ployment, physical and mental condition, and then makes whatever recommendation she deems proper. Action is taken on these recommendations by the hospital authorities in whatever way is thought advisable or necessary.

These reports are then filed away with the hospital records. It not infrequently happens that we are called upon for information about patients who were resident in the hospital twenty, thirty or even fifty years ago. Needless to say our records for these early periods are meager and unsatisfactory, but I am sure that in the future these reports together with the records of the medical department, full and complete as they are, will be of priceless value.

If I were to make any criticism of our service system I would say that we have not sufficient workers. Our hospital district comprises the western half of the state and extends from Lake Superior to the Illinois line. The territory is too large for one agent to cover. There should be at least one and better two other workers so that paroled patients may be visited as often as two or three times yearly.

Let me now recite to you two or three instances in which the service agent has been of distinct help to us.

Lettie J., a feebleminded woman of thirty years of age, had been adopted into the family of a well to do Norwegian farmer. Lettie became obstreperous, and it was found necessary to send her to Mendota. After a hospital residence of three months, she was allowed to return home. All went well for a year, when Lettie became sleepless, prowled around the house at night, became threatening in her attitude towards her foster parents, and they began to fear for their own safety. At this juncture our welfare worker called at the home. The old mother told me the rest of the story herself-that as soon as the door was opened and the worker explained who she was and the purpose of her visit, the old mother grabbed her in her arms and exclaimed, "I know the Lord has sent you. I wanted someone to advise me in my trouble."

The opinion has often been expressed that the worker would not be welcomed in patient's homes, that she would be looked upon as a sort of sleuth, trying to ferret out some excuse for returning the patients to the hospital. Such has not been the experience of our worker. Sometimes she is met with a little coldness, restraint or timidity, which her professional training qualifies her to break down. Friendship disarms suspicion, cordial relations are soon established, and she obtains a complete record of the patient's home life, his attitude towards society, his means of recreation, and the character of his employment, all of which

go so far to complete our records and give us grounds on which to base future action.

However, were any such trouble encountered at first, I apprehend that the longer the service agent remained at her post, the more intimate her acquaintance became with patients on the ward, and the more extensive the knowledge of her service became in the community, the less difficulty she would have in gaining an entrance into the patient's homes.

Mable Z's mother died in a hospital for the insane when Mable was twelve years old. A stepmother soon appeared upon the scene. Mable and the stepmother did not agree and Mable suffered a frank attack of manic depressive insanity. She came to us in August, 1919. By the following November she had recovered sufficiently to be allowed to go home. The old trouble returned, and in March 1920, Mable came back to us. By November of the same year she had made a second recovery, and, realizing the futility of sending her back to her old home environment, I asked the social service worker to make an effort to place her with a well-to-do farmer. She succeeded beautifully. Mable was provided with suitable clothing, sent to school, and required to help with the house work. Our last report, but a few months ago, was to the effect that the child was well and happy, and had had no recurrence of her former mental trouble, but she was fearful that her father would come and take her away.

Gladys J. was married at sixteen to a man much older and very much larger than herself. She was taken to his home and obliged to live with a quarrelsome, faultfinding mother-in-law. At twenty-three Gladys was the mother of three children. She suffered a mental breakdown and was sent to Mendota, made a good recovery, and returned to her home. Relations between the husband and Glady's parents became strained to such a point that there was no cooperation between them for the patient's benefit. Affidavits were sent to me showing that Gladys was again insane, had quarreled with her mother-in-law, and, as a consequence, had been put down cellar by her husband. Affidavits came also from the neighbors to the effect that her husband was kind to her and was giving her good care. The husband refused to consent to the parole of his wife to her mother as I afterward found out for pure cussedness. I stood between the devil and the deep sea. In my extremity I sent our social service agent to make an inspection and report her findings. She submitted a wholly unbiased report and advised Glady's return to

the hospital. She came back much emaciated and five months pregnant with her fourth child.

The three cases just recited to you are only samples of what has been done. Many others of a similar character could be given wherein the service agent has rendered assistance by advice and help in untangling domestic troubles, finding employment for paroled patients, breaking down estrangements between patients and relatives, and reestablishing friendly relations.

I have made no attempt to evaluate the social service departments in terms of dollars. To my mind that would be a difficult, if not an impossible task inasmuch as the primary purpose of the department is to reestablish paroled patients in their home communities. It is the missionary spirit, the spirit of service, that actuates the worker and no monetary value can measure it. For instance, the acquaintance the worker forms with patients on the wards the many little courtesies, like running errands, writing letters, furnishing books, soon ripen into a friendship which paves the way for a better understanding and more substantial assistance when the patient is released on parole. On the face of things, these are matters of small moment, yet in the aggregate they loom large and become matters of great importance.

