The scientific research workers in many national centers are in constant communication. Knowledge is being applied more effectively to the problems in the field, and information about methods and results is being disseminated more systematically and rapidly.

Governments are sending attachés of hygiene into each other's territories. Vital statistics on an international scale are being reported more accurately. Prompt notification of epidemics is being facilitated.

Outposts against plague and other diseases are being stationed and supported. The League of Nations' committee has organized a barrier against typhus for the protection of Western Europe and the United States.

Leaders and technical experts are in training in larger numbers and under more favorable conditions. Underlying medical training is being improved, and schools of hygiene are being established in Baltimore, Boston, London, Prague, Warsaw, Calcutta, and elsewhere.

A committee of the League of Nations is attempting to standardize internationally vaccines and sera which now vary widely in potency and purity from nation to nation and even within the same country.

Popular knowledge about preventive medicine and personal hygiene is increasing. Intercommunications of many kinds are being improved and multiplied.

It is more and more evident that curative and preventive medicine are two aspects of the same thing. Emphasis shifts from care of the sick to the avoidance of sickness. The doctor of the future will be more useful as a periodic examiner and health counselor than as an emergency man called in after disease has made serious progress. Curative medicine deals with the individual patient; preventive medicine concerns itself with communities, states, nations, the world.

Public health is primarily a government responsibility. Private health agencies may aid governments but should not seek to serve as substitutes for them.

Private health associations may render important service in conducting experiments and demonstrations, in co-operating with public authorities, and in organizing popular support for government policies.

There is an order of importance in public health projects. Fundamental things like sanitation and control of epidemics should not be neglected for more spectacular and emotionally appealing activities.

There should be constant appraisal and readjustment of public health work in the light of world experience. Here as in every other field there is danger of waste of money and effort.

A fundamental theory to guide health policies is lacking. On the one hand extremists welcome disease and even vice as essential means of weeding out the weak and unfit. On the other, it is affirmed that all individual lives and all races are to be regarded by health organizations as equally valuable.

Probably no philosophy of preventive medicine can ever be agreed upon, but the problems involved cannot be ignored. Manifold world-wide contacts and interdependencies make the health of each in some sense the concern of all.

MENTAL HYGIENE

William A. White, M.D., Superintendent of St. Elizabeth's Hospital, Washington

The writer of a book I was reading on the way down on the train said that our problem has shifted since the war, that whereas we fought the war to make the world safe for democracy, now it is our business to make democracy safe for the world. If that is so perhaps it is a good formula with which to open a discussion of mental hygiene. I was further reminded on my way down here that several years ago in preparing a statistical study of the prevalence of mental disease throughout the United States I discovered that the state of Rhode Island had the lowest percentage of any state in the union. I was surprised because I had not expected to find it so. Geographically Rhode Island had no right to such a low percentage, so I looked into the situation to find the explanation, and I discovered the fact that the insane in Rhode Island were so miserably provided for and her institutions were so atrociously conducted that people were hiding their insane to keep them from public recognition so that they would not have to go into the public institutions. That was thirty-five years ago. Today I happened to be the guest of Dr. Ruggles of the Butler Hospital, which is one of the best privately conducted institutions for mental disease in the country. And your state hospital at Howard is a finely conducted state institution. Whatever the philosophy under which these improvements have developed, they have come to pass, and they are an indication that we may approach the problems of public health with faith that things are improving.

In the first place, with regard to a public health program as it affects mental health, it is important to approach it with the distinct understanding that we are not attempting to appeal to sentimentalism. Public health is not a matter of sentiment. Your ideals must be appealed to, not your sentiments. Public health probably has never been supported materially because of wishy-washy sentimentalism. There has always been a good reason back of what has been done. In the primitive days I can imagine when men of the tribe had differences they got into a fight, and when it was over it was realized that they could not afford to let individuals settle their differences in that way. A small number of people banded together as a tribe depended upon their total strength to such an extent that individual killing was too serious a matter to be permitted.

