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JOURNAL ^ PSYCHO = ASTHENICS
September and December 1909
O ■ 1
March and June 1910
AMERICAN ASSOCIATION
FOR THE
STUDY OF THE FEEBLE-MINDED
Published Quarterly at Faribault, Miun.
*
JOURNAL OF PSYCHO-ASTHENICS
Vol. XIV
September and December. 1909 XT 100,4
March and June. 1910 IN OS. 1, £, 6, 4
Devoted to the
CARE. TRAINING AND TREATMENT OF THE FEEBLE- MINDED AND EPILEPTIC
Published Quarterly at Faribault, Minnesota
SUBSCRIPTION, $1.00 PER ANNUM SINGLE COPIES, 30 CENTS
Entered at the post-office at Faribault, Rice County, Minnesota, as second-class matter
l-'icss of the Minnesota School for Feeble-Minded and Colony for Epileptics, Faribault
JOURNAL OF PSYCHO=ASTHENICS.
The only periodical in the English language of general cir- culation devoted exclusively to the interests of the Feeble-Mind- ed and of Epileptics. Published under the auspices of the Ameri- can Association for the Study of the Feeble-Minded.
Officers: President, Miss Mattie Gundry, Falls Church, Va. ; Vice President, Dr. A. R. T. Wylie, Faribault, Minn. ; Secretary and Treasurer, Dr. A. C. Rogers, Faribault, Minn.
Subscription, $1.00 per annum ; single copies, 30c. Special rates for reprints and quantities of any one issue for distribution. Address communications to the Journal of Psycho-Asthenics, or to Dr. A. C. Rogers, Faribault, Minnesota.
CONTENTS
The Correlation of the Sciences— W. N. Billiard. M. I).. Boston. Mass 3
A Growth Curve for Feeble-Minded Children, Height and Weight — Henry H.
Goddard, M. D., Vineland, N. J 9
The High Grade Mental Defectives— William N. Billiard, M. D.. Boston. Mass... 14 The Imbecile With Criminal Instincts — Walter E. Fernald. M. D., Waverley,
Mass '. 16
Moral Degeneracy — Hortense V. Bruce. Hudson. N. Y 39
Suggestions for a Prognostical Classification of Mental Defectives — Henry H.
Goddard, M. D,, Vineland. N. J 48
Talipes Equiuo-Varus — H. P. McChesney. M. D.. Brooklyn, N. Y 55
Theory Regarding Certain Fundamental Principles Involved in the Production
of Epilepsy— A. L. Beier, M. D.. Chippewa Falls. Wis ' 61
Relation of Feeble-Mindedness to Disease— A. R. T. Wylie, M. D., Faribault,
Minn ■ 77
Special Classes in the Cleveland Schools — Miss Grace M. Boehme, Rochester,
X. Y S3
Special Classes for Mentally Defective Children in the Boston Public Schools —
David F. Lincoln, M. D.. Boston, Mass SO
The Multiple System of Institution Control — J. C. Carson. M. D., Syracuse, N. Y. 93
The Board of Control System — A. C. Rogers. M. D.. Faribault, Minn 101
System of Case Recording at Iowa Institution for Feeble-Minded — A. R. Seiner,
M. D., Glenwood. Iowa .- 105
Modern Studies in Heredity — A. C. Rogers. M. D., Faribault. Minn 117
The Summer School for Teachers of Backward Children — E. R. Johnstone,
Vineland. X. J 122
Minutes of the Association '. 131
Methods of Commitment 132
Reports from States 138
Treasurer's Report, 190S-1909 149
Journal of r sycho-A
\t„, YT\7' September and December, 1909 \Jr»c 1 9 *3 A
VOL. yVIV March and June, 1910 INOb. 1, £, O, *.
THE CORRELATION OF THE SCIENCES* BY W. N. BULLARD, m! D., BOSTON, MASS.
GENTLEMEN AND LADIES :- Before entering on the sub- stance of this address, I wish to express to you my appreciation of the honor that you have done me in choosing- me as president < if the association for this year.
I had thought at first to follow the old custom of presenting to you a syllabus or resume of the condition of our specialty in some of its scientific aspects, but on further consideration such work seemed to be rather in the nature of a compilation and a criticism than of that serious character which should call forth thought, even if it can produce nothing new. I shall therefore, to-day, present to your notice some aspects of a general truth which, though logically admitted by the thoughtful, is yet not so fully settled in practice as to be a guide in our actions. No one department, division, or subdivision of science can long and profitably exist, much less grow, enlarge and prosper, unless by
*The president's annual address delivered at Chippewa Falls, Wis., June 21, 1909.
4 JOURNAL OF PSYCHO-ASTHENICS
the help, support, assistance and guidance of the other branches and divisions which are related to, or coterminate with it on all sides. It ma}' be possible, on account of a peculiar conjuncture of circumstances, that for a short period some one division or branch of knowledge may be largely isolated, but in order that any real progress should continue it is found by stress of nature always to take refuge in the sympathy and aid of the cognate branches. Without this recognition it becomes narrower and more constricted until finally its conclusions become erroneous and its practices harmful.
These general considerations form but the introduction to the more special consideration of our own case and to some de- liberation on the practical results to be achieved by a wide and liberal action.
The last fifty years may truly be entitled, "The Age of the Birth and the Formation of Specialties in Medicine." With the unprecedented rapidity of the increase of scientific and medic- al knowledge, with the introduction of new forms of medical investigation and new instruments of scientific precision, each branch of medical knowledge and practice offered opened large fields of investigation previously unexplored and now com- paratively easy to enter into and promising to cultivate. Thus well trained and highly educated men found themselves inter- ested in these new and special lines of work and devoted their lives to the stud)'' and the practice of special branches of medi- cine. Among these we must consider our own specialty as a peculiarly limited one. It is, as it were, a division of a specialty. While the study and the care of the feeble-minded offer a full and, in my opinion, a most interesting and valuable occupation for a man's whole life, it is peculiarly important for those of us who have devoted our lives to these things to remember that in certain directions it is a very definitely limited subject. More than almost any of the ordinary specialties in medicine it is removed from cognate subjects and cognate interests. This work is capable of being made of the highest value and of the most progressive character. Yet, unless the physician who de- votes himself to this work broadens and widens himself and
THE CORRELATION OF THE SCIENCES 5
takes in the cognate branches of science there is danger that he may become one-sided.
Xq thoroughly trained, educated and broadly cultivated man should permit himself to become a mere overseer of institutions or competent manager of a farm and its appurtenances. A glance at the former position of the superintendents of some of our hospitals for the insane shows us that dangers of this sort are not chimerical. Time was, and that not many years ago, when there was great danger that many of these superintendents would lose their hold on the profession and become administra- tors only. They had, it is true, a special charge, but none the less their primary duty was rapidly being narrowed into that of organizing an institution thoroughly so that, while the inmates were suitably and kindly cared for, they should cost as little as possible and the authorities should be able to credit the superintendent with the ability to manage the institution satisfactorily in general, but more especially skillfully and eco- nomically from a financial point of view.. Such a superintendent was expected to know the prices of all the articles he needed to buy and to be a good bargainer. He should himself be an excellent steward. But in addition to this he should have a little higher knowledge; he should be able to raise vegetables and crops on the land belonging to the institution, with the help of the inmates, so cheaply that money could be saved which would otherwise be needed to buy them. He should also know how buildings should be built; the difference in the various grades of lumber; howr electric wires should be insulated. If the superintendent had this knowledge and could do these things as well or better than his colleagues, and if he was able to avoid complaints or scandals in his hospital management, he was a success ; and if he could get money for his institution through the legislature or otherwise, he was still more a suc- cess. Medical knowledge among these men was at a discount. What was the use of medical knowledge in dealing with incura- bles? If intercurrent disease or contagious disease broke out among the inmates, it was a misfortune to be dealt with mdically by the young assistant who having been recently graduated, had
6 JOURNAL OF PSYCHO-ASTHENlCS
not forgotten all his medicine; and politically or socially only, by the superintendent.
Thus in man}' cases the superintendents of institutions for the insane were becoming- organizers, managers and stewards. Their general medical knowledge was small and out-of-date; their special medical knowledge, beyond a certain skill in the diagnosis of mental disease in general which they could scarcely avoid, was devoted to speculative classification absolutely lim- ited to their own specialty. They were rapidly growing away from their own profession. Other physicians cared nothing for psychiatry, were absolutely ignorant in regard to it, and never desired to know more than to be able to certify to the insanity of a patient and to have him removed to a place where he would be cared for. There their responsibility ceased. The physicians who dealt with the insane in institutions felt themselves apart from the rest of the profession. As before said, they knew little, or no general medicine ; they had no special interest in it. They did not attend the meetings of the medical societies of their state, or county, or city. They formed a class by themselves. Being experts on insanity, they saw much more of the lawyers when they did any medical practice or work — for they often testified in court — than they did of other medical men. This class of men— were it not for their court practice — was in great danger of being removed from the position of physicians in actuality. They were specialists in insanity, organizers and stewards, but not general physicians or practitioners. From this position the psychiatrists have been awakened, at least partially. Various causes have led to this result. Weir Mitchell's famous address turned the attention of the profession as a whole, as well as that of the superintendents themelves, to this state of affairs. Psychiatry began to be better taught in the medical schools although even at the present day its condition, as re- gards instruction in this country, is pitiable. But more impor- tant than all else a new spirit has entered into many of the younger psychiatrists. Superintendents are beginning again to ally themselves with their other medical brethren. Clinics at the institutions for the insane are opened for the general medical
THE CORRELATION" OF THE SCIENCES 7
practioner. The psychiatrist sometimes attends a general medical meeting- and almost feels himself a real member of the profession.
I venture to bring before you to-day for your consideration these well known facts because in certain respects we. engaged in the treatment or care of the feeble-mindd. have been exposed to the same dangers as the psychiatrists. It is one of the highest functions of this society, it is one of the things for which it stands foremost, for which it is most valuable, that it enables us to avoid these dangers. It brings to us all ideas, thoughts and suggestions from specialties not our own. It is evident that all divisions or departments of knowledge are connected with each other directly or indirectly. In some, the connection is so close that their boundaries may be said to match or even to overlap. In other cases the connection is indirect and distant. Taking another point of view, some touch all along a given line so that one side of the science cannot be studied without a knowledge of the cognate sciences, while other sciences touch or approximate each other only at one or two points. Those sciences which are so closely connected that a thorough study or comprehension of one is not possible without a considerable knowledge of the other, may be said to be coterminous, or their boundaries may be said to match for a greater or less extent. In the study of our own specialty, the care and treatment of the feeble-minded, numerous other branches of knowledge are not only useful but necessary. From the medical point of view there is, first, general medicine; secondly, morbid pathology (in the sense of the study macroscopic and microscopic of the tissues and organs of the body diseased or abnormal) ; thirdly, the es- pecial study of psychiatry is very valuable and its cognate science not yet sufficiently appreciated since it is only rising out of the slough of subjective theories, psychology.
This science leads us back again to another side of our spe- cialty through pedagogy or the science of teaching. The relation of the science of teaching to the feeble-minded has only lately been thoroughly estimated and through the application of knowledge of this character many of our problems are likely
8 JOURNAL OF PSYCHO-ASTHENICS
to be solved. Psychology itself is also directly connected with our work.' Certain psychological problems can best be solved with such material as we have under control, while only by a clear acquaintance with known psychological facts can we under- stand the significance of man)- of the symptoms and condi- tions which are presented to us, or do the best possible to cure them, to alleviate them, or to turn them to the advantage of the possessor.
Philosophy, closely related to psychology, is, though valu- able, of less practical importance to us and comes only within the circle of those subjects secondarily related. But with general medicine, morbid pathology and psychiatry, with the study of pedagogy, or psychology, and perhaps philosophy, we have only summed up the branches of science most closely related to our study on two sides. There are other sides to our work and other branches of knowledge. Still other related departments of knowledge will appear as our understanding of our subject is more thorough and intimate. Not merely those branches of learning which appear the most closely related are the only ones which are of importance. Sometimes a science apparently most remote is the cause of the greatest step in advance in the one we are engaged in. The discover}" of the aniline dyes was the cause of much of the knowledge we have gained in pathology. The study of optics produced the microscope.
The high function of this association in widening and broadening the scientific sympathies and knowledge of all its members is secondary only to that of bringing them together into personal contact and into a better and more personal ac- quaintance with each other.
A GROWTH CURVE FOR FEEBLE-MINDED CHILDREN*. ETC. 9
A GROWTH CURVE FOR FEEBLE-MINDED CHILDREN, HEIGHT AND WEIGH!'
BY HENRY H. GODDARD. M: D.. VINELAND, N. J.
This study of height and weight of the feeble-minded is es- pecially the work of this association. You contributed the data; I have worked them out.
In the curves the data have come from thirteen institutions. One or two others have sent their data in since I left home ; there are some that are getting" them ready ; and 1 have found. since coming here, that there were one or two who by some cu- rious mischance have never been asked to contribute. I should like to say — you will see it when we come to look at the curves — that we have not yet enough data. I should be very glad to have an}" of you who have not contributed the height and the weight of your children, furnish them if you can do so. 1 may say, in that connection, that we do not need any more cases over thirty years of age. All the rest we should like Aery much indeed; especially should we like cases between twenty and thirty. I was encouraged by the records that came in from this institu- tion at Chippewa Falls to think that we might even get some sort of a curve under five years of age. If any of you know of individual cases under five, I should be very glad to have them.
The upper group, of curves represents weight; the lower, height. That is true of all the charts. For the upper group — the weight — the ages are across the top and the weight in pounds is given at the side. For the lower — the height — the age is given at the foot of the chart and the inches at the side. The black lines are in all cases the lines of normal children. That curve is taken — mostly from the ages of six to eighteen — from Burke's Compila- tion of all the American Statistics. Under six and over eighteen, it is taken from the English. The solid red line is the curve for all defectives, without any attempt to divide them into grades. By the other three lines we represent the idiot, the imbecile, and
10 JOURNAL OF PSYCHO- ASTHENICS
the defective. This line represents the idiot; this, the imbecile: and this dotted one. the feeble-minded group. We see, from looking at the curve, two or three rather striking things. Let me call your attention to the fact that we have been able to run that red line down to birth. It "is rather interesting that in one hundred and sixteen cases of weight at birth — these were all from our institution — they average heavier than the weight of normal children at birth. The idiots are the heaviest, the imbe- ciles come next, and the feeble-minded follow. The feeble- minded are almost as light as normal children ; however, they lose that advantage you see. This is based on very few cases. It looks as though they lost the advantage within six months al- most, and from that time they are practically almost never above, and, with the exception of the highest group, never up to normal ; but they do run along parallel to the normal until the age of nine, which is represented here. The idiots are from four to six pounds lighter than normals ; the imbeciles are from two to four pounds lighter; the feeble-minded do not differ very much from normal. We had no feeble-minded boys at the age of five in all the data that were sent in. They run parallel, which means, of course, that they are growing at the same rate. They are not as heavy, but increasing up to nine. At that point the idiot group falls. Tliey never again come up anywhere near the normals. The imbecile follows along very closely to the normal until fourteen, and then he falls back. The feeble-mind- ed follows on with practically no difference from the normal un- til the age of nineteen, and then growth is stopped. Normal boys go on until twenty-two, when they have attained their max- imum weight.
The same thing is seen in the course of height. Here they run on from nine, when the idiot falls away. At fourteen the imbe- ciles drop away. For the feeble-minded we could take nineteen as the age ; at least on the figures we have now. We should have to regard seventeen as the point at which they fall away from the normals ; that is to say, their energy for growth up- wards ceases earlier than their energy for growth in weight, and I take it that that means that the vitality, the growth energy of
A GROWTH CURVE FOR FEEBLE-MIXDED CHILDREN. ETC. 11
mental defectives runs exactly in that way. This points to what seems to be a most suggestive thing. We know, from a great manv studies of normal children and adults, too, that there is a very close correlation between physical growth — in some sense, at least — and intellectual capacity. It has even been demon- strated that to a certain slight extent, in the mass, the brighter children in school are the taller; the taller children are ordinarily brighter than the short and light ones. After we have tested the mental capacity of our children long enough, we shall be able to rind out whether their intellectual growth runs the same way as their physical growth. Tf so. whatever of training the idiot can take he must get before nine ; the imbecile, before four- teen and the feeble-mined, before nineteen.
I will call attention to one other thing. After twenty, the lines are very crude because we have not enough data.
We have practically the same thing on the girls' chart. The idiots are way below. With the imbeciles the curve is much more erratic.
The main thing to be noticed here, however, is this : recall- ing the normal growth curves for boys and girls you remember that the boys grow taller and heavier up to between eleven and twelve; then the girls take a sudden upshoot and keep ahead of their brothers until fifteen, when their brothers again go ahead. That is due, to a very decided acceleration in the growth of the girls — adolescent acceleration in growth as it is called.
Take our feeble-minded, now. At twelve years they are be- low normal ; from twelve to thirteen they grow exactly in the same ratio as the normals ; but from thirteen the) take a shoot up very much more rapidly than normals.
If you look at the situation there does not seem to be anv reason why feeble-minded children should grow abnormally fast ; there is every reason why they should not. They have bad heredity and bad environment, usually, until we get them. After coming to the institution they have a regular life and a sane, normal existence, being well fed and well cared for. It may be said that the normal group is not so good as that be- cause it includes slum children, but such is not the case. All
12 JOURNAL OF PSYCHO-ASTHENICS
our statistics are based on school children, and the slum chil- dren are eliminated from the schools before thirteen. This very curve with which we are making the comparison is based on a splendid group of children ; children of very fair heredity, if not excellent ; good home surroundings ; a group of children having apparently every advantage over our children. The only thing left seems to be the condition of things as they exist with these children. What are they? In the first place, it is the be- ginning of the puberal period. .'We are having those enormous physical changes which are even more severe than the changes at birth, and at that time they are either taking their last year in the grammar school or entering the high school. Their work is very heavy ; it is measured out for their brothers, — for the boys in the school. The task is set more in accordance with what the boys can do than with what the girls can do. Every- body expects boys will shirk, so they make the course that much longer. The girls, being too conscientious to shirk, simply worry over it. Furthermore, it is the time when girls begin to put on corsets, which I understand may be taken literally to mean that it is a time when they begin to interfere with the normal circulation ; and taken figuratively, to mean that they are beginning to enter society, to be out late at parties, to lose sleep, to be troubled over the other girl's brother, and all those things, which must create a mental condition that interferes with growth. If our interpretation is right, it seems to be that our feeble-minded children are not growing abnormally but as nor- mal girls ought to grow ; that normal girls are retarded, and while they do accelerate, they do not accelerate as they ought to.
I have drawn the curves of the lowest grade of idiots, both boys and girls, to see if they followed the same law of crossing that the normals do. The girls are ahead of their brothers from eleven to sixteen ; they keep ahead a little bit longer than nor- mals. If normal girls grew more normally, they would keep ahead of their brothers a little longer.
In height the situation is different and difficult. There is no crossing except just at that point, and the curves are so crook- ed it looks as though it ought not to be there. We should like
A GROWTH CURVE FOR FEEBLE-MINDED CHILDREN, ETC. 13
to know whether in height the girls in the idiot class never get ahead of their brothers.
DISCUSSION
Dr. Bernstein : In connection with the puberal period, thirteen to fourteen. I wonder if the nervous manifestations are not more marked in normal girls than in feeble-minded ones. The appearance of the menstrual period means nothing to the feeble-minded girl ; it does to the normal one. In connection with this dropping off of feeble-minded from nine to fifteen, I wonder if that might not suggest to the institutions that they would better look after their diet? Perhaps we are feeding such persons an infantile diet when we ought to begin earlier on the adult diet.
r$m&*
14 JOURNAL OF PSYCHO-ASTHENICS
THE HIGH-GRADE MENTAL DEFECTIVES BY WILLIAM N. BULLARD, M. D., BOSTON, MASS.
As the careful and scientific clinical study of the dependent classes advances our knowledge of the various grades of mental development and of mental power increases and we are able to distinguish with more certainty the higher degrees of mental impairment. These higher degrees can only be thoroughly studied at present in connection with some institution where de- tailed histories of the patients covering a term of years are available.
A chief difficulty in our classification and grading of these cases is that even the experts have not sufficiently realized the inequality of natural and pathological development. It is only in a modified way that intellectual^ ability can be accepted as a test for the mental powers. Other mental qualities have a large part in the sum of mental characteristics which may make up the mentality of the normal child. Among these is, first, the moral sense.
Secondly, we have a class of persons who are only slightly weak in power of intellectual acquisition but are wholly lacking in practical judgment. Again, there is another class whose diffi- culty seems to be lack of self-control. We should be most guarded in making any diagnosis of mental irresponsibility and this should only be done in carefully observed cases. Great care should be used in diagnosticating a case as one of moral imbecility.
Our real question is, What must be done for this class? We shall consider for the present only the females as for evi- dent reasons the need for them is the most" pressing.
