In Germany, and generally in Italy, the medical staff is still larger in proportion to the number of patients. Jacobi apportions to an asylum for 150 or 200 lunatics, a chief physician, a second, and an assistant, besides the dispenser. Roller coincides with this, and the asylum at Illenau under his superintendence, consisting of two divisions, one for recent, the other for chronic cases, and containing in all 414 patients, has three physicians besides two assistants or ‘internes.’ So at Leubus, in Silesia, there are three physicians, although the inmates are only 150 in number; and the rule is, in other German asylums, containing 100 inmates, to have two physicians, besides one or two internes and a dispenser (pharmacien).
Allowing the opinions and practice of the eminent men quoted, and which in truth are shared in by every asylum superintendent, their due weight, it would seem no extravagant arrangement to allot to an asylum accommodating from 150 to 200 patients (recent and chronic cases together), a physician superintendent and an assistant; and a similar medical staff to an institution for 300 or 350 inmates, all in a state of confirmed chronic insanity, imbecility, and dementia. If the population in an asylum for chronic cases is further augmented to 450 or 600,—the latter number we hold to represent the maximum which can economically and with a just regard to efficient government and supervision and to the interests of the patients, be brought together in one establishment,—the medical superintendent will require the aid of two assistants and a dispenser.
Such aggregations as of 1000 to 2000 insane people are unwieldy and unmanageable with the best appointed medical staff, unless this be so numerous as utterly to invalidate the plea of economy, the only one, fallacious as it is, that can be produced by the advocates for their existence. And not only are they unmanageable, but also hygienically wrong; for it is a well-recognized fact, that the accumulation of large numbers of human beings in one place, tends to engender endemic disease, uniformly deteriorates the health, and favours the onset, progress, and fatality of all disorders. The history of large asylums bears testimony to the truth of this; for cholera has scourged more than one most severely, and dysentery and chronic or obstinate diarrhœa are pretty constant visitants in their wards.
The contrast between the opinions and practice of the distinguished men referred to and those of some Committees of Visitors respecting the value of medical attendance on the insane, the nature of the duties to be performed, and the amount of labour the superintendent of an asylum may accomplish, is most remarkable. What those of the former are, is stated already; what those held by the latter are, we have an illustration in the administration of the Colney Hatch and of the Hanwell Asylums. In the latter establishment we find two medical men appointed to superintend 1020 insane inmates, besides nearly 200 persons employed about it. True, we are informed by the Committee, that the superintendent of the female department, who has the larger number, some 600, under his charge, is assisted by the matron; and we are sure he must be thankful for any assistance rendered him; yet it is the first time that we have been called upon to recognize a matron as an assistant medical officer. However, we must accept it as a fact,—gratefully we cannot,—but with a protest against placing a subordinate officer on such an independent footing, against entrusting her with duties incompatible with her education and position, and with the relations which should subsist between her and the superintendent, and against making her his equal in the remuneration for her services.
Did occasion offer, we might ponder over this new development of the matronly office; inquire respecting the medical qualifications demanded, and the manner in which the Hanwell Committee have ascertained them; and meditate at length on the notions which govern the Visiting Justices in organizing and directing an asylum; but for the present, we will, for further example’s sake, note some of their opinions and doings in the management of the sister ‘refuge for lunatics’ at Colney Hatch. We shall, for this purpose, appeal to the Report for 1856, and to make the quotations used intelligible, will premise, that the steward, at that date, had turned architect, and produced a plan for the extensive enlargement of the asylum as proposed by the Magistrates; and that, very naturally, when writing about it, he was intent to prove that his plan was the best, the cheapest and the most convenient even to the medical superintendents who would be called upon to officiate in it when completed. This much being premised, we will quote the steward’s own words.
“I must also remind the Committee,” he observes, “that some three years since it was with them a matter of serious deliberation, whether it was advisable that the male and female departments should be placed under the care of one medical superintendent, and, in fact, whether one medical officer should have the supervision and direction of 1250 inmates, and an extended range of building; or whether the two departments should continue, as they are at present, separate and distinct.” What an excellent insight does this revelation of the cogitations of the Committee-room of the Middlesex Magistrates afford us of the sentiments these gentlemen entertain of the requirement and value of medical skill in an asylum; of the capacity, bodily and mental, of a superintendent for work! But, without waiting to fill up a sketch of the wondrous virtues and faculties which the superintendent of the 1250 insane patients need to possess in order to know all, supervise them, direct them, and attend to the multitudinous duties of his office as a physician and director, we will by a further extract gather clearer notions of the extent of the work thought to be not too much for him. The gist of the ensuing paragraph is, that the steward strives to prove that by adding a new story here and there, besides spurs from the previous building, he will increase greatly the accommodation without much augmenting the ambulatory labours of the medical officer. And alluding to one, the male division of the establishment, he proceeds to argue, that “if it is considered feasible for one person to superintend 1250 patients of both sexes in a building extending from one extreme to the other, nearly two-thirds of a mile, would it not be equally feasible to superintend 840 patients in a building one half the extent [here Mr. Steward forgets to count the number of furlongs added by his proposed new wards], provided they are conveniently and safely located, although these patients are all males?”
