LIPPINCOTT’S 
NURSING MANUALS 
MENTAL HYGIENE AND THE 
PUBLIC HEALTH NURSE 
BY 
V. MAY MACDONALD, R.N. 
Formerly Assistant Superintendent of Nurses, Johns Hopkins 
Hospital; Formerly Secretary of the Connecticut Society 
for Mental Hygiene; Lately Organizer of Social Work; 
National Committee for Mental Hygiene Lippincott’s Nursing 
Manuals 
DESCRIPTIVE CATALOGUE ON REQUEST 
NUTRITION OF MOTHER AND CHILD 
By C. ULYSSES MOORE, M.D. of University of Oregon Medical School. 
27 illustrations. 
HOW WE RESIST DISEASE. An Introduction to Immunity 
By JEAN BROADHURST, Ph.D., of Teachers College, Columbia University. 
138 illustrations and 4 plates. 
COOKE’S HANDBOOK OF OBSTETRICS 
Revised by CAROLYN E. GRAY, R.N., and PHILIP F. WILLIAMS,M.D. 
Ninth edition, revised and enlarged, 468 pages, 189 illustrations and 4 full 
pages in color. 
CARE AND FEEDING OF INFANTS AND CHILDREN 
A Text-Book For Trained Nurses by WALTER REEVE RAMSEY, M.D., 
of University of Minnesota. Second edition, revised, 290 pages, 123 
illustrations. 
SURGICAL AND GYNAECOLOGICAL NURSING 
By EDWARD MASON PARKER, M.D. and SCOTT DUDLEY BRECKIN- 
RIDGE, M.D.,of Providence Hospital, Washington, D. C. Second edition, 
revised, 425 pages, 134 illustrations. 
ESSENTIALS OF MEDICINE 
By CHARLES PHILLIPS EMERSON, M.D., of University of Indiana. 
Fourth edition revised, 401 pages, 117 illustrations. 
PHYSICS AND CHEMISTRY FOR NURSES 
By A. R. BLISS, Jr., Ph.G., Ph.Cn., A.M., Phm.D., M.D., Grady Hospital, 
Atlanta, Ga., and A. H. OLIVE, A.B., Phm.D., Hillman Hospital, Birming- 
ham. Third edition, revised, 239 pages, 49 illustrations. 
MATERIA MEDICA AND THERAPEUTICS 
By JOHN FOOTE, M.D., of Providence Hospital, Washington, D. C. 
Third edition, revised and enlarged, 310 pages. 
FEVER NURSING 
By J. C. WILSON, A.M. M.D., of Jefferson Hospital, Philadelphia. Ninth 
edition, enlarged and revised, 271 pages, illustrated. 
PRACTICAL BANDAGING 
By ELDRIDGE L. ELIASON, A.B., M.D., F.A. C.S., University of Pennsyl- 
vania Hospital. Second edition, revised, 126 pages, 163 illustrations. 
NURSING AND CARE OF THE NERVOUS AND THE INSANE 
By CHAS. K. MILLS, M.D., and N. S. YAWGER, M.D. Third edition, 
revised, 142 pages, 12 illustrations. 
ESSENTIALS OF SURGERY 
By DR. ARCHIBALD L. MCDONALD. Second edition, 2G5 pages, 46 
illustrations. 
MAKING GOOD ON PRIVATE DUTY 
By HARRIET CAMP LOUNSBERY, R.N., President West Virginia State 
Nurses’ Association. 208 pages. 
MENTAL MEDICINE AND NURSING 
By ROBERT HOWLAND CHASE, M.D., Physician-in-Chief, Friends’ 
Asylum for the Insane. Third edition, revised, 244 pages, 78 illustrations. 
NURSING TECHNIC 
By MARY C. WHEELER, R.N., Superintendent Illinois Training School 
for Nurses, Chicago. Second edition, 265 pages, 32 illustrations. 
STATE BOARD QUESTIONS AND ANSWERS 
By JOHN FOOTE, M.D., Assistant Professor of Therapeutics, Georgetown 
University Medical School, Washington, D. C. Second edition, revised. 
429 pages. LIPPINCOTT’S NURSING MANUALS 
MENTAL HYGIENE AND THE 
PUBLIC HEALTH NURSE / 
PRACTICAL SUGGESTIONS FOR THE NURSE OF TODAY 
BY 
V. MAY R.N. 
FORMERLY ASSISTANT SUPERINTENDENT OF NURSES, JOHNS HOPKINS HOSPITAL; FORMERLY 
SECRETARY OF THE CONNECTICUT SOCIETY FOR MENTAL HYGIENE; LATELY ORGANIZER 
OF SOCIAL WORK, NATIONAL COMMITTEE FOR MENTAL HYGIENE 
WITH A FOREWORD BY 
THOMAS W. SALMON, M.D. 
PROFESSOR OF PSYCHIATRY, COLUMBIA UNIVERSITY; LATELY MEDICAL DIRECTOR 
OF THE NATIONAL COMMITTEE FOR MENTAL HYGIENE 
PHILADELPHIA, LONDON & CHICAGO 
J. B. LIPPINCOTT COMPANY COPYRIGHT, 1923. BY J. B. LIPPINCOTT COMPANY 
PRINTED BY J. B. LIPPINCOTT COMPANY 
AT THE WASHINGTON SQUARE PRESS 
PHILADELPHIA, U. S. A WITH GRATEFUL ACKNOWLEDGMENT TO THOSE WHO 
FIRST OPENED MY EARS AND HEART TO THE GREAT 
CRY OF THE MENTALLY AFFLICTED AND GAVE ME 
HELP AND ENCOURAGEMENT DURING PIONEER EFFORT. “It is evident that some knowledge of the principles of mental 
hygiene and of the sources that are available for dealing with 
mental illness and the mental factors in general illness must in- 
creasingly be a part of the public health nurse’s equipment. 
She can hardly be a witness to the disintegrating 
effects of psychopathic conditions in the family circle and re- 
main content merely to observe the play of forces of which she 
is ignorant. She cannot be content to see the feeble-minded 
mother set the health standards of a home without wishing to 
possess knowledge of the avenues of instruction and encourage- 
ment that are open to the feeble-minded It goes 
without saying that to be successful, the public health nurse 
must not only be aware of these facts (concerning mental dis- 
ease and defect) and vigilant to detect them, but she should 
be trained also to know whatever practical resources exist for 
dealing with them.” 
—Report of the Rockefeller Foundation Committee 
for the Study of Nursing Education. FOREWORD 
During the years that saw the birth of nursing and the 
greatest growth of medicine as a science there came into the 
thought and speech of those working in both fields an un- 
founded distinction between mind and body that was destined 
to cause an untold amount of needless human suffering. When 
asylums and shelters for the sick were transformed into hos- 
pitals in which the new resources of medicine and surgery could 
be applied, the mentally ill were left behind in institutions 
that were capable of providing only custody and protection. 
When the new profession of nursing brought greatly increased 
comfort and chances for recovery to the sick, its benefit did 
not reach as far as those institutions in which men and women 
suffering from mental diseases had been left. When the pre- 
vention of disease became a practical aim instead of a pious 
hope, the most glowing prediction of what might be accom- 
plished by hygiene and sanitation failed to forecast the con- 
trol of disorders of the mind. 
Slowly this “ deadly parallelism ” between mind and body 
is disappearing, and last summer a great leader in science 
said that man must again be looked upon as an integrated organ- 
ism if the secrets of disease are to be fully revealed. Again, 
after a century of separation, mind and body are being studied 
together in preparation for the care of the sick, and today 
mental hygiene has a place in every broadly conceived program 
for the prevention of disease. Nevertheless, the isolation of 
mental medicine has not been fully destroyed and there still 
remain many of the differences of viewpoint and of practice 
that came into existence during the long period of parallelism. FOREWORD 
It is of the utmost importance that those who are working 
in allied fields in nursing, health and medicine should know 
the aims and methods of mental nursing, mental hygiene and 
mental medicine. There is need for books, clearly, simply and 
correctly written, to hasten the time when there shall be a 
reintegration of man in the prevention of his diseases as well 
as in their scientific study. Such a book is that which Miss 
MacDonald has written, chiefly for those who are to become 
public health nurses, but for a much larger group of readers 
as well. Drawing upon her own wide experience as well as 
the work of those who are adding to our knowledge of the 
mind in disease, she has brought together the information that 
is certain to be most useful to the public health nurse who is 
desirous of widening her own vision of her task. 
Columbia University, THOMAS W. SALMON. 
February 8, 1923. INTRODUCTORY 
PREVENTIVE MEDICINE 
Protection Against Special Diseases.—For many years now 
an increasing emphasis has been put upon the prevention of 
disease, and great advances have been made in this most produc- 
tive field of endeavor. One by one the great scourges of 
human life are giving ground before the protective processes 
which are robbing them of their former easy victories. Small- 
pox, diphtheria, tuberculosis, typhus fever, malaria, syphilis, 
typhoid fever and many others have had the secret of their 
power dragged to light, and powerful weapons have been forged 
to overcome them. It is now possible to protect the human 
body to a great extent by the methods of science. 
We have thus our armament for the fight against special 
diseases. But many weaknesses are revealed in the men and 
women who suffer these attacks. These weaknesses in adult 
life are very often the result of bad health habits in childhood. 
Could these not have been prevented? Good habits may be 
fostered rather than bad ones. Beyond the crowded ranks of 
those carrying the burdens and bearing the ills of adult life 
we see the oncoming millions of those who in their turn must 
be subjected to the common dangers. Can we not make of 
them a hardier race? Can we not envelope them from child- 
hood in a protective covering of good health habits? Eminent 
authorities encourage us to believe this possible. 
Side by side, therefore, with the increase of preventive 
and curative medical discoveries is growing the belief that in 
the education of children in habits of health lies the greatest 
promise of success in the campaign for public health. 
Preventive Measures in Mental Disease.—Not until very INTRODUCTORY 
recently has there been any wide recognition of the possibility 
of similar methods producing favorable results in the field of 
mental disorder. For centuries men have seen the splendid 
machinery of the human body rendered useless through dis- 
orders of the governing intelligence, and have accepted the 
condition as divinely ordered, inexplicable, hopeless and unpre- 
ventable. Now at last the light of science has brightened the 
wards where long rows of hopeless, helplessly idle men and 
women have sat through the long years waiting for death. It 
has penetrated the dark corners of almshouses where the men- 
tally sick have been herded with the pauper, the idiot, and the 
senile. It has revealed the cage which even today is still found 
in some districts of more than one of our enlightened countries 
as the sole method of treatment for a distraught mind. But 
still more far-reaching in effect, it is bringing to men’s 
knowledge the laws of mental health, and we are learning 
slowly how mental stability may be promoted, mental 
vigor secured. 
The Nurse as an Agent for Prevention.—The public health 
nurse is recognized as one of the most important agents in 
the struggle against disease and in the promotion of the physi- 
cal health of our people. “ In the campaign against disease 
the nurse is not merely an agent for the alleviation of suffering, 
but also the most powerful force at our disposal for its preven- 
tion and control. ’n The nurse is already obtaining wonderful 
results by implanting in children the simple basic habits of bodily 
health. She cannot longer ignore the field of opportunity 
that now lies before her to assist in the promotion of mental 
hygiene and in the detection and prevention of mental disease. 
1C.- E. A. Winslow, Dr. P. H., Director of Dept, of Health, League 
of Red Cross Societies. International Journal of Public Health, Sept.-- 
Oct., 1921. INTRODUCTORY 
Education in the laws of mental health and training in 
good mental habits will of course be the most constructive form 
of effort to reduce the burden of mental disease. No nurse, 
however, who has been brought into contact with mentally 
afflicted patients will be willing to ignore the suffering of those 
already definitely affected, and the present day hope of curing 
or arresting many forms of mental disease will make her eager 
to secure proper treatment for incipient or suspected cases. The 
public health nurse will therefore be not only an advocate of 
good mental training but also an agent to secure treatment for 
the mentally sick. Her work in constructive and preventive 
mental hygiene must inevitably be linked up with efforts to 
meet the needs of those already afflicted. Writing of preven- 
tive medicine Dr. Haven Emerson says, “It has been quite 
inevitable, because of the peculiar genius of American effort, 
that the obvious, the immediate, the so-called practical needs 
of the sick should be first met, and the theories and principles 
of prevention and action looking towards health promotion 
and protection be left until a new public opinion and a keener 
vision of relative values in medical services could be developed.” 
Advances in psychiatry have been so rapid and so recent that 
public understanding has not kept pace with them. The needs 
of the mentally sick must therefore be explained and met while 
we strive for a more general comprehension and application of 
the laws of mental health. CONTENTS 
Page 
INTRODUCTORY 
Prevention of Disease, Health Education, Application of These 
Principles in the Field of Mental Health vii 
SECTION I. 
THE PUBLIC HEALTH NURSE AND MENTAL DISORDERS 
CHAPTER I. 
Prevalence, Cost, and National Results of Mental Disorders 4 
Prejudice, Blindness and Self-deception of the Public 6 
Need for Educational Agents 8 
CHAPTER II. 
Training to Recognize Cases That Need Special Advice 9 
Symptoms to Arouse Suspicion 13 
CHAPTER III. 
Community Contacts for the Mental Hygiene Nurse 19 
CHAPTER IV. 
Field of Work 24 
SECTION II. 
THE PUBLIC HEALTH NURSE AND MENTAL HEALTH 
CHAPTER V. 
Mental Health of Children 33 
CHAPTER VI. 
Preventable Forms of Mental Disorder 47 
CHAPTER VII. 
