On the Construction, Organisation, and General Arrangements of Hospitals for the Insane
With some remarks on Insanity and its Treatment. By Thomas S. Kirkbride,M.D., LL.D., &c. Second Edition. Philadelphia: J. B. Lippincott & Co., 1880.
This valuable work is a perfect encyclopaedia of every matter connected with the arrangements of hospitals for the insane. It is thoroughly practical and comprehensive, and the author has minutely detailed every requisite for the health and comfort of the iumates of an asylum. We quite agree with the writer, that the insane are more effectually and more economically treated in a well-regulated asylum than in private care ; and we feel confident that our contemporary would have no sympathy with the popular clamour against lunatic asylums in this country. He objects to very large asylums, and thinks two hundred and fifty patients the utmost number that can receive the necessary care and supervision. We have at various times, in our defence of private asylums, insisted on this principle. It must be admitted, by every candid observer, that when the patients are very numerous, it is scarcely possible they can have the same minute attention as they would if the inmates were fewer. The first edition of this work, the author informs us, was published twenty-six years since; and the substance of it had previously appeared in the pages of the American Journal of Insanity. His experience of asylum work extends over a period of forty-five years, which has given him ample opportunities for extensive observation. The author makes the following good remarks as to the enclosures and ventilation of asylums :?
” It is desirable that the pleasure grounds and gardens should be securely enclosed, to protect the patients from the gaze and impertinent curiosity of visitors, and from the excitement occasioned by their presence in the grounds. This, therefore, becomes a matter for consideration in the selection of a site. ” This enclosure should be of a permanent character, about ten feet high, and so located-that it will not be conspicuous, even if it is at all visible, from the building. The site, as well as the position of the building on it, should have some reference to this arrangement. If sufficient inequalities of surface exist, the wall or fence, as it may be, should be placed in the low ground, so as not to obstruct the view ; but if the country is too level to admit of this, the same end may be attained by placing the wall in the centre of a line of excavation of sufficient depth to prevent its having an unpleasant REVIEWS AND BIBLIOGRAPHICAL NOTICES. 123 appearance, and yet to render it entirely effective. Although the first cost of a wall will be about double that of a fence of the proper kind, still its durability and greater efficiency in every respect, will make it cheaper in the end.”
” Although a forced ventilation is deemed indispensable in every hospital for the insane, still a natural ventilation should never be neglected. In most parts of the United States, during one-half the year, there is a comfort in the fresh, cool breezes which may often be made to pass through the wards, that can not be too highly estimated, and every precaution should be taken to derive full advantage from them. The darkest, most cheerless, and worst ventilated parts of such establishments, will generally be found to be where a wing joins the centre building, or where one wing comes directly in contact with another running at right angles to it. The first of these defects, however, is easily and effectually remedied, by leaving on each side an open space of ten or twelve feet, with movable glazed sash extending from near the floor to the ceiling, and which may either be accessible to the patients, or be protected by ornamental open wire work on a line with the corridor; this arrangement gives nearly every advantage of light, air, and scenery. Behind such a screen, even in the most excited wards, may be placed with entire security, the most beautiful evergreen and flowering plants, singing birds, jets of water, and various other objects, the contemplation of which cannot fail to have a pleasant and soothing effect upon every class of patients. To remedy the other difficulty alluded to, instead of allowing a second wing to come directly in contact with the first, it should be placed on a parallel line, but made to recede just so far as will allow its corridor to be open at both extremities, or as much more as may be deemed desirable, and these ends should also be furnished with movable glazed sashes, terminating in a bay window, accessible to the patients, or protected and ornamented as already suggested, according to the class by which it is to be occupied, and other circumstances. If the second range of wings is placed at right angles to the first, the same arrangement is required, as that suggested where the first wing joins the centre building. I deem this mode of finish of great importance, and one of the most valuable features of the plans under notice. These open arrangements, where one ward joins another, give all possible advantages of light and air, and are infinitely preferable to structures entirely detached, which, besides being more expensive, without having compensating advantages, have many inconveniences, that must be obvious to those who are practically familiar with the management of hospitals.
