THE RELATION OF MENTAL SYMPTOMS TO BODILY DISEASE.

THE RELATION OF MENTAL SYMPTOMS TO BODILY DISEASE.

1796

Hospital Ship

D. S. O.,

late belligerents in South Africa shown themselves since peace has been declared which have call attention of that occurred

Princess of

Wales:Major A. H. Morgan, Captain A. Pearse, R.A.M.C.; Clara Mavesyn Chadwick, Queen

feeling existing between

A.M.S. (retired);

Superintendent Miss Alexandra’s Imperial Military Nursing Service ; Nursing Sister Miss Helen Hogarth, Queen Alexandra’s Imperial Military Nursing Service Reserve ; Staff-Sergeant W. Higgins, R. A. M. C. ; and Lance-Sergeant J. Brown, lt. A. M. C. In a despatch from Lord Kitchener, dated Pretoria, April 8th, 1902, the name of Lieutenant-Colonel J. D. Edge, R. A. M. C., is mentioned.

we

may

to at Standerton.

the

one

a pathetic nature

A Boer officer of the Standerton Commando named Swarts who had died from enteric fever was buried with military honours. The coffin was covered with the Union Jack and carried to the graveside on a guncarriage. Colonel Batson, the commandant, all the officers of the garrison, and all the garrison followed the cortége. General Britz also attended.

recently

DEATHS IN THE SERVICES. SOUTH AFRICA. of Hospitals and Fleets William Henry General Inspector. Peace has come and has been practically sealed and ratified R. N. at Paignton, Devonshire, on June 10th, (retired), Sloggett, by the gathering together and the laying down of arms on the in his He entered the Royal Navy in 1842 year. eighty-second to us in Boer the of the various forces lately opposed part of inspector-general in 1875. The and retired with the rank field. The news of the surrender of some 17,000 of our late which took place on June 13th at Paignton, was funeral, the of conditions and still more promising enemy, perhaps under which this has taken place, has been everywhere very largely attended. The deceased gentleman since his received as glad tidings of great joy. If in the past history retirement had resided at Paignton, where he was highly of the world the saying was ever true that the unexpected esteemed. is that which happens it has been emphatically so in the case THE BOYAT, ARMY MEDICAL CORPS AND THE CORONATION. of the late war. Turn which way we will we are met with Six officers and 200 non-commissioned officers and men of facts at variance with almost all that was confidently the Royal Army Medical Corps with 24 horses will take part expected or predicted as at any rate most probable. in the Coronation procession of June 26th and 27th. It is impossible even for the most thoughtless to avoid It will be seen by a reference to our Parliamentary Intelliall reflection on the events that have occurred within the past three years. To begin with, the British Govern- gence that as there are instances on record of the award of to the masters of transport and hospital ships, the ment did not expect war and the Kruger ultimatum medals Office is considering whether these precedents should War making it inevitable found this country unprepared for war, whereas the Boers were prepared ; and now that be followed, and, if so, to what extent in the case of masters, and crews of transport and hospital ships employed peace has come all that was prognosticated about what officers,the war in South Africa. would be the spirit and conduct of our late enemy has turned during out to be as ill-founded as it could well be. The Boers manifest no signs of that depression and humiliation which are supposed to characterise a defeated army. Looking back, as they may well do with great pride, to the part they have played throughout the campaign they now apparently recognise and accept the inevitable and manfully as well as loyally take "Audi alteram partem." their place among the subjects of King Edward VII. There are no signs of that bitter and inextinguishable hate and racial animosity which were prophesied would be the case ; THE RELATION OF MENTAL SYMPTOMS and the Boer officers and soldiers have been everywhere TO BODILY DISEASE. received with every mark of sympathetic respect, good To the Editors of THE LANCET. feeling, and comradeship by the soldiers of the British army. SIRS,—There is much in Dr. Nathan Raw’s excellent Every Tommy Atkins is now a strong pro-Boer. The war has taught us lessons that were sorely needed, it has been article on "The Relation of Mental Symptoms to Bodily the graveyard of several military reputations, it has revolu- Disease 1 which provokes comment-mostly laudatory, some of our ideas and military systems, it has en- times critical ; but from comment of either kind I could have tionised larged our views and experience of army medical administra- refrained, had he not in his closing paragraphs violently tion, surgery, and medicine, and it has led to a scheme of assaulted one of my most cherished fads. He says of persons reform in our army and naval medical services the full effects suffering from delirium tremens that they are "the most of which have yet to appear. That our army system generally dangerous lunatics for the time and yet they cannot be will be tried and reformed by the results of the experience certified as legally insane." If the Lunacy Act, 1890, were so drawn that the most dangerous lunatics could not be gained in the late war can scarcely be doubted. legally certified as insane, it would be a greater legislative SOUTH AFRICAN CASUALTIES. failure than even the last Workmen’s Compensation Act. We desire to direct the attention of those of our readers But I venture to assert without the slightest hesitation that who have not yet seen it to an interesting article from "An it is not so drawn. The certifier must state that the patient Actuarial Correspondent"in the Times of June 16th on is a lunatic, an idiot, or a person of unsound mind, and a this subject. The article should be referred to and read in proper person to be taken charge of and detained under care extenso by those interested in the casualty statistics of the and treatment. The words of the Act make no reference to late war. Tables are given of the death-rates per 1000 among the cause of the malady or to its probable duration, and officers who have been killed or died from wounds and from whether the insanity is due to excessive drinking or to other disease respectively during the first, second, and third years of cause, whether it is likely to be temporary or permanent, are the war, and for non-commissioned officers and men for the not matters which the certifier need take into consideration same years, also calculated at rates of 1000 per annum, of in order to satisfy the law. They may or may not make a those killed or died from wounds and deaths from disease. great difference as to the wisdom and policy of certifying the From these tables it would appear that, while the men have patient, but to the legality of the certificate, if the symptoms suffered much less in battle than the officers they have been are sufficient to warrant the certificate being made, they more subject to disease. The disease-rates of both officers make no difference whatever. For my own part I should and men are, however, stated to be remarkably low, especially have no hesitation in certifying a patient with delirium when it is remembered that the ordinary rate of mortality of tremens if he were sufficiently insane to be certified, and British troops on foreign service is 15 per 1000 per annum. such patients are admitted into lunatic asylums every week Comparing one period with another the improvement during without the legality of their certifications being questioned. the last eight months in South Africa was, moreover, most In one case in which the legality was questioned, the judge marked, few more officers and men having, it is stated, died explicitly ruled that the causation of the insanity had from disease than would have died if no war had been going nothing to do with the matter-that if a man was insane on. With the exception of the first year’s fighting, when the from drink he was as rightly certifiable as if he were insane losses both from battle and from disease were very heavy, from any other cause. the casualties in the late war compare favourably with Dr. Raw is exercised as to whether it is necessary for a; those of most recent campaigns-the Franco-Prussian and man I I to bear the stigma of having been certified as a lunatic when he was simply suffering from temporary mental aberraAmerican civil wars for example. tion the result of bodily disease. There can be no question BOER AND BRITISH. 1 THE LANCET, June 14th, 1902, p. 1681. Amid the many manifestations of the present mutual good THE LATE WAR

