Coordinates: 51°22′51″N0°01′50″W / 51.3809°N 0.0306°W / 51.3809; -0.0306
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. It has moved three times from its original location, and is Europe's first and oldest institution to specialise in mental illnesses.
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 Partnersacademic 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 outside of Moorfields 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 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.
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. 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. Bethlem was not initially intended as a hospital, in the clinical sense, much less as a specialist institution for the insane, but as a centre for the collection of alms to support the Crusader Church and to link England to the Holy Land. 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. 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. 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.
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, but its linkage to the Order of Bethlehem increasingly unravelled, putting its purpose and patronage in doubt. In 1346 the master of Bethlem, a position at that time granted to the most senior of London's Bethlemite brethren, 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. 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. By this time the Bethlehemite bishops had relocated to Clamecy, France, under the surety of the Avignon papacy. 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. 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. 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. 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. 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. 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.
In 1546 the Lord Mayor of London, Sir John Gresham, petitioned the crown to grant Bethlem to the city. 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". This charter came into effect in 1547. The crown retained possession of the hospital while its administration fell to the city authorities. 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. 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.
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
It is Europe's oldest extant psychiatric hospital and has operated continuously for over 600 years. 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. 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. It is unknown when it began to specialise in the care and control of the insane, but it has been frequently asserted that Bethlem was first used for the insane from 1377. This date is derived from the unsubstantiated conjecture of the Reverend Edward Geoffrey O'Donoghue, chaplain to the hospital, who published a monograph on its history in 1914. 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. This recorded that amongst other patients there were six male inmates who were "mente capti", a Latin term indicating insanity. 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. While mechanical restraint and solitary confinement are likely to have been used for those regarded as dangerous, little else is known of the actual treatment of the insane for much of the medieval period. 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.
From the fourteenth century, Bethlem had been referred to colloquially as "Bedleheem", "Bedleem" or "Bedlam". 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. 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). 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). 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; it may also have been coincident with that other theatricalisation of madness as charitable object, the commencement of public visiting at Bethlem.
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. The appointment of the masters, later known as keepers, had lain within the patronage of the crown until 1547. 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. Compared to the masters placed by the monarch, those who gained the position through the city were of much more modest status. 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, appears to have been his occupation as a grocer. Rest died in 1571, at which point the keepership passed on to John Mell in 1576, known for his abuse of "the governors, those who gave money to the poor, and the poor themselves." 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. 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.
John Mell's death in 1579 left the keepership open for the long-term keeper Roland Sleford, a London cloth-maker, who left his post in 1598, apparently of his own volition, after a 19-year tenure. 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. Their purpose was "to view and p[er]use the defaultes and want of rep[ar]ac[i]ons". 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 "...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".
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. 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. 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. 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.
At the bidding of James VI and I, Helkiah Crooke (1576–1648) was appointed keeper-physician in 1619. 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) 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". 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. 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.
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. 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. Such were the depredations of his regime that an inspection by the Governors in 1631 reported that the patients were "likely to starve". Charges against his conduct were brought before the Governors in 1632. Crooke's royal favour having dissolved with the death of James I,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". 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. 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]
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". It is likely that this arrangement was not significantly different in the sixteenth century. 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. 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] 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.
Bethlem had been built over a sewer that served both the hospital and its precinct. This common drain regularly blocked and resulting in overflows of waste at the entrance of the hospital. 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. 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. 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. 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.
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. 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. 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.
The year 1634 is typically interpreted as denoting the divide between the mediaeval and early modern administration of Bethlem. It marked the end of the day-to-day management by an old-style keeper-physician and its replacement by a three-tiered medical regime composed of a non-resident physician, a visiting surgeon and an apothecary, a model adopted from the royal hospitals. The medical staff were elected by the Court of Governors and, in a bid to prevent profiteering at the expense of patients that had reached its apogee in Crooke's era, they were all eventually salaried with limited responsibility for the financial affairs of the hospital. Personal connections, interests and occasionally royal favour were pivotal factors in the appointment of physicians, but by the measure of the times appointees were well qualified as almost all were Oxbridge graduates and a significant number were either candidates or fellows of the College of Physicians. Although the posts were strongly contested, nepotistic appointment practices played a significant role. The election of James Monro as physician in 1728 marked the beginning of an 125-year Monro family dynasty extending through four generations of fathers and sons. Family influence was also significant in the appointment of surgeons but absent in that of apothecaries.
The office of physician was largely an honorary and charitable one with only a nominal salary. As with most hospital posts, attendance was required only intermittently and the greater portion of the income was derived from private practice. Bethlem physicians, maximising their association with the hospital, typically earned their coin in the lucrative "trade in lunacy" with many acting as visiting physicians to, presiding over, or even, as with the Monros and their predecessor Thomas Allen, establishing their own mad-houses. Initially both surgeons and apothecaries were also without salary and their hospital income was solely dependent upon their presentation of bills for attendance to the Court of Governors. This system was frequently abused and the bills presented were often deemed exorbitant by the Board of Governors. The problem of financial exploitation was partly rectified in 1676, when surgeons received a salary, and from the mid-eighteenth century elected apothecaries were likewise salaried and normally resident within the hospital. Dating from this latter change, the vast majority of medical responsibilities within the institution were undertaken by the sole resident medical officer, the apothecary, owing to the relatively irregular attendance of the physician and surgeon.
