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STATE HOSPITAL  FOR THE INSANE FOR 250 PATIENTS. 
ON THE
CONSTRUCTION, ORGANIZATION
GENERAL ARRANGEMENTS
HOSPITALS FOR THE  INSANE.
     THOMAS S. KIRKBRIDE, M.D.,




PHYSICIAN TO THE PENNSYLVANIA HOSPITAL FOR THE INSANE.
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PHTL'A'frfcLPHTA
1854. 
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CONTENTS.
                 ON  CONSTRUCTION.
                                                      FAGi,
 Preliminary Remarks...............................   1
 Public Hospitals....................................   4
 Private Institutions.................................   5
 County Hospitals...................................   5
 Association of Medical Superintendents of Ameiican Ins-
        titutions for  the Insane___.....................   5
 Appointment of Building Commissioners...............   6
 Site for a Hospital for the Insane.....................   (i
 Amount of Land................... _................   7
 Supply of Water...................................   8
 Drainage..........................................   8
 Enclosures.........................................   9
 Patients'  Yards.................................... 10
 Size of the Building.................................10
 Position, Form and General Arrangements............. 11
 Number of Patients in a Ward....................... 14
 Cellar............................................. 14
 Materials of Walls.................................. 14
 Plastering......................................... 15
 Security from Fire................................. 15
 Roof......................._..._................... 15
 Size of Rooms___................____.............. 15
 Height of Ceilings.................................. 15
 Floors............................................ 16
 Doors___.......................................... l(i
 Locks............................................. 10
 Windows and Window Guards....................... 17
 Inside Window Screens.............................18
 Stairs............................................. 18
 Associated Dormitories.............................. 18
 Infirmaries........................................ 19
 Bath Rooms....................................... 19
 Water  Closets.....................................20
 Sinks.........................•....................21
 Urinals •...........................................21
 Ward Diying Rooms...............................21
 Water  Pipes...................................... 22
 Dust Flues........................................22
 Soiled Clothes Hoppers............................. 22
 Kitchens and Distribution of Food.....................22
 Dumb Waiters..................................... 23
 Speaking Tubes.................................... 23
 Heating and Ventilation............................. 23
 lighting..........................................28
 Washing Arrangements............................. 29
 Drying        do      ............................. 29
Ironing        do      ............................. 29
Baking        do      ............................. 29
Farm Buildings..................................... 29 
                              11
                                                        PAGE
  Cost of a State Hospital............................. 30
  Description of Plates............................_-.. 31
  Height of Ceilings in Plan ................-.....____34
  Width of Corridors in do___...........-.....—.----34
  Size of Rooms in      do............................34
  Remarks on the Plan................................34

ON ORGANIZATION AND GENERAL ARRANGEMENTS.

  Preliminary Remarks___.......................---37
  List of Officers............_...............-........38
  Trustees---....................-------............38
  Treasurer.........................-................ 40
  Physician.................-........................40
  Assistant Physicians.........................-.......44
  Steward........................................... 44
  Matron...........................................45
  Chaplain.......................................... 46
  Consulting Physicians............................... 46
  Supervisors........................................47
  Teachers..........................................47
  Attendants......................................... 48
  Night Watch......................................49
  Seamstresses____..............___________..'________51
  Farmers.................................__________51
  Gardeners......................................... 51
  Engineer and Firemen_____„........................51
  Carriage Driver................................____51
  Carpenter......................................... 51
  Jobber........_..............................._... 51
  Baker..............._.............................51
  Domestics......................................... 51
  Remarks on the number employed and their Compensation 51
  Schedule of a complete  Organization with rate of Com-
         pensation ..............,.................____52
  Residence of the Physician.........„............____54
  Hospital Furniture..................................56
  Classification of Patients.............................58
  Should Curables and Incurables be  separated?..........58
  Separation of the  Sexes..............................59
  Restraint and Seclusion..........................:___60
  Labor, Out-Door Exercise and Amusements............61
  Means of Extinguishing Fire......................... 63
  Supervision of Hospitals for  the Insane'................ 64
  Provision for Insane Criminals........................ 65
  Visitors........................................... 67
  Admission of Patients...............................70
  Importance of a correct Nomenclature.................72

                        APPENDIX.
  Propositions relative  to the  Construction of Hospitals for
         the Insane............A......................76
  Propositions relative to the  Organization of Hospitals for
         the Insane................................... 7H 
CONSTRUCTION AND ORGANIZATION
or
HOSPITALS  FOR  THE  INSANE.
  The proper custody and treatment of the insane, are now recognized
 as among the duties which every State owes to  its citizens; and as  a
 consequence, structures for the special accommodation of those laboring
 under mental disease, provided  at the general expense, and under the
 supervision of the public authorities, will probably before any long period,
 be found in every one of the United States.
  There is abundant reason why every State should make ample provi-
 sion, not only for the proper custody, but also for the most enlightened
 treatment of all the insane within its borders.  Most other diseases may
 be managed at home.  Even with the most indigent, when laboring un-
 der ordinary sickness, the aid of  the  benevolent may supply all their
 wants,  and furnish every thing requisite for their comfort and recovery,
 at their own  humble abodes.  It is not so, however, with insanity; for
 the universal experience is that  a large majority of all such cases can be
 treated most successfully among strangers,  and very generally, only in
 institutions specially provided  for the management of this class of dis-
 eases.  It is  among the most painful features of insanity, that in its treat-
 ment, so many are compelled to  leave their families ; that every comfort
 and luxury that wealth or the tenderest affection can give, are so fre-
 quently of little avail at home;  and that as regards a restoration or the
 means to be employed, those surrounded with every earthly blessing are
placed so nearly on a level with the humblest of their fellow beings.
  Although,  with great inconvenience,  the affluent  might provide  suit-
able private accommodations, a large proportion of our best citizens, «11
                             1 
                                 o

in moderate circumstances, no less than  those dependent  on their daily
exertions for support, without some public provision, must be  deprived
of much that is desirable, almost as completely as the pauper portion of
the community.  The simple claims of a common humanity, then, should
induce each State to make a liberal provision for all its insane, and it will
be found that it is no less its interest to  do so, as a mere  matter of eco-
nomy,  especially as regards the poor.
  Of the recent cases of insanity,  properly treated, between PO and 90
per cent recover.   Of those neglected or improperly managed,  very few
get well.  Where fifty or one hundred dollars may be required  to cure a
case, ten times that amount may not be sufficient to support one that is
uncured through lil j.  Those who recover may become valuable citizens;
if they do not add directly to the wealth of the State, they at least sup-
port their families ; those who become incurable, are often during a long
life, a source of constant expense to the public, and not unfrequently their
families also become a public burthen.   More than all this, when ample
provision is  made for all the insane, recent cases are likely to be placed
promptly under treatment, and retained in a place  of security  till they
are well.  The effect of this, is greatly to increase the ratio of recoveries,
and to spare the  community a  recital of the most  atrocious acts com-
mitted on the  innocent  and unoffending,  by irresponsible  individuals,
simply because their  friends, or the proper authorities, have neglected
the obvious  duty  of placing them  in a place of security, not only to pro-
mote their restoration, but for the protection of the public.
  The location of a hospital for the insane, its general arrangements and
official organization, must ever exert so important  an influence on the
comfort and happiness of all its patients, on the prospects  for a recovery
in those that are  curable, and  of the mental and physical well-being of
those that are incurable, that no apology is required for any  one, who
having some practical knowledge of the subject, desires a general  dis-
semination of the views and conclusions which have resulted from actual
experience  among those for   whom these  institutions are  specially
intended.
  The physicians to the hospitals for the insane  in the United States,
almost invariably exercise a general superintendence of all their depart-
ments, and  they  are so frequently consulted in reference to the details
of these institutions, that their opinions can hardly fail to exert an im-
portant influence  on  the  character of the buildings hereafter to be
erected.  In common with his brethren throughout  the countiy,  the
writer has been  frequently honored with these inquiries, and detailed
Statements  of his views  on nearly eveiy subject connected  with  the
treatment of the insane  have been so often solicited, that he is induced 
to present some of tha results of his experience in the present form, aa
a convenient mode of answering these questions, and of aiding those who
are commencing their investigations on the subject, rather than from any
belief that his opinions possess great novelty or particular interest for
those who, like himself, are engaged in the care of the insane.
  Sixteen years residence among the insane, in three  different institu-
tions—the last thirteen of the time being in immediate superintendence
of that with which he is now connected,—and the care of more than
2,700 patients under very varied circumstances, joined to  a familiarity
with the defects as well as the advantages of a majority of the American
hospitals, have not failed to settle the writer's own views on most of the
subjects that will be referred to.  Others, not less interesting, but about
which there has  seemed to be  more uncertainty, have been purposely
avoided.
  It is pretty generally conceded, that a more convenient style of archi-
tecture, and better  arrangements, are desirable in most establishments
for the care of the insane; and  those who have been personally familiar
with the losses sustained by imperfect accommodations, and the advan-
tages derived from improved ones, will be sure to be found most anxious
to secure a high character to eveiy  one of these institutions, without
regard to the class of patients they are intended to receive.
  No better proof need be given of the necessity for improvements in the
construction and arrangements  of hospitals for the insane, than the sim-
ple fact that some of the very last which have  been put up, exhibit in
many parts most glaring defects, and that nearly all  erected till within a
veiy few years, have required extensive and costly alterations or additions;
or if these changes have  not been  made, the buildings still remain un-
suited for the proper and convenient treatment  of the patients.  Many
of these  lamentable defects,—which  often  can  scarcely be remedied
without actually re-building the hospital,—and the large expenditures of
money, in making alterations and improvements, have often resulted al-
most entirely from  the buildings having been planned by persons who,
whatever may have been their taste, architectural  skill or good inten-
tions, had no  knowledge of what is  required for the  proper care and
treatment of the insane.
  No reasonable person at the present day, when planning a hospital for
the insane, would think it necessary or desirable  to  propose a building
entirely original in  its design; for such a structure could hardly fail to
loose in usefulness what it gained in novelty.   Instead of something en-
tirely new, the object should rather be to profit by the experience of the
past, by the knowledge of those who have a practical familiarity with the
wants and requirements of the insane, and after a careful study of existing 
4
 institutions, to combine, as far  as possible, all their good features, and
 especially to avoid their defects and inconveniences.
   These institutions, especially when put  up under  State  authority,
 while having a plain, but still good and agreeable style of architecture,
 should not involve too large- an expenditure of money in their erection;
 but, nevertheless, should be so  conveniently arranged as to be economi-
 cal in their  subsequent management, and should have every  possible
 advantage for the best kind of classification and supervision of their pa-
 tients, and for their comfort and treatment.
   Every one concerned in providing accommodations for the insane, may
 rely upon the fact being established by all experience, that the best kind
 of hospitals,—not only best built, but with the most perfect arrangements
 and fixtures of every kind, and managed in the  most liberal and  enlight-
 ened manner,—are sure to be most economical in the end—(for true eco-
 nomy consists, not only in avoiding all waste and extravagance,  but also
 in doing thoroughly whatever is undertaken)—will fulfil most completely
 the objects for which they  are erected,  and ultimately give most satis-
 faction to eyery enlightened community.
   The plan proposed in the following pages,  is for a State hospital to
 accommodate 250 patients; this number  being now almost universally
 conceded to be as many as  should be collected in any  one institution.
 State hospitals, it is to be remembered, are not for the pauper portion of
 the community alone, but for every class of citizens.  All who pay taxes
 aid in their erection, and all have the right to participate in then* advan-
 tages, while in most of the States they furnish the only accommodations
 for the care of any portion of the insane.  Except in the  vicinity of a few
 of our largest cities, it is not probable, at least for many years, that any
 other class of institutions will be put up in any section of the  United
 States; and on that account, it is particulary desirable that public opinion
 should be settled  as to what is indispensable for this description of hospi-
 tals.  The same plan and arrangements are applicable, however, to the
 hospitals intended for the insane poor of large cities, and also, with some
 slight variations, would answer for the corporate institutions, connected
 with the hospitals for the sick in Philadelphia, New York and Boston.
   In nearly all of these  different institutions, it is necessaiy that a  strict
 regard should be had to  first cost, and, as before observed, to economy in
 subsequent management.  On these accounts, I propose recommending
 only what I deem absolutely necessaiy for the proper  accommodation
 and treatment of the insane  in any of the classes of hospitals previously
 referred to.
   There are several variations that might be suggested,  where it was
proposed to provide the  most perfect arrangements, without regard to 
5
cost, or to furnish  accommodations for the most wealthy in the commu-
nity ;  for I know of no reason why an individual who has the misfortune
to become insane, should, on that account, be deprived of any comfort or
even luxury, that is not improper or injurious, to which he has been ac-
customed,  or which  his income  will justify.  An insane member of a
family, wherever he may be, has really a claim for every thing that will
contribute to his  comfort and gratification, far beyond those who are in
health and have so many other resources; and the justice or morality of
a different course,  as occasionally observed, can not for a single moment
bear examination.
   The only other class of institutions for the care of the  insane, not al-
ready referred to, are private establishments belonging to individuals, and
having no supervision by boards of managers, or the public authorities.
So far as I know,  only two or three of this kind have proved successful
in the United States; and for various and sound reasons, it is not desirable
nor probable, that  the number will hereafter be materially increased.
   In some sections of the country it has become a matter of interest to
the community, and the question has been freely discussed, whether
certain classes of the insane may  not  be  as well kept, and more econo-
mically, in county hospitals than in State institutions, and  whether it is
not desirable that such establishments should be provided in connection
with the alms houses in  many districts of country.  The  best interests
of the indigent insane are closely  connected with the proper settlement
of this question;  and on  that account,  without entering fully into its
discussion,  it  may not  be amiss  to remark, that my observations
and reflections  have  entirely  satisfied me that nothing could  be  more
improper or injurious than such  an attempt to separate the supposed
curable and incurable insane.  I am also well  convinced that nowhere
can the pauper insane, curable or  incurable, be properly treated at a less
cost than in a well conducted State institution, and that  the only case
where county hospitals for the insane are desirable, or should be provided,
is in the vicinity of large towns, or in very populous counties, which can
furnish about one  hundred patients, or enough to make it expedient  to
have a regular organization, with a resident medical superintendent, and
all the other arrangements hereafter to be referred to, as proper in a
State hospital.
   The general principles which should regulate the construction, organi-
zation and varied  arrangements of  hospitals for the insane, are much
better understood than formerly, and the unanimous resolutions of "the
ASSOCIATION OF MEniCAL  SUPERINTENOENTS OF AMERICAN INSTITU-
TIONS  for the insane," show a gratifying degree of unanimity among
those engaged in the care of this  afflicted class throughout the country. 
6
 This association, formed in 1844, and holding annual sessions in different
 parts of the country, has visited and carefully inspected a large number
 of institutions, and has  among its members the  chief medical officers of
 nearly every respectable institution for the insane on the continent.  A se-
 ries of twenty-six propositions in reference to the construction of hospitals
 for the insane, adopted  by the association at its meeting in Philadelphia,
 in 1851, have  already been recognized as authority by the  general and
 several of the  State governments, and by various corporate bodies inter-
 ested in the welfare of those laboring under  mental disease.  The plan
 proposed in the present essay, is intended to be in eveiy respect, fully in
 accordance with the expressed views of the association, as shown in the
 propositions just referred to in reference to construction, and also with
 those subsequently adopted at the meeting at Baltimore, in 1853, in refer-
 ence to organization, both of which series will be found in the appendix.
   Of these propositions, it may be safely asserted, that if carried out in
 their true spirit, they can not>fail to give us  institutions of a high order,
 every way superior to those formerly  erected, and it  is believed at as
 small a cost,  as  can thoroughly effect  the  objects aimed  at by their
 provision.
   Whenever it is seriously .proposed to establish a State hospital for the
 insane, it  becomes the friends of this unfortunate class carefully to attend
 to the first steps taken  to promote this  object.   Those  who frame the
 legislative bills providing for these institutions, frequently have it in their
 power to do much towards deciding their future  character and useful-
 ness, by a careful attention to the nature of the  acts which  are passed,
 and by insisting upon a judicious selection of the men who are to choose
 the site, decide upon the plan, superintend the erection of the building,
 and control its subsequent management.  As great power is commonly
 placed in the hands of  these individuals, it  will  readily be understood
 how important it is that they should  be men of high character, strict
 integrity,  active  benevolence, and of business habits.   They should be
 willing fully to inform themselves  of the character and responsibility of
 the high trust confided to them, and should avoid hastily taking any step
 which might mar to a greater or less extent,  the usefulness of the insti-
 tution as long as it may  exist.
   Site.—When it has  been determined to  erect a hospital for the in-
 sane, the first object to be attended to,  by those to whom this important
 duty has been  delegated,  is to select  a suitable  site for the  buildings.
The utmost caution should be observed in taking  this step, on which
may depend to no small extent,  the future character and usefulness of
the institution; for the best style of building and the most liberal organi-
zation  can never fully  compensate for the  loss  sustained by a  location 
7
that deprives the patients of may valuable privileges, or subjects them to
varied annoyances.   It is now well established that this class of hospitals
should always be located in the country, not within less than two miles
of a town of considerable size, and they should be easily accessible at all
seasons.   They should, if possible, be near turnpikes or other good roads,
or on the line of arailroad.  While  two or three miles from a town
might be named as  a good distance on  the former, the facilities afforded
by a railroad might make ten or twelve miles unobjectionable; for it is the
time spent in passing and ease  of access, rather than distance, that is most
important.  Proximity to a town of considerable size has many advanta-
ges,  as in procuring supplies, obtaining domestic help or mechanical
workmen,  and on account of the various matters of interest not elsewhere
accessible  to  the patients,  in selecting a site,  facility of access from
the  districts of country from which  the  patients will be principally
derived,  should never be overlooked.
  The building should be in a healthful, pleasant  and fertile district of
country; the land chosen should  be of good quality and easily tilled;  the
surrounding scenery shouM be of a varied and attractive kind, and the
neighborhood should possess numerous objects of an agreeable and inter-
esting character.   While the hospital  itself should be retired and its
privacy fully secured, it is desirable that the views from it should exhi-
bit life in its active  forms, and on this  account stirring objects at a little
distance  are desirable.   Reference should also be made to the amount of
wood and tillable land that may be obtained, to the supply of water, and
to the facilities for drainage, and  for enclosing the pleasure grounds.
  Amount  of  Land.—Eveiy hospital for the insane should possess at
least one hundred acres of land, to enable it to have the proper amount
for farming  and gardening purposes, to give the desired degree of privacy
and to secure adequate and appropriate  means of exercise, labor and oc-
cupation to  the patients, for all these  are now recognized as among the
most valuable  means of treatment.  Of the total amount, from thirty to
fifty acres immediately around the building-?, should be appropriated as
pleasure grounds, and should be so arranged and enclosed as to give the
patients the full benefit of them, without being annoyed by the presence
of visitors or others.  It is desirable that several acres of this tract should
be in groves or woodland, to furnish shade in Summer,  and its general
character should be such as will admit of tasteful and agreeable, improve-
ments.   To enable the patients generally to  have the greatest possible
amount of  benefit  from their pleasure grounds, those  of the males and
females should be entirely distinct; and one of the best means of sepa-
rating them will be found to  be  the appropriation of a strip of neutral
ground, properly enclosed between them, as a  park for various kinds of 
8
animals, or to be otherwise handsomely cultivated.  While less than one
hundred acres should be deemed too little for any institution, many State
hospitals having a large number of farmers or working men,  will find
it useful to possess double  that amount; and extensive walks and drives
on the hospital premises oner so many advantages, that the possession of
a large tract for this purpose alone is often desirable. It is hardly possible
under any circumstances,  for  such an institution to control too much
land immediately around it.
  Supply  of Water.—An abundant supply of good  water is one of
the necessaries of eveiy hospital, and should be secured whatever may
be the cost or trouble required to effect it.  A veiy extensive use of
baths is among the most important means  of treatment, and  the large
number of water closets that are indespensable in the wards, the great
amount of washing that is  to be done, as  well  as various other arrange-
ments requiring a free use of water, and above all, abundant means for
extinguishing fire,  in case  such an accident  should occur, make it of the
utmost importance that the supply should be permanent and of the most
liberal kind.
  The daily consumption  for all purposes  in an institution for 250 pa-
tients, will not  be much, if any less,  than  10,000 gallons, and tanks to
contain more than  this amount should be  placed in the dome or highest
part of the building.
  When a sufficient elevation can be met with to cany the water to the
tanks by gravity, nothing can be better; or a steady water power will be
both convenient and economical; but so few sites will be found having
either of these advantages,  combined with the other requisites for such
an institution, and as a  steam engine will always be desirable on various
other accounts, it  will  be  safe to say that this will be the best reliance
in most locations.  Horse  power is not to be recommended.   The wa-
ter should be distributed to every part of the building, and arrangements
should be made to  furnish  a full supply, both hot and cold, to every ward
and in every section of the house.  One or two wells near  the  building,
for furnishing drinking water, will be desirable, and a large cistern out-
side  of the hospital  should be provided, to  secure  a  supply in  case
of fire.
  Drainage.—All the drainage should be under ground, and in  selecting
a site, facilities for  making  this very important arrangement should never
be overlooked.  All the waste water from the kitchens, sculleries, baths,
water closets, &c, should be carried off beneath the surface, and to such
a distance as will prevent.the possibility of its proving an annoyance
to the hospital.  All the entrances to the culverts should be trapped, and
the culverts should be made so large and with such a descent as will ob- 
9
viate all risks of obstructions.  If the rain water from  the roof and the
surface drainage are taken  in another direction,  that from the hospital
may be  made to add greatly to the fertility of the farm;  but  it is much
better to carry  all off through the same culvert and loose this  advantage,
than incur the slightest risk of having the  air in the vicinity of the hos-
pital contaminated by these fertilizing arrangements.
  Enclosures.—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 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  ine-
qualities 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 coun-
try 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 appearance, and yet be entirely effective.  Al-
though 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.  The amount  of land thus enclosed
should never be less than thirty acres, while forty or even fifty acres will
be a more desirable amount, so that the pleasure grounds of the male and
female patients, which, as before observed, should be  entirely distinct,
may be  sufficiently extensive.  Important as I regard the permanent en-
closure of extensive pleasure grounds and gardens, in the manner  sug-
gested, as protecting the patients from improper observation, keeping out
intruders, enlarging the liberty of the insane generally, securing various
improvements from injury, and permitting labor to be used as a remedy
for more patients than could otherwise be done, still it is proper to add,
that high walls around small enclosures, and in full view from the build-
ings, are even less desirable than  a simple neat railing,  which would
neither keep determined visitors out, nor active patients in. The first of
these objects—keeping the public  out,—-it must  not be forgotten, is the
prominent one  thought of  in recommending a Wall to be placed around
the pleasure grounds of a hospital.   The presence and watchfulness of
intelligent attendants must still be the grand reliance to prevent the es-
cape of patients, and I regard any arrangement that does away with the
necessity of constant vigilance, undesirable  about a  hospital for the
insane. 
10
  Patients' Yards.—Although it does  not  seem to me desirable to
have a large number of private yards in immediate connection with a
hospital for the insane, it will still be found convenient to have two for
each sex, of a large size, well provided with brick walks, shade trees and
such  other modes of protection from  the sun  and weather as may be
deemed useful.   These yards  enable many patients,  who at certain
periods wish to aviod the greater publicity of the grounds, to  have the
benefit of the open ah*, and to take exercise at hours when the attendants
cannot conveniently leave the wards; but most of the  patients should
have a more  active and longer continued kind of exercise  than  these
yards afford.  They should look to the walks in the open fields and about
the grounds, which can readily  be made  a mile  long for each sex, for
their principal exercise.  Four-fifths of all the patients will, under pro-
per regulations, be able to take w~alks of this kind for at least a  couple of
hours morning and afternoon, at all seasons; and in warm weather, when
proper summer houses and seats are provided, they may thus profitably
spend one half the entire day in the open air.  It is always much better
for patients to be  comfortably seated in a pleasant parlor or hall,  at any
season of the year, than to be lying on the ground, or otherwise soiling
their clothes, and  exposing themselves to the risk of taking cold, as is very
apt to be the case, when certain classes are allowed to consult their own
pleasure as to the mode of passing their time while in the small yards,
adjoining the building.
  Size of the Building.—A suitable site having been selected, it will
next become necessary to decide upon the size of the institution. What-
ever differences of opinion may have formerly existed on this point,  I
believe there are none at present.   All the best authorities agree that the
number of insane confined in one  hospital, should not  exceed two hun-
dred and fifty, and it is very important that at no time should a larger
number be admitted than the building is calculated to accommodate com-
fortably,  as a crowded institution cannot fail to exercise an unfavorable)
influence on the welfare of its patients.  The precise  number  that may
be properly taken care of in  a single institution, will vary somewhat, ac-
cording to the ratio  of acute  cases received, and of course to the amount
of personal attention required from the chief medical officer.  In State
institutions, when full, at least one half of all the cases will commonly be
of a chronic character, and require little medical treatment.  Even when
thus proportioned, 250 will be found to be as many as the medical super-
intendent can visit properly  every day, in addition to the performance of
his other duties.  When the proportion of acute or recent  cases is likely
to be much greater than  that just referred to, the number of patients
should be proportionately reduced, and two hundred will  then be found 
                                 11

