Bethlem Royal Hospital: why did the infamous Bedlam asylum have such a fearsome reputation?

Bethlem was founded in 1247 and through most of its history reflected contemporary views on the treatment and care of people with a mental illness. There was, however, a darker period when the hospital became more conservative, secretive and, eventually, abusive in the treatment of its patients. This lasted for more than a century and, despite later reforms, has led to the permanent association of the term 'Bedlam' with anything that is chaotic or unruly.

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For most of its history Bethlem was the only dedicated mental institution in Britain, which automatically made its medical staff the foremost experts in the diagnosis and treatment of mental illness. Medieval thinking held that madness was a disease of the body, not of the brain, which could be cured using strong medicines to purge the individual of ‘melancholic humours’.

All mental illness, it was thought, could be cured by inducing recurring bouts of vomiting and diarrhoea, and by bleeding from the veins. The skin would be blistered with caustic substances and patients would have their heads shaved and be placed in cold baths. This regime would be administered repeatedly and for as long as ‘the strength would bear’. It inevitably led to deaths.

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This treatment was still universally accepted in 1676, as Bethlem moved from its cramped medieval building at Bishopsgate into a magnificent and ornate hospital at Moorfields. It remained Britain’s only mental health facility, and had developed a nepotistic tradition which saw medical posts pass between friends and family, ensuring that treatments methods were similarly inherited.

Doctors at war

The 18th century saw a rapid expansion in London’s population and also a decline in the traditional treatment of insanity within the family home. Bethlem had space for just over 120 patients and a long waiting list for admissions. As a consequence, many private ‘madhouses’ appeared around London, some of which were no more than unregulated prisons that enabled families to lock up perfectly sane but inconvenient relations.

In 1750, a group of medical reformers wished to see a progressive alternative to Bethlem and so St Luke’s Hospital was created. This was located directly opposite Bethlem, with William Battie serving as its chief physician. In contrast to traditional medical thinking, Battie publicly denounced the use of “bleeding, blisters, caustics, opium, cold baths and vomits’ in favour of patients being ‘removed from all objects that are known causes of their disorder”.

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A stone’s throw from St Luke’s, Bethlem’s then doctor was John Monro (son of the previous doctor, James Munro) who strongly disagreed with Battie’s methods, writing that “the most adequate and constant cure is by evacuation” and that he “never saw or heard of the bad effect of vomits”. The two doctors battled publicly and promoted their views in books which, rather bizarrely, were widely accepted as being simultaneously correct.

It was not just the views of the doctors that separated the two hospitals, however. St Luke’s treated its patients through individual diagnosis and care, the belief being that there were many forms of mental illness and not just one. At the heart of patient care was a clean, calm environment. Perhaps most surprising of all was that St Luke’s would not admit paying visitors, a practice that Bethlem had allowed for centuries.

Did people visit Bedlam as tourists?

By the 1750s Bethlem was accepting tens of thousands of paying visitors a year, making it a top tourist attraction for Londoners, second only to St Paul’s Cathedral in popularity. Most did not wish to admire the manicured gardens or ornate architecture but came instead to visit the hospital’s ‘crackbrained’ patients. For as little as a penny, anyone could gain access to Bethlem’s wards in order to stare at, taunt or abuse inmates.

At some time or other most Londoners seem to have visited the ‘madman’s college’ including the likes of Samuel Pepys, Dr Johnson and William Hogarth. It is from their writings that we get a glimpse at what conditions inside Bethlem were like for visitors and patients.

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The account of diarist Ned Ward is typical. He visited Bethlem in 1699 and found himself immersed in a terrifying world of noise and disorder. “We heard such a rattling of chains, drumming of doors, ranting, hollering, singing and rattling that I could think of nothing but... [a vision] where the damn’d broke loose, and put Hell in an uproar.”

With the patients locked in their cells, Ward was able to join other visitors in making taunts and jeers through the bars and peepholes. Some inmates were verbally insulted while others were goaded into doing or saying ridiculous things. Those who were beyond conversation tried to dissuade people from staring at them by spitting or throwing objects or, if suffering from ‘melancholia’, by not responding at all.

By modern standards this behaviour seems cruel, degrading and counterproductive to the patients’ mental health. However, 18th-century medicine dictated that madness robbed the individual of shame, emotion and reason to the extent that any verbal or physical abuse they suffered could surely have no lasting effect. Charging admission and accepting donations was also lucrative, raising up to £450 a year for the hospital, while staff topped up their salaries with bribes for private tours and access to cells and wards.

