Chapter XI: Part 11

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.

Did not a necessity for an improved and extended organization on behalf of the interests of the insane exist, the plea of its cost would probably defeat an attempt to establish it, notwithstanding the plainest proofs of its contingent advantages, and of the fact that sooner or later its adoption would be imperative. But, looking at the question merely with reference to the cost entailed, we believe, that this would not be considerable, and that, as a new burden, it would indeed be very small: for, as we have pointed out, there are certain moneys now paid under Acts of Parliament, which would, by the organization advocated, become available towards defraying its expenses. For instance, the fee of ten shillings per annum, payable for the quarterly visits to every pauper lunatic not in asylums, would revert to the district officers; as likewise would the fee payable to the physician called upon by the visitors to the licensed houses in every county. We have also proposed a fee to be paid for a quarterly visit to all county patients in lunatic asylums, and to all private patients provided for singly, and are of opinion that a payment should be made for each lunatic or 'nervous' patient, when registered as such, whether pauper or not; the sum, in the case of a pauper, however, of a smaller amount than that for a private lunatic.

Considering the character and extent of the supervision and attention proposed to be rendered, and the numerous advantages, direct and indirect, which would necessarily accrue from the establishment of the organization suggested, there are certainly good grounds for enforcing payment for services rendered, so as to make the whole scheme nearly, or quite, self-supporting. To repeat one observation before concluding this chapter,--it should be so ordered, that all moneys levied on account of the visits of district medical officers, and of registration, should be paid to the credit of the Lunacy Board, through the medium of which those officers would receive their salaries.

CHAP. X.--ON THE LUNACY COMMISSION.

We put forward our remarks upon this subject with all becoming deference; yet it was impossible to take a review of the state of Lunacy and of the legal provision for the insane without referring to it. Indeed, in previous pages several observations have fallen respecting the duties and position of the Commission of Lunacy, and the operation and powers of this Board have also formed the topic of many remarks and discussions in other books, as well as in journals, and elsewhere.

There appears to be in the English character such an aversion to centralization as to constitute a real impediment to systematic government. Various questions in social science are allowed, as it were, to work out their own solution, and are not aided and guided towards a correct one by an attempt at system or organization. Confusion, errors, and miseries must prevail for a time, until by general consent an endeavour to allay them is agreed upon, and a long-procrastinated scheme of direction and control is submitted to, and slowly recognized as a long-deferred good. Such is the history of the care and treatment of the insane. After ages of neglect, evils had so accumulated and so loudly cried for redress, that some plan of conveying relief became imperative; and it is only within our own era, that the first systematic attempt at legislation for the insane was inaugurated. From time to time experience has shown the existence of defects, and almost every Parliament has been called upon to amend or to repeal old measures, and to enact new ones, to improve and extend the legal organization for the care and treatment of lunatics and of their property.

One most important part of this organization was the establishment of the Lunacy Commission, which has given cohesion and efficacy to the whole. To the energy and activity of this Board are mainly due the immense improvements in the treatment of the insane which characterize the present time, and contrast so forcibly with the state of things that prevailed before this central authority was called into power. The official visitation by its members of all the asylums of the country has imparted a beneficial impulse to every superintendent; the Commissioners have gone from place to place, uprooting local prejudices, overturning false impressions, and transplanting the results of their wide experience and observation on the construction and organization of asylums, and on the treatment of the insane, by means of their written and unwritten recommendations, and by their official reports, which form the depositories of each year's experience.

An attempt to show the manifold advantages of this central Board would be here out of place; but we may, for example's sake, adduce the recent investigation into the condition of lunatics in workhouses, as one of many excellent illustrations of the benefits derived from an independent central authority. But, whilst illustrating how much and how long the supervision of independent visitors has been, and, in fact, still is needed over lunatics in those receptacles, it also proves that the existing staff is inadequate to fulfil the task. We have, indeed, suggested the appointment of a class of district medical officers who would relieve the Commissioners from the greatest part of the labour of inspecting workhouse lunatic wards, but we would not thereby entirely absolve them from this duty. An annual visit from one Commissioner to each Union-house containing more than a given number of lunatics would not be too much; and, to make this visit effectual, the Commissioner should be armed with such plenary powers as to make his recommendations all but equivalent to commands, though subject to appeal. At present the Lunacy Commissioners are practically powerless; the law orders their visits to be made, and sanctions their recommendations, but gives neither to them nor to the officers of the Poor Law Board the power to insist on their advice being attended to if no reasonable grounds to the contrary can be shown. In this matter, therefore, a reform of the law is called for. The court of appeal from the views of the Commissioners might be formed of a certain number of the members of the Poor Law Board and of the Lunacy Commission, combined for the purpose when occasion required.

