To give these suggestions a legal force, his Lordship produced the following clauses as additions to the Lunacy Act (Evid. Comm. query 432, p. 43):—
“Whereas many persons suffer from nervous disorders and other mental affections of a nature and to an extent to incapacitate them from the due management of themselves and their affairs, but not to render them proper persons to be taken charge of, and detained under care and treatment as insane; and whereas such persons are frequently conscious of their mental infirmity, and desirous of submitting themselves to medical care and supervision, and it is expedient to legalize and facilitate voluntary arrangements for that object, so far as may be compatible with the free agency of the persons so affected, be it enacted, as follows:—
“Subject to the provisions hereinafter contained, it shall be lawful for any duly-qualified medical practitioner or other person, by his direction, to receive and entertain as a boarder or patient any person suffering from a nervous disorder, or other mental affection requiring medical care and supervision, but not such as to justify his being taken charge of and detained as a person of unsound mind. No person shall be received without the written request in the form, Schedule —., to this Act, of a relative or friend who derives no profit from the arrangement, and his own consent, in writing, in the form in the same schedule, the signatures to which request and consent respectively shall be witnessed by some inhabitant householder.
“The person receiving such patient shall, within two days after his reception, give notice thereof to the Commissioners in Lunacy, and shall at the same time transmit to the Commissioners a copy of the request and consent aforesaid. It shall be lawful for one or more Commissioners, at any time after the receipt of such notice aforesaid, and from time to time, to visit and examine such patient, with a view to ascertain his mental state and freedom of action; and the visiting Commissioner or Commissioners shall report to the Board the result of their examination and inquiries. No such patient shall be received into a licensed house.” Lord Shaftesbury proceeds to say that by this plan “every person, professional or not, who receives a patient into his house, or attends a patient in such circumstances, should notify it to the Commissioners; but we should not require them to notify it until after three months should have elapsed, because a patient might be suffering from brain fever, or a temporary disorder; but I would say that any person accepting or attending a patient in these circumstances should notify it to the Commissioners, after three months shall have elapsed from the beginning of the treatment.”
In the after part of his evidence (Query 921, p. 100), his Lordship desired to supply an omission in the preceding clause, viz. to make it compulsory on a medical man attending a nervous patient, and not only the person receiving one, to communicate the fact to the Commissioners, so that they might go and see him, and form their own judgment whether he should or should not be placed under certificate.
There is much that is excellent in the clauses suggested, yet some improvement is needed in their wording. Thus it is provided that a medical practitioner, or a person under his direction, may receive a ‘nervous’ patient, and the subsequent provisions are made in accordance with this principle, as though only medical men could receive such patients, or that they alone were amenable to the laws regulating their detention. Sir Erskine Perry detected this oversight (Query 434), and Lord Shaftesbury admitted the want of sufficient technicality in the drawing up of the clause.
Again, we do not conceive there is adequate reason for postponing the report of a case until three months after the commencement of the treatment; a delay, not imposed, indeed, under the clause as propounded, but implied in his Lordship’s subsequent remarks. To refer to the class of patients mentioned as properly exempt from a return to the Lunacy Commission until after three months have elapsed:—a case of so-called ‘brain fever’ is not likely to be sent from home to board with a medical man or other person during the existence of the acute malady commonly known under that term. On the other hand, genuine cases of acute mania get called by the same name, and such certainly ought to be reported to the Commissioners before the expiration of three months. Besides, the delay to notify ‘temporary disorder’ for so long a time is likely to be injurious and to defeat the object of the clause. Delirium or mental aberration lasting for three months is something more than a symptom of any one commonly recognized bodily disease, and rightly deserves the designation of madness; and, if this be the case, it also claims the supervision of the Commissioners or other duly appointed officers over its management, particularly when this is undertaken, with the object of profit to the person treating it. Moreover, the delay proposed involves an idea not flattering to the discernment and the powers of diagnosis of the members of the medical profession; for its intent, we take it, is solely to prevent giving unnecessary trouble and distress to all concerned, in having to send a notification of the disorder, while yet unconfirmed, to the Commissioners: an annoyance which ought never to happen; for every medical man should be able to distinguish the delirium of fever, of drinking, or of other corporeal conditions it is sometimes linked with, from insanity; and it would be very discreditable to the medical skill of any one not to find out the true nature of the case long before the expiration of three months. Further, for the sake of promoting early and efficient treatment, the notification of disorder, whether called ‘nervous’ or mental, should be given before the end of three months. The change from home to board with a medical man may be all that is desired for a ‘nervous’ patient; but if it be a case of recent insanity, something more than solitary treatment at home or in a private lodging is essential. The evils of the last-named plan are largely illustrated in the evidence of Lord Shaftesbury himself, and of other witnesses before the Select Committee. It is consequently desirable to have cases, under what designation soever they are received, reported before the close of three months, so that the Commissioners may see them and determine whether or not the conditions under which they are placed are conducive to their well-being and recovery, and may give their recommendations accordingly.
