The University of Michigan, an encyclopedic survey ... Wilfred B. Shaw, editor.
University of Michigan.
The Relationship of the Hospital to the State

In the year 1939-40 the University of Michigan Hospital received 26,728 patients. Of these, 6,619 were to some extent dependent on the counties or on the state, and the expenses of 715 other patients were guaranteed by public officers and payable from public funds (P.R., 1939-40, pp. 308-9).

Although the University Hospital opened in 1869, it received no state support until 1875, and only since the 1880's have there been laws governing the care and maintenance of public patients. Nevertheless, as early as 1859 the concept of a state almshouse to be maintained by the University for clinical as well as charitable purposes was presented to the Michigan State Medical Society.

Ten years later, when the Regents were planning a hospital, the medical faculty set forth the scope and purposes of the institution, stating that its main object should be "to utilize for practical instruction all the clinical material that may present itself" and adding that they believed the Regents neither designed it to be a "public charity" nor meant to restrict its benefits only "to those who were competent to meet the necessary charge" (R.P., 1864-70, p. 366). A maintenance charge sufficient to cover food and medical and surgical supplies was recommended, and all patients were to be utilized for clinical instruction. The medical faculty was to have general control.

Summer operation of the Hospital was postponed until 1878, although at that time there was no instruction during the summer. Until 1872 charges to patients covered only their food. After that date all except "paupers" paid for medical supplies.

References to "paupers" and "charity patients" seem to indicate ability of the patients in some cases to pay for food and supplies, but the scanty records are not clear. Indigent patients must often have found even nominal fees impossible, especially in cases of long or chronic illness. Since medical service was free, fees from the well-to-do could not have provided for the poorer patients, and yet the Hospital was attempting to maintain itself from fees adjusted to the actual cost level. How this difficulty was solved, the records do not state. Possibly, charitable agencies maintained some patients.

The year in which the Hospital was established, Henry P. Baldwin, a Detroit philanthropist, became governor of the state. He had visited jails and county almshouses and had been shocked by the unsanitary conditions, lack of medical care, and nonsegregation of criminals. He was aroused over the conditions of children forced to remain in these places of ignorance, disease, and crime. Illnesses which might have been temporary often Page  976went untreated, eventually became incurable, and made patients permanently dependent on public funds.

Governor Baldwin secured the appointment of a state investigating commission, the adoption of children into normal homes, and the authorization of a central school to care for them before adoption, thus avoiding the county almshouse. He also demanded a remodeling of the state's charitable and penal systems. The state public school thus established in 1871 was opened at Coldwater in 1874, the first institution of its kind in the United States. In 1879 the investigating commission became the State Board of Corrections and Charities and so remained until 1921, when it was replaced by the Department of Social Welfare.

While this commission was examining the county almshouses, a committee of the University medical faculty reported, in 1870, on the first year of operation of the Hospital. Although additional beds had been secured during the year the Hospital had been filled to capacity, and the committee recommended a large state hospital in connection with the Department of Medicine and Surgery. While there were no immediate results of the proposal, discussion of the plan undoubtedly had some bearing on later developments.

A "state almshouse hospital," on the general plan of such institutions in Massachusetts, was proposed. Free medical service and medicines prepared inexpensively by the pharmacy were offered the state for its invalid poor in return for the benefit of clinical material. The commission believed that with help from the legislature such a plan would be feasible.

The Regents, however, were slow to act on this recommendation, although a committee conferred with Governor Baldwin's commissioners. Then a new Regent, Dr. Charles Rynd, serving as head of the committee on the Medical Department, reported unfavorably on the value of large hospitals for instruction, preferring the old preceptor system.

Later, however, the committee changed its view, for in the spring of 1872 (R.P., 1870-76, pp. 189-91) it strongly urged the establishment of a large state hospital at the University, the best place "in the West" for pursuing the "higher clinical field of thought." It requested a large and modern hospital:

Not only are our alms-houses the repositories of many persons who are thus incarcerated to languish, suffer on and die without that aid to which the suffering poor are justly entitled, but many persons of wealth and refinement labor from diseases which if treated at all by the private practitioner, are treated but poorly, and with indifferent and unsatisfactory results.

(R.P., 1870-76, p. 189.)

