We put forward our remarks upon this subject with all becoming deference;
yet it was impossible to take a review of the state of Lunacy and of the
legal provision for the insane without referring to it. Indeed, in
previous pages several observations have fallen respecting the duties and
position of the Commission of Lunacy, and the operation and powers of this
Board have also formed the topic of many remarks and discussions in other
books, as well as in journals, and elsewhere.
There appears to be in the English character such an aversion to
centralization as to constitute a real impediment to systematic
government. Various questions in social science are allowed, as it were,
to work out their own solution, and are not aided and guided towards a
correct one by an attempt at system or organization. Confusion, errors,
and miseries must prevail for a time, until by general consent an
endeavour to allay them is agreed upon, and a long-procrastinated scheme
of direction and control is submitted to, and slowly recognized as a
long-deferred good. Such is the history of the care and treatment of the
insane. After ages of neglect, evils had so accumulated and so loudly
cried for redress, that some plan of conveying relief became imperative;
and it is only within our own era, that the first systematic attempt at
legislation for the insane was inaugurated. From time to time experience
has shown the existence of defects, and almost every Parliament has been
called upon to amend or to repeal old measures, and to enact new ones, to
improve and extend the legal organization for the care and treatment of
lunatics and of their property.
One most important part of this organization was the establishment of the
Lunacy Commission, which has given cohesion and efficacy to the whole. To
the energy and activity of this Board are mainly due the immense
improvements in the treatment of the insane which characterize the present
time, and contrast so forcibly with the state of things that prevailed
before this central authority was called into power. The official
visitation by its members of all the asylums of the country has imparted a
beneficial impulse to every superintendent; the Commissioners have gone
from place to place, uprooting local prejudices, overturning false
impressions, and transplanting the results of their wide experience and
observation on the construction and organization of asylums, and on the
treatment of the insane, by means of their written and unwritten
recommendations, and by their official reports, which form the
depositories of each year's experience.
An attempt to show the manifold advantages of this central Board would be
here out of place; but we may, for example's sake, adduce the recent
investigation into the condition of lunatics in workhouses, as one of many
excellent illustrations of the benefits derived from an independent
central authority. But, whilst illustrating how much and how long the
supervision of independent visitors has been, and, in fact, still is
needed over lunatics in those receptacles, it also proves that the
existing staff is inadequate to fulfil the task. We have, indeed,
suggested the appointment of a class of district medical officers who
would relieve the Commissioners from the greatest part of the labour of
inspecting workhouse lunatic wards, but we would not thereby entirely
absolve them from this duty. An annual visit from one Commissioner to each
Union-house containing more than a given number of lunatics would not be
too much; and, to make this visit effectual, the Commissioner should be
armed with such plenary powers as to make his recommendations all but
equivalent to commands, though subject to appeal. At present the Lunacy
Commissioners are practically powerless; the law orders their visits to be
made, and sanctions their recommendations, but gives neither to them nor
to the officers of the Poor Law Board the power to insist on their advice
being attended to if no reasonable grounds to the contrary can be shown.
In this matter, therefore, a reform of the law is called for. The court of
appeal from the views of the Commissioners might be formed of a certain
number of the members of the Poor Law Board and of the Lunacy Commission,
combined for the purpose when occasion required.
The proposition has been made (p. 179) to institute a Committee of
Visitors of Workhouses, chiefly selected from the county magistracy; and
it is one that will no doubt be generally approved. But to the further
proposition, that the supervision of workhouse lunatics should be entirely
entrusted to these Committees, and that the Commissioners in Lunacy should
not be at all concerned in it, we do not agree; for, in the first place,
we wish to see the Lunacy Commissioners directly interested in every
lunatic in the kingdom, and acquainted with each one by their own
inspection or by that of special officers acting immediately under their
authority; and, in the second place, we desire to retain the visitation of
the members of the Commission in the capacity of independent and
experienced inspectors. The advantages of an independent body of visitors,
as stated in the Commissioners' 'Further Report,' 1847 (p. 93), chiefly
with reference to asylums (see p. 192), have much the same force when
applied to the visitors of workhouses,--that is, if the insane in these
latter receptacles are to be placed on an equality, as far as regards
public protection and supervision, with their more fortunate brethren in
affliction detained in asylums. But, besides the arguments based on the
advantages accruing from an independent and experienced body of visitors,
there is yet another to be gathered from the past history of workhouses
and their official managers: for among the members of Boards of Guardians,
to whom the interests of the poor in workhouses are confided, are to be
found, in a large number of parishes, magistrates holding the position of
ordinary or of honorary guardians; and, notwithstanding this infusion of
the magisterial element, we find that almost incredible catalogue of
miseries revealed to us by the Lunacy Commissioners to be endured by the
greater number of lunatics in workhouses. In fact, to assign the entire
supervision of workhouse lunatic inmates to a committee of visiting
Justices is merely to transfer the task to another body of visitors, who
have little further recommendations for the office than the Boards of
Guardians as at present constituted. From these and other considerations,
we advocate not only the visitation of lunatics in workhouses by the
district medical officers proposed, but also, at longer intervals, by one
or more of the Commissioners or of their assistants; and, if this idea is
to be realized, an increase of the Commission will be necessary, at least
until Union-houses are evacuated of their insane inmates.
The beneficial results flowing from the visitation of asylums by the
Lunacy Commissioners is a matter of general assent; and the opinion is
probably as widely shared, that this visitation should be rendered more
frequent. A greater frequency of visits would allay many public suspicions
and prejudices regarding private asylums, and would, we believe, be
cheerfully acquiesced in by asylum proprietors, who usually desire to meet
with the countenance and encouragement of the Commissioners in those
arrangements which they contrive for the benefit of their patients. The
proceeding in question would, likewise, furnish the Commissioners with
opportunities for that more thorough and repeated examination of cases,
particularly of those which are not unlikely to become the subject of
judicial inquiries. The ability to do this might, indeed, often save
painful and troublesome law processes; for, surely, the careful and
repeated examinations of the Commissioners, skilled in such inquiries,
when terminating in the conclusion that the patient is of unsound mind,
and rightly secluded, should be accounted a sufficient justification of
the confinement, and save both the sufferer and his friends from a public
investigation of the case.
The decision of the Lunacy Commissioners, we are of opinion, should be
held equivalent to that of a public court, and should not be set aside
except upon appeal to a higher court, and on evidence being shown that
there are good reasons for supposing the original decision to be in some
measure faulty. Is not, it may be asked, the verdict of a competent,
unprejudiced body of gentlemen, skilled in investigating Lunacy cases, of
more value than that of a number of perhaps indifferently-instructed men,
of no experience in such matters, under the influence of powerful appeals
to their feelings by ingenious counsel, and confounded by the multiplicity
and diversity of evidence of numerous witnesses, scared or ensnared by
cross-examination in its enunciation?
Again, the more frequent visitation of the insane by the Commissioners
would be productive of the further benefit of obviating the imputation
that patients are improperly detained after recovery; and it would also,
in some cases, be salutary to the minds of patients, fretting under the
impression of their unnecessary seclusion; for the inmates of asylums
naturally look to the Commissioners for release, anticipate their visits
with hope, and regret the long interval of two, three, or more months,
before they can obtain a chance of making their wants known, particularly
since they are conscious how many affairs are to be transacted during the
visit, and that only one or two of their number can expect to obtain
special consideration.
