On the State of Lunacy and the Legal Provision for the Insane / With Observations on the Construction and Organization of Asylums

by J. T. Arlidge

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.