909ROYAL COMMISSION ON LUNACY LAW AND ADMINISTRATION.

thereby the common manifestations-for example,the oculo-lethargic and the myoclonic types-might beinsufficiently emphasised. In the differential diagnosis,meningitis-tuberculous and syphilitic-could inthe majority of cases be excluded by examination ofthe cerebro-spinal fluid. Difficulty in diagnosisoccasionally occurred in cases of (i.) sinusitis, especiallyfrontal sinusitis associated with brain abscess,(ii.) infective endocarditis of the cerebral type, (iii.)uraemia especially associated with myoclonus, and(iv.) post-diphtheritic paralysis. Papilloedema wasso rare as to suggest intracranial neoplasm or abscess,though undoubted fundus change occurred in epidemicencephalitis-slight in degree and rarely. Dr. Cohenconsidered that the figure given by Dr. Gullan forcomplete recovery (50 per cent.) was too high. Treat-ment of the sequelae was disappointing, thoughhyoscine hydrobromide in the Parkinsonian syndrome,luminal in the myoclonic types with pain, and Lust’streatment in cases presenting reversal of sleep rhythmwere useful in many cases. Pitcairn’s method andmagnesium sulphate injections were disappointing.

Mr. C. O. DAVIES read a note on PharyngealDiverticula with an account of two cases recentlytreated at the Liverpool Royal Infirmary.

1

CARDIFF MEDICAL SOCIETY.

A MEETING of this Society was held on Oct. 15th,when Dr. R. M. F. PICKEN, M.O.H., Cardiff, spoke on

Present-day Health Tendencies in Cardiff.After referring to the importance of the medicalprofession reviewing locally from time to time theresults of public health activities, Dr. Picken empha-sised the important use of the statistical method ofinquiry and dealt with the absence of reliable localstatistics of sickness, as a result of which informa-tion in the mass was available only through deathreturns. The death-rate in Cardiff had fallen morerapidly than in England and Wales generally since1851, and at the present time Cardiff was favour-ably placed in relation to the acute infectious diseases.So far as infant mortality was concerned, there hadbeen a satisfactory decline which was shared in almostequal degree by all the other towns of importance.Dr. Picken considered at some length the variousexplanations which had been given for this decline,and mentioned that in his opinion the continuous fallin the birth-rate was probably the most importantfactor. Examples were given of towns where theredid not appear to be any definite correlation betweena low birth-rate and a low infant mortality, but inplaces like Bradford and Huddersfield this might bedue to special circumstances affecting the employmentof married women. The fact that the decline ofthe infant mortality commenced 25 years after thecommencement of the fall in the birth-rate was notnecessarily an argument against the former being theresult of the latter. The problem of tuberculosis wasdealt with at some length, and it was shown that inCardiff the death-rate from pulmonary tuberculosis,more particularly among males, was actually increas-ing. Various possible reasons for this were considered,and it was shown that the cause could not be foundeither in excessive unemployment as compared withother places or in the foreign seafaring population, whoadmittedly suffered heavily from tuberculosis, or inthe migration of the population in such way as toincrease the number of susceptible persons in the city.The problem remained unsolved. Having dealtbriefly with the increase of cancer and the tendencyfor the male cancer mortality to equal the femalecancer mortality-rate, some practical questions affect-ing the administration of public health and hospitalsin Cardiff were discussed, and a plea was made forbetter local sickness statistics and greater use of thegeneral practitioners’ opportunities for gathering andpooling information which might solve some of theproblems touched upon.

LUNACY LAW AND ADMINISTRATION.OPENING SITTINGS OF THE ROYAL

COMMISSION.

THE first meeting of the Royal Commission onLunacy Law and Administration and Mental Disorderwas held at Old Palace Yard on Tuesday, Oct. 7th.Mr. H. P. Macmillan, K.C., presided.

EVIDENCE OF THE BOARD OF CONTROL.Sir Frederick Willis, chairman of the Board of

Control; Mr. S. J. Fraser Macleod, K.C., and Dr.C. Hubert Bond, Commissioners of the Board, werethe first witnesses.

- Development and Duties of the Board.Sir F. Willis said that the Board really had its

inception in 1845. It was to consist of three legalmembers and three medical members. He attributedthe state of efficiency in asylums to-day in a largemeasure to the work of the Board, although, ofcourse, there had been also the growth of a rightspirit all through the lunacy system. He spoke of theenlargement of the duties of the Board consequentupon the passing of the Mental Deficiency Act, 1913.The Chairman said that the class of persons to

whom the Mental Deficiency Act related were dif-ferent from those with whom the Commission wasconcerned in that inquiry. That Act had created aseparate code from the code of lunacy law andadministration-a code with which that particularinquiry had nothing to do. He added that he wasanxious to appreciate the principles upon which thisbranch of law had developed. It appeared to him tobe a compromise between the liberty of the individualon the one hand and the protection of the publicagainst abnormal individuals on the other, togetherwith the protection of the individual himself againstthe consequences of his abnormality.

