Early American psychiatry was influenced to a large extent by practice in Britain and France. The American Journal of Insanity (forerunner of the American Journal of Psychiatry) carried regular columns of views and book reviews from abroad. Some American psychiatrists even traveled to Europe to study asylum construction and treatment practices.

In 1831, for example, Dr. James McDonald went to Britain to gather ideas that would help him and his colleagues plan for the new Bloomingdale (N.Y.) hospital; in 1846 Dr. Luther Bell did so to prepare for the construction of the new Butler Hospital in Rhode Island; and in 1863 Dr. Tilden Brown gathered information for the proposed Sheppard Asylum in Baltimore.

Dr. Pliny Earle reported visiting 17 institutions in Austria and Germany in 1849.

Information-gathering trips went the opposite way across the Atlantic as well. Dr. John Bucknill, F.R.P.C., Late Lord Chancellor’s Visitor of Lunatics, visited 10 asylums in the United States as well as other types of facilities and published reports of his findings in the British publication Lancet. He also participated in the annual meeting of the Association of Medical Superintendents of American Institutions for the Insane (predecessor of the American Psychiatric Association) held in Auburn, N.Y., and was elected the first honorary member of the Association.

Dr. Bucknill had praise for the several private hospitals he visited: Pennsylvania Hospital in Philadelphia, Bloomingdale in New York, and McLean in Boston. These hospitals provided pleasant surroundings as well as occupation and recreation, he reported. He thought the hospitals were too warm with their 72-degree temperatures, in contrast to British hospitals, which were kept below 62 degrees. He noted as well that there was little opportunity for patients in American hospitals to be outdoors, and no beer or wine was permitted.

He did have severe criticism for some of the public hospitals he visited, among them the Blockley Asylum in Philadelphia and the New York City hospitals on Ward and Blackwell islands. These places were overcrowded, and patients were dirty, neglected, and ill fed, he noted. He had praise for the physicians but blamed corrupt politics and politicians for the lack of adequate support for the hospitals. Several of the public hospitals did meet his approval, including Utica in New York and the Government Hospital for the Insane (now St. Elizabeths) in Washington, D.C.

Dr. Bucknill was especially interested in the use of mechanical restraint for patients. In Britain, Dr. John Conally (1794-1866), superintendent of the Hanwell Pauper Lunatic Asylum, had abolished restraint in 1834, a practice many other hospitals followed. Dr. Bucknill saw little use of restraint in the private hospitals he visited here but frequent use in the public asylums.

At the annual superintendents’ meeting in Nashville in 1874, long discussions were held about patient restraint. The group agreed that mechanical restraint should be kept to a minimum, but that some type of restraint was necessary for some patients.

At the superintendents’ meeting in 1875, which he attended, Dr. Bucknill offered a wager of £100 to any American superintendent who would go to British asylums over a one-month period with free access to all wards and find any form of restraint being used. He apparently had no takers.

Dr. Bucknill wrote in his Lancet notes that the Americans were prejudiced and ignorant about the use of restraint despite "their highest motives of humanity." He said, "In a few years they will look back. . .upon their defense of restraint with the same wonderment. . .that has been said in the defense of domestic slavery."

In 1881 Dr. G.A. Tucker of Australia visited more than 100 asylums in the U.S. He was a strong advocate for occupational and recreational activities for patients, the abolition of restraint, and humane patient treatment. He found some hospitals using no restraint, such as the ones in Athens, Ohio, and Kings County, N.Y., but terrible conditions in other places, including the hospitals in Anchorage, Ky., Richmond, Va., and Northampton, Mass.

In England Dr. Tucker visited 14 hospitals that used mechanical restraint and 47 that did not. In France, all 17 hospitals he visited used restraint, as did the Italian hospitals. The use of patient restraints, now including by chemical means, has obviously remained unresolved more than a century after these psychiatrists published their reports.