Chapters in the History of the Insane in the British Isles Part 26

Ireland 74,256 Scotland 46,051 -------- 451,071

The proportion per cent. of patients in A on the total number of pauper lunatics is, for--

England 60 per cent.

Ireland 70 Scotland 68

Of the 6505 Scotch pauper lunatics, there were--

In public asylums 1930 In district asylums 1763 In private asylums 77 In parochial asylums 746 In lunatic wards of poor-houses 557 ---- 5073

In private dwellings under sanction of the Board, viz.--

With relatives 875} With strangers 529} 1432 Alone 28} ---- 6505

A return was also made of the average weekly cost of each lunatic at that time--

s. d.

In public asylums 9 2 In district asylums 9 9 In private asylums 11 1 In parochial asylums 8 4 In lunatic wards of poor-houses 6 8 -------- Total in establishments 9 0

With relatives 4 0 With strangers 5 6 Alone 3 5 -------- Total in private dwellings 4 3

There should be added to the above an expenditure for all pauper lunatics of threepence a head per week, being the cost of certificates of lunacy, expenses of transport, etc.

Twenty-one years after the appointment of the Lunacy Commissioners, their Report of 1878 enables us to mark the progress which had been made during this period in the accommodation afforded for the insane in Scotland. The labours of the Commissioners had been followed by highly satisfactory results, and it would be difficult to speak too highly of the value of their Reports during these twenty years.

On January 1, 1878, 1569 patients were maintained from private sources, 7473 by parochial rates, and 55 at the expense of the State.

Twenty years before, the distribution of the insane was as follows. In a parallel column is seen a like return for 1878.

--------------------------------+-----+-----------+-----+----------- | |Proportion | |Proportion Location. | |to 100,000 | |to 100,000 |1858.| of |1878.| of | |population.| |population.

--------------------------------+-----+-----------+-----+----------- In Royal and district asylums |2380}| |5449}| In private asylums | 745}| 131 | 208}| 206 In parochial asylums and lunatic| }| | }| wards of poor-houses | 839}| | 736}| In private dwellings |1804 | 60 |1493 | 42 In lunatic department of general| | | | prison | 26 | | 55 | In training schools | 29 | | 156 | +-----+-----------+-----+----------- |5823 | 191 |9097 | 247 --------------------------------+-----+-----------+-----+-----------

At the present time[246] the numbers and distribution of the insane in Scotland are as follows:--

NUMBER OF LUNATICS IN SCOTLAND ON JANUARY 1, 1881.

-------------------+--------------+------------------+------------------ Location. | Private. | Pauper. | Total.

+---+---+------+-----+-----+------+-----+-----+------ | M.| F.|Total.| M. | F. |Total.| M. | F. |Total.

-------------------+---+---+------+-----+-----+------+-----+-----+------ 19 Royal and | | | | | | | | | district asylums |670|584| 1,254|2,244|2,422| 4,666|2,914|3,006| 5,920 6 private asylums | 49|108| 157| -- | -- | -- | 49| 108| 157 6 parochial asylums|-- |-- | -- | 599| 743| 1,342| 599| 743| 1,342 14 lunatic wards of| | | | | | | | | poor-houses |-- |-- | -- | 324| 390| 714| 324| 390| 714 Private dwellings | 41| 72| 113| 604| 912| 1,516| 645| 984| 1,629 +---+---+------+----+------+------+-----+-----+------ |760|764| 1,524|3,771|4,467| 8,238|4,531|5,231| 9,762 Lunatic department | | | | | | | | | of General | | | | | | | | | Prison, Perth |-- |-- | -- | -- | -- | -- | 38| 17| 55 3 training schools | | | | | | | | | for imbeciles | 72| 49| 121| 51| 23| 74| 123| 72| 195 +---+---+------+-----+-----+------+-----+-----+------ Totals |832|813| 1,645|3,822|4,490| 8,312|4,692|5,320|10,012 -------------------+---+---+------+-----+-----+------+-----+-----+------

We have in this chapter had to record a melancholy condition of things as regards the insane, not only out of asylums, but in them; such a condition as fully justified Lord Shaftesbury employing exceptionally strong language in reference to the treatment of lunatics in Scotland.[247] But this is happily now only _history_, and a.s.suredly the physicians who superintend the Scotch asylums have done their utmost to wipe out the stain which at one time dishonoured their country's treatment of those who had lost or had never possessed their reason; while the Lunacy Commissioners deserve the highest praise for their continuous and efficient labours in the difficult work to which they have devoted themselves. The efficiency of the asylums in Scotland is now such, owing in great measure to the action taken in 1857, that foreigners, not to say the English themselves, may cross the Tweed to learn from the physicians of the mind, important lessons in the care and cure of the insane. The chartered asylums of that country have for a long period received encomiums from those who have visited them.

