The Project Gutenberg eBook of A Psychiatric Milestone, by The Society of the New York Hospital.

The opening of Bloomingdale Asylum on June 1, 1821, was an important event in the treatment of mental disorders and in the progress of humanitarian and scientific work in America. Hospital treatment for persons suffering from mental disorders had been furnished by the New York Hospital since its opening in 1792, and the Governors had given much thought and effort to securing the facilities needed. The treatment consisted, however, principally in the administration of drugs and the employment of such other physical measures as were in vogue at that time. Little attempt was made to study the minds of the patients or to treat them by measures directed specifically to influencing their thoughts, feelings, and behavior, and what treatment of this character there was had for its object little more than the repression of excitement and disordered activity. The value and importance of treatment directed to the mind had, indeed, been long recognized, but in practice it had been subordinated to treatment of the actual and assumed physical disorders to which the mental state of the patient was attributed, and, in the few hospitals where persons suffering from mental disorders were received, means for its application were almost or quite entirely lacking. The establishment of Bloomingdale Asylum for the purpose of ascertaining to what extent the recovery of the patients might be accomplished by moral as well as by purely medical treatment marked, therefore, the very earliest stages of the development in America of the system of study and treatment of mental disorders which with increasing amplification and precision is now universally employed.

A hundred years of growth and activity in the work thus established have now been accomplished, and it seemed fitting to the Governors of the Hospital that the event should be commemorated in a way that would be appropriate to its significance and importance. It was decided that the principal place in the celebration should be given to the purely medical and scientific aspects of the work, with special reference to the progress which had been made in the direction of the practical usefulness of psychiatry in the treatment of illness generally, and in the management of problems of human behavior and welfare. Arrangements were made for four addresses by physicians of conspicuous eminence in their particular fields, and invitations to attend the exercises were sent to the leading psychiatrists, psychologists, and neurologists of America, and to others who were known to be specially interested in the field of study and practice in which the Hospital is engaged. It was felt that, in view of the place which France and England had held in the movement in which Bloomingdale Asylum had its origin, it would add greatly to the interest and value of the celebration if representatives of these countries were present and made addresses. How fortunate it was, then, that it became possible to welcome from France Dr. Pierre Janet, who stands pre-eminent in the field of psychopathology, and from England Dr. Richard G. Rows, whose contributions to the study and treatment of the war neuroses and to the relation between psychic and physical reactions marked him as especially qualified to present the more advanced view-point of British psychiatry. The other two principal addresses were made by Dr. Adolf Meyer, who, by reason of his scientific contributions and his wonderfully productive practical work in clinical and organized psychiatry and in mental hygiene, is the acknowledged leader of psychiatry in America, and by Dr. Lewellys F. Barker, who, because of his eminence as an internist and of the extent to which he has advocated and employed psychiatric knowledge and methods in his practice, has contributed greatly to interesting and informing physicians concerning the value and importance of psychiatry in general medical practice. The addresses given by these distinguished physicians, representing advanced views in psychiatry held in Europe and America, were peculiarly appropriate to the occasion and to the object of the celebration. They were supplemented by an historical review of the origin and development of the Hospital and of its work by Mr. Edward W. Sheldon, President of the Society of the New York Hospital, and by a statement concerning the medical development, made by Dr. William L. Russell, the Medical Superintendent. The greetings of the New York Academy of Medicine were presented in an interesting address by Dr. George D. Stewart, President of the Academy.

Of scarcely less significance and interest than the addresses was the pageant presented on the lawn during the intermission between the sessions, depicting scenes and incidents illustrating the origin and development of the Hospital, and of psychiatry and mental hygiene. The text and the scenes displayed were prepared by Dr. Charles I. Lambert, First Assistant Physician of the Hospital, and by Mrs. Adelyn Wesley, who directed the performance and acted as narrator. The performers were persons who were connected with the Hospital, twenty-two of whom were patients.

The celebration was held on May 26, 1921. The weather was exceptionally clear, with bright sunshine and moderate temperature. The grounds, in their Spring dress of fresh leaves and flowers, were especially beautiful. This added much to the attractiveness of the occasion and the pleasure of those who attended. Luncheon was served on the lawn in front of the Brown Villa and the pageant was presented on the adjoining recreation grounds. The beauty of the day and the surroundings, the character of the addresses and of the speakers, the remarkable felicity and grace with which they were introduced by the President, the dignity and noble idealism of his closing words, and the distinguished character of the audience, all contributed to make the celebration one of exceptional interest and value to those who were present, and a notable event in the history of the Hospital.

For the purpose of preserving, and of perhaps extending to some who were not present, the spirit of the occasion, and of placing in permanent form an account of the proceedings and the addresses which were made, this volume has been published by the Society of the New York Hospital.

ILLUSTRATIONS

BLOOMINGDALE HOSPITAL CENTENARY

The One Hundredth Anniversary of the establishment of Bloomingdale Hospital as a separate department for mental diseases of The Society of the New York Hospital was celebrated at the Hospital at White Plains on Thursday, May 26, 1921. The addresses were given in the Assembly Hall.

MORNING SESSION

The exercises opened with an invocation by the Reverend Frank H. Simmonds, rector of Grace Episcopal Church at White Plains:

Oh, most mighty and all-merciful God, whose power is over all Thy works, who willest that all men shall glorify Thee in the constant bringing to perfection those powers of Thine which shall more and more make perfect the beings of Thy creation, we glorify Thee in the gift of Thy Divine Son Jesus Christ, the Great Physician of our souls, the Sun of Righteousness arising with healing in His wings, who disposeth every great and little incident to the glory of God the Father, and to the comfort of them that love and serve him, we render thanks to Thee and glorify Thy Name, this day, which brings to completion the hundredth anniversary of this noble institution's birthday. Oh, Thou, who didst put it into the hearts and minds of men to dedicate their lives and fortunes to the advancement of science and medicine for the sick and afflicted, we render Thee most high praise and hearty thanks for the grace and virtue of the founders of this institution—men whose names are written in the Golden Book of life as those who loved their fellow men.

We praise Thee for such men as Thomas Eddy, James Macdonald, Pliny Earle, and these endless others, who from age to age have held high the torch of knowledge and have kept before them the golden rule of service. Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.

Be pleased, oh merciful Father, to bless this day and gathering. Lift up and enlighten our hearts and minds to a higher perception of all that is noble, all that is true, all that is merciful. Awaken our dull senses to the full knowledge of light in Thee, and may all that is said and done be with the guiding of Thy Holy Spirit.

We pray for the continued blessing of this institution and hospital, and on all those who are striving to bring out of darkness those unhappy souls, into the pure light of understanding.

Bless the Governors, physicians, and nurses, direct their judgments, prosper their undertakings, and dispose their ministry that the world may feel the blessing and comfort of life in the prevention of disease and the preservation of health. And may we all be gathered in this nation to a more perfect unity of life and purpose in the desire to spend and be spent in the service of our fellow men.

We ask it all in the name and through the mediation of Thy Son Jesus Christ, our Lord. Amen.

ADDRESS BY
MR. EDWARD W. SHELDON

MR. SHELDON

It is with profound gratification that the Governors welcome your generous presence to-day on an occasion which means so much to us and which has perhaps some general significance. For we are met in honor of what is almost a unique event in our national history, the centennial anniversary celebration of an exclusively psychopathic hospital. A summary of its origin and development may be appropriate.

A hundred and fifty years ago the only institutions on this side of the Atlantic which cared for mental diseases were the Pennsylvania Hospital, chartered in 1751, a private general hospital which had accommodations for a few mental cases, and the Eastern State Hospital for the insane, at Williamsburg, Virginia, a public institution incorporated in 1768. No other one of the thirteen Colonies had a hospital of any kind, general or special. With a view of remedying this deplorable lack in New York, steps were taken in 1769 to establish an adequate general hospital in the City of New York. This resulted in the grant, on June 11, 1771, of the Royal Charter of The Society of the New York Hospital. Soon afterward the construction of the Hospital buildings began on a spacious tract on lower Broadway opposite Pearl Street, in which provision was also to be made for mental cases; but before any patients could be admitted, an accidental fire, in February, 1775, consumed the interior of the buildings. Reconstruction was immediately undertaken and completed early in the spring of 1776. But by that time the Revolutionary War was in full course, and the buildings were taken over by the Continental authorities as barracks for troops, and were surrounded by fortifications. When the British captured the city in September, 1776, they made the same use of the buildings for their own troops, who remained there until 1783. A long period of readjustment then ensued, and it was not until January, 1791, that the Hospital was at last opened to patients. In September, 1792, the Governors directed the admission of the first mental case, and for the hundred and twenty-nine years since that time the Society has continuously devoted a part of its effort to the care of the mentally diseased. After a few years a separate building for them was deemed desirable, and was constructed. The State assisted this expansion of the Hospital by appropriating to the Society $12,500 a year for fifty years. This new building housed comfortably seventy-five patients, but ten years later even this proved inadequate in size and undesirable in surroundings. In the meanwhile a wave of reform in the care of the insane was rising in Europe under the influence of such benefactors as Philippe Pinel in France, and William and Samuel Tuke in England. Thomas Eddy, a philanthropic Quaker Governor of the Society, who was then its Treasurer and afterward in succession its Vice-President and President, becoming aware of this movement, and having made a special study of the care and cure of mental affections, presented a communication to the Governors in which he advocated a change in the medical treatment, and in particular the adoption of the so-called moral management similar to that pursued by the Tukes at The Retreat, in Yorkshire, England. This memorable communication was printed by the Governors, and constitutes one of the first of the systematic attempts made in the United States to put this important medical subject on a humane and scientific basis. To carry out his plan, Mr. Eddy urged the purchase of a large tract of land near the city and the erection of suitable buildings. He ventured the moderate estimate that the population of the city, then about 110,000, might be doubled by 1836, and quadrupled by 1856. In fact, it was more than doubled in those first twenty years, and sextupled in the second twenty. He was justified, therefore, in believing that the hospital site on lower Broadway would soon be surrounded by a dense population, and quite unsuited for the efficient care of mental diseases. The Governors gave these recommendations immediate and favorable consideration. Various tracts of land, containing in all about seventy-seven acres, and lying on the historic Harlem Heights between what are now Riverside Drive and Columbus Avenue, and 107th and 120th Streets, were subsequently bought by the Society for about $31,000. To aid in the construction and maintenance of the necessary hospital buildings, the Legislature, by an act reciting that there was no other institution in the State where insane patients could be accommodated, and that humanity and the interest of the State required that provision should be made for their care and cure, granted an additional annual appropriation of $10,000 to the Society from 1816 until 1857. The main Hospital, built of brownstone, stood where the massive library of Columbia University now is, and the brick building still standing at the northeast corner of Broadway and 116th Street was the residence of the Medical Superintendent. The only access to this site by land was over what was known as the Bloomingdale Road, running from Broadway and 23d Street through the Bloomingdale district on the North River to 116th Street, and from that fact our institution assumed the name of Bloomingdale Asylum, or, as it is now called, Bloomingdale Hospital. This beautiful elevated site overlooking the Hudson River and the Harlem River was admirably fitted for its purpose. The spacious tract of land, laid out in walks and gardens, an extensive grove of trees, generous playgrounds and ample greenhouses, combined to give the spot unusual beauty and efficiency. This notable work finished, the Governors of the Society issued on May 10, 1821, an "Address to the Public"^[1] which marks so great an advance in psychiatry in our country that it deserves study. The national character of the institution was indicated in the opening paragraph, where it announced that the Asylum would be open for the reception of patients from any part of the United States on the first of the following June. Accommodation for 200 patients was provided, and to these new surroundings were removed on that day all the mental cases then under treatment at the New York Hospital on lower Broadway.

In this retired and ideal spot the work of Bloomingdale Hospital was successfully prosecuted for three-quarters of a century. But the seven miles that separated it from the old hospital was steadily built over, and before fifty years had gone the growth of the city had passed the asylum grounds. Foreseeing that they could not maintain that verdant oasis intact for many years longer, the Governors, in 1868, bought this 300-acre tract on the outskirts of the Village of White Plains. After prolonged consideration of the time and method of development of the property, final plans were adopted in December, 1891, construction was begun May 1, 1892, and two years later, under the direction of our Medical Superintendent, Dr. Samuel B. Lyon, all the patients were moved from the old to this new Bloomingdale. The cost of the new buildings was about $1,500,000. From time to time the original Bloomingdale site was sold and now supplies room, among other structures, for Columbia University, Barnard College, the Cathedral of St. John the Divine, St. Luke's Hospital, the Woman's Hospital, and the National Academy of Design. With the proceeds of those sales of the old Bloomingdale, not only was the cost of the new Bloomingdale met, but the permanent endowment of the Society was substantially increased, and Thomas Eddy was proved to have been both a wise humanitarian and a far-sighted steward of charitable funds.

In their "Address to the Public" to which I have referred, issued when Bloomingdale Hospital was opened in 1821, the Governors of the Society spoke of the new conception of moral treatment of the mentally afflicted which had been established in several European hospitals and which was supplanting the harsh and cruel usage of former days, as "one of the noblest triumphs of pure and enlightened benevolence." In that same spirit those founders dedicated themselves to the conduct of this institution. Their devotion to the work was impressive. Looking back on those early days we see a constant personal attention to the details of institutional life that commands admiration. The standards then set have become a tradition that has been preserved unbroken for a hundred years. Humane methods of care, the progressively best that medical science can devise, the utilization of a growingly productive pursuit of research, have consistently marked the administration of this great trust. The Governors of to-day are as determined as any of their predecessors to maintain that ideal of "pure and enlightened benevolence." New paths are opening and larger resources are becoming available. Under the guidance of our distinguished Medical Superintendent, with his able and devoted staff of physicians, a broader and more intensive development is already under way. Animated by that resolve and cheered by that prospect, we may thus confidently hope, as we begin the second century of Bloomingdale's career, for results not less fruitful and gratifying than those which we celebrate to-day.

ADDRESS BY
DR. ADOLF MEYER

The Chairman: In celebrating our centenary we are naturally dealing also with the larger subject of general psychiatry. Our success in this discussion should be materially promoted by the presence with us of Dr. Adolf Meyer, Professor of Psychiatry in the Medical School of Johns Hopkins University, and Director of the Phipps Psychiatric Clinic, of Baltimore. Before taking up this important work in that famous medical centre, Dr. Meyer was actively engaged for several years in psychopathic work in New York. He will speak to us on "The Contributions of Psychiatry to the Understanding of Life Problems."

DR. MEYER

When Dr. Russell honored me with the invitation to speak at this centenary celebration of the renowned Bloomingdale Hospital, my immediate impulse was to choose as my topic a phase of psychiatric development to which this Hospital has especially contributed through our greatly missed August Hoch and his deeply appreciated coworker Amsden. I have in mind the great gain in concreteness of the physician's work with mind and the resulting contribution of psychiatry to a better knowledge of human life and its problems. The great gain this passing century is able to hand on to its successor is the clearer recognition of just what the psychiatrist actually works with and works on.

Of all the divisions of medicine, psychiatry has suffered longest from man's groping for a conception of his own nature. Psychiatry means, literally, the healing of souls. What then do we actually mean by soul or by psyche? This question has too long been treated as a disturbing puzzle.

To-day we feel that modern psychiatry has found itself—through the discovery that, after all, the uncritical common-sense view of mind and soul is not so far remote from a critical common-sense view of the individual and its life activity, freed from the forbidding and confusing assumptions through which the concept of mind and soul has been held in bewildering awe.

Strange to say, good old Aristotle was nearer an understanding than most of the wise men and women that have succeeded him for these more than two thousand years. He saw in the psyche what he called the form and realization or fulfilment of the human organism; he would probably now say with us, the activity and function as an individual or person.

Through the disharmonies and inevitable disruption of a self-disorganizing civilization, the Greek and Roman world was plunged into the dark centuries during which the perils of the soul and the sacrificial attainment of salvation by monastic life and crusades threatened to overshadow all other concern. This had some inevitable results: it favored all those views through which the soul became like a special thing or substance, in contrast to and yet a counterpart of the physical body. As long as there was no objective experimental science, the culminating solution of life problems had to be intrusted to that remarkable development of religious philosophy which arose from the blending of Hebrew religion and tradition and the loftiest products of the Greek mind, in the form which St. Paul and the early Church fathers gave to the teachings of Christ. From being the form and activation, or function, of the organism in life, the soul feature of man was given an appearance in which it could neither be grasped nor understood, nor shaped, nor guided by man when it got into trouble. From the Middle Ages there arose an artificial soul and an artificial world of souls presented as being in eternal conflict with the evil of the flesh—and thus the house of human nature was divided against itself.

Science of the nineteenth century came nearer bringing mind and body together again. The new astronomical conception of the world and the growing objective experimental science gradually began to command confidence, and from being a destroyer of excessively dogmatic notions, science began to rise to its modern constructive and creative position. But the problem of mind remained on a wrong basis and still does so even with most scientists. Too much had been claimed for the psyche, and because of the singling out of a great world of spirit, the world of fact had been compromised and left cold and dry and unattractive and unpromising. No doubt it was necessary that the scientist should become hardened and weaned from all misleading expectation, and shy of all the spurious claims of sordid superstition and of childish fancy. He may have been unduly radical in cutting out everything that in any way recalled the misleading notions. In the end, we had to go through a stage of psychology without a "soul," and lately even a psychology without "consciousness," so that we might be safe from unscientific pretensions. All the gyrations no doubt tended to retard the wholesome practical attack upon the problems in the form in which we find them in our common-sense life.

The first effort at a fresh start tried to explain everything rather one-sidedly out of the meagre knowledge of the body. Spinoza had said in his remarkable Ethics (III, Prop. II, Schol.): "Nobody has thus far determined what the body can do, i.e., nobody has as yet shown by experience and trial what the body can do by the laws of nature alone in so far as nature is considered merely as corporeal and extended, and what it cannot do save when determined by mind."

This challenge of Spinoza's had to be met. With some investigators this seemed very literally all there was to be done about the study of man—to show how far the body could explain the activity we call "the mind." The unfortunate feature was that they thought they had to start with a body not only with mind and soul left out but also with practical disregard of the whole natural setting. They studied little more than corpses and experimental animals, and many a critic wondered how such a corpse or a frog could ever show any mind, normal or abnormal. To get things balanced again, the vision of man had to expand to take a sane and practical view of all of human life—not only of its machinery.

The human organism can never exist without its setting in the world. All we are and do is of the world and in the world. The great mistake of an overambitious science has been the desire to study man altogether as a mere sum of parts, if possible of atoms, or now of electrons, and as a machine, detached, by itself, because at least some points in the simpler sciences could be studied to the best advantage with this method of the so-called elementalist. It was a long time before willingness to see the large groups of facts, in their broad relations as well as in their inner structure, finally gave us the concept and vision of integration which now fits man as a live unit and transformer of energy into the world of fact and makes him frankly a consciously integrated psychobiological individual and member of a social group.

It is natural enough that man should want to travel on the road he knows and likes best. The philosopher uses his logic and analysis and synthesis. The introspectionist wants to get at the riddle of the universe by crawling into the innermost depth of his own self-scrutiny, even at the risk—to use a homely phrase—of drawing the hole in after him and losing all connection with the objective world. The physicist follows the reverse course. He gives us the appreciation of the objective world around and in us. The chemist follows out the analytic and synthetic possibilities of his atoms and elements, and the biologist the growth and reproduction and multiplication of cells. Each sees an open world of possibilities and is ready to follow as far as facts will carry and as far as the imagination will soar. Each branch has created its rules of the game culminating in the concept of objective science, and the last set of facts to bring itself under the rules of objective science, and to be accepted, has been man as a unit and personality.

The mind and soul of man have indeed had a hard time. To this day, investigators have suffered under the dogma that mind must be treated as purely subjective entity, something that can be studied only by introspection, or at least only with ultra-accurate instruments—always with the idea that common sense is all wrong in its psychology. Undoubtedly it was, so long as it spoke of a mind and soul as if what was called so had to be, even during life, mysterious and inaccessible, something quite different from any other fact of natural-history study.

The great step was taken when all of life was seen again in its broad relations, without any special theory but frankly as common sense finds it, viz., as the activities and behavior of definite individuals—very much as Aristotle had put it—"living organisms in their 'form' or activity and behavior." Psychology had to wake up to studying other minds as well as one's own. Common sense has always been willing to study other persons besides our own selves, and that exactly as we study single organs—viz., for what they are and do and for the conditions of success and failure. Nor do we have to start necessarily from so-called elements. Progress cannot be made merely out of details. It will not do merely to pile up fragments and to expect the aggregates to form themselves. It also takes a friend of facts with the capacity for mustering and unifying them, as the general musters his army. Biology had to have evolutionists and its Darwin to get on a broad basis to start with, and human biology, the life of man, similarly had to be conceived in a new spirit, with a clear recognition of the opportunities for the study of detail about the brain and about the conditions for its working and its proper support, but also with a clear vision of the whole man and all that his happiness and efficiency depend upon.

All this evolution is strongly reflected in the actual work of psychiatry and medicine. For a time, it looked to the physician as if the physiology and pathology of the body had to make it their ambition to make wholly unnecessary what traditional psychology had accumulated, by turning it all into brain physiology. The "psychological" facts involved were undoubtedly more difficult to control, so much so that one tried to cut them out altogether. As if foreshadowing the later academic "psychology without soul and consciousness," the venerable Superintendent of Utica, Dr. Gray, was very proud when in 1870 he had eliminated the "mental and moral causes" from his statistics of the Utica State Hospital, hiding behind the dogma that "mind cannot become diseased, but only the body." To-day "mental and moral causes" are recognized again in truer form—no longer as mere ideas and uninvestigated suppositions taken from uncritical histories, but as concrete and critically studied life situations and life factors and life problems. Our patients are not sick merely in an abstract mind, but by actually living in ways which put their mind and the entire organism and its activity in jeopardy, and we are now free to see how this happens—since we study the biography and life history, the resources of adaptation and of shaping the life to success or to failure.

The study of life problems always concerns itself with the interaction of an individual organism with life situations. The first result of a recognition of this fact was a more whole-hearted and practical concept of personality.

In 1903 I put together for the first time my analysis of the neurotic personality, which was soon followed by a series of studies on the influences of the mental factors, and in 1908 a paper on "What Do Histories of Cases of Insanity Teach Us Concerning Preventive Mental Hygiene During the Years of School Life?" All this was using for psychiatry the growing appreciation of a broad biological view-point in its concrete application. It was a reaction against the peculiar fear of studying the facts of life simply and directly as we find and experience them—scoffed at because it looked as if one was not dealing with dependable and effective data. Many of the factors mentioned as causes do not have the claimed effects with sufficient regularity. It is quite true that not everybody is liable to any serious upset by several of the handicaps sometimes found to be disastrous during the years of development; but we have learned to see more clearly why the one person does and the other does not suffer. Evidently, not everybody who is reserved and retiring need be in danger of mental disorder, yet there are persons of just this type of make-up that are less able than others to stand the strains of isolation, of inferiority feeling, of exalted ambitions and one-sided longings, intolerable desires, etc. The same individual difference of susceptibility holds even for alcohol. With this recognition we came to lay stress again on the specific factors which make for the deterioration of habits, for tantrums with imaginations, and for drifting into abnormal behavior, and conditions incompatible with health.

It was at this point that our great indebtedness to the Bloomingdale Hospital began. Dr. August Hoch, then First Assistant of the Bloomingdale Hospital, began to swing more and more toward the psychobiological trend of views, and with his devoted and very able friend Amsden he compiled that remarkable outline,^[2] which was the first attempt to reduce the new ideals of psychobiology to a practical scheme of personality study—that clear and plain questionnaire going directly at human traits and reactions such as we all know and can see at work without any special theories or instruments.

After studying in each patient all the non-mental disorders such as infections, intoxications, and the like, we can now also attack the problems of life which can be understood only in terms of plain and intelligible human relations and activities, and thus we have learned to meet on concrete ground the real essence of mind and soul—the plain and intelligible human activities and relations to self and others. There are in the life records of our patients certain ever-returning tendencies and situations which a psychiatry of exclusive brain speculation, auto-intoxications, focal infections, and internal secretions could never have discovered.

