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Chapters in the History of the Insane in the British Isles
by Daniel Hack Tuke
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I wish to record here that, so far back as 1838, some of the Scotch asylums were remarkable for the extent to which labour was introduced. Being engaged in writing an introduction to Jacobi's work "On the Construction of Asylums," the editor (Mr. S. Tuke) visited the asylums of Scotland in that year, accompanied by Mr. Williams, the visiting medical officer of the York Retreat, and found at Perth, Dundee, and Aberdeen, the men's wards nearly empty, so large a proportion of their inmates were in one way or other engaged in labour. "At Perth," he writes, "more than twenty came in together to dinner from the labours of the farm; others were employed in the garden and about the premises. At Dundee at nine o'clock in the morning, out of fifty-seven men patients of the lower class, twelve were engaged in stone-breaking, eight in gardening, thirteen in weaving, one in tailoring, two as shoemakers, whilst a few were engaged in the preparation of tow for spinning, and several in the various services of the house. In the Aberdeen Asylum, in which the labour system is extensively introduced, we were particularly pleased with the state of the lowest class of women patients—chiefly in an idiotic and demented state. All of these but one, and she was in a state of temporary active mania, were employed in picking wool or some other simple occupation. Indeed, in the three asylums which I have just mentioned, the state of the lowest class of patients offers a striking contrast to that in which they have been usually found in our asylums. Those dismal-looking objects, cringing in the corners of the rooms or squatting on the ground, almost lost to the human form, are here not to be seen. I must not omit to mention that at Aberdeen the manager had succeeded in inducing the higher class of patients to engage in gardening, etc. At Glasgow the governors were contemplating arrangements for the more extensive introduction of the labour system. In all these asylums the superintendents expressed their decided conviction of the benefit which, in a great variety of ways, was derived from the employment of the patients, more especially in outdoor labour."

In connection with the Dundee and Glasgow asylums, the great services rendered by Dr. McIntosh ought not to be forgotten, as also those of Dr. Poole (Montrose), Dr. Malcolm (Perth), and Dr. Hutcheson (Gartnavel).

Scotland south of Edinburgh and Glasgow had not, until 1839, any retreat or place of confinement for the insane, except six squalid stone cells attached to the public hospital of Dumfries. Violent or vagrant lunatics were physically restrained in their own houses, allowed to roam at large, or incarcerated in prisons or police stations. In the year mentioned, the Crichton Institution was opened for the reception of patients of all ranks and means, from the pauper to the peer, in other words, at rates of board from L17 to L350. In those days the building was regarded as magnificent, commodious, and much in advance of the prevalent psychiatry in Scotland, in the provision for the restoration of mental and physical health, and for securing the comfort and happiness of the inmates. The funds providing this building and surrounding fields, had been bequeathed by Dr. Crichton, of Friars Carse, Dumfriesshire, to his widow, who determined the precise application of the magnificent legacy, which it is reported amounted to L120,000. The benevolent foundress caused the structure to have the Bible as a foundation, instead of a stone, and announced her solemn intention that the establishment should be conducted, not merely in accordance with science, but the principles of Christian philanthropy. The first medical superintendent, Dr. W. A. F. Browne, who had made a critical examination of European asylums, and had acted as the chief officer in the Montrose Lunatic Asylum during four years, opened the Crichton Institution in 1839, with what were regarded as sound but advanced views, and with the resolution of carrying into effect all that had been discovered or suggested for the amelioration, cure, and care of those who might require treatment or seclusion.

Before the close of the first year of his management, there would appear to have been about a hundred individuals, of various stations and in various mental conditions, consigned to his charge. For these and the gradually increasing numbers of the population, he instituted daily exercise, amusement, occupation in the open air and in the grounds of the establishment, and during winter or inclement weather, billiards, bagatelle, "summer ice," and walking in the protected balconies connected with every ward or gallery in the house. Collections of books were contemporary with the laboratory, and the medical officers invariably carried a catalogue, along with a prescription book, in their daily medical visits to every patient. As a rule, remuneration was ordained for every description of labour, whether it was mental or manual, and might take a pecuniary or honorary form. From the commencement no personal restraint was resorted to, although the medical director did not bind himself either by rules or avowed opinions to prohibit mechanical resources, should they appear to be demanded for the preservation of life or strength, or quiet, or in any respect as a remedial agent. In 1840 a medical assistant or pupil was appointed. The experiment proved eminently successful, and the course thus foreshadowed has been universally adopted, and improved upon by increase in the number of such fellow labourers, by the addition of clinical clerks, and so forth. The next advance was in instituting recorded observations of the state of patients during the night as well as the day; in the addition of carriages as a means of enjoyment and distraction, one of these being an omnibus, so that groups of the inmates might be conveyed to distant parts of the surrounding country; and in the multiplication of hygienic and moral influences, music, painting, translation, study of medicine, acquisition of languages, teaching, reading prayers, etc. The next stage of development may be described as the separation of different classes of patients; provision for the agitated, for abstainers; mental culture for all capable of receiving impressions, lectures, public readings, the production of a monthly periodical which is still continued. Of this institution we shall have to speak again.

