Philipp Gutmann
email: philipp.gutmann@medizin.uni-halle.de

On the way to a scientia sexualis: 'On the relation of the sexual system to the psyche in general and to cretinism in particular' (1826) by Joseph Häussler

Keywords: anti-onanism-discourse, cretinism, Friedreich, German psychiatry, Heinroth, history, sexual science, 19th century

At the beginning of the nineteenth century, several works were published by physicians trying to explain, in an increasingly systematic manner, the emergence of psychic derangements with sexual disorders. A contribution to this development was provided by Joseph Häussler with his monograph 'On the relation of the sexual system to the psyche in general and to cretinism in particular' (1826). Häussler was interested in whether the sexual system was the cause of psychic disturbance. He accused some sexual behaviours and exercises (e.g., onanism and unsatisfied sexual instinct) of being causes, but, nonetheless, accepted that morphological deviations of the sexual organs could also evoke mental diseases. Furthermore Häussler attempted to determine if stimulation of the sexual system could cure psychic illnesses. Finally, he dealt with sexual conditions in the mentally ill. A complete chapter was devoted to cretins and their sexuality.

Introduction

The first publications written by physicians dealing with the connection between sexual disorders and mental diseases appeared at the beginning of On the way to a scientia sexualis: 'On the relation of the sexual system to the psyche in general and to cretinism in particular' (1826) by Joseph Häussler the nineteenth century. The search for prerequisites and causes of psychic illnesses -a search characterized at the time mainly by the dispute between the so-called 'somatics' and the 'psychics' -included a debate which had started at the beginning of the eighteenth century. This debate was called an 'anti-onanism discourse' [START_REF] Lütkehaus | O Wollust, o Hölle[END_REF][START_REF] Van Ussel | Sexualunterdrückung, 2nd edn (Gießen: focus)[END_REF][START_REF] Wettley | Von der 'Psychopathia sexualis' zur Sexualwissenschaft[END_REF]). In the publications from the early nineteenth century lie the roots of a sexual science which continued to develop and, by the time Richard von Krafft-Ebing had written Psychopathia Sexualis (1886), the roots had been firmly established. Sexual science developed as a sexual pathology, and the point of view of the authors of the nineteenth century was almost exclusively nosological. The early writers lacked solid entities of disease -for example, the 'contrary sexual sensation' (today's homosexuality) as it was known to Krafft-Ebing -and their publications lacked the heavily systematizing structure underlying not only Krafft-Ebing's book but also Heinrich Kaan's with the same title (1844).

The dissertation text De mentis aberrationibus ex partium sexualium conditione abnormi oriundis (About confusions of the mind due to abnormal conditions of the sexual organs) by Hermann Joseph Löwenstein was published in 1823 (for translation, see [START_REF] Gutmann | About confusions of the mind due to abnormal conditions of the sexual organs' by Hermann Joseph Löwenstein (Classic Text No. 65)[END_REF], and in 1826 a work entitled Ueber die Beziehungen des Sexualsystemes zur Psyche überhaupt und zum Cretinismus ins Besondere was published in Würzburg. The author was Joseph Häussler. These two works adopted the somatic position in the dispute between 'somatics' and 'psychics' and continued the anti-onanism discourse which was already raging. (This will not be dealt with here in detail, but see [START_REF] Braun | Die Krankheit Onania. Körperangst und die Anfänge moderner Sexualität im 18. Jahrhundert[END_REF][START_REF] Gutmann | Zur Reifizierung des Sexuellen im 19. Jahrhundert. Der Beginn einer Scientia sexualis[END_REF][START_REF] Gutmann | Die Dissertationsschrift 'De mentis aberrationibus ex partium sexualium conditione abnormi oriundis[END_REF] The dispute between the 'somatics' and the 'psychics'

The controversy began in the year 1818 when the standpoint of the psychics was explained by Johann Christian Heinroth's Lehrbuch der Störungen des Seelenlebens oder der Seelenstörungen und ihrer Behandlung. Vom rationalen Standpunkt aus entworfen (Textbook of the disturbances of the psychic condition or soul disorders and their treatment considered from the rational point of view). Christian Friedrich Nasse (1778-1851) provided a somatic reply in the Zeitschrift für psychische Aerzte (1818a, 1818b). In spite of the increasing tension of the controversy, both views were based on the same premise -that the soul has an existence independent of the body -a theory which was also often substantiated by somatics with the divine origin of the soul. A primary illness of the soul was inconceivable to both sides in the debate (Roelcke, 1999: 49 ff).

For Heinroth (1773Heinroth ( -1843)), the knowledge of mental disease could not be derived from clinical-empirical indications, but only by rational reflection. For him, this rational point of view was religiously inspired: Heinroth's anthropology is theological. Man was endowed with reason and moral conscience by nature (i.e., in the end, by God) and therefore has the possibility of distinguishing morally different alternatives, i.e., freedom. Psychic disturbances are a consequence of a 'voluntary abandonment of freedom' (Roelcke, 1999: 55). Heinroth regarded it as a sin, however, to take a decision against freedom, and thus sin lies at the origin of mental disturbances. All forms of psychic illnesses arise, according to Heinroth, from this voluntary abandonment of freedom. He sketched a similar anthropology for the field of forensic psychiatry, in which he rejected the exculpation of mentally ill felons because basically crime, too, is the consequence of a culpable action.

In addition, it should be mentioned that for Heinroth sinful behaviour alone was not sufficient for the development of a mental disturbance; further prerequisites had to be added, for instance, 'intense agitation, very strong temptations' or a 'responsive body' (Roelcke, 1999: 56).

A totally different position was held by the somatic Nasse, a disciple of Johann Christian Reil and his immediate successor as Professor of Therapy in Halle. For Nasse (1818aNasse ( , 1818b)), corporeal diseases are 'necessary' and 'preparatory causes' for mental derangements, whereas psychic factors perform the function of a trigger. The soul itself does not fall ill. Even in the state of insanity it is undamaged, but it is restricted in its expressions by the physical illness. Mental diseases are always dependent on a corporeal ailment. Nasse demanded systematic examinations, especially on the effect of remedies and diseased conditions of the body on psychic disturbances. Systematic dissections also seemed sensible to him. In contrast to Heinroth, it was Nasse's aim to establish psychotherapy as a medicinal discipline.

Yet it has to be stressed that a religiously inspired anthropology is common to both branches. Nasse, too, had to harmonize the appearance of empirical psychopathology with his premise of the inviolability of the soul. Nasse and the somatics concentrated on the interaction between body and soul, whereas for Heinroth and the other psychics, the inner dynamic of the psychic entities was significant.

Häussler and his 1826 publication

Little is known about Joseph Häussler. In his publication, written as an inaugural paper and published in Würzburg in 1826, he called himself 'doctor of the entire medical science, and assistant physician at the outpatient clinic of Würzburg'. In it, he thanked his 'highly honoured teacher' Professor J. B. Friedreich several times; Friedreich was an explicit somatic, under whose aegis Häussler apparently wrote his paper.

Right from the start, Häussler clearly adopts the somatic position in the debate with the psychics, writing:

Fortunately, the old ruins of a decayed structure of psychiatrics have entirely collapsed now, and a brighter light has chased away creeds and prejudices which held many a head enmeshed, and portrayed the psyche out of an exaggeratedly pietistic delusion as a Noli me tangere, as it were, to talk of which already is a mortal sin. 2 (Preface, p. III)

In the tradition of vitalism, Häussler remarks that the same power, i.e., the 'organic vigour', is the basis of both body and soul. With the help of the new point of view, especially among forensic psychiatrics, many innocent people could be saved from execution. Häussler's preface concludes with a note of thanks to his mentor, Professor Friedreich.

After some remarks about cretinism, Häussler attempts to explain the relation of the sexual organs to the nervous system, which he designated 'consensual'. Häussler deals with the subject in three ways:

(A) Is the sexual system the cause of psychic disease? (B) How can stimulations of the sexual system cure diseases? (C) What is the condition of the sexual system in the mentally ill?

Concerning the first question, Häussler states apodictically that the fact that 'deviations from the normality of the sexual organs and their functions can produce mental diseases is a (long) proven fact' (p. 3).

He deals with 'sexual abuse and the satisfaction of the sexual instinct in an illegal way'. The sexual abuse debilitates 'in a high degree' the entire organization of the organism. The consequences are, for example, the pangs of conscience and the repentance of 'voluptuaries and onanists' which can lead to melancholy. The mind can also become stirred up which then manifests as mind frenzy or confusion. At an advanced age, the organism is endangered by the additional use of 'spiritual beverages', by venereal contagion or the use of mercury. As a consequence, insanity and hallucinations appear more often. This insanity is mostly of a religious kind, and visions with phonemes can frequently be found:

It is known, particularly by back desiccation, how closely the sexual organs are connected to the spinal marrow, and that a treatment of the spinal cord which extends up to the cervix affects the inner auditory tools in a superior way. (p. 4f) Häussler makes special mention of the 'psychic kinship between lustfulness and homicidal mania'.

