founded in 1796, gained international prominence as a centre for moral treatment and a model of asylum reform following the publication of samuel tuke's description of the retreat (1813). until the nineteenth century, the care of the insane was largely a communal and family responsibility rather than a medical one. the vast majority of the mentally ill were treated in domestic contexts with only the most unmanageable or burdensome likely to be institutionally confined. this situation was transformed radically from the late eighteenth century as, amid changing cultural conceptions of madness, a new-found optimism in the curability of insanity within the asylum setting emerged. increasingly, lunacy was perceived less as a physiological condition than as a mental and moral one to which the correct response was persuasion, aimed at inculcating internal restraint, rather than external coercion. this new therapeutic sensibility, referred to as moral treatment, was epitomised in french physician philippe pinel's quasi-mythological unchaining of the lunatics of the bicêtre hospital in paris and realised in an institutional setting with the foundation in 1796 of the quaker-run york retreat in england. patient, surrey county lunatic asylum, c. 1850–58. the asylum population in england and wales rose from 1,027 in 1827 to 74,004 in 1900. from the early nineteenth century, as lay-led lunacy reform movements gained in influence, ever more state governments in the west extended their authority and responsibility over the mentally ill. small-scale asylums, conceived as instruments to reshape both the mind and behaviour of the disturbed, proliferated across these regions. by the 1830s, moral treatment, together with the asylum itself, became increasingly medicalised and asylum doctors began to establish a distinct medical identity with the establishment in the 1840s of associations for their members in france, germany, the united kingdom and america, together with the founding of medico-psychological journals. medical optimism in the capacity of the asylum to cure insanity soured by the close of the nineteenth century as the growth of the asylum population far outstripped that of the general population. processes of long-term institutional segregation, allowing for the psychiatric conceptualisation of the natural course of mental illness, supported the perspective that the insane were a distinct population, subject to mental pathologies stemming from specific medical causes. as degeneration theory grew in influence from the mid-nineteenth century, heredity was seen as the central causal element in chronic mental illness, and, with national asylum systems overcrowded and insanity apparently undergoing an inexorable rise, the focus of psychiatric therapeutics shifted from a concern with treating the individual to maintaining the racial and biological health of national populations. emil kraepelin (1856–1926) introduced new medical categories of mental illness, which eventually came into psychiatric usage despite their basis in behavior rather than pathology or underlying cause. shell shock among frontline soldiers exposed to heavy artillery bombardment was first diagnosed by british army doctors in 1915. by 1916, similar symptoms were also noted in soldiers not exposed to explosive shocks, leading to questions as to whether the disorder was physical or psychiatric. in the 1920s surrealist opposition to psychiatry was expressed in a number of surrealist publications. in the 1930s several controversial medical practices were introduced including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (leucotomy or lobotomy). both came into widespread use by psychiatry, but there were grave concerns and much opposition on grounds of basic morality, harmful effects, or misuse. in the 1950s new psychiatric drugs, notably the antipsychotic chlorpromazine, were designed in laboratories and slowly came into preferred use. although often accepted as an advance in some ways, there was some opposition, due to serious adverse effects such as tardive dyskinesia. patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. there was also increasing opposition to the use of psychiatric hospitals, and attempts to move people back into the community on a collaborative user-led group approach ("therapeutic communities") not controlled by psychiatry. campaigns against masturbation were done in the victorian era and elsewhere. lobotomy was used until the 1970s to treat schizophrenia. this was denounced by the anti-psychiatric movement in the 1960s and later. women it was very difficult for women to become doctors in any field before the 1970s. elizabeth blackwell became the first woman to formally study and practice medicine in the united states. she was a leader in women's medical education. while blackwell viewed medicine as a means for social and moral reform, her student mary putnam jacobi (1842–1906) focused on curing disease. at a deeper level of disagreement, blackwell felt that women would succeed in medicine because of their humane female values, but jacobi believed that women should participate as the equals of men in all medical specialties using identical methods, values and insights. in the soviet union although the majority of medical doctors were women, they were paid less than the mostly male factory workers. places china finally in the 19th century, western medicine was introduced at the local level by christian medical missionaries from the london missionary society (britain), the methodist church (britain) and the presbyterian church (us). benjamin hobson (1816–1873) in 1839, set up a highly successful wai ai clinic in guangzhou, china. the hong kong college of medicine for chinese was founded in 1887 by the london missionary society, with its first graduate (in 1892) being sun yat-sen, who later led the chinese revolution (1911). the hong kong college of medicine for chinese was the forerunner of the school of medicine of the university of hong kong, which started in 1911. because of the social custom that men and women should not be near to one another, the women of china were reluctant to be treated by male doctors. the missionaries sent women doctors such as dr. mary hannah fulton (1854–1927). supported by the foreign missions board of the presbyterian church (us) she in 1902 founded the first medical college for women in china, the hackett medical college for women, in guangzhou. japana doctor checks a patient's pulse in meiji-era japan. european ideas of modern medicine were spread widely through the world by medical missionaries, and the dissemination of textbooks. japanese elites enthusiastically embraced western medicine after the meiji restoration of the 1860s. however they had