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.

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 or 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

qualifications, though he may have no experience in dealing with lunacy. Medical men themselves recognise that pyschiatry finds only an insignificant place in the medical curriculum. Only one-third of the students who qualified during the years 1921 to 1924 were required to show any knowledge whatever of mental diseases in their written papers. The average prior to 1924 must have been considerably less. Yet, notwithstanding this, the British Medical Association inclines to the view that any qualified practitioner is also qualified to sign a certificate. A somewhat dangerous doctrine, and one scarcely likely to inspire public confidence. It is, of course, necessary that medical men should be protected from the possibility of actions being brought against them for wrongful certification. But, after all, the remedy is in their own hands. If mental diseases have not formed part of their curriculum, or if they have not formed part of their after study, they have only to refuse to undertake such duties in connexion with their profession. No one could blame them. Mental diagnosis is essentially the work of a specialist, and for any other medical man to undertake it is only courting eventual appearance in a Court of Law in an action for damages for wrongful certification. The attitude at present taken by some of the speakers in the discussion on the Report of the Lunacy Commission (England and Wales) in July at the meeting of the British Medical Association in Edinburgh was in defence of the medical man who gave certificates, when it was obvious that he was not competent to do so either by study or practise. It is a dangerous line to take and one which can never commend itself to the common sense of the public. One of the speakers, Sir Frederick Willis (Chairman of the Board of Control, England and Wales), went so far as to say: His own feeling was that that sort of question [actions for damages for wrongful certification] should be taken out of the province of juries. If it were left to the judges of the High Court much greater justice would be done. In these cases it was usual for "experts" to come in, and it had been rather distressing to see the sort of evidence given by one doctor against another doctor.' This is a strange view to take. It would have been thought that the Chairman of the Board of Control would have been