As good as it gets: an empirical study on mentally-ill patients and their stay at a general hospital in Sweden,1896

Abstract

General hospital care and treatment of mentally ill patients in a Swedish town was studied in records for 503 patients, 1896–1905. Restraint was extremely rare; 65% left the hospital as healthy or improved. Non-psychotic and alcoholic patients spent fewer days in hospital than patients with psychosis or dementia. There was no evidence of a social status bias. For 36% of the patients a certificate for mental hospital care was issued, with additional information. The cause of illness was stated as unknown for 42% of these patients; adverse circumstances were recorded for 18%. Heredity for mental illness was found in 50% of the patients, particularly in those with mania. Patients with a higher social status were underrepresented.

Keywords

Gender general hospital psychiatry history precipitating events sociodemographic factors state at discharge Sweden treatment 19th century

Introduction

What are the causes of mental illness? How should those who suffer from it be controlled, cared for or even cured? These elusive questions have been discussed for centuries. Older concepts of insanity as a moral aberration have been replaced by theories about psychological disorders or brain dysfunction.

Research on the history of mental care has been divided between two divergent approaches. The first – influenced by civilization theory – views the effort to treat mental illness as part of a humanitarian endeavour, the continuing struggle to improve society. The second – informed by Foucault’s discourse on disciplinary power – considers mental hospital care to be a tool of social control and an instrument for exerting power. Proponents of this theory tend to describe mental care as oppressive and inhumane.

Closely related to this discussion is the idea that insane people can be cured with medical treatment (Larsson, 2001).

Sweden during the nineteenth century

During the nineteenth century, Sweden was transformed by industrialization and its new lifestyle, and innovations such as electric light, telephones and film impacted the lives of all citizens. The Swedish population increased from 2.3 to 5.1 million during the century. In 1850, 80% of Swedes were farmers; in 1910 the figure was 50% (Hedenborg, 2015: 253).

In the industrial society, with its clear class divisions, the debate on social reform intensified. The proponents of welfare measures were influenced by new and more active forms of liberalism (Montgomery, 1951: 39, 113). In step with economic growth, the Swedish government developed and expanded schools, health care and relief for the poor (Furuhagen, 1999; Norborg, 1995: 60). The first Poverty Act was adopted by the Swedish parliament in 1847 (Magnusson, 2000: 177; Montgomery, 1951: 40). This Act was revised and made more restrictive in 1871, in response to failed harvests and an economic recession (Elmér, 1975: 48). The new law confirmed the central function of the local parish in poor relief, yet it was far from obvious where the role of the authorities ended and the responsibility of the individual began (Andersson, Björkman and Humlesjö, 2005: 60; Lyxell, 1996: 18).

In 1900, 4.7% of the Swedish population depended on poor relief. The ratio was higher in the cities, for example 10% in Stockholm (Montgomery, 1951: 172–3); 1% of the whole population lived in almshouses (Nilsson, 2003: 223).

The development of health care and psychiatry

In the early 1800s, the care of the mentally ill became the subject of a new branch of medical science: psychiatry. There was optimism about treatment, and the number of inmates at various hospitals increased steadily; it was a time of organization and centralization. In Sweden, a national network of state mental hospitals was established after a decision by parliament in 1823 (Qvarsell, 1982: 49, 70), and general health care was thoroughly reorganized in 1862. A new regional authority, the County Council (landsting), was put in charge of the general hospitals, while the mental hospitals remained under state control. According to the Lunacy Act, the general hospitals should have a limited number of beds for mentally ill patients.

Contrary to what is often believed, there was a deep concern for the well-being of the mentally ill in the nineteenth century. Handbooks from the time, as well as the successive Swedish Lunacy Acts (from 1858, 1883 and 1901), emphasize that mentally ill patients must be treated with respect; they were to receive good care with few restrictions. Constraint could be used only if patients were in danger of hurting themselves or someone else (SFS, 1858, 1883, 1901a). The Swedish Lunacy Acts of 1883 and 1901 state that the family carries the main responsibility for the care of a mentally ill patient, but that if this fails, the municipality will step in. The patient and his or her relatives could apply for mental hospital care free of charge. If no free beds were available at the mental hospitals, the general hospital was obliged to take care of the patient at a subsidized charge. It was also possible to apply directly for care at the general hospital (SFS, 1883, 1901a).

In 1900, a patient admitted to the Kristianstad general hospital for a physical condition paid 0.50 Swedish krona (SEK) per day, with an additional fee for better food or a single room. The charge for one of the beds reserved for patients with a mental illness, which were always in a single room, was 0.75 SEK, but some patients with mental conditions were treated on the general ward of the hospital and they paid accordingly. The hospital was financed by the county council (46.9%) and an additional hospital tax (31.6%), as well as the patients’ fees (21%) (Hedlund, 1903). During the period 1901–5, the average daily wage for a labourer was 1.54 SEK and for maids 0.93 SEK (Centralbyrån, 1914: 135).

In the late 1800s, it was difficult for patients to obtain care at a Swedish mental hospital. These hospitals held 5000 beds, but twice as many were needed. Contemporary doctors complained of the lack of hospital beds for the mentally ill (Gadelius, 1900: 11). According to national statistics from 1901, asylums or mental hospitals held 39% of the reported mentally ill (3733/9582). Many patients were taken care of at home (46.6%) or at an almshouse (12.2%). Some received treatment at a private nursing home (0.9%) or at a local general hospital (1.3%) (BiSOS, 1903b). Mental patients were sometimes ill-treated at home or at the almshouse.

According to the Lunacy Acts of 1883 and 1901 (SFS, 1883, 1901a), the Royal Medical Board nominated a psychiatrist to inspect all medical facilities with mental patients (mental and general hospitals, private nursing homes and almshouses) at least once a year, but due to lack of time, not all these places were inspected every year. The mental hospitals were prioritized, focusing on the use of restraints and on complaints from patients to the Medical Board. These hospitals were only rarely criticized, and less than half of the general hospitals received any substantial criticism. The almshouses were more often severely criticized (Medicinalstyrelsen: c).

A prominent patient category was the alcoholics. Abuse of distilled beverages was widespread (due to lower production costs and rising standards of living), but in 1860 the production of homemade spirits was outlawed in Sweden. In the following years, temperance societies were founded in almost every province. Nevertheless, at the end of the nineteenth century alcohol consumption was estimated to be four times higher than the present-day level. The harmful consequences of alcohol – physical as well as psychological – were already known. To some extent this was thanks to the Swedish physician Magnus Huss, who also was one of the architects behind the first Lunacy Act in 1858. Yet – until 1917 – there were no restrictions on the purchase of alcohol (Hedenborg, 2015: 271; Norborg, 1995: 132).

At the end of the nineteenth century, one of the major problems in psychiatry was defined as lack of psychiatric knowledge, both among ordinary people and the medical staff at the mental hospitals (Gadelius, 1900: 1). As a result of this, booklets with information about psychiatric illness and treatments were distributed to Swedish medical institutions, almshouses and local authorities (Scholz, 1899; Schultheis, 1906). Some of them embraced a new paradigm that ascribed mental illness to biological causes. Insanity was presented as a brain disorder that could be cured with the right treatment (Gadelius, 1900; Griesinger, 1892; Kraepelin, 1916; Svensson, 1907).

