In this book in the Studies for the Society for the Social History of Medicine series, Anna Shepherd compares and contrasts Brookwood Asylum and Holloway Sanatorium between approximately 1860 and 1900. The former institution was a county pauper lunatic asylum and the latter a middle-class sanatorium offering both charitable and private accommodation. Shepherd’s text makes a direct comparison between the two regimes, a rare approach which challenges some of the assumptions historians have previously made about the asylum system by showing unexpected similarities between institutions, despite their different clientele and circumstances.

The author’s main aim is to provide a detailed account of daily life in both institutions, including treatment, patient admissions and discharges, occupation and entertainments, and the recruitment and duties of staff, in particular, the aims of the respective superintendents. While similar work has been carried out on individual institutions (such as Ticehurst House Hospital, the York Retreat, and Buckinghamshire County Asylum), Shepherd’s comparative approach is unusual and offers a more nuanced picture of nineteenth-century British asylum psychiatry.

Throughout the text, Shepherd challenges a number of existing assumptions. In particular, she claims that socio-economic status was a much more important factor than gender in the admission, treatment, and discharge of patients in Victorian asylums. While a number of other historians have certainly challenged the conclusions made by Elaine Showalter and others in the 1980s, what is new here is the detailed way in which Shepherd explores social class as a major feature of Victorian life. Surprisingly, while rigid class distinctions informed some elements of asylum experience (in particular through the distinction between the work-based employment demanded of patients at Brookwood compared to the recreational activities at Holloway), this was not always the case – entertainments, for example, were common to both institutions. Shepherd also shows that there was more crossover than we might imagine between the inhabitants of the two institutions: pauper did not necessarily mean destitute as it did within the workhouse system, and the charitable status of Holloway Sanatorium meant that some poorer patients were admitted, albeit comparatively rarely.

In addition, Shepherd argues that in both Brookwood and Holloway many patients would have experienced better conditions than at home – at Brookwood, in particular, the effects of poverty on the physical health of many patients was starkly evident on admission. Unlike some earlier writers in the history of psychiatry, Shepherd thus considers the asylum within the context of alternative care options (such as the workhouse) as well as the impact of asylum admission on the individual and his or her family. This also leads her to challenge the old claim that, by the end of the nineteenth century, asylums had become warehouses for chronic, long-stay patients, resulting in a sharp decline in therapeutic optimism and a reduction in the quality of care and treatment offered to patients. In neither Brookwood nor Holloway does Shepherd find such a stark picture, supporting the work of more recent historians, including David Wright and Peter Bartlett, on the permeability of asylum walls in the late Victorian era.

Institutionalizing the Insane is a standard social history of two institutions and doesn’t shed any specifically new light on the period, primarily confirming other histories of psychiatry written over the last decade. The chapter on suicide and self-harm, for example, does little to expand on the interesting article the author co-wrote with David Wright in 2002, largely ignoring more recent work on the topic.Footnote ¹ Moreover, the inclusion of ‘self-harm’ in the chapter title suggests a somewhat presentist perspective, given that this was not a term Victorian alienists would have used. Nowhere does Shepherd engage with any distinction between self-harm and suicidal behaviour, which is surprising given that Thomas Brushfield (the first superintendent of Brookwood) did distinguish in his published work between suicidal acts and self-mutilation for other motives. The use of modern terminology and ideas even leads the author to use Victorian attitudes toward suicide to ‘confirm’ twenty-first-century research suggesting that ‘self-harm was a risk factor in attempted suicide’ (155). This surprisingly ahistorical contention sits uncomfortably alongside the detailed contextual analysis offered throughout the rest of the text.

The book is most interesting where the institutional research opens up little-explored topics in the history of psychiatry. For example, the material on voluntary boarders, who were heavily represented at Holloway in comparison to other asylums, deserves greater emphasis. The fact that the admission of voluntary patients continued despite opposition from the Commissioners in Lunacy indicates a certain opposition to the bureaucracy of the asylum system at the end of the nineteenth century. Shepherd also provides detailed examination of staffing in both institutions, paying great attention to the role and recruitment of attendants. Of particular interest here is the early employment of female alienists at Holloway, and their roles and experiences might have been explored at greater length.

In general, Institutionalizing the Insane is well written, with an engaging style and great attention to detail. Shepherd clearly evokes the institutional life of both Brookwood Asylum and Holloway Sanatorium, supporting recent historiography on late Victorian psychiatry that emphasises the importance of a nuanced exploration of individual asylums within their social context.