The Construction of Hospitals for the Insane
PART I.
Chapters 1 - 10- Chapter I
- PRELIMINARY REMARKS
- Chapter II
- DEFINITIONS OF INSANITY
- Chapter III
- FREQUENCY OF INSANITY
- Chapter IV
- CURABILITY OF INSANITY
- Chapter V
- ECONOMY OF CURING INSANITY
- Chapter VI
- HOSPITALS THE BEST PLACES FOR TREATMENT
- Chapter VII
- DIFFERENT CLASSES OF HOSPITALS FOR THE INSANE
- Chapter VIII
- STATE PROVISION TO BE FOR ALL CLASSES
- Chapter IX
- THE ASSOCIATION OF MEDICAL SUPERINTENDENTS OF AMERICAN INSTITUTIONS FOR THE INSANE
- Chapter X
- FIRST STEPS TO SECURE A HOSPITAL
- Chapter XI
- FORM OF LAW FOR ESTABLISHING A HOSPITAL
- Chapter XII
- BUILDING COMMISSIONS
- Chapter XIII
- SELECTION OF A SITE
- Chapter XIV
- AMOUNT OF LAND
- Chapter XV
- SUPPLY OF WATER
- Chapter XVI
- DRAINAGE
- Chapter XVII
- ENCLOSURES
- Chapter XVIII
- PATIENTS' YARDS
- Chapter XIX
- IMPORTANCE OF ARCHITECTURAL ARRANGEMENTS
- Chapter XX
- CHARACTER OF PROPOSED PLANS
- Chapter XXI
- SIZE OF BUILDINGS AND NUMBER OF PATIENTS
- Chapter XXII
- POSITION, AND GENERAL ARRANGEMENTS OF THE BUILDING
- Chapter XXIII
- FORM OF BUILDING
- Chapter XXIV
- HEIGHT OF HOSPITALS
- Chapter XXV
- TEMPORARY OR WOODEN STRUCTURES
- Chapter XXVI
- NUMBER OF PATIENTS IN A WARD
- Chapter XXVII
- NATURAL VENTILATION
- Chapter XXVIII
- CELLARS
- Chapter XXIX
- MATERIALS OF WALLS
- Chapter XXX
- PLASTERING
- Chapter XXXI
- SECURITY FROM FIRE IN CONSTRUCTION
- Chapter XXXII
- ROOFS
- Chapter XXXIII
- SIZE OF ROOMS AND HEIGHT OF CEILINGS
- Chapter XXXIV
- FLOORS
- Chapter XXXV
- DOORS
- Chapter XXXVI
- LOCKS
- Chapter XXXVII
- WINDOWS AND WINDOW GUARDS
- Chapter XXXVIII
- INSIDE WINDOW SCREENS
- Chapter XXXIX
- STAIRS
- Chapter XL
- ASSOCIATED DORMITORIES
- Chapter XLI
- INFIRMARY WARDS
- Chapter XLII
- BATH ROOMS
- Chapter XLIII
- WATER CLOSETS
- Chapter XLIV
- WARD DRYING ROOMS
- Chapter XLV
- WATER PIPES
- Chapter XLVI
- DUST FLUES AND SOILED CLOTHES HOPPERS
- Chapter XLVII
- KITCHENS AND SCULLERIES
- Chapter XLVIII
- DUMB WAITERS AND DISTRIBUTION OF FOOD
- Chapter XLIX
- RAILROAD
- Chapter L
- HEATING AND VENTILATION
- Chapter LI
- AXIOMS ON HEATING AND VENTILATION
- Chapter LII
- HOT AIR AND VENTILATING FLUES
- Chapter LIII
- LIGHTING
- Chapter LIV
- PATIENTS' WORK ROOMS
- Chapter LV
- GENERAL COLLECTION ROOM
- Chapter LVI
- WASHING, DRYING, IRONING, AND BAKING
- Chapter LVII
- FARM BUILDINGS
- Chapter LVIII
- COST OF HOSPITALS FOR THE INSANE
- Chapter LIX
- DESCRIPTION OF THE PLATES
- Chapter LX
- DESCRIPTION OF THE FRONTISPIECE AND ITS GROUND PLAN
More to come...