IN

Correspondence.

(

many

OBSERVATIONS ON DIET. - whatever that an asylum of some sort is the best place for ,the patient, but he need not be certified as insane, at any rate until it is seen whether the insanity is likely to be permanent or not." Dr. Raw is not alive to the practical diffl. oulties of dealing with insane persons without certification. The law which would render an insane person liable to be sent to, and detained in, an asylum, deprived of the control of his person and of the management of his property, without certification, would lay the same liability upon a sane person, and without certification every safeguard of the sacred liberty of the subject would be utterly swept away. I am unable to appreciate the distinction drawn by Dr. .-Raw between insanity on the one hand and "temporary mental aberration the result of bodily disease " on the other. It is but rarely that we can be quite sure that mental aberration will be of short duration, and even if we could usually -do so, and even if we could agree upon the precise duration which is to be termed temporary, there remains the fact, or what I believe to be the fact, that, whether " temporary " or permanent, every manifestation of insanity is the result of bodily disease. With Dr. Raw’s conviction that a large number of people are certified as lunatics who are simply suffering from insanity the result of, or associated with, some form of bodily disorder or of poisoning, I should be in com-, plete accordance ; but when he contends that such persons are not really insane, I should join issue with him, for I should contend that the "large number"includes every insane person who is certified as such. In short, I deny altogether the existence of Dr. Raw’s distinction between mental aberration and insanity. All that I recognise is a difference in degree. Every case of mental aberration or insanity is. in my view, the result of, or associated with, some form of bodily disorder or of poisoning ; and I protest with all the vehemence of which I am capable against the view that insanity is a thing apart, a specific entity, having no community of nature with trifling and temporary "aberrations of mind." This view is a lingering remnant . of the belief in the demoniacal possession of the insane aand is the most serious obstacle to the right understanding of insanity. That it should be held by a man of Dr. Raw’s ability and eminence goes far to excuse the otherwise unpardonable length of this communication.

