John Conolly, 1847 The Construction and Government of Lunatic Asylums and Hospitals for the Insane

CHAPTER 2.

Arrangement of Galleries and Sleeping-rooms.- Inspection-plates - Doors and Windows - Warming and Ventilation - Lighting at Night - Cleanliness - Sources of Offensive Smells - Dormitories, Water-closets, Sinks, etc. etc., their most convenient Arrangement.- Store-rooms.- Washing-rooms. - Baths. - Modifications required in Asylums for Patients of various Classes

The door of every bedroom at Hanwell is fitted up with what is called an inspection-plate, placed at so convenient a height that it may be looked through, if necessary, as the attendant passes along the galleries. The plate is made of iron, and towards the gallery merely presents a flat surface and a small circular opening, over which there is a cover, which moves without noise, and may be fastened when desirable ; the inside of the plate is broad and concave towards the patient's room, all parts of which thus become visible by looking through the opening from the outside. These plates are convenient in every part of the asylum, but only absolutely necessary for rooms in which refractory patients are occasionally secluded in the daytime. This little contrivance is connected with a very essential particular in the treatment of violent patients, being a means of ascertaining, from time to time, the state of any patient who is placed in temporary seclusion. When the use of restraints was first forbidden, the safety of the attendants, and of the patients themselves, required that those in charge of the wards should have authority to place violent or unruly patients in their bedrooms for a time, locking the door. By occasionally looking through the inspection-plate, the attendant is enabled to ascertain the effect of the seclusion; and the medical officers, to whom every [p.27] seclusion is, or ought to be, immediately reported, are enabled to judge of the propriety of continuing or putting an end to it. "We expect, when going through any gallery, to be informed what patients are in seclusion ; and as the state of the patient can be immediately ascertained, a check is exercised over the abuse of an important remedial measure. The inspection-plate should be so made that the lid can be moved without the slightest noise ; and a very little movement of it is sufficient. Some patients are peculiarly sensitive concerning being watched, and contrive to hang up clothes so as to obstruct inspection. This is chiefly the case with patients whom it is not necessary to look so closely after when left to themselves; but in the refractory wards the practice must not be permitted, or in the case of patients disposed to suicide.

The inspection plate at Hanwell is simple and efficient: the insertion of glass or wire in the opening, as sometimes recommended, would be attended with inconvenience ; but as some patients are disposed to injure the eyes of the attendants when applied to the opening, a little caution is required, which is easily practised. In some foreign asylums, the patient's room is inspected through a window above the door; and for this the attendant requires a ladder; and the ladder has to be brought from the end of the gallery ; so that the inspection cannot be expected to be very efficient. In other asylums, secret openings in the walls or roof have been proposed; but this, like most departures from simplicity of arrangement in an asylum, would seem to be a mere perversion of ingenuity. The active curiosity and sharpened senses of most of the patients would immediately discover these supposed secret openings; and they would be more likely to be offended by them than by a more avowed watchfulness, and would even triumph over the defeated contrivance. I have sometimes derived useful suggestions from intelligent patients, in the intervals between their paroxysms, respecting the management of others, or even of themselves, when refractory; and in most of such cases, all attempts at concealment or deception have been shown by their [p.28] observations to be eminently useless. However troublesome such patients may occasionally be, they know and appreciate everything that is done, whether they are well or ill, and any deceptions practised upon them are usually worse than futile.

Another useful application of the inspection-plate is found in its enabling us to ascertain the state of the sick and feeble, or of the restless, whom it may have been desirable to leave for a time undisturbed. Patients in a very helpless state, or patients who have just had violent epileptic attacks, are often most securely placed in rooms in which there is a very low bedstead, and no other furniture, - or in rooms of which the whole floor is covered with bedding. Our padded rooms are much more frequently required for such patients than for violent patients, or for those disposed to strike their heads against the wall. Some of our paralytic patients, when reduced to a state of extreme helplessness, are placed in such rooms, and several of our epileptics ; but when restraints were employed, such patients were fastened to common bedsteads, often in loose straw, and became violent from excess of physical misery. Restraint was the grand substitute for inspection, superintendence, cleanliness, and every kind attention. It was not until restraints had been for some time abolished that I ever found the inspection-plates properly attended to. Troublesome patients were securely fastened down, and nobody seemed to care what condition they were in.