to be a preferable maximum.   While no more patients should be received
into any hospital than  can be visited daily by the chief medical officer,
it is desirable that the number should be sufficiently  large to give an
agreeable company to each class, and to permit a variety of occupations
and amusements that would prove too costly for a small institution, unless
filled with patients paying a very high rate of board, or possessed of some
permanent endowment.   It might  be supposed that institutions for a
much larger number of patients than has been recommended, could be
supported at  a less relative cost, but this is  not found to be the case.
There is  always more  difficulty in superintending details in a veiy large
hospital,—there are more sources of waste and loss, improvements are
apt to be  relatively more costly, and without great care on the part of the
officers, the patients will be less comfortable.
   Whenever an existing State institution built for 250 patients, contains
that number, and does not meet the wants of the community, instead of
crowding it, and thereby rendering all its inmates uncomfortable, or  ma-
terially enlarging its capacity by putting up additional buildings, it will be
found much better at once to erect an entirely new institution in  another
section of the State; for under any circumstances, the transfer of acute
oases from a great distance, is an evil of serious magnitude and constantly
deplored by those who have, the care of the insane.
   Position, Form and  General Arrangements.—The size of the
building having been determined, its form and general arrangements  will
next require attention; and no plan, however beautiful its  exterior may
appear, nor how apparently ingenious its interior may seem, should ever
be adopted without having been first submitted to the inspection and re-
ceived the approval of some one or more physicians who have had a large
practical acquaintance  with the insane, and who are  thoroughly familiar
with the  details of their treatment, as well as with the advantages and
defects of existing hospitals for their accommodation.  So different from
ordinary buildings or other public structures are hospitals for the insane,
that it is hardly possible for an architect, however skillful, or a board of com-
missioners, however intelligent and well disposed, unaided,  to  furnish
such an institution with all  the conveniences and arrangements indis-
pensable for the proper care and treatment of its  patients.  No desire
to make a beautiful and  picturesque exterior should ever be allowed to
interfere with the internal arrangements.  The interior  should be  first
planned, and the exterior so managed as not to spoil it in any of its details.
   Although it is not desirable to have an elaborate or  costly style of
architecture, it is, nevertheless, really important that the building should
be in good taste, and that it should impress favorably not only  the pa-
tients, but their friends and others who may visit it.  A hospital for the 
12
 insane should have a cheerful and comfortable appearance, every thing
 repulsive and prison-like should be carefully avoided, and even the means
 of effecting the proper degree of security should be  masked, as far as
 possible, by arrangements  of a pleasant and  attractive character.   For
 the same reason,  the grounds about the building should be highly im-
 proved and tastefully ornamented; a variety of objects of interest should
 be collected around it, and trees and shrubs, flowering plants,  summer-
 houses, and other pleasing arrangements, should add to its attractiveness.
 No one can tell how important all these may prove in the treatment of
 patients, nor what good  effects may result from first impressions thus
 made upon an invalid on  reaching a hospital,—one who perhaps had left
 home for the first time, and was looking forward to a gloomy, cheerless
 mansion, surrounded by barren, uncultivated grounds for his future resi-
 dence, but on his arrival  finds eveiy thing neat, tasteful and  comfortable.
 Nor is the influence of these things on the friends of patients unimpor-
 tant; they cannot fail to  see that neither labor nor expense is spared to
 promote the happiness of the patients, and they are thus led to have a
 generous confidence in those to whose care their friends have  been en-
 trusted, and a readiness  to give  a steady support to a liberal course of
 treatment.
  Great  care should be observed in locating the building, that eveiy pos-
 sible advantage may be derived from the views and  scenery  adjacent,
 and especially from the  parlors  and other rooms occupied  during the
 day.  The prevailing winds of summer may also be made to minister to
 the comfort of the inmates, and the grounds immediately adjacent to the
 hospital should have a gradual descent in all directions, to secure a good
 surface drainage.
  For an institution like that under consideration, I believe the best and
 most economical form will  be found to  be a centre building with wings
 on each side, so arranged as to give ample accommodations for  the resi-
 dent officers and their families, and for the classification and comfort of
 the patients.   A  building  having a basement above  ground,  and two
 stories above this, will generally be adopted on account of its being less
 expensive and of smaller extent than one  of only two stories.  The cen-
 tre building and projecting  portions of the wings, may be carried  up a
 few feet higher, but the  wards should never be.   In the highest part of
 the structure, as in a dome, the water tanks should be provided for.
  In the centre building should be the kitchens, main store  rooms, a re-
 ception room for patients,  a  general business  office, superintendent's
 office, medical office and library, visiting  rooms for friends of  patients,
 a public  parlor and managers' room, the lecture room and chapel, and
 the apartments for the superintending physician's family,  and for  the
other officers of the institution. 
13
  The wings should be so arranged as to have eight distinct classes  of
each sex; each class should occupy a separate ward,  and each ward
should have in it a parlor, a dining room with  a dumb waiter connected
with it, and a speaking tube leading to the kitchen or some other central
part of the basement story, a corridor, single lodging rooms for patients,
an associated dormitory for not less than four beds, communicating with
an attendant's chamber, one or two rooms of sufficient size for a patient
with a special attendant, a clothes room, a bath room, a wash and sink
room, and a water closet.  There should also be provided for each sex  in
their appropriate wings,  at least one infirmary for patients who are too
ill to remain in their own chambers, two work rooms, a museum  and
reading room, a school room, a series of drying closets,  at least one on
each story, and various other fixtures, the general character, position and
arrangement of which will be more particularly referred to when des-
cribing the accompanying plan, in which they will all be found provided
for.  The parlors  may be dispensed with in the wards for the most ex-
cited patients, but not elsewhere, and all the other conveniences suggested
will be as necessary for them as any other class.
   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 com-
fort in the fresh cool breezes that 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 cheer-
less, 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, it will hereafter be seen, is easily and ef-
fectually remedied by leaving on each side an  open space of about eight
feet, with  movable glazed sash extending from near the floor to the ceil-
ing, and which may either be accessible to the  patients or be protected by
ornamental open wire work, on a line with the corridor, and giving nearly
every advantage of light,  ah 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 and various other
objects, the contemplation of which can not fail to have  a pleasant  and
soothing effect upon every class of patients.   To remedy the other dif-
ficulty 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,
which should also be furnished with movable glazed sashes, to be acces-
sible to the patients, or protected and ornamented as already suggested, 
14
 according to the class by which it is to be occupied, and other circum-
 stances.   I deem these  arrangements of great importance, and as being
 among the most valuable features of the plan under notice.
   Number  of Patients in a Ward.—As the total number of patients
 designed to be accommodated is 250, the  average in each of the sixteen
 wards would  be a little over  fifteen, but the number  may be varied
 somewhat by the character of the cases.  Of the quiet, or incurable
 demented, as many as twenty could be taken care of in one  ward, with
 quite as much facility as less than half that number that are highly ex-
 cited.  Patients that are excitable rarely do well in large wards, and bet-
 ter discipline is almost invariably preserved in those that have a small
 number of inmates.   Where seclusion is to be carefully avoided,  it be-
 comes particularly important that means should be provided by which
 even the most highly excited or violent patient  may at proper times be
 out of his room, without being surrounded by a crowd of persons affected
 like himself.  Every one familiar with institutions for the insane, will
 recall numerous instances of almost daily occurrence, where a single  excit-
 able patient introduced into a comparatively quiet ward, will  in an hour
 have almost entirely changed its character.
  The basement or first story of the building, should be raised two steps,
 or about sixteen inches, above the surface of the ground around it, and a
cellar should be excavated under the entire structure. The cost of a cel-
 lar is trifling, and it is desirable in many respects, but especially in refer-
 ence to a proper arrangement of the heating apparatus and of the air re-
servoirs connected with it.
  Materials of Walls.—A hospital should be constructed of stone or
brick, as may be found most convenient and economical.   If of stone, the
walls may be pointed or stuccoed.  If of good brick, they may be painted
to give them an agreeable shade of color.  Advantage will be found from
using hydraulic cement in laying the foundations, and  the  floor of the
whole cellar, if at all disposed to dampness, should be covered with the
same material, while lime and sand will answer in other localities.
  On account of the great number of flues that will be required, the inner
or corridor walls should be not less than eighteen inches thick and con-
structed of brick.  All the flues for heat and ventilation should be carried
up in them, and about the whole space will be required for these pur-
poses.  The  construction of the outer wall with a space between the
two courses of brick, where that material  is used, is  an admirable ar-
rangement for giving a perfectly dry house, and one little affected by sud-
den changes of temperature.  If stone is adopted as the material for the
building,  those  parts  especially exposed to dampness  should  be bat-
tened. 
15
  Plastering.—The plastering throughout should be what is styled a!
hard finish, and calculated for being scrubbed, whether kept white  or
painted of some more agreeable shade  of color.  When rooms are likely
to be much abused by patients, the plastering may be veiy advantageously
done with hydraulic cement and sand, and rubbed down so as to be per-
fectly smooth.  The color can afterwards be made whatever is deemed
most desirable.
  Security  from Fire.—Every precaution should be taken to provide
against accidents from fire, an,d the building should be made as nearly fire
proof as circumstances will permit.  Brick arching between the different
stories would be desirable, but its first cost will probably mostly lead to
counter ceiling  and  other substitutes.  The kitchens, in which rooms
alone it will be necessary to have fires of any size, should be arched, and
the flues leading from them should be constructed with great care.  The
passages between the different ranges of the wings should be arched, then*
side walls should run up from the cellar to the roof, they should also have
stone floors and iron doors  on each  side, that could be closed whenever
desired.  By  this arrangement,  a  fire  commencing in any 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 or hot water, and the fires for
generating these, should always be  in a detached structure, at least 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 fire
in institutions for the insane.
  Roof.—The roof should be of copper, tin or slate, according to cir-
cumstances, and the cornice should  project boldly over the walls for their
protection, as well as for the sake of a  good appearance, and to give a free
passage for the water falling on the building.   For a flat roof, the best
tin thoroughly painted, will probably  be found  most desirable, although
with  a good pitch and the slate properly put on, that material will gene-
rally give satisfaction.
  Size of Rooms  and Height of  Ceilings.—-The ceilings in every
part regularly occupied by patients, should be at least twelve feet high,
and certain parts of the centre building should  be more.  The corridors
of the wings should not be less than twelve feet wide,  nor those of the
centre building less than fourteen.  The parlors and other large rooms-
should occupy a space equal  to about twenty  feet square.  The single
chambers for patients should  be  made as large as  can  be well brought
about, provided their size  is not so  great as to lead to two patients being
placed in the same room, which ought not to be  allowed.  Nine feet 
16
front by eleven deep will probably be adopted as the best size, although
eight by ten is admissible.   Great convenience will be found in having in
each ward at least one  chamber of the size of two single rooms, for tho
use of a patient with a special attendant.
  Floors.—-The floors of all patient's rooms, without any exception,
should  be  made of well seasoned wood, and counter ceiled to prevent
the transmission of sound.   When it is expected they will require fre-
quent washing, they may incline very slightly towards the door.  Instead
of the ordinaiy washboai'd, which after a certain time is apt to become a
harbor for vermin, cement or mastic painted should be used.
  Doors.—The door of a patient's room should be about 6 feet 8 inches-
by 2 feet 8  inches, and the frame should be well built in, and thoroughly
secured to  the wall.  Over each door in the principal frame may be an
open space, not exceeding  five inches in width, which can be closed from
the outside when desired,  by a moveable board or covered frame.
  Although not absolutely  necessary in but a small portion of the rooms,
it will be found very convenient,  to  have a  neat wicket, secured by a
spring lock, in many, if not all of the doors of every ward, to enable the
night watch to ascertain the condition of a patient with facility, and with-
out disturbing his rest—to give food or water, or indeed at any time to see
what a patient is doing, when it might not be prudent for a single indi-
vidual to enter the room.  What is  called a bead  and  butt door, Well
made of thoroughly seasoned timber will probably be  found one of the
best kinds;  and if greater  security is desired for very violent patients, a
casing of boiler iron, firmly secured on the  inside  and  neatly painted
will make them entirely safe, and  scarcely be observed, or a door,  made
by having the outside strips perpendicular, and those on the inside hori-
zontal is both cheap and very strong.
  The doors may be made to open either into the rooms or corridor as
may be  deemed most desirable.  As the patients' chambers however are
small, and  as great annoyance and  no little danger frequently result
from patients' barricading their doors from the inside, so as to render it
almost impossible to get access to them, the  plan of having the  doors
to open  into the corridor is generally to be preferred.  The only advan-
tage resulting from the door opening into the room is that it is less likely
to be forced by the efforts of patients from the inside.  A good lock and
two suitable bolts on the outside however will be found sufficient to pre-
vent risk from this cause, except in very extraordinary cases.
  Locks.—The  locks in  a hospital for the  insane, are subjected  to
such  constant use, that  they should be  made  with  great  care, and
the parts most likely to wear should be case hardened.   This will add
but little to the expense and save  much  trouble afterwards.    The 
17
keys for  the male and female wards should be so entirely different that
it will be impossible by any slight alteration to make those for one side
open  the locks for the other; for it is scarcely necessary to say that
male attendants should never be allowed to go into a female Avard, which
would any where be conclusive proof of a most defective discipline.
  The bolts used should be so made, that while having sufficient strength,
they should not be conspicuous, and should  move without sound.
  Windows  and Window Guards.—When in order to give a proper
architectural effect to the building, the rooms in  its centre must have
lull y 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.
  More care, however, must be observed in reference to patients' cham-
bers and ordinary ward windows.  A window about 5 feet 6 inches by 3
feet, will be found of a convenient size, and this will  give  two sashes,
each containing ten lights 5£ by 16 inches.  The  window seat  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 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 fill throughout its whole  extent.   The space opposite the
lower sash should be protected by a wrought iron window guard, which,
if properly made, and painted of a white color, 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.  When of a taste-
ful pattern and neatly made, it will be found very preferable in appear-
ance and quite equal in security, to the unglazed cast iron sash occasion-
ally used, and which after all, when the glass 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.
  Although there are various other forms of windows in use, which look
well and  have some advantages, upon the whole I regard that which has
been suggested as being the best and most economical for a State insti-
tution.  If desired, the upper or iron 6ash may  be ballanced, so as  to
                                   S 
18
drop five inches, but this adds materially to the expense, and where
proper attention is paid to a forced ventilation, can hardly be necessaiy.
By having the glazing done from the inside  of the patients' rooms, es-
pecially in the upper stories, a gi'eat amount of trouble will be saved in
the facility with which broken glass, so common an incident in hospitals
for the insane, can be repaired.
  Where the chamber windows are exposed to a strong sun, Venetian
blind shutters on the outside, will be pleasant and useful, or a painted or
simple stout muslin  verandah awning  over each window, will be found
to add much to the comfort  of the patients,  especially  in a  southern
climate.
  The verandahs along the whole front, which have been suggested for
the South,  would prove very costly and could not be used with safety by
the patients, unless made so as almost  to resemble  extensive cages.
Good thick walls, with other less costly  arrangements, will be found more
effectual in promoting the comfort of the patients.
  Inside Window Screens.—For various purposes, it becomes neces-
sary to screen the inside of the windows of a portion  of the patients'
rooms.  It is not only  to prevent the  breaking of glass when their in-
mates are excited, and  to secure the windows from being opened at im-
proper times, but also as a protection in some very determinedly suicidal
cases.   For nearly all purposes, a neat  wire screen well secured on a
hinged frame,  and having a spring lock, will be  found sufficient, while
it admits the ah and light, and does not obstruct the view of the sceneiy
beyond.  Two  or three such guards  will be found desirable in every
Ward, while in those for  the most excited,  something stronger will be
required in a few rooms, such as a close wooden  shutter, but with per-
forations for the admission of light, which I do not think ought to be
entirely excluded under any circumstances of excitement.  The plan of
hinging these window screens is the simplest and cheapest, but in put-
ting Up a new building it may easily be arranged to have them slide
into the wall, to fall down, or be raised  up by weights, as may be prefer-
red.  For a veiy few rooms in the most  excited wards, it may be desirable
to have only a small window, too narrow to permit the escape of a patient,
and too high to be easily accessible.
  Stairs.—All the stairs used by patients should be made of iron, firmly
secured to the walls, ample in number, convenient of access, and easy of
ascent and descent.  They should be so arranged as not to be exposed in
any ward.  The well around which they are placed, may be made a fine
ventilating  shaft.
  Associated -Dormitories.—A certain portion of the patients may,
without disadvantage, be  lodged in dormitories containing from four to 
19
*ix beds and communicating by means of a partially glazed door with the
room of an attendant.  As far as this can be done with safety, it is un-
questionably the cheapest mode of providing  for patients.   About one
fourth of all the patients in a State hospital may probably be thus lodged
without material disadvantage, and perhaps a twelfth of the whole num-
ber may really do better in associated dormitories than in single rooms.
These last are  principally among the timid, who dread being alone at
night, and some of the  suicidal, who will remain quietly in bed if ano-
ther person is in the room,  but who could not be trusted without com-
pany.  The great majority of patients would strenuously object to such
an arrangement, just as much in a hospital as they would in a hotel or
boarding house; and most of them regard with especial feeling the pri-
vilege of enjoying at times the privacy and quiet of their own rooms.
   It is convenient to have one or two rooms of the size referred  to, in
each ward, which if not required or used for this  special purpose, will
be found  particularly convenient  in some cases of sickness  when it is
not desirable to remove  a patient  from the ward, or when the friends of
an individual desire a more spacious apartment than usual,  or where a
patient has a special attendant lodging in the same room.
   Infirmaries.—In case of any serious sickness in a hospital for the
insane, especially if of a contagious nature, it  will be desirable to have
at least one room for each sex, of good size, airy, well ventilated, and
separated from the wards, where patients can  receive more special at-
tention and enjoy greater quiet than in  their own chambers.  Thus
situated, they may be  visited by their friends with gi'eat facility,  with-
out annoyance to the other patients, or any interference with the ordi-
nary operations of the house.
   In some cases of protracted illness, especially if likely to terminate
fatally, it is a gi'eat comfort to the friends of patients, even if not to the
patients, to be able to be with them at times, and to render some of those
attentions which the character of their disease prevented their receiving
at home.
   Bath Rooms.—The bath rooms in each ward should be of about the
size of one of the ordinary chambers, and should contain a cast iron bath
tub of proper size and shape, with the improved arrangement for admit-
ting hot and cold  water through a common opening, just at the lower
part of the tub, and for discharging it from a separate one in the bottom.
   By drawing  a small amount of cold water before the hot  is admitted,
there  is never any vapor in the room.  This arrangement also offers great
facilities for keeping up any desired temperature, when long continued
hot baths are given, without oxciting the patient's fears that he is going to
be injured, or leading him to suppose that the water is much  hotter thaa 
20
it really is, as often happens, when the continued flow of warm water into
the tub is directly under the patient's observation.  The fixtures for admit-
ting and discharging the water not being over the tub, but entirely beyond
it, prevents, in a great measure, the bath tub being used for any but its
legitimate purposes.   The admission and discharge of the water through
different openings, varying very slightly in their  level, is preferable to
any arrangement which allows one opening to answer both  purposes;
for in the latter case, the  deposits which take place in the  pipe are
pretty sure to be returned into the tub when the next bath is drawn.
  There should also be three  marble or enameled cast iron wash basins
in one section of the bath room, and  furnished with hot and cold water
pipes.  An arrangement for shower baths and for the douche, similar to
what are used in private families, may also be introduced over  the bath
tub, but there is little necessity for the formidable fixtures often provided.
Unless a patient can be persuaded to take the shower bath or the douche
voluntarily, its use is very problematical.   Provision should be made  for
hip, foot and hand baths,  and a few roller towels properly secured,  with
some flesh brushes, should be a part of the furniture of each bath room.
  The floors of bath rooms that are  much used, should be of smooth
German flag stone or  other material, that will not absorb moisture, and
po wood should be used for wash boards.   A strip of carpet laid in front
of the tub when in use, will obviate the objection to the coldness of the
floor, especially as all bath rooms should be kept well warmed.
  Water Closets.—No part of the  arrangements  of our hospitals,
even a few years  since, were more imperfect than their water closets.
A constant source of complaint, and a perfect nuisance in every part of
the  building where they were found, they gave  so  much  annoyance
that some practical men  gravely  proposed dispensing with  them alto-
gether.  Our present knowledge  of the subject,  however, is such that
they may be placed wherever they are required,  and without their pre-
sence being known in the adjoining part of the ward.   To effect this, it
is necessary to occupy for the purpose a small room having an external
window opening directly into it, to have the floor and  other parts made
so as not to  absorb moisture, to use only iron in the  construction of the
apparatus, to have no basins or complicated fixtures to get out  of order,
and above all, to secure a steady and strong downward ventilation.   All
this can be done, and no reasonable expense should be spared to effect it.
A special flue for each range of water closets, and an abundance of heat
to secure  an uninterrupted downward current of air through the receiver
and discharge pipe, will well repay all they may cost;  for with  this  ef-
fect produced, unpleasant odors in the wards from this cause are scarcely
possible. 
21
  Where the water closets are near a flue of sufficient size, that is al-
ways heated, that may answer, and in private houses rarely fails to be
successful;  but if the slightest doubt is entertained, it is much better to
provide a flue for that special purpose.
  Various  modes of letting on the  water,  have been suggested, and
which answer the purpose, but I am disposed at present, to prefer that
which gives a full supply to wash out the whole surface of the receiver,
every time  the door is opened.
  Near the water closet, should be a sink, for washing various articles
that it is not desirable to take into the bath room, and for obtaining wa-
ter for the  necessary cleansing of the ward.
  The urinals should also be made of cast iron, well enameled, with a
downard current of air through them, and have a steady stream of water
passing over their whole surface, without both of which they are more
likely to be a source of offensive odors than the water closets themselves.
  A number of designs have been tried for permanent close-stools in the
rooms of the most excited and careless patients, but none of them seem
admissible which communicate with a common discharge pipe, unless a
most thorough downward ventilation is secured through it.   An enamel-
ed cast iron receiver,  of suitable shape, with an opening at  the bottom
so small as  not to admit a hand, firmly secured  to  a strong lid, and this
locking as it falls on the top of a box, in  which is a tin pan always  con-
taining half a gallon of water, will be found convenient and but little of-
fensive.  The whole box should be well fastened to the floor in a way that
will allow air to pass freely under it, and tend to secure perfect clean-
liness.
  It is especially  important  about  bath rooms, water closets and sink
rooms that  nothing should be boxed up.  Every thing should be left open
and exposed to view, there should  be no harbor for vermin of any kind,
no confined spot for foul air, or the deposite of filth, and all wood and
every other material that will absorb moisture should as far as possible be
discarded from the floors and from every other  part.
  Ward Drying Rooms.—Another source of annoyance and  unplea-
sant odors in our hospitals for the insane, is that rather peculiar  one, ex-
haled from the wet cloths and brushes so constantly required to be used,
and which  must necessarily be kept in the wards.   To remedy this pre-
valent difficulty, which must be familiar to all  who spend much time in
the wards,  it is proposed to have a series of rooms—one connected with
each ward, or  serving for two contiguous wards—thoroughly heated by
steam pipe and with a good current of air passing through them, in which
every article of the kind should be placed immediately after being used
and kept till dry.   The same room may  also be used for drying various 
22
wet articles of bedding or clothing which it may not be deemed neces-
sary to send to the wash house.
  Water Pipes.—The great amount of water pipes used in a hospital
for  the insane, their liability after a few years service to become defec-
tive, and the injury and disfigurement which fine buildings often receive
from this cause, make it very  desirable that those  that belong in the
same neighborhood should, as far as possible, be gathered together  and
pass from the cellar to the attic  in an open space sufficiently large to give
free access to them on all sides, for inspection and repairs; and so that
in case  of leaks, there will be no injury done to the ceilings  or  other
parts of the structure.
  It will be found expedient in most situations to use iron pipe for nearly
every purpose  connected with the water fixtures.  Its durability will
generally be found a sufficient recommendation, but as some water acts
on  these pipes in a remarkable manner, it will  be well always to have
them made  of good  size and of rather more than the ordinary thickness,
especially when passing horizontally for any  gi'eat distance.   Block tin
anakes  an admhable pipe for water, but is more expensive.  Lead pipe
and reservoirs lined with that metal, for either drinking water or cooking
purposes, should  be entirely discarded.  Serious injury is thus often
done when least suspected, and all risk from this source should be avoided.
  Dust Flues.—A large  tin flue, through which the  dust, sweepings
of the halls,  &c, may pass, should reach from each ward, or from points
contiguous to two adjacent wards, directly to the basement  or cellar,
from which their contents can be removed when most convenient.
  Soiled Clothes Hoppers.—At least one of these should be provided
for  every two contiguous halls, and through which all the soiled clothes,
bedding, &c, should be conveyed to  the basement, preparatory to their
being taken charge  of by those whose duty it is to convey them to  the
wash house.
  Kitchens and Distribution  of Food.—With the exception of a
6inall kitchen for the use of the superintendent's family, one main kitchen
in the centre building is all that is required for the purposes of an  insti-
tution of the size and character of that under notice.  This position is
certainly the most convenient for this important room, and there can be
little question but that the proposed arrangement will be found most eco-
nomical  in reference  to supplies, fuel,  the force employed to do  the
cooking, and for facility of supervision.  The kitchen is the only  room
in the whole establishment in which  there will be a large fire, and it
should  be arched for additional security and  to prevent the steam and
odors from  it passing through the floor into the rooms above.   A  large
ventilating shaft should  be built expressly for the kitchen, and a strong 
23
and steady upward draft secured by carrying up in its centre a cast iron
flue of good size, through which the gas from the fires is to pass.
  Arranged as proposed, this location for the kitchen can scarcely prove
objectionable  in any climate; for  the  heat, steam and odors will be
promptly earned off, without interfering in any way with  the comfort
of the  inmates  of any part of the building.  The very common annoy-
ance from basement kitchens, has generally resulted from  no provision
being made for their ventilation, or if any has been attempted, it has been
of the most imperfect kind.
  Besides a cooking range and a rotary roaster, the main kitchen should
have in it a complete  steam apparatus for cooking vegetables, making
soups,  &c, constructed entirely of iron and tin, and with so good a ven-
tilation that  no vapor will  escape into the room.  A  steam  table for
keeping up the heat of the cooked food and of the dishes, is also desir-
able.   The steam for the use of the kitchen may be derived from one of
the boilers in the detached building  hereafter to be referred  to.  The
best floor for  the  kitchen  is  the smooth brown German flag  stone.
Cement should be used for the wash board, and wood should be avoided
as much as possible.
  A dumb waiter should be provided for each series of dining rooms that
are immediately over each other,  so that the food and other articles  re-
quired in the wards may be passed directly from the basement story into
the dining rooms, or to points immediately contiguous to them.
  The food, after being prepared in the kitchen, and put while hot in
tightly closed bright tin vessels or boxes, should be  placed on a car of
sufficient size to cany what  is required for one side of the house,  and
which is brought to  a point adjoining the kitchen.   When filled, this car
is to descend  so as to rest upon  a  railroad which extends through one of
the cold air reservoirs from under the kitchen to the  extreme wings on
either side, and passes in its course  the bottom of each of the dumb waiters.
By  these means the food is delivered promptly and  hot to every part of
the house.  The refuse from the different dining rooms is in like manner
to be sent down in closed tin vessels.   Each ward should have a bell and
a speaking tube, extending to the  kitchen or other suitable part of the
basement, by means of which whatever articles are required, may be
called for without the  attendants having ever to leave the ward for any
thing from the kitchen, into which they should not  be admitted.
  Heating  and Ventilation.—There seems to  be  no diversity of
opinion among those who have the charge  of American hospitals for the
insane, in reference to the proper mode of warming and ventilating these
institutions;  the  "Association of Medical Superintendents"  having
unanimously resolved that "all hospitals should be warmed  by passing an 
24
 abundance of pure fresh air from the external atmosphere, over pipes or
 plates containing steam under  low pressure, or hot water,  the tempera-
 ture of which at the boiler does not exceed 212° F., and  placed in the
 basement or cellar  of the building to be heated," and that " the boilers
 for generating steam should be in a detached structure;" while they also
 agree with equal unanimity, that " a complete system of forced ventila-
 tion in connection with the heating, is indispensible to give purity to the
 air of a hospital for the insane, and that no expense that is required to
 effect this object  thoroughly can  be deemed either  misplaced or inju-
 dicious."
   In the plan recommended in the present essay, it is proposed to place
 the detached structure alluded to,  at a distance of not  less than one hun-
 dred feet in the  rear of the  centre building.  The precise  position,
 however, will vary according to the  character of the  ground, and other
 circumstances connected with the  different  uses to which it will be ap-
 plied.  It may be at the distance  of five  hundred feet  without incon-
 venience or disadvantage if the  pipe conveying the steam is under ground
 and surrounded  by  some non-conducting  substance.  The boilers,  of
 which it will be necessary to have four, unless they are of  very large
 size, are to be placed under a shed with a slate roof and good skylights,
 adjoining the cellar of the detached  building, and, if possible, sunk  so
 deep that the condensed steam may return  to them by simple gravity.
 If this can not be effected, the boilers must be kept supplied with water
 by a force pump driven by the engine.  These boilers  may be either
 tubular, which have  the advantage  of being easily put in place, requiring
 little space  and  generating steam veiy rapidly, or plain cylinder boilers,
 which are much less costly, quite  as safe, and  not so likely to need re-
 pairs.  It is of great importance to have an abundance  of boiler room
 and to use the steam under low pressure.  The vaults for coal should be
 immediately adjoining the boilers, and so arranged that the coal may be
 dropped into them directly from the carts, while the ashes can be raised
 by a crane and windlass.
   The steam is to  be conveyed from the boilers through an eight inch
 cast iron pipe, till it reaches the air chambers under the centre building,
 and from this point a smaller pipe diverges to each extremity of the
 hospital.   The radiating tubes  may  be  either  large cast iron or small
wrought  iron  pipe.   The latter is  to  be  prefered on account of the
greater facility  with which it can be taken down or put up, corners
turned and repairs  of all kinds made, while the cost of it is no greater.
  The  radiating  pipes should be prepared in three distinct sets, one or
all of which  can  be used at pleasure.  In the cool mornings and evenings
which occasionally occur even  in the summer months, and during  the 
25
 mild weather of spring and autumn, one series of pipe will be sufficient.
 With the ordinary winter weather, two will be required, and when the
 temperature is veiy low, especially if accompanied by much wind, the
 whole three ranges must be  put in operation.  This  arrangement will
 be found veiy economical, and do away with all the difficulties sometimes
 experienced in the proper  distribution of heat from a steam apparatus.
 So easy is it to control steam as a heating agent  in the mode proposed,
 that there is no reason why heat should not be purchased in large cities
 or long ranges of buildings,  as light and water now are.   Such a sugges-
 tion was made by  the writer some  years since, and an entirely respon-
 sible firm was subsequently prepared to contract for the  warming of the
 whole  block of buildings on Girard Square, and  owned by the city of
 Philadelphia, from one central apparatus entirely under ground.  With
 such an arrangement, the occupant of a dwelling could have just as much
 heat admitted as he desired, by simply turning the stop cock which con-
 trolled the admission of steam into the radiating pipes in his cellar.  The
 neatness,  comfort and efficiency of such a plan,  if once properly tried,
 would soon  lead to its being extensively adopted.
   For supplying steam to  the hospital, kitchen  and diying rooms, for
 forcing ventilation, pumping water, driving washing machinery, and heat-
 ing  water for all  purposes,  the different  boilers  may  be used alter-
 nately in summer, and the pipe conveying  the steam for the purposes
 indicated, should be protected by appropriate wrapping, so that no heat
 can be given out in the air chambers, to the annoyance  of  those in the
 rooms  above.
   It is recommended that  the space under the corridors of the wings,
 should be made the hot air chambers, and the rooms on either side used as
 cold air reservoirs.  The external atmosphere should  be admitted into
 these reservoirs through various hinged windows, and from them into
 the air  chambers by small  openings about one foot from the floor, and
 formed by leaving out the space occupied by each alternate brick.  The
 amount of cold air to be admitted, will depend somewhat on the severity
 of the weather, the prevalence  or absence of strong winds and their di-
 rection, as well as upon the general efficiency of the apparatus.   On
 these accounts, controlling windows are necessary.  A full supply of fresh
 air, however,  is indispensable to the proper working of  any apparatus,
 and  this should not  be left to the discretion of any subordinate.   The
 hot ah chambers may extend the whole length of a wing, or be divided
 into shorter sections.
  In arranging the radiating pipes, it must not be forgotten that a large
amount of ventilation is required in every hospital, and that all ventilation
in winter is  loss of heat.  A building not ventilated may  b© thoroughly
                               4 
26
heated by one half the fuel required for one that is, but nothing can be-
more destructive to health than a residence in the former.
  A common cause of failure in the experiments for heating in the man-
ner  recommended, has resulted  from an attempt to effect the desired
object with too little radiating surface, and with less fuel than is abso-
lutely indispensable.  There can  be only a  certain amount of heat ob-
tained from a ton of coal or a cord of wood, and the fuel being applied to
the generation of steam, can not alter the principle.
  It is to be remembered too, that fresh air heated by steam or hot water
on the plan proposed, can  never  attain a veiy high temperature, and of
course must be introduced in much larger quantities than if from  a
common hot air furnace,  and  as a consequence, the flues must be very
large and pass as  directly upwards as possible  from the ah chambers.
All lateral or sloping flues  should be avoided.   The flues frequently put
into public buildings  are not one fourth as  large as are desirable.   They
should be made perfectly smooth on  the inside, and the amount of air
passing through them should be controlled by appropriate registers.
  Although the heat from  a hot water apparatus is entirely unexcep-
tionable, and for private dwellings or small establishments even prefer-
able to steam, still for a large institution  like that under notice, steam is
on  many accounts more desirable.  Wkh steam,  less radiating surface
is required,  because  the temperature of the inside of the pipes through-
out is nearly uniform, and never below 212° F., smaller pipes may be
used, the heat is distributed and controlled  with much greater  facility
and rapidity, and besides steam is  required for various other  purposes
about the institution.  The steam, too, may be generated at almost what-
ever point may be considered most desirable, even at a distance of several
hundred feet from the building,  and yet be conveyed to it promptly and
with little loss of heat.   Such a location for the boilers allows a proper
site to be selected for the wash-house,  gas works, pumps, &c, which
should always  be together,  so that they may be superintended  by the
same engineer. It also protects the  institution from one of the most
common and dangerous sources of fire, and at the same time saves the in-
mates from all danger from explosions,  and from the annoyance of the
dust, dirt and gas connected with the fuel and ashes, and which, if in the
building, are pretty  sure  some time or other, to escape into the rooms
above.   If hot water is used, it will be much more difficult to keep large
fires at a distance from the building,  and  large fires in a hospital are al-
ways  dangerous.    By using steam  as proposed, the only fire really
necessaiy in the whole establishment, is that in the kitchen.
   It is best that all the flues for the admission of hot ah and for ventila-
tion should  be carried up  in the  interior or  corridor walls, which being 
27
eighteen inches thick, will allow each flue to be about nine by twelve
inches.   In most of the wards it is proposed to introduce the heated air
near the floor, and to have the ventilators to open near the ceiling.  In
the wards for the most careless and uncleanly patients, it will be well to
reverse this arrangement, admitting the warm ah near the ceiling and
having the openings for impure air near the floor.   When the warm ah
is admitted near the floor, especially when  the patients are likely to in-
terfere with the openings, a contrivance should be put up which would
allow the air to escape freely and yet prevent any thing being thrown into
the air chambers below.
  The ventilating flues should terminate in the attic, in gradually ascend-
ing trunks of a size equal to the aggregate of the flues entering them, and
leading to the different main shafts  which rise  above  the roof of the
building.  The upward current in these shafts is to be secured by means
of coils of steam pipe placed in them,  or from the  iron pipe carrying  off
the gas from the kitchen or other fires that may be used.  Steam jets,
fires in the attic, or gas burners, have some objections in a hospital for
 the insane, and as steam will be required  for so many other purposes,
 its use, as suggested, will be found most desirable.
   In addition  to the several openings in the corridors,  which should
 be numerous enough to secure the free diffusion of the air, there should
 be at least one for heat and another for ventilation in every room in the
 building.
   Whenever  a  steady driving power can be obtained, fans are of all
 means the most reliable and effective for forcing ventilation.  There can
 be no question as to the forcible displacement of ah from every corner of
 an apartment by this means, and the steam engine may often be brought
 into use for this most important purpose.  Even fans driven by hand are
 often very useful in some of the wards.
   The great amount of ventilation required in hospitals for  the sick or
 iiasane, renders it important that there should be a considerable excess,
 rather than any deficiency of radiating surface.  About one  superficial
 foot of radiating surface, the temperature of which is  212°  F., will  be
 required for every hundred cubic feet of space to be heated, in the lati-
 tude of Philadelphia.  In some of the colder sections of the United States,
 it will require one foot of radiating surface to every seventy-five or even
  fifty feet of space to  be heated, while  in the South the ratio will be
  proportionably diminished.
    The radiating pipe should be placed directly under the openings to the
  flues, and near them, so that all ah passing upwards must come in con-
  tact with them.
    To secure to each story and to every class of patients its due proportion 
28
 of heat, it has been proposed  to have a distinct arrangement for each
 story, and this can not  fail to effect the desired object; or the point in
 the air chamber,  at which the flue commences will also regulate the
 supply of air to the apartment to which  it leads.  Without attention  to
 these points, it is quite possible for the upper  stoiy  to be over heated,
 while the patients in the lower one may be suffering from cold.
  Although it is  entirely inadmissable to warm a hospital by direct ra-
 diation from steam pipes, still, rooms that are not regularly used or only
 for short  periods,  as, for example,  work rooms or  halls or apartments
 that are particularly exposed to  the admission of cold air, may have some
 steam pipe distributed in them to keep up the proper temperature, while
 the fresh warm air that is also admitted from the  flues is relied on for
 ventilation.   Great care, however, must be taken that this mode of heat-
 ing is not so much extended as to interfere with the general ventilation
 of the house.  In crowded wards, or in any part particularly exposed to
 impurity of the air, it should be entirely avoided.
  Where the heated air is admitted near the ceiling and the foul air flue
 opens near the floor, it is particularly important that the windows should
 be tight and kept closed, to secure a regular  circulation.  There should
 also be registers in the foul air flues, near the ceiling, for use in summer
 weather or when the rooms have become accidentally over-heated.  This
 mode of admitting warm air has peculiar advantages for the class of pa-
 tients for whom it is recommended, for it  not only  prevents their con-
 gregating around the hot air openings and using the flue as a spittoon, but
 effectually secures the  wards from all the offensive odors with which it
 is frequently filled from articles thrown through the registers.  At the
 same time it must be acknowledged, that for  those who are not addicted
 to these habits, there is great comfort in being able to approach the
 warm ah when coming in cold and chilly, and subsequently regulating
 their distance from it as may be most agreeable to their feelings.
  There is really nothing so pleasant or  probably  so healthful in the
 way of heating, as the warm air derived from an open wood or coal fire,
•with which  there is never any deficiency of ventilation.  If with this,
 a reasonable amount  of pure  and slightly heated  air is admitted into
 the halls of a private dwelling to moderate  the general temperature, and
 to prevent currents of cold air when the room doors are opened, we
 have the most comfortable of all modes of heating.  Open fires would
 not be less  pleasant in the parlors of a hospital for the  insane, but the
 risks attending them at times,  even in  the  least excited wards, are  so
 numerous  as to render it prudent to dispense with  them in every part
 of the building regularly occupied by patients.
  Lighting.—Every hospital should be lighted with gas, and the ne- 
29
cessary pipes should be put in during the progi'ess of the building.  If
gas can not be conveniently obtained from a company's works, it may be
made on the premises without difficulty, by persons who are necessarily
employed for other purposes, and at  a cost that will  render it cheaper
than any other kind of illumination.  In addition to the economy of its
use, the thorough lighting of a hospital for the insane  has really a re-
medial effect, and gas is certainly the safest, neatest, and in all respects,
most convenient mode  of  effecting it.  The retorts for manufacturing
the gas can be  conveniently placed  in  the  basement of the detached
building hereafter to be more particularly referred to, and the room can
be thoroughly ventilated through the main shaft in its immediate vicinity.
The gas holder  should  be of sufficient size to contain several days con-
sumption, although it may be best for the works to keep them from get-
ting entirely cold, by making some gas every day.
  Washing, Drying,  Ironing and  Baking.—All these  operations
should be carried  on  in a building  entirely detached from  the  main
structure, and at least one hundred feet  from it.  Under some peculiar
circumstances, the baking may be done in the hospital building, but ordi-
narily it will be desirable that it should be in the position first suggested.
  The detached building should be about forty feet by fifty feet, and two
stories high.   On one side of it should be a shed, covered with slate, and
well lighted from the roof, under  which  the boilers for warming the
building, &c, should be placed.
  The steam engine and the work shop of the engineer, should be in the
basement of the building, and behind these, the room in which the gas
is to be manufactured,  so that the engineer can readily superintend all
these processes.  The main chimney stack will be  at the rear of the
building, and must be carried up to a height that will secure a good cur-
rent of ah to all the fires for which it is to be used.
  On the first floor of this building  in  front,  may  be placed the bake
house, baker's store room, and a  stairway leading to the chambers of the
baker, engineer  aud firemen in the second story.  In the rear of the first
story would be the  wash room, containing a large cylinder for washing,
and a centrifugal wringer, both driven by the steam engine, besides some
permanent wash tubs,  and a drying closet heated by ah passing over
steam pipe and driven  through it with sufficient velocity by means of a
fan worked by the engine.  In  the  second stoiy  over  the wash room,
with which it communicates by a stairway, is the honing room, in which
besides the iron heater and mangle, should be another drying closet,
made thoroughly effective by the means already suggested.
  Farm  Buildings.—The character of the out-buildings required, will
depend very much upon the amount and kind of land owned by the  insti- 
30
tution, and the mode in which it is cultivated.  Under any circumstances
where farming is earned on, it will be necessaiy to have a barn of suf-
ficient size to stable six or eight horses and twenty cows, and to contain
the hay and grain raised on the  premises; a carriage  house to accom-
modate the  vehicles used about the hospital and the farm wagons; and
a piggeiy for about forty hogs.  A carpenter or work shop,  and an ice
house, will also be required.  All of these buildings should be inside the
general inclosure,  although  seperated  from  the  patients'  pleasure
grounds,  and care should be taken that the barn and piggeiy are not so
near the  hospital as to be an annoyance to its inmates.
  Cost.—The cost of a hospital like that discribed, will vary in different
sections  of  country, according to the price of materials and labor, and
the facilities for manufacturing the various fixtures that may be required
for the different purposes of the institution.  The estimates for com-
pleting such a building at Philadelphia, as made by competent architects
is $155,000.  To this sum, I would  add for the heating and ventilating
apparatus, for bath and wash rooms, water closets,  sinks, water tanks
and pipes, cooking apparatus, washing and  drying  fixtures, bake room,
and steam engine and pumps,  $25,000.  The cost of furniture for every
part of such a hospital when full of patients, would  amount  to  about
$15,000.   The farm stock, wagons and tools,  and the different vehicles
required, would cost probably $3,000 additional, so that  exclusive of the
farm, which of late has generally been presented to the State,  either as
a gift from benevolent individuals,  or by some town desirous of having
the institution near it; the entire cost of building such a hospital for the
insane, providing all its fixtures and furnishing it in every part, would be,
in this section of country, not far from $200,000.
  In making an estimate of the cost of a hospital for the insane,  I have
felt no disposition to underrate it.  Believing, as before remarked, that
every State  is bound by the double claim of interest and duty, to provide
such establishments for the benefit of its citizens; and that the best con-
structed, best arranged, and most liberally managed hospitals are always
cheapest in the end, I have  rather been anxious that the public gene-
rally should  understand that such institutions, from their character and
objects, must necessarily be costly as compared with cheap  boarding
houses or alms houses;  and that the cost of simply supporting life and
preventing absolute suffering in the latter, can never be made the stan-
dard for the rate of expense of a proper custodial and  curative treatment
in the former.
  It must be remembered too, as already observed, that these State hos-
pitals are for all classes, and it has been well said, that various comforts
and arrangements which are necessary to prevent some  portions of the 
• 
No. 1.
PLAN OF CELLAR.
No. 2.
J  Llf
PLAN OF BASEMENT,  OR FIRST STORY. 
31
community from feeling positive privations, are equally valuable as prov-
ing curative to their less fortunate fellow beings.
  The difference in cost between a hospital that is well built, and one
that is badly, between one complete  in all its arrangements and one that
is imperfect, between one liberally  and one meanly managed, is really
so small, that if the good citizens of any  State would make the simple
calculation how much of this extra expense would fall upon each one of
them, it can scarcely be credited that a single individual could be found
any where, who would be willing to admit that he would not cheerfully
bear  his proportion of it, even if it had  never occurred to him that at
some period or other, he might himself be  compelled personally to test
the character of the provision for the insane made by his State.

