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there has been a very general tendency to subordinate medical to administrative qualification, which is, in my opinion, largely responsible for the slow development of our state hospitals. They are almost universally well managed in the way of general upkeep, but there is only too often a decided poverty in professional progress.
Under the Illinois system the managing officer of a state hospital is responsible for the operation of the institution to the superintendent of charities, but is subject to the direction of the alienist in regard to matters involving the professional care and treatment of patients. Means for cooperation between the various divisions is provided by holding staff meetings over which the director presides.
The administrative machinery is perhaps a little complex, but in practice works very smoothly. The purchase of supplies is made by the superintendent of a division of purchases and supplies in the Department of Public Works and Buildings and not by the Department of Public Welfare. Requisitions from the managing officers pass through the hands of the fiscal supervisor and are then sent to the purchasing division which buys everything used by the state government. The forms to be used for bookkeeping, vouchering, etc., the preparation of the budget and the financial supervision generally are vested in the Department of Finance. The erection of buildings, supervision of architecture and engineering work for the whole state including the institutions under the Department of Public Welfare are upon requisition conducted by the Department of Public Works and Buildings.
To ensure cooperation in these interdepartmental activities meetings of the directors are held at frequent intervals at which general policies are discussed and decisions reached. This body thus acts as a cabinet to the governor and serves to preserve a proper balance in the work of the state.
I have already called attention to the provision for separate control of the administrative and professional work of the institutions. This division of duties brings with it the possibility of establishing a clear-cut professional organization of the state hospital which should be the central feature around which the administration is built instead of dividing the institution for convenience in administration as is usually done. As yet the department is too young to have succeeded in finally defining such a scheme, but a tentative arrangement has been adopted which I have described in some detail in a paper now in the press. This I may here briefly outline.
The scheme is shown in graphic form on the accompanying chart. The two groups in the top line represent the agencies through which a patient enters the institution that to the left being part of the hospital organization chart. The chief feature of the plan consists in the establishment of a “reconstruction " division through which all patients must pass before being either released,
with or without supervision, or being placed in the custodial or, as here called, industrial division. This reconstruction division carries out work which should be considered as the principal function of a state hospital. Its aim is the rehabilitation of the individual to the highest degree possible, whether he must remain permanently within the institution, in which case he is trained for taking part in its industrial work, or is to be permitted to resume more or less of the responsibilities of citizenship. In this latter case the effort is made to fit him better for life in the world by giving instruction in occupation and habits of adjustment.
The hospital divisions, one for acute mental disorder and the other for somatic disease, take their place as adjuncts for temporary residence in which are provided special means for treatment designed to promote a return to sufficient health to permit of reconstructive work.
Special attention may be directed also to the provision for special observation wards and outpatient departments which, according to circumstances, may or may not be located within the confines of the hospital. In any event they form a most important part of the organization both for prevention and after care and will also include the means for obtaining information for use in diagnosis. The diagnostic division, which will include the laboratories, corresponds with what is usually known as the reception service, but is given this title in order to emphasize and clearly define its functions.
The division labelled "industrial” corresponds with what is more commonly designated as the custodial service and necessarily contains the large bulk of the inmates of the institution. The title here used is intended to convey what I believe should be its real function. Idleness should not be permitted and the fullest use possible should be made of the capacity for employment of those who must remain segregated from the world not only for economy, but also for the benefit of the patients themselves. As already indicated, special training with this in view will be given in the reconstruction division.
Such, in brief, is the plan upon which the Illinois state hospitals are being organized, but before concluding let me call your attention to another feature in the provisions of the civil code which we regard as one of the most important. This concerns the inclusion of the penal and correctional, in the same department with the insane and charitable, institutions. That crime and delinquency are disorders of behavior requiring similar methods of study and diagnosis to those of insanity, feeble-mindedness and dependency is gradually being recognized. Under the Illinois system there becomes possible a very close cooperation between the two groups with interchange of means for study and treatment. The medical staffs have been amalgamated in the sense that physicians can be transferred from one group to the other, thus providing for a broader training of medical officers and the introduction of psychiatric methods into the penal and correctional institutions. The general plan for the professional organization of the penitentiaries is being made to follow very closely the lines laid down above for the hospital.
The machinery for research and preventive and after-care work will also, to a large extent, be fused so as to avoid unnecessary duplication and permit of the greatest economy. This work is as yet in its infancy in this state, but a beginning has been made by the establishment, in temporary quarters, of the Juvenile Psychopathic Institute in Chicago which is, at present, serving not only in the study of delinquency and juvenile behavioristic problems, but also in the after-care of cases from those state hospitals which receive from the Chicago district. This it is planned to greatly enlarge and to incorporate with the Psychopathic Institute in permanent quarters. This institute thus formed will act as a research and teaching center which will in all probability have close relations with the medical college of the State University.
The outline here given is necessarily somewhat sketchy, but will afford a general idea of the plan of operation. Its principal advantages are: (1) The establishment of direct responsibility in all fields; (2) the elimination of much unnecessary reduplication of machinery, and (3) the clear recognition of the distinction between professional and administrative functions.
PSYCHOPATHOLOGICAL OBSERVATIONS IN A
GROUP OF FEEBLE-MINDED.
BY ESTHER LORING RICHARDS, M. D.,
Instructor in Psychiatry, The Johns Hopkins University. The material comprised in this paper does not represent an attempt to write what Goddard has called “ A chapter in the story of feeble-mindedness which is not yet written," namely, the relation of insanity to constitutional mental retardation. The subjectmatter here is offered for what it is worth, merely as a record of psychopathological facts observed in the examination of certain cases from The Training School for Feeble-Minded at Vineland, N. J., which were referred by Superintendent Johnstone as having “insane streaks.” In the examination of these patients all data of the family history, past history, behavior curves since admission to the institution, as well as the psychological tests for determining the patient's mental level, have been taken directly from the institutional records.
Three of the 16 patients examined were found to be frank epileptics with episodic outbursts of irritability, combativeness, and confused behavior, such as wandering about unclad. These episodes followed a convulsive seizure, or a series of the same, and all were followed by complete amnesia for the behavior during the attack.
Four of the remaining 13 patients showed in association with their original mental deficit a definite psychotic development. The following are brief records of these cases:
(1) A. B.; æt. 24. Female. Family history, negative.
The patient did not walk until 20 months and is described by her parents as always stubborn, affectionate at times, sometimes untruthful, resentful of correction, sly, morose, moody, seclusive with no play interest, but almost daily temper tantrums. She was backward in school. On admission to The Training School, March, 1915, her “mental age,” according to the Binet-Simon test, was 9 years, the basal year 4, with scattering successes which brought her up to 9 years. On admission she was neat in appearance and in the care of her room, did a little housework about the cottage, but showed no interest in anything around her. She was inclined to be impudent