Tl)e of the Insane 
WITHOUT MECHANICAL RESTRAINTS. 
A TAPER READ BEFORE THE “ CONFERENCE OF CHARITIES,” 
AMERICAN SOCIAL SCIENCE ASSOCIATION, AT THE ANNUAL 
MEETING /AT SARATOGA, SEPTEMBER 6TH, 1876. 
BY J. L. BODINE, M D, OF TRENTON, NEW JERSE&' 
Improvements in the social condition of the insane have 
been the outgrowth of that spirit of philanthropy which 
has characterized the civilization of the last hundred years. 
The practical Christianity which, recognizing the universal 
brotherhood of man and avowing that love for God involves 
love of the brotherhood, led Howard and his successors in 
their agitation for prison reform, constrained Clarkson and 
Wilberforce in their efforts for the slave, urged Robert Owen 
in his sacrifices for the elevation of the workingman, and 
has been the moving spirit in the development of popular 
education and of organized modern charities ; the same 
spirit of unselfish love lias led to the substitution of sympathy 
for severity, trust for deceit, and kindness for mechanical 
restraints, in the management of the insane. 
The condition of the insane before the advent of the spirit 
of modern philanthropy, was, for the most part, deplorable, 
although at all times and in all countries, under exceptional 
circumstances, the insane have been treated with kindness, 
wisdom and skill. The Jews were taught by the law of Moses 
that insanity was a punishment for sin. In the Book of 2 
Deuteronomy, among the curses pronounced for disobedi- 
ence, it is declared “the Lord shall smite thee with mad- 
ness and yet, when the evil spirit from the Lord took pos- 
session of Saul, his servants advised the restoring influence 
of sweet sounds to drive away his melancholy. The mental 
malady of Saul progressed, notwithstanding the wise use of 
remedial emotional influences. Delusions of suspicion, jeal- 
ousy and fear came upon him, and he had hallucinations of 
sight and hearing, for he saw the dead Samuel alive, and 
talked with him. He afterwards had homicidal impulse, and 
sought death by suicide. The Greeks appear to have had 
very accurate notions in regard to the causation and rational 
treatment of insanity. The dependence of mental disorder 
upon conditions of bodily-ill health, and the effect of emo- 
tional influences, both in causing and in curing mental 
malady, was recognized by them. The reciprocal influence 
of body and mind upon each other was the basis of their 
treatment for the disease. During the dark ages the insane 
were not better cared for than other classes of weak and 
afflicted human beings, and after the dawning of modern 
civilization the Judaic spirit of the Christian world was so 
influential that insanity was looked upon as diabolic posses- 
sion, and the demon was to be exorcised or subdued by 
stripes and punishment, cruelty and deceit. The people, 
who put witches to death and became persecutors for right- 
eousness’ sake, would be very likely to regard insanity as a 
result of sin, and to meet its manifestations with cruelty and 
chains, the dungeon and the lash. 
In the year 1792 Pinel entered upon his duties as Physi- 
cian to the Bicetre in Paris, and there inaugurated the 
modern treatment of insanity, a work which has made his 
name immortal. He struck the chains from the lunatic, 
treated him with kindness, and exercised a wise confidence 
towards him. He made use of the principle of mental diver- 
sion to relieve maniacal excitement and melancholia, and 
secured the confidence and affection of his patients by his 
infinite patience and courageous kindness. The condition 3 
of the insane before the time of Pinel is only paralleled by 
the atrocities of the inquisition or the horrors of the middle 
passage. Chains, stripes, dungeons, dirt, filth and damp- 
ness, furious mania, violence begetting violence and murder, 
cruelty by keepers of madmen, leading to cruel revenge by 
the maniac, bodily tortures superadded to the mental ago- 
nies of the lunatic, scenes of turmoil and excitement, which 
have disappeared with the barbaric cruelty which gave rise 
to them, such were the sights which characterized the re- 
ceptacles for the detention of the insane before Pinel’s intro- 
duction of the peace policy in its relation to the madman. 
The principles of this great social reform did not at once 
receive full and complete acceptance. On the contrary, they 
met with the most bitter opposition, reproach and misrepre- 
sentation, and all the power of ignorant prejudice and selfish 
interest was invoked for the continuance of the old system. 
Pinel’s successor, Esquirol, did very much in France to con- 
tinue and further the work which Pinel had begun, and 
their influence in other countries has led to very great im- 
provement in the social condition of the insane. 
