October 6, 2000

history notes

Kirkbride: Hospital Innovator

By Lucy Ozarin, M.D.

The asylum was the alternative to the jail or almshouse for the mentally afflicted in the U.S. in the 19th century. The growing population of these facilities and the importunities of Dorothea Dix put pressure on state governments to provide humane facilities for the mentally ill.

Thomas Kirkbride, superintendent of the Pennsylvania Hospital for the Insane in Philadelphia, furnished the pattern for building state hospitals in more than 31 states, a pattern that endured for more than 50 years and led to their being labeled Kirkbride buildings.

The Pennsylvania Hospital, a general hospital established by the Quakers in 1752, had designated a basement ward complete with shackles to house the insane. The need for more space led to the opening of a separate building for those patients. At that time, care of the insane in Great Britain and France furnished a pattern. The York Retreat, opened by the Quakers in England in 1792, provided a philosophy of moral treatment for the mentally ill, namely home-like surroundings and a treatment regimen emphasizing normal daily activities. In 1815 William Tuke published an account titled "Practical Hints on the Construction and Economy of Pauper Lunatic Asylums." In 1854 Kirkbride published his book The Organization and General Arrangements of Hospitals for the Insane.

Kirkbride, who was born into a Quaker family near Philadelphia, studied medicine as an apprentice and then earned an M.D. at the University of Pennsylvania Medical School. He spent the year 1832 at the nearby Quaker Friends Hospital, which was patterned after the York Retreat. This was followed by a residency at the university and several years of private practice in Philadelphia. In 1840 a new Pennsylvania Hospital for the Insane was built, and Kirkbride agreed to become its superintendent. This building, too, was quickly overwhelmed by the number of people it needed to serve, and in 1856 a new hospital was built that conformed to Kirkbride’s ideas.

Kirkbride’s philosophy of care and treatment for the mentally ill was highly influenced by his experience at Friends Hospital. His design for the new hospital was linear, with a central building to house administration and other offices, as well as a kitchen and staff living quarters. Wings extended from each side with setbacks—men on one side, women on the other. Each ward had a wide central corridor with several sitting alcoves, single-patient rooms, and small dormitories opening off the corridor. The multiple wards allowed for housing patients according to illness classification.

Kirkbride’s writings paid considerable attention to the details of construction: size of the hospital, positioning, drainage, heating, ventilation, sanitary arrangements, ceiling heights, windows, etc. Wards were to be furnished comfortably, and occupation and recreation facilities for patients were to be provided.

Kirkbride proposed a regimen similar to the "moral treatment" approach of York Retreat. He also detailed a plan for organization and management of the hospital.

The Association of Medical Superintendents of American Institutions for the Insane (forerunner of APA) adopted 26 propositions on hospital construction and management written by Kirkbride in 1851 and 1853, principles that were the organization’s official policy on hospital design for 40 years. However, as conditions in state psychiatric hospitals deteriorated after 1870, Kirkbride’s influence and status declined. Within the superintendents’ association, differing ideas arose about the best way to treat psychiatric patients. For example, Should wealthy and poor patients be treated together? How about the curable and the chronic? Should restraint be used? And what should be done about the criminally insane?

Until his death Kirkbride remained superintendent of his hospital and devoted to his principles about how it should care for its patients. At the Association meeting in 1888, however, the superintendents voted "not to affirm" Kirkbride’s propositions.