HV 5006 .6ta"brook, Dr. J^ (q Mental defectives^ A4 In Jn\i ann. R ep rt of th e Conrni t te e on I' en tal Defectlvee, Hov. 1916. HV 3006.I6aT" ''"'"*'"">' '■"'rary ALBERT R. MANN LIBRARY New York State Colleges OF Agriculture and Home Economics Cornell UNrvERsmr »°6' '12 wr -iw A N'asnoBjXg MENTAL DErECTIVES IN mMk Report of the Gommittee on Mental Defectives Appointed by Governor Samuel M. Ralston Indianapolis, Indiana, November 10, 1916. (2 CONTENTS Page Appointment of the Committee 1 The Problem 3 Definition of Groups of Mental Defectives 3 The Problem Outlined 4 Data Collected 7 Survey of Two Counties 7 School Questionnaire 15 Population of State and County Institutions 15 Relation op Mental Defectives to Schools, Pauperism, Dependency and Delinquency 18 The School Problem 18 The Problem of the Pauper, the Dependent and the Delinquent 18 Activities of Other States 30 Conclusions 31 Recommendations 32 (^C33^Z Report of Committee on Meril^c % Defectives ^^^; To The Honorable Samuel M. Ralston, Governor of Indiana and President OF THE Board of State Charities. Sir: The committee appointed by you August 6, 1915, to study the prob- lem of mental defectiveness in Indiana, has the honor to submit a report of its observations and conclusions. The circumstances under which the cominittee was appointed are perhaps best explained by the following quotation from the report of the Board of State Charities of Indiana, for the fiscal year ending Septem- ber 30, 1915: "The state faces no more serious problem than that involved in the care of mental defectives. No other class of public wards is increasing so rapidly, none other is so burdensome, socially and economically. The state has established seven great institutions for their care and treat- ment. It spends one and one-third million dollars annually for their maintenance. With all this it is not even keeping pace with the problem. Faster than the state can receive them in its institutions, the number of defectives increases, largely, as we are coming to know, through bad heredity, syphilis, and drug habits, including alcoholism. The task be- fore the state is one not only of institutional care but of prevention. ' 'To the end that a thorough study of the situation might precede further legislation on this subject, the Board of State Charities, on April 22, 1915, adopted the following resolution: Whereas, the problem of the mental defective is one of our greatest social as well as financial burdens and is in- creasing with importance and weight every year; and Whereas, Mental defectiveness is believed to be one of the most important if not the most important cause of pauperism, degeneracy and crime; therefore be it Resolved, That it is essential that we know what the problem of mental defectives— including the epileptic, feeble- minded and insane— is in Indiana, what is being done for them here and elsewhere, and in the light of the best ex- perience what program can be suggested for this state; and be it further Resolved, that this board select a committee of eight (8) persons to carry out the purposes of these resolutions, who shall serve without compensation for their services. 1 Such committee to consist of two members of the last legis- lature, one of them a hold-over senator and the remainder persons who have given special attention to the subject in some of its phases. That the Governor be requested to in- vite them to serve in such capacity and report in writing their observations and conclusions to this board and the Governor by November 1, 1916. "Acting on this resolution, Governor Samuel M. Ralston appointed the following to serve as a Committee on Mental Defectives. Rev. Francis H. Gavisk, chairman of the Board of State Charities' Committee on Hospitals for the Insane, chairman; Dr. George P. Edenharter, med- ical superintendent of the Central Indiana Hospital for the Insane, Indi- anapolis; Dr. Samuel E. Smith, medical superintendent of the Eastern Indiana Hospital for the Insane, Richmond; Dr. Charles P. Emerson, dean of the Indiana University School of Medicine, Indianapolis; Dr. W. C. Van Nuys, superintendent of the Indiana Village for Epileptics, New Castle; Dr. George S. Bliss, superintendent of the School for Feeble- Minded Youth, Fort Wayne; Senator D. Frank Culbertson, Vincennes, and Representative Charles A. McGonagle, Muncie. " At its first meeting, December 17, 1915, Amos W. Butler, secretary of the Board of State Charities, was elected secretary of the committee. Since that date, the .committee has met once and'some times twice each month, excepting June, its members giving freely of their time and at some personal expense. The difficulties under which they labored, ow- ing to the lack of an appropriation, were in some degree lessened by the generosity with which certain public and private agencies, as well as public-spirited citizens, interested in the general problem, gave of their counsel and experience. Prominent among these were the United States Public Health Service, the Federal Children's Bureau, the Nation- al Committee on Provision for the Feeble-Minded, the National Com- mittee for Mental Hygiene, the National Association for the Study of Epilepsy, the Eugenics Record Office, and, in our own state, the Board of State Charities, the State Board of Health, state and county medical societies, the Department of Public Instruction, county and city superin- tendents of schools, the State Bar Association, and the superintendents of state charitable and correctional institutions coming in touch with or devoted wholly to the care of mental defectives. Three field workers, trained by the Eugenics Record Office, were assigned to the committee for the purpose of making special investiga- tions under its direction. Two of these were in the direct service of the Eugenics Record OflSce, the third was in the employ of the Northern Indiana Hospital for the Insane. The Problem Definition of Groups of Mental Defectives For the purposes of this committee's investigation and consideration the term, mental defective, includes the epileptic, the insane and the feeble-minded. The mental defective then may be broadly defined as a person below the generally accepted standard of mentality by reason of which he is in- capable of caring for himself and his affairs with reasonable prudence. This definition is admittedly inexact, because standards of mentality vary with communities, and yet it defines with sufficient accuracy for present purposes. Some one lately and aptly has said that the mental defectives in- clude the two per cent, of the general population lowest in the scale of intelligence. This is near the truth, and being so, the burden of their care should not stagger the ninety-eight per cent., or normal population; nor would it if systematically and thoroughly done. An epiteptic is a person subject to "falling sickness, " or periodical convulsive seizures generally called epilepsy. The term, epilepsy, as used by the medical profession does not stand for a thoroughly well-de- fined disease, but includes a multiplicity of conditions characterized by unconsciousness associated with convulsions. While the causes of epilepsy are unknown, it is an established fact that conditions favoring its development are transmitted from parent to