THE JOURNALOF MENTALSCIENCE

THE JOURNALOF MENTALSCIENCE.

No. 35. OCTOBER,i860. VOL.VII.

The President's Address to the Association of Medical

Officers of Asylums and Hospitals for the Insane, onThursday, July 5th, 1860.

GENTLEMEN,The new position in which you have done me the honour

this day to place me, entails upon me the duty of passing inreview the varied interests and difficult problems of socialand medical science, which are necessarily involved in promoting that which is the primary object of this Association,the welfare of the insane. The welfare of the insane ! Whata world of interests does not this small phrase include ; whatquestions of individual happiness or misery ; what questionsof the prosperity or ruin of families ; what questions of morality and law, of religion and politics ; in fine, does it not'inferentially include the welfare of the human race. From

â€¢ili-(time when Nebuchadnezzar ate grass, the happiness of

. tue human race has often been at the mercy of the not metaphorical insanity of its rulers ; and how often does not madness in lower stations imperil all that is precious. A madorator on the floor of the house, or in the pulpit, may do comparatively little mischief, for opinion breaks no bones ;but madness in a man of action, in an admiral for instancewho commits suicide in the heat of an engagement, or anengineer in charge of a railway train ; to what fearful disastersmay it not give rise ? In the world there is nothing greatbut man, in man there is nothing great but mind, saya

VOL. vii. NO. 35. 6

2 President's Address.

Hamilton. liow vast, how wonderful a subject of study, therefore, is mind, whether in its integrity, or its decadence andruin, in its health or its disease ! Mental physicians, are wepledged to devote ourselves to the contemplation, and, as faras may be, to the full appreciation of this great subject, that wemay oppose decay, and relieve disease ? Would it were possible to prevent it ! Mental hygiene is, indeed, a subject vastas that of human progress. The highest and lowest stages ofhuman development, those of the savage and the practicalphilosopher, are, perhaps, almost equally free from this direstscourge of human pride ; the one with passions undeveloped,the other with passions under subjection. But the line ofprogress from one to the other of these termini, is strewn withthose who have fallen in their weakness to linger and to die.Madness, the Nemesis of that ill-directed, ill-regulated development that we call civilization, what if it were to increase until the tendencies to mental disease overweighed inthe community the conservative powers of health ! Therehave been communities and times in which physical diseasehas threatened, or actually put an end to a race of men ; andthere have been communities and times in which folly andpassion and delusion have been so widely endemic, that thefabric of society has been torn down, and even its veryfoundations shaken ; and were it not for the resiliency ofnature, the benign law of adjustment, by which deviations from law are a check upon further deviation, it ispossible to conceive that the tendencies to mental infirmityand disease should increase ; that passionate selfishness andinsane folly should have continually augmenting power to reproduce themselves until acquired, and hereditary tendencies tomadness should overbalance the forces of self-control andsanity, so that an observer, neither cynical nor metaphorical,might justly exclaim upon the "mad world," and races, like

families, become impotent for all except mischief and disaster,until time, the great physician, brought the only cure inextinction. Such speculations as these are not without theiruse, impossible as their realization may appear ; they at leastserve to make us value rightly the blessings we enjoy, bless-

President's Address. 3

ings which from their commonness we are too apt to overlook. We have no earthquakes in this country, and wecalculate upon the stability of our buildings ; we have nodead calms, and that world without motion, whose stagnantputridity has been painted by Byron and Coleridge, is to usa dread but impossible imagining. But the stability of ourdwelling-place, and the restless agitajtion of the elements,

although among those simple elementary conditions uponwhich our being depends, are also conditions which it is mosteasy to conceive might have been otherwise.

" All precious things are still the commonest,Earth, Water, Air, and God's abounding Grace."

The possession of that precious thing, the harmonious co-operation of the complicated mental functions which

constitutes our mental sanity, is so much a matter of course,that man accepts it without recognition or gratitude, andcontemplates the isolated instances of its interruption withwonder and dismay, although at the same time he makesnot the slightest effort to prevent such interruptions, andcourses on in his career of emulation and avarice, in thefierce struggle for social pre-eminence, as if the contrary

were inconceivable and impossible. Will mental hygiene;ever win the same relative position in our department ofmedicine, to the cure of actually developed disease, whichcommon hygiene, the scientific care of the physical healthof the community, has already taken in relation to the artand science of medicine proper ? Or is not this almost toohigh an aspiration to be ever realized ?

To forestal and prevent the development of insanity. Whata thought is this ! What a world of well-regulated desires,

of subdued selfishness, of rational employments, would there notneed to be constituted in order that the idea might obtainthe slightest approximation to a practical realization ! Takeas one example the influence of religion ; it has been welland truly said, that the religion of the Gospel never produced a case of insanity ; but how many thousands havefallen victims to a misinterpretation thereof ? On the righthand and on the left we see the mental devastation of fanati-


ckÃ¤mand bigotry ; the unnatural life of isolated asceticism imposed by the tyranny of a dogma, filling with lunatics themonastic cells ; and the exercise of freedom of religiousthought on the other hand, giving rise to epidemics ofinsane fanaticism, like that of the Ulster revival. This lattercause of insanity is of great and increasing interest. Thehistory of the Agapemone in our own country, and of theMormonite sect in America, afford recent examples of theextremes of folly to which the right of man to worship theCreator according to the light of his own conscience maylead, his feeble, foolish and selfish creature.

