Bethlem Hospital in Southwark

Melancholy
Raving Madness

Melancholy and Raving Madness, two life-size sculptures created by Caius Gabriel Cibber in the late 17th century, were positioned over the entrance gateway to Bethlem Hospital at Bishopsgate. When the Hospital moved to St George's Fields, the figures were kept in the entrance hall behind curtains which were drawn back on public occasions. Today the figures are on display at the Bethlem Royal Hospital Museum, Monks Orchard Road, Beckenham (http://www.bethlemheritage.org.uk)

" ... the chains and the lash, the cell and the straw, which formerly were the appendage of a lunatic Hospital, now exist in imagination only; and in place of harshness and coercion, we find that kindness and rational treatment are the best assistants we have."

So spoke Peter Laurie, the President of Bethlem Hospital in 1838 at the ceremony of laying the first stone for buildings that were added to the existing building in St George's Fields. By saying this, he was hoping to reassure the public and the Government that practices of the hospital that had been exposed and caused a scandal in the past were now a thing of the past and the hospital was now run along more humane, progessive lines.

The building that had formerly housed the hospital in Moorfields had been decaying and crumbling for many years and after much negotiation with the City of London, the hospital swapped the Moorfields site for the one in St George's Fields, former site of the infamous Dog and Duck, whilst also retaining a financial interest in the remainder of the lease in Moorfields. Building commenced in 1812 and completed in 1815. The building works however coincided with a campaign to improve the conditions for patients in asylums which led to a change in the way the insane viewed. The campaign and a subsequent Select Committee Report greatly damaged Bethlem's reputation.

Leading the campaign was a wealthy land agent, Edward Wakefield, who had been inspired by the work of fellow Quaker William Tukes' asylum, the York Retreat. Rather than remaining inactive and often chained in cells, patients were set to work like gardening, sewing, washing and cleaning, and given exercise in the fresh air. The retreat was furnished with normal household furniture and given the appearance of a home. Staff were instructed to interact with patients and to show kindness, compassion and firmness. The York Retreat's system of treatment was called 'moral therapy.'

aerial

An aerial view of the hospital that dates from the early 20th century. Note the Obelisk from St George's Circus which was moved here in 1905. It was returned to its original location in the late 1990s.

The practice of allowing paid visitors to the asylum to view the lunatics as entertainment had been banned in 1770 but the disadvantage of this was that the public had no idea of the conditions the patients lived in. After initial obstruction from the hospital, Edward Wakefield visited Bethlem. The lack of humanity and brutality that he saw horrified him. He saw many patients in chains, naked under a blanket. He saw violent patients in chains next to those more melancholic patients who were often assaulted by the violent patients. He saw patients lying on straw and likened the men's ward to a dog kennel. He spoke to patients who were in chains and found them lucid and aware of their circumstances.

His findings were exposed in newspapers who in particular picked up on the case of James Norris. James Norris was an American Marine who had entered Bethlem in 1800 where a year later he had been designated an incurable lunatic. Edward Wakefield arranged for a sketch of the Norris to appear in the newspapers which showed a sad looking man sitting on his bed with a iron collar around his neck that was attached to a wall by a short chain and with an extremely restrictive harness around his arms and upper body. He had been restrained for 14 years and the hospital maintained it was for the safety of staff and other patients for though Norris was lucid he had sudden savagely violent episodes.

Wakefield's exposure caused a scandal and whilst the hospital maintained their treatment of the patients was necessary they nevertheless attempted damage limitation by sacking the steward and retiring the matron. They were replaced by staff of more progressive attitudes and whilst what they were able to achieve was limited within the hierarchy, they nevertheless freed patients from their chains and got them out of bed, washed them, dressed them and allowed them to walk about and exercise. But this proved too little too late and more revelations came out in evidence given to the Parliamentary Select Committee formed in 1815 to discover means of improving treatment of the insance. The apothecary, John Haslam, and the physician in charge, Thomas Munro, gave evidence but they incriminated themselves and were removed from their positions. Thomas Munro was the third of the Munro dynasty to hold the position at Bedlam. They were very conservative in their treatments which were based on purging, bleeding, blistering and vomitting, and lacked any interest in expanding medical knowledge and introducing new treatments. Unbelievably Thomas Munro was replaced by none other than his son, Edward Munro, though a second physician was also appointed to go some way to appease those governors who were against Edward Munro's appointment. Sir George Tuthill was 44 years old and a progressive thinker whlst Edward Munro had only been qualified a year. Perhaps surprisingly the two worked well together and Tuthill initiated reforms that saw the use of chains and restraints greatly reduced though not abandoned, encouraged an emphasis on exercise and occupation for patients, and a reduction in purges and bleeding.

