We think it will be generally acknowledged that the problem which the treatment of noisy, destructive, and dirty patients sets to their medical officers is greatest as regards their management at night. It is then undoubtedly that noise, destructiveness, and dirty habits have the greatest chance of getting free play, and it is then that the efforts for reformation have to be greatest. If these efforts are successful considerably more than half the problem will have been solved. It is to this part of the question, viz. the supervision of such patients during the night, that we desire in this paper to direct attention. At the outset it may be stated that our proposals are not theoretical. They are the result of practical experience gained during the past four years in the Sunderland Asylum. The special arrangements we propose to describe were instituted by one of us at the opening of the institution four years ago. At first a few cases were dealt with tentatively, but, as the first results were so encouraging, the number of cases was gradually increased, until all the patients who were restless, noisy, destructive, or of dirty habits came without exception to be dealt with. The asylum, situated at Ryhope, is a small one, containing only 350 beds, and on this account, as well as because it was new, it was conveniently suited for such an experiment. It may be well before going further to describe the arrangements now in existence there. There are 175 beds for each sex, made up as follows:—45 single rooms, one fully padded, and 2 half-padded; 2 small dormitories of 7 each, 2 of 13 each, 2 of 19 each, and 2 of 26 each. In the last two there is a night attendant, and one also in one of the dormitories for 19, which is the hospital ward. There is, in addition, a head night attendant who visits the patients in these dormitories and also all the remaining patients every hour, or oftener when necessary. There are thus 4 of a night staff for 175 patients. Though this is probably a large proportion compared to most public asylums, it is not claimed as a new departure in asylum management, as we are aware that in a number of asylums the advantage of having a large night staff is fully realised and acted on. The essential feature of the arrangements at Ryhope, to which we wish to direct attention, is the selection of cases placed in dormitories under constant supervision. Of course, all epileptics and suicidal patients are placed there. But, in addition, all recent cases of whatever kind, all dirty and destructive cases, and those who sleep badly and are in consequence inclined to chatter or be noisy, are also placed under constant supervision. Looked at from the other side, all single rooms and dormitories not under constant supervision are reserved for quiet and well-behaved patients who do not require any special attention during the night. This plan has been found to work exceedingly well, and since it was organised we have never had occasion to think of adopting any other. Another testimony to its effectiveness is that those of the staff who have the actual supervision of the patients and have had experience in other asylums are unanimous in their opinion that the arrangement is a very decided improvement. This opinion, let it be observed, is not based on the ground that now their duties are lighter than they were, because, as a matter of fact, they are more onerous.
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