Case Notes, Case Histories, and the Patient's ...

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Case Notes, Case Histories, and the Patient's Experience of Insanity at Gartnavel Royal Asylum, Glasgow, in the Nineteenth Century ByJONATHAN ANDREWS*

KEYWORDS: case notes, case histories, authorship, function, censorship, confidentiality, patients' experiences, silence, asylums, insanity, Glasgow

New emphases within social history on 'history from below' and within medical history on the patient's experience of illness have placed a higher premium on the value of case notes and individual histories for medical historians.1 For historians of nineteenth-century British psychiatry case notes constitute an especially important and extensive resource. They may provide the surest basis we have for understanding the changing nature of the experience of the insane in asylums since 1800. Case notes have also been recognized as affording a welter of insights into medical treatment and practice. Those belonging to institutions may provide additional illumination of the inner environment of the hospital or asylum; the influence of official and public visitors on institutional life, and the whole spectrum of an •Wellcome University Award Holder and Senior Lecturer in the History of Medicine, Oxford Brookes University, Gipsy Lane Campus, Headington, Oxford OX3 OBP, UK. ' See e.g. F. Krantz, History from Below: Studies in Popular Protest and Ideology (Oxford, 1988); D. Vincent (ed.), Bread, Knowledge and Freedom: A Study of Nineteenth-Century Working Class Autobiography (London, 1981); R. Porter, 'The Patient's View: Doing Medical History from Below', Theory and Society, 14 (1985), 175-98; L. M. Beier, Sufferers and Healers: The Experience of Illness in Seventeenth-Century England (London, 1987). 0951-631X Social History of Medicine Vol. 11 No. 2 pp. 255-281

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SUMMARY. This article is concerned primarily with questions as to how and why case notes were produced and utilized, and how they may (or may not) be used by historians. More specifically, it discusses how the Glasgow Royal Asylum's case notes may be deployed to access patients' experiences of madness and confinement. The deficiencies and biases of the case record are also explored. So too is the relationship of case notes with other asylum based records, including reception order questionnaires, with a separate section on patient writings as part of the case history corpus. This leads into an analysis of how the Asylum's case notes became case histories and for what purposes. These subjects are related to changes and continuities in medical ideologies about insanity, social attitudes to the insane and the nature of medical practice in asylums. Some fundamental shifts in emphasis in the use of the case note and case history occurred in this period. These shifts were associated with an increased emphasis on organic interpretations of mental disease and on clinical approaches to insanity; with the medicalization of asylum records and the wider discourse on insanity, and with declining deference to the public at large in the presentation of cases. The survey concludes by analysing the changing place of patient testimony within the case record.

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institution's intramural and extramural relations. Less successfully, case notes have been used to apply, and to make analogies with, modern diagnoses.2 Yet medical case notes still remain a resource for psychiatric history which has been much neglected by British scholars.3 The explanation for this has more to do with convenience than utility. Printed material is easier to access and lends itself more immediately to assimilation and generalization than the agglomeration of data contained in patient records. Some scholars have simply been unaware of the rich resources of case note material available for nineteenth-century asylums.

2 See e.g. T. H. Turner, 'Rich and Mad in Victorian England', in R. M. Murray and T. H. Turner (eds.), Lectures on the History of Psychiatry: The Squibb Series (London, 1990), pp. 170-93; S. F. Klaf and J. G. Hamilton, 'Schizophrenia—a Hundred Years Ago and Today', Journal of Mental Science, 107 (1961), 819-27. A. Scull was criticized on this account recently; A. Beveridge, 'From Witchcraft to "Grande Hysterie": Three Hundred Years of Psychiatry', British Journal ofPsychiatry Review of Books, 2 (1991), 5. 4 For an example of such, see e.g. the 1763 casebook of John Monro, Physician to Bethlem, in private possession of Dr F. J. G. Jefferiss. For instances of non-psychiatric case books pre-1800, see e.g. C. F. A. Marmoy (ed.), The Case Book of 'La Maison de Charitek de Spittlefields', 1739-41 (London, 1981); S. T. Anning, 'A Medical Case Book: Leeds, 1781-84", Medical History, 28 (1984), 420-31; S. Wood, The Library: Two Further Letters ofJohn Hunter and Notes on Rockingham 's Last Illness from Hunter's Case Book (London, 1949). 5 T. Percival, Medical Ethics (Manchester, 1803), pp. 27-8; R. Hunter and I. Macalpine, Three Hundred Years of Psychiatry 1535-1860 (London, 1960), pp. 510 and 585. 6 Rules and Ordersfor. . . Bethlem.Hospital (London, 1818), pp. 63-4, 68-9. 7 Reports from the Committee on Madhouses in England, 25 May, 2 and 12 June, and 11 July 1815; and 26 April 1816 (London, 1815-16).


Before 1800, no public asylum appears to have required staff to keep notes of cases, although medical practitioners had evidently long kept their own private notes on patients.4 The Manchester Infirmary physician, Thomas Percival, seems to have been the first British practitioner to appeal in 1803 for asylums to keep 'journals' of patients, seeing this as a key means to augment medical knowledge of insanity.5 It was not until 1815-16, however, that case books began to be completed even at the leading English institutions, like Bethlem and St. Luke's. Bethlem's declared objects in keeping case notes, were diagnostic and therapeutic, although their envisaged use for generating statistical and other knowledge of insanity may also be inferred. Medical officers were to register 'the state of each Patient on Admission' and to record 'a progressive statement of the means both moral and medical, that are pursued for the recovery of each Patient, and the result of such treatment'.6 However, quite apart from acquiring knowledge of insanity, the underlying motivation for this initiative was probably a recognition of the need for extending surveillance internally at a period when external vigilance over asylums was being exercised more vigorously. This may be inferred from the timing of the inquiry by the 1815—16 House of Commons Committee on Madhouses, which had exposed scandalous abuses at Bethlem and other institutions.7 Evidently spurred on by this Committee's censures, Bethlem introduced case notes as part of a wider revamping

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Ill The case notes of Glasgow Royal Asylum appear to represent the earliest and one of the most extensive series for any Scottish psychiatric institution. Case books were not introduced at Sunnyside Royal, Montrose until 1818 (37 years after the Asylum's opening);12 nor at Aberdeen Royal (opened 1800) until 1821.13 Case 8 Bridewell and Bethlem Committee Minutes and Sub-Committee Minutes (held at Bethlem Royal Hospital Archives), 1, 7, 10 and 21 May 1816, fols 383, 387, 389, and 395. 9 1815 Madhouses (Scotland) Act, An Act to Regulate Madhouses in Scotland, 7 June 1815, 55 Geo. Ill, Cap. 69; 1808 County Asylums Act, 48 Geo. Ill, Cap. 96; 1815 Amending Act, 55 Geo. Ill, Cap. 46; 1828 Madhouses Act, 9 Geo. IV, C.41. See e.g. K. Jones, Asylums and After. A Revised History of the Mental Health Services: From the Early 18th Century to the 1990s (London, 1993), pp. 79, 97; K.Jones, Lunacy Law and Conscience (London, 1955), p. 142. 11 Jones, Asylums, p. 77. 12 Archives, Sunnyside Royal Hospital, Montrose, SR/4/1—103. 13 Grampian Health Board Archives, Aberdeen, GRHB2/4/1.


of regulations governing its medical officers' attendance and duties.8 In doing so, however, the institution's managers made no direct mention of the Committee's findings. Instead, they strove to maintain Bethlem's traditional aura of independence by attributing reforms rhetorically to the move to a new site and building at St George's Fields. In fact, the Madhouses Committee had made no binding or explicit recommendations for reforms in record keeping (or anything else). There was no contemporary legislative requirement for British asylums to keep case books. Nor were such records stipulated under the Scottish Madhouses Act of 1815 and the English County Asylums and Madhouses Acts of 1808, 1815, and 1828.9 Early legal requirements for record keeping were mostly confined to private asylums, or to certification and discharge documentation—reflecting contemporary preoccupation with the threat of false confinement, rather than with the ill-treatment of patients and the acquisition of medical knowledge of insanity. The 1828 Act did extend such requirements to records of restraint. During the first decades of the nineteenth century, nevertheless, asylums displayed active resistance to outside, especially central state, interference in their affairs. Bethlem asserted its royal charter and traditions of self-determination in successful eschewal of exposure to visitation.10 Private madhouses had obvious business interests at heart in striving (less successfully) to avoid or limit inspection. Anxieties about privacy—seen as a particular entitlement of the genteel—disposed private and public institutions alike to wariness of exposure to the prying eyes of officialdom.'' Yet Bethlem, whose patrons were strongly represented in Parliament, was the only public institution in Britain exempted (until 1853) from inspection under the Madhouses Acts. Concerns with lunacy had intensified in influential governmental and public circles, as had medically-oriented concerns with providing reliable clinical material. And such concerns made for a gradual recognition (if grudging and ambivalent) that it was in the public (and in asylums' own) interest to keep some record of patients' conditions and of medical attendance upon them.

