OLD AND NEW IDEAS WITH REGARD TO THE 
WORK AND THE ORGANIZATION OF 
INSTITUTIONS FOR THE 
INSANE. 
RICHARD DEWEY, M.D. 
Read before the Chicago Medical Society, January 4th, 1892. 
Reprinted from The Chicago Medical Recobdek, February, 1892. 
press ot 
1R. 1R. flftcttabe & Go. 
144 flbonroe Street, Gbfcago OLD AND NEW IDEAS WITH REGARD TO THE WORK 
AND THE ORGANIZATION OF INSTITUTIONS 
FOR THE INSANE.* 
By RICHARD DEWEY, M.D. 
The occasion of this paper is the discussion and agitation which 
have been rife of late in reference to the need of new measures of 
treatment for the insane, and new and differently arranged institutions 
for their care and cure. 
The conditions required for the care and treatment of insanity 
have been supposed heretofore to differ from those required by any 
other disease whatever, and the places of care and treatment for the 
insane have always been institutions apart and wholly special, rurally 
located and under management quite different in its character, to that 
of ordinary hospitals; but of late we hear the question raised whether 
the insane, especially the acute cases, cannot be more generally, and 
with better results, treated in institutions differently organized, located 
in cities and assimilated more to the general hospitals in having a 
visiting staff of specialists, and it is suggested that even the general 
hospitals might receive cases of insanity. 
The first consideration in connection with this idea occurring to 
one familiar with the care and treatment of the insane is that insanity 
is little understood. It has not been studied or taught in any adequate 
way in the average course of instruction of our medical schools. The 
average practitioner as well as the people generally have most insuffi- 
cient views of insanity. Indeed, insanity is to day regarded with far 
more of awe and superstition than intelligence by both the lay and 
professional public. This condition of affairs is due to a variety of 
causes, but among others to the fact that the functions of the brain 
and the interdependence between manifestations of mind and the work- 
ing of the brain and nervous system, have only recently begun to be 
intelligently studied and elucidated. The world of insanity has been 
for the most part terra incognita, and the average practitioner, in the 
presence of a case of insanity, has been apt to have either a feeling of 
more or less helplessness, or a disposition to pursue mistaken methods, 
and generally, as my experience goes, there is a desire to be rid of the 
case as cleverly as possible, and place the responsibility of its care 
upon somebody else. 
The institutions for the insane are therefore more or less aloof 
from the general current of medical thought and activity, and an 
* Read before the Chicago Medical Society, January 4th, 189>.-j: 2 
injury is thus done to the cause of scientific progress. The general 
practitioner, having learned nothing about insanity, may be said to 
have no interest in it, and, on the other hand, the medical men engaged 
in the care of the insane have been in an isolated position, hurtful both 
for themselves scientifically and for those under their care, as well as 
disadvantageous to the profession at large. At the same time thpse of 
our profession making a specialty of insanity and nervous diseases in 
private practice or occupying chairs in our schools, who do most of the 
writing and publishing on these subjects, have drawn their ideas 
largely from what is most familiar to them-insanity in its incipiency, 
or complicated with neurasthenia, hysteria or structural brain disease, 
and from the hospitals of the cities controlled by a visiting staff of 
specialists. 
The continuous and very considerable increase of insanity 
throughout our country, and the somewhat discouraging results of 
treatment, have led to dissatisfaction and to seeking after new ideas 
and methods, and this tendency has been further stimulated of late by 
the great advances in neurology, neuropathology and psychopathology 
and operative cerebral surgery. 
This general recognition of the defects of present methods and 
search for newer and better ones has, like all things human, its good 
and its evil side. It is undoubtedly a good thing in itself, but there 
has been a disposition on the part of more recent converts to an 
interest in nervous and cerebral diseases to discard all past and present 
ideas as antiquated and insufficient, and to form extravagant expecta- 
tions of results from newer appliances, while at the same time those 
already occupying the field have been perhaps too little aware of the 
possibilities brought within reach by the rich discoveries of recent 
years. 
