176

THE LANCET.

LONDON : SATURDAY, FEBRUARY 9, 1867.

THE QUEEN’S SPEECH AND THE PUBLIC HEALTH.

THE Queen’s Speech at the opening of the present session ofParliament will be memorable for the prominence it gives toquestions of public health. While expressing deep thank-fulness to Almighty God for the great decrease which hastaken place in cholera and in the cattle plague, it directs atten-tion to the continued prevalence of the latter in foreign coun-tries, and its occasional reappearance in this, and wisely pointsout that special measures of precaution are still necessary. Alike wise forethought is not urged, by some curious omission,with regard to cholera; but a hope is expressed that the visi-tation "will lead to increased attention to those sanitary mea.sures which experience has shown to be the best preventive."The question of an adequate supply of pure and wholesome

water is referred to as of the highest importance, and the ap- pointment of a Commission notified (see THE LANCET, Jan. 5th,1867) to inquire into the best means of permanently securingsuch a supply for the metropolis and for the principal towns ofthe densely-peopled parts of the kingdom.

It is announced that Bills will be laid before Parliament for

the extension of the Factory Acts, and with particular refer-ence to the better regulation, according to the principles ofthose Acts, of workshops where women and children are

largely employed.The condition of the mercantile marine, with especial refer-

ence to the health of the seamen as well as to their discipline,will receive serious consideration, and measures to increase the

efficiency of the Service will be submitted to Parliament. It

is peculiarly gratifying to find a subject which has so re-

cently been examined in detail by THE LANCET, occupying aprominent place in the projects for the session.

It is equally gratifying to learn that another subject, theimportance of which was first brought to light, and the needfor reformation shown, by THE LANCET Sanitary Commission-to wit, the condition of the sick poor in the metropolis, willalso be brought before Parliament. Measures for improvingthe management of sick and other poor of the metropolis, andfor the redistribution of some of the charges for relief therein,will be introduced in the course of the session.

That so numerous and important questions affecting thepublic health should occupy a prominent position in the Queen’sSpeech is of the highest interest and moment. It gives pro-mise that these questions will engage a larger and more seriousshare of the attention of the Government and the Legislaturethan it has been customary to concede to them. But even the

gratification of this promise cannot override the regret that anepidemic of small-pox, which has risen to the pitch of a

gigantic public scandal, has not sufficiently impressed herMajesty’s advisers with the present need of an amendment ofthe Vaccination laws. The omission of this subject from theQueen’s Speech, while, perhaps, even less pressing matters ofpublic health appear there, is curious, but scarcely inex-

plicable.

THOSE recent trials in which the question of mental sound-ness formed the chief consideration for the decision of the

court or the finding of the jury in some degree illustrate thedifficulty of the very responsible duty which medical men aresometimes called upon to discharge. We have on manyoccasions lamented the differences of opinion which have beenshown to exist amongst experts of the highest professionalexperience, when required to give evidence on an admittedstate of facts. It is scarcely to be wondered at that physicianswho have made the various phases of mental disorder their

specialty should at times widely differ in their estimate of aparticular mental condition, inasmuch as in the majority ofsuch cases the individual’s standard of mental health is want-

ing as a guide. What idiosyncrasy of constitution is in phy-sical suffering, individual disposition is in mental malady;observation and personal experience are in both instances

requisite for the formation of a sound judgment. It there.

fore not unfrequently happens that when medical men arecalled in to give an ex-parte opinion, forming their judgmentsfrom the results of some special examination, and basing theiropinions on personal inspection, and it may be but a verylimited opportunity of studying the special case, they speakaccording to the light that is in them, even though that lightbe no more than enough to make darkness visible. At thesame time it must be borne in mind, that, for the furtherembarrassment of the profession, to comparatively limitedopportunities of forming independent judgments there are

not unusually added the extraordinary complications reo

sulting from not always impartial statements, varying ac-

cording to the particular interests the consultant may be

desirous to uphold. To those who take a superficial viewof the matter it must appear strange that, as in a recentcase, medical men of the most undoubted ability, and alto-gether uninterested in the support of any theory, should deli-berately state their belief in the continuing madness of theinmate of an asylum; while others, scarcely less distinguished,should arrive, if not at an opposite, certainly at a greatlymodified opinion. In such a case, is science or is observation

