LUNACY REFORM, 
III 
OUR ASYLUMS AS SEEN BY A COMPETENT FOREIGN 
VISITOR. 
During the past winter a German physician, skilled in the study 
of nervous and mental diseases, one of Professor Westphal’s as- 
sistants in the Charite at Berlin, visited this country and made a 
careful inspection of all the asylums within a reasonable distance 
from New York. Dr. von den Steinen paid particular attention to 
the two City asylums on the Islands, and the editor of the Arch- 
ives requested a statement of his experience. 
The following are the editor’s letters and Dr. von den Steinen’s 
reply : 
New York, Nov. 16, 1879. 
Dear Doctor: 
In your capacity of expert and impartial observer, 
you have had an unusual opportunity of judging of the condi- 
tion of the two City asylums for the insane—the one for females 
on Blackwell’s Island, and the one for males on Ward’s Island. 
The medical profession in this City and State would, I am sure, 
be glad to learn your opinion of these institutions. 
If you reply, pray do so frankly, as those of us who hope to- 
see an improvement in the treatment of the insane are not afraid 
to hear the truth, even though- it be not flattering. 
Very truly yours, 
E. C. Seguin. 
[Reprinted from the “Archives of Medicine,” Vol. iii, No. 2, April, 1880.] 2 
VON DEN STEINEN. 
Dear Doctor : 
I would not venture to accept your invitation 
had I not visited a number of American institutions for the in- 
sane, and found opportunities of forming an opinion in regurd to 
the present condition of psychiatry in your country. There is, 
however, no claim to impartiality on my part, except in so far as 
personal remarks are concerned. I shall admit that in thorough 
discussions with many confreres, whose views did not agree with 
mine, I had occasion to observe, as I believe, the best intentions 
and interest of doing justice to the patients. In regard to the 
subject itself, my judgment is not at all unbiassed ; on the con- 
trary, I should like to proceed as radically as possible to ensure 
in the American system of treating insanity an improvement in 
keeping with modern experience and the assistance so lavishly 
bestowed. 
A visit to your asylums is of two-fold interest to a German asy- 
lum physician ; for what we are beginning to overcome, and the 
most difficult part of which—the resistance of the old school—we 
have already surmounted, is here still in a most flourishing condi- 
tion. A confrere in Utica, of whose humane character I am fully 
convinced, even went as far as to assert that the crib was a “ hu- 
mane ” means of restraint. Conolly has not yet lived for Amer- 
ica ; but when a change occurs the asylum physicians will have 
let the glory escape them of having introduced the spirit of pro- 
gress in their profession. 
If most of your institutions are not as good as they might be, 
Blackwell’s Island and Ward’s Island are, I think, in as poor a 
condition as they possibly could be. In October, 1879, I visited 
these two asylums, and in January, 1880, also the branch asylum 
on Randall’s Island. These visits were necessarily of short dura- 
tion, but I fear that a prolonged stay would not have made the 
impressions received any more favorable. Even my views in re- 
gard to asylum buildings differ so materially from the system here 
employed, that I would probably not leave one stone upon the 
other on Blackwell’s Island. I have heard of the new expensive 
institutions called “ palace prisons,” and I must admit that I A MERIC A N A SYL UMS. 
3 
believe the name to be appropriate,‘since it brings to mind both 
their impracticable and cruel side. If proceeding from the idea 
that the buildings are for the patients, and not the patients for 
the buildings, then the two-story structures ought not to be so 
much neglected, where the inmates might live in the basement, 
freely move about in the court-yard and garden, and sleep in the 
second story. To be confined in the third or fourth •story, just 
beneath the roof, to be released only at certain hours, to have the 
beautiful aspect of the surrounding country before one’s eyes all 
day long—oh, what person in Poughkeepsie, Middletown or Dan- 
vers could place himself in the position of a patient without ex- 
periencing that it is hardly possible to make the deprivation of 
liberty, so keenly felt by many, more unbearable ? But it seems 
as if the idea of providing a hospital for the acute patients and a 
home for the chronic inmates, had hardly yet occurred to any 
one; indeed it would seem as though the sole object were to 
keep a large number of human beings safely behind lock and key, 
and that what may be termed modifications of the workhouse and 
jail, are built for that purpose. Thus the “ palace” prison of 
Blackwell’s Island is located in a worthy neighborhood. In the 
“ lodges” the refractory patients live in rooms where a high iron 
grating, provided with a door, separates a corridor running along 
the window from the main apartment, and I noticed that patients 
were kept outside or inside of this grating at the discretion of the 
nurse. To judge from the result attained, it would seem that the 
builder had before,his mind’s eye a menagerie for beasts of prey. 
