NEGLECT OF THE EARLY SYMPTOMS OF INSANITY.

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Correspondence. "

Audi alteram partem."

"BLIND CÆCOSTOMY." To the Editor of THE LANCET. criticism of the operation SIR,-Mr. J. E. Adams’s " of " blind caecostomy in your issue of April 5th will, I am sure, meet with considerable support among the younger surgeons, to whom falls the task of operating upon many of these cases of acute intestinal obstruction in old people. During two years of emergency operating at Guy’s Hospital I developed an increasing aversion to this expedient, and this dislike is shared by my surgical contemporaries. Mr. Adams has pointed out the occasional occurrence of a simultaneous obstruction of the large and small intestines by a growth, a condition which cannot be diagnosed without laparotomy, and in which a blind csecostomy would not only be useless, but would allow the chance of a life-saving operation to slip by. A further disadvantage is that a second operation is always required if the patient survives, and that no data are available for the information of the patient or the guidance of the surgeon. Laparotomy allows us, if the growth be inoperable, to perform at once a permanent colostomy in the correct position, and if it be removable, to drain the intestine at a point which will best relieve the obstruction and facilitate subsequent resection. I do not believe that caecostomy provides really efficient drainage of the colon except in its proximal half. I was deeply impressed by a case of acute obstruction due to a growth at the pelvirectal junction, which died from rupture of the bowel just above the site of obstruction four days after I had established a csecostomy. Where the obstruction is in the ascending or transverse colon caecostomy is in any case the operation of choice, but the caecum is often found distended almost to bursting-point with multiple linear ruptures of the peritoneal coat, and drainage is more easily, rapidly, and safely performed through a median incision into which the caecum can be brought out and packed off, than through a small opening directly over it, which involves the risk of rupture and escape of highly toxic contents into the peritoneum. These cases die after the relief of the obstruction, in many instances, from a low-grade peritonitis due to the presence in the abdomen of infected fluid and blood which has exuded from the distended bowel. Blind caecostomy will not avert this tragedy ; laparotomy, on the other hand, allows gauze to be packed into the pelvis to mop up fluid while drainage is being

outlined by the copyright holder of free insurance, the success of which has been phenomenal as evidenced by all the leading newspapers of to-day." No such statement was made by His Royal Highness. The King’s Fund published on April 13th, 1921, a report which mentioned insurance as a method that should be thoroughly explored. The King’s Fund has since declared itself in favour of the general principle of schemes of mass contributions as suggested by Lord Cave’s Committee, and this principle has already been adopted by various hospitals and by the Hospital Saving Association. But the scheme of the United Kingdom Free Hospital Insurance Fund is not one which the King’s Fund could approve. I am, Sir, yours faithfully,

SOMERLEYTON,

Hon.

Secretary, King Edward’s Hospital Fund for London.

Walbrook, K.C., April 7th, 1924.

THE

PANCREAS AND DIABETIC METABOLISM.

To the Editor of THE LANCET. SIR,-In THE LANCET of April 5th Prof. Horst Oertel has attacked the view that the islands of Langerhans are secretory units for purpose of an internal secretion and produce insulin. He has not brought forward any new work, but has restated the case against this view. He has, however, completely omitted all reference to the work of F. M.Allen (Jour. Exper. Medicine, 1920, xxxi., 593). Allen showed that when one-eighth of the pancreas of a dog was removed it was possible to produce definite changes in the &bgr; cells of the islands of Langerhans if the animal was overfed with either sugar or starch. The a cells of the islands and the cells of the acinous portion were quite unaffected. It would take too long to describe the experiments fully, but the work seems to show conclusively that there is a very close relation between the 13 cells and sugar metabolism. I am, Sir, yours faithfully, GEORGE GRAHAM. Devonshire-place, W., April 5th, 1924.

