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

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.