In Our Time - Bedlam

Episode Date: March 17, 2016

Melvyn Bragg and guests discuss the early years of Bedlam, the name commonly used for the London hospital of St Mary of Bethlehem outside Bishopsgate, described in 1450 by the Lord Mayor of London as a place where may "be found many men that be fallen out of their wit. And full honestly they be kept in that place; and some be restored onto their wit and health again. And some be abiding therein for ever." As Bethlem, or Bedlam, it became a tourist attraction in the 17th Century at its new site in Moorfields and, for its relatively small size, made a significant impression on public attitudes to mental illness. The illustration, above, is from the eighth and final part of Hogarth's 'A Rake's Progress' (1732-3), where Bedlam is the last stage in the decline and fall of a young spendthrift,Tom Rakewell.With Hilary Marland Professor of History at the University of WarwickJustin Champion Professor of the History of Early Modern Ideas at Royal Holloway, University of London and President of the Historical AssociationAndJonathan Andrews Reader in the History of Psychiatry at Newcastle UniversityProducer: Simon Tillotson.

Thank you for downloading this episode of In Our Time, for more details about in our time, and for our terms of use, please go to BBC.co.com.uk slash Radio 4. I hope you enjoy the programme. Hello, the Priory of St. Mary of Bethlehem was founded in London in 1247. At first it cared for the needy in general, but within 200 years it was known as the place to send people with mental illnesses, or lunatics, as they were called, supposedly disturbed by the moon. Bethlehem became Bethlehem, which slanged into Bethlehem.

Before modern reforms, that name was synonymous with chaos. Tourists could and did pay to see patients raving some in change. Peeps went, so did Dickens. When others were trying more enlightened psychiatric therapies, Bedlam kept the medieval ideas persisting with purges and vomiting to remove excesses of black bile. Conditions became notorious. Corruption led to a parliamentary inquiry in 1815,

which revealed that one patient had been held in a form of cage for almost a decade, as statutory. said his wrists were too slim for manacles. With me to discuss the early history of Bedlam are Hilbray Malin, Professor of History at the University of Warwick, Justin Champion, Professor of the History of Early Modern Ideas at Royal Holloway University of London and President of the Historical Association,

and Jonathan Andrews, reader in the history of psychiatry at Newcastle University. Justin Champion, what were the circumstances in which Bedlam was founded? Well, the founder was the sometime sheriff and alderman of the city of London. and Fitzmaury, who for various reasons to do with the papacy, the Crusades, wanted to create a priory, so an institution that would pray for him and also support the priors of St. Mary in Jerusalem. Jerusalem had fallen in 1157, and this was a project that would do God's work in one sense.

And that 1547 foundation laid the physical space for what eventually became Bedlam in the 17th century. You said 1540s, 1247, yes, absolutely. And the first instances of, let's call them, you know, in a non-politically correct way, lunatics, as the contemporaries did, was in the early 15th century, around 1403. I think there were six men who were perhaps, restrained by manacles,

stocks and chains. After the Reformation, of course... I'll come to the Reformation in a minute. So we've got this... Founding as Bethlehem, a place of mercy. Very few people are, about 20 and that sort of thing, caring for the poor, the church doing the best of Christian,

caring and looking after the poor, poor and ill. And that's how it's... How did Bethlehem turn into Bedlam, the word? Well, I think it's the way people contracted, Bedlam, Bethlehem, Bethlehem, Bethlehem, it just evolved. And of course, in the later period, the slang for Bethlehem was Bedlam.

And we need to separate the institution, the care, the charitable works that went on in that physical space from the idea of a bedlam. So we have that and it carries on, let us say, much the same from 1247 to 13, 47, 14, 17. And then we're coming to the Reformation. Now, you think that had a big change in the way people regarded. the way people took on their own anguish. Absolutely. I think that the Reformation has an impact in a sort of institutional sense

that Henry VIII is very keen to separate from the papacy. So charitable Catholic foundations like the Priory get a form of independence. And of course the institution was outside the city walls, so those jurisdictions were at play. But I think the anxieties that are especially brought on by Calvinist's sort of theory of predestination, are you saved or not?

