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

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.