Judging from the facts and figures presented above, it is seen that the high rate of readmissions among the Jewish patients as compared with the rate of readmissions to all the state hospitals cannot be ascribed to a higher rate of readmissions among the cases diagnosed as suffering from either dementia praecox or manic depressive insanity. The variation in the percentages of certain psychoses, particularly dementia praecox and manic depressive insanity, as shown in the statistics for all the state hospitals for a five year period indicate such a wide divergence,1 that the only safe method that may be pursued in arriving at comparative figures is to take only the percentages for the hospitals to which the Jewish patients were admitted in large numbers. Following along these lines, the readmission rates to the Manhattan and Central Islip State Hospitals, as shown in Table 23, should be those which alone might properly be used to arrive at a just comparison. Even then, the Jewish patients as already explained, show up favorably when compared with the total readmissions, though they have a higher readmission rate among the cases of manic depressive insanity. The variation in the basis for diagnosis among the different hospitals, the marked difference between the reported percentages of certain of the psychoses among the several hospitals, despite the attempts of the staff of the

1 S. H. C., 30th A. R., p. 294.

Psychiatric Institute to standardize the methods used in arriving at diagnoses for particular groups of cases, indicate that the statistics as thus far presented cannot be taken at full face value, at least insofar as the diagnoses of a large number of cases which may be classified as borderline are concerned.

VIII. REASONS FOR HIGH READMISSION RATES

The reasons for the higher rate of readmissions among the Jewish patients than among the others committed to the state hospitals are as yet unexplained, though a higher rate of readmissions among those patients diagnosed otherwise than dementia praecox and manic depressive insanity, may in part cover the added percentage of these readmissions. The importance of the question of a higher rate of readmissions among Jews involves even more fundamental matters than that of distribution of patients according to diagnosis. It again raises the question discussed in another connection, namely, the effect of a proper classification of patients according to social, racial, language, etc., groups, upon the percentage of recoveries.

An indication of some of these difficulties encountered by the staff of workers in the wards is the statement recently made to the writer by a physician in one of the largest state hospitals. He remarked that he had in one of his wards a group of fifty patients whose language was entirely alien to him as well as to the nurses and attendants on the ward. The result was that these patients did not receive the attention that should have been bestowed upon them by the doctor and others in helping them to improve and ultimately to recover. This condition is particularly applicable to the Jewish patients of foreign birth, though the hospital authorities have tried to do all they could to remove such hindrances to the well-being and recovery of the large

number of non-English speaking charges under their care. The question of agreeable and palatable food is a matter which applies particularly to Jewish patients, most of whom have been brought up in homes where the Jewish dietary laws are observed, for the eating of food that is not prepared according to these laws is more or less obnoxious. The result is that patients who understand the difference, among them being a large number of those ultimately paroled or discharged, demand of their relatives that steps be taken leading to their release from custody, often before they are sufficiently recovered to insure against a relapse. In the long run such premature discharges necessitate readmission to the hospital.

Assuming that the reasons for the high readmission rates among the Jewish patients can be ascribed to the causes just outlined, as well as to the fairly large number of cases of manic depressive insanity that have to be returned to the hospitals, the thought comes to mind that there must be some way or ways of so altering the present methods of dealing with the insane cared for in state institutions, that high readmission rates may be materially reduced. Several methods are obvious from the discussion of the subject, such as introducing into the hospitals physicians and nurses as well as attendants who understand the languages spoken by large groups of patients of foreign birth; applying a more thorough and selective classification to all the patients, supplying "kosher" kitchens in the hospitals in which large numbers of Jewish patients are cared for, etc. The impossibility of doing these several things at the present time because of the overcrowded conditions in the hospitals has already been touched upon, and nothing can be done along these lines until plans already prepared for the further extension of the facilities of the state hospitals are sufficiently matured to furnish a basis for further suggestion and criticism.

IX. MOVEMENTS FOR ESTABLISHMENT OF JEWISH PSYCHO

PATHIC HOSPITALS

Referring particularly to Jewish patients, movements have been set afoot in New York City aiming at the establishment of a hospital for the mentally sick Jews whose diagnosis indicates a prognosis of possible recovery or at least of improvement so marked in both physical and mental conditions, as to render it advisable to care for and treat such patients in an institution resembling in plan and scope the psychopathic hospitals of Boston and Baltimore. Many members of the Jewish community in New York who have given this matter thought seem to agree that such an institution would not only be of much service to those unfortunates among the Jews who become mentally unbalanced, but would at the same time effect a higher proportion of cures, reduce the expenditure of state money, and also act as an experimental station for the study of various phases of the problem. The plans for such a hospital have not as yet progressed sufficiently to make it advisable to pass judgment upon the matter. However, it is safe to state that any project is worthy when its purpose is to reduce human suffering which is involved in the loss of the power to reason and to live the life of a rational being. Mental hygiene agencies have been at work in New York City as well as in different parts of the country for some years past, their activities being almost altogether limited to extra-institutional care of those who are either in danger of a mental breakdown or are discharged patients from state or private institutions for the insane. The possibilities for good work inherent in these organizations or societies for the social care of the insane will be dealt with at length in a subsequent chapter.

X. DIAGNOSIS OF ADMISSIONS TO STATE HOSPITALS

Mention has already been made of the difficulties encountered in attempting to supply an adequate definition of the term "insanity," and of the disagreement among students of psychiatry regarding a proper scheme or system of classification of the forms of mental alienation. These perplexities extend to the field of diagnosis of mental cases as well; in the tables that follow there will be found indications of a marked variance in the number of cases diagnosed and classified under particular divisions, in the ratio of cases reported as recovered and improved, etc., even in the statistics for two of the largest of the metropolitan hospitals. As long ago as 1874 Maudsley wrote:

It would certainly be vastly convenient and would save a world of trouble, if it were possible to draw a hard and fast line, and to declare that all persons who were on one side of it must be sane and all persons who were on the other side of it must be insane. But a very little consideration will show how vain it is to attempt to make such a division. That nature makes no leaps, but passes from one complexion to its opposite by a gradation so gentle that one shades imperceptibly into another, and no one can fix positively the point of transition, is a sufficiently trite observation. Nowhere is this more true than in respect to sanity and insanity; it is unavoidable therefore that doubts, disputes, and perplexities should arise in dealing with particular cases.1

Since this statement was originally written psychiatry has advanced in leaps and bounds, and more scientific methods of diagnosis have been evolved; however, the possibility of erring on the part of the individual making and recording observations is well known, particularly in the proper interpretation of given facts. The engagement of experts.

1

Maudsley, Henry, Responsibility in Mental Disease, 1874, pp. 38-39.