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Practically all of the State hospitals now have a clinical director, who could and should be held responsible for the type of patients admitted, suitability, parole possibilities, etc. I believe it is still desirable to see all voluntary, physician's certificate and criminal order admissions and for all wards to be visited and any patient desiring it to be given a special interview. The rest of the time I would prefer to spend in making actual inspection of the hospital, discussions with the superintendent and staff, surveys of medical and psychiatric work, equipment, laboratory work, staff meetings, investigation of reported injuries and escapes, investigation of complaints, etc.

One of the prime objects of inspections is to improve the care given patients, and to make the inspections in the way I have outlined would, I believe, serve this purpose, at the same time make the reports of more value to the Commission and the superintendents and place the inspectors in a better position to point out in constructive comparisons the advantages and good features of one hospital to another, also render the inspector's opinion of greater value in the making of service record ratings and in serving on the Examination Committee.

As done now we see the hospital in an artificial setting. The patients are kept in from work or from occupational therapy classes. The routine of the ward physicians and of ward activities is quite different from the usual. It is comparable to the inspection of a factory with all work suspended and the employees standing at attention. This is entirely due to the statutory provision that we see all new admissions and the tendency to collect these in one place on a service to save time, a measure more or less necessary. to complete the work on schedule.

I, therefore, recommend that Section 4, Article 2, of the Insanity Law, as printed on page 54 of the Handbook, be changed by the elimination of the phrase "Especially those admitted thereto since his preceding visit" and that General Order No. 23, entitled "Duties of the Medical Inspector and Deputy Medical Inspector in relation to State Hospitals" be modified by the following changes in Subdivisions A, C and F. (A) now reads:

"He shall see all patients admitted and remaining since the last medical inspection and preserve a list of their names and in the case of voluntary patients determine whether or not they are suitable cases for voluntary admission and shall see any patients desiring an interview. In

his tour of the ward he shall go among the old patients
with a view of aiding in the discharge of aliens, dotards,
hemiplegics, idiots and other cases unsuitable for detention
in the hospital.

I would reword it somewhat as follows:

He shall see all voluntary, physician's certificate and criminal order patients admitted and remaining since the last medical inspection, preserve a list of their names and determine whether or not they are suitable for the various types of admission specified. He shall also see any patients desiring an interview, and in his tour of the wards go among the old patients with a view of aiding in the discharge or parole of any considered unsuitable or no longer in need of detention in a State hospital.

Subdivision (C) now reads:

"He shall visit all parts of the premises, all wards, rooms, dormitories, closets, attics, basements, kitchens, dining rooms, stables and outhouses at least once a year and shall note the efficiency of provisions for fire prevention and the adequacy of the fire escapes."

I would introduce a direction regarding the making of rounds with physicians and it would then read something like this:

He shall make rounds with the physicians in charge of the various divisions of the hospital, visiting all wards, rooms, dormitories, closets, attics, basements, kitchens and dining rooms, and at least once a year the shops and the various out-buildings. He shall note the efficiency of provisions for fire prevention and the adequacy of fire escapes. Subdivision (F) which now reads:

"He shall from time to time note the efficiency of the medical work of the hospital." I would change by omitting the words "from time to time" and introducing psychia,tric, so that this subdivision would direct that he shall note the efficiency of the medical and psychiatric work of the hospital.

General Order No. 27, relating to the duties in private licensed institutions, I would leave unchanged except to add physician's certificate after voluntary in Subdivision (C), that is, this subdivision would read:

He shall see all patients admitted and remaining since the last medical inspection and preserve a list of their

names, and in the case of voluntary and physician's cer-
tificate patients determine whether or not they are suitable
for such admission and shall see any patient desiring an

I think there can be no question but that it is desirable to continue to see all new admissions to private institutions and in the smaller ones perhaps to see all patients both old and new.




Dr. Kline regrets that he is unable to attend this conference and he has asked me to tell you something about the subject which he was to have presented and in which he is very much interested.

It would be well to state that in Massachusetts we do not use the word "parole," but prefer to use the term "trial visit." "Parole" is suggestive of penal methods, to our minds, and implies liberty and freedom as long as the individual does not violate the terms of his parole. We prefer to convey to the patient's mind that, although he may not have fully recovered from a mental illness, nevertheless his condition is such that, under supervision, home care in his case is proper and advisable and that, should he require further hospital care and treatment, the hospital is ready to offer its facilities again without formality or delay.

The parole system in Massachusetts has somewhat the same history as the parole system in New York. It has been developed more or less in the same way. In 1883 a law was passed permitting patients, unrecovered but suitable to be taken out of the hospital and cared for in their homes, to leave the hospital on a trial visit for a period of 60 days. At the end of this time the patient was automatically discharged from visit, provided it had not become necessary to return the patient to the hospital before that time. This period, however, was too short and many patients had to be recommitted soon after the expiration of the visit, with the resulting inconvenience and delay to the families in recommitting the patients who might have benefited by prompt return to the hospitals, and it also involved an additional expense to the county for the commitments. In 1905 the period of trial visit was extended to six months. For the same reasons in 1917 the length of the visit was again extended, and since that time patients have been permitted to leave the hospital for a period of one year. This period of trial visit is long enough so that the patient can demonstrate his fitness to get along in the community, even though he may not have fully recovered, and also, if necessity demands it, he may, because his condition, be returned to the hospital without formality should he desire to return, or should the hospital authorities advise it.

* Address at Quarterly Conference at Brooklyn State Hospital, December 16, 1926.

A considerable sum of money is saved by obviating the necessity of recommitment, and the easy access to the hospital of patients who need to return has a wholesome effect on the patient and family, who might hesitate to seek re-admission to the hospital with the formality of a commitment facing them. This open-door policy is advantageous both to the hospital and to the patient. It relieves, to some extent, the crowded hospitals. Suitable patients are returned to their homes early and a return to the hospital, if necessary, is far less formidable.

In 1910 there were 539 patients out on visit from the state hospitals of this state. In 1916 there were 1,065 on visit. In 1918, the year following the extension of trial visit from six months to one year, there were 1,100 patients on trial visit and in 1926 there were 1,675 out on visit.

Massachusetts has a very liberal policy in allowing patients to return to their homes or to leave the hospital, and the superintendents of the hospitals are urged to dismiss patients to families or friends at the earliest possible time, so that if a relative makes application within a few months, or earlier, and can show that the patient will be properly cared for, and if the superintendent knows that the patient's condition is such that he can safely go into the community, being neither suicidal or homicidal, he is permitted to go home on trial visit. Section 90, Chapter 123, of our laws, provides that any patient who has been dangerous, or is likely to become so, shall not be discharged even on a trial visit unless the discharge is approved by the Department of Mental Diseases, so that no patient who is known to be dangerous is dismissed without sufficient safeguard.

Massachusetts, of course, is a smaller state than New York. Our hospitals are nearer together and serve a smaller community than the hospitals in New York State, so that it is easier to send patients out than it would be in New York, and for that reason we are able to exercise a little more supervision. When a patient leaves a hospital he is expected to report at the institution, or at one of the outpatient clinics, at certain stated periods during the time of his trial visit. In a small community this can readily be done without great inconvenience or expense to the patient. We have a large percentage of patients out on trial visit. There are about 22,000 patients in our hospitals. About 17,000 of these are in mental hospitals,

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