Bethlem Royal Hospital

Bethlem Royal Hospital
South London and Maudsley NHS Foundation Trust
BethlemRoyalHospital.jpeg
Bethlem Royal Hospital
Bethlem Royal Hospital is located in London Borough of Bromley
Bethlem Royal Hospital
Shown in Bromley
Geography
LocationBeckenham, Bromley, London, England
Organisation
Care systemNational Health Service
Hospital typeSpecialist
Services
Emergency departmentAdmissions through A&E
BedsApprox 350
Specialitywww.slam.nhs.uk
ListsHospitals in England

Bethlem Royal Hospital, also known as St Mary Bethlehem, Bethlehem Hospital and Bedlam, is a psychiatric hospital in London. Its famous history has inspired several horror books, films and TV series, most notably Bedlam, a 1946 film with Boris Karloff.

The hospital is closely associated with King's College London and, in partnership with the Institute of Psychiatry, Psychology and Neuroscience, is a major centre for psychiatric research. It is part of the King's Health Partners academic health science centre and the NIHR Biomedical Research Centre for Mental Health.

Originally the hospital was near Bishopsgate just outside the walls of the City of London. It moved a short distance to Moorfields in 1676, and then to St George's Fields in Southwark in 1815, before moving to its current location at Monks Orchard in West Wickham in 1930.

The word "bedlam", meaning uproar and confusion, is derived from the hospital's 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.

1247–1633

Foundation

A map of the original Bethlem Hospital site
Plan of the first Bethlem.[1]
Map of London in c. 1300. St Mary Spital is shown north of the city wall, outside Bishopgate.

The hospital was founded in 1247 as the Priory of the New Order of our Lady of Bethlehem in the city of London during the reign of Henry III. It was established by the Bishop-elect of Bethlehem, the Italian Goffredo de Prefetti, following a donation of personal property by the London alderman and former sheriff, Simon FitzMary.[2] The original location was in the parish of St Botolph, Bishopsgate's ward, just beyond London's wall and where the south-east corner of Liverpool Street Station now stands.[3] Bethlem was not initially intended as a hospital, in the clinical sense, much less as a specialist institution for the insane,[4] but as a centre for the collection of alms to support the Crusader Church and to link England to the Holy Land.[5]

De Prefetti's need to generate income for the Crusader Church and restore the financial fortunes of his see had been occasioned by two misfortunes: his bishopric had suffered significant losses following the destructive conquest of Bethlehem by the Khwarazmian Turks in 1244, and his immediate predecessor had further impoverished his cathedral chapter through the alienation of a considerable amount of its property.[6] The priory, obedient to the Church of Bethlehem, would also house the poor and, if they visited, provide hospitality to the bishop, canons and brothers of Bethlehem.[5] Thus, Bethlem became a hospital, in medieval usage, "an institution supported by charity or taxes for the care of the needy". The subordination of the priory's religious order to the bishops of Bethlehem was further underlined in the foundational charter, which stipulated that the prior, canons and inmates were to wear a star upon their cloaks and capes to symbolise their obedience to the church of Bethlehem.[7]

Politics and patronage

During the thirteenth and fourteenth centuries, with its activities underwritten by episcopal and papal indulgences, the hospital's role as a centre for alms collection persisted,[8] but its linkage to the Order of Bethlehem increasingly unravelled, putting its purpose and patronage in doubt.[9] In 1346 the master of Bethlem, a position at that time granted to the most senior of London's Bethlemite brethren,[10] applied to the city authorities seeking protection; thereafter metropolitan office-holders claimed power to oversee the appointment of masters and demanded in return an annual payment of 40 shillings.[11] It is doubtful whether the city really provided substantial protection and much less that the mastership fell within their patronage but, dating from the 1346 petition, it played a role in the management of Bethlem's finances.[12] By this time the Bethlehemite bishops had relocated to Clamecy, France, under the surety of the Avignon papacy.[9] This was significant as, throughout the reign of Edward III (1327–77), the English monarchy had extended its patronage over ecclesiastical positions through the seizure of priories under the control of non-English religious houses.[13] As a dependent house of the Order of Saint Bethlehem in Clamecy, Bethlem was vulnerable to seizure by the crown and this occurred in the 1370s when Edward III took control.[14] The purpose of this appropriation was, in the context of the Hundred Years' War between France and England, to prevent funds raised by the hospital from enriching the French monarchy via the papal court.[15] After this event the masters of the hospital, semi-autonomous figures in charge of its day-to-day management, were normally crown appointees and it became an increasingly secularised institution.[16] The memory of its foundation became muddied and muddled; in 1381 the royal candidate for the post of master claimed that from its beginnings it had been superintended by an order of knights and he confused its founder, Goffredo de Prefetti, with the Frankish crusader, Godfrey de Bouillon.[17] The removal of the last symbolic link to the Bethlehemites was confirmed in 1403 when it was reported that master and inmates no longer wore the star of Bethlehem.[17]

