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TRULY comparative studies of residential health care systems for mentally retarded are virtually nonexistent. This situation exists despite the fact that all mentally retarded comprise perhaps 5 per cent of the national population, and in the face of the fact that over 200,000 mentally retarded are in public residential facilities, cared for by nearly 100,000 staff members at a cost of over $500,000,000. The research from which this paper is drawn addressed this research lacuna, and was perhaps the first to collect comparative data on a broad range of health care system components in residential centers for mentally retarded and the technological bases influencing them. The present paper presents findings on certain indexes of comprehensiveness of health care in these institutions and their technological influences at five public facilities in widely different locations in this country. It need only be mentioned that care to the youth and adults in these institutions influences the pattern of services for mentally retarded children and youth in the community, and for those who will be admitted to these facilities in the future.

CANADA Geese (Branta canadentsis) are highly traditional in their use of circumscribed nesting, migration, and winter localities (Hanson and Smith, 1950; Martin, 1964; Sherwood, 1966), patterns of movement and roosting in local areas (Raveling, 1969a), and timing of daily activities (Raveling, 1967: 135-157). This regularity is accompanied by facilitation behaviors (Crawford, 1939) serving mood transference and induction of reaction by contagion. Particularly prominent in Anserini are movements of the head and often the neck, which have been previously described as social signals communicating the intention to fly (Heinroth, 1911; and many subsequent papers). Purposes of this paper are to document the variation of preflight intention movements of Canada Geese as related to social status (i.e. family, single, age, sex) and thereby to discuss more fully the probable functions of behavioral and morphological patterns associated with coordination of flight. Results are based on observations of a large winter flock and from quantification of the activities of radioand color-marked individuals and families of known social status.

Clinical neurologists and neurosurgeons are beginning to realize the usefulness of quantitative testing batteries to augment the qualitative measurements of the standard neurological examination in evaluating treatments for neurological diseases. This paper briefly reviews the literature on the subject, defines what is meant by a clinical quantitative neurological test, discusses the advantages of quantitative testing, considers some essential ingredients in constructing a quantitative testing system, and describes the battery of tests which is being used currently by the authors. A sample of patients from a recent study of the efficacy of thalamotomy in Parkinson’s disease is used to develop an example illustrating the usefulness of quantitative testing.

How little we realize the complexities attendant upon the lives of wild animals until we have undertaken to investigate and reveal them. So it was in connection with the gathering of material for this paper, when observations were undertaken to determine the active life movements of the Columbian ground squirrel (Citellus columbianus columbianus) in regard to seasonal and daily activities, aside from its normal periods of aestivation and hibernation. To gain the information recorded here, field observations were made, supplemented by studies of the animals in the very liberal confinement provided for those under control and study (Shaw, '25a). Binoculars were used for more certain identification in the field, while temperatures were taken in degrees Fahrenheit. The elevation at Pullman is 2536 feet at the Campus of the State College of Washington. The hours of each day of observation were continuous throughout as to time and made by one person, the writer. The time involved extended across four years, 1910 to 1914, with the chief investigations of these problems pursued in 1910 and 1911. For the sake of economy and brevity, wherever the term "squirrel" is used through the text, it will be understood to refer to the Columbian ground squirrel. In studying the activities of this squirrel and to some extent its related forms, it was necessary to regard them especially from two view points, seasonal and daily. Such investigations showed that these movements were subject to and modified by many influences such as season, sun, wind, rain and snow, drought, slope of the land and altitude. It was also noticed that the species was influenced both seasonally and daily by such complexities as the warmth and brightness of the sun's rays and their ability to reach all parts of the earth's surface equally; bringing the animals from their winter nests later in spring on the north slopes of hilly territory, where the snow remains piled deep and also later of a morning, on a sunless slope (Shaw, '25c). Of course the action of the sun on the vegetation and the relation of the animal to surounding food so produced, is of intimate association (Dice, '19, pp. 17-18).

