"Cure, Comfort and Safe Custody": Public Lunatic Asylums in Early Nineteenth-Century England (review)

"Cure, Comfort and Safe Custody": Public Lunatic Asylums in Early Nineteenth-Century England, by Leonard D. Smith; pp. ix + 310. Leicester and New York: Leicester University Press, 1999, £55.00, $80.00.

In the United Kingdom, the opening of the twenty-first century has heralded a radical reconsideration of the relative positions of publicly funded and private healthcare in the curative regime of national life. The key concept in this volatile and often heated debate is that of a "mixed economy"—a public system of state-funded and -administered health care supplemented, and at times superseded, by the institutions of medical private enterprise. For some observers, the adoption of such a position represents a marked departure from previous practice in the public administration of health, and indeed a challenge to the socialist principle of a state-funded National Health Service, freely available to all citizens and implicitly egalitarian in its provision.

As Leonard D. Smith's "Cure, Comfort and Safe Custody" reveals, though, the concept of a "mixed economy" is far from novel in British mental health care: indeed, it may be suggested that the two systems—public interest and private profit—have operated in parallel, occasionally with hostility, sometimes in productive cooperation, but more often than not in profound ignorance of each other, for a period far exceeding that enjoyed thus far by the British National Health Service. The legislators of the late- eighteenth century, with whose work this book is in part concerned, may have been more radical than their counterparts over one hundred years later.

Culturally, therefore, this is a valuable book, in that it treats not merely of individual case and institutional studies, but of an entire medical and psycho-medical culture which arguably influenced care elsewhere in the world. As Smith observes, much has been written in recent years on the "hardware" of mental health care—not merely the manacles, chains, strait waistcoats, and restrictive chairs which he succinctly discusses and illustrates in the latter portion of the book, but also the institutional buildings, similarly memorialised in "Cure, Comfort and Safe Custody". Less, though, has been written on the more transient and often obscure aspects of care related to these physical artefacts—the social origins of asylum staff, the processes by which medical supervisors and governors were appointed and dismissed, the relationship of the staff to the governing body, and the relationships of asylums to each other, particularly where this involved the interface of private and public care. Smith covers this fascinating contextual field, often in great detail, but always with relevance and, indeed, acute observation. The transition from a regime based upon custodial attitudes to moral management, which by implication leads, eventually, to more recent medicalised and managerial discourses in health care, is crucial in its relationship to the greater field of medical history.

At the functional heart of Smith's volume lies a detailed explication of the County Asylum Act ("Wynn's Act") of 1808, a parliamentary instrument formally known as "An Act for the Better Care and Maintenance of Lunatics, being Paupers or Criminals in England." This act, which facilitated the option of treatment in a public rather than private madhouse, runs like a vital artery throughout Smith's work, becoming a reference point to which good intentions, occasional malpractices, and supplementary legislation and amendments such as those in 1811 and 1828, are related. Wynn's Act provided the legislative basis for the construction and management of a first generation of county madhouses, as well as guidance on the standards expected of care and carers. This, as Smith adroitly observes, may represent not merely a range of practical developments on a strictly local basis—the first two asylums erected under the terms of the Act opened in Bedford and Nottingham in 1812—but also "the strategic and practical foundation for the English lunatic asylum system" (6). It is a mark of the success...