Throughout the preceding portion of this book we have pointed out numerous
instances wherein the legal provision for the insane fails in its object
from the want of duly-appointed agents, possessing both special experience
and an independence of local and parochial authorities; and we have many
times referred to a district medical officer, inspector or examiner, as a
public functionary much needed in any systematic scheme to secure the
necessary supervision and protection of the insane, particularly of such
as are paupers. We will now endeavour to specify somewhat more precisely
the position and duties of that proposed officer; but, before doing so, we
may state that the appointment of district medical officers is not without
a parallel in most of the Continental States. In Italy there are
provincial physicians, and in Germany Kreis-Artzte, or
District-physicians, who exercise supervision over the insane within their
circle, besides acting in all public medico-legal and sanitary questions.
In our humble opinion, the institution of a similar class of officers
would be an immense improvement in our public medical and social system.
The want of public medical officers to watch over the health and the
general sanitary conditions of our large towns has been recognised and
provided for; although the machinery for supplying it is much less perfect
than could be wished: for to entrust the sanitary oversight and regulation
of populous districts to medical men engaged in large general practice,
often holding Union medical appointments, and rarely independent of parish
authorities, is not a plan the best calculated to secure the effectual
performance of the duties imposed; for, as a natural result, those duties
must rank next after the private practice of the medical officer, and
constitute an extraneous employment.
In the establishment of a class of district medical officers,--chiefly for
the examination, supervision and registration of all lunatics or alleged
lunatics and 'nervous' patients not in asylums, but placed, or proposed to
be placed, under surveillance, accompanied with deprivation of their
ordinary civil and social rights,--we would protest against the commission
of such an error in selecting them, as has, in our opinion, occurred in
the appointment of sanitary medical officers generally: for the
performance of the duties which would devolve on the district medical
officer, it would indeed be essential that he should be perfectly
independent of local authorities, that he should not hold his appointment
subject to them, and that his position among his professional brethren
should be such as to disarm all sentiments of rivalry or jealousy among
those with whom his official duties would bring him in contact. What
should be his position and character will, however, be better estimated
after the objects of his appointment are known.
The extent of the district assigned to this official would necessarily
vary according to the density of population; so that some counties would
constitute a single district, and others be divided into several. In the
instance of a county so small as Rutland, the services of a separate
district medical officer would hardly be required, and the county might be
advantageously connected with an adjoining one.
One principal purpose of his office would be to receive notice of every
case of insanity, of idiocy, or of 'nervousness' (as provided for by Lord
Shaftesbury's proposal), and to register it; the notice to be sent to him
by the medical attendant upon the patient. Upon receiving such notice, he
should forthwith, except under certain contingences hereafter indicated,
visit the case, and determine whether it should be rightly placed under
certificates as one of lunacy, or as one of 'nervous' disorder, amenable
to treatment without the seclusion of an asylum; and should transmit the
result of his examination and the report of the case to the Lunacy Board.
It might supply an additional protection to the lunatic, and be
satisfactory otherwise, if the signature of this officer were required to
the original certificates (see p. 165) before their transmission to the
central office in London.
The return made by the district medical officer to the Commissioners in
Lunacy would be of much service to them in determining their future course
with reference to the visitation of the patient (in carrying out Lord
Shaftesbury's proposal, p. 161), supposing him to be detained at home, or
in lodgings with strangers, instead of being transferred to an asylum or
licensed house. So again, if the patient were removed to an asylum, he
would furnish a report of his history and condition to the physician or
proprietor, and thereby render a valuable service, particularly in the
case of paupers, of whom next to nothing can frequently be learnt from the
relieving officers who superintend their removal to the County Asylum. The
want of a medical report of cases on admission is, in fact, much felt and
deplored by medical superintendents; and, since it is proposed that the
district officer should visit the patient at his own home, or, in
exceptional cases, elsewhere, and inquire into his mental and bodily
state, and into the history of his disorder, before his removal to the
asylum, and as soon as possible after the onset of the attack, he would be
well-qualified to render a full account of his case.
We have spoken of a notice of idiots within his district being sent to the
district inspector, and of his duty to register them. This matter we
regard as certainly calling for attention, for, as remarked in a previous
page (p. 149), idiots need be submitted to appropriate educational and
medical means at an early age to derive the full benefits of those
measures; and among the poor, they certainly should not be left uncared
for and unnurtured in the indifferent and needy homes of their friends,
until, probably, their condition is almost past amelioration.
Again, with reference to the transmission of pauper lunatics to county
asylums, we are disposed to recommend that the order for it be signed by
the district medical officer, without recourse to a justice, in those
cases where he can visit them, and in comparison of which indeed others
ought to be exceptional. Where, for instance, by reason of the remoteness
of the patient's home, or of the workhouse or other building wherein he is
temporarily detained, the district medical officer's visit could not be
specially made except at great cost, the removal of the patient to the
asylum might be carried out under the order of a magistrate, and the
examination made by the district officer, as soon after his reception as
possible; or better, at his own residence, which ought to be in a town not
far from the county asylum.
