International and Local Approaches to Health and Health Care

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International and Local Approaches to Health and Health Care

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International and Local Approaches to Health and Health Care Astri Andresen William H. Hubbard Teemu Ryymin (eds.)

NOVUS PRESS – OSLO 2010

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© Novus AS 2010. ISBN 978-82-7099-606-3 Omslag: Geir Røsset Omslagsbilde: ©iStockphoto: aydinmutlu Trykk: Interface Media AS, Oslo. Det må ikke kopieres fra denne boka i strid med åndsverkloven eller avtaler om kopiering inngått med KOPINOR, interesseorgan for rettighetshavere til åndsverk.

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Content Astri Andresen, William H. Hubbard and Teemu Ryymin: International and local approaches to health and health care . . . . . . . . . . .

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Iris Borowy: The League of Nations Health Organization: from European to global health concerns?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Josep L. Barona: Public health experts and scientific authority  . . . . . . . .

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Volker Roelcke: Changing historiographies and professional identities: Nazi medical atrocities in post-World War II German psychiatry  . . .

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Val Harrington: Learning about mental health services through local histories: case studies from the Manchester region  . . . . . . . . . . . . . . . . . . . . . 63 Øyvind Thomassen: Diagnosing the criminal insane in Norway 1895–1915  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Anne Kveim Lie: Constructing “the other”: menstruation as pathology in Norway 1850–1900 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Anne Hardy: Us and them: bacterial invasion and colonization in the twentieth century  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

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Diagnosing the criminal insane in Norway 1895–1915 Øyvind Thomassen “Are you insane?” This was one of the first questions posed by the managing psychiatrist to newcomers at Kriminalasylet (The Criminal Asylum) in Trondheim. If the newcomer answered “no”, he confirmed incomprehension of his own mental condition. If he answered “yes”, he confirmed what everyone else already knew, for the courts and the health authorities had formed their opinions about the mental condition of the patients before these had arrived at the institution. The seeming paradox of this scene provokes two questions that are the focus of this chapter: why did the psychiatrist ask this specific question on the patient’s arrival, and what were the consequences of the patient’s answer for himself as well as for the psychiatrist? Insanity is not a definitive condition and is especially difficult to distinguish from a mere strange behaviour, a different appearance or way of living. This lack of precision becomes especially problematical for the analyst when the strangeness of a given patient is reinforced by the political, judicial and medical opinions of the authorities regarding what kind of individual behaviour is socially acceptable or desirable in the society. In 1913 the American psychiatrist Edward Huntington Williams discussed in his book The Walled City the life conditions in a criminal asylum and the challenges of identifying a truly insane person. He asked two questions: what are the signs that distinguish the insane from the non-insane, and how can we detect an insane patient when we meet one? The answer is a difficult one: so difficult indeed, that no one has yet been able to express it satisfactorily. And yet there is a very definite answer; one upon which all the rulers of all walled cities [asylums] will agree. But it is born of experience, and no one can learn it from rules found in books, any more than the diamond expert can learn to detect the gem from the imitation except by long practice. The significant thing is that he can detect the difference with unfailing certainty. If asked to tell just how he did it, he is at a loss of answer. He could not lay down any rules or give scientific tests that would enable anyone to learn to detect the gem at a glance – anyone but an expert like himself who has learned by long practice what apparently cannot be learned in any other way.1

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According to Williams, we cannot recognize the insane by physical appearance alone, but we can learn to know him through continuous observations in what Williams called a “walled city”. Kriminalasylet was in fact a “walled city”, where the managing psychiatrist carried out continuous observations and exhaustive surveys of the insane and his relatives’ life stories. Through those observations and surveys, the psychiatrist tried to develop a structured scientific knowledge about the insane individual, which eventually could help in the recognition of insane patients in general. In central Europe, psychiatry became part of legal practice at the beginning of the nineteenth century. In Norway, a similar inclusion took place in the late 1880s and 1890s, when the forensic psychiatrist appeared as a new branch of psychiatry. In 1887, the Norwegian parliament adopted a new Criminal Procedure Act which formalized the new role of forensic psychiatrists. In 1902, a new Criminal Code came into force, which regulated sanity provisions and determined the required conditions which had to be present in order to exempt the accused from legal responsibility and therefore sentence. These two acts consolidated new ideas, mainly inspired from France, Germany and Italy, about criminality and punishment as well as insanity and treatment. Since that time, it was not only the crime that was important but also the criminal himself.2 This chapter is based on an exploratory study of the patient journals from Norway’s first criminal asylum, Kriminalasylet, which was in operation from 1 February 1895 to 28 January 1963. In August 1894, the Norwegian parliament passed a temporary act to establish a new asylum with a capacity of 15 patients in an old prison building from 1834 located in downtown Trondheim. The parliamentary decision was a culmination of a long-standing discussion since the 1850s among politicians, physicians and lawyers on how to deal with the criminally insane and the location of a new national criminal asylum. In 1898, a second parliamentary act about Kriminalasylet legalized special procedures for treating criminal insane patients, such as long-term isolation and attachment of the patients to the wall with chains. Such practices had not allowed by the existing legislation covering the regular insane. At the same time, it was decided to increase the capacity of the asylum to 30–35 beds by opening a second floor of the asylum building in 1900.

1. Edward Huntington Williams, The Walled City: A Story of the Criminal Insane, New York and London: Funk & Wagnalls Company, 1913: 17–18. 2. Kari Ludvigsen, Kunnskap og politikk i norsk sinnssykevesen 1820–1920, Bergen: Dr. polit. dissertation, Institutt for administrasjon og organisasjonsvitenskap, University of Bergen, 1998: 291–92.

