A PSYCHIATRIC MILESTONE
BLOOMINGDALE HOSPITAL CENTENARY
"Cum corpore ut una Crescere sentimus, pariterque senescere mentem." —LUCRETIUS
BY THE SOCIETY OF THE NEW YORK HOSPITAL
HOWARD TOWNSEND BRONSON WINTHROP R. HORACE GALLATIN
The opening of Bloomingdale Asylum on June 1, 1821, was an important event in the treatment of mental disorders and in the progress of humanitarian and scientific work in America. Hospital treatment for persons suffering from mental disorders had been furnished by the New York Hospital since its opening in 1792, and the Governors had given much thought and effort to securing the facilities needed. The treatment consisted, however, principally in the administration of drugs and the employment of such other physical measures as were in vogue at that time. Little attempt was made to study the minds of the patients or to treat them by measures directed specifically to influencing their thoughts, feelings, and behavior, and what treatment of this character there was had for its object little more than the repression of excitement and disordered activity. The value and importance of treatment directed to the mind had, indeed, been long recognized, but in practice it had been subordinated to treatment of the actual and assumed physical disorders to which the mental state of the patient was attributed, and, in the few hospitals where persons suffering from mental disorders were received, means for its application were almost or quite entirely lacking. The establishment of Bloomingdale Asylum for the purpose of ascertaining to what extent the recovery of the patients might be accomplished by moral as well as by purely medical treatment marked, therefore, the very earliest stages of the development in America of the system of study and treatment of mental disorders which with increasing amplification and precision is now universally employed.
A hundred years of growth and activity in the work thus established have now been accomplished, and it seemed fitting to the Governors of the Hospital that the event should be commemorated in a way that would be appropriate to its significance and importance. It was decided that the principal place in the celebration should be given to the purely medical and scientific aspects of the work, with special reference to the progress which had been made in the direction of the practical usefulness of psychiatry in the treatment of illness generally, and in the management of problems of human behavior and welfare. Arrangements were made for four addresses by physicians of conspicuous eminence in their particular fields, and invitations to attend the exercises were sent to the leading psychiatrists, psychologists, and neurologists of America, and to others who were known to be specially interested in the field of study and practice in which the Hospital is engaged. It was felt that, in view of the place which France and England had held in the movement in which Bloomingdale Asylum had its origin, it would add greatly to the interest and value of the celebration if representatives of these countries were present and made addresses. How fortunate it was, then, that it became possible to welcome from France Dr. Pierre Janet, who stands pre-eminent in the field of psychopathology, and from England Dr. Richard G. Rows, whose contributions to the study and treatment of the war neuroses and to the relation between psychic and physical reactions marked him as especially qualified to present the more advanced view-point of British psychiatry. The other two principal addresses were made by Dr. Adolf Meyer, who, by reason of his scientific contributions and his wonderfully productive practical work in clinical and organized psychiatry and in mental hygiene, is the acknowledged leader of psychiatry in America, and by Dr. Lewellys F. Barker, who, because of his eminence as an internist and of the extent to which he has advocated and employed psychiatric knowledge and methods in his practice, has contributed greatly to interesting and informing physicians concerning the value and importance of psychiatry in general medical practice. The addresses given by these distinguished physicians, representing advanced views in psychiatry held in Europe and America, were peculiarly appropriate to the occasion and to the object of the celebration. They were supplemented by an historical review of the origin and development of the Hospital and of its work by Mr. Edward W. Sheldon, President of the Society of the New York Hospital, and by a statement concerning the medical development, made by Dr. William L. Russell, the Medical Superintendent. The greetings of the New York Academy of Medicine were presented in an interesting address by Dr. George D. Stewart, President of the Academy.
Of scarcely less significance and interest than the addresses was the pageant presented on the lawn during the intermission between the sessions, depicting scenes and incidents illustrating the origin and development of the Hospital, and of psychiatry and mental hygiene. The text and the scenes displayed were prepared by Dr. Charles I. Lambert, First Assistant Physician of the Hospital, and by Mrs. Adelyn Wesley, who directed the performance and acted as narrator. The performers were persons who were connected with the Hospital, twenty-two of whom were patients.
The celebration was held on May 26, 1921. The weather was exceptionally clear, with bright sunshine and moderate temperature. The grounds, in their Spring dress of fresh leaves and flowers, were especially beautiful. This added much to the attractiveness of the occasion and the pleasure of those who attended. Luncheon was served on the lawn in front of the Brown Villa and the pageant was presented on the adjoining recreation grounds. The beauty of the day and the surroundings, the character of the addresses and of the speakers, the remarkable felicity and grace with which they were introduced by the President, the dignity and noble idealism of his closing words, and the distinguished character of the audience, all contributed to make the celebration one of exceptional interest and value to those who were present, and a notable event in the history of the Hospital.
For the purpose of preserving, and of perhaps extending to some who were not present, the spirit of the occasion, and of placing in permanent form an account of the proceedings and the addresses which were made, this volume has been published by the Society of the New York Hospital.
WILLIAM L. RUSSELL.
Page PREFACE vii
INVOCATION 3 REV. FRANK H. SIMMONDS
HISTORICAL REVIEW 7 EDWARD W. SHELDON, ESQ. President of the Society of the New York Hospital
"THE CONTRIBUTIONS OF PSYCHIATRY TO THE UNDERSTANDING OF LIFE PROBLEMS" 17 ADOLF MEYER, M.D. Director of the Henry Phipps Psychiatric Clinic, Johns Hopkins Hospital, and Professor of Psychiatry, Johns Hopkins University, Baltimore, Maryland
"THE IMPORTANCE OF PSYCHIATRY IN GENERAL MEDICAL PRACTICE" 55 LEWELLYS F. BARKER, M.D. Professor of Clinical Medicine, Johns Hopkins Medical School, Baltimore, Maryland
GREETINGS FROM THE NEW YORK ACADEMY OF MEDICINE 79 GEORGE D. STEWART, M.D. President of the Academy
"THE BIOLOGICAL SIGNIFICANCE OF MENTAL ILLNESS" 89 RICHARD G. ROWS, M.D. Director of the Section on Mental Illnesses of the Special Neurological Hospital, Tooting, London, England
"THE RELATION OF THE NEUROSES TO THE PSYCHOSES" 115 PIERRE JANET, M.D. Professor of Psychology, College de France
"THE MEDICAL DEVELOPMENT OF BLOOMINGDALE HOSPITAL" 147 WILLIAM L. RUSSELL, M.D. Medical Superintendent
THE TABLEAU-PAGEANT 171
NAMES OF THOSE WHO ATTENDED THE EXERCISES 177
APPENDIX I 191 COMMUNICATIONS FROM DR. BEDFORD PIERCE Medical Superintendent of The Retreat, York, England EXTRACT FROM MINUTES OF BOARD OF DIRECTORS OF THE RETREAT, APRIL 30, 1921. TRANSCRIPT FROM THE VISITORS BOOK OF THE RETREAT, 1803-17.