NEGLECT OF THE EARLY SYMPTOMS OF INSANITY. To the Editor of THE LANCET. SIR,-A Royal Commission to study the administration of the Lunacy Laws being about to be appointed, the present seems an opportune occasion to draw attention to an important aspect of lunacy adminis-

tration. I have notes of 296 cases of suicide by persons sane and insane, and of murders by insane persons, including four cases where the crime was only attempted, reported in the press of England and Wales between Jan. 1st and March 13th, 1924-i.e., surgical procedure. in 73 days, or one-fifth of the year. These figures, I am, Sir, yours faithfully, however, only give a rate of less than 1500 a year. H. H. OGILVIE. W. Wimpole-street, W., April 6th, 1924. Evidently they do not include more than one-third of the total number of suicides that have occurred, as statistics for the year 1921 show that 3759 suicides THE UNITED KINGDOM FREE HOSPITAL were reported in that year, besides 1187 other deaths INSURANCE FUND: by violence as to which open verdicts were recorded, A CORRECTION FROM KING EDWARD’S HOSPITAL many, if not nearly all, of which were due to suicide. Evidently two-thirds of the suicides occurring were FUND FOR LONDON. not reported in the press, or were overlooked by my To the Editor of THE LANCET. press-cutting agency. It is therefore probably justihas come to the knowledge of King fiable to multiply my figures as regards suicides by SIR,-It Edward’s Hospital Fund that a circular addressed three in order to arrive at the real facts. to " Employers of Labour, Tradesmen, and PhilanthroThe 296 cases reported may be classified as follows : pists " has been issued by the" United Kingdom Suicides, 274 ; joint suicides, 3 ; attempted suicide, 1 ; Free Hospital Insurance Fund," 17, Ironmonger-lane, murders and suicides, 5 ; double murder and suicide, 3 ; E.C. The second paragraph of the circular reads : treble murder and suicide, I ; suicides after attempted "In a speech on 13th April, 1921, the Prince of murder, 3 ; murders, 2 ; attempted murders, 2 ; Wales expressed a desire that the King Edward’s attempted murder and attempted suicide, 1 ; murder Hospital Fund should be assisted through some and attempted suicide, 1. In all, 292 suicides and means of insurance, and the present scheme has been 17 murders, besides attempts, occurred in 73 days-

established. I do not believe that a rapid exploration under gas and oxygen carries greater risk to the patient than a blind cæcostomy, and it is undoubtedly a more

776

i.e., at the rate of 1460 suicides and 85 murdersmight be found by imposing the duty of certification

And, as stated above, the number ofE on special medical officials, as it is an act prescribed probably treble that number. by law. This proposal would also probably have the Signs of brain disorder, more or less definite, had additional advantage that the official certifier would been noticed before the crime in no less than 200 cases-presumably be an expert medico-psychologist, as is i.e., in over two-thirds of the cases. Insomnia, greatnot usually the case at present. The official would depression, pains in the head, moroseness, silence, be responsible to his administrative superiors if he "neurasthenia," fits, strange or changed demeanour, did not exercise due care. The drawbacks of the jury system would, however, desire to die, and tiredness of life were among the, commonest symptoms. But only 20 of these cases: remain in criminal trials, in lunacy inquisitions and were reported to have been under medical treatment. in civil actions.-I am, Sir, yours faithfully, JOHN WARNOCK, Forty-three cases were reported to have been noticed Late Director, Lunacy Division, Ministry to be very insane for some time previous to the of the Interior, Cairo. crime, suffering from delusions or hallucinations, or Addison-road, London, W., llarch 21 st, 1924. behaving and talking quite insanely. Twenty-one were stated to have been formerly inmates of asylums. The newspaper notices were usually very short CERTIFICATES OF INSANITY. paragraphs, and little information as to the circumTo the Editor of THE LANCET. stances of the case was furnished. If the officiall reports of the coroners’ inquests were examined I if I misunderstood Dr. Eager, SIR,-I apologise have little doubt but that the existence of symptoms; but his first letter, following that of Dr. Rayner, did of brain disorder could be demonstrated in many seem to suggest that professional etiquette forbade others of these cases. In analysing these statistics; our revealing to certified patients the reasons for the verdict of suicide during temporary insanity has; their confinement. In his letter last week he seems been disregarded as evidence of insanity. Fifty of: even to emphasise this position, for he says, " In the cases of suicide had already shown their suicidal other words, are they [certificates] not of the nature tendencies by previous attempts or threats or by of confidential statements furnished by one doctor expressing a desire to die. to another ? " Dr. Eager refers to Dr. Macnamara’s Many of the causes to which the mental breakdown letter, which pleads for secrecy on therapeutic grounds, Butbut does not indicate what classes of cases would be was attributed are very doubtfully correct. in 69 cases the evidence appeared to show the harmed nor what harm they would suffer through cause fairly definitely as follows : Physical ill-healthbeing Dr. Macnamara shown their certificates. (various diseases), 17 ; excessive pain from cancer, &c., appears to have in mind insanity with gross derange3 ; influenza, 5 ; fracture of skull, 1 ; the result ofment of intellectual functions ; but no one proposed air-raids (shock), 4 ; war (strain, disease, or injury), 9 ; to show these patients their certificates. There is, drink, 1 ; domestic troubles, 8 ; love affairs, includ- as he says, no point in it," but equally there would ing seduction, 3 ; deaths of relatives, 7 ; financial be no harm. The cases that here concern us are the difficulties, 3 ; poverty, 2 ; unemployment, 6. hypomanics and paranoiacs, and I should be interested The fact that the 200 persons mentioned in the to know precisely how Dr. Macnamara thinks these statistics for 73 days as having shown signs of brain diseases would be aggravated by the procedure in disorder before the crime, and perhaps 578 persons question. Emphatic generalities arenot sufficient ; in the same period if we treble the figures of the we want definite and reasoned objections, for it suicides as suggested above, and doubtless five times seems quite probable that an attempt might be made to enact that all patients must be shown their as many in the whole year-i.e., nearly 3000 personsEven from the therapeutic point of were not placed under proper care in time to prevent certificates. their committing murder or suicide, seems to me view it seems to me that the balance of advantage is extraordinary, and to suggest that there must be on the side of non-concealment. I am, Sir, yours faithfully, something seriously wrong with the Lunacy Laws or per