Much is gained by the frank recognition that man is fundamentally a social being. There are reactions in us which only contacts and relations with other human beings can bring out. We must study men as mutual reagents in personal affections and aversions and their conflicts; in the desires and satisfactions of the simpler appetites for food and personal necessities; in the natural interplay of anticipation and fulfilment of desires and their occasional frustration; in the selection of companionship which works helpfully or otherwise—for the moment or more lastingly throughout the many vicissitudes of life. All through we find situations which create a more or less personal bias and chances for success or failure, such as simpler types of existence do not produce. They create new problems, and produce some individuals of great sensitiveness and others with immunity—and in this great field nothing will replace a simple study of the life factors and the social and personal life problems and their working—the study of the real mind and the real soul—i.e., human life itself. Looking back then this practical turn has changed greatly the general view as to what should be the chief concern of psychology. One only need take up a book on psychology to see what a strong desire there always was to contrast a pure psychology and an applied psychology, and to base a new science directly on the new acquisitions of the primary sciences such as anatomy and histology of the nervous system. There was a quest for the elements of mind and their immediate correlation with the latest discoveries in the structure of the brain. The centre theory and the cell and neurone theory seemed obligatory starting-points. To-day we have become shy of such postulates of one-sided not sufficiently functional materialism. We now call for an interest in psychobiological facts in terms of critical common sense and in their own right—largely a product of psychiatry. There always is a place for elements, but there certainly is also a place for the large momentous facts of human life just as we find and live it.

Thus psychiatry has opened to us new conceptions and understandings of the relation of child and mother, child and father, the child as a reagent to the relations between mother and father, brothers and sisters, companions and community—in the competitions of real concrete life. It has furnished a concrete setting for the interplay of emotions and their effects.

It has led us from a cold dogma of blind heredity and a wholesale fatalistic asylum scheme, to an understanding of individual, familiar, and social adjustments, and a grasp on the factors which we can consider individually and socially modifiable. We have passed from giving mere wholesale advice to a conscientious study of the problems of each unit, and at the same time we have developed a new and sensible approach to mental hygiene and prevention, as expressed in the comprehensive surveys of State and community work and even more clearly in the development of helps to individuals in finding themselves, and in the work in schools to reach those who need a special adaptation of aims and means. To the terrible emergency of the war it was possible to bring experienced men and women as physicians and nurses, and how much was done, only those can appreciate who have seen the liberality with which all the hospitals, and Bloomingdale among the first, contributed more than their quota of help, and all the assistance that could possibly be offered to returning victims for their readjustment.

It is natural enough that psychiatry should have erred in some respects. We had forced upon us the herding together of larger numbers of patients than can possibly be handled by one human working unit or working group. The consequence was that there arose a narrowing routine and wholesale classifications and a loss of contact with the concrete needs of the individual case; that very often progress had to come from one-sided enthusiasts or even outsiders, who lost the sense of proportion and magnified points of relative importance until they were supposed to explain everything and to be cure-alls. We are all inclined to sacrifice at the altar of excessive simplicity, especially when it suits us; we become "single-taxers" and favor wholesale legislation and exclusive State care when our sense for democratic methods has gone astray. Human society has dealt with the great needs of psychiatry about as it has dealt with the objects of charity, only in some ways more stingily, with a shrewd system and unfortunately often with a certain dread of the workers themselves and of their enthusiasm and demands. Law and prejudice surrounded a great share of the work with notions of stigma and hopelessness and weirdness—while to those who see the facts in terms of life problems there can be but few more inspiring tasks than watching the unfolding of the problematic personality, seeking and finding its proper settings, and preventing the clashes and gropings in maladjustments and flounderings of fancy and the faulty use and nutrition of the brain and of the entire organism.

What a difference between the history of a patient reported and studied and advised by the well-trained psychiatrist of to-day and the account drawn up by the statistically minded researcher or the physician who wants to see nothing but infections or chemistry and hypotheses of internal secretion. What a different chance for the patient in his treatment, in contrast to what the venerable Galt of Virginia reports as the conception of treatment recommended by a great leader of a hundred years ago: "Mania in the first stage, if caused by study, requires separation from books. Low diet and a few gentle doses of purging physic; if pulse tense, ten or twelve ounces of blood [not to be given but to be taken!]. In the high grade, catch the patient's eye and look him out of countenance. Be always dignified. Never laugh at or with them. Be truthful. Meet them with respect. Act kindly toward them in their presence. If these measures fail, coercion if necessary. Tranquillizing chair. Strait waistcoat. Pour cold water down their sleeves. The shower bath for fifteen or twenty minutes. Threaten them with death. Chains seldom and the whip never required. Twenty to forty ounces of blood, unless fainting occurs previously; ... etc."

To-day an understanding of the life history, of the patient's somatic and functional assets and problems, likes and dislikes, the problem presented by the family, etc.!

So much for the change within and for psychiatry. How about psychiatry's contribution beyond its own narrower sphere? It has led us on in philosophy, it has brought about changes in our attitude to ethics, to social study, to religion, to law, and to life in general. Psychiatric work has undoubtedly intensified the hunger for a more objective and yet melioristic and really idealistic philosophical conception of reality, such as has been formulated in the modern concept of integration.

Philosophical tradition, logic, and epistemology alike had all conspired to make as great a puzzle as possible of the nature of mental life, of life itself, and of all the fundamental principles, so much so that as a result anything resembling or suggesting philosophy going beyond the ordinary traditions has got into poor repute in our colleges and universities and among those of practical intelligence. The consequence is that the student and the physician are apt to be hopeless and indifferent concerning any effort at orderly thinking on these problems.^[3]

Most of us grew up with the attitude of a fatalistic intellectual hopelessness. How could we ever be clear on the relation of mind and body? How could mind and soul ever arise out of matter? How can we harmonize strict science with what we try to do in our treatment of patients? How can we, with our mechanistic science, speak of effort, and of will to do better? How can we meet the invectives against the facts of matter on the part of the opposing idealistic philosophies and their uncritical exploitations in "New Thought"—i.e., really the revival of archaic thought? It is not merely medical usefulness that forced these broad issues on many a thinking physician, but having to face the facts all the time in dealing with a living human world. The psychopathologist had to learn to do more than the so-called "elementalist" who always goes back to the elements and smallest units and then is apt to shirk the responsibility of making an attempt to solve the concrete problems of greater complexity. The psychiatrist has to study individuals and groups as wholes, as complex units, as the "you" or "he" or "she" or "they" we have to work with. We recognize that throughout nature we have to face the general principle of unit-formation, and the fact that the new units need not be like a mere sum of the component parts but can be an actually new entity not wholly predictable from the component parts and known only through actual experience with the specific product. Hydrogen and oxygen, it is true, can form simple mixtures, but when they make an actual chemical integration we get a new specific type of substance, water, behaving and dividing according to its own laws and properties in a way not wholly predictable from just what we know of hydrogen and oxygen as such. Analogy prompts us to see in plants and animals products of physics and chemistry and organization, although the peculiarity of the product makes us recognize certain specificities of life not contained in the theory of mere physics and chemistry. All the facts of experience prompt us to see in mentation a biological function, and we are no longer surprised to find this product of integration so different from the nature and functions of all the component parts. All the apparent discontinuities in the intrinsic harmony of facts, on the one hand, and the apparent impossibility of accounting for new features and peculiarities of the new units, are shown to be a general feature of nature and of facts: integration is not mere summation, but a creation of ever-new types and units, with superficial discontinuities and with their own new denominators of special peculiarities; hence there is no reason to think of an insurmountable and unique feature in the origin of life, nor even of mentally integrated life; no need of special mystical sparks of life, of a mysterious spirit, etc.; but—and this is the important point—also no need of denying the existence of all the evidence there may be of facts which we imply when we use the deeply felt concepts of mind and soul. In other words, we do not have to be mind-shy nor body-shy any longer.

The inevitable problem of having to study other persons as well as ourselves necessarily leads us on to efforts at solution of other philosophical problems, the problem of integrating materialism and idealism, mechanism and relative biological determinism and purpose, etc. Man has to live with the laws of physics and chemistry unbroken and in harmony with all that is implied in the laws of heredity and growth and function of a biological organism. Yet what might look like a limitation is really his strength and safe foundation and stability. On this ground, man's biological make-up has a legitimate sphere of growth and expansion shared by no other type of being. We pass into every new moment of time with a preparedness shown in adaptive and constructive activity as well as structure, most plastic and far-reaching in the greatest feat of man, that of imagination. Imagination is not a mere duplication of reality in consciousness and subjectivity; it is a substitute in a way, but actually an amplification, and often a real addition to what we might otherwise call the "crude world," integrated in the real activities of life, a new creation, an ever-new growth, seen in its most characteristic form in choice and in any new volition. Hence the liberating light which integration and the concepts of growth and time throw on the time-honored problem of absolute and relative determinism and on the relation of an ultra-strict "science" with common sense.

In logic, too, we are led to special assertions. We are forced to formulate "open definitions," i.e., we have to insist on the open formulation of tendencies rather than "closed definitions." We deal with rich potentialities, never completely predictable.

This background and the demands of work in guiding ourselves and others thus come to lead us also into practical ethics, with a new conception of the relation of actual and experimental determinism and of what "free will" we may want to speak of, with a new emphasis on the meaning of choice, of effort, and of new creation out of new possibilities presented by the ever-newly-created opportunities of ever-new time. We get a right to the type of voluntaristic conception of man which most of us live by—with a reasonable harmony between our science and our pragmatic needs and critical common sense.

The extent to which we can be true to the material foundations and yet true to a spiritual goal, ultimately measures our health and natural normality and the value of our morality. Nature shapes her aims according to her means. Would that every man might realize this simple lesson and maxim—there would be less call for a rank and wanton hankering for relapses into archaic but evidently not wholly outgrown tendencies to the assumption of "omnipotence of thought," revived again from time to time as "New Thought." Psychiatry restores to science and to the practical mind the right to reinclude rationally and constructively what a narrower view of science has, for a time at least, handed over unconditionally to uncritical fancy. But the only way to make unnecessary astrology and phrenology and playing with mysticism and with Oliver Lodge's fancies of the revelation of his son Raymond, is to recognize the true needs and yearnings of man and to show nature's real ways of granting appetites and satisfactions that are wholesome.

Hereby we have indeed a contribution to biologically sound idealism: a clearer understanding of how to blend fact and ambition, nature and ideal—an ability to think scientifically and practically and yet idealistically of matters of real life.

To come back to more concrete problems again, a wider grasp of what psychiatry may well furnish us helps toward a new ethical goal in our social conscience. The nineteenth century brought us the boon and the bane of industrialism. More and more of the pleasures and satisfactions of creation and production and of the natural rewards of the daily labor drifted away from the sight and control of the worker, who now rarely sees the completed result of his work as the farmer or the artisan used to do. Few workers have the experience of getting satisfaction from direct pride in the end result; as soon as the product is available, a set of traders carries it to the markets and a set of financiers determines, in fact may already have determined, the reward—just as the reward of the farmer is often settled for him by astounding speculations long before the crop is at hand. There is a field for a new conscience heeding the needs of fundamental satisfactions of man so well depicted by Carlton Parker, and psychiatric study furnishes much concrete material for this new conscience in industrial relations—with a better knowledge of the human needs of all the participants in the great game of economic life.

Psychiatry gives us also a new appreciation of the religious life and needs of our race. Man's religion shows in his capacity to feel and grasp his relations and responsibility toward the largest unit or force he can conceive, and his capacity for faith and hope in a deeper and more lasting interdependence of individual and race with the Ruler or rules of the Universe. Whatever form it may take expresses his capacity to feel himself in humility and faith, and yet with determination, a more or less responsible part of the greatest unit he can grasp. The form this takes is bound to vary individually. As physicians we learn to respect the religious views of our fellow beings, whatever they may be; because we are sure that we have the essentials in common; and with this emphasis on what we have in common, we can help in attaining the individually highest attainable truth without having to be destructive. We all recognize relations that go beyond individual existence, lasting and "more than biological" relations, and it is the realization of these conceptions intellectually and emotionally true to our individual and group nature that constitutes our various religions and faiths. Emphasizing what we have in common, we become tolerant of the idea that probably the points on which we differ are, after all, another's best way of expressing truths which our own nature may picture differently but would not want to miss in, or deny to, the other. One of the evidences of the great progress of psychiatry is that we have learned to be more eager to see what is sane and strong and constructively valuable even in the strange notions of our patients, and less eager to call them queer and foolish. A delusion may contain another person's attempt at stating truth. The goal of psychiatry and of sound common sense is truth free of distortion. Many a strange religious custom and fancy has been brought nearer our understanding and appreciation since we have learned to respect the essential truth and individual and group value of fancy and feeling even in the myths and in the religious conceptions of all races.

Among the most interesting formulations and potential contributions of psychiatry are those reaching out toward jurisprudence. Psychiatry deals pre-eminently with the variety and differences of human personalities. To correct or supplement a human system apparently enslaved by concern about precedent and baffling rules of evidence inherited from the days of cruel and arbitrary kings, the demand for justice has called for certain remedies. Psychiatry still plays a disgraceful rôle in the so-called expert testimony, largely a prostitution of medical authority in the service of legal methods. Yet, out of it all there has arisen the great usefulness of the psychiatrist in the juvenile and other courts. There it is shown that if psychiatry is to help, it should be taken for granted that the person indicted on a charge should thereby become subject to a complete and unreserved study of all the facts, subject to cross-examination, to be sure, but before all accessible to complete and unreserved study. This would mean a substantial participation of law in the promotion of knowledge of facts and constructive activity, and a conception of indeterminate sentence not merely in the service of leniency but in the service of the best protection of the public, and, if necessary, lasting detention of those who cannot be reformed, before they have had to do their worst. Whoever is clearly indicted for breaking the laws of social compatibility should not merely invite a spirit of revenge, but should, through the indictment, surrender automatically to legalized authority endowed with the right and duty of an unlimited investigation of the facts as they are.

Looking back then, you can see how the history of the human thought about what we call mind and psyche displayed some strange reactions of the practical man, the scientist, the philosopher, and theologian toward one of the most important and practical problems. It is difficult to realize what it means to arrive at ever-more-workable formulations and methods of approach. We do not have to be mind-shy or body-shy any longer. To-day we can attack the facts as we find them, without that disturbing obsession of having to translate them first into something artificial before we can really study them and work with them. Since we have reached a sane pluralism with a justifiable conviction of the fundamental consistency of it all, a satisfaction with what we modestly call formulation rather than definition and with an appreciation of relativity, we have at last an orderly and natural field and method from which nobody need shy.

The century that has passed since the inspiration of a few men of the Society of the New York Hospital to provide for the mentally sick has cleared the atmosphere a great deal. We can start the second century freer and unhampered in many ways. Much has been added, and more than ever do we appreciate the position of just such a hospital as that of Bloomingdale as a centre of healing and as a leader of public opinion and as a contributor to progress.

The Bloomingdale Hospital has a remarkable function. It is a more or less privileged forerunner in standards and policies. Without having to carry the burdens of the whole State with its sweeping and sometimes distant power and its forced economy, a semiprivate hospital like Bloomingdale aims to minister to a slightly select group, especially those who are in the difficult position of greater sensitiveness but moderate means in days of sickness. It serves the part of our community which more than any other sets the pace of the civilization about us—the intelligent aspiring workers who may not have reached the goal of absolute financial independence. It creates the standard of which we may dream that it might become the standard of the whole State.

When we review the roster of Superintendents—from John Neilson to Pliny Earle and from Charles Nichols, Tilden Brown, and Samuel Lyon down to the present head, our highly esteemed friend and coworker William L. Russell—and the names of the members of the staff, many of whom have reached the highest places in the profession, and last, but not least, the names of the Governors of The Society of the New York Hospital, we cannot help being impressed by the forceful representation of both the profession and the public, and we recognize the wide range of influence.

Instead of depending on frequently changing policies regulated from the outside under the influence of the greater and lesser lights and exigencies of State and municipal organization, the New York Hospital has its self-perpetuating body of Governors chosen from the most public-spirited and thoughtful representatives of our people. Bloomingdale thus has always had a remarkable Board of Governors, who, from contact with the General Hospital and with this special division, are in an unusual position to see the practical aspects of the great change that is now taking place. You see how the division of psychiatry has developed from practically a detention-house to an asylum, and finally to a hospital with all the medical equipment and laboratories of the General Hospital. And you begin to see psychiatry, with its methods of study and management of life problems as well as of specific brain diseases, infections, and gastrointestinal and endocrine conditions, become more and more helpful, even a necessity, in the wards and dispensary of the General Hospital on 16th Street. The layman cannot, perhaps, delve profitably into the details of such a highly and broadly specialized type of work. But he can readily take a share in the best appreciation of the general philosophy and policy of it all.

The shaping of the policy of a semiprivate hospital is not quite as simple as shaping that of a State Hospital with its well-defined districts and geographically marked zones of responsibility. Bloomingdale has its sphere of influence marked by qualitative selection rather than by a formal consideration. It does not pose as an invidious contrast to the State Hospital, and yet it is intended to solve in a somewhat freer and more privileged manner the problem of providing for the mentally sick of a more or less specific hospital constituency, the constituency of the New York Hospital; and since it reaches the most discriminating and thinking part of our population, it has the most wonderful opportunity to shape public opinion. Like all psychiatrical institutions, it has to live down the traditional notions of the half-informed public; it has to make conspicuous the change of spirit and the better light in which we see our field and responsibilities. This organization can show that it is not mere insanity but the working out of life problems that such a hospital as this is concerned with. The conditions for which it cares are many. Some of them are all that which tradition and law stamp as insanity. But see what a change. Seventy-five per cent of the patients are voluntary admissions; and more and more will be able to use the helps when they begin to feel the need, not merely when it becomes an enforced necessity.

By creating for this Hospital a liberal foundation, by completing its equipment so as to make possible a free exchange of patients and of workers from the Hospital in the city and this place in the country, much has been done and more will be done to set a living example of the very spirit of modern psychopathology and psychiatry. We know now that from 10 to 40 per cent of the patients of the gynecologist, the gastroenterologist, and the internist generally would be better treated if a study of the life problems were added to that of the special organs and functions. To meet this need it should be possible to have enough workers in this branch of the Hospital to take their share of the consulting and co-operation work in the wards and dispensary of the General Hospital, and perhaps even in the schools provided for the same type of people from which you draw your patients. The grouping of the patients can be such that the old prejudices need not reach far into the second century of the life of the Hospital. With a man of the vision and practical experience of Dr. Russell, there is no need for an outsider to conjure up a picture of special practical achievements as I have done of the more general principles to-day.

An institution is more than a human life. Many ambitions combine and become part of a group spirit permeating the organization and reaching their fulfilment in the succession of leaders. The life and growth and happy self-realization of an institution is not the bricks and mortar—it is a living and elastic entity—never too stable, never too finished, a growing and plastic plant—to use a metaphor that has slipped in perhaps without arousing all the implications the term plant might carry and does carry.

Some years ago my wife celebrated her birthday and told her colored cook jocosely: "Geneva, I am a hundred years old to-day." The cook's jaw dropped and then she suddenly remarked: "Lord! you don't look dat ole." That is the way I feel about Bloomingdale Hospital as we see it to-day pulsating with ever-fresh life and ever-fresh problems! How different from a simple human being, after all! The heart and wisdom of many a man and woman has gone into the perpetuation of what a few thoughtful men started in 1821 and the result is that it is ever renewing its youth.

Many a dream has been realized and many a dream has given way to another. Here and there the past may make itself felt too much. But the spirit and its growth show in recruiting ever-new lives to meet the present day and the days to come, and this all the more so if we can show the younger generation that every effort is likely to have its reasonable direct support. We all want a man like Dr. William L. Russell to have the fullest opportunity to bring to its best expression the rich and well-tried wisdom of over twenty-five years of devoted work in the field. This is no doubt a time of stress when many personal and general sacrifices may be needed to bring about the fruition and culmination of the labors of the present generation. Yet is it not a clear opportunity and duty, so that those who are growing up in the ranks to-day may really be encouraged to get a solid training, always animated by the conviction that one can be sure of the practical reward for toiling through the many years of preparation in a psychiatric career, whether it be as a physician or as a nurse or as an administrator?

I cannot help feeling as I stand here that I am in a way representing not only my own sentiments and convictions but those of our dear old friend Hoch. We all wish that he might be with us to express himself the warm feelings toward the Bloomingdale Hospital and its active representatives, from the managers to the humblest workers. Hoch in his modesty could probably not have been brought to state fully and frankly his own share in the achievements of this Hospital. But I know how much he would have liked to be here to express especially the warmth of appreciation we all entertain of what our friend William L. Russell means to us and has meant to us all through the nearly twenty-five years of our friendship and of working together. We delight in seeing him bring to further fruition the admirable work he did at Willard, and later for all the State hospitals; and that which we see him do at all times for sanity in the progress of practical psychiatry, and now especially in the guidance of this institution. We delight in seeing his master mind given more and more of a master's chance for the practical expression of his ideals and convictions concerning the duties and opportunities of such a hospital as Bloomingdale.

Our thanks and best wishes to those who invited us to stand here to-day at the cradle of a second century of Bloomingdale Hospital! It is a noteworthy gathering that joins here in good wishes to those who have shaped this ever-new Bloomingdale. With a tribute to our thoughtful and enthusiastic friend in internal medicine, Lewellys F. Barker, to our English coworker, Richard G. Rows, to the illustrious champion of French psychopathology, Pierre Janet, to our friend and leader in practical psychiatry, William L. Russell, to our friends and coworkers of the Bloomingdale staff, and especially also to the Board of Governors who shape the policy and control the finances, and exercise the leadership of public opinion, I herewith express my sincerest thanks and best wishes.

ADDRESS BY
DR. LEWELLYS F. BARKER

The Chairman:—The Johns Hopkins Medical School lends us also to-day Dr. Lewellys F. Barker, its Professor of Clinical Medicine. Dr. Barker has done so much to define and settle the contradictions of mind and matter, and has clarified so much, and in fields so varied, as teacher, research worker, and practitioner, that we welcome this opportunity of listening to his discussion of "The Importance of Psychiatry in General Medical Practice."

DR. BARKER

We have met to-day to celebrate the hundredth anniversary of the founding of a hospital that, in its simpler beginnings and in its evolution to the complex and highly organized activities of the present, has served an eminently practical purpose and has played an important rôle in the development of the science and art of psychiatry in America. I desire, as a representative of general medicine, and, especially, of internal medicine, to add, on this occasion, my congratulations to those of the spokesmen of other groups, and, at the same time to express the hope that this institution, historically so significant for the century just past, may maintain its relative influence and reputation in the centuries to come.

The interest taken in psychiatry by the general practitioner and by the consulting internist has been growing rapidly of late. Some of the reasons for this growth of interest and heightening of appreciation I have drawn attention to on an earlier occasion.^[4] Psychiatry as a whole was for a long time as widely separated from general medicine as penology is to-day, and for similar reasons. It was a long time before persons that manifested extraordinary abnormalities of thought, feeling, and behavior were regarded as deserving medical study and care, and even when a humanitarian movement led to their transfer from straight-jackets, chains, and prison cells to "asylums for the insane," these institutions were, for practical reasons, so divorced from the homes of the people and from general hospitals that psychiatry had, and could at the time have, but little intercourse with general medicine or with general society. Mental disorders were moral and legal problems rather than biological, social, and medical problems. Their genesis was wholly misunderstood, and legal, medical, social, religious, and philosophic prejudices went far toward preventing any rational scientific mode of approach to the questions involved or any formulation of investigative procedures that promised to be fruitful. Even to-day the same prejudices are all too inhibitory; but thanks to the unprecedented development of the natural sciences during the period since this hospital was founded, we are witnessing, in our time, a rapid transformation of thought and opinion concerning both the normal and the disordered mind, a transformation that is reaching all circles of human beings, bidding fair to compel the strongholds of tradition and prejudice to relax, and inviting the whole-hearted co-operation of workers in all fields in a common task of overcoming some of the greatest difficulties by which civilization and human progress are confronted. And though the brunt of this task is borne and must be borne by the shoulders of medical men, physicians assume the burden cheerfully, now that they know that they can count upon the intelligent support and the cordial sympathy of an ever-enlarging extra-medical aggregate. No better illustration could be given, perhaps, of the change in the status of psychiatry in this country and in the world than the contents of the programme of our meeting to-day at which a distinguished investigator from London tells us of the biological significance of mental disorders, an eminent authority from Paris explains the relationship between certain diseases of the nervous system and these disorders, and a leading psychiatrist of this country speaks upon the contributions of psychiatry to the understanding of the problems of life. Psychiatry, like each of the other branches of medicine, has come to be recognized as one of the subdivisions of the great science of biology, free to make use of the scientific method, in duty bound to diffuse the knowledge that it gains, and privileged to contribute abundantly to the lessening of human suffering and the enhancement of human joys. General practitioners of medicine and medical specialists—at least the more enlightened of them—welcome the developing science of psychiatry, are eager to hasten its progress, and will gladly share in applying its discoveries to the early diagnosis, the cure, and the prevention of disease.