These facts are illustrated by the abortive movement inaugurated 
a short time ago in London to establish a hospital for the insane to be 
solely managed by a visiting staff of specialists in various branches 
with scarcely a man among them connected with any institution for the 
insane, or possessing a practical knowledge of the care and manage- 
ment of the insane, and there are numerous illustrations of the same 
thing in our own country. The men engaged in private practice, in 
the specialties of brain and nervous diseases, on the one hand, and the 
men in charge of institutions for the insane on the other, have in times 
past affiliated to only the slightest degree, and have misunderstood 
each other oftentimes; and furthermore the former have furnished 
some striking illustrations of their practical ignorance of insanity and 
its management, marked by calamitous results among their patients, 
while the latter have been found wanting in the scientific spirit 
and have too often been absorbed in purely administrative matters, 3 
while the rich opportunities for pathological study and for original 
research have failed to be improved. 
If there were difficulty or blame for such a state of affairs it rests 
equally on the two sides, and is by no means confined to one, but I 
think the chief difficulty has been inherent in the nature of the situa- 
tion, and it is to be hoped that there is at present a disposition to pro- 
gress " all along the line," and there are many indications that afford a 
happy augury of a newer and better spirit which will have its outcome 
in united action. 
On the one hand it is needful that practical knowledge of insanity 
shall be secured to all who would qualify themselves for the practice of 
medicine, by teaching it in our medical schools, and on the other, and 
to this very end, our institutions for the insane must be thrown open to 
the student, and the student required to visit them, while at the same 
time the appliances and equipment of the institutions for the insane 
need to be assimilated to those of the general hospitals with their facili- 
ties for every possible research and method of treatment, whether in 
the line of pathological study, laboratory work with microscope and 
microtome, special treatment of all the bodily organs, electrotherapeu- 
tics, balneotherapeutics, surgery of brain and spine, etc. And our 
practitioners and professors who make nervous diseases and insanity a 
specialty, need to familiarize themselves with the views of insanity and 
its needs, which our large public institutions alone can afford. 
Let us now inquire whether the existing institutions for the insane 
are fully adapted for their work and what if any changes are needed. 
The most striking fact that presents itself in examining present 
institutions for the insane, is that while the patients found in them are 
alike, in all needing separate and special confinement or treatment, 
there is an infinite variety among them in all other respects;-some 
idea of the extent of this variety may be derived from the following 
tabular statement. Of course, the table is only prepared for showing 
the enormous variations among those who are called insane, and would 
be unphilosophical for any other purpose, as in many cases the same 
individual would come under one or more of the different headings. 
Taking first the cases that would come under the old familiar 
classification, we have 
I. Mania; Melancholia; Dementia; Imbecility; Delusional insanity; Paranoia, 
or Monomania, etc. 
II. Insane Epileptics, 
alcohol, 
morphine, 
chloral and other drugs. 
nearly all chronic, incurable and dangerous. 
III. Insane victims of 
Often not insane in the 
stricter sense of the word. 
IV. Insane criminals, 
convicts, 
'•mittimus'' cases, i. e. persons acquitted of crime on 
plea of insanity. 
persons committing crimes while in the hospital. 4 
V. Insane persons from 
organic brain dis- 
ease 
paralytics, traumatic cases, general paralysis or 
" paresis," apoplexy, cerebral embolism, tumor and 
other structural brain diseases. 
VI. Neurasthenic and 
hysterical cases, 
often not insane in the stricter sense of the word. 
Now, the above may almost all be subdivided into at least seven minor 
groups, as follows: 
1st, recent and largely curable. 
2d, chronic and largely incurable. 
3d, mild and inoffensive, 
4th, dangerous, violent and destructive; including two important subdivisions, 
the " suicidal " and the " homicidal." 
5th, untidy and uncleanly 
6th, neat and orderly. 
7th, helpless or in stuporous condition. 
And finally all have to be again considered as to their possession 
or non-possession of this world's goods, and are 1st, pauper; 2d, 
indigent; 3d, comfortably off; 4th, wealthy. 
