My interests in history look straightforward enough: the representations and experiences of marriage, family relationships, and feminine and masculine identities. Yet all this actually means that I’m often driven into reading in specialist areas that are entirely unfamiliar. Along the way I’ve had to get to grips with several aspects of the law (common, canon, poor, settlement and vagrancy). I’m forever finding out about artistic, literary and cultural trends and genres. I’ve mugged up on medical and lay attitudes towards bodies and reproduction. And now, my latest unexpected journey is into madness (yes, sometimes literally, but also its historical scholarship). This follows thinking about how men encountered ‘rules’ about unmanly behaviour and emotions (You can see the first stages in this blog post). Having long been familiar with eighteenth-century men described as mad when they acted irrationally and violently towards their families, I also realised that men who did not control their passions more generally could also be medically defined as insane.
Thus I have begun to read about the treatment of the insane. Let’s be frank, I’ll only ever skirt round the edges of this established scholarship. I’ll read some absolute classics, but I’m also letting serendipity guide me. For example, I’m interested in ‘moral treatment’ and fond of the Quaker Tuke family so Anne Digby’s book on the pioneering Retreat in York is essential (and she’s my former colleague!). I also need to push further into the nineteenth century and my wonderful colleague Dr Carol Beadle recommended an Oxford Brookes PhD on two Surrey mental asylums by Anna Shepherd. I was then delighted to see that Anna’s thesis has just been published as a monograph in the Pickering & Chatto ’Studies for the Society for the Social History of Medicine’ and have decided to review it here as a little thanks to the gods of serendipity.
Institutionalizing the Insane in Nineteenth-Century England is a really effective comparative study of Brookwood, a public county asylum (established by the Metropolitan Asylum Board in 1867), and Holloway Sanatorium, a private asylum (set up by private bequest and completed 1884. The first served poor patients, the second middle-class certified patients and voluntary boarders. Shepherd covers the construction, staffing, and management of the asylums and closely analyses their patients. This is ideal for my attempt to get to grips with the diagnosis of insanity, its treatment and outcomes. Although I’m predominantly interested in male patients, this empirical study examines both sexes and thus sets my interests into context. Strikingly, it shows that social class was more influential than gender in shaping patient treatment and outcomes. Shepherd challenges several stereotypes of madhouses: as forms of social control; of county asylums as dumping grounds for poor people with no curative agenda; and of the institutions as convenient places for men to deposit troublesome females. What emerge are the humane endeavours of both institutions to provide the best care they could for patients, and the care of families who sought out the best treatment for mentally ill family members.
Still, Shepherd finds that money and status mattered. In design Brookwood was far larger and more utilitarian and Holloway catered for fewer patients and was more luxurious. Holloway had more resources because it charged its patients, the wealthiest of whom subsidised treatment for others. Hence it could afford more costly treatment and innovative regimes. One of the interesting features of Holloway was that it also accepted voluntary boarders who were intriguingly defined by a contemporary as the ‘semi-sane’ (p. 75). I’m really interested in this group who – along with their families – must have seen the sanatorium as a temporary refuge, a place to get respite care for less serious mental health conditions. As Shepherd points out, this was a way to enter an asylum without the stigma of being certified; a taint which the medical staff recognised could undermine successful treatment.
There were numerous similarities between the institutions too. Though both asylums were served by rail-transport links, they were fairly isolated in the Surrey countryside which affected their capacity to attract and retain staff (chapter 2 on doctors and attendants). Both implemented moral treatment and activity-based therapy where patients were removed from the causes of their troubles in order to aid recovery. Patients’ lives were scheduled with activities to distract their minds. Gender shaped Brookwood patients’ work with women doing cleaning, sewing, and knitting and men carrying out outdoor work and gardening. Social status remained critical, with Holloway providing recreation-based activities to its paying middle-class clientele in contrast to the early forms of occupational therapy at Brookwood. Nonetheless, both laid on entertainments of various kinds. Christian values were promoted, and it speaks volumes about attitudes towards emotions that the commissioners in lunacy advocated that sermons promoted cheerfulness to avoid melancholy (p. 127).