In the year 1796 the Retreat, at York, England, was 
founded by the Society of Friends, William Tuke being 
especially prominent in the organization of the institution, 
and his grandson, Samuel Tuke, in perpetuating it in the 
spirit of its founders, the spirit of love, gentleness and kind- 
ness to the patients, so that it might indeed be “ a quiet 
haven, in which the shattered bark might find the means of 
reparation or of safety.” The Retreat was organized because 
of the dissatisfaction of ihe Quakers with the management 
of the York lunatic asylum ; and the success of the Retreat 
drew public attention to the mismanagement of that insti- 
tution. The York lunatic asylum, adopting the policy of 
exclusion of visitors from its halls, had become pre-eminent 
for every wrong and iniquity of management, and an at- 
tempt, made in 1788, to reform the abuses of that institution, 
was signally defeated; but the establishment of the Retreat, 
and the publication, in 1813, of a history of its origin, pro- 4 
gress and modes of treatment, by Samuel Tuke, excited such 
universal public interest, that an exposure of the abuses of 
the York lunatic asylum, and their removal, resulted. 
This result was reached in opposition to the Governors of 
the asylum, who adopted a policy of concealment and at- 
tempted to prevent and to stifle investigation. They declared 
that the insane were treated “ with all possible care, atten- 
tion and humanity,” and adopted a resolution of censure 
upon those who presumed to criticize the management of an 
institution with which gentlemen of their high character 
were connected. The investigation still went on. Falsifi- 
cation and fraud appeared at every step. “A patient disap- 
pears and is never heard of—he is said to be removed; a 
patient is killed—the body is hurried away to prevent an 
inquest.” The Steward’s books are given to- the flames, and 
a partially successful attempt is made to fire the institution 
itself. 
In 1815 a Committee of the House of Commons of England 
published the result of an investigation into the state of 
Bethlem and other hospitals. The evidence taken by the 
committee furnishes a sad chapter in the history of civilized 
society. It is by no means a pleasant thing to recur to these 
records of the past, but “ they are written for our admoni- 
tion, upon whom the ends of the world are come.” Unre- 
generate human nature is the same now that it ever was, 
and the forces of civilized life too often place nothing more 
than a thin veneering over the savagery of man’s nature. 
The contemplation of, and participation in, acts of cruelty, 
hardens man’s heart and brutalizes his character, and the 
temptation to oppression of the weak and defenceless by the 
strong and powerful is an ever present one to the human 
mind. The use of power, the love of power, and the abuse 
of power, lie very near each over. Habitual publicity and 
efficient supervision are ever necessary to prevent abuses 
and personal wrongs in asylums for the insane. By the 
evidence of the Parliamentary Committee, it appeared that 
in Bethlem numbers of female patients were chained in rows 5 
to a wall, with only one garment to cover them, and that 
the patients were shamefully neglected and unclean. In 
one of the cells was found the historic William Norris, who 
had been closel}7 encased for twelve years in rings and 
bands of iron, and firmly secured by chains to an iron bar, 
which was fastened into the wall of his cell. The assigned 
reason for this caging in iron was an act of violence com- 
mitted upon a drunken keeper who had provoked Norris to 
retaliation by wanton and brutal cruelty. The Governors 
of Bedlam declared there was no foundation for the charge 
of cruelty and bad management of the institution, and that 
the patients had every indulgence which their security and 
the safety of the officers and attendants would permit. In 
regard to Norris, they asserted that his confinement was, 
“ upon the whole, rather a merciful and humane than a 
rigorous and severe imposition.” The whole system of man- 
agement in many of the asylums in England, as disclosed 
by the evidence of the Parliamentary Committee, was a 
system of neglect, cruelty and terrorism, with the result that 
madmen and their keepers alike were by it transformed into 
brutes. Fear and cruel punishments were the means used 
to subdue and to control the insane long after Pinel and 
Tuke had demonstrated the greater efficacy of the law of 
kindness, and had shown that in its operation the law of 
kindness is “ twice blessed.” 
Medical teaching tended to uphold the terrifying system. 
