THE MENTAL HEALTH OF THE COIiL,.uNITY AND THE WORK OF THE PSYCHIATRIC DISPENSARY By C. MACFIE CAMPBELL, M. D. Johns Hopkins Hospital THE NATIONAL COMMITTEE FOR MENTAL HYGIENE, Inc. 50 Union Square New York City REPRINT No. 21 w Wyt Rational Committee for JHental FOUNDED 1909 INCOBPOBATED 1916 50 UNION SQUARE, NEW YORK CITY President DB. LEWELLYS F. BARKER CHARLES W. ELIOT Vice^Presidenta Treasurer OTTO T. BANKAHD DR. WILLIAM H. WELCH Executive Committee DB. WILLIAM L. RUSSELL, Chairman DR. LEWELLTS F. BARKER DB. WALTER E. FEBNALD Da. GEORGE BLUMER MATTHEW C. FLEMING STEPHEN P. DUGGAN DR. GEORGE H. KIBBT Committee on Mental Deficiency DR. WALTER E. FERNALD, Chairman DR. L. PIERCE CLARK DR. CHARLES S. LITTLE Finance Committee RUSSELL H. CHITTENDEN, Chairman OTTO T. BANNARD DR. WILLIAM B. COLET WILLIAM J. HOGGSON War Work Committee MAJOR PEARCE BAILET, Chairman DR. FRANKWOOD E. WILLIAMS, Vice-Chairman Executive Officers DR. THOMAS W. SALMON, Medical Director DR. FRANKWOOD E. WILLIAMS, Associate Medical Director CLIFFORD W. BEEBS, Secretary MEMBERS MBS. MILO M. ACKER, Hornell, N. Y. JANE ADDAUS, Chicago EDWIN A. ALDEBMAN, Charlottesville, Va. MBS. A. A. ANDEBSON, Greenwich, Conn. DR. PEABCE BAILEY, New York DB. CHARLES P. BANCROFT, Concord, N. H. OTTO T. BANNABD, New York DB. LEWELLYS F. BARKER, Baltimore DR. ALBERT M. BABBETT, Ann Arbor, Mich. DB. FBANK BILLINGS, Chicago SUBG. GEN. RUPEBT BLUE, Washington DR. GEORGE BLUMEB, New Haven DR. G. ALDER BLUMER, Providence WILLIAM H. BURNHAM, Worcester DR. C. MACFIE CAMPBELL, Baltimore RUSSELL H. CHITTENDEN, New Haven DR. L. PIERCE CLARK, New York DR. WILLIAM B. COLBY, New York DB. OWEN COPP, Philadelphia DR. CHARLES L. DANA, New York C. B. DAVENPOBT, Cold Spring Harbor, N. Y. STEPHEN P. DUGGAN, New York CHARLES W. ELIOT, Cambridge DB. CHABLES P. EMERSON, Indianapolis ELIZABETH E. FABRELL, New York W. H. P. FAUNCE, Providence KATHEBINE S. FELTON, San Francisco DR. WALTER E. FERNALD, Waverley, Mass. JOHN H. FINLEY, Albany IRVING FISHER, New Haven MATTHEW C. FLEMING, New York HORACE FLETCHER, New York HOMER FOLKS, New York DR. CHARLES H. FRAZIER, Philadelphia JAMES, CARDINAL GIBBONS, Baltimore ABTHUB T. HADLEY, New Haven DR. WILLIAM HEALY, Boston DR. ARTHUR P. HERRING, Baltimore HENRY L. HIGGINSON, Boston DR. AUGUST HOCH, Santa Barbara, Cal. WILLIAM J. HOGGSON, Greenwich, Conn. DR. WALTER B. JAMES, New York MBS. WILLIAM JAMES, Cambridge DAVID STARR JORDAN, Palo Alto, Cal. HARRY PRATT JUDSON, Chicago DR. CHARLES G. KEBLEY, New York DR. GEORGE H. KIRBY, New York FRANKLIN B. KIRKBRIDE, New York DR. GEORGE M. KLINE, Boston JOHN KOBEN, Boston JULIA C. LATHBOP, Washington ADOLPH LEWISOHN, New York SAMUEL McCuNE LINDSAY, New York DB. CHABLES S. LITTLE, Thiells, N. Y. GEOBGE P. McLEAN, Simsbury, Conn. V. EVERIT MACY, Scarborough, N. Y. MARCUS M. MARKS, New York LEE MEBrwETHER, St. Louis MRS. WILLIAM S. MONROE, Chicago DR. J. MONTGOMERY MOSHER, Albany DR. FRANK P. NORBURY, Jacksonville, 111. CYRUS NORTHROP, Minneapolis WILLIAM CHUBCH OSBORN, New York DB. STEWART PATON, Princeton DB. FBEDEBICK PETERSON, New York HENBY PHIPPS, New York GIFFORD PINCHOT, Washington FLOBENCE M. RHETT, New York DB. ROBERT L. RICHARDS, Talmage, Cal. MRS. CHAS. C. RUMSEY, Wheatley Hills, N. Y. DR. WILLIAM L. RUSSELL, White Plains, N. Y. JACOB GOULD SCHURMAN, Ithaca DR. ELMER E. SOUTHARD, Boston DB. M. ALLEN STARR, New York DR. HENRY R. STEDMAN, Brookline, Mass. ANSON PHELPS STOKES, New Haven DR. CHARLES F. STOKES, Briarcliff, N. Y. SHERMAN D. THACHER, Nordhoff, Cal. VICTOR MOBBIS TYLER, New Haven MRS. WILLIAM K. VANDEBBILT, New York HENRY VAN DYKE, Princeton DR. HENRY P. WALCOTT, Cambridge LILLIAN D. WALD, New York DR. WILLIAM H. WELCH, Baltimore BENJAMIN IDE WHEELER, Berkeley, Cal. DR. WILLIAM A. WHITE, Washington DR. HENRY SMITH WILLIAMS, New York ROBEBT A. WOODS, Boston ROBEBT M. YERKES, Minneapolis CHIEF PURPOSES: To work for the conservation of mental health; to promote the study of mental disorders and mental g defects in all their forms and relations; to obtain and disseminate reliable data concerning them; to help raise the st of care and treatment; to help co-ordinate existing agencies. Federal, State and local, and to organize in euery State affiliated Society for Mental Hygiene. ,,^ ..,,., - [Reprinted from MENTAL HYGIENE, Vol. I, No. 4, October, 1917] THE MENTAL HEALTH OF THE COMMUNITY AND THE WORK OF THE PSYCHIATRIC DISPENSARY* C. MACFIE CAMPBELL, M.D. Johns Hopkins Hospital THE unfortunate patient, who suffers from one of the countless ills to which human flesh is heir, as a rule has insight into his condition and knows in a general way where to get help; even though unable to pay special fees he can go to a special clinic such as the eye clinic, or can consult the dispensary of the general hospital, where he is referred to