APPENDIX II 195 A LETTER ON PAUPER LUNATIC ASYLUMS FROM SAMUEL TUKE TO THOMAS EDDY, 1815.
APPENDIX III 200 THOMAS EDDY'S COMMUNICATION TO THE BOARD OF GOVERNORS, APRIL, 1815.
APPENDIX IV 209 EXTRACTS FROM THE MINUTES OF THE BOARD OF GOVERNORS IN RELATION TO ACTION TAKEN RESPECTING THOS. EDDY'S COMMUNICATION DATED APRIL, 1815.
APPENDIX V 212 ADDRESS TO THE PUBLIC BY THE GOVERNORS, 1821.
APPENDIX VI 216 BOARD OF GOVERNORS OF THE SOCIETY OF THE NEW YORK HOSPITAL, 1821 AND 1921.
APPENDIX VII 218 ORGANIZATION OF BLOOMINGDALE HOSPITAL, 1821 AND 1921.
New York Hospital and Lunatic Asylum, 1808 Frontispiece FACING PAGE Bloomingdale Asylum, 1821 2 Bloomingdale Asylum, 1894 80 Bloomingdale Hospital, 1921 148 The Tableau-Pageant 172 Thomas Eddy 195
THE SOCIETY OF THE NEW YORK HOSPITAL
BLOOMINGDALE HOSPITAL CENTENARY
The One Hundredth Anniversary of the establishment of Bloomingdale Hospital as a separate department for mental diseases of The Society of the New York Hospital was celebrated at the Hospital at White Plains on Thursday, May 26, 1921. The addresses were given in the Assembly Hall.
Mr. Edward W. Sheldon, the President of the Society, acted as Chairman.
The exercises opened with an invocation by the Reverend Frank H. Simmonds, rector of Grace Episcopal Church at White Plains:
Oh, most mighty and all-merciful God, whose power is over all Thy works, who willest that all men shall glorify Thee in the constant bringing to perfection those powers of Thine which shall more and more make perfect the beings of Thy creation, we glorify Thee in the gift of Thy Divine Son Jesus Christ, the Great Physician of our souls, the Sun of Righteousness arising with healing in His wings, who disposeth every great and little incident to the glory of God the Father, and to the comfort of them that love and serve him, we render thanks to Thee and glorify Thy Name, this day, which brings to completion the hundredth anniversary of this noble institution's birthday. Oh, Thou, who didst put it into the hearts and minds of men to dedicate their lives and fortunes to the advancement of science and medicine for the sick and afflicted, we render Thee most high praise and hearty thanks for the grace and virtue of the founders of this institution—men whose names are written in the Golden Book of life as those who loved their fellow men.
We praise Thee for such men as Thomas Eddy, James Macdonald, Pliny Earle, and these endless others, who from age to age have held high the torch of knowledge and have kept before them the golden rule of service. Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.
Be pleased, oh merciful Father, to bless this day and gathering. Lift up and enlighten our hearts and minds to a higher perception of all that is noble, all that is true, all that is merciful. Awaken our dull senses to the full knowledge of light in Thee, and may all that is said and done be with the guiding of Thy Holy Spirit.
We pray for the continued blessing of this institution and hospital, and on all those who are striving to bring out of darkness those unhappy souls, into the pure light of understanding.
Bless the Governors, physicians, and nurses, direct their judgments, prosper their undertakings, and dispose their ministry that the world may feel the blessing and comfort of life in the prevention of disease and the preservation of health. And may we all be gathered in this nation to a more perfect unity of life and purpose in the desire to spend and be spent in the service of our fellow men.
We ask it all in the name and through the mediation of Thy Son Jesus Christ, our Lord. Amen.
ADDRESS BY MR. EDWARD W. SHELDON
It is with profound gratification that the Governors welcome your generous presence to-day on an occasion which means so much to us and which has perhaps some general significance. For we are met in honor of what is almost a unique event in our national history, the centennial anniversary celebration of an exclusively psychopathic hospital. A summary of its origin and development may be appropriate.
