I need hardly say, I was much gratified to find by the pamphlet, that the importance of moral treatment in the cure of insanity, was duly appreciated in America. When we consider, as Lord Bacon observes, speaking of common diseases, that "all wise physicians in the prescription, of their regimen to their patients, do ever consider accidentia animi, as of great force to further or hinder remedies or recoveries;" it is difficult to account for the general neglect of moral considerations in the treatment of deranged mind. I hope, however, though in many instances medicine may not be employed with advantage, and its indiscriminate use has been seriously injurious, that we shall not abandon it as altogether useless, in what we term disease of the mind. All the varieties, included under this general term, have been produced by physical causes: by external accidents, by intoxication, the improper use of medicines, repelled eruptions, obstructed secretions, &c. In some instances, dissection has discovered, after death, the cause of the mental affection, and though, in many instances, no physical cause can be detected, yet, when it is considered, how limited are the investigations of the anatomist, and that the art is so imperfect, that diseases occasioning instant death, cannot always be discovered on the most minute dissection, it is not unreasonable to suppose, that the body is in all cases the true seat of the disease.

All I would infer from this speculation is, the importance of having judicious medical attendants, to watch the progress of the disorder, to be ready to apply their art as bodily symptoms may arise, and to ascertain, with greater precision than has. .h.i.therto been done, "how and how far the humours and effects of the body, do alter and work upon the mind; and how far the pa.s.sions and apprehensions of the mind, do alter and work upon the body." Even if the disease is not confined to the corporal organs of mind, but extends to the pure and eternal intelligence, medical aid may still be useful from the well known reciprocal action of the two parts of our system upon each other.

I hope my unknown friend will excuse the length and freedom of this letter: its length has much exceeded my intentions, yet I may have omitted information which the experience of the Retreat might afford, and which would have been useful to promoters of the New-York Asylum, Should this be the case, I shall be glad to answer, as well as I am able, any questions which they may propose; and, with the best wishes for the success of their benevolent and important undertaking,

I remain, respectfully,

Thy friend,

SAMUEL TUKE.

FOOTNOTES:

[Footnote 21: A letter on Pauper Lunatic Asylums, by Samuel Tuke, New York, 1815. Reprinted Bloomingdale Hospital Press, June 3, 1919.]

[Footnote 22: Appendix III.]

APPENDIX III

THOMAS EDDY'S COMMUNICATION TO THE BOARD OF GOVERNORS, APRIL, 1815[23]

Of the numerous topics of discussion on subjects relating to the cause of humanity, there is none which has stronger claims to our attention, than that which relates to the treatment of the insane.

Though we may reasonably presume, this subject was by no means overlooked by the ancients, we may fairly conclude, it is deservedly the boast of modern times, to have treated it with any degree of success.

It would have been an undertaking singularly interesting and instructive, to trace the different methods of cure which have been pursued in different ages, in the treatment of those labouring under mental derangement: and to mark the various results with which they were attended. The radical defect, in all the different modes of cure that have been pursued, appears to be, that of considering mania a _physical_ or _bodily_ disease, and adopting for its removal merely physical remedies. Very lately, however, a spirit of inquiry has been excited, which has given birth to a new system of treatment of the insane; and former modes of medical discipline have now given place to that which is generally denominated _moral management_.

This interesting subject has closely engaged my attention for some years, and I conceive that the further investigation of it may prove highly beneficial to the cause of humanity, as well as to science, and excite us to a minute inquiry, how far we may contribute to the relief and comfort of the maniacs placed under our care. In pursuing this subject, my views have been much extended, and my mind considerably enlightened, by perusing the writings of Doctors Creighton, Arnold, and Rush; but, more particularly, the account of the Retreat near York, in England. Under these impressions I feel extremely desirous of submitting to the consideration of the Governors, a plan to be adopted by them, for introducing a system of moral treatment for the lunatics in the Asylum, to a greater extent than has. .h.i.therto been in use in this country. The great utility of confining ourselves almost exclusively to a course of moral treatment, is plain and simple, and incalculably interesting to the cause of humanity; and perhaps no work contains so many excellent and appropriate observations on the subject, as that ent.i.tled, _The Account of the Retreat_. The author, Samuel Tuke, was an active manager of that establishment, and appears to have detailed, with scrupulous care and minuteness, the effects of the system pursued toward the patients. I have, therefore, in the course of the following remarks, with a view of ill.u.s.trating the subject with more clearness, often adopted the language and opinions of Tuke, but having frequently mixed my own observations with his, and his manner of expression not being always adapted to our circ.u.mstances and situation, I have attempted to vary the language, so as to apply it to our own inst.i.tution; this will account for many of the subsequent remarks not being noticed as taken from Tuke's work.

