It's a madhouse! Caring for lunatics in the past

foolMy latest novel, Moriarty Takes His Medicine, revolves around the goings-on inside a private hospital for women suffering from nervous disorders. These inmates were well-to-do. Many of them entered the hospital voluntarily to enjoy a month-long respite from daily care and strife. Some of them suffered from mental illnesses we would recognize, such as obsessive-compulsive disorder and bipolar disorder.

There were lots of luxurious private hospitals in Europe in the nineteenth century. We’ll look at them more below. Only a few of the mentally ill could afford such establishments, however. We’ll look at the options for the hoi polloi also. But long before the idea of a private madhouse had even emerged, English patients had only two options: stay at home or go to Bedlam.

From the beginning of time…

Through the medieval and early modern periods, families would keep their mentally ill relatives at home, if they could, although it would have been a great burden then, as now, to take care of a person who roamed and shouted and threw things. Most people were hard pressed to feed and clothe the productive members of their families.

In the early modern period, households typically consisted of on the nuclear family. Grandparents, aunts, and uncles and other relations lived in their own homes, if they could. They might not be nearby; people were more mobile than we tend to imagine. Thus the parents would have to figure out how to cope with Mad Little Johnny or Jane by themselves, with help from the other children. That’s challenging for modern families with doctors, therapists, and programs supplying information and support. We can only imagine how destructive of normal family life caring for a mentally ill person must have been in earlier times.

Let’s bear that in mind as we tour the most notorious lunatic asylum in English history.

Bedlam: a refuge for lunatics


Plan of the First Bethlem Hospital from Daniel Hack Tukes’ Chapters in the History of the Insane in the British Isles (London, 1882), p. 60.


The Priory of the New Order of St Mary of Bethlehem was founded in London in 1247, during the reign of Henry III. The priory housed the poor and provided hospitality to bishops and other grandees when they visited. Hence the term ‘hospital,’ a word which dates to about this time. Here’s the second entry in the OED: “c1330  R. Mannyng Chron. (1810) 135  To temples in Acres he quath fiue þousand marke, & fiue thousand to þe hospitale.” (To Temples in Acres, he bequeathed five thousand marks and five thousand to the hospital.)

In 1546, Henry VIII ceded the hospital to the City of London, to be owned by the crown, but managed by the city authorities. Wikipedia doesn’t know when Bedlam first became a refuge for lunatics, but surmises it happened gradually over the course of the fourteenth and fifteenth centuries. By Shakespeare and Francis Bacon’s time, that function was well established.

Looking at the plan, notice the Tenter Grounds at the top. This was a field where wool cloth could be stretched to dry between hooks to maintain its size and shape. Hence to be on tenterhooks, a condition we wouldn’t want to with on the poor men and women in Bedlam. Bishop’s Gate, at the bottom, is in the northwest portion of the wall around London. The Curtain theater stood just to the north of the hospital; handy for playwrights in search of material.

It’s a mad, mad, mad, mad couple of centuries

I tend to skim through the years between Francis Bacon’s death in 1626 and 1880, the year in which the first Sherlock Holmes story is set (“The Gloria Scott.”) I’ll just touch on some highlights.

For the sixteenth and seventeenth centuries, Bedlam was the only hospital “devoted to the care ‘of hogarth bedlam 1distracted persons.'” Today that sounds like a facility for people addicted to social media. That sense of the word ‘distracted’ (confused or troubled in mind) dates from the dawn of the seventeenth century. Here’s a quote from Hamlet, 1604: “Remember thee, ..whiles memory holds a seate In this distracted globe.”

Arnold make special note of the location of the hospital in the midst of the suburbs that sprang up outside Bishopsgate during the Elizabethan period. Outside the city walls, they were also partly outside the jurisdiction of city rules. This area became especially popular with theater people after the Curtain and the Theatre were built.

Writers and other tourists visited Bedlam to observe the madmen and women housed therein. Madmen figure importantly in plays by Shakespeare and Thomas Dekker, among others. Dekker wrote,

“And, though ‘twould grieve a soul to see God’s image

So blemish’d and defac’d, yet do they act

Such antics and such pretty lunacies,

That spite of sorrow they will make you smile.”

Bedlam continued to inspire writers and artists with its combination of pity and grotesque humor. Jonathan Swift, the Irish satirist, was a governor of Bedlam in 1714. In A Tale of a Tub, he argued that the commissioners ought to “scout Bedlam for appropriately insane people to command regiments, carry out scientific experiments and rage and brawl in the law courts and political elections,” since all greatness had more than a touch of madness. He begged to be admitted as a patient on the grounds of being an incurable scribbler.

William Hogarth’s immortal series of paintings The Rake’s Progress ends in Bedlam (shown above). Where else? Our rogue has exhausted both mind and body by his dissolute style of living.

Not all madness is poetic

Conditions inside the hospital were appalling by modern standards, but by the standards of the time, especially compared to prisons, maybe not the worst thing that could happen to a mentally ill person with nowhere else to go. Wikipedia says, “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.”bedlam rebuilt1828 1

The article goes on to describe short rations and filthy conditions, largely caused by sparsely provided facilities for washing and waste management, and by the disturbed condition of the patients.

By the early nineteenth century, the building itself, poorly maintained for centuries, was falling apart. The decision was made to build a new Bedlam “at St. George’s Fields in Southwark, south of the Thames… in a swamp-like, impoverished, highly populated, and industrialised area.” (Wikipedia.) Sounds lovely. The new building looks pretty swank though, at least from the outside.