That the majority of medical and surgical specialists and even most of the widely experienced general practitioners, though constantly coming in contact with major and minor psychic disturbances, are, however, still far from realizing the full meaning and value of the principles and technic of modern psychology and of the newer psychiatry must, I fear, be frankly admitted.^[5] But dare we blame these practitioners for their ignorance of, apathy regarding, and even antipathy to, the psychic and especially the psychotic manifestations of their patients? Ought we not rather to try to understand the reasons for this ignorance, this apathy, and this aversion, all three of which seem astonishing to many of our well-trained psychologists and psychopathologists? Are there not definite conditions that explain and at least partially excuse the defects in knowledge and interest and the errors in attitude manifested by those whom we would be glad to see cognizant and enthusiastically participant? Psychiatrists, who have taught us to understand and rescue various types of "sinners" and "social offenders" will, I feel sure, avoid any moralistic attitude when discussing the shortcomings of their brethren in the general medical profession, and will, instead, seek to discover and to remove their causes.

As an internist who values highly the gifts that modern psychology and psychiatry have been making to medicine, I have given some thought to the conditions and causes that may be responsible for these professional delinquencies that you deplore. Though this is not the time nor the place fully to discuss them, the mere mention of some of the causes and conditions will, perhaps, contribute to comprehension and pardon, and may serve to stimulate us all to livelier corrective activity. Let me enumerate some of them:

(1) A social stigma still attaches, despite all our efforts to abolish it, to mental disorders and has, to a certain extent, been transferred to those that study and treat patients manifesting these disorders.

(2) The organization of our general education is very defective since it fails to make clear to each student man's place in the universe and any orderly view of the world and man; it fails adequately to enlighten the student regarding the processes of life as adaptations of organisms to their environment, man, himself, being such an organism reacting physically and psychically to his surroundings in ways either favorable or unfavorable to his own preservation and that of his species; it fails to teach the student that the human organism represents a bundle of instincts each with its knowing, its feeling, and its striving component, that what we call "knowledge" and what we call "character" are gradual developments in each person, and that if we know how they have developed in a particular person we possess clues to the way that person will react under a given stimulus, that is to say, what he will think, how he will feel, and how he will act; and it fails, again, properly to instruct students regarding the interrelationships of members of different social groups (familial, civic, economic, occupational, ethical, national, racial, etc.); in other words, our general educational organization is as yet far from successful in inculcating philosophical, biological, psychological, and sociological conceptions that are adequate symbols of reality.

(3) Though our medical schools have made phenomenal advances in the organization and equipment of their institutes and in provision for teaching and research in a large number of preclinical and clinical sciences, they have up to now almost wholly ignored normal psychology, psychiatry, and mental hygiene. The majority of the professors in these schools are so absorbed by the morphological, physical, and chemical aspects of their subjects, that students rarely get from them any inkling of the psychobiological aspect, any adequate knowledge of human motives, or any satisfactory data regarding human behavior, normal or abnormal.^[6] It is only recently and only in a few schools that psychiatric clinics have been established as parts of the teaching hospitals, that medical students have been able to come into direct contact over an appreciable period of time with the objects of psychiatric study, that the psychic manifestations of patients have received any direct and particular attention in the general medical and surgical wards, and that there has been any free and constant reciprocal exchange of thought and opinion between students of the somatic on the one hand and students of the psychic on the other.

(4) The language of the psychiatrist is unique and formidable. The names he has applied to motives and impulses, to symptoms and syndromes, are foreign to the tongue of the general practitioner who is so awed by them that he withdraws from them and remains humbly reticent in a state of enomatophobia; or, if he be more tough-minded, he may be amused by, or contemptuous of, what he refers to as "psychiatric jargon" or "pseudoscientific gibberish." There is, furthermore, a dearth of concise, authoritative, well-written text-books on psychiatry, and the general medical journals rarely print psychiatric papers designed to interest the average practitioner. The most widely diffused psychiatric reports of our time are the sensational news items of the daily press.

(5) The overemphasis of psychogenetic factors to the apparent neglect of important somatogenic factors by some psychiatrists has tended to arouse suspicion regarding the soundness of the opinions and methods of psychiatric workers in the minds of men thoroughly imbued with mechanistic conceptions and impressed with the results of medical researches based upon them. The ardor of the psychoanalysts, also, though in part doubtless justified by experience, has, it is to be feared, excited a certain amount of antipathy among the uninitiated.

(6) The fears of insanity prevalent among the laity and the repugnance of patients to any idea that they may be "psychotic" or "psychoneurotic" (words that, in their opinion, refer to "imaginary symptoms," or to symptoms that they could abolish if they would but "buck up" and exert their "wills") undoubtedly exert a reflex influence upon practitioners who put the "soft pedal" on the psychobiological reactions and "pull out the stop" that amplifies the significance of any abnormal physical findings.

(7) Psychotherapy, to the mind of the average medical practitioner, is (or has been) something mysterious or occult. He uses much psychotherapy himself but it is nearly always applied unconsciously and indirectly through some form of physical or chemical therapy that he believes will cure. He is usually quite devoid of insight into the effect of his own expressed beliefs and bodily attitudes upon the adjusting mechanisms of his patients. Conscious and direct psychotherapy is left by the average practitioner to New Thoughters, Christian Scientists, quacks, and charlatans. If he were to use psychotherapy consciously and were to receive a professional fee for it he would feel that he was being paid for a value that the patient had not received. A highly respected colleague once privately criticised a paper of mine (read before the Association of American Physicians) on the importance of psychotherapy. "What you said is true," he remarked; "we all use psychotherapy but we are a little ashamed of it; and it is better not to talk about it." Even he did not realize that every psychotherapy is also a physical therapy.

(8) The rise of specialism, through division of labor and intensification of interests restricted to limited fields, in practical medicine, the necessary result and to a large extent also a cause of the rapid growth of knowledge and technic has brought with it many advantages, but also some special difficulties, among them (a) the impossibility any longer of any single practitioner, unaided, to study and treat a patient as well as he can be studied and treated by a co-ordinated group whose special analytical studies in single domains are adequately synthesized by a competent integrator, and (b) in the absence of such group work, the tendency to one-sided study, partial diagnosis, and incomplete and unsatisfactory therapy. Through the rise of specialism, it is true, psychiatry itself has arisen and the psychiatrist, like the skilled integrating internist, is interested in the synthesis of the findings in all domains, for only through such synthetic studies, such integration of the functional activities of the whole organism, is it possible to gain a global view of the patient as a person, to make a complete somatic, psychic, and social diagnosis, and to plan a regimen for him that will ensure the best adjustment possible of his internal and external relationships.^[7]

Working in a diagnostic group myself as an integrating internist, I have been much helped by the reports of personality studies made by skilful psychiatrists; these are linked with the special reports on the several bodily domains (cardiovascular, respiratory, hæmic, dental, digestive, urogenital, locomotor, neural, metabolic, and endocrine) in order finally to arrive at an adequately co-ordinated and (subordinated) total diagnosis from which the clues for an appropriate therapeutic regimen can safely be drawn. If group practice is to grow and be successful in this country, as I think likely, groups must see to it that psychiatry, as well as the other medical and surgical specialties, is properly represented in their make-up.^[8] From now on, too, general practitioners should, as Southard emphasized, be urged to be at least as familiar with the general principles and methods of the psychiatrist as they are with those of the gynecologist, the dermatologist, and the pædiatrist.^[9] Well organized group-diagnosis and general will then help to counteract the inhibiting influence of earlier isolated specialism upon the appreciation of psychiatry.

This enumeration of some of the causes of the ignorance and apathy (existent hitherto) in the general profession regarding psychiatry may perhaps suffice as explanation. These causes are, fortunately, rapidly being removed. We are entering upon an era in which psychiatry will be recognized as one of the most important specialties in medicine, an era that will demand alliance and close communion among psychiatrists, internists, and the representatives of the various medical and surgical specialties.

The internist and the psychiatrist will ever have a common interest in the obscure problems of etiology and pathogenesis of diseases and anomalies that are accompanied by abnormalities of thought, feeling, and behavior. Progress in this direction is bound to be slow for the studies are exceptionally complex and there are many impediments to be removed. Though the problems are deep and difficult, they are doubtless soluble by the mind of man, and they exert an uncommon fascination upon those who visualize them. Causes may be internal or external, and are often a combination of both. The tracing of the direct and indirect relationships between these causes and the abnormal cerebral functioning upon which the disturbances of psychobiological adjustment seem to depend is the task of pathogenesis. The internist who has studied the infantile cerebropathies with their resulting imbecilities, syphilis followed by general paresis, typhoid fever and its toxic delirium, chronic alcoholism with its characteristic psychoses, cerebral thrombosis with its aphasias, agnosias, and apraxias, thalmic syndromes due to vascular lesions with their unilateral pathological feeling-tone, frontal-lobe tumors with joke-making, uncus tumors with hallucinations of taste and smell, lethargic encephalitis with its disturbance of the general consciousness and its psychoneurotic sequelæ (lesions in the globus pallidus and their motor consequences), pulmonary tuberculosis with its euphoria, and endocrinopathies like myxoedema and exophthalmic goitre with their pathological mental states, is encouraged to proceed with his clinical-pathological-etiological studies in full assurance that they will steadily contribute to advances in psychiatry. The eclectic psychiatrist who is examining mental symptoms and symptom-complexes ever more critically, who is seeking for parallel disturbances in physiological processes and who considers both psychogenesis and somatogenesis in attempting to account for psychobiological maladjustments will welcome, we can feel sure, any help that internal medicine and general and special pathology can yield.

These studies in pathogenesis and etiology are fundamentally necessary for the development of a rational therapy and prophylaxis. Already much that is of applicable value in practice has been achieved. The internist shares with the psychiatrist the desire that knowledge of the facts regarding care, cure, and prevention of mental disorders may become widely disseminated among medical men and at least to some extent among the laity. Experts in psychiatry firmly believe that at least half of the mental disturbances now prevalent could have been prevented, if, during the childhood and adolescence of those afflicted, the facts and principles of existing knowledge and the practical resources now available could have been applied.

We have recently had an excellent illustration of the benefits of applied psychiatry in the remarkable results achieved during the great war through the activities of the head of the neuropsychiatric division of the Surgeon General's office and his staff ^[10] and those of the senior consultant in neuropsychiatry and his divisional associates in the American Expeditionary Force. In no other body of recruits and in no other army than the American was a comparable success arrived at, and the credit for this is due to American applied psychiatry and its wisely chosen official representatives.

The active campaign for the preservation of the mental health of our people and for a better understanding and care of persons presenting abnormal mental symptoms carried on during the past decade by the National Committee for Mental Hygiene marks a new epoch in preventive medicine.^[11]

The prevention of at least a large proportion of abnormal mental states through the timely application of the principles of mental hygiene is now recognized as a practically realizable ideal. Many important reforms are now in process throughout the United States, no small part of them directly attributable to the active efforts of our leading psychiatrists and to our National Committee's work. The old "asylums" are being changed into "hospitals." Psychiatric clinics are becoming attached to teaching hospitals and psychiatric instruction in the medical schools is being vastly improved. The mental symptoms of disease now receive attention in hospitals and in private practice and at a much earlier stage than formerly. Even the courts, the prisons, and the reformatories are awakening to the importance of scientific psychiatry; before long penology may be brought more into accord with our newer and juster conceptions of the nature and origin of crime, dependency, and delinquency. That schools of hygiene and the public health services must soon fall into line and consider mental hygiene seriously is obvious. The objection sometimes made that the practical problems are too vague, not sufficiently concrete, to justify attack by public health officials is no longer valid. In no direction, probably, could money and energy be more profitably spent during the period just ahead than in the support of a widely organized campaign for Mental Hygiene.^[12] Psychiatrists can count upon internists and general practitioners to aid them in educating the public regarding the nature and desirability of this campaign.

Man is now consciously participating in the direction of his own evolution. To cite England's poet laureate, who, you will recall, is a physician: "The proper work of his (man's) mind is to interpret the world according to his higher nature, and to conquer the material aspects of the world so as to bring them into subjection to the spirit."

Cf. Salmon (T.W.), "War Neuroses and Their Lesson," New York Medical Journal, CIX, 993, 1919; also, "The Future of Psychiatry in the Army," Mil. Surgeon, XLVII, 200, Washington, 1920.

Cf. "Origin, Objects, and Plans of the National Committee for Mental Hygiene" (Publication No. 1, of the National Committee, New York City); and, "Some Phases of the Mental Hygiene Movement and the Scope of the Work of the National Committee for Mental Hygiene," in Trans., XV, Internal. Congr. for Hygiene and Demography, III, 468-476, (1912), Washington 1913.

Cf. Russell (W.L.) "Community Responsibilities in the Treatment of Mental Disorders." Canad. J. Ment. Hygiene, 1919, I 155—.

Hincks (C.M.), "Mental Hygiene and Departments of Health," Am. J. Pub. Health, Boston, IX, 352, 1919; Haines (T.H.), "The Mental Hygiene Requirements of a Community: Suggestions Based upon a Personal Survey," Mental Hygiene, IV, 920-931, New York, 1920.

Beers (C.W.), "Organized Work in Mental Hygiene," Mental Hygiene, 567, New York, 1917, also, Williams (F.E.), "Progress in Mental Hygiene," Modern Hospital, XIV, 197, Chicago, 1920.

The Chairman: We had hoped to receive to-day the greetings of our sole elder sister among American institutions, the Pennsylvania Hospital, of Philadelphia, which since its foundation in 1751 has pursued a career much like our own, treating mental cases in the general hospital from the very beginning, and since 1841 maintaining a separate department for mental diseases in West Philadelphia. Dr. Owen Copp, the masterly physician-in-chief and administrator of that department, was to have been here, but unfortunately has been detained. Our morning exercises having come to an end, Dr. Russell asks me to say that your inspection of the occupational buildings and other departments of the Hospital is cordially invited; a pageant illustrative of the origin and aspirations of the Hospital will be given on the adjoining lawn; and that after the pageant our guests are desired to return to the Assembly Hall, where we shall have the privilege of listening to addresses by Dr. Richard G. Rows, of London, and Dr. Pierre Janet, of Paris, who have come across the Atlantic especially to take part in this anniversary celebration.

ADDRESS BY
DR. GEORGE D. STEWART

AFTERNOON SESSION

The Chairman: For the first seventy-five years of its existence the New York Hospital was the nearest approach to an academy of medicine that the city possessed. When the now famous New York Academy of Medicine was established in 1847, a friendly and cordial co-operation between the two institutions arose, and while the activity of this co-operation is not as pronounced as it was, we still cherish in our hearts a warm regard for that ancient ally in the cause of humanity. Its President, Dr. George D. Stewart, the distinguished surgeon, has come to extend the greetings of the medical profession of New York City.

DR. STEWART

The emotions that attend the birthday celebrations of an individual are often a mixture of joy and sadness, of laughter and of tears. In warm and imaginative youth there is no sadness and there are no tears, because that cognizance of the common end which is woven into the very warp and woof of existence is then buried deep in our subconscious natures, or if it impresses itself at all, is too volatile and fleeting to be remembered. But as the years fall away and there is one less spring to flower and green, the serious man "tangled for the present in some parcels of fibrin, albumin, and phosphates" looks forward and backward and takes in both this world and the next. In the case of institutions, however, the sadness and the tears do not obtain—for a century of anniversaries may merely mean dignified maturity, as in the case of Bloomingdale, with no hint of the senility and decay that must come to the individual who has lived so long. This institution was founded one hundred years ago to-day; the parent, the New York Hospital, has a longer history. Bloomingdale, as a separate and independent concern, had its birthday a century ago.

It is curious to let the mind travel back, and consider what was happening about that time. Just two years before the news had flashed on the philosophical and scientific world that Oersted, a Danish philosopher, had caused a deflection of the magnetic needle by the passage near it of an electric current. The relation between the two forces was then and there confirmed by separate observations all over the civilized world. This discovery probably created more interest at that time than Professor Einstein's recent announcement which, if accepted, may be so disturbing to the principia of Newton and to our ideas of time and space. There can be no doubt that the practical significance of Oersted's experiment was much more widely appreciated than the theory of Einstein, for an understanding of the latter is confined, we are told, to not many more men than was necessary to save Sodom and Gomorrah. Its immense practical significance, however, could have been foreseen by no man, no matter with what vision endowed. Just two years prior to the founding of this institution the first steamboat had crossed the Atlantic and in the same year that great conqueror, who had so disturbed the peace of the world which was even then as now slowly recovering from the ravages of war, breathed his last in Saint Helena, yielding to death as utterly as the poorest hind.

In 1815, Bedlam Hospital in South London was converted into an asylum for the insane who were at the time called "lunatics." The name Bedlam is a corruption of the Hebrew "Bethlehem"—meaning the House of Bread—and while the name popularly came to signify a noisy place it was the beginning of really scientific treatment for the tragically afflicted insane. While the treatment of the insane in Europe was being steadily raised to a higher plane of efficiency, America has also reason to be proud of her record in this respect. During all the years that have followed, Bloomingdale has been an important factor in the medical world of New York.

There are two phases of its existence which might be emphasized—first, it was founded by physicians; even then and, of course, long before doctors had proven that they were in the forefront in the promotion of humanitarian activities. Medicine has always carried on its banners an inscription to the Brotherhood of Man. It is worthy of note that when Pinel and Tuke had begun to regard mental aberration as a disease and to provide scientific hospital treatment therefor, American physicians, prepared by study and experimentation, were ready to accept and apply the new teachings.

A second phase of great importance is that institutions like Bloomingdale have promoted the study of psychology far more than any other factor, particularly because in them the personality stripped of some of its intricacies, the diseased personality, permits analysis, which the normal complex has so long defied. That it is high time that mankind was undertaking this knowledge of himself is particularly emphasized by the unrest and aberrance of human behavior now startling and disturbing the whole world. If mankind does not take up this self study as Trotter has said, Nature may tire of her experiment man, that complex multicellular gregarious animal who is unable to protect himself even from a simple unicellular organism, and may sweep him from her work-table to make room for one more effort of her tireless and patient curiosity. Psychology should be taught to every doctor and to every lettered man.

Digressing for a moment, to every one capable of understanding it, there should be imparted a knowledge of that simple economic law announced from the Garden of Eden after the grounds had been cleared and the gates closed: "By the sweat of thy brow thou shalt earn thy bread." The economic phase indeed constitutes a highly important aspect of modern psychology, for abnormal elements are antisocial, and from pickpockets to anarchists flourish on the soil of pauperism. The key-note of the future is responsibility. To the educated and enlightened man who still asks, "Am I my brother's keeper?" Cain has bequeathed a drop of his fratricidal blood; and he who spurns to do his share of the world's work, electing instead to fall a burden upon the community, deserves the fate of the barren fig-tree.

However, amidst the social unrest, buffeted and perplexed by the cross currents of our time, we should not be pessimistic but should look forward with courage, parting reluctantly with whatever of good the past contained and living hopefully in the present. As Ellis says: "The present is in every age merely the shifting point at which past and future meet, and we can have no quarrel with either. There can be no world without traditions; neither can there be any life without movement. As Heraclitus knew at the outset of modern philosophy, we cannot bathe twice in the same stream, though as we know to-day, the stream still flows in an unending circle. There is never a moment when the new dawn is not breaking over the earth, and never a moment when the sunset ceases to die. It is well to greet serenely even the first glimmer of the dawn when we see it, not hastening toward it with undue speed, nor leaving the sunset without gratitude for the dying light that once was dawn."

So to-day I bring to you from the New York Academy of Medicine felicitations on your one hundredth anniversary and greetings to your guests who have come from all over the world to join in your birthday celebration.

ADDRESS BY
DR. RICHARD G. ROWS

The Chairman: Besides the Royal Charter, the New York Hospital is indebted to Great Britain for invaluable encouragement and financial aid in our natal struggle in Colonial days. Dr. Rows has added charmingly to that debt by journeying from London to take part in these exercises. His subject will be, "The Biological Significance of Mental Illness."

As Director of the British Neurological Hospital for Disabled Soldiers and Sailors, at Tooting, he is giving the community and the medical world the benefit of his rich professional experience in the trying years of war as well as in peace, and gaining fresh laurels as he marches, like Wordsworth's warrior, "from well to better, daily self-surpast."

DR. ROWS

I must first express to you my keen appreciation of the high honor you have conferred on me by inviting me to come from England to address you on the occasion of the centenary celebration of the opening of this Hospital.

It is perhaps difficult for us to realize what resistances lay in the way of reform at that time, resistances in the form of long-established but somewhat limited views as to the nature of mental illnesses, as to whether the sufferer was not reaping what he had sown in angering the supreme powers and in making himself a fit habitation for demons to dwell in; in the form of a lack of appreciation of the need of sympathy for those who, while in a disturbed state, offended against the social organism or in the form of an exaggerated fear which compelled the adoption of vigorous methods of protecting the social organism against those who exhibited such anti-social tendencies. The men and women of the different countries of the world who recognized this and made it the chief of their life's duties to spread a wider view of such conditions and to insist that the unfortunate people should be regarded and treated as fellow human beings will ever command our admiration.

By the courtesy of Dr. Russell I have had an opportunity of seeing the pamphlet in which are recorded the efforts of Mr. Thomas Eddy in the year 1815 to move his colleagues to consider this matter.^[13] The result of those efforts was the establishment of an institution on Bloomingdale Road.

Various changes followed until we arrived at the Bloomingdale Hospital of to-day with its large and trained staff of medical officers, who, while still recognizing the difficulties of the task, are imbued with a hope of success which has arisen on a basis of wider knowledge, but which was unknown to many of their predecessors. To have the opportunity of joining with you in celebrating the big advance made a hundred years ago, of exchanging ideas with you with regard to the difficulties which still confront us, whether in America or in England, and which demand a united effort on the part of all who are interested in the scientific investigation of the subject, cannot fail to afford one the liveliest satisfaction.

In the brief history of the Hospital prepared by Dr. Russell we find the recommendations of another reformer, Dr. Earle, who in 1848 was evidently still not satisfied with the treatment provided for the sufferers from mental illness.

Both Mr. Eddy and Dr. Earle were influenced by their observation that even in those suffering from mania much of their behavior could not be described as irrational. If you will allow me I will quote a sentence of two from each.

Mr. Eddy said: "It is to be observed that in most cases of insanity, from whatever cause it may have arisen or to whatever it may have proceeded, the patient possesses small remains of ratiocination and self-command; and although they cannot be made sensible of the irrationality of their conduct or opinions, yet they are generally aware of those particulars for which the world considers them proper objects of confinement." With reference to treatment Dr. Earle said: "The primary object is to treat patients, so far as their condition will possibly permit, as if they were still in the enjoyment of the healthy exercise of their mental faculties."

To superficial observation these suggestions might well have appeared as the phantasies of dreamers and perhaps at the present day their importance is not always fully appreciated. Recent advances in knowledge, however, have led us beyond the moral treatment recommended a hundred years ago and have enabled us to see that a more important truth underlay these suggestions.

We are all familiar with the frequent difficulty we encounter in our efforts to discover the actual mental disturbance which is supposed to exist in our patients. It is often a question of wit against wit as between patient and doctor, and not infrequently a rational and intelligent conversation may be maintained on an indifferent subject. The fact too that the disturbance is so frequently only temporary suggests that the loss of rational control is a less serious phenomenon than was generally supposed and we know that the control can be frequently restored by a period of rest or by a helpful stimulus. Quite recently a patient who in hospital had been confused, undisciplined, abusive, and threatening, was removed to a house of detention. The shock of finding himself, as he said, amongst a lot of lunatics, led him to face reality from a fresh point of view. He admitted that it had taught him a lesson and when he revisited the hospital, if not entirely grateful to us for the experience, he evidently bore no ill will.