Dr. Cullen, whose writings greatly influenced the English 
speaking medical world of his own and the succeeding gen- 
eiation, wrote less than a hundred years ago. u Fear being 
a passion which diminishes excitement, may therefore be 
opposed to an excess of it; and particularly to the angry and 
irascible excitement of maniacs. These being more suscep- 
tible of fear than might be expected, it appears to have been 
commonly useful. In most cases, it has appeared to be 
necessary to employ a very constant impression of fear, and 
therefore to inspire them with the awe and dread of some 
particular persons, especially of those who are to be con- 6 
stantly near them. This awe and dread is therefore, by one 
means or other, to be acquired, in the first place, by their 
being the authors of all the restraints that may be occasion- 
ally proper: but sometimes it may be necessary to acquire 
it even by stripes and blows.” 
Dr. Benjamin Rush, the pupil of Dr. Cullen, the advocate 
in this country of Cullen’s theories, and himself the most 
illustrious of American physicians, in his work on the Dis- 
eases of the Mind, published in 1812, after expressing most 
enlightened viewTs of the necessity for and the means of 
establishing mental and moral influence and control over 
the insane patient, really gives his influence for the perpet- 
uation of the system of restraint by physical and mechanical 
forces. He insists that insane patients should be treated 
with justice, kindness, and a strict regard for the truth, and 
he observes that mad people “seldom forget three things 
after their recovery, viz: acts of cruelty, acts of indignity, 
and acts of kindness.” After recognizing in the fullest man- 
ner the power of the law of kindness in dealing with the 
insane, Dr. Rush recommends the use of coercion to prevent 
destruction of furniture and clothing, and to punish the 
patients for outrages upon their keepers and each other. As 
instruments of coercion, punishment and subjugation, he 
made use of the strait waistcoat, the restraint chair, which 
he called a “ tranquillizer,” the shower bath continued for 
fifteen or twenty minutes, the fear of death and under cer- 
tain circumstances chains and the whip. Dr. Rush remarks 
upon the advantages of solitude and darkness for the mad- 
man. He says darkness invites silence and promotes fear, 
and that he has seen the happiest effects from confining 
noisy patients in the dark cells of the Pennsylvania Hospi- 
tal. He thought the same means might be used for subdu- 
ing madmen, that had been found effectual for taming 
refractory horses. The horse is impounded and then kept 
from lying down or sleeping for two or three days and nights 
by thrusting sharp pointed nails in his body. The mad- 
man was to be kept awake and standing, by less severe 7 
means, for twenty-four hours. Dr. Rush recommends his 
“gyrater,” made in imitation of the circulating swing of Dr. 
Cox, as a curative and punitive agent. It gave the patient 
a rotatory motion, at a more or less rapid rate, and produced 
“ vertigo, nausea and a general perspiration.” Dr. Cox 
naively remarks that he has seen a patient “ who required 
the combined strength and address of several experienced 
attendants to place him in the swing,” so tranquillized by 
its protracted action that he has been easily carried from it 
by a single person ; and that the recollection of the swing 
produces such an impression on the mind of the patient that 
“ the physician will only have to threaten its employment 
to secure compliance with his wishes.” Dr. Cox thought the 
swing “ would afford relief in some very hopeless cases if 
employed in the dark, where, from unusual noises, smells or 
other powerful agents acting forcibly on the senses, its effi- 
cacy might be amazingly increased.” It would seem that 
association with the insane often produces manifest deterio- 
ration in the mental and moral characteristics of even the 
most enlightened, benevolent and conscientious medical 
men. 
The year 1829 marks another point in the history of 
asylum reform. In that year, a patient in the asylum at 
Lincoln, England, had died in the night from being strapped 
in bed with a strait jacket on, and this event led to the adop- 
tion of a rule in that asylum that when restraints were used 
at night an attendant should remain with the patient. It 
was found that restraints at night became less frequently 
necessary under this rule. It was soon found that restraints 
could be dispensed with by day as well as by night, and for 
long periods it was not found necessary to make use of them. 
At last, in 1837, under the direction of Dr. Charlesworth and 
Mr. Gardiner Hill, the use of mechanical restraints was alto- 
gether abolished from the Lincoln asylum. In 1839, Dr. 
Conolly was appointed Resident Physician and Superintend- 
ent of the Middlesex County asylum, at Han well, England, 
and by his successful introduction and gradual extension of 8 
the s}rstem at Han well, the name of Conolly has become 
associated with the 11011-restraint system of management of 
the insane, the great principle of which, as Conolly expresses 
it, is “ to exclude all hurtful excitement from a brain already 
predisposed to excitement.” 