We advocate the delegation of the authority to the district officer to
make an order in lieu of a justice, on the production of the legal medical
certificate required, because we consider him much better qualified to
administer that portion of the lunacy law, particularly as that law at
present stands, which puts it in the power of a justice to impede the
transmission of a lunatic for treatment, if, in his opinion, the patient's
malady do not require asylum care: and it is a fact, that the clause
permitting a justice this influence over a patient's future condition is
often exercised; at times, contrary to the decided advice of medical men,
and to the detriment of the poor patient. Lord Shaftesbury refers to such
an occurrence in his evidence (_op. cit._, query 846). Having in view
private patients especially, his Lordship remarks that nothing could be
worse than to take them before a magistrate: "there would be a degree of
publicity about it that would be most painful ..., and to have the matter
determined by him whether the patient should or should not be put under
medical treatment. In ninety-nine cases out of one hundred, the magistrate
knows little or nothing about the matter. A case occurred the other day of
a poor man who was taken before a magistrate, and he refused to certify,
because the man was not in an infuriated state. 'A quiet person like him,'
he said, 'ought not to be put into an asylum; take him back.' He was in a
low, desponding state, and if he had been sent to a curative asylum, he
might have been cured and restored to society."
Mr. Gaskell also adds his evidence to that of the noble chairman of the
Board, in reply to query 1385 (_op. cit._ p. 133) put by Sir George
Grey:--"Is the magistrate to be quite satisfied on the evidence that the
pauper is a proper person to be taken charge of in the county asylum?" Mr.
Gaskell replies, "Yes, as I said, on the medical gentleman giving a
certificate. Then it is his duty to make an order, and if he is not
satisfied by his own examination, or the medical evidence is not
sufficient to justify the order, he declines. I am sorry to say that they
frequently do."
It is also to be remembered that the existing law allows the justice's
order to be dispensed with, if it cannot be readily obtained, or if the
patient cannot be conveniently taken before him, and admits as a
substitute an order signed by an officiating clergyman and an overseer or
a relieving officer, upon the production of a medical certificate.
Moreover, by the interpretation clause, the chaplain of a workhouse is to
be deemed an officiating clergyman within the meaning of the Act. Now,
these conditions seem to us to frustrate the undoubted intent of the law
in requiring a magistrate's order, viz. to guard against the unnecessary
detention of an alleged lunatic; for they place the liberty of the pauper
entirely in the hands of parish officers and paid servants, who will
naturally act in concert; and it is conceivable that workhouse authorities
might be anxious to get rid of a refractory pauper, and could together
with the relieving officer influence in a certain degree the opinions and
sentiments of the salaried chaplain and medical officer, in order to
sanction his removal to the county asylum.
We have, indeed, in previous pages (p. 91, _et seq._), shown that unfit
and occasionally non-lunatic patients are sent to asylums; but, even did
such an event never happen, we should still hold that the protection to
the alleged lunatic intended by the requirement of an order signed by the
officials designated, is very little worth, and would be advantageously
replaced by the order of a district medical officer appointed and
authorized by the scheme we propose. It is also worthy of note, that
patients sent to asylums under the order of the chaplain and relieving
officer feel themselves sometimes much aggrieved that no magistrate or
other independent authority has had a voice in the matter. They regard the
relieving officer or the overseer, as the case may be, to be directly
interested in their committal to the asylum, and only look upon the
chaplain of the union as a paid officer, almost bound to append his
signature to any document matured at the Board of Guardians, when called
upon to do so. Moreover, they can recognise in him, in his professional
capacity as a clergyman, no especial qualifications for deciding on the
question whether they are proper persons to be confined on the ground of
their insanity. This remark, too, extends to every other clergyman called
upon to act in the matter. Nay, more, there is another more potent
objection at times to a clergyman signing the order; viz. when the patient
is of a different faith, or when perhaps animated by strong prejudices
against the clergy of the English Church, and when, consequently, it is
possible for him to imagine himself the victim of religious persecution or
of intolerance.
Even Lord Shaftesbury, who is so identified with the interests of religion
and of its ministers, manifests no disposition to entrust to the clergy
the interests of the insane. In reply to the query (No. 838, Evid. Com.),
whether he would desire ministers of religion to pronounce on the fitness
or unfitness of persons for confinement as of unsound mind, he replies, "I
should have more distrust of the religious gentleman than I should have of
the medical man; and I say that with the deepest respect for the ministers
of religion. The difficulty of it would be incalculable, if you were to
throw the duty on the parochial clergy in the neighbourhood, who are
already overburdened."
