somnambulism. I lately saw in the Edinburgh prison a man named Simon Fraser, whose heredity was highly neurotic, who had been an aggravated sleep-walker all his life, who during his somnambulism had vivid conceptions, hallucinations, and illusions, and who in that condition did all sorts of purposive acts in accordance with those false beliefs. He remembered his somnambulistic impressions in a vague way after he awoke. He was most difficult to awake. He once went up to his neck in the sea in Norway, and did not awake. At last, one night he got up, and while in a state of somnambulism, imagining he saw a white animal in the room, he seized it and dashed it against the wall. This turned out to be his child, whom he thus killed on the spot. He was passionately fond of the child, and had played with it the last thing before it had gone to sleep. The question is-What should be done with such a man to protect himself and others, he being perfectly sane when awake? Neither the lunacy nor the criminal laws at present make any provision for the treatment of such a state and its consequences.

1 Dr. Yellowlees has given a full account of this case and the trial in the Journal of Mental Science, vol xxiv. p. 451.

LECTURE XIX.

THE MEDICO-LEGAL AND MEDICO-SOCIAL DUTIES OF MEDICAL MEN IN RELATION TO MENTAL DISEASES.

THE medical profession has grave medico-legal responsibilities thrown on it by the provisions of many of the forty enactments that stand on the Statute Book relating to the insane. In addition to those statutes, judges, juries, and administrators of the law constantly call in medical men to help them in the solution of questions that they only can solve. There are few things about which the British public is more sensitive than those relating to the liberty of the subject, to civil capacity, and to the control of property. In addition to these responsibilities, there are most delicate duties of a purely medical and medico-social kind thrown on our profession by the exigencies of practice, and the impossibility of finding elsewhere so qualified and wise an adviser as the family doctor. There is no doubt that all those duties should be done with much care, searching inquiry into facts, and a grave consideration of the whole effects of any opinion expressed, or of any act done; and a special knowledge of the subject, experience, sound judgment, and caution, are all qualities requisite in dealing medico-legally with the insane.

The chief medico-legal and medico-social duties of medical men in relation to mental diseases may be thus classified:

1. Taking the responsibility involved in treating cases at home, placing them under the care of attendants, advising that they be restricted as to liberty, and prevented from transacting business. This, in doubtful cases and in the early stages, of the disease, is often a very serious thing to do. The patient does not know he is ill, says in fact he is quite well, resents as an insult and a degradation being put under control, and threatens all who have to do with it with the most dire consequences. The doctor often loses the family practice after a case of insanity, whether the patient recovers or not. The only sound and safe rule for the doctor is to make it clear that he only advises and does not take any legal responsibility whatever for the steps by which a patient is controlled. Let that fall on a relation who has the legal right to take measures for the safety of the patient, and on no account be assumed by the doctor, to whom the law gives no such authority whatever but to grant certificates. If the patient is removed to lodgings to be under treatment, the relatives must do so. It need not be the nearest relative. It is often desirable to

have family councils under those circumstances. Especially when husbands or wives are mentally affected, some of the blood relations of the patient should, if possible, be taken into consultation. But as regards the doctor the rule is clear. Let him advise, but not act. I have even in some rare cases refused to take the responsibility of regular

attendance and treatment, without first getting a letter of protection from legal risk. The attendants in charge are the servants of the relatives, and under their order technically and legally, however much in fact they may be under the doctor's directions.

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In England a patient can be treated at his own home or anywhere else, if not for profit," without certificates of lunacy, as long as his friends desire, and so long as he is not badly treated, which last procedure subjects those responsible for it to very heavy punishment. In Scotland, a patient can be treated, with a view to cure, anywhere out of an asylum for twelve months without formal certificates, if a medical opinion to that effect and intimation is sent to the Commissioners in Lunacy. I do not wish to discourage the early treatment with a view to cure of insane patients in private houses. I only point out the conditions on which only it can legally be done.

2. The most common of all the medico-legal duties thrown on medical men is that of signing the statutory medical certificates for placing patients in asylums, or under care in private houses. This is done for the proper treatment of the patient, and often for his safety as well as for the safety of the public. The form of certificate is fixed by statute, and no other form will do. The form is practically the same in England, Scotland, and Ireland, though the mode of placing a patient in the asylum is different in the three countries. În England and Ireland a private patient can be placed in an asylum on the "order" of a relation or of anyone else after the two medical certificates have been obtained; in Scotland the sheriff must sign the "order," after having seen the certificates. Pauper patients are placed in asylums in England and Ireland on the order of a magistrate, who must see the patient, and on one medical certificate, while in Scotland pauper patients are placed in asylums in the same way as private patients, that is, on two certificates and a sheriff's order.

