The History of Bethlem.

Lawrence, Susan C.

The History of Bethlem, edited by Jonathan Andrews. New York, Routledge, 1997. xiv, 752 pp. $250.00 U.S.

Published 750 years after Simon fitzMary granted property to the Bishop of Bethlehem for the foundation of a priory of the Order of Bethlehem in London, The History of Bethlem charts the story of an institution, a place, and a confinement that became a metaphor for madness. Readers seeking a history of madness, mad-doctors and psychiatry, or parts of London will find only fragments of these topics here. These themes, and others, come and go. What ultimately unites the volume and gives it coherence is "Bethlem" repeated over and over again.

The authors of this massive task divided the text into four chronological sections. Part I covers 1247 to 1633; Part II, 1633 to 1783; Part III, 1783 to 1900; and Part IV, 1900 to the present. Except for Chapter Thirteen in Part II, "The architecture of Bethlem at Moorfields," written by Christine Stevenson, the rest of the book stands as the collective endeavor of the rest of the authors. Since the different parts vary considerably in tone and historical style, however, the volume reflects both the variation in sources that are available for different historical periods and the range, of attention the authors give to the social and medical contexts of this institution.

Part I lays out the history of the foundation of the priory of the Order of Bethlehem and its gradual transformation into a secular home for the insane. Details on the complexity of land ownership and politics in the City of London dominate much of the discussion. The authors concentrate on an account of the site of the priory from 1247 to the 1630s, in part due to the attention to land found in surviving documents, but also based on the results of recent excavations of medieval and early modern London. As separate chapters concentrate on different aspects of the Bethlem's history over nearly four centuries -- "politics and patronage", "Bethlem's income", "medieval attitudes towards and treatment of the insane" -- there is no single narrative of the history of the institution. Certainly by the 1460s, the priory had become a hospital for the "distracted," but this change was gradual and the causes are unclear. The authors draw on wider treatises concerning the treatment of the insane, including spiritual and physical therapies, to present the likely approaches to the care of Bethlem's inhabitants, as only hints remain about what went on within its walls during this period. By 1633, after much squabbling between the City, the Crown, and various sub-factions over who controlled its revenues and patronage, Bethlem started to be run by a Keeper appointed by the City aldermen. In 1633, as well, the City first appointed a physician to visit Bethlem and care for the inmates' medical needs.

The last chapter in Part I is the one that cultural historians may find most appealing. It is in this chapter that "Bedlam" appears, the "alter ego" of Bethlem (p. 11). During the late sixteenth century, Bethlem' s governors started to allow, and perhaps even to encourage, people to visit the hospital to view the insane. The expectation that visitors would leave alms, perhaps even substantial donations, makes this practice something more than the exploitive sightseeing that it later appears to have become. This practice cannot be directly connected to the emergence of the word"Bedlam" as meaning more than a madhouse, however. The authors of this chapter draw on literature, particularly Jacobean and Caroline plays, to reveal a "bedlam" that was "both the synonym for and epitome of insane chaos: not a place, but a state ... a metaphor to describe an irrational world" (p. 131). Bethlem, then, was not Bedlam, even though assumed connections between the institution and the metaphor persist and darken its image into the modern period.

Part II takes Bethlem through the early modern period. Like Part I, the chapters in Part II are organized around topics rather than chronology, so it is often up to the reader to move among them in order to connect "administration and finance" to "the politics of committal to early modern Bethlem," or "therapeutics" to "admission and discharge." The authors are at pains to discuss the use of force, such as keeping patients in chains, and apparent neglect, including sequestering incontinent patients naked in rooms strewn with straw. While the persistent image of Bethlem as a place of squalor and abuse stretches back to earlier centuries, the authors counter this continuing assumption with details from the institution's administrative records about the "order" in the house. The authors also put such treatment in context. Some of the patients were quite violent; others incontinent and abusive. Staff -- basically servants -- were afraid of these inmates, or could not keep up with the work required to keep them tidy at all times. Take away the assumption that the staff were deliberately cruel and punitive (for such people were dismissed when known), and the penchant that later reformers had to sensationalize accounts of inhumane treatment, and a much more nuanced understanding of seventeenth- and eighteenth-century institutional care emerges.

