74 / Mental Welfare
By H. O. WlLDENSKOV. (Senior Assistant Medical Officer, Kellers Institution for Mental Defectives, Brejning-, Denmark.)
The question of sterilisation was first raised by Professor Keller, Brejning, Who, in 1920, and 1924, required the Ministry to take the initiative in legislation. As the law stands at present, sterilisation is illegal and punishable by penal servitude with a maximum of 12 years. Though the question was raised by a recognised leader in the care of mental defectives, the matter was left in abeyance until, in December 1924, a Commission was appointed by the Government with the object of discussing social measures to be taken about persons characterised as degenerates. This Commission was composed of representatives of the Legislature, and of the prison administration, psychiatrists, of students of heredity, and those responsible for mentally defective persons and epileptics, numbering altogether 13 members.
The Commission began with a series of sittings, at which experts gave a survey of various fields of work relevant to the inquiry. Later, the Commission visited several Institutions. It then took up the question of sterilisation, and a report on this matter appeared in December 1926.
The report begins with a general view of sexual functions and the surgical methods applicable to sterilisation. It is a matter of congratulation that a sharp distinction is made between vasectomies, by which only procreativeness is lost, and castration, where procreativeness, and the general sexual impulse are lost. Heretofore there has been a good deal of confusion on this point.
Experience from other countries is then given, more especially from the USA and Switzerland.
Sterilisation may be performed on account of either. (1) Danger arising from the individual, which would necessitate the curtailment of his liberty; or (2) The quality of any progeny, and the conditions of life possible for it. Both of these points may occasionally have to be considered together. Re (1).?The Commission considers it safe and desirable that surgical intervention should be made available by law.
Re (2).?This point gave rise to interesting contributions from the expert members of the Commission on the present position of research work on heredity and its bearing on psychiatry, and the present knowledge of mental deficiency and epilepsy.
There has been considerable confusion regarding mental deficiency. Of late years, pathological-anatomical, endocrine, and other research have shown that the term mental deficiency covers more than mental defects due to a single origin, as, for instance, heredity. In a certain proportion of cases, mental deficiency is due, not to morbid inheritance, but injuries to the brain of the child, primary or secondary, occurring before or during birth, or within a more, or less short time after birth.
In some, though perhaps the minority of cases, innate causes cannot be traced. But the occurrence of mental defects, epilepsy,and degeneration of every form, alcoholism, and criminality in the family of the defective, makes it probable that the deficiency is the result of morbid inheritance, a congenital faulty foundation of the brain. In a great Danish Institution researches have been carried out on the heredity of 436 cases, but these numbers are still too small for any definite conclusions to be drawn. Of these cases 44%, indicated heredity in so far as mental trouble could be recognised in the family. The results so far obtained show the peculiar and yet unexplained fact that the less pronounced cases display a higher percentage of inheritance in the above-mentioned sense than the severer cases (about 50%, compared with 30%.).
From German scientific sources it has just been stated that thorough researches have shown the group of cases where the mental defect is due to injury or disease to be considerably greater than the group where it is due to innate causes. It is essential carefully to examine the individual mental defective in order that we may, so far as possible, state the probable causes of his mental defect. The general failure to give to heredity its proper place is sufficiently described above. But it may be emphasised that any estimate as to the role heredity may have played in the genesis of the defect should never in practice (for instance, in regard to eugenical endeavour) be the deciding factor.
It is the weighing of the evidence in a concrete case which is important. Taking into account our knowledge of the individual, in relation to our general knowledge of hereditary factors, we may in many cases be able to pronounce judgement with such a degree of probability that we shall be able to determine whether we are entitled to employ certain eugenical measures, including sterilisation.
According to the evidence at hand, it may be said that the time for legislation, with the object of actual ” racial improvement,” has not yet come. On the other hand, the Commission is under the impression that it is desirable to legalise sterilisation on other grounds than those already mentioned under the heading (1).
They believe that the scientific results before us offer a sufficient basis for this.