In that way I take it crime had its origin. It was an act addressed to the detriment of the tribe, which the tribe came to feel it had a right to interfere with. Then the tribe grew into a nation and it became evident that certain individuals impaired the progress of the tribe as such, and they met and agreed that those individuals had to be removed. The insane and the feebleminded were seen to be impediments in the way of the progress of the nation and had to be removed, and that was the beginning of the removal from the group of the people who were dangerous because of mental disease and defect. Later on, when civilization became complex and large communities grew up, often about industrial centers, it was found that the accumulation of filth that occurs where large numbers of people live closely together provided breeding places for disease, and disease threatened the lives of the community, and because of it they cleaned up these places as a matter of self-preservation. There was no sentiment about it at all; it was a movement for self-preservation. Later on, in the present day, we find feebleminded children being put into special schools. I take it there is not a great deal of

sentiment about that. The defective children interfere with the education of the normal children and we have seen that they must be segregated. Wherever we find defective children we find centers of crime, disease, potential trouble of every sort, and it becomes our selfish interest to see that the problems that surround that class of people are intelligently dealt with. That does not mean cruelly dealt with, but dealt with in a spirit free from sentimentalism, which is a different thing from kindness and humanitarianism. They need to be dealt with because we are interested in the results if they are not dealt with. Unless we found our public health program upon selfinterest it is in danger of not being carried out.

For many years we have been dealing with these defective classes in large masses, segregating them in public institutions, prisons, asylums, hospitals, not as individuals but as groups, and we have been climbing to the point where we have got to change our methods and because we have found we cannot longer deal with them in that group manner effectively. You may perhaps not realize that there are as many patients in the insane institutions of the United States as there are pupils in all the universities of the United States. And they cost many, many millions of dollars to care for, and it is because of the tremendous expense of their care-not only the insane and the defective, but the criminal-that an enormous amount of attention is being directed to the problem of every possible means of prevention as well as to the treatment and cure of the dependent, the defective, and the delinquent. And they cost in many other ways. Since we have begun to investigate these matters of cause and cure and prevention we find that we can no longer deal with them in the large and on the basis of mathematical averages. Averages are delusive. They have their value. Public health officials use them, and to good purpose, but they are deceptive. The existence of individual disease is so universal that the average can never be found, and therefore if we want to deal with the problem of disease as it is met in the individual we have got to get away very largely from the obsession of mathematical averages. There is, however, one significant average which resulted from the study and testing of 1,700,000 of the four million soldiers in our recent army. The average age of this group was found to be thirteen years. When you speak of the great public being exposed to educational ideas, you must realize that the great public has an average age of thirteen years. That makes the program seem a rather difficult one to put over. However, I take it public health program makers have no such public as that. We have somewhat of a different public. We have to expose our theories to a different public and trust that public to guide and direct the public of the thirteen-year-old age.

With regard to this individual problem of mental hygiene, I have indicated that we cannot approach it on the theory of mathematical averages. We have to deal with the individual persons. In order to make known what I mean let me draw an analogy. Dr. Vincent talked about automobiles, telling you that we do not deal with the probems of our physical health with anything like the intelligence that we bring to bear on the mechanism of our automobiles. That is very true. It is peculiarly true of the problems of our mental health. We are beginning to learn to deal with the problems of physical health so far as they relate to the control of epidemic diseases, and water supply, and sewage disposal. Matters of that kind are pretty well solved-not that all these problems are known in all details, but the way to tackle them is well known. We know, when we go into a given community and find typhoid fever, just how to go to work to clean up the situation. But the problems of mental health are not by any

means so near solution, and one of the reasons they are not is because the whole subject of the human mind has been studied by psychologists in laboratories who were more philosophers or metaphysicians than psychologists, not intent upon finding some practical solution for mental problems. Until the present generation the mind has never been appreciated as an instrument for use in adapting ourselves to life and solving our life-problems. We have done this and that, from the making of judgments to the building of cities, without any thought, or little thought, of the most important instrument we use in the comsummation of all these things, and that is the human mind.

In the chemical laboratory when I was in college the first thing I had to do before making any analysis was to carefully calibrate all my instruments, and if they were found to be inexact to make the necessary corrections, so that in weighing or measuring things I knew exactly how much error was included in the reading of the scale. How many people have considered that the human mind needs that same degree of study? If we are going to use the human mind intelligently we must calibrate it. That is not an academic statement, because this mind of ours has a way of playing us all sorts of scurvy tricks. A previous speaker was talking about getting things out of focus. All the illustrations he indulged in might be used by me to show the errors of the human mind. The suicide is under a misapprehension of what he is doing. He is not intent upon destroying his own life, but upon destroying a certain aspect of his personality which has become unendurable. Oftentimes would-be suicides can correct the difficulty and instead of destroying themselves can get well.