In old age, the relationship between physical incapacity and mental state is apparently circular; that is, degree of physiological degeneration both affects and reflects psychic state. This paper focuses on two questions: 1) To what extent do old people referred for psychiatric care differ from the general aged population in their own ratings of level of self-care? 2) To what extent do age, sex, and mental symptoms play a part in how old people referred for psychiatric care evaluate their physical activity level and health? Interviews with a sample of 140 old people referred for mental hospitalization suggest that they're neither homogeneous in their self-evaluations of health nor in ability to perform activities of daily living. There seem to be two elements that make up the pattern of self-evaluations by mentally ill old people. One of these is presence or absence of observable symptoms of mental illness. The second is the sex of the respondent. Men, regardless of mental state, feel themselves as independent more often than do women and are even more likely to stress independence when confronted by a female interviewer. The differences between men and women probably reflect sex role behavior persisting even after work and parental roles have been abandoned.

In the present paper the aged are defined for convenience sake as those who are over 60 years old. In the authors' hospital 2, 614 in-patients have undergone the orthopedic functional training, and the aged patients among them are 84 in number (3.2%), 61 cases (73%) of which had fractures. Among fractures in the aged those of the femur predominate, and then come the vertebral and the fibula and tibia fractures. The patients at the age of 65 make up the largest number, and the number of male-patients is twice as large as that of female. As the cause of fractures tumbling predominates, then, falling and blow. After they sustained fractures 23% of the patients retired from their jobs, and 7% changed their jobs. In comparison with the younger patients of fracture the aged patients are naturally slower to develop bony union and consequently the period of plaster fixation, hospitalization, and training is likely to be prolonged. Besides, because of the atrophy of soft tissues during this period the adjacent joints tend to develop contractures easily.Since the aged are generally lacking in active motivation for the functional recovery return to the society and very prone to accidents, it is of importance to watch them closely during the orthopedic functional training, and to give them a positive psychological support, while taking the above tendencies into consideration. At the same time it is necessary to direct them with sympathy and kindness to continue the functional training by themselves regularly without undue overstrains. This should also be taken into consideration in cases of the aged patients. Besides, the treatment of the aged patients who suffer from complications requires the utmost caution. However, through above mentioned cautious treatment and training it is possible for the aged patients to recover their function to a level as high as that of the ordinary patients, though it must be admitted that the level of recovery of the aged is slightly lower as expected. But the question remains in the case that the knee joint contracture is apt to stay on even after the treatment of lower limb fracture, as in the cases of general fractures.The questionaire on pain was sent to 37 patients who had undergone the hospital training. Answers were obtained from 77% of them. Generally speaking, among pains numbness predominates, but the incidence of numbness among the aged patients is lower than that among the ordinary patients. And pain occurs most frequently in cold environment and then at the time of fatigue. The cause of pain is the impediment of blood circulation at the affected part. The incidence of pain caused by the impediment of blood circulation is rather high among the aged. And the means of treatment given by the patients are hot spring bath, massage, and hot compress in order. The questionaire indicates that such heat treatments as hot spring bath and others relax muscle tones at the affected part, relieve nervous excitability and improve circulation, and at the sametime, psychologically give them a peaceful rest. The fact acupuncture and moxacautery are resorted to by some patients is considered co be characteristic of the aged.The questionaire on activities of daily living was sent to 23 patients who had undergone the hospital training (16 of them were judged physically handicapped according to the National Annuity Law), and to 6 patients who had received the indoor training. All these patients suffered from fractures of the lower limb and trunk. It is important to notice that the patients of lower limb fracture comlain-ed mainly of difficulty in walking and kneel sitting. By the examination according to the National Annuity Law quite many patients of fractures are judged physically handicapped, because of their inability to do kneel or crosse legged sitting. in sitting upright or cross legged. This kind of impediment becomes serious for the Japanese who spend their home life on tatami matts.

