Abstract
At a time when there seem ever more barriers to publishing, it is good to see that the Studies for the Society for the Social History of Medicine are still flourishing in partnership with Pickering and Chatto. This is an impressive series, combing quality with accessibility, and Anna Shepherd’s much anticipated study is more than worthy of inclusion. The thoughtful introduction respectfully surveys the now extensive historiography exploring the management of insanity in the nineteenth century, but the author is not afraid to pose new and difficult questions. Choosing to study two contrasting institutions offers illuminating insights into patient and staff experiences with useful emphasis on class, gender and family relationships. Letters emerge as a particularly useful resource, and support a rich but very readable account of asylum life that will be of great interest to scholars in the field. The book is also very suitable as an introductory text for students who will appreciate its accessible style and well-organized chapters that deliberately highlight key themes and issues. Alongside the expected concern with institutions, together with their staff, patients and governance arrangements, the attention given to suicide (chapter 6) opens new fields of inquiry.
One of the most interesting findings is that the smaller private asylum, arguably well placed to offer excellent care, did not necessarily offer a better patient experience (p. 55) or improved patient safety (p. 13). Instead the author suggests that a ‘concern to provide a luxurious environment with the most up-to-date equipment overrode more practical considerations of providing secure and legally compliant accommodation for patients’ (p. 18). Shepherd usefully explores how different ideas about the management of the insane and the therapeutic value of design were enshrined in both the Brookwood Asylum and the Holloway Sanatorium, which were both in Surrey. A thoughtful discussion about the similarities as well as differences between the two institutions contributes to debates about what it meant to be a pauper patient, and the complex financial arrangements needed to support relatives in private and charitable institutions. The family dynamics thus revealed are fascinating, but important insights are also gleaned from discussion of staffing issues.
It is interesting that both the Brookwood Asylum and the Holloway Sanatorium sought to recruit staff with similar qualities (p. 50). The chapter on ‘therapeutic agents’ offers a wealth of detail that challenges what can still be stereotypical views of caregivers. When discussing the recruitment and retention problems faced by the institutions, Shepherd is realistic about the demands placed on caregivers and their ability to meet them. Nevertheless, she follows the more optimistic strand of the recent historiography that gives agency to the attending/nursing staff in terms of managing their own careers rather than simply dismissing them as victims of poor working conditions and/or oppressors of patients. It was also good that careful consideration was given to medical careers enjoyed and endured in the sector. I was pleased to see discussion about the contribution of women practitioners and also intrigued by the attention given to the mental health problems of doctors working in the sector (p. 73). Both themes are usefully grounded in the recent historiography, but Shepherd consistently finds new and interesting things to say.
Although the book takes a thematic approach the chronology of events is always clear and there is a good sense of change over time. The approach adopted sheds light on neglected areas that would benefit from further research. Policies and procedures for admitting children to Brookwood (p. 27) and voluntary patients to Holloway (p. 32) seem to merit further attention when looking at other facilities. Shepherd is careful not to idealize or mythologize care at either of her case-study institutions and instead points to the variety of patient experiences inside, outside and on the way to the different asylums. She highlights the presence of long as well as short stay patients, and those already experiencing what we would now understand to be a revolving door of placements. There is a large data set, and arguably Shepherd could have done more number-crunching, but statistics neither can nor should replace the individuals that she places at the heart of her analysis. In particular the trauma of the incarceration process (p. 71) comes across vividly and, while Shepherd is careful to avoid a presentist approach to her narrative, there is much that resonates with modern debates about policy and practice.
This is a lovely book, with much to engage the attention of the general as well as the specialist reader. The only sign that its origins lay in a thesis is in the detail of the references, and it is a little annoying that these appear at the end of the volume rather than at the ends of the chapters. Otherwise it is a really excellent publication.