‘THINKING IN CASES’: FROM THE MICRO TO A BROADER EXPLANATORY FRAMEWORK
Evelyn Fuller came to national prominence in 1938 due to her dramatic escape from a London asylum, and only weeks later, due to her death by suicide. At the time of her death, she was still on the run, a ‘lunatic at large,’ after having escaped her incarceration in the Camberwell House Mental Institution in South London. It appears that she took her life as an act of despair after having been dismissed from her work –her life’s work– for the Society for the Provision of Birth Control Clinics (later the Family Planning Association), following her certification as insane and her absconding from the asylum. Fuller had entrusted her care to a woman doctor and friend, Dr Greta Graff, who ultimately betrayed that confidence and set her, in Fuller’s own account, on a downward spiral from voluntary to incarcerated (and doped and abused) mental patient. Generously documented in an otherwise neglected file in the Wellcome Library, her story had sensation value on many registers, and it was widely reported in the newspapers.
COMPETING NARRATIVES
Equally interesting are the competing narrations, the contradictory explanations, many factual inconsistencies in the accounting and the reporting, and the attempts at explicating her suicide, including Fuller’s own rationalisation. Fuller left a number of testimonials that give us rare insight into her case, and ‘case’ here refers to both the psychiatric and the legal. Read together, these sources illuminate the historically entangled questions of bodily autonomy, reproductive control, psychiatric confinement, and self-determined death—issues that were intensely contested in interwar and 1930s Britain and remain far from settled. The richness of these intimate sources illuminating the psychological, psychiatric and philosophical dilemmas of an otherwise little-known figure provide an excellent opportunity to conduct a ‘history from within’.
The denouement to Fuller’s death should be read in the nexus of the gendered construction of mental illness, nervous disorder– personal and collective– and suicide in this period. The public responses to her story offer a vivid illustration of the growing sense of compassion and of support for the liberalisation of the laws governing mental illness and suicide, the latter a crime until the Suicide Act (1961). We can observe an unmistakable attitudinal shift from moral-religious stigma to the recognition of individual rights and bodily self-determination, and the consequent call for legal reform and decriminalisation. Feminist-minded women were prominent in the campaigns for these reforms, such as suffragist, pacifist, psychiatrist, lesbian and legal reformer Dr Doris Odlum, who emerged as a leading voice for reform of the suicide law. Women figure prominently in this tangled history of public health, mental health, psychoanalysis and campaigns for reform, even though most subsequently have been written out of institutional histories.
The highly public exposure of these two episodes in Fuller’s life deserve closer scrutiny. Fuller’s intersecting social and personal identities made her especially vulnerable, unprotected, and at the mercy of institutional, medical, and legal forces beyond her control. She would have been one of interwar Britain’s ‘surplus’ women (the surplus of women of marriageable age due to the loss of so many young men during the war) or, as the Daily Mail stigmatized even further, one of the ‘superfluous women’. Born in 1894 at Gillingham in Kent, she was the youngest child of an Admiralty official and a former Church of England school teacher. She came to maturity during the First World War. She herself was trained as a school teacher, but gave up the profession to join the Malthusian League’s newly formed Walworth Women’s Welfare Centre in South London in 1922. She devoted her life to the birth control movement, and progressive welfare politics and philanthropy, also working part time for the newly-founded Save the Children Fund. In light of her precarious socio-economic status as an unmarried woman, she had limited means and needed to work for a living.
IN HER OWN WORDS
She had, in her own words, “held a responsible position at four or five pounds a week for over 14 years.” (about twice the average working-class male wage). She went by ‘Mrs Fuller’, when she was in fact Kitty Evelyn Read and had never married. While she may have been well educated and from a lower middle-class family, Fuller occupied multiple minority groups in respect to gender, marital status, generation, employment and, not least, what experts at the time, and she herself saw, as her mental ill health. Since the publication of Émile Durkheim’s On Suicide in 1897, sociological analyses have emphasized the inverse relationship between levels of social integration within a given community and its incidence of suicide. Although Durkheim’s seminal study was not translated into English before 1952, his work was the cornerstone of the developing international field of suicidology.
