NEIGHBORLINESS AND A COUNTRY COMMUNITY

SARAH LOWRIE

With the growth of large cities in our country and the desertion of the farms for the town, there has been a less observable but quite as remarkable desertion of the city in favor of the country.

One would suppose that these two migrations would so balance each other that neither the town nor the country would suffer by the exchange of citizens. It would be reasonable to hope that going to the country would bring just the right impetus needed by the stay-at-homes of each community to brace them into new life.

But the thing has not worked out that way.

However much the shops and offices of the cities may have benefited by the advent of the farmers' sons and daughters, and however much the real estate agents and provision merchants of the country may have benefited by the advent of the well-to-do towns-folk, the morale of the country town, the ideals of the country people and the amalgamation of the native men with their new neighbors into a better citizenship have not prospered. Nor have the city institutions been able to replace the men of affairs who, having ceased to use the city except as a means for carrying on their business, have transferred their family and their leisure interests into the country.

The city churches, the city philanthropies, and the civic improvement organizations all tell the same tale: the rich men, the special executive men, the professional men, once their actual business engagements are over, turn their backs on the city with a sigh of relief and depart country-wards for rest and enjoyment for the night, for the week-end, and for the summer vacation. The city loses them, and they gain the country. But it must not be supposed that the country in any vital sense gains them. A man who has professedly moved from the town to the country for rest and pleasure, and who observably needs both, feels as free as a debutante to enjoy what is set before him in the way of diversion, with no moral obligation toward his neighbors but that of paying with a wry grin the outrageous prices levied upon all outsiders by the genial natives.

Without quite meaning to, without indeed quite realizing it, the richer men and women of this country, especially in our eastern states, have so shifted the obligation of neighborliness that they have the air of being transients everywhere and neighbors nowhere. Even their country places are not theirs year in and year out for as long as a single generation. We Americans like to change our minds and there is no telling what kind of scenery or what style of architecture we may fancy next.

One hears a great deal about the unfaithfulness of the Irish cook who may "up and leave" any day that she hears of a chance of "bettering herself" elsewhere; but the mistress's unrest is nothing to the plight of the farmer when one considers the lottery of the city folks. The gamble of his crops and the weather is nothing to this other gamble. For the farmer knows that no power under heaven can keep the city man satisfied with his site, his house with five bathrooms, his fancy chicken run, and his concrete garage if the whim should take his wife that the environment was no longer a suitable one for the children. There is no romance, therefore, to the farmer about either his potato crop or his city neighbor. He knows it is not philanthropy that led the city man to buy five acres of poor farm land at the highest notch price, and that no desire for his company has urged the new comer to plant his house on the other side of the back pasture. Being a sensible farmer he makes what profit he can out of his potatoes and his city neighbor before either crop has time to depreciate in value.

"What are you city people for, but to be skinned?" was the frank remark of one of my nearest country neighbors one day, apropos of an outrageous bit of sharp dealing on his part as property appraiser for that district. It was not a flattering summing up of a relationship, nor did its grim humor hide any more indulgent version of our economic value as neighbors. In fact we were not, nor ever had been accepted by him and his kind as neighbors. We were a crop. A crop more lucrative than his potatoes, but from our arbitrary and unexpected demands, and the shortness of our seasons, and the variation of our types a much more "pernickery" crop to deal with. Perhaps I should have been flattered by his frankness, but I was not! For the moment indeed, I even resolved to deal no more with him or his, but on second thought I concluded that, although he would be the loser of some $200, I would be out a wash-woman, a chore boy, many dozens of fresh eggs, many quarts of milk, a care-taker for the house during the winter, and an immunity from his cows in my garden in the summer. In fact, I stood to lose double as much as he, if peace of mind and leisure to enjoy my home could be computed in hard cash. I concluded therefore that it would not pay to get mad.

But the remark rankled and in the end set this and that motive to work in my mind until my brain and heart became fallow ground for the cultivation of another sort of relationship than that of city folk and native, buyer and seller, employer and employed, or even giver and receiver. In the end we learned to be neighbors—he and I—not because his ground adjoined mine, but because we both began to feel a common civic interest in the same village and in the same country side, and because in a very particular and picturesque sense we both shared in an enterprise from which we both derived comfort and pleasure. The change in me was greater than the change in him for he had always been interested in the village life apart from his property, and apart from his comfort, and during all the year. The bond that brought us together was not the church, nor the library, nor the base-ball field—all donations in times past of the summer people to the natives, but it was the Neighborhood House, a donation from the country people and the summer people alike, not to any particular class but to all the dwellers in that mountain valley.