Considering the above great differences to be found among the 
insane patients in every large public asylum, it is no wonder that agi- 
tation has developed for some variation in the construction, arrange- 
ment, equipment and management of institutions for the insane; and 
the defects of our institutions, as they at present stand, are, to a con- 
siderable extent, attributable to the fact that they are compelled to 
receive under the same roof all these great varieties of insane persons, 
without possessing in their organization and equipment, in their con- 
structive or economic features, the variation, adaptability, and elasticity 
that the great contrariety of demands upon them would necessitate. 
This evil is partly to be overcome by removing certain classes, as 
criminals, epileptics and inebriates, and for the rest, by more 
thoroughly specializing the insane asylums and hospitals. 
If our large public institutions for the insane may be regarded as 
at present one of the " peculiar institutions" of our country,, it is in 
part because of the extraordinarily diverse functions they are called 
upon to perform in serving as almshouses, sanitariums, inebriate 
homes, hospitals, reformatories, asylums and prisons, and in serving 
all these uses for persons coming from the most diverse stations in life. 
What has the poor victim of simple nervous exhaustion to do in 
the same building or in the same ward with a chronic, untidy, noisy 
dement ? What need has the helpless paralytic of the bars and locked 
doors? What reason is there for putting a patient who has been 
accustomed always to the best moral and material surroundings, in the 
same environment with those who are unfortunately ignorant, degraded, 
or perhaps brutal and criminal ? And a score of similar questions 
might be asked. 
I am not advocating class distinction, but simply the eternal fit- 
ness of giving all patients, so far as good for them, what they have 5 
been accustomed to in their previous lives, for the simple reason that 
they cannot improve in surroundings utterly unfamiliar, foreign and 
unsuitable to them. 
Stock drovers and stock brokers are not congenial in the outside 
world and each choose their own atmosphere. Hostler Joe will not be 
comfortable by the side- of Berry Wall; George Francis Train, who 
loves children and birds, is ill-assorted with the imbruted wretch who 
cares only for gratification of evil passions. Dougherty with the curse 
of blood upon him ought not to be the companion of mild and harm- 
less lunacy. The contortions of epilepsy should not be witnessed by 
susceptible convalescents. The woman of reputable rearing ought not 
to associate with one who comes from a life of ill-repute. And yet, 
one or all these things, or similar ones, may occur as the inevitable 
result of the present system, or lack of it, and without any blame being 
attributable to any individual. 
All the patients in any asylum have their individual peculiarities 
which should be considered in providing for them, and, indeed, must 
be taken into account if we would do them justice or cure them of their 
malady. 
It is the state of affairs indicated above that has been one import- 
ant factor in the call for different arrangements for the insane, and 
one half of the misery of asylums is caused by throwing people 
together who do not belong together, and never would come together 
except as their misfortune makes them inmates of an asylum. There 
is no virtue in associating the insane. They are not put together for 
their own good. It is done simply because it has to be, as there is no 
other provision made. Many can not be cared for in their own homes. 
The world is weary of them, or afraid of them, and so they are thrown 
together in a most heterogeneous way in the various asylums, and it is 
too true that they often make each other worse. This is not always so. 
There are always numerous patients in every asylum who have a 
mutually good influence over one another, and if our means of classifi- 
cation were better this would be still further true. But as the matter 
now stands too many are mutually harmful. 
Dissatisfaction with the present status, increase of insanity, dis- 
couraging results in treatment, though the discouragement is partly 
from ignorance, or lack of understanding of the problem-all these, in 
conjunction with the stimulation due to that powerful drug, " the fluid 
extract of novelty," have produced the movement for new conditions. 
With the dissatisfaction with older and useless methods, and the 
itching for something novel, I would combine one more idea, more 
fruitful than all others, as I believe, viz: that of having all the policies 
adopted for the insane guided by the principle of approaching in every- 
thing that is done, as near as the fact of insanity will allow, to the 6 
conditions of ordinary, every-day, sane existence, and in the light of 
this principle let us examine the question as to the requirements of the 
insane for curative treatment. 
