Over the last two decades, significant elements of mental health-care provision in Britain have been transferred from the National Health Service into the hands of private entrepreneurs or corporations. This applies particularly in certain sectors, such as secure hospitals for people with complex presentations or who exhibit challenging behaviours, and residential or nursing care homes which either provide for rehabilitation or accommodate individuals with longer-term, more chronic needs.1 Such a profound shift toward an overtly commercial ethos in the mental health field is perhaps regarded by many observers as a relatively recent economic, ideological and cultural phenomenon. However, business-orientated activity has been deeply embedded within the historical development of institutional care for mentally disordered people in England for almost four centuries. For a substantial portion of that time, what generally became known as private madhouses, and later as private lunatic asylums or mental hospitals, have comprised an important element of specialist provision for people whose manifestations of mental disturbance could not be contained within the wider community.
This book will examine the emergence of private madhouses in seventeenth-century England and their subsequent steady rise to become the predominating element in institutional care for people deemed insane by 1815. It provides the first comprehensive study of the early ‘trade in lunacy’ for almost half a century,2 delineating the locations, structures, facilities and modes of operation of madhouses. The men and women who owned or operated them occupy a central place in the narrative, for it was they who reconciled commercial endeavour with the practical aspects of accommodating and managing people regarded as highly problematic. The proprietors’ attributes and practices largely determined the nature of treatment and conditions experienced by the socially disparate groups of patients who were confined. Historians of eighteenth-century psychiatry are not blessed with the wealth of case-book material that later became ubiquitous. Consequently, much of the material that follows has been assembled from new research into recently discovered or previously under-utilised sources, many of them fragmentary and scattered. They reveal people and places that were previously lost or obscured. The records indicate that, almost from the outset, madhouses were more numerous in London and elsewhere in the country than has hitherto been appreciated, and that their comparative significance has been under-estimated.
Origins and Influences
In 1600, Bethlem Hospital in London constituted the country’s only significant institution for confinement and care of the insane.3 Its relatively small site and restricted accommodation, as well as admission policies geared mainly towards people with limited means, helped to stimulate the development of alternative options for those who could afford to pay for them. Over the following decades, in the capital and elsewhere, a number of private practitioners established houses to accommodate and treat people variously described by contemporaries as ‘mad’, ‘frantic’, ‘distracted’ or ‘lunatic’. By the 1670s, if not earlier, the term ‘mad-house’ had entered common usage to describe these places. In his collection of poems, Lucida Intervalla, the episodically deranged Admiralty clerk James Carkesse satirised his own confinement in ‘Finnes-bury Mad-house’.4 At that juncture, the term was still largely descriptive, having not yet acquired all the negative connotations and cultural stereotypes with which it later became associated. It was during the course of the eighteenth century that the private madhouse was increasingly identified in popular consciousness as a locus of unjustified incarceration, neglect, malpractice and more flagrant abuses. Such perceptions were doubtless justified in some, perhaps many, instances. However, the reality was more nuanced and historical justice requires the construction of a balanced portrayal of what were, in reality, key formative institutions in the history of mental health services.
The emergence and rise of private madhouses occurred against a background of the fundamental economic, social, cultural and political changes occurring in England during the seventeenth and eighteenth centuries. After the bitter religious and political conflicts that culminated in the Civil War from 1642 until 1651 were succeeded by the constitutional settlement of 1688, the ensuing century witnessed ‘revolutions’ in commerce, agriculture and industry, all informed by the intellectual currents of the Enlightenment. Such profound societal upheavals doubtless impacted upon many individuals, particularly within the aspirant middling ranks and the marginalised poorer classes, contributing in some measure to a perceived higher incidence of ‘melancholy’, the ‘English malady’ and other more serious mental disorders. In response, an increasingly sophisticated ‘consumer society’ was presented with diverse service options for dealing with a range of health-related problems, including those affecting the mind.5
Historians have discerned significant changes in attitude towards insanity and the insane in England during the ‘long’ eighteenth century. In one construction, a conception of the mad person as being akin to a wild animal, who required taming by forceful means, was gradually giving way to a recognition that he or she was a human being who had lost their reason. Consequently, measures were required to promote the restoration of reason. As Andrew Scull highlighted, these would often be implemented in the context of a controlling, coercive ‘domestication’ approach to madness, whereby the practitioner sought to impose order and rationality upon the insane person.6 At the same time, more permissive, gentle methods were being applied in certain quarters, as attempts were made to encourage or engage with lucid elements of the lunatic’s thought processes. The discourses of coercion and mildness, at times conflicting and at others complementary, informed the operational practices of the new private madhouses. Their independent status and relatively small physical scale provided opportunities for some to act as genuine sites of experimentation and innovation.7
Concurrently, as Michael MacDonald has argued, a process of ‘secularisation’ saw the identification and treatment of madness pass definitively from the religious to the medical sphere. In their writings, practitioners increasingly construed madness either directly as a disease of the brain or otherwise as being closely linked to identifiable physical disorders. It followed, therefore, that its curative treatment needed to be conducted under the direction of a medical man, in a suitably ordered and protective environment. This conception directly influenced the establishment and operation of most private madhouses, as well as the charitable or voluntary lunatic hospitals established in several cities during the course of the eighteenth century. Both public and private institutions participated in the same expanding medical market-place, where they competed and interacted with one another, in several instances sharing or exchanging key medical and other personnel, all within a developing ‘mixed economy’ of health-care.8
The consolidation of the private madhouse sector was rooted in the preoccupations with rank and social class that increasingly pervaded English society during the period.9 Even if space might be available in Bethlem or one of the other lunatic hospitals, most people within the higher and middling ranks would not be inclined to consign their insane relatives to a stigmatised public institution, associated with images of madness, disorder, squalor and material hardship. Rather, they were often prepared to pay handsomely for the person’s placement in a smaller, more exclusive, retired domestic environment wh...