In the 18th and 19th centuries, where could someone with a mental illness get help? Like everything else back then, it depended on how much money you had.
Those who could afford to pay for treatment could go to a small private madhouse. In England, they had existed since the 17th century, for example, at Box in Wiltshire (1615), Glastonbury (1656) and Bilston, Staffordshire (c. 1700).
In London, several madhouses were established from about 1670, particularly in the Hoxton and Clerkenwell areas.
The ‘trade in lunacy’
In the 18th and early 19th centuries, the number of private madhouses in England increased steadily to meet the demand of the so-called ‘trade in lunacy’. They operated on a profit basis within the free market economy.
Some were run by lay proprietors while the most sought-after and expensive were superintended by medical professionals such as Thomas Arnold MD’s Belle Grove Asylum in Leicester and Nathaniel Cotton MD’s ‘Collegium Insanorum’ in St Albans.
One of the most superior madhouses was Ticehurst House in East Sussex. Founded in 1792 by surgeon-apothecary Samuel Newington, patients could live in separate villas in the grounds, bring their own cooks and even ride to hounds.
At the other end of the market was Hoxton House, an unusually large establishment where overcrowding led to some patients having to share beds.
With such differing standards of care, new legislation introduced in 1774 sought to regulate the madhouse industry.
All private madhouses in England and Wales now had to be licensed by magistrates, and their annual licenses could only be renewed if admission registers had been properly maintained.
Madhouses outside the capital were visited by Justices of the Peace accompanied by a medical practitioner, while in London, the inspecting body was the Royal College of Physicians.
Medical certification for patients was also required, giving some protection to sane people perceived as an inconvenience to their families, who might otherwise have been incarcerated with the insane.
Perhaps surprisingly, most private madhouses accepted pauper lunatics as well as private patients, their fees being paid by the parish or poor law union which had sent them.
This was because there was a distinct lack of public asylums for the poor. In fact, before 1713, London’s Bethlem was the only public charitable asylum in Britain.
During the 18th century, various other charitable asylums were established across the country, but they only treated small numbers.
Most mentally ill paupers were looked after by their families or the parish. However, they could not cope with dangerous and unmanageable lunatics so these people were sent to asylums.
In 1800, there were around 50 private licensed madhouses in England, most of which accommodated both private and pauper patients. The lack of public asylums became a source of national concern.
Although legislation was passed in 1808 to encourage counties to build pauper lunatic asylums, this was only permissive. Most counties were reluctant to establish new institutions because of the considerable cost.
There were therefore large areas of the country without public asylums, so parishes continued to use private madhouses to accommodate pauper lunatics.
In 1814, scandals of mistreatment and neglect of paupers had been exposed at York Asylum and at Bethlem. Between 1815 and 1819, there were also numerous government inquiries into institutions accommodating lunatics.
Further legislation passed from the 1820s established the Commissioners in Lunacy, first for London in 1828 and then for England and Wales in 1844.
Their inspectors visited all premises housing lunatics, including private madhouses, without prior notice, and had the power to prosecute and withdraw licenses.
Life in the madhouse
After 1834, the use of private madhouses continued when responsibility for paupers transferred to poor law unions.
For example, the Dudley Union in Worcestershire used various private asylums including Ricketts’ Asylum in Droitwich, Hunningham House in Warwickshire, and Duddeston Hall near Birmingham.
From the early 1840s, private madhouses were increasingly criticised over standards of care, excessive use of mechanical restraint, and inferior accommodation for paupers.
It was common for proprietors to buy an old mansion, use the impressive main building for the private patients and confine the paupers in the stables and outbuildings.
This was the case at Duddeston Hall, a former banker’s mansion.
Opened in 1835 by surgeon Thomas Lewis, it was licensed for 30 private patients and 60 paupers. The private patients lived in the spacious mansion and used the gardens and grounds for recreation and exercise.
By contrast, the paupers in the outbuildings had “hard and knotty” beds with insufficient bedding.In 1844, the only place for recreation for these patients was “one dull yard” each for males and females.
Despite the poor living conditions, the Commissioners commented that Thomas Lewis treated the pauper patients with kindness.
Differing standards of care
In the mid 19th century, a staff to patient ratio of 1:10 or 1:12 was common in county asylums, while in the best private asylums, attendant numbers were much greater.
Yet there was no set limit on how many patients one keeper could be in charge of. Asylum proprietors could legally keep their costs low by employing few keepers, but to retain control, mechanical restraint had to be used.
During the night at Duddeston, patients were locked in their rooms and the more disturbed and dangerous were strapped into their beds.
Poor law unions always needed to cut costs, so they waited until their mentally ill inmates were unmanageable before sending them to a madhouse.
Sadly, these patients had passed the acute, curable stage and were now deemed chronic and hopeless.
When magistrates visited Droitwich Asylum in 1844, they discovered large numbers of dirty (incontinent) patients,
it being the custom of the neighbouring Unions to send Patients in a very bad state, after they have been kept in workhouses until their condition has become truly deplorable.
After legislation was passed in 1845 making it compulsory for counties to establish public asylums, the use of madhouses for paupers declined sharply. Private madhouses did, however, continue to provide an important service for wealthy patients.
Featured image: William Hogarth’s ‘In The Madhouse’, between 1732 and 1735 (Credit: Sir John Soane’s Museum).