Contributed
Nearly all German Hospitals, and Institutions are supported out of public funds, many partially or entirely out of insurance funds. About 65 per cent, of the patients are members of compulsory insurance societies and many others have joined voluntary insurance societies. This makes the question of treatment and disposal easier as questions of assessment for payments, etc., do not arise. Mental Disorder
Legislative provision for the treatment of Mental Patients in Germany does not differ widely from the provision made in England. Modern English Mental Hospitals may well be compared with the German ” Heillanstalten.” There is however one outstanding characteristic of the German system not found in England. All the large hospitals have their psychiatric wards; and every German University has its clinic for the treatment of early mental cases. The clinics have no hard and fast regulations for the admission of patients; a medical certificate is generally all that is required and the paramount consideration is whether or not the Medical Superintendent considers that treatment is needed. In the majority of Clinics, the patient has to sign a Form of Consent during the first three days of treatment, and it is found that as a rule he is more willing to do this after he has settled down a little than he would have been before entering the Clinic. If he refuses his consent ” Kreisarzt ” (a Government Health Officer) is called in and if necessary the patient is certified as insane and thus deprived of his civil rights. But in Germany, the question of certification is hardly a serious problem for it must be borne in mind that the German submits more readily to restraint than does the Englishman with his zeal for personal liberty. The aim however, everywhere, is that as many patients as possible shall be treated voluntarily, and certification is only resorted to where a patient’s condition is dangerous to himself or to others, or where he persists in refusing food. There is no provision for ” Temporary ” patients similar to that made under the English Mental Treatment Act.
If a patient’s condition is diagnosed as ” chronic “?i.e., if these appears to be no hope of recovery within a year or so, he is usually transferred from the Psychiatric Clinic or the Psychiatric Ward of a Hospital to a Mental Hospital? the so-called Provincial Hcilanstalt. For wealthy patients there are a great number of very well-equipped ” Sanatoria ” providing excellent care both for recent and for chronic cases.
It is true to say that nowadays the public no longer regard the Clinics or the Mental Hospitals with fear or suspicion, but in some circles it is felt that only Voluntary patients should be in private care in order that their possible exploitation may be prevented.
The German Psychiatric Clinics and Mental Hospitals do not employ specially trained Social Workers, but these play an important role in the Offene Fucrsorg<c which is a combination of the English “After-Care” and, the Supervision of Boarded-Out patients. For the training of Social Workers there are 30 different schools in Germany?the Socialc Frauensclnden,?providing two year Courses, but specialised training is only given during the last term. None of these Schools are attached to Universities as these tend to have a purely scientific and academic outlook and to hold the study of the practical application of knowledge in something very like contempt!
In addition to the system of the Boarding-Out of chronic mental patients, which is more highly developed in Germany than in England, there are colonies in which the patients are made as far as possible self-supporting. Professor Keoppe started the colonisation of mental patients on a large scale on the estate of Alt-Scherbitz in Saxony. At llten, near Hanover, an experiment is being carried on, with considerable success, based on the Gheel method. Another very interesting experiment is that of Professor Simon in Guertersloh; here all the wards are empty during the day for everybody, even the oldest chronic catatonic cases, is working, and no isolation appears to be necessary.
Mental Deficiency
Preliminary tuition in Mental Deficiency has for about 30 years been made part of every course for medical students on Mental Disorder, and full use is made of the clinical material available. The early recognition and disposal of the defective has always been thought to constitute the greatest need in this field of care.
The first Special Classes (Auxiliary Classes or Hilfsklasse) were established as early as 1859, though recently the tendency in many German Towns has been to establish centralised schools for defective children rather than separate classes in the ordinary elementary schools. Berlin, however, is still in favour of Special Classes.
J11 1900, the so-called Sickinger System was established in Mannheim, which has continued to prove very successful. This consists of four parallel classes : (1) The ordinary classes. (2) Backward classes for 10 per cent, of the slow pupils who follow the same curriculum with special adaptations. (3) Auxiliary ciasses for the Feeble-minded children who need an education of an individual and non-academic type.