Of course, I realize that the particular Neighborhood House, which fits so well the need of our valley, might not do for just any valley. For instance, our valley in the Adirondacks has a scattered population of nearly a thousand people with two villages about five miles apart, and several little settlements here and there among the hills. In the larger village there are perhaps one hundred children in the school. The nearest hospital lies twenty-four miles across a mountain road, and several hours by boat across Lake Champlain at Burlington, Vt. An infirmary that could be used by the natives for long illnesses, and by the city cottagers for emergency operations was vitally needed; so our Neighborhood House has a sunny airy infirmary and a perfectly equipped little operating room.

Our village and the country people and the lumber camps back in the mountains can only depend on the services of two physicians, one of them an old and feeble man. To supplement their visits and for emergency calls for the summer visitors a district nurse was needed, so a bed-room, bath-room, and pleasant sitting-room for such a nurse were planned in the Neighborhood house to connect with the infirmary. To supplement the somewhat limited primary grades in the village schools and to provide occupation for restless little city children, a summer kindergarten had been established and proved most successful, so on the lower floor of the Neighborhood House a large, many-windowed room was set apart to be used, not only for this purpose, but for adult classes in domestic science, sewing, embroidery and dancing. There was no proper room in the village for fairs, church suppers, glee clubs, rehearsals, informal village meetings, etc. There was added, therefore, to this large room a kitchen to be used in connection with it for such entertainments and for cooking classes. There had been a successful men's club in the village for years, but the women and girls had no common meeting place and indeed no real center of interest outside their homes. A woman's club room therefore was made an important part of our Neighborhood House. It has an open fireplace, a store closet and cupboards, a writing table, tea and game tables, comfortable chairs, and a pretty color scheme, with prints and water colors on the wall, oriental rugs on the hardwood floors, pleasant chintzes, books, and flower bowls.

Though the village women had been long accustomed to make extra pin-money by selling eggs, maple sugar, balsam pillows, bread and cake, and rag-carpet rugs, there has been no store where these things could be ordered. We set apart one room in our Neighborhood House, therefore, for a Village Exchange, which was open for three months in the summer. During the winter months this pleasant little room was used by the boys for a game room. There was no hotel or even boarding house in the village for transient guests, which remained open throughout the winter; so two guest rooms were set aside in our Neighborhood House to be used by the strangers, lecturers, clergymen, visiting surgeons, and city visitors who might pass that way during the late autumn and the winter months.

Neither the village people nor the summer cottagers were well supplied with sick room appliances, and among the poorer citizens of the valley there was even a lack of necessary articles for confinement cases, while crutches, invalid chairs, and wheel chairs were difficult to procure in an emergency by rich and poor alike. So an emergency closet, stocked with such things was set aside for general use in the Neighborhood House. The rooms in the rest of the house were the house dining-room and kitchen, the pantry, cool room, linen and store closet, the stewardess's bed-room, and an up-stairs sleeping porch for the infirmary, and a splendid attic. Outside the house were the wood shed, earth closet, tool shed and ice house, an ample vegetable and fruit garden, a lawn space for croquet and tether ball, a small flower and shrub garden, and wide verandas.

The house was originally a boarding house, and the only additions which had to be made to the original structure were the cellar, summer kitchen and the sleeping porch. The total cost of these additions and of the equipment and alterations including all gifts came to about $3,000. The original purchase price of the property was $2500. The cost of maintaining the house including the salary of the visiting nurse, the wages of the stewardess, and all household expenses, as well as the expenses of the summer school, extra service, etc., amount to about $2,500 yearly. The income derived from patients in the infirmary, transients boarding in the house, and out-patients' fees, exchange dues, etc., amount to about $700 a year.

I suppose in different localities expenses of such an enterprise as the Neighborhood House would be dealt with in a variety of ways. In our valley a number of men and women bought the property and made the fundamental improvements. An association was then formed comprising as many of the citizens of the valley as cared to join. The annual dues for each associate member were fixed at one dollar. To this association the owners of the property leased the house and grounds for a period of several years. The duties of the association were to pay the taxes and maintain the property in good condition, and their privileges were to use the property for the benefit of the members of the association and, as they saw fit, for the general good of the community.

There were three kinds of memberships in the association:

Through this means the annual income of the Neighborhood House Association amounts to about $1,800, irrespective of the income derived from the fees, etc., mentioned above. Without any great strain on any one's purse, therefore, the house has been maintained by the association without a deficit.

