The Project Gutenberg EBook of A Psychiatric Milestone, edited by 
Howard Townsend, Bronson Winthrop and R. Horace Gallatin

This eBook is for the use of anyone anywhere at no cost and with
almost no restrictions whatsoever.  You may copy it, give it away or
re-use it under the terms of the Project Gutenberg License included
with this eBook or online at www.gutenberg.net


Title: A Psychiatric Milestone
       Bloomingdale Hospital Centenary, 1821-1921

Author: Various

Editor: Howard Townsend
        Bronson Winthrop
        R. Horace Gallatin

Release Date: March 14, 2005 [EBook #15365]

Language: English

Character set encoding: ASCII

*** START OF THIS PROJECT GUTENBERG EBOOK A PSYCHIATRIC MILESTONE ***




Produced by Suzanne Lybarger, Kathryn Lybarger and the
Online Distributed Proofreading Team.






[Illustration: THE NEW YORK HOSPITAL, DUANE STREET AND BROADWAY

The building to the left was erected in 1808 for the exclusive use of
patients suffering from mental disorders.]


A PSYCHIATRIC MILESTONE

BLOOMINGDALE HOSPITAL CENTENARY

1821-1921

                            "Cum corpore ut una
Crescere sentimus, pariterque senescere mentem."
                                --LUCRETIUS

PRIVATELY PRINTED

BY THE SOCIETY OF THE NEW YORK HOSPITAL

1921


ANNIVERSARY COMMITTEE

HOWARD TOWNSEND
BRONSON WINTHROP
R. HORACE GALLATIN




PREFACE


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.

WILLIAM L. RUSSELL.




CONTENTS

                                                                       Page
PREFACE                                                                 vii

INVOCATION                                                                3
  REV. FRANK H. SIMMONDS

HISTORICAL REVIEW                                                         7
  EDWARD W. SHELDON, ESQ.
    President of the Society of the New York Hospital

"THE CONTRIBUTIONS OF PSYCHIATRY TO THE UNDERSTANDING OF LIFE PROBLEMS"  17
  ADOLF MEYER, M.D.
    Director of the Henry Phipps Psychiatric Clinic, Johns Hopkins
      Hospital, and Professor of Psychiatry, Johns Hopkins University,
      Baltimore, Maryland

"THE IMPORTANCE OF PSYCHIATRY IN GENERAL MEDICAL PRACTICE"               55
  LEWELLYS F. BARKER, M.D.
    Professor of Clinical Medicine, Johns Hopkins Medical School,
      Baltimore, Maryland

GREETINGS FROM THE NEW YORK ACADEMY OF MEDICINE                          79
  GEORGE D. STEWART, M.D.
    President of the Academy

"THE BIOLOGICAL SIGNIFICANCE OF MENTAL ILLNESS"                          89
  RICHARD G. ROWS, M.D.
    Director of the Section on Mental Illnesses of the Special
      Neurological Hospital, Tooting, London, England

"THE RELATION OF THE NEUROSES TO THE PSYCHOSES"                         115
  PIERRE JANET, M.D.
    Professor of Psychology, College de France

"THE MEDICAL DEVELOPMENT OF BLOOMINGDALE HOSPITAL"                      147
  WILLIAM L. RUSSELL, M.D.
    Medical Superintendent

THE TABLEAU-PAGEANT                                                     171

NAMES OF THOSE WHO ATTENDED THE EXERCISES                               177

APPENDIX I                                                              191
  COMMUNICATIONS FROM DR. BEDFORD PIERCE
    Medical Superintendent of The Retreat, York, England
  EXTRACT FROM MINUTES OF BOARD OF DIRECTORS OF THE RETREAT,
    APRIL 30, 1921.
  TRANSCRIPT FROM THE VISITORS BOOK OF THE RETREAT, 1803-17.

APPENDIX II                                                             195
  A LETTER ON PAUPER LUNATIC ASYLUMS FROM SAMUEL TUKE TO
    THOMAS EDDY, 1815.

APPENDIX III                                                            200
  THOMAS EDDY'S COMMUNICATION TO THE BOARD OF GOVERNORS, APRIL, 1815.