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14

Lothian Health Board Archives, Edinburgh University Library, LHB7/51/1. While case notes survive for Royal Dundee Liff Asylum from 1826-1912, the series is incomplete and currently uncatalogued. The. books are held at the existing Royal Dundee Liff Hospital, although negotiations are underway for their transfer to the Health Board Archives. A limited amount of other patient records are held at Tayside Health Board Archives, Dundee University Library, THB7/10. 16 Greater Glasgow Health Board Archives (henceforth, GGHB), Ruchill Hospital, Glasgow; GGHB13/5/1 and 195. 17 Edinburgh Review, No. LV1, cited in Fourth Annual Report of the Directors of the Glasgow Asylum (henceforth, GAR) (Glasgow, 1818), p. 23. W. L. Parry-Jones, The Trade in Lunacy: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries (London, 1972). " GGHB13/5/29-32. For further supplements (1838-44), see GGHB13/5/16 and 28. 20 GGHB13/5/33-63 and GGHB13/5/68-99. 21 GGHB13/5/123-177. 22 A 'Ladies Case Book' series, consisting of twenty volumes covering the period 1858-91, misses only two volumes; GGHB 13/5/103-122. There is, however, no obvious 'gentlemens' equivalent. Four supplementary volumes cover male West House (or gentlemen) patients from 1854—84, and three cover female West House patients from 1856-84; GGHB 13/5/64-67 and 100-102. 15


books do not survive for the Royal Edinburgh Asylum (opened 1813) until 1840,14 and for Dundee Royal (opened 1820) until 1826.15 Glasgow Royal's case books, however, are extant for its male patients from 1814 (the date of the Asylum's opening), and for females from 1816.16 In this context, Glasgow Asylum was clearly ahead of its time in its record keeping. The Edinburgh Review of 1817 commended to all asylums the practice at Glasgow and Nottingham where case books were kept 'to be inspected under proper sanction and restrictions'.17 Beside their use for internal oversight, they were clearly being seen as a prime means of ensuring external scrutiny. Yet, only with the 1845 Lunacy Act was the keeping of case books made compulsory by statute for English asylums. Case notes were already in use at all the Scottish Royal Asylums by this date, the medical, bureaucratic and legal needs for such having readily been recognized. The fact that the keeping of case notes was never stipulated by law in nineteenth-century Scotland was partly, no doubt, because existing practice made it unnecessary. Possibly, the small number of private asylums there did not constitute so strong a wedge of lay and business interests against comprehensive record keeping as had the English 'trade in lunacy'.18 Glasgow Royal's case notes appear to comprise a remarkably complete series over the century's duration. Prior to the Asylum's removal to Gartnavel in 1843 (from the old site at Parliamentary Road), only a single volume of the female case notes seems to be missing. While, for male patients, at least seven volumes have failed to survive, the lack is made up by a series of'Medical Reports' (1814-37).19 A novel series of volumes entitled 'House Surgeon's Notes for [the] Physician' (1841-84), divided between male and female cases, are virtually complete.20 For the 'New Case Book Series'—also divided solely according to gender, introduced in 1884 and continued until 1921—every single volume remains extant.21 The more significant gaps appear amongst notes taken for upper-class patients.22 In sum, this means that patients' histories can, more often than not, be traced as a continuum through the case notes. However, there are substantial variations in both the form of the case books and the assiduity with which they were


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23 Regulations of the Glasgow Asylum for Lunatics (Glasgow, 1814), N o s lsc, 2nd, 5ch, p . 9 ; 2 n d e d n . (Glasgow, 1823), N o s 1, II, V , p p . 1 2 - 1 3 . 24 See e.g. 5th GAR (1819), p. 17; 6th GAR (1820), p. 9; 8th GAR (1823), pp. 10, 14-15; 9th GAR (1823), pp. 12-14. 25 See e.g. GGHB13/5/22, fol. 253; GGHB13/5/30, fols 115, 250, 484; GGHB13/5/31, fol. 253. 26 GGHB13/5/33 and GGHB13/5/68. 27 Ibid.


completed. Case notes appear to have been instituted first and foremost with the intent of guiding and improving medical practice, although concurrent concern with explication of practice and restricting access to the notes hints at their additional use as a means of scrutiny. The first printed Regulations of Glasgow Asylum (1814 and 1823) stipulated that the 'Case-Book' was to begin with a history of the case taken by the Apothecary, and was then to comprise of'regular reports . . . of the effects of the prescriptions, and of the variations... in the disease' as recorded by the Physician. The Physician was also to 'add to the history' whatever 'remarks' he felt appropriate 'for explaining and improving the practice'.23 Prior to the appointment of medical superintendents to the Asylum, however, the notes are largely rather terse accounts of patients' conformity, or non-conformity, with the discipline of the house. Rarely was patients' language, or the precise nature of their delusions, accorded much attention. This was despite the evident influence of 'moral therapy' on the asylum regime; emphasis on 'persuasion' and winning the patient's 'confidence', and qualified acceptance of the possibility of reasoning with the insane.24 Officers often failed to record anything in the notes beyond an opening statement of the case.25 With the clear intent that case notes would be better kept henceforth, a list of 'Directions' for the new series of Surgeon's Notes for the Physician was drawn up in 1841.26 Concurrently, moreover, the case notes begin to record more detailed information, often taken directly from the patient's mouth and manifesting a greater interest in patients' delusions. The existence of these comprehensive instructions for the surgeon makes it possible for the historian to assess the controls under which these notes were created. The Surgeon was instructed to register the patient's physical appearance and condition, and any effects or alterations in medicines and treatment. He was also to record the patient's 'mode of answering questions', his 'conversation', 'delusions', 'conduct', 'habits' and the 'effects of [the] visits of friends'.27 The requirement that these reports 'be made daily' in 'cases under active treatment' and 'weekly' otherwise was evidently quite faithfully adhered to. Once patients had been adjudged as chronic, reports tended to become monthly or quarterly. However, time and space made it impracticable for surgeons to record all of the multifarious 'circumstances' they were supposed to observe and, at times, they were still negligent in writing cases up. For most of the century, little attempt was made to structure Glasgow Royal's case notes. At best they are organized by a case number allocation, a record of the patient's name, age, occupation, admission date and maintenance rate, and a statement of the patient's history and present state. Often, not even all of this limited history is supplied. Subsequently, notes simply become a continuous series of dated reports by medical officers, carried from volume to volume until the

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28 See J. Andrews, 'A Failure to Flourish?': David Yellowlees and the Glasgow School of Psychiatry in the Nineteenth Century', History of Psychiatry, 8 (1997), 177-22, 333-60. 29 T. Clouston, 'The Medical Treatment of Insanity'Jouma/ of Mental Science, XVI (1870), 24-30. 30 A. H. Newth, 'Systematic Case-taking' Journal ofMental Science, XXVI (1900), 256-60, p. 257. 31 Ibid., p. 255.


patient leaves the Asylum. Separate case files for patients were not introduced to Gartnavel until the 1920s. Cross-references to volume and folio numbers usually enable cases to be followed longitudinally through their stays. Under Hutcheson's superintendence, a pro forma was briefly introduced to the case books. From 1838—41, information on each admission was subsumed under headings and subdivisions. This classification of the patient's history by: 'description'—'personal' and 'premonitory'; 'malady'—'form', 'hallucinations' and 'propensities'; 'causes'—'predisposing' and 'exciting'; and 'treatment', was a logical, if rudimentary, reflection of contemporary medical thinking on mental illness. In 1840, the heading 'treatment' in the Glasgow Royal case notes was also sub-divided into 'previous' treatment and treatment whilst in the Asylum. Changes in patient record keeping in Glasgow should be set in the context of changes in Britain and Europe as a whole, although there were considerable variations from one asylum and one region to another. The nineteenth-century psychiatric community was never wholly convinced as to the merits of intricate nosologies. While some British alienists did produce or apply elaborate nosologies, most remained critical of their practicability. Initially, Glasgow Royal seems to have taken its lead from the looser classificatory systems of early French nosologists, like Pinel and Esquirol.28 Hutcheson's subsequent more structured format for the notes was soon abandoned, as were early proformas at the Royal Edinburgh Asylum. Nevertheless, during the last decades of the nineteenth century, an increasing onus on more 'scientific', approaches to mental medicine saw important changes being recommended and (to a lesser extent) adopted for asylum case notes. Scotland clearly took a leading part in these developments. The impact of the highly classificatory approach to mental diseases taken at Edinburgh Royal Asylum by David Skae and Thomas Clouston, also rendered case notes at a number of Scottish asylums (including Crichton Royal and the Murray Royal, Perth), much more systematic records. As early as 1869, Clouston had appealed for a more 'systematic plan of treating cases' at asylums, and his own asylum became very much a champion of the systematic case note. 29 This approach was taken even further at the Murray Royal, where, as Newth later described it, comprehensive printed particulars meant that all that was necessary in taking histories was 'to score out some parts and enter a few words at other parts'.30 Rather than 'keeping up the case-book simply for the satisfaction of the Commissioners, as a check on malpraxis or neglect, for reference in case of inquiries, or as evidence of work done in the asylum', this generation of alienists espoused case-taking 'from the scientific point of view for the advancement of the study of insanity'.31 Maintaining more systematic records, it was hoped, would also expedite the arduous and time-consuming task of case-taking, and thus free asylum medical


32

A n d r e w s , ' A Failure t o Flourish'. F. Fish, 'David Skae, M . D . , F . R . C . S . F o u n d e r o f the E d i n b u r g h School o f Psychiatry', Medical History, 9 (1978), 3 6 - 5 3 ; J. C r i c h t o n - B r o w n e , 'Skae's Classification o f Mental Diseases', Journal of Mental Science, X X I (1875), 3 3 9 - 6 5 . B u r r o w s w a r n e d his colleagues t o 'free' themselves from ' t h e trammels of nosology'; G. M . Burrows, Commentaries on the Causes, Forms, Symptoms and Treatment, Moral and Medical, of Insanity (London, 1828), p. 258. 34 Journal of Mental Science, X V (1869), 2 2 3 - 3 2 ; R . Russell, ' T h e Lunacy Profession and its Staffin the Second Half of the Nineteenth Century, with Special Reference to the West R i d i n g Lunatic Asylum', in W . F. Bynum, R . Porter, and M . Shepherd (eds.), The Anatomy of Madness: Essays in the History of Psychiatry (London, 1985-88), 3 vols, iii, pp. 2 9 7 - 3 1 5 . 35 A R s o f G B C L S (1871 a n d 1872); Journal of Mental Science, 24 (1878), 4 7 5 . R e c o r d s o f physical condition served an ambivalent function for asylums, insuring them against neglect of, and blame for, patients' bodily ills and mortalities, but also increasing their exposure to external monitoring. See GGHB13/14/3, MS Reports of GBLCS, 1867-83, report by A. Mitchell dated 9 December 1870. 33