A hundred and fifty years ago the only institutions on this side of the Atlantic which cared for mental diseases were the Pennsylvania Hospital, chartered in 1751, a private general hospital which had accommodations for a few mental cases, and the Eastern State Hospital for the insane, at Williamsburg, Virginia, a public institution incorporated in 1768. No other one of the thirteen Colonies had a hospital of any kind, general or special. With a view of remedying this deplorable lack in New York, steps were taken in 1769 to establish an adequate general hospital in the City of New York. This resulted in the grant, on June 11, 1771, of the Royal Charter of The Society of the New York Hospital. Soon afterward the construction of the Hospital buildings began on a spacious tract on lower Broadway opposite Pearl Street, in which provision was also to be made for mental cases; but before any patients could be admitted, an accidental fire, in February, 1775, consumed the interior of the buildings. Reconstruction was immediately undertaken and completed early in the spring of 1776. But by that time the Revolutionary War was in full course, and the buildings were taken over by the Continental authorities as barracks for troops, and were surrounded by fortifications. When the British captured the city in September, 1776, they made the same use of the buildings for their own troops, who remained there until 1783. A long period of readjustment then ensued, and it was not until January, 1791, that the Hospital was at last opened to patients. In September, 1792, the Governors directed the admission of the first mental case, and for the hundred and twenty-nine years since that time the Society has continuously devoted a part of its effort to the care of the mentally diseased. After a few years a separate building for them was deemed desirable, and was constructed. The State assisted this expansion of the Hospital by appropriating to the Society $12,500 a year for fifty years. This new building housed comfortably seventy-five patients, but ten years later even this proved inadequate in size and undesirable in surroundings. In the meanwhile a wave of reform in the care of the insane was rising in Europe under the influence of such benefactors as Philippe Pinel in France, and William and Samuel Tuke in England. Thomas Eddy, a philanthropic Quaker Governor of the Society, who was then its Treasurer and afterward in succession its Vice-President and President, becoming aware of this movement, and having made a special study of the care and cure of mental affections, presented a communication to the Governors in which he advocated a change in the medical treatment, and in particular the adoption of the so-called moral management similar to that pursued by the Tukes at The Retreat, in Yorkshire, England. This memorable communication was printed by the Governors, and constitutes one of the first of the systematic attempts made in the United States to put this important medical subject on a humane and scientific basis. To carry out his plan, Mr. Eddy urged the purchase of a large tract of land near the city and the erection of suitable buildings. He ventured the moderate estimate that the population of the city, then about 110,000, might be doubled by 1836, and quadrupled by 1856. In fact, it was more than doubled in those first twenty years, and sextupled in the second twenty. He was justified, therefore, in believing that the hospital site on lower Broadway would soon be surrounded by a dense population, and quite unsuited for the efficient care of mental diseases. The Governors gave these recommendations immediate and favorable consideration. Various tracts of land, containing in all about seventy-seven acres, and lying on the historic Harlem Heights between what are now Riverside Drive and Columbus Avenue, and 107th and 120th Streets, were subsequently bought by the Society for about $31,000. To aid in the construction and maintenance of the necessary hospital buildings, the Legislature, by an act reciting that there was no other institution in the State where insane patients could be accommodated, and that humanity and the interest of the State required that provision should be made for their care and cure, granted an additional annual appropriation of $10,000 to the Society from 1816 until 1857. The main Hospital, built of brownstone, stood where the massive library of Columbia University now is, and the brick building still standing at the northeast corner of Broadway and 116th Street was the residence of the Medical Superintendent. The only access to this site by land was over what was known as the Bloomingdale Road, running from Broadway and 23d Street through the Bloomingdale district on the North River to 116th Street, and from that fact our institution assumed the name of Bloomingdale Asylum, or, as it is now called, Bloomingdale Hospital. This beautiful elevated site overlooking the Hudson River and the Harlem River was admirably fitted for its purpose. The spacious tract of land, laid out in walks and gardens, an extensive grove of trees, generous playgrounds and ample greenhouses, combined to give the spot unusual beauty and efficiency. This notable work finished, the Governors of the Society issued on May 10, 1821, an "Address to the Public" which marks so great an advance in psychiatry in our country that it deserves study. The national character of the institution was indicated in the opening paragraph, where it announced that the Asylum would be open for the reception of patients from any part of the United States on the first of the following June. Accommodation for 200 patients was provided, and to these new surroundings were removed on that day all the mental cases then under treatment at the New York Hospital on lower Broadway.
In this retired and ideal spot the work of Bloomingdale Hospital was successfully prosecuted for three-quarters of a century. But the seven miles that separated it from the old hospital was steadily built over, and before fifty years had gone the growth of the city had passed the asylum grounds. Foreseeing that they could not maintain that verdant oasis intact for many years longer, the Governors, in 1868, bought this 300-acre tract on the outskirts of the Village of White Plains. After prolonged consideration of the time and method of development of the property, final plans were adopted in December, 1891, construction was begun May 1, 1892, and two years later, under the direction of our Medical Superintendent, Dr. Samuel B. Lyon, all the patients were moved from the old to this new Bloomingdale. The cost of the new buildings was about $1,500,000. From time to time the original Bloomingdale site was sold and now supplies room, among other structures, for Columbia University, Barnard College, the Cathedral of St. John the Divine, St. Luke's Hospital, the Woman's Hospital, and the National Academy of Design. With the proceeds of those sales of the old Bloomingdale, not only was the cost of the new Bloomingdale met, but the permanent endowment of the Society was substantially increased, and Thomas Eddy was proved to have been both a wise humanitarian and a far-sighted steward of charitable funds.
In their "Address to the Public" to which I have referred, issued when Bloomingdale Hospital was opened in 1821, the Governors of the Society spoke of the new conception of moral treatment of the mentally afflicted which had been established in several European hospitals and which was supplanting the harsh and cruel usage of former days, as "one of the noblest triumphs of pure and enlightened benevolence." In that same spirit those founders dedicated themselves to the conduct of this institution. Their devotion to the work was impressive. Looking back on those early days we see a constant personal attention to the details of institutional life that commands admiration. The standards then set have become a tradition that has been preserved unbroken for a hundred years. Humane methods of care, the progressively best that medical science can devise, the utilization of a growingly productive pursuit of research, have consistently marked the administration of this great trust. The Governors of to-day are as determined as any of their predecessors to maintain that ideal of "pure and enlightened benevolence." New paths are opening and larger resources are becoming available. Under the guidance of our distinguished Medical Superintendent, with his able and devoted staff of physicians, a broader and more intensive development is already under way. Animated by that resolve and cheered by that prospect, we may thus confidently hope, as we begin the second century of Bloomingdale's career, for results not less fruitful and gratifying than those which we celebrate to-day.
[Footnote 1: Address of the Governors of the New York Hospital, to the Public, relative to the Asylum for the Insane at Bloomingdale, New York, May 10th, 1821. Reprinted by Bloomingdale Hospital Press, White Plains, May 26, 1921. See Appendix V, p. 212.]
ADDRESS BY DR. ADOLF MEYER
The Chairman: In celebrating our centenary we are naturally dealing also with the larger subject of general psychiatry. Our success in this discussion should be materially promoted by the presence with us of Dr. Adolf Meyer, Professor of Psychiatry in the Medical School of Johns Hopkins University, and Director of the Phipps Psychiatric Clinic, of Baltimore. Before taking up this important work in that famous medical centre, Dr. Meyer was actively engaged for several years in psychopathic work in New York. He will speak to us on "THE CONTRIBUTIONS OF PSYCHIATRY TO THE UNDERSTANDING OF LIFE PROBLEMS."
When Dr. Russell honored me with the invitation to speak at this centenary celebration of the renowned Bloomingdale Hospital, my immediate impulse was to choose as my topic a phase of psychiatric development to which this Hospital has especially contributed through our greatly missed August Hoch and his deeply appreciated coworker Amsden. I have in mind the great gain in concreteness of the physician's work with mind and the resulting contribution of psychiatry to a better knowledge of human life and its problems. The great gain this passing century is able to hand on to its successor is the clearer recognition of just what the psychiatrist actually works with and works on.
