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Published by Authority of

The Association of Medical Officers of Asylums and
Hospitals for the Ensane.

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This opinion expressed thus authoritatively by those best qualified to form a just one, has been contravened and censured by more than one of our contemporaries. So far as we have been able to understand their plea for the appointment of visiting physicians to asylums, it is made to rest mainly on two grounds, which without circumlocution may be thus stated. In the first place it is supposed, that such officials would act as a check upon any maladministration or objectionable conduct on the part of resident officers, and as a security to the public that neither cruelty nor neglect was practised in the institutions placed under their inspection. In the second place, these appointments are advocated in order that by intellectual collision with medical superintendents the latter may be prevented from passing

into a state of "passive sloth" or absolute dementia, owing to their seclusion from the external world and their too great devotion to a monotonous routine of duties.

To the first argument it may be objected, that it is scarcely consistent with sentiments of nice honor, for a physician to act as an inspector under the disguise of a colleague. In campaigning every one knows what is thought of an officer who is found within the lines in an assumed character, and what is done with him. For heaven's sake let not the sacred character of a physician be ever degraded into that of a spy. Few will deny that both public and private asylums require thorough and frequent inspection to satisfy the public mind, and to prevent abuses from creeping in. The law provides that such inspection shall be given, and public asylums do for the most part receive it, though according to Lord Shaftesbury, "nothing can be more imperfect and unsatisfactory than the inspection of private asylums." If the appointment of visiting physicians is necessary, that they may serve as guarantees to the public independent of the Commissioners and of the asylum staffs, surely their services are needed infinitely more in private asylums than in public ones, since in the former alone is any great deficiency of inspection stated to exist. Our contemporaries, however, have entirely overlooked this very obvious inference.

We are well aware, that in a few county asylums the visiting justices discharge their duties unpunctually and imperfectly, but with these exceptions it may be truly asserted that no kind of public institutions are more thoroughly inspected according to law than those

devoted to the insane poor. In some notorious instances, indeed, the visiting justices far exceed the boundaries of inspection and 'general control, taking upon themselves the legitimate duties of the psychiatric physician. Assisted by talented matrons and stewards, certain committees almost elbow medical men out of the field. Instead of needing visiting physicians to assist them in the duties of inspection, they with the exception of the drugging part of the business almost monopolize the duties of the physician to themselves. Why should asylums be the last places where the old proverb of ne sutor, ultra crepidam, can be applied?


Besides the visitation of county asylums and their inmates by commissioners, visiting justices, guardians and overseers of the poor, and union medical officers, provided for by the law of the land, there is frequently a great amount of unofficial visitation. At Hanwell the unofficial visitors during the year have been counted by thousands, and at most other asylums their number very considerable. If, however, for the complete satisfaction of the public mind any extension of visitation is needed, by all means let it be effected, but let it be done openly and avowedly. If it is deemed necessary to have medical visitors in addition to the medical commissioners, let them be members of committees of visitors, as indeed is frequently the case already. But in the name of honesty and candor, let us have no smuggled underhand inspection under the disguise of medical assistance. Besides experience has proved that visiting physicians cannot, or do not, act as a detective police in plain clothes, since it has happened that those asylums in which serious abuses have been brought to light, have had such officials upon the staff, a broken staff to trust to, as the governors of Bethlem found.

That the superintendents of asylums are in any danger in falling into "a dull unvarying system of routine," and a condition of "passive sloth," owing to seclusion from the "external world," may or may not be correct. The captain of a ship is secluded from the external world still more strictly than the superintendent, without much danger of falling into a state of "passive sloth," or "a dull unvarying system of routine." But should such a danger really exist, it is incredible that the occasional visits of some elderly medical gentleman from the neighbouring town will have any influence in preventing so undesirable a result. The latter, indeed, must himself submit to the inglorious routine of merely indorsing the acts of the superintendent; unless he is not to be deterred from striving for independent action, by the contrast of theoretical knowledge with that which is both practical and theoretical, and by proving painfully to himself, the folly of coming into those wards as a teacher, where he ought first to come as a laborious and patient learner.

