Reprint from The Alienist and Neurologist, April, 1880. 
On the Propositions of the Asso- 
ciaton of Superintendents of 
American Hospitals for the 
Insane. 
By JOHN CURWEN, M. D.)t 
J J riiiTinuMMnn r 11 , 
Harrisburg, Penn. Art. IV.—On the Propositions of the 
Association of Superintendents of 
American Hospitals for the Insane. 
John Curwen, M. D., 
SUPERINTENDENT AND PHYSICIAN OF THE PENNSYLVANIA STATE LUNATIC 
HOSPITAL, HARRISBURG, PA. 
/~TAHE principles which underlie the arrangement and 
construction of a hospital for the insane are founded 
on the dictates of sound, rational common sense, and the 
results of experience obtained by residence in such build- 
ings, and derived from the careful study of the require- 
ments of the peculiar class of persons for which they are 
to be constructed, and whose comfort and treatment are 
alone to be considered in such construction. The most 
important of these principles may be stated to be such a 
plan as will facilitate to the greatest degree, and render 
practicable at all times, the readiest and most thorough 
supervision of every department by the officers, careful 
selection of the best material for the construction, and the 
most unwearied attention to the proper arrangement of 
the different kinds of that material in the various parts of 
the building, that everything may not only be of the best 
quality, but put together in the best manner calculated to 
secure the purpose designed ; the most systematic adapta- 
tion of every part to the wants and requirements of those 
who are to occupy the wards; ease and economy of 
administration; and ready and prompt distribution of heat, 
food and other articles constantly required, and special 
care that every part of the building shall have abundance 
of light and air. 4 
John Curwen, 
While the greatest latitude may be allowed, in what 
may be termed the architectural arrangements, the plan 
which has been found to combine, in the greatest degree, 
all the points above enumerated is the lineal plan, in 
which each wing shall be opened to the full light at both 
ends, and the different wings shall be continued in the 
same line as that nearest the center, but falling back so 
far as to leave the second open at both ends, and so on 
through all the wings, in contradistinction to that plan 
which would place the second wing at right angles to the 
first, and so make the whole surround an included square. 
This plan was first fully elaborated and explained by Dr. 
Thos. S. Kirkbride, for so many years the able and ac- 
complished superintendent and physician of the Pennsyl- 
vania Hospital for the insane, in Philadelphia, and has been 
adopted in the majority of hospitals for the insane erected 
within the last thirty years. While adhering strictly to 
this principle of construction many changes in interior 
detail and arrangement have been made by different per- 
sons, but these changes do not in any manner affect the 
original idea. 
VI.—“All such buildings should be constructed of stone 
or brick, have slate or metallic roofs, and, as far as pos- 
sible, be made secure from accidents by fire.” 
Circumstances connected with the locality of the build- 
ing will often determine the fact of the use of stone or 
brick in the construction, but when stone is used it is 
always best and, in the end, most economical, to line the 
outer wall with brick with an air space of about three 
inches between the brick and the stone. 
The brick should be well joined with or “tied into” 
the stone, at short distances, so as to make the brick 
secure and firm, and the space thus left between the walls 
will not only render the walls more dry and prevent the 
penetration of moisture, after a long continued driving 
storm, as is often seen in solid stone walls, but will also 
have the effect of making the building warmer in winter 
and colder in summer, from the fact that neither heat nor On the Propositions of the Association. 
5 
cold can penetrate beyond the layer of air confined 
between the walls. 
The same effect could also be obtained in the con- 
struction of brick walls in a similar manner and thus avoid 
what is so often required, the furring off or nailing strips 
of wood to the walls on which the lath is nailed. Lath 
and plaster partitions are always objectionable in parts of 
a hospital occupied by patients, from the ease with which 
they may be broken, and also from the fact that they 
furnish a more ready receptacle for rats, mice and vermin 
of various kinds. The wood used in furring off walls, 
and lath and plaster partitions are also objectionable from 
the fact that fire is easily started in them, and when so 
started is extremely difficult to trace or to extinguish. 
The objection to metal roofs in this climate arises from 
the injurious effects caused by the alternate expansion and 
contraction of heat and cold, the thermometer often fall- 
ing twenty or more degrees in the course of a few hours; 
and in certain metals the constant tendency to rust, 
requires the frequent use of paint to preserve them from 
the corroding influence of heat and moisture. 
Sufficient care is not generally exercised in preparing 
the sheathing of the roof on which the metal roof is to 
be laid, or for the slate. 
The best plan is carefully to plane and plough and 
groove the boards, and have them laid as carefully as a 
floor. Slate, when properly laid on a roof, thus carefully 
prepared, furnishes the best material for roofing in a 
climate subject to so many changes in temperature. 
