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rate to 98. But during the same night his condition againtook a sudden turn for the worse ; the temperature shot upto 104°, the pulse-rate was 140, and localised tenderness wasdetected in the right iliac fossa.On the fourth day, in the morning, he became steadily

more ill. He developed severe hiccup and vomited fourtimes, the vomit being dark-coloured fluid, which was foundto be bile. Consent was now obtained for operation, and aright paramedian incision about 5 in. long was made. Theperitoneal cavity was opened and the omentum presenteditself showing some yellowish areas of fat necrosis. A littleblood-stained fluid was mopped out. The stomach andduodenum showed no perforation; a quantity of blood-stained fluid escaped from the lesser sac and the pancreasshowed haemorrhages and presented areas of sclerosissuggesting existence of a chronic pancreatitis. The appendix.was adherent to the csecum. The gall-bladder was distendedand some concretions were felt at its neck. After pro-tecting the general peritoneal cavity I aspirated a quantityof fluid from the gall-bladder. It was black, like Indian ink, Iand had the same character as what had been vomited in I

the morning. After incision of its capsule the pancreas wasdrained through the lesser sac. The gall-bladder was rapidlydrained through another incision on the right side. Thepatient collapsed, however, two hours after the operationand died, in spite of intravenous injection of saline and ofpituitrin.

The onset in this case was very insidious ; thepatient suffered from a subacute type of pancreatitis.It is difficult to explain the lull in the symptoms duringthe afternoon before the day of operation. Probablythe fluid exudate in the lesser sac escaped into thegeneral peritoneal cavity through the foramen ofWinslow and led to toxic absorption, giving rise torapid pulse, high temperature, and hiccup. Thevomiting of pure bile was a very striking phenomenondue to regurgitation through the duodenum. Iexamined the patient specially for cyanosis and forecchymosis in the loins, which is considered patho-gnomonic by some surgeons, but they were absent.

Medical Societies.ROYAL MEDICO-PSYCHOLOGICAL

ASSOCIATION.JOINT MEETING WITH THE SECTION OF MENTAL

DISEASES OF THE BRITISH MEDICAL ASSOCIATION.

AT a joint meeting held on Friday, July 22nd, inthe Edinburgh University New Buildings, Dr.HAMILTON MARR (Commissioner of Control forScotland) presided and Prof. G. M. ROBERTSONopened a discussion on the

REPORT OF THE LUNACY COMMISSION.The Lunacy Laws of England and Scotland were, hesaid, in urgent need of amendment. Great changesin social life and in the scientific world had occurredsince the passing of the Scottish Act in 1857, but thisAct had the advantage that it recognised . theparamount position of the medical profession in thetreatment of mental diseases. Under it no laymanwas called upon to see the patient on certification,and no lay committee was responsible for his removalon discharge. To this feature must be ascribed thesuccess of the Scottish system, which had gained thecomplete confidence of the people. No case ofimproper detention had ever been recorded in thecourts. The English Act of 1890 was a complete,logical, and accurately drafted instrument. Its veryperfection from the legal and administrative points ofview had been a calamity to the patient. The medicalaspect of the problem had been overshadowed by thehaunting fear of improper detention, so that lawsenacted for the welfare of the insane person had turned

out to be to his detriment. One gratifying andimmediate result of the Royal Commission had beento allay all anxiety in the minds of reasonable peopleas to improper detention ; such cases had not beenfound. Future legislation, therefore, should not bedominated by suspicion and misgivings. The Com-mission had also found that, since the stigma ofcertification was keenly felt, it should be a last resortand not a preliminary to treatment. The facilities fortreatment without it therefore called for extensivedevelopment. The keynote of the past had beendetention ; the keynote of the future should be preven-tion and treatment. The arrangements suggested forvoluntary treatment were satisfactory. For theinvoluntary three procedures were recommended :the Emergency Order, the Provisional TreatmentOrder, and the Reception Order. The first of these,signed by one doctor and a friend or public official,was not a certificate of insanity and remained in forcefor seven days only. It appeared quite satisfactory.

