Nights on the ward - the Night Superintendent's Report

This week, Alice has been looking at a little-used but fascinating set of records that shed light on the daily workings of the Royal Infirmary of Edinburgh

In order to reform nursing and nurses training at the Royal Infirmary of Edinburgh (RIE), in the 1870s trained ‘Nightingale Nurses’ were recruited and a training program instituted. Under this new system, the nurses reported to the Lady Superintendent of Nurses, rather than individual ward doctors. In addition to the Lady Superintendent there was the Night Superintendent, who monitored staff and patients throughout the night.

As there was little cross-over in their hours, the two used small bound notebooks as a means of communication between night shift and day shift. The left-hand pages of each book contains instructions recorded by the Lady Superintendent at the end of her day; and on the corresponding page the Night Superintendent would record the happenings of the night).

These little volumes are a fascinating way to supplement some of the other records we hold. Some pages contain snippets about staff which paint a vivid picture of the differing personalities of nurses, such as this entry:

27^th-28^th March 1876

“I made 3 rounds, nurses all in their places but Louise of 4 M[edical] I found her twice in one hour absent from her ward. She was with the night nurse in 5 M[edical] each time. I told her I would report it to you…

Nurse McLeod was not well at 5am but thought she could do her work so I let her” - (LHB1/103/7)

LHB1/126/50 - Christopher's entry in the General Register of Patients

Others add life to the lists of patient names that are recorded in the General Registers. For example, where in the register 8 year-old Christopher Yeoman appears as one name amongst many, this small detail from the Night Superintendent’s report paints a picture:

30^th – 31^st March 1876

Lady Superintendent: “The mother of the child in 3 S[urgical] is staying with him tonight so Nurse Black is not there”.

Night Superintendent: “The boy has had a quiet night; he is always much better with his mother”.

 The job of nurse was a risky one; often, the Superintendents’ notes to each other either request or provide details about unwell colleagues. There are numerable instances of nurses falling ill, and and Mary Anne Barclay is one such nurse.

LHB1/97/1 - Nurse Fraser's training record shows the perils of the job

Mary Barclay entered the RIE as a probationer on 19^th January 1876 having previously been employed for a time at Chalmers Hospital in Banff. According to her training record, she spent three months working in the Infirmary’s medical wards before she fell ill.

LHB1/97/1 - Nurse Barclay's training record

The first mention of Nurse Barclay’s illness in the Night Superintendent’s reports comes at the start of April 1876. As part of her general instructions for the night of the 6^th April, the Lady Superintendent requested that the Night Superintendent “please visit Nurse Barclay [in] 1 lower dormitory”. The return reply records that “Nurse Barclay has not had a bad night – Nurses Brown and McLeod each gave her a fermentation”. The following days’ correspondence suggests continuing concern for her well-being:

7^th - 8^th April 1876

                Lady Superintendent: “Nurse McDonald will stay on duty with Nurse Barclay til Dr McLeod has seen her.”

Night Superintendent: “Nurse Barclay had some sleep but had pain when awake so I told Nurse McDonald to stay with her.”

The next night shows a further downturn as Nurse Barclay was admitted into the hospital as a patient:

8^th - 9^th April 1876

Lady Superintendent: “Nurse Barclay was warded in 14 M[edical]. Will you report of her in the morning.”

Night Superintendent: “Nurse Barclay has been quiet but has not slept much : she looks very bad.”

Her recovery was slow but ultimately successful, with her training record noting that she was “about ten weeks absent” before continuing her training with “nine months in surgical wards”. Ultimately, her hard work and commitment to the vocation paid off. She was described as “patient, obedient and industrious, of slow intelligence but very painstaking, high principled and kind”, and after two years working on the night staff of the RIE she left to take up the post of Matron of Wallasey Cottage Hospital in Birkenhead.

The Superintendents were also there to offer guidance and mentor the novice nurses and support them in carrying out an often difficult vocation, as can be seen from these snippets:

                19^th – 20th^th April 1876

Lady Superintendent: “Bad case in 3 M[edical]. The nurse there is timid, please assist as often as you can”

Night Superintendent: “3 M[edical] - The poor old man died at 3.40am”

                1^st – 2^nd May 1876

Lady Superintendent: “Nurse Collins being off duty, Nurse Munro is in 16 S[urgical]. Nurse Macrae is also off duty, and Nurse Wyllie is on 4 M[edical]. Both these are young nurse and will need some looking up, especially as there is a sharp typhoid case in 4 M[edical]”

                8^th – 9^th May 1876

                “7 M[edical] - Nurse Small is taking charge of the tracheotomy case and Nurse Callow to do the rest of the work. The latter being new to us, give good heed to this ward.”

Although intended as administrative records, these volumes are a wonderful way to experience more of life on the ward, and the nurses’ concern for their patients really comes through. 

A poetic patient

In this week's blog, Archivist Louise looks at hospitals from a different angle...