It is desirable to have window-shutters to most or all of the bedrooms. They are indispensable in the bedrooms of refractory wards, and should be made to shut easily, and to fasten with a small spring-lock, or in some way which occasions no delay, and so as not to be unfastened by the patients. Sufficient light should be admitted through perforations in the shutter to make the inspection of a patient secluded in the daytime practicable. Seclusion in total darkness is seldom, perhaps never, necessary ; and it would often be a dreadful punishment, either much aggravating the patient's agitation, or exciting frightful [p.29] thoughts. In visiting patients in private houses, I generally find the rooms made totally dark, but filled with anxious relatives, attendants, and half the servants of the house. All these things are unfriendly to the patient's tranquillity, and produce suspicion, fear, and increased violence. The locks of the bedroom doors should not be spring-locks, but simple locks, of a strong construction. There is great danger of injuring a patient who tries to come out of his room against the will of the attendant if the door fastens with a spring-lock; and the doors would, of course, be locked whenever closed, which would be highly inconvenient both to patients and attendants. The doors of the galleries should have spring-locks, without which they will seldom be locked at all. All the locks in the house should be so made, and so kept in order, as to open and close with the least possible noise. The jingling of keys, the clang of the locks, and the violent opening or shutting of the doors of bedrooms and galleries, are generally considered of no consequence by the attendants ; but they produce the most uncomfortable feelings in the patients. The gallery doors should have large handles, enabling those who pass through to shut the door quietly. The state of a whole ward may immediately be altered by persons hastily and noisily passing through. There is, however, no point so little attended to by the generality of attendants, servants, workpeople, officers, and even by the official visitors of all asylums. The physician's caution is generally despised, and his example disregarded. Doors are thrown suddenly open; attendants are loudly or fiercely called for; unexplained intimations are given of something being wrong somewhere ; the ward is hastily passed through ; the hindering patients are put aside; the door is violently shut; the next ward and the next are similarly invaded ; and the whole of the inmates, attendants as well as patients, are left in a state of agitation, or even of alarm. I have often, in former times, discerned the impression of these impetuous visits so distinctly left as to make me inquire into its cause ; and have had deep reason to lament that it should be so much forgotten that the [p.30] manner, the voice, the words, the very step of those who pass through a house full of insane people ought to be calm and tranquillizing. Those most conversant with the insane will the most readily acquit me of exaggerating the importance of these matters. Being desirous, whenever I suggest arrangements which appear at first sight to be but remotely connected with medical treatment, to append the reason to the suggestion, my remarks on all points of building and construction become unavoidably mingled with some details of treatment; for the only standard I acknowledge in all the arrangements, is that of their bearing on the patients. There is no other test of their goodness or badness.

No part of the subject of the construction of asylums is more difficult to give a satisfactory opinion upon than that which relates to the proper method of warming and ventilating such buildings. Different plans are in use in different asylums, and yet ventilation is generally found to be imperfect, and the temperature of different parts of the building in winter very unequal, varying in different wards as much, sometimes, as twenty degrees of Fahrenheit. If story is piled upon story, and basement wards and dormitories are excavated, I believe no system of ventilation will prevent the air of the asylum from being generally unwholesome, and often highly offensive. From subterranean dormitories insidious streams of corrupted air are for ever rising, pervading every room above ground, ascending every staircase, and infecting every corner. Visitors go round such buildings in the middle of the day, and do not perceive this, although in certain states of the weather it is very perceptible; but those who live in asylums, and who have to return to them after breathing the fresh air of the evening, or who visit the wards, and occasionally enter the bedrooms at night, or who even pass the head of staircases leading to basement dormitories, in which the patients have been sleeping two or three hours, know too well that the air becomes so impure as sometimes to occasion immediate sickness; and although the governing bodies may persist in accumulating [p.31] beds wherever they can be placed, so close to each other as almost to touch, and subservient officers will permit these un-salutary practices, nothing is more certain than that all this is done at the expense of the general health of the whole establishment. In such asylums some of the attendants are always sick; febrile attacks, attended with great debility, are very common among them; what is called influenza becomes, as it were, domiciled and perpetual among them; and no one living under the roof of the asylum has the appearance of being in perfectly good health. Impaired health induces impaired spirits, and the efficiency of the attendants, and even of the officers, becomes manifestly diminished. They are too soon fatigued, and too easily dispirited; they are less comfortable, and less forbearing; and the final result of all these faults, and their consequences, is, that the patients suffer.