But is there so great Merit and Dexterity in being a mad Doctor? The common Prescriptions of a Bethlemitical Doctor are a Purge and a Vomit, and a Vomit and a Purge over again, and sometimes a Bleeding, which is no great mystery
The medical regime, being married to a depletive or antiphlogistic physic until the early nineteenth century,[n 5] had a reputation for conservatism that was neither unearned nor, given the questionable benefit of some therapeutic innovations,[n 6] necessarily ill-conceived in every instance. Bathing was introduced in the 1680s at a time when hydrotherapy was enjoying a recrudescence in popularity. "Cold bathing", opined John Monro, Bethlem physician for 40 years from 1751, "has in general an excellent effect"; and remained much in vogue as a treatment throughout the eighteenth century. By the early nineteenth century, bathing was routine for all patients of sufficient hardiness from summer "to the setting-in of the cold weather". Spring signalled recourse to the traditional armamentarium; from then until the end of summer Bethlem's "Mad Physick" reigned supreme as all patients, barring those deemed incurable, could expect to be bled and blistered and then dosed with emetics and purgatives. Indiscriminately applied, these curative measures were administered with the most cursory physical examination, if any, and with sufficient excess to risk not only health but also life. Such was the violence of the standard medical course, "involving voiding of the bowels, vomiting, scarification, sores and bruises," that patients were regularly discharged or refused admission if they were deemed unfit to survive the physical onslaught.
The reigning medical ethos was the subject of public debate in the mid-eighteenth century when a paper war erupted between John Monro and his rival William Battie, physician to the reformist St Luke's Asylum of London, founded in 1751. The Bethlem Governors, who had presided over the only public asylum in Britain until the early eighteenth century, looked upon St Luke's as an upstart institution and Battie, formerly a Governor at Bethlem, as traitorous. In 1758 Battie published his Treatise on Madness which castigated Bethlem as archaic and outmoded, uncaring of its patients and founded upon a despairing medical system whose therapeutic transactions were both injudicious and unnecessarily violent. In contrast, Battie presented St Luke's as a progressive and innovative hospital, orientated towards the possibility of cure and scientific in approach. Monro responded promptly, publishing Remarks on Dr. Battie's Treatise on Madness in the same year.
Bethlem rebuilt at Moorfields
Although Bethlem had been enlarged by 1667 to accommodate 59 patients, the Court of Governors of Bethlem and Bridewell observed at the start of 1674 that "the Hospitall House of Bethlem is very olde, weake & ruinous and to[o] small and streight for keepeing the greater numb[e]r of lunaticks therein att p[re]sent". With the increasing demand for admission and the inadequate and dilapidated state of the building it was decided to rebuild the hospital in Moorfields, just north of the city proper and one of the largest open spaces in London. The architect chosen for the new hospital, which was built rapidly and at great expense between 1675 and 1676,[n 7] was the natural philosopher and City Surveyor Robert Hooke. He constructed an edifice that was monumental in scale at over 500 feet (150 m) wide and some 40 feet (12 m) deep.[n 8] The surrounding walls were some 680 feet (210 m) long and 70 feet (21 m) deep while the south face at the rear was effectively screened by a 714-foot (218 m) stretch of London's ancient wall projecting westward from nearby Moorgate. At the rear and containing the courtyards where patients exercised and took the air, the walls rose to 14 feet (4.3 m) high. The front walls were only 8 feet (2.4 m) high but this was deemed sufficient as it was determined that "Lunatikes... are not to [be] permitted to walk in the yard to be situate[d] betweene the said intended new Building and the Wall aforesaid." It was also hoped that by keeping these walls relatively low the splendour of the new building would not be overly obscured. This concern to maximise the building's visibility led to the addition of six gated openings 10 feet (3.0 m) wide which punctuated the front wall at regular intervals, enabling views of the facade. Functioning as both advertisement and warning of what lay within, the stone pillars enclosing the entrance gates were capped by the figures of "Melancholy" and "Raving Madness" carved in Portland stone by the Danish-born sculptor Caius Gabriel Cibber.
