In 1854, Thomas Story Kirkbride published his widely read book, On The Construction, Organization and General Arrangements Of Hospitals For The Insane. If you’ve ever done any research on historical insane asylums, you have probably heard the term, “Kirkbride Buildings.” This book or manual, was used as the blueprint on how to correctly construct and arrange hospitals for the mentally ill during the nineteenth century. Dr. Kirkbride was a visionary leader in the early, formative years of psychiatry who advocated for “Moral Treatment,” which was the belief that patients should be treated with kindness and sympathetic care. He encouraged the use of the term “hospital” and discouraged the use of the terms “asylum” and “lunatic.” New York State did not adopt the term “hospital” for all its asylums for the insane until 1890, 36 years after the book was published. Dr. Kirkbride also recommended that hospitals for the insane should not exceed 250 patients, which, as we all know, was never followed and is probably the reason why they failed so miserably. The following two excerpts will give you some insight into the man and his accomplishments. To read the books in their entirety, click on the RED links below.
“During the last four years of his life he was an invalid, and, at the early part of that period, death seemed so near that all preparations were made in anticipation of that event, but he was permitted to enjoy a period of nearly three years of comparative health, but not with the return of his physical strength, and about nine months before the end came he was taken down, and was so reduced that only for a short period was he able to go about without assistance.
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Thomas Story Kirkbride – July 31, 1809 to December 16, 1883.
He continued to manifest the same earnest interest in all matters pertaining to the care of the insane, and his mind continued clear and free until the closing time which came shortly before midnight of December 16, 1883. His mortal part was laid to rest in Laurel Hill Cemetery on a bleak December day, but his spirit had entered into the ” rest that remaineth.”
At a special meeting of the Board of Managers of the Pennsylvania Hospital, held December 17, 1883, the following was unanimously adopted:
This Board, having received with sincere sorrow, the intelligence of the death of Dr. Thomas S. Kirkbride, Physician-in-chief and Superintendent of the Insane Department of this Hospital, desire to place on their records some fitting and grateful tribute to his memory, both for his great services to the institution over which he so long and ably presided, and for his high character and worth as a man. Dr. Kirkbride’s first connection with our Hospital was in 1833, when he was elected as a Resident Physician in the Pine Street Hospital, in which capacity he served most acceptably until 1835. When the Insane Department of our Hospital was removed to its present site in West Philadelphia, in 1841, Dr. Kirkbride was elected the first Physician-in-chief and Superintendent of that Institution. At this date there was but one hospital building for both male and female patients. In 1859, a new Hospital was constructed for male patients only, female patients being retained in the Hospital first erected, and from thenceforth both were under his care.
From his election to the post above designated, until his death, Dr. Kirkbride has been continuously elected to office as the head of the Department for the Insane, without suggestion or thought, either on the part of the Managers of the Hospital or the public, that a more efficient or faithful administrator of the duties of this important place could be found.
Dr. Kirkbride possessed in a remarkable degree the characteristics and qualities, intellectual and moral, to fit him for the position he so long held. To excellent medical training, and a great aptitude for that branch or specialty to which he devoted so much of his life, he added a nature full of sympathy for human suffering and affliction, great natural benevolence and kindness, rare administrative ability and great rectitude and moral worth. Possessed of those endowments, and with a heart full of zeal in his great work, and a keen insight into the needs of the patients brought under his care, his success in his professional work has been pre-eminent, and his usefulness to the community hard to estimate. It is, therefore,
Resolved, That by the death of Dr. Kirkbride, this Institution has lost a most faithful and efficient officer, whose untiring and welldirected labors for some forty years, have not only met with the cordial approval and co-operation of this Board, but have wrought a high and enduring reputation for him, and for our Hospital for the Insane, over which he so long and ably presided.
Resolved, That Dr. Kirkbride’s works for the relief of the insane both in the administration of his office in our Institution, and by his contributions to medical literature upon the subject of insanity, and its proper treatment, entitle him to rank very high among the benefactors of his race.
