Introduction

From ancient notions of the ‘wandering womb’ as the seat of a host of physical and mental disorders in women, to the recent addition of Pre-Menstrual Dysphoric Disorder (PMDD) to The Diagnostic and Statistical Manual of Mental Disorders,¹ for millennia the perceived relationship between madness and the fundamentally ‘pathological’ female body, particularly its reproductive system, has captured both the popular imagination and the interest of scholars.² Yet, within the history of psychiatry, the development of a scholarly agenda which sought to investigate these long-held associations is a relatively recent phenomenon. Serious systematic historical inquiry began with the work of second-wave feminists, situated within the wider zeitgeist of revisionism occurring within the history of psychiatry more generally. The last quarter of the 20th century witnessed a flourishing of feminist histories of psychiatry, with the publication of Phyllis Chesler’s radical Women and Madness (1972) proving instrumental in sparking a wave of research that fundamentally overturned the physician-focused, teleological narratives that had come to characterise traditional histories of psychiatry.³

Positioning psychiatry as ‘a tool in the subjugation of women and a denial of their avenues to knowledge or to the occupational roles held by men’, Elaine Showalter’s highly influential The Female Malady (1985) captures the essence of such early feminist scholarship.⁴ Pointing to the overrepresentation of women as patients in asylum admission statistics, and to a cultural tradition ‘that represents women as madness’, Showalter argues that insanity was perceived not only by the male medical profession, but in wider society, as a distinctively female complaint.⁵ Madness, she contends, was seen as a ‘female malady’, one in which the female body and its biological functions were intrinsically linked with women’s propensity for mental illness.⁶ Consolidating the notion of the victimised madwoman, Showalter’s study drew attention to the ways in which social and cultural constructions of gender became entwined with medical conceptions which could, in turn, be used to both justify and reinforce women’s subordinate place in society.

In some respects, early feminist histories were more of ‘a manifesto than a measured historical evaluation of the gendered aspects of psychiatry’.⁷ Such scholarship was nevertheless a trail-blazing development as, prior to the 1960s, the history of psychiatry was, in essence, ‘a world without women’.⁸ Indeed, the work of feminists was essential in stimulating the diversity of scholarship that followed. In contrast to their more ideologically-driven predecessors, the post-revisionist scholars of the late 20th and early 21st centuries took what Nancy Tomes describes as a more ‘symmetrical approach’ to histories of women and madness, one that ‘acknowledged the rich associations between femaleness and madness in the representational tradition’ but rejected the argument that madness was a condition experienced more by women than men.⁹ For example, in her 1994 article ‘The Female Malady?’, Joan Busfield challenges Showalter’s thesis, observing that while the notion of madness as the ‘female malady’ had become ‘part of feminist orthodoxy’, it was actually a claim that had ‘little empirical support’.¹⁰ Re-examining Showalter’s use of statistics and cultural representations, Busfield argues that there was, in fact, ‘no clear monopolization of madness either in terms of cultural representations or in terms of patient populations’.¹¹

More broadly it has been argued that, in the context of the rapid growth of purpose-built, state-supported asylums during the 19th century, psychiatry has offered a powerful and, at times, controversial means to segregate and control people deemed deviant, difficult or dangerous, regardless of their gender. Scholars have debated the extent to which the identification of a distinct problem population, labelled ‘mad’, and the ‘expanding empire’ of specialist institutions to contain them, was the consequence of a desire to care humanely or medically for the vulnerable, a convenient solution for ‘inconvenient people’, or a more sinister tool of bourgeois social control.¹² More recent research into the pluralism of welfare provision has complicated earlier carceral narratives by demonstrating the multiple routes in and out of the asylum, the significant role of families in the processes of institutionalisation and discharge, as well as the ways in which gender dynamics played out within asylums.¹³

These institutional histories complicate any straightforward narrative that the psychiatric profession used mental illness as a tool to oppress women, by drawing attention to the fact that ‘within the asylum, women occupied more complex roles than the earlier stereotype of powerless victims subdued by arbitrary diagnoses’ would suggest.¹⁴ While continuing to highlight the ways in which asylums and conceptualisations of psychiatric illness were organised through ‘patriarchal relations of the era’, post-revisionists broadened the scholarly landscape by allowing for greater nuance in how the dynamics of gender, madness and psychiatry actually played out within and beyond the asylum context.¹⁵ These revisions were also central in prompting the shift from an exclusive focus on women to a consideration of gender as a category of analysis. Emphasising the need for an examination of the ‘complex interrelation of gender and madness, not just of women and madness in isolation’, Busfield in particular has argued for a closer and more critical investigation of madness as the female malady, highlighting that, when one disaggregates madness into specific categories, it becomes clear that ‘rather than being a or the female malady, madness took many forms, some of which were strongly linked to women and to femininity, others far less so’.¹⁶