As to the grounds on which a British subject can be legally deprived of his liberty on account of lunacy, the common law of England only recognized as a sufficient cause danger to the patient or to the public, and a recent decision seems to imply that some judges still hold that to be the law. But by the universal practice of the country, sanctioned by the Commissioners in Lunacy, the recent statutory law is taken as superseding or supplementing the common law; and that, without defining insanity, or prescribing any specific grounds on which a patient may be detained as a lunatic, clearly enacts that "care and treatment" are the chief objects of his detention, and his being dangerous is nowhere made a sine qua non. This being so, the first thing a medical man with an insane patient who needs care and treatment in an asylum, or to be boarded with a private family, has to do, is to make up his own mind in regard to the definite grounds on which the steps are to be taken. Having done so, his next business is to convince the patient's responsible relatives of the necessity for certification. In doing this, it is far better not to press them too strongly at first if they do not see the necessity for it. All that is necessary is to explain that the responsibility rests on them, not on the doctor. It may in some rare cases be necessary, before certifying, to get a letter from a responsible person, protecting the doctor from risk

of a legal action. That is a risk no medical man in signing a certificate of lunacy should subject himself to if he can help it. The lunacy statutes give exemption from actions if the facts are correct, and the certificate bona fide and correctly filled in; and if in spite of this, under the common law, actions can then be brought against medical men for doing a statutory duty in a legal way, they must just protect themselves by a letter of indemnification, or as best they can. In the case of pauper patients, the chief responsibility undoubtedly rests on the medical man, to whom the relieving officers or inspectors of poor must refer the question of asylum treatment, and must act on his opinion.

In solving the question of whether a patient should be certified as a lunatic or not, the first thing, of course, to ask one's self is, "Is the patient insane?" And it is well to be prepared to say what kind of insanity he labors under. To determine this question, one must have evidence of mental disease observed by one's self, but may also use any facts proving it as ascertained from others who have seen the patient. If he is insane, then comes the further question, "Is he a proper person to be detained under care and treatment?" Many persons are insane in a medical and even in a legal sense, yet have so much self-control left, or their mental peculiarities are so slight and harmless, that they are not proper persons to be detained under care and treatment. I would say that the chief things that constitute the statutory fitness are danger to themselves or others; disturbance of the public peace; inability to care for and manage themselves and their affairs; acute mental symptoms of any kind; or amenability to curative treatment which cannot be applied without certification. No doubt all sorts of considerations-social, monetary, and domestic-come in before determining the expediency of certification. One has to ask what are the reasons for his removal from home, where he would naturally be in sickness, and how will it affect him and his affairs generally? Then, of course, it is proper, having determined that he should be certified, to ask what legal risk there is to yourself or to his relations. I know an undoubtedly dangerous lunatic who has kept himself out of an asylum by bribing one member of his family by money gifts to oppose his seclusion under all circumstances, and by threatening anyone of his children who moves in the matter with disinheritance in his will. It may be necessary to see the patient several times before you can make up your mind. When those questions have been answered, and you proceed to certify, (a) fill in the first and purely formal part of the certificate in all cases as if it were an important business and legal document, looking at the directions on the margin. Our profession is not always sufficiently particular about this. Lawyers look on this part as of much importance. Not to designate the patient, and put in his residence at the proper place, is, according to Sir Cresswell Cresswell's judgment, to invalidate the whole document, and the English Commissioners always return it to the writer for correction if this is not done. The reason, no doubt, is that, there being ten thousand Thomas Jones in the country, it is necessary to discriminate clearly which one is the lunatic. In England and Ireland you must have seen the patient within a week of certification, in Scotland on the same day.

(b) Then comes the most important part of all, viz., the "facts indicating insanity observed by myself." Without these facts the certificate is not valid at all. By all means put in first the most evident and outrageous insane delusions the patient labors under in as crisp and clear a way as you can. No evidence of insanity is so satisfactory to lawyers as insane delusions. Next to those in cogency come incoherence of speech, or shouting, or outrageous conduct, or loss of memory and reasoning power. Put into the certificate some of the patient's very words, if possible. Next to those come such "facts" as relate to the patient's appearance, expression of face, and manner. If you have known him before, any changes from his normal condition should be noted. By the way, in putting down delusions it is necessary often to add to a statement of one, the words "which is a delusion." Some things may be quite true, e. g., "He says he has £10,000 a year," and therefore needs this explanation. On the other hand, such delusions as "Says he is God Almighty" do not need anything of the kind. If any suicidal or homicidal expression can be got hold of, put it among the facts, but usually these have to come under the "facts communicated by others." Negative signs, such as absolute taciturnity, insensibility to impressions from without, are good enough "facts." It is better to put no "facts" that do not clearly indicate insanity, if possible, but there are some cases where the evidence must consist of lesser things than those I have mentioned put in a cumulative way, e. g., "His manner is very peculiar. He is slightly incoherent and silly in speech. His memory is impaired somewhat. He has no sane interest in his affairs or in his relations or belongings. His eye is vacant in expression. His whole conversation gives me the impression that he is unfit to manage his affairs," were really all the facts observed by myself that I could put down as the results of one interview with a person of mildly enfeebled mind. It is quite proper to use facts observed at previous interviews, though it is better to use those at the last interview if possible.

I could give instances of most ridiculous "facts" put into lunacy certificates by medical men. "He is incoherent in his appearance. "Eyes restless and wandering, but following the usual occupation of breaking stones." "She says she is in the family way (she had a baby in a few months)." "Reads his Bible, and is anxious about the salvation of his soul," are examples.

Never put in such statements as these " He has no delusions." "His self-control is not lost." Those, in fact, prove sanity, and are not un

common.

(e) The "facts indicating insanity communicated to me by others' that follow, are very important as subsidiary and not essential points of the certificate. Among them you can insert descriptions of previous aggravations of conduct and speech, of attempts or threats of suicide, or danger to others. You must put down the name of your informant.

(d) The signature, residence, and dating must be carefully done. After the whole certificate is completed, I advise every man to run it over carefully. Few men are so accurate that they will not sometimes omit something.