It is, in the first place, to be observed, that in most cases of insanity, from whatever cause it may have arisen, or to whatever extent it may have proceeded, the patient possesses some small remains of ratiocination and self-command; and although many cannot be made sensible of the irrationality of their conduct or opinions, yet they are generally aware of those particulars for which the world considers them proper objects of confinement. Thus it frequently happens, that a patient, on his first introduction into the asylum, will conceal all marks of mental aberration; and, in some instances, those who before have been ungovernable, have so far deceived their new friends, as to make them doubt their being insane.

It is a generally received opinion, that the insane who are violent, may be reduced to more calmness and quiet, by exciting the principle of _fear_, and by the use of chains or corporal punishments. There cannot be a doubt that the principle of fear in the human mind, when moderately and judiciously excited, as it is by the operation of just and equal laws, has a salutary effect on Society. It is of great use in the education of children, whose imperfect knowledge and judgment, occasion them to be less influenced by other motives. But where fear is _too much_ excited, and especially, when it becomes the chief motive of action, it certainly tends to contract the understanding, weaken the benevolent affection, and to debase the mind. It is, therefore, highly desirable, and more wise, to call into action, as much as possible, the operation of superior motives. Fear ought never to be induced, except when an object absolutely necessary cannot be otherwise obtained.

Maniacs are often extremely irritable; every care, therefore, should be taken, to avoid that kind of treatment that may have any tendency towards exciting the pa.s.sions. Persuasion and kind treatment, will most generally supersede the necessity of coercive means. There is considerable a.n.a.logy between the judicious treatment of children and that of insane persons. Locke has observed "the great secret of education is in finding out the way to keep the Child's Spirit easy, active and free; and yet, at the same time, to restrain him from many things he has a mind to, and to draw him to things which are uneasy to him." Even with the more violent and vociferous maniacs, it will be found best to approach them with mild and soft persuasion. Every pains should be taken to excite in the patient's mind a desire of esteem.

Though this may not be sufficiently powerful to enable them to resist the strong irregular tendency of their disease; yet, _when properly cultivated_, it may lead many to struggle to overcome and conceal their morbid propensities, or at least, to confine their deviations within such bounds as do not make them obnoxious to those about them. This struggle is highly beneficial to the patient; by strengthening his mind, and conducing to a salutary habit of self-restraint, an object, no doubt, of the greatest importance to the care of insanity by _moral means_.

It frequently occurs, that one mark of insanity is a fixed false conception, and a total incapacity of reasoning. In _such_ cases, it is generally advisable to avoid reasoning[24] with them, as it irritates and rivets their false perception more strongly on the mind. On this account, every means ought to be taken to seduce the mind from unhappy and favourite musings; and particularly with melancholic patients; they should freely partake of bodily exercises, walking, riding, conversations, innocent sports, and a variety of other amus.e.m.e.nts; they should be gratified with birds, deer, rabbits, etc. Of all the modes by which maniacs may be induced to restrain themselves, regular employment is perhaps the most efficacious; and those kind of employments are to be preferred, both on a moral and physical account, which are accompanied by considerable bodily action, most agreeable to the patient, and most opposite to the illusions of his disease.

In short the patient should be always treated as much like a rational being as the state of his mind will possibly allow. In order that he may display his knowledge to the best advantage, such topics should be introduced as will be most likely to interest him; if he is a mechanic or an agriculturalist, he should be asked questions relating to his art, and consulted upon any occasion in which his knowledge may be useful.

These considerations are undoubtedly very material, as they regard the comforts of insane persons; but they are of far greater importance as they relate to the cure of the disorder. The patient, feeling himself of some consequence, is induced to support it by the exertion of his reason, and by restraining those dispositions, which, if indulged, would lessen the respectful treatment he wishes to receive, or lower his character in the eyes of his companions and attendants.

