235
Art. v.?the lunacy laws. Committee which sat during1 last year to into the inquire working1 of our Lunacy Acts has brought forth no fruit?as we suggested in a previous number, ex nihilo nihil fit. Mr. Dillwyn, who alone is responsible for the Committee, has introduced a Bill, but nothing has been as yet decided. We give the valuable remarks and suggestions of the Commissioners on the existing Lunacy Laws; these appear to fill a and studied by gap long existing, and should be carefully read all interested in the question of Lunacy. " In the course of the Parliamentary Session of 1877, on the motion of Mr. Dillwyn, M.P. for Swansea, a Select Committee of the House of Commons was appointed 'to inquire into the Operation of the Lunacy Law so far as regards the Security afforded by it against violation of Personal Liberty.' " This Committee proceeded to take evidence, but had not made a final report at the end of that Session. It was therefore re-appointed in February 1878, and presented a final report to the House in the following month. " It was with some satisfaction, but with no surprise, that we found that the Committee, after sitting 27 days to receive evidence, and examining a great number of witnesses, including the persons who had promoted the inquiry, and who held very strong opinions as to the objectionable and dangerous character .of the present system, were able to report as their conclusion that, 'Although the present system was not free from risk, which might be lessened though not wholly removed by amendments in the existing law and practice, yet, assuming that the strongest cases against the present system were brought before of mala fides, or of serious abuses, were not them, The
Parliamentary
allegations
substantiated.' "
repeat, language, guarded though it be, is, wemuch of unsatisfactory to us, on whom necessarily rests Such
not
the ot the Lunacy Law. administration the due for responsibility " Among other suggestions contained in the Report of this Committee, is one of the importance of which we have long been convinced, namely, that the existing Lunacy Acts should be consolidated. " The Secretary of State for the Home Department having, since the presentation of the Keport of the Select Committee,
23G
THE LUNACY LAWS.
informed the House of Commons that your Lordship has the amendment of the Lunacy Laws under consideration, we are perhaps justified in assuming that, in due time, Bills for the consolidation of the Lunacy Acts (a work advised by us as far back as 1868) will be presented for the consideration of Parliament. A proper opportunity will then arise for considering what amendments ought to be introduced, and due weight will, no doubt, be given to the recommendations of the Select Committee. " For ourselves, we are not disposed to advocate any radical changes in the existing law regarding the care and treatment of the insane, and in particular, so far as our present experience extends, we are quite satisfied that the present system of certification, both of private and pauper lunatics, and of visitation of the asylums, hospitals, licensed and unlicensed houses where they are received, affords, in practice, ample safeguards as well against the admission of persons of sound mind, as for the discharge of the insane patients without undue detention. " At the same time we are far from thinking that no improvements could be made in the existing regulations. On the contrary, our daily experience of the working of the Acts has induced us to note many points where amendment would be useful. " The present occasion does not appear suitable for stating seriatim all these points. This could only be done on the preparation of Bills for consolidation and amendment; and indeed very many minor difficulties which have from time to time arisen on the construction of the Acts would disappear on redrafting the faulty clauses, and further experience may, of course, show the desirability of other improvements. " We think, however, that we may with propriety avail ourselves of this opportunity of suggesting, for your Lordship's consideration, and in anticipation of any legislation, the following modifications of the present system as to the reception of patients under order and certificates, on which that system chiefly rests, and at the same time we may notice a few other, and perhaps the most important, of the miscellaneous amendments which we should be glad to see effected. " 1. And, first, as to Medical Certificates: " The present form is certainly susceptible of improvement. The names of the persons (if any) furnishing facts indicative of insanity not observed by the certifier himself, together with their addresses, should be given. In the case of private patients it has long been our practice to require the names of informants, but we should be glad to have both names and addresses made a statutory requirement in all cases. The alterations we pro-
TIIE
LUXACY
LAWS.
237
pose will appear more clearly from the form of certificate which have caused to be drafted, and which will be found in the
we
Appendix (P).*
2. As to the Order for Eeception: In private cases this is a mere request addressed to the person taking- charge of the patient, to admit him into the "
"
be well to substitute the ' order.' " As the law stands, the order in private cases may be signed by anyone who chooses to take the responsibility, and who has seen the patient within' a month. He must state his relationother circumstances in connection with' or if no relation, ship, the patient. " It sometimes happens, though not very frequently, that in the urgency of the case no relative can be found to sign the order, which has therefore to be given by a friend or acquaintGreat exception ance, and indeed, occasionally, by a servant. has lately been taken to this, and where it can be avoided it is doubtless undesirable. At the same time we are bound to say that we are unable to recall any instance in which we have had occasion to question the good faith of orders so made. " We should be loth to insist in all cases on the signature of a relative, for instances undoubtedly occur when immediate steps must be taken, and no relative can be found. For example, a foreigner, in good or fair circumstances, becomes insane, and unless his banker or agent, his fellow clerk, or the landlord of his hotel, comes forward to sign the order, he must be treated, to his manifest disadvantage, as a lunatic wandering at large, or not under proper care or control, and must be sent, through the police or a relieving officer, to a pauper asylum, with, in all likelihood, especially in London, a preliminary detention in a workhouse. We think, however, that the order or authority should state distinctly that no relative is available, and should give more precisely than by the present form is required, the reason for the signature. Added to this, power might be given to us to inquire into the circumstances of the signature, and to permit the substitution, as the person entitled to discharge, of some relative or other person willing to assume the responsibility, or of the person who makes, or proposes to make, the payments for the patient's maintenance. This would be in accordance with one of the recommendations of the Select Committee of the House of Commons. It should be enacted that no minor should sign an order. expressly " By the Act 9 Greorge IV. cap. 41, being the Act of Parliament which, up to 1832, regulated the care and treatment of
asylum or other word authority' '
It
house.
or
'
request'
*
might
for the word
See page 247.
