L I B RARY 
 
 OF THE 
 
 UNIVEI^SITY 
 
 or ILLINOIS
 
 

 
 / 
 
 THE 
 
 CARE AND TREATMENT 
 
 INSANE POOR.
 
 f;r!/;r:v 
 
 THE CARE AND TREATMENT OF THK 
 INSANE POOU: 
 
 THE PRESIDENT'S ADDRESS 
 
 BEAD AT THE 
 
 ANNUAL MEETINa 
 
 THE MEDICO-PSYCHOLOGICAL ASSOCIATION 
 
 {Held at the Royal College of Phi/sicians, Jtdy 31, 1867.) 
 
 BY 
 
 0. LOCKHAKT ROBEKTSON, M.D. Cantab., 
 
 IFEBICAL SUPEEINTKNDENT OF THE SUSSEX LUNATIC ASYLUM, HAYWAEP'S HEATH; 
 
 MEMBRE ASSOCIE ETBANGEK DE LA SOCIETE MEDICO-PSYCHOIOGIQUE 
 
 DE PARIS ; ETC. ETC. 
 
 Insane persons me everywhere regarded as proper objects of the care of the State. — 
 John Stnart Mill. 
 
 Our present business is to affirm tliat Poor Lunatics ought to be maintained at the PubUc 
 Charge. I entertain, myself, a very derided opinion that none of any class should bi- received 
 for profit; but all I hope will agree that Paupers at any rate should not be the objects of 
 financial speculation. — Lord A.ihley. (Speech m the House of Commons. 6th .lune, 184.5.) 
 
 LONDON : 
 PRINTED BY J. E. ADLAED, 
 
 BARTHOLOMEW CLOSE. 
 
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 THE 
 
 CARE AND TREATMENT 
 
 INSANE POOR. 
 
 " Insane persons are everywhere regarded as proper objects of the care of the 
 Stute."— John Stuart Mill. 
 
 " Our present business is to affirm that Poor Lunatics ought to be maintained 
 at the Public Charge. I entertain, myself, a very decided opinion that none of 
 any class should be received for jirofit ; but all I hope will agree that Paupers at 
 any rate should not be the objects of financial speculation." — Lord Ashley. 
 (Speech in the House of Commons, 6th June, 1845.) 
 
 Among the many social problems included in the domain of 
 Medico-Psychology there is none of more importance, or more inti- 
 mately related to the duties of the community, than that of the Care 
 and Treatment of the Insane Poor. At this time, moreover, it is 
 the subject of much discussion in the general and medical press. 
 I do not therefore think, that I shall otherwise than meet with your 
 approval, if I use this present opportunity, which I owe to your 
 favour, to review the several relations of this grave social question. 
 
 In England our existing arrangements are only of twenty years' 
 standing, and owe their origin, as you are all awai'e, to the intro- 
 duction into the House of Commons by the Earl of Shaftesbury 
 (then Lord Ashley) of the Lunacy Act, 1845, which transferred to 
 the present Lunacy Commission the supervision of the insane poor 
 throughout England and Wales.
 
 6 The Care and Trtainieiil of lite Lnsaiie Poor ; 
 
 The condition of tliese patients previous to the passing of the 
 Lunacy Act, 184'5, is detailed in the 'Report of the Metropolitan 
 Commissioners in Luuac//' (1844), who had for the first time been 
 authorised by the 5 & 6 Vic, c. 87, to inspect the condition of the 
 various pubhc and private asylums throughout England and 
 Wales.* 
 
 It is not within my present purpose to relate again the tales of 
 misery and neglect recorded in this official report. Suffice it, that 
 their investigations enabled the MetropoHtan Commissioners to 
 make those suggestions for the amendment of the law, which were 
 embodied in the Lunacy Act, 1845, and form the basis of our 
 present arrangements for the care and treatment of the insane poor. 
 
 The leading principle asserted in the Lunacy Act, 1845, as it 
 relates to the care and treatment of the insane poor, is, that the 
 permissive power to justices given by the 48 Geo. Ill, c. 96, to 
 build county asylums, and which led to the erection of the seven 
 asylums for Nottingham, Bedford, Norfolk, Lancaster, Stafford, 
 Cornwall, and Gloucester, containing in all only 1500 beds, should 
 be compulsory, and that each county in England and Wales should 
 under the authority of the Quarter Sessions be compelled to make 
 provision for the care and treatment of its insane poor. Another 
 principle was, that the whole detail of these arrangements should 
 be controlled by the Justices of the County under the general super- 
 vision of the Commissioners in Lunacy. The medical character of 
 these asylums, as hospitals for the cure of mental disease, was for the 
 first time formally asserted, in their being placed under the govern- 
 ment of a resident medical superintendent. The subsequent Lunacy 
 Acts, relating to the care and treatment of the insane poor, which 
 
 * The following was the mnnher of pauper lunatics chargeable iu August, 
 1843, with their place of maiuter.auoe : — 
 
 MALE. FEMALE. TOTAL. 
 
 In County Asylums 1,670 1,855 3,525 
 
 In Licensed Houses 1,059 1,239 2,298 
 
 In Workhouses 1,813 2,250 4,063 
 
 In Private Dwellings 2,204 2,702 4,906 
 
 Total 5,746 8,046 14,792 
 
 Population of England and Wales (estimated) 16,000,000 
 
 Number of Pauper Lunatics and Idiots to ropulalion, 1 in 1066
 
 ly Dr. C. Lockhart Robertson. 7 
 
 have been passed^ viz. the 'Lunatic Asylums^ Act, 1853/ and the 
 ' Lunacy Acts' Amendment Act, 1862/ are simply amplified details of 
 these principles. The time has now arrived when these legal enact- 
 ments might most wisely be consolidated into one intelligible statute. 
 
