With the Compliments of the x^uthor. 
Points, Facts, Opinions and Experiences in Favor 
of the Reception of Voluntary Patients for 
Care and Treatment in Hospitals for 
the Insane, and More Especially 
for Care and Treatment in 
Private Hospitals for the 
Insane. 
by V 
RALPH L. PARSONS, M.D. 
REPRINTED FROM 
THE JOURNAL OF NERVOUS AND MENTAL DISEASE, 
February,1891 Reprinted from the Journal of Nervous and Mental Disease, February, 1891. 
POINTS, FACTS, OPINIONS AND EXPERIENCES 
IN FAVOR OF THE RECEPTION OF VOLUN- 
TARY PATIENTS FOR CARE AND TREAT- 
MENT IN HOSPITALS FOR THE INSANE, AND 
MORE ESPECIALLY FOR CARE AND TREAT- 
MENT IN PRIVATE HOSPITALS FOR THE 
INSANE. yy' 
By RALPH L. PARSONS, M.D. 
The question regarding the reception of voluntary 
patients in hospitals for the insane is one of very great 
importance to many interested parties: to nervous invalids 
who are desirous of placing themselves under the care of 
the physician in charge of a particular hospital; to persons 
who are near, but have not yet crossed the border line of 
insanity; to the innocent victims of a habit that so dom- 
inates the will as to render the subject utterly powerless to 
help himself, if his mental weakness does not constitute 
actual insanity, as is oftentimes the case ; to the insane them- 
selves, who are placed in such hospitals against or without 
their volition ; to the friends of all those sufferers who are 
interested in whatever is of benefit to them ; to the whole 
community, any member of which may at any time become 
either such a patient or a friend of such a patient; to phy- 
sicians generally; to physicians in charge of hospitals for 
the insane: and it is believed that the facts, opinions and 
experiences to be adduced are sufficient to demonstrate 
that the practice of voluntary admissions to hospitals for 
the insane has a strong, if not an overwhelming support. 
This subject is of such general importance that its discus- 
sion with reference to any individual or class of individuals 
would be too narrow. 2 
There are many nervous invalids who have not yet so 
far lost the use of their reason that they could properly be 
declared lunatics, but yet whose minds and nervous system 
are so far disordered that they need the same sort of care 
and attention as is given in hospitals for the insane ; and 
who are desirous of placing themselves under treatment in 
some particular hospital. In some of these cases the choice 
of the sufferer is influenced by the fact that an acquaintance 
has received benefit at this hospital; and in others that the 
patient himself has been there as a committed patient, 
finds the premonitory symptoms of insanity recurring, and 
wishes to return to the place where he was formerly cured 
early enough to avert the full development of the disease. 
There is another class of persons who are not technic- 
ally insane but yet whose minds are as really disordered as 
are the minds of many certified lunatics. These persons 
are not vicious, nor were they in any way knowingly re- 
sponsible for their condition. They have become the 
slaves of opium or of alcohol through the immediate influ- 
ence of disease ; as in the case of some women after child- 
birth, or through the unfortunate advice of some physician 
or friend. If they are sent to a place where many such 
persons are congregated and associated together, their 
influence upon each other is liable to be prejudicial; asso- 
ciation with many similar sufferers tends to lower their 
moral tone and diminish their power of self-control. If 
they wish to place themselves under treatment in a hos- 
pital for mental diseases, they should have the right and 
the power to do so. In the State of Massachusetts special 
provision is made for the admission of this class of patients 
in the State Hospitals for the Insane. They have always 
been received in the private hospitals of that and of other 
States without objection. 
The admission of voluntary patients, like the above, in 
hospitals for the insane is of advantage in several ways. In 
the first place, it is in the interest of preventive medicine, 
and in the interest of patients suffering from any of the 
forms of disease which are liable to lead to fully developed 
insanity, that provision be made for their early treatment in 3 
a hospital especially adapted to the treatment of mental 
diseases. If admission to hospitals for the insane could be 
so arranged that persons suffering from the early symptoms 
of insanity would avail themselves of the advantages of 
such hospitals as early as they would seek efficient medical 
advice for other ailments,' a step would be made in the 
direction of diminishing the vast crowd of mental wrecks 
which now encumber our public asylums. If, by reason of 
the great demands upon their resources, the public hospi- 
tals cannot now undertake the duty of receiving such 
patients, the reason is all the greater why private hospitals 
should not only be permitted, but encouraged to receive 
them. 