APPENDIX IV                                                             209
  EXTRACTS FROM THE MINUTES OF THE BOARD OF GOVERNORS IN RELATION TO
    ACTION TAKEN RESPECTING THOS. EDDY'S COMMUNICATION DATED
    APRIL, 1815.

APPENDIX V                                                              212
  ADDRESS TO THE PUBLIC BY THE GOVERNORS, 1821.

APPENDIX VI                                                             216
  BOARD OF GOVERNORS OF THE SOCIETY OF THE NEW YORK HOSPITAL, 1821
    AND 1921.

APPENDIX VII                                                            218
  ORGANIZATION OF BLOOMINGDALE HOSPITAL, 1821 AND 1921.




ILLUSTRATIONS

New York Hospital and Lunatic Asylum, 1808       _Frontispiece_
                                                    FACING PAGE
Bloomingdale Asylum, 1821                                     2
Bloomingdale Asylum, 1894                                    80
Bloomingdale Hospital, 1921                                 148
The Tableau-Pageant                                         172
Thomas Eddy                                                 195




THE SOCIETY OF THE NEW YORK HOSPITAL




[Illustration: BLOOMINGDALE ASYLUM

As it appeared when it was opened in 1821. It was located near the seven
mile stone on the Bloomingdale Road, now 116th Street and Broadway.]




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.

Mr. Edward W. Sheldon, the President of the Society, acted as Chairman.


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.

FOOTNOTES:

[Footnote 1: Address of the Governors of the New York Hospital, to the
Public, relative to the Asylum for the Insane at Bloomingdale, New York,
May 10th, 1821. Reprinted by Bloomingdale Hospital Press, White Plains,
May 26, 1921. See Appendix V, p. 212.]




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 role 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.

FOOTNOTES:

[Footnote 2: A Guide to the Descriptive Study of the Personality, with
Special Reference to the Taking of Anamneses of Cases with Psychoses, by
Dr. August Hoch and Dr. George S. Amsden.]

[Footnote 3: See, for instance, Moebius, The Hopelessness of All
Psychology, reviewed in the Psychological Bulletin, vol. IV, 1907, pp.
170-179.]




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
role 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, haemic, 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
paediatrist.[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 sequelae (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 [Transcriber's note: original reads
'Committe'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."

FOOTNOTES:

[Footnote 4: In an address at the seventieth annual meeting of the
American Medico-Psychological Association, 1914, entitled "The Relations
of Internal Medicine to Psychiatry."]

[Footnote 5: _Cf._ Polon (A.) "The Relation of the General Practitioner
to the Neurotic Patient," Mental Hygiene, New York, 1920, IV, 670-678.]

[Footnote 6: _Cf._ Paton (S.) Human Behavior in Relation to the Study of
Educational, Social, and Ethical Problems. New York, 1921. Charles
Scribner's Sons, p. 465.]

[Footnote 7: _Cf._ Meyer (A.), "Progress in Teaching Psychiatry,"
Journal A.M.A., Chicago, 1917, LXIX, 861-863; see also his, "Objective
Psychobiology, or Psychobiology with Subordination of the Medically
Useless Contrast of Medical and Physical," Journal A.M.A., Chicago,
1915, LXV, 860-863; and, "Aims and Meanings of Psychiatric Diagnosis,"
Am. Journal of Insanity, Baltimore, 1917, LXXIV, 163-168.]

[Footnote 8: _Cf._ "The General Diagnostic Survey Made by the Internist
Cooperating with Groups of Medical and Surgical Specialists," New York
Medical Journal, 1918, 489,538,577; also, "The Rationale of Clinical
Diagnosis," Oxford Medicine, 1920, vol. I, 619-684; also, "Group
Diagnosis and Group Therapy," Journal Iowa State Medical Society,
113-121, Des Moines, 1921.]

[Footnote 9: _Cf._ Southard (E.E.), "Insanity Versus Mental Disease";
the Duty of the General Practitioner in Psychiatric Diagnosis, Journal
American Medical Association, LXXI, 1259-1261, Chicago, 1918.]

