This system, which is obviously open to many theoretical objections, especially the opportunity it affords for political and other considerations to play an important part, is safeguarded by the fact that the present probate judge is above allowing such factors to influence his judgment. The medical examiners are free from the objection of being interested in the State hospitals, especially since the law requires that no physician officially connected with these may serve as examiner for the Probate Court.

In regard to the relation of medical examiners to commitment of insane persons, there is this to be said: The law which authorized the payment to the medical examiner of a fee for each case committed obviously places a premium on committing individuals; it would seem that the interest of the physician was to commit persons rather than to keep them out of institutions. Any possible tendency in this direction is counteracted, however, by the equally potent restraint of laws concerning malpractice and other legal actions.

Nevertheless, the recompensing of these special witnesses is a bad practice. Physicians are not only open to the influence above mentioned, but personal considerations enter in which have no place in this connection, such as the fact that these fees, which are paid through public funds, are in the nature of a largesse and should, therefore, be distributed among as large a number of physicians as possible. In the eyes of the more unscrupulous it will appear as a downright "graft," which may be connived at only if every one gets his full share. In Cleveland, as in other cities where this system is used, the work is done with little, if any, evidence of bad influences. Nevertheless, from the point of view of efficiency, and above all that of educating public opinion, it should be changed.

The tendency in all matters pertaining to insanity, at least since Charles Reade published Hard Cash, has been to remove all specific incentive in the matter of commitments. This fact, probably more than any other, has resulted in the respect shown for the State hospital and the prejudice in favor of this institution as compared with private institutions for mental cases.

The decision, whether a person should be segregated to a certain extent and deprived of his liberty, should be made on purely objective evidence, and while it is true that the court makes the final decision and examines the records, it is nevertheless upon the evidence submitted by the medical experts that such a decision is made by the court. If, then, medical examiners are swayed, either consciously or unconsciously, by other reasons than those based upon purely objective evidence, the court,

even if ignorant of this, cannot act in an unbiased way. The result is that medical examiners should be paid either a salary or a fixed fee for every examination they make, regardless of whether commitment is recommended or not. At present they are paid for the certificate issued and not for the examination made.

The same statements which apply to the question of expert witnesses in general apply here. There may be, and probably should be, two kinds of experts available to the courts, the one serving as a public official on salary, for either full or part time, the other physicians who, in addition to the usual medical qualifications, have qualified and been appointed as experts. When a court or other public official or a private individual requires the services of an expert other than the officially salaried expert, he may select one from this qualified list. This system does not force any expert upon either courts or private individuals, nor does it require the poor man to suffer because he cannot afford the expensive specialist. Furthermore, it guarantees that the public official will be non-partisan and that the privately retained expert will at least measure up to the minimum standard requirements.

There is another phase of the relationship between the medical and particularly the mental expert and the Probate Court. In the Probate Court questions of property rights, guardianship, and conservatorship continually arise. While the question of mental disease or mental deficiency may not arise, there may, nevertheless, be important considerations in which the expert knowledge of the qualified psychiatrist would be of considerable value to the court. This refers particularly to that very large field of personality factors which we are just beginning to study scientifically. Every judge of the Probate Court will readily recognize what is referred to here, and probably every judge who has served in the Probate Court has made use of his experts in non-insane and nonfeeble-minded cases, for the purpose of evaluating the personality factors before making a decision.

This important work requires specialization and, furthermore, cannot be done satisfactorily unless experts making the examinations are employed on full time; that is, the experts cannot be expected to be efficient if they are called in only occasionally on such cases-they must be dealing with them as a matter of daily routine.

In the last year 560 cases have been examined by medical commissions for the Probate Court at $10 a case, or a total expenditure of $5,600 for medical fees alone. This does not include the sheriff fees, witness fees, and other incidentals.

Recommendations

1. A chief psychiatrist should be appointed by the judge of the Probate Court from a civil service list.

2. The chief psychiatrist should be empowered to appoint from a civil service list three assistant or deputy psychiatrists, one psychologist, and one assistant psychologist.

3. Suitable salaries should be provided to attract properly qualified experts.

4. The necessary clerical assistance and office quarters should be provided in the new court-house office building or county jail.

5. The chief psychiatrist should examine and pass upon all cases coming from the Probate Court, the Municipal Court, and the Court of Common Pleas, in which the question of sanity or insanity, epilepsy, or mental deficiency is raised.

6. The chief psychiatrist should cause to be examined, physically and mentally, in so far as possible, all persons coming before the Municipal Court.

7. The chief psychiatrist should present to the courts in writing a statement of the findings and opinion of the psychiatrist in each case examined.