Kristianstad, a city with two faces

Situated in Scania, Sweden’s southernmost province, Kristianstad was a medium-sized city with 10,318 inhabitants in 1900; the largest city in the province, Malmö, had 60,857 residents. As a comparison, the Swedish capital, Stockholm, was inhabited by 300,624 persons (Centralbyrån, 1914: 7).

Before 1658 Kristianstad belonged to Denmark and was named after King Christian IV, who founded it in 1614 as a stronghold against Swedish incursions. Thus, from the very beginning Kristianstad (Christianstad) was a city of officers and soldiers. The closure of the fortress in 1847 did not change this: uniforms and parades were characteristics of this environment (Munck af Rosenschöld, 1949; Sandström, 1956). Furthermore, it was the residence city of a county governor, and since 1821 it has been the site of a court of appeal. This fashionable city was also well known as a meeting point for landed nobility and other members of high society. It had excellent connections with the royal house and was sometimes referred to as ‘Little Paris’ (Johannesson, 1972: 351). The class-conscious and conservative élite, living in large stone or brick houses, maintained the city’s official façade (Nilsson, 1974).

However, Kristianstad also had another side, for the majority of the population lived in wretched conditions, mostly having to spend their lives in overcrowded and unhygienic apartments. In the countryside, labourers and peasants lived in small wooden houses that were dark, unpleasant, cold and damp in winter (Appelquist and Nilsson, 2005; Mårtensson, 2000). This situation was closely connected to all sorts of health problems, one being excessive drinking. The agricultural conditions in the Kristianstad area – then as now – were suitable for distillers. This region was known as the ‘Potato Belt’, and in 1879 industrialist L.O. Smith started producing what would later become Absolute Vodka (Ohlsson, 2013: 177–84; Ottosson, 2013: 88).

At the end of the nineteenth century, Kristianstad had a general hospital which served a region of approximately 116,000 inhabitants and had 146 hospital beds, of which seven were reserved for the mentally ill (BiSOS, 1898, 1903a). The mentally ill who were unable to stay at this general hospital, for economic reasons or the lack of beds, could be admitted to the almshouse.

Dr Hedlund, head of the general hospital of Kristianstad

The general hospital in Kristianstad was led by Dr Johan August Hedlund from 1896 to 1923. He had completed his medical education in Stockholm in 1888 and received the compulsory two months of psychiatric training during his education. His contemporaries described him as a kind person and as an ambitious and determined professional (Thorsén, 1953). After an inspection it was noted that Dr Hedlund had an interest in the mentally ill, and that the department was clean and in good order (Medicinalstyrelsen: b).

Also, in other respects, Hedlund appears to have been a broadminded person. He was the first doctor in Sweden to employ a female surgeon, Gertrud Gussander, whom he supported and who later defended a doctoral thesis in surgery. After Hedlund retired, he became private physician to the internationally known feminist writer Ellen Key (Kristianstadsbladet, 1936; Westling, 2005).

Research on nineteenth-century psychiatric history has largely focused on the mental hospitals, which have been discussed within a framework of intellectual history, and often used to support different theories of aberrant human behaviour. There have been few empirical studies of how the mentally ill were actually treated and cared for outside the mental hospital (Berge, 2007: 274; Qvarsell, 1982: 15). The present study endeavours to widen the scope of research by focusing on patients treated for mental illness at a general hospital. Case records from patients treated between 1896 and 1905 are the basis for an investigation of background factors for diagnostic classification, such as gender, age, heredity and social status; and the records are also used to describe the treatment provided and its outcome.

Patients and methods

General hospital patients

In 2011, a collection of 208 medical certificates for mental hospital admissions issued between 1896 and 1905 was found in the basement of today’s general hospital in Kristianstad. These, and the corresponding notes and admissions ledgers, were the basis for the present study together with case notes for all patients treated for a psychiatric condition in hospital during this period. The methods used to analyse the records are described in a previous study (Appelquist, Bradvik and Åsberg, 2018). Briefly, all 589 cases, representing 503 patients (some were admitted more than once) with any mental diagnosis, were extracted from the 11,458 admissions recorded in the general admission ledgers. In 115 of the 589 cases, the case records from the general hospital were missing; these contained, for example, notes of treatment.

Procedure

The case records were studied by the first author (MA) as previously described (Appelquist et al., 2018). Information about the patient’s age, date of birth and marital status was collected from the hospital records and also from the parish records and the Swedish Death Index 1901–2013. The information was tabulated by name, diagnosis, gender, age, marital status, length of stay, treatment, heredity, precipitating events, employment, diagnosis and treatment outcome at the time of discharge from the general hospital. For children or married women, the occupation of the father or the husband was used. There is no generally accepted categorization of occupations in Swedish historical data (Lilja, 2004); we therefore divided the different occupations into six categories (see Table 1).

Table 1.

The distribution of diagnosis by profession and class of patients at Kristianstad general hospital, 1896–1905.

	Unknown^*	Pauper	Workers	Craftsmen	Military	Middleclass	Upperclass	Total
Alcoholism	2	1	24	10	6	13	5	61
Hysteria	12	1	38	3		6	1	61
Hystero-neurasthenia	4		5	2		2	1	14
Neurasthenia	13	3	83	22	2	16	2	141
Melancholia	4	4	27	12		2	2	51
Mania	1	5	23	10		3	5	47
Paranoia	1	3	13	4	2	2	2	27
Psychosis	3	1	12	1		1	1	19
Insania simplex	2	2	28	8	2	4		46
Dementia		2	5	2		1	1	11
Others^†	2	4	10	1		6	2	25
Total	44	26	268	75	12	56	22	503

Unknown: e.g. children, widow, widower or not documented; †others: Amentia, Apoplexia cerebri, Hypochondria, Hysteromelancholia, Idiotia, Insania epileptica, Intoxico phosphorus, Katalepsia, Paralysé generale, Suicidum, Thrombosis arteria, Traumatic neurosis, Tumor hemorrhoids.

The medical certificates contained information about heredity and precipitating events. These data are presented for individual patients, unlike our other analyses which concern cases rather than individuals. The patient’s latest stay at the hospital, and their diagnosis, were used. Information about mental illness (or its absence) in relatives was noted. In the analysis, relatives were grouped into first degree (parents and siblings) and second degree (grandparents, aunts, uncles and cousins). Heredity for alcohol abuse was included as a separate group (regardless of first- or second-degree relatedness). Some patients had two hereditary factors, the second always being alcohol abuse; those cases are presented separately.

Figure 1.

Kristianstad general hospital in 1902; the building to the left contained the ward for the mentally ill and the financial department (photographer unknown; available at: http://www.kristianstadvykort.se/).

Precipitating events were recorded in medical certificates according to a checklist provided by the Lunacy Act. In our analysis, we grouped events into larger categories as shown in Table 5 (see later).

The state at discharge was noted when the patient left the general hospital in Kristianstad. Some patients had to leave due to lack of bed space, while others chose to leave by themselves (against the doctor’s recommendation), or left to go to the poorhouse, or to the mental hospital in the city of Lund. Patients who were transferred to the mental hospital were more severely ill (Appelquist et al., 2018).

