Akihito Suzuki rightly points out that historians working in the field of insanity have hitherto tended to focus their attentions on institutions (madhouses and asylums) and on the rise of a profession and a discipline that has become known as psychiatry. As he acknowledges, this has been to an extent inevitable because of the nature and availability of historical source material. Suzuki has, however, deliberately embarked along a different trajectory and has set out to write “a history of lunacy from the family's viewpoint” (4). Making use primarily of reports on the legal proceedings of commissions of lunacy, he carefully constructs an alternative interpretive model in regard to changing approaches to the management of insanity in late Georgian and early Victorian England.

The central tenet of Suzuki's argument is that families retained a much more significant role in dealing with an insane member than has previously been recognized. Despite the multiplication and expansion of the different types of institution, many sufferers continued to be looked after within the household. The families taking on their care and management were able to exercise considerable influence over the practices of the doctors engaged to treat them. A delicate process of negotiation between the professional and the paying customer would reconcile the relatives’ perspectives with the medically based, or “scientific,” approach of the practitioner. In this manner, “the lay interpretation of madness” (64) continued to be a key determinant of diagnosis, treatment, and management practices.

Suzuki deftly contextualizes his analysis in the shifting mores and dynamics of early Victorian family life. He shows how relationships grounded in evangelical principles served to influence family members’ conceptions of their responsibilities toward a sick member, even if he (or she) were an embarrassment or a drain on material and emotional resources. In this construction, the family acted as a “community of hearts,” which provided the space for distressed member's “unbosoming” of what troubled him or her (113–14). If possible, the relatives would contain the patient within the household or the wider family, supported by a doctor sympathetic to the principles of domestic psychiatry.

When domestic care of the lunatic proved too onerous, the family might hire a suitable personal keeper. If all else failed, there could be recourse to a public or private asylum, but preferably one appearing to provide a homelike environment. As Suzuki aptly suggests, the relationship between home and institutional treatment might be symbiotic rather than antagonistic. Indeed, his contention is that the very techniques of “moral treatment” may have originated in the family, to be subsequently adopted in the best-managed institutions, though this perhaps takes the argument beyond the available evidence.

The interests of relatives, however, might not always be in accordance with those of the suffering member. For them, protection of reputation, the prevention of public embarrassment, or the integrity of property or finances would often take precedence over other considerations, and it was normally the relative who was the doctor's paying client and the determinant of priorities. There were, however, constraints. Suzuki demonstrates how the public awareness of “abuses” in the treatment of lunatics, following the scandalous exposures in 1815 of practices in certain public and private asylums, had permeated through into the sphere of private care. Unscrupulous relatives or medical practitioners were subsequently less able to act with impunity. Even a prominent specialist physician like George Man Burrows, in 1829, became an unwitting casualty of critical public perceptions, while ostensibly acting on behalf of concerned relatives.

Suzuki skillfully delineates the “public” and the “private” domains and demonstrates the manner in which they influenced one another. The reported proceedings of commissions of lunacy provided a focus for the growing public interest in the arena of madness, particularly where they involved prominent people or exposed lurid details of unusual lifestyles. There was a significant theatrical element, comprising both drama and pathos, as audiences within the court and in the country at large could indulge themselves in watching the antics of the lunatics. Suzuki draws a compelling parallel with the role of Bethlem Hospital (“Bedlam”) as a place of public resort in the previous century.

The relationship between public and private was mediated through the manner in which the state and its mechanisms carried out their functions. Suzuki demonstrates a perceptible shift toward the interests of relatives, as successive lord chancellors oversaw a gradual widening of the legal definition of insanity. Concepts of capacity to manage one's affairs were added to the equation, alongside the more clear-cut presentations of delusions and other first-rank symptoms. In the process, the distinctions between insanity and immorality could become blurred. This extension of the boundaries was reflected in the writings of practitioners like James Cowles Prichard, with his creation of the specific category of “moral insanity,” which could serve to provide intellectual justification for intervention in a broader range of instances (81–87). Although there may not have been an overt alliance between state and family, the effects were as if there had been.

Suzuki's overall analysis is highly persuasive. There is, however, one significant problem with it, and he is quite honest in making proper acknowledgment. The cases on which he bases his arguments are all drawn from the middle and upper classes of English society. This is largely unavoidable from the sources that have been used, for only people with sufficient financial means were in a position to seek a commission of lunacy. His conclusions are, therefore, not in themselves open to generalization throughout society, though other historians have elsewhere demonstrated the particular influence that working-class families could exercise on physicians in relation to asylum admissions.

This limitation notwithstanding, Akihito Suzuki's excellent and superbly written book is an extremely significant addition to the historiography. It will certainly become regarded as a seminal text in the social history of psychiatry in the nineteenth century.