Madhouse
A History of London County Lunatic Asylums & Mental Hospitals

3,142 words

Ed Brandon
A History of London County Lunatic Asylums & Mental Hospitals
Pen and Sword History, 2022

Some of the news aggregators I watch online show clips from TikTok, and the fascination of watching this menagerie of psychological dysfunction reminded me of something I read or heard long ago. It seems that the Victorians in England would pay a penny to enter lunatic asylums, where they would watch the unfortunate inmates grimace and cavort for their entertainment in those pre-cinematic times. I never bothered to confirm this over the years, but always had a hankering to get hold of a decent history of English asylums. Such a book recently came my way, and it has the advantage of being not only a history of asylums and mental hospitals, but also of those in the area in which I grew up, greater London being the site of the first major program of asylum expansion. I have visited some of the buildings described by the author, and in fact worked in one. So, I approached Ed Brandon’s book, A History of London County Lunatic Asylums & Mental Hospitals with great expectations.

The author presents an 800-year timeline for the development of state care of the mentally infirm in England. Until the 13th century, those unsound of mind would generally be cared for by the church, in monasteries or almshouses. In 1275, however, the first purpose-built structure was made, Bethlehem Priory, later shortened to Bethlem, and further still to Bedlam. The word still remains in the English language as a noun defined as “a scene of uproar and confusion.”

Bethlehem was effectively the first asylum, which served as “a resting stop for pilgrims and other Catholic figures and invariably acts as the starting-point for any timeline of mental health care in Britain.” This rather unfortunately implies that pilgrims and other Roman Catholics were the first inmates, but I am sure this was not the author’s intention. If you read my piece on the Peasants’ Revolt, you will have met King Richard II, the boy-king crowned in 1377. That same year, Richard “had the ‘lunatic’ inmates of a small hospital in Charing Cross marched off to Bethlehem Priory in shackles because the noise they made was apparently disturbing the poor boy’s pet ravens, housed nearby.” Mental health has obviously been a problem for the English monarchy other than just in the case of George III. More on him later.

Henry VIII spared the building, even though it was a Catholic institution and he was flattening all the others, and bequeathed it to the Anglican Church on his deathbed. Families began to commit their problematic children to, effectively, state care, and Bethlehem began to become of significance as the first of many similar asylums. And I got the answer to my question:

Group tours were even organized, and paying visitors allowed to enter in order to ogle, irritate, and mock the inmates, or to study them for the purposes of scientific, artistic, philosophical, or more general curiosity.

I heard right, it just didn’t start with the Victorians.

When Bridewell Prison burnt down in the Great Fire of London of 1666, and the committee was forced to relocate to Bethlehem, they saw both its state of disrepair and its potential for taking that section of society’s overspill which was not criminal. A “New Bethlem” was built at Moorfields (now Britain’s most famous eye hospital) in 1676, and was the first ever purpose-built lunatic asylum. Rather bizarrely, it also featured statues of obviously insane people above its entrance arches. Possibly this was a form of advertisement, an attempt to attract customers in the same way as a barber’s pole.

By the eighteenth century, the fabled madness of King George III had, as we would say today, “raised the profile” of mental health, and Parliament passed the County Asylums Act in 1808. Bethlehem had been rather secretive in its operating practices, but was used as a model for a building program solely designed, for the first time perhaps in history, for the mentally ill. There were voices raised in opposition. Why should taxes pay for those unfortunates who cannot participate in society? The question echoes today. But mental health care was now fully under governmental control, and at the end of the 19th century, the Commissioners in Lunacy were not the rock band you might expect today, but the governmental body which oversaw the new sector.

An investigative committee which included a Member of Parliament and an architect were hurried along in their findings by a shocking death in Bethlehem – a fairly wretched place – which captured the nation’s attention, and their report of 1815 gave the government no choice but to institute a program of asylum-building. The revised County Asylums Act of 1845 made it mandatory for each county and county borough to construct an asylum sufficient for its “registered pauper lunatics.” One assumes that the upper classes either hid their lunatic sons away, or got them promoted to the House of Lords.

The architecture of the buildings is dwelt on by Brandon throughout the profile of each of the dozen or so asylums whose biographies he gives. The main innovation of asylum architecture was that buildings began to be designed on a radial plan, with corridors branching out from a central hub. Connecting walkways between the “spokes of the wheel”, as it were, meant reduced time spent travelling about the hospital, rather than that taken in the standard hospital design of very few, very long corridors. There was another consideration built into the new design:

By the 1820s, it had become more widely accepted that lunatics should not be incarcerated as a form of punishment and this shift toward considering the welfare of the patients as well as ease of management is evident.

The first purpose-built pauper asylum opened at Hanwell in north-east London in 1831, and took in 24 male and 18 female patients. The new facility was more like a new town than the standard picture of an asylum, and as its population grew, it established within its grounds a bakery, apothecary, piggery, carpenter’s, printing-rooms, upholsterers, and indeed everything one might expect to find in a rural farming village. It even had a brewery, although the production of alcohol within asylums slowed and ceased as alcohol abuse became an increasing factor in mental health admissions.

