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The situation was made worse by the fact that the patient's brother, to whom she was devotedly attached, was for many years a drunkard and a source of terrible anxiety, which was all the more intense from the fact that she felt obliged to conceal it from her friends. Many a time she has stood with trembling limbs, waiting for him to return in the middle of the night, and prepared almost to “faint away” in anticipation of what she was to see.
Again, her father, to whom she was so much attached, was a man of fine and strong character, but probably not unlike herself in temperament, though with chances for self-expression and sublimation which had been denied to her. She took him in many respects as a model for herself, and was consumed with fear lest he should suspect what was passing in her mind. She believes, however, that had he not been able to turn his passions into work, it might easily have happened that they would have consumed him as they did her, or found expression in some subtle symbolism.
The patient's dreams deserve careful study, and so, too, do certain other temperamental symptoms, from which I will select the following:
There seems little reason to doubt that the sort of anxious sadness, accompanied with a causeless sense of distress, that marked her earlier years, was a species of anxiety hysteria. She recalls, indeed, that even in the cradle the rolling of her head from side to side gave her a passionate excitement. Crowds affected her strangely and unpleasantly, so that she had to go away from them a hint at the strong, one might say electric, nature of the personal bonds that established themselves so readily between her and others. I have spoken of the strong impression made on her by storms and wind, and will add that the same was true of death, and indeed everything that savored of mystery and fear. She recalls that after a severe snowstorm, when she was a little girl-on which occasion her brother was sent to bring her home from school in a sleigh-she was overcome by terror lest she should not be able to get into the house.* She was subject to nightpalsies, so that on waking she would be unable to move. There can be little doubt that these, too, contained an erotic element which lay in wait for her under many circumstances and gave a special color to many forms of excitement, as it did to the rolling of her head in the cradle. In frequent nightmares she would feel as if some animal or vaguely defined person was trying to climb on to her bed. Until eight or ten years old she suffered from incontinence of urine, and would sometimes dream of the dripping of water from the faucet that she was not able to control. In later years she dreamed occasionally of her attacks, which is rather rare; but in these dreams there were people around who would protect her, just as in reality she longed for some one to touch her and bring the spell to an end, or, again, just as one might suppose that Andromeda and Brunhild longed, after their fashion, for some young protector to release them. For my patient, however, there was no satisfying joy; only desire not to be appeased, but still able to be endured better when understood and faced. In one of her dreams she seemed to see a team of horses, strong and vigorous, * These fears, like that of crowds, were, of course, "phobic" in their nature.
trying to drive into the entry of her house, while she denied them entrance. This tells, after a fashion, the story of her life.
I have said that this patient was fifty-two years old when she first came to me for treatment. She lived out of town and could not attend with regularity, and, in spite of being intelligent, her temperament was not such as to make the case an easy one for treatment. Nevertheless she improved considerably, and her attacks lost their worst features. If her life had had more outlets of a congenial sort she might perhaps have lost them all.
The second case of which I wish to speak is that of a young man of about twenty-seven years of age, of fine training and intelligence, who suffered from singular fainting attacks that occurred whenever he was called upon to come prominently before others, especially other people of his own sex and older than himself. His brother had suffered from similar attacks under like circumstances, and neurotic symptoms of an analogous, though not the same, sort, had been present in the case of one or more male relatives on the father's side.
No real difficulty in differential diagnosis between this condition and true epilepsy might ever have arisen, especially if all the conditions had been taken into consideration. There are cases of fainting, however, where the diagnostic difficulty is quite great. On that account it is worth calling attention to the fact that this young man, in spite of his intelligence, suffered greatly from an overwhelming sense of self-abasement attended by a longing for the affection and protection of those who stood toward him in a position of authority. Such persons were generally of his own sex, and the longing which he showed for their affection and protection, attended as it was with lack of confidence in himself, showed itself likewise in the recognition of a strong attraction toward younger boys, toward whom he in his turn could assume the attitude of protector. In brief, his temperamental development was, in these and kindred respects, relatively one of childhood, and the consciousness that he was thus retarded led him to be self-conscious, egoistic, and suspicious, in his intercourse with his fellows.
