People Who Shaped Our World
The ‘revolving door’
Article by Dr Paul Tobia
Up until now I have concentrated on the patient records from Bristol’s purpose built asylum in the nineteenth century, but in this article I begin my exploration of the period 1900-1915 before the asylum became Beaufort War Hospital in 1915.
This period, often called the Edwardian era, has been characterised as a
‘leisurely time when women wore picture hats and did not vote, when the rich were not ashamed to live conspicuously, and the sun really never set on the British flag’
https://www.pbs.org/manorhouse/edwardianlife/introduction.html
The staff and patients of Bristol’s asylum probably viewed the era somewhat differently.
This first article will be part of a series considering the continuities and changes to life in the asylum, often focusing on individuals whose stories illustrate facets of this era.
In many respects the asylum does not seem to change much; there were no new treatments and the annual reports continue to include sundry items such as the disposal of potato skins in 1911. However one important change was the national introduction of compulsory coding for all asylums. This meant that the medical registers had to include a code for both the diagnosis and causes of each patient’s condition. I have included the actual schedule, as it provides an insight into the thinking at that time. In future articles, I will look at patients’ stories and relate them to these categories, thinking about whether putting them in a box is ‘ jail’ or ‘ home’?
The schedule is the forerunner of the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.) used by psychiatrists across the world today. It remains controversial. The following quote is from a medic justifying its use:
‘Classification of mental disorders is very important. Without a manual that guides health professionals to the same diagnostic processes, two different health professionals might come up with two different diagnoses.’
https://medium.com/@Jiminlew/criticisms-of-the-dsm-5-d8fcd2dc0a53
But to suggest that two professionals will still not come up with different diagnoses is ludicrous. I will not debate classification at length but when I managed an acute psychiatric ward the different consultants would have personal favourite diagnoses and often made decisions only vaguely related to the patient’s symptoms.
This picture is of Harriet Nowland, the first female patient to be classified at Bristol Asylum using the new medical coding system in 1907.
SCHEDULE OF FORMS OF INSANITY as at the time of record.
(FORMS 1B AND 2B OF RULES OF COMMISSIONERS IN LUNACY.)
- Congenital or Infantile mental deficiency (Idiocy or Imbecility) occurring as early in life as it can be observed. Symbols to be entered in the Registers.
Intellectual—
- a. With Epilepsy.
- b. Without Epilepsy.
- Moral.
Insanity occurring later in life.
- Insanity with Epilepsy.
- General Paralysis of the Insane.
- Insanity with the grosser brain lesions.
- Acute Delirium (Acute delirious mania).
- Confusional Insanity.
- Stupor.
- Primary Dementia.
Mania—
- a. Recent.
- b. Chronic.
- c. Recurrent.
Melancholia—
- a. Recent.
- b. Chronic.
- c. Recurrent.
- Alternating Insanity.
Delusional Insanity—
- a. Systematised.
- b. Non-Systematised.
Volitional Insanity—
- a. Impulse.
- b. Obsession.
- c. Doubt.
- Moral Insanity.
Dementia—
- a. Senile.
- b. Secondary or Terminal.
These diagnoses are in line with early twentieth century thinking but certain aspects are interesting to the modern reader.
Firstly, the list shows epilepsy and insanity were seen as synonymous. There is an assumption that they are linked, which today we do not accept.
Secondly categories are divided into moral and intellectual categories. The term moral insanity might seem strange or judgemental to the modern reader but then it was used somewhat differently. A Dr Pritchard defined it in 1835 as:
‘There is a form of mental derangement in which the intellectual faculties [are uninjured], while the disorder is manifested principally or alone in the state of feelings, temper, or habits. . .The moral. . .principles of the mind. . .are depraved or perverted, the power of self-government is lost or greatly impaired, and the individual is. . .incapable. . .of conducting himself with decency and propriety in the business of life.’
https://psychnews.psychiatryonline.org/doi/full/10.1176/pn.36.10.0021
Moral Insanity is also listed as an aspect of volitional insanity which is where someone is aware that what they do is wrong but has an irresistible impulse to complete the act. Interestingly this is a very contested diagnosis in legal cases now, for instance next time I rob a bank and get caught I will describe it as volitional insanity.
Having labelled the diagnosis there was an extensive list of causes and associated factors of insanity (see list below). Several to the modern viewer do not seem reasonable, such as lactation and masturbation (many more would become ‘crazy’ if this were the case). There is also the absence of emotional trauma.
