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.