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The individual journals analysed in this chapter were written by the asylum’s first two managing psychiatrists in the years 1895–1915. During this period 77 patients were admitted to the asylum. Mainly two groups of patients were committed to the asylum. The first group consisted of individuals who had committed a serious crime or a series of minor crimes (the incorrigibles) and were evaluated as insane previous to the trial or after imprisonment. The second group comprised those who were considered as too dangerous for the staff and the other patients in the regular asylums. Historians have not yet studied the two Norwegian criminal asylums that were in operation in the twentieth century (Kriminalasylet, 1895–1963 and Reitgjerdet sykehus, 1923–1987). In history of psychiatry in general in Norway there have been published several books and dissertations focusing on institutional developments and the epistemology of psychiatry related to the international development. I will comment on the work of two authors who have actively studied psychiatric journals as the main primary source for their analysis. The first is the literary scholar Petter Aaslestad, who has analysed the literary differences of patient journals written in three separate periods between 1890 and 1990. His ambition was to make visible the narrative mechanisms in these journals and to study how the science of medicine utilizes modern narratology. Using a selection of texts from the journals of patients diagnosed with schizophrenia at the Gaustad asylum in Oslo, Aaslestad developed the understanding of the literary genre of the psychiatric journal. He uncovered parallels between the writing of patient journals and the writing of fiction which led him to question the boundary between fiction and factuality.3 The second is the historian of medicine, Svein Atle Skålevåg, who discussed the concept of “insanity” and its historical presumptions in his doctoral thesis From the History of Normality. Insanity 1870–1920 [my transl.]. According to Skålevåg, the concept of insanity is indissolubly related to the development of psychiatry. Through detailed reading of patient journals and forensic reports he analyses the rise and fall of the contemporary concept of insanity in the period 1870–1920. In this way he unveils new aspects of the relation between body and mind, and science and morality. He argues in favour of approaching the history of knowledge from the level of scientific practices and contends that such an approach has an important impact on metahistory.4 The construction of an insane criminal personality In the introduction I addressed two questions concerning why the managers at the asylum asked the patients if they were insane or not. To explore these ques3. Petter Aaslestad, Pasienten som tekst. Fortelleren i psykiatriske journaler. Gaustad 1890–1990, Oslo: Universitetsforlaget, 1997. 4. Svein Atle Skålevåg, Fra normalitetens historie. Sinnssykdom 1870–1920, Bergen: Dr. art. dissertation, Historisk institutt, University of Bergen, 2003.

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tions further I will focus on how the two managing psychiatrists in Kriminalasylet in the period 1895–1915 carried out their missions as psychiatric experts through diagnosing the criminal insane. Did their diagnosing practices in the context of a criminal asylum differ from those in a regular asylum, and did their diagnoses have any other impact than as a tool to cure the patients? I have chosen to focus the period 1895–1915 because it covers the first twenty operational years of the asylum, during which it had two managing psychiatrists: Waldemar Bødtker (1895–1901) and Hans Evensen (1901–1915). They represented two different generations and schools of psychiatry. Bødtker was born in 1824 and passed his final university examination as general physician in 1848. He had been in service at the local city asylum in Trondheim for 41 years (1854–1895) when, at the age of 71, he was appointed as Kriminalasylet’s first managing psychiatrist. Evensen was born in 1868 and qualified as a general physician in 1892. In 1904 he became the third Norwegian to earn a doctorate in psychiatry, submitting a dissertation on the diagnosis of dementia praecox (later known as schizophrenia). In 1901, at the age of 33, Evensen accepted the appointment as the criminal asylum’s managing psychiatrist. Two types of journals were written during the managing periods of Bødtker and Evensen. The main journal, written by the managing psychiatrist, contained the “personal journal” of all patients. The psychiatrist had a significant literary freedom. Nevertheless, he was obliged to provide some mandatory information about each patient on their arrival and to submit annually statistics on all patients as a whole to the national central office of statistics. While the regular asylums started to use a new type of individual journals in 1915, Kriminalasylet continued to use the old system until the closure of the institution in 1963.5 The second type of journal was written by the inspector in charge and contained mainly day-to-day-notes concerning everything that happened in the asylum. These notes described everyday events and individual behaviour but also special incidents which were considered by the inspector in charge as significant information for the continuous psychiatric evaluation or the general security in the asylum. The inspector’s journal will not be discussed here; I want to focus solely on the psychiatric diagnoses. Were the journals of the criminal asylum in any sense different from the journals written in regular asylums? Not formally. The pre-printed columns were identical, and the psychiatrists were more or less forced to use the same descriptive framework. Both Bødtker and Evensen had practised in regular asylums, and they did probably not greatly change their acquired notions about how to write up psychiatric cases. As regards the content and literary style there were many similarities between the two types of asylum. In the Gaustad journals from 1890–1920 Aaslestad found a focus on behaviour, the absence of 5. Aaslestad 1997.

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descriptions of slow improvement of the insane, and the non-existence of the illness when nothing extraordinary occurred.6 Yet the patient journals of the Kriminalasylet always included two subjects that were not systematically present in the journals of the regular asylums. Firstly, the mental condition of the patient at admission was linked to a description of his overall criminal career. Secondly, whenever a patient’s release was proposed or considered, there was a thorough evaluation of both the mental condition and the general dangerousness of the patient in question.

Figure 1: The first page of the personal journal for a patient admitted to Kriminalasylet in 1909; it was written by psychiatrist Dr. Hans Evensen.

The personal journal kept by the managing psychiatrist was handwritten and organized in a special way. Every time a new patient arrived at the asylum, the psychiatrist dedicated the next empty page in the journal to the newcomer, even if the notes concerning the previous patient were not completed. When the page dedicated to a patient was full, the psychiatrist continued the case on the next 6. Aaslestad 1997: 57–64.

