On the State of Lunacy and the Legal Provision for the Insane
Tekst6. 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.
Another advantage will accrue from the system proposed. The amount of cleaning will be much diminished, for the two floors will be used only alternately, and not only the wear and tear of the entire building, but also the exposure to dirt will be greatly lessened; above all, the small extent of corridor will make an immense difference in the labour of the attendants in cleaning, compared with that which now falls to their lot.
Again, the drying of floors after they have been washed is always a difficulty, particularly in winter, and is the more felt in the case of the bedrooms, which have, when single-bedded or small, but a slight current of air through them, and consequently dry slowly. This difficulty is augmented, when, as it often happens, it is necessary for them to be kept locked, to prevent the intrusion of their occupants or of others. The ill effects of frequently wetted floors in apartments constantly occupied, and therefore dried during occupation, have been fully recognized and admitted by hospital surgeons, and have impressed some so strongly, that, to escape them, they have substituted dry rubbing and polished floors to avoid the pail and scrubbing-brush. By the arrangements submitted, however, this difficulty in washing the floors is removed, since there is no constant occupancy of the rooms, and therefore ample time for drying permitted.
Further, by the plan in question, the distribution of food, of medicine, and of stores, becomes more easy and rapid; the collection, and the serving of the patients at meals, are greatly simplified and expedited. A regularity of management in many minor details will likewise be promoted. As the majority of the patients are quite removed from proximity to their sleeping-rooms, the temptation and inducement to indulge in bed by day, or before the appointed hour at night, will be removed, as will also the irregularity frequently seen in wards some time before the hour of bed, of patients prematurely stowed away in their beds, and of others disrobing, whilst the remainder of the population is indulging in its amusements, its gossips, or in the ‘quiet pipe,’ before turning in.
7. Management facilitated. – Our own experience convinces us that there is no plan so effectual for keeping otherwise restless and refractory patients in order as that of bringing them together into a room, under the immediate influence and control of an attendant, who will do his best to divert or employ them. We are, let it be understood, only now speaking of their management when necessarily in-doors; for, where there is no impediment to it, there is nothing so salutary to such patients as out-door exercise, amusement, and employment. On the contrary, to turn refractory patients loose into a large corridor, we hold to be generally objectionable. Its dimensions suggest movement; the patient will walk fast, run, jump, or dance about, and will, under the spur of his activity, meddle with others, or with furniture, and the like; and if an attendant follow or interfere, irritation will often ensue. But in a room with an attendant at hand, there are neither the same inducements nor similar opportunities for such irregularities. Some would say, such a patient is well placed in a corridor, for he there works off his superabundant activity. But we cannot subscribe to this doctrine; for we believe the undue activity may be first called forth by his being placed in a corridor; and that it is besides rare that a patient, particularly if his attack be recent, has any actual strength to waste in such constant abnormal activity as the existence of a space to exercise it in encourages. And, lastly, it is better to restrict the exhibition of such perverted movement to the exercising grounds, or better still to divert it to some useful purpose by occupation; for in a ward such exhibitions are contagious.
These remarks bear upon the question of the purpose and utility of corridors as places for exercise, concerning which we have previously expressed ourselves as having a poor opinion, and have throughout treated corridors mainly as passages or means of communication.
8. A less staff of attendants required. – If the foregoing propositions, relative to the advantages of the system propounded, be admitted, the corollary, that a less staff of attendants will suffice, must likewise be granted, and needs not a separate demonstration. There is this much, however, to be said, that the proposition made in a former page to distinguish attendants upon the insane from the cleaners or those more immediately concerned in the domestic work of the house, would be an easier matter when the construction followed the principles recommended. The attendants upon the occupants of the sitting-rooms need be but few, for their attention would not be distracted from their patients by domestic details; for the cleaners would prepare the apartments ready for occupation, would be engaged in fetching and carrying meals, fuel, and other things necessary for use, and the attendants would thereby be deprived of numerous excuses for absence from their rooms, and for irregularities occurring during their occupation with household duties.
9. The actual cost of construction of an asylum on the plan set forth would be greatly diminished. – It has just been shown that the proposed plan will ensure a more ready and economical management; and if structural details could be here entered upon, in connexion with an estimate of costs for work and materials, it could without difficulty be proved, that the cost of accommodation per head, for the patients, would fall much under that entailed by the plan of building generally followed. The professional architect who assisted us made a most careful estimate of the cost of carrying out the particular plan we prepared (designed to accommodate 220 patients), and calculated that every expense of construction, including drainage of the site, gas apparatus, farm-buildings, &c., would be covered by £19,000, i. e. at the rate of less than £90 (£87) per head.
