Mad, Bad, and Sad: A History of Women and the Mind Doctors

by Lisa Appignanesi

  For all his work with Mary and patients in Bridewell and Bethlem, Tuthill nowhere appears as a specialist in madness. There is as yet no such established discipline. Those whom the period names as specialists in madness are largely ‘managers’ of the insane. Dr Francis Willis, whose authority was such as to make George III fear him enough to become ‘manageable’ in his lunacy, was initially a Reverend, unrecognized by the medical fraternity. His model asylum, Greatford Hall, in Greatford, Lincolnshire, which opened in 1776, as well as his treatment of the King, made him famous. With Maria I of Portugal, Willis was less successful. The Queen, who came from a family in which insanity claimed a number of members, suffered from what was diagnosed as melancholia and religious mania. A sequence of deaths and misfortunes, not to mention fears sparked by neighbouring revolutions, exacerbated her condition. When Willis came to her bedside in 1792, she believed herself eternally damned, had hideous nightmares, prolonged insomnia and stomach problems alongside delirious outbursts, often lewd in content, and melancholia. Willis’s moral management calmed her a little at first, but relapse was quick.

  Nonetheless, this new form of dealing with the mad began to take hold. Willis’s therapy–in so far as it was one–shunned physical brutality and replaced it with moral authority. Willis would, the accounts go, pierce patients with his powerful eye–like the early continental mesmerists with whom he was contemporary–and make them obedient to his will. As Michel Foucault has pointed out, with moral management, the manacles, chains, handcuffs, strong chairs and scold’s bridles–the whole apparatus of physical coercion–gradually went, to be replaced by the moral tools of talk, observation and judgement. The control of the mad moves inward and works through regimentation and an instilling of discipline.

  Dr Willis’s asylum and William Tuke’s famous York Retreat provide the models for what becomes asylum life in the first and more optimistic part of the nineteenth century. Willis’s fame spread, in part because his reports to Parliament on the King’s health were widely reprinted in cheap editions. Hardly a revolutionary himself, Willis ended up by profoundly influencing the founders of French revolutionary psychiatry. This description originally appeared in a French source:

  As the unprepared traveller approached the town, he was astonished to find almost all the surrounding ploughmen, gardeners, threshers, thatchers and other labourers attired in black coats, white waistcoats, black silk breeches and stockings, and the head of each ‘bien poudré, frisé, et arrangé’. These were the doctor’s patients, and dress, neatness of person, and exercise being the principal features of his admirable system, health and cheerfulness conjoined to aid recovery of every person attached to that most valuable asylum.

  At the York Retreat, run along Quaker principles and best described by its founder’s grandson Samuel Tuke in his 1813 account, all physical restraints were put aside in favour of a system of rewards and moral punishments which encouraged self-restraint in the inmates. The keepers effectively became stern but kind parents eliciting good behaviour from unruly children, who needed to be kept busy and orderly. Work, with its regular hours, its obligations and requirements of attention, served, with talk, as an exemplary treatment which could contain ravings, instil self-esteem and mould the mad into a semblance of good citizenship.

  The Willis family, the Quaker Tukes and the English practice of moral management were to help shape the field that grew into a specialism and became known first as alienism and later as psychiatry. When moral management crossed the Channel to meet the Revolution, it abandoned its religious hue altogether: madness and its French medics and managers were at first emphatically secular. Indeed, with the application of a little theory and more state regulation, the English Malady became a French Science.

  BEING A WOMAN

  In 1801 the Lambs’ friend George Dyer wrote what became a popular poem evoking the plight of a fetching young Ophelia-like innocent in Bedlam:

  If moon-struck horrors haunt thy restless head,

  All-hopeless Pity here shall take her stand…

  In 1815 the two writhing, brutish and chained male personifications of madness in front of Bedlam were replaced by figures of women–a ‘youthful, beautiful, female insanity’. Madness, at least in representation, it would seem, was becoming feminized and tamed, no longer wild, raving and dangerous, but pathetic.

  Elaine Showalter in The Female Malady has persuasively argued that nineteenth-century cultural ideas about women–their supposed irrationality at a time when Reason was male, their weakness and lability occasioned by a biology which includes the coming of menses at puberty, then pregnancy and lactation, then menopause, together with notions about ‘proper’ feminine behaviour–shaped the time’s definitions and treatment of women’s insanity. Pretty, victimized Ophelia, Lucia di Lammermoor who on her wedding night murdered the bridegroom chosen by her parents, and the servant girl Crazy Jane, abandoned by her lover, are the three iconic figures around whom she sees understanding of female madness coalesce. All link women’s madness in one way or another to their sexual relationships to men.

  Does this help us to understand Mary Lamb’s case?