If the objection should be made that the admission of 
voluntary patients to hospitals in which certified patients 
are detained might be injurious to the latter, the reply 
would be that a large experience has shown that this is not 
the case; but, on the contrary, that it is better for the 
insane to be associated with persons who are less diseased 
rather than with those who are more diseased than them- 
selves. 
The association of voluntary patients in the same hos- 
pital with committed patients is of advantage to the latter 
in another way. If all the patients in a particular hospital 
are certified lunatics, the mere fact of having been an 
inmate of that hospital affixes the stigma of being, or of 
having been, a lunatic ; the hospital, too, becomes known 
distinctively as a lunatic asylum, a crazy house, or a luny 
house, and its inmates as lunatics. Whereas, if patients 
who have the use of their reason, or who at least are not 
technically insane, are associated in the same hospital with 
patients whose insanity requires to be certified, the latter 
are relieved to a great extent, if not altogether, from the 
implication which a residence in such hospital would other- 
wise involve. Now, the friends of insane patients and the 
patients themselves, after their recovery, highly appreciate 
the advantage thus afforded, while the voluntary patients 
have no cause of complaint because they have had their 
own choice, and in any case are supported by the knowl- 4 
edge that they are not certified lunatics and so class them- 
selves with the sane members of the family. It is of no 
avail to urge that insanity is no more disgraceful than any 
other disease and is less disgraceful than many others ; for 
all rational persons know and feel that the loss of the 
reason involves a disability and oftentimes a degradation, 
compared with which almost any other calamity sinks into 
comparative insignificance ; that death, even, would be far 
preferable to incurable insanity. And what is true with 
regard to the interests of the insane and of their friends is 
also true in regard to the interests of the whole community, 
if they did but know it ; for not one can truthfully say that 
he is assured against an attack of this dreadful disease. 
It will readily be admitted that voluntary patients, 
whether by themselves or in association with committed 
patients, are oftentimes causes of greater annoyance to the 
physician in charge of the hospital than committed patients 
are. The latter are under the more absolute control of the 
physician. He has the power to detain them whether they 
are pleased or displeased. He can listen to their com- 
plaints or refuse to listen. He can interest himself in a 
multitude of matters relating to their happiness and wel- 
fare, or he can refrain from doing so. And he can give 
plausible and more or less satisfactory explanations and 
reasons for all he does, or fails to do. In the case of volun- 
tary patients, however, he must manifest an active interest 
in their welfare and listen patiently to their inquiries and 
complaints, or else he is liable to lose his patients ; and 
this would be a damage both to his pocket and to his 
reputation as a wise and skillful physician and manager of 
men. 
But these annoyances have their compensations. No 
man or body of men can for a long time have a dominating 
power and control over other men without the imminent 
danger of losing somewhat of that refinement of manner 
and of that delicate consideration for their views, feelings 
and wishes which he would naturally have toward them if 
they were less within his power. Men with great power 
tend to become arbitrary and unyielding; and this applies 5 
to physicians in charge of the insane, as well as to other 
men. So the mingling with their other patients of some 
who can go or remain, as they see fit, is of positive advan- 
tage to the physician himself. His voluntary patients tend 
to stimulate him to high endeavor, and to restrain him from 
idleness and from inattention to the interests and feelings of 
those who are under his charge. And this favorable influence 
of necessity extends to and pervades the moral atmosphere 
of the whole hospital. Nurses and other employees attain a 
higher grade of excellence ; they become unconsciously 
more gentle in their demeanor, and more attentive to and 
interested in their duties. The patients who are under 
commitment are favorably influenced by the general tone 
of the household and by observing the friendly relations 
between the voluntary patients and the physician and how 
cheerfully and implicitly they follow his advice and conform 
to the rules and regulations of the establishment, although 
they may not even suspect that there is any difference 
whatever between their own relations to the physician and 
those of the voluntary patients. 
