What is Bethlem Royal Hospital?

Introduction

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.

Bethlem Royal Hospital Main Building.

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 Partners academic 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 a short distance to Moorfields in 1676, and then to St George’s Fields in Southwark in 1815, before moving to its current location in Monks Orchard in 1930.

The word “bedlam”, meaning uproar and confusion, is derived from the hospital’s 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.

1247 to 1633

Foundation

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 (1327-1377), 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

It is unknown when Bethlem, or Bedlam, 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.

Management

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.

Helkiah Crooke

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, 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, the last of the old-style keepers, along with his steward on 24 May 1633.

Conditions

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”. 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, 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”, 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.

1634 to 1791

Medical Regime

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 a 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.

The medical regime, being married to a depletive or antiphlogistic physic until the early nineteenth century, had a reputation for conservatism that was neither unearned nor, given the questionable benefit of some therapeutic innovations, 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, oriented 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, 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 façade. 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, 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”.

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 1725-1739 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.

It was London’s first major charitable building since the Savoy Hospital (1505-1517) 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.

Public Visiting

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. 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. 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. 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.

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 – 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, 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, 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, including being poked with sticks by visitors or otherwise taunted, given drinks and physically assaulted or sexually harassed, but its curtailment removed an important element of public oversight. In the period thereafter, with staff practices less open to public scrutiny, the worst patient abuses occurred.

1791 to 1900

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: 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. Holland’s successor to the post of Surveyor, James Lewis, was charged in 1799 with compiling a new report on the building’s condition. Presenting his findings to the Governors the following year, Lewis declared the building “incurable” and opined that further investment in anything other than essential repairs would be financially imprudent. He was, however, careful to insulate the Governors from any criticism concerning Bethlem’s physical dilapidation as, rather than decrying either Hooke’s design or the structural impact of additions, he castigated the slipshod nature of its rapid construction. Lewis observed that it had been partly built on land called “the Town Ditch”, a receptacle for rubbish, and this provided little support for a building whose span extended to over 500 feet (150 m). He also noted that the brickwork was not on any foundation but laid “on the surface of the soil, a few inches below the present floor”, while the walls, overburdened by the weight of the roofs, were “neither sound, upright nor level”.

Bethlem Rebuilt at St George’s Fields

While the logic of Lewis’s report was clear, the Court of Governors, facing continuing financial difficulties, only resolved in 1803 behind the project of rebuilding on a new site, and a fund-raising drive was initiated in 1804. In the interim, attempts were made to rehouse patients at local hospitals and admissions to Bethlem, sections of which were deemed uninhabitable, were significantly curtailed such that the patient population fell from 266 in 1800 to 119 in 1814. Financial obstacles to the proposed move remained significant. A national press campaign to solicit donations from the public was launched in 1805. Parliament was successfully lobbied to provide £10,000 for the fund under an agreement whereby the Bethlem Governors would provide permanent accommodation for any lunatic soldiers or sailors of the French Wars. Early interest in relocating the hospital to a site at Gossey Fields had to be abandoned due to financial constraints and stipulations in the lease for Moorfields that precluded its resale. Instead, the Governors engaged in protracted negotiations with the City to swap the Moorfields site for another municipally owned location at St. George’s Fields in Southwark, south of the Thames. The swap was concluded in 1810 and provided the Governors with a 12 acres (4.9 ha; 0.019 sq mi) site in a swamp-like, impoverished, highly populated, and industrialised area where the Dog and Duck tavern and St George’s Spa had been.

A competition was held to design the new hospital at Southwark in which the noted Bethlem patient James Tilly Matthews was an unsuccessful entrant. The Governors elected to give James Lewis the task. Incorporating the best elements from the three winning competition designs, he produced a building in the neoclassical style that, while drawing heavily on Hooke’s original plan, eschewed the ornament of its predecessor. Completed after three years in 1815, it was constructed during the first wave of county asylum building in England under the County Asylum Act (“Wynn’s Act”) of 1808.] Extending to 580 feet (180 m) in length, the new hospital, which ran alongside the Lambeth Road, consisted of a central block with two wings of three storeys on either side.[186] Female patients occupied the west wing and males the east; as at Moorfields, the cells were located off galleries that traversed each wing. Each gallery contained only one toilet, a sink and cold baths. Incontinent patients were kept on beds of straw in cells in the basement gallery; this space also contained rooms with fireplaces for attendants. A wing for the criminally insane – a legal category newly minted in the wake of the trial of a delusional James Hadfield for attempted regicide – was completed in 1816. This addition, which housed 45 men and 15 women, was wholly financed by the state.

The first 122 patients arrived in August 1815 having been transported to their new residence by a convoy of Hackney coaches. Problems with the building were soon noted as the steam heating did not function properly, the basement galleries were damp and the windows of the upper storeys were unglazed “so that the sleeping cells were either exposed to the full blast of cold air or were completely darkened”. Although glass was placed in the windows in 1816, the Governors initially supported their decision to leave them unglazed on the basis that it provided ventilation and so prevented the build-up of “the disagreable effluvias peculiar to all madhouses”. Faced with increased admissions and overcrowding, new buildings, designed by the architect Sydney Smirke, were added from the 1830s. The wing for criminal lunatics was increased to accommodate a further 30 men while additions to the east and west wings, extending the building’s façade, provided space for an additional 166 inmates and a dome was added to the hospital chapel. At the end of this period of expansion Bethlem had a capacity for 364 patients.

1815-1816 Parliamentary Inquiry

The late eighteenth and early nineteenth centuries are typically seen as decisive in the emergence of new attitudes towards the management and treatment of the insane. Increasingly, the emphasis shifted from the external control of the mad through physical restraint and coercion to their moral management whereby self-discipline would be inculcated through a system of reward and punishment. For proponents of lunacy reform, the Quaker-run York Retreat, founded in 1796, functioned as an exemplar of this new approach that would seek to re-socialise and re-educate the mad. Bethlem, embroiled in scandal from 1814 over its inmate conditions, would come to symbolise its antithesis.

Through newspaper reports initially and then evidence given to the 1815 Parliamentary Committee on Madhouses, the state of inmate care in Bethlem was chiefly publicised by Edward Wakefield, a Quaker land agent and leading advocate of lunacy reform. He visited Bethlem several times during the late spring and early summer of 1814. His inspections were of the old hospital at the Moorfields site, which was then in a state of disrepair; much of it was uninhabitable and the patient population had been significantly reduced. Contrary to the tenets of moral treatment, Wakefield found that the patients in the galleries were not classified in any logical manner as both highly disturbed and quiescent patients were mixed together indiscriminately. Later, when reporting on the chained and naked state of many patients, Wakefield sought to describe their conditions in such a way as to maximise the horror of the scene while decrying the apparently bestial treatment of inmates and the thuggish nature of the asylum keepers. Wakefield’s account focused on one patient in particular, James Norris, an American marine reported to be 55 years of age who had been detained in Bethlem since 01 February 1800. Housed in the incurable wing of the hospital, Norris had been continuously restrained for about a decade in a harness apparatus which severely restricted his movement. Wakefield stated that:

… a stout iron ring was riveted about his neck, from which a short chain passed to a ring made to slide upwards and downwards on an upright massive iron bar, more than six feet high, inserted into the wall. Round his body a strong iron bar about two inches wide was riveted; on each side of the bar was a circular projection, which being fashioned to and enclosing each of his arms, pinioned them close to his sides. This waist bar was secured by two similar iron bars which, passing over his shoulders, were riveted to the waist both before and behind. The iron ring about his neck was connected to the bars on his shoulders by a double link. From each of these bars another short chain passed to the ring on the upright bar … He had remained thus encaged and chained more than twelve years.

Wakefield’s revelations, combined with earlier reports about patient maltreatment at the York Asylum, helped to prompt a renewed campaign for national lunacy reform and the establishment of an 1815 House of Commons Select Committee on Madhouses, which examined the conditions under which the insane were confined in county asylums, private madhouses, charitable asylums and in the lunatic wards of Poor-Law workhouses.

In June 1816 Thomas Monro, Principal Physician, resigned as a result of scandal when he was accused of ‘wanting in humanity’ towards his patients.

Dr T.B. Hyslop came to the hospital in 1888 and rose to be physician in charge, bringing the hospital into the 20th century and retiring in 1911.