An Act to alter and amend certain Acts regulating mad-houses in Scotland, and to provide for the custody of dangerous lunatics, was passed in June, 1841 (4 and 5 Vict., c. 60). It amended 55 Geo. III., c. 69, and 9 Geo. IV., c. 34. A penalty of L200 and the expenses of recovering the same might be imposed on persons sending any lunatic to a mad-house without a licence; persons convicted of receiving lunatics without a licence, or the required order, might be imprisoned in default of penalty; the sheriff on application of the Procurator Fiscal might commit dangerous lunatics; the expenses were to be defrayed out of the rogue money, if the person had not the means of defraying, or if it could not be recovered out of his estate, then the same was to be defrayed by the parish which would be liable for the maintenance of such lunatic if he or she were a pauper; lunatics might be removed on application by the Procurator Fiscal; parish pauper lunatics were to be confined in public hospitals; if no public hospital in the county, the sheriff might send lunatics to an adjoining county; the death of a lunatic was to be intimated to the sheriff in writing by the person keeping the licensed mad-house; fees of licences might be diminished if the moneys received exceeded the sums required for carrying this Act into execution.

A form of register was to be kept in all licensed mad-houses in Scotland, indicating the house; where situated and kept; names and designations of individuals confined; date of reception; at whose instance confined, and on whose medical certificate; whether curable or incurable; date of removal or discharge, and authority for either; date of death; disease or cause of death, and duration of disorder; name of medical practitioner; when first called to give special attendance, and how often he afterwards visited the deceased, with the place of burial.

We must not omit to mention that in 1848 further legislation was attempted—an attempt, the failure of which was frequently deplored in the debates of succeeding years. A good Bill designed to amend the law of Scotland relative to the care and custody of the insane, and to regulate existing asylums, and to establish asylums for pauper lunatics, was brought in by the Lord Advocate (Lord Rutherfurd), Sir George Grey, and the Secretary at War. After the second reading it was referred to a Select Committee, which included the names of the Lord Advocate, Lord Ashley, Sir James Graham, Mr. E. Ellice, Mr. Stuart Wortley, and Mr. H. Drummond. Petitions now poured in from almost every shire in Scotland, and the Bill had unfortunately to be withdrawn. Undaunted, the Lord Advocate made another attempt in the following year, but with the same result.

It is not necessary to dwell longer on the condition of the insane, or the legislation adopted on their behalf, till we come to the year 1855, which proved to be the commencement of a new departure in the care taken for them by the State. Unfortunately, in spite of legal enactments, the state of the insane in Scotland, at this time, outside the asylums was as bad as it could be, and even in some asylums it was deplorable. At this period a well-known American lady, Miss Dix, who devoted her life to the interests of the insane, visited Scotland, and the writer had the opportunity of hearing from her own lips, on her return from her philanthropic expedition, the narration of what she saw of the cruel neglect of the pauper lunatics in that country. She caused so much sensation by her visits and her remonstrances, accompanied by the intimation that she should report what she had witnessed at head-quarters in London, that a certain official in Edinburgh decided to anticipate "the American Invader," as Dr. W. A. F. Browne called her. Miss Dix was, however, equal to the occasion, and, hurriedly leaving the scene of her investigations, she took the night mail to London, and appeared before the Home Secretary on the following day, when the gentleman from Edinburgh was still on the road, quite unconscious that the good lady had already traversed it.[231] The facts she laid before the Home Office were so startling that they produced a marked effect, and, notwithstanding counter allegations, the conclusion was very soon arrived at that there was sufficient prima facie evidence to justify an inquiry. A Royal Commission was appointed, dated April 3, 1855, "to inquire into the condition of lunatic asylums in Scotland, and the existing state of the law of that country in reference to lunatics and lunatic asylums."

The statutes forming the code of lunacy law for Scotland at that period were, for all practical purposes, the 55 Geo. III., c. 69; 9 Geo. IV., c. 34; and 4 and 5 Vict., c. 60.

The number of ascertained patients at this period (1855) amounted to 7403. The classification was as follows:—Private patients, 2732; paupers, 4642; criminals, 29 = 7403. Curable, 768; incurable, 4032; congenital idiots and imbeciles, 2603 = 7403. Males, 3736; females, 3667 = 7403. The proportion of the insane and idiots to the population was 1 in 390. The number of congenital idiots was greatest in proportion to the population in those counties remote from influences that incite to mental activity—the Highland population containing more than three times the number found in an equal Lowland population.

The 2732 private patients were thus distributed: In chartered asylums, 652; licensed houses, 231; poor-houses, 9; reported houses, 10; school for idiots, 12; unlicensed houses, 18; with relatives, 1453; with strangers, 297; not under any care, 50; total, 2732.

The 4642 paupers were thus distributed: In chartered asylums, 1511; licensed houses, 426; poor-houses, 667; reported houses, 31; school for idiots, 3; unlicensed houses, 6; with relatives, 1217; with strangers, 640; not under any care, 141; total, 4642.

The receptacles for the insane were thus distributed:—

A. Chartered asylums. The Royal Asylums at Aberdeen, Dundee, Edinburgh, Glasgow, Montrose; the Crichton Institution, Dumfries, including the Southern Counties Asylum; James Murray's Royal Asylum, Perth.

B. Public asylums not incorporated. The only institution of the kind, that of Elgin, was exclusively for paupers.

C. Poor-houses with separate wards for the insane (twelve given in the table).

D. Prisons. The only one specially adapted for the reception of the insane was the lunatic department of the general prison at Perth.

E. Poor-houses without separate wards for the insane (fourteen given).

F. Private asylums (twenty-three in number).

G. Private houses reported to the sheriff.

H. Houses of relatives and strangers.

I. Schools for idiots. Baldovan, near Dundee; and Gayfield Square, Edinburgh.

This Commission did not report until 1857, and unhappily the evidence more than justified the necessity of the appointment of the Committee, and of a sweeping measure of reform. The difficulty in selecting passages from the Report is to know where to stop. We shall restrict ourselves within moderate bounds; and first let us cite the reference to the condition of the insane and idiotic not in asylums. "It is obvious," says the Report, "that an appalling amount of misery prevails throughout Scotland in this respect. When estimating the condition of the insane not in establishments, it should be remembered that the details furnished by us give only an imperfect representation of the true state of matters. They form only a part of the picture of misery; and, had we been able to extend our investigations, it would, we are convinced, have assumed a much darker shade.