The current BBC series, Trust Me, follows staff nurse Cath Hardacre from Sheffield to Edinburgh. Suspended for whistle-blowing down in Yorkshire, she seizes a chance for a new life when a job is advertised working for 'South Lothian NHS Trust' at the 'Southern General Hospital' (some death certificates actually do state this institution, which was possibly an early twentieth century name for the infirmary at Glenlockhart poorhouse). The only snag is, the post is for an A&E doctor, not a nurse - but Cath's doctor friend Ally has just left Sheffield for New Zealand, fortuitously leaving her CV prominently in the bin. Cath plucks the document out, watches a few YouTube videos, applies for the Edinburgh job under Ally's name and is soon enough installed in a very nice flat with a view of Arthur's Seat. After all, being a doctor in A&E can't be too hard, can it??

The series, filmed right here at the University (you can see the Library where LHSA is based in this week's trailer), made me think about the portrayal of hospitals by artists and writers. I've recently become aware of William Ernest Henley (1849-1903), for example, who was a patient of the Royal Infirmary of Edinburgh (RIE) in the 1870s. Born in Gloucester, Henley developed tuberculosis as a child, leading to his left leg being amputated below the knee when he was just 16. In young adulthood, he started to write, but the tuberculosis infection returned when he was 23, and he was faced with amputation of his other leg. In a last-ditch attempt to save his leg, he traveled to Edinburgh, where he'd heard that a doctor called Joseph Lister was making great strides with aseptic surgery. Lister accepted him as a patient on a Reserved Ward of the RIE, where Henley stayed from August 1873 to May 1875, undergoing an operation that scraped out the dead bone from his infected leg, which was then packed with lint soaked in carbolic. Whilst Henley slowly recovered, he had plenty of time to write, including these lines on Lister himself:

"His brow spreads large and placid, and his eye,
Is deep and bright, with steady looks that still.
Soft lines of tranquil thought his face fulfil -
His face at once benign and proud and shy."

From A Surgeon, later The Chief)

A young Joseph Lister (sitting, centre) when a trainee doctor in the Infirmary, 1854 (LHSA photograph collection)

Henley wrote 28 poems in all during his time in the RIE; some first published in The Cornhill Magazine as Hospital Outlines: Sketches and Portraits. The poems also give a view of the other patients around Henley ('Through the loud emptiness and airy gloom,/A small, strange child, so old and yet so young!/Her little arm besplinted and beslung,/Precedes me gravely to the waiting room.'), nursing staff in the process of professionalization ('Her plain print gown, prim cap and bright steel chain/Look out of place on her'), and the general atmosphere of the hospital ('A square squat room that stinks of dust and drugs'). However, unfortunately we only have a very scant record of Henley's time in hospital in our records, with only one page of the Infirmary register filled in for his line, out of the usual two:

Henley's original admission record from 24th August, 1873 (third down). The second page of the register, which records information about medical condition and discharge date. is blank (LHB1/126/39)

One Infirmary patient mentioned in Henley's poems was 'John Gallagher', who 'Fell, some eighteen months ago/Smashing his shin'. No 1870s' case notes survive in the archive - however, from Henley's description, we get an idea of Gallagher's character that we just could not glean from institutional records:

"He like a collier swears, prays like a child,
Roars like a bison, laughs like something wild,
And makes us all like, pity, and despise him."

From A Patient 

According to his biography, Henley also went on to marry Anna Boyle, whom he'd met when she was visiting her elder brother, who occupied the next bed to Henley. Captain Boyle was in the merchant navy, son of Edward Boyle. The only Boyle I found mentioned in our records coinciding with Henley's time in hospital who could match the description was this gentleman:

Admission for an Edward Boyle, 'master mariner', admitted on 2 March 1874, bottom line (LHB1/126/40).

Henley's hospital stay inspired more new relationships - his poems prompted a visit by Robert Louis Stevenson, with Henley becoming the inspiration for Long John Silver. Henley remained a prolific writer until his death in 1903, and his obituary was even published in The Lancet, which praised the accuracy of his descriptions of general hospital life. His view of the sights, sounds and personalities of the Infirmary might not be widely known, but they provide a precious patient perspective into a changing world of hospital care:

"This is a ward in hospital. You see
The Field where Science battles with Disease,
And Hope - sweet Hope - succumbs to Death alone."

From The Ward

The Cockenzie Mystery - more insights from the Royal Edinburgh Hospital

We continue our journey into the Royal Edinburgh Hospital case books with our second volunteer blog. This one is from Carmen, a first year history student at the University of Edinburgh.

Since I began volunteering for Lothian Health Service Archives in April of this year, I have discovered a whole new perspective of eighteenth-century psychiatric treatment. Having the opportunity to access the Royal Edinburgh Hospital records has allowed me to have a glimpse of the lives of those who needed said treatment, and also the attitudes towards them.