Create mental instability, create this sort of powerful sense, am I saved or not? Can I read my own sort of salvation through the way I behave? So those sorts of inward-looking introspection from that radical Protestant theology create a very unhealthy environment for madness. How did that differ from the previous two centuries when we were very? under Roman Catholicism and one of the notions of the reasons for the word

lunatics was that they were possessed by the devil, it was diabolical. Absolutely. So how did these two things control? Well, I think that the Protestant culture still brought into diabolical possession and a sign of your damnation is that you've become possessed

by some wicked spirit. But the Catholic theology allowed the priests to take intervention methods, to to exercise, to sort of finesse the possession. And sometimes not very finessed. I mean, they'd drill a hole in somebody's head to let out the devil. Oh, absolutely.

I mean, the modern clinical trepanning that we know releases pressure on the brain was initially to create a space for devils to crawl out of. And then the slow turnover to the internalisation of madness. Yeah, I think... And what was called madness. What was called madness? And I certainly think by the end of the 16th, the start. of the 17th century, there is more understanding of how the mind works.

You know, the Robert Burton's anatomy of melancholy, the sorts of projects that investigate, what are dreams? Can we tell the difference between what's going on inside our brain and what's going on outside? There's an introspection that comes out of, I think, a lot of the Protestant theology. Look inside yourself. You know, madness is something, an imbalance of the mind. Hilary Marlin, the prevailing view of mental health was one prevailing view. It was that it relied on a balance of humours. If the balance of your humours is in the right proportion, one to the other, you were okay. What's the story behind that?

Yes, both the treatment of madness and understandings of madness for a considerable length of time from the classical period onwards through the medieval period and through the Reformation was based on partly on the principle of four humours. And these were vital fluids that were contained in the body, blood, phleg, yellow bile and black bile. And if they were in balance, then all was well, constitutionally, physically and mentally. However, if they went out of balance, this could cause either physical problems or indeed mental disorders. And a good example of that is accumulation of black bile. If there was too much black bile in the body, this could result in melancholia, it was believed.

And it would even result in a kind of discoloration. It was thought that the person would even look black, have black looks. But that is all theory, isn't it? I mean, there's no, they didn't bring any hard evidence to bear. No, it's theory. And it's come from Galen.

It's come from Galen. It came through the Doroma period. But it was a very, very durable theory. It was a principle that was used to sort of govern medical practice, really right through to the 18th century. I'm not disputing the durability of the thesis. It's just the fact that it rested on theory and was about 2,000 years old.

It did, yes, which is quite surprising. And it became, I mean, one of the things that Bethlehem is associated with, as you mentioned in introduction, is the use of bleeding and purges, which was used by other institutions, by other medical practitioners, certainly throughout the 17th and 18th century, when it starts to be brought into question, But it's this very persistence, this therapeutic conservatism, which I think is particularly associated with Bethelam. And these were the principles of treatment, and particularly spring bleeding.

It was thought appropriate to do this at certain times of the year. And of course this was also something that was shared in popular culture as well. There was a sort of broader understanding outside the medical realm that you had to sort of keep the body in balance. So it was something which had a broad acceptance also outside of Bethelam. And there was a sense that lunatics, if the word was used then, were like animals and they had to be flogged if they misbehaved. They had to be encouraged to vomit in case they'd eaten something that was causing this problem that their carer, someone else, who were the word looked after, this was in force too. That's right, and you're right about the word lunatic.

They're often referred to as poor lunatics in Bethlehem. I think the word patient only starts to come into more common usage in the 18th. century. And it's certainly true in earlier centuries, probably up to the 17th century, the flogging was used as a form of treatment and even very eminent physicians like Thomas Willis, who was a physician working in Oxford in the mid-17th century, was advocating bonds and strokes and threatenings as a way of treating lunacy. And I think towards the end of the 17th century, this starts to change. And in Bethlehem, a rule is brought in in 1670s. forbidding the flogging of lunatics.

In that 400 years, that was a course they followed. How did they know when they thought somebody was cured? Well, I think probably most people, if they were cured, were cured by themselves, not by any medical intervention. But were people let out? People were let out. And Bethlehem was all about curing people. It was a charity, so it relied on a good record of curing.

claims were made that around a third of patients and in some periods were cured, but they probably spontaneously recovered, and many, of course, were readmitted, which was something actually Bethlehem committed to, that if the patient fell ill again, they would take them once again into their care, if you could call it care.