"A practice prevails in some workhouses, as in a few of the licensed asylums, of fastening the hands behind the back, by which much unnecessary pain is inflicted on the patient."

Of the methods employed in asylums to repress violence, etc., the Report thus speaks:—

"Instrumental Restraint and Seclusion.—Personal restraint by the application of the strait waistcoat, or of the straps or muffs, is almost entirely banished from the chartered asylums; but we have reason to think that seclusion for long periods is frequently used. This remark applies more especially to the asylums of Montrose, Glasgow, Aberdeen, and Edinburgh. In Montrose we found, on one occasion, eleven patients in seclusion out of a population of 174, several of them having been so secluded for considerable periods, and one woman for several months; and it is to be observed that the seclusion rooms in this asylum are mere cells, with stone floors and darkened windows, and that the patients who are placed in them are frequently allowed no other covering than blankets, and no other bedding than loose straw cast on the floor."

Here is a picture of the way in which one asylum was conducted: "We have grounds for fearing that the patients suffered from cold. The house is carelessly conducted and the state of the patients very unsatisfactory. The bed-frames, which are about the ordinary size with only spars of wood at the lower part, were dilapidated and saturated with filth; and the quantity of straw in them was very scanty and mixed with refuse; it was wet, offensive, and broken into small portions, and had clearly not been renewed for a considerable time. A certain number of the patients, males as well as females, were stripped naked at night, and in some cases two, and in one case even three, of them were placed to sleep in the same bed-frame, on loose straw, in a state of perfect nudity." The proprietor in his evidence says, "I never go into the rooms at night. The floor is constantly soaked with wet. There is an epileptic lad who is frequently fastened to the rings in the wall. The nurses keep the muffs in their custody. I dare say half of the dirty patients would sleep naked; seven would, therefore, sleep with others, I cannot say that more did not sleep together in a state of nudity. I consider the treatment is proper for them."

Again: "The bad treatment of the patients, and the very unsatisfactory treatment of the patients, are not fully known to the official inspectors. Indeed, it would appear that in some houses the instruments of restraint are systematically removed from the persons of the patients after the arrival of the sheriff at the asylum, for we find in Dr. Renton's evidence that, speaking of L—— Asylum, in which two male patients are kept constantly in restraint by means of handcuffs, he says, 'There are not many patients under restraint at L——.' And, further, in reference to Mrs. B——'s house at N——, he states, 'In Mrs. B——'s house I don't think there are many cases of restraint. There is a Miss W—— lately come, and a Miss M——. I don't think restraint is used to them.' We have ascertained, however, that these two patients were frequently restrained. These instances might be multiplied.

"Rent is saved by placing patients in small houses, making them use the same rooms both as day and sleeping accommodation; they are also crowded into small airing-courts, inadequate to afford proper exercise and a proper separation of the sexes. The inmates during the winter months pass the greater part of each twenty-four hours in their bed, whereby candle-light is saved. In L—— Asylum, the patients are not allowed candle-light at any season.

"We cannot doubt that in many instances practices obviously wrong, and detrimental to the patients, have been adopted in licensed houses, because an increased profit would thereby be obtained by the proprietor."

In short, both as regards licensed houses and unlicensed houses, the Report winds up by giving a dismal picture; for, as to the former, "they are crowded in an extreme degree, profit is the principal object of the proprietors, and the securities against abuse are very inadequate;" and as to the latter, they "have been opened as trading concerns, for the reception of certain classes of patients who are detained in them without any safeguard whatever against ill-treatment and abuse." Strange to say, the persons properly authorized to inspect, did not avail themselves of the powers of inspection granted them by law; and the officials chose to interpret the law "in conformity with their respective views." Such was the unfortunate condition into which Scotch lunacy had drifted, at so comparatively recent a date as 1857, and out of which those who drew up the Report—Alexander E. Monteith, James Coxe, Samuel Gaskell, and William George Campbell—proposed to deliver it by the following remedial measures:—The erection of district or county asylums for pauper lunatics, including accommodation for the insane belonging to the labouring classes, who are not strictly paupers. Likewise, more suitable accommodation for criminal lunatics. Means for insuring greater caution and discrimination as regards the licensing of houses for the reception of the insane; for imposing some check upon the licensing of new houses; and for conferring powers to close those already opened for paupers so soon as public asylums shall be erected, or at any other time, if not properly conducted. Regulations by which all pauper lunatics not in asylums shall be brought under proper visitation and care, and periodical reports be made as to their condition by medical men, so as to afford a safeguard against abuse and ill-treatment, and secure the ready and careful transmission of all proper cases to asylums. An accurate definition of the powers and duties of sheriffs in reference to the insane, so as to secure a more uniform practice and united action amongst them. Rules for the guidance of the Board of Supervision, parochial boards, inspectors of poor, and district medical officers in all matters relating to the management of the insane. More complete regulations in reference to medical certificates; to prevent interested parties signing them; to specify the length of time the document shall remain in force; and to require a statement of the facts or evidence upon which the opinion as to the patient's insanity is founded. Also a limitation of the time during which the sheriff's order shall remain in force, previous to the admission of the patient, and also in case of escape. The formation of a complete system of schedules and returns, together with full records of all admissions, discharges, deaths, and accidents. Also the institution of registers and case-books, showing the medical treatment pursued in each case, and whether, and to what extent, restraint and seclusion were employed. Comprehensive regulations applicable to licensed houses and poor-houses, while continuing to receive lunatics, for securing to the patients sufficient medical and other attendance; kind and appropriate treatment; proper diet, clothing, bedding, exercise, and recreation; and adequate means of religious consolation. A requirement that, on recovery, patients shall be discharged by the medical attendant of the establishment. Restrictions on the removal of pauper patients by inspectors before recovery. Precautions for preventing injustice in transporting aliens. Better regulations as to dangerous and criminal patients. Measures by which persons labouring under insanity may voluntarily place themselves under care in an asylum. Special regulations for prolonging control over cases of insanity arising from intoxication. Enactments for extending further protection to the property of lunatics, and for insuring the proper application of their funds. The imposition of suitable penalties for infringement of the law, and power to modify them according to circumstances. Powers to raise sufficient funds for the purposes of the Act. The creation of a competent board, invested with due authority, to whom the general superintendence of the insane in Scotland shall be entrusted, including power to license houses for the reception of the insane; to visit all asylums, licensed houses, poor-houses, and houses containing only single patients; to order the removal of patients to or from an asylum, or from one asylum to another; to give leave of absence to convalescent patients; to regulate the diet in asylums and licensed houses for pauper patients; to make regulations for their management, etc., etc.; with direction to report to the Secretary of State for the Home Department. The formation of local boards for the management of individual asylums, which shall act in conjunction with the general board.