1930 to the Present

In 1930, the hospital moved to the suburbs of Croydon, on the site of Monks Orchard House between Eden Park, Beckenham, West Wickham and Shirley. The old hospital and its grounds were bought by Lord Rothermere and presented to the London County Council for use as a park; the central part of the building was retained and became home to the Imperial War Museum in 1936. The hospital was absorbed into the National Health Service in 1948.

750th Anniversary and “Reclaim Bedlam” Campaign

In 1997 the hospital started planning celebrations of its 750th anniversary. The service user’s 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 the current practices of mental health professionals towards those in need of care. A campaign called “Reclaim Bedlam” was launched by Pete Shaughnessy, 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. The historian Roy Porter called the Bethlem Hospital “a symbol for man’s inhumanity to man, for callousness and cruelty.”

Recent Developments

In 1997, the Bethlem Gallery was established to showcase the work of artists that have experienced mental distress.

In 1999, Bethlem Royal Hospital became part of the South London and Maudsley NHS Foundation Trust (“SLaM”), along with the Maudsley Hospital in Camberwell, and the merger of mental health services in Lambeth and Lewisham took place.

In 2001, SLaM sought planning permission for an expanded Medium Secure Unit and extensive 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 that most patients could be from inner London areas and were, therefore, not locals and that drug use was rife in and around the hospital. Bromley Council refused the application, with Croydon Council also objecting. However the Office of the Deputy Prime Minister overturned the decision in 2003 and development started. The 89-bed, £33.5m unit (River House) opened in February 2008. It is the most significant development on the site since the hospital opened in 1930.

Fatal Restraints

Olaseni Lewis (known as Seni; aged 23) died in 2010 at Bethlem Royal Hospital after police subjected him to prolonged restraint of a type known to be dangerous. Neither police nor medical staff intervened when Lewis became unresponsive. At coroner’s inquest, the jury found many failures by both police and medical staff which played a part in Lewis’s death. They said “The excessive force, pain compliance techniques and multiple mechanical restraints were disproportionate and unreasonable. On the balance of probability, this contributed to the cause of death.” Ajibola Lewis, Olaseni Lewis’s mother, claimed a nurse at Maudsley hospital where Lewis had been earlier warned against allowing his transfer to Bethlem. “She said to me, ‘Look, don’t let him go to the Bethlem, don’t let him go there’,” his mother said. A doctor later persuaded her to take her son to Bethlem hospital. She was concerned about the conditions there. “It was a mess,” she told the court, “It was very confused, a lot of activity, a lot of shouting. I was not happy; I was confused.”

Police were trained to view Lewis’s behaviour as a medical emergency, but the jury found police failed to act on this. The jury found that “The police failed to follow their training, which requires them to place an unresponsive person into the recovery position and if necessary administer life support. On the balance of probability this also contributed to the cause of death.” A doctor did not act when Lewis became unresponsive while his heart rate dramatically slowed.

The Independent Police Complaints Commission first cleared officers over the death, but following pressure from the family, they scrapped the conclusions and started a new inquiry. The IPCC was planning disciplinary action against some of the police officers involved. Deborah Coles of the charity Inquest, who has supported the Lewis family throughout their campaign, said the jury had reached the most damning possible conclusions on the actions of police and medics. “This was a most horrific death. Eleven police officers were involved in holding down a terrified young man until his complete collapse, legs and hands bound in limb restraints, while mental health staff stood by. Officers knew the dangers of this restraint but chose to go against clear, unequivocal training. Evidence heard at this inquest begs the question of how racial stereotyping informed Seni’s brutal treatment.”

A disciplinary hearing conducted by the Metropolitan Police found the officers had not committed misconduct. The hearing was criticised by the family because it was held behind closed doors with neither press nor public scrutiny.

In 2014, Chris Brennan (aged 15) died of asphyxiation while at Bethlem hospital after repeated self-harming. The coroner found lack of proper risk assessment and lack of a care plan contributed to his death. The hospital claimed staffing problems and low morale were factors. Lessons were learned and the adolescent unit where Brennan died was assessed as good in 2016.

In November 2017, a bill was debated in the House of Commons that would require psychiatric hospitals to give more detailed information about how and when restraints are used. This bill is referred to as “Seni’s law”. In November 2018, the bill received Royal Assent as the Mental Health Units (Use of Force) Act 2018.

Facilities

The hospital includes specialist services such as the National Psychosis Unit.

Other services include the Bethlem Adolescent Unit, which provides care and treatment for young people aged 12-18 from across the UK.

The hospital has an occupational therapy department, which has its own art gallery, the Bethlem Gallery, displaying work of current and former patients.

The Bethlem Museum of the Mind features exhibits about the history of Bethlem Royal Hospital and the history of mental healthcare and treatment. It features a permanent collection of art created by some of its patients, as well as changing exhibitions.

Media

In 2013, the South London and Maudsley NHS Foundation Trust (SLaM) took part in a Channel 4 observational documentary, Bedlam. Staff and patients spent two years working with television company The Garden Productions. The four-part series started on 31 October.

The first programme, Anxiety, followed patients through the 18-bed Anxiety and Disorders Residential Unit. This national unit treats the most anxious people in the country – the top 1% – and claims a success rate of three in four patients.

The next programme was called Crisis; cameras were allowed in Lambeth Hospital’s Triage ward for the first time. In a postcode with the highest rates of psychosis in Europe, this is the Accident and Emergency of mental health, where patients are at their most unwell.

The third programme, Psychosis, films a community mental health team. South London and Maudsley NHS Foundation Trust provides support for more than 35,000 people with mental health problems.

The final programme, Breakdown, focuses on older adults, including the inpatient ward for people over 65 with mental health problems at Maudsley Hospital.

Notable Patients

  • Richard Dadd – artist.
  • John Frith – would-be assailant of King George III.
  • Mary Frith – also known as “Moll Cutpurse” or “The Roaring Girl”, released from Bedlam in 1644 according to Bridewell records.
  • Daniel M’Naghten – catalyst for the creation of the M’Naghten Rules (criteria for the defence of insanity in the British legal system) after the shooting of Edward Drummond.
  • Jonathan Martin – set fire to York Minster.
  • William Chester Minor – surgeon who was committed for murder; best known for being one of the largest contributors to the Oxford English Dictionary.
  • James Hadfield – would-be assassin of King George III.
  • Margaret Nicholson – would-be assassin of King George III.
  • Edward Oxford – tried for high treason after the attempted assassination of Queen Victoria and Prince Albert.
  • Augustus Welby Northmore Pugin (1812-1852) – English architect, best known for his work on the Houses of Parliament as well as many churches; in the last year of his life he suffered a breakdown, possibly due to hyperthyroidism, and was for a short period confined in Bethlem.
  • Hannah Snell (1723-1792) – a woman cross-dressing as a male soldier; spent the last six months of her life in Bethlem.
  • Bannister Truelock – conspirator who plotted to assassinate George III.
  • Louis Wain – artist.

What is the Eastern State Hospital (Virginia)?

Introduction

Eastern State Hospital is a psychiatric hospital in Williamsburg, Virginia. Built in 1773, it was the first public facility in the present-day United States constructed solely for the care and treatment of the mentally ill. The original building had burned but was reconstructed in 1985.

Francis Fauquier and the Enlightenment

Eastern State Hospital traces its foundation to a speech by Francis Fauquier, Royal Governor of the colony of Virginia, on 06 November 1766. At the House of Burgesses’ first meeting since the Stamp Act and Virginia Resolves, Fauquier primarily discussed the relationship between the Mother Country and these colonists, and expressed optimism for their future. His speech also unexpectedly addressed the mentally ill, as follows:

“It is expedient I should also recommend to your Consideration and Humanity a poor unhappy set of People who are deprived of their senses and wander about the Country, terrifying the Rest of their fellow creatures. A legal Confinement, and proper Provision, ought to be appointed for these miserable Objects, who cannot help themselves. Every civilized Country has an Hospital for these People, where they are confined, maintained and attended by able Physicians, to endeavor to restore to them their lost reason.”

