Bethlem Royal Hospital

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Bethlem Royal Hospital

Bedlam in 1896
Established 1247 as a catholic Priory
Opened 1330 as a Hospital
Current Status Active
Building Style Pre-1854 Plans
Location Monks Orchard Rd Beckenham, London BR3 3BX, United Kingdom
Architecture Style Georgian/Victorian/Edwardian
Peak Patient Population 364 (in 1830)
Alternate Names
  • Bethlehem Hospital
  • St. Mary Bethlehem
  • "Bedlam"

Bethlem Hospital at St George's Fields, 1828

Bethlem Royal Hospital is an active hospital for the treatment of mental illness located in London, United Kingdom; and is currently owned and operated by South London and Maudsley NHS Foundation Trust. Although no longer based at the original location of its 1247 founding, it is recognized as Europe's first and oldest psychiatric institution. Bethlem has been accepting patients suffering from Insanity since the 14th century. The current hospital has been closely associated with King's College-London, and remains in partnership with the King's College-London Institute of Psychiatry. The hospital itself remains a major center for psychiatric, neurological and psychological research. The current hospital includes a range of specialist psychiatric services, such as the National Psychosis Unit for the United Kingdom. Other services on the hospital grounds include: the Bethlem Adolescent, which provides care and treatment for young people aged 12–18 from across the country. Bethlem also has an occupational therapy department, which has its own art gallery displaying work of current patients, and a number of noted artists have been past patients at the hospital over the years. Several examples of their work can be found in the Bethlem museum.

The word bedlam, meaning 'an uproar or confusion', is derived from the hospital's prior name. From the fourteenth century, Bethlem had been referred to colloquially as "Bedleheem", "Bedleem" or "Bedlam". Initially Bedlam functioned merely as an informal, alternative moniker for the institution but, from approximately the Jacobean era, it emerged as Bethlem's doppelgänger, detaching itself increasingly from the hospital, and entering everyday speech to signify a state of madness, chaos, and the irrational nature of the world. Although currently a modern psychiatric facility, historically it became representative historically of the worst excesses of asylum abuses and neglect. In recent years the British government has attempted to reform the image of the site, and in 1997, celebrated in 750th anniversary as a public facility. The service user perspective was not to be included, however, and members of the Psychiatric survivors movement saw nothing to celebrate in either the original Bedlam or in current mental health care. A campaign called "Reclaim Bedlam" was launched by Pete Shaugnessey, which was supported by hundreds of patients and ex-patients and widely reported in the media. A sit-in was held outside the earlier Bedlam site at the Imperial War Museum. Despite this it remains a model for psychiatric care in both Britain and the Americas.


Foundation as a Catholic Priory: 1247-1330[edit]

Bedlem as it appeared in the 13th century

Bethlem Royal Hospital's origins are unlike any other psychiatric hospital in the western world. As a formal organization, it can be traced to its foundation in 1247, during the reign King Henry III, as a Roman Catholic Monastery for the Priory of the 'New Order of St Mary of Bethlem' in the city of London proper. It was established by the Italian Bishop of Bethlehem, Goffredo de Prefetti, following a donation of personal property by the London Alderman and former City-Sheriff, the Norman, Simon FitzMary. It bears its name after its primary patron and original overseer. The initial location of the priory was in the parish of Saint Botolph, in 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, much less as a specialist institution for the mentally ill. Rather, its purpose was tied to the function of the English Church; the ostensible purpose of the priory was to function as a centre for the collection of alms to support the Crusaders, and to link England to the Holy Land. Bishop De Prefetti's need to generate income for the Crusaders, and restore the financial fortunes of his apostolic see was occasioned by two misfortunes: his bishopric had suffered significant losses following the destructive conquest of the town of Bethlehem by the Khwarazmian Turks in 1244; and the immediate predecessor to his post had further impoverished his cathedral chapter through the alienation of a considerable amount of its property. The new London priory, obedient to the Church of Bethlehem, would also house the poor, disabled and abandoned; and, if visited, provide hospitality to the Bishop, canons and brothers of Bethlehem. The subordination of the priory's religious order to the bishops of Bethlehem was further underlined in the foundational charter which stipulated that Bethlems's prior, canons and male and female inmates were to wear a star upon their cloaks and capes to symbolize their obeisance to the church of Bethlehem.