A11 insane man is out of his proper relation to the world 
about him 011 account of disease, functional or organic, in 
the brain, the organ of the mind. Mental manifestations are 
dependent upon and only recognized through material organ- 
ization. The causes of mental disease are the causes of other 
forms of nervous disease. The heredity of neurotic diseases, 
and the interchangeability or transformation in their trans- 
mission of these diseases, are recognized facts. Changes in 
the nutrition of the brain, either from disease in the blood 
itself or in the vessels which supply blood to the brain, or 
from disease in some distant part of the body, inducing irri- 
tation of the central nervous system, may produce epilepsy, 
chorea, paralysis, neuralgia, or other forms of nervous disor- 
der; and just as well those forms of mental disorder, which 
become manifest in the depression of melancholia and the 
excitement of mania, may be produced by the same patho- 
logical conditions. Again, intellectual and emotional strain, 
physical excesses, and sudden and violent shock, acting 
upon an exhausted or an unstable nervous system, will pro- 
duce states of mental as well as forms of nervous disorder. 
The habitual surrender of one’s self to any one pursuit or 
passion until the one pursuit or passion dominates the whole 
man, is a cause of physical as well as mental degeneration, 
and the natural culmination of such domination is the de- 
thronement of reason. Insanity is a disease physical in its 
causation and mental in its manifestation, and the demands 
of treatment are the same as for other forms of disease of the 
nervous system, viz: healthy blood for healthy nutrition, 
and physiological rest for the exhausted, depressed or irri- 
tated nervous system, to allow time to work the restorative 
changes which may result in health. We do not ignore 
mental and emotional influences in treating physical dis- 9 
ease, and we ought not to neglect physical states in the treat- 
ment of mental malady. Insanity is just about as curable 
as other serious diseases of the nervous system, and its cura- 
ble stages are its early stages, when organic cerebral changes 
have not taken place. Of five persons attacked with the 
disease, it appears from the carefully prepared statistics of 
Dr. Thurnam that not more than one of them is likely to be 
permanently restored to health and reason, so that insanity 
is one of the most incurable of curable diseases. 
Viewing insanity as a physical disease, and an asylum as 
a place' for the treatment of mental malady, Dr. Conolly 
entered upon his duties at Hanwell. He not only abolished 
all forms of mechanical restraint from the discipline of the 
asylum, but he strove to eliminate all disturbing influences 
from the social life of the insane, so that the curable might 
be restored to health, happiness and reason, and that the 
incurable insane, no longer suffering more from their treat- 
ment than from their malady, might enjoy as great a degree 
of comfort and happiness as their afflicted condition would 
permit. When a patient came to Hanwell, under the reign 
of peace and kindness, which Conolly introduced there, he 
was at once released from his bonds. His own safety, and 
that of those about him, was looked after, but he was not 
needlessly interfered with, and his desire for muscular activ- 
ity was not unnecessarily obstructed. Excited action often 
relieves excited feeling, and it was found that morbid ex- 
citement would often be discharged with safety, if the patient 
was allowed unobstructed freedom of movement. The mad- 
man, like the angry man, is made more violent by opposi- 
tion or needless interference. If the patient was uncontrol- 
lably violent, he was temporarily secluded from the sights 
and sounds which were sources of irritation to him. This 
seclusion was, if possible, effected by persuasion and without 
resort to force, for force begets resistance and an increase of 
excitement. If force was necessary, four or five attendants 
removed the patient quietly, and without a contest, to a 
place where he was protected against injury to himself or 10 
others. In the interval succeeding the paroxysm of excite- 
ment, the peculiarities of the individual patient, the mode of 
onset of his disease, and his condition of bodily health, were 
inquired into, and the foundations of mental and moral in- 
fluence over the patient were, if possible, established. The 
patient was made to feel that he was in the care and guar- 
dianship of friends who would protect him and treat him 
with kindness. All his surroundings were quiet, orderly 
and tranquillizing. His clothing and bedding were clean ; 
his food was good and carefully served, and all the arrange- 
ments of the institution were made and administered to 
promote the well being of the patients. Provision was made 
for their occupation, employment, amusement and instruc- 
tion. Everything which thoughtful care, benevolent kind- 
ness and intelligent skill on the part of the Superintendent 
could supply, was furnished to the patients at Hanwell. 
