Feeblemindedness in children of school-age

Front matter

PUBLICATIONS OF THE UNIVERSITY OF MANCHESTER

Medical Series— No. XIII.

FEEBLEMINDEDNESS IN CHILDREN OF SCHOOL-AGE

Preface To The First Edition

Up to the present time the immense importance to our national welfare of effective methods in dealing with the Feebleminded has not been generally realised. The report of the Royal Commission on the Care and Control of the Feebleminded, published in 1908, has, however, served as a stimulus, so that, latterly, there has been a large amount of interest taken in the subject. This has rendered necessary the provision of a book suitable for school medical officers and also for teachers or social workers who have to deal with feebleminded children. The further objects of this book are (1) To emphasise the importance of the subject of mental deficiency and of the prominent place that efficient care of feebleminded persons should take in the measures for the welfare of the community.

(2) To point out that feeblemindedness is an inherited taint handed on from generation to generation, and that every feebleminded person, who is a free and unrestrained agent, may, by becoming a parent, transmit that taint and so affect tens or hundreds in future generations.

(3) To demonstrate that the only way to deal effectively with the problem is to provide suitable supervision and care, which will last during the whole lifetime of the feebleminded individual, and to show how such care may best be administered.

I wish to express my great indebtedness to Miss Dendy for her help and advice, and for the material which she has placed at my disposal. Her appendix on the

vii viii PREFACE TO THE FIRST EDITION

Treatment and Training of Feebleminded Children adds immensely to the practical value of the book.

I also wish to thank Professor Lorrain Smith for his help, and Dr. J. Mcllraith (Medical Officer to the Sandlebridge Colony), Mr. Wyatt (Director of Elementary Education in Manchester), and Miss Dickens (Superintendent of the Manchester Special Schools) for so kindly placing material at my disposal. Most of the photographs were taken by Mr. Quinn. Mr. G. Lapage has also given me much assistance with the proofs.

C. P. L.

Manchester, November, 1910.

Preface To The Second Edition

Very great advances have been made in the work for the Mentally Defective since the First Edition of this book was published.

The passing of the Mental Deficiency Act and the progress consequent upon this have rendered necessary inclusion of much new material.

The Second Edition has been long overdue, and its preparation was in fact begun in 1913; but war duties prevented its completion.

I wish to express my thanks once more to Miss Dendy for her help and advice, and to the Governing Body of the Lancashire and Cheshire Society for the Permanent Care of the Feebleminded for allowing me access to plans and documents; and to Mr. Richards, Secretary to the above Society, in sending me literature and information when I was abroad, and for his later assistance with the proofs.

C. P. L.

Manchester, August, 1920.

IX

Contents

3HAPTER PAGE

I. Introductory and Statistical . , 1

II. Present Methods of Dealing with the

Chapter I

History. — In 1904 it was thought necessary to appoint a Royal Commission on the Care and Control of the Feebleminded, and as a result of their report, the Mental Deficiency Act was passed on August 15, 1913. Thus was reached the culmination of the efforts which had been going on in various quarters to promote the welfare of the mentally deficient. The pioneer work of Seguin, Itard, Howe, Wilbur and others in distinguishing the treatment and care of "idiots " from that of " lunatics " has been described in other text-books ; here we shall deal chiefly with the history of the movement in England.

In the past the words " lunatic " and " idiot " have stood for two divisions of mentally deficient persons, the one implying " disorder of the mind in a person who has been in possession of his faculties," and the other " a state of mental incapacity, which has been present from birth or from an early age." The Lunacy Acts included under their jurisdiction both lunatics and idiots, but the Idiots Act of 1886 (since repealed, 1913), dealt with idiots apart from lunatics, and by the use of the word imbecile, as referring to mental defect of a lesser degree than idiocy, recognised a sub-class of the mentally defective. Later a further sub-class of still higher mental power, the feebleminded, was recognised.