The proposition has been made (p. 179) to institute a Committee of Visitors of Workhouses, chiefly selected from the county magistracy; and it is one that will no doubt be generally approved. But to the further proposition, that the supervision of workhouse lunatics should be entirely entrusted to these Committees, and that the Commissioners in Lunacy should not be at all concerned in it, we do not agree; for, in the first place, we wish to see the Lunacy Commissioners directly interested in every lunatic in the kingdom, and acquainted with each one by their own inspection or by that of special officers acting immediately under their authority; and, in the second place, we desire to retain the visitation of the members of the Commission in the capacity of independent and experienced inspectors. The advantages of an independent body of visitors, as stated in the Commissioners' 'Further Report,' 1847 (p. 93), chiefly with reference to asylums (see p. 192), have much the same force when applied to the visitors of workhouses,--that is, if the insane in these latter receptacles are to be placed on an equality, as far as regards public protection and supervision, with their more fortunate brethren in affliction detained in asylums. But, besides the arguments based on the advantages accruing from an independent and experienced body of visitors, there is yet another to be gathered from the past history of workhouses and their official managers: for among the members of Boards of Guardians, to whom the interests of the poor in workhouses are confided, are to be found, in a large number of parishes, magistrates holding the position of ordinary or of honorary guardians; and, notwithstanding this infusion of the magisterial element, we find that almost incredible catalogue of miseries revealed to us by the Lunacy Commissioners to be endured by the greater number of lunatics in workhouses. In fact, to assign the entire supervision of workhouse lunatic inmates to a committee of visiting Justices is merely to transfer the task to another body of visitors, who have little further recommendations for the office than the Boards of Guardians as at present constituted. From these and other considerations, we advocate not only the visitation of lunatics in workhouses by the district medical officers proposed, but also, at longer intervals, by one or more of the Commissioners or of their assistants; and, if this idea is to be realized, an increase of the Commission will be necessary, at least until Union-houses are evacuated of their insane inmates.

The beneficial results flowing from the visitation of asylums by the Lunacy Commissioners is a matter of general assent; and the opinion is probably as widely shared, that this visitation should be rendered more frequent. A greater frequency of visits would allay many public suspicions and prejudices regarding private asylums, and would, we believe, be cheerfully acquiesced in by asylum proprietors, who usually desire to meet with the countenance and encouragement of the Commissioners in those arrangements which they contrive for the benefit of their patients. The proceeding in question would, likewise, furnish the Commissioners with opportunities for that more thorough and repeated examination of cases, particularly of those which are not unlikely to become the subject of judicial inquiries. The ability to do this might, indeed, often save painful and troublesome law processes; for, surely, the careful and repeated examinations of the Commissioners, skilled in such inquiries, when terminating in the conclusion that the patient is of unsound mind, and rightly secluded, should be accounted a sufficient justification of the confinement, and save both the sufferer and his friends from a public investigation of the case.

The decision of the Lunacy Commissioners, we are of opinion, should be held equivalent to that of a public court, and should not be set aside except upon appeal to a higher court, and on evidence being shown that there are good reasons for supposing the original decision to be in some measure faulty. Is not, it may be asked, the verdict of a competent, unprejudiced body of gentlemen, skilled in investigating Lunacy cases, of more value than that of a number of perhaps indifferently-instructed men, of no experience in such matters, under the influence of powerful appeals to their feelings by ingenious counsel, and confounded by the multiplicity and diversity of evidence of numerous witnesses, scared or ensnared by cross-examination in its enunciation?

Again, the more frequent visitation of the insane by the Commissioners would be productive of the further benefit of obviating the imputation that patients are improperly detained after recovery; and it would also, in some cases, be salutary to the minds of patients, fretting under the impression of their unnecessary seclusion; for the inmates of asylums naturally look to the Commissioners for release, anticipate their visits with hope, and regret the long interval of two, three, or more months, before they can obtain a chance of making their wants known, particularly since they are conscious how many affairs are to be transacted during the visit, and that only one or two of their number can expect to obtain special consideration.

There is, moreover, a new set of duties the Commissioners propose to charge themselves with, involved in the clause of the Bill introduced in the last session of Parliament (clause 26), requiring information to be given them of the payment made for patients in asylums, in order to their being able to satisfy themselves that the accommodation provided is equivalent to the charges paid. This task will necessarily entail increased labour on the Commission, and lead, not only to inquiries touching the provision made for the care and comfort of the patients within the asylum, but also to others concerning the means in the possession of their friends, and the fair proportion which ought to be alloted for their use. In short, we cannot help thinking that the duties proposed will frequently lead the Commissioners to take the initiative in a course of inquiries respecting the property of lunatics available for their maintenance.