officers for more interesting and scientifically 'useful' clinical work. It would render the case note a more functional record and facilitate the collation of more accurate and valuable statistics. Newth's end of century appeal was, however, for how things ought to be rather than how things were. Most asylums had remained rather conservative laws unto themselves in the case notes they kept, with physician-superintendents staunchly defending their autonomy in the matter. Glasgow Royal under David Yellowlees (Physician-Superintendent, 1874—1901), if not the majority of British asylums, resisted moves to introduce greater uniformity into case note keeping. Despite his training at Edinburgh under Skae, Yellowlees was deeply suspicious of'system' in psychiatry, preferring a much more independent and empirical approach to the day-to-day management of the asylum.32 And trenchant assaults had been made by a number of leading alienists on the Edinburgh classificatory system.33 Despite efforts by the Medico-Psychological Association (MPA) to introduce standardization and structured classification into case note taking,34 Glasgow Royal remained relatively impervious to such moves, which indeed failed to gain unanimous support amongst British alienists. (The MPA's campaigning and the Lunacy Board's requirements for official returns from asylums did ensure that considerable uniformity and structure began to appear in other forms of record keeping, such as registers of patients, restraint and accidents.) If this suggests a surprising lack ofdirigisme and nosological interest at Glasgow Royal, it also means that the case notes remain less adulterated as records of patients' histories and experiences. Only Gartnavel's House Surgeons' notes were arranged, from 1883, according to any sustained formal structure. Even these notes merely comprise an opening statement subsumed under the headings: 'Prior History'; 'Bodily/Physical Condition'; and 'Mental Condition', before reverting to the standard format of previous years. Since 1872, the Scottish Lunacy Commissioners had required returns from asylum superintendents stating the 'physical condition' of patients on admission.35 The introduction of 'Registers of Physical Condition' at Gartnavel in this year, and the insertion of separate sections for bodily and mental condition into the Surgeon's notes in the next decade reflected the increased somatic emphases within mental medicine.36 These developments in record keeping may also be

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IV Some of the foremost difficulties in using questionnaires and case notes to reconstruct a patient's history are in the area of incompleteness and inter-textual discrepancies. On the whole, what patient records at Glasgow Royal reveal about the before or after-life of inmates is very limited. Questionnaires were occasionally not filled in and, anyway, allowed little space for detailed descriptions. Those that were answered tended to be given variant and often narrow interpretations by respondents.38 In one 1875 questionnaire every 'question was answered by the word "unknown" \ 3 9 Obtaining reliable histories was a problem not just in outlying and rural areas, where medical advice was less available and local inhabitants may have been less well educated, but 'even in Glasgow'.40 Possibly, there were other advantages for asylums in rural areas, where communities were smaller, and often more tightly-knit and better informed about their members' pasts.41 The real and ascribed reasons for the inadequacies of histories may say much about contemporary social propriety and medical ideologies. According to authorities at Glasgow Royal, families were often averse to providing information about their insane members because of 'false delicacy', 'unreasonable' sensitivity and 'the mystery and horror surrounding insanity', and for fear of casting scandal on 37 J . T h u r n a m , Observations and Essays on the Statistics of Insanity ( L o n d o n , 1845), part 2, p p . 57—60; Hunter and Macalpine, 300 Years, pp. 941—5. 38 E.g. 4th GAR (1818), p. 22. 39 62nd GAR (1875), p. 25. 40 4th GAR (1818), p. 22; see also, e.g., 15th GAR (1829), p. 4; 16th GAR (1830), p. 4. 41 62nd GAR (1875), p. 24.


seen within the wider context of reformers' attempts to 'hospitalize' the asylum environment. At Glasgow Royal, for nearly every admission, an initial statement detailing the previous history was entered in the case book. This statement was normally derived from answers given by patients' relatives/guardians and attending medical men to a query sheet which formed part of the reception order. It might also be produced from letters or verbal accounts delivered at the Asylum, and from the medical certificates. From its beginnings as a cramped sheet ofjust twelve queries, the Glasgow questionnaire was revised in 1840 and rendered more extensive and elaborate, being divided into three sections on 'History', 'Causes' and 'Treatment'. It had been extended again by 1843, when it comprised a prodigious twenty-five questions, but was reduced after the 1857 Lunacy (Scotland) Act to nineteen or twenty queries. My research has confirmed that these questionnaires were common to most, if not all, of the Scottish Royal Asylums, and to English asylums as well. While there are important differences in their content, their basic function and emphases appear to have been relatively uniform. They anticipate the format devised later (1845) for the York Retreat, and recommended by the Association of Medical Officers of Hospitals for the Insane (the subsequent MPA) for 'every public hospital in these kingdoms'.37


42 39th GAR (1853), p. 23; 41st GAR (1855), pp. 31-2; 46th GAR (1860), pp. 22-4; 70th GAR (1883), p. 10. 43 46th GAR (1860), pp. 23-4. 44 See e.g. 40th G A R (1854), p . 24. 45 39th GAR (1853), p. 24. See, also, 40th GAR (1854), pp. 25-6; 63rd GAR (1876), p. 15. 46 4th GAR (1818), p. 22. 47 43rd GAR (1857), p. 7. 48 See, e.g., 62nd GAR (1875), p. 25; 70th GAR (1883), p. 10. 49 62nd GAR (1875), p. 25. 50 Cases of James Mearns and William Cleland admitted in 1818; GGHB13/5/3-4 and GGHB13/7/1.


the family name.42 The 'domestic discord' surrounding many an admission might also provoke the concealment of information about the case history.43 Yet relatives saw limited necessity, and were sometimes offered inappropriate incentives, to submit entirely to the clinical gaze. Clinicians' profound interest in the hereditary roots of insanity, in particular, was litde shared by relatives anxious to avoid being tarred with the same brush, and to secure their members' good names, marriageability and futures.44 Often, however, respondents must have simply been unable to provide the information required, and could not be expected to place the. same importance on completing query forms as did the Asylum. Frequently, even when information was forthcoming from relatives, clinicians dismissed it as ignorant and erroneous. Clearly, this was one way for alienists to assert their own expertise in diagnosing and treating the insane. It also suggests one way for the historian to prise open the disparities between 'expert'/'professional' and 'lay'/'popular' ideas on insanity. A heightened somatic emphasis regarding insanity, for example, led asylum officers to discount emotional causes ascribed to some of their patients' disorders as 'symptoms' not 'real causes'.45 In transferring aetiological information from admission papers into case notes and asylum registers, clinicians often left off or altered original ascriptions. And their supplanting of moral with physical causes can elucidate significant areas of divergence between lay and medical views of insanity in this period. Yet, families were frequently coached in their answers to questionnaires by medical practitioners, and it is often impossible to distinguish reliably lay from medical viewpoints in such sources. As with case notes, from their very beginnings it was hoped that patient histories recorded in the printed queries would assist 'in guiding the practice' at the Asylum.46 Such histories were additionally perceived as precautionary of perils to physically unfit patients.47 They would also help in avoiding unnecessary drains on asylum resources and compromising the Asylum's statistics and reputation. Yellowlees stressed the need for accurate histories as a particular imperative. Despite observing how 'elaborate statistics' founded on such data were liable to be rendered 'fallacious',48 Yellowlees moreover underlined how incomplete case histories had grave implications for treating and managing patients.49 While the case notes generally record very accurately information contained in admission documents, there are frequently important omissions and occasional inconsistencies. For example, for two patients admitted in 1818,50 their occupational record is discrepant, while one patient's headaches and constant wearing

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51

Regulations ( 1 8 1 4 ) , N o s 1st, 2 n d , 5 t h , p . 9; Regulations ( 1 8 2 3 ) , N o s 1, II, V , p p . 1 2 - 1 3 . Regulations (1814), 2nd-6th, pp. 6-7 and 2nd, p. 9; Regulations (1823), Nos II-V1, pp. 8-9 and No. II, p. 12. 53 Ibid. ( 1 8 1 4 ) , 3 r d , p p . 6 - 7 ; ( 1 8 2 3 ) , N o . Ill, p . 8. M Ibid. 55 Ibid. ( 1 8 1 4 ) , 1st a n d 3rd, p p . 8 - 9 ; ( 1 8 2 3 ) , N o s I a n d III, p . 1 1 . A r r a n g e m e n t s at G l a s g o w s e e m t o have reflected those at other contemporary asylums. Yet at Bethlem, the Physician's role as regards case notes was defined rather more narrowly. He was merely to sign the case book entry on patients' admissions and discharges/deaths, the Apothecary being the officer responsible for keeping a 'progressive' record of patients' conditions and their moral and medical treatment; Bridewell and Bethlem Committee (and Sub-Committee) Minutes, 10 and 21 May 1816, fols 389 and 395. 56 Regulations (1814), 1st, p. 6; (1823), No. I, p. 8. 52


of a napkin round his head is only derivable from the questionnaire. Warrants and letters accompanying admissions occasionally give detailed accounts of patients' former employment, illnesses, and treatment, not reproduced in the case notes. Admission documents also contain the odd item of subsequent correspondence, such as letters requesting a patient's discharge. It is essential, then, to use case books in conjunction with admission papers (where available), and to validate and supplement the processing of case note material by reference to other documentation. Another of the major problems with attempting to extract patients' histories from case notes and questionnaires is that of authorship. Initially, Glasgow Royal's case notes were written primarily by the superintendents. This helps to explain why early notes record so much about the orderliness or disorderliness of patients' behaviour, and so little about their clinical histories. The early superintendents also officiated at the Asylum as qualified apothecaries, and it was in this capacity that they were responsible for keeping the case books. It was the Apothecary who was required to write the initial history of the case, as derived from friends' statements, or 'by communication with the Patient', according to asylum regulations.51 Yet, in prescribing and reporting on the patient after his admission, the Physician was supposed to have the major role. He was to dictate subsequent case note reports to the Apothecary, who was very much his inferior within the medical hierarchy. The Physician was also to make a summary statement at the termination of the case.53 In general, nevertheless, the early case notes are mainly written in the Apothecary's hand. Changes in handwriting may help to unravel lingering doubts over authorship. Even the final statement of the case and prophylactic advice were sometimes narrated in first person or other terms that make the Apothecary's authorship evident.54 This is not surprising considering the merely visiting nature of the Physician's office before the 1840s. The Superintendent and Apothecary were resident officers, who would see patients every day.55 Case note entries do seem to coincide with the Physician's periodic examinations of patients (ordinarily weekly, but more frequent in feverish and 'acute' cases).56 But, often, the Physician could only have'known about the condition of a patient since his last visit from what the Apothecary told him. Both officers must have collaborated closely in writing the case note entry. All this suggests something significant about the hierarchical nature of contemporary medical practice. The superior relationship of the Physician to the Apothecary arid their distinct medical roles were