The superintendent of an asylum is far more likely to fall into "a dull unvarying system of routine," from a divided responsibility, and a consequently divided interest and anxiety concerning the welfare of his patients, than for want of the intellectual "collisions" which are recommended as a preventive. The visiting physician may be a spur to his resident colleague, he is more likely to be a cushion; he may act as a

stimulant, but it is far more probable that he will act as a sedative. With divided responsibilities it is impossible that either blame for shortcomings and disaster, or credit for progress and success, can be justly apportioned to those who merit them; and the consciousness of this fact may make both resident and visiting officers careless of incurring the one, and negligent of deserving the other. But the superintendent who is left to his own resources and responsibilities will feel, with King Harry,

"The fewer men the greater share of honor."

On more than one occasion have we been assured by superintendents, that they have felt themselves withheld from this or that attempt at improvement, because they were hampered by visiting physicians, who would either defeat their efforts or purloin their credit. At the present day, the visiting physician is indeed generally an ornamental and useless flourish only on the asylum staff, a mere incubus on the finances, without in the slightest degree either aiding or impeding the labors of the superintendent. But where such is not the case, he will be liable to become either a passive impediment, or actively detrimental to the best interests of the institution to which he has the misfortune to belong.

The plan of appointing visiting physicians was in vogue so long as diseases of the mind were attacked almost entirely by pharmaceutical remedies, and before the moral system of treatment was understood, or indeed discovered. At that time the visiting physician

of an asylum discharged his duties like the corresponding officer of a general hospital. Two or three times a week he visited the institution, for an hour or so, and prescribed for the patients bleedings or vomitings, bolus, blister, or glyster; and if, notwithstanding, the patients recovered, so much the better: otherwise chronic mania and restraint, or dementia and filthiness, awaited them. None of those innumerable influences, great and small, unpurchaseable at Apothecaries' Hall, and denominated in the aggregate moral treatment, were put in requisition. The physician, at that time, might be no mere pretender to occult science and mysterious power; but an earnest man making the best of the means at his disposal; but he was as if fighting pugilistically with one fist, and that not the best one. Drugs alone might, perhaps, effect some good, but moral influence is now universally acknowledged to be the most potent and beneficial agent of treatment. The non-resident officer was found to be powerless in the use of the latter. The moral system of treatment can only be properly carried out under the constant superintendence, and by the continuous assistance of the physician ; a circumstance which rendered it necessary that he should be resident on the scene of his labors, and not an occasional visitor merely. The introduction of this system, therefore, necessitated a change in the plan of medical attendance, and the old fashioned one has for some time been gradually falling into well merited dissuetude.

In a few asylums the visiting physician, full of years and honors, is still retained on the staff, a relic of the past; doubtless in acknowledgement of old services, rather than for the discharge of present ones. In two or three others, this officer still presides over the drugging department, everything else being of

necessity left into the hands of his resident colleague, exceedingly suitable to the peculiar duties under disA plan rather more unreasonable than it would be in cussion. Provided with a central station, the "psywar, to confide the command of the cavalry to one chological physician of the best and highest class "might independent general, and that of the infantry to flash intelligence to all asylums between Aberdeen and another. In confirmation of our opinions we extract Cornwall, and stir up the drowsy faculties of all their the following judicious observations from Dr. Thurnam's resident superintendents with the newest psychological Statistics of Insanity. revelations. But to maintain that the medical superintendents of county asylums need either inspection or instruction from provincial medical men, who have paid no particular attention to the subject of insanity, is a proposition bordering on absurdity. It is sufficiently intelligible why the London specialist should desire to find himself attached officially to some great asylum, and to gild the solid pudding of lucrative private practice with the honor of public distinction. But what time could a metropolitan "psychological physician of the best and highest classs find in which to study the peculiarities of thought, habit, and disposition, of some hundreds, or say a thousand, of insane paupers? What leisure to obtain the smallest insight into their characters? What chance of gaining the slightest influence over them?

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"That the plan of government here advocated is the one most calculated to secure energetic action, and unity of plan, appears in the very nature of things at least probable; and is also, I think, established (as far as such questions can be) by observation and experience. Which, it may be asked, are the establishments, which as a general rule have contributed most extensively to our knowledge of insanity, and its treatment, those chiefly under the direction of resident or of visiting physicians? And, again, we may ask without unity of plan, and that energy of action which an undivided responsibility will generally be found to secure, what is it probable will be the character of the moral treatment; or, indeed, can any moral treatment worthy of the name exist? And what unity of plan can there be, when instead of a single resident directing head, availing himself of the observations and assistance of his younger and less experienced colleagues, we have a resident physician or other medical officer, whose responsibility is more or less lessened, as soon as a visiting medical officer enters the house; and who to a like extent is at least liable, however inadvertently, to have his authority, and influence with the patients depreciated and diminished? It is, perhaps, hardly possible, except by living in an hospital for the insane, for any one to be made aware of the disturbing effect which the visits of a nonresident medical officer, even when acting in friendly concert with the resident physician, may produce on the patients. A word, a look, or a gesture on the part of one is often sufficient to encourage hopes or excite fears, or it may be to revive delusions or propensities, to effect the suppression of which may have been the labor of weeks on the part of the other."-p. 79.

