MENTAL AND NERVOUS DEFECTS
Some of the most important and serious problems which confront humanity
to-day lie in the realm of mental and neural maladjustments. For human
progress and social welfare are in last analysis based fundamentally on
the results of normal reactions of human nervous systems. Any serious
derangement of the latter may, and in certain cases must, lead to more or
less disaster for the individual and disorder for society of which he is a
unit. So appalling has the number of neuropathic subjects become in modern
times that the matter may well cause even the most thoughtless citizen to
pause and consider.
=Prevalence of Insanity.--=As to the prevalence of insanity, one learns
from recent charts prepared by a member of the National Committee for
Mental Hygiene that in 1910 we had more insane (187,454) in our
institutions than there were students (184,712) in all our colleges and
universities in the United States, or officers and enlisted men (142,695)
in our combined United States army, navy and marine corps; further, the
yearly cost ($32,804,450) of caring for these insane is greater than the
annual cost of construction ($32,520,100) on such a stupendous undertaking
as the Panama Canal. In New York over twenty per cent. of the revenues of
the state go to support the insane. Doctor Lewellys F. Barker, President
of the National Committee for Mental Hygiene, says: "It is calculated that
some 250,000 people in the United States are insane. One of every five men
discharged from the United States army for disability is discharged
because of insanity, 60 per cent. of the cases being _dementia precox_."
Even in individual states with exceptionally large university populations
we still find these outnumbered by those of the insane. Thus in Wisconsin
by 1914 the state university had attained a population of about 4,700
students resident at the university during the regular school year, and of
approximately 6,000 attending during some part of the year, but the number
of insane under restraint in public institutions in the state June 20,
1912, was 6,851, with an additional 1,284 on parole. This does not include
the insane in various private sanatoria, and moreover a considerable
greater number of patients had been treated in these public institutions
than were resident there June twentieth.
To make such comparisons complete one should, of course, know the average
length of residence of students in college, and of insane patients in
institutions. No accurate data on this point are at hand. The average
period of residence in hospitals for the acutely insane is doubtless
considerably shorter than the average period of attendance of students in
college, while on the other hand the average period of residence of
inmates in asylums for chronic insane is probably considerably longer. For
example, the Wisconsin State Hospital for the Insane reports a total of
1,224 patients under treatment, but an average population at any one time
of only 622 during the year 1911, and the Northern Hospital for the
Insane, a total of 1,194, with a daily average of 613 during the same
period. The combined thirty-four county asylums in Wisconsin, for chronic
insane, had a total population of 5,384 during the year 1911, with a loss
of 517, or approximately 10 per cent. During 1912 the figures for these
same institutions run 5,758 and 742 respectively, or a loss of over 12.5
per cent. The conditions in other states are probably much the same.
In other representative states we find the number of insane in public
institutions as follows: California, 7,909; Michigan, 7,703; Minnesota,
5,329; Pennsylvania, 16,992. Epileptics are estimated by alienists to be
about equal in number to the insane, feeble-minded to be more numerous.
The estimate that in the United States there are 300,000 feeble-minded is
probably a minimal figure.
=Imperfect Adjustments of the Brain Mechanism Often Inheritable.--=The
outside layer or "cortex" of the brain is the region in which the more
complicated adjustments occur, especially such as pertain to human
behavior, and inasmuch as this portion of the brain is extremely complex
and delicate in its mechanism, it is peculiarly liable to derangements
which, even when slight, may have far-reaching effects.
This brain-mechanism is as much a product of ancestry as is any other
structure of the body, and it is obvious therefore that imperfect
adjustments of its structure must be as subject to the laws of
inheritance as are other malformations of the body. And just as with
other defects, mental disorders may thus flow from pre-existing ancestral
maladjustment of the nervous system or from immediate causes thrust upon
it, such as syphilis, alcoholism, degeneration of the blood vessels and
traumata. Or, in other words, the mechanism of mentality may be faulty
from the beginning, or it may be made faulty by bad environmental
conditions.
The records of the inheritance of insanity, imbecility, feeble-mindedness
and other forms of nervous and mental defects are truly startling. Active
researches in this field have been in progress now for several years, and
as each new set of investigations comes in the tale is always the same. It
is questionable if there is a single genuine case on record where a normal
child has been born from a union of two imbeciles. Yet the universal
tendency is for defective to mate with defective. Davenport gives a list
of examples, beginning with such a one as this: "A feeble-minded man of
thirty-eight has a delicate wife who in twenty years has borne him
nineteen defective children." Little wonder, in the light of such facts as
these, that the number of degenerates is rapidly increasing in what are
called civilized countries.
=Many Mental Defectives Married.--=But, it may be urged, these are
exceptional cases, there is surely no considerable number of mental
defectives who are married. Let us look at the available facts. In Great
Britain in 1901, of 60,000 known feeble-minded, imbeciles and idiots,
19,000 were married, and in the same year, of 117,000 lunatics, 47,000
were married; that is, a sum-total of 66,000 mentally defective
individuals were legally multiplying, or had had the opportunity to
multiply their kind, to say nothing of the unmarried who were known to
have produced children.
