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"The Burden Of Feeble-Mindedness"

Creator: W.E. Fernald (author)
Date: March 1913
Publication: Journal of Psycho-Asthenics
Source: Available at selected libraries


* This address, delivered before the Massachusetts Medical Society, as the "Annual Discourse," is essentially, though abbreviated, the same as the author's discussion at Vineland, before the American Association for the Study of the Feeble-Minded, June, 1912.


The methods of patient research and collective investigation which have led to such brilliant results in the study of various diseases in general medicine and surgery are now beginning to be applied to the study of the causation, extent, significance, treatment and prevention of feeble-mindedness -- the synonym of human inefficiency and one of the great sources of human wretchedness and degradation.


The past few years have witnessed a striking awakening of professional and popular consciousness of the widespread prevalence of feeblemindedness and its influence as a source of wretchedness to the patient himself and to his family, and as a causative factor in the production of crime, prostitution, pauperism, illegitimacy, intemperance and other complex social diseases.


The exact number of the feeble-minded in the community is not known. There are probably two to 1,000 of our population, over 7,000 in Massachusetts alone. These cases are found in the families of the rich and of the poor, in the city and in the country. There is scarcely a village or a school district in my state where one or more will not be found. There is no reason for believing there is a greater proportion in my state than in other states or countries.


The fact that feeble mindedness is the result of pathological conditions of the brain, either gross lesions caused by faulty development or by the destructive results of disease, or perhaps numerical deficiency or imperfect evolution of the ultimate cortical cells, makes it obvious that the resulting mental defect is incurable and permanent. If a nerve cell is damaged or destroyed by traumatism or disease, it is gone forever. It is never replace by the multiplication of other similar cells, as may happen in other bodily tissues.


The various known causes of feeble-mindedness occur in two main groups -- the hereditary and the accidental. The hereditary cases are those where the person is feeble-minded because his parents, or other ancestors were feeble-minded. The accidental group includes those who are feeble-minded as a result of environmental causes, without hereditary influence.


The hereditary cases are the most numerous. The recent intensive study of the family histories of large numbers of the feeble-minded by Goddard, Davenport, and Tredgold show that, in at least eighty per cent. of these cases, the mental defect had been preceded by other cases of defect in the immediate family line. Goddard finds that sixty-five per cent. of his institution cases had one or both parents actually feeble-minded. It is believed that this hereditary defect is the result of protoplasmic defect in the germ plasm of the family stock.


There is no doubt as to the potency and certainty of this hereditary tendency. Often the feeble-minded child represents a feeble-minded family. Davenport believes that aside from the Mongolian type, probably no imbecile is born except of parents who, if not mentally defective themselves, both carry mental defect in their germ plasm.


So far as is known, if both parents are feeble-minded, all the offspring will be feeble-minded. If one parent is feeble-minded, it is probable that some of the offspring will be feeble-minded, and the children who are themselves normal will be likely to beget defectives. These normal persons in tainted families who are potential "carriers" of the defective germ plasm may keep up the sequence. If both parents come from tainted families, the probability of defect in the children is much increased. The normal members of tainted families who mate with healthy individuals with no family taint are not so likely to have defective children; indeed, the tendency may be eradicated by judicious breeding-up for several generations. This tendency may be expressed by one or more cases in every generation, or it may skip one generation to reappear in the next. Inheritance is not merely a question of fathers and mothers, but the family tree goes farther back.


Among the probable accidental or environmental causes of feeblemindedness are injuries to the head at birth, blows or falls in infancy, inflammatory brain disease, toxemia from infectious diseases, abnormal mental or physical conditions of the parents, etc., or the absence of certain vital substances from the blood, as in cretinism. Cases of feeblemindedness often occur in families where there has been no mental disease or defect for several generations. But even where the exciting cause is undoubtedly accidental, there is often a strong hereditary predisposition. Similar injuries or causes in sound families do not result in feeblemindedness. In the majority of these cases the environmental causes are only accessory. The real origin of the disease lies in the defect of the germ plasm.


Certain types of defect are usually if not always due to accidental or sporadic causes, viz., the Mongolian, hydrocephalic, post-meningitic, the cerebral hemorrhagic, etc. Acquired characteristics are not likely to be transmitted, but there is reason for the belief that alcoholism, syphilis, tuberculosis and other environmental factors may initiate germinal variation which may become hereditary. The cases of purely accidental origin with no morbid heredity are not likely to be followed by other cases in that family. The purely accidental cases themselves would probably beget normal progeny.


To sum up, there is a large number of feeble-minded persons in our community. The great majority of these persons are feeble-minded because they come from a stock which transmits feeblemindedness from generation to generation in accordance with the laws of heredity. Many of the members of these families are not defective themselves, but to a certain extent these normal members of tainted families are liable to have a certain number of defectives among their own descendants.