Even when it is absolutely necessary to employ coercion, if on its removal the patient promises to control himself, great reliance may frequently be placed upon his word, and under this engagement, he will be apt to hold a successful struggle with the violent propensities of his disorder. Great advantages may also be derived, in the moral management of maniacs, from an acquaintance with the previous employment, habits, manners, and prejudices of the individual: this may truly be considered as indispensably necessary to be known, as far as can be obtained; and, as it may apply to each case, should be registered in a book for the inspection of the Committee of the Asylum, and the physician; the requisite information should be procured immediately on the admission of each patient; the mode of procuring it will be spoken of hereafter.

Nor must we forget to call to our aid, in endeavouring to promote self-restraint, the mild but powerful influence of the precepts of our holy religion. Where these have been strongly imbued in early life, they become little less than principles of our nature; and their restraining power is frequently felt, even under the delirious excitement of insanity. To encourage the influence of religious principles over the mind of the insane, may be considered of great consequence, as a means of cure, provided it be done _with great care and circ.u.mspection_. For this purpose, as well as for reasons still more important, it would certainly be right to promote in the patient, _as far as circ.u.mstances would permit_, an attention to his accustomed modes of paying homage to his Maker.

In pursuing the desirable objects above enumerated, we ought not to expect too suddenly to reap the good effects of our endeavours; nor should we too readily be disheartened by occasional disappointments. It is necessary to call into action, as much as possible, every remaining power and principle of the mind, and to remember, that, "in the wreck of the intellect, the affections very frequently survive." Hence the necessity of considering _the degree_ in which the patient may be influenced by moral and rational inducements.

The contradictory features in their characters, frequently render it exceedingly difficult to insure the proper treatment of insane persons; to pursue this with any hopes of succeeding, so that we may in any degree ameliorate their distressed condition, renders it indispensably necessary that attendants only should be chosen who are possessed of good sense, and of amiable dispositions, clothed, as much as possible, with philosophical reflexion, and above all, with that love and charity that mark the humble Christian.

Agreeably to these principles, I beg leave to suggest the following regulations to be adopted, in accomplishing the objects in view.

1st. No patient shall hereafter be confined by chains.

2nd. In the most violent states of mania, the patient should be confined in a room with the windows, etc., closed, so as nearly to exclude the light, and kept confined if necessary, in a straight jacket, so as to walk about the room or lie down on the bed at pleasure; or by strops, etc., he may, particularly if there appears in the patient a strong determination to self-destruction, be confined on the bed, and the apparatus so fixed as to allow him to turn and otherwise change his positions.

3rd. The power of judicious kindness to be generally exercised, may often be blessed with good effects, and it is not till after other moral remedies are exercised, that recourse should be had to restraint, or the power of fear on the mind of the patient; yet it may be proper sometimes, by way of punishment, to use the shower bath.

4th. The common attendants shall not apply any extraordinary coercion by way of punishment, or change in any degree the mode of treatment prescribed by the physician; on the contrary, it is considered as their indispensable duty, to seek by acts of kindness the good opinion of the patients, so as to govern them by the influence of esteem rather than of severity.

5th. On the first day of the week, the Superintendent, or the princ.i.p.al keeper of the Asylum, shall collect as many of the patients as may appear to them suitable, and read some chapters in the Bible.

6th. When it is deemed necessary to apply the strait-jacket, or any other mode of coercion, by way of punishment or restraint, such an ample force should be employed as will preclude the idea of resistance from entering the mind of the patient.

7th. It shall be the duty of the deputy-keeper, immediately on a patient being admitted, to obtain his name, age, where born, what has been his employment or occupation, his general disposition and habits, when first attacked with mania; if it has been violent or otherwise, the cause of his disease, if occasioned by religious melancholy, or a fondness for ardent spirits, if owing to an injury received on any part of the body, or supposed to arise from any other known cause, hereditary or advent.i.tious, and the name of the physician who may have attended him, and his manner of treating the patient while under his direction.

8th. Such of the patients as may be selected by the physician, or the Committee of the Asylum, shall be occasionally taken out to walk or ride under the care of the deputy-keeper; and it shall be also his duty to employ the patients in such manner, and to provide them with such kinds of amus.e.m.e.nts and books as may be approved and directed by the Committee.

