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(an average of less than two visits to each patient on parole); 727 visits to other patients outside the hospital; 1,841 other visits on behalf of patients, and 245 visits in behalf of preventive cases. Situations were obtained for 132 patients from the hospital and for eleven preventive cases.1 More recently arrangements have been made by the State Hospital Commission to provide one after-care worker for every 100 patients on parole. Apropos of this welcome addition to the staff, it is of interest to note that the social service department of the Boston Psychopathic Hospital does not assign more than 20 or 25 patients to each worker.

There is no intention to disparage the good work of the follow-up staff of the state hospitals; it is desired, rather, to point out its inadequacy. The whole situation regarding this particular phase of the problem was well summarized by one of these workers when she stated that she hardly had the time to keep track of the names of those discharged and paroled, much less to serve them. This is probably a somewhat extreme statement, though it reflects the state of mind of the follow-up agents who are serving the state in the different hospitals as best they can considering the handicaps under which they labor.

(c) Need for Follow-Up of Jewish Patients. Table 25 indicates that 63 Jewish patients were discharged as recovered from the Central Islip and Manhattan State Hospitals, that 201 were paroled as much improved and improved, and that 21 were taken home by relatives in an unimproved condition. This makes a total of 285 patients who left these institutions during the year to return to their homes and previous environment, with but very little, if any, supervision and follow-up work. If action on the part of the state in appropriating sufficient funds for the

1 S. H. C., 30th A. R., p. 237.

establishment of large and well organized social service staffs in the several state hospitals is as slow in materializing as it has been heretofore, the question arises as to whether it would not be advisable that some properly officered and equipped Jewish agency assist the state in following up and serving these patients, all of whom are residents of the City of New York. A further alternative presents itself, namely, that some mental hygiene agency already functioning among Jewish patients, or one to be organized on a much larger scale, be requested by the state hospital authorities to take over the work of rendering social service to the Jewish discharges. Some arrangement might be perfected whereby Jewish social workers and psychiatrists who understand the unique Jewish psychology could assist the state social workers and augment the service and assistance now being rendered.

The entire problem of after-care work among Jewish patients is one that should and must in the near future be brought to the serious attention both of the state authorities charged with the proper care of the insane, and of representatives of Jewish organizations and agencies prepared to render this particular kind of service. In order that the abnormally high readmission rate prevalent among Jewish patients of state hospitals be materially reduced through timely and adequate mental hygiene service, some such action is imperative.

XIII. DEATHS IN STATE HOSPITALS

(a) Death Rates of Jewish Patients. Those who are engaged in some form of service in the psychopathic wards of general hospitals to which insane or alleged insane persons are brought prior to their commitment, are frequently asked by the friends and relatives of these patients what the possibilities are for the recovery of committed cases. The

facts regarding the rate of discharges and recoveries have already been noted. Table 24 shows the number of patients who were otherwise disposed of, particularly those who died in the institutions. Of the total of 784 admissions there were 107 deaths, a death rate equivalent to 13.6 per cent of the admissions; of 436 males admitted during the year, 67 or 15.3 per cent died, and of 348 females admitted in the same period, 40 or 11.5 per cent died. It is at the present time difficult to draw any valid comparisons between the death rate for Jewish admissions and for the total admissions to the several state hospitals, this being altogether due to the fact that the statistics prepared for all the patients are based not upon the admissions for the given year, but upon the total number of patients under treatment during the year. Thus, in 1918, the death rate per 1,000 patients under treatment excluding transfers, which are comparatively few in number, was 85.5; the male death rate was 98.9, and the female rate 73.5. The one point of comparison is the higher death rate indicated for males in both groups of figures.

(b) Reasons for Increasing Death Rates. Somewhat debatable ground is entered when considering what significance is to be attached to the fact that the death rate per 1,000 patients under treatment for all the hospitals has been slowly but definitely increasing from year to year, a condition found to exist ever since accurate statistics bearing on this phase of hospital care for the insane have been kept. In the year 1897 the total rate, that is, including males and females, was 66.0 per 1,000 patients under treatment; in 1917 it had increased to 88.8, with a somewhat lower rate for 1918, namely 85.5. The irrefutable fact is that the death rate has been increasing though the reasons therefor are not so obvious. The increasing tendency to send cases of acute mental illness to state hospitals has

probably contributed to this condition. The ability in recent years more readily and accurately to diagnose cases of general paralysis, as well as other psychoses with high death rates, has resulted in the commitment of such cases to state hospitals. For instance, the highest death rates per 1,000 patients under treatment were found among patients suffering with general paralysis, the rate in 1918 having been 352.8; for cerebral arteriosclerosis the death rate was 340.2 during the same year. Furthermore, up to the last decade of the nineteenth century many cases of senile psychosis were housed in county institutions, whereas at present all such cases as reach public institutions are committed to state hospitals. When it is realized that for cases of senile psychosis the death rate per 1,000 patients under treatment in a given year, as in 1918, was 297.2, it is at once seen why the general death rate has increased so much in more recent years. The factors just mentioned have undoubtedly been largely responsible for the increased death rate, though the sum total of their effect upon the statistical averages must to some extent, at least, be neutralized by the better and higher standard of care accorded to state hospital patients during the past twenty or more years, with the resultant increase in the length of life of large numbers of patients.

1

The following table shows that those who died suffering from general paralysis were 43 in number, equivalent to 40.1 per cent of the total number of deaths; 1 the deaths from senile psychosis numbered 20, or 18.6 per cent of the total deaths.

1Dublin, Louis I., Mortality Statistics of Insured Wage-Earners and their Families, 1919, pp. 271-272, presents a discussion of death rates among a large number of insured persons where the cause of death was general paralysis.

TABLE 26. DIAGNOSIS OF PATIENTS WHO DIED IN STATE HOSPITALS

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The total number of cases admitted during the year and diagnosed as afflicted with general paralysis was 99, out of which as already noted, 43 died within the year. This gives a death rate of approximately 400 out of 1,000 such patients admitted within the year, a figure somewhat higher than the death rate for all the patients similarly diagnosed. The death rate for the senile cases was about the same as the rate for all the cases classified under this diagnosis.

XIV. LENGTH OF STAY IN THE HOSPITALS

Reference has already been made in explanation of Table 25 to the difference between Central Islip and Manhattan State Hospitals in the ratio of patients signed out as "recovered"; in analyzing the above figures the statements referred to should be taken into consideration. This table furthermore emphasizes the facts noted in Chapter II regarding the recovery rate of the different psychoses, parti

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