 The following table shows the number of pauper lunatics and 
 idiots chargeable in England and Wales at the decenniums 1847, 
 1857, and 1867 :—
 
 The Care and Treatment of the Insane Poor ; 
 
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 55
 
 ly De,. C. Lockhart Robertson. 
 
 9 
 
 I purpose to-dav, to offer a few remarks for your consideration, on 
 the care and treatment of the insane poor in the three pLices of 
 maintenance in which we now find them, viz. : — 
 
 I. The Insane Poor in Public Asylums. 
 II. T/ie Insane Poor in Workhouses. 
 III. The Insane Poor in Private Dwellings. 
 
 The following table shows the relative proportions in which the 
 insane poor are distributed in these three divisions in England and 
 Wales, in Scotland, and in Ireland : — 
 
 Table shoiving the Distribution per cent, of Pauper Litnatics and 
 Idiots in England and Wales, in Scotland, and in Ireland, on the 
 \st of January , 1867. 
 
 In England and In Scotland of In Ireland of 
 Where maintained. Wales of every every 100 every 100 
 
 100 there are there are 
 
 In Public Asylums . . 58*0 
 (County and District, and 
 Lunatic Hospitals.) 
 
 In Private Licensed Houses 3'5 
 
 24-0 
 
 15-5 
 
 100-0 
 
 In Workhouses 
 
 In Private Dwellings 
 
 43-0 
 
 10-0 
 18-5 
 
 28-5 
 100-0 
 
 there are 
 
 60-0 
 6-0 
 
 34' (including 
 
 gaols.) 
 none. 
 
 100-0 
 
 I. The Insane Poor in Public Asylums. 
 
 I begin my subject with a few remarks on the care and treatment 
 of the insane poor in public asylums. I do not feel called upon 
 from this place (nor does time admit) to enforce and illustrate the 
 incontestable superiority of public asylums for the care and cura- 
 tive treatment of the majority of the insane poor to either work- 
 houses or private dwellings. Yet in here recording the untold 
 success which has followed the efforts of the legislature since 1845 
 to ameHorate the condition of the insane poor through the com- 
 pulsory erection of county asylums — a success which led a recent 
 Harveian orator to call the sight of one of our English county 
 asylums 'the most blessed manifestation of true civilisation that the
 
 10 The Care and Treatment of the Insane Poor ; 
 
 world can present/ I cannot refrain from adfling my humble word of 
 praise to the memory of one 
 
 Of the simple great ones gone 
 For ever and ever by, 
 
 to that of my revered friend John Conolly, whose work of 
 freeing the insane from their restraint, and of thereby founding the 
 English School of Psychological Medicine, preceded the legislation 
 promoted by the Earl of Shaftesbury, and ensured the success of 
 these enactments."^ 
 
 * " In June, 1839, Dr. Conolly was appointed resident physician at Han'wen. In 
 September he hud abolished all mechanical restraints. The experiment was a 
 trying one, for this great asylum contained eight hundred patients. But the ex- 
 periment was successful; and continued experience proved incontestably that in 
 a well-ordered asylum the use even of the strait-waistcoat might he entirely dis- 
 carded. Dr. Conolly went further than tliis. He maintained that such restraints 
 are in all cases positively injurious, that their use is utterly inconsistent with a 
 good system of treatment ; and that, on the contrary, the absence of all such 
 restraints is naturally and necessarily associated with treatment such as that of 
 lunatics ought to be, one which substitutes mental for bodily control, and is 
 governed in all its details by the purpose of preventing mental excitement, or of 
 soothing it before it bursts out into violence. He urged this with feeling and per- 
 suasive eloquence, and gave in proof of it the results of his own experiment at 
 Hanwell. For, from the time that all mechanical restraints were abolished, the 
 occurrence of frantic behaviour among the lunatics became less and less frequent. 
 Thus did the experiments of Charlesworth and Conolly confirm the principles of 
 treatment inaugurated by Daquin and Pinel ; and prove that the best guide to 
 the treatment of lunatics is to be found in the dictates of an enlightened and re- 
 fined benevolence. And so the progress of science, hy tvay of experiment, has led 
 men to rules of practice nearer and nearer to the teachings of Christianity. To 
 my eyes a pauper lunatic asylum, such as may noio he seen in our English counties, 
 with its pleasant grounds, its airy and cleanly icards, its many comforts, and wise 
 and kindly superintendence, provided for those ivhose lot it is to hear the douhle 
 burthen of poverty and mental derangement — I say this sight is to me the most 
 blessed manifestation of true civilisation that the ivorld can present. 
 
 " This result we owe to the courage and philanthropy of such men as Pinel and 
 Conolly. Pinel's large acquirements and practical intellect would alone have 
 availed nothing ; his first step would never have been taken but for the generous 
 impulses of a feeling heart and courageous spirit. Conolly's experiment at 
 Hanwell would have been foiled by opposition and discouragement, had he 
 not been sustained by a spirit of earnest benevolence towards his unhappy 
 patients. 
 
 " The spirit which animated these two men is the spirit without which much of 
 the progress of practical medicine would have been impossible. For, however 
 diverse may be the intellectual powers that find their several fit places in the
 
 hij Dk. C. Jjockiiaut Robertson. 11 
 
 Dr. Couolly's four Annual Reports of the County Lunatic Asylum 
 at Hauwell for 1839, 1840, 1811, 1812, still form the groundwork 
 of our treatment of the insane poor in the English county asylums, 
 while these asylums themselves — whose fame (I may be permitted to 
 say) based as it is on the successful application of the English non- 
 restraint system has gone forth into the whole civihsed world, and 
 thus brought rescue to the most suffering and degraded of our race — 
 stand throughout this fair land imperishable monuments of the 
 statesman to whom they owe their origin, and of the physician who 
 asserted the great principle on which the treatment within their 
 walls is founded. 
 