Towards the equipment of the house gifts were received to the amount of $2,635.82. But besides these gifts of money, the village people themselves donated both labor and building materials and furniture and rugs. The summer kitchen, so far as labor was concerned, was the gift of the village carpenters. The infirmary was furnished principally by the women and the girls of the village who raised the money among themselves. The farmers of the neighborhood donated wood, potatoes, apples, etc., to the store closet. One man donated his weekly Sunday paper, another the vines for the porches. One New York physician, whose child had profited by the care of the visiting nurse, gave the sleeping porch, three or four of the other physicians who had summer cottages gave the surgical instruments for the operating room, the children of the village brought plants for the garden, one old lady knitted washcloths for the bath-room, the village house painter helped hang all the pictures and the bracket-lamps, and the village artist helped raise the money for the emergency closet by painting the scenery for the benefit play. There was really a chance for every one to give to that house, and with but few exceptions, every one did give, not only willingly and generously, but eagerly and joyfully.

And because each in his or her way had had a share in making that house a Neighborhood House, the valley people, natives and cottagers alike, promptly and without any self-consciousness turned heartily in and used the house. It had never occurred to most of us that the village had needed such a house, indeed the woman whose beautiful thought it was, had died a year before the Neighborhood House Association was so much as spoken of; but once it stood there, warm and glowing with its happy life that winter night of its opening, there was no question as to its usefulness all day long, summer and winter, in most of our minds.

During the past year the visiting nurse has been occupied in and out of the House over 2,600 hours and has treated fifty-four cases; the infirmary has had seven patients with 160 hospital days; from the emergency cupboard 300 loans have been made. The Women's Club has eighty-two members and has met weekly for lectures and socials. The Girls' Club with twenty-seven members has met once and sometimes twice weekly. The Glee Club has held many rehearsals and gave a concert in May. The sales from the exchange, open only in the summer, in two years have amounted to about $900.00. The Village Improvement Committee has held two farmers' institutes, has made progress in securing good side walks, has planned for improved roads and tree planting, and has arranged for a prize essay and oratorical contest by pupils of the public school. During the past year there were about 5400 visits to the house; the largest number of visits in one month was 1064 in December.

The question may well be asked, however: Who guides these clubs and classes, who arranges for these parties, who welcomes these guests, who sees to it that the house is clean and orderly, that the meals are properly served, that the patients are well looked after, that the stewardess is up to her work? Who is the hostess, and who, at the close of the house's festivities, speeds the parting guest? It would have to be a woman of tact and gentle blood, for the village people would not brook so much power lodged in any one who was less or even quite one of themselves. It would have to be a person who lived in the valley both winter and summer and who thus understood the conditions of both the summer and winter life. It would also require one who understood the care of an infirmary, as well as the care of the house, who could devise sick room diet, as well as substantial meals for transient guests. Fortunately for our Neighborhood House we found such a woman in our visiting nurse and after some experimenting on other lines, she was made the head of the house. She is a social worker when she is not required in the infirmary or for out-patients, and when these last demand all or more than all of one nurse's time, an emergency nurse is procured who works under the head of the house.

The fact that this head is a nurse has made our social worker the confidant of many families to which another outsider would find but a coolly polite welcome. The fact that she is a social worker makes her interest in her cases widen to their families and remain after her professional duties are no longer needed. Being the head of the house, she can dictate as to the time of meals and the activities of the house for the good of the infirmary patients, yet being the social worker, the interest of the clubs and classes in the house are not needlessly sacrificed to the whims of her patients. Her training as a nurse and her experience has made her more executive than the ordinary young social worker, but her authority as head of a house of so many interests and as executive for so active and powerful an association, gives her prestige, and with that prestige a power for self-development which utilizes the best qualities she possesses. Moreover, in a country district such as our valley, where sickness is the exception, a nurse who was confined to her profession would have much idle time on her hands, and a social worker who was solely a social worker might be discouraged as to the slowness of the growth of her ideals in the minds of those about her. For where people live twenty-five miles from the railroad, tomorrow is always as good as today for beginning a new work. The women are, to say the least, conservative, and the girls are shy about showing enthusiasm for a new idea. The audiences for lectures arrive with sublime dilatoriness, and the boys stay outside until they are quite sure that what is going on inside is a roaring success.

Of course, the head of the house has a comprehending executive committee behind her. Of course, too, each department of the Neighborhood House, infirmary, summer school, exchange, clubs, etc., has its own committee and chairman. Her responsibilities, also, are only those of a trusted agent and all her reports are filed for the benefit of the Association, so that while each department depends practically upon her, she in her turn depends upon each committee and upon the executive committee and above all upon the able president of that committee for her inspiration and encouragement in carrying out her share of the usefulness of the house. All these good things did not come the first night the house was open. They are fruits of a happy growth. There have been many minor difficulties and prejudices and some evils to overcome. The prejudices died easiest, one of them, the fear that Neighborhood House provided for needs that did not exist, went most quickly of all.