If sterilisation is made available on the ground set out under heading (2), it will be in the nature of an experiment, which will, provided that favourable results can be proved, be capable of serving as a basis for further measures of a definite eugenic character. In view of the difficulty of an accurate diagnosis of the nature and degree of disease in the individual, it is judged more expedient to proceed by way of experiment. The Commission determined to limit the experiment to those persons suffering from mental defect or disorder who were under the care of an Institution, and to require the consent of the individual or/and his guardian. Further, the Act was to be re-enacted after 5 years.
A Bill to render sterilisation available for mental defectives, insane, and certain other persons, is suggested by the Commission as follows :
CLAUSE 1.
Persons whose abnormal intensity or direction of sexual desire may lender them liable to commit crime, thus creating danger to themselves and to the community, may, upon their personal request, be subjected to castration or other interference with the sexual organs, provided that the request is sanctioned by the Commission described in Clause 3.
A request of this nature can only be submitted by persons who have reached full age. It must be accompanied by a medical certificate and must contain as complete information as possible as to the reasons leading the applicant to submit the request. If the applicant has been declared incapable of managing his or her own affairs the request must be endorsed by his or her guardian. If the applicant is married and is living in a state of married life, the consent of the spouse must, as a rule, be obtained.
CLAUSE 2.
The ‘Commission described in Clause 3 may consider the question of taking away the power of reproduction in mentally abnormal persons, who are under the care of an Institution, and in whose case it is considered of special importance to the community, that they should be incapable of having progeny, although they do not exhibit such danger to the public safety as is detailed in Clause 1.
Petitions must be submitted to the Commission by the Governors of the Institution concerned, accompanied by a declaration by the physician of the Institution or the Local Medical Officer; and the consent of the person concerned must be obtained, or, if he, or she has been declared incapable of managing his or her own affairs or is underage, the consent of the guardian. If the person concerned, without having been declared incapable of managing his or her own affairs, is unable, on account of mental defect, to understand the importance and consequence of such an operation, the petition must be endorsed by a guardian appointed for the occasion. If the person concerned is married and his or her married life has not been broken off by separation or by the married couple having actually lived apart for some considerable time the consent of the spouse must, as a rule, be obtained.
CLAUSE 3.
To decide the questions dealt with in Clauses 1 and 2?a Commission shall be appointed, composed of a judge appointed specially by the Minister of Justice and 2 members of the Medico-Legal Council,* appointed by the Council, one of whom must be a psychiatrist. The Minister of Justice may, on the suggestion of the Commission, appoint 2 additional members. The Commission may, before deciding with regard to the applications submitted, demand from any public authority or office such information or declaration as is found necessary; may examine or cause to be examined any persons supposed to be in possession of knowledge of the facts or conditions concerned, and take any other action, necessary, or suitable, to procure information.
It is the duty of the Commission to ascertain that the person concerned, or, as the case may be, the guardian, has a clear understanding of the probable consequences of the interference which may have to be made.
If the Commission sanctions the interference, the nature of the operation must be defined by its medical name. With regard to the cases dealt with under Clause 1 the person concerned must himself or herself select a surgeon possessing the necessary training to perform the operation, while, with regard to the cases dealt with under Clause 2, the surgeon must be appointed by the Institution concerned. It is the duty of the surgeon, after having performed the operation, to give notice of this fact without delay to the Commission. If the request is refused by the Commission it cannot be renewed until one year after the date of the refusal, unless circumstances, or facts of importance bearing upon the decision have appeared, which were not available at the time of the previous application.
CLAUSE 4.
The members of the Commission are bound to observe secrecy with regard to what they learn in the execution of their duties.
CLAUSE 5.
Salaries may be paid to the members of the Commission in accordance with the considered decision of the Minister of Justice.
The necessary funds for this purpose, as well as other expenses incurred by or through the work of the Commission are granted on the yearly budget.
CLAUSE 6.
Any person, who without due authority performs or undertakes operations dealt with in this Act, is punishable by fines of from 500 to 5?000 Kroner, provided that other legislation does not impose any heavier punishment.
