^, IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 1.25 s us 1.4 2.5 22 [1 2.0 1= 1.6 -^ - ^J' ^ I c?/l ^ Photographic Sciences Corporation ^ ^ \ 4^ !» \\ ^^. ^% conformity avac las conditions du contrat da flimage. Originai copiaa In printed paper covers are filmed beginning with the front cover and arding on thfr last page with a printed or illustrated imprea- sion, or tha back cover when appropriate. Ail other original copiaa ara filmed beginning on the first page with a pfintad or illustrated imprea- sion, and andlng on tha laat page with a printed or illustrated impreaaion. Lea axamplairaa originaux dont la couvertura an papier eat imprim^a sent fiimte an commandant par la premier plat at an tarminant soit par la derniire page qui comporta une amprainta d'impraasion ou d'illustration, soit par ia second plat, salon la eaa. Toua lea eutras axamplairas originaux sont filmte an commandant par la premiere page qui comporta une amprainte d'impraaaion ou d'illustration at an tarminant par la darnlAre page qui comporte une telle empreinte. The iaat recorded frame on esch microfiche shall contain thm symbol —^(meaning "CON- TINUED"), or the symbol ▼ (meaning "END"), whichever appiiea. Un das symbolea suivants apparaitra sur la damlAre image de chaque microfiche, seion le cas: le symbole -*• signifie "A SUIVRE". !e symbole V signifie "FIN". Mapa, plataa, charts, etc., may be filmed at different reduction ratioa. Thoaa too large to be entirely included in one exposure are filmed beginning in tho upper left hand corner, left to right and top to bottom, aa many framea aa required. The fallowing diagrama illuatrate the method: Lea cartea, planches, tableaux, etc., peuvent Atre fiimte A dee taux da rMuction diff Arcnts. Lorsque le document est trop grand pour 4tre raproduit an un seul clichA, ii est fiimA A partir de I'fingle supirieur gauche, de gauciie h droite, et de haut an baa. en pranant \@ nombra d'imagea nteassaira. Lea diagrs Times suivants illustrent la mAthode. 1 2 3 1 2 3 4 5 6 jyT^HZ^ '-'^ rJZ^t.'fL Colonial Hospitals and Lunatic Asylums. sewerage, drainaip,"' 1. A CIRCULAR despatch of January Ist, 1863, addressed to the Governors of colonies, after reciting thaS certain evilg and^defects which bad recently been disclosed in he pjiblic hospital at Kii}gstoH in Jamaica, and flagrant abuses an4 cruelties of lung Sianding \chich had been detected in the lunatic asylum ai the same place, had suggested the expediency of making inquiry into the state of similar institutions in other colonies, procee(|ed to request information on .opics set forth in one series of intfrrogatories relating to public b@i|p^N^ ; and in a aeqond, relating to lunatic asylums. Answers to these fei1;^iW^atories have, up to the present time, been received from thirty-three ■i|Q)oa!6s, comprising accounts of tlie condition of thirty-nine hospitals and 'wenty-eight asylums.* 2. The following minute comprises : — I. Such an account as these answers supply of the general condition of the hospitals and asylums of the colonies, iu each of the four groups respec- tively forming four divisions of the Colonial Office; the materials being arranged in each group under the five heads of, — (fl.) Endowment and funds. (6.) Structure and sanitary airangements (si> water, space, ventilation). (c.) Internal economy (doctors, attendants, diet, reUgious services), (d.) Governmer.t or constitution. And (e.) Provisions for supervision, and reports. II. A summary of the classes of defects most generally prevaiUng. III. Suggestions for the cure of such defects ; and IV. A hst of all the institut'ons, with the particular defects found to exist in them severally.! 3. It must be prelimmarily observed that '' e information furnished by the returns is generally speaking insufiScient, and t dt more especially in the case of the worst institutions. There is enough stated to show that in many instances the present arrangements are compatible with the unchecked existence of the grossest abuses, and that gross abuses very commonly do exist ; but there is a general absence of exact information as to their extent, and as to the facts which are requisite to form the ground of specific suggestions for their cure. There seems to prevail ir the large majority of cases an almost incredible igno- rance of the necessary condrtious of efficiency, and it frequently happens that arrangements are described with complacency which are totally at variance with the most elementary principles. Still more frequently a general statement of satisfaction is substituted for any precise description. Yet, how far such gsneral and unverified statements ma) be from representing the actual condition of things is to be understood from the instance of Antigua. In October 1868, it ♦ A list of those Colonies which have not yet replied is appended, Note 1, p. 86. Five of those which have replied maintain no public hospitale or lunatic asylums, vi«., Tobago, Nevis, Gold Coast, Heligoland, and Labuan. t Statements of the coiiditioa of the hospitals and asylums ere to be t^en to apply to the condition in which such hospitals or asylums were at the time of the writing of the answers in each case. The dates of the despatch) ndoiing the answers are given with the particular accounts of the several ini^tutions in Part IV. ri021 B r / V' 4:> I 3 was reported in general terms tha ihe hospital and asylum of that island were in a completely satisfactory condition ; and yet it appears from more partictilar returns subsequently furnished that both those institutions, though far from being the worst of their class, are very defective in several of the most vital points of construction and management. The insufficiency and want of certainty which impair the value of the answers generally have been fatal to the utility of most of those which are replies to demands for exact statistical information. The proportions of deaths, discharges, and cures are wholly omitted in a large number of instances, and in many of those in which they are given, the clearness of tlie iiuestiona has not prevented the answerers from selecting ways of reckoning often incon- venient in themselves and incapable of being compared with each other. It must be remembered in considering the necessity for reformation, that these returns are made by persons on whom tliere lies at least a moral responsi- bility, and that they mnst be construed accordingly. 4. Statements made in Part I with reference tofthe general condition of hospitals and asylums in the colonies of each division are not to be taken *o apply to every such institution in the division, unless it is expressly so stated, but to have refertnce to the characteristics generally prevailing in the majority of instances. Any important exceptions to general statements are mentioned either with the general statements, or under the head of the particular institution in Part I V . Cases where no information is given, or ma be implied, are disregarded in the general statements. Part I. — GENKaAi, CoifoiTioN or the Hospitals and Asylums. We8t Indian Colonies. n. Endowment and Funds. he West Indian hospitals and asylums are universally destitute of perti^anent endowments, and receive bnt little aid from private subscriptions. A portion, generally inconsiderable, of their ftinds is derived from payments ^^Aia^ by patients who are not paupers, or in the case of seamen and labourers, by their captains or employers, and the remaining charges, after having been passed by the managing boards, and, in some cases, by the Grovernor, are paid by tho public treasuries. b. Structure and 6. In the character of their buildings and iu all sanitary arrangements Sanitary State. j^ese institutions are for the most part signally defective. The buildhigs are in many cases old barracks, prisons, or private houses, in no way adapted for their present purposes, and wanting la ery requisite for economy of labour, or the first conditions of health. In jnly three out of the whole nuniber of twenty-seven, from which answers have been received in this division, is there any tolerable providon for sewerage, drainage, and latrines ; and of ■hcse, three, namely, the Port of Spain hospital in Trinidad, and the Antigua iind Jamaica asylums, the first has lieen supphed only since the date of the ^despatch, and the third is a new structure erected since the Commission of 1861. Drainage left to nature, often in cases where nature would have to work uphill, latrineswithout water, and adjoinmg the wards, sewerage passing through open gntters into cesspools, the very cleansing of which in a tropical climate only diffuses miasma, are tlie ordinary arrangements in matters vital tn hospitals, and not less than ordinarily invjiortant in asylums. Space and "ventilation are equally disregarded. Whilst it is now established that from 800 to 1,000 cubic feet of space per head is necessary in associated and feata 1,250 to 1,500 in single dormitories in temperate cUmates, and probably a quarter 'tnore under tlie tropics, there are six places where less than 500 is allowed. The asylum of Dominica gives 300 in single cells, the Vi(;uxfort hospital in St. Lucia 281 in associated wards, and the majority of the rest range from 600 to 800, and this often with the most imperfect ventilation ; with reference to which it must be remembered that it is found to be practically impossible to ventilate properly a room of very insufficient size. /' / / From the tone of the answers, it wouW appear tlmt thero is a general ignorance of tiie necessiliy for any extraordiuary care ia tlicse respects, and of the existence of any settled principles regardijig them. The efiects aure wt the 1b8B manifeat in the prevalence and destnuitiveness of gangrene,, dysentery, and skin and bowel complaints generally, wluch, as is well known ia European hospitals, are the invariable concomitants, and often the first indications, of sanitarv defects.* Taere is one of these institutions the sanitary condition of which calls for particular remark aa an instance of inveterate neglect in the face of warning^ and as a proof of the necessity for strong measures of reform. In November 1861, the Coramiasioners app. ' ited to examine into the state of the hospital and asvlum at Kingston in Jamaica, reported that— " riTo doubt can exist as to the unsuitableness of the Female Hospital aft a place of medical treatment. It may be almost said to reverse every condi- tion which ought to be observed imder such circumstances. The wards, which are of wood, are small, low in the roof, close, and ill-ventilated. They are so slightly raised above the ground that the earthy exhalations, aftor rain, cannot but act injuriously on the patients. Except by closing the windows, and substituting one evil for another, no efficient protection exists against the damp or cold. Unglazed, few in number, and badly constructed for the admission of light and air, those windows are only apertures. Of Ward No. 5, the position is such as to expose its inmates to the rays of the western sun, which beat in upon it with a glare and intensity certain to cause suffering. To remedy this inconvenience by a screen, or other contrivance, no attempt has yet been made. As regards sewerage, matters could not possibly be in a more unsatis- factory condition. Of the privy, when we visited the institution, the state wa* such as to make it disgusting to approach it. No apartment is provided for the performance of operations, but only a shed, open at the sides, in which formerly, from the pure necessity of the case, this nice and delicate department was conducted. Originally (1860) the subject of these remarks was nothing, but a makeshift (having been formerly what is known as a negro yard) to relieve temporarily the Male Hospital, and was never intended as a permanent ^ institution," &c. (Page 10 of Report.) ^^ Nothing appears to have been as yet done to destroy the applicabiljdl^' of these strictures. 7. Defects of internal economy are very difficult to discover, and in estimating them many allowances must be made both in excuse and in aggrava- tion. The hospitals uniformly make a merJt of entirely excluding " contagions " or " infectious " cases : an exploded prejudice where the wards are roomy and well- ventilated, but one which may not be groundless where the atmosphere is of, itself enough to breed fever, though it can be no apology for not providing proper wards for the treatment of sudi cases with others.f Some of the hospitals are crowded with incurables, and the asylums with mere idfots who take nothing but harm from confinement and association with the insane. In the majority of instances there is no resident medical officer, a want which is the occasion of great evils. The proportion of nurses or keepers to patients, though not always of itself apparently insufficient, is yet really so in many cases if all the circum- stances are taken into account. Many fewer nurses in proportion are reqiured where there are a great number of patients properly classified in large wayds with every appliance for economy of labour and time tlxan are necessary m. these small and inconvenient and ill-found establishmentj^. Lastly, the asylums are generally without p/ovision for ohgiqus serviq^Sij and uniformly without proper means for the amusement and uployment oi the insans. Curative treatment of insanity is, ind^d, not yet in its infancy ii* the West Indian colonies. It is, however, satisfactory to find that the idea ot excessive restraint is generally repudiated even in them. 8. The government is m almost all case§ vested in boards '^wsh are d. Constitution, composed partly of ex o^cio members, p&rtiy of nominees of the Govw-APrs, w4 *' Jki the R«s«»« infirmary in Drasu&ica, 12 out of 29 deaths, in 1862, were fran skin diseases 80,4 dysentery ; and di^rrhoa «!ss the cau^e of 2 deaths out vf 3 at th« Bermuda aayiuav. I- Sraall-pox must be excepted from the nenersl rujb ; mi «» B> 2ft- B 2 c. Internal Eco- nomy. «. Supenrision and Repons. Mauritius. usually include some members of the councils. These boards monopolize all superior functions. They make regulations subject to the Governor's approval, they judge of complaints, they administer the finances, appoint to offices, inspect ana report (nominally at least), and finally some of their members, as being also members of the Legislature, approve in council what they have done as commissioners. In one instance (Castries in St. Lucia) unlimited power is given to the medical officer, and in other cases there are more or less slight variations, but such is the general model. 9. In the matter of inspection and reports, which rise in importance in pro- portion to the badness of the management, there is a great deficiency. Except the discretionary visitations of th(; Governors, which arc not ahvays very frequent, there is seldom any provision for inspection by persons not connected with the institutions. The regulations in some cases provide for the appoint- ment by the boards of visiting committees from their own number ; but as they are the only check on themselves, there is no security that they perform their duties, and as a matter of fact in at least two instances even the statutable inspections are confessedly neglected. Reports or lists of admissions, discharges, and deaths, are sent annually or semi-annually to tlie Governors, and frequently to the boards, which themselves publish annual statements ; but there is nowhere any provision for that kind of reports which is of more value than any others — reports, that is, of the actual working of every part of an institiition, made frequently to superior authorities otlierwise unconnected with the management. 10. To sum up, of all the twenty-seven establishmouts, putting aside the new asylum in Jamaica, one only, the Port of Spain liospital in Trinidad, can be said to be in a most satisfactory condition. Throughout all tlie rest, in a greater or less d<'gree, runs the same complexion of structural and sanitary defectiveness, of insufficient attendance, internal mismanagement, and want of supervision, resulting in the case of the hospitals in an unnecessary waste of life and means, and in the asylums in the substitution in effect of a system ef imprisonment for one of cure. Conspicuously the worst are the hospitals and asylums of British Guiana, St. Lucia, and Dominica^ which hardly yield, it may be believed, to what those of Jamaica were two years ago, and have not yet wholly ceased to be. 11. No doubt much of what is bad in these West Indian institutions is to be ascribed to the smallness of the islands, and of their populations and revenues. Their poverty suggested the mistaken economy which accepted the first site and building which offered as sufficient for the wants of a limited number of applicants ; and to minuteness of scale is chiefly to be traced their general want of system, and their slovenly and ineffective management. But it is to be feared that much is also, in the case at least of the hospitals, the result of a want of due consideration for the immigrants for whom they were in many instances originally established. Though the first of these causes cannot be obviated, it is time that the second should cease to operate to the discredit and loss of the entire communities. 