‘Occasionally heard to be answering voices’: aural culture and the ritual of psychiatric audition,1877–1911

On a rainy Friday afternoon in January 1911, five of the top physicians at St Elizabeths Hospital in the District of Columbia had a meeting with superintendent William Alanson White to discuss the case of patient 4388, native Virginian Laura Sears. ¹ They worked from ward notes begun upon Sears’s admission to the federal mental institution in 1877, notes that continued sporadically through the first month of 1910. The admitting physician had scribbled that she suffered from chronic mania, a form of insanity the symptoms of which included some combination of anxious physical movements, emotional exaltation, uproarious noisemaking and verbal inability. ² In 33 years of residence, Sears’s attendants most often found her sitting on the floor of the ward while she cried, laughed and talked to herself. If not herself, she would often speak with the rag dolls she had pieced together from scraps of her own clothing. ³ White refrained from comment as his medical staff debated the diagnosis. Bernard Glueck, a recent addition to the team, was the first to wade into conjecture. ‘It might just as well be classified as undifferentiated dementia’, he suggested. Nicholas Dynan proposed ‘dementia unclassified, probably praecox’, highlighting Sears’s perceived mental deterioration and disorientation. When Alfred Glascock emphasized the patient’s auditory hallucinations and incoherent, delusional conversation by suggesting unclassified psychosis as an alternative, Mary O’Malley agreed but thought there may have been a cognitive element as well. ‘She may have been an imbecile or idiot,’ O’Malley speculated, ‘or may have at one time had school knowledge and become demented.’ George Schwinn, unconvinced by O’Malley’s digression, aligned himself firmly with Glascock. The entire discussion could not have taken more than 10 minutes. White revised Sears’s diagnosis from chronic mania to ‘dementia unclassified’ and then shifted his team’s attention to yet another case file for diagnostic consideration. It was an unspectacular professional moment, one to be tucked away among thousands of other patient case files.

This moment may also appear unspectacular for those familiar with the history of psychiatry. The profession’s tendency toward copious classification is well documented in both the primary and secondary literature, a tendency that most agree fell out of favour over the course of the twentieth century with both internal and external critics of the profession. The broader public – and even practitioners themselves – lamented that centuries of professional preoccupation with nosology had not resulted in its ultimate goals of effective treatment and cure. In their attempts to distance themselves from their predecessors, goes the traditional historical narrative, twentieth-century practitioners abandoned the art of classification in favour of the scientific pursuit of knowledge made possible in the wake of advances during the second half of the nineteenth century (Lunbeck, 1994: 115). Yet this dichotomy between modern medical science and the antiquated art of classification depends upon a surprisingly narrow definition of science that neglects the layers of meaning the term carried at the turn of the century. ⁴ Even historians aware of these multiple layers neglect certain iterations of sciences that developed synchronically (such as those considered in this essay) in favour of those sciences that we prefer today (such as advances associated with looming figures Robert Koch, Louis Pasteur and Joseph Lister) (Bynum, 1994: 118–41, 195). ⁵ This may in part be a reaction to what historian W.F. Bynum has described as psychiatry’s isolation ‘from general medicine and from society itself’: in efforts to legitimize their chosen specialty to other physicians, practitioners have lamented the habits of their predecessors to lay more solid claim to their own efficacy and relevance (Bynum, 1994, 195; Grob, 1994, 130.). This is also a misstep of historians, however, who similarly attempt to establish psychiatry’s importance in medical history broadly conceived. Encouragingly, historians such as Elizabeth Lunbeck have attempted to disrupt this dichotomy by demanding that we set aside the ‘curiously presentist distinction between classification and science’ and realize that ‘the science of psychiatry . . . was classification tout court’ (Lunbeck, 1994: 115). Yet even Lunbeck follows this by claiming that the ‘landmark discoveries of the late nineteenth century – in bacteriology, for example,’ left ‘classification as an avocation of the small-minded’ (Lunbeck, 1994: 115).