About a year later, on 11 April 1767, Governor Fauquier addressed the same issue before the next House of Burgesses, thus:

“There is a subject which gives me concern, on which I shall particularly address myself to you, as it is your peculiar province to provide means for the subsistence of the poor of any kind. The subject I mean is the case of the poor lunatics. I find on your journals that it was Resolved, That an hospital be erected for the reception of persons who are so unhappy as to be deprived of their reason; And that it was Ordered, that the Committee of Propositions and Grievances do prepare and bring in a bill pursuant to the above resolution. But I do not find that any thing more was done in it. It was a measure which I think could offend no party, and which I was in hopes humanity would have dictated to every man, as soon as he was made acquainted with the call for it. It also concerns me much on another account; for as the case now stands, I am as it were compelled to the daily commission of an illegal act, by confining without my authority, a poor lunatic, who, if set at liberty, would be mischievous to society; and I would choose to be bound by, and observant of, the laws of the country. As I think this is a point of some importance to the ease and comfort of the whole community, as well as a point of charity to the unhappy objects, I shall again recommend it to you at your next meeting; when I hope, after mature reflection, it will be found to be more worth your attention than it has been in this.”

Governor Fauquier’s benevolent and bold expressions did eventually lead to the establishment of the Eastern State Hospital, although he died 03 March 1768, before it was built. His compassion and humanitarian care for those who needed it the most, made it easier for his ideas to be developed and a facility built.

Fauquier’s concern probably rested in Enlightenment principles, which were so widespread throughout the time. The 18th century was a time for rejecting superstitions and religions, and substituting science and logical reasoning. The philosophers David Hume and Voltaire were studying and investigating the worth of human life, which would ultimately alter perceptions of the mentally ill. During this time in London, insane people were viewed and used for as entertainment and comical relief. The Bethlehem Royal Hospital (sometimes called Bedlam) attracted many tourists and even held frequent parades of inmates. Enlightenment attitudes encouraged more sensitivity towards the mentally ill, rather than treating them as outcasts and fools. Some started to believe that being mentally ill was, in fact, an illness of the mind, much like a physical disease or sickness, and that these mental illnesses were also treatable.

Before Governor Fauquier’s speeches, a person who was mentally ill was not diagnosed by a doctor, but rather judged by 12 citizens, much like a jury, to be either a criminal, lunatic or Idiot. Most classified as lunatic were placed in the Public Gaol in Williamsburg. Taxpayers probably appreciated the hospital idea only if they had a family member or close friend who was mentally ill. The only hospital where mentally ill patients were sometimes taken before Eastern State Hospital was built, was the Pennsylvania Hospital, a Quaker institution in Philadelphia. Until a campaign by Benjamin Rush in 1792 to establish a separate treatment wing, mentally ill patients were kept in the basement and out of the way of regular patients who needed medical assistance.

Percival Goodhouse was is thought to be one of the first patients admitted to the Eastern State Hospital after its opening on 12 October 1773.

Civil War and Decline

In 1841, Dr. John Galt was appointed superintendent of the hospital, with roughly 125 patients (then called “inmates”) at the time. Dr. Galt introduced Moral treatment practices, a school of thought which viewed those with mental illness as deserving of respect and dignity rather than punishment for their behaviour. Galt provided his patients with talk therapy and occupational therapy, and argued for in-house research. He decreased the use of physical restraints, even going an entire year without using them, relying instead on calming drugs (including laudanum), and also proposed deinstitutionalizing patients in favour of community-based care, though this proposal was repeatedly rejected. As the head of the hospital, Galt was successful in pressing for admission for enslaved people with mental illness, and taught the enslaved people owned by the hospital to provide talk therapy alongside nurses and aides. Although he claimed to treat patients equally regardless of their race, Galt did not publish racial breakdowns of his patients.

When the Civil War came to Williamsburg, the hospital found itself alternately on one side of the lines and then the other. On 06 May 1862, Union troops captured the asylum. Two weeks later, on 17 or 18 May, Dr. Galt died of an overdose of laudanum, though it is unclear whether this was intentional or accidental. When the hospital was captured, Union soldiers found that the 252 patients had been locked in without food or supplies by the fleeing white employees. Somersett Moore was the only non-African American employee to return following the capture, and he gave the keys to release the patients to the occupying men.

In the following decades, the increasingly crowded hospital saw a regression in methodology as science was increasingly viewed as an ineffective means of dealing with mental illness. During this era of custodial care, the goal became not to cure patients, but to provide a comfortable environment for them, separate from society. On 07 June 1885, the original 1773 hospital burned to the ground due to a fire that had started in the building’s newly added electrical wiring, a consequence of the great expansion of facilities at this time.

Restoration

By 1935 Eastern State Hospital housed some 2,000 patients with no more land for expansion. The restoration of Colonial Williamsburg and development of the Williamsburg Inn resulted in the facility being at the centre of a thriving tourist trade. The hospital’s location and space issues made a move necessary. Between 1937 and 1968, all of Eastern State’s patients were moved to a new facility on the outskirts of Williamsburg, Virginia, where it continues to operate today.

In 1985, the original hospital was reconstructed on its excavated foundations by the Colonial Williamsburg Foundation.

On This Day … 14 August

People (Births)

  • 1840 – Richard von Krafft-Ebing, German-Austrian psychologist and author (d. 1902).

Richard von Krafft-Ebing

Richard Freiherr von Krafft-Ebing (full name Richard Fridolin Joseph Freiherr Krafft von Festenberg auf Frohnberg, genannt von Ebing; 1840-1902) was an Austro-German psychiatrist and author of the foundational work Psychopathia Sexualis (1886).

Life

Krafft-Ebing was born in 1840 in Mannheim, Germany, studied medicine at the University of Heidelberg, where he specialized in psychiatry. He later practiced in psychiatric asylums. After leaving his work in asylums, he pursued a career in psychiatry, forensics, and hypnosis.

He died in Graz in 1902. He was recognized as an authority on deviant sexual behaviour and its medicolegal aspects.

Principal Work

Krafft-Ebing’s principal work is Psychopathia Sexualis: eine Klinisch-Forensische Studie (Sexual Psychopathy: A Clinical-Forensic Study), which was first published in 1886 and expanded in subsequent editions. The last edition from the hand of the author (the twelfth) contained a total of 238 case histories of human sexual behaviour.

Translations of various editions of this book introduced to English such terms as “sadist” (derived from the brutal sexual practices depicted in the novels of the Marquis de Sade), “masochist”, (derived from the name of Leopold von Sacher-Masoch), “homosexuality”, “bisexuality”, “necrophilia”, and “anilingus”.

Psychopathia Sexualis is a forensic reference book for psychiatrists, physicians, and judges. Written in an academic style, its introduction noted that, to discourage lay readers, the author had deliberately chosen a scientific term for the title of the book and that he had written parts of it in Latin for the same purpose.

Psychopathia Sexualis was one of the first books about sexual practices that studied homosexuality/bisexuality. It proposed consideration of the mental state of sex criminals in legal judgements of their crimes. During its time, it became the leading medico-legal textual authority on sexual pathology.

The twelfth and final edition of Psychopathia Sexualis presented four categories of what Krafft-Ebing called “cerebral neuroses”:

  • Paradoxia, sexual excitement occurring independently of the period of the physiological processes in the generative organs.
  • Anaesthesia, absence of sexual instinct.
  • Hyperaesthesia, increased desire, satyriasis.
  • Paraesthesia, perversion of the sexual instinct, i.e., excitability of the sexual functions to inadequate stimuli.

The term “hetero-sexual” is used, but not in chapter or section headings. The term “bi-sexuality” appears twice in the 7th edition, and more frequently in the 12th.

There is no mention of sexual activity with children in Chapter III, General Pathology, where the “cerebral neuroses” (including sexuality the paraesthesias) are covered. Various sexual acts with children are mentioned in Chapter IV, Special Pathology, but always in the context of specific mental disorders, such as dementia, epilepsy, and paranoia, never as resulting from its own disorder. However, Chapter V on sexual crimes has a section on sexual crimes with children. This section is brief in the 7th edition, but is expanded in the 12th to cover Non-Psychopathological Cases and Psychopathological Cases, in which latter subsection the term paedophilia erotica is used.

Krafft-Ebing considered procreation the purpose of sexual desire and that any form of recreational sex was a perversion of the sex drive. “With opportunity for the natural satisfaction of the sexual instinct, every expression of it that does not correspond with the purpose of nature—i.e., propagation,—must be regarded as perverse.” Hence, he concluded that homosexuals suffered a degree of sexual perversion because homosexual practices could not result in procreation. In some cases, homosexual libido was classified as a moral vice induced by the early practice of masturbation. Krafft-Ebing proposed a theory of homosexuality as biologically anomalous and originating in the embryonic and fetal stages of gestation, which evolved into a “sexual inversion” of the brain. In 1901, in an article in the Jahrbuch für sexuelle Zwischenstufen (Yearbook for Intermediate Sexual Types), he changed the biological term from anomaly to differentiation.

