Extracts an analysis of the 1881 Report of The General Board of Commissioners in Lunacy for Scotland made in the Journal of Mental Science in January 1882, included in chapter 9 (Scotland) of Chapters in the History of the Insane in the British Isles

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 desirip 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 m 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, anc 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 asylun 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 fenceSj 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:-

The efforts of medical officers of institutions to discharge chronic lunatics whom they consider suitable for being cared for in private dwellings.

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.

The amount and accessibility of asylum accommodation in each district.

The rate of maintenance in asylums.

The supply of suitable guardians.

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 three-fold:

1. they may initiate the removal of their chronic insane from institutions;

2. they may co-operate with asylum officers in readily removing such lunatics as these officers intimate to be fit for being boarded out, and in procuring suitable guardians and homes for them ; and

3. they may, by well-directed efforts, instead of hurrying every lunatic into an asylum, as the practice with some is, provide in like manner for those idiotic and insane paupers who, even when they first become chargeable, do not require asylum treatment and care. . . .

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

The Amount and Accessibility of Asylum Accommodation in each District

It has now become a matter of everyday observation, that where there is ample asylum accommodation the boarding out of the insane is either entirely neglected or avoided, or but languidly attempted. . . .

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

The Rate of Maintenance in Asylums.

In Dumfriesshire, where special 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. .

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