kept in cages, maintained and paid fully by community attendants. Wealthier colonists kept their insane relatives either in their attics or cellars and hired attendants, or nurses, to care for them. In other communities, the mentally ill were sold at auctions as slave labor. Others were forced to leave town. As the population in the colonies expanded, informal care for the community failed and small institutions were established. In 1752 the first "lunatics ward" was opened at the Pennsylvania Hospital which attempted to treat the mentally ill. Attendants used the most modern treatments of the time: purging, bleeding, blistering, and shock techniques. Overall, the attendants caring for the patients believed in treating the institutionalized with respect. They believed if the patients were treated as reasonable people, then they would act as such; if they gave them confidence, then patients would rarely abuse it. The 1790s saw the beginnings of moral treatment being introduced for people with mental distress. The concept of a safe asylum, proposed by Philippe Pinel and William Tuke, offered protection and care at institutions for patients who had been previously abused or enslaved. In the United States, Dorothea Dix was instrumental in opening 32 state asylums to provide quality care for the ill. Dix also was in charge of the Union Army Nurses during the American Civil War, caring for both Union and Confederate soldiers. Although it was a promising movement, attendants and nurses were often accused of abusing or neglecting the residents and isolating them from their families. The formal recognition of psychiatry as a modern and legitimate profession occurred in 1808. In Europe, one of the major advocates for mental health nursing to help psychiatrists was Dr. William Ellis. He proposed giving the "keepers of the insane" better pay and training so more respectable, intelligent people would be attracted to the profession. In his 1836 publication of Treatise on Insanity, he openly stated that an established nursing practice calmed depressed patients and gave hope to the hopeless. However, psychiatric nursing was not formalized in the United States until 1882 when Linda Richards opened Boston City College. This was the first school specifically designed to train nurses in psychiatric care. The discrepancy between the founding of psychiatry and the recognition of trained nurses in the field is largely attributed to the attitudes in the 19th century which opposed training women to work in the medical field.