The proposition appended by the noble Earl, to the effect that every medical man attending a ‘nervous’ patient should communicate the fact to the Lunacy Commissioners, is most important, and in its scope approaches that of enforcing a registration, as advocated by ourselves: for we presume that his Lordship would desire the paragraph to be so worded, that the notice should be demanded from the medical attendant, as well in the case of a lunatic or alleged lunatic as in that of a so-called ‘nervous’ patient.
A similar defect attaches to the clauses proposed as to those actually in force under existing Acts; that is to say, the want of means of enforcing them. By the Act 8th and 9th Vict. cap. 100, sect. xlv., it is made a misdemeanour to receive or detain a person in a house without a legal order and medical certificates; and by sect. xliv. it is declared a misdemeanour to receive two or more lunatics into any unlicensed house. These clauses are, however, valueless in preventing the abuses they aim at checking; for, as so often said before, alleged and undoubted lunatics are perpetually received by persons into their private houses as ‘nervous’ patients, mostly without certificates, or, if under certificates, unreported to the Commissioners.
No solid argument is conceivable, why a person having two lunatics under charge should be liable to punishment for a misdemeanour, whilst another may detain one with impunity. The penalty should be similar in each case. The same legal infliction, too, should, we think, be visited alike upon the friends putting away a relative under private care and upon the individual receiving him. It might also be rendered competent for any relative or friend to call upon those concerned in secluding, or in removing the patient from home under restraint, to show cause for so doing; and the production of the medical certificates and of a copy of the notification sent to the Commissioners, with or without a certificate from such an officer as we propose as a district medical inspector, should serve to stay proceedings. The detention or the seclusion of a person, whether at home or elsewhere, contrary to his will, and at the sacrifice of his individual liberties and civil rights, appears to us tantamount to false imprisonment, and an act opposed to the principles of English liberty, whether it be perpetrated by relatives or strangers, if done without the knowledge and sanction of the law and of its administrators.
But whatever amendments be introduced, we hold them to be secondary to a complete system of registration of lunatics and ‘nervous’ patients rendered compulsory upon the medical men attending them, or taking them under their charge, and likewise upon the relatives, or, in the case of paupers, upon the relieving officers or overseers of their parish. The family medical attendant appears the most fitting person to make a return of the sort: his professional knowledge must be called in to testify to, or to decide on, the nature of the disease, and the fact can be best communicated by him in his medical capacity. The Lunacy Commissioners of Massachusetts had recourse to the physicians living in every town and village of the State; and it was only by so doing that they were enabled to arrive at an accurate knowledge of the number of the insane, and to correct the statistics gathered through other channels, which might, at first sight, have appeared ample to their discovery.
Further, as already noted, we advocate another step in conjunction with registration; for we would convey the notification of the existence of the alleged insane or nervous patient primarily to the district medical officer, and then call upon this gentleman to visit the patient, with every deference to family sensitiveness and necessary privacy, in order that he may make a report on the nature and character of the malady, and the conditions surrounding the patient, to the Commissioners in Lunacy. The immediate visitation of a reported case by such a skilled officer would be of advantage to the patient, to his friends, and to the Commissioners. Without overruling or controlling the medical attendant or others, his advice on the wants of the case would be useful, and he could fulfil one purpose proposed to be effected by a visit from the Commissioners, viz. that of signifying whether the patient should be placed under certificates or not; his opinion being subject to revision by the visiting Commissioners, should the nature of his report appear to them to call for their personal examination of the case. If, again, medical certificates were required, these might be countersigned by the district officer in question, after a separate examination, and an additional protection be thus applied against illegality in the legal documents required to sanction the patient’s restriction or detention. This plan would likewise afford a check to the transmission to the Lunacy Board of those insufficient certificates which at the present time involve such frequent trouble. But, although the district officer’s signature or certificate might by its presence be held to increase the validity of the evidence for a patient’s insanity, yet its absence, where his opinion differed from that of the medical men called in to sign the legal certificates, should not operate as a bar to dealing with the alleged lunatic as such, until an examination by one of the Board of Commissioners could be had; and therefore the registrar should be bound to transmit the order and certificates, when properly filled up, accompanied by his own report of the case.
Supposing these provisions just sketched to be carried out, and that an individual is found lunatic by his immediate medical attendants, by the official registrar, a perfectly disinterested person, and, sooner or later by the Commissioners, there certainly appears no reason why the lunatic himself, or any officious friend or sharp lawyer in search of business, should be able to challenge by legal proceedings a decision so cautiously arrived at by so many competent persons. The determination of a trial by jury we hold to be less satisfactory, and less likely to be in accordance with fact; so easy is it in some instances for a clever counsel to frighten witnesses, to get fallacious evidence, and to represent his client’s cause, and appeal to the passions of the jurors of very miscellaneous mental calibre, often with more feeling than judgment, and generally to use all those arts which are thought legitimate by the practitioners of the law to win a verdict.
