from infection from any such disease." A further statement might well be added to marriage licenses-one which would inform the healthy partner to a marriage contract of former attacks of insanity in the other.

VII. PAROLE SYSTEM OF STATE HOSPITALS

Before discussing the discharged cases and the facts brought out as a result of following them up some time subsequent to their discharge from the state hospitals, it might be well to present the outstanding features of the parole and out-patient departments of the state hospitals. It is to these departments that discharged patients are referred and to which they are expected to report during the parole period, usually of six months, though occasionally of longer duration.

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(a) Development of Out-Patient Departments. In 1913 the legislature, at the suggestion of the State Charities Aid Association, passed a law authorizing each of the state hospitals to establish an out-patient department, assign a physician to it and employ a field agent or social worker. At that time this law was referred to by competent authority as the most important law in behalf of the insane passed in a generation. It was some years, however, before all the thirteen state hospitals had organized this branch or department of their work and engaged the services of a social worker. Had sufficient funds been available and the new activity been initiated with more vigor, it is apparent that a considerable number of persons who eventually were committed to the state hospitals because of the lack of competent advice or early treatment would have been saved the rather unpleasant experience of residence as patients in a state hospital for the insane.

1 S. H. C., 28th A. R., p. 352.

The out-patient departments and the parole activities of the state hospitals are naturally inter-related, for it is to the clinics established under the law of 1913 that the parole patients report; and similarly, the social worker assigned to the out-patient department also looks after the parole cases. The effects of the mental clinics upon the hospitals are several; they provide a means whereby the hospital can supply medical supervision to its patients even when they live at a distance from the institution itself; they provide an inconspicuous place to which sensitive patients are willing to come when they would hesitate to return to the hospital; and also, by giving parole patients an opportunity regularly and frequently to see a physician who understands them, the hospital is enabled to keep a number of patients on parole who would otherwise have to return. The clinics are also of value to the hospital physician, as he is given the opportunity to do preventive work and meet types of cases in the milder forms which rarely reach the state hospital.1 There would be little hesitancy in denominating such a system of out-patient and parole departments of state hospitals a great force and factor in preventive work and of the highest form of medical and social usefulness, provided only that its standard of service and effectiveness was high. Whether or not such is the case at present may be readily judged from the facts presented in the following paragraphs.

(b) Extent and Effectiveness of Parole System. The procedure followed by the writer in attempting to arrive at a fair and at the same time convincing conclusion as to the value and usefulness of the out-patient and parole activities, was to consult the parole records of the patients discharged from both the Manhattan and Central Islip State

1 The Parole System of New York State Hospitals, published by New York State Charities Aid Assn., Nov., 1917.

Hospitals, limiting the study however, to those cases which have been considered in the preceding chapters. There was some difficulty in attempting to carry out this plan, due altogether to the fact that the field agent or social worker attached to one of the hospitals frankly admitted that her routine work was so heavy and the number of parole patients so large, that she had been unable to keep any records of value during the time to which this study is limited. A year later, with some clerical assistance, she was in a better position to keep some kind of record for each patient out on parole, usually not more than a note by the examining physician that the patient reported at the clinic and was discharged from parole on a given date. The records of the clinics of the other hospital were somewhat more complete, due to the fact that the social worker had a sufficient knowledge of stenography and typewriting to enable her to take the dictation of the clinic physician and transcribe the notes into the records of the patients reporting at the clinics. Following are excerpts taken from the parole records of several patients:

In the case of patient No. 13,671 the report read, "He (the patient) does not agree that the abnormal sexual sensations are any less since he left the hospital; conversation tends to be quite disconnected and poorly constructed. parole is due to expire in a few days and he is discharged from the clinic."

His

In No. 14,011, a case of dementia praecox, katatonic type, the clinical report stated that the patient was childish and not fully recovered; also that "his condition is of course far from satisfactory, but his parole having expired three days ago, nothing can be done except to discharge him from the clinic." This patient was engaged to be married at the time of his last visit to the clinic, and the notes quoted were written at that time.

No. 14,140 reported to the clinic, and it was found that "he was not altogether recovered, but discharged from the clinic since parole period expired within a few days of visit to clinic." A few months later, the patient was readmitted to the hospital.

The report in No. 13,936 reads, "Discharged at the end of parole period though should ordinarily be continued under care."

In the case of No. 13,738 the record shows that after his discharge from the state hospital, the patient came to the clinic once and was not followed up. Also, the record of the first and only visit reads that "Owing to his poor English he (the patient) did not appear to understand the advice of the examiner." Some months later this patient was readmitted to the hospital.

It is needless to point out the implications of the problem as brought out by citing the above cases, which were taken at random and are typical of much of the work in the clinics at the present time. It should not be gathered that nothing at all is done, for out of a considerable number of patients paroled from one of the hospitals, the writer found that practically every patient who had been paroled reported to the clinic and was seen by the physician at least once during the six months parole period. This in itself was of value, though the general criticism of the work as a whole is that not sufficient is now being done by the state for paroled patients and such as come to the clinics for advice. The social workers are able in a number of cases to assist the patients in placing themselves in positions and in otherwise serving them. As has already been pointed out, however, it is impossible for one worker to follow up paroled and discharged patients from any one of the large state hospitals, and so to serve them and their families that the maximum amount of service will be rendered to these un

fortunates. This would involve a large expenditure of money in a kind of service which the state is not prepared to render. The only funds that the state hospitals are empowered to give directly to the patients or their relatives are provided for in the following section of the Insanity Law:1

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No patient shall be discharged or paroled from a state hospital without suitable clothing adapted to the season in which he is discharged or paroled; and if it can not be otherwise obtained, the steward shall, upon the order of the superintendent, furnish the same, and money not exceeding twenty-five dollars, to defray his necessary expenses until he can reach his relatives or friends, or find employment to earn a subsistence.

In only a few of the cases discharged or paroled is any money granted to tide the patients over until they find employment. Beyond that and the clinic work the state is not at present supplying any further mental hygiene service to discharged or paroled patients or others in need of such service, the term "mental hygiene service" being used in its broadest sense.

VIII. PAROLED AND DISCHARGED PATIENTS

Mention has already been made of the four-fold division into which the patients have been classified for the purpose of surveying the results of state hospital care and treatment. Regarding the first group, made up of those still in the state hospitals and without dependents or family responsibilities, it is seemingly obvious that very little, if anything, could be accomplished by a detailed study of the families of these persons, more especially from the point of view of their social needs and requirements. It would be possible to unearth facts relative to the heredity, behavior prior to com

1 Chap. 27 of the Consolidated Laws, Sect. 95.