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empty page. Only one page or a few pages in the journal were dedicated to those patients whose stay was short. Those who were confined for a longer period received more attention and more pages were dedicated to them. It is not my intention to describe the nosology or etiology of psychiatric diagnoses, nor all the symptoms described in each psychiatric diagnosis. My objective is rather to show some of the challenges that the managing psychiatrists faced in their diagnosing practice around 1900. In this study, 83 individual journals concerning 77 patients admitted to the asylum from February 1895 to January 1915 have been examined. Of these 77 patients, five of them were admitted two times, and one three times.7 Ethnicity was not systematically recorded in the journals of the asylum, and it is not evident in the diagnosing process why such information might be needed and registered. Nevertheless, three of the 77 newcomers registered between 1895 and 1915 were identified as “Tater” (today Romani). A majority of the patients shared the experience of vagabondage. The number of native Norwegians among the patients who lived as vagabonds exceeded the total number of Romani.8 The tendency of many Romani to adopt Norwegian names makes it difficult to distinguish them from other Norwegians with a travelling habit. It is interesting to note that during the 68 years of the asylum’s operation no patient was identified as belonging to the Sami or Finnish (Kven) minorities in Norway. The geographic origin of the patients was very diverse. They came from all over Norway, but there was a predominance of patients from small and recently industrialized towns along the east and southern coast. Children from workingclass families were also overrepresented among the patients. Only four patients came from farming or fishing communities. Some common features link the patients together. Most of the patients had travelled a great deal in Norway, in Europe or/and on other continents. All of them had a lower-class background: they were labourers, sailors, miners, vagabonds, and so on. When they were not in institutions, they made a living from random jobs, mercenary activities, begging and/or vagabondage. All were men. Most of them were single and had never experienced much intimacy with another person. A majority shared the experience of instable childhood, orphan homes, reformatory schools, forced-labour institutions, regular asylums and penal institutions. During childhood, they had experienced many kinds of vio-

7. The 77 patients have the journal serial numbers 1–83. Statsarkivet in Trondheim, Kriminalasylet, Prot.: 5.01.01, 5.01.02 and 5.01.03. 8. My estimation, until a more detailed study is made on the ethnicity of the patients in general, indicates that five to seven patients were taters. The “taters” do not consider themselves as gypsies, but as an ethnic minority living mainly in Sweden and Norway.

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lence, conflicts, tensions, diseases and deaths. Their education was generally also quite chaotic. The story below illustrates, however, an exceptional case: The patient is born 2 July 1859 from good and respectable parents. ... There was no insane person in the family and his father is considered as, in all respects, an exemplary and proper man. None in the family is recognized to be addicted to drinking. Until the age of 18, the patient lived with his parents in a decent and well-maintained home. In his childhood he developed well and was a clever and healthy child. One of his teachers has characterized him as a gifted boy who used his gifts not as well as he could... In general, he was a nice and complaisant boy, not evil... But, at the time of his confirmation he started to look for bad friends and entered devious ways... (patient no. 13).9 It was Waldemar Bødtker who wrote this introduction to the personal journal of a patient admitted in 1896. He continued with the description of one of the most terrible sexually motivated homicides of a child ever recorded in the asylum’s journals. This individual, who died in the asylum 38 years after admission, was one of the most difficult patients to manage. The literary shift in the drama, from the description of a well-mannered kid to a man who, without any clear reason, became an insane criminal, expresses a very powerful argument for both the admission of the patient and his continuing confinement in the institution. However, it is interesting to observe that Bødtker did not discuss the diagnosing of this patient in relation to his childhood. Although few patients came from what was considered as better-off homes, the study of their life histories indicates that such individuals became the most difficult and challenging patients during their stays in the asylum, which were always for very long periods. On the other hand, among the less well-off patients their childhood and, with a few exceptions, the mental and social situation of their relatives were consistently used as a reason to explain their insanity. The insane and their crimes Patients came to the criminal asylum either because the courts’ forensic experts had classified them as insane and dangerous to the public security or because the psychiatrists at the regular asylums had classified them as a threat to the general life in asylums. The first group included two subgroups: firstly, patients 9. Statsarkivet in Trondheim, Kriminalasylet, Prot.: 5.01.01, p. 61a: “Pat’n er født den 2den Juli 1859 af brave og agtværdige Forældre … Der har ikke været Sindssyge inden familien, og hans Fader omtales som en i enhver Henseende exemplarisk ordentlig Mand, ligesom ingen i Slægten vides at have været henfalden til Drik. – Ligetil 18 aarsalderen opholdt Pat’n sig hos sine Forældre i et ordentliggt og hellerikke fattig hjem. I barneaarene udviklede han sig vel, og han var som barn altid flink og frisk. En af hans Lærere har karakteriseret ham som en begavet gut, som benyttede sine Evner mindre godt. … Men i Konfirmationsalderen begyndte han at søge slet Selskab og kom paa afveie…”.

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who were considered by the forensic experts as insane previous to or during the committed crime; and secondly, patients considered as insane by the prison staff after imprisonment. Some of those transferred from ordinary prisons did not exhibit severe enough symptoms to warrant classification as insane and the removal to an asylum, but were recognized as a serious problem by the prison doctors.10 Because a subsequent detection of a prisoner’s insanity did not exclude the possibility that the person had not been insane when he committed the crime, it is actually hard to determine the relative proportion of the two groups. Many of the patients had accumulated a serious criminal record and started serving in prison as youths. The patients can be divided into five groups according to the crimes committed. The first group comprises murderers who had either committed a homicide as the only crime or a homicide as the last of a long series of crimes. On average, they spent 15 years in Kriminalasylet. Nine of the 16 patients in this group had never been imprisoned previous to the homicide. Seven of the homicides were linked to a motive (sexual, jealousy, quarrel or escape from prison) related to the crime, and the rest were explained as random killing without an explainable cause. One of the patients in this group stayed 50 years in Kriminalasylet after having been incarcerated in regular prison for six-seven years. The second group consists of those who had committed different kinds of assaults and batteries towards other people or animals. I have not distinguished between serious and minor assaults and batteries, or sexual and non-sexual assaults and abuses. This group encompassed a majority among the older inmates, and most of them had had a crime career mixed with thefts. On average these persons remained 11 years and 3 months at Kriminalasylet. The third group are those who had committed different kinds of crime, generally simple thefts or burglaries, for profit or survival. The patients in this group stayed on average 7 years and 10 months in the asylum. The second and third group generally had in common that they had been imprisoned several times and had been diagnosed as insane by the forensic experts during their last trial, or that they had developed so-called “prison psychosis” after the last imprisonment. In this regard it should be noted that violent and sexual offenders became subject to psychiatric observation after the second or third offense, and those with a thieving or burgling habit after five or more sentences. Arsonists constitute the fourth group of patients, who numbered only three. All were first-time criminals when sentenced, and collectively they had the longest average stay at Kriminalasylet (16 years and 4 months). Their long stays were partly justified by forensic evaluations – as extremely dangerous and 10. J.F. Saunders, “Criminal Insanity in 19th century asylums”, Journal of the Royal Society of Medicine 81 (1988), 74; Hans Evensen, “Fra de første 10 aar af Kriminalasylets virksomhed”, Tidsskrift for Den norske lægeforening 26:3 (1906), 61–71.