Legislation followed in due time.

On the 29th of May, 1857, Mr. Ellice,[232] the member for St. Andrew's, asked the Government what steps they intended to take for securing to pauper lunatics in Scotland proper protection and maintenance, in order to alleviate the sufferings of the persons to whom the recent Report of the Commissioners of Inquiry into the state of Lunatics in Scotland related. He was ashamed to have to admit that in that country, unfortunately, the state of things had been lamentably different from England and Ireland, where boards had been appointed under which, generally speaking, the law for the protection of lunatics had been satisfactorily administered. In Scotland, instead of a Board of Commissioners specially appointed to take care of lunatics, the charge had devolved upon the sheriffs of counties and the Board of Supervision, which latter body stood in the place of the Poor Law Board in this country. He charged the Scotch authorities with an almost total neglect of the duties which were incumbent upon them under the law, which "in a great measure was very ample for the protection of the great proportion of the pauper lunatics in Scotland, if it were properly administered." The powers and duties of the sheriffs, as laid down in the Act, were amply sufficient. Yet the granting of licences, which was their duty, formed the exception, and, in fact, houses were opened generally without any licence whatever; the patients were detained without any order, or without even any medical certificate; if they died, their friends were not informed of their deaths, which were not reported to any constituted authority, "the unfortunate persons disappearing in that mass of misery and filth which he should shortly depict." The pauper lunatics were under the charge of the parochial boards. These were under the control of the Board of Supervision, sitting in Edinburgh, and similar to the Poor Law Board in London. The statute enacted that whenever any poor person chargeable on the parish should become insane, the parochial board should, within fourteen days of his being certified, take care that he was properly lodged in an asylum. The Board of Supervision had, under the same Act, peculiar power with respect to lunatics, and it was competent for them to dispense with an asylum, and allow the patient to remain with his friends under due inspection.