It was not just tourists who were drawn to Bethlem. Intermixed with the cacophony, smells and sights of the wards were prostitutes, pickpockets and merchants of food, drink, trinkets and other wares. Bedlam, wrote Ward in his journal, “is an alms-house for madmen, a showing-room for whores, a sure market for lechers, a dry walk for loiterers”. Despite this, Londoners loved it.

Bethlem was a top tourist attraction for Londoners, second only to St Paul’s in popularity

Year on year visitor numbers increased, leading to overcrowding, especially during the Christmas and Easter periods. From 1770, to limit riotous behaviour by both visitors and patients during seasonal holidays, admission was gradually tightened; by the 1780s, outside access was only possible if accompanied by a hospital governor or senior officer.

Mental health reformists such as William Battie had argued that patients required calm and quiet to aid their recovery, and the removal of visitors from Bethlem’s wards certainly achieved this. But it also had an unexpected downside. Public admission allowed anyone to come and make their own judgement on the conditions inside Bethlem. After the ban, the hospital operated behind closed doors with its facilities, care and medical practices operating unobserved and unregulated.

Bethlem soon found itself at the centre of a major financial embezzlement which, together with a general drop in income, placed it in debt. The state of the building, which had been hastily erected in just over two years, was also of concern. It had always suffered from being damp and cold, but increased instances of subsidence and leakage led to a surveyor declaring the edifice to be falling apart. Repair was impossible and its continued use was declared to be ‘unwise and improvident to the highest degree’.

Was anyone cured at Bedlam?

As parts of the building became uninhabitable, so patients were bunched ever closer together with the ‘raving mad’ being placed in the same cells as the quieter inmates. Violence was commonplace and so many patients were chained either to their beds or to the walls. Adding to the misery was a lack of clothing and heating, rats, and medical officers whose adherence to debilitating purgative cures had become increasingly out-of-step with contemporary thinking.

To be sent to Bethlem wasn’t just a matter of shame. It also presented the serious risk of injury or even death

As the 19th century dawned Bethlem remained outwardly visually magnificent while inside it had become a dilapidated, cash-starved institution operating without any accountability or scrutiny. With no inspectors or even outside visitors to check on the patients, conditions were squalid and abusive. To be sent to Bethlem was no longer just a matter of shame, it also presented the serious risk of injury or even death.

Nor was there much prospect of being cured. Bryan Crowther, surgeon at Bethlem from 1789–1815 was reported to be “generally insane and mostly drunk”. The doctor, Thomas Monro (son and grandson of previous incumbents), preferred collecting art to medicine. His visits to Bethlem were infrequent, brief and never involved touring the patients’ wards. There were reports of widespread alcoholism, of buckled ceilings and walls and of male staff making improper visits to the female galleries.

What treatments were administered at Bedlam?

They say you have to be cruel to be kind, and judging by the treatments below that’s certainly the outlook held at Bethlem...

Rotational therapy

Developed by Erasmus Darwin, grandfather of the famous Charles Darwin, rotational therapy usually involved placing a patient in a chair suspended from a beam by ropes attached to its legs. The chair would be turned 20-40 times one way and allowed to spin back to its original position. Darwin himself, in 1796, recommended the practice be performed for “an hour or two, three or four times a day for a month”.

Deemed an effective way to evacuate the bowels, bladder and stomach and make an impression on the ‘organs of sensibility’ (the brain and the nervous system), it was also thought that this treatment would induce restful sleep in a patient, much like rocking a baby. The swing chair could also be used as punishment – a way of asserting dominance over patients who refused to comply with staff orders.

Cold water therapy

Cold bathing was introduced at Bethlem in the 1680s and became a way of ‘shocking’ inmates out of mental illness; it remained a popular course of treatment for much of the 18th century. Patients could be submerged in cold water for long periods of time, wrapped in towels that had been soaked in ice, or sprayed with cold water.

Bleeding and purging

In the 18th century there was little understanding as to the causes of mental illness and patients – whether depressive, manic or paranoid – received the same course of treatments. Mental illness was viewed as a disease of the body rather than the brain, and patients were often prescribed weeks of enforced bleeding, vomiting and diarrhoea in order to purge the body of its ‘melancholic humours’. Caustic substances were also applied to the skin, to make it burn and blister.

What were conditions like inside Bedlam?

Away from Bethlem, the discovery of similar conditions elsewhere, most notably the York Asylum, had led to the development of a coherent reformist movement whose influence was beginning to be felt inside Parliament. With legislation threatened, Bethlem’s governors used their considerable influence to keep the hospital exempted from outside scrutiny. This succeeded for several years until 1814, when campaigner Edward Wakefield and a small group of MPs gained admission to Bethlem’s wards. The visit had been rebuffed for weeks by Bethlem’s staff and it soon became apparent why.