238
THE
LUNACY LAWS.
o
the insane in licensed houses, it was provided that the person whose authority a patient was admitted should, personally, or by a deputy specially appointed, visit the patient once at least in every six months, though no special penalty was imposed in case of non-compliance. A similar provision was inserted in the draft of the repealing and amending Act of 1832 (2 & 3 Will. IV. c. 107), but was struck out of the Bill by the House of Lords ; and in 1845, when the present Act was passed, it was not re-inserted. Since then the principle has been adopted in the case of lunatics so found by inquisition, whose Committees enter into an undertaking to visit them periodically. " Although in some recent and acute cases of insanity the visits of friends may have a prejudicial effect on the patient, and therefore a compulsory personal visit ought not to be insisted on from the particular individual who may have signed the order, yet we think that the principle is right which would enforce on the friends of patients the obligation to make inquiries after their welfare, and to ascertain from time to time that their treatment is proper. " To enforce visits of this kind under a penalty would, we think, be impossible; but it occurs to us as feasible to subjoin to the form of the authority for reception, an undertaking by the person signing it to visit, either personally or by deputy, once in six months. " The Select Committee made a recommendation as to such visits, adopting suggestions emanating from our chairman and another member of the Board. " A draft of an ' authority,' embracing these suggestions, will be found prefixed to the draft of certificate in Appendix (P).* "With regard to orders for admission of pauper lunatics, which stand on a different footing, a modification of the language of the 67th and 68th sections of the Act 16 & 17 Vie. cap. 97, and corresponding changes in the form of order, are, we think, needed, so as to make clear what we believe to have been the intention of the Legislature, viz., that the justice, or the officiating clergyman and the relieving officer, shall not merely (as we know is now often done) sign the order after reading the medical officer's certificate, but shall be required to examine the lunatic in the presence of and jointly with the medical officer himself. " No order of admission for a pauper lunatic should be made by an officiating clergyman and relieving officer, except after notice to a justice, and this should be made more distinctly than at present a condition of the validity of such order. The relieving officer should state in the order the reason why, after
by
*
See page 246.
THE
LUNACY LAWS.
239
the justice could not attend to examine the exists for the patient not being taken reason what patient, to the justice for the purpose. " These orders in their present form are on the face of them perfectly regular, even though no notice of the lunatic has in fact been given to a justice, and the form itself, we think, should therefore be altered. " 3. It would, we think, be advisable to extend the prohibition against the admission of private patients on certificates signed by certain relatives of the person signing the order, or taking the charge, to connections by marriage, as wife's father or brother, stepson, or daughter's husband. " 4. The so-called statement of mental condition of the patient forwarded to our office after two and within seven days subsequent to admission, should be made by Statute more precise than it at present needs to be so, as to constitute, in fact, an additional certificate. It should set forth, as a 'certificate' now does, the facts observed by the medical superintendent or attendant, leading to the conclusion that the patient is insane, and stating whether any improvement has been observed, and giving a succinct note of the main features of the case. " The requirements of the present Acts are fulfilled if the medical officer gives merely the form of the mental disorder, ' and reports the bodily health to be ' good or ' inditferent,' ' ' as the case may be, and most statements contain little more, unless indeed some doubt exists as to the continuance of the insanity, when longer explanations are inevitable. "From some asylums, however, and notably from the Worcester and the Wilts asylums, and from Brislington House, we receive ' statements,' giving concise particulars of health, especially the mental health of the patient, which we frequently find of great service. "This 'statement' should be headed 'First Report,' and we accept the recommendation of the Select Committee, framed indeed upon a suggestion emanating from our chairman, that a second report of mental and bodily condition should in all cases be transmitted to us at the expiration of a month after admission of the patient. " 5. The Select Committee, while not pronouncing either for or against the continuance of licensed houses, advocate the extension of institutions of the character of the present such notice
given,
or
registered hospitals. While of opinion "
that for the reception of the richer class under proper management are not houses licensed patients unsuitable, and will continue to find favour with the friends of such patients, rather than quasi public institutions, we are of
240
THE LUNACY LAWS.
well aware that for persons of small means, and for the class removed a degree or two above the mechanic paid by weekly wages, an increase in the number of public institutions for the insane, adequately supported, would be a great boon. " The Select Committee appear to think that establishments of this kind might be provided, in the first instance, by a compulsory charge on the county rate, as in the case of asylums. " It is impossible for us to say whether or no such a proposition would find favour with Parliament or with the country; but we feel that any extension of the registered hospital system on its present basis must be accompanied by stricter provisions than now exist both as to foundation and as to
management. While acknowledging the advantages which many of the existing lunatic hospitals offer, and while making no charges against the present management of any of them, for, as a rule, it is very good, we think that it is not too much to say that any one of these institutions, under the existing law, and in the hands of a weak committee, might easily be worked so as to become, instead of a philanthropic and charitable foundation, an establishment maintained mainly for the personal benefit of the resident staff, subject to none of the control exercised by commissioners and justices over the proprietor of a licensed "
house. "To obviate these objections, and others which have from time to time arisen, we woidd suggest several provisions, of which the following is a summary :? (a) All hospitals where lunatics are received should be registered as at present, but applications for registration should contain a statement of the nature of the proposed hospital, who are the founders, what persons, and by whom appointed, are to form the Governing Body, what class of patients, and at what average payments, are to be received. (b) Plans of the building and estate should be deposited in our office. (c) Prior to registration the premises should be inspected, and a report made thereon to our Board. (d) Registration should be, primarily, a matter for the discretion of this Board, and should not be compulsory, as
(6)
at
present.
Should the Board decline to register the hospital, a statement of their reasons should be laid before the Secretary of State, who should decide absolutely whether the certificate, presentlv referred to, is to issue or
not.
THE
(/)
(,g) (h)
LUNACY
LAWS.