 During the twenty years (1847-67) the Lunacy Act, 1845, has 
 been in force, the number of beds in the county asylums in England 
 and Wales has increased from 5,500 to 26,000. In 1847 there 
 was ])rovided in the public asylums accommodation and means of 
 treatment for 36 per cent, of the pauper lunacy of the country; in 
 1867 we have advanced on this state of things, and provided for 60 
 per cent, of the whole pauper lunatics and idiots chargeable. During 
 this period the total number of pauper lunatics and idiots has increased 
 from 17,952 to 42,943, while in 1847 1 in every 880 of the whole 
 population was a pauper lunatic. This proportion is now, in 1867, 
 1 in every 494. I do not attribute these numbers to any actual 
 increase of insanity, but rather to the fact of the more accurate 
 returns which are now made of the pauper lunacy of the country, 
 and also in some degree to a number of persons in the lower middle 
 class, successfully contriving to evade the restrictions of the Poor 
 Law, in order to procure for their insane relatives treatment in the 
 county lunatic asylums. This opinion of the absence of any positive 
 increase in the lunacy of the country is further supported by the 
 relative proportion of private patients to the ])opulation during the 
 same period. In 1847, 1 in 3913 was certified as a private lunatic; 
 in 1867, 1 in 3577. 
 
 study and practice of medicine, there is but one right temper for it — the temper 
 of benevolence arid courage ; the temper in which Larrey invented the ambulances 
 volanfes, that he might bring help to the wounded under tire ; tlie temper in 
 which physicians have devoted themselves to the study of the plague and other 
 infectious fevers; that same temper which has originated and sustained the 
 highest Christian enterprises, and which ennobles any man who, possessing it, 
 with an honest and true heart doiis his duty in our j)rofession." — The Harveian 
 Oration, 1866, by George E. Paget, M.D. Cantab.
 
 12 The Care and Treatment of the Insane Poor ; 
 
 Thus, I thiuk I am justified in saying that we see the limits of 
 our labours in providing for tlie care and treatment of the insane 
 poor ; and, further^ that we have nearly gained the desired end. It 
 is allowing a wide margin in our calculations for the future if we 
 place the possible total number of pauper lunatics and idiots at 
 1 in 400 of the population. This would give on a population of 
 22,000,000 about 55,000 pauper lunatics and idiots. 
 
 Here the question at once arises. For hoio many of these 55,000 
 pauper lunatics and idiots will public asylum accommodation be 
 requisite ? The table I have given above shows the existing pro- 
 portions in England, in Scotland, and in Ireland, in which the Insane 
 Poor are divided between the public asylums, the workhouses, and 
 the private dwellings. 
 
 In calculating the wants of the future it is at once necessary to 
 determine whether this proportion in the distribution of the insane 
 poor — the result of the last twenty years' experience — is a fair and 
 proper one ? My own opinion is that the English proportion is, on 
 the whole, a fair standard, and that we may safely assume for our 
 future guidance that the pauper lunatics and idiots (whom I place at 
 the ultimate average of one in 4-00 of the population) may with 
 due consideration of all their claims and requirements be thus 
 distributed : — 
 
 ^R Fahlic Asylums, 60 per cent. 
 In Workhouses, 25 per cent. 
 In Private Dwellings, 15 per cent. 
 
 And if, as we hope and believe, the population continue to increase, 
 and if mental disease, as we fear it will for many generations, increase 
 in proportion with the population, it must be remembered that wealth 
 increases in a tenfold degree, and that it cannot be otherwise than 
 the duty of a Christian government to charge on this marvellous 
 wealth the cost of the care and treatment for those who have fallen 
 by the wayside, poverty-stricken and mentally wounded in the 
 strife. During the last ten years, for example, the rental in the 
 county of Yorkshire, exclusive of the represented boroughs, has 
 increased by one million and a half. Is it an unreasonable burthen 
 on this increase to add another penny to the county rate to build — 
 as the justices are about to do — two new asylums for the insane poor 
 of this great county ?
 
 ly Dr. C. Lockhart Eobertson. 13 
 
 We should thus require, with a population of 22,000,000, 
 33,000 beds in the public asylums. Of these 26,000 are already 
 provided. The problem then is not so difficult to solve as certain 
 recent writers would lead the public to imagine. The machinery 
 which has so successfully and to the satisfaction of all classes of the 
 community, provided in twenty years the 20,000 beds may I think 
 fairly be trusted to add 7,000 more to the number. 
 
 How best can these 7,000 beds be procured ? First in order 
 comes the question of the possible increase in size of the county 
 asylums. Many years ago the opinion prevailed that 300 patients 
 were ample for the care of one superintendent. This number has 
 now gradually been allowed to increase to 600, and it is apparently 
 still on the increase. If our public asylums were like those in 
 Germany and consisted of two distmct establishments, the Re'il- 
 anstalt and the Pfleffanstalt (although there also this division is being 
 by the force of events broken through), there could be no question 
 whatever that 300 recent and acute cases of mental disease would 
 tax the efforts of the most unwearied medical superintendent. But 
 in estimating the fit numbers for an English county asylum it must 
 be remembered, that these hospitals are of a mixed character and 
 include a large proportion of incurable lunatics, whose treatment, 
 speaking generally, is a matter of organized system rather than of 
 individual observation. My own experience coincides with the 
 general result arrived at by force of circumstances, that a county 
 asylum with 600 beds may perfectly well be managed by one medical 
 superintendent and under one authority. Indeed, I go further, and 
 say that an asylum with 600 patients will in most points be better 
 organized, at the same cost per bed, than a smaller one of 300. In 
 asylums containing a large number of chronic cases I would even 
 allow that 800 patients might with the aid of two assistant medical 
 officers be treated. Beyond this number I should be most unwilling 
 to go. The experience of all larger asylums shows an increase of tlie 
 average cost, and also, unquestionably, a decrease in the comfort and 
 wellbeing of the patients, with a further increase of number. 
 
