Analysis of the Evidence Op The Dill- Wyn Committer In So Far as it Refers to The Scotch Lunacy Acts and their Administration, with Remarks Thereon
44 Art. IV.?.# :Author: JAMES ROME, M.I). &c. Medical Superintendent Dundee Royal Lunatic Asylum, Dundee.
This voluminous Report?which consists of 582 pages, quarto size, of closely printed matter, contains 11,645 different questions and their replies, and weighs nearly 31bs. 8oz.?is the result of the examination of 63 witnesses by a Select Committee of the House of Commons, under the chairmanship of Mr. Stephen Cave. As the object of the present paper is not to consider the whole evidence, but only as much of it as concerns the Scotch Lunacy Laws and their administration, it will be necessary to take notice of the evidence of those witnesses only who refer to this subject, and who would appear to be five in number?namely, Sir James Coxe, Dr Arthur Mitchell, Dr Cameron, Dr Gilchrist, and Mr. William Balfour.
The evidence, however, naturally arranges itself into two divisions, which will be considered separately?1. As showing how far the present law in Scotland is satisfactory, in what respects defective, and the suggestions made for its further amendment; and 2, as exhibiting the results of the application of the present law as shown in the condition of the patients in asylums and poorhouses, and of those boarded out with friends and relatives and strangers, and the other effects of its adminis- tration generally.
Information on the former of these heads is afforded principally from the examination of the Commissioners in Lunacy, Sir James Coxe and Dr Arthur Mitchell. Both Commissioners begin by referring at considerable length to the differences existing between the Scotch and English laws as to the admission of patients into Asylums; and Dr Mitchell particularly speaks to the guarantees that are afforded by the Scotch law in preventing persons being improperly received into these Institutions. The first subject that appears worthy of mention, however, in regard to the admission of patients is the fact disclosed by Sir James Coxe in answer to questions 1949, 1950, and 1951?namely, that there is no limit laid down by the statute as to the time within which the petition and certificate must be presented to the sheriff for the purpose of obtaining his order; that ” in fact the certificate may be given to the sheriff six months after the patient has been seen by a medical man,” “provided the petition is also dated as far back.” This is certainly a curious omission and?although, as stated in reply to question 2109, that “in practice the sheriff would never grant his order upon old certificates “?there can be no difference of opinion that the suggestion there also made, ” that the medical certificates should be within a certain time of the application to the sheriff, instead of within a certain time of the date of the petition,” would be a satisfactory amendment of an evident defect in the law as it now stands.
A subject of greater importance, however, is raised by question 1958, namely?”To secure admission into an asylum in Scotland can the medical certificates be granted by English practitioners as well as by Scotch ?” To this Sir James Coxe replies, ” No ; they must be resident in Scotland under the Scotch law. It is the same in England; Scotch certificates are not accepted in England.” It woidd seem, however, that this opinion must be received with a certain amount of reservation, as the question has not been decided in any of the law courts. In answer to question 9961, Dr Mitchell states that, “in the year 1807, an opinion was obtained from the law officers of the Crown to the effect that certificates of lunacy granted by medical men resid- ing in Scotland could not be accepted in England, and in like manner that certificates of lunacy granted by medical men in England and Ireland could not be accepted in Scotland.” ” So far as I know, all the sheriffs of Scotland act on this opinion, except Mr. Sheriff Hope, who holds that lie is entitled and bound to interpret the law for himselt. I express no view,” continues Dr Mitchell, ” as to the soundness of the legal opinion given by the law advisers of the Crown ; but I think that the practice founded on it tends in some measure to prevent the improper committal of persons to asylums, and I also think that it causes no serious inconvenience to any one.” In corrobora- tion of the above Dr Gilchrist, in reply to question 4244, says ” that as regards the Sheriff ot Dumfries, he is perfectly willing in all cases signed by either Irish or English medical men to grant his warrant; he entirely opposes the Commissioners of Lunacy on the subject; he says it is perfectly legal.” It is obvious that it. would be extremely desirable that this unsatisfac- tory state of matters should be definitely settled, but when members of the legal profession differ so widely it would be to be guilty of more than presumption to offer any opinion as to which side is in the right. I may mention, however, that my own practice has been to insist on Scotch certificates being obtained when the patient has been brought from beyond Scotland.