Mental Defectives 56 
CHAPTER VIII. 
Opportunities for Giving Instruction in Mental Hygiene 63 SECTION I 
THE PUBLIC HEALTH NURSE AND MENTAL 
DISORDERS MENTAL HYGIENE AND THE 
PUBLIC HEALTH NURSE 
CHAPTER I 
THE SIGNIFICANCE, SIZE AND URGENCY 
OF THE PROBLEM 
Mental Defect and Disease Hamper Success in Efforts for 
Public Health.—The hampering influence on the success of their 
efforts for public health which is exerted by mental defect and 
disease in the community is being recognized by workers in all 
branches of the work. Good results from careful instruction in 
pre-natal hygiene and later in the care of the infant depend very 
largely on the mental status of the mother and her capacity for 
intelligent cooperation. The most dangerous to the community 
of all tuberculosis patients is the mental defective who cannot 
be trained to observe precautions and does not realize the neces- 
sity for the protection of others. Communicable diseases can 
be controlled with difficulty when the sick child’s mother or the 
germ-carrying man himself cannot grasp or carry out the regu- 
lations for isolation and disinfection. Personal hygiene is not 
possible without comprehension and memory, and health teach- 
ing makes little impression on a dwarfed intelligence. It is 
apparent, therefore, that full success in the field of general 
hygiene is of necessity linked with the development of 
mental hygiene. 
To the honor of the nursing profession it may be safely 
said that no sooner is an epidemic reported than trained nurses 
are found ready to grapple with it, often under trying conditions. 
If it were possible to foretell a visitation of a new and devas- 
tating sickness that would claim 50,000 victims within the com- 
3 4 
THE PUBLIC HEALTH NURSE 
ing year the whole body of nurses would hasten to learn every- 
thing known about the prevention, the early symptoms and 
the treatment of the expected scourge. Such devastation will 
come upon this country this year, but because it will be spread 
over the whole country rather than dramatically attacking one 
locality, nurses may ignore this challenge to their skill 
and sympathy. 
Prevalence, and Cost of Mental Disease.—The importance 
of the present day belief in the possibilities of prevention and 
the benefit of early treatment of mental disorders may be realized 
if we study for a moment the figures relating to their prevalence. 
In institutions in the United States on January I, 1920, there 
were 232,680 patients with mental disease, or 220 for every 
100,000 of population. From the latest available figures, about 
the same ratio is found in Canada. We learn that after careful 
investigation “ it may be concluded that during the year 1919, 
there were approximately 50,000 new admissions with mental 
disease to the hospitals in this country and 14,000 re-admis- 
sions.”1 There is no adequate reason for considering that 
year exceptional. “ From the point of view of cost, misery and 
the numbers of our people involved, mental disease constitutes 
a larger problem than any of the others. In addition to the 
beds reserved for the feeble-minded and for sanatorium care of 
the ‘ nervous breakdown,’ there are as many beds for the insane 
in this country as there are hospital beds for all other diseases 
combined. And the significance of this is greater when we 
see that the needs of medical, surgical and tuberculosis patients 
are fairly met, while less than half of those suffering from ner- 
vous and mental disorders, who should be! cared for apart from 
their homes, are at present provided for throughout the 
1 “ Social Facts Relative to Patients with Mental Diseases.” Edith M. 
Furbush, Statistician, National Comm, for Mental Hygiene. POSSIBILITIES OF PREVENTION 
5 
country.”2 Apart from the incalculable amount of human 
suffering which it entails, mental disease brings on the country 
an immense financial burden. The average cost of providing a 
year’s treatment for a patient in an institution for mental disease 
has been carefully estimated at $385. The average yearly earn- 
ings above their necessary maintenance of both men and women 
throughout the country have also been calculated. It is not 
difficult therefore, to compute the loss suffered by the country 
from the ravages of mental disorders. Accepting as a basis the 
results of a careful study of 46 widely separated state hospi- 
tals we find the general proportion of men and women among 
the patients and can arrive at definite conclusions. The total 
of the cost of care, and the sum of the earnings lost by these 
232,680 patients with mental disease during that one year 
amounted to $162,63 3,000.3 Apart from humanitarian 
motives, this enormous loss in itself calls for every effort to 
lessen this public burden. These figures do not refer in any 
way to the great army of the mental defectives, or feeble- 
minded, both in and out of institutions. Their cost to the 
country must be studied less in the sums expended for institu- 
tional care and special teaching than in their large share of 
responsibility for the grievous burden of inefficiency, pauper- 
ism, prostitution, delinquency and crime. 
Possibilities of Prevention.—If we read now the statement 
of an eminent psychiatrist, Dr. E. Stanley Abbot, Director of the 
Pennsylvania Mental Hygiene Committee, we shall discover 
the opportunity for preventive work. He writes, “ An inde- 
terminate but very large amount of feeble-mindedness can be 
* “ Place of Mental Hygiene in the Public Health Movement.” Haven 
Emerson, M.D., Mental Hygiene, April, 1922. 
3 “ Social Significance of Dementia Prsecox.” E. M. Furbush, Mental 
Hygiene, April, 1922. 6 
THE PUBLIC HEALTH NURSE 
prevented; of the insanities proper, the alcoholic and drug 
psychoses and general paralysis—a fifth of all the cases occur- 
ring each year—can be absolutely prevented; of the fatigue 
psychoses a large proportion, possibly a half or three-quarters, 
might be avoided; possibly a small proportion of the dementia 
prsecox and arteriosclerotic psychoses might be obviated; and 
a small proportion of the remaining forms also might be pre- 
vented. Thus if the means here suggested should be universally 
known and applied throughout the state, it would happen in 
the course of a generation that there would occur yearly, at a 
very conservative estimate, a quarter, and at a reasonable and 
moderate estimate, a third less insanity in the state, and I 
do not dare to say how much less feeble-mindedness—perhaps 
three-fourths.” 
We have long realized our responsibility for the preven- 
tion of typhoid fever, a disease which, when not fatal, does not 
generally incapacitate the patient for more than eight or ten 
weeks. Here are a number of preventable diseases which 
remove their victims from home and work for years, if not for 
life. Surely this is a challenge to all the forces working 
for prevention. 
Prejudice, Blindness and Self-deception of the Public.— 
When some bodily function is impaired and very obvious 
results soon follow, the sufferer is conscious from the beginning 
that all is not well, and his family soon seek advice from 
their own physician or the clinic or the hospital. Not so when 
symptoms of mental abnormality become apparent. There still 
lingers more than a hint of the mediaeval attitude towards men- 
tal disorders. The victim is either “ queer,” or considered hope- 
lessly stricken. In any case it is a matter to be kept hidden as 
long as possible. The family is sometimes more concerned 
over its own “ disgrace ” than over possible treatment for the PREJUDICE, BLINDNESS AND SELF-DECEPTION 
7 
sick one. Very often the fear of being required to “ put her 
away ” prevents a loving mother from revealing the queer 
behavior of her adolescent daughter. The hospital for mental 
disease is still for many people the old custodial asylum, over 
the door of which they think might properly be written, “ Leave 
hope behind who enter here.” The wonderful advances in 
the understanding and treatment of mental diseases in the 
last twenty years are not yet appreciated by the general public. 
They do not realize that psychiatry has passed from a science 
descriptive of groups to an analytical study of the individual, 
and that a new era has dawned. They do not know that 
treatment in the earlier stages means more frequent cure, or 
that proof of family devotion lies now most often in securing 
hospital care at the onset. With the legal barriers to admis- 
sion to mental hospitals being removed by the increasing pro- 
vision for voluntary commitment, much of the painful publicity 
and the resulting distress of the family will disappear. 
Mental diseases are as a rule slow in development. Insidi- 
ous in their growth, they are not soon recognized. It is true 
that Mary has passionate outbreaks of temper, becoming more 
frequent of late, but then her grandfather was always hot- 
tempered even before he made that murderous attack—and 
Mary probably “ takes after him.” Sarah is certainly growing 
very suspicious of everyone and will not join the other girls 
in their fun. She mopes by herself, and is growing very untidy 
in her dress—but then all girls are not alike. Mrs. Overthe- 
way, who has those six little children and a drunken husband, 
has seemed queer ever since the last baby came, and talks in a 
very funny way—but who wouldn’t be upset with all her 
worries? And so it happens that mental hospital superin- 
tendents say that hardly a patient comes to the hospital for 
treatment who has not had his disease for at least a vear, 8 
THE PUBLIC HEALTH NURSE 
Perhaps, on the other hand, the behavior of a son or daughter 
or parent does arouse some apprehension. Then any reason 
is sought and accepted before the possibility of mental sick- 
ness is acknowledged. It is school, or business worries, or a 
love affair, or physical sickness—anything other than the early 
symptoms of an illness which demands very skillful handling. 
Is it any wonder that with all this prejudice and blindness 
and self-deception it is still difficult to secure the best results 
from the discoveries already made? To do this there must 
be some means of bringing home to the community the scien- 
tific and more hopeful attitude of the present day towards 
mental disorders. Public health nurses, coming and going in 
innumerable homes in their districts, may prove themselves 
acceptable and effective agents for this service. CHAPTER II 
TRAINING FOR WORK IN THE FIELD OF 
MENTAL HYGIENE 
Training in Psychiatry Essential but often Inadequate.— 
The great increase of interest in psychiatry has been so recent 
that there are still only a few of the foremost schools of medi- 
cine that give adequate training in the treatment of mental 
disorders. Many do not give more than a few lectures on 
the whole immense subject, so that it is rarely one finds a 
general practitioner who is equipped to deal with these patients. 
This failure of medical schools to give sufficient instruction 
in psychiatry is reflected in the general training schools for 
nurses. One can readily count the few schools which give their 
pupils anything more than the briefest introduction to psychol- 
ogy and psychiatry. Fortunately in the curricula of eight or 
ten good general schools there is included a fairly comprehen- 
sive course of lectures and practical experience with mentally 
sick patients. This means a steadily increasing group of nurses 
who will remember that human beings have both mental and 
physical mechanisms, either of which may get out of order 
and react on the other. Post-graduate courses in public health 
nursing usually include a series of lectures on mental hygiene, 
an essential part of a good course. Special training in psy- 
chiatry and experience in this field are, however, absolutely 
necessary for the nurse who expects to take responsibility in 
the care of a mentally disordered person. 
It is now being recognized that the cause of many physical 
sicknesses must be sought in the patient’s nental condition. 
A large group of returned soldiers suffering from functional 
9 10 
TRAINING FOR WORK 
heart disorders remained for months at a government hospital 
without improvement from the usual cardiac treatment. An 
eminent psychiatrist was sent to study their condition and 
under his management of the mental factors excellent results 
were soon obtained. In the forms of hysteria and the psycho- 
neuroses it is easy to see the influence of the mind on the 
machinery of the body. The time is not far distant when no 
nurse will be considered fully trained who has not had at least 
three months of psychiatric training. 
Meantime there are thousands of nurses already engaged in 
various forms of public health work who, if they will, may equip 
themselves to give valuable aid in mental hygiene by learning 
the basic facts about normal mental processes just as they 
understand the healthy functioning of the body, by familiar- 
izing themselves with the early symptoms of mental diseases 
and bringing suspected cases to the attention of specialists, and 
by spreading a knowledge of the laws of mental health. More 
than this, they may disseminate their own common-sense, intel- 
ligent attitude toward mental disorders and promote a more 
sympathetic understanding of the needs of the mentally 
sick individual. 
Basic Facts of Psychology.—The basic facts of psychology 
must be known if one would comprehend the machinery of our 
mental life. Nurses whose instruction has not included simple 
psychology should rectify this serious omission. The relation 
between the various mental processes forms a fascinating study, 
and community nurses who must deal with many individuals 
will find this study a help in solving their problems. Anatomy 
and physiology teach us the response of the nervous system 
to stimuli and the protection of the whole organism by the 
resulting impulses leading to suitable action. The action may 
be reflex, as in the hasty withdrawal of a finger from a hot BASIC FACTS OF PSYCHOLOGY 
11 
iron, or voluntary, representing a choice of action. The per- 
ception of sense impressions begins our mental life. All human 
beings are found to have from birth certain instincts with 
their accompanying emotions. These are the general inheri- 
tance of the race and are ever seeking expression throughout 
life. Their purpose is the preservation of the individual and 
the continuance of the race. We find, for example, the instinct 
of flight with the emotion of fear, pugnacity with anger, curi- 
osity with wonder, reproduction with sex-love. Besides this 
general inheritance is the individual inheritance of a spe- 
cial temperament. 
Habit formation is believed to be due to the formation of 
pathways among the brain cells by the repeated discharge of 
an impulse from a similar stimulus over the same route. Every 
repetition makes the path more marked and the response more 
immediate. This is true not only of muscular habits such as 
walking, piano-playing and the like, but also of habits of 
thought. These can be developed by practice just as surely 
as skill of fingers. Bad habits of either body or mind can most 
surely be broken by practicing healthful ones instead. It is 
not enough to try to drive out bad mental habits by force of 
will. New pathways must be formed in their place. Weeds 
always grow in an unplanted and untended garden. 
Of greater importance is the fact that all mental impres- 
sions are retained either in the corlscious mind or in the store- 
house of the subconscious mind. The treatment of certain 
functional nervous and mental disorders is based on this fact. 
Other facts of basic importance are the growth of reason and 
judgment from the facts of experience, the influence of emotion 
on conduct, the control of impulses by the will, and the presence 
in man of a spiritual element expressed in ideals. A developed 
and normally acting mind brings about through these mechan- 12 
TRAINING FOR WORK 
isms an adequate adjustment of the individual to his physical 
and social surroundings. Such an adjustment is a test of 
mental health. 
