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TWO CASES OF ACUTE HÆMORRHAGIC PANCREATITIS.
276 We are not concerned here to defend or otherwise the rationale of treatment by salvarsanised serum. We merely wish to draw attention to the character of the ventricular, as compared with the lumbar, cerebro-spinal fluid ; they were withdrawn simultaneously except on the first of the three occasions. From the table of results given above it will be seen that the first specimens of ventricular and lumbar fluid were obtained on different dates. The results suggested that the investigation of fluids obtained simultaneously would be of considerable interest. A point of interest in connexion with the Wassermann reaction was that, with the ventricular fluids, the haemolysis tailed off over a considerable number of tubes-there was no free complement in the fluid itself-there being a trace of haemolysis even in the earlier tubes, whereas with the lumbar fluids the point between inhibition and haemolysis was sharply defined. Incidentally, in none of the fluids was any blood present, nor were spirochaetes detected in any of them. ,
FATAL
CASE
OF
By
A. H. D.
given, however, by those present was most suggestive. I was called to see him in the evening. He was in a deep stupor and could not be aroused. He did not recognise me. His extremities were again extremely cold and clammy but the pulse was good, regular in rate and rhythm, and about 100. He was retaining his feeds and the diarrhcea had much improved. In the early hours of the morning of July 17th his respirations became very rapid, and he rapidly went downhill and died.
FOOD
POISONING,
WITH DELAYED NERVOUS SYMPTOMS.
HON. SURGEON AND
and was unable to retain a mixture of bismuth salicylate. The diarrhoea had subsided to a large extent, but he was inclined to get out of bed and his mental state was not as alert as it had been previously. There was a suspicion of a slight delirium. He had also complained of dimness of vision and of transient diplopia and there had been a suspicion of slight ptosis. I now saw him again late on Friday, and suspected from these nervous symptoms that the infection had been by Bacillus botulinus. As, however, the onset of nervous symptoms had been so long delayed it was felt that the use of antitoxin was not likely to be of any value. A marked feature at this stage was the coldness and clamminess of his limbs in marked contrast to his pulse which was full and regular and about 90 in rate. Early on Saturday morning, July 16th, he had what his attendants thought was a convulsion. When seen by his doctor he was stuperose and not convulsed. The description
SMITH, M.C., M.B., CH.B. EDIN., RADIOLOGIST,
LLANELLY GENERAL HOSPITAL.
THE following are notes on a case of poisoning attributable to food. The patient, a commercial traveller, aged 53, was first seen by Dr. Hugh John, of Llangennech, on July 12th, 1927, about noon. He stated he had always enjoyed good health and gave the following history of his illness. On July 10th, while out camping with his wife and daughter and three friends, he had a meal about 8 P.M. and ate heartily of a veal and ham pie. All the other members of the party except his wife ate the pie, but his daughter ate only a very small portion. The daughter did no develop symptoms, but all the others, including the wife who did not eat the pie, developed gastro-enteritis. The food eaten by the party on the Sunday, with the exception of the pie, was prepared by the wife. At 2 A.M. on July llth one of his friends was taken ill with diarrhoea and vomiting ; another had similar symptoms at 8 A.M., and another at 2 P.M. His wife was taken ill on Tuesday ; her symptoms seem to have been mainly those of gastritis and she was up and about on Friday. The daughter ;’, did not develop symptoms. The patient left his home by the 9.10 train on the morning of July llth seemingly quite fit. He arrived at his destination at 10 P.M. and then complained of feeling unwell. His symptoms seem to have been at that time those of malaise, and he went to bed. In the early hours of the next morning he developed severe diarrhoea and vomiting and was seen by Dr. John about noon. At this time he complained of severe diarrhcea and vomiting and of thirst, On physical and gave the history already recorded. The pulse examination nothing untoward was found. was full and regular and the rate was under 100, the temperature was 102 ° F’. The motions were extremely frequent, greyish in colour, and watery in consistence, They contained no blood or slime. Vomiting and retching was very marked, and the vomit consisted of what he had just taken. Dr. John gave him a gr.pil. morph. and advised abstinence from all food, recommending the patient to take sips of water. The symptoms up to this time were those of a severe gastro-enteritis. The next day, July 13th, the gastro-enteritis was still very marked but the temperature had fallen to normal. On that night Dr. John asked me to see the case. At that time the patient complained of abdominal discomfort and of exhaustion and thirst. The vomiting and retching were still very severe and the movements of the bowel almost continuous. The temperature was normal and the pulserate about 90. The pulse was regular in rate and rhythm and surprisingly good for a patient who had had such severe symptoms and persistent dehydration. He was alert mentally and answered questions readily and clearly and at this time there was not the slightest suggestion of any involvement of the nervous system. He was unable to retain anything given by mouth so morphia, gr. , was given hypodermically, and those in charge of him were advised to give him brandy 3ss. in water every two hours and albumin water. By the morning of July 14th he had improved somewhat and by Friday, the 15th, he was able to keep his feeds down for a longer time. He still, however, suffered from retching
The interesting feature in this case is the delayed onset of recognisable nervous symptoms in contrast to a fairly rapid onset of classical symptoms of gastroenteritis. It was only after five days that evidence of involvement of the nervous system appeared. In view of the statement that antitoxin has definite value if injected within a few hours of the ingestion of contaminated food, antitoxin was not given. I now wonder whether antitoxin treatment might not have been advantageous even if given late on in the disease. A further interesting feature in this case was the regular and full pulse contrasting with the clamminess and coldness of the limbs so suggestive of collapse. The illness of his wife, who had not eaten the pie, is
peculiar.