There is a popular belief that feeble-mindedness is greatly on the increase. We do not know, and are not likely to know, whether or not there is now relatively more feeble-mindedness than there was fifty or one hundred or five hundred years ago. There is some reason for the belief that the remarkable shift of population from rural to urban conditions in the last half-century, with the resulting industrial and social stress, and a greater liability to syphilis, tuberculosis and alcoholism, has increased the ratio of defectives in the families with hereditary predisposition. It is certain that the feeble-minded girl or woman in the city rarely escapes the sexual experiences that too often result in the birth of more defectives and degenerates. At the same time the steady withdrawal of the more sturdy and virile individuals from the country to the towns leaves the ineffective and defective men and women in the country to marry and beget offspring even less efficient than themselves. Recent study of certain isolated rural communities in Massachusetts where the more vigorous families have migrated for several generations, shows a marked deterioration in the quality of the population, with a large number of the feeble-minded and a notable amount of immorality, intemperance and shiftlessness. The defective persons in these communities are very apt to be attracted to each other, and to marry or to intermarry, thus intensifying the degenerative process. The members of this society are only too familiar with these rural foci of feeblemindedness, immorality, crime and destitution.


The social and economic burdens of uncomplicated feeble-mindedness are only too well known. The feeble-minded are a parasitic, predatory class, never capable of self-support or of managing their own affairs. The great majority ultimately become public charges in some form. They cause unutterable sorrow at home and are a menace and danger to the community. Feeble-minded women are almost invariably immoral, and if at large usually become carriers of venereal disease or give birth to children who are as defective as themselves. The feeble-minded woman who marries is twice as prolific as the normal woman.


We have only begun to understand the importance of feeble-mindedness as a factor in the causation of pauperism, crime and other social problems. Hereditary pauperism, or pauperism of two or more generations of the same family, generally means hereditary feeblemindedness. In Massachusetts there are families who have been paupers for many generations. Some of the members were born or even conceived in the poorhouse.


Every feeble-minded person, especially the high-grade imbecile, is a potential criminal, needing only the proper environment and opportunity for the development and expression of his criminal tendencies. The unrecognized imbecile is a most dangerous element in the community. There are many crimes committed by imbeciles for every one committed by an insane person. The average prison population includes more imbeciles than lunatics. The term "defective delinquent" is applied to this special class of defectives where the mental lack is relatively slight, though unmistakable, and the criminal tendencies are marked and constant.


At least twenty-five per cent. of the inmates of our penal institutions are mentally defective and belong either to the feeble-minded or to the defective delinquent class. Nearly fifty per cent. of the girls at the Lancaster reformatory are mentally defective. The class of defective delinquents of both sexes is well known in every police court, jail, reformatory and prison. There is a close analogy between the defective delinquent and the instinctive criminals who form a large proportion of the prison rounder type. Under present conditions these irresponsible persons are discharged at the expiration of their sentences to lay tribute on the community, to reproduce their own kind, to be returned to prison again and again.


A very large proportion of the neglected and dependent children in the care of the State are feeble-minded and are the offspring of the feeble-minded.


Many of the immoral and diseased girls found in rescue homes and shelters are defective and absolutely incapable of reform or of self-support. Many prostitutes are mentally defective. A large proportion of the mothers of illegitimate children at Tewksbury and elsewhere are feeble-minded. In one county almshouse in Pennsylvania there were 105 mothers of illegitimate children, and of these mothers one hundred were feeble-minded. A majority of the parents prosecuted by the Society for the Prevention of Cruelty to Children for abuse of their own children are feeble-minded. In England seventy per cent. of the habitual drunkards who are dealt with under the Inebriate Act are mentally defective.


The modern intensive study of the family trees of individual degenerates, the insane, epileptics, criminals, prostitutes, hereditary paupers and feeble-minded has emphasized the fact that these various conditions of degeneracy are often merely different phases or expressions of the same fundamental inferiority. In these degenerate families the form of defect varies from generation to generation, feeblemindedness in one generation, pauperism or criminality in the next, and then some form of insanity, alcoholism, etc.


It has been truly said that feeblemindedness is the mother of crime, pauperism and degeneracy. It is certain that the feeble-minded and the progeny of the feeble-minded constitute one of the great social and economic burdens of modern times.


The realization of these truths and the recognition of the strong tendency to hereditary transmission has produced a sort of panic on the part of those who have just learned of these facts. Visions of a feeble-minded peril in future generations are seen, and have resulted in a "wild panic for instant action." There is no occasion for hysterical, ill-considered action.


It is probable that intelligent study of the whole problem on a large scale will furnish data for adequate treatment and control. The full problem should be stated by a complete and permanent census of the feeble-minded of the entire State. This is possible by the co-operation of physicians, teachers, social workers, court and prison officials, local authorities, etc. Such registration would be analogous to the required notification and registration of contagious and infectious diseases, and would be the first step in the regulation and elimination of defective strains from the community. The Massachusetts State Board of Insanity has already begun an informal and tentative census of this sort.


