Remembrance of Patients Past: Patient Life at the Toronto Hospital for the Insane, 1870-1940 (review)

While not the first historian of medicine to use institutional records as a source for psychiatric patients' lives, Geoffrey Reaume is the most passionate. Occasionally that passion leads him to overstatement, but overall, it is productive. For example, he offers useful reminders of the limitations of institutional abuse records, the often-devastating impact of diagnostic labels, and the need to rethink institutional practices as well as therapies. When he says that his work lacks a sophisticated methodology and simply tells a story about "people, rather than labels, free from the clutter of medical terminology and diagnostic categories" (p. 5), Reaume does himself a disservice. Although most of his book is descriptive rather than analytical, the cumulative effect of the patient histories he recounts is powerful and inevitably reshapes historians' understanding of the psychiatric past.

In addition, Reaume also offers a useful institutional history. After a careful description of the Toronto Hospital between 1870 and 1940, he discusses a number of important topics: admissions procedures, daily routines, entertainments (and lack thereof), patient work assignments, familial and community responses to the mentally ill, and patterns of discharge and death. Although most interested in capturing patients' voices directly, whenever possible, he uses as well the administrative and medical materials generated by the medical staff. These help him contextualize, and occasionally themselves reveal, patient life.

While the general picture drawn by Reaume will be familiar to historians of psychiatry, his book deepens our understanding of a number of specific aspects of patient lives. Typical is the fascinating discussion of runaway patients, especially those who left repeatedly and later were recaptured. Often, he notes, runaways came from the ranks of the most trusted patients, and most were males. Women found escaping substantially more difficult than did men because they usually worked in locked wards, not out-of-doors. In addition, their heavy clothing made climbing over walls and fences more difficult.

Early on, Reaume proposes a three-part categorization of therapeutics as a way of framing patient experiences. From 1870 through 1904, the "Non-Interventionist Period," Toronto Hospital physicians continued to rely heavily on moral therapy. For the subsequent twenty years, they stressed classification and the scientific method, collecting large amounts of data. Finally, in 1924, they began what Reaume characterizes as an "Interventionist Period," during which treatments included lobotomies, intramuscular injections of salvarsan, insulin and metrazol shock, and "fever cabinets" for those with syphilis. Yet, despite such important shifts in therapeutics, the care of the long-term mentally ill changed little over this seventy-year period.

Reaume argues repeatedly that his work is much more centered on the experiences of patients than is that of his predecessors. In this respect, he most often compares himself to me and to Gerald Grob. He finds our work useful but too-accepting of institutional rationales for abuse and stereotypes about the mentally ill. While I disagree with some of his characterizations of my own work, he offers a useful reminder of the variety of patients and the range of their institutional experiences, whatever their diagnoses. Reading this book once again reminded me both of the importance of patient stories to medical historians and of the difficulties involved in locating and interpreting them. This is a particular problem for all of us studying periods for which only written records (plus a few scattered photographs) survive. Reaume's effort to search such materials for patient voices, however muted, is both valiant and imaginative.