Although the primary focus is on sexual behaviour in men, there are sections on Sadism in Woman, Masochism in Woman, and Lesbian Love. Several of the cases of sexual activity with children were committed by women.

Krafft-Ebing’s conclusions about homosexuality are now largely forgotten, partly because Sigmund Freud’s theories were more interesting to physicians (who considered homosexuality to be a psychological problem) and partly because he incurred the enmity of the Austrian Catholic Church when he psychologically associated martyrdom (a desire for sanctity) with hysteria and masochism.

Works

A bibliography of von Krafft-Ebing’s writings can be found in A. Kreuter, Deutschsprachige Neurologen und Psychiater, München 1996, Band 2, pp.767-774.

  • Die Melancholie: Eine klinische Studie (1874) OCLC 180728044.
  • Grundzüge der Kriminalpsychologie für Juristen (second edition, 1882) OCLC 27460358.
  • Psychopathia Sexualis: eine Klinisch-Forensische Studie (first edition, 1886).
  • Die progressive allgemeine Paralyse (1894) OCLC 65980497.
  • Nervosität und neurasthenische Zustände (1895) OCLC 9633149.

Translations

  • Domino Falls translated and edited Psychopathia Sexualis:The Case Histories (1997) ISBN 978-0-9820464-7-0.
  • Charles Gilbert Chaddock translated four of Krafft-Ebing’s books into English:
    • An Experimental Study in the Domain of Hypnotism (New York and London, 1889).
    • Psychosis Menstrualis (1902).
    • Psychopathia Sexualis (twelfth edition, 1903).
    • Text Book of Insanity (1905).

What was the Erwadi Fire Incident (2001)?

Introduction

Erwadi fire incident is an accident that occurred on 06 August 2001, when 28 inmates of a faith-based mental asylum died in the fire. All these inmates were bound by chains at Moideen Badusha Mental Home in Erwadi Village in Tamil Nadu.

Large number of mental homes existed in Erwadi which was famous for the dargah of Quthbus Sultan Syed Ibrahim Shaheed Valiyullah, from Medina, Saudi Arabia who came to India to propagate Islam. Various people believe that holy water from the dargah and oil from the lamp burning there have the power to cure all illnesses, especially mental problems. The treatment also included frequent caning, beatings supposedly to “drive away the evil”. During the day, patients were tied to trees with thick ropes. At night, they were tied to their beds with iron chains. The patients awaited a divine command in their dreams to go back home. For the command to come, it was expected to take anything from two months to several years.

As the number of people seeking cure at dargah increased, homes were set up by individuals to reportedly take care of the patients. Most of these homes were set up by people who themselves had come to Erwadi seeking cure for their relatives.

The origins of the fire are unknown, but once it spread, there was little hope of saving most of the 45 inmates, who were chained to their beds in the ramshackle shelter in which they slept, though such shackling was against Indian law. Some inmates whose shackles were not as tight escaped, and five people were hospitalised for severe burns. The bodies of the dead were not identifiable.

Aftermath and Legacy

All mental homes of this type were closed on 13 August 2001, and more than 500 inmates were placed under government’s care. As per Supreme Court directions, a commission headed by N. Ramdas was set up to enquire into these deaths. The commission recommended that care of mentally ill people is to be improved, that anybody wishing to set up a mental home to acquire a license, and that all inmates be unchained.

In 2007, the owner of the Badsha Home for the Mentally Challenged, his wife and two relatives were sentenced to seven years imprisonment by a magistrate Court.

What was the Alleged Lunatics’ Friend Society?

Introduction

The Alleged Lunatics’ Friend Society was an advocacy group started by former asylum patients and their supporters in 19th-century Britain.

The Society campaigned for greater protection against wrongful confinement or cruel and improper treatment, and for reform of the lunacy laws. The Society is recognised today as a pioneer of the psychiatric survivors movement.

Background

There was concern in the United Kingdom in the 19th century about wrongful confinement in private madhouses, or asylums, and the mistreatment of patients, with tales of such abuses appearing in newspapers and magazines. The Madhouses Act 1774 had introduced a process of certification and a system for licensing and inspecting private madhouses, but had been ineffectual in reducing abuses or allaying public anxiety. Doctors in the 19th century were establishing themselves as arbiters of sanity but were reliant on subjective diagnoses and tended to equate insanity with eccentric or immoral behaviour. Public suspicion of their motives was also aroused by the profits that were made from private madhouses.

In 1838, Richard Paternoster, a former civil servant in the East India Company, was discharged after 41 days in a London madhouse (William Finch’s madhouse at Kensington House) having been detained following a disagreement with his father over money. Once free, he published, via his solicitors, a letter in The Times announcing his release. The letter was read by John Perceval, a son of prime minister Spencer Perceval. Perceval had spent three years in two of the most expensive private asylums in England, Brislington House in Bristol, run by Quaker Edward Long Fox, and Ticehurst Asylum in Sussex. His treatment had been brutal in the Brislington House; at Ticehurst the regime was more humane but his release had been delayed. Perceval contacted Paternoster and they were soon joined by several former patients and others:

  • William Bailey (an inventor and business man who had spent several years in madhouses);
  • Lewis Phillips (a glassware manufacturer who had been incarcerated in Thomas Warburton’s asylum);
  • John Parkin (a surgeon and former asylum patient);
  • Captain Richard Saumarez (whose father was the surgeon Richard Saumarez and whose two brothers were Chancery lunatics); and
  • Luke James Hansard (a philanthropist from the family of parliamentary printers).

This group was to form the core of the Alleged Lunatics’ Friend Society, although the Society would not be formally founded until 1845.

The group began their campaign by sending letters to the press, lobbying Members of Parliament (MPs) and government officials, and publishing pamphlets. John Perceval was elected to the Board of Poor Law Guardians in the parish of Kensington (although he was opposed to the New Poor Law) and was able to join magistrates on their visits of inspection to asylums. Richard Paternoster and Lewis Phillips brought court cases against the people who had incarcerated them. John Perceval published two books about his experience. Richard Paternoster wrote a series of articles for The Satirist magazine; these were published in 1841 as a book called The Madhouse System.

Formation

On 07 July 1845, Richard Paternoster, John Perceval and a number of others formed the Alleged Lunatics’ Friend Society. A pamphlet published in March the following year set out the aims with which the Society was founded:

At a meeting of several Gentlemen feeling deeply interested in behalf of their fellow-creatures, subjected to confinement as lunatic patients.

It was unanimously resolved:… That this Society is formed for the protection of the British subject from unjust confinement, on the grounds of mental derangement, and for the redress of persons so confined; also for the protection of all persons confined as lunatic patients from cruel and improper treatment. That this Society will receive applications from persons complaining of being unjustly treated, or from their friends, aid them in obtaining legal advice, and otherwise assist and afford them all proper protection.

That the Society will endeavour to procure a reform in the laws and treatment affecting the arrest, detention, and release of persons treated as of unsound mind…

John Perceval was listed as the honorary secretary, Luke James Hansard as treasurer, and Henry F. Richardson as honorary solicitor (Gilbert Bolden would later become the Society’s lawyer). Sixteen vice-presidents included both Tory and Liberal MPs; notable amongst them was the radical MP for Finsbury, Thomas Duncombe. New legislation, championed by Lord Ashley, was being introduced in parliament (the Lunacy Act 1845 and County Asylums Act 1845) and the creation of a formal society put the group in a better position to influence legislators. Four days after the Society was founded Thomas Duncombe spoke in the House of Commons, arguing for the postponement of new legislation pending a select committee of inquiry, and detailing a number of cases of wrongful confinement that had come to the Society’s attention. The legislation however went ahead, and the Society would have to wait until 1859 for an inquiry, although the Society’s supporters in parliament managed to secure a number of clauses to safeguard patients in the 1845 Act.

Although the Society had influential supporters such as Thomas Duncombe and Thomas Wakley (surgeon, radical MP for Finsbury and coroner), they did not gain widespread public support, probably never having more than sixty members and relying upon their own money for funding. A critical article in The Times of 1846 revealed the views and prejudices that the Society would have to counter:

“We can scarcely understand what such a society can propose to accomplish… There have been, no doubt, many cases of grievous oppression in which actual lunatics have been treated with cruelty, and those who are only alleged to be insane have been most unlawfully imprisoned… These, however, are evils to be checked by the law and not tampered with… by a body of private individuals… Some of the names we have seen announced suggest to us the possibility that the promoters of this scheme are not altogether free from motives of self-preservation. There is no objection to a set of gentlemen joining together in this manner for their own protection… but we think they should be satisfied to take care of themselves, without tendering their services to all who happen to be in the same position.”