Resolved, That by the death of Dr. Kirkbride we lose a friend, bound to us by uncommon ties of affection and esteem. No one could come within the range of his influence, without being made to feel that his rare endowments of head and heart were such as to attract the love and confidence of his fellow-men; and throughout his life he well deserved that love and confidence.
Resolved, That the Board will attend his funeral in a body, and that a copy of these resolutions, attested by the President and Secretary, be forwarded to the family of our departed friend.
William Biddle, President.
B. H. Shoemaker, Secretary.”
Memoir of Thomas S. Kirkbride, M.D. LL. D.
SOURCE: Memoir of Thomas S. Kirkbride, M.D., LL. D., Prepared by Direction of the Association of Medical Superintendents of American Institutions for the Insane by John Curwen, M.D., Charles H. Nichols, M.D., John H. Callender, M.D., Warren, PA.: E. Cowan & Co., Printers, 1885, Pages 35-37.
Importance Of A Correct Nomenclature.
“The erroneous views of insanity formerly entertained, and the unfortunate modes of treatment which resulted from them, led to the adoption of terms which are now without meaning, and the continued use of which has an unfavorable influence on the best interests of the insane.
It seems especially desirable that this malady, now so much better appreciated by the whole civilized community than formerly, and the importance of the proper treatment of which is so generally admitted, should have every advantage that can result from a correct nomenclature. It is seldom that a disease so well recognized, so important and so prevalent, has had the misfortune to be called by so many ill-selected names, that have themselves tended to produce errors and confirm wrong impressions in the community.
Without any inclination to be hypercritical, it is proposed briefly to allude to some of these misnomers, which custom alone seems to have retained amongst us.
It must seem singular to any one who reflects on the subject, that the term “lunacy,” as applied to this disease, should still be retained as generally as it is by the community, by the medical profession, and even by some of the latter whose labors in this specialty have done so much to promote the best interests of a large class of sufferers. “Lunacy” and “lunatic” are terms which have no meaning in reference to the diseases of the mind, and originated from a popular belief in influences that have long since been shown to have no existence.
Both these terms are particularly objectionable from their very derivation, tending to give wrong impressions of the disease and to perpetuate popular errors. Prevalent as the idea may have been with our ancestors, that the insane were specially under the influence of the moon, it is hardly to be supposed that such a sentiment is now seriously entertained by any considerable number in or out of the medical profession. If such are to be found, they would scarcely claim so decided an effect from lunar influence as to make it a ground for giving a name to one of the most important diseases to which man is subject. “Lunatic” is put down, in one of our best modern medical dictionaries, as “moonstruck,” and such a term applied to a sick man or connected with an institution for the treatment of diseases of the brain, is certainly not in character with an age which puts forward so many just claims to be called one of progress. The fact that these terms are still used in law writings is no reason why they should be continued by the medical profession. If universally discarded by physicians, it is not unreasonable to suppose that the bar, with all its fondness for ancient terms, would ultimately reject names which, beyond their antiquity, have not a single claim for retention. As applied to individuals, they have become offensive from their ancient associations. The term “insanity,” which I conceive is the only proper name to apply to the disease under notice, is a correct one; it simply means unsoundness, is sufficiently common, and its import generally understood.
With all its distinguishing features, insanity has nothing about it to prevent its being ranked with other diseases. A functional disorder of the brain, it belongs to the same category as those of other organs. Prevailing at all ages, among all classes of civilized men, without regard to talent, fortune or profession, there would seem to be no sound reason why the institutions specially provided for its treatment should have names different from those that are prepared for the relief of the sick suffering from other maladies. It is of great importance to a correct appreciation of insanity by the community, that it should be generally understood, that, treated properly from its commencement, it is commonly a curable disease, and that when patients are sent from home to an institution, it is only that they may have advantages and chances for a restoration nowhere else to be obtained. It should also be impressed upon all, that cases of insanity, however chronic they may be, or however discouraging their symptoms, should still be regarded as worthy of attention, and demanding treatment, if we can do no more, to promote their comfort and happiness, and to keep active, as far and as long as we can, their mental and physical powers.