The Provisional Treatment Order.In the provisional order one doctor would make the

recommendation, which would last from one to sixmonths only. It was intended to ensure treatment for

the probably recoverable patient without certification.The signature of one doctor only was, however, amistake ; as a safeguard and a second witness orobserver only, apart from his value as a second medicalopinion, the second doctor must meet with generalapproval. A niggardly economy where the libertyof the subject was concerned was indefensible, but itwas particularly objectionable if the omission of thesecond doctor were responsible for the repeated visitsby laymen.

’

Another difficulty was the basis of the order, whichwas made a matter of prognosis, notoriously the mostdifficult and uncertain problem in psychiatry. It hadto be solved by the general practitioner who had littleexperience and by the justice who had none. Everysuccessful doctor. was an optimist, and it might safelybe assumed that if this became law every patient,save a chronic or absolutely hopeless case, would getthe benefit of the doubt and be treated under theprovisional order-an excellent thing. The termswere better expressed in the Scottish Schedule G,which used the words " where the malady is notconfirmed " and " with a view to his recovery." Theintention could always be honestly remedial, howeverfaintly hopeful the outlook. It would be better todrop the dubious procedure of prognostication alto-gether, and give every patient for whom there wasthe least hope the benefit of the provisional ordertreatment for six months. No objection to fullcertification could be taken after the six months’ testhad failed, or for chronic cases.

It was a matter of profound regret that the justicehad to intervene in the provisional order ; such arecommendation was astonishing in a report thatrecorded no case of improper detention and thatbreathed medical aspirations and professed thera-peutic and preventive ideals. It was clear thatunmedical legal procedures had in the past been thechief impediment to early treatment. The treatmentto be given under this order was only temporary andessentially remedial. There was no need for thejustice, particularly if two medical men were involved.Miscarriages of justice had occurred in the law courts,yet no comparable cases could be found in the mentalhospitals. In Scotland for 70 years thousands ofpersons had been placed in mental hospitals withoutseeing a magistrate, and no case of improper detentionhad ever been found. This record of the medicalprofession was beyond all praise, and proved that theirhonour and vigilance were no mean safeguard.Another safeguard which the Royal Commission

did not seem to have appreciated was the Scottishright of appeal to two independent medical men.The sheriff’s reception order was wholly given on thewritten opinions of the two doctors first called in,and the patient, his friends, the sheriff, or the GeneralBoard of Control could call in two other doctors, whoformed for the time being the supreme and final courtof appeal. Thus in Scotland there was a purelymedical system that afforded complete protection,had stood the test of time, and satisfied publicopinion.

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Judicial Intervent-!on.Infringement of the liberty of the subject with-

out the intervention of the judicial authority wasnot without precedent in the domain of mentaldisease. It appeared to have been practised inEngland for 45 years without abuse, and was stillpractised in Ireland. Judicial intervention was notdesired by the patient nor by his relatives. It wasquite alien to medical feeling. It created difficulties,added complications, and caused delay at a time of greattrouble. If there must be some form of judicial inter-vention the Scottish procedure at least preserved theintegrity of the medical ideal, respected the sanctityof the home, and introduced the judicial element in apurely legal capacity. The sheriff who examined thecertificates was an experienced barrister and a salariedjudge ; he made no quasi-medical examination of thepatient, and if the forms were in order and the factssatisfied him he invariably signed the order. All theseduties were just as carefully performed by the GeneralBoard of Control, and there was no reason why thecertificate should not be signed by that body insteadof by the sheriff.

Dr. Robertson then drew a vivid picture of theprocess of treating a mental patient under theproposed scheme when the justice had to see thepatient in his own home, confer with relatives anddoctors, and exercise a " directed discretion." Sixmonths later the justice must see him again, and atthis time the patient could employ a solicitor ; witha manic patient lively scenes might well occur. Themore nearly judicial intervention was judicial incharacter, the more closely would this picture accordwith actual events. The perfunctory way in whichthe justice often performed his duties in the pastmight have been a saving grace. It was clear thatadequate protection existed and was afforded by othermeans. To Scotsmen this form of amateur medicineseemed a monstrous and intolerable invasion of thesphere of the physician, and nothing less than a

caricature and a mockery of medical science andpractice. Medical men in England had acquiesced init in the hope that it would relieve them of someresponsibility ; that hope had not been fulfilled.