[Footnote 10: _Cf._ Bailey (P.), "The Applicability of Findings of
Neuro-psychiatric Examinations in the Army to Civil Problems," Mental
Hygiene, New York, 1920, IV, 301; also "War and Mental Diseases," Am. J.
Pub. Health, IX, 1, Boston, 1919.]

[Footnote 11: _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.]

[Footnote 12: _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

[Illustration: BLOOMINGDALE ASYLUM

As it appeared in 1894 when it was discontinued and replaced by
Bloomingdale Hospital at White Plains, New York.]


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,
[Transcriber's note: original reads 'physican'] 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.

FOOTNOTES:

[Footnote 13: See Appendix III, p. 200.]




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 Salpetriere 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.

FOOTNOTES:

[Footnote 14: _Cf._ Janet, P., Les nevroses, 1909, p. 370.]

[Footnote 15: _Cf._ Les Medications psychologiques, 1920, I, p. 112.]

[Footnote 16: "Les Nevroses," 1909, p. 384.]

[Footnote 17: _Cf._ Janet, P., "Obsessions et Psychestenic," 1903, vol.
I, p. 997.]




ADDRESS BY
DR. WILLIAM L. RUSSELL

[Illustration: BLOOMINGDALE HOSPITAL, WHITE PLAINS, NEW YORK, 1921]


_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.

FOOTNOTES:

[Footnote 18: Homines enim ad Deos nulla re proprius accedunt, quam
salutem hominibus dando.]




THE TABLEAU-PAGEANT

[Illustration: SCENE FROM THE TABLEAU PAGEANT PRESENTED ON THE GROUNDS
OF BLOOMINGDALE HOSPITAL, MAY 26, 1921]


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 Salpetriere 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

Music: Orchestra
  Overture

_Prologue_

The Muse of History (Narrator): Adelyn Wesley
Spirit of the Past (Time): Dr. D. Austin Sniffen

Music: Orchestra
  "Amaryllis"


SCENE I

COURT OF KING GEORGE III.--GRANTING OF THE CHARTER

Characters:
  King George III
  Queen Charlotte
  Prince of Wales
  Court Chamberlain
  Court Ladies
  Emissaries
  Cherokee Chief
  Gavot

Minuet

     Through dramatic license, this scene takes place in the Court of
     King George III. Colonial emissaries, accompanied by a North
     American Indian, attend, and are graciously granted by the King a
     Royal Charter establishing the Society of the New York Hospital,
     along with a seal, insignia, and a money gift. A bit of color and
     romance attaches to the Cherokee's appearance in the scene.

Music: Orchestra
  "God Save the King"
  "Minuet Don Juan"
  "Largo"
  "Amaryllis"


SCENE II

PINEL A LA SALPETRIERE [Transcriber's note: original reads
'SALPTERIERE']

Characters:
  Pinel
  Patients
  Aides and Attendants

     A courtyard scene in Salpetriere in 1792. Hopelessness and chained
     despair are pictured. Pinel enters, is saddened and indignant at
     the sight of so much unnecessary suffering, and instantly orders
     the chains to be struck off. The historic episode closes in a
     graphic tableau depicting the gratitude of the released.

Music: Orchestra
  "Kammenoi Ostrow"


SCENE III

PORTRAITS--PERSONALITIES OF THE PAST


Thomas Eddy, of the Board of Governors, 1815-1827.

Dr. James Macdonald, First Resident Physician, 1825-1837.

Dr. Pliny Earle,[Transcriber's note: original reads 'Early'] Organizer,
  1844-1849.

Miss Eliza Macdonald, daughter of Dr. Macdonald, unveils the portrait of
her father.

Music: Orchestra
  "Long, Long Ago"


SCENE IV

DOROTHY LYNDE DIX BEFORE A LEGISLATIVE COMMITTEE

Characters: [This instance of 'Characters:' added by transcriber]
  Dorothy L. Dix
  Members of the Committee
  Chairman

     Miss Dix appears before a Committee of the Legislature and is heard
     in an impassioned appeal on behalf of adequate provision and care
     for the mentally ill. The scene closes with the Committee
     indicating their approval and congratulating Miss Dix on her
     successful effort.

