Dangerous Motherhood: Insanity and Childbirth in Victorian Britain (review)

Dangerous Motherhood is a carefully researched and well-written work whose specific focus on puerperal insanity—a relatively mild and curable condition tied to the clear physical events of childbirth—complicates and enriches earlier scholarship on women and mental illness in the Victorian period. Puerperal insanity, argues Hilary Marland, was a disease of the nineteenth century, a diagnosis made possible by the Victorian sense of woman as a "victim of her fragile nervous system and unpredictable reproductive organs" (p. 6). During the "golden age" of puerperal insanity, roughly 1840–70, environmental explanations for insanity still held sway over the hereditary explanations that would consume late nineteenth- and early twentieth-century medicine. According to the Victorian domestic ideology of these decades, it was to the ideal of natural mother and moral wife that women were supposed to conform, and to which doctors were supposed to restore them. That puerperal insanity was so disruptive to this ideal and to domestic order is what makes it such a significant disease to scholars of Victorian culture.

Through the seven chapters of her book, Marland demonstrates the broad scope of puerperal insanity and the many factors that complicated its diagnosis and treatment. The disease itself took two forms—melancholia and mania—each with its own dangers and type of treatment (p. 35). Doctors of this period saw environmental factors as integral to puerperal insanity; Marland is therefore particularly sensitive to differences in the class and social position of women sufferers. Wealthy women and those with mild cases were often treated at home by private physicians or midwifery practitioners. Severe cases and impoverished women—those who could not afford private medical care, or to whom an asylum actually represented a respite from the home—were treated by alienists in large institutions. Part of this story, then, concerns the changing nature of medicine and the rivalry between alienists and midwifery practitioners.

At the center of Dangerous Motherhood are chapters that balance the scope of the book with in-depth treatments of puerperal insanity; these help Marland maintain the individuality of patients while developing a more generalized picture of the female sufferer. Chapter 3 looks at cases of puerperal insanity in the bourgeois home, where doctors attempted not only to cure the patient but to "repair the household" that had been disrupted (p. 74). The illnesses of Isabella Thackeray and Sara Coleridge illustrate this phenomenon, but also show how women sometimes "foiled the physicians' potential to put the household to rights" (p. 92). In chapter 4, Marland uses the rich archives of the Royal Edinburgh Asylum to examine how asylum doctors acted upon medical theory about puerperal insanity. Chapter 5 broadens the discussion to institutions beyond the Royal Edinburgh Asylum, including the Warwick County Lunatic Asylum, and to published case notes and other records. The examples from the Warwick Asylum show us the extent to which poor health and poverty contributed to and exacerbated mental suffering. In chapter 6, Marland looks at how diagnoses of puerperal insanity could win sympathetic verdicts for infanticides by explaining this "antithesis of womanhood" as a temporary and "almost 'normal' side-effect of giving birth" (p. 198).

Finally, Marland notes how by the end of the nineteenth century puerperal insanity, considered so prevalent in the Victorian period, was being "written out" of medical textbooks and records—an apparent victim of the Kraepelinian diagnostic system, as heredity and biological psychiatry displaced environment as the dominant explanation for puerperal insanity. With this shift, treatments became less humane, with "heavier dosing and sedation" and less emphasis on "beef tea and rest" (p. 206). Marland sees in these changes continued significance for the care of women who "become disturbed after giving birth" (p. 204).