 The present average accommodation in the English county asylums 
 is about 400. An average increase of from 200 to 400 beds in these 
 asylums would then entirely solve the problem of public asylum 
 accommodation for this generation. Possibly the lunatics of the
 
 14 Tlie Care and Treatmerii of the Insane Poor ; 
 
 future iniiy attain their city of refuge in new Gheels; sufficient for 
 our present purpose be the wants of this generation. Enlargements 
 have been made in several asylums, owing to our progressive views of 
 asylum architecture, to the manifest improvement of the original 
 structure, as in the appropriating to the patients' use of the Medical 
 Superintendent's quarters, the central chapel, &c., &c. ; in others 
 detached blocks have been built of a more domestic and inexpensive 
 stvle. In either case experience has amply shown that these addi- 
 tions may be made for one third of the original cost ; that is, while 
 the average cost of asylum construction has been £170 per bed 
 (including furnishing and every item), the alterations and enlarge- 
 ments I have spoken of have been completed at the Devon, at 
 Chester, at Hayward's Heath, &c., from £50 to £60 abed, A. very 
 desirable means of relieving the county asylum is one now in 
 progress, viz., the buildmg of separate borough asylums, such as 
 Leicester, Norwich, &c,, &c. ; when, instead of these boroughs 
 paying rent to the county asylum for the beds they occupy, they 
 will without further cost have an asylum of their own, and have the 
 entire control of all relating to their patients. 
 
 In larger and more populous counties, like Lancaster, Surrey, and 
 Chester, a territorial division of the county has been adopted and 
 which is much to be preferred, on the ground ahke of proper 
 management and economy, to the huge asylum extensions of Han- 
 well, Colney Hatch, and Kent, 
 
 II. The Insane Poor in I for I- houses. 
 
 On the 1st of January, 184-7, there were 4631 pauper lunatics 
 and idiots confined in the workhouses in England and Wales, 
 
 On the 1st of January, 1857, their number rose to 6800; and 
 on the 1st of January, 1867, it had increased to 10,307, In 1847, 
 they formed 25 per cent, of the toial number of pauper lunatics; in 
 1857, 25 ])er cent.; in 1867, 21 per cent. Thus, although the 
 total number of pauper lunatics chargeable has trebled daring the 
 twenty years 1847-67, the proportion of those confined in work- 
 houses has not increased. 
 
 By the 111th section of the Lunacy Act, 1845, the Commissioners 
 in Lunacy were authorised to visit (and report to the Poor Tiaw
 
 hy Dii. C. LocKHAUT Robertson. 15 
 
 Board) all lunatics and idiots confined in the workhouses in England 
 and Wales. 
 
 We have, in the ' Further Report of the Commissioners in Lunacy I 
 a general statement of the position in 1847 of the insane poor 
 confined in the workhouses. This was the first occasion on which 
 any legal inquiry had been made as to the condition of the lunatic 
 inmates of these houses. Considerable discrepancy prevailed in the 
 numbers returned by the Poor Law Board, and those actually found 
 by the Visiting Commissioners. The majority of these lunatics 
 were idiotic and demented, but some of the severe and more recent 
 forms of insanity were also met with by the Commissioners. 
 
 In 1859 the Commissioners in Lunacy published a detailed report 
 on the condition of the lunatic inmates of workhouses.^ This report 
 gave a most unsatisfactory account of their state and treatment. 
 The state of these patients was also fully investigated by the Select 
 Committee on Lunatics in 1859, and an effort was made in the 
 Lunacy Acts' Amendment Act, 1862, to regulate the conditions 
 under which pauper lunatics are now detained in workhouses. 
 Thus section 20 provides, that no lunatic or alleged lunatic, shall 
 be detained beyond fourteen days in a workhouse, unless the medical 
 officer of the parish give a certificate in writing, that he is a proper 
 person to be kept in a workhouse, nor unless the accommodation in 
 the workhouse is sufficient for his reception. It is further provided 
 by section 21 that a quarterly return shall be sent by the medical 
 officer of the workhouse to the clerk of the union, who is required 
 to forward copies to the Commissioners in Lunacy and to the clerk 
 of the Visitors of the County or Borough Asylum. The 30th 
 section gives the Commissioners in Lunacy power at their visits to 
 send any pauper lunatics detained in workhouses to the county 
 or other asylum without further order or certificate — a most valuable 
 provision. The 37th section requires the Visiting Committee of 
 the Board of Guardians to record, at least once a quarter in the 
 visitors' book, such observations as they may think fit to make 
 respecting the dietary accommodation and treatment of the lunatics 
 
 * ' Supplement to the Twelfth Report of the Commissioners in Lunacy to the 
 Lord Chancellor.' Ordered hy ike JTou^e of Commons to be printed, 15fh April, 
 1859.
 
 16 The Care and Treatment of the Insane Poor ; 
 
 or alleged lunatics in the workhouse, which book shall be laid 
 before the Commissioners at their next visit by the master. 
 
 The Commissioners manage apparently to visit the 10,000 lunatics 
 and idiots detained in the 688 workhouses in England and Wales at 
 least once in three years; taking the 100 workhouses which have 
 separate wards for the insane once a year, and the others at least 
 once in three years. 
 