The light in which these products of religious libertyought to be viewed is a question which deserves the attentionboth of the statesman and the psychologist ; for upon thedetermination whether they are simply blasphemous or examples of imitative and endemic madness will depend theright and rational mode of dealing with them.

But we must leave these speculations, these thoughts whichthough they fathom not the realities before our eyes, yet carryus beyond our depth in the great sea of human motive, " likelittle wanton boys that swim on bladders," rather than like

men who in the well-found vessel of scientific truth navigate

and explore its farthest waters. We must leave thesespeculations, and apply ourselves to those realities whichdemand our attention rather than to those subjects of widertruth which invite but satisfy not our unfructifying reflections.

The history of this Association marks its aim and objectas eminently practical. Originally founded by the Superintendents of County Lunatic Asylums, for the purpose of affordingthemselves opportunities of social intercourse at each other's

homes, and by friendly and unostentatious talk on the subjectsof their calling, to gather knowledge of each other, and fromeach other, this worthy but limited object was soon satisfied;the few members of the Association became friends ; theyfound that they could communicate by letter, and the meetingsof the Association fell into disuse. It was in this way probablythat tne Association became for many years to all appearance dead. Without any of those causes which usually break


up societies, without any disruption of amity or change ofcircumstance, all activity in the Association ceased, and formany years it shewed no signs of life, though in truth onlydormant. This state of things continued until the year 1853â€¢flehenthe first step to the rejuvenescence of the Association

was taken at the meeting at Oxford, under Â¿he auspicesof my friend Mr. Ley, at which it was determined thatefforts should be made to vivify our dormant life by theestablishment of a literary organ of the Association. Itwould ill become me to speak of the manner in which thenumbers and strength of our present Association havegathered around this centre of our vitality. I am too conscious of the errors and shortcomings of the part of the workwhich has been placed in my hands, not to feel gratifiedsurprise, at the effect which this real but simple bond ofinterest and communion has exercised upon the members ofour specialty. Infinitely more successful as it might have beenas a literary enterprise, it has at least been successful beyondall our expectations as the means of vivifying and extendingand uniting this Association of medical men, scatteredas the members are over all parts of the United Kingdom ;working as they do in every department of the special branchof medicine to which they belong ; influenced by diverseinterests ; entertaining widely different opinions, and onlyunited by that strong bond of sympathy which is to be foundin one great common object, which to them is the welfare of theinsane, and the desire to promote all legislative and scientificand social measures which are calculated to attain this object.Is there no selfish intention in the object of this AÂ»sociation?no after-thought of common advancement or common defence?

As an object and intention in itself as distinct from the welfare of the insane, certainly not As an object and intentionintimately allied with the welfare of the insane, certainly thereis. Let the fickle and purblind public in moments of its prejudice, say what they will; let statesmen who look to^the opinions of the public for their inspirations, do what they choose,the welfare of thÂ« insane does and must intimately dependupon the enlightened appreciation and honourable discharge


of their duties by those who have charge of the actual careand treatment of the insane. Neither newspaper articles norActs of Parliament can touch the insane, except through theinfluence they exercise upon their guardians. As thisinfluence is for good or for evil, it will work benefit ormischief upon the wretched mass of lunacy, which the writingand declaiming public, not unwillingly deals with at adistance, but which it would not itself touch with oneof its fingers. The feeling and conduct of the Britishpublic towards the insane reminds one of nothing somuch as that of the enlightened citizens of the freeStates of America. Noble and just sentiments towardsthe negro race are in every one's mouth, but personalantipathy is in every man's heart. For our part let us claim

and maintain the character of working missionaries, who inthe face of difficulty and peril labour to comfort and upholdand restore the branded bondsmen of disease. The insaneare under the bonds of morbid passions, of ignorant andwicked habits, of the physical accidents and the tainteddescent which cause their disease. We strive to rend thesebonds, not by the philandering philanthropy of a verbal andunreal sympathy, but by dire and life-long effort and labour,in which we sacrificeÂ«^-what do we not sacrifice ? Do wenot sacrifice the good-will of the community, not so muchfor the short-comings, which in our great task are inevitable,

but because the public extends its unreasonable antipathyto the insane, to all those who are connected with insanity :even to those who wrestle with the great evil, and, to the bestof their ability, hold it down ? We are part of a disagreeablesubject, which the public, except when frightened from itspropriety, is too happy to ignore and to forget. Our very meritsplace us in taboo. This is a great sacrifice, the extent ofwhich it is difficult to conceive, and impossible to calculate, forwhat will repay a man for placing himself in a position in lifewhich his fellow men consent to look upon with unfavourableeye ? Let this consideration at least have the good effect ofdrawing us nearer to each other in the bonds of amity ; letthe fanciful line which the public, hugging itself in the bash-


fulness of its maiden sanity, draws between itself and allthe distasteful objects of our calling, be to ourselves a notfanciful bond of union and brotherhood.