In the state of Wisconsin I note from the tenth biennial report of the
Board of Control that of 574 patients admitted to the Northern Hospital
for the Insane during the year from July 1, 1908, to June 30, 1909, 274
were married and 29 others were known to have been married; this is a
total of 303 out of 574, considerably over half. At the Wisconsin State
Hospital for the Insane we find the conditions are no better, for out of
499 admitted in the year 1909-10, 208 were married and 65 others had at
some time been married, or a total of 273 out of 499. There is every
reason to believe that conditions are approximately similar in other
states.
=Disproportionate Increase in the Number of Mental Defectives.--=Writing
of conditions in England the Commissioners in Lunacy state in their
fifty-fourth report that now (1901) there is one officially known lunatic
to 301.32 individuals of population, whereas in 1859 there was only one to
536 individuals of population. In Great Britain, taking into account
mental defectives of all kinds, the 1901 census showed a total of 485,507,
or 1:85 of total population. Rentoul estimates that 1:50 would be nearer
the truth because of the fact that the number of officially known mental
defectives is much less than the actual number. The conditions in Ireland
are even more impressive, for in 1851 there was one known lunatic to 657
individuals of population; in 1871, one to 328, and in 1901 one to 178.
When all allowance is made in these statistics for the greater accuracy of
recent enumeration, and for other modifying influences, such as migration,
we are still forced to believe that an alarming increase in insanity is in
progress and that society is woefully derelict in permitting the marriage
of such unfortunates.
A census of the insane under public care in Wisconsin June 30, 1910, not
counting the paroled, shows 6,537, or one to each 357 of population, since
the population of the state was then 2,333,860. If, however, we should add
the number of insane in private sanatoria and the number unconfined the
proportion of normal individuals would be very much reduced.
In the United States as a whole, while I know of no data giving the number
of married insane, it is estimated that at least one-fourth of the insane
are not in asylums or hospitals. In all states the number of insane in
state institutions (there are no available records of most private
institutions) is rapidly increasing. According to the special census of
1903 covering a period of fourteen years, during which the general
population increased thirty per cent., the number of insane in
institutions increased one hundred per cent. This is due doubtless in part
to the fact that because of better facilities for keeping them a
proportionately greater number of insane are being sent to state hospitals
than in former years. Moreover, improved sanitation has cut down the
death-rate in asylums. The increase is in such vastly greater proportion
than the increase in general population, however, that it seems impossible
to attribute it wholly to the greater accuracy of recent enumerations and
the increasing custom of confining the insane in asylums. This is a matter
that demands our gravest attention and one that should be investigated
with the greatest thoroughness. One of the most disquieting facts in the
situation in most states is that many patients--an average of
approximately one thousand a year, in Wisconsin for example--are on parole
subject to recall. This means that although it is recognized that these
patients are likely to have to be returned to the asylum or hospital,
little or no restraint in the meantime is placed on their marital
relations.[8]
=Protests Voiced by Alienists.--=Is it any wonder under the circumstances
that we find Doctor Charles Gorst, superintendent at the Mendota Hospital,
voicing in his 1910 report the following vigorous protest--and certainly
such men as he are in the best position to know. He says: "No one doubts
for a moment that defective mental conditions are transmitted from parent
to child as surely as the physical defects and deformities. Every one
knows that it is common for defectives to be attracted to each other and
marry, and that the defects of both parents are liable to be transmitted
to the children. It is also true that there are more children born in such
families; and for that reason the percentage of defectives is continually
on the increase. The report of the state of Illinois shows the increase to
be alarming, and many other states are no better. It is absolutely wicked
that the persons suffering from periodical insanity should be allowed to
return to their homes to propagate and scatter their children about the
state as dependents."
=Examples of Hereditary Feeble-Mindedness.--=No one can look at the
remarkable series of charts and records brought together by Doctor Goddard
of the institution at Vineland, New Jersey, and by other directors of
similar institutions, and doubt for an instant the inheritability of
feeble-mindedness and allied defects. In some instances the family history
has been followed back as far as five generations, and it is always the
same dire sequence of insanity, idiocy, epilepsy or feeble-mindedness,
from generation to generation. For example, Fig. 33, p. 236, is one of
Doctor Goddard's charts. It shows thirteen descendants of a supposedly
normal father (possibly a carrier) and a feeble-minded mother, of whom
seven were feeble-minded, the others dying in infancy. The mother herself
was one of seven feeble-minded children, who were in turn the descendants
of feeble-minded parents, of whom the woman had five feeble-minded
brothers and sisters. In Fig. 34, p. 237, he shows mental defects running
through four generations. Fig. 35, p. 238, is a remarkable exhibit which,
starting in the fifth generation back with a feeble-minded, alcoholic
man--the mental condition of his wife being unknown--shows that in every
generation down to and including the present there has been nothing but
feeble-minded (or worse) offspring, leaving out of account two unknown
and a number who died in infancy without revealing their mental condition.
This is true notwithstanding the fact that in the course of the various
generations there had been several matings with apparently normal
individuals. The new blood, however, instead of redeeming the tainted
stock, itself became vitiated. The numerous specific cases of inheritance
of family traits reviewed in recent books or in special reports of trained
workers give us abundant confirmatory evidence of the inevitable
inheritance of various nervous and mental defects.
[Illustration: FIG. 33
Inheritance of feeble-mindedness (after Goddard): squares represent males,
circles females; F, feeble-minded; N, normal; E, epileptic; I, insane; C,
criminal; T, tuberculous; d. inf., died in infancy; the hand shows the
individual from whom the record was traced back; small black circle
indicates miscarriage.]
