Other important developments affecting the parole system had taken place. The most important of these was the establishment of a system of after-care of patients. This consisted of three principal factors, namely, voluntary after-care committees, after-care agents, later termed social workers, and dispensaries, later designated mental clinics. The organization of the first after-care committee in New York City in 1906 was due to the vision, wisdom, and initiative of the late lamented Louisa Lee Schuyler. This committee, which was connected with the State Charities Aid Association, employed Miss E. H. Horton as its after-care agent. On April 13, 1906, she began her duties as a social aid to the paroled and discharged patients of Manhattan and Central Islip State Hospitals. This innovation had the hearty support of both Dr. Smith and Dr. Mabon.

About the same time a similar social service for out-patients was being developed at the Rochester State Hospital by its alert and progressive superintendent, Dr. Howard. He assigned a hospital nurse to supervise paroled patients and to assist them in adjusting to community life.

On October 1, 1911, Miss Horton was directly employed by the State to continue the after-care work, the value of which she had demonstrated for five years.

At the Quarterly Conference held in Albany, February 21, 1913, paroles and after-care were discussed in papers by Drs. Howard and Mabon, and at the September Conference of the same year the matter was further discussed by Mr. Homer Folks. At the 1913 session of the Legislature a bill was passed providing for the establishment of dispensaries by the superintendents of the State hospitals. This became Chapter 626 of the Laws of 1913.

At the end of the fiscal year of 1906 when after-care began, there were 196 patients on parole from the civil State hospitals. These constituted 0.7 per cent of the total patient population. A steady, although not rapid, increase followed year by year. In 1910, the number on parole reached 589 and in 1912, 813. Then came the year 1913 when the Commission, the superintendents, the Quarterly Conference and the State Charities Aid Association, all got intensely interested in the matter of paroles. The papers of Howard, Mabon and Folks were published, a few more social workers were employd and a start was made in the organization of out-patient clinics. At the end of that year the number of patients on parole reached 1,300. This great gain was the direct result of the special interest that had been aroused.

The feasibility of maintaining large out-patient departments having been demonstrated, progress became relatively easy. In 1920, the daily average number of patients on parole reached 2,322, and in 1925, 3,362. In 1926 the number dropped to 3,231.

With the increase in the number of paroles has gone an increase in mental clinics and social workers. This branch of the service suffered severely during the war, but now is operating on a larger basis than ever before. At the end of the last fiscal year there were 36 social workers employed and 51 mental clinics in operation.

In several State hospitals one physician, usually a senior assistant, is specially assigned to conduct the out-patient work. With the aid of the physicians on the several services and with the advice and direction of the superintendent and the clinical director the out-patient physician selects the patients to go on parole, and directs the work of the social workers in the placement and supervision of paroles. The concentration of responsibility involved in this arrangement insures greater uniformity and regularity in paroling patients and better supervision of those on parole.

It is evident that our State hospitals are better equipped than ever before to supervise paroled patients; but since 1923 the number of patients on parole has not been increasing. In fact, on November 1, 1926, we had fewer patients on parole than on June 30, 1923. The percentage of daily average patients on parole dropped from 8.1 in 1923 to 7.3 in 1926. Comparison of the percentages of daily average patients on parole from the several hospitals in 1923 and 1926, shows that the percentages in 1926 were higher in 8 hospitals and lower in 5. Utica State Hospital was in the lead in 1926 with a percentage of 13.9 on parole and Rochester was second with a percentage of 12.3. Other hospitals having percentages above the average were Brooklyn, 11.3; Buffalo, 11.1; Gowanda, 9.6; Manhattan, 8.0; and Kings Park, 7.4. The percentages of the other hospitals were: Hudson River, 6.7; Willard, 6.2; Middletown, 5.8; Central Islip, 5.3; Binghamton, 5.2; St. Lawrence, 2.8; Marcy, 0.8; Harlem Valley, 0.7; and Creedmoor, 0.0. Had the Utica average been reached by all of the State hospitals in 1926 the daily average number of patients on parole would have been 6,129 instead of 3,231.

In view of the serious overcrowding which reached 28.3 per cent on November 1, 1926, we naturally ask: Can the situation be relieved by paroling some of the patients now in the hospital? Judging from our previous experience and from the present status of paroles in some of our hospitals, it seems probable that a con

siderable increase in the total number of paroles might safely be made.

