VOLUNTARY ADMISSIONS

With increasing knowledge of the provisions of the statute of 1908 permitting the admission to the State hospitals of persons who desire to place themselves under the regimen of these institutions either to ward off an original attack of insanity or to guard against a relapse from a previous attack and to avoid the necessity of commitment at a later date, the number of voluntary admissions to the hospitals advances year by year. The total reached 381 during the past year.

The beneficent features of this law are now apparent to every person connected with the hospital system. No patient is received under this statute whose mental condition does not permit him to make application for admission, and no evil results have been reported by any of the institutions. The Commission is convinced that among the 381 cases placing themselves under treatment, were many who under former conditions would have sunk into chronic insanity necessitating prolonged hospital support at the expense of the State.

A certain proportion of the cases is found each year by the Commission's medical inspector to be mistakenly classed as voluntary patients; i. e., they have required greater control than could be exercised over them under the terms of their applications for admissions. The inspector's recommendation for either discharge or recommitment in these cases has been observed by the institution authorities.

Certain of the private institutions were guilty of remissness during the year in failing to obtain written applications before admitting patients of the voluntary class.

OUT-PATIENT DEPARTMENTS FOR THE STATE HOSPITALS

In its last report mention was made by the Commission of the proposed establishment in connection with each State hospital of out-patient departments or dispensaries in the several hospital districts under the authority granted by section 45, subdivision 11-a of the Insanity Law.

The Commission hoped to be able to record in its present report considerable progress in this feature of its campaign of prevention and after-care; having outlined plans for the detail of

hospital physicians and nurses to dispensary work during a portion of each week. Indeed the work had been begun in a few of the institutions when the unexpected decrease in the supplemental allowance for maintenance made it necessary to curtail expenditures in all directions with a consequent cessation of activities in this field.

The Commission expects very material results from the establishment of these mental hygiene clinics. Certainly if properly supervised by experienced and tactful hospital assistants, a considerable number of border-line cases can be afforded the precise kind of help of which they are in need and their commitment to hospitals can be averted; furthermore patients who have suffered from previous attacks and fear relapses can often be carried over the periods of their greatest stress and strain through the practical suggestions of experienced alienists, based on a knowledge of the patient's home conditions after inquiry through the trained nurse attached to the dispensary.

A proof of the practical benefit of the dispensary to patients of this kind is found in the report of the Long Island State Hospital, which has maintained two dispensary branches throughout the year, one at the Long Island College Hospital and the other at the State Hospital. Eighty-three patients applied for advice and suggestions, and numerous letters were received from early mental cases and from charitable organizations as well as from private parties, all of which received appropriate attention.

This general subject of prevention, paroles and after-care is now attracting the attention of charitable agencies in every direction and the Commission strongly urges its recognition by the Legislature through adequate appropriations for its extension, along proper lines.

PREVENTION AND AFTER-CARE

The time has now arrived for the establishment under the authority of the State of a systematic plan of prevention and aftercare; prevention through publicity and through the recently authorized out-patient departments of each of the State hospitals cooperating with all medical practitioners of the district: aftercare work through trained social service workers, giving all nec

essary attention to patients paroled or discharged from every hospital for the insane to enable them to maintain themselves in the community. Since it seems almost impossible to stem the inrushing tide of aliens to this country (and this State seems to attract hundreds of thousands each year, sound and unsound), and since it is becoming increasingly difficult to persuade the Legislature of the necessity of adequate provision for this class, other means of meeting a most difficult situation must be adopted. The Commission has noted with satisfaction the sustained and admirable work of the social service volunteers and paid employees attached to four of the State hospitals, and is only awaiting adequate appropriations to extend this system to the remaining nine institutions. It is perforce confined to financial considerations in new developments of this kind, and it is because of very promising financial returns that it proposes to perfect a State-wide system of paroles and after-care. For certain it is that if through the efforts of these adjuncts of the State system, paroled or discharged patients can be helped over the rough places inseparable from life in the community, the necessity thus obviated of recommitment to hospitals for the insane, a very considerable reduction in the number of these dependents on public charity can be brought about.