 On the 1st of January, 1867, the numbers had risen from 6800 
 to 10,307, and again the Commissioners in their last report furnish 
 us with an insight into the present condition of these patients. The 
 same fact is recorded that the insane in the small country workhouses, 
 who are mixed with the other inmates, are generally in a favorable 
 condition. Employed with the rest indoors, or in the garden and 
 fields, and enjoying often some indulgences of diet, the idiotic and 
 demented patients in these houses are placed in as favorable con- 
 ditions of existence as can be expected, or as is necessary for their 
 wellbeing. Likewise, in some of the larger town workhouses, where 
 special lunatic wards have been arranged, the condition of the 
 patients is very satisfactory. To this, however, there are marked 
 and numerous exceptions in the workhouses in town districts, where 
 the numbers of the insane poor are neither small enough for the 
 domestic treatment of the country unions nor large enough for 
 the asylum arrangements adopted in the large houses, and where 
 patients requiring asylum treatment are detained without anything 
 of asylum comforts, where there are cheerless rooms, insufficient 
 and incompetent attendance, a low diet, no records of the simplest 
 kind, and no provision whatever for healthful exercise of mind or 
 body. 
 
 The Poor Law Board continue to evince the greatest solicitude 
 for the welfare of the insane poor, and give their uniform support to 
 the recommendations made by the Commissioners in Lunacy at 
 their visits. The change, since 1847, in the condition of the 
 insane poor in workhouses has been on the whole a progress. The 
 guardians and medical officers take a more hberal view of their obliga- 
 tions towards these patients, and a more uniform practice has been 
 enforced of sending the recent and acute cases at once to the county 
 asylum for treatment, the most important point of all connected with 
 the care and treatment of the insane poor. . 
 
 10
 
 hy Dr. C. Lockhaut Robertson. 17 
 
 The experience of the last twenty years places the treatment in 
 the public asylums beyond all cavil or comparison with similar 
 attempts in workhouses or in private dwelHngs, alike for all 
 cases of recent mental diseases, and for the majority of those of 
 chronic mania and dementia, with their natural complications of 
 paralysis, softening of the brain, epilepsy, kc. With every desire to 
 reduce the numbers of the insane poor requiring the accommodation 
 of the county asylums, I do not think, as I have already said, it can 
 ultimately be placed at less than 60 per cent, of the total number of 
 pauper lunatics and idiots. All efforts to reduce this number by send- 
 ing back cases of chronic mental disease to the workhouses, as has 
 been done in numerous asylums, has resulted in a lam^entable failure, 
 and in the return of the patient, after a limited time, with a marked 
 increase of his disease. This is so far evidence in favour of the 
 '^5^ present English standard of the proportion of the insane poor (60 
 per cent.) requiring asylum accommodation, and that we do not 
 (as has recently been often asserted) indiscriminately and without 
 necessity, sequestrate the insane poor. This is a point on which I 
 -am disposed strongly to insist. 
 
 Yet, on the other hand, experience leads me to say that the aged, im- 
 becile, and demented lunatics prefer the workhouse to county asylums, 
 partly from the greater freedom from discipline (from enforced 
 order and cleanluiess, baths, &c.) which they enjoy, partly from the 
 association with sane persons there instead of the insane, and partly 
 because it is situated nearer their ow^n parish and family. It may 
 be a want of judgment and taste, but the truth certainly is that the 
 insane poor who are sufficiently sane to argue the point, the aged, 
 the infirm, the epileptics, the imbeciles, &c., are constantly asking to 
 be sent back to the union. I am sure the experience of the medical 
 superintendents of oui" large asylums will confirm this fact. 
 
 I would say, speaking generally, that 25 per cent, of the pauper 
 lunatics and idiots chargeable may, with great relief to the wards of 
 the county asylum, and with satisfaction to themselves and their 
 friends, be kept under proper restrictions in the workhouse. The 
 mixing there with persons of sound mind is a comfort much ap- 
 preciated by this class of patients, as also the greater freedom, the 
 facility of visiting old friends and associations and such like. In 
 rountry districts, the workhouses would thus prevent the ronstont
 
 18 The Care and Treatment of the Insane Poor ; 
 
 tendency to tlie accumulation in tlie wards of the county asylums of 
 harmless and incurable lunatics. A similar relief was contemplated 
 in rather a different way by the 8tli section of the Lunacy Acts' 
 Amendment Act, 1802 ; but the wording of the clause is so obscure 
 that the Attorney and Solicitor-General advised in May of this year 
 " that further legislation is needed^ in order to define more clearly 
 the true position of chronic lunatics removed to workhouses, and 
 of the visitors, guardians, and others with respect to their 
 lunatics." 
 
 When by sucli high authority further legislation on this point is 
 stated to be necessary, I may perhaps be permitted to say, that in 
 order to place the arrangements for the care and treatment of the 
 insane poor in workhouses on a satisfactory and permanent basis, it 
 is above all things necessary that one system and authority should 
 regulate the same. 
 
 Parliament has already in theory confided the charge of the insane 
 poor to the Justices of the Peace, under the supervision of the Com- 
 missioners in Lunacy. I would urge that this theory be put in 
 practice. To this end I would suggest : — 
 
 1. That it be illegal to detain any lunatic or idiot in a workhouse 
 without the same medical certificate and a justices' order, as is re- 
 quisite for admission into the county asylum, and that copies should 
 be transmitted by the clerk of the union to the Commissioners in 
 Lunacy, and to the visitors of the county asylum. 
 
 2. That the visitors should depute the medical superintendent, or 
 one of the medical officers of the county asylum, to visit the work- 
 houses in the county at least once a year,'^ to arrange for the inter- 
 change of suitable cases, and to report to them on the condition 
 and treatment of the insane inmates ; such report to be submitted to 
 the Sessions, with the document relating to the management of the 
 county asylum. 
 
 3. That the case books and statutory records of the workhouses, 
 so far as relates to the care and treatment of the insane poor, be 
 assimilated to those in use in the county asylums. 
 