Aerial view looking into large enclosed courtyard of the Bridewell Palace
"The Prospect of Bridewell" from John Strype's, An Accurate Edition of Stow's "A Survey of London" (1720). From 1557, Bethlem was administered by the Bridewell Governors.

In 1546 the Lord Mayor of London, Sir John Gresham, petitioned the crown to grant Bethlem to the city.[18] This petition was partially successful and Henry VIII reluctantly ceded to the City of London "the custody, order and governance" of the hospital and of its "occupants and revenues".[19] This charter came into effect in 1547.[20] The crown retained possession of the hospital while its administration fell to the city authorities.[21] Following a brief interval when it was placed under the management of the governors of Christ's Hospital, from 1557 it was administered by the governors of Bridewell, a prototype house of correction at Blackfriars.[22] Having been thus one of the few metropolitan hospitals to have survived the dissolution of the monasteries physically intact, this joint administration continued, not without interference by both the crown and city, until incorporation into the National Health Service in 1948.[23]

From Bethlem to Bedlam

A Church of Our Lady that is named Bedlam. And in that place be found many men that be fallen out of their wit. And full honestly they be kept in that place; and some be restored onto their wit and health again. And some be abiding therein for ever, for they be fallen so much out of themselves that it is incurable unto man

William Gregory, Lord Mayor of London, c. 1450 [24]

It is Europe's oldest extant psychiatric hospital and has operated continuously for over 600 years.[25] It has also been the continent's most famous, and infamous, specialist institution for the care and treatment of the insane. Its popular designation – "Bedlam" – has long been synonymous with madness.[26] Precisely dating its transition to this role is difficult. From 1330 it was routinely referred to as a "hospital" but that does not necessarily indicate a change in its primary role from alms collection – the word "hospital" could as likely have been used to denote a lodging for travellers, equivalent to a hostel, and could have described an institution acting as a centre and providing accommodation for peregrinating alms-seekers or questores.[27]

It is unknown when it began to specialise in the care and control of the insane,[28] but it has been frequently asserted that Bethlem was first used for the insane from 1377.[29] This date is derived from the unsubstantiated conjecture of the Reverend Edward Geoffrey O'Donoghue,[30] chaplain to the hospital,[31] who published a monograph on its history in 1914.[32] While it is possible that Bethlem was receiving the insane during the late fourteenth century, the first definitive record of their presence in the hospital is in the details of a visitation of the Charity Commissioners in 1403.[33] This recorded that amongst other patients there were six male inmates who were "mente capti", a Latin term indicating insanity.[34] The report of the visitation also noted the presence of four pairs of manacles, 11 chains, six locks and two pairs of stocks but it is not clear if any or all of these items were for the restraint of the inmates.[35] While mechanical restraint and solitary confinement are likely to have been used for those regarded as dangerous,[36] little else is known of the actual treatment of the insane for much of the medieval period.[37] The presence of a small number of insane patients in 1403 marks Bethlem's gradual transition from a diminutive general hospital into a specialist institution for the confinement of the insane. This process was largely completed by 1460.[38]

Curtain Theatre circa 1600 (cylindrical building in the background). Some authorities believe this to be a depiction of The Theatre, the other Elizabethan theatre at Shoreditch in west Moorfields. Both playhouses were a stone's throw away from the original Bethlem site at Bishopsgate.

From the fourteenth century, Bethlem had been referred to colloquially as "Bedleheem", "Bedleem" or "Bedlam".[39] Initially "Bedlam" was an informal name but from approximately the Jacobean era the word entered everyday speech to signify a state of madness, chaos, and the irrational nature of the world.[40] This development was partly due to Bedlam's staging in several plays of the Jacobean and Caroline periods, including The Honest Whore, Part I (1604); Northward Ho (1607); The Duchess of Malfi (1612); The Pilgrim (c. 1621); and The Changeling (1622).[41] This dramatic interest in Bedlam is also evident in references to it in early seventeenth-century plays such as Epicœne, or The Silent Woman (1609), Bartholomew Fair (1614), and A New Way to Pay Old Debts (c. 1625).[42] The appropriation of Bedlam as a theatrical locale for the depiction of madness probably owes no little debt to the establishment in 1576 in nearby Moorfields of The Curtain and The Theatre, two of the main London playhouses;[43] it may also have been coincident with that other theatricalisation of madness as charitable object, the commencement of public visiting at Bethlem.[44]