12. Mauritius. — The expenses of the treatment of lunatics at the lunatic asylum of Mauritius are chargeable to the poor relief funds of the districts in which they are domiciled. The same rule seems to be followed at the hospital. The sites and buildings of both institutions arc small and inconvenient, and better situated and more commodious structures are urgently required. Several of the present wards are too confined, and the existence of sanitary defects, though not otherwise confessed, seems to be indicated by the great prevalence of bowel diseases. The asylum provides no sufficient employment for the lunatics, and the hospital is without any resident or restricted medical officer, and without any proper system of inspection by superior authorities. In other respects these two institutiors eeom to be very well managed. The rapid increase of Indian immigrants necessitates the establishment of district hospitals fo; their accommodation.* It is remarked in Mauritius that the Indians and coloured Creoles or ex-apprentices feel a great dread of entering the hospital, and conceal their d:™«« — ~ „A — iiii ii 1 : vi- nscaBcs OIicu till iiicy ucuuiiic iuv:ui'ciuic • See 8. 74, p. 28. ■a -•A a o ■s s? -* *' i s m 1 s » "S i4 m ■< H m > ... H •< « ■< Ik 1 -* *' ■3 o ■s ^ i s 3 « » H « < H H > H ■< at ■< Oi •f s.-a; !-S S .S-0 7 ,1 II 39 a. a I li •o 3. s 11 ^p^ I, ss &•! M jimnMM I t IS HOI g I I I 1-2 ■* ■* * « 1 1 m S 5 n .9 e 2 I „ o .«>- I J ?i i S S S ll^ ■a ' a 82 n Si 52 |3 -if 1^ J, -^8 1 I? 31 i.i| llitl^liililiii H n CO n . s §■5 • ii II 5 J is I / r a a o _ ii is -I e ^ ■1° Si •s-g . s SI is s b S 2 J r NORTh AMEniCAN COLONIES. Funds. c. Internal economv. d. Constitution. e. Supervision anp reports. 14. The grosser defects which diaprace the West Indian hospitafe and asylums do not exist at ad so generally, or in the same degree, in those of the North American colonies. It is remarkable that in the six coloni.'is which have replied m this division there are twelve asylums, and only three public hospitals; New Brunswick, Nova Scotia, and Prince Edwartl IsLind being without hospitals. It can hardly be doubted that some public provision for the iudi<,'ent sick is necessary in each of these cases. The number of asylums is explained by the great and increasing amount ot' insanity, which, in Newfoundland, is sometimes said to be caused cliieflv by the dangers and vicissitudes in summer, and the poverty and monotonous life in vvinter, of the fisliing population, together with their habits of intermarriage with relations, and their want of education, but is generally regarded as ine!xplicablc. It is calculated that there are at present, in the Lower Province of Canada alone, 130 insane persons who cannot be accommodated in the asylums, and tliat in Nova Scotia 223 out of a total of 340 are still unprovided for.* 15. The revenues are, in most cases, chiefly derived from fixed grants from the provincial treasury ; but in Nova Scotia each county is chargeable with the expense of maintaining its insane poor; and the medical superin- tendent, in a published re!)ort, strongly objects to a proposed plan of charging the province, as tending to relieve the nearer counties unfairly and at the expense of tiie rest. 16. There are in all these institutions great structural do*^ciencies. In no instance is sufReient space generally allowed. The basemt..c cells in the Prince Edward Island asylum give no more than 323 cubic feet to each patient, and this in a climate where the cold ia winter may be supposed to be as preventive of ordinary ventilation as heat is within the tropics. The St. John's asylum, in Canada, is so bad that the qnc'Sstions are said to be " inapplicable." The Newfoundland hospital and Prince Edward Island asylum are without any but surface sewerage or drainage, discharged into cesspools. 1 7. Under the head of internal economy the only general defects which appear are the frequent insufficiency of attendance, and the want of amuse- ment and employment for the insane. The general cry is for more land, which provides the best kind of occupation, and is profitable when it can be obtained on fair terms. A situation where enough land cannot be had ijs not fit for an asylum. Contagious and infectious cases are admitted into the Newfoundland hoB^tal, and no mention is made of any inconvenience resultmg from this practice. 18. The boards in which the government is in several cases vested ane differently constituted from those of the West Indian colonies, and hav£ less general powers, greater authority being entrusted to the medical superin- teodents. The Prince Edward Island asylum is governed on the West Indian model, and is the worst, after St. John's, of the whole number of North American asylums. All the Canadian institutions are unde • the general control of a central board of Inspectors of Asylums, Prisons, &». , to whom belongs the credit of the great improvements wl ' h have been made in those establishments. 19. The system of visitation and reports now in use in Canada cannot be improved, unless by the addition, in the case of asylums, of daily reports, by head wardsmen or keepers, in the form suggested by the Commissioners ifi Lunacy, and appended in note 5, p. 39. But some better arrangements in these respects are very nece;«ary in New Brunswick and Prince Edward Island, in neither of which are there any records of the emptoyment of restraint, aad in the first of which oo viiwtatioD is ever made, except once by each Governor during bis whole term of ofiice. • It may te romarfced that insmitv seems in thaw oolonias to be generally connected with coosuKiptiott. Two-thirds of the dcatta'at the Deauport asylum, in Lower Canada, 60 out of 145 at Toronto, 13 in 25 at Maiden, and 18 in 103 in New Brunswick, were caused or hastened Hy pulaaonary ajseaso. No such close Eclatioii is diac-orerabie in other oiv'.sisns. 20. The Bermudas asylum, perhaps the worst of all the criully ifl-inanaged prisons for lunatics in the colonies, is a strii. Cubic Feet of Spue per Hetil. a. In AteociAteil, A. InSinrlnAoomi SuperlleUI Area, and Intervnl between Jlcdi. ATarafo Numttere under Treatment«t one Ttuic. .N'unilitir of U'diral limcera, mil wtiitllier lleii.lrnt and Rrttricted in Pnctice. Nonilier of Nuraoa or Keepera. af «. i. taatnanl. ClHAO« Quvitntinc IIui|iilal Ittrliii; Hoipital TwooU) Atjluni OiUl!- Drancli) Aijlum Vairenltjr i Iranch) Aijrlun ... Haldrn Aayluni BooltwooU (Crimiiwl) A»ylam... ■oiiport (Pniprittarf) Aayloin •MJcbiitAiytnii Hcrct. 600 10 Bt 6H H 160 MO-TtO 780 (rei rn 600 (fei MM 650 (gen n 7 .SO lartl «Te> ?el •ral ATI. lO erulivc- 951 ■ li ft. intertal 9{ rt. InteTTAl 307 adoiiMioQi ISO In (iMinirr 70 m winter 380 191 «7 391 groat caiei «0 443 68 1 recideiit and 1 not rt'Kiiiriit 1 nniilriii and 4 viaitini; 1 reanlmt (f) 1 reaident (T) 1 reiideat 1 resident 1 reaidL'iii imd te. Teral viiilin^ 1 not reaident nor reatricti-d 1 to ^6 pallaala 7 1 to U itaUata 13 i'li 1 to Hi ratiOiU e ll«tra tOdaji ■lllayn liManMM Syeara M years Na» SaviitwniK. •Aiylam 37 174 1 reiidunt 18 • aontk* NiwrouNDLAiin. SIISK':;: :;: 18 fl7ei (140 8071 4-6 ft. interval 35 88k 3 not resident 1 reaident 4 * •Bdaya MS Uaya NOTA SCOflA. Aijlam 86 610 1,1C3 „ 130 (?) 1 Ntldent U «»*i}a Piiilci ISdwabd Isuhd, toylin 10 588 (33 _ )a\ 1 not reaident i SMihy* BlEMUOAa. 'A«yl«> «i, or which U only can b« cul- tlTMMl (40401 . - 12 1 not reaident nor rattricted .J ■* S ycra 11 *»y> Mediterranean and African Colonies. 22. Whilst in the North American colonies, insanit)- almost engrosses public attention and care, the six African dependencies from which answers have been received, maintain only three asylums, and those iil-constructed and ill-managed. On the other hand, the eight public hospitals, though not without great defects, are for the most part managed with care an(l are generally moare under the direct inQuence of the Governors than is usually the case in tlie other divisions. The very small asylum at St. Helena is parochial, and to this its badness is to be attribnted. The parochial authorities ouglu not to be suffered to retain the exclusive control of an institution which they can hardly have either the knowledge or the means to conduct properly. The Cape asylum in Robben Island suflers both from wcT>t of connection with any central medical authorities who might exercise super Ijion and suggest improve.nents, and from an anomalous subordination to the Somerset hospital. The lunatics are admitted to the hospitrd and then handed over to the asylum, an arrangement wliich residts in the frequent loss or detention of the certificates and other preliminary documents relating to the proofs, causes, and previous nature of the disease. 23. The funds for tlie maintenance of the pauper patients are generally a derived from the colonial treasuries. It does not appear that there are fixed grants. The Albany and Port Elizabeth hospitals at the Cape are chiefly, if not entirely, supported by private endowments and private subscription. In St. Helena the parochial authorities are chargeable. They contract with a private person for the care of the insane. Amongst the many bad results to be expected from this arrangement, the following may be selected as the worst : i. The mi, >agement of the insane is withdrawn from publicity and * The Governor and Council appear to form the bourd of control. Bbbmudai. Funds 8 h. Striictiirr and «anitarv slate. c. Internal oconomv. Constitutions. f. Supervision and reports. (lIBIIAl.TAR. external control, ii. It is the intorost of the conlracUng keeper to retain patients for whom lie is paid as long as possible, and to treat them as cheaply as possible, iii. It if competent t:) him, as it is his interest, to minimise the intervention and supervision of medical men. Such a system, indeed, excludes the idea of curative treatment. There was formerly a hospital in Gold Coast, but it was closed in 1861, in consequence of the refusal of the people to pay the poll-tax, and has not since been opened. 24. There are very general sanitary deficiencies. The Somerset and AlOiiny hospitals at the Cape arc the only instances of sufficient space and ventilation ; whilst at the Robben Island a-jylum only 600 cubic feet, at that of Sierra Leone 603, are allowed to each patient. A' the Grcjys hospital, in Natal, two patients are sometimes placed in cells containing 71Bi cubic feet, which is insufficient for one, whilst the nature of th'* building prevents ventilation. The Somerset, Sierra Leone, SL Helena, and Natal hospitals are provio-d with some artificial sewerage and drainage. Of the other instiintions, five have no artificial arrangements of this kind. The usual latrines are holes over uncovered gutters, loading into adjoining cesspools, wliich are occasionally cleared by hand. 25. In only three instances is there a resident medical officer. The St. Helena contract asylum is witliout any regular medical attendance, the parish doctor visiting only when summoned by the keeper. It does not appear that there is in these colonies any general numerical insuffi'^iencv of nurses or keepers, the service of native or other coloured uttend'-ints being easily and cheaply obtained. There is in the asylums the usual want of employment for the insane. The managers seem to be generally incapable of devising any occupation for them except in menial services. There is reason to believe that excessive and arbitrary use of seclusion and restraint prevails in the Robben Island asylum ;* and at the two others, though excess is denied, no records are preserved. 26. The Albany and Port Elizabeth liospitals at the Cape are managed by boards appointed by the subscribers, in both cases without the intervention of any resident medical officer. The ether institutions are, it appears, directed by their respective medical officers, generally non-residont, under the control of the governors. The regulations which ure at present in force at the Robben Island asylum were framed when it was much smaller tlian it is at present, work very badly, and require to be altered. 27. There is an universal want of any proper system of visitation and reports. At the St, Helena asylum there are no registers or rccoids of any kind. 28. In the hospital of Gibraltar the ordinary evils of government by a board are aggravated by the board in this case being composed of representa- tives of subscribers of different religious creeds, whose jealousies divert the resources from the general good. The asylum is a part of the gaol. • See Fart IV., s. 84. 29.— CoMPARATIVl Tab..* of HotpHiitr, and AaTlDirii m the Moditemnean DiTiiion \fiic»). (with Nunr M tka iBitltulioa. .H,.« or Kile or Uiiantitjr III iMid. acrei. v.mo Cable "eet or t|iMe »r Held. • In AeeMbit«d, t. In Untie Room'. Snptrflriil Am. nni) lulrn.il lirtwnii Itcde. NumW't uniirr ■""rfetmenl at one ■''Inn- (or Annual Admlaelanii. Mttmhfr of MadUKi (llllnira. en4 whether ■UaMeHtend lUnrleUd In Pr*^U». Niimbtr of tfareae oiKeepere. Annae Dunlftn of TrttlBWBl. 4. 70(H0« t. UllULTAI. HMplUl Aijrium I.(M lOIMit 10 9 midnit, not re- ■tncud . IS4>;e Oamiia Hoipitiil i ft. ialerrel - 1 rmident, not rt- alrtctcin 93 grvii caeei ' not resident nor rcttricted I not rrai lent ujr rcttricted 7 n 30i daja 81 dajra Note.— No answer hns been received from Multa, but from other sources of information it appears thut a model hospiti"! is in course of erection there. (^See Miss Nightingale's "N'-.: on Hospitals," p. 104.) Australian and Eastkrn Colonies. 30. Hong Kong falls under iio natural group. The prominent defects of Hong Kono. its two public hospitals are the usual ones of sanitary condition and super- vision. 31. There remain Tasmania and the Australian colonies. The jiublic hospital and asylum of the first are apparimtly faultless in every respect, except that in the asylum tiiree wards are very deficient in sp?ce. Since 1860 the hospital has been under the management of a board of twelve members, appointed by and responsible to the Colonial Governmont. The a'^ylnm is adniiniste/fd by nine Commissioners appointed by the Governor. 32 Of the Australian colonies, Victoria and Western Australia have furnished accounts of the condition of six public hospitals and two lunatic asylums. In this case, as m the other colonies generally, the asylums are inferior to the hospitals, not only in matters belonging specially to their particular province, but in the common requirements for sanitary and economical efficiency. 33. The four Victorian hospitals appear to be supported chiefly by private a. Funds, endowments and subscriptions. They are managed liberally, and are objects of f;eneral interest. The Yarra Bend asylum in Victoria, and in W^estern Australia the Perth hospital, appear to be supported by the colonial GovernniDnts; whilst the Frcmantle hospital, and, apparently, the asylum at the same place, are portions of the convict establishment. 34. The Melbourne and Fremantle hospitals alone are sanitarily efficient. A. Structure and Of the rest, the Gcelong and Castlemaiue hospitals, and notably the two sanitary s.ato. asylums, are very deficient in :pace. Geclong, Ballarat, Perth, and the Fremantle asylum have no proper sewerage or drainage, the h.st being also without baths or lavatoj ii^s. There appears to be only a single latrine provided V ith water in the whole tliroc-quarters of a mile over which the buildings of the Yarra Bend asylum are scattered. 35. The internal economy of these institutions seems to be geacrall}- c. Internal satisfactory. The Pertli hospital and Fremantle asylum are the only ones ecoio "}• vvitliout a resident medical officer, and th-, staff of attendants is ample in all [102] C le ii. Constitution. e. Sopervisinn and reports. but one instance. This exception is Castiemaine, which, giving only an average of 533 cubic feet to each of 90 patients, provides no more than four nurses foi them : two defects which seem to connect themselves with the fac that the average stay of the patients is here about 60 days, which is double the average of tlie other Australian hospitals. The F'remantle asylnm is almost destitnte of land, or any other moans for the employment of tlie insane ; and the management of that at Yarra Bend must 1)0 inipedcd by tlie wide dispersion of the buildings. Tlie state of this asylum is said i" have improved much since Mr. PaU^ys arrival. 36. The four hospitals of Victoria arc governed by boards, but very different ones from tliosc vvhifh are responsible for the abuses permitted to exist in tlie W(!St Indian inst.aitions. Here the boards are not committees unconnected, except by their office, with the establisliments of which they engross all the control, and uniting in themselve.