Numerous scholars have since responded to her call. Mark Micale’s examination of male and female hysteria, and studies on various forms of nervous disease, from neurasthenia to shellshock, have contributed to an increased diversity of research on historical conceptualisations of gendered categories of psychiatric illness.¹⁷ While nervous disorders dominate historical examinations of 19th-century psychiatric classifications, others have sought to draw attention to hitherto neglected diagnostic categories. For example, Hilary Marland’s ground-breaking study of puerperal insanity explores the relationship between psychiatric disorder and childbirth, highlighting the complex ways in which the medical profession sought to explain this concerning form of insanity in ways that moved beyond the oft-cited notion of the illness-prone woman.¹⁸

However, despite this tradition, scholarship pertaining to the gendered conceptualisation of psychiatric disorders has stalled in the last two decades, with very little published on psychiatric conceptualisations of menstruation, reproduction, or the lifecycle, despite a proliferation of diagnostic labels to capture each stage of the lifecycle, from pubescent to climacteric insanity. With the notable exception of Morag Allan Campbell’s study of puerperal insanity in Dundee,¹⁹ the gendered dynamics of asylum life, and the supposed psychiatrisation of the female lifecycle, have been neglected, particularly within the Scottish context. The complex and ambiguous position of menstruation within Scottish psychiatry is yet to be disentangled.

Therefore, this article seeks to address this key historiographical gap through an interrogation of psychiatric conceptualisations of the female body in 19th-century Edinburgh. Drawing primarily upon the influential work of leading alienist (as psychiatrists were formerly known) Thomas Clouston—physician-superintendent of Scotland’s largest and most prestigious asylum, the Royal Edinburgh Asylum (REA), 1873–1908—we explore the various purported biological ‘crises’ of the female lifecycle, from puberty, through pregnancy and childbirth, to menopause, and constructions of the ‘fragile’ or ‘pathological’ menstruating body as articulated in Clouston’s Clinical Lectures on Mental Diseases. Having demonstrated the multiple ways in which the female body was conceptualised through the psychiatric lens, this article then situates Clouston’s theories, particularly his concerns regarding the supposed demands placed upon the female mind by her transition from child to woman, within wider contemporary public debates regarding girls’ health and education. Through a close analysis of Clouston’s public lectures, ‘Female Education from a Medical Point of View’, and their reception in the local Scottish press, we tease out two key features of the 19th-century debate that are echoed in the 2020 Period Products (Free Provision) (Scotland) bill debate, the focus of this special collection.²⁰ These are, firstly, the tension between perceptions of menstruation as a normal versus a pathological process and, secondly, the deleterious impact of menstruation upon female education and, by extension, women’s status in society. By highlighting the continued resonance of these historical beliefs and practices, and connecting them with more recent discussions around menstruation and its impact on women’s health and social status, it is hoped that this article will contribute to a deeper understanding of the beliefs and conditions that have shaped the Period Products (Free Provision) (Scotland) Act 2021 which, upon closer examination, bears remnants of much older and enduring attitudes towards menstruation.

The Consolidation of Psychiatric Authority in Victorian Edinburgh

Scotland’s largest and most prestigious institution for mental illness, the Royal Edinburgh Asylum, opened in 1813, its foundation reputedly triggered by the death in Bedlam of the young poet, Robert Ferguson.²¹ By the late 19^th century, the asylum housed over one thousand patients, allowing the medical profession unparalleled opportunities to observe, classify and treat those deemed insane. This medical knowledge was consolidated and disseminated through new specialist journals and clinical textbooks. One of the most prolific writers within this context was Thomas Clouston, the doyen of British alienists. Clouston (1840–1915) was physician-superintendent of the REA, 1873–1908, and, among the many honours ‘showered upon’ him, was subsequently knighted in 1911.²² As his obituarist claimed, during Clouston’s 35 years at the helm, the REA ‘came to stand for all that was good scientifically and medically, as well as for all that was humane and efficient, in the treatment of mental diseases and in the management of the inmates’.²³

In addition to editing the Journal of Mental Science (one of the premier ways in which alienists’ specialist knowledge was shaped), Clouston’s own publications included Clinical Lectures on Mental Diseases, which was revised through six editions between 1883 and 1904, and brought him international recognition. This textbook, like much of Clouston’s writing, was intended to appeal to a wide audience and was broadly conceived, surveying the ‘many moral and social problems’ that he considered to relate to the work of the alienist, including education, marriage and eugenics.²⁴ Clouston’s considerable influence was further enhanced by his appointment as the first official Lecturer in Mental Diseases at the University of Edinburgh in 1879, the culmination of a campaign which began in the early 19th century to achieve academic recognition for the study of insanity.²⁵ His Clinical Lectures was the recognised textbook for the students of Edinburgh’s internationally renowned medical school.