He did not believe it necessary to define the 'satisfaction of the sexual instinct in an illegal way' in detail, and apparently supposed that his readers had adequate knowledge about masturbation because much was known about it. There were numerous examples of cases where onanism had confused the mind -the madhouses were full of such individuals, and it was the cause of many suicides.

Consistently following the homoeostatic model of the humoral theory, Häussler also considers the non-satisfaction of the sexual instinct to be precarious. Here 'insanity with increased sexual instinct, nymphomania, satyriasis, melancholy of the religious kind, etc.' (p. 6) usually develops. Thus, 'women of harems' or 'many a nun' are often overcome by melancholy and insanity as a result of the impossibility of gratifying their desires.

Concerning the 'diseases and disfigurements of the sexual organs', the resulting mental illnesses could, according to Häussler, be divided into three types. Firstly, they are marked by an 'obsession' which is directly connected with the sexual organs. For instance, in one case, a woman who had the fixed idea that she was pregnant was found to have a degenerated ovary. Secondly, mental diseases appear in the form of a 'religious rapture'. These are often associated with an 'infatuated insanity'. Thus, religious zeal in monasteries is often mixed with enormous sensuousness: 'The legends of the zealots, the files of the inquisition of the witches and obsessed yield many such facts' (p. 10). Thirdly, diseases and disfigurements of the sexual organs produce an urge to commit suicide or to murder someone. Häussler gives different examples of this, too: in female suicides, for instance, their ovaries have been found 'bursting with blood and distended' (p. 12).

Häussler, like other authors of his time, attached great importance to puberty. The alterations which take place in puberty in both sexes are: too great to be limited to the sphere of the sexual, they interfere in the whole somatic as well as the psychic life, and the diseases of formation of the sex which appear truly proteus-like in many ways are similarly related to the psychic as well as to the somatic sphere of the body. (p. 14) In young men in particular the production of the semen, with especially high levels of animal spirits (Gutmann, 2002: 65), interferes with their lives. In this phase of their development, 'the eternally pointless mobile play of ideas, i.e. folly' (p. 15), often occurs. Sometimes, an irritation of the mind verging on melancholy appears, but also a 'strife in the capability of desire, which shows that it is pathologically stirred time and again by the strangest urges' (p. 15).

Additionally, the urge to commit arson frequently occurs in young men and has to be seen as a developmental disease; however, this phenomenon is more common in females.

In young women, a melancholy tinged with religion or infatuation repeatedly occurs in the years of puberty. Häussler tries to substantiate the inclination for arson with several casuistic examples. Again and again the connection between changes in menstruation and particular psychic disturbances became obvious. In summary, Häussler arrives at the conclusion that the tendency towards arson can, with good reason, be considered to be a developmental disease. Here, Häussler offers a pathophysiological hypothesis: he sees the inclination for arson as a consequence of a 'desire for light' which: now has to be searched for, probably in the efflux of arterious blood at one and the accumulation of venous blood at another spot, especially in the region near the ophthalmic nerve. For, in the course of puberty, just when the blood is directed to the sexual organs, the longing for fire manifests itself, i.e., the longing of the visual organs lacking in irritability for a stimulus of light. (p. 19) However, this pathological urge can occur in other mental diseases as well.

In the course of female development, at times a 'mysterious or religious' melancholy appears. An example is Joan of Arc, who was turned into the wonderful girl of Orleans by a mysterious rapture in her early years of development. When she was burned as a 19-year-old, she had never had her monthly 'cleansing'. Yet from time to time, an elevation of the mind can also be found in the years of development, those affected displaying an unusual acumen and wit, some even poetic fire and rhetoric eloquence.

Furthermore, 'disturbed menstruation' can cause all sorts of mental illness, but melancholy is the commonest. Here, too, Häussler presents a pathophysiological explanation. The disturbance of the soul caused by suppressed menstruation can develop in two ways. The bloodstream can, as a result of this suppression, change its direction and cause a 'congestion of blood in the head'; thus the brain is chiefly threatened by pressure, and 'imbecility, a slip of the memory and the like' results. Alternatively, if the congestion of blood in the head is not very great, the brain becomes excited, and 'insanity, folly and frenzy', etc., arise. Sometimes, however, the portal system can be disturbed, whereby melancholy usually develops. This kind of melancholy bears a resemblance to that caused by suppressed haemorrhoids. In addition, Häussler notes that menstruation combined with pain can evoke states of insanity.

The female breasts are related to the psyche, too. Corresponding diseases are also liable to cause disturbances of the soul. Pregnancy also jeopardizes the sanity of women. The bodily alterations combined with pregnancy are capable of deranging the normal performance of the mind and of causing a mental illness. The psychic disturbance can become apparent as an obsession or general insanity, and often as melancholy or disturbance of the 'capability of desire'. At times, pregnant women assault their husbands or are inclined to steal, behaviour which disappears after they have given birth.

In addition, the freedom of will is endangered by giving birth. Through spasms and nervous fits of all kinds, mental diseases can arise. The physical ailments experienced during birth -and also shame because of an extramarital affair and the dread of discovery -can produce the strongest disruptions. Häussler adheres consistently to the contemporary model of a medicine that regarded all conditions troubling harmony, for example, epileptic fits, as a menace to the health and sanity of a person. Thus, he depicts the twitches and convulsions of a woman giving birth as the cause of many mental derangements. Forensically, there are numerous examples of women, confused by the delivery, killing their children, and only through 'forensic pharmaceutics' could many of these 'innocent victims' be saved from execution. Häussler vehemently defends women who commit infanticide after delivery and expresses his annoyance at the numerous forensic physicians who probably have only a slight knowledge of psychology and therefore sometimes assess guilt wrongly.

With respect to the changes occurring at childbirth, several can be distinguished with regard to their cause and psychic character. For example, when it has been preceded by an exhausting condition like strong pain during the delivery or convulsions, then the psychic derangement is characterized by 'confusion of ideas, incoherent loquaciousness, blithe insanity, superciliousness and shamelessness ' (p. 33). As a result of disturbances in the flow of lochia, tranquil brooding, melancholy or frenzy appear because of the congestion of blood in the head. Another possible derangement in the puerpera is the 'blood drift': the entire volume of humours of the puerpera is 'fertilized' with a liquid analogous to milk, which shows a tendency towards the breasts. If this normal tendency towards the breasts is disturbed by any cause, the efflux of milk-like substances into several other parts of the body results. These effluxes appear mainly in the cerebellum. The consequences are shamelessness, obscure words and actions alternating with religious insanity. After all, 'gastritic impurity' was adduced by several authors as the cause of mental diseases in puerpera, where frenzy and an inclination for anger often occurred.

Then Häussler turned to his second basic question: can psychic diseases be relieved or even cured by alterations in the sexual system? It was generally known that diseases like epilepsy disappeared at the beginning of puberty. Several authors recommended coitus as a treatment of mental illnesses, and women especially could benefit from it. However, women were 'satisfied with greater difficulty' because they could become pregnant. For men, the situation was different. Häussler quotes the 'ingenious' Reil, with approval:

The profane, foolish platonic who surmises a spark of a divine creature in the virtues of the female sex, and has become a fool from it, shall be given a brothel nymph as companion: I do not doubt, she will convert him from his delusion, when he himself is capable of it, and soon lure him from the summit of his ideal into the puddle of impure tendencies. (p. 38) Finally, Häussler turns to the question of the sexual life of the mentally ill themselves, and remarks that it is very much more important: 'Where there is purely mental vegetating, a mental void is present, and the beastly emotions and urges, hunger and sexual instinct are all the more vivid' (p. 38). When the sexual instinct and its satisfaction 'admit a normal and noble meaning', its origin can lie solely in love. In the mentally ill, one cannot speak of love as in normal life. The 'blind propensity' would not stick to the limits love prescribed; it would become licentious and be more like the instinct of animals. Most patients try to satisfy their desires in an unnatural way (i.e., by onanism, etc.) and, as a result of continuous stimulation, the sexual organs are in a more developed condition than usual.

In a separate chapter, Häussler deals with the sexual conditions of cretins. He describes in detail the external features of, for example, the penis, scrotum and testicles. He was able to write less about the female sexual organs because he had not had the opportunity to examine a sufficient number of women during his studies in Iphofen near Würzburg. In line with his hypothesis that the less the mental abilities were developed, the more the sexual instinct would strive for satisfaction, he regarded cretins as often particularly lustful, irrespective of their reproductiveness.

Häussler's work ends with some pictures of the sexual organs of cretins, seen in his examinations in Iphofen.

