Guest Blog: Medical Case Studies and Nineteenth-Century Literature

By Kimberly Robinson, The University of Arkansas – Fort Smith

The rise of the asylum is shrouded in mystery and uncertainty, and, in the absence of facts, the Romantics obsessed over wrongful institutionalization, but the bureaucracy that handled the treatment of the insane is more tangible than most people might expect. Culturally speaking, the Romantics represented, among other competing ideologies, the shifting realities for what individuals could feasibly expect in exchange for their time and effort in labor markets. These markets were driven by national and industry agendas where people who were unable to work were often forced into institutions and then labeled insane. In France, there were significant improvements in psychiatric treatment over what had been happening in England. However, because England lagged behind in dealing with disenfranchised populations, grass root tensions forced legislative changes in the way asylums were being operated. These laws shaped the cultural movement toward the creation of the medical case study.

The medical case study was used to regulate communities viewed through the shifting nineteenth century context of mental illness. Susan G. Wells traces the backgrounds of its development back to the mid-nineteenth century in her article, “Freud’s Rat Man and the Medical Case Study: Genre in Three Keys,” and she makes a strong case for how nineteenth century readers forward have read medical case studies in the context of literature (Literary History, 2003). One only has to look to Freud’s Dora for proof of this point, but the medical case study predates Freud by 75 years or so and can be examined within the context of the French Romantic artist, Jean-Louis André Théodore Géricault’s “Portraits of the Insane.”  Géricault’s paintings were commissioned by his doctor as therapy, but they were then included in patients’ medical case files as supporting documentation for diagnoses of “monomania,” a general term which describes a person with a single, driving obsession.

Although the Romantics were fascinated with melancholy, suicide, and focused introspection, part of the problem in identifying mainstream Romantic ideologies is there seems to be no unifying focus. While these qualities are most often acknowledged in Shelley’s Frankenstein, unreliable narrators serve as voices in Hogg’s Private Memoirs and Confessions of a Justified Sinner, Tennyson’s “Maud,” Browning’s “Porphyria’s Lover” and The Ring and the Book, and Stevenson’s Jekyll and Hyde, so even if it is difficult to point to one identifying feature operating within the nineteenth century, the unreliable narrative voice appears in a variety of genres where it was used to articulate what was increasingly becoming the Romantic preoccupation with insanity and the associated practice of documenting the treatment of individuals in asylums, which is where the interdisciplinary connection between literature and medicine, in the form of the medical case study, enters the conversation.  That said, urban legends regarding the unfair treatment of the insane grew out of control in a time when anyone, regardless of gender or social standing, could be locked away based upon the testimony of a relative or a self-declared medical professional, such as Mrs. Rebecca Batt, widow of Edward Batt and the proprietor and resident superintendent of the private house at Witney, Oxfordshire, England, from 1827 to 1842.

William Parry-Jones claims in The Trade in Lunacy there is no written evidence for either of the Batts having received any formal medical training, but this did not prevent Mrs. Batt from issuing “Medical Certificates” in accordance with the Madhouse Act of 1828. While these documents do at least form a written record for patients admitted into the asylum system, which, up to this point, had been largely absent, Mrs. Batt was operating far afield of the law’s original intent, which was to verify a person’s need for treatment based upon a thorough examination by medical personnel at the time of patient admittance. Over filled private houses such as Witney and others, such as those in Hoxton (London), created a growing social anxiety regarding forced treatment where record keeping, when in existence, was minimal although, by 1832, patient records did include patient names, signatures of admitting personnel, declarations of lunacy, and, rather surprisingly, caricatures of patients. Diagnoses were largely absent, except as in the case of Géricault and others like him who were diagnosed very generally as monomaniacs, for example, but these were early days in the field of psychiatry.

Because patient caricatures were a prominent feature of the emerging medical case study, I would like to return to Géricault’s personal situation for just a moment. It is unclear exactly when he painted his asylum colleagues, but it is generally thought that during the latter of his two mental breakdowns, his attending physician, Doctor Étienne-Jean Gorget, who worked both at the Pitié-Salpêtrière teaching hospital in Paris and the private asylum in Livry, prescribed he paint as therapy. Géricault had suffered a mental breakdown, and he was definitely a workaholic whose life was out of control, especially after having undertaken a tour of England in 1819. This was a working trip showcasing The Raft of the Medusa, an oil depicting a small group of survivors abandoned at sea after the wreck of a French frigate in 1816. Also, a back injury he had sustained had never properly healed, and it may have contributed to his death at the age of 32. Even so, his work record speaks for itself as he was classically trained, a relentless researcher, and artistically gifted, and his paintings up until his institutionalization depicted subjects of great historical and social significance.

However, during his asylum stay, he produced his most culturally significant work in the images of the poor, the elderly, and the indigent. Thus, Géricault’s “Portraits” stand apart from anything else produced at the time, and they exist due to the medical and legal movements underway which would continue to shape the fields of the soft sciences, such as sociology and psychology, criminology, and statistics. Practically, medical case studies are a blend of science and rhetoric, of insight and observation. Géricault’s observations constitute an error on the part of Gorget because he allowed Géricault, a patient who was under treatment for mental illness himself, to comment on the state of his asylum colleagues, thus creating a good example of what Wayne Booth would later identify in the twentieth century as “the unreliable narrator.”

Imagine lying in bed at night wondering if, at any moment, without prior warning and perhaps without proper cause or recourse, you might be spirited away and incarcerated against your will based upon the authority of the wife of the surgeon who is also the caretaker of the asylum. The attending physician, by the way, can verify none of his training, and the school from which he claims to have received his training bears no record of his matriculation. In fact, if there is no physician on the floor when you arrive, the housekeeper might actually issue the necessary paperwork.  The diagnosis you receive might be suspect, but the certificate used for admittance will be legal and, therefore, binding. While this system was obviously rife with problems, it was a definite improvement over the absence of any formal documentation in the warehousing of asylum inmates.

In addition, within the medical case study, there lies a narrative function. Ideally, a medical case study represents a particular person whose pertinent information is unique.  During the nineteenth century, medical case studies as a new rhetorical form often misused bureaucratic forms, recorded invalid signatures, and included unqualified eye witness accounts of patient behaviors in the diagnoses of mental illness.  At the same time, the historical record indicates the converging influences of literature and art onto the politics of the developing field of psychiatry. Further, the history of the medical case study provides a tangible document mirroring much of the defining literature and art produced during the nineteenth century which employs the unreliable narrative voice as a substitute for an informed, credible perspective. The condition of mental institutions, the nature of madness, and the questionable validity of evidentiary documentation, fostered this unstable voice, and it is still very much with us today.

Dr. Kimberly Downing Robinson is an Associate Professor at the University of Arkansas – Fort Smith where her teaching duties are divided between the rhetoric and literature programs. Her research interests include rare book collecting, bibliography, art history, assessment methodologies, and pedagogical innovation. Her recent interdisciplinary collaborative course design, “Thrift as an Ideology,” can be viewed here.

Image: Théodore Géricault, Portrait of a Kleptomaniac or Portrait of an Insane Person (1822)