The emergency certificate would seem to have attracted considerable attention, and to have been considered on the whole beneficial, although open to abuse. In reply to question 2202, Sir James Coxe thus defines its nature : “As it was originally” intended, a certificate of emergency was meant to be acted upon if a man were in a state of violent excitement which made it necessary to remove him immediately to an asylum. It is of course still made use of in this way, but in many cases the patient is sent into the asylum without any urgent necessity for immediate removal, and the sheriffs order is then got in a leisurely sort of way;” and in reply to question 2203?” Is not that a practice which is liable to the greatest abuse ? “?says,” It is liable to abuse, but I do not think it ever has been abused, I mean to the detriment of the patientand adds: ” When the Act was brought before the House I pointed out the risk to Lord Moncrieff, who was then Lord Advocate, and he said he thought that the action of damages, which would be sure to be raised upon any man getting out who was improperly confined, would be a sufficient guarantee against abuse.” Dr Mitchell, in reply to question 9898, in pointing out that this certificate may be granted by the medical officer of the asylum into whicli the patient is to be received, adds: ” I think it would be a sounder principle to prohibit every medical man connected with an asylum from granting any certificate on which would depend the admission of any patient into the asylum with which he was connected.” Few will deny the soundness of this principle. It has certainly often appeared to me to be a curious sort of legislation that enables a person by his own certificate to confer on himself the power of depriving another of his liberty, but the practical difficulty is to find a better arrangement. It frequently happens that owing to many circumstances, such as the ignorance of the relatives, or the nature of the case itself, a patient is driven into an asylum without certificates or papers of any kind, in such a condition that practically he cannot be sent out and kept out till these are procured ; say, for example, furiously maniacal and denuding himself of liis clothing, or with his throat cut, or otherwise seriously injured. In such cases, were the power of granting emergency certificates withdrawn from the medical officers of the asylum, they would evidently be left in a very unenviable dilemma; because they must either act illegally, and detain the patient without any authority whatever until the services of the nearest medical practitioner unconnected with the asylum could be procured, or they must outrage every principle of humanity by turning the patient out of doors. The extent to which this certificate is made merely a certificate of convenience is great, as may be seen from the fact that of the last 05 pauper patients admitted into the Dundee Royal Asylum the emergency certificate was granted in 42 instances. One curious point connected with this subject may be referred to, namely, that, so far as I can make out, there is nothing in the statute to prevent a patient from being detained in an asylum for an indefinite period by means of a repetition of the emer- gency certificate ; that is by discharging the patient at the end of every third day and having him immediately readmitted on a new certificate.
Another of those questions which must be left to the legal profession to settle satisfactorily, is the relation in which the duties of the sheriff stand to the facts indicating insanity em- bodied in the medical certificates. In reply to question 1954, Sir James Coxe says : ” The practice of different sheriffs varies. Some are particular, and object if the certificates are not satis- factory ; in that case the sheriff calls upon the certifier to amend the certificate; other sheriffs take less pains and are apt to adopt the certificates just as they are presentedand, in answer to question 2086, expresses his opinion that if ” it were made incumbent on the sheriff by statute to examine as to the competency of the certificates that are granted by the medical men, and judge of their validity and competency, that it would be an additional protection to the subject.” To this might have also been added, and a great protection to the medical profession in granting certificates of lunacy, as it would to a certain extent transfer the responsibility of deciding that the person certified was really a lunatic according to the common law of Scotland?which is the essence of the whole matter?from the medical man granting the certificate to the sheriff, who undoubtedly ought to be the judge of the question. As I already pointed out in a paper read before this Society in 1875,* this difference in the practice of the sheriffs has probably arisen in consequence of the confusion which was introduced into the statute by the alteration made in the statutory definition of lunacy by the Amendment Act of 1862. I then pointed out that, ” according to the definition clause of the Act of 1857, it was evidently the duty of those certifying persons to be insane, to satisfy themselves that the patient was a lunatic in terms of the common law of Scotland; and al- though this in many cases may prove no easy matter, in con- sequence of the obscurity which surrounds the subject, still great assistance was afforded to those granting certificates under this Act in so far as the certificates were, in a measure, subject to revision by the sheriff or his substitutes, whose duty it was to see that the facts mentioned in the certificates amounted to evidence of insanity in the legal sense, before granting their warrant for the transmission of the patient to an asylumthat “the definition adopted in the Act of 1862 may simply be said to have conferred on the general medical profession a power of manufacturing lunatics; for all that is now required under this Act is that the individual be duly certified by two medical persons to be a lunatic, an insane person, an idiot, or a person of unsound mind, and, whatever may be his real state of mind, a statutory lunatic he forthwith becomesand that ” it does not even appear to be obligatory on the sheriff or his sub- stitutes to examine the evidence of insanity given in the certificates ; it would seem to be sufficient that they satisfy themselves that the certificates are drawn up in due form.”