Concluding remarks

To today's reader, much of Häussler's work may seem odd, and the causal connections he postulated may be regarded as unsubstantiated. Yet Häussler's paper is a serious attempt to provide a contribution to the exploration of the aetiology of psychic derangements. He made a considerable effort to include a broad range of authors of the time. Noteworthy is the fact that he dedicated a complete, though short, chapter to the subject of how mental disturbances could be cured by experiences or conditions in the sexual sphere. This idea was not a given, because sexual science was established as sexual pathology. Eventually, Häussler's work came to be considered a small contribution to a sexual science which was to be established 100 years later and was systematically set out by Krafft-Ebing in Psychopathia sexualis (1886).

  Martin-Luther-University Halle-Wittenberg History of Psychiatry, 17(1): 045-053 Copyright © 2006 SAGE Publications (London, Thousand Oaks, CA and New Delhi) www.sagepublications.com [200603] DOI: 10.1177/0957154X06059734

Acknowledgement

I thank Leonie Gutmann (Detmold, Germany) for her assistance with translation.

Notes

This work is a revised version of a paper first published in Schriftenreihe der Deutschen

Gesellschaft für Geschichte der Nervenheilkunde (Gutmann, 2003). 2. All translations are mine.


Andrew Scull's latest book is a fascinating account of medical scandal and psychiatric practice in the first half of the twentieth century. It is like a jigsaw: each piece, superbly crafted and researched, produces a totally interlocking and absorbing narrative. The completed picture is a damning critique of the application of medico-biological theories of mental illness in twentieth-century psychiatry. It is, furthermore, a thriller, a detective story with a small number of whistleblower heroes and rather more zealous villains. Not only is the reader presented with the sensational details of what the application of science to psychiatry meant for patients' lives and bodies, Scull also provides a rigorous exposure of the complicity and connivance of prominent figures in the medical establishment to avert a public scandal. In all these respects his book informs the reader of a significant and shameful period in the recent history of psychiatric practice.

The context for Scull's discussion is the application of laboratory-based science to the treatment of mental disorder -an innovation which, its proponents believed, would free psychiatry from its late nineteenth-century pessimism and therapeutic impotence and bring it into the increasingly confident medical mainstream. One of the storm-troopers of this revolution was Henry Cotton who, between 1907 and 1930, was the head of Trenton State Hospital in New Jersey. It is Cotton's career -and the impact of his belief that hidden bodily infections were the cause of psychiatric disordersthat Scull explores in such meticulous and fascinating detail. It was a belief that promised much to anxious relatives, tax-paying citizens and those concerned with social problems. But its cost was also high, as Cotton and his assistants surgically removed 'the infected teeth and tonsils of dozens of his patients, not to mention their stomachs, gallbladders, colons, testicles and ovaries.' A tragic tale, indeed.

Cotton's fame and methods extended beyond the USA. He was fêted by the Medico-Psychological Association in the UK (which had received its

Book Review

History of Psychiatry, 17(4): 499-500 Copyright © 2006 SAGE Publications (London, Thousand Oaks, CA and New Delhi) www.sagepublications.com [200612]

  Andrew Scull. Madhouse: A Tragic Tale of Megalomania and Modern Medicine. New Haven and London: Yale University Press, 2005. Pp. xiii + 360. £18.95. ISBN 0-300-10729-3. DOI: 10.1177/0957154X0606072901

HISTORY OF PSYCHIATRY 17(4)

Royal charter by the time of his second visit in the late 1920s). Meanwhile, at Ruberry Hill and Hollymoor mental hospitals in Birmingham, Thomas Graves the superintendent also made the treatment of toxins a key feature of his work.

Yet, as Scull shows, Cotton's treatment and his increasingly dogmatic and mono-causal belief in focal sepsis came at the price of high death rates, brutalized bodies and patients who remained very ill. Not surprisingly, therefore, Cotton's regime came under critical investigation: research studies that questioned his alleged successes, a series of state investigations in New Jersey, and a commissioned scientific inquiry carried out by Phyllis Greenacre under the supervision of Adolf Meyer.

Despite all this attention and activity, however, a public scandal was averted. It is one of the strengths of Scull's analysis that, by the use of documentary and oral history testimony, he pieces together the way in which Cotton's powerful personality, prestige and the tenacity of his beliefs led to the suppression of much independent and critical evidence, including that of Dr Greenacre. A key player at this stage was Meyer himself, the Swiss neurologist (Cotton's mentor and director of Grenacre's research), who by that time occupied a position of considerable eminence in the American medical establishment. Meyer's prevarication, as much as Cotton's promotion of his own alleged successes, saved the latter's reputation, although from 1930 until his death three years later he was no longer Superintendent at Trenton but its Director of Research.

Scandal has become a leitmotif in histories of mental disorder and learning difficulty. The significance of Scull's book is that he delineates its dimensions with consummate skill and, as a good detective, helps his readers to understand why continuity -and not change -was an integral part of Cotton's legacy to psychiatric practice in the first half of the twentieth century.

DAVID GLADSTONE University of Bristol


V A Kral

Kral

Jeremia Heinik
email: heinik@post.tau.ac.il

Keywords: Benign Senescent Forgetfulness, Canada, Mild Cognitive Impairment, Montreal Hebrew Old People's and Sheltering Home, V. A

The term Benign Senescent Forgetfulness, introduced in 1958 by V. A. Kral, constitutes the origin of the concept of Mild Cognitive Impairment (MCI), a widely studied but controversial entity. The ambiguities surrounding MCI warrant a re-assessment of its historical origin. Any attempt at an in-depth investigation of Kral's works on that subject should begin with a description of the patient population and professional arena in the Montreal Hebrew Old People's and Sheltering Home, where Kral was a consultant. Based on archival and published sources, I describe the Home's facilities, population, staff and programmes/services, followed by an overview of the dynamic factors inducing a re-examination of its mode of operation in the mid-1950s when Kral joined the Home's professional staff as a consultant.

Introduction

Currently, Mild Cognitive Impairment (MCI) designates an intermediate state between normalcy and dementia, characterized by a certain clinical representation (not normal, not demented), 1 scores on neuropsychological measures, and presumably by imaging studies, cerebro-spinal fluid findings and other biological markers [START_REF] Winblad | Mild cognitive impairment -beyond controversies, towards a consensus: report of the International Working Group on Mild Cognitive Impairment[END_REF]. There is controversy regarding whether MCI is a clinical entity and treatment target [START_REF] Petersen | Mild cognitive impairment as a clinical entity and treatment target[END_REF], or not [START_REF] Gauthier | Mild cognitive impairment is not a clinical entity and should not be treated[END_REF], and

Some background historical and demographic notes

During the period 1901-11, the Jewish population in Montreal, Canada, increased from 6,975 to 28,838. 6 In 1912 7 a small Old People's Home and Orphanage, initially housing orphans as well, was established by the Federation of Jewish Philanthropies. 8 Gradually the focus turned to the care of the aged, and the number of old persons in this establishment grew to 20. As the Jewish population continued to grow (to 45,846 in 1921, and 58,032 in 1931), another home -the B. and S. Steinhouse Nachlas Zkeinim -was set up in 1924 on City Hall Avenue, housing about 20 residents. In 1928, as a result of ever-expanding needs to serve Montreal's Jewish elderly, a new four-storey structure was built on land purchased at 4373 Esplanade Avenue, and the two earlier homes were merged into the 'Montreal Hebrew Old People's and Sheltering Home', which had 40 residents when it opened. By 1935-36 the number of applicants continued to grow, so another floor with an additional 40 beds had to be added. (The Jewish population of Montreal was 63,937 in 1941; the percentage of those aged 65+ years increased from 2.6% in 1931 to 4.8% in 1941.) In around 1950, in response to the further demand for more beds, an adjacent property was purchased which was joined to the main building, thus providing 30 additional beds.

A description of the Home in 1956 9

The Home consisted of a main building, six stories high (a fire-proof building with two automatic lifts), plus a basement and an adjacent building (the annex), which had two storeys and a basement. At the rear of this annex there was a small building containing two apartments, one for the resident physician and one for the engineer. Fig 1 . summarizes the Home's facilities. The fifth floor was the infirmary floor for chronically ill residents in need of long-term care, as well as for those who required protective care. Also situated on the fifth floor were two wards for acutely ill residents with shortterm illnesses (8 beds). In total there were 60 rooms for residents. More than half of them contained 3 or 4 beds. Several of the rooms in the annex contained from two to four individual cubby holes with 6-foot high partitions.

Population

During 1956 the total number of residents in the Home for any one month ranged from 140 to 146, and these figures were the same during 1954-57. Generally, females constituted 60% of the residents. In September 1956 the average age was 78.5 years, with 24% aged up to 74 years, 53% aged 75-84, and 23% aged 85 years and over. The typical resident was described as an aged person who had lived with relatives or friends prior to his/her admission to the institution; orthodox; 10 of Eastern European origin, having arrived in Canada between 1900 and 1930; and a Canadian citizen.

