Part 24

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.

CHAP. X.--ON THE LUNACY COMMISSION.

We put forward our remarks upon this subject with all becoming deference; yet it was impossible to take a review of the state of Lunacy and of the legal provision for the insane without referring to it. Indeed, in previous pages several observations have fallen respecting the duties and position of the Commission of Lunacy, and the operation and powers of this Board have also formed the topic of many remarks and discussions in other books, as well as in journals, and elsewhere.

There appears to be in the English character such an aversion to centralization as to constitute a real impediment to systematic government. Various questions in social science are allowed, as it were, to work out their own solution, and are not aided and guided towards a correct one by an attempt at system or organization. Confusion, errors, and miseries must prevail for a time, until by general consent an endeavour to allay them is agreed upon, and a long-procrastinated scheme of direction and control is submitted to, and slowly recognized as a long-deferred good. Such is the history of the care and treatment of the insane. After ages of neglect, evils had so accumulated and so loudly cried for redress, that some plan of conveying relief became imperative; and it is only within our own era, that the first systematic attempt at legislation for the insane was inaugurated. From time to time experience has shown the existence of defects, and almost every Parliament has been called upon to amend or to repeal old measures, and to enact new ones, to improve and extend the legal organization for the care and treatment of lunatics and of their property.

One most important part of this organization was the establishment of the Lunacy Commission, which has given cohesion and efficacy to the whole. To the energy and activity of this Board are mainly due the immense improvements in the treatment of the insane which characterize the present time, and contrast so forcibly with the state of things that prevailed before this central authority was called into power. The official visitation by its members of all the asylums of the country has imparted a beneficial impulse to every superintendent; the Commissioners have gone from place to place, uprooting local prejudices, overturning false impressions, and transplanting the results of their wide experience and observation on the construction and organization of asylums, and on the treatment of the insane, by means of their written and unwritten recommendations, and by their official reports, which form the depositories of each year's experience.

An attempt to show the manifold advantages of this central Board would be here out of place; but we may, for example's sake, adduce the recent investigation into the condition of lunatics in workhouses, as one of many excellent illustrations of the benefits derived from an independent central authority. But, whilst illustrating how much and how long the supervision of independent visitors has been, and, in fact, still is needed over lunatics in those receptacles, it also proves that the existing staff is inadequate to fulfil the task. We have, indeed, suggested the appointment of a class of district medical officers who would relieve the Commissioners from the greatest part of the labour of inspecting workhouse lunatic wards, but we would not thereby entirely absolve them from this duty. An annual visit from one Commissioner to each Union-house containing more than a given number of lunatics would not be too much; and, to make this visit effectual, the Commissioner should be armed with such plenary powers as to make his recommendations all but equivalent to commands, though subject to appeal. At present the Lunacy Commissioners are practically powerless; the law orders their visits to be made, and sanctions their recommendations, but gives neither to them nor to the officers of the Poor Law Board the power to insist on their advice being attended to if no reasonable grounds to the contrary can be shown. In this matter, therefore, a reform of the law is called for. The court of appeal from the views of the Commissioners might be formed of a certain number of the members of the Poor Law Board and of the Lunacy Commission, combined for the purpose when occasion required.

The proposition has been made (p. 179) to institute a Committee of Visitors of Workhouses, chiefly selected from the county magistracy; and it is one that will no doubt be generally approved. But to the further proposition, that the supervision of workhouse lunatics should be entirely entrusted to these Committees, and that the Commissioners in Lunacy should not be at all concerned in it, we do not agree; for, in the first place, we wish to see the Lunacy Commissioners directly interested in every lunatic in the kingdom, and acquainted with each one by their own inspection or by that of special officers acting immediately under their authority; and, in the second place, we desire to retain the visitation of the members of the Commission in the capacity of independent and experienced inspectors. The advantages of an independent body of visitors, as stated in the Commissioners' 'Further Report,' 1847 (p. 93), chiefly with reference to asylums (see p. 192), have much the same force when applied to the visitors of workhouses,--that is, if the insane in these latter receptacles are to be placed on an equality, as far as regards public protection and supervision, with their more fortunate brethren in affliction detained in asylums. But, besides the arguments based on the advantages accruing from an independent and experienced body of visitors, there is yet another to be gathered from the past history of workhouses and their official managers: for among the members of Boards of Guardians, to whom the interests of the poor in workhouses are confided, are to be found, in a large number of parishes, magistrates holding the position of ordinary or of honorary guardians; and, notwithstanding this infusion of the magisterial element, we find that almost incredible catalogue of miseries revealed to us by the Lunacy Commissioners to be endured by the greater number of lunatics in workhouses. In fact, to assign the entire supervision of workhouse lunatic inmates to a committee of visiting Justices is merely to transfer the task to another body of visitors, who have little further recommendations for the office than the Boards of Guardians as at present constituted. From these and other considerations, we advocate not only the visitation of lunatics in workhouses by the district medical officers proposed, but also, at longer intervals, by one or more of the Commissioners or of their assistants; and, if this idea is to be realized, an increase of the Commission will be necessary, at least until Union-houses are evacuated of their insane inmates.

The beneficial results flowing from the visitation of asylums by the Lunacy Commissioners is a matter of general assent; and the opinion is probably as widely shared, that this visitation should be rendered more frequent. A greater frequency of visits would allay many public suspicions and prejudices regarding private asylums, and would, we believe, be cheerfully acquiesced in by asylum proprietors, who usually desire to meet with the countenance and encouragement of the Commissioners in those arrangements which they contrive for the benefit of their patients. The proceeding in question would, likewise, furnish the Commissioners with opportunities for that more thorough and repeated examination of cases, particularly of those which are not unlikely to become the subject of judicial inquiries. The ability to do this might, indeed, often save painful and troublesome law processes; for, surely, the careful and repeated examinations of the Commissioners, skilled in such inquiries, when terminating in the conclusion that the patient is of unsound mind, and rightly secluded, should be accounted a sufficient justification of the confinement, and save both the sufferer and his friends from a public investigation of the case.