At Hanwell the ventilation is merely effected by the ordinary doors and windows, aided in some parts of the building by openings in the walls, or openings communicating with the roof. These openings, and some additional doors and windows in the basement story, have much improved the general ventilation of the building within the last few years, and it is seldom now that the heavy and peculiar atmosphere which used to pervade the wards is perceptible. The circular portions of the building, and the large dormitories in the basement, present the greatest difficulties in respect to efficient ventilation. Nearly the whole of the asylum is warmed by means of steam admitted into iron pipes, placed, in the older wards, about seven feet from the floor of the galleries, and in the newer parts, beneath the floor, and in some of the sleeping-rooms a little above the floor, inclosed in perforated wooden cases.

The chief objection to warming an asylum by steam is, that the warmth thus produced is very unequal in different parts of the building; oppressive in the wards nearest the boilers, and not sufficient in wards more remote; and that it also varies at different heights of the building. Generally speaking, the newest portions of the asylum, in which the steam-pipes are [p.32] beneath the floor, are the most comfortable in cold weather, and the temperature appears to be more equally kept up in them. The general coldness of the bedrooms is a great evil; they never attain the warmth of the galleries, except when steam-pipes are introduced into them. At night, except in very severe weather, the steam is turned off, and the coldness of some of the wards then, and in the morning when the patients are expected to get up, is extreme.

It is difficult to keep up the proper heat all night for the production of steam; and this particular inconvenience may be avoided, by adopting the plan of warming an asylum by means of hot-water pipes, in which the water will circulate if its temperature is kept at 120" Fahr. But this mode of warming is only applicable to small buildings, and a general preference seems now given to providing for the general warmth of a building by the admission, to all parts of the building, of air warmed by passing over pipes containing hot water, provision being also made for the passing out of foul air, either through simple openings in the galleries and rooms, or through shafts containing fires, so as to draw or pump out the used or foul air, and all the steam and effluvia from the kitchen and other offices.

This plan of "air-drainage" is adopted in the plan for the Derby asylum; and it is stated by Mr Duesbury, that the areas of the flues, and the rate of motion of the withdrawn and supplied air, will be such as to secure a change of air of from sixty to one hundred feet per minute for each individual, the supply depending on the variations of the general temperature. The model prison at Pentonville, the prison at Derby, and other buildings, are already warmed and ventilated in this manner, which seems peculiarly adapted to such buildings, as the prisoners pass the greater part of the day, as well as the night, in their cells. It is possible that the complete ventilation of a well-constructed and not over-crowded asylum may be effected with a less elaborate apparatus, or, at least, without the shafts.

But whatever mode of ventilating and warming an asylum [p.33] is adopted, it should be compatible with having the fresh air admitted unwarmed, and by open windows, in all temperate weather, and with having open fireplaces in every day-room, or, if there are no day-rooms, in every gallery, and in many of the work-rooms. Our windows at Hanwell do not admit air enough in the summer time; and advantage is gained in some asylums, as at Stafford, from having the glass of a part of the gallery or bedroom window set in wooden frames, corresponding in size and situation to iron frames placed exterior to them, so that the whole wooden frame can be opened without leaving the danger of an open window, and yet closed without any appearance of iron bars. When the wards are warmed by artificial means, there is too frequent a tendency to economize such means, by excluding the fresh air, and thus substituting warm, foul, and expired air, for fresh air warmed. This is one of the many faults which a specious economy too readily covers.