To this we may be allowed to subjoin some remarks we penned in a critique published in the ‘Asylum Journal’ (vol. ii. p. 271) for 1856, and in which many of the observations contained in the present work were briefly sketched. “Who, we ask, can dispute the feasibility of a medical or of any other man superintending 840, 1250, or two or three thousand patients, collected in an asylum or in a town, in the capacity of a director or governor, if subordinate agents in sufficient number are allowed him? But we think the question in relation to asylums is not, how we can govern our insane population most easily and at the least possible cost, but by what means can we succeed in curing the largest number of cases of insanity as they arise, and thus permanently keep down expenditure and save the rates. These results are certainly not to be attained by persevering in the old scheme of congregating lunatics by tens of hundreds, but by making suitable provision for the immediate treatment of the pauper insane in asylums properly organized for it, and under the direction of a sufficient medical staff.”
How totally different, too, are the views of Jacobi to those of the Middlesex Magistrates concerning the office of superintendent, and the extent of work of which he is capable! In his treatise on Asylum Construction (Tuke’s Translation, p. 23), he presents the following sensible remarks:—“It is not that I should consider a more numerous family (than 200) incompatible with the right management of the farming and household economy, nor with the domestic care of the patients; both these might perhaps be organized in an establishment containing a number equal to the largest just named (four or six hundred), in such a manner as to leave nothing to be desired; but it is in regard to the higher government of the establishment, and the treatment of the patients as such, in its widest signification, which must rest upon the shoulders of a single individual,—the director of the establishment,—that I am convinced the number of patients should not exceed two hundred. For when it is considered that the duties of the governor embrace the control of all the economical and domestic arrangements, as well as of the whole body of officers and servants; that he must devote a great share of his time to the writing, correspondence, and consultations connected with his office; that as first physician, he is entrusted with the personal charge and medical treatment of every individual committed to his care; that he must daily and hourly determine, not only the general outlines, but the particular details of the best means for promoting the interests of the collective community, as well as of every separate person composing it; and that, besides all this, he is responsible to science for the results of his medical observations in the establishment over which he presides; nor less so for the promotion of his own advancement as a man and a philosopher;—it will be readily granted, that the given maximum of two hundred patients for a single establishment ought never to be exceeded. Indeed, a man of even extraordinary abilities would find himself unequal to the task of discharging these duties, in an establishment containing two hundred patients, were he not supported by such assistance as will hereafter be described; and were there not a great number amongst even this multitude of patients requiring not constant, or at least, a less degree of medical attention.”
Many writers on asylum organization, particularly those of the Continent, insist very strongly on so far limiting the size of asylums for the insane, that they may be superintended by one chief medical officer, aided indeed by assistants, but without colleagues of coordinate powers. The venerable Jacobi took this view, and desired that the director of an asylum should be the prime authority in all its details of management, and insisted that the institution should not by its size overmatch his powers to superintend it and its inmates as individuals. Thus, after reviewing the nature of the duties devolving on the chief physician, he observes (p. 192, Tuke’s translation), “It follows as a necessary consequence that one man must be placed at the head of the establishment,” ... and that “his mind must pervade the whole establishment.” Likewise M. Parchappe joins in the same opinion; and after speaking (Des Principes, p. 43) of the impossibility of proper medical supervision in a very large asylum, observes, “that to divide the medical direction among two or more physicians is extremely detrimental to the superiority which the medical superintendent ought to hold in the general administration of asylums, and to that unity of purpose and opinions required in the interests of the patients.”
Without citing other foreign writers to substantiate the view under consideration, we may call attention to the fact, that the Lunacy Commissioners, who have always so stoutly advocated the position of the medical officer as the superintendent of an asylum, likewise appear to accept the same principle; for in their Eleventh Report (p. 11), they remark, that besides the direct injury inflicted upon patients when congregated in excessive numbers in the same institution, “experience has of late years shown, that the absence of a single and undivided responsibility is equally injurious to the general management.”