Kirkbride, Thomas Story
- Nancy Tomes
Kirkbride, Thomas Story (31 July 1809–16 December 1883), psychiatrist, was born on a farm in eastern Bucks County, Pennsylvania, the son of John Kirkbride and Elizabeth Story, farmers, who were active members of the Bucks County Society of Friends.
Thomas Kirkbride was a delicate child thought to be ill suited to farming. His father, after suffering a painful illness, encouraged him to become a doctor, a profession highly respected among the Quakers. Kirkbride recalled in his “Autobiographical Sketch” (1882) that while still a boy, he “began to regard medicine as his path in life.”
To prepare his son for a medical career, the elder Kirkbride made sure Thomas got a good education. He attended two excellent local academies, then was apprenticed to a prominent New Jersey physician, the French émigré Nicholas Belleville. Belleville taught his pupil the basics of bedside medicine: how to diagnose common illnesses, make up prescriptions, and treat injuries. The majority of early nineteenth-century doctors got the sum of their medical training in this fashion; but for Kirkbride, the preceptorial served only as preparation for a more ambitious goal: to attend medical school. In the fall of 1828 he entered the University of Pennsylvania Medical School, the oldest and one of the most prestigious medical schools in the United States.
The revolution in clinical observation and pathological research taking place in the hospitals of Paris had yet to influence American medical schools. Instead, Kirkbride learned by rote a system for explaining and treating disease that had changed little since the time of Benjamin Rush, Philadelphia’s most prominent eighteenth-century physician. Kirkbride found himself more interested in the practical art of surgery than the theoretical speculations about disease emphasized in his professors’ lectures.
After finishing his M.D. in 1832, Kirkbride applied for a residency at the Pennsylvania Hospital, but lost out in the fierce competition for the post. To gain experience that would improve his chances for the next year, he accepted a residency at the Friends Asylum, a small Quaker-run mental hospital in nearby Frankford, Pennsylvania. There he supervised the medical care of the patients and learned the elements of “moral treatment,” a new approach to treating insanity pioneered by Quakers at the York Retreat in England. The proponents of moral treatment believed that the insane could be benefited, and in many cases cured, by following an ordered, daily routine. The staff rewarded cooperative patients with praise and privileges, and subjected unruly ones to constant surveillance and restrictions. The asylum milieu was designed to bring out the “inner light” of reason Quakers believed to remain in even the most hopeless of cases.
Kirkbride left the asylum after a year to begin his residency at the Pennsylvania Hospital. In 1836 he finished his residency and started a private practice in Philadelphia. Kirkbride determined to get as much surgical experience as he could, hoping ultimately to return to the Pennsylvania Hospital as attending surgeon.
In 1840 Kirkbride received a job offer that dramatically changed the course of his medical career. The managers of the Pennsylvania Hospital had decided to build a separate asylum for the institution’s mental patients, which was to be located across the Schuylkill River, near the rural village of Blockley. They approached Kirkbride to assume the duties of chief superintendent. Despite his love of surgery, Kirkbride found himself tempted by the job; he had begun to wonder if an extensive surgical practice might be too taxing for his health, which was never robust. He was probably also attracted by the unusual degree of administrative authority he would enjoy at the new hospital; as chief superintendent of the asylum, he would have far more power than an attending surgeon in the general hospital. Thus Kirkbride decided to switch specialties and devote his career to asylum medicine, as psychiatry was then termed.
Under his management the Pennsylvania Hospital for the Insane, which opened in 1841, soon became recognized as one of the best mental hospitals in the country. Following the principles of moral treatment he had learned at the Friends Asylum, Kirkbride dispensed with the routine use of physical restraints and provided the patients a full schedule of amusements including lectures, parties, and exercise. Although simple in style, the asylum was comfortable and meticulously maintained. Kirkbride created varied landscapes around the hospital to form the backdrop for the patients’ walks and rides. By these measures he made “Kirkbride’s”, as the asylum came to be known, attractive to middle- and upper-class families looking for relief from the care of insane relatives.
In 1844 Kirkbride helped to found the Association of Medical Superintendents of American Institutions for the Insane (now known as the American Psychiatric Association), the first medical specialty organization in the United States. He published articles on asylum construction and management in the American Journal of Insanity, which were subsequently published in 1854 as a book, On the Construction, Organization, and General Arrangements of Hospitals for the Insane. In 1851 and 1853 the association adopted a set of propositions on hospital design written by Kirkbride, which remained its official policy for over thirty years. According to Henry Hurd’s 1916 survey, Institutional Care of the Insane, mental hospitals in twenty-seven states and the District of Columbia were built according to the so-called linear or Kirkbride plan. Kirkbride’s advice on asylum design was also sought by state legislators, governors, and even presidents.
Kirkbride’s architectural plans showed his skill at balancing the need for control and surveillance with the need to attend to small details, which had an influence on patients but were “not readily appreciated by a careless observer,” as he wrote in On the Construction. He stressed that whether a window was left locked or opened could make the difference between life and death for a suicidal patient. To ensure the safety and well-being of patients, Kirkbride believed it was essential to have the asylum ruled by one all powerful, ever vigilant medical authority.