The types of treatment used are described in the Appendix (at the end of this paper) and summarized in the groups tabulated in Table 6 (see later). Upon discharge, it was noted whether the patient was recovered, improved, not improved or dead. The hospital reports and inspection reports from the Royal Medical Board were studied from mental and general hospitals, almshouses and private nursing homes from 1899 to 1902. These reports contained information about the buildings, number of patients, treatment, number of beds, and the cases of patients who disputed that they were mentally ill and did not want to stay at the mental hospital. They also contained reports if any restraints had been used. For Kristianstad hospital, a general hospital report was found for the year 1891, as well as an inspection report about the mentally ill from the general hospital for the year 1900 and from the local almshouse for the year 1904 (Medicinalstyrelsen: a, b, c ).

Statistical methods

Duration of hospital stay was highly skewed, and the Kruskal–Wallis test, followed by individual comparisons by the Mann–Whitney test, was used for comparing diagnostic categories (non-psychotic, psychotic or demented). The Mann–Whitney test was also used for gender differences in age and hospital stay. Logistic regression was used to assess certification (yes/no) in relation to diagnostic category, age, gender, profession and living alone or not.

Ethics

By Swedish law, medical case records are protected by strict confidentiality for a period of 70 years. Since all our case notes were more than 100 years old, no research ethics review was considered necessary. We have applied for an ethical review of another part of the current series of studies, concerning causes of death. The Ethical Review Board in Lund did not see any objection to the project from an ethical point of view and did not consider that a full ethical review was needed (2016/497).

Results

Sociodemographic factors

Age distribution by diagnoses is presented in Figure 2. Overall, the mean age was 37.6 (± 14.2) years, median 36 years, and age range 6 years (sic) to 77 years (only one patient was older than 74). For psychotic patients, the average age was the same (about 35 years) in the groups of those with mania, paranoia, psychosis or insania simplex. Melancholic patients had a mean age of 42 (± 14.3) years; if the single patient younger than 18 was excluded, the mean age was 43.3 years. The five patients with idiotia (only males) were younger than the other groups– 28 years on average.

Figure 2.

Age distribution in years, for different diagnoses at Kristianstad general hospital, 1896–1905; the number of admissions for each diagnosis is given in brackets. (Note: other diagnoses (n = 29) are included in the total– see Table 1; the age of one patient with neurasthenia could not be found. End lines show upper and lower percentiles; boxes show upper and lower quartiles; in each box, a cross indicates mean value and a line, median value.)

For 23 admissions (21 patients), the patients were 17 years or younger. Another 30 admissions (24 patients) were 18–20 years old; 89 admissions (76 patients) were 21–25 years. Thus, 24% (121/503) of the patients were children or young adults (under 25 years). The women were significantly older than the men (mean 38.9 ± 14.6 years, median 39 vs 36.5 ± 13.7 years, median 34, Mann–Whitney U = 38576.5, p < 0.03). The youngest patient with a medical certificate was 15 years old.

The distribution of diagnosis by professions is presented in Table 1. Paupers represented 5.2% and the upper classes (military, middle and upper class) represented 17.9%. Civil status (unmarried/married/divorced/widowed) in different diagnostic categories and age groups are shown in Tables 2 and 3. The latter also shows comparison data for the general population (Centralbyrån, 1914). Marriage was allowed from the age of 17 years, and (ignoring 0–15 years) in all age groups, with the exception of the very old, the percentage of married patients was lower than in the general population. Of the 503 patients included, 25 had unknown civil status and 15 were not of marriageable age. The marriage rate varied with diagnostic category and was highest in alcoholics (54% married, 5.6% widowed) and next highest in melancholia (42.8% married, 10.2% widowed). The most common diagnoses among the 28 patients who were widowed were neurasthenia (8), melancholia (5), alcohol (3), mania (3) and dementia (3). Of these 28, 14 had a precipitating event note. Four of those were ‘grief due to loss of a husband/wife’ (2 melancholia, 1 mania, 1 dementia).

Table 2.

Civil status (at the latest admission during the period studied) in different diagnostic categories.

	n	Unmarried	Married	Widowed	Divorced	Unknown*
Alcoholism	61	22	29	3		7
Dementia	11	6	1	3		1
Hysteria	61	38	19	2		2
Hysteroneurasthenia	14	10	3			1
Mania	47	28	15	3		1
Melancholia	51	23	21	5		2
Neurasthenia	141	80	46	8		7
Paranoia	27	15	10	1		1
Psychosis	19	12	7
Insania simplex	46	31	13		1	1
Others†	25	14	6	3		2
Total	503	279	170	28	1	25

Unknown: see Table 1; † others: see Table 1.

Table 3.

Percentages of patients and their civil status in age groups (years), compared with national data from 1910 (Centralbyrån, 1914), added in brackets.

Age	n	Unmarried	Married	Widowed	Divorced	Unknown
0 ̶ 15	10	100 (100)
16 ̶ 20	35	94 (99.5)	(0.5)			6
21 ̶ 25	76	95 (87)	5 (13)
26 ̶ 30	55	65 (57)	24 (42.5)	(0.5)		11
31 ̶ 35	70	54 (35.5)	39 (63)	(1.5)		7
36 ̶ 40	64	39 (25.7)	53 (71.4)	1.5 (2.5)	1.5 (0.4)	5
41 ̶ 45	50	46 (21.4)	46 (74.1)	4 (4.1)	(0.4)	4
46 ̶ 50	42	43 (18.6)	48 (74.7)	5 (6.3)	(0.4)	5
51 ̶ 55	37	38 (16.8)	38 (73.4)	19 (9.3)	(0.5)	5
56 ̶ 60	20	20 (15.1)	60 (70.8)	20 (13.7)	(0.4)
61 ̶ 65	22	14 (14.4)	50 (65.8)	27 (19.4)	(0.2)	9
66 ̶ 70	14	29 (13.5)	43 (58.8)	29 (27.4)	(0.3)
71 ̶ 75	6	17 (13)	50 (49.3)	33 (37.4)	(0.3)
76 ̶ 80	1	(12.1)	100 (38.5)	(49.1)	(0.3)
?	1					100
Total	503	55.9 (61.1)	33.4 (32.8)	5.6 (5.9)	0.2 (0.2)	5
>21	458	52 (34.3)	36.7 (55.5)	6.1 (10)	0.2 (0.2)	5

Medical certificate or not

Patient age, gender, and living alone or not were not significantly related to whether a medical certificate was issued. Compared with diagnosis category ‘other’, the probability for certification was higher for those diagnosed with Insania simplex and mania, and lower for those diagnosed with hysteria (p < 0.01). (None with neurasthenia had a certification.) Compared with professional category ‘unknown’, the probability for certification was higher among craftsmen, manual workers and paupers (p < 0.01). The existence of a certificate does not mean that the patient was actually referred to the mental hospital. Preliminary perusal of the corresponding ledgers from the mental hospital suggests that about 50% were sent home. The fate of the certified patients will be the subject of a further paper.

Notations in the case records showed that conflicts sometimes occurred between different municipalities, and between the municipality and the county council, about who should pay the hospital fee if the patients could not afford to pay it themselves.

Heredity and precipitating life events

Heredity for mental illness is presented in Table 4. Patients with mania had the highest rates of heredity (parent/siblings plus grandparents: 58%) and even higher when heredity for alcohol misuse was included (65%). Sometimes two hereditary factors were mentioned in the case records, and the second was always for alcohol; this occurred in 7% of records. The cohort contained one pair of twins (zygosity unknown, but both had mania), two pairs of siblings (with diagnoses hysteromelancholia vs melancholia and mania vs insania simplex), one pair of half-siblings (mania vs melancholia) and a mother and her son (both melancholia).