the suitable special department. The nature of the work of each special department is familiar in its general outline to the man in the street. The situation is somewhat different with regard to the depart- ment that deals with mental disorders; the public and even the medical profession are here not so well informed. The patient suffering from a mental disorder may have no inkling of his sickness; the family and social agencies frequently fail to realize that the situation is one demanding expert medical advice. It is important, therefore, to diffuse more widely the knowledge of what help is offered by a psychiatric dispensary, and of what type of cases should be brought there. To many the name "psychiatric dispensary" suggests little or nothing; the term "mental clinic" or "mental out-patient de- partment" sounds more familiar, and yet even so simple a term may call up in the minds of many a very misleading picture. Although living in the twentieth century, we are not free from the trammels of medieval thought. We are apt to deal with words the symbols of reality, rather than with the facts of experience. So the term mental disorder, like the legal term insanity, has a certain ominous ring about it which makes people tend to. avoid it. It is well, therefore, to begin by freeing our minds from some general misconceptions before passing on to the presentation of concrete facts. Mental disorders are disorders of human adjust- ment, maladaptations, unhygienic compromises, immature or distorted methods of meeting the complex situations of life. The mental out-patient clinic or psychiatric dispensary deals with such * Read before the Mental Hygiene section of the National Conference of Charities and Correction, Pittsburg, June 12, 1917. 1 2 MENTAL HYGIENE disorders of adjustment; it deals with the failures of the individual to meet life's problems. Unlike internal medicine, psychiatry cannot limit itself to the failure of single organs or groups of organs to deal with their problems; it has to deal with the malad- justments of the personality as a whole. Psychiatry may there- fore be considered as personal medicine, as opposed to impersonal medicine; while in other departments the personality may be ignored, although not always with impunity, in the mental clinic the personality is the organic unit with which we work. It is true that disorders of the individual organs and of groups of organs may cause modifications of the personality. The per- sonality is not something outside of and apart from the constituent organs of the body; it is the total activity of these organs more adequately conceived. The study of the personality and its disorders involves the study of all the bodily organs, but in a more complete setting than is necessary in internal medicine. In the mental clinic, therefore, we deal with patients whose symptoms require for their understanding a study of the per- sonality and of its problems. Mental disorders are not disorders whose symptoms necessarily are mental, but whose roots are mental, that is whose roots cannot be understood without study- ing the patient in his complete human relations. The symptoms may be insomnia, or headache, or vomiting; they may consist of a paralysis or a tremor; they may be limited to an apparent blind- ness or deafness or dumbness; and yet the disorder may be a mental disorder because its roots lie in the difficulty the person- ality has in its adjustment to the situation. The personality, in the face of difficulties, may find refuge in phantasies, deliria or hallucinations, but also in aches and pains and palsies, and the latter may be as truly evidence of mental disorder as the former. Symptoms such as paralysis or blindness may be the signal of a complex human difficulty while the individual organs are sound; on the other hand changes of personality, moods, hallucinations and delusions may be the sign of the disorder of some individual organ or group of organs. The organs involved may be the central nervous system, the glands which are at the very basis of the emotional life, or some other organ such as the stomach, or lungs. Where the personality is involved in this secondary way the mental symptoms are merely symptomatic of disorders, the study and treatment of which can be carried on along the nar- rower lines of internal medicine. MENTAL HEALTH OF THE COMMUNITY 3 A survey of the actual work done in the psychiatric dispensary may begin properly with the children; these may be divided con- veniently into the subnormal and the neurotic group. With regard to the former group, the early recognition and complete study of any constitutional defect is extremely im- portant; this enables the physician to advise the teacher, to guide the mother, to safeguard the child from deleterious influences, from