« botli tlie interest and the power to repiTss expenditure, but representatives elected by tlie subscribers, and responsible to them, placed in their position only by their own liberality, and Hkely to econo uise only to the extent of maldng the money wliich they have already contributed extend to do the greatest amount of good. In addition, these hospitals are immediately managed by resident medical officers, and are further protected by the public interest which they excite. The Fremantle Convict hospital has been governed by the Comptroller- General ; the asylum at the same place, and that at Yarra Bend, with the Perth hosjntal, are managed by paramount medical chiefs. It is to be observed, in reference to the unsatisfactory condition of the Castlemai'ie Jiospital, that the Managing Committee complain that the action taken by the Government with reference to private contributions has helped to prevent them from adding a new female ward and makii.g other necessary improvements ; but there is no explanation of what is the action referred to. 37. Tlio provisions for visitation and reports are generally insufficient. The Yarra Bend asylum is inspected by a visiting board of five^ members (of whom two are medical) appointed b} the Governor in council; but the Melbourne, Ge(;long-, iiud Ballarat hospitals seem never to be visited by superior civil authorities; and the rest require a more systematic supervision than that to which they are at present subject. 38. The Governor of Victoria expresses his regret that a design of building three new lunatic asylums in difTerent parts of that colony has been postponed. 39. — CoMPAUATivu 'I'abli-: ol- Hospitals ami Asylums in tlie Australian and Eastern Division. Name of the luslitution. Si!C ..f Site op Quantity of l.aiia Cubic !-unilj.Tof Medical onicers, and nhi-tli, r lUaiilciii and ll«PlriclKll 111 l'rai;lil;c. Jsiniiliurof ■ Nurses i.'i' Kcpert. Average Unnilioa of ' li. Treatment. HoltqiKoKG, Uenoral Hospital i.ock llASpital - SCO 1 ft. liitcrvjil Mi 1 resident and re rttricted and 1 not re- siaeotnorreitFieted 1 not resident nor restricted 22 days T.VSSCAMA. IlospitM ... AsyUiin SactcsC:) 40 anus a .200-1,5* SDO-l.uiU oorfii'i.iuterral i.;6 1 resident, .-ind re- atnctedaiid4not resident 1 n«id(Mit. nut rc- HlTiOtCll 11 OOdnya 44«duys Vicroiu.'.. Mtllmunu: Ui,&Biglit - (icclong Hoiiiilal - o:»-si!o ■I fi. iiitcnal i.jr. 1 .caidciit and r(> stricteii ami 4^ lionornry 1 ruhidani and w- slTJetcd and 4 lloll paticiits 87 days Castiequuue Di'ia^iiuiL - 53:'. (geqw iii.uvcru|;c) 3i ft. i«tcrvBl mi 1 00 days BaUnrat IltxpiM - 1,200 4 R. internal !M 1 rcfiidenl and ic- alBCloU , aiul fl > 33 days Y:irrii,Beiid.Asjhim . 010 acres. 69& imw il avenngi^ - 71):; houonn-j 8triel«d ,-, ».|UUlM« \Vt:aTttt!i Ai.iia.Ai.i\. ) I'erlli Ilospital 9B8:J.200 i- Htq. fl Si.llrt.intiKal 1 H atlmiasinns 1 not resident nor eeatricted 1 V rMident nut -rt.. o 11 ttl \n natih^t. 21 days As/lam •2i aim [ ) - «(?) stncMd 1 nut resiilnut nor H SOmontUa 11 h. Structure and Part II. — Summary of the CijiaBES of Defects most qenbsaily PRBVAIUNG. 40. The apparent condition of tho colonial hospitals and asylums may be summed up in a few words. There aro few, if any of them, in which positive cruelties, deliberately committed, can be asserted actually to find place, but there is hardly a single uistitution in which, in a greater or less degree, primary sanitary reciuircments are not neglected ; and few in which there is any sufficient security, in the nature of inspections and reports, against the present or the possible existence of even the grossest secret abuses. Tho worst cases are the small institutions of the West Indian colonies, Bermuda, and Gibraltar; but even the largest establishments in the richest colonies, with a few exceptions, show something of a make-shift character, and of utjHty narrowed by mistaken economy. The asylums, except in Canada, which has only two general hospitals, are almost universally worse than the hospitals, and sometimes suggest the impression that they are, perhaps unconsciously, regarded too much as means of relief from a troublesome class, without care for curative treatment. They are apt to be considered, on the one hand, as less imperatively requiring specific skill in theii management ; and, on the other, as dangerous subjects for the interference of lay reformers. Nor does insanity appeal so strongly to common sympathy as those diseases to which men ordinarily feel themselves liable. It cannot be a matter of wonder that the evils which till lately disgraced the asylums of this coimtry should occasionally repeat themselves' in the colonies. 41. Following the order of the five heads above distinguished, it is to be a. Funds, observed, first, that the endowments being almost always supplied or supple- mented by the colonial treasuries, the enforcement or neglect of reforms rests in the power of the Legislatures. 42. With regard, next, to sanitary arrangements, it appears that the sites are, in many cases, bad ; but bad sites often mean convenient situations, sanitary state, and the site is often of comparatively small consequence if the buildings are good and well-arranged. Of this the Port of Spain hospital, in Trinidad, is an instance, which, though occupying the site of the once deadly Orange Grove Barracks, is not only the best managed, but the most healthy' of all the West Indian hospitals. But no such corrective is generally applied to the natural evils of the sites. In general the buildings are ill-arranged and ill- cleansed. Open scwerajje and cesspools adjoining the houses, bad enough in this country, arc fatal in tropical climates, or when aggravated, as at Gibraltar and Bermuda, by the absence of any provision^ for determining the cours(> or position of filth, which, being left to make away with itself, breeds pestilence, and renders the hospitals centres of disease.* Not second to this is the crowding and smallness of the wards. It is not merely that, without a certain capacity in the ward, proper ventilation is impossible, but the space allowed to the patients is so small that it would still be destructive, even if ventilation could be supplied. In eight instances there are associated wards in which the sick poison themselves and one another in an average of less than 400 feet of cubic space per head ; and there are two where, what is worse, the space of single cells falls below the same amount : and of the ten institutions thus deficient five are in hot climates. Equally deficient, in many cases, is the area or superficial space allotted to each bed. On this, quite as much as on cubical space or artificial ventilation, and more than on the height of the rooms, depends the purity of the air, and it is this easily cured defect which is the only excuse for the non-admission of contagious and, infectious diseases which are, in genera], dangerous only when beds are crowded too closely together. If any of these sanitary defects were to exist, even for a sliort time, in a London hospital, they would speedily make themselves felt in the prevalence of hospital gangrene, and in the general aggravation of many classes of disorders. In the Lariboiai^re hospital in Paris, a wind blowing for a few hours from the direction of a malarious (luarter of the town was enough to give a malignant character to healthy sores. Yet in such influences the diseased in many colonial hospitals and asylums, pass their weeks or years. this plea is of weight as an etciise for those whose duties do not require them to inform hemielm, ay of .ipsjlogy for siirh drfff ta : .lad eertiinlv I though not for others. C 2 12 c. Internal economy. (d.) Constitution. (i?.) Supervision and reports. 43. With the smallness of the wards is connected also another defect, which, though generally not great, is still sensible,— that of insufficient attendance. The same number of nurses which suilices for a ward of thirty- two beds is not too much for one of twenty.* Another, and perhaps the most prominent, defect of internal economy, is the frequent want of any resident or restricted physician or surgeon. It is needless to dilate on the evils which must result from the absence Oi perpetual medical care, and from the hicrcased extent of important and difficult duties which arc tluis left to the ignorance of nurses overpressed with their own work. Two more points of internal economy, which remain to be noticad, apply solely or chiefly to lunatic asylums. The first is the general insufficiency of means for the emplovment and amusement of the insane. It is certain that nothing is so important in their treatment as this, and yet menial services and circulation in confined yards in many cases exhaust the list. The perpetual cry of the Canadian inspi^ctors and physicians for more land is not answered, and the Jamaica asylum provides for the occupation and amusement of 200 lunatics a barrel organ. The other defect is the insufficient provision for religious services. But this is a difficult question, and its solution had better b.; left in each case to the Governor of the colony, or the chief inspector of the asylum. Injudicious religious attendants niav be worse than none. ' 44. The questions arising under the head of government will have to be considercil separately. 4.5. Lastly, tlie most general defects after tliose of a sanitary kind, and not second in disastrous effect to them, are the want of proper supervision and reports. In the West Indian colonics the inspectors are committees of the managing boards, and are not likely to be zealous in reporting their own neglect, or to bo able to detect in one capacity faults which they cannot see in another. Most of the Governors visit with more or less frecjuency, but in some cases their zeal appears to be checked by fear of awakening the jealousy of the boards, or by other causes. In some of the African colonies the Governors and colonial Secretaries visit zealously, but their activity can jj hardly coujpensate for the want of specific knowledge. The Canadian ;/ institutions are the only ones which are subjected to a special body of general I inspectors properly qualified and devoted to their business.t f Reports of some son, in greater or less quantities, are furnished by all but two or three institutions to the superior authorities, but they are generally of a statistical or financial kind only. There is apparently no instance of reports of that sort which alone are of much practical value, those, namely, which are made by various independent officers to the inspecting authorities at short intervals, of the actual working of the institutions, and of iheir reasons for exceptional treatment. Under the present system there is no security that proper control is exercised by superior over inferior officers, or that the rules are observed. It is certain that the continued existence of tlie defects discovered is chiefly owing to this want of proper provisions for inspection and reports. 46. As for the results of these defects, it is unnecessary to dwell on the extent to which " inadequate provision for the insane multiplies the number of incurables," or on the loss of life and time which is the consc(|uence of the deficiencies of the hospitals ; but it is worth while to state that whilst in twenty-four London hospitals the annual proportion of deaths to the average number of inmates is 90-84 per cent., and that in twenty- five English provincial hospitals only 39-41, the proportion in Jamaica (no longer the worst managed of the colonial hospitals) is 145-50, that in the Roseau infirmary in Dominica 130, and that in the Barbados hospital 200,J whilst at the Castries iisylum in St. Lucia, which is not devoted to incurables, the deaths exceed the discharges. 47. There is nothing so striking in the condition of these institutions as the almost total want of system and of recognized principles of construction and ■* Seo " Notes on Hospitals," p. 54. f Tlieie is a lunacy commission in Mauritius, but its powers and duties are not described, nor do tliey appear to extend to supervision of the iiospital. I Thai is to say, each bed >erience, and must be generally unfit to make regidations about matters which demand both professional knowledge and practical experience, and even though they may be presumed to receive the suggestions of the medical officers, and though their rules must be submitted to the Governors, an originally defective scheme is not likely to be made complete by after-suggestions. Again, they are too far removed from the actual working of the arrangements to be able to exercise that continuous supervision which is necessary for guarding against abuses and testing results. They are liable either to disagreement or to. an apathy which leaves everything in the hands of two or three who may be actuated by interested motives ; they cannot judge of the efficiency of attendants whom they see in a manner only on parade, and they have no professional pride to gratify, nor the misery to endure of having daily before their eyes the evil consequences of a defective system. Lastly, if from these causes the institutions mffcr, there is no one on whom to fix the blame of abuses or omissions, and if the guilt is at last brought homo to them tkey cannot be made answerable. It is impracticable to mako a board, e8i>eeially if composed of unpaid members, effectually responsible for the minutJae of their administration, and the difficulty is much aggravated where, as in the See Section 58, p. 22. 15 majority of these cases, members of tlic board are also members pf the council. There ought always to be one person, properly qualified and devoted to the work, investcrl with paramoimt powers within the institmion, and directly responaible to dtiinito axithoritics for the doing or not doing- of each particular act : and there can bo no doubt that this person should be the cliief resident medical officer. It is the profession of sucfi a chief to be efficient in this particular province; the success of his institution is to him a matter of professional pride and interest ; if anything goes wrong, on him naturally lies the blame, and he can be (?asily called to account. Therp is no comparison between the two systems in certainty as tr who is responsible and the ease with whicli he can be reached. Especially in the case of huiatic asylums it is certain that considering the multitude of particulars which require constant vigilance and practised judgment, the number of intangible abuses which may easily prevail in secret, and the influence which such small but pervading and perpetual causes exercise over tlie mind and condition of tlie patients, boards, however zealous and well-intentioned, are incompetent to deal with tlie practical difficulties of management.* It may be added that .if a resident medical superintendent is intrusted with any powers at all, he ought to be intrusted with as much as possible ; otherwise ho. is likel\ to become indifferent, and, what is of great importance, will think the diptection of abuses is not his business, but that of the actual governing body. Yet he is the only person who is in a position to detect them with certainty. ' Before proci^eding to suggest a definite sclieme for the redistribution of powers, the comparative merit of the two systems, as at present in use, must be tested by their results. The w^hole number of institutions which have sent information as to their government, omitting tlie four Victorian hospitals which are managed by boards of a peculiar kind. ;ind the hospital and asylum of Jamaica, which are in a transition state, may be roughly divided into 30 which are very unsatisfactory and 22 which, though not without great defects, are on the whole much more satisfactory. Of the 30 which are bad, 20 are governed h\ hoards and 10 by chiefs ; "of the 22 which are good, 9 are under boards and 14 under chiefs. In other words, the good ones under boards are to the bad as 2^ to 5 ; under chiefs, as fl to 5. The numbiT of those which, though governed by paramount medical chiefs, are still bad would be greatly lessened, or it may be liclieved reduced to nothing, if proper provisions of other kinds were bror.glxt into operation. Such provisions would of course lessen also the number of those under boards, whicli are ill-managed, but this does not affect the general result. There are four eases which require particular notice. The hospital and asylum of Tasmania are governed by boards and yet are ver} good, — appa- rently indeed the best in the colonies. There is also a single instance in the West Indian group (the Port of Spain hospital in Trinidad) where thr; result of government by a board has been good ; but that result is here owing solely to the exertions of Dr. Mercer, the resident surgeon, and may fairly be said to be in spite of the system. On the other hand, at the Castries asylum in St. Lucia, tliougli unlimited power is given to the medical officer, the result is eminently bad ; but then in this case the medical officer is non-resident and unrestricted in practice, is only bound to visit once a week, and fc. the sole care of this asylum and of three hospitals receives 170/. per annum, out of which lie has to find all medical and surgical appliances. This is such an exception as goes to prove the rule. It is to be added that the hospital and as>lum of Jamaica were at first (1855) under a board of commissioners. This sptem was found to vi'ork so ill that in 1859 an Amending Act transferred their powers and duties for the most part to an officer called an '• Inspector and Director." But some legal and other blunders rendered the new Act practically inoperative, whilst the old one was disph«ced, and the deplorable state of things in 1861 seems td have been .partly the result of the temporary anarch) . 