John Perceval replied that the law afforded patients insufficient protection, and that the Society existed to give legal advice to individuals and draw the government’s attention to abuses as well as to encourage a more general discussion about the nature of insanity. In response to the article’s reference to the fact that several members of the Society had been patients in asylums, Perceval had this to say:

“I would remind the writer of that article, that men are worthy of confidence in the province of their own experience, and as the wisest and best of mankind hold the tenure of their health and reasoning faculties on the will of an Inscrutable Providence, and great wits to madness are allied, he will do well to consider that their fate may be his own, and to assist them in saving others in future from like injustice and cruelties, which the ignorance of the fondest relations may expose patients to, as well as the malice of their enemies.”

Social worker Nicholas Hervey, who has written the most extensive history of the Alleged Lunatics’ Friend Society, suggested that a number of factors may have contributed to the lack of wider public support, namely: alignment with radical political circles; endorsement of localist views, rather than support of the Lunacy Commission’s centralism; fearless exposure of upper-class sensibilities regarding privacy on matters concerning insanity, thus alienating wealthy potential supporters; attacks on the new forms of moral treatment in asylums (what John Perceval referred to as “repression by mildness and coaxing”).

Achievements

As well as lobbying parliament and campaigning through the media and public meetings, during the next twenty years or so the Society took up the cases of at least seventy patients, including he following examples:

  • Dr Edward Peithman was a German tutor who had been falsely imprisoned in Bethlem Hospital for fourteen years after he had tried to gain access to Prince Albert.
    • John Perceval took up his case and, after the Commissioners in Lunacy released him in February 1854, took him home with him to Herne Bay.
    • Dr Peithman promptly tried to speak to Prince Albert again, and was committed to Hanwell Asylum.
    • Again Perceval obtained his release, this time escorting him back to Germany.
  • Jane Bright was a member of a wealthy Leicestershire family, the Brights of Skeffington Hall.
    • She was seduced by a doctor who took most of her money and left her pregnant. Soon after the birth of her child, her brothers had her committed to Northampton Hospital.
    • On her release she enlisted Gilbert Bolden, the Society’s solicitor, to help her recover the remains of her fortune from her family.
  • Anne Tottenham was a Chancery lunatic who was removed from the garden of Effra Hall Asylum in Brixton by Admiral Saumarez.
    • This course of action was a rare exception to the Society’s more usual rule of following legal routes to secure the release of patients who had been wrongly confined.
  • Charles Verity was serving a two-year prison sentence when he was transferred to Northampton Hospital. He contacted John Perceval in 1857 about abuses in the refractory ward and the Society secured an inquiry.
    • The Commissioners in Lunacy reported in 1858 that charges of cruelty and ill-usage had been established against attendants and the culprits had been dismissed.

Not all the Society’s cases were successful:

  • James Hill (father of Octavia Hill) was a Wisbech corn merchant, banker, proprietor of the newspaper the Star of the East and founder of the United Advancement Society.
    • He had been declared bankrupt and had been committed to Kensington House Asylum.
    • After his release in 1851 the Society helped him sue the proprietor of Kensington House, Dr Francis Philps, for wrongful confinement but the case was unsuccessful.
  • Captain Arthur Childe, son of William Lacon Childe, MP, of Kinlet Hall in Shropshire, was a Chancery lunatic who had been found to be of unsound mind by a lunacy inquisition in 1854.
    • The Society applied on his behalf for another lunacy inquisition in 1855, claiming he was now of sound mind.
    • The Society was unsuccessful; the jury found Captain Childe to be of unsound mind and there was a quarrel about costs.

The Society was successful in drawing attention to abuses in a number of asylums. Notable amongst these was Bethlem Hospital, which, as a charitable institution, had been exempt from inspection under the 1845 Lunacy Act. The help of the Society was enlisted by patients and they persuaded the home secretary to allow the Commissioners in Lunacy to inspect the asylum. The Commissioner’s critical report in 1852 led to reforms. Together with magistrate Purnell Bransby Purnell, the Society ran a campaign to expose abuses in asylums in Gloucestershire.

One of the aims of the Society had always been to persuade parliament to conduct a committee of inquiry into the lunacy laws. This, after numerous petitions, they finally achieved in 1859. John Perceval, Admiral Saumarez, Gilbert Bolden and Anne Tottenham (a patient they had rescued from Effra House Asylum) gave evidence to the committee. The results were disappointing; the committee made a number of recommendations in their 1860 report but these were not put into place.

Legacy

The Society’s activities appear to have come to an end in 1860s. Admiral Saumarez died in 1866, and Gilbert Bolden had a young family and moved to Birmingham. In 1862 John Perceval wrote a letter to the magazine John Bull:

“I am sorry to say that this Society is so little supported, in spite of the great good it has done, and is in consequence so entirely disorganised, that I have repeatedly proposed to the committee that we should agree to a dissolution of it, and I have only consented to continue acting with them, and to lend my name to what is rather a myth than a reality, from their representation that however insignificant we were, we had still been able to effect a great deal of good, and might still be further successful…”

Nicholas Hervey concluded:

“The Society’s importance lies in the wide panorama of ideas it laid before Shaftesbury’s Board. Unrestrained by the traditions of bureaucratic office, it was free to explore a variety of alternatives for care of the insane, many of which were too visionary or impolitic to stand a chance of implementation. The difficulty it faced was the blinkered perspective of the Commission and of Shaftesbury in particular… it would not be an exaggeration of the Society’s worth to say that patients’ rights, asylum care, and medical accountability all suffered with its demise in the 1860s.”

The cause for lunacy law reform was taken up by Louisa Lowe’s Lunacy Law Reform Association, whose aims were very similar to those of the Alleged Lunatics’ Friend Society. In more recent years the Society has been recognised as a pioneer of advocacy and the psychiatric survivors movement.

What was the Kirkbride Plan?

Introduction

The Kirkbride Plan was a system of mental asylum design advocated by Philadelphia psychiatrist Thomas Story Kirkbride (1809-1883) in the mid-19th century.

The asylums built in the Kirkbride design, often referred to as Kirkbride Buildings (or simply Kirkbrides), were constructed during the mid-to-late-19th century in the United States. The structural features of the hospitals as designated by Dr. Kirkbride were contingent on his theories regarding the healing of the mentally ill, in which environment and exposure to natural light and air circulation were crucial. The hospitals built according to the Kirkbride Plan would adopt various architectural styles, but had in common the “bat wing” style floor plan, housing numerous wings that sprawl outward from the centre.

1848 lithograph of the Kirkbride design of the Trenton State Hospital.

The first hospital designed under the Kirkbride Plan was the Trenton State Hospital in Trenton, New Jersey, constructed in 1848. Throughout the remainder of the nineteenth century, numerous psychiatric hospitals were designed under the Kirkbride Plan across the United States. By the twentieth century, popularity of the design had waned, largely due to the economic pressures of maintaining the immense facilities, as well as contestation of Dr. Kirkbride’s theories amongst the medical community.

Numerous Kirkbride structures still exist today, though many have been demolished or partially-demolished and repurposed. At least 30 of the original Kirkbride buildings have been registered with the National Register of Historic Places in the United States, either directly or through their location on hospital campuses or in historic districts.

Background

Basis and Philosophy

The establishment of state mental hospitals in the US is partly due to reformer Dorothea Dix, who testified to the New Jersey legislature in 1844, vividly describing the state’s treatment of lunatics; they were being housed in county jails, private homes, and the basements of public buildings. Dix’s effort led to the construction of the New Jersey State Lunatic Asylum, the first complete asylum built on the Kirkbride Plan.

Thomas Story Kirkbride (1809-1883), a psychiatrist from Philadelphia, Pennsylvania, developed his requirements of asylum design based on a philosophy of Moral Treatment and environmental determinism. The typical floor plan, with long rambling wings arranged en echelon (staggered, so each connected wing received sunlight and fresh air), was meant to promote privacy and comfort for patients. The building form itself was meant to have a curative effect, “a special apparatus for the care of lunacy, [whose grounds should be] highly improved and tastefully ornamented.” The idea of institutionalisation was thus central to Kirkbride’s plan for effectively treating the insane.