annum.

suicides

was

.

,

"

their administration.l Apparently the early stages of mental disorder, the condition in the majority of these cases, failed to receive adequate treatment. There is a very natural reluctance to proceed at once to the extreme measure of certification. Meanwhile the tragedy occurs, because short of certification no adequate steps can usually be legally taken, the law not allowing detention except after this drastic measure. The proposed Mental Treatment Bill is calculated to amend the present state of affairs. There are reasons, however, for thinking that no great improvement is to be expected until another radical change is made in procedureviz., the withdrawal from the jury of the issue of insanity at all trials, and its reference to expert

medico-psychologists. The recent lunacy

case, Harnett v. Bond and has intensified the already prevalent hesitation of doctors to certify insanity, especially in its earlier stages. Dr. H. Rayner points out in THE LANCET of March 15th that a private practitioner, not being a Government servant, should not be required to take any responsible part in carrying out an act prescribed by law, his duty consisting in advice as to the treatment necessary. He should not be held responsible for whatever action the authorities choose to take upon his opinion. The law, however, may object to accept certificates unless responsibility is cast on their framers. A solution of the question

another,

1 While 22,740 persons were certified and treated in 1922 under the laws, nearly 3000 a year do not receive proper treatment and suffer violent deaths in consequence, besides killing heir neighbours in many cases.

I

Perth, April (ith, 1924.

IAN D. SUTTIE.

PREPARING HANDS AND GLOVES FOR OPERATION. I

1’0 the Editor of THE LANCET. SIR,-In 1906, when the use of rubber gloves in surgery was becoming common in this country, I tried the effect of mechanically cleansing them under running water, the gloves being on the hands. After dipping the fingers into a mixture of pus obtained

from a dental abscess and from an ischio-rectal abscess and thoroughly soiling them, I held them under a rose tap and worked the fingers against each other until all apparent trace of pus had disappeared. I then rubbed the fingers on agar plates. No growth was obtained with either the smooth or the crenated gloves, but after opening an abscess in a fat patient I found growth occurred. I tried this again but could never be sure of getting a sterile surface in a crenated glove covered with fat and pus, although the growths were few and small. Whether the fat dissolved the rubber or merely clung to it and anchored the I have not repeated the bacilli I do not know. experiments with a modern glove, but have frequently relied on them especially for examination and dressing. The first thing we did on moving into our operation theatre at the 43rd General Hospital in Salonika.was to improvise a rose tap and elbow-piece. In handling a large number of heavily infected cases in rapid succession with a small staff and overworked sterilising appliances the risk of trusting to mechanical cleansing