 * This would occupy about a fortnight off and on in the year, and would form 
 a healthful change of work, and be alike beneficial to the medical superintendent 
 and to the inmates of the Unions whom he would visit. Of course this arrange- 
 ment implies the presence at the county asylum of one or more assistant medical 
 officers — a point much insisted on by the Commissioners.
 
 ^ hu Du. C. LocKHAUT Robertson. 19 
 
 Similar provisions were long ago recommended by tlie Earl of 
 Shaftesbury in the speech (6th June, 1845), in which he introduced 
 the Lunacy Act, 18 i5, into the House of Commons ; — 
 
 " In erecting (he said) new asylums, and providing farther ac- 
 commodation where it is required, regard should be had to the pro- 
 l)ortion of curable and chronic lunatics, I purposely avoid the use 
 of the term incurable. Separate buildings, I propose, should be 
 provided for chronic lunatics at a less cost, and parts of the work- 
 houses, with tlie consent of the Poor-Law Commissioners, may he 
 adapted, in ivhich case they are to he separated from the other part 
 of the huilding, and to he deemed county asylums." 
 
 Placed on this footing, the workhouses might in the majority of 
 the country districts become valuable means of relieving the over- 
 crowding of the county asylum, and, where the workhouses cannot 
 be used for this purpose, there is no doubt that auxiliary asylums 
 of an intermediate character between the workhouse and the asylum, 
 as recommended by the Commissioners in their last report (1867), 
 might be built and fitted for about £80 a bed. Such auxiliary 
 asylums would even more efficiently relieve the overcrowding of the 
 county asylum, and could be conducted as economically as the 
 lunatic wards of the workhouses. 
 
 Tor London and Middlesex the Metropolitan Poor Act 1867 pro- 
 vides district asylums for the reception and relief of the insane poor. 
 I believe there are about 3000 insane inmates of the metropolitan 
 workhouses for whom provision is thus to be made, and a consider- 
 able number of the inmates of Hanwell and Colney Hatch might 
 yearly be drafted into these district asylums as they pass into the 
 chronic and harmless stages of the disease. Such district asylums 
 would essentially resemble the German Pfleganstalten, or houses of 
 care, as opposed to the asylums or hospitals for cure. They ought 
 not to contain more than 1200 beds each. Their construction 
 should be of the most simple kind ; probably detached three-storey 
 buildings, with dormitories and dayrooms on the pavihon principle, 
 will be found the best method of construction. 
 
 The act provides for the election of aii independent board of 
 management, partly chosen by the vestries, partly nominated by the 
 Poor-Law Board, to whom great authority for the erection and sub- 
 sequent conduct of these district asvlums is entrusted.
 
 20 The Care and Treatment of the Insane Poor ; { 
 
 Connected with this division of my subject is the question of the 
 care and treatment of the idiot children of the poor. Of the 
 40,000 pauper lunatics and idiots in England and Wales, 10,000 are 
 idiots from birth. These idiots are maintained partly at home_, partly 
 in the workhouse, and the more hopeless and troublesome are sent to 
 the county asylum. As every experienced superintendent will admit, 
 nothing can be more detrimental to their chance of improvement 
 than to place these congenital idiots in the wards of a lunatic 
 asylum; still more unsuitable are those of the workhouse. In the 
 private dwellings of the poor the difficulties are even greater. The 
 treatment of lunatics and of idiots is distinct in principle and in 
 practice, and they cannot be dealt with under one system. The 
 remedy lies in the establishment in the several districts of England 
 of idiot asylums. Probably one for each of the eleven poor-law 
 districts would suffice. 
 
 By extending the provisions of the lunacy acts to the erection 
 of these idiot asylums, and to the cost of maintenance there, no 
 new machinery would be requisite. It needs no words of mine to 
 urge the claims of the idiot — of those tvho cannot plead for them- 
 selves — to a share of the gifts of fortune and of healing which have 
 been so richly poured on this generation. We have already at 
 Earlswood a model idiot asylum, and marvellous proof, what wise 
 treatment can effect to the amehoration of this sad affliction. An 
 idiot asylum with 400 beds in each of the eleven poor law districts, 
 and which might be built at £80 a bed, would amply meet this 
 pressing want, and so far lessen the per-centage of pauper lunatics 
 and idiots requiring care and treatment in the county asylum, in the 
 workhouse, and at home. 
 
 III. The Insane Poor in Private Btvellings. 
 
 In England and Wales 15-5 per cent, or upwards of 6000 of 
 the insane poor are boarded out, chiefly with their relations, under 
 the authority of the Boards of Guardians and the certificate of their 
 medical officer, but without any magistrate's order to legalise their 
 detention. A cjuarterly list of these patients by the medical officer 
 of the district, stating the form and duration of the disease, and the 
 date of his quarterly visit, &c. &c., is sent by the clerk of each 
 union to the visitors of the county asylum, and to the Commissioners
 
 ht/ Du. 0. LocKHART Robertson. 21 
 
 iu Lunacy. They are cliiefly cases of congenital idiocy and de- 
 mentia. The allowance for their maintenance averages 6d. a day. 
 No official inspection of their condition is made by the Commis- 
 sioners iu Lunacy, and the little that is known of their condition is 
 not encouraging as regards the extension of the present system. 
 
 In Scotland there is an excess of thirteen per cent, on the English 
 proportion in the number of pauper lunatics treated in private 
 dwellings. These numbers tend, however, towards a steady decrease. 
 Thus, while in the last eight years there has been an increase of 969 
 pauper patients placed in public asylums, there has been a decrease 
 in the same period of 216, or thirteen per cent, in the number of 
 those treated in private dwellings. Another such eight years' ex- 
 perience would bring the proportion of cases, thus treated, down to 
 the English average. 
 