drifting into unhealthy or delinquent habits, from becoming the tool of the unscrupulous. Pronounced backwardness at school without obvious cause is a sufficient indication that a psychiatric examination is required. The neurotic group is composed of those children who show such symptoms as night-terrors, bed-wetting, tantrums of temper, excessively fidgety behavior, poor sexual habits, pilfering, ro- mancing, unexplained moods, marked cruelty or other anomalous traits of character. In every case the physician aims first at a thorough study of the child from the point of view of his physique, his intelligence, his emotional life and general balance; and then at a study of the in- fluence of the environment on the formation of habits of the child. With the teacher he discusses the school situation; with the parent he has to review carefully the home behavior of the child, the development of the neurotic traits, and the conditions which may influence them. The individual child thus may get help, symptoms be relieved, improper habits checked; but an important by-product is that the teacher gains a broader con- ception of the nature of education, the parent a deeper insight into the problem of training the child a task often so honestly taken up and so inefficiently carried out. In order that the teacher may furnish essential data to the dis- pensary physician, the latter should supply simple forms in which the important facts can be briefly entered; the teacher may then learn to fill in such a form, not as a burdensome routine duty but with the same interest with which the physician makes his notes. Similar co-operation should be obtained from all social workers dealing with the problems of childhood, when they bring one of their wards to the dispensary for examination. This of course applies equally where the ward is a child, a wayward adult, or delinquent, or drug addict. The social worker should realize the importance of a psychiatric opinion on such cases, and should prepare the available data with some insight into the require- 4 MENTAL HYGIENE ments of the physician; while the latter, in the light of these data and the examination of the individual, should be prepared to fur- nish the worker an opinion, which will make the actual manage- ment of the case more efficient. Such work will be a source of instruction to the individual worker; it will make less haphazard and more firmly based on rational principles the work of many organizations dealing with prisoners, unmarried mothers, juvenile delinquents, and dependents of other types. Work of this type will do much to instruct the whole community as to the under- lying causes of these disorders of conduct and the necessity of dealing with them at an early stage, that is, in the school period. The adult patients of the dispensary present a great variety of practical problems. Sometimes the problems are those of the general dispensary; that is especially true where the mental symp- toms point to some underlying disease, either of the central nerv- ous system (e. g., brain tumor) or of some other organ or group of organs (e. g., exophthalmic goitre). But in a large group of cases the symptoms are intimately associated with personal difficulties of adjustment, and a thorough study has to be made of the whole attitude and balance of the patient, and of the life-situation in which he finds himself. A painstaking review and discussion of those factors, which make for happiness or unhappiness in life, is often a relief and revelation to patients, whose ailments have hitherto been treated in the traditional impersonal way by drugs, rest-cures, and opera- tive measures. Thus a young man came prepared to enter the hospital for the treatment of persistent headache; the headache was associated with worry over faulty sexual habits. A frank discussion of the whole situation relieved his mind considerably; he was en- couraged to improve his adaptation outside rather than to take refuge in the hospital. Accordingly, a somewhat uncongenial en- vironment was given up for residence in town, suitable employ- ment was found, the patient took up the regular gymnasium work of the Y. M. C. A. along with other recreation in the evening. Since then the patient's attitude toward life has been transformed from one of sensitive seclusiveness to a much more healthy out- look; instinctive control is satisfactory; headache is no longer spontaneously referred to, while his improvement has been an enormous relief to his family. Encouraged by the improve- ment of the patient, a brother has also sought advice. MENTAL HEALTH OF THE COMMUNITY 5 While the aim of the treatment is the readjustment of the patient to the environment, the method is largely re-educational; at the same time, such general measures as drugs, diet and