This essay follows Lunbeck in its pursuit of nosology as a site of knowledge production and power contestation by calling for renewed attention to the ritual of psychiatric classification. ⁶ It extends and sharpens her critique, however, by suggesting that we might gain a deeper understanding of both the ritual and the professionals who enacted it if we place late nineteenth-century psychiatry alongside the synchronic rise of the linguistic sciences. ⁷ Doing so, I argue, demonstrates that what fell out of favour was not the efficacy of classification itself, but the methods with which psychiatrists entered into the practice. ⁸ Taking as its case study the interaction of professionals and patients at St Elizabeths Hospital between 1877 and 1911, this study analyses the routinization of professional approaches to – and subsequent codification of – what I call the institution’s aural culture. ⁹ For patients, both sound production and listening were individualized, internal phenomena often disconnected from the sense organs proper. Yet professional listening, or psychiatric audition, was an acquired skill that evidenced the scientific nature of psychiatric practice. The term aural culture thus emphasizes identity proliferation, individual encounter, and the ways in which aural experience is developed, practised and learned. For, while Sears’s contribution to the institution’s aural culture remained relatively unchanged between her admission in 1877 and her death in 1910, professional methods of audition did not.

The aural culture created by Sears, her fellow patients and their psychiatric observers emerged at the intersection of shared aural culture and hallucinatory aural culture. The latter encompassed those sounds that doctors believed only the insane could experience and know. Although psychiatrists could not hear them, they noted that patients had ‘hallucinations of hearing’ and verbally responded ‘to imaginary persons’. Such ward notes resulted from physicians’ psychiatric audition, a method that operated within shared aural culture, which consisted of sounds to which any person with auditory potential could gain access. The abundant documentation of these various moments of aurality – whether experienced by a single individual or by all individuals present within the given architecture – evinces its importance and suggests that the aural was a fundamental site of power contestation within the institution. ¹⁰

Far from being a distinct break with an antiquated asylum tradition of classification, early twentieth-century medical practitioners at St Elizabeths developed their scientific approach to listening through an intergenerational reliance on ward notes and other written documentation dating from the 1870s, 1880s and 1890s. At the hospital, these changes culminated in the months following August 1904 when, under the leadership of Superintendent White (1903–37) the hospital’s medical staff began a massive reclassification of a patient population that approached 2300 (Hurd et al., 1917a: 149). Ostensibly, this reclassification was necessary in light of the extensive building projects begun under superintendents William W. Godding (1877–99) and Alonzo Richardson (1899–1903) (Hurd et al., 1917a: 147–9). Nevertheless, the new pathological identities that accrued to patients in the wake of conferencing, retroactive diagnosis and reclassification depended in large part upon decades of professional ritual and the ward notes it produced. In the decade between 1877 and 1887 alone, the medical staff at St Elizabeths admitted nearly 3000 men, women and children. ¹¹ The roots of reclassification thus rest in the histories and case files of those patients admitted under Godding’s regime. ¹²

In the decades following the Civil War, the cultivation of psychiatric audition held promise as the crucial site at which psychiatrists might secure a professional identity that was increasingly under attack. In the District of Columbia, anxieties about the boundaries of professional and pathological identity played out in Washington Post reports of neighbourhood children capturing ward attendants and returning them to the institution as escaped patients (7 July 1883: 2; 18 Feb. 1889: 3; 9 Oct. 1896: 1). Such cases of mistaken identity also became a staple in the patient protest narratives that inundated the national print culture of the 1870s and 1880s with allegations of institutional mismanagement and patient abuses suffered at the hands of psychiatrists and ward attendants (Agnew, 1886; Packard, 1868). Within the medical profession, scepticism toward institutionalization and the practitioners associated with it developed in tandem with a new generation’s emphasis on scientific medicine and laboratory science. Even members of the Association for Medical Superintendents of American Institutions for the Insane (AMSAII) were no longer convinced of the efficacy of traditional therapeutic methods. Pliny Earle, a leader of the community and a physician with intimate ties to St Elizabeths, publicly claimed in 1876 that insanity was not, as early advocates of the asylum movement had long purported, curable (Earle, 1887). Particularly in the urban centres of the east, neurologists began to challenge the assumption that mental disease was territory for the psychiatrist (Grob, 1994: 79–165; McCandless, 1996: 270–92; Rosenberg, 1995). Members of the latter group thus found themselves battling neurologists’ allegations of scientific backwardness, the scepticism of patients and their families, and the challenges of dealing in large part with subjective, intangible evidence of mental pathology. In this context, the ability to profess scientific objectivism was a pressing need. Rather than cultivating objectivism by distancing themselves from patient subjectivities, they paradoxically sought it through greater – and more systematic – attention to subjective experience as evidenced by patient narratives, vocalizations and noisemaking. ¹³