Of the Dumfries inst.i.tution I have already spoken, and would add, in proof of the pains taken by the former superintendent, Dr. Browne, to break the monotony of asylum life, that he introduced private theatricals, in which vaudevilles and farces were performed by and for the lunatics, and even before the public. A practice still beneficially preserved is that of making excursions to places noted for their natural beauty or antiquity, even temporary vacations at the seaside or elsewhere, const.i.tuting valuable novelties and auxiliaries in these ministrations to the mind diseased. Such resources, in connection with dramatic festivities, attendance on all accessible entertainments in the neighbouring town, were utilized in affording a stimulus or a solace to inmates of the cultivated cla.s.ses; nor were the higher aids yielded by religious services and instructions neglected, and, with unwonted liberality of sentiment, chaplains representing the three grand sections into which Christianity is divided, Presbyterianism, Episcopacy, and Catholicism, were appointed, and exercised their functions, it is believed, wisely and discreetly in their respective spheres. The benefit of this step suggested a resort to frequent intercourse between the different ranks of patients, with a.s.sociates from the external world, and the creation of all arrangements which could recall or a.s.similate such a place of seclusion with home, rational liberty, and natural pursuits. Whilst the mingling of distinct grades was employed as a remedy, rigid cla.s.sification was enforced, founded upon position in society, as well as upon the phase or stage of disease. In furtherance of this view it was resolved to remove the paupers and poorer inmates from the original structure, and to erect a distinct apartment, capable of containing four hundred individuals, within the grounds, provided with all necessary requirements, but to be conducted with the most rigid economy and consideration of the resources of the country, as well as of the habits of the patients. This movement was made, and a hospital was added, conducted, however, by the same superintendent and upon precisely the same principles as regulated the Crichton Inst.i.tution proper. We speak confidently upon this and other points, because there is before us a series of valuable annual reports, containing not exclusively the history of the progress of the inst.i.tution, but the results, medical and moral, of the superintendent. For the behoof of both houses a museum of natural history was formed, and proved a considerable attraction in stormy weather, or to lazy or lethargic observers. While in such a climate it was inevitable that indoor objects of interest should be supplied, attempts to draw those under treatment from the deteriorating atmosphere of seclusion were not wanting. Parole was accessible to the trustworthy, under suitable attendants; patients were allowed to travel long distances, and for specific purposes, such as angling, botanizing, and so forth; their presence was permitted in the _fete champetre_ and in country sports, and every effort was made to give to anniversaries, public and private, a prominent place in the annual calendar. But fun and frolic seem to have occupied but a subordinate place, as composition, re-education of every kind, cla.s.ses for drawing, flower-making, dancing, singing, joining in concerts, are repeatedly insisted upon. But while these engagements availed in winter, promenades, dances on the green, bowling, quoiting, the care of pet animals, and, for a few, interest in the botanic garden, diversified the summer months. These const.i.tute a pleasing and encouraging part of the picture, but it should be broadly and boldly confessed that there were agitated and intractable spirits in the community that could not be tranquillized or guided by such agencies, and that, although restraint in its vulgar and repulsive aspects was not adopted, seclusion, padded rooms, and the conservative bed were occasionally in use. During the last twenty years the asylum has been under the superintendence, first of Dr. Gilchrist, trained within its walls, and secondly of Dr. Adam, but while there has been undoubted progress, the improvements and ameliorations have been, to a certain extent, the evolution or development of the views and facts which have been above enumerated.

I would add to what has already been said of the Royal Edinburgh Asylum, that the managers appointed Dr. McKinnons, the first physician-superintendent, in 1840, with complete administrative and medical authority. He was a man of advanced ideas, as his reports show.