Table 4.

Percentage heredity based on the latest diagnosis during the studied period 1896–1905 for patients with a medical certificate for mental hospital care.

	n	None	Parents/siblings	Grand-parents*	Alcohol**	Unknown
Dementia	8	37.5	50		12.5
Mania	43	23	46	12	7	12
Melancholia	39	56	26	3	10	5
Paranoia	20	30	30	5	5	30
Psychosis	10	50		30	20
Insania simplex	46	41	24	13	15	7
Others †	14	36	21.5	14	7	21.5
Total	180	39	30	10	10.5	10.5

Including uncle/aunt and cousins; **heredity for alcohol misuse; †others: Apoplexia cerebri, Katalepsia, Paralysé generale, Thrombosis arteria, Tumor hemorrhoids, Amentia, Hypochondria, Hysteria, Insania epileptica.

Precipitating events are presented in Table 5. Patients who had received a medical certificate for hospital care had more notes about the possible causes of the disease (this information was mandatory before admission to the mental hospital), while such information was lacking in the non-certified cases. ‘Rumination’ most often concerned religion or love; ‘Stress’ includes chronic stressors as well as adverse events, for example poverty, exhaustion, loss of a loved one, and travelling (e.g. patients who fell ill on emigration to the USA and were sent back home). In a few records, childhood trauma was mentioned as a possible causative factor.

Table 5.

Percentage of precipitating life events for types of the latest diagnoses for patients with a medical certificate for mental hospital care.

	n	Heredity	Somaticillness	Alcohol	Rumination*	Stress**	Sleepdeprivation	Unknown
Dementia	8		12.5	12.5	12.5			62.5
Mania	43		12		21	21	7	40
Melancholia	39	5	13		15	28	8	31
Paranoia	20		25	15	5	15	5	35
Psychosis	10		30			10	10	50
Insania simplex	46	4.5	13	4.5	13	11	2	52
Others†	14		21	7	7	21	7	36
Total	180	2	16	4	13	18	6	42

Rumination: about religion or love; **stress: travels, extended work, economic problems, loss of a loved one (grief); †others: see Table 4.

Length of stay

Duration of hospital stay is illustrated in Figure 3. Average time was 41.6 days, median 22, range 1–593 days. Women stayed longer than men, on average 46.5 versus 37.2 days (median 26 resp. 18 days, Mann–Whitney U = 33,508.5, p < 0.00001). There was a significant influence of diagnostic category (nonpsychotic, psychotic or demented) on the duration of stay (Kruskal–Wallis H = 101.8, p < 0.0001). Patients with dementia had significantly longer stays than nonpsychotic patients (Mann–Whitney U = 961.5, p < 0.013). The difference in duration of stay between psychotic and demented patients was not significant.

Figure 3.

The length of stay (in days) at Kristianstad general hospital, 1896–1905, for different diagnoses; the number of admissions for each diagnosis is given in brackets. (Note: other diagnoses (n = 29) included in total, see Table 1; information for eight admissions was missing, mostly from those with Insania simplex. See Figure 2 for explanation of boxplots.)

Only three patients stayed for more than a year. Those who received a medical certificate for mental hospital care (mostly those with melancholia or psychotic disorders) stayed longer than those without. The average hospital stay for certified patients was 70.1 days, median 44 days; and for those not certified: average 26.4 days, median 17 days. Women who were not certified stayed longer than non-certified men (mean 32.7 vs 21.2 days, Mann–Whitney U = 12,092.5; p < 0.00001), while there was no gender difference among the certified patients (women 70.7, men 69.2 days). Non-certified patients with Insania simplex (denoting more severely ill patients regardless of diagnosis; see Appelquist et al., 2018) had much longer hospital stays (average 108.5 days) compared with the certified patients with the same diagnosis (average 62.5 days), possibly because the latter were transferred to the mental hospital. Dr Hedlund wrote in some of the case records that there was a long wait for patients before they could be transferred to the mental hospital in Lund, due to shortage of beds.

It was noted in the case records that patients really wanted to get help from the general hospital, or the mental hospital, for their mental illness. On the other hand, some patients left the hospital against the doctor’s recommendation, which, of course, shortened the stay. Sometimes the hospital doctor had to prioritize and ask the patient to leave, due to lack of hospital beds. Mentally ill patients were sometimes moved to the poorhouse unless the family could take care of them. The municipality sometimes also arranged care for the patients outside the hospital, in agreement with legislation at the time. Patients with no home address were a bone of contention for quarrelling municipalities that disagreed about who was responsible for the patient, and who should pay the hospital fee.

Medical treatment

Types of treatment are presented in Table 6. The most common treatment was bromide, which was given to 40% of the cases; it was mainly used for patients with psychosis, mania, melancholia and hysteria (43–52%). Patients diagnosed with non-psychotic diagnoses (neurasthenia, hysteria and hysteroneurasthenia) were treated with anti-inflammatory medicines (e.g. aspirin) and mineral supplements (e.g. iodine and iron); polypharmacy was more common in these patients. Some patients (43, i.e. 25%) with hysteroneurasthenia and neurasthenia were also investigated for their stomach problems, and their hydrochloric acid levels were measured after they had received a standardized breakfast (Berg, 1919: 1239).

Table 6.

Percentage of patients within each diagnosis who were given each type of treatment listed in the Appendix.

	Alcoholism (n = 68)	Hysteria (n = 69)	Hystero-neurasthenia (n = 16)	Neur-asthenia (n = 160)	Melancholia (n = 62)	Mania(n = 64)	Paranoia (n = 31)	Psychosis (n = 21)	Insania simplex (n = 58)	Dementia (n = 11)	Total† (n = 589)
Bromine	32	43	17	34	48	50	29	52	38	36	40
Sedative	35	7	6	6	23	47	16	29	32	27	21
Opiate	22	7	6	9	8	19	16	33	9	27	21
Anti-inflammatory	6	12	6	13	8	5	3		2		7
Digestion medicine	16	20	31	24	10	5	6	5	7		14
Laxative	16	32	6	31	18	20	19	33	12	18	23
Valeriana		9		12							5
Cognac	51										6
Others	10	7	19	12	6	8	6	5	3		9
Bath	18	28	38	38	16	22	16	10	17	18	25
Shower	4	13	6	7	5	2	3		2		5
Massage	3	3		9	2		3				4
Wrapping	7	9		6		5			2		4
Electricity		20	13	9		5					6
Mineral water	3	6		1	3					9	2
Unknown*	19	20	19	37	37	22	39	24	43	45	27

Note: If a patient received more than one type of treatment, each type was recorded (except where the treatments were in the same group).

Patients with no treatment notes in the case record (45 cases) and those with missing hospital case records (115 cases); † Totals include other diagnoses; see Table 1.

Non-medical treatment

A quarter of the admitted patients received balneotherapy. This treatment was more commonly used for non-psychotic patients. Baths were warm (37°C), showers usually colder (20–30°C). No notes about the duration of the bath or shower could be found, but in the later case notes (1903–1905) the bath is described as a sitting bath. There was no indication that any restraint was used during the bath.

The patients with non-psychotic disorders also received alternative treatments more often, such as electricity, wrapping, massage and ingestion of mineral water.