Neglect to furnish the information dealt with under Clause 3, section 4, paragraph 3, is punishable by fines of from 10 to 200 Kroner.
The fines accrue to the Exchequer.
CLAUSE 7.
This Act will be in force from and will expire 5 years after it has come into operation.
Further Comments on the Bill: The Commission is of opinion that the petitions ought to be approved by a specially appointed authority, not only to guard against an individual institution carrying out experiments on insufficient data, but also to insure a common line of action, to enable material to be gathered for a later judgement on the extent to which permission is sought, granted, and as a matter of fact used. The Commission can to a certain degree procure information about the after-effects of sterilisation, with a view to considering the possible future legal extension of the practice. While the person in Clause 1 must have reached full age, this b not necessary for the person dealt with under Clause 2 of the Bill.
It ought to be emphasised regarding Clause 2, that sterilisation may be a matter of weighty consideration to the individual interests of the person concerned, beside the social aim.
In many cases the sterilised will be permitted to enjoy far greater freedom of movement within the Institution than before,^ or be released from the Institution, which otherwise could not be permitted. Discharge will specially apply to those mental defectives with the propensities of the group included under Clause 1. The main reason for an individual petition for sterilisation will then frequently be the intention of granting a temporary or final discharge. * The Medico-Legal Council in Denmark consists of medical experts, and reference is made to this Council before conviction in all cases where the Court suspects mental defect.
The Commission has been careful, however, not to lay stress on the possibility of discharge as being one of the main reasons for the recommendations of the Commission. This is partly to prevent the awakening of expectations which may be disappointed, as for other reasons discharge may involve too much risk, and partly because too much emphasis on this point might be misinterpreted, and be taken as an expression of opinion that the economical gain to the community subsequent on the decrease of the burden of institutional care, should be the deciding factor.
So far I have summarised the views of the Commission. It seems audacious in this Magazine to profess myself an advocate of sterilisation. I only need to mention the following publications:
1. Sterilisation and Mental Defectives. Centr. Ass. f. Ment. Welf., 1923. 2. Tredgold: The Sterilisation of Mental Defectives. Ment. Welf., 192?G. 3. Norwood East, mentioned in Ment. Welf., 1927, page 58. 4. Douglas Turner: The Royal Eastern Counties Institution, Sixty-seventh Annual Report, page 31. 5. Langdon Down: The Eugenics Review, 1926, page 205, to show that many of the leading experts in England are opponents to sterilisation.
The advocates of sterilisation base their case upon research into heredity. The figures are well known. For instance, Goddard states that hereditary causes were present in 65%, of cases of mental defect; and Tredgold, that in a series of over 200 cases, over 80%, were the descendants of a pronounced neuropathic stock (see Tredgold, Mental Deficiency (4th Edition), page 41).
My researches, quoted in the Commission’s Report, were carried out among children only, as the information obtainable was of more recent date, and therefore more reliable. I took into consideration mental defect in the parents and brothers and sisters only, so that I obtained more reliable figures. Altogether I procured information on 800 mentally defective children. If we now take from among this number, without any selection, 100 idiots, and 100 feeble-minded, among these 100 idiots only 8 have between them 11 mentally defective brothers and sisters, whereas among the 100 feeble-minded, 17 have between them 37 mentally defective brothers and sisters.
Among the idiots only 6 have one or both parents mentally defective, whereas among the feeble-minded 17 have one or both parents mentally defective.1 The researches of Dollinger and Potter 2 confirm this view. Dollinger says:
“On the less pronounced cases of innate mental defect such an influence (ie, heredity) might perhaps be admitted, but in the severer forms, as far as my experience goes, it can be taken into consideration only in a few quite distinct types.”
Potter 3 selects 100 cases, half of which belonged to the group with hereditary mental defect and the other half to the group with non-hereditary mental defect. In the hereditary group there were no idiots, 5 were imbeciles, 35 were morons, and 10 were borderline types. In the non-hereditary group there were 12 idiots, 12 imbeciles, 24 morons, and only 2 of the borderline type.