Girls of the classes described must be cared for by the state. The reasons for this are: (i) There is no class of persons in our whole population who, unit for unit, are so dangerous or so expensive to the state. This excepts no class, not even the
THE HIGH-GRADE MENTAL DEFECTIVE 15
violently insane. They are much more dangerous and expensive than the ordinary insane or the ordinary feeble-minded or the ordinary male criminal. Why is this? They are dangerous be- cause being irresponsible wholly or in part they become the prey of the lower class of vile men and are the most fertile source for the, spread of all forms of venereal disease. They have not the sense or understanding to avoid disease or any care as to its spread.
They are most expensive to the state because they are the most fruitful source of diseased and mentally defective children who are apt to become state charges.
It is but a sign of financial wisdom to pay two dollars now to avoid paying one hundred in the future. It would be wise without consideration of the financial question to pay well now simply to avoid the public spread of foul disease. Syphilis is on the whole much worse than small pox.
The details of the provision for these cases must be settled in every state, according to their special conditions.
16 JOURNAL OF PSYCHO-ASTHENICS
THE IMBECILE WITH CRIMINAL INSTINCTS* BY WALTER E. FERNALD, M. D., WAVERLEY, MASS.
In this paper, I shall briefly consider the class of imbeciles who as a part of their life history present certain persistent ten- dencies or repeated acts of a criminal nature. 1 use the term "'imbecile" advisedly as an adequate synonym for the many dif- ferent expressions used to describe various degrees of lesser men- tal defect, resulting from causes operating before birth or in early childhood, as contrasted with mental impairment or disease developed later in the life of the individual, like dementia prae- cox, epilepsy, etc. Cases of actual idiocy are also excluded from this discussion.
The term imbecility was formerly applied only to a class of persons presenting simple, obvious intellectual shortcomings. The field of mental defect has been gradually extended and widen- ed so that the time-honored definitions and classifications have become incomplete and obsolete. To-day institutions for defect- ives are often expected to receive patients where the intellectu- al defect is apparently only moderate, and the principal reason for institution treatment is the failure to harmonize with the en- vironment as shown by low tastes and associates. In other cases the prominent symptoms are general incorrigibility, purpose- less and needless lying, a quarrelsome disposition, a tendency to petty stealing, a propensity for setting fires, aimless destruction of property, a tendency to run away and lead a life of vagrancy, sexual precocity or perversions — these may be the symptoms which impress the parent or the physician..
The recognition and understanding of these and other less obvious phases of defect are largely due to the correlation of the results of the modern scientific study of normal psychology, peda- gogy, degeneracy, criminology and sociology.
*Read by title at the sixty-fourth annual meeting of the American Medico-Psychological Association, Cincinnati, Ohio, May 12-15, 1908. Also at the meeting of the association at Chippewa Falls, Wis., June 21, 1909.
THE IMBECILE WITH CRIMINAL IXST1XCTS 17
A brief review of the ordinary phenomena and symptoms of imbecility is necessary for the proper interpretation of the cases to be described. From a biological standpoint the imbecile, is an inferior human being". If the mental defect is due to direct heredi- ty or to developmental abnormalities of the central nervous system having" their genesis in the ovule or in foetal life, the vari- ous anatomical, physiological and psychical stigmata of degene- racy are usually present. Indeed, in no other class of human be- ings are these various stigmata found so constantly, so frequent- ly and so well-marked as in the congenital imbecile. If the men- tal defect is caused by traumatism, or acute local disease, or other causes operating at birth or soon after birth, the physical stig- mata of degeneracy are often absent.
Some of the physical evidences of mental defect are as fol- lows : abnormalities in the size and shape of the skull and crani- um : in the size, shape and weight of the brain ; variations in the size, shape and relative position of the ears ; abnormalities in the form, situation, and structure of the teeth ; protruding lower jaw : congenital deformities of the hard palate : pallor of the skin ; scanty beard, etc.
Imbeciles of all grades exhibit in varying degrees certain well-marked mental characteristics. In mere memory exercises they may excel. They have weak will-power. The power of judgment is defective and uncertain and often determined by chance ideas, not by the outcome of past experience. Thought is scanty, limited mainly to daily experiences. They are unable to grasp and utilize the experiences of life.
Pronounced backwardness in ordinary school studies is, of course, a constant feature of the uncomplicated cases. At the end of his school life, at the age of 15 or 16 years, the imbecile may be able to read in the third reader, to do simple addition and subtraction, and easy multiplication. Division is not often achieved.
Imbeciles are childish even in adult life. They make friends quickly and are cheerful and voluble. They are boastful, ungener- ous, ungrateful. Notwithstanding their stupidity, they are cunning in attaining their own ends. They seem to have but lit-
18 JOURNAL OF PSYCHO-ASTHENICS
tie sympathy with distress or suffering. They are often cruel, especially to small children or weaker persons. They seem to take special delight in stirring up trouble and are often fond of tale-bearing.
They are vain in dress and love bright and gaudy colors. They like to be well dressed, and are indifferent to cleanliness of body.
In actions and conversation their own personality always comes into prominence. They manifest unbounded egotism, leading to marked selfishness. Their whole life revolves around their own personal well-being and the possession of things de- sired.
They are prone to lie without reason and often lie unhesita- tingly when truth would be to their own interest. They are in- clined to steal.
The}' are morally insensible. As a rule, they are able to carefully differentiate in the abstract between what is right and what is wrong as applied to their personal environment, but in practice their ability to make these distinctions bears no relation to their actions and conduct.
They seldom show embarrassment or shame when detected in wrong-doing. I have never known an imbecile to exhibit traits of remorse. Correction or punishment is of little effect.
They revel in mawkish sentiment. They are susceptible to the emotional phase of religious expression. They are very apt to choose intimate companions very much younger than them- selves, or persons very much beneath them socially or below them in the scale of intelligence. They are generally cowardly in the presence of actual physical danger. They are very susceptible to suggestion and are easily led.
They show marked physical insensibility. Galton says, "To the imbecile pain comes as a welcome surprise."
Few imbeciles have been seen to blush. They show an earlv craving for tobacco and alcohol. They are proverbially lazy and fond of idleness. They seem incapable of forethought.
Imbeciles of both sexes usually show active sexual propensi- ties and perversions at an early age.
THE IMBECILE WITH CRIMINAL INSTINCTS 19
There are two traits common to all imbeciles with few ex- ceptions. One is that they will cheerfully risk severe punishment for the sake of some slight gain which appeals to their personal desires. The other is that the'y seem unable to apply themselves continuously in any one direction. The imbecile often becomes skilled in some. one line, perhaps in some branch of a mechanical trade, but unless under the closest supervision, he will not apply himself to the work which he is perfectly capable of doing well.
The above generalizations apply to a very large number of the imbecile class. Many of these symptoms and tendencies may be appreciably modified or suppressed by suitable environment and training. The expression of these tendencies is varied ac- cording to sex, age, state of physical vigor, opportunity, etc.
The cases to be reported were selected from the 1236 pa- tients now in the Massachusetts School for the Feeble-Minded. They include various degrees and types of defect, from cases bor- dering on actual idiocy to so-called "borderline" cases, where the mental impairment is slight compared with the moral and social deficiencies. Some of these cases now in adult life have been in the school continuously since earl}- childhood. Other cases, at large in the community until the time of puberty, were then sen- tenced to the reform school by the criminal court and thence transferred to this school. Others were referred to the school from the community without an actual criminal court record.
In many cases repeated acts of a criminal nature have been committed in the community. In other cases the persistent criminal tendencies have been expressed only as modified by in- stitution conditions, but I have no hesitancy in classifying these "criminals who have actually committed no crime" in this group.
The tendency to promiscuous and precocious sexual vice, common to all types and degrees of imbecility, is considered only as incidental and corroborative evidence.
Case I. — F. M., female.
Age when admitted, 18 years. Personal history very meagre a'nd nothing known of ancestry. It is known that this patient has been a prisoner at the State Industral School, at Sherborn prison, and in various jails and houses of correction. She was a state ward and was placed out in families several times, but al-
20 JOURNAL OF PSYCHO-ASTHENICS
ways absconded after the theft of money and other articles. The experienced court officer who brought her to the school stated that in her language and in the fredom with which she discussed her various escapades, she was "the most brazen and depraved human being he had ever seen." She gloried in her misdeeds and unblushingly related stories of her various adventures. At times she shamelessly revealed her sexual propensities. She stole everything she could get her hands on. She was wantonly destructive of property. Even attempted violence toward her attendants. Showed ability as an organizer and as an inciter of rebellion and mischief.
Degenerative stigmata: Supra-orbital ridges prominent. Zygoma prominent.
Present age 22 years. Reads in 4th reader. Is fond of books and magazines. Expresses herself fluently and well. Adds and substracts slowly to 20. Cannot multiply 4x5. No division. Pa- tient is childish in her ideas and tastes. Conceited and egotisti- cal. Sly and cunning in small things, but shows lack of caution in concealing her serious lapses in conduct. Kind to children. At several periods has shown a marked infatuation for patients much her inferior mentally, and who were, in fact, of a very low grade of mentality. She has never chosen as her particular chums, patients of her own grade. Easily influenced by people of whom she is fond, and is scrupulously loyal to her special chums. She is selfish and ungrateful. She is always in sym- pathy with any evidences of rebellion or insubordination. At first was quite slovenly and careless in her work. Of late, she has become more particular, and to-day, with close supervision, is quite the equal of the average seamstress. Without super- vision the quality of her work at once becomes poor.
Case II. — J. C, female.
Age at admission, 17 years. Paternal grandfather and grand- mother both insane. Father and mother not up to the standard mentally. Mother had convulsions to age of six years. Patient dishonest, untruthful, destructive. Could not apply herself in school work. Liked to play with younger children. Had con- vulsions in early childhood. Wet bed until 14 years old. Showed no remorse when detected in theft. Would tell lies without any apparent reason. Was at "George Junior Republic" for a while. Says she was "in jail" there almost continuously for lying, steal- ing and general incorrigibility.
Degenerative stigmata: High, perpendicular forehead. Re- ceding chin. Small mouth. Ears badly made, with adherent lobules. Teeth badly placed. Face markedly asymmetrical.
Can read in 4th reader. Likes to read story-books and maga-
THE IMBECILE WITH CRIMINAL INSTINCTS 21
zhies. Penmanship good. Uses language intelligently. Adds and subtracts by hundreds, and multiplies by two or three fig- ures. No division. Patient is childish, deceitful, boastful. Likes to tell stories of her connection with men and boys, although her family say these stories have no foundation in fact. Likes to change from one thing to another, but does fairly good work under supervision. Likes to be well-dressed, but has to be forced to wash neck and ears. Forms violent attachments towards other patients. Chooses very defective patients for her chums. Indolent, untidy. No. affection for relatives. Gloats over her misdeeds. No shame or remorse. Shows absence of motive by stealing things for which she has no use.
Case, TIL — F. S.. female.
Age when admitted, 16 years. Colored. Committed to State Industrial School when 14 for stubbornness and violence towards brothers and sisters. Tn a fit of jealousy tried to kill baby broth- er. Mother was ugly tempered and quarrelsome. Cirl wet bed until 16 years old. Had attacks of irritability and violence during which she walked about aimlessly. Always incorrigible. Ordered out of public school at age of 12.
Degenerative stigmata : Prominent zygoma. Face asym- metrical. Ears gross, with adherent lobules and exaggerated details.
Present age 22. Reads easily in 4th reader. Likes to read newspapers, books and magazines. Slow of speech but ex- presses herself well. Handwriting admirable. In number work can add slowly to ten, but not above that. Can tell time by five-minute intervals. Patient is vain, fond of dress and of orna- ment. Selfish. Exceedingly proud of whatever she does her- self. Disobliging, stubborn, often sulk}" and rebellious. Shows no affection for relatives. Has attacked other patients and at- tendants in fits of temper, brought on by failure to get her own way. Can do beautiful laundry and other work, but will not do it unless very closely supervised. Sexual pervert. Her indecent actions with other patients are carried on regardless of the pres- ence of others.
Case IV. — M. B., female.
Age at admission, 15. Mother intemperate. Father in prison mi charge of assault and sexual connection with this girl and an older sister. Persistent thief and liar. Sexually precocious.
Degenerative stigmata : Deep orbits. Face asymmetrical. Lars asymmetrical, with adherent lobules. Palate high-vaulted. Teeth badly placed.
Present age 17. Reads in 3d reader. Likes to read story- books. Uses language expressively and fluently. Adds and sub-
21 JOURNAL OF PSYCHO-ASTHENICS
tracts sums in three figures and multiplies by two or three fig- ures. No division. Can tell time by five-minute intervals. This patient is selfish, conceited, egotistic, indolent. Lies habitually with no motive. Sly and cunning in attaining her own ends. Selfish and grasping. Very ungrateful in every way. Has been taught to do work under supervision. Will not work if not watched. Deceitful, unreliable. Silly and childish in her be- havior and actions. No modesty. Steals things for which she has no use. An inciter of mischief and insubordination. Loves to talk of crimes and criminals. Referred to school by criminal court after persistent habits of thieving, etc.
Case V. — K. N., male.
Age when admitted, n. No family history. No personal his- tory previous to admission.
Degenerative stigmata : Bushy eyebrows, meet in center. Heavy supraorbital ridges. Deep orbits. Ears crinkled and dis- similar in shape and position. Face asymmetrical. Palate high- arched. Very deaf.
Present age 21. This patient was in school classes from the time of his admission until he was 18 years old. He is now able to read fairly well in- 3d reader. Reads newspapers and magazines intelligently. "Has a good vocabulary and uses lan- guage understandingly. Can add numbers to 10 accurately, but cannot subtract these numbers. Cannot subtract or multi- ply. Patient is vain and boastful. Excels in athletics and likes to exploit his athletic prowess. He is contemptuous in his com- parisons of his own doings with those of his companions. Very egotistical. Profane and obscene. Lies unblushingly in securing his own desires. A cruel practical joker. Is wantonly cruel to smaller boys and to his associates. Steals anything he may de- sire. Shows good intelligence in many directions. Absolute dis- regard for the rights of others. Greedily reads the newspaper accounts of crime and criminals and boasts of the crimes he would commit against property and persons if he were at large. Is an inciter of mischief. Industrious and capable in all forms of ordinary work under close supervision.
Case AT. — C. X., female.
Age when admitted, 16 years. Was abandoned by parents at an early age. Says mother was intemperate. Patient had an illegitimate child when she was 14 years old. Committed by criminal court to State Industrial School for theft and incorrigi- bility.
Degenerative stigmata : Very high cheek bones. Deep or- bits. Face markedly asymmetrical. Ears asymmetrical, with ad- herent lobules.
THE IMBECILE WITH CRIMINAL" INSTINCTS 23
Present aye 24. Reads well in 3d reader. Good command of language. Adds and subtracts in hundreds ; multiplies numbers of two figures. No division. This patient can do first-class ta- ble-waiting and other forms of domestic work when closely su- pervised. If not supervised does very poor work. Has keen sex- ual propensities. Forms violent friendships for girls much less intelligent. Chatters and giggles endlessly in a simple way. Very deep and cunning in carrying out her own schemes. Is tyrannical to weaker people. Cruel to animals. Harsh to young children. Aery neat in dress and person. Very vain, ungrateful, selfish. Lies unblushingly. "Will run the risk of losing some much-desired pleasure for some small gain. Never shows signs of remorse for wrong-doing. Skims through the paper eadi day for accounts of crimes and murders. Her general behavior is that of a child of 11 or 12.
Case VII. — X. C. female.
Age when admitted, 20. Father intemperate : mother epi- leptic. As a small child, patient was untidy, played with children younger than herself, was cruel to animals. When 13 years of age was committed to State Industrial School for fornication and assault. Had been incorrigible previously.
Degenerative stigmata: Ears large and gross, with adherent lobules. Astigmatism. Prominent supra-orbital ridges. Deep orbits, prominent xygoma. Face asymmetrical.
Present age 27. Reads well in 4th reader; handwriting legi- ble ; adds and subtracts slowly to 20. No multiplication or 'di- vision. Can tell time by five-minute intervals. Patient is loud and assertive in manner. Always puts herself forward. Has a great opinion of her own ability. Sly and cunning. Fond of dress and jewelry.- Domineering and overbearing towards others. Shows no affection towards relatives. Quick tempered and vio- lent at slight provocation. Can do good work but will not stick to it unless closely supervised. Masturbates. Sexually per- verted. '"Oversexed." Becomes sexually excited when men are around. In the institution environment these propensities are usually kept under control, with occasional outbreaks of temper and sexual distrubance. She unwillingly does under supervision the work of a rather inefficient domestic.
Case VIII.— X. E., male.
Age at admission, 16. Colored. Committed here at instance of criminal court. Has record of having been before the court repeatedly for incorrigibility, destructiveness, stealing of money, etc. Rachitic and undersized.
Degenerative stigmata : Receding forehead. Prominent su-
24 JOURNAL OF PSYCHO-ASTHENICS
pra-orbital ridges. Prominent zygoma. Ears small, dissimilar and with indistinct details.
Present age 21. Patient reads well in 4th reader. Enjoys reading magazines, etc. Handwriting is admirable. Adds cor- rectly to 20. but is uncertain in adding numbers above 20. No subtraction, multiplication or division. This patient is a vain, bombastic egotist. Has a great opinion of everything he has or does. Is neat and tidy in dress. Sly and cunning. Lies without hesitation. Steals. He is a trouble-maker and inciter of mis- chief. Polite and courteous in his manner and use of language. Has learned to do excellent work as a house painter, but if not closely supervised is very careless and slovenly about his work. Will not work continuously without supervision.
Case IX. — S. U., female.
Age when admitted, 17. Father intemperate; has prison record. Patient illigitimate, although father still lives with moth- er of girl. Neither father nor mother can read or write. At age of 14, patient was committed to State Industrial School for theft and incorrigibility. In court, she testified that the father had committed incest with her, and accused the mother of venally using her for lewd practices. She was placed out from the In- dustrial School repeatedly, but always with the history of sexual irregularites and theft at each place.
Degenerative stigmata : Has deep orbits ; prominent zygoma ; ears asymmetrical and poorly proportioned with adherent lobules.
Present age 33. Can read in 3d reader. Reads simple story- books but shows poor understanding of wdiat she reads. Cannot spell. Uses language intelligently. In number work, can add a little under ten ; no subtraction or multiplication. Can tell time by five-minute intervals. Patient is childish, selfish, disobedient. Fond of dress but careless about her personal cleanliness. Fond of music and dancing. Sly and cunning. Is an habitual liar and thief. Is inclined to be stubborn and sulky. iTan do beautiful laundry work if closely supervised, but if supervision is with- drawn, does very poor work. Chooses younger and less intelli- gent companions.
Case X. — K. I., male.
Age when admitted, 7 years. No family history. Illegiti- mate. When admitted could not read nor write. Wet bed. Mis- chievous and sly- Degenerative stigmata: Skull asymmetrical. Forehead lined with heavy transverse wrinkles. Face asymmetrical. Ears show adherent lobules.
Was in school continuously from time of admission until 18 years old. Now 32 years old. Is an omniverous reader.
THE IMBECILE WITH CRIMINAL INSTINCTS 25
Reads newspapers, magazines, books and literature of all kinds. Reads scientific reports, agricultural hand-books, etc. Has not a very clear appreciation of what he reads. Expresses himself well. Can add, subtract, and multiply up to ioo. Can divide mentally with an easy divisor. Has a vast fund of miscellaneous information. Has a good memory for facts and events, and is especially good at remembering the exact dates of important events at the school in his time. He is an inveterate liar. In an apparently innocent way tells malicious falsehoods which he knows will make trouble. He is boastful and likes to be promi- nent. He loves to stir up trouble and mischief. Will tell a new patient that he heard the doctor say that the boy's father is dead. etc. He has been detected in perverted sexual actions with other patients. Occasionally runs away and leads a vagrant life for a week or ten days, when he returns to the school of his own accord. He is never in sympathy with the officers who have him in charge. Once attacked an attendant with a knife. Urges other patients to attack afficers. Is always sly and cunning in his mischief-making, and always seems prejudiced against the con- stituted authorities as a matter of general principle.
Case XI. — F. Q., female.
Age when admitted, 16 years. No bad heredity. Unhappy home conditions. Patient always high-tempered, jealous and hard to get on with. Always desirous of attracting attention. Untrustworthy. Lied about everything. An inveterate thief. Stole money and small articles repeatedly. When accused, lied glibly, and when detected in falsehood or theft showed no signs of sorrow7 or shame. Would repeat theft at next opportunity. Cruel to little children. Was precocious sexually and had no reserve about exposing her person or in her language or behavior with men or boys.
Degenerative stigmata: Face asymmetrical. Ears asym- metrical in shape and size. Adherent lobules.
Age now 17. Reads in 4th reader. Fond of novels, maga- zines, etc. Handwriting good. Uses language intelligently. Adds and subtracts slowly to 20 only. No multiplication or di- vision. Patient shows about the same characteristics as noted at time of admission. She lies and is deceitful. Fond of dress, boastful and indolent. Will do good work if closely supervised, but if not supervised is very careless.