According to present arrangements, although every asylum in the country is under the jurisdiction of the Commissioners in Lunacy, yet, beyond the metropolitan district, their jurisdiction is divided, and the county magistrates share in it. Indeed, provincial asylums are placed especially under the jurisdiction of the magistrates, by whom the plans of licensed houses are approved, licences granted or revoked, and four visitations made in the course of each year; whilst the Commissioners, although they can, by appeal to the Chancellor, revoke licences in the provinces, are not concerned in granting them, and make only two visits yearly to each licensed house beyond the metropolitan district. This variety in the extent of the jurisdiction of the Lunacy Board in town and country, is, to our mind, anomalous, and without any practical advantage. If the magisterial authority is valuable in the regulation of asylums at one portion of the country, it must be equally so at another; the 'non-professional element' (Evid. Com., Query 126), if of importance in the country, must be equally so in the neighbourhood of the metropolis. We do not argue against the introduction of magisterial visitation of asylums, but against the anomaly of requiring it in the country and not in town, and against treating provincial asylums as not equally in need of the supervision of the Central Board with the metropolitan. We perceive a distinction made, but cannot recognize a difference. There is a single jurisdiction in the instance of one set of asylums, and a divided one in that of another; and yet the circumstances are alike in the two.

The real explanation of this anomaly in the public supervision and control of asylums, is, we believe, to be found in the fact of the inadequacy of the Lunacy Commission to undertake the entire work. The superiority of the Commissioners, as more efficient, experienced, and independent visitors, will be generally admitted; but they are too few in number to carry out the same inspection of all the private asylums in the country, as they do of those in the metropolitan district. The Commissioners are free from local prejudices, unmixed in county politics, and constitute a permanent, unfluctuating board of inspection and reference; whereas county and borough magistrates owe their appointment usually to political considerations and influence: politics are a subject of bitter warfare among them in most counties; local and personal prejudices and dislikes are more prone to affect them as local men; and, withal, the Committees of Visiting Justices are liable to perpetual change, and, out of the entire number elected on a committee, the actual work is undertaken only by a few, who therefore wield all the legal powers entrusted to the whole body.

A passage from the 'Further Report' of the Lunacy Commissioners (1847) recently referred to (p. 189) may be serviceably quoted in this place. Speaking of the extracts selected by them for publication in the Report, "to show that occasions are continually arising, where the intervention of authority is beneficial," the Commissioners proceed to remark that "the defects adverted to in the extracts may sometimes appear to be not very important; but they are considerable in point of number, and, taken altogether, the aggregate amount of benefit derived by the patients from their amendment, and from the amendment of many other defects only verbally noticed by the Commissioners, has been very great. It is most desirable that no defect, however small, which can interfere with the comfort of the patient, should at any time escape remark. A careful and frequent scrutiny has been found to contribute more than anything else to ensure cleanliness and comfort in lunatic establishments, and good treatment to the insane. These facts will tend to show how advantageous, and indeed how necessary, is the frequent visitation of all asylums. It is indispensable that powers of supervision should exist in every case; that they should be vested in persons totally unconnected with the establishment; and that the visitations should not be limited in point of number, and should be uncertain in point of time: for it is most important to the patients that every proprietor and superintendent should always be kept in expectation of a visit, and should thus be compelled to maintain his establishment and its inmates in such a state of cleanliness and comfort as to exempt him from the probability of censure. We are satisfied, from our experience, that, if the power of visitation were withdrawn, all or most of the abuses that the Parliamentary Investigations of 1815, 1816, and 1827 brought to light, would speedily revive, and that the condition of the lunatic would be again rendered as miserable as heretofore."

We have in past pages referred to magisterial authority in relation with the pauper insane, as frequently exercised prejudicially, and with reference to asylum construction and organization, as sometimes placed in antagonism to acknowledged principles and universal practice, much to the injury of the afflicted inmates. Its operation is not more satisfactory when extended to the duties of inspection. We have heard complaints made that magistrates sometimes act very arbitrarily in their capacity of visitors to asylums, and that it is not uncommon for them, instead of acting in concert with the Commissioners in Lunacy, to place themselves in opposition to their views. In fact, the Annual Reports of the Commissioners testify to the not unfrequent want of harmony between the visiting magistrates and the Commissioners in Lunacy; and the very facts, that the latter have to make special yearly reports to the Lord Chancellor on the neglect or unfitness of certain private houses, and that they have sometimes to apply to him to revoke licences, demonstrate that the magisterial authorities are at times backward and negligent in their duties. Indeed, the impression to be gathered from the annual reports of the Commission is, that almost the only efficient supervision and control of provincial asylums are exercised by the Lunacy Commissioners.