Dreams bore out in an interesting way the evidence given by his waking experiences, and showed, moreover, more strongly than one would have otherwise been led to believe, that although manly and courageous in his principles he found himself forced to combat with a species of effeminacy, obviously based on an inadequately defined sex development in early years. The fainting attacks were so frequent and so serious at one time that they bade fair to mar, if not wreck, a promising career. But under an analytic treatment of no great duration a satisfactory improvement occurred all along the line, and it is fair to anticipate that he will meet with a success reasonably commensurate with his abilities, which are above the average. Thoroughgoing recognition of his handicaps, on the one hand, and an emphasis on social obligations and interests of all sorts, small and large, are likely to prove, in the future, as they have during the treatment, the main factors in his progress.
E. J. EMERICK, M.D.
The object of this paper is to give you a little outline of what we have been doing for the feeble-minded in Ohio; not in any boastful mood, however, as I do not feel that we have accomplished as much as we might have done, and, possibly, not as much as some of you have been able to achieve, in other states.
We have been arduously working in Ohio to make more adequate provision for the care of the feeble-minded, but as all of your are aware, since state institutions are dependent upon legislatures for their funds, they do not always get what they ask for. We feel, however, that the general public in Ohio is becoming awakened somewhat from its lethargy, and is beginning to realize the necessity and urgent desirability that better provision be made for the care of the feeble-minded.
We have children on our waiting-list from nearly every county in the state; some counties having several hundred applicants for whom admission is sought, and the public is resorting to all sorts of expediencies to produce pressure to have these children admitted. They are appealing to the governor, their legislators and in some cases employing attorneys. While this is somewhat annoying to the institution, it has a beneficial influence upon legislation.
We have enrolled in the Institution for Feeble-Minded at Columbus, 2,430. We have two cottages under construction which will care for 240 more children, and the past legislature appropriated funds for the erection of 11 more cottages; making provision, all told, for an increased population of 940. It seems easier to get the legislature to appropriate funds for more buildings, for the institutions we already have, than it does to get new institutions. However, the institution at Columbus is now so large that the superintendent cannot keep in personal touch with the inmates, and it might just as well have a population of 10,000 as 3,000.
We have not in the past been wholly stationary, as our institution has doubled in population in the last ten years. But we have fallen far short of our duty to the feeble-minded, as we have 8,000 or more at large in the state of Ohio who can never be made self-sustaining, law abiding citizens, and who are being cared for at a much greater expense than it would cost to maintain them in an institution properly adapted for their care and training.
In these momentous times when practically the whole world is in carnage, and the best blood of the country is being called to the front, it is of paramount importance, that something be done to stem the tide of this oncoming army of feeble-minded and defective delinquents, which seems more threatening at the present time than ever before in the history of the world. I wish to quote from a copy of a letter that I recently received, which was written to the Secretary of War, “I wish to call to your attention the desirability of extending the scope of the examination of the recruit for the army and navy to include examination of their mentality to the end that irresponsible men, those whose mentality is such as to interfere with their judgment and stability may be rejected for the fighting arms of the army and navy.”
* Read before the American Association for the Study of the Feeble-Minded June 1, 1917.
The great misfortune of war is that it destroys our best blood and leaves the weaker brother home to multiply.
I feel that the defective delinquent demands special attention. The problem is much simplified if we can get hold of these defective delinquents while they are young and before they become hardened criminals.