Use of physical restraint

Restraint measures could be used, but only when the patients were violent or harmed themselves. The use of physical restraint was strictly regulated in the Lunacy Act and had to be noted in the case record and in a special list. Two types of restraint were used in Kristianstad: the straitjacket and the cell. In the case records studied, straitjackets were mentioned three times. One example was a patient who was very violent, ‘kicked like a horse and sang about the Lord’ in his home. The doctor wrote that they ‘had to tie him, when four men could not hold him’. When patients were very violent, they were kept in a cell; notes about this were found five times in all the records studied. Some patients could not stay at the general hospital due to their violent behaviour, so when no cell was free, and there was no bed available at the mental hospital, they were sent home.

In summary, many different treatments were administered in Kristianstad. Three case records state that a patient communicated suicidal thoughts, and because of this had to be discharged. The patients were recommended to obtain all necessary certificates to apply for mental hospital care instead.

State at discharge

An analysis of treatment outcome is shown in Figure 4. We found that 65% (365/589) of the patients admitted had recovered or improved at discharge. The best outcome was found among patients with non-psychotic disorders (neurasthenia, hysteria or hysteroneurasthenia) or alcohol diagnoses. Patients with mania, melancholia, insania simplex, paranoia and psychosis had a poorer outcome, with fewer improved cases. Patients with idiotia, dementia and paranoia had the worst outcome: only 20–45% improved during their hospital stay. In total, 18 patients died; half had an alcohol diagnosis. The causes of death will be reported in a later communication.

Figure 4.

Status at discharge from Kristianstad general hospital, 1896–1905, for different diagnoses; the number of admissions for each diagnosis is given in brackets (Note: other diagnoses (n = 29) included in total; see Table 1.).

Patients who were certified for mental hospital care were more severely ill and only 48% had recovered or improved during their stay at the general hospital in Kristianstad. Of the certified cases, 38% did not improve, 3% died and in 11% of the cases it was not clear what happened.

Discussion

General hospital psychiatry has been neglected by historians and psychiatrists (Mayou, 1989). Most historians are unfamiliar with the way case records were written and how the patients were classified and analysed by psychiatrists (McCarthy et al., 2017). In the present study, psychiatric history is discussed from the point of view of a local general hospital where all kinds of mental patients were cared for, not only the most severely ill who qualified for commitment to a mental hospital. We also wanted to present psychiatric history in an empirical way, based on contemporary local history; as far as we know, no similar study has been presented previously.

Main findings

This study shows that mentally ill patients received treatment based on the best available knowledge at the local general hospital in Kristianstad during the period studied. Little compulsory treatment was used. Many patients recovered or improved, especially those with less severe illnesses such as hysteria, neurasthenia or hysteroneurasthenia.

Most of the patients were not married, although more of the older patients were married or widowed. A low percentage were poor (5.2%) and 17.9% belonged to the middle and upper classes. This mirrors the distribution of Kristianstad’s inhabitants at the time and suggests that there was no overrepresentation of poor people from the lower social groups.

Sociodemographic factors

Studies of data from Wales for the same period show a slightly higher mean age for all patients (41 years) compared with our study (38 years), as well as for melancholia (46.5 vs 43.3 years) (Harris et al., 2005, 2011; Healy et al., 2001). This may be due to the virtual absence of patients above 75 years of age in our material (only one of our patients was older than 75), while in the Welsh study 20% of the patients with melancholia were older than 75 (Healy, 2013).

Only 4% of our patients were younger than 18. Psychiatric problems in the young are obviously not a recent phenomenon, and 20% of the patients hospitalized more than a century ago were between 18 and 25 years old (see earlier). Their most common diagnoses were non-psychotic illnesses, such as hysteria, hysteroneurasthenia or neurasthenia. These probably represent the current diagnoses of anxiety disorders, personality disorders and sometimes neuropsychiatric conditions (Appelquist et al., 2018).

We have been unable to find precise sociodemographic data from the district, or even national data, for comparison. It has been suggested that mainly poor people were hospitalized for mental disorders (Freeman, 2010; Myers, 1998; Åman, 1976: 202), but this was not the case in the present study, and furthermore some poor people did not receive the hospital care they needed but were referred to the almshouses. The sociodemographic data in this study reflect the local history of Kristianstad as a military city, with a difference between labourers and the upper classes. The high rate of alcohol disorders among the military is evident in the case records. Other categories with alcohol diagnoses were craftsmen, and middle- and upper-class people, possibly because they had the money to buy liquor.

All social groups were represented in our cases and, as in the population as a whole (Centralbyrån, 1914: 14–15), most patients were manual workers. Interestingly, the most common diagnosis among upper-class patients was mania (mania indicated severe illness, often with psychotic symptoms; Appelquist et al., 2018). Despite this, patients from the upper classes were underrepresented among those certified for mental hospital care. People with higher status had a better economy and were more often able to take care of their sick relatives at home, but if the patient became continuously hyperactive and violent, as may happen with mania, this was no longer possible.

The general hospital demanded a fee that was sometimes paid by the municipality. If the municipality refused to pay, the patient was referred to the almshouse, where the staff had less knowledge of mental diseases, the conditions were worse and more constraint was used (Berge, 2007: 104). According to law, the municipalities were responsible for the care of their inhabitants, but this entailed costs that the municipality preferred to avoid as far as possible. Admission to a mental hospital was cheaper for the municipality than arranging for care of the mentally ill in the community. It has been argued that this may have been a factor behind the dramatic increase in mental hospital beds in Sweden during the first half of the twentieth century (Montgomery, 1951: 86–7, 136).

The mental hospitals were run by the state. The matter of who paid for the care may have been a reason why patients accumulated in the mental hospitals, where patients did not have to pay. The municipalities did not have the means to build nursing homes for chronic patients. This resulted in a type of horse trading, where mental hospitals countered by refusing to admit a new patient until a chronic resident could be released for community care (Appelquist, in preparation; Berge, 2007: 99). Economic issues have been important for the quality of mental care throughout history (Montgomery, 1951: 200), in Sweden as well as internationally (Larsson, 2001; Myers, 1998; Nenadovic, 2011).

Compared with the general population, a smaller percentage of the patients were married, partly because some patients were young (mainly those with hysteria and neurasthenia). The mean age for marriage in Sweden at the time was 28.5 years for men and 26.5 for women (Centralbyrån, 1914: 11). In a study from the Wales project, only 40% were married (Healy et al., 2001). For those who were married, it was maybe easier to get help from their family; and for those who were mentally ill, it was harder to get married. For those who had received a psychiatric diagnosis it was also legally harder to get permission to marry (Flensburg, 1922: 21–34).

When comparing our results for civil status in five-year age groups with data from the National Statistics for 1910 (the earliest available), we saw an overrepresentation of the unmarried in all age groups, and of widowers among patients over 56 years of age, underlining the overlap between loneliness and mental illness (West, Kellner and Moore-West, 1986).

Heredity and precipitating events

In our study 50.5% of patients had a relative with a mental illness, but this decreased to 40% when alcoholism was excluded. This is a higher percentage than in a UK study for 1896 (29%; Healy et al., 2001). Other reports from the same study show that 50% of those with melancholia or bipolar disorder had a sick relative, most often a parent or a sibling (Harris et al., 2005; Healy, 2013).