01 all their various and inconsistent powers it wx)uld seem to be ddsirable thai the boards should retain only the appointment of the medical offi^cdrs and * It ''i the opinion of the Conimissiouers in Ltinacv tliat asylums should always be ttwtnj^ti bv ■ par&.-nount medical chiefs. 16 pcrliaps the control of the finance, together »vith a povvjr of visitation besides or in conjnnction with other inspectors, ami a limited authority to hear complaints brou«?lit against the medical chief, and to report their conclusions to the inspector or the Governor, The first of these functions is one which requires only honesty, and could hardly be transferred with equal convenience to any other person or body ; and for the second, the boards are not n(!ccssarily unfit, though the work might be more efficiently performed by the auditor-general of the colony in cases where there is no property to be administered. If they should retain this duty, it would perhaps be advisable tliat, in connection with it, they should have the appointment of the clerk or bursar, and that they should be incorporated and granted all necessary powers for holding and dealing with interests in realty. In case it sliould at any time appear necessary to remove a medical superintendent, the power of removal, subject to tlie sanction -"f the Governor, ouglit to follow that of appointment. As for their legislative functions, these ought to cease to be necessary. If a proper code of regulations were drawn up once for all by competent professional authorities, nothing more would remain to be done except to give the medical chief tlie power to make alterations in the executive arrangements subject to the approvaf of the inspectors, and, as at presenr, of the Governor, or to give a similar power to the inspectors themselves. The patronage of all inferior offices, such as those of head-nurses nurses, or keepers, ought undoubtedly to go to the medical chief. He ought to have the power both of appointment and of summary removal, dnee no one else can judge of the actual efficiency of the attendants, and great harm might be done to the patients by delay. Should the removal be unjust, a complaint would lie against the chief to the board, as suggested above. A difficult question arises with reference to the appointment of chaplains in asylums. H^^wever great the spiritual oi" the disciplinary value of religious services may be to the insane, ".ant of j\xdgment in their use may sometimes give occasion to more than countervailing evils. Considering the delicacy of the (juestion in each case, it would seem to be desirable that the appoint- ment should be made by the governor of the colony. There remains the power of visitation and inspection, which must form the subject of a separate section. A% suggested above, it would be well that the boards should visit and report at certain and uncertain times, in con- junction with other visitors, but they are very unfit to be the sole depositaries of such a power. With reference to the measures suggested in this section, it is to be observed that they do not necessarily involve any increase of expense. It may not always be easy to find a medical officer who will reside and relinquish private practice without a lai'ger salary tlian in some cases is at present provided ; but on other grounds it is absolutely necessary to find one on some terms, and under the proposed system he may not be less willing to come, inasmuch as he will have larger powers and freer scope for action. A note of the institutions to which it is suggested that these provisions shoidd bo extended more or less completely as may be practicable in each case is appended.* The four hospitals of Victoria are managed by committees of the subscribers. The nature of their government has been described in section 36. The evils which exist in them are of a kind which would disappear unaer the influence of a sanitary act, and of more efiective inspection. But in those institutions where the provisions above described might be adopted, they would at once cut off the source of those two great classes of defects which flow from divided opinions and want of specific knowledge in the governing body ; they would make abuses of omission more rare in proportion, as what is one man's business is more likely to bo done than what may be the business of either of several men : and though it may be true, on the other hand, that the plan of government by a sinjzle chief is compatible vyith the existence of greater positive wrongs than Any whicii the mere inefficiency of boards places it in the power of subordinates to practise, ^et sucli a plan, whilst giving greater power to commit them, would admit also of more comiilete and more manageable securities against their commission. Such seciu'itics are to be found in inspections and reports. • See Appendix, Note II. 17 51. Where these are wanting, there is no protection against the existonce Inspectors, of abuses even under good forms of government. Much less under the present forms is it possible to be satisfied of the non-existence in many cases of graver faults than any which are confessed, merely from their not appearing in answers made by officials who are not under the check of regular and efficient inspection, and who, if they are responsible, have a strong reason for ilence, or, if they are so little responsible as to be relieved from fear of blame, must be ill situated for the acquisition of any certain or intimate knowledge of the conduct of their subordinates. It is suggested that in all cases there should be general inspectors not otherwise connected with the institutions, whose duty it should be to make regular and irregular inspections., (^specially of the sanitary arrangements, to receive the reports made by inferior officials and by unofficial visitors, and to report at stated times to the Governors, suggesting measures which may appear necessary. The institutions already subjected to such inspection are, with one temporary exception, amongst the best of the whole number, and they owe their excellence to the exertions and suggestions of their inspectors. The faults which they still retain are those sanitary ones which it appears to be hopelees to attempt to cure without the operation of sanitary acts. In the larger colonies, with many institutions, it would be necessary to appoint two or more inspectors, and to give them regular salaries. In the smaller ones, where the work would be light or occasional they might be unpaid, or receive only fees for their reports. In addition to such general visitation, and to the present inspections by the boards and the Governors, it would be well that visits sliould also be made in all cases by judges and juries, and that their attention and that of casual visitors should be directed, by a regular form of questions, to those important points which are likely to escape their notice.* General inspections must be further supplemented by a better svstem of Reports, reports. Reports may be of three kinds. The first sort are reports of the actual working of a system made by the officers who carry out the system to the inspectors or other governing body ; and this kind cannot be too many or too minute, for they are the best, if not the only means of keeping the officers in a state of thorough attention. An attendant will slur over many things if he is to have himself for his sole judge, which he will do exactly and conscien- tiously if lie lias to write down an accotint of his measures, and of his reasons for them, for the judgment of superior authorities ; and the mere fact of having to state reasons will necessitate his having some reason in cases where he would otherwise act by impulse or routine. This is of especial importance in the case of those who have the care of lunatics. It ought to be the first principle in the treatment of the insane, to deal with them as nearly as may be as if tney were sane, and to infringe firmly when necessary, but otherwise as little as possible, both as a matter of right and for the purpose of cure, on their habits and natural independence. It is not more the business of a keeper to do all that is necessary to supplement what is wanting in the judgment and self-preservative instincts of the patient, than it is his business to do no more than this, and not to drive or confine him unnecessarily : and yet in practice those who have had experience of lunatic asylums say that nothing is more common than causeless tightening or relaxing of discipline in particular cases, without consideration of whether there is any reason for so intcrferiiig or neglecting to interfere with the patient's inclination. If the keepers were required to report both the particular departures from rule, and also the reasons for them, they would be less likely to act without reasons. lu this view it is greatly to be desired that it should be made a part of the duty of all head keepers or matrons in asylums rnd hospitals to report any case of exceptional treatment, and the reasons for it, and a part of the duty of the inspectors to examine such reports, and judge of the validity of the causes assigned. A list of questions to be filled up weekly by the chief keeper of each ward of an asylum with reference to this object has been framed by a Commissioner in Lunacy, and is appended in Note 5. A similar form for head nurses in hospitals ought to be obtained from medieal authorities. • Appendix, Note IX. ri02j D I 18 I Summary. This first kind of re^wrts would be for the information nnd satiifaction of the inspectors, Tlic! second sort are already to some extent in use, but require to be modified if they an; to produce much benefit. They are, general reports made at stated periods (1) by the medical chiefs, and (2) by the Inspectors where they exist, of the condition and fiirther requirements of the institutions. These reports should be as sliort as posslb! \ ".nd directed particularl y to certain prescribed points, and might be made semi-auuMally. If they were sent to this country and published in one general velume, together with Rejiorts of the kind next to be mentioned, and the whole rs-distributed throughout all the colonies, they would become a valuable means of comparison and of dis- seminating useful suggestions and true principles of management. The third sort are reports of a statistical kind for scientific purposes. It is no doubt very important that such reports should be periodically made up on an uniform plan, but they are involved in so many difficulties that it does not appear to be desirable to attempt to introduce them generally, except in the most simple form. It must be remembered that a mere numb, i nd that even if full statistics were obtained from all the cobnier, the area from which they would be drawn would still be but a small povtion of th(; globe, so tliat the importance of the returns would not by any means equal their number.* An extended form of statistical returns for lunatic asylums has been prepared which s intended to illustrate those relations which, seemed to be most important. This form has been modified by the Commissioners in Lunacy, who suggest that it sliould be tried as an experiment in one of the larger colonies. Canada would seem to be the best field for trial, both because of its nearness and because of the number of its asylums, and of the perfection of its system of inspection. There is also appended a short and ' manageable form for all other asylums, and another for hospitals. If more full statistics are desired from hospitals, it will be desirable to procure forms from the College of Ph\sicians, or to obtain a sufficient sanction for those whicli are given in Miss Niglitingale's " Notes on Hos^ntals" (1863), and wh'ch are not untried, and apjwar to be approved by high .authorities. There would be this advantage in enforcing somewhat elaborate returns — that whether accurately filled up or not, they would lead to greater care and diligence in tlie use of the ordinary ease-books and records. 52. To sum up the measures proposed ki the three last sections, it is suggested — I. That for those colonies, for the con^taon of which the Crown Is responsible, a draft ordinance should be framed to regulate all conditions of sites and construction in future hospitals and asylums, and to enforce such alterations in existing ones as may be necessary for the provision of proper sewerage, drainage, space, area, ventilation, water supply, light, and other sanitary recjnisites; and also, if this should appear practicable, to fix a minimum number of attendants in eadi kind of institution, with other permanent economical regulations ; and that the great expediency of framing and passing similar measures should be sugge^d to the legislatures of the o^nies which liave responsible governinents. II. Tliat where boards exist, if the local authorities should see fit, they * It would be necesRary in general t» Jimiiilie dejnwd fw returns to such as could le famished bv officers of ordinary intellicrence without any luireasonable amount of trouble. t • » ^ ■ '• t • liiotild be reniittee fnnctiona of appointing the medical chief, controlling the finance, hearing complainte ami reporting them to tl)e inspf^ctors or the GoveiUor, and visitation > wliilat, on the other hand, thoy shonkl be deprived of all executive i>ower, which shonld go to a resident medical chief; tnat their l^gislutive. power should cease, a limited authority to alter the regulations being transferred to the medical chief and the inspectors ; and that the medical chief should exercise the patronage and control of all oflices except that of the clerk or bursar, which ahonld remain with the boards, and that of the chaplain in the case of asylums, which should be given to the governor. III. Tliat inspectors should be appointed to visit and report, with especial reference to sanitary condition, and should have the power of suspending all officers, except the medical chief J That reports in the form given in Note 6 for asylums, and similar ones for hospitals, should be required to be filled up by uU liead keepers and matrons, and sent regularly to the inspectors ; That statistical returns should be demanded from the medical chiefs of hospitals and asylums, in the forms set forth in Notes 6 and 7 respectively ; That the more extended additional statistical form of Note 8 sliould be tried in the Canadian asylums, if the authorities should «ee fit. That the form of questions given in Note 9 should be required to be filled up by all official visitors, and sent to the inspectors ; and That the medical chief and the inspectors should make independent feports of the condition and requirements of the several ins*':utions, and that these togetlier with the statistical returns should be public . '. and redistri buted througliout tlie colonies. Should these changes be made, it would bo necessary to define and distinguish accurately the powers and duties of the medical chiefs, the inspectors, and the boards* 53. Theso three principal recommendations for Acts to regulate sanitary arrangements, for the transfer of powers from boards to single chiefs, and for more complete inspection and reports, apply equally to hospitiils and asylums. Of the following minor suggestions, the first six contained in Section 54, also are applicable to both -, t^e seven in Section 55, regard hospitals only, and the remainder in Section 56, h^ve reference only to lunatic asylums. One alone of the whole number (that in Section 56, v) involves any consi- derable expense. 54. Minor suggestions, with reference to both hospitals and asylums : — i. (a.) Open sewerage, sewerage into adjoining cesspools without outlet, and untrapped and unflushed sewerage, ought not to be permitted. (b.) As a condition of easy and effectual ventilation, as well as for econo- mical reasons, associated wards should in general contain not less than sixteen nor more than about thirty-two beds. (c.) It is equally necessary for ventilation that there should be allowed for each patient, 1,000 cubic feet of space, in associated wards, and 1,500 in single rooms in temperate climates, and a quarter more where the climate is tropical, and this in addition to thorough ventilation and frequent cleansing of walls, ceilings, and floors. (d.) In associated wards the total superficial space allowed to each patient, including the area of the bed, should not be less than 7 feet by 11, in general hospitals, and about 5J by 9 in asylums. The height of the ward should not fiiU short of 13 feet, nor the width of 22 feet. {e.) The air introduced by ventilation must not have been previously heated. Such heating destroys its purity and gives it unwholesome properties. The only proper means of ventilation are open grates and ventilating flttes. (/.) In very cold climates, as in Canada, sufficient warmtli cannot be obtained by iiot water pipes. Stoves or grates are the only efficient means. {g.) It is of great consequence that the wards should be well lighted. It is laid down by high authority that in hospitals the windows should be one third of the wall space.