When I first started cataloguing the volumes I was looking at mostly pauper patients – those whose treatment was funded by their parish – and I really resonated with many of those who found themselves suffering from mental illnesses. There was one patient in particular who stood out to me as she had lost 4 children within the space of a year because of diseases such as tuberculosis and typhoid. I remember thinking that any person would find themselves mentally vulnerable if they had lost so many loved ones in such a short period of time. There were also other records of other women who had been admitted because they had symptoms of what we today would diagnose as postpartum depression. By just looking at these records, it is clear that we have come a long way in terms of both diagnosing and understanding mental health problems. 

Since finishing my first volume, I have now moved onto one of the Hospital’s volumes that was specifically for private patients. What is most interesting about this volume is that because these patients were paying significant sums of money for their treatment, the doctors were more likely to include information about their personality. For example, it was said that one patient was “the most generous of men” and was known for buying magazines and newspapers for everyone in the ward. Others were not described so kindly, with one being labelled as “a moody, taciturn old man” who entertained himself by scribbling on any pieces of paper he could find; and another “sullen” for refusing to speak to any doctor but Dr Clouston, the director of the entire hospital. Another patient was admitted because she had “delusions” that she had been seduced when she was young - whether this was actually a “delusion” or not is questionable. Information like this is invaluable in helping historians understand the lives of those who suffered from mental health issues in a time where knowledge on the subject was limited. If not for these insights from contemporary doctors, we would not know what the people who were treated at these hospitals were really like.

Another interesting discovery I had when looking at these volumes was the fact that many of these patients seemed to go to “Cockenzie” for several weeks at a time, and little else of the place is mentioned. When I brought this up to Alice, the Archive’s Access Officer, she suggested that the patients may have had something like a holiday home - as Cockenzie is by the coast – and may have gone there to get into the open air and get a break from the city. If this is true, this is fascinating as it shows that Clouston could put another of his theories into practice. Dr Clouston was a strong believer that people had to have a positive environment in order to have a positive mind, and he tried to ensure that his patients lived in the best conditions possible because of this. Since volunteering at the archives, I have been fortunate enough to also read several of Clouston’s published works, including one in which he explains that his inspiration for the asylum layout came from a luxurious Swiss hotel. However, as the volume I am cataloguing has not been looked at in much detail yet, the archivists here at LHSA still know little about Cockenzie and what that actually meant for the patients at the Royal Edinburgh Hospital. Nevertheless, that is one of the best things about working in archives and handling contemporary material: we may never know what Cockenzie actually was, but by looking at the records we have in our collection, we do know that it existed and was of some significance to the daily life of the hospital.

Overall, I have loved every minute of volunteering at the LHSA Archives and think it is fantastic that the University offers its students the opportunity to look at the wealth of material that they have in their collection. I have been able to learn even more about the city that I now live in and love, all the while gaining invaluable skills that will prepare me for my dream job in the heritage sector. 

UPDATE:


One of our wonderful Twitter followers has unraveled this mystery for us! Kirsty Nicol (@Kirsty_Nicol) dug into census records for Cockenzie and found a property called Hawthorn Villa, with residents who gave their occupations as Medical Students and one Asylum Matron. She then checked this information against digitised map collections held at the National Library of Scotland, and found that Hawthorn Villa was a property on the Western edge of Cockenzie. This certainly seems like a likely candidate for a convalescent-type home!

Many, many thanks to Kirsty for her outstanding detective work – and what a fabulous example of the benefits of digitising collections!

Hi there. I'm a freelance researcher and I can't resist a challenge!
A bit of a dig through the Cockenzie censuses suggests there was 1/5

— Kirsty Nicol (@Kirsty_Nicol) August 11, 2017

The dangers of tea-drinking: highlights from the Royal Edinburgh Hospital

We're handing over to our volunteers over the next two weeks to hear a little more about the Royal Edinburgh Hospital case book indexing project they've been working on. Starting us off is Iona, who recently graduated with a first-class history degree from the University of Edinburgh. 

Since April I have been helping with the Royal Edinburgh Hospital Case Book indexing project to create a database of patients admitted between 1840 and 1932.  Every week I work on my own volume detailing the cases of women admitted from the late 1850s. I have gleaned amazing details of what these women’s lives were like across social strata within the wider framework of Victorian attitudes towards medicine and gender. Every case illuminates the perception of women’s greater susceptibility to different forms of ‘mania’, many related to life-cycles of puberty, menstruation, childbirth, menopause, and old age.

Working through the case entries, I am very aware of looking at a top-down source; the female patients are viewed through the prism of the medical institution and the men that run it. At times, it is almost as if I am reading a novel with unreliable narrators, trying to prise the text apart to catch a glimpse of the patients’ point of view. Despite this limitation, many stories are harrowing, dramatic, even amusing, with a strong sense of each woman’s individual character. This interplay between the patients’ experiences, the narratives of the medical men, and my own subjective interpretations is fascinating, a unique way of bringing history alive.