   Description of Plates.—To  render  some of the  arrangements
which have been proposed more clearly understood, and to give a better
idea of the style of building which  has been recommended, the accom-
panying plans have been prepared.  They were drawn for a State hos-
pital  intended to give ample accommodations  for the officers of the ins-
titution, for all persons employed about the establishment, and  for the
custody and treatment  of two hundred and fifty patients.
   The building consists of a basement and two principal stories in every
part,  except the centre and the projecting portions of the wings, which
will rise a few feet higher.  On the centre building will  be a dome, iu
which will be placed the water  tanks made of boiler iron, and of suffi-
cient size to contain  12,000 gallons.
   The ventilating shafts will terminate on the projecting portions of the
wings and in the central dome.
   The centre building separates the two sexes, and on either side of it
are three  ranges of wings.  The first range  is separated from the centre
building by a space,  eight feet wide, with movable glazed sash, on each
side of  the passage,  and the other ranges fall back just far enough to
leave the  corridors open at both extremities.
   This arrangement, as will be seen, gives eight distinct Wards for each sex,
exclusive  of some additional provision for very noisy or violent patients.
   No. 1 represents the cellar excavated throughout its whole extent to
the depth of seven  and a half feet below the floor of the  first story.
The centre passage {a) is the hot ah chamber, extending through the
entire  building, and in which the radiating  steam pipes are  placed.
The spaces on both  sides of this chamber  are for cold  air  reservoirs,
into which the external atmosphere is admitted  through  a portion of
the windows  marked  on the  outside of the  building.  In one of these
ah reservohs is a railroad (r.  r.) for conveying food from the kitchen
to the different dumb waiters between it and the extreme wings. 
32
   No. 2 shows the basement or first story, which is raised two steps or
 sixteen inches above the ground.  In  the centre, is the principal en-
 trance, with a broad flight of easy steps leading to the main story above.
 On one side of this entrance in front, is a reception room for patients
 {a), and back of it is the steward's chamber {b), on the opposite side is
 a parlor and dining room  for the steward and matron  (c), and back of
 this, the matron's chamber {d).  These rooms are shut off" from those
 in the rear by a glazed partition.   In the rear, on one side, is the main
 kitchen (e), and a store room (/);  on tne other side, a small kitchen {g),
 a store room1 (/i),  and a  dining room  (?) for the  female  domestics and
 the hired men employed on the  farm and  in the garden.  There are
 also two water closets  in this stoiy of the centre building.
   In the first range of wings next the centre on one side, are two work
 rooms for the female patients {k), two store rooms for materials used and
 for articles manufactured in them («,) two  chambers for the superinten-
 dents of the work rooms (m), two ordinary store rooms («), a bath room
 and a water closet, and the remaining small rooms are the chambers of
 the female domestics employed on the premises.   The large room  {q) is
 intended for one  of the infirmaries for  sick women, especially for those
 who are likely to be much  visited by  their friends or others, making
 easy access particularly desirable.
   Precisely the same  arrangement will be found on the side occupied
 by the males, so that throughout, a description of one suffices for both.
   The second range of wings on this stoiy constitutes the seventh ward
 for patients, and the third range the eighth ward.  In both these, (r) is
 the parlor, (s) the dining room, {t) the associated dormitory or large room
 for a single patient and attendant, (w) is an attendant's chamber, and (o) a
 bath and wash room.   The water closets, sink rooms,  clothes rooms,
 drying rooms,  dumb waiters, dust flues, soiled clothes hoppers, flues for
 ventilation of water closets, rooms for the water pipes, and all the other
 conveniences suggested in the foregoing pages, have been provided for
 in the larger plan, but its reduction to the size of a single page,  has pre-
 vented their being distinct enough to have  a separate reference. They
 are nearly all arranged for the accommodation of every ward, and those
for two contiguous wards are grouped together as far as practicable.
  At the extreme end of the eighth ward, and of those immediately
above it, will be found on each side of the main corridor,  three single
rooms,—being six for the ward,—which open on a private passage way,
and are Intended for the most violent and noisy on the  corresponding
floor or for those whom, for any reason, it  is desirable to have  particu-
larly secluded.
  No. 3 represents the second or main story throughout.  In the centre 
No. 3.
nrLiiiiC
::nniniiilLLLLiLL
PLAN OF SECOND AND THIRD STORIES OF WINGS, AND SECOND STORY OF CENTRE BUILDING.
NO. 4.
ix
DC
^n_iJ L£
j;
J LJ
-h
^        -t*J
PLAN OF THIRD STORY CENTRE BUILDING, AND PROJECTIONS OF WINGS. 
 