241
If the Board is satisfied with the constitution of the hospital and the building, &c., or is directed by the Secretary of State to register, a provisional certificate of registration should be issued, to be valid for six months, or until approval by the Secretary of State of the regulations to be proposed, as at present, by the Governing Body. During currency of the provisional certificate, the Governing Body to be at liberty to receive patients. On approval of the Eegulations, a complete certificate of registration to issue. Within three months of passing of the Act, all hos-
pitals, except Bethlehem, ought, we think, to deposit plans of land, of whatever tenure, occupied by the Governing Body, and on any new purchase or hiring of land, fresh plans should be deposited. No building in the occupation of the Governing Body should be deemed part of the hospital for any purpose connected with the care and treatment of patients, unless the same be situate wholly upon some part of the land of which plans are deposited. The reception of patients in any buildings not so situate should be a misdemeanour. The superintendent and all others concerned in taking charge should then be liable to the same penalties as persons receiving lunatics in an unlicensed house. (i) The accounts of Hospitals, audited by a public accountant, should be printed annually, and a copy sent to us, together with a list of names and addresses of members of the Governing Body, and principal officers,
(k)
(I)
"
medical or otherwise. Our Board should have power, with the previous consent in writing of the Secretary of State, given upon a representation from the Board, and after such inquiries as the Secretary of State might please to make, in case of wilful neglect of, or disobedience to, Regulations,. to prohibit by sealed order the further reception of patients for a period not exceeding six months. At the end of that time further power should exist, with like consent, to' order the Hospital to be closed. No person directly or indirectly concerned in supplying the hospital with goods of any kind, and no medical officer thereof, should be a member of the Governing
Body.
6. As noticed in our thirtieth Report, the system of removing patients from licensed houses and hospitals to the seaside, or elsewhere, for a change, has extended much of late
242
THE
LUNACY
LAWS.
years, and is a most beneficial arrangement, much to be encouraged, under proper checks. " Several committees of hospitals and proprietors of asylums engage furnished houses at the seaside, to which, during the season, their patients are brought in relays. Such a plan was never thought of in 1845, when the Act 8 & 9 Vic. c. 100 was passed, and consequently some question has heie and there been raised as to its legality. "The practice, we think, should now be distinctly legalised, as it is greatly to the advantage of patients. It would not be difficult to provide against any abuse; as, for example, by requiring notice to be given to the clerk of the peace of the county that, under sanction of the Commissioners, Visitors, or Committee, as the case might be, two or more lunatics under certificates would for a specified time be brought to the county for change of air. an unlicensed house within Whereupon it might be competent to any two of the Visitors of licensed houses in that county to enter and inspect at their
pleasure.
" As it is desirable that we should always be acquainted with the movements of patients, especially private patients, we should recommend that notice should be sent to us whenever leave of absence is given, on trial, or for the benefit of
health,
to any
patient
in
a
registered hospital
or
provincial
licensed house. " 7. The death of a person in charge of a single patient, and the consequent requirement of a new order or authority, ought not, as at present, to involve the procuring of fresh certificates. This is often a hardship to persons of small means, and it, besides, occasions unnecessary disturbance to the patient himself. Power should, we think, be given to transfer the patient, but not without our previous consent, into the care of a person substituted for the deceased. " 8. There appears to be no reason why the present powers of the Commissioners to discharge a patient from an hospital or licensed house, on being satisfied that he is detained without sufficient cause, should not extend to a single patient. " 9. The provisions against ill-using and abusing patients should extend to make the carnal knowledge of a female patient by any officer, attendant, servant, or artisan employed in or about an asylum, hospital, or licensed house, an indictable offence. " 10. With regard to idiot children of the private and the pauper class, power should be given to relax, in the case of hospitals or licensed houses where idiot children and congenital imbeciles alone are to be kept, the rules as to residence of a
TIIE
LUNACY
LAWS.
243
medical officer, and as to the constant entries in case books and medical journals. " A few words added to the existing provisions on tlie subject would make it more clear than at present that justices can (if they desire) restrict the use of a separate or joint county Asylum to the reception of idiots and congenital imbecile cases. Express power might well be added to charge boards of guardians with the expense, not only of maintenance and clothing, but of the industrial training of these objects of compassion. "11. Power should be given to appoint a substitute for a Commissioner temporarily disabled by illness or unavoidably absent. Such a power exists in the case of ' the Lord Chancellor's Visitors of Lunatics,' and in that of the County Court
Judges.
" Having thus briefly enumerated the principal of those amendments in the Lunacy Law which from time to time have occurred to us as desirable, we will, with your Lordship's permission, proceed to notice, so far as appears to lie in our province, those recommendations of the Select Committee which have not been already touched upon. " The Committee, after suggesting admission in case of emergency on a single medical certificate (which, we may remark, is already provided for in the case of private patients under the existing law), recommend (page iv of Report) that in all other cases two certificates should be required. This can only apply to pauper patients, and in every such case a magistrate can at present, if not satisfied, require two certificates. We should not object to make a second certificate compulsory, but we must point out that this would involve additional expense to ratepayers, and we do not ourselves think it necessary
as a
t;
protection.
We should raise no objection to the introduction into England of the Scotch law, that an order of reception should be valid for three years only, with a special report at the end of that time from the medical superintendent, to be repeated at the end of each subsequent year. (Report, p. iv.) " The Committee (Report, p. v), without making a distinct recommendation for amending the law, dwell on the importance that detention should cease as soon as the patient is no longer dangerous to himself or others, and is not likely to benefit by further detention. They believe frequent and careful visitation to be the surest mode of guarding against unduly prolonged detention, with full power in the hands of the Commissioners to order discharge, and in the more general adoption of probationary discharge. " The Committee have here omitted an important qualification,
244
THE
LUNACY
LAWS.
that the
patient, though neither dangerous to himself nor to likely to benefit by further treatment, should not be of such habits as would offend against public decency or morality, if allowed to be at large. If remitted to the care of friends, they would of course be responsible for his conduct, and even where detention in an Asylum may no longer be proper, detention under certificates in a private house may still be necessary. It must always be remembered that the Committee discovered no viz.,
others,
nor
of ( undue detention.' The Committee's remark as to probationary discharge applies (to judge by the context) rather to Scotland than to England, where discharge upon trial is an everyday occurrence. " The Committee (page v) repeat, on the subject of the risk of mal-treatment by attendants, observations constantly made cases
"
by
us.
