University of Pennsylvania, Philadelphia, United States
Perhaps no hospital has made its mark on human imagination as much as Bethlem Hospital, located outside London. The first hospital in England to specialize in the care of the insane, Bethlem gave birth to the caricature of the lunatic asylum as a place filled with chained patients in filthy living conditions. Indeed, the word “bedlam” derives directly from this image of Bethlem as the epitome of insane chaos. But Bethlem Hospital was a historic place that housed real patients. Over the span of seven-and-a-half centuries, this pioneer institution welcomed inmates under its eaves while evolving in its purpose, practice, and ideology in ways that reflect the evolution of medicine and society itself during this time period.
The origins of Bethlem Hospital lay not in any humanitarian purpose or medical principle but rather in religious rivalry. In 1244 the town of Bethlehem in modern-day Palestine was seized by the Turks, in one of many transfers during the crusading Middle Ages of cities from Christian hands to Muslim and vice-versa). In reaction, the religious Order of Bethlehem was founded in France for the purpose of raising alms. A chance meeting around this time between the Bishop of the See of Bethlehem and a London alderman named Simon fitzMary resulted in the latter granting land just outside the walls of London for the establishment of the Priory of St. Mary of Bethlem. So Bethlem Hospital was born in 1247.1
As a medieval hospital and religious priory, Bethlem initially functioned very little as a hospital in the modern-day sense of the term. Medieval hospitals occupied one of several possible functions: as leper communes, in which those with leprosy lived; as almshouses, or homes for the healthy poor; as hostels, or temporary homes for travellers; or as infirmaries, where the sick poor could obtain care. Notably, only the latter usually provided care for the ill.2 Bethlem was intended to act in this third capacity, as a temporary home for travelling persons of the Order, in addition to its role as a priory, or permanent home for members of the Order.3
Evidence suggests, however, that within a century and a half after its establishment, Bethlem accommodated private individuals unaffiliated with the Order, most likely tenants who provided income for Bethlem. These individuals were most likely housed in separate buildings adjacent to the Master’s House, church, and the building that was to become the hospital housing the insane. Over the years, other developments within the precinct of Bethlem included an inn called the Black Bull and potentially a tavern at one point.4 Far from being only a place at which the sick or the insane received care, Bethlem in its first two centuries housed a variety of individuals, private and religious.
At some point in its early history, Bethlem began to acquire some of the characteristics of a modern-day hospital, admitting the sick and caring for them. It may have done so as early as 1292, but certainly by 1403 it had begun to accommodate the sick. Furthermore, by 1403 Bethlem had its in care several insane men, perhaps transferred from an institution at Charing Cross out of concern that the latter posed an unnervingly proximate location for a lunatic asylum to the royal palace. Bethlem’s transition into an institution exclusively for the care of the insane seems to have been accomplished by the mid-fifteenth century, when the Mayor of London described Bethlem as a center of care for the mad.5
As a lunatic asylum, Bethlem was notorious for its noise and disorder. Lady Eleanor Davies, who spent a period in the 1630s in the Master’s House, compared Bethlem to “hell, such were the blasphemies and the noisome scents.”6 A contemporary of hers, Donald Lupton, wrote of the “cryings, screechings, roarings, brawlings, shaking of chaines, swearings, frettings, chaffings” that filled Bethlem Hospital in the 1630s.7 Indeed, the image of Bethlem as the epitome of chaos developed into a trope in the seventeenth century, as Jacobean and Caroline plays began to portray scenes in “Bedlam” as dramatic loci of madness, squalor, and chaos.8
The accuracy of this portrayal of Bethlem, however, is less than absolute. Certainly, by modern standards, Bethlem was not a sanitary place to live. Rats and insects chronically infested the hospital, and a single cistern on the grounds, from which water was to be carried to the hospital via bucket, constituted the sole water supply at Bethlem before 1657. Through the seventeenth century, chamberpots, rather than proper latrines, were de rigeur—although as straw bedding was seen as an advantage over linen bedding due to its capacity to permit urine to drain away, clearly not every patient enjoyed the luxury of one of these “piss-pots.”9 Nor did patients necessarily cooperate in efforts to maintain sanitation; minutes from the Court of Governors record patients throwing “filth & Excrement … into the yards.”10 In short, the standards of cleanliness at Bethlem were low.