Music: Orchestra
  "Maryland, My Maryland"
  "Columbia, the Gem of the Ocean"


SCENE V

OCCUPATIONAL-RECREATIONAL ACTIVITIES

Men's Crafts
Women's Crafts
Men's Sports
Women's Sports

Maypole Dance

     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.

Music: Orchestra
  "Boccherina"
  "Henry VIII, Maypole Dance"


SCENE VI

INSPIRATIONS

Characters:
  Hygeia
  La Belle France
  Britannia
  Columbia

     The closing scene is in the nature of a processional symbolizing
     international unity of purpose and a determination to pursue, until
     finally attained, the goal of Health and Happiness, personified by
     the goddess Hygeia.

Music: Orchestra
  "Marseillaise"
  "God Save the King"
  "Battle Hymn of the Republic"
  "The Star Spangled Banner"
  "Tammany"




NAMES OF THOSE WHO ATTENDED THE EXERCISES[19]

E. Stanley Abbot, M.D.              Philadelphia, Pa.
Louise Acton                        White Plains, N.Y.
Elizabeth I. Adamson, M.D.          White Plains, N.Y.
William H. Allee, 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.

FOOTNOTES:

[Footnote 19: If any names are omitted it is because these names and
addresses were not obtained.]




APPENDICES




APPENDIX I

COMMUNICATIONS FROM DR. BEDFORD PIERCE, MEDICAL SUPERINTENDENT OF THE
RETREAT, YORK, ENGLAND


May 5th, 1921.

DEAR DR. RUSSELL:

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.

I remain,

Yours sincerely,

BEDFORD PIERCE.


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.

Signed,

CHARLES WEOMANS, _Chairman_.

OSCAR F. RUMLEN, _Treasurer_.

       *       *       *       *       *

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).

[Illustration: [*HANDWRITING: Thy Assured Friend, Thomas Eddy*]

In 1815 Thomas Eddy, one of the Governors of the Society of the New York
Hospital, presented a communication in which he advocated the
establishment in the country of a branch for the moral treatment of the
insane. This led to the establishment of Bloomingdale Asylum.]

FOOTNOTES:

[Footnote 20: Bloomingdale Hospital Press.]




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,

THOMAS EDDY.

New-York, 12th month, 30th, 1815.


YORK, 7mo. 17th, 1815.

To Thomas Eddy,

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,

I remain, respectfully,

Thy friend,

SAMUEL TUKE.

FOOTNOTES:

[Footnote 21: A letter on Pauper Lunatic Asylums, by Samuel Tuke, New
York, 1815. Reprinted Bloomingdale Hospital Press, June 3, 1919.]

[Footnote 22: Appendix III.]




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.

1st. No patient shall hereafter be confined by chains.

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 [Transcriber's note: original reads 'apportunity']
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.

FOOTNOTES:

[Footnote 23: "Hints for Introducing an Improved Mode of Treating the
Insane in the Asylum"; read before the Governors of the New York
Hospital on the 4th of Fourth-month, 1815. By Thomas Eddy, one of the
Asylum Committee. New York, 1815. Reprinted Bloomingdale Hospital Press,
1916.]

[Footnote 24: 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


_April 4, 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.


_July 3, 1815._

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.


_8th Month (August) 1st, 1815._

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, 371/2 per cent on 1st November and 373/4 per
cent on 1st February next, with interest.

THOMAS EDDY, Chairman


August 1st, 1815

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 [Transcriber's note: original reads
'scite'] 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
[Transcriber's note: original reads 'varius'] 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.

_By order of the board of Governors._

MATTHEW CLARKSON, _President._

THOMAS BUCKLEY, _Secretary._

_New-York, 10th May, 1821._

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.

FOOTNOTES:

[Footnote 25: Address of the Governors of the New York Hospital to the
Public, Relative to the Asylum for the Insane at Bloomingdale. New York,
May 10th, 1821. Reprinted Bloomingdale Hospital Press, May 1921.]




