The present position of the insane poor under private care in Scotland / by T. W. L. Spence.

  • Spence, T. W. L. (Thomas William Leisk), 1845-1923.
Date:
1902
    population of man)' hundred thousands. The business of the parish is managed in the case of all parishes small and great alike by a popularly elected body called the Parish Council, whose main duty consists in managing the affairs of the ordinary and the insane poor, except the insane poor provided for in asylums which are under the management of District Lunacy Boards. The principal executive officer of the Parish Council is the Inspector of Poor who, in addition to being the servant of the Parish Council, has certain independent statutory duties for the due performance of which he is personally responsible. Each parish has also one or more Parochial Medical Officers who have the medical oversight of the poor, sane and insane, within the parish and are the advisers of the Parish Concil in all medical matters. Parish Councils responsible for Inspection and Care of their Insane Poor in Private Dwellings wherever resident. Pauper lunatics in private dwellings are, subject to the inspection and control of the General Board of Lunacy, under the entire management of the Parish Councils of the parishes which pay for or contribute to their support. If they are not resident in the parish to which they belong, their immediate supervision may be entrusted to the officials of the parish of residence ; but the parish to which they are chargeable still remains primarily responsible for their due inspction and proper care. Insane Poor come on Board's Register of Insane in Private Dwellings (a) by being left at home on receiving relief; or (b) by being removed to Private Care from Asylums. By a general provision of the Lunacy Law of Scotland all pauper lunatics — that is, all persons certified to be insane by two medical practitioners, and on whose behalf any relief or assistance is given by a Parish Council — must be removed to the asylum serving the Lunacy District to which they belong, unless the Board shall sanction their disposal otherwise. It is this provision which brings the Board into official relations with all pauper lunatics under private care. The Board keep a register of such lunatics, the number upon which is added to in two ways. Firstly, persons duly certified insane and admitted by Parish Councils to be entitled to public relief may be exempted by the Board from removal to an asylum and provided for, with their sanction, under private care. Secondly, pauper lunatics in asylums, who are unrecovered, may be removed therefrom, by a resolution of the Parish Council of the parish which pays for their maintenance, and if their circumstances are such as to make it necessary that the parish should continue to provide for their support, they may be placed under the care of guardians in private
    dwellings, under conditions which must have the approval of the Board. When a resolution is passed Iry a Parish Council for the discharge of an unrecovered patient, the Superintendent may refuse discharge and appeal to the Board, if he thinks discharge would be injurious to the patient or a risk to the public. The Board then make enquiry, and either order discharge or confirm the Superintendent's refusal. Discharge is, however very rarely opposed by Superintendents, as Parish Councils have in most cases taken care to ascertain beforehand that persons whose discharge is desired may be removed with safety. If sanction to the residence of a patient under private care is not refused by the Board it is always given « until visited », and solely on the satisfactory nature of the medical and other evidence furnished to the Board in the documents on which sanction is applied for. The experience of the Board shows this to be sufficient. Majority of Insane Poor on Board's Register were formerly of the class left at home on relief being given : They now mainly consist of patients removed from Asylums. In 18S8, when the General Board entered on its functions, the great bulk of the insane poor found resident under private care had come upon the official roll in the former manner, that is, by being left in private dwellings upon admission to public relief ; and for more than twenty years after the General Board had been established, the annual additions to the register of pauper lunatics in private dwellings were mainly of that class. During the subsequent twenty years, however, a change occurred. The number annually admitted to relief and left under the care of their families increased to some extent during the second twenty years, as might be expected from the increasing population of the country ; but the increase of that class was far surpassed during the second twenty years by the number removed from asylums and placed under care in private dwellings. In the twenty years 1860-79 the class certified and left at home averaged nearly 80 persons in each year ; in the following twenty years, 1880-99, they averaged about 99 yearly. On the other hand, in the period 1860-79, the average annual number removed from asylums and provided for as pauper patients under private care was about 43 only, while in the period 1880-99 their number had risen to an average of about i52 annually. Thus, to put the point in other words, in the first twenty years those certified and left at home were about 84 per cent more numerous than those removed from asylums to private dwellings, whereas in the second twenty years the yearly additions to the register from the latter class had become about 53 per cent more numerous than the yearly additions from the former class.
