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c. Internal rcononly.
(d.) Constitution.
(r.) Supervision and reports.
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13. 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 suffices 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 of perpetual medical care, and from the increased extent of important and difficult dütfes which are thus left to the ignorance of nurses overpressed with their own work.
Two more points of internal economy, which remain to be noticed, apply solely or chiefly to lunatic asylums. The first is the general insufficiency of means for the employment 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 inspectors 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 be left in each case to the Governor of the colony, or the chief' inspector of the asylum. Injudicious religious attendants may be worse than none.
44. The questions arising under the head of government will have to be considered separately.
45. Lastly, the most general defects after those of a sanitary kind, and not second in disastrous effect to them, are the want of proper supervision and reports. In the West Indian colonies the inspectors are committees of the managing boards, and are not likely to be zealous in reporting their own neglect, or to be able to detect in one capacity faults which they cannot see in another. Most of the Governors visit with more or less frequency, 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 hardly compensate for the want of specific knowledge. The Canadian institutions are the only ones which are subjected to a special body of general inspectors properly qualified and devoted to their business.†
Reports of some sort, 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 their 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 the defects discovered is chiefly owing to this want of proper provisions for inspection and reports.
16. 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 consequence 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 30-84 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, whilst at the Castries asylum 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
* See Notes on Hospitals,"
P. 54.
†There is a lunney commission in Mauritius, but its powers and duties are not described, nor do they appear to extend to supervision of the hospital.
average.
That is to say. esch bed in the Barivados hospital is emptied of a corpse twice a-year on the
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treatment. Even supposing that there had been no principles perfectly settled, it would have been better to have acted on doubtful ones as if they had been certain, and so to have tested and verified, or finally rejected them, than to have abandoned all rule and permitted what is certainly destructive. But there are some principles or rules which are perfectly well settled, and it is also well settled that these rules cannot be disregarded without increasing the rate of mortali y, and the duration and cost of treatment, and proportionately diminishing the capabilities of the institutions; and if there are such principles, it may be a question whether institutions of this kind ought to be permitted to exist except on the condition of their observance. Institutions of pure benevolence require regulation and supervision; much more do establishments maintained, as are some of these, merely as the cheapest mode of getting rid of a social obligation.
For the rest, the defects as stated in the accounts of the several institu- tions (Part IV) must plead for themselves.
PART III-GENERAL SUGGESTIONS.
48. It is evident that the objects desired in the treatment of the diseased. Objects desired in in curative hospitals and asylums are, that the greatest possible proportion of the managemen! patients should be cured and in the shortest possible time, to which must be of hospitals and
asylums. added in the case of asylumus that the normal condition and rights of the insane should be infringed upon in as small a degree as may be consistent with efficient management. It is not justifiable to rest satisfied with a less number of cures than the disease reasonably admits of, or with a system which permits any unnecessary restraint.
The means to these ends are of three kinds,-material condition and resources, provisions for the management and application of those resources, and guarantees for such proper management and application; and, setting aside the question of whether in each case sufficient funds are provided, a matter which must here be taken for granted and cannot be made the subject of any general recommendation, three cardinal conditions may be selected which it is necessary to secure, (and which being secured all minor improvements will follow almost as of course), and which are fit subjects for general measures. These are-
(1.) The primary condition of sanitary efficiency,
(2.) That the administrative and executive powers should be vested where they will be most effectively and responsibly exercised. And
(3.) That there should be ready and certain means of testing and verifying the good working of every part of the machinery.
These three points are by far the most generally important. Several minor measures are suggested by the revealed condition of the institutions and by the reports of experienced authorities in this country and in the colonies. and may, perhaps, be properly pressed on the local administrators by way of. suggestion and advice.
49. The first condition to be considered is that of sanitary efficiency. For Sanitary Act. all defects in this kind, taking into account the prevailing ignorance, or the disregard of what is known, there seems to be but one remedy which would be certain or continuing in its operation, namely, the introduction into the several colonial Legislatures of bills to regulate the construction and sanitary state of hospitals and asylums.
It is difficult to see in what way such a bill could be resisted unless its provisions were extravagant. The class for whom such institutions are intended, they are treated at all, have a strong claim to be treated according to the conditions which seientific experience has found to be indispensable.
But as the poorer colonies (whose institutions are often the worst) could
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