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unpredictable – and partly by a strong unwillingness in their home communities to have them back. A medical report from a local doctor describing the mental condition of an arsonist demonstrates the lack of a psychiatric diagnostic vocabulary: “[He has] a dangerous form of impulsive madness” (patient no. 14).11 The description did not correspond to the vocabulary of psychiatry at the time, but it represented the best ability of the doctor to express his point of view about the patient. However, the doctor’s opinion was clear: it was not possible to control the patient’s impulsiveness; the local community was not able to control him, and he was dangerous for the society. As often in such cases, the local doctor evaluated both the mental and legal condition of the patient in his report. The fifth group is composed of those who had not committed a serious crime or no crime at all. They were four patients whose average stay was 15 years. Two of them were addicted to alcohol; one had escaped from a regular asylum; and one had set fire to the coal storage at Gaustad asylum in Oslo (not considered as arson). They were generally considered as dangerous for the public security, but they were also special because they were subject to preventive measures without having committed a (serious) crime. During the asylum’s first five years 1895–1900 the average age of the patients on arrival was about 36 years, and the overall average time of confinement was 10.5 years. From 1900 to 1915 the average age at admission slowly decreased to 31–32 years, mainly because of the accumulation of patients previously lodged in prisons and regular asylums. Some of the patients were released after the stipulated term of their sentence, but the majority was evaluated by the Ministry of Justice as still dangerous and was hence retained in the asylum for an unlimited time. A patient’s discharge from the asylum did not necessarily imply release to a free or regular life outside public institutions. Evensen commented on this in 1915: Over the years most of them develop dullness, which does not suspend their dangerousness, but makes it less noticeable... Over the years the insanity will also make them less active and thereby less dangerous.12 Eight of the 77 patients admitted to the asylum in 1895–1915 died there; the others were discharged to nursing homes, regular asylums, or prisons; either because they had not paid the penalty for their crimes or because they had became so dull that they were not considered as dangerous. None of them reestablished a regular life outside the criminal asylum, and practically all of them became institutionalized for the rest of their life. At the time of discharge 59 per cent of the patients admitted between 1895 and 1915 were considered as not 11. Statsarkivet in Trondheim, Kriminalasylet, Prot.: 5.01.01, p. 66a 12. Hans Evensen, “Forvaringen av farlige og særlig vanskelige sindsyke”, Tidsskrift for Den norske lægeforening 28 (1908), 1020.

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cured, 22 per cent as cured and 9.5 per cent as improved. The remaining 9.5 per cent were those who died in the asylum. In 1978 Michel Foucault published an article where he argues that it was not through “the ill-defined zone of day to day disorders” that legal psychiatry in France apparently was able to penetrate the penal justice system in full force; rather it was by tackling the great criminal events of the most violent and rarest sort.13 In Norway this was not the case. Here the penetration of psychiatry into the legal system was characterized by a high diversity in types of crimes and mental disorders. Literary style and valid information The journals of Waldemar Bødtker do not follow a strict formal disposition and he could use one-four pages of each individual journal to write the biography of the patient. The first year he mainly gave his attention to the institutional history of the patients, from asylums or prisons, and he was very brief in his remarks about the medical history of the patient’s family and the cause of the disease related to his life history. During the next years Bødtker slowly expanded his attention to include more aspects of the patients’ life history. He did not confine himself to written sources. Sometimes it is evident that the information recorded came directly from the patient or was based on Bødtker’s own observations. Expressions entered in the column for social causes related to the disease were: “drinking”, “heritable predisposition”, “indulgent life”, “unknown”; most commonly the column was empty. In the first year after his appointment, Hans Evensen followed Bødtker’s example, but from 1903 his descriptions gradually became more expansive, especially concerning the medical and social history of the patients’ families: Aunt (according to the doctor sick), Grandmother epilepsy (very intense and attempts to escape), A cousin is very intense, wants to escape. Father tended to drink when he was young. Mother nervous, intense (at least before). Mother’s aunt mentally reduced. Aunt, “chest spasms”. Many relatives of the mother hallucinates, but, exemplary people. An uncle wanted to beat his wife on her head with a shoe, because she wanted him to pick up a sleeve ... During one period jealous without reason. Insane? (patient no.81)14

13. Michel Foucault, “About the Concept of the ‘Dangerous Individual’ in 19th-Century Legal Psychiatry”, International Journal of Law and Psychiatry 1 (1978), 4–5. 14. Statsarkivet in Trondheim, Kriminalasylet, Prot.: 5.01.02, p. 133b: “Faster (efter leg. sygdom). Mormor epilepsi (heftig og rømmelysten). Far i sin ungdom drikfældig. Mor nervøs, hidsig, ialfald før. Mors faster små evner. Moster “brystkrampe.” Mange i slegten på morssiden halun., men udmerkede mennesker. En morbror vilde således slå sin kone i hodet med en begsøm sko, fordi hun bad ham ta op en manchet … En tid jaloux uden grund. Sindssyg?”