Design and Architectural Features

The Kirkbride Plan asylums tended to be large, imposing institutional buildings, with the defining feature being their “narrow, stepped, linear building footprint” featuring staggered wings extending outward from the centre, resembling the wingspan of a bat. The standard number of wings for a Kirkbride Plan hospital was eight, with an accommodation of 250 patients. Kirkbride’s philosophy behind the staggered wings was to allow individual corridors open to sunlight and air ventilation through both ends, which he believed aided in healing the mentally ill. Each wing, according to Kirkbride’s original guidelines, would house a separate ward, which would contain its own “comfortably furnished” parlour, bathroom, clothes room, and infirmary, as well as a speaking tube and dumbwaiter to allow open communication and movement of materials between floors. The furthest wings from the centre complex of the building were reserved for the “most excitable,” or most physically dangerous and volatile patients. Patient rooms were suggested to be spacious, with ceilings “at least 12 feet (3.7 m) high,” but only large enough to room a single person. The centre complexes of the Kirkbride Plan buildings were designed to house administration, kitchens, public and reception areas, and apartments for the superintendent’s family. Architectural styles of Kirkbride Plan buildings varied depending on the appointed architect, and ranged from Richardsonian Romanesque to Neo-Gothic.

In addition to the intricate building design, Dr. Kirkbride also advocated the importance of “fertile” and spacious landscapes on which the hospitals would be built, with views that “if possible, should exhibit life in its active forms.” Kirkbride also suggested the hospital grounds be a minimum of 100 acres (40 ha) in size. The foliage and farmlands on the hospital grounds were sometimes maintained by patients as part of physical exercise and/or therapy. Over the course of the nineteenth and twentieth centuries, the campuses of these hospitals often evolved into sprawling, expansive grounds with numerous buildings.

Operations and Staffing

In his proposal, Dr. Kirkbride outlined specific guidelines as to how a Kirkbride Plan hospital should be staffed and operate on a daily basis. Dr. Kirkbride suggested a total of 71, all of whom were required to live within, or in the immediate vicinity of, the hospital. The superintending physician, or physician-in-chief, was required to live in the main hospital or in a building contiguous to it, while his family had the option of residing at the hospital or seeking private lodging. The staff was also to have a balanced gender distribution, with approximately 36 female and 35 male staff members.

Among the staff of a Kirkbride Plan hospital were the superintending physician, an assisting physician and nurses, supervisors and teachers of each sex, a chaplain, matron, and a nightwatchman. Kirkbride urged that at least two attendants be working in each ward at any given time, and stressed the importance of the superintendent’s “proper selection” of attendants, given the extent of their management responsibilities: “The duties of attendants, when faithfully performed, are often harassing, and in many wards, among excited patients, are peculiarly so. On this account pains should always be taken to give them a reasonable amount of relaxation and their position should, in every respect, be made as comfortable as possible.” For general labour at the hospital, he suggested that the able-minded patients help maintain the hospital grounds and assist in duties in their respective wards.

Dr. Kirkbride’s estimation of the number of staff as well as their respective compensations was outlined in an 1854 publication on the Kirkbride Plan design. He proposed a living wage for all employees of the hospital, noting that “although in a few institutions a liberal compensation is given, in many, the salaries are quite too low, and entirely inadequate to be depended on, to secure and retain the best kind of talent for the different positions. The services required about the insane, when faithfully performed, are peculiarly trying to the mental and physical powers of any individual, and ought to be liberally paid for.” Salary for the superintending physician according to the 1854 guideline was to be USD$1,500 (equivalent to $43,206 in 2020) if the physician’s family resided at the hospital, and $2,500 (equivalent to $72,009 in 2020) if they found lodging at a private residence. In addition to the medical staff and attendants, the Kirkbride Plan hospitals also employed labourers of various trades, including resident engineers, carpenters, cooks and dairymaids, gardeners, seamstresses, ironworkers, clothing launderers, and a carriage driver.

Decline and Phasing Out

By the late-nineteenth century, the Kirkbride design had begun to wane in popularity, largely because the hospitals (which were state-funded), had received significant budget cuts that rendered them difficult to maintain. General psychiatric and medical opinion of Kirkbride’s theories regarding the “curability” of mental illness were also questioned by the medical community.

Future

Status

A total of 73 known Kirkbride Plan hospitals were constructed throughout the United States between 1845 and 1910. As of 2016, approximately 33 of these identified Kirkbride Plan hospital buildings still exist in their original form to some degree: 24 have been preserved indicating that the building is still standing and still in use, at least, in part. 11 of the 24 preserved properties received secondary condition codes of deteriorating, vacant, partial demolition or a combination, while the remaining nine have been adaptively reused. Of the 40 hospital buildings that no longer exist (either via demolition or destruction from natural occurrences, such as earthquakes), 26 were demolished to be replaced with new facilities.

The highest concentrations of Kirkbride Plan hospitals were in the Northeast and Midwestern states. Fewer Kirkbride Plan hospitals were constructed on the West Coast: In California, the Napa State Hospital was a notable Kirkbride Plan hospital, though the original structure was severely damaged during the 1906 San Francisco earthquake, and was ultimately demolished. The two surviving Kirkbride structures on the West Coast are both located in the state of Oregon, at the Oregon State Hospital, and the Eastern Oregon State Hospital, the latter of which now houses the Eastern Oregon Correctional Institution. While the vast majority of Kirkbride hospitals were located in the United States, similar facilities were built in Canada, and the Callan Park Hospital for the Insane in Sydney, Australia (constructed in 1885) was also influenced by Kirkbride’s design.

Preservation Efforts

Due to their intricate architectural features and historical significance, Kirkbride Plan hospitals have attracted conservation efforts from local and national groups, and (as of 2016) approximately 30 of the buildings have been registered with National Register of Historic Places. Local conservation groups and historical societies have made attempts to save numerous Kirkbrides from demolition: The Danvers State Hospital in Danvers, Massachusetts is one example, in which a local historical society filed a lawsuit in 2005 to stall demolition of the building. The majority of the Danvers State Hospital was demolished in 2007 in spite of the lawsuit, with only the centre portion of the building receiving restoration and conversion into apartments. The Northampton State Hospital in Northampton, Massachusetts, was demolished in 2006.

Many of the surviving Kirkbride Plan buildings in the United States have undergone at least partial demolition and have been repurposed, often with the centre portions of the buildings being most commonly preserved. The centre complexes of the Hudson River State Hospital in Poughkeepsie, New York, and the Oregon State Hospital in Salem, Oregon, for example, have been retained in spite of the majority of the outermost wings being demolished. One such Kirkbride Plan facility that has survived in its entirety is the Trans-Allegheny Lunatic Asylum, though does not contemporarily function as an active hospital. As of 2017, Trans-Allegheny Lunatic Asylum has not undergone demolition.

Several facilities originally established as Kirkbride Plan hospitals are still active in the 21st century, though not all have retained the original Kirkbride buildings on their campuses. The Oregon State Hospital, the longest continuously-operated psychiatric hospital on the West Coast, retained the majority of its original Kirkbride building during a 2008 demolition, seismically retrofitting and repurposing it as a mental health museum in 2013.

In Popular Culture

Numerous Kirkbride Plan hospitals and buildings have been featured in the arts: the Danvers State Hospital in Danvers, Massachusetts was both the setting and primary filming location for the 2001 psychological horror film Session 9. It has also been suggested by historians as an inspiration on H.P. Lovecraft, and in turn an inspiration for the fictional setting Arkham Asylum in the various Batman series. The Oregon State Hospital was also featured as the primary filming location for the film One Flew Over the Cuckoo’s Nest (1975), and was also the setting of “Ward 81,” a 1976 series of photographs by photographer Mary Ellen Mark.

The Trans-Allegheny Lunatic Asylum in West Virginia was featured on the Travel Channel reality series Ghost Adventures.

What is a Psychiatric Hospital?

Introduction

Psychiatric hospitals, also known as mental health units or behavioural health units, are hospitals or wards specialising in the treatment of serious mental disorders, such as major depressive disorder, schizophrenia and bipolar disorder.

Psychiatric hospitals vary widely in their size and grading. Some hospitals may specialise only in short-term or outpatient therapy for low-risk patients. Others may specialise in the temporary or permanent containment of patients who need routine assistance, treatment, or a specialised and controlled environment due to a psychological disorder. Patients often choose voluntary commitment, but those whom psychiatrists believe to pose significant danger to themselves or others may be subject to involuntary commitment and involuntary treatment.