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We apprehend that even the overworked and underpaid resident may find greater opportunity for intellectual culture, than such a person with his private practice, and his private asylums, and his public societies, and his various other psychological devices for obtaining name, and fame, and money. That the medical staff of some metropolitan asylums is usually deficient, no well informed person will deny; we feel assured, however, that the only mode of applying a real remedy, and of affording efficient aid to the resident officers will be, by the appointment of resident medical assistants, officers whose hours are not worth guineas, and who can afford to employ them in the tardy occupation of studying and influencing the insane. The metropolitan "psychological physician of the best and highest class" must find himself too fully and profitably occupied in attendance upon the noble and the wealthy, to condescend to the drudgery of being really useful in a great pauper asylum.

There is but little analogy and much contrast between the asylum and the general hospital. In the latter, the great visiting surgeons perform the great operations, and the poor must put up with having their fractures put up, and their dislocations put in, by his young dressers. The great physician prescribes for the great cases in the wards, leaving the youngsters to watch the effects of his remedies, and

"Their prentice han' to try on man,"

It is the opinion of an eminent contemporary, writing on this subject, that the "posts of resident medical officers to our county lunatic asylums" are not sought for, and therefore are not occupied by "the best and highest class of psychological physicians." This, it must be allowed, is a matter of opinion; therefore, notwithstanding the proverbial odium of judgments arrived at by personal comparisons, we must be permitted to express a contrary one. Whatever may be the case in the metropolis, and under the in the out-patients' room. observation of the learned writer himself, it must be conceded as at least probable, that the resident physician of a county asylum will know something more of insanity, both practically and theoretically, than a medical man distracted by the cares of practice in the neighbouring provincial town. If it be true that asylum men are not comparable with the learned psychologists who are carving out their fortunes in the great metropolis, it must be remembered that London cannot supply visiting physicians to more than three or four county asylums at the utmost unless, indeed, they make use of the electric telegraph, a mode of performing work which we beg leave to suggest as

But in the asylum all cases which are capable of treatment are great cases; they are all affections of the same vital organ, and under negligent or unskilful treatment, are all liable to terminate in the most lamentable manner. At the hospital the gamut runs from lithotomy to phlebotomy, and, indeed a few notes lower; but in the asylum diseased mind presents a monotone. There it is impossible to set aside important cases for the consideration of the great visiting psychologist; all cases are all important and require the unintermittent exercise of the best medical skill which can be procured for them.

At the hospital, a prolongation of physical suffering

which it was reared and nourished from a precarious infancy to the period of adult and vigorous maturity; and few will dispute that this connection, so long as it lasted, conferred at least as much honor upon the in

we believe that no visiting medical officer of any asylum in this country has undergone any probationary education as a resident medical officer. Such appointments have been conferred upon the strength of personal interest, irrespective of any claims founded upon peculiar knowledge or experience in the treatment of insanity: they must consequently be considered as little honorable as they are useful.

may in a few instances be the result of entrusting a|place, of the new system of treatment; a home in considerable share of the practice to juniors, against which occasional evil, the constant advantage to the public of affording students practical experience in the treatment of disease constitutes an important set off, but mental disease treated by the unskilful and the in-stitution as upon the officer. But at the present time experienced, may become permanent and incurable; a result so fearful to the patient and of so grave a nature to society, that no possible advantage to learners, can for one moment be put in the balance against it. We are assuming for the sake of argument that the visiting physician proposed for an asylum is on a par with those of hospitals; this, however, is but an assumption, and is incorrect in fact. The latter have for long years been laborious and pains-taking students, cli- The above observations are intended to have refernical clerks, and assistants in the hospital wards, ence to county and borough asylums alone. There are patiently qualifying themselves for practice in the only several hospitals for the insane partaking in part of the true school, namely, that of experience. But where character of charitable institutions and in part of that of and how has the visiting physician of the best and private asylums, wherein the visiting medical officers highest class qualified himself for the duties he covets have considerable if not paramount authority. To in the county asylum? His claims to psychological the support of such institutions the visiting medical distinction may be dependent upon authorship, or rela-officers contribute largely by sending and recommendtionship, or upon divine genius, but he has certainly not worked his way through gradations of experience and of office in an asylum, and therein he differs widely from the visiting physician of the general hospital.