Last summer when an army officer from West Point lay convalescing in one room, sharing his nurse with a little blind pauper baby, there was no doubt as to the need of an infirmary for rich and poor. When the exchange, which sold impartially the rag rug made by a guide's wife, the oil painting of an artist, and the home-made candy of a school child, and turned in $500 profits to its members, there was no doubt as to the democratic practicability of the exchange. When the women came from the Adirondack Club, and from the summer cottages to debate with the women of the village on domestic science, there was no question as to the success of the Woman's Club. And when the women of the church sewing society came to count their gains from the country supper, and the village Glee Club met to rehearse for its great concert, and the boys invited the girls to their birthday suppers and the girls invited the boys to their dancing classes, and the young married people of the village invited last year's debutantes of far away cities to teach them new figures and steps, and the clergymen who supplied the village church and the lecturers sent by the government to answer the farmers' questions about agriculture, all shared the hospitality of the house, there remained no doubt in any one's mind as to its great usefulness to the entire community.

As to whether it has made neighbors of us all in the spiritual sense—as loving one another as we love ourselves—that has not become noticeable to a degree which has affected the price of eggs! And yet I noticed with a pleasant thrill at my heart last summer that when a woman, quite two miles away from my cottage, came down from her porch with a loaf of bread which she insisted upon my taking as a gift from her baking because she knew the bakery was shut and that I was in a sudden stress, she called me: "Neighbor!" "For goodness' sake!" said she. "Don't you dare to pay me. You'd do the same for me, I just guess! Aren't we neighbors?"

Yes, surely we are neighbors—we city folk and country folk! But it took the Neighborhood House to teach us as a community the beginnings of the art of neighborliness.

A NEW MINISTER TO MINDS DISEASED

MICHAEL M. DAVIS, Jr.

DIRECTOR BOSTON DISPENSARY

AND

MABEL R. WILSON

SOCIAL WORKER, MENTAL CLINIC, BOSTON DISPENSARY

Early last June Mrs. R., a rosy-cheeked, attractive Irish-American woman of thirty years, came to the mental clinic of the Boston Dispensary in a depressed and emotional condition. She was obsessed by the idea that every one in the world had syphilis, and that she in particular was a menace to her husband and their three young children. So firm was this conviction that she had seriously contemplated suicide.

Four years previously Mrs. R. had shown distinct manifestations of syphilis, and had received medical treatment. The infection the physicians believed was accidental, and the husband and children had proved, upon examination, to be free from any symptoms. For over a year in Mrs. R.'s case Wassermann tests had indicated that the disease had been cured; but the doctor's assurances were of no avail.

The blackness of this patient's depression had almost wrecked her home. For months she had not prepared a single meal. The patience of her relatives and friends and of the priest of her church—who considered her what she looked, the picture of health—was entirely exhausted.

Ordinarily the income of the family was sufficient for self-support. Mr. R., a bright, clean-looking young bar-tender, who was well thought of by his employers, earned $18 a week. He had been making a desperate effort to meet the extra expenses due to his wife's illness. The strain was beginning to tell upon him, however, and the health of the children was also falling below normal. The family lived in a five-room tenement in a congested and undesirable neighborhood. Mrs. R. for this reason worried constantly about the possible bad influences upon her two elder children, who were just beginning to go to school.

Thus the mental clinic faced an acute situation. If it were not effectively dealt with it would, at worst, terminate in suicide, and, at best, in breaking up a promising family.

The facts just recited were, of course, not secured at the physician's first interview with Mrs. R., but were in part gained by the social worker in the clinic and at the home. It was apparent that the home situation must be considered as well as the medical problem. There was clearly a joint task for the social worker and the mental specialist. Consultation led to the conclusion that the home arrangements would have to be changed until Mrs. R. was able to undertake housekeeping again. A long month of explanation and persuasion passed before the family, friends, and priest were converted to a plan which involved the temporary dissolution of the home. Consent was finally obtained, and the children were placed by a children's agency. Probably most important of all, the earnest co-operation of the patient herself was won. For four months she reported at the clinic two or three times a week. After the many interviews held with her by doctor and social worker, her depression gradually cleared up, and she became ready to take up the battle of life again.

As improvement grew more marked, the doctor advised that she should work three hours each day outside her home. Three hours' work every day in a good restaurant was secured. The benefit was so marked that after a month the doctor suggested that the working time be doubled.