In the light of our present knowledge, the only way to reduce the number of the feeble-minded is to prevent their birth. The perpetuation of defective family stocks should be inhibited. This would be possible to a great extent if every feeble-minded person and potential "carrier" of the defective germ plasm could be prevented from parenthood. There is already a strong popular demand for the logical and thorough application of our present knowledge of the laws of morbid heredity in the way of prevention. Massachusetts has begun the policy of the segregation of the feeble-minded, especially those of childbearing age. This segregation carried on thoroughly for a generation would largely reduce the amount of feeblemindedness. The high-grade female imbecile group is the most dangerous class. They are not capable of becoming desirable or safe members of the community. They are never able to support themselves. They are certain to become sexual offenders and to spread venereal disease or to give birth to degenerate children. Their numerous progeny usually become public charges as diseased or neglected children, imbeciles, epileptics, juvenile delinquents or later on as adult paupers or criminals. The segregation of this class should be rapidly extended until all not adequately guarded at home are placed under strict sexual quarantine. Hundreds of known cases of this sort are now at large because the institutions are overcrowded.


Only 2,000 feeble-minded persons are now cared for in institutions in Massachusetts, and over 1,000 applicants are awaiting admission to the institutions. There is an urgent demand for greatly increased institutional provision for this class. The cost of this provision will be great, but not as great as the present cost of caring for these same persons, to say nothing of their progeny, in future generations. It would cost less money, be more economical in social life and of immense value morally. These people are never self-supporting, but are eventually supported by the public in some way. From the economic stand-point alone no other investment could be so profitable, not even in canals or railroad or factories. The present generation is the trustee for the inherent quality as well as for the material welfare of future generations.


In a few years the expense of institutions and farm colonies for the feeble-minded will be counterbalanced by the reduction in the population of almshouses, prisons and other expensive institutions. When the feeble-minded are recognized in childhood and trained properly many of them are capable of being supported at low cost under institution supervision.


Not that we regard the institution as the panacea for feeble-mindedness. If adequate institution provision were available today, it would not be feasible to secure the detention of large numbers of defectives, and those the most dangerous class, where parents or friends are unable or unwilling to see the necessity for such segregation. We have no laws compelling this action. The Anglo-Saxon respect for the liberty of the individual would make it difficult to enact laws compelling such custody. This difficulty could be approached by the suggested registration of the feeble-minded which would afford a basis for some sort of extra-institutional supervision and control. The observed misconduct and incapacity of many of these people would soon show the need of legal provision for their forcible segregation.


In a rational policy for controlling feeblemindedness it is essential that we recognize the condition in childhood. Our compulsory school laws bring every child to official notice. Every case of feeblemindedness should be recorded. At the proper time the parents should be informed of the condition of the child, of the necessity for life long supervision and of the probable need of institution treatment. Sooner or later the parents will probably be willing to allow their child to be cared for in the institution. The parents who are not willing should be allowed the custody of their child, with the understanding that he shall be properly cared and provided for during his life, that he shall not be allowed to get into mischief and that he shall be prevented from parenthood. Whenever the parents or friends are unwilling or incapable of performing these duties, the law should provide that the child shall be forcibly placed in an institution, or otherwise legally supervised.


There are now special public-school classes for the feeble-minded in most of our cities and large towns. These classes insure diagnosis and treatment at an early age, they help to inform the parents as to the dangers of the condition and they admirably serve as clearing houses for permanent segregation before adult life is reached. They should be extended and increased in number.


The mental defectives in our penal institutions should be recognized and transferred to permanent custody in suitable institutions and farm colonies and not discharged at the expiration of their sentences, to beget other defectives and to re-enter their careers of crime. We now have a law in Massachusetts authorizing the permanent control and custody of this criminal imbecile class which only needs the provision of suitable buildings to become effective. No other state or country has yet made similar legal recognition of these so-called defective delinquents. The logical application of this law would materially modify our present methods of dealing with certain classes of so-called "criminals" in the prisons, jails, reform schools and the courts. The elimination of these defectives from the prisons would increase the opportunities for reforming the normal offenders who are really capable of reform.


Compulsory surgical sterilization of all defectives is proposed as a radical method for preventing the hereditary transmission of feeblemindedness. At least six states have passed laws authorizing or requiring this operation. In no state, however, has this remedy been applied on a large scale. There are many objections to this plan. The friends of the patient's are not willing to have the operation performed. The normal "carriers" of defect would not be affected. The presence of these sterile people in the community, with unimpaired sexual desire and capacity would be direct encouragement of vice and a prolific source of venereal disease. Sterilization would not be a safe and effective substitute for permanent segregation and control.


It is probable that education in the broadest sense will be the most effective method in a rational movement for the diminution of feeblemindedness. The public generally should be intelligently informed as to the extent, causation and significance by means of suitable literature, popular lectures and other means. There is how great demand for such information from women's clubs, church societies, charitable organizations, etc. General knowledge of this subject in a community will insure the rational protection and control of the feebleminded persons in that community.