In conclusion Dr. Robertson said that the provi- Isional treatment order formed the most strikingdeparture from precedent of all the recommendationsin the Report of the Royal Commission. It conferredits privilege not only on voluntary patients, but alsoon volitional but resistant ones. For the enjoymentof its full benefits, however, there should be certainmodifications. Two doctors should be called in, withthe right of appeal to two independent doctors. Thiswould make it unnecessary for the judicial authority tovisit and see the patient, a requisite which perpetuatedthose legal formalities that had in the past delayedtreatment, blighted attempts at prevention, anddifferentiated mental disorders from other illnesses.The justice should be replaced by the Board of Control,a strong medico-legal body accustomed to visitpatients and familiar with the requirements of thelaw. The conditions of the order should be altered,from prognosis to the terms of Schedule G.

Disc’l.lssion. IDr. E. MAPOTHER said he had been profoundly

disappointed with the Report, which was chieflydevoted to the doubtful prevention of non-existentabuses. The public were much more concerned withthe questions of where and how than with the preciseprocedure under which they were to be treated.Voluntary treatment in county mental hospitals, forinstance, would make a lot of difference. The Reportlacked constructive imagination. The distinctionbetween voluntary cases and involuntary was, paceProf. Robertson, not clear-cut, and this ignoring ofthe voluntary patient was the Report’s chief defect.Many of the most recoverable cases were voluntary,and those ought to have the best treatment withoutthe intervention of justices. Again, under the Report,the voluntary patient who passed into a state of

unwillingness would have to be certified within a

month (the Provisional Order was nothing but acertificate, except that the patient saw a magistratemore often). Some other method was necessary for-these patients, by which they could be treatedtemporarily outside an asylum. Another graveobjection was that the doctor might have to wait sevendays to have his patient seen by a magistrate, andthat would drive most mental consultants to theuse of the emergency order. He was in favour ofhaving a special certifying medical man to givecertificates under the Provisional Order. Finally hepointed out that, when the Provisional Order ter-minated and a reception order was in preparation,a justice, assisted by his clerk, examined the doctorand the patient. The patient might choose anyone he-liked to attend on him, and the justice could call uponthe doctor to " justify " his certificate. This kind oftrial, at which the patient could be represented bycounsel and the medical man could not, was mostobjectionable.

Dr. T. B. HYSLOP reminded the meeting that thefirst duty of a practitioner was to his patient, the nextto the community, and the last to himself. The fear ofcertification and the stigma which it attached to thefamily of the patient were, he said, often moreformidable than the disease and capable themselves ofcontributing to the development of mental disorder.He desired a sporting chance of relieving patients oftheir difficulties without imposing this stigma uponthem, and for this reason he welcomed the Report,which would remove many of the evils of certification.He favoured the elimination of the judicial authority.the selection of magistrates with knowledge of thesubject, and the provision by local authorities ofspecialists to advise the general practitioner.

Dr. W. F. MBNZiES stated that medical men hadeveryone on their side in this matter-practitioners,patients, relatives, and friends ; against them wereonly the lawyers and the cranks. Lawyers, however,were necessary to the community. He sympathisedwith the medical man who, under the ProvisionalOrder, had to have three interviews with a justice andhis clerk, and perhaps to forego a whole day’s work andtravel a long distance to settle whether his patientwas to be immured or not. The profession had todecide firmly whether to oppose the Royal Commis-sion’s Report altogether, or to take the good points ofit and concentrate on amendment, keeping in theforefront the needs of the non-volitional case. He wasagainst opposing the Report, but held that theattendance of justices at the patient’s home wasabsolutely impossible in any but the largest centres.It usually took a justice three weeks to see a patient atpresent, and with 100 voluntary patients out of 200 ina hospital the scheme would break down. Three-quarters of the non-volition patients would have to bedischarged because no justice would ever see them.He suggested that the visiting committees and boardsof management of county mental hospitals should bemade justices ad hoc.