Of all the divisions of medicine, psychiatry has suffered longest from man's groping for a conception of his own nature. Psychiatry means, literally, the healing of souls. What then do we actually mean by soul or by psyche? This question has too long been treated as a disturbing puzzle.
To-day we feel that modern psychiatry has found itself—through the discovery that, after all, the uncritical common-sense view of mind and soul is not so far remote from a critical common-sense view of the individual and its life activity, freed from the forbidding and confusing assumptions through which the concept of mind and soul has been held in bewildering awe.
Strange to say, good old Aristotle was nearer an understanding than most of the wise men and women that have succeeded him for these more than two thousand years. He saw in the psyche what he called the form and realization or fulfilment of the human organism; he would probably now say with us, the activity and function as an individual or person.
Through the disharmonies and inevitable disruption of a self-disorganizing civilization, the Greek and Roman world was plunged into the dark centuries during which the perils of the soul and the sacrificial attainment of salvation by monastic life and crusades threatened to overshadow all other concern. This had some inevitable results: it favored all those views through which the soul became like a special thing or substance, in contrast to and yet a counterpart of the physical body. As long as there was no objective experimental science, the culminating solution of life problems had to be intrusted to that remarkable development of religious philosophy which arose from the blending of Hebrew religion and tradition and the loftiest products of the Greek mind, in the form which St. Paul and the early Church fathers gave to the teachings of Christ. From being the form and activation, or function, of the organism in life, the soul feature of man was given an appearance in which it could neither be grasped nor understood, nor shaped, nor guided by man when it got into trouble. From the Middle Ages there arose an artificial soul and an artificial world of souls presented as being in eternal conflict with the evil of the flesh—and thus the house of human nature was divided against itself.
Science of the nineteenth century came nearer bringing mind and body together again. The new astronomical conception of the world and the growing objective experimental science gradually began to command confidence, and from being a destroyer of excessively dogmatic notions, science began to rise to its modern constructive and creative position. But the problem of mind remained on a wrong basis and still does so even with most scientists. Too much had been claimed for the psyche, and because of the singling out of a great world of spirit, the world of fact had been compromised and left cold and dry and unattractive and unpromising. No doubt it was necessary that the scientist should become hardened and weaned from all misleading expectation, and shy of all the spurious claims of sordid superstition and of childish fancy. He may have been unduly radical in cutting out everything that in any way recalled the misleading notions. In the end, we had to go through a stage of psychology without a "soul," and lately even a psychology without "consciousness," so that we might be safe from unscientific pretensions. All the gyrations no doubt tended to retard the wholesome practical attack upon the problems in the form in which we find them in our common-sense life.
The first effort at a fresh start tried to explain everything rather one-sidedly out of the meagre knowledge of the body. Spinoza had said in his remarkable Ethics (III, Prop. II, Schol.): "Nobody has thus far determined what the body can do, i.e., nobody has as yet shown by experience and trial what the body can do by the laws of nature alone in so far as nature is considered merely as corporeal and extended, and what it cannot do save when determined by mind."
This challenge of Spinoza's had to be met. With some investigators this seemed very literally all there was to be done about the study of man—to show how far the body could explain the activity we call "the mind." The unfortunate feature was that they thought they had to start with a body not only with mind and soul left out but also with practical disregard of the whole natural setting. They studied little more than corpses and experimental animals, and many a critic wondered how such a corpse or a frog could ever show any mind, normal or abnormal. To get things balanced again, the vision of man had to expand to take a sane and practical view of all of human life—not only of its machinery.
The human organism can never exist without its setting in the world. All we are and do is of the world and in the world. The great mistake of an overambitious science has been the desire to study man altogether as a mere sum of parts, if possible of atoms, or now of electrons, and as a machine, detached, by itself, because at least some points in the simpler sciences could be studied to the best advantage with this method of the so-called elementalist. It was a long time before willingness to see the large groups of facts, in their broad relations as well as in their inner structure, finally gave us the concept and vision of integration which now fits man as a live unit and transformer of energy into the world of fact and makes him frankly a consciously integrated psychobiological individual and member of a social group.
It is natural enough that man should want to travel on the road he knows and likes best. The philosopher uses his logic and analysis and synthesis. The introspectionist wants to get at the riddle of the universe by crawling into the innermost depth of his own self-scrutiny, even at the risk—to use a homely phrase—of drawing the hole in after him and losing all connection with the objective world. The physicist follows the reverse course. He gives us the appreciation of the objective world around and in us. The chemist follows out the analytic and synthetic possibilities of his atoms and elements, and the biologist the growth and reproduction and multiplication of cells. Each sees an open world of possibilities and is ready to follow as far as facts will carry and as far as the imagination will soar. Each branch has created its rules of the game culminating in the concept of objective science, and the last set of facts to bring itself under the rules of objective science, and to be accepted, has been man as a unit and personality.
The mind and soul of man have indeed had a hard time. To this day, investigators have suffered under the dogma that mind must be treated as purely subjective entity, something that can be studied only by introspection, or at least only with ultra-accurate instruments—always with the idea that common sense is all wrong in its psychology. Undoubtedly it was, so long as it spoke of a mind and soul as if what was called so had to be, even during life, mysterious and inaccessible, something quite different from any other fact of natural-history study.
The great step was taken when all of life was seen again in its broad relations, without any special theory but frankly as common sense finds it, viz., as the activities and behavior of definite individuals—very much as Aristotle had put it—"living organisms in their 'form' or activity and behavior." Psychology had to wake up to studying other minds as well as one's own. Common sense has always been willing to study other persons besides our own selves, and that exactly as we study single organs—viz., for what they are and do and for the conditions of success and failure. Nor do we have to start necessarily from so-called elements. Progress cannot be made merely out of details. It will not do merely to pile up fragments and to expect the aggregates to form themselves. It also takes a friend of facts with the capacity for mustering and unifying them, as the general musters his army. Biology had to have evolutionists and its Darwin to get on a broad basis to start with, and human biology, the life of man, similarly had to be conceived in a new spirit, with a clear recognition of the opportunities for the study of detail about the brain and about the conditions for its working and its proper support, but also with a clear vision of the whole man and all that his happiness and efficiency depend upon.
