THE TREATMENT OF THE INSANE OUTSIDE 
OF ASYLUMS. 
BY 
FREDERICK PETERSON, M.D., 
OF NEW YORK. 
FROM 
THE MEDICAL NEWS, 
March n, 1893. [Reprinted from The Medical News, March n, 1893.] 
THE TREATMENT OF THE INSANE OUTSIDE 
OF ASYLUMS} 
By FREDERICK PETERSON. M.D., 
OF NEW YORK. 
It is only a short time since in Christendom the 
insane were believed to be cursed and possessed 
of devils. In some parts of heathendom, on the 
other hand, they were supposed to be blessed, in that 
their souls had been removed by God. Medieval treat- 
ment was founded upon that pathology. One por- 
tion of the world ducked, whipped, tortured, chained 
in dungeons, and occasionally burned the insane to 
death. Upon the whole, the heathen have treated 
their insane comparatively well. 
After a time, many of the therapeutic measures 
employed by the Europeans of the Middle Ages were 
abandoned as unsatisfactory. But society still had 
to be protected ; so the insane were fettered in the 
cells of jails and fortresses, and solitary towers, until 
a realizing sense of the inhumanity of such treat- 
ment struck a responsive chord somewhere in the 
breast of a Tuke, a Connolly, a Pinel, a Rush, a 
Kirkbride, an Earle, and doubtless other but un- 
known immortals, both before and after them. 
1 Read before the N. Y. County Medical Society, Feb. 27,1893 2 
Thus, gradually insanity came to be regarded in the 
light of a disease, and, instead of prisons, special 
buildings were set apart for the particular custody 
of the insane. The great object of the asylums at 
first was to afford protection to society from luna- 
tics, to protect them from themselves, and to pro- 
vide for their care and support, when at public cost, 
in an economical manner. A hundred years ago, 
however, the asylum was still a species of jail, for its 
evolution had not yet proceeded far. Dungeons, 
and iron chains, and staples in stone walls and stone 
floors, were still in use in many places. Indeed, it 
is even less than eighty years ago since Norris, a 
patient in Bedlam (Bethlehem Hospital), in the 
great Christian city of London, was kept for twelve 
years in a cell with an iron collar riveted around his 
neck, and iron bands and rings around his waist, 
arms, and ankle, the neck being fastened to the 
wall, and the leg to a rude box of filthy straw. 
The asylum having evolved so recently from the 
prison, it is not strange that it should in some places 
still possess rudimentary structural appendages and 
organs which are reminiscent of its embryonal 
stage; nor is it remarkable that a certain sense of 
disgrace or stigma has been popularly attached to 
confinement in an asylum. The people have still 
to be educated to the idea that insanity is a disease 
often requiring treatment of a particular nature in 
the special institutions built for the purpose, and 
that the asylum is .rapidly becoming a pleasant 
refuge for the hopeless and a hospital for the curable 
cases of mental disorder. 
It is a wise move to change the name “asylum” 3 
to “hospital,” for it will aid in the diffusion among 
the people of a true conception of insanity, as 
now understood by medical men. But there are 
comparatively few, even in the profession, who 
are aware of the great improvements which 
have been made in asylums of late years; how 
the depressing barren halls and wards and naked 
floors have given place to pleasantly furnished and 
carpeted, cheerful-looking parlors, sitting-rooms, 
and bedrooms; how muffs and strait-jackets have 
disappeared ; how the unintelligent attendant has 
in many instances given place to the trained nurse; 
how every new means of treatment is carried out in 
some places to the best of the ability of the asylum 
physicians; how schools, employment, theatricals, 
music, and out-of-door walks are provided in the 
place of the old deadly monotony, and, in fact, 
how the asylum has gradually undergone a meta- 
morphosis,until its character has completely changed. 
There are, to be sure, not many perfectly ideal in- 
stitutions as yet in existence, but there are some 
which approach very near to it, as, for instance, 
that at Alt-Scheritz near Leipzig, and the new asylum 
at Rome, both of which I visited and described in 
1887.1 These are, of course, constructed on the 
cottage and pavilion plan, so arranged as to impress 
one as small colonies or villages, with separate 
buildings for those merely there for custody because 
of dangerous propensities, those brought there to be 
cared for kindly during the remainder of their use- 
less lives, those who carry on various occupations, 
1 “ Some European Asylums,” Am. Journ. Insanity, July, 1887. 4 
and finally, for such as enter particularly to secure 
treatment for the brain-malady which has bereft 
them temporarily of their reason. 