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Evensen did not restrict his diagnoses to the patients’ conditions alone, but included even relatives’ symptoms and simple attempts to diagnose them as well with the objective of refining or confirming the diagnosis of the original patient. During his six years as managing psychiatrist, Bødtker commented on the social, medical and mental condition of approximately 20 relatives, while Evensen surveyed the same conditions for more than 100 relatives during his 14 years in office. In addition Evensen included general social, medical and mental characteristics of the families in his judgements, such as: “The family to some extent unintelligent”, “The family is thievish”, and “The parents are strange”. It is difficult to understand the intention of recording this information as other than an attempt to survey the heritable (social and biological) causes explaining crime and insanity. However, it is not possible to discover any practical impact of all this information. Gradually Evensen organized his journals on individual patients in a more structured way with subject areas such as physical descriptions, list of prison sentences, and so on. He also extended the range of sources of patient information. He consulted court documents, reports made by forensic experts, doctors, priests, directors in prisons and asylums, other patients, policemen, relatives, friends, crime witnesses, not to forget the interviews of the patients. In addition, from reading the asylum inspector’s journals I have concluded that some of the patients were retained in the asylum after their recovery in order to provide Evensen with tacit knowledge about other inmates. Like Bødtker, Evensen did not care much whether the information before him was first- or second-hand. Indeed, it looks like Evensen was putting all available information into a “blender” and mixing it with the purpose to make an atrocious, but well-organised and liable story. The validity of the information was not of the highest importance for either Bødtker or Evensen. More and more as I read the individual journals, I developed the impression that “the truth” was of minor interest when they were writing about the patients. What they searched for was relevant information, whatever the source, in an attempt to create a coherent story which supported the next and conclusive step: the diagnosis. For instance, they never questioned the information provided by the patients or others. The only information they ever questioned – a few times – was the diagnostic evaluations by the forensic experts of the courts. The construction and use of diagnosis The first time I opened the journals, I expected to find screaming and unbridled examples of insanity, shocking in all their madness. I did not find this. After reading one, two, three and many more individual journals, everything looked normal to me. There were, to be sure, descriptions of life histories which were shocking and of serious incidents which regularly occurred, but nothing that

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could not happened anywhere else in the society under similar conditions. Slowly the question of where the insanity was hidden became more and more present in my mind. While I studied the journals in detail, searching for Bødtker’s and Evensen’s descriptions of insanity, I gradually realized that it was not me who was not able to interpret the complexity of the journals. It was Bødtker and Evensen, who had an impossible challenge to solve. They were not able to express the insanity they observed by using the available means. They never expressed this problem, but it is evident and it is difficult not to feel sympathy for their never-ending effort. What were they trying to achieve? From what I understand, they tried to get linguistic access to the inner core of what was going on in the mind of the patients. But they desperately lacked a sufficient vocabulary to scientifically describe the unknown world of the insane mind, and they did not have any source to get such a vocabulary from. It did not exist!15 Psychiatry, as it developed in the nineteenth century, contrasted with general medicine in the absence of the human body. This does not mean that psychiatry did not search for organic correlations with physical lesions involved in the cause of insanity. There was a continuous search for such correlations and some were discovered, such as meningeal lesions as after-effects of syphilis. However, the main problem to be resolved in psychiatry was not whether a particular form of behaviour – strange speech, illusions or any kind of hallucinations – was related to a form of lesion, but whether a certain kind of behaviour unconditionally belonged to insanity or not.16 What is a diagnosis and what does it do? What a diagnosis is has no plain answer, but more recent textbooks in medicine consider it both a process (differential diagnostics) and a label (diagnosis).17 The diagnosing process of each patient is performed by the doctors and includes the integrating and evaluating of data that are obtained during the examination to describe the patient’s condition in terms that will guide the prognosis, the plan of care and treatment strategies. Added to this, as I explore in this chapter, the result of the diagnosing process is also a continuous negotiation process involving the doctor, the patient, and the interests of other actors involved. The definitional meaning of what a diagnosis is has not changed considerably during the twentieth century. What do diagnoses do? This question is more complex. On the one hand, today 15. In their study of the journals of patients at Rønvik asylum Elgarøy and Aaslestad had a similar impression, that the only “technical terms” they found in the period 1902–40 were almost merely the naming of the diagnosis. Sigmund Elgarøy and Petter Aaslestad, “‘... det er ingen rede at faa paa ham’: Samiske pasienters psykiatrijournaler 1902–1940”, Tidsskrift for Norsk psykologforening 47:7 (2010), 587–92. 16. Jacques Lagrange (ed.), Michel Foucault: Psychiatric Power, Lectures at the Collège de France 1973–74, New York: Picador, 2003: 266–67. 17. APTA, Guide to Physical Therapist Practice, 2nd ed., Alexandria, VA: American Physical Therapy Association, 2001.