Now, since provision has been made for the care of the 
insane, apart from the great body of the patients received 
in general hospitals, certain classes of patients have been 
found who were not insane in any such sense as would 
justify a forcible deprivation of their liberty or of their civil 
rights, but yet who can be treated in immediate connection 
with the insane, better than either at their own homes or 
elsewhere. The mental condition of these persons is an 
abnormal one which is on the borderline of well pronounced 
insanity, or in addition to this, their habits or their physical 
condition is such as will probably develop an attack of 
insanity unless suitable means are taken for their restora- 
tion to a state of health. They are in fact as insane as 
many of the patients in hospitals for the insane are during 
a considerable portion of their term of treatment, and need 
the same kind of treatment and surroundings. A question 
naturally arises in regard to a suitable provision for such 
patients. 6 
An important element in the investigation of a question 
of this sort is the experience of others. 
A letter was sent to the superintendents of most of the 
private hospitals for the insane in the neighboring States, 
making inquiry about their practice, experience and opinions 
regarding the domiciling and treatment of voluntary pa- 
tients in immediate connection with the quiet class of certi- 
fied patients. 
A reply was received from each of the physicians ad- 
dressed ; and, without exception, these physicians stated 
that they did receive voluntary patients, and treated them 
in immediate association with their certified patients. All 
of them wrote favorably of the practice, and some of 
them expressed themselves very strongly in its favor. 
These letters are omitted for want of space ; but the follow- 
ing extracts from the printed reports of two of them are 
especially worthy of attention, inasmuch as they express 
the well-marked opinion of the authors, and are entirely re- 
moved from all possible suspicion of having been influenced 
by a letter of inquiry. 
The following extract is from the Annual Report for 
the year 1888 of Dr. John B. Chapin, Medical Superinten- 
dent of the Pennsylvania Hospital for the Insane : 
" Several persons have been under treatment as volun- 
tary boarders, who are suffering with nervous disorders or 
threatened with insanity. While the hospital may be will- 
ing to receive such persons if in a mental condition to 
comprehend the nature of the. proceeding, without a med- 
ical certificate of insanity, no detention has been or can be 
legally exercised. It has seemed that in a population 
numbering one million, within a moderate radius, a number 
of cases in the incipient stages of insanity must occur 
annually who might be properly treated in the wards of 
this or some other hospital, and a more serious calamity 
might thus be averted. The knowledge that voluntary 
boarders who have no fixed delusions and are not in a con- 
dition to be certified to be insane, may be received at their 
request for admission, and that the doors of a hospital may 
move inward and outward with equal ease, would do much 7 
to remove the ill-founded prejudices that exist in regard to 
hospitals for the insane. A tendency of recent years has 
been to surround the admissions to asylums with greater 
safeguards as to personal liberty, as if this were the prin- 
cipal question to be decided in the management of the 
insane, until the public mind has come to look upon a hos- 
pital or asylum for the insane as a place rather for the 
detention than for the curative treatment of the insane, and 
to which they are to be admitted only after the commission 
of overt acts. With a satisfactory lunacy law, such as we 
have in Pennsylvania, and its efficient and wholesome ad- 
ministration by the Committee of Lunacy, we shall hope 
that a more intelligent public sentiment may come to pre- 
vail." 
The following extract is from the Annual Report for the 
year 1889 of Dr. Edward Cowles, Medical Superintendent 
of the McLean Asylum : 
" The voluntary system, as it has been in practice here 
in the nine years since the enactment of the law establish- 
ing it, has yielded most beneficent results. It has not only 
been a blessing to the many patients who have gladly 
availed themselves of its benefits, but it has done good to 
the asylum itself in stimulating improvement in the care of 
all its patients. Many persons who are in the earlier stages 
of simple melancholia, or who have some one of the milder 
forms, or are in an early stage of mental disorder, are well 
aware of the nature of their illness, and yield readily and 
often gladly to the advice of friends or physicians to place 
themselves under special care. Intelligent patients appre- 
ciate the privilege of avoiding a formal examination and 
the dreaded declaration of insanity, and, therefore, with the 
voluntary system they seek hospital care earlier, and under 
the helpful influence of the consciousness that it is their 
own act." 
