A SCOTCH INSANE ASYLUM. [Reprinted from The Boston Medical and Surgical Journal, August 12, 1875.] A SCOTCH IHSAHE ASYLUM. Messrs. Editors, It was my privilege, about a year ago, to spend a day with Dr. Fraser at his asylum, and it seemed to me that he had made his real treatment of mental disease so fully correspond with the best ideal treatment (which consists in treating disease of the mind, as far as possible, like any other disease) that I asked him to favor the profession here with a statement of his methods. I confess I feared that a description, in my own words, of what I saw would be looked upon as somewhat wild. Dr. Fraser’s letter is so full of interesting and suggestive points that I send it to you entire. Although this is looked upon still as an experiment, its success is established, and it cannot fail to have a great influence on the treatment of mental disease throughout the world. In fact, it is likely to be classed with those great movements of Pinel and Tuke toward the close of the last, and of Conolly and Griesinger about the middle of the present century. Of course accurate diagnosis, faithful study of character, 'trained nurses as well as trustworthy at- tendants, and constant care are needed. If Dr. Fraser had described his autopsy and microscope rooms, it would have been seen that he considered careful pathological research of the utmost importance. Herbert Spencer quotes Dr. Tuke as having said of this asylum in 1872 that in ninety-five per cent, of the patients the policy of unlocked doors was successful. How ap- propriately the wox-ds “ The more you trust, the more you may ” come from a countryman of Romilly, Dr, Arnold, and Maconochie ! The history of the treatment of mental disease for the past century has been a succession of proofs that all efforts to bring elevating and refining influences to bear upon the insane, and to educate their self-respect and self-control, have been followed by the most beneficent results. Great Britain stands unquestionably at the present day at the head of the nations of the world in these respects. Very respectfully yours, Charles F. Folsom. Fife and Kinross District Lunatic Asylum, ) Cupar, Fife, Scotland, January 28,1875. ) My dear Sir, I have the greatest possible pleasure in acceding to your request for a description of my asylum. It is the district or pauper asylum for the counties of Fife and Kinross. The population of the two counties is one hundred and seventy thousand. The institution is capable of holding two hundred and eighty inmates. The present numbers are, one hundred and ten males and one hundred and thirty- eight females, or about two hundred and fifty altogether. The yearly admis- 2 A Scotch Insane Asylum. sions are from eighty to ninety. There is one attendant for every twelve pa- tients. The patients are classified and each class has its own gallery; the highest number in any gallery is twenty-four, the lowest twelve. The female department has seven galleries, each complete in itself; that is to say, each of them has its own day-room, dormitory or dormitories, single sleeping-rooms, lavatory, and conveniences. Four have two attendants, two only one. This divisional arrangement, though I believe it adds to the working expenses, admits, as I have said above, of classification of the patients. The day-rooms or sitting-rooms for twenty-three patients are thirty feet long, twenty-one feet broad, and eleven and a half feet high. The windows of these rooms are nine feet by seven feet, and the panes are twenty-two inches by eighteen. There are no window panes smaller than twelve inches by ten and a half anywhere. The lower half of the windows has brass rods three eighths of an inch thick running transversely across the panes and through the wood-work of the win- dow-frame. I could wrench these x’ods out with my hands. There is no such thing as an iron bar across a window, and all our window-frames are of wood. You ask me for the features which distinguish my asylum. I believe these to be, Ist, unlocked doors; 2d, the great amount of general freedom; and 3d, the large number on parole. In common with the Argyllshire asylum, airing courts are not in use. The great attention given to the occupation of the patients and the large percentage of those employed are characteristics of this asylum as well as of two others in Scotland. First, as regards open doors. Here is a paragraph from my last annual report:— “ I wish now to describe the peculiar feature of your asylum, namely, the open-door system. It was originated about three years ago by your former physician superintendent, Dr. Tuke, and I have no hesitation in saying that the introduction of this system will mark an era in the history of the treat- ment of the insane. As you are well aware, there are no high boundary walls surrounding the grounds, and the entrance gates stand always open. To make this system as clear as possible, let me suppose that a visitor calls and wishes to see through the asylum. He is received at the front door, which will be found open; he is then conducted through the whole of the male gal- leries, containing