 In Scotland, wliere this system has been highly lauded and offered 
 for an imitation as the remedy in all our difficulties, the care and 
 treatment of the insane poor in private dwellings is carried out under 
 the official authority and inspection of the Lunacy Board. Insane 
 paupers may there either be boarded singly in a labourer's cottage, 
 or these cottagers may procure (witliout fee) a license from the 
 Lunacy Board^ to receive patients to the number of four. The 
 average parochial allowance for lodging and maintenance is sixpence 
 a day — about the same as in England. The guaranteesf provided 
 for the protection of the subjects of these humble lay speculators 
 in lunacy are a quarterly visit by a medical man, a half yearly visit 
 by an inspector of poor, and an annual visit by one of the deputy 
 commissioners, unless in Orkney or Shetland, or in the Western 
 Isles, where this official visit is paid once in two years. According 
 to Dr. Mitchell,J the great majority of pauper patients in private 
 dwellings consist of '' the fatuous and the idiotic, that is, of mindless 
 persons whose appreciatioTi of liberty cannot he great or strikingly 
 shown," and patients in this condition (he reports) should always, 
 in his opinion, constitute the majority of single patients. I think 
 the existence of the system is condemned by this official admission. 
 
 * 25th and 26th Vict., cap. 54, § 5. 
 
 t ' Ninth Annual Report of General Board of Commissioners in Lunacy for 
 Scotland, 1867.' 
 
 X ' General Reports on Lunatics iu Private Dwellings, 1867.'
 
 22 The Care and Treatment of the Insane Poor ; 
 
 The demented and tlie idiotic {mindless persons) cannot complain. 
 They neither remember the restraints placed on their liberty, nor the 
 neglect and want to which they may have been subjected. Their 
 power of contributing by their labour to the income of those to 
 whom they are farmed out is small. There is little in the Scotch 
 practice but the sixpence a day between them and neglect and want. 
 The amount of official inspection they receive cannot be worth 
 much. I would just ask you to recall the demented and fatuous in- 
 mates of one of our county asylums, with their depraved habits and 
 many wants, and to remember the daily, hourly care required to 
 keep them decently clean, and to retain some faint image of 
 humanity and civilisation around them, in order to realise what their 
 condition must be when all the costly remedial agents of the asylum 
 are once withdrawn. It needed not the graphic detail given by the 
 writer of an oft quoted paper, ' Gheel in the North,^^ to realise how 
 far removed from sober truth are the pictures of rural bliss — of 
 the demented and mindless patient in the quiet enjoyment of the 
 ever-shifting busy scene in the cottage kitchen, and of the freedom 
 and kindly guardianship there enjoyed — which are yearly chronicled 
 in the appendix to the Scotch lunacy commissioner's reports. 
 
 The principle asserted by the Lunacy Act of 1845, that the insane 
 poor should not be the objects of financial speculation, but that 
 they should be maintained and treated at the public charge, has 
 been throughout consistently adhered to by the English commis- 
 sioners.t The recent practice of the Scotch commissioners in 
 licensing private pauper houses of three or four inmates to ignorant 
 and needy persons is a retrograde step in the care and treatment of 
 the insane which I think we shall all condemn. 
 
 I cannot then cite the theory or practice of the Scotch Lunacy 
 
 * " Glieel in the North."—' Journal of Mental Science,' July, 1866. 
 
 t " If to this estimate of the most recent additions to the jjublic accommodation 
 provided for pauper lunatics we apply the ratio of increase in the number re- 
 quiring accommodation observable during the last year, some conclusion may be 
 formed as to the period for which these additional beds are likely to be found suf- 
 ficient to meet the constantly increasing wants of the country, and hoio far they 
 will tend towards the object we have sought most anxioush/ to promote eoer since 
 the establishment of this Commission, namely, the ultimate closing of Licensed 
 Souses for Pauper Lunatics." — ' Twelfth Report of the Commission in Lunacy to 
 the Lord Chancellor, 1858.'
 
 hi/ Dr. C. Lockhart Robehtson. 23 
 
 Board, in perpetuating the practice of farming out for profit, singly 
 or in parties of four, to the care and treatment of the peasantry, the 
 insane poor as one at all worthy of farther consideration on our 
 part. The pressure on our English asylums will uot, I am sure, so 
 far as the English Commissioners in Lunacy or the Justices in 
 Quarter Sessions are concerned, be relieved by the re-introduction in 
 this most objectionable form of the principle of lay speculation in 
 pauper lunacy. 
 
 While thus coudemnmg entirely the Scotch practice of boarding 
 the insane poor with the peasantry in the villages throughout the 
 country, I am very far from asserting the opuiion that all the insane 
 poor without exception ought to be treated in the county asylum or 
 in the workhouse. A certain proportion (I have placed it at 15 per 
 cent.) might, with increased enjoyment of life, be restored to their 
 own families, were suitable provision made for their care and main- 
 tenance. As medical superintendent of a large county asylum I am 
 weekly receiving applications to allow patients to return to their 
 homes, and though many of such cases are unfit to be discharged, 
 others certainly might under proper restrictions be so restored. 
 What is required to give this plan a fair trial is some simple 
 organisation connected with the county asylum, similar to the per- 
 missive powers which now exist of allowing patients to be tem- 
 porarily absent on trial, with a weekly allowance. Were this 
 permissive power converted into a permanent system of home treat- 
 ment for the insane poor, great comfort would result to many 
 families in having their afflicted loved ones again with them."^" If the 
 