The index to casebook volume 13

The intertwining of morality and medicine pervades the volume, from the formulaic language describing patients’ everyday behaviour as ‘industrious’ or ‘slovenly’ to diagnoses of ‘moral insanity’. The unsettling combination of familiarity and strangeness in the way that the doctors evaluate their patients is highly compelling. Through my modern lens, it seems straightforward to identify symptoms of alcoholism, post-partum depression, and the simple need for people to receive more care as they get older. The doctors’ assessment of these cases range from comparatively up-to-date understandings to the down-right odd, my favourite example being the condemnation of dissipation through excessive tea-drinking.

The following are my highlights from my case book volume. I have chosen just a few examples to demonstrate some of the themes I have found particularly interesting during my time at LHSA.

Work, work, work

Each entry makes some reference to the patient’s occupation and class, revealing the social roles of women at the time. The entries often identify patients by their husband’s profession, such as brewer’s wife or sailor’s widow, and if employed are most often domestic servants or seamstresses. I have found tantalising exceptions among these common entries, such as Clara the London stage-dancer and Helen the map-colourist.

In addition, cases like that of 26-year-old Christina reveal contemporary wariness of female education and ambition. Her ‘acute mania’ was caused by ‘something which had excited her beyond ordinary’, which turns out to be ‘the study of composition’ and her attempt to write a novel. This diagnosis connects Christina to many women of the later nineteenth- and early twentieth-century whose literary energies were medicalised in connection to their mental health. Two of the most famous examples of this are Virginia Woolf and Charlotte Perkins Gilman, who both wrote about the frustrations of their medical treatment. In 1882, the Royal Hospital’s own Dr Clouston gave a lecture entitled ‘Female Education from a Medical Point of View’, which demonstrates the widespread disapproval of these developments. He states that new school curricula have ‘warped the woman’s nature, and stunted some of her most characteristic qualities’, not only to the detriment of the female population but to the health of the nation itself. In this way, Christina’s case and Clouston’s lecture hint at how women’s bodies became ideological battlegrounds over medical practice and appropriate gender roles.

Medicine and moral sensibility

The doctors’ descriptions of their patients’ cases frequently act as moral commentaries on their way of life and their place in society. I came across one woman called Mary Ann who used the name Jane as an alias; this factor and her diagnosis of ‘moral insanity’ perhaps hints at a criminal past. Although the previously-mentioned Clara is ‘naturally of a cheerful disposition and steady industrious habits’, the entry notes that ‘employment as a dancer on the stage might not be considered advantageous for this development.’

Instances of alcoholism elicited condemnation as a manifestation of both physical and moral degradation. In another lecture given at the University of Edinburgh, Clouston describes women as more predisposed towards alcohol abuse because they possess ‘less resistive power’, as well as the ‘nervous disturbances incidental to the female sex and to motherhood, and the climacteric period.’ The case of a woman called Flora with an ‘inclination for stimulants’ caused a great deal of trouble for the Hospital as the staff debated over her treatment. After escaping to go drinking, Flora was investigated by the Board of Lunacy and examined by several doctors. When contacted, her family requested that she remain at the Hospital because she was ‘quite unable to keep from drinking and from disgracing herself and them by her conduct’. The Board released Flora, however, because when sober she was ‘not at present a lunatic in the statutory sense and therefore however doubtful they may be as to the manner in which [she] may comport herself when free from control they have no alternative but to order her discharge.’

LHB7/51/13

As the previous cases show, most often the entries convey the attitudes of the hospital staff, yet some details display the strong moral compass of the patients’ themselves. Helen was engaged to a ‘respectable young man’ but ‘began to entertain fears that…he was not a Christian.’ This led her to postpone the marriage but ‘the delay of her lover in assuming the Christian character threw her into a deep melancholy.’ Interestingly, her postponed marriage also led Helen to ‘adopt the idea of going as a missionary to the Indians.’ I like to think that perhaps her work as a map-colourist encouraged her desire to travel as well as her deep religious sensibilities.

The cup that cheers and inebriates

One of the most bizarre attributed causes of mania I have found in my casebook is the effect of excessive tea-drinking. For example, another patient called Christina sought refuge ‘in the inordinate imbibition of tea, which she takes in the form of a strong decoction several times a day’, a good summary of my own tea habit.

LHB7/51/13 - when tea drinking becomes a threat to health...

The case of Joan, a dressmaker from Glasgow, also hints at a class dimension that may have influenced the doctors’ attitudes towards her tea consumption. The record states: ‘She has led a very unhealthy life, having subsisted like many of her class almost entirely on tea taken at every mealtime and seldom supplemented by more than bread and butter, and the occasional salt herring.’ Like Christina, Joan’s ‘indulgence in tea seems in her case to have amounted to dissipation, leaving her, after the stimulant effects pass off, in a state of considerable depression.’