There is, moreover, a new set of duties the Commissioners propose to
charge themselves with, involved in the clause of the Bill introduced in
the last session of Parliament (clause 26), requiring information to be
given them of the payment made for patients in asylums, in order to their
being able to satisfy themselves that the accommodation provided is
equivalent to the charges paid. This task will necessarily entail
increased labour on the Commission, and lead, not only to inquiries
touching the provision made for the care and comfort of the patients
within the asylum, but also to others concerning the means in the
possession of their friends, and the fair proportion which ought to be
alloted for their use. In short, we cannot help thinking that the duties
proposed will frequently lead the Commissioners to take the initiative in
a course of inquiries respecting the property of lunatics available for
their maintenance.
According to present arrangements, although every asylum in the country is
under the jurisdiction of the Commissioners in Lunacy, yet, beyond the
metropolitan district, their jurisdiction is divided, and the county
magistrates share in it. Indeed, provincial asylums are placed especially
under the jurisdiction of the magistrates, by whom the plans of licensed
houses are approved, licences granted or revoked, and four visitations
made in the course of each year; whilst the Commissioners, although they
can, by appeal to the Chancellor, revoke licences in the provinces, are
not concerned in granting them, and make only two visits yearly to each
licensed house beyond the metropolitan district. This variety in the
extent of the jurisdiction of the Lunacy Board in town and country, is, to
our mind, anomalous, and without any practical advantage. If the
magisterial authority is valuable in the regulation of asylums at one
portion of the country, it must be equally so at another; the
'non-professional element' (Evid. Com., Query 126), if of importance in
the country, must be equally so in the neighbourhood of the metropolis. We
do not argue against the introduction of magisterial visitation of
asylums, but against the anomaly of requiring it in the country and not in
town, and against treating provincial asylums as not equally in need of
the supervision of the Central Board with the metropolitan. We perceive a
distinction made, but cannot recognize a difference. There is a single
jurisdiction in the instance of one set of asylums, and a divided one in
that of another; and yet the circumstances are alike in the two.
The real explanation of this anomaly in the public supervision and control
of asylums, is, we believe, to be found in the fact of the inadequacy of
the Lunacy Commission to undertake the entire work. The superiority of the
Commissioners, as more efficient, experienced, and independent visitors,
will be generally admitted; but they are too few in number to carry out
the same inspection of all the private asylums in the country, as they do
of those in the metropolitan district. The Commissioners are free from
local prejudices, unmixed in county politics, and constitute a permanent,
unfluctuating board of inspection and reference; whereas county and
borough magistrates owe their appointment usually to political
considerations and influence: politics are a subject of bitter warfare
among them in most counties; local and personal prejudices and dislikes
are more prone to affect them as local men; and, withal, the Committees of
Visiting Justices are liable to perpetual change, and, out of the entire
number elected on a committee, the actual work is undertaken only by a
few, who therefore wield all the legal powers entrusted to the whole body.
A passage from the 'Further Report' of the Lunacy Commissioners (1847)
recently referred to (p. 189) may be serviceably quoted in this place.
Speaking of the extracts selected by them for publication in the Report,
"to show that occasions are continually arising, where the intervention of
authority is beneficial," the Commissioners proceed to remark that "the
defects adverted to in the extracts may sometimes appear to be not very
important; but they are considerable in point of number, and, taken
altogether, the aggregate amount of benefit derived by the patients from
their amendment, and from the amendment of many other defects only
verbally noticed by the Commissioners, has been very great. It is most
desirable that no defect, however small, which can interfere with the
comfort of the patient, should at any time escape remark. A careful and
frequent scrutiny has been found to contribute more than anything else to
ensure cleanliness and comfort in lunatic establishments, and good
treatment to the insane. These facts will tend to show how advantageous,
and indeed how necessary, is the frequent visitation of all asylums. It is
indispensable that powers of supervision should exist in every case; that
they should be vested in persons totally unconnected with the
establishment; and that the visitations should not be limited in point of
number, and should be uncertain in point of time: for it is most important
to the patients that every proprietor and superintendent should always be
kept in expectation of a visit, and should thus be compelled to maintain
his establishment and its inmates in such a state of cleanliness and
comfort as to exempt him from the probability of censure. We are
satisfied, from our experience, that, if the power of visitation were
withdrawn, all or most of the abuses that the Parliamentary Investigations
of 1815, 1816, and 1827 brought to light, would speedily revive, and that
the condition of the lunatic would be again rendered as miserable as
heretofore."
We have in past pages referred to magisterial authority in relation with
the pauper insane, as frequently exercised prejudicially, and with
reference to asylum construction and organization, as sometimes placed in
antagonism to acknowledged principles and universal practice, much to the
injury of the afflicted inmates. Its operation is not more satisfactory
when extended to the duties of inspection. We have heard complaints made
that magistrates sometimes act very arbitrarily in their capacity of
visitors to asylums, and that it is not uncommon for them, instead of
acting in concert with the Commissioners in Lunacy, to place themselves in
opposition to their views. In fact, the Annual Reports of the
Commissioners testify to the not unfrequent want of harmony between the
visiting magistrates and the Commissioners in Lunacy; and the very facts,
that the latter have to make special yearly reports to the Lord Chancellor
on the neglect or unfitness of certain private houses, and that they have
sometimes to apply to him to revoke licences, demonstrate that the
magisterial authorities are at times backward and negligent in their
duties. Indeed, the impression to be gathered from the annual reports of
the Commission is, that almost the only efficient supervision and control
of provincial asylums are exercised by the Lunacy Commissioners.
The publication of the evidence before the Select Committee (1859) adds
fresh proofs that magistrates make but indifferent visitors of asylums,
and but imperfectly protect the interests of the insane; and that an
extension of the jurisdiction and of the inspection by the Lunacy
Commissioners is much needed. We would refer for particulars to queries
and answers numbered from 2582 to 2605, and from 2788 to 2789.
We have commented in previous pages on the manner in which the Visiting
Justices of public asylums perform their duties, and need not repeat the
statements already made; yet we may here remark that the visitation of the
wards of county asylums is often so very carelessly made, that it has
little or no value, and that it is frequently difficult to get the quorum
of two Justices to make it, the majority objecting on personal and other
grounds.
From the foregoing considerations we would advocate the extension of the
Commissioners' jurisdiction, and its assimilation to that in force within
the metropolitan district. To extend it merely to thirty miles around the
metropolis, as some have proposed, would be only to increase the anomaly
complained of. The lunatics, and those in whose charge they live, in every
district in England, should be under one uniform jurisdiction, with the
authority and protection of one set of public officers and one code of
rules. If magisterial supervision have a real value, let it be superadded
to a complete scheme of inspection and control exercised by the Lunacy
Commissioners; and if it exist anywhere, let no district be exempt from
it; for the existence of any such exemption furnishes a standing argument
against the value attributed to its presence. For instance, it may be
fairly asked,--Are the metropolitan licensed houses any the worse for the
absence of magisterial authority, or, otherwise, are the provincial any
better for its presence?
