The Bethlem Royal Hospital is a hospital in London, United Kingdom for the treatment of mental illness, part of the South London and Maudsley NHS Foundation Trust. It has been known by various names including St Mary Bethlehem, Bethlem Hospital, Bethlehem Hospital and, informally and most notoriously, Bedlam.
Originally the hospital was near Bishopsgate just outside the walls of the City of London. It moved to Moorfields just outside the Moorgate in the 17th century, then to St George’s Fields in Southwark in the 19th century, before moving to its current location at Monks Orchard in West Wickham, in the London Borough of Bromley in 1930.
The word “bedlam”, meaning uproar and confusion, is derived from the hospital’s prior nickname. Although the hospital became a modern psychiatric facility, historically it was representative of the worst excesses of asylums in the era of lunacy reform.
At one point, the hospital, in an attempt to wring pity (and money) from wealthy donors, opened its doors to a steady stream of visitors.
The Governors actively sought out “people of note and quallitie” – the educated, wealthy and well-bred – as visitors. The limited evidence would suggest that they enjoyed some success in attracting such visitors of “quality”. In this elite and idealised model of charity and moral benevolence the necessity of spectacle, the showing of the mad so as to excite compassion, was a central component in the elicitation of donations, benefactions and legacies. Nor was the practice of showing the poor and unfortunate to potential donators exclusive to Bethlem as similar spectacles of misfortune were performed for public visitors to the Foundling Hospital and Magdalen Hospital for Penitent Prostitutes. The donations expected of visitors to Bethlem – there never was an official fee – probably grew out of the monastic custom of alms giving to the poor. While a substantial proportion of such monies undoubtedly found their way into the hands of staff rather than the hospital poors’ box, Bethlem profited considerably from such charity, collecting on average between £300 and £350 annually from the 1720s until the curtailment of visiting in 1770. Thereafter the poors’ box monies declined to about £20 or £30 per year.
Aside from its fund-raising function, the spectacle offered moral instruction for visiting strangers. For the “educated” observer Bedlam’s theatre of the disturbed might operate as a cautionary tale providing a deterrent example of the dangers of immorality and vice. The mad on display functioned as a moral exemplum of what might happen if the passions and appetites were allowed to dethrone reason. As one mid-eighteenth-century correspondent commented: “[there is no] better lesson [to] be taught us in any part of the globe than in this school of misery. Here we may see the mighty reasoners of the earth, below even the insects that crawl upon it; and from so humbling a sight we may learn to moderate our pride, and to keep those passions within bounds, which if too much indulged, would drive reason from her seat, and level us with the wretches of this unhappy mansion”.
Whether “persons of quality” or not, the primary allure for visiting strangers was neither moral edification nor the duty of charity but its entertainment value. In Roy Porter’s memorable phrase, what drew them “was the frisson of the freakshow”, where Bethlem was “a rare Diversion” to cheer and amuse. It became one of a series of destinations on the London tourist trail which included such sights as the Tower, the Zoo, Bartholomew Fair, London Bridge and Whitehall. Curiosity about Bethlem’s attractions, its “remarkable characters”, including figures such as Nathaniel Lee, the dramatist and Oliver Cromwell’s porter, Daniel, was, at least until the end of the eighteenth-century, quite a respectable motive for visiting.
From 1770 free public access ended with the introduction of a system whereby visitors required a ticket signed by a Governor. Visiting subjected Bethlem’s patients to many abuses, but its curtailment removed an important an element of public oversight. In the period thereafter, with staff practices less open to public scrutiny, the worst patient abuses occurred.
Despite the palatial pretensions, by the end of the eighteenth century it was suffering physical deterioration with uneven floors, buckling walls and a leaking roof. It resembled “a crazy carcass with no wall still vertical – a veritable Hogarthian auto-satire”. The financial cost of maintaining the Moorfields building was onerous and the capacity of the Governors to meet these demands was stymied by shortfalls in Bethlem’s income in the 1780s occasioned by the bankruptcy of its treasurer; further monetary strains were imposed in the following decade by inflationary wage and provision costs in the context of the Revolutionary wars with France. In 1791, Bethlem’s Surveyor, Henry Holland, presented a report to the Governors detailing an extensive list of the building’s deficiencies including structural defects and uncleanliness and estimated that repairs would take five years to complete at a cost of £8,660. Only a fraction of this sum was allocated and by the end of the decade it was clear that the problem had been largely unaddressed. Holland’s successor to the post of Surveyor, James Lewis, was charged in 1799 with compiling a new report on the building’s condition. Presenting his findings to the Governors the following year, Lewis declared the building “incurable” and opined that further investment in anything other than essential repairs would be financially imprudent. He was, however, careful to insulate the Governors from any criticism concerning Bethlem’s physical dilapidation as, rather than decrying either Hooke’s design or the structural impact of additions, he castigated the slipshod nature of its rapid construction. Lewis observed that it had been partly built on land called “the Town Ditch”, a receptacle for rubbish, and this provided little support for a building whose span extended to over 500 feet (150 m). He also noted that the brickwork was not on any foundation but laid “on the surface of the soil, a few inches below the present floor”, while the walls, overburdened by the weight of the roofs, were “neither sound, upright nor level”.