In some cases external causes were considered, such as stress and somatic illness, but most often the cause was stated as ‘unknown’. Other investigators have found precipitating events in the case history such as grief, ‘trouble’ (pregnancy or illegitimate child or disappointment in love), childbirth, death of a family member, domestic problems and somatic illness (Harris et al., 2005; McCarthy et al., 2017; Radhika et al., 2015), but the proportion of unknown causes is not stated. Traditionally, the absence of a cause that is proportional to the severity of the symptomatology and its duration has been an important criterion for mental illness (in contrast to understandable reactions to life’s hardships) (Wakefield, 2007).

Treatment

Treatment was used to control symptoms, rather than curing the disease. The treatments used were in agreement with textbooks of the time (Svensson, 1907; Gadelius, 1913; Kraepelin 1916). It is difficult to know whether the treatment arsenal at Kristianstad is representative of other Swedish general hospitals, or for hospitals in other countries, since we know of no other relevant studies. Apparently, some general hospitals were merely used for confinement, rather than for treatment of mental patients (Mayou, 1989).

Patients with more severe diagnoses received more potent treatments, like opiates or sedatives. The alcohol detoxification strategy had similarities to current guidelines, but today we tend to use benzodiazepines rather than cognac (National Institute for Clinical Excellence (NICE), 2011). Some treatments, for example laxative and digestives, were also frequently used for nineteenth-century patients with somatic disorders (Fröderberg, 1976). Patients diagnosed with non-psychotic disorders (neurasthenia, hysteria or hysteroneurasthenia) could be treated with anti-inflammatory medicines (e.g. aspirin) and mineral supplements (e.g. iodine and iron). The symptoms of these disorders often included headaches and other pains, which may be the reason for the use of painkillers such as aspirin. This may also be an explanation for the treatment of these patients with ‘electricity’, perhaps an early version of the modern TENS (Transcutaneous Electric Nerve Stimulator) treatment, with its evidence-based effect on pain (McWhirter, Carson and Stone, 2015). The recommended treatment for neurasthenia was rest, electricity and medications (Beard, 1869). Similar treatment was also given to non-psychotic patients at Swedish health resorts (BiSOS, 1903a).

Use of restraints

Older texts on the history of psychiatry often dwell on the exaggerated use of physical restraints (Kraepelin, 1962: 505). Some historical studies do and some do not support this view (Jönsson, 1998: 197; Qvarsell, 1982: 150; Sjöström, 1992: 167). Opinions on the use of restraint in nineteenth-century Swedish psychiatry vary among Scandinavian authors. Some, for example Jönsson (1988: 185), believe that it was commonly used, while others, for instance Qvarsell (1982: 150), suggest that it was rare. Scandinavian doctors were influenced by the non-restraint culture from Germany and England (Retterstol, 1973). The Swedish Lunacy Acts of 1883 and 1901 recognized the need for physical restraint in certain cases, but stressed that it should be avoided as far as possible (SFS, 1883, 1901a). In our study, physical constraint was apparently a rare event. The case records report the use of a straitjacket in three instances, and of isolation in five cases, out of 589 admissions. According to the general Hospital Act, any patient who wished to leave the hospital could do so (SFS, 1901b). Only a handful of patients left against the recommendation of the doctor.

The inspection reports are quite detailed and contain comments on both the use of restraints and the quality of the care. There were no complaints about the treatment at Kristianstad, but the high standard of the ward for the psychiatric cases received a favourable comment from the inspector, supporting the evidence from the case records that the care was indeed good and humane. This is in stark contrast to the inspection reports on care of the mentally ill in the almshouses, which had no legal regulations until 1919 (Berge, 2007: 59). Berge comments on the maltreatment that often occurred when the mentally ill were treated at home, which was also described by nineteenth-century psychiatrists (Gadelius, 1900: 9–11; 1913: 53; Svensson, 1907: 124 ).

Length of stay

Patients with more severe diagnoses had longer stays. Many recovered at the general hospital and were never referred to the mental hospital in spite of having been certified. Compared with the Welsh patients studied by Healy et al. (2001), the duration of hospital care was much shorter in Kristianstad. To some extent, this may be due to the lack of beds in Kristianstad, with seven beds serving a population of about 116,000 inhabitants, and also to the fact that patients had to pay for the care. The alternative was to send patients home or to the poorhouse, and this meant substandard care.

The outcome of the given treatment depended on diagnosis. Overall, 65% recovered or improved after their hospital stay in Kristianstad. This is somewhat more than the 55% of patients who left Swedish mental hospitals recovered or improved in 1900 (BiSOS, 1902). The latter figure is similar to that reported from the Welsh mental hospital studied by Healy et al. (2001), which was 53%; this rose to 61% when dementia and organic disorders were excluded. In the present study, 84% of the neurasthenia patients recovered or improved, which is in line with an American study from 1869 (83%; Beard, 1869). Kristianstad patients with melancholia recovered or improved in 53% of cases, similar to the Welsh patients (56%; Harris et al., 2011). In all these studies, patients with psychotic disorders recovered to a lesser extent than affective patients, a finding also reported in another study by Healy et al. (2012).

Strengths and limitations

The strengths of our study are that (1) we have consecutive material for 10 years, and few case records were missing (8 estimated missing and 589 found; Appelquist et al., 2018); (2) the sample represents all sorts of mental illness, not only the most severe as in a mental hospital study; and (3) patients from different social status and age are represented. An obvious limitation is that we do not know whether the Kristianstad hospital is representative of hospital care for the mentally ill in the rest of Sweden, but the available inspection reports suggests that care at Kristianstad was unusually good.

To what extent the generally favourable outcome was due to treatment, or to the natural course of an illness, cannot be ascertained from our data. The relief from external pressures, and the opportunity for sleep aided by hypnotic drugs may have provided a favourable milieu for a natural healing of the illness.

We have retained the original diagnostic classification in the case records, which makes the comparison with the Welsh data in the series of studies by Healy and coworkers more difficult, since these authors reclassified their patients according to the ICD-10 (International Classification of Diseases, 10th Revision) diagnostic system. A previous study on our patients showed, however, that it is possible to ‘translate’ the nineteenth-century diagnoses in our study to contemporary diagnoses (Appelquist et al., 2018).

Final comment

The patients with mental illness admitted to the local general hospital received adequate care and treatment according to recommendations at the time. Physical restraints were rarely used. Although mental illness as well as the hospital that cared for its victims were stigmatized and regarded with fear patients wanted to be admitted to the mental hospital more often than was possible. Many patients at the Kristianstad general hospital recovered or remitted, and usually their stay there was brief. Apparently, it was a good alternative when the mental hospital in Lund did not have any free beds.

Clearly, the results of our study favour the civilization theory for psychiatric care as a humanitarian endeavour aimed at helping sick people, rather than an effort to discipline and punish. At least, this is the impression gained from the written material. Things may have appeared different from the patients’ points of view, and we have no way of ascertaining this. However, the lack of complaints and the small number of patients who left the hospital against medical advice suggests that patients may have been satisfied with their care. We also have no way of knowing whether the situation at Kristianstad was representative, or whether Dr Hedlund was an unusually good and humane doctor. He obviously did the best he could for the mentally ill, and, for that period, the treatments he used were ‘as good as it gets’.