According to Lord Shaftesbury's evidence,--and his Lordship is favourable
to the authority of the Justices being perpetuated,--the system of
licensing provincial houses is sometimes loosely conducted; the house is
only known to the licensing magistrates by the plan presented, and its
internal arrangements must be virtually unknown, inasmuch as no inspection
is made of the premises. This furnishes an argument for handing over the
licensing power to the Commissioners in Lunacy, who exercise this portion
of their duties with the greatest care and after the most minute
examination. But, besides this, the position of a magistrate does not
afford in itself any guarantee of capacity for estimating what the
requirements of the insane ought to be, or of judging of the fitness of a
house for their reception. The act of licensing should certainly be
conducted upon one uniform system and set of regulations; and the
revocation of licences should likewise be in the hands of one body. No
division of opinion should arise between a public Board and a Committee of
Justices respecting the circumstances which should regulate the granting
or the refusing, the continuation or the revocation of a licence. A
divided, and therefore jarring jurisdiction, cannot be beneficial; and the
arguments for the introduction of the magisterial element depend on the
popular plea for the liberty of local government,--a liberty, which too
often tends to the annihilation of all effectual administration.
If our views are correct, and if the jurisdiction of the Commissioners in
Lunacy ought to be increased, then, as a result, the number of
Commissioners must also be augmented. In the need of this increase, very
many, indeed the large majority of persons acquainted with the legal
provisions made for the care and treatment of lunatics, concur; and
reasons for it will still further appear upon a review of the other
functions assigned to the Commissioners, and of those with which we would
charge them.
By existing arrangements there are two State authorities concerned with
lunatics, one particularly charged with their persons, whether rich or
poor,--the Lunacy Commission;--the other with their estates, and
therefore, with those only who have more or less property,--the office of
the Masters in Lunacy. Here, then, is another instance of divided
jurisdiction, although it is one wherein there are no cross-purposes, the
distinction of powers and duties being accurately defined in most
respects. Perhaps the separation of the two authorities is too distinct
and too wide, and a united jurisdiction might work better; but on this
point we forbear to speak, not having the knowledge of the laws of
property and of their administration necessary to guide us to a correct
conclusion. Yet we may thus far express an opinion, that the visitation of
lunatics, whether found so by inquisition or not, should devolve on the
members of the Lunacy Commission. We can perceive no reason for having
distinct medical visitors to Chancery lunatics; as it is, a large number
of such lunatics is found in asylums and licensed houses, and comes
therefore under the inspection of the Commissioners. Thus, according to
the returns moved for by Mr. Tite (1859), it appears there are 602
lunatics, in respect of whom a Commission of Lunacy is in force, and of
these, 300 are inmates of asylums; therefore one-half of the entire number
of such lunatics is regularly inspected by the Lunacy Commissioners, and
the visits of the "Medical Visitors of Lunatics" are nothing else than
formal; we would therefore suggest that two Assistant Commissioners should
be added to the Lunacy Board, who should receive the salaries now payable
to the Chancery lunatics' medical visitors, be disallowed practice, and be
entirely engaged as medical inspectors under the direction of the Board;
or that, in other words, the moneys derived from the Lunacy Masters'
office should be paid over to the Commission for its general purposes,
upon its undertaking to provide for the efficient protection and
visitation of all lunatics, so found on inquisition.
The plan of bringing all lunatics and all so-called 'nervous' patients,
whether placed out singly or detained in asylums of any sort under the
cognizance and care of the Commission, as enlarged upon in previous pages,
would materially augment the labours of the central office; and, in our
humble opinion, a greater division of labour than has hitherto marked the
proceedings of the Commission would greatly facilitate the work to be
done. At present, the members of the Commission perform a threefold
function; viz. of inspectors, reporters, and judges. The task of
inspecting asylums and their insane inmates, of ascertaining the treatment
pursued and examining the hygienic measures provided, is peculiarly one
falling within the province of medical men, and should be chiefly
performed by medical Commissioners. On the other hand, the business of the
Board, in its corporate capacity, is only indirectly and partially
medical. Lord Shaftesbury, indeed, goes so far as to say (query 14, Evid.
Com.) "that the business transacted at the Board is entirely civil in
ninety-nine cases out of one hundred. A purely medical case does not come
before us once in twenty Boards." These considerations certainly appear to
indicate a natural and necessary division of the Board into a deliberative
central body, sitting _en permanence_, once, twice, or oftener in the
week, if necessary, and a corps of visitors and reporters to examine the
state of asylums and the insane throughout the country. This division of
the Commission would obviate the chief objection to an increase of the
number of members; viz. that a larger number of Commissioners than at
present would render the Board unwieldy, and rather impede than facilitate
its business as a deliberative assembly. We entertain, moreover, the
opinion that it would be more satisfactory to those who sought
instructions, or whose affairs or conduct were in any way the subject of
investigation, to have to deal with such a permanent deliberative or
judicial body as proposed, than with one combining, like the members of
the present Board, the various functions of inspectors, reporters, and
judges; a condition, whereby any question agitated must, to a certain
extent, be prejudged by the official reports of the very same persons
called upon to examine it.
Again, if this proposed division of the Lunacy Board took place, it would
furnish a better justification for increasing certain of its powers, as
these would be wielded by a permanent deliberative body, instead of, as at
present, by a Commission exercising mingled functions. The value of the
Board would be increased as a court of reference in all matters, such as
the construction and the size of asylums, where the authority of the
State, by duly ordered channels, is called for to overrule the decisions
of local administrative bodies. Lastly, this arrangement would facilitate
the amalgamation, proposed by some persons, of the office of the Masters
with the Commission in Lunacy; or it would, at least, render the
co-operation and combined action of the two offices more simple and easy.
There are other reasons for an increase of the staff of the Lunacy
Commission, following from the amount of work which, by any revision of
existing statutes, must fall within the compass of its operations. For
instance, we regard the suggestion that we have made, that no uncured
lunatic or 'nervous' patient should be removed from an asylum or other
establishment, without the sanction of the Commissioners and their
approval of the place and conditions to which the removal is intended,--as
very important for the protection of the insane. To carry out this duty
will involve a certain amount of labour, particularly as it would often
require some member of the Commission to examine the patient and the
locality in which it is proposed to place him, and to report on the
expediency of his removal. Often, perhaps, this business might be
entrusted to the district medical officer, particularly in the country. On
the other hand, in the metropolitan district, the work of district medical
officers might be advantageously performed,--at least in all that concerns
the insane,--by a couple of the Assistant Commissioners hereafter spoken
of, in addition to their other duties elsewhere.
