On the State of Lunacy and the Legal Provision for the Insane

Chap. IX. – Appointment of District Medical Officers

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.