    Most patients resided formerly with Relatives and were of the Imbecile type : The majority now reside with Strangers and suffer from Acquired Insanity. This change was associated with two other changes which arose from it. In i858, when the Board entered on its functions, three-fourths of the insane poor were under the care of relatives and only one-fourth were placed with unrelated guardians. Further, of all the insane poor then on the Board's register, it was estimated that about two-thirds were suffering from imbecility or idiocy, and one-third from various forms of acquired insanity. Twenty 3'ears afterwards, when the system of removing suitable patients from asylums to private care began to be developed, the condi- tions above referred to were reversed. At the present time the number of the insane poor boarded with strangers far exceeds the number boarded with relatives, while the patients in private dwellings labouring under acquired insanity are now probably more numerous than imbeciles and idiots. Misunderstanding of term « Boarded-out n : Board's Rules and Requirements alike for all Insane Poor, whether removed from Asylums or otherwise. The increased prominence given in more recent years to the removal of pauper lunatics from asylums to private care has led to the system followed in Scotland, of giving relief to the insane poor in private dwellings being sometimes spoken as a system of « boarding out i>, the word « out » conveying the impression that the essence of the method lies in removing patients from asylums. This however never was and is not now the essential feature of the method, which does not concern itself with the question of whether a patient has been removed from an asylum, or has never been an inmate of an asylum, further than to make a record of the fact as part of the patient's history. What the system aims at and attains is that no insane person in Scotland who receives parochial relief while under private care shall receive such relief unless under conditions prescribed by the State through the Board, and under governmental inspection ensuring the fulfilment of these conditions. It is the broad sweep of this principle, which is a fully applicable to the wealthiest and most populous and busy centres of life in Scotland as to the poorest and most remote parts, which really distinguishes the Scottish method from that followed in other countries. Condition of Insane Poor in Scotland prior to Establishment of Board : Sir Arthur Mitchell's « Insane in Private Dwellings ». Before going further on this subject, it will be advisable to touch briefly upon the history of the system as now consolidated in Scotland.
    The Report of the Royal Commission of iS55 showed that there was an ample field and urgent need for improving the condition of the insane poor under private care ; and when the General Board was established in i857 two medical officers were attached to it as Deputy Commissioners in Lunacy, whose chief duties were to visit all the insane poor under private care in Scotland and to inform and advise the Board as to the steps which should be taken in regard to them. One of the two Deputy Commissioners first appointed was Dr. Arthur Mitchell, afterwards Sir Arthur Mitchell, K. C. B., Commissioner in Lunacy. After six years experience of this work throughout Scotland, Sir Arthur Mitchell published a book on the subject entitled « The Insane in Private Dwellings » (i) which shows that within five }'ears frbm the institution of the Board the system of caring privately for the insane had been esta- blished upon the firm and satisfactory basis on which it now stands. This was accomplished merely by working upon the mass of insane material already found under private care, removing to asylums those clearly requiring that mode of care, improving the condition of those not needing such care, and providing securities for all against the occurrence of unsa- tisfactory features in their mode of treatment. This book contains many painful pictures of the extreme misery and neglect which was found among the insane cared for at home. These cases were not confined to the pauper insane. They were as frequently met with in as painful forms among the poor of the community who were receiving no public relief; and sometimes even in families possessed of a certain rough affluence. Terrible as are the details of the extreme misery to which these insane persons had been brought, it may well be doubted whether cruelty or inhumanity had anything to do with it. Sometimes it was probably the result of pride which recoiled at the idea of asking public relief; some- times because such relief, if asked for, would not have been given ; often it seems to have been the outcome of silent, helpless, despair in the face of a calamity which the famil}- neither had the knowledge nor the means to contend with ; so that in reading of such cases one hardly knows whether to feel most for the wretched sufferer himself or for the sane members of his family to whom his presence was a veritable curse : and alter all, the picture drawn of the worst of these cases is not in any respect more painful than the pictures descriptive of the condition of the insane in asylums in the most enlightened parts of Great Britain, not much more than forty years earlier (2). In both cases ignorance and not inhumanity was at the root of the evil. (1) Edinburgh, Edmonston and Douglas, 1864. (2) Browne on Lunatic Asylums 1837, p. i32, quoted on page 74 of Sir Arthur Mitchell's Book.
    Picture of their condition had a bad side; but also an instructive and good side. But it must not be supposed that these pictures of wretchedness and neglect were descriptive of the general condition of the insane under private care when they were first visited by the Board's officers. Sir Arthur Mitchell expressly states that he is illustrating the dark aspect of their condition, and he gives many and convincing reasons showing the necessity for drawing this dark picture. But he warns the reader against thinking that this picture represents the condition of the whole class. He does this not once nor twice, but again and again, and with great emphasis. To quote only one passage, Sir Arthur, after a warning of the kind indicated; proceeds : « There is, however, another side of the picture, » and this exhibits not merely a negation of evil but is a picture of a » highly satisfactory and instructive character. In actual fact a very » considerable proportion of the insane in private dwellings were found )) to be well-treated, and the instances were numerous in which we » encountered the most pleasing illustrations of self-sacrifice and devotion, » of affection and good feeling, of kind and judicious management, of » cleanliness and comfort, of happiness and content. » Comparatively few changes needed to establish the System upon a satisfactory basis. In point of fact of 207S original applications to the Board to dispense with removal to asylums of pauper lunatics then provided for in family, only 167 were refused and removal to asylums ordered. Of the patients to whom these refusals referred only 56 were at once ordered to be removed to asylums. Others were eventually so removed, but only after efforts had been made without success, to improve the arrangements for their care at home. In several hundred cases sanction was given to home care only on condition of various improvements being effected, and the improvements stipulated for were duly carried out. The ease in attaining these impro- vements in the home care of the insane, and the observation of the immense mental and bodily changes for the better which followed, were lessons which were not lost. « Through these forced efforts », says Sir Arthur Mitchell, « to ameliorate the condition of the insane at home a i) good thing was accomplished, for in many instances they were » attended with complete success, and thus a fuller experience was » obtained of the extent to which the insane can be provided for in )) private dwellings (1) ».