The medical histories of 150 residents of the Old People's Home were analysed by the co-medical directors of the Home in July-September 1956. However, the summary below is based on the medical histories of 138 residents (12 had died, and not all medical histories were available on March 1957, the date of the Report). The vast majority of the residents (93%) suffered from circulatory-cardiac disease, and about half of them (49%) from what was called a mental illness (including loss of memory, mild senility, etc.). About a third (35%) suffered from partial or total deafness, and 22% from total or partial blindness. The analysis is followed by a long list of diagnoses (obesity, incontinence, strokes, paralysis, recent fractures, crippled, diabetes, anaemia, arthritis, parkinsonism, etc.), but no totals were given since often one resident suffered from more than one disease. Table 1 describes the functional activity of the residents, and Table 2 presents the types of medical care needed.

In 1956, 27 residents died, 2 were discharged, 4 left, and 2 were discharged from day care. During the same period, 32 persons were admitted as residents and 2 to day care. The average stay of residents was 5 years.

Intake policy and procedure

An applicant to the Montreal Old People's Home had to be of Hebrew birth and had to be willing to observe Kosher dietary laws at the Home, and also had to be unemployed. The minimum admission age was 60 years for women and 65 for men. Individuals and couples were admitted. The two categories of persons admitted were: the 'well-aged' and the chronically ill who did not require help in dressing, bathing or eating and who were not permanently bed-ridden. The applicants had to be able to look after their Preliminary enquiries were made by telephone, letter or in person at the office. At this time an appointment was made with the social worker for personal interview with the applicant and a member of his/her family, if possible. Each applicant had to be seen by the worker for the purpose of developing a social and medical history in relation to the request for admission of the aged person. In order to determine the applicant's eligibility, he/she was required to complete questionnaires as well as the actual application form. Each applicant was required to have a medical examination on the premises by the resident physician and a member of the medical board. He/she was also required to have a psychiatric examination. As part of the pre-admission study, where deemed necessary by the social worker, the applicant's home was visited. Upon presentation of a summary of all the findings, the admission committee of the Home considered and determined whether or not an aged person was eligible for admission. In 1954, for example, a total of 60 persons applied for admission: 23 of these applicants were chronically ill (7 were ambulatory requiring supervisory care, 8 were ambulatory requiring extensive medical care, 8 were semiambulatory, requiring extensive medical care); 7 of the group had an acute or terminal illness, 10 applicants had some kind of mental condition (7 were mild incipient cases and 3 were advanced cases requiring hospital services). Twenty of the 60 applicants were so-called 'well-aged'.

The typical applicant (of the 'well-aged' group) was female, widowed, 70-79 years old, living in Montreal, a citizen of Canada though born in Eastern Europe and had lived in Canada more than 10 years. She was a housewife and, if she had worked, was unskilled or semi-skilled. She had a private source of income which included an old-age pension plus help from either her children or savings. She had been referred to the Old People's Home by her children and her application to the Home was pending for about four months. She was able to care for herself but occasionally needed some physical care. She presented some form of minor mental aberration usually associated with advancing age. She needed continued light routine medical care and was not known to a social agency.

Staff, programme and services

In 1956 the staff of the Home included 49 persons, with the following fulltime personnel: Executive Director, Associate Executive Director, social worker, office clerk, administrative assistant, resident physician, 4 nurses (1 registered nurse, the others practical nurses), 3 nurses aides, 3 orderlies, 1 night watchman, an engineer, an assistant engineer, 7 cleaners, two spare cleaners, one cook, 3 assistant cooks, 1 dishwasher, 1 potwasher, 1 matron, 4 assistants to the matron, 1 laundryman, 1 assistant laundryman, 2 waiters. Part-time staff included the supervisor of religious activities, 1 part-time practical nurse, a neuropsychiatrist (Dr Kral), 2 physicians-in-chief and a dentist.

The resident Home physician carried out the medical programme under the supervision of the medical directors. Two physicians affiliated with the Jewish General Hospital Geriatrics Programme acted as co-medical directors. Each assumed responsibility for two 3-month periods a year. The medical director visited the Home twice weekly for a 3-hour period. His responsibility was supervising the medical programme and the establishment of medical records, as well as for referral to the Jewish General Hospital (and other hospitals).

The resident physician took care of the infirmary ward located on the fifth floor together with three nurses, three nurses aides and one orderly. He was also available daily to the other residents at fixed hours. A general physical examination was given to every resident twice yearly. The neuropsychiatrist visited the Home for one hour three times a week. The dentist came to the Home twice a week and other consultants (gynaecologists, dermatologists, etc.) were eventually on call, as needed. The residents had eye examinations as needed.

The recreation programme, organized by the Recreation Committee, was carried out by groups of volunteers. It lacked a group-worker and included passive participation activities, such as parties, concerts, single games, films, etc. However, the Home was an open institution: visiting hours were 9:00 a.m. to 9:00 p.m. daily, and visits were encouraged; most residents had at least one visit per week. Volunteers were asked to visit residents with no relatives. Residents were able to spend weekends and holidays with relatives. Even though 10:00 p.m. was the routine bedtime, there was no provision for night lights, though arrangements could be made by a resident to be admitted at a later hour.

An informal day care programme was initiated in 1953, and in January 1955 this became an official programme of the Home. 11 By 1956 the Home could serve a maximum of 7 day care persons, providing them with meals, medical care and other institutional facilities, except sleeping spaces.

Dynamic factors and forces inducing changes during the mid-1950s

In 1956 the Montreal Hebrew Old People's and Sheltering Home was an active institution, unique to Montreal and proud of its extensive medical programme. No less important, the Home had not operated on a deficit for the previous five years (in 1956 the annual total income and expenditure were $153,093 and $147,063, respectively). Of course, there were minor problems which also affected similar institutions, for example, the Home was short-staffed since it was difficult to obtain workers due to the low salaries paid, and some friction seems to have existed between medical staff (e.g., 'The co-medical Directors of the Home's relationship with the resident physician has not been clearly defined'; Report, March 1957). Other limitations (e.g., lack of active recreational and rehabilitation programmes) were acknowledged. At the beginning of 1957 Dr Giangrais, an outstanding local authority in the field of rehabilitation, surveyed the Home at the request of the co-medical directors and presented his report to the Board of Directors. Dr H. Caplan (Director of the Jewish Mental Health Service) on one of his first visits to the Home, was 'aghast at all the old people sitting around and literally doing nothing with their leisure time' (Report, March 1957). Consequently, the Home's social service was upgraded to a 'Department' level (October, 1956), and a part-time group worker was added (temporarily) to the one social worker. In addition, services of a physiotherapist and an occupational therapist became available to the residents (Social Service Report, 1958). These, however, constituted only short-term remedies.

Evidently, four major dynamic factors and forces shaped the Home's destiny for the years to come.

(a) Demographic The increase in absolute numbers of Montreal's Jewish elderly population during the first decades of the twentieth century has already been mentioned. In the Canada 1951 census, Jews constituted the third largest ethnic group in Montreal (80,829 out of 1,395,400, i.e., 6.0%) after the French and the Anglo-Celtics, and their natural annual rate of increase exceeded that of the French population (18.7 per 1,000 vs. 16.6 per 1,000, respectively). Jewish persons over 65 years were 6.4% of the Jewish population in 1951, and these figures were estimated to be almost double by 1981 (to 10.1%). In 1956 the estimated Jewish population in Montreal was 95,000, and the number of aged persons served by the Home represented about 2% of all those aged 65+ years. The annual number of new applications to the Home nearly doubled (from 60 to 108) during 1954-58. Evidently the Home with its constant capacity of 140-145 beds was facing a problem.

(b) Professional/medical Advances in medicine achieved after World War II increased life expectancy, and the illnesses which beset elderly people had by then been more extensively studied. The field of geriatrics was introduced and was progressing [START_REF] Evans | Geriatric medicine: a brief history[END_REF][START_REF] Morley | A brief history of geriatrics[END_REF], followed by geriatric psychiatry (Hilton, 2005a(Hilton, , 2005b;;[START_REF] Rabins | The history of psychogeriatrics in the United States[END_REF]. In Montreal, a Gerontology Unit was opened at the Allan Memorial Institute of Psychiatry in 1944, the first of its kind in North America [START_REF] Shorter | A Historical Dictionary of Psychiatry[END_REF], and the Jewish General Hospital operated a Geriatric Programme and Clinic beginning in 1955. The new field of gerontology designated and studied new, specialized services for the elderly, in the community and in institutions (Stones,1999). In addition, the methods of meeting the needs of the elderly in other Jewish communities were considered by the Home's administration, as Nathan Deskin mentioned in his report (Brief study, 1954):

Larger communities, as in New York City, 1 2 solved some of their problems by providing specialized services to the aged. This community had, in different localities, apartment projects for those aged who were well, homes for the chronically ill, and homes for those who required custodial care. In other communities of approximately our own size, the existing Homes for the aged were adding wings to their present structures, to house the chronically ill. Where this was impossible or impractical, as in Toronto, a new Home [the Baycrest] including a fully-equipped modern hospital and an ambulatory section, was built to accommodate 250 residents. This Home contained single and double rooms and other facilities to maintain the individual's privacy, self-respect and dignity.