But not only is it necessary to recognize what rational powers remain to the patient, we must also inquire how much in their disturbed mental activity can be considered a rational reaction to the stimuli which have operated, and still may be operating, on them.

In connection with this I would suggest that there are two aspects to be considered. First, what is the standard according to which we are to judge them? Secondly, to what extent are the reactions of the patient abnormal in kind to the driving stimulus? They may perhaps be reckoned abnormal in degree, but, to what extent, if at all, are they abnormal in kind?

It may be readily admitted that the behavior of those suffering from mental illness offends against conventional usages and is anti-social. It must also be recognized that amongst human beings living in aggregates some conventional usages must be evolved and insisted on in order to insure the greatest good of the greatest number. These usages are regarded not merely as protective measures for the body corporate, but they are also supposed to indicate a beneficial standard for the individual. But such a standard being adopted, observation is liable to be limited so much to results without sufficient attention being given to the causes which had led to those results.

By the recent advances in scientific knowledge and in methods of investigation we have been led to see that the conditions under consideration cannot be understood without a study of the mechanisms on which mental activity depends and without discovering the psychic and physical causes, arising from without and from within, which have disturbed the function of these mechanisms. We have learned that these illnesses do not arise from one cause alone and that they are the result of influences to which we all may be subject to some degree.

The originator of these modern methods, Prof. Freud, has stimulated us to regard the ordinary symptoms of mental illnesses as directing posts indicating lines to be investigated, and he and others have suggested various methods which may usefully be employed.

It is essential that we carefully distinguish what are primary from what are secondary symptoms. Two thousand years ago a physician, Areteus, pointed out that mania frequently commenced as melancholia, and he drew attention to the extreme frequency of an initial depression in cases of mental illnesses. But he did not offer any explanation of this initial state.

Such an initial state may perhaps be, to a certain extent, understood if we assume that the first evidences of mental disturbance consist in some difficulty in carrying out ordinary mental processes, some difficulty in exercise of the function of perceiving, thinking, feeling, judging, and acting, and that any disturbance of the harmonious activity of these functions must give rise to an emotional condition of anxiety and depression. Some such disharmony will, by adequate investigation, be found in a large number of cases to exist in the early states of the illness and will be appreciated by the patient before there occur any obvious signs, any outward manifestations of disability.

But in any disharmony which may occur it must be recognized that the mental mechanisms affected are those with which the patient was originally endowed, which he has gradually trained throughout his past experience and which he has employed more or less successfully up to the time the illness commenced. There is no new mechanism introduced to produce a mental illness, but a putting out of gear of those common to the race and their disturbance is the result of the action of influences which may befall any one of us, unbearable ideas with which some intense emotional state is intimately associated. The normal function of these mechanisms, simple at first and remaining fundamentally unaltered, although possibly much modified gradually by added experiences from within and without, depends on the maintenance of a harmonious balance between stimuli received and emotional reaction and motor response to those stimuli so that the feeling of well-being may arise.

If from any cause there occurs a failure to appreciate the stimuli clearly, if the emotional reactivity be disturbed, if the sense of value becomes biassed in one direction or another so that the response is recognized by the patient as abnormal there will result a disharmony and a feeling of ill-being of the organism. Under these conditions the processes of facilitation along certain definite lines and inhibition of all other lines—processes which are essential to clear consciousness—will become difficult or perhaps impossible and a mental illness will develop. In the slighter degrees the disharmony may be known to the patient without there being any outward manifestation to betray the conflict going on within. In the severe degrees the mental activity of the patient may be under the control of some dominant emotional state so that it may be impossible for him to adapt himself to his surroundings in a normal manner although his behavior may not appear so irrational when we know the stimuli affecting him. Within these extremes we discover all degrees of disturbance, and all varieties of signs and symptoms may be encountered.

But the signs which become obvious to superficial observation are, to a large extent, secondary products. The primary symptoms are felt by the patient as a disturbance of the capacity to perceive, to think, to feel, to judge, and to act, and with these disabilities there will be associated a certain degree of confusion and anxiety which cannot fail to appear as the result of such alterations of function.

The obvious signs may represent merely a more intense degree of the primary affection, disturbed capacity together with some confusion and anxiety; or they may represent efforts on the part of the patient to overcome or to escape from the disturbance or to explain it to himself. And now the total lack of knowledge of the processes on which mental activity depends, the altered standard of judgment due to some degree of dissociation, and the necessity of obtaining relief in some way or other will have much to do with determining the character of the symptoms with which we are all familiar. So many factors are concerned in the production of these secondary characters that it is difficult to assign to the symptoms their true value or to decide whether they possess much value at all with regard to the fundamental disturbance which constituted the primary illness. So often they appear to be mere rationalizations, mere false judgments on the part of the patient; they thus form subjects for investigation rather than fundamental constituents of the illness.

We, therefore, must not accept the outward and visible signs at their face value but attempt to discover what past experiences in the life of the patient have led to such disturbance of function, to such a change in his mental activity.

It will possibly be of some assistance to provide one or two examples in order to demonstrate the importance of the past experiences as agents capable of producing such alterations.

The first case will illustrate the results produced by the development of a dominant emotional tendency during early childhood. The patient up to the fifth year of her life had been an ordinary, normal child, attached to her mother, fond of her nurse, interested in her toys. During the next two years she endured much bad treatment at the hands of a new nurse which produced such an impression on her that she felt she was a changed child. This nurse, described to me by the patient as a handsome woman, having met the inevitable man, used frequently to meet him clandestinely. The child was neglected, was sometimes left alone, on one occasion in a graveyard, but she was forbidden to mention the subject to any one under threats of being carried away by a "bogey-man." The child became very frightened by this, to such an extent that one night she had a severe nightmare in which a "bogey-man" came to carry her away. At the end of two years a profound change had taken place in her which she now describes thus: "I was a changed child; I was separated from my mother and could no longer confide in her nor did I wish to do things for her as I had done before; I could not enjoy my toys; I had no confidence in myself; I was not like other children." And from that time on, as girl and as woman, she has never felt that she has been like others of her sex. Such a condition, being started and confined by repetition, interfered with her free development and it was remarkable how many incidents occurred in her life to confirm the disability, but the germ of her serious breakdown thirty years later was laid in her fifth and sixth years.

The second case is that of a patient who, as a child, had some convulsive attacks. She was therefore considered delicate and was thoroughly spoiled. When nearly thirty she lived through a sexual experience which caused extreme anxiety; she broke down and was admitted to an asylum. After admission she looked across the dormitory and saw a head appearing above the bed-clothes, the hair of which had been cut short for hygienic reasons. With a memory of her sexual indiscretion still vivid in her mind she jumped to the conclusion that she was in a place where men and women were crowded together in the same room. She got out of bed, refused to return to it, fought against the nurses and was transferred to a single room, with the mattress on the floor and the window shuttered. She wondered where she was and came to the conclusion that she was in a horse-box. Then arose a feeling of terror that she would be at the disposal of the grooms when they returned from work. The sound of heavy footsteps of the patients passing along the corridor to the tea-room suggested that the grooms were returning and that her room would soon be invaded. The feeling of terror increased and she tried to hide in the corner, drawing the mattress and clothes over her. And so on.

Months later when I had my first interview with her, her sole remark during the hour was "How can I speak in a place like this?" This was repeated almost without intermission throughout the hour. It formed a good example of the origin of the process of perseveration, a process frequently adopted by the patient to guard against the disclosure of a troublesome secret.

If we attempt to trace out some of the mechanisms employed in these two cases we shall see that in response to definite stimuli each reacted in a manner which cannot be considered abnormal in kind. It was normal reaction for the child to be distressed at being separated from her mother in such a way, to be frightened by being left in the graveyard alone, or at the threat of her being carried away by a "bogey-man" if she dared to mention anything of the clandestine meetings to her mother. It was not very abnormal that after her sexual experience the other patient while still in a confused state caused by the intense emotional condition of anxiety, should, on seeing a head with the hair cropped short, jump to the conclusion that there was a man in a bed in the same ward with herself, or that she should feel frightened and wish to leave the room.

The mental activity in each case depended on mental content, that is, memory of past experiences with their intense emotional states which acted as the driving force and also made the recall of the experience go extremely easy. The further developments after being placed in the single room with mattresses on the floor and the window shuttered were rationalizations also based on mental content, i.e., on the memory of rooms somewhat similar to that in which she found herself and of the use of such rooms. It is interesting to note also in the first case that in her wildest delirium during an acute attack she lived through episodes of her past life. One example may be given. In the course of her delirium she thought that a "blackbird" had flown to her, touched her left wrist and taken away all her vitality. This depended on an experience of her going to Germany when a girl and meeting a young German officer whom she did not like. A few years later she went to Germany and met the officer again. Without going into full details I may say that on one occasion when walking with him he seized her left wrist with his right hand and attempted to kiss her; she struggled fiercely and ran from him. Here we see that not only is her delirium based on a past experience, but that the whole memory is symbolized in the "blackbird" which was the emblem of the German nation in whose army the officer was then serving. Connected with this there was also another unpleasant episode which dated from her tenth year. Much of her delirium was worked out in such a way that most of the details could be traced back to experiences of her earlier life.

But however absurd her statement regarding her being touched by a "blackbird" and all her vitality removed might appear to superficial observation, it must be admitted that when we know the mental content of that patient, we cannot but see that at any rate it was not so irrational. And not only was this recognized by the doctor, but, and this is much more important, by the patient herself.

It is, therefore, the mental content which must be discovered before doctor or patient can understand the disability and before any common ground between the two can be found. And when the mental content is known it will be easy to recognize the affective condition of the patient to be a normal response. It will also be specific and if intense will dominate the patient. "Why is it I can never feel joy as I used to do?" was the pathetic inquiry of the patient dominated by a feeling of misery and fear. Was it not for the reason that being dominated by misery and fear, joy could find no place? The emotion of misery because of its intensity could more or less inhibit the feeling of joy, but joy could not inhibit the misery.

No repetition of the memory of the unpleasant experiences with their associated emotion of misery and fear led to the formation of a habit of mind and feeling. And when once such a habit of mind is established it is remarkable by what a host of stimuli received in ordinary daily life the cause of the disturbance can be recalled.

This question of stimuli deserves further notice. It is not so difficult to realize the mechanism by which a stimulus which clearly crosses the threshold of consciousness can lead to a given reaction. But it is perhaps difficult to imagine how so many stimuli which do not cross the threshold of consciousness or which, if they do, are not recognized by the patient at the time as having any reference whatever to the special memory can yet set the memory mechanism into action. The result may not be seen till after the relapse of some considerable period of time, as in the case of a man who for years had been disturbed by terrific nightmares, based on the idea of snakes coming out of the ground and attacking him. He complained one day that he was much worse, that three nights before he had had the worst nightmare of his life. On being questioned as to what could have suggested snakes to him he could not tell. A few minutes later he said: "I think I know the cause now. I spent the evening before I had that nightmare with a sergeant who had returned from the service in India." This friend amongst other things had mentioned that whenever they were about to bivouac they had to search every hole under a stone and every tuft of grass to see that there were no snakes there. This, which had been received as an ordinary item of information, had been the stimulus which had set his memory mechanism into action and the nightmare between two and three o'clock in the morning had been the result.

The result in many instances is evidenced by an emotional state alone and the actual memory of the original experience may not come into consciousness. Many examples of this might be given. The sound of a trolley wheel on a tram wire in one case gave rise to terror instead of its normal reaction, viz., that of satisfaction at getting to the destination quickly and without effort. This terror was produced because the sound on the wire resembled that of a shell which came over, blew in a dugout, killed three men, and buried the patient. No memory of this incident came into consciousness, only a terror similar to that experienced at the time of the original incident was experienced. Or, the time four o'clock in the afternoon could act as a stimulus to arouse an emotional state of misery similar to that experienced at the same time of day during an illness some years previously. Or, passing the house of a doctor when on a bus could produce a sudden outburst of anxiety, giddiness, and confusion; the patient had been taken into that house at the time of an epileptic attack. Or, showing photographs of the front could lead to an epileptic attack which was based on the memory of the time when the patient was wounded in the head; this has occurred on two separate occasions separated by an interval of some months. Or, noticing a familiar critical tone in a remark made at a dinner-table could lead to an acute change of feeling so that the subject who, before dinner, had felt she would like to play a new composition on the piano so as to obtain the opinion of the guest who had exhibited the critical tone, after dinner felt incapable of doing so. Her feelings had been hurt on many former occasions by critical remarks made by him in that tone. The critical remarks were not called to memory but there arose the feeling that under no circumstances could she play that piece to him.

Of special importance also are the experiences of childhood. An unhappy home or unjust treatment as a child may warp the development of the personality, lead to a lack of self-confidence, to the predominance of one emotional tendency, and so prevent that balanced equilibrium which will allow a rapid and suitable emotional reaction such as we may consider normal. This may lead to a failure of development or a loss of the sense of value, because the existence of one dominating emotional tendency so often produces a prejudiced view which may render a just appreciation of our general experience almost impossible and may seriously disturb our mental activity.

And if, as Bianchi suggests, all mental activity depends on a series of reflex actions, or, as Bechterew and Pavlov have insisted, a series of conditioned reflexes becomes established, it will assist us to understand how such stimuli can give rise to mental disturbances, to mental illnesses. We shall see that there may be something of real importance underlying such remarks as "I felt I was a changed child"; or "It is because of the treatment I received from my father that I have taken life so seriously." "I have never imagined that what I went through in my childhood could so influence me now"; or "I have never had confidence in myself and often when I have appeared vivacious and interested I have had an awful feeling of incapacity and dread within myself."

The outward and obvious manifestations, therefore, are not necessarily a true index of our mental and emotional conditions. This is true of all mental illnesses, even the most severe.

One patient who had been in an asylum more than ten years illustrated this in a most striking manner. His outward manifestations led one to feel that he thought he possessed the institution in which he was confined and also the surrounding property and that the authorities were a set of usurpers and thieves who kept him incarcerated in order that they might enjoy what was really his money and his property. On one occasion I said to him, "George, what is that incident in your life which you cannot forget and which has troubled you so seriously?" The reply was a flood of abuse. I put the question to him several times without getting any further answer, but when I came to leave the ward, George came up behind me and whispered over my shoulder, "Who told you about it?" No abuse, no shouting as usually occurred, but a whisper, "Who told you about it?" Was not George running away from a memory with its emotion which was unbearable to an idea which allowed him to be angry with others instead of with himself? Many examples of this might be given and really might be found by us in our own experience. It is the mental content which is important, a mental content which can be recalled by various stimuli, and which will be more persistently with us the more intense is the emotion associated with it.

But the basis of the condition is not completely understood when we have apparently arrived at the psychic cause of the disturbance.

It is recognized that the emotions are accompanied by physical changes, changes which are specific for each emotional state. The physical changes which normally are associated with fear differ from those of joy or anger. This has been appreciated for a long time but recent researches have recalled other reactions to us. Reactions in the internal glands which further knowledge will probably prove to be of great importance, in fact to form an integral part of the sum of activities, connect with mental processes. The secretions of the glands exert an influence on the sensibility and reaction of the organs connected with psychic phenomena and their functions themselves are affected by reactions occurring in the nervous system. Revival of a memory may thus affect the functions of these glands, and the changes produced in them may react on the sensibility and reactivity of the nervous mechanisms. If this be so, it will be evident that the organism works as a whole, that a disturbance of one organ may interfere with the function of another and that in the repetition of all these influences we may find an explanation of the chronicity of many of these illnesses. A study of the activities and interactivities of all the organs of the body is therefore essential and must be made before we shall understand the biological significance of mental illness.

ADDRESS BY
DR. PIERRE JANET

The Chairman: Our country may be hesitating a little—I hope it will not be for long—in joining a league of nations to prevent war, but there can be no doubt of our immediate readiness to co-operate internationally to prevent and reduce disease. Our distinguished guest from gallant France, Dr. Pierre Janet, professor in the College of France, evidently feels confident of our sympathy and willingness to collaborate in this latter respect, for he has ventured across the ocean, with Madame Janet, in response to our urgent invitation. His introduction to an audience of American psychiatrists would be quite out of place. His fame as a pathological psychologist has circled the world. In the science of medicine he is a modern Titan. For to-day's address he has chosen as a subject, "The Relation of the Neuroses to the Psychoses."

DR. JANET

Mr. President, my dear colleagues, ladies, and gentlemen: The Americans and the French have met on the battle-fields and they have faced together the same sufferings for the defense of their common ideal of civilization and liberty; it is right that they should meet likewise where Science stands up for the protection of health and human reason, and that they should celebrate together the Festivals of Peace. The President and the organizers of this Congress have greatly honored me in asking me to represent France at the celebration of the centenary of the Bloomingdale Hospital; but above all they have procured me a great pleasure in offering me the opportunity of coming again to this beautiful land, of meeting once more friends who had welcomed us kindly in former days; our old friends of past happy days who have become still dearer to us since they have been tried during the bad days.

Allow me, in the first place, to present you with the best wishes of the French Government who have had the kindness to charge me to interpret the sentiments of sympathy which they feel for all manifestations tending to render the relations that unite our two countries closer and more fruitful. The Academy of Moral and Political Sciences has equally charged me to assure you that it is happy to be represented by one of its members at the commemoration of the centenary of Bloomingdale Hospital that has so brilliantly and generously continued the tradition of Pinel and Esquirol. The Academy takes a lively interest in the psychological and moral studies of this Congress that seek the cure of diseases of the mind and the lessening of mental disorders. The Medico-Psychological Society, the Society of Neurology, the Society of Psychology, the Society of Psychiatry of Paris are happy to take part in these festivals and are desirous of associating still more closely their work to that of the scientific societies of the United States.

The celebration of the centenary of a lunatic asylum gives birth to-day to a national festivity in which all civilized nations participate. This is a fact that would have well astonished the first founders of lunatic asylums, the Pinels, the Esquirols, the William Tukes, and the first organizers of Bloomingdale. The public opinion respecting the diseases of the mind, the care to be given to lunatics, is vastly different to what it was a century ago. This transformation of ideas has taken place, in a great measure, as a result of the studies devoted to neuroses and that is why it seems to me interesting to present you to-day with a few reflections on the connections which unite neuroses and psychoses; for it is the discovery of these connections that has shown to the man sound in mind, or who imagines himself to be so, how near he always was to being a lunatic and how wise it was always to consider the lunatic as a brother.

Formerly a lunatic was considered as a separate being, quite apart from other members of society. The old prejudices which banished the patient from the tribe as a useless and dangerous individual had diminished no doubt with respect to the diseases of the body, which were more and more regarded as frequent and natural things to which each of us might be exposed. But these prejudices persisted with respect to some sexual diseases that were still considered ignominious and chiefly with respect to diseases of the mind. No doubt some intelligent and charitable physicians took interest in the lunatic, endeavored to spare him many sufferings, to defend him, to take care of him. But the people feared the lunatic and despised him as if he had been struck by some malediction which excommunicated him. I have seen lately a patient's parents upset with emotion, as they had to cross the gardens of the asylum to visit their daughter, at the single thought that they might catch sight of a lunatic. This individual, in fact, had lost in the eyes of the public the particular quality of man, reason, which, it appears, distinguishes us from beasts; he seemed still living, but he was morally dead; he was no longer a man.

No doubt it was a dreadful misfortune when some member of a family became insane, but this terrible calamity, which nothing could make one anticipate or avoid, was happily exceptional, like thunderbolts. The other men and even the members of the family presented nothing similar and regarded themselves with pride as very different to this wretched being transformed into a beast. This victim of heavenly curse was pitied, settled comfortably in a nice pavilion at Bloomingdale and never more spoken of. People still preserve on this point ideas similar to those they had formerly about tuberculosis, known only under the form of terrible but exceptional pulmonary consumption. Now it has at last been understood that there are slight tuberculoses, curable, but tremendously frequent. It will be the same with mental disorders; one day it will be recognized that under diverse forms, more or less attenuated they exist to-day on all sides, among a crowd of individuals that one does not feel inclined to consider as insane.

Little by little, in fact, men have had to state with astonishment that all lunatics were not at Bloomingdale. Outside the hospital, in the family of the unfortunate lunatic, or even in other groups, one observed strange complaints, moanings relating to lesions which were not visible, inability to move notwithstanding the apparent integrity of the organs, contradictory and incomprehensible affirmations; in one word, abnormal behaviors, very different to normal behaviors, regularized by the laws and by reason.

What was the meaning of these queer behaviors? At first they were very badly understood; they were supposed to have some connection with being possessed (with the devil), with miasmata, vapors, unlikely perturbations of the body and animal spirits that circulated in the nerves. One spoke, as did still Prof. Pomme at the end of the eighteenth century, "of the shrivelling up of the nerves."^[14] But above all, one preserved the conviction that these queer disorders were very different to the mental disorders of lunacy. These peculiar individuals had, it was said, all their reason; they remained capable of understanding their fellow creatures and of being understood by them; they were not to be expelled from society like the poor lunatics; therefore their illness should be anything but the mental disorders of lunacy.

Physicians, as it is just, watched their patients and only confirmed their opinion by fine scientific theories. They christened these new disorders by the name of neuroses, reserving the name of psychoses for the mental disorders of lunatics. During the whole of the nineteenth century the radical division of neuroses and psychoses was accepted as a dogma; on the one side, one described epilepsies, hysterias, neurasthenias; on the other, one studied manias, melancholias, paranoias, dementias, without preoccupying oneself in the least with the connections those very ill-defined disorders might have the ones with the others. This division was accentuated by the organization of the studies and the treatment of the patients. The houses that received the neurotic patients and the insane were absolutely distinct. The physicians who attended the ones and the others were different, and even supplied by different competitions. In France, even now, the recruiting of asylum house pupils and hospital house pupils, the recruiting of asylum doctors and that of hospital doctors, give an opportunity for different competitions. One might almost say that these two categories of house pupils and doctors have quite a different education. The result was that the examination of the patients, the study thereof, and even their treatment, were for the most part often conceived in quite a different manner. For example, neuroses were studied publicly; the examination was on elementary sensibilities, the movements of the limbs, and especially reflexes; the insane were more closely examined in the mental point of view, in conversations held with them by the physician alone. Their arguments, their ideas were noted more than their elementary movements. Strange to say, just when the psycho-therapeutic treatments by reasoning and moralizing with the patients were being developed, they stood out the contrary of what one might have supposed—that this treatment should be applied to neurotic patients alone. It was admitted that lunatics were probably not able to feel this moral and rational influence; they were treated by isolation, shower-baths, and purgatives.

This complete division did not fail to bring about singular and unfortunate consequences. In a hospital such as La Salpetrière the tic sufferers, the impulsive, those beset with obsessions, the hysterical with fits and delirium were placed near the organic hemiplegics and the tabetics who did not resemble them in the least, and completely separated from the melancholic, the confused, the systematical raving, notwithstanding evident analogies. If Charcot who, moreover, has brought about so much progress in these studies, committed some serious errors in the interpretation of certain phenomena of hysteria, is it not greatly due to his having studied these neurotic patients with the neurology methods without ever applying psychiatry methods? Is it not strange to refuse psychological treatment precisely to those who present psychological disorders to the highest degree, and to place the insane who thinks and suffers altogether outside of psychology?

In fine, this distinction between the neurotic sufferer and the mental sufferer was mostly arbitrary and depended more than was believed on the patient's social position and fortune. Important and rich families could not be resigned to see one of their members blemished by the name of lunatic, and the physician very often qualified him as neurasthenic to please the family. A few years ago this distinction of the patients and of the physicians gave rise to a very amusing controversy in the newspapers. The professor of the clinic for diseases of the nervous system asserted that neurotic sufferers should be patients set apart for neurologist physicians alone, whereas the alienist should content himself with real lunatics. The professor of the clinic for mental diseases protested with much wit and claimed the right of attending equally the neurotic patients. All this proved a great confusion in the ideas.