An important part of the evidence now under consideration has reference to the removal of the so-called harmless and in- curable insane to the lunatic wards of poorhouses. In answer to question 1966, Sir James Coxe explains “that all the pauper lunatics in Scotland, wherever they are placed, are under the authority of the Board of Lunacy ; whether they are in asylums or in lunatic wards of poorhouses, or in private dwellings, the Board of Lunacy takes cognisance of them; the Board grants its license to lunatic wards to receive patients of a certain class.” 1968?That they are harmless patients, ” generally after being discharged from the asylum, but sometimes they are admitted directly from their parishes?for instance, if helpless idiots.” 1969?That ” evory patient is admitted upon special permission from the Board of Lunacy. Every case is investigated and j udged upon its own merits.” 1970?That ” no person can be detained in the lunatic wards of a poorhouse ” ” not only not without the cognisance but not without the sanction of the Board. It is the sanction of the Board that then comes into play instead of the sheriff’s order. The sheriffs order is not in use for lunatic wards of poorhouses. Although patients may be admitted upon a sheriff’s order, yet in practice they very seldom are.” And again, in reply to question 1986?” What is the certificate for detention for poorhouses ? What is the duration and the scope of it ? “? replied, ” That is generally granted by the medical officer of the poorhouse; the patient is sent into the poorhouse, and as it re- quires the sanction of the Board to detain him, there is a certifi- cate which lasts for a week, which is granted by the medical officer of the poorhouse, or by any medical man, to the effect that the patient is in his opinion a fit subject to be placed in the lunatic wards, and authorising his temporary detention for a week until the decision of the Board of Lunacy can be had.” 1989?
That ” there is only one medical certificate required for admis- sion into the lunatic wards of poorhouses;” and (2192) further explains?” We (the Board) examine the lunatic wards and license them ; they must receive a license; the in then case of ever}’ patient who is admitted, the papers are submitted to us; we here take the place of the sheriff;” “our control over the lunatic wards of the poorhouse is simple hut sufficient.” Dr Mitchell gives similar evidence. After replying to question 9941, ” That the relieving officer cannot take a person into the poorhouse in Scotland and when there place him in the lunatic ward without the previous consent of the Commissioners,” he further explains, in reply to question 9942, as to whether it is upon certificates in the same way as regards all other patients? ” No, there is a difference in that respect, which I should like to point out. If these establishments are to be regarded as asylums, the uniformity of the Scotch procedure, to which I have alluded as an important feature, is so far broken. Pauper lunatics may be received into these institutions either on an order of the sheriff, or on an order of the Board of Lunacy, and in either case the order may be granted on one medical cer- tificate. In nearly all I have hitherto said, I have not re- garded these establishments as asylums. All kinds of mental disease cannot be received into them. Only patients Avho are incurable and inoffensive are admitted, and the single certificate which accompanies the application for their admission is specially designed to show that they are of this character, and suitable for admission into such institutionsand, after stating that 75 per cent, of the patients received into lunatic wards of poorhouses are cases transferred from asylums, he adds (9946): ” It would not, in my opinion, be a bad provision of the law, if no person could be admitted into the lunatic wards of the poor- house otherwise that by transference from an asylum.” Even were the practical effect of the law in regard to the admission of lunatics into poorhouses so satisfactory, that none but harmless and incurable cases are ever received into them? and it will be presently shown that this is far from being the case the most cursory examination of this evidence is enough to satisfy any one that the state of the law in regard to this matter is capable of considerable amendment. The clauses of the Act of Parliament which rule the licensing of lunatic wards of poorhouses and the admission of patients into them (iii. and iv. clauses, 25? and 26 Vic., cap 54) provide that the lunatics shall be only those ” who are not dangerous and do not require curative treatment,’’ and that their admission into these wards, and their detention therein, shall be ” according to forms and subject to regulations approved of by the Board.”
In other words, their admission and detention is not regu- lated by direct statutory enactment, but as it has been termed by a sort of bye law of the general Board of Lunacy. Looking then at the condition of patients in the asylums proper, and of those in the lunatic wards of poorhouses, from a legal point of view, we have this curious anomaly presented to us. In both cases the Act amounts to the deprivation of the subject of his liberty for a longer or shorter period, it may be for life ; but in the former case this can be done only on two independent medical certificates and the authority of the sheriff, while in the latter the same result may be arrived at on a certificate of the medical officer of a poorhouse and the sanction of an irresponsible Board ; for in judging of this matter it has also to be kept in mind that by clause viii., 20? and 21? Vic., cap. 71, it is specially provided that the Commissioners shall not be personally responsible for anything done bona fide in the execution of the Act. As illustrating a further differ- ence in which the liberty of the subject is treated in these two cases, it may be observed that, while all the patients who have been resident in an asylum for more than three years have to be thereafter certified annually by the superintendent as requiring continued detention, no such certificate is granted in the case of patients detained in these lunatic wards, although it is difficult to see why any difference should exist in practice. No doubt lunatic wards of poorhouses are not specially men- tioned in the clause of the Act referred to (vii. 29? and 30? Vic., cap. 51), the terms being ” any asylum or house ” wherein any patient is received and detained by a sheriff’s order; but we have already seen that Dr Mitchell at least would appear to entertain doubts whether these wards should not really be regarded as asylums.