CHAPTER LVIII
COST OF HOSPITALS FOR THE INSANE.
THE cost of a hospital like either of those described, will vary in different sections of the country, according to the price of materials and labor, and the facilities for manufacturing the various fixtures that may be required for the different purposes of the institution. For these reasons, instead of giving in detail what should be the cost of such an institution, as was done in the first edition, it is preferred simply to state the actual expenditures made for a few hospitals that have been built, the period at which they were completed, and the conclusions to which, after careful observations, practical men have recently been led, as to the proximate sum that may, in these times, be expected to be required for the proper construction of such institutions. From these data, the price per patient, where from two hundred to six hundred are to be accomodated, will be found to be somewhere between one thousand and fifteen hundred dollars. The latter sum will probably be required where the smaller number mentioned is to be provided for, while for the larger number, where materials are readily procured, and great care is observed in keeping close to the estimates—and not otherwise—something like the first named sum may prove sufficient. Even now the expenditure of less than this sum is pretty sure to leave much work to be done after the opening of the building, or to involve an inferior kind of construction in the building itself. It is scarcely necessary to say that additions may be made to an existing hospital for a much smaller average per patient, than for putting up the original structure; the administration building, and a great number of expensive arrangements being already provided.
In making estimates of the cost of hospitals for the insane, the author has felt no disposition to underrate the expense. Believing, as before remarked, that every State is bound by the double claim of interest and duty, to provide such establishments for the benefit of its citizens; and that the best constructed, best arranged, and most liberally managed hospitals are always cheapest in the end; he has rather been anxious that the public generally should understand that such institutions, from their character and objects, must necessarily be costly as compared with cheap boarding houses or almshouses; and that the cost of simply supporting life and preventing absolute suffering in the latter, can never be made the standard, for the rate of expense of a proper custodial and curative treatment in the former.
It must not be forgotten either, as already observed, that these State hospitals are for all classes, and it has been well said, that various comfots and arrangements which are necessary to prevent some portions of the community from feeling positive privation, are equally valuable as proving curative to their less fortunate fellow-beings.
It may also be fitly repeated here, that while all extravagance and needless ornamentation are to be avoided, there are many reasons why these buildings should to some extent sustain the dignity of the State to which they belong, and at least be readily distinguishable froma factory or workshop, and the cost of effecting this, is too small to be worthy of controversy.
In all discussions in regard to the cost of providing accomodations for the insane, it is to be remembered, that whatever the cost of a hospital may be, it is not to be divided among the number who first fill its wards, but among all, the thousands, who in future—all the future, while it lasts—are to avail themselves of the accommodations it offers. The necessity for these institutions not being likely to diminish in the slightest degree, it can be understood that the excellence of workmanship and materials, which alone secures permanence, is nowhere more justifiable or desirable, and is nowhere more truly economical.
The difference in cost between a hospital that is well built and on that is badly constructed; between one that is complete in all its arrangements and one that is imperfect; between one liberally and one meanly managed, is really so small, that if the citizens of any State would make the simple calculation, how much of this extra expense would fall upon each one of them, it can scarcely be credited that a single individual, could anywhere be found, willing to admit that he would not cheerfully bear his proportion of it, even if it had never occurred to him, that at some period or other, he might himself be compelled personally to test the character of the provision for the insane made by his State. Practically, the people on whom ultimately the cost of such insitutions devolves, as far as I know, have never hesitated in contributing their share of what was necessary to effect the object thoroughly. They have only asked that what was done, should be fully up to the knowledge of the times, and calculated to give the afflicted every possible benefit that could be derived from the expenditure, and that all waste and useless ornamentation should be avoided. All that has been expended, in those States where there are the largest number of hospitals and of the costliest character in the country, when divided among the taxpayers, has been shown to give so extremely small a sum to each, that scarcely any one would object to contribute his quota of what would be required to complete the great work of providing equally well, for all the insane still without proper hospital accomodations.
