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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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”.

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.