In truth, there is no more reason for assigning to the clergy the
determination of the question of sanity or insanity of an alleged lunatic,
than for entrusting it to any other respectable and educated class of
society. We have seen that magistrates sometimes exercise their privilege
of deciding the question in an arbitrary and injudicious manner, and it is
permissible to suppose the clergy not to be always in the right in
exercising the same function. Indeed, we have at least one instance on
record that they are not, in the Supplement to the Twelfth Report of the
Commissioners in Lunacy; viz. in the case of an epileptic woman, subject
to paroxysms of dangerous violence and destructiveness,--such as are
common to the epileptic insane in asylums, and reported by the master of
the workhouse "as unsafe to be associated with the other inmates. For
these offences she had been subjected to low diet, restraint, and
seclusion, and on three occasions had been sent to prison. The medical
officer of the workhouse considered her of unsound mind, not fit to be
retained in the workhouse, and improperly treated by being sent to prison.
In March 1856, and February 1857, he had given certificates to this
effect, and steps were taken to remove her to the asylum. When taken on
those occasions, however, before the vicar of the parish, he refused to
sign the order, and she was consequently treated as refractory, and sent
to prison."
Taking the foregoing remarks into consideration, the only circumstances
under which we would call upon an officiating clergyman, not being the
chaplain of the Union, to make the order, would be where no magistrate
resided in the neighbourhood, and where, from the remoteness of the
locality, the district medical examiner could scarcely be expected to
visit the individual case,--an event that would be of rare occurrence in
this country.
There are indeed cases, such as of acute mania, where the justification of
the confinement of a lunatic, by the order of a magistrate or clergyman,
is a mere formality, and might be altogether dispensed with, and all legal
protection guaranteed by the medical certificate, and an order signed by a
parish officer to authorize the asylum authorities to receive the patient
at the charge of the parish sending him. But if this were objected to,
then assuredly the examination of the lunatic immediately upon or just
before his admission into the asylum by the district medical officer,
would supply every desideratum in the interests of the patient, and such
an examination would, according to our scheme, be always made at this
stage of the patient's history.
Lastly, let it be remembered that a magistrate's order is not required for
the admission of a private patient into an asylum or licensed house. A
relative or friend may sign the order and statement, and the alleged
lunatic is thought to be sufficiently protected by the two medical
certificates. Now, were a magistrate's or a clergyman's order any real
security against the commission of a wrong to an individual, it would be
much more necessary in the instance of private patients possessing
property, and whose confinement might serve the interests of others, than
in the case of paupers, for whose confinement in an asylum no inducement,
but rather the contrary feeling, exists. In fact, the confirmation given
to the propriety of placing a pauper lunatic in an asylum by the district
medical officer, as proposed, might be considered supererogatory,
considering that a certificate is required from the superintendent of the
asylum shortly after admission, had it no other purpose in view.
According to the proposition advanced by us, an experienced opinion by an
independent authority would be obtained in lieu of one formed by an
inexperienced magistrate (who would generally prefer escaping an interview
with a madman, mostly act upon the medical opinion set forth, or if not,
be very likely to make a blunder in the case), or of one certified by two
inexperienced, paid, and therefore not sufficiently independent, workhouse
functionaries.
The clause proposed by the Commissioners (Supp. Rep. 1859, p. 37), "that
the medical officer of the workhouse shall specify, in the list of lunatic
inmates kept by him, the forms of mental disorder, and indicate the
patients whom he may deem curable, or otherwise likely to benefit by, or
be in other respects proper for, removal to an asylum," is virtually
unobjectionable; but, with due submission, we would advocate that, whether
with or without this list and those expressions of opinion, the District
Medical Officer's Report should be considered the more important document
whereon to act. The evidence given before the late Committee of the House
of Commons (1859) shows that we must not expect much book-keeping or
reporting from the parochial medical officers, and that many
misconceptions and erroneous views prevail, and will damage results
collected from them. The Union medical officer will necessarily have his
own opinions respecting the nature and prospects of the lunatics under his
observation, and no great objection can be taken to his recording them, if
thought worth while: yet they would be sure to be given, even without any
legal requisition; and might often help, when privately expressed, the
District Examiner in his inquiries; and it would, besides, be better to
avoid the chances of collision between the written opinions of two
officers who should work together harmoniously.
Also, in the instance of private patients to be placed in an asylum,
licensed house, or elsewhere with strangers, we look upon the visitation
and examination of such a medical officer as we suggest as a valuable
additional protection and security to them. He would constitute an
authority in no way interested in the detention, and, by the nature of his
office, bring to bear upon any doubtful cases an unusual amount of special
knowledge and experience. We cannot help thinking that such a functionary
would be much more efficient and useful than a magistrate (to whom some
have proposed an appeal), as a referee to determine on the expediency of
placing a person under certificate as of unsound mind.
