Chapters in the History of the Insane in the British Isles

by Daniel Hack Tuke

"'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.