it seems almost impossible that he can be changed by any ordinary human means." That is undoubtedly the attitude that the Juvenile Court judge of any of our progressive courts would take.

The remarkable and far-reaching development of prevention and education which has been induced by the growth of the probation departments is unquestionably making itself felt in the institutional field. With the exception of a few of our less advanced communities, in the outlying districts of the state of Illinois, all the juvenile courts, especially the Juvenile Court of Chicago are satisfactorily solving the problems of the great majority of those cases which come up before them so that they are not only "reforming" in the old sense all those cases which in by-gone days would have redounded to the credit of the institutions as cures, but are actually sorting out for institutional commitment with ever-increasing accuracy only those cases which do not respond to the educational and social treatment, and who therefore are finally sent to an institution not so much for what it is hoped to secure for them, but rather as a precautionary method of protection for the community. It is a last desperate hope with the emphasis rather on the community's interest than on the child's. It is no wonder, therefore, that our institutional staffs are not so sanguine about the beneficial effects of the institution as were those of a generation ago.

While all this may be important to a certain extent, it does not explain the main problem which crops out again and again in the study of delinquents, especially in institutions. That problem is: What is the difference between the delinquent child who is finally sent to an institution and the one who is successfully maintained on probation? It is not the nature or the quality or the degree of his behavior difficulty, for every kind of delinquency that is represented by the institution population is found in larger numbers among successful parole cases. It is not a difference in intelligence, for in spite of certain evidence in this direction, further experience has not borne it out. And again we know that for every feebleminded person who has to be committed to an institution because of dangerous behavior, there are two or three at least of equally lowgrade intelligence who are safely kept at work in the community.

Probably no characteristic distinguishes the institutional from the non-institutional case more frequently than that of temperamental insubordination. One might almost say that the child who is sent to a state correctional institution, in the main, goes there because in addition to his behavior difficulties he has exhausted the patience of the authorities, first in the home and the school and then in the court and on probation, and finally in those institutions which act as buffers between the correctional schools and the community, such as the truant schools, the detention homes, and in the case of Chicago, the Chicago and Cook County School for Boys, which receives boys for no longer than three months.

The only generalization that seems justified on the basis of these statements is that when it comes to dealing with the delinquent child no generalization will hold. Each is an individual problem-a trite and oft-repeated statement indeed; and yet do we apply it in our organizations? The juvenile courts which do their work almost entirely on the basis of the individual case, of course, have demonstrated and will demonstrate increasingly the fact that it is by individual study and individual treatment that results can be obtained-often thoroughly astonishing results.

In our institutions there is little evidence of this. Even in those institutions, glowing accounts of which have penetrated to us in Illinois where the work of reclama

tion is said to go on at a remarkable rate, it would appear that there is little more than a picking-over of the junk-pile for the uttermost remnant of reclaimable materials. The final residue remains, in a large proportion if not the major proportion of the institutional group, unresponsive to the group methods, the generalizing discipline, and repressive social atmosphere which under the guise of military or other discipline serves merely as a cloak for ignorance or incompetency on the part of the institutional staff.

It is not my purpose here to call names, and as I stated before, I do not believe that the institutional staffs are to be held responsible for this state of affairs. But the community itself must accept the full responsibility so long as it continues to hoodwink itself by clinging to the long discredited methods of repressive discipline as a cure for behavior difficulties.

And why should an institution's efficiency be made dependent upon the number of "cures" that it can demonstrate in its annual report? Such cures, it is true, may be the ultimate objective, but unless somebody has at present a specific curative method, which will work with 100 per cent efficiency, or even 90, or 80 per cent, or any major fraction, with the consequence that the institution has merely to carry out the precepts to obtain results, why should we demand such things of our institutional staffs, especially since the latter are dealing with cases in which the elaborate and highly skilled juvenile court staffs have failed? This is not a field in which any one person may claim to have the answer. Neither the psychiatrist nor the psychologist, neither the sociologist nor the educator, neither the jurist nor the penologist. The answer is yet to be found, but are we doing anything to find it?

Where is the correctional institution in which the entire energies of the staff are bent upon utilizing these unreclaimed cases for the obtaining of facts upon which to base logical action? Which institution in this country, even among those in which research is being conducted, can say the major object of the entire institution is to conduct such research and in which it is not the truth to say, rather, that research is also being done? And, finally, even where the will is strong, where is the institution in which the staff is not so weak in intelligence, in education, or in special training, as to be almost powerless to this end?