Another class of duties to devolve on a district medical officer comprises
those required to watch over the interests and welfare of pauper lunatics
sent to, or resident in, workhouses. At p. 73, we have advanced the
proposition, that, in future, no alleged lunatics should be removed to a
workhouse, except as a temporary expedient under particular conditions,
such as of long distance from the asylum or unmanageable violence at home;
and that in all cases a certificate to authorize any length of detention
in a workhouse should emanate from the district medical officer. The
object of this proposal is to prevent the introduction of new, and
particularly of acute cases of insanity, into workhouses; for, as we have
shown in the section 'on the Detention of Patients in Workhouses' (p. 40,
_et seq._), the tendency is, when they are once received, to keep them
there. According to our scheme, the district officer would receive notice
of all fresh cases from the medical practitioner in attendance upon them,
and, in general, visit them at their homes before removal to the workhouse
or elsewhere. With respect to the actual inmates of the workhouse, it
would be equally his duty to ascertain their mental and bodily state, to
suggest measures to ameliorate their condition, and to report on those
whom he might consider fit for removal either to the County Asylum or to
lodgings out of the Union-house. He would make his report both to the
Committee of Visitors of the workhouse, hereafter spoken of, and to the
Lunacy Commissioners. It should devolve primarily upon the Committee to
act upon the reports, or, on their omission so to do, the Commissioners in
Lunacy, either with or without a special examination made by one or more
of their number, should be empowered to enforce those changes which might
in their opinion be absolutely necessary.
Again, by Suggestion 5 (p. 73), we provide that no person shall be
detained as a lunatic or idiot, or as a person of unsound or weak mind,
except under an order and a medical certificate to the existence of mental
derangement, just such as is needed to legalize confinement in an asylum.
The order would best come from the District Medical Examiner, whilst the
certificate would, as usual, be signed by the Union medical officer.
Now, by one of the propositions contained in the Supplementary Report of
the Commissioners in Lunacy (1859, p. 37), it is sought to render a
similar protection by another expedient; viz. that the alleged lunatic
"shall be taken before a justice or officiating clergyman, and adjudged by
him as not proper to be sent to an asylum." By the next paragraph, it is
further proposed that, "In any case wherein an order for a lunatic's
reception into an asylum shall be made by a Justice or officiating
clergyman, it shall be competent for him, if, for special reasons, to be
set forth in his order, he shall deem it expedient, to direct that such
lunatic be taken, _pro tempore_, to the workhouse, and there detained for
such limited period, not exceeding two clear days, as may be necessary,
pending arrangements for his removal to the asylum."
Now, with all becoming deference to the position and experience of the
Commissioners, we must confess to a predilection for our own plan, which,
indeed, was drawn out before the appearance of the Supplemental Report.
This preference we entertain for the reasons shown when speaking of the
relative qualifications of magistrates and clergymen to make the order for
admission into asylums; viz. that on the one hand there are no à priori
grounds for supposing their discrimination of insanity, and of its wants
and requisite treatment, to be better than that of other people; that some
direct objections attach to clergymen, and that experience proves that
neither Justices nor clergymen have hitherto so performed the duty as to
afford any inducement to increase its extent; and, on the other, that in
the district medical officer we have an independent and skilled person to
accomplish the work.
Nevertheless the suggestion offered by the Commissioners is a great
improvement upon the practice in vogue, which leaves the determination of
the place and means of treatment, and of the capability of a patient to be
discharged or removed, to the parish authorities. On this matter we have
commented in previous pages, and illustrated at large in the history of
the condition of the insane in workhouses, or boarded with their friends
outside.
By suggestion 4 (p. 73), we propose that no lunatic or other person of
unsound mind in a workhouse should be allowed to be discharged or removed
without the sanction of the district medical officer. This proposition we
regard as of great importance; for we have seen (p. 90, _et seq._) with
what recklessness, contempt of common sense, and cruelty, poor lunatics
are removed from workhouses to asylums under the operation of existing
arrangements. Again, some directing, experienced and independent authority
is needed (p. 89) to overrule the removal of imbecile and other inmates to
the houses of their relatives or of strangers; to indicate the cases to be
sent, and to examine the accommodation, and ascertain the character and
fitness of the persons offering to receive them. These functions also we
would delegate to the district medical officer. Once more, imbecile,
partially idiotic, and occasionally patients more rightly called lunatic,
are sent away, or allowed to discharge themselves from, the workhouse,
with the sanction of the authorities of the House and of the Guardians.
The terrible evils of this proceeding are alluded to at p. 77, and more
fully entered into in the Commissioners' Supplementary Report (1859), and
in the evidence before the Committee on Lunatics (1859, Queries
1594-1596). The district medical officer would here again come into
requisition, and, under a distinct enactment of the law, resist the
discharge, unless satisfied that the relatives of the disordered or
imbecile paupers, particularly when females, could afford proper
supervision and accommodation, and exercise due control over them.
The sixth suggestion we have made (p. 73) contemplates the visitation of
lunatics in workhouses, not only by the Lunacy Commissioners, as
heretofore, but also by a Committee of Magistrates, and the district
medical officer.
The powers committed to the Lunacy Commissioners by existing Acts to
inspect workhouses are very inadequate and unsatisfactory; for, as the
Commissioners observe, they can make recommendations, but have no
authority to enforce attention to them, and the only course open to them
is, to get their views represented through the medium of the Poor Law
Board; and, although this Board co-operates most readily in their
recommendations, yet it has no positive power to enforce them. The result
is, the Commissioners find that the circuitous and troublesome proceeding
to which they are restricted renders their endeavours in behalf of
workhouse lunatics almost nugatory.