Footnotes

Appendix: List of treatments used at the general hospital in Kristianstad,with short explanations

Acknowledgements

The authors thank the librarians and archivists at the Kristianstad hospital and at the University of Lund for their invaluable help, and Kimmo Sorjonen PhD for equally invaluable help with the statistical data; and, last but not the least, the support of the psychiatric clinic in Kristianstad and its operations manager.

Declaration of conflicting interest

The authors declare that there is no conflict of interest.

Funding

This research received financial support from the Theodor Nerander Foundation and the Sjöbring Foundation in Sweden.

References

Records kept at Kristianstad psychiatric clinic, now in Arkiv Center Syd, Lund: Case records from Kristianstad General Hospital, 1896–1905.

Medical certificates for mental hospital care at Kristianstad General Hospital, 1896–1905.

Admission ledgers for Kristianstad General Hospital, 1896–1905.

BiSOS (1898) Befolkningsstatistik [Demography in Sweden] 1896. Stockholm: P.A. Norstedt & söner.

BiSOS (1902) BiSOS, Bidrag till Sveriges officiella Statistik, Sinnessjukvården KII 1900 [Contributions to Swedish Official Statistics, Mental Care 1900]. Stockholm: P.A. Norstedt & söner.

BiSOS (1903a) BiSOS, Bidrag till Sveriges officiella Statistik, Hälso och sjukvården K I 1903 [Contributions to Swedish Official Statistics, Health Care 1903]. Stockholm: P.A. Norstedt & söner.

BiSOS (1903b) BiSOS, Bidrag till Sveriges officiella Statistik, Sinnessjukvården K II 1901 [Contributions to Swedish Official Statistics, Mental Care 1901]. Stockholm: P.A. Norstedt & söner.

Centralbyrån

(1914) Statistisk årsbok för Sverige [Statistical Annual for Sweden]. Stockholm: Kungliga Boktryckeriet P.A. Norstedt & söner.

Medicinalstyrelsen [Royal Medical Board]. Vård- och omsorgshistorisk databas [Database of health care history]; accessed (18 Mar. 2018) at: (a) Inspection of Kristianstad General Hospital, 1900: https://sok.riksarkivet.se/Register/Vardomsorg/1636 (b) Inspection of Kristianstad General Hospital, 1891: https://sok.riksarkivet.se/Register/Vardomsorg/1313) (c) Inspection of Kristianstad Almshouse, 1904: http://www.ep.liu.se/databases/medhist_data/arkivdokument/overinsp/1904/I90411KK.htm

10.

Riksarkivet

SNA

(1901–2013) Dödboken [Swedish Death Index]; accessed (18 Mar. 2018) at: https://webbutik.riksarkivet.se/en/products/cd-dvd/swedish-death-index.html

11.

SFS (1858) SFS, Svensk Författningssamling [Swedish Statute Book] 1858: no. 50. Stockholm: P.A. Norstedt & söner.

12.

SFS (1883) SFS, Svensk Författningssamling [Swedish Statute Book] 1883: no. 63. Stockholm: P.A. Norstedt & söner.

13.

SFS (1901a) SFS, Svensk Författningssamling [Swedish Statute Book] 1901: no. 48. Stockholm: P.A. Norstedt & söner.

14.

SFS (1901b) SFS, Svensk Författningssamling – lasarettsstadga [Swedish Statute Book] 1901: no. 83.Stockholm: P.A. Norstedt & söner.

15.

Andersson

Björkman

Humlesjö

(2005) Välfärdsstatens skräpvind [The Lumber-room of the Welfare State]. Lund: Studentlitteratur AB.

16.

Appelquist

Nilsson

(2005) Folkhälsan i östra Skåne 1860–1899 – en studie utifrån provinsialläkarrapporter [Public health in eastern Skania 1860–1899 – a study based on district medical officers’ reports]. Svensk Medicinhistorisk Tidskrift 9: 95–113.

17.

Appelquist

Bradvik

Åsberg

(2018) Mental illness in Sweden (1896–1905) reflected through case records from a local general hospital. History of Psychiatry 29(2): 216–231; doi 957154X18756528.

18.

Beard

(1869) Neurasthenia, or nervous exhaustion. Boston Medical and Surgical Journal 3: 217–221.

19.

Berg

(1919) Läkarebok [Medical Book]. Göteborg: Elanders boktryckeri.

20.

Berge

(2007) Sjukvårdens underklass [Health Care’s Underclass]. Umeå, Finland: Boréa.

21.

Åman: reference follows Westling

22.

Elmér

(1975) Från Fattigsverige till välfärdsstaten [Sweden – From Poor to Welfare State]. Lund: Aldus.

23.

Flensburg

(1922) Advokaten [The Solicitor]. Stockholm: Fröléen & Co.

24.

Freeman

(2010) Psychiatry in Britain, c. 1900. History of Psychiatry 21(3): 312–324.

25.

Fröderberg

(1976) Glimtar från Kristianstads lasarett under 1890-talet [Glimpses from Kristianstad General Hospital during the 1890s]. In: Sydsvenska medicinhistoriska sällskapets årsskrift. Lund: Berlingska Boktryckeriet, 50–57.

26.

Furuhagen

(1999) Äventyret Sverige – en ekonomisk och social historia [The Adventure of Sweden – An Economical and Social History]. Trelleborg: Berlings Skogs AB.

27.

Gadelius

(1900) Vården af sinnessjuka – förr och nu. Trenne uppsatser [The Care of the Mentally Insane – Then and Now]. Lund: C.W.K. Gleerups förlag.

28.

Gadelius

(1913) Sinnessjukdomar och deras behandling förr och nu [Insanity – Its Treatment Then and Now]. Stockholm: Hugo Gebers förlag.

29.

Griesinger

(1892) Pathologie und Therapie der psychischen Krankheiten für Ärzte und Studierende. Berlin: Verlag von August Hirschwald.

30.

Harris

Chandran

Chakraborty

et al (2005) The impact of mood stabilizers on bipolar disorder: the 1890s and 1990s compared. History of Psychiatry 16: 423–434.

31.

Harris

Farquhar

Healy

et al (2011) The incidence and prevalence of admissions for melancholia in two cohorts (1875–1924 and 1995–2005). Journal of Affective Disorders 134: 45–51.

32.

Healy

(2013) Melancholia: past and present. Canadian Journal of Psychiatry 58: 190–194.

33.

Healy

Le Noury

Linden

et al (2012) The incidence of admissions for schizophrenia and related psychoses in two cohorts: 1875–1924 and 1994–2010. BMJ Open 2: e000447.

34.

Healy

Savage

Michael

et al (2001) Psychiatric bed utilization: 1896 and 1996 compared. Psychological Medicine 31: 779–790.

35.

Hedenborg

Kvarnström

(2015) Det svenska samhället 1720–2014 [Swedish Society, 1720–2014]. Lund: Studentlitteratur AB.

36.

Hedlund

(1903) Kristianstads Länslasarett Årsberättelse för år 1902 [Kristianstad General Hospital – Report for 1902]. Kristianstad: Kristianstad Läns Tidnings AB’s tryckeri.

37.

Johannesson

(1972) Skånes historia [The History of Skane Province]. Stockholm: Alb. Bonniers boktryckeri.

38.

Jönsson

(1998) Det terapeutiska rummet – rum och kropp i svensk sinnessjukvård 1850–1970 [The Therapeutic Space – Space and Body in Swedish Mental Health Care 1850–1970]. Stockholm: Carlssons Bokförlag.

39.