baths are not neglected. Re-education of the patient means that he studies his own personal difficulties in a rather intensive way (assuming he has the requisite intelligence); he traces out the factors which have influenced his habits and attitudes; he learns to face the facts of his life in their biological crudity as well as in their ethical and aesthetic setting; he gains courage to discard mental make- shifts and disguises. But this gain in honest insight into the problems of life must not be a barren intellectual exercise; it must go hand in hand with a search for those practical aids to the formation of better habits which the community may offer, and must be accompanied by the actual utilization of these aids. In the daily and weekly program the varied needs of human nature must get sufficient recognition; work should yield its own return, opportunities for recreation should be available, the social, intellectual, aesthetic and religious aspects of life must not be ignored; balancing factors in the way of hobbies are to be encouraged, and the fundamental relations of the patient to his own family are of cardinal importance. While the physician with his special knowledge helps the patient to unravel his tangles, the trained social service worker plays an essential role in directing the first steps of the patient. It is the aim of this communication to outline this work and illustrate it. A girl of twenty-one with a slight physical deformity took it very seriously to heart, saw her life as without any promise, and harped on a number of physical complaints which seemed to have no adequate cause. A review of her case showed that, partly owing to personal difficulties, partly owing to faulty training and difficult circumstances, she had developed her invalidism as a pro- tection, while her true interests found no outlet. Frequent inter- views with the physician enabled her to adopt the latter's attitude toward her symptoms. At the same time the social service worker* got in touch with the patient's sister, and did much to correct the attitude of the latter, who had fostered the patient's invalidism. She put the patient in the way of developing her artistic talents by arranging for an exceptional educational op- * I take this opportunity to express my indebtedness to Miss S. L. Lyons, in charge of the Social Service Department of the Psychiatric Dispensary, for her assistance in the preparation of this paper. 6 MENTAL HYGIENE portunity. The patient was soon able to discard her protective invalidism; she has made a good start on the road to economic in- dependence; her attitude toward life is one of cheerfulness and hope instead of discouragement and resignation, while the slight physical deformity has shrunk in her perspective from a mountain to a molehill, and as a matter of fact is not noticed by her com- rades. The fact that the patient was referred to the dispensary by the physician who was consulted for the physical deformity, illustrates the benefit of the medical profession in general being trained to recognize such disorders, which are so apt to masquer- ade in disguise. The general social worker, too, does well to respond with some sensitiveness to anomalies of personality, and to know when to invite a psychiatric opinion before planning the life of the indi- vidual. A young woman of eighteen, with some artistic talent and superficially bright, enlisted the sympathy of a district social service worker through her story of ill-treatment at home. The latter obtained for the girl the opportunity of going to town to take up the study of art. The girl soon attracted the attention of her companions by her phantastic stories and lack of respon- sibility and she was brought to the psychiatric dispensary for examination. A thorough review of her condition and of her early development showed that she was constitutionally in- ferior, not in the sense of being intellectually defective, but in her response to ethical standards. This condition of constitutional psychopathic inferiority, which gives rise to so many legal and other difficulties, made it necessary in view of her actual behavior to have her placed in a state hospital. The well-meant endeavor of the social worker to help the patient went astray, because the former was guided rather by sentimental considerations than by trained insight into the personality of the patient. The contact of the general social worker with the psychiatric dispensary should broaden the basis of much social work and be one more step in diffusing knowledge of mental hygiene throughout the community. The consistent and conscientious treatment of the patient means that whatever necessary conditions are indicated for the readjustment of the patient should, if possible, be placed at the patient's disposal, although