1847] Site and Construction. 129 He is the central point around which all must hinge and turn. Take every imaginable pains in his selection, but having chosen him remunerate him handsomely, and clothe him with the necessarily despotic authority. The present humiliating position of most of our resident officers, as contrasted with that of their brethren on the other side of the Atlantic, is as distressing as it is mischievous. Dr. Conolly's little work consists chiefly in a reprint of some Lectures which appeared in the Lancet last year, as supplementary to his valuable clinical course which we had hoped would also have been re-published. It is full of matter of the highest importance, especially at this epoch, when so many new establishments for the reception of the insane are upon the eve of erection. We may notice some of the chief topics he adverts to; but we may here observe that, we do not participate in the fears which he entertains that the projected separation of the chronic from the more recent cases will be attended with the diminution of the comforts or attentions at present enjoyed by the former, at all events we are certain that it need not be so. While we acknowledge that each county is bound to provide suitable establishments for all its lunatics, it seems only reasonable that such provision should be made with all the view to curability and economy that the comfort of the patients admits of. Site and Construction of Asylums.-Dr. Conolly properly insists that, any plan for the construction or alteration of a lunatic asylum, should be submitted to the consideration of a physician well acquainted with the characters, habits, and wants of the insane prior to its final adoption, he frequently being best able to point out the defects, or to suggest improvements. Heretofore, asylums had too much the appearance of prisons, and in point of fact, both descriptions of edifice were constructed for merely the safe detention of their inmates. A great improvement in this respect has taken place in the case of recently-erected asylums, and we hope ere long none of the establishments so destined will retain the repulsive and forbidding appearance which some yet have. Dr. Conolly lays much stress upon a gentle eminence being chosen for the site; and all those who have seen the beautiful situation of the Lincoln Asylum, and are aware of the generally healthy state of its inmates and the happiness which the extended prospect imparts to them, will be disposed to agree with him. He thinks the building should not be constructed for more than 360 or 400 patients, great care being taken to enclose sufficient space within the walls to furnish ample gardens, airing courts, and to admit of the due classification and employment of the insane, and of the enlargement of the building, if necessary, without violating the original plan. In all asylums the proportion of separate sleeping-rooms is too small, and Dr. Conolly always recommends that at least two-thirds of the patients should be so accommodated. With large overcrowded dormitories a sweet state of the air cannot be maintained. Whatever system of ventilation and warming be adopted, Dr. Conolly lays great stress upon the necessity of having windows large enough to admit an abundant supply of fresh air in temperate weather, and open fire-places, with all their cheering associations in Winter. He insists, too, upon having the galleries well-lighted, for not only is it an error to suppose that the insane are benefited by being kept NEW SERIES, NO. XI.--VI. K in a state of darkness or semi-darkness; but they suffer grievously when condemned to this from motives of economy. "In visiting patients in private houses," he observes, "I generally find the rooms made totally dark, but filled with anxious relatives, attendants, and half the servants of the house. All these things are unfriendly to the patient's tranquillity, and produce suspicion, fear, and increased violence." The maintenance of the most perfect cleanliness, both of the persons and the chambers of the insane, seems so obviously of the first importance, that one is surprised to find it is one of the essentials only quite recently and not yet universally recognized. It is one, indeed, impossible to put into force by other means than a well-organized superintendence. Exercise and Recreations.-We sincerely hope that, in any new establishment that may be erected, ample provision will be made for out-of-doors exercise, in which most of our public asylums, and nearly all the private ones, are terribly deficient. The sight of hundreds of restless lunatics cooped up within a miserable space of ground, encompassed by high walls, is one of the most mournful of spectacles, and the wonder is that reason is ever restored under such discouraging circumstances. Even in our best asylums, the curative, ameliorating, and composing effects of exercise are not developed, by reason of the rules which prevent the patients passing beyond the walls. Large, indeed, must be the space enclosed if traversing it again and again for months and years do not prove insupportably monotonous. In America, all the patients who can be depended upon are permitted, with the best effects, to take walks and excursions into the adjoining country, and why the same practice should not be followed here it would be difficult to say. The various out-of-door amusements should be encouraged, as far more useful than those of a more sedentary character, and as acceptable to the attendants, who stand as much in need of relaxation, as well as to the patients. Within-doors, the means of amusement are now freely resorted to in most asylums; and, indeed, since attention has been drawn to the necessity of providing a variety of such as a substitute for restraint, some have been introduced into some of the foreign asylums, such as dramatic representations, debating societies, &c., of questionable utility. Upon the defective condition of the majority of private asylums in regard to exercise, Dr. Conolly observes as follows: "It is astonishing to find that one