Jonathan Andrews, the late early 16th century, has been briefly alluded to, those looking after people in Bedlam as it became called mentally ill people how were they trained were they recognizing that things were different from the humours and so on the black bile and the yellow bile and they were they bringing a different form of evidence and medical practice to bear well the one of the early physicians at Bethelham Helchia Crook was effectively an anatomist with no special

knowledge of insanity before he arrived at Betham. And that was relatively typical of most of the physicians who attended Betham initially. Now, Helkaya Crook, though, was a critic of Galen, had published a work called Microsmographia, where he was actually quite critical of Gellanic medicine, published quite controversially. And...

In a way, what did he say that was relevant to this? He was somewhat critical of the ideas of humoral passage, and he provided a model for, anatomy that was a rather challenging of anatomical knowledge that had been inherited from Galen. But really, the early

masters of Betham were actually quite commonly lay men, and the people doing the day-to-day management, the keepers were not medically trained at all and were often coming from kind of lower class service professions. Sometimes with backgrounds in the army or from labouring class is actually quite poor, poorly qualified in a modern sense. Also, Bethelm was, of course, attended by surgeons and apothecaries throughout the 17th century.

And only, though, in a visiting capacity. So they would both attend Bridewell, which Bethelam was conjoined to and jointly governed by the archetypal House of Correction in London. And they would submit bills, but they didn't actually have to show up at the hospital except to basically give purging, bleeding and vomiting. They were under no obligation to attend. There was no actually even rules requiring to attend on particular days. Eventually, this shifted to require attendance on two or three days a week.

But really surgeons and apothecaries at this time were largely trained through apprenticeship. And again, would have had general experience in general medicine, weren't recognised as necessarily specialists, you know, with specialist knowledge of insanity. So would it be too much to say that from 1347 until the end of the 17th century, much the same thing had gone on in Bethlehem, including the corruption, including people turning up for half a day, saying this, that and the other end going off with part of the money, and that the exploitation of the inmates, let's call them, was quite severe and deprived of sufficient food very often and certainly of clothing and so on and so forth? Well, the conditions in Betham certainly were rather rudimentary at times, but this can be exaggerated, and in a sense of the institutions an unchanging institution is, I think, wrong. One can point towards the end of the 17th century the introduction of, for example, a wardrobe at Betham, which provided clothing for patients whose parishes didn't provide,

the introduction of arms and a kind of temporary leaves of absence for, for, patients as well who were in a state of convalescence and recovery introduced during the period of Edward Tyson's physician's ship. So towards the end of the 17th century, early 18th century, you begin to see increasing focuses on the welfare of patients in terms of their material needs. But you also see physicians like Richard Hale developing reputation for less of a reliance on external restraint or mechanical restraint and a reliance on the use of medicaments opiates, for example. So we do see some elements of change

in this period. And of course, Bethlehem moves to a glorious new palatial dwelling in the 17th century, which is a very important shift too. We're not quite there yet. You're seeing the good side, and that's all, that's fine, and that's what

you should see. But nevertheless, it was regarded as hell by most observers. I mean, we have a list of, it's in Wycliffe, it's in Tyndall, it's in Shakespeare, several times, it's in Swift, it's in, and even, they all talk about it as a,

as a desperate place, so we'll leave it as desperate for the moment. But how did, Justin, how did it get his broader reputation? This is a small place, even at the end, through the 17th century, a very small place, he becomes nationally notorious. All these writers and presidents of the Bible are mentioning it, and they're mentioning it in the same terms as chaos and madness. How did it get that far? I think that's a very, very interesting question, because until the latter part of the 17th century,

really there are very, very few patients, maybe as many as 20 or 30. So it's not really a national project. But we know from the middle of the 16th century, there are ballads, the Tom Obedlam ballads, that Shakespeare incorporates into King Lear. Certainly by the end of the 16th century, there are 20 or 30 plays that have, bedlam either as a situation or people from bedlam as key players. And of course, by the 1630s, we've got very, very famous plays like Middleton's Changeling that actually have a play within a play that's set in Bedlam.

And the key thing, I think, is that very often the Bedlam inmates are clowns. We would find it pretty reprehensible to have that sort of character in a play on the television or at the theatre. using the clownish sort of vaudevillian behaviour of the mad as an entertainment, as humorous. But certainly by the time of Middleton, Bedlam is a space where you can think about what madness is. The liminality between being rational and being mad is very, very difficult for audiences. So in Middleton, the question that's posed is, what would you do for love? Would you pretend to be a madman to go into bedou? with the possibility of having a relationship with somebody you love.