The principles of heredity, as they are unfolded, and especially of morbid heredity, should be taught in the colleges, the normal schools, and, indeed, in the high schools. The adolescent has a right to be informed on a subject which is of supreme importance to himself, to his family and to his descendants. The great majority of these young people will later marry and become parents. The dangers of a marriage with persons of diseased stock should be presented plainly. The young woman about to marry should be taught that her most important duty to herself and to her race is to choose a man of good heredity as the father of her children. The young man should be taught that the quality of the family stock of his future wife largely determines the health and efficiency and sanity of his children, and of his children's children. Those who have been privileged to address groups of young people on these subjects can but be deeply impressed with the breathless interest and appreciative understanding of their auditors.


The biological, economic and sociological bearings of feeblemindedness have overshadowed the fact that it is fundamentally and essentially a medical question. This subject should receive more attention in the medical schools. At the present time only a few schools in this country give any instruction whatever in the subject. General hospitals and dispensaries should have out-patient departments for the diagnosis and treatment of feeble-mindedness. These clinics would also provide for the instruction of students. No medical student should graduate until he has a general knowledge of the causes, varieties, prognosis and treatment of feeble-mindedness.


Every physician in general practice will find cases of feeble-mindedness among his patients. He has the unwelcome task of informing the parents of the misfortune of their child. He is called upon to advise as to treatment and life-long care and protection.


The prevention of the accidental type of feeble-mindedness largely depends upon the knowledge and skill of the physician in recognizing and in removing or modifying the environmental conditions which may cause the defect.


The recognized field of mental defect has been gradually extended and widened, and clinical types and degrees of feeble-mindedness are recognized by the alienist which are not yet familiar to the medical profession generally. It is most important that the physician should recognize the so-called "border-line" cases, where the intellectual defect is apparently slight, and is overshadowed by the immoral and criminal tendencies. These cases may be glib and plausible often bright-looking and attractive, but are unable to apply themselves at school or at work without constant supervision, and are wholly indifferent to the consequences of their behavior and actions. The inability to get or keep a situation or to support themselves is most significant. These cases often present a bad family history, a personal history showing backwardness in infancy and school life, and the presence of various physical stigmata of feeble-mindedness. Psychological tests of these adolescents or adults show that they have a mental age of only seven or eight or nine years. In fact, they are cases of real feeblemindedness differing only in degree and not in kind from the more obvious varieties.


The growing appreciation of the medico-legal bearings of feeblemindedness, the increasing tendency of the courts to inquire into the mental status of persons accused of crime, and the widespread movement to recognize and treat mental defect in the public schools have created an urgent demand for the services of physicians skilled in the diagnosis of mental defect which cannot be met at the present time. Indeed, the social worker, the charity visitor, the teacher and the court official often recognize cases of feeble-mindedness which they are unable to properly treat and control because they cannot secure the co-operation of suitably qualified physicians. A medical diagnosis of feeble-mindedness is necessary before a case can be properly or legally considered.


If, as we believe, the prevalence of feeblemindedness can be most effectively reduced by educational methods, the remedy largely depends upon the medical profession. The physician has knowledge of family histories and tendencies. He has access to family councils. His advice in individual cases is eagerly sought and generally followed. He has exclusive opportunity to teach and inculcate certain accepted principles of practical eugenics.


The most important point is that feeblemindedness is highly hereditary, and that each feeble-minded person is a potential source of an endless progeny of defect. No feeble-minded person should be allowed to marry, or to become a parent. The feeble-minded should be guarded or segregated during the child-bearing period.


The normal members of a definitely tainted family may transmit defect to their own children, especially if they mate with one with similar hereditary tendencies. These potential carriers of defect should mate with sound stock, if they marry at all. If the hereditary tendency is marked and persistent, the normal members of the family should not marry. Certain families should become extinct. Parenthood is not for all.


Persons of good heredity run a risk of entailing defect upon their descendants when they marry into a family with this hereditary taint. Intelligent people are often willing to forego a proposed marriage if the possibilities of heredity are fully understood. The immediate sacrifice is less painful than the future devoted to the hopeless care of feeble-minded children. What can be more tragic than the familiar cry of the agonized mother, "If I had only known?"


The well-informed physician has the pleasant privilege of allaying the fears of those who misinterpret and magnify the possibilities of morbid heredity in their own families. It should be remembered that a single case of defect of accidental origin, with no hereditary tendency, is not likely to be followed by other cases in the same family. Indeed, a case of this sort may be found in a family where the other members are of exceptionally brilliant and gifted mentality. The ordinary family is safe and sound and whole, and is extremely unlikely to produce feeble-minded children.