                                33

in front, on one side is a parlor (a), behind it, a room for visitors to fe-
male patients (6), on the other side, a managers' room (c), and behind it,
a room for visitors to male patients {d).   Both the rooms for visitors to
patients, communicate directly with the adjoining wards.  In the rear,
on one side, is  the general business office (e), back of which is the su-
perintending physician's private office  (/); on the opposite side, is the
apothecaiy shop and general library (g), and adjoining it, the chamber
of the assistant physician and apothecary {h). A small window forms a
means of communication between  the  apothecary  shop  and general
business office, and the wards of their respective sides, through the din-
ing rooms (s), so that those  employed among the patients may always
communicate  with  the  officers in the  centre  without leaving their
wards.   The  fire  proof safe is on this story.
  Adjoining the centre building in this story is the 4th ward, beyond it,
in the next range is the 5th, and in the extreme range, is the 6th ward.
The general arrangements of all these are the same as have been already
described for the 7th and 8th wards.
  This plate also represents the story  above in the  wings throughout,
being exactly like those below, and  making the 1st, 2nd, and  3rd wards.
The dining rooms (s) of the 1st and 4th wards, are in the adjoining part*
of the centre  building.   The  arrangements of the third  story of the
centre building will be shown in the next plate.   The stairways for the
wards next the centre, have been accidentally omitted in this plate, but
they correspond with those shown in plate No. 2.
  No. 4 shows the third story of the centre building, and the fourth story
of the projecting portions of the wings.  All the rooms in the front of the
centre building, including bath room, water closet, &c, are appropriated
to the family of the superintending physician, and are strictly private,
one of the stairways from the second story being for their use exclusively.
The other stairway  for  visitors and others passes up to the  dome.   In
the rear of this story is the lecture room  {g), which may also be used
as a chapel, extending up through the fourth story, and having a direct
communication with the wings of either side through the 1st ward din-
ing rooms (s).
  In the front of the first projection, is the museum and reading room,
(m), and in the same part of the second projection is the school room {n).
Both of these rooms have arched ceilings and sky-lights.  Behind them,
are the chambers of  the night watch, and of the teacher (c.)  The large
rooms in the rear, on this floor, may be  used for  the sick,  especially
during the prevalence of a contagious disorder.   The tanks  containing
hot water for the supply  of the wards below are also in this story.
  No. 5, (the  frontispiece,) gives a perspective view of the entire struc- 
34
ture.  It will be observed  that the  usual  portico, with high flights of
steps has been dispensed with, as being costly, destroying the usefulness
of the upper portion of the building,  and not particularly appropriate for
a structure of this character.  The double verandah, which  has been
substituted, is to be made of iron,  and being six feet wide, will make a
good protection to persons getting in, or out of carriages, in wet weather,
and form a not unsightly appendage to the building.   The style of dome
for the centre building, and the varied forms of termination of the seve-
ral ventilating shafts, have been left as drawn  by the architect, with the
single remark, that if  deemed expedient, something less costly may be
substituted.
  Height of Ceilings, Width of Corridors and Size of Rooms.—
The height of the ceiling in the whole basement of the building, and in
every part of the wings is 12 feet, in the second story of the centre 16
feet, in the third story of the centre, 14 feet, and in its fourth story, 10
feet.  The ceiling of the lecture room is 24 feet high.
  The main corridor of the centre building is 16 feet wide,  the ward
corridors, 12 feet, and the small passages  at  the extreme ends  of the
wings are 9 feet wide.
  The main kitchen is 32 by 22 feet, the small kitchen 22 by 14, main
store rooms 22 by 18, rooms in the  centre building generally 22 by 18,
the lecture room is 64 by 34, patients' parlors 20 by 24, patients' dining
rooms 20 by 24, large rooms for patients with special attendants, 18 feet
9 in.  by 11 feet, associated dormitories 18 feet 9 in. by  11, patients'
single rooms 11 by 9, work rooms  18 feet 9 in. by 11, bath rooms 11 by
9, drying rooms 11 by 5 feet 6 in.,  fire proof passage ways between
wards 11 by 5, water closet rooms 11 by 5, museums and reading rooms
34 by 24,  school rooms 24 by 20, and infirmaries 24 by 20 feet.
  The plan which has just been described, was prepared under my su-
pervision  and direction  by Sloan  & Stewart, Architects, of Philadel-
phia.  These gentlemen are now superintending the erection of the new
State  Hospital for the Insane in Alabama,  and have also furnished simi-
lar drawings for two new institutions in Ohio.  To their taste and prac-
tical knowledge, I am indebted for valuable suggestions in reference to
many of  the arrangements of the building.
  Remarks on the Plan.—The general features of the plan proposed
in the present essay, were originally prepared by the writer at the re-
quest of  the Commissioners for putting up a State Hospital for  the In-
sane in New Jersey,  and the designs for that building were made from
the sketches at that time furnished its architect.  Convenient, as most
of the arrangements of that institution have been found to be, it is to be
regretted that various  modifications were made in the details of the ori- 
35
ginal plan, which although diminishing its cost, impaired its complete-
ness ; and the want of the last range of wings,—which are now in pro-
gress of erection—has always proved a serious  interference with the
comfort of its patients.
  Many points of resemblance to the New Jersey plan, will also be
found in the State institution of Indiana, at Indianapolis; of Illinois, at
Jacksonville; of Pennsylvania, at Harrisburg; and in those of Ohio, at
Dayton and Cleveland; carried out, however, with veiy vaiying degrees
of completeness.  The State hospital now being built at Tuscaloosa, Ala-
bama, is the only one yet  commenced in which all the details and the
whole extent of building recommended have been adopted at the very
beginning of the work.
  No proper estimate of the value of any plan for a hospital for the in-
sane, can be formed, except it is judged of, as a whole.  In reference to
that'under notice,  I regard it, as every way important, that the building
should be  put up at once, of the full size recommended;  and there is no
reason to believe that such an institution will be found too large for any
State, which has  no other provision for its insane, with the single ex-
ception of Delaware.
   If there was any doubt of the propriety of putting up the whole build-
ing at once, I should have no hesitation in saying that rather than leave
off the extreme wings, it would  be advisable that the work should be
commenced at both extremities  and made gradually to approach the
centre; for the centre building could be dispensed with for a time with
about as little inconvenience as those most important wards.   It is quite
probable, too, that appropriations to fill up such a vacancy between the
wings  might be more readily procured, than for adding new wings to
the building.
  The first patients sent to a State hospital,  are very apt to be  of the
most noisy, violent or careless description,—those, indeed, who could no
longer, without gi'eat inconvenience,  be kept either at home or in the
county jails or alms houses.  For these patients, the  extreme ranges of
the wings are particularly desirable; and without them, the classification
must necessarily  be very  imperfect.  Such patients  occupying  wards
near the centre, render them to a greater or less extent, unfit for  those
who are expected  ultimately to be received in them.
   My own experience has satisfied me that the form of  building shown
in the plan, and carried out as suggested  in  the  foregoing  remarks,  is
every way preferable to any one which has wings passing off at right
angles to each other.  There is more certainty of the free circulation of
light and air, better prospect  are secured from all the patients' rooms
and parlors, there is less opportunity for patients on opposite sides seeing 
3G
or calling to each other, and less probability of the quiet patients being
disturbed by those who are noisy.
  As parlors are desirable in all the wards except those for the most ex-
cited  classes of patients, and as the corridors are to  have glazed and
movable sash at both extremities, there does not appear  to be any objec-
tion to rooms being on both sides of them.  If there were to be no par-
lors in a hospital, and the corridors were to have their ends obstructed
in any way, or were to be used throughout as sitting rooms,  then pa-
tients' chambers would be admissible only on one side.  Generally how-
ever, a ward having its corridor of good width, and not extended to an un-
reasonable length, open at both extremities and with rooms on each side,
with their doors and windows opposite, will be found quite as pleasant,
aiiy,  and cheerful, and at least as easily ventilated, especially in sum-
mer, as one with a corridor closed at its ends, and  rooms only on one
side.   A corridor thus arranged, with a double wall as  it were on each
side,  can hardly fail to prove  more comfortable  in  summer,  even in a
warm  climate,  than one wmich has its whole extent  exposed to the
direct rays of the  sun; while  the  free currents of air  passing through
its entire length, and the transverse ones through each range of doors
and windows, would seem to be all that could  be desired.  The plan
of having rooms only on one side is necessarily  a more expensive one,
and throws the extreme  portions at a greater distance  from the centre
of the hospital, for even  if it is  a rectangular  structure, the distance
is to be measured, as it would be passed over by a person going through
the house,  and  not by an air-line from one point to another.  The ex-
periment  of having rooms only  on one side of the  corridor,  originally
adopted in this country in 1817, has not been so satisfactory as to cause
its repetition in more than two or three out of the 27 institutions which
have since been provided for in the United States.
  The proposed arrangements obviate the necessity of  any mingling of
the patients, unless perhaps to some extent in passing to  the lecture room
from the two extreme  wings  of the  upper stories,  when the patients
must go through the wards nearer the centre, but as the patients from
these will have aheady preceded them to the room, in which  all will be
mingled to some extent, no great disadvantage can result.  In going out
of doors, the patients never pass through any ward but their own.  A
classification that admits of no greater mingling of patients than this, is
quite rigid  enough for all practical purposes.
  The arrangements for the most noisy class of patients is probably about
as good as can be adopted.  The extreme  ends of the wings in each
story being thus occupied, patients who become  unexpectedly excited
can be promptly removed, without having to  pass up or down stairs, or 
37
under any circumstances, disturbing more than  one  quiet  ward on
their passage.   Even in the most excited wards, it will generally be found
that one or two individuals make nearly all the noise, and directly or in-
directly cause most  of the  excitement among the patients.   The six
rooms, divided by the main corridor, at the extreme end  of each story
are so arranged that these patients can be comfortably provided for, and
their noise or violence prove but little annoyance to any other part of the
house.  It is especially important to have means of classifying and sub-
dividing,  at least for short periods, the excited and the noisy,  and also
those who have an uncontrollable irritability and disposition to  worry all
who are near them.  In no other position can these be better provided
for than in that suggested in the plan, where they may be subject to a
close inspection, as it is especially important they should be, and yet not
seriously annoy the other inmates of the institution.
   In conclusion,  the plan will be found, it is believed, to give at as small
a cost as can effect the object thoroughly, what was originally proposed
as desirable in a Hospital for the Insane,—ample provision for the accom-
modation of the officers and all employed,  eveiy thing  requisite for the
custody, comfort and enlightened treatment of the patients, and arrange-
 ments throughout  that will  allow the  supervision to  be thorough and
 effective, and the management liberal and at the same time strictly eco-
 nomical.
 ORGANIZATION  AND  GENERAL  ARRANGEMENTS  OF
               HOSPITALS  FOR THE INSANE.