the search for them takes one from the hospital into the school, the labor market, and the church. The concrete needs of the individual patient have to be defined MENTAL HEALTH OP THE COMMUNITY 7 and .supplied; by that we do not mean that the situation is made too easy for the patient, nor that the patient is encouraged to become dependent on the support of the clinic. But the patient must be given more than general directions, must at first be led, perhaps, until the way is more familiar. To make the steps and nature of the treatment clear, further individual cases may be quoted. A woman of twenty-six for several years had complained of severe headache, dizziness, vomit- ing, burning pains, insomnia and nervous feelings; the physician who had treated her by the usual medical measures for a long period without result, recognized the true nature of the case and transferred her to the psychiatric dispensary. The mental roots of the disorder were not difficult to discover, and the mental hygiene of the patient was placed on a better basis. She was sensitive about her ignorance of English; she got little satisfaction from her few household duties; she squandered much time and energy in day-dreaming. Under the stimulus of the social worker, she was encouraged to take systematic lessons in English; she became a member of a gymnasium class at the Public Athletic League; she joined the swimming class; she learned to develop her home responsibilities, attended the weekly occupation class at the psychiatric dispen- sary, and did some volunteer social service work. When the patient first came under observation her condition was such that admission to a state hospital was seriously considered and would have been welcomed by the husband. With the help of the measures outlined above the patient improved greatly, although leaning frequently on the social service worker. The husband was much encouraged by the improvement; his hearty co-opera- tion in the treatment was the result of the support by the clinic, and replaced his previous resignation to the prospect of having her leave home for a long residence in a hospital. It is often so; with the dispensary to fall back on in time of need, the husband or wife, parent or child, is often much more willing to undertake the task of looking after the patient at home. The treatment of the patient is the treatment of the whole situation and the other members of the family must often receive psychiatric attention, as in the following case. A man of forty-seven, with epileptiform convulsions, was sus- pected of malingering by the social organization which helped to support his family. Examination at the psychiatric dispensary 8 MENTAL HYGIENE determined the organic nature of the disorder; he was operated on in the hospital, unfortunately without relief; after leaving the hospital he continued to visit the psychiatric dispensary where he attended the weekly occupation class, his sole recreation. His wife preferred to care for him at home than to have him admitted to a state hospital. It was found that two of his children showed neurotic symptoms ; they were accordingly examined, their mother was advised as to the necessary home hygiene, their school teachers were interviewed and informed of the medical opinion, gymnasium privileges were arranged for and the necessary shoes provided. The range of the work done by the dispensary in treating ade- quately the situation presented by a patient is shown in the fol- lowing case. A foreigner, cultured but eccentric, was referred to the dispensary from the tuberculosis clinic on account of his depressed condition; his funds were low, there had been friction with the church authorities, the fault not being altogether on his side. In view of his prejudices and somewhat difficult personality, the problem of readjustment was rather complicated. The friction with the church authorities was smoothed over, a suitable position was obtained for the patient, debts were paid in order to let him move from a quite uncongenial environment to one more suitable for him and for his children, clothing was provided for the family, artificial teeth for the wife, some literature was put at the patient's disposal, and the basis for some congenial friendships was laid. Such a series of steps may seem to stretch rather far the function of the dispensary, but so long as the therapeutic problem is taken seriously they are as essential as the individual steps in surgical or ordinary medical treatment. From the economic standpoint the outlay in such a case comes up for scrutiny. The serious probability was that this eccentric man, with his cultural interests starved in a drab environment, unable to earn his living owing to the church friction, would show progressive embitterment and develop definite