Through the efforts of our social service worker we have been able to carry into the homes of our patients the real spirit and purpose of our hospital activities. Relatives of the patients appreciate the friendly interest shown them, and this humanitarian spirit reacts favorably on the patient and also on the community. On the other hand we ourselves have acquired a better insight into the patient's living condition, his struggles against adverse circumstances in an unsympathetic world where the spirit of "do unto him as he would do unto you and do him first" too often holds sway. Moreover, extra-mural care teaches and encourages the patient to keep in friendly touch with the hospital. He comes to know and appreciate our friendship, and voluntarily seeks our counsel and help upon the return of threatening symptoms.

Enough has been said, I believe, to show you the advantages, yea, the necessities of such a department in a well organized hospital, the nature and extent of a service agent's duties, and the invaluable assistance thus rendered to the hospital authorities, and more particularly to the community, and to the unfortunate people in our charge.

MEDICAL SERVICE IN A CHILDREN'S INSTITUTION.

A. A. Pace, M. D., Physician to State Juvenile Home, Toledo, Iowa.

When invited by the program committee to read a paper on the medical service of a state children's institution before your honorable body I felt somewhat diffident in complying because of the fact of my somewhat limited experience in state institutional work, and the inadequate material which a new institution affords. My observations are based on the medical care of 288 children, ranging in age from four to eighteen years of age, with no particular medical program provided for. In developing a medical service it has been necessary to take into consideration the intent of the institution, and the class of individuals received.

The object of a home of this kind, as I view it, is threefold in character: namely, to improve the mental, moral and physical wellbeing of the children committed to its care. When we take into consideration the strata of society from which most of these children come, the neglect of hygienic surroundings, the immoral atmosphere, the lack of nourishment, and the hereditary diseased conditions of many of the parents, with the social diseases contracted by many of the children before their entrance into the institution, our problem is one of more than mere medical service. Many of these children come to us undernourished, undersized, with a low mental and physical makeup. Many are afflicted with nutritional diseases, unstable nervous ailments and hereditary manifestations of tuberculosis and syphilis. Various skin diseases from lack of care and cleanliness are present in a considerable number. To develop and make over these children into strong, healthy, clean and useful members of the social structure is our problem. Cooperation of the various departments of the home with willingness to give freely of service is essential in developing the proper atmosphere and care of those entrusted to us. Mere medical service would be labor illspent without sympathy and kindness to these half-starved souls. As a chain is only as strong as its weakest link and an army must measure its efficiency by that of its least capable contingent, so the progress of a nation many times is advanced or retarded according to the status of its flotsam and jetsam, its misfits, its down-and outers. It is a distinct and clear sign of better conditions approaching. The wreckage of society, the waifs and strays are receiving greater attention and more constructive and efficient

help than ever before. A slogan coined by a great religious organization of our country. "That a man may be down but is never out," has put new heart into many wrecks of humanity, and has helped them to come back and become useful members of society.

It is a pleasing commentary to know that our own state has been one of the foremost in salvaging these citizens by the institution of such homes as are located at Davenport, Toledo and other places throughout the state. The results aimed at in the medical and health supervision of a children's home are:

First: Normal physical growth and development as shown by height and weight according to age, physical activity as demonstrated by reasonable athletic exercises and correct posture.

Second: Normal mental growth as evidenced by various intelligence tests and psychic development and behavior as shown by response to the usual social and community situations and re-actions to school discipline and responsibilities.

Third: The understanding of the simple necessary habits of personal hygiene of body and mind as observed in the school and contact with others.

Fourth: Correction of such physical defects as interfere with the progress of physical and mental growth or are likely to increase the hazard in others.

Fifth: The prevention of disease or conditions known to be preventable especially the communicable diseases, digestive disturbances and errors of nutrition.

Sixth: Shortening of the course of sickness and convalescence by early observation of symptoms and prompt hospitilization.

The plan of medical service as it has been worked out is intended to be practicable. It has been a gradual development with limited facilities for a restricted population. Emergencies have been met as they have arisen. The medical staff at the State Juvenile Home is composed of a local physician who makes daily calls and whenever emergency requires, a specialist on eye, ear, nose and throat subject to call of the superintendent; a psychiatrist from the State University for mental and intelligence tests; and the state epidemiologist when required, and a resident nurse. Special nurses are put in service when the occasion requires. The local physician has general supervision of the medical service, makes the diagnoses, prescribes the necessary drugs, performs minor and emergency surgery and directs when special medical service is required. He also advises with and suggests to the administration of the home any needed hygienic and sanitary changes.

The eye, ear, nose and throat specialist visits the Home from time to time for the examination of eyes and fitting of glasses, and is subject to call for special operative work. The state psychiatrist averages about three visits a year making a complete