We are trying in Ohio to make a little advancement along these lines. Several years ago, we made a very careful survey of 100 consecutive admissions both at our Boys' and Girls' Industrial Schools. At the Boys' Industrial School we found out of 100 consecutive admissions, 46 were distinctly feeble-minded; 26 were from 1 to 3 years retarded; 11 were 11 years old mentally, but were 15 and above chronologically; 17 were considered normal; 17 were recidivists; some of them having been returned to the institution four or five different times, but there was not a single one of the boys in the normal group who had ever been there before. The repeaters were all in the distinctly feeble-minded group, except three and these three were among the borderline cases. At the Girls' Industrial School we found out of 100 consecutive admissions, 59 were distinctly feeble-minded; 14 were from 1 to 3 years retarded; 13 were 11 years old mentally but were 15 and above in chronological age, and 14 were considered normal. It is a crime that a normal boy, who through mismanagement or bad environment, should land in our Juvenile Courts should be sent to an institution, where practically 50 per cent of the inmates are feeble-minded. In our endeavors to correct this state of affairs, we finally succeeded in getting the legislature to pass a bill in 1914 creating the Bureau of Juvenile Research. Dr. A. F. Shepherd, who, at the time was a member of the Board of Administration, in my opinion, deserves more credit than anyone else for the formulation of this bill. The aforesaid legislature which passed this meritorious bill only made a small start, as they did not appropriate any funds with which to erect buildings; only appropriating a small amount for salaries. Of course, the bureau could not do the work for which it was intended without buildings, but we felt that we had the wedge in, and we have been pounding with all our might ever since. Through the last legislature, we succeeded in getting appropriations for $100,000 for buildings to house this bureau. While this amount was not as much as we asked for, yet, it will be an initial step.
The object of this bureau is to act as a clearing house. In other words, to have a place, where the children from the Juvenile Courts can be sent, studied and sorted with reference to their mental capacity and responsibility, rather than to their physical size or age. Our aim also is to have competent physicians, who are specialists along different lines, give these children thorough physical as well as mental examinations, and if they are found to be suffering from any physical defects, remedy their condition as far as possible. For instance, if a child is found to have defective vision, correct it; if enlarged tonsils or adenoids, remove them. In other words, put him in the very best physical condition possible to cope with the problems of life. If he is found to be hopelessly feeble-minded, segregate him, instead of sending him to an industrial school for a short period; to be returned soon after being released; then on to the reformatory and finally numerous times to the penitentiary. In the meantime, he has probably been at liberty enough to have several offspring. We have whole families in our institutions whose mothers were at one time inmates of our industrial schools. I believe that not only the state but every one of our large cities should have a bureau or clearing house of its own. Such institutions will not only be of immense value in sifting out the feeble-minded, but they can do much, in saving the normal boy or girl from ever reaching a penal institution, and of carrying the stigma throughout life of at one time having been an inmate of such an institution. In this way, we would then have an opportunity of getting hold of these children and studying them. If they are found to be normal, investigations could then be made as to why they are in trouble. If the cause is found to be from bad environment at home and the conditions in these homes cannot be corrected, new homes could then be found for them. However, if this is not possible, it would not be any great expense for the state to own a few scattered homes, in charge of responsible and Christian men and their wives, where groups of children could be sent and treated the same as though they were their own children. They could be sent to church and to our public schools; thereby, eliminating all institionalization of these children. A child who is sent to an institution for only a year becomes more or less institutionalized and handicapped.
The problem of the defective delinquent boy and girl is one of our greatest and most urgent problems. Defective delinquent boys are the timber out of which is carved our most dangerous type of criminals, who are beyond redemption, and the only remedy is permanent segregation. We have 80 of this type of boys in a cottage at our custodial farm. While they are thoroughly unreliable, being composed of thieves and pyromaniacs, yet, we regard them as quite a valuable asset to our large farm, because they are our best workers. Of course, they must have a building adapted to their care and should not be in buildings with the inoffensive feeble-minded boy, as in that event, they would always be a source of trouble. Personally, I see no objections to their being in an institution for feeble-minded if they can be in separate buildings arranged so they can be retained; in this case, they cause but little trouble. We hardly feel that we could run our large farm without them. They not only make good farmers but are of great