It is very satisfactory and gratifying to know that certain individuals have achieved results with certain small and carefully selected groups of individual cases, and it may be interesting to learn that they believe their success was due to the fact that they used a certain amount of tact in their work or that they started out with the idea that these children were "at heart like any other children" or because they have themselves "a knack" or "charm" or "strong personality" and so on.

But what good does that do us, who are not gifted in this way, who are not able to select our cases, or who have not the climatic or other conditions which enabled a particular piece of work apparently to succeed? No facts have come out of these experiments beyond the one that intelligence, refinement, and industry will achieve results in the field of juvenile delinquency, as elsewhere. No one, to my knowledge, is in a position to say "by this and this rule can this selection be made," or "this and that quality indicates a favorable case," or the reverse. It is all a matter of opinion based largely upon personal prejudice or, if you do not like this term, to borrow a phrase from my friend, Mr. Albert Kales, upon "subliminal hunches."

When once the correctional schools will change their attitude from that of more or less consciously assuming responsibility for achieving results in the nature of cures or corrections to that of experimenters, then may we hope that real progress will reward our labors; then will the correctional school no longer assert pedantically that it is devised and equipped to change the delinquent into a well-behaved person and more or less hypocritically to hide its failures behind outward semblances of orderliness within the institution; and then will the courts, and perhaps the families of children with behavior difficulties seek out the help of the correctional school as, in acute disease, they now seek the surgeon or physician; and then the correctional school will no longer be the symbol of failure and of a forlorn hope, but will stand for knowledge upon which effective, purposeful, and intelligent treatment may be based; and above all it will be the source of preventive measures which will still further reduce the number of cases requiring to be sent to the school.

EDUCATIONAL VALUE TO THE COMMUNITY OF MENTAL HYGIENE AGENCIES

A. THE PSYCHOPATHIC HOSPITAL

William F. Lorenz, M.D., Director, Wisconsin Psychiatric Institute, Madison

The psychopathic hospital is probably the most potent influence from the standpoint of the general public in furthering mental hygiene. Its greatest influence lies in the fact that it is a simple, tangible expression of all modern views concerning mental diseases; that is, the hospital features of caring for these conditions are so much emphasized and so much in evidence that probably no other means help as much to develop the general belief that a mental disease is in fact an illness and not an offense against society.

The two outstanding features of a psychopathic hospital which in my belief impress the public are: first, the hospital atmosphere which obtains in these modern institutions; and second, the results of treatment which the public soon learns to know as being far more satisfactory then the results obtained in the old type of institution. The better results obtained in the psychopathic hospitals are due in a great measure to the individual attention a patient receives. His mental and physical state is more carefully analyzed and the means of readjustment to normal health are provided; but this alone does not account for the better results. Unquestionably these are due also to the fact that the mental case is received at a much earlier period in the course of the disease. The early treatment of a mental case has long been known to result in more recoveries and were it possible to receive mental cases in their incipiency, even at our more or less poorly equipped state institutions, better results might be expected. The trouble, however, lies in the hesitancy on the part of the public to send an early or mild case of mental disease to an institution which already has a well-established reputation as an insane asylum. All the efforts that have been expended to change the old type of institutions, to promote a different atmosphere to increase equipment and facilities, from the public standpoint at least, have been quite barren of results. This is probably due to the fact that the modernizing efforts have not been universal. Here and there a state institution stands out in the reformation that has been so

generally attempted, but the truth remains that the few which have succeeded have been insufficient to actually mold public opinion and belief. There is no need to blind ourselves to the fact that most of the old institutions are still far from modern in their equipment, and what to my mind is far more serious, in their policy.

As a consequence when one meets with a mild mental case in private practice, it is with great hesitancy that one advises treatment at a state institution and even when no other solution exists one finds the friends and relatives very much opposed to the suggestion. The usual protest is, Oh! so-and-so is not crazy, or so-and-so is not dangerous, he or she can be easily handled,-evidencing the popular conception that a state institution is for the protection of the public and not a hospital for the patient. It would seem that the only answer to the public attitude lies in the establishment of new hospitals, newly located, newly equipped, and newly named. The efforts at masquerade have not been successful; the mere changing of a name has not promoted faith; in fact these things have helped create the belief that a subterfuge has been resorted to. The greatest difficulty, in my experience at least, lies in attempting to reform the spirit that obtains in an old, established institution. Rarely does one find a sympathetic ear to any of the modern methods of treating mental diseases that are being advocated. More frequently, even if some interest is manifested, the difficulty of getting sufficient financial support from a legislature is offered as an excuse. One cannot help but feel that this difficulty is at times embraced as a way out of a situation, a way which tends to place the responsibility for failure to improve upon an agency which cannot readily be attacked. Yet, from personal experience, it is maintained that the fault frequently lies in the failure to properly present and emphasize the needs of modern scientific care of mental disease. Possibly these efforts are misdirected and might better be used for the establishment of something entirely new and different from the old type of institution. Wherever this policy has been pursued the reaction of the public and of the legislature has been all that any ardent worker for the welfare of mental cases could desire. It is owing to this reaction that I believe a psychopathic hospital to be the most potent influence in promoting mental hygiene.

