cases and at that stage that curative treatment is most valuable and is likely to be productive of the best results, which certainly would not be obtained by premature certification.

The existing lunacy code bristles with precautions against improper detention. No safeguards that can be devised can be absolute, but the postponement of certification of incipient cases until they have been observed and treated for at least months by experts in mental disease would be a step in the right direction, and would probably provide not only an additional safeguard which would satisfy public opinion, but would give the patient at any rate a chance of ultimate recovery. At present, when a case must in general be either certified or not certified and can only be received in a public mental hospital for treatment if certified, both doctors and judicial authority may in doubtful cases be influenced to take the course which they think may be attended with least risk to the patient and the public. The truth is that insanity is not always a definitely ascertainable state. This recalls to my mind a concrete instance. A soldier in India was sent to hospital as being insane. The regulations prescribed that all such were to be sent home to England. The form which accompanied him there was headed in red ink Insane' and below was appended the medical officer's certificate, which read as follows: 'I hereby certify Private to be of sound mind.'

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Under the present Lunacy Laws there is always the risk of the person who is not insane being nevertheless subjected to detention as insane. Against this risk in any new legislation legal safeguards plainly must be provided, however undesirable in principle may be the intervention of the law in cases of illness, whether mental or physical. Insanity has long been associated with imprisonment, so much so that under the present system it may almost be said, ' once a lunatic always a lunatic.' The end to be aimed at should be: (1) that no mental patient's liberty is infringed longer or to a greater extent that his symptoms necessitate in his own or the public interest; (2) that advantage is not taken of his disabilities to neglect or ill-treat him; and (3) that he receives proper treatment for his ailment.

The present legal status of the great bulk of the

insane persons in this country is that of paupers. This, in a great measure, is due to the very high cost of maintenance in Mental Nursing Homes. Many persons are compelled to accept the status of paupers because they cannot afford to adopt any other course. They have become in law paupers because they have been overtaken by this particular form of illness, although they may never before have been in contact with the poor law. There runs, however, through the whole existing lunacy code a distinction in procedure between the pauper and the private case, the justification for which has largely disappeared under modern social conditions. The problem of insanity is essentially a public health problem to be dealt with on modern public health lines. So only will the atmosphere of suspicion and aversion with which the subject is viewed be overcome. No doubt that atmosphere is partly due to the instinctive abhorrence of the normal mind for everything connected with insanity, but it is apt to be fostered by the present system itself. Patients and their relatives alike feel aversion from the idea of resort to an asylum, with all its existing associations. Consequently, resort to these institutions is put off to the last possible moment, when the chances of cure or alleviation have been greatly diminished. It is probably not possible to eradicate this feeling entirely from the public mind by any modifications of the present system, but much might be done to mitigate it by associating lunacy administration as far as possible with general public health administration. Nothing lingers so long in the human mind as prejudice. Statistics show that a substantial number of cases, often very acute, recover completely within a short time. This is proof positive that a considerable number of persons are certified who might avoid certification if it were preceded by a period of observation and treatment coupled if necessary with temporary or provisional powers of detention. The number of cases who would avoid certification altogether would undoubtedly be increased if greater facilities existed for persons who are willing to submit themselves to treatment, and if access to treatment were not preceded by the necessity of taking the irrevocable step of certification.

Persons may be certified as lunatics in various ways. Vol. 250.-No. 495.

E

They may be found to be so by a judicial inquisition made by a petition to the Judge in Lunacy, but as this procedure has in the course of the last ten years fallen into almost complete disuse, it is unnecessary to enter into the intricacies of its law and practice. The ordinary course is a petition for a reception order presented, if possible, by the husband or wife or a relative of the alleged lunatic. The petitioner must be at least twentyone years of age and must have seen the alleged lunatic within fourteen days of the presentation of the petition. He must give an undertaking that either personally, or by some one specially appointed by him, he will visit the patient at least once in every six months. The petition must be accompanied by a statement of particulars and by two medical certificates in the form prescribed by the Second Schedule of the Act, which requires inter alia that the examination by the two medical men shall be made separately and that the certificate shall be given on separate sheets of paper. The certificate is to the effect that the patient is a lunatic or person of unsound mind and a proper person to be taken charge of and detained under care and treatment.' The grounds for this conclusion must be specified under: (a) facts observed by the medical practitioner at the time of the examination, which may be amplified if the same other facts were observed previously; and (b) facts communicated by others.

