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The rise of the lunatic asylum and its gradual transformation into, and eventual replacement by, the modern psychiatric hospital, explains the rise of organized, institutional psychiatry. While there were earlier institutions that housed the 'insane,' the arrival at the answer of institutionalisation as the correct solution to the problem of madness was very much an event of the nineteenth century. To illustrate this with one regional example, in England at the beginning of the nineteenth century there were, perhaps, a few thousand "lunatics" housed in a variety of disparate institutions but by 1900 that figure had grown to about 100,000. That this growth should coincide with the growth of alienism, now known as psychiatry, as a medical specialism is not coincidental.

Beginning stages

In 1632 it was recorded that the old house of Bethlem had "below stairs a parlor, a kitchen, two larders, a long entry throughout the house, and 21 rooms wherein the poor distracted people lie, and above the stairs eight rooms more for servants and the poor to lie in".Inmates who were deemed dangerous or disturbing were chained-up or shut-up but Bethlem was an otherwise open building for its inhabitants to roam around its confines and possibly throughout the general neighborhood in which the hospital was situated.

Humanitarian Reform

Europe

Franz Mesmer

Franz Mesmer was a physician who was interested in the use of magnets in healing the sick and the forerunner of hypnotism . His theory was that the magnetism of iron affected a magnetic fluid in the body and with this theory he treated patients with ranges of physiological symptoms including paralysis, blindness and chronic pain. Mesmer's clinic introduced the idea of psychotherapy as theater.

Mesmer's theory was that disease was the result of "obstacles" in the flow of the fluid through out the body, and the obstacles could only be broken by what he called a crises. Crises were trance states that often ended in delirium or convulsion.

Philippe Pinel

"In all public asylums as well as in prisons and hospitals, the surest, and, perhaps, the only method of securing health, good order, and good manners, is to carry into decided and habitual execution the natural law of bodily labour, so contributive and essential to human happiness." - A Treatise on Insanity, Section 1. Translated by D. D. Davis.

Philippe Pinel was a French physician who was responsible for a widespread reform in French asylums and is credited as being one of the founders of psychiatry. Also an author, Pinel's book A Treatise on Insanity gave an improved and simple classification system for mental disorders.

Pinel arrived to the hospital of Bicêtre in 1792. Before his arrival, inmates were chained in cramped cell like rooms where there was poor ventilation and filth. Pinel requested that the French government allow him to implement a new treatment plan for the inmates. Pinel's new treatment consisted of allowing the inmates to have more freedom,physical exercise, and teaching them to make logical choices that were followed up with reasonable punishment if needed.

Due to more humane treatment, patients began to reform their behavior and Pinel was able to slowly liberate fifty patients. Pinel was also able to petition the Revolutionary Committee to discontinue bloodletting and purging as customary medical treatments.

He advocated against the idea that mental illness was cause of demoniacal possession but instead the result of excessive exposure to social and psychological stresses of heredity and physiological damage.

Jean-Marc Itard

Jean-Marc Itard was a French teacher of the deaf who made an accidental discovery in the area of mental deficiency. Itard's work started when a young boy was found by hunters. The boy was unable to talk and was diagnosed by Pinel as an "incurable idiot". While Itard worked with the boy for two years, he was not able to speak but made progress and became affectionate. Itard work suggests what could happen on a bigger stage with children and mental retardation.

Edouard Seguin

Edouard Seguin was a Frenchmen who developed a systematic approach for training individuals with mental deficient. In 1839,Séguin opened the first school for the severely retarded and developed a method of treatment based on that the mentally deficient did not have a disease or an abnormal brain. Seguin later on moved to the United States and created schools for retarded children as well as opening up his own practice. He also became the founding president of the Association of Medical Officers of American Institutions for Idiotic and Feebleminded Persons in 1876.

America

i) Rush

Benjamin Rush of Philadelphia also promoted humane treatment of the insane outside dungeons and without iron restraints, as well as sought their reintegration into society. In 1792 Rush successfully campaigned for a separate ward for the insane at the Pennsylvania Hospital. His talk-based approach led to modern occupational therapy and addiction medicine, although most of his physical approaches have long been discredited, such as bleeding and purging (unlike Pinel), hot and cold baths, mercury pills, a "tranquilizing chair" and gyroscope. In Italy, Vincenzo Chiarugi may also have banned chains before this time. Johann Jakob Guggenbühl in 1840 started in Interlaken the first retreat for mentally disabled children.