We will first inquire what are the means for greater curative 
efficiency and adaptability from the constructive and administrative 
point of view, and from that of medical care and treatment. 
First, as to constructive features, it is to be said that greater 
diversity and individuality and diminished size of buildings, admitting 
of division into smaller and more homogeneous groups of patients, is to 
be sought. It is, perhaps, unnecessary to contend for this very strenu- 
ously, for the fact is, the tide has plainly set in the direction of building 
hospitals for the insane on the detached ward system, commonly known 
as the "cottage system." 
Where ten years ago only a few hundred insane could be found in 
detached wards, or cottages, there are to day over 5,000 insane in such 
institutions in Illinois, in Indiana, in New York, in Dakota, in Michi- 
gan, in Ontario, Canada. The advantages of this style are: Greater 
means of classification and opportunities for a more free and domestic 
life, and for separating in each and every case the individual patient 
from influences, sights and sounds that are harmful, and on the other 
hand securing influences, sights and sounds that are helpful, and are 
especially calculated for the one patient in question; and I believe it to 
be true that if an asylum is to be an extensive institution, receiving 
from 600 to 1,000 patients, the detached wards or cottages are an 
advantage in classification, while the same number all under one roof 
suffer in proportion from too close contact and other disadvantages. 
Next, from the administrative point of view we may ask what 
improvements can be made, especially with reference to medical 
administration. 
It is believed the asylums of our country have been too much 
isolated from the professional and every-day life of the people. In 
some ways this has been a necessity, real or supposed, of insanity; the 
peculiar nature of the malady necessitates in some measure confine- 
ment. seclusion, estrangement from the actual world, and not only are 
the inmates thus isolated, but the various officers and attendants as 
well. Thus every day natural interests and activities are impeded or 
cut off, to the injury of all concerned, and if the principle of intro- 
ducing all possible features compatible with the patient's condition of 
the usual life of the world were followed, it seems to me that many of 
the opprobrious things supposed to be inherent in insanity would dis- 
appear, and the number of recoveries would increase. 
Experience shows that a natural and domestic mode of life tends 
to contentment, admits of greater industries, or greater freedom, and 
softens many of the asperities. 7 
Then as to the medical administration, the introduction of all 
possible features of the ordinary general hospitals and sanitariums 
cannot fail to do good to the patient, to the medical men and to the 
public generally. Who can deny that it would be an advantage to 
every institution for the insane to have a consulting staff of able 
specialists in all the disorders that complicate or are essential features 
of insanity? Who would venture to claim that trained attendants, 
analogous to the trained nurses of the general hospital, would not be 
an advantage? How can it be denied that the gymnasium, the bath- 
house, the Swedish movement, the electrical appliances of the sanitari- 
ums would furnish supplementary means of beneficial treatment, and 
would have a great influence for good on patients, and render at- 
tendants more skillful and efficient in their work? And yet these 
appliances are seldom to be found. Further, the greater the freedom 
and facility for communicating with the outside world, the more fully 
the public are made familiar with the methods of care and treatment, 
and the less the insane are treated as if there were something peculiar 
and unlike the rest of mankind about them, the better. 
In fact, it is to be feared that many of the features of insanity 
regarded as most repugnant, and of the acts that create most fear and 
apprehension, are the result of misunderstanding or of bad outward 
conditions, or management, often continued through long years in 
and out of the asylum, or even dating from past generations. 
Taking the public institutions as they exist to-day, and inquiring 
what may be done to make them more curative and successful in 
helping to stem the rising tide of insanity, there* are some things that 
suggest themselves as called for by the increased intelligence and 
humanity of the present time. 
Every case that can be considered a curable one should be 
given all the opportunities and resources that can possibly be made 
available. There should be a most careful individual study of each 
such patient. All the bodily organs and functions, aside from the 
nervous system, should be scrutinized and their defects or disorders 
relieved or cured, if possible. 
The eye and ear expert, the gynecologist, the devotee of heart, 
lungs, nose, throat, the surgeon of brain and spine, the alienist and 
the neurologist should each and all bend their energies to the cure of 
the patient. 