That a considerable saving must attend the system propounded will be evident from the fact, that, instead of a corridor, on the first floor, at least twelve feet wide, as constructed on the prevailing plan, one of six feet, or less, simply as a passage for communication, is all that is required, and thus a saving of about that number of feet in the thickness or depth of the building, in each story above the ground-floor, is at once gained. A similar, though smaller, economical advantage is likewise obtained on the ground-floor, for the corridor there need be nothing more than an external appendage, and of little cost to construct.
A further saving would attend the construction of an asylum on the plan set forth, both from the concentration of the several parts for night and day use respectively, and generally from the rejection of the ward-system. The construction of almost all the sleeping accommodation on one floor would render many provisions for safety and convenience unnecessary, – for instance, in the construction of the windows. So the substitution of what may be termed divisions, or quarters in lieu of wards, would do away with the necessity of many arrangements requisite for apartments, when intended for use, both by night and day. As constructed commonly, each ward is a complete residence in itself, replete with all the requisites for every-day life, except indeed in the cooking department; and the consequence is, there is a great repetition throughout the institution of similar conveniences and appurtenances. Indeed, in the plan we designed, the influence of example or general usage led us to introduce many repetitions of several accessory apartments, which were, in fact, uncalled for, and added much to the estimate. For instance, we assigned a bath-room to each division, although we consider that a room, well-placed, to contain several baths (i. e. in French phrase, a ‘salle des bains’), would more conveniently serve the purpose of the whole ground-floor inmates, and be much cheaper to construct and to supply. Yet, if this notion of a ‘bath-house’ be unacceptable to English Asylum Superintendents, a smaller number of bath-rooms than was either provided in the particular plan alluded to, or is usually apportioned to asylums, would assuredly suffice. The same may be said of the lavatories, sculleries, and store-rooms.
10. The plan removes most of the objections to the erection of a second-floor or third-story.
These objections generally owe their force to the difficulty of assuring the inmates of a third-story their due amount of attention, and their fair share of out-door exercise, and of much indoor amusement, without entailing such trouble upon all parties concerned, that a frequent dereliction or negligence of duty is almost a necessary consequence.
Dr. Bucknill (‘Asylum Journal,’ vol. iii., 1857, p. 387, et seq.) has well argued against the erection of a third-story, on economical grounds; and remarks that “practically, in asylums built with a multiplicity of stories, the patients who live aloft, are, to a considerable extent, removed from the enjoyment of air and exercise, and the care and sympathy of their fellow-men. They are less visited by the asylum officers, and they less frequently and fully enjoy the blessings of out-door recreation and exercise. Those below will have many a half-hour’s run from which they are debarred; the half-hours of sunshine on rainy days, the half-hours following meals, and many of the scraps of time, which are idly, but not uselessly spent, in breathing the fresh air.”
The foregoing considerations are certainly sufficient to condemn the appropriation of a third story for the day and night uses of patients, according to the ‘ward-system’ in operation; but they have no weight when the floor is occupied only for sleeping. We must confess we cannot appreciate the chief objection of Dr. Bucknill (op. cit. pp. 388, 389,) to the use of a third floor for sleeping-rooms only, for we do not see the reason why “the use of a whole story for sleeping-rooms renders the single-room arrangement exceedingly inconvenient;” for surely, on the common plan of construction, a row of single rooms might extend the whole length of a third floor on one side of a corridor, equally well as on the floors beneath.
Without desiring to enter on the question of the relative merits of single-room and of dormitory accommodation, to examine which is the special object of the paper quoted, we may remark, that the addition of a third story, when the plan we have advocated is carried out, obviates the generally admitted objections to such a proceeding. The same arrangement of apartments may obtain in it as on the bedroom-floor below, and the proportion of single rooms to dormitories, viz. one-third of the whole sleeping accommodation to the former, insisted upon by Dr. Bucknill, can be readily supplied. Attention would only be required to allow in the plan sufficient day-room space on the ground-floor, – a requirement to be met without difficulty.
The existence of a third story is no necessary feature to an asylum constructed on the principle discussed, and we have adverted to it for the sole purpose of showing that the ordinary objections to it are invalid, when the arrangement and purposes of its accommodation are rendered conformable to the general principles of construction advocated in this chapter.
A hint from Dr. Bucknill’s excellent remarks on the advantage of being able to utilize spare half-hours must not be lost. Two flights of stairs, he well states, constitute a great obstacle to a frequent and ready access to the open air, and we are sure he would allow even one to be a considerable impediment to it; and, consequently, that an asylum with no stairs interposing between the patients and their pleasure-grounds would possess the advantage of facilitating their enjoyment of them.
These remarks on the advantages of the principle of construction we advise for adoption would admit of extension, but sufficient has been advanced, we trust, to make good our views. We have taken in hand to write a chapter on some principles in the construction of public asylums, but we must stop at the point we have now reached; for it would grow into a treatise, did we attempt to examine the many principles propounded, and entirely surpass the end and aim of this present work.