President Angell, in 1872, made a vigorous plea for a state hospital for almshouse patients or a large hospital for special diseases, the funds to come either from private or from public benefactions. At the same time Dr. Alonzo Palmer reported the medical faculty's views to the Regents and promised to have a hospital plan ready for consideration at the next meeting.

A joint committee of Regents and faculty members was then appointed to confer with the governor's committee on state charities. This joint committee discussed the necessity for such a hospital and favorably considered a proposal to build it at Ann Arbor, but it was not deemed "judicious to ask for an appropriation" (R.P., 1870-76, p. 251). Possibly some new difficulty in the controversy over the proposed homeopathic school made the University reticent in pressing any demands for state funds. When the Homeopathic Medical College Page  977was established three years later, the legislature contributed several thousand dollars toward the construction and equipment of a larger and more modern University Hospital, provided a stated amount could be raised in Ann Arbor.

Act No. 207 of 1875, granting funds for the old Pavilion Hospital, was the first specific appropriation for the University Hospital, henceforth called a "state hospital." Though no funds were provided for running expenses, it did set a precedent for a series of future appropriations separate from grants for buildings and equipment. These were also distinct from somewhat later state disbursements made under public-patient laws.

No sooner was the new building completed in 1876 than the faculty requested, as it had in 1869, that the Hospital remain open throughout the year and that the medical session be extended from six to nine months. These requests were approved by the legislature in May, 1877.

During the vacations of 1878, 1879, and 1880, the Hospital remained open, but for the following eleven years it was closed in the summer, although the appropriations by the legislature continued, averaging until 1891, about $4,000 a year. Throughout this period these grants were used for Hospital running expenses. In the year 1891-92 the Hospital received $10,000 from the state in addition to funds for the new Hospital on Catherine Street, then in the course of construction. The following year an additional $8,000 was received for salaries and general expenses, but no direct grants for expenses were made during the next four years.

The opening of the Catherine Street Hospital in 1891 brought a marked increase in receipts, but, nevertheless, over the four-year period, 1893-97, there were regular deficits to be made up from the University's general fund. Despite financial difficulties, however, the Regents directed that the Hospital be kept open in summer, although the effects of the nationwide financial crisis in 1893 forced its closure during the summers of 1895 and 1896.

Relief came in 1897, when Act No. 203 provided $3,000 a year regularly "for the use and maintenance" of the University Hospital and the Homeopathic Hospital, provided the hospitals were operated during the summers. Though this law has never been repealed, it remained in practical effect only until July, 1919. After that date the payments were refunded to the state, and whatever annual deficits have been incurred have been offset by the surpluses of other years.*

First public-patient laws, 1881-97. — The metamorphosis of the University Hospital into a state hospital accommodating many public patients has been slow. There have been three types of public-patient laws: those for children, those for adults, and those for either adults or children suffering from certain specified disorders. Of these, only the first two types came before 1900.

The board in control of the State Public School at Coldwater first advocated state laws for hospitalizing public patients in the University Hospital. The secretary of this board wrote to President Angell in 1878, suggesting that it would afford great relief to the Cold-water school if the state would provide for dependent children afflicted with chronic diseases requiring surgical operations, since they were not admissible to the school and had of necessity to be returned to the poorhouses, where they could receive no proper treatment. He Page  978suggested that the Regents might recommend appropriate action to the legislature and that the "State Hospital at Ann Arbor" was the proper place for such patients.

This letter was printed in full in the Regents' Proceedings, but the committee on the Medical Department reported that they had no funds for such a program. They promised, however, to join in a request that such children be provided for, and eventually the two boards secured the passage of Michigan's first law for the treatment of the invalid poor in the University Hospital, the children's act (No. 138) of 1881.

This act provided not only for sick and diseased children from the State School at Coldwater, but for all children suffering from conditions preventing eventual self-support. Transportation, board, nursing, and other expenses were to be paid by the state upon recommendation by the proper authorities, but admission depended upon the decision of the resident physician at the University Hospital as to whether or not the child could be benefited.

Thirteen children were treated under the provisions of this law during the first year, but many were turned away because of the Hospital's crowded condition. Transportation and maintenance for these thirteen children amounted to $634.68; the following year the corresponding payment was $434.84.

President Angell made it clear in his report for 1878 that he did not consider the Pavilion Hospital adequate and insisted on aid for adults, as well as for children, pointing out that the University's hospitals had already returned more than their cost to the state.