" The essential value of this system is that its success 
depends upon the active exercise of human sympathy and 
mutual confidence in the place of custodial restraint ; and 8 
not only are the conditions of'moral treatment' rendered 
greatly more effective, but all who are concerned in these 
kindlier relations are lifted up by them. It is significant 
that in the nine years' working of the voluntary law of 
Massachusetts so little criticism of it has been made, and 
so much good has come of it, of a kind that none but those 
who make use of it can properly appreciate. 
" In the forecasting of what may be, another considera- 
tion of broad import that has long been held in mind may 
well be mentioned. The law bears fruit here that a new 
principle established in the conduct of affairs will, if a true 
one, evolve higher truths that in turn contribute to 
advancement. The voluntary system already described 
was established on correct lines ; its workings here have 
evolved a breadth of moral results but dimly foreseen. More 
than these, patients, friends, and physicians alike have 
seized upon its provisions as a happy relief from the com- 
monly felt 'stigma' of resort to an 'asylum.' Many sup- 
pose, and erroneously say, that there is a special and 
separate department here for the treatment of nervous dis- 
orders. This allays the repugnance to hospital care, and 
great good is gained because it is earlier and more freely 
sought. Let the truth this teaches be clearly seen ; it is 
not a new asylum that is wanted, it is a new hospital. 
The McLean Hospital-for nervous and mental diseases, 
if this specification be needed-will be a fitting and inviting 
place, not only for the insane, but for a class of allied 
neurotic and mental disorders that are now repelled from 
such an asylum as this, where they can best be treated." 
The following extract is from the "London Lancet'' 
editorial of October II, 1890, on a new Lunacy Act that 
has been passed in England : 
"One advantage of the Act consists in the protection it 
gives to men generally who sign certificates of insanity; 
and another is that it allows persons wishing to place 
themselves under care and treatment to enter private 9 
asylums as voluntary boarders, without any order or med- 
ical certificate." 
It is a fact that not only have voluntary patients been 
admitted to hospitals for the insane in the past, both in our 
own and in other countries, but that this practice continues 
to be favored ; and not only this, but that in States and 
countries where these patients were formerly received in 
such hospitals without legalized procedures and without 
detention, certain methods of procedure authorizing a cer- 
tain period of detention have now been legalized. 
In the State of Massachusetts it appears that the law 
mentions only the State hospitals and the McLean Asylum 
in relation to the reception of voluntary patients. This 
was, undoubtedly, because the framers of the law pre- 
sumed that there might be an obstacle to the reception of 
such patients in the State hospitals, without some form of 
permission or legalization, while no such permission was 
required in the strictly private hospitals; and this last 
inference would seem to be entirely logical and correct, 
however desirable it might be on special grounds that the 
form of legislation should also be extended to the private 
hospitals. Voluntary patients, however, are received and 
treated in immediate association with committed patients in 
all the private hospitals for the insane in the State of 
Massachusetts in like manner as they are in the public 
hospitals for the insane. 
The recent passage of the English law regarding the 
reception of voluntary patients in private hospitals for the 
insane emphasizes the fact that throughout the civilized 
world measures are now being actively taken to remove 
those obstacles which tend to prevent the early treatment 
of the insane and of persons suffering from diseases which 
are liable to result in mental derangement, and also to 
relieve hospitals for the treatment of mental diseases from 
the stigma which unfortunately, but certainly, attaches 
both to these hospitals and to their inmates whenever 
legally declared lunatics only are admitted within their 
walls as patients. 10 
It is true that a few superintendents of hospitals for the 
insane do choose to restrict themselves to the care of 
certified patients only, but this does not affect the main 
question in the least. As in any other calling, so in this, 
different physicians have different views and different ways 
of management; and within reasonable limits these differ- 
ences in views and in management should be respected. 