The human mind constantly approaches its difficulties under misapprehensions of one sort or another and it should be studied with care and intelligence in order that these errors may be corrected. In other words, it needs calibrating. I am reminded of a medical illustration of that. We had brought into the hospital some years ago an old gentleman who was a pianist. He was alcoholic and upon one occasion when he was drunk he broke his collar bone and was taken to the hospital. The young physician fixed him up and put on a dressing. It was a beautiful dressing. It held the two parts together perfectly. He had it on for several weeks, but when we took it off we found that the collar bone had made a perfect union but also found that the old gentleman's hand and arm had been bound up so long that the fingers were stiff, so stiff that it was impossible to relieve the condition and the old gentleman never played the piano again. Now, that doctor was a very good surgeon, but he was a mighty poor mental hygienist and his mind had played him a bad trick for which the patient had to suffer. He got a perfect surgical result but forgot that the collar bone belonged to this individual and that the individual had one particular accomplishment and it was the only thing in his life that was worth while. The surgeon destroyed that because he was unable to look at this individual except through the glasses of the surgeon; because he could not see the mental aspect of his patient he practically destroyed this human life so far as its usefulness was concerned.

We have had campaigns for physical health; we have had them for moral health, and for spiritual health, but the one thing largely left out of consideration is mental health. The mental health of our nation is perhaps as important, and perhaps more important, than all the others, because after you have this healthy body of yours and have protected the sanitation of the district in which you live and eliminated epidemic disease, what are you going to do with your perfect health, your perfect body if your body is but the instrument of your mind?. If the mind is not healthy, of what good

is your health of body? Perhaps you are in a more dangerous situation than if you had not paid so much attention to your physical health.

We might ask what has been accomplished up to the present time for the understanding of our minds and how they function, what has been accomplished in the campaign which puts happiness as a goal, which is as desirable as a pulse rate of seventytwo or a temperature of ninety-eight and three-fifths? A great many things have been accomplished. Our state hospitals for the care and treatment of the mentally ill are coming into the open and becoming the centers of the medical knowledge of mental illness, our outpatient clinics are bringing to a considerable number of people in their community an amount of information and help which is getting larger every day. Our outpatient clinic in Washington, established two years ago, is running with one physician full time, one physician part time, two psychiatric social workers, and is being besieged by organizations and individuals for help which it is unable to deliver. The hospital physicians have begun to go outside the walled inclosures of the state hospitals and get into the communities. They are training social workers, especially in the work of making adjustments of the mentally ill and helping them over the rough places after discharge. Special courts have been established for the peculiar delinquent children. There are psychologists connected with these courts who deal specifically with the problems of juvenile delinquency. Special schools are being established for abnormal children, defective children are being segregated from normal children. We are beginning to see a movement for the recognition and the study and the development of the defective child, and the unusual child who may perhaps become a genius is beginning to be properly studied. We are making marvelous strides in every direction. Psychiatry is not only as active but perhaps more active than any other department of medicine today. It has only recently come out of the Dark Ages and is going forward by leaps and bounds. Another thing the mental hygiene movement is credited with is its association by implication with all public health movements. When the health officer goes into a community-a small county, for example, in the country districts-what is the first problem he has to deal with? It is a problem of psychology. He has to insert himself into the good feelings of that community, secure their intelligent co-operation before he can accomplish anything. That is a psychological problem.

There are other burning questions. The hereditarian is telling us alarming things about our present-day civilization, more particularly in regard to some of the things that have happened as a result of social changes following the great world-war. The hereditarian tells us that the defective, the dependent, and the delinquent classes are increasing rapidly, that the intelligentia, and élite, are decreasing, are not even holding their own, that the great middle classes from which the élite is drawn are not holding their own, and that we are threatened with being overwhelmed and really submerged by this undercurrent of the inefficient. They tell us that in all the countries where there are signs of failure of great leadership, not only in Russia but in other countries, the submerged classes are increasing. Here we have a subject from which mental hygiene cannot be left out, because the value of these things is a psychological value. We must learn to determine who the efficient people in society are, how their qualities are transmitted, how we are going to build them up and how escape being submerged by these tremendous undercurrents that the hereditarians say threaten us so seriously. The part mental hygiene plays in such questions is that of seeing to it that those who deal with them approach them with a judicial mind. The human eye is a defective instru