Notwithstanding these difficulties, Charcot's studies themselves on hysterical accidents began to make people's minds uneasy and to modify conceptions of neuroses. They showed that neurotic sufferers presented disorders in their thoughts, that many of their accidents, in all appearance physical, were in connection with ideas, with the conviction of paralysis, of illness, with the remembrance of such or such an event which had determined some great emotion. Without doubt, this interpretation of hysteria, which I have myself contributed to extend, must never be exaggerated, and it must not be concluded from this that every neuropathic accident always and solely depends on some remembrance or some emotion. In my opinion, this is only exact in a very limited number of cases; and then it only explains the particular form of such or such an accident and not the entire disease. Without doubt it seems to me exaggerated to-day to see in neuroses those psychological disorders alone, whereas the disorders of the circulation, the disorders of internal secretions, the disorders of the functions of the sympathetic which will be spoken of just here must also have a great importance. But, however, this observation proved very useful at that moment. A remembrance, an emotion, are evidently psychological phenomena, and to connect neuropathic disorders with facts of the kind is to include the study thereof with that of mental disorders. At this time, in fact, they began to repeat on all sides a notion that had already been indicated in a more vague manner; it is that neuroses were at the root, were in reality diseases of the mind.

If such is the case, what becomes of the classical distinction between neuroses and psychoses? No one can deny that the latter are above all diseases of the mind and we have here to review the reasons which seem to justify their complete separation. Will it be said that with psychoses the disorders of the mind last very much longer? But some patients who enter the asylum with a certificate of insanity are very frequently cured in a few months and some neuropathic disorders may last years. I could name you patients who since thirty years keep the same obsessions, and who at the age of fifty still ask themselves questions upon their pact with heaven, as they did at the age of twenty. Shall we speak of the consciousness the patient has of his state? But this consciousness may be complete in certain melancholies and very incomplete in certain impulsions.

Is it necessary to insist on the presence or absence of anatomical lesions which one tries to ascertain at the post-mortem examination? Shall we say with Sandras, Axenfeld, Huchard, Hack, Tuke, that neuroses are diseases without lesions? One finds lesions in general paralysis which is ranged with insanity and we find some also in epilepsies which are considered as neuroses; one no more finds lesions in melancholic conditions than in conditions of obsessions. Besides, as I have often repeated, this absence of lesions is of no importance; it is quite in keeping with our ignorance. Every one admits that organic alterations more or less momentary, but actually not suspected, must exist in neuroses as in other diseases. Neuroses as well as psychoses are much more likely to be diseases with unknown lesions than diseases without lesions, and it is impossible to take this characteristic into account to distinguish the ones from the others.

In reality, the notion of lunatic has lost its former superstitious signification and it has taken no precise medical signification. That word is now the term of the police language. It indicates only an embarrassment felt by the police before certain persons' conduct. When an individual shows himself to be dangerous for others, the public administration has the habit of defending us against him by the system of threats and punishments. As a rule, in fact, when a normal mind is in question, threats can stop him before the execution of crime, and punishments, when crime has been committed, can prevent him from beginning again; that is the psychological fact which has given birth to the idea of responsibility. But in certain disorders it becomes evident that neither threats nor punishments have a favorable effect, for the individual seems to have lost the phenomenon of responsibility. When an individual shows himself to be dangerous for others or for himself, and that he has lost his responsibility, we can no longer employ the ordinary means of defense; we are obliged to defend ourselves against him, and defend him against himself by special means which it is useless to apply to other men; we are obliged to modify legal conduct toward him. All disorders of the mind oblige us to modify our social conduct toward the patient, but only in a few cases are we obliged to modify at the same time our legal conduct; and these are the sort of cases that constitute lunacy.

This important difference in the police point of view is of no great importance in the psychological point of view nor in the medical point of view, for the danger created by the patient is extremely varied. It is impossible to say that such or such a disorder defined by medicine leaves always the patient inoffensive and that such another always renders him dangerous. There are melancholies, general paralytics, insane who are inoffensive, and whom one should not call lunatics; there are impulsive psychasthenics who are dangerous and whom one shall have to call lunatics. The danger created by a patient depends a great deal more upon the social circumstances in which he lives than upon the nature of his psychological disorders. If he is rich, if he has no need to earn his living, if he is surrounded by devoted watchfulness, if he lives in the country, if his surroundings are simple, the very serious mental disorders he may have do not constitute a danger. If he is poor, if he has to earn his living, if he lives alone in a large town and his position is delicate and complex, the same mental disorders, exactly at the same degree, will soon constitute a danger, and the physician will be forced to place him in an asylum with a good certificate. This is a practical distinction, necessary for order in towns, which has no importance in the point of view of medical science.^[15] If we put these accidental and slightly important differences on one side, we certainly see a common ground in neuroses and psychoses. The question is always an alteration in the conduct, and, above all, in the social conduct, an alteration which tends, if I am not mistaken, toward the same part of the conduct.

The conduct of living beings is a special form of reaction by which the living being adapts himself to the society to which he belongs. The primitive adaptations of life are characterized by the organization of internal physiological functions. Later on they consist in external reactions, in displacements, in uniform movements of the body which either keep him from or draw him near to the surrounding bodies. The first of these movements are the reflex movements, then are developed those combinations of movements which we called perceptive or suspensive actions in keeping with perceptions. Later came the social acts, the elementary intellectual acts which gave birth to language, the primitive voluntary acts, the immediate beliefs, then the reflected acts, the rational acts, experimental, etc. As I said formerly, there is, in each function, quite a superior part which consists in its adaptation to the particular circumstance existing at the present moment. The function of alimentation, for instance, has to exercise itself at this moment when I am to take aliments on this table in the midst of new people, that is to say, among whom I have not yet found myself in this circumstance, wearing a special dress and submitting my body and my mind to very particular social rites. In reality it is nevertheless the function of alimentation, but it must be noted that the act of dining, when wearing a dress suit and talking to a neighbor, is not quite the same physiological phenomenon as the simple secretion of the pancreas. Certain patients lose only the superior part of this function of alimentation which consists in eating in society, in eating in new and complex circumstances, in eating while being conscious of what one is doing, and in submitting to rules. Although the physiologist does not imagine that these functions are connected with the exercise of sexual functions in humanity, there is a pathology of the betrothal and of the wedding-tour.

It is just on this superior part of the functions, on their adaptation to present circumstances, that the disorders of conduct (self-government) which occupy us to-day bear. If one is willing to understand by the word "evolution" the fact that a living being is continually transforming himself to adapt himself to new circumstances, neuroses and psychoses are disorders or halts in the evolution of functions, in the development of their highest and latest part.^[16]

This halt in evolution can be connected with different physiological causes, hereditary weaknesses of origin, infections, intoxications, disorders of internal secretions, disorders of the sympathetic system. These diverse etiologies will most likely be of use later to distinguish between forms of these diseases; but to-day the common character of neuroses and psychoses is that this diminution of vitality bears upon the highest functions of self-government.

Whatever be the disorders you may consider, aboulias, hysterical accidents, psychasthenic obsessions, periodical depressions, melancholics, systematized deliriums, asthenic insanity, you will always find a number of facts resulting from this general perturbation.

In plenty of cases, the acts, far from being diminished, appear exaggerated; the patient moves about a great deal, he accomplishes acts of defense, of escape, of attack, he speaks enormously, he seems to evoke many remembrances and combine all sorts of stories during interminable reveries. But pray examine the value and the level of all these acts; they are mere gestures, shocks of limbs, laughter, sobs, reactions simply reflex or perceptive, in connection with immediate stimulation, with inhibition, without choice, without adaptation by reflection. The thoughts that fill these ruminations are childish and stupid, just as the acts are vulgar and awkward; there is a manifest return to childhood and barbarism. The behavior of the agitated individual is well below that which he should show normally. It is easy to explain these facts in the language we have adopted. The agitation consists in an activity, more less complete, in inferior tendencies very much below those the subject should normally utilize.

It is that in reality the agitation never exists alone, it is accompanied by another very important phenomenon which it dissimulates sometimes, I mean the depression characterized by the diminution or the disappearance of superior actions, appertaining to the highest level of our hierarchy. It is always observed that with these patients certain actions have disappeared, that certain acts executed formerly with rapidity and facility can no longer be accomplished. The patients seem to have lost their delicacy of feeling, their altruism, their intelligent critique. The stopping of tendencies by stimulation, the transformation of tendencies into ideas, the deliberation, the endeavor, the reflection; in one word, both the moral effort and the call upon reserves for executing painful acts are suppressed. There exists visibly a lowering of level, and it is right to say that these patients are below themselves.

The two phenomena, agitation and depression, are almost always associated in neuroses as well as in psychoses. It is likely that their union depends upon some very general law, relating to the exhaustion of psychological forces. It is probable that the superior phenomena exact under a form of concentration, of particular tension, much more power than acts of an inferior order, although the latter seem more violent and more noisy. "When the force primitively destined to be spent for the production of a certain superior phenomenon has become impossible, derivations happen, that is to say, that this force is spent in producing other useless and especially inferior phenomena."^[17]

A very great number of phenomena observed in neuroses and psychoses are in connection with depression and agitation. Convulsive attacks, diverse fits of agitation, prove to us that before the fit there existed disproportion between the quantity and the tension of the psychological forces, and that the spending of forces during the fit re-establishes the equilibrium. But at the same time, after this spending, one observes a notable lowering of the mental level, a real psycholepsy. It is very likely that studies of this kind will produce some day the key of the epilepsy problem, for vertigos and certain epileptic fits are certainly phenomena of relaxation, the meaning of which we do not comprehend because we do not study sufficiently the state of psychological tension before and after the accidents.

The difficulty of accomplishing superior acts, the exhaustion resulting from their accomplishment, renders them fearful to the patient who has the fear, the phobia of these acts, just as he has the terror of that depression which gives the feeling of the diminution of life. The shrinking of activity and conscience, phobias, negativisms, generally take their starting point in this fear of exhaustion caused by some difficult action. In other cases the patient feels incapable of accomplishing correctly the reflected acts necessary to social and moral life, and feeling no longer protected by reflection, he is afraid of willing or believing something, as one is afraid of walking in a dangerous path, when one cannot see. The vertigo of life produces itself like the vertigo of heights, when one is not sure of oneself.

Depressed patients have felt, wrongly or rightly, a certain excitation after a certain action. Through some curious mechanism, certain acts, instead of exhausting them, have raised their psychological tension. The need, the desire to raise themselves inspires them with the wish to renew such acts, and we behold the impulsions to absorb poisons, impulsions to command, to theft, to aggression, to extraordinary acts, varied impulsions which play a great part in psychoses as well as in neuroses.

I shall not insist any more on a very interesting phenomenon in connection with the oscillations of the mind and which still plays a great part in these diseases. I am speaking of the change of feeling which may accompany the same action in the course of the oscillations of the mind. At the level with the reflected action, more or less complete, the thought of an action which appears important and of which one often thinks, determines interrogations, doubts, scruples. If the individual descends one degree, if he becomes quite incapable of reflecting and therefore of doubting, the same action he continues to think about may present itself under the form of an impulsion more or less irresistible.

There are patients who in the first stage have the fear and horror of committing an act and who in the second stage are driven to accomplish it. In other cases a subject may make use of an action as a means of exciting and raising himself; he seeks it, and the thought of this action is accompanied by love and desire. Let him become depressed and he will no longer be able to accomplish this same action without exhausting himself; he is then reduced to dread it and take an aversion to it. That which was an object of love becomes an object of hatred. Thence these turnings of mind that are so often to be observed in the course of neuroses and psychoses. In a score of my observations the frenzy of persecution and hatred presents itself as an evolution of those obsessions of love and domination.

These are very curious facts that one observes in the oscillations of the mind, in particular when the psychasthenic depression becomes more serious and transforms itself in psychasthenic delirium, which is more frequent than one generally imagines. As a rule the properly so-called psychasthenic has only disorders of the reflection; he doubts but he does not rave. But under different influences, his depression may augment, and when he drops below reflection he has no longer the doubts, the hesitations, he no longer shows manias of love and of direction, he transforms his obsessions into deliriums and often his loves into hatreds.

These are a few examples of the perturbations of conduct common to neurotic sufferers and the diseased in mind. One perceives that the same laws relating to the diminution of force and the lowering of the psychological tension intervene in the same way with the one as with the others. The distinctions, which have been established for social reasons and practical conveniences, no longer exist when one tries to find, by analysis of the symptoms, the nature of neuroses and psychoses.

The latter reflection shows us, however, that in certain cases, at least, there is a certain difference in degree between neuroses and psychoses. The evolution of the human mind has been formed by degrees, by successive stages, and we possess in ourselves a series of superposed layers which correspond to diverse stages of the psychological development; when our forces diminish we lose successively these diverse layers commencing with the highest. It is the superior floors of the buildings that are reached first by the bombardments of the war and the cellars are not destroyed at first; they acquire even more importance, as people are beginning to inhabit them. Well, according as the depression descends more or less deeply, the disorders which result from the loss of the superior functions and the exaggerated action of the inferior ones become more and more serious and are appreciated differently. The superior psychological functions are, in my opinion, experimental tendencies and rational tendencies. They are tendencies to special actions in which man takes in account remembrances of former acts and of their results, in which he enforces on himself by a special effort obedience to logical and moral laws. A little fatigue and a slight degree of exhaustion are sufficient for such an action to become difficult and impossible to prolong for a long time. Furthermore, the disorders of the experimental conduct or of the rational conduct are very frequent. These disorders only reach the superior actions which are not absolutely necessary to the conservation of social order. They can be easily repaired by inferior acts: if the man does not obey pure moral principles, at least he can conduct himself in appearance in an analogous manner through fear of the prison. Also, these disorders of the superior functions are considered as slight; they are called errors, or faults, and it is admitted that the subjects remain normal beings.

At the other extremity of the hierarchical series of tendencies the acts are simply reflex. When the disease descends to this level, when the elementary acts can no longer be executed correctly, we do not hesitate either, and we consider these disorders (related with known lesions) as organic diseases of the nervous system. But between these two terms we note disorders in behavior which are more difficult to interpret. These disorders are too grave and too difficult to modify by our usual processes of education and punishment for us to consider them as mere errors or as moral faults; they are variable; they are not accompanied by actually visible lesions and we have trouble in classing them among the acknowledged deteriorations of the organism. There is the province of neuroses and psychoses, intermedium between that of rational errors and that of organic diseases of the nervous system. It corresponds to the disorders of medium psychological functions, to the group of these operations which establish a union more or less solid between the language and the movements of limbs and which give birth to our wills and beliefs.

Can one establish, in this group, a distinction between neuroses and psychoses that rests on some more precise notion and that is not limited to distinguishing them in a legal point of view? A more profound knowledge of the mechanisms of the will and belief would perhaps permit us to do so. We are capable of wills and beliefs of a superior order when we reach decision after reflection. The operation of reflection which hinders tendencies and maintains them in the shape of ideas, which compares ideas and which only decides after this deliberation, constitutes the highest form of the medium operations of the human mind. Lower, still, there exists will and belief, but they are formed without reflection, without stoppage of ideas, without deliberation; they are the result of an immediate assent which transforms verbal formulas into wills and beliefs as soon as they strike the attention, as soon as they are accompanied by a powerful sentiment. The immediate assent is the inferior form of these tendencies.

If one wished to establish a scientific distinction between neuroses and psychoses, I should say, in a summary fashion, that in neuroses the reflection alone is disturbed, that in psychoses the immediate assent itself is affected. The shrinkage of the conscience, doubts, aboulias, obsessions, scruples are always disorders of the reflected will and belief. On the contrary, irresistible impulsions, deliriums, indifferences which suppress desires and only allow elementary agitations to subsist, show alterations in the immediate assent, in the will, and the primitive belief and must be considered as psychoses. Below could be placed the disorders of elementary intelligence, the disorder of the perceptive and social functions which characterize the mental deficiencies of imbeciles and idiots. One might also distinguish these disorders according to the degree of depth the destruction of the edifice has reached, according to the more or less distant state of evolution to which the patient goes back. But these psychological classifications are purely theoretical, and in practice many other factors intervene which oblige us to consider such a patient as incapable of doing any harm and such another as dangerous; this is the only difference to-day between neuroses and psychoses. Later on, without doubt, we shall be able to substitute for these simply symptomatical and psychological diagnostics, some etiological and physiological diagnostics. We shall be able from the very outset to recognize that a disorder, in all appearance slight and which is not deeply set, presents a bad prognosis, and we shall be able to foresee a serious and deep psychosis in the future. To-day, without doubt, one can often distinguish from the outset the future general paralytic from the simple neurasthenic. But in the actual state of science this ability to distinguish is not frequent and the future evolution of a depressed state can scarcely be foreseen with precision.

Certain individuals pass in a few years from psychasthenic depression with doubts and obsessions to psychasthenic deliriums with stubbornness and negativism, then to asthenic insanity with irremediable and complete want of power. Is it necessary to say that we made a mistake in our diagnostic and that from the first demential psychosis should have been recognized? I am not convinced of this: these diseases, excepting a few cases with rapid evolution, are not characterized from the outset. Without doubt we must note that these depressions which disturb the reflective tendencies of young patients in full period of formation, are dangerous and can bring on still deeper depressions of the psychological tension. But that evolution is rarely fatal; it can very often be checked, and it seems to me fair to preserve the distinction between neuroses and psychoses considered as different degrees of psychological decadence.

Neuroses are, therefore, the intermedium between the errors and the faults which appeared to us almost normal, and alienation which seemed exceptional and distant from us. The first appearances of that depression which in a continuous manner descends to alienation are to be found already in the disorders of character which seemed to be quite insignificant. The miser, the misanthrope, the hypocrite are described by the writer before they are claimed by the physician. A great number of neuropathic disorders which I have described are related to the popular type of mother-in-law. This type is not necessarily that of a woman whose daughter has married, but the type of a depressed woman of about fifty, aboulic, discontented with herself and others, domineering, and jealous, because she suffers from the mania of being loved though she is incapable of acquiring any one's affection. All exhaustions, all moral failings have the closest connection with neuroses and psychoses.

These reflections prove to us that the alienist physician should interest himself more and more in the treatment of neuroses even slight, to rectifying the disorders of temper, to the education of the young, to the direction of the moral hygiene of his country. On many of these points America leads the way; your works of social hygiene, the good battle you are righting against alcoholism, are examples for us. You are the new world, younger, not rendered so inactive by secular habits. You can act more easily than we. We may have the advantage, in the old world, of the experience of old people and the habit of observation, but we are slack in reform and action. "If youth had experience and old age ability," says one of our proverbs. We must remain united and join your strength to our experience for the greater progress of the studies which are dear to us and for the greater good benefit of our two countries.

ADDRESS BY
DR. WILLIAM L. RUSSELL

The Chairman: The year 1921 is rich in anniversaries for the New York Hospital. Next October we plan to celebrate the one hundred and fiftieth anniversary of the granting of our charter. To-day we are occupied with the Bloomingdale Centenary. A fortnight ago the twenty-fifth annual graduating exercises of our Training School for Nurses were held in this room. This year also marks the decennial of Dr. Russell's term of office as Medical Superintendent. When his devoted predecessor, Dr. Samuel B. Lyon, asked in 1911 to be relieved from active duty and became our first Medical Superintendent Emeritus, we were most fortunate in securing as his successor Dr. Russell. Coming to this institution after a broad psychiatric and administrative experience, he has taken up our special problems with deep insight and gratifying success. He has selected for his subject this afternoon "The Medical Development of Bloomingdale Hospital." No one can speak with greater authority on a theme of which it may be said quorum magna pars—fortunately not only fuit—but est and erit as well.

DR. RUSSELL

The object of this celebration is not merely to glorify the past and least of all is it to laud the present. What we hope from it is that it will establish a milestone, not only to mark the progress thus far made but to point the way to a path of greater usefulness. The advances in medical science and practice and in the specialty of psychiatry during the past hundred years fill one with wonder and hope. It is worth while to review them merely to obtain this help. The outlook for the century to come is, however, so far as can be anticipated, still brighter.

To review the past is, at a time like this, not unprofitable. It may prevent us, in our zeal for the new, from discarding what is valuable in the old, and from overvaluing some things which may have outlived their usefulness. We must be careful that we do not fall into errors similar to those from which the medical profession was rescued by the movement of which Bloomingdale Asylum was an offspring. It should be recalled that the establishment of the asylum was due to the initiative of the Governors of the New York Hospital, especially Mr. Eddy, rather than to the active interest and direction of physicians. The object of the establishment was, according to Mr. Eddy, to afford an opportunity of ascertaining how far insanity may be relieved by moral treatment alone, which, he says, "it is believed, will, in many instances, be more effective in controlling the maniacs than medical treatment." The moral management he referred to, though advocated by Pinel and a few others, some of whom were benevolent and intelligent laymen, had not been accepted by physicians as a distinct form of medical treatment. Few physicians of the period had accepted management of the mind as described and practised by Pinel as being a distinct medical procedure, as having the same value in overcoming mental disorders as the drastic medical remedies which they were accustomed to employ, or as having any exclusive healing power. This is clearly shown by the case records of the mental department of the New York Hospital which have been preserved since 1817, and of those of Bloomingdale Asylum for some years after its opening in 1821. It is plainly set forth in Dr. Rush's book on diseases of the mind, which was first published in 1810 and again in a fourth edition in 1830. Rush was physician to the Pennsylvania Hospital and his book was the principal, if not the only, one of the period by an American author. American physicians like their European brothers, had, as Pinel observes, "allowed themselves to be confined within the fairy circle of antiphlogisticism, and by that means to be deviated from the more important management of the mind." Rush believed that madness was a disease of the blood-vessels of the brain of the same nature as fever, of which it was a chronic form. "There is," he says, "not a single symptom that takes place in an ordinary fever, except a hot skin, that does not occur in an acute attack of madness." He found in his autopsy observations confirmation of this view and concludes that "madness is to phrenitis what pulmonary consumption is to pneumony, that is, a chronic state of an acute disease." The reason for believing that madness was a disease of the blood-vessels, which seemed to him most conclusive, was "from the remedies which most speedily and certainly cure it being exactly the same as those which cure fever or disease in the blood-vessels from other causes and in other parts of the body." The treatment he recommended and which was generally employed was copious blood-letting, blisters, purges, emetics, and other severe depleting measures. When Bloomingdale Asylum was established, therefore, the provision for moral treatment did not contemplate that this should be applied by the physician or that he should have full control of the resources by means of which it could be applied. The records do not indicate that either the physicians or the Governors realized that this might be necessary or advantageous. The present system of administration in which the chief physician is also the chief executive officer of the institution was a result of an evolution which took many years to reach its full consummation.

Pinel, many years before Bloomingdale Asylum was opened, had shown by the most careful observation and practice that the management and discipline of the hospital was a most powerful agent in the treatment of the patients. The manner in which he was led to this conclusion is a remarkable example of the scientific method. When he became physician to the Bicetre he found that the methods of classification and treatment recommended in the books seemed to be inadequate, and, desiring further information, he says: "I resolved to examine myself the facts which were presented to my attention; and, forgetting the empty honor of my titular distinction as a physician, I viewed the scene that opened to me with the eye of common sense and unprejudiced observation.... From systems of nosology, I had little assistance to expect; since the arbitrary distributions of Sauvages and Cullen were better calculated to impress the conviction of their insufficiency than to simplify my labor. I, therefore, resolved to adopt that method of investigation which has invariably succeeded in all the departments of natural history, viz., to notice successively every fact, without any other object than that of collecting materials for future use; and to endeavor, as far as possible, to divest myself of the influence, both of my own prepossessions and the authority of others. With this view, I first of all took a general statement of the symptoms of my patients. To ascertain their characteristic peculiarities, the above survey was followed by cautious and repeated examinations into the condition of individuals. All our new cases were entered at great length upon the journals of the house." Having thus studied carefully the course of the disease in a number of patients who were subjected only to the guidance and control made possible by the management of the hospital under the direction of a remarkably highly qualified Governor, it came to him with the force of a new discovery that this man who was not a physician was doing more for the patients than he was, and that insanity was curable in many instances by mildness of treatment and attention to the state of mind exclusively. "I saw with wonder," he says, "the resources of nature when left to herself, or skilfully assisted in her efforts. My faith in pharmaceutic preparations was gradually lessened, and my scepticism went at length so far as to induce me never to have recourse to them, until moral remedies had completely failed." So convinced did he become of the significance and importance of the management and discipline of the hospital in the treatment of the patients, that, when a few years later, he wrote his "Treatise on Insanity," he states that one of the objects of his writing it was, "to furnish precise rules for the internal police and management of charitable establishments and asylums; to urge the necessity of providing for the insulation of the different classes of patients at houses intended for their confinement; and to place first, in point of consequence, the duties of a humane and enlightened superintendency and the maintenance of order in the services of the Hospitals."