* {h.) Not less tiiun 25 galloris of water per putient per Minor Suggestions. uiCul, uXCiUsivi Notes on Hospitals, p. 1 9. D 2 20 Medical Chief. Ckrk. Sab-Chiefi. AttecdanCi* Diet. il f ral.iwatcr, should be providt'd. It shonld be cnrefullv analysed, to determine the proper material fur pipes and tanks. The tanks should be covered in. ii. The resident medical chief should have qualiiied both as a suiaeon and as an a^wthocary. He shonld pay especial attention to sanitary matters and to the conduct of the servants, and should have the cliarge of all records, and frequently inspect the wards, cells, and every other place, and the provisions in store. In cases whore the lowers of boards may be transferred to him, he shonld have the same powers of suing for all duos and debts to the institution which at present belong to the boards. iii. The clerk or storekeeper should examine all contract supplies before acceptance and all tlie stores daily. Ho should give the security of a bond for the performance rf his duties. He may be non-resident. iv. The institutions should be in pM cases divided into sections, each under the superintendence of a head matron or keeper, wliose especial duty it would be to enforce cleanhness, and overlook the inferior attendants, and to make daily reports to the medical chief and to the inspectors. Such head attendants ought ti be well erough paid to make it an object to tliem to keep their places by Zealand lionesty. V. On the character of the attendants depends in a great degree, espe- cially in asylums, the comfort, tranquillity, and chances of recovery of the diseased. Their wages ought to be liberal, and they should rcL-eivo periodical increase for good service. They ought to be, if possible, sufficiently well educated to be able to read to the patients. vi. Patients ought not to be limited in the quantity of their food by way of punishment,'^ unless with the express authority of the medical chief. Also the food should be from time to time varied in kind, and sliould be, so far as may be practicable, assimilated to that naturally used by the patients. 55. Suggestions with reference to hospitals only : — i. In many of the hospitals the existing small wards should be consoli- dated wherever it is practicable, by removing the partitions. ii. Provision should be made for limiting the period of office, if not in the case of the medical chief, at least in that of the other physicians and surgeons. Such a system was tried by Sir H. Barkly in Demerara, and afterwards by him introduced into Jamaica. It is said, by increasing the chances of appoint- ments, to induce the immigration of students. iii. There will almost always be private practitioners who would be willing to visit as honorary medical officers. The external element thus introduced would be of great value. iv. In everv hospital having twenty beds or more there should be at least one resident medical officer who sliall not be engaged in private practice. v. With proper provisions for sufficient space, area and ventilation, contagious and infectious diseases, with the exception of small-pox, may be recei\x>d in limited numbers in general wards appropriated to adult patients. vi. In wards containing less than thirty patients, the proportion of nurses should not bo less than one to seven. For any number of patients not exceeding forty contained in a single ward one night nurse is sufficient. For forty distribut(!d in two or more wards at least two night nurses are required. vii. Whore there are many native or Indian patients there should be a native or Indian employed to advise as to prejudices and requirements. It is founc' in Mauritius and elsewhere that natives are very unwilling to entelr the hospitals. 56. Suggestions as to asylums only : — i. The provisions regulating the admission of lunatics into asylums are not in the majority of the smaller colonies sufficiently definite, or calculated to exclude the possibiUty of abuse. The forms which are prescribed in Nova Scotia* seem to be well adapted for such small colonies as have not regularly organized Lunacy Conmiissions. The certificatos should be made upon oath. ii. Classification of lunatics is generally precluded by the nature of the buildings, but its want is in some of the returns made a matter of regret. It is, thcrefon;, necessary to observe that all recent experience has proved much classification to be generally injurious. Many lunatics of one type Appendix, N"*" IV. dt confined to their own society only become confirmed by one anothor'8 example. iii. 'J'his rule docs not extend to the case of idiots. They are imitative, and are only made worse by contact with the positively insane. There is no doubt that they ought to be excluded from the general asylums, which they in several instances encumber, and which ought to be retained for those who are curable or dangerous. iv. Where restraint is necessary the arms alone should be confined, and it is less injurious to the patient to be allowed to run or leap and work off his excitement with his legs free in a padded room, than to be forcibly held down by t'lc strength of attendants. V. The most important means for the proper employment and n.muse- ment for the insane is a sufficiency of land for exercise and for cultivation. The Chief of the Toronto asylum, which is the best in Canada, says that " no curative means had recourse to in the treatment of insanity can be compared to thu^ of moderate field or garden labour." The Canadian Inspectors- General of Asylum?, Prisons, &c., perpetually urge the necessity for additional land. "Tlie cultivation of the soil," they say, "is not only the most pleasing Canada, O. \3. occupation for the insane, and that in which they are apt to take most interest, but it is also the one moot conducive to their bodily and mental health, and bears most directly upon the diminution of expense to the Government in their support." And again, '• It is held by all writers on insanity that employment Canada, 0. 87. in the fields has not only a most beneficial tendency as a curative process in the treatment of the patients, but tliat it is, at the same time, a kind of employ- ment in which patients can be induced to engage when they will refuse to do anything else. It is also a work in which many of them, though unwiUing at first, come to take an interest, keeping alive the faculties of the mind, while it ministers to a healthy exercise of the body." In the United States, it is asserted in the report of the Toronto asylum, no new public asylum is allow-ed to be established without at least 150 acres adjoining ; and tlie Commissioners in Lunacy of this country have laid it down that the land belonging to an asylum should, wlien practicable, be in proportion of not less than one acre to four patients. It may, however, be doubted whether in tropical climates, out-door labour can be so extensively or beneficially employed. It would be desirable to invite suggestions from experienced persons as to this point, and as to the best substitutes which may be practicable. Other means which may be suggested as of proved or obvious value are gymnasia, regular military drill, regular festivals to vary the monotony of life and provide subjects for expectation, music, books, newspapers, and games, which it would be superfluous to mention if the inventiveness of the officials did not at present, in many asylums, limit •*^'?elf to walks in airing-courts and menial services.* It is to be added that, since the insane in many cases are, and generally might be, employed in profitable work, there ought to be stringent regulations to prevent any being retained in confinement for the value of his services, an abuse of which there liave been instances both in this country and in the colonics. With tl:id object the attendants should be forbidden to derive any profit from the labour of the patients, whose work should be estimated, and the surplus value, if any, after payment of the cost of their treatment, be refunded to them on their discharge. vi. Rewards in money, or otherwise, for good behaviour have been found to be beneficial. vii. Tlie friends of patients should be allowed to visit them on any days if thev live at a distance, or one or two set days in each week if near, subject only to refusal by the medical in chief, the precise reasons for which refusal should be in each case noti.'^ed to the inspectors. viii. The proportion of attendants should be not less than one to fifleen patients. ix. Separate cstablishnignts should if possible be provided for incurable patients. They are an i*- cunibrance in curative institutions, and can be more • It is not meant that there is anything necessarily objectionable in employing to a limited extent, on some kinds of menial serv ce, patients who have been used to it nt home. But in no^case should such employments be the only or the chief resource. I cheaply maintuinwi uepurately. {Stt Report of the Stjlect Cominitl J of tb» Houae of Umh on the State of the Lunatic Poor in Irelaaii, 1843, p. x%^ ai»d»8. 3806-3H10.) 57. Thesi auggestiona are based cliiefly on tlie reports an*', recomnien- dationB of the Comniiitisioners in Liinecy, on (he facts carot'ull) rollectetl and ilhiBtrat^d by e)*i)erienee in Urn NiditinKaloii "Notes on Hospitals," and oil the statements of the detects actually existiiig in the colonial hospitals and Hsylunis. The rides with reference to the residence? of a medical otficer in hospitals, to his restriction from private practice, to the size ot wards, the space and area proper to be allowed to each patient, and the admission of eases of contagious and infectious diseases in general wards, have l)oen subnuitted to the Royal College of Physicians, ami have received tlio sanction of its approval and concurrence. [iS. In conclusion it is to be observed, that it is vain to expect complete or permanent reformation until the existitis systems shall have been changed by the transfer of powers to efficient ami responsible persons, and by provisions for mor*^ complete and more authoritative iiis{)ection8 supplemented by more practical reports, or until some moans shall have been found for enforcing regard to the primary and indispensable conditions of sanitary security. The measures which have been proposed for the al tain- ment of these clJef ends involve great changes and diilicultios, out any reform which should be cffectuar would save as great difficulties in the future as anj which would have to be encountered in the present. The state of these insti* tutions, if they are allowed to remain unaltered or half reformed in essential points, will long be a perpetual source of increasing complications, to be patched up by expensive makeshifts ; whilst if these primary conditions are secured tbcy will quickly and inevitably draw with them all minor reforms. Though such reformation cannot be thoroughly effected in most cases without heavy initial expense, it would be an expense not wholly barren of returns. The outlay would produce good interest in tlie forms of speedier and therefore cheaper cures, of increased capabilities whicli wouU delay the oflen pressing need for extension, and in the ciuicker restoration of the sick to profitable labour In this country it is calculated that every death of art agricultural labourer at the age of twenty-five involves a loss of more than 200/. to the wea'th of the nation, and though the value of a labourer in the colonies may in soine cases be less than his value here, in most it would be much more. Another illustration of the economical difference between good and bad avstems may be taken from Miss Nightingale's " Notes on Hospitals." It is there calculated that in Europe the anuuul cost of properly ni rsing 1,000 patients in wards of nine beds would be 12,832/. 5s., and in wards of tliirty beds, 6,GG0Z., or not much more than half< However this ma) be (and it is the calculation of one than vvliom no one has had greater experiejice), it is certain that the difference would be great enough to make reform dein;-t;ble even from the point of view of interest. To this is to be added the considera- tion of justice to those whom it is pretended to cure. There is no excuse for any preventible excess in the rate*" ' mi . tality or duration of treatment, and if institutions of mercy do not conii . far as is reasonably practicable, to those conditions under which ,; ■ . • i u patients l.ave a ftiir chance of recovery, it must be a question iu numc cases whether they ought to exist at all. Despatches, 5,288, Mav2, 1863; 11.542, Nov. 5, 1863 ; 12,052, Nov. 24, 1863. Paht IV. 59. Jamaica.— The labours of the Commissioners appointed in 1 86 1 to report upon the Kingston hospital and lunatic asylum, and to suggest such measures as mig-ht to them seem necessary for the improvement of those institutions, liave left little to be done but to ascertain how far their recommendations have been executed. Great improvements, some of them dating froni a period before the Comraisoioii, have undoubtedly been made, and iu T[\tiny -mportsnt points the suggestions of the Commissioners have been, or arc in course of being;, carriod Into tfCrct. At the hospital, two out of thn tlirce bnil(Hn<»3 for male patients arc now in a generalh wtisfactory condition ; a n.uch-needed 8^8t(!m of drainage i^nd sewerage, though ciiefayed by the failure of the engineer, is at Inst in uro'^ress ; and out-pntients receive relief at the; houaft^ Of if neccssar"^ at thoir lionies. The new asylum also promises in a Bluirt time to be complete and effici( nt, and the two Institutions are at length provided pach with a separate medical staff, and both are subjected to a more complete nyatem of visits and inspection, by the Governor, by an honorary lK)ard of inspectors, and by an officer whose especial h.tslness it is to scrutinize their sanitary and linanclal arrangements. Hiit though many defects have b«!cn remedied much has yet to b" done, At the hoopital one male building remains unimjtroved and deficient in space and ftccorrmod.Uion. The fcmalo building in still as imflt an adjimct to an Institution I'f mercy as when it was characterized l)v the Comniissiohv-rs ns almost "cversi'i^r every condition vvhici, onght to be observed under such clrctimstauce*". It remains disgracefully wanting in every sanitary and structural requirement. (Sec. 6, supra.) In addition to tliesc deficiencies, both sides of the hospital are in- pijfttciently supplied with hot baths. Two only of the nurses are resident ; merely Innrm paupers still crowd the wards— "blind and paralytic, and utterly destituf, persons, who sometimes remain for a long serieH of \ears." One blind woman has been a resident for more than nineteen years. Tlie only declared faidts in the new asylum are the want of proper employ- ment ami amusement for the insane, and ot'lavntorles. Large grom^ds are being prepared, init in 1863 the only provision for the one^ besidt s menial services, was a barrel organ ; for th(* other, a basin in each ward. 'V(w only Information given as to space is a statement that the grcjs internal mt asurement of fho entire building gives 2,(K)0 feet to e?ch paticrt. Deducting walls, day roonid, servants' rooms, surgeries, gtore-rooms, passages, stairs, ik,e., it is to be feared that the single cells must be much too small. Considering the attention which the Commissioner- s id the Gcvernor have given to this subject, and their opportunities for acquiring; iilbrmation on the spot, it is improbable that ai y more efficient scheme o*' reform which should be- practicable can be inveiite-d at this distance, and with very imperfect materials for tbrm'ng a judgment. It is therefore suggested that' the attention of the Legislature and of the board should be again directed to the necessity of remedy'us:, as speedily as may be, the above-mentioned defects in the execution of the Commissioners' recommeudations, and, in i-ddition, tliat their attention should be called to the measures described in paragraphs 60 54, 65, and 66 A new set of rules tor tlic administration o ' the hospital have recently been drawn up, amended by the board of visitors, the Executive Conunittee, and the Lieutenant-Governor, and finally approved by the Executive Committee. The rules had been the subject of adverse comment by Dr. Bowerbank, tiie original instigator of inquiry into the state of the hospital and asylum, and some of the amendments were madr at his suggestion. He is still dissatisfied, but now that the attention of the Legislature and the Lieutenant-Governor has been strongly drawn to the subject, it does not appear probable that there can be any ground for further action in the matter of rules and regulations. Nor, supposing i^r. Bowerbank's views to be correct, do the points in which they have not been carried out appear to be of great importance. One only of his charges calls for remark. In his original dis.sont from ihe rules he said, " I am cognizant of the fact that the majority of the officers, nurses, and servants at present attached to this institution,' strange to say, were those emploved under the old r^j^ime and who thus, as they did or could see nothing wrong in the management, are likely now to adhere to their old ways and practices if altered [allowed?]