9th. The female keeper shall endeavour to have the female patients Constantly employed at suitable work; to provide proper amus.e.m.e.nts, books, etc., to take them out to walk as may be directed by the Committee.

10th. It shall be the indispensable duty of the keepers, to have all the patients as clean as possible in their persons, and to preserve great order and decorum when they sit down to their respective meals.

11th. It shall be the duty of the physician to keep a book, in which shall be entered an historical account of each patient, stating his situation, and the medical and moral treatment used; which book shall be laid before the Committee, at their weekly meetings.

The sentiments and improvements proposed in the preceding remarks, for the consideration of the Governors, are adapted to our present situation and circ.u.mstances; but a further and more extensive improvement has occurred to my mind, which I conceive, would very considerably conduce towards affecting the cure, and materially ameliorate the condition, and add to the comfort of the insane; at the same time that it would afford an ample opportunity [Transcriber's note: original reads 'apportunity']

of ascertaining how far that disease may be removed by moral management alone, which it is believed, will, in many instances, be more effectual in controlling the maniac, than medical treatment especially, in those cases where the disease has proceeded from causes operating directly on the mind.

I would propose, that a lot, not less than ten acres, should be purchased by the Governors, conveniently situated, within a few miles of the city, and to erect a substantial building, on a plan calculated for the accommodation of fifty lunatic patients; the ground to be improved in such a manner as to serve for agreeable walks, gardens, etc., for the exercise and amus.e.m.e.nt of the patients: this establishment might be placed under the care and superintendence of the Asylum Committee, and be visited by them once every week: a particular description of patients to remain at this Rural Retreat; and such others as might appear suitable objects might be occasionally removed there from the Asylum.

The cost and annual expense of supporting this establishment, are matters of small consideration, when we duly consider the important advantages it would offer to a portion of our fellow-creatures, who have such strong claims on our sympathy and commiseration.

But, it is a fact that can be satisfactorily demonstrated, that such an establishment would not increase our expenses; and, moreover, would repay us even the interest of the money that might be necessary to be advanced, for the purchase of the ground and erecting the buildings. The board of patients (supposing fifty) would yield two hundred dollars per week, or ten thousand four hundred dollars per annum.

Supposing the ground, building, etc., to cost $50,000, the interest on this sum at 6 per cent. would be $3,000, there would yet remain $7,400, for the maintenance and support of the establishment; a sum larger than would be required for that purpose.

We had lately in the Asylum, more than ninety patients; and, at that time, had repeated applications to receive an additional number; the Committee however, concluded, that as the building was not calculated to accommodate more than seventy-five, it would be an act of injustice to take in any more; they, therefore, concluded to reduce the number of seventy-five, and strictly to refuse receiving any beyond that number.

This may serve clearly to show, that we might safely calculate, that we should readily have applications to accommodate one hundred and twenty-five patients.

This succinct view of the subject may suffice, at this time, as outlines of my plan; and which is respectfully submitted to the Governors, for their Consideration.

FOOTNOTES:

[Footnote 23: "Hints for Introducing an Improved Mode of Treating the Insane in the Asylum"; read before the Governors of the New York Hospital on the 4th of Fourth-month, 1815. By Thomas Eddy, one of the Asylum Committee. New York, 1815. Reprinted Bloomingdale Hospital Press, 1916.]

[Footnote 24: The following anecdotes ill.u.s.trate the observation before made, that maniacs frequently retain the power of reasoning to a certain extent; and that the discerning physician may oftimes successfully avail himself of the remains of this faculty in controlling the aberrations of his patient:--A patient in the Pennsylvania Hospital, who called his physician his father, once lifted his hand to strike him. "What!" said his physician, (Dr. Rush), with a plaintive tone of voice, "Strike your father?" The madman dropped his arm, and instantly showed marks of contrition for his conduct. The following was related to me by Samuel Coates, President of the Pennsylvania Hospital:--maniac had made several attempts to set fire to the Hospital: upon being remonstrated with, he said, "I am a salamander"; "but recollect," said my friend Coates, "all the patients in the house are not salamanders;" "That is true," said the maniac, and never afterwards attempted to set fire to the Hospital.]