When the subject is looked at from a medical point of view, the defects of the present state of the law are even more apparent. Although the control of the Board of Lunacy over the lunatic wards of poorhouses may be simple and sufficient, yet the mode in which patients may be selected for these wards must be regarded as open to grave objections. Where the wards are licensed for only a few patients the selection of suit- able cases is generally made by the superintendent of the asylum whence they are to be transferred. But when the license has been granted for a large number, as has been the case in Dundee, the following different modes of procedure have been adopted. The patients in the asylum have first been examined by the inspector of poor and governor of the poor- house ; the patients regarded by them as suitable have been taken note of, and the parochial medical officer afterwards sent to re-examine them and to certify as to their fitness for the wards of the poorhouse ; a sub-committee of the parochial board, accompanied by their medical officer, have taken the place of the inspector and governor with the same results ; while on other occasions the governor of the poorhouse, accompanied by the medical officer of the parish, have examined the patients, and those approved of by the former have been there and then certified by the latter. When the patients thus transferred to the poorhouses are found unsuitable, prove troublesome, or become dirty and degraded in their habits, they are replaced in the asylum on new certificates and the sheriff’s order?and a fresh examination of the patients is then made, and more patients selected until a sufficient number of manageable cases have been obtained to fill the lunatic wards to the extent for which they have been licensed. Frequent references have been made to the unsatisfactory nature of this system in the annual reports of the Dundee Asylum, and as far back as 18t>6 it was pointed out that “the requirements of the statute would have been more fully satisfied, had the Board extended to the parochial medical officers the restriction of incompetency which they imposed on the attendant medical officers of the poorhouse. One parochial medical officer at least has freely admitted that he loiks upon his certificate as a mere matter of form, and that the selection of the patients might as well be left entirely in tlie bands of the inspector of the poor or the governor of the poor- house. The effect on the asylum is obvious ; an undue propor- tion of paralytics, epileptics, and patients of degraded habits, accumulate; the percentage of recoveries is lessened in conse- quence of many of the patients removed being more or less convalescent, and often serious mischief is done to the recent and curable patients from the annoyance to which they are thus subjected and the fear they often have of being selected for transference. If the system of lunatic wards in connection with poorhouses is to be contim.ed-and from Dr Mitchells reply to question 9971 it would appear that they may even bo increased in number-it seems to me imperative that some alteration in the present state of the law should be made A more satisfactory state of matters could he easily brought about ?1. By more stringent legislation as to the nature of the cases to be received into these wards. 2. By adopting Dr Mitchells suggestion that no cases should be admitted into them unless they have previously been under treatment in a regular asylum. 3. By enacting that no cases shall he eligible for examination unless they have been under treatment in the asylum for a period not less than three years ; and 4. That the medical officer selecting the cases shall be alike independent both of the asylum and the parochial authorities, say one of the Commissioners in Lunacy.
A subject of considerable importance not only to those concerned in the detention of the insane but also to the general public, is the evidence given relative to powers conferred by the statute for the removal of patients from asylums who are harmless but not absolutely sane; and in considering’ this the remarks made by the witnesses examined as to the nature and operation of the prescriptive certificate determining the duration of the sheriff’s order required to be granted by the superintendents or medical officers of asylum in terms of vii. 29? and 30? Vic., cap. 51, may at the same time be discussed. In answer to question 2034?” What provision is there for taking patients out of custody or detention and restoring them to liberty ? “?Sir James Coxe replies: ” In the original Lunacy Act, the only person who could take persons out of asylums was the sheriff. The sheriff had and still has the power, upon receiving certificates from two medical men that the patient had recovered, or that the patient was in a state fit to be discharged, to order the removal of the patient. A like power was given to the Commissioners but restricted to recovered patients. They could not order any unrecovered patient to be taken out of an asylum. Of course the party who places the patient in an asylum can take him out at any time,” (2035) ” unless the superintendent certifies that he is in a dangerous state,” (2036) when “reference is made to the general Board of Lunacy to decide whether he is in a fit state,” (2037) and ” in the case of private patients the matter is referred to the fiscal, and the fiscal proceeds to take evidence upon it.” And in reply to question 2043, which certainly must be regarded as the most extreme view possible to take of the subject?” Sup- posing the superintendent considers that the patient ought not to be let out, and the relations do not want him to come out, but still he is sane; in such a case as that what chance is there of the patient being taken out ? ” ? replies : ” He would appeal to the Commissioners at their visits, and if they saw reason to think that he was sane, they would send two medical men to examine him; it is a frequent procedure with us. The difficulty with us is that we seldom get certificates of complete sanity, and then we fail to get the patient out;” and in answer to question 2046, “though he is an improper person to be there? ” adds ” that he is not, perhaps, an improper person to be there, but he is a person who might be out. It is difficult to say exactly what is a proper person to be in an asylum, there is statutory reason for his detention ;” and further, in answer to question 2052??’ But in fact, if the patient is perfectly harmless and might be at large without injury to himself, or anybody else, yet cannot be certified as entirely sane, lie may be detained in an asylum all liis life ?”?states, ” Yes, there is no doubt he may.” This witness further thinks that it would be ” an advantageous alteration of the law” and ” an additional protection to the liberty of the subject, if (2054) the “Board should have the power which is given to the sheriff, of allowing a man to get out upon certificates that he is harmless.”