-
TWO CASES OF
ACUTE HÆMORRHAGIC PANCREATITIS. BY J. D.
DHRUV, M.S. BOMBAY, F.R.C.S. ENG.,
SURGEON, JAMSETJI JIJJBHOY HOSPITAL, BOMBAY.
THE
following
cases
have
interesting
features.
CASE I.-A man, aged 45, complained of dull pain in the epigastrium for the previous four days. The severity of the pain had forced him to take to his bed on the last two days, and for three days there had been severe constipation. On examination there was marked tenderness and rigidity in the epigastrium. The tongue was moist and clean; the temperature was 101’F.. and the pulse-rate 120. As influenza was prevalent he was labelled " abdominal influenza." Next day the temperature was 102°, and the pulse-rate 110, but the patient said he was feeling better, though he looked anxious. On the seventh day the pulserate rose to 140 and the temperature to 104°. The pain became more severe and the patient died. At autopsy patches of fat necrosis were found in the omentum and areas of softening and necrosis in the pancreatic tissue. CASE 2.-A stout male, aged 40, for a week had continuous dull aching pain in the hollow of the stomach, not related to taking food, though it was worse between 3 and 5 P.M. It did not interfere with his sleep and for five days he continued to attend to his work. Then he took to his bed, and when I saw him seven days from the onset he was acutely ill and had an anxious look. There was rigidity and tenderness in the region of the stomach. On question he admitted that he had had a similar attack two years before, which had subsided after a week’s treatment in bed. Since then he had suffered off and on from flatulent dyspepsia. A tentative diagnosis of perforated gastric ulcer or acute cholecystitis was made. The patient’s friends refused to allow abdominal exploration, and he was kept under observation. He was placed in Fowler’s position, and the diet was restricted to small sips of water. An enema was given without result. The tongue was clean and moist. On the third day after admission he became worse; the temperature was 102F and the pulse-rate 120. In the evening, however, the bowels were opened spontaneously; he felt better ; the temperature fell to 985° and the pulse1 Price’s Text-book of the Practice of Medicine, p. 375.
277 But during the same night his condition again the morning. After incision of its capsule the pancreas was rate to 98. took a sudden turn for the worse ; the temperature shot up drained through the lesser sac. The gall-bladder was rapidly to 104°, the pulse-rate was 140, and localised tenderness was drained through another incision on the right side. The detected in the right iliac fossa. patient collapsed, however, two hours after the operation On the fourth day, in the morning, he became steadily and died, in spite of intravenous injection of saline and of He developed severe hiccup and vomited four pituitrin. more ill. times, the vomit being dark-coloured fluid, which was found The onset in this case was very insidious ; the to be bile. Consent was now obtained for operation, and a suffered from a subacute type of pancreatitis. patient right paramedian incision about 5 in. long was made. The It is difficult to explain the lull in the symptoms during peritoneal cavity was opened and the omentum presented itself showing some yellowish areas of fat necrosis. A little the afternoon before the day of operation. Probably blood-stained fluid was mopped out. The stomach and the fluid exudate in the lesser sac escaped into the duodenum showed no perforation; a quantity of blood- general peritoneal cavity through the foramen of stained fluid escaped from the lesser sac and the pancreas Winslow and led to toxic absorption, giving rise to showed haemorrhages and presented areas of sclerosis rapid pulse, high temperature, and hiccup. The suggesting existence of a chronic pancreatitis. The appendix. vomiting of pure bile was a very striking phenomenon was adherent to the csecum. The gall-bladder was distended I and some concretions were felt at its neck. After pro- due to regurgitation through the duodenum. tecting the general peritoneal cavity I aspirated a quantity examined the patient specially for cyanosis and for of fluid from the gall-bladder. It was black, like Indian ink, ecchymosis in the loins, which is considered pathoand had the same character as what had been vomited in gnomonic by some surgeons, but they were absent.