Most people are familiar with the type known as the " village idiot," and anyone who has to deal with such

A 1 persons will know how helpless they are, how often they form the butt of gibes and jests, how they can be goaded to fits of passionate and uncontrollable rage during which they may commit acts of violence, and finally how subservient they are to the will and suggestion of others. Such persons were obviously in need of care and help ; but in spite of the fact that much attention had been devoted to lunatics, it is only comparatively recently that any other than the idiots with the lowest grade of intellect have been generally recognised as being in want of care. The existence of a very large number of persons who, though certainly of too low a mental level to look after themselves without assistance, are still of a higher level than idiots, had in the past only been partially recognised, and though various more or less isolated attempts had been made to care for special classes of the weakminded no comprehensive scheme had been adopted. The great majority of such persons had been dealt with by various authorities such as the poor-law, the prisons, the inebriate homes, and the education authorities, according to whether they were destitute, habitual criminals, drunkards or too deficient to benefit from instruction in the ordinary schools, as the case may have been. Obviously it was wrong to make it impossible for them to come under care until they had committed an offence of some sort, and it is better to take them under care and prevent such offences.

Past efforts at care. — In the attempts that have been made to deal with this class of mental deficiency we can trace several distinct movements. First, there was the establishment of the institutions known as the idiot asylums, which were founded at a time when idiocy was thought to be more or less curable, and the importance of lifelong care had not been realised.

To quote the Commissioners : —

In general we may say that the object of the asylums is

PAST EFFORTS AT CARE 3

primarily educational, and that, originally at least, they were the outcome of a belief that in many cases special education would prepare " for the duties and enjoyments of life " the children or young persons, who gained admission to them.

Since the regulations of the asylums included the discharge of pupils after a period varying from four to seven years, it is evident that lifelong care formed no part of the original idea of their founders.

The first idiot asylum, Earlswood, was founded in 1847, but a small school had been established at Bath in 1846, and this became the Magdalen Hospital School. Other idiot asylums were established later, the Eastern Counties at Colchester in 1859, the Western Counties at Starcross in 1864, the Royal Albert at Lancaster in 1864, and the Midland Counties at Knowle in 1868. In all, these institutions provided accommodation for about 1,900 cases. To these must be added the important colony at Darenth, under the Metropolitan Asylums Board. But it should be pointed out that until a few years ago when they changed their names to " Training Schools for the Feebleminded," these asylums, except Starcross, were largely devoted to the care of the lower grade cases.

Secondly, taking the Poor Law Authorities, the Commissioners showed that, though the Guardians had had permissive powers of making provision for the mentally defective class, they had not evolved any suitable scheme of dealing with such persons on the ground of their mental condition, but, had treated them rather on the ground of their pauperism and need of relief, the mentally defective being then kindly looked after but maintained rather than treated, and no attempt being made to separate the Various grades. The evidence on this point is, as the Commissioners say, " quite conclusive " : —

It comes almost entirely from persons who as Inspectors .••.". or as Guardians are thoroughly familiar with the facts, and it relates practically to the whole country. There are special arrangements here and there . . . but it is admitted that, as a whole, the accommodation now provided for these persons is insufficient, unsuitable and unsatisfactory. It is not asserted that they are treated with unkindness . . . nor are the Poor Law Guardians throughout the country to blame. The system of indoor relief is merely a housing system and . . . there has sprung up a demand for a more discriminating and individual treatment of mentally defective persons. . . .

The practice of giving outdoor relief or of boarding-out such cases has also had very bad results in England and is undesirable for many reasons. Its limitations will be discussed later.

The Guardians have had power to make use of other institutions, and to pay for the maintenance of the mentally defective there ; in some instances, especially after the report of the Commission, they did avail themselves of this power, but not nearly to a sufficient extent.

Thirdly, taking the Education Authorities, the Education Act of 1870 gave the school boards the duty of dealing with all educable children, and the establishment of schools for the physically defective soon followed (1872). The Royal Commission on the Blind, Deaf and Dumb (1889) recommended that every parent should cause his or her child " to receive instruction suitable to it," and that " with regard to feebleminded children, they should be separated from ordinary public scholars in public elementary schools in order that they may receive special instruction and that the attention of school authorities be particularly directed towards that object." The later recommendation arose from the evidence of several witnesses, especially Drs. Shuttleworth and Warner, with regard to those children defective in sight, hearing, and speech because they were mentally deficient. London and seven provincial towns* established such schools, but the cost was a very heavy charge on local expenditure, when unsupported by a

* Towns that first established special schools for feebleminded children are Birmingham, Bradford, Bristol, Leicester, Liverpool, London, Manchester, Oldham and Salford, Leicester being the first of all.