Dr.Mitchell,in his evidence on the above subject,corroborates the opinion given by Sir James Coxe. Thus in his reply to question 10092 he says, ” the very fact of restoration to sanity makes the detention of a patient illegal. No particular procedure, however, is laid down by the law foi such a case. The superintendent simply discharges the patient as recovered, and gives notice of the discharge to the Boaid. If the patient thinks that he is still detained though he has reached a state of sanity, he can appeal to the Board, who can order his discharge on being satisfied by the certificate of two medical persons, whom they may think fit to consult, of his recovery or sanity. The Board cannot order the discharge of any patient of whose complete restoration or sanity they are not thus satisfied; but it is a provision of the law that any person having procured and produced the certificate of two medical persons approved by the sheriff, either of the recovery of any patient, or bearing that the patient may, without risk of injury to himself or the public, be set at large, may petition the sheriff to order his discharge, which order the sheriff is empowered to grant This procedure relates both to recovered and unrecoyered patients. The Board can thus only discharge recovered patients, but the sheriff can discharge both recovered and uncovered The Commissioners and the sheriff alike require to have the condition of the patient testified to by medical men of whom they approve And in answer to question 10095- ” 1 on think that it is a defect in the Scotch law that the Commissioner have not the same power as the sheriff to order the discharge of people who they think ought to come ont ?”-says, ?1 es we feel that it would be an advantage if we had that power, though we may often manage to obtain our end by other means.
With regard to the certificate which is required by the statute to continue the force of the sheriffs order after the patient has been three years in the asylum, Sir James Coxe observes 2059): ” I think, too, that it would be well to consider whether the present law which limits the duration of the sheriffs order is sufficient, because at present it is continued in force by the certificate of the superintendent or the proprietors of the asylum. I do not think,” he continues, ” there is any temptation to detain pauper patients : I think superintendents may be very well trusted to grant a certificate for pauper patients, but I am not sure that the proprietor of a private asylum should be trusted to continue the sheriff’s order in forceand (20(51) suggests as an improvement on the present practice that the power of continuing the sheriff’s order “should emanate from a medical man appointed by and acting for the sheriff.”
Now, with all due deference to the Commissioners, whose opinions this evidence represents, it seems to me that many,of the apparent obstacles which they declare to exist in the Scotch lunacy laws, against the discharge or removal of patients, both private and pauper, arise from a misconception of their true tenor and spirit. It is quite true that an apparent difference seems to exist between the powers of the Board and those of the sheriff, for while according to xcii. clause of 20? and 21? Vic., cap. 71, in regard to the sheriff’s powers, it is enacted that ” It shall be lawful for any person having procured and produced the certificate of two medical persons, approved by the sheriff, of the recovery of any lunatic, or hearing that such lunatic may, without risk of injury to the public or to the lunatic, be set at large, and also an order from the sheriff for the liberation of the lunatic, to require the superintendent of the asylum in which such lunatic is to liberate such lunatic, and such lunatic shall be liberated ac- cordingly ;” in regard to those of the Board, the same clause says: ” It shall, in like manner, be lawful for the Board, upon being satisfied by the certificate of two medical persons, whom they may think fit to consult of the recovery or sanity of any person confined as a lunatic, to order the liberation of such person.” It is here evident that the whole question at issue hinges on what is to be considered as the legal interpretation of the term “recovery ” or restoration to sanity, and nothing appears clearer to my mind than that, as it is necessary that a patient should not only be insane in the ordinary sense of the term, but also in some measure dangerous to himself or others, offensive to public decency, or in fact in such a state as would render him amenable to the operation of the ordinary protec- tive laws of Society, before he can be sent into an asylum; so these dangerous or offensive elements of the case must be in existence before he can be legally detained, and that as soon as they cease to be operative, the patient should be discharged, even although he may manifest delusions or other symptoms of what is popularly known as insanity, provided these delusions or symptoms be of a harmless nature. That such is really the case will be evident from a consideration of the xvii. clause, 2o? and 26? Vic., cap. 54, where it is enacted that ” when it shall appear to the superintendent of any asylum or house that any lunatic detained therein has so far recovered that he may he safely liberated without risk or injury to the public or the lunatic, such superintendent shall grant a certificate to that effect, or procure one from the ordinary medical attendant of such asylum or house, and shall transmit a copy thereof to the person at whose instance such lunatic is detained ; or in the absence of such person to the nearest known relative of the lunatic, and in the case of a pauper lunatic to the person or pari si 1 by whom the expense of the maintenance of the lunatic is defrayed; and on the failure within fourteen days from the despatch of such copy certificate of the person to whom the same was transmitted, to take steps for liberation of such re- covered lunatic, such superintendent shall intimate the facts to the Board, who may direct such inquiry into the circum- stances as they deem necessary, and if satisfied that the lunatic has recovered, or that he may be safely liberated without risk or injury to the public or himself, the Board may order his discharge forthwith.” It is clear from this clause that when a patient reaches such a state of convalescence that he may be safely intrusted with his freedom, that he is a recovered case in terms of the statute, and that if the Board can produce a certificate signed by two medical men, that any patient, private or pauper, may be liberated without risk or injury to the public or to himself, there can be but little difficulty in enforcing his discharge from any asylum. It was from a consideration of the light which this clause throws on the whole of the Scotch Lunacy Acts, that I was led in the paper already referred to to express the opinion that the clause terminating the power of the sheriff’s oider after the expiry of three years, unless continued by an annual certificate, was an extraordinary, impracticable, and an unnecessary piece of legis- lation, and this opinion would appear to be fully confirmed by the comparatively negative results which have followed its operation during the eleven years in which it has now been in force. The proposal to have this certificate granted by a medical man appointed by the sheriff, and who can have no practical acquaintance with the history and nature of the cases, instead of by the medical superintendent under whose care they are, appears to me also so clearly impracticable that it need require no further notice.
If it should, however, be thought by the Legislature ad- visable to take into consideration the question of granting exactly the same powers to the sheriff and Board of Lunacy, it might then be advisable to ascertain how far it would be an improvement that the medical men selected to examine any doubtful patient should be to the satisfaction of the superin- tendent of the asylum in which the patient is detained, as well as to the satisfaction of the sheriff and the Board. In this manner the case would be resolved into one simply of arbitra- tion, and would no doubt prove more satisfactory to all con- cerned.
Amongst what may be called the curiosities of the evidence may be noticed the subject raised by question 2077?” Can the police arrest an escaped lunatic ? “?The answer given is that the Board ” have never been able to decide exactly what powers the sheriffs order gives to the police, whether the police would be justified or not in arresting him. I do not think the question has ever been decided in a court of law. If a man were to get across the border into England, I believe he would be free : that the sheriffs order, whatever power it may have in Scotland, does not extend into England.” The presumption, however, is that, viewed legally, a lunatic being an individual dangerous to himself or others, or unable to look after himself, the police would be justified in taking in charge any one answering that description found at large.
Another is the question whether all letters written by lunatics in asylums should be sent to those to whom they are addressed. After explaining (10071) the statutory powers regulating the correspondence between patients and the Board of Lunacy, Dr Mitchell adds : ” I can scarcely see how there could be any compulsory forwarding of letters beyond this, though I think the grounds for not forwarding any letter should be well considered and strong. Where there is a free admis- sion of visitors, there will always be a free forwarding of letters. In Scotland it is seldom a subject of complaint that letters are not forwarded. I should like to add that, as regards the for- warding of letters to the Board, there is no difference whatever in Scotland between private patients and pauper patients, and no difference between private asylums and public asylums;” and in reply to question 10078?”Two proposals have been made : one is to adopt what I believe is the plan in some asylums in America, to have a post box in the asylum which is cleared by a regular postman, and from which every letter is sent, and the other is that all letters should be sent to the Commissioners, who would have a clerk who might sift the correspondence, and send on what he thought was fit to be sent on, retaining the rest, what is your opinion about that ? “?replies: ” I do not think any change is necessary, but of these two proposals, I think the second is the better. It would be a little hard to forward every letter, because by so doing you would pain a number of people; you would forward letters which would give p-reat distress to people ; and I think that if any change is resolved on, the second would be the better.” It is very doubtful how far even this would be an improvement. The propriety of sending letters written by patients depends so much on the individual circumstances of each case that it seems to me impossible that any clerk attached to the General Lunacy Board could discharge a duty at once so delicate and requiring so much discrimination, in anything like a satisfactory manner.