of the particulars of treatment in which the rich patient is sometimes more unfavourably situated than the poor, is that of having an opportunity of enjoying free and frequent exercise. The untrodden lawn, the dusty and desolate courts, the paved yards, the wretched sheds, the lonely out-houses, together with the closed doors and windows of a private asylum, often give to such places an external character, which makes the visitor regard them with dread, and the passer-by speak of them in whispers. The idea of their entrance is connected with that of the fatal gate, which whoso entered left all hope behind. If a patient is visited in such a house, the unlocking of doors, the threading of passages, and the ascent of gloomy stairs, with the close atmosphere of apartments, filled with patients sitting by the walls, oppressed with indolence and monotony, are all features too familiar to those who knew such houses before better improvements penetrated into them. And it is only in a few of the best private asylums that we even now find cheerful sitting-rooms, opening into gardens, into which patients may walk when they please; and the 18471 Paucity of In-door Employment. 131 benefit of this improvement is yet too generally limited to the most rational of the patients, and not extended to the irritable and troublesome, who ought also to be able to go out of their sitting-rooms, although into gardens more secluded and secure." P. 59. Dr. Conolly believes that attention to the dress of patients is too much neglected, and all those who have seen the humiliated mien of some lunatics when presented to friends or strangers in unsuitable attire, will allow that this may act very detrimentally upon them. "Many private asylums are open to the charge of great neglect as respects the dress of the classes far above pauperism. Tattered and thread-bare coats, very shabby hats, trowsers not always free from an offensive smell; and equally slovenly dresses on the female side of the asylum, shoes out of repair, hair in curl-papers, make the unfortunate patients objects of pity or of ridicule. They feel themselves degraded, lose their self-respect, and with it the little self-control their malady has left them. It is very true that, in some cases, the patients will not dress themselves properly, that they have an affection for old and ragged garments, insist upon their being fit to go to court in, and are evidently offended if better clothes be substituted for them; but such cases only form a small proportion in any asylum; and, in many instances, habits of personal neatness may be long preserved, and in some restored, after being long lost." P. 63. Employment,―The value of this can scarcely be over-estimated, when discriminately furnished. "We consider labour," says Dr. Brigham in his Report," as among the most essential of our curative means of this we become more convinced every year." It should, however, never be regarded apart from the other portions of the treatment of the patient, and its amount therefore regulated by the opinion of the physician, not by its economical results, important though these be in large establishments. of-doors employment is far more conducive to health and recovery than that of a sedentary character. Regular work should never be attempted to be enforced from an unwilling patient upon the plea of idleness. According to the last Hanwell Report, 219 out of 418 male patients were employed, and 314 out of 567 women. All the patients' clothing, except shoes, and bedding is made up in the asylum, and all the washing and mending for so large a population performed. There are a garden and farm, on which labour is performed, carpenter's, tailor's, shoemaker's, tinman's, &c. shops, the expense of employing instructors being an obstacle to the multiplication of occupations. Dr. Brigham complains also of this, and that in a much smaller establishment than Hanwell. "In Winter, we find it difficult to furnish suitable and sufficient labour for all who would be benefited by it. Some engage in sawing wood, but this furnishes but little labour for 60 or 70 men. Some work in the joiner's shop, and a few are employed in other kinds of business. Still, for a considerable number we have not sufficient employment, and we apprehend this is a difficulty which all large asylums have to encounter. We have studiously examined this subject, and reflected much upon the propriety of establishing some kind of business, in which many can engage. But we find it difficult to determine what kind is best. Hitherto, we have found none better than carving toys and making small wooden articles. Several of our patients have become very skilful at this business: Some articles carved here are not inferior to the handsomest Swiss specimens, of which in fact ours are imitations." P. 33. K * The difficulty becomes greater still in devising occupation for male patients in the upper walks of life. Attendants. Upon no one circumstance does the well-doing of an asylum so essentially depend as upon the possession of an efficient corps of attendants. The securing this is of the first consequence then, for without it no ameliorations can be carried out to the extent they are capable of, and no improvement can be prevented from eventual degeneration. Two chapters are therefore devoted by Dr. Conolly to this important subject, in which he points out the defects of the present modes of appointing and governing these functionaries, and suggests some of the numerous alterations these are capable of, and urgently demand. It is so evident that these persons should be the faithful and passive instruments in the hands of the physician for carrying out his designs, that it is scarcely to be believed that they are chosen without reference to his wishes or their own qualifications, called upon to perform duties of a nature and at a time that have not his sanction, and dismissed or changed with as little consideration of his feelings upon the subject or the true welfare of the patients as prevailed in their appointment! We are constantly hearing complaints