In the annual discourse for 1907 Dr. Adams said: "A medical practitioner is, to a greater or less extent, a missionary. He is always finding and doing some work, unpaid or underpaid, for his fellowman, because his training and his position make such work possible and natural. In all philanthropic measures he is to be relied upon as a helper, and in those pertaining to public health he is naturally a leader. He has unequaled facilities for disseminating knowledge, for awakening interest and for guiding benevolence. The evidences of this influence are to be seen on every hand."


The imminent problem of dealing effectively with this burden of feeble-mindedness presents a fertile and pertinent field for the exercise of these extra professional activities and obligations of the medical practitioner. The community looks to him for education and guidance on this subject. Concerted action by the medical profession will surely create the strong public sentiment which will demand a prompt and effective plan for the proper care of all the feeble-minded, and for the elimination of feeble-mindedness so far as that is possible.


Dr. Charles Bernstein: Mr. Chairman, this paper of Dr. Fernald's has been very instructive to all of us and he has very carefully covered the subject of feeble-mindedness, especially borderline feeblemindedness. I am more than glad to have two or three of our managers here today. I don't know of any better place that I could have brought them to get the benefit of this matter. In New York State at the present time under the auspices of the State Charities' Aid Association there exists a position as County Agent. There are about twenty, I think, of these agents in New York State at the present time. They originally had only the placing out of children from the orphan asylum. Then they found children who should not be placed out. They wanted to know whether they were normal or abnormal and they have asked us to take them. They were committed to us originally as feeble-minded, which we felt was very wrong. If they were not feeble-minded they should not have had that stigma attached to them. As a result the legislature last year passed a law, giving us power to take these cases, as they say, voluntarily for the purpose of examination to see whether they are feeble-minded or not, thus avoiding the stigma of commitment when there is doubt as to diagnosis. We have only operated under the law a couple of months, though we have operated in a measure under the theory of it for a couple of years. I am more and more convinced that we must have these cases for a year to know them and to determine whether they are feeble-minded or not. Of course we know we have no laboratory test to help us with certainty in these borderline cases today. Just at the present time we are facing the question what to do with these borderline cases which have already been committed to us and who, we feel, are not actually feeble-minded. Are we to let them go? Are we to have a placing-out system or to hold them in the institution? They have committed no crime. They have done nothing to warrant our holding them there indefinitely for fear they may do something. Three cases have been refused and this action the courts have sustained.


I have been interested in the matter of placing out boys and I have been trying to convince our managers of the advantage of that for a year or more. One of them heard something about the Kentucky system, and thought it was pretty fine in the way in which it worked out. As I understand it, under the Kentucky system the parent of the feeble-minded child (Dr. Rogers will correct me if I am wrong) is said to take care of it. I would not recommend that. We propose to do as Dr. Fernald has done, let these boys go out on the farm. We know the difficulty in New York of finding labor, and the farmers are very much in need of this class of laborers. We have a few boys out at the present time and I would like to see more of them placed out. I don't know but what I would like to see some of the girls sent out if the families could be well picked and we could have a supervision over them.


Then another matter that I was glad to hear Dr. Fernald discuss is that of sterilization. The very cases which most need to be sterilized can never be reached. Therefore, the place for them is in the institution or on the farm; but on the other hand, in our experience in placing these boys out, I have had three or four come back in the last few months with infectious and social diseases. Of course they did not have proper supervision, though we have picked out families very carefully. Two or three boys work in the mills and they have the privilege of coming back and seeing the entertainment every Friday. These boys have money that they have saved and placed in the saving bank, but the danger from social diseases makes their employment in the country advisable instead of in the city. Those that we have in the country are the ones that are getting along the best.


Now for the purpose of finding these borderline cases in the community, that is, these cases which ordinarily do not come under the action of the law, the present legislature in New York State has this year created a Bureau of Analysis and Investigation under the State Board of Charities. The first thing they will attempt to do is to correlate family names in the prisons, charities and insanity departments. Then they will send their agents out in the community to find the actual conditions, which action certainly looks very promising.


Dr. Fernald refers to two other very important points, the matter of educating the public concerning the nature of feeble-mindedness and expert advice concerning the possibility of other children being defective, when one such has been born into any given family. The former is very important. In regard to the latter, I have been consulted in several cases and in this connection I would like to ask for information on one thing in animal breeding whether there is anything in the literature of human breeding confirming it. I refer to the notion prevalent among animal breeders that the first offspring will be defective.


Mr. Van Wagenen: Professor Raymond Pearl has lately written a paper which I have on this subject, making some observations from his studies of animal breeding in regard to the question of sterilization. Looking at this matter simply from the scientific and eugenic point of view, any person who is defective, or in whose family, within two generations prior there is known to be one or more defective or insane, should not be permitted to procreate. Any person having one defective child, as soon as the fact becomes known, should not be permitted to procreate any further. He derives these conclusions from his experience in animal breeding.