As with alcoholism, the risks of tea were linked to women’s natural weakness and susceptibility. This is also suggested by an article entitled ‘The dangers of tea drinking’ by a Dr J E Cooney published in the Windsor Magazine in 1895. Cooney writes: ‘Warm tea-drinking is very popular with women, and is quite an institution in this country. It is drunk at all hours – even before rising in the morning – but the climax is reached at about 4pm. Many, in the course of paying their afternoon calls, drink no less than a dozen cups of tea…that one is naturally left in astonishment of the depravity of their sense of taste, without contemplating the terrible consequent ravages their respective constitutions must inevitably undergo.’ To me, Cooney’s focus on women’s daily social rituals conveys a sense of uneasy disdain not just for tea drinking but for codes of female behaviour in general. This is heightened by the next paragraph, evoking the image of a deviant female cult: ‘Tea-water worship, carried on by its fair devotees in the prettiest of drawing-rooms, in the smartest of tea-gowns, with the daintiest of paraphernalia in the form of silver and china, may to a large extent disarm them as to the real nature of this insidious but implacable fiend, but nevertheless it is there.’ The article further reinforces the dangers of this ‘implacable fiend’ through its illustrations, which juxtapose rough men drinking from bottles on the street with well-dressed women before trays and teacups. Although this connection of tea with ill-health and morality is funny with hindsight, it provides a fascinating example of how medical attitudes could be bound up with ideas of class and gender.

This blog has been only a small taster of the remarkable stories of women admitted to the Royal Edinburgh Hospital in the nineteenth-century. My attitudes towards history have been greatly enriched by this experience; I have thought much harder about the many filters that lie between the past and present, and about my own subjectivity as a researcher. I encourage anybody interested to volunteer with LHSA for the privilege of spending time with these fractured but powerful voices of history.

Link

J E Cooney, ‘The dangers of tea drinking’, The Windsor Magazine 2 (1895), pp. 218-22, https://search-proquest-com.ezproxy.is.ed.ac.uk/docview/4139113?accountid=10673&rfr_id=info%3Axri%2Fsid%3Aprimo

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Objects of mystery

Archivists like lists. We like box lists, catalogues, inventories. We like knowing what we have and where it is. This isn’t always straightforward, though, and sometimes things turn up that stump us all. For example, my first ever cataloguing assignment involved working with the papers of a prominent Scottish art critic. Two days in I came across an instruction manual for a radio. Was this an integral part of this critic’s routine? Did she listen to the radio whilst writing? Did she read the manual before she sat down to an assignment? Were there some particularly striking illustrations that she enjoyed looking at to put her in the right frame of mind? Or was it that the manual had just fallen in to the box before she’d loaded up the car and driven to the archive?

Deciding what to keep from a donation or accession is a process called ‘appraisal’, which involves assessing the value of materials according to pre-agreed criteria – although what ‘value’ means is a very contentious and much debated issue! Sometimes, we have to take things in without being in a position to make informed decisions about their value. As we’re seeing more digital media come into the archive in obsolete or hard-to-access formats like floppy-disc or Betamax tape, we can’t always be sure what is on them, so sometimes we agree to take them in on the assumption they will be of value. Other times, it’s not accessing the information that’s the problem – sometimes we simply don’t know what an item is!

The LHSA objects database is a good example of this. Broadly speaking, archives tend not to collect objects - this is more the purview of museums - but LHSA does hold over 1000 objects, ranging from badges and condoms to straitjackets and clocks. The collection includes around 300 medical instruments and implements, such as these wonderful drug cabinets:

M026 & M027 - Drug cabinets

With so many objects, it’s not too uncommon to come across entries in the database with the description ‘function unknown’. Now, my archivist’s brain finds this difficult to deal with and internally I’m screaming “everything must be correctly labelled and identified!”, but although we’ve come to know a lot about the history of medicine through working at LHSA, none of our staff are medically trained, and nor are we medical historians.

M250 - previously listed as an 'unknown device' from Leith Hospital 

Earlier this week, Twitter came to my rescue when Robert Culshaw (@RobertCulshaw) helpfully clarified that these mysterious and alien-looking metal items were in fact the two parts to an amputation shield, explaining “they go around the bone to retract the muscle out of the way ready to saw through it”.

Eep.

With that in mind, we’re calling on the expertise of our followers – can you help us identify some other instruments? We’ll be sharing photos of a few 'unknown' objects on Twitter over the weekend. Get in touch if you can help solve any of these mysteries! Here are two to get you started....

M202

M214

How Pleasant Surroundings and Conditions affect the Health and Happiness

How do our surrounding affect our mental health? Access Officer Alice recently attended a conference organised by the Churches Conservation Trust and [Mind UK] to celebrate the opening of Quay Place, a new community mental health resource in Ipswich. Throughout the conference, there was a lot of focus on the impact our environment can have on us, and on the development of hospital architecture. Here at LHSA, we’ve been working with a number of artists and researchers involved in the redevelopment of hospital spaces across the Lothian area, and this has got us thinking about hospital architecture in a bit more depth. This week, Alice looks at Dr Thomas Clouston’s views on asylum design, and how the physical space of the Royal Edinburgh Hospital in Morningside was tied to its therapeutic outlook.