The asylum is unlike the general hospital in many particulars, besides the above mentioned. It is not a charity; the services of its medical staff are not gratuitous, and its inmates are not such by their own free will. By the act of abrogating the liberty of its inmates, society has incurred the responsibility of supplying them with sufficient care and treatment; and payment is provided in the same manner as taxes are provided for the State and tithes for the Church. If through the imperfection of laws or the parsimony of those who execute them, the inmates of public asylums do not receive skilful and sufficient care and treatment, they are defrauded of their just rights; and to remedy such a defect by procuring medical aid as the great hospital charities procure it, would be a condonation of the wrong.

ing private patients. At the present time we express no opinion on this arrangement; nor on that adopted in those hospitals for the insane unfortunately situated in the midst of towns and cities, and in which the modern system of moral treatment is to a great extent impracticable. But for county and borough asylums for the insane poor, the Commissioners in Lunacy have decided against visiting physicians. They have done so after long and ample observation, and it is fair to suppose, that independently of any theoretical opinions, they have not permitted themselves to come to a decision on so important a subject except upon the sure ground of experience.

Of thirty-five county and borough asylums now open in England and Wales, seven only, namely, those for Surrey, West Riding, Kent, Stafford, Nottingham, Norfolk, and Bristol, are returned in the Commissioners' Report as having visiting medical officers. With the exception of the Surrey, these asylums are amongst the oldest in the country; and in the three new asylums for Yorkshire and Lancashire the practice of the old asylums for these counties has not in this respect been imitated.

control. And we think it improbable that the staff of any new county asylum will be provided with such officers, or that in old asylums when vacancies of such

The comparison of the asylum to the general hospital as an argument, was fit only ad captandum vulgus; it may also serve to shew with what ease "the psychologist can reason without logic and illustrate without In despite, therefore, of the objections of our conaptitude." temporaries, we feel assured that the Commissioners in The opinion is not unreasonable, that it may some-Lunacy have given to visiting justices the soundest times be advantageous to secure for an asylum the and best advice, in recommending them not to appoint occasional services of a retired superintendent, with visiting medical officers to institutions under their whom the patients and all the difficulties of the place are as familiar as twice-told tales. But this opinion derives all its force from the very arguments we have used against the general appointment of visiting phy-offices occur they will be refilled. sicians, since such an officer would possess the indispensible qualifications of special experience. Special circumstances may, no doubt, arise from time to time, under which the appointment of such a person as a visiting physician may be equally honorable to himself and expedient to an asylum. Every one must have acknowledged the propriety of retaining the services of Dr. Conolly as visiting physician to that institution which he has rendered famous throughout the world as the home, if not the birth

The Visiting Justices of the Devon County Asylum have requested the Editor of the Asylum Journal to publish their Annual Report therein, offering to pay the additional expense so incurred. While the best thanks of the Association are due to the Visitors for this graceful compliment paid to its organ. It has been deemed prudent to postpone such undertakings for the present.

nifestations of mind are not inherent in the cerebral organism from which they result. To such an argument one might not inappropriately answer "fiddle de dee;" if it was not merely thrown out as a sop to Cerberus, as a saving clause to avert the claws of any spiritual antagonist. We observe that Mr. W. C. Dendy in his recent writings, compares the spirit of man to the blood. "What the blood is to a secreting gland the spirit is to the brain. The gland forms its especial product from the blood, the brain acting with spirit produces the mind." The cerebral function may on this theory be said to be analagous to acetous fermentation: turning spirit into vinegar. Truly such analogies are enough to turn even the milk of human kindness sour, and to give one the stomach ache, if not the head ache. Why will not such writers as Mr. Noble and Mr. Dendy leave discussions on the nature and existence of the soul to men whose holy office gives them privilege in matters spiritual, or at least meddle not with that simple and upright faith which requires no scientific buttressing. Why should every writer on cerebral disease sully and tarnish the pure soul, pawing it over with anatomico-metaphysical fingers! Let physicians stick to physics, leave the soul to theologians. "In suâ arte cuique credendum est."