PAST EFFORTS AT CARE 5

Government grant, and representations were made for special legislation in favour of feebleminded children. General F. J. Moberly, who was then Chairman of the Sub-Committee of the London County Council Schools for the physically defective, gave evidence before this Commission and later became the Chairman of the Sub- Committee in charge of the Special Schools for the Mentally Defective.

In 1876-77 a Special Committee of the Charity Organisation Society of London reported on the education and care of idiots, imbeciles, and harmless lunatics, estimating their number at 49,041, and recommending the establishment of schools and asylums in every large centre or group of counties.

Again in 1890 the same Society appointed a special committee to consider and report on " the public and charitable provision made for the care and training of the feebleminded, epileptic, deformed, and crippled." This Committee issued in 1891 an interim, and in 1892 a final report, which embodied the results of an examination of a very large number of school children by Dr. Francis Warner and others, who found that approximately 1 per cent, of the children examined required special care and training.

In 1893 the Elementary Education (Blind and Deaf Children) Act was passed, and by it the teaching of blind and deaf children became compulsory. In 1895 a Committee under the auspices of the British Medical Association, the Charity Organisation Society of London, the British Association for the Advancement of Science, the International Congress of Hygiene and Demography, and other public bodies issued " A Report on the Scientific Study of the Mental and Physical Conditions of Childhood with particular reference to Defective Children " from the Parke's Museum, Margaret Street, W.*

* See Shuttleworth and Potts, Mentally Deficient Children.

The interest in defective children created by these various reports was great, and led up to the appointment of a Departmental Committee on Defective and Epileptic Children in 1896. The Committee consisted of the Rev. F. W. Sharpe, C.B., then Her Majesty's Chief Inspector of Schools ; Messrs. Pooley and Newton of the Education Department; Mrs. Burgwin and Miss Douglas Townsend; and of Professor Wm. Smith and Dr. Shuttle worth ; Mr. H. W. Orange acting as Secretary. Their report was issued in 1898, and one of the main conclusions they formed was " that children exist who, on the one hand, are too feebleminded to be properly taught in ordinary elementary schools by ordinary methods, and, on the other hand, are not so feebleminded as to be imbecile or idiotic. These feebleminded children exist as a distinct class from imbeciles, they are not certified as imbeciles, not provided for as imbeciles, they differ both from ordinary children and from imbeciles in the treatment they require during their school-life." The Committee also found that approximately one per cent, of the children in the public elementary school classes appeared to be feebleminded, and they recommended that such children should attend school when possible rather than remain idle at home.

These suggestions were embodied in the Elementary Education (Defective and Epileptic Children) Act of 1899, defective children being there defined as " children who, not being imbecile and not merely dull and backward, are by reason of mental and physical defect incapable of receiving proper benefit from the instruction in the ordinary public elementary schools, but are not incapable, by reason of such defect, of receiving benefit from instruction in such special classes or schools as are in this Act mentioned," and the period of compulsory education for these children was extended to 16 years instead of 14, as for ordinary children.

INCREASING EFFORTS FOR CARE 7

By this Act the authorities were empowered but not compelled (1) to establish special classes for defective children in some of their schools ; (2) to board them out in houses near to special classes or schools; (3) to establish either special day or boarding schools for them. This Act was really a very moderate measure, and only touched the fringe of the subject since its powers were permissive only, and also since it made no provision for the bad cases of mental defect. For epileptic children boarding schools only were allowed.

Fourthly, taking Voluntary Agencies, for some 30 years much attention has been paid to means for helping feebleminded women, especially those who had been led into disgrace by reason of their mental defect, and Lady Frederick Cavendish established the first home for this purpose. Her efforts were followed by Miss Stacey in Birmingham, Miss Grayson in Liverpool, and Miss Scott at Hitchen.