The publication of the evidence before the Select Committee (1859) adds fresh proofs that magistrates make but indifferent visitors of asylums, and but imperfectly protect the interests of the insane; and that an extension of the jurisdiction and of the inspection by the Lunacy Commissioners is much needed. We would refer for particulars to queries and answers numbered from 2582 to 2605, and from 2788 to 2789.

We have commented in previous pages on the manner in which the Visiting Justices of public asylums perform their duties, and need not repeat the statements already made; yet we may here remark that the visitation of the wards of county asylums is often so very carelessly made, that it has little or no value, and that it is frequently difficult to get the quorum of two Justices to make it, the majority objecting on personal and other grounds.

From the foregoing considerations we would advocate the extension of the Commissioners' jurisdiction, and its assimilation to that in force within the metropolitan district. To extend it merely to thirty miles around the metropolis, as some have proposed, would be only to increase the anomaly complained of. The lunatics, and those in whose charge they live, in every district in England, should be under one uniform jurisdiction, with the authority and protection of one set of public officers and one code of rules. If magisterial supervision have a real value, let it be superadded to a complete scheme of inspection and control exercised by the Lunacy Commissioners; and if it exist anywhere, let no district be exempt from it; for the existence of any such exemption furnishes a standing argument against the value attributed to its presence. For instance, it may be fairly asked,--Are the metropolitan licensed houses any the worse for the absence of magisterial authority, or, otherwise, are the provincial any better for its presence?

According to Lord Shaftesbury's evidence,--and his Lordship is favourable to the authority of the Justices being perpetuated,--the system of licensing provincial houses is sometimes loosely conducted; the house is only known to the licensing magistrates by the plan presented, and its internal arrangements must be virtually unknown, inasmuch as no inspection is made of the premises. This furnishes an argument for handing over the licensing power to the Commissioners in Lunacy, who exercise this portion of their duties with the greatest care and after the most minute examination. But, besides this, the position of a magistrate does not afford in itself any guarantee of capacity for estimating what the requirements of the insane ought to be, or of judging of the fitness of a house for their reception. The act of licensing should certainly be conducted upon one uniform system and set of regulations; and the revocation of licences should likewise be in the hands of one body. No division of opinion should arise between a public Board and a Committee of Justices respecting the circumstances which should regulate the granting or the refusing, the continuation or the revocation of a licence. A divided, and therefore jarring jurisdiction, cannot be beneficial; and the arguments for the introduction of the magisterial element depend on the popular plea for the liberty of local government,--a liberty, which too often tends to the annihilation of all effectual administration.

If our views are correct, and if the jurisdiction of the Commissioners in Lunacy ought to be increased, then, as a result, the number of Commissioners must also be augmented. In the need of this increase, very many, indeed the large majority of persons acquainted with the legal provisions made for the care and treatment of lunatics, concur; and reasons for it will still further appear upon a review of the other functions assigned to the Commissioners, and of those with which we would charge them.

By existing arrangements there are two State authorities concerned with lunatics, one particularly charged with their persons, whether rich or poor,--the Lunacy Commission;--the other with their estates, and therefore, with those only who have more or less property,--the office of the Masters in Lunacy. Here, then, is another instance of divided jurisdiction, although it is one wherein there are no cross-purposes, the distinction of powers and duties being accurately defined in most respects. Perhaps the separation of the two authorities is too distinct and too wide, and a united jurisdiction might work better; but on this point we forbear to speak, not having the knowledge of the laws of property and of their administration necessary to guide us to a correct conclusion. Yet we may thus far express an opinion, that the visitation of lunatics, whether found so by inquisition or not, should devolve on the members of the Lunacy Commission. We can perceive no reason for having distinct medical visitors to Chancery lunatics; as it is, a large number of such lunatics is found in asylums and licensed houses, and comes therefore under the inspection of the Commissioners. Thus, according to the returns moved for by Mr. Tite (1859), it appears there are 602 lunatics, in respect of whom a Commission of Lunacy is in force, and of these, 300 are inmates of asylums; therefore one-half of the entire number of such lunatics is regularly inspected by the Lunacy Commissioners, and the visits of the "Medical Visitors of Lunatics" are nothing else than formal; we would therefore suggest that two Assistant Commissioners should be added to the Lunacy Board, who should receive the salaries now payable to the Chancery lunatics' medical visitors, be disallowed practice, and be entirely engaged as medical inspectors under the direction of the Board; or that, in other words, the moneys derived from the Lunacy Masters' office should be paid over to the Commission for its general purposes, upon its undertaking to provide for the efficient protection and visitation of all lunatics, so found on inquisition.