And especially is this true in regard to private enterprises 
of any kind. Methods which succeed admirably with one 
may do badly under the management of another, either 
owing to differences in experience and temperament, or to 
varying conditions and circumstances. 
Now, if it be conceded, as it is assumed must be the 
case, that certified patients in hospitals for the insane are 
not liable to be injured by association with voluntary 
patients ; but that, on the contrary, they may and often do 
receive benefit from such association, there remain only 
three prominent objections that can be urged against the 
admission of voluntary patients to these hospitals : first, on 
account of lack of room ; secondly, because a suspicion 
might exist on the part of the public to the effect that the 
alleged voluntary patients were, after all, detained against 
their will; and, in the third place, because the law is sup- 
posed to require the restriction. 
The first of these objections applies only to State hos- 
pitals for the insane. It is claimed, and without doubt 
correctly, that there is not room enough in these hospitals 
for the accommodation of those persons within the State 
whose mental condition and circumstances require their 
involuntary detention in a public institution. If this be the 
case, the restriction of the State hospitals to the reception 
of certified patients only is evidently a matter of necessity, 
however desirable it may be that accommodation be made 
in these hospitals- for the reception of certain voluntary 
patients, as has already been done in other States. 
But this objection does not apply to private hospitals 
for the insane ; for a private hospital is not bound at any 
time to receive a definite number of patients. They simply 
have permission to receive a certain number. 11 
The objection is understood to have been made that, 
inasmuch as the people are very jealous in regard to the 
preservation of the personal liberty of the citizen, there 
might be a suspicion that so-called voluntary patients were 
detained against their will if they were domiciled in the 
same building occupied by committed patients, and that 
the existence of such a suspicion would be prejudicial to 
the reputation and usefulness of the hospitals. Or, to put 
the objection in still stronger terms, if voluntary patients 
were to occupy the same buildings occupied by patients 
who were under legal detention, these voluntary patients 
might readily be detained against their will in like manner 
as the committed patients are detained. 
There are several valid answers to this objection. In 
the first place, this suspicion has not yet been seriously 
expressed, and it may fairly be presumed that there is no 
likelihood of its being expressed in the future. Suspicions 
have often been expressed that committed patients have 
been, unjustly committed, or that they have been detained 
after the necessity for detention had ceased to exist; but 
it is believed that no such charge has been made in regard 
to voluntary patients under treatment in licensed houses, 
although this practice has long existed and is constantly 
increasing. The legal penalties for the detention of uncom- 
mitted patients are such as to avert not only the fact, but 
the suspicion even of their detention. 
Even if expression should be given to the above- 
mentioned suspicion, this would not justify the adoption of 
measures designed to prevent something which has not 
taken place and is not likely to take place. Extraordinary 
precautions to avert an imaginary evil always have a ten- 
dency to increase the fear of that evil. If extraordinary 
and unnecessary regulations are adopted for the specific 
purpose of preventing the improper detention of persons in 
licensed houses, these'measures will be in themselves liable 
to excite the suspicion that persons are improperly detained 
in these houses. It is the sharp distinction of the sane 
from the insane, the setting of them apart as an entirely 12 
different class of beings, their seclusion, the mystery that is 
made to surround them and their treatment, that causes 
suspicion ; and so the treatment of voluntary patients in 
the same house or institution with them has a direct 
tendency to diminish rather than to increase any suspicions 
that may exist in the public mind. 
A modification of the law of the State of Massachusetts 
on the subject may be suggested for enactment in the State 
of New York, in relation to the admission of voluntary 
patients at private hospitals for the insane. 
The English law recently passed is reported as requiring 
even less formality than the law of Massachusetts, the theory 
seeming to be that the doors of hospitals for the insane 
should open easily, both inward and outward, to the end 
that early and preventive treatment may be encouraged, 
and that the sharp and invidious distinction and separation 
of the insane from the sane may be diminished, if it cannot 
be altogether abolished.