Peace, quiet, order, content and hope sprang up in breasts 
where before wrath, turbulence, disorder and hopeless dis- 
content had reigned. The object of treatment was to develop 
what there was of mental soundness in the patient and by 
the expulsive power of a new interest, to divert the maniacal 
from the sources of his excitement and the melancholic from 
His subjective grief. Habits of self restraint and of self help 
were encouraged in the patient. Physical force compulsion 
was ignored, and reliance was had upon moral forces alone. 
The patients were treated with kindness, forbearance, watch- 
fulness, attention, gentleness and truthfulness. By this 
treatment, confidence, content, trust, affection and hope were 
developed in their mental experience, and mental health 
was restored to many who, under the old system of neglect 
and mechanical coercion, would have become incurable and 
hopeless lunatics. The insane man was to be cured, if pos- 
sible; but, at any rate, he was entitled, by reason of his 
affliction, which takes away the joy and crown of his life, to 
a double share of that never failing charity “ which suffereth 
long and is kind, is not easily provoked, beareth all things, 
endureth all things.” 11 
The attendant is the weak point in the non-restraint sys- 
tem. The natural impulse of the average attendant is to 
treat the patients entrusted to his care ‘‘ like dumb, driven 
cattle;” but well chosen attendants, being treated by their 
superior officers with kindness, consideration and humanity, 
will thus be prepared to extend the same law of humane 
kindness to their afflicted and often perverse charges. The 
Superintendent always gives tone to his whole institution, 
and the insane unconsciously assimilate the character of 
their surroundings and associations very much as children 
do. The attendant never will be more careful and consid- 
erate of the interests and welfare of the patients than his 
superior officers are. A selfish and neglectful Superintend- 
ent, one who is engrossed with other cares than the restora- 
tion to health and the humane treatment of the patients 
entrusted to his care, will have in his institution attendants 
no less selfish and neglectful than himself. With such a 
Superintendent attendants are unreliable, and mechanical 
restraints become a necessity. Habitual severity or syste- 
matic neglect in the management of an institution will lead 
surely to manifestations of excitement, turbulence, disorder, 
resentment and revenge on the part of the suffering patients. 
Deceit, treachery, hate and scenes of violence are the neces- 
sary accompaniments of such management. 
In his last annual report at Han well, Dr. Conolly says: “ 1 
will only further simply state that now for ten entire years no 
hand or foot has been fastened in this large asylum, by day 
or by night, for the control of the violent or the despairing; 
that no instrument of mechanical restraint has been em- 
ployed or even admitted into the wards for any reason what- 
ever ; that no patient has been placed in a coercion chair by 
day or fastened to a bedstead at night; and that ever}' 
patient, however excited or apparently unmanageable, ar- 
riving at the asylum in restraints, has been immediately set 
free, and remained so from that time. I wish to overstate 
nothing, but I am justified in adding that the results, more 
and more seen in every successive year, have been increased 12 
tranquillity, diminished danger, and so salutary an influ-, 
ence over the recent and newly admitted and most violent 
cases, as to make the spectacle of the more terrible forms of 
mania and melancholia a rare exception to the general 
order and cheerfulness of the establishment.” Dr. Conolly, 
by his courageous and successful experiment of non-restraint, 
contributed very much to ameliorate the condition of the 
insane in the asylums of Great Britain. The reform has 
not met with universal adoption there, but even in those 
institutions, which have rejected it, restraints have been very 
much lessened in their frequency and rigor. From the ad- 
ministration of some of the English asylums, seclusion as 
well as mechanical restraint is excluded. Dr. Batty Tuke 
has further extended the non-restraint principle within a 
few years, and has introduced into the Fife and Kinross 
asylum the policy of unlocked doors. He finds that more 
trust and reliance upon the sense of honor of the insane is 
followed by improved conduct, and that when bars and 
bolts are removed the desire to escape often disappears. 
