H.—B.

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management of Asylums containing a large number of patients have been repeatedly stated by us, and they continue to be matters of constant experience. In such Asylums the careful treatment of individual patients is next to impossible, a proper supervision of attendants is extremely difficult, and the working expenses are generally increased.' And again in 1867: 'For every instance of an Asylum above the middle size challenging praise, there are, unfortunately, several instances of the opposite kind to be adduced.' " The Scottish Commissioners are equally opposed to large Asylums. They consider that no Asylum should contain more than 350 patients; that the individual treatment of a larger number is impossible; and that the cost increases with anything above that number. These opinions they repeatedly expressed in their reports. "In 1852 the Association of Medical Superintendents of American Institutions for the Insane unanimously agreed that 'the highest number that can with propriety be treated in one building is 250, while 200 is a preferable maximum ;' but as the principal Asylums in the Eastern States were gradually increased in size to meet the wants ofthe population, no marked inconvenience was found to result from the congregation of a larger number in one building, and a further expression of the opinion of a majority of the members of the Association on this subject is to be found in a resolution passed at the meeting of the Association held at Washington in 1866, rescinding that above stated, which is as follows : —' The enlargement of a city, county, or State institution for the insane, which in the extent and character of the district in which it is situated is conveniently accessible to all the people of such district, may be properly carried to the extent of accommodating 600 patients, embracing tho usual proportions of curable and incurable insane in a particular community.' " The opinions of authors both English and foreign are at accord on this subject. M. Eerrus, one of the Inspectors of Asylums iv France, says, in his book entitled 'Dcs Alienes,' which is quoted at second-hand from Dr. Arlidge's work, 'An Asylum for the treatment of mental disorder ought not to contain above 150 or at most 250 patients ; but one having a mixed population of cases requiring treatment, of incurables and idiots may receive 400 or 500 such inmates, provided the physician is afforded sufficient medical assistance.' " M. Parchappe, lately Inspector of Asylums in France, says, ' After taking every consideration into account, I think the minimum of patients ought to be fixed at 200, and the maximum at 400. Below 200 the economical advantages rapidly decline,* without compensatory benefit; about 400, although the economical advantages augment, it is at the detriment of the utility of the institution in its medical character.' " M. Guislain, the eminent Belgian authority, in his large work on insanity, which is quoted by Dr. Arlidge, says, 'It would be absurd to bring together in the same place a very large population ; it would tend to foster an injurious degree of excitement, would render the management difficult or impossible, would destroy the unity of plan, aud neutralize all scientific effort. The maximum number ought not to exceed 300 or 350 insane persons.' " Dr. Jacobi, in his treatise on Asylums, which has been translated into English by Dr. Kitching, of the York Retreat, says, ' I am convinced that the number of patients should never exceed 200.' He is, however, speaking of Asylums for acute cases only. " Dr. Arlidge, in his work on the state of lunacy, mentions the opinion of Roller and Damerow, two of the most eminent of German alienist physicians on this subject, both of whom consider that Asylums for acute cases should be limited to 250, but that these for both acute and chronic cases may admit from 450 to 500 inmates, but no more; and at page 118 states his own opinion that 600 ' represents the maximum which can be economically and with just regard to efficient government and supervision, and to the interests of the patients, be brought together in one establishment.' " In the face of the above authoritative opinions, no one can contend that au Asylum of 1,000 patients is an efficient or economical institution. I would more particularly draw attention to the opinion of the Scotch Commissioners, that no Asylum should contain more than 350 patients. In Scotland the Asylums vary in size from one containing upwards of 700 patients, and having four resident Medical Officers, who are' hardly able to overtake their work, down to the small County Asylums of Elgin and Haddington, which contain about eighty patients, and have only Visiting Physicians. A reference to the annual reports of the Scotch Commissioners will show that their experience, while abundantly confirming the opinion of the English Commissioners, that Asylums of a moderate size are in all respects better than large ones, goes still further, and shows that even small Asylums for seventy or eighty can be as efficiently and cheaply managed as those for 200 or 300. In their seventeenth annual report they remark : " A great difference of opinion exists among those who have given attention to the subject as to the limit in size which Asylums should not surpass. Our own experience leads us to give the preference to small establishments, as being more tranquil and home-like than those in which large numbers of patients are congregated together. * * * * * " It has frequently been argued that large Asylums are able to secure to their patients advantages which smaller Asylums cannot afford—such as medical attendance of a higher order, the services of a chaplain, and more extensive and more varied means of amusement. These advantages are certainly not to be contemned, but they seem to us to be more than neutralized by the baneful results of the association of large numbers of the insane—results which are due partly to the increased risk of neglect to which the patients are subjected by the difficulty of individualizing them, and partly to the tendency of large establishments to become mere places of detention, instead of hospitals or places of treatment. The argument that economy is promoted by the association of large numbers is shown by experience to be fallacious. The difficulty of efficient supervision increases with the extension of the establishment, and the waste which follows in the wake of increased accommodation and increased numbers more than counterbalances any saving which might result from the expenses of the medical staff being thrown upon a larger proportion of patients." The objections to a large Asylum are strong enough, even when as in England it is situated in a populous district, and intended only for the insane of the immediate neighbourhood, to whom it is * This has not been found to be the case in Scotland. —P. W. A. S.