This brief survey indicates how, in the development of the work of the institution, it required years of practical experience to show to the Governors that, in order to secure for the patients the treatment which the Asylum had been established to furnish, it was necessary to extend the powers and duties of the physician so that he could control and direct the internal management and discipline, and all the resources for social as well as individual treatment. This extension was continued until finally the present form of organization was adopted in which the chief physician is also the chief executive officer of the institution. This was, however, not fully accomplished until 1877. It is now universally recognized that the physician must be the supreme head of the organization, and all American institutions and most, if not all, of those in other countries are now similarly organized.
In the early development of Bloomingdale Asylum, this extension of the influence and authority of the physician is the outstanding medical fact. It did away with division of responsibility and removed from discussion the question of moral as distinct from medical treatment. Thereafter a harmonious and effective application of all the resources of the institution to the problems of the patients became more easily and certainly possible. Since then, the resources for treatment directed to the mind have been developed as steadily and fully as those required for the treatment of physical conditions. The use of the organized agencies which were regarded by the founders as the main reliance in moral treatment, namely occupations, physical exercises and games, diversion, social contacts, and enjoyment, and management of behavior has been greatly extended, and specialized departments have been created for their application with system and growing precision. Great advances have also been made in the methods of examining the minds of the patients and of determining the mental factors in their disorders and the means of restoring their capacity for adjustment to healthy thinking and acting. Psychiatry has been furnished with a body of well-arranged facts, and with a technic which is not inferior in system and precision to that of many other branches of medicine. In the study and management of the minds of the patients the physician is thus enabled to apply himself to the task as he does to any other medical problem.
The advances in general medical science and practice have also necessitated great elaboration of the resources for the study and treatment of the physical condition of the patients. Instruments of precision, laboratories, x-ray departments, dental and surgical operating rooms, massage and hydrotherapy departments, facilities for eye, throat, nose, and ear examinations and treatment, and all the other means of determining disease processes and applying proper treatment have been supplied and the methods and standards of modern clinical medicine and surgery are utilized. It can now be clearly seen that it is necessary to direct attention to the whole personality of the patient, including his original physical and mental constitution, the physical as well as the mental factors which may be operating to produce his disorder, and the environmental conditions to which he has been and may again be exposed. In the treatment of mental disorders it is necessary to beware of what Pinel found to be the fault of the physicians and medical authors of his time, who he says were more concerned with the recommendation of a favorite remedy than with the natural history of the disease, "as if," he says, "the treatment of every disease without accurate knowledge of its symptoms involved in it neither danger nor uncertainty," and he quotes the following maxim of Dr. Gault: "We cannot cure diseases by the resources of art, if not previously acquainted with their terminations, when left to the unassisted efforts of nature." Exclusive attention to the physical condition and factors, or to the mental condition and factors, or concentration on one theory or one form of treatment to the exclusion of all others is sure to lead to neglect of that careful general inquiry into the whole personality of the patient, into the conditions out of which his disorder arose, and into all the manageable factors in the situation which is so essential to intelligent and effective treatment. Notwithstanding the great benefit which has been derived from physical measures in the study and treatment of mental disorders, and the well-founded hopes of greater advances in this direction, the main task still continues to be what Pinel calls the management of the mind. Experience and increasing knowledge show that this is a task which can only be successfully performed by the physician and by means of organized resources which are under medical direction and control. The hospital for mental disorders furnishes the means of providing social as well as individual treatment. It is a medical mechanism and for its proper management and use it is required of physicians that they accept the burden of much executive work and give their attention to many subjects and activities that may interfere seriously with what they have been taught to regard as more strictly professional interests. Like Pinel, one must be willing to forget the empty honor of one's titular distinction as a physician, and do whatever may be necessary to make the institution a truly medical agency for the healing of the sick. Considerable progress has been made in developing executive assistants to relieve the physicians of much of the administrative work which requires little or no medical supervision and direction. Special provision for the training of such executives has, however, received insufficient attention. This question might, with great advantage, be taken up by the hospitals and colleges. Nothing would add more to the quality of the service which the hospitals render than to supplement the work of the physicians by that of well educated and highly trained executive assistants who would themselves find an extremely interesting and productive field for their efforts.
