions, interesting themselves in nothing 
else, i.e., their usual duties or pleasures. Physically they ex- 
hibit similar states : they are sleepless, the appetite is poor, the 
intestinal action is sluggish, and there is general malnutrition. 

The difference is, that in the first the mental pain and de- 
pression have an adequate cause in some previous occurrence, 
and are the physiological reaction from it, while in the other 
there has been no external cause, or at least not a sufficient 
one, but it has arisen from an internal process, the result of a 
diseased brain. The self-consciousness is too much affected to 
distinguish the true from the false. 

The laity rarely make this distinction, especially when 
some cause exists, and try vainly to arouse the patient by change 
and occupation. The analogy is the same for mania : it is only 
a permanent state of the joy following, for instance, a good 
piece of news ; observe also the slight line between genius and 
insanity. 

ETIOLOGY. 

The causes of insanity are predisposing and exciting. 

Predisposing. — The predisposing causes are those which 
come under a general head, as civilization and race ; the latter, 
however, except where races have isolated themselves from 
others, has very little influence. Among the Chinese there is 
very little mental disease. This may be due to their methodi- 
cal habits of living and temperate use of alcohol. Age, with 
its transitional periods — e.g., childhood, puberty, senility — sub- 
ject the individual to special danger. It is difficult to say 
whether celibacy has an influence in this disease, although the 
proportion of those admitted into asylums, as given in the re- 
port of the Lunacy Commission in England, shows a much 
larger number among the unmarried. Occupation, where men- 
tal worry or monotony is present, as in sailors, teachers, prison- 
ers, etc., has a deleterious influence. 

Inhabitants of cities are more liable to mental disease. 
This is probably the result of the increased demands on the 
energy of the individual to maintain his social position or in 
the greater struggle for mere existence; there is also greater 
dissipation of all kinds. 

There is one form of insanity which is peculiar to modern 



164 INSANITY — FISHER. 

lite— that which Kirn has termed the characteristic psy- 
chosis of the nineteenth century, namely, general paresis. 

This disease does not seem peculiar to any race, but depends 
on the surroundings of the individual and the vicissitudes and 
anxieties of life. 

Before slavery in the United States was abolished, the negro 
was never affected with this form of insanity ; it is now com- 
mon among those who have flocked to the cities and who have 
been compelled to assume the responsibilities of supporting 
themselves. 

This can also be said of the Irish, that is, after leaving their 
agricultural pursuits, and being exposed to the vicissitudes and 
excitement of large cities. 

The Chinese in this country also supply their quota, several 
cases having come under my observation. We observe no 
change in the class of symptoms from mere difference of race: 
there are the same delusions of grandeur, the feeling of power, 
and the ideas of great wealth, associated with the physical signs 
of tremor and disturbance of articulation. 

Heredity. 

A most important element among the individual predis- 
posing causes is heredity. It is more often the inheritance of 
an unstable nervous organization than any special form of insan- 
ity. The effect of predisposition to insanity is seen in its rela- 
tions to all the direct and exciting causes. 

Injuries, fevers, grief, stress of any severe form, with the 
hereditary tendency to mental disease in the individual, result in 
insanitj'^, where in other persons the tendency would be slight. 

This predisposition by inheritance may be due to various 
nervous disorders in the progenitors, as epilepsy, dipsomania, 
neuralgia, hysteria, etc., all producing alike an unstable nerv- 
ous organization. The reverse of this is also true, nervous dis- 
orders being the result in the descendants of insanity in the 
antecedents. 

Marriage between persons either too similar in mental 
characteristics or tastes, or again too dissimilar, not unfrequently 
results in insanity, especially if there is any consanguinity. 

The tendency to inheritance of insanity depends largely on 



PREDISPOSING CAUSES. 165 

the condition of the parent at the time of procreation. If the 
insanity developed after the birth of the child the influence of 
heredity is not so great. In regard to the special form of 
disease inherited, it may be of the same kind. Especially is this 
seen in suicidal tendencies, occurring not infrequently at the 
same age, or again the occurrence of insanity at the puerperal 
and climacteric periods when it has been directly inherited. 

Certain forms, as general paralysis, are rarely directly in- 
herited, although the children may be idiotic or subject to the 
various neuroses (Savage). 

Individual Predisposing Causes :— Occupation. 

Prisoners. — Among those confined in institutions, mental 
disease is not uncommon. Here it is also that the different 
forms of insanity are often feigned in order to avoid work or to 
procure hospital treatment. In the older method of treating 
criminals, where punishment by separation from others was 
common, mental disease was very frequent. The monotony of 
work without mental exercise may result in delusions common 
to various forms of mental disease, especially those of persecu- 
tion. Epilepsy may also result. Mania is not common, but 
impulses, homicidal and suicidal, are frequent. Masturbation 
with its accompanying result, dementia, is frequent; but where 
a system of occupation is carried out, all these conditions are 
much lessened. Perhaps the mental disturbance most often 
feigned among prisoners is that of dementia. It is also the 
easiest and the least liable to detection. Still epilepsy is not 
infrequently assumed, as in the case of the so-called "dummy 
chucker" in Sing Sing prison. This patient had deceived 
many expert examiners, and was only detected after many 
years. The opposite condition of attempt at concealment of in- 
sanity is more rarely present. It is observed sometimes on 
examining the patient, especially in the degenerative type of 
disease. Where the symptoms can be restrained, it implies a 
certain amount of control; however, under provocation, or 
when the patient is taken unawares, the true condition can 
usually be determined. It is only by frequent examinations, or 
allusions to the special delusion of such cases, that the true 
mental condition can be discovered. In melancholia we find 



166 INSANITY — FISHER. 

this tendency to concealment of the condition, where it is of a 
mild type. After partial recovery from acute attacks, care is 
necessary to discover whether the delusions and hallucinations 
are still present. Our only method of estimating the sanity or 
insanity must ultimately rest on the conduct, whether expressed 
in speech or act. 

There is little difference noted in the various business occu- 
pations. Those, however, whose life is more solitary or confined, 
as sailors, soldiers, governesses, teachers, etc., show greater 
tendency to mental disease. Professional beggars and prosti- 
tutes are especially liable ; this is probably the result of sexual 
excess, drunkenness, and general privation. 

Kirn finds that prisoners, probably through the physical 
weakness induced by imprisonment, and the influence of re- 
morse, especially when solitary confinement has been carried 
out, are liable to melancholia with delusions of persecution 
and hallucinations of the special senses. 

It has not been found that those engaged in the care of 
the insane are much affected. Certainly imitation is rare 
of the same form of disease. The social conditions do not seem 
to have any especial influence, except in so far as poverty and 
bad hygienical surroundings have in a general way a deleterious 
effect. 

Eeligion. 

According to Kirn religious formalism favors the occurrence 
of (primary) religious paranoia ; this may even become epidemic 
under favorable circumstances. Investigation generally proves, 
however, that its effects are shown mainly in those predisposed 
to mental disorder by heredity or a neurotic disposition, or again 
at special periods of life, as puberty, the puerperal period, 
and during the climacteric. In regard to this latter class, also, 
it may be observed that the condition is not usually a perma- 
nent one, recovery taking place, while in true paranoia, which 
is itself a chronic delusional state, the religious excitement has 
acted simply as an exciting cause, and has given direction to the 
form of mental disturbance. Anxiety in regard to success in 
any special department, as in art or politics, especially when 
failure results, or even, though more rarely, great success, may 



EXCITING CAUSES. 1,57 

give rise to paranoia, though of a different type, as, for instance, 
with delusions of persecution. 

During revivals mental disorder is common. The term " re- 
ligious insanity" is misleading, and is to be deprecated. Where 
the delusions are of a religious character it is not infrequent 
to find associated with them an element of eroticism, so that 
those addicted to sexual abuse are frequently subject to such 
delusions. Communications with God are frequent, either 
through hallucinations of sight or hearing, leading to de- 
lusions in which special commands are received or in which 
a change of personality occurs. The character of God himself, 
or of some prophet is assumed. We find these conditions not 
infrequently among the uneducated, or among those of a low 
type of mental development. We often find among this class 
those who subject themselves to self-mutilation in their desire 
perhaps to atone for some crime, imaginary or otherwise. It 
is really a type of paranoia. Epileptics are especially in- 
clined to religiosity, taking great pleasure in all exercises 
of a religious character. This, however, has little or no effect 
on their action, nor is true remorse likely to follow acts of the 
most extreme violence. Depression or seK-condemnation is 
felt most often for imaginary acts of disobedience to God, 
especially in relation to self -abuse rather than to actual pres- 
ent wrong-doing. 

Exciting Causes. 

In those predisposed by heredity or a neurotic disposition, 
physical causes, as injuries, fevers, physiological states as 
pregnancy, lactation, etc., may induce mental disorder, but 
these causes may be the primary ones themselves. 

The various inflammation of the meninges, and the cor- 
tex of the brain, rarely result in insanity. We may indeed 
have delirium and mania, but these symptoms are usually of 
comparatively short duration, and with the subsidence of the 
provoking cause they also subside. 

We exclude from these remarks the specific characteristic 

affection of the brain peculiar to certain diseases, as general 

paralysis, as they are the pathological changes observed in the 

disease and not the cause. 
III.— 13 



168 INSANITY — FISHEE. 

Cerebral hemorrhage, tumors, multiple sclerosis impair 
the functional activity of the brain and tend to dementia rather 
than any well-defined psychosis. Here again we must not in- 
clude in the list of causes what is a symptom of the disease, 
as apoplectic seizures in general paralysis. 

Injuries to the skull may not manifest themselves in a dele- 
terious way for years, but no doubt have an influence even after 
a long period, either directly or indirectly, in causing insanity. 
While we cannot consider it a predisposing cause to general 
paralysis it may be an exciting one. 

Insanity may result from various diseases of the nerv- 
ous system, as Basedow^s disease, or exophthalmic goitre, 
hysteria, epilepsy, chorea, etc., tabes, multiple sclerosis. 
With the exception of tabes no special form is the result; here 
perhaps general paralysis not infrequently results. There are 
many allied and similar symptoms in these two diseases. 

Following Griesinger we find that constitutional disease may 
result in insanity. General ansemic states following exhaus- 
tive disease, repeated loss of blood, special conditions as lacta- 
tion, exposure as in the states of inanition following in ship- 
wrecks, produce those forms of insanity which come under the 
head of functional psychoses, i.e., mania, melancholia, hallu- 
cinatory and delusional insanity, and primary dementia. 

Tuberculosis is very common among the insane, the mor- 
tality from this disease being large. I can scarcely agree that 
it is very frequently a direct cause of it, or that we are justified 
in establishing a special form under the name of phthisical 
insanity. Tuberculosis of the brain substance, or tubercular 
meningitis rarely terminates in insanity ; the course of these dis- 
eases is usually a rapid and fatal one, and while such cases not 
infrequently are brought to the asj'lum, they cannot properly 
be considered as examples of insanity. The delusions and 
hallucinations may be excessive and the patient require re- 
straint, the course of the disease resembling acute mania or 
delirium grave. In such a patient under my observation, 
careful examination showed no physical signs of tuberculosis, 
either abdominal or cerebral. The temperature had suggested 
tuberculosis, and special attention had been given to these symp- 
toms. Death ensued from exhaustion, and the post-mortem re- 
vealed a general miliary tuberculosis, involving the abdominal 



EXCITING CAUSES. 160 

region and the convex surface of the brain, the base not being 
affected. 

The direct cause of the delirium and hallucination was the 
cerebral irritation by the miliary tubercles. 

There was nothing characteristic to differentiate it from 
similar states occurring in acute mania, or in meningitis oc- 
curring in the course of acute inflammatory rheumatism. 

Tuberculosis may run its course in the insane without being 
observed, the mental symptoms obscuring it, especially as the 
patients themselves frequently offer no complaint. The course 
of the disease is apt to be rapid, owing to the generally impaired 
nutrition. 

My experience would not indicate that melancholia is more 
frequent than mania. Suicidal mania is not uncommon. 

Syphilis stands in an important relation to insanity, asso- 
ciated as it is with disease of the meninges and the blood-vessels, 
as well as the brain substance itself. We frequently find acute 
conditions present. 

Cerebral syphilis not infrequently passes into general paral- 
ysis of the insane. This implies organic changes in the men- 
inges and cortex, secondary usually to the endarteritis, which 
are incurable. The estimate of the proportion of these latter 
cases due to syphilis varies with the author, some writers going 
so far as to say that it is the basis of general paresis in all 
cases with few exceptions. The initial stages in both may be 
very similar ; in general paralysis, however, the fatal course of 
the disease is not affected by specific treatment, while cerebral 
syphilis not infrequently entirely clears up under the iodides 
and mercury. 

Fevers, especially the infectious, may during their course 
cause insanity; this can be ascribed often to the high tempera- 
ture or to the overwhelming of the brain by the direct poison. 
These states are rarely protracted, although at times they pass 
into chronic incurable forms. It is usual to find an hereditary 
history if that is the result, the constitutional condition acting 
only as the exciting cause. 

Another cause for these mental states is the exhaustion and 
cerebral anaemia, which may result in hallucinatory mania or 
melancholia. This occurs in the course of all the fevers, as 
typhus, typhoid, small-pox, pneumonia, scarlet fever, etc. 



170 INSANITY— FISHBB. 

Qriesinger speaks especially of psychoses occurring in tbe 
course of intermittent fever, in regions where intermittent 
fever is endemic, the regular quartan or tertian attacks of fever 
being superseded by attacks of insanity (violent mania, sui- 
cidal impulse) without fever. This may terminate in chronic 
disease. 

Influenza is not an infrequent cause of the functional type 
of the psychoses. The recent epidemic of the past few years 
has given occasion to many observations. While apparently 
melancholia is more common, mania of a violent character may 
follow. It would seem to be largely due to the exhaustion. 

Rheumatism, when acute, causes meningeal irritation, the 
symptoms being usually acute and marked by delirium and 
hallucination. Clouston, Savage, and others speak of rheu- 
matic insanity, but this is hardly a proper term. However, the 
close connection between the mental disturbances and the rheu- 
matic attack can be noted by the fact that not infrequently a 
total disappearance of articular inflammation may be marked 
by the appearance of the mental symptoms, and vice versa. 

Gout may be mentioned in the same relation and as follow- 
ing the same course. 

The cause in both instances seems to be an overwhelming 
of the system with a distinct poison, and not to be due to the 
temperature changes. It can be compared to cases of metallic 
poisoning, as especially observed in lead and mercury, or again 
with uraemic conditions. The system can absorb slowly a large 
amount of these poisons, but if for any cause they are thrown 
suddenly into the system cerebral symptoms manifest them- 
selves. 

Alcohol, morphine, cocaine, quinine in excessive amounts 
show a similar class of mental symptoms, characterized by ex- 
citement or depression with various illusions and hallucinations 
of tbe special senses. 

These acute conditions are to be distinguished from the 
chronic forms of mental disease, dependent principally upon ar- 
terial degeneration with its consequent malnutrition. 

Too much weight is often placed on malaria in the produc- 
tion of mental disorder. Where mental disturbance has fol- 
lowed, it occurs in those previously disposed by a neurotic tem- 
perament or other hereditary forms of disease. Its occurrence 



QENITO-URINARY IRRITATION. 171 

in the insane cannot be said to have any marked effect, except 
in a general way, upon the course of the disease. 



AN.ffiSTHETICS AND MENTAL DISEASE. 

Many cases of mental disturbance have been recorded as 
following the administration of anaesthetics, whether chloro- 
form, ether, or nitrous oxide. This has often been observed 
in very slight operations, such as the extraction of the teeth 
while under the influence of nitrous oxide. It may take the 
form of maniacal excitement, or of marked stupor, or of acute 
dementia. It is, however, not as a rule of long duration. 
Dr. T. G. Thomas reports several cases following operations 
in which acute dementia followed, and several have come 
under the author's own observation. The most usual form in 
his experience has been of that type, or of a condition of stupor- 
ous insanity ; rarely has it been of a maniacal character. It 
is probable that the nervous condition of anticipation is the 
effective cause of this mental disturbance rather than the use 
of the anaesthetic. It seems hardly possible that it alone would 
be effective, except in those who by their habits, as by the 
excessive use of alcohol, etc., are specially predisposed. 

Genito-Urinary Irritation and Insanity. 

Irritation of the sexual apparatus, whether due to disease 
or the practice of masturbation, not infrequently causes ner- 
vous and mental disorders ; but these are more often of a func- 
tional than an organic type. They occur especially in those 
predisposed to nervous disorder by hereditary or acquired in- 
stability of organization. It is rare in my experience to find 
insanity per se due to masturbation, whether in the male or in 
the female. In all forms of insanity, especially in the later 
stages, as in dementia, where the higher powers of the mind 
have been affected, this practice is very frequent, but a true 
masturbational insanity probably does not exist. The effect of 
operations on the diseased organs is, as a rule, unsuccessful in 
producing recovery from mental disease if the hereditary pre- 
disposition is of the degenerative type. In other cases, it may 



172 INSANITY^ — FISHER. 

be favorable. In any case where disease is present, an opera- 
tion for the removal of the abnormal condition is indicated. 



Insolation and Insanity. 

The influence of the sun, except in so far as it may cause 
inflammatory disease affecting the meninges, is not an impor- 
tant factor in insanity, but in connection with exhaustion, 
anxiety, and alcoholism it is of importance as a causative agent. 

The heat of summer does not apparently influence the oc- 
currence of mental disease, according to Krafft-Ebing, although 
Esquirol considered that more insane were received into asy- 
lums during the months of May and June. Arndt, Schiile, 
and Kraepelin think that great heat favors the outbreak of 
mental disease, especially mania. It is difficult, however, as has 
been remarked, to state when the disease commenced. The 
old idea that suicide due to insanity occurs in the gloomy month 
of November seems disproved and to be without foundation. 

Change of climate seems to have some influence. Among 
those coming to a new country, especially among female domes- 
tics, I have observed a general impairment of nutrition, with 
amenorrhoea, associated with mental disease usually in the 
form of melancholia, either simple or with stupor. 

Moral causes may act directly as the exciting agent. Espe- 
cially is this seen following loss of relations, or business reverses, 
or any intense emotional disturbance, as disappointment in love, 
or the strain of great poverty, where the necessaries of life even 
are impossible of procurement. The mother in her despair may 
even be led to destroy herself and offspring to relieve them from 
suffering. Fear or terror following a criminal assault, or the 
shock from exposure to some great danger, as a railroad ac- 
cident or fire, or the fear arising from epidemic disease — indeed, 
excessive anger itself — may cause insanity ; but as has been said 
in reference to all these exciting causes, they fall most heavily 
on those already predisposed to mental disease. 

Cretinism. 

This is commonly a congenital condition, or commences 
early in life. The congenital type manifests itself by the stunted 



GENERAL INDICATIONS OP INSANITY. 



173 



appearance of the child, the thickness of the skin, and an ap- 
pearance not unlike that of myxoedema. The intelligence is 
usually low, and the subsequent development is slow and im- 
perfect. Speech is often, but not always, defective. The spe- 
cial senses are not infrequently affected, especially the senses 
of smell and hearing. 

Table showing causes of insanity in patients admitted into 
the asylums and registered in hospitals in England and Wales 
during the ten years from 1878 to 1887 : ' 



Moral. 
Domestic trouble (loss of relatives) . 
Adverse circumstances (business 

losses, etc,)- 
Mental anxiety and worry. 
Love affairs (including seduction) . 

Physical. 
Intemperance in drink. 
Intemperance (sexual)-. 
Venereal disease. 
Self-abuse. 
Over-exertion. 
Sunstroke. 
Accident or injury. 



Pregnancy. 

Parturition and the puerpural state. 

Lactation. 

Uterine and ovarian disease. 

Puberty. 

Changes of life. 

Fevers. 

Privations and starvation. 

Old age. 

Other bodily diseases or disorders. 

Previous attacks. 

Hereditary influence ascertained. 

Congenital defect ascertained. 

Other ascertained causes. 

Unknown. 



GENERAL INDICATIONS OF INSANITY. 

" The diagnosis of -insanity presents itself to the physician 
in a purely medical or in a medico-legal point of view. In both 
cases, the grounds of the diagnosis must be the same. For 
although, in criminal trials, the nature of the crime itself and 
the manner in which it has been effected must often be allowed 
to have no inconsiderable weight in the formation of the judg- 
ment, yet these circumstances are essentially no other than a part 
of the conduct of the patient ; and the conduct must be carefully 
estimated even when the question is not purely medical." " 

" The conduct of the alleged lunatic himself at, before, and 
immediately after, the critical transaction, is relevant evidence 
of lunacy." ^ 

' Tuke : " Dictionary of Psycholo- ^ Beavan v. McDonnell, 10 Ex. , 

gical Medicine." 184; Lovatt v. Tribe, 3 F. and F. , 

= Bucknill and Tuke : " Psycholo- 9. 
gical Medicine." 



174 INSANITY — FISHER. 

Mere eccentricity of dress and behavior, though admissible 
as evidence, goes but a little waj'- to establish lunacy.' 

The clinical phenomena and pathological changes do not 
stand in such close relation as in other diseases of the body. 
As Krafft-Ebing has well said : " We have not auscultation and 
percussion to help us in making our diagnosis ; we have only 
psychological phenomena to deal with." From the disturbances 
of the ego, of the consciousness, of the memory (quantitatively 
and qualitatively), of the feelings, conceptions, and volition 
we must determine the nature of the cerebral disease. This 
special character is, however, only an apparent one ; for if 
insanity is a disease of the brain, its symptoms must follow 
the laws of physiology and pathology which obtain in the nerv- 
ous system. We must have the latency and the intermissions 
of disease; the exacerbations, the remissions, periodicity, and 
relapses ; the response to irritation ; the loss of response, the re- 
flex action, etc. , as in all nervous diseases. We can best under- 
stand this when we deal with it in the language used in disease. 
So we can speak in a certain sense of psychical or mental hyper- 
sesthesia and anaesthesia; psychical convulsions or paralysis; 
increased or decreased reflex action or resistance to action. We 
must always remember that insanity is a disease, and that dis- 
ease is life under abnormal conditions. Disease and health are 
not necessarily opposite ; analogies and a neutral ground exist 
for both. The elements out of which diseased mental action 
results are the same for healthy mental action ; the only differ- 
ences are the conditions of their origin. The conditions for 
the process of psychical function in normal mental life are ex- 
ternal irritation, that is, of the senses — sight and hearing — as 
well as an adequate cerebral reaction to this irritation. Along 
with this we have an understanding of the relation or agree- 
ment between the consciousness and the external irritation. 
In insanity the brain is under abnormal conditions. It is the 
seat of disease in which internal irritations will cause mental 
action. The mind acts spontaneously, uninfluenced by occur- 
rences in the external world. So the patient stands in his inner 
world in opposition to the outer world, but this inner irritation 
produces the same result as if due to external irritation. This 

' Boughton V. Knight, 1873, L. R. 3 P. & D., 84; D. Hack Tuke: "Dic- 
tionary of Psychological Medicine." 



H-ALLUCINATIONS. 175 

spontaneous internal action is the result of disturbed nutri- 
tion of the cortex of the brain. 

We have two important disturbances resulting, viz. : (1) 
a changed reaction to external irritation, either increased or 
decreased, or qualitatively changed; (2) a change in the ego, 
that is, in the self -consciousness, and therefore a danger of tak- 
ing the subjective internal irritations for objective external 
ones. The disturbance of the ego is the basis for the under- 
standing of insanity. It consists especially in the failure to re- 
call former experiences, and is important, therefore, as ex- 
plaining the origin of delusions; or again, in taking for, or 
confounding, former perceptions with the present objective per- 
ceptions through mistaken interpretation of impressions in the 
disturbed consciousness. As all mental action is expressed 
through the feelings, thoughts, and actions, we must especially 
direct our attention to these three divisions. Under the head 
of feelings we shall therefore, as already said, observe changes 
in the individual, as indicated by depression or exaltation. As 
all thought or conception depends upon the perceptions, and as 
the latter are only received through the special senses, we must 
look for errors of perception of the special senses, such as hear- 
ing, smell, etc. We therefore find hallucinations and delusions 
among the common symptoms of mental disease. 

Hallucinations. 

Hallucinations may be defined as erroneous perceptions, not 
dependent on present external impressions, but evolved from 
the diseased brain itself, and dependent upon previous percep- 
tions ; or, as Taylor has defined them : " Those sensations which 
are supposed by the patient to be produced by external impres- 
sions, although no material object acts upon his senses at the 
time." 

While, in general, we may accept this statement that hal- 
lucinations are not due to excitation of the special sense in- 
volved, still they may depend on some disease of that sense organ 
which without external irritation is thus capable of exciting an 
impulse to the receptive centre in the brain. It is more proba- 
ble, however, that the actual cause is the morbid cerebral state, 
as otherwise the irritation would be correctly interpreted. An- 



176 INSANITY — PISHER. 

other evidence of this lies in the fact, that where the special sense 
is congenitally absent, no hallucinations referred to that spe- 
cial sense take place. Those born blind do not have hallucina- 
tions of sight, but again, on the other hand, those who become 
blind may have them, showing that the hallucination depends 
on previous sight-perceptions. 

Hallucinations are very common in the insane, Esquirol 
putting the percentage as high as eighty per cent, which is 
probably too high. In many cases they are recognized as such, 
but of tener are accepted as real and lead to acts as a logical se- 
quence. The character of the hallucination will depend largely 
on the occupation or the object which immediately interests 
the person. Sights may constantly recur, which were but im- 
perfectly observed as at the time of a surgical operation, while 
the patient was passing under the influence of ether. A patient 
related to me that, following an operation, he felt as if he were 
before an abyss, and that the surgeon was about to throw him 
into it. An interesting feature in this case was the occur- 
rence of a double hallucination, in which he heard voices say- 
ing that he was damned. 

While realizing that these voices were not real, if spoken to 
about them, he could not prevent himself from firing his pistol 
in the court from which they apparent^ came. 

Hallucinations may affect any or all the special senses, as 
sight, hearing, taste, smell, as well as the general sensibili- 
ties or sensations. Hallucinations of sight and hearing are 
the most common, and the latter more so than the former; the 
importance of those of hearing is greater, as here we more often 
have imperative orders from God, or some other influence di- 
recting the performance of some act. Without warning an 
act may be suddenly committed. These forms are most common 
in melancholia and mania, and while their presence cannot 
be absolutely accepted as evidence of insanity, they are strong 
proofs in its favor. Hallucinations of smell and taste are 
much more rare ; however, some of the disgusting acts of the 
insane, as the eating of human excrement, or the covering them- 
selves with it, may be due to them. 

I have observed in the blind that hallucinations of smell are 
not uncommon. Among the class of so-called degenerates this 
form is frequent, and may be of a sexual character. Religious 



HALLUCINATIONS. 177 

hallucinations are of frequent occurrence, in which God or the 
Virgin Mary or the devil may appear or may address them. 

An illusion, according to Griesinger, is a " false interpreta- 
tion of an external object." The distinction between it and a 
hallucination, therefore, lies in the fact that the object in the 
one case is not present, while in the other it is. In illusions 
and hallucinations the perceptions in both cases are false. 

There is always some confusion in law in understanding 
these terms, often no distinction being made. 

The remarks in regard to hallucinations involving the special 
senses and general sensibility apply equally to illusions. Per- 
haps, in regard to general sensibility, they are more frequent. 
Visceral disturbances or cutaneous states, being misinterpreted, 
lead oftener to illusions than hallucinations. 

Delusions are erroneous or false conceptions which may 
result from hallucinations and illusions or be the result of false 
reasoning. A delusion may be defined as an absurd and un- 
founded belief (Foster). 

Delusion has reference to the reason, differing in this re- 
spect from illusion and hallucination, which have to do with the 
senses. It involves, therefore, more seriously the mental proc- 
esses, and is a surer indication of insanity. 

It is not, however, always present in the insane, as Grie- 
singer well says : " In many cases no special delusion is pres- 
ent, or at least none is exhibited, but the sentiments, disposi- 
tions, and conduct are altered in a morbid manner, and owing 
to a morbid state of the brain the individual is influenced, so 
that the healthy faculty of judgment is obscured, the intel- 
ligence formally involved, and the spirit held in bond." 

Delusions vary in character, especially as they so often 
depend on false perceptions of the special senses. Their charac- 
ter depends largely also on the form of the mental disorder in 
which they appear. 

Those occurring in the various forms of mania are generally 
of an expansive character, in which the ego has become so altered 
that changes in the personality occur. The person imagines 
himself some exalted personage, either a great general, or artist, 
or even God himself. Especially in this form do delusions of 
an erotic or religious character occur. The sexual element is 
frequently prominent in religious delusions. This may be ob- 



178 INSANITY— FISHER. 

served in those cases of religious delusion where young women 
having hallucinations of sight or hearing have had the delusion 
of being pregnant through the influence of the Holy Spirit. 

Delusions may be systematized; by which we mean, there is 
usually some basis for their origin. It may indeed be an absurd 
one or have actually some ground for belief. In any case the 
patient has established a chain of logical reasoning, satisfac- 
tory to himself in explanation. Another element in this form 
of delusion is its permanence. They are as a rule few in num- 
ber; indeed, there may be but one. They may exist for years, 
the intellectual faculty being but little impaired with the course 
of time. 

Conjoined with this form of delusion is that oi persecution. 
The process of reasoning in these cases is simple and logical. 
The ego or self-consciousness being unable to understand the 
various false perceptions received into consciousness, the in- 
dividual arrives at the conclusion that, as he feels a definite 
change in his personality, he must be some personage of impor- 
tance, but realizing that he is not so considered by others, he 
readily assumes the idea that some one is preventing him from 
assuming his proper position, and that, therefore, he is being 
persecuted. 

It is a short step from this to delusion of suspicion, of being 
followed, etc. 

Unsystematized delusions, to use a term which has fast- 
ened itself upon our nomenclature^ are usually multiple, varying 
with the circumstances of the individual and the causes. There 
is not, as a rule, any attempt to explain them on the part of the 
patient; they simply arise, and, according to their character, 
cause elation or depression. 

Especially in this form do we observe sudden impulses 
arise, imperative conceptions (Hamilton). The logical ele- 
ment is absent. They may be those of suspicion, of persecution, 
of changed personality, etc. In these cases, however, the in- 
tellect is much more involved — their tendency to disappear is, 
however, much greater than in the former kind. The imme- 
diate cause, as exhaustion, fear, worry, alcohol, toxic agents of 
various nature, being removed, they cease. 

While delusions are, as we said, not necessary to a diagnosis 
of insanity, they are of great importance and perhaps the strong- 



LUCID INTERVALS. 179 

est evidencie, when observed, that we possess. This is true in a 
inedical as well as a legal sense. 

The law, however, requires that the delusion shall have 
reference to the particular act committed, both in civil and 
criminal relations, and it is here that the great difference be- 
tween the medical and legal aspect of the question of insanity- 
manifests itself. 

Another element in delusions is of great importance; that 
is, the concealment of them by the insane. 

This is especially observed in systematized delusions; here 
the intellect not being involved to so great an extent, the person 
may with great curming suppress them. A patient who has 
been many years under observation, and who considers himself 
a great mathematician as well as the inventor of a theory in 
regard to the ocean tides, has a systematized delusion of perse- 
cution. 

Ordinarily nothing can be elicited from him in regard to it 
— to the general observer, he has the appearance of a dignified, 
learned gentleman. So long as he can see no object in speak- 
ing of himself the delusion is concealed ; if, however, he thinks 
he has before him a person or audience with influence, he be- 
comes loquacious to a degree in the expression and defence of 
his delusion. 

Concealed delusions are of great importance in a legal as- 
pect, and many instances could be cited from the coxirts show- 
ing how court and jury have been deceived by the cunning and 
skill of an insane person. 

Lucid intervals may occur in the course of mental dis- 
ease, and are of importance in a legal sense. Bucknill and 
Tuke define them " as consisting, not in a mere cessation of 
the violent symptoms of the disorder, but an interval in which 
the mind, having thrown off disease, has recovered its general 
habit. The party must be capable of forming a sound judg- 
ment of what he is doing, and his state of mind such that any 
indifferent person would think him capable to manage his own 
affairs." Ordronaux defines a lucid interval as "a suspension 
of the active manifestations of mental disorder. It does not 
imply complete restoration; it simply means restoration to a 
degree of enabling the party to judge soundly of the act." 
Lucid intervals not infrequently occur in melancholia and 



180 INSANITY — FISHER. 

mania, lasting sufficiently long to enable the patient to be fullj 
cognizant of the legal responsibility of his acts, whether ir 
civil or criminal relations. "In regard to criminal offences 
committed during a lucid interval, it is the opinion of manj 
alienists that no person should be convicted under such cir- 
cumstances, because there is a probability that he might at the 
time have been under that degree of cerebral irritation -whicli 
renders a man insane. This remark applies especially to those 
instances in which the lucid interval is very short" (Taylor'). 

A lucid interval in a legal sense, therefore, implies that a 
condition may arise during the continuance of mental disease, 
in which the individual may be able to understand his relations 
to the outer world ; especially does this apply to his civil capa- 
city. Where the act carried out is consonant with what is 
known of the character and wishes of the person, there seems 
to be nothing out of the way in this view. In a medical sense, 
especially in the so-called functional psychoses, it would seem 
reasonable to expect that in mental disease, as in the delirium 
of typhoid fever, there could occur intervals in which the self- 
consciousness would be able to reassert itself for a longer or 
shorter period. 

The burden of proof in these cases would naturally rest with 
the side making the assertion. It is difficult to define the differ- 
ence between a remission and a lucid interval, except perhaps, 
as we might saj', the latter is more complete than the former. 

In a remission there is a mere abatement of the symptoms. 
It has been said that a lucid interval is only a more perfect re- 
mission, and that, although the lunatic may act rationally and 
talk coherently, yet his brain is in an excitable state, and he 
labors under a greater disposition to a fresh attack of insanity 
than one whose mind has never been affected. 

Of this there can be no doubt, but the same reasoning would 
show that insanity is never cured, for the predisposition to an 
attack is undoubtedly greater in a recovered lunatic than in one 
who is and always has been perfectly sane. Even admitting 
the correctness of this reasoning, it cannot be denied that luna- 
tics do occasionally recover for a longer or shorter period to 
such a degree as to render them perfectly conscious of and 
legally responsible for their acts.'" ' 

' Taylor's "Medical Jurisprudence," 11th ed. 



MEMORY. 1P1 

The statement that a lucid interval " consists not in a mere 
cessation of the violent symptoms of a disorder, but an interval 
in which the mind, having thrown off the disease, has recovered 
its general habit" (see OoUinson on " Lunacy") , is hardly correct, 
for while we observe a return to a reasonable judgment in his 
acts, and " that any indifferent person would think him able to 
manage his own affairs," still it is rarely that we can say that 
there is a return to a normal state. The emotions still remain 
affected, the intellect shows evidence of improvement indeed, 
but were there a complete return there would no longer be a 
question of insanity at all. The law, in its attempt to be pre- 
cise or exact, passes beyond the bounds of the probable or 
possible. 

Memory is involved in all forms of insanity. When the 
consciousness is much affected, as in a profound condition of 
melancholia, it may be almost a complete blank. In mania, 
with its rapidity of ideas, it may appear as even accentuated, 
but this in reality is not the case. The passing conceptions 
have lasted for so short a period individually that they have 
made no permanent impression. All perceptions and concep- 
tions require time and intensity to be properly received into the 
consciousness and be capable of recall — the image must at one 
time be a distinct one. 

This loss of memory refers especially to matters of the pres- 
ent; past history may remain as clear in the consciousness as 
ever. While these statements are true in the main, yet even 
in profound depression it is not rare to find that the individual 
can recall many if not all of the incidents that have occurred. 
This is not so often true in mania. In dementia there may be 
a complete loss of memory, but this is general in character, no 
idea of time, place, or even of the identity of the person himself 
remaining. 

More important are the temporary losses of memory during 
special emotional or paroxysmal conditions, as in the mania fol- 
lowing epileptic seizures, or in cases which have been defined 
as mania transitoria. The importance of this condition is very 
, apparent in a legal aspect. A complete blotting-out of all pre- 
vious experiences may take place, the patient living only in the 
present, so that there are really two individualities. Rare in- 
stances in certain forms of mental disease are recorded, when, in 



183 INSANITY — FISHER. 

passing from one state to another, no recollection of the previ- 
ous state is recognized in the succeeding one. Persons met or 
places seen are no part of the experience in the separate states. 
These statements are always to be received with caution, how- 
ever, especially if any motive can be suspected. 

Delirium is " a perversion of the mental processes, the per- 
version being manifested in speech or action. The disturbance 
is characterized by incoherent speech, hallucinations, illusions 
and delusions, restlessness, watchfulness, apparently purpose- 
less actions, inability to fix the attention. Delirium in a 
general sense implies disorder of the mind, and according to 
this definition is equivalent to insanity." ' 

From the fact that in delirium the patient is subject to delu- 
sions frequently accompanied by hallucinations and illusions of 
sight and hearing, this term is frequently used for, and confused 
with, delusion. 

While delirium, either active or quiet, is often present in 
well-defined mental disease, it is more frequently due to either 
the exhaustion of the disease or accompanies the initial acute 
onset as in acute mania. It is rather a physical sign of mental 
disorder, following upon the various false perceptions and con- 
ceptions. 

It is a mistake to speak, therefore, of various forms of de- 
lirium, as delirium grandiosum, delirium epileptoid, etc. The 
condition is simply the result in the first case of delusion of 
grandeur and general exaltation common to mania and espe- 
cially to the earlier stages of general paralysis. 

The proof of this statement is shown by the fact that in the 
various fevers, as typhoid and pneumonia, or in toxic conditions 
caused by various drugs, similar stages are common, and 
while they are truly mental disturbances, and therefore mani- 
fest themselves by disturbances in the field of feeling, thought, 
and volition, we do not consider such states as forms of mental 
disease. 

In a legal sense the question would naturally and only arise 
in regard to responsibility, and the general rule would apply that 
where there is such a loss of consciousness as to prevent any 
knowledge of the act, all responsibility ends. 

Heredity as an aid in diagnosis is of vast importance, as 
' Tuke : "Diet, of Psych. Medicine." 



PREVIOUS ATTACKS. Ig3 

can be seen from the importance in which it is held, as an 
etiological factor. It has especial value when the disease is 
directly received from the parents or even when a predisposition 
to mental disease can he presumed from the existence of vari- 
ous conditions in the parents or even collateral branches, as 
nervous diseases, alcoholism, or consanguinity. It is admitted 
as legal evidence in criminal and civil cases. 

" The degree of hereditary taint may to a certain degree be 
ascertained and estimated. Thus the insanity of one parent 
would indicate a less degree of predisposition than that of a 
parent and an uncle, and still less than that of a parent and 
grandparent or of two parents. The insanity of a parent and 
a grandparent with an uncle or aunt in the same line, may be 
held to indicate even stronger predisposition than the insanity 
of both parents. The influence of the insanity of parents in 
creating a predisposition will depend to a great extent upon 
whether it has taken place before or after the state of parentage 
commenced. The insanity of a parent occurring after the birth 
of a child, if it arises from a cause adequate to excite it, without 
previous predisposition, would, of course, be held as of no value 
in the formation of an hereditary tendency. The insanity of 
brothers or sisters may be of much or little value, as evidence 
of predisposition, according to the circumstances under which 
it has shown itself. If several of them, both older and younger 
than the patient, have become insane, the fact' shows strongly 
in favor of predisposition, although neither parent nor grand- 
parent may have been lunatics; since it is well known that 
other conditions in the parent besides that of actual insanity 
may create this predisposition ; for instance, violent and habit- 
ual passion, the debility of old age, and most of all, habits of 
intemperance at the time of procreation. It will thus be seen 
that the evidence of hereditary predisposition may be of such a 
character as to render the insanity of the patient an event in 
the highest degree probable; or, on the other hand; it may be so 
weak as to add a scarcely appreciable amount of probability to 
the character of the disease." ' 

Previous attacks must be considered as strong evidence 

in favor of insanity, especially when th"e act committed bears 

on its face signs of being irrational or lacking motive. Its 

' Bucknill and Tuke : "Psychological Medicine." 
111.-14 



184 INSANITY — FISHEK. 

importance is much increased if it can be shown that the pres- 
ent attack commenced in a similar manner with the previous 
one. It has long been observed that succeeding attacks follow 
the same course, even in detail, of those preceding them. 

This can be observed in periodical insanity, and is of special 
interest, as months or years may elapse between the different 
seizures. 

Again, complete recovery from even the simple psychoses is 
difficult to predicate, as there is frequently left a change or at 
least an instability in the emotional and intellectual condition. 

Slight attacks, if due to some adequate cause, as domestic 
loss, financial reverses, injuries, or some special illness as fevers, 
have not as much weight. 

While these special signs of mental disease are more or less 
marked in every case, there is also to be observed the general 
change in the individual himself. A most important indication 
is whether the disposition, which may have been lively, has be- 
come the reverse, whether extravagance or parsimony is present 
in contradistinction from the usual habit. 

Excesses, alcoholic or venereal, occurring in a person whose 
life has been previously correct, even without any evidence of 
delusion or other signs, is significant. 

Somatic Indications. 

Physical or somatic conditions are of importance, especially 
in certain forms of mental disease, as tremor, paralysis, loss or 
exaggeration of the reflexes, contraction or inequality of 
the pupils, interference with articulation, which may become 
involved or clumsy, interference with general nutrition, etc. 

HEeatoma Auris— Insane Ear.— Among the insane, 
especially the chronic, this affection of the ear is not uncommon. 
Is is difficult to say that it can be regarded as a sign, for we 
find it among the sane, especially pugilists, who are exposed to 
blows in this region. M. D. Field showed this in a number of 
cases which he described among this class of professionals. 

However, it cannot be denied that, outside of the consider- 
ation of injuries received by the insane, this condition appears 
very frequently, and must be regarded as an indication of defec- 
tive nutrition. 



FACIAL EXPRESSION. I85 



Facial Expression in the Insane. 

Various types of mental disease are often characterized by- 
special facial expression. Physiognomy is of considerable im- 
portance, especially in the class of patients coming under the 
head of the so-called degenerative types. We find among the 
insane irregularity of features, especially noted in the ears, 
which show various malformations in the structure of the helix 
or rim of the ear, and in the lobe. The former is not infre- 
quently very much flattened so as to be almost absent. The 
lobe is often adherent or deficient. There may also be a ten- 
dency for the ears to stand out far from the head. The whole 
structure may be very much deformed. This condition is usu- 
ally a congenital one. 

The eyes and orbits are also frequently irregular, the almond 
shape being not uncommon, or one eyebrow being higher than 
the one on the opposite side, or there being an inequality in the 
size of the eyeballs. 

The nose and jaw may show peculiarities, and there is not 
infrequently facial asymmetry. The cranial measurements 
show asymmetrical conditions or excessive developments beyond 
the physiological limits. The palate, especially in congenital 
conditions, is frequently very highly arched. 

Many of the insane, it must be remembered, however, pre- 
sent almost classical features and typically correct cranial mea- 
surements, while excessive deviations are frequently observed 
among our most distinguished and highly gifted men. 

The expression of the face as shown in various well-defined 
mental disorders can be classified under a few heads. In mel- 
ancholia the angles of the mouth are usually depressed, the fore- 
head wrinkled, the eyes downcast, and there is an appearance 
of despair associated with mental anxiety. The features are 
also extremely immobile and fixed. This condition has various 
grades of development. At times, the mental agony, as ex- 
pressed in the wrinkling of the forehead, is the essential fea- 
ture. Where the dementia is more marked and mental action 
has been more completely stopped, the simple depression as 
shown in the lower part of the face and mouth is the most 
prominent feature. Delusions, if present, of sight or hearing, 



186 



INSANITY — FISHER. 



will again give an expression of attention in these directions, 
the patient appearing to see and watch for something or to listen 

attentively. I f 
fear be present, 
the attitude will 
be expressive of 
this condition. 

In mania there 
is the reverse of 
what has been 
described. The 
features are mo- 
bile, constantly 
changing, and 
there is an ap- 
pearance of pleas- 
ure and exalta- 
tion. The eye is 
bright and con- 
stantly changing 
its position. Here 
the hallucinations 
come and go more rapidly, and lead to a marked facility of ex- 
pression, changing with each new emotion. Fear and delusions 
of persecution show themselves by an alertness of expression 
and an energy of resistance. 
(See photographs of Mental 
Disease.) 

In paranoia, while perhaps 
not showing any well-defined 
expression, to the experienced 
eye the face reveals a sense 
of general self-satisfaction 
which is peculiar to the dis- 
ease. Vanity and personal 
pride in their physical ap- 
pearance is a marked feature. 
The fear of opposition or per- 
secution so commonly pres- 
ent, but ascribed to envy of Fis. 2.-Maiiia. 




Fia. 1.— Melancholia. 



f 




{ 

^ 


1 




!>5 


1 




I 


1 




\ 


\ 


£i 


I'LV 


J'hlii 




mm 


L...„ 


jm 


yii 


■iiiliH 




EBmWI 



FACIAL EXPRESSION. 



187 




Fio. 3.— Dementia. 



personal attain- 
ments or ability, 
or physical supe- 
riority, is here 
seen. 

Dementia man- 
ifests itself chief- 
ly by loss of ex- 
pression, or vacu- 
ity. This is inter- 
rupted from time 
to time in less ad- 
vanced cases by 
expressions of joy 
or depression, ac- 
cording as the 
emotions are ex- 
cited by corre- 
sponding d e 1 u - 
sions or hallucinations. In chronic cases where the delusion 
has become fixed, the expression remains permanent and de- 
pends on its nature. 
In general paral- 
ysis the face is 
characteristic o f 
the disease. There 
is usually a vrash- 
ing-out of the par- 
ticular lines char- 
acteristic of the in- 
dividual — a blank- 
ness and flatness 
almost diagnostic 
of this disease. 
There is rarely, 
however, any ap- 
pearance of depres- 
sion or anxiety, 
but rather that of 

Fia. 4. -General Paresis. fatuOUS placidity. 




188 INSANITY — FISHER. 

Too much importance has been attached to the facial expres- 
sion in the insane, the rolling eye, the hair standing erect, giv- 
ing a wild appearance to the individual. The hair may become 
coarse and thick in chronic mania, and in melancholia it may 
become thin ; these states are, however, dependent on the general 
state of nutrition. Certainly in acute cases of mania I have 
not observed any special change. The scalp may in cases, usu- 
ally of imbecility or dementia, especially in hereditary or con- 
genital diseases, be formed into folds or rugae. Some such cases 
have been reported, and I have had one under my observation — 
the hair was coarse and thick. Many of these ideas have been 
handed down by tradition. The malingerer usually attempts 
such a characterization. 

Changes in Manners and Habits. 

An important sign of mental disease is a complete change 
in manner of living and in dress. The more distinct this is, 
the more valuable does it become. If a sedate, methodical man 
becomes prodigal and profligate, or if he becomes depressed and 
sees nothing but ruin and loss when there is no cause for it, we 
must regard it as a strong indication of mental disturbance. It 
is necessary to inquire carefully into the previous habits ; often 
latent tendencies, when the balance of self-control is removed 
by disease, will develop themselves. Every one is more or less 
influenced and controlled by his surroundings ; what makes a 
person honest or moral is frequently simply his regard for the 
opinions of others ; if this feeling is removed by emotional ex- 
citement or depression, acts of a character entirely foreign to 
what has been known of the character of the individual may be 
committed. 

The appearance and dress are often strong indications of 
insanity. 

The emotion which is predominant, or the delusion which 
prevails, frequently leads to gross carelessness in dress ; a gen- 
eral lack of order and method in aU personal arrangements, and 
in home and business relations is usually present. Erotic ten- 
dencies may lead to ornamentation of the person, or to indecent 
exposure of the person. Again, if the delusion of being some 
important personage is present, there may be a tendency to 



EYE SYMPTOMS. lyQ 

decoration of the person with innumerable medals, often of a 
perfectly valueless character. 

An epileptic long under my observation always decorated 
his coat with any badges of the various societies, city depart- 
ments, as the police, fire, etc., which he could obtain. These 
were of absolutely no value, but afforded him infinite pleasure, 
as showing the importance with which he was regarded. 

This is especially noticed in the chronic insane, who are apt 
to decorate themselves with any bright colors which they can 
obtain. 

Sudden changes are of especial significance. Mere exag- 
geration of natural characteristics does not have so much weight. 

Due consideration must also be given to a provocative cause 
if present. Loss of friends or property, or any annoyance, pro- 
duce an exaggeration of feeling and action, which, although 
normal in character, is increased beyond that found in the sane. 
The action and gestures are important, different forms of 
mental disturbance manifesting themselves in special ways. 
The maniacal are restless and constantly in motion ; they never 
seem to tire, their muscular system seeming to correspond to 
their mental state. As no two thoughts or ideas are the same 
or continue long, so their motions and gestures never remain 
long the same. In depression the attitude is often expressive 
of the despair within them. " It cannot be called acting, since 
it is real, and hence arises the most frequent cause of failure in 
attempts to simulate insanity." 

Eye Symptoms. 

These are of importance more especially in organic diseases. 
There cannot be said to be anything diagnostic in them in the 
so-called functional psychoses, as melancholia or mania, as they 
are not constant, depending on the physical state or nutrition. 

Dr. Clifford AUbutt found in fifty-one cases of mania in the 
West Riding Asylum, which he examined, ansemia of the optic 
disc. 

In general paresis inequality of the pupils is common, or 
there may be marked myosis. The Argyll-Robertson pupil is 
also present and perhaps has especially connection with cases 
involving disease of the spinal cord. According to Mickle in 
his work on general paresis, marked contraction of the pupil 



190 INSANITY — FISHEK. 

succeeded by dilatation is a bad sign. The optic nerve not in- 
frequently shows evidence of hyperaemia in general paresis, and 
it may even go on to atrophy. These conditions are not present, 
as a rule, except in the later stages of the disease. Rarely do 
we find ptosis or strabismus. 

Aphasia in Insanity. 

Aphasia is generally due to a lesion within the brain in- 
volving the cortex area for speech or regions in the internal 
capsule, pons, and medulla. The motor centre for speech in the 
cortex is in the third frontal convolution, while the sensory 
perceptive centres are posterior, in the parietal and temporal 
lobes. The two forms of aphasia are motor and sensory. The 
former represents an inability to articulate words with or with- 
out a loss of memory of the word or name itself. Sensory 
aphasia implies a loss of the power to understand spoken or 
written language, resulting in word-deafness or word-blind- 
ness. This latter condition especially indicates some mental 
impairment, and in fact in most cases we find loss of emotional 
control. Such persons are easily provoked to laughter or tears. 
The memory of present events may be impaired. 

The question of responsibility, civil or criminal, is one 
of considerable importance in these cases. It is perfectly possi- 
ble, especially in motor aphasia, for the patient, although unable 
to speak, to possess a full comprehension of his surroundings 
and of what is presented to him, either in words or in writing. 
In sensory aphasia the question is more doubtful, if neither 
writing or spoken language is intelligible. This latter condi- 
tion in the double state is, however, very rare, and if the disease 
were so extensive, other symptoms showing marked evidence of 
dementia would probably be present. "Where, therefore, as in 
making a will or executing legal documents, there is nothing 
inconsistent with the previous character of the patient in the 
statements made, or where no motive is shown which is con- 
trary to what would be naturally expected from the previous 
character and actions of the patient, the person should be con- 
sidered as capable, and as possessing sound reasoning power. 
This is often of great importance where estates have been de- 
vised away from the immediate relations. 