Mental Disorder, Insanity and Mental Defect.—By mental 
disorder is understood a departure from normal mental health. 
There are many types of mental disorder. Insanity is the con- 
dition of “ those members of the community who are so far 
from able to adjust to the ordinary social requirements that 
the community segregates them (perhaps forcibly), and takes 
away their rights as citizens.”4 Many persons suffer from 
some form or degree of mental disorder who are not com- 
mittable by legal measures to an institution for treatment. 
Paranoiacs in the early stages of their malady are not infre- 
quently found whose delusions make them a nuisance to their 
friends, and yet whose management of their ordinary affairs 
makes it impossible to dispossess them of their freedom. There 
are many forms of mental disorder of varying causation, dura- 
tion and prognosis. The condition may be acute, as in acute 
alcoholic psychosis, or chronic, as in dementia praecox; curable, 
as exhaustion psychosis, or hopeless, as senile dementia; 
organic, as general paresis, or functional, as maniac-depressive 
insanity. Many of these may develop on a normal makeup. 
Mental defect is a condition of checked mental growth, resulting 
in permanent mental childhood at a stage which varies with the 
individual. A mental defective may develop a mental disease, 
but the two conditions must not be confused. For those suffer- 
ing from mental disorders there are appropriate treatments, 
expected to cure or to ameliorate the condition. For the defec- 
tive there is education in good habits and simple crafts suited 
to the dwarfed intelligence, and social treatment calculated to 
protect both himself and the public, and to help him attain 
* Outlines of Psychiatry, William A. White, M.D. SYMPTOMS WHICH SHOULD AROUSE SUSPICION 
13 
whatever success his condition allows. Nurses must be care- 
ful to discriminate between the mentally sick and the mentally 
dwarfed. Much confusion of thought results from the too 
common confusion of terms. 
Odd Behavior Always Worth Noting.—Sickness of mind 
most often registers itself first in altered behavior. The mind 
is the governing machine for our actions. Marked changes in 
conduct will arouse the interest of an alert nurse, since marked 
deviations from a person’s usual standard of behavior are 
always worthy of attention. Actions are considered so signifi- 
cant that in modern mental hospitals “ behavior charts ” are 
carefully kept. Persons who are reported by their neighbors 
as “queer” are worth investigating. How often in a newspaper 
account of a murderous attack by an insane man does one read 
that for a long time his neighbors had noted his odd behavior 
but believed him harmless! That means that the early symp- 
toms of a year or two previous had been overlooked or their 
significance not appreciated. Suitable treatment for the men- 
tally sick man and the protection of the public alike demand 
that this careless attitude be abandoned. It is true that in 
following such clues, if given by the ignorant, the nurse may 
discover a person living an ordered life based on a standard 
different from his neighbors’, or may even find a genius. These 
will be pleasant surprises, only too rare. Mental disease or 
feeble-mindedness is more likely to be revealed. No public 
health nurse would fail to follow up a rumor of an uncared- 
for case of bodily sickness, and her interest in a person des- 
cribed as “acting queerly” may serve to prevent a tragedy. 
Symptoms Which Should Arouse Suspicion.—There are 
certain early symptoms of mental disorder for which a nurse 
should be on the alert, just as she is quick to perceive condi- 
tions which suggest possible tuberculosis. “ A better knowledge 14 
TRAINING FOR WORK 
of these early danger signals should be useful to all those who 
have to deal with children and young people. . . These earliest 
signs deserve more particularly to be pushed into the foreground. 
They undoubtedly represent unhealthy ways of living.”5 There 
are three strong reasons for the early treatment of persons with 
mental disorder. It is the most hopeful period for obtaining 
the best results for the patient. It will most surely prevent 
serious social consequences resulting from the neglect of irre- 
sponsible people. It will prevent suicide in a large number of 
cases, a reason sufficient in itself. In 1920, there were 8,959 
suicides in the registration area of the United States. We may 
conclude that there were 10,899 suicides in the whole country 
during that year. 
The nurse will not attempt to diagnose the condition of a 
suspected case, and she must not suggest to the family the 
possibility of mental disease, but she will know whether special 
advice should be sought. Conditions which should arouse her 
suspicions are not of necessity always followed by insanity. 
The following are among the more important: 
Persistent unhealthy emotional states, such as exaggerated 
anxiety, groundless fears, moodiness, sadness, without 
sufficient continuing cause. 
Marked change in disposition and temper, as from good- 
natured to irritable and violent, from prudent to fool- 
ishly extravagant. This is well exemplified in the early 
stages of general paresis. 
Seclusiveness, reticence, gradual withdrawal from ordinary 
social intercourse. The girl will not join with others 
of her age, the woman refuses for months to go out- 
side her own door. 
Marked suspiciousness of others without cause. 
*Early Manifestations of Mental Disorders, by August Hoch, M.D. SYMPTOMS WHICH SHOULD AROUSE SUSPICION 
15 
Ideas of persecution, as when a man believes that the fac- 
tory foreman arranges the work to his disadvantage, 
that fellow-workmen are conspiring against him, that 
people are trying to poison him, that electric currents 
are being turned on him, etc. 
Ideas of self-reference. A woman believes that neighbors 
stopping to converse must be talking about her, people 
in street cars are saying evil things about her, the simple 
overheard remarks of strangers refer to her. In short, 
that all the common happenings of the world around 
have a special reference to herself. 
Marked inability to work harmoniously with others. Fre- 
quent dismissals from employment for this reason. 
Marked and increasing exaggeration of any one set of ideas, 
as self-importance, seen in the grandiose ideas of the 
paretic; feelings of inferiority, self-depreciation—many 
of the depressed types believe that they have 
committed the “ unpardonable sin.” Religion, dispro- 
portionate fervor, as in the case of a woman who 
neglected her house and starved herself by continuous 
praying. 
Delusions, false beliefs which cannot be shaken by argu- 
ment or proof. 
Hallucinations, sensory impressions without foundation in 
fact. Generally of hearing, smell, sight. Often uncon- 
fessed for a time, but the patient is seen in a listening 
attitude when there is nothing to hear, or may be over- 
heard when alone replying to “ the voices.” Patients 
with this symptom should have immediate attention 
because they may feel compelled by “ the voices ” to 
commit impulsive acts. 16 
TRAINING FOR WORK 
It will be noted that most of these conditions result in 
altered conduct. Mental disorder most often reveals itself in 
departures from normal conduct before there is any change in 
the intellectual faculties. The first recognition of mental dis- 
ease will not be a matter of tests of intelligence, but of care- 
fully noted behavior which habitually differs from the man’s 
usual custom and the accepted standard. The difference tends 
to become greater and brings the patient into conflict with 
accepted laws and customs. 
Epilepsy.—“ Epilepsy and the mental disturbances con- 
nected with it are so intimately related that they can hardly 
be considered separately.”6 In the mild form of the disorder 
(petit-mal) there is a slight momentary loss of consciousness 
without convulsions. The patient does not fall, and proceeds 
with whatever he was doing, so that spectators may consider 
the attack only “ absence of mind.” The condition tends to 
grow serious. True epilepsy (grand mal) is characterized by 
sudden attacks of complete unconsciousness, often with some 
premonitory sensation, in which the patient falls wherever he 
may be. A rigid state is followed in a few seconds by a jerking 
of all the voluntary muscles. This lasts some minutes, rarely 
up to ten, and the patient sinks into a stuporous sleep. If he 
apparently regains consciousness between the convulsion and 
the sleep he should nevertheless be carefully guarded because 
he is not at that stage responsible for his actions. 
Epilepsy is essentially a home problem, since comparatively 
few of these sufferers are sent to an institution for treatment. 
It is a disorder which is often allowed to go without adequate 
attention because the obvious symptom is accepted as summing 
up the whole situation. The nurse can do much to make the 
6Mental Diseases, by James V. May, M.D. PSYCHONEUROSES 
17 
family understand that suitable occupation and recreation and 
an unirritating environment may do much to control the con- 
dition. L. Pierce Clark advocates teaching adjustment to the 
surroundings, reducing environmental friction, and finding 
suitable outlets for the individual’s desires. He has reported 
a series of cases showing that the frequency and severity of 
seizure can be greatly influenced, “ with the more or less per- 
manent arrest of the disorder in not a few cases.”7 The general 
tendency of epilepsy is toward mental deterioration, but patients 
may carry on guarded occupations for years. Because of the 
suddenness of the seizures they should never be employed 
around machinery, fires, boilers, or on elevated places. Epilep- 
tics showing marked irritability, excitement, moodiness or de- 
pression should have medical supervision at once. 
In Jacksonian epilepsy, which is due to pressure in some 
area of the brain, the convulsive twitching begins in one set 
of voluntary muscles and may spread till all are affected. 
The mother should be taught to observe carefully the progress 
of an attack. At the instant of seizure she should note the exact 
spot, which finger or toe, first begins to twitch. The accuracy 
of her observation will guide the surgeon to the spot needing 
surgical relief. 
Psychoneuroses.—There is a group of disorders which pre- 
sent both mental and physical symptoms and hence are often 
spoken of as border-line conditions. These are the psychoneu- 
roses, including neurasthenia, psychothenia with its obsessions, 
doubts, anxiety, phobias, and the forms of hysteria. These 
disorders are very frequently the result of unhealthy modes 
of living, and all require re-education as an important factor 
7 “ Clinical Studies in Epilepsy” (Concluded). L. Pierce Clark, M.D., 
Psychiatric Bulletin, January, 1917- 18 
TRAINING FOR WORK 
in treatment. They will be discussed in the section 
on prevention. 
RECOMMENDED READING 
Elements of Psychology, Thorndike. 
Social Psychology, MacDougall. 
The Psychology of Insanity, p. 176, Bernard Hart, G. P. Putnam’s Sons, 
N. Y. 
Outlines of Psychiatry, William A. White, M.D. 
Nursing Mental Diseases, Harriet Bailey, Macmillan Co. CHAPTER III 
COMMUNITY CONTACTS 
The nurse who hopes to bring help and comfort to the 
much neglected group of the mentally sick must first of all 
have a right attitude herself towards mental disorders. Any 
levity or word of ridicule about the mentally abnormal is 
beneath the dignity of her profession. No nurse who even 
guesses at the depth of suffering endured by a mentally sick per- 
son and his family will be guilty of the bad taste and heart- 
lessness of facetiousness about “ nuts,” “freaks,” etc. One 
such remark may check the revelation of an unsuspected family 
problem needing her help. On the other hand, her sympathetic 
attitude will make people ready to talk to her of their carefully 
concealed anxieties. 
How Incipient Cases May Be Found.—Since there is so 
little public understanding of the nature of mental disorders 
and the possibilities of modern treatment, it follows that the 
early cases must be looked for in the community if they are 
to receive the help their condition demands. The public health 
nurse goes into many homes and may locate at firsthand an 
incipient case. But the claims on her time are many, so that 
if she wishes to do much preventive work in mental hygiene 
she must enlist other eyes and ears and understanding minds 
to help her find those who need special advice. There are in 
the community many means of contact through responsible 
people who are in touch with large groups. A few minutes’ 
description of the misfit persons whom she seeks from a desire 
to help them will result in securing the cooperation of these 
men and women in reporting possible patients to the nurse for 
her investigation. 
19 20 
COMMUNITY CONTACTS 
The nurse should explain to the local clergymen and church 
visitors what preventive work and early treatment will do, and 
ask them to let her know which are the problem cases among 
their people. Settlement workers see many young men and 
growing girls, and can point out the odd one who does not fit 
in with the usual groups. The superintendent of the Salvation 
Army shelter will know the hopeless “ repeater ” among his 
proteges who seem “ not quite right.” The secretaries of the 
Young Men’s and Young Women’s Christian Association will 
always have two or three members of their clubs who cause 
them some anxiety because of abnormal behavior. 
The nurse should go into the factories and tell the overseers 
and foremen why she would like to be told of the men or women 
who cannot work harmoniously with their fellows. Welfare 
workers in factories can bring to her attention not only the 
tuberculosis suspects but also the mentally unstable employe 
who is always a problem. The possibility of helpful treatment 
for these difficult people is only beginning to be thought of in 
factories, although in a few progressive places mental hygiene 
in industry is recognized as a problem important enough to 
justify employing a special worker for its promotion. One 
printer, who was the representative for his shop of a work- 
men’s anti-tuberculosis association, exclaimed on hearing of 
the possible use of mental clinic, “If we had only known this 
last year we might have saved a man in this shop who was 
queer for a long time and then committed suicide.” The 
stress of daily work and constant adjustment to one’s fellows 
often reveals the incipient mental case. 
It is highly desirable to make the acquaintance of the local 
judge, the parole officer and the chief of police. The nurse 
should ask them to let her get special advice for the epileptic 
who is often in court, for the growing boy so often in trouble, HOW INCIPIENT CASES MAY BE FOUND 
21 
and for the man who has made repeated assaults on his family. 
One man had been arrested four times for drunken attacks 
before a mental hygiene nurse learned of his behavior and had 
him examined by a psychiatrist. He was a definite case of 
alcoholic insanity, and instead of receiving another useless jail 
sentence was sent to a mental hospital. An old Italian had 
been three times jailed for riotous behavior which was ascribed 
to drink, when a friend sought out the nurse to say that the 
old man was temperate, and perhaps was sick. Examination 
disclosed a mental disease. In many large centres there is 
now a psychiatrist and a psychiatric social worker attached 
to the city court, but this sensible provision is yet comparatively 
rare. When not already well informed, parole officers should 
be made acquainted with the literature on the connection between 
feeble-mindedness and delinquency. 
