tion and condition of the other horn. That being determined leads us to the question of

Treatment. This I hold should be laparotomy, not only for those cases that are diagnosed as pregnancy in a subsidiary horn, but for those that, in the present position of opinion, are usually called "missed labour." As I have already pointed out, I regard all, or nearly all, the cases of so-called missed labour to have been cases of pregnancy in a subsidiary horn of a bifurcated uterus. Nothing else to my mind can account for all the conditions, but it can. If we consider the fearful mortality of so-called "missed labour," we shall have no difficulty, I think, in reconciling ourselves to this mode of treatment.

Laparotomy with simple removal of the entire unopened sac, as in my case, is suitable for those cases when, after many months or even years, the containing sac has shrunk so far as to make this practicable. But for the more recent cases, it seems to me that to facilitate the delivery the opening of the sac and removal of its contents previously to the permanent ligature of the pedicle may be advisable on technical grounds, that is the employment of either the Porro or Porro-Müller method.

The only other admissible treatment of such a case as mine would be to let it alone. But when we consider the very advanced state of destruction in which the membranes and parts of the fœtus were found, and collate that fact with the disastrous histories of most of the cases of so-called missed labour, the prudent obstetrician will, I feel satisfied, give the weight of his opinion in favour of early operation, so as to avoid the risks of putrescence of the contents of the sac and consequent blood poisoning, or those of ulcerative perforation of the sac, the dangers connected with which are known to be very great. If Litzmann's case had been operated upon sooner, there is every reason to believe that all would have gone well, as the patient, to judge from the record of the sectio, manifestly did not die of the operation, but of the infection of her system before it was attempted. Salin's case did excellently, so apparently has an as yet unrecorded case of Sänger's. Mine could not have done better. In such an operation a mortality of 1 in 4 is certainly not large.

It is to be remembered that as the placenta is included in the tumour to be removed, one of the greatest risks attendant upon operation for extrauterine pregnancy is non-existent when we deal operatively with pregnancy in a subsidiary horn of a bifurcated uterus. Besides, the principle urged here is in accordance with the universal axiom of midwifery, viz., that by all means a patient whose labour comes on at full term must be delivered—as safely as practicable-but she must never be left undelivered.

Before concluding I would beg to express my deep obligations to Dr Caird for the accompanying drawings in illustration of the

paper.

Addendum. Since writing the above, I find I have overlooked the following references in which the same idea as I have endeavoured to bring out in the paper is indicated.

"After Oldham, these prolonged pregnancies with a dead foetus are called missed labour (most probably in these cases there has occurred a confusion with fœtuses retained in extrauterine subsidiary horn pregnancies)." 1

"I entertain little doubt that some cases of presumed missed uterine labour, a part of whose history is the subsequent discharge of fatal bones by the os uteri and vagina, were cases of interstitial gestation, or of gestation in one horn of a two-horned uterus." "

II. THE POSITION OF THE MEDICAL PROFESSION IN REGARD TO CERTIFICATES OF MENTAL UNSOUNDNESS AND CIVIL INCAPACITY.

By T. S. CLOUSTON, M.D., F.R.C.P. Ed.

(Read before the Medico-Chirurgical Society of Edinburgh, 4th March 1885.) FROM the earliest Greek times we have evidence that physicians have been called in to treat mental diseases in all civilized countries, but it is only in comparatively recent years that our profession has, in law and practice, been made the virtual judge as to what constitutes unsoundness of mind and incapacity for civil affairs.

It does not appear that in ancient Rome any formal proceedings were required for placing an insane person under suitable treatment, but for the appointment of tutors and curators for the furiosi and mente capti there were written laws and a formal procedure. Dr Sibbald says, "Careful provision was made for the treatment of the Roman citizen when he became insane." "The Romans looked on this condition as a disease which was to be cured, if at all, by ordinary medical treatment," but, "the evidence upon which a Roman magistrate declared a person to be furious was not the opinion of experts, but such evidence as showed that the fact was admitted by the general voice of those to whom the circumstances of the case were well known." 3 That statement applies as a description of legal practice in appointing a guardian to an insane person and his property for at least 1500 years. The first recorded instance we have of medical knowledge being rendered available in a formal way to enable a court of law to come to a decision in regard to the existence of mental disease was when, in 1589, fourteen persons condemned to death for witch1 Kleinwächter Grundriss der Geburtshülfe, s. 190, Wien, 1877.

? Barnes's Diseases of Women, 2nd edition, p. 368, London, 1878.

3 Dr Sibbald, Morison Lectures on Insanity, Journal of Mental Science, July 1877. 4 Ibid., October 1877.

EDINBURGH MED. JOURN., VOL. XXX.—No. X.

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craft appealed against the judgment to the Parliament of Paris, which named four commissioners-Pierre Pigray, the king's surgeon, and Messieurs Lerois, Renard, and Falaiseau, the king's physicians -to visit and examine these witches, and see whether they had "the mark of the devil upon them." The mode of diagnosis adopted by these gentlemen was this-" The visit was made in presence of two counsellors of the Court. The witches were all stripped naked, and the physicians examined their bodies very diligently, pricking them in all the marks they could find, to see whether they were insensible to pain, which was always considered a certain proof of guilt. They were, however, very sensible of the pricking, and some of them called out very lustily when the pins were driven into them." "We found them," continues Pigray, "to be very poor stupid people, and some of them insane. Our opinion was that they stood more in need of medicine than punishment, and so we reported to the Parliament, which, after mature counsel among all the members, ordered the poor creatures to be sent to their homes without inflicting any punishment upon them." In all respects, except their method of diagnosis, Pigray and his colleagues were to be congratulated. They stood, then, as our profession has almost uniformly done of late years, on common sense and scientific ground, disregarding the stereotyped legal views of the time, which largely reflected the popular opinions and the superstitious theories of the Church. Most of us think that this mode of formally calling to its assistance medical knowledge by the Parliament of Paris was a better method of arriving at the truth than the present British and American method of allowing each side to call in its own skilled evidence as to whether a man is to be adjudicated of unsound mind or not.

In England the first Act of Parliament relating to the insane was that of 17 Edward II. in 1324, and the first in Scotland was of Robert II. in 1371. The object of both of these was to provide that the king should have the custody of the lands of idiots and insane persons during their lives, rendering the same after their death to the right heirs. But there was no provision in those Acts, or in any subsequent lunacy statutes, for medical certificates or medical evidence to prove unsoundness of mind or civil incapacity, till the English Act of 1774 for the regulation of private madhouses (14 Geo. III. c. 49) made a medical certificate, in addition to the order of a relation, requisite for the admission of every private patient to those institutions. Paupers were by that Act to be sent to such places as received them on the authority of the parish officers alone. Thus it is just 110 years ago since the adoption of that system of medical certification of unsoundness of mind, which is now universally prevalent in the three kingdoms. Every statute relating to the placing of the insane in asylums or under private care, passed since that time, makes special provision for either one or two medical certificates in the case of every patient, private or pauper.