Mrs. R. now reports weekly to the clinic, but her depression has disappeared. She is cheerful, interested in life, and is looking forward to the re-establishment of her home this spring.

Recent conferences on mental hygiene have emphasized the fact that the traditional conception of mental disease, raving insanity, is far behind the times. We recognize today that there are in the community all classes of mental disorders, from the maniac or imbecile to persons who are "just a little queer," or who, like Mrs. R., have a definite and curable obsession.

The time has also gone by when we associated the treatment of mental disease with the straight-jacket. The hopelessly defective and insane must indeed be segregated in institutions. But it is public economy to diagnose and treat the great mass of incipient and curable cases of mental disorder, since these, if uncared for, mean the wrecking of lives, the breaking up of families, and material loss to the community. The psychopathic clinic, or clinic for mental diseases, is an agency the importance of which is now recognized by all who have given attention to this field. Such clinics have usually been conducted in hospitals or institutions which specialized in mental disorders. They have rarely been managed as adjuncts of general hospitals or dispensaries. There is a distinct place for them in this connection, however, for in this way they catch patients who do not know that their troubles are really symptoms of mental disease.

Mrs. R.'s case illustrates not only the service of such a mental clinic, but also the two chief agents in achieving the service, the physician—specialist in mental diseases—and his aide, the social worker. Mrs. R.'s case belongs to one of three classes of mental disease which such a clinic can benefit—the incipient type. The second class comprises cases of mental defect which require diagnosis and institutional care.

For example. Mrs. B., a middle-aged Irish woman, came to the clinic much excited, fancying that people were locking her into her rooms. Among other delusions she feared that she might injure her two children.

The doctor diagnosed her case as involutional insanity, and thought that immediate arrangements were desirable for her entrance into an insane hospital as a voluntary patient. Mrs. B. did not remember her street number, and undoubtedly she would have been a "lost" patient if the social worker had not taken her home. Arrangements were made and carried out for a transfer to the insane hospital that same afternoon, and a children's agency agreed to assume supervision of the children during Mrs. B.'s absence. The help of a friendly landlady was also enlisted.

Within three months Mrs. B. was discharged from the insane hospital in excellent condition, with the understanding that she should report regularly at the clinic. Her improvement continues. She is at present earning good wages as a housekeeper and looks forward in the future to a little store and the re-establishment of a home for her children.

Another illustration of this type is Mr. D., a German forty-eight years old, who has been in the United States twenty years.

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Mr. D. became known at the dispensary through his wife, who had been a patient. The man went on periodic "sprees" at this time, apparently because his work as an order clerk had occasioned considerable nervous strain. Temporary financial assistance and a new job outside of Boston, seemed to put the man on his feet again; and, with a happier home life, his wife's health improved.

In a short time, however, distinct symptoms of mental disorder began to manifest themselves. Mr. D. talked much to himself, and was haunted by doubt in everything that he did. If he put on his hat he was forced to step in front of the mirror several times to be sure that the hat was really on his head. After completing a piece of work, he returned many times to make sure that it was really done. Occasionally he remained at home in bed, because his fellow workmen, noting his peculiar actions, had laughed at him. Upon this basis a fear of meeting people grew up, and he shunned every one. Once or twice he approached his wife threateningly. The superintendent feared to keep him at the factory any longer, and discharged him. After a careful medical examination, the prognosis for the patient was not very favorable. A possible outcome was an active and incurable form of insanity. It seemed necessary, in order to have a reasonable hope of cure, that a radical change of life be made.

Therefore, Mr. D. was induced to go as a volunteer patient to a hospital for the insane. There he remained six months, during which time, with the assistance of the Associated Charities, suitable quarters and light work were found for his wife. Mr. D. was allowed to visit her weekly, until she became ill with an attack of Bright's disease, which, complicated by cardiac symptoms, occasioned her death. This loss retarded Mr. D's. recovery; but, at the end of six months the hospital considered him sufficiently improved to be discharged to the dispensary for continued observation.

At present, six months after his discharge, the situation is very encouraging. Mr. D. is working most satisfactorily as a porter for a large department store. He has secured an excellent room with some old friends, has given up drinking, and, from his twelve dollars a week, is paying back the advances made by the Associated Charities. His "insanity of doubt" seems to have vanished, and his outlook upon life is once more interested and hopeful.

Still another case is that of R., a boy of eleven years. He was born in Russia, of Russian Jewish parentage and has been in the United States six years:—

R.'s own story of his first visit to the mental clinic, was in a manic condition and talked incoherently. A week before his appearance at the dispensary the child had returned from school in a much disturbed state. Since that day he had not been able to sleep, and had manifested great nervous depression with hallucinations and had attempted several times to jump from the window.