Increasing Efforts for Care. — Largely owing to the establishment of Special Day Schools, which revealed the very large numbers of the weakminded children for whom no special provision was made, the subject of feeblemindedness assumed increasingly more importance, and in 1896 was founded the National Association for Promoting the Welfare of the Feebleminded.

At this time a new development in the care of the feebleminded began with the foundation in 1898 of the Lancashire and Cheshire Society for the Permanent Care of the Feebleminded, since hitherto no large society or institution had grasped and emphasised the essential point in dealing with the problem, that of lifelong care.

The foundation of this last society followed directly as a result of the efforts of Miss Mary Dendy and the late Dr. Henry Ashby. Miss Dendy's attention had been attracted to the large numbers of obviously weakminded children in the elementary schools under the

Manchester School Board, and Dr. Ashby examined and reported on 500 mentally defective children selected by her from 39,600 scholars.

This examination, entailing as it did a questioning of the parents, only served to emphasise the point that, valuable as special day schools may be, the work done in them must be largely wasted and nullified if the children are discharged at the age of sixteen, the most critical period of their lives, to become in many instances the parents of children similar to themselves. Miss Dendy's efforts led to the foundation of the above society, to which she was for fifteen years Honorary Secretary, and which has now attained important dimensions. The late Mr. C. H. Wyatt, when Director of Elementary Education in Manchester, did a great deal to aid the work of the Society. The whole policy of this Society is based on the fact that only lifelong care of the feebleminded is satisfactory, and the success of its colony at Sandlebridge demonstrates the feasibility and value of this method of caring for the persons of weak mind. There is no doubt that the colony school system with lifelong care is by far the most satisfactory, and wherever possible it should be adopted for all grades of cases. Nobody who is familiar with the problem, and also with the results of a colony such as that at Sandlebridge, can have the least doubt on this point.

Royal Commission. — In April, 1903, a petition signed by some 140 influential persons especially interested in the subject, was sent to the Home Secretary pleading for the appointment of a Royal Commission " to consider and report upon the existing provision for Idiots, Imbeciles, and the Defective or Feebleminded, and to make recommendations." This led up to the appointment in 1904 of the Royal Commission on the Care and Control of the Feebleminded.

The Marquis of Bath was first appointed Chairman of the Commission, but he resigned and the Earl of Radnor

ROYAL COMMISSION 9

was appointed in his place. The other members were (2) W. P. Byrne, Esq., Principal Clerk to the Home Office; (3) C. E. H. Chadwick-Healey, Esq., K.C. ; (4) C. E. H. Hobhouse, Esq., M.P. ; (5) F. Needham, Esq., M.D., Commissioner in Lunacy; (6) H. B. Donkin, Esq., M.D. ; (7) J. C. Dunlop, Esq., M.D. ; (8) H. D. Greene, Esq., M.D. ; (9) The Rev. H. N. Burden, Manager of Brentry and other Inebriate Reformatories ; (10) W. H. Dickenson, Esq., M.P., Chairman of the National Association for promoting the welfare of the Feebleminded; (11) C. S. Loch, Esq., Secretary to the Charity Organisation Society; (12) Mrs Hume Pinsent, Chairman of the Special Schools Sub-Committee of the Birmingham Education Committee.

Their report consisted of eight volumes ; volumes one to four being minutes of evidence, volume five appendix papers, volume six the reports of the medical investigators, volume seven the report on the visit of certain of the Commissioners to America, and volume eight the Report Volume. The report was issued in August, 1908, and served to correlate and focus the knowledge on the subject, to bring forward much fresh evidence, and to bring out prominently the urgent need of a comprehensive scheme for dealing with the feebleminded.

The Commissioners were at first directed to consider the methods of dealing with idiots, epileptics, imbecile, feebleminded, or defective persons not certified under the Lunacy Laws, but later the scope of the enquiry widened, and they were also directed to enquire into the Lunacy Laws with a view to the suggestion of some scheme that would provide care for all persons of deficient intellect whether they were lunatics, dements, idiots, imbeciles, epileptics, or feebleminded. The Commissioners examined 248 witnesses, obtained information from foreign countries, and visited American institutions. At the outset it was found that there were no available statistics; medical investigators were, therefore, appointed in various districts, their duties being to examine the following groups of persons : —

(1) Children in Public Elementary Schools.