I will say that I believe improvement and reform 
are constantly going on in asylums throughout the 
world, that no one is more anxious than are their 
superintendents to make progress in the care and 
management of the insane. They are rapidly reach- 
ing the best methods of dealing with the insane poor. 
If any are tardy in this advance, it is because they are 
so often hampered by the never-ending over-crowd- 
ing of our public asylums, by the interference of 
politics, by the lack of money, by the want of a 
sufficient number of medical assistants, and by a 
multiplicity of official duties. 
While these statements are undoubtedly true, and 
great credit is due the asylum-physicians of the pres- 
ent day for their strenuous efforts in behalf of their 
charges, I believe that the ideal treatment of almost 
any insane person is to be sought outside of an 
asylum. After an asylum-experience of some years, 
and an experience of many years, too, in private 
practice, I feel that I am in a position to judge 
fairly well of the relative merits of treatment in and 
out of asylums. 
Theoretically, it ought to be the right of every 
individual in sickness to receive the best treatment 
that medical science affords ; but this right can be 
enjoyed by very few. There are too many interfer- 
ing conditions. Not every injured man is within 
reach of the best surgeon, not every fever-stricken 
one convenient to the best physician, and few are 
the deaf, the blind, the lame, those with crippled 5 
bodies, and those with disordered minds, who ever 
really receive the best treatment that the world can 
give. The intelligent doctor and the scientific 
skill are not the only requisites. Other conditions 
are good nursing, the most suitable climate, the best 
hygienic surroundings, the best moral atmosphere. 
In dealing with affections of the body solely, there 
is often much to be desired ; but it is particularly 
in the treatment of those who are mentally as well as 
physically afflicted that so much which should be 
done is left undone. The obstacles in the way of 
securing the best treatment are multiplied in the 
case of the insane by the dethronement of the will, 
the reason, the judgment, and the emotions. 
Just as a hospital is a better place than a tene- 
ment house for a surgical patient, or a case of fever, 
so is the asylum superior to the home in the care- 
taking of the pauper and indigent lunatic. The 
acutely insane of the poorer classes are best treated 
at present in our large State institutions; and those 
of the moderately well-to-do, either at home or in 
the small private asylums. Only the insane of the 
wealthy classes can perhaps enjoy and carry out 
ideal methods of treatment, in their own homes, in 
country-houses, or in foreign travel. 
It is, of course, needless to say that there are many 
degrees of insanity; that there are hundreds of cases 
that are never obliged to go to an asylum at all; that 
in society are many insane people carrying on legit- 
imate occupations, and caring for themselves and 
families; and that, on the other hand, there are 
cases for which nothing but commitment to an 
asylum would be suitable or leasible. I have many 6 
insane people who visit me at my office, or at 
clinics, who are regularly following their vocations. 
Two very insane sisters are private patients of mine. 
I have described their condition in a paper on 
folie a deux} One teaches music; the other is a book- 
agent. For twelve years they have been supporting 
themselves, and laying up money for a rainy day. 
Another case is in a'night-watchman. Another has 
for years been switching hundreds of trains daily on 
a great railroad. Another is a young wife with a 
worthless husband, who cares for the household and 
supports her children. Another is a bookkeeper ; 
another is a private secretary ; another is a superin- 
tendent of a manufactory. Two or three are authors 
of noteworthy books, and support themselves by 
their valuable contributions to literature. They are 
all marked cases of chronic or subacute insanity of 
one form or another. Less noticeable cases at large 
in society are legion; so that it would be idle to dis- 
pute the fact that there are great numbers of insane 
persons who do not require to be put into custody. 
Indeed, we should not send any patient to an asy- 
lum, unless he needs restraint because of danger to 
himself or others, or because proper treatment and 
supervision are difficult in his home, owing generally 
to poverty or other insurmountable conditions. 
The sooner a case of acute insanity, occurring in a 
pauper or indigent, is removed to an asylum the 
better are his chances for recovery. With cases of 
acute insanity in those who are able to afford the 
expense of trained nurses at home, the case is differ- 
1 “ Paranoia in Two Sisters.’' Alienist and Neurologist, Jan. 
