The Chairman: The year 1921 is rich in anniversaries for the New York Hospital. Next October we plan to celebrate the one hundred and fiftieth anniversary of the granting of our charter. To-day we are occupied with the Bloomingdale Centenary. A fortnight ago the twenty-fifth annual graduating exercises of our Training School for Nurses were held in this room. This year also marks the decennial of Dr. Russell's term of office as Medical Superintendent. When his devoted predecessor, Dr. Samuel B. Lyon, asked in 1911 to be relieved from active duty and became our first Medical Superintendent Emeritus, we were most fortunate in securing as his successor Dr. Russell. Coming to this institution after a broad psychiatric and administrative experience, he has taken up our special problems with deep insight and gratifying success. He has selected for his subject this afternoon "The Medical Development of Bloomingdale Hospital." No one can speak with greater authority on a theme of which it may be said quorum magna pars—fortunately not only fuit—but est and erit as well.
DR. RUSSELL
The object of this celebration is not merely to glorify the past and least of all is it to laud the present. What we hope from it is that it will establish a milestone, not only to mark the progress thus far made but to point the way to a path of greater usefulness. The advances in medical science and practice and in the specialty of psychiatry during the past hundred years fill one with wonder and hope. It is worth while to review them merely to obtain this help. The outlook for the century to come is, however, so far as can be anticipated, still brighter.
To review the past is, at a time like this, not unprofitable. It may prevent us, in our zeal for the new, from discarding what is valuable in the old, and from overvaluing some things which may have outlived their usefulness. We must be careful that we do not fall into errors similar to those from which the medical profession was rescued by the movement of which Bloomingdale Asylum was an offspring. It should be recalled that the establishment of the asylum was due to the initiative of the Governors of the New York Hospital, especially Mr. Eddy, rather than to the active interest and direction of physicians. The object of the establishment was, according to Mr. Eddy, to afford an opportunity of ascertaining how far insanity may be relieved by moral treatment alone, which, he says, "it is believed, will, in many instances, be more effective in controlling the maniacs than medical treatment." The moral management he referred to, though advocated by Pinel and a few others, some of whom were benevolent and intelligent laymen, had not been accepted by physicians as a distinct form of medical treatment. Few physicians of the period had accepted management of the mind as described and practised by Pinel as being a distinct medical procedure, as having the same value in overcoming mental disorders as the drastic medical remedies which they were accustomed to employ, or as having any exclusive healing power. This is clearly shown by the case records of the mental department of the New York Hospital which have been preserved since 1817, and of those of Bloomingdale Asylum for some years after its opening in 1821. It is plainly set forth in Dr. Rush's book on diseases of the mind, which was first published in 1810 and again in a fourth edition in 1830. Rush was physician to the Pennsylvania Hospital and his book was the principal, if not the only, one of the period by an American author. American physicians like their European brothers, had, as Pinel observes, "allowed themselves to be confined within the fairy circle of antiphlogisticism, and by that means to be deviated from the more important management of the mind." Rush believed that madness was a disease of the blood-vessels of the brain of the same nature as fever, of which it was a chronic form. "There is," he says, "not a single symptom that takes place in an ordinary fever, except a hot skin, that does not occur in an acute attack of madness." He found in his autopsy observations confirmation of this view and concludes that "madness is to phrenitis what pulmonary consumption is to pneumony, that is, a chronic state of an acute disease." The reason for believing that madness was a disease of the blood-vessels, which seemed to him most conclusive, was "from the remedies which most speedily and certainly cure it being exactly the same as those which cure fever or disease in the blood-vessels from other causes and in other parts of the body." The treatment he recommended and which was generally employed was copious blood-letting, blisters, purges, emetics, and other severe depleting measures. When Bloomingdale Asylum was established, therefore, the provision for moral treatment did not contemplate that this should be applied by the physician or that he should have full control of the resources by means of which it could be applied. The records do not indicate that either the physicians or the Governors realized that this might be necessary or advantageous. The present system of administration in which the chief physician is also the chief executive officer of the institution was a result of an evolution which took many years to reach its full consummation.