at fault ? We answer by an affirmation: too much is expectedfrom both. Undoubtedly it is a grave matter to deprive any-one of personal liberty; and in the majority of cases of thosewho are inmates of an asylum their own personal safety, evenmore than that of others, is generally the chief inducement fortheir committal. The question of fitness of a person for the careof an asylum may be thus regarded from a different point ofview; for many who are mad are harmless, and many whoare most dangerous afford little proof of madness. It may be

that medical practitioners, in examining a given case, becomeimpressed with either view, according as it presents itself,and do not sufficiently consider the case as a whole. On

what other hypothesis can we explain the wide and almostirreconcilable differences of opinion which find expression inthe witness-box when the question of insanity is under dis-cussion ? This is perhaps one of the most difficult psycho-logical problems medical men are called upon to solve-

Under what circumstances should an individual be committed

to a lunatic asylum ? The question is more easily asked than.

answered. As a general rule, it may be stated, that com-mittal should follow when the form of malady is of a naturelikely to prove dangerous to the sufferer or others. But the ex-

177MEDICAL EVIDENCE IN CASES OF LUNACY.

ceptions and qualifications to this rule are so numerous thatthey impede the consideration of the abstract question.Mrs. A, the wife of a clerk, may be unsafe out of an asylumbecause of the imperfect supervision capable of being exer-cised over her ; while Mrs. B, similarly affected, the wife of abanker, may be perfectly safe at her own home. The sur-

rounding circumstances, the prudential considerations of eachcase, forming as they do an important part of the curative orprotective treatment of the case, must enter into the estimateof every experienced physician, and, to our mind, may be re-garded as leading to much of the apparent, though, scien-

tifically speaking, unreal, differences of opinion which at publictrials are affirmed to exist. On this point we desire to impressour readers with the necessity of considering every example ofalleged insanity in its entirety, estimating all the circum-

stances, and, as far as possible, assisting their judgment by areview of the antecedent and coexistent facts. Common sense

and science are, in such cases, the best guides one to the other.Scarcely less important than the deprivation of personal

liberty is that interference with the power of personal dis-position or control of property which the law under medicalsanction is occasionally called on to enforce. Memorable

instances are not wanting in which efforts have been made to,place under legal supervision many who claimed the privilegesof our constitution and insisted successfully on their right to,exercise personal freedom. In numerous such instances an

analogy might be instituted between the spendthrift of fortuneand the reprobate in character-one wanting prudence, theother indifferent to moral guidance, but neither mad, thoughboth sadly in need of control. In such cases medical men

have often difficult and most distasteful duties to discharge ;and in all such cases a marked difference of medical opinion is ’!sure to exist. Here again the public is disposed to cavil atMedicine, and to complain that its doctrines are uncertain,and that its tenets are as practically unsafe as they are

scientifically unsettled. Here, however, the public and not theprofession is to blame. Public liberty is never considered bythe public as the aggregate of individual freedom, but as asentiment of which the illustration under discussion is the

rule rather than the exception ; forgetful of the fact that

true safety consists in the public protection from self-inflictedwrong as well as in the vindication of self-acquired rights.All questions affecting personal control over property are

necessarily complicated. There is the prodigality of the im-becile "not strictly insane," and that of the vicious very farfrom wise; the spendthrift by choice, and the weak, reckless ex-travagant, who each fritters away his short hours of life to thedestruction of his property and the disgust of his friends.In such cases medical opinions will also conflict. With whom

should the blame rest ?-with the public, who look to personalruin as the merited result of personal recklessness, or with themembers of our profession, who in such cases refuse to excludethe public voice from an influence in their decision?In questions of mental competency as regards the making of

wills even more complicated considerations arise. An analo-

gous condition to that of "imbecility not strictly insanity" isfound in the mental state which admits of undue influence, as

contradistinguished from that of admitted mental insufficiency.In such cases medical opinion almost invariably conflicts. Thesame arguments in explanation fairly apply. On their inves-

tigation it too frequently occurs that an abstract standard of

mental soundness is formed, and opinions are given in relationto the ideal, rather than the real. Here, likewise, medical menfail to more closely approximate their opinions, because theytoo frequently exclude from their consideration the same prac-tical common-sense views of everyday life which stand themin good service for their ordinary affairs of business, andregard the mind as an abstract problem, rather than as a partof a complex relationship, which acts and is reacted upon bysurrounding circumstances. Some definite proposition is de-duced from almost indefinite relations ; and it is sought tolimit professional opinion to an abstract sentiment, ratherthan let science vindicate her title to public confidence byproving her capability of profiting by the ordinary teachingsof worldly experience. We never read a disputed will casewithout pain, especially where all the facts are submitted toexperts, and they from the same premises arrive at oppositeresults. It is in circumstances of this character that the publicare best entitled to lament the uncertainty of our so-calledinexact science.