Dr TS Clouston was Physician Superintendent of the Royal Edinburgh hospital (REH) between 1873 and 1908, and during this time he also published extensively on the causes and treatments of mental illness. One of Clouston’s preoccupations seems to have been asylum design – indeed, whilst Physician Superintendent he undertook an expansive rebuilding programme, with a key part of his legacy being the opening of Craig House, a series of buildings specifically tailored for the treatment of private, paying patients of the Royal Edinburgh Hospital. As part of our Royal Edinburgh Hospital collection (LHB7), we hold two of his papers that give an insight into his thinking on asylum design: these are “An Asylum or Hospital - Home for Two Hundred Patients” (Boston, 1879), and “How Pleasant Surroundings and Conditions affect the Health and Happiness” (Edinburgh, [1887]).

As the title suggests, “An Asylum or Hospital…” was very much concerned with how to make the buildings under his charge comfortable for its inhabitants, and foster the community ideal that he felt was crucial to the successful recovery of patients. In it, Clouston begins by pointing out how attitudes to ‘insanity’ had changed over the years:

“In planning the asylums for the insane, built 70 years ago, the dominant idea in the minds of their architects was secure custody : in the case of those built 30 years ago, the idea of curing the patients had modified in a marked degree the jail-like features of the earlier buildings. Since that time, under the new regime in this country, improvements in the character of the hospitals for the insane have been going on steadily”.

The concept of custody was indeed a key shift in the attitudes of the time. Although ‘open-door’ policies didn’t find real traction until the mid-twentieth century, Clouston saw it as important that patients didn’t feel like inmates, and effort was made to obscure any necessary security features: “all the special arrangements of rooms, window-shutting, strong-rooms, padded rooms, &c., should be as little prominent and offensive as possible ; and above all, they should not be suggestive of what they are intended to prevent”. Not only could these security features be obscured, Clouston suggested, they could also become decorative features in themselves that added to the general positive feeling of the institution. For example, he details how to installed padded leather walls in  a secure room: “the surface of the leather should be neatly stencilled, and coated with four coats of the best varnish. It is then soft, impervious to urine, strong, and makes a pleasant-looking room, just like an old library hung with stamped leather. In this way the forbidding features of an ordinary “padded room” on the patient’s mind are avoided”.

LHB7/14/5 - A block plan for 'An Asylum or Hospital Home for 200 Insane Patients'

Indeed, Clouston seems to have wanted his patients to think of themselves more as residents in a grand hotel than patients in an institution: “in the general arrangements, furnishings, &c., I took a first-class hotel as my model, and not any pre-existing asylum at all”. In defending this relaxed and accommodating attitude, Clouston argued that, even if there were accidents or escapes, and if some physicians had relaxed their attitudes too far, “their indiscretion has done good. It has had for its object the restoration to ordinary conditions of life a portion of humanity that lay in fetters and chains 100 years ago”. By avoiding the tropes of the ‘insane beast’, Clouston thought, the patients of the asylum would develop a greater sense of self-respect, take more interest in their own personal care and appearance.

In this respect, the social aspect of the hospital was an important factor. By bringing patients together to dine “in rooms … the general arrangements of which are precisely those of a table d’hote in a good Swiss hotel in the summer”, Clouston relied on the enduring social nature of people to help improve patients’ opinion of themselves and capacity for social intercourse. He stated that “since we began to use a common dining-room … several inveterately untidy patients have been cured of their slovenliness of dress [and] self-control is taught. The public opinion of the room or the table won’t tolerate noise or disturbance”. The greatest complaint of patients, he stated, tended to be around their lack of control, lack of entertainment and often, their horror at being locked up with ‘lunatics’, and he therefore tried to remedy this by providing opportunities for what he considered “pleasant conditions of life”. These included, in his view, “suitable work for the doer of it with some leisure time, some agreeable companionship, games, amusements, newspapers, books, baths, and liberty of action”.

LHB7/14/5 - the ground plan for 'An Asylum or Hospital Home'

Another key element of Clouston’s design was to avoid “uniformity of accommodation and arrangements” throughout the hospital: in an awareness of different types of mental illness, and the illogicality of treating all patients in the same manner, Clouston stressed that all patients had different needs based on a number of factors such as their bodily health, their propensity to be dangerous to themselves or to others, and their potential ‘curability’. Accordingly, “it should be a principle, never departed from, that the structures and arrangements that are necessary for the worst classes of patients should not be used for the best…”.

In the same vein, Clouston believed that this lack of uniformity should extend to the décor: “variety in the shape, size, and aspect of buildings and rooms, tends to interest, rouse, and cheer the patients, when they pass from one into the other”. He acknowledged that architects and painters were often unwilling to expend their talents on an asylum, whether their efforts might not be as well received as they would be elsewhere in society, but stressed that variation and a lack of monotony in surroundings had a greatly beneficial impact on the mental health of patients.