Case XII.— N. M., female.
Age when admitted, 18 years. Father intemperate. Mother 48 when patient was born. Patient committed from State Indus- trial School. Had court record of fornication, street-walking and repeated thefts. Had been repeatedly placed out from the In-
26 JOURNAL OF PSYCHO-ASTHENICS.
dustrial School with the invariable history of promiscuous sex- ual intercourse, frequent running away, and several arrests for street-walking. Was a chronic thief, often stealing' things for which she had no use.
Degenerative stigmata: Prominent supra-orbital ridges. Prominent zygoma. Deep orbits. Prominent chin. Good ears, hut with adherent lobules. Face asymmetrical.
I'resent age 24. Reads easily in y\ reader. Fond of reading and likes magazines and story-books. Uses language easily/ and well. Can add and subtract in hundreds. No multiplication or division. Patient is childish and easily led. Noisy and boisterous in daily life. ( )bliging and anxious to please. Marked sexual propensities and unable to control herself when men are around. Masturbates and has perverted sexual relations with other pa- tients. Sly and cunning, but shows little real foresight. Capable of doing good work, but is slovenly and careless unless closely su- p< rvised. Was formerly a great inciter of mischief and a trouble- maker, but during the last year has "settled down" and grown much more tractable and industrious.
Case XIII.— T. Q., male.
Age when admitted (October, 1907), 16 years. Parents Rus- sian jews. No bad heredity. Patient was committed here as an alternative to being sentenced in police court for stealing money from his employer. States that he has stolen money repeatedly^ in places where he was employed. At time of his commitment here, there was a warrant out for his arrest for rape committed on a young girl. Me claims that this rape was committed as the result of a "dare" by some of his associates.
Degenerative stigmata: Skull asymmetrical. Iiair grows low on forehead. Eyebrows bushy and meet in center. Heavy supra-orbital ridges. Ears asymmetrical and unevenly placed. Teeth dark, discolored and crowded in jaw. Teeth at irregular angles, cuspids parallel with bicuspids. Face asymmetrical. j
Reads fluently in 3d reader. Spells well. Good handwriting. Can add to 20. but cannot subtract, multiply or divide. Can tell time by hours but not by minutes. This patient is frank about his escapades and describes them freely. Says he found it very hard to do school work. Rather stupid and heavy but with fair understanding of ordinary affairs. Memory as to times and places very uncertain. Apparently an uncomplicated case of im- becility.
Case XIV. — X. E., male.
Age when admitted, [8 years. Mother feeble-minded. Father unknown. Boy. illegitimate. Was committed to the school as an alternative to being sentenced for rape committed on a young
THE IMBECILE WITH CRIMINAL INSTINCTS 27
girl. This was the third time this boy had committed rape. Had repeatedly stolen money and other articles, and had committed assaults on boys who bothered him.
Degenerative stigmata : Hair low on forehead. Heavy supra-orbital ridges. Eyebrows bushy and meet in center. Deep orbits. Ears asymmetrical and badly made. High-arched pal- ate. Face asymmetrical.
Present age 21. Patient had been in public school continu- ously up to time of his admission here, but is able to read only simple books like the»primer. Cannot spell simple words; can write a little; knows nothing of number. Cannot tell time. In using language is able to express himself well. Has a large fund of general information. This patient is extremely talkative very pompous in manner and language. Vain of his personal appearance. Neat in dress and person. Is a persistent and senseless liar. Is rebellious and contrary with new attendants. Has attacked several attendants without provocation. On gener- al principles is opposed to those in power. Masturbates, but is not a sexual pervert.
Case XV.— N. T.. female.
Age at admission, 16 years. Father moral pervert in every sense. Mother confesses to having lived with many different men. Brother of patient has a history of incorrigibility and multiple court record. Patient had fits of temper as a child. Learned to talk late. Wet bed. Stubborn, wilful, passionate, and "could not tell right from wrong." Liked to play with younger children. Cruel to other children. Immediate occasion for commitment was result of being brought into court for incest with father. While patient was with mother on vacation two years ago, she became pregnant and gave birth to a child.
Degenerative stigmata : Large supra-orbital ridges. Re- ceding chin. Receding forehead. Prominent zygoma. Palate very high and narrow. Ears asymmetrical.
Present age 21. Reads easily in 3d reader. Writes good hand. Can add in hundreds; subtract slowly under ten ; no mul- tiplication. Can tell time. Expresses herself fluently and in- telligently. Patient is indolent, cunning; has no sense of shame. Quarrelsome. Exceedingly crafty in gaining her own ends. Has attacked other patients and attendants with knife without provo- cation. Had no love for her baby and manifested no real grief when it died. Becomes sexually excited when men are around.
Case XVI.— O. L., female.
Age when admitted, 14 years. Father and mother both in- temperate and degenerate, and always on the verge of pauperism. Patient admitted here from Tewksbury almhouse, with history of
28 JOURNAL OF PSYCHO-ASTHENICS
incorrigibility. Cruel to animals, etc. Had put a cat on a red- hot stove. Had thrown knives and stones at playmates. Said she would like to have a small baby to strike and kick. Very untruthful and chronic thief.
Degenerative stigmata: Eyebrows bushy.- Zygoma promi- nent. Face asymmetrical. Nose small and rudimentary. Ears badly shaped, with adherent lobules. High palate. Teeth crowd- ed, and placed on different planes. Low forehead. Body small and undersized.
Present age 16. Reads in 4th reader. Uses language easily. Can add a little under 5. Can tell time. This patient is sly and cunning. Vain and boastful. Fond of teasing. Has fits of temper when she screams, tears clothing and pulls out her hair. Likes to attract attention and is very vain of her personal ap- pearance. Is in a state of chronic rebellion against the constitut- ed authorities, a trouble-maker and inciter of mischief. About two years ago this patient, with another patient, drowned a fel- low patient in a bath tub.
Case XVII. — K. L, male.
Age when admitted, 17. Irish-American. Family history unkonwn. Patient walked at 18 months, did not talk until 7, could not learn in school. Had convulsions in first year. Began use of tobacco at age of 8. Referred to the school from the criminal court where he was held on a charge of rape committed on a young girl. Had worked for several years in a factory where he carried goods from one part of the factory to another.
Degenerative stigmata. Very prominent supra-orbital ridges. Face asymmetrical. High palate. Ears prominent and outstanding.
Present age 18 years. Reads easily in 4th reader. Poor speller. Adds to 10, but cannot subtract. Typical imbecile of medium grade. Llappy-go-lucky fellow. High tempered. Works well under supervision ; idle otherwise.
Case XVIII —0. K., male.
Age when admitted, 9. No family history. Peculiar from early infancy. Has always been nervous.
Degenerative stigmata : Face asymmetrical. Eyeballs pro- truding. Eyes widely spaced. Deep orbits.
Present age 11 years. Beginning to read easy sentences in primer. Cannot spell, except 3-letter words. Can add to 5 fair- ly well. Cannot tell time. Patient very troublesome and incorri- gible. Has a bright, knowing and intelligent manner. Has a fund of general information, and seems brighter than he really is. Talkative. Has used tobacco since an early age. Very cruel to smaller children. Has ungovernable temper. Is a malicious
THE IMBECILE WITH CRIMINAL INSTINCTS 29
liar. A very successful inciter of discontent and rebellion among the other patients. Is most ingenious and convincing in his falsehoods. Inveterate thief. Xo appreciable motive for his bad behavior.
Case XIX. — J. E., male.
Age when admitted, 13 years. Parents of Irich descent. Father not very strong mentally. Patient eighth child in a fam- ily of 14. Seven children have died, 3 still-born, 1 hydrocephalic. Patient committed to the school after being before the local court repeatedly for incorrigibility, theft, destruction of property, etc.
Degenerative stigmata : Skull of microcephalic type and asvmmetrical. Ears dissimilar. Xasal septum deviated. Palate high-arched.
Present age 15 years. Reads well in 26. reader. Soells simple words. Can add to 15 slowly and rather uncertainly. Cannot subtract ar multiply. This patient is one of the most incorrigible boys I have ever known. He lies persistent!}', purposejessly and maliciously. He is a great thief. Very impatient of control. AYantonly destructive. Cruel to other children. Vain, conceited, quick-tempered, insolent. Very fond of tobacco which he has used since he was 8 years old. Absence of motive characterizes manv of his actions. Works well under supervision.
In everv case with a court record, and in the cases from the reform schools, the offense for which the patient was origin- ally committed was not a first offence, but was the climax of a long series of petty misdeeds which finally became unbearable. Probably all this group were committed by the police courts without question as to their mental condition. In several cases it was only after the patient had been "placed out" to service sever- al times, from the reform school, and had repeatedly failed to respond favorably to good environment that it was realized that mental defect was the underlying cause of the delinquency.
A large proportion of the cases described well represents the class of cases who formerly would hav been considered merely as criminals, with no thought of mental defect.
By reason t>f early incorrigibility or bad home surroundings many of these cases had few school advantages in childhood. In court their mental deficiency was probably mistaken for igno- rance from bad inheritance or lack of opportunity.
Nearlv everv case shows either no familv historv obtain-
30 JOURNAL OF PSYCHO-ASTHENICS
able — which in the case of a child usually means a dubious heredi- ty— or a positive history of bad inheritance.
Nearly every case presents various physical stigmata of de- generacy in skull, ears, face, teeth, palate or physiognomy. All of the cases described are in the period of adolescence or early adult life, and yet only a few present the usual comeliness of fea- ture and physical attractiveness usually shown at this period of life.
All of these patients boast of their evil acts and eagerly dis- cuss the criminal experiences of a new-comer. They gloat over newspaper stories of crime and shame. They delight in "yellow journalism." They reveled in the exploits of Tracy the despera- do and of Thaw the assassin.
Of the cases described, none seem able to apply themselves continuously in any one direction, even for a greatly desired re- ward. Even- the brightest were unable to master more than the merest rudiments of arithmatic.
The patients described vary greatly in general intelligence, and in the amount of definite knowledge which they have acquir- ed, but they greatly resemble each other in their childish tastes, excessive vanity, unreliability, aggressive boastful egotism, sel- fishness, moral insensibility, fondness for malicious mischief and trouble-making; indolence, willingness to run great risk for the sake of some small gain, untruthfulness, lack of shame and re- morse, lack of sympathy, etc.
The cases described fairly represent the criminal imbecile type. I have no doubt as to the actual imbecility and the result- ing moral irresponsibility of every one of these cases. As a group, the female cases especially well illustrate the so-called "high-grade imbecile." In fact, the physical and psychical stig- mata exhibited by the group of imbeciles, selected because of their criminal tendencies and acts, are merely the usual signs and symptoms found in the ordinary case of imbecility, modified only in degree and not in kind.
This class of borderline cases with criminal tendencies now constitutes a troublesome and puzzling factor in our institutions for the feeble-minded. They are often malicious, deceitful and
THE IMBECILE WITH CRIMINAL INSTINCTS 31
inciters of mischief and insubordination. They have a wonder- ful power of suggestion over their simple-minded fellow-pa- tients. The_\ are generally committed to the institution against the wishes of their parents. The efforts of their friends to ob- tain their release are constant and perplexing. If a case of this description is taken before the Supreme Court on a writ of ha- beas corpus it is more than likely that the patient will be re- leased, indeed, it is not difficult t<> hud reputable medical men win i would testify that the case "is by no means a fool." and that he ought not to be deprived of his liberty. It is evident that clinical types and shadings of mental deficiency have become fa- miliar to the alienist which have not been so definitely formu- lated and classified as to be readily recognized by the profes- sion generally. It is equally true that the legal definitions and precedents pertaining to ordinary cases of imbecility are inade- quate when applied to these high-grade imbeciles. We have, therefore, to face the anomalous fact that it is easy to have a class of patients committed to our institutions who are promptly discharged by the higher courts because these lesser types of de- ficiency have neither been adequately formulated medically nor recognized legally.
The diagnosis of borderline cases of imbecility is simplified if it is possible to obtain the family history and the personal histo- ry of the patient, with special reference to the period of infancy and early childhood. Even in the cases with very slight mental defect there is usually a history of delayed dentition, late walk- ing, delayed speech, relatively long continuance of untidy habits, and very likely a history of convulsions as part of the history of the first few years of life.
The public school history of the patient is almost always il- luminating. As a rule these cases do n6"t compare at all favorably in their school work with the average child. It is seldom these cases are carried beyond the standard of third-grade work. Dif- ficulty in understanding simple arithmetical abstractions is very significant. The presence or absence of various degenerative stigmata is significant.
Selfishness, moral insensibility, willingness to run great risks for slight possible gain, childish tastes, lack of affection for
32 JOURNAL OF FSYCHO- ASTHENICS
relatives — all these are significant symptoms. A very constant symptom is inability on the part of the patient to apply himself continuous!}' either in school work or in any other occupation without constant supervision. In some cases with only slight intellectual defect, the inability to "make good" socially will be a deciding factor in the diagnosis. In a given case the age, sex, socia1 condition, physical health, school advantages, etc., have a distinct bearing on the interpretation of the case.
Some of the cases reported were considered as typical cases of so-called "moral imbecility" without intellectual defect, until long observation and close analysis demonstrated that "the}'' were cases of true imbecility, where the anti-social tendencies of the ordinary "imbecile were exaggerated to such an extent as to over- shadow the presence of intellectual impairment, and the ex- istance of the characteristic physical, mental and moral signs of congenital mental defect.
I have never happened to see a well-marked case of so-call- ed "congenital moral imbecility" which did not exhibit many, or indeed most, of the significant stigmata of true imbecility.
With the moral imbecile the stock of showy and superficial knowledge, the confident and boastful manner, the glibness of tongue, the spurious brightness, the cunning and carefully planned schemes — all these serve to mask the significance of the su- preme selfishness, the lack of shame and remorse, the unbounded egotism, the absence of adequate motive, the cruelty, the lack of fear of consequences, the lack of judgment, the love of notoriety, the failure to keep a situation, the failure to respect the feelings of relatives, the abnormal social reactions, the idleness and ten- dency to early vice, which are so apt to characterize this type of defective.
Kraeplin admirably describes the modern conception of ''moral imbecility" as follows :
Moral imbecility represents a form of mental weakness which includes chiefly the realm of the feelings. It is character- ized by the absence or weakness of those feelings which inhibit the development of marked selfishness. The intellect, as re- gards matters of practical life, is moderately developed ; patients apprehend well; they are able to accumulate mofe or less knowl-
THE IMBECILE WITH CRIMINAL" INSTINCTS 33
edge, which they use more or less for their own advantage; pos- sess a good memory and show no defects in the process of thought. Thev do, however, lack the abilitv to obtain general viewpoints, to perform an}" work of a high grade, and to form an adequate conception of life in the outer world.
Morally, their lack of sympathy is manifested from youth up in their cruelty towards animals, their tendency to tease and roughly use playmates, and an inaccessibility tumoral influences. They develop the most pronounced selfishness, lack of sense of honor and of affection for parents and relatives. Tt is impos- sible to train them because of the absence of love and ambition. The}- tell falsehoods, become crafty, deceitful and stubborn. The egotism becomes more and more evident in their great conceit, bragging and wilfulness, their inordinate desire for en- joyment, their violence and dissipation.
They are incapable of resisting tempetation and give way to sudden impulses and emotional outbursts, while the susceptibili- ty to alcohol is especially prominent.
So-called "moral imbeciles" frequently commit the most heinous and revolting crimes. The boy Pomeroy was a high- grade imbecile who had been accepted for admission to the Mas- sachusetts School for the Feeble-Minded when he committed his in itorious crimes.
Every imbecile, especially the high-grade imbecile, is a po- tential criminal, needing only the proper envirenment and op- portunity for the development and expression of his criminal ten- dencies. The unrecognized imbecile is a most dangerous ele- ment in the community. The fact that the high-grade imbecile often excels in one or more. lines — music, painting, some limited branch of mechanics — is misleading. Maliciously "mischievous children, runaways and vagrants, the incorrigibles, disorderly and ungovernable children, are often of the imbecile type. Lighter grades of imbecility often fail of recognition in early child- hood, but as soon as some unusual situation arises demanding discretion and decision of action, and self-control, the mental, moral and social incapacity becomes evident. The mental in- capacity becomes more evident in youth and adolescence as con- trasted with the rapid mental development of their playmates.
The juvenile expression of this slight degree of imbecility,
34 JOURNAL OF PSYCHO-ASTHENICS
especially in children watched and guarded in good homes, is trivial and harmless. The reaction of these patients to the temp- tations of adolescent and adult life is another matter.
The life history of the case put under permanent protection and training" at an early age is very different from that of the cases which grow up at large in a modern urban or town communi- ty. Nearly all of the cases trained from childhood or youth may be taught habits of industry and comparatively good behavior, and at from 25 to 30 years of, age a large proportion of them "settle down" to a condition of inhibition of the anti-social traits, and indeed to a condition of ostentatious pride in the virtues which they unwillingly practice.
Constant occupation at congenial work, with strict but kind- ly discipline, and with proper recreation, is the basis of the treat- ment required.
Butler of Indiana says :
In the country and local jails we have frequent cause to note the relationship between feeble-mindedness and crime. Boys and young men mentally weak are often found being held for trial or serving a jail sentence for rape, or attempted rape, incen- diarism, or other crime.
Many of the children whose cases are brought before the juvenile courts are mentally weak or come from homes where, because of the weak wills of the parents, they were not given proper training or direction.
The last resort of the juvenile courts is the State Reform Schools. In these institutions are many children of this class of mental defectives.
Mental defectives are frequently committed to the reforma- tories for adults. From studies made at the New York State Reformatory it is stated that this class constitutes about one- fifth of the population of that institution. A far larger pro- portion is reported as being incapable of controlling their pow- ers or co-ordinating their faculties, and are termed 'control de- fectives.' The superintendent of the schools at the Indiana Re- formatory states that about 21 per cent, of those received are mentally defective on admission.
In the state prisons are also to be found those who are feeble-minded. Some of these were nuisances in their respective communities ; some were sent here because there appeared to be no other place to send them, others for the commission of offences for which they were not really responsible.
THE IMBECILE WITH CRIMINAL INSTINCTS 35
In both reformatories and prisons these defectives are the most troublesome class of prisoners. Irrational, irritable, their weak minds led by their impulses, they interfere with discipline and their management requires the highest skill. Their pres- ence at times leads to disturbances and sometimes to serious, if not fatal assaults upon officers and inmates
The literature of criminology teems with references to the close analogy between the imbecile and the instinctive criminal They have a common heredity, and criminal anthropology proves that the evidences of degeneration — anatomical, physiological and pyschical — are identical in the two groups.
Is there not more than a close resemblance between the imbecile and the instinctive criminal? Is not the typical instinct- ive criminal of Lombroso a typical adult imbecile of middle or high grade, plus opportunity and experience in the community?
AYe have only begun to study the relationship between imbe- cility and crime. The criminal tendencies of the epileptic are fairly well-known. The insane criminal is being studied from many points of view. There are many crimes committed by imbe- ciles for every one committed by an insane person. The aver- age prison population includes more imbeciles than lunaties.
We shall eventually apply our knowledge of imbecility to the study and management of juvenile incorrigibles and adult criminals. The ultimate application of that knowledge will ma- terially modify the action of the courts and the methods of treat- ment and management of prisoners.
Cases of imbecility with criminal propensities — "criminals who have committed no crime" — will be recognized at an early age before they have acquired facility in crime, and permanently taken out of the community and given life-long care and super- vision in special institutions, combining the educational and de- velopmental methods of a school for the feeble-minded with the industry and security of a modern penal institution. Such provision would be only a rational extension of the principle of indeterminate sentence, and if safe-guarded by careful and re- peated expert examination and observation could do no injus- tice and would greatly diminish crime in the immediate future. Adult criminal imbeciles, or instintive criminals, would be com-
36 JOURNAL OF PSYCHO-ASTHENICS
mitted to an institution under the same conditions. Similar cases developing in institutions for ordinary imbeciles would be permanently transferred to the special institution.
DISCUSSION
Dr. Smith Baker : With reference to caring for cases at the earlier stage I wish to quote a case briefly : A boy five years old was brought to me with the complaint that he could not learn to read, and that in consequence he was becoming a truant, was .rapidly learning the little vices of childhood, and was becoming a nuisance in the school and in the neighborhood. Under the care of an older sister, whom I endeavored properly to instruct, within only about three years the boy learned to read as rapidly and as much as any boy of his age, had gotten off of the street, and had become a respectable boy, and is to-day a respectable man. The family had unwittingly provided him with all the tendencies necessary to make a vicious criminal of him later on. The defect in reading had thrown him into such a miserable sort of contact with the rest of the school and the community, that he was naturally urged on in all such vicious directions, very rapidly. Getting him interested in the right kind of studies under the right kind of direction, in the right kind of environ- ment, resulted in what I have told you — a respectable boy, a respectable young man.