As medical historians have noted, these practitioners also sought to reintegrate themselves into the medical profession by pursuing involvement beyond the asylum, focusing on prevention in addition to rehabilitation, and developing new treatment for mental disease (Grob, 1994: 130). Superintendent Godding, for example, appointed Isaac Blackburn as St Elizabeths’ first full-time pathologist and encouraged among his assistant physicians a focus on research and scholarly publication (Hurd et al., 1917b: 358). Godding supported staff interest in alternative therapeutics, particularly developing the use of hydrotherapeutics to treat patients experiencing paralysis (Hurd et al., 1917a: 147–8). He further carved out professional space for himself and his peers as expert witnesses in legal cases in which the defendant entered a plea of insanity. Godding himself testified in a great number of such cases, the most infamous being the murder trial of presidential assassin Charles Guiteau during the winter of 1881–2. ¹⁴ Within months of Guiteau’s conviction and execution, Godding published Two Hard Cases: Sketches from a Physician’s Portfolio (1883), which outlined his assessment of Guiteau’s mental condition.

Yet psychiatrists sought not only to reintegrate themselves into the medical profession, but also to nurture interdisciplinary associations with members of non-medical professions who shared similar interests and concerns. On a Saturday afternoon in 1884, for example, members of the Anthropological Society of Washington (ASW) gathered at the National Museum to listen to Godding speak fervently about a ‘study in social science’. Despite the weekend’s unseasonable coolness and threat of storms, the Washington Post (14 Apr. 1884: 4) reported a sizeable crowd in attendance as Godding emphasized that the battle against the ‘scepter of alcohol’ would take place in both the medical and the social realms. His presence at the ASW and the earnestness with which he emphasized the non-medical aspects of intemperance suggest his commitment to fostering connections with the broader scientific community. By the spring of 1884, the city had become the epicentre of an emerging anthropological profession (Silverman, 2005: 260). This was evidenced in part by the presence of the ASW, the federal Bureau of American Ethnology (BAE), the Smithsonian Institute (SI), the Geological Survey (GS) and a variety of other societies dedicated to scientific pursuit. ¹⁵

At St Elizabeths, Godding and his medical staff focused on more than scientific medicine, substantive research and medico-judicial procedure. His first assistant physician, Abram Witmer, participated in the city’s Medical Society (MSDC), the American Medical Association (AMA), and the American Medico-Psychological Association (AMPA). ¹⁶ He was also a member of the National Geographic Society (NGS) (Hurd et al., 1917b: 537). Similarly, Isaac Blackburn maintained membership with the American Association for the Advancement of Science (Hurd et al., 1917b: 359). George Foster, who served as assistant physician in 1880–2 and again from 1893 to 1901, was active in a number of ‘scientific societies of Washington’ (Hurd et al., 1917b: 405). Godding and his physicians, those men and women responsible for the diagnosis of patients admitted to St Elizabeths in the final third of the nineteenth century, nurtured non-medical interdisciplinary alliances by developing the intellectual similarities between their own work and that of likeminded professionals. ¹⁷

These similarities developed from an increasing concern with language as site of both species and cultural differentiation. They highlighted the role of aurality in identity formation by demonstrating the types of interdisciplinary exchange that contributed to the development of psychiatric audition. Because aural observation of a group’s spoken language was the primary method by which an observer could access that group’s culture, listening became a primary ethnological method for determining primitive status. In the 43 years between the publication of Charles Darwin’s Origin of Species (1859) and the foundation of the American Anthropological Association (AAA) in 1902, the discursive connections between cultural difference, language and linguistic classification expanded. ¹⁸ The work of early ethnologists such as John Powell and his research team at the BAE posited linguistic classification as the ‘paramount means of organizing Indians for national administrative purposes’ (Darnell, 2008: 39). The study and classification of language became ‘linguistic science’, a worthy pursuit unto itself. The circulation of such texts solidified theories of primitive mental powers and the illogical nature of primitive man (Darwin, 1871: 66–130; Kuper, 1988: 5). Edward Burnett Tylor, a British anthropologist who argued that certain contemporary societies such as the Mennonites could be considered primitive evolutionary stragglers, was among the first to advance such ideas (Tylor, 1865). It was this very theme that occupied his thoughts as he spoke to the ASW in the autumn of 1884, just six months after Godding’s lecture to the same group (Washington Post, 12 Oct. 1884). For Darwin, Tylor and their cohort, the evolution of human language and sound production was intimately tied to – indeed, predicated upon – the development of intellectual and emotional ability (Darwin, 1873: 89–91). Much as such primitive groups existed as atavistic remains of earlier stages of civilized achievement and social development, the insane existed as atavistic remains of early stages of human intellectual and emotional development. Linguistic scientist William Dwight Whitney, for example, wrote that:

