LUNACY VERSUS LAW AND PHYSIC.
"Audi alteram uartem."
To the Editor of THE LANCET.
SIR,-I beg you will allow me an opportunity to direct the Iattention of the profession to the apathy and apparent care-lessness at present existing in the treatment and care of personsof unsound mind. No steps are taken of a sanative natureuntil some outrageous or even sanguinary act has been com-mitted, and then the patient is sent to an asylum to be con-fined, rather than with the idea of his being placed under aplan of treatment suitable for his case. Obsta principiis is notthe motto adopted in the treatment of mental diseases at thepresent time.One of the causes of this dangerous apathy and delay is, it
appears to me, to be found in those injudicious articles whicha few months ago appeared in several of the daily newspapersand other journals. The authors of these have now an oppor-tunity of seeing the effects of their miscalled " excellentarticles" and " public-spirited letters," written in defence ofthe liberty of the subject, and for the protection of the Eng-lishman’s fireside. It is to these in great measure that so
many distressing suicides are due-that so many uncuredlunatics are removed from asylums to become suddenly excited,and to inflict injury on their friends or relatives. Nor is ituncommon to find that medical men decline signing certificates,although conscious that the patient is a proper case for an
asylum, until they can safely state that the lunatic is dan-gerous ; for they know that practitioners of the highest re-spectability have had charges of serious import made againstthem, and have been obliged to appear in the law courts, forperforming their duty to their mentally-afflicted patient whenthe evidence of his alienation was not such as to be patent toeveryone at first sight.It not unfrequently occurs that almost as soon as a patient
(I here refer to private patients) suffering from insanity is Iplaced under treatment, even although the most favourableperiod for that being successful may have passed, a soli-citor is empowered, by some of the so-called friends of thepatient, to interfere and to demand his liberation, notwith-standing that medical men recommend delay and advise a con-tinuance of treatment. Their advice is unheeded, and theiropinion is treated as that of men whose only motive is to keepthe patient in order to receive the payments, and who haveno desire for the restoration of the lunatic to reason. If theasylum superintendent adheres to his opinion, and is supported
. by those who have a true desire for the patient’s recovery, awrit of habeas corpus can be obtained, or, if the patient hasmeans sufficient, the case may be taken before a jury. Now,although a jury may be composed of respectable and honourablemen in business transactions, they are not competent to decideon the more delicate indications of insanity; and they consideran asylum only as a prison or place of confinement, forgettingthe higher characteristic-that it is for the proper treatmentof a peculiar disease. They are also influenced in some measureby the feeling that it is " too bad " to deprive a fellow-creatureof his freedom. Unless an amusing delusion arrests their at-tention, or some glaring absurdity of conduct presents itself,they decide that the patient may have been insane, but is notso when brought before them. They believe that they arequite as able as "the doctor" to decide; in fact, that anyonecan tell whether a man is mad or not. Thus the evidence ofthe physician, who is best acquainted with the patient’s stateof mind, is set aside as that of an interested party, and he maycongratulate himself if he leave the witness-box without beinginsulted or treated with indignity; whilst the jury return averdict which does more credit to their hearts than to theirsagacity and discrimination.
In illustration of the error of the system, I may here remark,that such a jury might be able, when a man had cough, spatblood, and became emaciated, to decide that he suffered fromconsumption, or, in another case, that violent palpitation,difficulty of respiration, and cedema of extremities, indicatedheart disease; but they are not able to tell of the earlier andmore important indications of phthisis, of the gradual deve-lopment of cardiac valvular disease; nor from the copper-coloured spot of lepra could they diagnose the constitutionalcontamination existing. All these are left to the physician;and the more a man devotes himself to a special branch oj
these diseases, the more is his opinion relied on. Not moreobscure nor less important are the indications of insanity inmany cases, nor less difficult of diagnosis are the symptoms;but those who have the best opportunity of forming an opinionare not relied on; and unless something as evident as haemop-tysis in phthisis, or violent palpitation and dyspncea in heartdisease, is observable, the jury do not detect that the man isinsane, nor do they perceive that a plan of treatment is asnecessary for the partial lunatic as it is for the subject of con-sumption or syphilis. Their knowledge is insufficient to teachthem that retirement in an asylum, or away from business orrelatives, is more necessary for the recovery of the mentallyalienated than change of scene and climate for the subject ofthe former disease. In my opinion, a non-professional jury isnot fitted to decide in cases of insanity, for the members of itjudge only from exaggerated indications, and evidence is notwanting to prove the truth of this observation.To show that the preceding remarks are not uncalled-for, a
few recent cases are adduced: the first, to indicate the dangerto the patient himself, incurred by premature removal from anasylum; the second, to show the danger incurred by objects ofhis suspicion; and the last, to illustrate the wrong that is doneby delay in placing the patient under proper treatment.Some months ago, a gentleman in good position in business
showed evidence of mental alienation. There was no positivedelusion, but his conduct attracted attention, and his habits,previously steady, became dissipated. He soon conceived theidea of becoming member of Parliament for a borough in whichthere was no vacancv. and pnblished circulars, and 1)aradedthe streets accompanied by a large dog and a horse adornedwith blue ribbons. He associated with the worthless and noto-rions, and, having money at command, became their prey. Thepolice at last were compelled to interfere, and his friends wereapplied to that he might be taken care of and sent to an