" A further suggestion is made (on page v), that reports should be sent to the Commissioners of patients ' kept under restraint' (we use the language of the Committee) in private families or religious houses, not for profit. The reports to be confidential, and the patients confirmed lunatics. " We should be glad to see this suggestion pass into law ; but the mere report would be of no use unless we had power to visit, and to some extent regulate treatment, as, for instance, by insisting on periodical medical visitation, and entries thereof in a book. The only way to secure any such registration would probably be that suggested by Dr. Nugent (Q. 2879-81, Evidence taken by the Committee), to make it penal for the medical attendant to refrain from reporting where the illness and consequent restraint or detention had lasted for a period of, say, six months. " The recommendation (page v) as to visits by two medical men, to be sent by any person with the sanction of the Commissioners, to test the condition of any person under restraint, appears to require no alteration in the law to cause it to take effect, as the power exists. " The opinions and suggestions as to workhouse management, expressed on page vi of the Report, we leave to the consideration of the Local Government Board. " The Committee make a suggestion (Report, p. vi) as to the removal of restrictions on voluntary boarders, whose admission, they say, is to be reported to the Commissioners. The system of admitting boarders has answered well. We are quite prepared to extend it to any person who at any time has been an inmate of any institution for the insane, or has been a single patient (either as a lunatic so found, or under certificates). But we do not recommend the indiscriminate admission of
THE
LUNACY
LAWS.
*
245
persons never certified as insane. The following objections may be sufficient: " 1. The fear of attempts at evasion of the law by introducing as boarders persons who ought to'be under certificates. " 2. The fear of the introduction of mere drunkards. " 3. The fear of crowding the house to the inconvenience of the insane patients. " The previous consent of ourselves or the Visitors should Notice of admission is thus scarcely remain a sine qua non.
necessary.
to the recommendation of the the grounds of refusal by that (Report, superintendents to permit access to patients be entered in the case-book and communicated to us. " In spite of any evidence to the contrary which may have been brought before the Committee, we do not believe (and we conceive ourselves peculiarly well able to judge of such a matter) that any real grievance exists as to the detention of patients' letters under the present system, which requires all those addressed to us, the Visitors and Committees of Hospitals, to be forwarded unopened, the rest to be exhibited to the officials on their next visit. We may remark, parenthetically, that the Committee lay under some misconception as to the amount of labour occasioned by the examination of letters detained. The majority of them being obviously unfit for transmission, are easily dealt with on the spot. " We must very strongly object to the proposal of the Committee that all letters of patients not forwarded by the medical superintendent should be sent to us unopened. This would be a great grievance to the patients themselves. It is impossible that we should have in every case that full information as to the patient's exact state of mind at the time of writing, his family affairs, and other circumstances, which alone would enable us to judge whether a letter coherently expressed, and not containing matter of an obviously improper character, ought or ought not to be sent to the person to whom it is addressed. " If the letter were in the end kept back the patient would gain nothing; if it were posted it might not be until after several days' delay, and after critical examination in a public office. " The Committee themselves remark that it is plainly almost impossible to prevent the fraudulent suppression of letters. The scheme which they suggest will certainly not prevent it, supposing a medical superintendent thought it worth his while to suppress them. "
There Committee
PART II.
can
be
no
p.
VOL. V.
objection
vii.),
NEW SERIES.
S
*
24G
TIIE LUNACY' LAWS.
"
The Committee quote no evidence in support of their that every person discharged from confinement should have access, with our consent, to all documents connected with his detention. " If this were adopted we fear it would seriously check the free and unrestrained communication, both to us and to the medical superintendents and others, of information regarding cases which at present, as is well known, is treated as strictly confidential. " A Bill before Parliament for amending the Medical Act will, if passed, provide for the acceptance of Scotch and Irish certificates in England."
suggestion (page vii)
Proposed Form
of
Authority for the Reception Private Patient.
of a
I, the undersigned, being a person aged 21 years and upwards, hereby authorise you to receive A. B., a lunatic [*], whom 18 I last saw at on the day of [2] as a patient into your house [3]. Subjoined is a statement of particulars relating to the said A. B., whom I undertake to visit personally, or by some one specially appointed by me, ,
once at least in every six months while under ment under this authority.
riage)
[If
Dated this
[or Hospital].
and treat-
Name. Rank or profession (if any). Full postal address. Degree of relationship (by blood
(Signed)
To
care
or
mar-
patient.
relation, the person signing to briefly as possible: 1. Why the authority is not signed by a relation. 2. His connection with or interest (if any) in the patient, or the circumstances inducing him or her to sign.] not
state
day ,
to
a
as
18
of
Proprietor
or
.
Superintendent
of House
['1 Or an idiot, or a person of unsound mind. [2] Some day -within a calendar month from the date of the authority. [3] Or hospital. [4] Describing houso or hospital hy situation and name.
[4]
THE
LUNACY LAWS.
Statement
(As
in Schedule
A.,
of
the
Particulars.
No. 1, 16 & 17 Vic.
c.
variations.) Proposed Form
I,
247
undersigned
A.
B.,
do
of
96,
witli
slight
Certificate.
hereby certify
as
follows
:
1. I am a person registered under the Medical Act, and I am in the actual practice of the medical profession.
1857,
in the county [2] 18 2. On the , at [H day of of separately from any other practitioner, I personally in the county [4] examined C. D., of of conclusion the that he is a to and came ? [5], [lunatic, an idiot, or a person of unsound mind~\ and a proper person to be taken charge of and detained under care and treat-
[3]
ment.
on the following grounds, viz.:? Facts indicating insanity observed by myself at the (?) time of examination [6]. (?) Facts communicated by others [7].
3. I formed this conclusion
4. I make this certificate having first read the clause of the Act of Parliament printed below.
(Signed) of Act
in
[Clause certificates.]
imposing penalties
A.
B.,
of
[8]
for wilful false statements
['] Insert the name of the street or place, with number or name of house, or, should there be no number, then insert Christian and surname of occupier.
[2] City or borough, as the case may be. L3] Insert residence of patient. I ] City or borough, as the case may be. [5] Insert profession or occupation, if any. [6] If the same or other facts were observed previous to the time of the examination, the certifier is at liberty to subjoin them ina separate paragraph. [7] The names and Christian names (if known) of informants to be given,
together
with their names and addresses. full postal address.