offspring, and the tend- ency of the disorder is in the direction of mental deterioration, and not infrequently results in complete mental dilapidation. While the condition is incurable, convulsions may be reduced in frequency and mental deteriora- tion controlled in some degree by treatment and wholesome, well-directed employment under proper surroundings. An insane person is one incapacitated as the result of a mental dis- ease. Such disease usually results from other disease or injury of the brain and nervous system, yet sometimes has its origin in diseases of the more remote organs of the body. It is a disease of maturity and with few exceptions develops at or after the period of adolescence. It is curable or incurable depending upon the form, the cause, individual de- velopment of the person affected and early treatment. The vast majority of cases are preventable. Feeble-mindedness is a state of permanently arrested mental develop- ment at any level below that of adult intelligence. Again, it is often defined as a "state of mental defect existing from birth or from an early age, and due to incomplete or abnormal mental development in consequence of which the person afflicted is incapable of performing his duties as a member of society in the position of life to which he is born." The Royal Commission of England defines a high-grade feeble-mind- ed person as "one who is capable of earning his living under favorable circumstances, but is incapable from mental defect existing from birth or from early age of competing on equal terms with his normal fellows or of managing himself or his affairs with ordinary prudence. ' ' The condition is one of immaturity and the arrest in development may occur at any age below twelve years. Although the mind does not develop, the body continues to grow, and in time the feeble-minded in- dividual has a child's mind in an adult's body. Although incurable, the higher grades in proper institutions can be trained to usefulness and even self-support, and may lead harmless and happy lives under supervision outside of an institution. The highest types may accomplish some tasks, of even complicated work, but cannot plan. For convenience the classification usually accepted is as follows: (a) The high grade, or morons, whose mental develop- ment is comparable roughly to that of normal children of from 8 to 12 years of age; (b) The medium grade, or imbeciles, who are capable of some training and can do things in a routine way, and is comparable mentally to normal chil- dren of from 3 to 7 years; (c) The low grade, or idiot, like babies of one or two years, who are so lacking in intelligence that they are practically incapable of any training what- ever. The Problem Outlined While we know the problem of the mental defective is large, we cannot accurately measure it. Omitting the convincing estimates and statistics- which this report elsewhere sets forth, there are facts in abundance in plaift view of the thoughtful person which, with a little consideration, are suffi- cient to spur us to broader and larger means of care and to better meth- ods of prevention. In Indiana twelve hundred insane persons are annu- ally committed to our state hospitals which have a daily average popula- tion of fifty-three hundred patients, and yet there are approximately 1,300 insane persons throughout the state in jails, county infirmaries, in private families and at large, in need of hospital care, but denied it for lack of room in the hospitals. The Indiana Village for Epileptics is the result of a movement started twenty-one years ago by the Indiana Con- ference of Charities and Correction at its annual meeting in Fort Wayne, which resulted in the organic act by the legislature ten years ago. To- day it is caring for only three hundred and five epileptic men, and pro- vision is now being made for only a limited number of women, while there are approximately one thousand unfortunate epileptics throughout the state sadly in need of state care but denied it for want of accommoda- tions in the Village for Epileptics. The Indiana School for Feeble- Minded Youth is limited in the capacity of its buildings to thirteen hun- dred inmates, while there are approximately six thousand feeble-minded persons in urgent need of the institution's protection and training. In many jails of the state there are insane men and, shocking to say, a few insane women; in every county infirmary there are insane, epileptic and feeble-minded persons associated with the vicious and criminal classes, who should be placed under state care. The number of defective delinquents is increasing rather than dimin- ishing and the number already in the prisons, reformatories and state farm, is variously estimated from twenty to forty per cent, of the total . While the question of state care of the mental defective is large, it is not the whole problem. It is only one phase of it. While segregation under state supervision is admittedly and unquestionably the best method of treatment, care and prevention, yet devised and applied, the number of mental defects is so large and the manifestations of mental deficiency are so varied in kind and degree, that all can not and should not be pro- vided for under a state care system. While the well-defined cases of mental disease are best treated and cared for in the state hospitals, it is unnecessary and unwise to so curtail the liberty of the borderline cases. Likewise, a majority of the epileptics are not in need of constant and permanent detention in the Village for Epileptics. Also, some groups of the feeble-minded under favorable extra-mural conditions may support themselves and do well. It a part of the problem then to determine by some definite method and system the groups which should properly be segregated by the state. It becomes, also, no small part of the problem to devise wise and hu- mane methods of community care which will effectively extend a protect- ing and helping supervision over the large number of defectives inadmissi- ble to the state institutions. Such community care implies large responsi- bility and demands a wise discrimination in a line of endeavor having a two-fold purpose. The one is the education and training of the feeble- minded youth in the special schools, or classes, and in the family to some degree of usefulness, the treatment of the borderline cases of mental disease and the after-care of cases discharged, furloughed or paroled from the state institutions. The other aim, and not by any means the lesser, is the prevention of mental defectiveness by methods not yet fully determined. In the light of the established facts that the feeble-minded female is twice as prolific as the normal female, that prostitutes are largely recruited from the ranks of feeble-minded girls and women, who soon become victims of syphilis and alcoholism, which are the most potent factors in mental defectiveness, it is surprising that we are only now awakening to the grave duty of restricting the liberties of this menacing group. How this can be done and should be done is ' a part of the problem. Provision for the care of the mental defective can not be eflBcient and helpful without a reasonably accurate knowledge of the defectives themselves. It is necessary to know the number, their