All this evolution is strongly reflected in the actual work of psychiatry and medicine. For a time, it looked to the physician as if the physiology and pathology of the body had to make it their ambition to make wholly unnecessary what traditional psychology had accumulated, by turning it all into brain physiology. The "psychological" facts involved were undoubtedly more difficult to control, so much so that one tried to cut them out altogether. As if foreshadowing the later academic "psychology without soul and consciousness," the venerable Superintendent of Utica, Dr. Gray, was very proud when in 1870 he had eliminated the "mental and moral causes" from his statistics of the Utica State Hospital, hiding behind the dogma that "mind cannot become diseased, but only the body." To-day "mental and moral causes" are recognized again in truer form—no longer as mere ideas and uninvestigated suppositions taken from uncritical histories, but as concrete and critically studied life situations and life factors and life problems. Our patients are not sick merely in an abstract mind, but by actually living in ways which put their mind and the entire organism and its activity in jeopardy, and we are now free to see how this happens—since we study the biography and life history, the resources of adaptation and of shaping the life to success or to failure.
The study of life problems always concerns itself with the interaction of an individual organism with life situations. The first result of a recognition of this fact was a more whole-hearted and practical concept of personality.
In 1903 I put together for the first time my analysis of the neurotic personality, which was soon followed by a series of studies on the influences of the mental factors, and in 1908 a paper on "What Do Histories of Cases of Insanity Teach Us Concerning Preventive Mental Hygiene During the Years of School Life?" All this was using for psychiatry the growing appreciation of a broad biological view-point in its concrete application. It was a reaction against the peculiar fear of studying the facts of life simply and directly as we find and experience them—scoffed at because it looked as if one was not dealing with dependable and effective data. Many of the factors mentioned as causes do not have the claimed effects with sufficient regularity. It is quite true that not everybody is liable to any serious upset by several of the handicaps sometimes found to be disastrous during the years of development; but we have learned to see more clearly why the one person does and the other does not suffer. Evidently, not everybody who is reserved and retiring need be in danger of mental disorder, yet there are persons of just this type of make-up that are less able than others to stand the strains of isolation, of inferiority feeling, of exalted ambitions and one-sided longings, intolerable desires, etc. The same individual difference of susceptibility holds even for alcohol. With this recognition we came to lay stress again on the specific factors which make for the deterioration of habits, for tantrums with imaginations, and for drifting into abnormal behavior, and conditions incompatible with health.
It was at this point that our great indebtedness to the Bloomingdale Hospital began. Dr. August Hoch, then First Assistant of the Bloomingdale Hospital, began to swing more and more toward the psychobiological trend of views, and with his devoted and very able friend Amsden he compiled that remarkable outline, which was the first attempt to reduce the new ideals of psychobiology to a practical scheme of personality study—that clear and plain questionnaire going directly at human traits and reactions such as we all know and can see at work without any special theories or instruments.
After studying in each patient all the non-mental disorders such as infections, intoxications, and the like, we can now also attack the problems of life which can be understood only in terms of plain and intelligible human relations and activities, and thus we have learned to meet on concrete ground the real essence of mind and soul—the plain and intelligible human activities and relations to self and others. There are in the life records of our patients certain ever-returning tendencies and situations which a psychiatry of exclusive brain speculation, auto-intoxications, focal infections, and internal secretions could never have discovered.
Much is gained by the frank recognition that man is fundamentally a social being. There are reactions in us which only contacts and relations with other human beings can bring out. We must study men as mutual reagents in personal affections and aversions and their conflicts; in the desires and satisfactions of the simpler appetites for food and personal necessities; in the natural interplay of anticipation and fulfilment of desires and their occasional frustration; in the selection of companionship which works helpfully or otherwise—for the moment or more lastingly throughout the many vicissitudes of life. All through we find situations which create a more or less personal bias and chances for success or failure, such as simpler types of existence do not produce. They create new problems, and produce some individuals of great sensitiveness and others with immunity—and in this great field nothing will replace a simple study of the life factors and the social and personal life problems and their working—the study of the real mind and the real soul—i.e., human life itself. Looking back then this practical turn has changed greatly the general view as to what should be the chief concern of psychology. One only need take up a book on psychology to see what a strong desire there always was to contrast a pure psychology and an applied psychology, and to base a new science directly on the new acquisitions of the primary sciences such as anatomy and histology of the nervous system. There was a quest for the elements of mind and their immediate correlation with the latest discoveries in the structure of the brain. The centre theory and the cell and neurone theory seemed obligatory starting-points. To-day we have become shy of such postulates of one-sided not sufficiently functional materialism. We now call for an interest in psychobiological facts in terms of critical common sense and in their own right—largely a product of psychiatry. There always is a place for elements, but there certainly is also a place for the large momentous facts of human life just as we find and live it.
Thus psychiatry has opened to us new conceptions and understandings of the relation of child and mother, child and father, the child as a reagent to the relations between mother and father, brothers and sisters, companions and community—in the competitions of real concrete life. It has furnished a concrete setting for the interplay of emotions and their effects.
It has led us from a cold dogma of blind heredity and a wholesale fatalistic asylum scheme, to an understanding of individual, familiar, and social adjustments, and a grasp on the factors which we can consider individually and socially modifiable. We have passed from giving mere wholesale advice to a conscientious study of the problems of each unit, and at the same time we have developed a new and sensible approach to mental hygiene and prevention, as expressed in the comprehensive surveys of State and community work and even more clearly in the development of helps to individuals in finding themselves, and in the work in schools to reach those who need a special adaptation of aims and means. To the terrible emergency of the war it was possible to bring experienced men and women as physicians and nurses, and how much was done, only those can appreciate who have seen the liberality with which all the hospitals, and Bloomingdale among the first, contributed more than their quota of help, and all the assistance that could possibly be offered to returning victims for their readjustment.
It is natural enough that psychiatry should have erred in some respects. We had forced upon us the herding together of larger numbers of patients than can possibly be handled by one human working unit or working group. The consequence was that there arose a narrowing routine and wholesale classifications and a loss of contact with the concrete needs of the individual case; that very often progress had to come from one-sided enthusiasts or even outsiders, who lost the sense of proportion and magnified points of relative importance until they were supposed to explain everything and to be cure-alls. We are all inclined to sacrifice at the altar of excessive simplicity, especially when it suits us; we become "single-taxers" and favor wholesale legislation and exclusive State care when our sense for democratic methods has gone astray. Human society has dealt with the great needs of psychiatry about as it has dealt with the objects of charity, only in some ways more stingily, with a shrewd system and unfortunately often with a certain dread of the workers themselves and of their enthusiasm and demands. Law and prejudice surrounded a great share of the work with notions of stigma and hopelessness and weirdness—while to those who see the facts in terms of life problems there can be but few more inspiring tasks than watching the unfolding of the problematic personality, seeking and finding its proper settings, and preventing the clashes and gropings in maladjustments and flounderings of fancy and the faulty use and nutrition of the brain and of the entire organism.