a language is what its speakers make it: its structure, of whatever character, represents their collective capacity in that particular direction of effort. It is, not less than every other part of their civilization, the work of the race; every generation, every individual, has borne a part in shaping it. (Whitney, 1875: 224)

These professionals and St Elizabeths’ medical staff exhibited a number of methodological similarities in their approaches to aural observation of language, a practice that became more important in the context of the growing emphasis on language as access point to primitive cultures.

The medical staff at St Elizabeths, like linguistic scientists such as Whitney and ethnologists such as Tylor, Powell and Morgan, developed various methods of audition with which to observe their primitive, culturally distinct patient population. These physicians used three basic methods to do so: detection, elicitation and infusion. The first method involved a recognition and deconstruction of non-vocal instrumentalizations and vocalizations. The sounds of a patient ‘continually’ pounding ‘himself on the knees’ or ‘stamp[ing] his feet’ were principal examples of patient instrumentalization. ¹⁹ Non-linguistic vocalizations such as ‘unintelligible’ speech, laughter, ‘moaning and groaning’ and ‘cackling noises’ were likewise extraordinarily important for determining diagnosis. ²⁰ Another example of potential moments of detection occurred when, in response to auditory hallucinations, patients would ‘suddenly spring up and shout and curse as though answering back to the voices’. ²¹ The second technique of aural observation revolved around moments of elicitation that were achieved through careful and systematic conversation with patients. Physicians and attendants noted with interest when, as a result of questioning, patients reported that they were gods or that they ‘possessed the power to create planets and stars’. ²² They diligently recorded paragraph upon paragraph of patient conversation samples. ²³ One became frustrated in conversation with resident Andrew Leonard, noting that it was impossible to elicit any useful information because the patient ‘kept up a continual stream of words, absolutely lacking in sense, amounting to a word salad’. ²⁴ The third and final method of aural observation, unlike the previous two, depended not on the presence of sound but the lack thereof. The ability to infuse meaning into moments of patient quietude or utter silence constituted its own category of psychiatric audition.

The physicians at St Elizabeths used these methods to forge the boundary between the professional and the pathological, an ever-looming and fluid boundary that threatened to swallow even the most careful practitioner. Thus, uncritical participation in the hospital’s hallucinatory culture became a hallmark of pathological identity while psychiatric audition and classification of that culture became a hallmark of professional identity. Detection, the first method of audition, was particularly useful for defining forms of epilepsy and mania. It yielded a wide array of patient noises and vocalizations and relied on the auditory and ‘outward signs of mental distress’ (AMPA, 1886: 78). Members of the medical staff performed detection in a manner strikingly similar to that of early anthropologists, who observed people in the practice of daily life to listen to them in unguarded moments. Godding, White and their medical staffs described these clandestine moments of audition with adjectives such as ‘disturbed’, ‘noisy’, ‘rambling’ and ‘obscene’. ²⁵ The presence of sounds such as ‘bursts of laughter’, ‘weeping’, ‘affected respirations’ and ‘cackling noises’, and medical staff’s ability to codify them into clues of illness, allowed diagnoses. ²⁶