Throughout his physician-superintendency of the REA, Clouston stressed that good mental health was dependent on adherence to Victorian standards and social norms. He sought to distinguish harmful or self-destructive behaviour from that which was prudent and prophylactic, encouraging patients ‘to live according to physiological and moral law’.²⁶ The exercising of ‘self-control’ was particularly encouraged, referred to by Clouston as ‘the practical and important side of morals and religion’.²⁷ As a scientist, Clouston felt himself able to discern nature’s purpose and to advise society on the subject of healthy living in order to ensure ‘hygiene of mind’. As he argued: ‘The social reformer, the clergy, and the educationalist have an uphill fight with human nature, and as yet not an altogether successful one… Let science now step in to their aid’.²⁸ In the last third of the 19th century, disease boundaries were being expanded to include behaviour patterns that might have been dismissed as immoral or criminal by earlier generations: alcoholism, for example, became a potential diagnosis rather than a culpable failure of willpower.²⁹ The growth of secularism paralleled and lent plausibility to this medical reframing. Clouston encouraged alienists to assume a wider social role, replacing the judge and priest as the appropriate guardians of the rights and morals of society.

Before we consider how and the extent to which alienists feminised insanity, REA admission statistics demand that we proceed with caution by allowing us to assess the representation of women in asylum populations. As Figure 1 reveals,³⁰ across the 19th century women were not admitted to the institution in numbers disproportionate to men. Only a slight preponderance of female admissions can be detected, peaking at 58%, but it stands only at 50–53% during Clouston’s superintendency, and in certain years there was a noticeably higher spike in male admissions. Moreover, it is important to account for the gender ratio outside the asylum: in this, as in many other aspects, the REA appears to have been a microcosm of wider society, with successive censuses revealing a slight female preponderance in the Scottish population. The annual report statistical tables also suggest that the cure rate (based on discharge statistics) was slightly higher in female than in male patients. While the definition of ‘cure’ is ambiguous, it is also possible that families were more eager for male breadwinners to be discharged and therefore maintain the household economy. They may also have been slower to admit their male relatives for the same reason, so that men’s illnesses were more advanced and a ‘cure’ more elusive. However, as we turn to the processes central to the asylum system—classification and diagnosis—we will see more evidence for the pathologisation of women’s bodies throughout their life cycles in 19th-century psychiatry.

Figure 1

Graph depicting admissions to the REA 1832–1900, compiled by the authors from Royal Edinburgh Asylum Annual Reports, LHB7/7, LHSA.

The Pathologisation of the Female Lifecycle

Physician-superintendent Thomas Clouston’s most renowned publication, Clinical Lectures on Mental Diseases, offers important insights into how those patients admitted to the REA were conceptualised and diagnosed. Closely following and building upon his predecessor Dr David Skae’s classification system,³¹ Clouston’s textbook was based on 260 cases encountered at the REA, which he reportedly selected because they were the ‘good ordinary types’ that students and medical professionals might well meet in their career: the ‘useful’ rather than ‘wonderful’ examples that other medical publications, he disparaged, tended to focus on.³² As Figure 2 reveals,³³ the book’s Contents list provides a convenient overview of the major classifications of mental disease employed at this time:

Figure 2

Chapter titles of T.S. Clouston’s 1883 Clinical Lectures on Mental Diseases, first edition, London: J & A Churchill, p.vi.

Of the 17 chapters that focus on diagnostic categories, five chapters relate explicitly to the lifecycle: V and XIV–XVII. However, woven through the textbook are the overarching preoccupations of alienists at this time, and it is noteworthy that the first two chapters stress:

• The great physiological periods or crises of life (dentition, puberty, adolescence, the climacteric, and senility) and the great reproductive activities (menstruation, ovalation [sic], coitus, pregnancy, nursing, and care of children), bring into intense activity, or throw out of action wholly or partially, great tracts of convolutional brain tissue.³⁴

It is also noteworthy that, in many of the patient records examined throughout the textbook, the physicians-in-charge reference the menstruation cycles of their female patients. So, while we focus on the chapters that most explicitly relate to the lifecycle, it should be stressed that the body, lifecycle, and menstrual cycle constitute in this textbook something akin to leitmotifs. Somaticism was central to Clouston’s enterprise:

• A doctor must now-a-days be a physiologist, and a physiologist includes the mental as well as the bodily functions of man in his range of inquiry. In fact, it is one of the peculiarities of the physiological mode of studying human nature that man is looked on as a whole— body and mind together—a unity, in which they cannot be studied apart from each other.³⁵