Another piece of evidence, to our apprehension, that the present
Commission is inadequate to the multifarious duties imposed upon it, is,
that the Commissioners have never hitherto effectually inspected gaols,
nor succeeded in getting imbecile and lunatic criminals reported to them
with the least approach to accuracy. The inspection of workhouses proved
that it did not suffice to receive the reports of workhouse officials
respecting the existence and number of insane inmates, but that, to
ascertain these facts, personal examination by the Commissioners was
necessary; and there is no satisfactory reason for supposing the
discrimination of insane prisoners to be much better effected than that of
workhouse lunatics, in the many prisons distributed over the country. It
comes out, in the course of the evidence before the Select Committee,
1859, that the Commissioners know little about the insane inmates of
gaols, and that reports of the presence of such inmates are but rarely
supplied them. The law requires the Commissioners to visit gaols where any
lunatics are reported to them to exist; but the duty of reporting is made
the business of no particular individual, and therefore, as a natural
consequence, no one attends to it. In the evidence referred to, the case
of ten alleged lunatics, committed to York Castle and imprisoned there for
a series of years, as criminals acquitted on the ground of insanity,
elicited much attention, and Lord Shaftesbury alluded to the interference
of the Lunacy Commission on behalf of several lunatics in different
prisons. The fact we have brought to light from one Government report, as
stated at p. 6 of this treatise, is of much moment in discussing the
present subject; viz. that there were as many as 216 persons of unsound
mind in the ten convict prisons under the immediate control of the
Government, in the course of one year, and that of these the Dartmoor
Prison wards contained as many as 106 such inmates. There is no allusion,
in the Commissioners' reports or in the printed evidence of the Select
Committee, to show that these insane prisoners were visited by, or known
to, any members of the Lunacy Board. But, besides these insane inmates
thus distinctly made known to us to exist in so few prisons, there must be
many more detained in the numerous houses of detention throughout the
kingdom. These facts render it an obvious duty on the part of the
Commission of Lunacy to ascertaining the number and condition of this
unhappy class of lunatics, and to order suitable provision to be made for
them. There is a disposition on the part of some visitors of gaols to
erect, or set apart, special wards for lunatic prisoners; a system to be
much more deprecated than even the establishment of lunatic wards in
connexion with workhouses, and one which will require the active
interposition of the Lunacy Board to discourage and arrest.
It were easy to take up the duties of the Commissioners in Lunacy in
detail, and to show that they cannot be efficiently performed by the
existing staff; but the fact will be patent to any attentive reader of
this chapter and of the foregoing dissertations on the provisions
necessary for the care and supervision of lunatics in general. The scheme
which we have, with all due deference to established authorities, sketched
in outline, to increase the jurisdiction and usefulness of the Lunacy
Commission, provides for a division of its staff; in the first place, by
altering to a greater or less extent the character and position of the
present Board, so as to constitute it a fixed central Commission or
Council, chiefly charged with adjudging and determining questions put
before it; with superintending the public arrangements for the interests
of the insane generally, and with providing for the good and regular
management, organization, and construction of lunatic asylums; and in the
next place, by instituting, in connexion with this head deliberative body
(which need not, by the way, consist of so many members as the present
Commission), a corps of Assistant Commissioners, specially charged with
the duties of visitation, inspection, and reporting, and with the carrying
out of the resolutions determined on by the deliberative council. At the
same time, the power of visiting and reporting might still be left with
some Commissioners under certain circumstances, as well as in making
special investigations, and in examining matters of dispute raised upon
the reports of the Assistants.
Though differing from so high an authority as the noble chairman of the
Lunacy Board, we must say that we cannot conceive of it as at all a
necessary consequence, that, if the work of visitation to asylums and
lunatics is performed by a class of inspectors or Assistant Commissioners,
and not by the present members of the Commission, it must be indifferently
done, and prove a source of dissatisfaction:--that is, we have no such
apprehensions, provided always that proper men are appointed, and that
their official status is made what it ought to be, both in remuneration
and in independence of position. Nor can we agree to the giving up of the
proposed plan on the score of its expense. If the whole of the lunatic and
'nervous' people suffering confinement in this country are to be brought
within the knowledge and under the supervision of the Lunacy
Commissioners, if the enlarged provisions of the law necessary for their
proper care and treatment,--and even those only among them proposed by the
Commissioners themselves are to be carried into effect,--the Commission
must be increased. And, instead of adding new Commissioners on the same
footing and salary as the existing ones, we believe the public would be
better served by the appointment of Assistant Commissioners with the
duties we have proposed,--two of whom could be remunerated at the same
outlay as one full Commissioner. Moreover, we have proposed that the sum
payable out of the Masters' office to medical visitors be devoted to the
purposes of the Commission; and, if our notion of a central deliberative
body were accepted, one legal and one medical member of the present
Commission could well be spared to undertake more especially the duties of
visiting Commissioners.
Lastly, if the jurisdiction and powers of the Commission were extended to
all lunatics living singly and to so-called 'nervous patients,' a
considerable addition to the treasury would be obtained, even by a small
tax, or per-centage on income. Probably six Assistant Commissioners,
constantly employed in the work of inspection, with the aid of two
visiting chief Commissioners from the present Board, would suffice for the
discharge of the duties to be entrusted to them. If so, the cost of six
such additional officers would be very trifling, covered as it would be by
increased funds passing into the hands of the central office in the
administration of the improved legislation.
If precedent be a recommendation to a plan, it can be found in favour of
appointing Assistant Commissioners in the example of the Scotch Lunacy
Commission, and in the constitution of the Poor Law Board, which has a
distinct class of officers known as inspectors. In fact, every other
Government Board or Commission, except that of Lunacy, has a staff of
Assistants or of Inspectors.
CHAP. XI.--ON SOME PRINCIPLES IN THE CONSTRUCTION OF PUBLIC LUNATIC
ASYLUMS.
In the preceding pages of this book we have had occasion to discuss many
important points respecting the organization of public asylums; and, as we
entertain some views at variance with the prevalent system of asylum
construction, a supplementary chapter to elucidate them cannot be
misplaced. The substance of the following remarks formed the subject of a
chapter on Asylum Construction published by us in the 'Asylum Journal'
(vol. iv. 1858, p. 188) above a year since, and, as we then remarked, the
principles put forward had been adopted by us some five or six years
previously, and were strengthened and confirmed by the extended
observations we had personally made more recently on the plans and
organization of most of the principal asylums of France, Germany, and
Italy.
All the public asylums of this country are, with slight variations,
constructed after one model, in which a corridor, having sleeping-rooms
along one side, and one or more day-rooms at one end,--or a recess (a
sort of dilatation or offset of the corridor at one spot), in lieu of a
room, constituting a section or apartment fitted for constant occupation,
day and night, forms--to use the term in vogue--a 'ward.' An asylum
consists of a larger or smaller number of these wards, united together on
the same level, and also superposed in one, two, three, and occasionally
four stories. There are, indeed, variations observed in different asylums,
consisting chiefly in the manner in which the wards are juxtaposed and
disposed in reference to the block and ground plans, or in the
introduction of accessory rooms, sometimes on the opposite side of the
corridor to the general row of small chambers, to be used as dormitories
or otherwise; but these variations do not involve a departure from the
principle of construction adopted.
Those who have perambulated the corridors of monastic establishments will
recognize in the 'ward-system' a repetition of the same general
arrangements,--a similarity doubtless due in part to the fact of ancient
monasteries having been often appropriated to the residence of the insane,
and in part to the old notions of treatment required by the insane, as
ferocious individuals, to be shut apart from their fellow-men.
Whilst the ideas of treatment just alluded to prevailed, there was good
reason for building corridors and rows of single rooms or cells; but,
since they have been exploded, and a humane system of treating the insane
established in their place, the perpetuation of the 'ward-system' has been
an anomaly and a disastrous mistake. The explanation of the error is to be
found in the facts,--that medical men in England, engaged in the care of
the insane, have contented themselves with suggesting modifications of the
prevailing system,--than which indeed they found no other models in their
own country; and that the usual course has been, to seek plans from
architects, who, having no personal acquaintance with the requirements of
the insane, and the necessary arrangements of asylums, have been compelled
to become copyists of the generally-approved principle of construction,
which they have only ventured to depart from in non-essential details, and
in matters of style and ornamentation.