Clearly, the Home's heterogeneous fields and patient population (including mild chronic physical problems, bedridden, seniles, mentally sick, the 'wellaged', etc.) needed more specialized consideration (c) Conceptual/economic From its inception, the basic services of the Home had always been to provide, for those aged 65+, food, shelter, general medical care, and an environment which closely followed the Jewish tradition. It had also unanimously agreed that the Home should care for indigent persons only. However, if over the years the Home developed a programme of care and facilities to cater for the needs of different persons, what objections, asked Executive Director Nathan Deskin in 1954, could there have been to the Home making these services available to persons who had funds to pay for them or to pay even in excess of the cost of their care? Why should the large segment of the population which was the middle income bracket or even the wealthy, be precluded from the qualitative services, knowledge and techniques which had been built up over the years for the benefit of the aged?

Not that the Home administration waited for such a confirmation. Slowly, apparently due to changes of their own admission policy as well as to improved old-age pension legislation, the economic situation of the Home residents was changing. While in 1951 the majority of residents (119 of 167) were unable to meet the cost of their maintenance, by 1953 only one-half were classified as being dependent on the community for support, and in 1957 most residents met the cost of their maintenance. Thus, the applicants in the mid-1950s came mainly for health and social reasons, 13 not for economic reasons as in the previous decades. If an aged person had only an economic problem, The Baron de Hirsch Institute Family Welfare Department would supplement him/her in the community by supplying the old-age pension. These, however, seem to be unilateral steps, as a letter written on 12 January 1954 by David Weiss, Executive Director of the Family Welfare Department, to Nathan Deskin demonstrates: I am acknowledging your letter of 1 December 1953, in which the previous policy regarding our Agency participation in admission procedures to your House has been changed as of 1 January 1954. This means that the agreements that we made in 1949 . . . are no longer operative. All requests from the community for admission to the Old People's Home will have to be made directly to your office. Incidently, it would have been helpful if prior to your letter . . . we could have met with the Federation to discuss this change just as we met in 1949 for the agreements which are now nullified.

(d) Physical facilities and living conditions In the mid-1950s it was clear that older people in homes for the aged and nursing homes have certain characteristics which arise in the aging process. At the same time, they have the same essential rights and needs as the general population: the right to maximum self-determination, privacy of person and thought, and personal dignity. The older person also has the universal need to be regarded as an individual. Older people have widely differing experiences and outlooks, and also differ in degrees of intelligence, vigour, expectations, and capacity to adapt to changing life situations.

Regimentation and disregard of personal differences can be harmful to physical and mental health. In the light of the above, Deskin's description of the Home in 1954 is deeply instructive: 'a casual examination of the Home's quarters will disclose that the precious commodity-privacy, the last inalienable right which a person should be asked to give up -is just non-existent'. And he continues:

We still have 4-bed, 3-bed, and 2-bed overcrowded and poorly furnished bedrooms. In such quarters we house people with divergent social, economic and cultural backgrounds, ranging from the first generation immigrant, with the 'huddled masses' instinct, who forgot his Yiddish and has not as yet learned English, people with -to say it charitably -peculiar concepts of personal decency, cleanliness, food habits and sleeping habits, together with highly intelligent older citizens, whose daily living routine is just like yours and mine. Thrown together these people are a source of minor but constant irritation to each other, which is repeated day in and day out. Little things, like open windows or closed windows -what time does one go to bed, and how do people go to bed at different times with shuffling gait and assorted sounds without disturbing each other? The use of ointments and the resultant odours, snoring, going to and from the bathroom in various stages of undress, personal belongings to which an aged person clings desperately, and so forth. The lack of privacy strikes a person adversely at the most critical junctures of the 24 hour day, namely when he gets up in the morning to face a new day and when he retires at the end of the day. The damage to his prestige at these junctures is so severe that it cannot be completely offset by an interesting day including good food, weather, conversation, arts and crafts, playing cards, and visitors. Constant irritation has a snowballing quality. It spreads from resident to resident, to staff (and let's remember that the staff will take so much and no more). To be sure, to the outsider, everything looks peaceful. This is as it should be, but to those of us who have been living right here amidst and with the aged, it is otherwise. . . . Furthermore, we have only one large living room, which is used for many purposes indeed. It is at once a sitting room for the residents, a Synagogue on Saturdays and Holidays because the Chapel is much too small for the total population, a recreation hall when movies are shown, a television room must be darkened much to the annoyance of those who wish to read or play a game of cards, and a place where the residents must entertain visitors. Since this living room is situated on the second floor, it is used mostly by those who are in good health and able to come down to spend some time there. The others who have no sitting room or sun parlours on their floors must either remain in their rooms or sit out in the corridors staring at blank walls. These people have every right to a small, bright, well-ventilated and comfortable furnished sitting room on their floor, where they can spend some leisure time chatting with a friend or just relaxing in a comfortable easy chair with a good book.

Time for changes

It was evident that changes were needed, based on applied research and as part of long-term planning. As early as 1952 an FJCS Old Age Research Project was established (in the same year, the Montreal Council of Social Agencies conducted a survey on the needs of the chronically ill in Montreal). In 1953 the Council of Jewish Health Agencies 1 4 was established after recognition of the fact that it was necessary to develop a common platform on which the various health programmes and institutions could work together for the common good. In 1955 a Joint Study Committee of the Home and the FJCS was established. These agencies and projects nominated committees which sent questions to the Home's administration. This is reflected in Deskin's answers to a questionnaire delivered by Frank Shore, Old Age Research Project, and Louis Rosenberg, Chairman of the Research Committee in November 1952.

The questions were as follows: (1) When was your organization incorporated and when did it begin its programme -if there was a difference in time what were the reasons for it? (2) What were the needs that motivated the development of your programme? (3) How many people did your organization serve in its first year of operation? How many people did you serve in 1951? Has the growth (or decline) of the numbers served each year been gradual or have there been sharp rises or declines? (4) Give a brief outline of your present programme and the needs you feel that it meets. ( 5 Essentially similar were the questions raised at the Executive Committee meeting in January, 1954; they concerned the following: (1) the present population of the Old People's Home (number of men and women, ages, medical problems); (2) reasons for changes in the policy (of admission);

(3) progress of new building improvements; (4) special programmes developed;

(5) plans contemplated for the future; (6) a joint study of the Old People's Home.

Nathan Deskin's answers were brief and succinct. In a letter replying to Frank Shore and Louis Rosenberg he wrote somewhat apologetically: 'the answers given are based upon 30 years of experience gained in the Home, by extensive visits in Old Peoples Homes abroad and in the attending of numerous conferences on the subject of care for the aged'.

The time was now ripe for a thorough survey of the Home's residents (demographics, medical, etc.). This was conducted between July and September 1956, and its findings appeared in the Report of March 1957 (see Note 9). It seems that the demographic data were taken by the social worker, while the medical co-directors were responsible for the accumulation of medical data, as the above Report indicates. The Report's chapters followed the subjects of the questions raised above.

Concurrently, programmes and services of other similar Jewish agencies in North America were reviewed, and some professional visits held (e.g., Alex Schneiderman, the President, and other Board members visited the Jewish Homes for the Aged in Springfield, Massachusetts, Hartford, Connecticut, USA, and Toronto, Ontario), and Morris Zelditch of the Council of Jewish Federation & Welfare Funds (NY) had been invited to participate in a meeting held on 25 October 1955 as a consultant to the Joint Committee. Several points in Zelditch's speech (which was accepted with 'a spontaneus burst of applause') should to be mentioned. (a) The Home was one of only a few out of the 82 Jewish homes for the aged in the USA and Canada that barred applicants for reasons of ill-health. (b) Old people's homes were no longer boarding homes for the aged, but more essentially nursing homes with more than 50% of the beds being occupied by the chronically ill and the senile (he gave the example of the Toronto experience where the new home for the Jewish aged was constructed in two sectors, one to serve as a 'home' and the other, 'The Baycrest Hospital', as an infirmary; he added that by doing so a subsidy from the Government Hospital programme was obtainable). (c) For the senile patient, Jewish institutions might be preferable to public institutions. In fact this need was accentuated not only by the requirements for a programme of Kashrut, since most aged Jews were Orthodox, but also by the tradition of Jewish cultural patterns. He added that commitment to public institutes generally reduced the lifespan of the patient, not to mention that the families themselves were reluctant about such admissions. (d) The better 'homes' were open to all Jews, rich and poor alike, with everyone paying according to their ability. These homes also included, besides the 'well aged', the sick, the senile and disabled; they had a full complement of professional staff and, aside from the various services, they conducted a comprehensive programme of rehabilitation.

