in the diagnosis of mental diseases by both sides in murder cases, and the usual conflicting testimony is a state of affairs which has existed for a long time and doubtless will continue, so long as the standards according to which diagnoses of mental disorders are made, are not sufficiently developed to remove much of the possibility of error of judgment.

XI. RESULT OF ONE YEAR OF STATE HOSPITAL CARE

It may be affirmed without fear of contradiction that not principle in psychiatry is more firmly established than the fact that early treatment of the insane based upon a correct analysis of the physical and mental conditions is the key to success. The figures in the following tables represent in a way the gauge by which we can measure the ability of the state hospital staffs properly to diagnose patients, and of the hospitals to provide the proper standards of care and treat

ment.

1

1 Warner, Chas. G., "Reception, Examination, and Care of New Admissions,” Amer. Jo. of Ins., 1916-1917, p. 673.

Table 24 indicates the disposition of the patients admitted to the state hospitals, and the result of the care and treatment given to these patients during the period of one year. These figures show that at the end of the first year of care and treatment in the two state hospitals mentioned above, of the total admissions, there were 163 or 49.2 per cent of the patients still under care in Central Islip State Hospital, and 220 or 48.5 per cent in the Manhattan State Hospital. A word should be said at this point regarding the figures for Kings Park State Hospital; the admissions to this institution from Bellevue Hospital are altogether cases which have suffered a relapse and which it is found advisable to return to the institution where they have previously been confined. Also, the number of such patients for the entire year is so small that no dependable statistics can be drawn up.

The table that follows points out the rate of recovery and improvement of patients committed to the Central Islip and Manhattan State Hospitals:

TABLE 25. RATE OF RECOVERY AND IMPROVEMENT OF PATIENTS

The general average rate of recovery based on all admissions was 19.4 per cent for the year 1918, the rate for the males being 18.2 per cent and for the females 20.7 per cent.1 From the figures presented above, it is quite evident that the recovery rate for the Jewish patients was unduly small, for while the per cent of the total admissions recovered for Central Islip was 20.3, for Jewish patients it was only 13.9 per cent; and whereas the rate of recoveries. for Manhattan State Hospital for the year 1918 was 15.1 per cent, for the Jewish cases it was only 3.8 per cent, an abnormally low figure. The question naturally arises as to why there should be such a marked discrepancy between the rate of recovery for all patients and the rate for a particular group. Some reasons have already been given, though in connection with the discussion of another phase of the subject.

To recapitulate, it might be well to mention the fact that so many of the Jewish patients who find their way into the state hospitals do not speak English sufficiently well to permit the physicians who care for and treat them in the hospitals to recognize when the patients have recovered. The result is that a number of Jewish patients are discharged as improved or much improved, when by the method of classification adopted in the institutions many of them might properly be signed out as recovered. The figures of the improved and much improved cases seem to bear out this statement. The general rate for patients discharged, improved and much improved, based on all admissions, was 20.0 in 1918 and 18.6 per cent in 1917, while the rate for Jewish patients admitted to Central Islip and Manhattan State Hospitals was 24.1 for the former and 27.2 per cent for the latter, for the year 1918. During this

'S. H. C., 30th A. R., p. 307.

:

year the general rate for Central Islip was 21.9 per cent, and for Manhattan 21.7 per cent. After making due allowance for the larger number of Jewish patients discharged as improved and much improved, there still remains a wide margin between the total rate of recoveries and the small rate for Jewish cases. The fact that Jewish patients do not get along so well as do other patients in state hospitals has already been mentioned and Table 25 brings out this condition more clearly.

XII. FOLLOW-UP WORK IN NEW YORK CITY

(a) Need for This Form of Service. At this point it might be advisable to consider in brief a problem which has much bearing upon the question of the final disposition of the patients. Little need be said regarding those patients who are suffering from a more or less chronic ailment, necessitating their detention in the institutions. Table 24 brings out that of a total of 784 commitments, 383 or 48.8 per cent of the patients were still in the hospitals at the end of one year, with the probability that many would remain inmates of state institutions for many more years, and in some cases even until they died. The patients whom it is necessary to consider in greater detail however, particularly from the point of view of this study, are included in the recovered, much improved and improved groups. Experience of several years in the work of a mental hygiene agency has conclusively proved to the writer the importance of closely following-up and supervising patients thus discharged. They required advice and guidance in obtaining employment, in being directed into new and more suitable occupations, and in making those numerous readjustments which are essential to the mental well-being of former inmates of state hospitals, if relapses are to be prevented and the possibility of the development of a

chronic mental disorder is to be eliminated. Moreover, the patients should be made to feel that trained psychiatrists and social workers are always available to aid them in their difficulties, whether mental, medical or social.

(b) Extent of Follow-up Work in New York. The state, largely through the continued activities of the State Charities Aid Association and its committee on mental hygiene, has come to realize the genuine opportunities for service inherent in a system of after-care work and has accordingly made some provisions along these lines. But to what extent has this been done, and, how much has been accomplished? In view of the possibilities for financial saving alone, not considering at this moment the more humane aspects of the problem, the state has been very lax in failing to provide a sufficiently large corps of workers to follow up discharged and paroled patients and so help to prevent relapses. A very important additional service might be rendered by these workers in spreading educational propaganda where it was most needed, namely, in the families of those who have already suffered a mental breakdown.

According to the Thirtieth Annual Report of the State Hospital Commission, the number of patients on parole on June 30, 1918, was 1,880;1 this does not of course include those whose parole period of six months had expired. For the large number of patients technically considered as being out on parole there were only thirteen social workers in the service of the state, for whose salaries and maintenance-the only two items in the after-care budget-less than $20,000 was spent, out of a total annual budget of over $8,000,000. The actual accomplishment of this small body of workers was as follows: 3,418 visits to paroled patients,

1 S. H. C., 30th A. R., p. 238.