The literature of asylum architecture in this country evidences the little
attention which has been paid to the subject. The only indigenous work on
asylum-building--for the few pages on construction in Tuke's introduction
to his translation of Jacobi's book, and the still fewer pages in Dr.
Brown's book on asylums, published above twenty years ago, do not assume
the character of treatises--is the small one by Dr. Conolly, and even this
is actually more occupied by a description of internal arrangements in
connexion with the management of lunatics, than by an examination of the
principles and plans of construction. This bald state of English
literature on the subject of construction contrasts strongly with the
numerous publications produced on the Continent, and chiefly by asylum
physicians, the best-qualified judges of what an asylum ought to be in
structure and arrangements.
However, to resume the consideration of the 'ward-system' as it exists,
let us briefly examine it in its relations to the wants and the treatment
of the insane. Every day adds conviction to the impression, that the less
the insane are treated as exceptional beings, the better is it both for
their interests and for those who superintend them. In other words, the
grand object to be kept in view when providing for the accommodation of
the insane, is to assimilate their condition and the circumstances
surrounding them as closely as possible to those of ordinary life. Now,
though it is clearly impracticable to repeat all the conditions of
existence prevailing in the homes of the poorer middle and pauper classes
of society who constitute the inmates of our public asylums, when these
persons are brought together to form a large community for their better
treatment and management, yet we may say of the 'ward-system,' that it is
about as wide a departure from those conditions as can well be conceived.
It is an inversion of those social and domestic arrangements under which
English people habitually live.
The new-comer into the asylum is ushered into a long passage or corridor,
with a series of small doors on one side, and a row of
peculiarly-constructed windows on the other; he finds himself mingled with
a number of eccentric beings, pacing singly up and down the corridor, or
perhaps collected in unsocial groups in a room opening out of it, or in a
nondescript sort of space formed by a bulging-out of its wall at one spot,
duly lighted, and furnished with tables, benches, and chairs, but withal
not a room within the meaning of the term, and in the patient's
apprehension. Presently, he will be introduced through one of the many
little doors around him into his single sleeping-room, or will find
himself lodged in a dormitory with several others, and by degrees will
learn that another little door admits him to a lavatory, another to a
bath, another to a scullery or store-closet, another to a water-closet
(with which probably he has never been before in such close relation),
another to a _sanctum sanctorum_--the attendant's room, within which he
must not enter. Within this curiously constructed and arranged place he
will discover his lot to be cast for all the purposes of life, excepting
when out-door exercise or employment in a workroom calls him away: within
it he will have to take his meals, to find his private occupation or
amusement, or join in intercourse with his fellow-inmates, to take indoor
exercise, and seek repose in sleep; he will breathe the same air, occupy
the same space, and be surrounded by the same objects, night and day.
This sketch may suffice to illustrate the relations of a ward as a place
of abode for patients, and to exhibit how widely different are all the
arrangements from those they have been accustomed to. Let us now notice
briefly the relations of the ward-system to the treatment required for
insane inmates. The monotonous existence is unfavourable: the same
apartment and objects night and day, and the same arrangements and
routine, necessitated by living in a ward, are not conducive to the relief
of the disordered mind. Where access to the sleeping-rooms is permitted by
day, the torpid and indolent, the melancholic, the morose and the
mischievous, will find occasion and inducement to indulge in their several
humours; opportunity is afforded them to elude the eye of the attendants,
to indulge in reverie, and to cherish their morbid sentiments. When the
rules of the institution forbid resort to their rooms by day, the idea of
being hardly dealt with by the refusal will probably arise in their minds,
since the inducement to use them is suggested by their contiguity; the
doors, close at hand, will ever create the desire to indulge in the
withheld gratification of entering them. How many insane are animated with
a desire to lounge, to mope unseen, and to lie in bed, needs not to be
told to those conversant with their peculiarities; and, surely, the
removal of the temptation to indulge would be a boon both to physician and
patients.
Again, the corridor and its suite of rooms present obstacles to
ventilation and warming, and, as the former in general serves, besides the
purpose of a covered promenade, that of a passage of communication between
adjoining wards, it is less fitted for the general purposes of daily life,
and the passage to and fro of persons through it is a source of
disturbance to its occupants, and often objectionable to the passer-by. As
a place of indoor exercise, the corridor has little real value, especially
when considered in relation to the other objects it has to serve. Those
who desire to sit still, to read, to amuse or to employ themselves, feel
it an annoyance to have one or more individuals walking up and down, and
often disposed to vagaries of various sorts; few of the whole number care
for perambulating it if they can get out of doors for exercise (and there
are not many days when they cannot), and, as far as concerns the health of
those few who use the corridor for exercise, it would be better to
encourage them to walk in the grounds, than, by having such a space within
doors, to induce their remaining there.
When casual sickness or temporary indisposition overtakes a patient, and a
removal to the infirmary ward is not needed, though repose is required, it
is a great disadvantage to have an exercising corridor in such immediate
contiguity with the bedroom, and to have the room open into the corridor;
for it is an arrangement more or less destructive of quiet, and exposes
the poor sufferer to the intrusion of the other inmates of the ward,
unless the room-door be locked,--a proceeding rarely advisable under the
circumstances supposed.
The introduction of the plan of building an open recess in a corridor as a
sitting apartment instead of an ordinary room was a consequence of the
difficulties experienced in exercising an efficient supervision of the
inmates when dispersed, some in the corridor, and others in the day or
dining rooms. Yet, although the plan in question partially removes these
difficulties, no one could wish to exchange the advantages in comfort and
appearance of a sitting-room with the greater approximation it affords to
the ordinary structure of a house, for a recess in a corridor, if
effectual supervision could in any other way be attained. But the plan of
a corridor with an offset in lieu of a room does not secure a completely
effective oversight, control, and regulation of the occupants, since it
presents many opportunities, in its large space, and by the disposition of
its parts, for those to mope who may be so disposed, and for the
disorderly to annoy their neighbours, without arresting the attention of
the one or two attendants.
In the construction and arrangements of a ward, it is necessary to provide
for all the wants of the inmates both by day and night, to supply the
fittings and furniture needed by the little community inhabiting it; and
all such arrangements and conveniences have consequently to be repeated in
every one of the many wards found in the asylum, at a very large cost.
Again, by the ward-system, the patients are lodged on each floor of the
building, and therefore the service of the asylum becomes more difficult,
just in proportion to the number of stories above the ground-floor, or the
basement, where the kitchen and other general offices are situated. It is
chiefly to obviate this difficulty that the elevation of our public
asylums has been limited to two stories, and a greater expenditure thereby
incurred for their extension over a larger area. (See p. 212.)
From whatever point of view the ward-system may be regarded, there is in
it, to our view, an absence of all those domestic and social arrangements
and provisions which give a charm to the homes of English people. The
peculiar combination of day and night accommodation is without analogy in
any house; whilst the sitting, working, or reading, and, occasionally, the
taking of meals, in a corridor, a place used also for exercise, and for
the passage of persons from one part of the asylum to another, represent
conditions of life without parallel among the domestic arrangements of any
classes of the community.