[8] Insert
Art. v.?the lunacy laws. Committee which sat during1 last year to into the inquire working1 of our Lunacy Acts has brought forth no fruit?as we suggested in a previous number, ex nihilo nihil fit. Mr. Dillwyn, who alone is responsible for the Committee, has introduced a Bill, but nothing has been as yet decided. We give the valuable remarks and suggestions of the Commissioners on the existing Lunacy Laws; these appear to fill a and studied by gap long existing, and should be carefully read all interested in the question of Lunacy. " In the course of the Parliamentary Session of 1877, on the motion of Mr. Dillwyn, M.P. for Swansea, a Select Committee of the House of Commons was appointed 'to inquire into the Operation of the Lunacy Law so far as regards the Security afforded by it against violation of Personal Liberty.' " This Committee proceeded to take evidence, but had not made a final report at the end of that Session. It was therefore re-appointed in February 1878, and presented a final report to the House in the following month. " It was with some satisfaction, but with no surprise, that we found that the Committee, after sitting 27 days to receive evidence, and examining a great number of witnesses, including the persons who had promoted the inquiry, and who held very strong opinions as to the objectionable and dangerous character .of the present system, were able to report as their conclusion that, 'Although the present system was not free from risk, which might be lessened though not wholly removed by amendments in the existing law and practice, yet, assuming that the strongest cases against the present system were brought before of mala fides, or of serious abuses, were not them, The
Parliamentary
allegations
substantiated.' "
repeat, language, guarded though it be, is, wemuch of unsatisfactory to us, on whom necessarily rests Such
not
the ot the Lunacy Law. administration the due for responsibility " Among other suggestions contained in the Report of this Committee, is one of the importance of which we have long been convinced, namely, that the existing Lunacy Acts should be consolidated. " The Secretary of State for the Home Department having, since the presentation of the Keport of the Select Committee,
23G
THE LUNACY LAWS.
informed the House of Commons that your Lordship has the amendment of the Lunacy Laws under consideration, we are perhaps justified in assuming that, in due time, Bills for the consolidation of the Lunacy Acts (a work advised by us as far back as 1868) will be presented for the consideration of Parliament. A proper opportunity will then arise for considering what amendments ought to be introduced, and due weight will, no doubt, be given to the recommendations of the Select Committee. " For ourselves, we are not disposed to advocate any radical changes in the existing law regarding the care and treatment of the insane, and in particular, so far as our present experience extends, we are quite satisfied that the present system of certification, both of private and pauper lunatics, and of visitation of the asylums, hospitals, licensed and unlicensed houses where they are received, affords, in practice, ample safeguards as well against the admission of persons of sound mind, as for the discharge of the insane patients without undue detention. " At the same time we are far from thinking that no improvements could be made in the existing regulations. On the contrary, our daily experience of the working of the Acts has induced us to note many points where amendment would be useful. " The present occasion does not appear suitable for stating seriatim all these points. This could only be done on the preparation of Bills for consolidation and amendment; and indeed very many minor difficulties which have from time to time arisen on the construction of the Acts would disappear on redrafting the faulty clauses, and further experience may, of course, show the desirability of other improvements. " We think, however, that we may with propriety avail ourselves of this opportunity of suggesting, for your Lordship's consideration, and in anticipation of any legislation, the following modifications of the present system as to the reception of patients under order and certificates, on which that system chiefly rests, and at the same time we may notice a few other, and perhaps the most important, of the miscellaneous amendments which we should be glad to see effected. " 1. And, first, as to Medical Certificates: " The present form is certainly susceptible of improvement. The names of the persons (if any) furnishing facts indicative of insanity not observed by the certifier himself, together with their addresses, should be given. In the case of private patients it has long been our practice to require the names of informants, but we should be glad to have both names and addresses made a statutory requirement in all cases. The alterations we pro-
TIIE
LUXACY
LAWS.
237
pose will appear more clearly from the form of certificate which have caused to be drafted, and which will be found in the
we
Appendix (P).*
2. As to the Order for Eeception: In private cases this is a mere request addressed to the person taking- charge of the patient, to admit him into the "
"
be well to substitute the ' order.' " As the law stands, the order in private cases may be signed by anyone who chooses to take the responsibility, and who has seen the patient within' a month. He must state his relationother circumstances in connection with' or if no relation, ship, the patient. " It sometimes happens, though not very frequently, that in the urgency of the case no relative can be found to sign the order, which has therefore to be given by a friend or acquaintGreat exception ance, and indeed, occasionally, by a servant. has lately been taken to this, and where it can be avoided it is doubtless undesirable. At the same time we are bound to say that we are unable to recall any instance in which we have had occasion to question the good faith of orders so made. " We should be loth to insist in all cases on the signature of a relative, for instances undoubtedly occur when immediate steps must be taken, and no relative can be found. For example, a foreigner, in good or fair circumstances, becomes insane, and unless his banker or agent, his fellow clerk, or the landlord of his hotel, comes forward to sign the order, he must be treated, to his manifest disadvantage, as a lunatic wandering at large, or not under proper care or control, and must be sent, through the police or a relieving officer, to a pauper asylum, with, in all likelihood, especially in London, a preliminary detention in a workhouse. We think, however, that the order or authority should state distinctly that no relative is available, and should give more precisely than by the present form is required, the reason for the signature. Added to this, power might be given to us to inquire into the circumstances of the signature, and to permit the substitution, as the person entitled to discharge, of some relative or other person willing to assume the responsibility, or of the person who makes, or proposes to make, the payments for the patient's maintenance. This would be in accordance with one of the recommendations of the Select Committee of the House of Commons. It should be enacted that no minor should sign an order. expressly " By the Act 9 Greorge IV. cap. 41, being the Act of Parliament which, up to 1832, regulated the care and treatment of
asylum or other word authority' '
It
house.
or
'
request'
*
might
for the word
See page 247.