All my observation of the habits and condition of the insane at Hanwell has led me to be especially of opinion that whatever mode of warming is adopted, there is both utility and comfort in having fireplaces accessible to all patients, properly protected by a light iron guard, fastened with a small spring-lock. The inequality of temperature in different wards, and on different days, is a source of complaint all the winter; and in many autumnal days, as well as in the early spring, when the steam-warming or hot-air warming is discontinued, because it is no longer winter, or is not commenced because the winter has not yet come, the patients suffer excessively; and the feeble, elderly, paralytic, and epileptic are occasionally brought into a state of danger, only averted by removing them to a ward in which there is a comfortable fire. It is impossible to witness a party of lunatics sitting round a cheerful fire in winter, without wishing to see a fireplace in every ward. There is no comfort more missed by the poorest lunatic than that of an open fire, and many incidental conveniences are secured where this comfort is enjoyed. The visiting magistrates of Hanwell have lately authorized the introduction of [p.34] fireplaces into most of the day-rooms, to the evident satisfaction of the patients. It would appear that the mere keeping of the general temperature of the galleries at 60 is not sufficient for comfort, and that much gratification arises from greater warmth being applied to the surface than is absolutely necessary for health. Our patients try to obtain this, even in the wards most efficiently warmed by steam, by lying down close to the gratings which admit the warmth ; only imitating in this respect the general pleasure enjoyed by sane persons when they gather round a fireplace, although in warm apartments. The point becomes of more importance in relation to persons shut up in one place, and for whom the mere sight of a fire helps to break a daily monotony with difficulty imagined by those who are at liberty to go every day where they pi ease. I have mentioned fire-guards, although I know that they are disused in some asylums. I do not recommend their disuse in public asylums. Some patients are mischievous, and play with the fire dangerously; many are imbecile, and apprehend no danger from touching it; many are feeble, and may fall or be pushed into the fire ; and some, debarred from other modes of self-destruction, may wilfully try to destroy themselves by burning. The guard should inclose the whole fireplace, but there should be a large opening in front, of which the lock should close of itself when the open part, or gate, is shut. If it requires to be locked by an attendant, this duty will often be forgotten. In the older asylums I have seen iron handcuffs hanging to the fire-guards, and to these, poor shivering wretches, half clothed and half starved, were fastened, if they came near the fire at all; being thus deprived of much of the comfort of being near the fire, and in some cases exposed to the danger of being half roasted. I even now occasionally see fire-guards in houses for the reception of insane gentlemen and ladies, of a form so clumsy, and so dismal, as to present a strong contrast to the light guards found efficient in asylums for the poor; and I observe that they are secured by a common padlock,[p.35] which is objectionable both as regards appearance and convenience.

The manner in which the admission of light and air by the windows is made compatible with perfect security is illustrated in all asylums of recent construction. It is only in the older ones that windows are seen placed so high that no one can look out of them; windows of small and scarcely transparent panes of glass, set in thick and heavy frames of wood, and guarded on the outside by massive bars of iron, precautions which may have been necessary in asylums where violence and neglect reigned uncontrolled, but which are utterly superfluous under existing modes of treatment. A very thick window-glass has recently been adopted in the bedrooms of some asylums, admitting a modified light, but which cannot be seen through : no. invention can be more abominable. Our windows in the galleries and day-rooms at Hanwell are wide and cheerful, allowing the patients to look out as they sit at work. The panes are of good size, varying in different parts of the building from 10 inches by 6, to 8 inches by 5^ ; and they are set in a light frame of cast iron, which is painted white. Towards the upper part of each window there is a circular portion with two sets of frames, one turning on the other, so as to leave open spaces, the glass being set in alternate spaces in each of the circles. In parts of the building in which there are small square windows, as in the rooms in the third story, the frame containing the upper row of panes turns on a swivel, so as to be partially opened ; but this kind of window is far from secure without the protection of wire-guards. Even the ordinary large windows, with a complete qircle of panes capable of being opened, are not quite safe in bedrooms, unless there are shutters or wire-guards. The windows of the galleries of our refractory wards, and of some others, are guarded; the rest without guards; and on the male side, the experiment of having no window-guards in the day-rooms of two out of four of the refractory wards has been tried, without inconvenient results. In the Surrey Asylum I believe none of the windows [p.36] are guarded; but if light honeycomb wire-guards are placed interiorly to the windows, so as to permit plants and birds to be put between the windows and the guards, the guards being painted white, and having a green frame, nothing unpleasant is offered to the eye. For the mere protection of the windows the guards should be about a foot from the glass. When restraints were first discontinued at Hanwell, the destruction of windows was said to be ruinous. I believe it was often most negligently permitted by attendants partial to the old means of securing the patients: now it has become quite trifling, having diminished with the decrease of all other kinds of violence and irregularity. Window-frames of cast iron may be broken by a sharp and heavy blow with any hard instrument; and we had, some years agov a patient who was very expert in doing this, and making his escape from the asylum; but such accidents can only happen where the attendants are negligent, and perhaps they are only likely to happen where patients arc made unhappy by restraints. The patient alluded to was once or twice brought back to us. The period of emancipation from muffs and strait-waistcoats arrived in his time: he sometimes tried to provoke us to make him an exception, and to put restraints on him again ; but he was treated differently, began to mend, got well, and was discharged cured. Since restraints were discontinued, I remember no instance of escape being effected by breaking the window-frames.