Sir F. Willis agreed, and said that nowadays welooked to the cure of the individual.The Chairman said that the medical side had

shown a progressive effort to improve the conditionsunder which those of unsound mind were treatedand to aid their recovery. He asked if he might takeit that the main sources of the existing law were tobe found in the Lunacy Acts of 1890-91, with certainamending statutes, and asked also what other bodiesor persons were concerned, in addition to the Boardof Control, with persons of unsound mind.

Sir F. Willis said that the Lord Chancellor had anancient jurisdiction which related to the person aswell as to the property. Largely his powers werederived from common law. The Home Secretary, ofcourse, had jurisdiction over criminal lunatics. TheMinistry of Health had jurisdiction, not over buildings,but over persons.The Chairman asked whether any disadvantage

had arisen from the distribution of functions amongthese different bodies.

Sir F. Willis thought it desirable that the Boardof Control should be able to go to the Minister ofHealth just in the same way as the Ministry ofHealth as a department went to the Minister.He agreed that the number of persons found insaneby inquisition with whom the Lord Chancellor hadto do was decreasing, and that it was a reasonableinference to draw that inquisition is less necessarynow than formerly.

Sir F. Willis considered that the present methodof dealing with lunatics adequately met the publicinterest. The categories of patients with whom theBoard of Control had to deal were mainly (1) privateand (2) rate-aided. In the case of a pauper the justicemaking the order for detention was required to seethe patient. In a private case he need not doso. The places where the insane were dealt withincluded county and borough mental hospitals(80 per cent.) ; registered hospitals, where fees arecharged, but not with the object of making a profit;licensed houses or private asylums, which are run

910 ROYAL COMMISSION ON LUNACY LAW AND ADMINISTRATION.

for profit; naval and military hospitals ; criminallunatic asylums, Poor-law institutions ; private 1

single care, and outdoor relief. On Jan. 1st, 1924,there were in the county and borough mental hospitals 1

103,892 patients (45,897 males and 57,995 females) ;in registered hospitals, 2139 ; in metropolitan licensedhouses, 1187 ; in provincial licensed houses, 1610 ; in i

naval and military hospitals, 171 ; in criminal I

lunatic asylums, 785 ; in Poor-law institutions,11,323 ; in metropolitan hospitals provided by theM.A.B., 5266 ; in private single care, 417, andinsane people receiving outdoor relief, 3544, makinga total of 130,334. Boarded-out cases are includedin the first category, because they remain on thebooks of asylums. With regard to licensed houses,Parliament had enacted that the number of theseinstitutions should not exceed the number in existencein 1890. There were now 98 such institutions, includ-ing Maudsley, and there were 13 registered hospitals.

Various Safeguards.Mr. Macleod then described the procedure of

petition, and the difference of procedure in the caseof a private and of a rate-aided patient. The docu-ments relating to any patient on reaching the Boardof Control were carefully scrutinised by an experiencedclerk and later by a Commissioner. If they werewanting in any particular they were sent back, andif they could not be amended the order fell to theground. There was no distinction so far as the Board’sscrutiny was concerned between documents relating toprivate and those relating to rate-aided patients.Perhaps about 12 or 20 certificates a day were referredby the clerk to the secretary for scrutiny, thoughmostly on technicalities.

Dr. Bond said that it was not always possible togather from the certificates whether the symptomsthere set down were observed by the certifyingdoctor himself at the time of the examination, andsometimes the facts given did not necessarily indicateunsoundness of mind. The scrutiny of the Boardwas directed to the whole certificate, but the accentwas on the paragraph relating to what was seen bythe observer at the time of the examination. Theforms were not always examined by a medical Com-missioner, but if any purely medical point arose thelegal Commissioner would call the attention of hismedical colleague to it. He thought that the formcould be said definitely to be successful. Doctorsdid not always grasp the essentials of this certification,but education in this respect was going ahead,especially since some of the medical bodies hadestablished diplomas in psychological medicine.After admission of the patient a description of hismental and bodily condition was furnished to theBoard by the medical superintendent within sevendays. This was not a diagnosis, but simply adescription. The reason for the differentiationbetween private and rate-aided patients was that inthe case of the rate-aided patient, unlike, in somecases, the private patient, it was to no one’s interestthat he should be unnecessarily detained.

Sir F. Willis said that the real safeguard in all caseswas the character and ability of the men at the headof the institutions, not any documentary evidence.

Mr. Macleod then described the system of visitation.In county and borough asylums the visitation tookplace once a year by two Commissioners. Licensedhouses were visited twice a year by the Commissionersand registered hospitals once under statute, but infact twice. Single-care patients were visited as oftenas the Board ordered, but in any case at least oncea year. The statutory visit must be private, must bemade by a legal and a medical Commissioner, withoutprevious notice ; many questions were asked of theofficers, and every patient was spoken to. Anyprivate patient had a right under the statute to demanda private interview; any private interview askedfor by any patient was granted.

