Case books and the patient experience

It’s been a little tricky fitting in archive visits around part-time work and a toddler, so I’ve been delighted to find the Wellcome Collection have digitised some of the patient case books from Holloway Sanatorium, an asylum for middle-class men and women which opened in 1885. The asylum was housed in opulent buildings near Virginia Water in Surrey, and from the outset was equipped with the opportunities for recreation and entertainment that one might expect from its clientele. As most of the patients were unused to employment, recreational activities were all the more important in keeping them occupied and providing structure and discipline on a day-to-day basis. Concerts, choirs and bands were part of this, and the sanatorium employed ‘companions’ especially to help patients become engaged with a wide variety of activities.

Patient case books provide a rare opportunity for insight into the lives of individuals, their particular mental states and their responses to treatments and therapies. Each entry in the Holloway case books contains details of the patient’s background, age, marital state and occupation, together with a brief history of previous illnesses. There follows the two letters explaining the current complaint and reasons for certification. Finally, the asylum’s medical staff added a paragraph giving observations on arrival at the sanatorium. Following this, the pages were updated with relevant changes or, every couple of months, to note a lack of change. Case book A gives information on females certified between 1885 and 1887; reasons for illness include domestic trouble, inherited mental disorder and disappointment in love. One patient was convinced she was a steam engine. Women of all ages were represented, married women generally without occupation, but among the unmarried women were governesses and teachers.

The very first woman listed in the case book happened to be musical. Stella James was admitted in a state of Dementia, and took little part in activities. However, after a few months she began to sing and play the piano. Music was a sign of normality, engagement with others and mental functioning, but also became a subversive act for Stella: later on she is recorded as dancing and singing all night, her liveliness becoming ‘objectionable’. I find it interesting that music straddles the two sides in this way, reflecting both normality (for most women of this class would have learnt the piano) and disturbance. But this reflects in some ways the dual place of music throughout society. As an art form it could be refined, reflected in fashionable soirees or intellectual orchestral concerts; music was encouraged by philanthropists as a means of ‘rational recreation’ for the working classes. At the same time, music’s image suffered because of the link to the morally degrading activities of the music hall and tavern. Returning to health, music could both cause and cure madness. This dichotomy is one of the reasons music’s place in asylums is particularly interesting.

Link to Wellcome Collection digitised case books:



Music making at Worcester asylum is the only example widely known today, due to the involvement of Edward Elgar in the 1870s and 1880s. Elgar was appointed Band Master in 1878, succeeding his violin teacher. He rehearsed the band, led performances, and composed a small amount of dance music which survives.

As at other asylums, a band was formed in the 1860s, and the annual reports also attest to a choir in the chapel, both staffed largely by attendants. However, records for musical activity, with the exception of payments to band masters and the material associated with Elgar, are sparse.

View from Worcester Asylum site
View from Worcester Asylum site

The asylum site at Powick is beautifully situated, overlooking the Malvern Hills. Only the very central portion of the main building, and the house built for the medical superintendent, remain.

Main Asylum building, Worcester
Main Asylum building, Worcester
Superintendent’s House, Worcester

Worcester boasts two medical museums, and both of these contain exhibits dedicated to mental health and the work of the asylum. The George Marshall Medical Museum, contained within the Worcestershire Royal Hospital, includes medical instruments used within the Asylum, together with a death mask of one of the patients. See

The Infirmary Museum features a special corner devoted to the history of the asylum, including details on its use of music:

Singing and Health today

This week’s World Mental Health Day reminded me that singing is often linked with physical and mental health. We often see studies purporting to show the benefits of singing, particularly in a choir, and these opportunities are often part of life at hospitals and care homes. In 2012 Stephen Clift reviewed the literature on singing and health, concluding that there was little evidence for the positive effect on physical health, but that singing was clearly beneficial to overall health and wellbeing in many studies (see ‘Singing, Wellbeing, and Health’ in Macdonald et al. Music, Health, & Wellbeing (Oxford, 2012) pp. 113-121). A cross-national survey reported by Clift identified six key ‘mechanisms’ which resonate with some of the reports of patients and attendants  experiencing music in the asylum:

  • positive affect
  • focused concentration
  • controlled breathing
  • social support
  • cognitive stimulation
  • regular commitment


SSHM and RMA conferences

Over the summer I’ve had the privilege of sharing my early research at a number of conferences. In July I travelled to Canterbury to the Society for the Social History of Medicine, a large conference with an international flavour. It was great to be part of a session on asylums – in Venice, Sydney and North India as well as my own contribution on Norfolk.

conference programme:

The Royal Musical Association Annual Conference in September provided a very different context, with a session on music therapy at which I was the only historical scholar. It’s fascinating to find, though, that there is still plenty of debate about the overall aims of music therapy and the different roles music can play, whether as a means to an end or a goal in itself.

conference programme:

York Retreat

The York Retreat asylum represents a very different institution from the county-run pauper asylums I have previously visited. York also had a county asylum, and it was the unfortunate death of a young Quaker woman there in 1790 that prompted the local Society of Friends to set up a private charitable institution, run on Quaker principles, and intended to provide individual care to a small number of patients. The Retreat is most famous for its dedication to ‘moral treatment’, under the influence of the Tuke family, who were instrumental in its foundation and throughout the nineteenth century. From the mid-nineteenth century it came to resemble more closely the practice of the County asylums, though catered for a combination of Quakers of all social classes, and middle class private patients from non-Quaker backgrounds.

York Retreat Main Building
York Retreat Main Building

Due to the Quaker principles and the small initial size of the asylum, music does not feature in early records. However, as more affluent and non-Quaker patients were admitted, pianos and musical entertainments became more common.


The West Riding Pauper Lunatic Asylum in Wakefield was set up in 1818, and became well-known for its advocacy of non-restraint on a large scale. The asylum made use of the model provided locally by the York Retreat, a much smaller and private institution, using the advice and experience of the Tuke family (who ran the Retreat) but implementing its principles on a much larger scale. As other public lunatic asylums were founded, they often made use of Wakefield as a model.

The main asylum buildings at Wakefield
The main asylum buildings at Wakefield

Work therapy was a central part of asylum management from the outset, and within a few years of its foundation almost all patients were able to participate in some kind of labour, whether outside in the cultivated gardens, or inside, helping with maintenance, cleaning and mending. The Asylum management recognised the importance of work for occupying the minds of the patients and providing a distraction from the melancholy and distress which characterised many patients.

Entertainments and recreations were much less quick to become part of moral treatment. In this case, the management were clear that ‘frivolous’ entertainment was usually not suitable for pauper patients. Not only would such activity provide only temporary relief from the trials of mental health problems (in contrast to the longer-lasting effects of regular employment), it was also morally problematic, given the low status and restricted means of pauper patients. In this case, re-creating life outside the asylum meant only careful use of music and other entertainments.

The recreation hall at Wakefield
The recreation hall at Wakefield

Music became more prominent under the medical director between 1866 and 1876, James Crichton Browne. As well as developing new approaches to the medical treatment of mental disorder, Brown encouraged music and theatre. A large detached hall was built for a variety of purposes, initially as a dining hall, but soon played host to visiting musicians and theatre companies as well as successful in-house groups.