delusions. The result would then have been his admission to a state hospital, perhaps to remain for life, while his children became a charge on the community. By the measures taken, which involved an expenditure of less than two hundred dollars, he promises to be- come a productive economic unit, the support of the family, get- ting satisfaction out of life, an asset to the culture of the com- munity. Not only is he himself happy, but the prospects for the MENTAL HEALTH OF THE COMMUNITY 9 healthy development of his children are infinitely better. This is preventive medicine. Even in cases where the seriousness of the disorder allows only palliative treatment, the dispensary can do much to outline meas- ures to reduce friction with the patient; the physician, by giving the family an insight into the medical view of the disorder, may rob it of much of its bitterness. One important practical decision has frequently to be made, namely, whether the patient should be placed in a hospital even without his co-operation. The relatives are apt to take the symp- toms merely at their face value; the physician, however, realizes that a patient with incipient paresis may seriously compromise his name and fortune, that a patient with a mild depression may commit suicide, that a seclusive and embittered patient may suddenly commit a homicide. Impressed with these dangers he may urge the friends of the patient to take the necessary steps to have the latter admitted to a state hospital or private sana- torium. In the popular mind old associations still cling to the hospital for mental disorders; the man in the street hardly realizes that they are hospitals in the true sense of the word, specially staffed and equipped for the curative and palliative treatment of disease. One need not blame the man in the street, for physicians and social workers often require enlightenment on this topic. In illustration, I may quote an extract from the letter of a social worker, protesting against the advice to send a young woman to a state hospital: "From a physician's point of view, would you advise further hospital treatment outside of an insane asylum? So long as she is perfectly harmless, would she stand a better chance in a medical hospital for a little while longer, if we could so place her?" This reference to a state hospital as an insane asylum, a place which is not regarded as a medical hospital but where patients should be sent only when they cease to be harmless and can not be benefited by further treatment, illustrates a medieval trend from which contemporary thought must be purged. Where the medieval attitude still dominates the institutions of the state, it is an im- perative duty of the community to see that the hospitals are brought up to a modern level. It is not sufficient to give to the family the summary advice that commitment to a state hospital is necessary; the nature of the 10 MENTAL HYGIENE advice must be made clear, any prejudices removed so far as pos- sible, the actual steps for the admission of the patient arranged with the utmost consideration for the attitude of the patient. The relation between the patient and the physician in the state hospital may be seriously compromised by injudicious manage- ment of the patient before admission; there should be no deceit; non-medical interference, such as the co-operation of the police, should be avoided except in a serious emergency, and then a plain- clothes man should be employed. A frank attitude towards the patient may gain co-operation, even where the outlook is not promising. Thus a woman of forty -two at first rejected indignantly the advice to go to a state hospital; she had ideas of persecution, thought that she was fol- lowed by detectives, threatened to shoot her persecutor, and was incensed at the physician's guarded suggestion that her whole attitude required a detailed examination such as could only be adequately carried out in a special hospital. After two months' contact with the dispensary, she herself asked the physician to make the necessary arrangements for her admission to the state hospital. After a stay of over a year in the hospital she left it and visited the dispensary; she still clung to her old ideas and did not accept the physician's view of her sickness, but she had no resentment against him for having sent her for treatment to a mental hospital. Some months later, unable to establish herself in the community, she returned voluntarily to the state hospital. The detailed treatment of the individual case, so far as the analysis of the symptoms and the readjustment of the patient's attitude are concerned, belongs more to a technical medical dis- cussion than to the present review, which aims more at a discus- sion of the objective methods involving social co-operation. It may be