To rectify this objectionable state of things, the first principle to be
recognised is, that the Lunacy Board shall be charged with the custody of
all lunatics, whose interests it shall watch over and have the necessary
power to promote, however and wherever they may be found. It should not
have to exercise its authority, to enforce its orders and regulations,
through the medium or by the agency of any other Board. No competing
authority should exist. All lunatics should be reported to the
Commissioners; all should be subject to their visitation, or to that of
any assistants appointed under them; and the power of release should be
lodged in their hands in respect of all classes of patients when they see
reason to exercise it. In the instance of pauper lunatics in workhouses,
they should be able to interpose in their behalf, to require every
necessary precaution to be taken for their security, and due accommodation
and treatment provided.
The district medical officer would be their local representative; would
make frequent inspections, and report to them and act under their
direction. He would indeed be responsible to them in all duties connected
with the interests of the insane.
We have (p. 73) proposed a Committee of Visitors of Workhouses, for each
county or for each division of the county, selected from the magistrates
and from the respectable classes of ratepayers, not being guardians or
overseers, although chosen with a view to represent parochial interests.
This Committee should visit, at least once a quarter, every workhouse
containing a person of unsound mind or an idiot, in the district under its
jurisdiction; and it would be desirable that the district medical
inspector should visit in company with the Committee, besides making other
visits by himself at other times.
We are happy to find that this suggestion tallies in general with one made
by the Commissioners in Lunacy in their recent Supplementary Report, as
well as with the views of Dr. Bucknill. But we conceive it rather a defect
in the Commissioners' scheme that they propose that "the Visiting
Commissioner and the Poor Law Inspector be empowered to order and direct
the relieving officer to take any insane inmate before a Justice, under
the provision of the 67th Section of the Lunatic Asylums Act, 1853." For,
according to the principle enunciated in the last page, the Lunacy
Commissioners, as the special guardians of the insane, should alone be
concerned in the direct administration of the Laws of Lunacy, and on this
ground we object to the power proposed to be conferred on the Poor Law
Inspectors; and we take a further objection to their being called upon to
form an opinion respecting the lunatics who require Asylum treatment, and
those who do not. There is truly no impediment, in the abstract, to their
forming an opinion; yet, on the other hand, we would not have them to act
upon it, but desire them to report the circumstances falling under their
notice to the Lunacy Commissioners, who would thereupon examine into them,
and decide on the steps to be taken. By the plan, however, which we have
drawn out, and by the functions proposed to be entrusted to the district
medical officer, the whole clause last discussed would be rendered
superfluous.
The seventh suggestion (p. 73) submitted to consideration is, that every
workhouse containing lunatics should, under certain necessary regulations,
be licensed as a place of detention for them, by the Committees of
Visitors of Workhouses when situated in the provinces, and by the Lunacy
Commissioners when in the metropolitan district, and that the licence
should be revoked by the Committees, after reference to the Lunacy Board,
in the case of workhouses licensed by them, and by the Commissioners
solely in the instance of any workhouse whatever. This plan confers the
requisite power on the Commissioners to control the accommodation and
management of workhouse wards for lunatics, and resembles the one pursued
at present with regard to asylums. It would likewise permit them to order
the closure of lunatic wards, and the removal of all lunatics from a
workhouse, when they were persuaded that proper Asylum or other
accommodation was available for the insane inmates.
Whatever course they adopted, or whatever decision they arrived at on such
matters, they would be chiefly guided by the results of the inspection and
the reports thereon made by the district medical officer, and further
established by their own visitation. The present number of Commissioners
is far too small for them to visit each workhouse even once a year; and,
if our views respecting the necessity of a complete examination of every
one of such institutions, at least four times a year, be correct, it would
still be impossible to get this work done by them, even though their
number was trebled; therefore, as just said, the inspection made by the
district medical officer would afford the chief materials for their
guidance in dealing with workhouse lunatics, and save them an immense
amount of labour.
Our eighth suggestion (p. 73) is to the effect that all lunatics in
workhouses should be reported to the Lunacy Commissioners, and that this
should be done by the district medical officer (p. 97). The number, age,
sex, form and duration of malady, previous condition in life and
occupation, and all particulars touching the mental and bodily condition
of the patients, would be thus duly registered. The advantages of such a
system of reporting are obvious, and, as this branch of the district
officer's work has partially come under notice before, it need not be
enlarged upon here.