Dr. Murdoch : The point that appeals to me in the presen- tation of these cases is that they were almost without exception cases that entered the institution when they were past 14 or 16 years of age, some of them, I believe, 18 or 19 years. Most of them had come in contact with a vicious environment before coming into the institution. I would like to know if any of the institution children of this class have been under institution training from very early years. I believe if we can have the im- becile under training in proper institutions during early years that these vicious tendencies will not develop. I think it is largely
THE IMBECILE WITH CRIMINAL* INSTINCTS 37
a question of environment and the lack of appropriate training. In my experience in our own institution, I know, while we are not old, that has been our observation, that these children who have come to us earl}- have not developed these vicious ten- dencies in the institution, but we do see it in those children who have come to us too late, after they have been exposed to street life and evil association in the outside world. This is not only so of the imbecile, but I believe it is true of normal boys and girls; if they are protected from evils during early years the liability of generating or acquiring evil habits, alcoholism, etc., is not likely to occur.
Dr. YVilmarth : The point that appeals most to me is. the absence of true remorse. A girl released from the industrial school in Milwaukee murdered her illegitimate infant. The murder was discovered and she was brought before the justice, and the thing that strongly attracted his attention was her entire lack of remorse over her crime and her inability to appreciate its gravity. It strikes me that the lack of remorse signifies a lack of knowledge or appreciation of the gravity of the offence, and that lack indicates surely a lack of judgment. The lack of judgment, or the lack of will power, which is prominent in these cases certainly indicates the lack of a true mental formation or growth, and, therefore, indicates, in itself, an imbecility or feeble-mindedness. It does not seem to me that the term "moral imbecility" is misplaced, if used in that connection.
Dr. Goddard : 1 have been through the literature on moral imbecility, and I feel like saying that, in my opinion, the papers we have heard this afternoon on that subject are the first raal contribution we have had to the understanding of moral imbe- cility. There is no place in modern sociology or modern ethics for moral imbecility as it is found in the older waitings on that subject. The notion that a child may be born with his natural faculties all right and his moral faculties all wrong is a notion that belongs to the middle ages of sociology and ethics as well. I think this- marks the beginning of a new era in which we can get down to the point and study the imbecile, and find out, if you please, why, in imbeciles, some tendencies predominate
38 JOURNAL OF PSYCHO-ASTHENICS
over others. It would be foolish to anticipate the results of those studies, and yet, sometimes we must have certain impressions which will lead us in the right direction, and I have the impres- sion that the moral imbecile, so called, is the best answer to the argument that we heard last evening', that this whole thing is a mere matter of heredity, and if we stop that, the problem is solved. I believe the imbecility may be hereditary, but the moral part is a question of environment, and it is the child's revolt, or nature's revolt and reaction against a crude and ridiculous edu- cational and training system for that. kind of a child. As I said before, these three papers especially appeal to me as a tremen- dous contribution to this little understood subject.
Prof. Johnstone : I do not know that I can add anything to this discussion, but it seems to me there has been one word that has cried out all through this day, and that word is "ignor- ance." It seems to me this whole question is in our hands, it lies in the hollow of the hands of this association, and T think it is time for us to let people know. I think we ought to take some definite action to let people understand more of our work and its relationship to ordinary life.
St ? %
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MORAL DEGENERACY 39
MORAL DEGENERACY BY HORTENSE V. BRUCE, HUDSON, N. Y.
One who has the care of moral delinquents, who has to con- sider the causes of their delinquency, the methods of treatment and of re-establishing them in the world, must, perforce, make a study of "moral imbeciles." Frequent evidence of this fact will be found in annual reports of institutions for delinquents, and in papers discussing delinquency and criminality.
Among the girls committed to the New York State Train- ing School for Girls since 1904, from among whom the cases to be reported in this paper are entirely taken, there have been about forty girls- whom we have considered mentally deficient. Of these some have plainly been incapable, intellectually, of be- ing materially benefited by the discipline and training of the school and some have had intellectual capacity but have lacked to a greater of less degree, moral sense. The disposition of these cases when they must be freed from an institution, is a more seri- ous problem than the placing of a normal girl. Our difficulty lies not only in diagnosis but in the ignorance and lack of sym- pathy on the part of the public concerning these unfortunates. The fact that so many deficient in mental capacity are committed to us shows how largely still the offense classifies the offender in the public mind. If the girl, evidently lacking intellectually, is designated a delinquent because she commits an act which is an offense under the law, how much less is understood the case of the girl who has intellectual capacity but acts contrary to law be- cause unmoral.- To a surprising extent this lack of appreciation of the real status of the moral responsibility of certain girls ex- ists even among people dealing with sociological problems, though we feel that it requires special training and extended obser- vation correctly to interpret these cases, yet if it were more generally understood that there is moral as well as mental imbe- cility, the unfortunate would be properly placed before she had done harm to herself and the community.
40 JOURNAL OF PSYCHO-ASTHENICS
We, the physicians connected with the training school and myself, do not -conclude that all girls whom we cannot help to become good citizens are mentally deficient, but in the histories to be presented we think we have found the characteristics that differentiate the girls who do not appreciate good and evil and do wrong, from those who do appreciate good and evil and choose to do wrong. We approach the study of a new case with the optimistic theory that no normal person is incorrigible. In time, each gird gets classified either among those readily suscepti- ble to good influences or amongst those who are not. If among the latter, further differentiattion is made ; of one class we feel sure that they understand and feel the proper emotions about right and wrong; of the other, we, to cpiote Dr. Barr, "get an im- pression o_f something different from the ordinary." We are baffled ; there is a gulf we cannot cross ; the words right and wrong are to the girl mere labels we have put upon certain lines of conduct, the reason for which she has no brain power to under- stand, and which, therefore, are of no compelling force when she has to make a choice between the two. As with their conduct so with their thoughts and the verbal expression of them. Girls who have indulged in a perfect revelry of obscenity have im- pressed us as having had no such comprehension as had we of the vileness of the words they were using. The impression was distinctly different from that we get of disorderly girls who at- tempted-to join them in their songs and conversation.
From different authorities, chiefly Doctors Kerlin and Barr, I have taken the following quotation's and list of characteristics of which we have made use in confirming our diagnosis. These are : "In the moral imbecile the degeneration of the psychic forces is the peculiar and distinctive feature, the perversion or the complete absence of the moral sense being revealed accord- ing to the character of the grade in which it appears." Again, "The fundamental disorder is manifested in derangement of the normal preceptions or emotional nature rather than in the intel- lectual life." And again, "Psychic forces are wanting, feeble, or lacking in quality, just as we have noted are the physical powers in the idiot. Judgment and will, power of discrimination, and
MORAL DEGENERACY 41
even a certain amount of discretion there may be ; but even when strengthened and built up, at the best these are only such as a well grown boy or girl will exhibit ; vacillation, indolence, or an acute susceptibility to suggestion, may be at any time his undoing, for unstable as water, he will not excel unless sustained and protect- ed by a will stronger than his own." "Some of the forms in which the congenital deficiency of the moral sense manifests it- self are : unaccountable and unwarrantable frenzies ; long periods of sulks and comfort in sulking; motiveless and persistent lying; thieving, generally without ecquisitiyeness ; a blind and head- long impulse toward arson ; delight in cruelty ; self-inflicted vio- lence, even to drawing of blood; habitual wilfulness and defiance, even in face of certain punishment ; hebetude or insensibility under disciplinary inflictions." As a further aid to diagnosis from simple wickedness or badness, there are mentioned : "Per- sistency of the trait and the utter destitution of any reason for it ;" "the confessed helplessness of the child to do differently ;" "the fact that in one class of these cases the conduct is the re- verse of what might be expected from the environment in which the child has developed ;" "the ancestral or prenatal history of the child is such as to project a strong light for the interpreta- tion of this condition as that of a neurotic inheritance."
The cases which I now present not only have been in court and committed as delinquents, but I fear would again be so com- mitted were they again brought into court. Three were tried on parole from the institution. Without this trial we should not have classified them as moral imbeciles. The characteris- tics of the other three were such that we could not ask any fami- ly to take them into a home.
Case i — E. P., aged fourteen years when admitted to the training school in January, 1905. Not noticeably peculiar in ap- pearance. Gait awkward ; expression commonly downcast and rather blank; bites finger nails. Only stigmata a high arched palate and some flecks in iris. _Has some mental capacity but her general instability affected also her school work. Able to do housework under supervision. Does beautiful darning and takes pleasure in it. The personal habits of this girl are exceed-
42 JOURNAL OF PSYCHO-ASTHENICS
ingly filthy and in this respect there was little or no improve- ment during her stay in the school. She is exceedingly obsti- nate, inclined to be lazy and her interest in any sort of work is fitful. Has a sullen disposition, is often impertinent, profane or obscene in talk. Her fits of temper are easily provoked and when angry she has torn her clothes and broken windows. She has gleams of good impulses but they are transitory and she seems to be entirely unstable, without any real desire or ambi- tion to do better. Family stock poor. She is said to belong to the notorious "Pool tribe," well known in the southern part of the state and in northern Pennsylvania. In this case there ap- pear the unreasonable fits of anger; the long periods of sulks; the habitual wilfulness and defiance in fa-ce of certain punish- ment ; the persistency of the traits, and the ancestral history as affording interpretation of the condition .
Case 2 — P. S., aged fifteen years on admission to the train- ing school in January, 1905. Brunette, rather good looking, no physical marks of degeneration ; manner, good-natured and indolent. Forgetfulness and instability of attention made her school work discouraging for herself and for her teachers. Though between eighteen and nineteen years of age when she left the training school, she was still struggling with the multi- plication table. In industrial work her leading characteristics were lack of concentration and almost total irresponsibility : e. g., her cottage work required constant supervision and in such rou- tine work as the daily making of bread she was apt to leave out the yeast unless some one were by to remind her. She was un- truthful. When tried on parole she displayed in several in- stances a perfect passion for the society of men and young boys, making improper and unwarranted advances and talking in a vulgar way. She seemed to be quite irresponsible in this re- spect saying with apparent honesty that she didn't know why she had acted thus shamelessly. Since her discharge from the training school and release from the regularity of its life and dis- cipline, she has deteriorated, her work being done in a still more slovenly way than when she was in the school and her tendency to purposeless lying has been accentuated. The ancestral his-
MORAL DEGEXERACY 43
tor}- shows degeneration of originally good stock. Father in- temperate; has an imbecile uncle on father's side. In this case the determining characteristics are motiveless lying, limited mental capacity, lack of judgment and will power, confessed helplessness to do differently. The ancestral history gives some reasons for the condition.
The third and fourth cases are sisters, colored; Jamaican ancestry; mother insane; father a criminal. Both brought up in an orphan asylum; both indentured and returned to asylum because of unsatisfactory conduct. The older one, case 3, aged fifteen when admitted to the training school, February, 1905, has no physical stigmata of degeneration. She had peculiar manner- isms and often a rather startled look suggesting a wild thing that had not known civilization and resented restraint, an im- pression at times furthered by a peculiar animal cry which she gave when discipline was necessary. Those familiar with her came to recognize a peculiar expression of her eyes which pre- ceded an outbreak. Possessed of attractive traits ; a natural leader; capable of strong affection ; having mental capacity; fond of reading but not of study ; very active and liking work except- ing when in one of her bad moods ; particularly fond of outdooi work; never amenable to discipline; a creature of impulses; violent at times ; noisy and destructive ; for prolonged periods and after days filled with outdoor work which she liked, she would spend hours in obscene talk and in singing vile songs ; she would pound the walls and floors with hands and feet, con- tinuing the noise and talk nearly all night ; she was not danger- ous for she did not bear malice though she might have inflicted an injury accidentally; indifferent alike to punishment and re- ward ; latterly she was less violent but never more obedient to the general rules of the institution. The conclusion, reached gradually following modification after modification of plans to reach and hold this girl, was that she was a moral imbecile. In no other way could we explain the unaccountable and unreason- able frenzies ; the habitual wilfulness and defiance in face of cer- tain punishment; the insensibility under disciplinary inflictions; the persistency of the traits ; the lack of reason for them. She
44 JOURNAL OF PSV'CHO-ASTHENICS
was in the training' school until May, 1907, when she was admit- ted to the State Custodial Asylum at Newark.
The younger sister, case 4, aged fourteen when admitted to the training school in October, 1905, was in form and face notice- ably unattractive but having no stigmata of degeneration ; ex- pression, habitually ill-natured ; figure, short and thickset ; a masturbator; intellectually capable; liked to read and to study but too insubordinate to be kept in school; possessed of tireless but wilful activity ; irresponsible about work. She was more un- reasonable and more violent than her sister; would have inflict- ed injury ; most of the time was as disagreeable, irritating, dis- gusting, obscene and destructive as she knew how to be ; she was daring, having no fear of punishment and no regard for reward ; at no time during her stay in the training school could she be said to have shown a desire to do well, rather, she was actively in revolt. Our diagnosis was based upon her unaccountable and uncontrollable frenzies; her willingness to inflict injury; her habitual wilfulness and defiance in face of certain punishment; her insensibility under disciplinary infliction; the persistence of the traits without reason for them ; the condition having inter- pretation from the ancestral history. In November, 1906, she was. returned by the training school to the county from which she came because "mentally incapable of being materially bene- fited by the discipline and training of the school," and by the county authorities committed to an institution for the feeble- minded. This institution returned her to the court as an im- proper subject, not agreeing, I understand, with our diagnosis. The last informaton I have of the girl is that she is in a Catholic institution and is docile. I do not know whether or not they think she could do well if free.
Case 5 — M. C, aged fourteen years on admission to the train- ing school in November, 1904. White, no physical stigmata, at- tractive in looks and manners ; low, pleasant voice ; expresses herself well in conversation. As a child, learned readily but for- got quickly. At one time could spell well and later became a poor speller. During the time she has been in .the training- school she has shown aptness and pleasure in school work; she is
MORAL DEGENERACY 45
bright mentally a'nd has some gift of expression in writing ; is very capable in all kinds of housework and in sewing. She was adopted at the age of five into the ordinarily comfortable Amer- ican home where particular attention was constantly given to her moral and religions instruction. In her sixth or seventh year she developed extremely filthy habits having to be watched like an infant to be kept clean personally. She was always untruth- ful but so plausible, so seemingly honest that it was very diffi- cult not to believe her. She had no pride either as to personal appearance or in choice of companions ; she would ruin a new garment on first wearing and laugh at its condition ; she would choose the low, the most common, for her friends. At one time, as a child, she was most attracted by a colored girl. She stole money once or twice after she was old enough to know what she was doing. She was indifferent to her home, destroying furni- ture and furnishings in her rompings. She loitered on her way from school and it could not be learned where she went. Final- ly she, wrote indecent notes to the boys in the school she attended and claimed she had had sexual intercourse with a young boy. This he always denied. Having once exposed her thoughts to her foster mother she seemed shameless about her knowledge of sexual matters. At home she was utterly lazy and irresponsi- ble. She was committed to the training school and there seemed to lose all these bad traits except untruthfulness and in this respect she improved greatly. In time it seemed proper to try her out of the school on parole. Within two weeks she had written tales of the home which later proved to have no founda- tion and which made us promptly transfer her to another home with which we were better acquainted. Here her stay was to be temporary and she was not treated as a servant, her youth, at- tractive appearance and manner making the woman feel that during her short stay she could treat her more as a daughter. The girl displayed all of her early characteristics; made the ac- quaintance of a low stable boy ; went driving with him nights ; visited with him at the house of a colored washwoman for whom she stole an expensive linen gown from the wonian with whom she lived ; told outrageous lies about nearly everything she spoke
46 JOURNAL OF PSYCHO-ASTHENlCS
of and finally ran away when she found the time had come for her to be taken to a new home. She was found in the house of an entire stranger and in a few minutes after her capture was laughing and talking as freely as ever with our parole agent. On my questioning her for reasons for her conduct by which she was cutting herself off from all opportunities, she was hard and sullen but finally she said she did not know why she acted as she did ; sometimes she wondered if she were crazy. At this time, particularly, she impressed me with her lack of apprecia- tion of the situation. She seems now to be more serious than she was formerly but the life in the school has never been irk- some as one would expect for a girl who came from such a home as she had. There is a strain in the family stock that is abnor- mal. Her paternal grandmother died insane. There are several divorces, and relatives of doubtful repute on her father's side. There are wayward cousins. The father is said to im- press one as "lacking in judgment." The diagnosis is based up- on the motiveless and persistent lying, more marked than in any other case with which we had experience; the lack of judgment and power of discrimination ; conduct the reverse of what might be expected from the environment in which the girl developed ; her confessed helplessness to do differently. The ancestral his- tory helps to explain the condition.
Case 6 — N. K., aged fifteen years when admitted to the train- ing school in February, 1905. Personal appearance attractive; manner bright and pleasing; expresses herself well; no physical stigmata; of average intellectual ability; as a child quick to learn. She has special aptitude for sewing and cooking; adopt- ed when three years of age ; claims her foster father was kind but his wife cruel and unjust and the child ran away four times. When angered by, something her foster mother said she put rat poison (arsenic) into some food intended for the mother. This was repeated frequently during the following six months, when the procedure was discovered and the girl sent to the State Industrial School. She remained there nine months when she returned to her foster parents, going to work in a tobacco factory ; got into bad company and her foster parents notified a
MORAL DEGENERACY 47
policeman to watch her on the streets at night ; angered at this she returned home early in the morning, broke into the house and took jewelry, money and clothes with which she ran away ; was overtaken, arrested and committed to the training school. She planned at least three escapes from Hudson, succeeding twice in getting away, both tims stealing clothing and material which she cleverly made up into clothing. On several different occasions she has planned to set fire to the building in which she lived but was betrayed by the girls whom she tried to induce to assist her. In November, 1907, she was paroled to a woman who had become much interested in her and who was anxious to give her a chance to make something of herself. As she is clever about sewing and likes it, a place with a good dressmaker was found but during the first two weeks she stole from her about $20. It was also found that she had stolen from the woman to whom she had been paroled. She also got possession of some jewelry in a way she would not explain. She told lies to this woman and to strangers and hinted with pride at having been immoral. While she had unusual advantages in this home she never showed any gratitude or appreciation for the many kind- nesses shown her. After her return to the training school which her conduct on parole necessitated, she was told of the death of her foster father and that she was considered indirectly responsi- ble for it. She showed no grief or regret for her act and this lack of feeling has always characterized her so far as we can de- termine. She indulged herself after her return in purposeless annoyances such as putting vinegar in the milk saved for the officers' table. Her father was very intemperate and served a sentence in prison for attempted murder. In this case the charac- teristics that led us to conclude that the girl lacked moral sense were the motiveless lying, the thieving, the impulse to- ward arson, the conduct different from what might be expected from her environment, the indifference, ingratitude, lack of nor- mal emotions, stupidity in the planning and execution of her mis- demeanors. The ancestral history shows poor stock. We were not really hopeful about this girl at any time but before parole I should have classed her as one of the wilfully "bad" eirls.
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JOURNAL OF PSYCHO-ASTHENICS
SUGGESTIONS FOR A PROGNOSTICAL CLASSIFICA- TION OF MENTAL DEFECTIVES
BY HENRY H. GODDARD, M. D., VINELAND, N. J.
In coming- to the question of classification, I should rather open a discussion than anything else. I have nothing final on the subject. I was early impressed with the fact that we are not all using the same classification. This results in much confu- sion. Roughly, we in the East, I think, say feeble-minded, im- beciles, and idiots. You in the West have only imbeciles and idiots.
Being agreed that a uniform classification is needed, the next question is, What shall it be? We have our medical classi- fication such as microcephalic, hydrocephalic, Mongolian, etc. What is the basis of classification here? Are we sure that there may not be a microcephalic Mongolian or a hydrocephalic Mon- golian ?
Again, what is the value of this classification? LIow closely can we classify? Take, for instance, the microcephalic. How small must a head be before it is microcephalic? It is a conveni- ent way to shelve these cases, perhaps, but does it help us in our dealing with them? Is a microcephalic defective limited defi- nitely in his powers? So far as my limited experience goes he is anything from a profound idiot to a high-grade imbecile so that we may have two-thirds of our entire range of defectives covered by this term. The other terms have the same difficul- ty. Suppose we turn to Barr's classification based on "train- ability," another valuable method but of no use until we have had the child in the institution long enough to find out how trainable he is. Also we must assume that the training we have attempted to give is the best possible. The child has had a fair chance and if he prove to be untrainable he is therefore an idiot; if he prove to be moderately trainable, he is an imbecile; if he
SUGGESTIONS FOR PROGNOSTICAL CLASSIFICATION, ETC. 49
prove to be highly trainable, he is feeble-minded. Here again it is of no value in itself unless we have had the child long enough to get well acquainted with him. But most serious is the fact that while we are getting acquainted with him the years in which he ought to be trained are passing. So it seems that we have great need for some sort of classification which will tell us at the outset very closely where this child is in mental development and what we may expect from him and what methods of treatment shall be applied. The ideal would be that in one-half hour we could get any case so settled that we should know accurately what to expect from him in the years to come and that we should know just what treatment to give him so that we should waste neither his time nor our energies in training. Whether we ever attain such a thing is a question. W nether we may not approxi- mate it seems not so discouraging a question. YYe may illus- trate by considering the classification of a library. We could classify the books by colored bindings. We could base our clas- sification on the size of the volumes if we liked. That seems very much like the size-of-the-head plan. WTe could arrange them according to the language in which they were written, as we sometimes do, or we could arrange them according to authors. According to this last, if we know the author we know what to expect. If So-and-so wrote this book you can depend upon its being good. If someone else wrote it you need read nothing but the title. So in this work we need titles — types — so that when we say a child is in such a class, that tells us the general facts about him.