THE daily activities of all individuals encompass, from time to time, situations which are associated with heightened degrees of emotional arousal. We usually refer to these situations as “stressful”, and we have recognized that such feelings as anxiety, fear, anger, or rage may occur during these experiences. Over the past decades investigations of the physiologic responses that accompany intense feeling states have been made either in the laboratory during induced emotional arousal or following some actual stressful experience in daily life. The development of miniaturized telemetering equipment has made it possible for certain physiologic responses to be recorded before, during, and after, an, actual stressful situation, and this report is concerned with observations of heart rate utilizing such a technique. The subjects of this study were physicians working in this medical center. The daily activities of physicians include several experiences which may be considered to be “stressful”. For the purposes of initial observation three situations were chosen: (1) The mid-day staff conference during which patient history presentations and discussion were conducted, (2) medical student presentations of patient examinations during attending staff ward rounds, and (3) diagnostic cardiac catheterization in the cardiac catheter laboratory. These situations were accompanied by varying degrees of anxiety in all physicians, and were considered by all participants to fit the general category of “stressful”. The individual variations in the physiologic response are of particular interest, however, and form the content of this report. METHOD The method used in this laboratory for radiotelemetry of the pulse rate has been previously reported [l]. The several modifications used in this study, included the following: the electrocardiogram, after being transmitted from the subject to the central receiving station, was also recorded on magnetic tape for future playback on standard electrocardiographic paper. This allowed subsequent direct measurement of the R-R interval providing a check on the value of heart rate recorded by the cardiotachometer. For the mid-day staff conferences, the physician who was to present the patient history was brought to the laboratory prior to the conference and the electrocardiograph transmitter applied. Anterior and lateral chest leads were used and the transmitter was worn either in a shirt pocket or in a speciallyfitted holster. The heart rate was recorded during the entire hour of the conference: before, during and after the actual patient presentation. The mean rates were calculated for each period in addition to the peak change during the presentation. The medical students observed during ward rounds were recorded throughout the full morning rounds, which also included periods of time when the student was not presenting a patient history, but merely observing other members of the group. The physician performing the cardiac catheterization wasrecorded from approximately a half hour before, to the final completion of the study. Particular stressful moments during the procedure were

SE VERA L recent studies have focused on clarifying the concepts involved in disability [l-4] and on factors affecting the assessment of disability [5]. Disease or injury are clearly necessary antecedents in the development of disability. The available evidence, however, indicates little relationship between the type of chronic condition and the extent of incapacity for expected performance [6-81. This paper examines the relationship of disability to the disease or injury identified as the major disabling condition and compares morbidity and disability rates for selected conditions. The relationship of the major disabling condition to age, sex, functional limitations and socio-economic factors is also examined. In a general sense, this analysis may be considered a test of the hypothesis that ‘disability is a distinct entity with characteristic causes and with features which are not necessarily related to the etiology or pathogenesis of the coextant chronic disease . . . [l]. Anatomic and functional abnormalities are frequently used as ‘the sole or real criterion of permanent disability . . . [9]‘. The Committee on Rating of Mental and Physical Impairment has pointed out, however, that the evaluation of disability is not a purely medical function [9]. The ability to engage in gainful activity may be affected by a variety of personal, economic and environmental attributes, in addition to the medical condition or impairment. Evaluation of impairment is ‘an appraisal of the nature and extent of the patient’s illness or injury as it affects his personal efficiency in one or more activities of daily living [9 : 13’. Impairments are often defined in terms of the precipitating chronic condition, however [IO, 113, rather than in relation to the consequential performance limitations. Hirschfeld and Behan [12] have noted that physicians are trained to focus on disease entities rather than on disability. Since mental and physical disorders vary in their severity, visibility and prognosis, the predictive value of the condition classification or diagnosis for disability evaluation is questionable. Hanman [13], for example, has observed that similar impairments do not always cause similar activity limitations nor are residual capacities the same.

The ideas expressed in this paper were developed in the course of a year spent exploring the life philosophies and religious outlooks of suicidal patients. Certain conclusions about the part played by the pa tient's and therapist's values in the suicidal situation seemed to force themselves on me as a result of observing and talking with patients and participating in the daily activities of a center devoted entirely to suicide prevention and research. I have interpreted the values and attitudes that patients and therapists communicated?explicitly and implicitly?in the light of my own conceptual framework regarding the role of values and beliefs in personality development and integration, taken together with my general experience as a psychotherapist. I shall present these conclusions, and then outline some of the general premises regarding the nature of values on which they are based. I might add that I take complete responsibility for these notions. Nothing I say should be construed as representing the policy of the Suicide Pre vention Center.