helpful to mention briefly those social organizations with which the psychiatric dispensary must keep in touch, through its social service department. To a large extent they supply the machinery for the readjustment of the patient, and the problem of the psychiatric social service worker is largely to co-ordinate their individual services. Contact with these organizations to be efficient must be personal and intimate, not formal and perfunc- tory. The dispensary must be in close touch with the school system and co-operate with principals and teachers, so that their problems are freely referred to the dispensary, and its advice actually carried MENTAL HEALTH OF THE COMMUNITY 11 into practice. Similar relations should exist with the juvenile court, with reform and parental schools, and with all official charity organizations, for no organization can deal adequately with the problems of dependency which does not realize the r6le played by mental defect or disorder. These organizations can not only bring their problems to the dispensary, but make a valuable social apparatus available for the readjustment of the psychiatric patient. Such readjustment is often facilitated when the psychiatric worker is in touch with the large employers of labor and with employment bureaus, such as the new Federal Employment Bureau; the economic readjustment is often an essential part of the total task. For the development of those human interests which are such important balancing factors in life, one must be in touch with the local opportunities for promoting self -culture, with organizations such as the night schools, the Jewish Educational Alliance, the Y. M. C. A. and the Y. W. C. A. The patient may also be grate- ful for some help in utilizing the other cultural opportunities of the community, the museums, libraries, picture-galleries and concerts. Simple recreative opportunities are sometimes to be found in well-run municipal dance-halls, while the humble "movies" may be recommended as an invaluable diversion in a community where the only alternative is the saloon. For physical culture, the development of the corpus sanum as a fit temple for the ideal mens sana, one must be able to utilize the gymnasia associated with the above organizations, with several churches, with the Public Athletic League, while in summer healthy exercise and recreative diversion are combined in summer camps, perhaps under the auspices of the Boy Scouts or the Camp Fire Girls. Where the patient has not cut himself adrift from his organic church affiliations, it is important that this most potent influence in human life should play its r6le in the readjustment or hygienic resurrection of the individual. This is to be done not by referring the patient to some hybrid organization, a blend of church and medicine, but by restoring the patient to the fellowship of that church of which he was an organic member; with his fellow- members he is entitled to get from his spiritual guide some prac- tical help in harmonizing his highest needs with the other insistent demands of human nature. Co-operation of this type will be 12 MENTAL HYGIENE more generally available when those preparing to be the spiritual leaders in the community are offered, during their training, a psychology that deals with the actual conflicts of the home and the market, and not a sterilized laboratory psychology. Here may well end our brief sketch of the organic connections of the psychiatric dispensary with the life of the community, and of the task of those who help us in building up again the struc- ture of human lives which have been badly shaken. "And difficult as it may be to transform the instincts that dwell in the soul, it is well that those who build not should be made aware of the joy that the others experience as they incessantly pile stone upon stone. Their thoughts and attachments, and love; their convictions, deceptions and even their doubts all stand in good service; and when the passing storm has demolished their mansion, they build once again with the ruins, a little dis- tance away, something less stately perhaps, but better adapted to all the requirements of life." SUMMARY Indigestion and headache may be mental disorders just as truly as are morbid phantasies and distorted attitudes; it depends on their origin. The mental out-patient department or psychiatric dispensary of a hospital deals with symptoms of mental origin, whether the symptoms are called physical or mental. The psychiatric dispensary will be of the greatest value to the community when physicians and social workers who come into contact with cases of mental disorder or defect know the type of work done there. The teacher who promptly secures a psychiatric opinion on her subnormal and neurotic pupils, develops deeper insight into her own special