Psychiatric hospitals may also be called psychiatric wards/units (or “psych” wards/units) when they are a subunit of a regular hospital.

The modern psychiatric hospital evolved from and eventually replaced the older lunatic asylum. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint. With successive waves of reform, and the introduction of effective evidence-based treatments, most modern psychiatric hospitals emphasize treatment, and attempt where possible to help patients control their lives in the outside world, with the use of a combination of psychiatric drugs and psychotherapy. Exceptions include Japan, where many psychiatric hospitals still use physical restraints on patients, tying them to their beds for days or even months at a time, and India, where the use of restraint and seclusion is endemic.

Brief History

Modern psychiatric hospitals evolved from, and eventually replaced, the older lunatic asylum. Their development also entails the rise of organised institutional psychiatry.

Hospitals known as bimaristans were built in Persia (old name of Iran) beginning around the early 9th century, with the first in Baghdad under the leadership of the Abbasid Caliph Harun al-Rashid. While not devoted solely to patients with psychiatric disorders, they often contained wards for patients exhibiting mania or other psychological distress. Because of cultural taboos against refusing to care for one’s family members, mentally ill patients would be surrendered to a bimaristan only if the patient demonstrated violence, incurable chronic illness, or some other extremely debilitating ailment. Psychological wards were typically enclosed by iron bars owing to the aggression of some of the patients.

Western Europe would later adopt these views with the advances of physicians like Philippe Pinel at the Bicêtre Hospital in France and William Tuke at the York Retreat in England. They advocated the viewing of mental illness as a disorder that required compassionate treatment that would aid in the rehabilitation of the victim. In the Western world, the arrival of institutionalisation as a solution to the problem of madness was very much an advent of the nineteenth century. The first public mental asylums were established in Britain; the passing of the County Asylums Act 1808 empowered magistrates to build rate-supported asylums in every county to house the many ‘pauper lunatics’. Nine counties first applied, the first public asylum opening in 1812 in Nottinghamshire. In 1828, the newly appointed Commissioners in Lunacy were empowered to license and supervise private asylums. The Lunacy Act 1845 made the construction of asylums in every county compulsory with regular inspections on behalf of the Home Secretary, and required asylums to have written regulations and a resident physician.

At the beginning of the nineteenth century there were a few thousand “sick people” housed in a variety of disparate institutions throughout England, but by 1900 that figure had grown to about 100,000. This growth coincided with the growth of alienism, later known as psychiatry, as a medical specialism. The treatment of inmates in early lunatic asylums was sometimes very brutal and focused on containment and restraint.

In the late 19th and early 20th centuries, terms such as “madness”, “lunacy” or “insanity” – all of which assumed a unitary psychosis – were split into numerous “mental diseases”, of which catatonia, melancholia and dementia praecox (modern day schizophrenia) were the most common in psychiatric institutions.

In 1961 sociologist Erving Goffman described a theory of the “total institution” and the process by which it takes efforts to maintain predictable and regular behaviour on the part of both “guard” and “captor”, suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of “institutionalising” them. Asylums was a key text in the development of deinstitutionalisation.

With successive waves of reform and the introduction of effective evidence-based treatments, modern psychiatric hospitals provide a primary emphasis on treatment; and further, they attempt – where possible – to help patients control their own lives in the outside world with the use of a combination of psychiatric drugs and psychotherapy. These treatments can be involuntary. Involuntary treatments are among the many psychiatric practices which are questioned by the mental patient liberation movement. Most psychiatric hospitals now restrict internet access and any device that can take photos. In the US state of Connecticut, involuntary patients must be examined annually by a court-appointed psychiatrist. Patients may also apply for release at any time and receive a full hearing on the application.

Types

There are a number of different types of modern psychiatric hospitals, but all of them house people with mental illnesses of widely variable severity. In the United Kingdom, both crisis admissions and medium-term care are usually provided on acute admissions wards. Juvenile or youth wards in psychiatric hospitals or psychiatric wards are set aside for children or youth with mental illness. Long-term care facilities have the goal of treatment and rehabilitation within a short time-frame (two or three years). Another institution for the mentally ill is a community-based halfway house.

Crisis Stabilisation

The crisis stabilisation unit is effectively an emergency department for psychiatry, often treating suicidal, violent, or otherwise critical individuals.

Open Units

Open psychiatric units are not as secure as crisis stabilisation units. They are not used for acutely suicidal persons; instead, the focus in these units is to make life as normal as possible for patients while continuing treatment to the point where they can be discharged. However, patients are usually still not allowed to hold their own medications in their rooms because of the risk of an impulsive overdose. While some open units are physically unlocked, other open units still use locked entrances and exits, depending on the type of patients admitted.

Medium Term

Another type of psychiatric hospital is medium term, which provides care lasting several weeks. Most drugs used for psychiatric purposes take several weeks to take effect, and the main purpose of these hospitals is to monitor the patient for the first few weeks of therapy to ensure the treatment is effective.

Juvenile Wards

Juvenile wards are sections of psychiatric hospitals or psychiatric wards set aside for children or adolescents with mental illness. However, there are a number of institutions specialising only in the treatment of juveniles, particularly when dealing with drug abuse, self-harm, eating disorders, anxiety, depression or other mental illness.

Long-Term Care Facilities

In the UK, long-term care facilities are now being replaced with smaller secure units (some within the hospitals listed above). Modern buildings, modern security, and being locally situated to help with reintegration into society once medication has stabilised the condition are often features of such units. Examples of this include the Three Bridges Unit, in the grounds of St Bernard’s Hospital in West London and the John Munroe Hospital in Staffordshire. However, these modern units have the goal of treatment and rehabilitation to allow for transition back into society within a short time-frame (two or three years). However, not all patients’ treatment can meet this criterion, so the large hospitals mentioned above often retain this role.

These hospitals provide stabilisation and rehabilitation for those who are actively experiencing uncontrolled symptoms of mental disorders such as depression, bipolar disorders, eating disorders, and so on.

Halfway Houses

One type of institution for the mentally ill is a community-based halfway house. These facilities provide assisted living for an extended period of time for patients with mental illnesses, and they often aid in the transition to self-sufficiency. These institutions are considered to be one of the most important parts of a mental health system by many psychiatrists, although some localities lack sufficient funding.

Political Imprisonment

In some countries, the mental institution may be used for the incarceration of political prisoners as a form of punishment. A notable historical example was the use of punitive psychiatry in the Soviet Union and China.

Secure Units

In the UK, criminal courts or the Home Secretary can, under various sections of the Mental Health Act, order the admission of offenders for detainment in a psychiatric hospital, but the term “criminally insane” is no longer legally or medically recognised. Secure psychiatric units exist in all regions of the UK for this purpose; in addition, there are a few specialist hospitals which offer treatment with high levels of security. These facilities are divided into three main categories: High, Medium and Low Secure. Although the phrase “Maximum Secure” is often used in the media, there is no such classification. “Local Secure” is a common misnomer for Low Secure units, as patients are often detained there by local criminal courts for psychiatric assessment before sentencing.

Run by the National Health Service, these facilities which provide psychiatric assessments can also provide treatment and accommodation in a safe hospital environment which prevents absconding. Thus there is far less risk of patients harming themselves or others. The Central Mental Hospital in Dublin performs a similar function

Community Hospital Utilisation

Community hospitals across the United States regularly see mental health discharges. A study of community hospital discharge data from 2003-2011 showed that mental health hospitalisations were increasing for both children (patients aged 0-17 years) and adults (patients aged 18-64). Compared to other hospital utilisation, mental health discharges for children were the lowest while the most rapidly increasing hospitalisations were for adults under 64. Some units have been opened to provide “Therapeutically Enhanced Treatment” and so form a subcategory to the three main unit types.

The general public in the UK are familiar with the names of the High Secure Hospitals due to the frequency that they are mentioned in the news reports about the people who are sent there. Those in the UK include Ashworth Hospital in Merseyside, Broadmoor Hospital in Crowthorne, Berkshire, Rampton Secure Hospital in Retford, Nottinghamshire, and Scotland’s The State Hospital in Carstairs. Northern Ireland and the Isle of Man have their own Medium and Low Secure units but use the mainland facilities for High Secure, to which smaller Channel Islands also transfer their patients as Out of Area (Off-Island Placements) Referrals under the Mental Health Act 1983. Of the three unit types, Medium Secure is most prevalent throughout the UK. As of 2009, there were 27 women-only units in England alone. Irish units include those at prisons in Portlaise, Castelrea and Cork.