And those sorts of questions, the instability of sanity in a world where the world is turned upside down is very difficult. That's a terrific survey, but can you pin it down? Why did Bedlam that word and that particular small place catch the imagination of so many people and became, become notorious and nationally referred to? Is there one reason or not? I'm given the answer.

Yeah, one reason that's been put forward is that certainly later in the century, people who go to the theatre have to go past bedlam. So in some sense, there is a physical experience. But we also need to remember that insanity isn't just captured in these institutions. We know from the case books of a minor sort of medical clergyman called Richard Napier, who's in operation until the 16th. he sees hundreds, if not thousands of people with mental problems and he treats them in a whole range of different ways in their villages, in their localities.

Hilary Marland, as has been said, it became a tourist attraction. Can you develop that? Yes, I can. And I think just to follow up on Justin's point, I'm the other thing about Bethlehem to point out until the 17th century, it is a one-off. It is the place in England where the mentally ill are treated. And as such, it becomes a major London tourist attraction. Especially when new building, Moorfields.

Exactly. New building, Moorfields is opened in 1676, and it's a palatial building on the outside. It's very impressive. And it becomes really part of a kind of Cook's tour of London. Visitors would go to Westminster Abbey, they would go to the tower, they would see the fireworks, they would go dining, and they would go and visit the poor lunatics

and observe the poor lunatics in Bethlehem. And Samuel Pepys talks of sending his cousin's children in 1669. As a treat, they were shown the lunatics of Bethlehem before being taken shopping and dining and to other sites of London. Do they describe the lunatics? Are they interested in the difference, the differences, the differences that the lunatics have to the rest of people? Yes, I think, I mean, there's a lot of interest in the sort of typology of madness,

sort of presenting lunatics as different types, where it was the delusional monarchs, the lunatic that thinks he's a member of the royal family, or the overstudious lunatic, or someone who's there because they've lost a child, the infanticide lunatic. So there are these different perceptions of different types of, people who were confined. And I think people had different motives for visiting. Bethlehem Hospital were rather fond of this idea of having visitors to the institution because they charged a penny or tuppence to go into Bethlehem to observe the lunatics.

And this was seen as an important source of revenue. And some people have argued as well that it wasn't solely bad. it gave the patients some contact with the outside world and that some of the visitors almost acted as a form of overseers and that contact with the outside world may have been quite important and the patients were brought gifts sometimes or given money and that perhaps observing these people in desperate circumstances was a kind of moral lesson as well

so not there are different ideas about what this visited meant. Jonathan Andrews, we come to the Munroes who run the place the four generations for 125 years. Can you tell us the dread story of the Munroes? Yes. Well, the Monroe dynasty began with the appointment of James Monroe, who's from a Scottish clan, who was the son of the principal of Edinburgh University, and he was the first physician at Betham, had out-competed, actually quite a strong number of other physicians for the post. There's a little,

really rather little, surprisingly known about James Monroe, because he didn't actually publish. We know he practiced in Greenwich before he came to Beth. And we know, again, he had no specific experience with madness. But he gave his son John, who inherited the physician ship in the 1750s from James, having served an apprenticeship at Betham. And it became almost natural then after John had experienced

a Radcliffe Travelling Fellowship, had gone to Leiden and gone to Edinburgh, and again acquitted himself very well. in committees for John to inherit the physician ship. This is... And two more Monroe's to complete the set, yes. And two more more rose to come.

Thomas to follow John very much with a sense of almost a cynicure and expectation. Although this wasn't unusual in medical dynasties, not just amongst physicians, but amongst surgeons to attend through families. I mean, 18th, 17th, the 18th century medical practice was often a family-run business. When you said troubled, it sounds as if you went on the travel for his medical studies and enriched his knowledge of mental illness, no such thing. Well, the Radcliffe Travelling Fellowships were about experiencing

medicine at other universities at practicing as a generalist really. Did they study what was still being called lunacy? Did they particularly study that? No. No. They didn't study that. So they're in charge of them to study it. They were generals. Very much so. And in fact, it was partly through, and

really it was the belief very much this time was that madness was known through experience empirically. John Monroe was very protective of that notion. So some extent, that made him hesitant to go into print. In fact, this, Raj explains why very few Bethlehem physicians

publish on insanity and we don't see that we see the first publication on insanity by a Bethlehem physician, almost forced into publication by his rival at St. Luke's Hospital, William, eponymously, an appropriately named Batty, at the rival St. Luke's Hospital,