APPENDIX VI

BOARD OF GOVERNORS OF THE SOCIETY OF THE NEW YORK HOSPITAL

1821 AND 1921


1821

Matthew Clarkson, President
Thomas Eddy, Vice President
Thomas Franklin
Jonathan Little
Thomas Buckley
William Johnson
Andrew Morris
John R. Murray
John B. Lawrence
George Newbold
Ebenezer Stevens
Peter A. Jay
Najah Taylor
Cadwallader D. Colden
Robert H. Bowne
Robert I. Murray
Thomas C. Taylor
John Adams, Treasurer
John McComb
Benjamin W. Rogers, Assistant Treasurer
William Bayard
Nathan Comstock
Duncan P. Campbell
Rev. F.C. Schaeffer
John Clark, Jr.
William Edgar, Jr.


1921

Hermann H. Cammann
Henry W. deForest
Richard Trimble
Howard Townsend
George F. Baker
Augustine J. Smith
Charles S. Brown
Edward W. Sheldon, President
Bronson Winthrop
Frank K. Sturgis
David B. Ogden
Joseph H. Choate, Jr.
Henry G. Barbey
Cornelius B. Bliss, Jr.
Paul Tuckerman, Treasurer
William Woodward
Arthur Iselin
Payne Whitney, Vice President
G. Beekman Hoppin
Lewis Cass Ledyard, Jr.
Henry R. Taylor
R. Horace Gallatin
Walter Jennings


BLOOMINGDALE COMMITTEE

1821

Thomas Eddy
Cadwallader D. Colden
Thomas C. Taylor
John Adams
Thomas Buckley
John B. Lawrence


1921

Frank K. Sturgis
Augustine J. Smith
Henry R. Taylor
Henry G. Barbey
Walter Jennings
Howard Townsend




APPENDIX VII

ORGANIZATION OF BLOOMINGDALE HOSPITAL

1821 AND 1921


1821

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


1921

Officers and employees:

Men       217
Women     195
          ---
Total     412

Patients:

Men       132
Women     156
          ---
Total     288

_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.


STATISTICS: 1821-1921

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












End of the Project Gutenberg EBook of A Psychiatric Milestone
by Howard Townsend, Bronson Winthrop and R. Horace Gallatin

*** END OF THIS PROJECT GUTENBERG EBOOK A PSYCHIATRIC MILESTONE ***

***** This file should be named 15365.txt or 15365.zip *****
This and all associated files of various formats will be found in:
        http://www.gutenberg.org/1/5/3/6/15365/

Produced by Suzanne Lybarger, Kathryn Lybarger and the
Online Distributed Proofreading Team.


Updated editions will replace the previous one--the old editions
will be renamed.

Creating the works from public domain print editions means that no
one owns a United States copyright in these works, so the Foundation
(and you!) can copy and distribute it in the United States without
permission and without paying copyright royalties.  Special rules,
set forth in the General Terms of Use part of this license, apply to
copying and distributing Project Gutenberg-tm electronic works to
protect the PROJECT GUTENBERG-tm concept and trademark.  Project
Gutenberg is a registered trademark, and may not be used if you
charge for the eBooks, unless you receive specific permission.  If you
do not charge anything for copies of this eBook, complying with the
rules is very easy.  You may use this eBook for nearly any purpose
such as creation of derivative works, reports, performances and
research.  They may be modified and printed and given away--you may do
practically ANYTHING with public domain eBooks.  Redistribution is
subject to the trademark license, especially commercial
redistribution.



*** START: FULL LICENSE ***

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg-tm mission of promoting the free
distribution of electronic works, by using or distributing this work
(or any other work associated in any way with the phrase "Project
Gutenberg"), you agree to comply with all the terms of the Full Project
Gutenberg-tm License (available with this file or online at
http://gutenberg.net/license).


