Alexandra Wallis examines the nineteenth-century use of “moral treatment” to enforce traditional gender roles on female patients suffering postnatal depression. This post is based on an article that appears in the 2020 issue of Lilith, available now on open access here.
Trigger warning: discussions of depression and suicide.
Postnatal depression affects one in every seven women who give birth in Australia each year and is monitored by hospital staff with several programs, helplines and organisations to support new families. However, in the nineteenth and early twentieth century, puerperal insanity – a diagnosis applied to postnatal depression at a time when the condition was poorly understood – could result in incarceration in an asylum.
In Western Australia, the Fremantle Lunatic Asylum was the primary asylum from 1858-1908, and as many as 452 women were admitted across that period. Research into the patient registers and casebooks for the asylum revealed that of those women, 62 (13.7%) were puerperal insanity patients. It was the third-highest reason for admission (after delusions at 24% and mania at 19%). These women were diagnosed with multiple terms, such as puerperal mania or melancholia, pregnancy, lactation, etc. However, it is important to note that male physicians wrote the patient records, recorded information inconsistently, and their context influenced their diagnoses.
There was a well-established connection between women’s bodies and insanity in nineteenth-century medicine. In 1878, Drs Bucknill and Tuke wrote that ‘the reproductive organs are frequently the seat of disease or abnormal function.’ This connection was most evident in puerperal insanity; in 1835, Dr James Cowles Prichard argued that ‘puerperal madness is a form of mental derangement in women soon after childbirth’. The women with puerperal insanity were perceived by doctors and society as “abnormal” women, rejecting or struggling with the role of motherhood.
One of the women admitted to the Fremantle Asylum for puerperal reasons was 30-year-old Presbyterian housewife, Florence ‘Flora’ Mary Brown. Flora was admitted by her husband on 27 September 1903 in a ‘puerperal state’ after the birth of her daughter. Dr Sydney Montgomery, the asylum Medical Superintendent, diagnosed Flora with puerperal mania noting that she was ‘destructive and at times violent.’ A month later Dr Montgomery reported that Flora was ‘very dull and stupid’ and would not ‘employ herself.’ Chores and jobs at the asylum were considered an essential part of treatment.
In the nineteenth century, asylum physicians began instituting more humane methods, prominently moral treatment which originated in England when William Tuke founded the York Retreat in 1796. It aimed to enforce “good” habits in patients, reinforcing social norms and skills according to gender. Work as rehabilitation was a staple of moral treatment. Historian Morag Allan Campbell notes that for women ‘curing the patient meant restoring her to a condition fit for return to home, family and the responsibilities of her role as wife and mother.’ Therefore, domestic tasks such as cleaning, laundry, sewing, and self-cleanliness were retraining women in expected gender roles.
Moral treatment and work as rehabilitation in Fremantle was implemented on all patients. For the puerperal patients, domestic jobs were crucial as their indifference or hostility to children or husbands contradicted physicians’ notions about women’s ‘maternal and wifely devotion.’ However, female patients were not labelled insane only because of their lack of feminine behaviours; the realities of women’s lives and their family living conditions were important factors.
Flora was noted in November 1903 to be ‘continually lazy.’ However, by June 1904, Dr Montgomery stated that she was ‘much better, is sewing and seems to take more interest in things.’ The sewing was an improvement. In September 1904 Dr William Blackall, the asylum Medical Officer, wrote that Flora ‘varies a great deal between fairly normal mental stability and distinct insanity, she has lately maintained her improved condition for a longer time than normal.’ Consequently, on 23 September, Flora was ‘discharged relieved to care of husband.’ Despite Flora’s fluctuating mental state, Dr Blackall believed she was well enough to care for her family.
Puerperal patients were often discharged from Fremantle; of the 62 women, 38 (61.3%) were discharged from the asylum at some point. The statistics align with nineteenth and early twentieth-century physicians’ beliefs that puerperal insanity was curable. In 1903, Australian asylum superintendent William Beattie Smith noted that ‘half the cases recover in four months, and thence onward to the ninth month, with a few recoveries even as late as a couple of years.’ Fremantle superintendents displayed this attitude as patients with puerperal insanity who completed domestic tasks would often have short asylum admissions. However, of all those puerperal patients discharged, 47.4% were readmitted to the asylum. Therefore, half of these women had not been effectually “cured.”
Flora was also readmitted to the asylum on 27 September 1905, a year after her discharge, and two months after the birth of her second child. She was diagnosed with ‘melancholia of lactation’. Historian Hilary Marland writes that lactational insanity, in manic or melancholic form, was seen by nineteenth-century physicians to lead to depression. Although curable, it would only occur in women with several children, not first-time pregnancies; and it was Flora’s second pregnancy.
Flora, observed by Dr Blackall, had ‘returned to very much the same condition she was in for months previous to her last discharge.’ In October 1905, Flora ‘secreted a knife in her dress “to cut her head off”’ and was placed on a red ticket (suicide watch). In November, Dr Blackall reported that Flora had not improved and that she was ‘chattering to herself all day long “why can’t I get out of this place; why was I brought here amongst all these people”.’ By 1908, Flora had made ‘no improvement, full of delusions’ and she was transferred to Claremont Hospital for the Insane when Fremantle closed. Flora’s suicidal ideation was deemed too risky for discharge.
After the birth of her first baby, Flora was admitted to the asylum for ten months, discharged when she began to function well enough to care for her family. However, her readmission suggests that her potential psychological issues were not cured or understood as she had similar issues at the next birth. Flora’s case also reveals that despite successfully undertaking domestic tasks, the moral treatment did not cure all the patients. Flora’s readmission suggests that she, and possibly others, were susceptible to recurrent issues that were seemingly left untreated.
Through examining the Fremantle Lunatic Asylum female patient records deeper insights are made into the lives of the women admitted for puerperal reasons. While not personal accounts, they reveal how nineteenth-century physicians categorised and treated women with a gendered form of madness, and are invaluable to understandings of the history of mental illness.
Today, societal myths of motherhood still result in women hiding their postnatal depression symptoms. However, an Australian study from 2019 reveals that awareness of postnatal depression has improved; although, there is still a lack of understanding regarding mental health during pregnancy and the impact on fathers. Therefore, continued research, such as the Parent Infant Research Institute (PIRI) in Victoria, contributes to removing stigma and constructing a dialogue on postnatal depression.
Dr Alexandra Wallis is sessional academic and lecturer at the University of Notre Dame Australia, Fremantle. Her research focuses on the female patients’ experiences at the Fremantle Lunatic Asylum from 1858 to 1908. She graduated with a BA Hons in History and English from Edith Cowan University in 2014.