Pinel's views had apparently not been fully understood or adopted by the physicians of America at the time Bloomingdale Asylum was planned and established. Dr. Rush did not mention him in his book, and Mr. Eddy, in his communication to the Governors of the New York Hospital, referred only to the writings of Drs. Creighton, Arnold, and Rush and the Account of the York Retreat by Samuel Tuke.

When Bloomingdale Asylum was opened, the form of organization introduced was that under which the department at the New York Hospital had been conducted. Mr. Laban Gardner was made Superintendent or Warden with two men and three women keepers to aid him in the control and management of the seventy-five patients. There was an Attending Physician who visited once a week and a Resident Physician, neither of whom received salaries. There is nothing in the records to indicate that in the beginning, the Governors of the Hospital looked upon the moral treatment of the patients, which was the object for which the institution was established, as the task of the Physicians. The aim was to furnish employment, diversion, discipline, and social enjoyment, without much attempt at precision or close medical direction and control. For a time the results were considered to be satisfactory. In 1824, however, a joint Committee of the Board reported that they were impressed by the necessity of improving the moral treatment, and recommended that two discreet persons be appointed to take charge of such of the patients as might from time to time be in a condition to be amused or employed on the farm or in walking exercises in the open or in classes to be designated by the Resident Physician "with," however, "the approbation of the Superintendent," who you will recall was not a physician. These patients were, the report recommends, to be particularly under the charge of the Resident Physician when thus employed or amused "out of the Asylum." At this time, the Attending and Resident Physicians were placed on a small salary, and the Resident Physician was instructed to "devote a greater portion of his time and attention to the moral part of the establishment and to communicate to the Committee such improvements as his experience shall suggest to be useful and necessary in carrying into more complete effect the system of moral treatment and to report from time to time to the Committee the effect of the measure adopted." This seems to have been the beginning of a realization that the moral management of the patients was inseparable from medical treatment and must necessarily be the task of the physician. Seven years after this, in 1831, the Committee found it advisable to spread upon the minutes an "interpretation and regulations," relating to the Superintendent and Matron of the Asylum and to the Asylum physicians, to the effect that the Committee understood that the regulations "placed the moral treatment on the physician alone, under the direction of the Asylum Committee, and that the responsibility remains with him alone, that this treatment commenced with the reception of the patient, the ward where he shall be placed, his exercises, amusement, admission of friends, the time of discharge from the house.... And that all orders to nurses and keepers which the physicians may think necessary to carry these orders into effect shall be communicated through the Superintendent" (or Warden). In 1832, the Resident Physician, Dr. James Macdonald, who had just returned from Europe after having spent a year in visiting the institutions for mental disorders there, made a report in which he rather significantly referred to the impracticability of making a sharp distinction between the medical and moral treatment of the patients, it being difficult to say where the one ended and the other began, or to put one into successful operation without bringing in the other. At this time the position of Attending Physician was abolished and the Resident Physician was made the Chief Medical Officer of the Asylum. It was not until 1837 that an amendment to the by-laws regulating the powers of the physician and the Warden was adopted which gave to the physician the power of appointing and discharging at pleasure all the attendants on the patients, while to the Warden was reserved the power of appointing and dismissing all other employees. Fourteen years had thus elapsed since the opening of the Asylum before the physician was given control of even the nursing service. The first Annual Report of the Resident Physician of the Asylum to be published appeared in 1842. In this, Dr. William Wilson makes a general statement in regard to the beneficial effects of the moral as well as the medical treatment pursued in the institution, and refers particularly to occupations, exercise in the open air, amusement, religious services, and he asks that a workshop be erected for the men. It is evident that by this time the authority of the physician in the management of the institution had been extended and it is perhaps significant that in his report of the following year Dr. Wilson refers to a plan for distribution of food which had been evolved in co-operation with the Warden. Under the direction of Dr. Pliny Earle, who was appointed physician to the Asylum in 1844, treatment directed to the mind was further elaborated and systematized, and the place of the physician in the management of the hospital was more firmly established.

This brief survey indicates how, in the development of the work of the institution, it required years of practical experience to show to the Governors that, in order to secure for the patients the treatment which the Asylum had been established to furnish, it was necessary to extend the powers and duties of the physician so that he could control and direct the internal management and discipline, and all the resources for social as well as individual treatment. This extension was continued until finally the present form of organization was adopted in which the chief physician is also the chief executive officer of the institution. This was, however, not fully accomplished until 1877. It is now universally recognized that the physician must be the supreme head of the organization, and all American institutions and most, if not all, of those in other countries are now similarly organized.

In the early development of Bloomingdale Asylum, this extension of the influence and authority of the physician is the outstanding medical fact. It did away with division of responsibility and removed from discussion the question of moral as distinct from medical treatment. Thereafter a harmonious and effective application of all the resources of the institution to the problems of the patients became more easily and certainly possible. Since then, the resources for treatment directed to the mind have been developed as steadily and fully as those required for the treatment of physical conditions. The use of the organized agencies which were regarded by the founders as the main reliance in moral treatment, namely occupations, physical exercises and games, diversion, social contacts, and enjoyment, and management of behavior has been greatly extended, and specialized departments have been created for their application with system and growing precision. Great advances have also been made in the methods of examining the minds of the patients and of determining the mental factors in their disorders and the means of restoring their capacity for adjustment to healthy thinking and acting. Psychiatry has been furnished with a body of well-arranged facts, and with a technic which is not inferior in system and precision to that of many other branches of medicine. In the study and management of the minds of the patients the physician is thus enabled to apply himself to the task as he does to any other medical problem.

The advances in general medical science and practice have also necessitated great elaboration of the resources for the study and treatment of the physical condition of the patients. Instruments of precision, laboratories, x-ray departments, dental and surgical operating rooms, massage and hydrotherapy departments, facilities for eye, throat, nose, and ear examinations and treatment, and all the other means of determining disease processes and applying proper treatment have been supplied and the methods and standards of modern clinical medicine and surgery are utilized. It can now be clearly seen that it is necessary to direct attention to the whole personality of the patient, including his original physical and mental constitution, the physical as well as the mental factors which may be operating to produce his disorder, and the environmental conditions to which he has been and may again be exposed. In the treatment of mental disorders it is necessary to beware of what Pinel found to be the fault of the physicians and medical authors of his time, who he says were more concerned with the recommendation of a favorite remedy than with the natural history of the disease, "as if," he says, "the treatment of every disease without accurate knowledge of its symptoms involved in it neither danger nor uncertainty," and he quotes the following maxim of Dr. Gault: "We cannot cure diseases by the resources of art, if not previously acquainted with their terminations, when left to the unassisted efforts of nature." Exclusive attention to the physical condition and factors, or to the mental condition and factors, or concentration on one theory or one form of treatment to the exclusion of all others is sure to lead to neglect of that careful general inquiry into the whole personality of the patient, into the conditions out of which his disorder arose, and into all the manageable factors in the situation which is so essential to intelligent and effective treatment. Notwithstanding the great benefit which has been derived from physical measures in the study and treatment of mental disorders, and the well-founded hopes of greater advances in this direction, the main task still continues to be what Pinel calls the management of the mind. Experience and increasing knowledge show that this is a task which can only be successfully performed by the physician and by means of organized resources which are under medical direction and control. The hospital for mental disorders furnishes the means of providing social as well as individual treatment. It is a medical mechanism and for its proper management and use it is required of physicians that they accept the burden of much executive work and give their attention to many subjects and activities that may interfere seriously with what they have been taught to regard as more strictly professional interests. Like Pinel, one must be willing to forget the empty honor of one's titular distinction as a physician, and do whatever may be necessary to make the institution a truly medical agency for the healing of the sick. Considerable progress has been made in developing executive assistants to relieve the physicians of much of the administrative work which requires little or no medical supervision and direction. Special provision for the training of such executives has, however, received insufficient attention. This question might, with great advantage, be taken up by the hospitals and colleges. Nothing would add more to the quality of the service which the hospitals render than to supplement the work of the physicians by that of well educated and highly trained executive assistants who would themselves find an extremely interesting and productive field for their efforts.

A period has now been reached in this field of work when what amounts to a movement not inferior in significance and importance to that of a hundred years ago, seems to be in active operation. The character and scope of this movement and the lines of its progress have, to some extent, been indicated in the illuminating formulations which have been presented here to-day. The medical study and treatment of the mind is no longer so exclusively confined within the walls of institutions nor to the type or degree of disorder which necessitates compulsory seclusion. Psychiatry is extending out from the institutions into the communities by means of out-patient clinics and social workers, through newly created organized agencies, through informed individuals, physicians, nurses, and lay workers, and through the general spread of psychiatric knowledge. This process is being expedited by the efforts of organized bodies such as the National and State Committees and Societies for Mental Hygiene, and the public is rapidly learning what can properly be expected of institutions, officials, physicians, nurses, and other responsible individuals in whom special knowledge and ability are supposed to be found. As in the prevention of tuberculosis, so, in the prevention of mental disorders, the informed public is likely to start a campaign which the medical profession may have to make haste to follow in order to maintain its needed leadership. Although much is yet required to improve the facilities necessary in carrying on the present work, it seems to us that at such a time a further extension of the activities of an institution such as Bloomingdale Hospital may be necessary to enable it to fulfil its possibilities for greater usefulness. To extend the work our experience indicates that a department in the city at the General Hospital would be of great advantage. During the past few years the oversight of discharged patients has grown to such an extent that it seems as though some organized method of carrying it on may soon become necessary. This and out-patient work generally could be best attended to in a city department. Much emergency work and preliminary observation and the treatment of certain types of cases now frequently subjected to unfortunate delays, neglect, and unskilful treatment would also be thus provided for. It can be seen too that developments in construction and organization which would furnish organized treatment for types of disorders which are not so incapacitating as the pronounced psychoses might be of advantage in the treatment of both adults and children. The property on which the Hospital is located is large enough to permit of further extensions and developments which could be as closely connected with, or as widely separated and distinguished from, the present provision as circumstances required. In this way much needed provision for the treatment of persons suffering from the psychoneuroses and minor psychoses could be furnished. Better provision for a further period of readjustment after a patient is ready to leave the Hospital but not yet ready to face the risk of ordinary conditions in the community is a felt want. A group of supervised homes or an occupational colony might best serve this purpose. The more extensive use of the Hospital as a teaching centre is also a subject for consideration. A School for Nurses is now conducted, and much instruction is given in the occupational departments. More, however, could be done, especially in medical teaching, which could be best carried on in a department in the city and would tend to advance the standard of medical service throughout the Hospital.

The lines of further development are, perhaps, not yet perfectly clear in all directions. It seems certain, however, that they will lead toward a broader field of usefulness, in which the hospital will be regarded as a responsible agency for dealing with psychiatric problems in the community which it serves and will take part with other agencies in extending psychiatric knowledge and in applying it to prevention, and to the management of mental disorders as an individual and social problem beyond the walls of the institution. We hope that this meeting will prove a real starting point for this development. We are greatly indebted to those who have taken part in it both as speakers and as audience. We are especially indebted to those who came across the sea to be with us. It is peculiarly fitting that representatives of France and of England should have been here, for to Pinel, the Frenchman, and to Tuke, the Englishman, are due more than to any others whose names we know the foundations of the modern institutional treatment of mental disorders.

The Chairman: This, ladies and gentlemen, concludes our exercises. As the representative of the Governors, I find it quite impracticable, in supplementing what Dr. Russell has just said, to express adequately our admiration of and gratitude to these eminent scientists and apostles of light for their presence here and for their inspiring addresses. These, if I may be permitted to appraise them, seem to make a notable addition to medical literature, and, with the permission of their authors, we purpose, for our own gratification and for the benefit of the profession, to have all of the addresses preserved in a volume recording this centenary celebration. In due course a copy of this volume will be sent to each of our guests. The celebration itself, I think you will all agree with me, has been a moving one, with an underlying note of philanthropic endeavor as high as the stars. You heard its refrain in the pageant on the lawn this afternoon. As I have listened to-day to these words of profound wisdom, uttered in so noble a spirit of human ministry, my mind has gone back to the sentence from Cicero's plea for Ligarius,^[18] which formed the text for Dr. Samuel Bard's eloquent appeal in 1769, mentioned this morning, for the establishment of the New York Hospital, and which may be freely rendered, "In no act performed by man does he approach so closely to the Gods as when he is restoring the sick to the blessings of health." And surely when that restoration to health consists in "razing out the written trouble of the brain" and reviving in the patient the conscious exercise of divine reason, it is difficult to imagine a more Godlike act.

THE TABLEAU-PAGEANT

SYNOPSIS

While the Symbolic Father Time bears witness, the Muse of History, as the Narrator, after alluding to the remote past, briefly summarizes the incidents leading up to the establishment of the Society of the New York Hospital by Royal Charter in 1771. The succeeding scenes are self-revealing. The familiar picture of Pinel at Salpetrière depicts conditions in that period. Several portraits of personalities intimately associated with the early history of Bloomingdale Hospital follow. These, together with an episode from the life of Dorothy Dix, stimulate our imagination with reference to the revival of interest in the care of the mentally ill in the first half of the last century. The closing scenes suggest the great advance which has taken place during the century, and the part that work and play take to-day in re-establishing and maintaining life's balances. Finally, in symbolic processional, tribute is paid to Hygeia, the goddess of Health and Happiness.

CHARACTERS AND SCENES IN TABLEAU-PAGEANT

Prologue

Scene I

COURT OF KING GEORGE III.—GRANTING OF THE CHARTER

SCENE II

PINEL À LA SALPETRIÈRE

SCENE III

PORTRAITS—PERSONALITIES OF THE PAST

SCENE IV

DOROTHY LYNDE DIX BEFORE A LEGISLATIVE COMMITTEE

SCENE V

OCCUPATIONAL-RECREATIONAL ACTIVITIES

Supplementing the general medical work, the therapeutic value of organized occupational and recreational activities is gaining increasing recognition. Those arts and crafts lending themselves to graphic presentation are here selected: dyeing, weaving, spinning, basketry, caning, modelling, painting, pottery, metal work, net making, gardening, etc.: and similarly, in the recreative activities, tennis, golf, hockey, baseball, croquet, bowling, skiing, and skating. A Maypole dance closes the scene.

SCENE VI

INSPIRATIONS

NAMES OF THOSE WHO ATTENDED THE EXERCISES ^[19]

APPENDICES

APPENDIX I

COMMUNICATIONS FROM DR. BEDFORD PIERCE, MEDICAL SUPERINTENDENT OF THE RETREAT, YORK, ENGLAND

I have read with much pleasure your pamphlet giving the history of Bloomingdale Hospital. The reproduction in facsimile of Thomas Eddy's communication ^[20] is especially interesting and it will be placed with the records of the early days of the Retreat.

We have looked through the Minutes, which are complete from the opening of the Retreat in 1796, and also examined a large number of original letters of William and Samuel Tuke respecting the Institution, but have not succeeded in tracing the letter from S. Tuke to William Eddy, to which you refer. As you are probably aware, S. Tuke was the grandson of William Tuke, the founder, and when he published the History of the Retreat in 1812 he was but twenty-eight years of age. This book had a far-reaching influence on the treatment of the insane, and it is remarkable that a man untrained in medicine and without university education should have been able to write it. The book is now very rare, but as we have three duplicate copies, I am authorized by the Directors of the Retreat to present your Hospital with one of them. I have already sent you a copy of an address of my own dealing with Psychiatry in England at about the time your Hospital was instituted.

The use of the term "moral treatment" as opposed to treatment of physical disease has in recent years become especially interesting. It is clear that Tuke and Pinel foresaw that psychotherapeutic treatment is necessary, and their efforts were directed towards providing effective "sublimation" of misdirected psychical energy.

One is pleased to see in your report the extent to which organized occupations are developed at Bloomingdale—a pleasure not unmixed with envy at seeing the picture of the men's occupational pavilion, and the prospective erection of a similar building for women.

In the early days of the Retreat large numbers of visitors came from all parts of the world. There is a gap in the Visitors' Book between 1800-1815, and the list of visitors is not complete.

We have copied out the names of the American Visitors, together with an entry by John W. Francis, M.D., in 1815. It is interesting to note that an American woman Friend, Hannah Field, was accompanied to the Retreat by Elizabeth Fry. In 1818 a party of North American Indians visited the Retreat and signed the Visitors' Book with pictorial representations of their names. These we have had photographed and I send the prints herewith.

May I congratulate you on the centenary of your Hospital and also congratulate you and the Governors on its remarkable development and progress. Here at the Retreat we carry on using the original buildings still, striving to give our patients modern treatment in premises now almost ancient, but which do not appear so out of date in this City of York. York congratulates New York upon its wonderful prosperity, and we gladly recognize its development in the practice of psychiatry fully corresponds with its development in other directions.

Extract from Minutes of Board of Directors of the Retreat

The Retreat, York

Meeting of Directors held on April the 30th, 1921

Copy of Minute No. 8

At this Meeting of the Directors and Agents of York Retreat we hear with pleasure that the Bloomingdale Hospital, the section of the Society of the New York Hospital devoted to the Treatment of Mental Diseases, is to celebrate next month the centenary of its foundation. The facsimile reproduction of the letter of Thomas Eddy which has been presented to the Retreat Library is specially interesting to us as it acknowledges the pioneer work at the Retreat and specially refers to correspondence with Samuel Tuke. We have pleasure in sending to the Governors of the Bloomingdale Hospital a copy of Samuel Tuke's classical work "The Description of the Retreat" in the belief that the principles therein set forth are of lasting importance. We send our hearty congratulations to the Bloomingdale Hospital on its century of good work and wish it every success in the future.

Transcript from the Visitors Book of The Retreat

EARLY AMERICAN VISITORS

1803. 3 mon 11th. Abrm. Barker, New Bedford, Massachusits, a young man (a Friend) on a tour; has been in Russia, Denmark, Sweden & Holland. (In William Tuke's writing)

1815. Nov. 30. John W. Francis, M.D. of N. York. J.W. Francis is not wholly ignorant of the State of the Lunatic Asylums in North America, and he has visited almost all the institutions for the Insane that are established in England. He now embraces this opportunity of stating that after an examination of the Retreat for some hours, he should do injustice to his feelings were he not to declare that this establishment far surpasses anything of the kind he has elsewhere seen, and that it reflects equal credit on the wisdom and humanity of its conductors.

Perhaps it is no inconsiderable honour to add that institutions of a similar nature and on the same plan are organizing in different parts of the United States. The New World cannot do better than imitate the old so far as concerns the management of those who labour under mental infirmities. J.W.F.

1816. 1 Mon 4. Sharon Carter, Philadelphia.

1816. 1 mon. Wm. S. Warder, from Philadelphia.

1816. 2 mon 21. Rev. Thomas H. Gallaudet, who visits Europe for the purpose of qualifying himself to superintend an Asylum for the Deaf and Dumb, proposed to be established in Hartford, Connecticut, of the United States of America.

1816. 4 mon 8th. Archibald Gracie, Junr., New York.

1816. April 29th. George F. Randolph, Philadelphia. John Hastings, Baltimore.

1816. 6 mon 19th. Charles Longstreth, from Philadelphia.

1816. 6 mon 19th. Jacob Smedley, from Philadelphia.

1817. 7 mon. Henry Kollock, of Savannah, Georgia. Dr. Wm. Parker, Savannah. G.C. Versslanchi, of New York.

1817. 11/24. Hannah Field, North America, with Elizabeth Fry.

1817. 12 Mo. G.J. Browne, United States of America (Cincinnati).

APPENDIX II

A LETTER ON PAUPER LUNATIC ASYLUMS ^[21]

The Governors of the New York Hospital, conceiving that the very judicious remarks and sentiments contained in the following letter, might be highly useful to the community, as well as to the institution with which they are connected, have requested the same to be published. The work alluded to in the letter, called, "Practical hints on the construction and economy of Pauper Asylums," is believed to be one of the most valuable and interesting works of the kind ever published. This work was sent by the author to one of the Governors, and is now deposited in the Hospital library. It is very desirable that it should be republished in this country; but as such republication would be expensive, on account of the few copies that would be wanted, the Governors have directed, that if any person, or trustees of any public institution, in any part of the United States, should be desirous of obtaining a copy of this very valuable work, with a view to aid them in erecting a similar Asylum, or the improvement of any already established, that a manuscript copy shall be furnished them, upon an application to the subscriber,

Our mutual friend, L. Murray, has put into my hands a letter and pamphlet, lately received from thee, respecting the erection of an asylum for lunatics near New-York.^[22] He has wished me to make any remarks which may occur to me on the perusal; but, having just published a few hints on the construction and economy of Pauper Lunatic Asylums, which contain much of the information thou requests, I shall have but little to add. Those hints, however, relating to institutions for the poorest class of society, must be applied with some modifications to establishments for persons of different pervious habits, and for whom a greater portion of attendance can be afforded. The great objects, however, which are stated in the hints to be so important for the comfort of lunatics, apply equally to those of all ranks and classes.

From the sum you propose to receive from the patients, intended to occupy the new building, I conclude you are providing for patients of the middle ranks of life, a class hardly less to be commiserated, when thus afflicted, than the very poorest, since the expense and difficulty of private management, may bring to ruin a respectable family, as well as expose it to great personal dangers. There would, I think, be considerable objection to the accumulation of 40 patients of this class, in three contiguous rooms, as proposed in the hints for pauper lunatics. You purpose building for 50 patients, and as you probably intend to accommodate both sexes, the number of each sex may be very suitable for the accommodation of three contiguous rooms, which, of course, need not be so large as those in the Wakefield Asylum. It would be difficult to offer a detailed plan, without knowing more than we do of your local circumstances, and the classes of patients you purpose to admit. I doubt, however, whether you can do better than to adopt the general form of the Wakefield Asylum, and as you are providing for only a small number, it deserves consideration whether all the rooms might not be advantageously placed on the ground floor. This plan affords great facilities to easy inspection, and safe communication with airing grounds, and the roof might project so far over the building, as to form an excellent collonnade for the patients; which seems peculiarly desirable under an American Sun.

With these views, I send a sketch drawn by the Architect whose plan is to be adopted at Wakefield; and though it may not be, in many respects, adapted to your particular wants, yet I hope it will not be altogether useless. Should it be thought too expensive, I think the rooms, 1, 2, and 3, might be dispensed with, and rooms marked "attendants, sick and bath," might be appropriated to the patients during the day. The attendants room is not a requisite, though it has been thought that it would be more agreeable to patients of superior rank, not to have the society of a servant. This, however, chiefly applies to the convalescents, and these might occupy the room marked 'sick', whilst the middle class, and the attendants, would be in the centre, marked "attendants." A sick and bath room might probably be obtained in the galleries: if you are inclined for the sake of appearance, to make the centre building two stories high, you might bring the wings nearer to the centre, and accommodate most of the convalescent patients with bed rooms in the upper story. In this case, perhaps it would be desirable to give the wings a radiating form. You will however be best able to modify the sketch to your particular wants, if the general idea should meet your approbation.

I observe with pleasure, that one leading feature of your new institution, is the introduction of employment amongst the patients, an object which I am persuaded is of the utmost importance in the moral treatment of insanity. It is related of an institution in Spain, which accommodated all ranks, and in which the lower class were generally employed, that a great proportion of these recovered, whilst the number of the Grandees was exceedingly small. It will however, require great address to induce patients to engage in manual labour, who have not been accustomed to it previously to their indisposition, and it must be admitted, that where the reluctance on the part of the patient is great, the irritation which compulsory means are likely to excite, will probably be more injurious to the patient, than the exercise will be beneficial. The employment of insane persons should, as far as it is practicable, be adapted to their previous habits, inclinations and capacities, and, though horticultural pursuits may be most desirable, the greatest benefit will, I believe, be found to result from the patient being engaged in that employment in which he can most easily excel, whether it be an active or a sedentary one. If it be the latter, of course sufficient time should be allotted to recreation in the air. Some persons imagine, that exercises of diversion, are equally beneficial with those that are useful. The latter appear to me to possess a decided preference, by imparting to the mind that calm feeling of satisfaction, which the mere arts of amusement, though not to be neglected, can never afford. To the melancholy class, this is an important distinction between amusing and useful employments, and labour is to be prefered for the maniacal class as less calculated to stimulate the already too much excited spirits.