What a difference between the history of a patient reported and studied and advised by the well-trained psychiatrist of to-day and the account drawn up by the statistically minded researcher or the physician who wants to see nothing but infections or chemistry and hypotheses of internal secretion. What a different chance for the patient in his treatment, in contrast to what the venerable Galt of Virginia reports as the conception of treatment recommended by a great leader of a hundred years ago: "Mania in the first stage, if caused by study, requires separation from books. Low diet and a few gentle doses of purging physic; if pulse tense, ten or twelve ounces of blood [not to be given but to be taken!]. In the high grade, catch the patient's eye and look him out of countenance. Be always dignified. Never laugh at or with them. Be truthful. Meet them with respect. Act kindly toward them in their presence. If these measures fail, coercion if necessary. Tranquillizing chair. Strait waistcoat. Pour cold water down their sleeves. The shower bath for fifteen or twenty minutes. Threaten them with death. Chains seldom and the whip never required. Twenty to forty ounces of blood, unless fainting occurs previously; ... etc."
To-day an understanding of the life history, of the patient's somatic and functional assets and problems, likes and dislikes, the problem presented by the family, etc.!
So much for the change within and for psychiatry. How about psychiatry's contribution beyond its own narrower sphere? It has led us on in philosophy, it has brought about changes in our attitude to ethics, to social study, to religion, to law, and to life in general. Psychiatric work has undoubtedly intensified the hunger for a more objective and yet melioristic and really idealistic philosophical conception of reality, such as has been formulated in the modern concept of integration.
Philosophical tradition, logic, and epistemology alike had all conspired to make as great a puzzle as possible of the nature of mental life, of life itself, and of all the fundamental principles, so much so that as a result anything resembling or suggesting philosophy going beyond the ordinary traditions has got into poor repute in our colleges and universities and among those of practical intelligence. The consequence is that the student and the physician are apt to be hopeless and indifferent concerning any effort at orderly thinking on these problems.
Most of us grew up with the attitude of a fatalistic intellectual hopelessness. How could we ever be clear on the relation of mind and body? How could mind and soul ever arise out of matter? How can we harmonize strict science with what we try to do in our treatment of patients? How can we, with our mechanistic science, speak of effort, and of will to do better? How can we meet the invectives against the facts of matter on the part of the opposing idealistic philosophies and their uncritical exploitations in "New Thought"—i.e., really the revival of archaic thought? It is not merely medical usefulness that forced these broad issues on many a thinking physician, but having to face the facts all the time in dealing with a living human world. The psychopathologist had to learn to do more than the so-called "elementalist" who always goes back to the elements and smallest units and then is apt to shirk the responsibility of making an attempt to solve the concrete problems of greater complexity. The psychiatrist has to study individuals and groups as wholes, as complex units, as the "you" or "he" or "she" or "they" we have to work with. We recognize that throughout nature we have to face the general principle of unit-formation, and the fact that the new units need not be like a mere sum of the component parts but can be an actually new entity not wholly predictable from the component parts and known only through actual experience with the specific product. Hydrogen and oxygen, it is true, can form simple mixtures, but when they make an actual chemical integration we get a new specific type of substance, water, behaving and dividing according to its own laws and properties in a way not wholly predictable from just what we know of hydrogen and oxygen as such. Analogy prompts us to see in plants and animals products of physics and chemistry and organization, although the peculiarity of the product makes us recognize certain specificities of life not contained in the theory of mere physics and chemistry. All the facts of experience prompt us to see in mentation a biological function, and we are no longer surprised to find this product of integration so different from the nature and functions of all the component parts. All the apparent discontinuities in the intrinsic harmony of facts, on the one hand, and the apparent impossibility of accounting for new features and peculiarities of the new units, are shown to be a general feature of nature and of facts: integration is not mere summation, but a creation of ever-new types and units, with superficial discontinuities and with their own new denominators of special peculiarities; hence there is no reason to think of an insurmountable and unique feature in the origin of life, nor even of mentally integrated life; no need of special mystical sparks of life, of a mysterious spirit, etc.; but—and this is the important point—also no need of denying the existence of all the evidence there may be of facts which we imply when we use the deeply felt concepts of mind and soul. In other words, we do not have to be mind-shy nor body-shy any longer.
The inevitable problem of having to study other persons as well as ourselves necessarily leads us on to efforts at solution of other philosophical problems, the problem of integrating materialism and idealism, mechanism and relative biological determinism and purpose, etc. Man has to live with the laws of physics and chemistry unbroken and in harmony with all that is implied in the laws of heredity and growth and function of a biological organism. Yet what might look like a limitation is really his strength and safe foundation and stability. On this ground, man's biological make-up has a legitimate sphere of growth and expansion shared by no other type of being. We pass into every new moment of time with a preparedness shown in adaptive and constructive activity as well as structure, most plastic and far-reaching in the greatest feat of man, that of imagination. Imagination is not a mere duplication of reality in consciousness and subjectivity; it is a substitute in a way, but actually an amplification, and often a real addition to what we might otherwise call the "crude world," integrated in the real activities of life, a new creation, an ever-new growth, seen in its most characteristic form in choice and in any new volition. Hence the liberating light which integration and the concepts of growth and time throw on the time-honored problem of absolute and relative determinism and on the relation of an ultra-strict "science" with common sense.
In logic, too, we are led to special assertions. We are forced to formulate "open definitions," i.e., we have to insist on the open formulation of tendencies rather than "closed definitions." We deal with rich potentialities, never completely predictable.
This background and the demands of work in guiding ourselves and others thus come to lead us also into practical ethics, with a new conception of the relation of actual and experimental determinism and of what "free will" we may want to speak of, with a new emphasis on the meaning of choice, of effort, and of new creation out of new possibilities presented by the ever-newly-created opportunities of ever-new time. We get a right to the type of voluntaristic conception of man which most of us live by—with a reasonable harmony between our science and our pragmatic needs and critical common sense.