I
Medical Societies. ROYAL MEDICO-PSYCHOLOGICAL ASSOCIATION. JOINT MEETING WITH THE SECTION OF MENTAL DISEASES OF THE BRITISH MEDICAL ASSOCIATION.
the probably recoverable patient without certification. The signature of one doctor only was, however, a mistake ; as a safeguard and a second witness or observer only, apart from his value as a second medical opinion, the second doctor must meet with general approval. A niggardly economy where the liberty of the subject was concerned was indefensible, but it was particularly objectionable if the omission of the second doctor were responsible for the repeated visits ’
by laymen.
Another difficulty was the basis of the order, which joint meeting held on Friday, July 22nd, in was made a matter of prognosis, notoriously the most the Edinburgh University New Buildings, Dr. difficult and uncertain problem in psychiatry. It had HAMILTON MARR (Commissioner of Control for to be solved by the general practitioner who had little Scotland) presided and Prof. G. M. ROBERTSON experience and by the justice who had none. Every opened a discussion on the successful doctor. was an optimist, and it might safely be assumed that if this became law every patient, REPORT OF THE LUNACY COMMISSION. The Lunacy Laws of England and Scotland were, he save a chronic or absolutely hopeless case, would get in urgent need of amendment. Great changes the benefit of the doubt and be treated under the said, The terms in social life and in the scientific world had occurred provisional order-an excellent thing. since the passing of the Scottish Act in 1857, but this were better expressed in the Scottish Schedule G, Act had the advantage that it recognised . the which used the words " where the malady is not confirmed " and " with a view to his recovery." The paramount position of the medical profession in the intention could always be honestly remedial, however treatment of mental diseases. Under it no layman the outlook. It would be better to faintly hopeful was called upon to see the patient on certification, and no lay committee was responsible for his removal drop the dubious procedure of prognostication altoTo this feature must be ascribed the gether, and give every patient for whom there was on discharge. success of the Scottish system, which had gained the the least hope the benefit of the provisional order No objection to full confidence of the people. No case of treatment for six months. complete detention certification could be taken after the six months’ test had ever been recorded in the improper courts. The English Act of 1890 was a complete, had failed, or for chronic cases. It was a matter of profound regret that the justice logical, and accurately drafted instrument. Its very had to intervene in the provisional order ; such a from the and administrative of legal points perfection view had been a calamity to the patient. The medical recommendation was astonishing in a report that no case of improper detention and that aspect of the problem had been overshadowed by the recorded haunting fear of improper detention, so that laws breathed medical aspirations and professed theraAT
a
peutic and preventive ideals. It was clear that unmedical legal procedures had in the past been the chief impediment to early treatment. The treatment to be given under this order was only temporary and essentially remedial. There was no need for the justice, particularly if two medical men were involved. Miscarriages of justice had occurred in the law courts, yet no comparable cases could be found in the mental hospitals. In Scotland for 70 years thousands of persons had been placed in mental hospitals without seeing a magistrate, and no case of improper detention had ever been found. This record of the medical profession was beyond all praise, and proved that their honour and vigilance were no mean safeguard. Another safeguard which the Royal Commission did not seem to have appreciated was the Scottish right of appeal to two independent medical men. The sheriff’s reception order was wholly given on the written opinions of the two doctors first called in, and the patient, his friends, the sheriff, or the General Board of Control could call in two other doctors, who formed for the time being the supreme and final court The Provisional Treatment Order. of appeal. Thus in Scotland there was a purely In the provisional order one doctor would make the medical system that afforded complete protection, recommendation, which would last from one to six had stood the test of time, and satisfied public months only. It was intended to ensure treatment for opinion. enacted for the welfare of the insane person had turned to be to his detriment. One gratifying and out immediate result of the Royal Commission had been to allay all anxiety in the minds of reasonable people as to improper detention ; such cases had not been found. Future legislation, therefore, should not be dominated by suspicion and misgivings. The Commission had also found that, since the stigma of certification was keenly felt, it should be a last resort and not a preliminary to treatment. The facilities for treatment without it therefore called for extensive development. The keynote of the past had been detention ; the keynote of the future should be prevention and treatment. The arrangements suggested for voluntary treatment were satisfactory. For the involuntary three procedures were recommended : the Emergency Order, the Provisional Treatment Order, and the Reception Order. The first of these, signed by one doctor and a friend or public official, was not a certificate of insanity and remained in force for seven days only. It appeared quite satisfactory.