over ninety patients, and thence, via the dining-hall, through five of the galleries in the female side, also containing over ninety patients, without once coming upon a locked door. Not only is there this free commu- nication inside the house, but the outer doors of the main ground corridors, which open out on the terraces, are also unlocked. The male convalescent building, which contains from twenty to twenty-five patients, has its doors open from shortly after six A. M. till eight p. M. The inmates are, of course, on parole. Two galleries in the female department still remain under the old system of locked doors. Though not necessary for the majority of their in- mates, yet the erratic and mischievous tendencies, as well as the excitement of some three or more in each division, render locked doors necessary. “ Greater contentment is, I believe, the result of the innovation I have just referred to ; the sense of confinement, or in other words, of imprisonment, of which even a lunatic is conscious, is absent. The asylum is converted into a home and a hospital. A Scotch Insane Asylum. 3 “ A greater number of escapes and accidents would a priori be expected from this state of freedom. The escapes have been nine in number, and there are oidy two which can be attributed to open doors. Four accidents, none of any import, except the suicide previously detailed, have occurred during the year, but none in any way attributable to this system.” This bold advancement in the treatment of the insane is, as I have said above, wholly due to Dr. Batty Tuke. It is to his original mind, to his enter- prising spirit, to his confidence in a portion of afflicted humanity hitherto un- confided in, and to his faith in the adage “ The more you trust, the more you may,” that this new era in the life of the insane has been initiated. I must confess I shook my head when the doctor first proposed it, and our matron said she could not see “ how it would do at all.” The history of this movement is interesting. At first a great deal of wan- dering about the house occurred, especially from the galleries to the kitchen. A number wandered outside, and some of course attempted escape. Gradually the patients were taught when they were to go out, and what parts of the house they were permitted to visit. Those who escaped were spoken to in presence of the others : they were informed of the inutility of escaping, of the certainty of their being brought back; that they must remain in the asylum until they were better, that every kindness would be shown them, that everything they had to say would be heard and attended to ; that when the time came they would go out by the front door, and that the doctor would be there to say good-by and wish them well. It was wonderful how the most determined bolters ceased from attempting to escape. I could quote a dozen cases where a remarkable change in this respect occurred. The most intelligent escapers were taken to the doors, shown their openness, and then informed that confidence was reposed in them, that escape was unproductive of any good, and that the way to get home was to show themselves worthy of trust. Not only Avith permanent residents did this state of imposed confidence have a beneficial effect, but also with trans- fers from other asylums. For example, a lady patient was admitted some time ago from another asylum. The account sent was that she was most de- termined in her attempts at escape, that she had broken the framework of her window and set fire to doors in order to escape. Her habits were said to be dirty. It was a case of moral insanity, and the intelligence was keen and clear. After admission, she was shown the open doors (one leading out to the terrace within ten yards of her sitting-room) and the freedom that existed. Confidence was preached to her and she was informed that good behavior of every kind was expected of her. She now walks out daily on the terraces, unattended whenever she likes, yet there has never been the least attempt at escape. She has never been dirty in her habits. This patient has been in three other Scotch asylums, and she says that this is not like an asylum at all, that it is unlike any of the others she has been in, and that here she has no desire to runaway. Your experience of the insane will cause you no doubt to say, “ But all can- not be treated in this wise.” I grant that, but what I wish to impress upon you is the great number that can. You will see I have two departments on the female side under the old regime. An attempt was made to leave one of these off the lock, but the mischievous doings of three chronic maniacs, and the 4 A Scotch Insane Asylum. incurable wanderings of two or three demented and suicidal patients, prevented the open door from being persevered in. Excepting these, the rest, number- ing from one to eighteen, would be all the better for the unlocked doors. The other department is one of our new buildings and is separate. From its situa- tion and its inhabitants, chiefly chronic maniacs, it would be inexpedient to attempt the step there. I wish especially to describe