In some towns, the schools have as many as four parallel classes, amongst which there is a free interchange of children, as nothing in the nature of certification exists.
Private lessons are given without fees in suitable cases.
For the feeble-minded, the tendency throughout Germany is to appoint the most successful of the young teachers who have taken a special course in the Heilpa dag ogischc Seminar where they learn the fundamental facts about mental defect and are taught special methods of handling defective children. These teachers receive additional salaries. In many cases it has been found that a marked temperamental change has taken place in a feeble-minded child on being released from ordinary class methods and put in the care of a young specially-trained teacher. These children are required to stay at school until they are 16.
The lower-grades of defectives are sent to special institutions. Here again there is no fixed method of certification, and even in modern German textbooks on Psychiatry no rigid distinction is made between feeble-minded, imbeciles and idiots.* Nor are all defectives in Germany systematically tested. It is emphasised that mental tests are only useful when every other aspect of the case has been taken into consideration, and that in the higher-grade cases they are of secondary importance, for a patient may be quite unable to manage his own affairs and yet pass all the tests. ” Life is really the only lest.” Low-grade defectives are as a rule kept under special care until they are 18 and they are afterwards supervised by an After-Care service for the purpose of safeguarding them from economic and moral exploitation. There is nothing comparable to the English system of Guardianship and Custody, and although there is excellent care provided for juvenile defectives things are not quite so satisfactory in the case of adults and it has been shown in recent statistics that about one-third of lower-grade imbeciles are not in institutions.
To-day there are over 60 large training institutions, some built on very elaborate lines and regarded as model institutions. They are all under Government control and all the teachers must hold special licenses from the Government. The mistake, so often made, has been made here too?viz., that cf regarding a feeble-minded person who had shown himself capable of working in an institution as being capable of supporting himself in the outside world. Grotjahn, the late * In his recently published “Practical Psychiatry,” Schulhof contends that the degree of defect is comparatively unimportant, and he himself uses the term “idiot” to denote defectives who exhibit physical malformations.
Director of the Berlin Institute of Social Hygiene, pointed this out again and again. He and many other leading specialists were in favour of permanent segregation for all lower-grade defectives in Colonies where they could live a comparatively free life and where many of them could do productive work. In Germany, where only the State and the provincial councils are concerned with defectives, a scheme of this kind could have been put into practice more easily than would be the case in countries where this particular responsibility partly devolves on voluntary or religious organisations.
Sterilisation
To-day, however, things in Germany are developing along altogether different lines. The Act whose object is to “avoid the inheritance of disease in posterity,” came into force on January 1st, 1934, and is bound to bring about great changes in the treatment and disposal of Mental Patients and specially of the Mentally Defective.
Introducing the Bill, Dr Frick, Home Secretary, pointed out that modern humanitarian ideas were in reality cruel?that to give exaggerated care to the individual while neglecting the interests of the nation as a whole was a form of madness, and that sentimental concern for the welfare of the unfit was killing the Will to Work. Instead of protecting the unfit, the aim of the community should be to support its healthy, useful members who were suffering in the struggle of life. He stressed the fact that the cost of supporting the insane and the mentally defective was about 4 RM daily; the cost of cripples and the deaf and dumb was still higher (5 to 6 RM) and that of criminals about 3| RM, and he contrasted these figures with the earnings of unskilled labourers which amounted to only 2A RM. He agreed that the basic aim of racial hygiene methods? the complete elimination of all those suffering from hereditary disease?could not be achieved for many generations, but he insisted that a Government conscious of its responsibilities had to think in terms of generations. He refuted the opposition of the Church to this point of view by saying that the Christian religion, although it taught the duty of supporting the weak and unfit, could not contend that it was good that they should be born. Dr Frick assumed that about 20 per cent, of the whole German population showed symptoms of mental depravity and that it was undesirable for them to have offspring.