However, the most important action seemed to be the retainment by the Joint Committee of the Home, of Ben Grossman, Executive Director of the Drexel Home for Jewish Aged in Chicago, to visit the Home and give a comprehensive report (one of Zelditch's suggestions had been to secure the services of an expert consultant to help in the developments of plans for the new institution). Although Grossman's 1957 report was accepted only in part, some recommendations were accepted almost unanimously: that 300 beds should be provided; that the admission policies of the new Home should specifically provide for care of the sick aged as well as the apparently 'well'; and that a hospital unit should be provided as part of the Old People's Home.

However, Grossman's suggestion that the present facilities of the Hebrew Old People's Home be remodelled to serve as a residential unit and that a separate medical unit be built on Jewish General Hospital grounds was questioned. Representatives of the Old People's Home, particularly, felt that it was inadvisable for a variety of reasons: (a) the present facilities did not easily lend themselves to renovation, and it was estimated that the cost of suitable alteration would be prohibitive; (b) after renovation the facilities would still be inadequate and allow no room for expansion; (c) the site of the present Home was a poor one in terms of Jewish population movement as well as the level of the neighbourhood itself (in fact until 1951, 75% of the Jewish population was contained in an area of half a square mile in the northeastern part of the city, while in 1956 this population was rapidly moving to northern and western areas of the island); (d) the medical and residential units should be in close proximity to each other, possibly in separate wings, for more effective administration and lower operating costs.

In 1961 the name of the Home was changed to 'Maimonides Hospital and Home for the Aged' (in honour of Rabbi Moshe Ben Maimon, the great medieval Jewish philosopher and physician), and shortly afterwards the building in Esplanade was sold and a 7.5-acre site in the Cote St-Luc was purchased. Here, in 1964, a new facility was built containing five floors, later expanded to seven floors with 387 beds, now called the Maimonides Geriatric Center.

V. A. Kral joins the professional staff of the Home as a consultant

That the Home needed a physician consultant with expertise in mental disorders was evident for the following reasons. (1) Almost half of the Home's population were known to have some kind of mental disturbance (including, as already indicated, those with memory impairment). ( 2) Some of them were 'real' psychiatric patients. All residents with 'other mental conditions' lived in the infirmary floor constituting 'a miniature mental hospital'. The problem, as seen by residents and staff, was that 'shortly after the resident physicians transferred an acutely ill patient to the Infirmary, the patient begs to return to his own room on the other floors long before he has recovered, so as to escape from the meshugaim [mad, Hebrew] house' (Brief study, Deskin, 1954). (3) Psychiatric hospitalizations and interventions were performed by non-sectarian institutions (e.g., the Verdun Protestant Hospital, the Allan Memorial Psychiatric Institute). However, concerning their suitability for Orthodox Jews, the same arguments as those on the commitment of Jewish senile patients to public institutes might apply here. (4) Before Kral, the psychiatric problems of the Home residents were dealt with by Dr H. Caplan, Chief of Jewish Mental Health Services, 15 who probably preferred to deal with child psychiatry. In a meeting of the sub-committee on Existing Services (Montreal Council of Social Agencies, Committee on Emotionally Disturbed Children) held on 20 January 1956, he said that 'a good deal of time was spent on becoming familiar with the problems of residents and management'. Nevertheless, in the short period in which he was consultant for the Home, out of 210 consultations made to all the agencies, 31 were done for 'Home' residents.

Kral was hired as a neuropsychiatric consultant to the Home in 1955. He was 52 years old with an impressive professional CV, and a painful personal record [START_REF] Lauter | memoriam of Professor Dr[END_REF]Merskey, 1989;[START_REF] Vojtechovsky | The development of old age psychiatry in the Czech Republic[END_REF]. Born on 5 February 1903 to a Jewish reform family in what was then part of the Austro-Hungarian Empire and is now the Czech Republic, he studied at the German Gymnasium in Prague, and later received his medical education in the German-speaking Charles University in Prague where he graduated MD in 1927. For the next 7 years he trained there in psychiatry and neurology, and also spent some time in the most famous psychiatric clinics and research institutes of central Europe (the Psychiatric Clinic in Zurich, the German Research Institute in Munich, the Pharmacological Institute and Psychiatric Neurologic Clinic in Vienna). From 1934 to 1939 he was a Privat-dozent in the Department of Neurology and Psychiatry in Prague. From December 1942 to May 1945, he and his family were detained in Thereisenstadt (Terezin) concentration camp; Kral, his wife and his mother-in-law were among the 13% who survived from that camp. In 1946 he and his wife fled secretly from Czechoslovakia, and started 'from scratch' in Canada. After 5 years at Verdun Protestant Hospital in Montreal, he was invited to move to the Allan Memorial Institute to become the Director of the Gerontologic Unit (this was the first to be inaugurated in North America, in 1944;[START_REF] Shorter | A Historical Dictionary of Psychiatry[END_REF]. In 1955 he was also a consultant in the Geriatric Clinic of the Jewish General Hospital, one of the first to use a multidisciplinary team approach (together with psychologist Blossom Temkin Wigdor, personal communication, 2002; also [START_REF] Kral | Psychiatric and psychological observations in a geriatric clinic[END_REF], and from 1952 served first as a lecturer and ultimately as an Associate Professor at McGill University, having achieved a Canadian Specialist Certificate both in Psychiatry and in Neurology. At retirement, in 1972, he moved to London, Ontario, where he pursued clinical work as well as academic and research activities, and became a Clinical Professor Emeritus at the University of Western Ontario. He died on 7 June 1988 during a visit to relatives in Israel, and is buried there. Today, Kral is considered one of the founders of geriatric psychiatry in Canada [START_REF] Reichensfeld | Geriatric psychiatry comes of age: The role of the CPA[END_REF], and of psychogeriatric research (second to Arnold Pick) in the Czech Republic [START_REF] Vojtechovsky | The development of old age psychiatry in the Czech Republic[END_REF].

It seems that Kral's appointment as a consultant to the Home might be considered an excellent 'acquisition'. In fact, being of a similar personal background to his patients there, he also filled an important position in Montreal's newly established geriatric psychiatry, not to mention his impressive knowledge and interest in amnestic syndromes and dementias of various aetiologies. Kral's interest in memory disturbances can be traced to the early 1930s (Merskey, 1989), even though his major initial research on amnestic syndromes and dementia was carried out in the late 1940s and early 1950s while at the Verdun Protestant Hospital [START_REF] Dorken | The psychological investigation of senile dementia[END_REF][START_REF] Kral | Neuropsychiatric sequelae of cardiac arrest during spinal anaesthesia[END_REF][START_REF] Kral | Postischemic dementia: a case report[END_REF][START_REF] Kral | The amnestic syndrome[END_REF][START_REF] Kral | Deterioration in dementia paralytica[END_REF][START_REF] Kral | A comparative study of the amnestic syndrom in various organic conditions[END_REF].

Given three hours a week, and apparently for $10 per hour (FJSC's rate of pay per hour for psychiatrist), Kral's primary duties included: (a) neuropsychiatric examinations of applications, and (b) development of a research programme.

As mentioned earlier, the Home's residents constituted the patient sample of Kral's original works on BSF, the most widely cited predecessor of MCI.

It is obvious that Kral arrived at the Home in a period of turbulence and major plans for changes. Years later some critics of Kral's work on BSF [START_REF] Bamford | Does 'benign senescent forgetfulness' exist?[END_REF][START_REF] Barker | Age-associated memory impairment: diagnostic and treatment issues[END_REF][START_REF] Blackford | Criteria for diagnosing age-associated memory impairment: proposed improvements from the field[END_REF][START_REF] Crook | Age-associated memory impairment: proposed diagnostic criteria and measures of clinical change -report of a National Institute of Mental Health work group[END_REF][START_REF] Reisberg | Age-associated memory impairment: the clinical syndrome[END_REF] would say that the population studied by him was un-representative (for demographic and clinical reasons), and the methods he used were inappropriate. However, as the present study demonstrates and as Kral himself indicated several times, the primary purpose of these studies was not memory research. Rather, it was to assess the state of mental health among the residents of the Home and to recommend whatever measure might seem advisable to improve present conditions (Kral, 1958b). Only in third place 'it offered the rare 16 opportunity to study more closely certain aspects of mental functioning in a relatively large number of aged people, most of them well preserved' (Kral, 1958b). Kral's methods of examination and his practical gero-psychiatric classifications leading eventually to the concept of BSF and Incipient Amnestic Syndrome (IAS), the true predecessor of MCI (Heinik, 2005b), need to be examined in light of this descriptive study. We might inquire whether the Home's arena permitted a comprehensive neuropsychiatric evaluation, whether neuropsychological tests used (e.g., the Wechsler Memory Scale, [START_REF] Wechsler | A standardized memory scale for clinical use[END_REF]) could be administered to the Home's residents, and in what way the Home's structural and content changes, needs and programmes might have influenced Kral's practical geropsychiatric classifications. These subjects will be dealt with separately in a future article.