Counseling for medical patients and their families which focuses on the emotional adjustment to long-term hospitalization, illness and disability is relatively new to the medical setting. Only in recent years have hospitals begun to recognize their responsibility in responding to the emotional and social components of illness through structured programs geared specifically to this process of adaptation to illness. Based on the assumption that families as well as patients experience emotional stress upon hospitalization of a family member, medical counseling groups were developed at St. Mary's Hospital and Extended Care Center in an effort to more effectively and efficiently support the patient and others in his family network. This paper describes some practical measures for assuring family involvement in physical rehabilitation and discusses some possible methods of establishing such groups in a hospital setting. Case examples in the areas of stroke, cancer, diabetes, and coronary care illustrate the encouraging results of these groups.

This paper describes a comprehensive rehabilitation program for multi-handicapped deaf adults. A brief review of three aspects of the psychology of deafness precedes a detailed description of counseling, personal-social, and vocational preparatory services. A longitudinal follow-up study of 180 ex-clients revealed that half had achieved competitive employment.

The need to demonstrate that health care has an influence on health status is increasingly pressing. Such demonstrations require tools of measurement which are unfortunately not available. Development of instruments has been hampered by a lack of consensus on appropriate frames of reference, and there appears to be little agreement on what should be measured and what relative importance should be ascribed to different dimensions of health status. An approach that does not require the assignment of numerical values or weights to various aspects of health status and is applicable to all age groups within the population and to the whole spectrum of health problems rather than to specific medical diagnoses would seem desirable. A scheme that is based upon the development of a “profile” rather than a single “index” for describing health status is proposed in this paper. The model is a conceptual framework whose usefulness will depend upon efforts of a large number of researchers from many disciplines to develop instruments which can be incorporated in it.

Behaviour modification techniques featuring token-economy procedures were used successfully to treat a ward of severely regressed and aggressive female psychotic patients. In case history fashion, this paper has reported on the character of the population treated, the nature of the procedures employed, and a set of outcome measures. The outcome measures reported fall into three classes: 1) target behaviours associated with meal- and bed-time, 2) standardized measures of adjustment and, 3) success rater after a two-year follow up. In the light of the original level of pathology and difficulty in management of these patients and the shortage of personnel to care for them, it has been concluded that these behaviour modification procedures are a most promising therapeutic agent.

“România curat?” represents a complex system of activities and actions judiciously correlated in order to improve the environmental conditions and population health, and implies the developing of an adequate mentality of community, a realistic evaluation of environmental problems. In this respect, the present paper approaches to one of the most important local community problems, namely collecting and cleaning of the waste waters resulted from daily activities. We attempted to create a model, which might be applicable in practice, of collecting and cleaning the waste waters resulted from daily activities of a village. This work also describes the impact that the exploitation of the sewage network-waste water treatment station system will have upon environmental factors.

The three rotations of the human hip joint can be approximated by using the electrogoniometric technique. Because the measuring device is not directly located at this point, potential errors exist between the recorded and the actual motions. The objective of this paper is to determine the magnitude and the distribution of these errors. The properly attached goniometer linkage and the femur form a 7-link spatial mechanism. The motion of this spatial mechanism is solved by using the 4 × 4 matrix method with three input motions defined from potentiometers attached to the goniometer linkage. From the solution of this mechanism, the corrected rotations of the hip-joint are obtained. The maximum error is less than 5 deg at any point in the walking cycle for a normal subject. The largest corrections occur at maximum internal and external rotations. Measurements of hip motion for several activities of daily living are also corrected, and the errors are magnified, compared to walking, since larger angles of rotation are involved.