Death rates were high, but not in the context of hospitals in general. In fact, Hanwell recycled. The 1832 Anatomy Act had loosened the laws about medical dissection of cadavers, and Hanwell covered some of its running costs via a brisk sale in corpses.

This was all long before the rise of the pharmaceutical industry, and drugs are now responsible for much long-term insanity. What were the routes to the insane asylum in Victorian England? Arrest for criminal activity followed by certification as a lunatic by a judge, the process which existed then, is very similar to so-called “sectioning” in modern Britain, whereby a person can be sectioned and held under the 1983 Mental Health Act. Victorian work-houses actually provided the largest number of admissions, and perhaps this is the origin of the famous office sign: You don’t have to be mad to work here, but it helps. As for the symptoms of insanity, they were divided into physical and moral categories, and the latter might see many more of us in Bedlam were they today’s criteria:

In Hanwell’s first decade of operation, recognized ‘physical causes’ of madness numbered only four: intemperance (excessive consumption of alcohol), epilepsy, head injury, and paralysis. The recognized categories for the ‘moral causes’ were broader and included poverty, disappointed affections, domestic unhappiness, religious enthusiasm, fright, grief, and anxiety.

I believe we have drugs for those now. This was, of course, still a Christian society, and its morality followed that civic structure, with the psychological aspects of medicine promptly following suit. By the time the first Diagnostic and Statistical Manual (now DSM V) was produced in the 1950s, what would become the Bible of psychiatry and thus the pharmaceutical industry contained no trace of morality left in the diagnoses of psychological conditions, which had been reduced to the purely behavioral and clinical. As the 19^th century became the twentieth, reasons for asylum admission refined somewhat, and divided again into new categories: heredity, mental instability (which seems to beg the question somewhat), lack of one or more senses, critical periods such as puberty or senility, child rearing, mental stress, physiological defects or errors (a very eugenic turn of phrase), toxic, traumatic, diseases of the nervous system, and “other bodily afflictions”. Much was learned about insanity by watching and recording it in a controlled environment; this was science as well as health care. The asylums were not by any means simply holding areas for those unable to partake in society, nor were they merely effective cottage industries useful in finding something to do for mad people that would not be a net cost to the state, they were also the laboratory for those who studied the eternal problem of mental unbalance.

Hanwell passed through very capable hands, with a succession of innovative and efficient directors. These men were philanthropic as well as medical men, psychologists and philosophers as well as administrators. They could not differ more from the technocrats who (mis)rule the British health service today. Innovations were made by observation of what was actually taking place in the asylum, and thanks to the radial design, owing something to Jeremy Bentham’s panopticon design for prisons to allow constant monitoring, the asylum was open for observation just as much as its residents. Work was encouraged for the inmates, with one director stating that,

the labour of patients within any asylum should never be perceived as a means of production or punishment, as it was in the workhouse and in prison, but rather a means to occupy unhappy minds and a way of distracting them from ‘morbid’ thoughts.

The use of language by the state in defining its institutions always repays inspection – as Orwell recognized – and Hanwell changed its name in 1918 to “London County Mental Hospital, Hanwell.” This pre-empted the 1930 Mental Treatment Act, designed to consolidate recent improvements in the treatment of the mentally ill and handicapped, and ending the use of the word “asylum.” They need not have worried that the word would slip into disuse.

Hanwell survived the war, losing only its laundry to German bombs in 1944, and by the 1960s, patient numbers were beginning to decline as the relaxation of incarceration as a guiding principle began to weaken with regard to the mentally unwell. Hanwell remained as both the main recipient hospital for the area, and a symbol of a government program from a time when those things were actually of some use to people who needed them. Like many of these beautiful and atmospheric buildings, Hanwell turned up as a location in various TV series and movies after it shut down as a hospital, including Tim Burton’s 1989 Batman. Also like many of the other asylums the author covers, developers bought much of the original site, and in 2022 (at the time of the book), an average two-bedroom apartment in the new development cost £430,000, the site being described in the sales literature as a “former hospital.” As some of the new residents of Hanwell will know from the cinema, that’s how horror films start.

In the early days of the asylum system, patients came mainly from the artisanal class, with “labourer” the most common occupation, with servants, shoe-menders, painters, and glaziers the next most psychologically perilous occupations. Mr. Brandon punctures a myth with his lunatic demographic, as the percentage of “hatters” admitted to asylums was just 0.06% of the total. It has always been believed that the phrase “as mad as a hatter” referred to the prevalence of insanity among hat-makers, supposedly due to exposure to mercury, but this is just a picturesque idea immortalized in Lewis Carroll’s Alice in Wonderland.

Colney Hatch and Banstead asylums followed, and overspill was becoming a problem which would be exacerbated during both wars, when of course the asylums had to double as hospitals for the war wounded. Banstead was followed by an asylum at Caterham, in Surrey, the town in which I grew up. It is scarcely mentioned by the author, being on the cusp of the catchment area he covers, but St. Lawrence’s hospital was for the mentally handicapped, and closed in the 1980s. My mother worked there as an art therapist – another curative pastime for the mentally ill discovered through the asylum system – and I played for the hospital’s cricket team. It was another extraordinary building and is also now a housing development.