ii) Trends

iii) Dix

Physical therapies

A series of radical physical therapies were developed in central and continental Europe in the late 1910s, the 1920s and, most particularly, the 1930s. Among these we may note the Austrian psychiatrist Julius Wagner-Jauregg's malarial therapy for general paresis of the insane (or neurosyphilis) first used in 1917, and for which he won a Nobel Prize in 1927. This treatment heralded the beginning of a radical and experimental era in psychiatric medicine that increasingly broke with an asylum based culture of therapeutic nihilism in the treatment of chronic psychiatric disorders, most particularly dementia praecox (increasingly known as schizophrenia from the 1910s, although the two terms were used more or less interchangeably until at least the end of the 1930s), which were typically regarded as hereditary degenerative disorders and therefore unamenable to any therapeutic intervention. Malarial therapy was followed in 1920 by barbiturate induced deep sleep therapy to treat dementia praecox, which was popularized by the Swiss psychiatrist Jakob Klaesi. In 1933 the Viennese based psychiatrist Manfred Sakel introduced insulin shock therapy and in August 1934 Ladislas J. Meduna, a Hungarian neuropathologist and psychiatrist working in Budapest, introduced cardiazol shock therapy (cardiazol is the tradename of the chemical compound pentylenetetrazol, known by the tradename metrazol in the United States), which was the first convulsive or seizure therapy for a psychiatric disorder. Again, both of these therapies were initially targeted at curing dementia praecox. Cardiazol shock therapy, founded on the theoretical notion that there existed a biological antagonism between schizophrenia and epilepsy and that therefore inducing epiletiform fits in schizophrenic patients might effect a cure, was superseded by electroconvulsive therapy (ECT), invented by the Italian neurologist Ugo Cerletti in 1938. In 1935 the Portuguese neurologist Egas Moniz devised the leucotomy, a surgical procedure targeting the brain's frontal lobes. This was shortly thereafter adapted by Walter Freeman and James W. Watts in what is known as Freeman-Watts procedure or the standard prefrontal lobotomy. From 1946, Freeman developed the transorbital lobotomy, using a device akin to an ice-pick. This was an "office" procedure which did not have to be performed in a surgical theatre and took as little as fifteen minutes to complete. Freeman is credited with the popularisation of the technique in the United States. In 1949, 5074 lobotomies were carried out in the United States and by 1951, 18,608 people had undergone the controversial procedure in that country.

In modern times, insulin shock therapy and lobotomies are viewed as being almost as barbaric as the Bedlam "treatments", although the insulin shock therapy was still seen as the only option which produced any noticeable effect on patients. ECT is still used in the West, but it is seen as a last resort for treatment of mood disorders, and is administered much more safely than in the past. Elsewhere, particularly in India, use of ECT is reportedly increasing, as a cost-effective alternative to drug treatment. The effect of a shock on an overly excitable patient often allowed these patients to be discharged to their homes, which was seen by administrators (and often guardians) as a preferable solution to institutionalization. Lobotomies were performed in the hundreds from the 1930s to the 1950s, and were ultimately replaced with modern psychotropic drugs

Drugs

The twentieth century saw the development of the first effective psychiatric drugs.

The first antipsychotic drug, chlorpromazine (known under the trade name Largactil in Europe and Thorazine in the United States), was first synthesised in France in 1950. Pierre Deniker, a psychiatrist of the Saint-Anne Psychiatric Centre in Paris, is credited with first recognising the specificity of action of the drug in psychosis in 1952. Deniker travelled with a colleague to the United States and Canada promoting the drug at medical conferences in 1954. The first publication regarding its use in North America was made in the same year by the Canadian psychiatrist Heinz Lehmann, who was based in Montreal. Also in 1954 another antipsychotic, reserpine, was first used by an American psychiatrist based in New York, Nathan S. Kline. At a Paris based colloquium on neuroleptics (antipsychotics) in 1955 a series of psychiatric studies were presented by, among others, Hans Hoff (Vienna), Aksel (Istanbul), Felix Labarth (Basle), Linford Rees (London), Sarro (Barcelona), Manfred Bleuler (Zurich), William Mayer-Gross (Birmingham), Winford (Washington) and Denber (New York) attesting to the effective and concordant action of the new drugs in the treatment of psychosis.

The new antipsychotics had an immense impact on the lives of psychiatrists and patients. For instance, Henry Ey, a French psychiatrist at Bonneval, related that between 1921 and 1937 only 6 per cent of patients suffering from schizophrenia and chronic delirium were discharged from his institution. The comparable figure for the period from 1955 to 1967, after the introduction of chlorpromazine, was 67 per cent. Between 1955 and 1968 the residential psychiatric population in the United States dropped by 30 per cent. Newly developed antidepressants were used to treat cases of depression, and the introduction of muscle relaxants allowed ECT to be used in a modified form for the treatment of severe depression and a few other disorders. Fluoxetine hydrochloride (fluoxetine) was developed in 1973 by Bryan Molly, David Wong and Roy Fuller of the Eli Lilly corporation and is today sold under the brand name Prozac.

The discovery of the mood stabilizing effect of lithium carbonate by John Cade in 1948 would eventually revolutionize the treatment of bipolar disorder, although its use was banned in the United States until the 1970s.

The use of psychosurgery was narrowed to a very small number of people for specific indications. New treatments led to reductions in the number of patients in mental hospitals.

Present Day (1900-2000)

United States

i) United States: Reform in the 1940s

ii) Psychiatric internment as a political device

iii) Deinstitutionalization

Other places

i) South America

ii) Asia

iii) New Zealand

iv) Africa

Further reading

http://www.uniteforsight.org/mental-health/module2

http://www.tiki-toki.com/timeline/entry/37146/A-History-of-Mental-Institutions-in-the-United-States/

http://www.english-heritage.org.uk/discover/people-and-places/disability-history/1485-1660/mental-illness-in-the-16th-and-17th-centuries/