." The Governor having called on Mr. Trench, tlie Inspector and Director, tor informatioii on this point, it appeared that fourteen of the attendants in the hospital and asylun? had been so employed, and further that five of them were proved by the evidence taken by tlic Conunittee to have been implicated in the former abuses. These five Mr. Trench was directed by the Governor to discharge >vithoi\t delay. It also appears that one of the present i.^edical officers had been attaclied to the hospital for the two jears ending in Marcli 184^, but no reflection Is cast upon his character. It is to 'be added that tlie more recent despatches disclose nothing which n'\-\i 24 Despatch, April 22, 1863. Despatch, May 12, 1863. Despatch, May 30, 1863. 60. British Honduros.— Lieutenant-Governor Seymour has not furnished any information in the form required by the circular of 1st of January 1833, respectinf; the hmatic asylum and public hospital at Belize, but reports that the two Institutions are supported with hberality, and that their inmates are kindly and attentively treated ; in proof of which, as regards the asylum, he adduces the fact that a lunatic has recently been released with his mind entirely readjusted. On the other hand he states that both tlie buildings are unsatisfactory, and that the necessity for a new as)'lum has been represented by him to the House of Assembly, which recognized the desirability of such a measure, but considered that the state of the public finances consequent on the fire of the 10th of March, 1%3. would not justify them in immediately proceeding to give effect thereto. Governor Seymour further states that Dr. Young, the late public Medical Officer, before his death, destroyed the records of all the public boards with which he was connected. That he should have had it in his power so to destroy all records, points to the inefficiency of the svstem of management and supervision. 61.' Turks Islands. — Tliere is no lunatic asylum in Turks Islands. The state of the hospital seems to be generally good, but there is no sufficient information as to details. It appears that there is no artificial sewerage, and the wards are too much sub-divided. The average space allowed to each patient is apparently under 700 cubic feet, an amount which is too small, but is said to be supplemented by good ventilation. The attention of the President and Council should be particrVirly directed to the sewerage, and to the expediency of throwing down tne partitions between the three sick male wards, and also those between the three sick female wards, an ?ltern.tion which would give some additional cubic feet of air to each patient, and would greatly assist ventilation. It seems also desirable to provide some system of out-door medical relief. 62. British Guiana.— Thore are in British Guiana tliree hospitals and asylums— a hospital and an asylum at Georgetown, Demerara, and a hospital at New Amsterdam, Berbice. The Georgetown hospital is extremely defective in its sanitary arrange- ments. The water supply is insufficient, and of bad quality in dry seasons ; the sewerage consists of open brick gntte'-s, and the latrines are allowed to be offensive for want of a pump or a water-lift. No more than an average of about 700 cubic feet of air are allowed to each patient, without any other means of ventilation than small windows, and at ihe date of the despatch there were no baths. The internal management is obstructed by indiscriminate admission, and the retention of numerous chronic and incurable cases. The total proportion of nurses is only as 1 to 16, and there are no more than 2 night nurses for 3,144 annual admissions. The supervision is merely nominal. Visitors are appointed for each month by the Directors, but they visit rarely, and the Governor had visited but once since his appointment in 1861. The asylum at Georgetown is very much worse even than the hospital, but the frame of a new building has been completed, and a vote has been passed for the necessary funds. No condemnation could be too strong for the present structure ; a collection of confined cells wholly unsuited for a tropical climate, almost without means of ventilation, with sewerage and latrines con- fessedly " faulty in the extreme," without sufficient, lavatories and without baths. No records of restraint are mentioned. There are absolutely no pro- visions for employment or amusement, and for exercise nothing but some small covered yards. There are no rehgious services. Some land which might be planted or cultivated is suffered to lie r.nused. Nor is this state of things to be wondered at \\here there are no inspections by superior authorities, and no information is required by or furnished to the Governor. A new building will avail little if it is to inherit the bad management and the want of supervision of the old. These two institutions are consolidated and governed by one board of administrative directors, who make the rules. The Colonial Surgeon- General is the cliief of both, and has the patronage of the inferior offices. At New Amsterdam, Berbice, there is a hospital, which is also a poor- house, and contains four cells in which maniacs are temporarily confined. 25 This also is to be given up when a new hospital shall have been built on lantt and with funds already appropriated. The site of the present structure is bad, and the buildings m utter dilapidation, happily beyond the possibilitv of repair. Each ^latient has about 800 cubic feet of space, not supplemented by ventilation. The sewerage and drainage are " very bad indeed." The latrines are mere soil-boxes. There is not sufficient accommodation for nurses, and there is only one doctor, who is non-resident and not restricted, and aided only by a resident dispenser,^ for an average of 116 cases under treatment. The management is vested in a board of seven mi^mbers, three ex officio, and four nominated by the Governor and the Court of Policy. , . , . , r. 63. Barbados.— The drainage of the Barbados hospital is on the surtace, and the sewage is collected in cesspools. Nothing is said of hot baths. Out- patients are treated onlv on one day in the week. There is no information as to whether the rules for visitation are observed, and there do not appear to be any reports of actual condition and requirements. The asylum is without sewerage or any but surface drainage, and its latrines are mere pits annually cleared, and which it is vainly attempted to deodorise by lime, soil, and dry leaves. There are no lavatories, and the only accommodation for bathing is in a single closet 6 feet by 7^. The most roomy wards give 958 cubic feet per head, but there are eight berths with only 450, and six with 453. There are no day rooms. The wards are much overcrowded, the ventilation very imperfect, and the west rooms (the smallest) have no windows. Employment is found for only ten out of fifty-eight inmates. Restraint by manacles and by seclusion appears to be very frequent. There are no religious services, and no regular visits of inspection. _ 64. Trinidad.— The state of the hospital of Port of Spain, Trinidad, is an honourable exception to the general condition of V»'est ln(han liospitals. Dr Mercer was appointed resident surgeon in 1857, and since that date great reforms have been made in every part of the institution. The last deficiencies, imperfect sewerage and the want of hot baths, will have by this time been supplied through his representations. It only remains to provide lor the continuance of ^ the present good management by the introduction of a more complete system of inspection and reports. The hospital of San Fernando is governed in the same way as that ot Port of Spain, but is less satisfactory. There is at present no proper water supply but better arrpugements are in progress. There is apparently no artificial sewerage or drainage, and the latrines are mere boxes emptied daily by the convicts. It is inevitable that they should be ofiensive and unhealthy There are no lunatic asylums in Trinidad. G7. St. Vincent.— There is no asylum. ,,„,,. r .i The hospital is very small, containing only 20 beds. The size ot the wards allows only 600 cubic feet per head, but the ventilation is said to be perfect. The sewerage is open, and the latrines are merely deep pits, deodo- rised by lime. . , . ii /i\ rn i. Besides general improvements it is in particular desirable--( 1 ) Ihat a hot bath should be provided ; (2) that the sewer should be covered in and the latrines flushed with water and made to discharge into the sewers ; and m that the salary of the doctor should be increased. He receives only 501. ■oer annum for attendance on the hospital, the almshouse, and the out-patients. In other respects this seems to be a satisfactory establishment, thougli very small for the population. . , . 68 Grenada.— In the hospital of Fort George there is accommodation for 42 patients, but the numbe treated does not exceed 27. Ihe sewerage and drainage are said to be naturally good, bat it is imt^ossible that they can be sufficient without artificial arrangements. The system of visits and of reports is insufficient. , , , ,/./-. j- r 4.i.„ The lunatic asjlum is governed by the board of Guardians of the poor It is a very small institution, and not satisfactory. There is no provi- sion for sewerage or drainage, or, apparently, for latrines, for hot baths, or for employment, unless in menial services. The doctor is non-resident and visits only once in forty-eight hours; the immediate care of the lanatics being vested in a keeper and a matron at 76/. 12s. per annum seemingly divided ^v,p tven Therft are no reeular renorts, and visitation is rare Despatch, May 16, 1863. Deipatch, June 29, 1863. Despatch, June 11, 1863. Despatch, May 12, 1863. betvvccii trie fl02j £ 26 De»p«teh, Feb. 28, 1863. Despatch, April 22, 1863. Despatchei, Oct. 29i and Nov. 4, 1863. 6© To&fti/o.— Tobago has no pubMc hospital or lunacic asylum. There is an asvluni at Fort King George for from 12 to 15 aged and infirm paupers, which is" under the direct control of the Government. 70. St. Lucia.— In St. Lncia there are five hospitals -.—three at Castries, one at Sonfri^re, and ono at Vieuxfort. There is also one lunatic asylum at Asvlum, Castries.— It would be difficult to find any institution more- defective in almost every requisite than this. It appears to be completely under the control of the Government, and is supported from the general revenue, but the Government delegates all its powers without supervision to ft non-resident and unrestricted physician, who for a salary of 1 m per annnfflT visits this asylum weekly, and also attends at the Poor and Yaws asylums and the Immigrant hospital, and has out of that sun. to provide all medicines and surgical appliances for the thr institutions. Tiiere are m general only seven inmates, but their paucity cannot justify the absolute want of sewerage, drainage, latrines, baths, and lavatories of any kind. Three acres of and are annexed, but only one-twelfth of this is under cultivation, and tliere are no enclosures, airing-courts, nor other places available for out-door occupation." Strait-waistcoats, manacles, and (what has no parallel in any other colony) even chains, are used for restraint, of which no records are kept. The two chief attendants receive the very insufficient wages of 121. and 7Z. 4*. per annum respectively, besides rations. There are no religious services. 1 here is au annu-al report and a meagre record by the visiting physician, and occa- sional visits are paid by an inspector and by the officer admmistermg the government. It is not strange that whilst the annual admissions are stated to average two on the last five years, there have been eight deaths as against six Tliero are in Castries three institutions of the nature of hospitals, namely, an Infirm Poor asvlum, a Yaws asylum, and a-. Immigrant hospital. The Poor asylum is entirely unprovided with sewerage or drainage, and for latrines are substituted certain jars in a shed. There are no baths nor any lavatories except tubs. The visits are occasional ; the reports annual and numerical only. ^ _ . i ^ • * The Yaws asylum is similarly destitute of sewerage, drainage, latrme^, baths, and lavatories, and of proper reports. The Immi is no information as to the government of tliese two hospitals, but the visits and reports do not appear to be necessarily insntficient. It would appear to be desirable that the hospital at Vi.nixfort should be abandoned and its funds applied to the improvement and, if necessary, to the enlargement of the others. The smallness of the Island suggests such a measure, and the natural site they could easily be made efficient. There is but one lavatory for both sexes. With reference to latrines, as well as to many other important points, there is no information. The wards are excessively sub-divided, and so far as any meaning can be gathered from the answers, may be conjectured to aflbrd no more than from 500 cubic feet of space in the best to 330 in the worst berths to each patient, even this amount apparently including the whole thickness of the walls and This hospital appears to be governed by a board of directors composed of the Bishop and members of the councils. They are said to visit weeklj;, the Governor occasionally. No mention is made of the powers or responsi- bility of the board or officers. ^ . . w ... The lunatic asylum now affords room for about forty-eight patients. Twenty-two of these are allowed less than 640 cubic feet per head. Strait waistcoats, straps, manacles, and confinement are the means of restraint, and are used at the discretion of the superintendent, who reports to the doctor. The doctor is non-resident, and visits regularly only twice a-week. The patients appear to be employed chiefly in menial services. . , r • The Governor will have, by this time, drawn the attention of the Legis- lature to the drainage of the Holberton hospital. The other particular reforms which seem to be most necessary are, (i) with reference to the hospital —the formation of proper lavatories, the removal of the partitions which hi .der ventilation and multiply labour in the wards, the increase^^ the staff of nurses, and the appointment of a resident medical officer with full power and responsibility : (ii) with reference to the asylum, the disuse or enlargement of the smaller wards. , 72 iVms.— Nevis has at present neither hospital nor lunatic asylum. Despatch, There is a small institution for aged and infirm paupers, supported by 150Z. June 19, 1863. per annum from the general revenue ; and certain port dues will be allowed to accumulate for the purpose of erecting an infirmary for seamen, but no o-eneral hospital seems to be proposed. Two persons acquitted of capital charges on the ground of insanity are confined .n the gaol in all respects as the ordinary prisoners, with whom they suffer the ill effects of the failure of the Prison inspectors to perform their duties with regard to visitation and reports. It is to be desired that the8(; lunatics should be transferred, upon terms of fair payracnt, to an asylum in some one of the adjacent islands, where they would have a chance of curative treatment. 73 Dominica.— A Poor asylum at Morne Bruce with about eighty-nme Despatch, patients' a lunatic asylum at the same place with from three to six, and an July 28, 1863. infirmary at Roseau with about twenty-one, are under the control oi one board of Guardians nominated by the Governor, which frames rules and re<^ulations. All three are supported wholly from the general revenue. ** The poor asyltim is managed by a master at a salary of 80L per annum, and a matron, his wife, at 301. There Ls no resident doctor. The visits and reports are very insufficient. There is apparently no provision for sewerage, drainage, latrines, or baths. Rain water from the root is preserved lor *^"^ Tlfe lunatic asylum is an old military prison, wholly unfit for its present purpose. It is managed by the medical officer of the Poor asylum, but directly by the master of the Poor asylum, and by a resident keeper at 45Z. per aunura without allowances. Sewerage and drainage do not exist, and there are no baths nor apparently any artificial latrines. The six cells, of which only three are at present occupied, contain only 300 cubic feet a piece. There are no airing courts or other provisions for employment or amusement, lemale lunatics do not seem to be admitted, though, to judge by other islands, they must J <^„ ;« „,,r«Vvn.. Tiir. nniv roo-iator is knnt hv the Master of the poor- Despatch, May 21, 1863. Despatch, Sept. 26, 1863. 