The question of employment for the insane is closely con- 
nected with the non-use of mechanical restraints in their 
management. Dr. Wilbur, in his report to the State Board 
of Charities of New York, has done a public service by call- 
ing attention to the extent to which employment is used in 
the asylums of Great Britain. In people, who are sane, idle- 
ness is a source of disease and of much bad conduct, and 
mental derangement is often intensified and bad conduct 
in the insane invited by the listlessness and hopeless apathy 
of the halls of our overgrown asylums. The disordered 
mind, having no interests outside of itself, turns inward, and 
an intense self consciousness is developed, which results in 
excitement and disorderly conduct. Samuel Tuke says, 
■‘that to Sir William Ellis we are indebted for the first ex- 
tensive and successful experiment to introduce labor syste- 
matically into public asylums.” “He first proved that 
there was less danger of injury from putting the spade and 
the hoe into the hands of a large proportion of insane per- 13 
sons, than from shutting them up together in idleness, 
though under the guards of straps, strait waistcoasts or 
chains.” Dr. Andrew Combe, in his work on Mental De- 
rangement, quotes from the tenth report of the Directors of 
the Dundee asylum, June, 1830, the statement that the Su- 
perintendent of their asylum, in visiting a number of insti- 
tutions for the insane, “found employment more or less 
resorted to as one of the most powerful efficients towards 
cure; but in one establishment in particular the beneficial 
effects arising from it have been such as to render restraint 
and confinement seldom, if ever, necessary, and the patients 
enjoy a freedom scarcely inferior to that which a person 
enjoys who is under no control.” 
Under the system of restraint, as I have seen it in one of 
the best of our American asylums, a maniacal patient is 
placed under some form of restraint. If he resists and is 
violent, restraints are made more effective. He is probably 
tied down in his bed and left locked in his room for hours, 
unattended. Of course, he becomes “ wet and dirty,” and 
even if he is restrained only with the strait waistcoat, the 
muff, or the belt and wristlet, uncleanly habits are thereby 
encouraged. Under any form or mode of restraint the reg- 
ular and sufficient supply of food to the patient is neglected, 
and his physical condition is thereby deteriorated. The 
cerebral excitement not being lessened, but rather aggrava- 
ted, by his treatment, he shouts and howls through restless 
days and wakeful nights, until cerebral irritation produces 
change of cerebral structure, and he becomes a dement, sub- 
jugated by the restraint system, but his intellect destroyed. 
Tf he gets well, and he sometimes will, he has a lasting 
resentment against those who have subjected him to such 
indignities. I have seen an epileptic patient tied down to 
his bed and left to have his convulsions in the solitude and 
loneliness of his own room, until death came to release him 
from the suffering and sorrow for which his brother man 
appeared to have no pity. I have seen an attendant, unre- 
buked, threaten a complaining patient in the presence of a 14 
medical officer, and I have known asylum Managers and 
others in authority to listen to the narration of such by no 
means exceptional scenes in asylum life, with incredulous 
pity or helpless indifference. I have seen restraints used to 
prevent suicide and the destruction of clothing, but the use 
of restraints in these cases is a weak surrender to the disor- 
derly impulses of the lunatic. Mechanical ingenuity can 
devise clothing which cannot be torn or taken off, and 
watchful care will prevent suicide. The use of restraints 
does not, surely, tend to make life more attractive to the 
victim of suicidal melancholy, for he is likely to mingle the 
realities of his treatment with the delusions of his disease. 
Restraint by the camisole, the muff, the belt and wristlet 
cannot and does not prevent sudden and even fatal assaults 
or the injuries and casualties of an asylum hall. To be 
effectual against such contingencies the restraints must be 
the chain and the dungeon of the olden days. Dr. Griesin- 
ger says that in an English institution, managed on the non- 
restraint system, containing about a thousand patients, he 
once saw a bloody nose and heard the crash of broken glass, 
but that he had noticed the same things in Asylums where 
the restraint chair and the strait jacket were in constant use, 
and that he had seen, with happy astonishment, in an 
English asylum, patients on the point of an outbreak 
speedily rendered calm by psychical diversion and skilful 
management, who, in most of the Continental asylums, 
would have had restraint applied. 
From what I saw of asylum life, now nearly ten years 
ago, and from much thought and painstaking inquiry on 
the subject since that time, I am persuaded that Dr.- Con- 
oily’s observation that he had “ never known all the patients 
properly attended to so long as even a few of them were 
habitually subjected to mechanical, coercion,” is strictly in 
accordance with the facts of asylum administration; and 
just as true is it now as when Dr. Conolly wrote that “re- 
straints and neglect may be considered as synonymous; for 
restraints are merely a general substitute for the thousand 15 
attentions required by troublesome patients.’’ Restraints 
are used to save trouble or to punish and terrify refractory 
lunatics; and statements by asylum officials that they are 
used from motives of humanity and from a regard for the 
best interests of the patients, are as little to be believed as 
the pretences of the respectable pedagogue, who whips his 
boys because he loves them so much. Reliance upon re- 
straints lowers the whole character of an institution. The 
attendant will not treat with respectful consideration the 
patient, whom he has seen or helped to place under restraint, 
and the patient will surely have a sense of resentment 
against those, who have directed or imposed such restraint- 
All the control of the patient, which might come from ap- 
peals to his better nature, is lost by appeals to physical force. 