our male convalescent building. It is a house capable of holding thirty-three patients, but at present there are only twenty-two resident there. Its doors are open every day from seven in the morning till eight and nine in the evening. The inmates are all on parole. No one has broken his parole during the last two and a half years. An attendant and his wife have charge of the place. They have a little child five years of age. They all sit down to meals together, the patients, the attendant, his wife and child. The latter two mix with the patients at all times. This was also a step of Dr. Tuke’s, and admirable have been the results. When men associate only with each other, they are apt to degenerate ; coarseness, swearing, and fighting predominate ; but when a woman is present, and especially when a sweet little girl mingles with them, then swearing and angry passions cease; at least such has been the effect in this department of my asylum. There are two dormi- tories up-stairs, one in which no attendant sleeps (ten patients are left to them- selves), and the other is in charge of an attendant who comes down from the main building for the night. This place is our Gheel. I believe that the conditions above described, coupled with constant occupa- tion, residt in (1) greater contentment and general happiness among the pa- tients, (2) better conduct in every one, i. e., less excitement, (3) the preserva- tion of the individuality of each patient, (4) less degradation, and (5) greater vigilance and care on the part of the attendants. As regards the fourth result, I believe it to be strikingly true. Our degraded patients are importations ; few, if any, are indigenous. 1 never allow any sitting on floors or crouching in corners like cats or dogs. It takes a long time to cure many of this habit; but of course, as you know, the insane take from four to six times longer than ordinary people to be taught anything. Occupation is what I have the utmost confidence in. Its results are most beneficial. Almost every male patient can fill and wheel a barrow, and the majority can use a spade. So almost every female patient can use a needle and thread or a knitting needle. Constant supervision soon teaches one what is most suitable to each, I beg to refer you to Sir James Coxe’s report, which you will find in the annual report which accompanies this letter. Here is another paragraph from my last annual report: “ Attention is being constantly and increasingly directed towards the occupation of both sexes. At the pres- ent date, all male patients, with the exception of from five to eight, are sent out every day in parties arranged according to their capabilities for work. Attendants accompany each set of workers. The head and sick-room attend- ants are the only ones retained in the house. On the female side there are three work-rooms, one devoted to the main sewing requirements of the house, and the others to the teaching and encouraging to work of the idle and de- mented. In these three rooms are above ninety patients. The laundry, the A Scotch Insane Asylum. 5 kitchen, and the house generally give employment to about forty more, so that the actually idle are reduced to a minimum. My desire and aim is to make your asylum a veritable bee-hive. The men work both forenoon and afternoon, but their hours are not long. The females, though kept at work in the fore- noon, spend the afternoon in walking and out-door recreation. lam at present dispensing with the use of airing courts, but I shall make no comment on this step until after a year’s experience.” Airing courts are a mistake, especially for females. Not long ago I used to send out the demented, the chronic maniacs, and the idle to the airing court of a morning. Of course, having nothing useful to do there, they did mischief, quarreling among themselves, getting excited, and increasing their destructive habits. The patients being safe within four walls and out of sight, the attend- ants were heedless, habits and practices occurred which the attendants for the sake of decency and for the respect of their sex would have been active and vigilant to prevent elsewhere. Those who used to go to the airing court in the morning are now collected around tables and set to work at knitting, sew- ing, darning, etc. The contrast between the airing court and this room is very striking. This very morning this work-room was quiet in the extreme. I went round them all, spoke to each, praised their doings, and encouraged the idle, and there was not a word out of place. Had they been in the airing court they would have squatting in all the corners, rampaging about, holding forth in loud tones, etc. Occupation and the working together in the way described have a most decided inhibitory effect. The airing-court system permits every insane propensity to run to weeds. You ask me to tell you about the treatment of the patients. Let me in com- plying with this request describe the plan of treatment I adopt in case of acute mania immediately after admission. It is much the same as Conolly’s, which is described by him in his work on The Treatment