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as in the late 1800s and early 1900s, they release some formal rights related to economic issues, treatment and cure. From the perspective of the patient, there is an explicit link between the confirmation of a diagnosis and the prescription of a treatment. On the other hand, diagnoses are results of negotiations between a variety of actors with scientific, social and political interests (psychiatrists, patients, relatives, health authorities, etc.). Each of them gives arguments to the content and use of diagnoses based on their own specialist understanding of the diseases and more general understanding of the society. In Kriminalasylet the interests of the legal and health authorities, the psychiatric discourse of the period, and to some extent the voices of the relatives and patients were continuously present. Yet during the period of my study, this was not an obvious link because it is not possible to trace any use of active treatment at all. Both Bødtker and Evensen seem to have been mostly interested in the diagnoses as labels and less in diagnosing as a process guiding a plan of care and treatment strategies. Psychiatric diagnoses as labels represent a classification of the state of mind, whereby each category (diagnosis) is related to the presence of some particular characteristics in behaviour or ways of thinking. From the perspective of diagnoses as label a diagnosis is a tool not only to confirm a specific condition, but also to understand differences in the human mind in general. It is expected to give a vocabulary to some specific features in the human behaviour and thinking that make them recognisable. Equipped with an almost unlimited curiosity and creativity, Evensen, like other contemporary psychiatrists, used three strategies to enter the unknown world of the patients’ minds: organic correlation, interviewing and observation. In the first strategy, organic correlation, Bødtker and Evensen looked for physical traits connected with a specific diagnosis, either by examining the shape of the head, weight, height, the appearance or shape of ears, the conditions of the eyes, body temperature etc., or by studying the brain through an autopsy. Both of these methods, which were attempts to try to learn by experience and collecting enormous amounts of data, turned out to have not much impact on the diagnosing of incoming asylum patients. The second strategy was to interview asylum patients on arrival. In somatic medicine the patient shows the doctor symptoms and the doctor informs the patient of the associated disease, but the psychiatrist wants much more than access to immediate symptoms in his diagnostic considerations. Especially Evensen wanted to be provided with the life history, the reason for people’s complaints, what the patient had said, and how he had behaved. Foucault has interpreted the objective of this collecting as an attempt to establish the legitimacy of the psychiatrist.18 The challenge confronting the psychiatrist in a crim18. Lagrange 2003: 268–69.

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inal asylum was the danger to become reduced to a mere prison manager, if the patient did not want to tell his life history. The challenge for both Bødtker and Evensen when interviewing was twofold. They wanted to get access to the pathological symptoms of the disease, and they wanted to develop the reputation of the institution as an therapeutic asylum rather than a punitive prison. The third strategy, observation, involved an ongoing activity that was not limited to the immediate identification of symptoms and finalization of a definitive diagnosis. It entailed subjecting the patient to a continuous and unlimited observation until he left the asylum, or another institution followed up, or he died. Observation was an everlasting process of lifetime examination of the patient. A manifestation of this strategy is the title of the diagnosis column in the journal: “temporary diagnosis”. Consequently, diagnosing became a lifetime process of diagnosing and rediagnosing. It was not unusual that asylum patients were re-diagnosed, or that new diagnoses were added to their former diagnoses many years after their admission. One of the patients at Kriminalasylet was registered with three distinctive diagnoses at the same time (amentia, insania paranoids and dementia praecox) that by definition were more or less mutually exclusive. Probably this is yet another example of the lack of psychiatric terminology and other means to interpret and classify patients’ condition. When confronted directly, all patients cheerfully and passionately at every opportunity denied the unspecific diagnoses as insane and opposed their sentences by claiming innocence or demanding the reopening of the criminal case. On the other hand, they rarely, if ever, questioned the specific diagnoses attached to them. Why did the specific diagnoses not interest them? Probably because they lacked the argumentative power to deal with these. The only and ultimate important question for the patients, the court and the forensic experts was: insane or not? The answer to this simple question was the only interesting issue, because it decided their continued stay in, or release from, the asylum. Scientific diagnosing and the patients Diagnosis as scientific classification went through a profound development and restructuring in the late nineteenth and early twentieth century, especially the diagnosis of schizophrenia. This development, with all its confusions, was evidently present in the diagnostic practice of Waldemar Bødtker and Hans Evensen. The term “schizophrenia” was introduced in 1908 by the Swiss psychiatrist Eugen Bleuler, but its diagnosis was derived mainly from the German psychiatrist Emile Kraepelin’s research on dementia praecox. “Dementia praecox”, first defined by Bénédict Morel in 1853 as a syndrome affecting teenagers and young adults, was the precursor of schizophrenia.19 Its symptoms were gen19. Roy Porter, Madness, London: Faber and Faber, 1991: 393–98.

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erally delusions, hallucinations, disturbed associations, lack of intentions, and insensibility. Morel argued that it was a mark of social degeneration. During his research on dementia praecox Kraepelin introduced a broad new distinction in the classification of mental disorders, “manic depression”. Kraepelin believed that dementia praecox was primarily a disease of the brain and particularly a form of dementia.20 The need for another concept to replace the dementia praecox diagnosis became evident to Bleuler when he realized that this disease did not necessarily develop solely among young people but was also found later in life. Schizophrenia was not a diagnosis found in the patient journals of Kriminalasylet before 1920, but dementia praecox was used coincidently with diagnoses which a few years later merged into schizophrenia. The second most used diagnosis at Kriminalasylet was “insania degenerativa”. Sixteen of the 106 single diagnoses, or 17 per cent of all diagnoses at the asylum between 1895 and 1915, were devoted to this mental disorder. Insania degenerativa was not merely a psychiatric diagnosis; from the 1880s it merged with criminological social theories, especially those associated with the Italian criminologist Cesare Lombroso. Lombroso introduced the concept of “the born criminal”, which was based on the postulate that some humans were predisposed to poverty, crime, alcoholism, moral perversion, insanity and the like. According to this theory, each generation of such persons became weaker and weaker until in the fourth generation they became sterile and the family died out.21 The diagnosing of insania degenerativa at Kriminalasylet seems partly to have been based on observed symptoms, partly on surveys of the individual’s crimes and mental history, and partly on evidence of alcohol addiction among the patient and his family. In 1911 Evensen was the first Norwegian psychiatrist to publish an article criticizing the degeneration theory.22 Paradoxically, he did not use the diagnosis insania degenerativa in the period 1905–09, but he reintroduced it before the appearance of his article and used it eight times during his last four years at Kriminalasylet. I will discuss this paradox below in relation to the use of the diagnosis alcoholismus and the conspicuous absence of the psychopathic personality disorder among the patients. Most of the patients at Kriminalasylet had already been diagnosed by forensic psychiatrists before their arrival there. Nevertheless, the asylum’s managing psychiatrist, especially Evensen, wrote up all the relevant facts about the patients that were available and made up his own opinion about the previous 20. Emile Kraepelin, Text book of psychiatry, London: Macmillan, 1907. 21. Mary Gibson and Nicole Hahn Rafter, Criminal man, Durham and London: Duke University Press, 2006. 22. Svein Atle Skålevåg, “En sykdom tar form: Om psykiatri og konstruksjonen av sinnssykdom i asylets æra”, Historisk tidsskrift 3/2000: 359.