Development as a Hospital: 1330-1546[edit]

An inmate at the Bethlem Asylum, circa 1500

During the 13th and 14th centuries, with its activities underwritten by episcopal and papal indulgences, Bethlem's role as a center for the collection of alms for the poor continued. However, over time, its link to the mendicant Order of Bethlehem increasingly devolved, putting its purpose and patronage in severe doubt. In 1346 the Prior of Bethlem, a position at that time granted to the most senior of London's monastic brethren, applied to the city authorities seeking protection; thereafter metropolitan office-holders claimed power to oversee the appointment of prios, and demanded in return an annual payment of 40 shillings from the coffers of the order. It is doubtful whether the City of London ever provided substantial protection, and much less that the priorship fell within their patronage, but dating from the 1346 petition, it played a role in the management of Bethlem's organization and finances.

By this time the crusader bishops of Bethlehem had relocated to Clamecy, France under the surety of the Avignon papacy. This was significant as, throughout the reign of King Edward III (1327–77), the English monarchy had extended its patronage over ecclesiastical positions through the seizure of alien priories, mainly French. These were religious institutions that were 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 English crown, and this occurred in the 1370s when Edward III took control of all English hospitals. The purpose of this appropriation was to prevent funds raised by the hospital from enriching the French monarchy, via the papal court, and thus supporting the French war effort. After this event, the Head Masters of the hospital, semi-autonomous figures in charge of its day-to-day management, were crown appointees, and Bethlem became an increasingly secularized institution. The memory of Bethlem's foundation became muddled. In 1381 the royal candidate for the post of master claimed that from its beginnings the hospital had been superintended by an order of knights, and he confused the identity of its founder, Goffredo de Prefetti, with that of the Frankish crusader, Godfrey de Bouillon, the King of Jerusalem. The removal of the last symbolic link to the mendicant order was confirmed in 1403 when it was reported that master and inmates no longer wore the symbol of their order, the star of Bethlehem. This was exclusively a political move on the part of the hospital administrators, as the insane were perceived as unclean or possessed by daemons, and not permitted to resided on consecrated soil.

From 1330 Bethlehm was routinely referred to as a "hospital" 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 would have been a perfectly apt term to describe an institution acting as a centre and providing accommodation for Bethlem's peregrinating alms-seekers or questores. It is unknown from what exact date it began to specialise in the care and control of the insane. Despite this fact it has been frequently asserted that Bethlem was first used for the insane from 1377. This rather precise 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 provided from the details of a visitation of the Charity Commissioners in 1403. This recorded that amongst other patients then in the hospital there were six male inmates who were "mente capti", a Latin term indicating insanity. The report of the 1403 visitation also noted the presence of four pairs of manacles, eleven chains, six locks and two pairs of stocks although it is not clear if any or all of these items were for the restraint of the inmates. Thus, 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 in Bethlem 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.

Rise of Infamy: 1546-1634[edit]

In 1546, the Lord-Mayor of London, Sir John Gresham, petitioned the crown to grant Bethlem to the city properly. This petition was partially successful, and King 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. Under this formulation, the crown retained possession of the hospital, while its administration fell to the city authorities. Following a brief interval when Bethlem was placed under the management of the Governors of Christ's Hospital, from 1557 it was administered by the Governors of the city 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 Bethlem's incorporation into the National Health Service (NHS) took place in 1948.

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 early masters of the hospital, later known as keepers, had lain within the patronage of the crown until 1547. Thereafter, the city, through the Court of Aldermen, took control of these appointments where, as with the King's appointees, the office was used to reward loyal servants and friends. However, compared to the masters placed by the monarch, those who gained the position through the city were of much more modest status. Thus in 1561, the Lord Mayor succeeded in having his former porter, Richard Munnes, a draper by trade, appointed to the position. The sole qualifications of his successor in 1565 appears to have been his occupation as a grocer. 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 during this period 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.

