Historical essay
“Better…at the Bottom of the Sea”?: Affect, Agency, and the Archive at Holloway Sanatorium

“Better…at the Bottom of the Sea”?: Affect, Agency, and the Archive at Holloway Sanatorium

Adriana C. van Manen

In August 1889, an English woman named Charlotte S. experienced a depressive episode marked by religious delusions. Convinced there “was no hope for her in Eternity,” the once “strong, healthy [and] active” fifty-five year old was certified insane[1] and institutionalized at Holloway Sanatorium.[2] When patients were admitted to Holloway, staff recorded their personal details in hefty leather casebooks. As treatment progressed, staff noted updates and, in about one third of all cases, affixed a photograph of the patient to their chart.[3] The casebooks are now fully digitized and available online through the Wellcome Trust. Although some patients recovered, the casebooks contain many tragic accounts of those who did not, and whose struggles surface in an archive that renders them “dirty” and “incoherent.”[4] One patient, a twenty-eight year old schoolteacher named Emily E., told doctors that it “would be better to her if she were at the bottom of the sea.”[5] She is long deceased, but the Holloway archive remains. Who should have access to the record of private pain? Ought we to consign the Holloway archive, and the suffering it contains, to oblivion?

When Holloway Sanatorium was founded in 1885, the co-ed institution positioned itself as a humane and modern asylum – an alternative to the madhouse for those who could afford it. Situated on twenty-two acres of lawns and gardens in Virginia Water, the sanatorium’s Gothic Revival campus was equipped with amenities like a bathhouse and chapel. Patients engaged in activities appropriate to their bourgeois social class, such as strolls on the grounds, dances, concerts, and excursions to stores in London.[6] The medical superintendent even hired a few same-gender companions for patients with the aim of encouraging “normality and socially acceptable behavior.”[7] While doctors at Holloway provided care based on their best abilities and the science of the time, 19th century understandings of mental illness were different from our own. There was little agreement about the causes of, much less cures for, mental illness.[8] Accordingly, etiologies in the casebooks are often circuitous (e.g. “the supposed cause of…attack is previous attack”)[9] or barely attempted (e.g. “the supposed cause being absolutely unknown”).[10]

Unlike the frontal, mug-shot style photographs taken directly upon admission at most asylums, photographs at Holloway were not systematized and presented subjects in a range of poses. Often borrowing from the dialect of Victorian family photo albums, staff cut the photos into shapes (an oval, or perhaps a square with trimmed edges) before pasting them into the patient’s file (below).[11] Their distinct visual register, which slips between the aberrant and the normative, has generated new scholarship examining these images more closely.[12] However, the photographs also surface key issues related to consent, privacy, and the potential for voyeurism in terms of both their original production and our current access to them. This concern is not just a modern ethical hang-up. At the 1901 meeting of the Medico-Psychological Association of Great Britain, one doctor asserted that “he did not think that anyone had a right to photograph insane patients.”[13] Yet the photos also present an opportunity to bear witness to how, even at a reform minded institution for the upper middle class like Holloway, attempts to cure the mentally ill involved control and coercion.

A photograph of a young woman with her hair pinned up. The photograph is pasted to a page with a handwritten note that reads, "She was today discharged 'Recovered.'"
Nineteen-year-old Eva M., MS.5158 23. (Courtesy Wellcome Trust)

For example, the first page of the entry for Constance C., a nineteen year old from Winchester, shows her being held by two nurses to be photographed – much like a butterfly pinned for display in a glass case (below). Although the nurses are sliced out of the photo, the book’s spine and the margin of the page do the same work of keeping Constance in line. The notes reveal that she “had to be subjected to slight restraint” and was confined to sleep in a padded cell rather than a general dormitory.[14] She was also given what were called “continuous baths,” in which the patient would sit for hours in a tub of hot water and have cold water poured over their head.[15] Physically restraining patients within the bath was not an uncommon practice, and the casebooks report that Constance C. had a “strong aversion” to this treatment. Considering this evidence, the camera can be seen – to borrow the words of the casebook chronicler – as a “slight restraint.” The “slight restraint” of photography was used at Holloway alongside forms of physical restraint such as sleeve jackets, locked gloves or leather mitts, padded rooms, hypnotic/sedative drugs like chloral and sulfonal, central nervous system depressants like paraldehyde, and electrotherapy.[16]