The plan of bringing all lunatics and all so-called 'nervous' patients, whether placed out singly or detained in asylums of any sort under the cognizance and care of the Commission, as enlarged upon in previous pages, would materially augment the labours of the central office; and, in our humble opinion, a greater division of labour than has hitherto marked the proceedings of the Commission would greatly facilitate the work to be done. At present, the members of the Commission perform a threefold function; viz. of inspectors, reporters, and judges. The task of inspecting asylums and their insane inmates, of ascertaining the treatment pursued and examining the hygienic measures provided, is peculiarly one falling within the province of medical men, and should be chiefly performed by medical Commissioners. On the other hand, the business of the Board, in its corporate capacity, is only indirectly and partially medical. Lord Shaftesbury, indeed, goes so far as to say (query 14, Evid. Com.) "that the business transacted at the Board is entirely civil in ninety-nine cases out of one hundred. A purely medical case does not come before us once in twenty Boards." These considerations certainly appear to indicate a natural and necessary division of the Board into a deliberative central body, sitting _en permanence_, once, twice, or oftener in the week, if necessary, and a corps of visitors and reporters to examine the state of asylums and the insane throughout the country. This division of the Commission would obviate the chief objection to an increase of the number of members; viz. that a larger number of Commissioners than at present would render the Board unwieldy, and rather impede than facilitate its business as a deliberative assembly. We entertain, moreover, the opinion that it would be more satisfactory to those who sought instructions, or whose affairs or conduct were in any way the subject of investigation, to have to deal with such a permanent deliberative or judicial body as proposed, than with one combining, like the members of the present Board, the various functions of inspectors, reporters, and judges; a condition, whereby any question agitated must, to a certain extent, be prejudged by the official reports of the very same persons called upon to examine it.

Again, if this proposed division of the Lunacy Board took place, it would furnish a better justification for increasing certain of its powers, as these would be wielded by a permanent deliberative body, instead of, as at present, by a Commission exercising mingled functions. The value of the Board would be increased as a court of reference in all matters, such as the construction and the size of asylums, where the authority of the State, by duly ordered channels, is called for to overrule the decisions of local administrative bodies. Lastly, this arrangement would facilitate the amalgamation, proposed by some persons, of the office of the Masters with the Commission in Lunacy; or it would, at least, render the co-operation and combined action of the two offices more simple and easy.

There are other reasons for an increase of the staff of the Lunacy Commission, following from the amount of work which, by any revision of existing statutes, must fall within the compass of its operations. For instance, we regard the suggestion that we have made, that no uncured lunatic or 'nervous' patient should be removed from an asylum or other establishment, without the sanction of the Commissioners and their approval of the place and conditions to which the removal is intended,--as very important for the protection of the insane. To carry out this duty will involve a certain amount of labour, particularly as it would often require some member of the Commission to examine the patient and the locality in which it is proposed to place him, and to report on the expediency of his removal. Often, perhaps, this business might be entrusted to the district medical officer, particularly in the country. On the other hand, in the metropolitan district, the work of district medical officers might be advantageously performed,--at least in all that concerns the insane,--by a couple of the Assistant Commissioners hereafter spoken of, in addition to their other duties elsewhere.