The cornices of the roof should be made of the best 
galvanized iron and carefully backed up with brick. 
The surest plan to avoid accidents by fire will be to 
have the whole interior constructed with brick partition 
walls, the floors made of brick arches between iron beams, 
and this arrangement carried through every part to and 
including the ceiling of the upper story directly under the 
roof, and the main division walls of brick carried up to 
the roof. 6 
John Curwen, 
This practically renders the building fire proof, as the 
only part in any hall which could burn would be the 
floor, and if that is well laid, of good and thoroughly sea- 
soned lumber, there will be the smallest chance for the fire 
to spread from one room to another. Every room is in 
effect a brick box. 
But where this cannot be done, and in institutions 
already built, the best plan will be to introduce pipe con- 
nected with the tanks in the attic, or from an outside 
reservoir on high ground, into each ward, and have sufficient 
hose to carry the water to every part of the ward, and 
fire-plugs outside with hose of large size. An additional 
means of security, when the institution is heated by steam, 
will be to carry pipes into the attic of the center and differ- 
ent wings from the boiler, so that by opening a few valves, 
the whole attic could be filled with steam, in case a fire 
should break out, and it is well known that no better fire 
extinguisher can be found than an abundance of steam. 
VII.—“Every hospital having provision for two hundred 
or more patients should have in it, at least, eight distinct 
wards for each sex, making sixteen classes in the entire 
establishment.” 
While this proposition says “at least eight distinct 
wards for each sex,” it implies that a larger number would 
be advisable, and, as a general rule, it could and should 
be arranged so that a more thorough classification could 
be obtained in a larger number of wards. 
This, in many cases, is very necessary for the comfort 
of patients and the greater success in treatment, so that 
those patients who were annoying to others and particularly 
to convalescent patients, may be removed from the wards 
for that class, and placed among those who could not be 
so much injured by their conduct or their manner of talk- 
ing. It is well known to every superintendent, that there 
always is' a certain class, generally quiet and free from 
excitement, and who can behave themselves very well, 
but who take special delight in retailing the most 
outrageous stories to all who come within their reach, On the Propositions of the Association. 
7 
particularly to recent and convalescent patients; and, the 
impression thus produced on this class of patients is often 
very injurious and calculated to retard their restoration, if 
it does not throw them into a state of excitement or lead 
to more serious results. 
The arrangements for classification should be such that 
all this class could be separated entirely from convalescents, 
and placed where they could have only those of a similar 
inclination with themselves to associate with, and less 
incentive therefore, to exercise their mischievous propen- 
sity. The subject is more fully stated in a proposition 
adopted in 1866, which reads thus: 
“The facilities for classification or ward separation 
possessed by each institution, should equal the require- 
ments of the different conditions of the several classes 
received by such institutions, whether those different con- 
ditions are mental or physical in their character.” 
VIII.—“Each ward should have in it a parlor, a corri- 
dor, single lodging rooms for patients, an associated 
dormitory communicating with a chamber for two atten- 
dants, a clothes room, a bath-room, a water-closet, a 
dining room, a dumb waiter and a speaking tube, leading 
to the kitchen, or other central part of the building.” 
The parlor should be so placed as to command the 
most pleasant outlook to be obtained, and should be of 
ample size so as to afford room for a piano, library, sofa 
and the other necessary furniture; and have as much light 
from windows as possible; and the whole front might 
easily be made to resemble a bay window by projecting 
the wall so far, in advance of the other walls, as to allow 
a window to be placed in the connecting wall on each 
side. 
Everything about this parlor should be made bright 
and attractive by pictures and other ornaments, so as to 
induce the patients to spend as much time in it as pos- 
sible ; though when bay-windows are placed in a ward, 
they seem to be places of greater attraction. 
The corridors should be made at least twelve feet wide 8 
John Curwen, 
and twelve feet high in the ceiling and “no chamber for 
the use of a single patient should ever be less than eight 
by ten feet, nor should the ceiling of any story occupied 
by patients be less than twelve feet in height.” 
Where the wing immediately adjoining the center 
connects with it, a space of at least ten feet should be 
arranged with windows open on each side from floor to 
ceiling, so as to give abundance of light and air at that 
point, and these windows, like all the windows in the 
wards, should be protected with some ornamental form of 
guard to prevent intrusion by outsiders, and to prevent 
also the escape of the patients. 
The omission of this open space makes that end of 
the hall dark, and at that point, also, the air will be very 
apt to be impure from the inability to obtain a free 
circulation. 