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" I b i d . (1814), 5th, p. 7. See Regulations of the Glasgow Royal Asylum for Lunatics (Glasgow, 1848), N o . 16, p . 2 8 ; Regulations of the Glasgow Royal Asylum, Gartnavel (Glasgow, 1899), N o . 8, p . 13. ?9 Regulations (1848), N o . 6, p p . 2 6 - 7 . 60 Ibid. No. 3, p. 23. 61 Ibid. No. 5. The 1899 Regulations merely stipulated that the assistants 'report the mental and physical condition of each new patient in the Case-Book', and 'from time to time report in the CaseBooks the condition, treatment, and progress of the individual Patients'; Regulations (1899), Nos 2 and 3, p. 15. E.g. queries 5 and 8 about lucid intervals and female obstructions. 58


strictly enshrined in formal terms. Yet, in practice, the Apothecary often encroached on to those areas of authority and activity formally reserved for the Physician. Subsequently, the balance of this relationship was to change. Initially, 'every volume of the Case-Book' was 'considered as the property of the Asylum', from where it was forbidden to remove it. The Physician, the Superintendent/ Apothecary and the Directors were officially accorded equal authority over 'access' to the books.37 From the 1840s, however, the Physician-Superintendent alone was designated 'the custodier' of the case notes and all other patient records.58 This seems to be a clear enough reflection of medicalization at the Asylum and of the rather more pyramidal hierarchy of the medical regime. Nevertheless, the Physician-Superintendent rarely wrote the case notes himself, a task evidently regarded as too menial and time-consuming, and generally left to juniors. According to the 1848 Regulations, he was simply required to 'note, or cause to be noted in the Case-Books, the progress of each case', and, 'at its termination', to make whatever 'observations' he thought appropriate.59 In fact, only William Hutcheson amongst the Physician-Superintendents seems often to have condescended to make a comment in the case book. It was now the Medical Assistants who were explicitly instructed to visit and report on newly admitted patients. This case report was to encompass the patient's 'state of mind and [bodily] health', and to take particular notice of 'fractures, bruises, scratches, swellings, or morbid conditions of the surface'.60 Quite apart from the medical reasons for taking special note of patients' external injuries, such would ensure that there was less confusion as to injuries sustained whilst inside the Asylum, for which there were important disciplinary, economic and legal implications. The Medical Assistants were also to report during future visits on patients' 'conduct, habits, peculiarities mental and physical, as well as their state of health, the management mental and medical, and the medicines prescribed, with their effects'.61 Perhaps the foremost difficulty in using case notes and questionnaires is that they often convey more about the preoccupations of the Asylum's medical regime than about patients and their histories.62 Far from representing patients' impressions, case notes pre-eminently constitute the impressions of the medical officers who wrote them. Inevitably prejudiced by the interests of medical men in portraying a favourable record of their own practice, case notes are also limited by the criteria governing the selection of what (and what not) to record. Recent studies of the Freudian case history corpus have stressed the many ways in which censorship has

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63

E.g. F. S. Sulloway, 'Reassessing Freud's Case Histories', his, 82 (1991), 2 4 5 - 7 5 . 37th G A R (1851), p p . 2 0 - 1 . In fact, Mackintosh did speak m o r e explicitly about 'masturbation' in his subsequent reports. H e also observed that 'Masturbation' was a term favoured m o r e by t h e French, 'Self-Abuse' being most c o m m o n l y used in Britain at t h e time. See 41st G A R (1855), p. 37; 42nd G A R (1856), p . 24; 46th G A R (1860), p . 24. 65 GGHB13/5/65, fols 86-7, 224-5, 398-9, and 724-5, esp. entries dated 12 May 1862, 20 October 1863, 23 April 1864. 66 See A n d r e w s , ' A Failure t o Flourish', p . 346. 67 See esp. GGHB13/5/47, fols 117, 207, 151-2. 64


distorted the psychoanalytic legacy.63 Censorship was vigorously exercised by the medical officers and administrators of nineteenth-century asylums. Those at Glasgow Royal were typically prudish when reporting on the sexual language and behaviour of patients. Before the 1850s, they rarely mentioned masturbation explicitly by name, referring to it, for example, as that 'morbid habit'.64 Occasionally medical officers remarked that certain expressions, or actions, were too offensive to be recorded even in a medical case book. Yet, while much of the direct record of patients' sexuality/perversity is thus lost, much is conveyed about the extra circumscriptions imposed on this dimension of patients' experience by the asylum regime. Some patients' case notes suggest that the greater vigilance exercised over their propensities to 'self-abuse', by the 1860s, merely enhanced their obsessive and paranoid disorders. Charles Gilmour's case notes, for example, record his fixation with hygiene and thoughts that 'any of the patients with their hands in their pockets [were] . . . masturbating'.65 Case notes indicate that, by the latter nineteenth century, masturbation had come further out of the closet of propriety only to be hurried into the clinical closet.66 Case notes are innately jaundiced, then, in the type of information they record, although this may itself provide quite another eloquent source of insight for the historian, especially into medical discourse and ideologies. This jaundice is a matter not just of authorship, but of function. Case notes were not designed to be complete records of a patients' interactions within the asylum, but rather to be clinical and managerial aids to those treating and attending the patient. Case notes were not written for historians, but for asylum medical staff, and for administrators and officials who required to keep tabs on staff and patients. The questions historians want to ask are often different from those which concerned contemporary medical men and on which basis patient histories were compiled. Any account of patients' experiences through the case note medium is also prejudiced in favour of the wealthy, educated, articulate or extrovert patient. Such patients tended to be regarded as more interesting and to receive more attention from medical officers than others found to be more degraded in their habits. Some patients were simply better at expressing themselves and demanding attention than others. The exceedingly literate (though delusional) George Reid, for example, who spent the last 29 years of his life (1845—74) in Glasgow Royal, receives extensive attention in the case notes. John Tudehope, on the other hand, a 'listless and taciturn' patient, suffering from depression and constipation, whose billeting in the same ward as Reid the latter complained bitterly about, emerges rather anonymously from a terse series of notes.67


267

the idea of two Commissioners in a few hours going into the details of an asylum, examining all the patients, and carefully scrutinizing the elaborate entries relating to several thousand patients in the case-books [as] . . . too absurd.72 V The need for circumspection in publishing the details of patients' case histories was emphatically acknowledged at Glasgow Royal and at other Scottish asylums, lest 'patients might be recognized'.73 This elucidates quite another reason for censoring patients' case histories—although one that had less to do with respect for patients' 'confidentiality' (in the modern sense), than for their families' reputations. Access to case notes was highly restricted, and Glasgow Royal's earliest Regulations also 68

Edinburgh Review, N o . LVI (1817), p. 463; 4th G A R (1818), p . 2 3 . Scottish Lunacy Commission, R e p o r t b y her Majesty's Commissioners appointed to inquire into the state of Lunatic Asylums in Scotland (Edinburgh, 1857), appendix, p. 4 6 3 . Also, see Annual Reports (henceforth ARs) of the General Board of Commissioners in Lunacy for Scotland (henceforth GBCLS) (Edinburgh, 1858-1900), passim; C . C . Easterbrook, The Chronicle of Crichton Royal (Dumfries, 1940), pp. 115, 124, 145. io As in 1864 w h e n they found gaps in Glasgow Royal's case notes; 7th A R of G B C L S (1865), appendix E, pp. 167, 169. ™ 2nd A R of G B C L S (1860), lxvii-lxix; Scottish R e c o r d Office, West Register House, Edinburgh 69

MS MC1/2, 28 Feb. 1860, fols 162-3; GGHB13/5/87, fols 352-3, and GGHB13/6/6, Case No. 548. 72 73

Newth, 'Systematic Case-Taking', p. 255. 6th GAR (1820), p. 9.