The Board of Supervision had absolute powers to dismiss any inspectors of the poor neglecting their duty to pauper lunatics. They acknowledged their obligation. In their first Report (1847) they, among other positive statements, affirm that they, in all cases in which they dispensed with the removal of pauper lunatics to asylums, were careful to preserve the necessary safeguards against abuse, by requiring a satisfactory medical certificate as to treatment, and so on. Mr. Ellice then showed that "these statements had no foundation in fact; that they were positively untruths, and entirely deceptive, year after year, as to the real state of the lunatics in Scotland." In subsequent Reports the Board boasted that it had endeavoured, not unsuccessfully, to improve the condition of the insane, but Mr. Ellice showed that "the condition and treatment of the pauper lunatics was diametrically opposite to what was there stated." He knew that more legislation would be promised by the Government, but the thing was to see that the law was enforced, and that due notice should be taken of the conduct of the authorities who had neglected their duties. He asked that a direct condemnation should be passed upon them, and that they should be compelled, as in duty bound, to protect pauper lunatics from continued neglect and abuse. The member for Aberdeen characterized the Report of Commissioners regarding the state of the insane in his county as "one of the most horrifying documents he had ever seen."[233] It was "a state of things which they could not before have believed to prevail in any civilized country, much less in this country, which laid peculiar claims to civilization, and boasted of its religious and humane principles."[234] "Distressing as were the cases which he had mentioned, there were others ten times worse remaining behind—so horrible, indeed, that he durst not venture to shock the feelings of the House by relating them."[235] Sir George Grey, after saying that the Report on the treatment of lunatics in Scotland contained statements of facts calculated to cast very great discredit upon that portion of the United Kingdom, admitted that the Board of Supervision was not free from blame, but thought the Report proved that the guilt must be shared by the parochial boards, the inspectors of the poor, the sheriffs, the clergy, the justices of the peace, and by the Commissioners of Supply. By this ingenious homoeopathic dilution of the blame, it was easy to show that individual responsibility was infinitesimal, and could not, therefore, be detected and punished in the way it so richly merited. Sir George Grey promised to introduce a Bill calculated to remove the defects in the law established by the Reports, and deplored the fate of the Bill brought in by Lord Rutherfurd,[236] when Lord Advocate, which would, in his opinion, have remedied all the evils now complained of. It was "referred to a Select Committee, but the opposition roused to it in Scotland, on the miserable ground of the expense it would incur, proved fatal to the measure. I trust the disgrace that now attaches to Scotland in this matter will be removed, and that this and the other House of Parliament will cordially co-operate with the Government in the adoption of those measures that are necessary for the relief and protection of the unfortunate class of persons referred to in the Report."[237] Mr. H. Drummond, who said he had assisted Lord Rutherfurd to pass his Bill, also deplored its rejection. "Both he and the Lord Advocate were beaten by the systematic opposition of every single person who was connected with the administration of the system in Scotland. They would not give the returns sought for ... and the ground of the opposition was the dread of the dirty expense which might be incurred. From one to the other it appeared that the object of care in Scotland was property, not persons. The way in which they treated the poor in Scotland was perfectly scandalous, and in nothing did the system appear so bad as in the treatment of pauper lunatics, the rich lunatics being sufficiently well taken care of." Mr. Drummond asked how it was "that throughout the whole of Scotland there was not one clergyman who could find time to visit these poor creatures? True, there was one, but when he went to the asylum he was refused admittance; and why? Because he was a Papist. The Poor Law, as managed by the Board of Supervision, had been well defined to be 'a law for depriving the poor of their just rights.'"[238] Sir Edward Colebrooke, as one of the members for Scotland in the previous Parliament, took his share of the blame that attached to the House in reference to Scotch asylums. In the Report issued in 1844, it was recommended that more stringent provisions should be introduced into the law, but they had not been attended to. Mr. Kinnaird, the member for Perth, thought that the Scotch members owed a debt of gratitude to Mr. Ellice for the manner in which he had laid the disgraceful feature in the administration of the Scotch Poor Law before the House. He was glad to find that the Perth Asylum was not one which had disgraced Scotland.[239] The Lord Advocate rejoiced at the publication of the Report, and the statements of Mr. Ellice, from the bottom of his heart, because the state of things had for a long time been a disgrace and a scandal to Scotland. "The people of that country had known that it was a disgrace and a scandal, and he regretted to add that it was not the first time that statements had been made similar to those to which they had just listened. Had Lord Rutherfurd's Bill of 1848 been passed, this disgraceful state of things would have been put an end to. But not a single petition was presented in its favour, while twelve of the largest and most important counties of Scotland petitioned against it! That noble-minded lady, Miss Dix, went to Edinburgh and visited the asylums at Musselburgh. After seeing them, she said there was something wrong, and she wished to be allowed to visit them at the dead of night, when she would not be expected. He felt a difficulty about giving a permission of that kind to a non-official person, and accordingly she applied to the Home Secretary. When asked by him his opinion of the subject, he at once stated that the whole system with regard to the treatment of lunacy in Scotland was utterly disgraceful, and that the evil could only be reached by a Commission of Inquiry. The facts were now so clearly proved that if he proposed the very remedy which was rejected in 1848, it would be adopted by both Houses of Parliament without any important opposition."

A Government Bill was brought in by the Lord Advocate, June 9, 1857, "to alter and amend the laws respecting lunatics in Scotland." In introducing it, he summarized the then law as follows:—The sheriffs of the counties, the justices, and some other parties had the power and duty of inspection once or twice a year; certain registers were ordered to be kept and certain regulations made. But there was no uniformity; every sheriff might interpret the Act as he pleased, and there was no obligation to erect asylums for the maintenance of lunatics. The duty was thrown on the Procurator Fiscal of seeing the Act executed, but no power was given him to ascertain whether it was executed or not, and there was no power of visitation. He need not say that these safeguards entirely failed, and the remedy he now proposed was that there should be appointed a Commission, an inspector-general who should be a medical man, a secretary, and a clerk; and that these should constitute the Lunacy Board for Scotland, though not under that name. They would have the power of granting and refusing licences for asylums. The sheriffs and the justices would retain the powers conferred on them already. Scotland would be divided into districts, in which asylums would be erected by an assessment laid on for the purpose. The Lord Advocate made a sort of formal defence of the Board of Supervision, of which he himself had been a member, and pointed out that in their first Report they had stated that the accommodation in the asylums was not equal to that required for one-tenth of the number of pauper lunatics. Sir John McNeill, who presided over the Board, when examined before the Select Committee on Miscellaneous Expenditure in 1848, stated this fact strongly. Mr. Ellice, however, adhered to the remarks he had previously made, reasserted his accusations, and repeated that if the question were put to a jury, they would come to no other decision than that gross culpability existed on the part of the authorities, and he only regretted that the Government had not had the courage to say that the Board of Supervision had deserved the condemnation of the House. Leave was given to bring in the Bill.[240]

On the second reading[241] (June 9, 1857) no serious opposition was offered to the Bill, although an attempt was made to show that the Commission had been carried away by exaggerated statements. Mr. Bruce, the member for Elginshire, who alleged this, hoped the Bill would not be hurried through the House that session. Mr. Blackburn, the member for Stirlingshire, said he agreed with every Scotch member that a permanent board would be of no use; it would be coercing the people by centralization. Mr. Cowan, member for Edinburgh, said that he had been requested to present a petition, signed by the Lord Provost and magistrates of Edinburgh, seeking for delay, but he did not like to incur that responsibility, and would therefore support the second reading. Mr. Dunlop, the member for Greenock, assumed, for the sake of argument, that all persons in Scotland had done their duty; but even if this were so, it was impossible but that cruelty and ill-treatment must have taken place when they considered the way in which pauper lunatics were treated, and he rejoiced that another session was not likely to pass over without something being done to remove what was at once a national calamity and a national crime, from Scotland.[242] Mr. Mackie, the member for Kirkcudbrightshire, protested against the creation of a new Board and the expensive machinery contemplated by the Bill. Sir William Dunbar, the member for Wigton, agreed, and maintained that the existing system was sufficient to insure all that was required. Sir John Ogilvy, member for Dundee, said a strong feeling existed in Scotland that the Board of Supervision furnished an efficient machinery capable of supplying all the defects of the present system, without the creation of a new Board. Mr. Hope Johnstone, member for Dumfriesshire, enforced these remonstrances, by stating that he had representations made to him from every quarter in opposition to the appointment of a new Board. Mr. Drummond hereupon made an observation, greatly to his credit, which deserves to be remembered. He said that the question was not so much what would be the most expensive as what would be the most efficient machinery. There were plenty of representatives of the ratepayers in that House, but no representatives of the lunatics of Scotland. They seemed to have no friends there, while really they were the persons who stood most in need of being represented.

