IN introducing for your consideration and discussion certain points in connection with the certification of insanity, 1 would beg to premise that this age is an age of inquiry and change; and that every institution and custom amongst us has been within recent years put upon its trial, and questioned as to its intrinsic merits. This must be in some part my excuse, if any were needed, for asking for a discussion on the merits of the certification of insanity, an institution neither venerable from

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... age nor greatly honoured in its practice, and which has already undergone some sort of investigation from the legal aspect during the recent lunacy legislation. A review of its conditions from a medical point of view cannot therefore be considered inappropriate. The legal opinion in regard to it, as expressed in the discussions upon this question in the Houses of Parliament, and as very forcibly enunciated in the penal provisions against medical men in the Lunacy Act, appeared to be that the certification of the insane was a sort of prerogative of the medical profession, from which it not only drew an enormous revenue by virtue of which it wielded a power of " incarceratingX" (that was the pet expression of two Lord Chancellors) their fellow countrymen in asylums, a power which was very dear to the medical heart. The popular view, we know, has always regarded, and still regards the certificate of lunacy as a lettre de cachet, which every medical man is ready to vend at the price of a guinea or so to all comers. The professional and selfish consideratioii of certification thus comes to the surface first, and we must consider later the much more important questions in which it is related to the treatment of insanity. First, then, in regard to the monetary value of certification. If the paupers, criminals, and military hospitals are excluded (and no allegations against the profession have been founded on the certification of these classes) the number of the persons certified in the year 1894 in England and Wales was: To metropolitan licensed houses 828 To provincial " ... 496 To registered hospitals ... ... 749 2, Of these, a considerable proportion admitted to t&e hospitals were charity cases, so that if we estimate the average fee for certification at two guineas per head we shall probably be wellwithinthemark, and the total incometothe i6,ooomembers of the profession would amount to 4,000 guineas, or to about 5s. per head per annum. This is the magnificent sum for which the profession has been abused heartily for any time in the last twenty years. So much for the monetary value of the so-called privilege. In regard to the power which the profession is supposed to value so highly, we know that there is a large section of the profession who will not sign lunacy certificates under any circumstances, and a still larger number who are most unwilling to sign them, and do so only under almost unavoidable circumstances. The reasons for this distaste are manifold. Thus, some are unwilling to undertake the responsibility; others know that by so doing they are almost certain to lose a family connection, and, in case of recovery, make for themselves an enemy who for years may threaten and persecute: while still more are deterred from fear of litigation, which, in spite of all the protection attempted to be given to medical men in the late Lunacy Act, is still a real danger-an action, even if quashed at its earliest stage in the law courts, often involving great expense and anxiety, for which there is absolutely no redress. Phis modicum of protection for medical men, it should be remembered, was only obtained after years of most strenuous representation on the part of this Association and other bodies of medical men; together perhaps with the fact that certification was becoming so difficult that the number and character of uncertified lunatics was becoming a public scandal, from the increase of homicides, outrages, and suicides by known lunatics who had not been certified from fear of the legal risks of certification which then existed. I cannot go fully into all the aspects of the question, but I hope you will agree with me that the certification of the insane is of very little value or importance to the profession at large, and so far from being a coveted power or privilege, is an obnoxious and even dangerous duty, which was never sought by the profession, but has been thrust on it by successive legislative enactments in a manner that has never recognised the consideration due to medical men. The signing of a certificate also involves a question of professional ethics-one which has been very prominent of late, namely, the question of the revelation of private matters relating to the patient. In filling up a certifcate it is often necessary to state objectionable language, filthy habits, immoral or obscene acts, etc., and although a certitcate is supposed to be kept private, we know that it is submitted to a magistrate (often a neighbour), sometimes to the magistrate's clerk, to the persons who convey the patient to the asylum, often to the asylum clerk, in hospitals to the Asylum Committee, as well as the Commissioners in Lunacy and theirclerks. It may also be adduced in courts of law or a copy obtained by a near relative. Although given for a legal purpose and under supposed secrecy, its publication is therefore tolerably wide. If the duty of certification were now for the f*rst time to be thrown upon the profession, I think this aspect of the case would bulk very largely in the discussion. I must admit that I have grave dousbt whether we are professionally justified in revealing and placing on permanent record such facts as those quoted, and on t is point I would invite an expression of opinion. The really important question, however, concerns the welfare of the patient, and to this I invite your earnest consideration. The reasons alleged for the necessity of certification are (i) the legal control of the patient for his own sake, (2) his legal control for the protection of the community; but in arranging for this legal control of lunatics it was found or alleged that sane persons had been or might be incarcerated as well as the insane, and to prevent this various safeguards were devised. The principal safeguards are the dual certificate and the intervention of the magistrate: the latter was introduced in the Lunacy Act, I891. The point to consider then is whether the procedures adopted to gain these ends are really the best that can be made or whether there are any remediable defects in them. The insaneperson, we as medical men must always insist, is a sickperson suffering from diseaseand as such is entitled to as prompt treatment as any other sick person. From the nature of his disease and his own inability to provide for himself, the necessity is indeed often more urgent. Moreover the necessity of prompt and early treatment has been urged by the universalconsensus of all authoritiesfor manyyearspast. My personal opinion is, that by making better provision for the early treatment of mental disorders than now exists, a great reduction would be made in the numbers of those who now drift on until they become certifiably insane. The first question, therefore, is whether the present procedure causes any delay in treatment. The answer to this must be, that it often causes serious hindrance and delay.