In the practical working of the Mental Deficiency Act the Board require to consider from time to time the question of discharge of a defective to home care, or to the care of an unrelated guardian.

The question of discharge is usually raised by the parents or by the relatives of the defective, on the ground that if allowed home some outdoor work could be found for him, or in the case of a girl that she could assist in the household duties or go to domestic service.

In considering an application for discharge it is the general practice of the Board to obtain from the Medical Superintendent of the Certified Institution in which the patient is resident a report as to his mental and physical condition and fitness for discharge to home or other care as the case may be.

Frequently this report shows that the defective has made progress under Institutional training and that he might be discharged to a good home under proper supervision, and employed in some form of suitable work.

Where the medical report is satisfactory the Board invariably call also for a report upon the home conditions and if that is also favourable the defective is usually discharged to home care.

If there is the slightest doubt as to the suitability of the home conditions, further inquiries may be made by one of the Board's Commissioners which may result in a recommendation that before issuing an Order for Discharge the defective's suitability to reside out of an institution should be tested by allowing him to leave the institution on licence for a period of three months. This expedient has proved very useful, and has frequently shown that the defective was not fit for discharge, or that the home conditions were not satisfactory in which case the patient has been returned to the Institution either during or at the expiry of the period of trial. In this way the necessity of fresh certification is obviated.

Each case is dealt with on its merits, but there are many instances where the history and the mental and physical condition of the patient render it undesirable that he should be dealt with outside an Institution.

It is important to repeat that no defective is ordered to be permanently detained in an Institution. As has been explained, all cases must be reviewed either annually or at intervals of three years, and in addition many cases are reviewed from time to time when the question of discharge is raised.

The outstanding feature with regard to Lunacy is the increasing tendency to have certification reduced to the minimum required by legal and social circumstances and to give all persons suffering from mental disorder in its early stages, or in a temporary form, the advantages to be obtained in Observation Wards or as voluntary inmates of Asylums.

The benefits conferred by the several Observation Wards throughout Scotland with regard to the treatment of early and temporary cases have been commented upon in several of our previous Annual Reports.

It is noted with interest that several of the Royal Asylums have established Nursing Homes for private patients and one proposes to set up a Dispensary and Clinic for the early treatment of those suffering from temporary mental disorders.

In Asylums generally there has been an increased use of physical means of treatment such as artificial and natural light treatment of various kinds and hydro-therapy. These have proved advantageous especially when given under the personal observation of the medical staff, and prescribed by the Medical Officers in the same way as drugs are prescribed. The extension of the use of Occupational Therapy in many Institutions has also been of noticeable benefit to many individual patients and the improvement recorded in their mental states has been noteworthy.

In 1864 while acting as Deputy Commissioner in Lunacy, Dr. Mitchell (afterwards Sir Arthur Mitchell) published a treatise on the subject of the insane in private dwellings. The deplorable surroundings of many of these patients were disclosed and an account was given of the endeavours made by the Board to meet the whole situation.

The treatise in question served a further purpose in showing in what directions and to what extent the insane could have proper care and treatment in private dwellings. It also indicated the type of patient specially suited for residence in private houses, and laid stress on the fact that this method of family care is an excellent means of preventing the accumulation of chronic cases in Asylums and at the same time providing for such patients humanely and economically.

Measures to improve the condition of the indigent insane in private dwellings were at once adopted. They consisted mainly in making arrangements for their supervision and visitation by Inspectors of Poor, local Medical Officers, and Deputy Commissioners of the then General Board of Lunacy, while the duties of guardians were defined and regulations were drawn up for their guidance and the system now known as "Boarding-out" was successfully inaugurated.

The system of dealing with the insane in private dwellings also found favour for economic reasons, and the numbers of boarded-out patients steadily increased. It was found much less costly to board out quiet, harmless and incurable cases of mental disease, who were not likely to benefit from further care and treatment in Asylums. Incidentally, it may be noted that patients are generally found to be better cared for with unrelated guardians than with their own relatives.

It is an essential part of the boarding-out scheme that, no matter how poor the home in which the patients are placed, they must share the home life and under no circumstances be treated as domestics or outdoor servants, and there is ample testimony to the fact that the conditions of life under private guardianship are much appreciated especially by patients who have resided for many years in Asylums.

The history of the insane in private dwellings-- the "boarded-out"was progressive until the year 1914 when the number on the Roll was 2,858. During the Great War the numbers fell each succeeding year until in 1919 there were 2,138 boarded-out patients, and the decrease has continued, though not so markedly, until the end of the present year when the number was 1,638.

This diminution in the number of boarded-out patients may be readily accounted for. In the first place, the Mental Deficiency and Lunacy (Scotland) Act, which came into operation in 1914, had the effect of removing a large number of patients from the Register of lunatics to that of mental defectives.

The term "imbecile," though not included in the definition of "lunatic" could be applied to a large number of lunatics of all ages and there were in fact on the Lunacy Registers many congenital imbeciles, i.e., persons showing congenital mental defect to a lesser degree than those to whom the term "idiot" could properly be applied.