The Act (20 and 21 Vict., c. 71) was passed August 25, 1857. It was entitled "An Act for the Regulation of the Care and Treatment of Lunatics, and for the Provision, Maintenance, and Regulation of Lunatic Asylums in Scotland." It repealed the Acts 55 Geo. III., c. 69; 9 Geo. IV., c. 34; and 4 and 5 Vict., c. 60.

To give a complete analysis of this most valuable Act, which consists of no less than 114 sections, would be wearisome to the reader. Its chief provisions were these:—

A Board of Commissioners in Lunacy for Scotland was to be appointed, consisting of three unpaid and two paid Commissioners; the Secretary of State was empowered to appoint one or two medical men as Deputy Commissioners; public asylums founded after the passing of this Act were to be subject to it; the duties of the Commissioners as to inspection were laid down; the sheriff was to visit and inspect asylums; private asylums were to be licensed by the Board; the patient was to be admitted by order of the sheriff on medical certificates; five shillings were to be paid for the sheriff's order for the admission of a patient not being a pauper, and half that sum for a pauper; the medical certificate was to specify the facts on which opinion of insanity was founded; no certificate was to be granted without examination, under penalty not exceeding L50, and if falsely granted, under a penalty not exceeding L300; houses where lunatics were detained under the order of the sheriff might be visited by the Board; one medical man was to be resident in every asylum licensed for a hundred patients or more, and a physician was obliged to visit daily those for more than fifty patients; those for fifty or less were to be visited at least twice in every week.

Scotland was divided into districts, set forth in a schedule, and a district board was to be appointed within six months, which should inquire into the necessities of the district; the Board was to require the district boards to provide district asylums; the provisions of 2 and 3 Vict., c. 42, were to be applied to this Act; district asylums were to be vested in district boards, and district inspectors were to be appointed.

Power was given to Public Works Loan Commissioners to lend money for purposes of the Act, provision being made for the money borrowed being paid off within thirty years.

In case the district asylum could accommodate more than the lunatics of the district, other lunatics, it was enacted, might be admitted.

Whether the property of a lunatic was or was not under judicial management, if it was not property applied for his benefit, application was to be made to the Court of Session.

Provision was also made for cases where insanity stands in bar of trial; the finding of the Court that the prisoner cannot be tried, to be followed by an order to be kept in strict custody during her Majesty's pleasure; a lunatic acquitted of a criminal charge on the ground of insanity, to be kept in custody by order of court in such place as it may see fit, during her Majesty's pleasure; prisoners exhibiting insanity when in confinement to be removed to an asylum, to remain there until it should be certified to one of her Majesty's Principal Secretaries of State by two medical men that such person has become of sound mind; whereupon the Secretary of State was authorized, if such person's term of imprisonment had not ended, to issue his warrant to the superintendent, directing that such person should be removed back to prison, and if no longer subject to imprisonment, that he should be discharged.

With regard to the liberation of patients from asylums, the certificates of two medical men approved by the sheriff were required, eight days' notice being given to the person at whose instance such lunatic was detained; the patient released to be entitled to a copy of order, certificate, etc., on which he was confined.

The punishment of maltreating any lunatic was a fine not exceeding L100, or imprisonment for any period not exceeding six months, without prejudice to action for damages.

Power was granted to the Secretary of State to order a special visitation of any place where a lunatic was represented to be confined.

The inspectors of the poor were to give intimation of pauper lunatics within their parishes.

The importance of this Act is enhanced by the fact that its framers had the advantage of a knowledge of the working of the great Acts of 1845 and 1852 in England and Wales.

Availing ourselves now of the first Report of the Commissioners[243] who were appointed under the foregoing Act, we shall present a statement of the number and distribution of the insane in Scotland on the 1st of January, 1858.

- - Location. Males. Females. Total. Private. Paupers. - - In public asylums 1226 1154 2380 786 1596 In private asylums 330 415 745 219 526 In poor-houses 352 487 839 6 833 In private houses 810 974 1784 1784 - Total 2718 3030 5748[244] 1011 4739 - -

The above table does not include private single patients; their number could not be accurately ascertained.

The Commissioners, as might be expected, report the state of the insane to have altered little since the Report of the Royal Commission. In the pauper licensed houses, if not in others, the overcrowding was great, though diminishing. "The patients, when within doors, are generally found sitting in cheerless rooms, ranged on benches, listless and without occupation; and when out of doors, they are usually lounging sluggishly about the airing-courts, or are crouching in corners." Among favourable indications noted by the Commissioners it is pleasant to read the following:—"Mechanical restraint has been entirely banished from the licensed houses, and patients who are recorded in the Report of the Royal Commissioners as almost always under restraint, are now habitually free from their bonds. The improvement in the condition of these cases under the more humane treatment now in use has been most remarkable, and is especially exemplified in the case of A. S——, a patient in M—— Asylum."