Space does not permit me to discuss adequately the causes 4 of this, but I wish here to emphasise the fact that the danger of heredity does not seem to arise from the idiots, but from the feeble-minded?those whom we release from the schools and workshops.
Now the opponents of sterilisation assert that the most effective measure to protect the community is segregation. Certainly, I agree that this is the ideal measure, but I am pessimistic enough to think that we cannot carry it through. In Denmark, we have 3?700 beds with a population of about 3? million. That is 1?000 beds per million. And the want of accommodation is still very great.
These figures disagree with the figures found by the Surrey County Council Mental Deficiency Committee, Mental Welfare, 19^7, page 52.
Dollinger: Beitrage zur Atiologie and Klinik der schweren Formen angeborener und friin erworbener Schwachsinnszustande, Berlin, 1921.
Potter: A resume of research work at Letchworth Village, USA, Mental Hygiene, 1925 page 772.
The Director of our research laboratory, E. Larsen, has commenced research on this point.
The results will be published later.
At the Brejning Institution alone we have a waiting list of 250. In England, According to the Annual Report of the Board of Control for 1925, there are 20?300 beds to a population of 36 million (census of 1911), ie, about 564 beds per million. To reach the Danish figures still quite inadequate about 15?696 beds would be required. England ought at least to have these 15?700 beds, but the problem would not then be solved, and I do not think the taxpayers and their representatives are disposed to go further.
The opponents of sterilisation point to supervision. We have in Denmark only 500 mental defectives under supervision. In England there are nearly 10 times as many per million inhabitants. I think the high figures in England are due to the admirable voluntary associations helping with supervision. But however carefully supervision is carried out, I do not think it can be extended to the whole day or night, and cannot, therefore, prevent the defective leading a sexual life. Thus the above-mentioned Report tells us that 252 mental defectives under statutory supervision have contracted immoral relations or perverted sexual habits, 195 have married, and 275 children have been born to married or unmarried defectives (page 74, 12th Annual Report of the Board of Control, 1926).
But if, as I believe to be the case, we cannot reach our aim through segregation and supervision, it is our duty to find other ways. One of them, I think, is sterilisation. In the Brejning Institution we have a good many defectives who could be returned to the community if we were sure they would not propagate their kind. Why should we not give them the choice : institution-life or sterilisation and free life in the community. I do not think the time is ripe for a compulsory Act. That often-mentioned bugbear, public opinion, would at present shrink from this but let us begin with voluntary sterilisation. Perhaps we here have in the fear of compulsion one of the fundamental reasons for the English opposition to sterilisation. I do not desire compulsory sterilisation, but I want permission to sterilise when my researches have shown that there is, according to my experience, a danger to the community in the propagation of the mental defective. It seems to me that some of us are afraid of public opinion, but if we are afraid, we are running in a circle. Who if not ourselves will undertake the work of educating public opinion? I quite agree with Dr Hutchinson, who says in her paper 1 : It seems to me the present-day task of eugenics is one of education, so that society may be made acquainted with the great prevalence of racial defectiveness… . And she concludes with the following recommendation:
” A campaign of education to be carried on which shall reach all classes of people.”
It is quite true we cannot say: Sterilisation will extirpate mental defectives and thereby remove all expense from the State, but we can say it will diminish the number of mental defectives and lessen the expense. Every expert who holds this opinion ought to fight for legal sterilisation.
Bulletin of State Institution, State of Iowa. Vol. xxvii, No. 4. Oct. 1926. Page 267.
ENCEPHALITIS LETHARGIGA
Weekly notifications (reproduced from the Lancet). Week ending Week ending Week ending Apl. 2 36?May?7 43?June?4 28 9 30 ? 14 25 ? 11 32 16 33 ? 21 38 ? 18 28 23 30 ? 28 28 ? 25 33 30 32 161 134 121 Total 416
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