Bethlem Royal Hospital is a psychiatric institution in Greater London. Despite its Kent postal address, it is in the London Borough of Bromley. It currently treats people with mental health and substance misuse problems. Services also include specialist units available for people across the UK and local psychiatric services for people from the Borough of Croydon. There are more than 1700 patients admitted each year, and over 50% of the patients are cured. It has over 800 members of staff.

This, however, is not the story of the current hospital; rather the story of Bedlam, where the Bethlem Royal Hospital began over 700 years ago.

Bethlem and Bedlam are two of the many medieval variants of Bethlehem, and are used throughout this entry.

Priory of St Mary of Bethlehem

Originally opened in 1247 by Simon FitzMary, an Alderman and Sheriff of London, as the Priory of St Mary of Bethlehem outside Bishopsgate¹. From as early as 1329 it was being used as a hospice, and received a licence to collect alms for the poor and needy of the local area and the Mother Church in Palestine.

In 1375 Bedlam became a royal hospital. It had been taken by the Crown on the pretext that it was an alien priory². It began the care of mentally ill patients two years later (the word 'care' here means chained to the wall and, when violent, whipped or ducked in water) and specialised in the care of mental illness from 1403. Records show that at this time it had one master, a porter and his wife and nine inmates. There were a number of servants. Patient numbers steadily increased, and records show that it was being called 'Bedlam' by 1450.

Early 16th century maps show 'Bedlame Gate' next to Bishopsgate. It led into a courtyard where a few small stone buildings were, a church and a garden could also be found here. There were 31 patients housed in a space for 24, and the noise was 'so hideous, so great; that they are more able to drive a man that hath his wits rather out of them'. The whip and chains were the usual 'treatment' for patients.

Some patients were allowed to leave the 'madman's pound'. They were 'tagged' with a tin badge on their left arm to signify their status. They were called 'anticks' or 'God's minstrels' because of their habit of roaming aimlessly. Violent or dangerous patients remained in Bedlam, manacled and chained to the floor or wall. The main ward was called Abraham - an Abraham man was a beggar who pretended to be mad.

Hospital of St Mary of Bethlem

Bishopsgate

Henry VIII granted Bethlem a charter as a hospital for the insane in 1547 when the priory was dissolved. The government of the hospital was granted to the City of London (with all its revenue), on condition that the City spend a certain amount on new buildings. It became a City institution as well as a Royal hospital. The management was granted to the City in 1557, who transferred it to Governors of Bridewell. Bridewell had originally been a palace, but its position next to the stinking Fleet River meant that royalty soon deserted it. It became a hospital, but was mainly used as a prison.

The Governors left the management of Bedlam to keepers (the replacement for the old 'masters'), who made what they could out of it in the same way that the keepers who ran prisons did. Each patient was paid for by his or her parish, livery company, or relatives. The charges largely depended on what the keeper thought the market could bear and what he thought he could get away with. At this time it was the only fee-paying, specialised hospital in London. The Governors gave most of their attention to Bridewell, and the patients of Bedlam suffered terrible neglect.

In 1598, Bridewell Governors inspected Bedlam - nothing had been spent on upkeep of the buildings, the 'Great Vault' (cesspit) badly needed emptying, and kitchen drains and sinks needed replacing. At this time there were 20 patients there - one who had been sent from Bridewell over 25 years previously. Five others had joined him from Bridewell over the last decade. Records do not show if any improvements were made at the time of this inspection. We can only hope that there were.

By early 17th century Bedlam was the only hospital for the insane in the country. Most of the patients were vagrants, apprentices and servants. There were a few scholars and gentlemen. Half a century later Bedlam had become badly over-crowded, noisy and polluted.

Moorfields

The madhouse became so squalid and dilapidated by the middle of the 17th Century that in 1673 it was decided to move the hospital to a new, modern building in Moorfields - what is now Finsbury Circus. Finished in 1675, it was built into the north face of the City Wall and was generally thought to be one of the finest buildings in London. It was designed by Robert Hooke³ and was the first purpose built hospital for the insane in the UK.

Bald-headed and half-naked figures decorated the entrance gates, created by the sculptor Caius Cibber, depicted 'Raving and Melancholy madness'. This is not the name of the statues, the title reflected the two categories of inmates. They reflect the names extremely well. 'Melancholy' looks defeated and vacant, and 'Raving' is chained to his plinth, a tortured expression on his face. The two figures now live in the Royal Bethlem Hospital museum⁴. A cast of 'Melancholy' is on view at the Museum of London. Made of Portland stone, the figures and hospital were one of the 'must see' sights of London at the time. It proved popular with those writing guidebooks and poetry, and engravers.

