Chapters in the History of the Insane in the British Isles Part 27

"'It was under the influence of such views that strait jackets, manacles, and chains were used before the introduction of what is called the system of non-restraint. When such restraints were used it was said that no blame could be attached to persons in charge of a patient for any violent deed which might be perpetrated, because it was held that every possible precaution had been taken to prevent it. The error that lurked beneath this statement was not perceived. It was not recognized that in taking precautions against one set of evils, other evils of a graver character were created. Even the evils which it was sought to avoid were not avoided. The first man from whom Pinel removed the manacles had, with those very manacles, killed one of his keepers. The superintendent who really takes most precautions against violence is not the man who applies the most complete restrictions upon liberty, but he who weighs the general results of different modes of treatment, and selects that which proves in practice most successful in decreasing the number of violent acts.

"'We cannot hope, in carrying out any system, to exclude the effect of mistakes in judgment and neglects of duty....

"'One difficulty for which no satisfactory solution has yet been found is the finding of employment for male patients during bad weather, when little outdoor occupation is to be had. It would be of great advantage if some simple indoor occupation, adapted to the peculiarities of the insane, were devised which could be taken up occasionally when outdoor occupation failed....

"'_Increased Comfort of Asylums._--It is satisfactory to record our conviction that all the changes just alluded to have tended not only to facilitate the administration of asylums, and to produce greater contentment among the inmates, but also, to exert a real curative influence. The scenes of turbulence and excitement which used to be of frequent occurrence in asylums have become much less frequent, and in the asylums where the changes in question have been most fully carried out, such scenes are comparatively rare. It does not admit of doubt that the occurrence of these fits of excitement had a deteriorating effect on the mental condition of the patients, and often r.e.t.a.r.ded, if they did not in some cases prevent, their recovery. It is not unusual now to pa.s.s through all the wards of some of the larger asylums without observing a single instance of disorderly behaviour, and we believe this is properly attributed to such changes as have just been noted. It is true that excitement may, to some extent, be kept in check by the use of calmative drugs; but we believe we are justified in saying that this practice is largely followed in no Scotch asylum, while it is scarcely adopted at all in those in which manifestations of excitement are least frequent, in which restrictions on liberty are most completely withdrawn, and in which industrial occupation has its greatest development.'"

Lastly in regard to that most important point, on which Dr. Fraser thus speaks:--

"'_The Influences which are at present operating on the Boarding out of Lunatics._-- ... The influences which, from my experience and observation, I believe to be operating upon these methods of provision for the insane, especially upon the pauper portion, seem to me to be as follows:--

"'1. The efforts of medical officers of inst.i.tutions to discharge chronic lunatics whom they consider suitable for being cared for in private dwellings.

"'2. The action of inspectors of poor in either initiating the removal of suitable cases, or in seconding the efforts of medical superintendents in this direction.

"'3. The amount and accessibility of asylum accommodation in each district.

"'4. The rate of maintenance in asylums.

"'5. The supply of suitable guardians.

"'6. The influence of the grant in aid.

"'_The Action of Medical Officers of Asylums._-- ... Owing to my having had at one time the superintendence of the asylum for Fife and Kinross, I am able to deal more satisfactorily with the statistics of this district than with those of other parts of the country. From a return which I have been favoured with, I find that the efforts to send out patients in this district have been effective and successful. During 1880 there have been discharged improved eighteen patients, five of whom were committed to the care of friends, and thirteen of whom were placed under the guardianship of strangers....

"'The question which naturally suggests itself is--What would be the result were this practice possible in every inst.i.tution, and in every district? On calculation I find that, had an equal proportion of the inmates of all asylums been similarly transferred to private care, no less than four hundred and three patients would have been removed from inst.i.tutions to care in private dwellings, whereas the fact is that only sixty-eight were so transferred. Only one patient out of the eighteen who were transferred from the Fife and Kinross Asylum has had to be returned to the asylum, and he was one of those who were boarded with friends....

"'_The Action of Inspectors of Poor._--The efforts of medical superintendents of asylums may do much, but it must be recognized that the success and extension of the boarding system is largely, if not mainly, in the hands of the inspectors of poor. Their action is threefold: (1) they may initiate the removal of their chronic insane from inst.i.tutions; they may co-operate with asylum officers in readily removing such lunatics as these officers intimate to be fit for being boarded out, and in procuring suitable guardians and homes for them; and (3) they may, by well-directed efforts, instead of hurrying every lunatic into an asylum, as the practice with some is, provide in like manner for those idiotic and insane paupers who, even when they first become chargeable, do not require asylum treatment and care....

"'Economy, one of the proper objects of parochial administration, is attained by this method of providing for the insane poor, and not only is it economical, as I will immediately show, but for a large proportion of chronic lunatics it is efficient and beneficial. From a return with which I have been favoured from the City Parish, Edinburgh, the average cost, inclusive of supervision and every other item of expenditure, for the insane boarded with strangers is 19 a year. The asylum rate during the last five years has been 27 per annum.

"'_The Amount and Accessibility of Asylum Accommodation in each District._-- ... It has now become a matter of everyday observation, that where there is ample asylum accommodation the boarding out of the insane is either entirely neglected or avoided, or but languidly attempted....