In re-emphasising the ‘great crises of life’, Lecture V (‘Alternation, Periodicity and Relapse’) holds ‘the period of reproductive activity’ to be ‘always, in both sexes, the period of greatest physiological mental exaltation’.³⁶ In using these terms, Clouston conceives life as a series of ebbs and flows between periods of activity and inactivity, particularly relating to matters of fertility and reproduction. Thus, the chapter stresses the concept of ‘periodicity’, and that ‘every activity and process’ of ‘reproduction of the organism’ is ‘subject to laws of periodicity of the most marked character’, all having ‘their origin in the nervous centres, chiefly the brain’.³⁷ Clouston acknowledges that periodicity is something of a fact of life, from alternating between being asleep and awake, to the rise and fall of temperatures, and ‘what man is there who is not more emotionally elevated or depressed, more active or inactive in mind at certain times’.³⁸ Both sexes are considered in this chapter, but with a degree of differentiation. Thus, ‘by far the majority of the cases in women’ are said to ‘follow the law of the menstrual and sexual periodicity’, whereas ‘the majority of the cases in men follow the law of the more irregular periodicity of the nisus generativus in that sex’.³⁹ Clouston does not explain what he means by the phrase ‘menstrual and sexual periodicity’ or why he connects them here, as nisus generativus refers to the urge or endeavour to reproduce. It is also noted that it is more common for youths and the female sex to experience relapse and periodicity.⁴⁰

Focusing specifically on the female sex, Lecture XIV groups together uterine, ovarian, hysterical, and masturbatory insanities. It stresses that the ‘regular and normal performance’ of the uterus and ovaries’ is ‘of the highest importance to the mental soundness of the female’, with ‘disturbed menstruation’ a ‘constant danger’ to women’s ‘mental stability’.⁴¹ However, to Clouston ‘it did not follow’ that such menstruation would cause whatever insanity befell a woman, because disordered and suspended menstruation could be a symptom as well as cause of insanity.⁴² Yet, even ‘absolutely normal menstruation’ is said to be ‘attended with great risk in many unstable brains’,⁴³ the outbreak of mental disease ‘coincident with the menstrual period in a very large number of women indeed’.⁴⁴ Normal menstruation has ‘a psychology of its own’:

• a slight irritability or tendency towards lack of mental inhibition just before the process commences each month, a slight diminution of energy or tendency to mental paralysis and depression … and a very considerable excess of energising power and excitation of feeling during the first week or ten days after it has entirely ceased.⁴⁵

Drawing on the case of a 20-year-old woman diagnosed with amenorrhoeal insanity (loss of menstrual periods), Clouston associates the cessation of menstruation with depression, a loss of appetite, and hallucinations of hearing.⁴⁶ After ‘a series of hot baths and mustard to her feet’, ‘she brightened up… as if a cloud had been lifted off her mind, and she has kept well ever since’. Such cases exemplify the somatic nature of treatment. A further common treatment, worthy of mention here, is Clouston’s ‘gospel of fatness’, a strategy of feeding up patients, generally with custard, egg, jelly, and milk, and thereby improving their general health. The alienist considered fat ‘that most essential concomitant of female adolescence’ and believed that fat would not form properly unless the blood was ‘rich’.⁴⁷

Clouston was somewhat dismissive of the diagnostic label ‘ovarian insanity’, which had been used by his predecessor, David Skae (REA physician-superintendent, 1846–1873), because, to Clouston, there was ‘really no definite proof’ that the ovaries were ‘either disturbed in function or diseased in structure in those cases’.⁴⁸ He instead associated the label ‘hysterical insanity’ with ‘undue excitation or disturbance of the functions of the ovaries’,⁴⁹ and selected as one of his case studies a 21-year-old patient with menorrhagia (heavy menstrual periods).⁵⁰ Instead of ovarian insanity, Clouston uses the term ‘old maid’s insanity’ to describe these patients, who are said to be aged 35–43, ‘severely virtuous in thought, word, and deed’, ‘the reverse of sensuous in appearance’, and who have suffered a ‘morbid transformation’ towards the opposite sex, subjecting ‘unfortunate men’ to ‘extreme annoyance’. Nature is said to have:

• take[n] revenge for too severe a repression of all the manifestations of sex, by arousing a grotesque and baseless passion for some casual acquaintance of the other sex whom the victim believes to be deeply in love with her, dying to marry her, or aflame with sexual passion towards her, or who has actually ravished her after having given her chloroform. Usually her clergyman is the subject of this false belief.⁵¹

The focus on clergymen helps to convey just how inappropriate these women’s ‘grotesque’ sexualised behaviours are.