And here a word with regard to the method of utilizing the 
services of all these specially qualified practitioners. They can not 
each do their part independently, but their various efforts need to be 
united and directed by one hand, cooperative with all, and this should 
be the hand of the resident medical director of each institution, who 
should be capable of utilizing all their services and carrying out all 8 
methods of treatment, and, one may say, of moderating their zeal or 
meeting with practical and comprehensive views the tendency, which 
we must admit exists in every specialty, to exaggerate its own import- 
ance. The medical chief should be a man of no specialties or hobbies 
himself, and capable of weighing the influence upon the nervous and 
mental disease of all the various bodily conditions. Otherwise we 
might have many a patient made the bone of contention between the 
disagreements of the doctors, and the treatment required for curative 
effect upon the mind itself might be wholly neglected. 
There should be a medical visiting staff, therefore, whose position 
should be advisory, composed of men of known expertness in their 
various fields. Then there should be a medical director, whose duty it 
should be to practically make available all the skill of the experts, who 
should be charged with responsibility and control, whose function 
would be necessitated not only in combining and carrying out the 
medical advice and treatment, but in a direction even more important 
would his services be needed. 
And here I come to a department in the care and treatment of the 
insane which has scarcely an existence in the management of other 
diseases, but is all-important with the insane-I refer to what is often 
called the "moral treatment of the insane," but which might be called 
mental, moral, social and hygienic treatment, and embraces the 
conditions of every kind which surround and influence the patient, the 
food and raiment, the employments and recreations, the society and 
solitude, and all the sights and sounds and companions the patient 
shall come in contact with-these things are for the insane of the first 
importance, and often far outweigh any possible medical treatment in 
its more limited sense, and all these things should be controlled by 
wisdom and philanthropy of the highest order. 
If the question be asked whether the insane could be treated in 
the general hospitals of our cities, the reply, it seems to me, is, that 
only such cases as are free from all unsafe tendencies and cases of 
structural or traumatic brain disease in which operations are called for, 
can be properly managed in a general hospital, and even these for only 
brief periods where no so-called mental or "moral" treatment is called 
for, and where the mental symptoms are immediately dependent upon 
the brain lesion and will disappear with that. To the above may be 
added cases of alcoholic insanity, in which the attack is of brief 
duration. 
Every institution for the insane of large size should have its 
curative wards exclusively for those patients who can be expected to 
recover, and by these I mean mostly cases of recent origin. There 
are, of course, numbers of very recent cases that are hopeless from the 
start, and other very chronic cases that are possibly curable, and every 9 
patient should have the benefit of the curative ward and of skilled 
and conscientious care in such ward until the incurability was un- 
mistakable, and many cases should have repeated trials in the curative 
wards at suitable intervals. 
Into these curative wards should be distilled all the healing influ 
ences which science and benevolence combined could exert. Into the 
details of organization of curative wards, it is impossible to enter in 
the present limits, further than to say there should be unlimited means 
of treatment, medical, mental, moral and hygienic. Every patient 
should have medicine, electrotherapeutics, balneotherapeutics, massage, 
muscle culture, manual and mechanical. There should be music, 
games, sociability, trained nurses and attendants, no patient should by 
any possibility annoy any other patient, and there should be such 
classification that every individual would form a class of his or her 
own if necessary; the architect, the physician and the Good Samaritan 
should concentrate their efforts on the curable patients. 
All the older institutions should introduce a system of " curative 
wards" as best can be. All new institutions should especially con- 
struct them. 
I have said that the insane asylums are the'" peculiar institution" 
of our country, and I believe that many of their peculiarities will be 
gradually lost. These peculiarities come largely from the vastly vari- 
ous sorts and conditions of patients they have to accommodate. There 
is only one thing in which all the inmates are alike, and that is that 
they cannot be cared for in private. But better adaptation of sur- 
roundings, improved classification, and increased skill and efficiency in 
attendants, will cause many of the undesirable peculiarities to vanish. 
