“In order to regain reason’s tottering throne”

The 19th Century Asylum

The 19th century saw tremendous change in the care and treatment of mental illness. Names still familiar to many influenced this transformation. In America, we had Rush, Kirkbride, and Dix. In Europe, Pinel, Esquirol, and Tuke. At all stages, those encouraging and instituting change felt that their proposals constituted progress, and in most situations it was concern for those living with mental maladies that drove the change. How, then, could things have gone so wrong that a genre of literature (the “insanity narrative”) developed in response to the repeated failings of this system of care? The usual suspects are to blame: economy, animosity, and fear. Thus, the confluence of the grand intentions and spectacular inadequacies of the 19th century asylum.

Benjamin Rush, Lecture Notes on the Practice of Medicine (Philadelphia, ca. 1790). Manuscript in blank notebook. Bequest of James Rush.

Benjamin Rush (1746-1813), the “father of American psychiatry,” considered insanity a medical condition to be treated, rather than a moral failing to be punished. In this volume, Rush composed his lecture notes for his University of Pennsylvania courses on mental illness. While Rush is often remembered for his continued advocacy of bloodletting even after that treatment became unpopular, his influence on the humane care and treatment of the mentally ill is his true legacy. Under his leadership, the wards of the mentally ill at Pennsylvania Hospital became “free from the clanking of chains, and the noise of the whip” according to his monumentally important 1812 work Medical Inquiries upon the Diseases of the Mind.

Philippe Pinel, A Treatise on Insanity (Sheffield, 1806). Bequest of James Rush.

French physician Philippe Pinel (1745-1826) coined the term “traitement moral” to describe a patient-centered approach to working with the mentally ill, founded on humane care. Pinel, who oversaw reforms at Bicêtre and Salpêtrière hospitals, believed that insanity did not indicate a complete loss of reason. Consequently, he stressed that caretakers should attempt to learn about their patients. They should treat them as otherwise rational human beings with varied experiences and expressions of their mental ailment. He prohibited physical punishments and ended the regular use of restraints. He also used pharmaceuticals sparingly to treat patients, and was disdainful of those who readily resorted to their application.

Illustration from Samuel Tuke, Description of the Retreat: An Institution near York, for Insane Persons of the Society of Friends (York, 1813).

The York Retreat was founded in 1796 under the supervision of Quaker philanthropist William Tuke (1732-1822). Tuke’s approach shared much in common with Pinel, though the settings of their work could not have been more different. Pinel’s Bicêtre and Salpêtrière were enormous public institutions while Tuke’s Retreat was small by comparison, and, at first, limited to Quaker patients. Also, unlike the French institutions, the Retreat was purpose-built to tend to those with mental illness. Its bucolic landscape allowed for greater use of occupational therapy. Its patients worked the land and received the physical and psychological benefits of air, sun, and exercise. The Tuke family carried on William’s work, with his grandson Samuel publishing the volume shown.

Illustration from Etienne Esquirol, Des Maladies Mentales (Paris, 1838). Gift of Charles E. Rosenberg.

This engraving shows James (sometimes William) Norris, an American sailor, during his confinement at Bethlem Royal Hospital in London. Norris was restrained in the manner shown for ten years, until philanthropists visiting the hospital took up his plight and arranged for his release. The illustration on which this engraving is based was used to build support for asylum reform in the United Kingdom and abroad. Psychiatrist, reformer, and Pinel student Etienne Esquirol (1772-1840) used the jarring image for this 1838 work on mental illness. Two other illustrations from this volume can be seen in the “Department for Males” and the “Department for Females” sections of this exhibition.

Illustration from George Lehman, Friends Asylum for the Insane, Near Frankford (Philadelphia: Lehman and Duval, 1836). Lithograph.

The Asylum for the Relief of Persons Deprived of the Use of Their Reason (later the Frankford Asylum and currently Friends Hospital) was one of several institutions inspired by the York Retreat. Founder Thomas Scattergood (1784-1814) had visited Tuke at his Retreat in its early days and met with the patients there. He later shared what he learned with other Philadelphia Friends who expressed an interest in building an asylum. Samuel Tuke’s 1813 work about the Retreat was used to help fundraise for the new asylum, which accepted its first patients in 1817. The view, published as the frontispiece to the asylum’s annual reports of the late 1830s, depicts the prescribed pastoral setting surrounding the institution that was so conducive to moral treatment.

Dorothea Lynde Dix, Memorial to the Legislature of Massachusetts (Boston, 1843).

Massachusetts school teacher Dorothea Lynde Dix (1802-1887) visited England for her health in the late 1830s, where she met Samuel Tuke and learned the principles of moral treatment. Upon her return, she toured her state’s almshouses and prisons to evaluate the conditions in which the indigent insane, who could not afford admittance to private asylums, were forced to live. In 1843, she presented this Memorial to the state legislature of Massachusetts, in which she described the often horrific and non-curative living conditions she witnessed. This was the first of many such written memorials Dix presented across the country and abroad, asking for, and frequently winning, the dedication of public funds to build institutions that would provide moral treatment to the mentally ill who were also impoverished.

Illustrations from Thomas S. Kirkbride, On the Construction, Organization, and General Arrangements of Hospitals for the Insane (Philadelphia, 1880). Gift of Thomas S. Kirkbride.

Thomas Story Kirkbride (1809-1883) served as superintendent of the Pennsylvania Hospital for the Insane from 1840 until his death. A strong proponent of moral treatment (or moral therapy, as it is often called), Kirkbride developed guidelines for asylum buildings that allowed the structures themselves to support the patients’ care and recovery. His famous “batwing” design, employed in at least seventy-five asylums across the country and abroad, allowed for maximum sun exposure and air circulation. Each segment of the wings represented different wards, which allowed superintendents to organize patients according to their needs or behaviors. The design also allowed for relatively easy expansion into the ample grounds that were to surround every Kirkbride-style asylum.