On his death in 1846, Dr. Skae was appointed his successor, and remained at his post till 1873, when Dr. Clouston became physician-superintendent. Dr. Skae extended the reputation of the inst.i.tution and consolidated its position. His reports were always medical and philanthropic, and, as regards the general public, educative and interesting. By attracting public sympathy and not becoming too official, it has always carried out the original intention of its founders to provide for all cla.s.ses, and has now no less than eight hundred patients who pay from 30 up to 500 a year. It has a Charity Fund of 10,000; its buildings are scattered, and number nine for patients. Like an old cathedral, it now shows, in common with long-established inst.i.tutions, such as the York Retreat, the successive ideas of various men and various times, and one would really regret to see the original sh.e.l.l of these charitable hospitals, though antiquated and a little inconvenient, ruthlessly destroyed to make way for modern structures. In the Edinburgh Asylum are large corridor wards, pavilion wings of different kinds, cottages and cottage hospitals, a mansion in its own grounds, and a seaside house twelve miles off, to which over a hundred and twenty patients go annually. Its present superintendent has still further extended the reputation of this asylum.

Were the object of this work to describe inst.i.tutions for the insane, instead of giving a general historical sketch of the progress of reform, I should have added notices of other excellent inst.i.tutions, as those of Gartnavel, Glasgow, so ably superintended by Dr. Yellowlees, and the Lenzie Asylum, where Dr. Rutherford has done wonders.

Of the Scotch royal or chartered asylums and their far-seeing and philanthropic founders it is not easy to speak too highly. For a small country and a poor people to have provided six asylums for all cla.s.ses before the lunacy legislation of the present day was inaugurated, shows at least that, if it did not initiate a movement in favour of humanity, it could see how good a thing it was to follow in the same path. At the present time in Scotland, through the foresight of the man who established inst.i.tutions "for all cla.s.ses," and combined business with philanthropy in making the rich help the poor, there is plenty of middle-cla.s.s asylum accommodation.

Perhaps nothing could more strongly show what a change has come over the condition of the insane in Scotland, and the praiseworthy efforts now made by those who are responsible for it, than the excellent Report of the Commissioners, published in 1881.[248] "It is well worth the careful perusal of every one who is interested in the treatment of the insane. In addition to the usual information, there is an attempt made carefully to describe what is special to Scotland in the management of asylums and in the treatment of the insane. In short, the 'Scotch System' is a.n.a.lyzed, and in concise terms we are told what it is and what results have followed. In the body of the Report, under the heading of 'Recent Changes in the Modes of Administering Scotch Asylums,' we have fourteen pages that well deserve and will attract much attention.

They will stand as a landmark in the history of the treatment of mental disease. That portion of the Report is a most carefully written piece of true scientific work, containing the facts themselves, the history of their application, the inferences to be deduced from them, and the reasons why the particular results have happened, or the medical philosophy of the matter....

"There were in Scotland on the 1st of January, 1881, 10,012 insane or idiotic persons known to the Scotch Board, being an increase of 378 over the number of 1880. The greater part of this increase, which is an unusually large one for a year, consists of rate-paid lunacy. Scotland still holds the honourable position of maintaining a far larger proportion of its insane and private patients than either of the other divisions of the United Kingdom. In Ireland (a.s.suming that all the inmates of private asylums are private patients) 5.5 per cent. only of the insane are supported out of their own means or by their relatives.

In England 10.7 per cent. are so supported, while in Scotland 16.4 per cent. are in this category. Of this most remarkable fact we have seen no adequate explanation. Is it the poverty of Ireland and England that place them so far below Scotland in this matter? or the want of asylum accommodation at low rates of board? or the lack of self-respect and natural affection in the peoples?...

"There were forty-nine voluntary patients admitted to Scotch asylums during the year, and the Commissioners express a favourable opinion as to this provision of the Scotch lunacy law. The recovery-rate in the asylums was 41 per cent. for the year, and the death-rate on the average numbers resident 7.6 per cent.... The reports of the Commissioners'

visits to asylums are, on the whole, of a favourable character. There is a cheerful ring about them, a hopeful spirit as to the remedies for present defects, and an encouraging yet stimulating tone towards the medical staff that shows a healthy confidence.