The claim is made, and with some truth, that the large public 
asylums do not utilize the material for study and research that is so 
abundant, and that as compared with their brethren in private practice 
or in general hospital practice they do not produce results fruitful to 
science. This difficulty, so far as it exists, is due to the fact that 
hospitals for the insane have stood apart from the stream of every-day 
life. This has been as much the result of indifference and standing 
aloof by the outside profession and public as of anything in the 
institutions themselves. It is time for both to begin to know more each 
of the other. The general profession stands in profound ignorance of 
insanity, and receives little or no instruction concerning it in the medi 
cal school. The hospitals for the insane should all be utilized in a 
judicious way for clinical instruction, and there should also be, as 
recommended and practiced to some extent in England, an "out-patient 
department" connected with every insane hospital where nervous per- 
sons, or persons with incipient insanity, could go for advice and treat- 
ment. Also post-graduate classes could be, with mutual advantage, 10 
admitted to wards. The Scottish " Universities Commission" has, 
recently passed an ordinance that all students at Edinburgh shall study 
mental diseases. 
It is claimed that a high order of talent is not secured for the- 
institutions for the insane, and this is true to some extent, and the reason 
generally is that the compensation afforded is not such as to attract 
the able and accomplished men of the profession to a work which has 
heretofore had many uninviting features, and is poorly remunerated. 
The result to the community in dollars and cents would be far 
more favorable, if there were provided to every institution scientific 
men of the first rank for medical direction, for consultation and patho- 
logical work, and for the resident staff. By the above means a new life 
would be infused into every hospital for the insane. The problems of 
insanity in its pathology of brain and spine would have new light and 
interest concentrated upon them. These problems are the most intri- 
cate presented to the mind, and the reason they are not solved to-day is 
not, as supposed sometimes, that the medical men in asylums are less 
industrious and able, but that the difficulties are greater than those 
encountered in any other department. 
If the results of treatment have seemed discouraging in insane 
hospitals, let it be remembered that they have not been less so in other 
diseases of far less obscure origin. 
The treatment of insanity in many cases will not consist in drugs 
or potions-as well may these be spilled upon the ground. The 
insane are often not physically ill and have no bodily complaint. 
There are constitutional nervous defects that can often only be reme- 
died by long and patient physical culture, renewal of nutritive 
processes, or by years of what is called " moral treatment." 
In regard to making insanity a subject of study in all the courses 
of the medical schools, a suggestion may not be out of place as bear- 
ing upon this question in this locality. There is now under construc- 
tion for Cook County, a Detention Hospital where there will always be 
a most valuable field which can be utilized for study, and to which 
under suitable restrictions students might be admitted. Again, there 
are always many richly illustrative cases which might be introduced to 
the classes at the medical school for purposes of clinical study, and 
furthermore, the Cook County Asylum at Dunning, with its hundreds- 
of patients, could be visited by the student, if suitable arrangements 
were entered into between that institution and the medical colleges. 
In conclusion I would endeavor to summarize the foregoing 
remarks somewhat as follows: 
1. The treatment of the insane requires institutions especially 
adapted for such work in location, construction, administration and 11 
■equipment, and quite different from the general hospital in all these 
respects. 
2. The curative work of institutions for the insane should be 
amplified in every way and given paramount importance, and to this 
end greater facilities for classification and treatment provided, "cura- 
tive wards " established, and certain classes, as the criminal, alcoholic 
and epileptic, removed. 
3. The study of insanity and nervous diseases should be made a 
necessary part of medical instruction, and the institutions for the 
insane utilized for this purpose, and thus brought more in touch and 
sympathy with the profession at large, and at the same time given 
more thorough equipment and specialization for their work. 
4. Only a very limited range of cases could ever be treated 
properly in a general hospital, and no treatment of confirmed idio- 
pathic insanity could be carried out in such an institution. 
5. All institutions for the insane should be under the direction 
of a medical officer capable of utilizing and combining all the resources 
of all the specialties for the restoration of his patients, and should be 
fully provided with consulting specialists. 
Kankakee, Illinois.