ABSTRACT
Bethlem's admission procedure mirrored practices at other psychiatric institutions. Until 1948, patients were admitted on a daily basis by the house physicians, their decisions validated by the assistant physicians. Patients had their personal belongings recorded on admission by the Steward and afterwards their mental and physical condition was examined. They were then taken to the ward that best reflected their mental condition and the level of supervision needed. Bethlem's former medical officers and local practitioners were prominent in referring cases, but the extent of family influence is uncertain. It was the family who decided when institutional care was needed, with doctors sanctioning their decision. Those who referred patients to Bethlem did so because they were familiar with the institution. Medical authority, however, did not dominate. Their judgment was constrained by Bethlem's regulations, which remained unaltered until 1948. These stipulated that patients could not be admitted if they were 'unlikely to prove curable', showed signs of physical illness, or required permanent nursing. The emphasis was on early treatment of acute cases. Patients who had been discharged and were unable to prove continuous mental health for twelve months were excluded. All patients were to be discharged after twelve months.2 In reality the doctors were given considerable leeway. Exceptions were made, especially over the definition of 'acute' and length of stay. 'Actively suicidal' patients were admitted, as were those suffering from General Paralysis of the
Insane (GPl), a condition that generally resulted in dementia and death. Occasionally, cases like Herbert A-, a civil servant described as 'hopeless' and 'impervious' to treatment, were admitted - but not regularly.3 Some patients also remained for more than twelve months. The Governors were not prepared to submit to family pressure to keep patients for longer than this, unless no immediate alternative was found. Nor were they keen to discharge patients against medical advice even when they had been in the Hospital for over a year. In the 1930s, 30 per cent of patients spent between one and two years in Bethlem. According to Desmond Curran, a house physician in 1928, most of these were 'burnt-out schizophtenics,.4 In the 1940S the number fell in response to new, more effective physical treatments with few patients staying for more than six months. Even when the regulations were ignored the Governors retained the final decision. Each Governor could recommend an applicant for admission, and frequently relatives of patients would write asking them to intercede, stressing the patient's exemplary character, deserving nature, or lack of funds. However, unable themselves to make a professional evaluation of a patient's psychiatric condition they relied on the judgment of their medical staff.