With the focus remaining exclusively on women, Lecture XV turns to the insanities of pregnancy, childbirth and nursing, all ‘liable to act as the exciting causes of attacks of mental disease’.⁵² ‘Few women’, Clouston claims, could ‘carry a child without being influenced mentally’: their reasoning power, moral sense, volitional power, imagination, and even memory, are often affected, with ‘endless caprices’, ‘unnatural desires for indigestible things’, and ‘causeless weeping and laughing’.⁵³ However, he differentiates these symptoms from ‘actual insanity’, which is judged to be rare in pregnancy.⁵⁴ More common, and indeed severe, is puerperal insanity, defined in Clinical Lectures as mental disease that occurs within the first six weeks after childbirth.⁵⁵ ‘Short of death’, Clouston argues that no more shocking event could occur to a family ‘as for a new made mother of a first-born child to become suddenly maniacal, and require to be sent to an asylum’.⁵⁶ This ‘most joyous’ time of life could turn to tragedy in the most extreme cases, and is said to affect one in every 400 women giving birth,⁵⁷ though is linked not only to the reproductive system but to ‘poverty … and having to get out of bed and to work too soon’.⁵⁸ The poor were similarly believed to be more liable to lactational insanity, with their ‘continuous reproductive struggle and family worries’,⁵⁹ and possibly their custom of ‘nursing each child a long time in order to delay the conception of the next’.⁶⁰

Clouston also saw puberty and adolescence as a time of crisis for both sexes. Lecture XVI describes puberty as ‘the first really dangerous period in the life of both sexes as regards the occurrence of insanity’.⁶¹ Yet, Clouston differentiates between the sexes: after puberty, mental development is said to take place in man ‘in the direction of energising and cognition, in the woman in the direction of emotion and the protective instincts’.⁶² While Clouston recognises the reproductive functions of both the male and female bodies, he attributes ‘the chief strain of reproducing’ to women, and thus greater risk to her mental functions ‘from the exhausting calls of ‘menstruation, maternity and lactation’.⁶³ As the next section will discuss, Clouston’s therapeutic strategy here is to ‘oppose strenuously … every kind and mode of education that in any way lessens the capability of women for healthy maternity.’⁶⁴

Even the cessation of menstrual periods provides cause for concern, such that Lecture XVII is devoted to the final stage of the lifecycle: the climacteric and senile insanities. As Clouston summarises,

• As unstable brains are apt in certain cases to be upset in their mental functions by the oncoming of the reproductive power and the sexual desire at the periods of puberty and adolescence, so they are apt to suffer as those great powers of the organism pass away.⁶⁵

It is noted that climacteric mental disease ‘need not be quite coincident with the menopause, but may occur some time before or some time after that event’, leaving another generous window of vulnerability in a woman’s life span.⁶⁶ There is something of a conflation here with ageing and loss of reproductive capacity, rather than a direct reference to menstruation and its cessation, or anything specifically physiological. While the typical patient is considered female, males are also diagnosed with climacteric insanity, but generally later in life, and with ‘nothing to mark it off so clearly as menopause’, the disease thus being ‘much more irregular and indefinite’.⁶⁷ Nonetheless, Clouston refers to men’s decreasing ‘procreative power’ and a lowering of ‘his energies, his functions, and his vitality’.⁶⁸

When a patient was admitted to the asylum, both a diagnosis and probable cause of disease were noted in the admission register, and these labels are the practical implementation, one could say, of Clouston’s textbook. Climacteric insanity is the most common diagnostic classification of female patients under Clouston’s superintendence, and, although ‘previous attack [of insanity]’ was the most common cause of insanity attributed to female admissions, ‘change of life’ is frequently listed. ‘Climacteric’ and ‘change of life’ appear to have been considered interchangeable terms. It is only in his first year, 1873, that something explicitly relevant to our interests features, with most female insanity attributed to ‘change of life’. Since this was the year that Clouston’s predecessor, David Skae (1814–1873), died, it is worth briefly reviewing his interest in that diagnostic term.

During Skae’s time in charge of the REA, while male insanity was most commonly attributed to intemperance, ‘change of life’ and ‘climacteric change’ were regularly deemed the most common causes of insanity in the female patients. Given the prominence of these supposed causes, it perhaps comes as no surprise that Skae’s son, Dr Francis Skae, Assistant-Physician at the REA under his father’s management, published specifically on climacteric insanity in women. His 1865 analysis of 200 cases of climacteric insanity in female REA patients opens with the claim that insanity is ‘one of the gravest and most important of the morbid conditions … incident to that time of life’.⁶⁹ Climacteric insanity is said to manifest first as a form of depression, sleeplessness and ‘inattention to ordinary domestic affairs’, followed by suspicion and ‘fear of undefined evil’, passing ultimately into ‘profound melancholia’ and suicidal tendencies. Of Skae’s 200 patients, however, 104 recovered and only 22 died.⁷⁰ The recommended treatments, which appear to have been fairly effective, are careful watching, a nutritious diet, and ‘the judicious administration of narcotics’ (opium).⁷¹

