The Bethlem Hospital, or Bedlam as it is more commonly known, is Europe’s oldest extant psychiatric hospital and has operated continuously for over 600 years. It was founded in London in 1247 during the reign of Henry III, as the priory of the New Order of St Mary of Bethlehem. Bethlem was not actually intended as a hospital, much less as a specialist institution for the insane, but rather as a house for the poor and a centre for the collection of alms to support the Crusader Church. However, the crown seized Bethlem in the 1370s and it became an increasingly secular institution staffed by crown appointees.

The first definitive record of the presence of the insane in Bethlem is from the details of a visitation of the Charity Commissioners in 1403. This recorded that among other patients there were six male inmates who were “mente capti”, a Latin term indicating insanity. The visitation also noted the presence of four pairs of manacles, eleven chains, six locks and two pairs of stocks, presumably used to restrain the most violent inmates. In c.1450 the Mayor of London described Bedlam 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, for they be fallen so much out of themselves that it is incurable unto man”. Little is known of the treatment of the insane for much of the medieval period, though mechanical restraint, a meagre diet and solitary confinement are likely to have been common practices. The name “Bedlam” developed in the 14th century as a corruption of “Bethlem”, or “Bethlehem”.

By 1600, Bethlem was co-owned by the crown and the City of London, and run by a board of governors. The change in management doesn’t seem to have benefited the hospital’s inmates; conditions in 16th- and 17th-century Bedlam were appalling. Bethlem had been built over a sewer which served both the hospital and the surrounding area, and as it regularly blocked, waste of all kinds would seep into the building. The 1598 visitation by the Governors had observed that the hospital was “filthely kept”, and a later inspection found inmates actually starving. Under the leadership of the aptly-named Helkiah Crooke, who was dismissed in 1632 on grounds of absenteeism and embezzlement, charitable goods and foodstuffs were stolen by the steward and either personally consumed or sold on to patients. Those without the resources to trade with the steward often went hungry. It was at approximately this time that the word “Bedlam” seems to entered everyday speech to signify a state of madness and chaos.

The admittance of public visitors as a means of raising hospital income may have been allowed since the late 16th century; certainly there are 17th century accounts which describe the “Swarms of People” which descended on Bethlem during public holidays in order to amuse themselves by watching the mad inmates. The number of visitors seeking entertainment rose in the 18th century, becoming one of Bedlam’s most notorious characteristics. Visiting was defended by some commentators as a form of moral instruction, as it illustrated the dangers of immorality and vice which could, in popular belief, lead to madness. As one spectator commented, “[there is no] better lesson [to] be taught us in any part of the globe than in this school of misery…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”.

All well and good, but for the vast majority, Bedlam was simply a titillating source of cheap amusement which provided what historian Roy Porter describes as the “frisson of the freak show”. An 18th century observer recorded how on one occasion, “a hundred people at least [were] . . . suffered unattended to run rioting up and down the wards, making sport and diversion of the miserable inhabitants, [some of whom were] provoked by the insults of this holiday mob into furies of rage”. Unrestricted public access continued until 1770, after which time visitors required a ticket signed by a governor of the hospital. As distasteful as it was to have crowds flocking to make fun of the mentally ill, some historians have speculated that the lack of public oversight after 1770 allowed for more flagrant abuses.

Being such an infamous institution, Bedlam did not lack for attention in the public sphere. Jonathan Swift memorably quipped, where better to recruit the nation’s politicians than Bedlam, since the inmates could not be any more insane than the ones in power! Bedlam provided a wonderfully melodramatic backdrop to literary texts, as in Eliza Haywood’s 1725 play The distress’d orphan or, Love in a mad-house. Haywood describes how “the rattling of Chains, the Shrieks of those severely treated by their barbarous Keepers, mingled with Curses, Oaths, and the most blasphemous Imprecations, did from one quarter of the House shock…tormented Ears while from another, Howlings like that of Dogs, Shoutings, Roarings, Prayers, Preaching, Curses, Singing, Crying, promiscuously join’d to make a Chaos of the most horrible Confusion”. Perhaps the most famous depiction of Bedlam is the final painting in Hogarth’s cycle The Rake’s Progress (1723-25). Driven mad by debauchery (probably an effect of syphilis), the cycle’s protagonist Tom Rakewell presents a sorry sight, sprawled on the floor of a dank cell in Bedlam. He is surrounded by other lunatics, one of whom thinks he is a king, another a bishop; wealthy visitors laugh at the wretched scene.

Bedlam’s medical regime – such as it was – was at best useless, at worst actively injurious to the mental health of the inmates. Mental illness was completely misunderstood at the time. Epileptics and people with learning difficulties and dementia were classed in the same group as people suffering from paranoia, schizophrenia and depression. Following Greek and Roman philosophy, it was believed that ailments were generally caused by an imbalance of the four humours; too much black bile, for instance, was thought to lead to depression. Consequently, a depletive medical system held sway in Europe until the 19th century.

The most common treatment in this system was blood-letting, but patients at Bedlam were also subject to forcibly induced vomiting, scarification and purgation. Such was the violence of the standard medical course that patients were regularly discharged or refused admission if they were deemed unfit to survive the physical onslaught. Alexander Cruden, a writer who was briefly incarcerated in Bedlam, said bitterly of the physicians there: “but is there so great Merit and Dexterity in being a mad Doctor? The common Prescriptions of a Bethlemitical Doctor are a Purge and a Vomit, and a Vomit and a Purge over again, and sometimes a Bleeding, which is no great mystery”.

The years 1814 and 1815 proved a turning point in Bedlam’s history. Edward Wakefield, a Quaker philanthropist and leading advocate of lunacy reform, visited several times during 1814 with the aim of inspecting conditions. Fearing bad publicity, Bedlam personnel tried to keep Wakefield out, but he eventually gained entry in the company of an MP and a governor of the hospital. He found that inmates were not classified in any logical manner, as both highly disturbed and quiescent patients were mixed together indiscriminately. Patients were chained to the wall, sometimes with thick iron rings around their necks; it was said that “chains are universally submitted for the strait-waistcoat”. In 1818 a former Bedlam inmate, Urbane Metcalf, described the case of a man named Popplestone, “whose leg rotted off as he was chained up for such a lengthy period that the metal cut into his flesh”. There was also the infamous case of the American marine, James Norris, whose intestines burst after being confined in chains for over a decade.

Wakefield and others revealed how keepers at Bedlam could be brutal and even sadistic towards their mentally ill charges. Wakefield recounted an incident in which “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 into his bed, and leg-locked, without enquiry or observation”. Metcalf reported an alleged case of murder: “Fowler [a patient], was one morning put in the bath by Blackburn [a keeper], who ordered a patient then bathing, to hold him down; he did so, and the consequence was the death of Fowler, and though this was known to the officers it was hushed up”. Metcalf also described a how a keeper named Davis, a “cruel, unjust and drunken man…for many years as keeper secretly practised the greatest cruelties to those under his care”.