Section 1.  General Terms of Use and Redistributing Project Gutenberg-tm
electronic works

1.A.  By reading or using any part of this Project Gutenberg-tm
electronic work, you indicate that you have read, understand, agree to
and accept all the terms of this license and intellectual property
(trademark/copyright) agreement.  If you do not agree to abide by all
the terms of this agreement, you must cease using and return or destroy
all copies of Project Gutenberg-tm electronic works in your possession.
If you paid a fee for obtaining a copy of or access to a Project
Gutenberg-tm electronic work and you do not agree to be bound by the
terms of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B.  "Project Gutenberg" is a registered trademark.  It may only be
used on or associated in any way with an electronic work by people who
agree to be bound by the terms of this agreement.  There are a few
things that you can do with most Project Gutenberg-tm electronic works
even without complying with the full terms of this agreement.  See
paragraph 1.C below.  There are a lot of things you can do with Project
Gutenberg-tm electronic works if you follow the terms of this agreement
and help preserve free future access to Project Gutenberg-tm electronic
works.  See paragraph 1.E below.

1.C.  The Project Gutenberg Literary Archive Foundation ("the Foundation"
or PGLAF), owns a compilation copyright in the collection of Project
Gutenberg-tm electronic works.  Nearly all the individual works in the
collection are in the public domain in the United States.  If an
individual work is in the public domain in the United States and you are
located in the United States, we do not claim a right to prevent you from
copying, distributing, performing, displaying or creating derivative
works based on the work as long as all references to Project Gutenberg
are removed.  Of course, we hope that you will support the Project
Gutenberg-tm mission of promoting free access to electronic works by
freely sharing Project Gutenberg-tm works in compliance with the terms of
this agreement for keeping the Project Gutenberg-tm name associated with
the work.  You can easily comply with the terms of this agreement by
keeping this work in the same format with its attached full Project
Gutenberg-tm License when you share it without charge with others.

1.D.  The copyright laws of the place where you are located also govern
what you can do with this work.  Copyright laws in most countries are in
a constant state of change.  If you are outside the United States, check
the laws of your country in addition to the terms of this agreement
before downloading, copying, displaying, performing, distributing or
creating derivative works based on this work or any other Project
Gutenberg-tm work.  The Foundation makes no representations concerning
the copyright status of any work in any country outside the United
States.

1.E.  Unless you have removed all references to Project Gutenberg:

1.E.1.  The following sentence, with active links to, or other immediate
access to, the full Project Gutenberg-tm License must appear prominently
whenever any copy of a Project Gutenberg-tm work (any work on which the
phrase "Project Gutenberg" appears, or with which the phrase "Project
Gutenberg" is associated) is accessed, displayed, performed, viewed,
copied or distributed:

This eBook is for the use of anyone anywhere at no cost and with
almost no restrictions whatsoever.  You may copy it, give it away or
re-use it under the terms of the Project Gutenberg License included
with this eBook or online at www.gutenberg.net

1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
from the public domain (does not contain a notice indicating that it is
posted with permission of the copyright holder), the work can be copied
and distributed to anyone in the United States without paying any fees
or charges.  If you are redistributing or providing access to a work
with the phrase "Project Gutenberg" associated with or appearing on the
work, you must comply either with the requirements of paragraphs 1.E.1
through 1.E.7 or obtain permission for the use of the work and the
Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
1.E.9.

1.E.3.  If an individual Project Gutenberg-tm electronic work is posted
with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any additional
terms imposed by the copyright holder.  Additional terms will be linked
to the Project Gutenberg-tm License for all works posted with the
permission of the copyright holder found at the beginning of this work.

1.E.4.  Do not unlink or detach or remove the full Project Gutenberg-tm
License terms from this work, or any files containing a part of this
work or any other work associated with Project Gutenberg-tm.

1.E.5.  Do not copy, display, perform, distribute or redistribute this
electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg-tm License.

1.E.6.  You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form, including any
word processing or hypertext form.  However, if you provide access to or
distribute copies of a Project Gutenberg-tm work in a format other than
"Plain Vanilla ASCII" or other format used in the official version
posted on the official Project Gutenberg-tm web site (www.gutenberg.net),
you must, at no additional cost, fee or expense to the user, provide a
copy, a means of exporting a copy, or a means of obtaining a copy upon
request, of the work in its original "Plain Vanilla ASCII" or other
form.  Any alternate format must include the full Project Gutenberg-tm
License as specified in paragraph 1.E.1.