"We now come to the really original and important part of the Report:--

"'_Recent Changes in the Modes of Administering Scotch Asylums._--The most important changes that have taken place of late have been manifested chiefly in three directions:--

"'(1) In the greater amount of liberty accorded to the patients; (2) in the increased attention that is devoted to their industrial occupation; and (3) in the more liberal arrangements that are made for their comfort.

"'Each of these changes has been a distinct improvement, and has conferred important benefits on the insane; but the effect of each has been made much more complete from the support it has obtained by being a.s.sociated with the others. For instance, the removal of restrictions upon liberty could not have been carried so far had steps not been taken to engage the energies of the patients in such occupations as tend both to check the morbid current of their thoughts and to prevent them from fretting at the control to which they must always be more or less subjected, while it is no less true that the comforts with which they are now surrounded render them both more able and more willing to engage in healthful occupations....

"'_The Abolition of Airing-Courts._--Circ.u.mstances such as these, perhaps, prevent any immediate prospect of the universal abolition of walled airing-courts; but the advantages which result from their disuse are now widely recognized. Most of the public asylums in Scotland are already without them, while in several, where they still exist, they are seldom used. One of the advantages which airing-courts with walls were thought to possess was their supplying a place where patients suffering from maniacal excitement might work off their morbid energy in safety.

It can scarcely be denied, however, that the a.s.sociation in confined areas of patients in this state, either with one another or with other patients in calmer mental states, is attended with various disadvantages. The presence of one such patient may be the cause of a great amount of excitement, and a source of irritation and annoyance to those confined in an airing-court along with them. After the disuse of the airing-courts, it was found that such patients could be treated satisfactorily in the wider s.p.a.ce of the general grounds. It was found by placing them more immediately in companions.h.i.+p with the attendants, and by keeping them from collision with other patients, that they could be made to vent much of their excitement with less disorder, and could often be saved a considerable amount of it altogether.

"'_The Open-Door System._--It is only of late years that the disuse of locked doors has been regarded as forming an important feature in the administration of an asylum. Detached houses, or limited sections of the main buildings, the inmates of which consisted chiefly of patients requiring little supervision, have long been conducted in some inst.i.tutions without locked doors. But the general practice of all large asylums has been to keep the doors of the various wards strictly under lock and key....

"'When an attendant could no longer trust to locked doors for the detention of troublesome and discontented patients, it became necessary that he should keep himself aware at all times of where they were and what they were doing. And it therefore became his interest to engage them in such occupations as would make them contented, to provide an orderly outlet for their energies, and to divert their minds from thoughts of escape. The relations of an attendant to his patient thus a.s.sumed less of the character of a gaoler, and more the character of a companion or nurse; and it was eventually found that this change in the character of the form of control could be adopted in the treatment of a much larger number of the patients than was at first antic.i.p.ated. It is not difficult to over-estimate the extent to which a desire to escape affects the minds of patients in asylums. The number who form a definite purpose of this kind really const.i.tutes only a very small proportion of them. The special watchfulness required of attendants in guarding against determined efforts to escape, therefore, need be directed to a few only of those under their charge, and it soon becomes habitual to the attendants to keep themselves aware of where those patients are, about whom they entertain doubt. And it should be borne in mind, in regard to this kind of watchfulness, that its very persistency renders it more easily kept up than if it could be occasionally relaxed. It appeared further that the disuse of locked doors had an influence on some of the patients in diminis.h.i.+ng the desire to escape. Under the system of locked doors, a patient with that desire was apt to allow his mind to be engrossed by the idea of watching for the opportunity of an open door, and it was by no means infrequent to find such a patient watching with cat-like eagerness for this chance. The effect of the constantly open door upon such a patient, when the novelty of the thing had worn off, was to deprive him of _special_ chances of escape on which to exercise his vigilance, since, so far as doors were to be considered, it was as easy to escape at one time as another; and it was found that the desire often became dormant and inoperative if not called into action by the stimulus of _special_ opportunity. It is, indeed, a thing of common experience that the mere feeling of being locked in is sufficient to awaken a desire to get out. This happens both with the sane and the insane; but it is certain that the mental condition of many patients in asylums renders them likely to be influenced in an especial manner by such a feeling. With many, however, the desire to escape dies away when it ceases to be suggested by forcing upon their attention the means of preventing it.

