Dr TS Clouston was Physician Superintendent of the Royal Edinburgh hospital (REH) between 1873 and 1908, and during this time he also published extensively on the causes and treatments of mental illness. One of Clouston’s preoccupations seems to have been asylum design – indeed, whilst Physician Superintendent he undertook an expansive rebuilding programme, with a key part of his legacy being the opening of Craig House, a series of buildings specifically tailored for the treatment of private, paying patients of the Royal Edinburgh Hospital. As part of our Royal Edinburgh Hospital collection (LHB7), we hold two of his papers that give an insight into his thinking on asylum design: these are “An Asylum or Hospital - Home for Two Hundred Patients” (Boston, 1879), and “How Pleasant Surroundings and Conditions affect the Health and Happiness” (Edinburgh, ).
As the title suggests, “An Asylum or Hospital…” was very much concerned with how to make the buildings under his charge comfortable for its inhabitants, and foster the community ideal that he felt was crucial to the successful recovery of patients. In it, Clouston begins by pointing out how attitudes to ‘insanity’ had changed over the years:
“In planning the asylums for the insane, built 70 years ago, the dominant idea in the minds of their architects was secure custody : in the case of those built 30 years ago, the idea of curing the patients had modified in a marked degree the jail-like features of the earlier buildings. Since that time, under the new regime in this country, improvements in the character of the hospitals for the insane have been going on steadily”.
The concept of custody was indeed a key shift in the attitudes of the time. Although ‘open-door’ policies didn’t find real traction until the mid-twentieth century, Clouston saw it as important that patients didn’t feel like inmates, and effort was made to obscure any necessary security features: “all the special arrangements of rooms, window-shutting, strong-rooms, padded rooms, &c., should be as little prominent and offensive as possible ; and above all, they should not be suggestive of what they are intended to prevent”. Not only could these security features be obscured, Clouston suggested, they could also become decorative features in themselves that added to the general positive feeling of the institution. For example, he details how to installed padded leather walls in a secure room: “the surface of the leather should be neatly stencilled, and coated with four coats of the best varnish. It is then soft, impervious to urine, strong, and makes a pleasant-looking room, just like an old library hung with stamped leather. In this way the forbidding features of an ordinary “padded room” on the patient’s mind are avoided”.
Indeed, Clouston seems to have
wanted his patients to think of themselves more as residents in a grand hotel
than patients in an institution: “in the general arrangements, furnishings,
&c., I took a first-class hotel as my model, and not any pre-existing
asylum at all”. In defending this relaxed and accommodating attitude, Clouston
argued that, even if there were accidents or escapes, and if some physicians
had relaxed their attitudes too far, “their indiscretion has done good. It has
had for its object the restoration to ordinary conditions of life a portion of
humanity that lay in fetters and chains 100 years ago”. By avoiding the tropes
of the ‘insane beast’, Clouston thought, the patients of the asylum would
develop a greater sense of self-respect, take more interest in their own
personal care and appearance.
|LHB7/14/5 - A block plan for 'An Asylum or Hospital Home for 200 Insane Patients'|
In this respect, the social aspect of the hospital was an important factor. By bringing patients together to dine “in rooms … the general arrangements of which are precisely those of a table d’hote in a good Swiss hotel in the summer”, Clouston relied on the enduring social nature of people to help improve patients’ opinion of themselves and capacity for social intercourse. He stated that “since we began to use a common dining-room … several inveterately untidy patients have been cured of their slovenliness of dress [and] self-control is taught. The public opinion of the room or the table won’t tolerate noise or disturbance”. The greatest complaint of patients, he stated, tended to be around their lack of control, lack of entertainment and often, their horror at being locked up with ‘lunatics’, and he therefore tried to remedy this by providing opportunities for what he considered “pleasant conditions of life”. These included, in his view, “suitable work for the doer of it with some leisure time, some agreeable companionship, games, amusements, newspapers, books, baths, and liberty of action”.
Another key element of Clouston’s
design was to avoid “uniformity of accommodation and arrangements” throughout
the hospital: in an awareness of different types of mental illness, and the
illogicality of treating all patients in the same manner, Clouston stressed
that all patients had different needs based on a number of factors such as
their bodily health, their propensity to be dangerous to themselves or to
others, and their potential ‘curability’. Accordingly, “it should be a
principle, never departed from, that the structures and arrangements that are
necessary for the worst classes of patients should not be used for the best…”.
|LHB7/14/5 - the ground plan for 'An Asylum or Hospital Home'|
In the same vein, Clouston believed that this lack of uniformity should extend to the décor: “variety in the shape, size, and aspect of buildings and rooms, tends to interest, rouse, and cheer the patients, when they pass from one into the other”. He acknowledged that architects and painters were often unwilling to expend their talents on an asylum, whether their efforts might not be as well received as they would be elsewhere in society, but stressed that variation and a lack of monotony in surroundings had a greatly beneficial impact on the mental health of patients.
Overall, Clouston was a strong believer that health and happiness were improved by pleasant surroundings. Furthermore, he saw the benefits of this for the professionals involved in the care of patients, asserting that “the management of an asylum is necessarily much affected by its construction … a cheerful, broken-up asylum is far more apt to be managed on principles that are pleasant to its patients”.