It must be very distinctly kept in mind that every part 
of a hospital for the insane, occupied by patients, should 
be as bright and cheerful and have as much sunlight as 
it is possible to obtain by means of windows and open- 
ings at the ends of the hall. No hall can be made too 
bright and cheerful at all times; and even when the warm 
rays of the sun in summer require to be excluded, that 
can be done without interfering in any way with the 
cheerfulness and brightness of the wards. 
The advantages of this abundance of light are two- 
fold : In the first place, as a matter of health, and, then, 
as tending to promote greater cheerishness in all within the 
range of its influence ; for it is a matter of common obser- 
vation, that persons obliged to be in dark rooms become 
dull and depressed, while they are at the same time more 
blanched and unhealthy in appearance and in fact. 
It has been objected to rooms on both sides of the 
hall that the effect will be to make the halls, if long, dark 
and gloomy, but if they have large windows from floor to 
ceiling at each end, with a large bay-window on each 
side in the center, no unpleasant gloom or darkness 
will be observed ; and the bay-windows will give a very On the Propositions of the Association. 
9 
pleasant sitting room which will be occupied nearly all 
the time by the patients, and will be a place where flowers, 
birds and other objects of interest may be kept. In the 
arrangement of the rooms in a ward, great care should be 
taken to have the door and window opposite, so that the 
bed may be placed to one side and out of the line of 
any drafts, which would be occasioned by opening the 
door and window. 
Every room should be provided with a flue for the 
admission of warm air, and also one for the removal of 
foul air, so arranged, that no unpleasant draft from the 
warm air shall strike the person who may occupy the 
room; and, where a system of forced ventilation, is used, 
this may readily be effected by having the warm air 
admitted above the level of the person’s head, and the 
foul air removed at a lower point; but unless a strong 
power is used to keep up the circulation, this arrangement 
will not answer satisfactorily in practice, whatever excel- 
lencies may be claimed for it in theory. 
The question of the particular arrangement of the 
window of the room must be left to the prevalent idea in 
any particular section. 
There are really three different forms of window; one 
where both sashes are of iron and the upper is made to 
balance the lower, and when the lower is raised about 
five inches, the upper is lowered the same distance, 
by an arrangement of connecting chains and pulleys ; 
another, where the upper sash is of cast iron and station- 
ary, and the lower sash, hung with cords and weights, 
raises the whole distance, and a guard of an ornamental 
character protects the space opposite the lower sash so 
that the patient cannot fall out or jump out; and, the 
third form is where both sashes are of wood and hung by 
ropes and weights so as to move up and down, and the 
space outside is covered with a guard, either plain or 
ornamental. 
The idea has been strenuously advanced by some that 
all guards to the windows and locks to the doors should 10 
John Curwen, 
be dispensed with, which we believe to be most erroneous, 
and one of those extreme measures wrhich will cure itself 
by the very state w'hich it will induce, of remissness on 
the part of those in charge of the wards and of acci- 
dents and injuries to the patients. It is going from the 
extreme of care to the extreme of carelessness, and avoid- 
ing that which has always been found the safest, the mean 
between the two extremes. If the insane be irresponsi- 
ble, as wall be generally admitted, the effort to give them 
full liberty to go and come as they please, places them in 
a position attended with risk to themselves and to others; 
to themselves, because it places them in a position to be 
subjected to influences and temptations which will have a 
decidedly injurious influence, and to others by the risk to 
life, person and property at the caprice, ill-will or the 
delusions of an irresponsible party, and it is neither right 
nor just to expose the innocent and unsuspecting mem- 
bers of any community to any such risks. 
It has been the fashion with many to insist on large 
associated dormitories, but we believe this to be contrary 
to the desire and habits of our people, who all insist on 
having a room to themselves. It is true that a hospital 
can be constructed more cheaply when the majority of 
the patients can be placed in associated dormitories, but 
there are many other things besides cheapness to be con- 
sidered in the construction of a hospital for the insane, 
and chief among these are the comfort and welfare of the 
patients. 
We have no sympathy, whatever, with that wretched 
sentiment, born of parsimony and disregard of the feelings 
and rights of others, which insists that the comfort, the 
welfare, the happiness and the restoration of the insane, 
of any class, are to be weighed in the balance with a few 
hundred dollars. The State is bound, in honor and duty, 
to make the very best provision for all its wards, and the 
more helpless and dependent, the greater care should be 
exercised in provision for them ; and while proper economy 
should always be exercised in the disbursement of all On the Propositions of the Association. 