"'It is year by year becoming more clearly recognized that many advantages result from the working of the open-door system, and it has now been adopted to a greater or less extent in most of the Scotch asylums....

"'_Liberty on Parole._--The practice of permitting certain patients to walk or work in the grounds without constant supervision, and of permitting some to take exercise beyond the grounds on _parole_, has been general in Scotch asylums for many years, but it is now much more extensively adopted in them than it used to be. Like the other removals of restrictions to which we have referred, this has found favour in the eyes of superintendents on account of the beneficial effect which it has on the patients, not merely in making their residence in an asylum less irksome, but also by improving their mental condition. The fears which were naturally entertained that this form of relaxation of control would be followed by an increase in the number of accidents and escapes, have not proved to be well founded.

"'In determining the desirability of any kind of restrictive discipline and supervision, it has to be considered, among other things, whether the irritation that it occasions may not render the danger of accidents from violent conduct greater than it would be if such discipline were not enforced....

"'_Benefits arising from the Removal of Restrictions._--The beneficial effects arising from the removal of the various forms of restrictions on liberty are no doubt due, in great measure, to the increased attention that is given to the features of each patient's condition, for it is only after a careful study of the disposition and tendencies of a patient that a trustworthy opinion can be formed as to the amount of liberty that he is fit to enjoy. But it must also be recognized that the freedom from irksome discipline and restriction tends to remove one of the sources of violent conduct in asylums, and consequently to diminish the number of accidents which result from it. Many patients have, under the freer conditions of their life, become calm and orderly in behaviour to whom the imprisonment in wards under lock and key, the confinement within high-walled airing-courts, and even the feeling of being under the constant supervision of attendants, were sources of irritation and excitement and causes of violent conduct.

"'There are other advantages which spring from this relinquis.h.i.+ng of some of the physical means of detention. One of these, the importance of which will be readily appreciated, is the inducement it affords, not only to superintendents, but to every one concerned in the management of the patients, to acquire a full and correct knowledge of the mental condition and character of each patient. It not only increases the interest they have in ascertaining how far, and in what ways, each patient is fit to be trusted, but it strengthens in a very practical manner their motives for endeavouring to secure his contentment and orderly behaviour. The judging of what is required for these purposes inevitably involves a good deal of intelligent observation of each patient, not only on admission, but during the whole time he is resident in the asylum. It becomes of practical importance to those in charge to note changes in his mental condition, whether in the direction of improvement or the reverse; and thus favourable or unfavourable symptoms are observed and considered which in other circ.u.mstances might receive little attention. The general effect of the change of system is to raise the position of the attendants from being mere servants who carry out more or less efficiently the orders of the superintendent to that of persons who have a direct interest in promoting the improvement of the patients, and who find it an advantage to themselves to carry out, to the best of their ability, whatever instructions they receive with that end in view. A good attendant must always have had more or less of this character, it is true; but even good attendants are stimulated under the freer system to become still better.

"'_Industrial Occupation._--One effect of the removal of physical restrictions has been to stimulate as well as aid the superintendents of asylums in their efforts to develop the industrial occupation of the patients. The disadvantages of prolonged idleness, to the insane as well as to the sane, and the advantages that result from such occupation as gives exercise to the physical and mental energies without overstraining them, are too obvious to require discussion. It was consequently an important result of the disuse of walled airing-courts and of the open-door system, that it became necessary to engage the attention of patients who were inclined to escape, and also of the much larger number who might wander away without any such definite purpose, so as to keep them under control and supervision. It did not require much study of the mental state of the patients, nor indeed much attention of any kind on the part of their attendants, to insure their safe custody, when the conditions of their life were either to be locked within their wards, to be confined within the high walls of airing-courts, or to be marched in military order at stated periods for exercise. Under such conditions, there was no strong motive for inducing those patients to work who showed no disposition to do so of their own accord. The morbid excitement, the apathies, or the gloomy feelings of many patients were allowed to remain unchecked, and not unfrequently the mental disease was intensified rather than alleviated. The more restless patients often spent much of their day in pacing the galleries or the airing-courts, nursing their morbid irritability, while others lounged on the benches or crept into corners, and so drifted downwards through the dreary stages of physical and mental decay. It does not require much consideration to show that it would tend to improve all such patients, both in their bodily and mental health, if they were engaged in some regular occupation during a reasonable portion of their time....