These and similar adjectives appear in ward notes and case histories with rigid regularity, indicating the routinization of audition that took place in the final decades of the nineteenth century and the earliest years of the twentieth century. ²⁷ Physicians described Laura Sears, for example, as ‘very noisy at times, talking and singing’. They documented her conversations with inanimate objects and, like ethnologists and later anthropologists, caught her ‘off guard’ and listened to what she said. Thomas Henry Nash was another resident who ‘would become disturbed and noisy’. Instead of conversing with rag dolls like Sears, Nash ‘would talk and shout to imaginary people on the outside’. The detection of Sears’s ‘rag dolls’ and Nash’s ‘imaginary people’ and the subsequent meaning that physicians assigned these two moments of vocalization are different in one important way. While both instances came to be seen as indicators of patient participation in the hallucinatory culture, it is interesting to note that, despite the identical end result, one vocalization had a clear referent while the other did not. Physicians believed that Sears was, quite obviously, entering into conversation with tangible entities. It was what they perceived as her inability or unwillingness to acknowledge these dolls as nonhuman that sealed her diagnostic fate as manic (and later, demented). Nash’s vocalizations, in contrast, did not have a clear external referent. The aural observation that Nash’s shouts and curses were directed towards ‘someone’ the physicians could not detect acted as proof of Nash’s access to and participation in the hallucinatory culture. The moments of misdirected vocalization, when he verbally abused ‘passersby and fellow patients’, stomped his feet and ‘curse[d] everyone connected with the institution’, indicated to the medical staff Nash’s more specific diagnosis of mania. ²⁸

While the method of detection was quite useful for ‘noisy’ patients whose screams, moans or yells could be heard at some distance, it was equally useful for those patients whose noise was subtler. William Berry’s tendency to ‘running up and down the wards’ and ‘chew[ing] his bed clothing’, Arthur Kingsley’s habit of coughing up food from fear that it was poisoned, and Gotlieb Ashwander’s propensity for ‘continually strik[ing] himself on the knees with his fist’ and for ‘beat[ing] his face and head’ were aural moments that the medical staff deemed essential in support of these patients’ diagnoses of mania. ²⁹ For physicians listening for signals of mental disease, the explosive ‘motor violence’ embodied in the sound of Berry’s repetitive footsteps or the sharp smack of Ashwander’s open palm on his cheek or temple acted as essential features of their maniacal insanity (Spitzka, 1887: 136). Those diagnoses resulting from the detection of non-vocal instrumentalizations and various moments of vocalization were essential components of patient identification. In the 1904 reclassification of the patient population at St Elizabeths, noisy patients such as Sears, Nash, Berry, Kingsley and Ashwander were separated from the quieter patient population (Hurd et al., 1917a: 150).

Unlike detection, the method of elicitation depended on aural observation of linguistic ability by means of intentional examination, uniform questionnaires and speech transcription. When seeking to elicit linguistic ability, members of the medical staff relied upon patients to act as informants and liaisons between the experience of shared aural culture and the less accessible, more highly individualized experience of hallucinatory aural culture. The list of questions included such enquiries as: ‘what year is this?’, ‘how long have you been here?’, ‘do voices talk to you?’ and ‘do you see sights?’ ³⁰ The questionnaire developed after Superintendent White’s arrival in 1903 for use by the medical staff at St Elizabeths also included a category with the heading ‘speech’. ³¹ Detailed instructions regarding this flawed method of elicitation, however, were widely available to mental disease specialists by the end of the nineteenth century. In a lengthy chapter detailing ‘how to examine the insane’, neurologist Edward Spitzka (1887: 322) warned that some patients were ‘not apt to be communicative to a stranger at first’. To circumvent this particular challenge, Spitzka (p. 323) instructed physicians to ‘approach [the patient] by a circuitous line’ of questioning that would ‘lead to ‘confidential’ communications as to alleged conspiracies, antipathies, attempts by others to poison food, marital infidelity, the ruin of fortune, or the commission of some crime’. This, Spitzka suggested, was the point at which the physician’s success was guaranteed. ‘As soon as a patient has reached this point the ice is broken, and the mental symptoms may be elicited in abundance.’ He cautioned that ‘as soon as [the patient] begins to reveal his mental state it is well to let the patient speak without interruption, and particularly to avoid asking leading questions’ (p. 324). In other words, well-trained members of any medical staff should know when to elicit and when to detect. Through this method of psychiatric audition, physicians would gain mediated access to the hallucinatory culture of patients and unmediated access to the linguistic ability of the patient.