238
THE
LUNACY LAWS.
o
the insane in licensed houses, it was provided that the person whose authority a patient was admitted should, personally, or by a deputy specially appointed, visit the patient once at least in every six months, though no special penalty was imposed in case of non-compliance. A similar provision was inserted in the draft of the repealing and amending Act of 1832 (2 & 3 Will. IV. c. 107), but was struck out of the Bill by the House of Lords ; and in 1845, when the present Act was passed, it was not re-inserted. Since then the principle has been adopted in the case of lunatics so found by inquisition, whose Committees enter into an undertaking to visit them periodically. " Although in some recent and acute cases of insanity the visits of friends may have a prejudicial effect on the patient, and therefore a compulsory personal visit ought not to be insisted on from the particular individual who may have signed the order, yet we think that the principle is right which would enforce on the friends of patients the obligation to make inquiries after their welfare, and to ascertain from time to time that their treatment is proper. " To enforce visits of this kind under a penalty would, we think, be impossible; but it occurs to us as feasible to subjoin to the form of the authority for reception, an undertaking by the person signing it to visit, either personally or by deputy, once in six months. " The Select Committee made a recommendation as to such visits, adopting suggestions emanating from our chairman and another member of the Board. " A draft of an ' authority,' embracing these suggestions, will be found prefixed to the draft of certificate in Appendix (P).* "With regard to orders for admission of pauper lunatics, which stand on a different footing, a modification of the language of the 67th and 68th sections of the Act 16 & 17 Vie. cap. 97, and corresponding changes in the form of order, are, we think, needed, so as to make clear what we believe to have been the intention of the Legislature, viz., that the justice, or the officiating clergyman and the relieving officer, shall not merely (as we know is now often done) sign the order after reading the medical officer's certificate, but shall be required to examine the lunatic in the presence of and jointly with the medical officer himself. " No order of admission for a pauper lunatic should be made by an officiating clergyman and relieving officer, except after notice to a justice, and this should be made more distinctly than at present a condition of the validity of such order. The relieving officer should state in the order the reason why, after
by
*
See page 246.
THE
LUNACY LAWS.
239
the justice could not attend to examine the exists for the patient not being taken reason what patient, to the justice for the purpose. " These orders in their present form are on the face of them perfectly regular, even though no notice of the lunatic has in fact been given to a justice, and the form itself, we think, should therefore be altered. " 3. It would, we think, be advisable to extend the prohibition against the admission of private patients on certificates signed by certain relatives of the person signing the order, or taking the charge, to connections by marriage, as wife's father or brother, stepson, or daughter's husband. " 4. The so-called statement of mental condition of the patient forwarded to our office after two and within seven days subsequent to admission, should be made by Statute more precise than it at present needs to be so, as to constitute, in fact, an additional certificate. It should set forth, as a 'certificate' now does, the facts observed by the medical superintendent or attendant, leading to the conclusion that the patient is insane, and stating whether any improvement has been observed, and giving a succinct note of the main features of the case. " The requirements of the present Acts are fulfilled if the medical officer gives merely the form of the mental disorder, ' and reports the bodily health to be ' good or ' inditferent,' ' ' as the case may be, and most statements contain little more, unless indeed some doubt exists as to the continuance of the insanity, when longer explanations are inevitable. "From some asylums, however, and notably from the Worcester and the Wilts asylums, and from Brislington House, we receive ' statements,' giving concise particulars of health, especially the mental health of the patient, which we frequently find of great service. "This 'statement' should be headed 'First Report,' and we accept the recommendation of the Select Committee, framed indeed upon a suggestion emanating from our chairman, that a second report of mental and bodily condition should in all cases be transmitted to us at the expiration of a month after admission of the patient. " 5. The Select Committee, while not pronouncing either for or against the continuance of licensed houses, advocate the extension of institutions of the character of the present such notice
given,
or
registered hospitals. While of opinion "
that for the reception of the richer class under proper management are not houses licensed patients unsuitable, and will continue to find favour with the friends of such patients, rather than quasi public institutions, we are of
240
THE LUNACY LAWS.
well aware that for persons of small means, and for the class removed a degree or two above the mechanic paid by weekly wages, an increase in the number of public institutions for the insane, adequately supported, would be a great boon. " The Select Committee appear to think that establishments of this kind might be provided, in the first instance, by a compulsory charge on the county rate, as in the case of asylums. " It is impossible for us to say whether or no such a proposition would find favour with Parliament or with the country; but we feel that any extension of the registered hospital system on its present basis must be accompanied by stricter provisions than now exist both as to foundation and as to
management. While acknowledging the advantages which many of the existing lunatic hospitals offer, and while making no charges against the present management of any of them, for, as a rule, it is very good, we think that it is not too much to say that any one of these institutions, under the existing law, and in the hands of a weak committee, might easily be worked so as to become, instead of a philanthropic and charitable foundation, an establishment maintained mainly for the personal benefit of the resident staff, subject to none of the control exercised by commissioners and justices over the proprietor of a licensed "
house. "To obviate these objections, and others which have from time to time arisen, we woidd suggest several provisions, of which the following is a summary :? (a) All hospitals where lunatics are received should be registered as at present, but applications for registration should contain a statement of the nature of the proposed hospital, who are the founders, what persons, and by whom appointed, are to form the Governing Body, what class of patients, and at what average payments, are to be received. (b) Plans of the building and estate should be deposited in our office. (c) Prior to registration the premises should be inspected, and a report made thereon to our Board. (d) Registration should be, primarily, a matter for the discretion of this Board, and should not be compulsory, as
(6)
at
present.
Should the Board decline to register the hospital, a statement of their reasons should be laid before the Secretary of State, who should decide absolutely whether the certificate, presentlv referred to, is to issue or
not.
THE
(/)
(,g) (h)
LUNACY
LAWS.