The central chapters, 3-6, focus on the patients, including their social origins, the reasons for admission, and treatment. Both admitted fairly equal numbers of male and female patients and larger numbers of single people than married. However, around 42-45% of Brookwood’s patients were transferred from workhouses and the same amount from home while almost all of Holloway’s patients arrived from their homes. Shepherd deduces that the workhouse transfers to Brookwood were often young men (single and aged 16-35, p. 95) who were deemed most difficult and troublesome by the workhouses and thus moved on as fast as possible. Moreover a number of the patients who arrived from workhouses were in a poor physical condition, vermin-ridden and undernourished. Poverty was thus a powerful determinant shaping the patients’ experience though, as Shepherd insists, Brookwood made considerable efforts to get these people back to good physical shape. Yet it is hardly surprising that more of the Brookwood patients were discharged ‘relieved’ or ‘not improved’ and the asylum had a higher mortality rate than at Holloway where recovery and mortality rates were higher (pp. 107-8). This did not guarantee the safety of wealthier patients, however. Middle-class patients were given a little more liberty and so the surveillance of those with suicidal tendencies was laxer. This resulted in more ‘completed’ suicides in Holloway (chapter 6) than Brookwood, which is just as well given that over a third of the patients admitted were perceived to have suicidal tendencies.
I particularly enjoyed chapters tackling the diagnoses and outcomes of patients, wherein the stresses and strains of nineteenth-century life are glimpsed. The asylums categorised patients within the ‘moral’ causes of insanity: mental worry, domestic troubles (including bereavement), and adverse circumstances. Many of these are familiar to us, with the causes for men often cited as business worries, or anxiety about work. Disappointment in love was also a trigger, along with religious excitement, which, one wonders, was perhaps class-related since Holloway had a higher number of patients whose mental health problems were seen as its result. The ‘physical causes’ of insanity were intemperance, bodily disease, and in the last couple of decades of the nineteenth century, hereditary insanity. Gender shaped expectations. The wage-earning and breadwinning demands must have exacerbated men’s mental strains when they failed to fulfill them. The Medical Superintendent at Holloway even claimed that men were more prone to ‘mental impairment’ for this reason, suggesting considerable cotemporary empathy with the pressures on men to work effectively and provide for their families (p. 108). Shepherd also proposes that this may well have encouraged families to invest in men’s treatment because of their vital economic contributions.
Gender was related to diagnoses too. Married women who showed inappropriate ‘erotic’ behaviour or other unacceptable conduct in public, such as trying to strip off clothing, for example, were deemed insane. Shepherd didn’t find that the two asylums were repositories for troublesome women, nonetheless. Middle-aged women did tend to stay longer than men, though as Shepherd points out, this was more likely due to the limited economic and residential options for women over 45 who had suffered from mental illness. Treatment seems to have been gender-related too. Men who were observed to excessively masturbate might have ‘blisters’ applied to their necks or genitals to act as a ‘counter-irritant’ to divert their minds. One can only speculate what moral strictures drove a 56 year old married tailor in Dorking Workhouse to amputate his penis with a pair of scissors after a short stay. Diagnosed as melancholic he was rapidly transferred to Brookwood for care in February 1877.
Shepherd takes a resolutely empirical tone and only occasionally lets slip her sense of the distressing nature of these records of people’s despair, mania, and terror. She talks of one of the ‘haunting’ cases, from which simple adjective I take to mean that some of these men and women’s stories remain with her. For her it is Catherine T, a 32 year old unmarried nurse with melancholia who in 1870-5 was transferred five times between four mental asylums before succeeding in her aim to commit suicide. I guess that what especially haunts Shepherd is Catherine’s declaration after being transferred to Brookwood that she could not sleep well at night owing
‘to her great joy at being treated as a human being’ (p. 163).
Indeed in the chapter on suicide, it is the relentless, dogged determination of the men and women’s repeated attempts to commit suicide that is so disturbing. In a world where the main strategy to prevent them succeeding was ‘careful watching’ the distress which drove them is too frightening to imagine.
I’m really delighted by the unexpected routes down which my research diverts. All in all, I’ve found Institutionalizing the Insane to be a tremendously effective, informative book. It is has been immensely useful to me in my ongoing endeavour to think about gender, the family, bodies, minds and institutions. In fact, as I find here, these journeys are not diversions, but another vital link in my mental map of life in the past.