Elements of Psychological Medicine, an Introduction spirit occur through organic intervention. A thousand to the Practical Study of Insanity, adapted for circumstances prove the fact; yet it is no more the Students and Junior Practitioners, by DANIEL No- case, that the material brain is the thinking principle, BLE, F.R.C.S., Medical Officer to the Clifton Hall and the separate parts divisions of the soul, than it is Retreat, and Lecturer on Psychological Medicine at true that the music of the lyre inheres in the instruthe Chatham Street School of Medicine, Manchester.ment, and that the melodies which art can elicit from (London, Churchill; pp. 340.) it, are self-produced by the particular strings."-p. 82. This may be put into other words thus: As the sonoThis work is a course of lectures published nearly rous vibrations of air are not inherent in the musical as delivered at the Chatham Street School at Man-instrument whose vibrations produce them, so the machester. Both the style and spirit of the book are excellent. The former is lucid and elegant, and the latter bespeaks the writer to be a man, too speculative indeed, but fair and candid and influenced by kindly and gentlemanly feelings. We have seldom arisen from the perusal of a work with which we disagreed so much, with a better opinion of its author. The most interesting feature in Mr. Noble's book is his recantation of his belief in phrenology. We read his book advocating the truth of phrenology, when it was published, and were impressed at that time with the conviction, that the arguments in favour of the so-called science were stated with much greater fairness than in any other phrenological work we had met with. The result proves that an honest and candid man is not of much use in the propagandism of error. The disciples of Gall would have been much better without Mr. Noble as a recruit; his recantation will be gall and wormwood to them. He concludes, "In my own instance many circumstances have utterly destroyed my confidence in the observations and judgment of large numbers of the phrenologists; among others I may adduce the striking fact, that the ranks of almost every philosophical folly of the present era, so distinguished in this point of view, have been largely recruited from the expiring phrenological school-teachers and disciples alike: some have become apostles or partizans of the water cure; others of clairvoyance and mesmeric prevision; and some again of homœopathy; whilst a few, I believe, have gone over to the spiritual rappers! With the same men there continues the same turn of mind-the excessive credulity, the readiness to see whatever is looked for, and to wink at, or most elaborately to explain away, anything which makes against the adopted faith; the same bigotry, too, and the same restless spirit of propagandism."—p. 52.

We honor the frank uprightness of the man who can thus resolutely turn his back upon a once cherished belief, upon discovering the meretricious nature of the facts upon which it is founded. If we differ widely from Mr. Noble's present opinions, through faith in his candor we believe, that as time rolls on and truth becomes more apparent in these difficult and perplexing fields of thought, these differences will diminish, perhaps disappear.

Mr. Noble appears to think it necessary to found his pathology of insanity on a physiology of the brain and nervous system. He is, however, not very certain on this point; his philosophy is still metaphysical, as the following passage will shew. "There is nothing in the physiological study of the brain and nervous system, which ought to suggest the approaches even of materialism. Whilst here below, the actions of the

The peculiarities of Noble's cerebral physiology consists in his "strong persuasion that the structures under consideration, the optic thalami and corpora striata, form the ganglia of that inner sensibility, which ideas rather than external impressions call forth: " "I regard them as the seat of the emotions."

"Their locality midway as it were, between the hemispherical and the sensory ganglia; their universal and very close connexion, by means of the central white mass of the brain, with the grey expansion of the convolutions; and their fibrous communication with the spinal cord, constitute good anatomical reasons for the opinion of their function which I have been led to entertain.”—p. 72.

Mr. Morell, we are told, has adopted these views on metaphysical grounds. We entirely agree with the author in his admission, that there is much speculation in them, indeed, we think they are altogether speculative and unfounded upon a single fair analogy or logical probability. The author does not agree with his friend, Professor Carpenter, concerning the function of these bodies. It appears to us, however, that Carpenter's view of their constituting the true sensorium commune, is based upon deductions drawn from comparative anatomy and experiment. chapter on the general pathology of insanity will be studied with advantage and profit. The observations respecting the diagnosis of insanity from hysteria are


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