241
If the Board is satisfied with the constitution of the hospital and the building, &c., or is directed by the Secretary of State to register, a provisional certificate of registration should be issued, to be valid for six months, or until approval by the Secretary of State of the regulations to be proposed, as at present, by the Governing Body. During currency of the provisional certificate, the Governing Body to be at liberty to receive patients. On approval of the Eegulations, a complete certificate of registration to issue. Within three months of passing of the Act, all hos-
pitals, except Bethlehem, ought, we think, to deposit plans of land, of whatever tenure, occupied by the Governing Body, and on any new purchase or hiring of land, fresh plans should be deposited. No building in the occupation of the Governing Body should be deemed part of the hospital for any purpose connected with the care and treatment of patients, unless the same be situate wholly upon some part of the land of which plans are deposited. The reception of patients in any buildings not so situate should be a misdemeanour. The superintendent and all others concerned in taking charge should then be liable to the same penalties as persons receiving lunatics in an unlicensed house. (i) The accounts of Hospitals, audited by a public accountant, should be printed annually, and a copy sent to us, together with a list of names and addresses of members of the Governing Body, and principal officers,
(k)
(I)
"
medical or otherwise. Our Board should have power, with the previous consent in writing of the Secretary of State, given upon a representation from the Board, and after such inquiries as the Secretary of State might please to make, in case of wilful neglect of, or disobedience to, Regulations,. to prohibit by sealed order the further reception of patients for a period not exceeding six months. At the end of that time further power should exist, with like consent, to' order the Hospital to be closed. No person directly or indirectly concerned in supplying the hospital with goods of any kind, and no medical officer thereof, should be a member of the Governing
Body.
6. As noticed in our thirtieth Report, the system of removing patients from licensed houses and hospitals to the seaside, or elsewhere, for a change, has extended much of late
242
THE
LUNACY
LAWS.
years, and is a most beneficial arrangement, much to be encouraged, under proper checks. " Several committees of hospitals and proprietors of asylums engage furnished houses at the seaside, to which, during the season, their patients are brought in relays. Such a plan was never thought of in 1845, when the Act 8 & 9 Vic. c. 100 was passed, and consequently some question has heie and there been raised as to its legality. "The practice, we think, should now be distinctly legalised, as it is greatly to the advantage of patients. It would not be difficult to provide against any abuse; as, for example, by requiring notice to be given to the clerk of the peace of the county that, under sanction of the Commissioners, Visitors, or Committee, as the case might be, two or more lunatics under certificates would for a specified time be brought to the county for change of air. an unlicensed house within Whereupon it might be competent to any two of the Visitors of licensed houses in that county to enter and inspect at their
pleasure.
" As it is desirable that we should always be acquainted with the movements of patients, especially private patients, we should recommend that notice should be sent to us whenever leave of absence is given, on trial, or for the benefit of
health,
to any
patient
in
a
registered hospital
or
provincial
licensed house. " 7. The death of a person in charge of a single patient, and the consequent requirement of a new order or authority, ought not, as at present, to involve the procuring of fresh certificates. This is often a hardship to persons of small means, and it, besides, occasions unnecessary disturbance to the patient himself. Power should, we think, be given to transfer the patient, but not without our previous consent, into the care of a person substituted for the deceased. " 8. There appears to be no reason why the present powers of the Commissioners to discharge a patient from an hospital or licensed house, on being satisfied that he is detained without sufficient cause, should not extend to a single patient. " 9. The provisions against ill-using and abusing patients should extend to make the carnal knowledge of a female patient by any officer, attendant, servant, or artisan employed in or about an asylum, hospital, or licensed house, an indictable offence. " 10. With regard to idiot children of the private and the pauper class, power should be given to relax, in the case of hospitals or licensed houses where idiot children and congenital imbeciles alone are to be kept, the rules as to residence of a
TIIE
LUNACY
LAWS.
243
medical officer, and as to the constant entries in case books and medical journals. " A few words added to the existing provisions on tlie subject would make it more clear than at present that justices can (if they desire) restrict the use of a separate or joint county Asylum to the reception of idiots and congenital imbecile cases. Express power might well be added to charge boards of guardians with the expense, not only of maintenance and clothing, but of the industrial training of these objects of compassion. "11. Power should be given to appoint a substitute for a Commissioner temporarily disabled by illness or unavoidably absent. Such a power exists in the case of ' the Lord Chancellor's Visitors of Lunatics,' and in that of the County Court
Judges.
" Having thus briefly enumerated the principal of those amendments in the Lunacy Law which from time to time have occurred to us as desirable, we will, with your Lordship's permission, proceed to notice, so far as appears to lie in our province, those recommendations of the Select Committee which have not been already touched upon. " The Committee, after suggesting admission in case of emergency on a single medical certificate (which, we may remark, is already provided for in the case of private patients under the existing law), recommend (page iv of Report) that in all other cases two certificates should be required. This can only apply to pauper patients, and in every such case a magistrate can at present, if not satisfied, require two certificates. We should not object to make a second certificate compulsory, but we must point out that this would involve additional expense to ratepayers, and we do not ourselves think it necessary
as a
t;
protection.
We should raise no objection to the introduction into England of the Scotch law, that an order of reception should be valid for three years only, with a special report at the end of that time from the medical superintendent, to be repeated at the end of each subsequent year. (Report, p. iv.) " The Committee (Report, p. v), without making a distinct recommendation for amending the law, dwell on the importance that detention should cease as soon as the patient is no longer dangerous to himself or others, and is not likely to benefit by further detention. They believe frequent and careful visitation to be the surest mode of guarding against unduly prolonged detention, with full power in the hands of the Commissioners to order discharge, and in the more general adoption of probationary discharge. " The Committee have here omitted an important qualification,
244
THE
LUNACY
LAWS.
that the
patient, though neither dangerous to himself nor to likely to benefit by further treatment, should not be of such habits as would offend against public decency or morality, if allowed to be at large. If remitted to the care of friends, they would of course be responsible for his conduct, and even where detention in an Asylum may no longer be proper, detention under certificates in a private house may still be necessary. It must always be remembered that the Committee discovered no viz.,
others,
nor
of ( undue detention.' The Committee's remark as to probationary discharge applies (to judge by the context) rather to Scotland than to England, where discharge upon trial is an everyday occurrence. " The Committee (page v) repeat, on the subject of the risk of mal-treatment by attendants, observations constantly made cases
"
by
us.