Overall, Clouston was a strong believer that health and happiness were improved by pleasant surroundings. Furthermore, he saw the benefits of this for the professionals involved in the care of patients, asserting that “the management of an asylum is necessarily much affected by its construction … a cheerful, broken-up asylum is far more apt to be managed on principles that are pleasant to its patients”.

Midwifery in Edinburgh

This is a big week for the history of obstetrics, gynaecology and midwifery in Edinburgh… May 1^st saw the 120^th anniversary of the opening of the Edinburgh Royal Maternity and Simpson Memorial Hospital; May 2^nd marked 83 years since the death of Dr James Haig Ferguson, founder of the first hospital outpatient antenatal clinic in Britain As today is also the International Day of the Midwife, we’re taking the opportunity to look back at the history of this discipline in Edinburgh…

  

LHB3A/15/1 - Certificate awarded to Margaret Reid, Midwife by Thomas Young, 1768.

Midwifery in Edinburgh as a ‘medical’ (as opposed to community) practice dates back to 1726, when Joseph Gibson was appointed Professor of Midwifery by the Town Council. It wasn’t until the 1740s that Midwifery was taught to students of the University of Edinburgh by practising surgeon Thomas Young. Young believed that practical clinical instruction was crucial for a full understanding of midwifery, and in 1781 he tried to rally support for the building of a general Lying-in Hospital in the city that would allow his students this close-up experience. Young died in 1783 before his vision could be realised, and his successor Dr Alexander Hamilton took up the mantle after him.

GD1/1/1 - Midwifery lecture notes, n.d.

Hamilton outlined a General Lying-in Hospital as constituting “a proper building, erected in an airy healthy situation, capable of containing twenty-five patients”, but advised that it “should be constructed in such a manner, that it may be enlarged when the funds can afford it”. [5/6] His appeal was successful. The General Lying-In Hospital, opened in 1793 at the site of what is now Teviot Row House, aimed to provide “women in low life” with the “management during child-bearing that opulence can produce”.

Hamilton’s hopes for the Hospital to be extended were less successful, however, and it wasn’t until 1879 that a purpose-built maternity hospital was opened. Named after one of Edinburgh’s most famous medical sons, the Simpson Memorial Hospital honoured Sir James Young Simpson’s many contributions to midwifery. He had succeeded Hamilton in the Chair in 1840, and in 1847 his infamous private experiments into the anaesthetic effects of chloroform led to it being used to relieve pain during labour.

In 1905, John Halliday Croom was appointed to the Chair, but being a specialist in obstetric alone, additional expertise had to be sought and Alex Hugh Freeland Barbour was appointed as lecturer in Gynaecology. This dualism reflected a general attitude towards the care of pregnant women at the time - as R.W. Johnstone puts it “any special care deliberately devoted to the object of preserving the health of the expectant mother [or of] forestalling dangers likely to arise in her labour … was virtually unknown”.

Portrait of James Haig Ferguson, from the collection
of the Royal Medical Society

The concept of antenatal care was introduced into Edinburgh by Dr James Haig Ferguson. Haig Ferguson had served as Assistant Gynaecologist at the Royal Infirmary of Edinburgh since 1896, and in 1899 had founded a home for unmarried women expecting their first baby. Encouraged by the impact that routine antenatal supervision had on the health of the women treated there, he successfully petitioned the managers of the Edinburgh Royal Maternity Hospital to allow him to open an out-patient clinic for married women, so as to offer them the same levels of supervision. Due to the fact that most married women gave birth at home at the time, the Hospital had somewhat of a reputation: Johnstone recounts how “to protect these respectable women from embarrassment, entrance to the clinic was arranged from an unfrequented side street, and I well remember the great consideration that had to be given to their modesty in putting up an unobtrusive and discreetly worded direction-board.”

LHB3/7/71 - Annual report, 1915

And so, Britain’s first ante-natal clinic opened its doors in 1915. This coincided with the Midwives (Scotland) Act of 1915, which made training, examination and registration for midwives compulsory. Prior to this, many women working as midwives had become ‘certified’ - that is, obtained a certificate confirming their training in a hospital - but most were still without formal training.

The Midwives (Scotland) Act also saw the introduction of the Central Midwives Board in Scotland (CMBS), which recognised three categories of midwife at first: those who had taken and passed the CMBS examination; the ‘certified’ midwives who had previously obtained a certificate; and the ‘bona fides’, women who were enrolled “by virtue of bona fide practice”. This last category covered women of good character who had been in practice as uncertified midwives or howdies for at least a year. Although they could be enrolled without examination, one third of those taking the first CMBS exam were already on the roll as bona fides. As Dr Lindsay Reid explains in her book Midwifery in Scotland: A History, midwifery before 1915 was “alegal”, with no qualifications to meet, and no regulations or licensing requirements. The passing of the Midwives (Scotland) Act of 1915 gave new status to this group of women, some who had been formally trained, some of whom had been working with the benefit of knowledge passed down through generations.