location, envir- onment, the kind and degree of deficiency, family history, and something of the causes responsible for the abnormal condition for the best results under state or community care. The same knowledge makes possible prevention, which after all is the most important step in the program. How to gather this information, classify and apply it is no small fea- ture of the problem. While public opinion accepts and supports segregation by the state of the insane and some of the feeble-minded and epileptic, and has provided limited means for the purpose, the system is far from complete, and it has demanded of the state little or nothing in the way of research and prevention. Likewise, the public mind is only beginning to appreciate the value and far-reaching importance of community care and the degree and kind of supervision the state should exercise over it is an open question. Therefore, the education of a wholesome public opinion concerning the treatment, care and prevention of the mental defective is a neces- sity and the best methods for doing it are, also, a part of the problem. These are some, but not all, of the phases of the problem. It is big but not hopeless, and today it is humanity's best problem. Data Collected Survey of Two Counties by Field Workers of Eugenics Record Office The committee on mental defectives early recognized the necessity of field studies of the mental defective, so they secured the services of three eugenic field workers, all trained by the Eugenics Record Office. These three investigators studied two counties in Indiana, designated "A" and "B", by inquiries, consultations and visits to physfcians, school author- ities, township trustees, boards of children's guardians, institution heads and social betterment agencies. Practically every person who has been studied in this enumeration of mental defectives, has been visited either in his own home, at school or at business. In many cases the investigat- ors have talked with parents and have advised as to the future care and training of some of the defective children. The three investigators spent about three and one-half months each in the field study. The data gathered are accurate and it is felt that the field has been fully covered, although a few cases of mental defectives may not have come to the attention of the investigators. About thirty to forty per cent, of the individuals reported to the investigators as defective have been classed by them as either doubtful, borderline cases or normal, and therefore have not been included in the totals presented. "A" County. The northern half of "A" county is composed of fertile land, the southern part is hilly, rather rough and unproductive and less accessible. A narrow strip along the western border is comprised of fertile land. There is one city of some size situated about the center of the county at the southern edge of the more fertile northern part already mentioned. The county was settled early in the history of Indiana mainly by immigra- tion from Kentucky. "B" County. "B "county is situated in a very fertile section of the state. One city of some size is the county seat and here there is much manufacturing taking place. This county was settled by immigration from Ohio and the eastern states. There are at present few foreign born people in "B" county. Statistical tables showing the results of the investigation in "^'A" and "B" counties follow: 4 9 22 37 1 5 Mental Defectives in "A" County Epileptic. Males Females Total Epileptics in community at large, not need- ing institutional care 12 5 17 Epileptics needing institutional care at present 8 6 14 Epileptics in State Village for Epileptics.. 1 1 Epileptics in Poor Asylum 1 1 Epileptics and low grade feeble-minded in School for Feeble-Minded Youth 2 2 Epileptic Insane in State Hospital for In- sane 1 1 2 22~ 15~ 37 Total epileptics, 37, or 1 to 554, or .18%, or 1.8 per 1,000 of population. Insane. Insane in community, needing care 3 4 7 Insane in community, needing no care at present 5 Insane now in State Hospital for Insane ... 15 Insane now on furlough from hospital 4 Insane discharged from hospital, still insane, need care 1 5 6 Insane discharged from hospital, may need care later 2 2 Insane now in Poor Asylum 9 2 11 Insane now in State Prison 1 1 38~ ~40 ~78 Total Insane, 78, or 1 to 263, or .38%, or 3.8 per 1,000 of population. Feeble-Minded. Feeble-Minded, High Grade. In community, not needing immediate care. 34 24 58 In community, needing institutional care now 47 In Poor Asylum In School for Feeble-Minded Youth 1 82~ Feeble-Minded, Medium Grade. In community, not needing immediate care .14 6 20 In community, needing institutional care now 47 In Poor Asylum 3 In School for Feeble-Minded Youth 3 67 8 39 86 3 3 4 5 70 152 25 72 2 6 6 9 39 106 Peeble-Minded, Low Grade. . Males Females Total In commiinity, not needing immediate care. 4 3 7 In community, needing institutional care now 4 7 11 In Poor Asylum 112 In School for Feeble-Minded Youth, also epi- leptic 2 2 In School for Feeble-Minded Youth 2 2 9 16 24 Feeble-minded in Indiana Girls' School 3 3 158 T2f 285~ Total Feeble-minded, 285, or 1 in 72, or 1.39% or 13.9 per 1,000 of population. Total defectives, subtracting duplications (1 male, 3 females) males 217, females, 179; total 396, or 1 in 52, or 1.90 fo, or 19 per 1,000 of population. Mental Defectives in "A" County Needing Institutional Care, Not Now in Care Males Females Total Epileptic 8 6 14 Insane 4 9 13 12 ^5~ 27 Feeble-minded, high grade 47 39 86 " " medium grade 47 25 72 " " lowgrade 4 7^ 11 Total Feeble-minded 98 71 169 Total defectives outside institutions, need- ing care 110 86 196 Mental Defectives From "A" County, Now in State Institutions Males Females Total Inmates Village for Epileptics 1 1 Inmates State Hospital for Insane 19 23 42 Inmates School for Feeble-Minded Youth. . . 4 14 18 Inmates Indiana Girls' School 3 3 Inmates Indiana State Prison 1 1 Total mental defectives in state institutions 25 40 65 Mental Defectives in "B" County Epileptic. Males Females Total Epileptics in community at large, not need- ing institutional care 17 18 35 Epileptics needing institutional care at pre- sent 4 4 8 Feeble-minded epileptics needing institu- tional care 5 2 7 Feeble-minded epileptic not needing insti- tutional care 1 1 2 Feeble-minded epileptic in Indiana Reform- atory 1 1 Epileptics at State Village for Epileptics. . 7 7 Epileptics in Poor Asylum Feeble-minded epileptics at School for Fee- ble-Minded Youth 1 2 3 Epileptic insane at State Hospital for In- sane 1 1 2 37 28 ~65 Total epileptics, 65, or 1 to 508, or .19%, or 1.9 per 1,000 of population. Insane. Insane in community needing care 7 3 10 Insane in community needing no care at present 5 4 9 Insane now in State Hospital for Insane . . 29 27 56 Insane discharged from hospital, still need- ing care 2 1 3 Insane discharged from hospital, still in- sane, may need care later 2 2 Insane in Poor Asylum 1 1 "46 "35" 81 Total insane, 81, or 1 to 408, or .24%, or 2.4 per 1,000 of population. Feeble-Minded. Feeble-minded, High Grade. In community not needing immediate care . . 49 28 77 In community needing institutional care now 23 18 41 In Poor Asylum 3 3 In School for Feeble-Minded Youth 1 4 5 Feeble-minded epileptic in Indiana Reforma- tory 1 1 77 50 127 Feeble-Minded, Medium Grade. In community not needing immediate care . . 