1.E.7.  Do not charge a fee for access to, viewing, displaying,
performing, copying or distributing any Project Gutenberg-tm works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8.  You may charge a reasonable fee for copies of or providing
access to or distributing Project Gutenberg-tm electronic works provided
that

- You pay a royalty fee of 20% of the gross profits you derive from
     the use of Project Gutenberg-tm works calculated using the method
     you already use to calculate your applicable taxes.  The fee is
     owed to the owner of the Project Gutenberg-tm trademark, but he
     has agreed to donate royalties under this paragraph to the
     Project Gutenberg Literary Archive Foundation.  Royalty payments
     must be paid within 60 days following each date on which you
     prepare (or are legally required to prepare) your periodic tax
     returns.  Royalty payments should be clearly marked as such and
     sent to the Project Gutenberg Literary Archive Foundation at the
     address specified in Section 4, "Information about donations to
     the Project Gutenberg Literary Archive Foundation."

- You provide a full refund of any money paid by a user who notifies
     you in writing (or by e-mail) within 30 days of receipt that s/he
     does not agree to the terms of the full Project Gutenberg-tm
     License.  You must require such a user to return or
     destroy all copies of the works possessed in a physical medium
     and discontinue all use of and all access to other copies of
     Project Gutenberg-tm works.

- You provide, in accordance with paragraph 1.F.3, a full refund of any
     money paid for a work or a replacement copy, if a defect in the
     electronic work is discovered and reported to you within 90 days
     of receipt of the work.

- You comply with all other terms of this agreement for free
     distribution of Project Gutenberg-tm works.

1.E.9.  If you wish to charge a fee or distribute a Project Gutenberg-tm
electronic work or group of works on different terms than are set
forth in this agreement, you must obtain permission in writing from
both the Project Gutenberg Literary Archive Foundation and Michael
Hart, the owner of the Project Gutenberg-tm trademark.  Contact the
Foundation as set forth in Section 3 below.

1.F.

1.F.1.  Project Gutenberg volunteers and employees expend considerable
effort to identify, do copyright research on, transcribe and proofread
public domain works in creating the Project Gutenberg-tm
collection.  Despite these efforts, Project Gutenberg-tm electronic
works, and the medium on which they may be stored, may contain
"Defects," such as, but not limited to, incomplete, inaccurate or
corrupt data, transcription errors, a copyright or other intellectual
property infringement, a defective or damaged disk or other medium, a
computer virus, or computer codes that damage or cannot be read by
your equipment.

1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
of Replacement or Refund" described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg-tm trademark, and any other party distributing a Project
Gutenberg-tm electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH F3.  YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

1.F.3.  LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
defect in this electronic work within 90 days of receiving it, you can
receive a refund of the money (if any) you paid for it by sending a
written explanation to the person you received the work from.  If you
received the work on a physical medium, you must return the medium with
your written explanation.  The person or entity that provided you with
the defective work may elect to provide a replacement copy in lieu of a
refund.  If you received the work electronically, the person or entity
providing it to you may choose to give you a second opportunity to
receive the work electronically in lieu of a refund.  If the second copy
is also defective, you may demand a refund in writing without further
opportunities to fix the problem.

1.F.4.  Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you 'AS-IS', WITH NO OTHER
WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO
WARRANTIES OF MERCHANTIBILITY OR FITNESS FOR ANY PURPOSE.

1.F.5.  Some states do not allow disclaimers of certain implied
warranties or the exclusion or limitation of certain types of damages.
If any disclaimer or limitation set forth in this agreement violates the
law of the state applicable to this agreement, the agreement shall be
interpreted to make the maximum disclaimer or limitation permitted by
the applicable state law.  The invalidity or unenforceability of any
provision of this agreement shall not void the remaining provisions.

