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.
Chap. IX.—Appointment of District Medical Officers.
Throughout the preceding portion of this book we have pointed out numerous instances wherein the legal provision for the insane fails in its object from the want of duly-appointed agents, possessing both special experience and an independence of local and parochial authorities; and we have many times referred to a district medical officer, inspector or examiner, as a public functionary much needed in any systematic scheme to secure the necessary supervision and protection of the insane, particularly of such as are paupers. We will now endeavour to specify somewhat more precisely the position and duties of that proposed officer; but, before doing so, we may state that the appointment of district medical officers is not without a parallel in most of the Continental States. In Italy there are provincial physicians, and in Germany Kreis-Artzte, or District-physicians, who exercise supervision over the insane within their circle, besides acting in all public medico-legal and sanitary questions. In our humble opinion, the institution of a similar class of officers would be an immense improvement in our public medical and social system. The want of public medical officers to watch over the health and the general sanitary conditions of our large towns has been recognised and provided for; although the machinery for supplying it is much less perfect than could be wished: for to entrust the sanitary oversight and regulation of populous districts to medical men engaged in large general practice, often holding Union medical appointments, and rarely independent of parish authorities, is not a plan the best calculated to secure the effectual performance of the duties imposed; for, as a natural result, those duties must rank next after the private practice of the medical officer, and constitute an extraneous employment.