Institutions for the treatment of other diseases, even if incurable, are called Hospitals; no other term is so common or so well understood, and there is none so appropriate in every respect to those devoted exclusively to the treatment and care of the insane, and, in my estimation, they should be known by no other name.
The titles often applied to institutions for the insane have no appropriateness, even if they do not have a mischievous tendency. The object of their original introduction would seem to have been to give an impression that those who entered them were not sick, or did not come for treatment, or, if ill, that they suffered from some malady which bore no relation to the other diseases which affect our race, but rather that they came as to a place of refuge or security, as though they had committed some crime, or been banished from the sympathies as well as the presence of society. It is quite true that, appropriate as the name of Hospital is for the institutions provided for the treatment of the insane at the present day, it could hardly have been proper to have so called the receptacles into which they were often thrown, much less than a century ago, where those who had the strongest claims for the sympathy and kindly attentions of their fellow men, were chained and flogged and treated with a cruelty far beyond the lot of most criminals.
The term “Asylum,” still so common amongst us, seems to me to be open to all the objections that have been referred to, and ought to be abolished as having an undesirable influence, while its derivation and true meaning certainly do not offer any reason for its retention by any curative institution. It would be about as reasonable to have an Asylum for small pox, or fever, or dyspepsia, or any other disease, as for insanity. Ludicrous as it would appear to have an institution called a Febrile Asylum or a Rheumatic Asylum, it would really be as proper as to have what custom alone has familiarized us to—an Insane Asylum.
The arrangements of a Hospital for the Insane—which is a more euphonious, if not a more correct term than an Insanity Hospital—it is true, are different in many respects from those of ordinary hospitals; but that is no reason why the same name should not be applied to all. The details of a hospital for children, for fever, for contagious diseases, or diseases of the skin, may also vary in their character, without requiring a change in their principal title.
The term “Retreat,” is not less exceptionable than that of Asylum, and for the same reasons. They both originated from the best of motives, and have done good in their day, as helping to banish that awful name, “the Mad House,” which, of old, had so many real horrors connected with it, and the truthful pictures of which in England and on the Continent have made such an enduring impression on the minds of men, that most of the popular prejudices existing in reference to modern Hospitals for the Insane, although they have no single feature of resemblance, will be found to have originated from this source.
The names of “cells” and “keepers,” as applied to the chambers of the insane, and to their attendants, originated at a time when those who were suffering from insanity were often worse treated than convicted felons, and when those who had charge of them exhibited much less humanity than common jailers. Both terms belong to prisons, and no argument is needed to show that they ought never to be heard within the walls of buildings devoted to the relief of the afflicted.
If every one connected with the various establishments provided for the treatment of those suffering from mental disease, would on all occasions discard not only the terms “cells” and “keepers,” and “lunacy” and “lunatic,” but also those of “Asylums,” “Retreats,” and whatever other titles fancy may have suggested, and would call their institutions what they really are, Hospitals for the Insane, and let the disease treated in them be spoken of only as Insanity, the public would soon see the propriety of abandoning the terms to which exception has been taken, and that are in so many respects objectionable.
Few, if any, of those who have the immediate charge of the institutions for the insane in America, whose titles are deemed inappropriate, have had any agency in originating their names, and cannot, therefore, be held at all responsible for these unfortunate misnomers. Most of the new institutions commenced within the last few years in the United States are styled “Hospitals for the Insane,” and it is well worthy of consideration by those interested, whether it would not be worth an effort to induce those who have the power to change the titles of those previously established, so as to secure accuracy and uniformity among American institutions.
APPENDIX.
At a meeting of “The Association Of Medical Superintendents of American Institutions For The Insane,” held at Philadelphia, in May, 1851, the following series of propositions relative to the construction of Hospitals for the Insane, was unanimously adopted as the sentiments of that body on the subjects referred to; and, in like manner, at the meeting held in Baltimore, in 1852, the succeeding series of propositions in reference to the organization of these institutions was also adopted, and, with the former, directed to be published in the “American Journal of Insanity,” and to be appended to the annual reports of the different institutions:
Propositions Relative To The Construction Of Hospitals For The Insane.