R.'s own story to the physician was broken and confused. He talked much of having been forced by his teacher to go down on his knees, and insisted that his hair was on fire. He appeared a sensitive and intelligent child.

Investigation revealed no history of mental disease throughout the families of both father and mother. A home visit by the social worker showed that the family of seven lived in a four room tenement in a congested and noisy Jewish section. The father was a tailor with an irregular income.

The boy was immediately sent to the psychopathic ward of the Boston State Hospital, where the diagnosis of acute insanity was confirmed and a week later R. was committed to the Danvers State Hospital. A co-operative connection was established between the social worker and the hospital physicians at Danvers who were in charge of the case. After he had sufficiently recovered, the plan was made that R. was to be placed in the country under the supervision of one of the children's societies for a period of at least six months. Dr. Mitchell, superintendent of the Danvers State Hospital, wrote in approval of this arrangement.

The plan was carried out with most successful results. At the end of six months he was released from the parole of Danvers State Hospital and returned to his home to report once a month to the mental clinic at the dispensary.

The social work in this case was not confined entirely to arrangements for the boy, but extended to the preparation of the family for his return, which involved moving to a less congested neighborhood in a Jewish section of a Boston suburb. It was also necessary to arrange for his attendance in an open air class, win his teacher's interest and co-operation, and educate the father to a realization of the need of discipline, the value of regular hours for eating and sleeping, the desirability that the boy should sleep alone, and the danger of exciting recreations.

R. has now been at his own home for twelve months. A recent entry on the medical record states: "Patient in excellent physical and mental condition."

The third class includes patients who have been discharged from insane hospitals as cured, or as so much improved that they should be able to maintain themselves and take part in family life again.

This work of after-care is extremely important. Many cases of mental disease can be safely discharged from an insane hospital if there is assurance that they will be properly followed up in their homes. Such supervision requires the joint efforts of the physician and the social worker.

Miss C., for instance, a woman of thirty-three years, was sent to the clinic for after-care, by arrangement with the superintendent of the insane hospital to which she had twice been sent for maniac-depressive insanity. Her mother had also been a patient for years in the same hospital. During the first weeks of her treatment at the clinic, she was still nervous, complained of gnawing sensations in the back of her head, and dreaded to ride in the street cars. When sitting, she constantly pulled and twitched different parts of her clothing, beat upon the floor with one foot, and kept one hand on her head, using the other one alone. She lived with a married sister who was in comfortable circumstances, and worked for her brother in an unprofitable little plumber's shop, which he apparently kept mainly to afford employment for Miss C. and a younger brother.

With this history it was plain that careful oversight and regular clinical visits were necessary to prevent future attacks. Advice and encouragement were given with the object of stimulating Miss C.'s normal interests and of persuading her to return to wholesome companionship. During the summer of 1912 it was decided to remove Miss C. entirely from home associations, and a desirable position as housekeeper was secured in the country. There she gained in weight and spirits, and acquired valuable experience. She still comes regularly to the clinic, and the medical and social prognosis seems favorable.

The value of organized social service in connection with the clinic for mental diseases has been strikingly shown since its recent establishment at the Boston Dispensary. In the department for mental diseases in this institution, which is a large and long-established dispensary taking all classes of diseases, a trained social worker was set at work in January, 1912. At the expiration of a year an efficiency test was made, comparing the clinic during 1911, when the medical staff had no social worker to assist them, with 1912, when she was at their service. The following table summarizes this test:

The gist of these statistics is that, with the aid of a trained social worker, it is possible to treat certain forms of mental disease effectively in an out-patient clinic. The physician becomes able to keep a grip upon all patients that he wants to hold. There is practically a closed circle, and the results of treatment bear favorable comparison with private work. It is not too much to say that such a clinic, provided with a staff of interested mental specialists and with trained social workers, can perform an important function in treating mental disease and preventing its spread in the community.[10]

The social worker at the Boston Dispensary works actually in the clinic. Here she meets each new patient and takes a careful social history, usually before the patient sees the physician. Often she is present when the doctor interviews the patient, and always, after this interview, the physician consults with the social worker. Then a plan of treatment is made which includes the social as well as the medical factors of the case. In a certain proportion of cases, home visits are not necessary. The efforts of the social worker in the clinic itself are sufficient to secure adequate treatment. Thus there appears a very important classification of the kinds of social work required:

1. Patients presenting acute family problems of poverty, ignorance, or undesirable home conditions and associations. These patients require home visits and intensive social work. In the mental clinic of the dispensary they constituted 48 per cent of the 141 patients.