The Hospital's congested condition was relieved to a certain extent by a legislative grant for an eye and ear ward in 1879, but once more no provision for adult invalids was made. The subject was not mentioned again until 1888, when certain groups endeavored to have at least part of the clinical work transferred to Detroit. President Angell in opposing such a step emphasized once more the need of a larger and more modern hospital:

It would doubtless be a real economy for the counties, which may now be burdened with the cost of maintaining through life persons who have curable maladies, to send such patients here. To some extent they do this now. But with ampler accommodations more patients could be cared for, and the interests of the counties, of the patients, and of our medical school would at once be subserved.

(P.R., 1888-1902, p. 22.)

In 1889 the legislature made a grant of $50,000 for the new Hospital, to be supplemented by a contribution from the city of Ann Arbor. A note of disappointment tempered President Angell's expression of gratitude. The appropriation would not permit the erection of a large hospital such as had been projected in earlier years, but it was his belief that the clinical facilities might be made "reasonably satisfactory."

At the same session the legislature passed the first state law (Act No. 246 of 1889) for the admission of three classes of adult public patients: those who had become county charges because of severe injury and were in need of special treatment to prevent their becoming permanently dependent; those dependent upon the counties because of acute disease or physical injuries and requiring major operations to preserve life; and such obstetrical cases as were a public charge upon the counties for care and treatment.

Unlike the preceding children's law, this act charged the transportation and maintenance of these patients to the counties and left local enforcement to local officers and physicians. While such medical service to adult county poor to Page  979some extent already was provided, the new law afforded a statutory basis for the procedure and undoubtedly encouraged further use of the Hospital.

Two laws enacted in 1897 authorized further medical aid, primarily for children. Act No. 42 required that the physician attending at the birth of a child of "any indigent poor person" should report, under penalty, any deformity or malady curable by surgical operation. On certification by the proper local officers, the child was to be brought at state expense to one of the University hospitals for treatment.

Under the first children's hospitalization act of 1881, only those enrolled in the State Public School at Coldwater or those who, if restored to health, could enter that school had been admissible for treatment. By an amending act (No. 233 of 1897) the same benefits were extended to any dependent persons in the state schools for the blind, deaf, and feebleminded, as well as to anyone entitled to enter one of these institutions. Actually, for two years the Hospital had been caring for the children from the School for the Blind at Lansing, at a charge of $2.50 a week.

This substitution of "dependent persons" for "dependent children" might seem to indicate that a large number of adults would be admitted under the new law, but this was not true, since the state charitable institutions existed chiefly for the benefit of defective children. Nevertheless, this oldest public-patient law is still in effect, and today patients recommended by the Michigan Children's Institute, which took the place of the State Public School in 1935, are treated under its provisions.

First special-disease laws, 1901-7. — In 1899 President Angell reported that the University had established an informal but valuable relationship with the state institutions for the insane, in each of which University graduates had been installed as resident pathologists, acting as assistants to the state's head neuropathologist at the University.

There had previously been grants to particular clinics, but until the present century no state provision had been made for the maintenance in the University Hospital of persons suffering from any specified diseases. The first such law was Act No. 161 of 1901, under which the construction of the Psychopathic Ward was begun. It was passed not upon the request nor with the consent of the Regents but in response to the efforts of friends of Professor William J. Herdman, head of the Department of Psychiatry. The Regents, however, accepted the gift, provided the unit be maintained at no cost to the University, and actual construction began in 1902.

The first special-disease law put into full effect was the rabies law of 1903 (Act No. 116), approved a few weeks after the Regents established the Pasteur Institute for the treatment of Michigan residents. It undertook to defray the expenses of indigent persons infected with the virus and assigned to the local boards of health the responsibility of sending them to the University, with transportation and other expenses to be paid by the township, village, or city.

Although the new Psychopathic Ward was practically completed and plans for its administration were under discussion in the spring of 1904, it was not occupied until Act No. 140 of 1905 shifted the payment of the director's salary to the state and introduced partial state control. It specified that a joint board composed of the Regents and the trustees of the state asylums should select a clinical psychiatrist to manage the institution and to oversee the clinical and pathological research in the state asylums and that this same psychiatrist, as a member of the medical faculty, should give instruction Page  980in nervous and mental diseases. The same act also appropriated $14,000 for equipment and $5,000 a year for running expenses for each of the following two years, out of which the new appointee's salary was to be paid.