In states already supplied with large state institutions it has not been especially difficult to provide psychopathic hospitals. What inference one can draw from this need not be emphasized. In states where psychopathic hospitals have not yet been developed, it is suggested that if a state university exists and has a medical department, the psychopathic hospital be made an integral part of such a medical school. Such a plan more nearly reaches the ideal than any other. In the first place the hospital itself, owing to its connection with a medical school, will adhere to modern policy, and in the second place the medical student receives early contact with this field of medicine and becomes equipped to recognize early conditions and later when in practice as a physician he serves as a true agent for mental hygiene. Our plans in Wisconsin contemplate such an arrangement. In the University General Hospital, which is now being erected at Madison, provision is made for the treating of mental cases. As an index of our attitude toward mental diseases I am happy to inform you that the first floor of a large five-story modern hospital building is to be devoted to mental and nervous diseases. Not many years ago such close association of mental cases with other forms of illness was unheard of. The mental case was thought to be a less desirable neighbor than plague or smallpox, yet here we are deliberately planning an installation which will give the mental cases the most desirable location in a large

general hospital. I know of no greater victory for those who have the welfare of these cases in mind than our Wisconsin plan. I feel certain that after a few years of this experiment we shall have gained the public confidence and what is most important, conversion to the belief that a mental case is a form of illness that should have hospital treatment. In many instances in my experience the public, or certain representatives of the public, have actually been the leaders in this movement and have occasionally been almost forced to convert the doctor.

The modern psychopathic hospital is here to stay. Wherever it has been established its success has insured its permanency. In it lies our greatest hope for the education of the great public to the need of mental hygiene. All the other agencies that are so potent in promoting mental hygiene fail absolutely unless in the background there is a psychopathic hospital to actually perform the task that these other agencies bring to light. For example, why have a well-developed field service, social agencies, psychiatric clinics, and similar modern activities unless there is, to back up these field activities, a place where cases may be handled with the sole purpose of restoring individuals to normal health? If the old type of state institution remains as the only method of treating mental cases the efforts of these worthy agencies in the field are wasted. It is evident therefore that in states which are not yet provided with psychopathic hospitals or in which the state institutions have not yet gained public confidence and have not demonstrated their fitness to treat mental cases, these extra-mural agencies for mental hygiene should not be established until this basic need of proper hospitalization has been developed.

B. PSYCHIATRIC SOCIAL WORK

Mary Jarrett, Associate Director, Smith College Training School for Social Work,

Northampton, Mass.

As an organized activity requiring special preparation and known by a name of its own, psychiatric social work has come into existence only within the last five years. Its function in relation to psychiatry has become fairly well defined; but its place among other branches of social work is not yet generally understood; and the lines of its future development are not yet clear. The principle of the social service needed was not merely an extension of the doctors' efforts to deal with social factors, partial and spasmodic of necessity, but an attempt to introduce into the plan for patients' care the point of view and special knowledge and technique of the social worker. The doctor added to his equipment an assistant trained in a special field.

The place of psychiatric social work in the mental hospital or clinic is now well established as an aid in diagnosis, treatment, and research. A committee of psychiatrists and social workers which met last summer under the auspices of the National Committee for Mental Hygiene to consider the function and training of the psychiatric social worker, defined her function as follows: (1) to facilitate admission to hospital or clinic and continuance of treatment; (2) to bring to the physician personal and social data helpful in arriving at a diagnosis and in outlining treatment; (3) to assist in carrying out treatment; (4) to interpret hospital and clinic to patient, family, and organizations of the community; (5) to make social investigations contributing to medico-social research. It is evident that with assistance of this kind the psychiatrist has greatly increased his facilities for both study and treatment of mental disease.