1890. 7 
ent. It would seem unfortunate to have to send a 
patient to a large asylum, with its locks, its bars, its 
associations, its over-crowding, its commingling of 
the intelligent and the refined with the offspring of 
the slums, and its inevitable stigma, when the case 
may prove to be mild, with an early recovery. How 
much better to make the trial of treatment at home ! 
Naturally, the responsibilities of the physician are 
often great with an insane patient in a private 
house, and it is certainly true that the asylum seem- 
ingly affords considerable protection from death by 
exhaustion, suicide, and the like. I say seemingly, 
for this protection is really not as efficient as is gen- 
erally supposed. From the annual reports of the 
New York State Commission in Lunacy I gather 
that the number who die from exhaustion in the 
public asylums of the State of New York yearly is 
much over 150, and that the nutpber-efsuicidesQf 
patients committed to their care is in the neighbor- 
hood of 15 per These facts are noted merely 
to show that the asylum is not an absolute protection 
against the death of a patient by exhaustion from 
mental disease or suicide, and that in view of this 
we may treat many patients at home with a clear 
conscience, and with little greater risk, always pro- 
viding that the room and the nurses and minor 
essentials are at our command. 
I believe it is not fully appreciated how much the 
asylum-authorities are striving to do to effect im- 
provement in the methods of management of the 
insane. Not only is the asylum itself undergoing a 
metamorphosis, but managers are actually doing 
all they can to extend the treatment of the insane 8 
outside of asylums. This is evident, for instance, 
from the fact of the opening of out-door depart- 
ments or dispensaries in connection with some of 
them, thus enabling those suffering from mental 
disorders in the earliest stages, or of the milder 
types, to obtain skilled treatment without entering 
the asylum at all, without being deprived of their 
liberty and rights as citizens. This was first under- 
taken by the West Riding Asylum in 1889, and has 
been so successful that it was determined to extend 
the system to other English asylums (Menston and 
Wadsley). Not only this, but in Scotland and in 
some parts of our own country, they actually send 
their quieter patients from the asylums out to board 
on farms in the country instead of keeping them 
massed together in large buildings with their more 
disturbed brethren. Then, too, some of the large 
asylums of this country have successfully inaugurated 
agricultural colonies, several miles distant from the 
main building, where quiet patients are sent to live 
in cottages or pavilions “ far from the madding 
crowd.” (This plan has been very successful at 
Kalamazoo and elsewhere.) 
In connection with this matter of the treatment of 
the insane poor, especially of the acute class, another 
feature was brought up by the author for considera- 
tion before the New York Neurological Society, in 
January, 1890, and in various editorials subse- 
quently, viz. : the admission of the acutely insane 
to general hospitals. The proposition made was 
that a law should be passed that nothing in the 
lunacy statutes should be construed to interfere with 
the reception and treatment of acute cases of in- 9 
sanity in chartered general hospitals, in the same 
manner and under the same conditions as patients 
suffering from other diseases are there received and 
treated, provided that such hospitals have suitable 
accommodations, approved by the State Commission 
in Lunacy. Thus, any of the sixty-five or more 
chartered general hospitals of this State would be 
empowered to receive and treat such cases, if they so 
desired, and every town and city would in this 
manner be provided with one or several emergency 
wards for the acutely insane ; and who can estimate 
how much good would thus be accomplished, not 
only to the particular patients admitted and treated, 
but to a vast number of other patients, by the train- 
ing of the nurses, hospital internes, and attending 
physicians, in clinical psychiatry? 
Some fourteen years ago the writer was resident 
physician in a general hospital with a hundred beds, 
in a large city. There was no asylum within 200 
miles, consequently emergency cases of insanity were 
sent in from the city and its immediate vicinity to 
the general hospital for a temporary sojourn. If quiet, 
they were treated in private rooms ; if disturbed, in 
a pavilion. They weie not more difficult to handle, 
even at their worst, than the cases of delirium tre- 
mens that were frequently admitted. This, too, 
was a hospital not specially arranged for such cases. 
Those who are familiar with Vienna, Berlin, Strass- 
burg, Bremen, Leipzig, and Paris, and other Con- 
tinental cities, know that provision is made in many 
of their general hospitals for acute cases of insanity. 