34 17 51 In community needing institutional care now 14 15 29 10 Males Females Total In Poor Asylum 5 2 7 In School for Feeble-Minded Youth 3 6 9 Feeble-minded, epileptic 5 2 7 Feeble-minded epileptic at School for Fee- ble Minded Youth 2 2 Feeble-minded, State Hospital for Insane. . . 2 , 2 63 44 107 Feeble-Minded, Low Grade. In community not needing immediate care . . 6 6 In community needing institutional care now 4 2 6 In School for Feeble-Minded Youth 3 3 Feeble-minded epileptic. School for Feeble- Minded Youth 1 1 Feeble-minded epileptic, needing care 1 1_ 2 6 12 18 146 106 252 Total Feeble-minded, 252, or 1 in 131, or .762fo, or 7.6 per 1,000 of population. Total defectives, subtracting duplications (11 males, 6 females) Males 215, Females 163. Total 378, or 1 to 88, or 1.14 %, or 11.4 per 1,000 of population. Mental Defectives in "B" County Needing Institutional Care, Not Now in Care Males Females Total Epileptic 4 4 8 Feeble-minded epileptics 5 2 7 Insane _9_ _^ 13 18 10 28 Feeble-minded, high grade 23 18 41 Feeble-minded, medium grade 14 15 29 Feeble-minded, low grade 4 2 6 41 35 76 Total defectives outside institutions need- ing care 59 45 104 Mental Defectives From "B" County, Now in State Institutions Males Inmates Village for Epileptics 7 Inmates State Hospital for Insane 29 Inmates School for Feeble-Minded Youth. . . 5 Inmates Indiana Reformatory 1 Total mental defectives in state institu- tions 42 42 84 11 Females Total 7 27 56 15 20 1 Discussion of Data of Field Survey Epileptic The ratio of 1.8 epileptics per 1,000 population in "A" county is so close to that of 1.9 in "B" county, that it is probable that the figure of 1.85 epileptics in every 1,000 people indicates the true amount of epilepsy in Indiana. Some of these epileptic cases show insanity and also feeble-mindedness, and a small proportion are now in some institution. In "A" county the investigators estimated that fourteen epileptics, eight males and six females, are in such condition physically or mentally as to need some sort of custodial care. In "B" county fifteen epileptics were found in need of and without care. Assuming that the ratio of 1.85 per 1,000 population is true for the whole state, there would be 4,995 epileptics in the state. (Population, Indiana, 1910 census, 2,700,000.) The number in the state needing institution care could only be found out by a complete survey, but an estimate would place it at about 1,000. Insane The insane from "A" county numbered 78, or 1 to 263 of the popu- lation. This figure is very close to the ratio of 1 to 279 found in Mass- achusetts in 1909; 1-282 in England in 1907 and 1-300 in New York in 1907. In "B" county there was found only one insane person to every 408 of the population, a ratio much less than in "A" county. No ex- planation for this difference is apparent. It is difficult to estimate the number of insane in the state from these two ratios and this difference shows that further information of the mental condition of the people of the state is necessary before the problem of the mental defective is- fully known. Assuming that the "A" county ratio holds for the whole state, there would be 10,000 insane in the state while the "B" county ratio of 1 to 408 would call for 6,617 insane in the state. Thirteen insane in "A" county and 13 in "B" county are now in need of institutional care, a total of 26 in the two counties. The popula- tion of "A" and "B" counties together is about one-fiftieth (1-50) of that of the whole state and this ratio carried out would indicate that there are about 1, 300 insane in the state now needing and without in- stitutional care. Feeble-Minded Until within a few years the problem of the feeble-minded has been less clearly recognized and understood by either the medical man or the social worker. The general public had no idea of its extent. It really is very large. The methods used in determining the mentality of those tabulated above have been the regular mental tests, the individual school ability and power to learn, and also the reaction to the environment which is the real and final test of any one's mental capacity. Two hundred eighty-five (285) feeble-minded persons were found in "A" county, or 13.9 per 1,000 of the population. In presenting this re- sult the investigators wish to call attention to the fact that many indivi- 12 duals are classed here as feeble-minded that are not recognized by the general public as defectives. Some of these are called "dull" or "stupid" or "peculiar" or "crazy" or "eccentric. Mental defectiveness is the cause of the atypical behavior of those of this group who are tabulated. In other cases the deficiency is only too apparent. The southern part of "A" county, hilly, rugged and unproductive, has sheltered for many years a class of people listless and lazy and indifferent. The people have in- termarried because of the geographical features of the county about them and have intermingled little with the more intelligent and mentally active people of the rich lands at the north of the county. There is little en- forcement of the law respecting marriage. The schools do their best, but the trained and highly capable school teacher will not remain in "these hills" when he or she can secure better wages and living conditions in the villages and cities nearby and so the young untrained teacher occu- pies the position where one older in experience should be placed to bring out the most and best there is in each scholar. Children grow up in homes away from the refining influences of the church and society and have no elevating example set before them. As a result the more effi- cient and capable of the population leave this unproductive and unat- tractive region for the rich lands and cities of industry and those weaker mentally remain to perpetuate their kind in a place where competition and strife are at a minimum. This part of "A" county has produced a large part of the defectives in that county. The northern part of the county has its mental defectives, too, but they are not as numerous per unit of population as in the southern part. Many of these feeble-minded are in good homes well cared for and the parents or those in charge re- alize that permanent care and training of these defectives is necessary, and are giving it. There are also many defectives who are old and in general harmless, and many feeble-minded women above the child-bearing age. The rest of the feeble-minded, the women of child- bearing age, the defective children who need care and training, and the men of all ages who are a menace to the community from sexual or other reasons, are classed as "needing institutional care at once." In "A" county one hundred and sixty-nine feeble-minded are in need of custodial care at once to care properly for the social welfare of the defectives in "A" county and to stop in a measure the increase of feeble- mindedness. In "B" county two-hundred and fifty-two feeble-minded persons were found, or 7.6 per 1,000 of the population. "B" county, as mention- ed, is, in general, flat and has very fertile land throughout. This uni- formly good land, rather level except for the valleys made by the three rivers which cross the