Another and a far more real matter in which we sacrificeour own welfare to the commou-weal is, that we consent to

spend our lives in a morbid mental atmosphere. The manwho consents to dwell in an insalubrious climate, expects tobe abundantly remunerated by the acquisition of wealth orhonour, or both ; although in his case only physical health isplaced in peril. But he who efficiently discharges the arduous functions attendant on the care and treatment of theinsane, dwells in a morbid atmosphere of thought and feeling,a perpetual " Walpurgis Night " of lurid delusion, the perils

of which he, who walks through even the most difficult pathsof sane human effort, can little appreciate.

No one can understand the insane, or exercise guiding andhealth-giving moral influence upon them, who cannot and does

not, so to say, throw his mind into theirs, and sympathize withtheir state so far as to make it, at least din-ing brief periods,

almost subjectively his own. The mail of rigid self-possession

to whom sympathy is but a weakness ; the man of stolid indifference to whom sympathy is but a word, can neither meritnor gain the confidence of the insane, and can exercise butlittle moral influence over them. But the true mental physician transfers for the moment the mind of his patient intohimself in order that, in return, he may give back some portion of his own healthful mode of thought to the sufferer.This operation is so trying and so depressing that if it werecontinuous it would be unbearable. Its influence upou thefeelings and character is, and must be felt deeply by all. Tomany, alas, it has been really destructive. The number ofmental physicians who have suffered more or less from theseeming contagion of mental disease, would form, perhaps, ifenquired into, a proportion of those who really fight in thiswarfare which might bear some comparison even with that ofmen who fall in the strife of the sword. And what are injuries tothe physical frame compared with those inflicted on the integrityof the mind ! Let me, therefore, before passing from this subject


attempt to impress upon you the imperative duty of guardingyour own mental health by frequent periods of relaxation andvariety. Let none of us, venture to persevere in the dischargeof our arduous duties until from the cause here pointed out, heis compelled altogether to withdraw ; for, depend upon it, themental health once shaken, is never so fully restored as to givethat power and elasticity of mind which the efficient dischargeof our peculiar functions imperatively demands. One safeguardwill be found in periodical relaxation and variety, in travel,and in temporary but entire change of interest. But it behoves \w also, in addition to this, to make use of that constantmental tonic which contact with sane minds can alone afford ;and for this purpose the pursuit of some study of an interestentirely disconnected from insanity will be more beneficial to usthan to others, for to us it will be actively sanative and preservative. The study of general literature, or the cultivationof natural science, or even pursuits like agriculture orfield sports, are to the mental physician not merely sourcesof mental gratification, but act powerfully as a counterpoiseto the morbid tendencies which his arduous professional calling involves.

The legislative agitation on our subject, which has nowcontinued for so many years as to suggest the idea that somepeople may think that insanity is to be cured by Act ofParliament, is now supposed to have come to that point ofmaturity which is marked by the preparation of a comprehensive bill. I shall venture to direct your attention to someof the more important points we may expect or hope to findin such a bill, and as the rights of seniority in this Associationbelong to the superintendents of county asylums, I shallventure to express in their behalf the reasonable hope theyentertain that the new bill will contain a just provision for aretiring pension for length of service.

The provisions of the present statute for this purpose holdout a delusive promise, inasmuch as the retiring pension atthe end of twenty years' service is left to depend entirely

on the good will of the Visiting Justices for the time being, orrather, on their good will and their courage to face their con-


stituents at the Quarter Sessions with the information that theyhave voluntarily added a burden to the county rate. Now, al-

although the magistrates of England, acting in the capacity ofvisitors to county asylums have, with few exceptions, behaved ina most exemplary manner towards the medical superintendents,it is neither consistent with past experience, nor probablefrom the nature of things, that they will display the sameamount of justice in granting retiring pensions as theyhave exercised in the remuneration of active service. Thepressure of economists at Quarter Sessions, the desire to staveoff the innovation of county boards of finance, and othersufficiently intelligible motives, will, undoubtedly, incline thevisitors of county asylums to discountenance the applicationfor retiring pensions from any superintendents who are notdisqualified by age or ill-health, or some other disability from

continuing the discharge of their active duties. But nothingcan be more unjust than to make the grant of a retiringpension for length of service dependent upon such disabilities.It is so in no other service, and k ought not to be so in ours.The prudent and temperate man who has retained all hiscapacity during a long period of service, has in all probabilityreally earned and merited a pension, by the amount of workdone, more fully than any unfortunate valetudinarian, whomthe Visitors might be willing enough to place upon theofficial shelf. Superintendents therefore will do well to keepthis matter earnestly in view, and to exert their individual andunited influence to obtain statutory provision that, for adefinite period of service, independent of age or infirmity,they shall receive a definite pension however moderate maybe its amount.