=Difficult to Secure Accurate Data.--=It is obvious, of course, that in
tabulations such as these there may lurk considerable margins of error.
Notwithstanding our Binet-Simon and other tests for feeble-mindedness, for
example, there is yet much to be desired in the way of accuracy. Many
cases just bordering normality are by no means easy to decide. Then again
in most human records, when one gets back beyond the third or, at most,
the fourth generation, the investigator has to depend on the hearsay
evidence of relatives, friends or neighbors, and how vague this generally
is can only be appreciated by those who have themselves tried to collect
such data. But in spite of all the difficulties, there is little doubt
that the more carefully prepared records are sufficiently accurate to
establish the fact beyond dispute that defective tends in large measure to
breed defective.
[Illustration: FIG. 34
Inheritance of feeble-mindedness (after Goddard); symbols same as in Fig.
33, p. 236.]
One serious drawback in making a study of the inheritability of insanity
and other nervous disorders is that so far we have dealt mainly with mass
effects rather than specific neuroses. But even when the latter is
attempted we are confronted by the fact that there are various
intergradations of the recognized types of defect, that because of
varying degrees of defect in the same type a standard is hard to
establish, and above all that what appears as a specific mental malady in
one individual may crop out in his descendants in an entirely different
guise. Moreover, not only the predisposition of the individual, but age
and precipitative cause enter as factors in determining the ultimate
symptoms.
[Illustration: FIG. 35
Inheritance of feeble-mindedness (after Goddard); symbols same as in Fig.
33, p. 236.]
=Feeble-Mindedness and Insanity Not the Same.--=Authorities make a sharp
distinction between insanities on the one hand and feeble-mindedness on
the other. According to Goddard, not only is there no close relationship
between the two conditions, but in reality they stand at opposite ends of
the psychical scale. In general, insanity is a degenerative process,
whereas feeble-mindedness is an arrest of development. In the first case
the victim loses part of the mentality he once had, in the second he stops
short of normal development.
=Many Types of Insanity.--=The commonest manifestations of insanity are
undue depression, apathy, excitement, instability, obsessions,
hallucinations and delusions. Some mental disorders are associated with
recognizable structural changes in the nervous system, but the structural
basis of many is not known.
In general there is more doubt about the inheritability of some of the
insanities than about cases of mental deficiency. The term insanity is
merely a loose descriptive one, and we shall gain little definite
knowledge about the inheritance of such maladies until we study each
separate insane diathesis specifically. Psychiatrists recognize many
different forms of insanity, some of them very distinct from others and
the product of unrelated underlying causes. Often it is only a question of
degree or sometimes a matter of chance as to whether a given individual is
certified as insane or not. A neuropathic person who manifests certain
anti-social activities is sure to be classed as insane, whereas another
individual with the same diathesis in a less degree might pass
unrecognized. It is almost impossible in some instances to tell just where
the border-line between a neuropathic and a normal constitution lies. Many
of the idiosyncrasies of the insane, indeed, are merely exaggerations of
characteristics seen in normal people. Recent studies of the psychology of
the insane show that most of their hallucinations and delusions are
closely related to some previous mental experience they had before
becoming insane. And it has been found that the surest means toward
removing the obsessions of the patient in curable cases is to ferret out
these earlier experiences and correct the wrong impressions regarding
them. Again, certain forms of insanity do not become manifest except as
special reactions to particular environmental conditions, and if these
conditions do not happen to occur, then the neuropathic constitution
though existing would not be revealed. Certain critical periods of life
such as puberty, pregnancy and the close of sexual life are particularly
likely to test out the mentally unstable, although such individuals may
have maintained normal mental balance up to the crisis in question.
=Not All Insanities of the Same Eugenical Significance.--=Of the various
kinds of insanity some seem to be of much greater eugenical significance
than others, not only because they are strongly heritable, but also
because of the periodicity of the attacks. The patient may be repeatedly
in and out of the asylum and in his sane intervals wholly unrestrained as
far as propagating his kind is concerned. _Manic depressive_ psychoses and
_dementia precox_ in the order named represented the largest number of
admissions to the Wisconsin State Hospital for the Insane in 1911 and
1912, and both of these very frequently have a hereditary basis. Fig. 36,
a chart showing the insanity in a local family as worked out by one of my
pupils, is a good example of a recurrent type. The father (Fig. 36, p.
241) was about eighty-two years old when the record was made. His memory
was poor and he could not talk connectedly, although this was possibly
attributable to old age rather than to insanity. His brother, written to
in Ireland, stated that to his knowledge there had never been insanity in
his side of the family. The mother (2) was insane at nine, again at
twenty-nine and again at thirty-six. In her later life she has been in the
Mendota Hospital for the Insane five times and in the County Asylum twice.
The eldest daughter (3) has been in the State Asylum five times and is now
at home. The next daughter (4) spent five months in the asylum in 1885.
Another daughter (5) likewise spent a short period in the asylum. Two sons
(6, 7) have each spent two periods in the asylum, and a third son (8) has
had an attack of insanity. The youngest child died at the age of three.
Thus of the eight adult children six have been insane at some time. The
cases in this family seem all to be instances of manic-depressive
insanity.
[Illustration: FIG. 36
Inheritance of insanity in the L---- family. See text for description.]