asylum. When admitted, he showed symptoms of incipientorganic cerebral disease; but his mind was only so muchaffected as to be classed as a case of partial insanity. Throughthe interference of some who called themselves his friends, hewas soon removed from the only place where he was likely toreceive benefit; but having been restrained for a period fromdissipation, he left in a relieved state. Under no supervision,he soon again became the prey of the designing and needy.After a period of excitement and dissipation, during which heunjustly charged his son with embezzlement, the mental agita-tion subsided, and the succeeding depression commenced. Butthis was only a phase of the disease; he had not recovered.He confessed to his family that he was ashamed of his pastconduct, and, under their supervision alone, he remained atlarge, depressed and melancholy. He attempted suicide bypoison and by a razor; but his children, remembering how theyhad previously been accused of desiring to get his business intotheir own hands, were deterred from again sending him to anasylum. An attendant at home had been found to be of littleuse. At last, one morning the family were disturbed by theexplosion of a pistol, and, on reaching his room, found himstretched lifeless on the floor.To whom was this man’s death due? Had the case been
subjected to a jury when the patient was in the asylum, themedical men would have been disbelieved; and yet such a re-sult was not unexpected, nor was it difficult to the practisedeye to diagnose that disease of a serious nature would becomedeveloped.The next case shows the danger to others when a lunatic is
prematurely removed from an asylum through indiscreet inter-ference. In this case, too, I believe a non-professional jurywould have decided that the patient was not a proper case foran asylum when he was first placed under treatment, although,to the unprejudiced mind, there was sufficient evidence toprove the necessity for it. Within a week of his removal, hewas again placed in an asylum, as the following notes show.The case is abridged from the reports of police cases in thedaily papers. It is headed " A Singular Case of Assault."Is it " singular" that a lunatic should assault those he suspectswhen he is not under any control ?The lunatic was charged at the police court "with commit-
ting a violent assault on his brother." A legal gentlemanstated that he "had been drinking very hard of late, andwhile he was inebriated acted like a mad·_nan.’’ "
"The complainant stated that his brother (the defendant)conducted himself in a very extraordinary manner on Thurs-day from morning till night. A man came opposite the shopwith fire-wood, when the defendant took up a large cheese-knife, and said forty-two bundles of wood for a penny werecheap enough, and he would soon cut them up. He then
turned round upon complainant, and said, ’ I will run thisknife through you,’ and brandished it. The defendant satdown a little while, and then got up and struck his wife. He
(the complainant) interfered for the protection of his sister-in-law. The defendant then took up a carving-knife, and bran-dished it; and, after making use of some threats, went out,and returned with a relative. The defendant committed otherstrange freaks, and took up a 7lbs. weight, threatening to dosome mischief. After his relative had left, he took up a pieceof iron and threatened to kill his wife. She screamed aloud,and the complainant remonstrated with his brother, who struckhim on the head. The complainant then related other strangeconduct on the part of his brother."
" The defendant told a very rambling tale about his beingsent to a lunatic asylum for three months, although he was notmad." The defendant’s solicitor said " he knew the defendant,and that all his friends did not think him mad, but he actedlike a madman." After the magistrate had expressed a beliefthat the defendant was mad, the solicitor said, "It can scarcelybe called legal madness; the defendant is excessively fond ofhorses, and he buys them when he don’t want them." " Inspite of the interference of his solicitor, the patient was takencare of by order of the magistrate till the necessary examina-tions by medical men were made, and he was afterwards re-
moved to an asylum.A most instructive case. Excitement of manner, violence of
action, alteration of habits, incoherence of language, and men-tal delusion, do not constitute "legal madness." No madness
but " legal madness" ought, it would appear, to be subjectedto treatment; and so such cases as are amenable to treatmentmust not be subjected to it, because they do not amount tolegal madness. Such is the popular opinion expressed by asolicitor.The case sufficiently illustrates the danger of premature re-
moval from treatment. The explanation of the lunatic’s con-duct, which does not appear in the report, was that, amongstother delusions and suspicions, he suspected that his wife andbrother were on too familiar terms ; hence his violence towardsthem. Is it probable that such a case would recover at home?I believe not ; hence the necessity for an asylum.The third case is that of a solicitor, who committed self-de-
struction by hanging. A surgeon, who gave evidence at the
inquest, stated that "the deceased was in a desponding stateof mind, and witness was not surprised at what had takenplace." The landlady stated that "he did not ring as usualfor his shaving water, and at about half-past two she went intohis room, where she found him standing (as she thought) in themiddle, with a handkerchief over his face and neck. She
thought he must be out of his mind, and went for some of hisrelatives." The surgeon who made the post-mortem examina-tion "had no doubt the brain was affected." And so this poorman, with relatives and a medical man occasionally visitinghim, was permitted to die the suicide’s death, and at the in-quest the admission of the medical attendant, "he was notsurprised at what had taken place," is allowed to pass unno-ticed. The coroner’s jury return a verdict " that the deceasedcommitted self-destruction while in a state of temporary in-sanity," and so the matter ends. No one is to blame ! No oneought to have looked after a man in a "desponding state ofmind," sufficiently marked to enable the surgeon to say 11 bewas not surprised at what had taken place" ! Thus melan-cholies are allowed to be without any supervision, and a manmay be allowed to hang in his chamber for twelve hours with-out being disturbed. Truly this is an enlightened land, butthe enlightenment does not appear to have yet extended tothe care of those who are unable to take care of themselves.Numerous cases under this head might be quoted, of mothers
murdering their offspring, and then attempting or committingsuicide ; of men permitted to drink themselves to death ; ofpersons who exhibited " more than usual evidence of lunacy,"and yet being uncontrolled, and allowed to end their days bya dose of oxalic acid or opium.