Several years ago the Victoria General Hospital 
opened reception wards for the insane. In connec- 10 
tion with the new clinic for mental diseases at 
Konigsberg, a department for the insane was re- 
cently opened in the town hospital, so that now 
every Prussian university (except Kiel) has a clinic 
for diseases of the mind, in most cases connected 
with some general hospital. 
Nor do we have to go out of our own country to 
find other instances of the insane occupying wards or 
pavilions in general hospitals. We have notable 
examples in Bellevue, in the Marshall Infirmary at 
Troy, and in the Philadelphia Hospital.1 
There is the greater necessity for some such pro- 
vision, as, unfortunately, in almost every town and 
city of this great Union* except New York City, the 
jail and the station-house at present serve in the 
capacity of reception-wards for the acutely insane. 
It will mark a great advance, therefore, in the treat- 
ment of the insane, when general hospitals open 
their doors and make special arrangements for the 
reception of acute cases, and their detention for a 
reasonable period of time, say a month or more, 
which would in many instances obviate the com- 
mitment to an asylum by process of law altogether. 
In the largest cities there should be at the dispo- 
sition of medical faculties a clinic of some kind for 
mental disorders. This want might, perhaps, be 
best met by the establishment of psychopathic hos- 
pitals on the plan of the psychiatric clinics in foreign 
1 In his last report of the Philadelphia Hospital, Dr. Hughes, 
the superintendent, speaks glowingly of the advantages to pa- 
tients of the new system that had just been adopted, of receiving 
insane patients in special wards. He reports 50 per cent, of 
cases cured, commitment to an asylum having been unnecessary. 11 
universities, small hospitals receiving from fifty to 
one hundred cases of insanity, provided with labora- 
tories for the study of the physiology and pathology 
of the central nervous system, ideally constructed 
in the midst of the city, and fully equipped for 
the best scientific treatment of patients, and the 
thorough instruction of students in the elements of 
psychiatry. 
The lines of advance, then, in our care of the 
insane of the poorer classes outside of asylums are: 
(i) the opening of special reception-wards or 
pavilions in general hospitals; (2) the establish- 
ment of psychopathic hospitals in large cities; (3) 
the colonization and boarding-out of the quiet 
chronic inmates of asylums; (4) the creation of 
out-door departments in connection with asylums 
situated in densely populous districts. 
When people are sufficiently well-to-do, the ideal 
methods of treatment are, of course, to be found 
outside of an asylum. The insane of this class may 
be treated at home, or in a seashore cottage, in a 
country house, or they may go travelling in the 
charge of a physician and a nurse. The kind of 
treatment best adapted to the nature of the case 
must be decided by the physician. The quiet of a 
private house in the city or country is best for some 
cases, while the tonic and stimulus of foreign travel 
are indicated in others. It may be stated that 
when travel seems to be the prescription required, 
the greater the change from the environment in 
which the mental disorder developed, the better. 
The cities of Great Britain and the Continent do 
not differ essentially from our own cities, and 12 
patients should not be sent to such places with the 
idea of securing a change of environment. Norway 
in summer, and Egypt in winter, are regions which 
offer the greatest inducements in the way of tonics 
to the nervous system, and stimulus to the mind, 
and both are at the same time peculiarly restful and 
calmative. 
If these methods of home, country house, or 
travel are for any reason impracticable, then the 
smallest private asylum that can be found is to be 
selected, for the fewer other insane people and the 
greater number of sane people the patient comes 
in contact with, the better will be his chances for 
recovery. There is a need for physicians in prac- 
tice in the country who will be duly authorized and 
empowered by law to receive in their own homes 
and care for one such patient. The chief draw- 
back in home-treatment, if long continued, is usu- 
ally the bad effect of association with an insane 
person upon other members of his family, particu- 
larly if they be neuropathic. With a sufficiency 
of nurses and room, there is no contingency 
in the treatment of the insane that cannot be 
guarded against. These being provided, the worst 
features in a case, such as violence, homicidal and 
suicidal tendencies, attempts at self-mutilation, etc., 
may be as well avoided outside as inside of an asy- 
lum. There are cases in which, though I am opposed 
to mechanical restraint in great measure, I should 
employ long-sleeved night-gowns, or even cami- 
soles, rather than let them go home before all means 
of cure had been tried at least for a few weeks’ time. 