In short, the style of building bespeaks the layman who is anxious 
to protect us from outbreaks of violence, but the physician who 
treats patients is not to be recognized from it. 
So much for the plans of buildings. How is it with the mode 
of treatment ? I am reminded of a scene I witnessed on Ward’s 
Island. There was a pretty small cell, the window of which was 
provided with a wire grating and heavy wooden shutters ; in this 
apartment, which was darkened at night, a patient having his 
arms in a muff was walking about. I now would ask, why did 
they not also put a gag into the mouth of this man, who was still 
able to abuse and scream ? 4 
VON DEN STEINEN. 
I observed much during my visit that did not quite meet my 
approval. On Blackwell’s Island I saw two fresh haematomas of 
the ear, and the physician could not tell how they originated ; he 
was surprised that both occurred on the left ear ; I requested him 
to question the nurses. In the one case he was fully satisfied 
when the nurse declared that “ she didn’t know ; ” in the other 
he accepted as an answer that the patient had got up in the morn- 
ing with the fresh haematoma. Two female patients were running 
about bare-footed, but not a word was said about it. According 
to the physician’s own assertions, one of them had already been 
sleeping in the “crib ” for eight months ! she had been successful 
in destroying the lock, and the lid was fastened every night by 
means of ropes. He showed me the straps and wristlets, of which 
a minute account was kept. I pointed to a girl who was tied to a 
chair by means of towels, and he remarked : “ But that is not re- 
straint.” 
I do not wish to cast unnecessary, and perhaps unintentionally, 
unjust reproaches, for the reply ; “ the asylums are crowded and 
overcrowded,” is too true. The figures bear testimony of this. But I 
may assert that more could be done than is actually accomplished ; 
for I have witnessed this myself. I visited Blackwell’s Island 
twice. The first time I was shocked at the stupid inactivity to be 
observed even in the quiet wards, and the question involuntarily 
forced itself on my mind, “ Must not one become demented here 
if he is not already so ? ” What are the patients doing the whole 
day ? In response to my inquiries, the physician replied : “ Well, 
they are doing the whole day what they are doing now.” The 
second time I came in company with a Commissioner of Charities 
and Correction. What a different picture now presented itself to 
us in the three wards ! A large number of patients were dili- 
gently sewing, one of the nurses giving them instruction ; in the 
centre was a small table, upon which were heaped the materials 
and implements required ; it was a pleasure indeed to behold this 
sight. I was really astonished at the order prevailing, which 
seemed to be even greater than that usually to be observed in an 
apartment where so many busy hands are at work, and the only AMERICAN ASYL UMS. 
5 
way in which I could explain this to myself was that we had ar- 
rived at the beginning of working hours, for the seams upon 
which they were sewing had in no case reached more than a foot 
in length. As they were all busy sewing, it was probably merely 
accidental that a large bundle of stockings was lying upon a 
chair, and could be triumphantly produced by the nurse to the 
Commissioner as a proof of past diligence. It was surely very 
wrong in the physician to have told me on the former occasion : 
“They are doing the whole day what they are doing now.” 
I presume that the impression received of Randall’s Island in 
the same way would have probably been less disconsolate at an- 
other time. After passing through the dining-room, which was 
furnished with benches, tables and a side-board, we entered a 
large hall, where the patients had assembled. On narrow, low 
benches, fastened to the walls between each two windows, there 
sat closely crowded about a hundred insane persons, the sad pict- 
ures of chronic insanity, hopeless wrecks ; the furniture consisted 
of two stoves in the centre of the spacious hall and a water reser- 
voir in the upper corner. Even Death is inhuman ! During the 
past six months only one of these unfortunates had died. And 
to him it may have happened as in a case in the Blackwell’s Island 
reports, that the pathological surgeon has pronounced “exhaust- 
ion and dementia ” as the “ cause of death.” 
Before an end is put to the overcrowding of the asylums, it is 
naturally impossible to think of improvements ; for the patients 
could not be kept sufficiently busy, and the number of nurses 
requisite not being procurable, non-restraint could not be intro- 
duced—even if that were desired. But I believe we have not 
much to hope from the present generation of Superintendents, 
unless the practical proof were furnished by an asylum in this 
country that psychiatry has at present a knowledge of a different 
mode of treatment, and is on the point of cultivating it. But how 
is a zealous cultivation of scientific interests possible, when the 
Association of Superintendents form an exclusive union, into 
which those gentlemen are refused admission who de facto have 
control of the really medical observations and of the treatment in 
asylums ? 6 
VON DEN STEINEN. 
