Part 23

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.