=A Neuropathic Constitution May Express Itself Differently Under Different
Conditions.--=Some of the difficulties of getting genealogies of specific
forms of insanity are obvious from the following quotations chosen from
the works of eminent psychiatrists. Kraepelin, for instance, expresses the
opinion that: "The psychopathic charge of a family may reveal itself not
only by the appearance of mental disorders but also by other forms of
manifestation. Here belong before all, those diverse slighter deviations
from mental health which go to make up the borderland of insanity:
nervousness, states of anxiety and compulsion, constitutional depressions,
slight hysterical disorders and forms of feeble-mindedness, tics; also odd
characters, peculiarities in mode of living, criminal tendencies, lack of
self-control, intemperance, love of adventure, mendacity, suicide on an
inner basis."
From the volume of Church and Peterson on _Nervous and Mental Diseases_ a
further confirmatory opinion may be cited: "In determining the factor of
heredity we must not be content with ascertaining the existence of
psychoses in the ascendants, but must seek, by careful interrogation of
various members of the family, for some of the hereditary equivalents,
such as epilepsy, chorea, hysteria, neurasthenia, somnambulism, migraine,
organic diseases of the central nervous system, criminal tendencies,
eccentricities of character, drunkenness, etc., for these equivalents are
interchangeable from one generation to another, and are simply evidence of
instability of the nervous system. It is the unstable nervous organization
that is inherited, not a particular neurosis or psychosis, and it must be
our aim in the investigation of the progenitors to discover the evidence
of this."
=Certain Forms of Insanity, But Not All, Seem to Behave as Mendelian
Recessives.--=A number of psychiatrists and investigators of the
inheritance of insanities (Rudin, Lunborg, Davenport, Rosanoff, Jolly),
although working independently and in different countries, concur in the
opinion that manic-depressive insanity, dementia precox and allied
psychopathic conditions tend to occur after the manner of a Mendelian
recessive. On the other hand such maladies as Huntington's chorea are
transmitted as a dominant and in all probability at least half of the
children of an afflicted individual will inherit and manifest the defect.
As to inheritance of various other psychoses we have too few accurately
charted pedigrees for most types to make very positive statements about
their degree or manner of inheritance. Little can be said beyond the
statement that there is a decided tendency for various forms to recur in
offspring. Where more than one case of insanity occurs in a given family
or stock it is strong presumptive evidence that a hereditary defect is at
the bottom of it. As Doctor Wilmarth says, "Mental accident may occur in
any family, but it is rarely a second case occurs unless there is a
tendency to nerve degeneracy." For example, of 818 insane at the Wisconsin
State Hospital for the Insane during the biennium 1909-10, 187, or
practically one-fourth were positively known to have insane relatives. Of
these, 24 had insane fathers, 31 insane mothers, 30 insane brothers, 23
insane sisters, 25 insane uncles, 21 insane aunts, and 21 insane cousins.
Where definite information could be obtained it was found that of the
5,700 admissions of insane patients to the New York state hospitals
during the year ending September 30, 1911, 27.7 per cent. of the cases
showed a history of insanity in the family and an additional 22.9 per
cent. showed a history of alcoholism, nervous diseases and the like.
=Grades of Feeble-Mindedness.--=As to the various grades of
feeble-mindedness, while no sharp lines of demarcation can be drawn, a
rough and ready test usually applied is the relative ability of such
subnormal individuals to take care of themselves. In all, the conditions
exist from birth or shortly after. _Idiots_ are such defective individuals
as are unable to take care of themselves even to the matter of guarding
against common physical dangers. Their mentality does not progress beyond
that of a two-year-old child. _Imbeciles_ can take care of themselves in
the cruder physical ways, but are unable to earn their living. Their
mental age ranges from three to seven years inclusive. _Morons_, or the
"feeble-minded" in a more specific usage of the term, can under proper
direction become more or less self-supporting but they are as a rule
incapable of undertaking affairs which demand judgment or involve
unrestricted competition with normal individuals. Their intelligence
ranges with that of normal children from seven to twelve years of age. The
last class grades up insensibly into the shiftless, ne'er-do-well types
which exist in every community. It is the hordes of the feeble-minded in
the restricted sense that afford our most serious problems to-day. The
idiot and the imbecile are usually early and easily recognized and are
kept more or less under restraint, but the higher grades of feeble-minded,
the so-called moron type, can be detected often only by carefully devised
tests.
=About Two-Thirds of the Feeble-Minded Have Inherited Their
Condition.--=Concerning the various types of feeble-mindedness there is
strong evidence that heredity is a factor of greater magnitude than in
most insanities. All facts point to the conclusion that most mental
deficiency is strongly inheritable and that the majority of our defectives
of this type come from degenerate stocks. Practically all specialists at
the heads of asylums and homes for the mentally deficient concur in the
opinion that about two-thirds of the cases are hereditary. For example,
Doctor Alfred Wilmarth, superintendent of the Wisconsin Home for
Feeble-minded, says: "My own observations, and those of others in this
country and Europe, would indicate that at least two-thirds of the
feeble-minded have defective relatives."
In his study of two thousand children tested by the Binet measuring scale
for intelligence, Doctor Henry H. Goddard, director of the Department of
Research at the Training School for Feeble-minded at Vineland, N. J.,
remarks concerning heredity of feeble-mindedness: "But we now know that
sixty-five per cent. of these children have inherited the condition, and
that if they grow up and marry they will transmit the same condition to
their offspring. Indeed, we know that this class of people is increasing
at an enormous rate in every community and unless we do something to stop
this great stream of bad protoplasm we shall some day be swamped in a sea
of degeneracy."