Employment bureaus all know the pitiful woman who can- 
not keep a place longer than a few days because the “ voices ” 
she thinks she hears all night goad her into noisy rejoinders. 
Playground supervisors can point out the very difficult children 
who seem always to be a storm centre. There are sometimes 
mental defectives among the group who are a moral menace 
to the others. 
In a rural community there is little chance of news of 
mental clinics or hopeful treatment reaching isolated farm- 
houses. The nurse will do well to ask for a hearing at a meet- 
ing of the local Grange or other farmers’ associations, to tell 
them what early treatment might do for cases allowed too often 
to remain on the farm for a year or two without advice. A 
widow was reported to be sacrificing her farm and stock, little 
by little, in a vain effort to work the place herself and keep her 
mentally sick son from “ having to go to the hospital.” One 
afternoon of persuasion and explanation of conditions resulted 22 
COMMUNITY CONTACTS 
in her placing the crushing responsibility where it properly 
belonged. 
An invitation can be procured to speak at the first meeting 
of local school-teachers. They should be asked to report the 
children who are truants, who are often excused from atten- 
dance, who are “ repeaters ” in classes. Among these one finds 
often the mental defectives. It will also be well worth while 
-to have reported the day-dreamers, those of solitary habit, the 
over-wrought child, and the child of passionate temper. Such 
children need comprehending government to assure mental 
stability. “ Children who suffer from an intense self-con- 
sciousness and shyness, who are fearful and apprehensive, who 
are markedly unsocial and do not mix with other children, who 
show tendency to depression, who are dreamy and unpractical, 
or who are apathetic and passive with little active interest in 
anything, are not recognized as problems because they give 
little or no trouble. They are frequently excellent in school- 
work and are models of good behavior. They are, nevertheless, 
quite as badly adjusted as the more spectacular group and in 
need of a training which will get at the root of their difficulties 
and help them to overcome their unhealthy tendencies.”1 Men- 
tal hygiene in some of its phases at least is now being included 
in the training at many normal schools, and nurses will find 
many teachers able to point out children who show unhealthy 
mental tendencies. 
The examples given above by no means exhaust the means 
of contact with the individuals who need special advice and 
guidance to avoid mental breakdown. They will serve, how- 
ever, to indicate the methods by which incipient cases may be 
discovered. In securing the cooperation of the individuals and 
agencies with opportunities of seeing large numbers of people 
the nurse must use discretion in discussing mental symptoms. 
1,1 How Can We Safeguard the Child Against Mental Disease? ” Jessie 
Taft, Ph.D. HOW INCIPIENT CASES MAY BE FOUND 
23 
There is so little knowledge of the subject even among other- 
wise informed people that statements may be misinterpreted 
or misquoted if care is not taken. It will be wise to stress the 
idea of prevention, and to arrange that she shall be allowed 
to approach the individual in her own way. 
It is a curious fact that cases of mental disease may have 
been recognized and known, even to members of the medical 
profession, and yet no responsibility felt to secure treatment 
for the patient and protection for others. This is a deplorable 
result of medical training that considers mental disease as 
a thing apart. A visiting nurse reported to a Mental Hygiene 
Society that the mother of a three weeks old baby who had lately 
come under her notice was acting and talking curiously, a condi- 
tion which neighbors had noted for some months. The doctor 
attending the confinement said that she was intemperate and 
perhaps insane. He had taken no further steps, however, though 
he said he was sure the infant would die from mishandling or 
neglect. The condition was common knowledge in the neighbor- 
hood. The mental examination revealed an alcoholic psychosis 
with ideas of persecution and a tendency to impulsive acts which 
made her a dangerous guardian for the child. Immediate 
arrangements were made for the care of the baby and hospital 
treatment for the mother. The public health nurse proved to 
be the means of protecting both the mentally sick and the 
helpless infant. 
The establishment of a mental clinic will of itself bring to 
light many cases needing advice. In the Thirty-third Annual 
Report of the New York State Hospital Commission, 1920-21, 
we find that out of the 13,328 visits made during the year to 
the 37 clinics maintained by the state hospital?, 4,609 visits were 
made by persons who had had no previous connection with the 
hospital. Of these, 2,861 were first visits. These figures should 
remove any doubt that accessible mental clinics are a necessity 
in the campaign for mental health. CHAPTER IV 
THE FIELD OF WORK 
Special Knowledge of the District Needed.—The public 
health nurse who means to include mental as well as physical 
sufferers among her patients should equip herself at the begin- 
ning with full knowledge of all the agencies for diagnosis1 and 
treatment that are within her reach. The state hospital should 
be visited, and all the cheerful modern provision for care and 
treatment particularly noted. It will be very helpful in break- 
ing down ignorant prejudice against “ asylums ” in a family 
whose son should have institutional treatment to be able to 
describe the wards and the occupations and diversions so that 
they may visualize the place as a hospital and not a prison. 
The nurse should make the acquaintance of the superintendent 
and the chief members of his medical staff and discuss with 
them possible cooperation in the work of prevention and early 
care. Where there are special social workers employed by the 
hospital they will be glad to assist her in securing treatment 
for her patients. 
Mental Clinics.—Mental clinics within reasonable distance 
should be located, and the hours for attendance and the names 
of the doctors and special workers ascertained. These clinics 
are now being established in many cities. All state hospitals 
are enlarging their horizons and realizing that the early clinic 
case may be kept from requiring institutional care. The secre- 
1 By “ diagnosis ” is meant, throughout this book, a statement of the 
problems presented by the individual case, the special dangers, the proper 
disposition of the case, and the prognosis, rather than the exact labelling of 
the condition. The latter sometimes requires months of observation. 
24 ADMISSION TO MENTAL HOSPITALS 
25 
tary of the New York State Hospital Commission reported 
that “ During the year ending June 30, 1920, a total of two 
thousand one hundred new cases attended these forty-one clin- 
ics (maintained by New York state hospitals). None of these 
patients had ever been in a state hospital, and the advice given 
them at the clinics was of sufficient value to enable them to 
continue their work in their own homes throughout the year.” 
Since clinic treatment tends to relieve the over-crowding in the 
state hospitals it is in the general interest to have reliable mental 
clinics widely accessible. In several states they are maintained 
in four or five towns by the neighboring state hospital. In 
a state where no mental clinics exist the public health nurse 
can give valuable public service by demonstrating the need for 
them by the number of cases needing advice which she dis- 
covers in the community. A plea for the establishment of a 
clinic, based on evidence of this kind, will not fail of result. 
If no clinic facilities are available the state hospital can advise 
as to which private physicians in the locality have most experi- 
ence in dealing with mental cases. The National Committee 
for Mental Hygiene has compiled a nation-wide list of mental 
clinics and private physicians interested in this branch 
of medicine. 
Admission to Mental Hospitals.—It is characteristic of many 
types of mental disease that the patient has no realization of his 
abnormal condition. He may refuse hospital treatment, or 
once in the hospital, may refuse to stay. Since no citizen may 
be deprived of his liberty and the control of his property with- 
out due process of law, hospital authorities could not hold him 
against his will, though he might be a menace to himself and 
to the community. For this reason the law has provided for 
his safety and for the protection of the public by a method 
of legal restraint, or commitment. 26 
THE FIELD OF WORK 
The regulations governing commitment to a mental hos- 
pital vary in different states. In general it is provided that 
some relative or friend shall make application to the court for 
the patient’s commitment. An appointment is made for the 
hearing, and a notice is sent to the patient, who is privileged 
to appear and contest the proceedings. At the hearing the 
magistrate receives the sworn testimony of two qualified physi- 
cians who have examined the patient. If the evidence proves 
that “ the acts, declarations and conduct of the person are incon- 
sistent with his previous character and habits,” and the physi- 
cians agree that he is a proper person to be taken charge of 
and detained for care and treatment, judgment to that effect 
is given, and he is committed to a hospital for mental diseases. 
The term of commitment is not set by the court but depends 
entirely on the patient’s condition. The cost of commitment 
and of hospital care is met differently in different states. The 
entire cost may be borne by the state, or it may be divided 
between state and city, or the whole or a part may be paid by 
the family. The nurse should acquaint herself with the regu- 
lations in her locality, so that she may assist in facilitating 
arrangements for hospital treatment when it is necessary. 
Voluntary Admission.—Essential as a safeguard for liberty 
and a protection against conspiracy as such legal procedures 
may be, their application is detrimental in many cases to the 
mental condition of the patient. In a confused mind courts are 
apt to be connected with guilt, crime, and punishment, and 
delusions are often more firmly fixed by this contact. The 
publicity and what seems to the ignorant the alarming charac- 
ter of such proceedings often deter a family from seeking the 
necessary treatment. Of late years there has been an increas- 
ing extension of the provision for voluntary admission to state 
hospitals. Many patients who realize their sickness are thus SECURING AN EXAMINATION 
27 
enabled to secure hospital treatment without legal interven- 
tion. The nurse should know whether this is a possibility in 
her community. 
Securing an Examination.*—When the nurse visits a family 
where it is suspected that there is a mentally sick person it 
will often require fine tact to secure their consent to seek spe- 
cial advice. The mistake must never be made of suggesting 
the possibility of insanity. People are still too unwilling to 
entertain such an idea. When a little talk has revealed the 
existence of “ nervousness,” depression, hallucinations, excit- 
ability, etc., the suggestion of a visit to a doctor who has made 
a special study of “ nervous ” diseases will be well received. 
Since families are often only half convinced of the necessity 
it is always easier to get their consent to a special examination 
when there is a free clinic. Of course families that are well 
able to pay a specialist’s fee should be expected to do so. If 
the examination proves the need of a period of hospital residence 
the nurse can give invaluable aid in securing the fam- 
ily’s cooperation. 
A small but important point for the nurse to remember 
is never to be guilty of speaking of the institution for the care 
of mental patients as an “ asylum,” but always to call it the 
mental hospital. The word asylum brings to mind all the 
gloomy, hopeless features of a place where people were hidden 
away as so much scrapped material, the dumping ground for 
human wreckage. A hospital suggests at once doctors and 
nurses and suitable treatment. The old word, inherited from 
an age when the mentally sick were shut up with paupers and 
idiots, usually for life, still lingers in many places and must 
be dropped. This suggested habit of speech will do much to 
foster a better conception of modern institutional care. In 
state after state the official name of the institutions is being 28 
THE FIELD OF WORK 
modernized to suit present day ideas, but nurses should abandon 
the old offending name without waiting for official action. 
Types of Helpful Service.—All public health nurses may 
give practical help in the fight against mental disorders. Hav- 
ing learned the early symptoms they will be alert to detect 
those conditions which demand a special examination, and can 
help to secure it. They can teach the public the value of early 
treatment. If hospital care is advised they can break down 
the prejudice of the family against mental hospitals. Public 
health nurses who have been adequately trained in psychiatry 
will have opportunities to assist in advising and supervising 
patients who have been allowed to return to their homes on 
a trial visit. Most state hospitals now have after-care workers, 
but their territory is often too large to allow the patients being 
visited frequently enough to see that their adjustment to work 
and to home life is proceeding satisfactorily. Occasional visits 
at the request of the hospital authorities would be a service 
that the nurse might well give. 
Special Training Essential for Supervision.—In the majority 
of early cases treatment will consist in visits to the clinic, with 
supervision, guidance and readjustment of conditions. This 
should be undertaken in a responsible way only by those who 
are trained for this special work. Mental clinics usually have 
their trained assistants, psychiatric social workers are increasing 
in numbers, mental hospitals have their field workers. The 
public health nurse without adequate training in psychiatry 
should turn over to these workers, who are experienced in 
dealing with the mentally abnormal, patients who require this 
type of supervision. In a locality where no such specially 
trained nurses or social workers are available, and the responsi- 
bility must remain for a time with the public health nurse, she 
must follow with scrupulous care the recommendations of the SUGGESTED READING 
29 
doctor in guiding the patient in work and recreation, in family 
and social relationships. 
It will require only a little contact with the needs and suffer- 
ings of the mentally sick to make every nurse realize that they 
are a group with an unescapable claim on her interest and assis- 
tance. Psychiatry is a science which is progressing so rapidly 
that constant reading is necessary if one would keep abreast 
of the new developments and applications of recent discoveries. 
Fortunately, the most important facts and their application 
to daily life are recorded in a large number of publications by 
acknowledged leaders in this long neglected field of medicine— 
publications for the most part written so simply that their 
lessons are easily learned. All nurses are urged to secure for 
their personal library a selection of the pamphlets issued free 
of charge by the National Committee for Mental Hygiene. 
They comprise the addresses and papers of all the leading 
psychiatrists, and treat of subjects with which every public 
health nurse must be acquainted if she is to do her work intelli- 
gently and thoroughly. 
Mental Hygiene, a quarterly magazine, National Committee for Mental 
Hygiene, New York. 
Principles of Mental Hygiene, p. 323, 1917, William A. White, M.D., 
Macmillan Co., New York. 
RECOMMENDED READING SECTION II 
THE PUBLIC HEALTH NURSE AND 
MENTAL HEALTH CHAPTER V* 
MENTAL HEALTH OF CHILDREN 
The modern public health nurse is first of all an educational 
force in the community. Whether she specializes in infant 
welfare, school-nursing, industrial hygiene, or any other type 
of community work, her most valuable contribution will be 
her teaching of health habits. The best school-nurses arrange 
drills, competitions, prizes, to assure the habitual carrying out 
of measures necessary for bodily health. We have come to 
realize that the inculcation of good mental habits is 
equally necessary. 