Dr. H. H. Goddard: Pearson says that the child labor laws in England which resulted in reduction of the size of the families, worked great injustice because the first and second children are inferior, and, exactly as you said, the third, fourth and fifth would have been brighter. Now that the size of the families has been reduced the value of the population has been reduced because the best children have been cut off.


Dr. Bernstein: In three instances, based on my interpretation of the subject and based on my understanding of animal breeding, for I have known of a great many breeders of horses and cattle who didn't think of keeping the first offspring as a part of their fancy stock -- where I couldn't trace any bad heredity within a generation or two, I have advised them to take the chance of having a second child. In one instance it was normal, and in one instance they took no chance. They were particularly interested in having us know the facts and they wanted information on the subject. The mere fact that they had begotten one feeble-minded child at first and there was no marked heredity in the family, did not seem to me to warrant their being deprived of the privilege of having a family.


Dr. Little: Mr. President, coming to the concrete question of placing out in homes, the defective delinquent and the high grade imbecile, the Doctor I know has been advocating that in New York State. As you know there has been a movement going over the state of New York this last year to spread the knowledge of feeblemindedness, but I think we are defeating our own purposes to some extent when some of us take the position that the feeble-minded and the defective delinquent and that higher group should be permanently placed in an institution, and some of us even think that they ought to be placed out in homes. I personally, without any experience in the matter, am opposed to the proposition of placing out in homes any one who has been adjudged a defective delinquent or feeble-minded. It is difficult enough to place in homes normal children, to find satisfactory places for them, and I haven't any faith that the defective delinquent or the feeble-minded will become a success to himself or herself or to the community and that there is no use of agitating a proposition that is bound to fail.


Miss Grace Boehne: Mr. President, may I ask Dr. Bernstein if he looks into the previous record of the child, the record which has caused the commitment of this child to the institution? We have been taught to believe that the high grade morons are quite normal in a way and can do fairly good work if they are under proper supervision, and does not that in many cases bias you in your judgment of the defective child? Would it not be a very advisable thing to get from the person who has committed the child, the previous record of the child's conduct? I know in several of the cases I have been able to persuade children to go to the institutions, the parents were perfectly willing to have them go because they had been taken into court many, many times, and besides, the children had failed utterly in the schoolroom. In one case, not at Dr. Bernstein's institution, the child was left in an institution for a year, and the report came back to me that the child was normal and we were severely criticized for having sent the child to an institution. Now I know definitely that there are two other children in the same family who are defectives. We have had one other child in special classes that has been an entire failure during his entire school experience. This boy, Frank, was continually in trouble, but he was sent from the institution as a normal child and put to work. He made a failure on the farm to where he was sent and belongs to a special class at the present time, though he has had to leave school because of his bad physical condition. Furthermore, another feeble-minded child in the family will be placed in the special classes as soon as she enters the public schools. Now will it not be to our advantage to use the experience we had with the child in the institution in taking care of this one about to enter the schools, or to consider the experience of the workers with the child at large? Now with reference to placing these children on farms throughout the state. It has been my experience that there are many parents who are unwilling to have their children placed in an institution, yet we have got to place them where we can feel that they will be cared for properly. When a child can be committed to an institution and placed in custody and there is no doubt as to the defect, isn't it going to be a wise plan to continue that child's custody? It has been my experience, too, that unless we are very very careful to have a social worker follow-up these cases who are placed on the farms, the children are very much overworked. The farmer does not understand the condition many times, and I know of one instance where the child's health was seriously impaired. He had to be taken from the farm and sent to a sanitarium to recuperate his health.


Mr. Von Wagenen: I would like to sound a note of warning in addition to that last statement in regard to placing high grade feeble-minded children out on farms. I have personal knowledge enough, I think, to make it proper for me to say that there is the greatest risk in placing these children out in that way on farms. There may be here and there a farmer who is in a position, both as to intelligence and affluence, to take an interest in the feeble-minded child and do for him or her as a child ought to be done by, but I am sure that he is the exception and that to attempt to dispose of any number of feeble-minded children in that way will be running the greatest risk to the individual child and furthermore to the continuance of the same type. Again, I assure you from my knowledge of rural life, that while there is less of actual immorality because there are fewer people, there is no less relatively, of immorality in the country than there is in the most densely populated part of the great cities. Some of the vilest places you can find are right in the hills of New England, and these children would be exposed, I am sure, to such things and without having in the great majority of cases any sufficient protection.


Dr. Bernstein: Mr. President, you cannot work those boys too hard. If they work them as hard as they can they will not practice the vices to which the gentleman alludes. Let them go out and work just as hard as they will work. That is what they have to do for me when they work on the farm. They work so that when they come in at night they go to bed and sleep. Then they get up the next morning and go to work again, and I am very sure that the farmers who are working them the hardest are keeping them the best in line of good behavior. Miss Boehne suggests that the boy was overworked. Of course, we know that there are some tubercular conditions among the feeble-minded, that should be considered. About half of our population are subject to these same conditions.


