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 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.