11 
money, both in public and private undertakings of any 
kind, and every dollar should be strictly accounted for, no 
State nor any private corporation or association can afford 
to do wrong, for wrong in every form is wasteful expen- 
diture, nor are any so poor that they cannot afford to 
provide for those who may be committed to their care, in 
that manner which will best promote the welfare of the 
insane in every way in their power. That cannot be 
done when the individual is placed in a position which 
injures his self-respect or is entirely at variance with all 
his previous habits and education. Men and women 
insist on some accommodation which will give them a 
degree of privacy, which cannot be obtained by being 
obliged to be in a large dormitory, and it will not do to 
say that because they are insane their feelings are not to 
be considered. 
The effort in these days seems to be to lower the 
standard of self-respect and make people feel their depen- 
dency ; but true humanity teaches that men, born in the 
image of God, should be trained to a proper regard for 
their high destiny, and that true charity consists in the 
dispensation of its gifts, in such a manner as to instill 
higher aims and more ennobling sentiments, and to lead 
all, of every class and condition, to seek that which will 
give true comfort in better and more enduring provision, 
for themselves and all within the sphere of their influence. 
The principle which should govern in all cases is: 
“Whatsoever ye would that men should do to you, do ye 
even so to themand regard must also be had to the 
consideration which sooner or later comes home to every 
one in some form, that he or his may at some time require 
some such accommodation as a hospital for the insane 
affords, and he must consider how the plan of such asso- 
ciation would suit his own case, or whether he would like 
some member of his family placed in such a position as 
has been indicated. Unfortunately this principle has too 
limited an application in governing bodies, and, particu- 
larly where the expenditure of money in public buildings 12 
John Curwen. 
is involved, but that is no reason why it should continue 
to prevail, but, on the contrary, every dictate of justice 
and humanity demands that the sooner men in every rela- 
tion of life do, as they would be done by, the better will 
mankind be. 
There is still another consideration directly bearing on 
the patients themselves, that the proper degree of sleep 
at night, and that calm state which should precede and 
is necessary to sound sleep, cannot be had in nervous and 
restless patients in a room where a number sleep, for the 
reason that among that number, particularly, if it exceed 
six. there will always be one or more who are restless 
and uneasy and are apt to be up and about the room, to 
the annoyance of others and interference with their sleep ; 
and unless the room is very well ventilated, the breath 
and other effluvia arising from a number of persons, soon 
vitiates the air so as to render it unpleasant and unhealthy. 
The argument in favor of dormitories, that those inclined 
to suicide may be placed in them with greater safety and 
less probability of an attempt on their part to effect their 
purpose, has only a very limited application, and really, 
as a rule, does not effect the object. 
The only preventive of suicide is careful and constant 
watchfulness by day and by night. 
Every room of the kind should have a strong wire 
frame in the upper half of the door, so as to answer the 
double purpose of easy inspection and more efficient ven- 
tilation. 
It is well known that associated dormitories are not 
used until it becomes a matter of necessity, and the fewer 
of them, and the more limited the number they can accom- 
modate, the better for the patients themselves. 
Where a dormitory of large size is used, the necessity 
of a chamber for two attendants communicating with it is 
requisite, in order that they may better minister to the 
patients in it, and prevent any disturbance, though, as a 
rule, if the attendants have attended to their duties dur- 
ing the day, they generally sleep so soundly, and they On the Propositions of the Association. 
13 
should have their full sleep for the proper performance of 
their daily duties, that they hear very little that may 
occur during the night, unless of a very unusual charac- 
ter, and the real dependence must be on the activity and 
efficiency of the night watch, which in cases of special 
emergency would be increased for the time. 
More thought and attention should be given to the 
room designed for the clothing of the patients in each 
ward than has usually been the case. It should be of 
ample size, well lighted and well ventilated, and placed in 
close proximity to the bath room, and should be conve- 
niently arranged with closets and boxes in which the 
clothing can be neatly folded and arranged, with hooks 
for hanging up coats and various other articles ; which are 
better hung up than folded and laid away. In addition 
to this there should be ample arrangements for the sheets 
and other bed clothing, with a convenient place in which 
hats and shoes may be placed by the men, instead of 
being allowed to lie promiscuously about the ward to the 
annoyance of all careful people, and the inevitable loss to 
those who wear them. 
The bath-room should be conveniently arranged with 
an ample supply of hot and cold water, and should also 
be kept at a warm temperature in the coldest weather so 
that the most delicate may suffer no injury before enter- 
ing or after leaving a bath. In immediate connection 
with the bath-room should be a wash room with station- 
ary basins and an ample supply of water, to which the 
patients can have ready access at all times. 