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diagnoses as a stage in arriving at his own assessment. Most of the time he agreed with the previous diagnoses, but it happened that he wrote a question mark behind them and entered his own diagnosis. Consequently, the diagnoses registered in the journal were the result of a negotiating process, whereby Evensen consulted previous forensic reports, his own interviews with the patient, information from other informants, his own observations as well as available scientific knowledge about mental diseases. The journals show that a huge majority of the patients in the asylum had serious alcohol abuse problems previous to their admission, but the diagnosis “alcoholismus” was used specifically only nine times (8.5 per cent of all the diagnoses). The first who used alcoholismus as a diagnosis was not Evensen himself, but his substitute in 1903–04, Johan Scharffenberg. Neither Scharffenberg nor Evensen used the degenerativa diagnosis in the period 1903–10, and the alcoholismus diagnosis seem to have been introduced as a replacement for the alcohol abuse part of the degerativa diagnosis during these years. This impression is supported by the fact that when the degenerativa diagnosis was reintroduced in 1910, the alcoholismus diagnosis was abandoned. The fact that both Scharffenberg and Evensen were prominent members of the Norwegian temperance movement and that both had a political, social and scientific interest in the correlation between alcohol abuse and insanity probably explains the introduction of the alcoholismus diagnosis. The reason why Evensen abandoned it in 1910 and reintroduced insania degenerativa is not obvious, but he probably realized that alcohol abuse was primarily a symptom or even a cause of insanity, not a diagnosis in its own right, and/or that in assigning “alcoholismus” he lacked a diagnosis covering patient symptoms other than alcohol abuse. Another diagnosis, which Lombroso included in the concept of degenerativa, was “epilepsy”. Seven patients (6.5 per cent of all the diagnoses) had this diagnosis. An interesting observation from the study of the journals from Kriminalasylet is the absence of the manic depressive psychosis, which was described by the German psychiatrist Julius August Koch in 1891 and by Kraepelin in 1904 as constituting “psychopathic personalities”. Kraepelin distinguished four varieties of psychopathic personalities: born criminals, pathological liars, querulous persons, and “Triebmenschen” – persons driven by a basic compulsion, including vagabonds, spendthrifts and dipsomaniacs.23 Again we find, as we did with the relationship between the alcoholismus and insania degenerativa diagnoses, a diffuse demarcation between Kraepelin’s new concept and other used diagnoses, especially the insania degenerativa diagnosis with its implicit socially undesirable forms of behaviour rather than medical symptoms. One double 23. Richard F. Wetzell, Inventing the Criminal: A History of German Criminology, 1880–1945, Chapel Hill and London: The University of North Carolina Press, 2000: 146–47.

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diagnosis, made by Evensen in 1905, of “insania periodica” and “insania manico-melancholica” could have been inspired by Kraepelin’s description from the previous year. The following quotation from the diagnosis column of a patient journal written by Evensen in 1914 indicates that psychopathic personalities were covered by the degenerativa diagnosis: Hereditary predisposition on both sides [of the family] concerning reluctance to work and thefts. Intense, difficult to stop his anger, brutal self-assertion. Aimless thefts, almost always in prison. When imprisoned he has periods of anger and destructiveness. Needs to draw attention to himself and impose on others, socially disabled, affected. Depressions, sleepless, hypochondriac, paranoia, 04. stuporious period, 07. Simulation, 10. anxiety, paranoid ideas, 11. threatening, impudent, pursued, 12. hypochondriac, pursued, incitement to riot (patient no. 80).24 The quotation above exemplifies the mixture of social and medical symptoms that went into making a diagnosis. The suspicion that psychopathic personalities already from 1910 had become included in the degenerativa diagnosis is strengthened by the fact that the term “psychopath” was used explicitly as a symptom of insania degenerativa in a number of diagnoses in the first half of the 1920s. “Insania degenerativa” was used at Kriminalasylet until 1920 and “dementia praecox” until 1929. The long use of these two diagnoses is probably related to the fact that the Norwegian diagnostic system did not include schizophrenia before 1926. In addition, Evensen’s successors at Kriminalasylet did not have the same scientific curiosity and interest in psychiatric diagnosis. Evensen had written a doctoral dissertation on dementia praecox, published scientific articles nationally and internationally, and had a huge collection of the most recent French and German psychiatric literature. His admiration of Lombroso’s criminological theories is probably less important as an explanation for his analyses of patient behaviour than his adoption of Kraepelin’s scientific methodology, that is, the extensive and systematic exploration of the patients’ lives. Added to this, he mainly, despite his theoretical interests, had a practical approach to patients’ everyday needs and challenges. The theories of Lambroso, in contrast to the more practical aspects of the scientific work of Kraepelin, were probably not very helpful for Evensen in his everyday work at the asylum. 24. Statsarkivet in Trondheim, Kriminalasylet, Prot.: 5.01.02, p.129a: “Arvelige anlæg på begge sider til arbeidsskyhed og tyveri. Heftig, vanskelig for at stope sit sinne, brutal selvhævdelse. Planløse tyverier, næsten uafbrudt I føngsler. Ved frihedsberøvelse sinnestogter med ødelæggelseslyst. Trang til at gjøre sig bemerket og dupere, knotet, affekteret. Depressioner, dårlig søvn, hypokonder, forfølgelsestanker, 04. stuporøs periode, 07. ‘simulasion’, 10 ængstelse, paranoide tanker, 11. Truende, uforskammet, ‘efterstræbet’, 12. Hypokonder, forfulgt, opviglende”.

