While private madhouses provided, in varying degrees, containment and care to large numbers of “mentally disordered” patients, particularly during the eighteenth century, they have loomed small in the vast scholarship on the institutionalization of “lunacy” in England that has focused largely on the county asylum system of the nineteenth century. This is put to rights in Private Madhouses in England, 1640–1815, Leonard Smith's new study, which builds substantially on his many articles on individual private institutions and William Ll. Parry-Jones's The Trade in Lunacy (1972), until now the go-to authority on private asylums. Through exploration of 150 private madhouses between 1640 and 1815, Smith reveals that over two-thirds of mentally ill patients during this period were confined in these establishments rather than public asylums. He also upends the widely held notion that there is a limited range of source material on private asylums; his meticulous research unearths a rich array of publications, print sources, parliamentary evidence, and newspapers, while his close scouring of local archives has produced a mass of detailed evidence across the country with which to compare and contrast provision in different localities.

Smith's analysis is both readable and well informed as he unpicks the emergence of the trade of lunacy in meticulous detail, focusing in his early chapters on very different patterns of early initiatives and then growth across the country, comparing London's institutions and networks, concentrated predominantly in the East End, with the various provincial districts of England. Already by the late seventeenth century, a network of private madhouses was laid down. His chapters explore in turn the diversity of madhouse entrepreneurs and patients and the therapeutic approaches adopted in different institutions. We learn that private asylums were established in substantial numbers at an earlier period than has previously been suggested, though many failed to thrive. While in London such institutions, many of which were initially set up by key figures in psychiatry, pivoted to become lay-run enterprises, in the provinces madhouses were largely founded by medical practitioners, who had little scope for accessing alternative private income streams, or laymen whose sons went on to pursue medical qualifications. That these institutions were often family enterprises is underpinned with numerous examples, such as the Lincolnshire Willis family, best known for their involvement in treating King George III, and the Prouds of Bilston. Many proprietors also ran multiple large-scale enterprises, notably in London, while some provincial centers witnessed the emergence of concentrations of private asylums. Also fascinating is Smith's well-evidenced argument that women—wives, widows, sisters and daughters—played very significant caring and managerial roles in private asylums, and on occasion became entrepreneurs in their own right.

The chapter on therapeutics provides excellent detail of medical approaches in these institutions, from physical and surgical treatments and the utilization of a modest range of drug-based therapies to management techniques that embraced the vigorous assertion of authority and moral therapies designed to enable the reassertion of rational behavior among patients, as well as the continued use of coercion and restraints. The final chapter provides confirmation, again drawing on excellent and numerous examples, of the broad spectrum of facilities and conditions in private asylums that varied from the disgusting and unmanaged to the comfortable and caring. Despite these huge variations—and the relative frequency of complaints about wrongful confinement—the driving ambition of madhouse proprietors, Smith concludes, was to cure, whether this was driven by the desire to demonstrate therapeutic skill and expertise or to evolve a viable business model. Drawing on patient accounts, he also provides evidence of the varied experiences of patients, revealing, as well as despair and protest at their confinement and complaints about conditions, agency, resistance and occasional accord and satisfaction with their treatment.

It is almost churlish to complain about over-abundance in what is such a vigorously researched volume, but at points Smith packs in too much detail and too many examples at the expense of the development of a selection of these examples in more depth. Clearly difficult choices had to be made in terms of structure, but the thematic approach adopted here meant that we lost out on a more detailed unpacking of the story of particular institutions, the motivations behind their establishment, their particular challenges, changing fortunes and focus over time, and the ways they functioned within local marketplaces of medicine and alongside other provisions for the confinement of lunatics, including gaols and workhouses. It would have greatly informed the analysis to have had more of a back story on individual doctors, such as George Man Burrows and the Munro family, with their Bethlem connections, to explain their involvement in the madhouse trade and how that aligned with their other work in the confinement of the insane. The point that treatment varied according to class and ability to pay might have been further developed, and continuing the analysis beyond 1815 would have enabled a more rigorous assessment of the very significant role of private madhouses in taking in pauper patients well into the nineteenth century, as well as the role of these institutions in confining criminal lunatics. The discussion might have been enriched by a deeper engagement with Andrew's Scull's work on the institutionalization of insanity and Smith's own earlier publications on public asylums. The question of how far private asylums, though often small in scale if not in number, pushed forward agendas that placed the care of the insane increasingly in the hands of specialists and institutions, and thus reconfigured “psychiatric” practice is left tantalizingly open, as is the issue of how far private asylums can provide a prism through which to explore changing ideas of mental disorder and responsibility for its treatment during the long eighteenth century.