Private and Pauper Patients.The examination of the Commissioners was con-

tinued on Wednesday, Oct. 8th.

Sir F. Willis described the procedure followed onthe discharge of a private patient.The Chairman remarked on the curious provision

that a patient who had escaped from detention andremained in hiding for 14 days was free from restraint.

Sir F. Willis said that he saw no reason in thisstipulation ; it was probably an inheritance from theold days of lunacy administration.The Chairman remarked that there were differences

in the procedure of discharge between private andrate-aided patients, and he supposed that here againthe reason was that there was no pecuniary induce-ment on the part of any person to retain the rate-aided patient in an institution.

Dr. Bond remarked, on the subject of medicalexaminations, that it was a growing practice-and inone hospital the routine practice-for the medicalsuperintendent, on the admission of a patient, todiscover the name of his family doctor, if there wasone, and inform him briefly as to the facts of detentionand invite him, if in the neighbourhood of the asylum,to come in and discuss the case.

Sir F. Willis said that the number of patients sentout on trial in 1922-23 from borough and countyasylums was 5525, but a large number had to returnto the institutions. On the question of accommodationhe expressed the view that mental hospital accommoda-tion was inadequate, and that in a short while theposition would be serious, owing, not to any undueincrease of insanity, but to the natural growth ofpopulation.The Chairman thought it might be necessary to

reconsider the policy which since 1890 had arrestedthe growth of the licensed house.

Sir F. Willis then spoke about medical certificates.He said that there were very few misdemeanoursin this respect under the Act, but difficulty did arisethrough medical practitioners withholding certifica-tion of one of their private patients in order to avoidthe stigma of detention. That was a contraventionof the Act. The practice of the Board on learning ofsuch a case would be to apply to the Lord Chancellorfor an order.The next question raised was on the provision for

insane patients in workhouses. The Chairman saidthat the workhouse was not the proper place for thereception of patients likely to improve under treat-ment ; if used at all it should be for chronic andhopeless cases.

Sir F. Willis said that his Board would welcome anypracticable suggestion for the better use of the totalaccommodation.

Steps Following the Arrival of the Patient at anInstitution.

Dr. Bond, at the request of one of the Commis-sioners, then detailed how a patient was dealt withon arrival at an institution. A preliminary physicalexamination was made while the persons who hadbrought the patient remained on the premises. The

patient was put to bed for at least a week, duringwhich time an elaborate examination was made bymore than one doctor, and a report sent to the Boardof Control. The examination was repeated at monthlyintervals, certainly for the first three months, andprobably for the first year, and later at quarterlyintervals.

Sir Humphry Rolleston asked how often it happenedthat the second certificate, the first having been givenby the family doctor, was given by an expert in mentaldisorder.

Dr. Bond said that in the metropolis this was veryfrequent, less so in other parts of the country. Dr.Bond also stated that faulty certificates were extremelyfew in number compared with the hundreds ofthousands of proper certificates which came beforethe Board.

Sir David Drummond raised the question of theclinical experience of medical officers at mentalhospitals, and asked whether it was necessary for suchofficers to have had a training in a general hospital.

Dr. Bond said that such training was recommendedby the Board, though it was not made a sine qua non.

911ROYAL COMMISSION ON LUNACY LAW AND ADMINISTRATION.

Mental hospital authorities had also been urged toappoint, in addition to their resident staff, certainconsulting physicians other than mental specialists-i.e., gynaecologists, and so forth. He doubted,however, whether it would be practicable to lay downa hard-and-fast requirement for clinical experience ;visiting committees even as it was did not getsufficient applications when there was a vacancy.

Allegations of Cruelty.The Secretary of the National Society for Lunacy

Reform asked permission to put certain questions,and these were put through the Chairman. The first

question was how frequently the Board had to investi-gate cases of cruelty.

Sir F. Willis said that the Board received a greatmany complaints of cruelty, chiefly from the patientsthemselves, in the form of letters. Every case wasinvestigated, if necessary by a sworn inquiry, but invery few instances was the complaint substantiated.In one case only in 1923 an attendant was prosecutedand fined for striking a patient, and there were veryfew cases, not more than half a dozen a year, in whichcomplaints were found proved and disciplinary actionother than prosecution taken. The right of an ill-treated patient to appeal to his doctor was veryjealously safeguarded, and in addition to this, thepatient could always write to the Board, and, as hehad said, every case was investigated. He had heardit stated that some patients were too frightened tocomplain, but he had not known this to be substan-tiated. He thought that the surprise visits of theCommissioners did much to allay any uneasiness onthis score, for it occasionally happened that the Com-missioners on going round the wards were apprised ofsome case, and held an inquiry forthwith, sometimeson oath.

