Madness at Home: The Psychiatrist, the Patient, and the Family in England, 1820-1860 (review)

Akihito Suzuki's Madness at Home follows closely the approach to the history of psychiatry of the Wellcome Institute for the History of Medicine. Suzuki is currently Professor of History at the School of Economics at Keio University in Japan, and his book began life as a doctoral dissertation in London ten years ago. Although the Wellcome Institute represents a brilliant locus for medical history, its approach to the history of psychiatry has been, generally speaking, anti-psychiatric. The current volume is no exception.

The book does not offer a comprehensive picture of "madness at home," which would require a variety of sources, including correspondence among families, patients, and asylum psychiatrists. It is rather a glimpse into the family dramas surrounding the legal declaration of a member as mentally incompetent, as seen through early nineteenth-century newspaper accounts of a singular English institution: the "commission of lunacy," a procedure to determine if someone were insane. The commissions were held in such public places as taverns and were extensively reported on by the press, as they generally involved wealthy people. Hence the author's clever idea to study 200 such commissions constituted in the years between 1820 and 1860 and see what could be learned about the family dynamics of mental incompetence, as well as the involvement of psychiatrists.

An initial chapter critiques the sources themselves, augmented, to the author's credit, by extensive supplementary research in public archives. Chapter Two, on "the structure of psychiatric practice," looks at the state of English psychiatry in those years and clinicians' involvement in these commissions. In Chapter Three, the author considers the drama of stripping individuals of the control of their property. Chapter Four shows how a "self-generated cultural framework" gave the families a kind of folkloric understanding of the behavior of their affected members; Suzuki calls it a culture of "domestic psychiatry," and argues that the famous "moral treatment" had a domestic origin. Chapter Five, which comes as close as Suzuki ever does to discussing the reality of psychiatric illness, shows families wrestling with manic, melancholic, and demented relatives—though Suzuki uses none of these terms, employing instead such concepts as the decline of "patriarchal authority" in "destabilizing these families." A final chapter shows the interplay between public authority and the domestic management of insane family members.

The book illustrates the great strengths of the Wellcome School in its emphasis on intense work in primary sources and linking one's findings to the big questions of social history. The weakness, in this reviewer's opinion, is the insistence that the "major analytical framework" for understanding the history of psychiatry should be not medical progress, but rather the work of anti-psychiatric writers such as Michel Foucault. Few historians of medicine today would use the term "medical progress" in an unqualified manner. But the problem here, from this reader's standpoint, is that Suzuki and the Wellcome School do not appear interested in the interactions between culture and biology and the unavoidable reality of illness. In Suzuki's analysis, the important early psychiatric writer George M. Burrows becomes "a militant supporter of the medicalization of the care of the insane." The author notes Burrows's "particularly keen concern to secure a medical monopoly on psychiatry" (45). The book shares the orotund jargon used for internal communication by those who style themselves as revisionists: "The development of domestic ideology is thus the second set of historical events in which I would like to contextualize the case of Lord Portsmouth" (16).

The issue is whether medical history is a narrative of power relationships, the provision of which is determined by market forces. Suzuki writes of "the supply side and the demand side of psychiatric care" (8). This terminology sounds jarring, as we would not normally speak, for example, of cardiac care as a result of supply and demand in the care of heart disease. We assume a certain level of...