A period has now been reached in this field of work when what amounts to a movement not inferior in significance and importance to that of a hundred years ago, seems to be in active operation. The character and scope of this movement and the lines of its progress have, to some extent, been indicated in the illuminating formulations which have been presented here to-day. The medical study and treatment of the mind is no longer so exclusively confined within the walls of institutions nor to the type or degree of disorder which necessitates compulsory seclusion. Psychiatry is extending out from the institutions into the communities by means of out-patient clinics and social workers, through newly created organized agencies, through informed individuals, physicians, nurses, and lay workers, and through the general spread of psychiatric knowledge. This process is being expedited by the efforts of organized bodies such as the National and State Committees and Societies for Mental Hygiene, and the public is rapidly learning what can properly be expected of institutions, officials, physicians, nurses, and other responsible individuals in whom special knowledge and ability are supposed to be found. As in the prevention of tuberculosis, so, in the prevention of mental disorders, the informed public is likely to start a campaign which the medical profession may have to make haste to follow in order to maintain its needed leadership. Although much is yet required to improve the facilities necessary in carrying on the present work, it seems to us that at such a time a further extension of the activities of an institution such as Bloomingdale Hospital may be necessary to enable it to fulfil its possibilities for greater usefulness. To extend the work our experience indicates that a department in the city at the General Hospital would be of great advantage. During the past few years the oversight of discharged patients has grown to such an extent that it seems as though some organized method of carrying it on may soon become necessary. This and out-patient work generally could be best attended to in a city department. Much emergency work and preliminary observation and the treatment of certain types of cases now frequently subjected to unfortunate delays, neglect, and unskilful treatment would also be thus provided for. It can be seen too that developments in construction and organization which would furnish organized treatment for types of disorders which are not so incapacitating as the pronounced psychoses might be of advantage in the treatment of both adults and children. The property on which the Hospital is located is large enough to permit of further extensions and developments which could be as closely connected with, or as widely separated and distinguished from, the present provision as circumstances required. In this way much needed provision for the treatment of persons suffering from the psychoneuroses and minor psychoses could be furnished. Better provision for a further period of readjustment after a patient is ready to leave the Hospital but not yet ready to face the risk of ordinary conditions in the community is a felt want. A group of supervised homes or an occupational colony might best serve this purpose. The more extensive use of the Hospital as a teaching centre is also a subject for consideration. A School for Nurses is now conducted, and much instruction is given in the occupational departments. More, however, could be done, especially in medical teaching, which could be best carried on in a department in the city and would tend to advance the standard of medical service throughout the Hospital.
The lines of further development are, perhaps, not yet perfectly clear in all directions. It seems certain, however, that they will lead toward a broader field of usefulness, in which the hospital will be regarded as a responsible agency for dealing with psychiatric problems in the community which it serves and will take part with other agencies in extending psychiatric knowledge and in applying it to prevention, and to the management of mental disorders as an individual and social problem beyond the walls of the institution. We hope that this meeting will prove a real starting point for this development. We are greatly indebted to those who have taken part in it both as speakers and as audience. We are especially indebted to those who came across the sea to be with us. It is peculiarly fitting that representatives of France and of England should have been here, for to Pinel, the Frenchman, and to Tuke, the Englishman, are due more than to any others whose names we know the foundations of the modern institutional treatment of mental disorders.
The Chairman: This, ladies and gentlemen, concludes our exercises. As the representative of the Governors, I find it quite impracticable, in supplementing what Dr. Russell has just said, to express adequately our admiration of and gratitude to these eminent scientists and apostles of light for their presence here and for their inspiring addresses. These, if I may be permitted to appraise them, seem to make a notable addition to medical literature, and, with the permission of their authors, we purpose, for our own gratification and for the benefit of the profession, to have all of the addresses preserved in a volume recording this centenary celebration. In due course a copy of this volume will be sent to each of our guests. The celebration itself, I think you will all agree with me, has been a moving one, with an underlying note of philanthropic endeavor as high as the stars. You heard its refrain in the pageant on the lawn this afternoon. As I have listened to-day to these words of profound wisdom, uttered in so noble a spirit of human ministry, my mind has gone back to the sentence from Cicero's plea for Ligarius,[[18]] which formed the text for Dr. Samuel Bard's eloquent appeal in 1769, mentioned this morning, for the establishment of the New York Hospital, and which may be freely rendered, "In no act performed by man does he approach so closely to the Gods as when he is restoring the sick to the blessings of health." And surely when that restoration to health consists in "razing out the written trouble of the brain" and reviving in the patient the conscious exercise of divine reason, it is difficult to imagine a more Godlike act.
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