In answer to a question from the Chairman, SirF. Willis said that the licensee made the appoint-ment of heads of licensed houses ; the licensee neednot be a doctor, but the Act required that there mustbe a resident doctor, and a visiting doctor accordingto the number of patients. Asked whether he hadany statistics of the number of persons who havebeen discharged from detention on the ground thatthey were not insane when admitted, he answered :" A very small number." He had had no experienceof cases where persons not insane had been wronglydetained in asylums, and he regarded the existingmachinery in the matter of certification and provisionswith regard to detention as adequately safeguardingthe liberty of the subject. On the other hand, ifingenuity could suggest any additional reasonableprecautions the Board would not resent them. Withregard to curative treatment in the hospitals them-selves, the Board had responsibility only in an

advisory capacity. The responsibility for the treat-ment of each individual case must rest with thedoctor of the institution. If the Board found aninstitution lax in this matter they could bring pressureto bear on the medical superintendent or the localauthority, but they could not insist that an extradoctor be appointed or a laboratory provided.EVIDENCE OF THE LORD CHANCELLOR’S DEPARTMENT.

Sir Claud Schuster, Permanent Secretary to theLord Chancellor, gave evidence with regard to thesmall number of patients in whom the Lord Chancellorhad an interest. These were patients found insaneby inquisition-a very small number-and those inwhose prorerty the Lord Chancellor had some con-cern. The Lord Chancellor’s visitors were three innumber-two medical and one legal-and they visitedthese lunatics at statutory intervals. Their concernwas with the individuals, not with the institutions.Asked whether the Lord Chancellor’s ancient juris-diction was worth retaining, the witness said he wasin doubt on that point ; it depended on the constitu-tion of the Board of Control, which should includethe very highest medical experts on the subject oflunacy, as well as legal men of great eminence. Thelegal mind was needed to counterbalance the specialpoint of view of the medical. On the whole, he thought

that it was as well to continue the Lord Chancellor’sfunctions, which were to some degree those of a,

champion of these people. He went on to complainof medical certificates, not as to their conclusion, butas to their selection and arrangement of facts leadingup to those conclusions, and said that here againthe legal mind was necessary to correct and counter-balance the medical.

The Rights of the Confined Patient.At the resumed sitting on Oct. 21st Sir Claud

Schuster, under the same chairmanship, expandeda reply he gave at the previous sitting when heexpressed the view that a lunatic in confinement hadnot been and should not be given the right to demanda public inquiry as to whether he had recovered.The conferment of such a right would be unfortunate.Lunacy was a disease which might or might not becurable, and, like other diseases, its cure or alleviationwas a gradual process. It would, therefore, be verydifficult in many cases to determine the point at whichthe patient might be said to have been cured or tohave made such progress as to be properly released,and this would be a matter peculiarly unsuited forpublic inquiry. Moreover, as the function of thosewho had to determine whether the patient was to bereleased or further detained was not to investigateany charge against the patient as though he were analleged criminal, but whether certain action shouldbe taken in his interests and those of the public,the matter was unsuitable for forensic treatment,and it would be very undesirable that the localauthority or the person in charge of the asylumshould be forced into an office analogous to that ofprosecutor. Again, a very large proportion of lunaticsconsidered that they were wrongfully detained, andevery one of these people would have the right todemand an inquiry and many of them would exerciseit. The question of a lunatic’s condition was un-suitable for discussion in public-often unpleasantand sometimes humiliating for the patient anddetrimental to his interests.

EVIDENCE OF THE MINISTRY OF HEALTH.Mr. L. G. Brock, Assistant Secretary to the Ministry

of Health, next gave evidence. He said that thepowers of the Local Government Board were trans-ferred to the Ministry of Health under the statutewhich set up the Ministry, while certain powers of theHome Office relating to lunacy and mental deficiencywere also transferred from time to time by Order inCouncil. The powers and duties entrusted to theMinister might be grouped under four heads :(1) The Minister had certain limited powers withregard to the individual lunatic. He had no power toorder the discharge of a patient, but he could initiateinquiries on complaint. (2) He was called upon toapprove the provisions made by local authorities forthe accommodation of lunatics. (3) He had certainpowers in relation to the Board of Control. He hadpower to recommend for appointment the non-legalCommissioners, and to approve other (staff) appoint-ments. He was also responsible for the Board’sestimates in Parliament. But, apart from theseultimate sanctions, the Minister had no power to givedirections to the Board for any specific administrativeact, though, as a matter of practice, the Boardinvariably met the Minister’s wishes. In the dailyadministrative work of the Lunacy division of theMinistry all patients’ letters were carefully read bythe responsible officer, and, whenever necessary, theBoard of Control was consulted regarding the latestmedical report on the patient’s condition. There were,of course, a number of chronic patients who wroteregularly, but whose mental condition was fully knownto the department, and in other cases the letters boreon the face of them unmistakable evidence ofinsanity; for example, correspondents frequentlycomplained of being ’’ poisoned by wireless." Allletters were carefully examined with a view to seeingif there was any allegation of wrongful detention orill-treatment. Where the Board of Control had notavailable a special report from the medical superin-