Notes

1. This representation is operationally defined to include: subjective memory complaint, preferably corroborated by an informant; memory impairment relative to age and education-matched healthy subjects (the amnestic variant); relatively normal general cognitive function; largely intact activities of daily living; no clinical dementia [START_REF] Gauthier | Mild cognitive impairment is not a clinical entity and should not be treated[END_REF][START_REF] Petersen | Mild cognitive impairment: clinical characterization and outcome[END_REF]. 2. A very brief biography of V. A. Kral is provided in Part 3 of this paper. 3. BSF was differentiated from Malignant Senescent Forgetfulness (MSF), a typical progressive amnestic syndrome, corresponding practically to today's Alzheimer's disease with or without a vascular component.

4. It is remarkable that the Montreal Hebrew Old People's and Sheltering Home is not mentioned in Kral's paper, 'Senescent forgetfulness: benign and malignant' [START_REF] Kral | Senescent forgetfulness: Benign and malignant[END_REF], which is the most widely cited BSF reference. This might be attributed to its publication in the transition period between the Home closure and the opening of its successor, the Maimonides Geriatric Center. 5. The method used for this study was a historical review of the Canadian Jewish Congress (CJC) archives in Montreal (containing annual reports, minutes of board meetings, memorandums, correspondence, publicity material, etc., with particular emphasis on the mid-1950s), and published academic papers and books. For the sources used for information on the Home, see Note 9. 6. These demographic data were taken from 'Canadian Jewish population studies. The history of the Montreal Hebrew Old People's and Sheltering Home has yet to be studied. 8. Jewish benevolent societies and organizations in Canada can be traced back as early as 1863. In order to improve efficiency, several organizations joined together in the second decade of the 20th century to form the Federation of Jewish Philanthropies, renamed in 1951 the Federation of Jewish Community Services (FJCS). On 18 January 1955 in a professional staff seminar, Donald Hurwitz, then Executive Director of the FJCS, lectured on the topic: 'Jewish community structure in Montreal'. He pointed out that 'Montreal is quite different than any other city in the American continent, not having a public social service department, having no community chest. This unique structure is a reflection of the cultural pattern of life in Montreal'. The FJCS was part of several main bodies (Federations) including: the Combined Jewish Appeal, the Canadian Jewish Congress (CJC), the Jewish Community Council and other independent organizations. FJCS was the representative, centralizing and programming parent body to eight agency affiliations of which the Old People's Home was just one. Among these eight agencies, two provided health services (the Herzl Health Service Center and the Mount Sinai Sanatorium), while the others served welfare, vocational and recreational purposes. Note, too, that the Jewish organizations in Montreal gave birth to other health services, e.g., the Jewish Hospital of Hope (in 1942) and, even earlier, the Jewish General Hospital (1934), which was an outgrowth of the Herzl Dispensary, an outpatient clinic established in 1912 to supply free medical care for the Jewish poor by Jewish doctors in their own language. 9. This section is based predominantly on the following sources: (1) 'The Montreal Hebrew Old People's Sheltering Home, March 1957, final draft' by L. Rosenberg [henceforward, Report, March 1957] Angell, Superior, Social Service Department [henceforward, Social Service Report, 1958].

Other archival sources consulted are descriptive, and helped in the elucidation of the influences during the mid-1950s. 10. This refers to the religious programme that was based on Jewish orthodox principles and laws. However, residents were under no obligation to attend religious services (in fact the small synagogue for only 40 was sufficient for most daily religious practices; for Saturdays and holidays the recreational hall was used). Religious views and practices were considered a private concern. 11. Probably the first of its kind in North America, Maimonides Geriatric Center operated the first Geriatric Day Hospital in 1964. 12. This refers to the Home for Aged and Infirm Hebrews of New York. 13. The following were the main reasons given by those applying to the Home: 'I cannot get along with my children', 'I am too much alone and desire companionship', 'I require the comfort, peace and security which the Home can offer me', 'I need medical care' (Brief study, Deskin, 1954). 14. Which included the following agencies besides the Home: Baron de Hirsch Institute (Family and Child Welfare Departments), Herzl Health Services Center (ambulatory services to persons who could not afford private medical care; however, the general medical clinic did not treat old people), Jewish General Hospital, Jewish Hospital of Hope (for the chronically ill), Mount Sinai Sanatorium (for TB patients), and the FJCS (ex officio). 15. The Jewish Mental Health services in Montreal, an FJCS agency, had a short-lived history as a independent service. Inaugurated on September 1954, it closed on January 1957 and was assimiliated into the psychiatric service at the Jewish General Hospital. Its team included a psychiatrist (Dr Caplan, also the chief of the service), a psychologist and a psychiatric social worker. Its main activity was to provide consultation to the various welfare and recreational agencies, and to the Home. The service was funded by a grant donated by the Mona Bronfman Shechman Foundation. An effort was made to obtain a Federal grant as well. The correspondence on that topic shows that Professor Owen Cameron -Chairman of Psychiatry at McGill, a dominant figure of North American psychiatry at that time and Kral's superior at the Allan Memorial Institute [START_REF] Shorter | A Historical Dictionary of Psychiatry[END_REF] -was serving as the government professional co-ordinator. In several letters to FJCS administration, he was in favour of such a project even though more statistical data and service information were required. The correspondence also mentioned that Kral served as a consultant to the Home. The grant processing procedure was slow. The grant refusal letter was received shortly after the transfer of the Jewish Mental Health Services to the Jewish General Hospital was accomplished. 16. It was evidently rare for a clinician working mainly with hospitalized psychiatric patients with major pathologies.

TABLE 1 .

 1 Functional activity of residents*

	Number	Percentage

immediate needs. Psychotic persons were not accepted, nor were advanced senile or mentally confused persons who probably would not have been able to adjust to the normal routine of the residents in the Home. Not admissible were applicants who: (a) suffered from acute infectious disease; (b) had inoperable terminal cancers or other terminal stages of disease; (c) had personality problems which would interfere with group living; (d) had advanced mental disease.

TABLE 2 .

 2 Type of medical care needed*

	Number	Percentage

  ) What age group are you serving? What is the average age? What economic group do you serve? (6) What needs do you feel are still unmet from the point of view of the service you are rendering? (7) What plans does your organization have with respect to enlarging your programme and entering new fields of service? (8) What suggestions can you make that you feel should be considered in old age programming in Montreal?

  Number 4' and '"Draft": Age and sex distribution of the Jewish population ofMontreal 1936Montreal - 1956' ' as they appear in the Source Material section of 'The Montreal Hebrew Old People's Sheltering Home, March 1957, final draft'. Both were by LouisRosenberg (1893Rosenberg ( -1987)), a social statistician of Canada Jewry(Weinfeld, 1993), and author of the monumental monograph Canada's Jews. A Social and Economic Study of Jews in Canada in the 1930s[START_REF] Rosenberg | Canada's Jews. A Social and Economic Study of Jews in Canada in the 1930s[END_REF]. This may suggest a working relationship between the Home's administration and Rosenberg himself. The latter moved from Regina to Montreal in 1945 to become the national research director of the Bureau of Social and Economic Research of the CJC, and continued until his retirement in 1972 -as Weinfeld (1993) comments, Rosenberg himself was the 'Bureau'. Rosenberg seems to have played a role in the mid-1950s dynamic processeses to be discussed in Part 2 of this paper. 7. According to Report, March 1957 (see Note 9); however, according to another source the Home was founded in 1910(Canadian Jewish Chronicle, Montreal, 12 Oct. 1928, p. 13).

  ;(2) 'A brief study of some of the problems of the Montreal Hebrew Old People's and Sheltering Home, 1954' by Nathan Deskin, Executive Director of the Home for several decades[henceforward, Brief study, Deskin, 1954]; (3) 'Annual report -1958. Social Service Department. Montreal Hebrew Old People's Home' by Sylvia

* Source: Report, March 1957 (see Note 9)

Acknowledgements

Mrs Janice Rosen, Director CJC National Archives, Montreal, Canada, for her gracious assistance in providing archival materials; Professor Blossom Temkin Wigdor (Emeritus), Department of Public Health Sciences, University of Toronto, for her in-depth discussion with me regarding her work with Professor Kral; Mrs Rena Kurs, for assistance in preparation of the manuscript.


Mogens Schou, the most prominent of the pioneers of modern lithium therapy, passed away on 29 September 2005. He was 86 years old. A couple of days before, he had returned home from an IGSLI (International Group for the Study of Lithium-Treated Patients) meeting in Poland. He succumbed to pneumonia, having managed to finish a last manuscript just hours before.

, should be counted among his early mentors.

, to the Australian publications on the Obituary

antimanic action of lithium by John F. [START_REF] Cade | Lithium salts in the treatment of psychotic excitement[END_REF] and by C. H. [START_REF] Noack | The lithium treatment of maniacal psychoses[END_REF]. H o w e v e r , Schou found these studies, although revolutionary, to be 'insufficiently stringent'. He theref o r e designed a protocol for a trial that was partly open, partly randomized and placebo-controlled. In fact, according to David [START_REF] Healy | The Antidepressant Era[END_REF], it was one of the first, if not the first, of its kind in psychopharmacology.