The following year by Act No. 278 the State Psychopathic Hospital ceased to be a department of the University Hospital and became an almost autonomous state institution. For many years thereafter, under an unusual arrangement, it was conducted in a non-University building on the University Hospital grounds. Its control was vested in a board of eight trustees, four Regents and four asylum trustees appointed annually by the four asylum boards.

Under the two acts of 1901 and 1907 expenses of all public patients except wards of the state were paid by the counties, although whenever possible these costs were to be reimbursed by relatives or guardians. Some public patients were sent by probate judges for curative, preventive, or diagnostic purposes and others came from the asylums. Private patients were also received and cared for at fixed rates.

Legislation for children, 1900-1913. — Between 1880 and 1910 the population of Michigan almost doubled. During this period measures for the relief of persons only partly dependent became more numerous. An 1889 law for veterans and their dependents gained popularity, and the children's law of 1881 was supplemented by amendment, by legislation for veterans' families, by the juvenile court act of 1903, and by other legislation relative to desertion and broken homes. A 1907 act for dependent, neglected, and delinquent children reflected the growing number of local hospitals, since under it county probate courts were authorized to place any child requiring special medical attention "in a public hospital or in an institution."

This measure might seem to have encouraged local treatment, but the University Hospital was gaining special recognition for its work in pediatrics, and after 1906 the Palmer Ward clinic supplied the impetus for modernizing and amplifying the hospitalization statutes affecting the University. Previous laws were considered inadequate since they provided only for certain classes of persons and "discriminated against the normal child who developed an illness requiring hospital care, in favor of the imbecile who never could be made into a good citizen" (Hosp. Rept., 1918-19, pp. 113-14).

The result was a new children's law (Act No. 274, 1913) which became the model for similar measures in other states. Under its terms deformed or afflicted children whose conditions could be remedied and whose parents could not provide proper treatment were to be reported to the probate judges and cared for at state expense at one of the University hospitals. County agents and superintendents of the poor not on fixed salaries were to be compensated for their time and expense in making the necessary investigations, and the examining physicians were guaranteed a standard fee.

While this 1913 law did not affect the Coldwater State School hospitalization act of 1881, in effect it replaced and led to the repeal in 1915 of the infants' hospitalization act of 1897. Unfortunately, the provision for compulsory report and treatment of deformities present at birth was not included in the new law. The Afflicted Children's Act was in force until the new Crippled Children's Act was passed in 1927.

The adult public-patient law of 1915. — Free treatment for adult residents of any Michigan county who would be benefited by medical and surgical treatment but who were financially Page  981unable to obtain it was provided in 1915 by Act No. 267, which also provided obstetrical service for mothers unable to pay for it and for the care of children born of women hospitalized under the statute. As in the children's law, the prospective patient was committed to treatment by a probate judge only after he had obtained a satisfactory financial and medical report, and the expense of the necessary investigation had been guaranteed.

This act for the adult poor specified that transportation and maintenance were to be paid by the counties, which were to reimburse the state for any funds advanced to the Hospital for these expenses. Although University authorities felt that this was a defect, since the county officers might be inclined to send patients to county houses, where they could be treated at less expense, rather than to the University, between July 1, 1915, and June 30, 1940, more than 70,000 patients were registered in the Hospital.

The effect of the laws of 1913 and 1915. — These new laws for adults and children extended the benefits of hospitalization. In fact, the only important restriction other than that pertaining to medical and financial needs was that the maladies and deformities to be treated could be remedied. The broader scope of these laws and also, possibly, the guarantee of payment of the agents' fees and expenses resulted in a notable increase in public patients. In 1913-14, 255 children were treated under the 1913 children's law; the next year there were 615. In 1915-16, 604 children were treated under this act, and under the 1915 adult law 411 patients were treated; during the following year 707 children and 647 adults were treated. Two years later more adult patients than children were being received under these laws.

Psychopathic hospital law of 1917. — Under Act No. 310 of 1917 the trustees of the State Psychopathic Hospital were given the right to establish centers for the treatment, care, and maintenance of patients at places other than the Psychopathic Hospital and to provide for the preservation of mental health in former patients. A $3,000 increase in the state's annual appropriation to the institution took care of the additional expense for these new services.