8. In cases of dispute or doubt the court should be able to appoint a special psychiatrist to examine a case.

9. The person to be examined, his counsel, relatives, or friends, should be permitted to be represented by a psychiatrist who should have access to the findings of the chief psychiatrist, and who may be present at and participate in the examination by the chief psychiatrist, but who may not interfere with the conduct of such examinations.

10. The sheriff of Cuyahoga County and the Director of Public Welfare should be able to call upon the psychiatrist to examine any person in their custody and to enter a petition for commitment of any person thus examined who shall be found to be insane, epileptic, or feeble-minded.

11. Whenever, in the opinion of the psychiatrist, any person examined requires more extended study or observation than can be given at the county or city jail, application should be made to the court having jurisdiction, for temporary care at the city psychopathic hospital for a period of ten days, or not more than three months, or until such time as the director of the psychopathic hospital shall depose in writing that the examination or observation has been completed.

I'

CHAPTER IV

PREVENTION

EARLY DETECTION OF SPECIAL CASES

F WE may correctly assume that delinquency in most instances is

not merely accidental, but is associated with characteristics and personal peculiarities inherent in the individual, it must follow that any attempt at prevention must include elimination at the source. By this we mean the examination of children of school age and even younger from the point of view of mental and personality characteristics, as manifested especially in behavior. It is by no means a certain or a simple matter to determine, even after careful examination, which children will present major behavior problems later in life. But it is certainly possible to determine which ones are in need of immediate special training and which show present behavior or mental deviations.

A careful study of this kind, followed by intensive training and observation of the physical, mental, and social factors involved, will, if applied to enough children, be comparable to the results obtained in the same circumstances by the methods of physical health training. If these methods now succeed in the Juvenile Courts, where they are applied after delinquency develops, there is every reason to expect even more satisfactory results when applied earlier, before the major problems of delinquency appear. When such a plan has been in operation for a generation, it is not unlikely that the problem of delinquency in the community will have changed so much as to make jails, as we now know them, quite unnecessary. We shall probably always require places of detention, but with a better understanding of the real causes of delinquency and crime and with more effective methods of prevention and treatment it is fair to assume that future detention institutions will differ from the present ones as modern hospitals differ from the ancient pest houses.

Meanwhile the police will continue to pick up and detain a large number of individuals who are a source of trouble and loss to the community and of little profit to themselves. Even in these cases an intelligent attitude requires that suitable studies shall be made of each individual case in order really to solve the problem, instead of depending entirely on forcible detention and segregation and the supposedly curative effects of

punitive imprisonment. The number of recidivists who pass through our jails is ample evidence against such misplaced confidence.

Even if a thorough examination of each prisoner is not possible, a sorting by simple examinations will identify extreme types of feebleminded or psychopathic individuals. Individuals who are brought to light by these sorting examinations cannot be properly disposed of without treatment, and the treatment which may be given is one of three general types or combinations of these, namely, physical, mental, or social.

Physical treatment is directed against physical disease, on the one hand, and physical handicaps and defects, on the other. It is not necessary to enlarge upon this familiar topic. The main thing to emphasize here is the importance of correcting all physical disabilities, even those of apparently minor significance, in the interest of improving the mental and behavior reactions. Physicians often err in minimizing the effects of minor physical ailments.

For example, in the field of the psychoneuroses, as exemplified by the cases of so-called shell-shock during the war, the slighter the physical injury, the greater the psychic disturbance. In the field of behavior difficulties this is often markedly true. It is obvious, therefore, that physical examination must be performed with subtlety and niceness of observation. Clearly a physician, to be effective in the physical examination of behavior cases, must approach his work from a different angle from his general medical practice. The examination thus performed must then be correlated with the mental and social factors of each case in order that suitable physical treatment may be prescribed.

Mental treatment consists in the main of two kinds: first, education and training of various mental faculties or talents, which are carried out in accordance with established principles of educational training and certain sorts of habit formation; second, treatment by various means of what may be considered pathological mental traits. Psychotherapy, hydrotherapy, mechanotherapy, occupational therapy, and other modern forms of treatment may be applied by trained experts to good effect.

Social treatment is perhaps the most modern and least well defined of all the various forms of treatment. As applied to delinquency, it consists mainly of adjusting environmental conditions to the needs of the individual case. The important point is not merely to change the environment, but to adapt the environment to the needs, temporary or permanent, of an individual more or less incapable of adapting himself. This form of treatment is consequently varied, and includes the adjustment of the individual to living conditions in his particular community, as well as social relief, recreation, or employment.