F2
FATAL
CASE
OF
By
A. H. D.
given, however, by those present was most suggestive. I was called to see him in the evening. He was in a deep stupor and could not be aroused. He did not recognise me. His extremities were again extremely cold and clammy but the pulse was good, regular in rate and rhythm, and about 100. He was retaining his feeds and the diarrhcea had much improved. In the early hours of the morning of July 17th his respirations became very rapid, and he rapidly went downhill and died.
FOOD
POISONING,
WITH DELAYED NERVOUS SYMPTOMS.
HON. SURGEON AND
and was unable to retain a mixture of bismuth salicylate. The diarrhoea had subsided to a large extent, but he was inclined to get out of bed and his mental state was not as alert as it had been previously. There was a suspicion of a slight delirium. He had also complained of dimness of vision and of transient diplopia and there had been a suspicion of slight ptosis. I now saw him again late on Friday, and suspected from these nervous symptoms that the infection had been by Bacillus botulinus. As, however, the onset of nervous symptoms had been so long delayed it was felt that the use of antitoxin was not likely to be of any value. A marked feature at this stage was the coldness and clamminess of his limbs in marked contrast to his pulse which was full and regular and about 90 in rate. Early on Saturday morning, July 16th, he had what his attendants thought was a convulsion. When seen by his doctor he was stuperose and not convulsed. The description
SMITH, M.C., M.B., CH.B. EDIN., RADIOLOGIST,
LLANELLY GENERAL HOSPITAL.
THE following are notes on a case of poisoning attributable to food. The patient, a commercial traveller, aged 53, was first seen by Dr. Hugh John, of Llangennech, on July 12th, 1927, about noon. He stated he had always enjoyed good health and gave the following history of his illness. On July 10th, while out camping with his wife and daughter and three friends, he had a meal about 8 P.M. and ate heartily of a veal and ham pie. All the other members of the party except his wife ate the pie, but his daughter ate only a very small portion. The daughter did no develop symptoms, but all the others, including the wife who did not eat the pie, developed gastro-enteritis. The food eaten by the party on the Sunday, with the exception of the pie, was prepared by the wife. At 2 A.M. on July llth one of his friends was taken ill with diarrhoea and vomiting ; another had similar symptoms at 8 A.M., and another at 2 P.M. His wife was taken ill on Tuesday ; her symptoms seem to have been mainly those of gastritis and she was up and about on Friday. The daughter ;’, did not develop symptoms. The patient left his home by the 9.10 train on the morning of July llth seemingly quite fit. He arrived at his destination at 10 P.M. and then complained of feeling unwell. His symptoms seem to have been at that time those of malaise, and he went to bed. In the early hours of the next morning he developed severe diarrhoea and vomiting and was seen by Dr. John about noon. At this time he complained of severe diarrhcea and vomiting and of thirst, On physical and gave the history already recorded. The pulse examination nothing untoward was found. was full and regular and the rate was under 100, the temperature was 102 ° F’. The motions were extremely frequent, greyish in colour, and watery in consistence, They contained no blood or slime. Vomiting and retching was very marked, and the vomit consisted of what he had just taken. Dr. John gave him a gr.pil. morph. and advised abstinence from all food, recommending the patient to take sips of water. The symptoms up to this time were those of a severe gastro-enteritis. The next day, July 13th, the gastro-enteritis was still very marked but the temperature had fallen to normal. On that night Dr. John asked me to see the case. At that time the patient complained of abdominal discomfort and of exhaustion and thirst. The vomiting and retching were still very severe and the movements of the bowel almost continuous. The temperature was normal and the pulserate about 90. The pulse was regular in rate and rhythm and surprisingly good for a patient who had had such severe symptoms and persistent dehydration. He was alert mentally and answered questions readily and clearly and at this time there was not the slightest suggestion of any involvement of the nervous system. He was unable to retain anything given by mouth so morphia, gr. , was given hypodermically, and those in charge of him were advised to give him brandy 3ss. in water every two hours and albumin water. By the morning of July 14th he had improved somewhat and by Friday, the 15th, he was able to keep his feeds down for a longer time. He still, however, suffered from retching
The interesting feature in this case is the delayed onset of recognisable nervous symptoms in contrast to a fairly rapid onset of classical symptoms of gastroenteritis. It was only after five days that evidence of involvement of the nervous system appeared. In view of the statement that antitoxin has definite value if injected within a few hours of the ingestion of contaminated food, antitoxin was not given. I now wonder whether antitoxin treatment might not have been advantageous even if given late on in the disease. A further interesting feature in this case was the regular and full pulse contrasting with the clamminess and coldness of the limbs so suggestive of collapse. The illness of his wife, who had not eaten the pie, is
peculiar.
