Mania, dementia and melancholia in the 1870s: admissions to a Cornwall asylum

In the 1870s St Lawrence's Hospital in Bodmin, Cornwall, had been running for 50 years, one of sixteen county asylums set up between 1811 and 1842. By examining 511 admissions between 1870 and 1875 to this typical Victorian asylum we hoped to shed light on this mid-point of the asylum era. The 511 patients were all classified as 'paupers', whose admissions were publicly funded. A few privately funded patients were admitted during this period but are not included.

Asylum populations rose greatly through the 19th century. Whether this rise was mainly due to an increase in psychotic illness or to a decrease in tolerance of the mentally ill in the community is unclear. Many patients were admitted under the Poor Law and Lunacy Acts. After amending acts of 1853, the parish medical officer was required to visit all paupers in his areas four times a year. He was expected to notify the guardians or the overseers of those who seemed in need of mental treatment.¹ If any were thought to need treatment in the asylum, admission was certified by the medical officer and the local justice of the peace.

METHODS

The Lunacy Act of 1845 stated that all asylums must keep an admission book—a contemporary record of each admission with basic demographic data and details of diagnosis, cause of disorder and age of first attack. It also contained records of the date of discharge or death and whether the patient had recovered or not. From the admission book dated 1870–1875 (County Record Office, Truro), the only surviving one for Bodmin, we obtained demographic data and information on illnesses and outcomes.

RESULTS

Diagnosis

All but a few patients were labelled as having mania (38%), dementia (35%), or melancholia (26%). Diagnoses such as 'moral insanity', popular in other parts of the country, were not used in provincial Cornwall. The following case record of an admission for St Lawrence's illustrates the use of all three terms in a single patient, possibly a case of bipolar disorder.

'Admitted 20th April 1872—age 33 draper's assistant. Form—Mania. In a very melancholic condition—says he is about to be married but has not work or money. Says he goes to Camborne churchyard and sits on the stones so as not to be a burden to his parents.

May 7th 1872 Suffering mania—has grandiose ideas, emotional and irritable says he is in love with the world. January 1873 Suffering from dementia—says he cannot remember things.

September 1873 Patient suffers from dementia—unable to concentrate his attention. Memory defects.'

Age at first episode

If mania and melancholia roughly equated with manic episodes and depression respectively, and dementia was at least somewhat related to the modern term schizophrenia, we would expect the age of the first episode to be similar to those of today. Table 1 shows a peak age of onset for mania in the 20s and 30s, with a very small percentage of cases beginning in later life. First episodes of dementia occurred at similarly young ages, whereas onset of melancholia was more evenly spread over the lifetime.

Table 1.

Age of 'first attack' for admissions to St Lawrence's 1870-1875

	No. of patients
Age at first attack (years)	Mania	Melancholia	Dementia
≤ 19	16	1	32
20-25	35	16	30
26-31	44	18	21
32-37	27	19	19
38-43	21	15	22
44-49	21	16	16
50-55	15	19	8
56-61	9	23	9
62-67	9	11	3
68-73	0	6	11
≥ 74	2	1	11

Duration of symptoms before admission

All admissions were compulsory and the system seems to have led to speedy admissions for the mentally ill in Cornwall, particularly those with mania. Of those admitted with mania, 70% were admitted within two months of the onset of symptoms, compared with 51% for dementia and 55% for melancholia.

Outcome

The admission register records whether, at discharge, patients had 'recovered', were 'relieved', had 'not improved' or had died. The trustworthiness of these data may be doubted, but clearly a substantial number of admissions lasted only a few weeks or months, the patient being discharged fully recovered (Table 2).

Table 2.

Length of stay of St Lawrence's patients and outcomes (at discharge or death)

Outcome as recorded in admission register	≤ 1 year	1-5 years	>5 years
Recovered	57.5%	23.5%	12.5%
Relieved	2.9%	15.2%	1.3%
Not improved	5.3%	8.3%	1.3%
Died	34.3%	53.0%	85.0%

Perceived aetiology of illness

In his annual report of 1877² the medical superintendent, Dr Adams, divides the causes of illness into moral and physical (Table 3). The meaning of moral seems to be equivalent to the modern 'emotional'. 14 patients were diagnosed as having general paralysis of the insane, all of whom died in the asylum.

Table 3.