RECOVERING LOST VOICES
Telling Fuller’s story is part of a familiar mission in the field of women’s history, an act of recuperation, giving voice to the silenced, and offering a woman-centred reading of her life against the grain of the legal, moral, and attitudinal constraints that undoubtedly acted as contributing factors to her personal tragedy.
Fuller’s case can be read as a microhistory of social and political attitudes and institutional structures pertaining to women’s health, women’s work, voluntarism, progressive causes, philanthropy, mental health, and suicide. Her ‘death story’ was the final but defining moment of her progressive politics and her mental health activism; in many respects, she functioned as what we would today recognise as a patient activist or a ‘service-user activist,’ vividly historicized in Barbara Taylor’s The Last Asylum (2015). Fuller used her personal lived experience to highlight institutional failing and dysfunctions. In her own words:
“The enclosed statements will indicate what has been happening to me. The stupidity of the statement of the doctor who signed the certificate that I was of unsound mind is almost unbelievable. The Secretary of the National Society for Lunacy Reform tells me that such flimsy grounds for certifying are typical of so many cases and shows the immediate necessity for the reform of the lunacy laws. I thought as soon as I was free I should be able to help others who were incarcerated unjustly and to expose asylum conditions generally and this thought buoyed me up and made me accept my fate with inward calm. The last thing that I expected was to find that the work to which I had devoted my best endeavours for fourteen years would be closed to me.” (From her written testimony)
Only days after recording her testimony, Fuller rented a bungalow on the remote Canvey Island, Essex. Her body was found there ten days later. The cause of death was gas poisoning, the most common method of suicide in the 1930s, when the widespread use of domestic coal gas (containing high levels of carbon monoxide) in British households made such deaths readily accessible. The Coroner passed the common verdict of ‘suicide while of unsound mind’, a tragic irony in and of itself, as Fuller’s obituarist noted how “[s]he cared, at times almost ruthlessly, for the oppressed, and she worked, reckless of her own strength, for the right of men and women to decide for themselves that great question whether or not to bring into this world another human life. In the end, she took her own. A hundred times she had already debated and determined herself an attitude to that act.” On this fateful matter, at least, her actions do not readily conform to the verdict of “unsound mind,” but instead suggest a deliberate and self-conscious decision.
SUICIDE AS A POLITICAL ACT
In Margaret Higonnet’s literary study of the feminization of suicide in the 19th century, she notes that “Suicide, like woman and truth, is both fetish and taboo. A symbolic gesture, it is doubly so for women who inscribe on their own bodies cultural reflections and projections, affirmation and negation.” Fuller left some cryptic and other more explicit messages in her deliberate staging and commission of her self-determined and ‘political’ death. To place her death by suicide in context, returns received from Coroners showed that during 1938 according to verdicts given, 5,262 persons committed suicide. Of these, 3,531 male, 1,732 female; and Fuller was but one of 391 females in the 40-50 age category.
Qualitatively, Fuller’s suicide was overtly political, and she conveyed her justifications in interviews with the press and in testimony she recorded and entrusted to friends during the various stages of her mental health ordeal. She meant to be seen, heard and have an impact on the reform of lunacy and suicide laws, just as she had worked tirelessly for women’s reproductive rights. Both the legal framework for suicide and for the asylum system and the rights (and lack of rights) of psychiatric patients were under heavy scrutiny and review in the 1930s. The two socio-medical problems were intrinsically linked, as cause and effect. When the Mental Health Bill was being debated in the House of Lords in 1930, Dr Vernon Davies (Con., Royton) argued that its passage would prevent a good many suicides in the future.