Another most important point to be watched by the superintendents of asylums is, the necessity for some provision in thenew statute by means of which all the destitute insane maybe brought under the immediate control of the magistracyand of their officers, and removed from the control of theguardians of the poors-rates and of their officers ; I say guardians of the poors-rates not of the poor. The principle has long

ago been admitted to be essential in the care and treatment


of the insane, that those who are directly interested in curtailing to the utmost the legal claims of the destitute insane,upon the property of the country, should have no control overthem. The sad history of the pauper lunatic but a few yearssince in this country, and almost up to the present time inScotland, is an unanswerable proof that provisions of this kindhave been absolutely necessary in the interests of humanityand of justice. But while this principle is nominally adopted,while the legislature holds a penalty over the head of any overseer or relieving officer who neglects within three days to takea pauper lunatic before a justice of the peace, for the purposeof being sent forthwith to the county lunatic asylum, whilethis is the law, what is the practice ? Why, that in Englandalone, some 14,000 pauper lunatics are maintained outof asylums, and are as entirely under the control of thepoor law officials, and as entirely beyond the control of themagistracies, as if there were no Lunatic Asylums Act onthe Statute Book. This number of pauper lunatics not inasylums is the official return made by the officers of thepoor law, but what the actual number of destitute lunatics notin asylums may be, who can tell ? for it is the obvious interest

of the poor law officials to regard no pauper who is detainedout of an asylum as an insane pauper. It was about this timelast year that, in a part of the country some hundreds of milesdistant from my own home, in passing by a roadside cottage,I observed an old man in the garden in a state of ravingmania. I went into the garden, but he ran away ; I overtookhim and examined him, and I can causcieiitiously say, I havenot a patient in my asylum in a worse state than I foundhim in ; his pulse was 120, and like a thread, his face washaggard, his tongue parched, his skin clammy, and he wasraving about the devils that had been pulling him out of bed.I went to the clerk of the board of guardians, who residedwithin two or three hundred yards of the old man's cottage,

and who passed and repassed it every day. I told this gentleman that the man ought to be removed to the countyasylum without delay. He admitted that the man had beenlong in the receipt of parochial relief, but said that he did not

President's Address. ÃŒ1

think the man was insane, that he was not worse than heliad been for months past, and that the policeman hadgiven him a thrashing two or three times, which had donehim good, and he would tell the policeman to look after him.I then went to the rector of the parish, whom I found wellacquainted with the old man's condition, and who expressed

sorrow and anger that he had been unable to persuade theparochial authorities to do what was needful for his propercare ; I explained to this gentleman, whose intentions weremost humane, but who was ignorant of powers which thelaw gave him, that if he would deliver a formal notice to therelieving officer that the pauper was insane, the latter wouldincur the liability of a penalty if he did not take him beforea magistrate within three days. This was done, but it wastoo late ; the poor old man was sent without further delayto the county asylum, but he died in about three weeks afterhis admission.

I know not what legislative remedy would reach such acase as this ; and how many such cases there may be scatteredthrough the bye-ways of England who can tell ? The con

dition in which numerous patients are admitted into countyasylums clearly enough indicates the extent of the evil. Theonly person whose duties compel him to see all paupers isthe relieving officer, but the responsibility of recognising theearly stages of insanity, could scarcely be fixed upon thisnon-medical official, so that a penalty for neglecting to take

any lunatic pauper before a justice, without notice tohimself of the supposed lunacy, would probably be inoperative. Thus far, however, the path of legislation wouldseem to be clear. First, to remove from the visiting justicesof county asylums the power of declaring such asylumsfull, and of closing their gates upon legal applicants foradmission. Secondly, to make it imperative upon the magistracies to provide asylum room sufficient for the accommodation of all pauper lunatics in the county, except those whoupon the report of their own officers, and in the exercise oftheir own discretion, they may deem to be in a fit state toreside at their own homes. Thirdly, to make it imperative

12 President's Address,

upon the Justices in Session, to appoint sub-committees who

shall, in company with a medical officer appointed by themselves, periodically visit every union house, and to give tosuch sub-committees the discretionary power of ordering the

removal of any pauper lunatic or idiot in such union housesto the county asylum. Fourthly, to render liable to penaltyany relieving officer, or overseer of the poor, who shall neglectto take any pauper of whose insanity he may have knowledge, whether by notice or otherwise, before a Justice ofthe Peace.