  Important as it is in every point of view that the buildings intended
for the custody and treatment of the insane should be constructed in the
best manner, and furnished with every convenience calculated to pro-
mote the comfort of the patients and to facilitate their management,—
still all these will result in comparatively small benefit to the afflicted,
unless the system of internal organization and the general arrangements
are based on correct principles and carried out with judicious liberality.
  Upon most of the prominent points connected with this subject, there
is believed to be nearly entire unanimity of sentiment, among those who
have charge of the Hospitals for the Insane, in the  United States,  so
that in expressing my own opinions on a large part of them, I have little
more to do than to record the convictions which have been forced upon
a majority of those who have had opportunities of testing practically
the actual requirements of this class of institutions. 
38
  During a somewhat protracted connection with Hospitals of this kind,
it has been my good fortune to be associated with Boards of Managers,
and with assistant officers, whose views have so generally harmonized
with my own, that our intercourse has always been of the most agree-
able kind, and my suggestions have ever received that prompt and liberal
consideration which leaves  me no  cause  for  complaints.   For these
reasons, as well as from a feeling that my period of service in the cause
has been nearly as much protracted as can reasonably be required of one
individual,  and not knowing of  any favors I am  likely to have to ask for
myself in the future, and being quite sure I have no past wrongs to re-
dress, I shall deem myself at  liberty to speak  with entire freedom on
this subject, without being chargeable with  the  slightest indelicacy, or
of being influenced by personal considerations,—as much so, as though
I neither had,  nor expected  to  have any connection with such  an insti-
tution.  My only motive is to be useful to the insane,  and the  commu-
nity, to save Boards of Trustees or  Managers, the trouble and disap-
pointment of resorting to experiments, which have been tried over and
over again, and always with bad results, and to enable  those  who take
charge of new Hospitals, to begin under circumstances that  will allow
them, from the start, to devote  themselves to  the welfare of their pa-
tients,  and thus show  the public how much good these institutions are
capable of effecting.
  Those who are hereafter to organize new institutions for the Insane,
can scarcely be expected, in the commencement of their career, to be able
to recommend what is  most desirable, unless they have the means of
comparing the candid sentiments and the results of the experience of
those who have gone before them.
  Officers.—The officers of a Hospital for the Insane should consist
of a Board of Trustees or Managers, as  they may be called, and a
Treasurer,—of a Physician in Chief, of one or  two Assistant Physicians,
according to the number and kind of patients  under treatment,  and of a
Steward and Matron.
                                    i
  Trustees.—The general controlling power over such  a hospital,
should be vested in the Board of Trustees, whose mode of appointment
will necessarily be varied according to the character of the institution
with which they are connected.   In private  charitable corporations they
will be chosen according to the prescribed forms, by those duly qualified
to vote,—while in State institutions, their appointment will generally be
either by nomination made by the Governor, and confirmed by the Senate,
or they will be  selected  directly  by the Judges of the Supreme  or other
Superior State Court.    The precise mode of election,  however, is not
of so much importance  as the kind of men  who are chosen, and that a
I 
39
determination should exist to prevent every thing like personal or political
influences controlling their appointment.
  The number composing this Board should never exceed twelve, while
nine will often be preferable.  Their tenure  of office should be so ar-
ranged, that if changes are deemed desirable, the terms of only a limited
number, should expire in any one year.  Every one nominated for such
a post,  should possess the public confidence in a high degree, be distin-
guished for liberality, intelligence and active benevolence, be a man of
business habits and able  and willing faithfully to attend to the duties of
the station.
  The Trustees will have the general supervision of the institution and
of its affairs, and they should  at  frequent stated intervals, either as a
Board, or by Committees, make visits through eveiy part of the Hospital,
and  exercise  so thorough an oversight of its  expenditures  and of its
operations generally, as  will tend to secure the confidence of the whole
community, and  especially  of those whose  friends are  committed to
its charge.
  One of the most important duties connected with the trust of these offi-
cers, will be the appointment of the Physician to the institution, and on
his nomination, and not  otherwise, suitable persons to act as Assistant
Physicians, Steward and Matron.
  The members of a Board of Trustees, performing their duties prop-
erly, are always able to exercise a most important influence on the pros-
perity of any institution,  and in the welfare of its inmates;  and they may
also by injudicious measures, or  a want of interest in its affairs, produce
effects of  an entirely different character.  While giving the strictest at-
tention to  theh own appropriate  functions, they should most carefully
avoid any interference with what is delegated to others, or meddling with
the  direction  of  details  for which others are  responsible.   Especially
should they avoid any personal interest in subordinates, that might lead
them to a course that would weaken the authority of the principal of the
institution. It would, indeed, be a safe principle to adopt,  that there
should be no ties of a personal or pecuniary character, between a member
of the Board of Trustees, and those who are employed in any of the de-
partments of an institution, which could at any time prevent an unbiassed
judgment  in a case of  difficulty.  Under no  circumstances, should a
Trustee so far forget the proprieties of his station, as to resort to subor-
dinates for information that should come from the principal,—or to  cir-
culate unfavorable reports in regard to the institution, without having first
informed this officer of their existence and tendency, and learned from
him their truth or falsehood, as well as the reasons which may have in-
duced acts, which  although correct  in  themselves,  might, without 
40
proper explanation, be readily so misunderstood as to do great injustice to
innocent parties.
   Boards of Trustees, while exercising the strictest honorable scrutiny
of their officers, should be prepared, on every proper occasion, to give
them a steadfast support in the  performance of their arduous and re-
sponsible duties.   They can thus add most essentially to their power of
doing good.   It is a great encouragement to those who are engaged in
this vocation, to find their efforts properly appreciated  by those, to
whom they are directly responsible, and who ought to be most familiar
with their  modes of management and the beneficial results of their la-
bors.
  It is scarcely necessaiy to say that it is quite inadmissible for Trustees
to have an interest, directly or indirectly, in any contract, with which the
Hospital is concerned.   Such a course may at least lead to suspicions, the
existence of which, however groundless, is always to be deprecated, and
might under some  circumstances prevent a trustee from acting honora-
bly and impartially.
  Boards of Trustees should perform their duties without  compensa-
tion, but the expenses actually incurred should be returned to them.
  Treasurer.—The Treasurer should  be a salaried officer, elected by
the Trustees, and giving ample security for the faithful performance of
his duties.  He  must reside in the vicinity of the hospital, but not in
it;  he should collect all  monies due the institution, and should receive,
hold and disburse all the funds that may come under the control of the
Trustees.
  He should pay the orders of the Steward, only when accompanied
by bills of particulars, specifying the object of the payment,  and  certi-
fied by the  Superintending Physician, as being correct, and  approved of
by him.                               s
  Physician.—" The Physician should be the Superintendent and  Chief
executive officer of the  establishment.  Besides being a well  educated
physician, he should possess the mental, physical and social qualities to
fit him for the post.   He should serve during good behaviour, reside on,
or very near the premises, and his compensation should be so liberal, as
to enable him to devote his whole time and energies to the welfare of the
hospital.  He should nominate to the  Board suitable persons to act as
Assistant Physician, Steward and Matron.   He should have entire con-
trol of the medical, moral, and dietetic treatment of the patients, the un-
restricted power of appointment and discharge of all persons  engaged in
their  care,  and should exercise a general supervision and dhection of
every department of the Institution."
  It will readily  be seen how important is the task of selecting an indi- 
41
vidual to fill the place, and to perform the duties, detailed in the forego-
ing paragraph which is in the exact words of the proposition, adopted
by  "the Association of Medical Superintendents of American Institu-
tions for the Insane."  When once chosen, however, there would seem
to be no doubt but that his tenure of office and his compensation, should
both be such that a man of proper  character would be willing  to lay
aside all other engagements, to enable him to devote himself to the per-
formance of his duties.  Without good reason to expect the situation to
be permanent and the  compensation liberal, no man possessing the re-
quisite qualifications and talents, could be expected to give up his pros-
pects of advancement  in other branches of the profession, and so com-
pletely to cut himself off from the lucrative results of a successful general
practice.
  Where it is possible to find a physician, who has already acquired a
practical knowledge of the details  of hospital management and treat-
ment, by personal observation and a residence in some good institution,
if joined with the other desirable qualifications, there is no question but
that such an  individual is preferable to  any other.  If the  Physician
chosen, however, has not had these advantages, he should be one that
is " apt to learn" and willing to embrace every possible opportunity to
make up his deficiencies,  especially by a  temporary residence in some
such institution, before venturing to take  charge of his  own.  A few
weeks thus passed in Hospitals of the best kind, and devoted to a careful
study of their varied arrangements,  and of their modes of managing the
insane, will save a Superintendent  a great amount of subsequent labor
and anxiety, and result most advantageously to his first patients.
  If the person chosen to occupy  the  post  of Physician-in-Chief, is
practically familiar with Hospitals for the Insane, and has a taste for the
details of building arrangements,  very great advantage will result from
his appointment being  made before the commencement of the buildings,
and thus securing to the Institution the benefit of his experience in ar-
ranging the different parts of the structure.
  It would seem to require but little argument to show that a Hospital
for tho Insane should have but one official head,—in reality, as well as
in name,—to whom eveiy one employed about it must be strictly subor-
dinate.  It would be as reasonable to suppose that  a proper discipline,
or that good  order would prevail in a ship with two captains, or in an
army with two generals-in-chief, or in a school with several principals,
as to expect to find them in  a  Hospital of the kind referred to, where
two or more individuals were acting independently of all others, or in
which there were certain  officers over whom the Physician-in-Chief
had no control.   If such an arrangement ever worked well anywhere,
                                6 
42
 it must have been owing to  some very peculiar mental organization in
 those acting under it, and not because the principle was  not radically
 wrong.
   The very peculiar character of a majority of the patients received in
 such institutions, the numerous body of assistants required in their care,
 the large number of persons employed in the various departments, the
 necessity for active  and unceasing vigilance, joined with gentleness and
 firmness in all our intercourse with the mentally afflicted, and for prompt
 decisions in cases of difficulty, render it indispensable,—if we wish the
 best results,— that a large amount of authority should be vested in the
 chief officer.
   It must always be borne in mind that every department of a Hospital
 for the Insane, its farm, and garden, its pleasure grounds, and its means
 of amusement,  no less than its varied  internal arrangements, its furni-
 ture, its table service and the food, the mode in which its domestic con-
 cerns are earned on, every thing connected with it, indeed, are parts of
 one great whole, and in order to secure harmony, economy, and success-
 ful results,  every one of them, must be under the same  general control.
 It is not to be supposed that the Chief Physician of the Institution should
 personally superintend all or a majority of these matters, or fritter away
 his time in  a constant attention to their details, or  even that he should be
 proficient in every one of them ; but it should be expected that he is so
 constituted, mentally and physically, as to be able and willing to make
 himself familiar with all of them, so far at least, as to know when every
 thing is in good order, and when all duties  are properly performed.   He
 should especially have that kind of tact and judgment, that will enable
 him to fulfill efficiently one of the most important functions  of his office,
that of selecting individuals for every department fully qualified to per-
form theh appropriate duties.
  It is a great error to suppose that there is any detail about the manage-
 ment  of a Hospital for the Insane, beneath the dignity, or unworthy the
 attention of its Chief Medical Officer.  Every thing that has any relation
to the patients,—and every thing has some direct or indhect connection
with them,—may have an influence not readily appreciated  by a careless
observer, and to preserve  unity of purpose nothing should be arranged or
 changed without consultation with the head of the establishment.
  The  Physician, who  voluntarily confines his attention  to the mere
 medical dhection of the patients, must have a very imperfect apprecia-
tion of his true position, or of the important trust confided to him.   He
becomes in  reality, a very secondary kind of officer, and his functions will
be pretty sure to be considered by many around him, as quite subordinate
 in importance to those of some others concerned in the  management of 
43
the establishment, which under such an arrangement can hardly attain,
or keep a permanently high character.
  No one will deny that the arrangement recommended,—which is the
only one that can be relied on to work satisfactorily,—places much power
in the hands of the Chief Physician, but it must be remembered too that
on  him  the responsibility  also mainly  rests.   A man to whom  this
amount of power cannot be safely intrusted, certainly is not the proper
person to be placed at the head of  an institution containing 250 insane
patients.
  The simple possession of adequate authority by the chief executive of-
ficer of such an institution, often prevents the necessity for its being ex-
ercised.  It may be unseen and unfelt, and yet a knowledge of its exist-
ence, will often alone prevent wrangling and difficulties in the household,
and secure regularity, good order and an efficient discipline about the
whole establishment.
  The long continued and uninterrupted performance of the duties of a
Hospital Superintendent among his  patients is a tax upon the mental en-
ergies, and ultimately upon  the physical powers  of an individual, not
easily appreciated by those  who  have not had some experience of the
kind; and one of the best modes of counteracting these effects, is for that
officer to devote a portion of his  time to the supervision  of out door
affairs.   By this means, he will not only have the invaluable advantages
of active muscular exercise in the open ah, but also a kind of occupation
for the mind, that will,  more  effectually than any other,  divert it from
the train of thought which had been induced by a protracted visit through
the wards.   Change of occupation,—both mental and physical,—is the
relaxation of a Superintendent of a Hospital for the Insane, and is indis-
pensable, if he expects  for any long period to preserve his health and
usefulness.  So many  noble spirits in our own country have already
broken down, while engaged in the zealous performance of these duties,
that hardly a better contribution could be made to the cause, or one
that would more subserve the interests of the  afflicted, than that which
would aid in preserving the mental and physical health of the right kind
of Hospital Physicians.
   The nomination of the Assistant Physicians, Steward and Matron, by
the Physician,  will probably secure harmonious action between these
officers,  in the operations of the house.  This point is one of great im-
portance, and without it, there can be little satisfaction in the manage-
ment of an institution.  No Board of Trustees having at heart the pros-
perity of a Hospital for the Insane, could be willing to select or retain in
office any of these named, «who did not cordially aid in promoting the
views and carrying out the plans of the chief executive officer. 
44
    In reference  to  all other persons employed about the patients, the
  power of appointment and discharge, as before observed, should be clearly
  and unconditionally with the Physician.   A single interference with this
  power, could hardly fail to lead to acts of insubordination, and a disre-
  gard of the  proper authority, and prove, to a greater or less extent,
  destructive of all good discipline.
    Assistant Physicians.—Assistant Physicians, besides being gradu-
  ates of medicine, should be men of such character and general qualifica-
  tions, as will render them respected by the patients and their friends, and
  able to represent creditably, or to perform efficiently, the more ordinaiy
  duties of the Physician, in his absence.  As considerable responsibility
*  will frequently rest on these officers, much more than simple medical at-
  tainments should be regai'ded in making a selection.  It would be to the
  ultimate interest of the afflicted, and of the whole community, if the
  post could generally be conferred on those who are likely to devote them-
  selves to this branch of the profession, and who seem to possess the kind
  of character, which in  due time, would probably make them desirable
  Chief Officers of Hospitals for the Insane.  They should  especially be
  men of the highest moral character, of a cheerful disposition, but  clear
  of frivolity of behaviour,  and above all, they should be likely to be pru-
  dent in their intercourse with the patients.  Although It must be ac-
  knowledged that some men make admirable Assistants, who are not so
  well calculated for  Superintendents, still it does not often,  if ever, occur
  that a poor assistant makes a good Chief Medical Officer.
    Where there are 250 patients, especially if there is a large proportion
  of recent cases, two Assistant Physicians will be required,  one of whom
  should perform the duties of Apothecary.  In some institutions, one As-
  sistant Physician and an Apothecaiy will be sufficient.   If the full time
  of two Assistant Physicians, however, is taken up by then* other duties
  among the  patients, an apothecary may still  be usefully employed in
  addition; and to him, other duties among  the  male patients may with
  propriety be assigned.  It is, nevertheless, of gi'eat importance to the
  proper discipline of a Hospital for the Insane, that no supernumeraries
  should be allowed in any department.
    Steward.—The duties  of the Steward,  and  the importance of the
  office, vary materially in the different American institutions.  In some,
  he not only performs the ordinary functions of that officer,  but is also
  really the  Treasurer of the institution,  and receives and disburses  large
  sums of money. The present essay, however, referring more particular-
  ly to State institutions, or those similarly constituted, the duties last  nam-
  ed will be understood to be performed by the Treasurer, as an officer of
  the Board of Trustees, and whose duties have already been detailed. 
45
  The details of the duties of both Steward and Matron, with the sanc-
tion of the Board of Trustees, should  bo arranged by the Physician, to
which officer they should be directly responsible.
  The Steward, under the dhection of the Physician, should make all
purchases for the institution, keep the accounts, make engagements with,
pay and discharge those employed about the establishment, and besides
having a care of the farm, garden and grounds, should be able to perform
many other important duties of supervision and police, that may with
propriety be assigned  him.   He should give adequate security for the
faithful performance of his trust; he should promptly pay into the hands
of the Treasurer all moneys received by him on account of the institu-
tion,  and should settle all demands,—except trifling incidental ones, for*
which he should regularly account,—by orders on the Treasurer, with
bills of particulars, duly approved by the Physician.
  Matron.—The Matron,  while having a general supervision of the
domestics and of the domestic arrangements  of the house, will also bo
able, under the  direction of the Physician, to contribute essentially to
the comfort of the patients, and all others  about the establishment.
Although the Matron  will have considerable intercourse with the pa-
tients, her principal and most important duties, will be more connected
with the housekeeping, while the general supervision of the patients,
their instruction, amusement and immediate care will be dhectly and
mainly confided to others, to be hereafter referred to.
  Some able hospital  physicians amongst us,  have proposed  having no
Steward or Matron, but this suggestion, I presume, has arisen from the
difficulties  which  in some sections of the country have  so  frequently
occurred with these officers, and which have, no doubt, originated from
improper persons having been selected for these stations, from  their
precise duties not having been accurately defined, or their subordination
to the principal not being well understood, and it  must also  be added,
occasionally from the very injudicious interference of Trustees, where
difficulties have arisen between them and the Physician.  Whether a,
Steward and a Matron are among the officers  of such an institution or
not, the duties commonly assigned them have to be performed by some
individuals, whether acting under these or different titles.   The  terms
used above are familiar to every body, and although those acting in these
offices occasionally may not  have correctly appreciated their true posi-
tion, still I should  scarcely deem it necessary,  on that  account, to reject
these titles altogether.   My own experience with Stewards and Matrons
has been so fortunate,  as to cause me to remember only their valuable
services, and a pleasant official intercourse with them. 
46
   The individuals thus far named, are officers that can not be dispensed
 with,  and are either appointed directly by the Board of Trustees, or on
 the nomination of the  Physician.   No reference, however, has been
 made  to Chaplains or to  Consulting Physicians, all of whom are occa-
 sionally deemed desirable.  If either are appointed, it should be by the
 Board of Trustees on the nomination of the Physician.
   Chaplain.—In reference to the  propriety of making the Chaplain a
 permanent officer, considerable diversity of opinion still  exists among
 hospital physicians,  the  varied circumstances  of  different institutions
 leading their Superintendents to contrary conclusions on the subject.
   The value of such an officer must depend almost entirely on the cha-
racter of the individual selected, and the sound judgment and discretion
 with which he performs his duties. Under all  circumstances,  I have
 no doubt but that it will be found best that he  should not be a resident
 of the institution.  In addition to this, it may be sufficient to quote the
 language adopted by " the  Association of Medical  Superintendents of
 American Institutions for the  Insane," viz : " If a Chaplain is deemed
 desirable as a permanent  officer, he should be selected by the Superin-
 tendent, and, like all others engaged in the care of the  patients, should
 be entirely under his direction."
   Consulting Physicians.—It has occasionally been  proposed that a
 Board of Consulting Physicians should  be  connected with Hospitals for
 the Insane, but this arrangement obviously could be of little service to
 the patients, and if it was intended that these  officers should make re-
 gular  visits, would on many accounts  be quite objectionable.  It is not
 possible for any one who sees insane patients only  at long intervals, to
 prescribe properly for their ever-varying condition, or judge from short
 interviews, the real character of their cases;  and medicines form so
 small  a part of the remedies for the insane, that the wisest adminstra-
 tion of them would be doing but little of what should be  expected from
 a physician to such an institution.
   Whenever from any cause it is deemed expedient to have Consulting
 Physicians permanently connected with  a Hospital for the Insane, it
 should be with the distinct understanding, that their visits  to the pa-
 tients should be only in  company  with the Superintending Physician,
 and at his request, or at least, if deshed by others, with his approbation.
   With the selection or retention of any of the individuals hereafter to
 be referred to, the Board of Trustees can  with propriety have nothing
 to do,  all being employed in the immediate care of the patients, or in
 positions connected with  the domestic departments, or the management
 of the farm, garden and grounds. 
47
  Supervisors.—There should be one Supervisor of each sex, and each
of these should exercise a general oversight of all the patients and their
attendants on one side of the  house, and thus form a  medium of com-
munication between them and the officers of the institution.   These in-
dividuals being exempted from the ordinary work of the wards, and their
duties being extended through all the apartments and grounds occupied
or used by their own sex, will have great facilities  for ascertaining the
mode in which prescriptions and directions are carried out, and the pa-
tients'  comforts and general condition are attended to.  They should be
persons who possess in a high degree, tact,  intelligence, activity, and
above all, true benevolence, with a feeling of sympathy and kindness for
all the afflicted.  They should be able to appreciate the views and wishes
of the Physicians, and in all their  intercourse  with the insane, or those
employed in their care,  should act with such coolness and prudence un-
der all circumstances, as to command their respect, and to impress upon
them by word and deed, the great importance  of a kind and enlightened
course of treatment.
  Teachers.—There should be for  each sex, at least one individual of
a kind, cheerful and affectionate  disposition,  with considerable mental
cultivation, and of refined manners, who also  without any ward duties,
or more than an indirect supervision of the attendants, should be able,
under  the instructions of the Physician, to devote  their whole time to
the promotion of the comfort  and happiness of the patients.   This may
be done by instructing them in some useful branch of learning or orna-
mental  handicraft, by reading or conversation, by joining them in their
walks,  rides or work, by suggesting or assisting them  in the different
means  of amusement and occupation, and by various other  modes that
will readily  suggest themselves to an individual of the proper qualifica-
tions.
  These individuals are intended to be companions to the patients, es-
pecially those  who are convalescing;  and they have been called Teach-
ers not only because it is a convenient term, and that they devote a por-
tion of their time to school instruction, but because it is hoped they will
also teach the  afflicted with whom they associate,—at least, to some ex-
tent,—the time character of the institution in which they are living, the
value of theh accommodations, the motives of those who have placed
them there, and of those who surround them, and as far as they can,
the road to health and happiness.
  The proper  performance of the regular duties of all the officers, and
of every attendant, occupy so much time, that it is not possible in most
hospitals as now organized, for any one of them to devote any consider- 
48
able period of the day to a single patient, however desirable it may be to
do so.  An individual of the proper qualifications, who can at the right
moment spend an hour or two with a timid patient, just arrived from
home, to whom all are strangers,  and who is  distressed by the novelty
of a new situation, may prevent days of sorrow, and perhaps thus aid
most essentially, in the first steps towards a recovery.  Judicious con-
versation at the right moment, a  brisk walk in the  open air, or simply
directing a patient's attention to a new object, may tend most effectu-
ally to prevent a paroxysm of grief, or an outbreak of violence.  The
appearance of a new face, in whom all feel confidence, when the atten-
dants in a ward are almost worn out by the long continued excitement
of the patients, will often prove as great a relief to them, as to those of
whom they have charge, and it is just at these periods that the presence
of the Teachers will often be found most valuable.
  One teacher of each sex has been mentioned as  desirable  in  every
hospital, but in those in which a large number of cases are under treat-
ment, especially where many patients of cultivated minds are received,
a larger number could be advantageously employed.
  Attendants.—There should always be two attendants in each ward
without regard to size, unless, as sometimes  happens, two contiguous
wards are so small and so arranged, that three persons can perform the
duties of both.  It should also be an unvarying rule, that, unless by spe-
cial instructions from the Physician, one attendant should always  be in
the presence of the patients in eveiy ward of a hospital for the insane.
Where there is but a single attendant to a ward, the patients must have
an insufficient amount of out-door exercise and employment, or those
left in the house  must often be alone, and the  supervision must be alto-
gether much less strict than is desirable.  A  certain amount  of labor,
out-door exercise and recreation, is as desirable for the attendants as for
the patients.  Work in the open  air, with the male patients at least,
should be a part of the duty of each  attendant.  Without it, those ac-
customed  to active pursuits,  are liable from  the gi'eat change in  their
habits, to have their  health impaired, their tempers rendered irritable,
and ultimately  incapacitated  for  the efficient performance  of their
duties.
  The proper selection of attendants is one of the many important duties
to be performed by the Physician, and it should be the earnest desire
of every governing Board, to sanction all regulations that tend to secure
to an institution a class of persons whose services are particularly desir-
able, and who seem from their natural character and their education, to
be specially qualified for such a post.  With all the supervision that can 
49
be given, the comfort of the patients in every Hospital for the Insane,
is essentially dependent on their attendants.
  The duties of attendants, when faithfully performed, are often haras-
sing, and in many of the wards, among excited  patients, are peculiarly
so.   On  this account  pains should always be  taken to  give them a
reasonable  amount of relaxation,  and theh position should,  in  every
respect, be made as comfortable as possible.
  The number of attendants proposed above, is deemed essential to keep
up the proper supervision, and to carry out thoroughly the best system
of treatment.  The  average is about one attendant to every eight pa-
tients, while the minimum that is regarded by the Association of Medi-
cal Superintendents, as  at all admissible,  is one to eveiy ten patients.
In some institutions,  the proportion of attendants may  advantageously
be higher.  Many hospitals  commence with a  less proportion of atten-
dants than has been suggested, from a belief on the part of the Physician,
that a larger number would  be objected  to by the  Board of Trustees.
I am disposed, however, to believe that this is  commonly an error, and
that if the matter were properly explained to any intelligent body of men,
and its importance to the happiness and recovery of the patients, and
the character of the institution, fairly insisted  on, no intelligent Board
would  refuse their assent to the wishes of their chief medical officer.
 Under any circumstances, there can be no doubt as to the course proper
to be pursued by this officer. He should  ask  for, and  earnestly urge
 upon the Board of Trustees, whatever he deems right,  and leave the
 responsibility and loss of having any thing less, with those to whose au-
 thority he is bound to yield, however much he may differ from them
 in opinion.
   Night  Watch.—An efficient  night watch  should always be main-
 tained, wherever many insane patients are collected, and should consist,
 if possible,  of a  man and  wife,  to whom  should be confided  the
 charge of the male and female wards respectively.   It is not simply to
 prevent accidents from fire,  that a night watch is considered indispens-
 able, although this alone is a sufficient reason for such a provision.
 When we recollect that the patients are in their rooms at least one third
 of the whole twenty-four hours, it seems surprising that while so much
 care is very properly shown in having them under constant supervision
 during one portion of the day, it should ever be thought justifiable to
 leave the  same individuals,  so totally unprotected and  unguarded as it
 were, during so long a continuous period as eight hours.   It is to be re-
 membered, too, that during this period, the patients are commonly lock-
 ed in their rooms, that they have no means of  assisting  themselves, no
                         7 
50
mode of securing prompt aid in case of unexpected sickness, except by
noise, which  disturbs others and does not always attract the  proper at-
tention, and that many of them are particularly subject  to sudden  and
alarming attacks, for which assistance should be summoned at the ear-
liest possible moment.  The regular night watch, too, may  render im-
portant services in guarding against suicidal attempts, in administering
remedies that are ordered for patients who do  not  require a special
nurse, in supplying drink or food, which will often  effectually quiet a
restless patient, for hours;  in soothing by a kind word those who have
become suddenly alarmed,  or by simply making up his bed or allowing
a patient to wash his face, to give sleep to one, who without these little
attentions, might have been restless, and disturbing all around him dur-
ing an entire  night.
  The night watch should also be employed to secure to the attendants,
as far as  can  be, sound and undisturbed rest at night.  Under any cir-
cumstances, the sleep of attendants will occasionally be disturbed by
night services ; but if they perform theh duty faithfully during the day,
the character of their occupation is such that without good rest gener-
ally at night,  their tempers are apt to become irritable,  and they  loso
that kind of interest in their business, without which they are of little
value in the care of the insane.   Besides all this, the  night watch is of-
ten a valuable assistant in the police of the establishment, and is able to
discover and  report various irregularities among the  sane part of the
residents, which without such officers might never become  known to
the Superintendent.
  It seems quite probable that great advantage would  often result from
having more than one individual of each sex on  duty at night—night
attendants, as well as those for day service.  So  large a proportion of
the  insane sleep indifferently,  there are so many who would receive
consolation from a kind word, or the occasional presence of a cheerful,
sympathizing face during their  long,  dreary, wakeful hours, so many
that ought really to have attention every  night for their safety as well
as comfort, that we may well inquire whether,  with our best arrange-
ments for the care of the insane, we have  not often been somewhat neg-
lectful of them by night.
  The objection to a night  watch,  sometimes made,  that they disturb
the quiet of the wards by their noise,  simply shows that incompetent
persons have  undertaken to perform the duty.  Those who are passing
about after all else have retired, should  accustom themselves to open
doors, and to  do whatever else maybe required, in the most quiet man-
ner, always to converse in a low tone of voice, to discriminate between 
51
those whom conversation will quiet and  those whom it will excite, and
they  should  always  wear woolen shoes when passing through the
wards.
  In addition to the individuals named, who are brought directly in con-
tact with the patients, there will be required one seamstress for each
sex, one farmer with two assistants, one gardener and an assistant, one
carriage driver, one jobber, one carpenter, one engineer with two fire-
men, and a baker, besides the females employed in the domestic depart-
ments of the house.
  A State Hospital will almost always have in its household many pa-
tients who can, advantageously to themselves, assist in the performance
of much of the work in the wards and about the premises, and thus aid
to a very limited extent in lessening the expenses of the institution.
  Remarks on the Number Employed and their Compensation.
—The circumstances of different institutions and the classes of patients
received, will, to some extent, influence the number of persons required
in their different departments.   So in regard to compensation, the sala-
ries and rates of wages must be regulated, in a gi'eat measure, by the
cost of living, the demand for the particular kind of labor required, the
rates that are paid for other kinds of service in the vicinity, and of course
must vary in different localities.
  It is believed that  all the persons who will be found named in the fol-
lowing list are required in  the organization of a State  Hospital for the
Insane, with 250 patients, and that none of them can be dispensed with,
without, to a greater or less extent, affecting the welfare and comfort of
the inmates, and the best interests of the institution.
  The salaries named are to be regarded as the lowest that ought in any
part of this country,  with which I am acquainted, to be offered for the
kind of service that is required, rather than what should be given to the
most competent  individuals.  More ought frequently  to be given, and
will often be required, to secure the proper kind of officers and assis-
tants, especially  attendants, and to induce them to remain for any con-
siderable period in the service of the  institution. In many large  insti-
tutions, the compensation of the Chief Medical Officer should be at
least from 30 to 50 per cent higher than what has has been named.
  Many of the  positions about a Hospital for the Insane, from the high-
est almost to the lowest, require persons of peculiar qualifications, and
when such are found, it will  be to the interest  of  their employers to
secure their services, even if a considerable increase of compensation is
necessary to effect the object.   A thoroughly good  and efficient officer
or assistant  of any kind may be more desirable to  an  institution,  at a 
52
large salary, than a bad or negative kind of one, working gratuitously.
While good officers and  assistants are desirable in eveiy department,
not only on  account of the direct performance of theh duties, but also
because their  example never fails to exercise a favorable influence on
others of  a less decided character, so an idle, vicious, or faithless one
may be worse  than none, simply from all  their  associations producing
unfavorable results.
  It may be regarded as a well established fact,  that although in a few
institutions  a liberal compensation is given, in many, the salaries are
quite too low, and entirely inadequate to be depended on,  to secure and
retain the best kind of talent for the  different  positions.  The services
required about the insane, when faithfully performed, are peculiarly
trying to the mental and physical powers of any individual, and ought
to be liberally paid for.  With the great demand for talent and labor that
constantly exists in this  country, it  is not surprising  that considerable
difficulty is often experienced  in finding the proper kind of persons to
take charge  of the insane, when less arduous and responsible duties are
frequently so much better compensated.
  When proper persons are engaged to act as the regular attendants
of the  patients, it will often be found desirable to secure their contin-
uance for  a certain period, by a yearly increase in  their compensation;
although it must also be acknowledged, that not unfrequently, even the
best of this important class, after a long residence  in a hospital,  seem
to lose  theh interest in their duties and to do  better to engage  for a
year or two in other pursuits.
  The services of certain of the officers, after a considerable residence
in an institution, often become  much enhanced  in  value, and  it is to
them a source of great encouragement to know that strict fidelity and
industiy are likely  to be recognized by an occasional increase in their
income.   No Superintendent would hesitate to say that the services of
his  assistants after two or three years' experience,  are often worth al-
most double what they were during the first months of their residence
in the institution.
  Schedule of a  Complete  Organization with  Rate  of Com-
pensation.—The following list, as before remarked, is believed to in-
clude only those that are necessary  about  a State Hospital for the In-
sane, when containing 250 patients, and that is to be managed efficiently,
viz:—