Inside the building it was stark, dirty and cold, with no glazed windows or hot water. In those parts that were habitable MPs found small, fetid cells populated by several people chained to walls or their beds. Many were “stark naked” with just a single blanket to protect them from the cold and rats. This included Anna Stone, whose treatment was called an act of “disgusting idiocy”. Patients’ limbs were found to be crippled with cold and subject to injury by the “raving patients” with whom they were chained.

The sight that most shocked the committee was that of James Norris, described as a clear and lucid man, who had been tightly chained by his neck to an iron bar in the wall. With additional metal restraints on his chest, waist, feet and arms, Norris complained that his muscles were atrophied and painful following a decade of confinement. The staff described Norris as violent and dangerous but to the MPs he seemed quiet and perhaps even sane. The inspectors had seen enough and called for a Parliamentary inquiry into conditions at Bethlem.

In those parts that were habitable, MPs found small, fetid cells populated by several people chained to walls or beds

During the inquiry the medical staff fared poorly, with the apothecary blaming others for the squalor while the doctor, Thomas Monro, argued that nothing the MPs had seen was amiss. The drunken and insane surgeon, Crowther, could not be interviewed as he had died a few weeks previously (as had James Norris himself).

Bethlem’s medical staff were dismissed, but the hospital’s governors were not ones to have their authority challenged – they immediately appointed Thomas Monro’s son Edward as the new doctor. It was an act of defiance that enraged reformers, but not the House of Lords, which blocked attempts at bringing Bethlem under official regulation.

When was Bedlam reformed?

In 1815, Bethlem was moved from its collapsing Moorfields site to a brand new building at St George’s Fields, south of the Thames. Lessons had been learned and the combination of a new building and new staff members brought about reforms of the sort that Wakefield and others had been calling for. An 1818 report found patients “clean, amply supplied with wholesome provisions and well clothed [with none] under restraint”. A financial audit suggested that the hospital was solvent and generally well-managed.

Patient care and finances had improved but individual problems still arose – such as the discovery, in 1830, of apothecary Edward Wright in the female galleries drunk and with his clothing dishevelled. When asked about Wright’s duties, a colleague replied: “Smoking and opening and taking off the heads of the dead patients occasionally.” It transpired that Wright had developed a Frankenstein-like fascination with the dead and had created his own laboratory in the hospital’s basement. Wright’s secret was out; he was immediately dismissed.

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These instances, and two further financial scandals, did not directly concern the treatment of living patients and so Bethlem was exempted from legislation passed in 1828, 1832 and 1845, continuing to operate outside the law. Protests by reformers became more vocal until, in 1853, Bethlem's exemption from outside inspection was ended. After more than six centuries, the hospital was no longer independent. "The farce has been played out to the last act," wrote The Lancet.

This drew a line under Bethlem’s notoriety and ensured that afterwards the hospital would no longer be a place of dread and fear. In 1930, Bethlem was relocated to Beckenham in Kent, where it continues as a psychiatric hospital (now within the London borough of Bromley).

Beyond Bedlam: London's private madhouses

Some of London’s mental asylums were run purely for financial gain...

Bethlem’s emphasis was on curing mental illness, which limited admission to those who were “raving and furious and capable of cure”. People who were deemed to be incurably ‘distracted’, ‘idiotic’, ‘mad’ or ‘lunatic’ didn’t qualify, and had to be treated at home or left to wander the countryside as ‘vagrant’ or ‘Tom O’Bedlams’.

By 1700, Bethlem had a lengthy waiting list but a persistent need for asylums led to private ‘madhouses’ springing up all over London. Owning and running a private madhouse required no licence, qualifications or duty of care, a situation that led to several high-profile scandals as husbands and relatives attempted to lock away inconvenient but otherwise sane relations.

In 1762, for example, a Mrs Hawley was kidnapped by her mother and husband, and admitted to a Chelsea madhouse. They wished to have her declared insane in order to gain power of attorney over her finances. Once in the madhouse, Mrs Hawley was assaulted and kept secretly hidden until friends found and eventually freed her. In the ensuing trial, the madhouse owner admitted that he in effect ran a private prison that admitted “all persons that are brought here”.

Concern over false imprisonment and abuse led to a 1763 inquiry by a Select Committee of the House of Commons, but a subsequent attempt at legislation was blocked. It was not until 1774 that the first Madhouse Act was passed, requiring private asylums to be licensed and inspected – although, at the behest of its governors, Bethlem was exempted. Exclusion from this was a probable contributory factor to the poor conditions discovered at the hospital in 1814.

Paul Chambers is author of Bedlam: London's Hospital for the Mad, recently released in paperback by The History Press

This content first appeared in the April 2020 issue of BBC History Revealed