E. R. Johnstone, superintendent of the training school at Vineland, N.
J., in a recent bulletin remarks concerning feeble-minded and epileptics,
"We are now convinced that from sixty to eighty per cent. of the cases are
hereditary."
Again, we find Doctor A. C. Rogers, superintendent of a school for
feeble-minded in Minnesota, saying, "We have no survey of mentality in
this country except in very small areas, but probably about sixty-five per
cent. of the feeble-minded children that we know of are feeble-minded from
heredity; that is, they come from families in which there is much
feeble-mindedness, usually associated with various neuroses or psychosis.
There are about thirty-five per cent. approximately that are acquired
cases. These cases develop from various things. Full development may be
prevented during gestation, or early childhood, or early adolescence, but
these acquired cases are entirely distinct from the hereditary ones."
In a recent paper Doctor Martin W. Barr, chief physician for the
Pennsylvania Training School for Feeble-minded Children, says: "In my
individual study of 4,050 cases of imbecility, I find 2,651, or 65.34 per
cent., caused by malign heredities; and of these 1,030, or 25.43 per
cent., are due to direct inheritance of idiocy; and 280, or 6.91 per
cent., to insanity." From these figures it will be seen that Doctors Barr,
Goddard, Wilmarth, Johnstone and Rogers all agree in their estimates;
namely, that two-thirds of our imbeciles are so through inheritance.
=Some Results of Non-Restraint of the Feeble-minded.--=The following
excerpt from a paper by Doctor Barr, is a fair sample of what happens
when such defective individuals are not restrained from propagating their
kind:
"My own study and observation alone, of over 4,000 degenerates, shows
such examples as: A man 38 years of age, the father of 19 defective
children, all living, he and his wife both under par mentally; as was
another couple, with 9 imbecile children; an idiot woman with 7 idiot
children. A forcible instance is that of a man with two daughters and
one illegitimate grandchild, all feeble-minded.... I could name a
family, one of the proudest in the land, where there are five
children, an aunt and two uncles, all feeble-minded.
"Yet another, which in seven generations numbering some 138
individuals, records 10 still-born children (premature births), 16
insane, 7 imbeciles, 3 epileptics and 32 with mental peculiarities so
pronounced as to occasion remark. Of the 138 there remain 80
apparently normal, who are nevertheless hopeless slaves of a neurotic
heredity, direct or collateral.
"In a study of 15 imbecile girls, 3 were recognized prostitutes, 9 had
each 1 illegitimate child (2 being the result of incestuous
intercourse with brothers); 1 had 2; 2 epileptics had, the one 3, and
the other 4 idiot children.
"Four feeble-minded women had 40 illegitimate children.
"A feeble-minded woman living in an almshouse since early childhood,
allowed to go out to service periodically, had given birth to six
illegitimate children, all inheriting her defect.
"An imbecile drunkard is the father of three feeble-minded children.
The daughter, seduced before the age of sixteen, gave birth to an
idiot child; one son is a harmless imbecile, but the other is a moral
imbecile, a sexual pervert, a thief on the streets, and a pyromaniac,
firing in sheer wantonness a large mill property.
"Another shows the entire family for three generations below normal.
Father, mother, mother's sister, and father's uncle, all imbecile.
Five children feeble-minded. One girl had a proposal of marriage, and
one boy is married to a feeble-minded girl.
"One insane woman, whose brother and sister committed suicide, had
five sons. The oldest, feeble-minded, a drunkard and hobo, had one
son, a criminal. The second son, insane, had three imbecile children.
The third, an insane epileptic, had three imbecile sons, one of whom
was an epileptic. The fourth son was insane. The fifth, apparently
normal, had a morally imbecile son and an epileptic daughter."
Yet striking as is the inheritance of these maladies, Doctor Barr points
out that of the 10,000 known cases of feeble-mindedness in Pennsylvania,
only 3,500 are sequestrated. This leaves a balance in that state of 6,500
totally irresponsible individuals to work havoc in society by producing
their kind.
=Inheritance Not a Factor in Some Cases of Mental Deficiency.--=On the
other hand as our data show, there remain about one-third of the mentally
deficient type to be accounted for on other than a basis of heredity. As
already noted, some of these are doubtless the product of suppressions of
normal development by various extraneous factors operating before or
shortly after birth. There is one class particularly, estimated by some
authorities as constituting as high as thirty per cent. of the
feeble-minded which is unusually puzzling. These are the so-called
mongolians. The name is given because the features of such individuals
bear more or less resemblance to those of some of the Mongolian races. The
defect does not seem to be hereditary although it is usually congenital.
It appears to be due to something which interferes with prenatal
development. Whatever the conditions, whether lack of nutrition in the
mother, alcoholic or other poisoning, the cases seem to be as hopelessly
incurable as are the hereditary forms. From the social standpoint, of
course, such individuals are in their immediate generation, as incompetent
or as dangerous to society as those suffering from the more surely known
hereditary forms of mental defect.