The extent to which we can be true to the material foundations and yet true to a spiritual goal, ultimately measures our health and natural normality and the value of our morality. Nature shapes her aims according to her means. Would that every man might realize this simple lesson and maxim—there would be less call for a rank and wanton hankering for relapses into archaic but evidently not wholly outgrown tendencies to the assumption of "omnipotence of thought," revived again from time to time as "New Thought." Psychiatry restores to science and to the practical mind the right to reinclude rationally and constructively what a narrower view of science has, for a time at least, handed over unconditionally to uncritical fancy. But the only way to make unnecessary astrology and phrenology and playing with mysticism and with Oliver Lodge's fancies of the revelation of his son Raymond, is to recognize the true needs and yearnings of man and to show nature's real ways of granting appetites and satisfactions that are wholesome.
Hereby we have indeed a contribution to biologically sound idealism: a clearer understanding of how to blend fact and ambition, nature and ideal—an ability to think scientifically and practically and yet idealistically of matters of real life.
To come back to more concrete problems again, a wider grasp of what psychiatry may well furnish us helps toward a new ethical goal in our social conscience. The nineteenth century brought us the boon and the bane of industrialism. More and more of the pleasures and satisfactions of creation and production and of the natural rewards of the daily labor drifted away from the sight and control of the worker, who now rarely sees the completed result of his work as the farmer or the artisan used to do. Few workers have the experience of getting satisfaction from direct pride in the end result; as soon as the product is available, a set of traders carries it to the markets and a set of financiers determines, in fact may already have determined, the reward—just as the reward of the farmer is often settled for him by astounding speculations long before the crop is at hand. There is a field for a new conscience heeding the needs of fundamental satisfactions of man so well depicted by Carlton Parker, and psychiatric study furnishes much concrete material for this new conscience in industrial relations—with a better knowledge of the human needs of all the participants in the great game of economic life.
Psychiatry gives us also a new appreciation of the religious life and needs of our race. Man's religion shows in his capacity to feel and grasp his relations and responsibility toward the largest unit or force he can conceive, and his capacity for faith and hope in a deeper and more lasting interdependence of individual and race with the Ruler or rules of the Universe. Whatever form it may take expresses his capacity to feel himself in humility and faith, and yet with determination, a more or less responsible part of the greatest unit he can grasp. The form this takes is bound to vary individually. As physicians we learn to respect the religious views of our fellow beings, whatever they may be; because we are sure that we have the essentials in common; and with this emphasis on what we have in common, we can help in attaining the individually highest attainable truth without having to be destructive. We all recognize relations that go beyond individual existence, lasting and "more than biological" relations, and it is the realization of these conceptions intellectually and emotionally true to our individual and group nature that constitutes our various religions and faiths. Emphasizing what we have in common, we become tolerant of the idea that probably the points on which we differ are, after all, another's best way of expressing truths which our own nature may picture differently but would not want to miss in, or deny to, the other. One of the evidences of the great progress of psychiatry is that we have learned to be more eager to see what is sane and strong and constructively valuable even in the strange notions of our patients, and less eager to call them queer and foolish. A delusion may contain another person's attempt at stating truth. The goal of psychiatry and of sound common sense is truth free of distortion. Many a strange religious custom and fancy has been brought nearer our understanding and appreciation since we have learned to respect the essential truth and individual and group value of fancy and feeling even in the myths and in the religious conceptions of all races.
Among the most interesting formulations and potential contributions of psychiatry are those reaching out toward jurisprudence. Psychiatry deals pre-eminently with the variety and differences of human personalities. To correct or supplement a human system apparently enslaved by concern about precedent and baffling rules of evidence inherited from the days of cruel and arbitrary kings, the demand for justice has called for certain remedies. Psychiatry still plays a disgraceful role in the so-called expert testimony, largely a prostitution of medical authority in the service of legal methods. Yet, out of it all there has arisen the great usefulness of the psychiatrist in the juvenile and other courts. There it is shown that if psychiatry is to help, it should be taken for granted that the person indicted on a charge should thereby become subject to a complete and unreserved study of all the facts, subject to cross-examination, to be sure, but before all accessible to complete and unreserved study. This would mean a substantial participation of law in the promotion of knowledge of facts and constructive activity, and a conception of indeterminate sentence not merely in the service of leniency but in the service of the best protection of the public, and, if necessary, lasting detention of those who cannot be reformed, before they have had to do their worst. Whoever is clearly indicted for breaking the laws of social compatibility should not merely invite a spirit of revenge, but should, through the indictment, surrender automatically to legalized authority endowed with the right and duty of an unlimited investigation of the facts as they are.
Looking back then, you can see how the history of the human thought about what we call mind and psyche displayed some strange reactions of the practical man, the scientist, the philosopher, and theologian toward one of the most important and practical problems. It is difficult to realize what it means to arrive at ever-more-workable formulations and methods of approach. We do not have to be mind-shy or body-shy any longer. To-day we can attack the facts as we find them, without that disturbing obsession of having to translate them first into something artificial before we can really study them and work with them. Since we have reached a sane pluralism with a justifiable conviction of the fundamental consistency of it all, a satisfaction with what we modestly call formulation rather than definition and with an appreciation of relativity, we have at last an orderly and natural field and method from which nobody need shy.
The century that has passed since the inspiration of a few men of the Society of the New York Hospital to provide for the mentally sick has cleared the atmosphere a great deal. We can start the second century freer and unhampered in many ways. Much has been added, and more than ever do we appreciate the position of just such a hospital as that of Bloomingdale as a centre of healing and as a leader of public opinion and as a contributor to progress.
The Bloomingdale Hospital has a remarkable function. It is a more or less privileged forerunner in standards and policies. Without having to carry the burdens of the whole State with its sweeping and sometimes distant power and its forced economy, a semiprivate hospital like Bloomingdale aims to minister to a slightly select group, especially those who are in the difficult position of greater sensitiveness but moderate means in days of sickness. It serves the part of our community which more than any other sets the pace of the civilization about us—the intelligent aspiring workers who may not have reached the goal of absolute financial independence. It creates the standard of which we may dream that it might become the standard of the whole State.
When we review the roster of Superintendents—from John Neilson to Pliny Earle and from Charles Nichols, Tilden Brown, and Samuel Lyon down to the present head, our highly esteemed friend and coworker William L. Russell—and the names of the members of the staff, many of whom have reached the highest places in the profession, and last, but not least, the names of the Governors of The Society of the New York Hospital, we cannot help being impressed by the forceful representation of both the profession and the public, and we recognize the wide range of influence.
