“Whenever an existing State Institution built for 250 patients, contains that number, and does not meet the wants of the community, instead of crowding it, and thereby rendering all its inmates uncomfortable, or materially enlarging its capacity by putting up additional buildings, it will be found much better at once to erect an entirely new institution in another section of the State; for under any circumstances, the transfer of acute cases from a great distance, is an evil of serious magnitude, and constantly deplored by those who have the care of the insane.”
French authorities take the same views. M. Ferrus, who wrote so long back as 1834, and is now one of the Inspectors of Asylums in France, says, in his book, ‘Des Aliénés,’ that an asylum for the treatment of mental disorder ought not to contain above 150, or at most 250 patients; but that one having a mixed population of cases requiring treatment of incurables and idiots, may receive 400 or even 500 such inmates, provided the physician is afforded sufficient medical assistance. However, his brother inspector, M. Parchappe, whose able work, ‘Des principes à suivre dans la fondation et la construction des Asiles d’Aliénés’ (published so recently as 1853), forms the most valuable treatise on those subjects, does not approve so large a number of inmates to be collected in an asylum as M. Ferrus would sanction. He writes:—“After taking every consideration into account, I think the minimum of patients ought to be fixed at 200, and the maximum at 400. Below 200, the economical advantages decline rapidly without a compensatory benefit; above 400, although the economical advantages augment, it is at the detriment of the utility of the institution in its medical character.”
M. Guislain, the eminent Belgian physician, in his grand work on Insanity, remarks (vol. iii. p. 347), “It would be absurd to attempt to bring together in the same place a very large population; it would tend to foster an injurious degree of excitement; would render the management difficult or impossible; would destroy the unity of plan, and neutralize all scientific effort. The maximum ought not to exceed 300 or 350 insane persons. This limit cannot be exceeded without injury to the well-being of the inmates; but unfortunately this has been but too often disregarded, under the plea of certain views of organization or of economy.”
Jacobi placed the maximum of asylum population at 200 (Ueber die Anlegung und Errichtung von Irren-Heil-anstalten, p. 24); Roller expressed his opinion (Grundsätze für Errichtung neuer Irren-anstalten, p. 84) that one instituted for the treatment of cases (Heil-anstalt) should not at the most receive above 200; but that an asylum for chronic cases (Pflege-anstalt), connected with the other, may admit from 250 to 300, making a total population, under the same general direction, of 450 or 500; and Damerow (Ueber die Relative Verbindung der Irren-Heil-und Pflege-anstalten) unites in the same opinion.
It would be useless to multiply quotations; for, in short, there is complete unanimity among all those concerned in the direction of asylums, that such institutions, when of large size, are prejudicial to their inmates and withal not economical. There is likewise a very near coincidence of opinion perceptible with reference to the question of the number of patients which ought to be placed in the same building. Supposing the asylum to be specially devoted to the reception of recent cases, it is agreed that it ought to accommodate not more than 200, and that the smaller number of 150 inmates would be preferable. If a receptacle for both acute and chronic mental disease, some would limit the population to 250, whilst others would extend it to 400, provided the medical officers were increased in proportion.
The example of the German asylums under the direction of Damerow and Roller is peculiar; for the curable and chronic cases are not mixed, but placed separately in two sections or two institutions under a general medical direction within the same area. This is the system of ‘relative connexion’ of the “Heil-anstalt,”—institution for treatment, or the Hospital, and the “Pflege-anstalt,” the ‘nursing’ institution, or the asylum; to the former they would allot 200, and to the latter 300 as a maximum, making a total of 500 inmates under the same physician in chief and the same general administration, but each division separately served by its own staff and specially organized.
§ Increase of the Medical Staff of Asylums.
In the next place, the medical staff of an asylum should be large enough to secure daily medical observation and attendance for each individual patient, along with a complete supervision of his moral condition, his amusements and employment. We have said that this provision is deficient in many English asylums, a statement amply confirmed by the opinions of others.
Dr. Kirkbride (op. cit. p. 44) lays it down as a rule, that “where there are 250 patients, especially if there is a large proportion of recent cases, besides the chief physician, two assistant physicians will be required, one of whom should perform the duties of apothecary. In some institutions, one assistant physician and an apothecary will be sufficient. If the full time of two assistant physicians, however, is taken up by their other duties among the patients, an apothecary may still be usefully employed in addition; and to him, other duties among the male patients may with propriety be assigned.”
French writers coincide in these views. M. Parchappe assigns to an asylum containing 200 to 250 patients, a physician with an assistant, besides a dispenser; to one having 300 to 360 inmates, a physician, two assistants and a dispenser, besides a director to superintend the general administration, who in some institutions is also a medical man.