The integrity of the case note was partially guaranteed (as well as inhibited) by its function. Case notes were not simply designed for internal readers and uses. They were also intended to act as insurance against lawsuits, and to be available for inspection by government officials.68 This helped to ensure that they survived as well-maintained records, and that patient testimony was preserved, even if primarily as substantive evidence of insanity. It was standard practice for the Sheriff to 'send for the case book' on his visits.69 Yet Sheriffs' reports rarely paid much attention to, let alone criticized, asylum record keeping. By contrast, the Lunacy Commissioners (in accordance with the 1857 statute) inspected the books twice a year and censured incidences of laxity.70 They also consulted the case books in order to assess specific issues, such as individual patients' demands for liberty. Consulting the case book in the case of Margaret McNicol in 1859, who had alleged assault by Glasgow Royal's staff, convinced the Commissioners that her injuries were self-inflicted, while also exposing the Asylum to official censure for failing to safeguard the patient from her own impulses.71 That the Glasgow Royal notes were better maintained after mid-century must have something to do with the more thoroughgoing supervision of the Commission. It probably owes more, however, to the energetic superintendence of Drs Hutcheson, Mackintosh, and Yellowlees during 1838—1901. The persistence of lacunae in the Asylum's case notes appearing without comment in Lunacy Commission reports demonstrates that central supervision was an inadequate insurance against laxity. Some alienists dismissed:

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74

Regulations (1814), 4th-6th, p. 7; Regulations (1823), Nos IV-VI, pp. 8-9. Regulations (1814), 6th, p . 7 ; (1823), N o . V I , p . 9. 76 See e.g. 46th GAR (1860), p. 33. 77 See 45th GAR (1859), p. 33. 78 See 50th GAR (1864), pp. 9-10. See, also, cases of two 'hermit' sisters, 51" GAR (1865), pp. 8-9, 28-9. 79 4th GAR (1818), p. 10. 75


outlawed the publication of cases except by, or with the authority of, the Physician or Directors.74 The improper disclosure of patients' names was prohibited. So too was the mentioning of 'any circumstance . . . which may tend to hurt the feelings of the friends or relations of any Patient'.75 The latter ruling manifests the enhanced appreciation of the protective role of the asylum as fostered by the philosophy of moral management. Yet it also reflects the limitations of contemporary regard for the patient's viewpoint. It not only subordinated patients' feelings to (while implicitly identifying them with) those of their relations, but it failed even to mention patients' feelings. While press coverage was eagerly courted by Glasgow Royal's managers, publicity was strictly tailored to promotional objectives. The press were invariably only invited to the Asylum's entertainments and were required to honour the same sub rosa rules in order to preserve patients' families from scandal and to present the best possible profile of the Asylum to the outside world.76 I have discovered only one patient being explicitly identified in Glasgow Royal's Annual Reports—Mary Westcott, an infanticide. And Westcott had already (prior to her admission in 1859) been named in the press, which had turned her case into something of a sensation.77 Just as the shocking nature of insane crime in earlier cases, like the would-be regicides, Margaret Nicholson and James Hadfield, could make their case histories public property, Westcott's crime and the furore surrounding it justified the Asylum in publishing her case. The preservation of anonymity was sometimes only a flimsy mask for the confidentiality of patients and their families. Unusual cases, whose histories had already become the object of public concern, were sometimes publicized in the Annual Reports in a journalistic fashion posing few problems for identification and with little other intention than that of gratifying public curiosity. The 1864 Annual Report legitimated telling the story of a Polish officer, who had been confined at Gartnavel five years earlier,78 because his case had been 'minutely enquired into' by the Government and a few notables. Patrons and the public evidently required satisfaction as to the outcome, while the Asylum might bask vicariously in the light of attention from such distinguished quarters. In the vast majority of cases, however, the Asylum seems to have respected the confidentiality of its patients. Confidentiality was one of many reasons that administrators and clinicians (as well as relatives) had for obfuscating patients' case histories. It is no surprise to find ample evidence in case notes countervailing the generalizations made about patients in annual reports. One might refer specifically to the publicity given to volitional seeking of refuge in the asylum, and the lack of coverage accorded patients whose case notes record them resisting and complaining about their committal.79 Yet this is another example of how case notes may be used by


269

historians—to test the public relations of the asylum against mundane reality, or how far patient testimony was transformed into a rhetorical device for serving the institution. VI

""Seeesp. ibid., pp. 9-10. 81 Regulations (1848), No. 10, p. 27; Regulations of the Glasgow Royal Asylum for Lunatics (Glasgow, 1874), N o . 17, p. 12; Regulations (1899), N o . 8, p. 13. 82 7th G A R (1821), p. 14. 83 See e.g. 9th GAR (1823), pp. 11-12. 84 47th GAR (1861), p. 38. 85 3rd G A R (1817), p. 8; J. Andrews, 'Bedlam Revisited: A History of Bethlem Hospital, c l 6 3 4 - c l 7 7 0 ' (unpublished P h . D . thesis, University of London, 1991). 86 4th G A R (1818), pp. 8 - 9 .


A significant part of the case note corpus is comprised of patients' correspondence and jottings. This large body of writings allows the historian to deal rather more directly with patient testimony. Of course, surviving testimony can represent only a fraction of patients' total output during their confinement. What does survive, furthermore, must be interpreted against the criteria for interception and selection.80 These criteria, nevertheless, may tell us a great deal about the Asylum's medical and administrative practices, and about contemporary social attitudes to the insane. Until the 1840s, patients' correspondence seems to have been subject to the censorship of the lay or Apothecary-Superintendent, with advice from medical staff and with assistance from asylum attendants. After the 1840s, this authority was placed in the hands of the Physician-Superintendent, who became the principal and ultimate arbiter of patients' communication with the outside world. The Asylum's 1848 Regulations laid down that 'all letters or parcels addressed to or proceeding from Patients, shall be disposed of by him'. This ruling was not significantly altered by the revised Regulations of 1874 and 1899.81 Throughout the period, however, decisions made by superintendents were also referred to the sensibilities of patients' relatives and correspondents. Letters were frequently stopped because deemed 'not proper to be despatched',82 for fear of causing offence to addressees. While numerous complaints were received about letters getting through, asylum ideology was particularly sensitive to demands from relations and the public for discretion and decorum.83 Despite its independent sources of finance, the Asylum also relied on the continuing contributions of its moneyed patrons, and could not afford to alienate their feelings. 'The feelings and wishes of relatives and guardians' were also respected when it came to patients' attendance at asylum entertainments.84 Yet, even in the early nineteenth century, the influence of patients' friends on the asylum environment was very much constrained by the prevailing canons of mental medicine. Some visitors demanded that writing paper be withheld from patients (as it had often been at eighteenthcentury madhouses like Bethlem).85 However, paper was 'still furnished to those who enjoy the composing of letters'.86 It was failure to abide by internally imposed

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87

7th GAR (1821), p. 14. •"* 4th GAR (1818), p. 8. 89 3rd GAR (1817), pp. 8-9. 90 40th GAR (1854), p. 36. 91 Ibid. p. 37.


regulations that dictated punishments and privations for 'the letter-writers'— medical priorities inside the asylum sometimes countermanding social proprieties outside. However, 'many' patients' letters were intercepted, although it is impossible to gauge exactly in what proportion. What these letters can say about patients' histories is plainly conditioned by biases in this interception process. Letters to asylum medical staff were naturally more liable to survive. Letters addressed to the Physician-Superintendent comprise a very large part of extant patient correspondence—signifying the real and perceived power the officer had over patients' lives. Only a minority of letters, however, were considered sufficiently interesting to be inserted in the case notes. Maybe such correspondence is more representative of patients' interaction with medical staff, of the extreme end of patients' productions and of asylum censorship, than of the balanced range of patient testimony. A patient's letters were also preserved 'as a record of the state of his mind' and as a potentially 'useful document' should litigation ensue87—criteria also strongly influenced by medical concerns and still informing policy at modern psychiatric institutions. However, a determination to adhere to the libertarian principles of moral therapy, or 'removing from the Asylum . . . all appearance of a prison',88 ensured some degree of relaxation about withholding patients' correspondence. While, the Directors might have hoped to intercept more letters, it was deemed preferable 'to allow some foolish ones to escape, than to adopt measures of too great severity', such as 'searching every visitor'.89 There was thus a considerably random element involved in the passage of patients' letters out of the asylum and, vice versa, in their retention in the case notes, mediated by the degree of regard felt for relatives' peace of mind and for mitigating the extent of sequestration in the asylum. In Scotland, apparently as a matter of customary practice rather than law, asylum patients were permitted 'unopened and unexamined' correspondence with the Sheriff. Such was accepted as a necessary means for patients to 'communicate their grievances, real or imaginary'.90 Beside mediating complaints and achieving demands, it was thus that patients could obtain personal interviews with the Sheriff, with the intention of proving their sanity and gaining their discharge. The Sheriff, having normally issued the original warrant for admission, had meaningful authority over a patient's continuing confinement. Unimpeded access was most strongly endorsed at the time with reference to libertarian arguments. Alexander Mackintosh (Physician-Superintendent, 1849—74) emphasized that 'any man whose liberty is invaded' should have 'means of legal redress' permanently open to him.91 It is a libertarianism which stands in stark contrast, however, to the Directors' earlier and enduring commitment to censorship of patients' mail. Rather unfortunately, furthermore, very little of this side of patients' correspondence survives.


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VII Clearly, then, case notes and patients' letters were selected and censored with specific purposes in mind, both before and after being written. The reproduction and paraphrase of these sources in annual reports is one of the best examples of how case notes became case histories. Which histories were chosen depended very much on the didactic purposes of the annual report. Generally, these case histories legitimated therapeutic ideology, serving to explain and justify mortalities at the Asylum, and to demonstrate the efEcacy of specific treatments, like the whirling chair.96 Histories were told of spectacular cures achieved after many years and against all the odds, and of unsuccessful but affecting cases for whom everything possible had been done.97 Tales of patients who chose to come to, to remain at, or to return to, the Asylum, advertised how it was performing its designated role as both centre of cure and refuge.98 Accounts of others who had long been cared for, or been able to find a functional niche in the Asylum's recreational and occupational life, emphasized the tolerance and homeliness of the institution.99 92

29 and 30 Viet., Cap. 51, XVI. Minute Books of the GBCLS, Scottish Record Office, West Register House, Edinburgh, MCI/2. 94 Journal of Mental Science, X X X V I I (1891), p . 506; An Act t o Consolidate Certain of the Enactments Respecting Lunatics (1890), 5 3 Viet., C h . 5, Sect. 4 1 . 95 Ibid. 96 See e.g. 5th GAR (1819), pp. 4-5; 6th GAR (1820), p. 8; 10th GAR (1824), pp. 15-16. 97 See e.g. 2nd GAR (1816), p. 16; 26th GAR (1840), pp. 4-5; 39th GAR (1853), p. 28; 44th GAR (1858), pp. 26 and 28-9; 46th GAR (1860), pp. 31-3; 47th GAR (1861), p. 8; 78th GAR (1891), pp. 12-13; 79th GAR (1892), p. 11; 81st GAR (1894), pp. 11-12. 98 See e.g. 4th G A R (1818), p . 8; 22nd G A R (1836), p p . 6 - 7 ; 24th G A R (1838), p p . 7 - 8 ; 26th G A R (1840), pp. 4 - 5 ; 44th G A R (1858), p. 19. 99 See e.g. 52nd G A R (1866), p . 27. 93