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The most frequently used diagnosis throughout the entire period 1895–1915 was “paranoia”. Twenty-six of the 83 admissions (24.5 per cent of all diagnoses) had this diagnosis, the most prominent feature of which was delusional beliefs. Paranoia was used more regularly in relation to serious crimes than to minor one. Paranoia originated in ancient Greek medicine and was introduced in Germany in 1772; it was defined as a peculiar mental disorder by the French psychiatrist Ernest Charles Laségue in 1852. Evensen’s predecessor as asylum psychiatrist, Waldemar Bødtker, used paranoia as a diagnosis more extensively than he did. Bødtker diagnosed it 15 times during his five years in office, Evensen 11 times over 14 years. Evensen used it less frequently probably because paranoia became more and more integrated with dementia praecox. Curiously, Evensen used it only once during his doctoral research on dementia praecox, but increased its use in the ten years that followed. “Idiocy” and “imbecility”, considered congenital mental disorders, were diagnoses applied to another large group of patients. There seems to have been an overlap between the idiocy and the imbecility diagnoses and another diagnosis, “amentia”. From the 1890s amentia was considered as a disease that disabled the patient’s ability to learn through his more or less conscious experiences. These three diagnoses were used 11 times, representing 10.5 per cent of all diagnoses. Other diagnoses assigned to asylum patients were melancholy (seven patients), insania periodica (three patients), insania hypochondria (four patients), insania hysterica (one patient), insania manico-melancholica (one patient), and simulation (two patients). The average age of these patients at arrival at Kriminalasylet was 30 years, and none was older than 40. Following Kraepelin, the diagnosis of “melancholy”, characterized by anxiety, irritability, agitation and delusions, was from 1899 devoted to depressive patients between 40 and 65 years old. Since the average age of the patients on arrival at Kriminalasylet was 30 years, and none was older than 40, this diagnosis fell into disuse. In all, fourteen different diagnoses were used by Kriminalasylet’s managing psychiatrists Waldemar Bødtker and Hans Evensen in the years 1895–1915. I have discussed the diagnoses as they are mentioned in the registering column in the journals. A few of the diagnoses assigned, such as “simulation” and “alchoholismus”, were not strictly speaking psychiatric diagnoses, but rather etiological explanations of insanity. Conclusions In 1974 Foucault asserted in one of his lectures on psychiatry that the psychiatric diagnoses appear to develop as the differential diagnosis of one illness as distinct from another. But in truth, he says, “I think all this is only superficial and secondary activity in relation to the real question posed in every diagnosis

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of madness, which is not whether it is this or that form of madness, but whether it is or is not madness.”25 In the introduction I asked why the managing psychiatrist asked all patients on arrival at Kriminalasylet: “Are you insane?” The question was frank, straight to the point and opened the dialogue between the managing psychiatrist and the patient. The question itself was not based on a scientific understanding of insanity but referred mainly to a popular understanding of the condition. It turned out to be the only question regarding the diagnoses that the patients answered directly. A “yes” from the patient settled the issue, for everyone agreed: authorities and patient. A “no” from the patient had several implications. On the one hand, the managing psychiatrist interpreted the denial as a confirmation of the patient’s real insanity. On the other hand, a patient’s “no” indicated his refusal to accept the legitimacy of his committal to the asylum. A “no” thus satisfied the need of both the psychiatrist and the patient to confirm their respective selfidentity. The psychiatrist achieved a confirmation of the importance of his presence as a psychiatrist, and the patient achieved an opportunity to oppose one of the two main reasons for his arrival at the asylum. Diagnosing was a difficult activity at Kriminalasylet, but it served several important functions. The criminal insane were defined as patients through disciplinary and interdisciplinary scientific dialogues and dialogues with the individual patient. Whether they liked it or not, the dialogues gave the psychiatrist a self-identification and defined the institution as an important instrument of government policy in the effort to achieve a less dangerous society. But these functions had also some more or less evident dysfunctions. Firstly, the psychiatrist wanted to diagnose his patients by understanding their mind despite the fact that he did not have any scientific vocabulary to describe the insane mind. Secondly, by denying their insanity the patients opposed the psychiatrist’s role as a diagnostic physician. Finally, the government wanted to achieve a more secure society, but that more or less entailed the denial of the legal and medical rights of the patients. The main reason why the patients were committed to the asylum was that they were considered a threat to the general security of society. The next reason was that they were insane and therefore required medical treatment. The main reason why Waldemar Bødtker and Hans Evensen were hired to manage the patients of Kriminalasylet was their professional medical training in psychiatry. The next reason was that they were positioned to keep the criminally insane locked up. Both Bødtker and Evensen did their job as psychiatrists apparently well, considering the expectations put on them and the resources which were available to them. They diagnosed the patients with a scientific curiosity, informed annually the relevant authorities on the mental conditions of each patient, 25. Lagrange 2003: 266.

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informed the relatives on request, and they tried as well as they could to be up to date on the scientific developments in psychiatry in Europe. They basically tried to carry out what they were trained to do, just as all psychiatrists in Norwegian asylums were trained to carry out. But all these efforts had little impact on the treatment or the mental improvement of the patients under their care. It is relevant to object that treatment in regular asylums also accomplished little, but in Kriminalasylet this lack had an additional consequence. Because the diagnoses were not followed up by any kind of active treatment, the main function of diagnosing was reduced to providing an additional reason for locking up the patients, supplementing the evaluation of patient dangerousness. The basic question at the end was not whether the patient was suffering from this or that form of insanity, but whether the patient was dangerous or not dangerous for society.