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In its heyday the Institute of Pennsylvania Hospital in Philadelphia acquired enormous local and national prestige. With its closing earlier this year, a glorious chapter in the history of modern psychiatry came to an end.
By Dilip Ramchandani, M.D.
David M. Ellis, M.D.
The Institute of Pennsylvania Hospital opened its gates to almost a hundred mentally ill patients of the Pennsylvania Hospital in the winter of 1841. In the wake of the movement for humane treatment for the mentally ill, which began with the unchaining of the insane by the French psychiatrist Pinel in the Bicetre 50 years earlier, the institute provided an unparalleled treatment setting on 113 acres in the then rural facility located west of Philadelphia. The impetus also came from the overcrowding of the Pennsylvania Hospital, founded in downtown Philadelphia in 1751, which often had more patients with a mental illness than those with a physical diagnosis.
The new hospital, which was then called the Pennsylvania Hospital for the Insane, was developed at the urging of Dr. Benjamin Rush. Rush, considered the father of American psychiatry, was among the first Americans to recognize that psychiatric illness could be diagnosed, classified, and treated, although some of his treatment methods were admittedly controversial. The hospital had spacious, sunny, individual bedrooms in a magnificent building surrounded by lush gardens, a deer park, and a circular cog railway built for the amusement of patients.
The hospital’s first chief physician was Dr. Thomas Story Kirkbride, a Quaker surgeon who had gained early experience working with the insane. He earned accolades for developing the "Kirkbride Plan," which stressed sunlight, ventilation, exercise, and privacy for patients. He was a strong proponent of moral treatment, which emphasized compassion, respect, and dignity for the insane. Restraining devices were used minimally; patients were given greater freedom to move about; they ate in dining rooms with proper utensils; and the staff encouraged patients to read, play checkers, bowl, and spend time in the surrounding farm and greenhouses. In the evenings there were concerts, readings, and lectures with lantern slide shows for patients. Dr. Kirkbride, who lived on the grounds, was a frequent participant; he believed that a medical superintendent’s role was paramount in managing the hospital.
Dr. Kirkbride’s innovations and zeal naturally catapulted him into a leadership role in American psychiatry. In 1844 the hospital superintendents of the 13 asylums then in existence in the United States met in this hospital to hold lively discussions on insanity, law, and moral treatment. This meeting led to the formation of the Association of Medical Superintendents of American Institutions for the Insane, now APA.
No wonder, then, that the Pennsylvania Hospital for the Insane was often referred to as Kirkbride’s Hospital. Dr. Kirkbride’s devotion to and his name’s synonymity with that of the hospital almost cost him his life in 1849, when an angry patient escaped and returned to shoot Dr. Kirkbride in the head from a tree on the grounds of the hospital.
Fortunately, Dr. Kirkbride survived the gunshot wound. In 1866 he married a former patient, Eliza Butler, who was a visible presence by her husband’s side during his remaining tenure at the hospital.
Subsequent psychiatrists in chief at the institute such as Drs. Earl Bond, Edward Strecker, and Kenneth Appel were household names in American psychiatry as the institute continued to gain in stature and remain in the forefront of innovative psychiatric treatment, education, and research. Indeed, the hospital’s ability to adapt to the changing views in psychiatric diagnosis and treatment and still maintain a leadership position as a premier institution was the hallmark of its success throughout its history.
Unfortunately, even this renowned institution began to crack under the intense pressure exerted by the changing health care delivery environment, with its refocus on patient populations rather than on patients as individuals in the 1980’s and the 90’s. As notions of "psychiatric interview" and "moral treatment" were replaced by "carveouts" and "covered lives," the story of the Institute of Pennsylvania Hospital turned full circle. This past winter, the hospital closed its gates to its patients and staff, some of whom traveled back to the Pennsylvania Hospital in downtown Philadelphia. The buildings and its 27 acres were sold to an organization that may establish a variety of services, such as nursing home beds, partial hospitalization programs, and acute inpatient units. Many in Philadelphia, whose lives have been touched by this venerable institution, view these developments with anxiety because the story of the institute reflects, in a microcosm, psychiatry’s 150-year history. The future of American psychiatry, therefore, may well hinge upon the prospects of the now renamed Kirkbride Center.