Subsequent Acts were passed, called for by the experience of the Commissioners in regard to the working of the Act of 1857, some imperfections in which were naturally discovered in the course of years.

The Lord Advocate and Sir George Grey brought in a Bill in 1862 to make further provision respecting lunacy in Scotland, which received the royal assent July 29 (25 and 26 Vict., c. 54).

By this Act, consisting of twenty-five sections, the Board was empowered to license lunatic wards of workhouses; to sanction the reception of pauper lunatics in workhouses; to grant special licences for reception in houses of not more than four lunatics; to grant licences to charitable institutions for imbecile children without fee; to sanction detention of pauper lunatics in asylums beyond the limits of their district; to take such steps as the Board may consider requisite towards providing accommodation for the district, etc., etc. Not to cite other sections, certain provisions of the recited Acts as were inconsistent with the Act were repealed, and the General Board of Commissioners was, of course, continued.

In their Report of this year (1862) the Commissioners observe, relative to the supposed increase of insanity, "Judging from the evidence which the tables afford, the increase is almost entirely due to the accumulation of the numbers of the insane, and certainly not, to any marked degree, to a greater disposition in modern times to mental disease; for while in the years 1858, 1859, 1860, and 1861, the admissions into asylums scarcely varied in number, the patients resident in such establishments showed every year a large and steady increase. Thus, on January 1, 1858, their number amounted to 3765; on January 1, 1859, to 4114; on January 1, 1860, to 4350; and on January 1, 1861, to 4462."

We have already noted the fact that more idiocy appears to be found in the counties least exposed to mental activity. In this Report, however, the Commissioners state that, as regards lunacy, its occurrence is considerably more frequent in urban than in rural districts. The word occurring is here used advisedly in contradistinction to existing lunacy. The explanation offered by the Commissioners is that there is a greater proportion of recoveries and deaths taking place among the patients of the rural district. They contrast the number of pauper lunatics intimated from urban populations with the number intimated from rural districts, and they find that in the former, the occurrence of pauper lunacy as compared with its occurrence in the latter, is as 100 to 54, whereas the proportion of existing pauper lunatics, January 1, 1861, in the corresponding districts was as 100 to 106. The Commissioners regarded as urban those parishes containing towns, or parts of towns, having more than 20,000 inhabitants, and as rural all other parishes.

We need not dwell on the Act passed in 1864 (27 and 28 Vict., c. 59) to continue the Deputy Commissioners in Lunacy in Scotland, and to make further provision for their salaries and the clerk of the Board.

In 1866 another Act was passed (29 and 30 Vict., c. 51) to amend the Acts relating to lunacy in Scotland, and to make further provision for the care and treatment of lunatics. One or two of the provisions made merit notice. Any person keeping a lunatic in a private house, although not for gain, longer than one year, was obliged, if the malady required compulsory confinement or restraint or coercion, to report to the Board, that it might make inspection and obtain an order for the removal of such lunatic to an asylum. Regulations were made as to persons entering voluntarily as boarders, whose mental condition is not such as to render it legal to grant certificates of insanity. Letters from patients to the Board, and from the Board to patients, were to be delivered unopened. Power was given to apply to the Court of Sessions to obtain improved treatment and care of any lunatic. Patients committed as dangerous lunatics might be liberated on the certificates of two medical men, approved by the Procurator Fiscal, that such lunatic may be discharged without risk of injury to the public or the lunatic. This is a valuable provision. Power was given to the directors of asylums to grant superannuations to officers, etc.

The above Statute, passed in 1866 to amend the Acts relating to lunacy, was succeeded, in a few years, by another statute having reference to a special class of the insane. Of this later Act in 1871 (34 and 35 Vict., c. 55) to amend the laws relating to criminal and dangerous lunatics in Scotland, it may be well to record the most important provisions. These were to apply to persons detained by judgment prior to the Act 20 and 21 Vict., c. 71. The lunatic department in the general prison at Perth was to be relieved from overcrowding by removing the insane prisoners to district, chartered, or private licensed asylums, with consent of managers of chartered and private asylums. As to the disposal of persons becoming insane in local prisons, these were to be removed to a lunatic asylum by a warrant of the sheriff; all asylums in which pauper lunatics were maintained by contract being bound to provide for the reception of such prisoner. The Act was to apply to any lunatic charged with assault or any offence, although not coming within the definition of a pauper.

There was in 1874 an interesting Parliamentary return, showing the total number of pauper lunatics in each of the three divisions of the United Kingdom, and the estimated annual amount of the proposed grant of four shillings per head per week towards the maintenance of pauper lunatics in asylums. The figures are as follows:—

A. In county, borough, royal, district, parochial, and private licensed asylums—

England 31,799 Ireland 7,140 Scotland 4,428 ——— Total 43,367

B. In work houses and elsewhere—

England 21,413 Ireland 3,125 Scotland 2,077 ——— Total 26,615

Total of A and B in England 53,212 " Ireland 10,265 " Scotland 6,505 ——— Total 69,982

Annual amount of four shillings weekly capitation grant towards maintenance of those in A:

England L330,710[245] Ireland 74,256 Scotland 46,051 ———— L451,071

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

With relatives 4 0 With strangers 5 6 Alone 3 5-1/2 ———— Total in private dwellings 4 3-3/4