(2) Children and Adults in Poor Law Institutions.

(3) Children and Adults in receipt of Outdoor Relief.

(4) Persons known to Sanitary Authorities.

(5) Persons relieved by Medical Charities. {6) Persons known to General Practitioners.

(7) Children and Adults in various Charitable Institutions

and Common Lodging Houses, Training Homes, and Reformatories and Industrial Schools.

(8) Persons to be heard of from other sources.

(9) Known to the Police.

(10) Idiots of the District in Idiot Asylums.

(11) Inmates of Prisons.

(12) Inmates of Inebriate Homes.

As a result of this report, the Mental Deficiency Act of 1913 was passed. But before discussing its provisions and effects, it is advisable to examine some further facts and figures brought out by the evidence given before the Royal Commission.

Classification and Definitions. — Strictly speaking the term Mental Deficiency includes all persons of unsound mind, and such persons can be divided into two classes : —

(1) Lunatics,* dements, or insane persons who from disorder of the mind or from a decay of their mental faculties have lost the power of managing themselves or their affairs.

(2) Aments, or persons who, because their brain is incapable of normal development, have never had and never will have the power of managing themselves or their affairs.

There has been and still is a tendency to limit the term Mental Defect to Aments as distinguished from Dements. In this book we shall use the term mentally

* There is in many quarters to-day a strong demand that the word lunatic shall be abolished. It is not agreed as to what term shall be substituted for it. As a matter of fact, it is little used by the Authorities, excepting in legal documents.

CLASSIFICATION AND DEFINITIONS 11

defective in reference to class (2), the aments, the terms idiot, imbecile, and feebleminded and moral imbecile being used to designate various grades. We shall dismiss class (1), or lunatics, with the two remarks that the Commissioners recommend that the words "lunatic" and " asylums " should be superseded and those of " persons of unsound mind " and " hospital " substituted, and that it is entirely undesirable that lunatics should be treated in the same institutions as the mentally defective.

Of the three grades of aments or mentally defective persons the feebleminded are intellectually the highest, the idiots the lowest, and the imbeciles intermediate.

Definitions. — The definitions of the three grades adopted by the Act are : —

(a) Idiots — that is to say, persons so deeply defective in mind from birth or from an early age as to be unable to guard themselves against common physical dangers.

(b) Imbeciles — that is to say, persons in whose case there exists from birth or from an early age mental defectiveness not amounting to idiocy, yet so pronounced that they are incapable of managing themselves or their affairs, or, in the case of children, of being taught to do so.

(c) Feebleminded persons — that is to say, persons in whose case there exists from birth or from an early age mental defectiveness not amounting to imbecility, yet so pronounced that they require care, supervision, and control for their own protection or for, the protection of others, or, in the case of children, that they by reason of such defectiveness appear to be permanently incapable of receiving proper benefit from the instruction in ordinary schools. Dr Goddard has suggested the name " Moron " for this type of mentally defective person.

(d) Moral Imbeciles* — that is to say, persons who from an early age display some permanent f mental defect coupled with strong vicious or criminal propensities on which punishment has had little or no deterrent effect.

These definitions emphasise the lifelong and incurable character of the mental affliction, and distinguish it from (1) temporary mental affections, and (2) from backwardness or retarded mental development, which is due to

* Imbecile is not a good word. f Lifelong is a better word.

adverse factors in infancy and childhood. Temporary insanity may be cured and a backward child may be brought up to the normal level by suitable treatment, but a mentally deficient child, though amenable to treatment and training to some extent, can never be rendered normal.

Causation. — When dealing with the causation of mental defect, the Commissioners found that twentyfive out of thirty-five witnesses attached supreme importance to the fact that, in a very large proportion of the cases of mental defect, there is a history of mental defect in the parents or near ancestors. The twentyfive witnesses, who held this opinion, had all had a very large experience, and had devoted special attention to the subject. Sir Clifford Allbutt said : —

I regard feeblemindedness (if not accidental) as always hereditary, or in other words it is a ratio of variation. I have never met with a case of manufactured feeblemindedness apart from some accident at birth or afterwards. ... I attach great weight to inheritance. . . . Feebleminded persons are prolific; the thing can only be bred out.