In giving the foregoing estimate of the cost of State hospitals for the insane, it is not intended to imply that a larger expenditure might not be made to give accomodations of a higher order, with arrangmenets more thoroughly complete in their character, or that it is not often, really right, to expend more, on such institutions. It is rather wished to show that a less sum than that mentioned, unless under peculiarly favorable circumstances, can hardly be expected to supply what is indispensable, and a provision less than this, ought not to satisfy any comunity.
There is great doubt of the propriety of requiring a building commission, inexperienced in the work on hand as it is apt to be, to complete a hospital in the best manner and at a specified smallest possible cost; this estimated cost being probably fixed by parties with as little practical knowledge of the subject, as the members of the commission themselves. It is particularly unfortunate, if without any references to the completeness of the arrangements, the law, with its other provisions, should couple the declaration that the hospital shall be finished and made ready for occupation by patients, for a specified sum for each, especially if the amount named, is less than is justified by the general experience of what is absolutely necessary,—for an unduly small expenditure per patient, may be anything but a wise economy.
During the last half century the variations in cost of nearly every article of living, and in the amount paid for wages, building materials and furniture, have been so great and frequent as to show, that estimates can only be reliably applicable to the times for which they are prepared. In the period alluded to in this volume, many of these variations have been as much as fifty per cent., and the prices paid in the various sections of he country have been so different, that while it would be quite easy just now to say what such State hospitals for the insane as have been referred to should cost in the neighborhood of Philadelphia, at the date when this paragraph is written, it would hardly be possible to indicate what might be the cost of their cnstruction, or of their management, even a few years in the future.
A striking illustration of the correctness of what has just been said on the subject of the cost of institutions for the insane, is shown in the erection of one of the last hospitals provided for by the State of Pennsylvania. In the law authorizing the work, it was required of the Commissioners to put up a building for a definite number of patients, at a cost not exceeding a specific sum for each, and when finished and handed over to the Board of Trustees it was, for this expenditure, to be complete in all its arrangements and fixtures, for the best and most economical treatment of its inmates. To give every opportunity to do this, the whole amount supposed to be required was appropriated in one sum, and the building was commenced under what seemed to be most favorable auspices. Long, however, before its completion, it became obvious to those engaged in the work, that what was needed, could not be finished properly with the appropriation in hand. An application was made to the Legislature for as large a sum as $170,000, to make up this deficiency; and this not being granted, the Commissioners felt themselves obliged to make changes in their designs, which although lessening the completeness of the hospital, would bring its cost somewhat nearer the amount of money which was placed at their disposal. These changes were, many of them, very unfortunate. One of the buildings for excited patients was given up entirely, some other buildings were diminished in size, all arrangements for forced fan ventilation were abandoned, the railroad for the distribution of food and supplies was not put down, the passage ways between the different buildings,—which were at some distance from each other,—were left uncovered and unprotected, the grounds remained in an exceedingly rough and unimproved condition, without any patients' exercising yards, and without any permanent enclosure for the buildings and premises, and the disposition of the drainage was not provided for; so that on the transfer of the hospital buildings and grounds by the Building Commissioners to the Board of Trustees, the latter exhibited a very natural reluctance to accept the same, without a clear understanding of their imperfect conditions, and an acknowledgment that a large amount of money would be absolutely indispensable to complete them, according to the intention of the Legislature.
If completed as planned, the cost would have been not less than $800,000, giving accomodations for about seven hundred patients, at an expenditure of $1142 for each patient, or if finished as now built, the cost cannot be much, if any, less than $700,000, with accommodations for six hundred patients, or $1166 per patient. The cost originally proposed was $800 per patient.
Before all these improvements are satisfactorily finished, it is quite safe to say, that the expenditures will have exceeded the sum mentioned on a previous page, as the minimum of a proper estimate for a State provision for the insane, and this attempt to put up a good hospital for much less than the usually recognized cost, will be shown to be a failure.
In this connection it may be observed that another Pennsylvania State Hospital, which is an entirely fireproof building, is now being erected in the most thorough manner, omitting nothing that is deemed desirable for the best provision for the insane. And although this work has been carried on under the very great disadvantage of limited appropriations, so as to retard or to stop all building operations when work could have ben done on the most favorable terms, I am assured, it will still be completed at a cost of $850,000, providing for six hundred patients, or $1416 per patient.