Not the least responsible, and by no means the least diffi-cult, is the position in which medical experts are placed whenrequired to assist the law in ascertaining the amount of re-

sponsibility which should or should not attach to a given act.In this, as in the other instances to which we have referred,the widest differences of opinion are occasionally manifested.Here, too, it may be asked-Is science or are its professors toblame ? No doubt it is lamentable to find men of the highestcharacter arguing questions of life and death with almost per-sonal acerbity, while the unhappy object of their observationalternates between the hopes and fears to which their differ-ences give rise. In such a case it may be asked-Where does

the blame rest? This is a grave question. Recent occur-

rences have led us to reflect on these matters with a view of

suggesting some professional and scientific system of inquiryor intercommunication by which, for the future, the recur-

rence of such anomalies might be prevented.

NOT the least exciting of the topics as to which the publicwaited for information from the Speech which was addressedto Parliament by Her Majesty at its reopening on Tuesdaylast, was the intention of the Government with respect tothe greatly needed reform of workhouse infirmaries in

London ; and it is with great satisfaction that we note theformal announcement by Ministers of a forthcoming measurefor " improving the management of the sick and other

poor in the metropolis, and for a redistribution of some ofthe charges for relief therein." The agitation in the publicmind, which has now risen to such a force and dignity thateven the proverbial conservatism of English legislators has feltits power and responds to its demands, was originally the re-sult of those inquiries into the condition of London workhouseinfirmaries which were set on foot by THE LANCET some nine-teen months since. The sensation which stirred the commu-

nity on the publication of the reports of our Commissionershas since enlarged the field of operations, and enlisted manypowerful recruits to the army of reform. But the seed of the

movement was undoubtedly sown in the publication in thisjournal of extensive and accurate information as to the prac-tical details of sick management in our workhouses.

It may not be amiss to explain in a few words the real diff-

178 WORKHOUSE INFIRMARY REFORM.

culties which we had to encounter in an enterprise which now the case, that, so far from that gentleman having been speci-has lost something of its novelty. It was difficult in the first ally inert or deficient either in shrewdness of observation orplace to know how to get at the requisite facts. Nearly all in willingness to promote the efficiency and good managementthe boards of guardians did indeed-with a willingness which, of infirmaries in his district, he was the only official who foras we have always maintained, proved their unconsciousness a long series of years ever broke the monotony of corruptof any serious faults in the working of their establishments- stupidity and inaciion in the management of the Londonadmit our Commissioners freely to the wards of their infirma- parishes by the Poor-law Board. He was, indeed, ignorant ofries. But the true difficulties only commenced when the many facts which he should, and of some, perhaps, which heCommissioners began to examine for themselves, to penetrate might, have known. But though only dimly aware of thebeneath the surface of things, and to sift the statements of magnitude of the evils which defaced the existing system, hethe workhouse masters and matrons by a rigorous cross- had sense and straightforwardness enough to perceive that aexamination of patients and pauper-nurses, and generally by a radical and not a patchwork alteration was needed ; and it isminute personal inquiry which refused to receive anything as certain that from him the late President of the Board, Mr.a fact unless it could be demonstrated to their own senses. VILLIERS, had learned the home-truths which decided him toWe place the greater stress on this, because the public has meet the allegations of our Commissioners by a searchingnow become familiar with workhouse inspections, and seems investigation, rather than to smother public curiosity andto take it as a matter of course that one has only to enter a interest with the customary wet blanket of officialism.workhouse ward, and, being there, to open one’s eyes, in On the occasion of that inquiry certain official questionsorder at once to obtain clear and full information as to the were addressed to the medical officer of each infirmary request-efficiency of its construction and of its management. This ing specific information respecting any deficiencies he mightmay be true to a certain extent at the present moment; but if consider to exist in his sick wards. The answers to that