been prepared by their knowledge of the dutch and german medicine, for they had some contact with europe through the dutch. highly influential was the 1765 edition of hendrik van deventer's pioneer work nieuw ligt ("a new light") on japanese obstetrics, especially on katakura kakuryo's publication in 1799 of sanka hatsumo ("enlightenment of obstetrics"). a cadre of japanese physicians began to interact with dutch doctors, who introduced smallpox vaccinations. by 1820 japanese ranpô medical practitioners not only translated dutch medical texts, they integrated their readings with clinical diagnoses. these men became leaders of the modernization of medicine in their country. they broke from japanese traditions of closed medical fraternities and adopted the european approach of an open community of collaboration based on expertise in the latest scientific methods. kitasato shibasaburō (1853–1931) studied bacteriology in germany under robert koch. in 1891 he founded the institute of infectious diseases in tokyo, which introduced the study of bacteriology to japan. he and french researcher alexandre yersin went to hong kong in 1894, where; kitasato confirmed yersin's discovery that the bacterium yersinia pestis is the agent of the plague. in 1897 he isolated and described the organism that caused dysentery. he became the first dean of medicine at keio university, and the first president of the japan medical association. japanese physicians immediately recognized the values of x-rays. they were able to purchase the equipment locally from the shimadzu company, which developed, manufactured, marketed, and distributed x-ray machines after 1900. japan not only adopted german methods of public health in the home islands, but implemented them in its colonies, especially korea and taiwan, and after 1931 in manchuria. a heavy investment in sanitation resulted in a dramatic increase of life expectancy. europe the practice of medicine changed in the face of rapid advances in science, as well as new approaches by physicians. hospital doctors began much more systematic analysis of patients' symptoms in diagnosis. among the more powerful new techniques were anaesthesia, and the development of both antiseptic and aseptic operating theatres. effective cures were developed for certain endemic infectious diseases. however, the decline in many of the most lethal diseases was due more to improvements in public health and nutrition than to advances in medicine. medicine was revolutionized in the 19th century and beyond by advances in chemistry, laboratory techniques, and equipment. old ideas of infectious disease epidemiology were gradually replaced by advances in bacteriology and virology. the russian orthodox church sponsored seven orders of nursing sisters in the late 19th century. they ran hospitals, clinics, almshouses, pharmacies, and shelters as well as training schools for nurses. in the soviet era (1917–1991), with the aristocratic sponsors gone, nursing became a low-prestige occupation based in poorly maintained hospitals. france paris (france) and vienna were the two leading medical centers on the continent in the era 1750–1914. in the 1770s–1850s paris became a world center of medical research and teaching. the "paris school" emphasized that teaching and research should be based in large hospitals and promoted the professionalization of the medical profession and the emphasis on sanitation and public health. a major reformer was jean-antoine chaptal (1756–1832), a physician who was minister of internal affairs. he created the paris hospital, health councils, and other bodies. louis pasteur (1822–1895) was one of the most important founders of medical microbiology. he is remembered for his remarkable breakthroughs in the causes and preventions of diseases. his discoveries reduced mortality from puerperal fever, and he created the first vaccines for rabies and anthrax. his experiments supported the germ theory of disease. he was best known to the general public for inventing a method to treat milk and wine in order to prevent it from causing sickness, a process that came to be called pasteurization. he is regarded as one of the three main founders of microbiology, together with ferdinand cohn and robert koch. he worked chiefly in paris and in 1887 founded the pasteur institute there to perpetuate his commitment to basic research and its practical applications. as soon as his institute was created, pasteur brought together scientists with various specialties. the first five departments were directed by emile duclaux (general microbiology research) and charles chamberland (microbe research applied to hygiene), as well as a biologist, ilya ilyich mechnikov (morphological microbe research) and two physicians, jacques-joseph grancher (rabies) and emile roux (technical microbe research). one year after the inauguration of the institut pasteur, roux set up the first course of microbiology ever taught in the world, then entitled cours de microbie technique (course of microbe research techniques). it became the model for numerous research centers around the world named "pasteur institutes. vienna the first viennese school of medicine, 1750–1800, was led by the dutchman gerard van swieten (1700–1772), who aimed to put medicine on new scientific foundations—promoting unprejudiced clinical observation, botanical and chemical research, and introducing simple but powerful remedies. when the vienna general hospital opened in 1784, it at once became the world's largest hospital and physicians acquired a facility that gradually developed into the most important research centre. progress ended with the napoleonic wars and the government shutdown in 1819 of all liberal journals and schools; this caused a general return to traditionalism and eclecticism in medicine. vienna was the capital of a diverse empire and attracted not just germans but czechs, hungarians, jews, poles and others to its world-class medical facilities. after 1820 the second viennese school of medicine emerged with the contributions of physicians such as carl freiherr von rokitansky, josef škoda, ferdinand ritter von hebra, and ignaz philipp semmelweis. basic medical science expanded and specialization advanced. furthermore, the first dermatology, eye, as well as ear, nose, and throat clinics in the world were founded in vienna. the textbook of ophthalmologist georg joseph beer (1763–1821) lehre von den augenkrankheiten combined practical research and philosophical speculations, and became the standard reference work for decades. berlin after 1871 berlin, the capital of the new german empire, became a leading center for medical research. robert koch (1843–1910) was a representative leader. he became famous for isolating bacillus