A Board of Trustees,.........................Expenses to be paid.
A Treasurer, non-resident,.................Salary,  $250 per annum. 
53
One Physician-in-Chief,.......................$1,500 per annum,
with furnished apartments and board of family.
If living detached and finding his family,........$1,000 additional.
One First Assistant Physician,...........Board and $500 per annum.
One Second Assistant Physician,.........     "    $300     "
One Steward,.........................    "    $500
One Matron,..........................    "    $300
One Male Supervisor,..................    "    $250
One Female Supervisor,................    "    $175
One Male Teacher,....................    "
One Female Teacher,..................    "
Sixteen Male Attendants,...............    "    $168     "
Sixteen Female Attendants,.............    "    $108
One Night Watchman,.................    "    $168
One Night Watchwoman,...............    "    $108
Two Seamstresses,.....................    "      $96
One Farmer,..........................    "    $200
Two Farm hands,......................    "    $144
One Gardener,........................    "    $200
One Assistant Gardener,................    "    $144
One Engineer,.........................    "   $240
 Two Firemen,........................    "    $144
One Baker,...........................    "   $150
One Carpenter,........................    "   $240
 One Carriage Driver,...................    "   $168
 OneJobber,...........................    "   $144
 One Cook,............................     "   $150
Two Assistant Cooks,...................     "   $]0°
 Four Female Domestics,................     "     $80
 OneDairyMaid,.......................     "   $1°°
 Three Washerwomen,.................     "    $1°°
 Three Ironers,........................     "    $1°°

   Exclusive of the Board of Trustees and Treasurer, who are non-resi-
 dents, this  list will be found to embrace 35 males and  36 females,  or a
 total of 71 persons, all of whom reside within, or in the immediate vi-
 cinity of the institution,  devote theh whole time to its service, and are
 engaged in the immediate care of the patients, in the domestic or me-
 chanical departments, in the cultivation of the farm and garden, in the
 care  of the grounds or in keeping the various buildings and fixtures in
 good order. The  whole of this force can be fully and profitably em- 
54
ployed, and if composed of the right kind of persons, under good disci-
pline, and with a well arranged hospital ought to be able to give the pa-
tients a high degree of comfort and all  the advantages to be expected
from a liberal course of treatment.  It is not to be denied that 250 pa-
tients, with a farm and large garden can  be  taken care of, with a less
number of persons than has been recommended,—for unfortunately it is
done every day,—but the more extended my own experience,  and the
fuller my reflections on the subject, the more thoroughly am I satisfied,
that there is a loss to the afflicted and the whole community, by every
such attempt to manage an institution with an  inadequate  force, much
too great to be compensated by the paltry annual saving of a few hun-
dred dollars, which may be effected by such  an arrangement.
  A very moderate degree of attention to this subject  ought to satisfy
any political  economist or legislator, that if a cost of  $3 per week is
necessaiy to give every patient in a State  Hospital for the Insane that
kind of treatment which is most likely to secure his prompt recovery,
a scheme of management which limits all his expenses to $2 per week
must deprive him of many important advantages, and in its ultimate re-
sults must prove much more costly to a State, than what would have
been  effected by more  liberal arrangements.   It is well  for all to re-
member that a low rate of weekly expense per patient is not necessarily
in itself any proof of a wise and judicious economy, although it may
occasionally be an attendant upon it.  If the rate is so low, as to prevent
the patients realizing the full benefits that are reasonably to be expected
from such institutions,  although it may be by some regarded as econo-
my, it is unquestionably of a kind against which every true friend of
this unfortunate class should enter a firm and earnest protest.
  Residence of  the  Physician.—The direct superintendence  of
every department of a Hospital for the Insane,  being vested in the Phy-
sician, it becomes necessaiy  that he should be exempt from ordinary
private practice and should reside on the premises, either in the hospi-
tal, or in a detached  building  contiguous to it.  His whole time being
devoted to the institution, great additional labor must be imposed on him,
if his residence is more than two or three hundred yards distant, and what
is of still greater importance, he will not be able,  without great incon-
venience, to perform his duties efficiently or  satisfactorily.
  If the Physician's family reside in the Hospital buildings, their apart-
ments should be made every way  comfortable,  they should be  entirely
private, and not exposed to visitors or those employed about the house,
while a distinct kitchen should be provided for their use.
  For various reasons, which I deem quite sound,  but which  it is liot 
55
necessary to discuss in detail, in the present essay, it is veiy questiona-
ble whether it is always desirable that the  Physician's family should
be accommodated in the Hospital building, although it is indispensable
that they should be in its immediate vicinity.  This is a question often
to be settled by the particular circumstances of an institution, and of the
person who is to  have charge of it.  Where  this officer has a  family of
children, it is clearly best,  in my estimation, that the Physician should
not reside in the  institution.  Fond as patients generally are of children,
and safe as they commonly are in the wards, still it is not desirable that
they should be permanent residents of a hospital, either for their own
sakes or for the comfort, quiet and discipline  of the institution.
   It is not difficult to have a house specially provided for the Physician's
family, not more than three hundred yards from the hospital, where they
can be entirely private,  see  their own friends,  and provide their own
table, without interfering in any way with the institution, or causing any
difficulty in the thorough performance  of that officer's duties.   With
an efficient and trustworthy Assistant, Steward, Matron, Supervisors
and  Teachers, it has been my experience that no disadvantage results
from this arrangement.  The time of the Physician will,  of course, be
mostly spent in or about the hospital, and his own residence is so near
that his presence can, at any time, be secured almost as quickly as if in
a distant section of the institution.   The Pennsylvania Hospital for the
Insane,  at Philadelphia, the Bloomingdale Asylum at New-York, the
Retreat at Hartford,  Conn., the Maryland Hospital at Baltimore, and
the S. Carolina Asylum at  Columbia, have this arrangement, and, so far
as I know, it has thus far worked satisfactorily to all concerned.
   It must be obvious, that the families of physicians may often be so cir-
cumstanced, that the most competent men might feel compelled, from
private reasons, to resign their posts, at the  very time when their ser-
vices were most  desirable, if they were forced  to live in the hospital
buildings, and this arrangement might also frequently prevent admirably
qualified persons from engaging in this branch of the profession.
   As already remarked, the greater part of the Physician's time will be,
as it ought to be, spent in or about the  hospital, but it is still important
that he should have a spot out of it, to which he can occasionally retire—
rare as the opportunity may be—for rest and  quiet.   An institution will
profit nothing by having its chief officer so situated that he can have no
moments of leisure, none  for study and reflection, no hour in which he
can occasionally get out of the sight of  his charge, or no time  to devote
to his own family, whose natural claims on him ought not to be enthely
absolved by any public duties.  The character of his pursuits, if zeal- 
56
ously and faithfully performed,  makes  some kind  of change of scene
and occupation more necessary than  in  almost any  other vocation.
Variety of thought and labor are rest to him, refreshing his mind, and
enabling him to return to his post,  with  fresh  energy  and renewed
strength.   Trustees sometimes make the lamentable error of supposing
that the more closely their Superintendent is confined to his post,—the
more arduous his duties, and the less assistance he receives from others,
the more benefit the institution obtains for what it pays him.  Hospital
Physicians are no more able to resist natural  laws than other men;
when long over-worked, theh ability becomes lessened, and when com-
pelled to spend their time in attending to unimportant details that could
as readily be done by others, matters of vital interest to the sick and the
institution must often be neglected, or be only superficially attended to.
It will be found,  I believe, that every well qualified Superintendent of a
Hospital for the  Insane is sufficiently disposed to devote his whole en-
ergies to the performance  of his duties, and to give the institution the
full benefit of all  that  he can  in  any way perform, with quite little
enough reference to himself or those immediately dependent on him.
  One very important effect that has resulted from the establishment of
"The Association of Medical Superintendents of American Institutions
for the Insane," and which has  not been sufficiently referred to, is that
these officers are  thus  compelled at least once a year to leave, if only
for a single week, their regular routine of duty to visit new scenes, and
meet new associates.   No one, I presume, who has ever attended these
meetings will hesitate to acknowledge that he has derived great benefit
from  this  short relaxation, and that he has returned to his post with
renovated powers and renewed zeal in the cause,  to which his life is
devoted.   Without  any special reference  to the  obvious good effects
which must result from a frequent  mingling of gentlemen engaged in
the same pursuits, and the abundant opportunities thus afforded for profit-
ing by the experience of the whole country,  it may not be amiss to ex-
press the belief that is now becoming universal, that no Board of Trus-
tees or Managers should ever  allow their  institution to be without a
representative at these annual assemblages, except for reasons of the
most urgent character.  Much as their Superintendent may be person-
ally benefitted, by being present, the institution over which he presides
cannot fail to be doubly so,  and no expenditure made  by a hospital  is
more certain to be returned to it, in its increased facilities for the best
treatment and comfort of its patients,  than what is incurred for this
object.
  Furniture.—The furniture in the wards of a  Hospital for the In- 
sane, should be varied according to the class of patients,  by whom it is
to be used.  Its general.character, however, should be made to corres-
pond as near as possible to what is used in private dwellings.   Neatness,
plainness and strength should be its prominent features; and for a con-
siderable part of the buildings, what would be used in a plain boarding-
house, would not be inappropriate.  It  would  be well, however,  in
making a selection, to avoid projections and sharp corners as much as
possible, and any arrangement that would offer facilities for self-injury
should be omitted.  Where patients are much excited, there should be
little movable furniture, either in the rooms or in the halls, especially
of a kind that could be used as weapons.  A  portion of the bedsteads
should be prepared for being permanently secured so as to prevent their
being moved, by which means many patients can use them who would
otherwise be compelled to have their beds on the  floor.  It will also be
desirable to have a few very low bedsteads for  those who are  liable to
fall out of bed, and who can be protected by having a good soft  mattress
on the floor by the bedside.   For very violent patients  it is often the
best arrangement to have the mattress and bedding on the floor, and to
remove all other furniture from the room.
   The parlors should  be comfortably furnished,  and the  room of
every well-conducted patient should  have in it, at least,  a neat bed-
stead, table and chair, and to these a strip of carpet  and a small mirror
may be appropriately added.  Every patient who is not filthy or des-
tructive in his habits should have a good bed,  either a hair or husk
mattress on a palliasse, as one of the means of inducing sleep.
   Iron bedsteads,  when made in the most approved  manner, are in
many cases preferable to those that are made of wood.   If made of cast
iron, they  should  be heavier than are  commonly used,  on account
of  the facility with which they may be broken.  For violent patients
wrought iron is much more desirable.   It is a  mistake to suppose that
iron bedsteads are  in themselves a security  against vermin. Unless
eveiy hole and crevice is filled with white lead and putty, or something
answering the same  purpose, before they are used, they may become
quite as troublesome as those that are made of wood.
   Provision should be made in every ward for vessels to  contain cool
drinking  water,  easily accessible  to the patients, so that no  one shall
suffer from thirst in warm weather.
   The table furniture of the dining-rooms should be neat and strong,
and white ware will commonly be found most desirable,  which, with
the ordinaiy round-ended case knife and fork, can  be used by nearly
 all the patients.  For a few, who habitually break whatever  is sent to 
58
them, tin vessels may be substituted, and there is occasionally an indi-
vidual to whom it will be safest  to give a spoon instead of a knife and
fork ; but where there is a proper classification, where pains are taken
to bring patients to the general table, and  where there is plenty of good
food and an efficient supervision,  the number of this class will generally
be very small.
  Classification.—Although, in the description of the plan  of build-
ing proposed for a State Hospital for the Insane, the  different  wards
were numbered, still little has been  said of the various  classes intended
to occupy them.  The only point insisted on was, that  there should be
eight distinct classes for each sex.   It will be found desirable, in prac-
tice, that the  least excited—what  is commonly called the best class of
patients—should  occupy the upper stories and be  nearest the centre
building, while the noisy should be at a distance,  and the feeble  in the
lower story; but  it is impossible to  give  any general rule that will be
satisfactory in all respects to a novice in the management of the insane.
The best arrangement, after all, will be  to associate in the same ward
those who are least likely to injure and most likely to ben'efit each other,
no  matter what  may be the  character  or form of their  disease, or
whether supposed to be curable or incurable.  No one,  of course, would
think of placing the violent  and the calm,  the  noisy and the quiet,
nor the neat  and the filthy, together;  but there are many grades
between most of these, and individuals of  extremely  different character,
who, nevertheless, do well together.  Variety is as pleasant to  a hos-
pital patient as to any one else, and even if it were  practicable, it is
not probable that it would be found satisfactoiy to have all our associates
exactly like  ourselves.   Patients are  often much interested in the de-
lusions  of their neighbors, and by their efforts to  relieve the afflictions
of others, frequently do much towards getting rid of theh own.
   Eveiy one  who has been long  with  the  insane knows that some
whose  cases are chronic and considered  incurable are  among the most
pleasant and agreeable patients to be  found in an institution;  they are
most beloved by all about them, are  noted for theh refined courtesy and
attention to strangers, and  for their devotion to the  afflicted,  which
make them regarded as treasures in the wards to  which  they belong.
At the  same time, of all in the house, many recent and supposed cur-
able cases, are often for long periods among the most violent, careless or
unpleasant patients, and in all respects the least desirable as associates.
   Should  Curables  and  Incurables  be Separated ?—The  re-
marks just made, as well as those in a previous part of this essay, might
perhaps be  deemed sufficient to indicate my views in reference to the 
59
propriety or expediency of providing separate institutions for those who
are supposed  to be curable, and those who are regarded as not likely
to be  benefitted  by treatment.   As propositions of this kind, however,
are frequently made,  I desire to enter my special and earnest protest
against any such arrangement.  The first grand objection to such a
separation is, that no one can say with entire certainty  who is incur-
able ; and to condemn any one to an institution for this particular  class
is like dooming  him to utter hopelessness.  In any other disease than
insanity,  it would hardly be  contended that its incurability was any
reason for a neglect of treatment, where there was the slightest reason
to expect even temporary benefit from its employment.   While chro-
nic cases are  so often agreeable ones and recent cases so frequently
not a little repulsive, it can hardly  be said with propriety that the in-
fluence  of the  former on  the  latter is  so  generally  injurious  as to
require  their being placed in  a separate building; to do so would
often be cruelty  of  the  rankest kind.   A  proper  classification  will
remove  every difficulty in providing for  these classes in the same
hospital.  It is somewhat presumptuous for us to say that a recovery is
impossible in any case.  When  patients cannot be cured, they should
still be considered under treatment,  as long as life lasts ;  if not with the
hope of restoring them to health, to do what is next in importance, to
promote  their comfort and happiness, and to keep  them from sinking
still lower in the scale of humanity.   Fortunately, almost precisely the
same class of  means are generally required for the  best management
and treatment of the curable and incurable,  and almost as much  skill
may be shown in caring judiciously for  the  latter as for the former.
When the incurable are in the same institution as the curable, there is
little danger of their being neglected ; but when once consigned to re-
ceptacles specially provided for them, all experience leads us to be-
lieve that but little  time will elapse before  they will be found gradu-
ally sinking, mentally and physically, their care entrusted  to persons
actuated only by selfish motives—the grand object being to ascertain at
how little cost per week soul and body can be kept together—and, sooner
or later, cruelty, neglect and suffering are pretty sure to be the results
of every such experiment.  When speaking of County Hospitals, I have
already expressed  my belief that the chronic insane can nowhere be
properly  taken care  of at  a less cost than in State  Hospitals, which
should be sufficiently  numerous to accommodate all classes of persons
laboring under this form of disease.
  Separation of the Sexes.—In every hospital the  arrangements
should be such that there should be little intercourse between the mala 
                                60