=Epileptics.--=Although epileptics are not classed as imbeciles
ordinarily, as a matter of fact no sharp distinction can be drawn between
the two classes. Doctor Wilmarth says, "Epilepsy and mental deficiency are
as closely related as branches on the same tree.... Over one-half and
perhaps two-thirds of all feeble-minded are subject to convulsive seizures
at some period of their lives, and we are never surprised at the
appearance of epilepsy in any feeble-minded person. On the other hand, so
small a percentage of epileptics maintain normal mental actions as hardly
to be worth consideration ... even those who retain a normal mind in the
early stages of the diseases almost infallibly become imperfect later."
How slight a chance the epileptic has of ever becoming normal may be
inferred from a statement made by Doctor Frank Billings in a paper read
before the Illinois State Medical Society in 1909 to the effect that "ten
per cent. or more can be cured by proper care."
According to the estimates of "The Committee of Fifty" in the state of
Illinois, who have been agitating for the establishment of a colony for
epileptics, there are 10,000 of these unfortunates in that state. The
consensus of opinion of experienced workers in various states is that
there is about one epileptic to each three hundred fifty to five hundred
inhabitants.
=In Heredity Conditions of Feeble-Mindedness Are Probably Recessive to
Normal Condition.--=As to the mode of inheritance of the various forms of
feeble-mindedness, the evidence points to such defects in the main as
being recessive. However, no particular grade can be picked out and shown
to be a pure recessive. For instance, the children of two epileptics will
be defective but it is impossible to predict always whether the defect
will appear as epilepsy or feeble-mindedness. This is doubtless due to the
fact that mental deficiencies even of the inheritable type are not all due
to the same specific cause, and in many cases the individual is defective
in more than one direction. If one or more of a great number of units
which are necessary for complete mental development are lacking, obviously
mental deficiency will result. In other words, feeble-mindedness and
allied disorders may not be definite characters, but simply evidences of
the fact that the nervous system has not developed all factors necessary
for normal mental coordination. Goddard, however, one of our best
authorities on the heredity of feeble-mindedness, is inclined to regard
the condition as a unit character, "due either to the presence of
something which acts as an inhibitor, or due to the absence of some
stimulus which sends the normal brain on to further development."
Supposing nervous defects finding expression in feeble-mindedness,
epilepsy and related conditions, to act as a Mendelian recessive, then the
marriage of one such defective with another should yield only mentally
enfeebled offspring. How nearly this expectation may be realized is seen
from the following examples.
In an extensive study[9] of feeble-mindedness, just from the press, Doctor
Henry H. Goddard points out that of 482 children with both parents
feeble-minded all but six were feeble-minded. Even the exceptions may be
apparent rather than real as there is possibility of mistake in judging
the condition of the parents or of the children themselves. Moreover, with
the feeble-minded one is not always sure of the paternity of a child, as
is instanced by Doctor Goddard in a case quoted from Doctor Emerick in
which of twelve children in a white family with both father and mother
feeble-minded ten were feeble-minded and two were not, but these two were
_mulatto_ children.
In a paper by Weeks (_The Inheritance of Epilepsy_), in part an extension
of an earlier joint paper by Davenport and Weeks, is recorded among others
a study of twenty-seven fraternities in which both parents were either
epileptic or feeble-minded. Of the 28 progeny, 19 lived long enough to
reveal their mental state. Of these 3 were feeble-minded, 8 epileptic and
8, from parents who developed epilepsy late in life, were what Doctor
Weeks terms "tainted." In 15 fraternities in which one parent was
epileptic and the other feeble-minded he found there had been 81
conceptions. Of these 7 were too young to classify and 19 had died before
fourteen years of age. Of the remaining 55, 28 were epileptic, 26
feeble-minded, and 1 insane. Again, in 9 families in which the parents
were both feeble-minded, of the 38 surviving offspring who were old enough
to classify, 7 were epileptic, 29 feeble-minded, and 2 drunkards. In 5
families where one parent was insane and the other epileptic or
feeble-minded, 5 children died before the age of fourteen, the condition
of 2 was unknown, 2 were epileptic, 4 feeble-minded, 1 insane, 8 tainted,
and 7 seemingly normal. Regarding the latter Doctor Weeks says they came
from two families where in one case the father's insanity seemed to be
traumatic and in the other alcoholic.
In a few cases where the defect in one parent has apparently been of a
type different from the defect of the other parent a "normal" child was
produced. That is, presumably each parent carried normality in the trait
defective in the other so that the child became simplex with reference to
each defect. Davenport points out that not infrequently two deaf-mutes
whose defects are due to different causes may have normal children.
In general, however, the reasonable expectation is that where two
feeble-minded individuals marry, a very common occurrence, the children
will all show mental deficiency. A mating between a feeble-minded person
and one of perfectly normal stock will apparently result in normal
children although they will be carriers. There is some evidence, however,
that such carriers may occasionally show "taints" of abnormality in the
form of migraine (nervous sick headache), alcoholism, queerness, violent
temper, etc. Thus according to the studies of Doctor Weeks, "In 50 matings
where at least one parent is migrainous, there were 350 conceptions, of
which number enough is known of 212 to classify 55, or 26 per cent., as
epileptic; 12, or 6 per cent., as feeble-minded, with the others tainted
or normal. In the 131 matings where at least one parent is alcoholic,
there were 845 conceptions. Of the 494 classified, 151, or 31 per cent.,
were epileptic; 54, or 11 per cent., feeble-minded, with the balance
tainted or normal." Marriage between two carriers will cause the defect to
reappear in active form in approximately 25 per cent. of the offspring and
50 per cent. will continue to be carriers.
