Reviews Book

Presumed Curable: An Illustrated Casebook of Victorian Psychiatric Patients in Bethlem Hospital

BMJ 2003; 326 doi: (Published 22 May 2003) Cite this as: BMJ 2003;326:1150
  1. Sean A Spence, reader in general adult psychiatry (S.A.Spence{at}
  1. University of Sheffield

    Bethlem is one of the most prestigious institutions in the history of psychiatry, its antecedents dating from the 13th century. Between 1886 and 1895 some 300 photographs were taken of its inpatients. At that time, evolution and its ugly sister, eugenics, were on the rise, and one can only speculate on the purpose of these images (though they were probably used for teaching).

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    Colin Gale, Robert Howard

    Wrightson Biomedical Publishing, £14.50, pp 128 ISBN 1 871816 48 3

    Rating: GraphicGraphic

    Sixty one of the patients featured in the book are identified by name, their photographs published along with extracts from their committal papers. From condensed summaries we learn the fate of each—approximately a third left Bethlem “well.” All the identified patients had psychotic illnesses: mania and melancholia, general paresis, and post-encephalitic states. Schizophrenia had yet to be defined, although catatonia is described. These people were admitted if considered curable; they were discharged after a year if deemed unresponsive. They emanated from the middle class; the poor went elsewhere, to the county asylum, while the wealthy had private care.

    Such a project throws up a number of questions. What do we expect to see in a book of such photographs? Staring eyes, torn clothes, drooling lips? Are we surprised if they appear unremarkable? Are we any the wiser if the photographs show ordinary people in everyday dress? And is being identified posthumously really a means by which one's “voice is heard” or “dignity accorded,” as the authors suggest? Which of us would choose to be remembered in this way? Or, perhaps more appropriately, how would an “average” Victorian wish to be remembered? It is noticeable that 16 patients avert their gaze.

    The case summaries serve to remind us how recent medical psychiatry really is and how treatments that we already take for granted have changed the medical landscape. Initially saddened by these fractured lives, I finished the text reflecting that we are mostly spared the severity of psychosis reported here. We take it for granted that any form of restraint is uncommon now, and if resort is made to “seclusion” then we monitor its use and restrict its length. But without the drugs we use we might still be living with violence and restraint, applied for months on end, with filth and padded clothing, and with all the residue of institutionalisation and concomitant physical decline. Although there is still much room for improvement, this text reminds us how bad things might otherwise be.

    Nevertheless, do we need to see the photograph and to know the name? Who is restored in such a text: the people as they were before psychosis intervened or the inpatients shown here at their lowest ebb? Any voices that are heard belong to the latter, not the former, and any dignity accorded has come too late.

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