Another piece of evidence, to our apprehension, that the present Commission is inadequate to the multifarious duties imposed upon it, is, that the Commissioners have never hitherto effectually inspected gaols, nor succeeded in getting imbecile and lunatic criminals reported to them with the least approach to accuracy. The inspection of workhouses proved that it did not suffice to receive the reports of workhouse officials respecting the existence and number of insane inmates, but that, to ascertain these facts, personal examination by the Commissioners was necessary; and there is no satisfactory reason for supposing the discrimination of insane prisoners to be much better effected than that of workhouse lunatics, in the many prisons distributed over the country. It comes out, in the course of the evidence before the Select Committee, 1859, that the Commissioners know little about the insane inmates of gaols, and that reports of the presence of such inmates are but rarely supplied them. The law requires the Commissioners to visit gaols where any lunatics are reported to them to exist; but the duty of reporting is made the business of no particular individual, and therefore, as a natural consequence, no one attends to it. In the evidence referred to, the case of ten alleged lunatics, committed to York Castle and imprisoned there for a series of years, as criminals acquitted on the ground of insanity, elicited much attention, and Lord Shaftesbury alluded to the interference of the Lunacy Commission on behalf of several lunatics in different prisons. The fact we have brought to light from one Government report, as stated at p. 6 of this treatise, is of much moment in discussing the present subject; viz. that there were as many as 216 persons of unsound mind in the ten convict prisons under the immediate control of the Government, in the course of one year, and that of these the Dartmoor Prison wards contained as many as 106 such inmates. There is no allusion, in the Commissioners' reports or in the printed evidence of the Select Committee, to show that these insane prisoners were visited by, or known to, any members of the Lunacy Board. But, besides these insane inmates thus distinctly made known to us to exist in so few prisons, there must be many more detained in the numerous houses of detention throughout the kingdom. These facts render it an obvious duty on the part of the Commission of Lunacy to ascertaining the number and condition of this unhappy class of lunatics, and to order suitable provision to be made for them. There is a disposition on the part of some visitors of gaols to erect, or set apart, special wards for lunatic prisoners; a system to be much more deprecated than even the establishment of lunatic wards in connexion with workhouses, and one which will require the active interposition of the Lunacy Board to discourage and arrest.

It were easy to take up the duties of the Commissioners in Lunacy in detail, and to show that they cannot be efficiently performed by the existing staff; but the fact will be patent to any attentive reader of this chapter and of the foregoing dissertations on the provisions necessary for the care and supervision of lunatics in general. The scheme which we have, with all due deference to established authorities, sketched in outline, to increase the jurisdiction and usefulness of the Lunacy Commission, provides for a division of its staff; in the first place, by altering to a greater or less extent the character and position of the present Board, so as to constitute it a fixed central Commission or Council, chiefly charged with adjudging and determining questions put before it; with superintending the public arrangements for the interests of the insane generally, and with providing for the good and regular management, organization, and construction of lunatic asylums; and in the next place, by instituting, in connexion with this head deliberative body (which need not, by the way, consist of so many members as the present Commission), a corps of Assistant Commissioners, specially charged with the duties of visitation, inspection, and reporting, and with the carrying out of the resolutions determined on by the deliberative council. At the same time, the power of visiting and reporting might still be left with some Commissioners under certain circumstances, as well as in making special investigations, and in examining matters of dispute raised upon the reports of the Assistants.

Though differing from so high an authority as the noble chairman of the Lunacy Board, we must say that we cannot conceive of it as at all a necessary consequence, that, if the work of visitation to asylums and lunatics is performed by a class of inspectors or Assistant Commissioners, and not by the present members of the Commission, it must be indifferently done, and prove a source of dissatisfaction:--that is, we have no such apprehensions, provided always that proper men are appointed, and that their official status is made what it ought to be, both in remuneration and in independence of position. Nor can we agree to the giving up of the proposed plan on the score of its expense. If the whole of the lunatic and 'nervous' people suffering confinement in this country are to be brought within the knowledge and under the supervision of the Lunacy Commissioners, if the enlarged provisions of the law necessary for their proper care and treatment,--and even those only among them proposed by the Commissioners themselves are to be carried into effect,--the Commission must be increased. And, instead of adding new Commissioners on the same footing and salary as the existing ones, we believe the public would be better served by the appointment of Assistant Commissioners with the duties we have proposed,--two of whom could be remunerated at the same outlay as one full Commissioner. Moreover, we have proposed that the sum payable out of the Masters' office to medical visitors be devoted to the purposes of the Commission; and, if our notion of a central deliberative body were accepted, one legal and one medical member of the present Commission could well be spared to undertake more especially the duties of visiting Commissioners.

Lastly, if the jurisdiction and powers of the Commission were extended to all lunatics living singly and to so-called 'nervous patients,' a considerable addition to the treasury would be obtained, even by a small tax, or per-centage on income. Probably six Assistant Commissioners, constantly employed in the work of inspection, with the aid of two visiting chief Commissioners from the present Board, would suffice for the discharge of the duties to be entrusted to them. If so, the cost of six such additional officers would be very trifling, covered as it would be by increased funds passing into the hands of the central office in the administration of the improved legislation.

If precedent be a recommendation to a plan, it can be found in favour of appointing Assistant Commissioners in the example of the Scotch Lunacy Commission, and in the constitution of the Poor Law Board, which has a distinct class of officers known as inspectors. In fact, every other Government Board or Commission, except that of Lunacy, has a staff of Assistants or of Inspectors.

CHAP. XI.--ON SOME PRINCIPLES IN THE CONSTRUCTION OF PUBLIC LUNATIC ASYLUMS.

