plaintiff to prove that the alleged injury or disease was due to the attending surgeon, and that the same might have been foreseen and avoided by proper treatment. Malpractice can only be proved when it is shown that the practitioner has set aside established principles and neglected to make use of means universally held by the profession to be necessary in a given case. It must be shown, however, that in all probability the treatment according to such established principles would accomplish the desired end, that such treatment never proves detrimental, and that it is sanctioned by the general practice of the profession.

It should be mentioned in this connection that gratuitousness will not exempt a practitioner from a charge of malpractice if it can be proved that his treatment was improper, or that he neglected the patient. On the other hand, a patient who refuses to co-operate with his physician cannot recover damages for any injury so sustained, unless the latter can be shown to have been due to malpractice. As it has been decided that a physician who takes with him, to a confinement case, any one except a physician or a student of medicine, renders himself liable for damages; except in cases of necessity, it would be well under any circumstances for him to obtain the consent of the patient before introducing a stranger into the sick

room.

In connection with the general subject of medical malpractice it may be mentioned that apothecaries render themselves liable to suits for damages or even to criminal prosecution, if it can be shown that, through their ignorance or carelessness, or that of inexperienced clerks in the putting up and selling of medicines, serious or fatal consequences ensued.

CHAPTER XIV.

Insanity-Varieties of Insanity-Idiocy-Mania-Dementia-Medicolegal Relations of Insanity-Criminal Responsibility-Medico-legal Terms in Insanity-Feigned Mental Diseases.

Insanity. The subject of insanity has so extensive a range as to render it impossible within the limits of this work to do more than indicate its salient features, more especially from a medico-legal point of view. Every practitioner should appreciate the importance of the fact that at any moment he may be called upon to visit a person said to have lost his reason, and should be qualified, therefore, to express an opinion as to his sanity.

Varieties of Insanity.-Systematic writers upon the subject of insanity differ very much in the manner in which

they classify the different varieties of insanity. For our present purpose insanity may be conveniently regarded as being of three kinds-Idiocy or Amentia, Mania, and Dementia.1

Dementia-Paralytic (Paresis)

Idiocy (Fig. 38) differs from all other kinds of mental disease in being congenital, depending upon an arrest of cerebral development. There are various degrees of it, varying from a condition in which there is an entire absence of mind to one in which there is a glimmering of intelligence, as in imbecility. Imbeciles are usually docile, and, in some instances, can be taught, by careful management, to talk and even to read. The causes of idiocy are usually syphilis, intemperance (of the parents), consanguineous marriages. Idiots can generally be recognized by the small size of the head (except in the case of congenital hydro

1 Ray, I.: A Treatise on the Medical Jurisprudence of Insanity, fifth edition, 1871, pp. 84, 430, 577; Georget: De la Folie, Paris, 1820, p. 101; Mandsley, M. D.: Physiology and Pathology of the Mind, London, 1868, p. 253.

cephalus, in which the head is very large), thickness of the lips, enlargement of the tongue, salivary glands, and tonsils, vaulting of the hard palate, irregularity of the teeth, with tendency to decay, deficiency of the lobules of the ear, defective vision, weakness in the fingers and thumbs. Idiots are not only characterized by the absence or deficiency of intellectual power, but also by undue development of the animal part of their nature, as shown by their filthy habits, gluttony, etc. Upon post-mortem examination, the convolutions and fissures in the brain of an idiot are usually found less numerous and less complicated in their arrangement than in the brain of an intelligent person. Together with the deficiency of the gray matter of the cortex, due to so simple a type of brain, important parts of the latter, such as the basal ganglia, corpus callosum, cerebellum, may be undeveloped or even entirely absent. Neither idiocy nor imbecility is likely to be mistaken for mania or monomania, for, although the intelligence in the latter conditions is perverted and irregular, hallucinations being common, there is not that entire absence of it which is so characteristic of idiocy. However, as we shall see presently, idiocy, in some respects, resembles dementia. It need hardly be added that idiots are entirely irresponsible, both from a civil and criminal point of view.

Mania (Fig. 39) is understood as a general perversion of the mental faculties, accompanied usually with more or less excitement, which in certain cases may amount even to fury. The reasoning powers are not absolutely lost, but are rather confused, disturbed, disordered. There is no orderly sequence of thoughts; ideas follow each other without any relationship. At one moment the maniac may be tractable, pious in his expressions, singing hymns; at another ungovernable, abusive, blasphemous. He sings,

dances, laughs, then cries, tears off his clothes, breaks anything that he can lay his hands on, often at such times exhibiting great strength. The skin is dry and hot; the eye has a very characteristic expression, a fixed, wild, brilliant sort of stare. The pulse and respiration are usually quick and the temperature high. The appetite is generally voracious. The urine and feces are often voided involuntarily. Sexual desire is usually increased, and when so occurring in women is known as nymphomania; in men as satyriasis.

One of the most striking features of mania is the total alteration wrought in the feelings of one so affected towards the members of his family; the maniac becoming suspicious of and hating those whom he had formerly naturally loved. When haunted by delusions, which is not unfrequently the case, he may become so dangerous as to necessitate physical restraint. Systematic writers upon the subject of insanity consider mania to be of different kinds, distinguishing the varieties, as mania proper or intellectual mania, which we have just described, melancholia, partial intellectual mania, moral mania, partial moral mania, kleptomania, pyromania, dipsomania, and homicidal, suicidal, puerperal mania. But, whatever views may be held by systematists concerning different kinds of insanity, moral, emotional, intellectual, etc., it should be understood that the law recognizes only one kind of insanity-that which affects the mind, the latter being adjudged as unsound when affected with delusions that cannot be dispelled.

Melancholia may be regarded as a variety of mania, differing more especially from the latter in being characterized by depression rather than excitement, by the patient refusing food rather than partaking of it eagerly. The face is pale and pinched, the eyelids droop, the pupils are