Batty being a former governor of Bethlehem, St. Luke's established in 1751, Monroe forced really into print at the behest of the governors because Bati had actually written some words that were implicit slights on the reputation of his father and on the reputation of Betham. The accusation that to some extent a certain narrow corpus of medical men were keeping knowledge of insanity themselves by not publishing, and of course St. Luke's famously encouraged medical students to walk the wards

and did so for much of the 18th century. Bethel never did and resisted. that. And Monroe argues very much, in fact, in his response to Batty's treatise, which was called Remarks on Dr. Batty's treatise, his opening statement is that madness is a December of which very little of real use can be said. And in fact, he was very concerned that public debate about metaphysical notions of lunacy could actually deprive the public of confidence in the empirical skills of mad doctrine. Is this all that...

Justin, I'm looking to you now. The... It seemed to me from the notes that I read from you three and from a bit of reading around that the Monroe's let in no new air. Ideas were being developed elsewhere about mental illness, but not with the Monroe's.

They had a system and they stuck to it and they did, again as was successive people did with... They creamed the money off the top. Now then, and anything else happened? Well, I think You know, underpinning the growth of that institution is the re-foundation of the physical building, designed and built by Robert Hook in the four years. He's everywhere.

He's absolutely everywhere. And Charles II comes as it's opened in the August to see this pretty powerful institution that, of course, have at the top the two statues, what Pope calls the brainless brothers, representations of mania and depression. and that that sense of mental illness being not the result of something somatic, something physical, the galenistic thing, is, I think, being replaced in the broader culture by the invention of the mind. In post-Dacart, we understand that reason is what controls passion. Hobbes is very powerful at showing that religious actually has a pathological effect on the mind

and drives people to prophecy and Lord knows what. The experience of the English Civil War, with the world turned upside down, prophetesses, who are locked up in Bedlam, Lady Eleanor Davis. Just for being a prophetess? Just for, well, and for occupying the episcopal chair in a cathedral and claiming herself as bishop.

But that sense in which pathology is caused by a derangement of reason, it becomes more dominant. It's an enlightenment mode, perhaps, and we could all debate about what is rational and what isn't. But I think that's something as the anatomies of the brain get sorted out with people like Willis, that does change the sort of medical infrastructure. So that's going on. That's an interesting development which we now in the 21st century can relate to. That's the beginning of something that led to the discussion that is now going on,

different from the medieval, diabolism and so on and so forth. On the other hand, Hillary, we know that we are told that Bedlam didn't change much and so did, how were people admitted there and how were they, I've said this before, but how were they released, but more importantly, on what grounds were they admitted still in the late 17th, early 18th century? In this particular place. To be admitted, you had to demonstrate or your family or your friends, whoever was presenting you to the institution had to demonstrate you were poor and you were mad. and most of the patients who were admitted to Bethlehem would have been poor.

There were labourers, minor tradesmen, people without much means. And there seems to have been almost a process of negotiation. Although it was a charity and it was reliable on benefactions and donations to run the institution, they did extract fees from the families or friends of the patients who were brought there. And it was almost a form of negotiation as they were brought to the hospital and admitted about how much they would pay. Patients were also sent by parishes through the poor law. Most patients were admitted from London or the London area,

but some were brought from great distances as well to be treated in Bethlehem. Is there much evidence of corruption on the side of the sender, as we know about corruption on the side of the receiver, those who ran it seem to be all of them for profit. But what about people who say, Were people sending relatives away so they could get access to the will, that sort of thing? Well, this is the 17th, perhaps even more so, the 18th century, is the period of wrongful confinement, where there's a huge ferority about the wrongful admittance of patients into asylums.

And by this time, you also have a private asylum trade, which has grown up. And in fact, that is where the association with wrongful confinement is perhaps the strongest. Lots of asylums all over the country. Small ones most often, but they're starting to proliferate and their money-making enterprises. They run on a principle of payment. And again, these are mainly treating well-to-do patients. And in Bethlehem as well, you find also the better class of patient

in smaller numbers. But probably by the 17th and 18th century, the private asylum is where these patients would end up. Jonathan Andrews. It has to be said there was a process of, form of certification at Bethlehem. There's no requirement for a medical certificate, but from even the 1650s, governors specify that patients should be seen and vetted by a committee. And this really, it's really post the Moorfields building and the move of Betham in 1676.

