confined, would, as we have said, save a great amount of useless double work and travelling.

These recommendations of the committee regarding the offices, definite though they were, have remained a 'dead letter' so far as practical result is concerned. But one remarkable effect may reasonably be ascribed to them. The Lunacy Act of 1890 has given power to the Lord Chancellor to amalgamate the two departments when and how he chooses. By § 337 the Lord Chancellor may, if it seems expedient to him so to do,

'by order under his hand, amalgamate the office of the Masters and their staff, and the office of the Chancery Visitors and their staff, or either of them, with the office of the Commissioners, and may give such directions as he thinks fit for the exercise and performance of their duties,' etc.

He is also empowered, with the concurrence of the Treasury, to fix the qualifications and salaries of the members of the amalgamated office, but not to the prejudice of the then holders of the posts. He is also empowered to pay such proportion of the cost as he may determine out of the percentage paid by the Chancery lunatics for the care of their property.

These powers are indeed of sufficient amplitude, but apparently, during the fifteen years which have elapsed, it has not seemed expedient' to the Lord Chancellor to exercise them. Can it have been with this object that the clause was inserted in the Act? The final provision for the payment of the expenses (which are to include the erection of offices) out of the percentages received from the Chancery patients, suggests that these must be considerable in amount. We find from the last revenue returns that the percentages were estimated, for the year 1904-5, at 18,000l.; and to this should be added the sum received for stamps in connexion with legal proceedings, which is not less than 90007. † Thus the Treasury receives from this department 27,000l., a sum which exceeds its cost (16,7577.) by 10,000l. The expenses of the Lunacy Commission amount to 15,2597., to which, however, should be added 3845l., of which the huge sum of 22601. is for office accommodation, furniture, etc., and

* Estimates Civil Service, Law and Justice, p. 243.

† Ib. p. 239.

11301. for 'non-effectives'-pensions, we presume. Against this the only receipts are the sums paid for licenses for private asylums, which amount to 11127. The salaries of the Visitors amount to 4500l. a year, those of the Commissioners to 90007.; but, omitting travelling expenses, the cost of visitation of each of the 718 Chancery cases works out at about 67. 10s. a year; that of each patient under the Commissioners at 2s. 6d.

The vested interests of officials always constitute a grave hindrance to any departmental reform. This was clearly anticipated in the Act of 1890, which provided that none of those holding office at that time should be prejudiced. An immediate improvement of conditions could therefore not be effected without an increase of expense; but, if the powers given had been used, the cost might by this time have been reduced to its earlier dimensions. An addition to the number of medical Commissioners is imperative. Two more might suffice for a short time, but not for long, if the present rate of increase in the number of the insane continues. They would, however, be enough if the two departments were amalgamated. On the other hand, as we have seen, three legal Commissioners are more than enough. If the offices were amalgamated, and if the posts of the legal Visitor and of one legal Commissioner were discontinued at the next vacancies, the two additional medical Commissioners would involve no increased charge on the taxpayer.

One other effect of the Act of 1890 should be noticed. It precluded the granting of any fresh licenses for private asylums, apparently under the idea that profit induced undue detention. It is doubtful, however, whether the latter is possible under the present careful observation of the Commissioners; at least it would not be possible were their number adequate for their work. But another intention was probably to encourage the choice of the semi-public 'hospitals,' and even the paying departments of public asylums. This result has been distinctly achieved. The clear independence of profit in the hospitals has had a considerable influence on the preference of the public; and the number of patients in purely private asylums has steadily lessened. It might be thought that this provision would have increased the pecuniary value of 'licensed houses' of this class, as it has been

thought that a similar enactment would enhance the value of licensed houses' of a very different nature. At present it has not had this effect, although it may hereafter. There is, in certain sections of the community, an inextinguishable demand for the seclusion and privacy of such asylums; even the upper classes often prefer them to single care, because thereby more specially experienced medical attention is secured.