The children's law of 1921. — A new children's law in 1921 (Act No. 137), primarily affecting local hospitals, empowered the counties to contract with agencies and institutions licensed by the State Board of Corrections and Charities for the care, maintenance, and medical treatment of children, all expenses to be paid from county funds.

Special-disease laws, 1921-25. — A general reorganization of all the public charitable, corrective, and penal institutions was effected in 1921 (Act No. 163), when the State Welfare Department was created to take the place of the old Board of Corrections and Charities. The State Psychopathic Hospital was particularly affected, since the old separate asylum boards were abolished and their powers transferred to the State Hospital Commission, one of four set up within the new department. All non-Regent trustees of the State Psychopathic Hospital were to be appointed by the governor, and while the medical director's functions of visiting and inspecting the other state hospitals were now a part of the activities of the new State Welfare Department, that department was to have no part in the management of the Psychopathic Hospital nor control of its board of trustees.

A new general insanity law (Act No. 151) superseded in 1923 the old Act No. 217 of 1903. It not only defined the functions of the new State Hospital Page  982Commission and of the institutions under its control, but also affected the mode of dealing with State Psychopathic Hospital patients. The same year authorization was given for sterilization operations at the University Hospital (Act No. 258, amended by Act No. 71 of 1925).

The University's Pasteur Institute ceased to be the only clinic in the state for treatment at public expense of persons infected with rabies when, in 1925, Act No. 321 was passed authorizing local health boards to make the necessary arrangements at the Institute or at some other treatment center for Pasteur treatment at an expense to the counties not to exceed $200 in any one case. It was held by the attorney general in 1929 that this act by implication repealed the old rabies law of 1903 and in effect shifted the costs from cities and townships to the counties. At the same time everyone in need of treatment became entitled to receive it regardless of economic status.

The adult-patient law of 1925. — A new general poor law in 1925 (Act No. 146) repealed the old law of 1869, which had made it "the duty" of county poor superintendents to send to the University county charges who would remain indigent because of severe injury unless specially treated, as well as those who needed major operations to save their lives. While the new law still provided that superintendents of the poor might arrange for the hospital care of such persons, they were no longer compelled to do so. Furthermore, patients might be committed either to the University Hospital or to any other hospital the superintendents of the poor might select — an "alternative" provision later inserted in the three laws under which the University Hospital now receives most of its public patients, the adult-patient act of 1915 and the two general laws for crippled and afflicted children (1881 and 1913).

The 1925 version of the poor law providing for medical aid was in most respects, however, identical with that of 1889, except that the terms "poor person" and "infirmary" were used in place of "pauper" and "poor-house." The retention of the terms "obstetrical wards" and "hospitals of the University" revealed a certain obsolescence in the statute, since for nearly twenty years there had been separate buildings for obstetrical patients and the Homeopathic Hospital had been merged with the University Hospital in 1922.

The years following the opening of the present Hospital building in 1925 witnessed significant developments in all three types of public-patient laws. The major law for the hospitalization of indigent adults (Act No. 267 of 1915) was materially altered by four amendatory acts. In 1927 Act No. 317 directed the University Hospital superintendent to send reports on persons hospitalized under the 1915 law to the probate judges and to release the counties from liability for hospitalization periods longer than six months, unless an extension order was obtained. In 1929 the boards of county auditors were made responsible by Act No. 293 for investigating the financial condition of prospective patients seeking aid under the 1915 adult-patient act and were permitted to arrange with patients to repay the counties for benefits received.

Under the earlier poor law and under certain other statutes, adults were treated in local hospitals, but those hospitalized under the adult-patient law of 1915 had to be committed to the University Hospital. This was changed in 1933 by Act No. 222, giving the probate judges the privilege of selecting other hospitals if they saw fit.

Act No. 304 of 1939 denied officials Page  983any authority to compel a patient to undergo an operation or treatment as provided under the terms of the 1915 adult-patient law. Only with the consent of the guardian or of the nearest relative could such treatment be undertaken for patients not in condition to decide for themselves. The same held true for children.

Since physicians not at the University were permitted to charge fees, the title of Act No. 267 of 1915 was altered in the 1939 law to omit the word "free" from the phrase "to provide free hospital service and medical and surgical treatment." Stricter financial controls were also prescribed, and any falsification regarding financial need was punishable by fine or imprisonment. Also, the optional repayment agreements were made compulsory. Where there were county boards of auditors, the Department of Social Welfare might conduct financial investigations and become responsible for obtaining repayment pledges.