of Insane, at pages 43 and 47. A warm bath is first given ; then the patient is put to bed in the padded room •, food is offered, and every plan is adopted to coax the patient to partake of it voluntarily. I often find feeding by the opposite sex succeed when an attempt by one of the patient’s own sex fails. Should food be refused, I have no hesitation in using the pump. The first two nights I give chloral, as it is my firm conviction that it is our positive duty to procure sleep as soon as possible. My idea is, the longer mania is allowed to go on, the greater risk there is of subsequent dementia. If sleep obtained by chloral cuts it short, what can be said against it ? I have tried both methods, the let-alone one and the treatment by sedatives (chiefly chloral and bromide) or medicinal treatment generally. As a medical man, as a student of clinical medicine and of therapeutics, and as one who hopes that careful investigation, physiological, pathological, and therapeutical, will erelong reveal a method of treatment whereby all cases of acute mania will be cured, I much prefer the latter course. I think precious little of the superintendent who can stand idly by and see a case of acute mania running on in its mad career day after day. What is such a superintendent’s raison d’etre ? Food! Food ! is such an one’s cry, but it is my experience that food will not subdue one case of acute mania in twenty. 6 A Scotch Insane Asylum. In one or two hours after the chloral and feeding, the patient gener- ally sleeps, and if next morning the excitement returns, I seclude for the day. I deem this seclusion most wise, in fact imperative to meet the requirements of the patient’s mental condition. Chloral is given again the second night and perhaps the third night; and by the third day the patient is generally quiet or disposed to keep in bed, and so avoid seclusion. The appetite is keen after chloral, so there is little trouble With food after the first dose. I have pur- sued this plan for the last two years and with the most decided success. When the patient is removed from the bedroom, the sick-hall is the next resort. Here there is quietness and every comfort, and the whole surround- ings inhibit any tendency to excitement. I seclude in epileptic mania and in paroxysms of impulsive, aggressive, and destructive mania* I have two very bad cases of the former and three of the latter. This is another paragraph, containing my opinion in regard to seclu- sion : “ Seclusion has on several occasions been resorted to by me. My present opinion is that it is the most humane, beneficial, and wise course of action under certain circumstances. During the present year there have been two or three cases subject to paroxysms of great excitement. I have occa- sionally been present in the galleries when such outbursts have occurred, and have been witness of how the peace, quietude, and industry of the other in- mates have been disturbed, and the exoitable roused. Great destructive pro- pensity is generally a feature of these attacks. In such cases, one of two things must be done: the patient must either be restrained by two or more attendants (the worst form of restraint), or put into seclusion. The former plan cannot be carried out where there is a minimum staff, but even had I sufficient at my command, I believe seclusion to be the more beneficial mode of treatment in every way. There are cases, at least this asylum possesses such, in which great coarseness of language characterizes the paroxysms; and I maintain that such cases, in consideration of the feelings of the other inmates and attendants, demand their temporary seclusion. Constant supervision of the galleries has determined me in this opinion. Restraint I have not resorted to.” As regards the chronic harmless insane, I here subjoin another extract from my report: “It is my opinion that many chronic lunatics do not re- quire asylum treatment; they can be sufficiently cared for and guarded by their friends or others whom the proper authorities deem fit custodians. The chronic lunatic I refer to is one who is harmless, trained to be cleanly and perhaps industrious, whose mental condition may be described as that of a premature second childhood, and of whose recovery no hope can be enter- tained. Such an one does not require constant medical supervision, the ex- pensive appurtenances of an asylum, nor the services of trained attendants. The proposed method of administering the grant from the Imperial Exchequer cannot fail to cause asylums to be crowded with such lunatics.” Dr. Arthur Mitchell’s book on the Insane in private dwellings will give you a most graphic account of what formerly existed and what exists at the present day. I trust the foregoing remarks convey the information you desire, and I A Scotch Insane Asylum. 7 shall be only too happy to answer any farther inquiries you may wish to make. If any of my professional brethren on your side of the water desire to see this asylum, they will find me a most willing cicerone. With best regards, I am dear sir, Yours most truly, John Fraser. Dk. Charles P. Folsom, Boston.