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

more concerned in looking after the interests of alleged lunatics, and would have welcomed any proceedings which might be instituted in their interest. Doctors are not any more infallible than other people, and it is scarcely surprising that the public should be inclined to accept the opinion of those among them who have made a special study of mental disease in preference to that of those who have neither their experience nor their knowledge. I remember the case of a lunatic who went about with two doctors' certificates in his pocket stating that he was quite sane, and with them for a time he defied all efforts to send him to an institution, until eventually he became a public danger and was shut up in spite of them. If any one wished to build a bridge, he would not go to a firm of sanitary engineers for the work. Yet they are engineers, and probably very good engineers in their own special line. So a man may be a very good doctor for the physical part of man's organism and yet know nothing of the mental side of that organism. The attitude sometimes taken by the British Medical Council appears to be a very narrow one, and savours too much of the Trades Union pushed to its extreme limits. It is unworthy of a great profession. It is quite right that the doctor should be protected, but that protection cannot be claimed so long as he persists in giving opinions on subjects outside his knowledge and experience. An expert may make a mistake, but he is less likely to do so than a man who is working outside his sphere. That is the view the public takes, and it will not be satisfied until the possibility of wrongful certification by casual doctors is altogether eliminated. Lunacy is essentially the province of the specialist, and to the specialist it should be strictly confined in order that public opinion may be

reassured.

It is open to doubt whether the intervention of the magistrate can be regarded as an independent safeguard. There is a certain amount of haphazardness about the procedure, which lacks formality, and no proper records of the decisions are kept. The public are obsessed with the idea that wrongful certification is possible : (a) through illegal procedure; (b) through mala fides; (c) through insufficient or inaccurate evidence; (d) under

conditions due solely to physical causes. It does not require a multiplication of instances to create uneasiness in the mind of the public. The cases of Beck and Edalji were sufficient to call into being the law of Criminal Appeal. The Royal Commission was, however, of opinion that the present safeguards against wrongful certification, if properly observed, were adequate. The whole crux of the question lies in the words, if properly observed. It is difficult to see how the Law of Lunacy as it is now constituted can be properly observed. There is an insufficiency of qualified alienists and the judicial authority consists in practice of Justices of the Peace who possess no qualifications for giving a separate opinion. They must almost invariably form their opinion on the medical certificate produced before them, which it must be remembered that any doctor, however recently qualified, is competent to give. The doctor is not on oath, his certificate has not even the solemnity of an affidavit. It is less important judicially than his evidence in a police court where the complainant had received a black eye. In such a case a certificate from a doctor would not be accepted as evidence. He must appear in Court and give his evidence on oath and be subjected to cross-examination. It is a strange anomaly that in cases of alleged insanity where the doctor is the sovereign arbiter, that his simple certificate should be accepted with its power to brand a man with the taint of insanity. If a patient is certified, not only is the patient subjected to a very invidious and unpleasant social censorship, hereafter, but the children are as well. How often do we hear it said: There is insanity in the family'! The statistics of various mental institutions show that there is a great deal of faulty prognosis on the part of medical men in dealing with insanity. Many alleged lunatics have been discharged a few days after their admission-a significant fact indicative of a tendency to premature certification. That the Royal Commission appreciated this state of affairs is shown by its proposal:

"That the treatment of mental disorder should approximate as nearly to the treatment of physical ailments as is consistent with the special safeguards which are indispensable when the liberty of the subject is infringed. That certification should be the last resort and not a necessary preliminary

to treatment; and that the procedure for certification should be simplified, and made uniform for private and rate-aided cases and dissociated from the Poor Law.'

The risk of an improper motive operating adversely to a patient obviously occurs in a case where relatives wish to keep a person under detention in order that they may benefit by his property. The possibility of this risk probably exists chiefly in the case of private patients. The power to discharge such a patient is vested primarily in the person on whose petition the reception order was made and who may be the relative interested adversely to the patient. A partial safeguard is, of course, provided, which requires the manager of a hospital or a licensed house, or the person in charge of a single patient, to report his recovery and discharge him. The possibility of a medical officer acting from an improper motive may be examined more directly in another connexion. In a licensed house, which is an institution conducted for private profit, the continued residence of a patient paying perhaps a high fee has a direct bearing upon the prosperity of the whole undertaking and, therefore, upon the livelihood of those employed in it. Indeed, the medical and other officers may have a direct interest in the finances of the house if they are shareholders or if their emoluments vary with the fluctuation of the profits. In such circumstances there may arise a conflict between interest and duty. That in the case of one licensed house an arbitrary profit was being made on extras supplied to the patients without the fact being disclosed to those who paid the accounts, gives rise to a suspicion that it is quite possible for interest to conflict with duty and that a certificate of discharge might be withheld for the sake of profit. The only prospect of liberty for a sane person who is wrongfully confined in such an establishment is to escape and to elude recapture for fourteen days. In such a case he cannot be detained without a fresh order and certificates. This is his only hope. It may be thought that visitation, in which a considerable number of authorities are engaged, would provide every safeguard against improper detention. This might be so if the visitation was effective. The Board of Control, at the time of the issue of the Report of the Royal Commission, consisted of eleven members,

of whom eight were paid. They are overwhelmed with administrative work. They have to scrutinise all the reception documents on which patients are received under care and the continuation reports which warrant their continued detention; the licensing of licensed houses in the metropolis; the examination of records and the preparation of statistics and other matters for the Annual Report presented to Parliament. In addition, they have to deal with a large correspondence from patients and their relatives. The Board of Control in short is the central authority for seeing that the lunacy code is administered in conformity with the Acts and Statutory Rules. They are also responsible for the administration of the Mental Deficiency Act. In addition to all this, and which is the most important part of their duties from the point of view of the public, they are charged with the visitation of all places where patients are detained. It is obvious that their task exceeds their power of performance owing to their number being inadequate for the discharge of the duties prescribed by the Act, and that much must escape their notice. In addition, the Chairman of the Board must often be absent giving his views at meetings where questions of lunacy are discussed. But it is the urgency order which is the chief danger. On it a person may be sent direct to an asylum on the certificate of one doctor with no confirmatory certificate from another and without being seen by any legal authority. It has been responsible for most of the actions which have been brought against medical men for wrongful certification, and lacking as it is in proper safeguards for the liberty of the individual, it is a danger to the community.

The feeling that mental sickness is not properly treated is growing, and the Royal Commission has proved that there is too much premature certification: that the Board of Control is inadequate for the duties it has to perform; that there is an insufficiency of qualified alienists; that the nursing service is not always what it might be; that there have been cases in institutions where patients have been unduly exploited; and that both the Lunacy Act and its administration are in urgent need of reform.

J. E. MARSHALL.