1.F.6.  INDEMNITY - You agree to indemnify and hold the Foundation, the
trademark owner, any agent or employee of the Foundation, anyone
providing copies of Project Gutenberg-tm electronic works in accordance
with this agreement, and any volunteers associated with the production,
promotion and distribution of Project Gutenberg-tm electronic works,
harmless from all liability, costs and expenses, including legal fees,
that arise directly or indirectly from any of the following which you do
or cause to occur: (a) distribution of this or any Project Gutenberg-tm
work, (b) alteration, modification, or additions or deletions to any
Project Gutenberg-tm work, and (c) any Defect you cause.


Section  2.  Information about the Mission of Project Gutenberg-tm

Project Gutenberg-tm is synonymous with the free distribution of
electronic works in formats readable by the widest variety of computers
including obsolete, old, middle-aged and new computers.  It exists
because of the efforts of hundreds of volunteers and donations from
people in all walks of life.

Volunteers and financial support to provide volunteers with the
assistance they need, is critical to reaching Project Gutenberg-tm's
goals and ensuring that the Project Gutenberg-tm collection will
remain freely available for generations to come.  In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a secure
and permanent future for Project Gutenberg-tm and future generations.
To learn more about the Project Gutenberg Literary Archive Foundation
and how your efforts and donations can help, see Sections 3 and 4
and the Foundation web page at http://www.pglaf.org.


Section 3.  Information about the Project Gutenberg Literary Archive
Foundation

The Project Gutenberg Literary Archive Foundation is a non profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service.  The Foundation's EIN or federal tax identification
number is 64-6221541.  Its 501(c)(3) letter is posted at
http://pglaf.org/fundraising.  Contributions to the Project Gutenberg
Literary Archive Foundation are tax deductible to the full extent
permitted by U.S. federal laws and your state's laws.

The Foundation's principal office is located at 4557 Melan Dr. S.
Fairbanks, AK, 99712., but its volunteers and employees are scattered
throughout numerous locations.  Its business office is located at
809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
business@pglaf.org.  Email contact links and up to date contact
information can be found at the Foundation's web site and official
page at http://pglaf.org

For additional contact information:
     Dr. Gregory B. Newby
     Chief Executive and Director
     gbnewby@pglaf.org

Section 4.  Information about Donations to the Project Gutenberg
Literary Archive Foundation

Project Gutenberg-tm depends upon and cannot survive without wide
spread public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can be
freely distributed in machine readable form accessible by the widest
array of equipment including outdated equipment.  Many small donations
($1 to $5,000) are particularly important to maintaining tax exempt
status with the IRS.

The Foundation is committed to complying with the laws regulating
charities and charitable donations in all 50 states of the United
States.  Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and keep up
with these requirements.  We do not solicit donations in locations
where we have not received written confirmation of compliance.  To
SEND DONATIONS or determine the status of compliance for any
particular state visit http://pglaf.org

While we cannot and do not solicit contributions from states where we
have not met the solicitation requirements, we know of no prohibition
against accepting unsolicited donations from donors in such states who
approach us with offers to donate.

International donations are gratefully accepted, but we cannot make
any statements concerning tax treatment of donations received from
outside the United States.  U.S. laws alone swamp our small staff.

Please check the Project Gutenberg Web pages for current donation
methods and addresses.  Donations are accepted in a number of other
ways including including checks, online payments and credit card
donations.  To donate, please visit: http://pglaf.org/donate


Section 5.  General Information About Project Gutenberg-tm electronic
works.

Professor Michael S. Hart is the originator of the Project Gutenberg-tm
concept of a library of electronic works that could be freely shared
with anyone.  For thirty years, he produced and distributed Project
Gutenberg-tm eBooks with only a loose network of volunteer support.

Project Gutenberg-tm eBooks are often created from several printed
editions, all of which are confirmed as Public Domain in the U.S.
unless a copyright notice is included.  Thus, we do not necessarily
keep eBooks in compliance with any particular paper edition.

Most people start at our Web site which has the main PG search facility:

     http://www.gutenberg.net

This Web site includes information about Project Gutenberg-tm,
including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how to
subscribe to our email newsletter to hear about new eBooks.

*** END: FULL LICENSE ***