The practice of charging entrance fee started around the time that the hospital moved, and a constant stream of visitors came to watch the patients. Not only locals but also foreign travellers and writers came to see the mad confined here. It was considered very important to the authorities that madness was seen to be managed and restrained, although many of the visitors who had not come to visit relatives ended up provoking the inmates for their own entertainment. All the visitors were charged a penny for the privilege. This was stopped in 1770 because it 'tended to disturb the tranquillity of the patients' by 'making sport and diversion of the miserable inhabitants'. Entrance was then by ticket only, designed to stop indiscriminate visiting.

There were two galleries, each made up of a corridor lined with cells on either side. An iron gate in the middle divided the men from the women. The patients were often manacled to the floor. It was clearly a prison, rather than a hospital concentrating on curing the insane that it housed. Medical treatment at this time was largely ineffectual, and at this time patients were discharged after 12 months whether they were cured or not. Surprisingly, some inmates did recover. They were not referred to as 'patients' until 1700.

As the hospital population grew, two extra wings were built between 1725-34. These became the 'incurable' wards, one for each gender. Once they were open, those patients who were released uncured were placed on the 'incurable' list. Once a place became available they were readmitted if they had no-one else to provide care. Patients were never admitted directly to the incurable wards, they always had to spend 12 months in the main section.

St George's Fields

By the end of the 17th Century the new Bethlem hospital was as decayed and desolate as the original had been. In 1807 it was decided to move the hospital again, after the building had been ruled unsafe - one wing had been demolished two years before for safety reasons. Having been built on the ditch outside the City Wall and on an area that had once been marshland, it had no foundations. The building work had been rushed and poor quality materials used. It was literally coming apart at the seams.

It was moved to a new building at St George's Fields in Southwark. The marshy common land known as Saint George's fields spread north and south of what was then Lambeth Road and is now St George's Road. Moving into an area filled with prisons such as the Marshalsea⁵ and the Clink, Bedlam seemed to have come home.

Built between 1812-15, the new building was just as impressive as the old one. It opened with space for 200 patients, although only 122 moved in when it opened. It had the land to double the size of the hospital when more money became available. This was not until 1838, when work on extra wings for the criminally insane began. Other additions included a great dome to top off the existing portico that was decorated with Ionic columns. Grand on the outside, miserable on the inside, the interior still reflected the conditions of the old hospital. The sculptures that had decorated the old gate came with the inmates and were housed inside into the vestibule. Damaged and eroded by the weather, they were covered by a curtain.

Restraints and physical punishment stayed the norm - one patient remained chained for 14 years. By this time other institutions for the mentally ill had been established; private asylums were much in demand to avoid the public provision at Bedlam. Fortunately the hospital had its own water supply, so diseases such as cholera and dysentery did not add to the misery of the patients.

It was not until the mid-19th Century when the hospital came under regular government inspection that the treatment policy was changed. After two inquiries which were severely critical of the system, treatment rather than punishment began. Patients were given jobs and other things to occupy them, as well as medical treatment such as chloral hydrate (a sedative and sleep-inducing drug) and digitalis (treatment for heart conditions). Wards were furnished with more thought for comfort and keepers were gradually replaced by, or became, nurses. With these changes came the penniless middle-class lunatics; the common poor began to be cared for local asylums in their own counties.

In 1864 the criminal patients were moved to Broadmoor, which was built to replace the cramped and prison-like criminal wings at Bedlam. They were then demolished.

Bethlem Royal Hospital

In 1930 Bedlam moved again. London was becoming more and more unhealthy to live in, and Southwark was not considered socially acceptable for the educated ladies and gentlemen who were receiving treatment there. The governors and staff wanted 'light, air and space' with 'ultra modern' facilities.

In 1925 the governors bought an old country estate in Kent, and the planning and building began at once. Although the grounds are extensive, the buildings occupy only a small portion of the site. The rest remains farm and woodland, with plenty of wildlife and native plants. Opened in July, 1930 by Queen Mary, the occupants moved in during October that year.

In 1948 it finally severed all ties with Bridewell, was merged with Maudsley Hospital and was governed by the new National Health Service. It is now governed by the South London and Maudsley NHS Trust. It is the oldest psychiatric hospital in the world.

Fascinating Facts

• The word bedlam, used to describe a place of uproar and confusion, derives from the behaviour of the inmates in the early centuries.

• Patients who refused to swallow medication had their mouths opened with a specially designed metal key.

• Although most of the building was torn down when Bedlam was moved to the country, the central block of the Southwark site now houses the Imperial War Museum.

• Famous Bedlam residents include Richard Dadd, the artist who murdered his father, and Louis Wain, 'the man who drew cats'. The museum houses an extensive collection of art and crafts created by the patients.