I will now conclude this portion of the subject by consider- in^ the evidence given on the question, whether any change seems desirable in regard to the medical attendauce on the in- sane in asylums, as some considerable attention has been already excited elsewhere on this matter. In reply to question 2092, {Sir James Coxe refers to the district asylums of Elgin and Banff “as beino- under the charge of laymen, non-medical men,” but visited sfTmany days a week, or daily, by a medical man froiv outside; and in reply to question 2093, whether these asylums are as well managed, and the patients as caiefully tieated, as they are in asylums where medical men hav e chaige, answers : ” I think they are just as well: I think the Banff Asylum is a model asylum in every way.” Again, in answer to question 2094-” Do you think in that respect, with inference to the curative treat- ment of patients, that the visit might be made by medical men resident in the district, without having medical men specially appointed as managers or superintendents . les, where you have a large asylum ; of course as the numbers increase there is always a greater demand for medical visits. In a small asylum a resident medical man is not necessaiy; in a arge asylum it becomes necessary from the frequency of ca h w it- l might be made upon him.” In further reference to the Banff Asylum, after stating that the number of patients 98 or 99, was as close to the extreme number as was permitted by the statute without a resident medical officer, he adds : ? There was a resident medical man originally. He had so little to do that upon the petition of the District Board to try how it would work with the appointment of a non-medical man as superintendent, we made the experiment, and the experiment has answeied remaikably well.” (2234) ? I think there is a great deal m the manage- ment of asylums that is non-medical. ^ I think the mode of management of this Banff Asylum, foi instance, depends very much upon the natural qualities of the superintendent, and his being a man who is well acquainted with the management of land. He employs the patients upon the land in a very satisfactory manner.” In reply to question 2243 ” Do I understand you rather to lessen the importance of medical treatment in asylums ? “?he answers: “No, but I think a great deal of the supervision of a good asylum is not medical. I think it is like the management of a large hotel, or something of that kind, and medical men are not necessarily the best hotel or farm managers.” He further explains his views on the special treatment of insanity in reply to question 2246?”ou have not much faith in the medical treatment of insanity as a special thing?”?when he states, “I have great faith in the medical treatment of insanity, by restoring the bodily functions to health, but I think you cannot treat insanity as a special entity. I think you must set to work to restore the health of the body, and that the mind then rights itself.”
In like manner, in answer to question 10000, whether he considers there is any necessity for a resident medical officer in a poorhouse with lunatic wards containing from 90 to 100 patients, Dr Mitchell replies: ” No, I do not think it is necessary. I am not quite certain that there is not a resident medical officer attached to the Edinburgh city poorhouse, but, if there is, his duties are chiefly with the ordinary paupers, and the medical officer whom we consider responsible for the patients is the superior officer of the poorhouse;” and in answer to question 10146?” You share the opinion of your colleague, Sir James Coxe, that the mode of supervision of an asylum, provided there are not 100 patients, need not necessarily be of a medical character?”?says: “I think experience lias put it beyond question that it can be satisfactorily done. The experience has been acquired by circumstances which we did not initiate; the experience is there, and it shows, I think, that it can be done very satisfactorily.” And in answer to 10147?”Why limit it to the number of 100; if 99 can be managed, why not 101 ?”? adds: ” We have no experience beyond this ; therefore I cannot go farther.”