Instead of depending on frequently changing policies regulated from the outside under the influence of the greater and lesser lights and exigencies of State and municipal organization, the New York Hospital has its self-perpetuating body of Governors chosen from the most public-spirited and thoughtful representatives of our people. Bloomingdale thus has always had a remarkable Board of Governors, who, from contact with the General Hospital and with this special division, are in an unusual position to see the practical aspects of the great change that is now taking place. You see how the division of psychiatry has developed from practically a detention-house to an asylum, and finally to a hospital with all the medical equipment and laboratories of the General Hospital. And you begin to see psychiatry, with its methods of study and management of life problems as well as of specific brain diseases, infections, and gastrointestinal and endocrine conditions, become more and more helpful, even a necessity, in the wards and dispensary of the General Hospital on 16th Street. The layman cannot, perhaps, delve profitably into the details of such a highly and broadly specialized type of work. But he can readily take a share in the best appreciation of the general philosophy and policy of it all.
The shaping of the policy of a semiprivate hospital is not quite as simple as shaping that of a State Hospital with its well-defined districts and geographically marked zones of responsibility. Bloomingdale has its sphere of influence marked by qualitative selection rather than by a formal consideration. It does not pose as an invidious contrast to the State Hospital, and yet it is intended to solve in a somewhat freer and more privileged manner the problem of providing for the mentally sick of a more or less specific hospital constituency, the constituency of the New York Hospital; and since it reaches the most discriminating and thinking part of our population, it has the most wonderful opportunity to shape public opinion. Like all psychiatrical institutions, it has to live down the traditional notions of the half-informed public; it has to make conspicuous the change of spirit and the better light in which we see our field and responsibilities. This organization can show that it is not mere insanity but the working out of life problems that such a hospital as this is concerned with. The conditions for which it cares are many. Some of them are all that which tradition and law stamp as insanity. But see what a change. Seventy-five per cent of the patients are voluntary admissions; and more and more will be able to use the helps when they begin to feel the need, not merely when it becomes an enforced necessity.
By creating for this Hospital a liberal foundation, by completing its equipment so as to make possible a free exchange of patients and of workers from the Hospital in the city and this place in the country, much has been done and more will be done to set a living example of the very spirit of modern psychopathology and psychiatry. We know now that from 10 to 40 per cent of the patients of the gynecologist, the gastroenterologist, and the internist generally would be better treated if a study of the life problems were added to that of the special organs and functions. To meet this need it should be possible to have enough workers in this branch of the Hospital to take their share of the consulting and co-operation work in the wards and dispensary of the General Hospital, and perhaps even in the schools provided for the same type of people from which you draw your patients. The grouping of the patients can be such that the old prejudices need not reach far into the second century of the life of the Hospital. With a man of the vision and practical experience of Dr. Russell, there is no need for an outsider to conjure up a picture of special practical achievements as I have done of the more general principles to-day.
An institution is more than a human life. Many ambitions combine and become part of a group spirit permeating the organization and reaching their fulfilment in the succession of leaders. The life and growth and happy self-realization of an institution is not the bricks and mortar—it is a living and elastic entity—never too stable, never too finished, a growing and plastic plant—to use a metaphor that has slipped in perhaps without arousing all the implications the term plant might carry and does carry.
Some years ago my wife celebrated her birthday and told her colored cook jocosely: "Geneva, I am a hundred years old to-day." The cook's jaw dropped and then she suddenly remarked: "Lord! you don't look dat ole." That is the way I feel about Bloomingdale Hospital as we see it to-day pulsating with ever-fresh life and ever-fresh problems! How different from a simple human being, after all! The heart and wisdom of many a man and woman has gone into the perpetuation of what a few thoughtful men started in 1821 and the result is that it is ever renewing its youth.
Many a dream has been realized and many a dream has given way to another. Here and there the past may make itself felt too much. But the spirit and its growth show in recruiting ever-new lives to meet the present day and the days to come, and this all the more so if we can show the younger generation that every effort is likely to have its reasonable direct support. We all want a man like Dr. William L. Russell to have the fullest opportunity to bring to its best expression the rich and well-tried wisdom of over twenty-five years of devoted work in the field. This is no doubt a time of stress when many personal and general sacrifices may be needed to bring about the fruition and culmination of the labors of the present generation. Yet is it not a clear opportunity and duty, so that those who are growing up in the ranks to-day may really be encouraged to get a solid training, always animated by the conviction that one can be sure of the practical reward for toiling through the many years of preparation in a psychiatric career, whether it be as a physician or as a nurse or as an administrator?
I cannot help feeling as I stand here that I am in a way representing not only my own sentiments and convictions but those of our dear old friend Hoch. We all wish that he might be with us to express himself the warm feelings toward the Bloomingdale Hospital and its active representatives, from the managers to the humblest workers. Hoch in his modesty could probably not have been brought to state fully and frankly his own share in the achievements of this Hospital. But I know how much he would have liked to be here to express especially the warmth of appreciation we all entertain of what our friend William L. Russell means to us and has meant to us all through the nearly twenty-five years of our friendship and of working together. We delight in seeing him bring to further fruition the admirable work he did at Willard, and later for all the State hospitals; and that which we see him do at all times for sanity in the progress of practical psychiatry, and now especially in the guidance of this institution. We delight in seeing his master mind given more and more of a master's chance for the practical expression of his ideals and convictions concerning the duties and opportunities of such a hospital as Bloomingdale.
Our thanks and best wishes to those who invited us to stand here to-day at the cradle of a second century of Bloomingdale Hospital! It is a noteworthy gathering that joins here in good wishes to those who have shaped this ever-new Bloomingdale. With a tribute to our thoughtful and enthusiastic friend in internal medicine, Lewellys F. Barker, to our English coworker, Richard G. Rows, to the illustrious champion of French psychopathology, Pierre Janet, to our friend and leader in practical psychiatry, William L. Russell, to our friends and coworkers of the Bloomingdale staff, and especially also to the Board of Governors who shape the policy and control the finances, and exercise the leadership of public opinion, I herewith express my sincerest thanks and best wishes.
[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."
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. 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. 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. 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.
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. 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. 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 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.
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. Psychiatrists can count upon internists and general practitioners to aid them in educating the public regarding the nature and desirability of this campaign.