It is proposed that the new asylum should be placed a few miles from the city. The visitors to it, (I do not mean the medical ones) will, I presume, be residents in New-York, and from what I have seen of the zeal of persons under such appointments in this country, it appears desirable, to render the performance of this duty, so important for the welfare of asylums, as easy as it can be with propriety. One mile perhaps would not be objectionable, and might probably afford as good air and retirement, as a greater distance.

I need hardly say, I was much gratified to find by the pamphlet, that the importance of moral treatment in the cure of insanity, was duly appreciated in America. When we consider, as Lord Bacon observes, speaking of common diseases, that "all wise physicians in the prescription, of their regimen to their patients, do ever consider accidentia animi, as of great force to further or hinder remedies or recoveries;" it is difficult to account for the general neglect of moral considerations in the treatment of deranged mind. I hope, however, though in many instances medicine may not be employed with advantage, and its indiscriminate use has been seriously injurious, that we shall not abandon it as altogether useless, in what we term disease of the mind. All the varieties, included under this general term, have been produced by physical causes: by external accidents, by intoxication, the improper use of medicines, repelled eruptions, obstructed secretions, &c. In some instances, dissection has discovered, after death, the cause of the mental affection, and though, in many instances, no physical cause can be detected, yet, when it is considered, how limited are the investigations of the anatomist, and that the art is so imperfect, that diseases occasioning instant death, cannot always be discovered on the most minute dissection, it is not unreasonable to suppose, that the body is in all cases the true seat of the disease.

All I would infer from this speculation is, the importance of having judicious medical attendants, to watch the progress of the disorder, to be ready to apply their art as bodily symptoms may arise, and to ascertain, with greater precision than has hitherto been done, "how and how far the humours and effects of the body, do alter and work upon the mind; and how far the passions and apprehensions of the mind, do alter and work upon the body." Even if the disease is not confined to the corporal organs of mind, but extends to the pure and eternal intelligence, medical aid may still be useful from the well known reciprocal action of the two parts of our system upon each other.

I hope my unknown friend will excuse the length and freedom of this letter: its length has much exceeded my intentions, yet I may have omitted information which the experience of the Retreat might afford, and which would have been useful to promoters of the New-York Asylum, Should this be the case, I shall be glad to answer, as well as I am able, any questions which they may propose; and, with the best wishes for the success of their benevolent and important undertaking,

APPENDIX III

THOMAS EDDY'S COMMUNICATION TO THE BOARD OF GOVERNORS, APRIL, 1815 ^[23]

Of the numerous topics of discussion on subjects relating to the cause of humanity, there is none which has stronger claims to our attention, than that which relates to the treatment of the insane.

Though we may reasonably presume, this subject was by no means overlooked by the ancients, we may fairly conclude, it is deservedly the boast of modern times, to have treated it with any degree of success.

It would have been an undertaking singularly interesting and instructive, to trace the different methods of cure which have been pursued in different ages, in the treatment of those labouring under mental derangement: and to mark the various results with which they were attended. The radical defect, in all the different modes of cure that have been pursued, appears to be, that of considering mania a physical or bodily disease, and adopting for its removal merely physical remedies. Very lately, however, a spirit of inquiry has been excited, which has given birth to a new system of treatment of the insane; and former modes of medical discipline have now given place to that which is generally denominated moral management.

This interesting subject has closely engaged my attention for some years, and I conceive that the further investigation of it may prove highly beneficial to the cause of humanity, as well as to science, and excite us to a minute inquiry, how far we may contribute to the relief and comfort of the maniacs placed under our care. In pursuing this subject, my views have been much extended, and my mind considerably enlightened, by perusing the writings of Doctors Creighton, Arnold, and Rush; but, more particularly, the account of the Retreat near York, in England. Under these impressions I feel extremely desirous of submitting to the consideration of the Governors, a plan to be adopted by them, for introducing a system of moral treatment for the lunatics in the Asylum, to a greater extent than has hitherto been in use in this country. The great utility of confining ourselves almost exclusively to a course of moral treatment, is plain and simple, and incalculably interesting to the cause of humanity; and perhaps no work contains so many excellent and appropriate observations on the subject, as that entitled, The Account of the Retreat. The author, Samuel Tuke, was an active manager of that establishment, and appears to have detailed, with scrupulous care and minuteness, the effects of the system pursued toward the patients. I have, therefore, in the course of the following remarks, with a view of illustrating the subject with more clearness, often adopted the language and opinions of Tuke, but having frequently mixed my own observations with his, and his manner of expression not being always adapted to our circumstances and situation, I have attempted to vary the language, so as to apply it to our own institution; this will account for many of the subsequent remarks not being noticed as taken from Tuke's work.

It is, in the first place, to be observed, that in most cases of insanity, from whatever cause it may have arisen, or to whatever extent it may have proceeded, the patient possesses some small remains of ratiocination and self-command; and although many cannot be made sensible of the irrationality of their conduct or opinions, yet they are generally aware of those particulars for which the world considers them proper objects of confinement. Thus it frequently happens, that a patient, on his first introduction into the asylum, will conceal all marks of mental aberration; and, in some instances, those who before have been ungovernable, have so far deceived their new friends, as to make them doubt their being insane.

It is a generally received opinion, that the insane who are violent, may be reduced to more calmness and quiet, by exciting the principle of fear, and by the use of chains or corporal punishments. There cannot be a doubt that the principle of fear in the human mind, when moderately and judiciously excited, as it is by the operation of just and equal laws, has a salutary effect on Society. It is of great use in the education of children, whose imperfect knowledge and judgment, occasion them to be less influenced by other motives. But where fear is too much excited, and especially, when it becomes the chief motive of action, it certainly tends to contract the understanding, weaken the benevolent affection, and to debase the mind. It is, therefore, highly desirable, and more wise, to call into action, as much as possible, the operation of superior motives. Fear ought never to be induced, except when an object absolutely necessary cannot be otherwise obtained. Maniacs are often extremely irritable; every care, therefore, should be taken, to avoid that kind of treatment that may have any tendency towards exciting the passions. Persuasion and kind treatment, will most generally supersede the necessity of coercive means. There is considerable analogy between the judicious treatment of children and that of insane persons. Locke has observed "the great secret of education is in finding out the way to keep the Child's Spirit easy, active and free; and yet, at the same time, to restrain him from many things he has a mind to, and to draw him to things which are uneasy to him." Even with the more violent and vociferous maniacs, it will be found best to approach them with mild and soft persuasion. Every pains should be taken to excite in the patient's mind a desire of esteem. Though this may not be sufficiently powerful to enable them to resist the strong irregular tendency of their disease; yet, when properly cultivated, it may lead many to struggle to overcome and conceal their morbid propensities, or at least, to confine their deviations within such bounds as do not make them obnoxious to those about them. This struggle is highly beneficial to the patient; by strengthening his mind, and conducing to a salutary habit of self-restraint, an object, no doubt, of the greatest importance to the care of insanity by moral means.

It frequently occurs, that one mark of insanity is a fixed false conception, and a total incapacity of reasoning. In such cases, it is generally advisable to avoid reasoning ^[24] with them, as it irritates and rivets their false perception more strongly on the mind. On this account, every means ought to be taken to seduce the mind from unhappy and favourite musings; and particularly with melancholic patients; they should freely partake of bodily exercises, walking, riding, conversations, innocent sports, and a variety of other amusements; they should be gratified with birds, deer, rabbits, etc. Of all the modes by which maniacs may be induced to restrain themselves, regular employment is perhaps the most efficacious; and those kind of employments are to be preferred, both on a moral and physical account, which are accompanied by considerable bodily action, most agreeable to the patient, and most opposite to the illusions of his disease.

In short the patient should be always treated as much like a rational being as the state of his mind will possibly allow. In order that he may display his knowledge to the best advantage, such topics should be introduced as will be most likely to interest him; if he is a mechanic or an agriculturalist, he should be asked questions relating to his art, and consulted upon any occasion in which his knowledge may be useful. These considerations are undoubtedly very material, as they regard the comforts of insane persons; but they are of far greater importance as they relate to the cure of the disorder. The patient, feeling himself of some consequence, is induced to support it by the exertion of his reason, and by restraining those dispositions, which, if indulged, would lessen the respectful treatment he wishes to receive, or lower his character in the eyes of his companions and attendants.

Even when it is absolutely necessary to employ coercion, if on its removal the patient promises to control himself, great reliance may frequently be placed upon his word, and under this engagement, he will be apt to hold a successful struggle with the violent propensities of his disorder. Great advantages may also be derived, in the moral management of maniacs, from an acquaintance with the previous employment, habits, manners, and prejudices of the individual: this may truly be considered as indispensably necessary to be known, as far as can be obtained; and, as it may apply to each case, should be registered in a book for the inspection of the Committee of the Asylum, and the physician; the requisite information should be procured immediately on the admission of each patient; the mode of procuring it will be spoken of hereafter.

Nor must we forget to call to our aid, in endeavouring to promote self-restraint, the mild but powerful influence of the precepts of our holy religion. Where these have been strongly imbued in early life, they become little less than principles of our nature; and their restraining power is frequently felt, even under the delirious excitement of insanity. To encourage the influence of religious principles over the mind of the insane, may be considered of great consequence, as a means of cure, provided it be done with great care and circumspection. For this purpose, as well as for reasons still more important, it would certainly be right to promote in the patient, as far as circumstances would permit, an attention to his accustomed modes of paying homage to his Maker.

In pursuing the desirable objects above enumerated, we ought not to expect too suddenly to reap the good effects of our endeavours; nor should we too readily be disheartened by occasional disappointments. It is necessary to call into action, as much as possible, every remaining power and principle of the mind, and to remember, that, "in the wreck of the intellect, the affections very frequently survive." Hence the necessity of considering the degree in which the patient may be influenced by moral and rational inducements.

The contradictory features in their characters, frequently render it exceedingly difficult to insure the proper treatment of insane persons; to pursue this with any hopes of succeeding, so that we may in any degree ameliorate their distressed condition, renders it indispensably necessary that attendants only should be chosen who are possessed of good sense, and of amiable dispositions, clothed, as much as possible, with philosophical reflexion, and above all, with that love and charity that mark the humble Christian.

Agreeably to these principles, I beg leave to suggest the following regulations to be adopted, in accomplishing the objects in view.

2nd. In the most violent states of mania, the patient should be confined in a room with the windows, etc., closed, so as nearly to exclude the light, and kept confined if necessary, in a straight jacket, so as to walk about the room or lie down on the bed at pleasure; or by strops, etc., he may, particularly if there appears in the patient a strong determination to self-destruction, be confined on the bed, and the apparatus so fixed as to allow him to turn and otherwise change his positions.

3rd. The power of judicious kindness to be generally exercised, may often be blessed with good effects, and it is not till after other moral remedies are exercised, that recourse should be had to restraint, or the power of fear on the mind of the patient; yet it may be proper sometimes, by way of punishment, to use the shower bath.

4th. The common attendants shall not apply any extraordinary coercion by way of punishment, or change in any degree the mode of treatment prescribed by the physician; on the contrary, it is considered as their indispensable duty, to seek by acts of kindness the good opinion of the patients, so as to govern them by the influence of esteem rather than of severity.

5th. On the first day of the week, the Superintendent, or the principal keeper of the Asylum, shall collect as many of the patients as may appear to them suitable, and read some chapters in the Bible.

6th. When it is deemed necessary to apply the strait-jacket, or any other mode of coercion, by way of punishment or restraint, such an ample force should be employed as will preclude the idea of resistance from entering the mind of the patient.

7th. It shall be the duty of the deputy-keeper, immediately on a patient being admitted, to obtain his name, age, where born, what has been his employment or occupation, his general disposition and habits, when first attacked with mania; if it has been violent or otherwise, the cause of his disease, if occasioned by religious melancholy, or a fondness for ardent spirits, if owing to an injury received on any part of the body, or supposed to arise from any other known cause, hereditary or adventitious, and the name of the physician who may have attended him, and his manner of treating the patient while under his direction.

8th. Such of the patients as may be selected by the physician, or the Committee of the Asylum, shall be occasionally taken out to walk or ride under the care of the deputy-keeper; and it shall be also his duty to employ the patients in such manner, and to provide them with such kinds of amusements and books as may be approved and directed by the Committee.

9th. The female keeper shall endeavour to have the female patients Constantly employed at suitable work; to provide proper amusements, books, etc., to take them out to walk as may be directed by the Committee.

10th. It shall be the indispensable duty of the keepers, to have all the patients as clean as possible in their persons, and to preserve great order and decorum when they sit down to their respective meals.

11th. It shall be the duty of the physician to keep a book, in which shall be entered an historical account of each patient, stating his situation, and the medical and moral treatment used; which book shall be laid before the Committee, at their weekly meetings.

The sentiments and improvements proposed in the preceding remarks, for the consideration of the Governors, are adapted to our present situation and circumstances; but a further and more extensive improvement has occurred to my mind, which I conceive, would very considerably conduce towards affecting the cure, and materially ameliorate the condition, and add to the comfort of the insane; at the same time that it would afford an ample opportunity of ascertaining how far that disease may be removed by moral management alone, which it is believed, will, in many instances, be more effectual in controlling the maniac, than medical treatment especially, in those cases where the disease has proceeded from causes operating directly on the mind.

I would propose, that a lot, not less than ten acres, should be purchased by the Governors, conveniently situated, within a few miles of the city, and to erect a substantial building, on a plan calculated for the accommodation of fifty lunatic patients; the ground to be improved in such a manner as to serve for agreeable walks, gardens, etc., for the exercise and amusement of the patients: this establishment might be placed under the care and superintendence of the Asylum Committee, and be visited by them once every week: a particular description of patients to remain at this Rural Retreat; and such others as might appear suitable objects might be occasionally removed there from the Asylum.

The cost and annual expense of supporting this establishment, are matters of small consideration, when we duly consider the important advantages it would offer to a portion of our fellow-creatures, who have such strong claims on our sympathy and commiseration.

But, it is a fact that can be satisfactorily demonstrated, that such an establishment would not increase our expenses; and, moreover, would repay us even the interest of the money that might be necessary to be advanced, for the purchase of the ground and erecting the buildings. The board of patients (supposing fifty) would yield two hundred dollars per week, or ten thousand four hundred dollars per annum.

Supposing the ground, building, etc., to cost $50,000, the interest on this sum at 6 per cent. would be $3,000, there would yet remain $7,400, for the maintenance and support of the establishment; a sum larger than would be required for that purpose.

We had lately in the Asylum, more than ninety patients; and, at that time, had repeated applications to receive an additional number; the Committee however, concluded, that as the building was not calculated to accommodate more than seventy-five, it would be an act of injustice to take in any more; they, therefore, concluded to reduce the number of seventy-five, and strictly to refuse receiving any beyond that number. This may serve clearly to show, that we might safely calculate, that we should readily have applications to accommodate one hundred and twenty-five patients.

This succinct view of the subject may suffice, at this time, as outlines of my plan; and which is respectfully submitted to the Governors, for their Consideration.

The following anecdotes illustrate the observation before made, that maniacs frequently retain the power of reasoning to a certain extent; and that the discerning physician may oftimes successfully avail himself of the remains of this faculty in controlling the aberrations of his patient:—A patient in the Pennsylvania Hospital, who called his physician his father, once lifted his hand to strike him. "What!" said his physician, (Dr. Rush), with a plaintive tone of voice, "Strike your father?" The madman dropped his arm, and instantly showed marks of contrition for his conduct. The following was related to me by Samuel Coates, President of the Pennsylvania Hospital:—maniac had made several attempts to set fire to the Hospital: upon being remonstrated with, he said, "I am a salamander"; "but recollect," said my friend Coates, "all the patients in the house are not salamanders;" "That is true," said the maniac, and never afterwards attempted to set fire to the Hospital.

APPENDIX IV

EXTRACTS FROM THE MINUTES OF THE BOARD OF GOVERNORS IN RELATION TO ACTION TAKEN RESPECTING THOS. EDDY'S COMMUNICATION DATED APRIL, 1815

A communication was received from Thos. Eddy suggesting several improvements in the mode of treating Insane persons, which is referred to Dr. Hugh Williamson, George Newbold, William Johnson, Peter A. Jay, and John R. Murray—Resolved that the Treasurer have fifty copies of the report printed for use of the Governors.

The Committee on the communication from Thos. Eddy, relative to the treatment of Insane patients, report attention to the subject and that in their opinion it is advisable to have a few acres of land purchased in the vicinity of the City for the better accommodation of this unhappy class of our fellow creatures—the Committee are continued.

On motion Resolved that Thomas Eddy, John A. Murray, and John Aspinwall, be a Committee to look out for a suitable spot of land, and to make a purchase, if in their opinion it shall become necessary.

The Committee on the communication from Thomas Eddy, made the following Report, which was intended to have been laid before the last meeting of the Board; which was now accepted, and ordered to be inserted in the minutes.

"The Committee appointed to consider the expediency of erecting another Building for the accommodation of Insane Persons Report:

That another building for the use of those unfortunate persons who have lost the use of their reason, is not only advisable, but seems to be absolutely necessary.

That though there are at present more patients in the Asylum, by nearly one third, than can with perfect Safety, and the best hopes of recovery, be lodged there; many more insane persons, perhaps twenty within a few months, have by their friends been soliciting a place in that Building—In speaking of the want of safety, the Committee only mean to express an opinion, that when two or more insane persons, from the want of room are lodged together in one cell, the life of the weaker must be somewhat endangered by the stronger, who in a high Paroxysm of insanity might strangle him in his sleep, or otherwise destroy him.

That such additional Building, from the want of room, cannot possibly be erected near the hospital, in this city.

That there are many reasons for believing that the recovery from a state of insanity would be greatly promoted, by having a considerable space of ground adjoining the Asylum or Public Building, in which many of the patients might have the privilege of walking, or taking other kinds of exercise.

That considering the various kinds of insanity, your Committee, are clearly of the opinion, that two buildings should be erected at the distance of at least one hundred yards from each other. The sedate or melancholy madman should not have his slumbers broken by living under the same roof with disorderly persons, who by singing, or other noisy proceedings, will not suffer their neighbours to sleep.

That for the above and similar considerations, it would be advisable, to purchase, within a few miles of this City, at least twenty acres of land, detached from private buildings, in a healthy and pleasant situation, where the water is good and where materials for buildings may be obtained on easy terms: and the portage of fuel not expensive.

Your Committee are aware that a smaller lot of ground might suffice for all the buildings that are now required, or all this Corporation may, in a short time, be enabled to complete. But they count it advisable to prepare for a period that must certainly come; a period in which such a lot will be needed, and not easily obtained, for it is evident from the topography, and geographical position of this City, that the time must come, when New York will be not only the greatest City in the United States, or in America; but must rival the most distinguished City's in the old Continent.

Wherefore it is recommended, that a Committee be appointed, who shall examine the sundry places, corresponding with the above description, that may be purchased. And that they report the means of making the purchase, and of erecting such Buildings, as seem at this time to be required."

The Committee to whom was referred, to purchase a suitable Lot of Land for the erection of a House for the accommodation of maniacs, Report that they have purchased 38 acres of Land, being part of the Estate belonging to Gerard Depeyster at Bloomingdale, at the rate of $246. per acre, payable 25 per cent down, 37½ per cent on 1st November and 37¾ per cent on 1st February next, with interest.

Whereupon Resolved that the Report of the Committee be accepted, and they are instructed to take the Titles, after P.A. Jay shall have examined the Records, and be satisfied that the property is free of incumbrance.

APPENDIX V

ADDRESS TO THE PUBLIC BY THE GOVERNORS 1821 ^[25]

The Governors of the New-York Hospital have the satisfaction to announce to the public, the completion of the Asylum for the insane; and that it will be open for the reception of patients, from any part of the United States, on the first day of June.

This Asylum is situated on the Bloomingdale road, about seven miles from the City Hall of the city of New-York, and about three hundred yards from the Hudson River. The building is of hewn free-stone, 211 feet in length, and sixty-feet deep, and is calculated for the accommodation of about two hundred patients. Its site is elevated, commanding an extensive and delightful view of the Hudson, the East River, and the Bay and Harbour of New-York, and the adjacent country, and is one of the most beautiful and healthy spots on New-York Island. Attached to the building are about seventy acres of land, a great part of which has been laid out in walks, ornamental grounds, and extensive gardens.

This institution has been established by the bounty of the Legislature of the state of New-York, on the most liberal and enlarged plan, and with the express design to carry into effect that system of management of the insane, happily termed moral treatment, the superior efficacy of which has been demonstrated in several of the Hospitals of Europe, and especially in that admirable establishment of the Society of Friends, called "The Retreat," near York, in England. This mild and humane mode of treatment, when contrasted with the harsh and cruel usage, and the severe and unnecessary restraint, which have formerly disgraced even the most celebrated lunatic asylums, may be considered as one of the noblest triumphs of pure and enlightened benevolence. But it is by no means the intention of the governors to rely on moral, to the exclusion of medical treatment. It is from a judicious combination of both, that the greatest success is to be expected in every attempt to cure or mitigate the disease of insanity.

In the construction of the edifice and in its interior arrangements, it has been considered important to avoid, as far as practicable, consistently with a due regard to the safety of the patients, whatever might impress their minds with the idea of a prison, or a place of punishment, and to make every thing conduce to their health and to their ease and comfort. The self-respect and complacency which may thus be produced in the insane, must have a salutary influence in restoring the mind to its wonted serenity. In the disposition of the grounds attached to the Asylum, everything has been done with reference to the amusement, agreeable occupation, and salutary exercise of the patients.

Agricultural, horticultural, and mechanical employments, may be resorted to, whenever the inclination of the patient, or their probable beneficial effects may render them desirable. To dispel gloomy images, to break morbid associations, to lead the feelings into their proper current, and to restore the mind to its natural poise, various less active amusements will be provided. Reading, writing, drawing, innocent sports, tending and feeding domestic animals, &c. will be encouraged as they may be found conducive to the recovery of the patients. A large garden has been laid out, orchards have been planted, and yards, containing more than two acres, have been inclosed for the daily walks of those whose disorder will not allow more extended indulgence. The plants of the Elgin Botanic garden, presented to this institution by the Trustees of Columbia College, have been arranged in a handsome green-house, prepared for their reception.

The apartments of the house are adapted to the accommodation of the patients, according to their sex, degree of disease, habits of life, and the wishes of their friends. The male and female apartments are entirely separated, so as to be completely secluded from the view of each other.

Care has been taken to appoint a Superintendent and Matron, of good moral and religious characters, possessing cheerful tempers, and kind dispositions, united with firmness, vigilance and discretion. A Physician will reside in the house, and one or more Physicians, of established character and experience, will attend regularly, and afford medical aid in all cases where the general health, or the particular cause of the patient's insanity, may require it. The relations or friends of patients will be at liberty, if they prefer it, to employ their own physicians, who will be allowed to attend patients, subject to the general regulations of the house.

The institution will be regularly visited and inspected by a committee of the Governors of the Hospital, who will, as often as they may think it advantageous, be attended by some of the physicians of the city of high character and respectability.

The charges for board and the other advantages of the institution, will be moderate, and proportioned to the different circumstances of the patients, and the extent of the accommodations desired for them.

Patients at the expense of the different towns of the state, will be received at the lowest rate.

Application for the admission of patients into the Asylum, must be made, at the New York Hospital, in Broadway, where temporary accommodation will be provided for such patients as may require it, previously to their being carried to the Asylum out of town. A committee of the Governors will, when necessary, attend at the Hospital in Broadway, for the purpose of admitting patients into the Asylum, and to agree on the terms and security for payment to be given.

N.B. The friends of the patients are requested to send with them an account of their cases, stating the probable causes of their insanity, the commencement and peculiar character of the disorder. It is desirable that this statement, where it is practicable, should be drawn up by a physician.

Applications from abroad, for information relative to the admission of patients, may be made by letters addressed to Thomas Buckley, Secretary of the New-York Hospital.

