Until about 1930, hospitals existed mainly for the destitute sick, the mentally ill, and people with contagious disease. The first asylum in Ontario “for the reception of insane and lunatic persons” opened in 1841 and after many changes evolved into the present Queen Street site of the Centre for Addiction and Mental Health in Toronto. The Archives of Ontario holds records from this and many other provincial mental health institutions. The 19th century psychiatric hospitals were designed as large, imposing edifices of civic progress and prosperity. They were typically situated with a number of outbuildings and considerable acreage of farmland. The Kingston psychiatric hospital was opened in 1856.
The sketch to the right shows that the Kingston psychiatric hospital was spread over 162 1/2 acres of which 83 1/2 were under cultivation.
Early patient records were transcribed by hand into large bound volumes called casebooks. Each patient was assigned a new page in the casebook, in order of admittance. Notes about the patient’s subsequent history were added to the page, which was cross-referenced to a second later page if additional space was needed.
Most entries are somewhat idiosyncratic notations documenting direct observations of conditions and behaviours, written down as an aid to memory.
Treatments such as tonics or other medications were recorded, but the role of 19th century hospitals was mainly a custodial one. Most casebooks had a name index.
Patient admissions, discharges, “elopements” (escapes) and deaths were recorded in a register. The register shown here is in poor condition, possibly initiated by a spilled liquid that has caused further damage over time.
The casebook volumes and registers were kept in a fixed location. By 1890, the number and complexity of registers had increased, and separate documents such as photographs, temperature charts, typewritten pathology reports and other machine-produced information were sometimes pasted into the casebooks.
The system depicted in the photograph below was almost universal in Ontario’s hospitals at the beginning of the 20th century. The ledgers on the stand at the back are from left to right: Application Book, Admission Register, Death Register, Discharge Register, Statistical Register, (gap,) and Casebook. A casebook is open on the stand. The Clerk is holding his pen over the General Register. The individual seated at the desk with the microscope box is a medical student.
A 1907 regulation introduced a new system in all Ontario psychiatric hospitals in which basic patient information was noted on index cards and patient records were kept in case files. In the ensuing years, patient records became more standardized and form-based, and the number and types of records increased significantly.
The case files of loose documents allowed the clinical records created by the many different people involved in the patient’s care to be filed together. A patient case file might include case histories, progress notes, lab reports, reports of surgical procedures, temperature charts, treatment sheets, doctors’ orders, diet cards, conference reports, social service reports, x-ray positives, photographs, a discharge summary or death certificate, correspondence, clothing lists, and other documents. By the 1940s there were expert staff with specialized training to look after patient records, and new technologies such as microfilming for inactive files.
Index card systems were a momentous 19th century innovation that allowed an easily accessible and modifiable arrangement of data. Electronic systems have largely replaced index cards for tracking patients – although some card systems remain.
Tray of index cards and card for Grace Marks, admitted to the Provincial Lunatic Asylum in Toronto in 1852. Many index cards were created for former patients when card systems became universal in the psychiatric hospitals in 1907. Prior to this time patient information was tracked using registers with alphabetical indexes.
Charts and attendant notes were kept at the bedside, as shown here, but few have survived. Nurses’ notes were sometimes filed in a second patient case file, which was later destroyed.