The law provides for the occasional visitation of pauper lunatics in
asylums chargeable to parishes, by a certain number of the officers, and
among them the medical officer of the parish to which, as paupers, they
are chargeable; and something, by way of remuneration for their trouble,
is allowed out of the funds of the union or parish. This arrangement keeps
up a connexion between a parish and the lunatics chargeable to it in the
county asylum, which in various respects is desirable, and probably
satisfactory to the ratepayers. But the lunatic inmates of an asylum
chargeable to the county do not receive the benefit of any such wise
provision: when once in the asylum, they find none interested in their
condition save the staff of the asylum, its visitors, and the
Commissioners. The last-named, in their annual visit, can have no time to
consider them apart,--not even to discover and distinguish them from the
rest. Very many of them are foreigners, and their condition is
consequently more deserving commiseration, as being, most likely, without
friends, to interest themselves in their behalf. If the inquiry were made
of the superintendents of county asylums, we believe it would be found
that the omission of the law in providing for the more immediate watching
of these poor lunatics is attended with disadvantages and injuries to
them. To supply this want, we are disposed to recommend the district
medical inspector as their special visitor; for he would be identified, on
the one hand, with the county in which his duties lie, and, on the other,
with the Lunacy Board, in such a manner as to be able to lay before it, in
the readiest and best manner, any circumstances respecting these county
pauper lunatics which it might seem desirable to report, and, when they
were foreigners, to bring about a communication with the Foreign Office,
and secure their removal to their own country.
The visitation of these lunatics would rightly entitle the district
officer to remuneration, which might be the same as that now paid per head
for the visitation of out-door pauper lunatics, viz. half-a-crown per
quarter. This amount would be payable by the county to which the patients
were chargeable, and would add to the fund applicable for the general
purposes of the Lunacy Board.
The Supplementary Report of the Lunacy Commissioners (1859, p. 13-14)
contains some observations relative to the decision, in the instance of
workhouse inmates, of the question who among them are to be reckoned as
"Lunatics, Insane Persons, and Idiots" on the parish books? It is at
present a task left to the guardians, the master, or to the parish medical
officer; but the Commissioners rightly recommend that it should be
entrusted to the last-named officer. However, we should prefer to see the
duty delegated to the district medical inspector, as better qualified, in
general, by experience, and, what would be of more importance, as being
independent of parochial functionaries: for the duty is a delicate and
responsible one; and, the disposition of guardians being economical where
money is to be expended on the poor, they always desire to escape the
heavier charge entailed by lunatics, and, where they can manage it, are
pleased to witness the discharge of imbecile paupers, and of others more
correctly called insane, whom they may choose for the time to consider as
sane enough to be at large. The difficulties besetting this question of
determining what paupers are to be considered insane, and what not, is
remarked upon by the Scotch Lunacy Commissioners in their
recently-published First Report (1859), and was referred to in the English
Commissioners' Report for 1847 (p. 239 & p. 257). The enormous evils
attending the present loose mode of deciding the question are sketched in
the Supplementary Report quoted, and in previous pages of this book.
We now come to the duties of the district medical officer in reference to
the pauper insane not in workhouses or asylums, but boarded with
relatives or strangers: as, however, we have, treated of them at some
length in the section on the condition of those lunatics (p. 83, _et
seq._), we will refer the reader back to that portion of the book. Suffice
it here to say, that the district medical officer is very much needed as
an independent and competent functionary to supervise and regulate the
state and circumstances of this class of poor patients. He should visit
every poor person wholly or partially chargeable, or proposed to be made
chargeable, to the parish, as being of unsound mind (p. 84), and make a
quarterly return to the parochial authorities and to the Lunacy Board (p.
87). He should also take in hand the selection of the residence and the
examination into the circumstances surrounding the patient (p. 89).
If the scheme of boarding the pauper insane in the vicinity of the county
asylums, in cottage-homes (see p. 90, and p. 145), were carried out, the
extent of the duties of the district inspector would be much curtailed,
inasmuch as a majority of such lunatics would fall within the sphere of
the asylum superintendents in all matters of supervision.
The subsequent publication of the "Evidence before the Select Committee on
Lunatics," 1859, enables us to refer the reader to other illustrations of
much weight, to show the pressing demand for an efficient inspection of
single cases, and for securing satisfactory returns of their condition,
particularly when paupers. The necessity for inspection is proved by Lord
Shaftesbury's exposure of the wretched state of single patients (at p. 33,
_et seq._), and the want of returns by the evidence of Mr. Gaskell (p.
134, _et seq._). The passages bearing on these points are too long for
quotation at this part of our work, and are very accessible (Blue Book
above-mentioned) to every reader desirous of seeing other evidence than
that adduced in preceding pages.
The appointment of the district medical officer would have this further
benefit with reference to out-door pauper lunatics, that it would set
aside discussions respecting the persons who should receive relief as
such; a circumstance, upon which turns, as noticed before (p. 84), the
question of the quarterly payment of two shillings and sixpence for each
lunatic visited. The district officer would possess an entire independence
of parish officials, and could not be suspected of any interested motive
in making his decision. In undertaking the inspection of this class of
pauper lunatics, he would certainly displace the parish medical officers,
and the small fee payable to these last would fall into the treasury of
the Lunacy Board; yet the loss to an individual union medical officer
would be scarcely appreciable; for the number of lunatics boarded out in
any one parish or portion of a parish coming under his care, would, in
every case, be very small; whilst, on the other hand, the sum in the
aggregate paid into the hands of the Commissioners, on account of all such
patients in the kingdom, would,--supposing, for example, our estimate of
8000 to be tolerably correct,--form a not inconsiderable sum; taking the
number mentioned, it would amount to £4000 per annum,--a useful
contribution to the fund for meeting the expenses of district medical
inspectors, and sufficient to pay the salary of eight such officers. But
the fee might be doubled without being burdensome to any parish.