912 ROYAL COMMISSION ON LUNACY LAW AND ADMINISTRATION.

tendent on any such allegations, or where there wasstill room for doubt, the Minister asked that theCommissioners at their next visitation should payspecial attention to the patient. If a case presentedmedical as distinct from psychiatric issues which calledfor investigation a medical officer of the Ministry wouldbe sent to report on it. He added that the correspond-ence did not afford any evidence whatever of personshaving been improperly certified or detained longerthan the medical superintendent believed to benecessary, nor had any allegations of ill-treatmentbeen fully substantiated. At the same time it wasclear that there were a number of patients in mentalhospitals who, though in no sense sane, could bedischarged without danger to themselves or thecommunity if their relatives were willing and able tolook after them. The exact point at which a personsuffering from mental disorder was sufficientlyrecovered to justify discharge was necessarily a

matter of opinion ; and some superintendents, mindfulof the risk they incurred by recommending dischargeprematurely, were more cautious than others. It wasalso remarkable that in many instances where therelatives were convinced that the case was one ofimproper detention, the medical report indicated adefinitely bad prognosis. The explanation might bethat in certain forms of insanity which were slow indevelopment there were periods of quiescence, and asthe relatives were only allowed to see the patients ongood days they formed an incorrect impression of hismental condition. Other cases developed acutesymptoms at an early stage, and, though the prognosiswas hopeful, the relatives, having seen the patientviolent or raving, had no doubt as to his insanity norhad they much hope of his recovery.

In reply to questions, Mr. Brock said that theMinistry had no alienist on its staff, though onemember of the medical staff had had some experiencein a mental hospital. He preferred not to answer aquestion as to the advantages of the Board of Controlas a separate authority instead of a department in theMinistry, but he said that the relations between themedical Commissioners of the Board and the medicalofficers of the Ministry were based on mutual courtesyand administrative convenience, and the result wasquite satisfactory.

Mr. H. W. S. Francis, Assistant Secretary of theMinistry of Health, in charge of the Poor-lawDivision, gave evidence dealing with the functions ofthe Ministry as the successor of the Local GovernmentBoard in dealing with the administration of Poor-law.The department kept closely in touch with thePoor-law authorities through a body of generalinspectors, medical officers, and women inspectors.Every Poor-law institution was visited at least oncea year. The general inspectors had statutory powerto hold inquiries upon oath in matters of Poor-lawadministration. During the past five years suchformal inquiries had been held in two cases in whichpersons of unsound mind were concerned. The numberof insane persons who were inmates of Poor-lawinstitutions, or institutions other than the publicasylums, maintained wholly or partly at the cost of thepoor-rate, was 27,432, of whom 8763 were inmates ofPoor-law institutions provided solely for mentalcases, and almost all the remainder were in the sick orother wards of Poor-law institutions. The witnesswas closely examined as to the procedure at inspectionsand inquiries, and in one case in which an inquiry

_

as to the ill-treatment of a patient had led to noconclusive result the Chairman remarked that thisdid not seem very satisfactory.

PROPOSALS OF RELIEVING OFFICERS.

Mr. E. J. Lidbetter, President of the NationalAssociation of Relieving Officers, suggested certainproposals to the Commission. He recommended thatthere should be no difference in the process of certifica-tion between the pauper and the non-pauper ; exceptin very rare cases, juveniles should not be certifiedas insane, nor should cases of senile dementia. The

provisions of the Mental Deficiency Act should beamended to enable juvenile pauper cases to be dealtwith under its provisions. The Board of Control, orsome other authority or commission, should beendowed with powers to determine, under propersafeguards, ambiguities under the statutes and pointsof law involved. His principal recommendation,however, was that workhouses should no longer beregarded as places of safety for alleged lunatics;asylums committees should be required to providesufficient reception houses in all urban areas. Insuch centres there would be sufficient cases to justifyand require a rota of justices holding a daily session,and therefore there would be an end to the troublewhich frequently at present arose, of securing a

justice. The preliminary period of detention underthis system need not be as long as three days. Thework of such daily centres would be more formaland the investigation of cases would be carried outin a more judicial atmosphere than was possible inthe wards of workhouses. There would be at thereception house a resident medical officer availablefor purposes both of treatment and observation. Thereception house would also serve the purpose of aclinic, providing advice and treatment to out-patients.On the recommendation for the discharge of a patientfrom an institution for lunatics, the staff of the recep-tion homes should be called upon to inquire into andreport upon the conditions into which it was proposedto release the patient, and also to make some provisionfor after-care. The method would also make possiblea system of information and record-keeping. Infact, there might be a cross-index containing particularsof every lunatic or alleged lunatic.The Chairman thanked Mr. Lidbetter for his com-

munication, and said that although the Commissionwas naturally anxious to do everything that waspossible this procedure seemed likely to involve greatexpenditure.

EVIDENCE GIVEN BY MAGISTRATES.