county, has determined to a great extent the char- acter of the people who live in the region. The commonly inefficient, lazy, degenerate families cannot gather in any large groups, as in the southern part of "A" county, because of the competition of the more ener- getic, normal citizens for the control of the land. The more inefficient are soon pushed off the fertile land by competition of the industrious ones and as there are no comparatively non-arable acres, the more shiftless and inefficient ones cannot exist so easily in the community. It is inter- esting to note that outside of the villages and cities, practically all the 13 degenerate families in "B" county lived along the bluffs or banks of the rivers. A few families, all of whose members were feeble-minded, lived on farms which they had inherited from their ancestors; but it was inter- esting to see that as time went on, these farms were becoming smaller and smaller as the neighbors pushed in on them and the feeble-minded folk were obliged to sell off parts of the farm for self preservation. The rest of the defectives in "B" county were found in the villages and cities where the competition was not so keen. Few extended family histories of the feeble-minded could be worked out in "B" county for this reason. This same condition of affairs has excluded much" intermarriage among defective families, because of the fact that these families are not segregated into any definite locality. As a result, there was not as much association of the feeble-minded with each other, and accordingly there are not so many cases of the defectives needing custodial care. In "B" county seventy-six feeble-minded were found needing institutional care at present, according to the definition just above. The difference between the ratios of one to seventy- two feeble-mind- ed in "A" county and one to one-hundred and thirty-one in "B" county is so great that no accurate estimate of the total amount of feeble-minded- ness in the state can be made. This point will be discussed more in de- tail. The field investigators realize in presenting this report that many children classed as feeble-minded are not so regarded by the community. In the same way some feeble-minded adults are not recognized as such by the populace. It has seemed particularly valuable, therefore, to add to the discussion on feeble-mindedness the following fact: in both "A" and "B" counties a number who are not now recognized as feeble- minded by those in contact with them, have been classed as feeble-minded by the trained field investigators. This statement is giv- en partly to show the problem of the unrecognized moron and also to in- dicate the fact that some few are defective who are not called such by the layman, but these are the ones who fill our jails and almshouses and whose children are likely to show more marked feeble-mindedness than their parents. The total number of defectives in "A" county was 396, including sixty-five now in state institutions, or one defective in fifty-two, or 1.90 per cent. In "B" county 378 mental defectives were found, of whom eighty-four are in institutions, or one to eighty-eight, or 1. 14 per cent, of the total population. The research in "A" and "B" counties shows that there is about one epileptic person to every 525 of the general population, or about 5,000 epileptic to the state of Indiana, only 305 of whom are now in the State Village for Epileptics. The figures for insanity vary. A fair estimate indicates that there are between 7,000 and 8,000 insane in the state. The great majority of these, over 5,300, are now cared for in state hospitals for the insane, besides 400 patients on furlough from and still under the supervision of the hospitals. In addition, there are 278 insane in the Hospital for In- sane Criminals at Michigan City. 14 The problem of the defective becomes apparent when the figures for feeble-mindedness are considered. This figure lies probably some- where between 7.6 and 13.9 persons per 1,000 of the population. Inas- much as almost twice the amount of feeble-mindedness was found in "A" as in "B" county, it is impossible to attempt to estimate the num- ber of feeble-minded in the state. A fair estimate will place it at about 20,000, including all grades. It is estimated that 6,000 of these should be under state custodial care, and only 1,350 are now receiving it. The total number of epileptic, insane and feeble-minded in Indiana then can be assumed to be about 32,000, or 1.2 per cent, or twelve to 1,000 of the general population. It is evident from these data that while more research and information is necessary in order to know exactly the problem of the mental defective in this state, yet it is very clearly evi- dent that the state should make immediate provision for many more of its defectives than it is now making. Data Secured by Questionnaire 5ent to Schools of ttie State The Committee on Mental Defectives, through the Superintendent of Public Instruction, sent out inquiries to the different county superin- tendents of schools of Indiana requesting a report of the number of feeble-minded, epileptic and insane children in the schools. A letter of explanation accompanied the inquiry and the committee understood that the returns would be based in but few cases on the advice of teachers trained to observe mental defectives. Seventy-three of the ninety-two counties of the state reported 1,245 feeble-minded, 196 epileptic and thirteen insane children in the schools. The field investigators of the Eugenics Record Office found, after study, that about sixty-six per cent, of the children reported as feeble- minded in one county were really feeble-minded and the other thirty- four per cent, were either doubtful cases or normal. All of the cases of epilepsy in this county reported were found to be true cases of epilepsy. Assuming that sixty-six per cent, of the total number of 1,245 reported were feeble-minded, there would be at least 833 feeble- minded children now in the public schools of Indiana. These children are defective enough to be a problem to the schools, otherwise they would not have been reported. Population of State and County Institutions With Respect to Mental Defectives The following table shows that there are 17,447 inmates in the state and county institutions of Indiana. Nine thousand, four hundred and eighty-four (9,484) of these are classed by the institutions as epileptic, insane or feeble-minded. One thousand and ninety (1 ,090) are epileptics. Three hundred and five (305) of these are in the State Village for Epilep- tics, 307 in the state hospitals for the insane, and the rest are scattered 15 among the other institutions. There are 5,794 insane, the majority of whom are in the state hospitals for the insane. This does not include 349 insane who are also epileptic and are classed in the table as epileptic. Two thousand, six hundred are feeble-minded. A large proportion of these are in the School for Feeble-Minded Youth, 791 are in the county poor asylums scattered throughout the state. The rest are found in the orphans' homes, the Boys' School and Girls' School, and other institu- tions. This number (2,600) does not include 297 feeble-minded who are also epileptic and are classed in the table as epileptic. It is readily seen from this table that the state is at present caring for a large number of defectives in the institutions built for that purpose, but there are also many defectives in institutions of a correctional or eleemosynary nature where they should not be, considering the natin-e of the institution. These 9,484 mental defectives now on public support form .35 per cent of the total population of the state. 