A certificate founded only on facts communicated by others will not justify a reception order. The Act also prescribes that one of the certificates shall wherever possible be given by the usual medical attendant of the patient, and if this is not practicable the reason therefor must be stated in the petition. Interested persons are debarred from signing certificates. The petition must be presented to a County Court Judge, a Stipendiary or Metropolitan Police Magistrate, or a Justice of the Peace specially appointed under the Act, which provides that the Justices of every county and quarter sessions borough shall annually appoint out of their number as many fit and proper persons as they may deem necessary to exercise the powers conferred by the Act upon the judicial authority. On the presentation of the petition the judicial authority is required to consider

the allegations in the petition, and the statement of particulars and the evidence of lunacy in the certificates. The consideration of the petition is in private, and no one may be present without the leave of the magistrate except the petitioner, the alleged lunatic (unless the magistrate otherwise orders), the certifying doctors, and any other person appointed by the alleged lunatic to represent him. It is within the discretion of the magistrate to see or not to see the patient, but he must state in his order whether or not he has seen him. If a patient is detained on an order by a magistrate who has not seen him the patient is entitled after admission to the institution or single care to be taken before or visited by some other judicial authority, unless the medical officer of the institution or the medical attendant of the patient in single care certifies that such a proceeding would be prejudicial to the patient. Failing such a certificate, the medical officer of the institution or the person in charge must give the patient within twentyfour hours of his admission notice of his right to see a judicial authority. If the right is exercised the report of the judicial authority is forwarded to the Board of Control to take such steps as may be necessary to give effect to it. If the judicial authority dismisses the petition he is required to give to the petitioner a statement in writing of his reasons, and to send a copy to the Board of Control. If, on the other hand, he decides to make an order this will be in the form prescribed by the Act, and will be addressed to the superintendent of the institution or the person in whose charge the patient is to be placed, authorising him to receive the patient. Notice of admission and a copy of the reception documents must be sent by the authorities of the institution or person in charge of the patient to the Board of Control within one clear day after admission, to be followed after the second day, but before the end of the seventh day, by a medical statement regarding the mental and bodily condition of the patient. The copies of the reception documents are scrutinised by the Board of Control, who may require incorrect or defective documents to be amended within fourteen days, and if these are not amended to their satisfaction they may order the discharge of the patient. There is a special provision for the certification of

private patients in cases of urgency. Where it is necessary for the welfare of the patient or the safety of the public that the patient should be forthwith placed under care, he may be detained on an urgency order. This order must be made if possible by the husband or wife or relative of the alleged lunatic, and accompanied by one medical certificate. If the order is not made by a husband or wife or a relative an explanation of the circumstances must be given in the order by such other person as may sign it. The person making the order must be at least twenty-one years of age, and must within two days before the order was made have seen the alleged lunatic. An urgency order remains in force for seven days only, or, if a petition for a reception order is pending, it remains operative until the petition is disposed of. Private patients are received in County and Borough Mental Hospitals, Registered Hospitals, Licensed Houses, and Single Care, and they may be removed from one institution to another under the original order.

Pauper patients are dealt with under summary reception orders. One medical certificate only is required, but the magistrate must see the patient before making the order. Any lunatic is a pauper lunatic who is in receipt of relief, or in such circumstances as to require relief for his proper care.

It is evident that simplification of the law is desirable. Why should there be a difference in the procedure between the pauper and the non-pauper? Why should the non-pauper have two medical men to examine him and two medical certificates? Why should it be only optional for the judicial authority to see the non-pauper and obligatory for him to see the pauper lunatic? Why should a man if he becomes mentally ill and requires institutional treatment become automatically pauperised? If the same man suffered from some physical illness he would have the option of being treated at one of the voluntary hospitals or of obtaining treatment provided by the public health authority out of public funds; in either case without any detriment to his status as a citizen.

A

very justifiable uneasiness exists in the public mind that a certificate may be given by any duly qualified medical practitioner immediately he has obtained his