I Dr. RISIEN RUSSELL said he would be content if

only England had the privileges of Scotland. He

wanted to be allowed to treat patients effectively forat least a year without legal intervention. The issues.were : should the profession have the whole say inthe matter of certification ? and should a doctor beimmune from civil action for wrongful certification ? z’Treatment was a medical matter, but depriving a personof civil rights was a legal one. The profession couldonly claim protection if they accepted legal interven-tion and were prepared to give evidence on oath.The examination of the patient by a legal authorityneed carry with it no publicity, and it would be anadvantage if the justice had no medical training, forhe would view the matter from a standpoint differentfrom the medical one. He welcomed the ProvisionalOrder ; the emergency order had been so much abusedin England that there was every justification for theinterposition of a magistrate. It was reasonableto have a specialist also signing the certificate,and to accept every safeguard of the patient’sinterests.

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Dr. DONALD Ross (Cassel Hospital) quoted theremark of a medical superintendent at Zurich thatthe borderline between the sane and the insane wascertification alone, and advocated that one of the

signatories should be a member of a hospital staff.Earl RussELL said that the Royal Commission had

been much impressed by Dr. Robertson’s evidence andthe system he was able to administer. They did notundervalue the medical point of view, but when dealingwith legislation it was no use discussing a matter fromthat aspect. The public feeling must not be over-looked, and an anti-medical view had been presentedto the Commission. For some reason or other therewas in England, among the great mass of the popula-tion, a suspicion of doctors, and no legislation that Iignored that could hope to get through Parliament.The House of Commons represented the stupidity aswell as the intelligence of the people. Those opposedto the medical view were not, as Dr. Menzies hadsuggested, only lawyers and cranks. A vast body ofuninformed and uneducated public opinion regardedthe doctors as only too ready to certify and withoutreason. No doubt we should get on as well withoutthe judicial authority ; indeed, the Board of Controlwas the real safeguard. It was entirely undesirablefor the justice to have medical knowledge it was notfor him to form an opinion, from a very imperfectmedical diagnosis of his own, whether the patient weresane or not. His duty was to see that care had beentaken and that the papers were in order. There werethe gravest objections to anything like a public orprivate trial; the less the proceedings took the formof a forensic contest the better. To treat voluntarypatients involuntarily would destroy the wholeadvantage of the voluntary system. The urgency orderwas often used unnecessarily and it was important thatit should not be abused.

Sir DAviD DRUMMOND (Newcastle-on-Tyne) ex-

pressed agreement with Earl Russell and pleasure atthe good reception the Association had accorded tothe Report. He regretted that it had not beenpossible to protect the practitioner more thoroughly.

Sir FREDERICK WiLMS (Chairman, Board of Control)said that the Minister of Health was very anxious topass a new Lunacy Law, but the Ministry was notParliament. Parliament was governed by publicopinion, which was still " frightfully superstitious."Something more than formalities prevented peoplegetting mental treatment; they hated to admit thatthere was anything mentally wrong with them becauseinsanity was still regarded as such a dreadful thing.Patients would be better divided into three groups-voluntary, involuntary, and unwilling. It was not aninfringement of a patient’s liberty to give him treat-ment. It was a pity that the Commission’s Reportstopped short at the statement about treatment foracute recoverable cases ; it should have gone furtherand stated what the Commissioners thought right.It was not for them to consider public opinion. TheBoard of Control believed that adequate safeguards.could be obtained without the intervention of thejustice, and suggested that the " Provisional Order "patients should only be admitted to institutions whichthe Board had previously approved. The Board hadbeen much distressed by certain recent legal cases.It appeared that a jury was an absolutely unsuitabletribunal for this purpose. It was quite absurd for sucha body to say they were satisfied that an individualhad been sane 12 years before. There was no groundfor insisting on two certificates other than the grati-fication of public sentiment, and a financial pointwas involved. It was extremely important thateveryone should do what they could to break downthe superstition surrounding mental illness.

Sir ARTHUR RoszJ (Scottish Board of Control) saidthat the Report was a very valuable strategical con-tribution, and had secured unanimity by going onlyjust as far as would be accepted. A minority reportwould have been most harmful to legislation.

