Leonard Smith is a social historian of psychiatry and mental illness in England in the eighteenth and nineteenth centuries. He has regularly produced academic books and research papers based on extensive and detailed investigations as well as solid analyses of these materials. One of his earlier books, Lunatic Hospitals in Georgian England, 1750–1830 (2007) was an important monograph on the history of English psychiatry, which examined the establishment of the asylum system in the Victorian era through the lens of developments in the long eighteenth century. In this new book, Smith has selected the subject of the private madhouse, revisited the issue of psychiatry and consumer society, and used his own research to build on major important works on the subject by pioneering historians such as William Parry-Jones, Michael MacDonald, Roy Porter and Andrew Scull.
The private madhouse has been the most controversial issue among historians of psychiatry in England. They might be the earliest and largest psychiatric institutions in the world: in 1815, there were more than 70 private madhouses, which provided for more than 70% of confined lunatics. The stereotype of these ‘successful’ private madhouses was, however, very negative from the early eighteenth century, when Daniel Defoe started to criticise this system. People took the private madhouse as the site of incarceration, neglect, malpractice and wrongful confinement. This controversial issue still exists. As Smith has pointed out at the opening of the book, British entrepreneurs, commercial entities and business corporations are the source of most new and so-called innovative ideas in mental health. Smith looks at the worlds of historical and present-day mental healthcare from the viewpoint of the psychiatric market in the long eighteenth century, paying particular attention to the major contributions made by the Act for Regulating Madhouses in 1774 and the Parliamentary Inquiry into Madhouses in 1815/16.
One of the strengths of this book is its clear and convincing distinction between the private madhouses in London and in the provinces. From the early seventeenth century, London had a large number of providers who answered to the demand for nonpublic places of incarceration for confining insane family members from the middle and higher ranks of society. One of the reasons for this demand was the public nature of the Bethlem Hospital. In the early modern period, relatively wealthy people in London were deterred by the ability of the public to visits Bethlem or ‘Bedlam’, in order to look at and laugh at the patients, and the cruel depictions of the institution on the theatrical stage. Instead, they asked the physicians of Bethlem for other more private or even secret treatments. In the early seventeenth century, Helkiah Crooke, a learned doctor who worked at Bethlem, started to maintain a private madhouse within Bethlem. Later physicians at Bethlem, such as Thomas Allen in the late seventeenth century, and the physicians from Monro families throughout the eighteenth, developed this prototype to introduce the families and other clients to their own private madhouses or to other practitioners whom they knew well. From around 1750, St. Luke’s Hospital for Lunaticks joined the game and provided William Battie and other physicians at the hospital with similar means to connect with a private madhouse.
The regime in London was not controlled solely by elite physicians of the metropolis, however. Practitioners and proprietors of private madhouses were either medically qualified physicians or lay practitioners who had other characteristics, which suited them to run private madhouses. Two rulers of the world of madhouse business were Sir Jonathan Miles and Thomas Warburton, who were lay and nonmedical proprietors who were associated with several private madhouses in the area of Hoxton. They were able to serve not just wealthy clients but also catered to the demand of parishes in London by taking care of pauper lunatics. Their charge for a lunatic was in fact cheaper than those of the provincial areas. This was one model for a flourishing business.
The provincial private madhouses were somewhat different in terms of how their basic structure was affected by the arrival of consumer society. Although provincial provision had overlaps with that of London, such as the creation of provincial voluntary hospitals and the rise of demand for the treatment of mental health conditions by physicians, commercialism was relatively weak and medicalisation was relatively strong. Although in 1815, the number of private provincial madhouses was 38, slightly higher than that of London, the relative rate of patients per population was much smaller and there was no large business. Proprietors were mainly physicians, Anglican clergymen and other Protestant preachers. The rise of the number of private madhouses in the provinces depended on the creation of voluntary hospitals, and the stimulation given by famous owners of private madhouse such as Francis Willis who successfully treated George III. This was another pattern of success for private madhouses.
The psychiatric market in private madhouses was strongly related to treatment, which had two distinct approaches in the long period of the eighteenth century. There were controversies between those who advocated medicalisation and somatic trends versus those who placed emphasis on religious, moral and psychological treatment. The first genres of treatment emphasised authority, control, ascendance over patients and creating fear in them. The most clear visual representation of this approach is found in Joseph Mason Cox’s rotating chair of patients. The second group are softer approaches, which stressed gentleness, kindness, care, humanity, tenderness and affection to the patients. In the early- and mid-nineteenth century, the humane approach became one of the bases of moral treatment. Into this complex world of treatment, entered literary figures, such as James Carkesse, Christopher Smart, William Cowper and Mary Lamb. Pamphleteers published highly critical commentary on neglect and wrongful confinements. Patients’ experience became an important concern for private madhouses and created many issues. Private madhouses were also sometimes able to endure though the dynamics of owners’ families: the proprietor’s wife and daughter were able to inherit private madhouses, which could continue under the same family’s ownership for several generations. With the economic and social change in England in the long eighteenth century, there opened up a lot of new ways to take care of and deal with insane patients.
Smith’s book is an excellent and well-balanced examination of private madhouses in England. Its most important merit is that it has opened the connection with new global histories of psychiatry. The book is attractive to those historians of psychiatry who examine different countries or different time frame. It is inspirational for many historians of psychiatry in England and other countries, for Smith has picked up fundamental frameworks, such as the capital and the provinces, roles of hospitals, medical professionalisation, gender issues of proprietors, and, perhaps most importantly, the role of consumer culture which was important in the eighteenth century and is controversial in the present.