Another reform is needed, with yet more obtrusive urgency, in the interests of the sufferers themselves. Of this there is some prospect. A large number of the insane, especially of those who are comparatively young, pass through a stage in which there is hope of recovery. Besides these, there is a still larger number of patients who are verging towards insanity but are not yet over the line. On the mental unsoundness of some of these, two doctors might differ in opinion. Such cases need the care of those who have had experience in 'personal conduct' on the road to health; and for this it is generally needful that those who take care of them should not be relations or familiar friends. But if such patients can be certified to be of unsound mind-and, if they are not, they may easily become so by a trifling intensification of the morbid state-they cannot legally be received by any person for payment without being stigmatised as insane by certification and placed under the control of the Commissioners in Lunacy. This sometimes induces definite unsoundness, or takes away the chance of recovery. It is harmful to the patient and painful to the friends. The need for milder measures in such cases had been brought before the Lord Chancellor by the Medico-Psychological and British Medical Association; and it was the chief subject of an address to the former society by Sir William Gowers in 1902.* What is needed is the adoption of a system similar to that which exists in Scotland, by which a person with incipient insanity, if fraught with no danger to himself or others, can be received for treatment for six months on a simple medical certificate that there is a prospect of recovery.

It may seem strange that the arrangements in Scotland

*Lancet,' November 22, 1902.

should be so far in advance of those in England as to furnish a model to be followed. We have already mentioned the Scottish system of Commissioners; and the whole history of the care of the insane north of the Tweed is of great interest. Only the briefest sketch can be given here. The earliest traces to be obtained reveal the doctrine of the pater patriæ, but with apparent disinterestedness. Idiots were consigned to the nearest male relative, the furious' to the charge of the King, as alone having the power of consigning them to control. The first attempt at systematic care was made in 1792; but the attempt 'hung fire' until, in 1806, the legislature appropriated certain moneys to two somewhat incongruous objects, the promotion of the fishing industry and the care of the insane. Meanwhile the York Retreat' was making its remarkable influence felt; and an asylum was finally opened in Edinburgh in 1813. Subsequent measures to improve the state of the insane in Scotland came slowly. The local opposition to the erection of district lunatic asylums was everywhere strong and for a long time effective; and the improvement in the state of the insane during the first half of the last century was even less than in England. But if slow in its approach, it was better for the delay. The experience of England was especially useful. No connexion exists between the two systems; but the lessons taught in various ways in England were not disregarded across the Border; and present arrangements in Scotland are such as to excite the envy of those in England who have the real interests of the insane at heart. Yet it must be remembered that the conditions differ considerably in the two countries. The arrangements made in Scotland were the more effectual because it was early realised that lunacy is a physical disease, and the Scotch were free from the regal and legal bonds which had such influence in England.

The fact should be realised that in England there are many cases of early and slight insanity in which the law must be broken, not to save pain to the friends, but, on the highest medical advice, to save the patient's mind from becoming permanently deranged. This This course necessarily involves some risk. If such a patient is distinctly 'over the line,' and can be technically said to be of unsound mind, the person who receives payment for

him, even if a relative, is liable to prosecution, and to a penalty if conviction follows. It is so even with nursinghomes; it is so in cases of organic brain disease, such as may also paralyse the patient; it is so also with cases of defective mind. Space precludes the quotation of examples of such prosecution; but some, of surprising character, will be found in the reports of the Commissioners for the last ten years, and were quoted by Sir William Gowers. A relative can keep any case uncertified, if no payment is made; and it is among such that the examples of cruelty have occurred which have occasionally shocked the public. It is of course essential that all cases should be under conditions that are salutary and likely to promote recovery. But this would be equally secured by a system of notification to the Commissioners, with the power of visitation if deemed necessary, and the ability to order removal if this appears desirable. At present the power of inspection can only be secured by the process of certification; and since this is, in many cases, needless and harmful, it is inevitable that the law should often be violated. It is not well that a law which must be broken should remain unmodified, or that so great a difference should exist between the law of Scotland and that of England; and it is most important that the needed relief should be given.

A Bill to effect this modification was introduced into the House of Lords in 1900 and 1901; but the Government did not give facilities to enable it to pass the House of Commons, into which a similar Bill was introduced, pro forma, in May 1904. Such a measure should not be longer delayed. It is indeed strongly recommended by the Commissioners themselves in their Report for 1903. They suggest also an important modification of one of the clauses (§ 7), which enacts that no person shall under this section receive more than one patient at the same time.' Literally interpreted, this would preclude the reception of another patient, of whatever nature, and would harmfully restrict the utility of the measure. The Commissioners suggest also a modification of clause 8, which enacts that,

'after the expiration of the period mentioned in the certificate, another certificate under this section in respect of the