Aphasia as a symptom in mental disease is commonly ob- 



HANDWRITING. 191 

served in general paralysis. It is usually of short duration and 
liable to recurrence. It is frequently associated with hemi- 
plegia and in most cases due to a meningeal hemorrhage. It, 
however, occurs at times as an isolated symptom and is of im- 
portance in point of diagnosis. 

This is not to be confounded with the diflSculty of articula- 
tion which is one of the common symptoms in paresis. 

It is usually in connection with paralysis, i.e., hemiplegia, 
that we have to consider aphasia, and especially in civil cases. 
The well-known Parish will case is an example. 

Masturbation, should be regarded as a symptom rather 
than a cause of insanity. It occurs in various forms of in- 
sanity, as paranoia, for example ; in fact, most cases of so-called 
masturbational insanity are to be classified with this disease. 
"We especially note the erotic and religious type. It is com- 
mon also among epileptics, general paretics, and in demen- 
tia resulting from melancholia and mania. It is a sign of 
mental impairment, indicating a loss of the higher ethical 
nature of the individual. It may occur as a symptom in se- 
nility, where the most shameless and open practice of it may 
be carried on. Savage refers to a case in a chronic lunatic of 
over ninety years of age. 

The same is observed among idiots and imbeciles. It may 
exist as an exciting cause of insanity or as an active agent in 
continuing the' mental disorder, and, by its effects oh general 
nutrition, prevent recovery. 

" Handwriting must be looked upon as a highly developed 
method of muscular expression, and as such will be affected by 
any nervous states or conditions which affect the nervous con- 
trol and the distribution of nervous energy. Persons suffering 
from any form of nervous exhaustion will show it in their 
methods of expression, the result being want of clearness and 
definiteness." ' 

We have two points to consider in the letters of the in- 
sane, the contents and the handwriting itself. 

In some cases they are a direct help in diagnosis, especially 
in the formation of the letters as evidencing tremor or again in 
the omission or repetition of certain letters in a word. 

This is especially seen in general paralysis of the insane; 
' Tuke: "Diet, of Psych. Medicine." 



193 PISHER — INSANITY. 

early in the disease, perhaps one of the first signs to be observed 
when the person has acted in the capacity of an accountant, 
there will be tremor causing indistinctness of the lines — again 
misspelled words are frequent. At times again the letters form 
no definite word. 

In the first three specimens here shown of well-marked gen- 
eral paresis — all represent educated men. Fig. 5 was an expert 



Fig. 5. 






accountant. The a,ttempt to write, "And they whistled as 
they drew near," is unintelligible; there is, however, very .little 
tremor. 

The confusion in the formation of the words is not unlike 
the indistinctness of the articulation in these cases. 

Fig. 6 is a letter of an educated man, a lawyer and college 



'"''^-'i'rt-*^ ru^^^^i^t^ €^.t-a.<,/i-*>- ^i«x«'?<v, Om/jJi^ 



FiQ. 6. 



graduate. The tremor is well marked, and the omission of 
certain words necessary to complete the sense. There is no 



HANDWRITING. I93 

structure to the sentence and the two words " this" and " thing" 
are run into one. 

Fig. 7 is an instance showing the mental confusion, the mis- 
spelling, the repetition of syllables, and the tremor characteris- 

NEW YORK, ^C^^^rXr- -y '' 188 '^ 
for $ <f7? S^ ^^ 

endorsed by you, and dm this day, having been duly presented for 
MSfin ent^j ^^was^duty demanded but refused, is protested for non^ 

'^gijmnu^ nttH tfiat the holders look to you for the payment thereof. 

Fia. 7. 

tic of these cases. This man had for years been engaged in 
serving notice in cases of notes going to protest. 

One peculiarity in most of these cases is the apparent 
absolute ignorance of anything wrong about their produc- 
tions; they appear perfectly satisfactory, and even when unable 
to read them, they are satisfied. This is the case long before 
the final stage of dementia has taken place, and while the delu- 
sions of grandeur and ideas of great wealth and wonderful plans 
are most prominent. 



Fia. 8. 




194 INSANITY — PISHBR. 

Figs. 8 and 9 illustrate the excessive tremor which is com- 
monly present. 

Tremor alone is insufficient to form a diagnosis on, as it is 



Fig. 9. 



present in various other conditions, as in alcoholism, mercurial- 
ism, old age, etc. 

In chronic mania there is a tendency to almost endless letter- 
writing, one subject being followed by another. No class of 
patients in our asylums are such voluminous writers as these. 
Here we find special characteristics, as the underscoring of 
words, the frequent use of capitals. This is especially seen in 
paranoiacs, where the egotism of the writer becomes very appar- 
ent. Where delusions pertaining to religion are present, the 
words God and Christ are very frequent, and usually under- 
scored and in large letters. 

Rhyming is not infrequent. 

The letters may be the only sign for a long time of any men- 
tal disturbance and are of importance in this direction. A delu- 
sion may be concealed before others, but the strong belief in it 
may find expression in letters. This is often observed in para- 
noia. Letters of the most obscene character may be written. 

The contents are often diagnostic of the form of the disease, 
In mania we have long epistles, carelessly written, with frequent 
omissions of words and letters; in hypochondria there is the 
dwelling on the personal ailments in great detail, the various 
hallucinations and delusions are minutely described. This is 
not rare among melancholies. Tuke quotes Dr. Bacon's sum- 
mary of the important points of handwriting in relation to the in- 
sane as follows : 

(1) The handwriting as illustrating chronic insanity; (2) 
as illustrating acute attacks; (3) as rarely the only evidence 
of insanity; (4) as a sign of convalescence; (5) as evidencing 
an oncoming attack ; (6) as illustrating phases of cases of ordi- 
nary mania; (7) as showing the changes in handwriting in 
general paralysis. 



GENERAL PATHOLOGY. I95 

In concluding the description of the indications I would de- 
signate the conditions of melancholia or depression and mania or 
exaltation as mental states, rather than definite diseases. In 
taking up the various forms of insanity, we shall observe that 
both these conditions are common to all the various forms of 
mental disease. 

Dementia can be considered as the final stage toward which 
all insanity tends, where recovery does not take place. 

In its completed form there is absence of the functional 
activity of mind. We have, therefore, an absence of all percep- 
tion and conception; there is merely a vegetative existence. 
Hallucinations and delusions are absent, only the somatic 
signs, as interference with nutrition, tremor, pupillary changes, 
etc., are present. 

Melancholia is "a condition of depression marked by a 
feeling of misery in excess of what is justified by the circum- 
stances in which the individual is placed" (Kirchhoff) . 

Mania, like melancholia, is one of the primal elements of 
mental disease, and is a term which has been used from the 
earliest days. In our simpler classification it represented one of 
the chief forms of insanity, as melancholia did on the other side, 
the final stages of both these conditions being represented by 
dementia. This classification was long used, and is still em- 
ployed in our hospitals, all oases being put under those three 
heads irrespective of the varying conditions under which they 
appear. Of late years, we know that mania may appear in 
various well-defined mental states which represent distinct dis- 
eases, and of which mania itself is simply one of various symp- 
toms — as, for instance, mania in general paralysis, in hysteria, 
in puerperal fever, or again in alcoholism, etc. 

Mania may be defined as consisting of great excitement 
characterized by increased mental activity, as shown in the 
great number of mental impressions or perceptions constantly 
received, and most frequently given out by continuous speech. 

General Pathology. 

In our classification of mental disease based on the patho- 
logical condition found in the brain, we divide insanity into the 
so-caUed functional and organic forms. Among the former we 



196 INSANITY— FISHER. 

do not find evidence of marked disease of the vessels of the 
brain, its membranes or structure ; while in the latter we find 
changes in some or all of these structures. In mania and mel- 
ancholia, functional diseases, anasmia or congestion is present. 
In melancholia there may be a tendency to thromboses of cere- 
bral sinuses, especially the longitudinal sinus. It is probable, 
however, that many of these thromboses occur a short time 
before death, so that it is questionable whether they can be 
considered as etiological factors in the disease. Hypersemia, 
active or passive, is always difiicult of recognition post mortem; 
similar conditions are frequently found in cases associated with 
high temperature, with or without delirium, in which no evi- 
dence of mental disturbance has been present clinically ; while 
again in some cases of mania grave, slight, if any, changes 
outside of congestion, which may not be marked, are found. 
Anaemia of the brain is present in most diseases of an exhaust- 
ing nature, as phthisis, and while in phthisis we not infrequently 
have insanity of a definite type peculiar to that disease, it is 
on the whole rare. In the so-called degenerative types of men- 
tal disease where heredity is an important factor in its causa- 
tion, or where insanity has resulted in the course of well-known 
neuroses, such as epilepsy, hysteria, neurasthenia, and hypo- 
chondria, no definite pathological changes characteristic of 
these diseases have been found. In the more chronic forms of 
these so-called functional diseases, where secondary dementia is 
present, it is not unusual to find arterial changes, as thickening 
of the walls of the vessels, or an increase in the neuroglia tissue, 
with atrophy of the nerve cells and nerve fibres. These changes, 
however, are not distinctive of these special diseases, either as to 
localization or as to character, not infrequently being present 
where mental disease has not manifested itself. In some cases 
of epileptic insanity, it has been held that the frontal lobes show 
special signs of atrophy, or that the temporal lobes (Meynert) 
give evidence of connective-tissue changes with cellular degen- 
eration. In organic diseases of the brain, as in general 
paralysis of the insane, we find inflammation of the dura 
mater with thickening associated with great increase of new 
blood-vessels, which frequently, on account of the thinness of 
their walls, lead to hemorrhages giving rise to pachymeningitis 
interna hemorrhagica. Again, there may be thickening of the 



GENERAL, PAIHOLOGY. I97 

pia mater with adhesions between it and the dura mater as well 
as the brain substance. The structure of the cortex of the brain 
gives also evidence of disease, being atrophied and showing 
slight punctate depressions which give it a worm-eaten appear- 
ance. This is probably caused by obstructions in the small 
capillaries entering from the pia into the substance of the brain. 
We not infrequently find along lymph tracts deposits of a 
hyaline nature. The vessels themselves are frequently thick- 
ened, and probably the seat of slight cortical hemorrhages. 
The neuroglia tissue is increased; the nerve cells are atro- 
phied and vacuolated, their processes lost, and in their in- 
terior we find granular substances, pigment, etc. The asso- 
ciation fibres which connect functionally adjoining groups 
of cells and different areas of the brain are also involved, 
explaining perhaps the loss of association of ideas, and con- 
sequently of memory and judgment so frequently seen in 
general paresis. In syphilitic insanity we find changes point- 
ing specially to arterial disease. The walls of the vessels are 
thickened, and an infiltration of a gummatous character de- 
creases the lumen, leading to atrophy following loss of nutri- 
tion from partial or complete thrombosis. "We may thus 
have in these cases more or less dementia. Insanity depen- 
dent upon alcoholism generally shows affections of the mem- 
branes of the brain, while in the brain structure there may 
be diseased vessels with increase of the neuroglia tissue and 
atrophy of the cortex cells. It is not surprising, therefore, 
that both of these latter diseases may have symptoms resem- 
bling general paresis, and may be not infrequently taken for 
that disease. In idiocy and imbecility, we have to deal with 
defective structure of the brain. The defects found are either 
atrophy, as seen in microcephaly or hydrocephalus with en- 
larged ventricles resulting in great decrease in the depth of 
the cortical substance; or we may find partial or complete 
absence of certain portions of the brain structure, as the 
greater part of the cerebrum, the basal ganglia only being 
present. The morbid changes in imbecility are of a similar 
nature, but the lesions have not been so destructive. Many of 
these changes seem inadequate to explain the various forms of 
insanity in a clinical aspect. H. A. Tomlinson, in a recent 
article entitled " The Inadequacy of the Morbid Changes Found 



198 INSANITY — FISHER. 

Post Mortem to Explain the Manifestations of Insanity," well 
says after a study of twenty-four cases : " A further proof of the 
want of significance of these changes in explanation of mental 
perversion is found in the facts that in an individual, no matter 
whether the condition be one of violent delirium or profound 
depression, if the attack has been acute, identical changes in 
the cortex and meninges will be presented, sometimes varying 
in their locality and extent, but never materially in their char- 
acter. Again, there appears the implication that these may 
not stand in the relation of a causative factor to the mental per- 
version, and that the histological changes found do not result 
directly from the manifestations of mental perversion, but in- 
directly through impaired nutrition and exhaustion following 
in the wake of excessive motor activity accompanying insanity 
— an auto-intoxication resulting from impaired or inhibited 
somatic activity. A further fact seldom referred to, but stated 
elsewhere by the writer in this relation, is the evidence furnished 
by primary and terminal dementia. Either of them may, and 
often do, proceed to a degree involving mental annihilation 
without interfering with the somatic activities which are auto- 
matically performed, and yet post mortem no distinct histologi- 
cal changes are to be found. Whether mental activity is repre- 
sented in the most unstable cells of the cortex independently, 
or whether, as I believe, it is represented synchronously with 
motor generative activity, and is the reflex of an association of 
all somatic activity, has not been demonstrated, and may not 
be capable of demonstration ; but the latter would seem to he 
the most reasonable assumption from the data we have ; espe- 
cially as it will most definitely explain the absence of distinctive 
changes in the mental perversion, and the uniformity of change 
in associated mental and somatic impairment or destruction. 
The first point to study in the pathology of insanity is that we 
have to deal with alterations, not destruction of function. The 
activities involved are the same in amount and kind in both 
normal and abnormal mental function." 

Nothing definite has been established in regard to the so- 
called criminal brain. The Italian school, especially among 
others Lombroso, have brought forward many interesting facts 
in reference to the convolutions and fissures in their efforts to 
establish a special type, but they are far from conclusive. 



CLASSIFICATION. I99 

The weight also shows but little diflference from those of the 
normal brain. Bischoff ' compared 137 brains of criminals with 
422 normal, and found but little difference. 

The difference between the two hemispheres is not signifi- 
cant. Giacomeni found in 42 criminal brains the right hemi- 
sphere heavier in 20 cases, the left in 18, while 2 were equal. 

Benedikt reports that in 16 criminal brains he found the 
cerebellum not covered by the cerebral hemispheres in six in- 
stances, and in three cases but partially so. 

The author is a strong advocate of the criminal type of 
brain. 

Bevan Lewis remarks that " our studies of the pathology of 
insanity would impress us with the important principle, that 
whenever the nervous elements of the cortex are primarily the 
seat of disease originating mental derangement, then the im- 
plication of the sphere of mind tends always to be more gener- 
ally or universally involved ; but where the nerve changes are 
secondarily induced as the result of vascular disease, the greater 
tendency is shown toward a local or partial implication of that 
sphere. Hence we find that whereas in ordinary uncomplicated 
acute insanity (acute mania or melancholia) the territorial im- 
plication is a very general one, although invariably expressed 
at certain sites more than at others; yet that in certain insani- 
ties {i.e., general paralysis) special sites of election are taken 
by the diseased process, one area being affected after the other, 
until ultimately the localizing character of the ailment fades 
into a widespread general implication." 

CLASSIFICATION. 

" The exigencies of affairs compelled the lawyers themselves 
to construct one of the earliest classifications of insanity, namely, 
that well-known one of Lord Coke, who divided insane persons 
into (1) idiots from birth ; (3) the accidentally insane who have 
wholly lost memory and understanding; (3) those who have 
lucid intervals ; and (4) those who deprive themselves of under- 
standing by vicious actions, as drunkards. Like all kinds of 
insanity which have any interest for lawyers, it is based upon 
the mental qualities and conditions, and not upon the physical 
' "Hirngewichtd. Mensch." Wi en, 1880. 
III.— 15 



200 INSANITY — FISHER. 

substratum. It is this point which more than any other we are 
bound always to bear in mind in the consideration of the diag- 
nosis of insanity for legal purposes." As the writer further 
says, it is not (disease) as the cause of disease in which law inter- 
ests itself, but rather the product of that disease. This is, how- 
ever, only begging the question, for we all acknowledge that 
insanity is simply a group of symptoms, the result of disease of 
the brain. 

This subject has engaged the attention of all writers, so that 
we have had presented many and various divisions. The etio- 
logical classification has always received many supporters, and 
has its advantages in so far as it definitely defines the character 
of the disease. It leads, however, into a very complex subdi- 
vision which is of little value in a medico-legal sense. The 
law recognizes simply the fact of insanity, not its particu- 
lar form, it is interested only secondarily in the latter in 
so far as it explains the degree of impairment of the mental 
faculties. " The medical terms are not recognized in law— 
the legal terms are dementia naturalis, which is equivalent to 
idiocy and imbecility, and dementia adventitia or acquired 
insanity. " ' 

Krafft-Ebing has in his classification carried out this idea 
in some respects, as he divides all insanity into that of the un- 
developed brain and that of the fully developed brain. 

In the first division fall idiocy and imbecility, correspond- 
ing, therefore, to "dementia naturalis," while in the second 
come all the true forms of mental disease or insanity proper, 
corresponding to dementia adventitia, or acquired insanity. 

He further bases his division of the various forms of insan- 
ity on the pathological changes found. All insanity must be 
ascribed to disease of the brain, either of a functional (nutri- 
tional) or organic character. Under the first head will come 
the so-called functional forms of mental disease, as melancholia 
and mania, and also he includes here the large class of degen- 
eratives in which the element of heredity is the most important 
factor, as well as the forms of insanities following from the 
various neuroses, as epilepsy, chorea, etc. Under the second 
head are included those diseases due to organic disease of the 
brain. We have here a practical basis for subdivision of the 
' J. Dixon Mann : "Forensic Medicine and Toxicology." 



CLASSIFICATION, 201 

various forms of insanity, retaining the advantages of the etio- 
logical plan. 

The attempt to divide insanities into those affecting the 
emotions and those involving the intellect and will, as has been 
done by Griesinger and Maudsley, seems to be based on a false 
principle. It is rare to find a distinct form of either class. If 
we include melancholia and mania as under this head, and as 
therefore being essentially emotional states, we are confronted 
with many cases where the intellect is also affected as shown by 
the presence of well-defined delusions. This last-named state 
implies an affection of the intellect, for delusion cannot take 
place without thought or conception. Again, in delusional in- 
sanity or the various organic forms, as general paresis, there is 
always emotional disturbance. We must conceive of the mind 
as a whole, in which no one element can be affected without to 
a greater or less extent affecting the integrity of the rest. 

There is no doubt, at times, an involvement of the emotions, 
almost to the exclusion of the other function, and as a rule it 
does not imply as serious a lesion. 

With some few modifications I will give Krafft-Ebing's 
classification : 

A. Psychical Disease of the Developed Brain. 

I. Functional neuroses or diseases without a pathological 
basis. 

(1) Melancholia (inhibition of mental action). 

a. Melancholia simplex.. 

h. Melancholia cum stupors. 
(3) Mania. 

a. Mania with exaltation. 

h. Mania with frenzy. 

(3) Confusional insanity, or primary dementia. 

(4) Stuporous insanity. 

(5) Secondary dementia. 

a. With agitation. 

b. With apathy. 

II. Psychical degenerations, that is, diseased conditions of 
the developed brain, inherited or acquired. 

(1) Constitutional affective insanity (folie raisonnante) . 



202 INSANITY — FISHER. 

Moral insanity. 
Impulsive insanity. 
Transitory mania. 

Kleptomania. 

Pyromania. 

Dipsomania. 

Homicidal mania. 

Suicidal mania. 

(2) Paranoia, 
a. Primary. 
h. Acquired. 

1. Typical form (with delusions of persecution and 

grandeur) . 

2. Questioning paranoia. 

3. Religious paranoia. 

4. Erotic paranoia (sexual perversion). 

(3) Periodical insanity — circular insanity. 

(4) Insanity from constitutional neuroses, 
a. Neurasthenic insanity. 

Agoraphobia. 
Claustrophobia. 
Aerophobia. 
Zoophobia. 
6. Epileptic insanity. 

c. Hysterical insanity. 

d. Hypochondriacal insanity. 

III. Cerebral disease with constant pathological changes, or 

organic psychoses. 

(1) Acute delirium. 

(3) General paresis (dementia paralytica) . 

(3) Syphilitic insanity. 

(4) Alcoholic insanity. 

(5) Senile insanity. 

B. Arrested Cerebral Development, 

(1) Idiocy. 

a. With predominant intellectual defect. 
h. With predominant ethical defect (primary moral 
weakness) . 



MELANCHOLIA. 203 

The mere statement of the varieties of insanity as given by 
the College of Physicians may be useful, although it can scarcely 
be placed under the head of a classification : 

Mania. 

Melancholia. 

Dementia. 

Imbecility. 

Idiocy. 

General paralysis. 

Puerperal insanity. 

Insanity of puberty. 

Climacteric insanity. 

Senile insanity. 

Toxic insanity (alcohol, gout, lead, etc.) . 

Delirium tremens. 

Traumatic insanity. 

Insanity associated with obvious morbid change or changes 
in the brain. 

Consecutive insanity, from fevers, visceral inflammations. 

SPECIAL FORMS OF INSANITY DESCRIBED. 

Following our classification we first take up the simple psy- 
choses and those mental diseases characterized by a loss of 
responsibility in civil and criminal relations. 

Melancholia. — Melancholia is characterized by marked 
mental depression, with or without cause. There is usually 
what may be termed mental neuralgia ; the patient is centred in 
himself, and ascribes his trouble to some act of his own. Hal- 
lucinations, illusions, and delusions may or may not be present. 
Those of hearing are more common than those of sight. Voices 
condemnatory in character are not infrequently heard. Sin 
against God, which is held as unpardonable, is frequently as- 
sumed. Life becomes wearisome from the tedium of one con- 
stant idea which cannot be driven away, and which absorbs the 
patient to the exclusion of all other thought. In extreme cases 
he is unconscious of his surroundings, and frequently assumes 
an attitude of despair or one of petition . The physical condition 
manifests itself by marked anaemia, loss of appetite— depend- 
ent often upon delusions, as of the fear of poisoning — emacia- 



204 



INSANITY — FISHER. 



tion, and insomnia. The pupils are frequently dilated, the 
pulse is slow and feeble. This condition may remain for sever- 
al weeks or months, the earliest signs of recovery manifesting 
themselves by the recognition on the part of the patient of his 
delusions as such, and an improvement in his physical condition, 




Fig. 10.— Melancholia. Shows very characteristically the attitude assumed in melan- 
cholia of the passive form— suicidal. M. S., female, set. 21, single; admitted to the 
hospital March, 1893. Patient has apparently no delusions, but cries and moans con- 
stantly and has suicidal tendencies. Death occcured in June, 1894, from phthisis, 

principally shown by an increase in weight. The terminal con- 
dition of this state, when recovery does not take place, is in 
secondary dementia. 

Melancholia comprises, therefore, all those morbid states in 
which depression of a painful character is the cardinal symp- 
tom. It may more especially involve either the emotions or 
the intellect. In the simple form there is usually an absence 
of delusions or hallucinations; in fact, these are often later 



MELANCHOLIA. 



205 



symptoms, dependent upon and arising from the depression 
(Savage). 

Melancholia is indeed a symptom in many of the different 
forms of insanity, but must in these relations be considered in 
a different light from the recognized psychosis. In true melan- 
cholia there is " a complete process in itself." It passes through 
certain stages, and its course of development can be followed. 

Holtzendo r f f 
defines melan- 
cholia as a dis- 
ease the essence 
of which is a 
painful depres- 
sion of mind, 
which is not jus- 
tified by any suf- 
ficient cause, be- 
ing an expression 
of a morbid 
trouble of the 
cerebral function. 
Those affected 
feel sad without 
reason, anxious, 
discouraged, 
troubled by 
gloomy thoughts, 
cares, and doubts. 
They feel them- 
selves and their 

relations with the outer world changed ; they are indifferent to 
their interests in life-; their usual occupations become diflScult, 
even impossible, for them. Thought is checked ; certain painful 
ideas are constantly before them (compulsory ideas), excluding 
or driving out all other ideas and thus destroying all volition. 
There is usually, at least at first, a clear recognition of this state 
by the patient, so that he feels himself under some mysterious 
control, often ascribing it to electricity or hypnotism. Subse- 
quently hallucinations and illusions of the senses arise, which 
are not infrequently rather secondary to the depression than its 




Fio. 11.— Melancholia. Exhibits typical facial expression 
of anxiety in melancholiacs. Patient, set. 53, female, widow, 
had an acute attack at age of 33 ; had delusions of hearing, 
and at times is violent. 



306 INSANITY — FISHER. 

cause. The mental agony may become so extreme that there is 
loss of self-consciousness, the individual becoming oblivious to 
his surroundings. Such conditions (raptus melancholicus) may 
occur in hypochondriacs, epileptics, hysterics, and in alco- 
holics, but the duration is brief and the course of the disease is 
irregular. The physical and mental symptoms generally go 
hand in hand. The face has an anxiov s expression, the fore- 
head is wrinkled, often characteristically, with special lines over 
and between the eyes (see Fig. 11). The general nutrition is 
impaired, the digestion is poor, flatulence is common, the skin 
is dry, the hands and feet are cold and blue, the cardiac action 
is weak, the pupils are usually dilated. There may be marked 
insomnia or the sleep may be restless, with little feeling of re- 
freshment on rising. The patient is frequently the victim of 
subjective sensations of numbness, or there may even be anaes- 
thesia. These states lead to hallucinations or delusions in 
many cases. A feeling as if the skin were pinched, as de- 
scribed by a man under my observation, was instantly ascribed 
to spirits about to seize him, and while perhaps laughing at the 
idea while speaking of it, he was unable to cast it aside when 
alone. There may be marked mental weakness, even approach- 
ing dementia ; but this is rare, the patients usually being able 
on their recovery to relate all the instances, or many of them, 
occurring during their illness. The refusal to speak or perform 
any act when requested is often due to a delusion; they may 
hear a voice advising them not to do it. 

The refusal to take food, which is so common among melan- 
choliacs, is usually based on some delusion, rather than sensory 
anaesthesia to the pangs of hunger. There may be the belief 
that the food is poisoned or that the stomach is diseased and 
can no longer digest it. Suicide is common and maybe an im- 
pulsive act or a deliberate one. Where the fear of being killed 
is present, to escape from it suicide may be attempted. 

A boy, set. 18, brought up in the lowest part of New York, after 
losing his position, became depressed and heard voices calling him 
opprobrious names, with threats of killing him. He applied to the 
police for protection and was sent to the asylum. He was completely 
filled with the terror of being killed, crying out constantly for protec- 
tion and saying that he had done nothing. To escape this constant 
fear, he attempted suicide. 



MELANCHOLIA. 207 

Homicide is not rare in the agitated or excited cases. 
Where excessive misery or want has been a causative agent in 
the disease, there may be the desire and wish to relieve the 
victims from like sufleering, or the fear that, after killing them- 
selves, the children, for instance, may be left without support. 
Again, when the belief of having committed the unpardonable 
sin is entertained, there may exist the wish to save others from 
a like condition. A mother may deliberately kill her children 
to save them from suffering, as in the case reported by Dr. M. 
D. Field, which I include here in full. 

The Case of Mrs. Wilhelmina C. D. Lebkiichner.^—'M.rs. Lebkuch- 
ner was indicted for the murder of two children. It was shown that 
on March 21st, 1888, she admininistered " Eough on Eats" to three 
children, two of whom died. 

I saw Mrs. Lebkuchner several times during the month of October, 
1888, and from time to time until the trial in March, 1889. I may 
state that I was called upon to make three reports. 

First. — Capacity to plead to the indictment. Was she capable of 
comprehending the nature of the crime charged, and of aiding her 
counsel in the formation of .a defence, if she had any? 

Second. — What was her probable mental condition at the time of 
the commission of this crime ? 

Third. — After acquittal, to determine whether she be discharged or 
committed to an asylum. 

First report was as follows : Physical condition poor. Is thin and 
appears at least ten years older than she really is. Her pulse is 108 
and irregular. She has anaemic heart murmur (i.e., a false sound of 
the heart due to poor blood). Her circulation is feeble ; the extremities 
being cool. She has an eruption on her face due to syphilis. She 
complains of numbness in right arm and leg ; examination shows ex 
cited reflexes and slight loss of power on that side. She complains of 
pain in her right side (abdomen), but much less than formerly. She 
states that she sleeps fairly well, and has an average appetite. While 
there is a very apparent indifference and lack of interest and she is 
without anxiety regarding her fate, little or no emotion, and no attempt 
to excuse or justify her acts, she is nevertheless rational, coherent, of 
good perception and rather remarkably good memory. She is free from 
illusions, hallucinations, and delusions so far as a searching and 
thorough examination could determine. She makes no attempt to sim- 
ulate insanity; on the contrary, she does not want the plea of insanity 
entered, and did not inform me when asked that she had a sister in- 

' By Matthew D. Field, M. D. , of New York. 



208 INSANITY — FISHER. 

sane, though she knew that her sister was or had been at the asylum 
on Blackwell's Island. 

My conclusions are that she is now capable of comprehending the 
nature of the crime of which she stands indicted, and of aiding hei 
counsel in the formation of a defence, if she has one, as far as her 
natural intelligence would permit under ordinary circumstances. 

Second report — probable mental condition on March 21st, 1888. 
To arrive at any satisfactory conclusion as to her mental state at the 
time when this deed was committed, it is necessary to carefully : 

1. Review her life, both before and after marriage. 

2. Her family history. 

3. Her physical condition. 

4. The ch'cumstances leading up to the deed. 

5. The deed itself. The manner of its execution. The time of day. 

6. Her conduct after the deed. 

7. The analogy and similarity of this deed with acts of the insane. 

8. Were there rational motives for the commission of this deed ? 

9. Finally, was this deed the probable outcome of a diseased body 
and mind ? 

1. She was horn in Germany some thirty-six years ago, and 
received a fair education, and in religion was brought up to attend the 
Gierman Reformed Church, but for years has neglected all church 
duties. She came to America in 1871, and was employed as a domestic 
up to the time of her marriage on the 28th of November, 1877, when 
she married a man over twice her own age, and whose daughters were 
as old as herself. Her husband lost his money, and then started a 
saloon and became a drunkard. Her relations with his children were 
always unpleasant. By this husband she had two children and two 
miscarriages, and was again pregnant on the 23d of June, 1883, when 
he deserted her, leaving her nothing in the saloon but bills and notices 
of dispossession. She struggled to keep the saloon and pay ofP the 
debts and make a living for herself and her children. She sought to 
find her husband, but his children and other relatives deceived her as 
to his whereabouts, and gave her no aid. On September 1st, 1883, she 
was compelled to abandon the saloon, and was with her two children 
and pregnant again upon the streets, without money, friends, or home. 
On the 7th of September she applied to the Superintendent of the 
Out-door Poor, Department of Public Charities and Corrections, and 
the Society for the Prevention of Cruelty to Children for aid, and 
on the following day her two children were committed to the care of 
the society. Her sister became insane and was taken to Bellevue Hos- 
pital, and on September 11th, 1883, was pronounced insane, and on 
September 13th, 1883, she was sent to the Lunatic Asylum on Black- 
well's Island. Mrs. Lebkuchner herself now fell ill, and on September 
12th, 1883, was admitted to Ward 11, Charity Hospital, where she was 
treated for syphilis. Christopher was born March 21st, 1884. The 



MELANCHOLIA, 209 

above dates and facts have been verified by me from inspection of 
records. 

Her husband died October 8th, 1888. For some time she lived with 
another man ofp and on, but was never married to him. He was also 
a drunkard, and contributed little or nothing to her support. By this 
man she had a child, born in February, 1887. This child was placed 
in some institution. In the summer of 1887 she found herself again 
pregnant, and during the late fall or early winter she injured her right 
side while carrying a stove. Such was her life up to the winter of 1887 
and 1888. 

2. Family history {heredity). Maternal grandmother was in- 
sane. Mother died of consumption. Father was an intemperate man. 
Sister Annie now an inmate of the City Asylum, where she was com- 
mitted in September, 1883 (I gave one of the certificates upon which 
she was committed). 

3. Her physical condition was bad. She is still in a very poor 
physical condition, and from those who saw her before and soon after 
the 21st of March, and from her own statements, she was at that time 
in very much worse physical condition than now. The matron and 
others about the Tombs tell me that she was much depressed and con- 
fused when first received, and that there has been marked improvement 
since her child was born. 

She was and still is suffering from syphiUs manifested by an erup- 
tion upon her face, and syphilitic disease of the brain is strongly sug- 
gested by the numbness, excited reflexes, and loss of power on the 
right ride, and slight irregularity and inactivity of the left pupil. She 
was approaching the end of pregnancy, her poor physique was being 
taxed to nourish this coming and developing child, had the morbid 
feelings of women at such times, aggravated by lack of food, hard 
work, harassed and crippled by pain in her side, and believing that 
she would not survive her confinement, and that she would be confined 
on the 29th of March. 

4. The circumstances leading up to the deed. We must not, in 
considering this part of the inquiry, lose sight of her physical condition 
as just cited. She was living in rooms for which she paid $8 a month ; 
was paying for a sewing-machine by instalments of $3 per month. 
Anthony was at the asylum, but in February she was notified to take 
him home or he would be sent to the West. Christopher was being 
boarded at twenty-five cents a day. Charlie was sent to a day nursery 
when she went out to work, and for this she paid ten cents, and it cost 
her ten cents a day for car fares in taking him up and. bringing him 
home, and then she allowed five cents for his supper, and this made 
twenty-five cents a day for Charlie. This made her monthly expenses 
(30 da; twenty-six dollars ($26). This is $1 for every week day, and 
not a cent was allowed for light, fuel, or food. When she went out to 
work she received her food. This problem was always with her, and 



210 INSANITY — FISHER. 

she says at night she could not sleep, thinking of what would become 
of them if it rained on the morrow and she could not work, for she 
could never make up for a day that was lost, and the expenses were 
all she could possibly earn, even if she could work every day. When 
the pain in her side got worse and she was unable to work, then she 
could not sleep. The officers of the society came to the house to make 
inquiries about her, and she got the idea that she was foUowed by 
detectives (this statement is verified by Mrs. Vermilyea, of No. 696 
Greenwich Street, where she was employed pretty regularly for some 
two years, and where she worked on Tuesday, March 20th). In Feb- 
ruary, when she was notified to take Anthony from the Juvemle 
Asylum, she was much depressed, and the idea of this crime first came 
to her, but she fought it o£P and things were better, and she could work 
more regularly. Anthony was sent home. She could not have him 
go West, because she had the idea that the West was a terrible place, 
and that there he would sufiPer worse than death. It was in describing 
what she thought the West to be that she displayed the only emotion 
shown during my interviews with her. On the 12th of March the 
"blizzard" came, and that week she could work little and was com- 
pelled to buy food and fuel, and everything was very expensive that 
week. She was compelled to spend the money she had been saving to 
pay the rent and the instalment on the sewing-machine. She had 
promised to pay the rent on March 21st, and the woman called for the 
sewing-machine money early on Wednesday morning (March 21st). 
The Friday before the crime she was sick and unable to work, and 
late in the afternoon she fell asleep on the sofa in her room and slept 
soundly, and when she awoke she found Anthony and Charlie looking 
at her and crying. When she asked them what was the matter they 
said they thought she was dead. This made a great impression upon 
her, and she began to think what would become of them if she should 
die, and she believed she was surely going to die when the baby was 
born, for she had never suffered such pain before as she was suffering 
from her side. Now the idea of killing the children and herself again 
came to her, and she told the little girl who came for the money for 
Christopher's board to briag him home to her the next night. She 
wanted aU the children together that they might die together. Satu^ 
day she was better and she was able to work, and on Sunday she 
took home some work and received a dollar and a half. She was 
brightened now and the idea left her. On Monday she could not work, 
but Tuesday she went to work and took little Christopher with her, but 
she suffered severe pain in her side, and in the afternoon was com- 
pelled to stop work. She took a car home, but on the way was very sick 
with great pain, and she had some discharge that soiled her clothes 
(says her petticoat would show this now if it could be recovered from 
her effects left at her rooms), and she believed that she would soon be 
confined. In this state she reached home; but she could not sleep that 



MELANCHOLIA. 311 

night; she "cried and prayed all night," and "she felt that it was 
best that she should km the children and herself than that she should 
die and leave the children behind." This idea took possession of her, 
and she sent Anthony out for a box of " Eough on JRats." While he 
was gone the woman called to collect the sewing-machine money. 

5. The deed itself. This was done in the morning, after a sleepless 
and troubled night. It was calmly and quietly done. She put all the 
poison in a pot of tea and made four portions, one for each of the 
children and one for herself. She did not take her own portion, be- 
cause she might die first, and she was not cowardly enough to leave 
them to sufPer without somebody to look after them. She gave them 
the tea containing the poison and told them to drink it, but she could 
not look at them, but turned away and became faint and sustained her- 
self by holding on to the mantel. 

6. Her conduct after the poisoning. She remained with and 
cared for them as best she could. She would have gone for help, but 
she could not leave them, but stayed and looked at them. Two died 
and she put them in the bed. On Saturday morning, 3:30, little 
Christopher fell asleep and then when he was quiet, and would not 
miss her, she ran to the police station and told them what she had done 
and asked them to send a doctor. She did not seek a doctor to save his 
life, she seems not to have thought of this, but to relieve his sufferings. 
She was calm, gave herself up, made no excuse, and showed no re- 
morse. She still believed that little Christopher could not recover, and 
that she would still die. She had not looked upon this as a crime, but 
thought that they would soon all be together in a better world. 

7. The analogy and similarity of this deed with acts of the 
insane. It does not appear that this deed was the result of a defined 
insane delusion, or was the result of a defined hallucination. By this 
I mean that she was not impelled by any fixed and governing false 
idea, nor by any commanding voice, or any vision pointing out to her 
what she should do. She did not appear to have had what is called an 
imperative conception, that is, any sudden irresistible impulse taking 
such possession of her as to overpower all will and reason. She does 
not appear to have been unconscious at the time of the commitment of 
this deed, nor is there any evidence that she ever had epilepsy, the 
existence of which might account for the crime. Nevertheless, this 
deed, contrary to every natural instinct of a human being, much 
worse, a mother, without selfish motive, apparently the only selfish 
motive that might be attributed would be that, at any cost, these chil- 
dren should be kept from the relatives of her late husband. Had she 
wished to have freed herself from the care in order to abandon herself 
to a dissolute life, as is claimed, she might have left her children with 
the society without committing this crime. It is evident that she in- 
tended to take her own life, but was unwilling to do this until she was 
assured that all the children were dead. Suicides and homicides of the 



212 INSANITY— FISHER. 

insane are committed more frequently in the morning hours, especially- 
after a sleepless and troubled night, and before the will and reason hare 
fully asserted themselves. Insanity involves the ego, the insane delu- 
sions and hallucinations always pertain to and involve the ego, and 
that which is closest to the ego ; and this is nowhere more conclusively 
shown than in the homicidal acts of the insane. Statistics show that 
thirty suicides are perpetrated by the insane to every homicide, and of 
the homicides committed by the insane those of the nearest and dearest 
relatives are eight times as frequent as of those not joined to them by 
these close ties. There was no attempt at concealment or self -protec- 
tion ; no effort to escape ; but, on the contrary, she voluntarily gives 
herself up and confesses, in the calmest manner, all that she had done. 
There was also lack of all emotion and remorse. 

8. Were there rational motives for the commission of this deedf 
Only that they would be better off dead than left unprotected ia this 
world; when it was plain to her that she was too sick and poor to care 
for the children longer herself, and that she was going to die. 

There was no motive of gain, anger, or revenge. In fact, there 
was nothing about the deed that was not irrational. 

9. Was this deed the probable outcome of diseased body and 
m,indf Yes. We find strong hereditary predisposition. We have 
syphilis, with symptoms of involvement of the brain. 

We have pregnancy, with its morbid fears. I have said that there 
was no defined delusion, but there was great mental depression, with 
the ill-defined delusions that she would die during her confinement. 
Her distorted ideas of the West, and what her children would suffer 
there. She saw no hope in the future, and want and starvation at 
hand for herself and her children. She was in very poor physical 
condition and not fit to work, yet working. She was suffering from a 
severe injury to her side while carrying a heavy stove. She was 
troubled in every way, and was sleepless, and was in too poor a physi- 
cal condition to appreciate the nature of her acts or to resist the im- 
pulse that impelled her to the commission of this act. 

The act seems to have been the result of heredity, pregnancy, 
circumstances, a diseased and worn-out body, a mind weakened by 
these, and harassed by poverty and want, and so deeply depressed that 
the judgment and will were unable to act with anything like their ac- 
customed power and force. 

The third report was in the form of a certificate of insanity, the 
body of which read as follows : 

" She is in very poor physical condition. She is thin, pale, and has 
an anaemic heart murmur, with a rapid, quick pulse. Her pupils are 
unequal, and there is loss of power and excited reflexes on the right 
side. She has an eruption upon her face, probably due to sypMlis. 
She is at times depressed, and at other times is elated without adequate 
cause. She does not appreciate the gravity of her present position, nor 



MELANCHOLIA. 3I3 

the enormity of her crimes. She has displayed both suicidal and 
homicidal impulses. On one occasion she poisoned three children, 
two of whom died. Considering this history, with her present 
physical and mental states, I believe her an unsafe person to be at 
large." 

This case presents many points of especial interest to both the med- 
ical and legal professions. She was at first put on trial before Judge 
Marttne and a jury as to her present sanity and capacity to plead to the 
indictment. The prosecution called Dr. Allen McLane Hamilton and 
Dr. George B. Fowler. Dr. Frank H. Ingram and myself were called 
by the counsel for the accused. The testimony was practically the 
same, and the jury found her sane. 

A month later she was placed on trial before Judge Gildersleeve 
and a jury upon the indictment ; insanity was interposed as the de- 
fence; the prosecution was conducted by Assistant District Attorney 
Macdonna, the prisoner being defended by Mr. John E. Heinzelman. 
The defence placed upon the stand, upon the question of insanity, Dr. 
Stuart Douglas, Dr. Allen McLane Hamilton, Dr. Frank H. Ingram 
and myself ; no expert witnesses were called by the people. His Honor 
Judge GUdersleeve charged the jury. After reviewing the evidence 
and defining the degrees of murder and manslaughter, he charged 
upon the question of responsibility as follows : 

"If you are satisfied, therefore, gentlemen, that she administered 
this poison and it resulted in the death of Charles Lebkuchner, and that 
she did it from a deliberate and premeditated design to effect his death 
and you are so satisfied beyond any fair and reasonable doubt, then she 
ia guilty of the crime of murder in the first degree, unless you are 
satisfied that the defence which she has set up here has been established, 
viz., that of insanity. 

"The 20th section of the Penal Code provides as follows : 'An act 
done by a person who is an idiot, imbecile, lunatic or insane, is not a 
crime.' It is claimed that the act of this defendant which it is charged 
resulted in the death of the deceased, is not a crime because she was 
insane at the tirae. Now that is a question of fact for you to decide in 
the light of all the evidence — her conduct, what she said and did, in the 
light of what the experts who have been called here have said in respect 
to that question. The rule of law that is controlling on the question of 
insanity seems to be clearly expressed in the opinion of Judge Andrews 
of the Court of Appeals in the case of Flanagan against the People, a 
portion of which was read to you by the learned District Attorney : 
' It must be regarded as the settled law of this State that the test of 
responsibility for criminal acts where unsoundness of mind is inter- 
posed as a defence, is the capacity of the defendant to distinguish 
between right and wrong at the time of and with respect to the act 
which is the subject of inquiry.' The physicians when asked their 
opinion as to the condition of the defendant's mind at the time of the 



214 INSANITY — FISHBE. 

commission of the act based upon the circumstances and condition of 
things disclosed by the evidence, such as her conduct, her previous 
history, all the circumstance under which the act was committed, their 
answer, you remember, was that it was their opinion that she was in- 
sane. Dr. Douglas was asked : ' Might she have known the differ- 
ences between right and wrong and yet not have capacity to act upon 
that?' The answer was: 'Yes.' Dr. Hamilton said: 'I think 
her will was afEected, that she committed this under a condition of 
diseased responsibility, she was irresponsible as the result of disease. 
Q. Do you believe that a person in the condition she was, was able to 
choose between the right and wrong? A. I do not. Q. You have 
heard the circumstances detailed under which it is claimed that this 
defendant poisoned her children? A. Yes, sir. Q. You have heard 
what her condition in life weis at that time ; without my stopping, 
therefore, to repeat all these conditions and all these details, bearing 
them in mind, what is your opinion now, at the time she administered 
the poison, was she sane or insane ? A. I believe her to be insane, sir, 
and from my conversation with her.' This answer, viz. : ' I think her 
will was affected, that she committed this under a condition of dis- 
eased responsibility, she was irresponsible as the result of disease : ' and 
then this question : ' Do you believe that a person in the condition 
she was, was able to choose between the right and the wrong?' and 
the answer : ' I do not ' — ^brings up the real turning-point in this case. 
You must find from the evidence, before she is entitled to be acquitted 
on the ground of insanity, that she had not the capacity to distinguish 
between right and wrong in respect to that particular act. If you find 
in the abstract that her mind was sufficiently sound to enable her to 
distinguish between right and wrong, she would not necessarily be re- 
sponsible. You may find that she had sufiBcient control of her inteUeot 
and of her faculties to be able to know and understand that it was 
■wrong to kill, that it was a crime to take life, and yet that would not 
fasten the responsibility of taking the life of the deceased upon her 
under the law. Was her mind sufficiently sound, did she have suffi- 
cient control of her judgment to be able to distinguish right from wrong 
in respect to this particular act, viz. , the taking of the life of her own 
child under those particular circumstances ? If her mind was so af- 
fected by reason of the poverty that had pursued her, by reason of the 
misfortunes that had befallen her and followed her along from month 
to month and from year to year, if the sufferings she saw ahead 
of her or in store for her chUdren in case of her death, or that she 
believed she saw in store for them, if this so affected her mind, so 
disturbed and deranged her judgment, so interrupted the ordinary and 
sensible course of reasoning as to honestly induce her to believe that 
she was doing a kind and merciful act, that she was taking this son 
from a world of trouble to a haven of peace and happiness, and ihat 
it was right for her to do it, although she knew and believed that 



MELANCHOLIA. 215 

murder in the abstract was wrong and a crime— if , induced by this 
condition of things she was brought around to that condition of mind 
and was not able by reason of that condition of things to distinguish 
right from wrong in respect to that particular act, then she is entitled 
to an acquittal. The rule is the capacity of the defendant to distinguish 
between right and wrong at the time of and with respect to the act 
which is the subject of inquiry. The principle, or more properly the 
theory upon which she is entitled to an acquittdl, if you believe that 
condition of things which I have named existed, must be distinguished 
from an uncontrollable impulse, because the courts have held that 
where it appears that a person takes the life of another under an un- 
controllable impulse by reason of the pressure or influence they feel 
brought to bear upon them, having sufficient capacity to know that the 
act was wrong, being of sufficiently sound mind to distinguish right 
from wrong in respect to that particular act, although they have not 
the will power to resist this impulse, this insane force that is operating 
upon them, nevertheless, the law holds them responsible. The law 
does not recognize a form of insanity in which the capacity of knowing 
right from wrong exists without the power of choosing between them, 
says one case. Another case says, it is no defence that in consequence 
of an uncontrollable impulse the prisoner has no power over his will. 
In a case where the accused have said: ' I felt a command from God 
to do this act; I knew it was wrong; I did not want to do it, but I had 
not the will power to resist what I believed was the command.' Now, 
under these rulings in these cases, a person taking life under those 
circumstances would be held responsible for his acts. So that all this 
reasoning, you will see, gentlemen, brings you right around back to 
this principle, what was the particular condition of mind of the defen- 
dant at the time of the commission of the act ? Was the defendant's 
mind so unsound that she was not capable of distinguishing between 
right and wrong in respect to the act which she was committing? This 
defence of insanity is an affirmative one. The burden is on the accused 
of establishing it; the burden is upon the accused of satisfying the jury 
that the defendant's mind was unsound at the time of the commission of 
the act. It is hardly proper for me to say to you that they are bound 
to go as far as the people are bound to go in making out a case, viz., to 
satisfy you beyond any fair and reasonable doubt, and yet the evidence 
must be convincing and satisfactory to the jury." 