of the unfit class of persons who follow the occupation of keepers or attendants of the insane, and can it be wondered at that such should be the case when our large asylums set so vicious an example as this. The Resident alone can appreciate their qualifications and their efficiency; to him alone should they owe their introduction to the esta blishment and their continuance in it; or at the very least he should possess a veto upon the one and the other. Nothing is more admirable than the spirit of benevolence which pervades the whole of Dr. Conolly's work, and this is not exhausted upon the insane themselves; for, while he de mands that steps be taken to provide them with more efficient attendants, he likewise insists that these ought to be more considerately treated in regard to their distribution of employment, relaxation and recreation, instruction, &c. With the present hard work and uncertain tenure of an asylum-assistant, no person will longer engage in the occupation than he can help, those best qualified for it indeed being the first to quit it, leaving the staff overburdened with the unwilling and the incapable. The duties to be performed at Hanwell, here described in full detail, are indeed multifarious and onerous, and make so large a call upon the benevolence, the mental energy, and the bodily activity of the attendants, that we are at a loss to understand how they can be efficiently executed by persons so miscellaneously chosen and so inadequately encouraged. Dr. Brigham says that, in his asylum, great advantage has been derived from a more judicious distribution of duties among the attendants, so as occasionally to exempt them from duties which, uninterruptedly continued for many hours, must produce a tension of mind utterly destructive to the retention of its elasticity and detrimental to the preservation of the temper. These supplementary attendants are derived from a class of persons sufficiently instructed to develop the amount of mental occupation the insane are capable of and benefited by. "Our observation for many years in various lunatic asylums, led us a long time since to regard the want of mental occupation as the greatestwant in modern 1847] Importance of Educated Attendants. 133 institutions for the insane. Go into any such establishment, and you will find some few, in Winter a very few, at work, some playing cards or other games; yet a still larger class will be found sitting about, listless, inactive, doing nothing, saying nothing, taking no interest in anything going on around them, gathering round the stove, looking forward to nothing but the hours for eating and retiring to sleep. For a short time each day, when the physician passes round, they will exhibit a little animation and say a few words, and then relapse into their former condition. "These patients give but little trouble in an asylum, and are very apt to be overlooked and neglected, and, if not already demented, soon become so. They are thought not to require much attention, as they have good bodily health, and are quiet, consequently they generally receive but little notice. But this class require great attention. They need mental exercise; they should attend school, and have their minds aroused into mental activity for an hour or two every day. Soon, by this course, their memories will improve, they will become interested in singing or study, and by perseverance some will be cured, and many, very many, rendered capable of much enjoyment, and be kept from sinking into a state of hopeless dementia. * * "Our teachers spend all their time with the patients, but have no labour nor any other duty to attend to, than to interest the patients, and contribute all they can by their presence and conversation to their contentment and enjoyment. Thus they join in their amusements and walks, and are their constant companions. The relief which they afford the attendants is very great, and enables us to dispense with some that would be otherwise necessary. We are satisfied that an establishment like this can be better managed, and with equal economy, by having an arrangement by which some should devote their time to their ordinary duties and labours of the halls, while others should have nothing to do but to accompany the patients and endeavour to instruct and amuse them. The latter having nothing to do with any coercive measures, the patients do not become prejudiced against them, and will readily hearken to their suggestions. Thus they serve as a constant guard, and by their presence and management prevent outbreaks and disorder, and make coercive measures, restraint, and seclusion rarely necessary.-Report, p. 37. There seems sound wisdom in this arrangement, both as regards the welfare of the insane and the comfort of the attendants; and it would be still more applicable to the pauper lunatics of England than to those of America, inasmuch as a much smaller proportion of the former are able to read, and thus amuse themselves by the perusal of light-reading, newspapers, &c., with which, too, our asylums are far more scantily provided. But the lack of well-informed attendants is most felt by the wealthy and educated lunatic, who finds himself condemned to the perpetual society of one possessed only of the acquirements of a menial, but invested with the authority of a master, and that too often a harsh one. Little matters it that a ray of intelligence may yet lurk amidst the ruins of his mental edifice, no sympathy and encouragement will enkindle it into an invigorating flame; and the mental apathy and listlessness which an utter absence of interesting conversation or other intellectual occupation engenders or augments, may confirm and render hopeless a condition which, more skilfully managed, might have had another issue. sidered how many persons there are of both sexes, whose mental acquirements and moral attributes would well fit them for the occupation of attending upon the insane, and the excellent remuneration the wealthy portion of so many of these unfortunates would enable them to furnish, it When it is con |