"'It follows that ample asylum accommodation though in itself a service and a safeguard to society, is yet apt to be an inducement to wasteful parochial administration....

"'_The Rate of Maintenance in Asylums._--In Dumfriesshire, where special circ.u.mstances have kept the asylum rate exceptionally low, and where agricultural avocations are well paid, the guardians require a high rate of board, and thus the cost of boarding out, when clothing, medical visits, and other expenses are included, is nearly equal to the rate of maintenance in the asylum for the district.

"'It therefore stands to reason that where the asylum rate is near to that required for outdoor care, the economic inducement to board out will apply only to those patients who have friends willing to have the charge of them. It thus appears that a low rate of maintenance in an asylum is practically prejudicial to the liberty of the chronic insane.

"'_The Supply of Guardians._--This feature of the system of boarding out the insane will appear to many to be all-important. The excuse which inspectors frequently advance for their lack of co-operation with medical officers of asylums is their inability to find suitable guardians. It is, however, an excuse which my experience does not permit me to regard as valid or sympathize with....

"'_The Influence of the Government Grant._--I feel I need do no more than mention this agency in increasing the number on the roll of single patients. The way in which it has led to this increase has been fully treated of in the published Reports of the Board....'"

Among the foregoing excerpts from the elaborate Report of the Commissioners, much, it will be seen, bears on the important question of the "cottage treatment" of the insane. In this direction, at least in the way of attempting to form a sort of lunatic colony (though on a very minute scale) after the manner of Gheel, Scotland has acted more definitely than England. Opinion is divided on the subject, and the measure of success can hardly be said to have been yet determined.

Whatever this may be, the counter disadvantages must not be overlooked.

Kennoway, in Fifeshire, where the experiment has been tried on a small scale, has had its supporters and detractors. Dr. John Smith, well known for his long practical experience of lunacy, and Dr. J. B. Tuke, at that time the superintendent of the admirably managed Fife and Kinross Asylum, visited Kennoway some years ago, and the report[249] of the latter was certainly anything but favourable; in fact, that the saving effected was by means detrimental to the lunatic. Notwithstanding, he arrived at the conclusion that the system might be employed with advantage in certain cases, if accompanied by stringent supervision. Dr.

Arthur Mitch.e.l.l, in his evidence before the Parliamentary Committee of 1877, so valuable on all the points to which he spoke, replied to the question why the patients boarded out had decreased in number, if the board approved of the system, that he, although warmly approving of it, was the person who had largely caused this decrease, the reason being that it was found there were a great number of persons totally unsuitable for private dwellings, and others were ill cared for. Hence it was necessary to weed them out. This observation does not specially apply to villages like Kennoway, but to the boarded-out cases, wherever placed.[250]

Much more of interest might be taken from this Report, but the foregoing will suffice to bring before the reader the salient points in the management of the insane in Scotland at the present day, by which he can judge for himself of the contrast between the present and the past. My main object is with the latter, but it can only be understood by a sketch, however brief, of the former, in each of the three divisions of the United Kingdom.

FOOTNOTES:

[227] These particulars are given in the Report of the Royal Lunacy Commission for Scotland, 1857, on the authority of Sir Thomas Craig.

[228] "A General View of the Present State of Lunatics and Lunatic Asylums in Great Britain and Ireland," by Sir Andrew Halliday, M.D., p.

28.

[229] _Op. cit._, p. 27.

[230] "An Act to Regulate Madhouses in Scotland."

[231] "The Commission was entirely due to Miss Dix's exertion. After visiting the lunatic asylums of E----, she proceeded to Scotland, where her suspicions were aroused by the great difficulty she experienced in penetrating into the lunatic asylums of S----; but when she did gain access, she found that the unfortunate inmates were in a most miserable condition. She came to London and placed herself in communication with the Secretary of State for the Home Department, and with the Duke of Argyll; and at her instance, and without any public movement on the subject, a Royal Commission was appointed to inquire into the state of the lunatic asylums of Scotland. No one, we are sure, could read the Report of the Commission without feeling grateful to that lady for having been instrumental in exposing proceedings which were disgraceful to this or to any civilized country."--Mr. Ellice, M.P., "Parliamentary Debates," vol. cxlv. p. 1025.

[232] "Parliamentary Debates," 3rd Series, vol. cxlv. p. 1020.

[233] Page 1025.

[234] Page 1027.

[235] Page 1035.

[236] See p. 338.

[237] Page 1042.

[238] Page 1043.

[239] Page 1044.

[240] Page 1468.

[241] "Parliamentary Debates," 3rd Series, vol. cxlvi. p. 1169.

[242] Page 1185.

[243] They were Melgund, chairman; G. Young, George Moir, James c.o.x, and W. A. F. Browne.

[244] If certain other figures be added, this total is 5823. See table on a subsequent page.

[245] This sum now amounts to nearly half a million.

[246] Twenty-third Report of the Commissioners, 1881.

[247] See pa.s.sage quoted in the last chapter of this book.

[248] The succeeding quotation const.i.tutes the a.n.a.lysis given of this Report in the _Journal of Mental Science_ for January, 1882.