The jury retired, and after about two hours forwarded to the judge 
the two following questions: 

"In case we find the defendant knew the difference between right 
and wrong, but had not the will power to resist the impulse to commit 
the crime, must we consider the law, as read by the District Attorney, 
binding, that is, take no regard as to her will power?" "Did the 
Court charge that in the case we found the defendant merely acted 
under an uncontrollable impulse, we should find her guilty ? " 
III.— 16 



316 INSANITY — FISHER, 

At this time I understood the jury stood nine "not guilty," and 
three "guilty;" the ground of difference being embraced in the two 
questions presented to the Court. The jury were again called into 
court and were addressed by Judge G-ildersleeve as follows : 

"Gentlemen of the jury : — In answer to these two questions which 
you have submitted, I doubt if I can do better than have the stenog- 
rapher read to you what I said, and yet I will add to what I have said 
by reading from som6 authorities from which I did not read at the time 
of delivering the charge. The question presented for your considera- 
tion is a very delicate one, and so the principles of law that control 
cases of insanity are not very well settled. They differ in different 
States. I am bound to give you the law as it maintains in this State, 
where this court has jurisdiction. It is not an easy matter to determiae 
just where responsibility ceases and irresponsibility begins in respect 
to particular acts, and I am not surprised that you ask for some 
further instruction. Now, the law does not recognize any moral 
power compelling a man to do what he knows to be wrong; that is 
substantially what I meant to say in reference to the operation of the 
alleged uncontrollable impulse. That convenient form of insanity 
which enables a person who does not choose to bridle his passions, to 
allow them to get and keep the upper hand just long enough to com- 
mit an act of violence and then subside, is not recognized by the law. 
The insanity which takes away the criminal quality of the act 
must be such as amounts to mental disease and prevents the accused 
from knowing the nature and quality of the act he was doing. The 
doctrine that a criminal act can be excused upon the notion of aa 
irresistible impulse to commit it where the offender has the ability to 
discover his legal, and moral duty in respect to it, has no place in the 
law. To establish defence on the ground of insanity — I now read an 
opinion of the Court of Appeals — it must be clearly proven that at the 
time of committing the act, the subject of the indictment, the party 
accused, was laboring under such a defect of reasoning, of diseased 
mind, as not to know the nature and quality of the act he was doing, 
and if he did not know it, that he did not know that he was doing 
wrong. Where insanity is interposed as a defence to an indictment 
for an alleged crime, the inquiry is always brought down to the single 
question of capacity to distinguish between right and wrong at the 
time the act was done; and, I might add, in respect to that particular 
act, it must be regarded as the settled law of this State that the test of 
responsibility for criminal acts where unsoundness of mind is inter- 
posed as a defence is the capacity of the defendant to distinguish 
between right and wrong at the time of and with respect to the Jwt 
which is the subject of the inquiry. That is the law of this State with 
reference to this defence, and it is the law by which you will be 
governed in determining the question whether the defence that has 
been interposed here has been established or not. Now, as to the 



MELANCHOLIA. 227 

burden of proof. Crimes can only be committed by human beings 
who are in a condition to be responsible for their acts ; and upon this 
general proposition the prosecutor holds the affirmative and the burden 
of proof is upon him. Sanity being the normal and usual condition 
of mankind, the law presuming every individual is in that state, hence 
a prosecutor may rest upon that presumption without other proof. 
The fact is deemed to be proved prima facie, and whoever denies this 
or interposes a defence based upon its untruth must prove it ; the 
burden of overthrowing the presumption of sanity and of showing 
insanity is upon the person who alleges it ; and if evidence is given 
tending to show insanity, then the question is presented to the court 
and jury whether the crime, if committed, was committed by a person 
responsible for his acts, and upon this question the presumption of 
sanity and the evidence are all to be considered, and the prosecutor 
holds the affirmative. If a reasonable doubt exists as to whether the 
prisoner is sane or not, he is entitled to the benefit of the doubt and to 
an acquittal. Now, I declined, you remember, to instruct you that 
the defence were bound to establish the insanity of the accused beyond 
any fair and reasonable doubt. The benefit of a fair and reasonable 
doubt upon the whole case, upon all the evidence for the people, and 
for the defence is always the property of any prisoner charged with 
crime. Now you will see that if the defendant was required to satisfy 
you beyond any fair and reasonable doubt of her insanity and 
succeeded in satisfying you from the evidence that there was some 
doubt of her sanity, and if I charged you the proposition of law 
that you are bound to find beyond any fair and reasonable doubt, 
although she did go far enough to create some doubt, she would not 
have the benefit of the general principle of law that the accused is 
always entitled to the benefit of any fair and reasonable doubt upon 
the whole case — that would be requiring the defendant to go further 
than the law requires. Now I will not go over what I said to you in 
the first instance. I instruct you according to my own recollections of 
the law, not with the accuracy and precision with which the law is laid 
dpwn in these authorities from which I have now read. These author- 
ites which I have read to you embody, as I believe, the principles of 
law which I intended to lay before you in my charge. I have empha- 
sized the principles by reading these authorities and perhaps have made 
clear to you the questions of doubt that were in your minds. If any 
of you have any question that you would like to ask, any point upon 
which you are not entirely clear , I will endeavor to it make clear. There 
can be no conviction unless an accused person has sufficient mind, has 
sufficient control over his reasoning faculties as to be able to form a 
criminal intent. Bishop, one of the leading authorities on criminal 
law, I think defines the question in about these words, and that is the 
test the jury is to apply. Was the mind of the accused, although 
diseased, sufficiently sound to be able to form a criminal intent ? It all 



318 INSANITY — FISHER. 

comes back to this original statement which I said to you was the law 
of this State. The test of responsibility for criminal acts where 
unsoundness of mind is interposed as a defence, is the capacity of the 
defendant to distinguish between right and wrong at the time of, and 
with respect to, the act which is the subject of inquiry. Now in 
determining that question you see you must take into consideration 
the defendant's condition of pregnancy, and all her troubles, and all 
that happened before, and her conduct subsequently, as I instructed 
you, for the purpose of determining that particular question. You may 
now retire, gentlemen." 

The jury rendered a verdict of not guilty, on the ground of 
insanity at the time of the commission of the offence. 

Subsequently, Judge Gildersleeve committed Mrs. Lebkuehner to 
the State Hospital for the Insane, at Poughkeepsie, upon certificates 
of insanity furnished by Dr. Ingram and myself. Mr. Heinzelman 
procured a writ of habeas corpus, returnable before Justice Beach of 
the Supreme Court, to show cause why she should not be discharged. 
Justice Beach discharged Mrs. Lebkuehner upon the ground that the 
commitment was unauthorized, illegal, and void. 

Again, the misery may be so great that instead of the usual 
passive state of these patients there may be ahnost a mani- 
acal state resembling acute mania, in which the patient feels 
impelled to do something to escape from the depression, and, 
knowing no cause for it on his own part, may ascribe his con- 
dition to some enemy or to a conspiracy against him. These 
impulses to suicide or homicide are frequently recognized by the 
patient himself, so that self-commitments are more common in 
this disease than in any other form of insanity. As Cullen 
says, however, crimes are rare in melancholia. There are spe- 
cial forms of melancholia either dependent on the nature and 
duration of the seizure or on some special character of the delu- 
sions accompanying it. 

Simple melancholia, by which we mean mental depression 
without delusions, is usually subacute or chronic. We find it 
most frequently among the overworked, or in persons subject 
to great strain or mental worry, especially of a domestic or 
financial character. There is a marked tendency to suicide, a 
constant fear that they will commit it. There is often a hypo- 
chondriacal element in these cases, the patients having an in- 
tense desire to explain their whole mental state. There is often 
a fear that the natural affection for their children, husband, 
wife, or family is absent. This condition is especially common 



MELANCHOLIA. 



21 'J 



in women, occurring in the j'oung and unmarried, when perhaps 
an unfortunate love affair may be the provocative cause. We 
observe it also at the menopause. 

As Savage has observed, the attempts at suicide are often not 
serious, resembling those in hysteria. 

The following cases illustrate the effect of over-strain in a 
patient with a predisposition to mental disease from hereditary 
taint, and also the influence .of mental disease in one patient on 
another : 

Two sisters, at. 36 and 38 respectively, were brought to the hospital 
with the history of having- attempted suicide. 

Family history was as follows : The mother, still living, had been 
confined in a hospital for some years for melancholia with suicidal 










t\ i .' ', 



i m M 




Fig. 12. — Shows melancholia occurring within a few months of each other in two 
sisters. Both markedly depressed, and possessed of the delusion that some one wished 
kill them. They were both single and lived together, being seamstresses by occupation. 

tendencies, and was at the time in a state of dementia. The father had 
also been in an asylum for several months, but had recovered to the ex- 
tent that he was able to return to his work, although somewhat weak- 
minded. 

Both sisters were very hard-working, conscientious women, and had 
tried successfully to support the family. They were of liighly nervous, 
hysterical temperaments and had both previously been confined in an 
asylum for several months, for melancholia with suicidal tendencies. 

The present attack, in the first sister, was due to anxiety and want of 
sleep, incurred in watching over tlae other sister during a severe attack 
of nervous prostration. She attempted to throw herself out of the 
window, and on being prevented became violent. The second sister, 



220 INSANITY — PISHEB. 

who was recovering from her illness, then became maniacal and ai 
tempted to take poison. There was the same idea present in both, tha 
her illness was preventing the other from working and supporting th 
aged parents. There was considerable mental confusion and extremi 
depression, without delusions of any kind (see Fig. 12). 

These periods of depression are usually most marked during 
the menstrual periods, or following sexual excess, especiallj 
masturbation, which is not uncommon in both sexes in thest 
cases. 

The following case of simple melancholia without delusion 
illustrates these conditions : 

A. B., female, aet. 27, family history negative. Five or six years 
previously, after a disappointment in love, had nervous prostration; 
following which she became filled with a constant desire to kill her- 
self ; however, was always anxious to have some one with her. These 
attacks would occur every spring. The patient became anemic, de- 
pressed, and lost flesh, and, suffered from amenorrhcea and dysmen- 
orrhcea. Any report of a case of suicide in the papers would in- 
crease this feeling, and she felt that she must read the full details. 
She made several futile attempts to take her life : in one she tied a 
handkerchief around her throat, and was found in a practically un- 
conscious state ; at another time she swallowed the sulphur from some 
matches which she had made into a solution. In none of her various 
attempts was the intent truly serious. She was always ready after the 
attack to take any remedy which might relieve her. 

This patient was an unusually intelligent person, of many 
accomplishments. She described herself as never free from this 
feeling, whether apparently enjoying herself at some place of 
amusement or alone in her room. 

This condition is quite distinct from acute melancholia 
with delusions, into which, however, it not infrequently passes, 
and which may be active or passive. In both these latter 
states there is a profound depression ; in the first, however, there 
is an inability to keep quiet, a constant desire to escape from 
themselves or from the hallucinations of hearing and sight. 
The second form seems to be often a stage on the way to mel- 
ancholia with stupor or melancholia attonita. It is in these 
latter cases, as we have already stated, that delusions fixed 
in character are at the base of all their actions. Cataleptic 
states are not uncommon in which the muscles become rigia 
and remain fixed in certain positions for a long period. Even 



MELANCHOLIA. 



331 



here, however, there is usually consciousness of what is going 
on around. Patients in this condition will frequentlj' accept 
food, when given, without opposition. ^4// these forins of mel- 
anclwlia may he regarded, however, as simply phases of the 
same condition. 

Chronic melancholia may result from either acute or 
uhacute states ; there is usually some more or less fixed delusions 
remaining, but it 
difi'ers from the 
fixed or system- 
atized delusion 
found in para- 
noia. There is 
no attempt to un- 
derstand it or ex- 
plain it, nor any 
logical process of 
reasoning con- 
cerning it. The 
legal relations are 
often difficult in 
those forms unas- 
sociated with stu- 
por. It is often 
difficult to find 
either a motive 
or the presence of 
a delusion to ex- 
plain some of the 
acts committed. 

Many of the acts are sudden and unexpected, but, as Casper 
has stated, careful investigation will often reveal delusions. 
This difficulty is increased by the fact that at times delusions 
are often concealed. 

Letters of the patient, in which the whole mental trouble 
has been defined, are frequently of great importance. 

There is usually a premonitory state, which, hoivever, has 
passed unobserved, giving the act the character of suddenness 
or impulsiveness. Casper relates the case of one Taylor, who 
had always had the reputation of being a loving father and had 




Fig. 13.— Melancholia. S. E., male. fet. 2,5, tailor; materaal 
uncle insane; habits temperate; admitted to the hospital De- 
cember, 1892. Patient would sit in one position all day and 
refused to answer any question. Had no hallucinations or 
delusions at any time. Was discharged improved. 



232 



INSANITY — PISHER. 



never been suspected of being insane b}- his friends. Having 
reverses, he killed his four children "to save them from becom- 
ing a public charge." He made a confession without any at- 
tempt at a defence of his act. Examination showed that his 
grandmother and sister had been insane; the latter (having a 
delusion of being pregnant by the Holy Ghost) had also mur- 
dered her children. 

The absence of all motive for the act, or repentance or 
remorse, or attempts at concealment or escape, is strong evi- 

dence, in a legal 

sense, of absence 
of responsibility. 
P. Max Simon' 
says til at impul- 
sive acts are es- 
pecially frequent 
in those melan- 
cholies who shut 
themselves up 
within them- 
selves, remaining 
oblivious to all 
their surround- 
ings. It is true 
that very often 
there has been a 
long struggle be- 
tween the impulse 
and the will, and 
that the sudden- 
ness of the act is 
only the final vic- 
tory of the impulse over the will, in a long but silent battle. 

He relates the case of a melancholic who had apparently 
recovered, who suddenlj"- struck his wife with a heavy stone 
which he had carefulty concealed, killing her instantly. He 
was filled with remorse but said that for a week past he had 
felt the desire to kill some one, which finally overcame all his 
powers of resistance. 

1 "Crimes et Delels dims la Folie." 




Fig. 14.— Melancholia. A. B., female, set. 24, duration of 
disease five years. On admission to tlie linspital in August. 
1893, was melancholie, witli the delusion of being followed, 
and also that she had been poisoned ; hallucinations of hear- 
ing. Patient has become demented and childish, but has not 
lost her delusions. 



MELANCHOLIA. 223 

This goes far to prove that these acts are truly morbid 
impulses and if the defence of insanity is pleaded they should 
only be put forward as symptoms of a definite psychosis. 

In this State a criminal act cannot be excused upon the 
theory of irresistible impulse, where the ofifender knew what he 
was doing and had the ability to discover his legal and moral 
duty in respect to it. Again the mere presence of a delusion is 
not sufficient to establish irresponsibility, as the decision in the 
following case shows : 

Appeal from judgment' of the Court of Oyer and Terminer of 
Cayuga County, entered upon a verdict rendered January 12th, 1893, 
convicting defendant of the crime of m.urder in the first degree. 

William Gr. Taylor, the defendant, upon a conviction for burglary 
was sentenced to Dannemora prison for a term of three years, which 
expired in the summer of 1888, he having received the usual commuta- 
tion for good behavior. Very soon after his discharge, and in the same 
year, he was returned to the prison to serve out two sentences for 
burglary, aggregating about eleven years. From the time of his read- 
mission Kis conduct was exemplary with a single exception, when, on 
April 28th, 1890, without provocation or warning, he assaulted his keeper 
with a hatchet and felled him to the floor. The prison physician stated 
melancholia (with sucidal and homicidal impulses) . On September 29th, 
1890, he was transferred to the asylum for insane criminals at Auburn. 
On September 20th, 1891, he was, as ' ' notinsane, " returned to the prison. 
The medical superintendent of the asylum stated that during this period 
he was sane, while his assistant was of the opinion that during all the 
time there was doubt as to his sanity. From the readmission his record 
was good. He had friendly relations with Salomon Johnson, the 
deceased, a fellow-convict, but in the month of April he exhibited, 
without any apparent cause, a feeling of great hostility to him, and dur- 
ing the summer he frequently threatened to kill him. On September 19th, 

1892, he effected a reconciliation with the deceased, and the next after- 
noon he lured him into a shed under the shop, upon the pretense that 
he had some contraband articles to show him, and there killed him 
with a knife which he had concealed upon his person. Without any 
emotion he confessed his deed, stating that he had to do one of three 
things : either starve to death, or kill the deceased, or kill himself, and he 
did it in order " to be electrocuted." Until his trial, on January 10th, 

1893, he was subject to medical examination. Three physicians stated 
melancholia (with homicidal, respectively homicidal and suicidal delu- 

'Eeports of cases decided in the People v. Taylor (vol. 188, p. 398), 
Court of Appeals of the State of New decided June 6th, 1893. 
York (by H. E. Sickels) . Albany. 



234 INSANITY — FISHER. 

sions), five physicians declared him to be sane. The jury found him 
guilty. He was sentenced to death. 

Maynard, J. , said : 

Proof on the trial of an indictment for murder that there existed in 
the mind of the defendant an insane delusion with reference to the 
conduct and attitude of the deceased will not excuse the homicide, 
unless the delusion was of such a character that if it had been true it 
would have rendered the act excusable or justLflable. 

Accordingly held, that proof upon trial of such an indictment of 
the existence of a delusion in the mind of the defendant that the de- 
ceased was acting as a spy upon the defendant and had betrayed a plan 
of escape, did not affect the criminal nature of the act. 

Under the provision of the Penal Code (§ 21) proof of partial or 
incipient insanity is not sufficient to require an acquittal, if there was 
stUl the ability to distinguish between right and wrong. 

Mania is a condition of exaltation which affects the emo- 
tions and the intellect, and expresses itself by increased activity 
— mental and physical. 

There are two forms to be considered, one in which there is 
mere excitement and the other in which this has passed on to 
frenzy. It is the reversal of the picture of melancholia; there is 
a rapid succession of ideas, and never a fixed idea. 

The feeling of well-being and power is as well-defined in 
mania as the sense of a depression, which it is impossible to ex- 
plain or throw off, is in melancholia. We have to do, how- 
ever, with an entity in both instances distinct from the depres- 
sion or exaltation which may accompany other well-recognized 
forms of mental disease. 

Mania rarely commences suddenly, it is usually preceded for 
some time by feelings of depression or irritability, with indiffer- 
ence to the usual interests of daily life. 

This depression soon changes to one of exaltation with a 
resistless impulse to activity in all directions, without, however, 
persistence in any one thing. The attempt to restrain the 
patient provokes opposition, he feels satisfied only when per- 
mitted to talk and act as he pleases. Esquirol defines mania 
as " a chronic affection of the brain, ordinarily without fever, 
characterized by the perturbation and exaltation of the sensi- 
bility, the intelligence, and will." 

Hallucinations, illusions, and delusions are usually pres- 
ent, the patient seems to have lost all restraint over his 



MANIA. 325 

thoughts and actions. He appears to be in relation with an- 
other world, entirely apart from his environment. He holds 
conversations with various imaginary persons. His delusions 
may take the form of grandeur, in which he thinks he is the 
greatest athlete or pugilist in the world, or that he possesses 
great wealth, or again, that he is the ruler of the universe. 

If the feelings go in the direction of sexual desire, there 
may be evidence of marked eroticism, and the speech may be 
obscene. This is frequently seen in those whose whole educa- 
tion has been directly the reverse. 

Combined with this, delusions of a religious character are 
often present, direct commands from God are received, and a 
change in the personality may take place. 

There is often the appearance of being under the special 
influence of some delusion, as in the position assumed of 
listening to some voice, or seeing something invisible to others 
(see Fig. 15). The special senses are especially acute, and 
general sensibility, as shown by thft irritation caused by the 
clothing and the desire to remove anything that might cause 
restriction of the movements. The intellect seems at times 
peculiarly active, attention is fixed for the time intently on 
the object before it, and the memory of details is sometimes re- 
markable. There is, however, a real loss or decrease of mental 
power. The judgment is weakened, as no idea remains long 
enough in the consciousness to become fixed. The most notable 
symptom is loss of control, with great emotional excitement. 

The physical condition seems to be an index of the mental. 
There is in the early stages an appearance of vigor, the appetite 
may be excessive, and a tendency to the use of alcoholic stimu- 
lants may precipitate the attack, while not being an etiological 
factor. 

Many such cases bear a close resemblance to alcoholic mania, 
when on investigation it has been shown that the mental dis- 
turbance preceded the drinking. 

There is always, however, finally a failure of nutrition with 
loss of flesh, the tongue becomes coated and the bowels are 
constipated. The pulse may be somewhat rapid, but frequently, 
even during great excitement, there is little change, it often 
being slow and small. Insomnia is a marked symptom, days 
passing without sleep despite the ceaseless activity. 



22(3 



INSANITY — FISHBK. 



There is one peculiarity about this constant activity, in that 
there seems to be no sense of fatigue accompanying it. There 
is, in fact, apjjarently a cerebral anaesthesia. This applies also 
to pain ijerception, as exposure to cold does not seem to be rec- 
ognized, and even painful operations can be carried on without 
apparent suffering. Acts of self -mutilation, which are espe- 
cially common where sexual disturbance is associated with the 
mania, are often done, which are harrowing in the extreme and 
yet are not appreciated by the patient. 

In one case under observation the attempt was made to cut 
off the testicles ; the patient in describing the act had no reah- 
zation that it was painful. The absorbing idea at the time 
precluded any other perceptions entering into his conscious- 
ness. 

The special forms are acute and chronic. In the former 
we may have actual frenzy, corresponding to the so-called 
raving madness. In such cases there is complete mental con- 
fusion, all knowledge of time and place is lost, no attention is 
given to what is going on around, one delusion foUows after 

another, the patient being in 
a state of muttering delirium. 
Such conditions are common 
in acute fevers, but the pres- 
ence of a high temperature 
differentiates them. There is 
great exhaustion, probably 
due largely to the loss of 
sleep (see Fig. 15). 

In chronic mania there is 
generally present some more 
or less fixed delusion, as the 
result of the previous delu- 
sional state. Thepatientmay 
consider himself a king or a 
great general. There is never, 
however, anj^ attempt to 
prove the truth of this belief; 
it is satisfactory to him to make the assertion. There is no in- 
congruence in the fact that he is in an asylum or dressed 
poorly. These patients are very excitable at times ; it is purely 




Fig. 15. — Maliia, Acute. There is f 
here of considerable excitement, and an lial- 
lucinatiou of hearing, as shown by the atti- 
tude of apparent listening. 



MANIA. 



237 









iSf 



an emotional state, however, which is easily aroused by some 
trivial irritation and usually as quickly subsides ; there is apt to 
be a quick response 
by a blow or a tor- i 
rent of abuse. (See 
Fig. 16.) 

These patients 
are great letter- 
writers, the prod- 
uct being a con- 
fused, incoherent 
mass of material, 
every passing 
thought being re- 
corded. There may 
be a tendency to 
write rhymes. 
There is almost 
always associated 
with this condition 
a generally happy- 
go-lucky state of 
mind. There is in 
fact more or less dementia, the state toward which all cases 
tend which do not end in recovery. 

The following poem and letter taken from hundreds written 
by the same patient show very clearly the mental condition re- 
ferred to : 

Lines on The Wreck ov the British Man-of-war "The Ser- 
pent"— On THE Coast of Spain on Nov. 12th, 1890— A. D. 

O Spain of Royal fame ; 

What occured on the main. 

Or Has the serpent and all his fangs ; 

Left the ocean on thy land he sprang- 

Or is thy monarch in his bibbs so short 

Thy shores invaded for war or extort — 

Thy infantile sway both night and day 

To thy Savour ever, ever pray 

To be saved from such a fate 

As befall the serpant of late 



Fia. ]6.— Chronic Mania.— Hallucinations of Siglit. Fe- 
male, set. 34, married, addicted to alcohol and morphine; 
has delusions of being followed by strange people who wish 
to kill her. Is passing into stage of dementia. 



2,'28 INSANITY — FISHER. 

Her Britanic majesty st monarch pure 
Would not envy thee in thy craddle sure — 
For in the days eer mans estate 
O'Donnell Euled thy dominion to date — 
Thy Royal Mother Queen Christina 
To Queen Victoria sends a line — 
With greetings from Her monarch son. 
Hail Queen Victoria my day will come 
When in kingly state I'll not write on slate 
But in languarge thy mariner I'll berate — 
Thy sailors Joyous, marines, and Jackets Blue — 
In Neptunes embrace all are strew. 
In numbers a hundred and seventy three 
AH are prisoners, and three are free — 
God in His power that rules the weeve 
Defend the defenseless, and bless the brave 
Many are the weeping eyes on english Shores 
Bereft of fathers laid in their Watery gore — 
Lunatic Asylum Wards Island 

U. S. America 16th Nov 1890, A.D. 
Count The O'Haughey X O. P. 
Lord and Poet to 
Queen Victoria — By Pope Leo XIII. 
Alfonso XIII. The O'Haughey XIIII. 

Ward's Island, State and City of New York, and U. S. of America- 
January 16 1891, An. Dom. 

I am The O'Haughey to P. D. D. M. D. M. America, late Sergeant 
and Hereditary chief of the Royal Irish Constabulary Ireland 36238 a 
Knight of the Garter and Coromander of the Bath and Hereditary 
Knight of St. Patrick Erin. Under all these circumstance I want 
Prince Thomas to bear all these titles each and every one them legally 
and constitutionally. I now put them in a row, so that they may not 
be confounded by the illiterate or inexperienced — or not know how to 
fix these titles or show the respect due to the wearer — : 

O. P. D. D. M. D. F. L. R. C. Q. C. V. C. S. L. B. A. &c., Ac- 
Sergeant at law and attorney General — and K. C. B. and Knight of 
St Patrick and Hereditary Prince of the Universe by the Eoman 
Pontiff — and by the special direction of the Blessed Virgin — and now I 
am The O'Haughey chief of R. I. C. 

"Are you there Moriarty." 

We have excluded from our description of mania a condi- 
tion called delirium grave, or delirious mania, as it represents 
an entirely diflEerent disease both in its clinical and pathological 



MANIA. 



229 



aspects. In our classification it is placed under the head uf 
organic insanities with definite pathological changes. Clinically 
also it is distinct, generally running an acute course with a 
high temperature of 103-106°, and, as a rule, ending fatally from 
exhaustion in five or six days (see Fig. 17). 

We also do not include here the special manias, associated 
with epilepsy, alcohol, the menstrual periods, etc., as their 
description belongs more properly to those special diseases. 

Criminal acts are rarely committed in mania; the general 



' • 


/ 




\ 




10 


<B»- 


m 




m 


^ 


K^ 






^m 


^%>*.,^ 






dW/' 


^^ 






^m'. 


.{^M^^s^^A 



Fig. 17.— Chronic Mania. T. O. H., fet. 30, single, no hereditary history ; admitted to 
hospital October, 1890. Had delusions that he was married spiritually to the queen of 
Heaven. Says that she appears to him and speaks to him by signs, never in words. Says 
also that he is the Poet Laureate of England, and a count by Pope Leo XIIL, etc., etc. 
Patient frequently asks whether any telegram has come from his royal highness for 
him. This case presents all the characteristics of chronic mania, e.g., the loquacious- 
ness and tendency to letter-writing and to poetry ; his condition has remained practically 
unchanged for five years. There is an expression of self-satisfaction in his face, depend- 
ent upon the absolute belief in his claims to royalty. 

disturbance of the intellect renders it impossible to carry out or 
form any plans. During the paroxysm of delirium to which 
the patient is sometimes exposed, there ma}^ be as a consequence 
acts of violence and destruction committed. In such cases the 
knowledge of the facts is sufficient for the appreciation of their 
character. 



230 INSANITY — FISHER. 

STXTP0R0X7S INSANITY OB PRIMARY DEMENTIA. 

It consists in an almost complete loss of all mental action. 

There may be hallucinations and delusion of sight and hear- 
ing. The patient appears to be under the influence of some 
overmastering spell. No notice is taken of the surroundings; 
there is no appreciation of the wants of nature; hunger or cold 
is not felt. One position may be taken and maintained for 
hours. A cataleptic state is not uncommon. 

While the attitude seems to be that of despair or melancholia 
to a certain degree, it represents more fully a condition of 
absolute loss of all mental action. New perceptions certainly 
do not take place, and no thought goes on. However, at times, 
from the movement of the lips and the muttering, old memories 
are apparently revived. Rarely is there any recollection of them 
after recovery. 

The physical state corresponds to the mental, the tempera- 
ture is lowered, the pulse, is feeble, the skin dry and cold, the 
pupils are dilated, loss of flesh is constant. It is essentially a 
condition of asthenia. The causes of this disease are those of 
an exhausting character, as loss of blood from any cause as 
during childbirth or shock consequent to an operation or in- 
jury. Fevers of an exhausting nature with high temperature 
may result in it. Mental anxiety and worry may cause it. I 
have observed a number of eases among immigrants to this 
country. Finding themselves among new surroundings, with- 
out friends or means of support, confused by the strangeness of 
the customs, or perhaps by a strange language, they sink into a 
condition of almost complete dementia. The onset appears sud- 
den, although as a rule the cause has been at work for a long 
period. Masturbation in a person weakened by various other 
causes or of a neurotic disposition may be the exciting cause. 

Heredity otherwise does not seem to be a direct agency in 
itsiproduction. 

Direct injury causing concussion of the brain may result in 
a traumatic psychosis, sometimes called traumatic hystero- 
neurasthenia. There seems to be an interference with the func- 
tional activity of the brain, an inability to think or act, a feel- 
ing of great fatigue on attempting to do anything. There may 
be great stupor with loss of personality. 



SECONDARY DEMENTIA. 



231 



The prognosis in these cases is usuaUy favorable. Of late 
years many such instances have been brought before the courts, 
the question of simulation or exaggeration of the symptoms 
being a difficult one to settle. 

In the criminal procedure these cases do not often appear, 
but are more frequent where the question of civil responsibility 
arises. Shock from fright, some sudden and unexpected loss, 
has been known to cause complete dementia accompanied by 
stupor. The condition maj' continue for weeks or months, or 
may even pass into secondary dementia. 

Secondary dementia is the form which generally pre- 
sents itself to us. It is the final result in all cases of insanity 
which do not progress toward recovery (see Fig. 18). 

In the various forms which we have so far considered it 
is not unusual, 
about forty per 
cent passing on 
to this state. 

Complete de- 
mentia would 
imply an absence 
of all thought, 
and while this is 
not the rule, we 
notice a decided 
loss of mental 
power. There is 
usually a substra- 
tum of the delu- 
sions which have 
been present in 
the acute condi- 
tions, which have 
become more or 
less fixed and 
permanent. The 
melancholic still 

possesses the feeling of being a great sinner. He may still be 
constant in prayer, although hopeless of pardon. An egotism, 
which centres everything around his own personality, is al- 
III.— 17 




Fie. 18.— Secondary Dementia followini? Mania. R. F., set. 
53, female, widow; duration of disease 1.5 years. On admis- 
sion was inclined to be ugly and obstinate, and liad delusions 
of wealth and self-importance. 
flLiiet and rarely speaks. 



Present condition, dementia; 



232 



INSANITY — FISHER. 



ways observed. With the gradual, or at times rapid, dementia, 
the identity becomes lost, the idea of time and place becomes 
confused, the relations of his previous life become vague and 

indistinct to his 
memory ; he 
speaks of his chil- 
dren or wife as if 
he were relating 
some instance 
concerning a 
stranger. 

The maniacal 
patient contin- 
ues with his hal- 
lucinations and 
delusions, which 
are always of an 
expansive char- 
acter. He speaks 
of being a rich 
man, or a great 
general, or God 
himself, with a 
certain pleasure, 
evident in his ex- 
pression that he 
All idea of time and 
Responsibility is ab- 




Fig, 19. — Secondary Dementia following Acute Melancholia. 
E. M. , female, set. 40 ; duration of disease 12 years. On ad- 
mission was depressed, remaining in one position, indifferent 
to her surroundings. At times is violent and has delusions 
of being the daughter of Queen Elizabeth. 



is able to talk and think so rapidly, 
place is likewise sooner or later lost. 
sent, reckless disregard of consequences is evident; the lan- 
guage is often profane and obscene. The actions are restless 
and apparently unceasing, but aimless. All acts are impulsive; 
it is impossible to think of motive or premeditation in the true 
sense. Affection or regard for family or friends is lost, and the 
ordinary observances in manners are forgotten. These patiente 
when examined are apt to exaggerate all their vagaries, giving 
loose rein to their actions and thoughts. 

Unless there is complete dementia, the character of the ex- 
isting delusions defines the nature of the preceding disease (see 
Fig. 19). 

While these cases may remain for j'ears under observation, 



SECONDARY DEMENTIA. 233 

and while there may be changes in their mental power, they 
have still in the main the same class of delusions in the end as 
in the beginning. 

It is so in cases which relapse after recovery. The new seiz- 
ure is frequently but a repetition of the previous hallucinations 
or delusions. We do not find on our records that the patient 
has been admitted at one time as melancholic, at another as 
maniacal. 

The condition known as alternate or circular insanity is an 
exception to these remarks. The peculiar fixed and permanent 
delusions which may manifest themselves in a changed person- 
ality, as in the belief of being a general or king, may be shown 
by the attempt at decoration with medals or ribbons. While 
claiming to be such great personages they feel no incongruity 
in their existing surroundings. There is no desire or attempt 
to explain or logically to support their delusion, as seen in the 
following case. 

A. B., set. 62, became melancholic and possessed with the delusion 
of persecution, fearing that he was to be shot. He applied to the police 
for protection and was sent to the asylum. His dementia progressed 
rapidly ; he was unable to state where he was or where he had formerly 
lived. He later had a delusion that his friends, to compensate him for 
his suffering and persecution, had raised $100,000,000 for him, and that 
it was subject to his draft at any time. He could not be reasoned out 
of this belief. His plans of using the money were in consonance with 
his previous religious delusions of self-condemnation, as he intended 
to give it to the churches. 

Such delusions differ entirely from the systematized delu- 
sions observed in the class of monomaniacs or paranoia. In 
these there is always a logical train of reasoning ever ready 
for the defence of their opinion. The emotional states are 
rarely so marked. Excitement may indeed be extreme if there 
is opposition to the carrying out of the plans — otherwise not. 
The same may be said in regard to depression : this is rarely so 
extreme as to manifest itself by marked melancholia with com- 
plete loss of all interest in external matters. There may be 
indeed suicidal intent, but then again it is the result of a proc- 
ess of reasoning never present in melancholia or in the dementia 
following it, with permanent delusions of a depressive charac- 
ter. There is almost invariably the history of hereditary or 



234 INSANITY — FISHER. 

acquired disease in those with the systematized logical delusions 
of paranoia. A good example of secondary dementia in melan- 
cholia is seen in the following instance : 

C. D., merchant, set. 51, family history negative. Patient has been 
a very active business man, and has amassed a fortune. He has, how- 
ever, been addicted to excess in the use of liquor, and in his sexual 
relation. In the past year he has had severe domestic trouble, which 
has caused much loss of sleep and anxiety. He resorted to Uquor to 
drown his sorrows. One year and a half ago had a severe attack of 
delirium tremens, from which he recovered, but has never since been 
able to carry on his business with the same vigor or efficiency as pre- 
viously. His judgment became unreliable and his memory defective. 

Two months previously, after considerable mental worry and some 
excess in alcohol, he became depressed and filled with hallucinations, in 
which he saw a two-headed monster which attempted to kill him ; also 
the porters and servants in the hotel appeared to him as threatening to 
do him harm. Patient would hold imaginary conversation vrith them. 
He became sleepless and refused all food, fearing that he would be 
poisoned. He interpreted all these terrors as a punishment and conse- 
quence of his previous life. He had no religious delusions of any kind. 
The depression increased, accompanied at times vsdth violence in his 
attempts to escape from his surroundings. He gradually passed into 
a state of dementia, which became almost complete, the patient for- 
getting the day of the week, the place in which he was, or any knowl- 
edge of his business affairs. All anxiety disappeared. He would eat any- 
thing placed before him ; seemed to have entirely lost all idea of the 
proprieties ; would urinate at any time and place, as the desire prompted 
him. 

The question from a legal point of view in this instance arose only 
as to his capability to enter into a business contract or to make a will. 
When aroused the force of habit made his conversation and actions 
apparently rational for a short period of time. Any attempt to state 
what his property consisted of, and to whom it should go, led to com- 
plete mental confusion. It was plain that the requirements of a dis- 
posing mind, as in the making of a will, were absent. Here also the 
question of undue influences would probably arise. 

Secondary dementia may be of two varieties, i.e., associated 
with agitation or with apathy. 

The jBrst form is more commonly the result in mania. 

Here we find almost ceaseless activity, a marked tendency 
to destruction of anything which comes into their hands. 
There is no motive present, but an aimless, objectless activity. 
Anything attracts their attention for the time, bright colors, 



SECONDARY DEMENTIA. 



235 



music, etc., but there is never anj' concentration on it for any 
length of time. There is no real joy or sorrow. All serious 
relationship with the outer world is lost. There is usually 
marked loquaciousness, a constant talking concerning innumer- 
able subjects, a change from moment to moment in the emo- 
tional field from pleasure to anger, an almost constant obsti- 
nacy to do as they please. Various hallucinations and delu- 
sions are present, as evinced by the expression of cunning or 
slyness or of self-importance shown in the face. Yet with all 
this activity there is complete loss of any appreciation of their 
circumstances. There is little feeling or regard for their near- 
est relations, a visit from whom causes but a transient evidence 
of pleasure. Their acts are all impulsive. 

They are subject to excesses of maniacal excitement, when 
their mental powers seem to be revived, their delusions becom- 
ing more exact, and their acts more purposive. These conditions 
are simply flashes from the pan, the tendency being toward 
relapses into more complete states of dementia. A final 
characteristic symptom is the disappearance of all the former 
hallucinations and delusions, or at least the absence of any influ- 
ence on the individual when present. They lead to no act on 
their part; there is no pressure to carry out any plan as the 
result of their feelings and thoughts. A condition of partial 
dementia may exist for years without apparently progressing 
to the final stage, although its terminal stage is sure to follow. 

The recognition of this state of dementia is at times difficult 
when the previous history is unknown. The continued obser- 
vation, however, of increasing intellectual weakness, decreas- 
ing emotional powers, increased loss of appreciation of the ordi- 
nary relations of life, and responsibility or care for any of its 
interests, with neglect of all the ethical and social considera- 
tions, indicate without question the final state of complete 
loss of mental activity, i.e., dementia (Krafft-Ebing). 

The description just given applies most truly to mania, but 
is not infrequently observed in melancholia. 

Feelings of mental anxiety, un explainable even by the 
patient himself, are apt to recur in the dementia of melan- 
cholia; in fact, a recurrence of the early stages is more common 
in all respects than in mania. We observe, therefore, a rest- 
lessness, a ceaseless attempt to escape from the unbearable men- 



33(5 INSANITY— FISHER. 

tal state. This may take the form of violence of a homicidal 
character, or, again, be suicidal in its nature. 

There is rarely any plan in these acts, the motive is a gen- 
eral one rather than a specific one, and at no time is there in 
any sense a conspiracy. It is rare, indeed, that in insanity 
there is any combination for carrying out a design, except 
perhaps in paranoia, and even in these instances it is rare. 
The absence of real motive or of the attempt to conceal or es- 
cape from the consequences of the act, while not positive evi- 
dence in a legal sense of the irresponsibility of the individual, 
necessarily has great weight in disproving criminality. Doubt 
can only arise where the dementia is but partial. 

The question of the knowledge of right and wrong in regard 
to the particular act committed is the only practical test which 
the law can make ; the further question whether the person was 
able to control his acts is of importance only in so far as it can 
be established by evidence that all knowledge of right and 
wrong was absent or lost at the time the act was committed. 

This does not involve at all the question of moral or impul- 
sive insanitj'' ; for in these cases the acts are never impulsive, 
except in so far as they are random and purposeless, or a gen- 
eral result of the mental confusion induced by some oppressive 
influences driving the individual to attempt to escape from it, 
as in melancholia, or as in mania induced by the continuous 
weakened mental activity of a purposeless nature, which even 
to the patient himself often appears as an abnormal, unnatural 
condition. This is seen in the often gradual loss of identity, 
the life and experience of the past seeming to belong not to 
themselves but to another individual. 

This condition differentiates itself from the remissions of 
either melancholia or mania by the fact that the intelligence in 
the latter is restored during these so-called lucid intervals, 
while behind all the evidence of the disturbances of the emo- 
tions and the presence of the hallucinations in dementia is seen 
the defect of the intellect. All attempts at judgment or opinion 
or reasonable action are impossible. No business can be carried 
on, no plan formed. 

Dementia with apathy is more commonly the result in 
melancholia than mania. We frequently find at the basis of 
this profound interference with all mental activity a fixed perma- 



HALLUCINATORY MANIA. 237 

nent delusion which controls and dominates the individual, 
preventing the entrance of any outside or new perceptions 
into consciousness. It is as if some cerebral compression was 
present, which if removed would permit the mind again to take 
up its functions. This idea is supported by the fact that in 
some rare instances, even after years of absolute passivity, dur- 
ing which the patient has apparently been unconscious of pass- 
ing events, of time or locality, after some sudden shock, as an 
acute illness, i.e., pneumonia, or again without any apparent 
cause there is a return of the mental powers. In many such cases 
there is a more or less complete knowledge of the past events. 

There is this to be noted, that the depression, the condition 
of mental or psychical pain, is no longer of such an acute char- 
acter. There is that condition previously referred to, as if 
all the events through which they pass were occurring to a 
third person. There is here also often the tendency for a stay 
in the progress of the dementia. However, the final stage is 
the same in all, interrupted as it may be by seizures of acute 
depression and anxiety — complete abolition of mind results if 
life is prolonged. The physical appearance corresponds to 
the mental. The vegetative processes are impaired. With 
the absence of active mental processes there is frequently a ten- 
dency to obesity, the face appears vacuous, differing from the 
characteristic expression of worry, with the lines of care on the 
forehead so generally present in the agitated form. There 
seems to be complete muscular relaxation ; the patient falls into 
an inert mass ; the position is one of flexion ; the chin sinks on 
the chest ; the saliva flows unnoticed from the mouth. 

As has been said, with " the loss of all mental action they 
appear as animals after the removal of the brain, and in fact 
the cortex of the brain has lost its function." They no longer 
appreciate danger, hunger is absent, requiring the necessity of 
feeding them, and in fact looking after all their wants. There 
may be indeed a true amnesic aphasia. Death results from a 
general defect of bodily nutrition ; and intercurrent diseases, as 
pneumonia, are common. 

Hallucinatory mania (Mendel), delusional stupor (New- 
ington), or hallucinatorischer Wahnsinn is an acute mental dis- 
turbance, the characteristic condition of which is the hallucina- 
tions and illusions of all the special senses. As a result there 



238 INSANITY— FISHER. 

is a complete loss of identity and of time and place, a mental 
confusion almost approaching acute dementia. 

There are no delusions in the proper sense of the term. It 
is essentially a disease consequent upon exhaustion. Therefore 
any cause, as exhausting fevers, inanition, overwork, alcoholic 
excesses, sexual excesses, the puerperal period, loss of blood, 
etc., may be the provoking agent. These are all accentuated 
in those hereditarily affected or of a neuropathic disposition. 
Hovpever, a distinction should be made between this disease 
and the acute forms of paranoia. Maschka, in my opinion, 
confounds what he terms primary paranoia, a primary psy- 
cho-pathological state, with this disease. If we hold fast to the 
idea, as will be discussed later, that all forms of paranoia are 
due to degenerative conditions, either inherited or acquired, 
we can separate without difficulty the two forms of insanity. 
Acute conditions may arise in paranoia, but when they subside 
we still have left the original defective mental condition ; while 
in hallucinatory mania, if that is recovered from, the patient 
returns to his normal mental soundness. It is essentially a 
disease, therefore, involving the affective or emotional element 
of the mind, and only secondarily the intellectual. Reason and 
judgment are for the time absolutely in abeyance, simply be- 
cause the numberless new and erroneous perceptions do not 
allow of any proper conception of them to take place, or, again, 
may crowd out former perceptions. The mental confusion may 
be increased by the attempt on the part of the patient to recon- 
cile the new and the old perceptions. 

The course of the disease may be rapid, lasting but a few 
weeks or months, and ending in recovery. Other cases pass on 
to complete dementia. 

The division of mental disturbance falling under the head 
of degeneration is one of the most important which comes to 
the attention of the jurist and physician. 

It is, as we have said, a disease of the brain without well- 
defined pathological changes, but in which the element of 
heredity with all its attendant predispositions is the most im- 
portant factor. 

Into this question to-day comes the discussion of many of 
the social conditions of our generation. The criminal, the 
anarchist, and socialist, all have their defenders as irresponsi- 



PSYCHICAL DEGENERATION, 239 

bles in relation to the crimes which they may commit. Per- 
haps no more important psychological considerations in their 
bearing on legal relations exist in the whole domain of insanity 
than in this 'class. It has been said that general paralysis is 
the distinctive disease which the exigencies of modern life have 
developed ; and while this is true to some extent, it is equally 
certain that the development of the wealth of the world, to so 
great a degree by modern scientific discoveries, the possibilities 
of the individual in sudden acquisition, together with the free 
discussion of all possible subjects of thought in the religious 
and philosophical fields, without the usual limits of control 
formerly allowed to the Church and established schools, have 
developed an egotism and idea of self-importance which espe- 
cially manifest themselves in the congenitally defective classes. 
This would probably have been held in check under strong cen- 
tral control, but the spirit of equality and frequently license 
thus evoked in the weak, and especially the ignorant, has devel- 
oped one of the characteristic symptoms of insanity as a whole 
—that is, concentration on the individual, or egotism. In our 
classification we have called this affective insanity, that is, 
a form in which the feelings and emotions are chiefly involved. 
We have to do with the desires, therefore, with the ethical side 
of human nature, and hence the whole field of the social and 
moral relations of the individual to his surroundings is in ques- 
tion. The judgment; the reason, is not so much affected ab- 
stractly; the mind as a reasoning organ is often but slightly im- 
paired ; actually it is so far affected in that the emotional state 
exerts such a control over the intellect that it no longer is free 
to use its powers, and as a result we find more or less impair- 
ment of the will in all these cases. 

The degrees of loss of free-will is the question for the 
jury to decide ; the fact that it is impaired is for the expert to 
establish. 

We find that the etiological factors are especially of an 
hereditary character. Either in the parents or in collateral 
branches of the family there were insanity, nervous diseases as 
epilepsy, chorea, hysteria, etc., or not uncommonly alcoholism, 
tuberculosis, etc. Again, during early life various deleterious 
causes may have been active in impairing the nervous system, as 
rachitis, which may have interfered with the development of the 



240 INSANITY — FISHER. 

skull and secondarily the brain ; or, again, acute diseases, as men- 
ingitis or encephalitis or the various acute exanthematous 
fevers, as scarlet fever or measles. In such cases we often find 
evidence in the body of defective organization, as in various 
asj'mmetries of the head. The ears may show evidence of 
irregularity, the eyes be placed too widely apart, the forehead 
be markedly receding, the palate high. We are now approach- 
ing indeed a class of degenerates which belong to the so-called 
borderland of insanity. There is evidence from the previous 
history of their departure from the normal type, but often in- 
sufficient proof of irresponsibility. 

There is no definite pathological condition which we can 
properly say belongs to it, except perhaps in those cases where 
we have evidence of injury to the brain structure from inflam- 
matory disease, mal-development, or traumatism. And these 
instances are largely in the minority, and when excessive cany 
our case to the class of idiots or imbeciles in which we have 
predominant ethical defects or primary moral weakness. We 
can and should in these cases recognize the actual intellectual 
impairment which prevents the individual from controlling the 
natural desires common to the brute creation. 

Kraflft-Ebing has classified the physical and psychical evi- 
dence of this diseased condition as follows : 

A quick reaction to all influences, whether atmospheric or 
those of disease; special inclination to various functional dis- 
turbances of the nervous system as convulsion, the various neu- 
roses, etc. , at the periods of development and decline (dentition, 
puberty, menstruation, climacteric period) . 

There may be a very early development of puberty and a 
mental precocity with slight bodily development. The sensory 
and motor fields show disturbances by hypersesthesia, anes- 
thesia, paralysis of a functional type, spasmodic contractions as 
chorea, epilepsy, or epileptic seizures. The sexual organs are 
either functionally abnormally active or the reverse, leading 
to masturbation and sexual excesses of various kinds. 

Similar mental disturbances of a functional character are 
present. Especially noticeable is the tendency, on slight provo- 
cation, to conditions of depression and excitement, which pass 
beyond the normal expression of pleasure or joy. Physiologi- 
cally all are subject to emotional states of depression and exalta- 



REASONING INSANITY. 241 

tion. Women at the menstrual periods and during pregnancy 
or lactation, and males are likewise subject to these periodical 
changes. At such times there is especially marked and noticed 
the ability to undertake a great amount of work, at other times 
there is (in both sexes) a condition almost of stupor and mental 
torpor. Among this diseased class, however, there seems to be 
no middle ground. In the exalted period there is a constant 
ceaseless activity in which often impulses of almost an " imper- 
ative" nature are present. The opposite condition of depression 
is characterized by equally intense mental pain and impulses 
to suicide, or a great fear of becoming insane. A special 
group of this form of disease is that class where the ethical 
part of their nature seems absolutely absent. Feelings of pity, 
right, honor, ordinary courtesy and consideration apparently 
do not enter into their minds. 

The imagination is active, hallucinations are common, and 
there is especially noticeable the rapidity of their association of 
ideas. In art and science they may show themselves as inven- 
tive, but the mental process is intuitive rather than logical, 
and is rarely persistently followed out. There is constant pres- 
sure, often impulsive, to acts eccentric and bizarre. 

Morel has described them as acting by instinct rather 
than reason. 

There is a contradiction in their character — apparently great 
mental power, even genius, with inability to get along in life ; 
they are the victims of grand schemes constantly formulating 
themselves without definiteness, and an inability to reproduce 
them accurately. They represent often our class of reformers, 
religious and political, and go to make up, as we have said, a 
large proportion of our leaders in social reform. 

The physical bearing, the manner of dressing, the egotism 
often indicate the mental condition. This mental state may 
remain unchanged for years ; the predisposition, however, on 
slight provocation to insanity is self-evident. Unfortunate 
financial condition, family loss, domestic trouble, failure to 
obtain, political preferment, ill health, and excesses, venereal 
and alcoholic, may be the exciting cause. 

Among the first of the various subdivisions of this class 
of the insane that we shall consider is reasoning insanity, or 
folie raisonnante. 



24a INSANITY — FISHER. 

It may assume the maniacal form or the melancholic, but 
more frequently the latter. Their acts imply a controlling in- 
terest, forcing them, despite their knowledge of the character of 
the act and its consequences, and often their fear of committing 
it, to do it. There is usually an absence of hallucinations or 
delusions. 

Griesinger defines the depressive form as hypochondriacal 
melancholia, the French authorities as folie raisonnante me- 
lancolique (Tuke). In these cases, however, there is a distinct 
difference from melancholia, either in the acute or in the 
chronic form. The depression is more of an emotional charac- 
ter, and rarely gives the impression of delusions, which, as we 
have said, are usually absent. Again, the condition, which is 
generally constant, so that the patient feels its presence whether 
at a place of amusement or alone, is not always as intense but 
occurs paroxysmally or even periodically, as during menstrua- 
tion. It differs, again, however, from so-called periodical 
insanity, although closely allied to it, especially in its etiolog- 
ical and pathological relations. Both occur in hereditary dis- 
ease, but the latter has a more typical course either of mania or 
melancholia, during which the intellectual faculties are affected. 

We have thus under this head reasoning mania, reason- 
ing melancholia, reasoning monomania, for it seems proper 
to include here all those forms of mental disorder characterized 
by desires, often obscure and impulsive to a certain extent, 
which manifest themselves in acts often cruel, indecent, or fool- 
ish. The individual understands what he is doing and the 
true relation of the act, in its social and legal aspect. He, 
however, prefers the consequences to the restless, unhappy state 
of mind which exists, until he has carried out his desire. This 
mental state must be recognized as a pathological entity, and 
belongs to the legal aspect of the question of insanity fully as 
much as to the medical ; in fact more so, as it rarely comes under 
consideration except in so far as the acts committed offend 
against the law. It is usually in regard to criminal procedure 
that we meet it. 

" These terms are given to each particular form of insanity: 
mania, melancholia, monomania, respectively, when still ac- 
companied by reasoning power, though the ordinary mental 
symptoms are evident " (Tuke). 



MORAL INSANITY. 343 

Moral insanity is simply a division of the form just de- 
scribed. We haye to do with mental defect especially charac- 
terized by the absence of the ethical side of man's nature. This 
was the last attribute to man's mental structure which we re- 
ferred to in describing the process of development of the mind. 
In these cases, therefore, we find loss of the ordinary feelings 
of love toward family or mankind in general. Ideas of honor, 
truth, sacrifice or regard for others are absent. Desire is the 
only motive for all their acts ; when therefore unrestrained by 
fear of punishment or by some power greater than their own, 
there is no limit to the cruelty or evil of their acts. This is not 
infrequently seen in the great tyrants of history, as Commodus 
and Nero, types of degeneratives so common during the degen- 
erative periods of Eoman history and which illustrate this 
point. Our criminal classes belong to this same order. 

Investigation has shown that the hereditary taint has been 
carried down for generations with the same tendency to crime 
as other forms of mental disease. There is, indeed, intellectual 
defect, although not necessarily manifested in the ordinary 
processes of thought. It is observed rather in the lack of idea 
of consequence, the apparent disregard for those things which 
are by most men held as valuable, i.e., respect, position, even 
wealth, if as its accompaniment any restrictions are added. 
This form of insanity is not infrequently associated with sexual 
excesses in which there may be perversion, the pain inflicted 
being the means of producing venereal excitement. 