23 hous(> There is a strange provision in the regulations, that the few persons Juslices and Clergymen^v^ the asylum shall not commum- cate with any inmate without express leave of the medical officer As to the Roseau infirmary there is really no information of value, but the little which is given shows a very bad state of things, with "» /'n^e™"; Toothing is said of the sewerage or drainage, or of the nature of the latrme whicli is said to exist. The lower wards give only 800 cubic feet per head, apparently without ventilation. There is no resident doctor, no visitation, no reports. A visiting committee was appointed two or three years ago, but has neve" visited. „ , , -a. i j i„.v, ;« 74. Mauritius.— The sites and buildings of the hospital and asylum m Mauritius are small and ill-situated, and there seems to be but one opinion as to the nocessitv for erecting new structures in more convenient localities, .he desirabilitv of such a measure was pressed by the ate Sir William Stevenson upon the Council, and recognized by both the Medical Charity Commission of 1859 and by a Committee appointed in 1860 to consider the Governors minute; and 'though its execution has been delayed by the precedence given to railways, Major-General Johnstone (Acting Governor) is of opinion that there is now both necessity and opportunity for immediate action. Money is more than usually plentiful, and the activity of trade renders the present sites and buildings so Valuable for commercial purposes, that they would now br ng as much as 45.000/. towards the 80,000/. which would be reqmred for the new establishments. , , , ,> , ..^ ^.i, ,f In the internal management of the hospital, no defects appear except tUat there is no resident or restricted medical officer, nor any regular system ot visitation by superior and independent authorities. The asylum also seems to be internally dehcient in notliing but means for occupation and aniusement-a want which is in part the result of the smallness of the present site, ar.d ought in another situation to be remedied by means of a sufficient endowment of land. The Acting Governor adds a strong appeal for the establishment ot new district hospitals for Indian immigrants, who have increased in numbers from 79,736 in December 1851, to 243,770 in June 1863 Sites have already been selected, and plans and estimates prepared at the instance of Sir W. ^Ts." Canada.— There a-e in Canada 7 lunatic asylums more or less under the control of Gov. iment, 5 in the Upper and 2 m the Lower Province, which give re\v to a yearly aggregate of 1,375 patients, at a cost of about 150 dolla per head per annum. The^' are, witli one exception, almost entirely supported by public mone^ That ot Toronto appears to be, of all the seven, the most effective, a result which is partly owing to the consignment of its incurable patients to Maiden University and Orillia, the two litter of which institutions are aftihated to it, and are under the control ot its head officer. Rockwood, which is as yet incomplete, is devoted o criminal lunatics. The St. John asylum is small and bad, but will, probably, shortly be replaced bv a larger building. It had been some time smce proposed to remove this establishment to a large unoccupied barrack, and the stall ot officers had been proportionabiy uicreased ; but at the last moment the transfer was prevented by f •. resumption of the building for military purposes. Ihe asylum at Beauport U the oldest and the largest. Being a private institution, and receiving no public money, except fixed payments for the care of some lunatics sent to it by the Government, it is uncontrolled by superior authorUies, except in the matter of inspection, which, in this instance, is carried out by a special commission. . • j a.,.« There are a number of private hospitals which receive no aid from Government , and are not subject to inspecti ' ut are known to be in a satis- flictory state. There are also eight private , pitals in Upper, and the like number in Lower Canada, which are subsidised by the GoN^rnment to the amount (in the last year) of 36,000 dollars for the Upper, and 17,400 tor the Lower Province. These also are free from supervision, but are believed to be well managed. Lastly, under the control of the Government, arc a Marine and Emigrant hospital at Quebec, and a Quarantine hospital at Grosse Isle. At the first of these 1,242 in-patients and 1,032 out-patients, chiefly of the class of sailors ana rccciu luimij^rauw, \veic tr-aan, .•• • - — : "' 7" :'\ mi from 16,000 ^o 20,000 dollars, besides payments from the wealthier sick. 1 lie 29 Quarantine hospital, at a cost of about 6,000 dollars, admitted, in the last year 367 cases. It is well situated, in extensive grounds. All these piiblic hosviiials and asylums are more or less under the control of a sveneral board of " Insj^ctors of Asylums, Prisons, &c.," five in number, who inspect and report specially, as may to them appear necessary, and also, at the end of each year, make a general report, vvhicli, with particular reports froir. the head officers of the several institution^, is presented to the Governor-General, and published. These reports are clear, comprehensive, and practical. . i • * „„ From the most recent reports, and the answers to the circular interroga- tories ^ npears that the two hospitals, and the Toronto, Beauport, and Rockv r.:- ; .vlums, are in a generallv satisfactory state ; but that the asylums of M ::., ''rillia, University, and St. John, and especially the three last, are defective in many points of structure and accommodv.tinn. In all, the internal economy and the treatment of the patients are said to be all tliat can be desired. It remains to point out particular defects in their material resources. In no one of these institutions is sufficient space, according to modern standards, allowed to each patient. , r .. i The Marine hospital requires artificial ventilation, and a bettev supply of water by means of a force-pump from the river, or by the addition of a large tank. , • i i. * •« ' The Quarantine hospital is built of wood, and is much out of repair. It is used only in tlie summer months, when the navigation is open. The Toronto asylum is ill-ventilatcd. Dr. Tache, in his able report, says that it ought to accommodate more than the present number of patients. The great rcciuirement is more land for purposes of recreation and employ- ™^" The defects of the Orillia Branch asylum for incurables are, the smallness of the space— onlv 500 cubic feet— for each patient, in the associated dormi- tories, and the want of land, of which there are only 8L acres. Ihe fences are also insecure, a defect which necessitates either excessive confinement and restraint, or a large staff of attendants. , „. ., -p u K„f u ic There is no particular information as to the University Branch, but it is said to be inferior, and to require more land and a better water-supply. At Maldea an average of only 550 cubic feet of space is allowed to each patient in the associated rooms. There is a sufficiency of land. The Proprietary asylum at Beauport is overcrowded. A recent structure, called " Biohardaon's building," is reported to be defective. ■ The Rockwood Criminal lunatic establishment is about to be transterred to a new building which is in course of erection by convicts. It is to be desired that immediate steps should be taken to transfer the inmates of the St. John's asylum to some better structure, f he present buildincr is wholly unfit for its purpose. The account given of this institution is that Ft "is still continued in the old building, formerly used as a court-house, which is only 60 feet by 40 outside, one story being 10 feet high, and the other, gained from the roof, only 9 feet. The dormitories, with an office of most contracted dimensions, a store-room, and a lavatory, occupy the whole building. There is no day-room nor dining-hall, but tlie former passage of the court-house "/made to do duty for both. Into this space 28 males and 29 females. 57 in all, with tlie necessary attendants, arc packed. It is impossible .o convey bv words an adequate ide:. of the miserable condition of this Asyhm. * Its condition is so bad that the interrogatories ar.i said to be inapplicable. All these asylums, except Beauport and Maiden, urgently require more land for the sake both of economy and officiency. „ , , ^, The Inspectors-General report (1st April, 1863) that lunacy or the number of candidates for admission into asylums is greatly on the increase m Canada They recommend that no expensive improvements or enlargement should be made at the Maiden asylum, which is a barrack, and niay at any time be required for military purposes, or at Orillia, where a sufficiency of land cannot possibly be obtained, except at too high a rent, or at Umversity, which is held rn a precarious tenure. With reference to the Upper Provmce * Canada, Despatch 9,676 of 1863. Inclosurs O, p. 14. JO they recommend — (i) the .immediate completion of the extensions at Roclc wood ; and (ii) either the construction of another new asyUim or tlie comple- tion of that at Toronto, according to the original design, by the constr\iction of wings, a plan which would save time, and would increase the facilities for classification and for economy of labour in the present establisliment. Some 3uch measures they consider imperatively necessary. They also urge (iii) the addition of hospitals to all the asylums. With reference to the Lower Province, they state that there are at the present time nearly 130 insane persons who are improperly provided for, in gaols and otherwise, and 60 who cannut find any accommodation at all. And (iv) they represent that there is a pressing necessity for the erection of a new asylum, with proper grounds, in the western part of the Province to replace the miserable make-shift at St. John's. Despatch, 76, A • Brunswick — New Brunswick, with a population whicli in 1851 March )6, 1863. reached 19o,800, has no pubhc hospital. It can hardly be that none is wanted in a colony which provides for an average of 178 lunatics. The Governor reports that the colony has reason to be proud of the condition of the asylum. It 's managed by a board of five unpaid Com- missioners appointed by the Governor. But it is insufficiently heated ; there are no lavatories, and no proper means for amusement in winter. There are no records of restraint, nor any visitation except by each Governor once in his whole term of office. There is an urgent necessity for some proper system of inspection and reports. Despatch, 77. Newfoundland. — The defects of the hospital are that the sewage June 30, 1863. collects in a cesspool adjoining the building ; that there are no baths except one slipper bath ; that only one portion, recently added, has any ventilation, whilst in nine of the wards the space per head is less than 700 cubic feet ; and that the reports are insuflScient. This hospital admits contagious cases, and no mention is made of any resulting inconvenience. The defects of the lunatic asylum are, that though designed for only 77 patients it is crowded with an average of 88^, and has once admitted i07 ; that some of the dormitories (and those the single ones, whicli ought to be especially roomy), give only from 510 to 561 cubic feet of spaces that there is a great want of more commodious airing-courts, and of better means of amitsement and employment, especially in winter, and tliat there are three criminal and violent inmates who greatly disturb the order of the establishment. Despatch, 78. ISovd Scotia. — A population which in 1851 reached 277,119 is without March 5, 1863. a pnblic hospital. The asylum is unfinished, very insufficient for the wants of th^ country, and crowded with helpless mbcciles who ought not to be; suffered to lessen the means of a curative institution, and who would be better off else A'liere. The associated dormitories allow only 510 cubic feet per head, and the^)ortion first built is damp and out of repair. The medical superintendent further asks for an airing-court for malf;s, and some other small impr'-^vements which may be left to local care. In other respects this asylum appears to he very satisfactory. Despatch, 79. Prince Edward's Island. — Prince Edward's Island is also without a Mav 13, 1863. public hospital. At the asylum drainage is effected Ijy an open gutter leading into a cesspriolj and the latrines can only be cleansed by hand. The basement cells allow only 323 cubic feet per head, and none of the rest exceed and few approach 600, an amount which it is needless to say is very insufficient. Nor is there any means for ventilation except the nominal one of window s. The means for employment are equally deficient. It does not appear that there are any records of restraint, or any reports except the statutable annual return. The combination in this case of a poor-house with a lunatic asylum is believed to be exceedingly prejudicial to bolli branches. Despatch, 80. Bermudas. — There is no hospital in the Bermudas. March 20, 1863. The asylum is one of the worst specimens to be found in the colonies. The site is bad and cold, the wails damp. The rooms are too few, over- crowded, ill-constructed, draughty in wniter, ill- ventilated in summer, and so small as to give in some cases no more than 540 cubic feet of space to each patient in single cells. There is no sewerage or drainage, and the 31 rafrincs . re mere pits without outlet of any kind, and are extremely oflcnsive. " Besides these there are in each ceil fixed commodes with a copper basin and chain leading to a pit placed either below or at the back of them— a pit for each commode; and as these are open throuf^hout, having no effluvium-traps, or convenient provision for frequently flushing them, tliey are fruitful sources of bad smells, as well as disagreeable objects to look at. Those attached to the noisy ward are made to open into a court at the back of it, overlooked by the windows, and arc especially disgusting." Tlic water-supply is incon- veniently arranged, and the baths and lavatories so defective that it may be said that there are no provisions for cleanliness. There is a warm bath, but it is so placed that its effects are neutraUzed by the necessity of passing from it through a cold and exposed passage. There is no land cultivated by the patients, nor are there any sort of means for employment or exercise. There IS a shower-batli in tlie " noisy ward,'* whicli it may be suspected is turned to no good purpose. The entire control is vested in the head keeper, who manages the stores and keeps the accounts, and seems to be practically irresponsible. The medical superintendent is non-resident, and receives only 60?. a-year, out of wliich he lias to provide all medical and surgical requisites* an arrangement wliich requires po comment. The tliree ex officio Inspectors visit only twice in the year, the Governor never. Seamy reports are returned half-yearly. Under this system the average stay of the patients is over three vears. It would be very little to saj' of this institution that it had better never have existed. Considering the defects of the present building, and that there is a great demanil for increased accommodation— a very large per-centage of the inhabitants of the Island, of all classes, being asserted to labour under or to be predisposed to mental derangement— a new structure seems to be urgently required. The plans ought to be prepared by some competent engineer, and submitted to the Home authorities. 81. GamiJa.— There is no lunatic asylum in Gambia. Despatcu, The hospital stands low and to leeward of a malarious swamp. It contains M»''«n 24, 1863. about thirty-two berths, with about 700 cubic feet of air per head, which is insufficient" of itself, but is to some extent supplemented by good ventilation. There is no sewerage, and the drainage is open. The one latrine, 'situate about thirty-five paces to the south-west of the hospital, is emptied when necessary, and the contents thrown into the sea." In otlier respects it i-eems to be good. The Governor visits very frequently, and is stated to be the sole author of its general efficiency. 82. Sierra Leone.— About 595 patients are annually treated in the Free- Despatch, town i ospital, which is under the immediate control uf the Colonial Surgeon. April 18, 1863. The wards are too much crowded, but are said to be well ventilated. There is no resident medical officer. In the Kissy asylum there are great sanitary deficiencies : the drains are open, the latrines discharge themselves into ci sspools, and the average space per head'isonly 003 cubic feet. The management is intrusted to a supeiintendent at a salary of 50/. per annum. The two Colonial Surgeons visit on alternate days, a system which it is difficult to reconcile with the rule of the asylum, ■ which req"uires the " Medical Attendant " to inspect the whole establishment three tiuies dailv. There are no regular visits by superior autlioritics, and the reports are insufficient. It. does not appear that any records of restraint axQ pieserved. A system can hardly be satisfactory which leaves the management to an ill-paid keeper. One of the visiting surgeons should at least be required to visit, inspect, and give orders for every part of the institution daily, and tints to bo made responsible for its condition. The same visitors inight inspi?ct and report on both the hospital and the a.sylum. It appears tliat there is also a Quarantine hospital at Kissy, which is used tor infectious cases. ]!