mitment, industrial history, etc.,of the patients. To obtain information of scientific value, it would be necessary to presuppose sufficient knowledge and power of observation and interpretation of given facts on the part of relatives and friends, matters in which large numbers have been found woefully lacking. This is so marked that little value can be attached to statements obtained along these lines from relatives of many of the patients.

In the second group are classified patients who prior to admission to a state hospital had certain family responsibilities, and at the end of one year were still confined in the institutions. The commitment of such persons involved family readjustments of one kind or another, which have already been dwelt upon.

(a) Details of Survey Form. The last group contains all those patients discharged or paroled from the state hospitals within a year after admission, and who were permitted to leave the hospitals on parole for six months. In order to study this group carefully it was found to be both. advisable and necessary to devise and draw up a form that would serve as the basis for the social investigation, and as a questionuaire and guide to the investigator. Aside from this, it was proposed to obtain as much reliable information. as possible regarding the important aspects of the life of the patient after leaving the institution. The form was therefore divided into four main headings, namely, (a) mental, (b) medical or physical, (c) social, and (d) recreational. The thought was that this kind of division would cover all the important factors regarding the lives of the patients and would at the same time bring out the facts relative to our present inadequacies in providing and caring for the mentally sick.

Under Mental, the aim was to ascertain the condition of the patient at least a year after discharge, the result of

the hospital treatment, after-care or mental hygiene clinic attended, and needs unfulfilled or not being met by the community.

The effect of the medical or physical condition of a person upon his mental well-being is so thoroughly recognized that it needs but little further elucidation. This is particularly true of persons who have been so ill mentally that their commitment to a state hospital or other institution has been found necessary. A discharged or paroled mental case with any one of a large number of serious or troublesome physical ailments will have his ultimate recovery or improvement seriously retarded or even prevented unless such physical difficulty receives timely and expert attention. It might properly be expected that most if not all remediable physical ailments be attended to while the patient is still in the state hospital, or, at least just prior to his parole; and if not then, through the help of the after-care workers, by whom patients can be taken to general hospitals. Because of the overcrowded conditions in the state hospitals any attempt adequately to care for the physical ailments of the patients would result in a state of congestion that would be intolerable. The result is that but little can be attempted in the way of giving patients the attention they actually require if their recovery is to be expedited and the possibility of a relapse eliminated as far as possible.

In a survey of this kind more definite and accurate information can be obtained regarding the social conditions. than of either the mental or physical status. Under the classification Social, the aim is to determine the condition and progress of the discharged patient, his relationship to his family, the needs of the family group, and what the community has done or is doing to help the family meet these needs. Some might question the necessity and advisability of conducting such an inquiry, presumably assuming that

the two problems, state hospital care and family readjustment are separate and distinct problems and not to be considered in conjunction with each other. To such, it is apropos to indicate that worry over lack of employment or even failure to be placed in a suitable position, family and financial difficulties, and innumerable other conditions that arise in family or group life influence mental health, more especially in the cases of those prone to mental disease. The mere fact that a patient has been discharged from a state hospital in an improved or much improved, or even recovered condition, all of these being relative terms only, does not assure him that when he returns to his family and reenters industry he will progress as any normal individual might reasonably expect to after a short or prolonged vacation, or even after residence in a general hospital. The safer assumption is that he will need guidance and advice, and probably financial or other assistance for some time after leaving the institution.

A matter too frequently ignored in considering the needs of mental cases is the important part that suitable forms of recreation can be made to play in facilitating the improvement and recovery of those who are or have been mentally ill. It is because of this that one of the main divisions of the questionnaire deals with the recreation of the discharged and paroled patients. Included under this heading are kinds of recreation sought; result of participation in recreational activities, such as the improvement in sociability, etc.; and also, recreational needs unfulfilled, either because the patient does not himself understand the value of proper recreation in the upbuilding and maintenance of health, or because of the lack of recreational facilities in the neighborhood in which the patient lives.

IX. SURVEY OF PAROLED AND DISCHARGED PATIENTS

The investigation of a comparatively large number of patients paroled and discharged from state hospitals involves difficulties not usually met with in surveys concerned with other groups of persons. There are several reasons for this. Patients are at times brought to psychopathic wards of general hospitals from places other than their homes, and, due to their mental condition, their names and more often their correct addresses cannot be obtained. During their stay in a state hospital from which they are subsequently paroled or discharged, it frequently happens that no correct address is ascertained, even though the social workers of the state hospitals aim to get in touch with the friends or relatives of all patients prior to their departure from the institutions. Many patients have no family or other ties in the city and they are consequently lost track of once they are discharged from the hospitals, unless they return to the clinics or to the hospitals following another attack.

It was found furthermore, that a number of families moved away shortly after a member of the family was committed to a state hospital for the insane, and all attempts to locate them were, as a rule, unsuccessful. Partly responsible for this was the circumstance that in making this survey the paroled and discharged cases were not followed up for a year or more after they left the different hospitals. As previously outlined, this lapse of time was permitted in order that after-care workers of the state hospitals might do what they could for the patients, and that they themselves might have time for readjustment before a valuation of the effectiveness of these methods was undertaken. During this time many patients, probably not wishing to return to the neighborhood in which they had been known as queer or crazy,” removed without leaving a forwarding address or telling their neighbors their new place of residence. Other

patients left the city or state and facts relative to their condition could not be obtained, All in all, approximately thirty per cent of the paroled and discharged patients were lost track of for the reasons given above, and the observations that follow are based upon the remaining seventy per cent, a sufficiently large number to provide an adequate and satisfactory picture.

X. MENTAL CONDITION

Table 24 shows that of the 784 patients committed to the Manhattan and Central Islip State Hospitals, 285 were discharged within a year after admission as recovered. improved or unimproved. As already indicated, approximately 30 per cent or 85 of the discharged patients could not be located when the attempt was made to follow them up. Of the remaining 200 patients, 20 per cent were found to have fully recovered, practically all of them having originally been diagnosed as cases of manic depressive insanity; 28 per cent showed much improvement, these also largely representing cases of manic depressive insanity; 19 per cent, composed mainly of cases of dementia praecox, showed some slight improvement; 8 per cent showed no improvement whatsoever; 20 per cent returned to the state hospitals within the year; and 5 per cent died within a year after discharge.

From these facts it would seem that about 50 per cent of the paroled and discharged patients were able to return to their former environment and occupations, with the chances in their favor of a future normal life. A question might well be asked at this point as to how many patients of the other 50 per cent might have improved sufficiently to have made it unnecessary for them either to return to the state hospitals for further care, or to remain at home in partial or total idleness, had there been an adequate follow-up system to help them and other patients with advice and