Categories of illness (from annual report of St Lawrence's Hospital, 1877)

Cause	No.
Moral
Domestic trouble	3
Religious excitement	8
Business and pecuniary	4
Mental anxiety and worry	8
Fright and various shocks	3
Physical
Intemperance	8
Accident and injury	1
Puerperal	5
Brain disease and general paralysis	6
Brain disease with epilepsy	10
Other forms of brain disease	4
Sunstroke	2
Hereditary	7
Congenital	1
Unascertained	27

DISCUSSION

By the 1870s large 'lunatic' asylums such as St Lawrence's were well-established. From our examination of the admission register we could not discern exactly what differentiated the principal diagnoses, mania, dementia and melancholia. In 1849 Ray³ was probably right in stating 'No one can be sure that by monomania, melancholia, moral insanity or many other terms, he understands precisely what his neighbor does'. By the 1870s, mania and melancholia had changed from being general terms, defining overactivity and underactivity, to mood-related diagnoses⁴ clearly akin to today's mania and depression.⁵ However, the fact that 71% of patients admitted to an asylum in Buckinghamshire⁶ were diagnosed with mania compared with 28% in Bodmin suggests that terminology was used differently around the country.

Use of the term dementia is more confusing. By the 18th century dementia described a state of acquired intellectual deficit, at any age and of any cause.⁷ So a young adult with serious head injuries, for instance, might have been labelled as having dementia. The label was also applied to severe psychotic illnesses, which were thought of as dementing processes—hence Kraeplin's 'dementia praecox', the forerunner of schizophrenia. However, the term dementia praecox was not coined until 1891, 20 years after the period studied here. By the end of the 19th century there was a tendency to confine diagnosis of dementia to patients with loss of cognitive ability. Senile dementia was not described until the turn of the century. The term dementia also had a behavioural connotation: Henry Munro,⁸ writing in 1856, stated that 'dementia should always be applied to a passive rather than an active state'. Our impression of the Cornwall records is that the term applied to a huge variety of cases, including both patients with cognitive difficulties from any cause and psychotic patients who were not behaviourally overactive enough to be described as manic. Irreversibility was also becoming part of its meaning by the 1870s, so chronic psychosis would presumably have been so labelled.

The data on age of first attack are consistent with bipolar disorder⁹ and schizophrenia. The very young age at first episode of dementia resembles modern data for schizophrenia; the cases presenting in later life may have been senile dementia or acute medical illnesses presenting as confusion.

The melancholia data show an even spread of first episode with a small peak in the late 50s. Modern data show a peak age onset of 50–70 years for psychotic depression, and 30–40 years for unipolar depression.¹⁰

If the data on 'duration of existing attack' are to be trusted, 21% of people with mania were admitted within a week or less of the episode starting and 70% within two months. Contemporary results¹¹ on duration of symptoms before admission are known for a private psychiatric clinic in Vienna, where 68% of patients with mania were admitted less than a month after the onset of symptoms. In Britain today, as in the 1870s, patients with mania get admitted faster than those with other psychiatric diagnoses.¹²

It was not true that, once a patient was admitted to an asylum, there was no way out other than death. The high discharge rate at Bodmin was mirrored in the Buckinghamshire Asylum, where half of those admitted were discharged, most of them within the first year.^6,13 Discharge of a patient could be initiated by the medical superintendent or at the request of the family, but also needed the signature of a magistrate. Medical superintendents were required to inform the 'visiting committee' if a patient had recovered and, when discharge had not occurred within 14 days, they would have to explain why to the Commissioners in Lunacy.

A very poor outcome in those resident for over a year has been reported in that era from the Buckinghamshire Asylum⁶ and also from a private institution in Ticehurst, Sussex.⁴ Our results show a much higher mortality than the private asylum in the first year after admission (34% versus 12%) but similar rates of death for those resident for more than 5 years (85% versus 83%).

Regarding causation, a substantial minority of the Bodmin admissions were recorded as being caused by 'organic' illness such as epilepsy, head injury, fever or general paralysis. Some of the patients who died soon after admission probably had acute medical illnesses, with psychiatric symptoms a secondary effect.

One reason proposed for the increase in asylum populations during the 19th century was the rising prevalence of syphilis, with consequent general paralysis of the insane. However, only 14 cases were recorded in Bodmin during the period examined. Since the end-stages of the disease are very characteristic, we can be fairly sure that these diagnoses were correct. This disease tended to affect middle-aged men of higher socio-economic class, perhaps because of their ability to pay for sex.¹⁴ The low level in Cornwall may reflect the poverty of the county and an undeveloped sex trade, though rates in the richer Buckinghamshire differed little. By contrast, in the private Ticehurst asylum between 1850 and 1889, nearly 18% of patients were diagnosed as having general paralysis.⁴

St Lawrence's Hospital is no more. The name was changed to Bodmin Hospital last year, perhaps partly because of the stigma attached to the old asylum. In the 1870s the great majority of patients were diagnosed with mania, melancholia or dementia. In most of these, the cause of the illness was recorded as unknown. In 2003, the most common diagnoses in the 18–65 age group are bipolar affective disorder, depression and schizophrenia. The causes of these are likewise unknown.