Taking a leaf from the book of the modern man of business the Commission plans this follow-up campaign along strictly progressive lines. It has been well said that the process of care is not complete when the hospital door opens and the patient is again subjected to the stress and strain of the outside world. The need of mental social service then begins and should continue so long as the experienced, tactful and resourceful social worker considers it necessary; i. e., until everything possible has been done to restore the patient's stamina and independence, and to adjust him completely to his outside environment.

The State Charities Aid Association's Committee on Mental Hygiene, headed by Secretary Elwood, has done fine work in publicity and in the preliminary organization of mental hygiene clinics, one of which, established on the East side of New York city, has already shown really admirable results. But from lack

of means certain features of after-care work cannot be undertaken on any comprehensive scale by volunteer organizations. One feature of the Commission's campaign for prevention is a series of short practical talks on mental hygiene in different parts of the State, illustrated by stereopticon slides. The causes of insanity will be featured and practical suggestions based on sustained studies and experience with insanity will be made with the view of clearing up at least some of the most flagrant misconceptions concerning the subject prevalent even in many enlightened communities of the State. Strong emphasis will be laid upon the easily preventable causes and hospital statistics covering the period of many years will be quoted showing the frightful inroads made by alcohol and sexual irregularities upon the mental stamina of the individual and the consequent loss in the wealth of the State. Practical suggestions will be offered as to the avoidance of errors in the rearing of children to which are so often due the chronic hysterias and neuroses of adult life. In a word, the Commission's paramount idea will be to lessen the number of persons requiring commitment to the public institutions of the State. Finally, it may be stated that if the propaganda proposed by the Commission is successful even to the extent of obviating the commitment each year of 50 individuals, the modest investment now planned will show most extraordinary financial results. The general work of the State Hospital Commission will be explained and full particulars given as to the expenditures of the annual appropriations for the care of the insane.

The parole and after-care or follow-up feature of our hospital work has engaged much of the Commission's time during the year, and the results have been very satisfactory. At the close of 1913 the number absent from all institutions on parole was 861, while at the close of 1914, it was 1,300, an increase of 51 per cent. The Commission's activities in this direction with the cooperation of the hospitals served to reduce the net annual increase in the average daily number of the insane in State hospitals to the lowest point with one exception for many years, viz., 647.

REMOVAL OF DOTARDS AND OTHERS FROM THE STATE

HOSPITALS

Section 94 of the Insanity Law provides for the discharge from State hospitals of non-insane epileptics, of dotards, and of persons not insane within the meaning of the Insanity Law, also of unrecovered patients to the care of their relatives and friends. The law further provides as to these classes that in the event of friends failing to assume their care, the local superintendent of the poor must do so.

It is the experience of every State hospital superintendent that when a patient belonging to either of these classes secures admission to a State hospital his discharge therefrom is only accomplished after his friends have used every possible means to secure his further treatment in the hospital. To an extent this action is an eloquent tribute to the high plane upon which these institutions are maintained and it is not surprising that superintendents yield from time to time to local pressure of this character. At this point, however, an important function of the Commission's medical inspector comes into play. In his careful examination of all new cases, if he regards any as unsuitable for support by the State, he formally recommends their early discharge. Probably an average of 200 patients are thus recommended for discharge every year. The pressure for accommodation for the acute and curable class is so great that our wards. should no longer be crowded with cases of physiological decay or advanced senility, which present no mental symptoms beyond those of so-called second childhood. These old people wander about hospital wards in an aimless fashion and require merely nominal supervision; active mental symptoms, while existing at the time of commitment, have long since disappeared and where suitable provision for them cannot be made by relatives, their care should be assumed by local authorities.

During the year the Commission assigned the supervision of this work to an experienced employee whose activities have already borne such fruit as to indicate considerable results during the coming year.