I have a feeling that a motor control — how the child handles its muscles — may be ultimately a stronger basis of classification than the mental process, — the more purely psychological. Mind is a very evanescent thing; it is no longer considered an entity; it is the sum of processes and experiences and consequently very difficult to measure. Movements, which are the expression of mind, we certainly can and do measure.
By way of illustration I will call your attention to a study we have made, and a word with regard to the history of it may interest you. Our plan of investigation included anthropometry,
50 JOURNAL OF PSYCHO-ASTHENICS
but for lack of time I was able to take only the following meas- urements:
i — Standing height
2 — Sitting height
3 — Weight
4 — Grasp of right hand
5 — Grasp of left hand
6 — Lung capacity Having taken these measurements of a number of children we compared them with normal children by means of Smedley's percentile gradings of normal children in Chicago. We were at once struck with the fact that our children were always lower than the normals and especially was this true in grip and lung capacity. We next tested all our children and grouped them ac- cording to our institution classification (Barr's) from one to seven. Then taking the average of the group we again compared them with Smedley's percentiles. The result was that in these measurements of -grip and lung capacit}' the percentage of normal that these children can do varies exactly as the grade of the child. The senveth grade do about fifteen per cent, as much as the normal ; grade one (the lowest grade) do nothing.
Here, then, we have one item in a classification based on voluntary control of muscles. The dynamometer or the spirome- ter is thus shown to be of use in classification. Other motor tests are being used that will doubtless show the same thing and serve to supplement this one. Coming to the mental tests, we have, so far as I know, only two that we can consider. Dr. Nos- worthy presented a paper two years ago before this association, but she studied only the very highest grade, the Waverley school cases, and the best of those, so there is nothing there available for us.
We have the De Sanctis tests, six in number, which have the advantage of being very quickly applied. It does not take long to put a child through the six tests. These are good as far as they go but they do not classify close enough for our purpose.
The most elaborate set of tests we have are those of Binet, of Paris. It seems to me that a decimal classification would be
SUGGESTIONS FOR PROGNOSTICAL CLASSIFICATION, ETC. 51
the most useful to us. If so. Riuet's plan lends itself to this very nicely. He actually makes ten grades of defectives. He has five grades of idiots. That is more than we need. Let us say three grades of idiots, three imbecile and three feeble-minded. That makes nine. Call ten of the scale the normal child. We could divide them roughly, to start with, into the idiot, the imbecile, the feeble-minded ; then subdivide each into high, middle and low. The following are Binet's tests for these grades:
First, you have the profound idiot, the child who responds to nothing at all ; then the middle-grade idiot who answers Binet's second or third test ; the high-grade idiot who recognizes nourish- ment. Then you come to the low-grade imebcile who is dif- ferentiated from the idiots because he imitates. The middle- grade imbecile who comes next corresponds to the three-year-old child and is able to name objects and to recognize them by the name. The high-grade imbecile corresponds to a child five years of age and can remember and repeat three figures . He can com- pare two lines; he can compare two weights when the}' differ as much as 3 grams and 12 grains and he can define usual ob- jects— not. of course, logically. He will tell you that a dog barks; a house is something in which to live.
The lower-grade feeble-minded corresponds to a seven-year- old child. He can give you phrases; he can compare lines, mak- ing some errors when it comes to the lines that differ by 1 to 3 mm. in a hundred ; out of fifteen such comparisons he has from one to five errors ; the rest he gets right. In the seriation of the 3, 6. 9, 12 and 15 gram weights of same size and appearance he makes from one to three errors ; he transposes two sometimes. In this test, when the weights are shuffled and one is taken away and he is asked to tell which one has been removed, weighing them by hand, he fails utterly. He can not make rhymes.
The middle-grade feeble-minded corresponds to the nine- year-old child. In the list of hypothetical questions— What ought you to do when tired ? What should you do when you have done an irreparable wrong? — he can answer some of them. He makes from one to four rhymes in a minute. He can repeat four phrases out of eight ; he can remember 6.2 pictures on a card of thir-
$2 JOURNAL OF PSYCHO-ASTHENICS
teen pictures. In the sedation of weights he commits four er- rors ; when one of the weights is taken away and he is asked to tell by lifting the rest which one is gone, he makes from two to five errors.
To the high-grade feeble-minded you can give rhymes and he gets a large majority of the hypothetical questions. He re- peats five phrases, remembers 7.2 images out of the thirteen and recites six figures. He makes .2 errors in comparing the lines and 2.4 errors in the seriation of weights.
Here we have, then, a tentative set of mental tests which might serve as a basis for classification. There are many diffi- culties, many things to be worked out. The thing I want to leave with you, the purpose of this paper, in fact, is the question: Is it likely to be worth while to work together and try to evolve such a classification or does it seem utterly hopeless and useless?
I may add that our experience with these Binet tests is on the whole encouraging. They do indicate the grade of the child with surprising accuracy.
DISCUSSION
Dr. Little : I am very much interested in this paper for the reason that it is a movement in the right direction. Whether there is anything there of permanent value is a matter I will not attempt to express an opinion upon, but it has seemed to me ever since I have had anything to do with this work that it is time for the older and well established institutions — those that are well organized and doing mighty good work for the feeble-mind- ed— to attack the scientific side of the question. We know so little about the feeble-minded scientifically and we shall continue to remain in ignorance unless this kind of work is done. If a half-dozen, or more of the older institutions with a large number of children were to start up and maintain scientific work, we should begin to accomplish something.
Dr. Murdoch : I enjoyed the paper very much. I think it
SUGGESTIONS FOR PROGXOSTICAL CLASSIFICATION. ETC. 53
suggests great possibilities. With regard to the classification, it depends a great deal on what we have in view. I would not minimize the importance of etiological, clinical or pathological classification, such as the classification with regard to micro- cephalic cases or hydrocephalic or Mongalian. Things of that kind have great importance. We have the Mongolian idiot, the Mongolian imbecile, and the Mongolian feeble-minded child. I think the classification of degree of mental defect given by the English is very simple and very interesting. They distinguish between the idiot, the imbecile and the feeble-minded, in this way. The idiot is the anient, who, on account of mental defect existing from birth or an early age. is unable to protect himself from common physical dangers. The imbecile is able to protect himself from ordinary physical dangers but is one who on ac- count of mental defect from birth or an early age is not able to make a living even under favorable conditions. The feeble-mind- ed is one who is able to make a living under favorable circum- stances and by direction but who, on account of mental defect existing from birth or an early age, is not able to compete on an equality with normals or to conduct himself with ordinary good sense or judgment. 1 think that is a very simple classifi- cation of degree and one which we all could very easily apply.
Dr. Bernstein : In connection with the so-called pathologic- al classification, I think we have no right to consider it of any worth at present. Here is a case of microcephalis or hydro- cephalis — what does it mean0 I do not consider these terms indicative of any definite pathological condition; they refer to size. Mongolian does not mean anything definite pathologically, it does not suggest any underlying condition. We have no in- telligent pathological classification at present.
Dr. Rogers : I wish to express my gratification to Dr. God- dard and Mr. Johnstone, who have been promoting this work and using their laboratory to conduct investigations of this kind. We certainly need some leadership to prosecute more thoroughly scientific work with the feeble-minded in the way of studying what our material is. Dr. Murdoch has referred to the classifi- cation of the Royal Commission of 1894. It appeals to me as a
54 JOURNAL OF PSYCHO-ASTHENICS
very practical classification for popular use and I have partially adopted, it for certain purposes because of its simplicity ; but, as Dr. Goddard has suggested, all classifications of that kind rep- resent very general groups and often it would take some time to determine where the borderline cases between these different rarities belong. We need, as he suggests, something by which we can determine from a pathological standpoint what is best to be done with a given child. Of course, the training of a child is not all done in a formal school room as we all know. All of his experiences of life are part of his training as is the case with the normal child, but when the limitations as to capacity and time are as marked as they are in the cases of feeble-minded children, we certainly ought to know the most obtainable about their capacities at the earliest possible moment. I congratulate the association upon having in its membership those who are taking up this work and pushing it as the Vineland people are. Dr. Keating: In the practical working of this subject, from what has been said it seems that the different men here who have charge of institutions are quite far apart as to their choice of a classification. It seems to me we ought to get together — the in- stitutions, anyhow — and have a basis of classification.
TALIPES EQUINO-VARUS 55
TALIPES EQUINO.- VARUS BY H. F. McCHESNEY, M. D., BROOKLYN, N. Y.
In this paper on talipes equino-varus 1 wish to be brief on in- troduction and spend the major portion of time and energy on treatment.
ETIOLOGY . That we know little or nothing about the etiolo- gy of clubfoot is perfectly illustrated by a casual glance at the literature on the subject for no authors agree as to the cause, except along two lines, and only in a half-hearted way on these, the one, abdominal compression in the uterine cavity, and the other, arrested development. The theory of arrested develop- ment will explain some of the forms of talipes but by no means all. One other theory that is brought to notice is that there is an inequality of muscle balance in utero due to some central nerv- ous system lesion; but in most cases of congenital clubfoot we have well developed muscles and bones well developed, but the relative position of these bones and muscles is where the trouble lies.
I wish to divide the subject into two classes— the congenital clubfoot and the acquired clubfoot, and of these 1 wish to pre- sent the congenital form. Just a word about the anatomy of clubfoot and then we will pass on to the treatment, for the diag- nosis is simple and unmistakable and the prognosis is dependent on the efficiency of your treatment, the co-operation of your pa- tients and your own stick-to-itiveness. For the cases are some- times tedious and it takes patient persistence until the deformity is over-corrected and held in that position over a long period.
ANATOMY: The main deformity is a dislocation inward of the anterior part of the foot, the dislocation taking place at the mediotarsal articulation. This effects bones, fasciae, ligaments and skin. The scaphoid articulates with the side and under sur- face of the head of the astragalus, and in one case I have seen there was such an extensive deformity laterally that the scaph-
56 JOURNAL OF PSYCHO-ASTHENICS
oid appeared to articulate with the internal maleolus. The cuneiform bones follow the displacement of the scaphoid. The metatarsal bones and the phalanges swing to a right angle and in some cases to an acute angle with the axis of the leg. In very young children the shape of the bones is but little altered, while in older children there are marked and permanent changes in the bones. The alteration in position and shape is mostly in the os calcis, cuboid, astragalus and scaphoid. The os calcis is drawn from the horizontal and, in marked cases, approaches the verti- cal. It also rotates on its vertical axis as the anterior extremity is directed outward and the posterior extremity inward. This leaves the anterior articulating facet set obliquely to the axis of the bone. The cuboid bone follows the inward direction of the extremity of the foot. The astragalus does not rotate on its ver- tical axis but is depressed forward on its horizontal axis so that only the posterior portion of its superior articular surface is in contact with the articular surface of the tibia. The metatarsals are spread out like the ribs in a fan making the anterior portion of the foot abnormally broad. The tendons are displaced inward and there is atrophy of the calf muscles from disuse. There is secondary displacement backward of the knee and laxity of the ligaments if the case has walked much ; and, of course, callous formation from pressure if the patient has walked. The adult type differs only in secondary results of deformity and an aggra- vated distortion of the bone and tendon elements as well as the fascial contractions.
TREATMENT: This varies according to age, duration and nature of the deformity and should be purely mechanical or both mechanical and operative. The object of the treatment is the cor- rection of the deformity and the holding in a corrected position until any return to a deformed position is impossible.
These cases may be classified thus : First, the congenital clubfoot of the infant; second, neglected cases, or those showing great resistance ; third, adult cases left untreated. This is but an arbitrary classification for my own convenience and I would like to take up the first class only. If this class of case is treated at the proper time and in the proper manner the majority of them
TALIPES EQUINO- VARUS 57
will give good functional results and the form of the foot will be little altered and little or no atrophy will remain. One may look at this infantile type more as a twisted foot, for the changes in the bones are slight and the bones are largely represented by yielding cartilage that will readily reshape under favorable con- ditions. The treatment may be divided into the operative, or quick method, and the gradual. The operative method consists of a light anaesthetic and mostly all manual manipulation in twist- ing the foot and overcoming the varus. If very resistant the use of a block (which see) helps a great deal. The block is five inches high and has a base of 3x7 inches tapering at the top to one inch in width. The cut-out portion begins £4 inch from each end and extends to within one inch of the base of the block. A groove is cut V_\ inch wide and 3-16 inch deep around the block and a strong oak tan strap buckled tightly into the groove. This gives a hammock effect to the strap. Over this a towel may be placed and the foot moulded into shape. It is also a very use- ful block for the treatment of flatfoot as the moulding effect of the strap pushes the bones up into place and does not injure the soft parts. Turned upon its side it may be used as a Lorenz block for operation on congenital dislocation of the hip. The block is made of laminated oak pieces Y\ inch thick, glued to- gether and tested up to 225 pounds. The tendo-achilles usually stretches out readily but a subcutaneous tenotomy of the tendo-achilles is very simple and safe. The foot is put up in an over-corrected position and retained by a plaster bandage. This constitutes the first part of the treatment and the subsequent brace treatment is the same as will be taken up later.
The slower method is the gradual replacing of the foot into its normal relations by first overcoming the varus. This is ac- complished by the plaster-paris bandage or by the Judson splint. Just a word about the plaster-paris bandage that may be of some practical use. First, have some good, quick-setting bandages about two inches in width ; these should be soaked in warm wa- ter and salt should never be used as it gives a brittle cast and one which softens in damp weather. Take Z O adhesive plaster and place a strip on the outside of the leg reaching from the knee to
58 JOURNAL OF PSYCHO-ASTHENICS
one inch below the heel : smear on some vaseline over the out- side of the foot where the skin throws into wrinkles when the de- formity is corrected, then use a light flannel bandage down the leg and over the foot while the foot is held hi the corrected posi- tion. Don't put on the bandage and then twist the foot or you will make ridges that with the cast pressure will get you into trouble. Just a thin layer of cotton around the anterior portion of the foot and below the knee, also a light pad over the external maleolus. Be sure to have cotton between the toes. Don't get too much padding on or there will be difficulty with the foot turn- ing in the cast. As the bandage is put on bring the free end of the Z O adhesive plaster out at the ankle and incorporate this with the cast, rub in each layer of plaster and don't get too heavy a cast. This should be changed once a week. Don't let the mother make you believe this will stunt the foot, — non-treatment is what stunts and gives atrophy of muscle. A cast changed each week will never stunt in an}* way. This treatment will leave the stretched parts more relaxed after each cast and you will gain ground with each application. Forget the equinus until the varus is over-corrected and the os calcis rotates on its axis, and then you will be able to appreciate just how much equinus is really present. Then you may begin to overcome the equinus. After three months you can expect to shift onto your retention- brace treatment.
In selected cases where the tendency to rotate was marked I have had some very satisfactory results with the Judson brace. This is very good for the varus part of the deformity but I can- not make it work for the equinus. When 1 get to that stage I use a little brace which I have improvised and for convenience sake may be called the X brace. This brace, will hold the varus correction gained and by gradual change of angle of the foot- plate the equinus can be very satisfactorily corrected and held. The varus is not only held corrected but over-correction can gradually be brought about. I will not take the time to describe the application of the Judson brace as I feel that you all know how it works, but the X brace you may not have knowledge of. The brace is made of tempered brass, 1-16 inch thick for most
TALIPES EQUIXO-VARUS 59
cases and is cut out according" to the size of the child's leg and foot. At the lower extremity, 1^4 inch in width is about right, tapering to y\ inch where it will be bent for the heel. The pos- terior upright is y\ inch in width and at the upper end it is left \y2 inch wide to get a good application to the leg with the ad- hesive plaster. The angle at the heel varies with the amount of correction or over-correction of the equinus and the foot-plate is rotated in relation to the upright axis as the varus is corrected until the outer side stands half an inch or more above the inner side, thus over-correcting the foot. The brace is wound tight with a flannel bandage and the foot-plate strapped to the foot with adhesive, first over the toes and then over the instep. Then the upright is swung into position and a strap of adhesive put around just below the knee ; this throws up the outside of the foot and flexes the dorsum toward the shaft of the tibia. The X brace may be used following the correction of the varus with the plaster-paris bandages or with the Judson brace or as a second dressing following the operative correction of the foot. It is a good brace to wear until the foot is entirely relaxed or the child begins to walk, then the regular brace with the right-angle stop joint and interior riser and toe-lacing with the lacing over the in- step, can be used. We use the double bar or single inside bar ac- cording to the perfection of the correction. If the deformity is not completely corrected the single inside bar is best, with the in- step lacing and the lacing over the toes as well as the riser. If the case is well corrected the double bar brace with riser and without toe-lacing is the better. This has but a light tape over the instep to hold the brace in position until the shoe is slip- ped on. In the young cases when over-correction is desired the single-bar brace can be so shaped as to hold the outside of the foot about half an inch high and then the outside of the sole of the shoe is built half an inch high, and the child encouraged to walk. This tends to make the child toe out and thus overcome any rotation tendency there may be in the tibia.
One thing of great importance is to impress on the parents the necessity of treatment, the slow nature of the treatment and
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the importance of observation of the case during the brace-wear- ing period.
It may suggest to your mind that building the shoes on the outside would give us a flatfoot condition. Well, it does not for when we get to the stage of the flatfoot we have the case pretty well cured. Take off the brace and you will get enough con- traction of the fascia to give a recurrent clubfoot if you don't ob- serve the case closely and see to the wearing of proper shoes and keep the shoes built up a little on the outside.
mm
5
^
THEORY REGARDING EPILEPSY 61
THEORY REGARDING CERTAIN FUNDAMENTAL PRINCIPLES INVOLVED IN THE PRO- DUCTION OF EPILEPSY
BY A. L. BEIER, M. D„ CHIPPEWA FALLS, WIS.
There are many theories to be found in medical literature that fail most remarkably to throw any light upon, or, at least, that fail to give us a clear conception of, the fundamental princi- ple involved in the causation of epileptic or convulsive phe- nomena. Apparently we are not much nearer to the truth now than we were when the study of convulsions was begun. How- ever, a lack of success in the past should not discourage us from endeavors directed toward the discovery of the ultimate cause. The explanatory faculty of the mind, based on the indi- vidual experience of the thinking organism, may evolve theories that are on first thought captivating and* apparently adequate, which upon thorough investigation are proven to be false and yet have the power of misleading and misdirecting the student, for he feels that he may be tearing down pet ideas ; and, again, that he may be bringing upon himself an avalanche of criticism, ofttimes tinged with bitter ridicule. However, we all have the sublime faculty of erring, and that, in and of itself makes it possible for us to undertake so hazardous an attempt.
Our deductions, based on the meager facts that we are able to glean from nervous physiology and, incidently, from the great variety of observations on epilepsy, we hope will meet with kind consideration, and, at the same time, some degree of leni- ency on the part of men who have spent a goodly part of their time in the earnest endeavor to solve one of the most mysterious and perplexing problems that the science of medicine presents to us. After all has been said, after all theories have been sifted and resifted, we still find ourselves wandering amidst mazes to which vagaries have attached themselves, and we are forced to
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recognize a sphinx-like problem in epileptic phenomena that is as difficult of solution as the sphinx itself. We are confronted with the problem daily in our inspections at institutions ; casu- ally, on the street; anywhere, in fact. We hear a cry. Before we have had time to see whence the cry came we see a body pitching forward, tonic and clonic msucular contractions, and then we ask ourselves over and over again the same perplexing questions, Why? How? What is it?
When attempting to explain natural phenomena we are balked at every step, yet we do not feel content until we have evolved an explanation that is, at least, satisfying. However, we may reason from false premises. We may be unable to state facts, yet still be allowed the privilege of adding a few results of observation which have, at least to us, the intrinsic value of facts. Medical literature abounds with theories that attempt to explain epileptic phenomena ; different forms of epilepsy and different types of convulsions are recognized ; nearly every kind and type is regarded as having a separate, fundamental cause. We believe, however, that we are justified in our conclusion that all convulsive phenomena have as a basis for their exist- ence the same underlying active principle in any and every case. But, as someone once said, "Hypothesis follows hypothesis; the ruins of theories are piled one upon the other; but truth never escapes us." It may be that this attempt is as futile as other attempts have been when ultimate truths are brought before the tribunal of human curiosity. We may be simply evolving another theory that will be consigned to that pile of ruined theories that time and experience have erected.
