Institutionalizing the Insane in Nineteenth-Century England by Anna Shepherd (review)

Its title notwithstanding, Anna Shepherd’s book is not a general history of the asylum in nineteenth-century England. Instead, she has attempted a comparison of two institutions that were only a few miles apart, but served quite distinct clienteles and were in other respects quite different from each other. Such studies of individual institutions became quite popular thirty years ago, with the appearance of Nancy Tomes’s highly original study of Thomas Kirkbride’s tenure at the Pennsylvania Hospital for the Insane and Anne Digby’s close examination of the experience of the Quaker York Retreat, the apparent inspiration for the explosion of asylums in the second half of the nineteenth century.¹ Nor is Shepherd the first to examine two contrasting institutions: Ellen Dwyer’s Homes for the Mad compared and contrasted the Willard and Utica asylums in New York State to great effect.² While useful in some respects, Shepherd’s book is not in the same league.

Brookwood Asylum was the second pauper asylum for the county of Surrey, established in 1867, and took patients both from highly urbanized parts of south London and from more rural parts of the county. Despite its status as a so-called pauper asylum, Brookwood’s patients were also drawn from the skilled working class and some of those who had previously formed part of the lower middle class. The key defining characteristic of its inmates was that the cost of maintaining them once they had been certified as mentally ill was borne by the public purse. Shepherd makes much of the social heterogeneity of this county asylum’s population, but this ambiguity about the term “pauper patient” was recognized from the very outset of modern work in the history of psychiatry, which we can date to the 1970s.

Brookwood’s neighbor, the Holloway Sanatorium, was opened by the Prince of Wales in 1885. As its coy name suggests, this institution sought a very different class of patient, the respectable middle classes. Some of these, to be sure, were down on their luck and unable to afford the full expense of their confinement and treatment. Others, however, were drawn from the ranks of the rich, bringing with them their own servants and carriages, for this helped to balance the cost of the charitable care Holloway sought to provide. And unlike its pauper counterpart (even in the face of the disapproval of the Lunacy Commissioners), a portion of Holloway’s patients were so-called voluntary borders—patients admitted without being officially certified as lunatic.

There were obvious differences in the staffing, the physical fabric, and the degree of comfort and amusements provided between the two institutions. Paying patients (or rather their families) had a choice, and had to be attracted, while pauper asylums were swamped with supplicants for admission. Still, both asylums found themselves facing a constant pressure to admit more patients than they had planned for, and both found their daily routines disturbed by the near-constant need for new buildings. At century’s end, however, there remained a stark difference, not just between the plain appearance of the one and the ornate exterior of the other, but in their respective sizes. Like other museums of madness of the era, Brookwood swelled till it contained over a thousand patients, while Holloway accommodated fewer than a third of that number.

Shepherd makes little attempt to give the reader a feel for life in these two total institutions and how it may have differed, save in some very obvious ways. Instead, she structures her account around a series of analytical questions. Who staffed the asylums, and what, in particular, were the characteristics of the attendants, the people who had the most extended contact with the patients? What do we know about the pathways into the asylum? What can one say of the demography of the patient populations, and their fates...