The Commission sat for the fourth time on Oct. 22nd,under the same chairmanship, when evidence wasgiven by magistrates as to the work done by themunder the Lunacy Acts.

Sir John Barnsley, magistrate for the city ofBirmingham and deputy chairman of the visitingjustices of that city, placed before the Commissionsuggestions and recommendations made at a specialmeeting of the Birmingham justices. He said thatas a rule he had no difficulty in signing a certificatefor detention. He saw alleged lunatics either at hisprivate residence or place of business, or, if theyhad been taken into custody, he saw them in a privateroom at the police station. It was no doubt thegeneral practice to see a patient personally beforesigning a certificate, but it was recommended bythe Birmingham justices that a personal interviewshould be compulsory. It was also recommendedthat where a doubt existed in the mind of the justicethere should be, before final certification, com-

pulsory preliminary observation in some place otherthan the workhouse or asylum, for instance, an

observation clinic. The witness agreed with theChairman that it should be a place to which thereshould be a right to send persons of any social position,whether they could pay or not, and that probablythe additional expenditure involved might be set offagainst the saving from the diminution of the probablenumber of cases which would have to be sent toasylums. Charges might be made for treatment andthe institution or clinic could serve as a centre forgiving advice and assistance to outdoor cases. Itshould also be possible for patients to enter theinstitution voluntarily for a period of treatmentwithout any detention order having been given. Ifsuch voluntary cases had dangerous tendencies, someform of compulsory detention would have to beadopted, and naturally such tendencies would bemanifest prior to treatment. As to visitation, it wasurged that some independent authority should, on

913ROYAL COMMISSION ON LUNACY LAW AND ADMINISTRATION.

the lines provided under the Mental Deficiency Act,periodically visit and report upon all persons detainedunder the Lunacy Laws. All patients should bevisited at the end of the first year, again at the endof the second year, and subsequently every five years.The rota for visitation under the Mental DeficiencyActs was so arranged that one magistrate saw thesame person each year and could therefore note theprogress that was being made. It would, of course,be necessary to enlarge the judicial authority andincrease the number of visitors if that method wasadopted.The Chairman pointed out that the visit would be

for the purpose of interviewing the patient whopresumably thought he was being unlawfully detained.He had some difficulty in seeing how the visitor woulddecide that the case was one that ought to be liberated.

Sir John Barnsley replied that he did not suggestthe visitor should have power to do anything morethan report to the Commissioners that he had visitedthe case and in his opinion, as a layman, the patientmight safely be discharged. It would then be forthe Commissioners either to accept that view or togive reasons why it should not be given effect to.

Mr. W. H. Lord, magistrate for the city of Bir-mingham, was in accord with the views expressedby the previous witness as to observational treat-ment. His evidence was confined to the admissionof patients; he said it was his practice to inter-view alleged lunatics in the cab in which they werebrought to his house by the relieving officer. He hadnever had occasion to doubt the medical certificatessubmitted to him. It was proper, he thought, thatrelatives and friends should know that a certificatemight be given in any particular case, though hedid not make a practice of inquiring of the relievingofficer if there were relatives, and why they werenot present. He was of the opinion that it would bewell to have a second certificate in pauper as well asin private cases.Answering a question with regard to treatment, the

witness said that in a large number of cases the

proceedings and treatment were often too longdelayed. He was under the impression that treat-ment prior to the stage at which certification couldtake place might prove to be remedial.

Sir Robert Walden, magistrate for the County ofLondon, and chairman of the visiting magistratesfor the county, agreed that personal contact was agreat advantage, though it did not exist when privatepatients were admitted. He had had occasion to idiffer from medical men and had refused to signcertificates in certain cases, referring them back forfurther observation. He knew he had the right to callin another medical practitioner to inquire into suchcases, but if they were difficult he would rather havethe advice of an expert. With regard to provisionalor experimental treatment, Sir Robert Walden wasin favour of the establishment of a hostel under themanagement of an expert neurologist, assisted bytrained nurses having psychological and other certi-ficates, who should be able from time to time toreport on the case. To such a home suspected casescould be sent before a certificate was issued, and hethought that since there would be no connexionwith the workhouse or asylum, there might in manyinstances be a better chance of recovery. Theremight be two such institutions, one north and theother south of the Thames.The Chairman said that at the end of the period of

trial it might be found that certain patients wereobviously cases for certification, and they wouldthen pass to the asylum or to the workhouse, orpossibly be the subject of application for receptionto a licensed house. On the other hand, it might befound that as a result of the trial a person was notcertifiable and ought to be returned to his or herfriends. Could it not be hoped that during the periodof provisional detention the cases benefiting by thequiet and treatment might completely recover ?