Habit Training Needed from Infancy.—Attention to the 
mental hygiene of children should not be deferred till school 
age. “ It is not sufficiently realized that mental hygiene should 
begin when the child is put to the mother’s breast.”1 The 
ignorant mother who feeds her child every time it cries is 
doing more than interfering with its digestion. She is teach- 
ing it to dominate the situation by violence. The same child 
will be found at five shrieking with rage when crossed—not 
a good preparation for adjustment to a world where individuals 
must respect the rights of others. “ This (infancy) is the period 
when all the tendencies which are to be the motive forces in the 
future history of the individual acquire their initial direction.”2 
“ As the child passes through the various phases of his develop- 
* Part of the material in this chapter and in Chapter VII has appeared in 
the American Journal of Nursing, and is reprinted by permission. 
1 “ The Experiences of the Child: How They Affect Character and 
Behavior,” by C. Macfie Campbell, M. D. 
a Mental Hygiene of Childhood, by William A. White, M.D. 
33 34 
MENTAL HEALTH OF CHILDREN 
ment he has to meet a series of tasks: he has to learn to adapt 
himself in an orderly manner to the problems of sleep, of nutri- 
tion, of cleanliness; he has to learn to accept certain social 
restrictions and conventions, to allow for the rights of others, 
to modify native self-assertiveness, to distinguish between make- 
believe and reality, to respond to standards of truth and honesty 
and decency, to put forth effort in the face of his tasks, to 
develop independence of judgment and action and feeling. The 
way in which the simple problems of childhood are handled 
moulds the child’s habits, and the ability to meet the later 
tests of life will be modified by his training in relation to the 
early tests. The child, capricious in diet, insistent on his own 
sleep conditions, obstinate in refusal of regular toilet habits, 
gaining his own ends by a display of unpleasant tantrums, will 
have difficulty in adult life in adapting himself to the demands 
of a real world, which is not prone to bow before tantrums, 
which exacts inexorably the price for neglect of simple hygiene 
habits; at an age when these problems should have been turned 
over to habit, leaving the man free for his real tasks, we find 
him tinkering with his bowels, studying his diet, groaning over 
his unsatisfactory sleep.” 3 
Mental disease has been described as a marked failure of 
adjustment to one’s surroundings. Mental hygiene must deal, 
therefore, not only with intellect but with conduct, and the child 
must be trained to think generously and to live harmoniously 
with others in his little world. Habits of mind must be formed 
with at least as great care as table manners and social graces. 
Each of us is a compound of tendencies inherited from a variety 
of ancestors, and, while a child of recognized neurotic inheri- 
tance requires more careful mental guidance, all should be pre- 
* “ The Experiences of the Child,” C. Macfie Campbell, M.D. SELF-CONTROL 
35 
vented from developing unhealthy habits of thought 
and conduct. 
A primary tendency in all children is imitation, and parents 
may be directly responsible for certain characteristics of their 
children which are credited to more remote ancestors. Hamper- 
ing fears may cling through life to the girl who has seen her 
mother terrified in a thunder-storm. Uncharitable comments 
on the neighbors will teach the listening child to be suspicious 
of others. “ The sneer, the jeer, the anxiety, the insincerity, 
do not have to be understood as such by the child, any more 
than it is needful for him to understand the nature of the physi- 
cal calamity that might befall him, in order to have the fear 
of lightning engendered in him. All that is needed is that 
the attitude of fear when the lightning flashes shall be taken 
in his presence by others. Let the attitude of parents and adult 
members of the family toward their daily occupations at home 
or in the office be that of dread, dislike or boredom, let real joy 
and lightness of heart appear only when the holiday, the rest 
hour or the diversion are being spoken of or experienced, and 
the child begins the formation of attitudes towards work that 
must be eradicated later if he is ever to find himself in his work 
as an adult.” 4 
Self-control.—Among the lessons that come first both in 
time and in importance is the steady teaching of self-control. 
Primitive instincts clamor for satisfaction, but they must be 
curbed and controlled if the child is to live a happy, civilized 
life. The needs of others around him soon modify the gratifi- 
cation of his desires. He must await his mother’s convenience. 
He learns not to grab at his food. He is made to say “ please ” 
before receiving the coveted toy. Gradually the accepted mode 
4 “ Mental Hygiene and the Parasite,” Margaret J. Hamilton. Mental 
Hygiene, vol. v, No. i, Jan., 1921. 36 
MENTAL HEALTH OF CHILDREN 
of conduct is imposed on him. Later on forces stronger than 
his instincts are developed and brought into play. The tempting 
apple is not eaten, because it belongs to another. The cake 
is shared with his little sister. 
Some children, especially those of poor nervous inheri- 
tance, are given to outbursts of temper. These occurrences 
should be prevented as far as possible by avoiding likely causes 
of irritation, or by fixing the child’s attention on something 
else when the storm is threatened. If the outburst has come, 
the child should be quietly but firmly carried away from its 
companions for a time, or even put to bed, though never left 
alone in a dark room when overwrought emotionally. None 
but a very ignorant or thoughtless person will find amusement 
in a childish outburst of rage. Unfortunately parents are found 
who think it good sport to goad a young child into a display 
of impotent wrath, not realizing the injury to the nervous 
system. A nine year old girl in a family of highly neurotic 
makeup destroyed all peace by her frequent rages over the most 
trifling incidents. When the despairing mother was induced 
to apply the remedy of isolation a few times, and the child 
had been shown between tantrums what an object for ridicule 
such conduct made her, there was a rapid and most gratifying 
improvement. Lack of self-control permitted through child- 
hood resulted a few years ago in the murder of a hotel clerk 
by a bell-boy who shot him in a fit of ungovernable rage. “ If 
a young infant be kept in a normal routine, despite any emo- 
tional outbreak which it may manifest, an excellent start in 
the training of the emotions will have been made. If a child 
learns that by crying or by an exhibition of temper it can gain 
the thing which it thinks desirable, a very bad start will have been 
made. Children should early be given to understand that they 
must control themselves before their desires will be gratified. SELF-RELIANCE AND INDEPENDENCE 
37 
The substitution of self-mastery for emotional outbreaks is 
easy when begun early but very difficult if begun late in life.” 5 
“The temperamental tendency toward oversensitiveness to 
the markedly painful or markedly pleasant emotions and sensa- 
tions is perhaps the most common and fundamental element 
which, if unrecognized and uncorrected, makes for later nervous 
breakdowns. This element is recognizable even in the early 
months of life. The training (of children with this character- 
istic) should have in view the distinct object of moulding the 
sensitiveness itself into a useful force.”6 The child may be 
shown that he can act in spite of his disturbing emotions. If 
he is afraid of the dark he should be told that lots of children 
have that silly feeling but of course he will not let that stop him 
from getting what he wants from the unlighted room. By actu- 
ally going into the dark room and getting it he will be shown how 
foolish his fear was and how worth while to get what he wanted 
in spite of it. Every effort should be made to make the interest 
in doing things and the results of doing things always stronger 
and more enticing than the interest in his own feelings. He 
must be encouraged to become a “ good sport ” rather than 
the slave of his fear or his anger. 
Self-reliance and Independence.—If a mother wants her son 
to be self-reliant and self-controlled, the delicious sense of her 
child’s dependence on her during the first three or four years 
must give way before the need to prepare his mind and spirit 
to fight independently in the arena of life. When should a 
child be allowed to walk three miles ? Obviously, when by easy 
stages he has learned to walk one—then two—without undue 
* Principles of Mental Hygiene Applied to the Management of Children 
Pre-disposed to Nervousness, Lewellys F. Barker, M.D. 
8 “ Nervousness: Its Cause and Prevention,” Austin Fox Riggs, M.D., in 
Mental Hygiene, April, 1922. 38 
MENTAL HEALTH OF CHILDREN 
fatigue. When should he be expected to assume individual 
responsibility in serious matters? When by little steps he has 
acquired the habit of successfully accomplishing small duties. 
Putting away his toys when through with play, picking up his 
discarded clothing, remembering each day to water his little 
plant, giving his rabbit its daily food—all these are a steady 
education in order, thoughtfulness for others and independence 
of action. He must not be spared the consequences for his 
failures, for it is by our mistakes that we most surely learn. 
It is better to let his plant die than to water it when he has 
neglected his responsibility. “ Another mental attitude that 
bears watching is the craving of the child for sympathy. Par- 
ents are really unkind in yielding too much to such a craving. 
True kindness will teach the child to rely more upon self-help. 
Another manifestation common in children is vacillation. While 
there are some children of the “hair-trigger” type who have 
to be taught deliberation in making decisions, there are more 
who have a tendency to doubt and indecision and who should 
be taught that it is better, after due consideration, to make 
a decision, even though it be wrong, and to stick to it, rather 
than to remain undecided.” 7 
Endurance.—Unwise sympathy which leads to self-pity is 
a damaging atmosphere with which to surround a developing 
mind. There are few children who will not shirk tasks which 
demand the full extent of their mental powers, unless encouraged 
to put up a good fight for success. As judicious exercise is 
necessary for physical growth, so definite mental efforts in 
steady progression are needed for mental development. The 
child who coaxes to be excused from learning his lesson, who 
will not concentrate or try to solve a difficult problem in arithme- 
7 Principles of Mental Hygiene Applied to the Management of Children, 
Lewellys F. Barker, M.D. ASSOCIATION WITH OTHER CHILDREN 
39 
tic, is losing more than his good marks for the day. He is 
delaying the growth of his mental powers. Too easily secured 
sympathy is destructive of moral fibre as well, even in such 
simple matters as physical hurts and bruises. The ability to 
take necessary knocks smilingly, to endure pain courageously, 
if learned early in life brings poise and self-control in 
later crises. 
Whims Regarding Food.—A source of much unnecessary 
distress to both mothers and children is the indulgence of 
whims regarding articles of food. From earliest years, so 
soon as general diet is permissible, no refusal to eat any suit- 
able article of food should be tolerated. Infinite discomfort 
for the individual and the family results when petty dislikes 
of this and of that must be recognized. Physical health often 
suffers later when these unfounded aversions, unchecked in 
childhood, have formed a definite neurasthenic habit. Confor- 
mity to general standards in small things reduces friction, and 
tends to render easier the necessary adjustments of adult life. 
Association with Other Children.—A healthy-minded child 
will share in the games and interests of other children. While 
all are not alike in temperament none should be allowed to in- 
dulge often in solitariness, to pass long hours in day-dreaming, 
to be suspicious, grudge-bearing, or sullen. Such unhealthy 
habits of mind may soon become the dominant characteristic. 
They are usually included in the childhood history of dementia 
prsecox cases found in state hospitals. A mother weeping over 
her sixteen year old daughter, a patient in a mental hospital, 
said, “ Doctor, I cannot understand it. She was the sweetest 
little girl. She would never go out to play with other children, 
but always sat at my knee and was so good.” 
“ Children naturally live in the present. They should be 
taught to live one day at a time, to settle their moral accounts 40 
MENTAL HEALTH OF CHILDREN 
every night, never to hold a grudge, never to let the sun go 
down upon their wrath, to look upon each morning as a new 
day in which to improve, but not to carry their troubles over 
from yesterday.” 8 Ungenerous suspicions of playmates are 
very harmful, and must be checked. The tendency to feel 
aggrieved, to consider oneself unfairly treated, to think all pro- 
hibitions and general criticisms aimed at oneself, to carry a 
chip on one’s shoulder—all these are habits of mind which 
make for unhappiness and consequent withdrawal from healthy 
companionship with other children. While these habits are 
most often broken up in the hurly-burly of school-life, there 
are frequent cases where bad habits grow into dominating 
moods, and later, when the more difficult adjustments of adoles- 
ence are required, there is no healthy mental attitude with which 
to meet the situation. A generous open habit of mind is the 
best bank account with which to pay the demands of life. 
Day-dreaming not Encouraged.—Practical activities must 
be provided for growing minds and bodies. Day-dreaming, if a 
marked characteristic, should give place to some active pursuit. 
A lively imagination is a delightful attribute of many children, 
but there must be no lack of ability to return to the practical 
affairs of every day. They must never lose touch with the real 
world in their attempted flights into the unreal. 
Fair Play.—The egotistic tendency of a child to secure every 
advantage for himself, a tendency which conflicts with the 
necessary social doctrine of the rights of others, can be most 
readily overcome by means of the games of childhood. The 
great principle of fair play must be implanted at the beginning 
of play experience, and the further concepts of generosity 
to playmates and of the dishonor of accepting an advantage 
8 “ Success and Failure as Conditions of Mental Health,” William H. 
Burnham. Read before Mental Hygiene Section, National Conference of 
Social Work, Atlantic City, June 5, 1919. ACCEPTANCE OF THE POSSIBLE 
41 
cannot be too early taught. Children who cheat at croquet, 
who peep when eyes are blindfolded, who let another take their 
rightful blame, should be made to feel the disapproval of their 
world. One removal from playmates for the afternoon because 
of these infringements of the moral standard will make the 
lesson sink deep in memory. Much more serious mental and 
moral conflicts of later life will be decided along the lines of 
habitual thought graven in the childish mind. William James 
has shown us clearly the potency of habit. He says: “ Could 
the young but realize how soon they will become mere walking 
bundles of habits, they would give more heed to their conduct 
while in the plastic state.” 
