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Single medical chief.

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not be called on to provide immediately the considerable funds which would be necessary in several cases for total reconstruction, and in others for extensive alteration, such a course would, by itself, be occasionally tantamount to the extinction of the institutions for a long time. To meet this difficulty it would probably become necessary in some cases to raise loans on the credit of the colonial revenues. The required sums would not be large, as they would be needed only where the institutions themselves are small; and as regards the additional burthen which the payment of interest would impose on small revenues, it may be confidently asserted that such initial expense would be in part, if not wholly, returned indirectly by the economy of management, and of valuable time and lives which it is the direct tendency of improvements in construction and system to produce.*

Should such a measure be carried into operation, it would probably be the commencement of general sanitary reform in countries where its advan- tages are at present unknown.

30. Next follows the consideration of who are and who ought to be the depositaries of power. It is not necessary to search for any special preliminary canons on the last point. It is enough to say that the government of the internal economy of hospitals and esylums ought to be given to persons who have the necessary knowledge and are in a position to give the necessary atten- tion, and can be readily made responsible to some other superior power. The actual systems are often extremely ill qualified to fulfil these requirements.

It is in some cases difficult to ascertain the exact nature of the existing constitutions, and from nine hospitals and asylums, including live in the West Indian division, no information is given on this subject.

Of the rest, omitting those of Jamaica, twenty-nine, including sixteen in the West Indian group, are governed by boards of a kind which will presently be described, four by boards of a different kind and with narrower powers, and twenty-five, including nine Canadian institutions, appear to be managed by medical superintendents without local boards. What the actual comparative results of these various systems are will appear subsequently.

The powers which in each case these governing bodies or persons have to exercise may be divided into four classes, being respectively the powers of making rules, or legislation, of financial administration, of patronage, and of inspection and supervision. It is plain that these powers are inconsistent, ought to be to some extent independent, and for their due exercise require very different qualifications. Yet in twenty-nine institutions nearly the whole are united in single boards, only some small fragments being here and there given to other and independent persons. These boards vary considerably in their composition and appointment, but they are usually made up of six or eight ex officio members, such as the mayor and last ex-mayor, clergymen, and Occasionally official physicians, together with perhaps an equal number of nominees of the Governor. Such boards, however well they may be appointed, cannot as a body have professional knowledge or practical experience, and must be generally nafit to make regulations about matters which demand both professional knowledge and practical experience, and even though they may be presumed to receive the suggestions of the medical officers, and though their rules must be submitted to the Governors, an originally defective scheme is not likely to be made complete by after-suggestions. Again, they are too far removed from the actual working of the arrangements to be able to exercise that continuous supervision which is necessary for guarding against abuses and testing results. They are liable either to disagreement or to an apathy which leaves everything in the hands of two or three who may be actuated by interested motives; they cannot judge of the efficiency of attendants whom they see in a manner only on parade, and they have no professional pride to gratify, nor the misery to endure of having daily before their eyes the evil consequences of a defective system. Lastly, if from these causes the institutions suffer, there is no one on whom to fix the blame of abuses or omissions, and if the guilt is at last brought home to them they cannot be made answerable. It is impracticable to make a board, especially if composed of unpaid members, effectually responsible for the minutia of their administration, and the difficulty is much aggravated where, as in the

• See Section 58, p. 22.

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majority of these cases, members of the board are also members of the council.

There ought always to be one person, properly qualified and devoted to the work, invested with paramount powers within the institution, and directly responsible to definite authorities for the doing or not doing of each particular act and there can be no doubt that this person should be the chief resident medical officer. It is the profession of such a chief to be efficient in this particular province; the success of his institution is to him a matter of professional pride and interest; if anything goes wrong, on him naturally lies the blame, and he can be easily called to account. There is no comparison between the two systems in certainty as to who is responsible and the ease with which he can he reached. Especially in the case of lunatic asylums it is certain that considering the multitude of particulars which require constant vigilance and practised judgment, the number of intangible abuses which

may easily prevail in secret, and the influence which such small but pervading and perpetual causes exercise over the mind and condition of the patients, boards, however zealous and well-intentioned, are incompetent to deal with the practical difficulties of managenient." It may be added that if a resident medical superintendent is intrusted with any powers at all, he ought to be intrusted with as much as possible; otherwise he is likely to become indifferent, and, what is of great importance, will think the detection of abuses is not his business, but that of the actual governing body. Yet he is the only person who is in a position to detect them with certainty.

Before proceeding to suggest a definite scheme for the redistribution of powers, the comparative merit of the two systems, as at present in use, must be tested by their results. The whole number of institutions which have sent information as to their government, omitting the four Victorian hospitals which are managed by boards of a peculiar kind. and the hospital and asylum of Jamaica, which are in a transition state, may be roughly divided into 50 which are very unsatisfactory and 22 which, thongh not without great defvets, are on the whole much more satisfactory. Of the 30 which are bad, 20 are governed by boards and 10 by chiefs of the 22 which are good, 9 are under boards and 14 under chiefs. In other words, the good ones under boards are to the bad as 24 to 5; under chiefs, as 7 to 5. The number of those which, though governed by paramount medical chiefs, are still bad would be greatly lessened, or it may be believed reduced to nothing, it proper provisions of other kinds were brought into operation. Such provisions would of course lessen also the number of those under boards, which are ill-managed, but this does not affect the general result.

There are four cases which require particular notice. The hospital and asylum of Tasmania are governed by boards and yet are very good,—appa- rently indeed the best in the colonies. There is also a single instance in the West Indian group (the Port of Spain hospital in Trinidad) where the result of government by a board has been good; but that result is here owing solely to the exertions of Dr. Mercer, the resident surgeon, and may fairly be said to be in spite of the system. On the other hand, at the Castries asylum in St. Lucia, though unlimited power is given to the medical officer, the result is eminently bad; but then in this case the medical officer is non-resident and unrestricted in practice, is only bound to visit once a week, and for the sole care of this asylum and of three hospitals receives 1701. per annum, out of which he has to find all medical and surgical appliances. This is such an exception as goes to prove the rule.

It is to be added that the hospital and asylum of Jamaica were at first (1855) under a board of commissioners. This system was found to work so ill that in 1859 an Amending Act transferred their powers and duties for the most part to an officer called an Inspector and Director." But some legal and other blunders rendered the new Act practically inoperative, whilst the old one was displaced, and the deplorable state of things in 1861 seems to have been partly the result of the temporary anarchy.

Of all their various and inconsistent powers it would seem to be desirable that the boards should retain only the appointment of the medical officers and

It is the opinion of the Commissioners in Lunacy that saylıms should always be maragesi by paramount medical chiefs.