educational task. The basis of much philanthropic work can be broadened if the psychiatric dispensary is freely consulted by workers dealing with the dependents on society, delinquents, prisoners, vagrants, drug addicts, unmarried mothers, etc. Many patients with mental symptoms have somatic disorders and present no different problems from those met in the general dispensary. Other patients do not react to the ordinary medical treatment (drugs, baths, exercise, rest, operation, etc.) because the symptoms are interwoven with the personal difficulties of the MENTAL HEALTH OF THE COMMUNITY 13 patient. The psychiatric dispensary, receiving these patients from the general dispensary or from outside physicians, helps to keep before the medical profession the importance of certain factors of health too often neglected, namely those factors which are the special province of mental hygiene. The treatment of a patient often means his re-education, his revaluation of the various factors in life, his progress from an im- mature attitude to one more mature and honest. Difficulties in the life-situation of the patient which are open to modification must not be neglected. At the same time, more hygienic adapta- tion to the complex demands of life, the formation of better social habits, are complex tasks where supervision by an intelli- gent social service worker is invaluable. The social service worker, to be of practical use to the patients, must keep in intimate personal touch with many aspects of the community life, economic, educational, philanthropic, religious and recreative. The treatment of a patient frequently means the treatment of his whole domestic and economic situation; the thorough per- formance of this task is to be considered preventive medicine. to* A 000 494 970 7 MENTAL HYGIENE QUARTERLY MAGAZINE OF THE NATIONAL COMMITTEE FOR MENTAL HYGIENE, INC. EDITOBIAL OFFICE: 50 UNION SQUARE. NEW YORK CITY EDITORIAL BOARD THOMAS W. SALMON, M.D. Medical Director, The National Committee for Mental Hygiene FRANKWOOD E. WILLIAMS, M.D. Associate Medical Director, The National Committee for Mental Hygiene GEORGE BLUMER, M.D. WALTER E. FERNALD, M.D. Dean of the Yale Medical School Superintendent, Massachusetts School for Feebleminded C. MACFIE CAMPBELL, M.D. AUGUST HOCH, M.D. Anociate Professor of Psychiatry, Johns Hopkins University Former Director, Psychiatric Institute, N. Y. State Hospital STEPHEN P. DUGGAN, PH.D. STEWART PATON, M.D. Professor of Education, College of the City of New York Lecturer in N euro-biology, Princeton University VOL. II, No. 1 INDEX JANUARY, 1918 The Management of War Neuroses and Allied Disorders in the Army [Col.] Sir John Collie 1 Mental Health for Normal Children William H. Burnham 19 A Consideration of Conduct Disorders in the Feebleminded L. Pierce Clark 23 Feeblemindedness and Industrial Relations C. S. Rossy 84 The Practical Function of the Psychiatric Clinic John T. MacCurdy 53 The Family of the Neurosyphilitic Harry C. Solomon, Maida H. Solomon 71 Better Statistics of Mental Diseases Horatio M. Pollock 81 Special Article A Study of 608 Admissions to Sing Sing Prison Bernard Glueck 85 Notes and Comments 152 Book Reviews 162 Current Bibliography Mabel W. Brown 168 Directory of Societies and Committees for Mental Hygiene 173 MENTAL HYGIENE will aim to bring dependable information to everyone whose interest or whose work brings him into contact with mental problems. Writers of authority will present original communications and reviews of impor- tant books ; noteworthy articles in periodicals out of convenient reach of the general public will be republished; reports of surveys, special investigations, and new methods of prevention or treatment in the broad field of mental hygiene and psy- chopathology will be presented and discussed in as non-technical a way as possible. It is our aim to make MENTAL HYGIENE indispensable to all thoughtful readers. Physicians, lawyers, educators, clergymen, public officials, and students of social problems will find the magazine of especial interest. The National Committee for Mental Hygiene does not necessarily endorse or assume responsibility for opinions expressed or statements made. Articles pre- sented are printed upon the authority of their writers. The reviewing of a book does not imply its recommendation by The National Committee for Mental Hygiene. Though all articles in this magazine are copyrighted, others may quote from them freely provided appropriate credit be given to MENTAL HYGIENE. Subscription: Two dollars a year; fifty cents a single copy. Correspondence should be addressed and checks made payable to "Mental Hygiene," or to The National Committee for Mental Hygiene, Inc., 50 Union Square, New York City. Copyright, 1917, by The National Committee for Mental Hygiene, Inc.