In the preceding pages of this book we have had occasion to discuss many important points respecting the organization of public asylums; and, as we entertain some views at variance with the prevalent system of asylum construction, a supplementary chapter to elucidate them cannot be misplaced. The substance of the following remarks formed the subject of a chapter on Asylum Construction published by us in the 'Asylum Journal' (vol. iv. 1858, p. 188) above a year since, and, as we then remarked, the principles put forward had been adopted by us some five or six years previously, and were strengthened and confirmed by the extended observations we had personally made more recently on the plans and organization of most of the principal asylums of France, Germany, and Italy.

All the public asylums of this country are, with slight variations, constructed after one model, in which a corridor, having sleeping-rooms along one side, and one or more day-rooms at one end,--or a recess (a sort of dilatation or offset of the corridor at one spot), in lieu of a room, constituting a section or apartment fitted for constant occupation, day and night, forms--to use the term in vogue--a 'ward.' An asylum consists of a larger or smaller number of these wards, united together on the same level, and also superposed in one, two, three, and occasionally four stories. There are, indeed, variations observed in different asylums, consisting chiefly in the manner in which the wards are juxtaposed and disposed in reference to the block and ground plans, or in the introduction of accessory rooms, sometimes on the opposite side of the corridor to the general row of small chambers, to be used as dormitories or otherwise; but these variations do not involve a departure from the principle of construction adopted.

Those who have perambulated the corridors of monastic establishments will recognize in the 'ward-system' a repetition of the same general arrangements,--a similarity doubtless due in part to the fact of ancient monasteries having been often appropriated to the residence of the insane, and in part to the old notions of treatment required by the insane, as ferocious individuals, to be shut apart from their fellow-men.

Whilst the ideas of treatment just alluded to prevailed, there was good reason for building corridors and rows of single rooms or cells; but, since they have been exploded, and a humane system of treating the insane established in their place, the perpetuation of the 'ward-system' has been an anomaly and a disastrous mistake. The explanation of the error is to be found in the facts,--that medical men in England, engaged in the care of the insane, have contented themselves with suggesting modifications of the prevailing system,--than which indeed they found no other models in their own country; and that the usual course has been, to seek plans from architects, who, having no personal acquaintance with the requirements of the insane, and the necessary arrangements of asylums, have been compelled to become copyists of the generally-approved principle of construction, which they have only ventured to depart from in non-essential details, and in matters of style and ornamentation.

The literature of asylum architecture in this country evidences the little attention which has been paid to the subject. The only indigenous work on asylum-building--for the few pages on construction in Tuke's introduction to his translation of Jacobi's book, and the still fewer pages in Dr. Brown's book on asylums, published above twenty years ago, do not assume the character of treatises--is the small one by Dr. Conolly, and even this is actually more occupied by a description of internal arrangements in connexion with the management of lunatics, than by an examination of the principles and plans of construction. This bald state of English literature on the subject of construction contrasts strongly with the numerous publications produced on the Continent, and chiefly by asylum physicians, the best-qualified judges of what an asylum ought to be in structure and arrangements.

However, to resume the consideration of the 'ward-system' as it exists, let us briefly examine it in its relations to the wants and the treatment of the insane. Every day adds conviction to the impression, that the less the insane are treated as exceptional beings, the better is it both for their interests and for those who superintend them. In other words, the grand object to be kept in view when providing for the accommodation of the insane, is to assimilate their condition and the circumstances surrounding them as closely as possible to those of ordinary life. Now, though it is clearly impracticable to repeat all the conditions of existence prevailing in the homes of the poorer middle and pauper classes of society who constitute the inmates of our public asylums, when these persons are brought together to form a large community for their better treatment and management, yet we may say of the 'ward-system,' that it is about as wide a departure from those conditions as can well be conceived. It is an inversion of those social and domestic arrangements under which English people habitually live.

The new-comer into the asylum is ushered into a long passage or corridor, with a series of small doors on one side, and a row of peculiarly-constructed windows on the other; he finds himself mingled with a number of eccentric beings, pacing singly up and down the corridor, or perhaps collected in unsocial groups in a room opening out of it, or in a nondescript sort of space formed by a bulging-out of its wall at one spot, duly lighted, and furnished with tables, benches, and chairs, but withal not a room within the meaning of the term, and in the patient's apprehension. Presently, he will be introduced through one of the many little doors around him into his single sleeping-room, or will find himself lodged in a dormitory with several others, and by degrees will learn that another little door admits him to a lavatory, another to a bath, another to a scullery or store-closet, another to a water-closet (with which probably he has never been before in such close relation), another to a _sanctum sanctorum_--the attendant's room, within which he must not enter. Within this curiously constructed and arranged place he will discover his lot to be cast for all the purposes of life, excepting when out-door exercise or employment in a workroom calls him away: within it he will have to take his meals, to find his private occupation or amusement, or join in intercourse with his fellow-inmates, to take indoor exercise, and seek repose in sleep; he will breathe the same air, occupy the same space, and be surrounded by the same objects, night and day.