Definition of Moral Insanity. — A disorder which affects 
the feelings and affections, or what are termed the moral 
powers, in contradistinction to those of the understanding or 
intellect (Pritchard). The diagnosis depends largely on the 
previous history of the individual. The fact that one from 
several children under the same moral teaching and restraint 
has always shown a tendency to be obstinate and unruly, has 
been beyond control, and has developed tendencies to excesses 
of all kinds, often indeed of a petty nature, as thieving, drunk- 
enness, etc., is strong evidence of congenital defect. 

There is always some difficulty in distinguishing such 
cases from those which merely represent depravity, and in 
which punishment and discipline are salutary. This is illus- 
trated again and again in our reformatories. The former class 



344 INSANITY — FISHER. 

are incapable of being reached by any influence ; training, edu- 
cation, religion making no change in them. They show no ap- 
preciation of kindness or regret for their acts, which they may 
be cunning and skilful in concealing or planning. 

The depraved, from lack of proper surroundings and educa- 
tion, will usually benefit by these systems. Delusions are usu- 
ally absent, but I have observed in a number of cases delusions 
of persecution ; nor is it to be forgotten that the so-called psy- 
choses, as melancholia and mania, may affect these defective 
persons, running their usual course, leaving them perhaps more 
demented but with the same tendencies as before. The condi- 
tion is essentially an incurable one. Its degree is the only point 
of interest as affecting the question of responsibility. The fol- 
lowing case illustrates it very well : 

A. B., set. 26, male; parents healthy; one brother very musical, in- 
terested in nothing else ; very nervous ; one sister very similar in her 
disposition and also very musical. The patient was always unruly, 
would play with the roughs of the neighborhood and frequented 
saloons; was never a good scholar, but was good at figures and could 
keep accounts well . At the age of 17 was arrested for maliciously robbing 
a grocery shop. There was never at any time any need of his stealing, 
as he had a good home. Was sent to a reformatory, where he remained 
for some time, and shdwed the same disregard for discipline and was 
constantly guilty of mischievous acts. He was then transferred to the 
asylum at Auburn for insane crimiafils. On his release he resumed his 
former habits of living, associating with criminals and drinking to 
excess. He passed some months in an insane asylum again. He now 
has delusions of persecution ; hears voices calling him opprobrious 
namies. Is unable to escape from this mental state and at times becomes 
violent in his effort to free himself from his supposed oppressors. 

Impulsive Insanity.— Under this head we are dealing 
with similar mental states as those previously described. The 
mental condition is not diflScult to recognize as the act defines 
it. The question of civil and criminal responsibility is not so 
easy. We are on the borderland of sanity. Here again care- 
ful investigation will usually show that hereditary influences 
are of the greatest impoi-tance in aiding us in the diagnosis. 

In all forms of insanity, especially, however, where we have 
exaltation or excitement, there is a tendency toward impulsive 
acts ; even in melancholia this is observed. This is, however, 
due to the loss of control, induced by the generally impaired 



IMPULSIVE INSANITY. 245 

intellectual state. There is, however, in impulsive insanity an 
irresistible impulse to the act, a feeling that the act must be 
carried out in order to satisfy some unexplained motive within 
the individual, and which no fear of consequences can prevent 
his carrying out. This is Illustrated by the case of a school 
teacher to whom reference has already been made. 

A. B., set. 45, early in life, at the age of puberty, showed signs 
of sexual perversion, in that he jrielded to an impulse to expose his 
genital organs to young girls. The consequences of this act were 
fully appreciated by him, he was ashamed of it immediately. He had 
always shown great aptitude in his studies, graduated from a univer- 
sity in Germany, and had good opportunities for advancement in 
life, from his social position and friends. Again guilty of a like 
offence against society, he escaped to England, where his acknowledged 
ability as a teacher soon procured him a good position. 

After procuring, however, a comfortable position, the anxiety for 
his livelihood being relieved, the same impulse seized him, and despite 
his knowledge of the necessary results to follow and the disappoint- 
ment to those friends who had aided him, he was again guilty of a 
similar offence. Coming to this country, he was again successful in 
securing occupation, and gained the respect of all with whom he came 
in contact, who never suspected him of his mental disorder. After be- 
coming thoroughly established in his position, and, as he said, all strain 
and anxiety being removed, the same impulse presented itself. He 
strove by all means possible to overcome it. Ordinary sexual inter- 
course gave him no relief, nor was the same pleasure experienced. He 
was guilty again of exposing himself in a public place to little girls. 

The patient, when I saw him soon after the committal of another 
offence, was perfectly cognizant of the extent of his crime against 
order, bewailed his condition, and threatened suicide. He presented 
the appearance of an educated, refined gentleman, and yet said that if 
he knew he was to have been killed the next moment he could not 
have prevented himself from committing the act. 

Here we have the full reasoning power of the individual intact, a 
full knowledge of the consequences understood, and the necessary pre- 
cautions of escape taken. The only element absent for constituting the 
act that of a responsible being is the motive. In this last every motive 
for not doing it, existed. Desire alone, and that certainly a morbid one, 
is the only explanation of the act. 

While in a medical sense this is a sufficiently explanatory 
reason for ascribing the cast to the field of disease, in the eye 
of the law we cannot recommend for the best good of the com- 
munity that such persons should be held as irresponsible. They 



346 INSANITY — PISHEK. 

do not belong to the borderland cases of insanity. The condition 
is purely a pathological one, still punishment should be meted 
out to them in order to conserve the best interests of society, 
where the few must suffer for the good of the many. Physi- 
cians should take this view of the matter and thus aid the law 
in coming to some modified ruling in regard to punishment for 
such crimes against decency and order. 

" In the normal condition every sensation tends to translate 
itself into an action, but this tendency is restrained by the ego 
which intervenes, perceives the sensation, analyzes it, and 
finally decides for or against the accomplishment of the act. 
The equilibrium between the tendency to the act and the re- 
straining power of the ego (determinism) constitutes the normal 
condition in this point of view. The impulse results from a 
rupture of this equilibrium. 

" The equilibrium being lost, either by weakness of the ego or 
by both together, it follows that the impulse may be the conse- 
quence of one or other of these conditions, hence it occurs in 
those forms of alienation in which it is observed. Practically 
it is especially in the emotional neurasthenic, the degenerative 
conditions, imbecility, dementia (enfeeblement of the ego), 
acute mania, hallucinatory insanities, and, finally, in epilepsy 
(mixed state), that we meet with impulsions. 

"Impulsions may be divided into besetting impulsions 
(obsessions) and reflex impulses (impulsions properly so-called), 
according as they act with or without resistance on the part of 
the individual. They may also he divided into intellectual, 
emotional, or motor impulses, according to the sphere 
affected. 

" Motor impulsions, which are those generally referred to in 
the clinic when we speak of impulsions, are further desig- 
nated by the morbid acts to which they give rise. Thus we 
speak of impulsion to theft (kleptomania), to incendiarism 
(pyromania), to drink (dipsomania), to murder, suicide, etc. 
At one time there was a tendency to consider each form of im- 
pulsion as an insanity, a special monomania ; nowadays that is 
completely abandoned, and it is generally admitted that morbid 
impulse is only a symptomatic element of insanity that may 
occur under different characters in widely different conditions." 
— E. Regis, " Practical Manual of Mental Medicine." 



IMPULSIVE INSANITY. 347 

I have quoted this author at large, as he truly represents the 
present status of opinion in regard to all those forms of mental 
disturbance which formerly -were classified as distinct forms of 
insanity. They are, as shown in our classification, simply 
symptoms of an insane state, coming under the head of the 
degenerative type, in which the emotional, rather than the 
intellectual, field is involved. The law can only recognize them 
in so far as they correspond to the generally accepted rulings in 
regard to civil and criminal responsibility. The practice of the 
courts in England and in this country, following the trial of 
McNaughton in 1843, has been that every man is presumed to 
be sane and to possess a sufficient degree of reason to be respon- 
sible for his acts, unless it can be clearly proved that at the 
time of committing the act the accused was laboring under 
such a defect of reason from disease of the mind as not to know 
the nature and quality of the act he was doing, or if he did 
know it, that he did not know that he was doing wrong. 

Under these rules, which may be taken as outlining, the law 
on this subject in a large number of the United States, the 
defence of irresistible impulse to do what is known to be morally 
wrong and what is legally a crime cannot be set up; for if the 
accused was conscious that the act was one which he ought not 
to do, and if that act was at the same time contrary to the law 
of the land, it is punishable. 

This denial of the right of a person who knows the wrong- 
fulness of an act to set up as a defence that he was under an 
insane and irresistible impulse to do it, has given rise to bitter 
denunciation of the law by medical writers who are practically 
agreed that such a condition of the mind may, and not infre- 
quently does, exist, and who maintain that a person in such a 
condition is as helpless to refrain from his act and as irresponsible 
for it as is a person who commits a crime under irresistible physi- 
cal compulsion. Acting upon the assumed truth of this proposi- 
tion, the courts of Scotland and those of a number of the United 
States have recognized this as a defence in criminal actions.' 

All forms of crime may be committed under the influence of 
irresistible impulse — homicide, suicide, arson, theft, and various 
acts indicative of sexual perversion. 

' F. S. Allen, " iDsanity before the Law. " Johnson 's " Universal Cyclo- 
paedia," vol. iv. New York, 1894. 
IIi;— 18 



248 INSANITY — PISHBR. 

We may have also melancholia or mania associated with 
this condition, and more rarely delusions and hallucinations. 
It is, however, not in these latter conditions that we should 
consider this disease as an entity. In fact, the only safe course 
is to follow the dictum of the law in this respect, which virtu- 
ally says that irresistible impulse is no defence unless a symp- 
tom of insanity.' In the case of Flanagan v. People,' Mark 
Flanagan was indicted for murder in the first degree, for killing 
his wife. The defence was insanity. Judge Andrews says : 

" We are asked in this case to introduce a new element into 
the rule of criminal responsibility in cases of alleged insanity, 
and to hold that the power of choosing right from wrong is as 
essential to legal responsibility as the capacity of distinguish- 
ing between them, and that the absence of the former is con- 
sistent with the presence of the latter. 

" The argument proceeds upon the theory that there is a form 
of insanity in which the faculties are so disordered and de- 
ranged that a man, though he perceives the moral quality of 
his acts, is unable to control them, and is urged by some mys- 
terious pressure to the commission of acts, the consequences of 
which he anticipates but cannot avoid. 

" Whatever medical or scientific authority there may be for 
this view, it has not been accepted by courts of law." 

In the case of People v. Walworth ' the same point of issue 
came up before Judge Davis. 

The defendant, Frank H. Walworth, was indicted June 9th, 
1873, in the court of Oyer and Terminer for the killing of his 
father. 

The evidence showed that the father had been estranged 
from the defendant as well as all his family for some years. 
The defendant in an altercation shot his father, but asserted that 
he had no intention of killing him. Judge Davis gave the 
following opinion : 

" If it be satisfactorily shown that the accused at the time of 
committing the act had not the capacity to understand what he 
was doing and know the consequences of his act, and know that 
it was wrong, then he is excused. But if he had capacity suf- 

' People V. Coleman (I. , p. 1) , Oyer Court of Appeals of the State of New 

and Terminer N. Y. County, Dec, York (vol. 63, p. 469). 

1881. Davis, J. "New York Criminal Reports, vol. 

' Reports of cases decided in the iv. , p. 355. 



IMPULSIVE INSANITY. 249 

ficient to know the legal and moral character of the act he was 
doing, the fact that he alleges that he had not the control of his 
will in respect to it, but that his will was controlled by irresis- 
tible impulses, is no defence." 

The jury found the prisoner guilty of murder in the second 
degree. 

Simon defines an irresistible impulse as consisting of an 
imperative necessity which the patient cannot overcome and 
which leads him to commit some act, as homicide, suicide, 
arson, or theft. 

There may be physical signs of this condition at the time of 
the act, as marked headache, flushing of the face, palpitation 
of the heart, etc. All these symptoms often disappear when 
the desire is yielded to. There may have been a long and pro- 
tracted struggle to overcome this impulse. Often, indeed, the 
patient may confess his fear of doing some violent act. The 
writer reports the following case : A lady who had married a 
widower with one child by his first wife had always shown 
great affection for the child. One day she was surprised in the 
act of choking the child. She had shown some time previous 
to this, signs of depression and preoccupation. Later she had 
similar attacks of violence, both suicidal and homicidal. She 
ultimately completely recovered. This author places the victim 
of irresistible impulse especially among cases of mania, melan- 
cholia, hysteria, alcoholism, and epilepsy. These conditions 
are, however, different from the form under consideration, in 
which the impulse stands out as the principal and often the 
only symptom of insanity. I would make an exception in epi- 
lepsy, for in this disease we find very frequently this condition ; 
in fact, on investigation we may find that we are dealing with 
epileptic insanity, as shown in the following case reported by 
Simon : A young quarryman had set fire to thirteen quarries, 
barns, and buildings. The multiplicity of the crimes, the iden- 
tity of the circumstances attending their accomplishment, and 
the doubt of the existence of a motive led the authorities to ask 
for an examination of the mental condition of the accused by 
Tardieu and Lasegue. They declared the accused impulsive 
and irresponsible and recommended his commitment to an asy- 
lum. An epileptic seizure soon after explained unmistakably 
the cause and nature of his impulses. 



250 INSANITY — FISHER. 

Homicidal impulse, homicidal mania, or monomania are 
terms which hav^ long been employed, so that they appear to 
represent distinct forms of insanity. 

The subject has, however, been pretty weU threshed out in 
the past century. Such writers as Pinel, Esquirol, Clouston, 
and Bevan Lewis, while not agreeing in all particulars, have 
established, that we have to do with a symptom which not only 
belongs essentially to the degenerative form of insanity, espe- 
cially of the hereditary type, but also to the acquired form. 

We have indeed in all forms of insanity tendencies to im- 
pulsive acts either homicidal or suicidal, as in mania, melan- 
cholia, alcoholism, general paresis, etc. ; but these are not con- 
sidered under this heading. In this class the cardinal symptom 
is a strong, at times irresistible, impulse to homicide. This 
may be struggled against and at last yielded to, as in the in- 
stance of impulses referred to previously in other relations, 
There' is to be observed here also the feeling of satisfaction 
after the completion of the act. The condition is often preceded 
by physical excitement resembling the aura in epilepsy. In 
fact, among epileptics we find during the interparoxysmal 
periods tendencies to impulsive acts. 

These cases are unattended by hallucinations or delusions 
and must be separated from this class, no motive being present. 
The manner in which the act is carried out does not indicate a 
motive, even though great care in all details is observed and 
careful plans of escape from the consequences are laid. It is 
not infrequent that the individual will calmly deliver himself 
up to the authorities, confessing without emotion the act com- 
mitted. Again there may be great remorse for the act. Such 
acts differ from those due to the fixed ideas of melancholiacs 
who commit homicide, as in these cases the motive, while a 
false one, based often on delusion, is apparent. 

Definition of Homicidal Insanity. — A fair statement of 
this character of impulse is given by Tuke "as a syndromi 
directly connected with hereditary moral degeneration, ant 
essentially characterized by the desire to murder, without anj 
intellectual disorder or passion, and necessarily requiring ai 
concomitant mental conditions persistence of consciousness 
anxious struggle against the besetting impulse, and lastly, it 
case the act is committed, subsequent moral depression." 



HOMICIDAL IMPULSE. 251 

The existence of such a condition cannot be denied ; the phy- 
sician is often the confidant of such fears of his patient. A 
woman, of bad hereditary tendency, would come to me and cry 
and bemoan the feeling which possessed her, that she would 
kill her husband and her child. This idea was always with 
her, but would come on especially at times almost parox- 
ysmally, during which periods her face would become flushed 
and she experienced a general feeling of congestion. 

This element of mental disease should be acknowledged by 
our courts, although it necessarily requires great care in its ac- 
ceptance when set up as a defence for criminal acts. Clouston 
records a letter of a patient of his, which explains well this com- 
plete possession of the person by a fixed idea : 

"My Dear Sir: — According to promise, I have written to the best 
of my ability what I feel mentally. God alone knows my feelings. 
They are truly awful to know. I lived in continual fear of doing 
harm each day. I had not a moment's peace in this world." (The 
patient was a physician and continues :) "I was afraid, when applying 
nitrate of silver to the throat of my patients, that I would push it down. 
. . . When I sat down at my own table I used to have horrible im- 
pulses to cut my children's throats with the carving knife," etc., etc. 

Such accounts could be multiplied almost indefinitely in the 
experience of any alienist. We find no evidence of intellectual 
defect, the memory and judgment are not impaired except in 
regard to this fixed idea. As one patient said: "I must be 
mad, and yet I can do everything as I used to. I can read and 
talk, and yet I feel as if I was not myself." 

Regis sums up the matter very well as follows : " The im- 
pulsion to homicide proceeds in an identical manner by inter- 
mittent and paroxysmal crises, preceded by melancholic prodro- 
mata. The patients are beset with the fixed idea of killing this 
or that person — for example, a child they adore. The sight of 
that child, of a weapon, a knife, arouses their obsession and 
plunges them into inexpressible torment. They realize that 
their will is bending, that they are yielding to the impulse, and, 
filled with horror, they lament, flee from home, ask aid and 
protection of physicians, not hesitating in some cases to have 
themselves locked up in order to escape from their morbid pen- 
chant." 

There is little doubt that in many cases suicide is committed 



252 INSANITY— FISHEE. 

from fear of committing homicide. This dread may be concealed 
for years from others, and probably the cause of certain mysteri- 
ous, unexplained suicides can be ascribed to this morbid mental 
condition. 

Suicide and Insanity. — This occurs in various forms of 
insanity, especially, however, in melancholia. It is, however, 
not infrequent in mania, epileptic insanity, general paresis, 
alcoholism, etc. The idea that suicide always indicates insanity 
is erroneous ; that a large number are insane is not to be doubted, 
but the act alone cannot be accepted as a sign; the motive 
must always be sought for, and if sufficient cause, as loss of 
property or fear of disgrace, is discovered, the common plea 
of temporary insanity under these circumstances cannot scien- 
tifically be accepted. 

Suicide among the ancients was very common, and it is re- 
ferred to frequently in the Bible — a general to escape from the 
ignominy of defeat would frequently kill himself on his own 
sword. The ancient Greeks did not regard it as a crime, nor 
was it so considered among the Romans. " Seneca held that 
suicide was an actual duty under certain circumstances, as in 
great poverty, slavery, grief, old age, or hopeless disease." The 
frequency of suicide markedly increases as a nation advances in 
civilization. This is probably dependent upon the more com- 
plicated relations of life and the difficulties of self-support. 

Climate, seasons, time of day have their influence: out of 
11,832 cases in four years in Prussia, from 1869 to 1872, the 
greatest number occurred in the night, that is, in the early 
morning hours. The influence of race, religion, culture, sex, 
morality, political life, city and country life, age, cehbacy, 
occupation, intemperance, heredity, is of importance. 

Suicide may occur in those who have shown no other sign of 
mental disease. It is frequently threatened in melancholia and 
in neurotic persons. It may be impulsive or deliberate. The 
impulsive form may occur among the neurotic, hysterical, 
maniacal, alcoholic, and epileptic; the deliberate form occurs 
more frequently among paranoiacs, the chronic insane, and 
melancholiacs. In children it is almost always in those heredi- 
tarily affected (see Tuke, "Psychological Medicine"). 

Suicidal Impulse.— Suicidal mania so called belongs to 
the same category of mental diseases as the form just de- 



KLEPTOMANIA. 253 

scribed. "What has been said in regard to hereditary and ac- 
quired degeneration applies equally well here. 
• Kleptomania.— Cleptomanie (i^'r.); Stehlsucht (G^er.) 

Definition.— An in-esistible impulse to steal (Tuke) . 

This condition must be classed among the neuroses, and is 
essentially a characteristic of defective mental development. 
We must make a sharp distinction between it and the tendency 
to steal or appropriate anything, whether valuable or not, so 
commonly observed in the well-defined forms of insanity. 

Imbeciles and idiots, without apparent regard or knowledge 
of consequences, will steal, and may do so more or less cun- 
ningly, avoiding detection if possible. They usually take such 
things as would naturally please them or satisfy their desires, 
as food or clothing, etc. ; these acts generally resemble those of 
children. They recognize that they are wrong because they 
have been punished for similar offences, but they have no feel- 
ing of moral responsibility in the act. 

Again, in chronic melancholia, or especially in chronic 
mania associated with exaltation of the ego or individual, 
the appropriation of various articles to ornament the person is 
very common. There is no special impulse or longing in these 
cases ; there is evident intellectual defect or there may be a delu- 
sion back of the act. Again, in the earlier stages of general 
paresis stealing is not uncommon, and persons have been con- 
victed who have later developed all the typical symptoms of 
this disease. 

Tuke refers to six cases related by Dr. Burman in the Jour- 
nal of Mental Science, January, 1873: "All were convicted of 
stealing and sent to prison, and in all of them general paralysis 
became manifest soon afterward." We must make a careful 
distinction between a symptom of insanity and a condition 
which stands out alone as a mental characteristic. 

The tendency of the past, as shown in the writings of Marc, 
Marie, Lasegue, to class all these cases as types of insanity with 
irresistible impulse, has of late taken the opposite direction. 
It is, however, without doubt a mental state, resembling in 
kind, but not so intense in degree, the various forms of mental 
disease already described under the head of homicidal and 
suicidal mania. We find an absence of the moral sense of 
wrong committed with the act. The only fear is that of detec- 



354 INSANITY — FISHER. 

tion ; there is no apparent loss of the moral aspect of other ques 
tions; the intellect is unimpaired. There is, however, almos 
invariably present a neurotic disposition and not infrequent!] 
an hereditary taint of insanity. 

One lady, long under observation, moving in the best society, anc 
universally respected and liked for her versatility and pleasant man 
ners, has for years been known to take articles of value from th( 
houses of friends whom she has been visiting. 

■ The motive was the desire to have the article which struck hei 
fancy. There was, however, no need to resort to such means of ob- 
taining it, as she could amply afford to purchase it. She at one time 
said that " she could see no harm in her taking it, her friend would 
have given it to her had she asked for it." This moral obHquity is not 
uncommon. 

Another lady rarely visits the city in her shopping tours without 
returning with various articles which she has abstracted from the 
various store counters. At certain of these places she is simply watched 
and the various articles charged up against her, which she subsequently 
pays for. Many of these articles are never used afterward, but simply 
accumulate. This patient represents more closely the cases of irresis- 
tible impulse. In other respects there is no evidence of mental disease. 
She is an estimable wife and mother. Many similar instances aredaUy 
reported in our papers. 

The question of responsibility is difficult to settle, and indeed 
most cases are settled by some arrangement. The absence of 
any real motive, the knowledge of previous acts of a similar 
character, the history of hereditary taint, and a neurotic 
disposition, seem to establish the proof of a mental weak- 
ness which approaches the confines of insanity. One cannot 
say that punishment should not be inflicted ; for, as in other 
cases of mental disease, when the emotional side of the mental 
functions is more involved than the intellectual, the knowledge 
that punishment will follow such acts has a great deterrent 
effect; and while as physicians we might claim immunity for 
such defective individuals, as jurists we can only believe that 
the best interests of society are subserved by holding the person 
responsible. 

Pyromania. — MoNOMANiE Incendiaiee (Fr.); Feui 
LUST, Brandstiftungs-Monomanie (Ger.). These terms 
indicate the idea of a fixed impulse, a single desire. 

Definition.— A morbid impulse to burn (Tuke). 



PYEOMANIA. 255 

There is less evidence of impulse of a so-called irresistible 
character in these cases than in those of the class just described, 
although we have to deal with the same more or less morally 
and intellectually defective type. 

These acts are more frequently committed by the young, 
about or before the age of puberty. There is often a well-de- 
fined history of imperfect mental development, diflSculty in ac- 
quiring learning, lack of ordinary affection, or the existence of 
a cruel disposition. It has been noted also in children brought 
up in institutions, where probably the motive has been revenge 
for fancied or real wrongs. Again, homesickness has been often 
the motive. 

While' frequently there is discoverable some motive, as a feel- 
ing of hatred toward persons who have perhaps treated them 
cruelly, it is more often a supposed injury than a real one; or 
even love for some one may be the motive, the attempt being 
made to rid them of their enemies. These latter cases are more 
often homicidal in character. Again, in cases where homesick- 
ness has been the motive of the act, the individual thought thus 
to escape or be sent back to his home. 

The true inconsequence of the acts is perceived in that no 
element of sorrow is experienced. These acts are similar to 
special acts of destruction, as breaking windows, destroying 
clothing, which have been performed by persons of this class. 
There is often a desire to attract attention, to be explained only 
by a morbid exaltation of the ego. There is not infrequently 
great skill and cunning shown in the concealment of these acts, 
or even shrewd attempts to throw the suspicion on others. This 
is often successful, as there is no reason to suspect them person- 
ally, as the extreme youth of the individual may make it seem 
impossible that they could have carried out the plan success- 
fully. There often is an hysterical basis in many of these 
cases, and even in the very young this cannot be excluded. 
There are, however, cases again where the mere act of incen- 
diarism, the pleasure and satisfaction derived, seems to be the 
only motive. The same condition is observed here as referred 
to in moral insanity or impulses toward other acts. There 
may be a long struggle to resist the impulse, which finally 
overmasters them, and there is also usually a sense of quiet 
and satisfaction following its accomplishment. It is not 



256 INSANITY— FISHER. 

unlike, as Lewis has stated, the quiet following an epileptic 
seizure. These patients resemble epileptics indeed in many 
mental characteristics. Lewis makes this distinction : " In the 
genuine impulsive forms of insanity consciousness is never so 
far impaired as to issue in forgetfulness of the details of the 
homicidal act. When such is the case, when any marked ob- 
scuration of memory is apparent, we may presume the impulse 
to have been of epileptic origin." This applies equally well to 
all impulses of the so-called imperative type. 

We must be careful not to confound the tendency to impulse 
found in all forms of insanity, especially melancholia and mania, 
with this form, for frequentlj- similar acts are committed by 
these patients, but the motive is usually perceived in the hallu- 
cination or delusion present. 

I would agree with Griesinger in objecting to the term 
pyromania as defining a distinct form of insanity, but this ap- 
plies equally well to all this class of impulses. It is simply a 
symptom, which, however, occurs so often and so uniformly 
among these defectives that, for convenience' sake, usage has so 
firmly established the term that we cannot well place it aside. 
The author just quoted says: "Away, then, with the term 
pyromania, and let there be a careful investigation in every 
case into the indiA'idual psychological peculiarities which lie at 
the bottom of and give rise to this impulse. The grand ques- • 
tion in foro in all such cases must ever be to ascertain whether 
there existed a state, of disease which limited or could have 
limited the liberty of the individual. Sometimes the feeling of 
anxiety, hallucinations, states of hysterical exaltation, in other 
cases the actual existence of a nervous disease (epilepsy or 
chorea), render probable the assumption that the accused has 
been subject to some passing mental aberration. We should 
not forget that usually very little is wanted to interfere with 
the liberty of action in such persons; they are, for the most 
part, young, childish, or half-childish, often morally and intel- 
lectually weak, silly, and suspicious individuals. The incendi- 
ary act often appears to be utterly without any motive, the 
feeble ego having opposed no resistance to the thought of the 
deed which suddenly sprang up." Clouston weU says that 
these cases represent "states of defective inhibition." "No 
doubt the theory of irresistible impulse is liable to abuse, and 



COPROLALIA. 257 

to be applied where it does not exist ; but one might as well 
assume that there is no real epilepsy because malingerers and 
hysterical girls simulate fits." 

Coprolalia — an impulse to use obscene or profane lan- 
guage. We not infrequently find in the hysterical and in the 
early, stages of acute insanity and in puerperal insanity the 
tendency to the use of words which at times it seems impossi- 
ble that the individual, often refined and educated, could have 
ever been in a position to have heard or learned. This may 
manifest itself especially when there is an erotic element pres- 
ent in the disease. Our condition, however, is distinct from 
this : it stands out as the principal or only symptom of disease. 
It is usually observed in the young about the period of puberty 
or earlier, and may result from some fright. It is not infre- 
quently associated with a neurotic predisposition to instability 
of the nervous system. The child may be very intelligent or 
the reverse, and often there has been noticed an absence of the 
usual moral understanding or estimate of things. Even in 
these patients there is evidence of some hysterical taint in the 
history. Many such cases are actual forms of mental disease 
developing later into the type of paranoiacs or showing signs of 
other impulses. 

These exhibitions of obscenity are often paroxysmal or period- 
ical, resembling in many aspects epilepsy, especially when there 
is convulsive excitement present. The consciousness is never in- 
volved, however, and a strong motive, as fear of punishment, 
may be suflQcient at times to end the attack. 

A. B., set. 10, was brought to me by his mother with the following 
history: Family history negative, except that there was a strong 
nervous element in both parents. The boy had always been exceed- 
ingly bright at school, although not as easily controlled as the other. 
This the mother ascribed to the fact that he had never been made to 
obey. Following a severe castigation by his father for some act, he be- 
came very much excited, and the following morning went out in front 
of the house and began to swear in a most excessive way. He was ap- 
parently conscious of his acts, but appeared to be in a very excited 
state. This was repeated every morning and at no other time, and 
usually after his father had left the house. His sudden return with the 
threat of punishment was often sufficient to end the attack. At all 
other times the child's language was very proper. He usually com- 
plained of a peculiar feeling in the head just preceding the attack, and 



258 INSANITY — FISHER. 

said he knew what he was saying, but could not help it. Under treat- 
ment these attacks became less frequent and finally ceased. The 
bromides were used, as the attack seemed epileptoid in character. 



Morphiomauia, or the opium habit, consists in an exces- 
sive desire for morphia. It resembles dipsomania in regard to 
the irresistible desire for this drug. The will power seems to 
be absolutely lost, and any subterfuge will he employed to 
obtain the desired stimulant. In extreme cases no regard for 
consequences or affection for others has any influence in con- 
trolling these persons. 

Again, we hold here that in the majority of cases, while the 
provoking cause may be simply the taking of the drug to relieve 
pain, its continuance and abuse with periodical excesses depend 
on a neurotic state which is due to an inherited degenerative 
nervous organization; in other words, rarely will this habit 
plant itself upon an otherwise sound organization. 

The symptoms manifest themselves in the first place, as seen 
from the use of the drug in ordinary administration, as a pleas- 
ant excitation, an increase of mental action, even to brilliancy, 
which soon passes, where large amounts are taken, into a con- 
dition of apathy and mental stupor, and finally to a toxic con- 
dition, as shown by coma from which the patient can only be 
aroused with difficulty, soon to fall back into his previous state 
of unconsciousness, associated with slow respirations and slow 
pulse. The skin is usually moist. There may be more or less 
tremor, paresis, and ataxia. The walls of the bladder are par- 
alyzed so that there is frequently incontinence, and there is also 
a paralysis of peristalsis. No special symptoms with reference 
to the reflexes exist. The secretions in all the organs are de- 
creased; in extreme cases there is also loss of sexual power. 
The physical condition gives evidence of malnutrition, and 
finally there may be even emaciation; the hair turns gray, the 
finger-nails become dry, and the pupils are contracted and at 
times are unequal. There may be considerable pain of a neu- 
ralgic character, which is widely distributed, suggesting 
neuritis. 

The mental symptoms are those of great loss of energy unle 
under the direct influence of the drug. A constant habit 
procrastination exists. In the true opium habit, one rarely h 



DIPSOMANIA. 359 

the pleasurable imaginations observed in those who are not 
habitues; there is, however, a feeling of self -contentment in- 
duced, which takes its place — a calming of the whole nervous 
system. When the drug cannot be obtained, the patient be- 
comes very tremulous, is subject to profuse sweatings, excessive 
cardiac action, and a feeling of impending death. There is 
also insomnia, and the patient may even pass into a maniacal 
condition, followed by intense exhaustion, and not infrequently 
by death. (Hallucinations, usually of sight, may be present. ) 
The final results are those of dementia — loss of judgment and 
of memory, the moral character being lowered. There is a 
special tendency to lying, and no statements which such pa- 
tients may make in their attempts to obtain the drug can be 
relied on. Forgery, neglect of family duties, etc., are not un- 
common. Mania is often marked by a delusion of persecution 
and exaltation, not unlike paranoia ; in fact, we may have to 
do with that disease in' these cases. 

Lead. — The special effects of lead on the nervous system are 
largely somatic rather than psychical. We find well-marked 
lesions affecting principally the peripheral nerves, causing 
paralyses and wasting of the muscles, especially of the extensor 
group of the upper extremities. Cord lesions, although more 
rare, are present, and in an autopsy made by me well-defined 
lesions involving the gray and white matter were present. This 
may also involve the cortex cells and association fibres of the 
brain, resulting in a mental condition in which the more prom- 
inent symptoms are those of lowered mental action, loss of 
memory, headache, and, in some few cases, great excitement of 
a maniacal type. Hallucinations of sight and of the other 
senses may be present. Convulsions are not rare. Depression 
is a not infrequent symptom, and if the patient remains still 
exposed to the poison, the condition advances to dementia. 
There is nothing, however, characteristic of the condition as 
far as any special well-defined form of insanity is concerned. 

Dipsomania. — We must make a sharp distinction between 
the class of drinkers who are given to excess only periodically, 
and those in whom the habit is continuous. In the former we 
recognize a mental condition similar to other neuroses, especially 
to epilepsy. In these cases we find an almost irresistible impulse 
to satisfy a well-defined craving which can only be satisfied by 



260 INSANITY — FISHEE. 

the use of alcohol. Under this head, we would refer to ex( 
in the use of other drugs, such as morphine and cocaine. I 
chronic habitual drinker, the excess is more apt to be inc 
by the physical condition following continual abuse of ale 
and its consequent exhaustion, resulting in a demand oi 
part of the system for a stimulant. In both instances, the 
result after excessive debauches may be the same, that is 
lirium tremens often follows, or a maniacal condition la 
frequently for weeks or even months. In dipsomania, 
ever, the condition of chronic alcoholism or alcoholic dem 
does not usually occur. There is more frequently an i 
mentaldisturbance of the type of the degenerative diseases 
as epileptic insanity or paranoia ; in fact,' in this class ol 
tients hereditary taint is marked. 

We can only regard dipsomania as a symptom of mi 
disease, or, in other words, as a sign or evidence. As we . 
already remarked, it occurs in the class of so-called degei 
tives, those affected with an hereditarj' taint or predispos: 
to insanity. It belongs to the same type as moral, impuL 
reasoning, and periodical insanity. 

In a legal sense it is difficult to accept it or the abov 
separate forms of insanity and their value in diagnosis is 
ply as one of a chain of symptoms, indicating mental disea 

It is of importance to establish the existence of the tend 
to periodical excesses, as it may prove at least that premedits 
in the commission of the act was absent, and also may be grc 
for a lessened degree of responsibility. 

Nymphomania is a state found in the female, the i 
marked feature being desire to satisfy the sexual appetitf 
irritation of the clitoris. It is a form of insanity when cai 
to great excess, in which eroticism is the chief feature. E 
individuals rarely obtain pleasure in the natural manner; i 
have a morbid tendency to self-gratification in this direct 
They may derive a morbid pleasure in this direction from obj 
of art or pictures, in which case the excitation is entire" 
psychical character. "We would also place this form of 
among those of the so-called degenerative type, in which 1 
and acquired instability are important etiological factors, 
occur at various periods of life, not rarely even at the 
teric. It is found especially among those who lead a 



MANIA TRANSITORIA. 261 

life. It is not confined to the uneducated classes. It is also 
observed in various forms of mental disease, in which there 
is a loss of the higher faculties of the mind as in idiocy, epi- 
lepsy, and hysteria. We note it also in various conditions in 
which delusions take a prominent part. It may be a symptom 
in various spinal diseases. It is at times caused by certain dis- 
eased conditions of the genital organs and by inflammatory 
affections of the uterus. 

Mania Transitoria — transitory mania; die transito- 
rische Tobsucht. 

" We understand by transitory mania that kind of acute 
frenzy which, developing suddenly and rapidly, soon reaches its 
climax" (Tuke). 

It is usually of short duration, lasting not longer, as a rule, 
than twelve hours, and passing off in a profound sleep, there 
being no recollection of the attack or the acts committed. It 
therefore very much resembles an epileptic seizure; and, in 
fact, many acts committed in known cases of epilepsy asso- 
ciated with mania, either preceding or following the convulsive 
seizures, are exactly parallel to those done in these cases. 

We must, however, as Tuke says, distinguish it from mania 
by adopting the term frenzy, as its course is so much more 
sudden in its onset and short in its duration, and leaves little 
or no trace on the mental state, its integrity being unimpaired . 
It also has no tendency to return, differing in this respect from 
epilepsy. It, however, stands out as a distinct condition by 
itself, and is of special importance in a forensic sense, as the 
absence of preceding symptoms, or anj' marked hereditary in- 
fluence, makes it difficult to establish as a defence in criminal 
cases, especially if any motive for the act is discoverable. In 
fact, it is not accepted as a defence in court. 

It is difficult to find any definite cause for the condition ; great 
excitement, physical exhaustion and mental worry, grief, in- 
somnia, acute fevers, injuries to the head, no doubt have 
their influence. Again, very little is known of the morbid 
changes outside of congestion of the brain, which is an uncer- 
tain condition, and is not infrequent in other diseases without 
producing transitory mania or frenzy. We do not include 
under this head mania resulting from alcoholic excesses or 
occurring during the puerperal state. 



362 INSANITY — PISHEK. 

Clouston believes that most of these cases are epileptii 
character, of the nature of the mental epilepsy of Hugh! 
Jackson, or of the so-called epilepsie larvee, or masked epile 
of Morel. It is difficult, as has been said, however, to thin 
a single epileptic seizure occurring without cause, and not b( 
repeated or leaving any of the signs of disease common to 
well-known neurosis. 

There is complete unconsciousness of the surroundings 
of the personality during the attack. The patient is subjec 
hallucinations of various kinds, both of hearing and sight, 
is usually violent and destructive, often homicidal. These a 
resemble those of impulsive homicidal mania. Instances 
reported of persons waking from sleep, and, probably under 
influence of some fixed delusion, showing a homicidal tendeu 

Maudsley also rather inclines toward the opinion that 
attacks are epileptic in character, as shown from the follow 
remarks quoted from Lewis' work on mental disease, 
admits that, " although epilepsy, masked or overt, will, I thi; 
be found to be at the bottom of most cases of mania transitoi 
it must be admitted that there are some cases in which then 
no evidence of epilepsy in any of its forms to be found ; but 
may well be doubted whether a distinct insane neurosis is ] 
always present in these cases. With such a constitutioj 
predisposition, a genuine attack of acute insanity, lasting : 
a few hours only or for a few days, may break out on 1 
occasion of a suitable exciting cause, and during the paroxyi 
homicidal or other violence may be perpetrated. After chi 
birth it sometimes happens that a woman is seized with 
paroxysm of acute mania of short duration, during which s 
kills her child without knowing; what she is doing. The eff( 
of alcoholic intemperance upon a person strongly predisposed 
insanity, or upon one whom a former attack has left predispos 
to a second, is sometimes a short but acute mania of viole 
character, with vivid hallucinations and destructive tendencif 
and a like effect may be produced by powerful moral c 
sexual excitement, and other recognized causes of insi 
(Maudsley, "Responsibility and Mental Disease"). 

Paranoia is a form of insanity which comes esp( 
under the class of degenerative diseases. 

It is essentially characterized by a delusion or delusic 



PARANOIA. 263 

a fixed and systematized character. They are usually indeed 
of one kind, and the disease has perhaps for this reason been 
called monomania. This is, however, an unfortunate term, as 
we find this symptom not infrequently in other forms of insanity, 
as melancholia, where we always observe decidedly fixed ideas 
of depression. The term delusional insanity, largely used by 
the English, is also not to be recommended, as it is not in any 
way descriptive of this special form. The main fundamental 
characteristic of this disease is a delusion which has become 
apart of the belief of the individual, and which he believes 
himself able to explain and defend. 

Paranoia is usually a primary disease, that is, congenital in 
its origin — the predisposition to the disease is born with the 
individual ; the exciting cause may not manifest itself until later 
in life. " The patients receive its germs at birth, and it develops 
at its appointed hour under the influence of the slightest cause — 
for example, poverty, diflSculties of social life, disappointments, 
mortifi ations, conjugal unhappiness, the menopause, etc. That 
is to say, that the principal cause of partial insanity is heredity. 
It is well known that it is more frequent in females, celibates, 
and especially those born out of wedlock" (Eegis) . The term 
progressive systematized insanity used by the preceding author 
explains very well the condition, and he has defined it as fol- 
lows: "A chronic, essential insanity, without disorder of the 
general activity, characterized by hallucinations, especially of 
hearing, by delusions tending to become systematized, and end- 
ing in a transformation of the personalitj'." 

The intellect is rarely much involved. In all other relations 
the individual may be able to carry on his business in life with or- 
dinary acumen ; where, however, the delusion affects his particu- 
lar occupation, it will be found running through all its course. 

This class of patients has been included, therefore, under the 
head of the partially insane. There is little doubt that in the 
general question of right and wrong, they are thoroughly re- 
sponsible in their understanding of the moral issue and of the 
consequences of their acts. However, in a particular act, if 
the result of their delusion, it is not so much a question of their 
ability to control their actions, as that they do not attempt to 
do so. Under their delusion, which may in their changed per- 
sonality appear to be a command from God, whose direc- 
III. -19 



264 INSANITY — FISHER. 

agent they may consider themselves, the question of the ri 
or Avrong of the act or its consequences is never taken into c 
sideration/ This condition differs from the so-called irresisti 
impulse of the former class which we have been consider]: 
based as it is on a train of reasoning often logical, thoi 
wrong and unreasonable in its premises. We have to do h 
with a class of the insane perhaps the most dangerous in c 
community. They have within themselves a law sufficu 
unto themselves. With intellects often acute, they are at tic 
patient and skilful in carrying out their plans, whether to 
generate the world or to remove a supposed tyrant. They m 
conceal their delusions from others, and in fact are usually rea 
to defend themselves against the accusation of being insai 
Many cases indeed are harmless in their tendencies, havi 
simply impracticable schemes, harmful only to their own pr 
pects in life. The disease is essentially a chronic and inct 
able one, and tends slowly to dementia, which is rarely, ho 
ever, profound. 

As one would expect, from what has been said, these cas 
constantly come into conflict with the law, and perhaps 
form of insanity has led to more protracted and heated disci 
sions, or more contradictory statements, by various well-knov 
experts in insanity in regard to their mental soundness and : 
sponsibilitj'. The trials of Oxford, Guiteau, and Prendergs 
are striking examples. There can be no question of the insani 
of such cases, and this from the medical standpoint might 
considered sufiBcient ground for relieving them from all respo 
sibility. But in law other questions, of policy, the welfare 
the community, etc. , have to be especially considered. To pe 
mit the idea to go forth, that persons known to be capable 
reasoning in a logical manner, and who are cognizant of wh 
is going on as reported in the papers, and yet have long be( 
considered in the vernacular of the times as "cranks," neverth 
less will not be held responsible for their acts, would probaK 
lead to a great increase of such crimes. 

These individuals are greatly influenced by the fear o 
law. In a milder way in our asylums the restrictions, plac 
this class of patients when they commit any overt act, res 
them from repeating them. The execution of homicides, 
the head of a government has been the victim, cannot be ( 



PARANOIA. 



265 



a "judicial murder" but a necessary measure for the prevention 
of similar acts and the protection of the government and the 
community in general. 

There are many physical signs of this form of mental dis- 
ease. The Italian school has especially developed this subject. 

There is frequently found asymmetry of the skull, of the 
face, irregularities of the jaw or palate, of the nose, ears, and 
eyes. These are not always present, nor can we say that any 
precise statement 
of uniform irreg- 
ularities has as 
yet been made. 
They occupy 
about the same 
importance a t 
present in diag- 
nosis as the so- 
called criminal 
type of brain 
does in pathology. 
Enthusiasts have 
brought a great 
mass of statistics 
together, but 
have not as yet 
thoroughly inves- 
tigated the other 
side of the ques- 
tion, i.e., the existence of like irregularities among the sane. 
It is true, generally speaking, that beauty and symmetry are not 
common to criminals or the degenerative insane (see Fig. 20). 

I have spoken of paranoia as essentially a primary disease, 
not a secondary one. It has led to considerable confusion in 
our understanding of this disease, that certain fixed delusions, 
remaining after the acute stage of melancholia or mania, have 
been ascribed to paranoia. The whole course of these psy- 
choses, and the attending dementia, should sharply mark them 
, out as different in their very nature. The term secondary 
monomania could be well used in these latter conditions. 

The prognosis in paranoia is unfavorable ; no cure can be 




Fig. 20.— Paranoia. 



266 INSANITY — FISHER. 

accomplished. However, the delusion may become less acti 
and the individual become at least harmless. Paranoiacs e 
usually unable to take their part in life, and frequently becoi 
the object of public care or charity. 

The subdivisions of the forms of paranoia, were we to ._ 
into the various special delusions which exist in these caa 
would be very numerous. Classifying them, however, und 
their principal headings, we would make the following: 

The typical form is one of exaltation with delusions 
grandeur, an increase in the feeling of importance. There mi 
be a change in the personality so that the simple artisan, i 
ordinary workman or shop girl, feels that royal blood real 
flows in their veins. Again, they may conceive themselves gre 
generals, or reformers, or specially appointed messengers fro 
God. It is interesting to watch the evolution of their delusior 
the gradual transformation into another personality, and tone 
the slight and trivial occurrences which are all conceived 
referring to themselves and adopted as explanations of, ai 
indications pointing inevitably to, the fact that they are wh 
they claim. At first there may be no hallucinations, althouj 
almost invariably they appear sooner or later. This is shov\ 
in the following case : 

A.M., set. 25, male, single.' Duration of disease fourteen yea 
previous to admission to the hospital in 1892. Has the usual egotis 
of this class. Has the delusion of possessing great wealth (mUlionj 
and that the title of Prince von Michael has been conferred on hii 
Has hallucinations of hearing, one voice being that of Jay Grould, 
whom he had written letters asking to be adopted as his son, etc. 
considerably demented. 

The estimate which friends may make of such a mental condition 
shown in the following letter: "I think A. wants to get a living wii 
out work. He thinks he is remarkably smart. I think that after 1 
finds that he can't humbug you with his aspirations he will be pe 
fectly sane." Patient's condition has not changed except that he h 
delusion of persecution (see Fig. 20). 

Instead of a change of the personality there may be si ^ 
an exaltation of the existing ego. The artist becomes i 
own estimation the greatest of living artists, the accountai 
one most expert. It is, however, more frequent for this 
geration of power and ability to be applied to a sphere i: 
apart from their ordinary occupation. 



PARANOIA. 



267 



This feeling of self-importance may manifest itself in a quiet 
self-assurance which nothing can shake, and no discouragements 
alter; or it may show itself in an aggressive form, asserting 
itself in its attempt to take the part of reformer, whether in the 
political or theological world. This evolution is one of gradual 
growth ; many things have occurred, perhaps at long intervals, 
suggesting to them that they are not what they seem. The pe- 
culiar feelings they have long had, and tlie hallucinations or illu- 
sions which at first produced only some slight mental confusion, 
finally, in a man- 
ner that appears 
sudden, manifest 
themselves in a 
fixed delusion in 
regard to their 
character and per- 
sonality. Their 
reasoning now 
takes on a more 
or less logical 
character, which 
remains the same 
from year to year. 
The positiveness 
and certainty of 
their convictions 
lead finally, as 
they find them- 
selves not be- 
lieved in by others or unable or prevented from following out 
their plans, to the stage of persecution, which invariably early or 
late makes its appearance. The delusion of persecution has 
been defined by French writers as a special form of insanity 
(Lasegue), but it is really simply a stage, as we have said, in 
this form of systematized delusional insanity. 

L. R. (Fig. 21) entered hospital May, 1874, set. 51. Duration of dis- 
ease approximately twenty -five years. 

Has delusions of being poisoned by his enemies with lead and cop- 
per, and also of being infected with syphilis and phthisis. 

Patient has many similar delusions, though his mind is active and 
his conversa.tion connected. 




Fio. 21. — ^Paranoia; Delusions of Persecution and Grandeur. 



368 INSANITY — FISHER. 

Has exaggerated ideas of his own importance. Is at work {i.e. , 1876) 
in making a translation of Horace, which he thinks will be of more 
practical use in classical schools than a.ny other. Says that he is be- 
ing persecuted as all great men from Galileo down have been. Very- 
slight causes excite his suspicions. The following letter was written 
on the library being closed for reorganization: 

Dear Sir : — Will you have the kindness to inform me whether, as 
far as you know, I have been supposed in my projected compilation from 
Horace to be in any way trenching upon rights of Prof. Chas. Anthon, 
Jr. (I presume the author of the part I was using) or of Gen. Cessnola 
(who is said to be writing on Cypress and early Eastern art), or any 
other elsewhere or here? I cannot see how such a thing can be pos- 
sible ; but if it is not so, let me speak to you as one educated man to 
another and entreat you will consider how much I must suffer in my 
feelings — a man as I am who has always been studious, thinking, in- 
dustrious ! at being stopped in my preparation of a treatise, etc. , etc. , etc. 

In 1890 delusion of poisoning continued unchanged. Says is about 
to write a book and make a new religion which will change the destiny 
of New York City. - 

Patient constantly writes letters asking for protection. L. E. is ex- 
ceedingly well read, and has held the position of professor in some 
college; his education has been, however, irregular and unsystematic. 

The delusion of persecution may be present in various 
forms of insanity. It is common in alcoholic cases, the halluci- 
nations of hearing and sight being usually of a terrifying char- 
acter, with the delusion of being followed or hunted down, or 
of a conspiracy formed against them to kill them. This is seen, 
again, in melancholia, where not infrequently we also find the 
fear of being killed or of being followed existing {Verfolgungs- 
wahn) . It is not always of the persecutory character, but is 
often the result, of the various hallucinations and illusions re- 
sulting from the sensory disturbances common to this disease. 

We observe it not less often in mental diseases accompanying 
puberty, great fear of being the subject of some conspiracy 
being very common. In all these instances the whole course 
of the development of this special delusion is very different 
from its logical development in paranoia. In the latter form 
it is either the result of the mental confusion or depression ex- 
isting, or consequent upon the hallucinations. It cannot be 
said that we have any form of insanity where the only ex- 
isting symptom is that of the delusion of persecution— ie-, 
of being followed from place to place, etc. We will find on 
careful investigation that there is a reason in the minds of 



PARANOIA. 



209 



these patients for the persecution ; it does not exist as an entity 
iiiexplicable to them. They may explain it on the ground 
that they have possession of some important invention, of some 
secret power which perhaps the Government would like to pos- 
sess; or, again, that they are the real king or governor of the 
country, which, if the fact were made public, would lead to the 
overthrow of the impostor who now is in power. 