Acceptance of the Possible for the Unobtainable.—From 
the earliest years the child should be taught to substitute the 
possible for the unattainable. The tears shed for the desired 
moon may be dried by the tangible toy, and the moon remain 
but a bright spot in the sky. If a heavy rainstorm prevents 
the looked-for picnic, provide some merry indoor games and 
do not let the children stand at the window and pout. If the 
noisy strumming on the piano must be stopped, suggest in 
its place a drawing contest, and train the children to enter into 
the new game with zest. Through life there must be no back- 
ward glances at the forbidden city, if we would escape conse- 
quences worse than the saline fate of Lot’s wife. The cheer- 
ful acceptance of the next best when the best is unobtainable, 
if steadily taught from childhood, will enable the boy in later 
years to meet disappointment with a cheerful courage. It will 
help the girl from whom family joys may be snatched away to 
find an outlet for her emotional life in service for others. 
Repressed and unsatisfied longings for which no substitute is 
found are a potent cause of mental breakdown. Safety lies in 
frankly acknowledging the natural longing for the satisfaction 42 
MENTAL HEALTH OF CHILDREN 
of normal desires, while accepting and developing to the utmost 
the best available substitute. Useless repining is a practice which 
corrodes the mind. 
Necessary Stimulus of Success.—No stimulus to healthy 
mental growth is more important, and more often ignored, than 
success. From the first glimmerings of intelligence and through 
the aspiring efforts of maturity it is success which step by 
step lures us on. The tiny infant making wavering clutches at 
his foot gurgles with satisfaction when he grasps it. “From 
this initial success all through the wonderful achievements of 
learning to walk, and to talk, and the various motor accomplish- 
ments of ordinary life, the same stimulus of success is con- 
tinuously active; and without it in large measure, arrest of 
development would occur.” Physical health also is affected by 
this stimulus. It is thought that the glands of internal secre- 
tion are involved, and the whole system toned up by it. Failure, 
if frequent or continuous, is inhibitory, and may depress func- 
tional activities, especially in children. Little successes should, 
therefore, be part of every day’s experience. Has the boy failed 
to accomplish some new task after honest effort? Then see 
to it that this is offset by a second task within his powers, so 
that discouragement does not kill his capacity for further 
attempts to succeed in the first. Is he cast down because he 
lags behind in the arithmetic class? Set him a copy for the 
writing he can do so well, and then show him why he must 
learn the multiplication table. But desirable and helpful as 
frequent little successes are, boys and girls must be shown that 
success is not in itself the thing of greatest value. Teach them 
that it is not the winning of the prize but the worthy running 
of the race that counts most. Were this more generally im- 
pressed on children we would not have that most deplorable of 
records, the annual account of girls or boys who have committed SUCCESS AND FAILURE 
43 
suicide because of failure in a school examination. Such 
tragedies reveal a shocking lack of instruction in proportion- 
ate values. 
“ For thence,—a paradox 
Which comforts while it mocks,— 
Shall life succeed in that it seems to fail: 
What I aspired to be, 
And was not, comforts me: 
A brute I might have been, but would not sink i’ the scale.” 
Success and Failure.—Necessary to our mental growth as 
is success, we could ill do without the corrective of occasional 
failure. Superficiality and conceit are the dangers of those 
to whom success comes to easily, and occasional failure is the 
needed antitoxin. Full growth is not attained without difficul- 
ties to overcome. Both success and failure play a part in the 
healthy growth of a child’s mind, and with a disproportionate 
amount of either comes a poor result. Constant sunshine 
withers tender plants, and unrelieved shadow produces pallid 
leaves. In the growing season we have long sunshiny days 
and short nights. In like proportion children should experience 
success and failure. 
Need for Proper Sex Instruction.—A sure foundation is 
needed upon which the child may begin to build his house of life, 
and he naturally finds this in his implicit confidence in mother or 
father. He depends first on the unfailing interest shown in all 
his small affairs, the sympathy for his troubles, the explanation 
of all his problems. He unburdens himself with wholesome 
frankness. Soon comes a day when answers are evasive. In- 
formation repeatedly withheld arouses a brooding curiosity 
more acute than any concerning subjects frankly discussed. 
Every adult can look back to some such experience in childhood, 
and most of us can remember how long the unanswered 44 
MENTAL HEALTH OF CHILDREN 
question remained clearly defined till some perhaps less desirable 
instructor enlightened us. More serious still, the first recognized 
evasion breaks the child’s perfect trust, and deprives him of his 
main support. 
No questions are so inevitable from children as those touch- 
ing on sex and reproduction. The child of six or seven will accept 
as a matter of course the statement of the responsibility of the 
mother rabbit for the arrival of the little bunnies. A new baby 
arrives next door and dawning powers of inference send the 
child breathless with the news and eager with questions. In how 
many cases is he met with the story of the cabbage-patch or the 
doctor’s satchell, and silently goes away, not believing, and with 
the feeling of a barrier between him and his mother. He scents 
a mystery and seeks information elsewhere. Sooner or later 
he picks up garbled or unclean hints, and becomes what has been 
aptly called a “ graduate of the hired man.” The question that 
confronts the mother is not, “ Shall or shall not my child be 
told early the simple facts of life? ” but rather, “ Shall / tell 
him naturally and gradually, or shall I let some coarser person 
poison his mind towards one of the fundamental facts 
of existence? ” 
Modern psychiatry is uncovering the far-reaching effect 
on the mental health of adolescents of a vicious presentation of 
sex matters to immature minds. This is strikingly shown in 
the study of juvenile delinquents by Dr. William Healy. Among 
boys and girls alike are found many instances of acute sex- 
consciousness, exaggerated shyness and much mental stress, 
the result of misinformation or a total lack of instruction on 
the subject. This mental distress may even approach mental 
disease, as may be seen in the following authentic case. A 
refined girl of fifteen had been plunged the year before into 
the industrial world without any proper sex instruction. Her NEED FOR PROPER SEX INSTRUCTION 
45 
fellow workers at the factory were of coarser grain, and she 
could not help hearing suggestive and indecent stories while 
at work. Her natural shrinking from impurity, coupled with 
the shock of the revelations, set up a serious distress. She 
became greatly depressed, lost much weight, could not sleep, 
wept incessantly and finally was contemplating suicide. Her 
mother realized the cause, but said she “ could not talk to a 
girl about things like that.” The family physician considered 
her in an early stage of mental disease, and as a last resource 
sent her to a mental hygiene clinic. Six months of supervision 
by a nurse who gave her proper instruction and a wholesome 
point of view on sex matters, coupled with the needful regu- 
lation of work and recreation, rescued her from mental break- 
down and set her successfully in the path of normal, happy 
girlhood. 
A boy attempting to drive a high-powered automobile 
through heavy traffic with no knowledge of the source or of the 
control of the force carrying him forward could hardly escape 
unscathed. Young people flung out into life without proper 
training for the control of one of the fundamental instincts 
can hardly avoid serious consequences. A wholesome attitude 
towards questions of sex is a safeguard against many mental 
difficulties of adolescence, and should be fostered from early 
years. It is the natural outcome of frank confidence between 
mother and child, accompanied by honest instruction suited 
to tender years. 
Children who are found to have formed bad sex-habits 
should not be driven into fear and concealment by harsh scold- 
ing. They should be talked to sensibly, encouraged in efforts 
to break the habit, assured of affectionate help. Active work 
and outdoor play, prompt rising as soon as awake, and care- 
fully chosen playmates will help to eradicate this evil. 46 
MENTAL HEALTH OF CHILDREN 
In mental life as in physical life it has been the study of 
disease which has uncovered the mechanism and revealed the 
laws of healthy growth, and mental hygiene now aims at guid- 
ing minds which are not diseased to the best possible develop- 
ment. The so-called normal child is just as much in need of 
mental hygiene as the neurotic child. For the latter, however, 
careful guidance is essential if serious difficulties in later life 
are to be avoided. After careful study of a large number 
of “ mal-adjusted ” persons at a Conference Centre for Women 
and Girls in New York the psychiatrist in charge was convinced 
of (a) the need for early detection and wise handling of such 
hampering tendencies as fear, suspicion, discontent, seclusive- 
ness, lack of self-control, dependence (on people, on the opinions 
of others, etc.), morbid or unproductive day-dreaming, a tend- 
ency to the dispersion of energy and interest, inferiority feeling, 
depression and secretiveness; (b) the need for rapport between 
children and parents and teachers; (c) the need for simple, 
straightforward but biologically sound sex instruction to chil- 
dren and adults.9 
RECOMMENDED READING 
Mental Hygiene of Childhood, p. 193, William A. White, M.D., Little, Brown 
& Co., Boston. 
* Nervous Children and Their Training, C. Macfie Campbell, M.D. 
* The Experiences of the Child, C. Macfie Campbell, M.D. 
* How to Avoid Spoiling the Child, Lewellys F. Barker, M.D. 
* Principles of Mental Hygiene Applied to the Management of Children 
Pre-disposed to Nervousness, Lewellys F. Barker, M.D. 
* Success and Failure as Conditions of Mental Health, William H. Burnham. 
Those marked * are pamphlets distributed by the National Committee for 
Mental Hygiene, New York City. 
*“ What Can Be Done for the Mal-adj usted ?” Mental Hygiene, vol. iv, 
No. 2, Apr., 1920. Anne T. Bingham, M.D. CHAPTER VI 
PREVENTABLE FORMS OF MENTAL DISEASE 
A child may be trained to observe all the rules of personal 
hygiene, but that will not certainly prevent him from becoming 
sick if he drinks milk infected with typhoid fever or bovine 
tuberculosis. His mental life may be established on whole- 
some lines but if he later acquires certain infections or toxaemias 
he may develop a type of mental disease. In other words, it 
is not enough to establish good mental habits in childhood. It 
is also necessary to avoid the causes of the preventable forms 
of mental disease due to infections and poisons. Public health 
nurses are building for the future in promoting the mental 
hygiene of childhood. They must also help in the present by 
spreading the knowledge of the known causes of the prevent- 
able forms of mental disease. 
Syphilitic Mental Diseases.—The most important single 
preventable cause of insanity is syphilis. “ In spite of contribu- 
ting factors and modifiers it is a true saying that there is no 
general paresis without an antecedent syphilis.” There are also 
other forms of syphilitic insanity, so that we find that ten out 
of every hundred new cases coming to the state hospitals 
throughout the country are due to this infection. 1 The highest 
rate is found in Colorado with fifteen per cent., Rhode Island 
with nearly fourteen per cent., and New York with thirteen per 
cent. More than four times as many of these patients come 
from towns and cities as from villages and rural districts.2 
1 “ Comparative Statistics of State Hospitals for Mental Diseases, 1920,” 
Pollock and Furbush, Nat. Comm. Mental Hygiene. 
*“ Mental Diseases in Twelve States, 1919,” Pollock and Furbush, Nat. 
Comm. Mental Hygiene. Mental Hygiene, vol. v, No. 2, Apr., 1921. 
47 48 
PREVENTABLE FORMS OF MENTAL DISEASE 
More persons die of paresis in New York City than die of 
typhoid fever. 
General paresis, often called by the public “ softening of the 
brain,” is a syphilitic disease of the brain which usually shows 
itself towards early middle life, the result of an infection which 
may have occurred many years earlier. It progresses steadily 
to dementia and paralysis. The earliest symptoms are often 
overlooked or ascribed to other causes. From slight changes 
in disposition the patients gradually show marked alteration 
in conduct and character, become boastful, garrulous about pri- 
vate affairs, choose undesirable associates, and show great lack 
of judgment. It is at this stage that their families are often 
involved in financial disaster by their ill-judged management 
of affairs. Absurd ideas of self-importance and grandeur are 
very characteristic. 
The prevention of the syphilitic insanities is of course linked 
up with the campaign against venereal disease, for “ the vast 
majority of syphilitics acquire the disease through prostitution 
and clandestine intercourse.” A few become infected un- 
knowingly and innocently. An infected husband may give the 
disease to his wife. Public drinking-cups, towels, soap, basins, 
bathing suits, a borrowed pipe, or a lead pencil which has been 
put in the mouth, any of these may be the medium of infection. 
Alcoholic Mental Diseases.—Another definite cause of men- 
tal disease is the continued use of alcohol. Not only the exces- 
sive drinker but also the so-called moderate drinker is liable 
to develop alcoholic insanity. Fortunately with the increase of 
temperance during the last ten years, and more recently with 
national prohibition, this type of mental disease is growing 
less common. “ The most remarkable change since 1919 has 
been the reduction of the alcoholic psychoses, the percentage 
having dropped from 4.6 to 2.3. This is apparently due to DEMENTIA PR^COX 
49 
more rigid restrictions of the liquor traffic. It will be noted 
that a few hospitals report no alcoholic cases. The gradual 
reduction of alcoholic cases from about 10 per cent, in 1910 to 
about 2 per cent, in 1920 is a noteworthy accomplishment.” 3 
Besides being the chief cause in the alcoholic psychoses, alcohol 
is a contributing factor in many other forms of mental disease. 
That means that the individuals in the latter groups had proved 
able to withstand the strain of necessary mental work and adjust- 
ments, often in spite of unfavorable tendencies, until their stock 
of mental strength was undermined by alcohol. It has been 
shown conclusively by a series of careful experiments that “ the 
man who habitually drinks even a couple of glasses of beer 
three times a day keeps his efficiency in accuracy, amount of 
7 rk and general judgment ten to fifteen per cent, below his 
normal; but he does not realize it. Alcohol, even in moderate 
doses, diminishes sensibility, physical, mental and moral. It 
lessens self-control, both moral and muscular.”4 It is evident 
from these findings that alcohol has no place in any plan of 
life designed to promote the mental health of the individual. 
