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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 hitherto been done, "how and
how far the humours and effects of the body, do alter and work upon the
mind; and how far the passions 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 hitherto 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 entitled, _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 illustrating 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 circumstances and situation, I have attempted to
vary the language, so as to apply it to our own institution; 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 passions. Persuasion and kind treatment, will most
generally supersede the necessity of coercive means. There is
considerable analogy 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 amusements; 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 circumspection_. For
this purpose, as well as for reasons still more important, it would
certainly be right to promote in the patient, _as far as circumstances
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 principal
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
adventitious, 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 amusements 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 amusements,
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 circumstances; 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 amusement 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 illustrate 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.]

APPENDIX IV

EXTRACTS FROM THE MINUTES OF THE BOARD OF GOVERNORS IN RELATION TO
ACTION TAKEN RESPECTING THOS. EDDY'S COMMUNICATION DATED APRIL, 1815

_April 4, 1815._

A communication was received from Thos. Eddy suggesting several
improvements in the mode of treating Insane persons, which is referred
to Dr. Hugh Williamson, George Newbold, William Johnson, Peter A. Jay,
and John R. Murray--Resolved that the Treasurer have fifty copies of the
report printed for use of the Governors.

_July 3, 1815._

The Committee on the communication from Thos. Eddy, relative to the
treatment of Insane patients, report attention to the subject and that
in their opinion it is advisable to have a few acres of land purchased
in the vicinity of the City for the better accommodation of this unhappy
class of our fellow creatures--the Committee are continued.

On motion Resolved that Thomas Eddy, John A. Murray, and John Aspinwall,
be a Committee to look out for a suitable spot of land, and to make a
purchase, if in their opinion it shall become necessary.

_8th Month (August) 1st, 1815._

The Committee on the communication from Thomas Eddy, made the following
Report, which was intended to have been laid before the last meeting of
the Board; which was now accepted, and ordered to be inserted in the
minutes.

"The Committee appointed to consider the expediency of erecting another
Building for the accommodation of Insane Persons Report:

That another building for the use of those unfortunate persons who have
lost the use of their reason, is not only advisable, but seems to be
absolutely necessary.

That though there are at present more patients in the Asylum, by nearly
one third, than can with perfect Safety, and the best hopes of recovery,
be lodged there; many more insane persons, perhaps twenty within a few
months, have by their friends been soliciting a place in that
Building--In speaking of the want of safety, the Committee only mean to
express an opinion, that when two or more insane persons, from the want
of room are lodged together in one cell, the life of the weaker must be
somewhat endangered by the stronger, who in a high Paroxysm of insanity
might strangle him in his sleep, or otherwise destroy him.

That such additional Building, from the want of room, cannot possibly be
erected near the hospital, in this city.

That there are many reasons for believing that the recovery from a state
of insanity would be greatly promoted, by having a considerable space of
ground adjoining the Asylum or Public Building, in which many of the
patients might have the privilege of walking, or taking other kinds of
exercise.

That considering the various kinds of insanity, your Committee, are
clearly of the opinion, that two buildings should be erected at the
distance of at least one hundred yards from each other. The sedate or
melancholy madman should not have his slumbers broken by living under
the same roof with disorderly persons, who by singing, or other noisy
proceedings, will not suffer their neighbours to sleep.

That for the above and similar considerations, it would be advisable,
to purchase, within a few miles of this City, at least twenty acres of
land, detached from private buildings, in a healthy and pleasant
situation, where the water is good and where materials for buildings may
be obtained on easy terms: and the portage of fuel not expensive.

Your Committee are aware that a smaller lot of ground might suffice for
all the buildings that are now required, or all this Corporation may, in
a short time, be enabled to complete. But they count it advisable to
prepare for a period that must certainly come; a period in which such a
lot will be needed, and not easily obtained, for it is evident from the
topography, and geographical position of this City, that the time must
come, when New York will be not only the greatest City in the United
States, or in America; but must rival the most distinguished City's in
the old Continent.

Wherefore it is recommended, that a Committee be appointed, who shall
examine the sundry places, corresponding with the above description,
that may be purchased. And that they report the means of making the
purchase, and of erecting such Buildings, as seem at this time to be
required."

The Committee to whom was referred, to purchase a suitable Lot of Land
for the erection of a House for the accommodation of maniacs, Report
that they have purchased 38 acres of Land, being part of the Estate
belonging to Gerard Depeyster at Bloomingdale, at the rate of $246. per
acre, payable 25 per cent down, 371/2 per cent on 1st November and 373/4 per
cent on 1st February next, with interest.

THOMAS EDDY, Chairman

August 1st, 1815

Whereupon Resolved that the Report of the Committee be accepted, and
they are instructed to take the Titles, after P.A. Jay shall have
examined the Records, and be satisfied that the property is free of
incumbrance.

APPENDIX V

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