The 1857 Lunacy (Scotland) Act did not rule on patients' correspondence. Patients were not accorded the protection of law and legal penalties for their freedom of communication with the new, centralized Scottish Lunacy Commission until the passing of the 1866 Lunacy (Scotland) Amendment Act.92 Even this act guaranteed patients very limited freedoms. Commissioners could send letters to patients without marking them 'Private'. More reasonably, perhaps, they had it at their discretion to send copies of all such correspondence to the PhysicianSuperintendent. Few patients' letters to the Commissioners survive, while responses from the Commissioners are mostly extant only in a minuted form93— emphasizing another area of deficiency in the case history record. In England, patients enjoyed freedom of correspondence with the Lord Chancellor as well as the Lunacy Board. Regrettably, however, by the Lunacy Act of 1890, heads of English establishments were (with certain exceptions) given virtual carte blanche to destroy patients' letters they adjudged 'unfit for publication'.94 It is unlikely that historians would breathe the same sigh of relief underlying the editors' comments in the. Journal of Mental Science at being spared poring over so much 'insane literature'.93

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Exceptionally, Annual Reports quoted directly from case notes, and from patients' mouths or pens. The 1820 report, for example, reproduced a lengthy statement from one patient, made to excuse his misconduct: In consequence of some strange power, which you have over me, I am obliged to obey you in all my motions. I often cannot . . . even stir a finger, unless you please; if, therefore, I broke the windows, it was your fault, not mine . . . .

100

6th G A R (1820), p . 10. See, also, 8th G A R (1822), p . 12,fora similar case. 8th GAR (1822), pp. 10-11. 102 Ibid. pp. 12-15; 24th GAR (1838), pp. 5-6. See, also, 8th GAR (1822), pp. 15-16. 103 9th GAR (1823), pp. 16-17. 104 14th GAR (1828), pp. 11-12. 105 SeeJ. Andrews, 'The Patient Population', inj. Andrews and I. Smith (eds.), 'Let There Be Light Again': A History ofGartnavel Royal Hospitalfrom its Beginnings to the Present (Glasgow, 1992), c h a p t e r 7 . 106 See e.g. 3rd GAR (1817), pp. 6-9; 4th GAR (1818), pp. 4-7, 9-10; 5th GAR (1819), p. 10. See, also, 8th GAR (1822), p. 12, for the fun poked at a patient who devised his own nosology of insanity. 101


Such quotations served both as amusement for readers and as an illustration of the perversity of madness. More interestingly, the quotation vividly encapsulates the highly moralistic framework within which pathological psychology and responsibility were interpreted. It also suggests the strict conformity which did prevail at the early Asylum. When the asylum regime endorsed a rather god-like conception of the Physician, whose 'commands' were supposed to seem irresistible, 'yet favours and indulgences appear to flow from him',101 is it surprising that patients felt under the Physician's thrall? In 1822 and in 1838, the Directors quoted at even greater length from their patients' letters. One patient's testimony was used to illustrate the strength of residual intellectual and moral powers exhibited in insanity by some patients, and the other to controversially support the value of divine service for the insane.102 Yet the ears of management were only half attuned to the meaning or legitimacy of patient testimony. While the Directors were impressed by the elegance of the former patient's prose and his continuing trust in God, they also emphasized the transience of such 'lucid intervals' and the insignificance of such lgleam[s] of reason'. The very cogency of patients' writings were seen as proof of the dangerousness of judging a case solely from such sources.103 On the other hand, the excessive tendency to dismiss lunatics' testimony, and to reject 'the Lunatic .. . [as] an incompetent witness of what passes around him', was also, in principle, appreciated.104 Diagnosing the problem, however, was a little different from acting on it. Case notes were certainly used to record patients' complaints and do indeed furnish evidence that their grievances were attended to. However, such records were minor, if not incidental, features and functions of the case note. 105 At other times, histories simply served the diversionary function of amusing subscribers, and in a way that regularly verged on patronizing ridicule—like the skit on one ex-military patient portrayed ordering his cohabitants about, or on another engaged in framing his own Act for Regulating Madhouses.106 Another characteristic example recounted a patient's expression of'great chagrin' when his letter was not delivered to the Russian Emperor: ' . . . not so much for his own


107

4th GAR (1818), p. 9. 8th GAR (1822), p. 17. Ibid. p. 11. 110 Ibid. p. GAR (1838), pp. 5-6. iDia. p. 16; IO; n24th ztcn ^IOJO;, pp. 1D—O. •11 c n Af\*u o o/vtv. /iQC/n «« in_i ' " E.g. 40th GAR (1854), pp. 10-11. 112 See e.g. 4th GAR (1818), p. 5; 9th GAR (1823), p. 10. 113 Edinburgh Review, LVI (1817), p. 463. 114 See e.g. 7th GAR (1821), pp. 14-15; 10th GAR (1824), pp. 15-16. 115 9th GAR (1823), pp. 16-17. 116 50th GAR (1864), pp. 22, 38-9. 108 109


fame, which, he observed, was sufficiendy established, as for the loss sustained by Russia'.107 The regime could be particularly responsive to patients' yearnings when expressed in an educated and artistic vein. Patients' literary productions were often quoted with pride and awe. The verses of one patient, for example, who imagined finding a paradise outside the Asylum, were sensitively perceived as genuine escapism arising from the 'irksomeness of his present situation'. Yet, this only went to confirm the Directors in a very traditional attitude towards the insane— namely, 'pity' mingled with 'mortification that human beings should be so humiliated'. The condescending, paternalistic stance often adopted towards patients' outpourings wholly accorded with the philosophy of moral management, which espoused the exercise of a 'parental kind of authority', designed to gain patients' 'confidence' whilst maintaining 'complete ascendancy' over them.109 Patients who accepted such a relationship were quoted with approbation in the Annual Reports, as was one patient who compared the relationship with that of 'school boys . . . to their parents or guardians', and another who complimented the way sermons were 'brought down to a level with the weak capacities of the Patients'.110 The main purpose of presenting case histories and patient commentary was promotional: to fortify subscribers' and patrons' faith in the institution, to arouse sympathy for patients in so far as it was in the institution's interest, and to sustain or elicit donations. 1 " Until the 1840s, with the inclusion of PhysicianSuperintendents' reports in the Annual Reports, the Directors denied that such were designed for 'medical disquisition'.112 On the contrary, they were explicitly for the 'benefit' of contributors. Likewise, case notes too were viewed as 'instruments of public [my emphasis] instruction'.113 Case histories were deployed to combat public prejudices about insanity, to stress, for example, the hazy bounds of rationality and the 'variety' of'the forms of lunacy',114 or to repudiate the belief 'that all who are confined in a mad-house, must be either stupid, or ferocious'.115 During the second half of the century, however, Glasgow Royal's medical officers were substantially more prepared to utilize case notes to educate not only the public about insanity, but also medical trainees and their professional colleagues. From 1842, the date of the first 'Physician's Report', greater readiness was shown to publish the clinical details of individual cases, and to emphasize what was clinically exceptional about them. As Mackintosh observed in 1864, the Physician-Superintendent's reports were largely 'based . . . on the Case-books'.116 Case notes and case histories were now deployed more directly than before to

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117

40th GAR (1854), p. 37. 28th GAR (1842), p. 57. E.g. ibid. pp. 49-57; 29th GAR (1843), pp. 49-70; 42nd GAR (1856), pp. 29-31; 46th GAR (1860), p. 30; 49th GAR (1863), pp. 42-6; 50th GAR (1864), pp. 43-5. 120 A. Ingram, The Madhouse of Language. Writing and Reading Madness in the Eighteenth Century (London, 1991), p. 64. 121 J. G. Fleming, Remarks on the Pathology and Treatment of Ramollissement of the Brain (Glasgow, 1833). 122 40th GAR (1854), pp. 28-31; 46th GAR (1860), pp. 25-9; 50th GAR (1864), pp. 36-8. Case histories were cited for similar reasons much earlier than this, however. See e.g. 19th GAR (1833), p. 4; 21st GAR (1835), p. 5; 22nd GAR (1836), p. 5; 24th GAR (1838), p. 7; 26th GAR (1840), pp. 6-7. 123 40th GAR (1854), p. 31. 124 42nd GAR (1856), pp. 26-8; 44th GAR (1858), pp. 23-5; 45th GAR (1859), p. 33. 125 47th GAR (1861), pp. 31-5, 39. 118 119


proselytize the profession at large, and to nurture and extend professional knowledge and status. Mackintosh (the first superintendent to take medical students into the Asylum's wards) used patient histories as didactic clinical material for the training of medical students and assistants. This new generation of clinicians also exerted themselves to ensure 'that the results of post-mortem examinations will be more freely given [in annual reports] than hitherto'.117 These developments reflected wider trends in mental medicine towards a greater emphasis on pathology. It was hoped that the more detailed documentation of individual cases' pathological signs might elucidate the subject in general.118 Accordingly, from the 1840s, post-mortems appeared much more regularly in Glasgow Royal's Case Notes, while their details were conveyed more often from case notes to annual reports.119 Of course, autopsies had long been a significant ingredient in medical case histories. Some eighteenth-century medical treatises, like those by John Haslam and Bryan Crowther of Bethlem, presented histories as simply 'preliminaries to autopsy'.120 Glasgow Royal's Surgeon, John Fleming, published a host of histories in this manner in his 1833 treatise on softening of the brain.121 The increasing attention given to autopsies in case descriptions from nineteenth-century asylums tended to be to the detriment of space allotted to reportage of patients' language and experiences. Hutcheson's presentations of patients' prior histories in annual report post-mortems amounted to but a few lines. Separate Pathological Registers were introduced to the Asylum in 1889 and autopsy details almost disappeared from other asylum records from this date. Mackintosh used case histories perhaps more brazenly than any of his predecessors or successors—in particular, to assert medical expertise, and to discourage the 'interference of relatives in the removal of Patients prematurely'.1 He cited cases cured after long probations, or removed at family insistence only to worsen, or die, as propaganda regarding 'the danger [of] . . . opposition to my [and other experts'] advice'.123 Using histories to support his own stance on forensic psychiatry, Mackintosh argued for the insufficiency of cognitive criteria such as ability to reason or premeditation in deciding guilt or sanity.124 Case histories of a few individuals were given at remarkable length, like that of the editor of the Gartnauel Gazette (the Asylum's patient magazine), and that ofJames Frame, who became one of the great promoters and success stories of the Asylum.125 Such