To accomplish this important end united effort on the part of hospital officers and employees is essential. Responsibility for the out-patient work should undoubtedly rest principally on one physician but he should have the hearty support of all the other members of the medical staff and of the social workers, supervisors, nurses and occupational therapists. In addition frequent intensive surveys of the patient population might be made to make sure that no one eligible for parole had been overlooked. The general aim should be to parole patients before they become institutionalized and lose interest in life outside the hospital. In most cases it is not necessary to hold the patient in the hospital until he completely recovers. It is well known that with proper environment and supervision many patients will continue to improve after leaving the hospital.

As our studies show that the first three months of hospital life are of most importance in determining the future status of patients, it is suggested that treatment during that period be made as specific and intensive as possible. This would require immediate examination and study of the case and prompt institution of treatment. It is possible that the day of parole might thus be advanced in many

cases.

For many patients the transition from hospital to community seems to be too great a step. An intermediate station to make the transition more gradual has often been suggested. Such station might be a farm colony like the Lake Farm of the Rochester State Hospital or a sheltered workshop colony like that established at Papworth, England, for arrested tuberculous cases. The patient would be employed at suitable productive work and might be wholly or partly self-supporting. As soon as he acquired an independent status he would be paroled. To be successful such colonies for mental patients should be very simple and living conditions therein should be similar to those found in ordinary homes.

Colonies of various types have proved of great value in making the feebleminded self-supporting and in restoring them to community life. I see no good reason why they could not be used to equally good advantage in the rehabilitation of convalescent mental patients.

Another great aid in strengthening our parole system will be the permanent mental clinics that I hope will soon be established in the principal cities of the State. Such clinics could take over the super

vision of paroled patients in their respective cities and give them much better attention than our periodic clinics are now able to give. In closing I wish to refer to the irrational outcry against the paroling of patients which followed the homicides of young Noel about two years ago. So far as we are able to determine, paroled patients on the average commit fewer crimes than a like number of so-called sane people of like age-distribution. In many communities the annual number of arrests equals five per cent of the population. Dr. Ashley in his intensive study of the history of 1,000 paroled and discharged patients covering several years found that 12 had been arrested, an annual rate of only a fraction of one per cent.

To refuse parole to a recovered or much improved patient because a few paroled patients commit offenses is unreasonable and an injustice to the patient. The paroling of patients under suitable supervision is the most humane and effective method yet devised of readjusting them to community life and instead of being decried should be encouraged and further developed.

Mental hospitals are curative rather than custodial institutions. They exist to restore disordered minds. All treatment is given for this purpose. To deny or obstruct the parole of the patient, which is the culmination of treatment, is to strike a death blow to curative work.

* STATE HOSPITAL QUARTERLY for November, 1922, page 65.

NOTES ON THE CLASSIFICATION OF DEFECTIVE

DELINQUENTS*

BY V. C. BRANHAM, M. D.

The following data has been secured from the study of 135 cases at the New York State Institution for Defective Delinquents made in the early part of 1924. The study is the first psychiatric report to be submitted by the institution. This article represents only in part the data obtained at that time.

The family history of these inmates seems to indicate that the percentage of foreign-born parents is double that to be found in the State as a whole, due possibly to inferior heredity from foreign stock or a certain relationship between the foreign-born parent and the child who is trying to Americanize himself. Nearly half of the parents of these inmates show marked intellectual inferiority, or chronic physical defects. The economic failure of the parents was just as decisively indicated as the social inadequacy. There were relatively nine times as many feebleminded among the brothers and sisters as among the community at large and nearly half of the total number studied had not succeeded in progressing beyond the sixth grade in school.

Among the inmates themselves, the percentage of foreign-born was found to be no higher than the average for the State, and New York City contributed slightly less than its quota to Napanoch. The rural districts, however, had nearly twice their share as might be expected when one recalls the tendency of the feebleminded individual to gravitate to the areas where the economic pressure is least. Furthermore, the mountainous districts of the State have been seeded by nests of low-grade stock which frequently has had its original source in the criminal classes of other countries. The proportion of negro population in Napanoch seemed to be about the average for the State, although in the prisons it was decidedly higher.

The first born and the last born child (18 per cent in each instance in this series) are found to occupy positions of strategic importance to gain privileges. There is a tendency for the parents to favor both types and often such children cannot readjust well after they leave the protection of the home. The most frequent position the inmate occupies in the family was found to be second in a family of three or four children, or third in a family of five. The significant

* An abridgment of an article printed in the Journal of Oriminal Law and Oriminology, Volume 27, Number 22, August, 1926.