You will please permit me to offer reasons in support of my 
unfavorable opinion of the condition of the treatment of insanity 
in your country. All hinges on the questions of employment, 
and on system. They run parallel, and consti- 
tute, in fact, but one question, although the one more particularly 
concerns chronic, and the other more freely touches acute cases. 
The former has already been so discussed, particularly by Wilbur, 
that I think it unnecessary to dilate on it. There is a lack of con- 
fidence in the ability to accomplish that which is accomplished in 
other places, where easy forms of employment, the requirements 
of religion and amusement are estimated at their full value. Al- 
though idiocy is not everywhere looked upon as being within the 
province of psychiatry, I still believe that many of those who are 
pusillanimous in this matter might profit by visiting a well-con- 
ducted idiot asylum ; they could there convince themselves how 
incessant employment is capable of spurring even more wretched 
minds than those of most chronic imbeciles to performances that 
could not have been anticipated ; this result being accomplished 
by uniting energetic exertions with the highest psychiatric art— 
exact individualizing. 
After many discussions, I must decidedly declare that my 
American confreres are not only lacking in courage but also in 
a proper understanding of the true nature and value of non- 
restraint. 
When I mention the fact that under unfavorable conditions ab- 
solutely no restraint is exercised on the considerable number of re- 
fractory patients in the Charite-Krankenhaus at Berlin, I am always 
certain of meeting somewhat dubious faces, and invariably re- 
ceive the answer : “ But in our experience we have found that in 
a certain number of cases ” (which, however, are always to be 
met with) “ it is impossible without restraint to prevent patients 
from injuring either themselves or others, and our apparatus is 
the best adapted for that purpose.” I must frankly confess that, 
in my opinion, they have no such experience as they believe them- 
selves entitled to claim. The non-restraint system cannot be sub- 
jected to many experiments ; it must either be rejected or accepted ; AMERICAN ASYLUMS. 
7 
the essence, the nature and secret of it is its unconditional ap- 
plication. The transitory stage at which you stop includes the 
greatest difficulties ; truce is not peace, but war. When you be- 
come doubtful of success, you put on the jacket again, but you 
cannot get along without it until you have none to use. Do not 
believe that we allow our patients to be abused by the fists of at- 
tendants and have their ribs broken ; do not suppose that we 
poison them by substituting chemical restraint, or, as Neumann 
has ingeniously termed it, “the restraint of the pedunculi ; ” and, 
lastly, do not believe—for the contrary would be correct—that the 
number of suicides is greater than in your asylums ; but still we 
do not require your means of restraint, because we are not in pos- 
session of them, and because we possess naught but a single 
jacket that serves to demonstrate to the students the method for- 
merly in practice. But something else is true : when the new 
system was introduced in the Charite, all the attendants, with the 
exception of one or two, had to be dismissed. Neither physicians 
nor attendants should know that a system of restraint is in exist- 
ence. In this point is involved as well the only possibility of solv- 
ing the task, as the greatest benefit of treatment. The asylum 
undergoes an entire change. A superintendent of very humane 
principles told me that he never employed cribs, although they 
might be of service at times, because if he had one the attendants 
would demand more. And so it is. Restraint serves to ensure 
the comfort of the attendants,* while now they are compelled to 
treat free patients kindly and deferentially to accomplish those 
results that were formerly obtained by force. 
In the better asylums I did not observe any of the cruelties for 
which they are reproached ; but I did notice in all instances that 
the patients sat downcast in their chairs while the nurse was tend- 
ing to his private affairs. In no case have I seen a ward for 
* In illustration of the correctness of this statement, I may quote the follow- 
ing, which has been learned on unquestionable authority. An assistant physi- 
cian in an asylum near New York, (not on the Islands) was asked by a medical 
visitor if the nurses in the violent wards (where many patients were in restraint, 
and where the din, etc., was horrible) would not like a temporary transfer to the 
quiet wards. “ O, no,” replied the Doctor; “they prefer to stay where they 
are ; it’s less trouble to take care of violent patients than of convalescents,” 
or words to that effect.—[Editor.] 8 
VON DEN STEINEN. 
