This book charts the steady growth of private madhouses in England within an expanding and increasingly competitive medical marketplace. Before the proliferation of the public lunatic asylums that were built in the wake of the 1808 County Asylums and 1845 Lunacy Acts, private madhouses were, as Smith notes, ‘key formative institutions in the history of mental health services’ (p. 2). In this book Smith expands upon existing histories such as William Parry-Jones's classic The Trade in Lunacy (1972) and case study approaches like Charlotte MacKenzie's Psychiatry for the Rich (1992), to offer a comprehensive account of private lunacy provision in England before 1815.

Smith identifies (and lists in an Index) over 150 private madhouses in existence between 1640 and 1815. These catered to around 70 per cent of England's mentally disordered (in contemporary parlance ‘lunatic’) patients. The committal of such patients was determined by a somewhat haphazard admission process until the 1774 Regulation of Madhouses Act, which implemented the requirement for a doctor's statement certifying that a patient was a fit person for treatment (the Act also required a licence for houses where more than one insane person was confined). In contrast to many existing histories, Smith makes a case for the 1774 Act as ‘a significant intervention in a field where parliament was hitherto reluctant to interfere’ (p. 90), arguing that despite some shortcomings ‘its powers and penalties were not inconsiderable’ (p. 91).

Sources for this period in the history of psychiatry can be fragmentary, with few madhouses keeping meticulous records of their work before the nineteenth century. Yet Smith has uncovered a vast amount of detail about these institutions, their patients, and their proprietors, combining digital resources with extensive archival research across England. Although London dominated the private madhouse market (there were around 1,600 people in licensed madhouses in London in 1815, compared to around 750 in the provinces), Smith draws a detailed picture of madhouse provision both in the capital and elsewhere. Three chronological chapters on the steady expansion and changing character of private provision are subdivided by region, serving to highlight specific points of interest: the centrality of private madhouses in the West Country where public institutions were few in number; the rapid growth of private provision in the industrialising West Midlands; and slower growth in the North of England.

Smith shows that the patient population of private madhouses was also more diverse than we might expect, both in terms of patient's domicile and social status. Although in earlier periods these institutions catered primarily (albeit not exclusively) to the middling ranks, they increasingly admitted pauper patients, some of them placed there by local parishes in the absence of alternative public facilities. Brislington House, for example, opened in 1806, offered accommodation for all classes of patient and was spread across seven buildings within a large and picturesque estate. Individual patient cases peppered throughout the book are a welcome counterbalance to the focus on madhouse proprietors, including the intriguing case of ‘Louisa, Lady of the Haystack’, a young woman who wandered a Bristol village in 1776 before eventually being committed to a private madhouse at Hanham.

Similarly, Smith draws an incredibly rich picture of the demographics of madhouse ownership. Private madhouses were not necessarily overseen by medically-qualified people – although a medical qualification was undoubtedly an advantage when competing for custom. William Arnold, who established his madhouse in the mid eighteenth century, was a baker and Baptist preacher; his son trained as a physician in preparation for the point when he would succeed him. Indeed, many private madhouses were family businesses built up and expanded over a period of years. As with individual patient histories, colour is added to these accounts with details of the family tensions that could affect the day-to-day running of madhouses: Smith cites the example of the Proud family whose Bilston madhouse became the centre of acrimonious disputes between two brothers who succeeded their father, one eventually leaving to set up his own rival institution. Several proprietors, such as the Hackney-based James Stratton, owned multiple madhouses, employing managers to oversee them.

Although the history of psychiatry tends to be dominated by the names of male practitioners and reformers, a welcome theme throughout the book is the central role of women in madhouse provision. Smith highlights that ‘there was always a female presence’ (p. 182) and identifies at least 36 women madhouse proprietors in London and the provinces between 1650 and 1815. From Priscilla Shotgrave's early eighteenth-century Chelsea establishment, to Mrs Andrews’ women-only establishment near Harrow, where treatment was based on hard work, several enterprising women entered the madhouse business, often without marital or family connections.

There is much here to interest and engage the reader who does not have specialist knowledge of the history of psychiatry. A chapter on treatment offers an informative overview of madhouse therapies and regimes, from the therapeutic optimism of eighteenth-century ‘moral management’ to the continuance of manual restraint at some institutions well into the nineteenth century. The question of mistreatment and scandal is also covered in a chapter on ‘Conditions and Controversy’, including the much-debated issue of ‘wrongful confinement’ – the use of private madhouses to confine sane but inconvenient individuals who families or partners wished to remove from their lives. As Smith highlights in his conclusion, some of the criticisms that dogged private madhouses can unfortunately also be glimpsed in relation to modern mental health care that has become increasingly reliant upon the private sector.

The book's end-point of 1815 marks both the close of the ‘long’ eighteenth century and the publication of the report of the Select Committee on Madhouses, which recommended better regulation of these privately-run institutions. As Smith notes in his conclusion, there is much more work to be done on private madhouses in the post-1815 period; the depth of detail that he has uncovered in this volume will surely make this a tantalising task for future historians.