The late Dr. Ashby, Medical Officer to the Special

Schools at Manchester, said : —

In at least 75 per cent, of the children with amentia that I have examined there was a strong probability that the amentia was hereditary and primary (i.e., spontaneous, not due to external influences). He further says that he has observed no special tendency in the children of alcoholics or of women who suffer privation during pregnancy or in those children who live in unfavourable conditions subsequent to birth, to develop amentia. The term "Amentia" is here used to cover all grades of mental defect in early life.

Dr. Bevan Lewis said : —

There is not the least doubt of it' in my mind. I look upon feeblemindedness as a germinal variation just as all " variations " are.

Dr. Tredgold found evidence of a neuropathic inheritance in 80 per cent, of his cases.

Mr. Frederic Wilkinson, Director of Education, Bolton

CAUSATION 13

Education Committee, gave evidence to the effect that in almost every case where parents of mentally defective children appeared before the Committee or before magistrates, it was found that the parents themselves were similarly affected.

In support of the importance of heredity in the causation of feeblemindedness were the facts that a large majority of " experienced witnesses " held this view as did "numerous observant individuals other than medical who visit the homes of the feebleminded," and " the almost overwhelming probability from the biological standpoint of this view being true." Professor Sir E. Ray Lankester held : —

that congenital feeblemindedness is spontaneous originally and truly hereditary subsequently and is not brought about by starvation and other such conditions : it is more probably due to easy conditions of life and the absence of the selection that obtains amongst more primitive men.

Dr. Archdall Reid expresses the opinion that the great majority of the cases of feeblemindedness are innate and tend to be inherited.

With regard to the fertility of mentally deficient persons, the Commissioners quote the evidence of " their medical investigators and of Miss Dendy, a very experienced witness," to show that in spite of the fact that there is a large mortality in the children bom to mentally deficient persons, they tend to have large families.

On the other hand it is only fair to quote Dr. Mercier's evidence, which was : —

clear and consecutive and amounts to the conclusion that, not only is the frequent transmission of feeblemindedness by inheritance not proved, but, also, that the organic defect of brain which underlies feeblemindedness may be often the result of external influences which during childhood affect the growth of the brain injuriously.

In conclusion, the Commissioners summed up : —

1. That both on the grounds of fact and of theory there is the highest degree of probability that " feeblemindedness " is usually spontaneous in origin — that is, not due to influences acting on the parent — and tends strongly to be inherited.

2. That, especially in view of the evidence concerning fertility, the prevention of mentally defective persons from becoming parents would tend largely to diminish the number of such persons in the population.

3. That the evidence for the conclusion strongly supports measures, which on other grounds are of pressing importance, for placing mentally defective persons, men and women, who are living at large and uncontrolled, in institutions where they will be employed and detained; and in this, and in other ways, kept under effectual supervision so long as may be necessary.

They added that, in their opinion : —

the general feeling of the people would at present rightly condemn any legislation directed chiefly or exclusively to the prevention of hereditary transmission of mental defects by surgical or other artificial measures. The possibility of adopting such measures having been referred to by twenty-one of the witnesses but only recommended by three.

Proportion of the Feebleminded to the General Population. — The statistics given on pages 192 and 193 of the Commissioners' report are very striking. Apart from lunatics (or, as the Commissioners recommend they should be called, " persons of unsound mind ") at least one in 217 or 0.46 per cent, of the population is mentally defective, i.e., is either idiot, imbecile, feebleminded, or a moral imbecile. When children on the school registers are considered, the proportion is still higher, partly because mentally deficient persons tend to die earlier in life and partly because proportionately more children than adults come under supervision and observation on the ground of mental defect. Taking the average of the results obtained from the figures collected by the medical investigators the proportion was 1 to 127 or 0.79 per cent., being approximately 1.0 per cent, in urban districts and 0.5 in rural. This difference may be due to the greater facilities for medical inspection appertaining in the towns at the time the estimate was made. In some towns the proportion was higher than 1 per cent., being in Birmingham 1.12 per cent., in Manchester