The statement of these facts raises a question for the grave consideration of legislators, of political economists, and of enlightened taxpayers too, whether having the unfortunate inmates of such an institution secured from the dangers and horrors of a conflagration, would not more than compensate for the difference in first cost,—even if greater than it is,—between the two institutions last referred to.
The Department for Males of the Pennsylvania Hospital for the Insane at Philadelphia, as shown in the frontispiece, was built between 1856 and 1859. The land on which it was placed was already owned by the corporation,—originally costing but $15,000,—and the funds for the erection of the building and its completion in every part for the accomodation of patients and all employed, with steam heating, fan ventilation, and complete waterworks, and for a wall surrounding fifty acres of pleasure-grounds and gardens, with gate-house, engine-house, laundry, stables, etc., were derived entirely from the voluntary contributions of benevolent citizens, mainly of Philadelphia and Pennsylvania: this institution being a benevolent corporation, devoted to the relief of the affected, and never receiving any aid from city, country, or State. The plan, as carried out in all its details, was prepared by the writer, after more than twenty years' experience and not a little reflection on the subject, and the building was intended to embrace everything desirable in a hospital of this description, for the best accomodation of two hundred and fifty patients and all concerned in their care. While it was determined that the work of every kind should be done in the most thorough manner, it was also resolved that no extravagance or useless ornamentation should be permitted. That this was done and with all possible economy, the writer knows from personal observation and a direct supervision of the work in all its stages. The cost for all that has been mentioned, including sufficient new furniture to commence the operations of the hospital, was about $355,000, or $1420 per patient.
While speaking of the cost of these buildings, it may be interesting to state that of some of the additions, made to the Department for Females of the same hospital. The Infirmary Ward, Plates XI, XII, and XIII,—which may be separated into six subdivisions,—was put up for the accommodation of twenty patients and all persons required for their care. With steam heating apparatus and fan ventilation, furniture and fixtures of every kind, it was completed for the sum of $24,850, or $1242.50 per patient. This ward was finished in 1868.
A Supplementary Ward, as a part of the same hospital, Plates XIV and XV, was also built and furnished, thoroughly provided with steam heating apparatus and fan ventilation,—including a large boiler, used for additional work,—giving superior accommodations for thirty patients and those engaged in their care, at a cost of $43,289.12, or $1442.97 per patient. This building was completed in 1873.
A new ward now in process of completion—similar to the last in all its arrangements, except that it requires no boiler for generating steam for heating and ventilation, which is secured from those already in use,—it is believed, will be finished for about thirty per cent. less than the amount last named, owing mainly to the diminution in the price of labor and materials.
The first two buildings mentioned on this page, were erected and furnished from funds specially given for the purpose, and are known as the South and North Fisher Wards—the first being regarded as good form for an infirmary ward, and the last showing a convenient mode of making extensions to an existing hospital.
The Alabama Hospital for the Insane, the plan for which was detailed in the first edition of this work, Plates III, IV, V, VI, VII, and of which an elevation, ground plans, and description are given in the present volume, was completed in 1860, the entire cost being rather less than $300,000. It was originally intended for two hundred and fifty patients and all employed in their care, but without crowding, it could be readily made to accommodate three hundred patients; so that the cost per patient, was little if any more than the lowest sum named as absolutely necessary to provide a hospital, that can properly regarded as up to the requirements of our present knowledge of the subject, the minimum sum to be expended for that object being set down as $1000 per patient, with a limit between that amount and $1500.
The modified linear plan, as shown in Plates VIII, IX, and X, for two hundred and fifty patients, is is estimated by Mr. Sloan, can now be built in the best manner, at or near Philadelphia, for $350,000, or $1400 per patient, while if the last wing is raised another story, the accomodations will be for three hundred patients, and the cost for each reduced to $1250. The additional cost of this improved linear plan, is deemed to be fully justified by its advantages.
The cost of other hospitals erected by Mr. Sloan, has not exceeded $1250 per patient. Various hospitals on nearly the same plans, already built or in process of erection, have not cost more, or will not be chargeable with a greater sum for their completion. Where the cost has been less, the cheapness of materials and other obvious reasons have accounted for the difference.