"'_The Industrial System cannot be adapted to all Cla.s.ses of Patients._--But there are patients, both among those of the private and among those of the pauper cla.s.s, whom it is undesirable, and whom it would also be wrong, to engage in work. There are cases, for instance, in which, for various reasons, such as physical weakness, it would be directly injurious to the patients to be engaged in active or fatiguing work; and it would be unsatisfactory if it were found that the efforts to develop the industrial system in asylums led to such patients being pressed to work....

"'_Advantage of the Farm as a Source of Occupation._--... The number of persons available for work on an asylum farm is always great; and in those asylums where full advantage has been taken of the opportunities which the farm affords, it is found that the directions in which the labour of patients may be utilized are much more numerous and various than at first sight may appear. For instance, one large outlet for their labour is supplied by the use of spade husbandry in circ.u.mstances in which the ordinary farmer would use the plough. Another outlet is to be found in the cultivation of crops of garden vegetables, which the ordinary farmer does not usually undertake. The carrying out of improvements on the farm or estate also gives employments of various kinds, and it is here, perhaps, that what may be called the elasticity of land as a source of labour for asylum inmates becomes more evident.

If the land attached to an asylum is of any considerable extent, it will nearly always happen that important re-arrangements are deemed desirable; and when there is a disposition to encourage improvements of this kind, it is generally found that they afford a very abundant and varied source of labour. Road-making, embanking, draining, fencing, planting, and even building, are generally found to be required; and in connection with these things, and with the work more accurately included under the term agricultural, there are subsidiary forms of industry developed. Indeed, the different kinds of work afforded by the re-arrangements and improvements on an estate prove of great value in asylum administration, for they afford some of the simplest kinds of outdoor labour. Many patients can be engaged in such occupations as digging and wheeling, who can with difficulty be engaged in less simple kinds of work; and by securing an ample supply of such simple work the number of patients who share in the benefits of active healthy labour in the open air is much increased....

"'It is impossible to dismiss the subject of asylum farms without some reference to the way in which they contribute to the mental health of the inmates by affording subjects of interest to many of them. Even among patients drawn from urban districts, there are few to whom the operations of rural life present no features of interest; while to those drawn from rural districts the horses, the oxen, the sheep, and the crops are unfailing sources of attraction. The healthy mental action which we try to evoke in a somewhat artificial manner, by furnis.h.i.+ng the walls of the rooms in which the patients live, with artistic decoration, is naturally supplied by the farm. For one patient who will be stirred to rational reflection or conversation by such a thing as a picture, twenty of the ordinary inmates of asylums will be so stirred in connection with the prospects of the crops, the points of a horse, the illness of a cow, the lifting of the potatoes, the laying out of a road, the growth of the trees, the state of the fences, or the sale of the pigs.

"'_Importance of Active Physical Work for Women._--... An attempt, attended with considerable success, has been made in some asylums to supply this deficiency by the development of the work of the laundry and was.h.i.+ng-house....

"'There are two directions in which the worth of the was.h.i.+ng-house may be developed. One is by obtaining work from outside sources, as has been done in some inst.i.tutions, where a considerable amount of was.h.i.+ng and dressing is done for persons living in the neighbourhood. Another direction is by avoiding the use in the was.h.i.+ng-house of all machinery which diminishes the amount of hand labour. And we are disposed to regard both these modes as deserving of encouragement....

"'_Difficulties met with in carrying out Improvements._--... In relaxing restrictions upon the liberty of the insane, there is a certain amount of prejudice in the public mind to be met and overcome. There is a feeling of timidity in regard to persons labouring under insanity, which leads to their being regarded as without exception and in all circ.u.mstances unfit to be trusted with any degree of liberty. As a result of this, there is a tendency, when a patient in an asylum inflicts injury on others or on himself, to blame the superintendent for having permitted the patient to have such liberty of action as made the inflicting of the injury possible; and there is consequently a temptation, to a superintendent who wishes to avoid adverse public criticism, to adopt restrictive measures of the most complete character.