Even the most disorderly and troublesome patients will 
become humanized under the rule of sympathetic kindness 
and inexhaustible patience. It is said that mechanical re- 
straints act without passion, but they act, at the same time, 
without mercy and without pity, and usually they cannot 
be applied without a contest, which invokes passion and 
violence. The question is not, as it is sometimes stated, 
between mechanical restraint and personal restraint at the 
hands of attendants, but between the comparative efficacy of 
mechanical and moral forces in dealing with the insane. 
Exceptional cases require exceptional management. The 
higher law of self preservation and of the protection of life 
may demand the use of physical coercion, but experience 
has shown that by watchfulness, forbearance and a kind and 
constant supervision, the morbid activity of insane patients 
can usually best be restrained without bonds. The consign- 
ment of an individual io a lunatic asylum by virtue of a 
readily procured physician’s certificate of insanity, ought 
not to deprive him of all his personal rights and of the pro- 
tection which the law offers to every citizen outside asylums* 
and ought not to subject him to a reign of terror and 
tyranny at the hands of irresponsible and unreliable attend- 16 
ants, who by neglect, threats and cruelty, invite the bad 
conduct, for which they administer punishment. 
In this country mechanical restraints are used, to a greater 
or less extent, in all our asylums. As a result, secrecy, 
concealment, and a jealous exclusion of the public, charac- 
terize their management. The asylum specialty has become 
a close, narrow and purely artificial one, and those medical 
men who are grafted into it, with some notable exceptions, 
become alienated from all interest in the progress of practi- 
cal medicine, and lapse into mere administrators of recepta- 
cles for the secure detention of madmen. Some of our asy- 
lums, leaving out the question of restraint, are managed as 
well as human institutions can be expected to be. In some 
of them the patients receive all the care which humanity, 
unenlightened by medical skill, can supply. In others, the 
patients appear to exist for the glorification of the manage- 
ment of the institution, and their welfare is regarded only 
so far as it may promote the exaltation of the institution. 
The medical officers of one of our asylums, by thorough 
work in the investigation of the morbid anatomy of insanity, 
and by careful and extensive observation of the therapeutic 
action of various drugs in the disease, have done a great 
deal to lift the American asylum specialty above the dead 
level of professional mediocrity which characterizes it. Some 
of our State asylums are built chiefly to satisfy the demands 
of local pride, and of a benevolence, which costs nothing to 
those, who most largely indulge in it. Log-rolling combi- 
nations, contracts to furnish necessary votes with needed 
supplies and all the appliances of the lobby, are made the 
means of securing needlessly extravagant appropriations 
from our State Legislatures for the construction of these in- 
stitutions. 
The management of most of our asylums is routine in 
its character, and the individual patient is made to keep 
step with the routine of the establishment, or he is hurt 
by its inexorable and pitiless movement. Dr. B. L. Ray, 
of Philadelphia, a gentleman who has a long and inti- 17 
mate acquaintance with American asylums, and who is 
always a defender and an advocate of our asylum system, 
in a review in the American Journal of the Medical Sciences 
for April, 1872, of the first report of the Board of State Char- 
ities of Illinois, thus puts it:—“Where one man must look 
after from four hundred to seven hundred patients, he can 
hardly give to individuals the personal attention their cases 
may require. The management of so large a household 
necessitates the enforcing of a sort of rigid, cast-iron, routine 
discipline which cannot yield to the needs of exceptional 
cases. The particular wants of the one curable patient are 
apt to be lost sight of in attending to the general comfort of 
his twenty incurable comrades.” 
Our asylum Superintendents consider it one of the peculiar 
“ felicities of their situation” that the American asylum, or in- 
sane hospital, is exempt from the intrusive visits of “ any su- 
pernumerary functionaries endowed with the privilege of 
scrutinizing the management of the hospital, even sitting in 
judgment on the conduct of attendants and the complaints of 
patients.” The complaints of the patients, without investiga- 
tion, must be treated as the vagaries of brains disordered, and 
the attendants must be protected in their abuse of the patients. 