But for early modern Britain, Bethlem was not so far from the standard. The English philosopher Thomas Hobbes famously proclaimed in his seminal 1651 book Leviathan, “The life of man [is] solitary, poor, nasty, brutish, and short.”11 For their part, the governors of Bethlem attempted to make the lives of their inmates somewhat less nasty and brutish. Accounts from various time points show repeated expenses on behalf of patients: in 1620, replacements for rotten and broken beds, in 1676 new beds and coverlets, from 1645 onwards regular purchases of clothing, and the establishment of a regular Wardrobe Fund in the 1690s to provide clothing for needy patients.12 After Bethlem Hospital moved to its new location at Moorfields in 1676, latrines replaced the chamberpots and efforts to instigate regular cleaning regimens increased, particularly as the eighteenth century wore on. By 1784, visitor Sophie von la Roche declared Bethlem to be “sound, spacious [and] clean.”13
In terms of the amount and forms of medical care provided, Bethlem similarly evolved. In the beginning, Bethlem’s care of the insane probably amounted to basic provisions including shelter, food, and spiritual guidance. In the early sixteenth century, therapeutic interventions arrived, though not any that would be recognized as such today: “betynge and correccyon” and “chains and fetters.”14 Occasionally, Bethlem administered medicines, though the specifics of these administrations are lost to history.15 From the 1630s onward, Bethlem staffed physicians, surgeons, and apothecaries, who prescribed the usual regimens of bleeding, purging, and vomiting to restore out-of-balance humors. In the eighteenth century, Bethlem banned physical beatings, and cold bathing came into vogue as a treatment for the physically sick. An on-site apothecary’s shop was added to dispense medications, and Bethlem even hired a nurse to look after its patients.16 From an initial posture of medical agnosticism, the governors of Bethlem increasingly moved toward managing their patients in ways they believed provided medical care, and even cures, for their patients.
At a societal level, ideas about insanity and the care of the insane likewise changed. Enlightenment thought pressed for a humane view of the insane that sympathized with the mad instead of censuring them for their insanity, and Evangelicalism created a moral duty out of social responsibility toward one’s neighbor. Accordingly, a new philosophy for the management of the insane emerged that emphasized rewards and punishments over physical restraints. Governmental reforms followed: the 1774 Madhouses Act required formal licensing and inspection of asylums; Wynn’s Act in 1808 built twelve new county asylums; a Parliamentary Select Committee created in 1815 investigated asylums including Bethlem;17 another Madhouse Act passed in 1828; and the 1845 Lunacy Act further expanded public madhouses and regulations.18
The sum of all this reforming Victorian zeal was to change Bethlem in substantial ways. Starting shortly after a damning report from the 1815 Select Committee, Bethlem hired an additional physician to share in the medical duties. Patient care transformed, as the administration emphasized the therapeutic benefits of physical exertion in the form of sport, recreation, music, and work. The number of attendants increased, and wages for staff and patient provisions like clothing improved. Even the hospital’s physical space underwent multiple alterations, as newer buildings and hospital wings in the latest design were built to accommodate the latest trends in hospital management.19 As the nineteenth century closed, Bethlem was on an upward trajectory.
In its last hundred years, Bethlem hurdled into a rapidly changing twentieth century. It acquired an affiliation with a medical school, a merger with Maudsley Hospital, and a new location at Monks Orchard. By the dawn of the new millennium, Bethlem had been incorporated into the National Health Service.20 From its origins as a religious institution to its latest incarnation as a modern psychiatric hospital, Bethlem moved with its times. Its ability to reinvent itself as society, medicine, and psychiatry changed ensured its survival and, indeed, flourishing. In the process, its transformation from bedlam to Bethlem was made complete.
1. Jonathan Andrews et al., The History of Bethlem (New York: Routledge, 1997), 26-7.
2. Martha Carlin, “Medieval English Hospitals,” in The Hospital in History, ed. Lindsay Granshaw and Roy Porter (New York: Routledge, 1989), 24.
3. Andrews et al, The History of Bethlem, 27.
4. Ibid., 40-40.
5. Ibid., 80-2.
6. Ibid., 51-2.
7. Ibid., 51.
8. Ibid., 130.
9. Ibid., 203-4.
10. Ibid., 205.
11. Thomas Hobbes, Leviathan or The Matter, Forme and Power of a Common Wealth Ecclesiasticall and Civil (London: 1651).
12. Andrews et al., The History of Bethlem, 116, 201-2.
13. Ibid., 207.
14. Ibid., 114.
15. Ibid., 114.
16. Ibid., 149-151, 275.
17. Ibid., 417-8, 427.
18. Ibid., 465-6.
19. Ibid., 441-456.
20. Ibid., 540-71.
Janice Tiao is completing her medical degree at the Perelman School of Medicine at the University of Pennsylvania. She graduated from Princeton University in 2011 with a bachelor’s degree in history.