Despite the public outcry and efforts of campaigners, the 1816 Madhouse Bill which proposed twice yearly inspections of all asylums and mental hospitals, including Bethlem, did not become law. The Governors of Bethlem fought strongly over the years against outside inspection as such inspection would compromise the hospital's independence and undermine their authority.

The new hospital at St George's Fields in many respects followed the pattern of the old building in Moorfields with a small central core that housed offices which was flanked on each side by two long wings, one side housing female patients and the other housing male patients. Each of the wings contained four galleries, or wards, each of which contained 23 bedrooms, a keeper's room, a dining room, a side room for confining patients who became violent or over-agitated, a pump, a washing place and a WC. Patients were segregated according to diagnosis with the basement housing noisy and dangerous patients who were not clean in their habits. Newly admitted patients were housed in the ground floor wing along with some patients who were deemed curable. The balance of curable patients were housed on the next floor and the gallery on the top floor housed incurable patients. In addition there were two wings that were totally separate to the main hospital which housed the criminal insane. The housing of the criminal insane in dedicated accommation outside prison was a requirement of the 1808 Lunacy Act, before this time the criminally insane had been housed in prisons and had caused extreme anxiety and even violence towards other prisoners. The criminal wing of the new Bethlem Hospital housed 60 patients and the main hospital 200 patients.

Patients in the main hospital slept on iron beds with sacking, sheets and blankets. Patients in the basement wings did not sleep on sheets but on straw which was changed everyday if necessary. In 1823 'Sketches in Bedlam' was published which contained descriptions of the behaviour and illnesses of 140 current patients. Written by someone who calls himself the 'Constant Onserver' it was clearly written by someone on the staff. The Governors held an enquiry as to who the author was as they felt publication of patients' histories in this way was a betrayal of trust but whilst suspicion fell on the apothecary Edward Wright this was never proved. Nevertheless, 'Sketches in Bedlam', although biassed, spoke in glowing terms of the progress Bethlem Hospital had made in caring for its patients:

"the skill and opinions of all the medical men most conversant with the subject were attentively consulted and compared. The detection and reform of errors and abuses; arising from ignorance, apathy, caprice or cruelty, which had been too long prevalent, constituted the happy result of that labourious, but humane inquiry; and benevolence was never, perhaps consecrated by a high triumph, than when it was satisfactorily demonstrated, that force and terror, instead of alleviating, tended but to aggravate the miseries and horrors of insanity and delerium. The philanthropic views of the British Legislature and the British nation were at length realized. Harsh usage and irritating coercion gave way to mildness, forebearance, and indulgence, and the wretched inmates of this asylum of mental derangement were liberated from unnecessary violence, intimidation, and solitary confinement."

'Sketches in Bedlam' reveals other details of day to day life in Bethlem. Beer was served at meals but a patient's intake rarely exceeded more than 2 pints a day. Port wine was given to those who were physically sick but prohibited to the healthy. Tea was not provided at mealtimes but patients were permitted to drink tea with the keepers for which they paid 2 shillings a week. Visitors were allowed between 10 am and midday on Mondays. Sir George Tuthill saw patients on Mondays and Fridays, Edward Munro on Tuesdays and Saturdays. In 1823 when the book appeared it seemed the previous scanadal that had attached to Bethlem still surrounded the hospital as there were at that time 38 vacancies for men and 12 for women. Publication of the book seems to have repaired some of that damage as the hospital was full soon after.