" A further suggestion is made (on page v), that reports should be sent to the Commissioners of patients ' kept under restraint' (we use the language of the Committee) in private families or religious houses, not for profit. The reports to be confidential, and the patients confirmed lunatics. " We should be glad to see this suggestion pass into law ; but the mere report would be of no use unless we had power to visit, and to some extent regulate treatment, as, for instance, by insisting on periodical medical visitation, and entries thereof in a book. The only way to secure any such registration would probably be that suggested by Dr. Nugent (Q. 2879-81, Evidence taken by the Committee), to make it penal for the medical attendant to refrain from reporting where the illness and consequent restraint or detention had lasted for a period of, say, six months. " The recommendation (page v) as to visits by two medical men, to be sent by any person with the sanction of the Commissioners, to test the condition of any person under restraint, appears to require no alteration in the law to cause it to take effect, as the power exists. " The opinions and suggestions as to workhouse management, expressed on page vi of the Report, we leave to the consideration of the Local Government Board. " The Committee make a suggestion (Report, p. vi) as to the removal of restrictions on voluntary boarders, whose admission, they say, is to be reported to the Commissioners. The system of admitting boarders has answered well. We are quite prepared to extend it to any person who at any time has been an inmate of any institution for the insane, or has been a single patient (either as a lunatic so found, or under certificates). But we do not recommend the indiscriminate admission of
THE
LUNACY
LAWS.
*
245
persons never certified as insane. The following objections may be sufficient: " 1. The fear of attempts at evasion of the law by introducing as boarders persons who ought to'be under certificates. " 2. The fear of the introduction of mere drunkards. " 3. The fear of crowding the house to the inconvenience of the insane patients. " The previous consent of ourselves or the Visitors should Notice of admission is thus scarcely remain a sine qua non.
necessary.
to the recommendation of the the grounds of refusal by that (Report, superintendents to permit access to patients be entered in the case-book and communicated to us. " In spite of any evidence to the contrary which may have been brought before the Committee, we do not believe (and we conceive ourselves peculiarly well able to judge of such a matter) that any real grievance exists as to the detention of patients' letters under the present system, which requires all those addressed to us, the Visitors and Committees of Hospitals, to be forwarded unopened, the rest to be exhibited to the officials on their next visit. We may remark, parenthetically, that the Committee lay under some misconception as to the amount of labour occasioned by the examination of letters detained. The majority of them being obviously unfit for transmission, are easily dealt with on the spot. " We must very strongly object to the proposal of the Committee that all letters of patients not forwarded by the medical superintendent should be sent to us unopened. This would be a great grievance to the patients themselves. It is impossible that we should have in every case that full information as to the patient's exact state of mind at the time of writing, his family affairs, and other circumstances, which alone would enable us to judge whether a letter coherently expressed, and not containing matter of an obviously improper character, ought or ought not to be sent to the person to whom it is addressed. " If the letter were in the end kept back the patient would gain nothing; if it were posted it might not be until after several days' delay, and after critical examination in a public office. " The Committee themselves remark that it is plainly almost impossible to prevent the fraudulent suppression of letters. The scheme which they suggest will certainly not prevent it, supposing a medical superintendent thought it worth his while to suppress them. "
There Committee
PART II.
can
be
no
p.
VOL. V.
objection
vii.),
NEW SERIES.
S
*
24G
TIIE LUNACY' LAWS.
"
The Committee quote no evidence in support of their that every person discharged from confinement should have access, with our consent, to all documents connected with his detention. " If this were adopted we fear it would seriously check the free and unrestrained communication, both to us and to the medical superintendents and others, of information regarding cases which at present, as is well known, is treated as strictly confidential. " A Bill before Parliament for amending the Medical Act will, if passed, provide for the acceptance of Scotch and Irish certificates in England."
suggestion (page vii)
Proposed Form
of
Authority for the Reception Private Patient.
of a
I, the undersigned, being a person aged 21 years and upwards, hereby authorise you to receive A. B., a lunatic [*], whom 18 I last saw at on the day of [2] as a patient into your house [3]. Subjoined is a statement of particulars relating to the said A. B., whom I undertake to visit personally, or by some one specially appointed by me, ,
once at least in every six months while under ment under this authority.
riage)
[If
Dated this
[or Hospital].
and treat-
Name. Rank or profession (if any). Full postal address. Degree of relationship (by blood
(Signed)
To
care
or
mar-
patient.
relation, the person signing to briefly as possible: 1. Why the authority is not signed by a relation. 2. His connection with or interest (if any) in the patient, or the circumstances inducing him or her to sign.] not
state
day ,
to
a
as
18
of
Proprietor
or
.
Superintendent
of House
['1 Or an idiot, or a person of unsound mind. [2] Some day -within a calendar month from the date of the authority. [3] Or hospital. [4] Describing houso or hospital hy situation and name.
[4]
THE
LUNACY LAWS.
Statement
(As
in Schedule
A.,
of
the
Particulars.
No. 1, 16 & 17 Vic.
c.
variations.) Proposed Form
I,
247
undersigned
A.
B.,
do
of
96,
witli
slight
Certificate.
hereby certify
as
follows
:
1. I am a person registered under the Medical Act, and I am in the actual practice of the medical profession.
1857,
in the county [2] 18 2. On the , at [H day of of separately from any other practitioner, I personally in the county [4] examined C. D., of of conclusion the that he is a to and came ? [5], [lunatic, an idiot, or a person of unsound mind~\ and a proper person to be taken charge of and detained under care and treat-
[3]
ment.
on the following grounds, viz.:? Facts indicating insanity observed by myself at the (?) time of examination [6]. (?) Facts communicated by others [7].
3. I formed this conclusion
4. I make this certificate having first read the clause of the Act of Parliament printed below.
(Signed) of Act
in
[Clause certificates.]
imposing penalties
A.
B.,
of
[8]
for wilful false statements
['] Insert the name of the street or place, with number or name of house, or, should there be no number, then insert Christian and surname of occupier.
[2] City or borough, as the case may be. L3] Insert residence of patient. I ] City or borough, as the case may be. [5] Insert profession or occupation, if any. [6] If the same or other facts were observed previous to the time of the examination, the certifier is at liberty to subjoin them ina separate paragraph. [7] The names and Christian names (if known) of informants to be given,
together
with their names and addresses. full postal address.
[8] Insert
