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8. Southard, E. E., and Stearns, A. W.: The Margin of Error in Psycho

pathic Hospital Diagnosis. Boston Med. and Surg. Journal, CLXXL, December, 1914 (Collected Contributions of Psycho

pathic Hospital and State Board of Insanity, 1914, p. 109). 9. Southard, E. E., and Solomon, H. C.: Latent Neurosyphilis and the

Question of General Paresis Sine Paresi. Boston Med. and Surg.

Jour., CLXXIV, January, 1916, p. 8. 10. Southard, E. E., and Solomon, H. C.: Neurosyphilis. W. M. Leonard,

Boston, 1917.

THE ORGANIZATION OF THE STATE HOSPITAL

SERVICE IN ILLINOIS.*

By H. DOUGLAS SINGER, M. D.,

State Alienist, Department of Public Welfare. The increasing interest of the general public in efficiency of state government has led to closer attention to the organization of the Department of the State devoted to the care of handicapped individuals which represents one of the largest items in a state budget. The subject is relatively simple where there are but one or two institutions to be considered, but becomes increasingly complex as the number rises. Each institution is a unit which, because of varying conditions in different localities, must have considerable autonomy and yet, for efficient administration, it is essential that there be uniformity of general policy with proper provision for real responsibility.

Prior to 1909, Illinois, like most other states, operated each of its institutions as an independent unit under the direction of a local board of trustees. A State Board of Charities, advisory only in its functions, served to establish some small measure of coordination. The great defect in this system was the fact that each unit worked for its own interests alone and could thus bring about considerable inequality in the distribution of funds and other means for operation. The superintendent again was responsible only to the board of trustees who were unpaid and, acting as a board, could not very well be called to account.

The interference by politicians which obtained during this kind of management in many institutions cannot be attributed to the system itself, but the fact that such domination with all its baleful consequences could continue unchecked and largely unknown to the public must be considered a defect in the method.

The first big change in system was an effort to eliminate this political control by means of a Civil Service Act which became

* Read at the seventy-fourth annual meeting of the American MedicoPsychological Association, Chicago, June 4-7, 1918.

operative in 1905. This, at first, was applied only to the state hospitals, but has since been extended to the penal and correctional institutions, although in all instances the managing officer is still excluded. In

1905, also, the State Charities Commission became much more active by reason of the character of its personnel and this body did much to improve conditions generally and to lay the foundation for the next step which was taken in 1909 when the various boards of trustees of the state hospitals, the colony for the feeble-minded and the charitable institutions were abolished and replaced by the State Board of Administration.

This body consisted of five members appointed by the governor with the consent and advice of the Senate. It was provided that one member of the board should be a physician experienced in mental diseases and that at least two members should be of the minority political party. In other words it was a bipartisan board with the control in the hands of the majority party. The provision for the bipartisan character of this board unquestionably tended to bring with it a recognition of politics as a factor in determining its personnel. An attempt was made to guard against the domination of the board by politics by arranging that the term of office should be six years, thus exceeding that of the governor by two years. The terms were so arranged that not more than two would expire in one year. In practice this provision was, however, nullified by the ability of the governor to secure the resignation of all members at his request.

The board acted as a whole, each member casting his vote upon any question which might come up even though the functions of the individual members were vaguely defined by their designation as president (elected by the board), secretary, fiscal supervisor and alienist. The fifth member had no title. The defect in this arrangement is obvious. The alienist, for example, although selected because of professional experience, had theoretically no more voice in determining the medical policies of the hospital than had the secretary or fiscal supervisor. Hence he could not in any sense be held responsible.

Through this administrative body it was possible to secure far greater uniformity of methods and budget organization within the hospitals. All purchases for all institutions were also made by it upon requisition of the managing officers thus rendering it possible to buy more economically. Although not inherent in the system, the practical result of its methods of operation was a gradual centralization of authority in the board, even in regard to details, with corresponding loss on the part of the individual superintendent. This is a danger that must always be guarded against by any central body for, under such conditions, the superintendent can no longer be held responsible.

To assist in the direction of the professional work of the hospitals, a state psychopathic institute, originated by the State Board of Charities in 1908, was officially established in 1909 by the act creating the Board of Administration. The alienist was designated by the board as the director in chief of the institute. Founded with the objects of giving psychiatric instruction to medical officers and conducting research into the problems of insanity it had, however, no authority in the hospitals except through the Board of Administration.

In 1917, as the result of the personal efforts of our present governor, Frank 0. Lowden, there was passed a code of civil government which has in effect resulted in the abolition of approximately one hundred boards and commissions and their replacement by nine state departments. The prime objects of this development were the removal of scattered, and often duplicated, authority and the establishment of really responsible management in all fields of state activity. Among others the Board of Administration was abolished and its functions centered in the Department of Public Welfare. At the same time the boards of trustees of the two penitentiaries and of the reformatory, together with certain other boards and commissions, were abolished and their activities brought under the same department.

The civil code provides that each of the nine departments (which are known as finance, agriculture, labor, mines and minerals, public works and buildings, public welfare, public health, trade and commerce and registration and education shall be under the command of a director responsible for the work of that department. It also creates a number of divisions within the departments each with an officer at its head. The directors and their staffs are appointed by the governor by and with the advice and consent of the Senate. All subordinate positions, with the exception of the managing officers of the various institutions who are appointed by the director, are selected through the Civil Service Commission.

The system of organization within each department is essentially similar and we need describe only that of the Department of Public Welfare in which mainly we are here interested. The staff consists of seven members, four of whom are administrative and three functional. They are: An assistant director, a functional officer who acts as secretary, keeps the records and has charge of the seal; a fiscal supervisor who superintends the business transactions of the whole department; a superintendent of charities who is responsible for the operation of the hospitals for the insane, the school for feeble-minded, the epileptic colony, the schools for delinquent boys and girls and the charitable institutions; a superintendent of prisons, responsible for the administration of the penitentiaries and reformatory; a criminologist who acts also as the director of the Juvenile Psychopathic Institute and is responsible for the professional work in the penal and correctional institutions and the direction of the machinery for the study and prevention of delinquency and the after-care of delinquents; an alienist who directs the teaching and research work of the Psychopathic Institute, supervises the medical and professional work of the state hospitals, school for the feeble-mindel, epileptic colony and the charitable institutions.

Besides these seven officers there is also within the department a Board of Public Welfare Commissioners, five in number, who serve without pay, but are provided with an executive secretary. The functions of this board, which replaces the State Commission of Charities, are advisory but they are specifically required to investigate the condition of the various institutions under the Department of Public Welfare, their equipment and management and to collect and publish statistics relating to insanity and crime.

Each officer is directly responsible to the director for the work of his division. The functions of each are now reaching a clear definition. The organization is therefore essentially different from that of the Board of Administration in which each member had equal authority in all matters. The scheme also provides for a very valuable distinction between administrative and professional work. These two functions are so different in character that it is very rare to find any individual capable of performing both and

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