16 (/3 c o . -*-> c 3 o U "V to c oa CO o S CO -2 ^ C Q c 2 ^ g-coc-egoo-^ooiOi-HOrxioeoososiot- S Tj< (N O iH U5 O CO 00 CD eg TJ< OD Tf< -^ rH CO i-HCOrH (» CO la OS 00 00 iH (M >H iH s .^ tH t- T3 ,^ O -a g S fe 0) ^ 0) 9 "ni S O 05 00 fH I CO IM I , COCO , t-CO , T» ON O yHCO lO (Nin-^ t- LO Tjl i-T 00 CO r- lO co ^ tH ■*rH-*,Heq COUD.-HO'^U5COTHOOCD CDOSUS'^lOTjti-tlOOCDCOCDlN'^'^OOlO (M CO iO 00 CD CO D3 lO a> 00 00 »H (N tH r-tO Q B 2 3 o a> ■■PQ cj" h' 2 . . . m m ^H %„ •» .2m mtfMO pLi C C ^ ^ cd „ ci ol c e C 5 g g.a.a.s _, QQ ^ 03 h O ^ • I S >? ffi '"' +" .9 5 'a ' , a> 13 » 6 2 S S^^S I oOti^ a>.J3_C 0+^+* « >. ^ (U ^^ o B >>b OU, ai a O (U +3 >. ^S^ S^ D+J ra U -l-* N O to Rl ^£ ■s c.S ^ M ai«H V 13° S. M ■Q ta ^ a o >> M.a m ^■o ■+3 o & o 173 m c o<>. o " o - T3 ^ ^13 « CO d.S ? m CJt. mr. ■^1 C5 H ^f o 9 9) c3 m e htH :3.s m o OJ2 ^ IS ',4he time of the birth was paid by the township trustee. Here are two feeble-minded people both incapable of taking proper care of themselves and their offspring, because they had not the mentality to profit fully by the training and care which has been given them in the institution, as a Substitute to the proper home they did not have. The facts given below may indicate the cause of juvenile delinquency in some cases: WILLIAM X, lived in "S" county for many years. He married an illiterate woman from Kentucky, by whom he had six children; the oldest born in 1901, the youngest born four years ago. In 1915, at the age of forty-four, the father was arrested on the charge of encouraging a child to delinquency: plead guilty, and was sentenced to the State Farm for six months. He is a laborer, but is classified as "idle and impecun- 25 ious. " His wife and children got along the best they could, following the father's incarceration, but at the end of three months, the burden was too great and the wife and six children went to the "S" county poor asylum, where they remained for about five months, at which time the mother left, taking with her all the children who had not left the poor asylum previous to that time. The oldest child, JOHN, born in 1901, was arrested for incorrigibility and confirmed truancy, while at the poor asylum, and sent to the Indiana Boys' School. His mental age by the Binet test is 9.8 years. He is now in the third grade in school, shows a dullness in comprehension, and his visual and auditory memory is far be- low normal. The next child, GRACE, born in 1903, left the poor asylum a short time after she entered it; was arrested a few months later for associating with dissolute characters, and sent to the Indiana Girls' School. Her mental condition is reported by the institution as "poor." PEARL, the next child, born in 1904, went away from the poor asylum at the same time as her oldest sister, .Grace, became im- moral, was arrested on that charge and in turn committed to the In- diana Girls' School. Her mentaLeeJl!^?ft«a is considered "fair." She is at the present time ^siifferiSg with gonorrhea. MAMIE, the next child &t Willia"'.; went to the poor asylum with her mother and remained there until she too was sent to the Indiana Girls' School, along with her two older sisters on the charge of associating with dissolute characters. Her mental condition is reported as "fair." The two yoimger children of this family were in the poor asylum at the same time as the mother, and are supposed to be with her at the present time. The mother is reported as "feeble-minded, criminal and consumptive." The inter-relation of mental defectiveness and recidivism is shown by the records of the four women, mentioned below, who have served sentences in the Indiana Woman's Prison and other institutions for criminals. DORA X, a white woman, aged 54, was arrested first at the age of 27 for drunkenness and loitering and sent to the Correctional Depart- ment of the Woman's Prison for thirty days with a fine of $110. She re- mained there four and one-half months, serving out both her sentence and her fine at that time. From then until the present time, she has been committed to tBe Woman's Prison 16 other times, the charges be- ing drunkenness, disorderly conduct or petit larceny. The sum total of her sentences amrunts to twenty-five months and her fines aggregate $896.00; this total amount of $896.00 has been worked out in time at the Woman's Prison. The superintendent of the Woman's Prison reports Dora as feeble-minded. MINNIE X, also a white woman, now aged forty-one, is reported by the superintendent of the Woman's Prison as formerly an inmate of the Indiana Girls' School and an alcoholic. Minnie served her first sentence in the Woman's Prison in 1908, this time being convicted of idleness and loitering, and sent to that institution for thirty days with a fine of sixty dollars. It is to be recalled that this woman was an inmate of the Indi- ana Girls' School previous to any conviction which necessitated her going to the Correctional Department of the Woman's Prison. 26 LIZZIE X, a colored woman, born 1884, was convicted in 1908 of prostitution and profanity, and sentenced for thirty days with a fine of sixty dollars. Four months after her discharge from the Woman's Prison after her first incarceration she was again convicted of prostitu- tion and again sent for the same term. In the succeeding seven years she has been convicted eight times of disorderly conduct, drunkenness or loitering. She is reported by the superintendent as feeble-minded from whiskey and drugs, a thief and a "hold-up woman." FANNIE X, a colored woman, 39 years old, is feeble-minded. She was sent to the Correctional Department of the Woman's Prison in 1916 for a term of thirty days and a fine of thirty dollars, for offending peo- ple on the street. Her record indicates that she has been previously ar- rested three times for idleness, loitering, drunkenness and vagrancy. Epilepsy and its Effect in Community Life The care of the epileptic in the community at large becomes more burdensome when the affected one has severe seizures, becomes mental- ly weak as a result and is unable to care for himself and earn a living. The following history from "A" county, in Indiana, is that of SARAH, who has epileptic seizures when she becomes excited or nervous. She was at one time mentally acute but now shows mental deterioration and cannot plan her work as formerly. Her husband is a hard working, in- telligent man. She has one child, a girl of twenty-five who was con- sidered one of the finest young girls in the community but she developed grand mal epileptic seizures at the age of sixteen and has gradually be- come so mentally weak that at times she is irresponsible and cannot at- tend to her simplest needs. She is in need of some sort of institutional care. Sarah had one sister who has had epileptic seizures for many years. She married an intelligent man and has seven children, one of whom is feeble-minded. The