I. Every hospital for the insane should be in the country, not within less than two miles of a large town, and easily accessible at all seasons.
II. No hospital for the insane, however limited its capacity, should have less than fifty acres of land, devoted to gardens and pleasure grounds for its patients. At least one hundred acres should be possessed by every State hospital, or other institution for two hundred patients, to which number these propositions apply, unless otherwise mentioned.
III. Means should be provided to raise ten thousand gallons of water, daily, to reservoirs that will supply the highest parts of the building.
IV. No hospital for the insane should be built without the plan having been first submitted to some physician or physicians who have had charge of a similar establishment, or are practically acquainted with all the details of their arrangements, and received his or their full approbation.
V. The highest number that can with propriety be treated in one building is two hundred and fifty, while two hundred is a preferable maximum.
VI. All such buildings should be constructed of stone or brick, have slate or metallic roofs, and, as far as possible, be made secure from accidents by fire.
VII. Every hospital, having provision for two hundred or more patients, should have in it at least eight distinct wards for each sex, making sixteen classes in the entire establishment.
VIII. Each ward should have in it a parlor, a corridor, single lodging-rooms for patients, an associated dormitory, communicating with a chamber for two attendants; a clothes-room, a bath-room, a water-closet, a dining-room, a dumb-waiter, and a speaking-tube leading to the kitchen or other central part of the building.
IX. No apartments should ever be provided for the confinement of patients, or as their lodging-rooms, that are not entirely above ground.
X. No class of rooms should ever be constructed without some kind of window in each, communicating directly with the external atmosphere.
XI. No chamber for the use of a single patient should ever be less than eight by ten feet, nor should the ceiling of any story occupied by patients be less than twelve feet in height.
XII. The floors of patients’ apartments should always be of wood.
XIII. The stairways should always be of iron, stone, or other indestructible material, ample in size and number, and easy of ascent, to afford convenient egress in case of accident from fire.
XIV. A large hospital should consist of a main central building with wings.
XV. The main central building should contain the offices, receiving rooms for company, and apartments, entirely private, for the superintending physician and his family, in case that officer resides in the hospital building.
XVI. The wings should be so arranged that, if rooms are placed on both sides of a corridor, the corridors should be furnished at both ends with movable glazed sashes, for the free admission of both light and air.
XVII. The lighting should be by gas, on account of its convenience, cleanliness, safety, and economy.
XVIII. The apartments for washing clothing, &c., should be detached from the hospital building.
XIX. The drainage should be under ground, and all the inlets to the sewers should be properly secured to prevent offensive emanations.
XX. All hospitals should be warmed by passing an abundance of pure, fresh air from the external atmosphere, over pipes or plates, containing steam under low pressure, or hot water, the temperature of which at the boiler does not exceed 212° F., and placed in the basement or cellar of the building to be heated.
XXI. A complete system of forced ventilation, in connection with the heating, is indispensable to give purity to the air of a hospital for the insane; and no expense that is required to effect this object thoroughly can be deemed either misplaced or injudicious.
XXII. The boilers for generating steam for warming the building should be in a detached structure, connected with which may be the engine for pumping water, driving the washing apparatus, and other machinery.
XXIII. All water-closets should, as far as possible, be made of indestructible materials, be simple in their arrangements, and have a strong downward ventilation connected with them.
XXIV. The floors of bath-rooms, water-closets, and basement stories, should, as far as possible, be made of materials that will not absorb moisture.
XXV. The wards for the most excited class should be constructed with rooms on but one side of a corridor, not less than ten feet wide, the external windows of which should be large, and have pleasant views from them.
XXVI. Wherever practicable, the pleasure-grounds of a hospital for the insane, should be surrounded by a substantial wall, so placed as not to be unpleasantly visible from the building.”
On The Construction, Organization and General Arrangements of Hospitals For The Insane by Thomas S. Kirkbride, M.D.
SOURCE: On The Construction, Organization and General Arrangements of Hospitals For The Insane by Thomas S. Kirkbride, M.D., Physician to the Pennsylvania Hospital for the Insane, Philadelphia, 1854, Pages 72-78.
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