Together with Strömgren, Niels Juel-Nielsen and Holger Voldby, Schou now selected, treated and observed a cohort of manic patients, whom he had allocated randomly to lithium or placebo. The trial, published in 1954, fully confirmed Cade's revolutionary discovery ( S c h o u et al., 1954). As the lithium historian Neil F. Johnson wrote (1984): ' [Schou's trial] was to prove a major turning point, not only in the fortunes of lithium therapy, but twentieth-century psychiatry as a whole: it heralded, in fact, the second era of lithium in medicine.' The antimanic effect of lithium therapy had become evidence-based.

Intriguingly, Eliot Slater, then an assistant editor of Journal of Mental Science (now British Journal of Psychiatry) had assessed Schou's manuscript and suggested it be sent it to 'a more out-of-the-way journal', i.e., Journal of Neurology, Neurosurgery and Psychiatry, as he 'did not think much of this report about an unknown drug' [START_REF] Healy | Altman)[END_REF].

Over the next decade, with never-abating energy and zeal Schou agitated internationally for the introduction of lithium in the treatment of mania -an uphill battle -assisted in this endeavour by Alec Coppen, Nathan Kline and Samuel Gershon.

Moreover, by 1964, independently of one another, G. P. Hartigan, Poul Chr. Baastrup and Schou had made sporadic observations which were suggestive of lithium also having prophylactic properties in manic-depressive illness [START_REF] Schou | Min rejse med lithium. Selvbiografiske noter [My journey with lithium[END_REF]. Subsequently, Baastrup and Schou followed up these fascinating observations in a non-blind lithium trial. They found the outcome so significant that they concluded that 'lithium is the first drug demonstrated as a clear-cut prophylactic agent against one of the major psychoses' (Baastrup & [START_REF] Baastrup | Lithium as a prophylactic agent. Its effect against recurrent depressions and manic-depressive psychosis[END_REF], and with great foresight Schou wrote to Cade (1966) that 'I should not be astonished if studies based on the observations with lithium would eventually lead to a real break-through in the control of manicdepressive psychosis'.

However, the 'Schou-Baastrup hypothesis' was met with great resistance by British psychiatry. Thus, to Aubrey Lewis and Michael Shepherd, lithium was 'dangerous nonsense' [START_REF] Wilkinson | Gaskell)[END_REF]. The ensuing 'battle of lithium' was waged in the international press, for and against 'the beleaguered Danes'. Shepherd, seconded by Harry Blackwell [START_REF] Blackwell | Lithium: prophylactic or panacea?[END_REF][START_REF] Blackwell | Prophylactic lithium: another therapeutic myth? An examination of the evidence to date[END_REF], called for controlled studies, as they found the prophylaxis hypothesis to be a 'therapeutic myth', which was based on 'serious methodological shortcomings' and 'spurious claims'. Even terms such as unethical and unscientific were used (Shepherd, 1970-71). In 1968, however, Baastrup and Schou had vigorously disputed the claims of their attackers.

The ethical issue rested heavily on Baastrup and Schou for, in their opinion, to deprive their patients of lithium prophylactic treatment would expose especially those with depression to increased safety risk and thus, in accordance with the Helsinki Declaration, be ethically indefensible. Finally, after painful consideration of this ethical dilemma, they fully confirmed their prophylaxis hypothesis with a double-blind trial of prospective-discontinuation design and with random allocation of manic-depressive patients (already on lithium) to lithium or placebo. This unique trial -according to Paul [START_REF] Grof | Has the effectiveness of lithium changed?[END_REF], 'unparalleled in psychiatry' -was published in The Lancet in 1970 [START_REF] Baastrup | Prophylactic lithium: double-blind discontinuation in manic-depressive disorders[END_REF]. Many trials internationally and with various designs corroborated this revolutionary outcome. Thus, lithium prophylaxis had also become established as evidence-based. Lithium became the first-choice mood-stabilizer in bipolar affective disorder.

Shepherd did not comment on the trial directly, whereas Blackwell (1970) found that it had 'methodological inadequacies thus rendering the evidence unreliable', a criticism that was disputed by [START_REF] Schou | [END_REF]. That both Shepherd and Blackwell as late as 1985 remained unrepentant is illustrated by their very critical reviews of Neil F. Johnson's excellent History of Lithium Therapy (1984) [START_REF] Blackwell | Review of: Neil Johnson: The History of Lithium Therapy[END_REF][START_REF] Shepherd | Review of: Neil Johnson: The History of Lithium Therapy[END_REF]. The tone was blunt. Blackwell, for his part, highlighted 'some personal motives' for Schou's 'resistance to placebo-controlled studies and his evangelical belief in lithium', namely 'a number of instances of manic-depression in Schou's family', including his brother who was being treated with 'maintenance lithium' and whose results appeared as a 'miracle' (Schou's expression) to the family, making Blackwell wonder whether 'this experience and attitude may also explain the somewhat sensitive (even paranoid) response to the opposition and criticism which developed towards lithium in the late sixties'! Claims of even the most distinguished scientists, Blackwell said, 'must be subjected to controlled scrutiny to eliminate bias especially when objectivity is compromised by clinical and ethical convictions derived from treating family members'.

Most intriguingly though, Strömgren later had the opportunity to ask Shepherd, whom he knew well, why he had continued this 'unreasonable' and 'denigrating' lithium controversy [START_REF] Schioldann | John Cade's seminal lithium paper turns fifty[END_REF][START_REF] Strömgren | Internationally famous psychiatrists[END_REF]. In Strömgren's words, Shepherd 'quite openly' conceded that the attacks were 'simply due to the fact that English psychiatry under the reign of Aubrey Lewis did not distinguish between psychogenic and endogenous depression, and if lithium were to be recommended against depression, all doctors in England would use it against all types of depression with the result that many patients not in need of it would only suffer damage from ittherefore lithium must be ravaged with fire and sword.'

Finally, authorities on manic-depressive illness such as Fred Goodwin and Kay R. [START_REF] Goodwin | Manic-depressive Illness[END_REF] hailed the ground-breaking discovery of lithium prophylaxis as 'one of the most important advances in modern psychiatry'.

Schou published approximately 540 works -papers, books and book chapters -on lithium and lithium therapy. Many international awards and honours were conferred on him, for example: the International Scientific Kitty Foundation Award (shared with Cade) [START_REF] Healy | Some continuities and discontinuities in the pharmacotherapy of nervous conditions before and after chlorpromazine and imipramine[END_REF] expressed the opinion that 'without Schou, there must really be a question mark as to whether lithium would have survived long after its rebirth in the 1950s'. But whether or not Healy will be proven right that 'its use may well fade away when Schou dies' is indeed an intriguing question. Just months before his death, [START_REF] Schou | Min rejse med lithium. Selvbiografiske noter [My journey with lithium[END_REF], looking back over 'My journey with lithium', was pleased to note 'a recent revival of interest in and use of lithium' Mogens Schou, a highly gifted but very complex man, achieved the exceptional. Psychiatry, medicine and millions of manic-depressive persons have much to thank him for. As [START_REF] Johnson | The History of Lithium Therapy[END_REF] put it, he was 'the driving force behind the modern use of lithium on a worldwide scale', finally concluding that 'he has been responsible, more than any other single individual for bringing about what Ronald [START_REF] Fieve | Moodswing. The Third Revolution in Psychiatry[END_REF] has called "the third revolution in psychiatry" . . .', i.e., the biochemical. Thus, Schou (together with Cade and Baastrup -the three fathers of modern lithium therapy) has inscribed his name in the history of psychiatry and medicine [START_REF] Johnson | The History of Lithium Therapy[END_REF][START_REF] Schioldann | Commemoration of the Centenary of the Death of Carl Lange. The Lange Theory of 'Periodical Depressions[END_REF][START_REF] Schioldann | Lithiumpioneren Mogens Schou -et halvt århundrede med lithium [The lithium pioneer Mogens Schou -half a century with lithium[END_REF].

  MOGENS SCHOU(photo given to the author by M.Schou)

  in 1974; the John Cade Memorial Award in 1982; the Albert Lasker Clinical Medical Research Award (the so-called 'little Nobel Prize') in 1987; The International Society For Bipolars' Mogens Schou Award For Distinguished Contributions (the first recipient) in 2001; the NARSAD Lifetime Achievement Award in 2004. He held several honorary doctorates (Aix-Marseille, Munich, Praha) and honorary fellowships. In 1988, with Bruno Müller-Oerlinghausen and Paul Grof, he initiated the aforementioned distinguished International Group for the Study of Lithium-Treated Patients (IGSLI), of which he was Honorary President. Moreover, he was Honorary Lifetime President of the International Society for Bipolar Disorders. As Pierre Pichot wrote (1983): 'It is probable that Cade's discovery would have been forgotten but for the persistent and systematic research of Mogens Schou'. Very similarly,