and red tape. There is no complaint about illegal detention; in fact persons confined in the clinics are simply regarded in the same light as patients in other hospitals.

All this is creditable in Germany, as it is not many years since that country was apparently hopelessly behind in the way of treatment of the insane. Indeed the study of psychiatry, as pointed out by Brush, is comparatively a new field in medicine. Not only were their views narrow, but their methods crude, harsh and unscientific until a very late period. The English and French were years ahead of them in their knowledge and methods. Now the reverse is the case and in her great awakening Germany has not neglected psychiatry. Only the narrowest provincialism could make us shut our eyes to this truth, and such being the case it is manifestly our duty to be up and doing. It is not a case of being loyal to old ideals, but of creating new and better ones.

Motes and Comment.

RESPONSIBILITY OF PHYSICIANS SIGNING CERTIFICATES OF INSANITY. In the May, 1908, term of the Superior Court of Baltimore City, a suit against two physicians who had signed certificates of insanity in the form required by the laws of Maryland, upon which the person named in the certificate in question, a woman, was committed to, and for a period detained in, an institution for the insane in the State, was tried upon the following issue as stated by the presiding Judge, Hon. Thos. I. Elliott:

The case in a few words is this: That the two defendants here entered into a conspiracy with the husband of the plaintiff in this case, for the purpose of depriving her of her liberty by incarcerating her in an insane asylum; that the two defendants in this case, knowing that she was sane, or knowing such circumstances with regard to her that ought to have told them, as reasonable, prudent and skillful physicians, that she was sane, notwithstanding that knowledge, actually possessed by them, and notwithstanding the responsibility which the law placed upon them to have that knowledge, entered into a conspiracy as between themselves and along with the husband of this plaintiff, and certified to a fact which they either knew was not true, or ought to have known was not true, if they had availed themselves of the opportunities which they had, and had applied to those opportunities the skill which, as physicians, the law implies they had.

Upon the prayer of the attorney for the defendants, Mr. John L. Sanford, of the Baltimore Bar, at the conclusion of the testimony of the plaintiff, the effect of the granting of which would have been to take the case from the jury, Judge Elliott, in continuation of the statement of the case, after reviewing the testimony and declaring that there was nothing in the testimony which would support the allegation of conspiracy, and therefore dismissing that count of the complaint, further said in reference to the allegation of mal-practice and false imprisonment:

Now, the other feature of the case, as I understand it, is this: In a situation where they had reason to believe and every opportunity of discovering whether or not the plaintiff was insane, and in a situation where men who had the knowledge which the law presumes they did have would

have known she was not insane, they issued these certificates to the effect that she was insane and that her insanity was of that character and that degree which justified her detention in some institution. Now, that is the strength of the complaint, and the strength of the testimony must equal it, and must be such as would necessarily lead the jury into believing that these two defendants did what was complained of them.

The plaintiff, in the course of the case, and under what were considered the exigencies of the situation, put one of the defendants upon the stand, and asked that defendant as to the circumstances under which his certificate had been issued. As I have already said, it must be shown that these certificates were issued by the physicians falsely and fraudulently, and issued at a time when the physicians knew the facts that they were stating in them were untrue, and also knew that the effect of those untrue statements was to deprive a woman who was entitled to her liberty of that liberty. This witness, in the course of the examination, gave facts and gave circumstances, no one of which has been contradicted, or, certainly, not all of which have been contradicted, by any testimony to the contrary offered by the plaintiff herself, which facts and circumstances the witness, Dr. Rennolds, said led him to think that the woman was insane, and was in that condition where she ought to be sent to some institution for treatment.

Now, it is not to be forgotten that the act of the physicians could have been performed by them, that both of these certificates could have been signed by these physicians, without this plaintiff ever having been detained in an institution. The certificates were simply steps in the procedure that was taken, not by the physicians, but by the husband of this plaintiff. They were not, therefore, things which necessarily compelled the result. They were not even the steps which were necessary to the detention of this woman, because this woman might have been sent to this institution, and might have been detained in this institution, through other means than the certificates of the two physicians, and there is not anything, as a necessary conclusion, to be drawn from the acts of these physicians to show that they were responsible for such detention. While they might have surmised, and while they doubtless knew it was intendeď that these certificates were to be used by the husband of this woman, there is nothing as a necessary conclusion, in the signing of those certificates which necessarily convinced these two physicians either that the woman was to be sent to an institution or that she was to be detained there for any particular length of time. We must, therefore, come down to the final discussion of this case within extremely narrow limits. And we say this: That unless there is testimony in this case which establishes the false and fraudulent character of these certificates as against these physicians, there cannot be any recovery against them, if this is all of the plaintiff's case, and if this is the conclusion of the plaintiff's case. Nowhere, that the court knows of, is the certificate of a physician presumed to be false until it is proven to be true, and there is not anywhere any presumption that a person incarcerated in an institution

is sane, so that the detention in the institution has to be justified by the proof of insanity before there is testimony on the other hand. The existing condition of affairs, provided it is justified by law, is presumed to be the correct condition of affairs, or the proper condition of affairs, until the contrary is shown.

