personal service. It is of course impossible to answer the question definitely at this time, though we know enough of the value and possibilities of social service in the field of mental hygiene to feel convinced that the state would have saved much eventually had mental hygiene work been estab lished on a broad and comprehensive scale.

Many of the paroled patients who report to the state hospital clinics seemingly do so out of fear that they will be returned to the hospitals unless they come to advise with the doctors regarding their condition during the six months for which they are paroled. In the end it is probably a good thing that they feel a compulsion to seek advice, particularly since most of the paroled patients are kindly disposed towards the doctors and nurses, realizing as they do that a genuine service has been rendered them and their families during a period of severe illness. Should the Jewish patients find themselves in need of further medical advice and treatment after their parole period has expired, they do not often go to the state hospital clinics, where their language is not sufficiently understood and their peculiar psychology is not grasped. They go rather to their family or lodge doctors who are not competent to advise them; or, in some instances, to well-known and thoroughly reliable psychiatrists; or to the mental hygiene clinics maintained by the Free Synagogue, where psychiatrists of established reputations and nurses and social workers trained in mental hygiene work are prepared to assist them socially, financially and otherwise.

In the questionnaire used, when asking the questions "Are needs for mental treatment being met," and "Any further provision for mental treatment needed," the idea was to learn wherein present facilities were inadequate and in need of being strengthened and augmented. The statements already made regarding the shortcomings of our

present provisions for the treatment of paroled and discharged patients were fully verified as a result of the study of these patients and their needs. Plans for the development of a constructive program to meet the situation will be presented in a following chapter.

XI. PHYSICAL CONDITION

There are few bodily diseases but what are accompanied by changes more or less severe in the mental condition of the persons affected. Consequently, a person affected mentally and at the same time suffering from some physical ailment, will stand a better chance of regaining his mental health, at least in certain types of cases, if the physical ailment is properly attended to without undue delay. These are fairly well-established facts and account for the questions asked of paroled and discharged patients regarding their physical condition.

It is almost needless to remark that in making the survey it was not feasible to give each paroled and discharged patient a physical examination. Dependence had to be placed in almost every case on what was learned regarding the physical condition of the patient while detained in the psychopathic wards of Bellevue Hospital, and on such other information as could be obtained from a reading of the case records in the state hospitals, the parole records in the clinics, and from the relatives and patients themselves after their discharge from the institutions. Despite all these sources of information, it was not possible to obtain much reliable data regarding the physical condition of the majority of the patients considered. It is easy to understand why this should be so. The psychopathic services of Bellevue and other hospitals are at present primarily concerned with deciding whether or not a given patient is insane and should be committed to a state hospital. The law allows only ten

days in which to determine this fact, and does not take into consideration the advisability of thorough physical examinations and treatment in a general hospital or one similarly equipped, of mental cases suffering from physical ailments.

The medical staffs of the state hospitals are trained in the diagnosis and treatment, such as it can be under present overcrowded conditions, of mental diseases; and, while they are quite competent to treat minor physical ailments, it does not need much explanation to make it obvious that they cannot in all fairness be expected to be specialists in all branches of medicine.

Specialists are occasionally consulted for a few of the patients, but this seems to be the exception rather than the rule. To cite just an instance: a former university teacher is a patient in one of the state hospitals in the metropolitan district. He has been diagnosed as a case of dementia praecox of two or more years standing, but despite that his mind is still quite alert. He is also a sufferer from a severe eye affection which seems to aggravate his mental condition. For many weeks he had asked that an eye specialist be called in to advise him as to whether or not he should wear shaded or other glasses, for which he was able and willing to pay. The physician on the ward explained that the patient would have to wait until a member of the board of managers of the hospital, who was at the same time an eye specialist, could find the time to visit him.

Experience in mental hygiene clinics covering a period of years has shown conclusively the need of thorough physical examinations and of the early treatment of the many minor and major illnesses from which a considerable number of persons suffer. The need for this kind of service is greater in mental cases; and, with adequate facilities, no person coming under the care of the state hospitals should be paroled before his physical ailments have been attended to.

At least, no patient should be discharged from parole until the clinic physicians and nurses have seen to it that he has been put in touch with a dispensary or hospital where his physical needs will be properly looked after.

XII. SOCIAL CONDITION

The responsibility of the community to care and provide for its sick members is well recognized by all, and acted upon according to the standards prevailing in different sections of the country. One of the aims of the survey was to learn what the community does through its various social agencies to maintain in health those who have been mentally ill and to prevent their relapse. In order to get at the facts in this matter, the following questions were asked of paroled and discharged patients: present occupation and earnings; regularity of employment since leaving the hospital; reasons, if any, for non-employment; assistance being rendered to patient by any agency, with name of agency and nature of service; assistance rendered to family of patient while latter was in the hospital; and social needs of the family and the patient not being met.

(a) Employment of Paroled Patients. In considering the question of employment, the patients must quite naturally be divided into males and females, particularly as far as the adults are concerned, for nearly all the married women resumed their former household tasks of caring for their homes and families. Some of the unmarried young women found it more advisable to remain at home and help in caring for it, than to return to the office or factory in which had formerly been employed. In such instances the change seemed to have quite a salutary effect and helped materially in the improvement of the patient, both physically and mentally. On the whole, the majority of the patients returned to the trades and occupations in which they had

been engaged prior to their commitment, for their absence from industry for a period of months made it necessary that they begin to earn money at the earliest possible time. This does not mean that they were all placed shortly after being paroled or discharged, for it must be remembered that many were formerly engaged in seasonal occupations, and if they left the hospital during the slack season it was difficult if not impossible for them to obtain work. On the other hand, if they happened to leave the institution during the busy season and at once returned to the shops and factories with the desire to make up the lost earnings, their health was often adversely affected.

Most of those who returned to their former occupations in industry were cases of manic depressive insanity, and they frequently found it impossible to continue regularly at their trades because they had not fully recovered and could not stand the strain. Others could not work at all as they had been ill since their discharge from the hospital, remaining at home and subsisting on the bounty of friends and relatives. This was true of practically all cases of dementia praecox, most of them working occasionally only and for short periods of time. There were some among these cases who became so discouraged because of their inability to retain a position that they finally gave up trying to find work and remained at home altogether, in some instances developing anti-social habits of conduct. A few of the recovered and much improved cases of manic depressive insanity established themselves in small retail businesses, and seemingly prospered both mentally and financially.

Concerning the earnings of discharged patients, from what has already been said regarding the non-regularity of employment, it is seen that there must have been, as there was, a decrease in the earning power. This entailed in a number of instances a severe financial loss to the families