Introduction In November 1859, Sarah Rebecca Thorley, a 28-year-old governess, was admitted to the Middlesex County Asylum at Colney Hatch. A letter, written by one Dr Fraser, accompanied her, which stated some extra information about the cause of her disease: Yesterday I signed a certificate of insanity in the case of Miss S.R. Thorley, previous to her removal to Colney Hatch - There is one circumstance connected with her condition which you ought to know, as it will guide you in adopting the treatment most likely to be beneficial - The fact was hinted to me by Mr Heally, in consequence of which I questioned Miss Thorley’s sister, and learnt from her that at an early age (9 or 10 years) the patient, being under the evil influence of the worthless maid servant, contracted vicious habits of selfindulgence which have increased with her years. An operation (probably excision of part of the clitoris) was performed, but without any apparent benefit. You will probably have a visit from the sister, who can give you further information respecting your patient’s antecedents, the family are strangers to me, but I promised the sister (a rather superior young lady, but straitened in circumstances) that I should write to you on the subject, as she might otherwise feel indelicacy in alluding to it. 1 This is a graphic example of how complex and delicate a task a psychiatric practitioner needed to perform when he attempted to identify the cause of madness a patient of his was suffering from: the aetiology of insanity, as well as the disease itself, was often located in an intensely private realm of family secret, hard to tell and harder to ask. Sheer technical difficulty aside, negotiating one’s way to the true cause of the disease, through the intricate web of secrecy, etiquette and protocols was obviously a daunting piece of detective work. Besides with the stigma associated with mental disease and the sense of shame the family felt over the madness of its member, one of the major reasons for the complication lay in the distinctive characteristic of psychiatric clinical encounter. Dr Fraser’s letter exemplifies the fact that the psychiatric doctor-patient relationship was normally a triangular one: the patients did not typically report their illness to the doctor, the accounts of the disease being normally given to the doctor by the third party, who did not experience the disease subjectively but knew the patient and their illness well enough - usually members of the patients’ family, or their relatives, neighbours and so on. (For the sake of convenience and historical correctness, below I shall refer to the third party in general as ‘friends’.) The doctor-patient relationship, especially in an institutional setting, has attracted the keen interest of historians of medicine in general, many of them utilising the rich resource of hospital case records. 2 These studies have paid special attention to the power structure of the clinical encounter in charitable settings and showed that complex power relations were going on, between the doctor and the patient, between lay governors and medical staff, and so on. Between the patient and the doctor, there existed a contest for interpretative authority over the act of decoding and defming disease, or what Katherine Hunter has called ‘a silent tug-of-war over the possession of the story of illness,.3 Moreover, the relationship at the bedside was affected in crucial ways by the pattern of control of the whole institution, often characterised by the doctors’ quest for medical hegemony over the charitable institutions and their bypassing lay governors’ power.4 Historians of medicine have found that such power relationships were embodied in hospital case records. The most famous and important among historical investigations of the role of case record is that of Michel Foucault. In his Discipline and Punish, Foucault famously observed that the practice of keeping case records was not merely record-keeping but the cornerstone of modern human science: ‘The examination, surrounded by all its documentary techniques, makes each individual a “case�?: a case which at one and the same time constitutes an object for a branch of With such historiographical concerns in mind, this chapter attempts to investigate changing practice of keeping patient’s case records at Bethlem in the nineteenth century and shifting patterns of the distribution of power in the triangular relationship between the doctor, patient and friends. To put it briefly, my argument is that a quiet but definitive change took place in 1852, the year of an important reform of Bethlem. Before 1852, the friends of the patient had relatively unchallenged authority over identifying the cause of the attack. Mter 1852, their authority was routinely impugned not only by the doctor, but also by the patient. At the core of this shift was the struggle over the power to define the identity of the patient. What kind of life had he or she really led? What had really driven him or her to madness? Who knew the best about his or her private secret, and who could best identifY him or her? I shall argue that after 1852, the patients were increasingly defined in the light of what the doctor observed in the institution, and, more interestingly and importantly, What the doctor heard from the patients. Put in another way, the doctor framed the patient’s subjectivity into their attempt to understand the real identity of the patient, hidden by or unknown to his or her family members.
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