Lunatic asylum
The lunatic asylum, insane asylum or mental asylum was an institution where people with mental illness were confined. It was an early precursor of the modern psychiatric hospital.
Modern psychiatric hospitals evolved from and eventually replaced the older lunatic asylum. The treatment of inmates in early lunatic asylums was sometimes brutal and focused on containment and restraint. The discovery of anti-psychotic drugs and mood-stabilizing drugs resulted in a shift in focus from containment in lunatic asylums to treatment in psychiatric hospitals. Later, there was further and more thorough critique in the form of the deinstitutionalization movement which focuses on treatment at home or in less isolated institutions.
Whilst it was used in the past, modern and more humane areas have been developed as opposed to the unorthodox methods of isolation and questionable therapies used in Lunatic asylum.
History
Medieval era
In the Islamic world, the Bimaristans were described by European travellers, who wrote about their wonder at the care and kindness shown to lunatics. In 872, Ahmad ibn Tulun built a hospital in Cairo that provided care to the insane, which included music therapy. Nonetheless, British historian of medicine Roy Porter cautioned against idealising the role of hospitals generally in medieval Islam, stating that "They were a drop in the ocean for the vast population that they had to serve, and their true function lay in highlighting ideals of compassion and bringing together the activities of the medical profession."In Europe during the medieval era, a small subsection of the population of those considered mad were housed in a variety of institutional settings. Mentally ill people were often held captive in cages or kept up within the city walls, or they were compelled to amuse members of courtly society. Porter gives examples of such locales where some of the insane were cared for, such as in monasteries. A few towns had towers where madmen were kept. The ancient Parisian hospital Hôtel-Dieu also had a small number of cells set aside for lunatics, whilst the town of Elbing boasted a madhouse, the Tollhaus, attached to the Teutonic Knights' hospital. Dave Sheppard's Development of Mental Health Law and Practice begins in 1285 with a case that linked "the instigation of the devil" with being "frantic and mad".
In Spain, other such institutions for the insane were established after the Christian Reconquista; facilities included hospitals in Valencia, Zaragoza, Seville, Barcelona and Toledo. In London, England, the Priory of Saint Mary of Bethlehem, which later became known more notoriously as Bedlam, was founded in 1247. At the start of the 15thcentury, it housed six insane men. The former lunatic asylum, Het Dolhuys, established in the 16thcentury in Haarlem, the Netherlands, has been adapted as a museum of psychiatry, with an overview of treatments from the origins of the building up to the 1990s.
Emergence of public lunatic asylums
The level of specialist institutional provision for the care and control of the insane remained extremely limited at the turn of the 18thcentury. Madness was seen principally as a domestic problem, with families and parish authorities in Europe and England central to regimens of care. Various forms of outdoor relief were extended by the parish authorities to families in these circumstances, including financial support, the provision of parish nurses and, where family care was not possible, lunatics might be 'boarded out' to other members of the local community or committed to private madhouses. Exceptionally, if those deemed mad were judged to be particularly disturbing or violent, parish authorities might meet the not inconsiderable costs of their confinement in charitable asylums such as Bethlem, in Houses of Correction or in workhouses.In the late 17thcentury, this model began to change, and privately run asylums for the insane began to proliferate and expand in size. Already in 1632 it was recorded that Bethlem Royal Hospital, London 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, but Bethlem was an otherwise open building. Its inhabitants could roam around its confines and possibly throughout the general neighborhood in which the hospital was situated. In 1676, Bethlem expanded into newly built premises at Moorfields with a capacity for 100 inmates.
A second public charitable institution was opened in 1713. Known as the Bethel in Norwich, it was a small facility which generally housed between twenty and thirty inmates. In 1728 at Guy's Hospital, London, wards were established for chronic lunatics. From the mid-eighteenth century the number of public charitably funded asylums expanded moderately with the opening of St Luke's Hospital in 1751 in Upper Moorfields, London; the establishment in 1765 of the Hospital for Lunatics at Newcastle upon Tyne; the Manchester Lunatic Hospital, which opened in 1766; the York Asylum in 1777 ; the Leicester Lunatic Asylum, and the Liverpool Lunatic Asylum.
A similar expansion took place in the British American colonies. The Pennsylvania Hospital was founded in Philadelphia in 1751 as a result of work begun in 1709 by the Religious Society of Friends. A portion of this hospital was set apart for the mentally ill, and the first patients were admitted in 1752. Virginia is recognized as the first state to establish an institution for the mentally ill. Eastern State Hospital, located in Williamsburg, Virginia, was incorporated in 1768 under the name of the "Public Hospital for Persons of Insane and Disordered Minds" and its first patients were admitted in 1773.