Perhaps more surprisingly, Skae published a further, significantly lengthier, article in the same year, ‘Climacteric Insanity in the Male’.⁷² In this, he considers there to be two forms of male climacteric: one caused by long periods of intemperance, and the other by ‘a premature senile dementia, the result either of atheroma or of fatty degeneration of the vessels of the pia mater’.⁷³ Thus, even the many cases of male insanity attributed to intemperance may have been considered related to this disease category. In reviewing 60 cases of climacteric insanity diagnosed in male REA patients, Skae notes that a ‘considerable proportion’ had been ‘eminently successful in business’ and ‘happy in their domestic relations’, yet they now seemed ‘oppressed by gloomy despondency’ and ‘impatient discontent’.⁷⁴ Symptoms are very similar to those found in women, though it is stressed that women’s suicidal determination is ‘more persistent’ and ‘more carefully concealed’ than men’s, demonstrating ‘a grotesque ingenuity strikingly feminine’.⁷⁵ Their treatment was similar to the female patients, and the number of recoveries and deaths proportionate.

An examination of annual reports published under Clouston’s management of the REA reveals that the numbers of female admissions attributed to pregnancy, childbirth, lactation, uterine and ovarian disease were stable but relatively low. ‘Insanity of menstruation’ accounts for a very small percentage of female asylum admissions, nor do menstrual disorders feature prominently as causes of female insanity. The percentage of female admissions diagnosed with amenorrhoeal insanity decreased, peaking at 5% of female admissions early in Clouston’s superintendency. By contrast, the predominance of classifications associated with transitions in the lifecycle— namely, puberty and the climacteric period— is striking. Up to 20% of female admissions were classified with insanity of adolescence and climacteric insanity respectively. While (disordered) menstruation was not commonly deemed the explicit cause of insanity, it is notable that the points where the menstrual cycle commenced (puberty), was temporarily disrupted (pregnancy and nursing), and ceased (menopause) proved such a focus of Clouston’s conceptualisation of female insanity.

‘Bloodless’ School Girls and the Perils of Female Education

The enduring tension between perceptions of menstruation as either a normal or pathological process is nowhere more evident than in late 19th-century medical debates over secondary and tertiary female education. While beliefs regarding the deleterious effects of study on the menstrual cycle and, in turn, the bodies and minds of young women can be traced back much further, the two decades from 1870 to 1890 witnessed a resurgence of somewhat alarmist medical ideas that emphasised the inherently fragile female constitution, and the perils of excessive strain upon it, with renewed vigour. Citing the publications of the American physician, Dr Edward Clarke, and the prolific London-based alienist, Dr Henry Maudsley, numerous scholars have examined the hotly contested topic of female education. The furore surrounding women’s entry to medical school, for example, has often been harnessed as an illuminating case study, one that demonstrates how the medical creation of a ‘biological straitjacket’ for women was used to transform supposedly ‘natural laws’ into ‘social conventions that reinforced restrictive gender roles’.⁷⁶ The term ‘biological straitjacket’ is used by the historian Anne Digby to refer to the ways in which women’s bodies were interpreted through the medical lenses of gynaecology and psychiatry. These disciplines’ inherently pathological theories of women’s bodies, legitimised by their association with a growing and increasingly prestigious medical profession, offered ‘a biological rationale for gender differentiation within society’ that served to reinforce women’s subordinate socio-economic position.⁷⁷ If women were naturally fragile and prone to insanity by virtue of their ‘biological destiny’, denying them access to a host of opportunities could be justified.⁷⁸

Alongside Clarke and Maudsley, Clouston’s was an equally authoritative voice on the perils of female education. Indeed, the Edinburgh alienist’s views were disseminated widely. Both within the medical sphere and in popular discourse, they registered differently. However, rather than being stimulated by concerns over women’s entry to the tertiary education system, which had been the original target of medical opposition, it was a new concern regarding an epidemic of over-study by school children, especially school girls, both in Edinburgh and further afield, that formed the focus of Clouston’s discussion. Reminding the audience that ‘the female organism is far more delicate than that of men’, the alienist argued that over-study and ‘misdirected education’ placed ‘immense strain’ on the female constitution but was especially damaging at a crucial stage in the female lifecycle: puberty and adolescence.⁷⁹

Clouston considered the lengthy period between the ages of 13 and 25 to be a crucial stage of development for young girls’ bodies and minds, during which a perilous ‘state of instability’ existed that could be disrupted by even the slightest of triggers, including over-study and excessive brain work.⁸⁰ Clouston’s rationale is underpinned by his belief in the ‘law of living beings’, the notion that all organisms have a certain amount of energy that takes different forms and is used for various bodily and mental processes such as ‘growth, nutrition, muscular force, thinking, feeling, or acquiring knowledge’.⁸¹ That amount of vital energy is, according to Clouston, finite; thus energy directed at one process would be made unavailable for the action of another. To Clouston, female adolescence is a period in which the vital energy is of utmost importance for bringing to ‘the harmonious perfect of full womanhood these combined bodily and mental qualities’.⁸² Clouston argued that the process of education, ‘with its competition, long hours of work, short hours of recreation’, took up all ‘the available energy of the girl’, exhausting ‘the energy needed for other purposes’.⁸³