Criticism

Hungarian-born psychiatrist Thomas Szasz argued that psychiatric hospitals are like prisons unlike other kinds of hospitals, and that psychiatrists who coerce people (into treatment or involuntary commitment) function as judges and jailers, not physicians. Historian Michel Foucault is widely known for his comprehensive critique of the use and abuse of the mental hospital system in Madness and Civilisation. He argued that Tuke and Pinel’s asylum was a symbolic recreation of the condition of a child under a bourgeois family. It was a microcosm symbolizing the massive structures of bourgeois society and its values: relations of Family-Children (paternal authority), Fault–Punishment (immediate justice), Madness-Disorder (social and moral order).

Erving Goffman coined the term “Total Institution” for mental hospitals and similar places which took over and confined a person’s whole life. Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organisations, orphanages, and monasteries. In his book Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone “dull, harmless and inconspicuous”; in turn, it reinforces notions of chronicity in severe mental illness. The Rosenhan experiment of 1973 demonstrated the difficulty of distinguishing sane patients from insane patients.

Franco Basaglia, a leading psychiatrist who inspired and planned the psychiatric reform in Italy, also defined the mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents. Patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism. American psychiatrist Loren Mosher noticed that the psychiatric institution itself gave him master classes in the art of the “total institution”: labelling, unnecessary dependency, the induction and perpetuation of powerlessness, the degradation ceremony, authoritarianism, and the primacy of institutional needs over those of the persons whom it was ostensibly there to serve: the patients.

The anti-psychiatry movement coming to the fore in the 1960s has opposed many of the practices, conditions, or existence of mental hospitals; due to the extreme conditions in them. The psychiatric consumer/survivor movement has often objected to or campaigned against conditions in mental hospitals or their use, voluntarily or involuntarily. The mental patient liberation movement emphatically opposes involuntary treatment but it generally does not object to any psychiatric treatments that are consensual, provided that both parties can withdraw consent at any time.

What was the Board of Control for Lunacy and Mental Deficiency?

Introduction

The Board of Control for Lunacy and Mental Deficiency was a body overseeing the treatment of the mentally ill in England and Wales.

Background

It was created by the Mental Deficiency Act 1913 to replace the Commissioners in Lunacy, under the Home Office however it was independent in that it reported to the Lord Chancellor who had responsibility for investigating breaches of care and integrity. The Board was transferred to the Ministry of Health by the Ministry of Health Act 1919, and reorganised in 1930.

The Board consisted of a Chairman, two Senior Medical Commissioners, one Senior Legal Commissioner, six Commissioners including lawyers and doctors, six Inspectors and administrative staff. By law, at least one of these had to be a woman. The Commissioners of the Board travelled around England and Wales ensuring that those detained under mental health legislation were legally in custody, their care was appropriate, and moneys and other properties owned by patients were not being misused or stolen.

The Board was based in Northumberland Avenue, London, until 1939 when it was moved to Hobart House, Grosvenor Place.

Its functions were transferred to the Minister of Health by the National Health Service Act 1946.

Refer to Chronology of UK Mental Health Legislation, Commissioners in Lunacy, Commissioners in Lunacy for Scotland, and Commissioners in Lunacy for Ireland.

Members

Announcements of members were carried in the major national newspapers, including The Times.

  • On inception of the Board in 1913, the chairman was Sir William Byrne with Arthur Rotherham and Mary Dendy joining the ex officio members of the previous Lunacy Commissioners; C.H. Bond, Marriott Cooke, S. Coupland, B.T. Hodgson, S.J.F. MacLeod, F. Needham L.L. Shadwell, and A.H. Trevor.
  • In 1916, due to Sir William Byrne moving on, Marriott Cooke became acting chairman, and Robert Welsh Braithwaite was appointed to the board.
  • In 1921, Dr Ruth Darwin was appointed to the Board
  • In 1926 due to Robert Welsh Braithwaite’s retirement, Robert Cunyngham Brown was appointed a commissioner.
  • In 1928, due to the retirement of the chairman, Sir Frederick Willis, Laurence George Brock was appointed chairman.
  • In 1929, Dr Bedford Pierce was appointed a commissioner.
  • From the start of 1931, the Board was reconstituted, with a chairman and four other members.
    • L.G. Brock continued as chairman, with S.J. Fraser MacLeod, C. Hubert Bond, Arthur Rotherham, Ellen Pinsent.
  • William Rees-Thomas was appointed to the Board in 1931.
  • In 1931, Dr Isabel Wilson was appointed as a Commissioner, holding the position until 1948.
    • From 1949 to 1960 she was a Senior Commissioner, after which the Board was abolished and her position was changed to the Principal Medical Officer, Ministry of Health.

What was the Madhouses Act 1774?

Introduction

The Madhouses Act 1774 (14 Geo. 3 c.49) was an Act of the Parliament of Great Britain, which set out a legal framework for regulating “madhouses” (insane asylums).

Refer to Chronology of UK Mental Health Legislation.

Background

By the mid-eighteenth century, the common methods in the United Kingdom for dealing with the insane were either to keep them in the family home, or to put them in a “madhouse”, which was simply a private house whose proprietor was paid to detain their residents, and ran it as a commercial concern with little or no medical involvement. This led to two forms of abuse: the first was the keeping of “legitimately” insane people in atrocious conditions, and the second the detention of those who were falsely claimed to be insane – in effect, private imprisonment.

At this stage, there was no legislation to regulate the incarceration of anyone other than a Chancery lunatic or a pauper; there was only a vaguely defined common law power to “confine a person disordered in mind, who seems disposed to do mischief to himself, or another person”.

In a case in the mid-1750s, a woman came to suspect that her son-in-law had committed his wife to a madhouse in Hoxton; with the aid of a Justice of the Peace, she secured the release of her daughter after obtaining a confession from the husband. A similar case in 1762 saw a man trying to obtain the release of an acquaintance, one Mrs Hawley, who he suspected had been confined in a madhouse. His initial application to Lord Mansfield for a writ of habeas corpus was rejected because he was not a relative and so had no standing, but the judge arranged for a doctor to visit the house and speak to the woman. On his report, a writ was granted; she was brought before the court, and discharged.

A Select Committee of the House of Commons, chaired by Thomas Townshend, was set up in 1763 to study the problem of unlawful detention in private madhouses and focused on the Hawley case. It found that she had been committed to the house solely on the word of her husband, who paid two guineas (two pounds and two shillings) a month for her board, and that she was unable to leave the house or communicate with anybody outside it. The inmates were treated as insane, but the agent who arranged their entry freely admitted that he had not committed a single insane person to the house in the past six years. No-one who would pay was turned away, no physicians attended the inmates, and no register was kept of their names. This was, the Committee stated, a common situation; they noted that a number of similar cases could have been studied, and they recommended that some form of legislative intervention was needed. The Commons ordered the committee to prepare a bill, but it appears this was never brought in.

The issue was next addressed in 1773 when Townshend’s son, also named Thomas Townshend, sponsored a bill to regulate private madhouses; within seven miles of London, this would be the responsibility of the Royal College of Physicians; and outside that, magistrates in county towns. The bill passed the Commons but was rejected by the Lords.

Legislative History

In 1774, Thomas Townshend again reintroduced the Madhouses Bill. The Bill was presented to the Commons for its first reading on 02 March, and was amended in committee on 23 March. The Lords voted on it on 21 April, and made two amendments (the addition of s.19 and s.31) on 06 May, before the bill returned to the Commons on 10 May. The bill received Royal Assent on 20 May.

Provisions

The Act required that all madhouses be licensed by a committee of the Royal College of Physicians. This license would permit the holder to maintain a single house for accommodating lunatics, and would have to be renewed each year. All houses were to be inspected at least once per year by the committee, who would also keep a central register of all the confined lunatics in order that people could locate them; outside London, the task of inspecting them would fall to the local quarter sessions.

The penalty for “concealing or confining” more than one insane person without a license was set at £500, and every keeper of such a house who took in a patient without an order from a doctor was liable to a fine of £100.

Implementation

The Act took effect on 20 November 1774, six months after receiving Royal Assent, and was originally stated to remain in force for five years and then until the end of the next Parliamentary session.

  • It was continued for a further seven years by the Madhouse Continuation Act 1779 (19 Geo. 3 c.15);
  • Then continued indefinitely by the Madhouse Law Perpetuation Act 1786 (26 Geo. 3 c.91); and
  • It remained in force until repealed by the Madhouses Act 1828.