A photograph of a woman pasted into a notebook with handwritten notes. The woman is being held up by the arms.
Nineteen-year-old Constance C., MS.5158 192. (Courtesy Wellcome Trust)

Evidence of coercion can also be located in images that, at a quick glance, appear to eschew such forms of control. These photos show patients posing outdoors in fashionable clothes. In one such image, a woman named Elizabeth M. dons a fur trimmed coat and glances away from the camera (below).[17] It is tempting to read her stylish appearance as an expression of individual agency and identity. However, the casebooks suggest the opposite. They observe that Elizabeth M. was “incapable of saying how long she has been here or where she lives”[18] while another patient, Hélène P., “invariably required about 10 nurses to dress + undress her.” [19] It is thus likely that many patients were dressed by staff. The effort to dress and photograph patients is consonant with the “moral treatment” favored by 19th-century asylums.

Photograph of a seated woman looking away from the camera.
Elizabeth M. (age unknown), MS.5158 35. (Courtesy Wellcome Trust)

The prominence of photography in the Holloway casebooks might be viewed as part of a wider effort to cure patients by assimilating them to the very image of bourgeois normalcy. This interpretation is supported by the fact that the casebooks often associate the recovery of female patients with their resumption of gender-appropriate behavior. For instance, notes marking an improved mental condition comment that Eva M. “begins to take an interest in her appearance, keeps her dress and hair tidy.”[20] Some patients thoroughly resisted being dressed. For instance, forty-five year old Mary J. repeatedly destroyed the dresses she was given, and instead accessorized herself with “pieces of wool + odd scarfs [sic] of paper.”[21] There is poetry in how her casebook portrait has slowly curled in on itself, disdaining to represent her in an outfit she did not want to wear (below).

Although the camera was used as a tool of restraint and conformity, it also often reveals what the written treatment histories cannot: the patients as distinct people. For example, in a photo of Henriette C., the patient at first appears to be sleeping (below). However, upon closer examination, she is looking directly at the viewer. The thirty-one-year-old mother was subjected to electrotherapy and either force fed or fed with a tube up to three or four times daily. She figures in the casebook as “very troublesome” for her physical resistance (“struggling, kicking + shouting”) to these forms of treatment.[22] Yet here we can glimpse an aspect of her personality – her particular, wakeful attention. She is laid out in bed like a supine Christ on his tomb, but she is not dead. Nor will she be surveilled passively; instead, she attends to us looking at her and even orchestrates our gaze with the raised placement of her hands. In contrast, the casebooks often fail to link Henriette C.’s affect with any deeper significance. For instance, they observe that she “is emotional, will burst into tears for no obvious reason.”[23] Yet as modern viewers, we can assume that every facial expression and bodily gesture has meaning, even when we cannot read the emotional iconography. Our task, in viewing these photos today, is to restore the coherence and integrity of the patients they depict.

A faded photograph of a woman lying in bed, pasted into a handwritten notebook.
Thirty-one year old Henriette C., MS.5158 191. (Courtesy Wellcome Trust)

The stakes for doing so are all the higher given that these images are easily accessible online. The risk of voyeurism is exemplified by a recent incident, in which two historians of medicine found psychiatric records offered for sale on eBay. This, they write, is part of a wider, “stigmatizing subculture around madness and disability, intended to evoke prurient curiosity, fear, and disgust.” Their concern is duly noted. Indeed, some of the Holloway images have already found their way onto Pinterest boards. At the same time, perhaps we can see the internet not just as a liability, but as an asset too, making it possible to share debates about sensitive images and histories with the broad public – something historians of medicine have called for.[24] After all, we are the heirs of Charlotte S., Emily E., Constance C., Elizabeth M., Mary J., and Henriette C. What they lived through is ours to contend with now, in a society in which ‘mental health’ has become an omnipresent buzzword, but the crisis of mental illness only continues to worsen. Furthermore, the language of psychology has increasingly entered the mainstream, with the dubious effect of pathologizing normal behavior and diagnosing relational conflict as toxic. While the Holloway photographs present neither easy solutions nor tidy narratives of recovery, they do offer an opportunity to nuance contemporary discourse around mental health. They ask: how do we attend to our vulnerable past? In looking closely at these photos, we do perhaps run the risk of disturbing the dead but for good reason. Through our attention, we wish to do them justice.