Hereditary Disease, in the meaning of this Act, is defined as : Congenital Feeble-mindedness, Maniac-Depressive Insanity, Schizophrenia, Hereditary Epilepsy, Huntington’s Chorea, Hereditary Deafness and Blindness, Hereditary Malformations, Chronic Alcoholism. The Act does not as yet include the healthy carriers of inheritable disease, but a supplementary Bill is planned for the future when research is more advanced.
The “subject for sterilisation” may present himself, or?if has been declared incapable of managing his own affairs?may be presented by his legal representative, a Medical Officer of Health or by the Governor of a prison. The proposal 74 M ENT A L W ELF A R E then comes before the ” Court of Eugenics,” composed of a magistrate, a Medical Officer of Health and a physician who has specialised in the study of hereditary hygiene. The Court’s decision, taken after a secret hearing, is subject to an appeal to a ” High Court of Eugenics.” Only after this final decision does sterilisation become compulsory, and only then is direct force permissible. The Act does not include the castration of criminals as it was desired to prevent the public from regarding it as a punishment. But there is a subsequent Act giving to the Courts of Justice power to order the castration of persons over 21 years who have been convicted of murder or manslaughter in which sexual elements were involved, or who have had two or more convictions for sexual offences. These sexual criminals who are convicted for the first time are sent to Training (Concentration) Camps when discharged. To avoid this they may apply for castration, which is regarded as ” treatment.”
Under “urgent cases” are scheduled the feeble-minded between 10 and 40, juvenile schizophrenic patients, and maniac-depressive patients in the state of remission. It is pointed out that 17 per cent of the siblings of mental defectives are themselves mentally defective, and that 60 per cent, of their children in turn are defective. Every case of Mental Defect is regarded as hereditary if it cannot be proved beyond doubt that there are exogenous factors (syphilis in the mother, infectious disease, or brain lesions). With few exceptions, all the pupils in auxiliary schools and classes are regarded as congenitally feeble-minded or imbecile and as subjects for sterilisation. (That is to say, 3 per cent, to 4per cent of the population in the large towns, and up to 10 per cent, in some rural areas!) It is assumed that of the 90,000 juveniles who are for some reason or other under institutional control, almost 50 per cent, are feeble-minded and must be sterilised before they can be discharged. In those forms of congenital Mental Defect where as a rule procreation is not possible?e.g., through early death or pronounced idiocy at adolescence? sterilisation is, as a general rule, not to be applied. It is pointed out, in connection with the Act, that it is the slight forms of mental deficiency which are to be regarded as the most dangerous from the eugenic point of view, for high-grade defectives usually associate with others of the opposite sex, they are lacking in self-control and the number of their offspring is far above the average. The natural elimination of these stocks, it is contended, is to-day prevented from operating, by reason of our sentimental care of the individual.
The Mentally Defective group as a whole, is regarded as the one most important for the purposes of this Act. Ruedin, Luxenburger and others who have carried out investigations into the so-called “prognostics of heredity” for more than 20 years, found that the conditions for the transmission of mental defect were present in about 100 per cent, of their defective cases, which makes it very likely that through sterilisation, the elimination of mental defect is really possible. On the other hand they estimate that only 70 per cent, of persons with schizophrenic dispositions become themselves schizophrenic and so subjects for sterilisation. This research has been, made in the course of studying identical twins suffering from mental defects, etc. German investigators state that environment plays no part whatever in the production or prevention of mental defect. Mental Defect and Huntington’s Chorea are placed at one end of the Scale (the socalled ” Pole of Heredity “) and Alcoholism at the other end (termed the ” Pole of Environment”). Schizophrenia, manic-depressive insanity and hereditary epilepsy come midway between the two poles.
There are estimated to be in Germany, 300,000 congenital mental defectives, 280,000 schizophrenics, 100,000 manic-depressives, and 100,000 epileptics. Recent figures as to the number of sterilisations are very difficult to obtain. The latest official statistics cover the year ending February 1st, 1935?the first year of the operation of the Act?when 120,000 operations were performed. Of these, 45 per cent, were on account of feeble-mindedness, 30 per cent, on account of psychoses, 18 per cent on account of epilepsy, and 3 per cent, on account of chronic alcoholism. The cost of the operation for men (vasotomy) is given as 20 RM, for women (salpingectomy) as 50 RM. Amongst the women, in whose case the operation is more severe, there was a mortality of about 4 per cent. The cost of procedure and operation is borne by the State, or for insured patients, by the Insurance Companies.
