On the State of Lunacy and the Legal Provision for the Insane / With Observations on the Construction and Organization of Asylums

by J. T. Arlidge

In this matter, we hope the liberal views of the noble Chairman of the Lunacy Commission will sooner or later be reciprocated by the Visitors of Asylums; in the mean time, the thanks of the medical profession are heartily due to his Lordship for his able advocacy of its just claims.

§ Limit to be fixed to the size of Asylums.

One remedy against extending the evil consequences of large asylums, is to restrict the size of future buildings within certain limits. We do not hope to persuade the advocates of gigantic asylums, by any representation we can offer of their ill-effects to the patients and their false economy, to abandon their notions; but we do hope that there will be a parliamentary interdiction to their perpetuation, or that the Commissioners in Lunacy will have sufficient authority lodged in their hands to limit the size of future asylums.

Although all persons conversant with the treatment and requirements of the insane concur in condemning such huge asylums as Hanwell and Colney Hatch, yet there is some difference in opinion, of no very great extent indeed, among them with regard to the number of patients who should be assigned to the care of a single superintendent. Moreover, the number who may be treated in the same building and by one physician, will differ according to the nature of the cases—whether all acute, or all chronic, or mixed, acute and chronic together. In this country all the asylums are of a mixed character, but, excepting two or three hospitals for the insane, contain a large preponderance of chronic cases. They are, moreover, all spoken of by the Lunacy Commissioners as Curative Asylums.

Let us now examine the opinions of some of the best authorities upon the subject, so that a tolerably accurate judgment may be formed of the limits within which the size of asylums should be restricted.

In 1844, the Metropolitan Commissioners in Lunacy laid it down as a rule that “no asylum for curable lunatics should contain more than 250 patients, and 200 is, perhaps, as large a number as can be managed with the most benefit to themselves and the public in one establishment.”—Report, 1844, p. 23. The present Commissioners have expressed similar views, which also were clearly stated before the Special Committee of the House of Commons this year, by the noble Chairman, the Earl of Shaftesbury.

If we look to American opinion, we find (Rep. Commiss. Massachus. 1855, p. 135) that “it is the unanimous opinion of the American Association of Medical Superintendents of Insane Asylums that not more than 250 patients should be gathered into one establishment, and that 200 is a better number. When this matter was discussed, there was no dissent as to the maximum; yet those who had the charge of the largest hospitals, and knew the disadvantages of large numbers, thought that a lower number should be adopted.

“Taking the average of the patients that now present themselves in Massachusetts, of whom 80 per cent. are supposed to be curable, and need active treatment, and 82 per cent. incurable, and require principally general management and soothing custodial guardianship, and having ‘due regard to the comfort and improvement of the patients,’ this limit of 250 should not be exceeded.

“The principal physician is the responsible manager of every case, and should therefore be personally acquainted with the character and condition of his patients, the peculiarities of the diseased mind, as manifested in each one, and the sources of trouble and depression, or exaltation and perversity. This knowledge is necessary, in order that he should be able to adapt his means of medical or of moral influence with the best hope of success.”

Dr. Kirkbride, in his special treatise on the Construction and Organization of Asylums, thus expresses his views (p. 10):—“Whatever differences of opinion may have formerly existed on this point (the size of the Institution), I believe there are none at present. All the best authorities agree that the number of insane confined in one hospital, should not exceed 250, and it is very important that at no time should a larger number be admitted than the building is calculated to accommodate comfortably, as a crowded institution cannot fail to exercise an unfavourable influence on the welfare of its patients. The precise number that may be properly taken care of in a single institution, will vary somewhat, according to the ratio of acute cases received, and of course to the amount of personal attention required from the chief medical officer. In State Institutions, when full, at least one half of all the cases will commonly be of a chronic character, and require little medical treatment. Even when thus proportioned, 250 will be found to be as many as the medical superintendent can visit properly every day, in addition to the performance of his other duties. When the proportion of acute or recent cases is likely to be much greater than that just referred to, the number of patients should be proportionately reduced, and 200 will then be found to be a preferable maximum. While no more patients should be received into any hospital than can be visited daily by the chief medical officer, it is desirable that the number should be sufficiently large to give an agreeable company to each class, and to permit a variety of occupations and amusements that would prove too costly for a small institution, unless filled with patients paying a very high rate of board, or possessed of some permanent endowment. It might be supposed that institutions for a much larger number of patients than has been recommended, could be supported at a less relative cost; but this is not found to be the case. There is always more difficulty in superintending details in a very large hospital—there are more sources of waste and loss; improvements are apt to be relatively more costly; and without great care on the part of the officers, the patients will be less comfortable.