G. B. (Fig. 2^), male, set. 53. Duration of disease twenty-seven years. 
Patient says that if he had his rights he would be high king of the 
earth of the Masons, 
and also that he is 
Christ, the Son of 
God, alias G. B., etc. 

The character of 
this delusion is not 
unlike those seen in 
chronic mania. 



The immediate 
cause for the es- 
tablishment of the 
delusion of perse- 
cution may be fail- 
ure to succeed ; es- 
pecially does this 
show itself in the 
professional walks 
of life. The worry 
and mental anxi- 
ety, perhaps over- 
work and strain, may result in a more or less sudden delusion 
of great self-importance, of great ability in their special lines 
of occupation, perhaps as a painter, a physician, or a banker. 

This idea of a conspiracy against them, in paranoia, is not as 
a rule sudden in its development : it is a gradual process. Many 
peculiar things have occurred which the patient at least is un- 
able to understand. These occurrences at first do not attract 
attention, but gradually they force themselves on the individual 
as having some particular meaning especially for him. This 
is not uncommonly seen in the ignorant, and the very fact of 
this ignorance is used by them as an argument in favor of their 




Fio. 82.— Paranoia; Delusions of Grandeur and Persecution. 



270 INSANITY — FISHER. 

delusion being the truth. It is not rare for them to entertain 
for a long time doubts as to the reality of the delusion. This 
was plainly seen in a negro, born in the South, who had had 
little or no education. He had been brought up without disci- 
pline or training. His first appreciation of anything unusual 
was hearing his name called at night, waking him up from his 
sleep. He at that time and subsequently thought it was simply 
a part of a dream. Later he began to think it was peculiar, 
and on investigation found that no one in the house could pos- 
sibly have called him. He then reached the conclusion that 
it was the voice of God calling him, an ignorant negro, to be 
His prophet and special messenger to the people of the whole 
world. His personality was completely changed; he began to 
study out passages of Scripture especially applicable to his new 
vocation and to assume the position of a prophet. His confine- 
ment became necessary, and this seemed to him the opposition 
and persecution from the powers of darkness which were natu- 
rally to be expected. In regard to all other affairs he was intel- 
lectually as able to carry them on as formerly. His commit- 
ment to the asylum he accepted and was not at all depressed 
by it, believing absolutely that in the proper time God would pro- 
vide a way to have his plan carried out. There is an appear- 
ance of self-satisfaction and exaltation and personal self-im- 
portance about him which is peculiar to these cases. He sees 
and laughs at the pretensions of others to similar aspirations, 
but is not disturbed at all by any doubts as to his position. 

This acceptance of their surroundings without opposition is 
not by any means always present. In fact, in almost all cases 
every opportunity is taken to appeal to friends or the public 
for release if confined. Epistles, many and voluminous, are 
sent, especially to those holding official positions. The case 
above referred to was arrested for addressing letters to the 
President and for attempting to obtain an audience with him. 

Ambitious Paranoia will fall properly under this heading. 
There are always delusions of grandeur present. They not infr 
quently take on the character of a political nature. There 
a belief that the political world is corrupt and needs refonni 
tion. They are especially called either to assume high office ( 
to remove those in power for the purpose of allowing others i 
take their place. 



PARANOIA. 371 

There is little doubt that many of the members of the vari- 
ous secret organizations, as the Nihilists, Anarchists, and vari- 
ous religious sects, are paranoiacs. The danger from such per- 
sons to the community is seen in the fact that intellectually they 
are capable of carrying out their plans, and possessed by the 
delusion, no fear of consequences can prevent them from attempt- 
ing to carry them out. 

There is usually, indeed, in these cases more or less mental 
weakness which may eventually pass on to dementia, but the 
progress is generally slow. The lack of mental balance or power 
is evident in the delusion itself, which is often an improbable 
or impossible belief. Their methods of reforming the world or 
establishing a righteous form of government, being foolish in 
every detail, are an evidence of mental weakness. In many 
cases there is a motive for the acts committed, often some posi- 
tion being sought which would be of advantage to the individ- 
ual himself. The fact that he has absolutely no knowledge of 
the duties of the office has no bearing on his opinions of his 
ability to fill the place. The delusions are not by any means 
always single, they may be almost numberless; but they, as 
a rule, pivot around some central delusion, as the belief in their 
being descended from the royal line, or that they are prophets or 
great inventors, etc. This development of new delusions was well 
illustrated in a patient for many years under observation in the 
asylum, in whom the delusion of persecution was very marked. 

Examples of political paranoia, where the element of self- 
interest or revenge introduced itself along with undoubted evi- 
dence of insane self -exaltation and a belief in their mission to 
remove certain officials, who prevented the proper carrying on 
of the government, are shown in the histories of Guiteau and 
Prendergast. In both instances the knowledge of the character 
of the act which they committed was full and complete, and 
the consequences thoroughly known. However, in neither case 
did they expect to suffer these consequences, but looked forward 
to the applause and appreciation of the public. There is a 
marked difference in the motive and in the mental reason- 
ing in these cases from the form of insanity included under 
the head of irresistible impulse. There is, as we have previ- 
ously said, however, grave doubt whether responsibility can be 
considered as absent. 



273 INSANITY— FISHER. 

QUERULANT PARANOIA. — Das Irresein der Querulanten und 
Processkramer ; Paranoia litigiosa. We find the same elements 
of egotism and delusions of persecution in these cases as in 
the other forms of paranoia. They are always in some form 
of litigation, either on their own account or for some one else, 
or for some class or principle. It is not infrequent for some 
cases who have been confined in an asylum, after their release, 
to start a crusade against all institutions. Endless suits for 
inventions and patents which they claim have been stolen from 
them, are instituted. Numerous letters are written, judges 
are appealed to, or others high in power, as the President or 
the king, are written to. Their egotism is usually shown by 
their belief in their own methods and plans of obtaining impos- 
sible results. Without understanding legal processes they may 
put together a large mass of high-sounding words, meaningless 
and useless, with a profound belief in their weight. Not suc- 
ceeding in their plans, the result is always ascribed to the 
treachery and corruption of the courts and judges or to the 
general failure of justice in this world. The feeling of perse- 
cution soon allies itself to this condition. They feel them- , 
selves martyrs, their oppdbents have used bribery and other 
evil methods against them. There is always present a certain 
absurdity in their plans giving evidence of their mental weak- 
ness. The persistence in their beliefs and in their attempts to 
carry them out is often remarkable. No amount of work or 
delay or number of defeats seems to have any effect in discour- 
aging them. A lawyer familiar with legal processes may, as in 
one instance under observation, carry out his plans with con- 
siderable acumen, observing the proper legal methods. 

The inconsequence of some of the charges, the absolute fail- 
ure of producing any creditable testimony, or even at times the 
failure to make any attempt to do so, is very striking and illus- 
trative of mental weakness. At times, however, such para- 
noiacs may get others to believe their statements and obtain 
their support. There is always a dangerous element in th""" 
cases, for not infrequently they show evidence of violence 
revenge for their supposed injuries, and often against thi 
holding high official position. This may take the form 
hatred to the lawyer or judges or others with whom they m 
have come in contact or against an unknown official, on 1 



PARANOIA. 373 

general principle that all are corrupt and must be removed 
before justice can be obtained. 

The general type of paranoia is seen in all these cases ; the 
form differs only in the line which the delusion happens to 
take. They are ready and often cunning in their defence 
when on trial, never for a moment allowing the plea of insanity, 
protesting their' sanity, and in this respect resembling especially 
the political and religious reformers. Hallucinations and illu- 
sions are rare in these cases. The provocative or exciting cause 
is not infrequently based on some actual or fancied wrong done 
them. On investigation, however, there will usually be found 
evidence of hereditary disease in their family history, or they 
will show marks of physical abnormalities, or at least they 
have always been considered eccentric if not actually insane by 
those who have known them. The question of responsibility 
in criminal cases of this class presents unusual difficulties. 

The law is not uncertain in its statements, but litigation is 
frequently protracted, expert testimony varying with the num- 
ber of experts called. The jury, left in doubt, generally decides 
on its own impressions, and in times of general public excite- 
ment usually against the plea of insanity and consequent 
irresponsibility. There is usually little doubt of the act having 
been committed, nor is any attempt made to conceal it, although 
at times plans have been well laid for escape. The egotism 
and feeling of self-importance, howaver, rarely permit the in- 
dividual to remain long quiet. The almost irresistible desire 
for notoriety soon leads to exposure, and not infrequently there 
is a voluntary acknowledgment of the act. Conspiracy is rare ; 
the combination of others with them in their plans scarcely ever 
occurs. This fact alone is strong evidence of their insanity. 

Religious Paranoia; religious insanity. — This form of 
mental disturbance, in which delusions of a religious character 
are the prominent feature, is not rare. 

S. M. (Fig. 23), female, set. 46. Duration of disease fifteen years. Pa- 
tient has delusions of a religious character ; thinks she has a mission to 
proclaim the rights of the -widows and orphans, and is being persecuted. 

Was arrested in the Cathedral for creating a disturbance. Has great 
desire to dress in a showy and gaudy manner. Delusion in regard to 
her greatness continues to increase, and she has become more affected 
In her manner and showy in her dress. 



274 



INSANITY - FISHER. 



The expression in the face shows clearly the absolute feeling of 
self -belief and satisfaction. 

We observe in various other varieties of insanity conditions 
in which hallucinations and delusions of a religious type are 
prominent features, but they lack the systematized logical 
process of thought which is the characteristic feature of paranoia 




Fig. 23.— Parauoia: Delusion of Graudeur and IViseculiuii, 

in general. In the latter the onset may be sudden, but is in fact 
rarely so. A careful history will develop that pecuharities in 
mental relations have been observed from childhood, perhaps a 
close concentration on one's self, a condition of mental reserve. 
It is true that there are exciting causes, as perhaps a revival 
going on at the time may be the beginning of the disease, so 
that its onset may appear acute aiul sudden. Again, financial 



PARANOIA. 275 

or domestic stress, disappointment of the afEections, overstrain 
from excessive study, or physical causes, such as the develop- 
mental periods of puberty, the climacteric period, etc., may 
appear as the direct exciting cause of the disease. These are, 
however, only, as we have said, the exciting causes, the real 
disease consists in the hereditary congenital degenerative sta.te. 
It is especially important that we should distinguish this form 
of paranoia from the ordinary delusional form of insanity com- 
mon to many conditions of mental disturbances, as in paranoia 
we have to do with a chronic, incurable state, often a most 
dangerous form of insanity so far as the peace and security of 
the community are concerned. Delusions of an imperative char- 
acter exist, leading to commission of acts usually not impulsive 
in character, but founded on well-defined beliefs, with aims 
and designs of afar-reaching character, which nothing but force 
and repression can prevent being carried out. These persons 
are willing to die the death of the martyr for the sake of their 
belief, and possessing, as they frequently do, considerable men- 
tal ability, perhaps eloquence, may induce others to believe with 
them that they are the special agents of God to carry on His 
behests, or to organize religious reforms throughout the world. 
Many prominent figures in history have without doubt been 
paranoiacs. The crudity of the delusion depends largely on 
the education and social position of the person affected, as well 
as on the manner in which the evolution of the delusion has 
become gradually and fully developed. 

Religious paranoia may manifest itself among the ignorant 
as well as the learned, among those living in J;he quietude of a 
small town or in the city. It is not rare among. the professional 
classes. It is not uncommon in the ignorant. In this respect 
it is similar to the other forms of paranoia which we have re- 
ferred to. It is this very fact, when occurring in the latter class, 
which doubly confirms them in their belief in their special selec- 
tion by God as his divinely appointed messenger. They fully 
appreciate their ignorance and lowly station in life, and reason 
that they could not possibly of themselves have such visions 
of God or the Virgin or such conversation with these holy per- 
sonages unless they had been chosen of God himself. This trans- 
formation of their personality is usually associated with exalta- 
tion, rarely depression, except, perhaps, in the beginning when 



27G INSANITY — FISHER. 

more or less mental confusion exists, when the hallucination 
and illusion of sight and hearing are more or less novel or in- 
frequent and have not as yet been classified and evolved into a 
fixed delusion. There is almost invariably an erotic element in 
these cases, but it is not the primary or fundamental form of the 
delusion. We have indeed a form of paranoia in which eroti- 
cism is the basis of the delusion, which we will refer to later; 
but in this form it is only secondary, as we often find in various 
well-defined forms of insanity, as melancholia, mania, epileptic 
insanity, etc. In fact, whenever the higher ethical powers are 
in abeyance the lower sensual nature manifests itself. 

Paranoia is rare in any form before puberty — that is, 
systematized delusions are not present in childhood. Certain 
mental and physical peculiarities may give strong indications 
of its future development, but it is rarely manifested before that 
period. However, at this time and during other developmental 
periods, it is especially apt to manifest itself. Under fortunate 
circumstances of life, wise educational care, absence of mental 
strain, a paranoiac may never have his delusions developed: suc- 
cess or the development of the mind in other directions may 
entirely overcome the inherited tendency. On the other hand, 
if the paranoiac becomes a priest or nun, the fixed attention on 
religious subjecte may result in this form of insanity; not indeed 
that religion tends to produce insanity of a religious type, but 
we that perhaps find more paranoiacs, as yet undeveloped into 
those with systematized delusions, naturally selecting such re- 
ligious separation as their mode of life. 

Tuke, in the " Dictionary of Psychological Medicine," under 
the head of religious insanity, describes seven forms. These, 
however, do not, properly ' speaking, all belong to paranoia. 
Religious delusions may be classified according as they — 

" (1) Accompany the mental development of over-stimulated 
and injudiciously educated children. The usual form is morbid 
fear ; he fancies he has neglected some religious duty, and he 
is before long overwhelmed by remorse for imaginary sins. 

" (3) Characterize the insanity of puberty. Here the men 
depression and fear of death lead to the desire to perform soi 
religious act as penance. 

" (3) Are caused by self-abuse. The patient is introspectii 
falls into the delusion that he has committed the unpardonal 



PARANOIA. 



37? 



sin. Auditory hallucinations, visions, trances, and ecstasies are 
common. Suicide and fearful self -mutilation may result." 

I would especially confirm the views of Tuke in regard to 
this class. While among masturbators there is not infrequently 
a marked degree of self-importance and exaltation associated 
with delusions of a sexual character in relation with the Virgin 
or Christ, it more frequently takes on the form, in my experience, 
of depression, in which their condition is altogether ascribed 
to their habits, which God is justly punishing them for. Many 
trivial errors of childhood will be recalled and self -accusations 
made, which take a far more important position in their minds 
as the cause of their hopeless condition than many more recent 
and more vulnerable acts, concerning which they will talk with 
but little repentance or sorrow. 

A young woman who had led the life of a prostitute for several 
years became rather suddenly melancholic, bemoaning her fate, that 
she had committed the unpardonable sin, that her soul was lost, etc. , 
but dwelt especially on an occurrence probably not ba^ed on fact, that 
she had attempted while a little girl to have unnatural relations with 
a New Foundland dog. ■ 

All these cases occurring in melancholia, as has been said, 
differ from the systematized religious delusions of paranoia, 
and complete recovery is possible. 

" (4) Are associated with (so-called) paranoia. Sexual excit- 
ability is often associated with misapprehended religious duty." 

This combination in a neurotic subject has repeatedly led to 
extravagant ideas and the foundation of fanatical sects. Texts 
of Scripture are applied personally, and nothing is too absurd 
for adoption under the guise of superior spirituality. The 
author has reference in this subdivision to the form of religious 
paranoia which is the subject of this chapter. It is not neces- 
sary that religion should have even interested this class previ- 
ously to their delusion. The casual reading or hearing of a 
passage of Scripture may be the starting-point, and may occur 
in a person ignorant not only generally but in regard to the 
Scriptures themselves. They not infrequently become thereafter 
students of the Bible, selecting and memorizing passages which 
apply to their special delusion. 

" (5) Are associated with epilepsy, dementia, and general 



;J78 INSANITY — FISHER. 

paralysis. In epilepsy Dr. Hurd says : 'There is never or rarely 
any sense of religious fear or unworthiness, but rather a sense of 
satisfaction in the perfornoance of religious duties.' In general 
paralysis as in mania there may be extravagant delusions of 
religious importance. 

" (6) Are observed in melancholic and climacteric insanity. 
Here the delusions may be the result of the influence of the 
special religious training. 

" (7) Arise in chronic mania or toxic insanity. These delu- 
sions are usually of an exalted character." 

In conclusion Tuke well says in regard to the course and 
determination of religious delusions : " As they are frequently 
associated with the insanity of pubescence the study of develop- 
mental insanities bears especially upon the subject of this article. 
The religious delusions which accompany masturbational insan- 
ity are not necessarily incurable. They are, however, liable to 
become persistent and are not readily amenable to treatment. 
They may be considered incurable whenever the patient has 
reached the stage of religious extravagance, which is surely in- 
dicative of mental deterioration. 

" The religious delusions of paranoia are essentially in- 
curable, being the legitimate development of a mental twist 
and the outgrowth of an abnormal personality. They event- 
ually become thoroughly assimilated by the mind, an integral 
part of its constitution. During the stage of persecution they 
may at times pass from the mind, but after the stage of trans- 
formation they cannot." 

I have quoted somewhat fully from Tuke, as he clearly de- 
fines the delusions of a religious nature as they appear in the 
various forms of insanity, and differentiates those peculiar to 
paranoia, as shown in his fourth subdivision. 

Erotic Paranoia — Erotomania — a form of paranoia in 
which the delusion pertains to love of the opposite sex, and is 
usually, as Krafft-Ebing has said, directed toward one in a 
higher station in life, or at least toward one who has given "" 
evidence of any knowledge of that person's existence. It 
essentialy a mental distortion, the result often of hallucinatic 
and illusions. The slightest acts are given a significance 
glance is taken as directed toward them, etc., etc. Notices 
papers are construed into reference to their relations. T 



PARANOIA. 379 

object of this affection may never have been seen or may not 
be known, except through the visual hallucinations. This does 
not in any way affect their belief in the existence of the mutual 
love. The laborer may become the beloved one of the princess, 
indeed he may be sought after. There are always present evi- 
dence of hereditary taint, signs of degeneration. 

The course of the disease is similar to paranoia in general, 
differing only in the special delusion. The exciting cause varies, 
often being excessive venery . Visions of a sexual character may 
be present, and this is specially so where the delusion has refer- 
ence to some exalted person, perhaps never seen except in public 
prints. There is a tendency in many of these cases to develop 
a delusion of a changed personality to correspond to their exalted 
affections. The circumstantial and detailed description of their 
own personality, and their description of the relations they have 
with their imaginary loved ones, are remarkable. This grows 
in distinctness with time and repetition until it has become 
thoroughly systematized. It is usually later that the delusion 
of persecution associates itself to this condition, after perhaps 
some public exposure has led to their apprehension. 

There may be religious delusions combined with the eroto- 
mania, and indeed sexual desire may not be present to anj' 
marked degree. There is little attempt at concealment, nor is 
there any shame felt. There is the same feeling of a special 
call to fin a mission as observed in the class of reformers. The 
evidence of mental weakness is apparent. 

There is another class of these cases, however, where appar- 
ently there are no hallucinations or illusions and in which the 
intellectual field is but little involved. The delusion is simply 
one of being loved and loving one who has shown absolutely 
no regard for them, or perhaps is not even conscious of their 
existence until their presence is forced on them, or they are 
followed from place to place, or various signs, letters, etc., are 
constantly giving them proof. It is especially here that the 
delusion of persecution arises, and the obstacles put in the way 
to prevent them from seeing the object of their affection are 
ascribed to a conspiracy. Never is the object of the affection con- 
sidered a party to this, but rather also the victim. This at least is 
at first the belief; it may finally take the form of hatred to the 
former object of their love, and result in a desire for revenge. 
III.— 30 



280 INSANITY — FISHER. 

These cases are often dangerous in the extreme, f ollowiug up their 
threats with skill and cunning ; and being little affected mentally 
except in regard to this one fixed delusion, their judgment is 
good in all other respects. There is usually, however, evidence 
-of some mental weakness. It is often most difficult on examin- 
ation to find any symptoms indicating insanity Especially if 
the patient is at all suspicious he will talk pleasantly and in- 
telligently on all other subjects, and will enjoy his success in 
eluding the various questions put to him. The most wary may 
be deceived by them, and even the subject of their delusion 
may be so mixed with known facts as to convince many who 
are not conversant with all the facts. It is rare that they will 
admit that they are subject to a delusion or will accept the 
plea of insanitj'- as a defence. However, when in confinement 
they may, for the purpose of obtaining their liberty, admit 
they have been subject to a delusion which they no longer 
entertain. These statements are always to be received with 
caution, as, from the opinion already given, their mental state 
is an incurable one. The recovery from a delusion, no matter 
how dangerous in its character, in mania and melancholia may 
be permanent, and its recognition by such cases is often the first 
sign of a permanent restoration to mental health. 

The well-known case of Dougherty, who labored under the 
delusion that a celebrated actress entertained feelings of regard 
for him, illustrates what has been said. He followed her from 
place to place, even to Europe. Every unconscious movement 
would be ascribed to some secret acknowledgment by her of his 
regard. He was enabled by his skill as a telegrapher to obtain the 
necessary means to follow out his plans. Nothing seemed to dis- 
courage him ; he possessed the usual feeling of exaltation and 
self-satisfaction peculiar to these cases. He at one time ac- 
knowledged that his opinion in regard to her liking for him 
was an error, but this was only for a purpose of his own. The 
dangerous character of the man was manifested later by his 
murder of a physician in the asylum to which he had been sent. 
His trial for this act, however, resulted in conviction, the pi 
of insanity not being accepted. There is no doubt that accoi 
ing to the law as it now stands the conviction was a just oi 
A clear knowledge of the right or wrong of his act existed 
the mind of the prisoner ; but we have to deal with a person w 



NEURASTHENIA. 2§1 

does not allow that question to arise in his mind. His desire is 
the only thing which he thinks of, all moral and physical obsta- 
cles are disregarded. It is this disregard of consequences which 
is the strongest evidence of their insanity, combined as it often 
is with absolutely impossible methods of accomplishing their 
ends. The question, however, of their responsibility before the 
law is one that really belongs to the field of sociology. 

INSANITY PROM CONSTITUTIONAL NEUROSES. 

Th^ various neuroses are described in books on diseases of 
the nervous system, and I shall not describe them except in so 
far as they bear on mental diseases. Under the head of neu- 
roses are included the so-called functional diseases, which show 
no structural or organic changes in the organs which are 
affected. We find the same conditions in the nervous system. 
There is indeed some change due to malnutrition, exhaustion, or 
some toxic agencies, but as 3'et what these are no investigation 
has satisfactorily settled. As advances are made in our study 
of disease this class will be reduced in number, as from the very 
nature of things disease cannot exist without an adequate 
cause. Epilepsy, hysteria, pursuing as they do a developmental 
and chronic course, must be due to some definite and deep-seated 
lesion. 

Neurasthenia. — Nervous prostration represents in general 
a lowering of the tone of the cerebro-spinal system. It may es- 
pecially involve the brain or the cord, in which case the sj'mp- 
toms all point to functional rather than permanent or organic 
disturbance of function. There is usually, however, an affec- 
tion of the whole nervous system, although one part may be more 
involved than the other. We may find almost absolute loss of 
function, an apparently sudden inhibition both in the physical 
and psychical fields. This inhibition often, however, disappears 
as suddenly as it arose. We see all the evidence of vaso-motor 
changes, temporary, as a rule, although at times they pass on 
into definite chronic states, ending in special neuroses resem- 
bling, although rarely exactly, those previously described. 

Neurasthenia must at present be accepted as a distinct ner- 
vous state, and while under its head such conditions as hysteria, 
hypochondria, melancholia, etc., may be falsely included, as 



,283 INSANITY— FISHER. 

many similar symptoms exist in all, yet despite this confusion 
careful examination will show that we have to do with a class 
of symptoms which, irregular and contradictory as they may 
appear, go to make an entity, as well defined and positive as 
other diseases, physical or psychical. A certain opprobrium 
has attached itself to the term or rather to the individual 
with the disease, as in the case of hysteria, as if the patient 
were capable of controlling or banishing altogether the symp- 
toms he complains of. There is also considerable confusion in 
separating these latter conditions from each other. This is not 
so surprising, as they have many symptoms in common, and 
indeed one disease may engraft itself on the other or become 
associated with it. 

Foster has defined neurasthenia as " a condition appearing 
in the early and middle periods of adult life, presenting objec- 
tive symptoms of deranged functions of the nervous system, 
slight in degree but definite in character, and persisting for 
months, for years, for life. There is inability to walk more 
than a short distance without fatigue ; a variable increase of 
myotatic irritability ; headache ; aching or pain in the back and 
legs, and spontaneous sensations of tingling, formication, heat 
and cold. Dj'spepsia, constipation, and other derangements of 
the functions may result in anaemia. There is a mental phase 
in the condition, the patient being irritable, unable to pursue a 
consecutive train of thought, or there may be a cheerful, egotisti- 
cal resignation to invalidism. It may be caused by emotional 
or mental strain, worry, fright, etc." 

He further makes several subdivisions which more or less 
accurately give its symptomatology, i.e. — cerebral, cerebro-car- 
diac, cerebro-gastric, cerebro-spinal, gastric, genito-urinary, 
neuralgic, spasmodic, spinal, vaso-motor, and sexual neuras- 
thenia. 

It is rare, however, that we find any one of these forms dis- 
tinct and by itself. They are usually associated, the cerebro- 
spinal type being the most common, with perhaps a predomi- 
nance of a certain class of symptoms, as spinal irritation or a 
feeling of mental incapacity and fear of insanity. 

Neurasthenia is by no means a disease peculiar to- modern 
times or to any one country. It has been described by the older 
writers, even by the ancients. It has only come more into 



NEURASTHENIA. 283 

prominence since its symptoms have been more clearly grouped. 
There can scarcely be made a differential diagnosis between it 
and cerebral and spinal irritation. Its symptoms are multitu- 
dinous and variable, but aU point toward exhaustion and a de- 
parture from normal reaction. Their interest to us lies in the 
bearing they have on mental disease, either as prodromal symp- 
toms of distinct psychoses as melancholia, general paralysis, 
epilepsy, etc., or in their relation to those ill-defined mental 
states lying in the so-caUed borderland of sanity, in which im- 
pulses more or less imperative manifest themselves. Here, 
perhaps, belong most properly aU those peculiar mental disturb- 
ances which express themselves in fear of disease, frequently 
of insanity, of open places (agoraphobia), of closed places (or 
claustrophobia), etc. "We shall describe these conditions later 
under this heading. These symptoms may pass beyond mere 
eccentricity into permanent states, which must be regarded as a 
true degenerative condition. 

Neurasthenia may be regarded as a degenerative state, at 
least in the chronic forms. It is more often congenital or 
hereditary than acquired. We have, in other words, a predis- 
position to disease, a soil in which exciting causes as worry, 
mental strain, shock, excesses, alcoholism, etc., have an effect 
not resulting in the healthy. The most common exciting causes 
are overstrain, physical and mental, associated with domestic 
or financial loss. Shock from an accident, whether accom- 
panied by actual physical injury or not, may precipitate the 
sudden or gradual onset of nerve exhaustion. Disappointment 
in the affections or in the attainment of some much wished- 
for position may excite in a constitution predisposed, either 
from hereditary taint or from long-continued overwork to dis- 
ease, this tendency to an absolute coUapse. It is not infre- 
quent to find such conditions result in unsuccessful candidates 
for high political position; again, in the young after the 
excitement and exhaustion consequent upon the severe ordeal 
of an examination. Shock of any kind is a very common 
cause, as has been said. The frequent trials for damages in 
our courts have done much to develop an extensive literature 
concerning the consequences of such occurrences on the nervous 
system. Some cases of interest have arisen in which claims 
have been made against the telegraph companies in which there 



284 INSANITY — FISHER, 

has been neglect or failure in conveying the proper message, 
resulting in a shock to the recipient. Death may result in some 
instances ; truly it is natural to expect some effect tending to 
disease of a serious nature. 

A gentleman under my observation was present in an accident on a 
railway in France. His car was not involved ia the wreck, and he 
was very active in rescuing and aiding the injured. He continued his 
journey, and it was not for some time that symptoms of a nervous 
character manifested themselves. He became timid while travelUng, 
and would have recalled to his remembrance all the horrors of the scene, 
were there the slightest delay on the train he was travelling on. This 
gradually developed into a fixed morbid fear of travelling, and later he 
became a distinct example of neurasthenia. 

Exhaustive diseases associated with pain, especially if much 
sleep is lost, are prone to result in this disease. Loss of 
sleep is indeed one of the most marked symptoms of neuras- 
thenia; it is also one of the commonest causes of it. Venereal 
excess, especially masturbation, is often the basis of the exhaus- 
tion of the nervous system, and when this is the cause it gives 
rise to a form of neurasthenia peculiar in itself, and may indeed 
be the origin of many of the cases of sexual perversion. 

The symptoms peculiar to neurasthenia are essentially cere- 
bral and spinal, and the latter are in fact subordinate to the 
former. 

" While neurasthenia is protean in its manifestations, there 
are still certain symptoms rarely in default, which for this 
reason have been called by Charcot neurasthenic stigmata. 
These are : a special form of headache (casque neurasthenique) 
and a sensation of emptiness in the head ; insomnia and disturbed 
sleep; psychic adynamia ; motor enfeeblement; spinal hyperaes- 
thesia, and rhachialgia with points of election (plaque cervicale, 
plaque sacree, and coccygodynia); gastro-intestinal atony; geni- 
tal and vaso-motor disorders" (E. Eegis, "Practical Manual 
of Mental Medicine") . 

In our study of the disease especial reference only will be 
given to the mental symptoms. Such patients complain of a 
feeling of loss of mental power, especially the power of concentra- 
tion upon any given subject. They cannot read because their 
attention soon wanders, or they experience great fatigue. They 
are unable to carry on their usual business, either from some 



NEURASTHENIA. 285 

cause as mentioned above or a fear that they will be unable to 
do so correctly. An almost insane dread of meeting business 
or social friends exists. The idea of an appointment, the antici- 
pation of it, will often be sufficient to start up a train of symp- 
toms, in which there is especially shown a loss of will power, 
even to the extent of absolute motor inability. The emotional 
state is also very much affected, as shown by a tendency to burst 
into tears, or even laughter ; this is not really based on any true 
grief or joy, but seems to be something outside of themselves. 
There is usually a tendency to irritability and anger on slight 
provocation. 

This state is fully recognized by the patients, who are usually 
introspective and love to talk over their various mental changes. 
Depression even to extreme melancholia is not uncommon as 
a result of morbid fear of losing their minds. They make con- 
stant threats of suicide, or fear that they will commit such 
an act. In fact such attempts are often made, but usually with 
no full intention of carrying them out. There is always a fixed 
idea present which has special reference to their mental con- 
dition. They constantly assert that they can bear any amount of 
pain if they could only get rid of the peculiar feeling of oppres- 
sion and weight in the head, and of the feeling of absolute loss 
of mental power and ability to exercise their will. Under 
special excitement, or if carried away by the necessity of action, 
or even in extreme pleasure, they find themselves capable of 
carrying on plans or doing things involving great fatigue. 
The reaction in these instances is often extreme when the 
necessity for exertion is removed. 

The intellectual faculties are rarely involved, the memory is 
not impaired . When the interest is awakened they will remem- 
ber all the details and every direction given by the physician, 
and if they have faith in him, will depend on and carry out 
with exactitude all his directions. 

Hallucinations, illusions, and delusions are rare, nor do we 
find a tendency to development into such forms of mental dis- 
ease characterized by them. They seem to be subject to im- 
pulses, to doubts and fears, which occur suddenly. Under cer- 
tain impulses they may be able to walk miles without fatigue; 
there is, in fact, rarely any actual motor weakness. At another 
time the sense of motor weakness is so extreme that they may 



286 INSANITY — FISHER. 

collapse before going half a block, and find themselves in- 
capable of proceeding another step. These functional motor 
disturbances are shown also in various spasms of the muscles, 
especially of the face ; or of the eyes, in frequent winking, or 
of the corners of the mouth. This may indeed involve the 
whole body. This is especially so if attention is drawn to it. 
It becomes indeed a habit, at first voluntary, but later it becomes 
more or less involuntary. The tremor of the hands is often 
shown in their inability to perform any act requiring skill; 
especially is this seen in writing. The mere attempt to write 
excites a feeling of mental and physical fatigue, although the 
ability to dictate a rational letter may not be impaired. 

The muscular system is not impaired, unless indeed the 
health has been so much affected as to confine the patient to 
the house or bed. 

Associated with these mental and motor disturbances there 
is much sensory disturbance. Hyperassthesia or pain exquisite 
in its character may affect the head, and involve one-half of the 
cranium, or, as is more common, remain limited to the vertex 
or base. This may often be only dull in character, a feeling of 
weight at the base of the brain. Pain is widely distributed 
along the spine, and over various regions as the heart, kidneys, 
ovaries, and even in the bones. Pressure may elicit consider- 
able pain, sometimes very extreme. Anaesthesia, loss of sensa- 
tion, is not uncommon; a feeling as if the parts were dead. 
This may follow certain lines, as one-half of the body, or over 
given areas. Rarely in examination do we find any objective loss 
of sensation to the various tests of heat, cold, pain, or touch. 

The symptoms are largely subjective. Vaso-motor disturh- 
ance is common. Sudden congestion or analgesia of the head or 
spine may cause vertigo, a sense of fulness, or a tendency to 
syncope. The pulse corresponds to this condition, so that we 
find marked variations in it, from a slow to a rapid one, with 
intermittence. These attacks are accompanied by a feeling 
of impending death. 

Insomnia is perhaps one of the most characteristic syr 
toms, and the one which tends to aggravate all the mer 
symptoms defined. Even when sleep is present, it is usus 
accompanied by dreams of a distressing character, and then 
no fee/ing of rest on waking. The interest, in a medico-lei 



NEURASTHENIA. 287 

sense, in these cases arises when, perhaps, unreasonable antip- 
athy or excessive friendship is present, which has influenced 
the individual perhaps unduly in his testamentary capacity; or, 
again, in criminal procedure the question of responsibility ma^ 
present itself. 

Many acts of these cases are, as we have said, impulsive in 
character, often imperative indeed. Not infrequently, especially 
when there is a sexual element in the form of neurdsthenia we 
have to deal with, there exists an almost irresistible tendency to 
some overt and often indecent act. We will consider this in 
more detail under a special head. This disease belongs to the 
class of degenerations, and has much in common with paranoia, 
especially in the presence of a fixed idea. It is, however, not 
as logical in its development, and although at times there is an 
accompanying delusion of persecution, it is rare. The fluctuat- 
ing character of the symptoms, the physical signs of physical 
exhaustion and pain, are absent in paranoia. The anxiety and 
depression are quite foreign to paranoia, in which indeed we 
usually find a spirit of egotism and self -appreciation. 

The prognosis is usually good. There is, however, a possi- 
bility of termination in one of the well-defined mental diseases, 
especially mania or melancholia, with homicidal and suicidal 
intent. 

It does not usually take the form of insanity with delusions, 
but rather that of melancholia with complete loss of hope of re- 
covery. There is usually the desire to recover, but the constantly 
present dread of becoming insane may result in some overt act. 

Tuke refers to neurasthenia as being a prodromal stage in 
general paralysis. This may be so, but is probably rare. 

One such patient has been under my observation : 

Male, set. 27, a butcher by occupation. His history was negative, ex- 
cept that he had been overworked ; he was, however, very successful and 
accumulated considerable money. He became sleepless and finally 
anxious about himself, and unable to attend to his business, which in- 
creased his anxiety. He feared that he was losing his mind. A year 
later he showed the symptoms of a typical case of general paresis. He 
became happy and self -satisfied, considered himself perfectly well, and 
in no way troubled himself about his business. 

There could be no greater contrast than that between the 
previous mental state and its termination. 



288 INSANITY — ^FISHER. 

Hysterical Insanity.— Hysteria is essentially a disease 
in which degeneration is the most prominent feature. We are 
unable to point out the pathological changes in the brain which 
account for the symptoms. We class it, therefore, as a func- 
tional disturbance. Perhaps no condition involves so completely 
the whole nervous system as hysteria. It manifests itself, there- 
fore, by both physical and mental symptoms. The former are 
multitudinous, simulating all other diseases. The multiplicity 
of the symptoms is, to a certain extent, a point of diagnosis; 
their shortness of duration and their sudden disappearance are 
as significant. We have noticed this same characteristic in 
neurasthenia, the two conditions having indeed much in com- 
mon ; often indeed we find them combined. 

In hyteria we have to do with great instability of the ner- 
vous system ; a slight cause may initiate marked mental 
symptoms. Despite, however, the multiplicity of the symptoms 
there is a certain uniformity about them, which more or less 
clearly defines them. 

The line between hysteria and hysterical insanity is not 
always easy to draw. We find the emotions more affected than 
the intellect, and therefore the acts are of the impulsive type. 

The most important element in the causation of hysteria is 
heredity — either of hysteria itself or the various neuroses as 
epilepsy, chorea, etc., or insanity. It is not rare to find in the 
descendants of the insane various functional diseases of the 
nervous system manifesting themselves, and among others this 
form of nervous instability. The exciting causes are various— 
any shock, whether traumatic or emotional, as fear, domestic 
loss, financial stress, disappointment in the affections, exhaus- 
tion from disease, as fever, loss of blood inducing anaemia, 
chlorosis, sexual excess, onanism, etc. 

Hysteria is most common in young females about the age 
of puberty, but may occur in the more advanced in life, even 
irdeed at the menopause; or, again, in children, although much 
more rarely. It is observed also in men. 

The typical forms, as described by Charcot and other Frei 
writers, are not so common in this country or in Englai 
Such cases present all the physical signs of the disease, 
hemiansesthesia ; hemiplegia, usually unassociated with wasti 
of the muscles; contractures, tremors, choreiform in charact 



HYSTERICAL INSANITY. 389 

unilateral loss of vision, taste, etc. There is usually also great 
vaso-motor disturbance, cardiac palpitation, unilateral sweating 
associated with heat or cold of the extremities. This class of 
symptoms is often very definite, but usually we find the anses- 
thesia is but partial. 

The paralysis, when present, whether hemiplegia in type or 
paraplegic, is too absolute and complete to render a diagnosis 
as a rule difficult. Still the previous history of other attacks 
is the most important fact in establishing an absolute diagnosis. 
Outside of the general physical condition which we have 
described are the convulsive seizures, so common in this dis- 
ease. They are frequently epileptoid in character, and when so 
we have a condition called hystero-epilepsy, which is essen- 
tially hysteria, however. A special characterisUc of these 
convulsive seizures is that, as a rule, the patient appreci- 
ates their onset and therefore receives a warning more often 
than in epilepsy. I believe, however, that these attacks are 
as impossible to check on the part of the individual as are true 
epileptic seizures. They, however, are usually able to get to 
a place of safety before the onset of the attack, although this 
is not always the case. The convulsions in hysteria of the 
milder or more usual form differ from those of epilepsy in 
that they are irregular. There may be rapid clonic convulsion, 
limited to one side, or one hand, or to both feet ; more rarely 
there is a sudden fall, followed by clonic and tonic convulsions. 
A complete loss of consciousness is rare. Patients will gener- 
ally remember what has occurred, and recall those who have 
been present. Following the attack, as a rule, there is not 
present the tendency to sleep which usually occurs in epilepsy. 

A distinct mental state is present, which manifests itself by 
excessive talking, crying, or laughing, showing that cerebral 
excitement is present. Especial emotional states may show 
themselves by the attitude assumed by the patients, as that of 
prayer, of fear, etc. These attacks may continue for several 
hours, and are not infrequently followed by a mental condition 
of confusion, lasting usually but a few hours or again for days. 

The severe form or hysteria major is, as I have said, rare 
in this country. Charcot 'describes three stages of the convul- 
sive attacks, first the epileptoid, resembling very closely an 
ordinary epileptic seizure; second, one in which we have ex- 



290 INSANITY — FISHER, 

treme opisthotonos, pleurosthotonos, or emprosthotonos ; and a 
third stage in which there is less of the convulsive character 
but mental symptoms are more marked. 

There is excitement, as shown by the tendency to talk or 
sing, or to assume special attitudes indicative of certain 
emotions. There is little difference in their forms except in the 
character of the convulsive seizures. We may find the convul- 
sive stage entirely absent, there being only successive attacks of 
mental excitement, a true maniacal seizure, which may require 
restraint. These attacks may occur several times during the 
twenty-four hours and continue for weeks. We frequently 
observe a religious or an erotic element in their conversation 
and their attitudes. There is no absolute loss of consciousness 
of what they are doing or saying, although it is beyond their 
control. They are frequently obscene in their language, and 
show signs of lasciviousness. 

These acute attacks of hysterical mania may be absent, there 
being simply a mental condition which by its general symp- 
toms of emotional instability, unreasonableness, selfishness, 
jealousy, and tendency to quarrel with every one, defines itself 
as hysteria. 

In women all these states are increased at the menstrual 
epochs; especially is this the case when sexual ideas are present. 
There may be excessive masturbation at these periods. This 
element increases and prolongs the mental excitement. This is 
shown by the following case : 

Miss L., set. 17, a modest and accomplislied young woman, is subject at 
her menstrual periods to attacks maniacal in character. She becomes 
suddenly excited, usually at night, and is aroused from her sleep by 
some frig'ht ; she cries out, talks upon innumerable subjects, has no 
convulsions, but has to be restrained owing to her incessant movements. 
She has such a sense of genital irritation that she resorts to masturbation, 
which she is unable to refrain from. These attacks are followed by 
a condition of extreme exhaustion, lasting several hours to several 
days, in which she seems to be unable to appreciate what is going on 
around her. These attacks may pass into cataleptic or trance sta 
lasting for days and weeks. 

In an Italian boy brought to the hospital in an apparently unc 
scions state, we watched carefully for any sign of simulation or fra 
There seemed to be almost complete anaesthesia — a needle could 
passed through the fleshy part of his leg or arm without appar 



HYPOCHONDRIACAL INSANITY. 291 

feeling on his part. Any position in which his arm or leg was placed 
remained fixed for a long time, no matter how uncomfortable it might 
be. Carefully watched, he would lie for hours in the same position, the 
respirations bein^ shallow and infrequent. There seemed to be no de 
sire for food, which was never voluntarily taken. Having, however, 
stopped feeding him by force, and all food having been removed, he 
was observed one night to rise from his bed and get some articles of 
food from tables of the other patients. 

This case corresponds to those which have been reported of 
the trance state, fasting mania, etc. Careful investigation will 
usually show that there is more or less simulation and fraud 
connected with them. There is without doubt a true condition 
of partial loss of consciousness similar to the hypnotic state. 

In the constitutionally hysterical temperament, which is a 
fixed condition and in which paroxysmal seizures are absent, 
melancholia is more common than mania. Suicidal impulses 
are common ; attempts are frequently made or at least threatened. 
They may indeed be carried out, though rarely. These pa- 
tients become very depressed and possessed with the fear of go- 
ing insane, or indeed of killing themselves or others. Halluci- 
nations or delusions are rare, nor is the depression of the same 
character as in melancholia. There is not unusually present the 
feeling of self-condemnation. In children hysterical attacks are 
not uncommon and may be associated with epileptic seizures. 
We may observe true hysterical contractures, anaesthesia, par- 
alysis, etc. 

The attacks of crying, laughing, vomiting, barking, using 
obscene language, etc. , are essentially hysterical. There is fre- 
quently present, even in these young cases, simulation or at least 
exaggeration. 

It is among this class we find cases of pyromania, or, again, 
when a sexual element is present, accusations of assault may 
be falsely made. In fact many cases of impulsive insanity, so 
called, have a hysterical basis. 

Hypocliondriacal Insanity.— In this disease we have a 
condition which has passed beyond the feeling of anxiety and 
depression in regard to some bodily disease they may have, to a 
fixed idea which cannot be removed. It resembles in many 
respects neurasthenia, and yet differs from it in that there is 
greater concentration on the personal condition. The same 



392 INSANITY — PISHBE. 

may be said in regard to melancholia ; in both we have marked 
depression, but in the latter it is caused by the thoughts or de- 
lusions which may be present in "the mind, while in hypochon- 
dria it is due to the actual or imagined disease bf some organs 
of the body. In most of these cases there is a special delight or 
at least a feeling of necessity to describe aU. the individual 
symptoms of their disease. The tongue, pulse, digestion, etc., 
are carefully and anxiously observed. 

The condition is generally observed in those with a predis- 
position to disease of the nervous system, especially those heredi- 
tarily affected. It may lead to a mental condition which com- 
pletely inhibits all ability to do anything except to think and 
talk of their iUness. The depression may become so extreme as 
to lead to suicide. We at least observe great loss of wiU power 
and inability to concentrate the attention. 

Many of these fixed ideas of hypochondria refer themselves 
to sensations in the brain. Every feeling of fulness or pain in 
the head is dwelt upon. There is a feeling of complete inabil- 
ity to fix the attention on anything. Reading or writing causes 
complete exhaustion or pain at the vertex or more usually at 
the back of the neck. 

Subjective sensations are common. The patient wiU com- 
plain that he can feel the blood all coming away from his brain. 
He feels certain that he will become insane, that his brain is 
dead, and so forth. These feelings are not infrequently ex- 
cited by what has been read, especially is this so if masturba- 
tion has been practised at any time. This class of patients cor- 
responds closely to those of sexual neurasthenia. 

The most bizarre yet fixed beliefs may exist, however. 

A young man under my observation maintained thatone-balfofhis 
face was constantly getting smaller. This prevented him from keep- 
ing at his work, and finally he went voluntarily into an asylmn for a 
year. During this period careful measurements were taken, which con- 
clusively showed that there was no difference between the two sides 
of his face. He remained under my care for some time, but no a 
ment could convince him of the truth of the facts. 

Hypochondriasis in connection with the digestive orgar 
very common— there may be fixed ideas of disease of the st 
ach or intestines. There is frequently a feeling that the ph 



EPILEPTIC INSANITY. 293 

cian is deceiving them. The depression is often excessive, pre- 
venting all attempts at occupation. Sleep and general nutrition 
are interfered with. Any new disease is readily taken up by 
some of these cases. 

Suicide is not rare. Hypochondriasis in regard to the sex- 
ual organs is frequently present in the young, more especially 
among men. There is usually a history of masturbation. The 
fear of impotency soon arises, the organs are felt to be under- 
going atrophy ; the penis is usually felt to be cold. This may 
occur about the time when marriage is contemplated or may 
have no reference to it. It was clearly illustrated in a patient, 
a professional man, who gave a history of marked venereal 
excess of all kinds. He had married and had_nine children, but 
was possessed with the fixed idea that his organs were under- 
going atrophy. The importance of the mental condition con- 
sisted in the depression associated with it and the tendency to 
suicide. 

EPILEPTIC INSANITY, OB MENTAL DISEASE IN 
EPILEPSY. 

I would here foUow the definition given by W. Bevan Lewis 
in his recent work on mental disease, viz. : " Epileptic insanity 
is that form of mental derangement, in the antecedent history, 
the oncome, and further development of which we recognize an 
intimate connection with the epileptic neurosis." 

CuUere defines epilepsy as a convulsive neurosis character 
ized by intermittent attacks of short duration and variable in- 
tensity, and accompanied by a sudden loss of consciousness and 
generally by mental disease (see Cullere, p. 419). 

The tendency of epilepsy is toward dementia. The vari- 
ations in its course are those found in all mental disease — ^that is, 
the periods of excitement and of depression either alternating 
the one with the other or, almost as in circular insanity, one 
following the other. There is likewise a special tendency to 
hallucinations, illusions, and delusions, but they have nothing 
about them which is characteristic of epilepsy proper. Any 
distinction between epilepsy per se and epileptic insanity is 
difficult, if not impossible, since, pathologically, we have the 
same iU-defined condition present in which, as Lewis has well 



294 INSANITY — FISHER. 

said, the question must often be asked in an asylum, why is 
such a patient confined? Indeed, we find many in whom epi- 
leptic seizures occur only at long intervals and whose condition 
in the interparoxysmal state is apparently normal, yet during 
the paroxysms they are maniacal, melancholic, or are pos- 
sessed of some strong delusion, and are not infrequently subject 
to marked hallucinations and illusions of the special senses, 
either preceding or following the seizure. 

In our study of epileptic insanity we must proceed on the 
same lines as in that of the neurosis itself; in fact, insanity is 
a mental condition to which all epileptics are liable, and prob- 
ably no cases exist in which there is not more or less mental 
impairment present. This subject is one of great importance, 
because perhaps no line of defence is more frequently adopted 
than the claim that there has been a history of epilepsy in the 
individual under examination. It is certainly very difficult to 
come to a conclusion as to whether at the time of the commis- 
sion of the act the person was influenced or under the control 
of some fixed delusion which was well defined at the time. 

It is perhaps advisable, where a positive history of epileptic 
seizure is obtainable, to mitigate the punishment for the crime, 
while not allowing the criminal to be held as absolutely irre- 
sponsible. 

While some examples of great mental brilliancy no doubt 
present themselves to the experience of aU among epileptics, the 
great majority show at least some evidence of moral or mental 
deterioration. In this disease, as in other forms of insanity, we 
find the higher moral qualities are the ones first affected, so that 
on the ethical side of the character the loss is most marked. The 
patient becomes more or less brutal, the face often shows a loss 
of the finer elements, and the emotional state becomes so unsta- 
ble that the individual is uncertain, impulsive, and suspicious. 
As a diagnostic point of a true epileptic seizure perhaps the most 
important is the suddenness of the onset of the attack, associ- 
ated with complete loss of consciousness and convulsive seizm ~ 
general or localized. The complete loss of the reflexes; as si 
in the pupil, in the conjunctival response, and knee jerk, 
well as the loss of reflex control over the bladder and rectu 
causing unconscious urination and defecation, are additio 
points of value in the diagnosis. No one of these, however, ( 



EPILEPTIC INSANITY. 



205 



be held as of supreme importance ; their association is princi- 
pally of value. 

We have considered two forms or groups of epileptics : those 
in whom the symptoms are dependent upon a general nervous dis- 
order — in other words, so-called idiopathic epilepsy — and those 
whose disorder depends upon some local brain lesion, either trau- 
matic or degenerative. The first class more properly belongs to 
mental disease, although in the second class the symptoms are 
often not dissimilar from those observed in the neurosis proper. 