Histo-pathology offers no solution of the problem that con- vulsive phenomena present to us. It has vainly attempted to pierce the veil shrouding it in darkness, but practically nothing of value has been learned. True, we have been taught to look somewhere else ; we have been taught that we must use other methods to solve the mystery. We believe that physiology, the study of functions, will aid us in determining the ultimate princi- ple underlying the generation and perpetuation of convulsions, for a convulsion points to a function of the nervous system that
THEORY REGARDING EPILEPSY 63
is present even under normal conditions. A convulsion, we be- lieve, is primarily a normal manifestation of the nervous system becoming a disease when the convulsive habit is established. A\ hen this occurs epilepsy exists.
Along- with the physiological aspect of the study, the next important factor that presents constant and interesting features, is the etiology of the condition. We will sum up brieflv the various causal agents that simply serve as so many sparks ignit- ing a function that lies dormant in an active part of the nervous system.
Heredity is an important factor both from a sociologic and a medical standpoint. It predisposes the organism to convulsive seizures in two ways. The active function may be directly transmitted from an epileptic parent to the offspring. Again, it may bequeath an instability as is evident in the children, the offspring of neurotic, psychopathic, alcoholic, syphilitic, tubercu- lotic, etc., parents. Xo one will venture to deny that chil- dren endowed with a faulty heredity are more prone to convul- sions than children whose ancestry approaches the normal more closely. In fact, it seems that only a slight factor is required to engender convulsive seizures in children some of whose an- cestry have been subjects of epilepsy.
Age, also, has quite an important influence. Convulsions are more frequent and more easy of production in children than in adults. Perhaps about eighty per cent, of all epilepsies are developed before the age of twenty years.
Traumatism is also a factor that perhaps produces the most pathetic results. The manner in which it is influential in the production of -convulsions will be considered later.
The emotions play some part. Fright, intense excitement, grief, profound anxiety, shock, etc., are considered capable of ex- citing convulsive attacks.
Intoxication is one of the most frequent, causes of convul- sions. Thus wre have puerperal eclampsia based on severe auto- intoxication; we have convulsions caused by diabetes; by uremia; by chronic nephritis; by syphilis, alcoholism, plumbism, and auto-intoxication due to a variety of causes. Convulsions
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are seen in connection with the various fevers : scarlet fever, measles, typhoid, tyhus, and yellow fever ; malaria, pneumonia, influenza, diphtheria, etc. The convulsions in these cases are undoubtedly due to the toxic state of the blood.
Convulsions arising from seats of peripheral or sympa- thetic irritations, the so-called "reflex epilepsies" of different writ- ers, are ofttimes met with.
All students of epilepsy agree that the study of the condition must be centered about the production of the first convulsion. A convulsion, we maintain, is a normal, physiological manifesta- tion of nervous phenomena subserving the function of a particu- lar nervous center, being pathological, not per se, but thorough the morbid causal agent which initiates it and through the mor- bid conditions it develops, arising, invariably, from sensory im- pulse. We find sensory and motor phenomena inseparably as- sociated with each other. Without the one the other does not exist. The function of the nervous system is to conduct, direct — not initiate — impulses. Associated with this function is the faculty of memory which means that an impression while being conducted leaves in its pathway a change more or less indelible, such that when another impression afterwards proceeds along the same route it finds, as Romanes said, "the footprints of its predecessors." Morat says, "An impression, by being itself renewed and by renewing the sensation, forms habitual paths for itself in the nervous system. . Not only does it create its own paths which cause it to have in this system always the same reverberation, but it continues permanently in them." A convulsion once pro- duced, a greater predisposition obtains, and, as a result, a slight causal factor may precipitate a repetition of the act, which repe- tition, if frequent " enough definitely thereafter establishes the habit.
Again we find ourselves confronted with the all-important question: How is a convulsion produced? A convulsion points mainly to motor phenomena in its expression. Sensory manifes- tations are barely observable, except in cases presenting sensory aurae ; and, yet, it is hardly to be doubted that all convulsions are initiated bv sensorv stimulation. Sensorv stimulation
THEORY REGARDING EPILEPSY 65
means . an expression of the motor properties of the neu- rone or neurones involved. A convulsion points to a common active force : a distinct action of an especial, organized media governing' certain activities ; producing disturb- ed consciousness and disturbed motility. An act of the nerv- ous system that presents such constant features, a force common to or observable in the act in its every manifestation, points neces- sarily to a center. Stimulation of a center may obtain in a variety of ways. A toxic condition of the blood may act as an irritant to the center, which irritation may suffice to produce the motor properties which characterize it. Again, it may undergo stimulation through any variety of impulses, sensory in charac- ter, which may be conducted directly to that point, or which may be reflected to that center over different pathways. The stimu- lus to the center may vary both in intensity and kind. Hence, if we admit that convulsions subserve the specific function of a center, we can readily see that there is a possibility of having a variety of convulsions differing both in degree and in kind.
Consciousness may be impaired or suspended for a variable length of time. Muscular coordination, in so far as volitional movements are concerned, is entirely lost. Contractions, tonic and clonic, occur in a great many cases. A part or the whole of the voluntary muscular system may be involved. There may be only a momentary suspension of consciousness, manifested, for example, by a repetition of an act that the individual was per- forming at the moment that the attack began. Again, the motor manifestations may vary from a slight start, a momentary tonic fixation of a group of muscles, to a generalized tonic contraction of the entire voluntary muscular system followed by clonic con- tractions. The movements are incoordinate and purposeless.
In studying the etiology of convulsions, it becomes ap- parent that any irritation to the nervous system, be it central or peripheral, if sufficiently intense and prolonged, is capable of producing convulsions. Hare, in his book on epilepsy, mentions a case where prolonged tickling of the feet resulted in a typical convulsion with loss of consciousness, in a man who was not subject to epilepsy. He cites another case where a man, not
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an epileptic, was thrown into a convulsive seizure after a pro- longed, intentional attempt at barely touching- the edge of a table with arms directly extended before him. He was experi- menting as to the length of time he could perform the act when he was thrown into a severe spasm. Convulsions seen in women during the puerperal period , convulsions occurring in diabe- tes, in uremia, and in the fevers, etc., in individuals apparent- ly normal, lead one to assume that the capacity for convulsions exists in all persons. No one seems to be immune. Young and old are liable to convulsive manifestations ; the old not so much so as the young in whom reflex activity is most pronounced. Dr. Wilmarth kindly mentioned a case to the writer where a man of powerful intellect, personally known to him, had at the age of sixty years a severe convulsion at the onset of an attack of pneu- monia, never before having had such an attack. Subsequently, up to the time of his death which occurred a few years later, there was no repetition of the act. Some time ago, while walk- ing through a ward, a low-grade boy was dozing or sleeping in his chair. I touched him rather lightly on the vertex of the head with a percussion hammer that I carried and was rather surpris- ed at the result of my interference with what seemed a peaceful siesta. The boy emitted a cry- that closely resembled the cry frequently heard at the beginning of an epileptic seizure. There may have been a generalized momentary tonic contraction which I did not observe for there was too rapid a sequence of events. There must have been a sudden contraction of the vol- untary muscles powerful enough to throw the boy to the floor. When T turned to see the result of my action his limbs were undergoing a number of rhythmic contractions in rapid succes- sion which lasted about one-half minute. He then arose slowly in a dazed way, reeled once or twice from side to side, then stag- gered to a chair and finally roused entirely. I do not think it probable that he was conscious of anything that transpired. This patient was not an epileptic, never to my knowledge having had a convulsion before or after.
Convulsions, then, are seen in young and old , occurring in individuals comparatively normal , initiated by a variety of
THEORY REGARDING EPILEPSY 67
causal factors. \Ye can not imagine so great a variety of causes as capable of producing" convulsions that present in their expres- sion such constant features, unless these causal factors simply act as excitants to a center of the brain whose function it is to initiate phenomena, under stimulation, seen in this disorder.
There is a tendency among students of epilepsy to regard the cortex of the brain as intimately concerned in the production of convulsions. Cortical epilepsy, considered as a disease, does not exist, for. in cases of traumatic epilepsy, in cases of hemiplegia where the injury can be more or less definitely located, removal or eradication of the existing lesion does not abrogate the con- vulsive seizures. Again, in cases of hemiplegia where the lesion is located in the higher levels, for instance, in or about the Roland- ic fissure, it is hardly rational to suppose that the convulsive seizures are governed by the area involved. It is highly improba- ble that a cortical area whose functions have gone into disuse is still capable of producing motor manifestations as severe as seen in epileptic phenomena, except that the lesion, simply by its presence, either acts as the seat of chronic irritation, or initiates new and varied impulses which are directed to some lower center for distribution, or inhibition, or conservation. Furthermore, such a diseased area can be regarded as one that has practically been eradicated by excision, at least until the part has suf- ficiently recovered to again assume its function. However, the convulsive seizures once begun do not cease. Moreover, experi- mental removal in animals of the entire cortex does not elimi- nate the possibility of eliciting convulsions by stimulation of the basal ganglia. Therefore, we are compelled to regard the lower centers as capable of producing such phenomena inde- pendent of the higher centers or the cerebral cortex. We believe that the basal ganglia are profoundly concerned in the evolution and the perpetuation of convulsive phenomena. We believe that there is a center that governs convulsive seizures, even as there are centers that govern vomiting, coughing, and other acts that nature has provided. We believe that generalized convulsions cannot be produced in an area higher or lower than the basal ganglia.
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Observers have been naturally led to suppose that the cere- bral cortical area marks their origin or governs their production because consciousness is always involved and because it is as- sumed that, consciousness is an attribute of the cortex of the brain alone. That consciousness is diffused through the entire cortical substance, is, to say the least, doubtful. Dr. Frederick Petersen, at a meeting of the New York Neurological Society held October 6, 1908, says: "In my opinion the seat of that pow- er which produces the manifestations of consciousness is in the basal ganglia, probably the corpora striata, and consciousness is a peculiar summation of energy at that point capable of being directed like the rays of a searchlight into this or that portion of the brain." Loss of consciousness is, perhaps, the principal feature in a convulsive seizure. Ofttimes it is the only symp- tom of the epileptic disorder. The suddenness of onset of un- consciousness is constant and unique. It is as rapid in develop- ment and similar to the unconsciousness produced by a sudden, severe blow on the head. Frequently the victim drops as quick- ly at the beginning of a convulsion as he would had he received a severe blow on the head or an injury to the base of the brain. This loss of consciousness may be the only manifestation of epi- leptic trouble, as is exemplified in an attack of petit mal.
There are certain conditions that closely simulate the un- consciousness produced in an epileptic seizure. As mention- ed before, a sudden loss of consciousness occurs as the result of a severe blow on the head ; there is no visible lesion. Faint- ing, or the so-called cardiac syncope, is another example. These occur without spasm. A gentleman who afterward developed grand mal seizures, stated that unconsciousness came upon him not infrequently while walking the street; that he would find himself, upon recovering, in the middle of the street or at some point a short distance from where consciousness left him. In this case the power of locomotion was not completely lost but consciousness of surrounding objects was momentarily obliter- ated. Dr. Wilmarth mentioned the case of a boy who came un- der his observation a few years ago. The case was unusual from the fact that the slightest touch anywhere on his head would
THEORY REGARDING EPILEPSY 69
cause him to tall as if struck a heavy blow with an axe. This would not occur it he was conscious of one's intention. After a little while he grew suspicious and would watch closely any person who showed any inclination to touch him. The observer one time lighted a Bunsen burner while the child watched him intently, and threw the match unthinkingly on his head. He fell instantly to the floor. The period of unconsciousness did not last at any time over half a minute when he would rouse, look- ing dazed, and resume his occupation. In a few months he de- veloped true epilepsy and thereafter these falls could not be induced by touching him, as formerly.
It is generally recognized that subjects suffering from svn- cope or subjects of vertigo, "blanks", "absences", "darknesses". are especially liable to the development of true epilepsy. Fur- thermore, epilepsy may follow traumatism of the head. What causes this sudden change from what seems a simple disorder to the development of one of the most awe-inspiring maladies? What causes the temporary loss of consciousness in any of these cases? The cause is difficult to explain. We know so little about consciousness that it is nearly impossible to draw any conclusion from phenomena seen in its suspension. It has been suggested that unconsciousness is due to a change in blood pres- sure, but the rapidity with which the change occurs arouses doubts as to whether any vasomotor disturbance could act quick- ly enough to account for it. Resides, this change in blood pres- sure has not been proven. Consciousness and epilepsy we find closely associated. Without at least a disturbed consciousness the latter does not exist. In cases of petit mal where uncon- sciousness may last only a momentary length of time it is rather difficult to understand how consciousness can be regained so quickly if the unconsciousness is due to a vasomotor disturbance. How could the entire cortex recover with such remarkable speed? We believe with Dr. Petersen, quoted heretofore, that the power of consciousness has a definite seat, and that it is "a peculiar summation of energy at a certain point in the basal ganglia capable of being directed like the rays of a searchlight into this or that portion of the brain." We believe that the uncon-
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sciousness due to a blow on the head is like unto the uncon- sciousness developed in an epileptic seizure, initiated by an im- pulse or a succession of impulses which find their way to some lower center which governs consciousness and which are too powerful for inhibition. Unconsciousness then supervenes. In epilepsy, impulses may issue from either the higher centers or from the peripheral space organs ; the result is practically the same and points to a similar nervous operation.
When conscious, we inhibit many reflex acts daily. It ap- pears that only with the loss of inhibition that consciousness exerts over motor manifestations, do purposeless motor acts arise." When the inhibitory influence of consciousness is lost, we naturally have a disturbance of motility which varies in both degree and kind, dependent on the kind and intensity of sensory stimulation. Immediately after the suspension of consciousness in convulsive seizures, the muscular movements begin, follow- ing each other with almost perfect rhythm until the nervous force appears to have exhausted itself. The subject may regain consciousness quickly or gradually. Here we are confronted with the original question : In what portion of the brain do these muscular or motor manifestations originate? As said before, it is hardly possible that they originate in the cortex. Convulsions are especially liable to occur in infancy ; they may occur even shortly after birth when the gray matter is but illy developed ; it would appear extremely improbable that so poorly developed a structure could bring about such terrific muscular movements. Moreover, a case is on record where an anencephalic monster, with the cerebral hemisphere practically wanting, had convul- sions during the brief period that existed before its death. Again, where generalized convulsions have been induced artificially or experimentally in animals, it has been found that they can only be generated by stimulation at some point higher than the me- dulla. Moreover the centers in the medulla have been quite thoroughly localized and no centers have been found that govern this act.
If all stimulated movements are regarded as being reflex acts, we would say that a convulsion is always a complex reflex
THEORY REGARDING EPILEPSY 71
act ; that is. is always dependent on some form of sensory stimu- lation of a center that appears to manifest its function, or motor responses, automatically. Even automatic acts are simply reflex acts. A nervous center cannot act spontaneously ; it must be ac'ted upon by some form of stimulation ; its response is automatic, subject, to a greater or lesser degree, to inhibition.
There is one reflex act that so closely simulates an epileptic seizure that observers cannot help but see the similarity. Fright, depending upon the causal factor for the intensity of the motor and psychical manifestations, elicits a reaction or reflex phenome- non as powerful, or nearly so, as an epileptic attack. We find conditions of the mind quite similar ; there is momentary un- consciousness, or at least confusion of ideas ; also disturbance of motility which in some instances bears a close resemblance to a slight tonic contraction of the voluntary muscular system ; this is sometimes followed by a shudder or even by a succession of tremors. Again, there is sometimes heard the cry which is en- tirely involuntary. We also ofttimes witness the ashen paleness seen at the beginning of a seizure. Severe fright even causes in- voluntary micturition and defecation, as is often remarked in a true epileptic convulsion : in fact, fright has been known to cause epilepsy, demonstrating that a convulsion differs only in degree from a severe attack of fright.
Severe, involuntary muscular movements, convulsive i n character, are seen in chills caused by exposure to cold ; the chills seen in malaria, in septic poisoning, at the beginning of an acute fever, vary in intensity and closely simulate the rhyth- mic movements seen in an epileptic seizure. True, conscious- ness is not lost, and yet it can be safely assumed that the same motor mechanism is brought into activity.
Life is filled mostly with reflex acts. Spencer defines life as "the continuous adjustment of internal and external rela- tions" ; ultimately and definitely, as far as we are able to say, it is a complex system of reflex acts. The lower we descend in the scale of development, the more evident reflex activities are. Consciousness has its analogue in reflex activity in the lower organisms. There seems to be a particular realm of the brain
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that has control over the major reflex acts, and, moreover, re- cords a memory of these acts. It is true that all psycho-neural acts by repetition or training- become more and. more easy of ac- complishment. A certain automatism is produced. We know that no matter how thoroughly we understand the mechanism of an act, it is first necessary to train our muscular system in the performance of the manoeuvers recpiired ; that after a number of repetitions but very little direction is needed. The attention of the individual performing the act may even be diverted, and yet, muscular movements of a complicated character go on smoothly and accurately. Thus we see a pianist capable of ma- nipulating the keys more or less automatically ; the rapid move- ments of a boxer or a fencer ; the perfect adjustment of force and direction shown in the act of throwing and catching a ball in individuals trained in ball playing. These phenomena occur as rapidly as the eye is able to appreciate the existence of an external influence. We feel justified in saying that it is highly im- probable that the higher centers are involved in the performance of an act whose accomplishment has not been subjected to the tardy action of volition. The memory of the act and of fore- going similar acts, persists and can be reproduced by volition. Automatic acts can be initiated or inhibited by an act of vo- lition; the presence of volition presupposes the presence of con- sciousness. We believe that the basal ganglia are intimately concerned in these rapid responses to suddenly arising stimuli and also have the inherent power of regulating automatically the motor responses necessary to the individual life of the or- ganism, independent of the so-called higher centers. Physiolo- gists claim that the corpora striata are deeply concerned in the regulation of automatic movements. These bodies lie in a po- sition convenient for the reception of impulses arising from the different senses. They are in close proximity to the corpora quadrigemina which are particularly connected with the exer- cise of the special senses, sight, hearing and smell. This we would expect, for the majority of the major reflex acts are closely associated with the impressions made on these senses. Again, the}' are directly connected with thalami which receive
THEORY REGARDING EPILEPSY 73
the sensory impressions from the entire body ; also with the in- ternal capsule, the cortex, and. lastly, they are attached by con- necting fibres to the nuclei of the gray matter of the pons. The elements which go to make up these connections convey im- pulses in one or the other direction; part of the fibres which compose it ascend, and the others descend. Little definite is known regarding the function of this area, but we do know that it is capable of coordinating into motor actions the impres- sions coming from the periphery, thus taking active part in the regulation of the higher and more complex psycho-neural re- Ilex acts. Furthermore, we know that irritation of one of these bodies results in contractions of the musculature of the side opposite the body stimulated.
This particular area must, indeed, be an important one, for comparative anatomy teaches us that it practically exercises the function of the brain, in a rudimentary way, in organisms where the cortical covering is still absent. In these organisms: — fish, for instance — the power of locomotion, though a reflexly or automatically performed act. is well developed. Consciousness, we can safely say, is present in these organisms in a rudimentary way. The higher consciousness, mind, including intelligence and volition, seems to have developed in direct proportion to the development of the superimposed structure. So long as we are unable to strictly define consciousness, it is not illogical to suppose that a specific area controls its various manifestations. Moreover, if we grant that consciousness is present, even in a rudimentary way, in organisms where the cortical covering is still absent, it would appear rational to assume that the various superimposed structures contain within themselves the elaboration of a system of more finely developed structures that act mainly as storehouses of the various experiences encounter- ed in the life history of the organism. If the power of con- sciousness is centered in the basal ganglia, or more particularly in the corpora striata, then we can readly understand how a nervous discharge proceeding through these bodies is capable of producing instantaneous unconsciousness or disturbed conscious- ness.
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We cannot find a more reasonable location for an area which governs such psycho-motor manifestations than the corpora striata if we are correct in our assumption that a convulsive center does exist. If our conclusion is founded on a shadow of truth it becomes an easy matter to explain the initiation and per- petuation of the convulsive habit. Thus, in looking over the various factors that we know to be capable of producing con- vulsions, the modality of its operation becomes more clear to us. We can readily understand why heredity plays such an important role, for in children, the offspring of psychopathic or neurotic parents, we find them more liable to convulsive attacks on ac- count of the fact that a nervous instability has been bequeathed to them ; and, furthermore, they may be considered to be,, in the scale of development, a little lower than the parent ; and, again, the lower we descend in organic life, the more evident is the reflex activity. Age has an important bearing because the younger the individual the more prone is he to the manifesta- tions of reflex activities. It appears probable that only an in- tense sensory stimulation of a portion of the brain that is intimately connected with every part of that organ and located at a point where it receives impressions from all over the body through the organs of special sense, and, furthermore, through the entire sensory apparatus, is required to render such marked disturbance of consciousness and motility possible. The corpora striata are in such intimate connection.