I observe in the last report of the Commissioners inLunacy, that the duties I have here suggested to be dischargedby committees, may be undertaken sua sponte, by any individual magistrate acting in a union house as ex-officio guar

dian. But such duties never have been thus performed, andtheir discharge would be too invidious for us to expect that theyever should be thus performed. The position of a committeeappointed under a statute for the definite purpose would bevery different to that of an individual magistrate acting ofhis own free will

I beg leave here also to suggest that the new statute shouldempower the Commissioners in Lunacy to establish anuniform system of asylum accounts, and to require that theyshould be annually published. As they are at present keptasylum accounts as often mislead as they instruct ;.yet asystem which would enable us to institute a just comparison of our expenditure would be of great service. Themaintenance charge in the different county asylums variedlast year nearly 50 per cent., namely, from 7s in the lowest to10s, 12s, and 13s in the highest. Even in old asylums thevariations are great. An uniform system of accounts, whichwould enable us at once to recognize the causes of this difference, whether of defect or of excess from the average,would be of infinitely more practical service than the unskilfuland partially eliminated statistics at which we have so muchlaboured, and with so little result.

The next subject of impending legislation which claims ourattention is one which will affect that esteemed class of our


associates who are the medical officers to the licensed housesfor the insane, legislation which appears to be demanded by thepublic lest auy of its sane members should through impropermotives be incarcerated upon the false imputation of insanity. It will at the present time be needless for me to domore than to refer to the recent agitation of the public mindon this subject, and to the various proposals which have beenmade to remove the supposed danger ; proposals, many of themso wild that they would themselves seem to furnish plausibleevidence that there are more people out of asylums thanthere ought to be. There have been proposals to havemedical juries to decide upon the lunacy of lunatics beforethey are admitted to treatment, to have commissions ofinquiry similar to those used under the great seal, to haveeach case of lunacy before it is placed under treatmentverified in the County Court, and various others equally wiseand practicable, which we may leave to sink into oblivionwith that public agitation which gave rise to them. Thevery remarkable and scarcely to be expected absence of allevidence before the Parliamentary Committee, that any sanepersons have been shut up in asylums as insane, would appearto any unprejudiced mind to afford abundant reason for thebelief that the existing guarantees for the liberty of the subject are amply sufficient.

I say that this absence of evidence was scarcely to be expected, because my own experience, tells me that in countyasylums, from whence there is every motive, except the needof care and treatment to keep patients away, persons aresometimes sent, and are admitted, who are not insane, butwhose conduct has been misinterpreted by unreasonable apprehension, or by medical ignorance ; and it would appearreasonable to expect that such accidents without any malafides might also occasionally occur in the wealthier classes ofthe community. But, although the Parliamentary Committee is now concluding its third year of enquiry, and,although there has undoubtedly existed among those who tookan active part in the late movement, no lack of good orrather of ill-will to make accusations, there has been a total


absence of all evidence, that any sane persons have beenadmitted as patients into private asylums. Here, on theother hand, is the positive evidence of one who has,during a generation of time, had the very widest field ofexperience, the noble Chairman of the Commissioners inLunacy, whose evidence on this point ought in itself to be considered as conclusive. "I do not think (says Lord Shaftesbury)

in my experience of nearly thirty years, that there has been asingle case, or not more than one or two cases, in which anyperson has been shut up without some plausible grounds forhis or her temporary confinement ; but, in every instance,with these exceptions, there have been certain plausiblegrounds, in fact, or in logic, sufficient to justify the temporary confinement of the persons, and their being submittedto medical treatment." It would be difficult in the face of such

positive evidence as this, and in the absence of all evidence tothe contrary, to assign any other motive for any legislativemeasures calculated to impede the early and curative treatmentof insanity in asylums, than the desire to indulge a prejudiceof the public mind rooted in ignorance and error.* The es

teemed and well-informed physician who has vacated the chair,

which I occupy this day, has well expressed the feelings andopinions of this Association, on the supervision of asylums,in the excellent address which lie made to us last year.

Sir Charles Hastings said :â€”"There can be no doubt that

every member of the Association will say it is quite rightthere should be a supervision of asylums, but let it be an enlightened supervision, not a system of secret enquiry, to whichunjust suspicion is the incitement. Let it be carried on bymen thoroughly versed in the intricacies of the abstruse subject to be inquired into ; not by men who have no specialexperience to guide them in the difficult questions they willhave to solve. The Commissioners in Lunacy are the partiesto whom all matters relating to the legality of detaining an

* " Que j'ai toujours haÃl̄es pensers du vulgaireQu 'il me semble profane, injuste, et tÃ©mÃ©raire,

Mettant de faux milieux entre la choseat lui,Et mesurant par soi, ce qu 'il voit en autrui."


insane person ought to be referred. If they are not sufficientlynumerous their numbers should be increased ; and in anyadditions that are made, special care should be taken, thatthose practically acquainted with the phases of insanity areplaced in office."