Now, there is no testimony at all as to the mental condition of this plaintiff at the particular moment of time when she was produced, as she was produced, and as she admits she was produced, before each and both of these physicians. I should hesitate very much to say anything or do anything that would induce any physician to view lightly or treat without consideration, the subject of the issuing of a permit, or the issuing of a certificate, which is intended to deprive a man or a woman of his or her liberty. I know nothing that is more important, or that is dearer to a human being, than his or her liberty. But, on the other hand, I should almost as much hesitate to say to a physician that you must, whenever you are called upon to do a thing, be certain that you can guarantee success before you make the effort, because that, practically, would deprive humanity of the opportunity of enjoying the skill of physicians who would, under those circumstances, refrain from the exercise of their skill unless they could guarantee a cure. We all know that there are many instances when people ought to be put away, and when the opportunities of discovering the fact as to whether or not they ought to be put away are no more abundant than they were in this case, and it would be in a great many instances a very sad condition of affairs if physicians should refuse to give certificates because they were not sure that when they were brought into court for the purpose of giving some justification of those certificates, they would succeed in justifying the giving of them. And, as I said before, there is a certain presumption in favor of the validity and of the correctness of certificates that are given under these circumstances by physicians who are reputable, and who are known, and who have, to say the least, the usual and ordinary skill which attaches to men of their profession and to practitioners who have been as long in the practice of medicine as these defendants have been.

So that there should be something in this case to have established positively, and not simply by a negative inference; there ought to be something in this case to have established positively the fact that at the particular time when these particular certificates were issued, these doctors knew or had some good reason to believe, they were doing a false or fraudulent act.

Now, on the other hand, the testimony of Dr. Rennolds-properly in this case, unless the court was wrong in the ruling it made at that point-the testimony of Dr. Rennolds established a condition of affairs, which, to say the least, whether it justified a commitment or not-and the Court is not going to express any opinion on that subject-certainly went to the extent of negativing any reasonable inference which this jury could draw

from that testimony that the doctor had been negligent in his diagnosis, or having made a diagnosis, had falsely and fraudulently misrepresented it. So that whether it is related to the first count of the declaration as a matter of conspiracy, or whether it is related to the second count of the declaration, and I must confess that when you analyze the two of them and bring them down to their final essence there is not, after all, a great deal of difference between the two counts-but whether you refer it to one count or the other in the declaration, I cannot see that there is any testimony in this case that would justify this jury in saying, under the circumstances which the doctor found in the presence of the plaintiff, with an opportunity of noting her actions and conduct, supported by what he had seen with his own eyes and independent entirely of what he had heard from others, but what he had seen with own eyes some days before, I cannot see any grounds for any reasonable conclusion on the part of this jury that the doctor falsely and fraudulently and deliberately misrepresented this case, or misrepresented the condition of the plaintiff for the purpose and with the object of depriving her of her liberty.

The answer which the court gives, and the answer which it has undertaken to give the reasons for in the remarks I have just been addressing to you, is this: That there is no testimony in this case, legally sufficient, which would justify this jury in finding a verdict for the plaintiff as against these defendants, on the testimony which has already been offered in the case by the plaintiff, which, of course, is now concluded. And, therefore, the action of the court will be to grant the prayer, and instruct the jury that, under the instructions of the court, they must find a verdict in favor of the defendants.

It will be seen that this opinion, while it in no degree tends to lessen the responsibility imposed upon physicians in making certificates of insanity, is practically in line with the leading opinions in mal-practice cases-that a physician is bound to exercise only that ordinary degree of skill and knowledge naturally expected from those who practice medicine, and that it further lays down. the rule, that, having in the examination of the patient concerning whom certificates of insanity are made by them exercised that ordinary knowledge and due care, the certifying physicians are not responsible for any results which follow the use of such certificates, in securing, under the regulations fixed by law, the commitment and detention of the person to whom they relate in an institution for the insane.

Certifying physicians must, therefore, be able to show that they possess the usual and ordinary skill of those engaged in the