The asylummedical service

Sirs, – I am glad to see by the letter of “M.B.” in your issue of Dec. 31st, 1904, p. 1888, that at least one assistant medical officer has the courage to protest against the treatment which is meted out to his colleagues in the asylum service. The present unsatisfactory state of affairs has gone on quite long enough and in the interest not only of the medical staff but also of the patients committed to their charge a change is desirable, even essential. As long as the medical staffs of asylums are content to exist under their present conditions it is useless to insinuate that the fault lies at the door of those in authority, be they Commissioners in Lunacy, visiting committees, or even medical superintendents. The fault and the remedy lie in their own hand. But how few will ever take the trouble to place their views on paper. There are three distinct classes of assistant medical officers in asylums: (1) those who on entering it intend to remain in the service, devoting their lives to the study and treatment of mental diseases and thus in time becoming specialists; (2) those who, newly qualified, seek an asylum appointment in order that they may read for some further examination, on the passing of which they have set their ambition; or (3), those who unable to afford to enter general practice immediately they become qualified take an asylum post with the intention of waiting for a suitable opening in some district which may be known to them. When the opportunity presents itself they leave and are succeeded by colleagues with possibly similar views. To such as these an asylum appointment is but a means to an end. The end having been attained they depart and as a rule trouble no more about lunacy or asylums unless they be called on to certify a patient in the course of their general practice.

In the case of an assistant medical officer who enters the asylum service with the intention of remaining permanently in it the case is very different. He starts full of enthusiasm and hope with an initial salary of anything from £ 120 to £150 per annum with the usual allowances. Three or four years pass by and he finds himself with some knowledge of mental diseases in addition to the general knowledge of his profession with which he started, but it suddenly occurs to him that notwithstanding his increased experience in a special science he is still drawing the same salary as when he entered the asylum service fresh from the hospital. His colleagues who are senior to him have little, if any, prospect of promotion in the future. True, they have had more years of service and consequent experience, but their salaries are very little in excess of what was considered sufficient remuneration for him when he entered the service without any special knowledge of lunacy. Then come weary years of waiting, hoping that one of his seniors may be promoted to one of the few vacant medical superintendencies which may chance to occur at rare intervals, and in most cases with resulting disappointment. His senior colleague, should he be unsuccessful in obtaining the post of medical superintendent in some other asylum, is in, if possible, a more hopeless plight. He has given the best years of his life to the study of mental diseases. What is his reward? A salary of perhaps £250 or £300 per annum and should he be over 40 years of age the probability that he may expect no further promotion or increase of salary. Moreover, there is a rule that no assistant medical officer can be married. (I believe there are one or two cases in which the senior assistant medical officer can do so if he likes.)

To the junior members of the staff, this is not such a hardship as to their seniors. The pay and accommodation of a junior assistant medical officer put matrimony out of the question but when a senior comes to the age of, say, 40 years he may have some desire to have a home of his own after living for years in two rooms. With all respect for the authorities who govern asylums I would ask, What has a man done who has given the best years of his life to their service that he should be debarred from entering the matrimonial state should he so desire? As far as I can ascertain there is no other branch of the public service in which such a restriction is imposed on the permanent medical staff. It may be argued by those who favour the present system of enforced celibacy in the case of asylum assistant medical officers that a similar rule is in force in the hospitals and Poor-law infirmaries. To them I would point out that in neither case do the medical officers accept their appointments as a permanency. They, as a rule, leave after longer or shorter periods and enter general practice or one of the services, the experience which they gained during their term of office being of immense value to them in their future careers. With the asylum medical officer the case is absolutely different. After some years, as “M.B.” correctly states, spent in the treatment of mental diseases a man has become a specialist and is thus more or less unfitted for general practice. The special experience he has gained in the asylum is of comparatively little use to him outside the walls, his duty for years having been more to treat mental diseases than physical ailments. Therefore there is no analogy between the cases.

With regard to the striking differences between the salaries paid to medical superintendents as compared with those of senior assistants I do not for a moment suggest that the medical superintendent, who is according to the Lunacy Act the chief responsible official of an asylum, is paid too much, but I maintain that there is far too great a drop from the medical superintendent with, say, from £800 to £1000 per annum and certain allowances to that of his deputy who, it must be remembered, in the absence of the chief has to take the full responsibility at one-third, or even in a few cases less than, the chief draws. This increase of responsibility, if prolonged owing to the illness of the medical superintendent or other cause, is not always recognised by the committee, or if it is a small honorarium is doled out to the senior assistant medical officer who has discharged the duties of medical superintendent in addition to his own routine work. It must be obvious that in these days of huge asylums the duties and responsibilities which were formerly personally discharged by the medical superintendent have now to be deputed to the assistant medical officers.

The Commissioners in Lunacy in their last report strongly condemned the erection of these huge places, but despite this, committees ignore the recommendations of a body whom the public look upon as experts in such matters and still continue to erect enormous costly “houses for the detention of the insane” – one really cannot call them hospitals for the treatment of mental diseases.

The question of leave is also the source of much complaint in asylums. The medical superintendent gets one month or in some cases six weeks annually, the assistant medical officers 28 days or perhaps in a few cases 31 days. Occasional leave is grudgingly accorded and then only one night can be spent outside the asylum gates unless a special appeal is made to the chairman of the committee who, unless there is some special reason given for wanting leave other than annual, may refuse it. Anyone with common sense must appreciate the fact that constant association with the insane is not conducive to exhilaration. Therefore a change of short duration at fairly frequent intervals, exclusive of annual leave, becomes not only desirable but even necessary to those who have charge of them. If the best men are to be attracted to the study of lunacy, which is becoming daily a more and more alarming factor in our social system, it behoves the authorities to amend the conditions of service of the assistant medical officers who have served them so long uncomplainingly. By this means alone can good men be induced to enter the asylum service as a permanency. Under the present system the junior post in asylums is usually sought after as a temporary abiding place where examinations may be read for or as a pleasant resting place until some better or more congenial employment turns up.

I am, Sirs, yours faithfully,

A.M.O.