Upon the enactment of this 1939 law the attorney general distinguished between the hospitalized group of special patients in the amended Act No. 267 of 1915 and the group given medical aid outside of hospitals under a 1939 welfare act (No. 280).

In certain instances county costs for administering the poor law of 1925 (No. 146) might be recharged to the smaller governmental units, which the afflicted adult act of 1915 did not permit. This led the attorney general to rule in March, 1939, that supervisors might not charge back expenses incurred under the 1915 act to the townships or cities.

Special-disease laws, 1925-40. — The Psychopathic Hospital act of 1927 (No. 207) was the first special-disease law affecting the clinical work of the Medical School after the opening of the new University Hospital. It repealed the amended law of 1907 and embodied the changes brought about by the abolition of the several asylum boards and the creation of the State Hospital Commission and the augmented State Administrative Board in 1931. In all matters not prescribed, the trustees of the State Psychopathic Hospital retained sole control. Non-Regent members were appointed by the governor for four-year terms, whereas the four Regent members continued to be selected annually by the Regents. The new law required that medical officers of the state mental hospitals receive University instruction, at the expense of the respective institutions.

A new law for sterilization (No. 281), repealing the amended act of 1923, was passed in 1929. The largest number of cases registered under it in a year was sixty-three in 1930-31; there were none in 1939-40.

The first tuberculosis legislation affecting the University Hospital was passed in 1929, when Act No. 115 abolished the board of trustees of the Howell State Sanatorium and created the state Tuberculosis Sanatorium Commission. The commission was given control of any sanatoriums to be established and the power to transfer patients from state tuberculosis sanatoriums to the University Hospital for special treatment, with the usual costs chargeable to the counties for all indigent patients except state wards. A fund for a one-hundred-bed University Hospital addition for tubercular patients, equipped for diagnosis and special surgical treatment rather than for prolonged care, was granted in 1929 by Act No. 324.

In 1935 the legislature, by Public Act No. 173, abolished the State Psychopathic Hospital board and transferred its functions to the Board of Regents. Since the Psychopathic Hospital still remained, nominally, a semi-independent state institution and not a part of the Page  984University Hospital, the Regents, in acting upon Psychopathic Hospital affairs, assumed that they were serving as a state board succeeding the old board of trustees (R.P., 1932-36, pp. 718 and 810). This act under which rules were to be formulated by the Regents, replaced, in general, all references to the regulations of the State Administrative Board as set forth in the Psychopathic Hospital law of 1927. The governing board retained the power to provide aftertreatment, but the provision for city or community dispensaries and mental hygiene departments was omitted.

The laws concerning institutions for mental diseases, feeble-mindedness, and epilepsy were revised in 1937, when, under Act No. 104, the State Hospital Commission within the State Welfare Department was replaced by a new, separate commission of the same name. Also, Acts No. 85 and 243 providing for the new five-story Neuropsychiatric Institute addition to the University Hospital, superseded and repealed the Psychopathic Hospital act of 1927 and abolished the State Psychopathic Hospital as an organization, but stipulated that the Regents should keep the property (see Part II: The Neuropsychiatric Institute and the State Psychopathic Hospital).

The main purposes of the Institute as outlined are: (1) to emphasize early diagnosis and treatment, (2) to establish a clinic for study of the prevention of mental illness, and (3) to conduct training and research in all phases of mental disease. The Institute, as part of the University Hospital, is controlled by the Regents. It does, however, receive state aid. In the three years ending June 30, 1940, this annual grant averaged about $105,000.

The provision that the medical director of the Psychopathic Hospital was also to be ex officio neuropathologist of all the state mental hospitals was discontinued by Act No. 85, as were the regulations regarding the visits by the outstate hospital staff members to the neuropathological laboratory at Ann Arbor. It also provided that all patients in the old Psychopathic Hospital should either be discharged as normal or declared insane, feeble-minded, or epileptic and committed to a suitable institution. State hospital patients might be transferred to the new Institute for treatment or for purposes of research, at the expense of the Institute. The law also permitted the temporary referral to the Institute of all persons suspected of mental disorder. Though not definitely committed, their detention periods could be extended to provide time to determine whether commitment to a state hospital was desirable.