While the logic of Lewis’s report was clear, the Court of Governors, facing continuing financial difficulties, only resolved in 1803 behind the project of rebuilding on a new site, and a fund-raising drive was initiated in 1804. In the interim, attempts were made to rehouse patients at local hospitals and admissions to Bethlem, sections of which were deemed uninhabitable, were significantly curtailed such that the patient population fell from 266 in 1800 to 119 in 1814. Financial obstacles to the proposed move remained significant. A national press campaign to solicit donations from the public was launched in 1805. Parliament was successfully lobbied to provide £10,000 for the fund under an agreement whereby the Bethlem Governors would provide permanent accommodation for any lunatic soldiers or sailors of the French Wars. Early interest in relocating the hospital to a site at Gossey Fields had to be abandoned due to financial constraints and stipulations in the lease for Moorfields that precluded its resale. Instead, the Governors engaged in protracted negotiations with the City to swap the Moorfields site for another municipally owned location at St. George’s Fields in Southwark, south of the Thames. The swap was concluded in 1810 and provided the Governors with a 12 acres (4.9 ha; 0.019 sq mi) site in a swamp-like, impoverished, highly populated, and industrialised area where the Dog and Duck tavern and St George’s Spaw had been.
A competition was held to design the new hospital in which the noted Bethlem patient James Tilly Matthews was an unsuccessful entrant. The Governors elected to give James Lewis the task. Incorporating the best elements from the three winning competition designs, he produced a building in the neoclassical style that, while drawing heavily on Hooke’s original plan, eschewed the ornament of its predecessor. Completed after three years in 1815, it was constructed during the first wave of county asylum building in England under the County Asylum Act (“Wynn’s Act”) of 1808. Extending to 580 feet (180 m) in length, the new hospital, which ran alongside the Lambeth Road, consisted of a central block with two wings of three storeys on either side. Female patients occupied the west wing and males the east; as at Moorfields, the cells were located off galleries that traversed each wing. Each gallery contained only one toilet, a sink and cold baths. Incontinent patients were kept on beds of straw in cells in the basement gallery; this space also contained rooms with fireplaces for attendants. A wing for the criminally insane – a legal category created in the wake of the trial of a delusional James Hadfield for attempted regicide – was completed in 1816. This addition, which housed 45 men and 15 women, was wholly financed by the state.
The first 122 patients arrived in August 1815 having been transported to their new residence by a convoy of Hackney coaches. Problems with the building were soon noted as the steam heating did not function properly, the basement galleries were damp and the windows of the upper storeys were unglazed “so that the sleeping cells were either exposed to the full blast of cold air or were completely darkened”. Although glass was placed in the windows in 1816, the Governors initially supported their decision to leave them unglazed on the basis that it provided ventilation and so prevented the build-up of “the disagreable effluvias peculiar to all madhouses”. Faced with increased admissions and overcrowding, new buildings, designed by the architect Sydney Smirke, were added from the 1830s. The wing for criminal lunatics was increased to accommodate a further 30 men while additions to the east and west wings, extending the building’s facade, provided space for an additional 166 inmates and a dome, providing a much-needed touch of grandeur, was added to the hospital chapel. At the end of this period of expansion Bethlem had a capacity for 364 patients.
The late eighteenth and early nineteenth centuries are typically seen as decisive in the emergence of new attitudes towards the management and treatment of the insane. Increasingly, the emphasis shifted from the external control of the mad through physical restraint and coercion to their moral management whereby self-discipline would be inculcated through a system of reward and punishment. For proponents of lunacy reform, the Quaker-run York Retreat, founded in 1796, functioned as an exemplar of this new approach that would seek to re-socialise and re-educate the mad. Bethlem, embroiled in scandal from 1814 over its inmate conditions, would come to symbolise its antithesis.
Through newspaper reports initially and then evidence given to the 1815 Parliamentary Committee on Madhouses, the state of inmate care in Bethlem was chiefly publicised by Edward Wakefield, a Quaker land agent and leading advocate of lunacy reform. He visited Bethlem several times during the late spring and early summer of 1814. His inspections were of the old hospital at the Moorfields site, which was then in a state of disrepair; much of it was uninhabitable and the patient population had been significantly reduced. Contrary to the tenets of moral treatment, Wakefield found that the patients in the galleries were not classified in any logical manner as both highly disturbed and quiescent patients were mixed together indiscriminately. Later, when reporting on the chained and naked state of many patients, Wakefield sought to describe their conditions in such a way as to maximise the horror of the scene while decrying the apparently bestial treatment of inmates and the thuggish nature of the asylum keepers.
Wakefield’s account focused on one patient in particular, James Norris, an American marine reported to be 55 years of age who had been detained in Bethlem since 1 February 1800. Housed in the incurable wing of the hospital, Norris had been continuously restrained for about a decade in a harness apparatus which severely restricted his movement. Wakefield stated that:
… a stout iron ring was riveted about his neck, from which a short chain passed to a ring made to slide upwards and downwards on an upright massive iron bar, more than six feet high, inserted into the wall. Round his body a strong iron bar about two inches wide was riveted; on each side of the bar was a circular projection, which being fashioned to and enclosing each of his arms, pinioned them close to his sides. This waist bar was secured by two similar iron bars which, passing over his shoulders, were riveted to the waist both before and behind. The iron ring about his neck was connected to the bars on his shoulders by a double link. From each of these bars another short chain passed to the ring on the upright bar … He had remained thus encaged and chained more than twelve years.
Wakefield’s revelations, combined with earlier reports about patient maltreatment at the York Asylum, helped to prompt a renewed campaign for national lunacy reform and the establishment of an 1815 House of Commons Select Committee on Madhouses, which examined the conditions under which the insane were confined in county asylums, private madhouses, charitable asylums and in the lunatic wards of Poor-Law workhouses.
In June 1816 Thomas Monro, Principal Physician, resigned as a result of scandal when he was accused of ‘wanting in humanity’ towards his patients.
In 1930, the hospital moved to an outer suburb of London, on the site of Monks Orchard House between Eden Park, Beckenham, West Wickham and Shirley. The old hospital and its grounds were bought by Lord Rothermere and presented to the London County Council for use as a park; the central part of the building was retained and became home to the Imperial War Museum in 1936.
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