W. & F. Langenheim, New Pennsylvania Hospital for the Insane, Building, Pa. (Philadelphia, ca. 1857). Stereograph. McAllister Collection.

This stereograph shows the building of the new Department for Males at the Pennsylvania Hospital for the Insane. Thomas Story Kirkbride was superintendent at the time and ensured that the new facility would be built according to his eponymous plans, which he first published two years before this construction began. It is believed that the gentleman in the foreground, facing right, is Kirkbride.

Pennsylvania Hospital for the Insane, Nurses Exercising on Steps (Philadelphia, undated). Reproduction created from the original negative.

Courtesy of the Pennsylvania Hospital Historic Collections

Kirkbride referenced “the refining influence of female society, and the great importance of good nursing by women” in his comprehensive work on Hospitals for the Insane.

Pennsylvania Hospital for the Insane, Occupational Therapy Workroom (Philadelphia, undated). Reproduction created from the original negative.

Courtesy of the Pennsylvania Hospital Historic Collections

What today is called occupational therapy was, from the beginning, a tenet of moral treatment. In his Treatise on Insanity, Pinel explained: “I am very sure that few lunatics, even in their most furious state, ought to be without some active occupation. … Laborious employment … is not a little calculated to divert the thoughts of lunatics from their usual morbid channel, to fix their attention upon more pleasing objects, and by exercise to strengthen the functions of the understanding.”

Illustration from J.J. Pease after J.X. Mason, New Jersey State Lunatic Asylum, Trenton (Philadelphia, ca. 1850). Engraving.

The New Jersey State Lunatic Asylum, which operates today as the Trenton Psychiatric Hospital, was the first institution built on the Kirkbride plan. The familiar “batwing” design can be seen in this engraving, along with the spacious and well-maintained grounds. The second Memorial Dorothea Dix wrote examined the state of the indigent insane in New Jersey, and was instrumental in the development of this asylum. Dix spent the last years of her life there, in a private apartment gifted to her as thanks for her role in the asylum’s founding.

Eugene Grissom, Mechanical Protection for the Insane (Utica, 1878). Gift of Charles E. Rosenberg.

The development of moral treatment was not free from contention. Perhaps the primary question that divided practitioners was that of mechanical restraint. In this pamphlet, asylum superintendent Eugene Grissom (1831-1902) defended the use of restraints in institutions, claiming that patients were imperiled without them. Not only might they suffer harm at their own hands or from other patients, but also from attendants who, in the absence of mechanical restraints, would instead need to use brute force to subdue their patients. Described on the pages shown here are patients who, Grissom maintained, benefited from the use of these devices such as straightjackets, cuffs (to restrict the use of hands), and special covered beds that were little more than recumbent cages.

National Association for the Protection of the Insane and the Prevention of Insanity, Constitution, By-Laws… (Boston, 1880). Gift of Charles E. Rosenberg.

Arguments in favor of the benefits of mechanical restraint did not convince the members of the National Association for the Protection of the Insane and the Prevention of Insanity. They argued that the use of restraints could be nearly eliminated with proper staffing, better funding, and various therapeutic approaches. The latter included keeping patients’ bodies and minds occupied with useful labor. Now called occupational therapy, it had always been a principle of moral treatment, but with overcrowded conditions and insufficient funding, restraining patients became easier than attempting to treat them.

Thomas G. Morton, Removal of the Ovaries as a Cure for Insanity (Utica, 1893). Gift of Charles E. Rosenberg.

As surgical procedures became more advanced and generally safer, some physicians began experimenting with sterilization as a cure for mental illness in women. Among these was Dr. Alice Bennett (1851-1925), head of the Department for Females at the State Lunatic Hospital at Norristown, Pennsylvania. In 1892, she began her experiments and sterilized six women in her care. Several members of the Pennsylvania Committee on Lunacy felt strongly that this was not only unethical, but illegal. In 1896, Bennett resigned her position, in part due to the criticism of her practice of sterilization. Here, fellow Philadelphia physician Thomas Morton (1825-1896) posits that this practice would never be allowed were the patients male.

Unfortunately, forced sterilization of both women and men did become a major component of psychiatric practice in the years following the Bennett controversy. Sterilizations for preventative purposes, rather than curative ones, became common. The theory of degeneracy and the eugenics movement it precipitated led to the forced sterilization of countless mentally ill patients to prevent the inheritance of insanity. In many cases, sterilization became a condition of release for patients in mental institutions. The history of eugenics has had a major impact on the care of the mentally ill. This exhibition acknowledges the need for this unethical movement to be recognized and reckoned with in any attempt to understand our past or improve our future.

Clifford W. Beers, A Mind that Found Itself (New York, 1914). Gift of Charles E. Rosenberg.

By the end of the 19th century, the promise of moral treatment was left unfulfilled. The number of people requiring mental health treatment had sharply increased, and the funding to provide it had concurrently decreased. Out of this failed system emerged Clifford Beers (1876-1943). After more than three years in both private and public asylums, Beers wrote A Mind that Found Itself, in which he recounted the horrific conditions he experienced firsthand. Beers described how he regained his sanity not because of his time in asylums, but in spite of it. With this book, he built the framework on which he would grow the mental hygiene movement, which sought to provide better care to the mentally ill and to remove the stigma of their illness. Among his many accomplishments, Beers established the first outpatient mental health clinic in the United States in 1913 and founded the National Committee for Mental Hygiene, still in existence today as Mental Health America.