Chapter XXIV: Act 1837: (In re Blewitt, 1880, 5 P.D. 116) (9)

The modern hospital for the insane does credit to latter-day civilization. Physical restraint is no longer practised. The day of chains--even of wristlets, covered cribs and strait-jackets--is past. Neat dormitories, cosy single rooms, and sitting- and dining-rooms please the eye. In the place of bare walls and floors and curtainless windows, are pictures, plants, rugs, birds, curtains, and in many asylums even the barred windows have been abolished. Some of the wards for milder patients have unlocked doors. Many patients are trusted alone about the grounds and on visits to neighbouring towns. An air of busy occupation is observed in sewing-rooms, schools, shops, in the fields and gardens, employment contributing not only to economy in administration, but to improvement in mental and physical conditions. The general progress of medical science in all directions has been manifested in the department of psychiatry by improved methods of treatment, in the way of sleep-producing and alleviating drugs, dietetics, physical culture, hydrotherapy and the like. There are few asylums now without pathological and clinical laboratories. While it is a far cry from the prisons and monasteries of the past to the modern hospital for the insane, it is still possible to trace a resemblance in many of our older asylums to their ancient prototypes, particularly in those asylums built upon the so-called corridor plan. Though each generation contributed something new, antecedent models were more or less adhered to. Progress in asylum architecture has hence advanced more slowly in countries where monasteries and cloisters abounded than in countries where fixed models did not exist. Architects have had a freer hand in America, Australia and Germany, and even in Great Britain, than in the Catholic countries of Europe.

Germany approaches nearest to an ideal standard of provision for the insane. The highest and best idea which has yet been attained is that of small hospitals for the acutely insane in all cities of more than 50,000 inhabitants, and of colonies for the chronic insane in the rural districts adjacent to centres of population. The psychopathic hospital in the city gives easy and speedy access to persons taken suddenly ill with mental disease, aids in early diagnosis, places the patients within reach of the best specialists in all departments of medicine, and associated, as it should be, with a medical school or university, affords facilities not otherwise available for scientific research and for instruction in an important branch of medical learning. A feature of the psychopathic hospital should be the reception of patients for a reasonable period of time, as sufferers from disease, without the formality of legal commitment papers. Such papers are naturally required for the detention and restraint of the insane for long periods of time, but in the earlier stages they should be spared the stigma, delay and complicated procedure of commitment for at least ten days or two weeks, since in that time many may convalesce or recover, and in this way escape the public record of their infirmities, unavoidable by present judicial procedures.

There should be associated with such hospitals for the acutely insane in cities out-door departments or dispensaries, to which patients may be brought in still earlier stages of mental disorder, at a period when early diagnosis and preventive therapeutics may have their best opportunities to attain good results. In Germany a psychopathic hospital now exists in every university town, under the name of Psychiatrische Klinik.

Colonies for the chronic insane are established in the country, but in the neighbourhood of the cities having psychopathic hospitals, to receive the overflow of the latter when the acute stage has passed. The true colony is constructed on the principle of a farming hamlet, without barracks, corridored buildings, or pavilions. It is similar in most respects to any agricultural community. The question here is one of humane care and economical administration. Humane care includes medical supervision, agreeable home-life, recreation, and, above all things, regular manual and out-of-door occupation in garden, farm and dairy, in the quarry, clay-pit or well-ventilated shop. Employment for the patients is of immense remedial importance, and of great value from the standpoint of economical administration. In the colony system the small cottage homes of the patients are grouped about the centres of industry. The workers in the farmstead live in small families about the farmstead group of buildings; the tillers of the soil adjacent to the fields, meadows and gardens; the brickmakers, quarrymen and artizans in still other cottages in the neighbourhood of the scenes of their activities. In addition to these groups of cottages, which constitute the majority of the buildings in the village, an infirmary for bedridden, excited and crippled patients is required, and a small hospital for the sick. All the inhabitants of the colony are under medical supervision. A laboratory for scientific researches forms a highly important part of the equipment. The colony is not looked upon as a refuge for the incurable; it is still a hospital for the sick, where treatment is carried on under the most humane and most suitable conditions, and wherein the percentage of recoveries will be larger than in asylums and hospitals as now conducted. In respect of the establishment of colonies for the insane upon the plan outlined here, Germany has, as in the case of the psychopathic hospital, led the world. It has been less difficult for that country to set the example, because she had fewer of the conditions of the past to fight, and with her the progress of medical science and of methods of instruction in all departments of medicine has been more pronounced and rapid.

Among the German colonies for the insane, that at Alt-Scherbitz, near Leipzig, is the oldest and most successful, and is pre-eminent in its close approach to the ideal village or colony system. In 1899 Professor Kraeplin of Heidelberg stated (_Psychiatrie_, 6th edition) that the effort was made everywhere in Germany to give the exterior of asylums, by segregation of the patients in separate home-like villas, rather the appearance of hamlets for working-people than prisons for the insane, and he said, further, that the whole question of the care of the insane had found solution in the colony system, the best and cheapest method of support. "I have myself," he writes, "had opportunity to see patients, who had lived for years in a large closed asylum, improve in the most extraordinary manner under the influence of the freer movement and more independent occupation of colony life."

In America the colony scheme has been successfully adopted by the state of New York at the Craig Colony for Epileptics at Sonyea and elsewhere.

That the tendency nowadays, even outside of Germany, in the direction of the ideal standard of provision for the insane is a growing one is manifested in all countries by a gradual disintegration of the former huge cloister-like abodes. More asylums are built on the pavilion plan. Many asylums have, as it were, thrown off detached cottages for the better care of certain patients. Some asylums have even established small agricultural colonies a few miles away from the parent plant, like a vine throwing out feelers. What is called the boarding-out system is an effort in a similar direction. Patients suffering from mild forms of insanity are boarded out in families in the country, either upon public or private charge. Gheel is an example of the boarding-out system practised on a large scale. But the ideal system is that of the psychopathic hospital and the colony for the insane.

AUTHORITIES.--Sir J. B. Tuke, _Dictionary of Psychological Medicine_,
(London and Philadelphia, 1892); W. P. Letchworth, _The Insane in
Foreign Countries_ (New York, 1889); _Care and Treatment of
Epileptics_ (New York, 1900); F. Peterson, _Mental Diseases_
(Philadelphia, 1899); "Annual Address to the American
Medico-Psychological Association," _Proceedings_ (1899). (F. P.*)

FOOTNOTES:

[1] The word for "lunatic" in several other languages has a similar
etymology. Cp. Ital. _lunatico_, Span. _alunado_, Gr. [Greek:
selêniakos] (epileptic), Ger. _mondsüchtig_.

[2] It has sometimes been stated that this power, which ought
clearly, in the interests alike of prisoners and of the public, to be
exercised with caution, is in fact exerted in an unduly large number
of cases. The following figures, taken from the respective volumes of
the _Criminal Judicial Statistics_, show the number of criminal
lunatics certified insane before trial. In 1884-1885, out of a total
of 938 criminal lunatics, 169 were so certified; in 1885-1886, 149
out of 890; in 1889-1890, 108 out of 926; in 1890-1891, 95 out of
900; in 1894, 78 out of 738; in 1895, 84 out of 757; in 1896, 88 out
of 769; in 1897, 85 out of 764; in 1898, 17 out of 209; in 1899, 13
out of 159; in 1900, 12 out of 185; in 1901, 15 out of 205; in 1902,
7 out of 233; in 1903, 11 out of 229.