-
TWO CASES OF
ACUTE HÆMORRHAGIC PANCREATITIS. BY J. D.
DHRUV, M.S. BOMBAY, F.R.C.S. ENG.,
SURGEON, JAMSETJI JIJJBHOY HOSPITAL, BOMBAY.
THE
following
cases
have
interesting
features.
CASE I.-A man, aged 45, complained of dull pain in the epigastrium for the previous four days. The severity of the pain had forced him to take to his bed on the last two days, and for three days there had been severe constipation. On examination there was marked tenderness and rigidity in the epigastrium. The tongue was moist and clean; the temperature was 101’F.. and the pulse-rate 120. As influenza was prevalent he was labelled " abdominal influenza." Next day the temperature was 102°, and the pulse-rate 110, but the patient said he was feeling better, though he looked anxious. On the seventh day the pulserate rose to 140 and the temperature to 104°. The pain became more severe and the patient died. At autopsy patches of fat necrosis were found in the omentum and areas of softening and necrosis in the pancreatic tissue. CASE 2.-A stout male, aged 40, for a week had continuous dull aching pain in the hollow of the stomach, not related to taking food, though it was worse between 3 and 5 P.M. It did not interfere with his sleep and for five days he continued to attend to his work. Then he took to his bed, and when I saw him seven days from the onset he was acutely ill and had an anxious look. There was rigidity and tenderness in the region of the stomach. On question he admitted that he had had a similar attack two years before, which had subsided after a week’s treatment in bed. Since then he had suffered off and on from flatulent dyspepsia. A tentative diagnosis of perforated gastric ulcer or acute cholecystitis was made. The patient’s friends refused to allow abdominal exploration, and he was kept under observation. He was placed in Fowler’s position, and the diet was restricted to small sips of water. An enema was given without result. The tongue was clean and moist. On the third day after admission he became worse; the temperature was 102F and the pulse-rate 120. In the evening, however, the bowels were opened spontaneously; he felt better ; the temperature fell to 985° and the pulse1 Price’s Text-book of the Practice of Medicine, p. 375.
277 But during the same night his condition again the morning. After incision of its capsule the pancreas was rate to 98. took a sudden turn for the worse ; the temperature shot up drained through the lesser sac. The gall-bladder was rapidly to 104°, the pulse-rate was 140, and localised tenderness was drained through another incision on the right side. The detected in the right iliac fossa. patient collapsed, however, two hours after the operation On the fourth day, in the morning, he became steadily and died, in spite of intravenous injection of saline and of He developed severe hiccup and vomited four pituitrin. more ill. times, the vomit being dark-coloured fluid, which was found The onset in this case was very insidious ; the to be bile. Consent was now obtained for operation, and a suffered from a subacute type of pancreatitis. patient right paramedian incision about 5 in. long was made. The It is difficult to explain the lull in the symptoms during peritoneal cavity was opened and the omentum presented itself showing some yellowish areas of fat necrosis. A little the afternoon before the day of operation. Probably blood-stained fluid was mopped out. The stomach and the fluid exudate in the lesser sac escaped into the duodenum showed no perforation; a quantity of blood- general peritoneal cavity through the foramen of stained fluid escaped from the lesser sac and the pancreas Winslow and led to toxic absorption, giving rise to showed haemorrhages and presented areas of sclerosis rapid pulse, high temperature, and hiccup. The suggesting existence of a chronic pancreatitis. The appendix. vomiting of pure bile was a very striking phenomenon was adherent to the csecum. The gall-bladder was distended I and some concretions were felt at its neck. After pro- due to regurgitation through the duodenum. tecting the general peritoneal cavity I aspirated a quantity examined the patient specially for cyanosis and for of fluid from the gall-bladder. It was black, like Indian ink, ecchymosis in the loins, which is considered pathoand had the same character as what had been vomited in gnomonic by some surgeons, but they were absent.