In the good sense of these remarks I am sure we must allconcur, for the full and satisfactory supervision of all asylums,whether public or private, is an undoubted function of theexecutive, to which no true friend of the insane, and no well-

wisher to the members of our Association will, even in thought,raise an objection. But the provisions of the Lunacy Billwhich have been withdrawn, and those which are understoodto be included in the one now preparing or prepared, go muchbeyond the aim of the fullest supervision, and appear in mymind to intrench in a dangerous degree upon the functions ofthe mediaal attendants of the insane. In the first bill it wasprovided that every patient admitted into an asylum shouldbe immediately visited and examined, and his sanity or insanity decided upon and reported by some neighbouring physician in a secret communication to the Commissioners. Thegreat difficulties which would be inevitable in carrying out thisprovision having been pointed out, it is now understood thatthe scheme for the appointment of Medical Examiners in theneighbourhood of each asylum is to be superseded by theappointment of District Inspectors of Lunatics. It is withmuch diffidence that I shall suggest to this Association anyobjection to this arrangement, inasmuch as I find that theoriginal suggestion of it was made by a gentleman who wasonce one of our members ; Dr. Forbes Winslow, in his comments on lunacy legislation, read to us at Edinburgh in 1858,having recommended the appointment of " Inspectors of Lu

nacy to preside over certain districts in the metropolis as wellas in the provinces ;" these " District Medical Inspectors," as

he calls them, whose appointment is understood to be contemplated in the new bill, would appear to hold somewhat thesame relation with regard to the Board of Commissioners,as the poor-law inspectors hold to that of the poor-law board.

Whether they will hold the same relation towards those they


are intended to inspect, I am unable to say ; but it must beevident on the slightest reflection that the responsibility ofdetermining upon the sanity or insanity of reputed lunatics,and of deciding and reporting upon the right or wrong judgment in this matter exercised in the certificates of medicalmen, will be infinitely more onerous than the duties of a poorlaw inspector employed to watch the proper discharge of thevery definite duties of poor law guardians and relieving officers.Those who are best acquainted with the personnel of the department of the profession to which we belong, will be bestable to judge whether the stinted salary which has beennamed for these district inspectors of lunacy will be sufficientto secure the services of men whose experience, character, andstanding, will be at the same time a sufficient guarantee forthe due discharge of their arduous functions, and for theavoidance of that irritation, mischievous to the best interestsof the insane, which will inevitably arise in the minds of themost highly qualified mental physicians, if they find thenirselves subjected to the official surveillance of men greatly inferior to themselves in professional reputation and standing. Mr.Campbell, one of the Commissioners in Lunacy, with a wiseforethought that cannot be too highly appreciated, warnedthe Parliamentary Committee of the evils which would resultfrom any legislation which would tend to degrade the positionand estimation of the medical men who are entrusted withthe charge of the insane ; and it may safely be asserted thatno legislative measure would tend more strongly in thisdirection, or be more calculated to disgust with their calling,and drive from it the most highly educated and esteemed ofthe physicians who practice in lunacy, than to subject themto the inspection of an inferior and ill-paid class of govern

ment officials.And would not this feeling be justified on more legitimate

grounds than that which may possibly meet with little regardas the mere ebullition of professional jealousy ! Let us supposefor the sake of argument, that the position of the district Inspectors could be made as unquestionable as that of the Commissioners themselves, who claim and receive from the best


of us, that deference which is due to their high official rank.Can we not foresee that the action of these district Inspectors would supersede the most important function ofasylum physicians, which I take to be the determination ofthe proper time to detain and to discharge a patient. Thisthe duty of the district medical Inspector, who is to examineand report upon the state of mind of every patient withina limited and brief period of his admission into an asylum,must necessarily supersede. Two men, placed for a definitepurpose in the same position, may be and often arejointly responsible for the same act ; but all the legislation which was ever perpetrated, from Solon downwards,could not make two men, occupying such distinct positionsas these, divide responsibility. When the captain places thehelm in the hands of the pilot his own responsibility in thenavigation of the ship ceases ; and so it must inevitably bewith the captain of an asylum, when the government pilotboards his vessel. It may be objected that it will be easy tolay penal obligation on the asylum physician to report hisopinion of the state of mind, as if there were no district Inspector at hand to endorse or contradict it ; but in practice noone can doubt that the discharge of a duty so imposed wouldbe merely formal, and that the real determination of the stateof mind would be left entirely to the Inspector. A moderateacquaintance with the principles of social or rather of moralscience will assure us that this must be so, and no profoundknowledge of affairs will be needed to confirm the assurance.Power and responsibility are correlative and equipollent. Ifthe one is diminished the other wanes, if the one is destroyedthe other ceases. If the detention or discharge of a lunatic ismade to depend upon the examination and report of a government official, the responsibility of that detention or dischargewill be as much removed from the shoulders of the asylumphysician, as all responsibility for the detention or dischargeof a prisoner is removed from the governor of a jail whoacts to the very letter of the law upon the orders of theexecutive.