While the only voluntary patients in the old Psychopathic Hospital were private patients, under the regulations of the Institute an indigent person might apply for admission under a private court order. The Institute was also organized to make special provision for the care of children. Up to June, 1940, patients were received under several different laws. Thus, transfer patients were admitted under Act No. 85 of 1937; adults came under Act No. 267 of 1915; and children entered under Act No. 138 of 1881, as well as under the two general laws for afflicted children, Act No. 174 of 1913 and Act No. 283 of 1939, and also under the crippled children's law, Act No. 158 of 1937.

Children's hospitalization laws, 1925-40. — More than half the laws affecting the University Hospital passed between 1925 and 1940 concerned children, and the changes were far-reaching. After Act No. 236 created the Michigan Crippled Children Commission in 1927, any crippled child could be treated either at the University Hospital or at any Page  985other hospital having an orthopedic surgeon, the commission to approve both surgeons and hospitals. Surgeons' fees in all hospitals except the University Hospital as well as transportation and hospital expenses were to be paid by the state. The commission was to locate as many as possible of the state's crippled children and report what was being done for them. It was to conduct diagnostic clinics and, in general, to secure the best possible surgical and medical treatment for the children, as well as to take charge of their convalescent care and education. By a further act (No. 317), in 1929, the commission was given the additional responsibility of follow-up supervision.

In the same session in which the Crippled Children's Act was passed, Act No. 274 of 1913, known since 1927 as the Afflicted Children's Act, was amended to provide for the treatment of obstetrical cases.

Although the 1927 Crippled Children's Act was supposed to end hospitalization of crippled children as provided under the old 1913 law, there is evidence that the law was sometimes used for the local hospitalization of "afflicted" but not crippled children. In fact, many probate judges continued to send crippled children to the University Hospital under the 1913 act.

In 1926-27, 2,614 patients were registered in the University Hospital under the children's act of 1913; the following year there were 2,760, and in 1928-29, 3,356. Apparently, no statistics are available on the corresponding numbers of patients registered under the Crippled Children's Act of 1927 until 1929-30, when there were fifty-three children under the Crippled Children's Act as against 4,244 under the Afflicted Children's Act, with seventeen children registered from state institutions under the amended Act No. 138 of 1881.

In June, 1931, the Crippled Children Commission obtained authority to pass upon hospital bills incurred under the Crippled Children's Act, but since the hospitals and courts were not obliged to report on children committed under the Afflicted Children's Act, it still had no way of estimating the total hospitalization of crippled children. Two years later an amendatory act (No. 248) sought to improve the situation, but conflicting provisions made the law difficult to administer. It introduced the use of local hospitals for "afflicted" children, gave the Crippled Children Commission charge of the administration of the Afflicted Children's Act, and forced a sharper separation of "crippled" and "afflicted" cases by making it illegal to hospitalize a crippled child under the Afflicted Children's Act.

Since under the adult acts only patients more than twenty-one years old were entitled to aid and under Act No. 248 of 1933 only persons under eighteen could be treated under the Afflicted Children's Act, there was no legal way to hospitalize "afflicted" persons between seventeen and twenty-one years of age. Act No. 5 of 1934 removed this difficulty.

Contradictory provisions in Act No. 248 regarding fee schedules and modes of payment as between the counties and state brought some confusion. The first difficulty was temporarily solved by the adoption of a satisfactory fee schedule. The commission also decided in 1933 to approve no hospital bills under the Afflicted Children's Act except those for fifteen-day treatment periods for which advance permission had been obtained, thus preventing state payment for children not hospitalized under proper probate court orders.

Hurley Hospital at Flint, Fairmount Hospital at Kalamazoo, and the Northern Michigan Children's Clinic at Marquette had been regarded as "branches" Page  986of the University Hospital, but when Act No. 248 went into effect the two former hospitals were made approved hospitals for afflicted children, the Marquette clinic remaining as a branch of the University Hospital.

In a 1935 ruling the commission provided reimbursement to the state by the counties for expenses incurred in cases of children suffering from adult types of tuberculosis, venereal diseases, or other communicable diseases and committed to hospitals under the Afflicted Children's Act. This became law in 1939.

