A Psychiatric Milestone Part 5

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 quant.i.ty 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 accomplis.h.i.+ng 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 accomplis.h.i.+ng 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 a.n.a.lysis 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 a.n.a.logous 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 cla.s.sing 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 distinguis.h.i.+ng 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, const.i.tutes 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 a.s.sent 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 a.s.sent 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 fas.h.i.+on, that in neuroses the reflection alone is disturbed, that in psychoses the immediate a.s.sent 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 a.s.sent, 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 cla.s.sifications 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 subst.i.tute 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 pa.s.s 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

[Ill.u.s.tration: 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 inst.i.tution 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 antic.i.p.ated, 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 princ.i.p.al, 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 inst.i.tution 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 cla.s.sification 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 t.i.tular 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 a.s.sistance 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 a.s.sisted 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 cla.s.ses 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 inst.i.tution 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 cla.s.ses 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, amus.e.m.e.nt, 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 inst.i.tutions 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 inst.i.tution, and refers particularly to occupations, exercise in the open air, amus.e.m.e.nt, 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 inst.i.tution 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 inst.i.tution, 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 inst.i.tution.

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 inst.i.tutions 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 inst.i.tution 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, ma.s.sage 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 const.i.tution, 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 una.s.sisted 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 t.i.tular distinction as a physician, and do whatever may be necessary to make the inst.i.tution a truly medical agency for the healing of the sick. Considerable progress has been made in developing executive a.s.sistants 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 a.s.sistants 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 inst.i.tutions nor to the type or degree of disorder which necessitates compulsory seclusion.

Psychiatry is extending out from the inst.i.tutions 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 inst.i.tutions, 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 leaders.h.i.+p. 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 inst.i.tution 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 p.r.o.nounced 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 circ.u.mstances 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 inst.i.tution. 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 inst.i.tutional 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 grat.i.tude 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 n.o.ble 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 G.o.ds 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 G.o.dlike act.

FOOTNOTES:

[Footnote 18: Homines enim ad Deos nulla re proprius accedunt, quam salutem hominibus dando.]

THE TABLEAU-PAGEANT

[Ill.u.s.tration: SCENE FROM THE TABLEAU PAGEANT PRESENTED ON THE GROUNDS OF BLOOMINGDALE HOSPITAL, MAY 26, 1921]