We see this sort of committee deridism at Betham, where we have Saturday viewing committees, where patients are vetted. And if unfit for the charity, and that can mean if too weak, to undergo the innovating physics or if deemed to be idiot, if deemed to be incurable, let's say epileptic, or deemed to be costly for the institution, i.e. pregnant women, they'll be rejected. And we also see clear-outs of patients from Beth and patients found to be sane. Every now and then governors would visit, and again, this was done both through lay governors' visits as well as visiting physicians. And we see some evidence of an emphasis on the incurable insane being actually inappropriate for admission to Betham. In fact, increasing numbers of the incurables.

are discharged and ejection from Bethlehem in the early 18th century, resulting in a huge appeal for the foundation of incurable wars. In fact, this actually generates a charitable response from the public and benefactions increasingly for the incurable insane and then the building of two wards for incurable's at Bethlehem in the 1720s and 1730s, first for male and then for female patients. These are famously, of course, depicted by Hogarth in the final scene of the Rake's progress, the male incurable ward.

Justin, yes. I want to ask you about, you say what you want. I want one of the two scandals because there are big scandals. I was just sort of thinking of the improper use of Bedlam. There was a small political theme. I can't remember her name.

Margaret Hamilton. Nicholson, who attempted to assassinate George III was encouraged to go into Bedlam. And of course, a little while later, George III had his own mental problem. There's the irony of the same doctor investigating whether she needs to be incarcerated or whether the king ought to be. Did the king... Can we just refer, get to one of the main point?

There were massive scandals, one about an American who had been locked in a cage in which he could scarcely move, he couldn't really sit, he couldn't really sit, he couldn't really sound for 10 years. He was then discovered by people who visited him, who knew a bit about things, saying, look, he'd perfectly signed to me. and they tried to justify it that his wrists were too thin to put money. In fact, they were torturing him now that. Not made a national scandal.

What happened? Who was the man? What happened? I don't know enough about him, I'm sure. Who knows about it? This is James Norris, an American Marine, who was found in the condition of severest strength with a harness that was effectively pinning on his arms to his sides, a neck lock,

and a chain that actually could be used by the keeper to draw him close in the adjacent cell. Now, what's often forgotten about Norris is that he was one of the most violent inmates Bethlehem had experienced that not only were his wrist thin, but they were almost double jointed and he could get out of wrist locks. That this was a very unusual form of device that only Norris had experienced,

but also that he'd attacked very brutally a member of staff and bitten the finger off a patient. But by the time he was found in Betham when Wakefield visits Bethlehem in 1814, he'd been in that situation, it seems for roughly nine years and seemed to be quite coherent, able to give a good account of himself,

was able to read newspapers, for example. So it was also about this statement in which he was found. And this, of course, Norris became one of the core celebrar cases that Wakefield brought this information, was scandalised by what he found. It wasn't the only thing he found. Cells within Betham where patients

had seemed almost to be forgotten about, chained by their legs or by their arms to benches. In states of semi-nudity with blankets, this was a quite traditional way of dealing with incontinence in Betham because that also came with cleaning and expenses and time constraints, so it was easier to put blankets on patients. But there was a sense in which some of these patients had been really neglected. Hilary, were alternative methods emerging,

say at the end of the 18th century, of dealing with people instead of naked on floors with blankets and however violent, chaining them up like dogs in a car, kennel. Well, to me that's the greatest scandal of Bethlehem, the new alternatives, alternative forms of treatment were emerging during the 18th centuries. And sometimes these were associated with the private asylums. Some of these were quite innovative and they were trying out new approaches and the people who ran them claimed a good deal of expertise by this time in treating mentally ill patients. And one such was Francis Willis who treated and perhaps

cured George III from his madness. Perhaps the institution though which is always put as the strongest contrast to Bethlehem was the York Retreat which was established in 1796 by the Chuk family, a local Quaker family of tea merchants, not medical experts but had an interest in in treating mental illness and at the York Retreat and at other institutions they devised a system which was known as moral management or moral therapy, which was very much based on establishing a regime of kindness and order which would involve occupying the mind of patients, a good diet, encouraging rest and recreation.