The decision of the Lunacy Commissioners, we are of opinion, should be held equivalent to that of a public court, and should not be set aside except upon appeal to a higher court, and on evidence being shown that there are good reasons for supposing the original decision to be in some measure faulty. Is not, it may be asked, the verdict of a competent, unprejudiced body of gentlemen, skilled in investigating Lunacy cases, of more value than that of a number of perhaps indifferently-instructed men, of no experience in such matters, under the influence of powerful appeals to their feelings by ingenious counsel, and confounded by the multiplicity and diversity of evidence of numerous witnesses, scared or ensnared by cross-examination in its enunciation?

Again, the more frequent visitation of the insane by the Commissioners would be productive of the further benefit of obviating the imputation that patients are improperly detained after recovery; and it would also, in some cases, be salutary to the minds of patients, fretting under the impression of their unnecessary seclusion; for the inmates of asylums naturally look to the Commissioners for release, anticipate their visits with hope, and regret the long interval of two, three, or more months, before they can obtain a chance of making their wants known, particularly since they are conscious how many affairs are to be transacted during the visit, and that only one or two of their number can expect to obtain special consideration.

There is, moreover, a new set of duties the Commissioners propose to charge themselves with, involved in the clause of the Bill introduced in the last session of Parliament (clause 26), requiring information to be given them of the payment made for patients in asylums, in order to their being able to satisfy themselves that the accommodation provided is equivalent to the charges paid. This task will necessarily entail increased labour on the Commission, and lead, not only to inquiries touching the provision made for the care and comfort of the patients within the asylum, but also to others concerning the means in the possession of their friends, and the fair proportion which ought to be alloted for their use. In short, we cannot help thinking that the duties proposed will frequently lead the Commissioners to take the initiative in a course of inquiries respecting the property of lunatics available for their maintenance.

According to present arrangements, although every asylum in the country is under the jurisdiction of the Commissioners in Lunacy, yet, beyond the metropolitan district, their jurisdiction is divided, and the county magistrates share in it. Indeed, provincial asylums are placed especially under the jurisdiction of the magistrates, by whom the plans of licensed houses are approved, licences granted or revoked, and four visitations made in the course of each year; whilst the Commissioners, although they can, by appeal to the Chancellor, revoke licences in the provinces, are not concerned in granting them, and make only two visits yearly to each licensed house beyond the metropolitan district. This variety in the extent of the jurisdiction of the Lunacy Board in town and country, is, to our mind, anomalous, and without any practical advantage. If the magisterial authority is valuable in the regulation of asylums at one portion of the country, it must be equally so at another; the 'non-professional element' (Evid. Com., Query 126), if of importance in the country, must be equally so in the neighbourhood of the metropolis. We do not argue against the introduction of magisterial visitation of asylums, but against the anomaly of requiring it in the country and not in town, and against treating provincial asylums as not equally in need of the supervision of the Central Board with the metropolitan. We perceive a distinction made, but cannot recognize a difference. There is a single jurisdiction in the instance of one set of asylums, and a divided one in that of another; and yet the circumstances are alike in the two.

The real explanation of this anomaly in the public supervision and control of asylums, is, we believe, to be found in the fact of the inadequacy of the Lunacy Commission to undertake the entire work. The superiority of the Commissioners, as more efficient, experienced, and independent visitors, will be generally admitted; but they are too few in number to carry out the same inspection of all the private asylums in the country, as they do of those in the metropolitan district. The Commissioners are free from local prejudices, unmixed in county politics, and constitute a permanent, unfluctuating board of inspection and reference; whereas county and borough magistrates owe their appointment usually to political considerations and influence: politics are a subject of bitter warfare among them in most counties; local and personal prejudices and dislikes are more prone to affect them as local men; and, withal, the Committees of Visiting Justices are liable to perpetual change, and, out of the entire number elected on a committee, the actual work is undertaken only by a few, who therefore wield all the legal powers entrusted to the whole body.

A passage from the 'Further Report' of the Lunacy Commissioners (1847) recently referred to (p. 189) may be serviceably quoted in this place. Speaking of the extracts selected by them for publication in the Report, "to show that occasions are continually arising, where the intervention of authority is beneficial," the Commissioners proceed to remark that "the defects adverted to in the extracts may sometimes appear to be not very important; but they are considerable in point of number, and, taken altogether, the aggregate amount of benefit derived by the patients from their amendment, and from the amendment of many other defects only verbally noticed by the Commissioners, has been very great. It is most desirable that no defect, however small, which can interfere with the comfort of the patient, should at any time escape remark. A careful and frequent scrutiny has been found to contribute more than anything else to ensure cleanliness and comfort in lunatic establishments, and good treatment to the insane. These facts will tend to show how advantageous, and indeed how necessary, is the frequent visitation of all asylums. It is indispensable that powers of supervision should exist in every case; that they should be vested in persons totally unconnected with the establishment; and that the visitations should not be limited in point of number, and should be uncertain in point of time: for it is most important to the patients that every proprietor and superintendent should always be kept in expectation of a visit, and should thus be compelled to maintain his establishment and its inmates in such a state of cleanliness and comfort as to exempt him from the probability of censure. We are satisfied, from our experience, that, if the power of visitation were withdrawn, all or most of the abuses that the Parliamentary Investigations of 1815, 1816, and 1827 brought to light, would speedily revive, and that the condition of the lunatic would be again rendered as miserable as heretofore."