=Many Apparently Normal People Really Carriers of Neuropathic
Defects.--=There is considerable evidence that many apparently normal
individuals of our average population are in reality carriers of some form
of neuropathic defect, some authorities placing the proportion
provisionally at over thirty per cent. This being true, then it is easy to
explain the apparently unaccountable appearance of epilepsy,
feeble-mindedness, or similar defects among the children of what pass for
normal stocks. The probabilities are that in many cases it means simply
that the parents of the defective children have been carriers.
As to the contention that in preventing the propagation of the
feeble-minded we may be depriving the world of geniuses, Doctor Goddard
remarks: "It is a significant fact that in our three hundred family
histories totaling 11,389 individuals not a single genius has been found.
Not only are there no geniuses but the fact can not be too strongly
emphasized that even the people who are considered normal ... are not as a
rule people of average intelligence...." However, between insanity and
genius he finds more kindred spirit.
=Tests for Mental Deficiency.--=As to tests for mental deficiency, the one
commonly meted out to victims in the every-day world is the
social-economic one of survival in the competitions of life. The mentally
deficient fail. Although often unrecognized as feeble-minded they drift
through life social and economical derelicts who have to be supported by
the community.
Of laboratory tests many have been devised. While all yet leave much to be
desired, still through their application the majority of mental defectives
can be detected. Fairly accurate standards of normality have been
established from which the relative degree of "backwardness" can be
determined. We have just awakened to the importance of detecting
defectives early in life, hence many of our tests have been planned with
reference to children. They are based not so much on training or conscious
learning as on fundamental processes which develop at certain ages in
children. Another impetus toward securing adequate criteria of mental
deficiency has been the crying need of having some easily applied standard
for detecting the very large numbers of defective immigrants who are
continually seeking to enter the United States.
Most of the methods consist of "performance" tests which are planned to
test the powers of perception, concentration, application, ingenuity and
education of the subject. Previous environment, education and the
difficulties under which the subject may be laboring at the time of the
test must, of course, be taken into account. It is particularly difficult
to get adequate tests for the immigrant which will enable one to
distinguish between ignorance, stupidity, fear and temporary psychic
depression on the one hand, and congenital mental deficiency on the other.
Perhaps the most successful single set of tests for mental deficiency is
that known as the Binet-Simon Scale. From an examination of large numbers
of French school children Binet constructed a scale of tests of increasing
complexity accurately graded to age and previous training of the average
normal child. In the Binet-Simon system tests are given for each age from
three years to thirteen. When a child successfully passes the tests for
his age he is classed as normal. If he succeeds only in tests which
normally are those given for a child a year younger then he is backward to
the extent of one year. Similarly he may show by these graded tests that
he is backward to the extent of two years, three years and so on. If a
child is more than three years backward according to the test he is
regarded as mentally defective. Various corrections and adjustments of the
original scale have been worked out to allow for unevenness in mental
development. On the whole the scheme works out satisfactorily when applied
by one skilled in its use. The attitude of the examiner, however, is of so
great importance that the tests are of less value in the hand of
inexperienced workers. A revision of the scale to adapt it better to
American children has recently been made by Doctor Goddard.[10] Besides
the Binet-Simon tests various performance tests, standardized for children
of different ages, such as Seguin's form board, Healy's pictorial
completion test, Fernald's construction puzzle, the Rossolimo test, De
Sanctis test, etc., are used by different investigators. Questions
designed to reveal moral tone are also employed. Doctor Howard A. Knox,
assistant surgeon United States Public Health Service, in a recent
article[11] gives an interesting account of the tests applied to determine
the exact mentality of immigrants entering the United States together with
a brief review of various tests. A full account and discussion of the
various tests for the mentally subnormal will be found in a recent
publication by Doctor William Healy,[12] director of the Juvenile
Psychopathic Institute, Chicago.
=The Backward Child in School.--=It is only in recent times that we have
come to realize the seriousness of the problem which the backward child
presents in our schools. It is of the utmost importance to discover early
in school life which of the backward children owe their condition to
adenoids, defective sight or hearing, poor nutrition, imperfect
circulation, or other remediable defects, and which are the victims of
innate mental deficiency. The treatment of the individual must be very
different in the two cases. In the one the condition can be cured by
proper manipulations or other treatments; in the other it can only be
ameliorated. All school children who are two or three years below grade
should be rigidly inspected by the medical examiner.
From a study of about two thousand children comprising the first five
grades of an entire public school system Goddard found that eighteen per
cent. were definitely "backward." Of these between two and three per cent.
were actually feeble-minded, the condition in the remaining fifteen per
cent. being presumably capable of correction. Other similar surveys have
given practically the same results.
=The Exceptionally Able Child Likely to Be Neglected.--=However, while we
must not forget that it is important to recognize backward children and to
see that they are segregated into small groups which are not required to
do the full amount of work in regular time, it is equally urgent to see
that the unusually bright individual is also given opportunity to advance
more rapidly than the rank and file. Only too often the holding back of a
child in school leads to lack of interest and habits of mental laziness,
and sometimes to truancy and incorrigibility. The general attempt in our
graded schools to keep all children close to the average is to be strongly
condemned.