Such, then, being the certain action of these proposedVOL. VII. NO. 35. C


officials, the question will arise whether it will be for good orevil. Many persons will perhaps rush to the conclusion thatbecause the judgment of these officials will be unbiassed by interest, the transference to them of the power and responsibilityof determining upon the detention or discharge of imputedlunatics will be an undoubted advantage. To support thisopinion, however, it would be needful to shew, that the judgment on this matter hitherto exercised by asylum physicians has, in fact, been biassed by interest contrary tothe welfare of their patients ; which, I repeat, has not beendone. The great disadvantage likely to result from this transference of responsibility is, that it will tend more than anything else could do to degrade the position of medical menengaged in the treatment of the insane, and to reduce themto that commercial position with which they have been so muchtaunted, and which it should be their most earnest desire andpurpose to avoid, and repudiate. With district medical Inspectors of Lunacy ready at every moment to visit and decide uponthe detention and discharge of patients, and eventually, as musthappen, upon their treatment also, (for in asylums, he who hasthe power of discharge has the sole power ;) the asylum physician, of liberal education, of large experience, and good repute,would become a social superfluity, and he would graduallygive place again to the old class who were formerly andproperly designated as the keepers of asylums. I do not saythat there would be any sudden change. There are no suchthings as strikes among classes of the community whose intelligence is cultivated, and whose vested interests are large ; butthere is a gradual and far more important, because more irremediable change in the quality of different classes of the community, which would, in my opinion, take place in the class towhich we belong. Men gradually withdraw from spheres of activity which they find uncongenial, and other men of the samequality and calibre are not found ready to take their place.Something of this might have been seen in the army medicaldepartment before the late changes, and a more striking instance of it is said to exist in the political arena of the UnitedStates, in which men of the highest education and character


refuse to engage. Our own statesmen, able and highly instructed as they are, seem scarcely competent to appreciate,much less to guide these slow movements which are constantly and gradually, like natural transmutations, changingthe face of society.

It is certain that legislation for lunatic asylums cannotachieve incompatihle ends ; it cannot elevate the characterand improve the position of medical men having charge ofthe insane, and at the same time subject them to the constant superintendence of inferior government officials. Theultimate choice would seem to lie between private asylumsconducted by their proprietors upon a purely commercial basis,in which all medical responsibility will be absorbed by thenominees of the executive ; or private asylums conducted oneven a more professional basis than at present, by the elimination, as far as possible, of lay speculators and women fromtheir management, and by granting licenses to medical menonly of approved reputation and ability, and by increasingrather than by diminishing their responsibilities in the management of their institutions, and in the detention and discharge of their patients.

An apparent objection to these views may seem to existin the power already possessed by the Commissioners in Lunacy to order the discharge of patients ; but the objection isapparent rather than real, for the action of the Board of Commissioners in Lunacy, the supreme authority in these matters,is a very different thing both in practice and theory, to thatwhich the more frequent intervention of inferior governmentofficials would be. The latter would be in danger of feeling itneedful constantly to assert their usefulness by small andirritating interference. The Board of Commissioners, on theother hand, appreciate the responsibilities of their high positiontoo justly to compromise themselves by the assumption offunctions which properly belong to the physicians actuallypractising in the treatment of the insane. In cases of exceptional difficulty the public have a right to the decision of theBoard, and physicians practising in lunacy will do wiselyto defer such cases to such decision ; which they can well do

c*

20 Presidents Address.

to a supreme authority of this kind without any loss ofprofessional dignity. And it cannot be affirmed that theCommissioners of Lunacy have hitherto discharged thisarduous portion of their duties otherwise than with greatdiscretion, and a just feeling of the responsibilities incurred,by giving liberty of action to persons of whose sanityphysicians of character and experience and knowledge ofthe case have expressed doubt and apprehension. Therehave been, and the very nature of things renders it inevitable that there should be, many points connected withasylums in which differences of opinion must exist betweenthe Commissioners and individual asylum physicians ; buton the large and broad principle of action, which maybe expressed as the supremacy of the medical man in thecare and treatment of the insane, the members of this Association are bound to give no ungrudging testimony to theearnest and consistent efforts of the Commissioners to uphold,both in public and private asylums, the authority and positionof the profession. Individually and collectively, we owethe Commissioners a debt of gratitude on this score, of the acknowledgment of which, in this place, I am happy to be theexponent. If the Commissioners on this subject had adopteddifferent views, it is possible we might still have seencounty asylums under the management of lay governors, theformer masters of union houses or men promoted from theranks of attendants. It is even probable that the unsatisfactory position of the medical men in some of our largestasylums, which the Commissioners have strenuously buthitherto in vain attempted to alter, might have been theirgeneral position throughout the country ; and in privateasylums it might still have remained the rule instead of theexception that these institutions should be in the hands ofwomen or of lay speculators, with the occasional attendance ofa visiting physician to give to them the semblance ratherthan the reality of places devoted to the medical treatmentof their inmates.