Sir Robert Walden thought that 50 per cent. ofthe cases might do so. The provision of such insti-

tutions would relieve the pressure on the asylumsin the metropolitan area, the accommodation inwhich had been inadequate for some time. Fromexperience gained in the course of frequent personalvisits to London asylums he had found, in con-

versing with patients, that in some instances therewas justification for their complaints. Frequently,however, the complaints were not substantiated.The Chairman asked whether Sir Robert Walden

had any views in regard to some independent tribunalor investigation as to the state of a patient in anasylum.

Sir Robert Walden replied that in a border-linecase it might be desired to consult an expert.The Chairman asked if the witness thought it

desirable that those dealing as medical practitionerswith mental cases should have some special qualifica-tion as distinct from the qualifications of the ordinarymedical practitioner. Sir Robert Walden replied thatover and above general medical education, suchpractitioners should be specialists in that particularbranch of work and have had considerable experience.

Sir Humphry Rolleston said he had been muchimpressed by the stress laid on the desirability of thejudicial authorities being highly experienced men andthe medical men specialists. Was the witness of theopinion that the judicial authorities should be as

specialised in regard to the inquiry into diseases ofthe mind as the coroner in regard to investigation asto the cause of death ?

Sir Robert Walden said it would be better, but hethought it was impossible. It would be necessary tohave a paid authority. As to the medical man beingas great a specialist as the coroner and pathologist,he maintained that a man dealing with mental casescould not have too much knowledge. Certainly theD.P.M. certificate should be held by all who dealtwith such cases.

Earl Russell asked the witness if he thought itdesirable that there should be instituted in Englandthe practice prevalent in Scotland of boarding outsuitable cases in villages. The witness replied thatprovided both the cases and the foster-parents werecarefully selected, that might prove a desirable coursein certain instances.

Councillor C. F. Sanders, magistrate for the city ofCardiff, said he had no difficulty in regard to certifyingcases. He was, of course, bound to rely on the certifi-cate of the medical officers. He did not understandit to be his task to examine a patient and satisfyhimself from his own observation as to whether thatpatient was sane or insane. Continuing, the witnesssaid that in the course of the past two years as manyas 333 cases had passed through his hands, out ofwhich number 58 had been discharged without acertificate having been granted. In answer to a ques-tion by the Chairman as to these 58 cases, CouncillorSanders replied that they were dropped for variousreasons, a large proportion of the cases having beenbrought in suffering from delirium tremens and thetaking of methylated spirits, whilst others apparentlysuffered from severe depression of sudden onset,which after a short rest had passed off. There wassufficient accommodation in Cardiff for all cases

arising in the area. Councillor Sanders had neverseen anything to suggest to him that any furtherprecautions to protect the public against unduedetention were required.The evidence elicited during the sitting showed that

there were differences of procedure as betweenBirmingham and Cardiff. Whilst Councillor Sanderssaid that in 19 cases out of 20 he had before him, whenconsidering the signing of certificates of detention,written statements from relatives or friends as towhat they knew of the alleged lunatics, Mr. Lord saidhe made no inquiry as to whether the patient hadeither relatives or friends. Again, in Birmingham theworkhouse was not used as an original place of deten-tion or as a place in which the justice might visit thepatient, whereas in Cardiff it was the almost invariablepractice to use the workhouse for both purposes.The Commission adjourned until Nov. 4th.

914 REVIEWS AND NOTICES OF BOOKS.

Reviews and Notices of Books.THIS EXTRA PHARMACOPOEIA.

Eighteenth edition. In two volumes. Volume I.Revised by W. HARRISON MARTINDALE, Ph.D.,F.C.S., and W. WYNN WESTCOTT, M.D. Lond.,D.P.H. Lond. London : H. K. Lewis and Co.,Ltd. 1924. Pp. 1163+xxxviii. 27s. 6d.IN the four years since the last edition of the

Extra Pharmacopoeia appeared much work has beendone on the chemical and physical properties of thesubstances used in medicine, research to which theauthors have made their own contribution. All thispractical laboratory work has been summarised andcritically sifted with a view to presenting to the

practitioner and pharmacist a key to up-to-dateinformation on drugs and therapeutic agents in apithy and concise form. Some new features appear-in the present edition. Notes on alkaloids deal withboth bench work and physiological trial, and a meansis suggested of enhancing the effect of these drugs bythe simultaneous use of alkali ; this " activation " iscorroborated by experiment on the authors and theirassistants. Information on periodides, unavailableelsewhere, is given in this book along with the actualtherapeutic doses determined by use in man. Attentionis called to the intravenous application of salts ofaspirin, the calcium salt having proved of definiteservice in relieving pain in sciatic and rheumaticaffections. A heroic attempt has been made to bringthe evidence regarding alkali bismuth tartrates intoproper order. The provisions of the Dangerous DrugsActs are set out in a form which makes the dutiesboth of medical man and pharmacist clear at sight.Timely information will be found on many currenttopics ; the value of ethanesal, the properties ofnucleinic acid in increasing the leucocyte count, thefact that solutions of cocaine hydrochloride reallycan be boiled in glass vessels, the claims of Besredkato produce vaccines effective on oral administration.The poisons schedule is brought up to date, and anintravenous dose table throws light on dosage in afield where standardisation has been imperfect. Notthe least interesting part of the book is the prefacecontaining some remarks straight from the heart of adispensing chemist who would welcome the confidenceof the physician on matters of doubt relating toprescriptions. The authors appeal to the practitionerto help forward the British drug industry.We have said enough to show that in its new form

the Extra Pharmacopoeia remains a storehouse ofcurrent information and a safe book of reference.We repeat our opinion that it is one of the few bookswhich the medical practitioner, the analyst, and thepharmacist cannot afford to be without.