=Cost of Caring for Our Mentally Disordered.--=Doctor Charles L. Dana,
member of the National Committee for Mental Hygiene, estimated in 1904
that the actual cost of caring for feeble-minded and insane in the
United States amounted to sixty million dollars, to which should be added
the corresponding loss in industrial activity on the part of the
afflicted,--at least twenty million dollars more, and he figures that the
amount was increasing at the rate of four per cent. per annum. Many
investigators concur in the opinion that our insane and feeble-minded
alone cost us far above one hundred million dollars. Adding to this
economic burden the cost of our delinquents and criminals the total
expense becomes stupendous. And when we consider still further the even
greater burden of suffering of the unfortunates themselves and the sorrows
of those to whom they are dear, a burden not measurable in money, the
feeling that something must be done to relieve the situation becomes
overpowering.
=Importance of Rigid Segregation of Feeble-Minded.--=As regards the really
feeble-minded little can be done beyond making them as happy as possible
and developing the limited gifts they have been given by nature. Their
teaching must be in the main concrete and simple. At the age of puberty it
is imperative to see that the sexes are separated and kept under
sufficient permanent supervision to prevent all possibility of
procreation. There is neither economic nor common sense in even allowing
the remotest chance of such occurrences as the following: "This is the
case of a feeble-minded and epileptic woman who had six children by
various persons while an inmate of a county poor house. One child at the
age of eighteen died in the almshouse, two died in infancy, one was
epileptic (the son of a man with a criminal record) and two who are now
living in the almshouse are feeble-minded, one being the son of a negro."
Again, we find a superintendent of an English almshouse reporting that one
hundred and two out of one hundred and five children born there in five
years were feeble-minded.
As conditions are to-day every institution for the feeble-minded has a
long waiting list and the same is true of most asylums for the insane.
Instead of providing the prolonged care necessary for such patients,
institutions are forced to discharge many prematurely in order to make
room for more urgent cases.
=Importance of Early Diagnosis of Insanity.--=In insanities, even when of
hereditary origin, there is much hope in certain cases of greatly
benefiting the individual, though a permanent cure, or at least the
establishment of procreative fitness may be impossible. It is extremely
important that the public realize how much can be done through early
examination and advice in such mental afflictions. Most of the insane who
recover usually do so within a few months of their first alienation, hence
the importance of losing no time in detecting the condition and securing
early treatment. It is now well known that many cases of chronic insanity
may be measurably improved under the care of a psychiatrist by systematic
re-education, especially in industrial lines. But how little of this may
be expected at the hands of the untrained custodians who "feed" the
inmates of our county almshouses, to which in many states the chronic
insane are entrusted, is obvious.
=All Insane Should Be Passed Upon by Competent Psychiatrists.--=The
atrocious system of turning the chronic insane over to county poorhouses
manned by supervisors whose chief qualification for the position has not
infrequently been the lowness of their bid for boarding and caring for the
inmates, can not be too strongly condemned. Incredible as it may seem, in
some states the court can on its own judgment send patients directly to
these institutions without first submitting them to the study of expert
physicians in the state hospital for the insane. The viciousness of such
procedure is evident when one realizes that often careful scrutiny on the
part of the very best experts, extending over a considerable period of
time, is required before the true condition of the patient can be
determined. Recently a psychiatrist of high standing, who was gathering
data on county asylums for a national organization, informed the writer
that beyond the shadow of a doubt he had come across case after case in
county asylums which would have been curable under proper treatment.
Here again the responsibility in last analysis must rest upon us as
citizens, for it is largely through our intelligent demands as voters that
conditions will be improved and competent experts be put in charge of
county asylums as well as of the state hospitals for the acutely insane.
=Some Insanities Not of Hereditary Origin.--=Some alienists believe that
self-poisoning known as _auto-intoxication_, due to improper elimination
of poisons generated through faulty digestion or metabolism, if of long
standing, may be not only a contributory but a more or less direct cause
of insanity. About twenty per cent. of insanities of men living in cities
and about fifteen per cent. of those living in the country seem to be
directly related to the intemperate use of alcohol. The corresponding
figures for women are seven per cent. and one per cent. respectively.
General paresis or softening of the brain is probably invariably preceded
by syphilis. About twenty-two and five-tenths per cent. of the first
admissions to hospitals for the insane from city-dwelling men, and eight
per cent. from men living in the country in the state of New York are
cases of this kind of insanity. The corresponding figures for women are
five and five-tenths per cent. and two and five-tenths per cent.
respectively.
=Importance of Heredity in Insanity Not Appreciated.--=We have already
seen that heredity plays an important part in insanities. There can be
little doubt that the tendency is to under-estimate rather than
over-estimate its importance. Many cases said to be "caused" by mental
strain such as those occasioned by domestic infelicities, business
reverses and the like should in all probability be fundamentally
attributed to something far more deep-seated than the more obvious cause.
In many such instances there is little doubt that an inherent weakness in
mental make-up exists which predisposes the individual toward mental
breakdown. This is more apparent when one recalls that there are thousands
of other individuals who undergo equally great or greater calamities
without loss of mental balance. There are well-recognized types of mental
disposition which later contribute to corresponding forms of insanity. In
many instances the final catastrophe may be averted if the "peculiar"
individual can be kept in good health and guided into right habits of
thought. Undoubtedly certain infectious diseases, arterio sclerosis,
various poisons in the blood, child-birth, and similar influences often
enter as important contributory factors. In all cases of cure, however, we
must face the fact that under existing conditions these mentally restored
individuals are released into society without let or hindrance as regards
their marital relations.