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

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.