While menstruation is not referred to explicitly, there are numerous euphemistic references to periodicity, blood and bloodlessness, including blood ‘not formed in sufficient amount’ or ‘renew[ing] itself properly’.⁸⁴ The adolescent girl exposed to ‘too much’ book learning is considered prone to a whole variety of bodily and mental disorders and pathological symptomatology, from ‘bloodlessness’, stunted growth and ‘morbid cravings’ to neuralgia, hysteria and a slew of nervous ailments.⁸⁵ The consequences are not only disastrous, but enduring: ‘growth is stopped, the blood is thinned, the cheeks are pallid, the fat destroyed, the wondrous forces and faculties …are arrested before they attain completion …the damage is irreparable’.⁸⁶ If ‘undue calls’ were made upon the adolescent girl’s ‘nervous force, or mental power, or the bodily energies’, she would never reach full womanhood.⁸⁷ Clouston’s image of the ‘bloodless’ young girl implies that ‘women’s highest function’ is at stake:

• When motherhood comes, and sound minds in sound bodies have to be transmitted to posterity, how is it to be then with the future race? This aspect of the question of female education during the period of adolescence is of absolutely primary importance to the world. Yet it is wholly ignored in many systems of education. What is the use of culture, if it is all to end with the present generation? What a responsibility to transmit to future generations weak bodies and oversensitive brains, liable to all sorts of nervous disease! …Why should we spoil a good mother by making an ordinary grammarian?⁸⁸

Clouston is concerned not only about the potential damage inflicted upon individual women, but the survival of the human species. Notions of the ideal woman are thus commonly entwined with wider ideas of race and nation. Foreshadowing the consolidation of eugenic theories of racial degeneration that characterised medical thinking at the turn of the century,⁸⁹ Clouston warns that, if puberty and adolescence are mismanaged, not only would the individual suffer, but so too would ‘society and the race of the future’.⁹⁰ A generation of overeducated, mismanaged, ‘dwarfish specimens’ of women producing ‘fewer offspring’ and ‘small and distorted’ sons threatened to ‘diminish the chances of the permanence of the race’, and as such, it was absolutely crucial, Clouston argued, that ‘the physiological view in regard to education were put in a plain way to the professional educator and to the parent’.⁹¹ Hence Clouston delivered two public lectures on ‘Female Education from a Medical Point of View’ to the Philosophical Institution of Edinburgh, reprinted in issues of Popular Science Monthly, presenting menstruation as a public health issue.⁹²

In terms of how seriously Clouston’s claims were taken, the editor of The Scotsman newspaper noted that ‘no medical authority’ had ‘ventured to dispute his conclusions’, and that ‘the public ought not lightly to disregard’ the ‘warnings’ of ‘a man of Dr Clouston’s position and experience’.⁹³ Similarly, a medical correspondent writing for another local newspaper, The Express, asserted his fervent hope that Clouston’s lectures would ‘not be ignored by school managers or neglected by parents’, but broadcast widely, especially in a city (Edinburgh) ‘famous for its educational advantage—if things go on as they are it will soon be famous for ugly, deformed, and infirm women’.⁹⁴ Yet, an abundance of letters to The Scotsman editor suggests that his views proved divisive amongst select medical professionals as well as the wider public. Sophia Jex-Blake, renowned physician and one of the ‘Edinburgh Seven’ (seven women who matriculated in medicine at the University of Edinburgh, and were the first to matriculate at a British institution), cites her own experience at her dispensary practice:

• I see quite as many little boys and girls with pitiful headaches that ought to be unknown to childhood and that have only come on since they went to school. I do not think it is the sex that is at fault, but the standard of education, of competitive examinations all over the country.⁹⁵

For Jex-Blake, over-study affects the supposedly stronger constitutions of young boys as much as young girls.

Others felt that Clouston’s claims were exaggerated. A member of the public took issue with Clouston’s ‘ante-medieval notions’, not only of what female education should be, but his ‘beau ideal of a woman’, while a correspondent for another local paper, the Evening News, suggested that Clouston’s preference ‘to keep girls under-educated’ was out of touch with the times.⁹⁶ Finally, an anonymous writer argued that, while many of Clouston’s remarks on female education were ‘undoubtedly true’, ‘we who have a larger acquaintance with every side of school-girl life may take comfort from the knowledge that these are exceptional cases’.⁹⁷ Clouston’s specialist experience was thus not always seen to be applicable to the population at large. Even Clouston himself recognised the scanty evidential basis of his claims: ‘the weak point of my argument is that it is not founded on any basis of collated statistical facts’.⁹⁸

