Chapter II: Part 2

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

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.