violent cases where the attendants were really intent upon sub- 
duing the excitement of the patient by kindly and intelligently 
adapting themselves to his humor. In at least four asylums I 
observed patients in bare feet, while neither physicians nor attend- 
ants seemed to take notice of that neglect. In a large asylum I 
found an enormous number of female patients with short-cut and 
shaven hair, and upon questioning for the reason of this pro- 
cedure, which at other times stamps the convict, I received the 
answer “ that there would be too much trouble otherwise.” Just 
because the care for the respectable appearance of the patients 
occasions trouble to the nurses, they should be employed as much 
as possible in that direction. And there is really no better school 
for teaching female nurses patience and self-command than the 
procedure of dressing the hair of weak-minded and violent 
female patients. It cannot be too often impressed on the minds 
of attendants that they are dealing with patients : this simple 
truth, which we so fully understand, they are unable to compre- 
hend when these so-called patients are bound. Where physicians 
are hard of access to the ideas of reform, attendants will fully be 
so. It is a matter of necessity that the physician live among the 
patients, and does not scorn to be himself the best nurse. 
It is true that in rare exceptions we resort to hydropathic wrap- 
ping of the patient, for the most important reason of subduing his 
excitement, and they say in such rare exceptions we really have 
restraint. But it is absolutely not restraint in the opinion of 
nurses and patients, for we also employ this mode of hydropathic 
treatment where such an indication would be utterly false. 
How are patients treated who have an inclination to suicide ? 
The crib or muff is employed, or it is deemed satisfactory if the 
watchman looks after them every half-hour. Such a guardian is 
no protection at all, because the patient may accomplish his pur- 
pose while he is absent for a moment. We put such patients, 
with all others who require special care, into a large dormitory, 
where two nurses, who relieve each other, are on guard all night, 
and are subject to strict control. 
We must admit, free treatment is not possible when the corps of AMERICAN ASYLUMS. 
9 
nurses is deficient in the qualities requisite. Nothing is more la- 
mentable ; for the nurses constitute a part of the therapeutic ap- 
pliances of the asylums, as bandages form part of the therapeutics 
of the surgical hospital. But there is a number of institutions 
where this fault has not to be overcome, and where restraint is 
nevertheless retained. If it is adhered to in asylums like that at 
Bloomingdale and in the Butler Hospital, Providence, it must, in 
my opinion, be ascribed to either a lack of knowledge or courage. 
I am told, “ we have but little; ” but even this little is a great 
deal too much. In stopping midway, by declaring the transitory 
stage as permanent, there is probably no less trouble occasioned 
than by introducing an energetic change. 
u Player: I hope we have reformed that indifferently with us. 
“Hamlet: O, reform it altogether.” 
There may be cases where it would be indifferent from the 
standpoint of humanity whether weak and violent patients were 
secured or not ; but I cannot emphasize too strongly that the 
value of strict non-restraint will be experienced from the whole- 
some influence it exerts on the hospital in general, and that even 
the few cases of restraint existing should be abolished ; two dis- 
cordant notes will spoil the effect of an entire piece of music. 
Free treatment is the only means of ensuring real medical ob- 
servation and of transforming the institute of detention into a 
hospital. 
The principal evil which at present checks the development of 
psychiatry in the United States, is, I believe, more deeply rooted 
at a point which is well known, but which, being obscured by too 
many personal remarks, can never be viewed in its true form. If 
I had not been aware of the fact I should hardly become cogni- 
zant of it here, that psychiatry has gradually developed into a re- 
spectable science, which, like all sciences, must be taught and 
learned. As in Germany, so it seems necessary here, to prove 
that a knowledge of the various forms of mental debility should 
be obligatory in the education of the physician. When does the 
general practitioner diagnosticate mental debility ? I am inclined IO 
VON DEN STEINEN. 
to believe that he does it very often after the family have made the 
diagnosis and the patient is in such a state that his immediate 
transfer to an asylum becomes imperative. But the many cases 
of beginning melancholia and hypochondria, the timely treatment 
of which would ensure gratifying results ; the interesting group of 
which we call “ Zwangvorstellungen,” which are almost solely 
confined to private practice ; the minor forms of “ circular ma- 
nia ; ” who traces them ? Who would be able by timely interven- 
tion in the first stage of general paralysis, before the patient has 
accomplished a thousand fatal deeds, to make a diagnosis before 
motor troubles appear ? And must not the student renounce the 
greatest advantage which psychiatry offers, and which, like no 
other branch of medicine, teaches him to fully understand the 
humane duty of his calling—which shows him not only the dis- 
eased organ but also the diseased human being, and places him 
on so elevated a standpoint that the actions of the mental faculty 
appear to him as being introduced into the circle of lawful, natu- 
ral phenomena ? 