The extraordinary circumstances of insanity required extraordinary clinical provision. Various restraining devices are shown in the book – along with prints of all the buildings covered – and Banstead was the first asylum in history to build and use a padded cell, an idea which it patented. Asylums also used ECT, or Electro-Convulsive Therapy, as well as the surgical procedure known as a trans-orbital leucotomy, the precursor to the better-known lobotomy. In the 1960s, Banstead was also the subject of a major investigation into neglect and cruelty. The efficiency with which the investigation was carried out is in bold distinction to today’s practice, in a health system hobbled by the fall in the educational standard of administrative staff, and perennially clogged with vexatious complaints.

Cane Hill Asylum was also very close to my hometown, and I would pass it on the bus to Croydon, a mysterious building with a beautiful clock-tower. The hospital was a part of local folklore due to its connection with two English showbusiness icons. Michael Caine’s half-brother spent his life there, most of it unknown to Caine. The half-brother was illegitimate, and Caine’s mother hid the secret from the family until Caine found out by chance about his half-brother’s existence in 2001. Another half-brother to have been admitted several times to Cane Hill, and who spent the last four years of his life there, was that of David Bowie. The author tells various stories of the famous and semi-famous English characters (mostly unknown outside England, although Charlie Chaplin’s mother was admitted) who were admitted to the asylums noted. Ronnie Kray, one half of Britain’s most notorious criminal gang, the Kray Twins, spent time in an east London asylum.

In the 20th century, the history of the buildings was obviously affected by two world wars, and several of the hospitals were themselves bombed. Later in the century, perhaps with the rise of the psychiatric and pharmaceutical industries, many of the hospitals became psychiatric units. At its peak, however, London had eleven county asylums housing almost 25,000 people. It is a matter of political argument whether or not the 1983 Care in the Community Act, under which low-risk patients were placed back in the community, brought into place under Margaret Thatcher was of benefit either to the communities or those receiving care.

The author raises an excellent point with his timeframe, which is that standards of hygiene and procedural efficiency come to differ over time, and it is thus not a simple matter to evaluate the true worth of the asylum system from any ideal standpoint:

[T]he simple question of whether the county asylums were a good or bad thing overall is not[…] straightforward to answer without bias, because any answer would necessarily depend on who was being asked. By the standards of differing eras, any given asylum might, for example, have been relatively comfortable and well-managed in 1890, then overcrowded and insanitary by 1930, and perhaps have offered a productive and therapeutic regime to willing, voluntary patients by 1980.

Whatever their worth to society, the asylums of England – and particularly those in and around London – have a history, and Brandon recounts it compellingly.

The asylum has a place in the English psyche, and my having grown up amid the cluster which Brandon so thoroughly records here means that I saw a lot of mentally handicapped people, both working at a hospital, and in the streets of my town. These were low-risk patients, and I don’t recall any incident involving a patient from my local hospital. They fitted into the community by virtue of generally walking round the place smiling at everyone. Although asylums and mental hospitals were undoubtedly variable in the service they provided, the descriptions Brandon gives of healthy diet, exercise, music and drama, art therapy and other therapeutic pursuits are at odds with the dark picture the asylum generally suggests. And the fate of those people who called asylums home had they been alive in other ages is adequately summed up by the author:

It is not necessary to evoke specific images of the kind of persecution that would have been suffered by the ‘mad’ in medieval times, but for most it would have been brutal and unforgiving, and was usually felt to be justified on a religious basis: before the business of ‘mad-doctoring’ became a distinct profession in the eighteenth century, mental illness was almost invariably believed to be the result of failed morals, evil deeds, or possession by demonic forces, and so whatever punishment was meted out was felt to be perfectly justified.

It is reflective of these post-asylum times that, whereas at one time one knew where the mad people were in England, now one does not. It is also the case that mental health care in Britain is in a shocking state, and the treatment of the mentally ill is an important performance indicator for any nation claiming to have a moral compass. It is not helped by the added strain of dozens of “new” disorders, sponsored by big pharma – who just happen to market drugs for these designer maladies – and a willingness of doctors to sign people off with various “neurodivergent” disorders just to clear their backlog.

This is a direct result, in my view, of a shift in focus in health care across in Britain whereby its center of attention has moved from the patient to the system. In the end, doctors became technocrats, and health authorities have long since replaced the philanthropic and intellectually gifted men who used to run asylums with people whose job is largely to manage meetings. Mental health is a demanding sector of government from which management emerges with credit in this book. It is noteworthy that the author apologizes for his lack of detail on the modern period, not during Queen Victoria’s reign, but post-1970s. Details held by health authorities, he writes, “relate more to opaque bureaucratic systems than the buildings themselves or what occurred within them.”

What a perfect symbol for the modern world.

Mr. Brandon’s book is a well-informed glimpse into a twilit world, a piece of secret history. The asylum buildings whose histories are given here, and what occurred within them, results in a fascinating piece of alternative, “ordinary” history, for which Mr. Brandon is to be applauded.

Welcome to the madhouse.