Whatever the exciting cause, it acts like a lighted match touching off what is otherwise a dormant cannon, eliciting, if powerful enough, a motor and psychical response so great as to throw the organism into unconsciousness, which means a loss of the inhibition that consciousness exerts over reflex acts and a resultant succession of motor discharges that sweep over cere- bral and spinal pathways uninhibited and that are sufficient to institute contractions in the muscular system until the center has become exhausted. The convulsive habit once engendered, only a slight physical rjr psychical disturbance is required to pre- cipitate a seizure and then the act appears to arise spontaneously.
If convulsions subserve the function of an especial center,
THEORY REGARDING EPILEPSY 75
the question naturally arises : What useful part can this func- tion play in life's history? Nature supposedly selects only those parts that are useful and these are transmitted. As organ- ization advances in the developmental scala, the useful parts are retained and the unnecessary, supplemental parts are gradu- allv eliminated. It is quite impossible to say just what role convulsive phenomena have played in life's history, and, yet convulsions have occurred since time immemorial. A convul- sion is apparently only one of the man}- incongruities with which life is filled. \\ "hen we understand vital phenomena somewhat better ; when we know what consciousness is ; when we thorough- ly understand normal nervous processes then we shall, per- haps, be more able to say what convulsions mean and how, where, and why. they arise.
If our supposition that there is a specific center that con- trols convulsive phenomena is correct ; if this center exists in all persons and is capable of being excited into activity at any time that the stimulus is sufficiently severe or long-continued, it demonstrates to us how little advance we have made in the treatment of established epilepsy. It shows us how truly un- scientific the present method is for we are groping in the dark hoping at the same time to find a something that will obliterate the tendency to convulsive manifestations. We dull the activity of the brain with opiates, bromides, and other drugs, but disap- pointment greets us in nearly every instance. It is impossible to treat an individual rationally while the real, existing cause eludes us. However, it must be confessed that in the present state of our knowledge it is the only course that we can pursue. The fact that the ultimate cause is difficult to discover should not deter us in our search for the underlying principle concerned in the production of that most terrible and pathetic condition, epilepsy. Laboratory and clinical work should be combined in order to facilitate the discovery of the true cause. It is a fact that the study of nervous diseases is less advanced than any other branch of medical science. The general practitioner natu- rally looks up to the medical men that have made this type of diseases their life work, for information. More research work
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should be done at institutions where clinical and laboratory ma- terial is never wanting. We see a case presenting peculiar symptoms during life. Why not at least try to discover the cause on the post-mortem table?
DISCUSSION
Dr. W ilmarth : I think those of us who have been in the work some years realize what a hopeless task we have had in the study of this malady- We have never been able, I think no one has ever been able, to locate it as a distinct disease. The hope of epilepsy lies in the pathological laboratory associated with clinical observation. Many years ago an effort was made to establish a regular bureau of observation, which was to collect material from the different institutions, but the bureau did not materialize. Such as is done is now principally done by officers in institutions whose numerous other duties constantly interfere with their work. It seems as though every state could hire someone to do this work and give him an adequate salary. I doubt the expediency of a central bureau for this work. I doubt the advisability of any one man pursuing it. If four or five in- stitutions could have officers who could get together and compare their work, I cannot help thinking that in a few years we should be in much better position to combat this dread disease, having a more thorough knowledge of its origin. Instead of spending time in alleviating, we might perfect more recoveries.
Dr. Smith : It would almost seem that an)' state that can positively number among its inhabitants one thousand epileptics could at least fmrnish pathological insight into the cause of that epilepsy. I wish this conference could furnish some influence that would enable us to bring that about in the states where at least that number occur.
RELATION" OF FEEBLE-MINDEDNESS TO DISEASE 77
RELATION OF FEEBLE-MINDEDNESS TO DISEASE BY A. R. T. WYLIE. M. D„ FARIBAULT, .MINN.
.Mental defect modifies the relativity of the individual in all its modes more prominently perhaps in the psychological, soci- ological and economical spheres but also in the pathological. And it is this last particularly to which we wish to call attention.
Feebie-mindedness is a morbid condition of the mind which renders it impossible to bring up a child to respond to his sur- roundings like a child of his own age in his own community. This condition is due to the imperfect or arrested development of the neuoms of the cerebral cortex. They are fewer in number than in the normal brain and are irregularly arranged. They are imperfectly developed, as shown by the large nucleus and ec- centric nucleolus of the pyramidal cells. These are often globu- lar or pyraform in shape with the angles wanting. There are fewer dendrite and gemmules. There are also found cells like neuroblasts. There is pigmentation in the deep pyramidal lay- er, and the tangential nerve fibres are less in number. These conditions have been found most pronounced in the pre-frontal and the parietal association centers of Flechsig. Thus we have a basis and in a way an explanation of the chief characteristics of feebie-mindedness, dullness of sensation, deficiency of atten- tion and perception ; limited association, narrowness of mental fields, lack of judgment and deficiency of initiative and will pow- er. These all modify to a more or less extent the course and progress of disease processes and our care and treatment in the handling of them.
The sense dullness of mental deficiency delays our recogni- tion of disease processes so that we often do not recognize our cases until they are much farther advanced than with normal people. H. Y., an epileptic with spastic diplegia and choreoform motion, inmate of our institution for ten years, had been of good health. On October 30, 1908, she was indisposed and re-
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fused her meals but was sitting up. The next day she was put to bed against her will and at 3. p. m. showed symptoms of col- lapse. Her temperature was 104.8 degrees; pulse, 120, but very weak at radials ; respiration, 30. Strychnine and adrenalin were administered and condition improved. There was myosis but pupils responded to light. Conjunctiva had been noticed to have been rather yellowish for some time. Large mucous rales throuohout the lung's. Diarrhoea with some blood. Abdomen not distended, not tender. Liver retracted. Bloody discharge from vagina. Skin muddy. On November 1st, was somewhat improved. Replied to "good morning". Temperature, 100.6 degrees; pulse, 120; respiration, 30. Coma returned and con- tinued to the end. Conjunctiva white. Mucous and bloody stools. November 2, temperature, 101 ; pulse, 130; stools, same. Died at 11 :20, p. m. Temperature, 103.8; pulse, 148 and respira- tion 44. At autopsy a few tubercles and some adhesion were found at apex of left lung. Liver hobnail and about one-half normal size. Left lobe very small. Microscopic examination showed cirrhosis and fatty degeneration. Diagnosis was given as cirrhosis of the liver with hipatic insufhciency.
Simetimes a disease may exist without symptoms, as Sollier, I think it is. mentions a case of gangrene of the lung which came to autopsy without a suspicion that such a condition existed. And no doubt some of our cases of sudden deaths belong here. Dull sensation, it seems to me, accounts for the common absence of cough in our cases of pulmonary tuberculosis. Physical signs show that there is plenty of secretions in the bronchia to call forth the reflex. So the sensitivity of the bronchial mucous membrane must be so dulled that the initiatory irritation never arises. Perhaps the effect of dulled sensibility is more notice- able in the realm of the pain sense. How often is our attention first called to a decayed tooth when it is badly ulcerated and the face swollen. Again we oftentimes do not make use of a local anaesthetic (cocaine) since the trouble attending its use is great- er than the pain from which we would wish to protect our pa- tient. Ingrowing toenails have been removed without a wince on the part of the patient. This has its good side. Our patients
RELATION OF FEEBLE-M1NDEDNESS TO DISEASE 79
are not in as great discomfort in their sicknesses. One of my pa- tients in the second stage of smallpox was so sore that the only comfortable position she could get into was on her hands and knees, yet she was playing games with one of her fellow suffer- ers. Many of our children even seem to enjoy poor health. One of my girls was much worried for fear she would not have small- pox when many of her friends were thus afflicted. Her hopes were finally realized and from the extent of the disease she must have been very well satisfied. This sense dullness leads to the enjoyment of strong sensations. I have one instance in which this seemed to have a stimulating psychological effect. One boy who was a good worker but did not or would not talk, came to the dentist chair one afternoon when I operated successfully with the assistance of half a dozen others and a bottle of chloro- form. For a year afterwards he never would stay within speak- ing distance of me. then, his fears being overcome somewhat, he always saluted me as often as he met me with a hearty "'Good morning, Doctor".
Defective vision is fairly common among our children, but correction of refractive errors does not seem to bring much bene- fit except among the higher-grade pupils. One boy, however, who was very near-sighted, after having a double tenotomy oper- ation, was fitted with a -15.00 sphere. This has enabled him to learn to read. The dullness and abnormalities of taste are especially noticeable among the lower grades and particularly the desirability of a strong sensation. How else can we account for the eating of and even the preference for garbage, dirt, dust, rags, stockings and skatophagia. Some of our children have passed pieces of stockings and one a bandage a yard long. One of our eastern institutions has a small snake that one of the children passed. One of our children seized a small dish of pins and swallowed a number of them. After a liberal diet of potatoes thirteen were recovered. Bolting of food is the rule among the lower grades so that ground food is necessary in order to nour- ish them and protect them from danger. Some years ago one of the custodial girls was thought to have had a spasm at the breakfast table. She was removed and a physician called, but
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before he reached her she was dead. At autopsy an insufficient- ly cooked half apricot was found securely wedged in her glot- tis. She had died of strangulation. As also showing the lack of the feeling of discomfort, it might be well to tell of a boy who was detailed to help the storekeeper in issuing weekly supplies. He came to the dispensary one noon complaining of something in his throat. On inquiry it was found that this condition had ex- isted for twenty-four hours and he had been unable to retain even water. It was found to be a piece of meat lodged part way down his gullet. This was dislodged by mean's of a stomach tube. In this connection and as bearing on the nature of milk as a food it might be well to relate another history. A boy was sent to the hospital with the symptoms of acute indigestion. He did not re- spond to treatment but the condition kept up. Eventually he threw up a white mass having the marks of a cast of the pylorus. On examination this was found to consist of milk curd with starch granules. The boy promptly recovered.
Defective nutrition and difficulty of cleaning are especially conducive to the early and quick decay of the teeth of the feeble- minded. The quickness of decay is especially noticeable, a month often showing marked changes in this respect. This, in turn, interferes with the nutrition of the child and a "vicious circle" is established. Peculiarities of appetite are often noticed, some children limiting themselves to one or two articles of diet to the exclusion of all others. A boy five years old was brought to our institution recently in a markedly rachitic condition, whose diet had consisted solely of oatmeal and milk because he would not take anything else. Continual perseverence on the part of his attendant has succeeded in getting him to take every- thing that our bill of fare affords. Some years ago a child — a spastic paralytic — was brought to us who refused to take any- thing. Whenever food was presented to him he would shut his jaws tightly and keep them thus. Various "stunts" on the part of his nurse would finally get him to take something. This pecu- liarity had existed during his whole life and persisted to the end.
Infectious diseases play a prominent part in the medical history of our institution. This is accounted for, no doubt, by
RELATION OF FEEBLE-MTNDEDNESS TO DISEASE 81
the fact that the immunity of our children is low and when infec- tion is once brought in it is especially hard to get rid of it. i hphtheria has been with us for some years, a case cropping" out now and then, but fortunately it has been of rather low virulence. ( >ur method of fighting it has been of taking cultures. Of 400 cultures taken in our institution at various times about ten per cent, were positive. The figure usually given for normal people is eight-tenths of one per cent. One girl was kept in quarantine for six months waiting for a negative culture. She at no time had clinical diphtheria. Tuberculosis is a common cause of death in our institution and seems to be increasing as the years go on. Of the 572 deaths which we have had since the institution began, in 178. or 31. 1 per cent, tuberculosis figured as a cause. Comput- ing by decades, we find 23.4 per cent, in the first, 24.5 per cent, in the second and 38.8 per cent, in the third. Physical signs as found on examination also seem to indicate ST high percentage of in- fected cases. We are hoping that with improvement in the method of diagnosis we may be able to determine this more ex- actly. As pneumonia is the old man's friend so tuberculosis seems to be the friend of the mental defective.
One might think that in a group of persons showing as many irregularities of development or stigmata of degeneracy as the mental defectives that malignant tumors would be more common especially if the Cohnheim hypothesis of m-isplaced em- bryonic cells were true. But the reverse seems to be the case. In some two thousand cases we have found malignant tumor only five times, twice involving the stomach, once the head of the pancreas, once the uterus and once, the face. One of these was admitted with the condition far advanced and two of the cases were epileptics. The fact that the majority of our children die before they reach the age when cancer is most common, tends to make this condition rare. We have found that 78.9 per cent, of our deaths have occurred before the thirtieth year. Seventy per cent, before 25.
Many of the children, of course, do not talk and if the frenum of the tongue is short, the parents think this backward condition is due to the tongue tie. I have been asked to remedy
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this condition several times but have never noticed any improve- ment'in speech as a result.
The deficiencies in association, perception and memory ren- der the subjective symptoms unreliable when present and in many cases they do not exist. So that we have to depend for diagnosis almost entirely upon objective symptoms. This has led one physican to remark that a course in veterinary medicine would be excellent training" for this work but one of my medical friends claims that this is an advantage since one is not misled by the unreliable statements of supposedly normal people.
SPECIAL CLASSES IN THE CLEVELAND SCHOOLS 83
SPECIAL CLASSES IN THE CLEVELAND SCHOOLS BY MISS GRACE M. BOEHME, ROCHESTER, N. Y.
The great need and value of the special classes for defectives is becoming more recognized each year, but in spite of the evident proof of their success we constantly hear the questions'-; Yi. Are the special classes, which necessitate more expen- sive teachers and equipment, really worth while?
2. Do not the majority of really defective children eventu- ally become state charges?
3. If not placed in an institution do they not marry and con- tinue -to fill our classes?
4. Is not the unfortunate child stigmatized by placing" him in a .special class and how can the objections raised by the pa- rents be overcome?
In answering the above questions let me state: We have maintained the special classes in our schools for the last four yea.rs and our observations are based entirely upon the result of oirr experience; I would meet the questions of the special class- es being worth while in the following way which I think will prove satisfactory to the parent or tax-payer who sees in the wel- fare of the normal child the value of efficiency of the future citL ,'zen. The effect of the subnormal child over an entire grade of ( normal children is appalling, for, with the normal child's keen sense of imitation, we find indescribable harm done and habits formed which oftentimes mar the future life of the bright child. Often a defective child will pollute an entire' class by his licen- tiousness. Often the defective child so disturbs the discipline of the grade as to make valuable study impossible. If the teach- er is over-conscientious, many times the normal child will be slighted and neglected because of special help which the teacher feels must be given to the atypical child; and, again, if the teacher has not the interest of the child at heart it is often al- lowed to sit idle for hours at a time getting more and more dis-
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couraged each day until it welcomes the time when it can stop school and go to work. The effect of such a child on the; teach- er's work during the year is demoralizing in every sense of the word. Thus, not considering the' welfare of the defective child, Ave find that for the sake of the normal children and their teach- er the removal of the subnormal from their midst is practically a necessity.
In answering the second question with regard to custodial care, we say it is our greatest aim to place these children in in- stitutions where they may have permanent custodial care. We appreciate fully the inheritance these children always givey their offsprings and if these special classes were to be used only as "clearing houses" they would more than pay for themselves each year by the removal of several cases a year who would not only eventually end in the almshouse or institution but take th«eir off- spring with them, if left at large. It may be of interest to note here that each year during the past four years, from four to six children have been placed in institutions through our special classes. Of course there are many who can never and should never be placed in an institution. Many of these are the chil- dren of illiterate parents — hard-working but ignorant people. Doubtless their fathers could not read before them and the prob- lem is still harder for the children. But by our special methods used we do teach them to read and "count their letters" inde- pendently, and^ enough arithmetic to get along in their smi?ll world. What are the methods used which bring success after seven and eight years of apparent failure? Why, industrial' work ! It has been said that movement is the first manifestation of life — not only that but it is so closely associated that in some occult way it carries with it a developing power capable of ex- panding the -individual towards a broader life. Hence, much is made of hand-training and allied means of education, in this work. Let the child who has always failed in his class see some- thing in his hands which he is doing and accomplishing and en- joys and the very fact that he has concentrated his mind half an hour on an interesting model which has made him happy will
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SPECIAL CLASSES IN THE CLEVELAND SCHOOLS 85
send him to his seat with more of a determination to conquer his spelling or arithmetic or reading.
Six boys left one class last year who had been made self- supporting; three of these boys had remained in school a year and a half past the regulation age for leaving school. It is true, that some of these boys have from four to six "jobs" in a week but they will become adjusted soon and prove worthy workmen.
We can only hope their offspring will be one step in advance of their own condition.
That the supposed stigma is really not so marked as one might imagine, the following incident will show : A boy of eleven or twelve, a child from a well-to-do family, who was in one of the regular grades came running up to one of the special teachers one day and in great glee said, "Oh Miss B., my teacher said, maybe I can go in your room." The teacher doubtless had meant to infer that the child would be punished if his lessons were not improved and little did she know that her method of punishment had been an inspiration to the child, but through an entirely different channel. The children from the special grade are frequently allowed to exhibit their work before the regular grades, until now, when a window-box, basket or rug- is desired, it is customary to ask the special grade to make it. Normal children are often, as an honor privilege, allowed to visit the children in the special grade. Objections from the parents, furthermore, have always been overcome in a week or two by the happiness of the child and his changed attitude towards school, but here again the success remains with the special teach- er who must have a superabundance of patience, skill, tact and resourcefulness for which she must be paid a better salary.
It may be of interest to cite the progress of one or two cases that have been with us several years. One boy, Edward G., ad- mitted in September, 1905, nine years old, had infantile paralysis and stammer. He seemed a hopeless case but because of good home conditions and unusual devotion it was impossible to con- sider him as an institution case. He could not even hold the scissors, could not read a word and knew no arithmetic. This is his fourth year and he is caning a chair; he can tap his shoes
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86 JOURNAL OF PSYCHO-ASTHENICS
and makes a good basket. He knows his multiplication table to the sevens and reads and spells in the third reader. He can do marketing" for his sister and although his speech is far from perfect it is much improved.
Each child has made marked progress in the special class. Some will never progress in some branches but the general im- provement is very noticeable. Each child has to pass a rigid medical inspection before being entered and only recently a child who at first sight was thought to be an imbecile by the medical inspector was found, on examination, to be suffering from choreic disturbances and poor eyesight, which he now believes to be cov- ering a fairly good brain. This discovery on entrance gives new- impetus to do more for what seemed on the surface to be a hope- less case.
In our laboratory we use a combination of tests by Simon, Binet, De Sanctis and Nosworthy, together with some inter- esting instrumental tests used by Dr. Henry H. Goddard in the laboratory of physiological research in the Vineland, N. J. train- ing school. We_ endeavor to separate the defectives from the backward pupils, thus making our aim entirely different in the backward classes. We recognize the fact that once defective, always defective, -nevertheless our aim is to develop every possi- ble faculty and make the unfortunate child happy.
DISCUSSION
Miss Gundry : Dr. Bernstein and I had a discussion of this subject a few years ago, .in which I appeared to disagree with him as to the value of manual training. I wanted, really, to agree with him thoroughly, but, being in private work, I could hardly do it. But today, I must say, I heartily indorse the manual train- ing, and the longer I am in the work the less I think of learning to read and write, alone.
Posibly I stand alone in that, as regards the private schools. I think I do. I have come to it by seeing the practical side of the
SPECIAL CLASSES IX THE CLEVELAND SCHOOLS &7
work done in the other institutions, and to-day we do very much more of the manual in our school, than the other work.
Within the past year we have had four teachers with us from the public schools of Washington. We have not had room to keep them all the time, or we should be very glad to do it. Our house is not very big, and we are in rather a crowded con- dition, but we have been glad to have them and will always- be glad to have them if they will come.
. Dr. Bock : From my examination of children in Rochester I rind ioo per cent, of them need something done physically. That is a good many, but there is not a child in any city that does not need tooth work, in the first place, and there is not anything that affects a child more than the faulty nutrition that comes with bad teeth. About 80 per cent, have bad noses, and bad ears and bad eyes, and in some sections of the city there are at least 25 or 30 per cent, with very irritating skin diseases. We are trying to educate the people up to the feeling that they must look after these things, if they really love their children. I do not know of any mother who does not want her child to be as bright as anybody else's. We tell the people that if Dr. So-and-So says that the child's first teeth do not need attention to go to some other dentist; and we are forcing the physicians to realize the importantce of the physical well-being of the child, on the ground that we believe no child can be mentally efficient if it is physically below par.
Dr. Roemer : Our work in Utica, the medical inspection of schools, is only of recent origin, and we have just got launched on it, commencing in June last. Our work at first, of course, was to preclude children who had contagious diseases, and next year we expect to start in and take up the mentally defectives and the physically defectives, and do some work along that line, and possibly segregate some of these children and have special classes for them. We have made a start already in that direction. .The superintendent of schools has asked the teachers to point out to the examing physician any children whom they think de- fective mentally, and already some 500 children have been point- ed out by the teachers to the physicians along that line. We ex-
88 . JOURNAL OF PSYCHO-ASTHENICS
pect to make a special examination of these children, and, if we can induce the school board to do so, we will have special classes for these children, I hope, next year.