The arrangements of water closets are generally on too 
limited a scale, and it is best to place in every ward at 
least two hoppers, so that there may not be any excuse 
for careless habits on the part of the patients, by inability 
to obtain the needed accommodation. 
While such improvements have been made, and are 
still making, in the arrangement for these conveniences, it 
is not requisite that any special plan should be insisted 
on further than that “all water closets should, as far as 14 
John Curwen, 
possible, be made of indestructible material, be simple in 
their arrangements and have a strong downward ventila- 
tion connected with them,” and, also, that “the floors 
should be made of material that will not absorb moisture.” 
The dining room should be of such size as to give 
comfortable sitting room for all who may occupy the 
ward, should be bright and airy, and should have con- 
nected with it, a neat china closet, where all the articles 
used on the tables can be kept in neat order; and in it a 
sink with hot and cold water attached, in which the 
plates, dishes and all articles used on the table can be 
washed. 
The dumb-waiter should be conveniently located in 
connection with the dinning room, and the apparatus for 
hoisting it should be such as to involve the least labor 
and trouble, and easy communication afforded with the 
kitchen by means of a speaking tube or, as may now be 
very satisfactorily arranged, by telephone. 
IX.—“No apartment should ever be provided for the 
confinement of patients, or as their lodging rooms, which 
are not entirely above ground.” 
The requirement of this proposition would appear super- 
fluous, but it seems needful in these days when the effect 
is made to cheapen things to the very lowrest point, and 
endeavor to make provision for a certain class of the insane 
in a manner, which is not in strict accordance with that 
proper regard for their comfort and welfare which their 
position imperatively demands, and also to place, so far as 
words and a protest can do it, a barrier to any further 
efforts in that direction. 
X.—“No class of rooms should ever be constructed 
without some kind of window in each, communicating 
directly with the external atmosphere,” and this, for the 
reason before stated, that every patient should have the 
benefit of sunlight to as great a degree as possible, and a 
better opportunity can be afforded for the freest admission 
of fresh air, which in many rooms is absolutely requisite to 
insure cleanliness. On the Propositions of the Association. 
15 
The eleventh proposition has been already consid- 
ered in connection with the size of the rooms to be used 
for patients. 
XII.—“The floors of the patients’ apartments should 
always be of wood.” It would seem scarcely necessary 
to insist on this requirement, but as stone and brick floors 
have been used in the past, and , are exceptionally cold and 
uncomfortable, particularly for that class who would be 
most probably compelled to occupy such rooms; there 
might be those who would consider it a good thing to do, to 
return to such a state of affairs in the future, on the ground 
that wooden floors would rot out by frequent scrubbing, 
and it would be economy to prevent such expenditure. 
Wooden floors may be rendered nearly, if not quite, 
impervious to all fluids by an application of boiled oil, 
applied hot, so as to saturate the floor, and having this 
repeated every few months. 
XIII.—“The stairways should always be of iron, stone 
or other indestructible material, ample in size and number, 
and easy of access to afford convenient egress in case of 
accident from fire.” Every ward should have, at least, 
two stairways, one at each end, leading directly to the 
ground, both front and rear, so that, by opening the doors 
the patients could readily be taken out to the ground 
around the building. The stairways must be of iron, stone 
or slate, and walled into a brick wall on each side, so that 
they shall be virtually fire-proof from top to bottom—all the 
landings being of the same material as the stairs. 
Circumstances peculiar to the location of the hospital 
will probably determine the character of the material to be 
used, as in some localities one of the articles named may 
be obtained at a more reasonable price than others. 
Slate forms really the neatest and pleasantest stairway to 
travel over, as it is less noisy when trodden on, and 
experience has shown that it wears very little by constant 
treading over it. 
Unless care is taken to have the iron slightly rough- 
ened on the top of the step, it will in time become smooth John Cur wen. 
and slippery, and the same may be said of certain kinds of 
stone—but it does not hold good in slate. In these days 
when so mnch is said about fire-escapes from public 
buildings, it is wisest and best to construct the stairway 
in such a manner as to be virtually a fire-escape from all 
the wards. This can readily be done in the manner indi- 
cated above, and then should a fire unfortunately take 
.place, the inmates can all readily be removed by the mode 
of egress to which they have been accustomed. 
Any fixture outside, such as is usually constructed, is 
worse than useless, for very few patients would venture on 
them, and they would be very likely to be used by mis- 
chievous persons, for the purpose of annoying the patients. 
For females such outside fixtures would be utterly 
impracticable; whereas, a stairway constructed of either of 
the materials named, and well built into a brick wall, 
would be perfectly safe and secure, and very easily avail- 
able at all times, and free from every objection which 
could be urged against outside fixtures.