There is one subject well deserving notice; one which acts as a stumbling-block to the treatment of mentally disordered persons, and will also do so, more or less, to registration; viz. the present legal necessity of placing all in the category of lunatics. The practical questions are, whether this proceeding is necessary, and if not, whether the present form of the order and medical certificates cannot be so modified, as to lessen the objections of friends to place their suffering relatives under the protection of the law and its officers; we should add, to remove the objections of patients themselves; for it is irritating to the minds of certain classes of the insane to know that they are accounted lunatics by law equally with the most degraded victims of mental disorder with whom they may find themselves associated; and it offers an impediment at times, as those conversant with the management of asylums know, to patients voluntarily submitting themselves to treatment.
The adoption of two forms of certificate, one for persons found to be of unsound mind, and the other for the class of ‘nervous’ patients, would undoubtedly involve some disadvantages. It would be the aim of all those in a position to influence opinion, to obtain the registration of their insane friends under the ambiguous appellation of ‘nervous’ patients; and this could be met only by placing it in the power of an officer attached to the Lunacy Commission to make the decision, after an examination of the patient, respecting the nature of the certificate required. Perhaps the examination to be made by a Commissioner, according to the scheme propounded by Lord Shaftesbury (p. 161), is intended, though not said to be so, to serve the purpose referred to; otherwise it would be a defect in his Lordship’s plan, that no person is empowered to discriminate the individuals he would legislate for as ‘nervous’ patients not properly the subjects for asylum treatment, from those mentally disordered persons who are so.
Although the introduction of a modified or mitigated form of certificate of mental unsoundness, besides the one now in use, may be open to the objection mentioned, and to others conceivable, yet it would, on the other hand, possess certain advantages, and would, among others, be certainly an improvement upon the present state of things, by promoting the registration of numerous cases now unknown to the administrators of the Lunacy Laws.
It would be impossible to draw the line rigidly between really insane persons and those suffering from temporary delirium, or ‘nervousness.’ No ready cut and dried definitions of insanity would serve the purpose, and the discrimination of cases in order to their return as ‘lunatic,’ or as ‘nervous,’ must within certain limits rest upon definitions imposed by law, and beyond these to common sense and professional experience. With such criteria to guide, no sufferers from the delirium of fever, of alcoholism, or other kindred morbid state, and no eccentric personages whose peculiarities are not necessarily injurious to themselves, to others, or to their property, should be brought within the operation of the laws contrived to protect positive mental disorder. They would not occupy the same legal position as those classes proposed to be under one or other form of certificate; for, in our humble opinion, all those under certificate, whether as insane or as ‘nervous’ patients, should be under like legal disabilities in the management of themselves and their affairs, and partake of equal legal protection. In the preamble to the clauses suggested by Lord Shaftesbury, the nervous disorder or other mental affection is very properly supposed to be of a nature and extent to incapacitate the sufferers from the due management of themselves and their affairs; that is, that they are to be rightly placed under similar civil disabilities with the insane;—a position, which could, moreover, not be relaxed even in favour of those voluntarily placing themselves under treatment, without giving rise to much legal perplexity and quibbling. But this last-named result we have some apprehension might ensue, if the next sentence of the clause to those quoted were retained: forasmuch as, farther to define the class of persons to be legislated for, this sentence requires that their disorder shall not render them proper persons to be taken charge of and detained under care and treatment as insane; a condition, which seems to exclude them from the catalogue of insane persons in the eye of the law, and therefore to relieve them from the legal disabilities attaching to lunatics; but, perhaps, it is from ignorance of law that we cannot conceive how it is proposed to provide for the care and official supervision of persons alleged to be incapacitated from the management of themselves and their affairs, and at the same time to pronounce them unfit to be dealt with as insane.
The Scotch Asylums Act (1857) contains a clause (41st) to authorize the detention of persons labouring under mental aberration, in its earlier stages, in private houses, under a form of certificate set forth in Schedule G, wherein the medical man certifies that the individual in question is suffering from some form of mental disorder, not as yet confirmed, and that it is expedient to remove him from his home for temporary residence in a private house (not an asylum), with a view to his recovery. This plan of disposing of a patient is permitted to continue for six months only. By some such scheme as this, it seems possible to bring the sufferers from disordered mental power within the cognizance of the public authorities appointed to watch over their interests, and at the same time to rescue them from being classed with the inmates of lunatic asylums, and from the frequently painful impression, in their own minds, that they are publicly considered to be lunatics. To avoid disputes and litigation, however, such patients should, even when under that amount of surveillance intimated, be debarred from executing any acts in reference to property, which might be subsequently called into question on the plea of their insanity.
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.
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.
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.