Dr. Murdoch: Mr. President, in regard to the defective delinquent, we know that this type requires a closer supervision and care than the ordinary feeble-minded child. We cannot allow the same amount of liberty to the defective delinquent that we can to our ordinary simple feeble-minded and imbecile. Now what are we going to do with them? Are we going to take care of them in our institutions for feeble-minded in special departments or are we going to take care of them in the institutions for delinquents, the reformatories, or are we going to have separate institutions for this particular class? I am somewhat in doubt as to the best practice but I think that this matter has been carefully considered in Massachusetts and I would like to hear from Dr. Fernald on this point.


Dr. Emerick: Possibly we do not all have the magnetic influence to keep in touch with these children who are farmed out that Dr. Fernald has, and it is possible that other states have not the environment Massachusetts has to put them in. Our experience in placing out has been anything but good. One of the first cases that came to my attention after going to the institution was that of one of our girls who was taken by one of the trustees into a home where the associations were of the very best. She soon drifted away and he said he would never try the experiment again. A former superintendent when he left took a little girl with him into a modern home. She was left alone at the house one day and one of the neighboring boys assaulted her. Of course, they never left her alone again. I let one of our boys go out and in sixty days he was married. I let another one out and he wound up in the police station. Another boy I call to mind went out with a very good farmer and an ex-school teacher a very intelligent and well-meaning man, but the boy has gone to the dogs. My experience has been so universally unfavorable in this matter and realizing as I do that these morons are the most dangerous ones -- that is, most prolific of any -- that I am very much opposed to placing them out.


Dr. Wallace: Mr. President, not to help Dr. Bernstein, because I know that he does not need it, but with this great wave of education sweeping over the land on one side, and with the great dearth of information that the members of the medical profession, and those who commit these people have upon the subject of feeblemindedness on the other, I think that we have some reason to use a little discretion in the institutions. I don't know how it is in the other states but I know that in Massachusetts it has become too easy a matter to get a child into an institution for the feeble-minded and I do not believe we who are at the head of institutions can idly sit by and allow children to be railroaded into our institutions regardless of their mental condition simply because they have been a little wayward; many of them orphans; many of them without a mother's love and care. An appreciable number, probably the same ones that Dr. Fernald has placed out successfully, had they had mother's care and a mother's guidance could have been prevented from ever acquiring the stigma of entering an institution for the feeble-minded. I do heartily believe that there is a good deal to be said on this side. With the social workers pressing the physicians and the physicians too ignorant of the conditions, there is a likelihood of error, and I know that there is error in commitment. Isn't the time ripe for requiring the judgment of some one who is familiar with feeble-minded conditions and feeble-minded children, to pass upon the cases before they come to the institution, or for allowing us in the institutions to use a little latitude. I believe that the time is ripe for this association to make some move towards framing legislation requiring competent judges to pass on children before they are admitted into an institution. The institution is becoming too popular. The school physicians in our big cities, even those who know feeble-minded children, and feeble-minded classes, because of the pressure that is brought to bear on them from the teachers, because the latter do not understand certain children, are often influenced in passing upon these brighter individuals by deferring to the opinion of the teachers who have had the best opportunity to observe them. I know this to be a fact. A boy, because he does some little foolish thing that the rest of us have done but escaped public censure because we had mothers and fathers to look after us, is passed up as feeble-minded and sent to the institution. We want to keep out of institutions all who don't belong there. I don't believe that the community wants to shirk its responsibility in that way.


Dr. Downing. Mr. President, referring to borderline cases, I have a child with respect to whom it is a question whether he is feeble-minded or not. Because of an accident it was thought best to have an X-Ray picture taken of his hand. The examination showed the too early ossification the carpal bones. In hunting over the literature I found that two men in New York had published a report on defective children, mostly at Randall's Island, where they found the carpal bones and hand bones were not alike in their ossification. I find in every case so far of my own, and I have taken children from two and a half to twelve years, this same condition of the carpal and hand bones.


Dr. Rogers: As to the advisability of placing out feeble-minded children, there can, I think, be no question concerning the wise course to pursue in regard to all who are definitely defective mentally, and we should be careful not to confuse the issue. The very conditions that render the existence of institutions for feeble-minded necessary, as custodial homes in the broad general sense, contraindicate the probability of placing out mental defectives, successfully. Of course, if now and then a child that is not mentally defective is committed or admitted to an institution, even though such a child is retarded in mental growth from some remedial cause, such a child should have a home in a good family as soon as one can be found for him. Again, a high grade moron boy of acquired mental defect, might be a very safe case to place out in a good family, though the good families that are willing to take such a person, give him a good home, be responsible for his keep, health, comfort, and conduct for what he can earn the year around, are in our north-west, at least, very rarely found.