The principle of construction we contend for is, the separation, as far as
practicable, of the day from the night accommodation. Instead of building
wards fitted for the constant habitation of their inmates, we propose to
construct a series of sitting or day rooms on the ground-floor, and to
devote the stories above entirely to bedroom accommodation. Not that we
would have none to sleep on the ground-floor, for we recognise the utility
of supplying accommodation there, both by night and day, for certain
classes of patients, such, for instance, as the aged and infirm, who can
with difficulty mount or descend stairs; the paralytics; some epileptics,
and others of dirty habits, and the most refractory and noisy patients.
The last-named are, in our opinion, best lodged in a detached wing,
particularly during their paroxysms of noise and fury, according to the
plan adopted in several French asylums. And we may, by the way, remark,
that if such patients were so disposed of, one reason assigned for
internal corridors as places requisite for indoor exercise, would be set
aside, inasmuch as these are supposed practically to be most useful to
that class of asylum inmates.
In our paper on construction in the 'Asylum Journal,' before referred to,
we illustrated (_op. cit._ p. 194) our views by reference to a rough
outline of a part of a plan for a public asylum we had some years before
designed; but it seems unnecessary to reproduce that special plan here,
since, if the principle advocated be accepted, it becomes a mere matter of
detail to arrange the disposition, the relative dimensions, and such like
particulars, whether of the day-rooms below or of the chambers above.
There is this much, however, worth noting, that, by the construction of
adjoining capacious sitting-rooms, it is easy so to order it, that any
two, or even three, may, by means of folding-doors, be thrown into one,
and a suite of rooms obtained suited for public occasions, for dancing,
for lectures, or theatricals. So again, even in the case of those who may
be placed together in the same section of the establishment, and who join
at meals, the construction of two or more contiguous sitting-rooms affords
an opportunity for a more careful classification, in consideration of
their different tastes, and of their capability for association, for
employment, or for amusement.
However, without delaying to point out the advantages accruing in minor
details of internal arrangements when the principle is carried out, let us
briefly examine its merits abstractedly, and in relation to the system in
vogue.
1. It assimilates the condition of the patients to that of ordinary life,
as far as can be done in a public institution. They are brought together
by day into a series of sitting-rooms adapted to the particular class
inhabiting them, and varied in fittings and furniture according to the
particular use to which they are applied,--as, for instance, for taking
meals, or for the lighter sorts of work, indoor amusements, and reading.
For the sections, indeed, inhabited by the more refractory and the
epileptic, a single day-room would suffice. When thus brought together in
rooms, instead of being distributed along a corridor and its divergent
apartments, association between the several patients can be more readily
promoted; and this is a matter worth promoting, for the insane are
morbidly selfish and exclusive. Likewise, it becomes more easy for the
attendants to direct and watch them in their amusements or occupations,
and to give special attention or encouragement to some one or more of
their number without overlooking the rest. Besides this, rooms admit of
being arranged and furnished as such apartments should be; whilst,
whatever money may be laid out in furnishing and ornamenting corridors,
they can never be rendered like any sort of apartment to be met with in
the homes of English people. The separation of the sleeping-rooms from the
day accommodation also has the similar advantage of meeting the wishes and
habits of our countrymen, who always strive to secure themselves a sitting
and a bed room apart: and, altogether, it may be said, that in a suite of
day-rooms disposed after the plan advocated, and in the perfectly
separated bedroom accommodation, there is, to use a peculiarly English
word, a _comfort_ completely unattainable by the ward-system, however
thoroughly developed.
2. Greater salubrity and greater facilities for warming and ventilation
are secured. It will be universally conceded that sleeping-rooms are more
healthy when placed above the ground-floor, so as to escape the constant
humidity and exhalations from the earth, particularly at night. The system
suggested secures this greater salubrity for the majority of the
population, who occupy the upper floors during the night; those only being
excepted, whom, for some sufficient reason, it is desirable not to move up
and down stairs, or not to lodge at night in the immediate vicinity of the
rest of the patients. Again, the separation of the apartments for use by
day from those occupied at night favours the health of the establishment
by rendering ventilation more easy and complete. In a ward occupied all
day and all night, the air is subject to perpetual vitiation, and, whilst
patients are present, it is, especially in bad weather, difficult or quite
unadvisable to attempt thorough ventilation by the natural means of
opening windows and doors,--a means which we believe to be preferable to
all the schemes of artificial ventilation of all the ingenious engineers
who have attempted to make the currents of air and the law of diffusion of
gases obedient to their behests. But "the wind bloweth where it listeth,"
and all the traps set to catch the foul exhalations, and all the jets of
prepared fresh air sent in from other quarters, will not serve their
bidding: the airy currents will disport themselves pretty much as they
please, and intermingle in spite of the solicitations of opposing flues to
draw them different ways. But if, on our plan, the apartments for day use
are kept completely distinct from those used by night, each set being
emptied alternately, a most thorough renewal of air may be obtained by
every aperture communicating with the external atmosphere.
The actual construction of a ward creates an impediment to the perfect
ventilation of all its apartments. There is a wide corridor, and along one
side a series of small chambers, the windows of which are necessarily
small, and sometimes high up; the windows, too, both in rooms and
corridor, must be peculiarly constructed, and the openings in them for
ventilation small. Although it is easy in this arrangement to get a free
circulation of air along the corridor, it is not so to obtain it for each
room opening out of it. By the scheme of construction we propose, these
difficulties are mostly removed. The day-rooms on the ground-floor need no
corridor alongside, and, as a single series or line of apartments, are
permeated by a current of air traversing them from side to side. But if,
for the convenience of the service of the house, some passage were thought
necessary, it would be external to the rooms, and in designing the asylum
it should be an object to prevent such corridors of communication
interfering with the introduction of windows on the opposite sides of each
sitting-room. On the bedroom-floor above, a corridor, where necessary,
would not be a wide space for exercise, such as is required for a ward,
but merely a passage, giving access from one part of the building to
another. So, with respect to the windows, except those in the single
bedrooms, it would be perfectly compatible with security to construct them
much after the usual style adopted in ordinary houses, and thereby allow
large openings for the free circulation of air.
Further, when the patients inhabit ordinarily-constructed sitting-rooms,
the warming of these may be effected by the common open fires, which are
dear to the sight and feelings of every Englishman, and impart a cheerful
and home-like character. Likewise, there would be no need of keeping the
whole building constantly heated at an enormous expense; for only one half
of it would be occupied at a time, nor would those most costly and
complicated systems of heating be at all required. The saving in large
public asylums would be something very large in this one item,--that of
fuel to burn, without counting the expenditure which is generally incurred
for the heating apparatus, flues, furnaces, and shafts. As with the
warming, so with the lighting of an institution constructed on our
model,--only one-half would require illumination at the same time, and
much gas-fitting would be saved by the diminution of the number of small
apartments, repeated, after the prevailing model, in every ward, and
requiring to be lighted.
3. Access to the airing courts, offices, workshops, &c., becomes easier to
all the inmates. According to the established system of construction, the
half, or upwards, of the patients have to descend from the wards on the
upper floors for exercise or for work, and to ascend again to them for
their meals, or to retire to rest. This ascent and descent of stairs may
have to be repeated several times daily; and it must be remembered that it
cannot take place without the risk of various inconveniences and dangers
necessarily dependent on stairs, and that it must frequently entail
trouble and anxiety upon the attendants, particularly in mischievous and
in feeble cases. The plan advocated obviates all these evils, so far as
practicable. The patients would have to go up and down stairs only once
a-day, and the attendants, therefore, escape much of the constantly
occurring trouble of helping the feeble, or of inducing the unwilling to
undertake the repeated ascent and descent,--a task ever likely to be
neglected, and to lead to patients being deprived, to a greater or less
extent, of out-door exercise and amusement.