The first group will, therefore, present in many instances a 
bad hereditary history, so that either in the parent or collateral 
branches epilepsy or other neuroses — insanity or alcoholism — 
will be present; in fact, the descendants of epileptics themselves 
may present these various disorder^ rather than that special 
neurosis. The proportion of insane in our asylums with 
epilepsy as a nause is very large. In England, out of 14,336 pa- 
tients admitted to the various asylums in the year 1887, there 
were 1,294 epileptics, of whom 777 were men and 517 women, 
or about nine per cent. The appearance of epileptic seizures 
among the insane is of very frequent occurrence, especially in 
general paresis; the distinction, however, between the neurosis 
proper and these irregular attacks is to be observed. The 
maniacal condition may precede the epileptic seizure or may fol- 
low it. It very often precedes the attack. For several hours, 
days, or even weeks a peculiar mental state may be observed in 
these patients which is noted by the attendants as premonitory 
of a series of attacks. They may be of the nature of hallucina- 
tions, and often those associated with the special sense of smell 
or taste, or of hearing or sight. Not infrequently the same kind 
of hallucinations precedes each attack, and this is especially in- 
dicative of some localized lesion as the seat of the disease. 
Delusions may follow and be founded on these hallucinations, 
and it is especially on this account that these patients are danger- 
ous. The wildest mania may he the result; it is more usually 
homicidal than suicidal in type. There is a special tendency 
to the so-called form of moral insanity in these cases. The 
most purposeless, impulsive, and cruel acts are committed by 
them at times; indeed, the crimes resemble not infrequently 
those committed by paranoiacs which from time to time startle 
the world. As a rule, they have no recollection of the acts com- 
UI.— 31 



296 



INSANITY — FISHER. 



mitted on returning to consciousness a double consciousness 
existing in many of these cases. 

F. M. (Fig. 24), xt. 45, female (colored), has tendency to become ex- 
cited and maniacal. Expression of the face indicates sullenness and 
obstinacy. 

In the milder forms of mental aberration long journeys have 
been taken by such persons, and even business has been trans- 
acted without there being any observable peculiarity in their 
actions, and on returning to consciousness they have been sur- 
prised at their 
new surround- 
ings. One should 
be cautious in 
forming opinions 
in regard to the 
statements made 
by the patient; 
the motive must 
always be care- 
fully investigat- 
ed, as this disease 
may be claimed 
simply as a cloak 
for various crimes 
which have been 
committed. Al- 
coholism must 
also be excluded. 
Automatic acts 




Fig. 24.— Epileptic Mania. 



apparently committed in the dream condition may be frequently 
observed after an attack of epilepsy, even of a mild character. 
In other cases mental disturbance may appear to take the place 
of a true convulsive seizure, and is then called •' masked epi- 
lepsy." More frequently, however, these mental disturbances 
follow or precede a true epileptic seizure. 

Idiocy is not present in ordinary epilepsy except when due to 
organic changes seen in infantile forms ; but here there is gener- 
ally associated some form of paralysis, either hemiplegia or di- 
plegia of cerebral origin, along with convulsive seizures. Thisis 



EPILEPTIC INSANITY. 297 

dependent upon actual destruction of the cortex surface of the 
brain, or upon the presence of cystic degenerations consequent 
upon a preceding inflammation, or upon direct injury and com- 
pression of the brain substance by a meningeal hemorrhage, 
occurring most frequently during a prolonged and tedious deliv- 
ery or from forcible compression with the forceps. More rarely 
the condition is one of intracerebral hemorrhage. In these 
patients there is usually dementia in varying degrees. The 
epileptic seizures do not differ in character or in response to 
treatment from those observed in the idiopathic form. The 
question of responsibility in relation to crime would rarely be in 
doubt, as the evidence of the disease would be well shown by the 
palpable conditions present. 

In reports of cases under my own observation there was evi- 
dence of marked degenerative changes in the conformation of 
the skull, actual measurement invariably showing in hemiplegic 
cases a diminution in the size of the skull on the affected side, 
while the brain frequently exhibited marked atrophy and shriv- 
elling of the convolutions, thinning of the cortex, and dilatation 
of the ventricle on the same side, with secondary degenerations, 
extending especially in the motor tract into the spinal cord. 

While the idiopathic cases do not show such definite brain 
lesions, still there is quite commonly a general affection of the 
brain of a degenerative type ; and while we do not to-day hold 
as positive any special change in the frontal lobes, or in the 
temporal lobes, as formerly stated by Meynert, still in the cor- 
tex, especially, according to Lewis, in the third layer, the nerve 
cells are not infrequently degenerated and their nuclei filled 
with pigment, and the cells themselves the seat of vacuolation. 
We also find increase of connective tissue and involvement of 
the association fibres. While many similar conditions are 
found in other degenerative forms of mental disease^ — and there- 
fore we are unable to speak of definite lesions peculiar to epi. 
lepsy — still we are certain of this much, that disease is present, 
and, in fact, is never absent on microscopical study of the brain. 

All forms of insanity have certain varieties of symptoms in 
common — the change in the individual and concentration of the 
attention on the ego. We next observe some alteration in the 
feelings and thoughts and actions, and finally dementia. In 
epileptic insanity we have all these functions more or less in- 



298 INSANITY — FISHBE. 

volved, and in a hundred cases which I made the subject of 
study, in none were these conditions absent. It is always diffi- 
cult to get an accurate history of these patients. 

One element observed in almost all cases is what might be 
called "religiosity." It is of an emotional type, and is perhaps 
more common among women. The attention to prayers and 
desire to attend religious services are very marked ; however, it 
seems to be merely a superficial feeling, as any remorse for 
acts committed while in this state is entirely absent, and indeed, 
when interrupted in some specially brutal act following an ex- 
pression of a high moral character, no appreciation of the dis- 
crepancy is apparent. 

Cloustou states that epileptic insanity is not so common 
among women as in men, nor does it respond so readily to treat- 
ment by the bromides. One feature — the suicidal impulse- 
seems to have been in my experience more frequent, especially 
among women, than is commonly recorded. Cullere and Clous- 
ton, however, report several such cases. In regard to treatment, 
the same course should be observed as in the neurosis itself. 

Among criminals guilty of the minor offences, as petty lar- 
ceny, etc., epilepsy is very common. We here find a bad her- 
editary history ; but among burglars or forgers, whose crimes 
are against property, mental disease in general, as well as 
epilepsy, is rare. 

As seen from our remarks on the character of the attack in 
epilepsy we must, especially in epileptic insanity, distinguish be- 
tween the mental conditions immediately preceding, during, 
and following the convulsive seizures, and during the intervals 
of the attacks. 

This is of great importance in a medico-legal sense; and, 
again, great care must be used to ascertain whether attacks of 
mania at times take the place of convulsive attacks. In speak- 
ing of transitory mania we referred to several writers as hold- 
ing the opinion that the condition in reality is an epileptic seiz- 
ure. The diagnosis, however, depends largely on the fact of 
well-known previous seizures, and also as to whether the act was 
committed just previous to an epileptic seizure or following one. 
During the intervals between the seizures the mental condition 
seems to be one, in many cases at least, in which dementia is 
'Tuke, "Psych. Med." 



EPILEPTIC INSANITY. 399 

not present, and in which the individual is fully conscious of all 
his acts. In these cases, therefore, we must carefully search for 
some motive for the act. If that is not present and the act is of 
the impulsive type, it is probably dependent on an hallucinatory 
condition due to the disease. The complete loss of memory of 
all the particulars of the act until informed, if deception in this 
respect can be excluded, is also of much diagnostic value. Re- 
morse for the act will also be present when there is not con- 
siderable mental weakness. Among, however, the cases where 
the character has been changed, although no well-defined con- 
dition of dementia is present, this feeling of remorse may be 
absent. This is not infrequently seen in hystero-epileptics and 
in those whom the attacks consist mostly in transient or partial 
loss of consciousness, without convulsive seizures. Here we 
find a mental weakness indeed, but not so extreme but what 
the full knowledge of right and wrong can be appreciated. 
There seems to be rather an absolute disregard of the ethical or 
moral side of the question, and the only repressive agency is 
the fear of punishment. 

Simulation of epilepsy has been referred to especially among 
the criminal classes and among prisoners. 

The diagnosis in regard to the character of the seizure is 
often a very difficult one — the presence of the reflex response on 
the part of the conjunctiva, and the response to light on the 
part of the pupils, indicate almost surely that the attack is not 
truly epileptic. The thumbs are usually turned into the palms 
in true epilepsy, but this is not always the case. When simu- 
lation is suspected, it is important to watch for any appearance 
of suspicion on the part of the personator, and again we often 
find that the attacks are most severe and frequent in the ma- 
lingerer when he is under observation. In a true epileptic seiz- 
ure the onset is sudden, generally without warning, and no 
recollection of the events occurring during the seizure is present. 

The prognosis in epilepsy is unfavorable as far as a cure is 
concerned, and this is of considerable importance in regard to 
the legal aspect of these cases. Months and in rare cases years 
may intervene between the convulsive and maniacal seizures. 
It is especially here that there may exist doubt as to the diag- 
nosis. We may have the condition called by Morel epilepsie 
larvee, in which, as we have said, the convulsive seizure is re- 



300 INSANITY — FISHER. 

placed by a maniacal state. Falret describes this form as fol- 
lows : The invasion of the morbid phenomena is sudden, the 
acts are instantaneous and of exceptional violence, the halluci- 
nations are usually of a terrifying character, there is also abso- 
lutely no recollection of acts committed. A peculiarity in these 
attacks is that if they are repeated the same phenomena occur 
in the same order. This is the case in the ordinary convulsive 
seizure, the psychical convulsion being analogous to the physical 
one. In this respect numberless cases could be cited of mania- 
cal attacks of violence, especially homicidal, just preceding 
or more usually following epileptic seizures. In these instances 
there is no doubt of the mental condition and absence of respon- 
sibility. It is, however, often difficult to make a difEerential 
diagnosis in the milder cases, in which, after perhaps an attack 
of the petit-mal type in which there has been simple obscura- 
tion of consciousness, for so brief a period as not to have been 
observed by others, the patient goes on with what he was doing 
or carries out some plan or piece of business with apparent cor- 
rectness, and yet afterward has no recollection of the acts. 
The following case illustrates this : 

A lady, unmarried, set. 40, had been subject to epileptic seizures 
for a number of years. Most of her attacks were of a mild type, of 
which she herself would be absolutely unconscious. On one occasion, 
while sitting at the breakfast-table in a hotel, she suddenly seized the 
newspaper of a gentlem.an sitting opposite and went to her room. She 
had no recollection of the act, and was surprised to find herself in 
her room with the paper. On another occasion she transacted con- 
siderable business involving the receiving of various sums of money, 
apparently attracting no attention as to her mental condition and 
performing her work correctly. Following these transactions, she 
had no recollection of seeing the various persons from whom she had 
received the money. Her acts were automatic, although in these in- 
stances of a character with which she was perfectly famihar. There 
was evidently in her case a dual existence. 

Chorea in Insanity. — Chorea is a disease with a spe"'°' 
motor disturbance. Under this head we would only cons 
the well-known neurosis in which we find motor disturbar 
hardly convulsive in character, but marked by a condi 
of incoordination. We refer to the so-called Sydenham 
ease in contradistinction to the condition found in defec 



PTJEEPEBAL INSANITY. 301 

brain formation, such as is seen in the imbecile or in cerebral 
hemiplegia the result of meningeal hemorrhages, inflamma- 
tory affections of the cortex, or porencephalus. Here, there 
are indeed choreiform movements, but the special condition is 
a mental defect dependent upon structural defect. 

Chorea is a disease most commonly of childhood, especially 
in its acute form ; the more chronic form occurs in adults. We 
also see it during pregnancy with special mental symptoms. 
Huntington described a form which is hereditary in certain 
families, associated with marked mental symptoms of the type 
of dementia. 

In children the disease runs an acute course, varying from 
three weeks to as many months, with a tendency to periodical 
semi-annual or annual returns. The mental symptoms are 
those of excitability, instability of temper, and an hysterical con- 
dition. There is also a considerable impairment of memory. 
The patients are excessively emotional, being subject to attacks 
of laughing and crying, and prone to impulsive acts. Illusions, 
especially at night, are not infrequent. 

We have already referred to the paroxysmal attacks of what 
has been termed coprolalia and echolalia in which there seems 
to be an irresistible impulse to the use of profane and indecent 
language, or again to especial attacks of obstinacy, the child 
being determined to do what it wishes, often being destructive 
and violent, in fact maniacal. Chorea occurririg in adults, es- 
pecially in young women, is often violent and uncontrollable, and 
there is indeed great cerebral excitement, resembling mania. 
It is usually chronic in its course. A hysterical basis often 
seems to exist in these cases. 

PuEEPEEAL Insanity. — We would here include all those 
mental disturbances occurring during or following gestation. 
There is, as Morel has well said, no special form of insanity 
peculiar to the puerperal state. The usual forms are melan- 
cholia and mania with hallucinations and delusions, which do 
not differ from these conditions under other circumstances. 

The causes are first heredity, the exhaustion consequent on 
the condition of pregnancy, fright, previous attacks, illegiti- 
macy, alcoholism, sepsis, etc. 

During pregnancy it is common to find unusual conditions 
of feeling, longings often for special articles of diet. Some 



302 INSANITY — FISHER. 

women are cheerful only when pregnant, others again are 
always depressed. The usual form is that of melancholia with 
suicidal tendencies. A milder condition resembling hysteria is 
common. There may be marked aversion to the husband or an 
irresistible impulse to produce abortion in some way, the most 
moral and conscientious woman during these periods being ab- 
solutely regardless of all moral obligations. It is not unusual 
to observe almost any of the various forms of the so-called im- 
pulsive insanities, such as a tendency to theft or to the excessive 
use of alcohol; or, again, there may be marked eroticism. This 
mental condition may pass away at the time of labor, but is 
more apt to continue. 

Insanity of delivery is usually of the maniacal type and 
is probably due to excessive pain (as I have seen in some cases), 
or, again, to the delay, since many instances occur in a tedious 
labor. This is more apt to occur in the primipara. There is 
often during the first few days, before or during the establish- 
ment of the flow of milk, a marked maniacal condition, dur- 
ing which infanticide may occur. 

Insanity following sepsis usually occurs within a ^ew 
days after delivery and is associated with high temperature. 
In these cases we find a maniacal condition as a rule, with mut- 
tering delirium, a constant agitation dependent often on hallu- 
cinations and delusions. 

In puerperal insanity per se, not dependent on septic con- 
ditions, the onset is usually later, the direct cause is often 
mental — that is, due to anxiety or worry, or, again, due to physi- 
cal exhaustion. There is usually an absence of high temperature. 
We may have mania with great excitement requiring restraint, 
or there may be marked melancholia in which there maybe 
aversion to the husband and the child. Both these states may 
pass on into more or less chronic conditions in which delusions 
of suspicion are common, and impulses usually of a suicidal 
nature. The majority of cases, however, recover. 

Insanity of lactation is usually of a depressive tyne. 
We have melancholia, usually subacute with delusions of s 
condemnation and suspicion. There may, however, be ac 
mania. The cause that is the direct one is exhaustion, so t 
we find it especially among the weak. I have observed it s 
especially of the melancholic type, among women who hi 



INSANITY AT THE MENOPAUSE. 303 

suckled their children beyond the usual time in order to avoid 
becoming pregnant again. This is not an uncommon practice 
among the poor. 

The crime most peculiar to these conditions is homicide. 
During pregnancy, however, the peculiar longings and desires 
may manifest themselves by theft, dipsomania, or infanticidal 
tendencies. 

Savage refers to a condition of transitory mania occurring 
within the first few days after delivery, in which the woman 
may injure herself or her child, being perfectly unconscious of 
her act. 

This may occur where there has been much exhaustion, or 
in cases where there has been marked cerebral excitement due 
to illegitimacy. In puerperal insanity of the ordinary type 
homicide or infanticide is the most usual crime. 

Insanity at the Menopause is usually of the depressive 
type, that is melancholia. It is usually subacute in character. 
The patients become anxious, sleepless, lose interest in a£fairs, 
and have a fear of impending evil. They are unable to apply 
themselves to their ordinary occupation. They feel that their 
family no longer has any regard for them. They become sus- 
picious, the fidelity of the husband is suspected, intense jealousy 
of a most unreasonable character may be present. Suicidal 
tendencies may develop.' It is not unusual also at this period 
to have a complete change in the character of the individual 
occur. They may become inclined to excessive use of alcohol 
or other drugs, they may manifest impulsive tendencies to theft, 
or become erotic. The most constant symptom is, however, 
that of depression, in which suicide is threatened and may in- 
deed be carried out. They become essentially selfish and de- 
manding, any inattention leading to reproaches of neglect. 
This may pass into a chronic state of dementia with delusions. 
There may often, however, be re-establishment of health after a 
few years. 

This condition occurs in men also, but is more rare. There 
is nothing especially characteristic in the form of the insanity 
which occurs at this period. It is simply that at this special time 
of life, when certain changes are occurring in the body itself, 
the brain is liable to disturbances affecting its integrity. It is 
therefore a critical epoch in the life history of women. 



304 INSANITY — FISHER. 

Insanity of Puberty implies a mental disturbance occur- 
ring at an important transitional period of the organization. 
It is especially liable to take place where there exists a pre- 
disposing cause, as heredity or a neurotic disposition. The ex- 
citing causes are various— fright, grief, mental strain from 
overstudy, and as a physical cause, masturbation. It is more 
frequent in females but not unusual in males. There is almost 
always a great concentration on the ego, leading to habits of 
introspection. It may take the form of depression or exaltation. 
In the former we observe the usual condition of self-condemna- 
tion with a marked tendency to suicide. This is often due to 
the belief that habits of self-abuse have alienated them from God 
and that forgiveness is impossible. Such patients become sus- 
picious ; they think every one is aware of their sin and regards 
them with aversion. They are subject to hallucinations, espe- 
cially of hearing, in which they imagine that they are called by 
the most obscene names, or that they are accused of acts of the 
most indecent character. 

In the maniacal state, which may at times be very violent, 
they frequently have a feeling of great self-importance, consid- 
ering themselves capable of carrying out great schemes. These 
ideas of importance often cover many fields, either in religion, 
art, literature, or business. They are impatient of all restraint 
and yet are unable to apply themselves long at any work. De- 
lusions of persecution are not rare. 

We observe also in these cases impulsions often of an irre- 
sistible character. There may be a marked erotic element pres- 
ent, leading to indecent exposure or open masturbation. In 
young girls this may lead to indecent proposals, and in the lat- 
ter we usually find an increase of aU these symptoms at the 
menstrual epoch. 

The prognosis is not unfavorable except when there is a bad 
hereditary history. 

The following case will illustrate this condition as occurring 
in a young boy : 

A. B., set. 17, family history negative. The patient had overworked 
and over-studied and had always shown himself very ambitious'to suc- 
ceed. His studies had to be carried on at anight school, as be worked 
by day. He was also a very regular attendant at the church meetings, 
frequently speaking at the meetings. He suddenly became quite 



RHEUMATIC INSANITY. 305 

changed in all liis habits, was aggressive and boastful. He no longer 
went to his work, but claimed that he felt that he could become a 
great preacher or architect, or in fact anything he wished to try for. 
He was irritable and at times violent, striking his mother if she did 
not do as he wished. This condition passed later into one of conf usional 
insanity, in which he seemed to lose all idea of time and place, and in 
which from time to time he would become excited and destructive. 
This patient made a complete recovery. 

A second case with a not dissimilar history, in which, however, 
there had been excessive masturbation as the exciting cause, had sexual 
desires of an unnatural character. He was evidently in great mental 
distress, and would remove all his clothing and beg the attendants to 
have relations with him in an unnatural manner. This case also made 
a good recovery. 

Many of these cases correspond to the type of masturbational 
insanity. However, while we find it present often as an excit- 
ing cause, it may again only be one of the symptoms of disease. 
It necessarily acts as an effective cause in continuing the mental 
disturbance. 

Insanity in Connection with Rheumatism seems to de- 
pend on either the high temperature or an overwhelming of the 
system with the special poison. 

We not infrequently observe in articular rheumatism a dis- 
appearance of the articular symptoms, and the onset of cerebral 
excitement resembling acute mania. There may be at the time 
a very high temperature, usually higher than we find in mania 
grave. The patient is delirious and is subject to illusions and 
delusions. 

There is, however, nothing characteristic in the mania 
which occurs in these cases ; there seems to be simply a metas- 
tasis of the poison from the joints to the brain and its meninges, 
resulting in excitement and delirium. It is rare that perma- 
nent or chronic mental disease results. It is more unusual for 
depressive conditions to result. 

The following case illustrates mania occurring in the course 
of acute rheumatism, with a fatal ending : 

A. R, aet. 35, was admitted to the hospital with acute articular 
rheumatism. He passed into a state of acute delirium with hallucina- 
tions and delusions. The temperature rose at times to 105°, and he died 
from exhaustion on the fifth day. There was nothing to distinguish 
the case in its course from acute mania. The autopsy showed nothing 
but acute congestion of the cortex of the brain. 



306 INSANITY — FISHER. 

GoTJT IN ITS RELATIONS WITH INSANITY is especially ob- 
served in the general diathetic state rather than in the acute con- 
ditions. In the former it is usually of the depressive type. It is 
rare that delusions are present, but there is often a well-marked 
suicidal tendency. Such patients are suspicious and irritable 
and there is present a fear of some impending evil. These 
cases are more liable to occur in advanced adult life, and may 
be explained on the ground of the general arterial degeneration. 
A well-defined attack of gout affecting the extremities will often 
clear up the mental state. Among the young, with hereditary 
gout, vrhich has never expressed itself locally except in various 
signs of malnutrition, indigestion, etc., there may be mental 
symptoms, usually of the nature of melancholia, vphich have been 
described under the head of cerebral neurasthenia. There is, 
however, at times observed in acute gout a metastasis from the 
inflamed joint to the brain and vice versa; its reappearance in 
the joint may relieve the brain affection. These acute states 
may assume the form of mania. There is no doubt of the close 
connection of this condition v^ith the direct overwhelming of 
the brain itself with the special toxic poison. 

Phthisical Insanity. — In phthisis among the insane it 
has long been noticed that certain mental symptoms character- 
istic of the disease are present, and, in fact, have a good deal to 
do with the progress of the disease. For a long time back the 
hopeful character of this class of patients has been referred to; 
even after periods of suffering and exhaustion we find them 
still believing and hoping that ultimate recovery will occur. 
Perhaps in no other disease do we find this condition so promi- 
nently present. Many diseases of different organs, as of the 
stomach and liver, frequently only of a functional type, will 
produce absolutely contrary mental states — marked depression, 
loss of interest in general affairs, hopelessness in regard to re- 
covery — in fact, many of the symptoms are such as we see in the 
so-called functional psychoses, as for instance mania and melan- 
cholia. It is, therefore, not surprising that the ancients ascriV"'' 
to various organs in the body the seat of diseases of the mind 

In the etiology of insanity, tuberculosis or phthisis 1 
been cited as a prominent factor. In certain families it i 
rarely results in insanity, or the descendants of the insane m 
have phthisis. Again, not infrequently certain members of t 



PHTHISICAL INSANITY. 307 

family will suffer from phthisis, while others have some form 
of mental disease. Atavism is also not infrequent. 

We have considered in this relation phthisis as a cause of 
insanity, and phthisis as occurring among the insane. The 
class of patients in which the first division may be considered 
will give us the symptoms of disease as seen in the so-called de- 
generative type of mental disease ; therefore it is not infrequent 
among paranoiacs and those subject to the various neuroses, 
such as epilepsy, chorea, neurasthenia, hysteria, etc. The sec- 
ond division, in which phthisis is an intercurrent disease in an 
already established mental derangement, is more frequently 
found where exhaustion or loss of nutrition is a marked feature, 
and therefore it is observed in melancholia and dementia from 
whatever cause. Many writers describe phthisical insanity as 
a special form of disease, while others, again, maintain that 
there is no special difference in the symptoms from those gen- 
erally recognized in insanity. 

An examination of patients with phthisis must be carried 
on with great care, as not infrequently it will run a very insidi- 
ous course, the mental condition obscuring the ordinary signs 
of the disease, so much so, indeed, that where phthisis is pres- 
ent and insanity occurs in its course, there is an apparent im- 
provement in the patient. The cough is no longer troublesome, 
and expectoration is apparently decreased ; and so marked is this 
change that many have held the opinion that the course of the 
phthisis has been checked by the addition of mental disease. 
This, however, can hardly be the case. The improvement con- 
sequent upon relief of the exhausting symptoms may seem to 
lead to a general improvement in the patient. Again, some 
have claimed, for instance, in dementia, that the appearance of 
phthisis has improved the mental state ; but this is probably ex- 
plained by the rise of temperature causing some increase in the 
circulation of the blood in the brain, and in that way clearing 
up the mental torpor. In almost every case, however, when 
the disease approaches the final stages the course is most rapid ; 
in fact, statistics would lead us to believe that the duration of 
the disease is shorter among the insane than among the sane. 
Phthisis is also more common among the insane than among 
people in general. The idea of improvement of the patient by 
the intercurrence of phthisis is not to be accepted. Certainly, 



308 INSANITY — FISHER. 

as in other diseases, such as typhoid, or in cases of injury or of 
extensive inflammation, we do notice for the time being an 
apparent improvement in the mental state, and while these con- 
ditions remain active, often in a case of extreme dementia or 
melancholia, the patient is much more active mentally than 
previously. On the conclusion of these acute conditions the 
previous symptoms return with increased severity, and it is evi- 
dent that there has been no permanent improvement. 

The special symptoms ascribable to phthisical cases seem to 
be those of suspicion ; hallucinations and delusions are not un- 
common, the tendency being to a morbid state in which the 
patients, from fear of poison or from suspicion of those around 
them, refuse to take food or medicine. There is frequently also 
a suicidal tendency, melancholia being the type of the disease, 
associated, as we have said, with marked suspicion. Some writ- 
ers go so far as to claim that aU cases which have a well-defined 
delusion of suspicion are ultimately the subjects of phthisis. 
In rare instances we find the opposite condition — of grandeur 
and a general feeling of well-being. We should be suspicious 
here of general paresis, for it is not uncommon to find among 
th^se patients phthisis either as an hereditary taint or as an in- 
tercurrent disease. It often passes unrecognized, and in fact 
the symptoms may run a course in which there is no indication 
of the existence of the disease until the final stages. Many of 
these patients continue at their work, or are out and around 
within a week or two of their death. 

A. B. (colored), male, general paresis ; family history negatire ; 
phthisis of an intercurrent nature, possibly hereditary. As far as the 
pulmonary disease was concerned, the illness was of only a tew weeks' 
duration. The post-mortem revealed extensive tubercular disease of 
the lungs. The symptoms were of the usual type of general paresis. 

In our present institutions, with the better attention to sani- 
tary arrangements, there is far less phthisis than was formerly 
seen, the percentage being decidedly lower. The element "^ 
hopefulness is not often so frequently seen as among the sa 
Strictly defined, phthisical insanity should not be considered 
a special form of disease. The character of the hallucinatii 
and delusions is not suflSciently distinctive to properly com 
tute a special type of insanity. There is this much, howev 



PERIODICAL INSANITY. 309 

in regard to all these cases : in the insane exposure often does 
not have the same deleterious effect in causing pulmonary or 
other disease as we find among the sane; hut, on the other 
hand, as all forms of mental disease generally lead to a low 
trophic state of the body, they are specially prone to phthisis, a 
proper nidus for the bacillus being ever present. 

Peeiodical Insanity is that form in which attacks of 
mania or melancholia occur at more or less regular intervals, 
the intervening periods being free from all mental disturbance. 
There is nothing peculiar in the attacks, the principal interest 
is from a medico-legal aspect, in regard to the complete remis- 
sion of all symptoms during the intervals. Melancholia is more 
frequent in this form than mania. Clouston, in his description 
of the disease, includes circular insanity under the same head. 
In the latter disease we have alternating conditions of mel- 
ancholia and mania, the first completing its course and often 
passing without intermission into the second form. There is 
usually a periodicity in these attacks also ; often, as in periodical 
insanity of melancholia or mania alone, intervals of months or 
years intervening between the seizures. There is indeed, as I 
have said, generally a complete return to a normal mental state, 
but there may be observed some alteration in the character. 
The person is not precisely the same. 

Marce divides periodical and circular insanity into three 
forms : 

1. La folic interinittente simple (periodical insanity) . 2. 
La folie a double forme, consisting of an attack of mania and 
melancholia with a lucid interval. 3. La folie circulaire, a 
form in which the attacks are continuous without an interval. 

Esquirol records a case of a merchant, set. 40, of a neurotic 
disposition, who each fall, for four years, had an attack of 
mania, a spontaneous recovery taking place in the spring. This 
patient ultimately recovered. During the intervals between the 
spring and autumn he resumed his business. 

A case of acute melancholia has long been under my observation, 
the attack recurring about once a year for the past six years. The 
onset is sudden, and came on first at the age of puberity. The recovery 
is always as sudden as the onset. During the intervals the patient, a 
young lady, returns to her family and resumes her usual occupation. 

The prognosis is, as a rule, unfavorable as far as the ulti- 



310 INSANITY — PISHBK. 

mate cure is concerned, as there is usually an Hereditary ele- 
ment present. 

Hypnotism is a subject concerning which much has been 
written for many years. Mesmer, in the Eighteenth Century, 
brought it prominently before the public, but the evident char- 
latanry and often fraud which were present in his methods led 
to the abandonment of its consideration by responsible scientific 
investigators. Braid, of England, in 1844, in his paper, de- 
scribed the condition most fully — in fact, little of importance 
has been added to our knowledge of it since. He also first used 
the name hypnotism. Since that time the subject has been 
investigated by various writers in France, as Charcot, Marie, 
Gilles de la Tourette, and others, and in Germany and England 
by Berger, Senator, Bramwell, and Tuckey. Early in the cen- 
tury surgical operations had been performed with success while 
the patient was under the influence of hypnotism. 

Hypnotism has been defined (Foster's " Encyclopaedic Medi- 
cal Dictionary") as "an abnormal state into which some persons 
may be thrown, either by a voluntary act of their own, such as 
gazing continuously and with fixed attention on some small, 
bright object held close to the eyes, or by the exercise of another 
person's will; characterized by suspension of the will and conse- 
quent obedience to the promptings of 'suggestion' from with- 
out. " The activity of the organs of special sense, except the eye, 
may be heightened and the power of the muscles increased. 
Perfect insensibility to pain may be induced by hypnotism, and 
it has been used as an anaesthetic. It is apt to be followed by 
severe headache of long continuance and by various nervous 
disturbances. On emerging from hypnotism the hypnotized 
person usually has no remembrance of what happened during 
its continuance, but in many persons such a remembrance may 
be induced by suggestion. 

About one person in three is susceptible of hypnotism, and 
those of an hysterical or neurotic tendency (but rarely the in- 
sane) are the most readily hypnotized.' Charcot regarded it " 
an " artificially produced morbid condition or neurosis, beca 
there is not, so far as we know, any anatomical lesion, but hi 
ing none the less its definite laws." " 

' C. J Braid, Month. Jour, of Med. ^ Tuke : "Dictionary of Psycl 
Sci., July, 1853. Medicine." 



HYPNOTISM. 311 

There are various methods of establishing this condition : the 
early one employed by Braid, in which the subject is requested 
to fix the attention on some bright object which is usually placed 
above the eyes in a position to cause fatigue (Voisin follows 
this plan), or pressure over the eyelids effects the same re- 
sult, the suggestion being made repeatedly that they will soon 
fall asleep, etc. Self -hypnotism is also possible by fixing the 
attention on some object. The principle is evidently the attempt 
to place one's self entirely under some one single influence and 
thus become oblivious to all other surroundings. 

Most healthy individuals can with practice allow themselves 
to be hypnotized ; and the reverse is also true, they can prevent 
it. In some hysterical temperaments, and also in the insane, 
their inability to fix their attention on any one thing makes 
hypnotization impossible. 

After considerable practice a bright light or a mere nod may 
be all that is necessary to establish this state. Charcot has de- 
scribed three conditions into which those hypnotized pass : cata- 
lepsy, lethargy, and somnambulism. In all three states sugges- 
tion is possible, and it is in reference to this latter condition that 
of late the subject has become of importance in legal medicine. 
While many acts, often foolish in character, will be carried out 
by the subject upon suggestion, it is doubtful whether a crime 
such as murder would be committed. The following cases, 
which have been reported, will explain the position which hypno- 
tism to-day holds as a ground for defence in criminal procedures. 

J. M. Baldwin ' says, in regard to criminal suggestion, that 
" cases have been tried in the French courts in which evidence 
for and against such infiuence of a third person over the criminal 
has been admitted. The reality of the phenomena, however, 
is in dispute. The Paris school claims that criminal acts, which 
are just as certain to be performed by him as any other acts, can 
be suggested to the hypnotized subject. While admitting the 
facts, the Nancy theorists claim that the subject knows the per- 
formance to be a farce, gets suggestions of the unreality of it 
from the experimenters, and so acquiesces. This is probably 
true, as is frequently seen in cases in which patients have refused, 
in the hypnotic sleep, to perform suggested acts which shocked 
their modesty, veracity, etc." 

' Johnson's "Universal Cyclopsedia, " 1894, p. 463. 
111.-23 



3ia INSANITY — FISHER. 

The undoubted fact that such a control is temporarily pos- 
sible was made the basis of a curious legal defence in the trial 
of a French woman, Gabrielle Bompard, for complicity in the 
murder of one Gouffe. At this trial in November, 1890, her 
counsel endeavored to secure her acquittal by introducing evi- 
dence to show that she was an hypnotic subject, and took part 
in the murder imder the hypnotic compulsion of her confederate, 
Michel Eyraud. The court, however, refused to allow any 
testimony on this head to be presented.' 

A very interesting case is reported by A. Motet." The 
" Chambre des Appels de Police correctionelle" reversed the de- 
cision of the " Tribunal de premiere instance" condemning Emile 
D. to three months' imprisonment. He had been arrested for in- 
decent acts in a public urinal. D. protested his innocence. Dr. 
Mesnet, under whose care D. had been in the Hopital St. An- 
toine, and who knew him to be subject to spontaneous attacks 
of somnambulism, with others was able to obtain a new trial, on 
the ground that D. was irresponsible during these mental states. 

The avocat-general, M. Bertrand, said that it was necessary, 
if D. passed into this mental condition, to prove its existence at 
the time of his arrest. Permission being granted to hypnotize 
the defendant, he was asked to undress himself, which he im- 
mediately did, but when roused from the hypnotic state, had no 
remembrance of his acts. The decision was based on the groxmd 
of irresponsibility. 

I would refer to the following articles on the subject: 

"Hypnotism," Moll, Albert, Berlin, 1890. Juridical Be- 
view, Jan. , 1890 (contains trial of Eyraud and Bompard) . " Bib- 
liographie des modernen Hypnotismus," Dessoir, Berlin, 1891. 
Contemporary Beview, Oct., 1890, " Hypnotism and Crime." 
A. T. Innes, " Der Hypnotismus in seiner psychol. Beziehung 
und forensischen Bedeutung," Schapira, Berlin, 1893. 

CEREBRAL DISEASES WITH CONSTANT PATHOLOGICAL 
CHANGES OR ORGANIC FSTCHOSES. 

Under this heading fall all those diseases of the brain 
which there are mental disturbances, dependent upon defii 

'"The International Cyclopse- ' Annates d'Hygiene Publiqui 

dia," New York, 1893, p. 763. de Medecine Legale, iii. sa 

tome v., Paris, 1881, p. 214. 



ACUTE DELIRIOUS MANIA. 



313 



lesions of the brain and its membranes. In all the other forms 
of insanity which we have described, with the exception of de- 
mentia, there have been no definite changes, outside of impaired 
nutritional states, whose exact relation to the disease itself it 
was possible to predicate. 

In these organic psychoses, however, we find destruction or 
impairment of the cells of the cortex, associated with changes 
in the connective tissue and the blood-vessels, which are amply 
sufficient to establish a basis for the statement that insanity is 
essentially a disease of the brain — allowing us by inference to 
positively conclude that the so-called functional forms of in- 
sanity and those dependent on degenerative states are likewise 
the result of disease of the brain, as the symptoms are similar 
in character ; that is, they consist in departure from the normal 
reaction of the various faculties of what we call mind, one on 
the other. Ev^n here, however, all is not clear, for various 
similar lesions of the brain substance and its membranes may 
exist without producing mental disease. "We constantly see 
inflammation of the membranes of the brain and the cortex 
itself, or even destruction of the brain substance by disease or 
traumatism, which does not result in mental disturbance, so that 
we are forced to accept the subdivision of this class of insanity, 
as stated by Krafft-Ebing, as consisting of brain disease, with 
predominating mental disturbance. 

The explanation of this apparent anomaly, that in all cases of 
disease of the cortex cells we do not get like mental symptoms, 
remains for the future investigator to give us. 

The tendency at present is, therefore, to study the cells them- 
selves in their normal and pathological states, which may finally 
lead to a discovery of those special cortex cells of the brain which 
carry on the mental processes, and enable us to differentiate them 
from those which are the source of motor and sensory function. 

The first disease under consideration in this class of organic 
insanities will be : 

Acute Delirious Mania. — Synonyms: Delirium grave; 
typhomania. 

We have to do with a condition in which there is great ex- 
citement and violence associated with extreme exhaustion and a 
high temperature. 

It differs essentially, therefore, from any other form of in- 



314 INSANITY — FISHER. 

sanity in that we have associated a high temperature. Acu 
mania, as described under our heading of functional psychose 
bears no resemblance to it in its clinical course, it being essei 
tially a non-febrile state, even the greatest amount of violenc 
rarely leading to an elevation of temperature of more than 
degree. The marked degree of exhaustion, the evidence c 
some real illness being at the back of the delirious state, is nc 
present in ordinary mania. As in the latter, there is frequent! 
present an appearance of great vitality, at least in the earl 
stages. The course of the disease is essentially different, deatl 
usually occurring within five to ten days. It suggests from tb 
beginning some severe febrile state, due to some cause of infec 
tion. We have to do with a distinct disease, an entity, anc 
not, as suggested by Regis, a higher degree of mania. 

Acute delirious mania is essentially an acute disease of thf 
brain, characterized by high temperature and extreme exhauS' 
tion, accompanied by hallucinations of sight and hearing, and 
delirium. 

The causes are predisposing and exciting. Among the first 
is hereditary tendency or a neurotic, unstable disposition. 
It is usually a disease of adult life from twenty-five to fifty, and 
affects both sexes about equally. Women at the climacteric 
period are especially liable to it. It is, however, one of the 
rarer forms of insanity. Extreme exhaustion from overwork, 
especially of a mental character, shock from domestic and finan- 
cial losses are exciting causes. It may foUow or accompany 
typhoid fever or pneumonia or rheumatism. It is, as Bevan 
Lewis well says, a disease especially marked by the rapid dis- 
integration, both mental and physical, of the patient. 

The onset of the disease may be and usually is sudden, mark- 
ing itself by acute delirium in which hallucinations are present, 
The patient requires restraint. This may be preceded by 
symptoms of a mild character, as of irritability, sleeplessness, 
and headache. In the early stages of rheumatism and miliary 
tuberculosis passing into acute delirious mania, the mental 
symptoms may entirely obscure the physical signs of the dis- 
ease. The patient soon passes into a low muttering delirium 
and is unconscious of his surroundings, with no after-memory of 
the passing events. There seems to be a feeling of terror, and 
fear with a desire to escape; the face is flushed, the pupils con- 



ACUTE DELIRIOUS MANIA. 315 

tracted or dilated, and the body bathed in a profuse perspiration. 
There is from the first rapid wasting; the tongue is dry and 
coated and the pulse frequent and small. 

There is every sign of extreme bodily iUness. The temper- 
ature from the beginning is usually high and continues to rise 
to 105°-106" before death. The course of the disease is rapid, 
death usually resulting within five days. The emaciation may 
be extreme despite the constant feeding. Eecovery at times 
occurs, leaving little after-effects, although there may be 
dementia. 

The post-mortem changes are often very inadequate to ex- 
plain the violent class of symptoms which have passed over the 
patient like a storm. There is usually evidence of excessive 
hyperaemia, which probably at this time is less marked than 
intra vitam. Krafft-Ebing considers the changes essentially 
due to hyperaemia followed by venous congestion. There is 
usually considerable increase of the cerebro-spinal fluid, the brain 
substance appearing cedematous. The cortex is found to have a 
rosy appearance from the overfilling of the capillaries. The pial 
vessels are marked by white lines, probably due to stasis in the 
accompanying lymph tracts. The cortex cells are usually in- 
volved and show evidence of disintegration. 

It would scarcely seem probable that such changes could 
presage the beginning of general paralysis, although this has 
been noted by some writers. 

The general distinction of this disease from the other forms 
would seem evident. From delirium tremens the absence of 
fever in the latter and the absence of the extreme exhaustion 
are sufficient. Should it, however, be complicated by an acute 
disease, such as pneumonia or meningitis, it is more difficult to 
make the diagnosis. 

The following case, which proved fatal in three days, and in 
which an autopsy was obtained, typically represents the disease : 

E., laborer, set. about 35, was admitted to the hospital November 
19th, 1893. During the night of admission and the following day he 
was very delirious and had to be restrained. He was at no time con- 
scious of his surroundings nor could he be aroused to give his name. 
He was constantly talking in an unintelligible manner and at times be- 
came very violent, calling out as if in great fear. There was constant 
twitching of the extremities, but no convulsions occurred at any time. 



316 INSANITY — PISHEK. 

The temperature never rose above 100° until November 31st, the 
respiration being between 9-12. On the 21st the patient passed into a 
state of low muttering delirium, becoming angry and combative when 
disturbed. The following is the chart taken at that time: 





Temperature. 


Respiration. 


Pulse. 


9 A.M. 


100° 


18 


100 


1 P.M. 


100° 


15 


104 


5 P.M. 


97° 


16 


100 


9 P.M. 


99° 


18 


104 


1 A.M. 


100° 


2Z 


112 


5 A.M. 


102° 


28 


126 



Death occurred 8:45 a.m. on the 22d. Toward the end there was a 
constant rise in the temperature and increase in the pulse and respira- 
tion. 

The autopsy showed the calvarium adherent over the convexity. 
The pia was raised up from the cortex by a serous effusion, and there 
was evidence of marked capillary congestion of the cortex. 

General Paresis. — Synonyms: General paralysis of the 
insane ; Paralysie generale, meningite chronique avec aliena- 
tion J periencephalite chronique diffuse. 

It is a chronic disease, as the various synonyms given indi- 
cate, in which there are both mental and physical symptoms 
present. 

The mental symptoms are those which most particularly in- 
terest us in a medico-legal sense, and they are rarely absent, 
although in some few cases, outside of a certain degree of de- 
mentia, they may be subordinate to the physical or somatic 
signs of the disease. 

It is essentially a disease of the fuUy developed brain, com- 
ing on in adult life, usually between the ages of twenty-five and 
fifty, although some cases in childhood, especially where there 
has been an hereditary history of syphilis, have been reported, 
and again in some instances it has occurred after the age of 
seventy. The course of the disease is a chronic one, extending 
usually over a period of two or three years, but it may termi- 
nate in a few months, and in certain irregular cases, especially 
where the somatic symptoms are more prominent than the 
mental, extend even to fifteen years. It is a disease of modem 
life and affects men more frequently than women, although of 
late years it is found much more frequently among women than 
formerly. This may be explained by the increased anxieties 



GENBEAL PARESIS. 317 

to which the latter are subjected in the more active part 
now assumed by them in business relations and the various 
professions. 

Heredity is, as in aU forms of insanity, an important 
element in its causation, it being present as a factor in about 
thirty-three per cent, of all cases. It is rarely directly inherited, 
but usually occurs in those whose antecedents have a history 
of epilepsy, chorea, alcoholism, phthisis, or in which the children 
are the products of old age or in families in which consanguinity 
in marriage has existed. Syphilis is perhaps the most impor- 
tant exciting cause, it being claimed by many writers that it 
always exists as the basis of every case. This is, however, 
probably not true. Among other exciting causes is found 
mental worry, especially when of a financial character, or even 
the struggle for existence. This is observed where certain races 
as the negro, the Chinese, etc., come in contact with a higher 
civilization, although in their own native surroundings the dis- 
ease is very uncommon. Excesses of any nature, overwork, 
alcoholism, venereal excesses have an active part in its causa- 
tion, so that we commonly find the disease among the pro- 
fessional classes, as lawyers, clergymen, physicians, brokers, 
merchants, and actors. It is not, however, confined to any class, 
affecting the highly educated and the ignorant. It is a dis- 
ease of the brain characterized by a more or less rapid disin- 
tegration, associated with inflammation. It is this latter con- 
dition which supports the theory of a syphilitic origin of the 
disease, which is in fact present in the majority of the cases. 
Hcfwever, I feel convinced from careful study of many cases, 
both in hospital and private practice, that in not a small propor- 
tion of such patients that element can be excluded. 

The course of the disease is generally described as passing 
through certain stages, but this is for convenience only, as there 
are no well-defined periods during the progress toward its al- 
ways fatal ending. In fact, there are often remissions in which, 
at times, recovery seems to have taken place. Especially is this 
observed when the patient is removed from the excitement and 
strain of ordinary life to the quiet and regular existence of hos- 
pital care. The course is rapid or slow also, depending on the 
frequency of epileptic seizures, one of the common symptoms of 
the disease. When these are present to a marked degree, there 



31 8 INSANITY — FISHER. 

seems to occur a rapid disintegration of the mental faculties and 
a tendency to physical exhaustion terminating in death. 

The onset of the disease is rarely sudden, although it may 
appear so, as the first indication of the disease to the friends 
may be some extravagant act, either in social or business 
relations'. Usually, however, if the patient has been closely 
observed, some change in the personality will have been noted. 
At times a condition of depression may precede the actual out- 
break of the disease, or there may be some excitement ex- 
pressed by irritability or obstinacy, or again in somatic symp- 
toms, as apoplectic or epileptic seizures, or an attack of 
aphasia lasting a few hours or days. These prodromal symp- 
toms are usually only remembered after the thorough establish- 
ment of the disease. 

In a medico-legal aspect, according to Legrand du SauUe, 
general paralysis may be divided into four distinct periods, a 
short summary of which I will give, although the pathology of 
the disease does not sustain any such artificial division into 
periods. 

1. " Periode prodromique," or prodromal period, in which, 
while many irregular mental or physical symptoms may be 
present, they cannot be distinctly recognized as characteristic of 
the disease except in the light of its future development. There 
may be indeed for several months, or even years, a combination 
of characteristic phenomena, as one or several apoplectic attacks 
with loss of consciousness and passing paralysis of the arm or 
leg, or temporary aphasia. More important is the change in 
the personality. There is often an exaggeration of fornler 
tendencies. There is usually extreme irritability, or again de- 
pression. There is also, even at this period, an impairment of 
the memory and an evident inability to perform the usual work, 
even that of the most routine character. About this period there 
will now appear the feelings of self-satisfaction and expansive- 
ness which really usher in the so-called — 

2. " Periode initiale" or initial period of the disease. T*"'*" 
is usually expansive, showing exaggeration of the ego, but r 
at times be depressive, the patient apparently recognizing 
mental condition. The delire des grandeurs is, however, 
more frequent. The sense of well-being is thoroughly esi 
lished at this period — a feeling of power and ability to 



GENERAL PARESIS. 



319 



entirely at variance with the actual mental weakness. There 
is an exaggerated idea of wealth and strength. It is at this 
period that speculations of the wildest character may be under- 
taken. In the depression there is constant dread of approach- 
ing ruin ; a belief that acts have been committed which have 
dishonored them. There may at this time be a cessation 
of the progress of the disease, or else what may appear 
as a recoverj', but there is sooner or later the establishment 
of the full physical and mental signs of the disease in the so- 
called — 

3. P6riode d'etat, which continues for months, passing 
into the stage of complete dementia, i.e., the fourth stage, or 

4. Periode terminale. 

The age and social condition of patients with general paresis 
is shown in the report furnished me by Dr. Louis C. Pettit, 
of the New York City Insane Asylum, of one thousand and six 
cases : 

Age at Death in One Thousand and Six Cases of Paresis. 



Sin- Mar- Wid- 

Age. Cases, gle. ried. owed. 

31 

22 1 1 

23 2 2 

24 1 1 

25 13 5 7 1 

26 9 8 1 

27 7 5 3 

28 14 5 9 

29 17 3 18 1 

30 32 13 9 

31 31 3 17 1 

32 33 14 18 

33 34 13 11 

34 37 4 33 

35 58 15 38 5 

36 38 7 37 4 

37 37 14 33 

38 43 16 25 1 

39 34 4 19 1 

40 70 14 53 3 

41 34 6 38 

43 46 12 33 3 

43 25 7 15 3 

44 33 8 21 3 

45 ...53 9 43 1 

46 28 5 31 3 

47 33 4 37 2 

Convulsions 387. Syphilis 117. 



Sin- Mar- Wid. 

Age. Cases, gle. rled. owed. 

48 37 7 17 3 

49 30 1 19 

50 48 6 39 3 

51 30 5 13 3 

53 19 4 14 1 

53 23 3 18 1 

54 14 3 7 4 

55 35 3 17 5 

56 17 2 13 3 

57 5 1 4 

58 17 4 11 3 

59 6 3 4 

60 16 3 13 1 

61 4 4 

63 6 1 4 1 

63 4 3 1 

64 6 1 2 3 

65 5 4 1 

66 7 2 4 1 

67 

68 3 3 

69 4 4 

70 

73 1 1 

79 1 1 

Total.... 1,006 343 701 63 



320 INSANITY — PISHEB. 

It is possible for the prodromal period referred to, in which 
there is evidence of change of character and great irritabihty 
with a tendency to exhibitions of anger or violence, which at 
this tinae is often bitterly repented of, to extend over a number 
of years. The actual establishment of the disease is marked 
intellectually by the absence of all feelings of regret for their 
acts and the natural feelings of anxiety or even interest in their 
personal affairs. A fatuous state of contentment takes its place, 
a belief that mistakes will be made right in some way. Habits 
of extravagance are established ; purchases of articles of every 
variety, often useless in character, are made; enterprises are 
entered into, houses built without regard to expense. The for- 
merly temperate man may order large quantities of wine, and 
during periods of excitement, which are often paroxysmal in 
character, may be subject to excesses in drinking. 

Appropriation of money or property may take place, due to 
the expansive ideas of the patient, his belief in his great wealth 
or his numerous plans causing him to utterly disregard the 
rights of others. It is at this period, therefore, before the con- 
dition has been recognized by those with whom he comes in 
contact, that questions of medico-legal interest may arise. It is 
important to recognize this early stage before fortunes are dis- 
sipated and the family disgraced. The mental change from the 
previous condition is, therefore, of primary importance. At this 
period, also usually accompanying or following close upon the 
intellectual impairment, appear bodily conditions which are as 
positively diagnostic of the disease as those affecting the mind. 
There is usually at an early stage more or less tremor of the 
muscles of the face, especially of the muscles of the mouth and 
the folds of the cheek, and also of the tongue. The speech 
becomes thus secondarily affected and is slow and clumsy— the 
ideas may flow rapidly, but cannot be enunciated clearly. There 
is not true aphasia, and there is no loss of memory of words, 
but there is marked inability to coordinate the muscles neces- 
sary for articulation. There is also some actual paresis of the 
muscles of the face, giving a characteristic blank and fatuous 
expression. The pupils are also soon involved, showing in- 
equality, and slowness of response to light, but retaining the 
power of accommodation ; later there is often permanent dila- 
tation or, more rarely, contraction. 