Such cases are still to be found as certified lunatics in all the establishments for the insane and in large numbers under private care, but since 1914 many of them have been transferred to the Register of mental defectives, the general tendency now being to certify all such persons under the Mental Deficiency Act. The inducement to do this (an inducement largely in abeyance at the present time owing to financial stringencies) is the fact that 50 per cent. of the net approved cost of certified rate-aided mental defectives is met by a grant from Treasury funds, whereas the Lunacy Grant, which has fallen to the sum of 2s. 8d. per week for each certified lunatic, is roughly less than 15 per cent. of their total cost. In consequence, the number of defectives in private dwellings has gradually increased from 88 in 1915 to 1,015 in 1926. If this number be added to the number of lunatics in private dwellings, the total is 2,653 which is 205 fewer than there were in private dwellings in 1914.

The decrease in the total number of boarded-out lunatics has therefore been greater than the increase in the number of certified defectives placed in private dwellings so that the working of the Mental Deficiency Act is not wholly accountable for the fall in the numbers of lunatics in private dwellings since 1914.

There is, however, another contributing factor in that conditions of living were greatly affected as the result of the Great War. In the cities the cost of living prevented guardians from accepting patients at relatively low rates of board, and in the country districts the rise in the value of agricultural produce and the increased wages resulted in a higher standard of living, and relieved many guardians of the necessity of taking in patients whose board might add to the household income.

These circumstances were not peculiar to Scotland. In a Report of a visit to French Asylums, issued as an Appendix to our Annual Report for 1923, one of our colleagues referred to the same conditions existing in France as affecting the number of patients boarded-out with private guardians in that country. Now that the effects of the War are passing, and the temporary impediments to boarding-out have been removed, the Board are confident that Inspectors of Poor and all concerned with Lunacy administration will again find it economical to board-out suitable patients in increasing numbers. This would not only prevent the accumulation of quiet and harmless patients in Institutions, some of which are at present overcrowded, but would add to the efficiency of the care and treatment of all classes of patients in these Institutions. The practice of retaining in Asylums patients who have become suitable for boarding-out is detrimental to other patients in the Institution as it tends to hinder the education and training of others who might become good working patients.

I.-NUMBER AND DISTRIBUTION OF THE INSANE AT 1ST JANUARY, 1927.

On 1st January of the present year, exclusive of insane persons maintained at home by their natural guardians, there were in Scotland 18,580 insane persons, of whom we had official cognisance, including the inmates of Training Schools for Imbecile Children who have not been certified under the Mental Deficiency Act and of the Criminal Lunatic Department of Perth Prison. Of these 2,972 were maintained from private sources, 15,540 by parochial rates, and 68 at the expense of the State. As the total number at 1st January, 1926, was 18,537, an increase of 43 has taken place during the past year.

The following table shows the number and distribution of the insane of each sex in the different classes of establishments and in private dwellings at 1st January, 1927, distinguishing between private and pauper patients :

,, Private Asylums

...

In addition to these there were 751 Inmates certified under the Mental Deficiency Act. † Greenock Parochial Asylum is now the only Asylum of this class.

The general results during 1926, as compared with 1925, are, in regard to registered* lunaties, as follows: (1) There was a total increase of 46, due to a decrease of private patients by 41, and an increase of pauper patients by 87. (2) The total increase of 46 resulted from an increase of the number in establishments by 104, and a decrease of the number in private dwellings by 58. (3) The increased number of 104 in establishments arose from a decrease of 36 private patients and an increase of 140 pauper patients.

CHANGES FROM THE PAUPER TO THE PRIVATE CLASS,
AND vice versa.

It must be kept in view, in connection with the statistical tables giving the number of lunatics classified into private and pauper patients, that each patient does not necessarily continue till his discharge in the class to which he belonged on being placed on the Board's register. The results shown depend partly on the number of persons who, while continuing on the Board's register, cease to be private patients and become paupers, and vice versa.

II. STATISTICS OF ESTABLISHMENTS FOR LUNATICS. (See Tables on Pages 1 to 12 of Appendix to Report.)

ADMISSIONS TO ESTABLISHMENTS.

(1) Admissions directly under a Sheriff's Order † the sanction of the Board or other Statutory Authority.

In arriving at the number of persons admitted to establishments who thereby add to the gross number of asylum patients, the number of admissions which refer to a mere transfer from one establishment to another must be deducted.

(a) The total number of patients admitted to establishments (excluding transfers) during 1926 was 3,035, which is 145 less than in the previous year, and 591 less than the average for the quinquennium 1920-24.

(b) The number of private patients admitted last year was 440, which is 41 less than in the preceding year, and 171 less than the average for the quinquennium 1920-24. The pauper patients admitted to establishments numbered 2,595, which is 104 less than in the preceding year, and 420 less than the average for the quinquennium 1920-24.

The number of patients who had never previously been registered, and who were admitted for the first time to establishments for the insane in Scotland during 1926 was 2,304-370 private patients and 1,934 pauper patients.

The number of private patients admitted for the first time is 49 less than in the preceding year. The number of pauper patients who had never previously been registered is 41 less than in 1925.

*The Inmates of Training Schools for Imbeciles and of the Criminal Lunatic Department of Perth Prison are recorded in separate books, and, not being on the Board's General Register of Lunatics, are not included in this statement.

† NOTE-Detention in an Asylum can only be by Order of the Sheriff or of the Secretary of State.