Spitzka was far from alone in his emphasis on the centrality of the second method of aural observation. In their 1886 training manual for attendants on the insane, the AMPA (1886: 85–6) stressed:

It is of great importance to ascertain the particular delusions and hallucinations of each patient, as in them we often find the explanation of the patient’s general conduct; and from their character we are enabled to judge better of the patient’s mental condition and of his propensities.

Like the AMPA and Spitzka, psychiatrist James Shaw also informed readers that, quite simply, ‘hallucinations must be sought for’. He suggested that ‘delusions may be brought out’ through ‘carefully led’ conversations, and that ‘even cunning chronic patients will generally, by their manner of answering questions, betray the fact that they still retain their delusions’ (Shaw, 1892: 151).

The ward notes of patients at St Elizabeths exhibit an everyday preoccupation of the medical staff with eliciting hallucinatory narratives. The word ‘hallucination’ – or one of its many variants – appeared in every case file consulted, and even when hallucinations were ‘impossible to elicit’ they were, quite clearly, being unfailingly sought. ³² Resident Adolph Ahlers, for example, told his physician that ‘spirits [were] making him sick’, and Susan Fisher likewise confided her ‘hallucinations of sight and hearing’. ³³ In proposing an explanation for her constant spitting, patient Sarah Trenis offered a glimpse of the hallucinatory culture:

Her explanation is that someone was in her mind and jumped in her throat and she had to spit. Recently she kissed her wrist, spit violently, and jumped suddenly. When the nurse asked her what the trouble was she said, ‘The flexions of Miss Laura Rice’s eyes hit me and I had to spit.’ She looked fixedly at one spot on her wrist while talking. When asked what she saw she pointed to it as if it were writing and said, ‘My beloved Mr Neil.’ ³⁴

More important for diagnostic specificity, however, were the physicians’ insights into the structure of the hallucinations and the linguistic abilities of the patients. Those patients whom physicians described as ‘incoherent’, ‘irrelevant’ and ‘unable to answer questions well’ were more likely to receive diagnoses of mania and dementia. In conversation with Hattie Ross, a patient diagnosed with chronic mania, a physician discovered that she had ‘delusions of grandeur’ of leaving St Elizabeths and living ‘in a house of gold’. ³⁵ The patient verbalized that she had ‘hallucinations of hearing’ and believed that there were ‘people around her’. Naturally, her physicians vigilantly noted that there were, in reality, no people around her. Fisher, likewise diagnosed with mania, told her physician that she would ‘revenge the person who killed her daughter’. ³⁶ This may seem a natural impulse, yet Fisher’s physicians were careful to point out, through a fastidious construction of biographical history, that all of her known children were alive at the time of the interview.

Ross’s and Fisher’s fellow patient, Joseph Kessler, lacked the ability to create a clear verbal narrative, a linguistic incoherence that convinced the medical staff that Kessler’s mania persisted. ³⁷ They included a conversational sample in their ward notes that served to illustrate ‘the mental condition of this patient’, which they described as ‘highly problematic in a propositional sense’. ³⁸ In answer to typically pointed questioning, for example, Kessler replied, ‘I don’t want to get out of bed – my head is too big . . . I worried about it and took it back because I don’t know all this – because I don’t want to be troubled with it.’ When the physician enquired what, exactly, all of this trouble was about, Kessler said, ‘If I would make any disturbance about it they would not like to be troubled more about it still at the same time they can’t help me . . . This is a village. I mean what I say, I don’t like the men.’ Like Sears, whose rag dolls acted as a point of contention between her sense of reality and that of her physicians, Kessler’s view of his head as ‘too big’ contradicted the empirical observations of the physicians that his head was in fine shape. As a result, the patient’s verbal narrative and thus his mental capacity were called into question. Like Nash, whose vocal outbursts had no clear referent, Kessler’s concerns about the ‘village’ and the ‘men’ indicated to physicians that the patient was operating within the hallucinatory aural culture. The physicians did not, perhaps, take into consideration that their patient’s remarks could be interpreted as astute comments on both the experience of living in an all-male ward as well as the geographical isolation of St Elizabeths. Set apart from the city and entirely self-sufficient, the hospital did indeed operate in a fashion quite similar to a village (Bien, 1860). Nevertheless, Kessler’s diagnosis of acute mania (later changed to dementia praecox) resulted from the discoveries made by physicians in moments of aural observation.