As a clinician Kirkbride was distinguished by his gentle manner and fervent devotion to moral treatment. Although he refused to rule out the use of physical restraints, he employed them rarely. Kirkbride also gained fame for the elaborate program of patient education and entertainment offered at the hospital. He early recognized the value of photography and was the first to introduce the lantern slide program as a therapeutic diversion for mental patients, an innovation that was widely copied at other asylums.
But even at the midcentury highpoint of enthusiasm about moral treatment, Kirkbride’s job as an asylum superintendent was a difficult one. His daily work involved constant attention to a myriad of details, overseeing patient care, answering inquiries from their families, supervising a large and sometimes unruly staff, and maintaining the heavily used buildings and grounds. Kirkbride experienced firsthand the anxieties, even physical dangers, of mid-nineteenth-century asylum life. In 1849 a former patient shot him in the head; fortunately his old-fashioned Quaker hat deflected the bullet. In the late 1860s he became embroiled in several lawsuits instituted by patients who challenged the commitment laws of the era, which made it very easy for families to commit relatives.
In a broader sense, Kirkbride’s conception of moral treatment suffered from the internal contradictions common to nineteenth-century humanitarian reforms. On the one hand, moral treatment brought about a more humane standard of care for the mentally ill, as compared to their often subhuman treatment in eighteenth-century institutions. On the other hand, the regimen subjected patients to a greater degree of surveillance and control, which many of them resented and resisted. Inmates themselves often found institutional life far from humane. And despite Kirkbride’s efforts to maintain perfect order in the wards, the fundamental character of mental disorder created an undertow of violence and chaos that belied his benign characterization of moral treatment.
Still, the most serious challenge to Kirkbride’s authority came from outside, not inside, his asylum. In the 1870s younger asylum superintendents and members of the new medical speciality of neurology began to question the older generation’s insistence on small, cure-oriented mental hospitals. As the number of chronic cases piled up in state mental hospitals and local almshouses, critics complained that Kirkbride’s asylum design was too expensive and inflexible to meet the needs of all of the insane. Instead, they urged public authorities to build more inexpensive cottage-style facilities for chronic cases. Kirkbride’s response was invariably the same: large institutions for incurable patients would inevitably deteriorate into custodial warehouses.
In states such as New York and Massachusetts, welfare authorities ignored his warning and built larger and larger hospitals in the 1860s and 1870s. But such was Kirkbride’s prestige in the profession that the resolutions he drafted in the early 1850s insisting on small “mixed” asylums providing acute and chronic care were not repealed until 1888. Even then, they were made nonbinding rather than repudiated outright.
In retrospect, Kirkbride’s insistence on small, expensive-to-maintain mental hospitals seems quite unrealistic. As head of an elite private hospital, he was relatively insulated from the political and economic problems their care posed for state officials. Yet his prediction that large state hospitals for incurable patients would degenerate into custodial facilities soon proved correct.
Kirkbride’s own institution offered probably the highest standard of care for the mentally ill available in nineteenth-century America. Because he maintained control over admissions, Kirkbride was able to prevent the accumulation of chronic cases. During his tenure the asylum’s cure rates remained cause for modest optimism about the value of moral treatment; although the number cured dropped, from 53 percent of patients discharged in the 1840s to 41 percent in the 1870s, the return of even a modest number of patients to a productive life seemed an accomplishment in light of the formerly grim prognosis for insanity.
In the 1880s and 1890s, the psychiatric profession abandoned moral treatment as a formal therapeutic rationale and turned to more somatic approaches to mental illness. But many of the basic elements of moral treatment developed in Kirkbride’s time, including the twentieth-century methods known as occupational therapy and milieu management, have remained essential to institutional psychiatry.
In 1839 Kirkbride had married Ann Jenks; they had two children. Four years after her death in 1862, he married Eliza Ogden Butler, a woman he had earlier treated as a patient; they had four children. Although such a relationship between doctor and former patient would now be considered an ethical violation, the Butler-Kirkbride marriage was not regarded as improper by the standards of their own times, which embodied a very paternalistic conception of doctor/patient and male/female relationships. After their marriage, Eliza Butler Kirkbride took an active role in asylum life, paying special attention to the women patients, and helped her husband prepare his widely read Annual Reports. Her continued mental health was regarded as testimony to his ability as a healer and to the value of asylum treatment in general. Thomas Kirkbride died in Philadelphia.
Kirkbride’s papers, including his journals, correspondence, and casebooks, are in the Institute of the Pennsylvania Hospital Archives, Philadelphia. The collection includes a copy of his “Autobiographical Sketch … Dictated in 1882,” privately printed in Philadelphia that same year. The Annual Reports of the Pennsylvania Hospital for the Insane, published during his years as superintendent, are a valuable source of information about his hospital career. The standard secondary account of Kirkbride’s career is Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum Keeping (1984). Other useful accounts of Kirkbride’s place in American psychiatry are contained in Gerald Grob, Mental Institutions in America: Social Policy to 1875 (1972), and Constance McGovern, Masters of Madness: Social Origins of the American Psychiatric Profession (1985). Obituaries include a memorial by his wife, Eliza Butler Kirkbride, “Memorial of Thomas Story Kirkbride,” Annual Report of the Pennsylvania Hospital for the Insane (1883), pp. 26–163, which is the longest and best of the published contemporary accounts of his life; and the Philadelphia Evening Star, 20 Dec. 1883.