Dementia Prascox.—By far the most important type of 
mental disease, both from a numerical standpoint and from 
the comparative infrequency of cure is that group of mental 
disorders known as dementia praecox. It occurs chiefly in 
youth and early adult life, and is responsible for at least a 
quarter of all new hospital cases each year and for more than 
half of all under treatment at any given time.5 The cause of 
this disease has not yet been determined, and is a subject of 
3 “ Comparative Statistics of State Hospitals, 1920,” Pollock and Furbush, 
Nat. Comm. Mental Hygiene. 
4 “ Preventable Forms of Mental Disease and How to Prevent Them,” 
L. Stanley Abbot, M.D. Boston Medical and Surgical Journal, vol. clxxiv, 
No. 16, Apr., 1916. 
'“Mental Diseases in Twelve States,” Pollock and Furbush, Nat. 
Comm, for Mental Hygiene. Mental Hygiene, vol. v, No. 2, Apr., 1921. 50 
PREVENTABLE FORMS OF MENTAL DISEASE 
wide research and discussion. For this reason it is not possi- 
ble to prescribe definite methods of prevention. “ One theory 
lays stress upon mental factors as causes, regarding the mental 
symptoms as outgrowths from and developments of faulty 
ways of meeting difficulties, shown even in early childhood. . . 
In a fairly large proportion of cases it may be one of the con- 
tributing factors.”4 These faulty ways, or bad mental habits, 
have been discussed in the preceding chapter. In general they 
are secretiveness, grudge-bearing, day-dreaming, brooding, 
withdrawal from companions. “ The best way we know to pre- 
vent this psychosis is for parents and teachers to begin at the 
first appearance of these traits, perhaps even as early as infancy, 
and to continue till adult life, to make unremitting, tactful and 
sympathetic efforts to get into the little mind, to understand its 
point of view, to suggest happier and healthier ones, to lead the 
child to more objective and so more healthful contacts and inter- 
ests, to teach more practical substitutions and aims, better ways 
of reacting and better attitudes towards persons and life. These 
better ways cannot be imposed upon the child from without, but 
the seed must be planted and must grow from within.”4 Sir 
Thomas Clouston, the famous Scotch psychiatrist, gives these 
general principles of prevention. “ Build up bone and fat and 
muscle by means known to us during the period of growth and 
development. Make fresh air the breath of life of the young. 
Develop lower centres rather than higher where there is a bad 
heredity. Do not cultivate, rather restrain the imaginative and 
artistic faculties and the idealisms generally in cases where such 
tend to appear too early and too keenly. They will be rooted in a 
better brain and body basis if they come later. Cultivate and 
insist upon an orderliness and method in all things. Fatness, 
self-control and orderliness are the three most important quali- DRUG ADDICTION 
51 
ties for them to aim at.” Since dementia prsecox is, in general, 
characterized by the tendency of the patient to withdraw 
into himself, to avoid contacts with the world about him, to give 
himself up to day-dreams about which he is reticent, it is evident 
that the successful uprooting of these tendencies in childhood 
will be a safeguard against the later development of the disease. 
Psychoses with Fatigue as an Important Factor.—A large 
group of preventable cases is that found suffering from the 
“ fatigue ” psychoses. About a sixth of the yearly admissions 
to mental hospitals are “ due to breakdowns in persons who are 
unable to withstand the hard continuous work, or the exhaustion 
of illness and pain, or the sudden intense or the long continued 
stress of conflicts between opposing desires, ambitions and 
duties, or the strain of prolonged responsibility, or the various 
combinations of these.” The causes of this lack of endurance 
are inherited tendencies, advancing years, physical illness, un- 
hygienic modes of life. Frequently among this group are found 
the mother worn out with anxiety, work, and too frequent child- 
bearing; the young man carrying too heavy a load of responsi- 
bility, the over-ambitious college youth, the over-active, ener- 
getic person who never takes the necessary rest. Public health 
nurses can do much to prevent the occurrence of this form of 
mental disease by insisting upon and helping to arrange for a 
period of rest and freedom from responsibility for those who 
are obviously carrying too great a burden. An explanation of 
the mental danger will secure the cooperation of relatives or 
some philanthropic society to provide the necessary change of 
surrounding conditions. 
Drug Addiction.—A small number of mental hospital 
patients are found there because of addiction to some drug, such 
as morphine and cocaine. Prevention of this habit will of 52 
PREVENTABLE FORMS OF MENTAL DISEASE 
course mean the prevention of the disease. In certain cities one 
finds that in spite of strict laws many boys of twelve and four- 
teen find means of obtaining one of the habit-forming drugs, 
and think it smart to use it. Information regarding its dangers, 
and the provision of suitable means of recreation for these boys 
will help to break up these practices. 
Pellagra.—Pellagra is responsible for hundreds of cases of 
mental disease in the localities where it is prevalent, chiefly 
in the southern states. The usual mental symptoms are a con- 
fusion with melancholy or dreamy delirium. There is also a 
great tendency to suicide by drowning. The definite cause of 
pellagra is not yet known, but it has been recognized for many 
years that a faulty diet is largely responsible. After a 
study of the cotton mill communities of South Carolina to com- 
pare the diet of pellagrous and non-pellagrous households the 
opinion was formed that the disease could be prevented by “ in- 
cluding in the diet an adequate supply of animal protein foods 
(particularly milk, including butter, and lean meat).’’6 
Psychoneuroses.—On the border-line between mental and 
physical disorders is a group of maladies with both mental and 
physical symptoms. These “ psychoneuroses ” include hysteria, 
neurasthenia, psychasthenia, and the anxiety neuroses. Preven- 
tion depends on a frank, courageous attitude towards the prob- 
lems of life, coupled with a hygienic mode of life without undue 
strain. These disorders need skillful handling by a physician 
well versed in modern psychiatric methods, and a sympathetic 
but firm attitude in those who help in the re-education of these 
patients. The typical psychoneurosis of the war, miscalled 
“shellshock,” well exemplified the need for an intelligent atti- 
tude in dealing with these patients. The paralyses, blindness, 
e Journal of the American Medical Association, Sept. 21, 1918. PREVENTION OF “ NERVOUSNESS ” 
53 
deafness, mutism, etc., of the affected soldiers soon disappeared 
when the psychic origin of their symptoms was explained to 
them and they were helped to a better adjustment to circum- 
stances. Similar conditions developing in civilians under the 
stresses of ordinary life have aptly been called “life shock,” and 
need the same probing by the physician and the same compre- 
hending assistance in re-education from the nurse. Persons 
suffering from fears, phobias or anxieties need sympathetic 
treatment. Their false ideas will not be removed by ridicule, 
but new habits of thought repeatedly suggested may help to dis- 
place the old painful ideas. 
Prevention of “Nervousness.”—In addition to all these more 
or less definite disorders of our mental machinery mental hygiene 
is deeply concerned with the prevention of that vague condition, 
“ nervousness,” that hampers efficiency, destroys peace and leads 
often to “ nervous breakdown.” We are daily learning more 
concerning the unnecessary mental effort and friction with 
which many of our tasks are accomplished, and the resulting 
exhaustion of nervous force. Dr. Austin Fox Riggs gives some 
excellent practical suggestions for the prevention of “ nervous- 
ness.”7 Briefly stated they are as follows: 
1. Neither run away from emotions nor yet fight them. Con- 
trol them and use them. 
2. Be efficient in what you do. Do things well in the easiest 
way. 
3. Do one thing at a time. 
4. Make clean-cut, practical decisions. They may be changed 
if new facts come to light. 
5. Avoid hurry by better planning and by not attempting the 
impossible. 
7 “ Nervousness: Its Cause and Prevention,” Austin Fox Riggs, M.D., 
Mental Hygiene, April, 1922. 54 
PREVENTABLE FORMS OF MENTAL DISEASE 
6. Avoid worry. Decide if the problem is your business, if it 
is your business now, and, if so, decide what to do and 
do it now. 
7. Keep work, play, rest and exercise in their proper relative 
daily proportions. Keep them separated. 
8. Shun oz/mxmscientiousness. 
9. After making a decision do not waste energy in “ getting 
ready ” to act. Just act. 
10. Recognize your problem as the universal one—to keep your 
ideals clear, to make them live in practical, everyday ac- 
tion, to play the game. 
Mental Defect.—While the mentally sick constitute a large 
and serious problem, the largest group of mentally abnormal 
persons is that of the mental defectives, or feeble-minded. No 
preventive efforts or curative measures will change the level of 
their mental stature. The public problems resulting from this 
condition must be met by provision for suitable training, super- 
vision and protection. Since mental defect is generally inheri- 
ted, efforts toward prevention must aim at arousing public senti- 
ment so that wise methods may be adopted to prevent a new 
generation of feeble-minded persons. It is estimated that eighty 
per cent, of feeble-mmdedness is due to heredity. Matings of 
defective persons must be prevented. Syphilis in one or both 
parents frequently causes mental defect in the child. Alcoholism 
in the parents is suspected as a cause, though not proved. Head 
injuries during birth or in childhood, acute inflammation of the 
brain or its coverings during childhood, and some rare bodily 
diseases are responsible for a small percentage of the cases. 
“ Eugenics requires that parents be well, unfatigued, and free 
from alcoholism at the time of conception.” The accepted meth- 
ods of dealing with the feeble-minded individual will be given 
in the next chapter. RECOMMENDED READING 
55 
RECOMMENDED READING 
* Menace of Syphilis to the Clean-living, Public, by J. Harper Blaisdell, M.D. 
* Preventable Forms of Mental Disease and How to Prevent Them, by E. 
Stanley Abbot, M.D. 
* The Relation of Alcohol and Syphilis to Mental Hygiene, by Frankwood E. 
Williams, M.D. 
* General Paralysis as a Public Health Problem, by Thomas W. Salmon, 
M.D. 
* Mental Adaptation, by Frederic Lyman Wells. 
* Mental Disorder in Adolescence, by Milton A. Harrington, M.D. 
* Anxiety and Fear, by Frankwood E. Williams, M.D. 
* What is Practicable in the Prevention of Mental Defect, by Walter E. 
Fernald, M.D. 
* The Right to Marry, by Adolf Meyer, M.D. 
Those marked * are pamphlets distributed by the Nat. Comm, for Mental 
Hygiene, New York. CHAPTER VII 
MENTAL DEFECTIVES 
Prevalence of Mental Defect.—Whether her work lies in 
town or country it will not be long before the public health 
nurse is confronted with the problem of the feeble-minded. 
Unfortunately, mental defect is not a rare condition. It is 
not limited to any special stratum of society. It is found in 
every country, and is coming to be universally recognized 
as an important factor in most of the difficult social questions. 
Careful surveys have proved that between one and two per 
cent, of public school children are unable to profit by the regular 
grade work because of mental deficiency. They are a burden 
to the teacher and a constant hindrance to the other pupils. 
We know also that the greatest single source of supply of delin- 
quents, of vagrants, of unmarried mothers, of paupers, and of 
prostitutes is this unnumbered army of the feeble-minded. 
Paradoxically, it is those who are less affected who are more of 
a problem, because the gross defect seen in idiots and the low- 
grade feeble-minded is apparent to everyone. The high-grade 
defective, or moron, is often recognized as such only when he 
tragically fails to stand up under the responsibilities of adult 
life. What can be done about it? 
Permanent Childhood.—The mentally defective individual 
is a child no matter how long he may have lived—a child of six 
or ten or twelve, thinking the thoughts, enjoying the games, 
wanting the daily interests, needing the constant affection, 
requiring the supervision and guidance natural to normal 
children of his permanent age. The late Dr. Pearce Bailey, of 
56 PERSONALITY OF DEFECTIVES 
57 
the New York State Commission for Mental Defectives, wrote: 
“ They can be taught to do useful things, and thrive and bloom 
under kindness, approval, praise and reward. Their affections 
are lively and attach readily to whoever wins their confidence. 
If all defectives could be brought up in good homes they would 
cease to be the social menace they are now.” Because of the 
great part that mental deficiency plays in our most serious social 
problems we are apt to consider a feeble-minded person as neces- 
sarily a menace. Do we not sometimes fail to realize that it is 
our faulty treatment or our neglect of him that brings the dan- 
ger ? The royalty of kings lies chiefly in the attitude of their sub- 
jects towards them, and the menace of the feeble-minded is 
in proportion to the public misunderstanding and neglect of 
his needs. 
The increasing possibility of scientific diagnosis of the con- 
dition is now relieving hundreds of teachers from the hopeless 
task of trying to force into heads incapable of reasoning a 
knowledge of arithmetic or civics. The defective children are 
sorted out for classes where the teaching is centred on training 
in habits of obedience and on skill in simple handiwork. Goddard 
says, “ The one thing that fits all of these children, the one 
thing that draws out whatever is to be drawn out of them, is 
training of the hand, manual training, industrial training.” We 
have to acknowledge that all our modern science cannot add one 
cubit to the mental stature of the feeble-minded. “No amount 
of training will ever make him a skilled workman, or ever enable 
him to direct his affairs with good judgment, common prudence 
and reasonable foresight.” Fortunately we have had our eyes 
opened to the possibilities that lie in the development of the 
simple manual crafts among these permanent children. 