The theme for this year’s International Day of the Midwife is ‘Midwives, Mothers And Families: Partners For Life’. By moving the focus away from the act of labour itself and onto the general health of the mother leading up to birth, Dr Haig Ferguson put in place the approach to maternity care that has led to this partnership; similarly, the decision by the CMBS to acknowledge the role that uncertified, locally-respected howdies occupied in the community ensured that those who might otherwise be reluctant to seek formal medical care were still being seen by an ‘approved’ practitioner. These partnership have now extended beyond the moment of birth, and in the words of the ICM, “midwives everywhere understand that by working in partnership with women and their families they can support them to make better decisions about what they need to have a safe and fulfilling birth”.

The REH and causes of insanity

The first Physician Superintendent of the Royal Edinburgh Hospital (REH), Dr William Mackinnon, initiated a practice of keeping detailed case notes for individual patients. These case notes have been bound into large volumes, and are now known by the shelfmark LHB7/51. They provide us with a rich resource for examining how attitudes to the causes of mental illness changed throughout the 19^th century.

LHB7/51/1 - The first volume of casenotes kept by the REH.

When an individual was admitted to the hospital certification papers would be produced. This was ‘a complicated procedure which involved with coordination of petitioners, medical men and legal representatives'[1]. These certification papers often described why admission was considered necessary – such as the patient posing a threat to themselves or others – and usefully for family historians, they can also carry a bit of information about the family’s medical history.

LHB7/52/633 - This note accompanied the patient's certification papers.

These papers were legal documents: the hospital was legally stating they had the resources to board, feed and care for the patient; medical professionals were legally affirming the medical need for the patient to be admitted; and someone was legal agreeing to pay the costs of care – in the case of private patients this was usually a relative, whereas pauper patients were paid for by the local authority.

In contrast to these structured and regulated documents, the first casebooks of the REH were freeform, and physicians recorded what they felt to be most necessary to understand and describe a patient’s mental state and the cause of their illness. For example, money matters were considered to be the cause of this woman’s melancholia:

LHB7/52/633

In 1846, the post of Physician Superintendent was taken up by David Skae (1814-1873). In the spirit of the Victorian passion for taxonomies, Skae was concerned throughout his career with the classification of insanity, approaching the subject from a physiological perspective rooted in a belief in the ‘physical basis of all insanity’[2]. Over the course of seventeen years, Skae developed a theory of classification that grouped the ‘varieties of Insanity…in accordance with the natural history of each’.

Skae's 'classifications'. Held by the University of Glasgow and accessible on the Internet Archive.

Some of these classifications strike us immediately as being firmly rooted in Victorian attitudes to morality, sexuality and gender roles. For example, in his address to the Royal College of Physicians of London in 1863, Skae described ‘Masturbatory Insanity’ as a condition in which “that vice produces a group of symptoms which are quite characteristic and easily recognised, and give to the cases a special natural history; the peculiar imbecility and shy habits of the very youthful victim; the suspicion, and fear, and dread, and suicidal impulses, and palpitations, and scared look, and feeble body of the older offenders, passing gradually into Dementia or Fatuity”; ‘post-connubial Mania’, was “occasionally met with, both in the male and female sex, but more frequently, I think, in the latter, developed immediately after marriage and, without doubt, connected with the effect produced upon the nervous system by sexual intercourse”; and of ‘Satyriasis and Nymphomania’ no description was offered.

Skae died in post in 1873 and his although his successor, Thomas Clouston, continued the practice of keeping detailed case notes, he did make some changes. In 1874 the case books moved from the freeform blank pages to pro-forma printed pages, requiring the physicians to provide pre-specified areas of information. These went into a great deal more detail that had previously been seen – I particularly like that information was recorded on a patient’s appearance.

This new style of case note also supplied a place in which to record Skae’s classification. This approach was largely ignored in the medical community and never really took hold outside of the REH, but the inclusion of it here allows us to examine not only what ‘disease’ patients were diagnosed with, but how the manifestations of their illness tell us something about 19^th century attitudes to the causes of mental illness. By the early 20^th century this section had begun to be left blank, and by was eventually removed from the proforma.

LHB7/51/107. Skae's classification is no longer asked for,
and the notes are sparse. 

As the number of patients admitted to the REH increased, the instances of these pages being left blank or only partially completed also increased. Faced with high demands on their time, physicians and clerks were not able to spend as long filling in detailed notes for each patient, and so we’re left with sometimes frustrating ‘teases’ of records such as these – this is a good reminder that, in the archive, an absence can speak as loudly as a presence.

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[1] Barfoot, Michael, and A. W. Beveridge. "Madness at the crossroads: John Home's letters from the Royal Edinburgh Asylum, 1886–87." Psychological medicine 20, no. 02 (1990): 265.

[2] Fish, Frank. "David Skae, MD, FRCS: founder of the Edinburgh School of Psychiatry." Medical history 9, no. 01 (1965): 42.