PATIENTS' RECORDS: CASE BOOKS

Books referenced H64/B/06/001-011 (1870 - 1911) are indexed by patient surname and give the Medical Officer's detailed examinations of patients, as follows:;Name, sex, age, marital status, occupation, religion, place of residence, whether first attack, age on first attack, when and where previously under care and treatment, duration of attack, possible cause, whether subject to epilepsy, suicidal, dangerous to others, whether hereditary, number of children, age of youngest child, diseases of children, 'previous habits of life', degree of education, state of bodily health, names and addresses of certificates of insanity, and detailed examination under 'Evidences of Insanity', name of informant, admission date, discharge and or death date. Also dated progress on treatment and other observational notes. Often cases notes are continued on later pages.;For some cases, copy Notice of Death (where the patient died at the hospital) giving cause of death, whether post-mortem was carried out and other details, temperature charts, original letters and notes from the patients and their relatives can also be found enclosed;Examples include: Sarah Elizabeth Blane, aged 40 admitted October 1870. The Medical Officer stated 'Believes she is followed and watched by people in the streets, that the organ boys in the street play tunes intended as an insult and an annoyance to her'...'her sister Mrs Stapleton tells me she has an antipathy to looking glasses and pencils, the house she lives in is tumbling to pieces - on one occasion was found throwing the linen downstairs in the night'. She was later discharged January 1871 'owing to pregnancy'. (catalogue reference H64/B/06/001 folio 1);Andrew Hoome, aged 33, warehouseman, of 7 Medina Road, Holloway admitted December 1870. The Medical Officer stated the cause as 'anxiety of business accelerated by stimulants' and observed 'severe manical excitement - great incoherency. Continues making out of doors for some imaginary purpose, irresistable desire to possess himself of flowers.'...'strong desire for theft particularly flowers and plants'...'expecting to be able to supply the French Army with all kinds of merchandise, being quite sure he can pass the Russian lines without being molested having friends there'. (catalogue reference H64/B/06/001 folio 22);Books referenced H64/B/06/012-013 (1912 - 1916) have a revised format providing similar information and contain sections for 'personal' and 'family' histories for each patient. They are not indexed.

Under rules made by the Commissioners in Lunacy, Medical Officers were required to keep a Medical Case Book. Rules 12 and 13, approved by the Lord Chancellor in 1895 stated:;Rule 12 - 'within seven days after the admission of a patient there shall be entered into the Medical Case Book for patients the following':

a) a statement on the patient

b) an accurate description of the external appearance of the patient

c) 'description of phenomena of the mental disorder'

d) previous history of the patient.;Rule 13 - 'Subsequent entries describing the course and progress of the case, and recording the medical and other treatment, with the results, shall be made in the Case Book at the times hereinafter mentioned':;'once at least in every week during the first month after reception, and oftener is necessary; afterwards, in recent or curable cases, once at least every month, and in chronic cases, subject to little variation, once every three months. But all special circumstances effecting the patient, including seclusion and mechanical restraint and all accidents and injuries, must be at once recorded'.