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E.g. 46th GAR (1860), pp. 26-8. 45th GAR (1859), p. 35. 128 See e.g. 71st GAR (1884), p. 11; 78th GAR (1891), pp. 12-13; 79thGAR (1892), p. 11; 81st GAR (1894), pp. 11-12. 129 See e.g. 62nd GAR (1875), pp. 23-4. 130 See e.g. 63rd GAR (1876), pp. 13-14; 64th GAR (1877), pp. 14-15; 67th GAR (1880), p. 11; 71st GAR (1884), p. 10. 131 E.g. D. Yellowlees, 'Remarks on the Recent Trial for Murder of Alexander Milne', Edinburgh Medical Journal, VII (1862), 912-21; D. Yellowlees, 'Homicidal Mania: a Biography; with Physiological and Medico-legal Comments', Edinburgh MedicalJournal, VIII (1862), 106-24; D. Yellowlees, On the Criminal Responsibility of the Insane, reprint (Glasgow, 1874); D. Yellowlees, 'The Plea of Insanity in Cases of Murder. The Case of Tierney', Journal of Mental Science, XXI (1876), 551-66; D. Yellowlees, 'The Plea of Insanity in Cases of Murder—Cases of Macklin and Barr', Journal of Mental Science, XXII (1876), 226-40. 132 62nd GAR (1875), p. 23. 127


special attention was normally reserved to 'star' patients of exceptional talents, eccentricities or pathology. Often, case histories of this type did little more than register the appreciation of Physician-Superintendents at patients' ability to function in many areas of their lives, despite extreme difficulties.126 Histories increasingly served, however, to couch important new 'facts' in medicine, and to endorse or criticize controversial medical treatments and aspects of the Lunacy Law. The Gazette editor's case history, for example, permitted Mackintosh to advertise the utility of the stomach pump (previously outlawed at the Asylum), and to expose the inequities arising from the illegality of voluntary admissions. Mackintosh still recognized considerable limits to what could be discussed in the Annual Reports, nevertheless, both in terms of their generalizing intent and the limitations of their readership. On the whole, for example, he avoided entering 'into any [great] detail' on the subject of treatment.127 Yellowlees was also to use case histories to support the use of artificial feeding.128 Indeed, Yellowlees' annual reports turned case notes into case histories in similar ways to Mackintosh's—in particular, to illustrate the danger of delaying admissions, to discredit popular misconceptions about madness and to assert psychiatric expertise.129 Yellowlees employed case histories in these reports to discuss homicidal insanity, insanity with typhoid fever, folie a deux, and other contentious topics.130 Yet Yellowlees' discussions of histories within this medium were much more terse than Mackintosh's. His high public profile in medical associations outside the Asylum and his numerous articles for medical journals meant that he utilized case notes in different areas and ways from his predecessor. Mackintosh wrote very little and his activities were largely confined to the Asylum's inner realm. Yellowlees, by contrast, used his clinical experience to publish a range of histories in the medical press, in particular in the area of forensic psychiatry.131 Much more than his predecessors, Yellowlees emphasized the impenetrability of medical subjects to a lay audience, averring that 'some . . . are so technical' as to be appropriate only for 'the pages of a medical journal'. 132 Under Yellowlees the case history became something of an esoteric medium, much less open to the perusal of those outside of the medical profession. Yellowlees' appointment as first Lecturer in Insanity at Glasgow University in 1880 meant that the case notes were

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VIII In his recent study of writings on madness in eighteenth-century England, Allan Ingram has underlined how much they endorsed a silence about madness.134 Medical writings in particular rarely reproduced the language of the insane, except to show it for the raving that it was. If the madman was divided from himself, what he said could not be trusted. It was meaningless, except as the manifestation of disease, or 'further evidence of insanity'.135 On the other hand, Ingram and other commentators have also emphasized the 'cracks in the walls' of silence, how sometimes a patient was accorded the 'privilege of speaking for henelf, rather than being simply the reported set of symptoms so common in medical case histories'.136 Contemporaries from Shaw and Cheyne to Erasmus Darwin validated their patients' individuality and experience, while philosophers and physicians began to appreciate the need for arriving at as complete a history as possible of an individual's mind if one were to fully understand mental functioning. A concurrent concern with the putatively more scientific knowledge derivable from the classificatory and evolutionary methodologies of natural history, anatomy and botany, argued the importance of also arriving at an anatomy or natural history of mind. The psychological stresses of moral therapy and the enduring influence of sensationalist cognitive approaches on British attitudes to insanity had encouraged clinicians, from early on in the nineteenth century, to give a limited weight to the 133 See e.g. Alistair Burns, 'Psychiatry in Glasgow in the Latter Half of the Nineteenth Century and Beginning of the Twentieth century' (unpublished dissertation for Diploma in History of Medicine, Glasgow, 1984). Ingram, The Madhouse of Language, esp. pp. 16—43, 48. For a provocative account of the disappearance of the patient's narrative in the eighteenth century, see M. E. Fissel, Patients, Power and the Poor in Eighteenth-Century Bristol (Cambridge, 1991). ' 5 Bums, 'Psychiatry in Glasgow'. 136 Ibid. esp. 42-76.


conceived of more than ever before as primary material for the instruction of medical students. Explicitly instructed by the Medical Faculty not to infringe upon existing teaching, Yellowlees had undertaken to teach entirely from the raw clinical material at his disposal on the asylum floor.133 As a result of these developments, the case history assumed a much more minor place in the Annual Reports under Yellowlees. Individual patients and their case notes were rarely quoted directly, or even referred to, but became fundamentally associated with the discourse of scientific medicine, with psychiatric teaching and with learned disputation in medical journals and societies. Case histories were now less about communicating with the public, than about communicating with one's professional peers, extending the bounds of expert psychiatric knowledge and establishing an alienist's reputation. The Directors' Annual Reports had also been severely curtailed since the first half of the century, rarely now describing particular cases and becoming little more than cursory bulletins on changes in the Asylum's environment and staff, and on its administrative and financial footing.


137

See e.g. 8th GAR (1822), p. 15; 22nd GAR (1836), p. 4. J. Haslam, Illustrations of Madness (London, 1810) (ed.) R. Porter (London; New York, 1988). 7th GAR (1821), p. 14. 140 9th GAR (1823), pp. 14-15. 141 Ibid. 142 22nd GAR (1836), pp. 4-5. 138 U9


language of mental disorder. It was not so much that the content of patients' speech and delusions per se was important. It was rather that (i) a record of delusions was important evidence of continuing derangement, just as their absence, or repudiation by the patient, was an important acid test of restitution; and (ii) that an accurate register of such signs might elucidate the special character, habits, and constitutional make-up of a patient, and thus guide an understanding of the patient's affliction. This appears particularly necessary to grasp in any assessment of the contemporary case record in the first half of the century. Abnormal speech and delusions were interpreted from a perspective which emphasized the formative, almost physical impression perceived objects and strong sensations had on the mind. It was a perspective which stressed the deep-seated fixity of ideas, as well as of any confusion of ideas. The comment was often made in Glasgow Royal's records that 'one of the surest signs of amendment is an admission by the Patient, of fallacy in any of his former illusions'.137 This was an old, established psychiatric truism. It says much about the continuing influence of sensationalist psychology, but also suggests one area of utility for the case note record. The case note could be a useful memorandum for registering such changes in patients' delusional systems. Yet early nineteenth-century asylum practitioners were rarely interested in interpreting this mad talk. Patients' testimonies tended to be referred to in a matter of fact way as exhibiting pathology, as proofs, or illustrations, of madness. Typical of such treatment is James Tilly Matthews's case history, presented by the Bethlem Apothecary, John Haslam in 1810, and appositely entitled Illustrations of Madness}39 Similarly, said to be 'characteristic' or to 'speak for itself, a patient's letter required and generally received no further elaboration from clinicians and administrators at Glasgow Royal. It was acknowledged that 'some Patients exhibit, in their letters . . . wonderful . . . consistency and acuteness'139 and that 'much' could 'be learned from' their 'conversation and writings'.140 Often what was learned, however, merely validated traditional and pre-existing judgements, as when two patients' accounts of their admissions were quoted in an 1822 Annual Report to support the efficacy of removing lunatics from familiar surroundings.141 It was still somewhat rare, furthermore, that listening to patients and charting their delusions was acknowledged as a way of entering into their minds or gauging the appropriate therapy. Early Annual Reports put significant store in psychological therapeutic techniques, such as 'corrective exercises for the mind'.142 Seldom, however, do asylum records register attempts to counsel patients out of their madness and delusions. This was mostly recognized as a futile exercise, which would merely serve to aggravate the delusion by drawing attention to it. Lunatics were conceived of as by nature 'obstinate', their commonly volatile reactions to contradiction as further confirmation of the inveteracy of their mental