This building only held a few hundred inmates; too few to satisfy demand in this age of increasing demand for professional medical care.

The trade in lunacy


The old ways

By Hogarth’s time in the mid-eighteenth century, private madhouses were springing up all over Great Britain. Owners could reap great profits by providing a place for families to send their troubled relatives.

Some private hospitals were luxurious and some were horrific. Ideas about the care and treatment of the mentally ill shift dramatically as we move into the nineteenth century, largely due to that little thing called the Enlightenment. People said no more chaining of pitiful lunatics in filthy dark rooms! Give them light, good diet, healthy exercise, clean clothes. Merest common sense for us, but all things are radical when new.

A wealthy family might invest in several private madhouses with a good expectation of yielding substantial profits. Doctors could gain most of their income from their private hospitals.

Here’s an example. Droitwich Lunatic Asylum was established in 1791 in Droitwich Spa, Worcestershire, a place known for its brine baths. The building provided separate apartments for inmates at 4 guineas a week (84 shillings.) That included a servant. You could house your distracted relative for 3 guineas a week without the personal servant. Shared apartments, no servant, cost 2 guineas a week. All of these inmates would dine with the family, if they’re able. Otherwise, they’d have meals in their rooms.

holloway sanatorium2 1

The new way: Holloway Sanatorium

84 shillings a week x 52 weeks = 4,368 shillings =~ 218 1/2 pounds per annum. It’s hard to find good figures for average incomes, especially since most sources conflate the whole Victorian century. But a ballpark is good enough for our purposes. According to Fascinating History, a vicar might make £140/year, while the governor of the Bank of England pulled down £400. He’d need other sources of income to house his beloved old Aunt Dottie at Droitwich, and wouldn’t save much by shopping around.

You could spend more. Ticehurst Lunatic Asylum was one of the best places. It’s still a rest home for well-to-do seniors. Ticehurst was “the Mecca of private asylums,” according to Parry-Jones (see references below.) The estate covered 900 acres. Patients lived in little cottages scattered about the handsome landscape. In 1842, many patients had their own rooms and attendants. In other cases, two or more patients shared the same parlor and bedrooms, and presumably attendants. Most of its patients came from the aristocracy and the upper class — not surprising, with fees like that!

Better care for the other half

holloway sanatorium1 e1485449646255Victorians regulated things. They believed in the power of government to improve society and in a lot of ways they were not wrong. The Lunacy Act of 1842 made it lawful to treat lunatics as patients needing treatment, not beasts who simply needed to be kept out sight. They started building big county hospitals to care for paupers who couldn’t afford the pleasant private hospitals that continued to flourish. (We still have such places: think about the swanky rehab centers advertised in magazines like the New Yorker.)

I’ve already blogged about the biggest county hospital, the Colney Hatch Lunatic Asylum. At its peak, it held some 3,000 patients. 

Holloway Sanatorium was built in Surrey by philanthropist Thomas Holloway. Opened in 1885, it aimed at the lower middle class, but also took fee-paying middle class patients. By this time, progressive medical men and philanthropists believed the best way to treat mentally-ill persons was to provide them with clean, safe, attractive housing and encourage them to interact socially, under supervision, and to adopt crafts and other pastimes to occupy them. The men had a billiard room, for example, fostering the illusion of life in a grand country house.

Institutions like Holloway were founded to make provision for the middle and lower middle class, since public asylums were for paupers and because middle-class culture regarded madness with shame. There was also a widespread fear, particularly aimed at private asylums, that scheming relatives could easily lock up their kin for financial or personal gain. Hence associations like the Alleged Lunatics Friends Society, founded in 1845, to defend persons who believed they had been wrongfully committed.

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Holloway Sanatorium 1884

The Lunacy Act of 1890 specified that certification of non-pauper lunatics must be witnessed by a magistrate. This sharpened the lunatic as a legal entity, increasing the stigma attached. These institutions fought the stigma by creating lovely elaborate material worlds, like middle class houses or upper class hotels.

Bedlam was still in operation, still in the building erected in Southwark. Now it was used mainly for lower class pauper lunatics, like Colney Hatch. In 1851, among male patients, clerks were the largest group. Clerks (office and retail workers) were apparently under great stress in those days, a condition of concern to the Victorians. But before we get too carried away with that thought, we should remember that in the world before typewriters, thousands of clerks were required. The Victorians believed in regulation. They also believed in thorough documentation.

Bethlem Royal Hospital was moved again in 1930 to an outer suburb of London. The original grounds have been converted to a park. Part of the original (1815) buildings are now the Imperial War Museum. Since war is certainly a form of rampant public madness, that seems quite fitting to me.

Happy birthday, Dad!

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Dale L. Johnson, 1929-2016.

My father would have been 88 today. He died last year in June. He served for many years as the President of the National Alliance on Mental Illness, a global advocacy group that has helped many families find the right answer for their troubled kinfolk. If you know such a person, check out NAMI. They may be able to help you get the information you need.


Arnold, Catharine. 2008. Bedlam: London and Its Mad. London: Simon & Schuster.

Hamlett, Jane. 2015. At Home in the Institution: Material Life in Asylums, Lodging Houses and Schools in Victorian and Edwardian England. Palgrave MacMillan.

Parry-Jones, William L. 1972. The Trade in Lunacy: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries. London: Routhledge & Kegan Paul.

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