Management

The position of master was a sinecure largely regarded by its occupants as means of profiting at the expense of the poor in their charge.[45] The appointment of the masters, later known as keepers, had lain within the patronage of the crown until 1547.[46] Thereafter the city, through the Court of Aldermen, took control and, as with the King's appointees, the office was used to reward loyal servants and friends.[47] Compared to the masters placed by the monarch, those who gained the position through the city were of much more modest status.[48] In 1561 the Lord Mayor succeeded in having his former porter, Richard Munnes, a draper by trade, appointed to the position. The sole qualification of his successor in 1565, a man by the name of Edward Rest,[49] appears to have been his occupation as a grocer.[47] Rest died in 1571, at which point the keepership passed on to John Mell in 1576,[50] known for his abuse of "the governors, those who gave money to the poor, and the poor themselves."[49] The Bridewell Governors largely interpreted the role of keeper as that of a house manager and this is clearly reflected in the occupations of most appointees as they tended to be inn-keepers, victualers or brewers and the like.[51] When patients were sent to Bethlem by the Governors of the Bridewell the keeper was paid from hospital funds. For the remainder, keepers were paid either by the families and friends of inmates or by the parish authorities. It is possible that keepers negotiated their fees for these latter categories of patients.[52]

John Mell's death in 1579 left the keepership open for the long-term keeper[49] Roland Sleford, a London cloth-maker, who left his post in 1598, apparently of his own volition, after a 19-year tenure.[53] Two months later, the Bridewell Governors, who had until then shown little interest in the management of Bethlem beyond the appointment of keepers, conducted an inspection of the hospital and a census of its inhabitants for the first time in over 40 years.[53] Their purpose was "to view and p[er]use the defaultes and want of rep[ar]ac[i]ons".[54] They found that during the period of Sleford's keepership the hospital buildings had fallen into a deplorable condition with the roof caving in and the kitchen sink blocked, and reported that[55] "...it is not fitt for anye man to dwell in wch was left by the Keeper for that it is so loathsomly filthely kept not fit for any man to come into the house".[56]

The committee of inspection found 21 inmates with only two having been admitted during the previous 12 months. Of the remainder, six at least had been resident for a minimum of eight years and one inmate had been there for around 25 years.[57] Three were from outside London, six were charitable cases paid for out of the hospital's resources, one was supported by a parochial authority, and the rest were provided for by family, friends, benefactors or, in one instance, out of their own funds.[58] The reason for the Governors' new-found interest in Bethlem is unknown but it may have been connected to the increased scrutiny the hospital was coming under with the passing of poor law legislation in 1598 and to the decision by the Governors to increase hospital revenues by opening it up to general visitors as a spectacle.[59] After this inspection, the Governors initiated some repairs and visited the hospital at more frequent intervals. During one such visit in 1607 they ordered the purchase of clothing and eating vessels for the inmates, presumably indicating the lack of such basic items.[60]

Helkiah Crooke

Title page of Helkiah's Crooke's text Microsmographiia: A Description of the Body of Man; underneath the title text are two naked, standing figures which face the viewer frontally; one figure is male and the other female; the male figure, whose upper torso is slightly turned to the right with its left hand hidden behind its back, is rendered to reveal the nervous system; the female figure's head is tilted to the right; its left hand covers one breast and its right hand covers its genitalia; the womb of the female figure is visible.
The title page of Helkiah Crooke's Microcosmographia (1615). Crooke was appointed keeper-physician to Bethlem Hospital in 1619.

At the bidding of James VI and I, Helkiah Crooke (1576–1648) was appointed keeper-physician in 1619.[61] As a Cambridge graduate, the author of an enormously successful English language book of anatomy entitled Microcosmographia: a Description of the Body of Man (1615)[62] and a member of the medical department of the royal household,[n 1] he was clearly of higher social status than his city-appointed predecessors (his father was a noted preacher, and his elder brother Thomas was created a baronet). Crooke had successfully ousted the previous keeper, the layman Thomas Jenner, after a campaign in which he had castigated his rival for being "unskilful in the practice of medicine".[46] While this may appear to provide evidence of the early recognition by the Governors that the inmates of Bethlem required medical care, the formal conditions of Crooke's appointment did not detail any required medical duties.[46] Indeed, the Board of Governors continued to refer to the inmates as "the poore" or "prisoners" and their first designation as patients appears to have been by the Privy Council in 1630.[65]