and female patients, or the male and female attendants employed in their
care.   There will no particular disadvantage result from their attending
religious services or lectures in the same room, but on other occasions it
will be best that they should be kept entirely separate.  The advantages
of frequent social parties, in which the two sexes meet on familiar terms,
are very problematical, and balls  and dancing parties for the males and
females together have appeared to  me to be decidedly objectionable.—
Most of our hospitals receive patients from all classes of society, and
where there is this indiscriminate mingling of both sexes and all con-
ditions in life, undesirable intimacies and acquaintances, in certain men-
tal conditions, will often be formed  that may at  least  prove somewhat,
mortifying to a sensitive mind  after a complete recovery.  Patients, es-
pecially females, should always be  protected from everything  of this
kind during their residence in  a hospital.  For these and other reasons,
lectures and entertainments of various kinds in the lecture room, where
there is no communication between the sexes, or parties for one sex
alone, will be found much more desirable than the assemblages previously
referred to.  If all the patients in a hospital occupy about the  same social
position, the frequent meeting of the two sexes might be less objection-
able, but even then I should not consider it very desirable.
  Where only one  hospital is  built in a State, it will, of course, be pre-
pared, as shown in  the plan, for patients of both sexes;  and even where
there are two hospitals, in entirely different sections of a State, it will
still be deshable that both males and females should be accommodated in
the same building,  because the conveyance  of patients from great dis-
tances to an institution involves much labor and expense, is often injuri-
ous to the sick, and is really in itself  an evil of much magnitude which
ought not to be unnecessarily increased.  Where a community, however,
is sufficiently populous  to require two hospitals of the same general
character in one vicinity, it appears to me there can be little question but
that many decided advantages,  and no disadvantages, will result from hav-
ing one of the institutions appropriated to males and the other to females
exclusively.  Such an arrangement will secure to  both  sexes a more ex-
tended classification and much greater freedom,  besides facilitating in
many respects the general management of the institution.   I have  yet
to learn of a single advantage that insane patients receive from having
the two sexes in the same building, but I do know of many inconveniences
and disadvantages which result from this arrangement.
  Restraint and Seclusion.—The use  of mechanical means of re-
straint, and the protracted seclusion of patients in  their rooms—although
t he firmer of them my be, and, as I believe, is occasionally desirable, but 
61
 not absolutely necessary, in the management of our Hospitals for the In-
 sane—ought both always to be regarded as evils of no trifling magnitude,
 and to abate which, as far as possible, no effort should be left untried.
 They both tend to produce a relaxation of vigilance, and it cannot be too
 often repeated, that whatever tends to make vigilance unnecessary is un-
 desirable about a Hospital for the Insane.  Besides leading patients into
 bad habits, the frequent use of the means referred to, in a ward, induces
 attendants and others to look upon them as a common resource in cases
 of difficulty or danger, to regard them as their grand reliance in every
 emergency, and to forget the great power of other measures that are
 entirely unobjectionable—the value of tact and kindness and sympathy
 in controlling the violence and  dangerous propensities of the insane.
 And yet,  without a proper force of attendants and an efficient classifi-
 cation, the use of mechanical means of restraint and the protracted se-
 clusion of certain classes of patients is almost unavoidable.
    Objectionable as I deem the use of restraining apparatus in a Hospital
 for the Insane, it can  not be too earnestly insisted on, that it is no advance
 to give up  mechanical means of restraint  and to substitute the frequent
 and long-continued seclusion of the patients.  Occasionally an individual
 may really be more comfortable and much better off in the open air, with
 some mild  kind  of restraining  apparatus on his person, than he would
 be  confined  to his room without it;  for this kind  of long-continued
 seclusion is pretty sure,  sooner or later, to lead  to habits revolting in
 themselves and  most unfortunate  for  the future  prospects of the
 patient.
    The  subject is introduced here  as a reason why no false notions of
 economy should be permitted to influence any Board of Trustees to ask
 the Superintendent of an institution  to attempt  its management with
 a force so inadequate as to compel him, against his better judgment, to
 resort to means so objectionable, and  which are  so  destructive to the
 comfort and proper treatment of his patients.
   Labor,  Out-Door Exercise  and  Amusements.—Having refer-
 red to the unfavorable results of an habitual use of restraint and seclu-
 tion in a Hospital for the Insane, it  is proper to indicate in more de-
 tail some of the  means  by which these unfortunate effects  may be
 obviated.
   A properly constructed building, admitting of a liberal classification
 of the patients, and the employment of an adequate number of intelli-
' gent and kind assistants,  has already been referred  to as being  indis-
 pensable for such an object.  The design, in establishing every such ins-
 titution, being the restoration and comfort of the afflicted, the  relief of 
62
their families, and the protection of the community,  there can  be no
question but that it is sound economy  to provide everything that will
effect these  objects promptly and in the most thorough manner.
  Without  adequate provision for out-door exercise and occupation for
the patients, and a  liberal supply of means of amusement, the excite-
ment of the  wards, and the violent and mischievous propensities of their
inmates, will be apt to be such as to require modes of management that
might  otherwise  be easily dispensed with.   The first cost of some of
these arrangements  will necessarily be considerable, but the ultimate
results can hardly fail to be  so gratifying as to satisfy the most rigid
stickler for economy, that the only wise course is to provide liberally of
everything likely to be beneficial to the patients.
  The farm and garden offer admirable  means of useful  occupation to
the insane at certain periods of the disease, for, useful as they are to a
large number, no greater  indiscretion  could be committed than  at-
tempting  to set all insane men at  work in every stage of theh malady.
To those accustomed to such pursuits, as well as to many who have been
differently occupied, regular moderate labor in the open fields or in the
garden contributes most essentially to their comfort, and tends to promote
theh recovery.  Labor, then, is one of our best remedies; it is as use-
ful in improving the health  of the  insane, as in maintaining that of the
sane.  It is  one of the best  anodynes for the nervous, it composes the
restless and  excited, promotes a good appetite and a comfortable diges-
tion, and gives sound and refreshing sleep to many who would without
it pass wakeful nights.
  The provision of adequate and comfortable workshops, in a convenient
position, and under the care of competent superintendents, may be made
a source of profit  to an institution,  and furnish another means of labor
of an interesting kind to a large number of the insane.
  The usual means of amusement, which demand active muscular ex-
ercise,  should not be neglected.   A Gymnasium, suitable in its fitting
up, for insane men, and a Calisthenum for insane women, will be found
useful.  The various games of ball, the exercise of using a car on a cir-
cular railroad, the care of domestic animals, as well as  regular walks on
the grounds  or in the neighborhood, are also among the kinds of exer-
cise that will be enjoyed by many patients; while means of carriage
riding seem  almost indispensable for many, who from physical and other
causes cannot resort to the  more active forms which have already been
referred to.
  Within doors,  the means of keeping a comfortable house are, in ad-
dition to the medical treatment, the constant presence among the pa- 
63
tients of intelligent attendants, active supervisors and judicious teachers
or companions, always ready to check  the commencement of excite-
ment,  to  separate quarrelsome individuals, and to change the train of
thought of those who seem disposed to be troublesome.  The means to
effect the objects in view are very numerous, and the tact of an indivi-
dual is shown in selecting those that are most applicable to a case.
   The introduction of regular courses of lectures, interesting exhibitions
of various kinds, and musical entertainments in the lecture-rooms of
our Hospitals for the Insane, has  done  much to break up  the mono-
tony of hospital life, which is so  common a source of complaint among
the insane.
   Regular courses of instruction  in well furnished school-rooms, read-
ing aloud by the teachers to the patients of the more excited wards,  the
use of well selected libraries, the  inspection of collections of curiosities,
the use of musical instruments,  and various games, are all among  the
many  means which an ingenious Superintendent  will suggest for  the
benefit and amusement of his patients, and which ought to be provided
for in every institution for the insane.
   Means of Extinguishing  Fire.—In a previous part of this essay,
much  stress has  been laid upon  the importance, when putting up  the
building,  of  attending to eveiy means  likely to prevent the occurrence
of a fire, or of its spreading; in case it should occur in any part of a Hos-
pital for the Insane.   These objects  are to be effected by making  the
structure, in  exposed parts, as nearly fireproof as circumstances will
permit, and by having the building heated by steam, and all large fires
kept at a distance from it.   In spite, however, of all these precautions,
a fire may occur from causes that could  not be  foreseen, and on that
account, it becomes a grave duty  for every body of men entrusted with
the erection or management of such an institution, to see that adequate
provision is  made for all desirable means to promptly extinguish  any
fire  that  may be discovered on  the premises; for no accident can be
more terrible to contemplate than a fire raging at night in a building
containing more than 200 insane  patients, confined in their rooms,  and
utterly unable to escape without aid from others.   Nearly all these ac-
cidents occur from  the intense heat of large hot air furnaces, or from
defective flues,  or from  wood being brought too near them ; so that if,
as proposed, steam is used for heating,  and an  effective  night watch
kept up, it would seem that every fire  should be promptly detected,  and
that means could be readily provided by which it could be easily extin-
guished, almost without injury to any  one.  To do this, the large iron
tanks placed in the attic of  the building should always be filled towards 
64
 night;  two large rain water cisterns should be provided near the build-
 ing, and kept full of water at all times; there should  be a fire engine
 and six hundred feet of hose belonging to the institution, and  the hose
 should  be so distributed that it could be attached to the  proper water
 pipes at the shortest notice on the occurrence of an alarm, and a  large
 stream  of water be immediately directed on any point either on the in-
 side or  outside  of the building.   In addition, an iron pipe three inches
 in diameter, should be laid at a proper depth around the whole  building,
 or at least on one side of it, and at a moderate distance from it; and, at
 proper intervals along this line, fire plugs should be placed, to which the
 hose can be attached whenever required.  This outside water pipe be-
 ing  connected  with that through  which the water is  forced into the
 tanks in the dome of the  building, all the water in them can be drawn
 through the fire plugs and used, while the steam engine is being started,
 and which, by closing a stop cock, can then  be made to force the water
 directly through the hose, upon whatever point is on  fire.  By proper
 provision for a quick fire  being  kept  on hand,  the engine can always
 be ready for working in less than  thirty minutes  from  the time of an
 alarm being given.
  To secure prompt and efficient action in case  of the occurrence of an
 accident of this kind,  it is important that those about every such estab-
 lishment should be regularly drilled at stated periods to  the proper use
 of the different apparatus.  The  early discovery of a fire  and its prompt
 extinction is nowhere of more importance than in  a hospital for the in-
 sane, for its inmates are more likely to suffer from the  smoke than from
 the heat, and on this account it is desirable  that some provision should
 be made by which the smoke may  be  to some extent prevented from
 passing  through the flues from the lower to the  upper stories.
  The mode of making the passage ways between the different wings
 fireproof, from top to bottom, as proposed in another part of this paper,
 will  do  much to prevent a general conflagration, and secure the safety
 of at least a large proportion of all the inmates, under almost  any cir-
 cumstances.
  Supervision of Hospitals for the Insane.—The best kind of pub-
 lic supervision for a hospital for the insane—that which will tend most
 effectually to prevent abuses of any kind, to secure good management,
 an economical administration of its affairs, and the  humane and  enlight-
ened treatment of all its patients, will be found to  be the regular visita-
tions, at short intervals, of a committee from a well constituted Board
of Trustees or Managers.   Such individuals being  men of benevolence,
high  character and intelligence, serving without  compensation, and
having no motive in giving their time and attention to the work, but  a 
65
desire to  promote the  best interests of the afflicted,  forms the surest
guarantee to the public, that no just complaint will pass without inves-
tigation, and no actual wrong  go unredressed ; while the frequent ex-
amination of the expenditures  and the finances generally, will be the
most  effectual mode of securing a strictly wise  and liberal economy in
every department.
  A permanently constituted Board of Trustees, or one not changed in
a body, soon acquires a knowledge of the details of such  an establish-
ment, that cannot be possessed by a new set of men, and for this reason
the visits from an intelligent board are much more likely to be thorough
and useful than those made by persons who are  comparatively strangers.
  The only other kind of inspection of Hospitals for the Insane, that is
likely to be at all valuable, would  be that made by a commission com-
posed in part, at least, of men practically familiar with the whole subject,
and  whose members should have characters so well established as to
command the public confidence in their statements and recommenda-
tions.  Where many private institutions exist, such a commission would
seem to be especially desirable, and their visits could hardly prove unac-
ceptable anywhere, if matters are properly managed.
  The visits of large bodies, like grand juries, as commonly constituted,
without any practical or professional knowledge of the subject, although
it might gratify a certain kind of curiosity, could hardly be productive of
any good result, either to the public or an institution, for their inter-
ests are entirely identical.  The want of familiarity with the details of
such establishments, of the peculiarities of mental disease or the best
modes of treating it, would prevent such a body from making valuable
suggestions; while the presence of so large a number of strangers in the
wards at one time, might prove detrimental, and would certainly be ob-
jected to by many  patients.
  Provision for  Insane  Criminals.—Steadily increasing  as  this
class unquestionably is,  and important as every one must acknowledge
it to be, that such  provision as  humanity and justice require should be
made in every community, the  subject is well worthy the attention of
those about erecting State institutions for the insane, as well as of the
Government.
  Insane individuals are found in all our prisons, and, as might reasonably
be expected, in a much greater ratio than in the innocent portion of the
community.  The relative number in the different prisons will be found
really to vary much less than is generally supposed, except, from the cir-
cumstance that some States having no other provision for their danger-
ous insane,  are  in the habit of using their  prisons as a place of  safe
keeping for most of this class.   There is often an apparent difference in
                                9 
66
the proportion in different prisons where none really exists, owing to the
rigid scrutiny which is made in regard to the mental condition of every
convict, in some;  while, in others, if a man is quiet and able to work, no
trouble is taken in regard to his mental soundness.
  There is a certain class of old offenders and notorious prison-breakers,
as well as dangerous homicides, who, whether sane  or insane,  should
never be allowed  to have a greater degree of liberty than can be found
within the walls  of a  well constructed  prison.  Hard as this opinion
may seem to bear on a few individuals, who have already taken or at-
tempted to take life, or have deeply outraged the laws and the peace of
society, still it is as nothing in comparison to the cruelty and injustice
that would be  done to a whole community, who had never committed an
offence, by exposing them to the risks which must always attend the en-
largement of such dangerous men, even during a lucid interval.  There
are many of this  class who can never be safely at large, nor yet be kept
securely in any hospital properly arranged for the treatment  of the in-
sane, without  converting a part of it into a prison, or exposing the other
patients to risks which no plea of that kind of morbid benevolence, which
seems to regard with much greater sympathy the fate  of  a condemned
felon than the sufferings of his innocent victims and  their families, can
ever justify.  There  are other cases,  however, who occasionally get to
prison wrongfully, persons who are not especially dangerous in theh pro-
pensities, but who, while in  a state of irresponsibility, have committed
acts contrary to the laws, and who ought originally to have been sent to
a hospital for treatment, instead of to a prison for punishment.  Certain
cases of insanity, too, that originate in prison may safely be transferred
to a hospital for  treatment,  provided it is deemed expedient to remove
convicts at all who become insane after entering a prison,  and thus in a
 measure relieving them from the penalties of their sentence.  If many
 of this class are received into any ordinary hospital for the insane, it can
 hardly be questioned  but  that  the popular sentiment will be strongly
 aroused against the measure,  especially as escapes will be of such fre-
 quent occurrence as to keep  the neighborhood in a state of alarm, unless
 apartments entirely distinct  from  those  of the other patients and of a
 different character are provided.
   A writer of large experience in prisons and prison discipline has re-
 cently urged with great force, that it is veiy questionable whether, under
 any circumstances, an individual who  has been justly  sent to prison for
 the commission  of crime should  be  removed from it till the complete
 expiration of his sentence.  The  certainty of every punishment fairly
 decreed by a court, is unquestionably  one of the most important means
 of deterring bad men from the commission of crime.  The deliberate 
67
sentence of a judge fairly implies that  the  offender is to take as a part
of the penalty for his crimes,—with his deprivation of liberty and loss of
character,—all the risk of suffering from ill health that may arise while
he is in prison.  The community, of course, is bound to see that no avoid-
able cause  for the production of disease is allowed to exist in a prison,
as well as to provide every proper means for its treatment when it oc-
curs.   All  this can be  done within the prison walls, whether the dis-
ease be insanity, or fever, or any of the ordinary maladies found in such
institutions.   Although to do all this properly may require a small hos-
pital inside of the prison  walls,  still there is certainly no greater objec-
tion to that, than to converting a portion of a State hospital into a prison.
One of the  two  alternatives must be  adopted.  It is veiy certain that
many insane convicts may safely be allowed a greater degree of liberty
in a prison yard than in a hospital for the insane, and it seems quite pos-
sibleto fulfill every claim of justice and humanity by treating all insane
criminals within a prison hospital.  If it be deemed preferable, however,
to send them to a State hospital, there can be no question as to the ne-
cessity of  providing a distinct building  for their accommodation.   Even
here classification would be important,  but the individuals of this kind
from a single State would not be a large enough number to justify a dis-
tinct hospital, as has been provided for this  class in some parts of  Great
Britain.  The experience of our State  hospitals  generally is decidedly
averse to mingling insane convicts  with the other patients, and the es-
capes have been very numerous  in nearly every institution from which
I have received any information.
  Visitors.—To secure  the comfort of the patients and the good disci-
pline of a hospital for the insane, it  is highly important that judicious
regulations in regard  to visitors should be made and enforced.  The
propriety  of the  friends  of patients visiting them while under treat-
ment, will, of course, in a great measure, be left to the discretion of the
physician.    What is quite  proper at one period of a case may be totally
inadmissible at another.  While at one  time such interviews may be
productive  of much benefit, at others they may be decidedly injurious.
When  the first  experimental  visit has  shown unpleasant results, it is
hardly to be supposed that any real friends of a patient,  after having had
the matter properly explained, would wish again to incur the risk  of in-
juring those in whose welfare they, more than any other persons, ought
to be interested.   There are but few individuals who should be allowed,
even if willing, to  incur this  responsibility  against the advice of the
physician.   Under ordinary circumstances, a parent could hardly be re-
fused an interview with a child,  a  husband with a wife, a wife with a
husband, a child with a parent, or a legal guardian with a ward.   With 
68
those thus related, after the physician has performed his duty by a plain
statement of the case, the whole responsibility of any injury that may
be done to the patient should be made to rest.  But with all others, un-
less  very peculiarly  related, the  chief officer of an institution would
hardly be justified, if,  for their  mere gratification, he permitted visits
that he thought likely to prove detrimental.   The interviews with friends
should  not  be allowed in a ward, among the other patients,  except in
cases of severe illness.
  In reference to  the large  class of visitors who resort to hospitals for
the insane merely  from an idle curiosity, the rules for their regulation
should be made under the sanction of the Board of Trustees at the com-
mencement of the institution.
  In the vicinity of most public establishments of this nature, especially
those provided by the States, there will always be found a large number
of persons, who, with a kind of feeling of right, are anxious  to have an
opportunity of inspecting their arrangements.  Carried to a reasonable
extent, this kind of visiting is advantageous, as giving the community an
opportunity of being disabused of old prejudices,  and of knowing some-
thing of the science,  liberality and benevolence which are now sought
to be enlisted in the care of the insane.   All this may be done, however,
without keeping the wards in a constant state of excitement,  or materi-
ally incommoding the patients, by the presence of strangers.  Two or
three hours in an afternoon, for example, during which only these visits
might be allowed, would be sufficient for every purpose, and suitable at-
tendants could, at these periods,  be prepared promptly to  wait upon
company.
  Large parties should rarely enter a ward together, for at such times
there is seldom much satisfaction for visitors, and a crowd always tends
to excite certain classes of  patients.   No visits in the wards should be
protracted.
  There are certain wards into which ordinary visitors should never be
taken, because few of them would be able to appreciate the mental con-
dition of their occupants, and the probability  of serious injury to the
sick would be too great to justify  such an experiment for the mere grati-
fication of this kind of curiosity.
  No visitor should be allowed to enter a ward, or to  pass through the
private pleasure grounds of the patients, without the permission of the
physician, and then should always be accompanied by an officer, or some
suitable person selected for that duty.
  The exceptions  in  regard  to the  parts  of hospitals to be visited, as
stated in a previous paragi'aph, apply to the Trustees  or Managers,  to
official visitors of every kind, to  the  officers of similar institutions and 
69
persons specially interested in them, and the  members of the medical
profession.   The  first named have the right, and it is theh duty to ex-
amine thoroughly every part, and it ought to be a pleasure to the physi-
cian to exhibit to all who have been named  every part of his establish-
ment, and to freely communicate the character of its arrangements and
modes of treatment.
   Official visitors, when thus making a minute examination of the con-
dition of a hospital and of its inmates,  may with entire propriety have
a more free and unreserved intercourse with all the  patients than can
rightfully be accorded to any  ordinary visitor.  On this  account, this
kind of official visits should not be connected with those of other persons.
The former have  a right, although its exercise is not always expedient,
to see every  patient,  whether they are willing or not; but it is a right
that cannot be transferred to any other person.
   It is not uncommon for visitors to make special requests to see certain
patients, of whom they have heard, or with whom they may have had
some acquaintance, and to exhibit disappointment, if they fail to be grati-
fied.   It  is scarcely  necessary  to say, that no physician has the right,
even if he had the inclination, to make this kind of an exhibition of his
patients.   Patients, indeed, who do not wish to be seen, should always
have the opportunity offered them of retiring to their own rooms while
visitors are passing through the wards.  It  would be about as reasonable
for a stranger to call at a citizen's dwelling, and, from motives of curiosity,
ask to see a sick member of the family, especially if delirious, as for an
ordinaiy visitor to a hospital for the  insane, from similar motives, to de-
mand  a  sight  of  some individual, of whose name or history only he
may have had some knowledge.  Reasonable visitors, when told that the
patients are not exhibited, that it is presumed they would not wish mem-
bers of their  own families unnecessarily exposed to the scrutiny of stran-
gers, if  unfortunately thus situated, and that such a proceeding is per-
sonally offensive to many, would at once see the force of  the objection
and  courteously acquiesce in its correctness.
   It would be well generally to impress on visitors through the wards,
that those they see there are always to be treated as ladies or gentlemen
would wish to be in any other situation, and that levity and rudeness of
behavior is quite  as  objectionable, and childish and unfeeling remarks,
or impertinent curiosity, can be as acutely felt and  as accurately appre-
ciated there as in a private dwelling.
   The names and residences of patients should  not  be given  to that
class of inquisitive or  thoughtless visitors who, after their return home,
are apt to take especial pleasure in retailing the results of their  obser-
vations on particular individuals, at  places   and  in a manner, to render 
                                 70

