Bethlem has always been a 'real' hospital, in the sense that patients were admitted in order to be cured, but in its early days, those who did not recover might stay for years. The first full list of patients, dating from 1598, includes one woman who had been in the hospital for 25 years, but ten of the 21 inmates had been in for a year or less.

In the next century it became the practice to discharge those who seemed unlikely to recover, and this developed into a rule that no patient should remain for longer than 12 months.

A Men's Ward in 1860

Reproduced courtesy of Bethlem Royal Hospital Archives and Museum

As the 1598 list already shows, patients were admitted from all over the country. This reflects the fact that for several centuries, Bethlem was the only public institution for the mentally disordered. (The main local alternatives which were to grow up later were the private madhouses, which flourished from the eighteenth century on, and the county asylums of the nineteenth century.)

Bedlam- A Chronology

1247
The Priory of St Mary of Bethlehem at Bishopgate, London is founded by Deed
of Gift of Simon Fitz-Mary.
1329
The Priory of St Mary of Bethlem is first described as a 'hospice' or 'hospital'.
1346
Matthew de Norton, Master of the Order, petitions the Mayor of the City of London for help in managing the hospital, and the city takes the hospital under its patronage.
1403
First public inquiry - a visitation by commissioners of King Henry IV - includes
a mention of 'men deprived of reason'.
1547
After the dissolution of the religious order, King Henry VIII grants the governors
of the hospital to the City of London.
1557
Bethlem and Bridewell, the House of Correction, are united under one management
1633
Royal Commissioners investigate the problems of the hospital, concerning the Keeper, Dr Helkiah Crooke.
1676
First change of site. Bethlem moves to a palatial new building at Moorfields, London
1723-33
Wings for incurable patients are constructed.
1733
Hogarth paints 'Bedlam' - the last scene in his 'Rake's Progress'
1770
Visiting is restricted to those with tickets of admission.
1815
Bethlem moves again, to another site at Southwark, London.
1815-16
Parliamentary inquiry into the treatment of the patients. Blocks for criminal patients are built .
1851-2
Inquiry by the Lunacy Commissioners, and major reforms begin.
1863-4
Criminal patients are transferred to the new Broadmoor Hospital
1870
Convalescent establishment opens at Witley in Surrey.
1882
The Charity Commissioners agree for paying patients to be admitted.
1923
The Maudsley Hospital for early and acute cases of mental illness opens in Camberwell, London.
1930
Bethlem transfers to a country estate at Beckenham, Kent.
1939
The Maudsley Hospital disperses to Middlesex and Surrey because of World War II.
1948
Bethlem Royal and Maudsley Hospitals amalgamate as a single postgraduate teaching hospital in the new NHS.
1967
The Maudsley takes over the management of the district catchment area service for the mentally ill.
1991
Bethlem Royal and Maudsley Hospitals become an NHS Trust.
1997
Bethlem Royal Hospital will be 750 years old.

For most of its history, Bethlem's patients have come from the ranks of the very poor, and with a few notable exceptions, little is known of most of them beyond their names and places of origin, recorded in admission registers which date back to 1683.

Even the more detailed casebooks of the nineteenth century tell us relatively little of these people outside their brief passage through the hospital, though a remarkable set of photographs taken in the 1850s adds an extra and moving dimension to the record.

A change in social status took place in the mid-nineteenth century. It was decided to exclude pauper patients, who could now be cared for in the new county asylums, and give preference to the poor of the middle classes. In 1882 the first handful of paying patients were admitted, and inevitably the numbers crept up (though the 'free list' was never wholly abandoned). By the time the new hospital opened in 1930, the prospectus was referring to "accommodation for 141 ladies and 109 gentlemen, each of whom must be of suitable educational status".

Under the NHS, in conjunction with the the Maudsley, Bethlem became part of a system based largely on specialist units and treatments, and clinical considerations took over from social and financial circumstances as the main criteria for admission. The new Trust has now taken responsibility for mental healthcare in the Croydon area, introducing for the first time (for Bethlem though not for the Maudsley) a service for the local community. As the 1598 list already shows, patients were admitted from all over the country. This reflects the fact that for several centuries, Bethlem was the only public institution for the mentally disordered. (The main local alternatives which were to grow up later were the private madhouses, which flourished from the eighteenth century on, and the county asylums of the nineteenth century.)

Contrary to popular belief, mental disorder has been regarded as potentially curable throughout the hospital's history. Whether popular 'cures' that have been in vogue throughout history have actually contributed to the patients' recovery is another question.

However, a proportion - possibly just over 30 per cent in the eighteenth century - did recover, though some were readmitted at a later date.
In the absence of effective treatments, most of which have been developed in the present century, physical restraint featured prominently in Bethlem's regime, but this was never the whole story. Both medical and psychological methods of treatment have long been in use. Medicines have probably always been administered, and in 1700 a fund was set up to provide 'Phisick' for discharged patients to prevent their relapse. However, under the Monro family's long reign as physicians, medication made little progress. Their practice, handed down from father to son, can be summarized as 'purges, vomits, and bloodletting' - standard treatment in the early eighteenth century, but distinctly outmoded by the mid-nineteenth.

Cold and warm bathing, introduced in the 1680s, seems more likely to have benefited the patients, particularly 'In the Heat of the Weather... to cool and wash them'. Occupation, and distraction from false, deluded or melancholy thoughts, was also considered important. By 1765, for example, it was one of the matron's duties to make sure that the women patients who were 'low spirited or inclinable to be mopish' should get up and not be allowed to slink back to bed, and to employ those who were capable at needlework. In the 19th century occupation and entertainments multiplied. Dances were held in Bethlem as early as the 1840s, outings and excursions took place, and many other activities were introduced.

Huge advances in scientific knowledge, particularly in the understanding of brain function and the development of effective drugs for many conditions, together with a wide range of techniques based on psychotherapy, have revolutionized treatments in the second half of the twentieth century.

The Bethlem Royal Hospital continues to play an important role in today's modern NHS. It provides specialist services, including those dealing with perinatal psychiatry, challenging behaviour, addictions, psychosis, child and adolescent psychiatry and forensic psychiatry.

Here many of the advances in neuro-imaging, genetics, biochemistry and neurophysiology are put into practice, targeting major mental health problems - problems that continue to be a leading cause of illness, distress, disability and mortality.

Policy changes in the NHS and Social Services call for the care of the mentally ill to take place in the community; nevertheless, the need for in-patient care continues. There are arguments against the further closure of hospital beds, especially within inner-city areas, and opposite arguments from those who believe the community care programme has not developed enough.