From 1619, Crooke unsuccessfully campaigned through petition to the king for Bethlem to become an independent institution from the Bridewell, a move that while likely meant to serve both monarchial and personal interest would bring him into conflict with the Bridewell Governors.[66] Following a pattern of management laid down by early office-holders, his tenure as keeper was distinguished by his irregular attendance at the hospital and the avid appropriation of its funds as his own.[61] Such were the depredations of his regime that an inspection by the Governors in 1631 reported that the patients were "likely to starve".[67] Charges against his conduct were brought before the Governors in 1632.[63] Crooke's royal favour having dissolved with the death of James I,[68] Charles I instigated an investigation against him in the same year. This established his absenteeism and embezzlement of hospital resources and charged him with failing to pursue "any endeavour for the curing of the distracted persons".[69] It also revealed that charitable goods and hospital-purchased foodstuffs intended for patients had been typically misappropriated by the hospital steward, either for his own use or to be sold to the inmates. If patients lacked resources to trade with the steward they often went hungry.[67] These findings resulted in the dismissal in disgrace of Crooke,[n 2] the last of the old-style keepers, along with his steward on 24 May 1633.[n 3][72]

Conditions

In 1632 it was recorded that the old house of Bethlem had "below stairs a parlour, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in".[73] It is likely that this arrangement was not significantly different in the sixteenth century.[73] Although inmates, if deemed dangerous or disturbing, were chained up or locked up, Bethlem was an otherwise open building with its inhabitants at liberty to roam around its confines and possibly the local neighbourhood.[74] The neighbouring inhabitants would have been quite familiar with the condition of the hospital as in the 1560s, and probably for some considerable time before that, those who lacked a lavatory in their own homes had to walk through "the west end of the long house of Bethlem" to access the rear of the hospital and reach the "common Jacques".[n 4][74] Typically the hospital appears to have been a receptacle for the very disturbed and troublesome and this fact lends some credence to accounts such as that provided by Donald Lupton in the 1630s who described the "cryings, screechings, roarings, brawlings, shaking of chaines, swearings, frettings, chaffings" that he observed.[74]

Bethlem had been built over a sewer that served both the hospital and its precinct. This common drain regularly blocked, resulting in overflows of waste at the entrance of the hospital.[75] The 1598 visitation by the Governors had observed that the hospital was "filthely kept", but the Governors rarely made any reference to the need for staff to clean the hospital. The level of hygiene reflected the inadequate water supply, which, until its replacement in 1657, consisted of a single wooden cistern in the back yard from which water had to be laboriously transported by bucket.[76] In the same yard since at least the early seventeenth century there was a "washhouse" to clean patients' clothes and bedclothes and in 1669 a drying room for clothes was added. Patients, if capable, were permitted to use the "house of easement",[n 4] of which there were two at most, but more frequently "piss-pots" were used in their cells.[77] Unsurprisingly, inmates left to brood in their cells with their own excreta were, on occasion, liable to throw such "filth & Excrem[en]t" into the hospital yard or onto staff and visitors. Lack of facilities combined with patient incontinence and prevalent conceptions of the mad as animalistic and dirty, fit to be kept on a bed of straw, appear to have promoted an acceptance of hospital squalor.[78] However, this was an age with very different standards of public and personal hygiene when people typically were quite willing to urinate or defecate in the street or even in their own fireplaces.[79]

For much of the seventeenth century the dietary provision for patients appears to have been inadequate. This was especially so during Crooke's regime, when inspection found several patients suffering from starvation. Corrupt staff practices were evidently a significant factor in patient malnourishment and similar abuses were noted in the 1650s and 1670s. The Governors failed to manage the supply of victuals, relying on "gifts in kind" for basic provisions, and the resources available to the steward to purchase foodstuffs was dependent upon the goodwill of the keeper.[80] Patients were fed twice a day on a "lowering diet" (an intentionally reduced and plain diet) consisting of bread, meat, oatmeal, butter, cheese and generous amounts of beer. It is likely that daily meals alternated between meat and dairy products, almost entirely lacking in fruit or vegetables.[81] That the portions appear to have been inadequate also likely reflected contemporary humoral theory that justified rationing the diet of the mad, the avoidance of rich foods, and a therapeutics of depletion and purgation to restore the body to balance and restrain the spirits.[82]