or discharge him; or if suffering from a chronic disease, until he dies, unless previously removed by relatives or others. Prior to leaving the state hospital the patient is given a parole card and instructed to report to the clinic or out-patient department of the hospital for further obervation and advice. The work of these clinics has already been summarized and nothing further need be added at this point. However, referring the patient to the clinic and advising him when he reports is to all intents and purposes the last step the state takes. The fact stands out that something further should and must be done if the insane and borderline cases of insanity in the community are to be properly and adequately served.

(a) Development of Mental Hygiene Movement. The initiation of the mental hygiene movement, at least insofar as it concerned the organization of state and national societies for the dissemination of facts gathered through surveys and original studies, was largely due to the publication of the autobiography, “A Mind That Found Itself," of Clifford W. Beers, who, since its organization in 1909, has been the secretary of the National Committee for Mental Hygiene. It is undoubtedly true that the publication of this very interesting and well-nigh epoch-making volume came at a time when certain groups in the community were giving much thought to the general problem of the insane, and that Mr. Beers' book served to crystallize opinion and helped to bring together those who shortly thereafter became the founders of the National Committee for Mental Hygiene.

The organization of this group followed closely the movement for the establishment of hospital social service departments in all general hospitals. Dr. Richard C. Cabot of Boston organized the first medical social service department in this country, when in 1905 he developed a social

service division in the out-patient department of the Massachusetts General Hospital. The reasons for the organization of this new branch of work were that the physician treating a patient could become acquainted with only certain phases of the mental and physical condition of the patient, and that it was necessary to call in the trained social service worker to assist the physician in making a more accurate diagnosis and in rendering the prescribed treatment more effective. This new form of service was at first designed primarily for those who came to the out-patient department of the general hospital. Since then the movement has spread to practically all the large general hospitals in the country, and the social service departments now serve both the ward and dispensary patients. The state hospitals for the insane in New York, following the development of the hospital social service idea, appointed social service workers to follow-up as many patients as they could, to assist at the clinics, and to obtain such additional information regarding particular patients as was found necessary by the attending physicians.

To those who became interested in the better care of the insane, it early became evident that the service rendered by the state to patients lacked one very essential element, and that was proper mental hygiene care. Organized work in mental hygiene may be described in various ways, depending upon one's viewpoint and special interest.1 The viewpoint expressed here is not that of the physician but rather that of the layman, interested in according to mental cases that kind of service which had its origin in medical social service, but which has during the past decade developed its own methods of work and means of serving. The state

1 Beers, C. W., Organized Work in Mental Hygiene," Mental Hygiene," Jan., 1917, p. 81.

hospitals, due to financial and legal difficulties, have stopped virtually at the point at which the hospital social service movement began, and it has been left to private organizations to develop the technique of rendering mental hygiene service.

II. ORGANIZATION AND DEVELOPMENT OF A MENTAL

HYGIENE AGENCY

Following closely the organization of a social service department by Dr. Cabot in Boston, a group of public spirited men and women helped to organize such a department in Bellevue Hospital, New York City, by providing the funds with which to carry on certain very important phases of the work for which the city did not and could not appropriate money. Because of the very large number of patients admitted to the hospital, as well as treated in the out-patient departments, the problem of supplying adequate social service to all groups of patients presented difficulties, some of which have not as yet been surmounted. It should be noted that to Bellevue Hospital come patients from practically all parts of the greater city; and that, besides its general wards for medical and surgical cases, it also has a psychopathic department which handles approximately 6,000 patients a year. Receiving such a large number of patients, it is apparent that many races and nationalities are represented in the lists of admissions.

Bellevue Hospital necessarily admits a rather large number of Jewish patients annually, for though the Jews of New York have organized and maintain several general hospitals to which Jews largely seek admission, nevertheless the number of beds is quite insufficient to accommodate all who want treatment in the semi-private Jewish institutions. In order to serve beween 5,000 and 6,000 Jewish patients who are admitted to Bellevue Hospital annually,

and of whom about 1,100 come to the psychopathic wards, a Jewish agency, namely the social service department of the Free Synagogue, has undertaken to serve particularly the Jewish patients, most of whom feel out of place in an institution in which the Mosaic dietary laws are not observed and in which their language, when not English, is not understood and their own distinctive psychology not fully grasped.

With the development of the work, the realization that the psychopathic cases demanded a different kind of service became apparent. It was found, for instance, that the resident psychiatrists often believed that certain cases could recover outside of a state hospital more readily than they could within the walls of such an institution; and yet, they did not feel safe in sending such patients back to their own homes, in which the mental difficulty had developed and to relatives who did not understand the nature of the ailment or the proper care of the patient. Since approximately 71 per cent of the patients admitted to the psychopathic wards were committed to a state hospital, the social service department was often called upon to advise the family and help, financially and otherwise, in their readjustment to new social conditions until the father or mother or other member of the family was discharged from the state hospital. A further phenomenon also aroused interest in the need for a special division to care for mental cases, and that was the considerable number of patients readmitted from year to year.

It was these facts, as well as the realization, through daily contact with psychopathic cases and their problems, of the shortcomings of the provisions made by the state and city officially, and by the community as a whole, that prompted the organization of a mental hygiene division as a part of

the social service department of the Free Synagogue.1 The series of steps in the development of this particular mental hygiene agency is probably more or less typical of the way in which other similar agencies have and will come into being, unless through propaganda and widespread education, various communities can be made to realize the duty they owe to the mentally sick in their midst.

III. ACTIVITIES OF A MENTAL HYGIENE AGENCY

Stating the matter briefly, the chief purposes of any society or committee for mental hygiene are: conservation of mental health; prevention of nervous and mental disorders and mental deficiency; and improvement in the care and treatment of those suffering from any of these disorders. Though methods of work and the amount of attention given to some activities vary, practically all societies for mental hygiene are seeking to achieve their aims in the following ways: (a) by means of campaigns of education; (b) through social service activities; (c) by surveys and special studies; (d) by influencing the enactment of proper and necessary legislation; (e) by cooperating with other agencies to achieve better results in the care and treatment of mental cases.

Several of the above items in a mental hygiene program explain themselves and need no further elaboration. The matter of social service activities, however, presents a definite problem which has many ramifications. To begin with, there is the question of the organization and the personnel of the clinic to which the patients taken under care are referred. The usual organization requires that there be a physician trained in psychiatry, a mental hygiene or psychiatric social worker, and a stenographic secretary.

1 State Hosp. Comm., 25th Annual Report, p. 451.