FERTILITY AND STRRILITY IN 1-LuMAN MARRIAGES.

By EDWARD REYNOLDS, M.D., and DONALD IMACOMBER, M.D. London and Philadelphia:W. R. Saunders Company. 1924. Illustrated. IPp. 285. 25s.THIS is a comprehensive monograph on a subject

that has received considerable attention in the last20 years. From the beginning the authors emphasisethe fact that modern research has shown more andmore emphatically the importance of the male inall questions of fertility, and for this reason they havesecured the collaboration of an expert on the subjectof male sterility, Dr. Edward L. Young, jun. Evensuch conditions as habitual miscarriage and one-

child sterility are, as they point out, not necessarilyindicative of trouble in the female. Miscarriage maybe due to decreased fertility of either partner, themiscarriage resulting from the death of the fcetusor from its imperfect attachment to the uterus.Observations on animals have shown that in the casesof impaired fertility the uterus contairs a percentageof blighted embryos interspersed among normal

ones, the condition being due to conjugation byimperfect gametes. In an interesting chapter dealingwith relative infertility in human m,arriages,the authorsdiscuss the influence of diet, habit, physical exercise,nervous overstrain, and minor constitutional derangE-ments on fertility. They quote instances of oligo-spermia in the human rnale which have been remediedby the adoption of a suitable diet and of sufficientoutdoor exercise to improve assimilation, and it isobvious that if such changes can be effected ii themale equally satisfactory results may be expectedin the case of the female. The diet which is mostfavourable to fertility is one which contains a highpercentage of anima,l proteins, together with someslight excess of vitamins and mineral salts. Asso-ciated with the alterations in diet should be a completeand prolonged change from habits of civilised lifewith the substitution of outdoor for indoor work.The alterations should, in the opinion of the authors,be made as early as possible in al! cases in whichmarriage is not promptly followed by pregnancy.In the absence of voluntary prevention failure ofprompt impregnation after marriage always impliesat least some slight abnormality in the condition ofone or other partner. In dealing with obviouslydiseased conditions of the genitalia it is interestingto note that the authors consider that the importanceof gonorrhoea in causing female sterility has beenexaggera,ted. This exaggeration they believe to haveresulted from an unwarrantable assumption thatchronic genital infections in a married woman, evenunaccompanied by the history of an acute onset,are always due to unrecognised gonorrhoea in thehusband. In actual fact non-specific irfetions arefar more common than is usually recognised, and inthe opinion- of the authors these can be differentiatedfrom gonococcal infections by the absence of a historyof acute onset.The book concludes with a chapter on the surgery

of sterility. This includes operative measures onthe cervix, such as Pozzi’s operation, curetta.ge,and the surgery of the ovaries and tubes. Includedin the latter is a description of the technique ofinsufflation of the tubes with carbon dioxide gasas a means of diagnosis and treatment of tubulardisease. Finally the authors point out that surgery,although it may be of use in remedying certaingrosser defects, is only one of the weapons with whichsterility can be attacked, and that in all cases it isof vital importan ce to consid er carefully the physiologyof the condition. It is indeed along physiologicalrather than pathological lines of study that futureprogress in this subject will be mad?.

This book is clearly written, well balanced in itsviews, and comprehensive in its outlook. We recom-mend it to all interested in this important subject,whether - they be gynaecologists, genito-urinarysurgeons, or general practitioners.

AMPUTATIONS.

By NoxMArr THOMAS KiRK, M.D., F.A.C.S., Major,Medical Corps, U.S. Army. Published under theauthority and with the approval of the Surgeon-General, U.S. Army. Washington, D.C.: TheMedical Interpreter. 1924. Pp. 110+ix.

Major Kirk is chief of the Amputation and Ortho-peadic Section of the Walter Reid General Hospitalat Washington, and here, as previously at No. 3General Hospital in New Jersey, he has had exceptionalexperience of amputations, some 700 of which he hashimself performed. He is therefore able to speakwith authority. This monograph may, moreover, beconsidered as embodying the views officially approvedby the medical authorities of the United States Army,seeing that Surgeon-General Ireland contributes aforeword to it. It must be a matter of congratulationthat Major Kirk seems to have arrived at conclusionsas to sites and methods of amputation very similarto those that were reached some years ago by Britishsurgeons and expressed in works published in thiscountry. The author- describes an ingenious and