Dr. C. 0. HAWTHORNE (London) said that the publicattitude towards certification must be most carefullyconsidered. The Board of Control was not to blame ; ’

it came on the scene too late. The stigma remainedeven if certification were found to have been wrong afew hours later. Enormous importance was attachedto the liberty of the subject. But in addition to thesetwo very important factors there was a third which hadimpressed him, and that was the position of the doctorsat this moment. The practical situation was thatmany doctors were not only reluctant but determinednot to sign certificates under the present circum-stances. Deeds of partnership were being drawn upwith the condition that neither member should under-take this work. Here was another sentiment whichmust be respected. Doctors alone were competent tojudge when mental disorder existed and how it shouldbe dealt with. Another sound position was that theState came in and said : This is a form of medicaltreatment which invades the liberty of the subject,and such treatment shall not be imposed until we aresatisfied that it is necessary. That being so, it wasfor the State to accept responsibility when it assumedauthority. The doctor might be asked for advice-i.e., for his contribution in the form of evidence, andought to have the same immunity as other witnesses.The choice of action lay between the high academicdoctrine that the public must be educated, and thepractical step of accepting the State’s claim tointervene, but emphatically telling it that it must thenaccept responsibility.

Dr. C. H. BOND (Commissioner, Board of Control)confirmed Sir Frederick Willis’s account of the attitudeof the Board of Control. He related the history of theCommittee of Inquiry into the Lunacy Acts in 1884,when the Earl of Shaftesbury was chairman of theLunacy Commission, and vividly described the distressof the great-hearted Earl, particularly at the suggestionof judicial intervention. Dr. Bond asked whether itwere yet too late to relieve the justice of a task forwhich in most instances he had no taste. If the publicreally knew this piece of history and the completeabsence of cases of wrongful detention, they themselveswould give the pendulum a swing in the other direc-tion. He did not think the law should impose on theBoard of Control the duty of visiting cases in single care ;any visitation should be done by medical members.

Dr. L. V. BRIGGS (Boston, Mass.) described hisexperiences on the Board of Control in Massachusettsunder three different political administrations. Themedical societies there had succeeded in educatingpublic opinion by joint meetings and discussions andby belittling the ideas of heredity in mental diseaseand of the stigma of entering a mental hospital.A review of 28,000 certified cases had shown anhereditary factor in 54 per cent. only. In his Statethere was a system of six months’ parole on releasefrom hospital; during that time the patient could bebrought back to the hospital without legal proceedings.The magistrate had a right to see the patient, butexercised it in less than 10 per cent. of cases. In onlyone instance had damages been awarded against adoctor, and then the judge had intervened, saying thatit was against the evidence and against the law.

DONATIONS AND BEQUESTS.-Mr. Henry PeterHodge, Kettering, left 250 to the Kettering GeneralHospital and 650 to the Kettering District NursingAssociation.-Among other bequests the late Mr. GeorgeEdwin Lowe, J.P., of Sutton Coldfield, Warwickshire,left 22000 each to the Princess Alice Orphanage, New Oscott(a branch of the National Children’s Home and Orphanage),the Birmingham General Hospital, the Queen’s Hospital,Birmingham, and the Devonshire Hospital, Buxton;21000 each to the Home for Incurables, Leamington, theWomen’s Hospital, Birmingham, and the Children’s Hospital,Birmingham.-The late Mrs. Sarah Wood, of Blackheath,left by will 21000 to the Victoria Cottage Hospital, Maryport,to found a bed ; 6100 each to St. John’s Hospital, Black-heath, the Blackheath and Charlton Cottage Hospital, andthe Miller Hospital, Greenwich.-The late Mr. EdmundThomas Child, of the Temple and Wimbledon, S.W., amongother donations, left 21000 each to St. Andrew’s Hospital,Dollis Hill, and the Hospital of St. John and St. Elizabeth,Grove End-road ; 2100 each to North Wimbledon Hospital,the South Wimbledon Hospital, and the Central Home forthe Poor Mentally Defective Children, Worcester.