” The character of the ground must often decide whether the building shall be in one extended line, or whether the second or third range shall be at right angles to the first or second, as the case may be. If the building is but for one sex there can be no objection to either of these, and of both plans, outlines are given.”
These remarks on security from fire are well deserving of attention:?
” In constructing a hospital, every precaution should be taken to provide against accidents from fire, and the building should be made as nearly fireproof as circumstances will permit. Iron girders and brick arching between the different stories would be desirable everywhere, but the first cost will probably mostly lead to counter ceiling and other substitutes; or better, the kitchens and bake-rooms, in which rooms alone it will be necessary to have fires of any size, should be arched above and.’ below, and the flues leading from them should be constructed with great care. Instead of making the entire structure fireproof, it will answer to have the parts just alluded to and the passages between the different ranges of wings made positively fireproof. These last also should be arched, their side walls should run up from the cellar to the roof, and they should have stone floors, and iron doors on one side, that can be closed whenever desired. By this arrangement, a fire commencing in one section of the wings, could easily be prevented from spreading to any other, and it might lead to the preservation of all parts of the structure, except the range in which the fire originated.
” The buildings should be heated by steam, and the fires for generating the steam should always be in a fireproof detached structure, from fifty to one hundred feet from the hospital. This mode of heating and this locality for the large fires, will remove the greatest source of accidents from this cause in nstitutions for the insane.”
Also what he says on windows and window-guards is noteworthy :? ” When, in order to give a proper architectural effect to the building, the rooms in its centre must have lofty windows, the lower sash may be guarded as hereafter described, while the upper may be left as in an ordinary building. This is sufficient for rooms not regularly used by patients ; but if constantly occupied, more attention must be paid to security. Inside shutters, with the upper half permanently closed, and the lower sash properly guarded, sometimes make a very neat arrangement in such rooms, and this, or something equivalent, is necessary for adequate safety.
” More care, however, must be observed in reference to patients’ chambers and ordinary ward windows. A window about six feet six inches by three feet, will be found of a convenient size, and this will give two sashes, each containing ten lights 5^ by 18 inches. The window seats may be like those in common dwellings, and the window should be placed low enough to make it pleasant to a person sitting in the room. The upper sash should be of cast or malleable iron, and well fastened into the frame, while the lower sash, of the same size and pattern, may be of wood, and hung so as to rise and fall throughout its whole extent. The cord may be entirely concealed. The space opposite the lower sash should be protected by a wrought-iron window guard, which, if properly made, and painted of a white colour, will not prove unsightly. This kind of guard is always to be very strongly secured to the window frame, and in such a manner that the screws may not be accessible to the patients. It should reach to within five inches of the upper sash, and to within the same distance of the frame below and at the sides. When of a tasteful pattern and neatly made, it will be found very preferable in appearance and quite equal in security, to the unglazed cast-iron sash occasionally used, and which after all, when the sash is raised, has to one in the room very much the appearance of two sets of iron bars, placed at right angles, while the wrought-iron screen is no more than what is every day seen in certain front windows of some of the best houses in our large cities. ” Those who recommend unguarded windows, would seem to have little appreciation of the risks, which are sure to occur, or of the fatal results, that sooner or later will scarcely fail to happen. Within a very brief period, without this protection, three casualties would have taken place in a single institution, each of which must have ended in most serious, if not fatal results. Such windows may be safe for certain patients, but the great difficulty in taking care of the insane, is to know who are to be trusted and who are not, so many of their actions come from sudden impulse. The kind of patients for whom ordinary windows are safe, might really be treated elsewhere than in hospitals. So of doors left unfastened and unguarded ; every superintendent can judge for himself of the safety and propriety of such a course, and the amount of responsibility he is willing to assume.”
Dr Kirkbride is opposed to the expediency of providing separate asylums for recent and chronic cases, or those supposed to be incurable. He says if the latter are confined to special institutions, there is a danger that, after a time, they will deteriorate mentally and physically
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