The Muse of History (Narrator)	Adelyn Wesley
Spirit of the Past (Time)	Dr. D. Austin Sniffen
Music	Orchestra

King George III	Court Ladies
Queen Charlotte	Emissaries
Prince of Wales	Cherokee Chief
Court Chamberlain	Gavot

Men's Crafts	Men's Sports
Women's Sports	Women's Crafts

Superintendent or Warden	1
Housekeeper	1
Keepers, Men	3
Keepers, Women	2
Chambermaids	1
Cooks	3
Baker	1
Assistant Baker	1
Dairymaid	1
Washerwoman	1
Assistant washerwoman	1
Yard Keeper	1
Waitresses	2
Gardener	1
Farmer	1
Assistant farmer	1

Total	22
Number of patients	75

Men	217
Women	195
	——
Total	412

E. Stanley Abbot, M.D.	Philadelphia, Pa.
Louise Acton	White Plains, N.Y.
Elizabeth I. Adamson, M.D.	White Plains, N.Y.
William H. Alleé, M.D.	Ridgefield, Conn.
Thaddeus H. Ames, M.D.	New York City.
Mrs. George S. Amsden	White Plains, N.Y.
Mrs. Isadora Anschutz	White Plains, N.Y.
Grosvenor Atterbury	New York City.

Pearce Bailey, M.D.	New York City.
Amos T. Baker, M.D.	Bedford Hills, N.Y.
Mrs. Amos T. Baker	Bedford Hills, N.Y.
Lewellys F. Barker, M.D.	Baltimore, Md.
Clifford W. Beers	New York City.
Christopher C. Beling, M.D.	Newark, N.J.
Harrison Betts, M.D.	Yonkers, N.Y.
Anna T. Bingham, M.D.	New York City.
Mrs. Martha Bird	Middletown, N.Y.
Charles E. Birch, M.D.	White Plains, N.Y.
J. Fielding Black, M.D.	White Plains, N.Y.
Mrs. J. Fielding Black	White Plains, N.Y.
G. Alder Blumer, M.D.	Providence, R.I.
Leonard Blumgart, M.D.	New York City.
J. Arthur Booth, M.D.	New York City.
Miss Helen Booth	New York City.
S.M. Boyd	Scarsdale, N.Y.
Mrs. S.M. Boyd	Scarsdale, N.Y.
Mrs. Sidney C. Borg	New York City.
Rose Bell Bradley	New York City.
V.C. Branham, M.D.	New York City.
Holly Brown	White Plains, N.Y.
Helen Brown, M.D.	New York City.
Sanger Brown, 2d, M.D.	New York City.
Miss Elizabeth O. Buckingham	Chicago, Ill.
Alfred C. Buckley, M.D.	Frankford, Philadelphia, Pa.
Alice Gates Bugbee, M.D.	White Plains, N.Y.
Jesse C.M. Bullowa, M.D.	New York City.
William Browning, M.D.	Brooklyn, N.Y.
Marie von H. Byers	New York City.
Karl M. Bowman, M.D.	White Plains, N.Y.
Mrs. Karl M. Bowman	White Plains, N.Y.
Edna L. Byington	White Plains, N.Y.

C.N.B. Camac, M.D.	New York City.
C. Macfie Campbell, M.D.	Boston, Mass.
Mrs. C. Macfie Campbell, M.D.	Boston, Mass.
Robert Carroll, M.D.	Asheville, N.C.
Mrs. Robert Carroll	Asheville, N.C.
Louis Casamajor, M.D.	New York City.
Ross McC. Chapman, M.D.	Towson, Md.
Helen Childs	White Plains, N.Y.
Mrs. Anne Choate	Pleasantville, N.Y.
E.H. Clarke	New York City.
Miss Marjory Clark, R.N.	New York City.
Joseph Collins, M.D.	New York City.
Michael Collins	White Plains, N.Y.
Arthur S. Corwin, M.D.	Rye, N.Y.
Mrs. Margaret Cornwell	New Rochelle, N.Y.
Henry A. Cotton, M.D.	Trenton, N.J.
Edith Cox	White Plains, N.Y.
C. Burns Craig, M.D.	New York City.
Henry W. Crane	New York City.
Raymond S. Crispell, M.D.	New York City.
Mrs. Seymour Cromwell	Mendham, N.Y.
Hugh S. Cummings, M.D., Surgeon-General U.S. Public Health Service	Washington, D.C.

Charles L. Dana, M.D.	New York City.
Thomas K. Davis, M.D.	New York City.
Henderson Brooke Deady, M.D.	New York City.
John W. Dean	White Plains, N.Y.
Mrs. Aline S. Devin	Eliot, Maine.
Allen Ross Diefendorf, M.D.	New Haven, Conn.
William Elliott Dold, M.D.	Astoria, L.I., N.Y.
George Drake	White Plains, N.Y.
John W. Draper, M.D.	New York City.
Nataline Dullas	White Plains, N.Y.
Charles S. Dunlap, M.D.	New York City.
Mrs. Alfred F. DeNike	White Plains, N.Y.

R. Condit Eddy, M.D.	New Rochelle, N.Y.
Joseph P. Eidson, M.D.	White Plains, N.Y.
Mrs. Emma Eldridge	Tuckahoe, N.Y.
Charles A. Elsberg, M.D.	New York City.
William Else, M.D.	New York City.
Everett S. Elwood, Secretary State Hospital Commission	Albany, New York.

Mrs. Ezra H. Fitch	New York City.
Ralph P. Folsom, M.D.	New York City.
Harold E. Foster, M.D.	Boston, Mass.
Diana Fowler	White Plains, N.Y.
Florence Fuller	White Plains, N.Y.
Isaac J. Furman, M.D.	New York City.

Leslie Gager, M.D.	New York City.
William C. Garvin, M.D.	Kings Park, N.Y.
Arnold Gesell, M.D.	New Haven, Conn.
Bernard Glueck, M.D.	New York City.
J. Riddle Goffe, M.D.	New York City.
S. Philip Goodhart, M.D.	New York City.
Miss Annie W. Goodrich, R.N.	New York City.
Phyllis Greenacre, M.D.	Baltimore, Md.
Menas S. Gregory, M.D.	New York City.
Miss Pauline P. Gunderson	White Plains, N.Y.

Louis J. Haas	White Plains, N.Y.
Thomas H. Haines, M.D.	New York City.
Miss Dorothy Hale	New York City.
Miss Natalie Hall	White Plains, N.Y.
Robert B. Hammond, M.D.	White Plains, N.Y.
Miss Elisa Hansen	White Plains, N.Y.
Milton A. Harrington, M.D.	Alfred, N.Y.
Isham G. Harris, M.D.	Brooklyn, N.Y.
George A. Hastings	New York City.
Winifred Hathaway	New York City.
Edna Haverstock	White Plains, N.Y.
C. Floyd Haviland, M.D.	Middletown, Conn.
F. Ross Haviland, M.D.	Brooklyn, N.Y.
Charles E. Haynes, M.D.	New York City.
Eunice W. Haydon	New York City.
Miss Katherine F. Hearn, R.N.	White Plains, N.Y.
Edna Hemingson	White Plains, N.Y.
George W. Henry, M.D.	White Plains, N.Y.
Mrs. George W. Henry	White Plains, N.Y.
Marcus B. Heyman, M.D.	New York City.
Beatrice M. Hinkle, M.D.	New York City.
L.E. Hinsie, M.D.	New York City.
P.F. Hoffman, M.D.	White Plains, N.Y.
John F. Holden, M.D.	White Plains, N.Y.
Hubert S. Howe, M.D.	New York City.
Thomas Howell, M.D.	New York City.
J. Ramsay Hunt, M.D.	New York City.
Helen Hunt	White Plains, N.Y.
Miss Augusta M. Huppuch	New York City.
Richard H. Hutchings, M.D.	Utica, N.Y.

Frank N. Irwin, M.D.	New York City.

Martha Joffe	White Plains, N.Y.
Walter B. James, M.D.	New York City.
Mrs. Walter James	White Plains, N.Y.
Professor Pierre Janet, M.D.	Paris, France.
Madame Pierre Janet	Paris, France.
M.E. Jarvis, M.D.	New York City.
Rev. Oscar Jarvis	White Plains, N.Y.
Walter Jennings	Cold Spring Harbor, L.I., N.Y.
Miss Gudron Johannessen, R.N.	White Plains, N.Y.
Miss Marguerite Jewell	White Plains, N.Y.
Miss Florence M. Johnson.	New York City.
Kenneth B. Jones, M.D.	Thiells, N.Y.
Miss Minnie Jordan, R.N.	New York City.

Mrs. De Lancey A. Kane	New Rochelle, N.Y.
Lilian A. Kelm	New York City.
James P. Kelleher, M.D.	New York City.
Foster Kennedy, M.D.	New York City.
Marion E. Kenworthy, M.D.	New York City.
John Joseph Kindred, M.D.	Astoria, L.I., N.Y.
George W. King, M.D.	Secaucus, N.J.
Hermann G. Klotz, M.D.	White Plains, N.Y.
George W. Kline, M.D.	Boston, Mass.
George H. Kirby, M.D.	New York City.
Henry Klopp, M.D.	Allentown, Pa.
Augustus S. Knight, M.D.	New York City.
Frank Henry Knight, M.D.	White Plains, N.Y.
Mary S. Kirkbride	Albany, N.Y.
Walter M. Kraus, M.D.	New York City.
Edward J. Kempf, M.D.	New York City.

Alexander Lambert, M.D.	New York City.
Charles I. Lambert, M.D.	White Plains, N.Y.
Mrs. Charles I. Lambert	White Plains, N.Y.
Arthur G. Lane, M.D.	Greystone Park, N.J.
G. Alfred Lawrence, M.D.	New York City.
W.A. Lawrence, M.D.	White Plains, N.Y.
Ruth W. Lawton	White Plains, N.Y.
Helen Letson	White Plains, N.Y.
Samuel Leopold, M.D.	Philadelphia, Pa.
Maurice J. Lewi, M.D.	New York City.
Mrs. Maurice J. Lewi	New York City.
Miss Ella H. Lowe	White Plains, N.Y.
Walter E. Lowthian, M.D.	White Plains, N.Y.
F.R. Lyman, M.D.	Hastings-on-Hudson, N.Y.
Samuel B. Lyon, M.D.	New York City.
Winslow Lyon	New York City.

William H. McCastline, M.D.	New York City.
John T. McCurdy, M.D.	New York City.
Carlos F. MacDonald, M.D.	New York City.
D.W. McFarland, M.D.	Greens Farms, Conn.
Miss Eliza Macdonald	Flushing, L.I., N.Y.
John W. Mackintosh	White Plains, N.Y.
Daniel W. Maloney	White Plains, N.Y.
Grace F. Marcus, M.D.	White Plains, N.Y.
L. Markham, M.D.	Amityville, N.Y.
Miss Anna Maxwell, R.N.	New York City.
John F.W. Meagher, M.D.	Brooklyn, N.Y.
Adolf Meyer, M.D.	Baltimore, Md.
Carlos J. Miller, M.D.	White Plains, N.Y.
Henry W. Miller, M.D.	Brewster, N.Y.
Mrs. R. Van C. Miller	New York City.
George W. Mills, M.D.	Central Islip, N.Y.
Henry Moffett, M.D.	Yonkers, N.Y.
Mrs. Maude G. Moody	New York City.
Miss Madeline Moore	White Plains, N.Y.
Joseph W. Moore, M.D.	Beacon, N.Y.
Eugene T. Morrison, M.D.	New Rochelle, N.Y.
Miss Cecil Morrison	White Plains, N.Y.
Richard W. Moriarty, M.D.	White Plains, N.Y.
Herman Mortensen, R.N.	White Plains, N.Y.
Walter W. Mott, M.D.	White Plains, N.Y.
Florence Munn	White Plains, N.Y.

Theodore W. Neumann, M.D.	Central Valley, N.Y.
Ethan A. Nevin, M.D.	Newark, N.J.
Miss Christine M. Nuno	New York City.

George O'Hanlon, M.D.	New York City.
James M. O'Neill	Harrison, N.Y.
Herman Ostrander, M.D.	Kalamazoo, Mich.
Mary F. O'Grady	White Plains, N.Y.

Flavius Packer, M.D.	Riverdale, N.Y.
Mrs. Flavius Packer	Riverdale, N.Y.
Irving H. Pardee, M.D.	New York City.
Jason S. Parker, M.D.	White Plains, N.Y.
Frederick W. Parsons, M.D.	Buffalo, N.Y.
Miss Margaret Patin	White Plains, N.Y.
Stewart Paton, M.D.	Princeton, N.J.
Christopher J. Patterson, M.D.	Troy, N.Y.
Guy Payne, M.D.	Cedar Grove, N.J.
Arthur M. Phillips, M.D.	New York City.
Charles W. Pilgrim, M.D., Chairman, State Hospital Commission, N.Y.	Central Valley, N.Y.
Mason Pitman, M.D.	Riverdale-on-Hudson, N.Y.
Miss Leah Pitman	White Plains, N.Y.
Miss Adele S. Poston, R.N.	White Plains, N.Y.
Howard W. Potter, M.D.	Thiells, N.Y.
Wilson M. Powell	New York City.
Mrs. Margaret J. Powers	New York City.
Miss Nina Prey	New York City.
W.B. Pritchard, M.D.	New York City.
Morton Prince, M.D.	Boston, Mass.
Rose Pringle, M.D.	White Plains, N.Y.
Sylvanus Purdy, M.D.	White Plains, N.Y.

Paul R. Radosvljevich, M.D.	New York City.
E. Benjamin Ramsdell, M.D.	New York City.
Edwin G. Ramsdell, M.D.	White Plains, N.Y.
Mortimer W. Raynor, M.D.	New York City.
Lawrence F. Rainsford, M.D.	Rye, N.Y.
Mrs. Lawrence F. Rainsford	Rye, N.Y.
Henry A. Riley, M.D.	New York City.
Miss Elise Reilly	White Plains, N.Y.
Frank W. Robertson, M.D.	New York City.
M.A. Robinson, M.D.	New York City.
William C. Roden, R.N.	White Plains, N.Y.
A.J. Rosanoff, M.D.	Kings Park, N.Y.
Miss Catherine Ross, R.N.	White Plains, N.Y.
John T.W. Rowe, M.D.	New York City.
Richard G. Rows, M.D.	London, England.
Frederick D. Ruland, M.D.	Westport, Conn.
William L. Russell, M.D.	White Plains, N.Y.
Mrs. William L. Russell	White Plains, N.Y.
Earnest F. Russell, M.D.	New York City.
Paul L. Russell	White Plains, N.Y.
Mrs. Paul L. Russell	White Plains, N.Y.
Walter G. Ryon, M.D.	Poughkeepsie, N.Y.
Miss Helen K. Ryce	Poughkeepsie, N.Y.

Miss Helen Sayre	White Plains, N.Y.
Thomas W. Salmon, M.D.	New York City.
Mrs. Thomas W. Salmon	New York City.
Irving J. Sands, M.D.	Brooklyn, N.Y.
James P. Sands, M.D.	Philadelphia, Pa.
William C. Sandy, M.D.	New York City.
Miss E. Saul	New York City.
William G. Schauffler, M.D.	Princeton, N.J.
Paul Schlegman, M.D.	White Plains, N.Y.
H. Ernest Schmid, M.D.	White Plains, N.Y.
Miss Gertrude Schmid	White Plains, N.Y.
Augusta Scott, M.D.	New York City.
Major Louis L. Seaman, M.D.	New York City.
Edward W. Sheldon	New York City.
George Sherrill, M.D.	Stamford, Conn.
Miss Eloise Shields, R.N.	White Plains, N.Y.
Lewis M. Silver, M.D.	New York City.
Mrs. A. Slesingle	New York City.
Mrs. Anna C. Schermerhorn	New York City.
Rev. Frank H. Simmonds	White Plains, N.Y.
Clarence J. Slocum, M.D.	Beacon, N.Y.
Mrs. Clarence J. Slocum	Beacon, N.Y.
Augustine J. Smith	New York City.
Miss M. Smith, R.N.	Titusville, Pa.
Philip Smith, M.D.	New York City.
Rev. George H. Smyth	Scarsdale, N.Y.
D. Austin Sniffen, D.D.	White Plains, N.Y.
John D. Southworth, M.D.	New York City.
Edith E. Spaulding, M.D.	New York City.
M. Allen Starr, M.D.	New York City.
Samuel A. Steele	White Plains, N.Y.
William Steinach, M.D.	New York City.
George S. Stevenson, M.D.	New York City.
Adolf Stern, M.D.	New York City.
Emil Strateman	White Plains, N.Y.
Israel Strauss, M.D.	New York City.
Frank K. Sturgis	New York City.
Miss Mary Ruth Swann, R.N.	Washington, D.C.
C.C. Sweet, M.D.	Ossining, N.Y.
Sarah Swift	White Plains, N.Y.

William B. Terhune, M.D.	New Haven, Conn.
William J. Tiffany, M.D.	New York City.
Walter Clark Tilden, M.D.	Hartsdale, N.Y.
Frederick Tilney, M.D.	New York City.
Walter Timme, M.D.	New York City.
Howard Townsend	New York City.
E. Clark Tracy, M.D.	White Plains, N.Y.
Walter L. Treadway, M.D.	Washington, D.C.
Miss Gertrude Trefrey, R.N.	White Plains, N.Y.

Miss Mary G. Urquhart	White Plains, N.Y.

J.L. Van deMark, M.D.	Albany, N.Y.
T.J. Vosburgh, M.D.	White Plains, N.Y.
Henry J. Vier, M.D.	White Plains, N.Y.

Emory M. Wadsworth, M.D.	Brooklyn, N.Y.
Miss Lillian D. Wald, R.N.	New York City.
Professor Howard C. Warren	Princeton, N.J.
Mrs. Caroline E. Washburn	White Plains, N.Y.
Miss Martha Washburn	White Plains, N.Y.
G.F. Washburne, M.D.	Hastings-on-Hudson, N.Y.
Chester Waterman, M.D.	New York City.
James J. Waygood, M.D.	White Plains, N.Y.
Mrs. James J. Waygood	White Plains, N.Y.
R.G. Wearne, M.D.	New York City.
Edward W. Weber, M.D.	White Plains, N.Y.
Israel S. Wechsler, M.D.	New York City.
Miss Kathryn I. Wellman.	White Plains, N.Y.
Mrs. Adelyn Wesley	New York City.
Lt. Col. Arthur W. Whaley, M.D.	New York City.
Mrs. Arthur W. Whaley	New York City.
Miss Margaret Wheeler	Short Hills, N.J.
Payne Whitney	New York City.
Frankwood E. Williams, M.D.	New York City.
Rodney R. Williams, M.D.	Poughkeepsie, N.Y.
O.J. Wilsey, M.D.	Amityville, N.Y.
John E. Wilson, M.D.	New York City.
Miss A. Wilson	New York City.
J.M. Winfield, M.D.	Brooklyn, N.Y.
G. Howard Wise	New York City.
Miss Frances E. Wood	White Plains, N.Y.
Robert C. Woodman, M.D.	Middletown, N.Y.
Robert S. Woodworth, Ph.D.	New York City.

Rev. John C. York	Brooklyn, N.Y.

Edwin G. Zabriskie, M.D.	New York City.
Charles C. Zacharie, M.D.	White Plains, N.Y.

General Administration:
Medical Superintendent	1
Steward	1-2
Clinical and Laboratory Service:
Physicians:
Resident	9
Consultants	3
Dentist	1
Assistant	1
Apothecary	1
Technicians	2
Stenographers	5-22
Nursing Service:
Director, Assistant, and Instructor	3
Nurses, attendants, and pupils	135
Maids and porters	46-184
Occupational Therapy	13
Physical Training	7
Hydrotherapy and Massage	5
Dietary Department	25
Housekeeping and Laundry Departments	60
Financial, Purchasing, and Supplies	10
Engineering Department	18
Building Department	20
Industrial Department	5
Farm and Grounds	38
Miscellaneous	8
Chaplain, Librarian, Watchmen, Telephonists, Postal Clerk, Barber.

Number of cases admitted 1821 to 1921	13,411
Number discharged recovered 1821 to 1921	4,651
Number discharged improved 1821 to 1921	3,873

Hygeia	Britannia
La Belle France	Columbia

A PSYCHIATRIC MILESTONE

BLOOMINGDALE HOSPITAL CENTENARY

1821-1921

PRIVATELY PRINTED BY THE SOCIETY OF THE NEW YORK HOSPITAL

1921

ANNIVERSARY COMMITTEE

HOWARD TOWNSEND BRONSON WINTHROP R. HORACE GALLATIN

PREFACE

CONTENTS

ILLUSTRATIONS

BLOOMINGDALE HOSPITAL CENTENARY

MORNING SESSION

ADDRESS BY MR. EDWARD W. SHELDON

MR. SHELDON

ADDRESS BY DR. ADOLF MEYER

DR. MEYER

ADDRESS BY DR. LEWELLYS F. BARKER

DR. BARKER

ADDRESS BY DR. GEORGE D. STEWART

AFTERNOON SESSION

DR. STEWART

ADDRESS BY DR. RICHARD G. ROWS

DR. ROWS

ADDRESS BY DR. PIERRE JANET

DR. JANET

ADDRESS BY DR. WILLIAM L. RUSSELL

DR. RUSSELL

THE TABLEAU-PAGEANT

SYNOPSIS

CHARACTERS AND SCENES IN TABLEAU-PAGEANT

Prologue

Scene I

COURT OF KING GEORGE III.—GRANTING OF THE CHARTER

SCENE II

PINEL À LA SALPETRIÈRE

SCENE III

PORTRAITS—PERSONALITIES OF THE PAST

SCENE IV

DOROTHY LYNDE DIX BEFORE A LEGISLATIVE COMMITTEE

SCENE V

OCCUPATIONAL-RECREATIONAL ACTIVITIES

SCENE VI

INSPIRATIONS

NAMES OF THOSE WHO ATTENDED THE EXERCISES[19]

APPENDICES

APPENDIX I

COMMUNICATIONS FROM DR. BEDFORD PIERCE, MEDICAL SUPERINTENDENT OF THE RETREAT, YORK, ENGLAND

Extract from Minutes of Board of Directors of the Retreat

The Retreat, York

Meeting of Directors held on April the 30th, 1921

Copy of Minute No. 8

Transcript from the Visitors Book of The Retreat

EARLY AMERICAN VISITORS

APPENDIX II

A LETTER ON PAUPER LUNATIC ASYLUMS[21]

APPENDIX III

THOMAS EDDY'S COMMUNICATION TO THE BOARD OF GOVERNORS, APRIL, 1815[23]

APPENDIX IV

EXTRACTS FROM THE MINUTES OF THE BOARD OF GOVERNORS IN RELATION TO ACTION TAKEN RESPECTING THOS. EDDY'S COMMUNICATION DATED APRIL, 1815

APPENDIX V

ADDRESS TO THE PUBLIC BY THE GOVERNORS 1821[25]

APPENDIX VI

BOARD OF GOVERNORS OF THE SOCIETY OF THE NEW YORK HOSPITAL

1821 AND 1921

1821

1921

BLOOMINGDALE COMMITTEE

1821

1921

APPENDIX VII

ORGANIZATION OF BLOOMINGDALE HOSPITAL

1821 AND 1921

1821

1921

STATISTICS: 1821-1921

PRIVATELY PRINTED
BY THE SOCIETY OF THE NEW YORK HOSPITAL

HOWARD TOWNSEND
BRONSON WINTHROP
R. HORACE GALLATIN

ADDRESS BY
MR. EDWARD W. SHELDON

ADDRESS BY
DR. ADOLF MEYER

ADDRESS BY
DR. LEWELLYS F. BARKER

ADDRESS BY
DR. GEORGE D. STEWART

ADDRESS BY
DR. RICHARD G. ROWS

ADDRESS BY
DR. PIERRE JANET

ADDRESS BY
DR. WILLIAM L. RUSSELL

NAMES OF THOSE WHO ATTENDED THE EXERCISES ^[19]

A LETTER ON PAUPER LUNATIC ASYLUMS ^[21]

THOMAS EDDY'S COMMUNICATION TO THE BOARD OF GOVERNORS, APRIL, 1815 ^[23]

ADDRESS TO THE PUBLIC BY THE GOVERNORS 1821 ^[25]