The conditions and propensities that we have to 13 
combat are many. The choice of method must be 
the result of careful deliberation, and after judicial 
survey of all the features presented. We usually 
need the assistance of skilled and experienced 
nurses. Thanks to the asylum training-schools, 
there are numbers of such trained nurses of both 
sexes to be had in our large cities. 
In acute cases, whether of mania or melancholia, 
it has been my experience that confinement to bed 
is a valuable factor in cure. Hence, on being called 
to such a case, I have the patient put to bed. Due 
precautions are taken as to the removal of all sharp 
instruments, weapons, drugs, cords, door-keys, and 
the like, and by a simple device the windows so 
arranged that they may not be opened beyond six 
inches; otherwise the furnishings may be left as 
they are without attention. 
Insomnia and mental and motor excitement most 
frequently demand our best skill. In emergency, 
I am in the habit of using duboisine sulphate hypo- 
dermatically in th? dose of one-hundredth of a 
grain, or sometimes hyoscyamine, or hyoscin hydro- 
bromate in doses of from one-hundredth to one- 
sixtieth of a grain hypodermatically, though these 
latter are not as satisfactory as duboisine. But for 
routine treatment of insomnia and maniacal excite- 
ment I much prefer hydrotherapy to drugs. In some 
cases the prolonged warm bath (’jo°-go°) for from 
one-half to two hours may be used, but in all cases 
the hot wet-pack is applicable. For full details as 
to these procedures I would refer to my paper on 
“Hydrotherapy in the Treatment of Nervous and 14 
Mental Diseases.”1 Sometimes when the wet-pack 
does not suffice to quiet fierce maniacal excitement, 
I use duboisine in addition, or give doses by the 
mouth of paraldehyde or sulfonal, both of which are 
valuable hypnotics. 
In acute depressed conditions, on the other hand, 
opiates usually act best in cases in which hydro- 
therapy does not subdue the insomnia, distress of 
mind, and disordered nervous system. Among opi- 
ates, codeine seems to offer advantages over others, 
and the contraction of a habit need not be feared. 
The refusal of food is another element of danger. 
Acute insanity, besides rest in bed, quiet and repose, 
needs overfeeding to balance the great waste of 
tissue going on in the system. While many cases of 
acute mania will eat and drink ravenously at times, 
from the nature of things their actions are uncer- 
tain, and the nurse should be instructed to feed the 
patient almost hourly and keep account of what 
is given. Milk, raw eggs, meat-juice, and occa- 
sional stimulants, must in extreme cases be our chief 
reliance. Having an intelligent and assiduous nurse 
at hand, the necessity of feeding with a tube will 
only rarely occur. When required, the soft rubber 
stomach-tube may be introduced by the physician 
through the mouth or nose, a funnel attached, and the 
liquid mixture of the substances named allowed to 
flow in. I cannot here refer to many other morbid 
conditions that must be met by appropriate medi- 
cation, and by moral treatment as well in acute as 
in subacute and chronic forms of mental disorder. 
i American Journal Med. Sciences, February, 1893. 15 
There are cases (some of the insanities of puberty 
and adolescence, and other forms) in which 
anaphrodisiacs modify distinctly the trend of 
delusions. There are cases in which intestinal 
antiseptics achieve noteworthy results; indeed, the 
instances are few in which attention to morbid 
states of the alimentary canal is not rewarded by 
considerable benefit to the mental condition of the 
patient. Arguments with patients upon delusions 
more or less fixed in character, often has, despite 
the opinions of numerous alienists to the contrary, 
decided value in altering their beliefs, and at times 
even eradicating their insane ideas altogether. It 
is true that occasional argument is generally of no 
avail. Such moral treatment must be sedulously 
and perseveringly employed, daily and for weeks 
or months, to insure success. Argument is a species 
of suggestion. 
In closing, I cannot but look forward to the time, 
which passing events foreshadow, when insanity 
will be recognized as a disease of the brain by the 
laity as well as by the medical profession ; when 
more of those thus afflicted will be treated in their 
own homes, and still large numbers in psychopathic 
and general hospitals; to the time when our present 
large aggregations of the insane will be disseminated 
in farm-houses and colonies, and the huge struc- 
tures now containing them be disintegrated into 
smaller buildings regularly distributed over large 
grounds on the community or village plan. 
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