 * "I cannot but think that future progress in the improvement of the treat- 
 ment of the insane lies in the direction of lessening the sequestration, and in- 
 creasing the liberty of them. Many chronic insane, incurable, and harmless, will 
 be allowed to spend the remaining days of their sorrowful pilgrimage in private 
 families, having the comforts of family life, and the priceless blessing of the ut- 
 most freedom that is compatible with their proper care. The one great impedi- 
 ment to this reform at present lies in the public ignorance, the unreasoning fear, 
 and the selfish avoidance of insanity. When knowledge is gradually made to 
 take the place of ignorance, then will a kindly feeling of sympathy for the insane 
 unite with a just recognition of their own interests on the part of those who re- 
 ceive them into their houses, to secure for them proper accommodation and good 
 treatment. Then, also, will asylums, instead ofbeing vast receptacles for the con- 
 cealment and safe keeping of lunacy, acquire more and more the character of 
 hospitals for the insane; while those who superintend them, being able to give 
 more time and attention to the scientific study of insanity and to the means of
 
 The Care and Treatment of the Insane Poor ; 
 
 visitors of the county asylum had the power of boarding with their 
 relatives, at an allowance not exceeding the asylum maintenance 
 rate, patients selected for this home treatment, many applicants would 
 be found, and the confidence of the poor in the authorities of the 
 asylum would be greatly increased. The only machinery necessary 
 would be to add a relieving officer to the staff of the asylum, for 
 the purpose of making a periodical visit and payments to these 
 patients. The medical practitioners in the district should be em- 
 ployed to make a quarterly medical report to the visitors, and 
 in exceptional cases further visitation could be made by the medical 
 officers of the county asylum. The certificates remaining in force 
 throughout the w^hole period, the patients could, without further 
 delay or trouble, be brought back to the asylum in any case of 
 relapse or other necessity. 
 
 Such a plan would ultimately supersede the present system in 
 England of boarding the insane poor in private dwellings under the 
 authority of the boards of guardians ; a system, although embracing 
 15 per cent, of those chargeable, of the working of which very little 
 appears to be known, and that little, I fear, not much to its credit. 
 
 To pass here from these general statements to a little further 
 detail, I would take the county of Sussex, with which I am officially 
 connected, and therefore best cognisant. The population of the 
 county, according to the last census, and corrected to July, 1866, is 
 377,180. The total number of pauper lunatics on the 1st January, 
 1867, was 837, or 1 in 450 of the population. They were thus 
 distributed : — 
 
 In the County Asylum at Hay- 
 ward's Heath 
 
 Male. 
 
 236 
 
 Female. 
 
 294 
 
 Total. 
 
 530 
 
 Per Cent. 
 
 63'3 
 
 In Workhouses 
 
 76 
 
 99 
 
 175 
 
 2I*0 
 
 Living with Friends 
 
 51 
 
 64 
 
 115 
 
 137 
 
 Boarded out in Private Dwell- 
 ings . . . . ■ . 
 
 9 
 
 8 
 
 17 
 
 TO 
 
 Total . . . 372 465 837 loo-o 
 
 its treatment, will no longer be open to the reproach of forgetting their character 
 as Physicians, and degenerating into mere house stewards, farmers, or secre- 
 taries." — ' TJie Physioloffij and Pathology of the Mind,' hy Henry Maiidsley, 
 M.D. Lond.
 
 by Dr. C. Lockhart Robertson. 25 
 
 We shall have at the county asylum about 700 beds when the 
 alterations in progress are completed^ and the entire plan for the 
 enlargement of the asylum provides 800 beds, viz. 350 male, aiid 
 450 female. The original building, fitted and furnished for 450 
 patients, cost £175 a bed. The extensive enlargements and altera- 
 rations to adapt it to 800, will, while materially improving the 
 building and the facility in working, be carried out, including 
 furnishing, for £60 a bed. 
 
 If, allowing for increase of population in the next twenty years,"^ 
 we place the inhabitants of the county at 500,000, we should, 
 taking 1 pauper lunatic and idiot to every 400 of the population, 
 have in this period a total of 1250 to provide for. On the standard 
 which I have taken, of 60 per cent, requiring asylum treatment, 25 
 per cent, workhouse accommodation, and 15 per cent, being placed 
 in private dwellings, we should have a population of 750 at the 
 county asylum, 300 to be maintained in the workhouses, and 250 
 to be boarded in private dwellings with their friends. This, it is 
 evident, is allowing a wide margin in our estimate, both as regards 
 increase of population, and of the number of pauper lunatics and 
 idiots chargeable, which I hardly think can, even under any likely 
 circumstances, exceed 1 in 400 of the population. 
 
 We shall be able to receive the 750 at the county asylum. 
 There can be no great difficulty in finding proper accommodation 
 for 300 in the twenty-five workhouses in the county, and I believe 
 that 250 families may be found, able and willing to undertake the 
 care of their insane relatives, under the arrangements which I have 
 just sketched. 
 
 You will thus see that I take a hopeful view of the future, as it 
 relates to the care and treatment of the insane poor. The difficulties 
 which beset the path of the early asylum reformers, have gradually 
 yielded to the progress of wiser and more humane sentiments, and 
 it is only matters of detail that now remain for us to arrange in 
 order to complete and consolidate the working of the system inau- 
 gurated by the Lunacy Act, 1845, and already brought to so suc- 
 
 * In 1851 the population of the county of Sussex was 336,844, and in 1801 
 363,735, being an increase of 26,891 in the decennium. I am allowing in my cal- 
 culations a possible increase of 137,205 in the two decenniums. 
 
 3
 
 26 The Care and Treatment of the Insane Poor. 
 
 cessful an issue by the united labours of the Commissioners in 
 Lunacy, and of the Visiting Justices and Medical Superintendents 
 of the English county asylums. I have thought that the oppor- 
 tunity which this day has given me would not be unwisely used in 
 reviewing, aided by the experience of the past twenty years, the 
 several details of this system as they relate to the present and 
 future treatment of tlie insane poor.
 
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