them particularly painful and offensive to the friends of those who have
had the misfortune to come under their  critical notice.   When  such
curious inquiries are frequently and pertinaciously urged, it will be quite
allowable to have a hospital name  for each patient, for the special ac-
commodation of this class of visitors.  Such a course can hardly be ob-
jected to, when it is remembered, that even in well conducted penal in-
stitutions, no inmate's name is divulged to gratify an idle  curiosity, and
that a number is used in all ordinary reference to every individual.
  Admission  of Patients.—While  the  legislature of a State is en-
gaged in framing the laws under which the organization and government
of its hospital is to be established, it is exceedingly desirable that there
should be a specific,  but simple provision  made for the admission of
insane persons into such  institutions and  for their retention and dis-
charge.
  The  law should be so clear as not to admit of misconstruction, and
should aim to have such provisions as will effectually secure to every in-
dividual his personal rights, and  yet enable him freely and easily to avail
himself of the advantages of such institutions, and at the same time com-
pletely protect those who  have the insane in  charge from vexatious
prosecutions for the performance of their onerous and responsible duties.
It is undoubtedly for the best  interests of the  entire  community,  and
especially for the welfare of the afflicted,  that all these ends should be
equally and effectually attained.
  Without wishing to enter elaborately into a discussion of this subject,
which in many of its  bearings is a most important one, .and deserving of
a more extended consideration that can be given to it in the present
essay, it may be sufficient at present  to remark, that a certificate of in-
sanity from competent medical authority, after a careful personal exami-
nation, with a written request for the admission, from some near rela-
tive,  friend or legal guardian, should be deemed indispensable prelimi-
naries to the entrance of any private  patient.   The proceedings in re-
gard  to the patients sent by counties,  or committed by the courts, will
vary in their character,  but should be such as will enable a benevolent
citizen to compel those having charge of the insane poor promptly to
transfer them from any place in which they are neglected, or suffering
from the want of proper treatment.
  It has occasionally been proposed, that no patient should be admitted
without the sanction of a regular commission of lunacy; but such a sug-
gestion shows a want of familiarity with the circumstances of a  large
majority of all the cases received,  and the plan, if carried out, would
be most oppressive and unfortunate in its results.
   Those who have proposed this tedious and costly plan  of proceeding 
71
can scarcely be aware that by it they would  prevent a large number
of most deserving and interesting cases from receiving  the  benefits of
such an institution,—would cause others to be kept at home till the best
period for treatment  had passed, from the unwillingness of friends to
give such publicity to their domestic sorrows and  afflictions,—while on
others, little able to bear it, it would bring an amount of expense, often
greater than the whole cost of restoring  a patient  to health.
  In the present day, many patients come willingly to a hospital for the
insane,—some travel long distances alone and make their own arrange-
ments for admission,—not a few, who are not originally willing to leave
home, soon become sensible of the benefit  they are receiving and stay
voluntarily,—and many are restored in so  short a time, that their absence
from their places of business is hardly longer than is required for a toler-
able journey, or would result from a severe attack of ordinary sickness,
and may scarcely excite remark even from those who are in the habit of
meeting them.
  Of all the cases admitted into our hospitals for  the insane,  there is
not really more than about one per cent., if so many, in which  there
could be the slightest advantage in having a commission of lunacy  pre-
vious to their entrance; and these are  cases with such a peculiar moral
temperament, and so likely to give trouble in various ways, that all con-
nected with them, as well as the officers  of an institution, are interested
in having them confined by legal process. But to subject the remaining
99 per cent., to the trouble, delay, annoyance  and  expense of a regular
commission before they could be placed under proper treatment for their
disease, certainly would not be adopting  a rule of action that is to give
the greatest good to the largest number.
  The desire to have such preparatory legal  proceedings has probably
originated from a belief that  the friends of the insane are disposed to
confine them unnecessarily, or from sinister motives.  A rather extended
experience has satisfied me that this is not the case,  the prevalent ten-
dency being decidedly to postpone the  period for this kind  of  action as
long as possible, without sufficient regard to the best interests of the pa-
tient; and I have yet to learn of any deliberate attempt to confine a sane
man in any of our hospitals, or to place an insane one there  from bad
motives.  The possibility of  all  this being attempted is unquestionable,
but that any such designs are often, if ever, entertained in the United
States is very doubtful, and, if attempted,  could hardly escape detection;
for the officers of these institutions, regarding themselves as the special
friends and protectors  of the insane, would be the first to discover and
expose such an outrage, and to brand those guilty  of such a proceeding
with deserved opprobrium.  It occasionally happens that habitual drunk- 
72
ards,  who are dangerous to their families, and  are bringing ruin on all
dependent on them,  but about whose insanity there is room for doubt,
for the want of any other provision, are occasionally sent to hospitals for
the insane, and these are the only class of individuals of doubtful insanity
whom I  have found any one desirous of confining in our hospitals; but
although the motive is good, the propriety  of their admission is quite
questionable, for, as our laws now are, they can rarely be retained long
enough  to bo permanently benefited, and generally their influence on
other patients is not at all desirable,  nor is their society deemed in any
way complimentary by the insane.
  The fact that the officers of our public institutions for the insane can
have no personal motive  or pecuniary interest in retaining any patient
for an improper period, is now well understood, and has veiy properly
relieved them, with all sensible people, of every such imputation.   De-
riving little credit for skill or successful treatment, but from  those they
send away, and constantly importuned by convalescent patients for a dis-
charge, they are much more  likely  to err by  yielding too soon to the
wishes of ill advised friends, than by retaining a patient for too long a period.
  When commissions in regard to the insanity of an individual are really
necessary for the protection of his property—and this should be most
sacredly guarded  during his sickness—it  would  be a  benevolent  act,
which would entitle its author to high honor, to render this proceeding
less expensive than it now is ; for, as at present managed, it frequently re-
quires no inconsiderable part of a poor person's estate to enable any one
to collect a debt or make a legal settlement of any business in which the
individual may have been interested.
  Importance of a Correct Nomenclature.—The erroneous views
of insanity  formerly  entertained, and the unfortunate modes of treat-
ment which resulted from them, led to the adoption of terms which are
now without meaning, and the continued use of which has an unfavor-
able influence on the best interests of the insane.
  It seems especially desirable that this  malady, now  so much better
appreciated by the whole civilized community than formerly, and the
importance of the-proper treatment of which is  so generally admitted,
should have every advantage that can result from a correct  nomencla-
ture.  It is seldom that a disease so well recognized, so important and
so prevalent, has had the misfortune to be called by so many ill-selected
names, that have themselves tended to produce errors and confirm wrong
impressions in the community.
  Without any inclination to be hypercritical, it is proposed briefly to
allude to  some of these misnomers, which custom alone  seems to have
retained amongst us. 
73
  It must seem singular to any one who reflects on the subject, that the
term  " lunacy," as applied to this disease, should still be  retained as
generally as it is by the community, by the medical profession, and even
by some  of the latter whose labors in this specialty have done so much
to promote the best interests of a large class of sufferers.  " Lunacy"
and "lunatic" are terms  which  have no  meaning in reference  to the
diseases of the mind, and originated from a popular belief in influences
that have long since been shown to have no existence.
  Both these terms are particularly objectionable from their veiy deri-
vation, tending to give wrong impressions of the disease and to perpe-
tuate popular  eiTors.   Prevalent as  the idea may have been with our
ancestors, that the insane  were specially under the influence of the
moon, it is hardly to be supposed that such a sentiment is now seriously
entertained by any considerable number in or out of the medical profes-
sion.   If such are to be found, they would scarcely claim so decided an
effect from lunar influence as to make  it  a ground for giving a name to
one of the most important diseases to which man is subject.  "Lunatic"
is put down, in one of our best modern medical  dictionaries, as " moon-
struck,"  and such a term applied to a sick man or connected with an
institution for the treatment of diseases of the brain, is certainly not in
character with an age which puts forward so many just claims  to be
called one of progress.   The fact that these terms are still used in law
writings is no reason why they should  be continued by the medical pro-
fession.  If universally discarded by physicians, it is not unreasonable to
suppose that the bar, with all its fondness for ancient terms, would ulti-
mately reject  names which,  beyond  their  antiquity, have  not a single
claim for retention.  As applied to individuals, they have  become offen-
sive from their ancient  associations.  The term " insanity," which I
conceive is the only proper name to apply to the  disease under notice,
is a correct one; it  simply means unsoundness, is sufficiently common,
and its import generally understood.
  With all its distinguishing features, insanity has nothing about it to
prevent its being ranked with other diseases.   A functional disorder of
the brain, it  belongs  to  the same category as those of other  organs.
Prevailing at all ages, among all classes of civilized men, without regard
to talent, fortune or profession, there would seem to be no sound reason
why  the institutions specially provided  for  its treatment should have
names different from those that  are  prepared for the relief of the sick
suffering from other maladies.   It is of  great importance  to a correct
appreciation  of insanity by the community, that it should be generally
understood,  that, treated  properly from  its commencement, it  is com-
monly a curable disease, and that when patients are sent from home to
                        10 
74
 an institution, it is only that they may have advantages and chances for
 a restoration nowhere else to be obtained.   It should also be impressed
 upon all, that cases of insanity, however chronic they may be, or how-
 ever discom'aging theh symptoms, should still be regarded as worthy of
 attention, and demanding treatment, if we can do no more, to promote
 theh comfort and happiness, and to keep active, as far and as long as we
 can,  their mental and physical powers.
   Institutions for the treatment of other diseases, even if incurable, are
 called Hospitals; no other term is so common or so well understood,
 and there is none so appropriate in every respect to those devoted ex-
 clusively to the treatment and care of the insane, and, in my estimation,
 they should be known by no other name.
   The titles often applied to institutions for the insane have no appro-
 priateness, even if they do not have a mischievous tendency.  The ob-
 ject of theh original introduction would seem to have been to give an
 impression that those who entered  them were not sick, or did not come
 for treatment, or, if ill, that they suffered from some  malady which bore
 no relation to the other diseases which affect our race, but  rather that
 they  came  as  to a place of refuge or security,  as though they had
 committed some crime, or been  banished from the  sympathies as well
 as the presence of society. It  is  quite true that,  appropriate  as  the
 name of Hospital is for the institutions provided for the treatment of
 the insane at the present day, it could hardly have been proper to have
 so called the receptacles  into which they were often thrown, much
 less than a century ago, where those who had the strongest claims for
 the sympathy  and kindly attentions of theh fellow men, were chained
 and  flogged and treated with a cruelty far beyond the lot of most
 criminals.
  The term " Asylum," still so common amongst us,  seems to me to be
 open  to all the  objections that  have been referred to, and ought to be
 abolished as having an undesirable influence, while its derivation and
 true meaning certainly do not offer any reason for its retention by any
 curative institution.  It would be about as reasonable  to have an Asylum
 for small pox, or fever, or dyspepsia, or any other disease, as for insa-
 nity.  Ludicrous as  it would  appear to have  an institution called a
 Febrile  Asylum or a Rheumatic Asylum, it would really be as proper
 as to have  what custom  alone has familiarized  us to—an  Insane
 Asylum.
  The arrangements of a Hospital for the Insane—which is a more
euphonious, if not a more correct term than  an Insanity Hospital—it is
true, are different in many respects from those of ordinary hospitals;
but that  is no reason why the same name should not be applied to all. 
75
 The details of a hospital for children, for fever, for contagious diseases,
 or diseases of the skin, may also vary in theh character, without requir-
 ing a change in their principal title.
  The term " Retreat," is not less  exceptionable than that of Asylum,
 and for the same reasons.  They both originated from the best  of mo-
 tives, and have done good in their day, as helping to banish that awful
 name, " the Mad House," which, of old,  had so many real horrors con-
 nected  with it, and  the  truthful  pictures of which in England and  on
 the Continent have made such an enduring impression on the minds of
 men, that most of the popular prejudices existing  in reference  to mo-
 dern Hospitals for the Insane, although they have  no single feature of
 resemblance, will be found to have originated from this source.
  The names of " cells" and " keepers," as applied to the chambers of
 the insane, and to their attendants, originated at a time when those who
 were suffering from insanity were  often worse treated  than convicted
 felons, and when those who had charge  of them exhibited much less
 humanity than common jailers.   Both  terms belong  to prisons,  and no
 argument is needed  to show that they ought never to be heard  within
 the walls of buildings devoted to the relief of the afflicted.
  If every one connected with  the various establishments provided for
 the treatment of those suffering from mental disease, would on all occa-
 sions discard not only the terms "cells" and "keepers," and " lunacy"
 and " lunatic," but also those of "Asylums," " Retreats," and whatever
 other titles fancy may have suggested, and would call theh institutions
 what they really are, Hospitals for the Insane, and let the disease
 treated  in them be spoken of only as Insanity, the public would soon see
 the propriety of abandoning the terms to which exception has been taken,
 and that are in so many respects objectionable.
  Few, if any, of those who have the immediate charge of the institutions
 for the insane in America, whose titles are deemed inappropriate, have
 had  any agency  in  originating their names, and cannot, therefore, be
 held at all responsible  for these unfortunate misnomers.   Most  of the
 new institutions commenced within  the  last few years in the United
States are styled " Hospitals for  the Insane," and it is well worthy of
consideration by those interested, whether it would not be worth an
effort to induce those who have the  power to change the titles of those
previously established, so as to secure accuracy and uniformity among
American institutions. 
76
                         APPENDIX.

   At a meeting of " The Association of Medical Superinten-
 dents  of American  Institutions  for the Insane," held at Phi-
 ladelphia, in May, 1851,  the following series of propositions relative to
 the construction of Hospitals for the Insane, was unanimously adopted
 as the sentiments of that body on the subjects referred to;  and, in like
 manner, at the meeting held in Baltimore, in 1852,  the succeeding se-
 ries of propositions in reference to the organization of these institutions
 was also adopted, and,  with the former, directed to be published in the
 " American Journal of Insanity," and to be appended to the annual re-
 ports  of the different institutions:—

 Propositions  relative  to the  Construction  of  Hospitals
                         for the Insane.

  I.  Every hospital for the insane should be in the country, not within
 less than two miles of  a large town, and easily accessible at all seasons.
  II.  No hospital for the insane, however limited its capacity, should
 have  less  than fifty acres of land,  devoted  to  gardens and pleasure-
 grounds for its patients.  At least one hundred acres should be possessed
 by every State hospital, or other institution for two hundred patients, to
 which number these propositions apply, unless otherwise mentioned.
  III. Means should be provided to raise ten thousand gallons of water,
 daily, to reservoirs that will supply the highest parts of the building.
  IV. No hospital for the insane should be built without the plan having
 been first  submitted  to some physician or  physicians  who  have  had
 charge  of a similar establishment, or are practically acquainted with all
 the details of their arrangements, and received his or theh full appro-
 bation.
  V.  The highest number that can with propriety be treated in one
 building is two  hundred and fifty,  while two hundred is a preferable
 maximum.
  VI. All such buildings  should be constructed of stone or brick, have
 slate or  metallic roofs, and, as far as possible, be made secure from acci-
 dents  by fire.
  VII.  Every  hospital, having  provision for two hundred or more pa.
tients, should have in it at least eight distinct wards for each sex, making
sixteen classes in the entire establishment. 
77
  VITI. Each ward should have in it a parlor, a corridor, single lodging-
rooms for patients, an associated dormitory, communicating with a cham-
ber for two attendants; a clothes-room, a bath-room, a water-closet, a
dining-room,  a dumb-waiter, and a speaking-tube leading to the kitchen
or other central part of the building.
  IX.  No apartments should  ever be provided for the confinement of
patients,  or as their lodging-rooms, that are not entirely above ground.
  X. No class of rooms should ever be  constructed without some kind
of window in each,  communicating  directly with the external atmos-
phere.
  XI.  No chamber for the use of a single  patient should ever be less
than eight by ten feet, nor should the ceiling of any  story occupied  by
patients be less than twelve feet in height.
   XII. The  floors of patients' apartments should always be of wood.
   XIII.  The stairways should always be of iron, stone, or  other inde-
structible material, ample in size  and number, and easy of ascent, to
afford convenient egress in case of accident from fire.
   XIV.  A large hospital should consist of a main central building with
wings.
   XV. The  main central building should contain the offices, receiving-
rooms for company,  and  apartments,  entirely  private, for the superin-
tending physician and his family, in case that officer resides in the hos-
pital building.
   XVI.  The wings should be so arranged that, if rooms are placed on
both sides of a corridor, the corridors should be furnished at both ends
with movable glazed sashes, for the free admission of both light and ah.
   XVII. The lighting should  be by gas, on account of its convenience,
cleanliness, safety, and economy.
   XVIII. The apartments for washing clothing, &c, should be detached
from the hospital building.
   XIX.  The drainage should be under ground, and all the inlets to the
sewers should be properly secured to prevent offensive emanations.
   XX. All hospitals should be warmed by passing an abundance of pure,
fresh ah from the external atmosphere, over pipes or plates, containing
steam under  low pressure, or  hot water, the temperature of which at
the boiler does not exceed 212° F., and placed in the basement or cellar
of the building to be heated.
   XXI.  A complete system of forced ventilation, in connection with the
heating,  is indispensable to give purity to the air of a hospital for the in-
sane ;  and no expense that is required  to effect this object thoroughly
can be deemed either misplaced or injudicious.
   XXII. The boilers for generating steam for warming the building 
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should be in a detached structure, connected with which may be the
engine for pumping water, driving the washing apparatus, and other
machinery.
  XXIII. All water-closets should, as far as possible, be made of indes-
tructible  materials, be simple in theh arrangements, and have a strong
downward ventilation connected with them.
  XXIV. The floors of bath-rooms, water-closets, and basement stories,
should, as far as possible, be made of materials that will not absorb
moisture.
  XXV. The wards for the most excited  class should be  constructed
with rooms on but one side of a corridor, not  less than ten feet wide,
the external windows of which should be large,  and have pleasant views
from them.
  XXVI. Wherever practicable, the pleasure-grounds of a hospital for
the insane, should be surrounded by a substantial wall, so placed as not
to be unpleasantly visible from the building.

Propositions  relative   to  the  Organization  of  Hospitals
                         for the  Insane.

  I. The general controlling power should be vested in a Board of Trus-
tees or Managers ; if of a State  institution, selected in such manner as
will be likely most effectually  to protect it from  all influences connected
with political measures or political changes; if of a private  corporation,
by those  properly authorized to  vote.
  II. The Board of Trustees  should not exceed twelve in number, and
be  composed of individuals possessing the public confidence, distin-
guished  for liberality, intelligence,  and active benevolence, above all
political influence, and able and  willing faithfully to attend to the duties
of theh station.  Their tenure of office should be so arranged that when
changes are deemed desirable, the terms of not more than  one-thhd of
the whole number should exphe in any one year.
  III. The Board of Trustees should appoint the Physician, and, on his
nomination, and not otherwise, the Assistant  Physician, Steward and
Matron.   They should, as a board, or by committee, visit and  examine
every part of the institution at frequent stated intervals, not less than
semi-monthly, and at such other times  as they may deem expedient,
and exercise so careful a supervision over the expenditures and general
operations of the hospital,  as to give to the community a proper degree
of confidence in the correctness of its management.
  IV. The Physician should  be the Superintendent and chief executive
officer of the  establishment.   Besides being a well educated physician, 
79
he should possess the mental, physical and social qualities to fit him for
the post.  He should serve during good  behavior,  reside on  or veiy
near the premises, and his compensation should be so liberal as to enable
him to devote his whole time and energies to the welfare of the hospi-
tal.  He should nominate to the board suitable persons to act as Assis-
tant Physician, Steward and Matron.   He should have entire control
of the medical, moral, and dietetic treatment of the  patients, the unre-
stricted power  of appointment and discharge of all persons engaged in
their care, and should exercise a general supervision and dhection of
every department of the Institution.
   V. The Assistant Physician, or Assistant  Physicians, where more
than one are required, should be graduates of medicine, of such charac-
ter and qualifications as to be able to represent and to perform the ordi-
nary duties of the Physician during his absence.
   VI.  The Steward, under the direction of the Superintending Physi-
cian, and  by his order,  should make  all purchases  for the Institution,
keep the  accounts,  make engagements with,  pay and discharge those
employed about the establishment; have a supervison of the farm, gar-
den and grounds, and perform such other duties as may be assigned
him'.
   VII.  The  Matron, under the direction of the Superintendent, should
have a general supervision of the domestic arrangements of  the house;
and, under the same dhection, do what she can to promote the comfort
and restoration of the patients.
   VIII. In institutions containing more than  two hundred patients, a
Second Assistant Physician and an Apothecary should be employed;  to
the latter of whom other duties, in the male wards, may be conveniently
assigned.
  IX.  If a  Chaplain is deemed deshable  as a permanent  officer, he
should be  selected by the Superintendent, and, like all  others engaged
in the care of the patients, should be entirely under his dhection.
  X. In every Hospital for the Insane, there should be one supervisor
for each sex, exercising a general oversight of all the attendants and
patients, and forming a medium of communication  between them and
the officers.
  XI. In no institution should the number of persons in immediate at-
tendance on the patients be in a lower ratio than one attendant for every
ten patients; and a much larger proportion of attendants will commonly
be deshable.
  XII. The fullest authority should be given to the Superintendent to
take eveiy precaution that can  gua«d against fire or  accident within an 
80
institution, and to secure this an efficient night-watch should always be
provided.
  XIII. The  situation and circumstances of different institutions may
require a considerable number of persons to be  employed in various
other positions ; but in every hospital,  at least all those that have been
referred to are deemed not only desirable, but absolutely necessary, to
give all the advantages  that  may be hoped  for from a liberal and en-
lightened treatment of the insane.
  XIV. All persons employed in the care of the insane should be active,
vigilant, cheerful, and in  good health.  They should be  of a kind  and
benevolent disposition ; be educated, and in  all  respects trustworthy;
and their compensation should  be sufficiently liberal to secure the ser-
vices of individuals of this description.
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