At the instigation of the Bridewell Governors and to make a grander architectural statement of "charitable munificence", the hospital was designed as a single- rather than double-pile building,[n 9] accommodating initially 120 patients. Having cells and chambers on only one side of the building facilitated the dimensions of the great galleries, essentially long and capacious corridors, 13 feet (4.0 m) high and 16 feet (4.9 m) wide, which ran the length of both floors to a total span of 1,179 feet (359 m). Such was their scale that Roger L'Estrange remarked in a 1676 text eulogising the new Bethlem that their "Vast Length ... wearies the travelling eyes' of Strangers". The galleries were constructed more for public display than for the care of patients as, at least initially, inmates were prohibited from them lest "such persons that come to see the said Lunatickes may goe in Danger of their Lives".[n 10]
The architectural design of the new Bethlem was primarily intended to project an image of the hospital and its governors consonant with contemporary notions of charity and benevolence. In an era prior to the state funding of hospitals and with patient fees covering only a portion of costs, such self-advertisement was necessary to win the donations, subscriptions and patronage essential for the institution's survival. This was particularly the case in raising funds to pay for major projects of expansion such as the rebuilding project at Moorfields or the addition of the Incurables Division in 1725–39 with accommodation for more than 100 patients. These highly visible acts of civic commitment could also serve to advance the claims to social status or political advantage of its Governors and supporters. However, while consideration of patients' needs may have been distinctly secondary, they were not absent. For instance, both the placement of the hospital in the open space of Moorfields and the form of the building with its large cells and well-lit galleries had been chosen to provide "health and Aire" in accordance with the miasmatic theory of disease causation.[n 11]
It was London's first major charitable building since the Savoy Hospital (1505–17) and one of only a handful of public buildings then constructed in the aftermath of the Great Fire of London (1666). It would be regarded, during this period at least, as one of the "Prime Ornaments of the City ... and a noble Monument to Charity". Not least due to the increase in visitor numbers that the new building allowed, the hospital's fame and latterly infamy grew and this magnificently expanded Bethlem shaped English and international depictions of madness and its treatment.
Visits by friends and relatives were allowed and it was expected that the family and friends of poor inmates would bring food and other essentials for their survival. Bethlem was and is best known for the fact that it also allowed public and casual visitors with no connection to the inmates. This display of madness as public show has often been considered the most scandalous feature of the historical Bedlam.
On the basis of circumstantial evidence, it is speculated that the Bridewell Governors may have decided as early as 1598 to allow public visitors as means of raising hospital income.[n 13] The only other reference to visiting in the sixteenth-century is provided in a comment in Thomas More's 1522 treatise, The Four Last Things, where he observed that "thou shalt in Bedleem see one laugh at the knocking of his head against a post". As More occupied a variety of official positions that might have occasioned his calling to the hospital and as he lived nearby, his visit provides no compelling evidence that public visitation was widespread during the sixteenth century. The first apparently definitive documentation of public visiting derives from a 1610 record which details Lord Percy's payment of 10 shillings for the privilege of rambling through the hospital to view its deranged denizens.[n 14] It was also at this time, and perhaps not coincidentally, that Bedlam was first used as a stage setting with the publication of The Honest Whore, Part I, in 1604.
Evidence that the number of visitors rose following the move to Moorfields is provided in the observation by the Bridewell Governors in 1681 of "the greate quantity of persons that come daily to see the said Lunatickes". Eight years later the English merchant and author, Thomas Tryon, remarked disapprovingly of the "Swarms of People" that descended upon Bethlem during public holidays. In the mid-eighteenth-century a journalist of a topical periodical noted that at one time during Easter Week "one hundred people at least" were to be found visiting Bethlem's inmates. Evidently Bethlem was a popular attraction, yet there is no credible basis to calculate the annual number of visitors. The claim, still sometimes made, that Bethlem received 96,000 visitors annually is speculative in the extreme.[n 15] Nevertheless, it has been established that the pattern of visiting was highly seasonal and concentrated around holiday periods. As Sunday visiting was severely curtailed in 1650 and banned seven years later, the peak periods became Christmas, Easter and Whitsun.
... you find yourself in a long and wide gallery, on either side of which are a large number of little cells where lunatics of every description are shut up, and you can get a sight of these poor creatures, little windows being let into the doors. Many inoffensive madmen walk in the big gallery. On the second floor is a corridor and cells like those on the first floor, and this is the part reserved for dangerous maniacs, most of them being chained and terrible to behold. On holidays numerous persons of both sexes, but belonging generally to the lower classes, visit this hospital and amuse themselves watching these unfortunate wretches, who often give them cause for laughter. On leaving this melancholy abode, you are expected by the porter to give him a penny but if you happen to have no change and give him a silver coin, he will keep the whole sum and return you nothing
The Governors actively sought out "people of note and quallitie" – the educated, wealthy and well-bred – as visitors. The limited evidence would suggest that the Governors 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[n 16] – 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,[n 17] 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 of Bethlem 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,[n 18] 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 its palatial pretensions, by the end of the eighteenth century Bethlem 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 (c. £1.1M as of 2013). 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.
“In addition to its social reform agenda, this series explored one of the era’s central philosophical concerns: the tragic disjunction – and essential fragility – of the human body, mind, and spirit. Notably, Cooke’s series anticipated by more than a decade similar bodies of work by Richard Avedon and Diane Arbus.”
— Keith F. Davis, American Century of Photography
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This photographic essay changed the way America viewed “Insane Asylums,” inspiring much needed reform. There were several significant photographs from this body of work that were not used in the Bedlam essay, including the award winning Family of Man image, “Ohio Insane Asylum.”
Many of the photographs continue to be included in exhibitions, and published widely in books, magazines, and mental health textbooks, describing the dehumanization and segregation that characterized may institutions in the twentieth century.