this be so, it is because official inspectors have been taught paper of questions have now been published by order of thewhere to look for the evils which their inspection ought to House of Lords, and from them the public will learn far morecorrect. One of the first lessons which our Commissioners forcibly than from the reports of Mr. FARNALL and Dr. SMITH,had to learn was this: that no’ true picture of the existing how real was the necessity for those reforms which THEstate of things could be drawn, unless the writer were tho- LANCET first demanded. But by the side of the official ques-roughly informed of many things which never could be learned tioning and parleying which have now been going on for thewithout the guidance of special preparatory knowledge. Their last eight or nine months, a real commencement of reform hasscientific information and their familiarity with ordinary hos- been proceeding which would itself have been deemed hopelesslypital management were great helps to this special knowledge. unattainable some two years since. In an early number weBut we may say now that it was not by the mere advantage shall trace these reforms with some minuteness; meanwhile wewhich medical training gave them that they were enabled to may just enumerate some leading abuses of workhouse in-direct their researches with the success which actually at- firmaries which our Commission attacked and which have

tended them. They made it their business to gather informa- been notably amended. We complained that the buildings intion respecting the affairs of each parish and the constitution which the sick were housed were in nearly all cases inade-of each board of guardians, which supplied them in numerous quate. In more than one instance boards of guardians havecases with the key to much that was otherwise inexplicable. determined to build new infirmaries, and are only withheld forMany exclusive sources of accurate information were freely the moment by the uncertainty as to the forthcoming Govern-and confidentially opened to them by private individuals whose ment scheme. We asserted that the present official standardheart was in the cause of reform, but who were restrained by of cubic space for each patient was entirely insufficient, andweighty considerations from appearing as public prosecutors; that the absence of any official regulations as to floor-spaceand the hints thus given led to many of the most important aggravated the evil. The Government has appointed a com-discoveries which were actually made by our Commissioners, mission composed of some of the first physicians and authoritiesand have now been proved before the eyes of the world. on ventilation in this country, who have investigated the matter,

In this peculiar character of our researches lies, as we have with the result that the ultimatum demanded will be pretty accu- -

said, much of the secret of their success. We began them ratelyfolloived. We protested against the enormity of trustingwith no other intention than to do strict justice to the poor on the nursing of the sick to ignorant, drunken, and decrepit pau-the one hand, and to the guardians on the other. And no pers. Already nearly every workhouse infirmary in London hassooner had it become apparent that we were determined at all been supplied with one or with several additional paid and skilledhazards to discover and to state the naked facts of the case nurses. We insisted on the necessity of proper baths, water-than we were regarded as the proper depository of much in- closets, &c. A very large number of these and other sanitaryformation which would never have been confided to the ears appliances have been provided. We urged the propriety ofof an official from the Poor-law Board, even though he might rendering the wards more cheerful in appearance, and sup-personally desire to know the truth. Here we wish to do an act plying many small articles of ward furniture. In several housesof justice to one gentleman who has been very unjustly treated a large number of such additions and alteratiO??87tave been made.in the inevitable storm of public wrath which the disclosures Above all, we insisted that the medical officers should be betterof the last year and a half have provoked. Mr. FARNALL, paid, and that additional resident medical assistance should bethe late metropolitan workhouse inspector, has been severely supplied where, as was mostly the case, there are large numberscensured for having neglected to expose and remedy’ the evils of patients, many of whom are seriously ill. In several infir-which were brought to light by our Commission. Now we de- maries there has already been either an increase of the surryeon’sliberately assert, from our intimate knowledge of the facts of pay or the appointment of a resident assistant, and there is no

179THE NATURAL SCIENCES TRIPOS AT CAMBRIDGE.

doubt that the measure to be brought forward in the presentsession of Parliament will make these changes universal.These improvements, and the still greater ones which may

be hoped for from the Government scheme, have not been ob-tained without hard fighting, and the co-operation of largenumbers of influential persons under the organisation of theAssociation for the Improvement of Metropolitan WorkhouseInfirmaries, aided most vigorously by the general press. But

we feel a legitimate pride in reflecting that the assistance

which this journal was able to give to the first public effortstowards reform was the foundation of that success with which

that good cause has since been favoured, and which we trustis now approaching rapidly towards completion.

