COMMENTARY VI. SEPARATION AND SECLUSION. THERE is no general maxim in the treatment of insanity wherein medical practitioners, ancient or modern, foreign or domestic, are so unanimous as that of separating the patient from all customary associations, his family, and his home; and there is none wherein the advice of the faculty is so commonly and successfully opposed. Thus, cases which in the early stages are comparatively manageable, obedient to medical discipline, and commonly curable, are rendered obstinate, tedious, unnecessarily expensive, and too often incurable. The observant Dr. Heberden, perhaps, goes too far: he remarks, that if insane persons are taken away from their friends and servants at the beginning of the attack, and placed under the care of strangers, that in a short time they recover without remedies. any * Few of the medical profession require arguments or proof to convince them of the great utility of separation. When the friends of any insane person have a doubt, and have not confidence in the advice or probity of their physician, they should consult the works of authors who have treated of insanity, and who can have no interest in the question. Such friends might then more readily and earlier yield their conviction, and consent to the separation and seclusion of the patient, whenever it is advised by those whom they consult, and think competent to judge. * De Insaniâ, Comm. cap. 53. I by no means imply that separation or insulation is indispensable in all cases of mental derangement. I have myself seen patients recover in their domicile; but, comparatively, those instances are rare indeed. The only case where it may be dispensed with, is when the affections are in no way perverted, nor the existing delusions associated with home, or any person or object about it. But even then there are other circumstances to be considered which may prevent recovery while in that situation. Few persons when they become insane acknowledge being so consequently, when they find themselves placed under control in their own houses, denied intercourse with their families, and their orders not only disobeyed, but their own servants concurring in controlling them, -they are naturally infuriated to a high degree, or imbibe a plausible and strong suspicion that a conspiracy is formed against their life, liberty, or property. These are irresistible reasons why insane persons should be removed from home. Reminiscences, whether agreeable or painful, may be associated with the most insignificant localities, which, when the feelings are morbidly sensitive, and reason cannot correct them, revive certain objects or ideas that powerfully excite or depress the passions. In whatever place an insane person is exposed to the danger of such mental associations, he ought to be removed from it. In a strange place, attended by those equally strange, and whom he has never been accustomed to command, and confided to the direction of a competent medical attendant, a moral influence over the patient is thereby established, to which he usually readily submits; and a cure then may be expected, which never otherwise can be accomplished. Unfortunately, separation and seclusion from friends, and confinement in a mad-house, have been considered as synonymous; and hence any proposal to remove the patient excites alarm and suspicion, perhaps gives offence, and is frequently at once rejected. We should first explain what separation and seclusion mean. There are three modes: first, secluding the patient in his own house, which can never be complete, for many obvious reasons besides those I have mentioned; second, removing him to an insulated cottage, or convenient lodging, under the care of an attendant or keeper, which is preferable, where the pecuniary means of the patient admit of a plan which is always expensive; and, third, removing him to a respectable asylum, private or public, as may be most suitable, when the desperate nature of the case precludes the possibility of its being managed elsewhere, or pecuniary circumstances cannot afford other accommodation. In my opinion, a patient in a recent state of insanity should not in the first instance be sent to any asylum, unless the nature of the case, or the circumstances of the party, admit of no alternative. In confirmed insanity, fatuity, &c. such a place is commonly most suitable. Confinement in an asylum is equally obnoxious, perhaps, to the poor as to the rich; therefore, before the former are consigned to an asylum, the feelings of their family ought, as much as possible, to be respected. But in a well-regulated asylum the middle orders and poor often meet with greater comforts, and those essential requisites to promote recovery, which they have not at home. Real humanity, therefore, in such cases, dictates less delicacy to be observed in respect to confining a lunatic; and, generally, a little reasoning soon convinces his real friends of the truth. The custom of sending the insane to hospitals seems to have originated in convenience and public safety, rather than with an intention of curing them. We do not meet with any accounts in ancient authors of hospitals appropriated to mad people. The first appears to have been established in the East. In the year 491 we read of one existing at Jerusalem.* Benjamin of Tudela mentions, that in the twelfth century there was a large building at Bagdad, called Dal Almeraphtan, or House of Grace, in which those who lost their reason were received during the summer, and where they were kept in chains till they recovered. This house was visited every month by the magistrates, who examined the state of the patients, and released those who were well.† In the same century, hospitals for the sick and the insane were founded, according to Anna Commenes, by her father, the emperor Alexius. Among the Moors, by whom medicine was once studied as a science, and hospitals were every where established, asylums for the insane were also common. There is still at Faz or Fez, a muriston, or mad-house, + where the poor patients are chained down, and treated, probably, as cruelly as the lunatics were in the Timarahane at Constantinople, in the sixteenth century.§ Perhaps the oldest hospital for lunatics now in Christian Europe is Bethlem, which was founded for the cure of lunatics in 1547. They are now numerous in most countries. Many, we learn from the descriptions of them, are excellent. From various causes, on which I have already cursorily touched, it appears that all the public, and most of the private asylums in the United Kingdom, are much improved; and in many of them all the means which science and humanity suggest are successfully resorted to for the cure of the patients. * Ueber Dic Einsamkeit, Leipz. 1784. Jackson's Account of Morocco, p. 131. § Haslam's Observ. p. 286. ! The objections, therefore, which formerly might be reasonably urged against sending a patient to such places rarely now apply; and where the case seems to require that kind of separation, it ought with more readiness to be resorted to. A very nice and important question arises when seclusion of an insane person has been carried into effect; and that is, the nature, if any, of the intercourse with his friends which may be permitted. No rule can be laid down in this respect. It must be left to the experience and discretion of the medical attendant. In some cases no mischief may arise from reasonable intercourse; others admit of it in a partial degree; in others, the slightest of any kind is decidedly injurious. I have known the sight of the hand-writing, so also of a garment, ornament, book, or any trifle, of a beloved, or respected, or detested object, destroy in a moment the most marked proofs of amendment; and the same effect will sometimes be produced from merely mentioning persons or things with which there was a morbid association of ideas. There is a source of keeping up these morbid associations in the minds of lunatics which often protracts and perhaps defeats recovery, and which is sometimes little suspected. This source is the physician himself. The medical attendant is frequently, especially in the country, esteemed by families not only as a professional character, but as a confidential friend. When known in that light by a lunatic, the same morbid association with home, or members of his family, or domestic circumstance, is as positively revived by his visit, as by that of any other friend. Medical men, in the course of their attendance on an insane patient, often discover this fact, and feel themselves in consequence compelled to cease their visits. One of the most painful duties of the physician is |