When these and worse accidents occurred at Hanwell, there was not an efficient window-shutter in the house. All kind of security had rested on fastening the arms and legs and bodies of refractory patients to bedsteads or to heavy chairs; and there was an interval between the removal of these fastenings and the supply of required shutters and other means, which interval was signalized by untoward occurrences, now seldom heard of in the asylum, and when occurring, attributable to some negligence of the same kind. Dr. Jucobi thinks that iron window-frames are attended with mam ether [p.37] inconveniences, and seems much to prefer the old iron bars; but his objections do not seem to be well founded. We do not find, at Hanwell, that the expansion or contraction of the iron ever breaks the panes, nor that they admit the air inconveniently, nor the rain generally ; nor do they darken the rooms, or open of necessity in a dangerous manner; nor do they stain and streak the glass in wet weather. The chief inconvenience, that of rendering it difficult to admit sufficient air through them in hot weather, has been already spoken of. The insertion of one pane of zinc in some of the windows, perforated for the admission of air, and making openings over the fireplaces, with a valve, permitting air to pass out of the ward also, as practised in some of the habitations of the poor in London, might perhaps remedy this fault.

The best method of lighting the galleries and day-rooms, as well as the chapel and larger apartments, in the winter evenings, is by coal-gas. If well prepared, it is the least offensive, and the cheapest kind of light. There should be several lights in each gallery and day-room, so placed as to enable the patients easily to read, write, work, or amuse themselves with cards, draughts, dominoes, &c.; and one moderate light should be maintained in each gallery all night. There is a refinement of economy practised in some private asylums which grievously interferes with the comfort of educated patients, and which consists of allowing a long interval to elapse between the departure of daylight and the introduction of lamps and candles. A great amount of suffering is entailed on the patients by this ingenious neglect. This is generally allied with an equal anxiety to save in the article of fuel; and servants are permitted to forget to mend the fires with entire impunity. The same principle creeps sometimes into public asylums; and to save the expenditure of a few shillings in a week, the patients are allowed to grope their way about the wards, and find their way to bed as they can, when the days are shortening, and when the patients are also cold and comfortless and irritable, in consequence of passing many hours in too low a temperature.

[p.38]

In whatever manner light and air are admitted into the wards, and warmth is diffused over the asylum, perfect cleanliness is indispensable. Nothing offensive to sight or smell should be permitted in any part of the asylum. Warmth must not be, obtained by excluding the air, nor light by means corrupting the atmosphere. No excuse should be admitted for a bad smell in any room or corner. If perfect cleanliness cannot remove it from any one part of the building, there must be something wrong in the drainage or ventilation of that part, which ought to be rectified at any cost. But instances of this kind are few in comparison with the origin of such bad smells in neglect. Attendants who have not been well instructed in their duty, or who are not well affected to the non-restraint system, will stoutly maintain that this or that bedroom cannot be freed from a bad smell, do what they will; but such is scarcely ever the case, and for a proof that it is not the case, I would refer every visitor to Hanwell to the male ward No. 1. It is a ward in which every inconvenience has to be contended with ; it is in the basement story ; it has small windows ; it has bed-rooms on both sides of the gallery, from one end to the other ; it is the longest ward in the asylum, and it contains fifty patients, all of whom are imbecile or idiotic, many paralysed or helpless, and three fourths what are called dirty patients, requiring all the care of children. Four male attendants keep this ward so scrupulously clean that there is scarcely ever the least smell in any part of the gallery, or in any bedroom. The admirable cleanliness and general state of this particular ward are favoured by each patient having a single sleeping-room. If they slept in large dormitories, the air of the ward, and of all the wards above it, would become noxious to health. Dormitories in which only four or five dirty patients sleep are seldom free, even after being empty for many hours, from an odour offensive to a person who has a delicate sense of smell.