The sweeping change of policy involved in Act No. 248 of 1933 caught most local officials unaware, and thousands of court orders under the old children's law of 1913 had to be returned for correction. But despite flaws, mostly corrected later, the act had a more pronounced effect on the over-all administration of children's hospital relief than did the special legislation and establishment of the Crippled Children Commission in 1927. The University, in June, 1933, was the only institution approved under the Afflicted Children's Act. A year later, in 1933-34, there were more than one hundred approved institutions with a resultant decrease in the University Hospital of nearly twelve hundred patients committed under the Afflicted Children's Act. Registrations under the Crippled Children's Act rose from 190 to 1,049, and the commission reported that the University Hospital increase accounted for more than three-fourths of the year's increase in cases for all hospitals under the Crippled Children's Act.

As a result of continuing dissatisfaction with the allocation of fees between state and counties, the old children's law of 1913 was once more amended. In 1935 Act No. 94 made transportation expenses of afflicted children rechargeable to the counties, but left treatment fees payable by the state. But then a new difficulty arose; the state appropriation for children's medical care was not adequate to cover physicians' fees. The commission estimated in 1936 that about one million dollars should have been added to the fund to cover these fees. The physicians, however, agreed to accept a nominal fee of one dollar a case during the 1934-36 biennium, and within a year a more liberal schedule was tentatively adopted.

The Afflicted Children's Act was further amended in 1935 by Act No. 208, which required that before a child could be hospitalized an agreement to reimburse the state for expenses was necessary between the auditor-general and the child's parents or guardian. Within two years such repayments rose from $841.92 to $11,723.88.

Three amendatory statutes in 1935 also changed the Crippled Children's Act of 1927. One (No. 169) shifted transportation costs to the counties, directed hospitals to report on the admittance and discharge of patients, and specified that no person should be considered a recipient of pauper aid because of inability to pay for a child's treatment. Another act (No. 182) prescribed that all collections from parents and school districts, as well as gifts to the commission, should be deposited to the commission's credit in the state's general fund. A third (No. 207) made repayment pledges by parents or guardians mandatory and fixed the amount per day payable by the state and local school districts for hospital schools. In 1937 these amendments were consolidated in Act No. 158, which replaced Act No. 236 of 1927.

This new law included the needed definition of "crippled child" and gave the commission additional responsibility, financial backing, and greater authority to enforce its decisions. It became responsible for handling each case committed Page  987by a probate judge. Collections, legislative appropriations, and gifts were to be held, as before, distinct from other state funds, but the new law omitted the provision that such funds be disbursed "as appropriated by the legislature." The commission and the auditor-general had the right to check all disbursements.

The new law emphasized preventive measures. Aid to children suffering from conditions that lead to crippling was authorized, and facilities for finding and serving such children, and those already crippled, especially in rural areas, were improved. In addition to diagnostic clinics, an expanded outstate service provided preventive treatment, minor orthopedic operations, follow-up supervision, and outpatient and convalescent service. In special cases transportation to clinics and treatment centers was furnished.

The commission was authorized to approve homes or hospital outpatient departments where adequate care and prevocational training could be provided those crippled children who would benefit very little from treatment. Rates for medical and hospital service were fixed for the first time: $4.50 a day for hospital service, doctors' fees at $75 for a major operation, and $200 for any one patient in a single year. One-half the costs of custodial cases was to be recharged to the counties; local school districts continued to furnish some support for the hospital schools, but under the new Crippled Children's Act all other expenses were paid by the state.

The desired definition of "afflicted child" was furnished by Act No. 217 of 1937, which also effected certain other changes in the Afflicted Children's Act, but two years later the old much-amended children's act of 1913 was replaced by Act No. 283. It extended the commission's jurisdiction in "afflicted" cases, established further financial controls, and systematized provisions added to the old act by the various amendments. It also limited the state's liability, allocating to the counties according to population three-fourths of the fund available each year, with the remaining one-fourth to be distributed according to need. The rate at which counties could consume their quota was also limited, and they were not allowed to reimburse themselves from later allotments. The commission was thus relieved from approving more services than could be paid for from available funds, and the state from the necessity of making supplementary appropriations.

In 1932-33, the year before the local hospitals were permitted to receive afflicted children under Act No. 274 of 1913, the number of patients in the University Hospital under the Afflicted Children's Act was nearly twice the number under the Afflicted Adult Act of 1915. By 1935-36 more patients were registered under the adult act of 1915 (No. 267) than under all three children's laws. In 1939-40, by far the greatest number of patients received under any one law was registered under the Afflicted Adult Act of 1915.