  One could say about Mary that her brother’s falling in love with another precipitated her sense of being entombed in a family from which, like Lucia, she had to break free. Donning Freud-tinted spectacles, we could even suggest that the needlework Mary herself singles out as oppressive signals not only her madness-inducing enslavement in drudgery, but also that (masturbatory) repression of sexual urges which leads to her fatal Oedipal act. Or we could stretch the Ophelia/victim line into our own time’s favourite psy narrative. This would entail examining her childhood not only for instances of maternal deprivation and lapses in thought, that Lockean cementing of incoherent ideas, but also for instances of sexual abuse bringing in their train dissociation and fears which make her younger, limping brother the only safe male in her life.

  Such accounts or stories shed some light on Mary’s case, though not quite the one she or her time would have chosen. In Mary’s own writing, apart from her complaints about needlework and the way it prevents women from indulging in the ‘idleness’ which might be renamed education, her only other emphasis on women’s condition has to do with a wish to warn a friend against romantic illusions and about the difficulties marriage may bring, not least amongst them the dangers of childbirth. Though one could rush to interpret this as Mary’s own unconscious sexual fears, it would be a mistake not to take her comments at face value, as well.

  What emerges from Mary’s and indeed Charles’s letters, is the sense that her feminine identity is tied up with being ‘useful’, ever busy in household tasks or indeed, needlework, or ever seeing friends, being serviceable to them, entertaining. Throughout the nineteenth century, talented, middle-class women were to shake off the chains of their socially restricted forms of usefulness by unconsciously choosing invalidism as a preferable form of life. The poet and political radical Elizabeth Barrett Browning, eldest of twelve children, developed an ailment at the age of fourteen which saved her from the drudgery of looking after her siblings and an autocratic father, and allowed her to take to the studious writing life she preferred. Wooed from her bedchamber by the poet Robert Browning, whom she loved ‘freely as men strive for right’, she was proud, invalid that she had been, to be able to give birth to his child at the age of forty.

  For Mary Lamb, the very feminine usefulness she prides herself on is also the agitation which leads to her exhaustion, which in turn brings on her mania. During these bouts of mania, the conversation she engages in to give friends pleasure takes on a speeded-up and elaborate mantle, full of descriptive detail, ‘like the jewelled speeches of Congreve only shaken from their setting…It was as if the finest elements of mind had been shaken into fantastic combinations like those of a kaleidoscope.’

  Mary’s culture, the possibilities, habits, restrictions of behaviour her time endorses for women, inflect her mania. But does her femaleness affect the
way her peers understand her madness and the treatment she receives for it? The response here is hardly a straightforward one, and historians over the last thirty years might differ in their assessment. Feminist challenges to more traditional history in the 1980s and ’90s stressed that women were more likely than men to be institutionalized as mad and indeed to have their dissatisfactions with their condition read as madness by their time. More recent historians have shown that asylum statistics do not altogether bear this out.

  The later nineteenth century may have enshrined women as the weaker vessel, frailer by constitution, and thus more easily susceptible to madness. But Mary Lamb’s brother and friends in their voluminous correspondence–which comprises most of the prominent members of the Romantic movement up until Charles’s death in 1834–rarely mention anything that would make a tender, vulnerable Ophelia of Mary. What they most often comment on is how surprising madness is in a person with so great a hold on good sense as hers. She is ‘the last woman in the world whom you could have suspected, under any circumstances, of becoming insane, so calm, so judicious, so rational was she’. As William Hazlitt used to say, ‘Mary Lamb is the only truly sensible woman I ever met with.’

  Cheyne, too, in his case histories of young women, even when he is describing what seem to be extreme psychosomatic symptoms, ‘histerick fits and collicks’ that can leave the sufferer crippled in hands and feet, rarely links these directly to a female condition or a weakness of mind or will. Then, too, his male cases outnumber those of women, just as during the Georgian period male admissions to asylums outstripped those of women.

  In 1845, the York Retreat showed men outnumbering women by about 30 per cent. The pattern changed after mid-century with the rise of the vast public asylums. The Lunacy and County Asylums Act of 1845 not only brought asylums more closely under medical inspection: it also required provision of public asylums for all pauper lunatics by local authorities. The mad and those thought to be mad by their families, the incapable, the troublesome, the geriatric, no longer had to be kept at home or be paid for where possible in private madhouses, but could be housed at government expense. This increased the asylum population and along with it that of women: according to the census of 1871, for every 1000 male pauper lunatics there were 1242 women pauper lunatics, a number somewhat in excess of the proportion of women in the general population, which was 1056 to 1000. But historians have recently argued that, important as gender was to psychiatric and psychological theory at the turn of the nineteenth century and in the early twentieth, this did not translate into asylum figures or practice in any simple way. The figures for admission and release do not vary greatly enough between the sexes in Britain: if anything, single men are over-represented amongst the mad in the nineteenth-century asylum.

