note that the state hospitals with half the wage contribute exactly double the turnover.

Yet notwithstanding the great advantage in favor of the teaching and guard class I want to quote a pertinent and patriotic remark of Major D. C. Peyton of the Indiana Reformatory which carries a recommendation of all the managing officers in definite form: "It seems to me that state institutions and all other organizations should make the necessary sacrifices in order to contribute toward winning the war; yet in order to keep the minimum number of competent employees to handle the state's business I think the scale of wages should be such as to attract the correct type of employees to successfully handle the state's business, but each institution should endeavor to get along with the lowest possible minimum of employees." The superintendent of the Illinois State Reformatory, Mr. Scouller, seems to voice the sentiment of this class of officers in the recommendation to make the entrance salary not less than $65 and maintenance, with a regular scale of increases to $100 and maintenance. I cannot close this particular discussion without quoting an illuminating statement from the warden of the Michigan Reformatory which is sarcastic, humorous or pathetic according to one's point of view. Warden Fuller says: "We pay a thousand dollars per year and average fewer than two vacancies per year. We have no difficulty in filling vacancies as fast as they occur and usually have more than 100 applicants on the waiting list. I understand the state hospitals for the insane in the state experience a great deal of difficulty in keeping a full force of attendants and if you will address the superintendents you can obtain a great deal of valuable data along this line." Thus we see plainly in the statement of fact followed by quotations from state officials the relation between wages on the one hand and stability (efficiency) on the other.

THE LESSON TO BE GATHERED FROM THE TWO QUESTIONNAIRES.

It seems clear that the inducements needed for the hospitals, as for the schools, are those which will allow the average man to live and enjoy a normal life; a wage sufficient to allow a man to live in his home and support a family and yet have something left for entertainment and some for investment.

The old state hospital class cannot be anchored, as it is inherently as instable as the quicksand of the sea. It is of this same class that Alder speaks in one of his papers on social conditions and in this connection remarks that in certain New England districts the mills were forced to employ six men per year for each position in order to keep the positions filled. So to do our broader work we must go to a new class, the latter class, the group more stable, and offer the one necessary inducement, the greater wage, to take up this most difficult and yet fascinating work of caring for and upbuilding wrecked human lives.

WHAT IS THE PROPER WAGE?

Difference of opinion may arise about the size of this living wage, but that matter may be settled through consultation with investigators in social fields; the second questionnaire (i. e., concerning teachers and guards) brought forth some important facts and correlated suggestions concerning wages; these are worth a second glance and are referred to at this time. Our high-grade employees may be given rent and supplies to some extent in lieu of cash and the cash equivalent for service might thereby be lessened. When the United States desired to meet such a problem in the ship-building program Congress hesitated not to spend millions of dollars for housing accommodations for the workmen. How far this plan can go in hospitals is a question, for men like to handle money and to spend it and the larger cash wage may be considered the most important item to meet the situation surrounding present conditions.

WITH STABILITY WHAT RESULTS ARE TO BE EXPECTED.

The great bulk of the inmates need not the nurse nor the group caretaker called the attendant, but the individual caretaker or teacher, and this is one of the points I have been leading up to, namely, the development of a stable service made up largely of educable employees in the shape of corps of nurses and teachers, few of the former and the bulk of the service of the latter. I use the qualifying word "largely " in the last remark for the reason that some few attendants may still be needed in a certain capacity to do simple, unskilled labor.

Granted a capable and ambitious superintendent safe in office and the staff he will soon assemble, what cannot be done with the aid of these two higher groups of fellow workers? One sees accomplished within hospital walls that which has heretofore simply been dreamed of, a service full of courtesy and of personal care; of the prevention of vegetative dementia; of the reeducation of those neglected in the past; of the development of the productive power in which economy is an end sought, but in a rôle minor to mental health; of economy in help and in clothing and supplies not now possible-all this means the widest personal care of each individual and of that individual's belongings and of the state's properties and effects supplied and maintained for his benefit.

THEN THE SUPERINTENDENT MAY BROADEN HIS FIELD.

With such a dependable and efficient organization at home he may feel as he never heretofore has felt, namely, that his efforts and skill may be extended and applied through practical means to the betterment of the mental health of his community. His new organization will supply him with efficient, trained mental nurses and with hospital-trained social workers who may be given such outside postgraduate advantages as seem necessary for best results. When that time comes within the hospital precincts why cannot each superintendent develop and organize outside the hospital in his district: prior care; proper care pending commitment; proper traveling custody of the committed; encouragement of voluntary and emergency commitments; boarding out; after care; public clinics; cooperation with the courts and with other public organizations-all these and perhaps more in every town and community in the district?

ADDED EXPENSE (IF ANY) FULLY NEUTRALIZED.

Expense may be alleged by some to be prohibitive. To my mind this is absolutely without foundation in fact. One good teacher with ambition, pride, interest and skill is worth many of the kind commonly attracted now to our state hospitals. Locally there will be that saving of man power patriotically recommended by Major Peyton; the conservation of clothing, ward furniture, fix

tures, supplies and food by these intelligent men will amount to a considerable item; the conservation of the productive power of inmates for their health and for the benefit of the state will prove astonishingly great; the courtesy and personal care now largely lacking and the higher grade of nursing facilities cannot be measured in dollars and cents, but should be recognized on their merits. Lastly when it comes to the operation of the superintendent's district organization founded on his better ward organization then I say that problems involving an immense amount of human misery and crime and the expenditure of millions of dollars are directly attacked in their home environment. Criminology, for instance, shows us that more than onehalf of all criminals, paupers, and prostitutes are feeble-minded or insane. And if these people can be handled psychiatrically by the superintendent and his organization before they have become involved with the law the financial and other advantages are so obvious that no discussion is required. There are so many of these problems that this field organization may assist in attacking from the economic as well as the humane point of view that it is rather difficult to mention them all, but a few of them are herewith given in addition to the above: The prevention of insanity through early advice and perhaps voluntary treatment in a hospital for the insane or elsewhere; the prevention of insanity through eradication of syphilis and other diseases directly or indirectly affecting mental health; cooperation and advice with the courts in mental cases; scientific examination of alleged criminals and especially those pleading insanity as a cause for crime; cooperation with other public agencies for mutual investigation, information and advice; the establishment of clinics in all the towns of the district; the establishment of psychopathic wards in general hospitals; control of the propagation of the insane and defective at large, whether prior to being taken into custody or after parole, discharge or escape from public institutions. These are some of the points of economic and human usefulness of such an organization, but the field is so broad that undoubtedly others will occur to the managing officer once that his organization is at work.

RÉSUMÉ.

So let it be repeated that the success of this plan for the hospital extension or community health work would appear to depend: (1) On stable constructive service at home; (2) the existence of this would seem to depend in turn on the employment of a class of ward workers as high in interest, ambition, pride and educability as the teaching class; correspondingly the reduction of the group" attendant service to the very minimum; (3) to secure the higher class dependence simply lies on one factorthe living wage; (4) lastly the living wage, so called, spells economy in hospital management and the development of a hospital extension work with possibilities that charm the man with vision.