This sketch may suffice to illustrate the relations of a ward as a place of abode for patients, and to exhibit how widely different are all the arrangements from those they have been accustomed to. Let us now notice briefly the relations of the ward-system to the treatment required for insane inmates. The monotonous existence is unfavourable: the same apartment and objects night and day, and the same arrangements and routine, necessitated by living in a ward, are not conducive to the relief of the disordered mind. Where access to the sleeping-rooms is permitted by day, the torpid and indolent, the melancholic, the morose and the mischievous, will find occasion and inducement to indulge in their several humours; opportunity is afforded them to elude the eye of the attendants, to indulge in reverie, and to cherish their morbid sentiments. When the rules of the institution forbid resort to their rooms by day, the idea of being hardly dealt with by the refusal will probably arise in their minds, since the inducement to use them is suggested by their contiguity; the doors, close at hand, will ever create the desire to indulge in the withheld gratification of entering them. How many insane are animated with a desire to lounge, to mope unseen, and to lie in bed, needs not to be told to those conversant with their peculiarities; and, surely, the removal of the temptation to indulge would be a boon both to physician and patients.

Again, the corridor and its suite of rooms present obstacles to ventilation and warming, and, as the former in general serves, besides the purpose of a covered promenade, that of a passage of communication between adjoining wards, it is less fitted for the general purposes of daily life, and the passage to and fro of persons through it is a source of disturbance to its occupants, and often objectionable to the passer-by. As a place of indoor exercise, the corridor has little real value, especially when considered in relation to the other objects it has to serve. Those who desire to sit still, to read, to amuse or to employ themselves, feel it an annoyance to have one or more individuals walking up and down, and often disposed to vagaries of various sorts; few of the whole number care for perambulating it if they can get out of doors for exercise (and there are not many days when they cannot), and, as far as concerns the health of those few who use the corridor for exercise, it would be better to encourage them to walk in the grounds, than, by having such a space within doors, to induce their remaining there.

When casual sickness or temporary indisposition overtakes a patient, and a removal to the infirmary ward is not needed, though repose is required, it is a great disadvantage to have an exercising corridor in such immediate contiguity with the bedroom, and to have the room open into the corridor; for it is an arrangement more or less destructive of quiet, and exposes the poor sufferer to the intrusion of the other inmates of the ward, unless the room-door be locked,--a proceeding rarely advisable under the circumstances supposed.

The introduction of the plan of building an open recess in a corridor as a sitting apartment instead of an ordinary room was a consequence of the difficulties experienced in exercising an efficient supervision of the inmates when dispersed, some in the corridor, and others in the day or dining rooms. Yet, although the plan in question partially removes these difficulties, no one could wish to exchange the advantages in comfort and appearance of a sitting-room with the greater approximation it affords to the ordinary structure of a house, for a recess in a corridor, if effectual supervision could in any other way be attained. But the plan of a corridor with an offset in lieu of a room does not secure a completely effective oversight, control, and regulation of the occupants, since it presents many opportunities, in its large space, and by the disposition of its parts, for those to mope who may be so disposed, and for the disorderly to annoy their neighbours, without arresting the attention of the one or two attendants.

In the construction and arrangements of a ward, it is necessary to provide for all the wants of the inmates both by day and night, to supply the fittings and furniture needed by the little community inhabiting it; and all such arrangements and conveniences have consequently to be repeated in every one of the many wards found in the asylum, at a very large cost. Again, by the ward-system, the patients are lodged on each floor of the building, and therefore the service of the asylum becomes more difficult, just in proportion to the number of stories above the ground-floor, or the basement, where the kitchen and other general offices are situated. It is chiefly to obviate this difficulty that the elevation of our public asylums has been limited to two stories, and a greater expenditure thereby incurred for their extension over a larger area. (See p. 212.)

From whatever point of view the ward-system may be regarded, there is in it, to our view, an absence of all those domestic and social arrangements and provisions which give a charm to the homes of English people. The peculiar combination of day and night accommodation is without analogy in any house; whilst the sitting, working, or reading, and, occasionally, the taking of meals, in a corridor, a place used also for exercise, and for the passage of persons from one part of the asylum to another, represent conditions of life without parallel among the domestic arrangements of any classes of the community.