The provisions necessary for cleanliness are humble things to dwell upon, but they are the auxiliaries of health, and deserve the most vigilant attention of the physician, who ought [p.39] to remember, when he detects a bad smell in passing any door in a gallery or passage, that some of the inmates of the asylum are exposed to that offensive air all the day long, and all the night, and that some of them never go out beyond the boundaries of the asylum grounds, so as to recruit, by change of air and scene, their constitutional power of resisting the influence of local malaria. And whoever pays much attention to the habits of human beings, must know how much the irritability of the mind is increased by habitual ill health, in whatever way produced; and it is with this irritability, on a large scale, that we have to deal, and which it is our business to remedy or prevent in asylums for the insane. It well illustrates the importance of everything in an asylum being regulated by the physician, when we find that even this point of cleanliness, so essential to health of body and mind, cannot be secured without well-chosen attendants. Their selection is allowed to rest at Hanwell, and in a few other asylums, with those who either do not understand or do not appreciate the comprehensive nature of the duties required by attendants, and the physician is compelled to work with inefficient instruments, and liable, any day in the week, and every week in the year, to find a great number of his patients deprived of the attentions of an efficient attendant, and placed at the command of those in whom it is impossible for him to place any confidence. But the subject of the selection, government, and duties of the ward-attendants will be subsequently treated of, with the fullness which its importance demands; and as I consider that I am addressing the public on subjects of more than ephemeral interest, I shall not abstain from condemning what is wrong merely because it happens to be practised in the asylum to which I am myself the physician, and which I would fain see a model for general imitation.

The sources of bad smells in an asylum are chiefly the large dormitories already alluded to; the water-closets, sinks, and urinals, and also the neglected persons, and clothing or bedding of the patients. Until lately, the sinks in most asylums [p.40] were at once sinks, and watering-places, and washing-places. The sinks should be used as sinks alone, and the door leading to them should be locked by the attendants. There should be in every ward a lavatory or washing-room, containing half-a-dozen enamelled-iron washing basins, sunk in a leaden table, and each basin supplied with a watercock, and having a movable plug. There should also be one or two large round towels in each room. Among the late additions to the wards at Hanwell, none has been more productive of comfort to the patients than this, and the washing-rooms are the perfection of neatness. These rooms are open to the patients of quiet wards at all hours of the day ; and the means of having a clean face and hands, and the refreshment of washing when fatigued, or after various occupations, is very much enjoyed. An additional means of personal cleanliness is also afforded by each patient having a warm bath once a week. Where these regulations prevail, the skin of insane patients loses its most repulsive and unwholesome aspect; general health is promoted, and with health, comfort, and cheerfulness ; and the peculiar odour of the insane, so often described, does not permeate every ward, and is, indeed, seldom perceived. There are private asylums, on the old plan, which I could recognize as such, if taken blindfolded into them; and where this terrible and peculiar smell tells the visitor, as plainly as any impression on the sense can tell, that the rooms are not thoroughly clean, that the bed and body linen are not sufficiently often changed, and that washing and bathing are very little attended to.

Every ward of an asylum should have one room in it appropriated to keeping the clothing and linen required for the immediate use of the ward ; and although certain general rules for the supply of clean linen must be observed, these rules must have many exceptions in favour of the patients. In or near every ward there should be a bath-room, containing one or two baths, raised above the floor, and of moderate depth. When many patients are required to take baths at the same time, the baths may even be shallow; their depth at Siegburg [p.41] is one foot five inches, their length five and a half feet, and their width two feet. The best material for the bath is stone, painted, and the edges rounded. There should be a matting, or rug, or carpet at the side of the bath when it is used. It is convenient to have the head of the bath towards a wall, and the two sides and the foot of the bath free, so that, when required, the attendants can stand round the patient. The best method of supplying the water is by a single opening at the bottom of the bath, admitting hot and cold water at the same time. The handles to turn the water off or on should be out of the patient's reach. To avoid the difficulty and pain attending the removal of feeble and bedridden patients to the bathroom, we had some slipper-baths at Hanwell placed on wheels, but they were not often employed. In the hospital of St. Louis, at Turin, (for incurable maladies,) there is a door behind each bed, and each bed is on wheels, so as to be moved, if required, to the bath-room. Shower-baths of moderate force are so often useful, that I should always prefer having an apparatus for one fixed over each bath. To be effective, they should be supplied from a large cistern, or reservoir. The ordinary shower-baths, only containing from seven to ten gallons of water, and which are filled slowly and with difficulty, are very troublesome, and are more fitted for refreshment or gentle excitement, than for subduing violent symptoms. As it is extremely difficult to keep a refractory patient under the shower, it is useful to have a few shower-baths made of a square shape, and inclosed; the upper half of the door being made of wirework, and the whole of the top of the bath perforated. Some of our bath-rooms at Hanwell are fitted up with a leaden pipe, to which a hose-pipe can be affixed, for the purpose of administering the douche-bath ; but I have long ceased to employ this form of bath, which occasions much more distress to the patient than the shower-bath, without any corresponding advantage.