Bullough and Voght note suggestive empirical evidence that a greater number of women did suffer from menstrual issues, given the poorer health and diet of the population at this time, and a possible correlation between menstrual difficulties and the restrictive nature of corsets and heavy skirts.⁹⁹ However, the wide medical acceptance of Clouston’s publicly contested claim that over-study and female education resulted in ‘bloodless’ school girls unfit for motherhood and prone to physical and mental disorder, can more convincingly be read as a response to a perceived threat to the status and established structure of the medical profession. As Bullough and Voght note, when the belief structure of a profession as highly regarded as medicine is threatened, the physician, usually male at this time, often harnesses ‘medical expertise to justify his prejudices and in the process strikes back with value laden responses which have nothing to do with scientific medicine’; ‘since he is assumed to speak with authority, his response, perhaps as he intended, has influence far beyond that of ordinary men’.¹⁰⁰ Given that the debate regarding female education coincided with the late 19th-century campaigns for women’s suffrage and entry to medical school (which could both be characterised as attempts to infiltrate the male sphere), and increasing anxiety regarding degeneration and race suicide, such an interpretation carries weight. Arguably, this would have been especially the case with psychiatry, a male-dominated profession that had struggled to gain legitimacy as a medical specialty since its inception, and thus had every incentive to straitjacket women.

Conclusion

The apparently benign and enlightened motivations that have shaped the 2021 Period Products (Free Provision) (Scotland) Act have nonetheless revealed some important and persistent historical trends in relation to menstruation. Scottish parliamentary debates suggest a continued tension between menstruation as a normal process and one with pathological features. References to ‘this most natural aspect of everyday life for every woman’ (Alex Cole-Hamilton, Liberal Democrat MSP for Edinburgh Western)¹⁰¹ stand in contrast to references to menstrual health-related conditions such as endometriosis and women who bleed excessively, as well as broader references to women’s health and sanitation. The emphasis on health conditions also suggests a continued desire to medicalise menstruation, though the persistent health focus is generally connected to the ‘detrimental effect on the health and wellbeing of women’ who lack access to period products (Elaine Smith, Labour MSP for Central Scotland), rather than the pathological nature of bleeding per se.¹⁰² Another notable feature of the Scottish debates is the acute concern over girls’ education and how to rectify the potential disruption caused by period poverty, with the estimate that nearly 13,000 girls missed a day of school in Scotland in 2019 because they were unable to access or afford menstrual products.¹⁰³ This, at least, contrasts with the debates discussed above, where the focus is on denying women access to education based on their inherently fragile health status. Nonetheless, there is clearly continuity: menstrual status impacts women’s rights, education and access to work—and potentially, thereby, their social advancement.

For alienists such as Clouston, good mental health required that one live in accordance with respectable Victorian values. A rigid sexual division of labour saw women’s work equated with motherhood; yet, even women who dutifully donned their ‘biological straitjacket’ could be diagnosed with diseases such as puerperal insanity, the antithesis of the maternal ideal. It was the instability of their reproductive system, coupled with their intrinsic biological weakness, that 19th-century alienists believed made women vulnerable to insanity. Moreover, the psychiatric fixation on the ‘crises’ of the female lifecycle stretched a woman’s vulnerability across most of her adult life, from the 12 years of puberty, through two decades of pregnancies and nursing, to the period ‘some time before or some time after’ menopause.¹⁰⁴ The specific role of menstruation is somewhat ambiguous here: it is implicit in the various lifecycle stages, and in the disorders of menstruation mentioned regularly, whether as cause or symptom of insanity. A thorough examination of female case notes would doubtless furnish more detailed insights into the extent to which the menstrual cycle, and its perceived disorders, were scrutinised by alienists.

It is instructive to consider whose interests were served by the pathologisation of the female body. As female emancipation began to gather force, psychiatry legitimised and reinforced the patriarchal status quo, not least in relation to female education, where girls were urged to reserve their finite energy for motherhood and to quit their ‘misdirected’ formal education. Yet greater scrutiny is required of how class intersected with gender: in contrast to the English system, where patients of different classes were admitted to class-specific institutions (namely, the county or private asylum), the REA, in line with many other Scottish Royal Asylums of the time, admitted the over-worked and poorly fed pauper patients alongside the more affluent middle class, and these admittances were rarely differentiated in REA annual reports or related publications.

Finally, a more rigorous and comparative investigation of the male lifecycle might encourage a more nuanced interpretation of the supposed gendering of madness. Both puberty and menopause were clearly considered ‘crisis’ periods of transition for men as well as women. Indeed, insanity of adolescence was diagnosed in more males than females admitted to the REA, despite the gendered focus of publications such as Clouston’s famous textbook. It appears, nonetheless, that female fragility and instability were major preoccupations of alienists, expressed particularly in their opposition to women’s education due to its supposedly damaging effects. This suggests that the menstrual aspect is key to explaining why women alone were required to be restrained by the biological straitjacket.

Competing Interests

The authors have no competing interests to declare.