I
Medical Societies. ROYAL MEDICO-PSYCHOLOGICAL ASSOCIATION. JOINT MEETING WITH THE SECTION OF MENTAL DISEASES OF THE BRITISH MEDICAL ASSOCIATION.
the probably recoverable patient without certification. The signature of one doctor only was, however, a mistake ; as a safeguard and a second witness or observer only, apart from his value as a second medical opinion, the second doctor must meet with general approval. A niggardly economy where the liberty of the subject was concerned was indefensible, but it was particularly objectionable if the omission of the second doctor were responsible for the repeated visits ’
by laymen.
Another difficulty was the basis of the order, which joint meeting held on Friday, July 22nd, in was made a matter of prognosis, notoriously the most the Edinburgh University New Buildings, Dr. difficult and uncertain problem in psychiatry. It had HAMILTON MARR (Commissioner of Control for to be solved by the general practitioner who had little Scotland) presided and Prof. G. M. ROBERTSON experience and by the justice who had none. Every opened a discussion on the successful doctor. was an optimist, and it might safely be assumed that if this became law every patient, REPORT OF THE LUNACY COMMISSION. The Lunacy Laws of England and Scotland were, he save a chronic or absolutely hopeless case, would get in urgent need of amendment. Great changes the benefit of the doubt and be treated under the said, The terms in social life and in the scientific world had occurred provisional order-an excellent thing. since the passing of the Scottish Act in 1857, but this were better expressed in the Scottish Schedule G, Act had the advantage that it recognised . the which used the words " where the malady is not confirmed " and " with a view to his recovery." The paramount position of the medical profession in the intention could always be honestly remedial, however treatment of mental diseases. Under it no layman the outlook. It would be better to faintly hopeful was called upon to see the patient on certification, and no lay committee was responsible for his removal drop the dubious procedure of prognostication altoTo this feature must be ascribed the gether, and give every patient for whom there was on discharge. success of the Scottish system, which had gained the the least hope the benefit of the provisional order No objection to full confidence of the people. No case of treatment for six months. complete detention certification could be taken after the six months’ test had ever been recorded in the improper courts. The English Act of 1890 was a complete, had failed, or for chronic cases. It was a matter of profound regret that the justice logical, and accurately drafted instrument. Its very had to intervene in the provisional order ; such a from the and administrative of legal points perfection view had been a calamity to the patient. The medical recommendation was astonishing in a report that no case of improper detention and that aspect of the problem had been overshadowed by the recorded haunting fear of improper detention, so that laws breathed medical aspirations and professed theraAT
a
peutic and preventive ideals. It was clear that unmedical legal procedures had in the past been the chief impediment to early treatment. The treatment to be given under this order was only temporary and essentially remedial. There was no need for the justice, particularly if two medical men were involved. Miscarriages of justice had occurred in the law courts, yet no comparable cases could be found in the mental hospitals. In Scotland for 70 years thousands of persons had been placed in mental hospitals without seeing a magistrate, and no case of improper detention had ever been found. This record of the medical profession was beyond all praise, and proved that their honour and vigilance were no mean safeguard. Another safeguard which the Royal Commission did not seem to have appreciated was the Scottish right of appeal to two independent medical men. The sheriff’s reception order was wholly given on the written opinions of the two doctors first called in, and the patient, his friends, the sheriff, or the General Board of Control could call in two other doctors, who formed for the time being the supreme and final court The Provisional Treatment Order. of appeal. Thus in Scotland there was a purely In the provisional order one doctor would make the medical system that afforded complete protection, recommendation, which would last from one to six had stood the test of time, and satisfied public months only. It was intended to ensure treatment for opinion. enacted for the welfare of the insane person had turned to be to his detriment. One gratifying and out immediate result of the Royal Commission had been to allay all anxiety in the minds of reasonable people as to improper detention ; such cases had not been found. Future legislation, therefore, should not be dominated by suspicion and misgivings. The Commission had also found that, since the stigma of certification was keenly felt, it should be a last resort and not a preliminary to treatment. The facilities for treatment without it therefore called for extensive development. The keynote of the past had been detention ; the keynote of the future should be prevention and treatment. The arrangements suggested for voluntary treatment were satisfactory. For the involuntary three procedures were recommended : the Emergency Order, the Provisional Treatment Order, and the Reception Order. The first of these, signed by one doctor and a friend or public official, was not a certificate of insanity and remained in force for seven days only. It appeared quite satisfactory.
F2