4. It facilitates supervision. Supervision, both by the medical officers
and by the attendants, becomes much more easy and effectual when the
patients are collected in rooms, affording them no corners or
hiding-places for moping and indulging in their mental vagaries, their
selfishness and moroseness. When the medical officer enters the day-room,
all the inmates come at once under his observation, and this affords him
the best opportunity of noting their cases, and of discovering their
condition and progress. By the attendants similar advantages are to be
gained; the patients will be more immediately and constantly under their
eye than when distributed in a corridor and connected rooms; their
requirements will be sooner perceived, and more readily supplied; their
peculiarities better detected and provided against; their insane
tendencies more easily controlled and directed; whilst, at the same time,
the degree and mode of association will call forth feelings of interest
and attachment between the two.
Just as supervision becomes more easy by day, so does watching by night;
for almost the whole staff of attendants would sleep on the same floor
with the patients, and thereby a more immediate communication between them
be established, and a salutary check on the conduct of the latter, from
the knowledge of the attendants being close at hand, more fully attained.
Perhaps these advantages will appear more clear when it is understood that
the subdivision of the bed-room floor into several distinct wards, cut
off from each other by doors, stair-landings, &c., would not be at all
necessary on the principle of construction recommended. The comparatively
few noisy patients in a well-regulated asylum would occupy the
sleeping-rooms of the ground-floor wings, if not placed in a distinct
section; and therefore, the inhabitants of the floor above being all quiet
patients, no partitions need separate their section of the building into
distinct portions or wards, and act as impediments to the freedom of
communication and ventilation.
This matter of the partitions needed is, however, a point of detail, which
would have to be determined pretty much by the general design adopted.
5. Classification is more perfect. Owing to the sleeping apartments being
quite distinct from those occupied by day, the rule usually observed in a
ward, as a matter of necessary convenience, of keeping the same group of
occupants in it both night and day, need not at all be followed. On
retiring from their sitting-rooms, where they have been placed according
to the principles of classification pursued, the day association would be
broken up, and their distribution in the sleeping-rooms might be regulated
according to their peculiar requirements at night. This valuable idea, of
arranging patients differently by day and by night, was put forward by Dr.
Sankey, of Hanwell ('Asylum Journal,' vol. ii. 1856, p. 473), in the
following paragraph:--"Whatever the basis of the classification, it will
not hold good throughout the twenty-four hours: why, therefore, should it
be attempted to make it do so? At night the classification should be based
on the requirement of the patient during the night; and during the day,
the patient should be placed where he can be best attended during the
day." Let us add, that the more perfectly Dr. Sankey's principle could be
carried out, the more easy would supervision be rendered.
Since mechanical restraint has been set aside, seclusion in a
specially-constructed chamber, or in the patient's own room, has in some
measure taken its place, and been frequently abused; for it is more
difficult to control the employment of seclusion than of instrumental
restraint, and in a ward there is almost a temptation to employ it where a
patient is inconveniently troublesome to the attendant; the single room is
close at hand, and it is a simple matter to thrust the patient into it,
and an easy one to release him if the footstep of the superintendent is
heard approaching. The plan of construction we would substitute for the
ward-system would almost of itself cure the evil alluded to. Furthermore,
since sitting-rooms and other apartments to meet the exigencies of daily
use are excluded from the upper floors, it would become easier for the
architect to dispose the single rooms and dormitories, and more
especially the attendants' rooms, with a view to the most effectual
supervision. We may, in fine, state under the two last heads, generally,
that access to the patients, their quiet and comfort, their watching and
tending and their classification will be more readily and also more
efficiently secured by the arrangement pointed out, than by the system of
construction hitherto pursued in this country.
6. Domestic arrangements will be facilitated in various ways.--The
patients, in the first place, will be less disturbed by the necessary
operations of cleaning, which every superintendent knows are apt to be a
source of irritation and annoyance, both to patients and attendants. The
ground-floor may be prepared for the day's use before the patients leave
their bedrooms; and in the same way the latter may be cleaned during the
occupation of the ground-floor. By the present constitution of a ward for
use both night and day, considerable inconvenience, and many
irregularities in management constantly result. The cleaning has to be
hurried over, or to be done at awkward hours, to avoid alike the
interruption of patients, or the being interrupted by them; and, at the
best, it will from time to time happen that patients are excluded from
their day or their bedrooms, or from the corridors, during the operation.
Another advantage will accrue from the system proposed. The amount of
cleaning will be much diminished, for the two floors will be used only
alternately, and not only the wear and tear of the entire building, but
also the exposure to dirt will be greatly lessened; above all, the small
extent of corridor will make an immense difference in the labour of the
attendants in cleaning, compared with that which now falls to their lot.
Again, the drying of floors after they have been washed is always a
difficulty, particularly in winter, and is the more felt in the case of
the bedrooms, which have, when single-bedded or small, but a slight
current of air through them, and consequently dry slowly. This difficulty
is augmented, when, as it often happens, it is necessary for them to be
kept locked, to prevent the intrusion of their occupants or of others. The
ill effects of frequently wetted floors in apartments constantly occupied,
and therefore dried during occupation, have been fully recognized and
admitted by hospital surgeons, and have impressed some so strongly, that,
to escape them, they have substituted dry rubbing and polished floors to
avoid the pail and scrubbing-brush. By the arrangements submitted,
however, this difficulty in washing the floors is removed, since there is
no constant occupancy of the rooms, and therefore ample time for drying
permitted.
Further, by the plan in question, the distribution of food, of medicine,
and of stores, becomes more easy and rapid; the collection, and the
serving of the patients at meals, are greatly simplified and expedited. A
regularity of management in many minor details will likewise be promoted.
As the majority of the patients are quite removed from proximity to their
sleeping-rooms, the temptation and inducement to indulge in bed by day, or
before the appointed hour at night, will be removed, as will also the
irregularity frequently seen in wards some time before the hour of bed, of
patients prematurely stowed away in their beds, and of others disrobing,
whilst the remainder of the population is indulging in its amusements, its
gossips, or in the 'quiet pipe,' before turning in.
7. Management facilitated.--Our own experience convinces us that there is
no plan so effectual for keeping otherwise restless and refractory
patients in order as that of bringing them together into a room, under the
immediate influence and control of an attendant, who will do his best to
divert or employ them. We are, let it be understood, only now speaking of
their management when necessarily in-doors; for, where there is no
impediment to it, there is nothing so salutary to such patients as
out-door exercise, amusement, and employment. On the contrary, to turn
refractory patients loose into a large corridor, we hold to be generally
objectionable. Its dimensions suggest movement; the patient will walk
fast, run, jump, or dance about, and will, under the spur of his activity,
meddle with others, or with furniture, and the like; and if an attendant
follow or interfere, irritation will often ensue. But in a room with an
attendant at hand, there are neither the same inducements nor similar
opportunities for such irregularities. Some would say, such a patient is
well placed in a corridor, for he there works off his superabundant
activity. But we cannot subscribe to this doctrine; for we believe the
undue activity may be first called forth by his being placed in a
corridor; and that it is besides rare that a patient, particularly if his
attack be recent, has any actual strength to waste in such constant
abnormal activity as the existence of a space to exercise it in
encourages. And, lastly, it is better to restrict the exhibition of such
perverted movement to the exercising grounds, or better still to divert it
to some useful purpose by occupation; for in a ward such exhibitions are
contagious.