No care can be too great to keep the water-closets within the building, and the outside privies, and the urinals, free [p.42] from offensive accumulations and bad smells. All urinals are invariably offensive unless there is a small stream of water continually running over their surface. Privies out of doors are required in courts where very maniacal patients, or imbecile patients, take exercise ; but in the airing-courts for the more comfortable patients they are superfluous. If there is a deep fall, there should be the security of a grating, to prevent the patients from leaping down; and if there is very little depth under the seat, the accumulation becomes highly inconvenient. All privies become sources of trouble and annoyance, unless made on the principle of a water-closet, or, at least, unless a powerful stream of water can be commanded, to carry away all accumulations. An abundant, never-failing supply of water is the great requisite for cleanliness, and to secure it no expense should be spared. It creates a benefit for ever. The asylum at Siegburg is for 200 patients, and it is computed by Dr. Jacobi that 4014 gallons of water are required daily. For the use of the Hanwell asylum, containing 1000 patients, we require 40,000 gallons of water per diem, or about double the proportion allowed at Siegburg; and at the cost of lO00l. a deep well has been formed, which supplies 100 gallons per minute at the surface, and about 20 gallons per minute 26 feet above the surface. When there is this abundant supply of water, I prefer, to all others, the plan of water-closet by which a current of water is carried through it whenever the door is opened and shut. The supply then depends on no one's attention, and no one's caprice, but there may possibly be some waste of water. When the current of water depends on the pressing down of the seat, and the subsequent removal of the pressure, various accumulations of an offensive kind may occur, from things poured into the closet without any pressure of the seat being made. The dependence of the current of water on the pulling of a string, or lifting up and depressing a handle by an attendant, is sure to lead to neglect. Even in private houses, it is well known that without constant care the water-closets infect the whole house.

[p.43]

All arrangements in an asylum for the insane, I would once more observe, and particularly those relative to doors, windows, and window-shutters, fire-guards, ventilators, baths, and water-closets, should be as simple and uncomplicated as possible. If much trouble is occasioned by opening and closing the window-shutters, or fire-guards, or ventilators, the trouble will be as often as possible avoided. Even when a fire-guard shuts with a spring-lock, the attendants will not take the trouble to close it, because in an hour or two they may have to employ a key to open it. Officers of asylums are sometimes prone to overload the attendants with minute duties, and the consequence is a neglect of some that are more important. The observations included in the present chapter have reference principally to County Asylums for Pauper Lunatics. In asylums for the classes above them, many modifications of the architect's plan are necessary. Several private sitting-rooms are required; and these may be on the ground-floor, and open into gardens, or into a gallery or corridor ; the bedrooms must almost all be single rooms, opening into a gallery above-stairs. Various other arrangements become obviously requisite, according to the rank of the patients, and their habits of living, and the extent of accommodation required by them. But the general principles of arrangement must be the same : there must be the same general attention to the health of the intended inmates ; and there must be apartments for the refractory, the noisy, and the dirty, although the furniture may be of different materials from those used in a pauper asylum. Where such arrangements are not adopted, restraint is the general substitute for them; and the richer patient is more unfavourably situated than the poorer lunatic, and is, indeed, not unfrequently treated with excessive cruelty.

Many of Dr. Jacobi's remarks on the construction of asylums contemplate providing in the same asylum for patients of different ranks, or of all ranks. But asylums built for the [p.45] reception of both rich and poor patients can never be free from many objections ; and the uncomfortable suspicion is inseparable from them-that the humbler patients have the refuse of the provisions, and the most indifferent attendance. If such a mixture of classes in one asylum should be unavoidable, the establishments for the different classes ought to be virtually distinct, although in immediate contiguity, as in the new asylum near Glasgow .

The buildings and arrangements in the greater number of private asylums continue to be very defective. Gloom and confinement seem to be inseparable from an ordinary private dwelling when made into an asylum ; and the cheerless aspect, the faded furniture, the want of fresh air, and of proper warmth and light, and of free egress to the courts or gardens, and even, too often, of proper attention to cleanliness, are oppressively conspicuous. Some assimilation in these respects, and in others, to the plan and arrangements of public asylums,- due attention being given to the requirements of patients who have been accustomed to enjoy every kind of comfort, and to the feelings of their friends on these points,-would greatly improve many of them.



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