We have occasionally found such a family, though in most instances even then the arrangements with them has not been of long duration. The boy has generally become unmanageable or has resented what he deemed to be insufficient compensation for services rendered and has returned to the institution or drifted into a more or less precarious method of securing a livelihood. We have a few boys in Minnesota who have gone out and are doing well, but the number is small, comparatively.


We have never deliberately placed out but two girls, both under exceptionally good circumstances and with former teachers. In one case the temperament of the girl and the very close home influence have combined to secure to her a happy and contented life. In the other case, the temperament and personal attractiveness of the girl and the indiscreet freedom permitted, resulted in the usual fall. Except as first stated, I have always discouraged the sending out of girls, but some have gone out against my judgment and their careers have not been satisfactory.


Dr. Keating: Before Dr. Fernald closes the discussion, I would like to revert to one point and that is the education of the public. The teachers in Baltimore, through the influence of Dr. Huey have been giving lectures to the children on the effects of feeblemindedness. We are familiar with the educational talks about the effects of tuberculosis and alcoholism but there has been nothing said about the nature of feeble-mindedness and the effect on the offspring. The teachings of these teachers are having a splendid effect, and we have been able to retain several children in the institution through the efforts of the teachers. I can't agree with Dr. Bernstein that it would take too long to wait for the effect of educational work. The children of today will be the heads of families tomorrow and I think it pays to educate the coming generation in regard to these very things. I hope the superintendents will never lose an opportunity to tell teachers about the effect of feeble-mindedness. Tell it to the children also and explain it to them in an explicit way, and they will think about it and it will bear abundant fruit.


Dr. Bernstein: I would like to know the age of those children you talked to.


Dr. Keating: The children I have spoken to are from fourteen to sixteen years of age.


Dr. Fernald: Mr. Chairman, I am afraid that my paper was not thoroughly understood because I tried to emphasize the importance of two points. First, that education in the broadest sense must be our chief weapon. We must educate the lawmaker; we must educate the judges, the doctors, the teachers. We must educate the children who go to the high school, and college, and normal school, and the medical student. We can thus leaven the population and they will spread the information to the rest of the public who are capable of being educated. We may deal with the other half of the community by our segregation and our sterilization propositions, or by other means. We all understand that laws on our statute books providing for the segregation and sterilization of the defective will be of no value unless the public is educated to demand an enforcement of them. The states in the Union which are successfully handling this matter, are the states where an intelligent campaign of education has been carried on for more than a generation.


The second point on which I seem to have been misunderstood relates to placing out. I am sure I don't want to be quoted as placing out feeble-minded boys and girls because I never intended to advocate any such principle. The cases which we have out on parole are morons who have been, say, trained and educated so that they seem very much like normal people. It is a question as to whether we should allow their parents to take them out for we want to keep a legal hold on them and give them a bit of supervision. We either have the choice of doing that or allowing them to be discharged and losing control. By the parole, we have a string on them. I believe that these persons would be better off in the institution but if we kept those forty patients, I think we would be violating the public sentiment of at least forty communities, and I think the presence of the feeble-minded people in the community in this way serves an educational purpose. I think there is a possibility that we may carry this segregation work so far and do our work so well that in a generation or two people would forget our teaching. So I think that the cases that can be returned to the community under proper parole restrictions are in a way, wholesome object lessons. They serve to prevent the community from forgetting. These boys who have gone out, with two exceptions, are city boys, because we deal almost entirely with the urban or town population, collected from manufacturing towns. I agree with the speaker who referred to the immorality of the country town. I think that the feeble-minded boy who is brought up in the city with city traditions in his blood is very unhappy on a farm. I think that the theory that the farm is necessarily good for people who are defective or criminal is open to a good deal of criticism. Placing-out agents from the reform schools for boys tell us that many boys who are happy, contented and do well in cities, being city bred and having the traditions of city life, will be perfectly lazy out with the trees.


There is a faction in Massachusetts who believe that the institution for feeble-minded ought to care for the defective delinquent. The first application of the new law will be a re-classification of the people now in the penal institutions. This merely means a separation of the mentally defective prisoners from the normal ones. It seems to be a good tentative method which promises growth and can be modified as found necessary. The defective delinquents are an incorrigible, troublesome class. They are not amenable to the altruistic principles which we see around us here. The ordinary defective delinquent in Vineland would co-operate with some of your customs and traditions, but if you had many, especially those who had criminal experiences, I don't think you could handle them. There is a very large class of these defectives. Any state with a population large enough to maintain an institution for the feeble-minded, would have a very large class of the type of feeble-minded who properly classify as defective delinquents. Some of them are very desperate and determined people. The mere prevention of escape is to them often a serious matter. The medico-legal significance of feeblemindedness we have only begun to study. We have institutions for insane criminals, and yet there are probably five imbecile criminals to one insane criminal. The imbecile is by his very nature susceptible to criminal influence. Probably no paper on the feeble-minded is read without that fact being stated and yet up to this time we have made absolutely no provision for the differentiation of this class from other criminals.