I now turn to the asylum physicians. A physician who knows 
nothing of psychiatry is entrusted with the treatment of patients, 
and great responsibility devolves upon him ; he becomes second 
assistant, first assistant, and will eventually be superintendent, if 
fortune and influential connections favor him. The superin- 
tendent is fully taken up by administrative duties, and has not the 
opportunity of instructing his assistants, and letting them profit 
by his practical experience. Nowadays no trade is learned auto- 
didactically, much less a science. Or are Griesingers more fre- 
quent in this country, who after studying mental diseases for two 
years are able to write a work of great merit on them ? Without 
sufficient education, neither pathological nor clinical results can be 
attained. Since the neglect of pathology is frankly admitted in 
all asylums, and as Utica takes an almost isolated position in the 
interest it shows for these problems, I will simply speak of clinical 
knowledge, although this can hardly exist without pathology. I 
do not wish to criticize the reports which often give proof of very 
confused ideas in regard to the classification of mental diseases ; AMERICAN ASYLUMS. 
11 
but I was often astonished in passing from the classification of 
the apartments to that of their inmates to come across—I cannot 
otherwise express it—real ignorance. Even a layman is able to 
term a raving person as maniacal, one who refuses aliment as 
melancholic, and will soon learn that a demented patient who 
cannot utter an articulated word, and from whose trousers the 
urine is dripping, must be designated as paralytic; but of the 
physician we might expect a scientific analysis and classification 
of the cases. How nonsensical to term all mental derangements 
expuerperis “ puerperal mania ” I am well justified in uttering 
reproaches when I find that even so plain a disease as general 
paralysis is so insufficiently known, as I have constantly had occa- 
sion to observe. I wish to know the number of paralytics, and 
after a hasty visit I ascertain as many more than have been re- 
ported. General paralysis of the female, which is of comparatively 
rare occurrence with us also, was said to be found hardly any- 
where ; but in each of three asylums I was able to point out a 
typical case while passing through the wards in company with 
the physicians, whom I envied for having them. 
I must necessarily suppose that these conditions are worse than 
I can determine. Without classification there is no prognosis; 
and the judgment in regard to the possibility of discharge cannot 
be base on scientific grounds. 
I presume that my implications are fully understood. I know 
that there is in existence something like psychiatrical instruction. 
That maybe better than nothing; but the students will learn 
no more of psychiatry than I know of astronomy (being able 
to tell the names of a few constellations, and knowing a few 
astronomical laws), they will never acquire practical experience 
and independent judgment unless they have seen and examined 
a number of insane persons. 
I believe the reformation of the asylums will be attended with 
lasting results only when the essential desideratum is expressed as 
follows : 
Asylums for curable lunatics and for clinical instruction—clinical 
hospitals for psychiatry as well as for every other medical specialty. 12 
VON DEN STEINEN. 
Such cases as are pronounced incurable to be transferred to asy- 
lums for chronic patients. From the experiments about to be 
made in Germany, it would seem that the following are the prin- 
cipal points : 
A two-story building with a few acres of land around it, con- 
necting with a general hospital, and being able to receive not more 
than 80-100 patients who are presumably curable. For new 
patients and such others as require special care, a large dormitory 
is suggested ; many separate apartments ; isolating cells of supe- 
rior construction ; as many bathing-rooms as possible. The su- 
perintendent to be a professor, with at least four assistants, ap- 
pointed for a term of two years ; liberal allotments of space and 
apparatus for utilizing the clinical and pathological material; one 
head nurse for the male and female sections respectively ; the 
proportion of the other nurses not to be less than one for three 
patients. 
The advantages to be afforded and attained by an institution of 
this kind consist in the cultivation of science and a rational sys- 
tem of medical treatment. The results will be these : The prac- 
tical physician will gain a knowledge of psychiatry ; the interest 
of those concerned is awakened, and an opportunity of training 
for asylum practice is afforded ; competent nurses are educated ; 
finally, a station for the examination of medico-legal cases is 
established. 
These institutions are undoubtedly expensive, but they are an 
urgent necessity, and the time will come when the people who are 
now so liberally contributing money to the care of the insane, 
will learn to expend it in the right direction.