Very few of the inmates of institutions have been sterilised as yet, and it is not considered that by means of it, many discharges will become possible. A new Bill is being prepared, to deal with the question of care after sterilisation. The collaboration of Mental Health workers, the Fucrsorg.crinncn is considered to be of special value in the work of educating the general public in the idea of sterilisation. The commentary on the Act says that great help can be given by the social worker in close contact with the family in collecting details about the health of each member, and in exacting secrecy as to the fact that a patient has been sterilised in order that an increase in prostitution may be avoided.
It should be understood that many psychiatrists were opposed to this Act, for various reasons. Professor Muckermann, the famous Director of the Department ?f Eugenics in the Kaiser Wilhelm Institute, resigned. Professor Bumke, the President of the German Society of Psychiatry, was violently attacked for having stated that Beethoven, whose father was a chronic alcoholic and a typical degenerate, would not have been allowed to be born in Germany to-day. He received *he reply that the German people only wanted gifted men who came from a healthy stock, and that genius could never be a contra-indication for sterilisation. On the other hand, this Act was not so completely new a thing as it seemed to the general public, for in 1932 a similar Bill had been under consideration in Prussia; but it could never have been passed by any Parliamentary form of government.
To-day in Germany, the State is supreme as never before, and it is using all the mighty weapons of the Modern Age to enforce its Will. The population is being taught to ” think in terms of hereditary biology “; it is the duty of every citizen to try to become a ” first-class specimen of the human race,” and so on. Thus they can accept the idea of Sterilisation without difficulty, and compulsion is seldom necessary.
A Survey of Mental Ability in a Rural Community*
The purpose of this investigation was to make a survey of the intelligence of the inhabitants of a rural area, by means of the intelligence testing of its school children supplemented by an attempt to ascertain the incidence of mental deficiency amongst persons of all ages and to collect the family history of every school child and every defective examined. The area?a pre-dominantly agricultural one, some 12 miles from the nearest industrial town?consisted of a small compact town with three surrounding villages and outlying farms. Its total population in 1931 was 1,534, and since the preceding census in 1921, had decreased by 107.
The total number of children tested by the Otis Primary or Advanced was 187 with homes in the district and 15 who were boarded out and attending the school. Every child between 8 and 10 years was also tested with the Stanford Binet Revision.
In this pamphlet are to be found graphs and particulars of the results obtained, which may be summarised as follows :?
(1) Of the 43 children tested with the Stanford Binet the Mean I.Q. was found to be between 95 and 96, lower than that usually found in urban populations. (2) The Mean I.Q. of the 25 children related to one another by consanguinity or marriage was 95.4; that of 18 children whose families were unrelated was 95.7. (3) The number of cases of mental defect ascertained of all ages was 24, giving an incidence of 1.6 per cent of the whole population. Of these only 20 belonged to the interrelated clan.
(4) Only one of the ascertained defectives was illegitimate, and the intelligence of the illegitimate schoolchildren tested was slightly above the average. On the other hand, indirectly illegitimate children (i.e. one of whose parents was illegitimate) were found to be of poor mental ability.
(5) The total number of cases of insanity in the area was found to be 7, all belonging to the interrelated group.
(6) Two thirds of the children belonged to a group of the population which was . interrelated by marriage. The children of this clan were just as intelligent as those outside it.
(7) The mean intelligence of children coming from the professional group was the highest; the trading group second; the artisan group third, and the labouring group fourth.
By M. V. Matthews, D. A. Newlyn and L. S. Penrose. Research Dept., Royal Eastern
Counties Institution, Colchester. Published in The Sociological Review, January, 1937.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.