PERHAPS there is no function so difficult as that of the

framer and arbiter of examination-papers. To select from

amongst the thousand phenomena contained in a particularscience those salient ones which test a candidate’s knowledgeis in itself a peculiarly arduous undertaking. It demands not

only a perfect acquaintance with the science itself, but also aknowledge of the methods by which it has been taught in thelecture-room or in the text-book, and of the precise degree ofattainment which may reasonably be expected of an averagelyintelligent student. To set and pronounce upon an examination-paper, in short, requires not only the accurate knowledge ofthe man of science, but the practical skill of the teacher ; andthe ordeal of examination becomes a satisfactory one in the

degree in which these two qualifications are adequately pos-sessed by the examiner.But another difficulty comes in to complicate the examiner’s

function. As the science in question is made a subject of exa-mination from year to year, it becomes more and more difficult

to vary the testing questions, to avoid repeating the sameseries of interrogations, and so to prevent anything like the

cramming process by which many candidates are known to

prepare themselves. "Grinders" and "coaches," we believe,are apt to train their pupils in the examination-papers offormer years, and so to furnish them with a series of parrot-like answers to nearly every question which an examiner canbe expected to put. Such being some of the more obviousdifficulties of the examiner’s task, we have always been dis-posed to take a lenient view of his real or alleged shortcomings,and to ascribe to the exigencies of his position a style of exa-mination which may appear capricious, arbitrary, or even

eccentric.

The Natural Sciences Tripos at Cambridge has been some-what harshly depreciated of late on account of its examination-papers. The questions, say certain censorious critics, are in-judicious, are inadequate to test the candidate’s knowledge,and even betray a little ignorance on the part of the examinerhimself. We apprehend that no series of examination ques-tions that were ever framed would escape a like criticism. It

is a remarkable fact that no two men of science, however com-

petent and accomplished, will hit upon precisely the samemethod of testing a candidate’s knowledge. One will lay stresson a fact or series of facts to which the other will attach no

importance. One will be anxious to ascertain whether or not

the candidate possesses a firm grasp of the principles of thescience; another will be more concerned to test his knowledgeof the details. Placed side by side with other examination-

papers, we do not see that the Cambridge series have anycause to deprecate a comparison. Perhaps now and then alittle too much stress is laid on the history of scientific opinion;and the candidate who is otherwise well informed on the prin-ciples of a science may find himself called upon, unexpectedly,to give some account of the life of a discoverer or inventor,and may thus be placed at a disadvantage. But, with this

exception, we cannot, after a careful perusal of the papers,find any reasonable ground of censuring the examiners in theCambridge Natural Sciences Tripos. On the contrary, wethink that considerable ingenuity has been shown by them inso framing the questions as to preclude their being anticipatedby the tutor or "coach. We could, if necessary, give examplesof this examining skill, and we would ask any candid reader

to take, for example, the questions on anatomy, and comparethem with those set at other Universities. We think that the

result of such a comparison would be to reflect, not blame, butcredit on the Cambridge examiners, and to sustain the cha-racter which that great seat of learning has generally borne forfair and searching examination of its candidates for degrees.Even at best, we repeat, the mode of testing a candidate’s

knowledge by question and answer is an unsatisfactory one ;and, in the case of such complex and comprehensive fields asthose of Medicine and Surgery, examination of any kind hasbeen pronounced by such authorities as Professors CHRISTISONand SYME to be next to valueless. Till some better mode

has been established, however, the prevailing system must bekept up; and while no set of examination-papers can be whollyfree from defect, it will be well if all are equally judicious,equally fair, and equally testing with those of the CambridgeNatural Sciences Tripos.

Medical Annotations."Ne quid nimis."

PRACTICAL EXAMINATIONS IN SURGERY.

THE last surgical examination at the College of Surgeon.was remarkable for the first introduction of an attempt to testthe practical knowledge of the candidates in the applicationof bandages and splints; and the natural result will be thatthe young gentlemen who are about to present themselves forexamination in April and May will take some little trouble toperfect themselves in these manipulations, and to ascertainwith certainty which is an arm- and which a leg-splint, andwhether it is customary to apply the padded side next thelimb or the reverse-points upon which some of them were byno means assured last month. This is a manifest improvementupon the old régime, and its introduction reflects great creditupon the President, Mr. Partridge, under whose auspicesthe new test has been inaugurated. We congratulate theCourt upon thus following, though at a humble distance, thesteps of other corporations; and, perhaps, in time they mayfind it possible to take the candidates to the bedside of hos-pital patients, and to examine them in operative surgery onthe subject.’ The obstacle to the latter proceeding (which, however, it isfound practicable to carry out twice a year in the case of theFellowship examination) is, we understand, the supposed diffi-culty of procuring subjects for the examination, or for stu-

dents to practise operations upon. With the latter questionthe College authorities have really nothing to do ; but, as weshall proceed to show, both suppositions are erroneous. At