Although the Commissioners in Lunacy might occasionally visit private
lunatics in their own homes, and more especially those boarded with
strangers, yet it would be impossible for them, even if their number were
doubled, to exercise that degree of supervision which is called for. This
would particularly be the case, were the system of registration, or of
reporting all persons under restraint on account of mental disorder or
mental weakness, carried out; and the only plan that appears for securing
the desired inspection of their condition, and of the circumstances and
propriety of their detention, is that of imposing the duty upon the
district medical officer. We have already suggested that this officer
should see all such cases when first registered; by so doing, he would be
brought into contact with the patients and their families, and would, as a
county physician, also constitute a less objectionable inspector than even
the Commissioners themselves in their character as strangers and as
members of a public Board.
The medical inspector's visit should be made at least four times a year,
and a moderate fee be paid on account of it to the general fund of the
Lunacy Board. If it were only half-a-guinea per quarter for each patient,
it would produce a considerable sum available for the purposes of the
Commission.
There is yet one other duty we would delegate to the district medical
officer, viz. that of visiting the private asylums not in the metropolitan
district, in company with the Committee of Visiting Justices, who,
according to the requirement of the present law, must join with themselves
a physician, in making their statutory visits. We conceive that the
assistance of such a physician as we would wish appointed in the capacity
of district medical officer, would render the magisterial visits more
satisfactory, and establish a desirable connexion between the Visiting
Justices and the Lunacy Board. We do hear, at times, of a species of
rivalry or of opposition between the visitors of private asylums and the
Commissioners, to the detriment of proprietors. If such an evil prevails,
one means of checking it would, we believe, be found in the position and
authority of the district medical officer when called on, as suggested, to
act as the visiting physician with the magistracy as well as the local
representative of the Commissioners in Lunacy.
On reviewing the duties to be undertaken by a district medical officer,
the propriety of the remarks with which we began this chapter will
appear:--viz. that he should occupy as independent a position as possible;
that, as a medical man, he should be free from all sentiments of rivalry,
and therefore not be engaged in practice,--or at least not in general
practice. It would be much better that he should not practise at all on
his own account, but should be so remunerated that he might devote all his
time and attention to the duties of his office.
He should receive a fixed annual stipend, and not be dependent on fees. By
this course, he could not be accused of having any interest in the
seclusion of the insane under his supervision. So, again, in order to
confer on him the necessary independence in the discharge of his duties,
his appointment should be made by the Lunacy Board with the concurrence of
the Home Secretary or of the Lord Chancellor,--not by the magistrates, nor
by any parochial authorities. It should also be a permanent appointment,
held during good behaviour, and revocable by the Commissioners only, after
an investigation of any charges of misconduct, and upon conviction.
The acquisition of the services of suitable and competent medical men
might be started as a difficulty in carrying out our scheme; yet it is
really of so little moment that it scarcely needs discussion. The
development of the country perpetually opens up new offices and creates a
demand for fitting men to fill them; but, by the law of political economy,
that where there is a demand there will be a supply, individuals rapidly
come forward who are adapted, or soon become adapted, to the new class of
duties. And so it would be on instituting the post of district medical
officer in each county or division of a county; for it is to be remembered
that the rapid extension of asylums has raised up a class of medical
practitioners specially conversant with the insane; so that, when a
vacancy occurs in any one such institution, qualified candidates spring up
by the dozen, and the difficulty is, not to find a suitable man, but to
decide which of many very suitable applicants is the most so. Moreover,
the anxiety, the mental wear and tear, and the greater or less seclusion
of an asylum superintendent's life, are such, that his retirement after
some fifteen or twenty years' service is most desirable, although his age
itself may not be so far advanced but that many years of active usefulness
are before him: to many such a retired superintendent, the post of
district medical inspector, even at a very moderate salary, would be
acceptable, whilst its duties would be most competently performed by him.