There were, however, patients who were much more reluctant to have their hallucinatory experiences elicited, and the quietude of such patients was a hallmark of the melancholic pathological identity. Infusion, in contrast to the first two methods of audition, relied upon patients’ reticence in addition to vocalizations, noisemaking and narrative. Ward notes suggest that Andrew Leonard, admitted with a diagnosis of melancholia, refused to act as a liaison to the hallucinatory aural culture. ‘We were unable to learn,’ his physicians wrote, ‘whether or not [Leonard] was oriented as to time, person, or place.’ ³⁹ The patient was ‘never known to give a relevant reply to questions. At times,’ Glascock conjectured, ‘his ridiculous and incorrect answers have a marked element of playfulness in them.’ More significant than his evasive nature is his physician’s dogged attempt to assign meaning to Leonard’s vocalizations by suffusing them with an intentional layer of ‘playfulness’. Where incoherent language made effective elicitation impossible, physicians offered their best estimations of Leonard’s inaccessible experiences of the hallucinatory aural culture.

Patients who maintained almost complete silence offered perhaps the most complicated challenge to the process of psychiatric audition. Physicians and attendants were warned to ‘be very vigilant with these quiet cases’, as these were the cases which were ‘in reality far more dangerous’ because of their tendency towards suicidal ideation and behaviour (AMPA, 1886: 92). Silence, like noise and narrative, was to be read for symptoms. Spitzka (1887: 145, 387, 390), for example, in considering ‘the frozen attitude’ and lack of vocal communication sometimes present in melancholic patients, explained that this withholding of sound was often the indication of ‘a fear and dread so intense’ that the patient was quite literally ‘struck dumb and paralyzed by them’. Physicians at St Elizabeths occasionally recorded their frustration with the evasive silence of melancholic patients such as John Humbrock, who ‘never ha[d] any thing to say’, ‘stay[ed] in bed very quietly days’, and was ‘glad to be let alone’. ⁴⁰ Similarly, Mary Hoffman sat for hours on the ward and never spoke voluntarily, both of which reinforced her diagnosis of acute melancholia. ‘She is quiet,’ her physicians recorded in her case file, ‘and takes no interest in anything’. ⁴¹

In describing the linguistic ability of patients diagnosed with melancholia who were willing to engage in conversation about hallucinatory experiences, the physicians at St Elizabeths used adjectives that emphasized the patients’ relative intelligence and verbal clarity and contrasted them with the incoherence of maniacal patients. Owen Kelley, for example, participated in the hallucinatory culture and reported to his observers that a ‘lightning bug has possession of him and that he is completely controlled by its magic light. Sometimes he complains of monkeys being on his head’. In describing this patient, however, these physicians wrote that he was ‘very friendly in address’ and was ‘able to talk with considerable intelligence upon most subjects’. ⁴² Edward Donahue, likewise diagnosed with melancholia, ‘answered questions intelligently’, although ‘often, owing to his mumbling, his replies could not be understood’. ⁴³ While mania and dementia were associated with uproarious noisemaking, verbal wildness and linguistic incoherence, melancholia was more often, associated with cautious quietude, verbal ability and linguistic effectiveness.

Analysis of the sounds of St Elizabeths demonstrates that the complex interaction of the hallucinatory aural culture and the shared aural culture – which together created the complete aural culture of the institution – allowed psychiatrists to reimagine and ritualize their professional identity. They accomplished this reimagining through systematic audition and the development of a psychiatric approach to aural observation. By the late nineteenth century, ‘a person’s mental state is judged of by (1) his conversation, and (2) his conduct’, and psychiatrists listened attentively for the sounds of screaming, murmuring, coughing and even restless pacing (AMPA, 1886: 75). The key signifiers of specific pathological identity emerged through physicians’ systematic audition as well as through more clandestine moments of aural observation. Ultimately, this approach resulted in changes to both professional and pathological identity. Even as psychiatrists diversified diagnostic possibilities, they confined this proliferation of identity within a larger group identity forged in part through its members’ participation in the hallucinatory aural culture. An analysis of these sounds and the various responses they provoked lays bare an alternative site at which the relations of power between physician and patient existed.