The 1845 Lunacy Act gave powers to the Lunacy Commission to monitor, regulate and inspect asylums and mental hospitals and ensure that standards were maintained. Despite outrage, again Bethlem was exempted, the only loop-hole in the legislation was that the Lord Chancellor or Home Secretary could order an inspection of Bethlem if there was a need for it. In 1851 the Luncacy Commission received two complaints regarding Bethlem, one from a former patient who had accused the nurses of random acts of violence and cruelty and another from the parents of a deceased female patient whose body had been covered in lacerations. The home secretary agreed to an inspection by the Lunacy Commission and the subsequent report found there had been systematic abuse and neglect although some felt this was to be the outcome of the report from its inception. Nevertheless, the Governors of Bethlem Hospital finally accepted external inspections. Alexander Morrison the physician who had replaced Sir George Tuthill was dismissed as was the apothcary. The report recommended the appointment of as resident physician who also combined the role of superintendent. Dr Charles Hood was appointed to this role and he is credited with finally bringing the hospital into line with what were then the most progressive and up to date methods. Edward Munro rode out the storm for a couple of years but resigned in 1853 which ended a tenure of over 120 years by the Munro family as physicians at Bethlem. Whilst the doctoring of the Munro family is seen as a highly negative influence to the development of Bethlem, they should not be viewed in isolation to many other 'mad doctors' of their day whose interests lay more in the revenue created by their own private hospitals than patient care and advancement of medical treatment in the larger public hospitals.

Dr Charles Hood was also responsible for changing the emphasis on patients admitted more toward the middle classes than to the poor who were increasingly treated in County Asylums. He wrote in 1862:

"It however appears certain, that a very large proportion of educated persons are admitted into Bethlem: a fact which shows that little alteration would be necessary, so far as the patients are concerned, if it were thought desirable, to send the uneducated poor to the Asylums which are provided for them on the most princely scale in every county, and to reserve Bethlem Hospital for the reception of the poor though educated insane of the middle class."

In 1867 Bethlem received the following unbiased report from John Timbs. Clearly the hospital had now laid the ghosts of the past:

"The patients employ themselves in knitting and tailoring, in laundry-work, at the needle and in embroidery; the women have pianos and occasionally dance in the evening, the men have billiards and bagatelle tables, newspapers, and periodicals; and they play in the grounds at trap-ball, cricket, fives, leap-frog, &c. Others work at their trades, in which, though dangerous weapons have been entrusted to them, no mischief has ensued, and the employment often induces speedy cure.

...

"...few sights can be more interesting than the present condition of the interior of Bethhem. The scrupulous cleanliness of the house, the decent attire of the patients, and the unexpectedly small number of those under restraint, (sometimes not one person throughout the building), lead the visitors, not unnaturally, to conclude that the management of lunatics has here attained perfection ; while the quiet and decent demeanour of the inmates might almost make him doubt that he is really in a madhouse. The arrangements, however, are comparatively, in some instances, defective: the building being partly on the plan of the old Hospital in Moorfields, in long galleries, with a view to the coercive system there pursued, is, consequently, ill adapted to the present improved treatment."

The last sentence points to the future for by the first world war the building had become totally unsuitable. It was not though until 1930 that the hospital moved again, to Monks Orchard in Beckenham where it remains today. At the time of the creation of the National Health Service in 1947 it merged with the Maudsley Hospital and ultimately became a part of the South London and Maudsley NHS Foundation Trust. The old building in St George's Fields, after a few modifications, became home to the Imperial War Museum in 1936.

Sources:
W Charles Hood MD, Statistics of Insanity; embracing a report of Bethlem Hospital from 1846 to 1860 inclusive (1862) London
'Constant Observer',Sketches in Bedlam(1823) London
Peter Laurie,Proceedings at Laying of the First Stone of the New Buildings at Bethlem Hospital (1838) London
John Timbs, The Curiosities of London(1867) London (http://www.victorianlondon.org)

Paul Chambers, Bedlam(2009) Surrey (An excellent book, moving and gripping)

Website for Bethlem Royal Hospital Archives and Museum Service (www.bethlemheritage.org.uk)
Website for Royal College of Physicians History and Heritage (http://old.rcplondon.ac.uk/history-heritage/exhibitions/Past-exhibitions/inside-bedlam/Pages/Overview.aspx)