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4 Oct 1844. On admission . . . Wished to be informed why he was brought here and was anxious to know whether or not he was insane. Complained very much of the treatment he had received when in Glasgow. Knew every movement of his was watched . . . 5 Oct 1844. Declares that he has not slept a moment during the night. Is up and dressed but looks very excited . . . Says that Mr Stirling of Cadder has done him serious injury . . . stated that the injury being great and Mr Stirling being arichman . . . the least he could give him was ,£30,000 or ,£40,000 . . . that marriage would put an end to his troubles—that he had repeatedly written his views to Miss Stirling but has received no answer—that her father as a part of his system, intercepted his letters. . . that Dr McFarlane & Dr Moffat both saw him twice at least—that he is quite sane & that both these medical men knew it—that he has been hurried here for the purpose of burying his wrongs in oblivion . . . 6th Oct. 1844. Is today rather excited. Complains that he has not slept during the night wishes to have a man to attend him constandy, but more particularly to walk out with him as he has always been in the habit of taking violent exercise—Feels the want of it already & knowing it will play the devil with his constitution—Talks in the same declamatory tone—Mind teeming with fancies—This morning wrote the following letter to Dr McFarlane . . . Dear Sir, it is perhaps owing to my not being so explicit as I ought to have been that I never intended this contest regarding the state of my mind should be closedfreeof a wife . . . 146 143 144 145 146

Ibid. Ibid, and 25th GAR (1839), pp. 4-5, 10. GGHB13/5/1, fol. 19, case ofjanet Craig. 28 May 1816. GGHB13/5/38, fols 167-8.


aberrations.143 False impressions were to be countered not by contrary proof, but by stronger, unconnected impressions. In this sense, the precise nature of a patient's history was less pertinent than its antitheses. When insanity was so frequently seen as a 'dream', defined by its 'prevailing delusions' from which the sufferer needed his 'attention' rousing and 'withdrawing', there was little point entering into discourse with the content of that dream.144 Only exceptionally do Glasgow Asylum's case notes record direct psychological intervention being used, as when one female patient was taken to town to prove to her that Glasgow had not been destroyed as she had believed.145 Nor, for the same reasons, was it so imperative to maintain a full or accurate record of patients' ravings. Direct and extensive patient testimony is conspicuous by its absence from the case notes during 1814-40. From around the 1840s to the early 1870s, however, the Glasgow Royal notes become a much more literal and reliable source for patients' own views of their histories. Despite all their limitations, the apparent faithfulness of much of the reportage and the amount of patient testimony that is reproduced verbatim are striking. This development was plainly connected with the medicalization of the case record; with the establishment of a more full-time medical department at the Asylum; with the firm endorsement of the Physician's role as custodian of the case notes, and with the merging of the authority of Physician and Superintendent in one man. Those who wrote the case notes were now less concerned with recording infringements of house rules by patients and counter-tactics, than with meticulously recording patients' various peculiarities, pathologies, and symptomatologies, to assist diagnosis, prognosis, and treatment. George Reid's case notes typify this more literal style of note taking:


he is coherent and seems quite to understand his position declares that he should never have been brought here and is a little discontented he was inclined to be a little delirious, muttering and confused but could be got to answer questions by a little patience and repetition.147 Case notes became more impersonal, aloof from the patient, and the patient more objectivized as the organizing principle of clinical enquiry. They catalogued in much greater detail every physical symptom presented by patients, every sign of underlying organic morbidity—noting bodily ailments, paralysis, fits, wounds, abrasions, and excretions, how the patient had slept, and abnormalities or alterations in the patient's pulse and temperature. By the century's end, temperature charts were appearing in notes, especially those of patients who had died in the asylum, thus measuring more graphically the process of decline. These changes were clearly associated with the enhanced emphasis on a more clinical, 'scientific' approach to mental medicine. They also suggest how the highly organic interpretations of mental illness dominating late nineteenth-century alienism encouraged a propensity to ignore, or downgrade, patients' impressions and experiences. Patients' letters were occasionally affixed to their case notes in this period. Yet such were a far from pervasive feature of the notes and rarely received more attention than a passing reference. Typically, in 1893—4, in the case of Isabella M., the medical assistant commented as follows: 'She writes at times very incoherent letters some of which are appended'; or 'She writes very incoherent letters to her family'.148 The majority of testimony by this and other patients was similarly dismissed as 'the usual nonsense', 'containing proof in abundance of. . . insanity' and so on.149 When it came to deploying case histories outside of asylum records, also, patient testimony tended to be a parenthesis rather than a major subject of enquiry, a paraphrase rather than a quotation. Yellowlees, like most contemporary alienists, 147 148 149

GGHB13/5/63, fol. 477, 31 December 1884-6 January 1885. Ibid., fols 519-20, 24 July 1893 and 24 March 1894, and appended letters. Ibid., fols 25-6.


This report, like those for many other patients, goes on in the same vein throughout the patient's stay, conscientiously recording his own words with very little apparent distortion. Significantly, clinical assessments and prescriptions, and other judgemental comments, are kept to a minimum, often inserted at the very end of the case note entry. From the 1870s, however, under David Yellowlees' superintendence, the style of the case note altered again. Direct patient testimony virtually disappeared from case-taking, which became a much more clinical, detached discipline. Patients' speech and writing were almost invariably recorded in the second-person, as the observations of medical assistants. When the language of patients was spoken of, it was referred to evaluatively, as, for example, 'incoherent', 'confused', 'violent'. Rarely was it allowed to speak for itself. Whether or not, and in what tone, patients answered questions became more important than precisely what they said. It was recorded in 1885 of Robert Clark, for example, that:

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IX This article has argued for the richness and utility of case notes as a source for historians of psychiatry. It has also emphasized, however, how problematic these records are. There are numerous deficiencies in the comprehensiveness and integrity of the case record, including inter-textual inconsistencies and sins of omission, and areas of bias and censorship. These problems were profoundly mediated by social proprieties and medical ideologies. Using case records successfully requires comprehending how they were generated and kept, how and why their format changed over time, and what functions they served. The necessity of setting the case note account against other available sources was also stressed. Legal and parochial records, admission papers and other patient records provide information not only supplementary, but sometimes contradictory, to that extractable from the case notes. Examples of such discrepancies 150 D. Yellowlees, On the Criminal Responsibility of the Insane, p. 3; D. Yellowlees, On Disorders of the Mind (Glasgow, 1881), p. 198. bl Ibid, and D. Yellowlees, OH the Causes and Prevention of Insanity, reprint (Glasgow, 1885), p. 42. 152 D. Yellowlees, 'Cases of Macklin and Barr', esp. pp. 231-2. See, also, D. Yellowlees, 'Case of Tiemey'.


was convinced as to the hereditary, organic roots of mental disorders.15 He saw mental symptoms as little more than signs of underlying structural disorder. Yellowlees clearly recognized the case history as important, emphasizing that the 'occurrence' of mental disorders 'is determined by special circumstances in the lifehistory of each individual'.151 Yet he was less concerned with the immediate psychological and environmental aspects of patients' histories, than with the broader contexts that had contributed to the hereditarily morbid organism. Thus, Yellowlees paid much attention in his published cases to the family history of patients, and to the physical signs and causes of nervous disease. Clinicians like Yellowlees regarded heredity as the single most important factor in insanity's aetiology. Not just evidence of insanity in immediate relations was pertinent to the case history; so too was every sign of peculiarity or nervous weakness, from flightiness and querulousness, to drunkenness and epilepsy, whether in parents and brothers, or in cousins, aunts, and uncles. It was in forensic evidence that patient testimony was rather more significant in the late nineteenth-century psychiatric case history. Indeed forensic cases were often decided on exactly what a plaintiff had said at, and after, the time of a crime. The faithful reproduction and close examination of such testimony was generally deemed absolutely necessary for deliberation as to responsibility. In his survey of the Barr case, for example, Yellowlees quoted extensively from the accused's own writings, which, he maintained, 'may be tolerated for the sake of what they revealed about 'the writer's mental condition'.152 However, it was still the (more tolerable) testimony of other witnesses, rather than of the accused, that received most attention and on which insanity defence decisions tended to turn.



were offered as both a counsel of caution and as exemplary of the genuine insights available from close textual comparison. A number of different purposes were served by case notes. They were often quoted from in annual reports to bolster outside support for the asylum. Case notes were also records for the purposes of administrative, legal, and central oversight of the asylum and its patients. Yet such oversight was often inadequate insurance, either that asylum records were properly maintained, or that cases were thoroughly dealt with. The medical functions of the case note, including the recording of data pertinent for diagnosis, prognosis, and therapy, have also been addressed. I have argued for the greater prominence of the latter functions of the case note record as the period went on. A central theme of this article has been how case notes and other asylum records became case histories, in particular through the selective reproduction of patients' histories in annual reports. Case histories were deployed for promotional and educative purposes, to generate public support and funding for the asylum. Case histories also served the purposes of amusing subscribers and satisfying public curiosity. The influence of patients' relatives on producing the case history is a measure of the asylum as a negotiated entity, more sensitive to the demands of its patrons than its patients. In addition, case histories were utilized to assert medical expertise, to nullify the threat of excessive interference from patients' friends, and to demonstrate the efficacy of certain treatments. While at other times patient testimony was often distorted and ignored, from roughly the 1840s until the early 1870s, such was integrated as a vital constituentof the case record at Gartnavel Royal. Patients were often quoted verbatim, and regularly had their writings reproduced and appended. Medical officers were less interested in interpreting patients' symptomatology, than in furnishing demonstrable proof of mental disorder. Yet, with the objects (inter alia) of bolstering psychiatric knowledge, officers were required to keep a conscientious note of patients' doings and sayings. I relate this trend to the inauguration of a more dominant medical department within the asylum and the greater cachet placed by medical men on compiling a comprehensive account of patients' histories. It was a trend strongly informed by classificatory emphases in other disciplines and the prevalence of approaches to insanity that gave more space to psychological and environmental influences. By contrast, the heightened organic emphases and the scientific interests of late nineteenth-century psychiatry made the case record a much more detached, clinical entity. From the 1870s, case histories virtually disappeared from annual reports and became more exclusively the material for medical journals and textbooks, for the training of medical students, and for disputation with the psychiatric (and legal) profession at large. Patients' language and thought processes were now much more the subject of evaluative commentary, with verbatim quotation assessed dismissively by clinicians. Patients became once again the rather silent objects of medical enquiry, the content of their speech often less significant that the fashion in which it was expressed.

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