SPECIAL CLASSES IN THE BOSTON SCHOOLS 89
SPECIAL CLASSES FOR MENTALLY DEFECTIVE
CHILDREN IN THE BOSTON PUBLIC
SCHOOLS
BY DAVID F. LINCOLN, M. D., BOSTON, MASS.
The credit for establshing these classes is due to Mr. Seaver, lately superintendent of Boston schools. In the fall of 1898 he secured the services of a most skillful special teacher, trained in the methods of the school at Barre, to whom he submitted a list of several hundred cases of backwardness. From these, after two or three months of close examination, she selected fifteen of the most urgent cases to form a class of which she assumed the charge in January, 1899. By gradual growth the number of classes has now risen to seven. No new class has been formed in the last four years, although there is no lack of material. One class is composed entirely of girls ; the others are mixed.
The two or three classes first formed were decidedly weighted down by low-grade cases, evidently fit candidates for asylums, gladly parted with by the grade teachers. Twenty-four pupils have been sent to Waverley from the special classes ; they have thus served a purpose as a kind of clearing-house for the asylum. Recognition should be paid to the intelligent work and influence brought to bear by the teachers upon the parents of so man}- defective children in inducing them to allow their offspring to be thus cared for. The point of view, however, has somewhat changed in later years. It is now held that the time of highly trained teachers ought not to be so largety given to the care of imbeciles or semi-idiots, and preference is given to children who give promise of being able to enter regular classes after training.
All the teachers so far have been either professional instruc- tors at such institutions as Barre, or the Seguin School or else have -been sent at the expense of the school board to a residence at Elwyn, Pa. The controlling" idea of Mr. Seaver was that a
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good teacher is the one essential to a good school. The greatest liberty of action has been given to these teachers. Their work was planned and their programmes arranged by themselves. A good mutual understanding existed among them from the outset, and the work in the different classes is substantially alike. This similarity is not due to centralized control or oversight, for such does not exist in any hampering way.
Manual training in many forms is a leading feature, and to it is devoted the closing hour of the session. The schools hold from nine to one o'clock, with half an hour for recess.
Admissions and discharges are controlled by a salaried medical examiner, Dr. Arthur Jelly, a well-known specialist. His decisions are subject to the approval of one of the assistant superintendents of schools. The examinations for admission are made in the most thorough manner, the parents and teacher be- ing consulted in order to make as thorough a diagnosis as pos- sible.
The statistics which follow are approximately correct, but are open to revision :
In all, 264 pupils appear to have been taught ; 24 of these were sent to Waverley ; 5 died, 15 were removed to private schools, 36 re-entered our regular public schools, 97 are still en- rolled in the special classes, and 87 have been dismissed as having reached the age-limit of sixteen, or on account of illness, removal, etc. Of the 36 sent back to regular school work, probably one- half are satisfactory pupils, mostly in the lower grades (first to fourth) and receiving promotion in the usual way. Not enough time has passed to determine their capacity for higher grade work. Some have been placed in ungraded or "coaching" classes, merely because their age disqualified them for primary grades, and have done well there. Others have been so placed because the pride of the parents forbade the children remaining in a "dummy class"; such cases are apt to do nothing but sit through the term. : Of the 87 dismissed, about 17 are known to be earning wages from a very trifling amount up to $3.50 per week. None are independent, but some might be called self-supporting under direction. Nearly the same number of girls are useful at home, much' as girls of their age usually are. About 19 or 20 are known as a menace to societv through vicious or criminal tendencies.
SPECIAL CLASSES IN THE BOSTON SCHOOLS 91
Not a few of the girls are of a class needing constant watching to keep them from going astray.
Friendly relations in the main exist between the special classes and other children in the same school buildings.
The teachers visit the families of their pupils, and in most cases find friendly support from the parents. Neighborhoods are gradually learning the truth about the special classes, ami public sentiment is thus being educated.
In expressing their personal view of the results of their work, the teachers generally lay the most stress on the moral improvement of their pupils. Obedience, self-control, and at- tention have to be built up from the foundation ; and in making these beginnings manual training is of priceless value.
The special classes are bringing about educational results in another and somewhat unexpected direction, that is, by bringing the question of feeble-mindedness in a practical and objective way to the notice of the teachers of our schools. The daily growth of appreciation in this quarter is laying the foundation for the wider usefulness of the classes.
As to the qualifications for teaching this class of children, it is held that good sense, sympathy, tact, motherliness and energy are of the first importance. Kindergarten methods, chiefly those involving manual work, should be understood. The teacher should also be a good instructor in primary grade work. But if she makes the three R's the basis of her work and is in- clined to judge of progress by mere academic tests, she is not in a way to succeed. It is hard for many to appreciate this, but failure to grasp the point of view is likely to compromise the best efforts of school boards, and is perhaps already doing so in some places.
As regards improvements which might be made in the special classes, only one is here suggested. By increasing the number of the classes it will be possible to place two at a given point, which will make it possible to grade the two in a certain way. It is the general feeling of the teachers that a great light- ening and improvement of the work could be accomplished by even this amount of grading.
92 JOURNAL OF PSYCHO-ASTHENICS"-
The question of furnishing a cup of milk or cocoa at lunch time has been approached in the charitable way in two classes, and with good effects upon the mental attitude of the pupils.
In conclusion, a word more in regard to the selection of subjects of training in the special classes. It has been urged that the presence of imbecile pupils gives the classes a bad name with the public. This is true, but it is also true that exclusion may do injustice, and that there may be danger of turning such children loose in the streets. In selecting cases it is the medical examiner's principle to reject such as are likely to inflict moral injury on the more innocent, and to accept some even of the lower types of children, not with a view to a complete course of training, but with a view to leading to their transfer to Waverley.
Even though preference be given to those who seem likely to "get promoted," there are always some children, who how- ever stupid, are deserving and trainable subjects.
NOTE: Although Dr. Lincoln does not mention it, the institution at Waverley was of great assistance to Mr. Seaver in the working up of the first special classes, and the teachers of those classes spent much time at Waverlev. — The Editor.
MULTIPLE SYSTEM OF INSTITUTION CONTROL 93
THE MULTIPLE SYSTEM OF INSTITUTION CONTROL BY J. C. CARSON, M. D., SYRACUSE, N. Y.
Prior to the year 1889 the institutions of this state, both the hospitals for the insane and the charitable institutions, were gov- erned by local boards. These local boards had practically the en- tire control of the institutions, financial and otherwise. There also existed during- that period, prior to 1889, a State Board of Charities, a State Commissioner in Lunacy, a State Charities Aid Association, and each one of these different commissions and boards had something -to do with the charitable institutions. The State Board of Charities inspected all of the hospitals for the insane and other charitable institutions, county poorhouses and poor matters generally, and made report to the legislature. They had not very much power. The State Commissioner in Lunacy visited the state hospitals for the insane and made a report to the legislature, but beyond that he had very little pow- er. The State. Charities Aid Association was an association of charitable people organized to look after different charitable work ; they had really no power or government over institutions and have not, to-day, beyond simple reports and recommenda- tions. There was a State Architect. At that time his work was mainly confined to the state capitol building. The institutions were required, or at least expected, to submit certain plans to him for his inspection and perhaps approval. There was also a State Civil Service Commission. They required that persons entering the service should comply with the rules adopted by the commission in regard to examinations as to whether they should be competitive or otherwise.
Institutions were supported by a mixed system ; some, by di- rect appropriations from the state ; others by partial state appro- priations and charges upon the counties, and, I think, some by charges upon the counties entirely. In the year 1889, what proved to be a radical departure took place and that was in
94 JOURNAL OF PSYCHO-ASTHENICS
the organization or the creation, rather, of the State Commis- sion in Lunacy. That commission in the original act was not given much power but was required to make visits to the state hospitals for the insane, make recommendations, give them their supervision, advice, counsel, etc. The next year, 1890, the State Care Act was passed. That law relieved the counties of the care of the insane and placed them under the control of the State Commission in Lunacy and made the insane a charge upon the state. At the same time the Commission in Lunacy had its pow- ers very much increased under this act in that the commissioners were authorized to make rules governing the management of the different institutions for the insane. About 1891, or 1892, the Commission in Lunacy had its powers still further extended by an act which became known as the Estimate Law which requir- ed all of the state hospitals for the insane to submit monthy es- timates to the State Commission in Lunacy for revision and ap- proval. I would say in this connection that the first year or two after the creation of the Commission in Lunacy, that commission assumed it had also control and direction over the institutions for the feeble-minded. The commission made a visit to the Syracuse institution in 1890, the year its powers were much in- creased and after certain rules governing state hospitals for the insane had been adopted. During this visit it very soon became apparent to me that the commissioners were not really making- proper distinction between our institution for the feeble-minded and those for the insane and, inasmuch as I had read the law and felt that under it the Commission in Lunacy had no authori- ty over institutions for the feeble-minded further than possible inspection, I raised the question of authority. The matter was appealed to the attorney-general who decided that the commis- sion had no authority whatever over the management of in- stitutions for the feeble-minded ; that its powers were confined to the insane, although it did possess the right of inspection and could require some statistics furnished concerning the feeble- minded. The commission, however, was rather reluctant in giv- ing up the idea of control over institutions for the feeble-mind- ed but never made any attempt to gain such control until the
MULTIPLE SYSTEM OF INSTITUTION CONTROL 95
year 1894 when the estimate law affecting" the charitable insti- tutions was enacted. I would say in regard to that legislation, it was done in a manner known as "sneak legislation." The es- timate law of 1894 was not heard of until after the two appropria- tion committees of the legislature had agreed upon their bill when at the last moment a rider was attached to it containing the present estimate law affecting the charitable institutions, and in that rider as it was originally drawn the Syracuse and Newark state institutions for the feeble-minded were required to make their estimates to the commission in Lunacy instead of to the comptroller's office as were the other institutions. For- tunately or unfortunately ( I am not quite positive, to-day, which it was) at the eleventh hour I happened to hear of the legislation proposed and was able to get the commission in lunacy clause stricken out and our estimates required to be sent in with the others to the comptroller's office.
As a result of the assumption of authority of the Commis- sion in Lunacy over the institutions for the feeble-minded, char- itable persons became interested in the subject, the State Board of Charities began to look at it and likewise members of the State Charities Aid Association, etc., and when the constitution- al convention of 1894 had finished its work, a clause was found injected into the constitution giving the State Commission in Lunacy authority over hospitals and institutions for the insane only, not including epileptics and idiots. It is now, therefore, unconstitutional for the Commission in Lunacy to exercise au- thority over institutions for the feeble-minded in this state. In • the new constitution adopted, both the Commission in Lunacy and the State Board of Charities became constitutional officers ; that is, neither the Commission in Lunacy nor the State Board of Charities can be legislated out of office and those commissioners must exist under our present constitution. The estimate law of 1894 required, as already stated, the state charitable institu- tions to send their estimates to the comptroller's office at Al- bany for his revision and approval. In 1901 the comptroller's office was relieved of that obligation and the office of fiscal super- visor was created. The fiscal supervisor, under the law, has
96 JOURNAL OF PSYCHO-ASTHENICS
full financial control of the state charitable institutions except the insane. The law requires that each institution shall submit an itemized estimate to the fiscal supervisor on or before the fifteenth day of each month, in minute, detail. Every item of ex- penditure must be included in that estimate for the next month. The fiscal supervisor has authority, under the law, to reduce that estimate in either quantity or in price and no money can be ex- pended for any purpose without his approval except that each institution is allowed a contingent fund of $250 per month for expenses which may be considered as emergencies, something which may arise and cannot be passed by without danger or loss to the institution or to its inmates. The estimate law as now construed by the fiscal supervisor not only requires the estimates to be rendered in minute detail but also elaborate explanations are required for the expenditure of nearly every item. There exists in connection with the fiscal supervisor's office at the present time several different boards of commissioners which have some control over or some connection with the state chari- table institutions and which together make up what may be considered the "Multiple System".
First, the fiscal supervisor has simply financial control. He has no control over the management except as it affects expenses or the expenditure of money.
There is besides the State Board of Chairities, the State Charities Aid Association, the New York State Civil Service Commission, the State Architect, a Classification Commis- sion, a Building Improvement Commission and the local boards. The State Board of Charities consists of one member from each judicial district of the state, appointed by the governor and con- firmed by the senate. To their credit I think I can say they have never been politicians. There have never been any oppointments made, so far as I know, by any of the governors to that board for political reasons. I think I am right about that. At the present time the State Board of Charities has nothing to do with the care of the insane or the state hospitals for the insane, these being left entirely, under the constitution and the law, to the State Commission in Lunacy. While the State Board of Charities has
MULTIPLE SYSTEM OF INSTITUTION CONTROL 97
had its powers and duties somewhat enlarged, I must say, to the credit of its members, that they have never been very grasping" in their desire for power and that they are at present free from politics and are not in very good favor with the politicians. I think the powers or duties of the State Charities Aid Association have not been very much changed since prior to 1889. This board has the power and right to visit and inspect institutions, to make recommendations and report. The New York State Civil Service Commission has no power over the management or the financial control of the institutions but it has much to do with persons employed at the institutions. In the first place it clas- sifies the service. It says what position shall be a competitive one and what shall not be competitive and what position shall be exempt from examination. Also, at the present time, it is not possible to pay any bill for services without the certification of the State Civil Service Commission. The name of every of- ficer and employe, as well as that of every man who comes into our institution to do plumbing, or fix our conductor pipes, or re- pair our roofs, has to go to the State Civil Service Commission to be certified before the bill can be paid for services rendered, if they are rendered upon the premises. Every pay roll must be submitted to the State Civil Service Commission for certifica- tion. The duties of the State Architect have been extended so that they cover all the institutions, hospitals for he insane, etc., where the services of an architect are needed. He makes the plans and, when special appropriations are made for buildings or improvements at the institutions, a copy of the estimate must be submitted in detail to him as well as to the fiscal supervisor and to the state comptroller. No money can be expended or work authorized under special appropriations, such as buildings and improvements, without the approval of the state architect as well as the fiscal supervisor. As to. the Building Improve- ment Commission, I really do not know who comprise that com- mission. I know there is such a commission and I know we can- not go ahead and put up new buildings without receiving its approval.
The Classification Commission was created, I think, in either
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1900, or 1901. That commission consists of the state comp- troller and the president of the State Board of Charities. It has the power to classify the different positions in the institutions and fix the compensation of every one employed. It is required, under the present law, to meet once a year in the month of September and if any changes are desired in the salaries or wages of officers or employes of institutions the reasons for the changes must be submitted to that commission by resolution, of the local boards, or managers. For instance, if we think that the wages of the cook are not high enough we have no power, neither the local board, the fiscal supervisor, the State Board of Charities, nor the superintendent, to change the rate of wages until it is authorized by the Classification Commission and the way to ob- tain that change is after the manner just described. Even then the changes adopted by the Classification Commission are inef- fective until they receive the approval of the governor. The lo- cal boards of managers, at the present time, have power under the civil service law to appoint a superintendent and to make rules and regulations governing the institutions. If they possess any other power I do not know what it is. In connection with their work they are required to meet at least as often as once each month, inspect the institutions and make a report in writing, a copy of which is to be mailed to the governor, to the State Board of Charities, and to the fiscal supervisor. These monthly reports must be signed by each member of the board present at the meeting. They are also now required, under a recent law, to submit at the same time a copy of their minutes to the gov- ernor, the State Board of Charities, and the fiscal supervisor.
The last legislature passed a law requiring an inventory to be kept on a form which had the approval of the fiscal supervisor, showing where every chair, dish, bed, etc., is located in the in- stitution, with some designating mark upon it, and that the board of managers, at their monthly meetings, shall condemn all property which has become useless and worthless and file their condemnation proceedings along with their monthly report to the fiscal supervisor.
In our monthly estimates the estimate covering the pay roll
MULTIPLE SYSTEM OF INSTITUTION CONTROL 99
comes first. We have to give the name of every person on the pay roll, the date when he was appointed, his position, rate, etc. That portion of the estimate is sent to the Civil Service Commis- sion for certification and then it is passed on to the fiscal super- visor. The next estimate takes up provisions, the next house- hold stores, etc., etc., etc. When compiled, these sheets comprise the month's estimate which is sent to the fiscal supervisor who gives it the attention of his office for the next week or two after its reception. A revision is made and returned each month to the institution. The estimate has to be made in triplicate, one copy going to the fiscal supervisor, one to the comptroller, and' one is retained at the institution. Following that, after each month's bills are paid, a treasurer's report has to be made up and that must conform with the estimate ; that is, nothing" must ap- pear on this treasurer's report in excess of anything included in the corresponding estimate. We can buy a less quantity or at a lower price and nothing will be said but there must be no ex- cess either in quantity or in price. I must say, in credit to the department, that savings are sometimes effected; there is not any question about it. The department may occasionally have knowledge of articles which can be purchased at a lower price, or suggest something of as good quality at a lower price. Many times, however, when the lower price is suggested the articles are of an inferior quality. As an offset to savings effected and as a result of the system, there is not any question in my mind but that every institution is compelled to expend one or two thous- and dollars a year extra. I know it costs us at least one thousand dollars a year because of the increased labor required. Before the system was adopted we had one bookkeeper and right away we had to appoint a storekeeper and another office helper in ad- dition. I do not see how it is possible to carry out the new in- ventory law effectually without still additional help. Further- more, the maintenance of the department in Albany now costs the state over $30,000 per year or an overage of about $2,000 for each institution required to submit estimates. We are supposed to get estimates from different firms.
A serious defect in our system here, as I view it, is that
100 JOURNAL OF PSYCHO-ASTHENICS
while we recognize that there is perhaps need of some central control over our charitable institutions, yet, to give one person a financial control alone, that separates it from the work and purposes of the institution. There is danger that an officer hav- ing simply financial control m£y have little sympathy with the work and purposes of the institution and that is the reason why I think, as we have a state board of charities which has a certain amount of control and supervision over the institutions, the finan- cial control should also be vested in the same board, or in some- one working in harmony therewith, because we know that the State Board of Charities has sympathy and interest in our work and purposes. Otherwise it may be simply a matter of dollars and cents and to make a showing of a saving for the department. Another thing, the fiscal supervisor, in his financial authority over the charitable institutions, stands in a little different rela- tion than does the Commission in Lunacy, from the fact that the commission has under its jurisdiction only hospitals for the in- sane, whereas the charitable institutions vary materially in their character.
Such is the system ; if you are anxious to have it adopted in your states, send your legislators to the state of New York for plans and specifications.
THE BOARD OF CONTROL SYSTEM 101
THE BOARD OF CONTROL SYSTEM
BY A. C. ROGERS, M. D.. FARIBAULT, MINN.
In compliance with the request of the program committee, I will outline system of institution management as exemplified by the Minnesota State Board of Control with whose methods I am most familiar.
The spirit characterizing any particular governing body' will depend largely upon the relative value placed by them upon good work and inexpensive work. Tt must be assumed, of course, that the individual members of any controling board are selected with reference to their fitness for the position. If we do not assume that much it does not make very much difference what form the organization is, it will be a failure from the standpoint of the best interests of the institution, and of the tax payers. You can always calculate safely that if you have an irritating system it is because somewhere there has been some abuse at some time and it has led to an over-restriction by legislative action.
The western states, as a rule, have started with separate boards for the several institutions, as has been the case pretty generally throughout this country, and I think, so far as Minne- sota is concerned, that the change to a central board was caused largely by the lack of uniformity in administrative methods in different institutions of a similar nature. The state authorities were astonished at the variation in prices of articles bought and the lack of uniformity generally in the systems adopted. It was not brought about by any special feeling that there was graft or dishonesty. So far as I have ever heard, Minnesota has been pretty free from anything of this kind. However; the time came when it was felt that the state of Minnesota was large enough to purchase its supplies at wholesale prices and under competitive bids. It had had a State Board of Charities which supervised institutions and did most excellent work, and this, of course, helped to enlighten the people in regard to the work of the state
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institutions. The hospitals for insane had one common board. The School for the Deaf,. the School for Blind, and the School for Feeble-Minded, had one common board. All of the other in- stitutions had each its one board.
The law as finally passed and as since amended provides for three members, each serving for six years, one vacancy occurring' every two years. The member whose term expires first is always chairman. These members are appointed by the governor with the consent of the senate. They are removable for cause. They cannot hold any other elective office, and must give their entire time to the Avork of the board. The board appoints its secretary, purchasing agent, all necessary office force, a state architect, and the superintendents and wardens of the institutions of which they have executive or financial control. There are three classes of institutions. Those over whom they have executive control are the three hospitals for the insane, the two asylums for chronic insane, the school for feeble-minded and colony for epileptics, the state prison, reformatory, and industrial school. In addition they have the financial control of the schools for deaf and blind and dependent children. They have charge of all the building construction of these institutions, the State University, which includes the agricultural college, and the five normal schools. They also have financial control of the sanitarium for tubercu- losis.
There are separate boards for the schools for deaf and blind,