There wasn't much medical intervention. These were institutions that did not bleed or give lots of medicines to the patients. It was very much about a system of management. And the contrast, between the York retreat and Bethlehem, I think, by the time of the 1815-16 inquiry was becoming very stark. And I think one of the strongest critiques of Bethlehem is that they, although the apothecary at Bethelm from 1795 John Haslam was interested in these new systems of

management and even wrote about them, they did not put them into practice it appears at Bethlehem. So there were innovations, as Jonathan described, and a kind of more, lenient regime and better conditions for the patients by the late 18th century. But somehow Bethlehem turned its back, really, I think, on these new approaches to treating mental illness. So can we get a sense of time and place, Justin, particularly of time, where at the end of the 18th century, and there's as much investigation going into the nature of the mind, one way and another in this, and all of Europe, in other parts too.

and Bedlam is lagging behind other institutions, especially the York retreat, way ahead and been taken up all over Europe. What's happening in this country in the 19th century? Dickens is still going and visiting Bedlam as a spectacle. And I think in one sense, the persistence of Bedlam as an institution and not as a physical space, but as a sort of mental representation of the dangers of insanity, you know, continues until to. today. We still use the language of Bedlam to describe things we don't like or things that threateners. My sense is that certainly the legacy of more inquiries into the nature of the human mind. How does it work? How does it become unstable? The role of rationality.

And I think it's, Tyson says somewhere around 1700, you know, madness is imposed by the mad on the less mad. and that tradition gets taken up later in the 20th century by historians of madness like Michel Foucault and more accessible Roy Porter, who see this tradition as one of confinement and medicalization rather than real medical innovation. And I think I'm not familiar enough with the treatment of insanity or mental disorders today, but my sense is if we look at things like one flu over the cuckoo's nest, brutal medical intervention lobotomies or massive pharmaceutical control is still a major issue. We just don't lock everybody up anymore. We don't confine them. Jonathan, do you see any changes moving through the 19th century,

but market changes in the institutions rather than the ideas? Yeah, I mean, in particular, the model of the York retreat, which it very much disseminates the doctrine, of moral therapy to Asylum's Generey and there's much emulation of a more moral managerial practice in Assamance. This means a shift towards an emphasis, for example, most importantly, on occupying insane, a kind of almost quasi-occupational therapy. With a greater variety of occupations available in Assamines, this includes the provision of workshops. Bethlehem itself gets workshops in the 1830s, for example. It also includes a program of recreational activity. And Dickens,

of course, attend St. Luke's curious dance, as he calls it, around a curious tree, the weekly balls and dances that become a real feature of the Victorian asylum, both a publicity op for the assignment to actually open itself out, to bring in musicians, to bring in performers, and to involve patients and staff and interactions. But there are also a time to demonstrate the kind of good behaviour of patients and the sense of the morally reformed asylum. We're also seeing a significant shift of emphasis in terms of,

of medical treatments at this time, more criticisms of standard evacuation, reliance and bleeding, purges and vomiting. We're seeing a shift towards, for example, the use of corral hydrate, chemical preparations, sulfan or opiate concoctions, and also the use not of restraint, but the use of self-restraint and seclusion. An emphasis on, in fact, increasingly on non-restraint from the 1830s and 40s, with the work of Connolly and others at Hanwell, for example. Hilary Marlin, when these new drugs were brought in,

do we see effects from them? Do we see, are the reports that we read? These are better than flogging and purging and so on. I think, yes, I think there's a positive response to these new innovations and the use of sedatives, as Jonathan pointed out, rather than the manacles and chains of old. And I think also this idea of management, in a way Besslam does start to fall into line with other public institutions

and you have a lot of big public institutions by the 19th century which are managed by the lunacy commissioners who would visit asylums regularly to assess treatments to see the patients, see the state the patients were kept in and after the 1850s Besslam is also under the auspices of the lunacy commission and they start to get innovative medical superintendents brought in and someone called Charles Hood becomes medical superintendent in 1852. And the big difference with Dr. Charles Hood is he lives in Bethlehem.

He's a resident superintendent. So he has much more day-to-day contact with the patients, observing their day-to-day improvement and recovery in some cases. So let's assume that Bedlam itself, let's sick to Bedlam for the last few seconds, Bedlam itself improved. Is there an improvement also in the... general, national consciousness about mental health, about lunacy. It was still called this, still called in my childhood.