When we will look at the Bristol Asylum patient records and the use of the Schedule there is only a rare entry in the causes section. Perhaps they did not know what caused the patient’s to have these problems, and did not venture to hazard a guess or perhaps they were not keen on using the Schedule and putting people in boxes.
SCHEDULE OF CAUSES AND ASSOCIATED FACTORS OF INSANITY.
To be returned as Principal Causes, or as Contributory or Associated Factors,
with Symbols for purposes of Tabulation.
(FORMS 1B. AND 2.A. OF RULES OF COMMISSIONERS IN LUNACY.)
Symbols to be entered in the Registers.
HEREDITY (excluding Cousins, Nephews, Nieces and off-spring)—
Insane Heredity … … … … … … A. 1.
Epileptic Heredity … … … … … … A. 2.
Neurotic Heredity [including only Hysteria, Neurasthenia, Spasmodic
(idiopathic) Asthma and Chorea] … … … … A. 3.
Eccentricity (in marked degree) … … … … A. 4.
Alcoholism … … … … … … … A. 5.
MENTAL INSTABILITY as revealed by—
Moral Deficiency … … … … … … B. 1.
Congenital Mental Deficiency, not amounting to Imbecility … B. 2.
Eccentricity … … … … … … … B. 3.
DEPRIVATION OF SPECIAL SENSE—
Smell and Taste (either or both) … … … … C. 1.
Hearing … … … … … … … C. 2.
Sight … … … … … … … … C. 3.
CRITICAL PERIODS—
Puberty and Adolescence … … … … … D. 1.
Climacteric …. … … … … … … D. 2.
Senility … … … … … … … D. 3.
CHILD BEARING—
Pregnancy … … … … … … … E. 1.
Puerperal state (nor septic) … … … … … E. 2.
Lactation … … … … … … … E. 3.
MENTAL STRESS—
Sudden Mental Stress … … … … … … F. 1.
Prolonged Mental Stress … … … … … F. 2.
PHYSIOLOGICAL DEFECTS AND ERRORS—
Malnutrition in early life (signs of Rickets, &c.) … … G. 1.
Privation and Starvation … … … … … G. 2.
Over-exertion (physical) … … … … … G. 3.
Masturbation … … … … … … … G. 4.
Sexual excess … … … … … … … G. 5.
TOXIC—
Alcohol … … … … … … … H. 1.
Drug Habit (morphia, cocaine, &c.) … … … … H. 2.
Lead and other such poisons … … … … … H. 3.
Tuberculosis … … … … … … … H. 4.
Influenza … … … … … … … H. 5.
Puerperal sepsis … … … … … … H. 6.
Other specific Fevers … … … … … … H. 7.
Syphilis, acquired} {all patients believed to have suffered}.. H. 8.
Syphilis, congenital} {at any time in their lives from Syphilis}. H. 9.
{to be entered.}
Other Toxins … … … … … … … H. 10.
TRAUMATIC—
Injuries … … … … … … … I. 1.
Operations … … … … … … … I. 2.
Sunstroke … … … … … … … I. 3.
DISEASES OF THE NERVOUS SYSTEM—
Lesions of the Brain … … … … … … K. 1.
Lesions of the Spinal Cord and Nerves … … … K. 2.
Epilepsy … … … … … … … K. 3.
Other defined} {Limited to Hysteria, Neurasthenia,}
Neuroses} {Spasmodic Asthma, Chorea}… … K. 4.
Other Neuroses, which occurred in Infancy or Childhood
(limited to Convulsions and Night-terrors) … … K. 5.
OTHER BODILY AFFECTIONS
Haemopoietic System (Anaemia, &c.) … … … L. 1.
Cardio-Vascular degeneration … … … … … L. 2.
Valvular Heart Disease … … … … … L. 3.
Respiratory System (excluding Tuberculosis) … … L. 4.
Gastro-intestinal System … … … … … L. 5.
Renal and Vesical System … … … … … L. 6.
Generative System (excluding Syphilis) … … … L. 7.
Other General Affections not above included (e.g., Diabetes, Myxoedema, &c.) … … … … … L. 8.
Instances in which NO PRINCIPAL FACTOR could with certainty be assigned, but in which one or more Factors were ascertained, and were returned as Contributory or Associated … … … M.
NO FACTOR ASSIGNABLE, notwithstanding full history and observation … … … … … … N.
NO FACTOR ASCERTAINED, history defective … … … O
Anyone interested in the accompanying notes please see https://www.academia.edu/2026526/Medical_Coding_in_Asylum_Records_in_England_and_Wales
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