  If within the madhouses of the turn of the eighteenth century woman’s fate seems to be no worse than man’s, there are nonetheless some abuses which–through their repetition in various reports–do add up to a pattern particularly suffered by women. Accounts of rape and sexual assault, sometimes occasioned by a woman keeper who is out to gain, occur frequently. Even more frequent are accounts of force-feeding. John Haslam, the apothecary at Bethlem, in his Observations on Madness and Melancholy of 1809, writes: ‘It is a painful recollection to refer to the number of interesting females I have seen, who, after having suffered a temporary disarrangement of mind, and undergone the brutal operation of spouting [force-feeding] in private receptacles for the insane, have been restored to their friends without a front tooth in either jaw.’ One is left wondering whether the violent impatience of this particular form of assault is an indication that there were greater numbers of women ‘starving’ themselves than men; and whether this might be a particularly feminine response to an illness one aspect of which is later specialized into anorexia.

  SYMPTOMS OF THE TIME

  In 1810, the London physician William Black prepared a table detailing the causes of insanity of patients admitted to Bethlem. The everydayness of these categories underlines the lack of a specific psychiatric language. The copious first category might be rewritten simply as ‘life drives you mad’. To compare this list with DSM IV, today’s most widely used and American-based diagnostic manual, is to see how far the mind doctors have moved in creating a ‘scientific’ discipline. Instead of the dozens of finely differentiated psychotic, cognitive, mood and substance-related disorders, the eating and anxiety disorders, the personality, sleep, adjustment, impulse-control and intermittent explosive disorders, Bethlem registered the following categories and causes:

  Misfortunes, Troubles, Disappointments

  Grief…………………………………206

  Religion and Methodism…………………………………90

  Love…………………………………74

  Jealousy…………………………………9

  Pride…………………………………8

  Study…………………………………15

  Fright…………………………………31

  Drink and Intoxication…………………………………58

  Fevers…………………………………110

  Childbed…………………………………79

  Obstruction…………………………………10

  Family and Heredity…………………………………115

  Contusions and Fractures of the Skull…………………12

  Venereal…………………………………14

  Small Pox…………………………………7

  Ulcers and Scabs dried up……………………………5

  It is worth noting that this list shows an interest in the causes of madness, unlike the DSM which focuses only on the fine-tuning of diagnoses based on visible signs and behaviours–on symptoms. The Bethlem table points to a wide set of explanations for insanity, ranging from the organic to the hereditary, from circumstances of environment or emotion, travails of life, to character defects. Interestingly, religion and Methodism appear as causes of insanity: we have entered a world where a secular medical discourse is beginning to nudge against and displace a religious one. Divine madness–and it was a time of great religious enthusiasm–is no longer simply a tolerable matter of holy fools, but one of intolerable extremes which lead to confinement.

  The table also points out that a substantial number of inmates are there because of insanity occasioned by ‘childbed’–that is, by giving birth or nursing. The figure is larger than that for drink which, as the condition of ‘alcoholism’, was to help fill the asylums of the second half of the nineteenth century. Mary Lamb had killed her mother. At the opposite generational pole were women who killed their children or who grew mad when they appeared. The specifically female diagnosis of puerperal madness was to remain an important one. French doctors, who from the Revolution on were interested in population politics and hence the welfare of mothers, were perhaps even more preoccupied than their British kin with the ramifications of this particular aspect of women’s experience.

  In Britain, until the First World War, despite Lunacy Acts and the implacable growth in the number and size of asylums and a rising profession of alienists, there is no generalized change in the way in which the causes of mental illness are categorized. A highly reputable, large private asylum like St Andrew’s in Northampton in the period up until 1907 differentiates mental illness along ‘Moral’ (by which is meant psychological) and ‘Physical’ lines. The first include anxiety, trouble, disappointment in love, fright, jealousy, pecuniary difficulties, religion, novel-reading and spiritualism. Life, it seems, causes madness. Reading may be even worse. For women, as the century goes on, certain activities are particularly dangerous, as the Victorians warn. Physical causes of insanity seem hardly more medicalized. Yes, there is apoplexy, brain disease, heredity, syphilis and, for women, change of life; but physical causes still also include over-study, overwork, self-indulgence and the Victorian category of mastu
rbation.

  Generalizing across the spectrum of mental illness and its treatment is hazardous. All changes in theory and practice come slowly and piecemeal, like long-term negotiations towards a treaty which would somehow reconcile the ongoing battle between sanity and insanity. The borders keep shifting, so does the terrain. Hospitals far from the front line carry out one set of practices. Those closer spell out treaty rules which some, but only some, follow. Patients may be more aware than doctors, particularly if they’ve travelled either from one institution to another or from one country or doctor to another. This said, however, certain trends emerge. Historians agree that a medical specialization to do with mental health took place first in France and the German-speaking countries. The practice of asylum management, however, was greatly influenced by the British experience, even if, in the first instance, asylum keepers were themselves hardly mind doctors.

  PART TWO