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

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.