two stories given below are characteristic of the epileptic who has no home or relatives, financially or physically capable of taking care of him. HARRISON, born 1896 was sent to the Julia E. Work Training School, at the age of thirteen. At this time he was considered bright mentally. Two years later he went to the poor asylum as his epileptic seizures had unfitted him for a place in a foster home. Later in 1916, he went to the State Village for Epileptics, where he is now living as normal a life as is possible considering his physical and mental condition. LAWTON, born 1884, an epileptic, entered the "H" County poor asy- lum at the age of twenty- seven, at that time weak-minded from epilepsy and remained at the poor asylum until 1911, when he went to the State Village for Epileptics, where he remains today. Insanity in the Community A pedigree showing how insanity occurs in a family and how the state is compelled to take care of many of the individuals in the family: ^ 27 DAVID X, both of whose parents died of tuberculosis, was one of five children. One of his sisters was in two different state hospitals for in- sane in Ohio, a brother was reputed insane, while David himself was sent to the Northern Hospital for Insane at the age of seventy-nine, with a diagnosis of "senile dementia", and died ten days after entering the hospital. David had married an alcoholic, immoral woman, the illeg- itimate child of an immoral woman and an alcoholic, licentious man. David and his wife, who was fifteen years younger than he, had eight children. The first was feeble-minded and died while young. The next, a girl, was neurotic, had migraine, married and had ten children, one of whom is feeble-minded. The next child of David is reported feeble- minded but not much is known of him. He died while still a young child. The fourth, BARBARA, bom in 1863, married but had no children. She was a morphine addict, and at forty-eight was sent to the Northern Hospital for Insane, her mental disturbance being due to "morphinism". The next member of this fraternity is a daughter and is reputed insane. She has several children, all of whom are reported as "stupid appear- ing" GEORGE, the next son of David is an epileptic. He has also been insane and was in the insane hospital at the age of twenty-one. His mental disturbance was diagnosed as "mania". He remained at the hospital but a short time. Some few years ago he committed suicide, but nothing is known of the particular circumstances. The next child of David was FRANK, who is mentally defective and it is reported that he has been mentally disturbed at different times. He married a prostitute woman who had had several previous husbands. Frank had never been in any institution. The last child of David was a girl, ELIZABETH, born in 1876, who has been immoral and was reputed to have been a criminal. She was sent to the Northern Hospital for Insane at the age of twenty- two, suffering with chronic mania. She remained at the institution for a short time but was returned later, in 1900, and remained at the insane hospital until her death, in 1904. A story of another family, some of whose members have been in hos- pitals for insane: ANDERSON has been an inmate of the poor asylum, the county jail, and at the age of thirty-eight was committed to the Northern Hospital for the Insane, diagnosis "alcoholic mania". Here he remained one year and was discharged as improved. His wife, a neu- rotic woman, has one sister who has been insane and was at the Northern Hospital for the Insane for six months during 1912, suffering from "de- mentia praecox". Her father was also insane at one time. Anderson and his wife had six children. The eldest of these is a rather nice-ap- pearing, intelligent woman, and has shown no mental disturbance to the present time. The other five children were all sent to the "M" County Orphans' Home at the time Anderson divorced his wife in 1905. The oldest of these five, HAZEL, born in 1891, remained in the orphans' home but a short time. Nothing further is known of her. The next child, ABRAHAM, remained at the orphans' home for about a year, when he was placed in a private home. Here he remained for several years, until he was returned by his foster parent to the "M" County Orphans' Home. He was again placed in a foster home, and was later reported as self- 28 supporting and doing well. At the age of eighteen, in 1912, he became mentally disturbed and was committed to the Northern Hospital for In- sane, with a diagnosis of "dementia praecox", physicial condition, "fair". He was discharged from the institution soon after that and his present where abouts are not known. MARGARET, the next child of And- erson, was placed from the orphans' home three years after her admis- sion, is reported mentally "bright", and the records of the State Agen- cy of the Board of State Charities show a good report of her behavior. The next, RUTH, born in 1899, was placed in the orphans' home along with the others, and later placed in the same private home as her oldest sister, Margaret. The State Agency has good reports of her behavior in the foster home. She is considered mentally "normal". The next child, GEORGIA, born in 1902, was sent to the orphans' home in 1905, where she remained two years when she was placed in a foster home. She is considered mentally "bright". Anderson's family history is interesting. His father and mother were first cousins, and the mother was temporarily insane previous to her marriage. The father was the most intelligent one of the fraternity of three, one of the other two being an imbecile, while the other was a neurotic, high tempered man and died of epilepsy. Anderson has one sister who was insane early in life, later became demented, and suf- fered from epileptic seizures before her death, at about fifty. Another sister of Anderson has been reported as "odd and peculiar." 29 Activities of Other States What Other States are Attempting to Do for the Care of Mental Defectives The State of Massachusetts has agitated the defective problem for many years, and has had recently (1911) a. commission to investigate the question of the increase of criminals, mental defectives, epileptics and degenerates. Among its recommendations are the prevention of the birth of defectives by extending the policy of custodial care of the male defectives; further study of defective delinquents and organized re- search in state institutions. The state legislature of 1915 made an ap- propriation of $50, 000 for the purchase of land for the establishment of a third school for the feeble-minded. The report of the commission to investigate provision for the men- tal defectives in New York in 1915 recommended increasing the capacity of the state institutions for the feeble-minded and epileptics, a new insti- tution for the mentally defective delinquents, a clearing house for' the mental defectives, and better training and supervision of the low grade mental defectives in the public schools. The New Hampshire Children's Commission, in 1914, carried out a comprehensive survey of the state. It reported one per cent, of the population as feeble-minded and recommended custodial care for the feeble-minded and special classes in the public schools. The New Jersey Commission on Care of Mental