Our business has been to point out wherein a necessity appears for the
appointment of a district medical officer in the interests of the insane,
and to indicate, in general, the duties which would devolve upon him in
regard to them; but we may be allowed to hint at another set of duties
which, we are of opinion, might most advantageously be allotted to him,
and afford an additional argument in favour of creating him a public
servant, so paid as legitimately to demand his withdrawal from private
medical practice. The duties we mean are in connexion with medico-legal
investigations in cases of sudden and of violent death, of criminal
injuries, and of alleged lunacy; duties, by the way, which are exercised
by the district or provincial physicians in Continental States. We should,
by such an arrangement, obtain the services of a medical man expert in all
those inquiries and trials which come before the coroner's court and the
higher courts of law; we should obtain a skilled and experienced
physician, occupying a position perfectly independent of either side, in
any trial or investigation where a medical opinion or the result of
medical observation was called for. Medical witnesses, in a legal inquiry,
are not unfrequently blamed, and still oftener criticized, and perhaps
unfairly so, by their professional brethren, respecting the manner in
which they may have made an autopsy, or conducted the examination in other
ways, touching the cause of death, or an act of criminal violence; and
they are always exposed to the rivalry of their neighbours; and wishes
that some skilled individual had been sent for in their stead to conduct
the investigation, find their way into the public papers. Again, it should
be remembered that a medico-legal inquiry is an exceptional event in the
practice of most medical men: they bring to it no particular experience,
and generally they would much prefer to escape such investigations
altogether, as they seriously interfere with their ordinary avocations,
and obtain for them no adequate remuneration. Yet withal, the plan
proposed would far from entirely prevent their being engaged in the
subjects comprehended in the term 'Medical Jurisprudence,' or deprive them
of fees. As the actual practitioners of the country and always near at
hand, they would be the first sent for in any case, the history or
termination of which might involve a judicial inquiry; whilst, on the
other hand, the district medical officer would have to be summoned and
would act in the case only as the representative of the public interests
and of the public security. Lastly, the district medical officer in the
discharge of his duties would not render the services of special medical
jurists unnecessary; the chemist, for instance, would be as important in
his special calling as he is at the present time, wherever death by
poisoning was suspected.
It would be beside our purpose in this treatise to enlarge upon the
medico-legal duties which would devolve on the district medical officer in
the position in which we would place him, or on the benefits that would
accrue from his labour to public justice, and to the interests of the
State. Reflection upon the plan will, we believe, convince any reader, who
knows how matters now are, that it would lead to an immense improvement.
It appears to be a feature of our countrymen, both in public and private
affairs, that they will avoid, as long as possible, recourse to a system
or to a plan of organization; they seem to prefer letting matters go on as
long as they will in their own way, and only awake to a consciousness that
something is wanting when errors and grievances have reached their
culminating point, and a continuation in the old course becomes
practically impossible. Then, when the evil has attained gigantic
dimensions, when much injury has been inflicted, and an enormous waste in
time and money has occurred, committees of inquiry and special
commissioners are hastily appointed, a sort of revelry indulged in the
revelations of past misadventures and past folly and neglect; and some
scheme is seen to be imperatively necessary, the costliness of which must
be endured; and, perhaps, the conviction all at once arises, that the cost
of the needed plan of organization, which can be estimated, is in fact
much less than what has been submitted to, without attempting an estimate,
for a long time before.
We lag behind most countries on the Continent in our state medical
organization; our individual instruments are better, yet they are not
co-ordinated in any general system. We trust that this has been in some
measure shown in the preceding pages, and that it has been made out, that
if the insane, and more particularly those in private houses and those who
are paupers, are to be efficiently looked after, and their protection from
injuries and their proper care and treatment secured, some such scheme as
we have indicated is now called for. Surely evils have sufficiently
culminated, when at least one-half of the insane inhabitants of this
country have either no direct legal protection, are unknown to the
publicly-appointed authorities under whose care they ought to be, or are
so situated that their protection and their interests are most
inadequately provided for.
Did not a necessity for an improved and extended organization on behalf of
the interests of the insane exist, the plea of its cost would probably
defeat an attempt to establish it, notwithstanding the plainest proofs of
its contingent advantages, and of the fact that sooner or later its
adoption would be imperative. But, looking at the question merely with
reference to the cost entailed, we believe, that this would not be
considerable, and that, as a new burden, it would indeed be very small:
for, as we have pointed out, there are certain moneys now paid under Acts
of Parliament, which would, by the organization advocated, become
available towards defraying its expenses. For instance, the fee of ten
shillings per annum, payable for the quarterly visits to every pauper
lunatic not in asylums, would revert to the district officers; as likewise
would the fee payable to the physician called upon by the visitors to the
licensed houses in every county. We have also proposed a fee to be paid
for a quarterly visit to all county patients in lunatic asylums, and to
all private patients provided for singly, and are of opinion that a
payment should be made for each lunatic or 'nervous' patient, when
registered as such, whether pauper or not; the sum, in the case of a
pauper, however, of a smaller amount than that for a private lunatic.
Considering the character and extent of the supervision and attention
proposed to be rendered, and the numerous advantages, direct and indirect,
which would necessarily accrue from the establishment of the organization
suggested, there are certainly good grounds for enforcing payment for
services rendered, so as to make the whole scheme nearly, or quite,
self-supporting. To repeat one observation before concluding this
chapter,--it should be so ordered, that all moneys levied on account of
the visits of district medical officers, and of registration, should be
paid to the credit of the Lunacy Board, through the medium of which those
officers would receive their salaries.