2. Patients requiring a home visit simply for the purpose of insuring the patient's return to the clinic—that is, cases in which there were no complex home problems but in which it was necessary to go to the home once in order to persuade the patient to come back for treatment. This class at the Dispensary constituted 20 per cent.

3. Patients to whom it was possible to give effective treatment by clinical interviews only, without home visits. This class constituted 32 per cent.

Inasmuch as the cost of the service per patient (estimating the time taken by the social worker) is enormously greater in class one than it is in class three, it is highly important to make this classification, and to keep a close watch upon the proportion of the different types, so that the cost of the work as a whole, with reference to its efficiency, can be accurately estimated.

An efficiency study from this standpoint during 1912 leads to the conclusion that the average cost per patient (the complete treatment of a case) in class three is sixty cents; in class two, a dollar; in class one, four dollars. The medical service is given gratuitously by the physician. More extended studies in this and in other mental clinics should be made in order to work out the cost figures more accurately.

There can be no doubt, however, that even if the cost of medical service were added, it is cheaper to treat mental diseases in the early stages, when patients can retain their places in the community, wholly or partly self-supporting, than to let the disease reach a point where permanent damage is done, and the insane hospital is the only resource.

That out-patient clinics should fill an important place in the new nation-wide campaign for mental hygiene, there can be no doubt in the mind of any one who has given attention to the matter. That organized social service is not only a desirable accompaniment of such clinics, but an essential condition of their efficiency, is a demonstrable and measurable fact.

CIVIL WAR IN THE WEST VIRGINIA COAL MINES

HAROLD E. WEST

[The Survey has not had staff or means to send a special representative to the West Virginia coal fields to make an intensive investigation of the conditions in the strike area. That is the sort of social interpretation we shall hope to perform with the growth of the slender resources of the Survey Associates. We have done the next best thing—viz., turned to the most promising newspaper source.

It has been current gossip among journalists that the press of West Virginia could not be relied upon to tell the truth about the situation in the Kanawha Valley. Of the metropolitan newspapers which up to March had had staff representatives in the field, the accounts of the Baltimore Sun stood out. They did not mince matters in telling of the brutal murder by the strikers of the mine guard Stringer; nor did they hedge in publishing what was done by the Cabin Creek and Paint Creek Colliery Companies. Mr. West was the representative the Sun had sent into the field, and from him The Survey requested an article, only stipulating that it be fair to both sides and tell not only the events of the strike but the conditions back of them.

"The article may seem unduly to favor the miners," wrote the Baltimore Sun man in sending it in. "I went to West Virginia absolutely unprejudiced, with the idea of telling the truth about the situation. I found conditions I did not believe could exist in America, and I am no novice in the newspaper game, having seen some pretty raw things in my time. I told the truth about them, and am afraid I have gotten myself disliked."

The fairness of the article is disputed by Neil Robinson, secretary of the West Virginia Mining Association. His protest is published in the forepart of the magazine.—Ed.]

For nearly a year a state of turmoil amounting in practical effects to a civil war has existed in the coal fields of West Virginia. The situation centers in the Kanawha Valley, hardly more than twenty miles from Charleston, the capital of the state.

The military power of the state has been used with only temporary effect; martial law has been declared and continues in force; the governor of the state has been defied and denounced from the state house steps and within his hearing; men and women have been thrown into prison and are still there for espousing the cause of the miners, and the grim hillsides of the canons in which the mines are situated are dotted with the graves of men who have been arrayed against one another in this conflict between capital and labor.

Of course, there have been errors and excesses on both sides. The men in the mines are not angels by any means, and neither are the men for whose profit they work. But there has been no profit on either side for the last year and it looks as if there would be none for a long time to come. The men of both sides are pretty good fellows away from the mines and the subject of mining; on the matter of mining, they show the obstinacy of men who look at a proposition from but one point of view, who see no justification of the position of those who oppose them and who seem to have lost absolutely the sense of proportion.

If the efforts made by William B. Wilson, former Congressman from Pennsylvania and former secretary-treasurer of the United Mine Workers of America, to have a federal investigation of the situation early in the struggle, had been successful, the whole matter might have been settled long since. But his resolution calling for a congressional investigation was buried at the last session of Congress and was never resurrected.