GENERAL PARESIS. 321 

Again at this early stage, though more rarely, there may be 
epileptic seizures at considerable intervals of time apart, or 
apoplectic seizures with hemiplegia rapidly recovered from, or 
true aphasia of a transient character. This latter disturbance 
of speech is entirely distinct from the slow, clumsy speech pre- 
viously referred to. We now recognize symptoms dependent 
upon disease of the spinal cord, as tremor of the hands, mani- 
festing itself in the writing or in any delicate work, even in 
dressing. There may also be marked ataxia of both the up- 
per and lower extremities, with loss or exaggeration of the re- 
flexes. Accompanying all these mental and physical symptoms of 
disease, as an undertone, there is usually a constant feeling of 
well-being, already referred to ; the patients are always feeling 
well, and this even continues to the final stage of dementia. 
There may be increase of the sexual appetite ; in this early 
period it being often regarded as the cause of the disease when 
in reality it is a symptom ; or again we may have the reverse 
condition. No disease shows such complete wrecking of all 
that can be called man in his moral and intellectual character- 
istics as general paresis. Paroxysmal attacks of mania of great 
violence, usually destructive or homicidal, may occur. It is at 
this period that remission may occur, or at least the disease may 
remain stationary for months or even years. 

The so-called third stage simply emphasizes the symptoms 
already detailed. The aphasia becomes more marked, until 
the speech is almost unintelligible, and the ataxia and paralysis 
increase, so that the patient is confined to his bed, unable to feed 
himself. The delusions of grandeur and hallucination continue, 
and still the absolutely helpless patient may express himself as 
never having felt better in his life. 

Epileptic seizures are at times very frequent, continuing for 
hours, and are usually of the clonic type, without loss of con- 
sciousness. These are dependent upon the meningitis, and are 
often the direct cause of the death of the patient from exhaus- 
tion. They have a great influence in increasing the demen- 
tia Apoplexies may cause paralysis, or when occurring, as 
they at times do, in the parietal and occipital regions of the 
brain, cause mind blindness, that is, a loss of appreciation of 
what an article is, or its use; or again word deafness and 
word blindness. These conditions are usually temporary. 



323 INSANITY — FISHER. 

The final dementia may be complete, but death usually results 
from exhaustion or some intercurrent disease, as pneumonia, 
before it is reached. 

The course of the disease as described is the usual and typical 
one ; there are, however, many -variations which occur in its 
onset and course. It is always fatal. The remissions, how- 
ever, in some cases are often of long duration, for a time mak- 
ing the diagnosis subject to question. 

In certain cases again, when the physical signs of the dis- 
ease are well defined, but the mental are not so well developed, 
there may be considerable difficulty of diagnosis, especially as 
this class may continue long beyond the usual term of the dis- 
ease. Again in the so-called spinal type the early affection of 
the cord, with the extension of the disease to the brain, may 
make it at first difficult to give a positive diagnosis. 

The first class is well illustrated in the following case : 

A. B., lawyer, aet. 34; family history negative. Patient had con- 
tracted syphilis in early life. Married and had several healthy children. 
Exciting cause of disease, financial anxiety, overwork, and grief from 
domestic affliction. It was recollected that for two or three years pre- 
vious to my examination of him, he had become very irritable and 
liable to outbursts of anger, his natural temperament being mUd and 
agreeable. This was, however, ascribed to his business anxiety and in- 
somnia. The first symptom ascribed to mental disease was a transient 
attack of aphasia, lasting a few hours. This was followed a few months 
later by a second attack, after which there seemed to be a permanent 
change in his disposition . He no longer had any anxiety in regard to his 
business, neglecting to appear in court at the time of trial, but expressing 
no regret for it. He became placid and contented, sleep and appetite 
improved. Memory for present wants became very defective, but he 
would relate with full details events occurring within the last few 
years. Was perfectly able to carry on accurately the routine business 
of his office. At no time did he have any delusion of grandeur or any 
expansive ideas. Became rather cai-eless at times Ln money-matters, but 
at no time extravagant. His speech became slow and clumsy, and 
from a brilliant, rapid talker in court, he at times became almost unin- 
telligible. Such catch-expressions as "Around the rugged rocks the 
ragged rascals ran," were impossible to him. There was considerable 
tremor of the several muscles of the face, and that characteristic flat, 
fatuous expression of countenance peculiar to general paresis. 

He at times is subject to maniacal attacks, in which he has struck 
his wife and children ; these are soon over, and he has deepest repent- 
ance for his acts. As a rule he is docile and easily forgets any ill-fed- 



GENERAL PARESIS. 323 

ing. Has at no time had any convulsive seizures, or been subject to 
hallucinations or delusions. 

He has relinquished all business, and although regularly going to 
his office and remaining the usual time, seems to have no appreciation 
of the fact that he is doing nothing. 

Is emotional, a sad story causing him to burst into tears, but is gen- 
erally in a happy and self-satisfied condition of mind. The disease 
has now lasted, with very little change except a slowly increasing de- 
mentia, for five years, which, with the previous two or three years 
which were a part of the disease, makes its course at least seven years. 

In this form the physical signs of the disease and dementia 
are the prominent symptoms. Another patient's history ex- 
tended over fifteen years. 

The onset was gradual and unexpected, the symptoms being alto- 
gether of a spinal character. However, he had still earlier delusions 
of an expansive character, which had resulted in speculation which in- 
volved him in financial ruin. During the last eight years of his life, 
while under my observation, he had no delusions. He was always 
happy and expressed himself as perfectly well. There was, however, 
a progressive dementia, interrupted at times by attacks of maniacal vio- 
lence, in which he had aai intense desire for alcohol. 

Complications. — Among the special complications peculiar 
to this disease is often the very early condition of failure or 
loss of appreciation of moral, ethical, and religious questions, so 
that we notice men and women commit acts opposed to the 
ordinary customs of society, often in public, without apparently 
any appreciation of their heinousness or any regard for the feel- 
ings of others. Combined with this there is more or less con- 
fusion of ideas, especially in regard to the rights of those around 
them, whether in reference to their comfort or to their property. 
Perhaps one of the most important signs of dementia which 
manifests itself even at an early stage is to be found in this 
direction. Long before there is any marked failure of mental 
power, as shown in the occupation or daily relations of life, this 
partial confusion of the proprieties is seen and here it is of im- 
portance to recollect that this symptom may long remain un- 
recognized, and probably is the premonitory sign of the disease 
itself. It may take the form of extreme nervousness, or of de- 
spondency, or again of irritability, or lack of consideration for 
others, whether in regard to their opinions or their rights. A 



334 INSANITY — FISHER. 

case under my observation first presented all the conditions 
common to neurasthenia and general nervous exhaustion, with 
inability to attend strictly to business. There was marked 
hypochondria with reference to the sexual organs, and the con- 
stant fear that he had contracted some imaginary disease. 
This was followed, much to my surprise, in the course of a year 
and a half, by all the characteristic phenomena of general pare- 
sis. In this case there has been no history of syphilis, but ex- 
cessive worry in regard to business, and his apparent appreci- 
ation of his inability to carry on his business with his former 
success seemed to be the exciting causes of the disease. A 
change in his condition, which was noticed by his physician, 
was supposed to be the beginning of improvement on his part; 
it was, however, the beginning of the mental derangement 
which is common to general paresis. At this time he began to 
see only the pleasant side of things, and to form great plans 
about his business, and he seemed to have no longer any fear 
of failure in his enterprises. The extensiveness of his schemes, 
with their impracticability, drew the attention of his business 
friends to his mental state, and when utterly unable to go to 
business, or to speak intelligently or connectedly about his busi- 
ness, he was as much over-sanguine as he had formerly been 
despondent. Few cases, however, apparently have this pro- 
dromal stage, most of them showing first more or less mental 
excitement, rather than a prolonged condition of general ner- 
vous ill-health. 

The differential diagnosis may require to be made at times 
from alcoholic dementia — a fuller description of which will be 
given later — from syphilitic disease of the brain, from acute 
mania, and from paranoia, where there may be ideas of gran- 
deur not dissimilar from those found in general paresis. The 
ambitious ideas of paranoia may offer special difficulties at first 
in the way of diagnosis. Intra-cranial growths are not likely 
to lead to errors in diagnosis. Disseminated sclerosis is at times 
most difficult to distinguish from it; but here we have 
marked tremor, the nystagmus, the peculiar speech, and 
rigid and almost spasmodic condition of the lower extremii 
to aid us in making the diagnosis. Both diseases may occu 
an early period of life, the disseminated sclerosis as a rule so 
what earlier than general paresis. In a few rare cases, gen 



GENERAL, PARESIS. 335 

paresis is found among elderly people, and under such circum- 
stances it may be difficult to differentiate it from senile demen- 
tia. In a case which I had under observation, a patient with 
strong religious ideas began to develop considerable excitement 
and irritability on account of the opposition to plans which he 
had devised for the union of all religious denominations. 
There was marked tremor, and also inequality of the pupils, and 
evident signs of exhaustion. It looked as though the disease 
would progress rapidly, but on removal to an asylum, the 
routine of the institution and the proper regulation of the diet 
and of all his actions, along with the needed rest, led to marked 
physical improvement. The case is still under observation, and 
it is probable that it will again progress rapidly as soon as the 
effect of the change in the patient's surroundings has passed 
off. From ordinary epilepsy and apoplexy there should be no 
difficulty in differentiating the disease. 

In legal relations general paresis comes very often in ques- 
tion. Especially is this seen in the early stages, before the dis- 
ease has been actually suspected. The extravagance in expen- 
diture may make it necessary to inquire into the mental state of 
the individual. Again the question of responsibility for theft 
committed (which is not unusual in this disease), or malfeasance 
in office, or the care of moneys or estate may arise, or even 
offences against decency, for erotic tendencies are not uncommon 
in the early stages of the disease. As we have seen, maniacal 
attacks with homicidal tendencies may also occur. 

Eemission simulating complete recovery often comes into 
question. There is no true remission in this disease. The later 
stages of the disease are so well defined that the question of re- 
sponsibility can scarcely arise. I would refer here to the follow- 
ing case in which the probate of a will was contested : 

Will of Kiedaisch, IS N. Y. Supp., 255. — Contested pro- 
bate of a will. Testator was confined to an insane asylum in 1 886 
as being afflicted with general paresis. In 1887 he was taken 
out, and in 1888 married the proponent. It was not objected that 
he was incompetent to marry, and the will was executed shortly 
after; in 1889 he was again confined to the asylum, where he 
died in 1890. During the time he was not confined to the asy- 
lum he transacted business. The testimony of experts was con- 
flicting. Held, that the testator was competent to make a will. 



326 



INSANITY — FISHER. 



/^^ 




; 


Mb 




M 




HPr 


: 4^^ 


m 


■'^MH^HLM^P^ 


w 


osiiKs^P^i^^ 




^ '.^X 








gjl'jlj^ "^y-rM 


^^ 


■H^^^^^^^k "* '.^^ 


^^^^^^^^1 



Fig. 25.— General Paralysis during Period of Excitement. 



The following 
cuts illustrate the 
facial expression 
in general paraly- 
sis, which is as 
distinctive as the 
mental symptoms 
themselves : 

A. B. (Fig.25),8et. 

3.5, male. Patient 

had all the charac- 
teristic symijtoms of 

believing- that he 

possessed great 

wealth and delu- 
sions of grandeur. 

Death occurred 

about three years 

from beginning of 

the disease. His 

brother died in another institution of the same disease, just preceding the 

time of his death. 

A. B. (Fig. 26), female, set. 44. In this case very few mental symp- 
toms except demen- 
tia were present, 
and the diagnosis 
remained sometime 
in doubt. The phy- 
sical signs were, 
however, well de- 
fined as the case 
pi'Ogressed. Marked 
tremor of the face 
and tongue and loss 
of facial expression. 
The speech was 
slow and clumsy. 
Epileptic seizures 
were frequent, one 
passing into the oth- 
er, and were chron- 
ic in character. 
Death followed one 
uou.raii,uahM. .,nhe,se seizures. 




SYPHILITIC INSANITY. 337 

Syphilitic Insanity is cerebral syphilis with predominating 
mental symptoms. 

It depends on disease of the cerebral vessels, which may be 
partially or completely occluded. We find gummatous infiltra- 
tions in the walls of the vessels and usually an affection of the 
membranes of the brain. The usual situation of the meningitis 
is at the base of the brain, extending into the cord, so that we 
have a diffuse cerebro-spinal meningitis, which usually in- 
volves some of the cranial nerves, especially the third nerve. 
The meningitis may affect the convex portion of the brain, 
especially the frontal lobes. Again there may be gummata, 
single or multiple, which, by their special situation, may cause 
epileptic seizures. 

The disease presents many symptoms resembling those found 
in general paresis. Again the acute psychoses, as melancholia 
and mania, may arise. The general tendency of the disease is 
toward dementia, usually progressive in its character. Not 
rarely, however, dementia, acute in character, may arise, in 
which the individual may become unable to recollect his own 
personality, or recognize his surroundings. This is probably 
due to anaemia of the brain dependent upon the circulation, and 
is more apt to precede any localizing symptom such as paralysis 
or convulsions. This was well illustrated in the following 
history : 

C, set. 42, a traveller for a New York house, while in Chicago 
became suddenly demented and was arrested in the street, being unable 
to give his name or address. He was taken to his home by friends and 
remained in a stupid, half-maniacal state for some weeks. Under 
special treatment for syphilis his mental state entirely cleared up. 
Spinal symptoms developed later, which were without doubt due to 
syphilis, from which he died. 

The special symptoms of cerebral syphilis are headache, 
usually nocturnal, paralysis, usually hemiplegic in type and 
accompanied by aphasia, and not infrequently epileptic seizures 
either unilateral or general. The paralysis may be entirely 
recovered from, according as the artery has been the seat of a 
complete thrombosis or a partial one. The paralytic attack is 
not infrequently followed by a second one, or a third, and may 
be on the same side as the previous one, or on the other side of 
the brain. Associated with this we may have a paralysis of the 
III.— 33 



338 INSANITY — PISHBE. 

third nerve, causing a paralysis of the upper eyelid or ptosis, 
and inequality of the pupils, which are usually very slow in re- 
action to light, and often irregular in outline. 

There may be marked tremor, especially of the tongue and 
hands or even of the face. The speech is often affected, but 
differs from the clumsy, slurring speech of general paralysis, 
being that resulting from paralysis, and usually accompanied 
by some loss of the names of articles. The reflexes of the 
paralyzed limbs are always exaggerated. The mental state is 
one usually of dementia, the memory is impaired, and at times 
there may be attacks of coma lasting for hours or even days. The 
prognosis is not altogether unfavorable. The mental disturb- 
ance may entirely disappear, and even the paralysis if the lesion 
has not been too severe. There is often considerable difBculty 
in making a differential diagnosis in some of these cases from 
general paresis. However, delusions are rare, and it is unusual 
to find ideas of grandeur and wealth. The apoplectic seizures 
with paralysis are more quickly recovered from in general par- 
esis, and the localized symptoms are rarely as well defined in the 
latter. Such cases, however, in general paresis, in which the 
physical signs of the disease are alone present or only accom- 
panied by a slight dementia, may make it almost impossible for 
the time being to make a diagnosis positively. The general 
course of general paresis is, however, as we have seen, compara- 
tively rapid and always ends fatally. 

In a legal sense these cases are often of great importance, 
especially in regard to testamentary capacity. Improvement, 
which would only imply a remission in general paresis, and no 
actual abatement of the delusions or of the dementia, would 
mean in cerebral syphilis a return or restoration to complete 
mental power, and, therefore, the right to resume control of the 
person's own affairs or property. 

Alcoholic Insanity. — As an etiological factor alcohol 
enters largely into the production of various forms of insanity. 
We find it frequently associated with other causes in produci"" 
general paresis, mania, etc. 

We have two conditions, however, to consider in alcoholi 
which by their course or class of symptoms mark themsel 
out as peculiar to alcohol, viz., acute and chronic alcoholiE 
In the first condition we have symptoms which are especia 



ALCOHOLIC INSANITY. 339 

characteristic of mania. It is usually due either to the exces- 
sive ingestion of alcohol or may occur after its withdrawal. 
This may be involuntary on the part of the individual, as the 
stomach may no longer be able to retain it. There is also much 
exhaustion associated with the withdrawal of the alcohol, as 
usually during these alcoholic excesses verj^ little food is taken. 

A neuropathic disposition inclines especially to the produc- 
tion of this excitable state, or a previous injury of the head. 
In the latter cases a small amount of alcohol may be sufficient 
to induce mania. The course is, however, brief in these 
cases, and is not associated with many of the physical signs of 
the disease, as tremor, etc. We make a distinction here be- 
tween delirium tremens and acute alcoholism in our description, 
which may indeed be partly artificial, but at the same time 
seems important. 

The patient is excitable and often violent, desirous of shout- 
ing and singing. In the majority of the cases we find a con- 
dition of great mental excitement continuing for days or weeks 
after the withdrawal of the alcohol, in which the patient is very 
loquacious, and subject to hallucinations, illusions, and delu- 
sions. He wanders from one subject to another, speaking 
rapidly but incoherently. The hallucinations affect both sight 
and hearing ; he converses with friends as if they were present 
and he saw and heard them. 

There is considerable confusional dementia present, all idea 
of time and place being lost at times ; any recollection of how he 
was brought into his present place being absent. There are 
many subjective sensory disturbances leading to illusions, as of 
creeping insects or animals being present. This may have its 
cause in a neuritis, commonly present in these cases. In ex- 
treme instances there may be an absolute paralysis involving 
the lower and secondarily the upper extremities, dependent upon 
disease of the peripheral nerves. This latter condition is often 
present in alcoholics without the presence of mental symptoms, 
but the association of the two conditions is not rare. 

There is associated with, these acute conditions a marked 
tremor affecting the extremities, especially the hands, and 
also the muscles of the face and tongue. This may resemble 
very closely the tremor of general paralysis, and if the ex- 
citement is associated with delusions of a boastful character, 



330 INSANITY — FISHER. 

which is not rare, may make the diagnosis for a time difficult, 
The physical condition, however, shows much more vasomotor 
disturbance, and there is usually a tendency to marked perspi- 
ration. There may be also epileptic seizures, which makes 
the diagnosis still more confusing. The comparatively rapid 
improvement, however, after the withdrawal of the alcohol soon 
removes all doubt in these cases. 

In an article entitled " Mental Symptoms in Alcoholic Mul- 
tiple Neuritis " I called attention especially to the mental symp- 
toms of these cases. The symptoms differ somewhat from those 
found in so-called chronic alcoholism or alcoholic dementia. 
The following case illustrates it, and also shows the possibility 
of complete recovery : 

A. B., female, set. 30. Subject to periodical alcoholic excesses, not, 
however, of the form of dipsomania. Was brought to the hospital 
with complete paralysis of the upper and lower extremities and suJBfer- 
ing from exquisite pain on pressure over the nerves and muscles of the 
extremities. Patient was unable to state how she had been brought to the 
hospital or by whom, although not at the time under the influence of 
alcohol in any degree. Was unable to state the day of the week, nor 
did she have any idea of time. Patient answered ordinary questions 
rationally, but would forget the next hour or day that she had spoken 
of the subject. There was no other delusion or hallucination of any 
kind. This condition continued for a year, a complete recovery of the 
paralysis occurring and a gradual but absolute mental restoration. 
The intervening year, however, always remained a complete blank. 

This latter class of cases is much rarer than the former, with 
mania and delusion. 

The pathological changes are often distinct and well defined. 
We find a multiple neuritis involving the peripheral nerves, and 
the brain shows evidence of degeneration of the cortex cells and 
the associative fibres. There is usually also a considerable in- 
crease of the cerebro-spinal fluid. 

These conditions may be completely recovered from or may 
pass on to the chronic changes which come under the head of 
alcoholic dementia. 

Chronic Alcoholism or Alcoholic Dementia is a con- 
dition characterized by a progressive dementia associated with 
special delusions, especially those of suspicion. 

The etiology of these cases is usually the constant and axces- 



A.LCOHOLIC INSANITY. 331 

sive use of alcohol, with periods of more or less prolonged de- 
bauches. We have, therefore, some of the symptoms of acute 
alcoholism just described associated at times. The chronic 
alcoholic becomes incapable of carrying on business, in fact 
loses all desire to do so; his memory is defective, and he loses 
all the higher qualities of his ethical nature. He is subject to 
delusions of persecution and believes that people are conspiring 
against him. Delusions of hearing are common ; he hears the 
voices of his enemies talking against him, threatening to kill 
him, etc. Visual hallucinations are also present. Circumstantial 
accounts of assaults and often robbery, with details founded on 
delusions, may be given which have absolutely no foundation 
in fact. On the other hand the individual may accuse himself 
of acts homicidal or otherwise, which were clearly not committed. 

One of the commonest delusions of suspicion is that of the 
infidelity of the wife or husband, as the case may be. 

These delusions may lead to acts of violence, homicidal in 
character. As the dementia progresses there is often a fixed 
delusion in regard to these acts. It is not rare to find a patient 
assert, with full belief in his statement, that he has been at a 
certain place and met certain persons and transacted business, 
when it is known that he has not left the house for weeks. 

He may be unable to recognize his surroundings, not know- 
ing that he is in his own house, or may be unable to State the 
time of the year or week. There are, however, marked changes 
in the course of the symptoms, depending on the amount of 
alcohol consumed. The physical signs show tremor and much 
muscular weakness, and at times epileptic seizures, which may 
be followed by mania or melancholia. 

The course followed by the law is that alcohol is no excuse 
for crime except where a distinct mental disease is induced 
as the result of the alcohol. In commitments care must be 
observed, as recovery from the delusions is often rapid when 
the alcohol is removed, and litigation for damages may result. 
There are laws at present regulating the confinement of women 
in certain institutions for a year, which relieves the physician 
and friends of the responsibility. 

The dementia in chronic cases has a tendency to remain per- 
manent, even after the removal of all opportunities of obtaining 
alcohol. The pathological changes in these cases are definite 



332 INSANITY — FISHER. 

and well defined. We find a chronic pachymeningitis, often 
aasociated with meningeal hemorrhage and a degeneration of the 
cortex cells and association fibres . There is also cerebral atrophy 
with increase of the cerebro-spinal fluid. 

The following cases will illustrate the condition described : 

A. B., male, set. 43. Family history negative. Always of a neu- 
rotic disposition. For the past ten years has been an excessive drinker, 
especially at night, when he would take large quantities of gin. B. 
has had several attacks of delirium tremens, and also gives history of 
several epileptic seizures. On examination found patient fairly well 
nourished, but there was marked tremor of the muscles of the face, 
tongue, and hands, so that his writing was scarcely intelligible. B. 
had an epileptic attack at the time, remaining more or less confused 
mentally for two hours. Memory was very defective — could not play a 
game of whist intelligently, although thoroughly well acquainted with 
the game. The question which arose in this case was his ability to trans- 
act business and his responsibility for his contracts. The partnership 
was annulled on these grounds. There were at no time any delusions, 
simply a dementia being present. Under care and the withdrawal of 
the alcohol, marked improvement followed. 

A second case, in which the question of the abOity to manage her 
own property arose, is as follows : Mrs. B., set. 65, has been addicted 
to excessive drinking for years, for which cause she is separated from 
her husband. 

The patient is naturally a very shrewd person and capable of trans- 
acting business of extensive proportions, when not under the influence 
of alcohol. 

After excesses she becomes maniacal and has delusions of being 
assaulted and robbed. She constantly hears voices speaking against 
her, calling her indecent names, and threatening to kill her. Has illu- 
sions of persons around her saying they assaulted her. After an un- 
usually prolonged debauch, in which she had fallen and injured her- 
self, she ascribed her injuries to an attack by these persons. 

Her story was that they had entered her house, seized her. by the 
hair, and robbed her of a large sum of money, which they knew she 
carried about her. This delusion, which she held after she was no 
longer under the influence of alcohol, was described with f uU details of 
the assault. Even during her relation of it, however, she would call 
attention to the voices in the room above, talking against her. Any 
sound was interpreted as evidence of a conspiracy. Under care, how- 
ever, all these delusions disappeared. 

Many cases similar in character can be recorded, in which 
the delusion of suspicion and conspiracy is associated with that 



ALCOHOLIC INSANITY. 333 

of the fear of being poisoned or of losing their property. This 
may lead to certain acts to avoid the impending ruin as seen 
in the case reported by Simon : 

A well-to-do business man, addicted to excessive alcoholism, im- 
agined that he was becoming poorer every day, and that his neighbors 
reproached him for the most necessary living expenses. He set fire to 
his house, to avoid the complete financial ruin. This patient ulti- 
mately recovered. 

This writer states that an irresistible impulse may often ex- 
ist in these cases and that homicides most often committed by 
chronic cases, are the result of these impulses. In my opinion 
these acts are usually the result of the hallucinations or delu- 
sions. 

The question of responsibility is often a difficult one. Eossi, 
Ortolan, Helie are in favor of allowing extenuating circum- 
stances in all cases of intoxication. As Cullere says, " a distinc- 
tion must be made between the individual who resorts to alcohol 
for the courage to carry out an act or crime, and he who in un- 
foreseen intoxication or in alcoholic delirium commits an illegal 
act. In case of drunkenness the expert must study exactly the 
habitual mental state of the individual, his hereditary tenden- 
cies, the moral or emotional shocks which may have shaken the 
stability of his nervous system." 

" Although drunkenness in itself is no palliation or excuse 
for crime,' yet mental unsoundness, superinduced by excessive 
intoxication, and continuing after the intoxication has sub- 
sided, may excuse; or when the mind is destroyed by long- 
continued habit of drunkenness, or where the habit of intoxi- 
cation caused an habitual madness ; and where a person is in- 
sane at the time he commits the crime, he is not punishable, 
although such insanity be remotely occasioned by undue indul- 
gence in spirituous liquors, or from what, in a moral sense, is a 
criminal neglect of duty. For if the reason be perverted or de- 
stroyed by a fixed disease, though brought on by his own vices, 
the law holds him not accountable. But temporary insanity, 
resulting immediately from voluntary intoxication, does not 
destroy legal responsibility, or constitute a defence for crime ; 
but when the question is, whether a murder is of the first or of 
• " American and English Encyclopedia of Law. " 



33 i INSANITY— FISHER. 

the second degree, the fact of drunkenness may be proved to 
show the mental status of the accused at the time of the act, 
and thereby enable the jury to determine whether or not the 
killing resulted from a deliberate and premeditated purpose." 

Senile Dementia. — This condition is one associated with 
old age, and is perhaps more frequently simply a sign of the 
gradual decay of the body as well as the brain ; in fact, as a 
rule, it depends upon arterial changes of a degenerative type. 
It manifests itself by loss of memory, inability to fix the atten- 
tion on the subject of the moment, and a tendency to recur to 
scenes and acts of a period long past. As has been said, "man 
is as old as his arteries," and consequently as a result of any 
cause, such as worry, emotional excitement or overwork, or 
disease due to alcoholism and syphilis, we often find true senil- 
ity present at a comparatively early age. It follows, therefore, 
that the peculiar symptoms of this condition may occur at the 
age of forty-five as well as at fifty or seventy-five years of age. 

The most common symptoms associated with it are suspi- 
cion of those nearest and most dear, hallucinations of hearing 
and of sight, and delusions which are often of a persecutory 
character. There is frequently a great fear of impending 
poverty or ruin. The habits change to those of extreme miserly- 
ness, so that even the ordinary expenses of living may he 
grudged, and even starvation may take place, although the 
money may be in their actual possession. We have aUuded to 
a similar set of delusions occurring in alcoholic dementia. 
While this condition is more common, we may find just the 
reverse take place. There may be special antipathies toward cer- 
tain members of the family arising from a delusion of suspicion, 
leading to great injustice in making a will, or for such reason 
all the property may be left to institutions. This necessarily 
leads to litigation either on that ground or that of undue in- 
fluences. Old age alone, even with decay of the natural 
powers, is not sufficient to render such a will invalid. 

Loss of memory of recent events leads to the development of 
a more or less marked confusion of thought, so that these 
patients even forget where they are, though they may be in 
their own homes which they have coccupied for years. They 
may even assert they are being confined by force in some dis- 
agreeable place, whereas as a matter of fact they are perhaps 



SENILE DEMENTIA. 335 

sitting in their own chair or room. On being convinced of their 
mistake, they will acknowledge it, but will almost immediately 
relapse again into the same or a similar error. Apoplectiform 
attacks are not infrequent, and probably explicable by some 
temporary occlusion of the cerebral vessels which has not been 
complete enough to cause a permanent lesion. This condition, 
therefore, represents the whole state of the circulation of the 
brain, and it is evident that not enough blood is carried to the 
various parts of the brain. The bodily condition often corre- 
sponds to the mental condition. Where the mental processes are 
more or less active, though impaired, there is usually loss of 
flesh and interference with the vegetative functions; where, 
however, the dementia is more advanced, so that hallucinations 
and illusions have a less permanent character, the physical con- 
dition will improve, or at least bodily weight will increase, and 
the general appearance of the patient will improve. This is, 
however, only the beginning of the end, and does not indicate 
recovery. There is also very commonly a condition of athe- 
roma affecting the vessels of the heart, leading to fatty degen- 
eration. 

This condition may be expected usually between the ages of 
sixty and eighty. The symptoms are generally mild, but they 
vary within rather wide limits. There may be a revival of the 
sexual desires which have long remained dormant, or there may 
be a tendency to alcoholism which may not have existed pre- 
viously, so that a person hitherto sober and orderly may become 
dissipated, and be given to sexual excesses and extravagance. 
These individuals naturally fall an easy prey to designing 
persons, and it is important to recognize the true nature of this 
condition in the early stage, for otherwise fortunes may be dis- 
sipated. Certainly it would seem that after years of correct 
living and business probity, acts contrary to the generally 
accepted character of the person should be considered as evidence 
of mental derangement rather than as evidence of previous hy- 
pocrisy on the part of the individual. 

The final stages of the disease are not dissimilar from those 
of general paresis. There may be considerable excitement, and 
even maniacal attacks sufiSciently severe to require restraint, 
or the removal of the person to an asylum. Depression is not 
so common as excitement ; stiU in many of these cases there is 



336 INSANITY — FISHER. 

a tendency to suicide as a result of such a profound depression 
as to almost simulate acute melancholia. 

This disease resembles at times the condition observed in 
women at the menopause, where it is not uncommon to see 
marked depression with more or less failure of the mental 
powers, loss of memory, and a series of illusions and delusions. 
However, this latter condition is often followed by recovery. 

The post-mortem changes observed would indicate rather a 
condition of atrophy and degeneration than any active process. 
The walls of the vessels are thickened and their lumen narrowed. 
The membranes are frequently thickened, with here and there 
evidence of a pachymeningitis. The fluid in the subarachnoid 
cavity and ventricles is increased. The volume of the brain is 
decreased. The convolutions are pale, anaemic, and flattened. 
The sulci are not so deep as in the normal brain. There is also 
an apparent increase in the Pacchionian bodies, and they are 
attached to the dura and pia along the longitudinal sinus. They 
may increase to such an extent as to lead to the formation 
of areas of softening in the cortex of the brain, not dissimilar 
to that found in general paresis. Microscopically, the cells of 
the cortex show signs of degeneration and loss of the processes. 
The walls of the vessels are seen to be considerably degenerated, 
and there may be evidences of aneurismal dilatations of the 
miliary type. 

These changes are all of a general rather than of a local 
character, pointing, as we have said, to a condition of atrophy 
and degeneration rather than to any active process. We would 
note that the association fibres connecting one area of the brain 
with another are also involved, explaining perhaps the loss of 
association of ideas and the impairment of memory, thus lead- 
ing to impaired judgment. This is perhaps not pecuhar to the 
disease under consideration, but is explanatory of similar mental 
states found in various other mental disorders. In conclusion 
I shall describe under this heading apoplexy. 

Cerebral Apoplexy — by which we mean a destructive 
lesion of the brain caused by hemorrhage into the brain, or 
softening from the plugging of the vessels by an embolism or 
thrombosis — may involve legal questions of much importance. 
We do not, as a rule, have what can be defined as insanity, 
but often there is dementia, with or without various delusions 



CEREBRAL APOPLEXY. 337 

and hallucinations, and conditions of impaired speech or aphasia, 
which makes it difficult for the individual to clearly express his 
wishes. This may render the testamentary capacity doubtful. 

The usual condition found in apoplexy is a paralysis of one- 
half of the body and aphasia, which may be permanent. 
Aphasia may be simply motor, in which there is difficulty to ex- 
press the ideas desired, by reason of impaired articulation, or 
there may also be a loss of the names of things, i.e., amnesic 
aphasia, so that communication has to be carried on by 
gesture. This condition does not, as a rule, or at least does not 
necessarily, imply that there is any lack of understanding of 
what is spoken or what is read, so that full intelligence may be 
maintained. In sensory aphasia, which may be of two 
varieties, there is what is understood as word blindness, that is, 
the patient is no longer able to understand written language, or 
again there may be word deafness, i.e., loss of understanding 
of spoken language. Mind blindness may be present, but this 
always implies an extreme degree of dementia, for the individual 
no longer comprehends the use of things, or their object ; this 
has been called apraxia. The whole character of the individual 
may be changed — he may become filthy and obscene in his 
habits, or lewd and addicted to alcohol. The essential point is 
really a matter of fact as to what the mental condition is at the 
time of examination. The mere fact of having had an apoplectic 
seizure does not necessarily imply such mental impairment as 
to incapacitate one from responsibility for his acts. The ques- 
tion arises most frequently in regard to the testamentary 
capacity of the individual and whether undue infiuence has 
been used at the time of the making of the will. 

The rulings as brought out in the celebrated Parish will case 
have not materially changed to the present time. In this case 
the will made while the testator was in the full possession of all 
his faculties was sustained, but the codicils made after his 
apoplectic seizure were not. The surrogate of New York found 
and decided as a matter of fact that the testator had not testa- 
mentary capacity on the 15th of September, 1853, or on the 
15th of June, 1854, to make the two codicils, and that they were 
not his will or any part thereof, and he refused to admit the 
same to probate. 

The weight of the testimony in the trial brought out that his 



338 INSANITY — FISHER. 

whole moral nature was changed, and that he was not morally 
responsible for the unbecoming and ungentlemanly conduct he 
so frequently exhibited. It was also shown that after his attack 
he never was able to utter an intelligible word, and the gestures 
made by him with the left hand were unmeaning and contra- 
dictory. " If Mr. Parish had no power to express a wish to 
destroy a will, it follows he had none to create one, and the 
manifestation of his wishes depended entirely upon the inter- 
preter, and the integrity of the interpretation." ' 

However, the will of a paralytic will be sustained, when, 
though unable to talk at the time of its execution, the mind is 
unimpaired and he is able to signify his assent to each item by 
an affirmative nod of the head as it is read to him." 

I would also refer to a case where the question of senile 
dementia following an apoplectic seizure arose in regard to pro- 
bating the will of the testator,' and a similar case in which the 
probate of the will was objected to, as the maker had had two 
apoplectic seizures, after which his observation became im- 
paired and he also failed to recognize acquaintances.* 



ARRESTED CEREBRAL DEVELOPMENT, OR DISEASE OF 
THE UNDEVELOPED BRAIN. 

Idiocy is a mental condition due to maldevelopment of the 
brain, which may be congenital, due to absence of parts of the 
brain structure, or to disease consequent upon inflammatory 
changes, or to defects in the blood supply to certain brain areas. 
The degree of actual brain defect will represent the degree of 
mental impairment. There can, therefore, be no actual sub- 
divisions of idiocy, although for the sake of convenience we 
may speak of several grades. 

In a medico-legal sense there is some importance in these 
cases both in civil and criminal relations. 

' Delafield v. Parish, " Report of gate's Court, December, 1879 ; Su- 

Cases Argued and Determined in the preme Court, second departi 

Court of Appeals of the State of General Term, September, 

New York, " vol. xi. (by E. Pe- Court of Appeals, 1381 ; Austi) 

schine Smith) . bott's New Cases) . 

« Rothrock v. Rothrock (Ore.), 30 * The New York State Rep 

Pac, 453. by R. M. Stover of New York 

* Swenarton v. Hancock (Abbott, roy Randall v. George H. E 

vol. ix., Rockland County Surro- ing). 



IDIOCY. 839 

Etiology of Idiocy. — There may be absence of almost the 
whole of the cerebral hemisphere, only the basal ganglia remain- 
ing. The brain may be the seat of meningeal inflammation, 
with hemorrhage either meningeal or, more rarely, in the brain 
substance. We find paralysis and usually epilepsy associated 
in these cases. They may be congenital or follow the diseases 
of childhood, as the exanthemata. 

Porencephalus, usually a congenital condition in which 
we have a loss of certain portions of the brain substance, usually 
resulting in a cyst or cavity connecting the cortex of the brain 
with one of the lateral ventricles, is associated with idiocy or 
imbecility. We also have in these cases paralysis and epilepsy. 
In this relation we must also consider traumatism, which may, 
of course, be productive of extensive destruction of the brain. 
Among other causes, not associated with brain defect, we must 
before all consider hereditary influences, as insanity, the various 
neuroses, syphilis, alcoholism, and consanguinity, etc. ; also 
microcephalus, hydrocephalus, hypertrophy, and cretinism. 

The changes observed in the brain depend largely on the 
cause. The absence of the hemispheres explains the mental 
condition in such cases. In the second class referred to, in 
which we find idiocy or imbecility associated with hemiplegia 
and epilepsy, there is usually considerable atrophy of One of 
the hemispheres of the brain ; the nerve cells and fibres also 
show degeneration, and there may be descending degeneration 
of the nerve tract into the spinal cord. In the cases dependent 
on hereditary syphilis and alcoholism, there is evidence of im- 
pairment of the cells of the cortex and a tendency to the for- 
mation of connective tissue, resulting in sclerosis of the cerebi'al 
substance. 

In microcephalic cases we find a decrease in the cranial 
measurements, which may be symmetrical. Most cases show 
evidence of dolichocephaly, and there is shortening of the an- 
tero-posterior diameter. There may be variations in the de- 
formity, as scaphocephaly, plagiocephaly, etc. 

In so-called cretinoid idiocy, which is dependent on some 
defect in the functional activity of the thyroid gland, or due to 
its absence, the conformation of the skull is flatter and gives the 
appearance of being square, the condition being brachycephalic. 
The bones of the face, especially the malar processes, are also 



340 INSANITY — FISHER. 

prominent; this with the infiltration and thickening of the 
skin gives the face a peculiar expression. The mental state 
corresponds, however, to idiocy, and should be properly in- 
cluded in this place. 

In hydrocephalus, which is a chronic condition resulting in 
dilatation of the ventricles, we may find the skull very much 
thinned, and the cranial measurements largely increased. The 
brain is, however, the seat of atrophy, the cortex being much 
reduced in thickness and the cell element showing impairment 
or destruction. The face appears much smaller than normal by 
the contrast with the increased size of the skull. In hypertrophy 
of the brain we find an increase especially of the white substance 
of the brain, and probably an increase of the neuroglia tissue. 
There is considerable increase in the weight of the brain. 
The skull measurements are not increased to the extent found 
in hydrocephalus." "Bourneville distinguishes, from an anato- 
mico-pathological point of view, the following forms in idiocy: 
(1) Idiocy symptomatic of hydrocephalus (hydrocephalic idiocy) ; 
(3) idiocy symptomatic of microcephaly (microcephalic idiocy); 
(3) idiocy symptomatic of the arrest of development of the con- 
volutions; (4) idiocy symptomatic of a congenital malformation 
of the brain (porencephaly, absence of corpus callosum, etc.); 

(5) idiocy symptomatic of hypertrophic or tuberculous sclerosis; 

(6) idiocy symptomatic of atrophic sclerosis — (a) sclerosis of 
one or both hemispheres; (6) sclerosis of one lobe of the brain; 
(c) sclerosis of isolated convolutions ; {d) sclerosis chagrime 
(like shagreen) of the brain (?) ; (7) idiocy symptomatic of 
chronic meningitis or meningo-encephalitis (meningitic 
idiocy) ; (8) idiocy with pachydermic cachexia, or myxoede- 
matous idiocy connected with absence of the thyroid gland. 
This latter form is called cretinoid idiocy." " 

The idiot manifests, according to the degree of his mental 
impairment, a more or less complete loss of mental activity. 
There is usually great restlessness, and inability to fix the 
attention on any one thing ; there is often understanding suffi- 
cient to comprehend what is said to them, but no idea of the 
necessity of doing what is requested — in fact, all sense of re- 
sponsibility is absent. Speech is usually involved. The vo- 

• Tuke's "Dictionary of Psycho- ' E6gis, "Practical Manual of 

logical Medicine. " Mental Medicine. " 



IDIOCY. 



341 



cabulary may be limited to but few words, or language may 
never be acquired, certain sounds intelligible only to those in 
charge being used to indicate their wishes, a language of their 
own being thus formed. The higher ethical nature is absent, 
so that the passions and desires are carried out unrestrainedly. 
The sexual propensities may be increased, masturbation being 
openly carried on, or assaults may be made on women and 
children. Such patients may be violent and homicidal, oppo- 
sition usually exciting them to anger. There are, however, 




Fig. 27.— Tjfplcal Face of Idiot. 

cases where affection seems to be exceedingly strong. We 
find in almost all instances a tendency to destroy articles, to 
appropriate anything within reach. When the intelligence is 
partially preserved, acts of assault and thieving may be car- 
ried out with some degree of cunning, and attempts at conceal- 
ment may be made. 

There is not infrequently a marked appreciation of music, 
and in some few instances a decided aptitude for certain things, 
as drawing, figures, or music. 

The general appearance of the idiot is indicative of his 
mental state. Physically he is usually small ; the head is, in 



342 INSANITY — FISHER. 

the majority of the cases, as we have said, microcephalic. The 
face lacks any fixity of expression, but is continually chang- 
ing; the mouth is open, the saliva passing unconsciously away; 
the teeth are irregular, and the palate often narrow and highly 
arched. The hands and, in fact, the whole body are subject to 
choreiform movements, and there are frequently present epi- 
leptic seizures. Various other asymmetries of the face are often 
present, as deformity of the ears and eyes. 

Imbecility is a congenital or acquired state of mental weak- 
ness, differing in degree rather than kind from idiocy, The 
same causes exist here as in idiocy. It not infrequently follows 
in the course of the neuroses, especially epilepsy and chorea. It 
may manifest itself especially in the moral or intellectual fields. 
We find the same inability to apply the attention to the acqui- 
sition of learning. 

Imbeciles frequently give evidence of moral perversion, in the 
absence of ordinary affection, and by acts of cruelty. They are 
frequently impulsive, and we not rarely find them committing 
acts such as we have described under the head of pyromania, 
kleptomania, etc. The motive often is very slight, perhaps a 
desire of revenge for some fancied wrong. There is rarely any 
feeling of remorse for what is done. Many such cases fill our 
reformatories, and are often among the most incorrigible and 
mischievous of the inmates. In the milder forms the condition 
may not have been observed in very early life, or until the re- 
straints of school show an almost complete inability to progress 
with others in the course of study. Again the exhibition of a 
sort of moral perversion may not manifest itself until later; the 
higher ethical nature seems to be absent. They may also be 
inclined to venereal and alcoholic excesses. Perhaps in these 
cases there is a greater tendency to some special talents, such 
as we have referred to, in music or mathematics, etc., than in the 
class defined as idiots. There is, however, observed through 
all their acts a seeming absence of the proper appreciation of 
the relations of ordinary life and its responsibilities. 



MODIFIED CLASSIFICATION. 343 

MODIFIED CLASSIFICATION, 

The modifications iu the classification of mental diseases have 
not been of great significance in the last ten years. 

The old basis of division has remained the same. No abso- 
lute adherence, either to the etiological, symptomatological, or 
pathological has been followed, but rather a combination of these 
factors has been employed. There is, in my opinion, no neces- 
sity for an exact system of classification either for legal or medi- 
cal practice. 

The real advance in psychiatry in the nomenclature of men- 
tal diseases is a more exact definition of the various diseases, a 
further separation of the symptoms — which have been classed 
together as the symptom complex of a single disease or its dif- 
ferent stages. 

The more careful clinical observation of these symptoms in 
the last ten years has led to a considerable advance in our un- 
derstanding of special forms of insanity. ITo new form has been 
discovered, but out of the confused aggregation of symptoms it 
has been possible to group a certain class, which appears almost 
constantly and with comparatively little variation with a fixed 
form sufaciently strong in each to enable us to apply a name to 
the entity. 

This has simplified two important conditions at least, and 
made the older forms more clearly defined, by thus withdrawing 
into a class by themselves cases which have always been difficult 
satisfactorily to place under the old headings. 

Prof. Emil Kraepelin has done this service for psychiatry. 
While Kraepelin is not optimistic in his statements, he has es- 
tablished a better working schedule of mental diseases than we 
have previously had. 

The general profession finds some difiiculty in accepting in 
full this classification, but the last three years have proved its 
practicability, so that it has been almost universally adopted in 
our various large public asylums and among psychiatrists in 
private practice and in the courts. The two forms of insanity 
referred to in this introduction are manic-depressive insanity 
and dementia prsecox. 

Manic-depressive insanity is a term which has been intro- 
duced within the past five years to cover a class of symptoms 



344 INSANITY — FISHEB. 

which have previously been classified under the head of melan- 
cholia and mania. We have in the description by Kraepelin 
no new symptoms given, in fact no new disease described, but 
rather a new grouping of well-known symptoms. 

Kraepelin would place all cases of mania or melanchoha in 
the young under the title of manic-depressive insanity. Melan- 
cholia in its typical form, characterized by depression, slowness 
of thought, impassivity, well-defined, fixed, but not systematized 
delusions, and self-condemnatory conceptions is a disease only 
of the involutional period of life, i.e., the climacteric. 

The degeneration of the individual is already greater than 
the repair ; in other words, the age is reached when no further 
growth takes place in the central nervous system, but rather a 
decline due to advancing age has commenced. He uses very 
aptly for this condition the term involution and thus distin- 
guishes true melancholia from all forms of depression, no mat- 
ter how similar they may be in many respects, which may occur 
in the young, where the process of evolution or growth is still 
going on. 

"With the definition of melancholia limited to this class of 
patients, he very properly says, the outcome of the disease is 
very different from that of so-called melancholia in the young. 

The former tends progressively toward degeneration, while 
in the latter the percentage of recovery is very much greater. It is 
also claimed by this author and his supporters that melanchoha 
in the young is rarely depressive alone, but either at the time is 
complicated by mania or in case of recurrence after recovery 
is as likely to begin with maniacal excitement as with depres- 
sion. He further claims that there is no assurance of a permanent 
recovery, but that as a rule it is a recurrent disease, alternating 
with depression and excitement, ultimately to end in dementia. 
We have then, in his opinion, in the young adult a disease char- 
acterized by melancholia or depression, resembling in its general 
symptoms the melancholia of the climacteric or involutional 
period of life, but differing from it in that it alternates with 
mania and is recurrent in its nature. This classification is not 
wholly acceptable to many experienced psychiatrists. I ac- 
knowledge with them that Kraepelin has separated out for us a 
special form of mental disease, for which the term manic-depres- 
sive is ample and satisfactory, cases with which we are all famil- 



MODIFIEB CLASSIFICATION. 345 

iar, but which we have not been able satisfactorily to class as 
mania or melancholia, as both conditions existed, either simul- 
taneously or following one the other every year or at intervals 
of five or even ten years. 

I hold, however, that we have a true melancholia or mania 
in the young, with little or no variation either in etiology or 
course from that occurring in the old, differing only in the prob- 
ability of recovery, which is easily explained by the greater re- 
sistance presented by the age of the patient. Kraepelin reports 
similar cases, but holds that the recovery is only an apparent 
one, as in his opinion, if these patients live long enough and 
have sufficient cause or provocation, a second attack will occur, 
either depressive or manic. This seems to me only begging the 
question, as we all see cases which after twenty years or more 
have no recurrence and in which no evidence of disease remains. 
Prom a medical and legal aspect we must regard such persons as 
sane and responsible for all their acts. This point of view is of 
especial significance in a legal sense. 

Dementia Prsecox. — Here again we owe to modern psy- 
chiatry in the last ten years a simplification in the classification 
of a most difficult set of symptoms in mental disease. It is a 
disease of adolescence. It belongs to the evolutional period of 
life, the greater number of cases occurring before the twenty- 
fifth year. 

It is usually congenital, rather than acquired. Stress, illness, 
privation, excesses in one previously inclined, developing symp- 
toms which under favorable conditions might have remained 
quiescent. There are three principal forms: the hebephrenic, 
katatonic, and paranoid. 

The first form occurs in the very young, from the ages of 
twelve to twenty-one. There is great loss of mental power, in- 
ability to understand the ordinary relations of life or to carry 
on either work or study. The power of concentration or atten- 
tion is lost together with responsibility. The emotions are in 
the ascendancy, depressive or excitable, varying with the hour, 
from mutism to volubility with verbigeration. The aesthetic side 
of life is much affected, leading to indecency in words and 
actions. This passes on rapidly to dementia, which may be per- 
manent or be recovered from in part, leaving, however, some 
degree of mental weakness. We see many such among the 



346 INSANITY — FISHER. 

young who are unable to apply themselves to any definite work, 
are mischievous, cruel, and without a true appreciation of the 
character of their actions. 

The katatonic form presents a condition in which katatonia, 
a .disease described by Kahlbaum, is a principal factor. 

Katatonia is a symptom rather than a disease, and is found 
in other forms of insanity, as melancholia, hysteria, and mania. 
In dementia prsecox it may take on an active character in which 
the various positions assumed by the patient, although fixed, for 
the time may change according to the hallucination or delusion 
which may arise. This state may end in dementia early in its 
course as in the hebephrenic form. It occurs most commonly 
between the ages of eighteen and twenty -five, and is frequently 
accompanied with delusions of grandeur and changed personal- 
ity, as the delusion of being God, king, etc. 

The paranoid type is more difficult of diagnosis, at least in 
the acute onset of the disease. It occurs at a still later period 
of adolescence. The patient in early life may have been con- 
sidered somewhat erratic or even brilliant, but usually some- 
what unstable. The early condition is often ushered in by 
depression or hypochondria, to be soon followed by excitement 
with egotistic ideas and delusions of persecution, with at times 
hallucinations of sight and hearing. The power of concentration 
is soon lost, a condition which is recognized by the patient him- 
self. There are oftentimes attacks, maniacal in character, or a 
tendency to alcoholic excesses. These cases resemble paranoia 
of a somewhat atypical form, and by many psychiatrists are still 
classed as that disease, but more properly fall under the head 
of adolescent insanity or dementia prsecox. Eecovery is rarely 
complete, and, as in the other forms, an early and permanent de- 
mentia wholly or in part results. 



MENTAL -UNSOUNDNESS 

IN ITS 

LEGAL RELATIONS. 

BY 
TEACY C. BECKER, A.B., LL.B., 

CounseUor-at-Law ; Professor of Criminal Law and Medical Jurisprudence in the Law 
Department of the University of Buffalo, etc. 

AND 
CHARLES ANDERSON BOSTON, LL.B., 

Of the New Torlt, City Bar. 



THE LEGAL ASPECTS OF Il^SAKITT AITD 
MEl^TAL IMPAIRMENT. 

INTRODUCTION. 