In 1598 the long-term keeper, Roland Sleford, a London cloth-maker, left his post, apparently of his own volition, after a nineteen-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 forty years. Their express purpose was to "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, the kitchen sink blocked up and reported that: " is not fitt for anye man to dwell in wch was left by the Keeper for that it is so loathsomly filthely kept not fitt for anye man to come into the sayd howse".

The 1598 committee of inspection found twenty-one inmates then resident with only two of these having been admitted during the previous twelve months. Of the remainder, six, at least, had been resident for a minimum of eight years and one inmate had been there for around twenty-five 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, while the rest were provided for by family, friends, benefactors or, in one instance, out of their funds. The precise 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 Bridewell 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.

List of the Priors/Masters[edit]

Bethlem Hospital in 1557
  • Thomas: 13th century
  • John de Norton: ?-1350
  • William Titte: around 1375
  • William Welles: ?-1381
  • John Gardyner: 1381-1388
  • Robert Lincoln: 1388-1423
  • Robert Dale: 1423-1437
  • Edward Atherton: 1437-1457
  • Thomas Arundel: 1457-1459
  • Thomas Hervy: 1459
  • Thomas Browne: 1459-1470
  • John Smeathe: 1470-?
  • John Davyson: ?-1479
  • Walter Bate: 1479-?
  • William Hobbs: 1479-?
  • Thomas Maudesley: around 1485
  • John Cavalary: 1512-1529
  • George Boleyn: 1529-1536
  • Peter Mewtys: 1536-?
  • Dr. Crooke: 17th century

The seal of the priory of Saint Mary of Bethlem is said to have represented the Assumption of the Virgin Mary, which was used by Bethlem Royal Hospital until 1948.

Bethlem in the 20th century[edit]

In 1930, the site of the hospital was moved to an outer suburb of London, on the site of Monks Orchard House between Eden Park, Beckenham, West Wickham and Shirley. This move to accomodate the need for psychiatric care is a more peaceful and rural environment. The old hospital site and its grounds were bought by Lord Rothermere and presented to the London County Council for use as a city park; the central part of the georgian styled building was retained as being of historic value, and became home to the 'Imperial War Museum in 1936'.

With the introduction of the National Health Service in 1948, the Bethlem Royal Hospital and Maudsley Hospital were merged to form a postgraduate psychiatric teaching hospital. The Maudsley’s medical school became the Institute of Psychiatry.

Current Hospital: 1990 to present[edit]

Bethlem Hospital as of 2012

In 1999, Bethlem Royal Hospital became part of the South London and Maudsley NHS Foundation Trust (or "SLaM"), along with the Maudsley Hospital in Camberwell. Later, in 2001, SLaM sought planning permission for an expanded Medium Secure Unit in 2001 and extensive further works to improve security, much of which would be on Metropolitan Open Land. Local residents groups organised mass meetings to oppose the application, with accusations that it was unfair most patients could be from inner London areas and therefore not locals and that drug use was rife in and around the Hospital. Bromley Council eventually refused the application, with Croydon Council also objecting. However the Office of the Deputy Prime Minister overturned the decision to refuse in 2003, and development started.

The new 89-bed, £33.5m unit (River House) opened in February 2008. It is the most significant development on the site since the hospital was formally opened at Monks Orchard in 1930. River House represents a major improvement in the quality of local NHS care for people with mental health problems. The unit provides care for people who were previously being treated in hospitals as far as 200 miles away from their families because of the historic shortage of medium secure beds in South-east London. This, in turn, was intended to help the NHS to manage people's progress through care and treatment more effectively.

The Hospital Trust still owns land throughout England, often left to it as a bequest. It owns a lease in Piccadilly for which it has paid the same peppercorn rent for over 200 years. This property is let out to shops and a hotel, which contributes to funding the hospital proper.

National Psychosis Unit[edit]

The National Psychosis Unit specialises in evidence-based treatment for people with schizophrenia, bipolar disorder and other similar disorders, particularly where local treatment has been unsuccessful or only partially successful in relieving symptoms. Anyone receiving NHS treatment can access the service free of charge following a referral by the person’s psychiatrist or general practitioner.