As ever, the change of direction in public opinion preceded legislative reform, indeed, by decades. The psychiatric impact of the First World War, women’s emancipation, and secularisation combined to generate near consensus that these laws had fallen into disuse. Further, the mainstreaming of psychoanalysis and the rapid establishment of the field of Medical Psychology, in institutional, therapeutic and discursive forms, are reflected and refracted through Fuller’s story and her life (and death) experience.
As historians, we seek to capture her experience and her embodiment of episodes of mental illness, although not without our own concerns about conducting forensic analysis and psychological autopsy without medical expertise. ‘Thinking in cases’ is both well established in this area of scholarship but still raises questions about the representativeness, historicity and the intrinsic analytical value of an ‘exemplar’ case like Fuller’s. Similarly, relying on Fuller’s testimony, recorded when she was presumably still mentally unwell, raises issues about veracity, accuracy, or as Michel Foucault termed it, ‘regimes of truth’ within the medical, legal, and cultural worlds of the period.
SERVICE-USER ACTIVISM IN HISTORICAL PERSPECTIVE
A longer historical perspective complicates the assumption that patient activism represents a recent development. As historians of sexuality have shown, for example, late nineteenth-century doctors writing on homosexuality were already confronted with patients and readers who responded to, challenged, and at times reshaped medical interpretations. These exchanges suggest that medical authority was never absolute, but negotiated. Similarly, from its inception, psychoanalysis depended on the patient’s words and narrative, yet this participation was structured within asymmetrical relations of authority and interpretation. Women—both as patients and as practitioners—did not simply occupy a passive position within this framework, but frequently resisted, and at times openly challenged their analysts’ authority and the interpretive models of the discipline.
Central to this dynamic was the case history itself. From its inception, psychoanalysis transformed the medical case from a relatively straightforward and brief clinical record into a complex and extended narrative form that combined patient testimony with theoretical interpretation. Patients’ accounts were indispensable, yet never accepted unmediated; instead, they were interrogated and reworked to produce scientific knowledge. The case became a hybrid genre in which individual experience was both preserved and subordinated to broader explanatory frameworks. Within this structure, women’s voices were neither silent nor fully contained. Female patients resisted at times the categories imposed upon them, while women analysts and theorists increasingly challenged the discipline’s formulations of sexuality and femininity. Psychoanalysis, and to a lesser extent other “psy sciences,” emerged as a contested field in which women played a central role, and in which case history functioned as a key site where patient participation was both enabled and constrained.
This history has important implications for understanding patient activism. It suggests that patient participation in medical knowledge is not new, but has long taken place within unequal and negotiated frameworks. Fuller’s case becomes more legible in this light. Fuller’s testimonies, her attempt to expose asylum conditions, and her insistence on the rationality of her own actions position her within a longer history in which patients did not simply receive medical judgments but actively contested them. Contemporary patient activism can thus be understood not as the sudden emergence of patient voice, but as a reconfiguration of enduring tensions between experience and interpretation, authority and resistance, and competing claims over who defines the meaning and changing boundaries of what is considered illness.
CONCLUSION AND POLICY RECOMMENDATIONS
• First, DHSC and local suicide-prevention partnerships should ensure that suicide prevention policy is explicitly gender-sensitive, not only in terms of statistics but also in terms of the social and institutional circumstances that shape women’s distress: work, reputation, reproductive autonomy, isolation, caring roles, previous experiences of mental health services.
• Second, NHS England, NICE, and relevant charities should strengthen service-user voice in the design of suicide prevention, crisis care and complaints procedures ; Fuller’s case shows that patient testimony can be dismissed or pathologised when it ought to be heard as evidence of institutional failure.
• Third, there should be more robust aftercare for people leaving coercive, inpatient, or crisis mental health settings. The practical consequences of such experiences should be treated as part of suicide prevention, not as separate welfare issues.
• Fourth, we recommend the use of historical case studies in professional training for clinicians, policymakers, and voluntary-sector workers. Fuller’s story shows how legal, medical, and gendered assumptions can combine to produce vulnerability — and, arguably, reform often depends on listening to those who are least powerful.