Trade in lunacy
There was no centralised state response to “madness” in society in century Britain until the 19thcentury, however private madhouses proliferated there in the 18thcentury on a scale unseen elsewhere. References to such institutions are limited for the 17thcentury but it is evident that by the start of the 18thcentury, the so-called 'trade in lunacy' was well established. Daniel Defoe, an ardent critic of private madhouses, estimated in 1724 that there were fifteen then operating in the London area. Defoe may have exaggerated but exact figures for private metropolitan madhouses are available only from 1774, when licensing legislation was introduced: sixteen institutions were recorded. At least two of these, Hoxton House and Wood's Close, Clerkenwell, had been in operation since the 17thcentury. By 1807, the number had increased to seventeen. This limited growth in the number of London madhouses is believed likely to reflect the fact that vested interests, especially the College of Physicians, exercised considerable control in preventing new entrants to the market. Thus, rather than there being a proliferation of private madhouses in London, existing institutions tended to expand considerably in size. The establishments which increased most during the 18thcentury, such as Hoxton House, did so by accepting pauper patients rather than private, middle class, fee-paying patients. Significantly, pauper patients, unlike their private counterparts, were not subject to inspection under the 1774 legislation.Fragmentary evidence indicates that some provincial madhouses existed in Britain from at least the 17thcentury and possibly earlier. A madhouse at Kingsdown, Box, Wiltshire was opened during the 17thcentury. Further locales of early businesses include one at Guildford in Surrey which was accepting patients by 1700, one at Fonthill Gifford in Wiltshire from 1718, another at Hook Norton in Oxfordshire from about 1725, one at St Albans dating from around 1740, and a madhouse at Fishponds in Bristol from 1766. It is likely that many of these provincial madhouses, as was the case with the exclusive Ticehurst House, may have evolved from householders who were boarding lunatics on behalf of parochial authorities and later formalised this practice into a business venture. The vast majority were small in scale with only seven asylums outside London with in excess of thirty patients by 1800 and somewhere between ten and twenty institutions had fewer patients than this.
Humanitarian reform
During the Age of Enlightenment, attitudes began to change, in particular among the educated classes in Western Europe. “Mental illness” came to be viewed as a disorder that required some form of compassionate but clinical, “rational” treatment that would aid in the rehabilitation of the patient into a rational being. When the ruling monarch of the United Kingdom, George III, who had a mental disorder, experienced a remission in 1789, mental illness came to be seen as something which could be treated and cured. The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke.In 1792, Pinel became the chief physician at the Bicêtre Hospital in Le Kremlin-Bicêtre, near Paris. Before his arrival, inmates were chained in cramped cell-like rooms where there was poor ventilation, led by a man named Jackson 'Brutis' Taylor. Taylor was then killed by the inmates leading to Pinel's leadership. In 1797, Jean-Baptiste Pussin, the "governor" of mental patients at Bicêtre, first freed patients of their chains and banned physical punishment, although straitjackets could be used instead. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel argued that mental illness was the result of excessive exposure to social and psychological stresses, to heredity and physiological damage.
Pussin and Pinel's approach was seen as remarkably successful, and they later brought similar reforms to a mental hospital in Paris for female patients, La Salpetrière. Pinel's student and successor, Jean Esquirol, went on to help establish 10 new mental hospitals that operated on the same principles. There was an emphasis on the selection and supervision of attendants in order to establish a suitable setting to facilitate psychological work, and particularly on the employment of ex-patients as they were thought most likely to refrain from inhumane treatment while being able to stand up to patients' pleas, menaces, or complaints.
File:RetreatOriginalBuildingssm.jpg|thumb|left|The York Retreat was built by William Tuke, a pioneer of moral treatment for the insane.
William Tuke led the development of a radical new type of institution in Northern England, following the death of a fellow Quaker in a local asylum in 1790. In 1796, with the help of fellow Quakers and others, he founded the York Retreat, where eventually about 30 patients lived as part of a small community in a quiet country house and engaged in a combination of rest, talk, and manual work. Rejecting medical theories and techniques, the efforts of the York Retreat centred around minimising restraints and cultivating rationality and moral strength.
The entire Tuke family became known as founders of moral treatment. They created a family-style ethos, and patients performed chores to give them a sense of contribution. There was a daily routine of both work and leisure time. If patients behaved well, they were rewarded; if they behaved poorly, there was some minimal use of restraints or instilling of fear. The patients were told that treatment depended on their conduct. In this sense, the patient's moral autonomy was recognised. William Tuke's grandson, Samuel Tuke, published an influential work in the early 19thcentury on the methods of the retreat; Pinel's Treatise on Insanity had by then been published, and Samuel Tuke translated his term as "moral treatment". Tuke's Retreat became a model throughout the world for humane and moral treatment of patients with mental disorders.
The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat. 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 could be considered as a rudimentary form of modern occupational therapy, although most of his physical approaches have long been discredited, such as bleeding and purging, hot and cold baths, mercury pills, a "tranquilizing chair" and gyroscope.
A similar reform was carried out in Italy by Vincenzo Chiarugi, who discontinued the use of chains on the inmates in the early 19thcentury. In the town of Interlaken, Johann Jakob Guggenbühl started a retreat for mentally disabled children in 1841.