Is not this want of care more than blameable ? And whenis it to end ? It is unfortunate that it at present exists. Themedical profession is, it appears to me, not free from blame inthe matter: first, for allowing the lunatic to be considered toomuch as a lawyer’s client, and too little as a patient; second,for not paying sufficient attention to the diseases of the mind;and, third, for not offering more opposition to the feeling ofthe age, which is tending, as much as possible, to removelunatics from the care of the medical man. Or does the pro-fession believe that the present tendency will come to a suicidaltermination, and that reaction in favour of the proper treat-ment of lunacy will occur? If this be the opinion, it is to be
regretted much; for ere the reaction happen, the suicides willbe numerous, and the murders many.Let something be done by the profession to keep the dia-
gnosis and treatment of this most interesting and importantclass of disease in their own hands.
I am, Sir, your obedient servant,April, 1860. M.D.
THE ROYAL COLLEGE OF PHYSICIANS ANDGENERAL PRACTITIONERS.
JOHN E. SMYTH. B.A., L.R.C.P. Edin.
To the Editor of THE LANCET.
SiR,—Perhaps you will allow me, through the medium ofyour columns, to direct the notice of your readers to someobservations of mine, published in THE LANCET dated May 28th,1859, relative to the bye-laws of the London College of Phy.sicians. From those observations it is clear, I think, that themajority of the Fellows, in adopting the recent resolution toopen the Licentiateship to practitioners who might dispensetheir own medicines, have not only acted, as it would seemfrom your remarks, in accordance with an established pre-cedent, but also in conformity with the bye-laws of the Collegeitself. In fact, the London Licentiates, if they chose, couldhave supplied their own patients with medicine, provided theydid not charge for it, just as the Edinburgh Licentiates can do,without any infringement of the rules under which they gainedtheir admission. Those Fellows and Members of the College,therefore, who might have been opposed to this element ofchange in its constitution ought to bear in mind that it is not,after all, an actual innovation, as it certainly is not a breach ofthe bye-laws in their proper and literal acceptation.
I remain. Sir. vour obedient servant.
China-terrace, Lambeth, April, 1860,
PIROGOFF’S OPERATION.[LETTER FROM DR. EBEN WATSON.]
EBEN WATSON. M.D.
To the Editor of THE LANCET.
SIR,-In your number for March 31st, page 320, you makesome remarks on the method of performing Pirogoff’s operation"without disarticulation," and you assert that it was " firstpractised by Prof. Pirrie, of Aberdeen, and dwelt upon by Dr.Eben Watson in his Clinical Remarks." Again, you speak ofthe advantages of this operation "as set forth by ProfessorPirrie, "
Now, I think these statements are not quite correct. I madethe proposal of the modification above alluded to as an originalproposal. I never knew of Prof. Pirrie’s having even performedthe operation in that way until the letter of Dr. Martin ap-peared in your journal. Dr. Martin said he had seen Prof.Pirrie perform it so; but it is quite obvious that Dr. Martinmay have been mistaken, and, even if he had not, his statementdid not detract from my claim of originality. How could Iknow what Prof. Pirrie had done in Aberdeen, where I havenever been in my life? But if Prof. Pirrie has published onthe subject prior to the appearance of my paper in yourcolumns, that alters the matter entirely. He then will be en-titled to the claim of originality, and I shall at once yield it tohim. You say in your remarks that the advantages of thisnew operation have been "set forth by Prof. Pirrie." I un-derstand that to mean that he has done so in some of the
public journals. You, however, make no reference to any ofthem, and I therefore write to ask you still to do so, or to ex-plain why you have written as above quoted.
Your obedient servant.Glasvow, April. 1860.
* * Our remarks on the subject of performing either Syme’sor Pirogoff’s amputation" without disarticulation" were
founded upon Prof. Pirrie’s " Principles and Practice of Sur-gery," published in 1S52. His practice in this respect has beenknown to the profession for many years, and understood toapply to either of the operations in question.-ED. L.
A SURREY INQUEST.To the Editor of THE LÂ.L,CET.
SiR,—On the llth inst., I was called to see the body of aman which had just been taken out of the Wandle, where ithad evidently been for some fourteen days or more. Over the