I do not say that the Commissioners in Lunacy have doneall that they might have done to strengthen and promote the

President's A ddress. 21

medical element in contradistinction to the commercialelement in the care and treatment of the insane ; but if I havecorrectly observed the tendency of their action, it has beenmore and more guided by this important principle, from thefuture development of which, we may anticipate the bestresults both to ourselves and to the well-being of the insane.In connection with this part of our subject, I shall ventureto remark that the large sums of money which are givenfor the good-will of private asylums, and regarding whichthe Commissioners have expressed dissatisfaction in theirlast report, are in this free country as little within thescope of legislative interference as the prices of houses orland. In a country where everything is bought and sold,where the cure of souls is a matter of open purchase, and the.Queen's commission to defend the country, is rated at an

officially fixed tariff, the utmost liberty must be given to menin the estimation of the value of an established lunatic asylum.But there is this one beneficial check which it is in the powerof the Commissioners to apply to the excess of which theycomplain, namely, to limit the market to medical men. Theadvowson or presentation of a living may be bought by anyone, but it can only be bought for the use of a Clerk in orders ;the sale of a commission in the army is still more strictlylimited to an officer in the next subordinate rank ; and itseems reasonable, and certainly offers the promise of vastlyadvancing the status of asylum physicians, if either by enactment or by the rules of the Commissioners the right and powerto hold possession of private asylums should be limited to dulyqualified and competent medical men. As we all know, theyare now purchased by speculators who invest in them as theywould in ships or rail ways or mining shares ; but if thiselement of competition were eliminated, the Commissioners inLunacy would have no more right to object to, or to commentupon the purchase of a medical practice in lunacy, than anyone has to object to or comment upon that every day transaction, the purchase of the good-will of a general medical

practice. I lay some stress upon these points, because Ibelieve that it should be one of the most earnest objects of


this Association to discuss all means calculated to promotethe professional status of the physicians of asylums whetherpublic or private ; and I believe that one of the most promisingdirections in which these means are to be sought in regardto the latter is in attempts to emancipate them fromcompetition with lay speculators ; and to prevent the latterfrom occupying the position of being the employers of medicalmen, who are thus placed in a position which, Lord Shaftes-bury truly says, "is not the true position which a medicalman ought to occupy." " The medical profession," says hislordship, in his 94th reply to the Special Committee, " the

medical profession stands too high to be placed in thatposition ; I have reason to speak in the highest terms ofestimation of some of the medical men that are in chargeof these asylums, and I can only deeply deplore they are notin their true position."

I trust you will not think I have exceeded the limits of myoffice, or of my position as a public asylum man, in havingadverted to these matters. I have for many years been toomuch called upon to review the whole subject of lunacy to beeither ignorant or uninterested in any department of it, andI feel strongly that the welfare of the whole body of medicalmen practising in lunacy is intimately and indissolubly oneand the same. Constant personal changes take place betweenthe two classes, if classes they can be called ; the physiciansof private asylums often leave that field of professionalaction to take the superintendence of public asylums, sothat about one-third of the latter are under the control ofgentlemen who have effected an exchange, so to say, inthe regiment but not in the service. Perhaps a still largernumber of men have made the same change in the reversemanner, so that to assume any difference of feeling foundedon personal grounds in these matters is either an error or ashallow pretence.

Moreover, if these constant interchanges in the personnel ofour corps did not exist, we should still be indissolubly allied bycommon sympathies and common interests, and especially mustour interests be intimately allied in considering the professional

Annual Meeting of the Association. 23

and social status which is attainable by physicians engaged inthe care and treatment of the insane, whatever may be theirparticular field of practice. The Association over which I havethe honour to preside is one brotherhood, devoted to a mostnoble, though arduous calling. Therefore, let there be emulation among us but no jealousy ; let there be faithfulness amongus in plain-speaking but no contention ; let the noble purposeof our lives be an ever present bond of sympathy and goodwill ; let the well-being of the insane, and the honour of ourprofession be to us our guiding motive, both as individualsand associates ; " let each one mend one," as the old proverb

says, and the progress of our department of the professionwill not be uncertain, either in its best interests or in thepublic favour.

ASSOCIATION OF MEDICAL OFFICERS OF ASYLUMS AND HOSPITALS FOR THE INSANE.

Official Report of Proceedings at the Annual Meeting heldat the Freemasons' Tavern, Thursday, July 5th, 1860.

DB. J. C. BUCKNILL,F.E.C.P.,President.

The Chair was taken by SIE CHARLESHASTINGS,D.C.L.The following members, among many others, were present :

DR. BUCKNILL SIR C. HASTINGSDR. CONOLLY DR. SUTHERLANDWM. LET DR. ROBERTSONDR. KIRKMAN DR. THURNAMDR. BURNETT DR. HARRINGTONTUKEDR. LALOR DR. STEWARTDR. FLYNN DR. PAULDR. STEWART DR. CAMPBELLJNO. MILLAR DR. JOHN MEYERT. N. BRUSHFIELD G. FIELDINGBLANDFORDDR. FAYRER Dr. DAVEYR. H. HUNTLEYSANKEY DR. HITCHMANDR. MANLEY DR. BLOUNTDR. SHERLOCK DR. LANGDONDOWNDR. PRICHARD DR. WILLIAMKIRKMAN

10.1192/bjp.7.35.1Access the most recent version at DOI: 1860, 7:1-23.BJP

BucknillAsylums and Hospitals for the Insane, on Thursday, July 5th, 1860The President's Address to the Association of Medical Officers of

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