Wilson charged that a condition of peonage existed in the mines and that men were held there by force and compelled to work against their will. The coal operators denied this vehemently, at the same time fighting bitterly a federal inquiry. Evidence I was able to gather on a trip of investigation to the mines convinced me that a form of peonage does, or did, exist; that the miners were oppressed; that the rights guaranteed under the constitution were denied them; that the protection of the law of the state was withheld from them and the law openly defied and ignored by the coal operators. These things were done, apparently, not because the operators were cruel, but—the old story of dividends—because they thought it necessary that a balance be shown on the right side of the ledger, and because competitive conditions in the coal fields were such that more of this balance had to be produced from the men themselves than from the bleak hills in which they toil.

The investigation is bound to come. Wilson is a cabinet member in the new administration, and could of his own volition carry it on under the broad terms of the act creating the new federal Department of Labor. But there is another agency which may look into the situation. When fellow members of the lower house balked Congressman Wilson's proposal, he interested Senator Borah of Idaho and the latter promised to introduce into the Senate, at the coming special session, a resolution calling for a full and complete investigation, by a committee of the Senate, of the whole situation in the West Virginia coal mines, including the question of peonage, the use of mine guards and other means of oppression. This would be a Senate resolution, it would not have to be concurred in by the House of Representatives, and it is understood that Secretary Wilson has votes enough pledged to pass it.

Even the close of the strike which has been rumored the past fortnight would not make such a fundamental inquiry during the spring and summer inopportune, but rather a measure of precaution in anticipation of future labor conflicts in the region. The fact that such an inquiry has been actively contemplated is not generally known; information about it has not been published in the newspapers, but has been given me for use in The Survey.

Backward View of the Trouble

The Kanawha trouble dates back about ten years. At that time the miners' condition was good, as things go for men in the coal fields, and the miners along Cabin Creek were organized. An ill-advised strike was called then, and it resulted in a disastrous defeat for the miners. This strike was ordered by officials of the union against the desire of the miners directly affected and it is charged by Cabin Creek miners that it was declared in the interest of the Ohio operators who desired to cripple their West Virginia competitors. Some of these operators have since admitted that they helped finance the strike. As long as the trouble lasted, operators in competitive fields could gobble the business of operators whose plants were shut down. Of course, after the men had been beaten and the strike broken and non-union conditions and wage scales went into effect, the competition was more bitter than it had been before, yet the pickings were good while they lasted. That, however, is all ancient history.

Ever since the strike of a decade ago the men on Cabin Creek have been restless. Conditions were burdensome although they were not so bad on Paint Creek which was organized. The operators were out after business and they cut prices on coal to the limit in order to meet the competition of Illinois, Ohio and western Pennsylvania operators and get a share of the "lake trade." For the driving force behind this civil war in the hills of West Virginia is to be found in the coal bins of 10,000 factories of the Middle West and beyond whose managers and workmen know little or nothing of the struggle.

By "lake trade" is meant the coal that goes to ports on Lake Erie for transportation by steamer and barge to Detroit and as far as Duluth and Superior for distribution throughout the Northwest. All the trade that passes over the lakes, no matter what its ultimate destination, is known as the "lake trade." The Pittsburgh operators have held that the opening of the West Virginia fields was an economic blunder, that the lake demand was no greater than Pittsburgh and Ohio could supply, and that it was a mistake for the West Virginia operators to enter that field. The latter took the position that they had the coal, and did not propose to let it remain undeveloped because it would interfere with the market of the operators of other fields. They would mine their coal and would sell it wherever they could, and if they could grab a big share of the lake trade they proposed to do it. It has been a battle of millions.

To strengthen their position the Pennsylvania operators have bought large blocks of West Virginia coal lands. The Lackawanna Coal Company has, for example, secured control of the principal operations on Paint Creek.

The operators in the Ohio, Illinois, and most of the Pennsylvania fields, get out their coal under terms as to hours and wages imposed by their agreements with the United Mine Workers. In order to be in a position to meet the growing competition of the West Virginia fields on an even footing in the matter of labor, it is an open secret, that they have given aid and comfort to the union in the effort to organize the West Virginia field. They have been fighting on the other hand for a reduction in their own freight rates or an increase in those of their West Virginia competitors, they did not care which, as the consumer finally pays the bill. Until a comparatively recent time, the rate from the Pittsburgh district to Ashtabula and Cleveland has been 88 cents a ton, while to Toledo and Sandusky, the rates from the West Virginia field have been 97 cents and $1.12 a ton.

Something more than a year ago the pressure on the railroads became so great that a meeting of the officers of the coal carrying roads and the operators from the Pittsburgh and the West Virginia districts was held in New York in an effort to settle the difficulty. No agreement could be reached and the roads, unable to resist the pressure of the Pittsburgh operators advanced the rate from the West Virginia fields 9-1/4 cents, making the differential in favor of the Pittsburgh field 18-1/4 instead of 9 cents.