This is practically the expressed conclusion of “ The Associ- 
ation of Medical Superintendents of American Institutions 
for the Insane,” an organized mutual admiration and mu- 
tual protection societ}7. which claims for itself boundless 
knowledge and infallible wisdom in regard to all questions 
of insanity and asylum management, and whose members 
manifest furious excitement upon any suggestion for asy- 
lum reform from any one outside their own narrow limits. 
The Association settles every question connected with in- 
sanit}7 by means of resolves. It has declared in favor of 
small asylums, and yet its leading members may be induced 
to commend and endorse plans for monstrous institutions, 
two or three or more times as large as the Association lias 
determined and declared to be the proper limit of capacity 
for asylums for the insane. It thinks that systematic espi- 18 
onage of the letters of patients is a most valuable means of 
obtaining information in regard to the mental movements 
of the patients. According to the theory of the Association 
the patient once committed to an asylum becomes the 
property of the Superintendent, and it is his office, as the 
custodian of the patient, to determine, at his infrequent and 
often perfunctory visits to the wards, “ the drugs the patient 
is to take, the privileges he is to enjoy, the letters he is to 
write or to receive, and the company he may see.” 
The abolition of mechanical restraints is closely connected 
with all other reforms in asylums. With the disappear- 
ance of these physical means of coercion and protection, the 
management of our asylums will be open, the access, under 
proper restrictions, of the friends of patients and of persons 
of intelligence and humanity to their halls will be encour- 
aged, and the policy of silence, secrecy and concealment wdl 
be eliminated from their administration. The government 
will acknowledge its duty to its wards by providing efficient 
supervision of the institutions in which they are placed, and 
“official accountability” will accompany this “administra- 
tive reform.” Asylums will become hospitals for clinical 
instruction in mental malady, or centres of knowledge and 
information for the districts in which they are located, in 
regard to all questions of insanity. Insanity, no longer re- 
garded as a mysterious visitation and a social disgrace, but 
as a form of physical disease, will become a subject for 
physiological and pathological investigation, and for the 
operation of the laws of preventive medicine. As it is now, 
the beginnings of insanity not being recognized by the gen- 
eral practitioner, who has been taught nothing of mental 
malady, the disease is not arrested. When excitement and 
symptoms of violent mental disorder set in, the patient is 
sent to an asylum where, subjected to a “ rigid, cast-iron, 
routine discipline,” his malady is aggravated, and he be- 
comes a hopeless lunatic. If asylums are to be hospitals for 
the cure and rational treatment of mental disease, they must 
be small enough to secure individualized treatment for the 19 
patients, and the medical Superintendent must be chosen for 
his medical skill and knowledge, and not because he is a 
successful and adroit manager and manipulator of men and 
measures, and skilled in all the arts of the modern “ states- 
man.” 
There are two ways of securing asylum reform. One is 
by the gradual pressure of an educated and awakened pub- 
lic opinion acting on these institutions from the outside. 
Reform from within has not been the usual order of history 
in asylums for the insane. In this country, whenever an 
investigation into the hidden recesses and dark mysteries of 
asylum life has been attempted, the officers and managers 
of the institution to be investigated, following the precedent 
established in the English asylums in the beginning of the 
century, have directed their efforts to prevent, in every way, 
any thorough knowledge of the truth in regard to the man- 
agement of their institution. Their administration must be 
justified. Enough has been shown of the brutal cruelties 
and unpunished acts of violence committed upon, and the 
reckless and systematic neglect of patients in the halls of 
asylums, to create a profound and widespread dissatisfac- 
tion with our American asylum system, and to deter almost 
any one from an attempt to draw back the veil which con- 
ceals the realities of asylum life, and which hides many 
great and cruel wrongs committed under the guise of philan- 
thropy. 
The other mode of promoting asylum reform is by put- 
ting new men in charge of them—men who have not ac- 
quired the vicious experience which is gained by habits of 
obedience to the routine of these establishments—men of 
courage, truthfulness, skill and kindness—men who are real, 
through and through, and who, therefore, cannot follow a 
policy of silence and concealment. Pinel, with a mind 
thoroughly furnished for all good works, introduced the rule 
of “ pity, goodness and justice’’into the Bicetre, and Con- 
olly was one of the best known and most accomplished of 20 
English physicians when he entered upon his duties at Han- 
well. 
For myself, I believe that the abolition of mechanical re- 
straints is a necessary step to all lasting reforms in our 
asylums, and I believe that the work begun by Pinel and 
Tuke, and advanced by Conolly, is destined to still further 
development in this land of freedom and progress.