The opinion here expressed would therefore appear to be that, although a number of carefully selected patients not exceeding 100 may be satisfactorily managed in lunatic wards attached to a poorhouse, or the same number of ordinary cases entrusted to the care of an exceptionally intelligent lay super- intendent, there does not exist any necessity for an alteration of the present law in this matter. There is no doubt a good deal of truth in the remarks which Sir James Coxe makes in regard to lay superintendents in asylums, especially those of small size, and that the successful management of even a large asylum does not essentially depend on the medical qualifications of the superintendent; for after all the medical wants of the patients have been attended to, no doubt much of the harmony of the Institution is the result of powers of general discipline and good management, which may unquestionably be possessed by persons not belonging to the medical profession. But, while this is admitted, it has to be kept in mind that the insane, taken as a whole, are not only mentally, but physically, below the average of the general community, and therefore entitled to a greater share of medical attention. Besides, there are no reasons for assuming that greater success in the management of asylums would result from the necessary absence of special medical qualifications. Complaints are continually made of the ignorance ot the general medical profession on the subject of insanity and the necessity urged of their being more thoroughly educated in this form of disease. It is, therefore, but reasonable to suppose that those who have made this subject their study, and by experience acquired a far more thorough knowledge of it than the general profession can ever possibly do by the most thorough tuition, should be the persons to whom the care of the insane ought to be committed, especially when it is kept in mind that in exceptional cases of illness?exceptional when regarded from an asylum point of view?the assistance and co- operation of physicians and surgeons of eminence can at any time be procured and indeed are frequently made use of. The difficulty is how to satisfy these two demands?experienced medical atten- dance and at the same time thorough discipline and general good management. In a large asylum, say containing over 200 patients, to adopt, the system of a lay superintendent and daily visits from an ordinary medical practitioner would evidently now not be tolerated, as it would be simply placing asylums in the position in which they were some 50 years ago. A satisfactory solution may, however, be found if a broader and more comprehensive view be taken of the whole subject than would appear to have as yet been entertained. In considering the whole matter, the fact must never be lost sight of that the question is not whether a limited number of the more manage- able lunatics can be kept in a satisfactory manner in wards attached to poorliouses specially ornamented for their reception, or whether a number of similar cases may not be boarded out among the peasantry without seriously violating the ordinary rules and principles of morality; but what really is the best system that can be adopted to maintain and supervise the insane poor with the greatest benefit to themselves and the least expense to the general community. A recent writer on this subject observes :* ” The extreme poverty of the inventive faculty in devising means for the reception of the insane is very striking. Of course this limit is imposed by pecuniary considerations, but it is very doubtful whether?first, the construction of a village for the incurable industrious around an asylum of ordinary dimensions would prove more expensive than a multiplication of blocks; second, whether the addition of farms or convalescent homes within a certain area, and at a short distance from the hospital for acute cases, might not prove more economical than the palatial structures at present provided; or, third, whether even the addition of large tenements of simple, unornamental form for chronic cases, within the grounds of the asylum proper, all these being under the superintendence of the same medical and other officers, might not meet the wants and the wishes alike of the curators of the insane, the ratepayers, and the general public.” While strongly in favour of some system such as is here indicated, it appears to me that the advantages of a lay superintendent referred to by Sir James Coxe might still be incorporated with it, and with the advantage of relieving the medical officers of much unprofessional work. Were the general management and economy of the asylum and surround- ing buildings confided to a lay superintendent, the medical officers would then be enabled to direct their attention without distraction to the more thorough performance of what must be considered as their proper duties, the medical treatment of the patients. Even in a large asylum this would not prove so onerous, but that similar duties might be engaged in beyond the boundaries of the asylum, and by none could the functions of local inspectors, as laid down in clause lsx., 20? and 21? Vict., cap. 71, be more thoroughly or efficiently performed than by the medical- officers of asylums. By this clause, which, so far as I am aware, has never been put in full operation, it is enacted that ” it shall be lawful for the District Board, in each of the several districts constituted by this Act, to appoint medical persons, one or more, as may from time to time be sanctioned by the Board, to be the inspector or inspectors of such district, and such inspector or inspectors shall hold their offices respectively at the discretion of the District Board, and shall be paid such fees as the District Board, with the sanction of the Board, may fix ; and it shall be the duty of such inspectors to visit the public, private, and district asylums and houses in terms of this Act, within their respective districts, at all such times as they shall be called upon to do so by the District Board, or the Board, or the sheriff, and otherwise in terms of this Act, &c.” In other words, were the duties of the medical officers of the central asylum extended to the district wherein it is situated and from which the patients are received, the harmless and imbecile patients residing with their friends or boarded out with strangers could be more frequently visited and consequently more thoroughly watched than they can possibly be at present. When they became violent or unmanageable, or otherwise unsuitable for being thus disposed of, they could at once be brought into the asylum and their places filled by more suitable cases, and thus the whole of the insane of the district supervised and controlled with much greater uniformity of principle and system than at present obtains. In this manner the efficiency of the General Board of Lunacy would also be increased and at a diminished cost to the community. On the one hand, this Board, relieved from the harassing and unprofit- able work of constant visitation and inspection, would naturally acquire higher and, as it were, quasi-judicial functions, and become, in fact, a sort of final Court of Appeal in all matters concerning the interests and welfare of the insane. On the other hand, the necessity of visitation and inspection, on the part of any members of the Board, becoming limited to those occasions only in which their interference might be called fox- by the local inspectors, directors of asylums, or District Boards, a much smaller staff of officials would be required than is found to be necessary under the present system of administration. Whether or not it would be a further improvement were the local inspector appointed by Government, as it is suggested in question 10181 superintendents of asylums might be, is also a matter well worthy of consideration.
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