These remarks bear upon the question of the purpose and utility of
corridors as places for exercise, concerning which we have previously
expressed ourselves as having a poor opinion, and have throughout treated
corridors mainly as passages or means of communication.
8. A less staff of attendants required.--If the foregoing propositions,
relative to the advantages of the system propounded, be admitted, the
corollary, that a less staff of attendants will suffice, must likewise be
granted, and needs not a separate demonstration. There is this much,
however, to be said, that the proposition made in a former page to
distinguish attendants upon the insane from the cleaners or those more
immediately concerned in the domestic work of the house, would be an
easier matter when the construction followed the principles recommended.
The attendants upon the occupants of the sitting-rooms need be but few,
for their attention would not be distracted from their patients by
domestic details; for the cleaners would prepare the apartments ready for
occupation, would be engaged in fetching and carrying meals, fuel, and
other things necessary for use, and the attendants would thereby be
deprived of numerous excuses for absence from their rooms, and for
irregularities occurring during their occupation with household duties.
9. The actual cost of construction of an asylum on the plan set forth
would be greatly diminished.--It has just been shown that the proposed
plan will ensure a more ready and economical management; and if structural
details could be here entered upon, in connexion with an estimate of costs
for work and materials, it could without difficulty be proved, that the
cost of accommodation per head, for the patients, would fall much under
that entailed by the plan of building generally followed. The professional
architect who assisted us made a most careful estimate of the cost of
carrying out the particular plan we prepared (designed to accommodate 220
patients), and calculated that every expense of construction, including
drainage of the site, gas apparatus, farm-buildings, &c., would be covered
by £19,000, _i. e._ at the rate of less than £90 (£87) per head.
That a considerable saving must attend the system propounded will be
evident from the fact, that, instead of a corridor, on the first floor, at
least twelve feet wide, as constructed on the prevailing plan, one of six
feet, or less, simply as a passage for communication, is all that is
required, and thus a saving of about that number of feet in the thickness
or depth of the building, in each story above the ground-floor, is at once
gained. A similar, though smaller, economical advantage is likewise
obtained on the ground-floor, for the corridor there need be nothing more
than an external appendage, and of little cost to construct.
A further saving would attend the construction of an asylum on the plan
set forth, both from the concentration of the several parts for night and
day use respectively, and generally from the rejection of the ward-system.
The construction of almost all the sleeping accommodation on one floor
would render many provisions for safety and convenience unnecessary,--for
instance, in the construction of the windows. So the substitution of what
may be termed divisions, or quarters in lieu of wards, would do away with
the necessity of many arrangements requisite for apartments, when intended
for use, both by night and day. As constructed commonly, each ward is a
complete residence in itself, replete with all the requisites for
every-day life, except indeed in the cooking department; and the
consequence is, there is a great repetition throughout the institution of
similar conveniences and appurtenances. Indeed, in the plan we designed,
the influence of example or general usage led us to introduce many
repetitions of several accessory apartments, which were, in fact, uncalled
for, and added much to the estimate. For instance, we assigned a bath-room
to each division, although we consider that a room, well-placed, to
contain several baths (_i. e._ in French phrase, a 'salle des bains'),
would more conveniently serve the purpose of the whole ground-floor
inmates, and be much cheaper to construct and to supply. Yet, if this
notion of a 'bath-house' be unacceptable to English Asylum
Superintendents, a smaller number of bath-rooms than was either provided
in the particular plan alluded to, or is usually apportioned to asylums,
would assuredly suffice. The same may be said of the lavatories,
sculleries, and store-rooms.
10. The plan removes most of the objections to the erection of a
second-floor or third-story.
These objections generally owe their force to the difficulty of assuring
the inmates of a third-story their due amount of attention, and their fair
share of out-door exercise, and of much indoor amusement, without
entailing such trouble upon all parties concerned, that a frequent
dereliction or negligence of duty is almost a necessary consequence.
Dr. Bucknill ('Asylum Journal,' vol. iii., 1857, p. 387, _et seq._) has
well argued against the erection of a third-story, on economical grounds;
and remarks that "practically, in asylums built with a multiplicity of
stories, the patients who live aloft, are, to a considerable extent,
removed from the enjoyment of air and exercise, and the care and sympathy
of their fellow-men. They are less visited by the asylum officers, and
they less frequently and fully enjoy the blessings of out-door recreation
and exercise. Those below will have many a half-hour's run from which they
are debarred; the half-hours of sunshine on rainy days, the half-hours
following meals, and many of the scraps of time, which are idly, but not
uselessly spent, in breathing the fresh air."
The foregoing considerations are certainly sufficient to condemn the
appropriation of a third story for the day and night uses of patients,
according to the 'ward-system' in operation; but they have no weight when
the floor is occupied only for sleeping. We must confess we cannot
appreciate the chief objection of Dr. Bucknill (_op. cit._ pp. 388, 389,)
to the use of a third floor for sleeping-rooms only, for we do not see the
reason why "the use of a whole story for sleeping-rooms renders the
single-room arrangement exceedingly inconvenient;" for surely, on the
common plan of construction, a row of single rooms might extend the whole
length of a third floor on one side of a corridor, equally well as on the
floors beneath.
Without desiring to enter on the question of the relative merits of
single-room and of dormitory accommodation, to examine which is the
special object of the paper quoted, we may remark, that the addition of a
third story, when the plan we have advocated is carried out, obviates the
generally admitted objections to such a proceeding. The same arrangement
of apartments may obtain in it as on the bedroom-floor below, and the
proportion of single rooms to dormitories, viz. one-third of the whole
sleeping accommodation to the former, insisted upon by Dr. Bucknill, can
be readily supplied. Attention would only be required to allow in the plan
sufficient day-room space on the ground-floor,--a requirement to be met
without difficulty.
The existence of a third story is no necessary feature to an asylum
constructed on the principle discussed, and we have adverted to it for the
sole purpose of showing that the ordinary objections to it are invalid,
when the arrangement and purposes of its accommodation are rendered
conformable to the general principles of construction advocated in this
chapter.
A hint from Dr. Bucknill's excellent remarks on the advantage of being
able to utilize spare half-hours must not be lost. Two flights of stairs,
he well states, constitute a great obstacle to a frequent and ready access
to the open air, and we are sure he would allow even one to be a
considerable impediment to it; and, consequently, that an asylum with no
stairs interposing between the patients and their pleasure-grounds would
possess the advantage of facilitating their enjoyment of them.
These remarks on the advantages of the principle of construction we advise
for adoption would admit of extension, but sufficient has been advanced,
we trust, to make good our views. We have taken in hand to write a chapter
on some principles in the construction of public asylums, but we must stop
at the point we have now reached; for it would grow into a treatise, did
we attempt to examine the many principles propounded, and entirely surpass
the end and aim of this present work.