Pinel, many years before Bloomingdale Asylum was opened, had shown by the most careful observation and practice that the management and discipline of the hospital was a most powerful agent in the treatment of the patients. The manner in which he was led to this conclusion is a remarkable example of the scientific method. When he became physician to the Bicetre he found that the methods of classification and treatment recommended in the books seemed to be inadequate, and, desiring further information, he says: "I resolved to examine myself the facts which were presented to my attention; and, forgetting the empty honor of my titular distinction as a physician, I viewed the scene that opened to me with the eye of common sense and unprejudiced observation.... From systems of nosology, I had little assistance to expect; since the arbitrary distributions of Sauvages and Cullen were better calculated to impress the conviction of their insufficiency than to simplify my labor. I, therefore, resolved to adopt that method of investigation which has invariably succeeded in all the departments of natural history, viz., to notice successively every fact, without any other object than that of collecting materials for future use; and to endeavor, as far as possible, to divest myself of the influence, both of my own prepossessions and the authority of others. With this view, I first of all took a general statement of the symptoms of my patients. To ascertain their characteristic peculiarities, the above survey was followed by cautious and repeated examinations into the condition of individuals. All our new cases were entered at great length upon the journals of the house." Having thus studied carefully the course of the disease in a number of patients who were subjected only to the guidance and control made possible by the management of the hospital under the direction of a remarkably highly qualified Governor, it came to him with the force of a new discovery that this man who was not a physician was doing more for the patients than he was, and that insanity was curable in many instances by mildness of treatment and attention to the state of mind exclusively. "I saw with wonder," he says, "the resources of nature when left to herself, or skilfully assisted in her efforts. My faith in pharmaceutic preparations was gradually lessened, and my scepticism went at length so far as to induce me never to have recourse to them, until moral remedies had completely failed." So convinced did he become of the significance and importance of the management and discipline of the hospital in the treatment of the patients, that, when a few years later, he wrote his "Treatise on Insanity," he states that one of the objects of his writing it was, "to furnish precise rules for the internal police and management of charitable establishments and asylums; to urge the necessity of providing for the insulation of the different classes of patients at houses intended for their confinement; and to place first, in point of consequence, the duties of a humane and enlightened superintendency and the maintenance of order in the services of the Hospitals."
Pinel's views had apparently not been fully understood or adopted by the physicians of America at the time Bloomingdale Asylum was planned and established. Dr. Rush did not mention him in his book, and Mr. Eddy, in his communication to the Governors of the New York Hospital, referred only to the writings of Drs. Creighton, Arnold, and Rush and the Account of the York Retreat by Samuel Tuke.
When Bloomingdale Asylum was opened, the form of organization introduced was that under which the department at the New York Hospital had been conducted. Mr. Laban Gardner was made Superintendent or Warden with two men and three women keepers to aid him in the control and management of the seventy-five patients. There was an Attending Physician who visited once a week and a Resident Physician, neither of whom received salaries. There is nothing in the records to indicate that in the beginning, the Governors of the Hospital looked upon the moral treatment of the patients, which was the object for which the institution was established, as the task of the Physicians. The aim was to furnish employment, diversion, discipline, and social enjoyment, without much attempt at precision or close medical direction and control. For a time the results were considered to be satisfactory. In 1824, however, a joint Committee of the Board reported that they were impressed by the necessity of improving the moral treatment, and recommended that two discreet persons be appointed to take charge of such of the patients as might from time to time be in a condition to be amused or employed on the farm or in walking exercises in the open or in classes to be designated by the Resident Physician "with," however, "the approbation of the Superintendent," who you will recall was not a physician. These patients were, the report recommends, to be particularly under the charge of the Resident Physician when thus employed or amused "out of the Asylum." At this time, the Attending and Resident Physicians were placed on a small salary, and the Resident Physician was instructed to "devote a greater portion of his time and attention to the moral part of the establishment and to communicate to the Committee such improvements as his experience shall suggest to be useful and necessary in carrying into more complete effect the system of moral treatment and to report from time to time to the Committee the effect of the measure adopted." This seems to have been the beginning of a realization that the moral management of the patients was inseparable from medical treatment and must necessarily be the task of the physician. Seven years after this, in 1831, the Committee found it advisable to spread upon the minutes an "interpretation and regulations," relating to the Superintendent and Matron of the Asylum and to the Asylum physicians, to the effect that the Committee understood that the regulations "placed the moral treatment on the physician alone, under the direction of the Asylum Committee, and that the responsibility remains with him alone, that this treatment commenced with the reception of the patient, the ward where he shall be placed, his exercises, amusement, admission of friends, the time of discharge from the house.... And that all orders to nurses and keepers which the physicians may think necessary to carry these orders into effect shall be communicated through the Superintendent" (or Warden). In 1832, the Resident Physician, Dr. James Macdonald, who had just returned from Europe after having spent a year in visiting the institutions for mental disorders there, made a report in which he rather significantly referred to the impracticability of making a sharp distinction between the medical and moral treatment of the patients, it being difficult to say where the one ended and the other began, or to put one into successful operation without bringing in the other. At this time the position of Attending Physician was abolished and the Resident Physician was made the Chief Medical Officer of the Asylum. It was not until 1837 that an amendment to the by-laws regulating the powers of the physician and the Warden was adopted which gave to the physician the power of appointing and discharging at pleasure all the attendants on the patients, while to the Warden was reserved the power of appointing and dismissing all other employees. Fourteen years had thus elapsed since the opening of the Asylum before the physician was given control of even the nursing service. The first Annual Report of the Resident Physician of the Asylum to be published appeared in 1842. In this, Dr. William Wilson makes a general statement in regard to the beneficial effects of the moral as well as the medical treatment pursued in the institution, and refers particularly to occupations, exercise in the open air, amusement, religious services, and he asks that a workshop be erected for the men. It is evident that by this time the authority of the physician in the management of the institution had been extended and it is perhaps significant that in his report of the following year Dr. Wilson refers to a plan for distribution of food which had been evolved in co-operation with the Warden. Under the direction of Dr. Pliny Earle, who was appointed physician to the Asylum in 1844, treatment directed to the mind was further elaborated and systematized, and the place of the physician in the management of the hospital was more firmly established.