Some of the chapters in Part III continue to focus on topics, while others concentrate on specific episodes, including the hospital's move from Moorfields to Southwark and the investigations of the 1815 Select Committee on Madhouses. In this period, Bethlem became "a Victorian institution," scrutinized by observers, classifying its patients, keeping more detailed records, and increasingly staffed by the new specialists in madness. In this part, the authors have a larger institutional and professional history to consider when placing Bethlem in the context of other Victorian asylums. That Bethlem was an endowed charity, and not a poor-law establishment, shifted its clientele towards the more "respectable" and "curable" among the mentally ill. While Bethlem continued to refuse admission to those who could afford private care, the Governors paid due attention to the "deserving" poor -- those "above the class entitled to the benefits of a county pauper asylum" (p. 457). The emphasis on curability, moreover, kept out the "idiots" and those with severe physical disabilities. By the late 1870s, Bethlem had become even more genteel, more "home-like," with attractive carpets and potted plants. The regimen included more social functions, notably dances, and moral improvement, such as music and amateur drama. In the it 880s, Bethlem started to accept a few paying patients on a trial basis. By the end of the nineteenth century, then, Bethlem had become a sanctuary for the shabby middle class, far removed from "Bedlam."

The last part of the book centers on the twentieth century, particularly on the hospital after its move out of London to its current site at Monks Orchard, in Beckenham, Kent, in 1930. Ornamental gardens, private rooms, lovely lavatories, rooms for billiards and for writing, all characterize the aura of the new hospital as a progressive, "modern" institution for in-patient care of the mentally ill. The authors concentrate on the institutional history of Bethlem -- the impact of the advent of National Health Service in 1947-49, the merger with Maudsley Hospital to annex Bethlem to the teaching hospital and the problematic shift from a S.H.A. (Special Health Authority) to a N.H.S. Trust -- which is mired in the complexities of British health politics and policies. The chapter on staff deals with the medical and nursing personnel together, which is quite helpful in understanding the emergence of specialty institution-based care. In contrast, the chapter on therapeutics disappoints; much is described, but far too little is explained with attention to a reader who is not already familiar with a technical history of twentieth-century psychiatry. The authors state that physicians routinely used sedatives on all patients admitted in the early twentieth century, for example, without explaining the context for this practice. Why did this routine become standard? And why did it stop? Many sections of Part IV need much more thorough copy-editing, as well. In the chapter on therapeutics, for example, when the authors discuss treatment for General Paralysis of the Insane (caused by syphilis) they remark that "NAB injections, a treatment for syphilis, were given to patients with GPI" before physicians switched to malaria treatment in 1925. The lack of definition of "NAB injections" characterizes the tone of much of Part IV: lots of details about what happened without enough attention to broader significance. For example, despite the assertion in the introduction that twentieth-century Bethlem administrators were "doing their utmost to obliterate the unwelcome associations which the Hospital's alter ego conjured up in the popular mind" (p. 11, original italics), the last part of the book does not discuss "Bedlam" at all, much less evidence about what "Bedlam" meant -- and means -- in the popular mind.

The coherence of the work as a whole rests on the idea that there is a continuity from the priory of the Order of Bethlehem to the Bethlem that is now part of Maudsley hospital. The book's authors believe that, underlying its complex history, Bethlem has a core entity that displayed a "series of personalities" over time. For the reader who stays with the entire volume, however, just what that core is remains as elusive at the very end as it is in the beginning of the text. The place moved, the buildings changed, but the name, a fund of money, and a collection of documents remain to give an illusion of continuity. Bethlem has this history because it has an archive and, in the end, the volume itself is "Bethlem" far more than the institution(s) it describes with such care.

Susan C. Lawrence

University of Iowa