1797

the argument is, I trust, a sufficient reply to Dr. Ross’s verb. sap. I am, Sirs, yours faithfully, ERIC PRITCHARD. London, June 13th, 1902.

mutandis,

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-To the -Editors of THE LANCET. have had very considerable experience in dieting SIRS,-I the aged during the last 20 years. My experience gained is quite the opposite from Dr. F. W. Forbes Ross’s views, expressed in THE LANCET of June 14th, and is more in accord with those of Dr. Harry Campbell if I read correctly what he intends to convey to the reader by the The aged do not require quantity term "spare diet." but quality in their foodstuffs and a full diet is generally I always preharmful to the majority of aged patients. scribe a diet rich in nutrient substance, easy of digestion and assimilation, but spare in quantity. The organs of aged people are more or less worn out, and this refers more particularly to the digestive organs, so that if you tax them with foods which require much digestion and contain a large quantity of waste material fermentation is sure to set in-the very bugbear of old age-which produces most dangerous and unpleasant symptoms. How many aged gentlemen who dine well but not wisely at their clubs have gone home and died suddenly after a full meal and how many suffer from most painful gouty affections from living on a full diet. Of course, there are manyexceptions. My old friend Dr. Pickett’s father, who died at the age of 95 years, always used to eat a hearty meal of bread, cheese, and ale before going to bed. My great-grandmother, who lived to 93 years of age, had three full meals a day. We are generally called to diet the feeble and weak, who, I am afraid, form the majority, not the minority, of the aged. The less chance of auto-toxin there is by there being little waste material in the diet the greater will be the success of

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Sirs

Catford, S.E., June 16th, 1902.

yours

faithfully

CHARLES MERCIER.

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THOMAS DUTTON.

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Manchester-square, W., June 14th, 1902.

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SORE-THROAT AS A PREMONITORY SYMPTOM OF ACUTE RHEUMATISM. To the Editors of THE LANCET.

SIRS,—The association of sore-throat with rheumatism is well known to the profession, but I desire to draw attention OBSERVATIONS ON DIET. to a certain condition of the throat which in not a few cases ’ signals the onset of the graver malady. To the Editors of THE LANCET. I have had under my care two cases which serve SIRS,—Probably Dr. Harry Campbell’s shoulders are the purpose of illustrating my meaning. 1. I was called sufficiently broad to withstand the onslaught which Dr. to attend a married man, aged 34 years, who comF. W. Forbes Ross has thought proper to direct against plained of sore-throat and a marked feeling of general him in THE LANCET of June 14th, 1902, p. 1724, on the illness. On examination I found the throat red and resubject of his "highly theoretic and erudite contribu- laxed but altogether clear of any ulceration or deposittion " with reference to the feeding of old people. Never- what might be quite properly and fully described theless, as one whose practical experience bears out and as a catarrhal throat, no swelling of glands or pain about confirms Dr. Campbell’s views I may be permitted to enter the neck and only little difficulty in swallowing ; temperathe lists and shiver a lance in the cause of ’’ physiological ture slightly raised, barely 100° F. ; a deposit of lithates feeding for the aged "-an expression which, I gather from in the urine which was otherwise normal, but no pain or So far the Dr. Ross’s letter, is the same thing as the metabolism of discomfort whatever about the body or limbs. case appeared simple enough with this exception-the man starvation. I find myself in complete accord with Dr. Ross’s seemed to be ill out of all proportion to anything I could observation that "it is quite time we as a profession discover. The usual treatment was adopted and at the began to revise our practice and preconceived notions in end of five days the patient was to all intents and pur- certain directions where diet is concerned,"as also with poses restored to his usual health and extremely anxious to his clinical experiences, but I take exception to the deduc- return to. work. I advised him strongly to the contrary ; tions and generalisations which he draws from the latter. in fact, to remain at home another week as I was not It is in the highest degree improbable that a man living on certain of his complete recovery. However, he persisted and "the fat of the land" or even on a "generous, good, full went, with the result that in four days’ time he was back diet," (vide Dr. Ross’s dietetic canons), with lung, kidney, in bed with a sharp attack of rheumatic fever. 2. This .and heart perhaps as the sequelæ of this mass stimulation, case was very much on all fours with the one described, would derive any immediate benefit from an ill-considered except that the patient’s throat was slightly worse, and restriction of diet ; indeed, deprived of the mass stimuli to that at the end of 10 days he complained of a fixed pain which his metabolism (pace Dr. Ross) has been educated and in one heel which was undoubtedly rheumatic. He decided accustomed I should expect the rapid dissolution which Dr. to follow the course I suggested, however, and remained at Ross so pathetically deplores. But what is this, after all, home, making a good recovery and resuming work at the - other than the phenomena which appear in the alcoholic or end of three weeks well and strong and none the worse for morphomaniac when his particular variety of poison stimulus his attack. is reduced to a physiological and pharmacopoeial dose ?? I These two cases which I have described and some few imagine it would not be seriously contended that a full, others of a like nature which have come under my notice generous -exhibition of either alcohol or morphia would be show at least the possibility of rheumatic fever supervening, prorluctive of longevity because when deprived of them the condition of the throat being its initial manifestation. suddenly their victimssink rapidly to dissolution." Mutatis The fact that there is no pain or swelling of joints at the