[4] Bethlem was not initially intended as a hospital, in the clinical sense, much less as a specialist institution for the insane,[5] but as a centre for the collection of alms to support the Crusader Church and to link England to the Holy Land.

[6] 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.

[8] 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,[9] but its linkage to the Order of Bethlehem increasingly unravelled, putting its purpose and patronage in doubt.

[15] 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.

[59] 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)[60] and a member of the medical department of the royal household,[n 1] he was clearly of higher social status than his city-appointed predecessors (his father was a noted preacher, and his elder brother Thomas was created a baronet).

[n 4][72] 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.

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.

[79] 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.

[81] 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,[82] 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.

[99] 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.

[101] Such was the violence of the standard medical course, "involving voiding of the bowels, vomiting, scarification, sores and bruises,"[102] that patients were regularly discharged or refused admission if they were deemed unfit to survive the physical onslaught.

[102] The reigning medical ethos was the subject of public debate in the mid-eighteenth century when the Paper War of 1752–1753 erupted between John Monro and his rival William Battie, physician to the reformist St Luke's Asylum of London, founded in 1751.

[104] 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.

[108] 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.

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.

[129] 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.

[158] While a substantial proportion of such monies undoubtedly found their way into the hands of staff rather than the hospital poors' box,[n 17] Bethlem profited considerably from such charity, collecting on average between £300 and £350 annually from the 1720s until the curtailment of visiting in 1770.

[167] Curiosity about Bethlem's attractions, its "remarkable characters",[168] including figures such as Nathaniel Lee, the dramatist, and Oliver Cromwell's porter, Daniel,[n 18][170] was, at least until the end of the eighteenth-century, quite a respectable motive for visiting.

[158] 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.

[177] 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.

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.

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.

[191] 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".

[192] 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".

[198] 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.

[204] 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[n 21] and the thuggish nature of the asylum keepers.

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.

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.

In the men's wing, in the side room, six patients were chained close to the wall by the right arm as well as by the right leg ... Their nakedness and their mode of confinement gave the room the complete appearance of a dog kennel.Whilst [we were] looking at some of the bed-lying patients, a man arose naked from his bed, and had deliberately and quietly walked a few paces from his cell door along the gallery; he was instantly seized by the keepers, thrown in his bed, and leg-locked, without enquiry or observation: chains were universally substituted for the straitwaistcoatPrimary sources Secondary sources