Part 22

According to the present state of the law, there is no intermediate position for a person suffering from any form of cerebral agitation or of mental disturbance; he must be declared by certificate a lunatic, or his insanity must be called 'nervousness.' Under the latter designation of his malady, he cannot receive treatment in an Asylum or Licensed House; and yet, all his acts in behalf of his own affairs, that is, where his friends do not arbitrarily assume the power to act for him, may at any future time be disputed as those of a lunatic. Yet, as noticed more than once before, all the probable disadvantages of this anomalous position are risked in very many cases, and the best chances of recovery thrown away, because the friends (and the patient too very often) are unwilling to have him certified as a lunatic. An alteration, therefore, of the law seems much required in this matter. The Earl of Shaftesbury has met this want partially by the clause he has proposed in favour of 'nervous' patients, and his Lordship, in a preceding portion of his evidence (Queries 191-192), expressed himself in favour of mitigating the wording of the medical certificates required. We have also heard Dr. Forbes Winslow express sentiments to a similar effect, that the law ought to recognise the legality of placing certain patients suffering from some varieties of mental disturbance under treatment in licensed houses, and especially those who will voluntarily submit themselves to it, without insisting on their being certified as lunatics.

This is not an improper place in our remarks to direct attention to the proposition to legalize the establishment of intermediate institutions, of a character standing midway, so to speak, between the self-control and liberty of home and the discipline of the licensed asylum or house, to afford accommodation and treatment for those who would be claimants for them under the mitigated certificates above considered. Such institutions would be very valuable to the so-called 'nervous patients,' and to the wretched victims of 'dipsomania'--the furor for intoxicating drinks; for there are many advantages attending the treatment of these, as of insane patients, in well-ordered and specially arranged establishments, over those which can be afforded in private houses. It may likewise be added, that the facilities of supervision by the appointed public functionaries are augmented, and greater security given to the patients when so associated in suitable establishments. We add this because, although the certificates are mitigated in their case, and they are not accounted lunatics, yet we regard that degree of visitation by the Commissioners, indicated by Lord Shaftesbury, to be in every way desirable.

It is not within the compass of this work to enter into the details for establishing and organizing these retreats: they have been discussed by several physicians, and more particularly in Scotland, where, it would seem, examples of drunken mania are more common than in England.

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.