Kraepelin

(1916) Einführung in die Psychiatrische Klinik. Leipzig: Barth.

40.

Kraepelin

(1962) ‘One hundred years of psychiatry’ [originally published in German in 1918]; accessed (15 Mar. 2018) at: https://archive.org/details/onehundredyearso011002mbp

41.

Kristianstadsbladet (1936) Dödsruna för [Obituary of] J. Aug. Hedlund. Nyaste Kristianstadsbladet (2 May).

42.

Larsson

(2001) Behandlingstanken inom svensk sinnessjukvård under början av 1800-talet [The idea of treatment in Swedish mental health care at the beginning of the 19th century]. Historisk tidsskrift 4: 511–536.

43.

Lilja

(2004) Marknad och hushåll. Sparande och krediter i Falun 1820–1910 utifrån ett livscykelperspektiv [Market and Household: A Study of Savings and Credit in the City of Falun 1820–1910 from a Life-cycle Perspective]. Stockholm: Elanders Gotab.

44.

Lyxell

(1996) Ryhovsminnen – psykiatrins historiska utveckling till modern tid [Memories from Ryhov – The Developement of Psychiatric History up to Modern Times]. Jönköping: Tabs tryckeri AB.

45.

Mårtensson

(2000) Kristianstad de senaste 150 åren [Kristianstad during the last 150 years]. In: Nya Kristianstad. Kristianstad: Kristianstads Boktryckeri, 9–30.

46.

McCarthy

Coleborne

O’Connor

et al (2017) Lives in the Asylum Record, 1864 to 1910: utilising large data collection for histories of psychiatry and mental health. Medical History 61: 358–379.

47.

McWhirter

Carson

Stone

(2015) The body electric: a long view of electrical therapy for functional neurological disorders. Brain 138: 1113–1120.

48.

Magnusson

(2000) An Economic History of Sweden. London: Routledge.

49.

Mayou

(1989) The history of general hospital psychiatry. British Journal of Psychiatry 155: 764–776.

50.

Montgomery

(1951) Svensk socialpolitik under 1800-talet [Swedish Social Politics during the 1800s]. Stockholm: KFs bokförlag.

51.

Munck

Rosenschöld

(1949) Kristianstad på 1880-talet [Kristianstad during the 1880s]. In: Föreningen Gamla Christianstad Årsskrift. Kristianstad: Kristianstads Länstryckeri, 49–52.

52.

Myers

(1998) Workhouse or asylum: the nineteenth century battle for the care of the pauper insane. Psychiatric Bulletin 22: 575–577.

53.

Nenadovic

(2011) Development of hospital treatment of persons with mental disorders. Srpski Arhiv Za Celokupno Lekarstvo [Serbian Archives of Medicine] 139 Suppl 1: 6–9.

54.

NICE (2011) Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence [National Institute for Health and Clinical Excellence, UK]; accessed (18 Mar. 2018) at: https://www.nice.org.uk/guidance/cg115/resources/alcoholuse-disorders-diagnosis-assessment-and-management-of-harmful-drinking-and-alcohol-dependence-pdf-35109391116229

55.

Nilsson

(2003) Kontroll, makt och omsorg – sociala problem och socialpolitik i Sverige 1780–1940 [Control, Power and Care – Social Problems and Social Politics in Sweden 1780–1940]. Lund: Studentlitteratur

56.

Nilsson

(1975) En minnenas snabbskiss från det tidiga 1900-talets Kristianstad [Memories from the Kristianstad of the Early 1900s]. In: Föreningen Gamla Christianstad Årsskrift 1974. Kristianstad: Kristianstads Boktryckeri AB, 93–99.

57.

Norborg

L-A

(1995) Svensk historia under 1800- och 1900-talen [Swedish history during the 19th and 20th century]. Klippan: Almqvist & Wiksell Förlag AB.

58.

Ohlsson

(2013) 400 år i Christians stad [400 Years in the City of Christian]. Bjärnum: Bokpro förlag.

59.

Ottosson

(2013) Renässansstaden i Vattenriket – Kristianstad 400 år [Renaissance City in the Water Kingdom – Kristianstad 400 years]. Kristianstad: Elanders AB.

60.

Qvarsell

(1982) Ordning och behandling: psykiatri och sinnessjukvård i Sverige under 1800-talets första hälft [Order and Treatment: Psychiatry and the Care and Treatment of the Mentally Ill in Sweden during the First Half of the 19th Century]. Stockholm: Universitetet i Umeå.

61.

Radhika

Murthy

Sarin

et al (2015) Psychological symptoms and medical responses in nineteenth century India. History of Psychiatry 26(1): 88–97.

62.

Retterstol

(1973) The history of psychiatry in Scandinavia up to the year 1900. Tidsskrift for den Norske laegeforening 93: 429–433.

63.

Sandström

(1956) Kring sekelskiftets Lilla Paris [Around the Turn of the Century in Little Paris]. In: Föreningen Gamla Christianstad Årsskrift. Kristianstad: Kristianstads Länstryckeri, 83–87.

64.

Scholz

(1899) Handbok för skötare af sinnessjuka [Handbook for Nursing Mentally Ill Patients]. Kristinehamn: J.L. Grundels boktryckeri.

65.

Schultheis

(1906) Råd och anvisningar rörande vården av sinnessjuka [Help and Advice on How to Treat Mentally Ill Patients]. Stockholm: P.A. Norstedt & söner.

66.

Sjöström

(1992) Kliniken tar över dårskapen [The Clinic takes over the Madness]. Uddevalla: Uddevalla Daidalos.

67.

Svensson

(1907) Lärobok i Sinnessjukvård [Textbook of Mental Health Care]. Stockholm: Aktiebolaget Ljus.

68.

Thorsén

(1953) Sjukvården i Kristianstad i äldre tider [Health care in Kristianstad in older times]. In: Föreningen Gamla Christianstad Årsskrift. Kristianstad: Kristianstads Länstryckeri, 34–36.

69.

Wakefield

(2007) The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. Oxford: Oxford University Press.

70.

West

Kellner

Moore-West

(1986) The effects of loneliness: a review of the literature. Comprehensive Psychiatry 27: 351–363.

71.

Westling

(2005) Gertrud Gussander – kvinnlig kirurgpionjär som byggde eget sjukhus. [Gertrud Gussander – the early female surgeon who built her own hospital]. Lakartidningen 102: 1994–1995.

72.

Åman

(1976) Om den offentliga vården [On Public Health Care]. Uddevalla: Bohusläningens AB.

As good as it gets: an empirical study on mentally-ill patients and their stay at a general hospital in Sweden,1896–1905

Abstract

Keywords

Introduction

Sweden during the nineteenth century

The development of health care and psychiatry

Kristianstad, a city with two faces

Dr Hedlund, head of the general hospital of Kristianstad

Patients and methods

General hospital patients

Procedure

Statistical methods

Ethics

Results

Sociodemographic factors

Medical certificate or not

Heredity and precipitating life events

Length of stay

Medical treatment

Non-medical treatment

Use of physical restraint

State at discharge

Discussion

Main findings

Sociodemographic factors

Heredity and precipitating events

Treatment

Use of restraints

Length of stay

Strengths and limitations

Final comment

Footnotes

Appendix: List of treatments used at the general hospital in Kristianstad,with short explanations

Acknowledgements

Declaration of conflicting interest

Funding

References