^o details arc given Despatch, Feb, 26, 1863. 83. Gold Coast. — The hospital of this colony was closed in 1831 in conso- quence of the refusal of the people to pay the poll-lax. 84. St. Helena. — Tlie only apparent deiiciencies of the public liospital of Despatch, St. Helena are its bad ventilation and tolal want of regular vis. ts of inspection, July 13, 1863 and ilie insuiScicucy of reports. Deapatcbei, 1j6S. Despatch, June 22, 1863. Despatch, Feb. 16, 1863. Despatch, May 27, 1863. 82 There is a parochial Pauper asylum, with about eight lunatic berths, supported by parochial funds, which is in a very bad state and destitute of any artilicial sewerap:e or drainage, and of baths and lavatories. The latrines are "verv primitive." There is no sufficient ventilation. The patients are onmloyed' in menial services. Restraint is said to be very rare, but is unre- corded. The parisli doctor visits when summoned by the keeper, and the Colonial Surgeon occasionally. " Neither register nor records are kept." and the Governor never visits. ' There is no information on several important points. as. Cape of Good Hope.— (I.) The Somerset hospital at Cape lown appears to be in a satisfactory condition, except as regards visitation. (2./ The Albany hospital at Graham's Town is in part an asylum for aged paupers. Tlio government is vested in a committee of management, members of which visit and report frequently. Under the prcient system a resident lay-superintendent is the immediate manager, and there are two non-resident visiting doctors, with honorary salaries of 25/. per annum. It is to be desired that greater powers and direct control over the whoh; eatablish- raeut should be given, with an increased salary, if necessary, to one of these. A proper outfall should also be substituted for the cesspools into which the sewage at present flows. (3.) The hospital at Port Elizabeth is sanitarily very imperfect. There is no drainage, and no proper baths. The latrines and the ventilation are very bad. There are two non-resident medical officers. A similar transfer of powers and responsibility to one of these is here also desirable. (4.) The lunatic asylum at Robben Island is in a very bad state, with much contemplation of improvements, for some of which funds were granted in the last session. It is under the management of a surgeon-superintendent, who acts under rules laid down by the Governor. The i)resent rules were framed at a time when the asylum was much smaller than it now is, and require alteration. The sewerage, drainage, latrines, water-supply, lavatories, and baths have been, and indeed, even at the present time, still appear to be, bad and defective in the extreme. The space allowed to each patient is, from over- crowding, only 500 cubic feet, and there are no day-rooms. There is no system of' subordination amongst the attendants, who seem to have been left to perform their duties in their own way, without check or supervision. These defects indeed are all said to be in course of being remedied, but there are others which equally deiri^nd immediate reform. The patients are employed in menial scirvices, and frequently subjected to mechanical restraint on frivolous grounds — for " being fooUsh in manner and action," or for attempts to escape. The only regular visits are those of the General Medical Committee. There nre no proper records or returns of the grounds of detention or circum- stances of admission of the patients, and complaints are made that they are not admitted directly to the asylum, but are sent, in the first place, to Somerset hospital, whence tlie certificates are seldom forwarded to Robben Island, so that there are no securities against improper confinement. 86. Natal.— The Grey's hospital is also a lunatic asylum and a poor asylum. There is no artificial sewerage or drainage. The arrangement of the building, which consist of wards opening from both sides into a central I^assage, is very strongly objected to by the pliysician as preventing ventilation, and tending only to diff*use miasma, especially as the passage is bent at the ends by being continued through the wings. There is one non-resident doctor, whose powers and responsibility are not described. There are no regular visits, and none but an annual report. In the Durban hospital no fault appears, except that each patient has only 700 cubic feet of space, and that there is no system of visit!>f.on. The doctor is non-resident. t ,• i a 87. He%o/ffnrf.— There is no hospital or asylum in Heligoland. 88. Gibraltar.— The condition of the Civil hospital of Gibraltar is very unsatisfactorv. The drains are too small, ineffective, and very offensive ; the latrines very'badlv constructed and ill-placed. There is nothuig in the nafare of a lavatory, e-icept some tubs in an open yard. The smell of the kitchen diffuses itself over the building. Of the wards, the jnh Catholic,^ the 3rd Hebrew, the oth and Gth Protestant, and the Jst, 2nu, 3rd, and4lii lOmale 88 Venereal, are by much too small and overcrowded. The 5th Catholic and 5th Protestant wards, and two of the Venereal wards, are intolerably ofFenrfve from the poison of the latrines, besides being ill-ventilated. The 6th Protestant ward is occupied by a female maniac, who is a great annoyaiice, and should at once be removed to the asylum, which is not full. The nurses are too few, and are consequently worked day and night. Visits of inspection are rare and irregular. This institution seems to swSer from a divided command, a large portion of the funds being subscribed and controlled by different religious communities separately, and the subscribers of each persuasion being on bad terms with the rest. The lunatic asylum is a mere adjunct to the gaol, and seem.' to be very badly managed by a superintendent and his wife with 80/. per a':inum, and a male assistant keeper with only 25/., without allowances. The otores are kept by the superintendent, the accounts by the civil gaol?". There is no employ- ment or provision for exercise, except in walking. Records, visits, and reports are all very insufficient. There are only from four to Eve patients, but some better arrangement ought to be devised than one which leaves the difficult and delicate care of insanity to an ordinary gaoler. There is no information as to the nature of the powers, duties, or responsibilities of the medical officer. He should be required to attend personally to every part of the management, and the visitors of the hospital might conveniently extend their supervision to the asylum. 89. Labuan. — There is neither asylum nor civil hospital in Labuan. 90. Hong Kong. — There is no lunatic asylum in Hong Kong. In addition to four military and naval hospitals the».e is a Government civil hospital with about fifty patients, and a Lock hospital, which admitted 485 cases in the course of 1862, Thece two stand close together, and the same remarks seem generally to apply to both. Syphilis is the predominant disease, even in the former. It is reported that " water has lately been introduced within the enclosure, but has not yet been carried into the buildings. The sewerage and drainage is very defective. There are no proper water-closets. Everything is carried away by hand, but it is by no means easy to keep the dwelling free from noxious exhalations, especially in hot weather." There are no baths of any kind. The Governor visits once a-year, and receives an annual report. It does not appear that there is any other visitation or report. If, in tlie absence of proper visits and reports, it were possible to judge ifely, it would seem that, excepting the great sanitary defects above-mentioned, these two hospitals are well managed. 91. Tasmania. — Since 1860 the Civil hospital has been under the manage- ment of a board of twelve members, appointed by and responsible to the colonial Government. The asylum is administered by nine commissioners, appointed by the Governor. Oae female and two male wards at the asylum give only from 600 to 660 cubic ftet per head, but in other respects both these institutions appear to be admirably conducted, and the board and the commissioners are on the watch to improve them. 92. Victoria. — The Victorian hospitals are generally satisfactory, but not without defects. That at Melbourne is not visited by superior civil authorities. The Geelong hospital is sanitarily defective. Open drains discharge themselves into a gutter in the street ; the sewage collects in cesspools and is carted away, and there are no latrines. There are none but portable baths. Six of the wards allow less than 700 cubic feet of space per head, and none more than 820. The only visits are those of the members of the Committee of Management appointed by the subscribers, and the reports are insufficient. The report of the Committee for 1862 is very favourable. In the Castlemaine hospital there are no latrines within doors. The space allotted to each patient is very insufficient, the most roomy ward giving only 800, and the two worst less than 325 cubic feet per head, whilst the average is 533. The provisions for visitation and reports seem to be insufficient. The Committee complain that the action taken by the Government with reference to private contributions has, with other causes, prevented them from [102] F Despatch, March 20, 1863. Despatch, April 9J. 1863. Despatch, July 21, 1863. Despatch, Aug. 26, 1863. Despatch, June 20, 18b3. :t4 ^dtling « now fem^B ward Mid makilif other n9atm»tjj I* » » (6.) Institutions of which the constitution is not described. British Honduras - - " , t" • ' St. Lucia (Poor and Yaws Asylums and Immigrant and SoufriSre Hospitals) Natal (Durban Hospital) - - - - Cape (Somerset Hospital) - - - - Hong Kong _ - - - - 1 Institution 4 1 1 2 [102] • Answers have been received from Bahamas since the date of the Minute. G I Note III.— Appointment, Powers, and Duties of Inspectoin. The Canadian StatuUs U'2 Vict., cap. IK), prescribe accurately the mode of appoint- ment and the powers and duties of such « general hoard of inspectors as mijrht advan- tageously be imitated in the large colonics. Ill those smaller dopendcncie.'' in which it might not be practicable to establish salaried boards, it woidd bo necessary to redore the amount of the inspector's duties, which ."dght extend to — i. Making rules with regard to matters not provided for by the standing regulations. •• Summary suspension of any officer except the medical chief Stated and occasional inspections. The consideration of all rq)ort» and returns made by the chiefs or subordinate ofliccrs ; and Mcking reports, at stated periods, of the condition and requirements of the institutions. is to be observed that the Canadian .\ct makes the inspectors responsible for the condition of the institutions. However '^'ooc' a precedent th- 1 Act mav supply in other respects, to follow it in thi^ would be to stultify a reformation the main object of which is to fix the responsibility on those who can be most easily and effectually reached ; in other words, on one per; .i instead of on several. It is true that if tl.e boards are salaried, any member can be made practically answerable to whom individually a fault or omission can be brought home; but if the medical superintei.d^::t Is to have the yxecutive powers, he ought also to be responsible for their exercise, and in holding him so responsible there will be no difficulties of shifting or apportionment of blame. Though, therefore, it cannot be worthwhile to interfere on this one account witb a generally successful system, such a provision ought not to be introduced into new constitutions. n. iii iv, V. It '. Nsme in fait. ^ QiUklifiontioD. •. Ploce. „ ••. County, 4c. % Residence. '. Occupation. '. 1. Appearanco. 3. ConducL 3, CoDTenation. Note IV.— Form of Medical Certificate for admission into a Lunatic Asylum.in use in Nova Scotia (api)ended to No. 2,609, March 3, 1863). I, the undersigned' being** on the d in' of > • and in actual practice, hereby certify that I, day of 18 , at' , , personally examined , and -that the said is a person of unsound mind, and a proper person to be taken charge of and detained under care and treatment ; and that I have formed this opinion upon the Mbwing grounds, 1 . Facts indicating insanity observed by myself ; » ". State the informa- 2. Facts indicating insanity communicated to me by others ; tioD, and horn whom. Dated at-. (Signed) Two certificates are required in every case. Eadb examination to ^ jepantet KoTi. — All such certificates ought to \ie made upon oath, for better security. 37 Not* v.— Form of Weekly Reports by Uead-keeperit or Matrons iti LMnatio Aaylums. 1. Sute of WardR. „ Furniture and Bedding. 2. Number of patients restrained scclude» » >» And why Note VI.— (Jeneral Statistical Form for all Lunatic Asylums. Tablr 1. Vnatles T«t4l Nnmben rtmiiinlni; on Jaiiuiiry lit of put Year. Admitted during liiblequeut Yeur. Anniiit lamntei during luch Yt-ftr. DM. Diacliarginl. Cored. » Relieved c. UiilmpnjTed. Aversfte Stnjr of tlione DcHd ^r Dinclmrfrrd during the Year. Number of thoie who having entered before ■uch Year mill rema'r. Table 2. Remained over from previous Year. Admitted durini/ i)ia( harged. Average Stay the Ynir, 1. Recovered. t. Relieved. Ihul. Discharftrd during the Year. Malel. 'Femnlei. Ma\en. Females. Males. Females. Males. Female:' .Miles. Females. Vales. FemalfS. Uuia ■ Melaneholia Dementia General I'aialyiii DpilepHv Other ioTJM — Tablk 3. — Obituary for the Year. Number in Register or Name. Date of last Admission and of Death. Age at Denth and whether Singlr, or Mni.-icdor Widowed, before .\dmission. Mental and Bodily State on AdmiHsion. Duriitioii uiid Cause of Disorder. Aiii^ned Cause of Denth. t'ost Mortem E. Tabi,e 2.— Ages in relation to Result. Recovered. Relieved. Died. Unchanged. Total. Age at Admission. 0^ •So .2 S C o 1^ • CI c m u £ * C o u -a 1^ |1 1^ "Ho a u "So B CO .2 & Under 20 years From 20 to 25 years. . 25 to 30 „ . . 30 to 35 years. . 35 to 40 „ . . 40 to 45 yeais. . 45 to 50 „ . . 50 to 55 years. . 55 to 60 „ . . 60 to 65 years. . G5 to 70 „ .. Over 70 years Total Deduct readmissions . . Total of Patients . , ■ Table 3. — Form in relation to Probable Causes. • • • • Probable Causes, e.g.^ Bodily Injury. Grief. Drink. &c. &c. Tola Mania Melancholia Dementia . . General Paralysis Epilepsy . . Other forms Totals • • Table 4.— Form in relation to Education. Mania .. Melancholia . . Dementia General Paralysis Epilepsy Other forms Totals , Educated. Uneducated. 40 Table 6. — Form in relation to previous Occupation or Profession. OocttpatisD) e.g., i-J SiiHon. Soldiers. Carpenters. &c. &c. Totals. Mania Melancholia . . * Dementia General Paralysis Epikspsjr Other forms . . Totals .. !■ - Table 6.- -Form in relation to Duration oi Malady and to result. Cured. Dead. Relieved. Unclianged. Totals. 1 CO %* ■s a 1 f w ■s s D s ■a C a o o Under 1 montli. Under 3 months. Under 1 jcar. 1 a is o c o i O 1 u 1 1 1 tJ a us iS i o 1 g 2 > O ■a § s 1 D 1 « I i a t3 II N us o S © i o § a 3 1 o B « 1 1 1>» 1 c -a a D 1 o o Hanu MeUiibholu _ — — — — — — — Dementia „ General Paralysis EiMlapty . _ Other forms — _ — Totals Table 7. — Duration of Malady before ' Treatment in relation to Resul f, Cured. Bifd. Relieved. Unchanged. Totals. Duation of PrtMBt Att«k before -Trtatment. ■3 C c K JZ i 1 a o a i a i a >. c i 113 s i' i 2 o i S s 1 w e — 1.^ « c i c t. G X si 1 E 1 •6 1 1 1 i c 1 IC d i 1 1 « a (»» ax B 1 LA 5 1 = "2. E I 1 E t 1 1 £ B i i {= a ! J- i 1 s ? B i B s i .0 E 1. 6 '1 c 1 1 B 1 1 B S a 1 .a i'i i 3 -> 5 . ; >^ s2 S 6 Under 1 Week- a. Thia beine first attack i. Thia not beiiig fint attack _ - - - Under J Weeks— a. This being first attack ^. This not being first attack Under 1 Month- 0. This beiiig first attack 1. This not being first attack Under 6 Honths- a. Thia baing first attack i. This not being first attack Under 1 Year- «. This behjt first attack ... i. Thia not being first attack Over 1 Tear— a. This being firat attack ,„ i. Thia not being first attack - - - - - - - - -- ToUla ^ I These additional tables must be filled up in two sets, one for males the tjthhr i Was the food comfortably served, and of good qualitv? 3. 4. 5. 6 T r» iv I- . ' oc. ,i=u, aim oi gooa quality t 7. Uo the patients appear to be on good terms with attendants ? And in the case of lunatic asylums — -^a^aa. 8. Were the patients provided with sufficient means of occupation>nd amusement? I M I ll ■ ■■*' - '5