THE LEGAL VIEW OF MENTAL IMPAIEMENT CON- 
TEASTED WITH THE VIEW OP THE ALIENIST. 

A person may be insane according to medical science, and 
yet responsible for his acts in law.^ 

To the alienist or the expert medical witness it must often 
appear that the law ignores psychopathic science ; and to the 
intelligent layman who examines the decisions of the courts, they 
must seem to be chaotic and glaringly inconsistent. 

It is true that this branch of the law cannot be praised as an 
all-wise and harmonious system. Yet many apparent contra- 
dictions arise from the mere technicalities of legal practice ; and 
the seemingly obstinate and perverse refusal of the courts to 
take notice of some of the scientific aspects of insanity is, on the 
contrary, to be justified by well-grounded reasons of public 
policy.^ 

For example, public policy is thought, by the courts of nearly 
all the States, to require a much more stringent definition of 
mental irresponsibility (in the criminal law at least) than any 
man of science would be likely to adopt for purposes of classifi- 
cation. 

A striking illustration of the difference above mentioned is 
afforded by the trial for murder, in the Criminal Branch of the 
Supreme Court of New York, of William Hooper Young (Feb- 
ruary, 1903). The Court, in the course of the trial, accepted a 

' State V. Kalb, 7 Ohio N". P., 547; mental state, when there is a con- 

5 Ohio S. & C. P. Dec, 738; State v. flict of evidence, to the jury, whose 

Tyler, 7 Ohio N. P., 443; 5 Ohio finding will not often be disturbed, 

S. & C. P. Dec, 588. though an aUenist mi^ht have reached 

^Another source of apparent con- an opposite conclusion. People v. 

fusion lies in the practice of the Taylor, 138 N. Y., 398; infra, p. 460. 
courts of submitting thf question of 

349 



350 MENTAL UNSOtJNDNaSS — BECKER AND BOSTON. 

plea of guilty of murder iu the second degree, for reasons which 
were thus explained by the judge to the jury: 

" It is only right to tell you, gentlemen, that the court ad- 
vised tW defendant's counsel to tender this plea, and that the 
court also advised the District Attorney to accept it. The man's 
mental condition was the cause for the action taken. You are 
aware that this man has been under medical observation. The 
experts reported this man legally sane, but insane from a med- 
ical point of view. He therefore is supposed to know the differ- 
ence between right and wrong, and should be held responsible. 
But as his insanity has been reported to me as being of the pro- 
gressive order, it is difficult to tell where one line merges into the 
other. It seemed to me that under the circumstances the law 
was not justified in inflicting the death penalty, and should be 
satisfied with a plea that sjiould confine this man to prison for 
life rather than run the risk of putting to death a possibly irre- 
sponsible man." ' 

"By medically insane they say they mean that a man may be 
well able to determine between what is right and what is wrong, 
yet not be physically able to restrain himself from doing wrong. 
While it is true that Young has delusions, still he knows what 
is wrong and what is right. !N"ow, there is a very narrow line of 
demarcation between these two kinds of insanity, and it is hard 
to tell where one merges and is lost in the other. . . . Under 
these circumstances I think the cause of justice can better be 
served by sending this man to prison for life, rather than that 
there should be any question as to whether we put to death a 
man that was irresponsible in any way for his deed."" 

GENERAL DEFINITIONS; LEGAL CLASSIFICATIONS. 

English common law anciently recognized two categories of 
mental diseases: 

(1) Dementia Naturalis, or idiocy; and (2) Dembntu 
Adventitia, under which general insanity is included. To this 
l£(,st the term " lunacy " is usually applied. 

The following definitions are from " The American and Eng- 
lish Encyclopaedia of Law " : 

' N. Y. Times, February 10, 1903. ' N. Y. Evening Sun, February 11, 

1903. 



DEFINITIONS AND CLASSIFICATIONS. 351 

An insane person is one whose mind is affected by general im- 
becility, or is subject to one or more specific delusions. 

A Lunatic. — At common law, a lunatic was one who hath had 
understanding, but by disease, grief, or other accident hath lost 
the use of his reason. 

An Idiot. — An idiot was one who hath had no understanding 
from his nativity. 

Non Compos Mentis. — The words non compos mentis seem to 
have been used as a generic term, including both idiocy and 
lunacy. They had, in the earlier cases, both in England and in 
the United States, a more restricted meaning than they bear at 
present, and were held to import a total deprivation of sense, 
and not to include mere imbecility or weakness of mind. In 
the more modern cases they are held to include not only cases of 
idiocy and lunacy, as strictly defined at common law, but also 
cases of imbecility where the subject is incapable of conducting 
the ordinary affairs of life, and liable to become the victim of 
his own weakness.* 

Dr. Beck uses the term "mental alienation" to cover all 
cases of unsoundness of mind, and divides these into: First. 
Those states of mental infirmity depending upon congenital de- 
fects of the brain, or on the imperfect development of its facul- 
ties during infancy, viz., idiocy and imbecility. Second. All 
those forms of mental derangement which arise from disease of 
the brain subsequent to its full development, and which may be 
said to constitute insanity proper. This class comprises those 
conditions of perverted mind commonly recognized by the terms 
mania, melancholia, monomania, and dementia. The legal defi- 
nition of a state of mental alienation, and the adjudications 
under it, are briefly treated at Vol. I. , page 765 et seq. of Dr. 
Beck's treatise.' 

Says Dr. Eay : " In the Roman law, the insane or demented 
are divided into two classes : those whose understanding is weak, 
or null, menti capti, and those who are restless and furious, furiod,. 
The French and Prussian codes make use of the terms dimenci, 
fureur, imbecilliti, without pretending to define them. 

"The English common law originally recognized but two kind** 
of insanity, idiocy and lunacy, the subjects of which were desig- 

' "Am. and Eng. Encyclopaedia of = Beck's "Med. Jur.," 12th ed. 

Law," 1st ed., vol. ii., title Insanity. 



353 MENTAIi UNSOUNDNESS'-BECKER AND BOSTON. 

Dated by the term non compos mentis, which was used in a generic 
sense, and meant to embrace all who, from defect of understand- 
ing, require the protection of the law. An occasional attempt has 
been made by jurists to attach some definite ideas to these terms, 
and to point out the various descriptions of persons to whom 
they may be applied. Lord Coke says there are four kinds of 
men who may be said to be non compos mentis : 1. An idiot who, 
from his nativity, by perpetual infirmity is non compos; 2. He 
that by sickness, grief, or other accident wholly loseth his mem- 
ory and understanding ; 3. A lunatic that hath sometimes his 
understanding and sometimes not, aliqucmdo gaudet lucidis hter- 
vallis ; 4. He that by his own vicious act for a time depriveth him- 
self of his memory and understanding, as he that is drunken. 

"Nothing can show more plainly how imperfect were the 
notions of the early law writers concerning insanity than this 
classification of insane persons, and their attempts to define the 
several classes. An idiot is defined to be a person who cannot 
count or number twenty pence or tell who was his father or 
mother, or how old he is, so as it may appear that he hath no 
understanding of reason, what shall be for his profit and what 
shall be for his loss ; but if he have sufficient understanding to 
know and understand his letters and to read by teaching or in- 
formation, he is not an idiot." * 

Bucknill on Criminal Lunacy^ describes tMsaM% as "a condition 
of the mind in which a false action or conception, or judgment, 
a defective power of the will or an uncontrollable violence of the 
emotions and instincts have separately or conjointly been pro- 
duced by disease." ° 

Intoxication, as a transitory phase of mental impairment, 
will be defined and considered below, under specific heads.* If 
it results in permanent mental impairment, the law regards the 
effect, insanity, rather than the cause. 

The committee of one judicially declared incompetent is a per- 
son appointed by a court having due jurisdiction to have charge 
of the person or property, or both, of the incompetent. 

1 Ray, "Medical Jurisprudence of and Stills, "Med. Jur.," vol. m.,p. 

Insanity, " 4th ed., p. 4, citing Colte's 118. „ 

Littleton, 247 c, and 1 Fitzherbert, *See infra, p. 354, "Contracts; p- 

"Natura Brevium," 583, ed. 1652. 384,"Wills;" p. 425, "Torts;" p. 421, 

» pp. 27, 28. "Witnesses;" p. 429, "Criminal re- 

"See also Taylor, "Med. Jur.," sponsibility;" p. 481, "Habitually m- 

6th Am. ed., p. 631; Wharton temperate person." 



STATUTORY DEFINITIONS. 353 

STATUTOEY DEFINITIONS AND STATUTOEY WOEDS 
OE PHEASBS DENOTING MENTAL UNSOUNDNESS. 

Occasionally a statute has defined the term used by it to de- 
note mental unsoundness ; for instance, in New York the term 
lunacy in the statutes includes every (continuing) unsoundness 
of mind except idiocy.^ 

But more frequently a word or phrase denoting mental im- 
pairment or mental soundness is introduced into a statute with- 
out any defiuition, and in such cases the courts have been called 
upon to define it; for instance: in Ohio, Eevised Statutes, 
§ 7, 240, authorizes a trial of the issue whether a person is sane ; a 
person is not " sane " within the meaning of the statute when he 
has not sufficient reason and mental capacity to understand that 
his act was wrong, or, having such sufficient reason to distin- 
guish right from wrong, has not sufficient will to refrain from 
the wrong.' 

An Ohio statute ' permits the making of a will by a person 
of sound mind and memory. A person suffering with pneumonia 
and approaching death, whose condition is such that there is im- 
mediate action on the brain cells which prevents consecutive 
thought, is not "of sound mind." * 

In Kentucky, one who is by reason of great age and mere 
'physical infirmity unable to control, manage, and care for his 
estate is not one "who is so imbecile or unsound as to be in- 
competent. " " 

A dditional cases discussing particular phrases used in statutes 
are cited in the note. ' 

'Statutory Construction Law, Laws ' R. S. § 5914. 

of 1892, chap. 677, sec. 7. See * /re re Burrows Est., 11 Ohio S. & 

Matter of Preston, 113 App. Div. C. P. Dec, 229; 8 Ohio N. P., 358. 

(N. Y.), 732; Code Civ. Pro. ^ 2335: ' Taylors. Moore, 23 Ky. Law Rep., 

"incompetency to manage affairs in 1572; 65 S. W. Rep., 612. 

consequence of imbecility and loss of ' Incompetent and incapable, — In re 

memory and understanding" is lu- Leonard's Est. (Mich.), 54 N. W. R., 

nacy vidthin this definition. In re 1082. Imbecile, — In re Emswiler, 8 

Schrodt,32 Misc. Rep., 540; 67 N. Y. Ohio N. P., 132; 11 Ohio S. & C. P. 

Supp., 244; "incompetent person and Dec, 10. Insanity, — State i). Helm, 

unfit to manage his affairs," In re 69 Ark., 167; 61 S. W. Rep., 915. 

Clark, 57 App. Div., 5; 67 N.Y. Supp., Unsound mind and incapable of 

631; Matter of Lewis, 57 Misc. managing his estate, — Hamrick v. 

(N. Y.), 670. State, 34 N. E. Rep., 3; 134 Ind., 324. 

* State V. Kalb, 7 Ohio N. P., 547; Unsound mind, — Maas v. Territory, 

6 Ohio S. & C. P. D., 738. 10 Okl., 714; 63 Pac R., 960. 
III.— 33 



354 MENTAL UNSOUNDNESS — BECKER AND BOSTON. 

LEGAL EFFECT OF MENTAL UNSOUNDNESS IN GENERAL. 

It will be seen in the specific treatment of particular subjects 
below that various mental impairments have diverse legal effects, 
and that legal considerations give rise to different measures of 
legal competency with respect to different classes of transactions. 
Accordingly it is necessary, in studying the legal relations of men- 
tal impairment, to consider separately these different classes. 

THE EFFECT OF MENTAL UNSOUNDNESS ON RESIDENCE. 

Change of residence ordinarily requires an intelligent intent;' 
but residence of an insane person can be changed by the act of 
his committee, '' or by one having charge of him, as his parent or 
guardian." Temporary residence of an incompetent, as in an 
asylum, does not change his legal residence. * 

THE EFFECT OF MENTAL UNSOUNDNESS ON CONTRACTS, 
INCLUDING DEEDS. 

At common law a party could not avoid his contract on the 
plea of lunacy, in accordance with an ancient maxim that no 
man of full age shall be allowed to disable or stultify hiinself ; 
though, at the same time, it allowed his heirs or other persons 
interested to avail themselves of this privilege. ° "Within a few 
years, however (1838), English courts ha^e almost entirely dis- 
regarded the ancient maxim," and in this country it has long 
since lost its authority altogether. " ' 

The effect of insanity on contracts is fully treated below." 

1 On the subject of domicile of R. , 405. C/. 7n re Fidelity Trust Co., 

persons of unsound mind see Woern- 27 Misc. (N. Y.), 118; 57 N. Y. Supp., 

er's "Law of Guardianship," S 206; 361. 

Woerner's "Am. Law. of Adm.," ' 2 Blackstone, 295. 

§ 206; Wharton, "Confiiot of Laws," « Baxter v. Earl Portsmouth, 7 

2d ed., § 52. On question of con- D. & R., 614; 9 Alb. L. J., 30; Chitty 

fliot of laws as to person of unsound on Contracts, 256; Gates v. Bain, 2 

mind see Wharton, "Conflict of Stride., 1104. 

Laws," 2d ed., g§ 574, 575. On ' Webster v. Woodward, 3 Day, 

jurisdiction based upon citizenship 90; Rice v. Peel, 15 Johns., 503; 

see m/ra p. 598; see "Foreign Cu- Mitchell v. Kingman, 5 Pickering,43l 

raters of Lunatics and the English But see O'Connell v. Beecher, 21 

Courts," 36 Law J., 480. App. Div. (N. Y.), 298; 47 N. Y. 

^ In re Sullivan, 24 Misc. R. (N.Y.), S.ipp., 334, where a person was not 

357; 53 N. Y. Supp., 717. permitted as a witness to express an 

^ In re Holcomb (Iowa), 82 N. W. opinion on his own mental condition, 

Rep., 1000.- to avoid his contract. 

^ In re Porter, 34 App. Div., 147; « Infra, p. 364. 
54 N. Y. Supp., 654; 28 Civ. Pro. 



COMPETENCY TO CONTRACT. 355 

At present it will be sufficient to state that the better rule now 
is that the agreement of an insane person is not void, but voida- 
ble, at his option or that of his representatives.^ But subsequent 
insanity of a party does not enable him to avoid his contract, 
made previous to his becoming insane, nor does it affect his 
obligation in any way, unless perhaps it be a contract for per- 
sonal services." 

COMPETENCY TO CONTEACT— MEASUEB OP COMPE- 
TENCY IN GENEEAL. 

When a contract is impeached on the ground of mental in- 
capacity of a party, not previously adjudged incompetent, the true 
inquiry is, whether he had the ability to comprehend in a rea- 
sonable manner the nature of the affair in which he partici- 
pated." If fraud or undue influence has been practised on a 
person of weak or impaired intellect, other principles apply ; ' 
but where mental incapacity is alleged, there must be inability 
to know what the act is to which the contract relates. So long 
as one possesses mental faculties requisite to transact rationally 
the ordinary affairs of life, ^ his contracts and deeds will be valid. 
He must have sufficient intellectual capacity to know what he is 
doing, ° but sufficient discernment or education to transact busi- 
ness with prudence and discretion is not required. ' 

1 Blinn v. Schwarz, 177 N. Y., ■* Difference in mental capacity 

252; Hanley v. Nat. Loan, etc., Co., between the two parties to a con- 

29 S. E. R., 1002; 44 W. Va., 450. tract is not ground for rescission, 

When a gift is made by a lunatic, the unless the stronger minded defrauds 

donee holds the property charged the other. Moore v. Cross, 87 Tex., 

with a constructive trust in favor of 557; 29 S. W. R., 1051. 

the donor. Teegarden v. Lewis, 35 ^ Raymond v. Wathen, 142 Ind., 

N. E. R. (Ind.), 24. 367; 41 N. E. R., 815; Davis v. 

« Sands v. Potter, 59 111. App., 206; Calvert, 18Ky. L. R., 975; 38 S. W. R., 

Pollock V. Horn, 13 Wash., 626; 43 .884. 

Pac. R., 885; Haines v. Scott, 35 " Ring v. Lawless, 190 111., 520; 61 

App. Div., 515; 54 N. Y. Supp., 844; N. E. R., 881; Ramsdell v. Ramsdell, 

Van Meter u. Darragh, 115 Mo., 153; 8 Det. Leg. News (Mich.), 541; 87 

. 22S.W.R.,30; Lindberg •!). Davidson, N. W. R., 81; Kelly v. Perrault 

72 Minn., 49; 74 N. W. Rep., 1018; (Idaho), 48 Pac. R., 45. 

Wurster v. Amifield, 67 App. Div., ■" Bishop on Contracts, §§ 972, 973, 

158; 73 N. Y. Supp., 609. 974. 

' He must have a reasonable per- Improvidence and unthriftiness 

ception of the nature and terms of and lack of business success do 

the contract. Elwood v. O'Brien, 74 not constitute mental incompeten e. 

N. W. Rep., 740; 105 Iowa, 239; Dominick v. Randolph, 124 Ala., 557; 

Swartwood v. Chance, 131 Iowa, 27 So. Rep., 481. Nor illiteracy and 

714; 109 N. W. R., 297; Sherbero ■;;. ignorance of business. Soberanes v. 

Miller, 65 Atl., 472 (N. J. Eq.). Soberanes, 106 Cal., 1 ; 39 Pac. R., 39. 



356 



MENTAL UNSOUNDNESS — BECKER AND BOSTON. 



If the transaction be of unusual complexity, it has been held 
that a higher degree of mental capacity is requisite than to at- 
tend to the ordinary affairs of life or to make a will ; for exam- 
ple, if the contract be one for the exchange of lands. ^ 

In any case the question to be considered is not whether the 
alleged incompetent understood the details of the transaction, but 
whether he, in fact, had the capacity to understand its nature ' and 
decide intelligently about it ; ' not whether the mind was insane 
or impaired * or had not capacity to transact business generaUy, 
but whether the mind had capacity to deal with the particular 
business in question. ' 

It is not sufficient to show merely a diseased mental state, to 
avoid a contract. Herein is the essential difference between the 
medical and the legal point of view ; one deals with the objective 
physical state, the other with the capacity of the mind for reason. 
It must be shown that mental disease had affected the under- 
standing to the degree above stated •' although, of course, if the 
disease falls within the extreme category of idiocy, lack of capac- 
ity may be presumed. ' 



1 Turner v. Houpt, 53 N. J. Eq., 
626; 33 Atl. R., 28. Cf. contrary 
rule as to wills, infra, p. 386. 

" Merritt v. Merritt, 32 Misc. 
(N. Y.), 21; 66 N. Y. Supp., 123; 
aff'd 62 App. Div., 617; 71 N. Y. 
Supp., 1142. 

' Mann v. Keene Guaranty Sav. 
Bk., 86 Fed., 51. 

* O'Neill V. Nolan, 66 Hun fN. Y.), 
631; 21 N. Y. Supp.,222. 

'Coffey V. Coffey, 74 111. App., 241'. 
Thus, where delivery of a deed of 
trust was delayed, the test w^as not 
capacity to understand the details 
of the contract at the time of de- 
livery, but at the time of signing; ca- 
pacity to complete the original trans- 
action at the time of deUvery was 
sufficient. S. c, Coffey v. Coffey, 179 
III, 283; 53 N. E. R., 590. See also 
Falk V. Wettram, 120 Cal., 479; 52 
Pac. Rep., 707; Lynch v. Doran, 
95 Mich., 395; 54 N. W., 882; Kroe- 
nung V. Goehri, 112Mo., 641; 20 S. 
W., 661; White v. Davis (N. Y.), 
62 Hun, 622; 17 N. Y. S., 548; 
Wnght V. Wright, 139 Mass., 177; 29 
N. E., 380; Brothers v. Bank of 
Kaukauna, 84 Wis., 381; 54 N. W. 



Rep., 786; Camagie v. Diven, 49 Pac. 
R., 891; 31 Ore., 366; Farnsworth o. 
Noffsinger, 33 S. E. Rep., 246; 46 W. 
Va., 410. In Overall v. Avant, 46 S. 
W. R«p., 1031 (Tenn.Ct.App.),abill 
of heirs to set aside deed_of ancestor 
alleged mental incapacity to transact 
business, paralysis a few weeks after 
execution of deed, old age, grantor 
easily influenced, and sale for small 
percentage of actual value, hM a 
sufficient statement of facts to show 
want of mental capacity, on de- 
murrer. See also illustrations of 
lack of mental capacity, Beasley v. 
Beasley, 180 111, 163; 54 N. E. Rep., 
187; Gait v. Provan, 79 N. W. Hep., 
357; 108 Iowa, 561. 

' It is not enough to show merely 
that a person was in the first stage 
of paresis. Haines v. Scott, 35 App. 
Div. (N. Y.). 515; 54 N. Y. Supp., 
844; Critchfield v. Easterday, 26 
App. D. C, 89. 

' An action will not lie on the 
admitted 



Supp., 920. 



DELUSIONAL INSANITY. 357 

DELUSIONAL INSANITY AND STATES OF MIND BOE- 
DEEING ON INSANITY. 

The greatest difficulties in connection with the application of 
the above tests to given cases have arisen where delusional in- 
sanity, and specifically paranoia, have existed. The courts have 
frequently been called upon to determine whether the presence 
in the mind of a maker of a will of systematic insane delusions 
incapacitated him for the testamentary act, but not so frequently 
in the case of contracts. The cases on wills are considered sepa- 
rately (infra, page 394), but may be consulted as generally ap- 
plicable to contracts also. As to both contracts and wills the 
general rule may be laid down that delusions alone, or even in- 
sane delusions, do not affect them, unless they operated di- 
rectly to induce the execution of the instrument.' For example, 
a mere belief in witches does not incapacitate to make a deed." 

In a suit by an insane person to recover the proceeds of a 
note assigned by her at a time when she was alleged to be insane, 
it was for the jury to determine whether plaintiff was compe- 
tent to make the contract, and it was proper for the judge to re- 
fuse to instruct that delusion is the true test of insanity in the 
absence of frenzy or raving madness. ' 

Delusions do not incapacitate where the subject-matter of 
the deed is not affected, * or where the insane delusion did not 
move the grantor to make the deed. ' 

Where the evidence showed that the maker of a trust deed 
was capable of comprehending and acting intelligently upon the 
business out of which the deed grew, and understood the nature 
and consequences of his act, evidence of monomaniacal delusions 
was held insufficient to invalidate the deed. ° 

In a certain class of cases, however, the question whether de- 
lusions are insane delusions or not is important. "Where the ex- 

' See Hughes v. Jones, 116 N. Y., Turner v. Union National Bank, 10 

67; Hay v. Miller, 48 Neb., 156; 66 Utah, 77; 37 Pac, 95. 

N. W. R., 1115; Dewey v. Allgire, * See Bowman v. N. W. Mut. Re- 

37 Neb., 6; 55 N. W. R., 276. lief Ass'n., 90 Wis., 144; 62 N. W. 

^ Schuettler v. Carman, 98 Iowa, Rep., 924; infra p. 396. 

276; 67 N. W. R., 249. ' Meigs v. Dexter, 172 Mass., 217, 

^Turner v. Utah Title Insurance 62 N. E. R., 75. 

and Trust Co., 10 Utah, 61; 37 Pac, « Seawel v. Dirst, 70 Ark., 166; 66 

91 (1893); Turner v. Wells, Fargo S. W. R., 1058. 
& Co., 10 Utah, 75; 37 Pac, 94; 



358 MEKTAL UNSOUNDNESS— BECKER AND BOSTON, 

ecution of a contract was induced by erroneous opinions and be- 
liefs, this does not invalidate it unless those particular errors 
amounted to insane delusions. If they were founded on facts it 
can rarely be held that they evidenced lack of capacity.* 

In Jones v. Hughes, 15 Abbott's New Cases, 141 (F. T. 
Supreme Court, 8th district. Special Term, 1883), Daniels, .Tudge, 
said : " This action has been prosecuted to set aside and annul a 
deed executed by Eichard Hughes, under the name of David 
Jones, to the defendant, Joseph Jones, because of mental in- 
capacity of the grantor. The deed was executed on the 7th of 
October, 1870, and recorded on the second day of the succeeding 
month. It in terms conveyed the property caUed Buckhorn Isl- 
and, situated near the foot of Grand Island in the Niagara 
Eiver. It has been owned and occupied by the grantor from the 
year 1853. The grantee in the deed is the son of the grantor by 
a second marriage, alleged to have been, as it probably was, un- 
lawfully contracted. The plaintiff is a son by a preceding mar- 
riage, and entitled to inherit the property in case the deed should 
be set aside. The grantee had nothing whatsoever to do with 
the transaction and in no measure influenced the conduct of the 
grantor in making it. The grantor was desirous of having the 
grantee and his wife occupy the property and be taken care of 
and supported by them during his natural life. His additional 
object was to secure a like support for his second wife. 

"Before the deed was made the grantor consulted an ac- 
quaintance, with whom he had dealt many years, concerning 
the execution of the deed, and went with him to a reputable at- 
torney to have the business done. These and other witnesses 
agree that in what he said and did on these occasions he appeared 
to act rationally and intelligently, and the evidence of all these 
persons tends very directly to establish the fact that he fully 
understood the business which was transacted and the object 
designed to be accomplished by it, as well as the property to 
be conveyed ; and that it was his deliberate purpose to make the 
disposition of it which he in form made by the execution of 
this deed. In the preceding month of March he made a twelve 
years' lease of the same property upon the same consideration 
to the plaintiff, who went into possession but surrendered it 

> See Cutler v. Zollinger, 22 S. W. Wills, m/ra, p. 394, "Mistaken belief;" 
Rep., 895; 117 Mo., 92. See also p. 395, " Insane delusions." 



DELUSIONAL INSANITY. 359 

afterward because of disagreemeut between himself and bis 
father. Testimony was given in behalf of the plaintiff, as well 
as by himself as a witness in the case, showing that his father, 
who was a man of very advanced age, was irritable in his dispo- 
sition, boisterous in his speech, suspicious of those who dealt 
with him or were employed by him in the management of his 
property, and indulged in the relation of marvellous and exag- 
gerated stories. This appears to have been his character and 
his habits for many years preceding the time when the deed was 
made, and while no one suspected his sanity or his ability prop- 
erly to manage his own affairs, the suspicions entertained by 
him appeared to have arisen from observations he had made, 
leading him to believe that the persons employed by him, or 
managing his property, dealt dishonestly with him; and the 
relations he repeated of marvellous occurrences, in which he 
had been a party, referred to transactions which had taken place 
in his early life. The statements he made and the suspicions 
he entertained appeared to have been exaggerated and in many 
eases extremely absurd in their character ; but as long as they 
were founded upon the facts from which he was satisfied to de- 
duce them, they were not indications of insanity or unsoundness 
of mind, although extended very much beyond what was justi- 
fied by the circumstances. They were, therefore, distinguisha- 
ble from mere delusions, and do not establish that unsoundness 
of mind which would legally disable him from making a binding 
disposition of his property. While he indulged in these state- 
ments and suspicions, he still continued to manage and conduct 
his affairs, and the persons having dealings with him apparently 
found no reason for suspecting his inability to do that business 
with accuracy and judgment. Toward the latter portion of 
his life, and before or about the time when the deed was made, 
he was impressed with the delusion that British ships lay in 
the vicinity of the island, manned by early acquaintances, for 
the purpose of protecting it ; but this delusion was in no form or 
manner connected with the execution and delivery of this deed. His 
mind still in other respects and on other subjects, although im- 
paired by age, in its strength was active and intelligent. Be- 
tween the delusion and the transaction of his business there 
seems to have been no connection whatever. Upon other occa- 
sions he became violent and vindictive in his conduct, but there 



360 MENTAL UNSOUNDNESS— BECKER AND BOSTON. 

was always a ground of offence calculated to produce resentment 
as well as irritation on his part. His conduct, though extreme, 
was not unnatural for a person of his disposition, education, and 
temperaiaent. He believed in witchcraft and feats which may 
be accomplished by the power of persons affecting it, but this 
was rather a matter of superstition than evidence of mental in- 
capacity or delusion. While he was boisterous, vindictive, re- 
vengeful, easily provoked and aroused, he still appears to have 
understood the business transactions to which he was a party, 
and to manage them with intelligence and judgment. Upon all 
the evidence elicited from the witnesses in the case upon these 
subjects, it cannot be concluded that he was, by reason of men- 
tal infirmity, incapable of making and executing this deed. On 
the contrary, this evidence sustains the conclusion that it re- 
sulted from intelligent consideration and reflection upon his 
part, and that it was understandingly made to carry into effect 
a fixed design which he himself alone had previously formed. 
Evidence was given showing that proceedings were taken under 
the statute in September, 1871, on the application of the grantee 
in this deed, to procure an adjudication determining his father, 
the grantor, to be a lunatic cr person of unsound mind. Previ- 
ous to that time he had been imprisoned in the county jail at 
the suit of the plaintiff, and evidence has been given tending to 
indicate that such an imprisonment would aggregate the ten- 
dency of his health in the direction of a state of insanity. This . 
theory is entirely natural, for the imprisonment of an old man 
at the instance of his son would ordinarily be attended by some 
effect on his character and mental condition. The fact that his 
conduct and speech impressed the jurors as weU as the jailer 
with the conviction that he was a person of unsound mind at 
the time can, for this reason, have no very decided influence 
upon the inquiry whether that was or not his condition at the 
time of the execution of the deed. To determine that, the im- 
portant evidence was that which related to the contemporaneous 
occurrences and the previous conditions in which this man ap- 
peared to have been. The application upon which the proceed- 
ings were instituted and carried on was based on the petition of 
Joseph H. Jones, the grantee of the deed. In this petition it 
was alleged, ' Davis Jones, the grantor, eighty-five years of age, 
had been a lunatic for the space of five years preceding that 



DELUSIONAL INSANITY. 361 

time and so far deprived of liis reason as to be wholly unfit and 
unable to govern himself or to manage his own affairs ' ; and 
upon the hearing under the authority of the writ which was is- 
sued, the jury in form found that to be his condition. But 
neither these allegations nor the conclusions of the jury pre- 
sented the inquiry — whether as a matter of fact he was compe- 
tent to execute this deed at the time when it was made. That 
was not a subject presented for trial by the petition, or the in- 
vestigation made by the jury ; it was not a matter alleged in the 
petition or in any manner drawn in question. No evidence 
could properly have been given upon it, and it was not the 
province of the jury to make a determination which would or 
would not sustain this particular transaction. The purpose of 
the proceeding was to determine whether from his age and im- 
becility he required a guardianship of a more competent person 
for the protection of himself and his affairs. The legal prose- 
cution of such an inquiry did not include the question now pre- 
sented in this case — whether or not the grantor of this deed was 
competent to execute it. Therefore, the finding of that jury is 
not in anj' way prejudicial to the present question (Am. Sea- 
men's Soc. V. Hopper, 33 N. Y., 619). It has been held accord- 
ingly that an inquisition of this nature, finding the party to have 
been of unsound mind for a preceding period of time, is not con- 
clusive as to his incapacity to make a will during that time 
(Campbell v. Consalus, 25 K. Y., 613), and a similar view of 
such a proceeding was taken in Banker v. Banker (63 N. Y., 
409). Judgment will, therefore, be ordered in favor of the de- 
fendant." 

This decision was affirmed by the IST. Y. Court of Appeals, 
Hughes^. Jones, 116 N. Y., 67. 

Old Age and Mental Weakness. Undue Influence. 

Though the grantor in a deed be extremely old or feeble men- 
tally, his understanding, memory, and mind enfeebled by age, 
and his actions occasionally strange and eccentric, and though he 
be unable to transact many affairs of life, yet if age has not ren- 
dered him imbecile so that he does not know the nature and 
effect of the contract, it is not invalid.' 

'Ball V. Smith, 83 Hun (N. Y.), Wilkinson, 147 111., 370; 35 N. E. 
43S; 23 N. Y. Supp., 54; Francis v. Rep., 150; Buckey v. Backey, 38 



362 MENTAL UNSOUNDNESS— BECKER A<ND BOSTON. 

Old age is not of itself evideace of incapacity to make a 
contract/ nor will age, weakness of mind, and eccentricity render 
a deed void if the grantor understands the nature and effect of 
his act." But where old age has rendered the grantor imbecile,^ 
or where he is unduly influenced * or imposed upon ^ by persons 
standing in a confidential relation to him,* or where the deed is 
voluntary and there is doubt whether the grantor understood or 
assented, " or where a person of great age is imposed upon in a 
season of excitement and distress,' his deed is voidable. In such 
a case his mental weakness is merely an element in a cause of 
action based on undue influence.* When the elements of age, 
infirmity, and mental weakness are blended with a contractual 
act of a suspiciously disadvantageous character, a presumption 
of fraud may arise. 

Contracts claimed to have been made with aged or infirm 
persons to be enforced after death, of an unreasonable nature, 
for example, disinheriting their lawful heirs, are properly sub- 
ject to suspicion, and must be established by the strongest 
evidence.' 

While a court can grant no relief against the consequences of 
mistaken judgment or mere imprudence on the part of the one 
making a contract, yet where the nature of the act by a person 

W. Va., 168; 18 S. E. Rep., 383; TomUnson, 103 Iowa, 740; 72 N. W. 

Davis V. Latta, 94 Iowa, 727; 62 R., 664; WiUe v. WiUe, 57 S. C, 413; 

N. W. Rep., 17. • 35 S. E. Rep., 804. 

' Carnagie v. Diven, 49 Pac. Rep., * Landfair v. Thompson, 112 Ga., 

891; 31 Oregon, 366; Peabody v. 487; 37 S. E. Rep., 717; Vanosdel 

Kendall (111. Sup.), 32 N. E. Rep., v. Hyce (La.), 46 La. Ann., 387; 15 

674; Argo v. Coffin, 32 N. E. Rep., So., 19. Dewey v. Allgire, 37 Neb., 6; 

679; 142 111., 368; Lynch v. Doran 55N. W., 276. 

(Mich.), 54 N. W. Rep., 882; Buckey « Hayes v. Kerr, 19 App. Div. 

V. Buckey, 38 W. Va., 168; 18 S. E. (N. Y.), 91; 45 N. Y. Supp., 1050; 

Rep., 383; see also infra p. 410. Dun- Thomas v. Crawford, 118 Mich., 253; 

can V. Mason (Ky.), 20 S. W., 252. 76 N. W. Rep., 394. 

' Delaplain v. Grubb, 44 W. Va., ' Bruguier i). Pepin, 76 N. W. Hep., 

612; 30 S. E. Rep., 201; see also 808; 106 Iowa, 432; Thomas v. 

McKissook v. Groom, 148 Mo., 459; Crawford (supra). 
50 S. W. Rep., 115; Richardson v. ' » Mays v. Prewett, 98 Tenn., 474; 

Adams, 110 Ga., 425; 35 S. E. R., 40 S. W. R., 483; Jennings v. Hen- 

648; Sibley v. Somers (N. J. Ch.), nessy, 26 Misc. (N. Y.), 265; 55 

50 Atl. R., 321. Supp., 833. 

' Brothers v. Bank of Kaukauna, » Shakespeare v. Markham, 72 N- 

84 Wis., 381; 54 N. W., 786; see also Y., 400. But see Looby i). Red- 

Henrizi v. Kehr, 90 Wis., 344; 63 mond, 66 Conn., 444; 34 Atl. Hep., 

N. W. Rep., 285; Boggess v. Boggess, 102. Deed of aged, infirm, fretful 

29 S. W. Rep., 1018; 127 Mo., 305. grantor, upheld. Francis v. Wikin- 

"Ross V. Payson, 160 111., 349; son (lU. Sup.), 147 lU., 370; 35 

43 N. E. Rep., 399; Tomhnson v. N. E., 150. 



OLD AGE AND MENTAL "WEAKNESS. 363 

mentally enfeebled is such as to justify the couclusion that ho 
das been imposed upon by artifice or undue influence, a court of 
squity will intervene. 

Though the mind of one party to a written contract had be- 
Bome impaired by age, the contract is none the less operative 
against the other party, if the latter was in full possession of his 
faculties.' 

Mere Physical and Mental Weakness Does Not 
Incapacitate. — In an action against the maker of a promis- 
sory note, given to settle a debt he had incurred, the defence 
was that he was non compos mentis. He had been of great 
physical and mental strength, but at the time of signing the 
note was physically very weak, and had lost much of his intel- 
lectual vigor, but was competent to attend to his ordinary busi- 
ness affairs. His letters concerning the transaction were clear, 
and showed a good memory, and his conduct and language after- 
ward showed that he fully understood what he had done. Held, 
that he was competent to make the contract." 

The principle is identical with that applying to old age which 
causes mental weakness, but not actual imbecility. ' 

And the same rules apply to all kinds of mental weakness, 
whether induced by pain, the use of anaesthetics,* or the ap- 
proach of death, ° or congenital. The effect of such weakness 
upon the capacity to contract is merely a question of its degree. ° 

' Elder v. Schumacher, 18 Colo., ness: Dewey ?'. Algire, 37 Neb., 6; 

433; 33 Pac, 175. 55 N. W. Rep., 276; Hay v. Miller, 

^ Des Moines, etc., v. Chishohn, 71 48 Neb., 156; 66 N. W. Rep., 1115; 

Iowa, 675. Mere weakness of mind Zeltner v. Bodman Home, 1 Ohio, 

will not invalidate a contract; if the S. & C. P. Dec, 306 (here the deed 

maker of a promissory note knew was made without the knowledge of 

what he was doing, to whom given relatives, to a home for the aged, 

and for whose benefit the contract in consideration of maintenance), 

was made, that it was for the pay- Turner v. Utah Title, etc., Co., 10 

mentof money, and the amount, he Utah, 61; 37 Pac. Rep., 91, 94, 95; 

had sufficient capacity. Ducker v. Kroenung v. Goehri, 112 Mo., 641; 

Whitson, 16 S. E. Rep., 854; 112 20 S. W. Rep., 661; Peters i'. Peters, 

N. C, 44. 59 N. W. Rep., 609; 101 Mich., 291; 

'Supra, p. 361. Ballard v. Chicago, etc., Ry. Co., 70 

^Cuttsi). Young, 147 Mo., 587; 49 Mo. App., 108; Hoeh v. Hoeh, 197 

S. W. Rep., 548; Swank v. Swank, Pa. St., 387; 47 Atl. Rep., 351; 

61 Pac. R, 846 (Ore.); Krause v. Bennett i;. Bennett (Neb.), 91 N. W. 

Stein, 173 Pa. St., 221; 33 Atl. Rep., R., 409; Eldredge v. Palmer, 185 

1031. 111., 618; 57 N. E. Rep., 770; Saffer 

= Loftus V. Maloney, 89 Va., 576; v. Mast, 79 N. E. R., 32; 223 111., 108; 

16 S. E. R., 749. Odell v. Moss, 130 Cal., 352; 62 Pac. 

° See generally on mental weak- R., 555. 



364 



MENTAL UNSOUNDNESS: — BECKER AND BOSTON. 



EFFECT OF INCOMPETBIfCY m GENEEAL. 



With the exception of certain cases hereafter mentioned, an 
agreement of an insane person immediately connected with and 
growing out of his insanity js voidable, at his option or that of 
his representatives, and not void. This is the law, by the great 
weight of authority, and it applies in all cases of contracts, in- 
cluding deeds of lands, where the incompetent has not been so 
adjudged by a tribunal having due jurisdiction.' 

A person incompetent to execute a deed is incompetent to 
execute a power of attorney to make a deed, and the deed exe- 
cuted under such power is void, if his deed would be void.^ 



1 Wharton's Law of Contracts, 
sec. 107, p. 138; Bishop on Contracts, 
sees. 873-874; Luhrs v. Hancock, 
181 U. S., 567; Blinn v. Schwarz, 
177 N. Y., 252; Smith v. Ryan, 191 
N. Y., 452; AUis v. BilUngs, 6 
Mete. (Mass.), 415; Lancaster Co. 
Nat. Bk. V. Moore; 78 Pa. St., 407; 
Long V. Long, 9 Md., 348; Riley v. 
Carter, 76 Md., 581; 25 Atl. R., 667; 
19 L. R. A., 489; Matthiessen & 
Weichers Ref. Co. v. McMahon, 38 
N. J. L.. 536; Wilder v. Weakley, 34 
Ind., 181; iEtna Life Ins. Co. v. 
Sellers, 154 Ind., 370; 56 N. E. R., 
97; Behrens v. McKenzie, 23 Iowa, 
333; Morris v. Gt. North. Ry. Co., 
67 Minn., 74; 69 N. W. R., 628; 
Hawley v. Nat'I Loan, etc., Co., 44 
W. Va., 450; 29 S. E. R., 1022; 
French Lumbering Co. v. Theriault, 
107 Wis., 627; 83 N. W. R., 927; 51 
L. R. A., 910; Moran v. Moran, 106 
Mich., 8; 63 N. W. R., 989; Wol- 
cott V. Conn. Gen. L. I. Co., 100 N. W. 
R., 569; 11 Det. Leg. N., 346; 
Robinson v. Kidd, 59 Pao. R. (Kan.), 
863; 62 Pac. R., 705; Arnett's 
Committee v. Owens, 23 Ky. L. R., 
1409; 65 S. W. R., 151; McAnan v. 
Tiffin, 143 Mo., 667; 45 S. W. R., 
656; Jamison v. Culligan, 151 Mo., 
410; 52 S. W. R., 224; Gribben v. 
Maxwell, 34 Kans., 8. Cf. Release, 
Tex. Pac. Ry. Co. v. Crow, 3 Tex. 
Civ. App., 266; 22 S. W. R., 928; 
Alabama & V. Ry. Co. v. Jones; 
73 Miss., 110; 19 So. R., 105, 
Ballard v. Chicago, R. I. & P. R. R. 
Co.,_ 70 Mo. App., 108. Contrary 
decisions.— In California a distinc- 



tion is ingeniously made between the 
contracts of persons entirely without 
understanding, which are void, and 
of persons not entirely without un- 
derstanding, though without under- 
standing of a particular transaction; 
in the latter case the deed, though 
voidable, is not void. Castro v. 
Geil, 42 Pac. R., 804; 110 Gal., 292. 
And by statute, contracts of insane 
persons are sometimes void. Payne 
i;. Burdette, 84 Mo. App., 332. 
In Georgia held, where the grantor 
was insane at the time of executing 
a deed and remained insane til 
death, the doctrine that the deed 
is voidable at the election of the 
grantor has no application. Boynton 
V. Reese, 112 Ga., 354; 37 S. ■£ R, 
437. In Nebraska, the deed is void 
though not induced by fraud or 
wrongdoing. Wager v. Wagoner, 
53 Neb., 511; 73 N. W. R., 937. See 
also cases holding contracts void: 
Dewey v. Algire, 37 Neb., 6; 55 N. W. 
Rep., 276; Gingrich v. Rogers, 96 
N. W. R., 156 (Neb.); German Savs. 
& Loan Soc. v. De Lashmutt, 67 Fed. 
R., 399; Colorado.— Elder v. Schu- 
macher, 18 Col., 433; 33 Pac. R., 
175. Alabama.— Wilkinson v. m- 
kinson, 129 Ala., 279. Massachu- 
setts. — Brigham v. Fayerweather, 
144 Mass., 48. 

^ Plaster v. Rigney, 97 Fed. Eep-, 
12; 38 C. C. A., 25; Dexter v. HaU, 
15 Wall (U. S.), 9; and if his deed 
would be voidable, the deed under 
the power is also voidable. WiUiams 
V. Sapieha, 94 Tex., 430; 61 S. W. 
Rep., 115. Cf. Daily Telegraph t. 



EFFECT OF INCOMPETENCY IN GENERAL. 365 

In England, and in a few States of the United States, in order 
to invalidate a contract because of the insanity of the maker 
before he is interdicted, in addition to showing his incapacity, 
it must appear that he was known by those who saw and con- 
versed with him to be in a state of mental derangement, or that 
the person who contracted with him hiew his incapacity.^ 

In Imperial Loan Co. v. Stone ^ (1892) it was held that a party 
to a contract cannot avoid it on the ground of his insanity at the 
time he entered into it, unless his insanity was at the time known 
to the other contracting party. And the burden of proving both 
the insanity and the knowledge of it by the other contracting 
party lies upon the party seeking to avoid the contract.^ This 
view is not at all universally accepted in the United States ; for 
instance, in Georgia the ignorance of the other contracting party 
does not make the contract binding on the lunatic or his repre- 
sentatives.* 

It has been held in Georgia and Alabama that neither igno- 
rance of the insanity on the part of the other contracting party 
nor the fact that an ordinarily prudent person could not have 
discovered it makes the contract binding on the lunatic or his 
representatives,' especially if it be an executory contract." 

It seems to be established, however, as a general rule of 
equity in the United States, that where a person in good faith 

McLaughlin, [1904] App. Dec. 776; Berger, 76 App. Div., 393; 78 N. Y. 

73Law J. P. C, 95; 91 LawT., 233; Supp., 709, the foreclosure of a 

20 Times Law R., 674 (Eng. H. of mortgage was permitted on showing 

L.). of good faith of mortgagee and his 

* Stockmeyer v. Tobin, 139 U. S., ignorance of mortgagor's insane con- 

176. In Louisiana this is the statu- dition. 

tory rule, Martinez v. Moll, 46 Fed. ^Orr v. Equitable Mtg. Co., 33 

Rep., 724, U. S. Cir. Ct. La., con- S. E. Rep., 708; 107 Ga., 499; Field 

Btruing Art. 1788, Louisiana CSvil v. Shorb, 99 Cal., 661; 34 Pac, 504. 

Code; Wolf v. Edwards, 106 La., ' Orr v. Equitable Mtg. Co., 33 

477; 31 So. Rep., 58; Imperial Loan S. E. Rep., 708; 107 Ga., 499 (in 

Co. V. Stone, 1 Q. B., 599 (Eng.); this case even though there had been 

Memphis Nat. Bank v. Sneed 97 no previous adjudication of incom- 

Tenn., 120, 36 S. W. Rep., 716 (case petency). In Alabama a note given 

of renewal note given by insane by an insane person, for necessaries, 

maker to replace prior note made by to a payee ignorant of insanity, was 

the insane person while competent). held not to bind the estate. MilHgan 

n Q. B. (Eng.), 599. v. Pollard, 112 Ala., 465; 20 So. Rep., 

"So held in Flach v. Gottschalk, 620. Cf. Walker v. Winn, 39 So., 

41 Atl. R., 908; 88 Md., 368, where 12 (Ala.). 

the contract was fair and the buyer " Cundell v. Haswell (R. I.), 51 

was a lunatic, the seller was ignorant Atl. R., 426 (insane purchaser at 

of the fact and could not be restored execution sale not liable to complete 

to the status quo. And in Hardy v. his purchase). 



366 



MENTAL UNSOUNDNESS — BECKER AND BOSTON. 



entered into a fair contract with another apparently sane, and the 
contract has been executed and an adequate consideration paid, 
the contract is voidable only if the consideration can be and is 
restored by the lunatic or those who represent him, so as to put 
the parties in statu quo.' 

But where the incompetent has suffered financially by an un- 
fair contract, it will be set aside, without restoration of benefits 
received.^ 

Who May Avoid Contract. — The insane person, or the commit- 
tee or other person representing him, or claiming under him,' 
and after his death, his personal representatives, but not the other 
party to the contract, may elect to avoid it.* If the insane per- 
son, or those above mentioned and claiming iu his right, do not 
so elect, no one else can plead his insanity to avoid the effect of 
his contract.' 

Batification. — An insane person is no more competent to ratify 
a contract than to make one ; therefore, it is no defence to an 



'See infra, p. 368, "Conditions of 
Avoiding Contracts." Ins. Co. v. 
Hunt, 79N. Y., 541; Bicknell v. Spear, 
Misc. (N. Y.), 389; 77 N. Y. Supp., 38, 
420; Haines v. Scott, 35 App. Div. 
(N. Y.), 515; Gribben v. Maxwell, 34 
Kans., 8; Young t7. Stevens, 48 N. H., 
133; Brodrib v. Brodrib, 56 Cal., 563; 
Copenroth v. Kienby, 83 Ind., 18; 
Bokemper v. Hazen, 96 Iowa, 221; 
Sohaps V. Lehner, 54 Minn., 208; 
Hosier v. Beard, 54 Oiiio St., 398; 
Myers v. Knabe, 51 Kan., 720; 33 
Pac. R., 602; D. M. Smith's Com. v. 
Forsythe, 90 S. W. R., 1075, 28 Ky. 
L. R., 1034; Rusk v. Fenton, 14 
Bush, 490; 29 Am. Rep., 413 (Ky.); 
Parker v. Marco, 76 Fed. R., 510; 
Harrison v. Otley, 101 Iowa, 652; 
70 N. W. R., 724; Rhodes v. Fuller, 
139 Mo., 179; 40 S. W. R., 7G0; 
Flach V. Gottschalk, 88 Md., 368; 
41 Atl. R., 908. 

^ Reason v. Jones, 119 Mich., 672; 
78 N. W. R., 899. Wilkins v. Wil- 
kins, 35 Neb., 212; 52 N. W. R., 1109. 

' Sander v. Savage, 75 App. Div., 
333; 78 N. Y. Supp., 189. But the 
wife and children of a grantor can- 
pot during his life question his 
capacity to convey land, as they 
have no interest therein presently 
enforceable. Baldwin v. Golde, 88 
Hun, 115; 34 N. Y. Supp., 587; cf. 



Hunt V. Rabitony, 7 Detroit Leg. 
News, 447; 84 N. W. R., 59; French 
Lumbering Co. v. Theriault, 107 Wis., 
627; 83 N. W. R., 927; 51 L. R. A., 
910. The grantee by a deed made 
after restoration to sanity of the 

frantor may have set aside a former 
eed by the grantor made when he 
was insane. Clay v. Hammondfi, 
199 111., 370; 65 N. E. R., 352. The 
contract of an insane partner does 
not bind his firm, if the other con- 
tracting party knew of his insanity. 
Schmidt v. Ottman, 15 So. Rep., 310; 
46 La. Ann., 888. 

' Bunn V. Postell, 33 S. E. B«p., 
707; 107 Ga., 490. 

' Atwell V. Jenkins, 40 N. E. Bep., 
178; 163 Mass., 362; Mead v. Stegall, 
77 111. App., 679; Warmsley v. 
Darragh, 12 Misc. (N. Y.), 199. 
Where the mind of one party to 
a contract has become impaired by 
age, the contract is no less opera- 
tive against the party who is in 
full possession of his faculties. 
Hannon v. Hannon, 51 Fed. ^Pi 
113. A remainder-man cannot dur- 
ing lifetime of insane life tenant 
avoid deed of such life tenant mth 
power to convey. McMillin v. Wm. 
Deering Co., 38 N. B. Rep., 398; 139 
Ind., 70. 



CONTRACTS FOR NECESSARIES. 367 

iction by his guardian to recover money paid by him, to say 
bhat the payment was made by him in settlement of his contract 
obligation entered into du