Over the past two decades epidemiologists interested in chronic illness have tended to concen trate on conditions which are lethal, and they have generally directed more attention to the elucidation of the causes of such diseases than to their social consequences. Although this work has been of great importance, one result is that we know less than we should about the burden on society of many diseases, especially those with a low case fatality rate such as the arthritides, varicosities, and even diabetes. To date one of the few large-scale sources of information of this kind is in the United States where the National Health Examination Survey (1966a and b, 1968) has shown that the prevalence of arthritic conditions is extremely high, although it has not included data on impairment and disability in objectively ascertained cases. In contrast, the US National Health Interview Survey (1960, 1964, 1969, 1971), which has had to depend on the respon dent's word for ascertainment of diagnosis, has collected data on the extent of limitations of activity. Throughout that country arthritis and rheumatism, which are treated in the National Health Survey as a single category, were by far the most serious cause of limited mobility, and in many areas they are also the most important chronic cause of limited activity (US National Health Survey, 1971). If arthritis and rheumatism are taken in combination with impair ments of the spine, hips, and legs, they have con sistently, between 1961 and 1967, accounted for 29% of all cases of limited activity and in this respect far outstrip in importance any other group of chronic diseases. Over the same seven-year period the next most important conditions have been those of the cardiovascular system, yet 'heart conditions' and 'hypertension without heart involve ment' taken together have accounted for only 22% to 23 % of the cases of chronically limited activity (US National Health Survey, 1968). In 1967 some 3,250,000 civilians who were not in hospitals or other institutions suffered limitation of activity because of these two conditions and in well over half of these there was serious loss of time at work (US National Health Survey, 1971). The communal problem of arthritis and rheumatism is accentuated by the fact that the burden imposed by them is heaviest among the poorest members of the com munity. In Britain the General Household Survey is collecting data which are similar to those from the US Interview Survey (1964, 1969, 1971). This paper presents some information about the interrelationship between impairment and disability and arthritic conditions in a group of adults from the general population of New Haven, Connecticut, and combines objective with interview data.

REHABILITATION is that part of medical care which aims primarily to relieve the disability produced by disease and to restore the person to a place in society. The basic defect to be corrected by physical medicine and rehabilitation is disability, which prevents performance of the person's usual functions. However, we have no generally accepted measure of disability. Consequently, rehabilitation workers have been slow to convince other health personnel that their methods are effective (1). Disability usually entails physical, mental, and socioeconomic problems, and for this reason complex measures which assess two or all three aspects have been attempted. Since 1955 the State of Maryland's three chronic disease hospitals have used a scoring method to evaluate the performance of independent movement by long-term patients. This disability score, usually called the Barthel index (2) and occasionally the Maryland disability index (3), assigns 0, 5, 10, or 15 points to performing each of 10 activities of daily living. The sum of these scores is 100 points when all activities are carried out skillfully and independently (table 1). The Barthel index is an empirical score developed by a physical therapist and physiatrist. It provides a simple method for evaluating the physical functioning of a disabled patient at a given time and for assessing change in physical function. The physical therapist and physiatrist discussed with nurses and physicians the physical, mental, and social importance of each activity to the patient and its importance in reducing the need for care. They decided not to refine scores for specific functions to values of less than 5 points. However, instructions were standardized to clarify the criterion of performance for each score and to improve repeatability (2). Patients scoring 100 points could have abilities ranging from barely being able to perform the activities of daily living to being able to earn a salary in skilled employment. Therefore patients can continue to improve after scoring 100 points. Similarly, the patient scoring 0 can emerge from a coma and be conscious though helpless in bed without a change in his score. Although abilities of patients with scores at either end of the scale can vary considerably, the functioning of patients with identical intermediate scores differs less. The lower the patient's score, the more severe is his physical impairment; a rise in score indicates an improvement in his physical functioning. The purpose of the analyses described in this paper is to assess the validity of the Barthel index. (Data for this study were made available by the staff of the Montebello State Hospital, Baltimore, Md.) The 1,223 patients in this study all had at least one cerebrovascular accident before their Dr. Wylie is associate professor of public health administration at the Johns Hopkins University School of Hygiene and Public Health, Baltimore, Md.