Defectives con- sidered a wider scope of matters relating to charities and correction, but the recommendations offered are in general the same as in the case of New York and Massachusetts. The Commission to Investigate the Extent .of Feeble-Mindedness, Epilepsy and Insanity, and other conditions of Mental Defectives, in Michigan, made a complete study of the mental behavior of the inmates of all the institutions in the state. The recommendations of the com- mission are, in part, enactment of a law requiring complete reports of the mentality of inmates of the institutions to the State Board of Health; a marriage law prohibiting the issuance of a license where eith- er party is insane, feeble-minded, epileptic or afflicted with syphilis or gonorrhea; and further institutional care for the feeble-minded. The Children's Bureau of the United States Department of Labor has recently (1915) made a survey of the extent of the problem of the 30 feeble-minded in the District of Columbia. A total of 798 feeble-mind- ed persons were found in the District of Columbia, 452 of whom were not in an institution of any sort. The District of Columbia has no institution for the feeble-minded. The report indicates that there is need of such an institution. Conclusions 1. The solving of the problem of the mental defective is vital to the state in the development of its social life. 2. One per cent, at least, of the general population, is mentally de- fective, i. e. either epileptic, insane or feeble-minded. 3. Nine thousand, four hundred and eighty-four (9,484) mental de- feetives, or thirty-five one-hundredths of one per cent., of the total population, are now on public support. 4. a. There are 1,300 epileptics in the state needing institutional care as epileptics, 1,000 in the community at large or in institutions not suited to their care, and 305 in the Indiana Village for Epileptics. b. The problem of the care of the insane in Indiana has been carefully worked out in the past fifty years, until now eighty-five per cent, of the insane in the state are cared for in state institutions. c. The actual problem of the care of the feeble-minded is great- er, inasmuch as it appears that the state at present is caring for but 1,350, or twenty per cent, of the estimated number who need care. 5. Mental defectiveness is a large factor in the cause of crime, de- linquency, pauperism, inefficiency and many other social ills. 6. Further study of the cause and prevention of mental defective- ness is imperative. 31 Recommendations In presenting its report with a summary of recommendations, the committee desires to state that it found the problem of mental defec- tives in Indiana one of serious magnitude. The committee could not go into each phase of the problem in detail as it should like to have done and as was attempted by similar commissions in other states. The committee felt that its work in studying the problem was preliminary only; but even this investigation has shown some urgent needs in Indi- ana, and it .believes that the subjoined recommendations, in summarized form, are quite conservative to meet the present requirements. The in- quiry made by the committee also shows such conditions to exist that it «alls especial attention to the recommendation for the appointment of a commission under legislative authority to make a more extended inquiry regarding mental defectiveness in Indiana. The Epileptic. 1. Additional provision for the care of women at the Vil- lage for Epileptics. 2. The enlargement of the Village for Epileptics to 1,200 capacity, and provision for larger medical ■ facilities at that Village. The Insane. 1. Indiana should at once provide additional institution- al accommodations for one thousand patients now in need of hospital care. It is quite generally agreed that the insane needing institutional care may best be divided into three groups: first, the acute insane; who require intensive hospital treat- ment; second, the largest number, who require constant supervision; and third, the chronic insane, quieter patients and others during the convalescent period not requiring con- stant supervision, who profit much by life in the open air and who may partially, or even in large degree, become self-supporting. Provision should, therefore, be made for the care of these one thousand patients, now in need of but not receiving institutional care, first by providing psychopathic depart- ments at each of the existing hospitals, for intensive hos- pital treatment for the acute insane; second, by the erec- tion of additional buildings at each of the existing hospitals as the plans of the several hospitals permit such expansion; and third, by the purchase of land for farm colonies and the erection of inexpensive buildings thereon in connection with these institutions where such colonies can be satisfactorily maintained. It shall be understood that these recommendations do not apply to the Central Hospital for the Insane, except for the establishment of a psychiatric department for the intensive treatment of its acute insane. This hospital is already much overcrowded and should immediately be re- lieved and should in the future be protected from such over- 32 congestion by a decrease in the size of the district tributary to it. If after the above jgrovisions have been made, there is still need of further hospital extension, we would recom- mend that the question be left to a committee appointed for that purpose. 2. There should, also, be provided at the Robert W. Long Hospital a psychiatric department, for observation and treatment of incipient mental cases. 3. At other general hospitals throughout the state de- tention wards should be established for observation and de- tention pending commitment and admission to the state hos- pitals. We feel that no person suffering from mental dis- ease should be placed in jail. 4. The development of means for occupational therapy for patients. 5. A law providing for voluntary admission to state hos- pitals, thus taking care of incipient cases at a time when re- covery is more hopeful. The Feeble-Mindbd. 1. The enlargement of the School for Peeble-Minded Youth at Fort Wayne by a colony in the southern part of the state, on not less than 1,000 acres of land, with inex- pensive buildings. 2. An additional law providing for commitment of pa- tients to the School for Feeble-Minded Youth, the same as to the Village for Epileptics. 3. That in the event of increase in the facilities for the care of the feeble-minded, there be a law providing for the committal of adult feeble-minded males similar to the law now existing for the commitment of adult feeble-minded females. General. 1. There should be mental as well as physical examina- tion of school children. Wherever it is possible, separate schools or separate rooms should be established. 2. We regard as highly important, and strongly recom- mend, the enactment of a law providing for a commission, with sufficient funds, to study the entire question of the men- tal defectives in this state. Respectfully submitted, THE COMMITTEE ON MENTAL DEFECTIVES. Francis H. Gavisk, Chairman George F. Edenharter, M. D. Samuel E. Smith, M. D. Charles P. Emerson, M. D. W. C. Van Nuys, M. D. George S. Bliss, M. D. D. Frank Culbertson, Charles A. McGonagle 33