Yes, I mean, I think if we take the long view from, you know, the foundation as a priory, the development of the institution as a hospital for the poor and mad, and then the creation of something called an asylum, the project has to have been beneficial. But one of the things we, even as in... historians often miss, is the voice of the mad, the voice of the powerless mad person. And we have fragments. There's a clergyman at the end of the 17th century called George Tross, who published an autobiography. He drank himself into insanity. He had a period of, you know, in the hospital, and then came out again and wrote about it. And for him,

the problem was always in his mind and with God. And my intuition, is that as the pressure of religious orthodoxy gets weaker, perhaps we get less need for asylums. Well, thank you very much to Justin Champion, Hillary Marland and Jonathan Andrews. Next week we'll be talking about Elizabeth Barrett Browning's epic poem Aurora Lee. Thanks for listening. And the In Our Time podcast gets some extra time now with a few minutes of bonus material from Melvin and his guests. I mean, I think one of the things that's fascinating me more and partially because there's this easily accessible catalogue online of prints and drawings that the British Museum has

and you can search by word or concept. It's the visual representation of madness and insanity gets, I don't know into the 19th century, but certainly in the 17th and 18th century, gets increasingly politicised. You are driven mad by priestcraft or drink or Tories. And that sort of visualization, I think,

is very, very interesting to think about how... It goes back to your question, Melvin, about how do people know about Bedlam? You know, if you're cranking out ballads and broadsheets with little representations, these are cheap. You know, there was a broadsheet,

wasn't there, in the 1740s, supposedly written by an inmate who says... With a poem and an image attached. Yes, and the word priestcraft is used in one of the first sort of time. to say this is what's making you mad, but the image is incredible. Well, that's true, but I think even more so,

it's the literature actually produced by both writers from a literary vein and the visitors of Bethlehem who recycle their visits, and often recycle visits on the basis of other accounts that they've read, so there's an awful lot of intertextuality, that is actually making Bedlam, building this sense of Bedlam as a touristic resort. And I think one of the things we missed in our discussion was that is what changes. is why it is that Betham actually closes its doors to indiscriminate visiting in 1769 to 70. Oh yes, we should have said that.

And this kind of major shift, attitudinal shift, as the fun almost goes out of the freak show of Betham, and you have an increasing volley of critical write-ups of visits to Betham, really excoriating the behavior of the masses in particular in the periodical magazine literature of the 18th century, in particular from the 1740s, 50s and 60s, when we know that visiting is actually at its height when Betham is more popular than ever as a resort.

St. Luke's, of course, closes its doors to indiscriminate visitors, doesn't allow visitors except the friends and families, and it's actually rather chary of allowing friends and families into visit patients. All of the second generation of Lomiswick hospitals founded after 750s also follow governor-ticketed visiting practices or set visiting hours. And Betham is rather belated once again in, in... actually meeting the demand and meeting the critique with action. And quite interestingly, John Monroe, even when he remarks on Batty's treaties,

suggests that visiting can be actually quite problematic, can be good and bad. And he largely excludes what he confines what he's saying about visiting to his private practice, always ignoring what's going on at Bethlehem. But what we are seeing is a significant shift in public attitudes, the sense in which the visiting of Bedlam is always consigned to the prostitute whipping. side that goes on at Bridewell of public entertainment. And a sense in which it's becoming not, it becomes for something for seeking out inmates who are entertaining, who are fun, it becomes a matter of seeking out the most moving stories to tell, a sense of engaging with

sensibilities, a sense also of recognising the sensibilities and feelings of the patients being visited. So we see much more dialogic visitors' reports and interactions, I think. And what we also see is the patient's view, the patient's account, which we didn't talk about, that they themselves produce literature, pamphlets or books, recording their experience, either their experience of being mentally ill, and many acknowledged that they were, they were not wrongfully confined, but many were making complaints against institutions and relatives and friends for wrongfully confining them. But we also get a really good insight into conditions, and Obein Metcalfe wrote a very interesting pamphlet in 1818,

describing his experiences of being in Bethlehem, and he acknowledged he had been mentally ill, he thought he was an heir to the Danish royal family, he was delusional, you know, he needed to be there or somewhere, but he did report on the terrible conditions in Bezham, the poor diet, the cold, the lack of hygiene, and also commented, of course, on the actual medical treatment that was being meted out in this period.

So the patients too give us this wonderful, rich insights into what these institutions, not just Bethlehem were really like during this period. Well, we're going to be released now if you want, because here's Simon Tillotson, the producer, to make you an offer you can't refuse. It's tea or coffee, what will be like. Coffee, please. There are many more history and discussion programmes from Radio 4 to download for free. Find these on the website at BBC.co.uk.uk slash radio 4.