Personality of Defectives Most Important.—An additional 
and most helpful light has been thrown on the whole problem 58 
MENTAL DEFECTIVES 
in very recent years. Following upon the recognition of the 
fact that feeble-mindedness is incurable, attention was fixed on 
the hereditary character of the condition. Then investigations 
began to show the frequency of mental defect among all classes 
of undesirable citizens, and lifelong segregation or sterilization 
of all feeble-minded persons was advocated. This accepted idea 
that the only place for most defectives to be safe and harmless 
was in an institution brought little but despair to social workers 
because of lack of accommodation. The conviction has now 
grown among the leaders of research in this field that the emo- 
tional makeup and tendencies of the defective play as great a 
part as his mental status in determining his fitness for a super- 
vised life in the community. “ There is a group of feeble- 
minded whose members give promise of delinquent careers, 
who from their very childhood show strong determiners for 
criminal conduct. This group is ordinarily egotistic, selfish, 
inconsiderate of others, suspicious, indolent, unappreciative, 
unsympathetic, unwilling to acknowledge mistakes, resists 
authority, and will not be guided by advice. There is such an 
apparent shallowness in the moral feelings of these individuals 
that they exhibit no desire to do better or to profit by their 
mistakes. Supervision of these persons outside of institutions 
is impossible. There is another group whose members show 
fairly good social adaptation, have reasonably good manual dex- 
terity, are active, ambitious, persevering and industrious; are 
usually conscientious, honest and truthful; accept authority and 
show a willingness to be guided by advice. These can undoubt- 
edly be supervised in the community.”1 The analytical study 
of the individual child has made possible the establishment of 
colonies of graduates from the institutions for the feeble- 
minded. The Rome State School at Rome, New York, has over 
1 Mental Clinics in the Court, Nat. Comm, for Mental Hygiene. CAREFUL TRAINING NEEDED 
59 
eight hundred more “ children ” under its supervision than the 
actual capacity of the school. 
Careful Training Needed.—With the adoption of the newer 
point of view institutions for mental defectives are becoming 
less custodial shelters and more educational training schools, a 
boon and a necessity for all those defectives who need a more 
intensive training and closer supervision than can be obtained 
by the pupils of the special classes of the public school system. 
Progressive communities are making use of both the classes 
and the institutions to provide the special training so essential 
for these handicapped children. The first step, then, is to find 
out what is the matter with the dull boy or girl who cannot keep 
up with the class in school. He may be backward owing to 
some rectifiable physical condition and need special care and 
instruction, or he may be mentally defective. We must have 
a diagnosis on this point. Dr. V. V. Anderson of the National 
Committee for Mental Hygiene writes, “ All serious minded 
students of mental deficiency deplore the hasty superficial 
methods employed by untrained persons, who, armed with a 
set of Bient tests, plus a few weeks training in abnormal psy- 
chology, pose before school authorities as diagnosticians of 
mental defect. Mental tests in the hands of a skilled psycholo- 
gist who has had adequate laboratory training and ample clini- 
cal experience are of immense value in gathering essential data 
that are to be used in the final diagnosis of the individual child. 
These tests do not give, however, all of the facts in the case, 
and sometimes not even the most important facts are thus 
obtained. The mental diagnosis of the individual child, the 
recognition of mental defect as against epilepsy, or psychopathic 
personality, or incipient mental disease, is a very complex matter 
requiring not only a training in general medicine and in nor- 
mal psychology, but a highly specialized training in the field of 60 
MENTAL DEFECTIVES 
psychiatry.” And again he says, “ The determination that a 
child is a proper subject for a special class is of serious conse- 
quence to its future welfare. If the decision is correct, it means 
an opportunity partially to overcome his prodigious handicap; 
but no greater injustice can be done a child than to class him 
as feeble-minded and at a critical period of his life surround 
him with feeble-minded children when the difficulty is but a 
temporary retardation in his mental processes which will dis- 
appear with the treatment of his physical disabilities and the 
removal of such other causes of his mental backwardness as 
may be found.”2 
Diagnosis by Competent Persons.—The rapidly increasing 
number of mental clinics will make it possible to obtain more 
easily a dependable diagnosis. What should be said, then, to 
a mother who is beginning to suspect that Willie is perhaps not 
just disobedient, but possibly cannot learn the usual lessons? 
She must be urged to secure a diagnosis from a recognized 
authority, and then to face the problem frankly and coura- 
geously. If a period of training in a public institution is advised, 
she must leave no stone unturned to secure this special educa- 
tion for the boy. It means the safety and happiness of his 
whole future. If he ought to remain at home and enter a 
special class she must learn to understand and supply his spe- 
cial needs when out of school. A feeble-minded child living 
at home should not be deprived of his share of the family 
affection and interest. Sometimes because of family pride such 
a boy or girl is kept out of sight or sent away into isolation 
with an attendant. This is cruelty when the victim is a simple- 
minded affectionate child though grown to adult stature. Spe- 
3 “ Education of Mental Defectives,” by V. V. Anderson, M.D., 
National Committee for Mental Hygiene. Mental Hygiene, vol. v, No. i, 
Jan., 1921. THE NURSE’S SHARE 
61 
cial care should be taken to provide him with suitable 
amusements and tasks in the watchful protection and affection- 
ate warmth of the home. 
The Nurse’s Share in Dealing with Mental Defect.—Dr. 
Walter Fernald writes, “ Those defectives whose defects are 
recognized while they are young children and who receive 
proper care and training during their childhood are as a rule 
not especially troublesome after they have been safely guarded 
through the period of early adolescence.” This indicates very 
clearly the duty of all nurses who meet with this problem. They 
must seek to secure a careful diagnosis in suspected cases, assist 
in getting the child placed in a suitable class or training school 
if his condition demands it, and instruct the families in the 
kind and extent of supervision these children will need for life. 
Such action is called for not only for the defective’s own sake, 
but also because untrained, unsupervised defectives in the com- 
munity can (as has been already pointed out) render unavailing 
much of the nurse’s effort in other forms of health work. Dr. 
Haven Emerson says, “ The worst spreader of tuberculosis is 
the feeble-minded open or active case. Irresponsibility is no 
more a personal liability alone than is communicable disease. 
The presence of the feeble-minded or of those otherwise irre- 
sponsible and incompetent in a family or in a community con- 
stitutes the danger point in all the communicable and occupa- 
tional diseases and drug addictions. . . . If we were free of the 
incubus of the feeble-minded our control of the venereal diseases 
would be infinitely simplified. ... In the saving of maternal 
and infant lives we come upon the irresponsible mothers of the 
illegitimate, where the infant deathrate is ten times that among 
children born in wedlock and reared with understanding of the 
simple rules of cleanliness, the necessity of constant protection 
of babyhood.” The neglected defective has thus a blighting 62 
MENTAL DEFECTIVES 
effect on the health of many others in his neighborhood, and 
careful provision for his needs will help to secure good results 
in many other departments of public health work. 
RECOMMENDED READING 
Feeble-mindedness: Its Causes and Consequences, by Henry H. Goddard, 
Ph.D., Macmillan Co., N. Y. 
Brightness and Dullness in Children. Woodrow. J. B. Lippincott Co. 
* Colony and Extra-institutional Care for the Feeble-minded, by Charles 
Bernstein, M.D. 
* Distributed by the National Committee for Mental Hygiene. CHAPTER VIII 
OPPORTUNITIES FOR INSTRUCTING IN 
MENTAL HYGIENE 
For average people in the community mental hygiene has 
as yet little meaning and therefore little interest. Those who 
think of it at all are likely to consider it as relating to unfor- 
tunates in institutions and in no way touching their own family. 
For this reason much educational work must be done to bring 
home to the public the significance and value of present day 
efforts to have the balance wheel of human machinery set run- 
ning and kept running smoothly. 
Public health nurses are constantly engaged in instructing 
individuals and groups in precautionary and preventive measures 
that will tend to secure bodily health. Very little has been 
done so far to draw attention to the need of protecting mental 
health. A nurse who realizes the importance of safeguarding 
the efficiency of the whole machine can find many opportunities 
to give instruction in constructive mental hygiene. 
'Mother’s Clubs.—Talks to mother’s clubs on the promotion 
of their children’s health are surely incomplete if they leave 
the mothers without some idea that the inculcation of the healthy 
mental habits described in an earlier chapter will be a desirable 
protection against future difficulties in the child’s adjustment 
to life. The health and strength of the mother herself will 
be conserved also if she learns the necessity of establishing 
in her tiny infant the habits of self-control, orderliness (as in 
regularity of feeding) and obedience from the first dawning 
of intelligence. These habits will prevent later domestic misery 
from the tyranny exercised by a self-willed, unmanageable child. 
63 64 
OPPORTUNITIES FOR INSTRUCTING 
Young Women.—Groups of young women should be given 
a clear idea of the contagious and hereditary character of 
syphilis so that they may realize why husbands should be 
chosen from the group of clean living men. They should know 
what sort of crop they and their children may reap from the 
“ wild oats ” sowed by possible future husbands. Girls must 
be shown the necessity of securing regular healthful recreation 
even though it means economizing still more in dress in order 
to secure gymnasium or athletic club privileges when work 
interferes with day-time sports. They should be encouraged 
to seek out a reliable older woman as a confidante and adviser 
in situations which worry and distress them. Fortunate are 
the girls who from childhood have kept an unbroken frankness 
of relations with their mothers. 
Boys’ Clubs.—Growing boys will show an amazing interest 
in the recital of the temperance habits of their baseball heroes, 
and of the reasons why alcohol would destroy their skill. The 
regulations of great railways for total abstinence in certain 
groups of their responsible employes will let them see that there 
are fine opportunities of success that are closed to young men 
who have a habit of drinking. The story of the later stages 
of the drug habit may show them that it is not just “ a lark ” 
to take the cocaine that some boy has got from a Chinaman. 
The lesson that games and plenty of exercise and the avoid- 
ance of any unclean habits will make such men of them that 
success will be infinitely more assured will not be without result. 
Leaders of boys’ clubs will welcome a brief talk on this subject 
if it is handled with discretion and due consideration for the 
youthfulness of the group. 
Women’s Clubs.—Women’s Clubs offer a splendid oppor- 
tunity for presenting the subject of mental hygiene in its broader 
aspects. These clubs usually include most of the thoughtful TEACHERS’ ASSOCIATION 
65 
and progressive women of the community. Their interest will 
be keen in the possibilities of prevention of mental disease and 
the best methods of dealing with the problem of the feeble- 
minded. A thoughtful address given at the annual meeting 
of the Federated Clubs will spread its influence through a 
whole state. If the institutional provision for mental cases in 
the state is inadequate, a picture of the real needs shown at 
such a meeting will secure valuable support for a movement 
to establish a clinic, or hospital or training school for defectives. 
Rotary Clubs.—Rotary Clubs are showing a fine, construc- 
tive interest in matters of public welfare. Public health nurses 
are often invited to speak at their luncheons, and could put 
before them the salient facts regarding the need and the value 
of a mental hygiene campaign. These would be the men who 
could find ways and means of establishing a free mental clinic 
to do the preventive and curative work needed for the early or 
suspected cases whose presence in the community the nurse can 
show. They will be able to influence the school board to estab- 
lish a special class for the defectives whom they will want to 
prevent from becoming a burden and a menace in the com- 
munity in a few years. 
Teachers’ Association.—A meeting of the Teachers’ Asso- 
ciation of the district provides a favorable occasion for dis- 
cussing with them the mental hygiene of the school child. While 
a considerable number of teachers have been given at least an 
introduction to the subject during their training, there are 
still many who are apt to give their attention to the subjects 
required by the curriculum to the exclusion of any critical 
observation of the personality of the pupils. Mutual helpful- 
ness will result from a clear presentation of the aims and scope 
of mental hygiene. 66 
OPPORTUNITIES FOR INSTRUCTING 
Civic Clubs.—Civic Clubs bring together men and women 
interested in the betterment of conditions, and in broad policies 
framed to meet existing needs. They should be reminded of 
the true public economy which is shown in attacking problems 
at their source by adequately providing for preventive work. 
Mental disease which yearly removes thousands of citizens from 
productive wrork, and mental defect which daily fills up the 
ranks of the delinquents, the prostitutes, the vagrants and the 
criminals, must receive the earnest attention which their serious- 
ness demands. Women as well as men can now impress in a 
practical manner upon their representatives in the Legislature 
their desire to have modern and effective provision for the 
care of mentally afflicted people. It is the responsibility of all 
workers in the field of public health to see that the needs of 
these groups are widely known. 
It is a noteworthy fact that after such simple talks as are 
indicated above there are always individuals who linger for 
a private word with the speaker. One invariably hears of the 
friend or relative whose conduct has been causing some anxiety 
but for whom no reliable advice has been secured. This means 
that such educational efforts not only help to secure an in- 
formed public, but they also pave the way for helpful work for 
threatened individuals. 
There is, then, a great opportunity for the public health 
nurse, and a great responsibility to make use of it. No field 
of public health is so little tilled, none offers a greater harvest 
of suffering alleviated, of devastating misery prevented, and 
of wholesome living promoted. By her comprehending efforts 
for individuals she may be the means of preventing the develop- 
ment of disease, or secure the special training that will enable 
handicapped individuals to reach the limit of their possible CIVIC CLUBS 
67 
effectiveness. By her educational work she may arouse the 
public interest and touch the public conscience so that suitable 
provision will be made for “ the most afflicted of all God’s crea- 
tures.” By her enthusiasm and her steadily growing knowledge 
of this fundamental division of public health she may prove to 
be an immense force for good in her community, and may 
assist in bringing about that desirable time “ when human 
brains will be so naturally endowed and so nurtured that people 
will think better, feel better, and act better than they do now.”