The service provides second opinions on medication, diagnosis or any other aspect of care. The service has an outpatient clinic and 24-bedded inpatient facility. As well as pharmaceutical treatments, there is a strong focus on psychological treatments, rehabilitation and recovery, and reducing the risk of readmission through exploring what has led to breakdowns in the past and how to avoid this happening in future. The Unit also hosts research into the treatment of psychosis, including clinical trials of new treatments for psychosis. The National Psychosis Carers' Group, which meets monthly, supports the carers and families of people with psychosis and allows them a forum for discussion.

The National Psychosis Unit has strong links with the Department of Psychosis Studies at the Institute of Psychiatry, King's College London. The Unit also has longstanding links with mental health charities, including Rethink and SANE.

Institute of Psychiatry[edit]

The Institute of Psychiatry (IOP) is a research institution dedicated to discovering what causes mental illness and neurological diseases of the brain. In addition, its modern aim is to help identify new treatments for them and ways to prevent them in the first place. The IOP is a school of King's College- London, England. The Institute works closely with South London and Maudsley NHS Foundation Trust. Many senior academic staff also work as honorary consultants in clinical services for the National Psychosis Unit at Bethlem Royal Hospital.

Bethlem Royal Hospital Archives and Museum[edit]

Exhibition at Bethlem Museum

Since 1970, there has been a small museum at Bethlem Royal Hospital, which is open to the public on weekdays. The museum is mainly used to display items from the hospital's art collection, which specialises in work by artists who have suffered from various mental health issues, such as former Bethlem patients William Kurelek, Richard Dadd and Louis Wain. Other exhibits include a pair of statues by Caius Gabriel Cibber known as Raving and Melancholy Madness, from the gates of the 17th century Bethlem Hospital. 18th and 19th century furniture, and documents from the medical archives are also on display. However, due to the size of the museum only a small fraction of the collections can be displayed at one time, and the exhibits are rotated periodically for public view.

Bethlem Royal Hospital also possesses extensive archives from the Maudsley Hospital and Warlingham Park Hospital, all in South London, and some of the archives of Bridewell Hospital. There are documents dating back to the 16th century, as well as full modern patient records (although these are not open to publiv viewing). The archives are open for inspection by appointment, and are subject to the laws of confidentiality governing recent patient records. The Bethlem Royal Hospital Archives and Museum is governed by a registered charity called the Bethlem Art and History Collections Trust. The museum is a member of the larger collaboration of the 'London Museums of Health & Medicine'.

Tom O'Bedlem[edit]

Edgar as Tom O'Bedlam

"Tom O' Bedlam" is the name of renown anonymous poem written in the 17th century about an inmate at Bethlem. It was first published in 1720 by Thomas d'Urfey in his 'Wit and Mirth, or Pills to Purge Melancholy'.

The term "Tom O' Bedlam" was used in Early Modern England, as well as following, to describe beggars and vagrants who had or feigned Insanity for alms. This practice is similar to that of the English Abraham-men. They claimed, or were assumed, to have been former inmates at the Bethlem Royal Hospital, who had been released and now composed the insane poor of the city. It was commonly thought that inmates were released with authority to make their way by begging, though this is probably untrue. If it happened at all the numbers were certainly small, though there were probably large numbers of mentally ill travelers who turned to begging, but had never been near Bedlam. It was adopted as a technique of begging, or a character. For example, Edgar in King Lear disguises himself as mad "Tom O'Bedlam".

It was a popular enough ballad that another poem was written in reply, "Mad Maudlin's Search" or "Mad Maudlin's Search for Her Tom of Bedlam" (the same Maud who was mentioned in the verse "With a thought I took for Maudlin / And a cruise of cockle pottage / With a thing thus tall, Sky bless you all / I befell into this dotage." which apparently records Tom going mad, "dotage") or "Bedlam Boys" (from the chorus, "Still I sing bonny boys, bonny mad boys / Bedlam boys are bonny / For they all go bare and they live by the air / And they want no drink or money.").

Images of Bethlem Royal Hospital[edit]

Main Image Gallery: Bethlem Royal Hospital

Related Links[edit]