  1. In the 19th century, insanity was both a medical and legal category. Carla Yanni, The Architecture of Madness: Insane Asylums in the United States (University of Minnesota Press, 2007), 162.
  2. “Females no. 2: Certified female patients admitted January-September 1889,” MS.5157 101, Wellcome Collection, London
  3. Susan Sidlauskas, “The Medical Portrait: Resisting the Shadow Archive,” nonsite.org, no. 26 (November 11, 2018), https://nonsite.org/the-medical-portrait/
  4. For instance, in MS.5157 321, Mary J. is “dirty + untidy + slovenly” while, in MS.5157 21, Eva M. “rambles off into flippant irrelevant nonsense…remains very incoherent, untidy + dirty.” My point here is not to contest that patients neglected their physical appearance or talked in ways that were hard to make sense of, but rather that this is frequently the extent of their representation within the casebooks.
  5. MS.5157 101
  6. Susan Sidlauskas, “The Medical Portrait: Resisting the Shadow Archive”
  7. Anne Shepherd, “The Female Patient Experience in Two Late-Nineteenth-Century Surrey Asylums,” in Sex and Seclusion, Class and Custody: Perspectives on Gender and Class in the History of British and Irish Psychiatry, ed. Jonathan Andrews and Anne Digby (Amsterdam, NL: Rodopi, 2004), 241.
  8. Yanni, The Architecture of Madness, 7.
  9. As in the case of Eva M. in MS.5157 21.
  10. As in the case of Constance C. in MS.5157 191.
  11. Susan Sidlauskas, “The Medical Portrait: Resisting the Shadow Archive”
  12. See Katherine DB Rawling, “‘The Annexed Photos Were Taken Today’: Photographing Patients in the Late-Nineteenth-Century Asylum.” Social History of Medicine 34, no. 1 (2019): 256–84; Susan Sidlauskas, “The Medical Portrait: Resisting the Shadow Archive”; Katherine DB Rawling, “‘She Sits All Day in the Attitude Depicted in the Photo’: Photography and the Psychiatric Patient in the Late Nineteenth Century.” Medical Humanities 43, no. 2 (2017): 99–100; and Susan Sidlauskas, “Inventing the Medical Portrait: Photography at the ‘Benevolent Asylum’ of Holloway, c. 1885–1889,” Medical Humanities 39, no. 1 (2013): 29–37. Sidlauskas suggests the need to develop an art-historical methodology that can attend to the formal qualities of medical photos. By reading agency into the Holloway photos (noting, for example, patients who close their eyes or cross their arms), embedded as they are within the repressive pole of portraiture, she resists what Allan Sekula called “the shadow archive” comprising photos of “the poor, the diseased, the insane, the criminal, the nonwhite, the female.” Rawling, meanwhile, focuses on how the photographs challenge the stereotype of the passive, victimized psychiatric patient. At times, she elides the practice of physical restraint in order to advance her view of the medical portrait as a site for affirming or re-fashioning identity.
  13. Quoted in Katherine DB Rawling, “’The Annexed Photos Were Taken Today,’” 102.
  14. MS.5157 192
  15. MS.5157 193
    Anne Shepherd, “The Female Patient Experience,” 242.
  16. The handwriting denoting her first name is illegible, so I am calling the patient by her middle name.
  17. MS.5157 33
  18. MS.5157 342
  19. MS.5157 22
  20. MS.5157 322
  21. MS.5157 192
  22. MS.5157 193
  23. As part of a wider reflection on the use and potential abuse of historical images, Jordanova writes, “It’s vital that these conversations are shared with audiences that are as broad as possible. It will never be feasible now to restrict the availability of digital imagery, but we can share widely our ideas about how to handle and interpret them. It will always be worth developing our self-awareness as historians, and as attentive, skilled interpreters of the visual culture generated in relation to medicine and health.” Jordanova, Ludmilla. “Attentive Looking.” Web log. AboutFace (blog), July 29, 2020. https://aboutfaceyork.com/2020/07/attentive-looking/

Featured image caption: Holloway Sanatorium in the c. 1933. (Courtesy Wellcome Collection)

Adriana C. van Manen is an Ada Comstock Scholar at Smith College, where she is on the editorial staff of the journal Dies Legibiles. Her interests range from 20th c. female surrealists to late medieval manuscripts. Her work has been published in NYU’s undergraduate journal of art history and she has presented at the SUNY New Paltz undergraduate symposium.