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 assuredly 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 institution 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, constituting 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 classes; 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 associates from the external world, and the creation of all arrangements which could recall or assimilate such a place of seclusion with home, rational liberty, and natural pursuits. Whilst the mingling of distinct grades was employed as a remedy, rigid classification 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 Institution 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 institution, 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, classes 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 constitute 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 institution 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 classes, and has now no less than eight hundred patients who pay from L30 up to L500 a year. It has a Charity Fund of L10,000; its buildings are scattered, and number nine for patients. Like an old cathedral, it now shows, in common with long-established institutions, such as the York Retreat, the successive ideas of various men and various times, and one would really regret to see the original shell 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 institutions for the insane, instead of giving a general historical sketch of the progress of reform, I should have added notices of other excellent institutions, 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 classes 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 institutions "for all classes," and combined business with philanthropy in making the rich help the poor, there is plenty of middle-class 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 analyzed, 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 (assuming 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 associated 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.—Circumstances 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 association 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 space of the general grounds. It was found by placing them more immediately in companionship 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 institutions 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 assumed 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 anticipated. 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 constitutes 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 diminishing 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 relinquishing 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 circumstances 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 Classes of Patients.—But there are patients, both among those of the private and among those of the pauper class, 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 circumstances 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 furnishing 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 washing-house....

"'There are two directions in which the worth of the washing-house may be developed. One is by obtaining work from outside sources, as has been done in some institutions, where a considerable amount of washing and dressing is done for persons living in the neighbourhood. Another direction is by avoiding the use in the washing-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 circumstances 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.

"'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 retarded, if they did not in some cases prevent, their recovery. It is not unusual now to pass 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 institutions 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 institution, 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 institutions 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 institutions; 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 L19 a year. The asylum rate during the last five years has been L27 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 circumstances 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 Mitchell, 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 Cox, 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 passage quoted in the last chapter of this book.

[248] The succeeding quotation constitutes the analysis given of this Report in the Journal of Mental Science for January, 1882.

[249] Journal of Mental Science, January, 1870.

[250] Dr. Fraser observes (Report, p. 124): "Dr. Arthur Mitchell, in his work on the insane in private dwellings, shows that this method of providing for the chronic insane is—1st, the best thing for the patient; and, 2nd, the best thing for the country; and in that opinion I heartily concur."



CHAPTER X.

IRELAND.

I have already spoken of the singular tradition which for so long a period invested the Glen-na-galt, near Tralee, with the character of possessing healing virtues in madness. The change which in our practical age has taken place in Kerry, by the substitution of a well-ordered asylum at Killarney, for popular superstitious practices, represents what has been going on throughout the whole of Ireland during the last half century or more. After examining all the Acts bearing on the provision for the insane from the earliest period, and the evidence given before Parliamentary Committees, I must say I find a very large amount of strenuous effort and labour devoted to the improvement of the condition of lunatics, miserably situated as they formerly were in general, when confined in houses of industry or at home in hovels, where their needs could not possibly be attended to, even when, as was doubtless frequently the case, they were regarded with great affection. Sometimes they were looked upon as possessed, and then the appropriate forms of the Church of Rome were employed.

In the evidence given before the Select Committee on the Lunatic Poor in Ireland in 1817, Mr. John Leslie Foster, a governor of the Richmond Asylum,[251] stated that he had seen two or three lunatics in one bed in the house of industry. There were fifty or sixty in one room. In the same room a lunatic was chained in a bed, the other half of which was occupied by a sane pauper, and the room was so occupied by beds that there was scarcely space to move in it.

Mr. Rice stated that when he visited the Clonmel Asylum in 1814-15, the patients were not clothed; some were lying in the yard on the straw in a state of nakedness. At Limerick he found the accommodation for the patients "such as we should not appropriate for our dog-kennels." There was one open arcade, behind which cells were constructed with stone floors, without any mode of heating or of ventilation, and exposed during the whole of the winter to the extremities of the weather. Thirteen cells were provided for thirty-three lunatics and idiots. As some were furious, the usual mode of restraint consisted of passing their hands under their knees, fastening them with manacles, securing their ankles by bolts, passing a chain over all, and lastly attaching them firmly to the bed. "In this state, I can assure the Committee from my own knowledge, they have continued for years, and the result has been that they have so far lost the use of their limbs that they are utterly incapable of rising." The rooms over the cells were appropriated to the sick. Mr. Rice found twenty-four persons lying in one room, some old, some infirm, and in the centre of the room a corpse; one or two were dying. In the adjoining room he found a woman in a state of distraction, the corpse of her child left upon her knees for two days; it was almost putrid. "There was not to be found one attendant who would perform the common duties of humanity. The most atrocious profligacy in another branch of the establishment prevailed."

The condition of a lunatic member of a family among the poor is thus graphically described by a member of the Committee which prepared this valuable Report: "There is nothing so shocking as madness in the cabin of the peasant, where the man is out labouring in the fields for his bread, and the care of the woman of the house is scarcely sufficient for the attendance on the children. When a strong man or woman gets the complaint, the only way they have to manage is by making a hole in the floor of the cabin, not high enough for the person to stand up in, with a crib over it to prevent his getting up. The hole is about five feet deep, and they give this wretched being his food there, and there he generally dies. Of all human calamity I know of none equal to this, in the country part of Ireland, which I am acquainted with."

In the physician's report of one asylum for 1816, he speaks of the miserable objects who wander over the face of the country, or are inmates of jails and hospitals. Such do not appear to have taken refuge in any Glen-na-galt.

The first asylum for the insane in Ireland (and the only one before the Richmond Asylum) was that founded in Dublin by Swift, whose act would probably have been little known or forgotten, but for the familiar lines in which he himself has immortalized it:—

"He gave the little wealth he had To build a house for fools or mad, To show by one satiric touch No nation needed it so much."

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