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Some observations on mental deficients
PUBLIC HEALTH.
I92O.
SOME OBSERVATIONS ON MENTAL DEFICIENTS. BY
A. H . NEWTON, M.B., Ch.B., A s s i s t a n t School Medical Officer for the City of Coventry.* L i k e p r o b a b l y m a n y other school medical officers I have tried to find some certain m e t h o d of differentiating b e t w e e n m e n t a l deficients, dull and b a c k w a r d , and n o r m a l children. P a r t l y with this o b j e c t and p a r t l y b e c a u s e it is of interest to see h o w local results c o m p a r e with those in other centres and w i t h those for the country at large, I have a n a l y s e d m y experiences with our C o v e n t r y children from various aspects. T a k i n g first physical conditions : N u t r i t i o n (as e s t i m a t e d by height a n d weight) shows a m a r k e d deterioration a m o n g mental deficients as a whole. A t seven y e a r s of age the a v e r a g e weight is 4 Ibs. below that of the normal child in C o v e n t r y ; this defect steadily increases until at 14 years the a v e r a g e is 13 lbs. below the same normal. In height the distinction is not so marked. T h e curve for the whole special school shows that the average is a b o u t }-in. below the normal. D u l l and b a c k w a r d children, on the other hand, show no such defect. Curiously enough, in C o v e n t r y the curve of a v e r a g e weights for these children shows a b o u t 2 lbs. to the good for all ages. T h e curve for their heights is p r a c t i c a l l y the s a m e as that for n o r m a l children. W i t h r e g a r d to defective vision : 33 per cent. of the children in our special school have a defect of 6/12 or worse. This compares v e r y unfavourably with the 7.5 p e r cent. found among n o r m a l children. I n only 2 cases out of 20 cases of defective sight are there corneal opacities to account for it. T h e most c o m m o n defect is astigmatism, with or without other errors of refraction. D e f e c t i v e hearing is present in 6"5 per cent. as c o m p a r e d with 2 per cent. among n o r m a l children. All these cases are due to otitis m e d i a or intra p h a r y n g e a l obstruction of some s o r t ; there being no cases of int. auditory deafness. Comparing dull a n d b a c k w a r d children with these, I find 25 per cent. with defective vision and a high percentage, viz., 13 per cent. with defectivehearing. One m a y note here a r e m a r k b y Dr. H a m e r in the A n n u a l R e p o r t of the Chief M e d i c a l Officer for * A paper read before the Midland Branch of the Society of Medical Officers of Health--29th January, 1920.
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1918. On page 109 he says " T h e special incidence upon the children classed as mental deficients of defects of the sense organs raises the question whether, if these defects could be prevented, fewer children would need to be relegated to the special schools." I think the a n s w e r is in the negative. C e r t a i n l y in our own schools, where atl but one or two with defective v i s i o n have had their refraction corrected with glasses, although there has been some i m p r o v e m e n t in their work afterwards, not one of t h e m has proved to be less obviously m e n t a l l y deficient. T h e a n s w e r to a similar question a s k e d with regard to dull and b a c k w a r d children would, I think, be in the affirmative. I have no evidence of this, however, as m y work a m o n g these children has been too recent to show any results. A m o n g other physical defects in our m e n t a l deficients I do not find s t i g m a t a of degeneration at all c o m m o n with the exception of the high a r c h e d palate with irregular t e e t h ; this occurs in very m a n y cases. I mention this because I think it is a c o m m o n idea that s t i g m a t a of d e g e n e r a t i o n are common among mental deficients. I t is certainly not so in Coventry, and Burt states that it is not so in L o n d o n except in such cases as Mongols, Cretins, H y d r o c e p h a l i c s , etc. I a m inclined to consider the n a r r o w palate, &c., coupled with a copious flow of saliva, as a point to be considered in weighing evidence for mental deficiency. Malnutrition is a v e r y c o m m o n and m a r k e d feature, 14 out of 61 cases (23 per cent.) being m a r k e d as puny. D e f e c t i v e articulation occurs in 16 per cent., m a r k e d nervousness (such that, although I a m frequently a m o n g them, I find it difficult to get t h e m to a n s w e r questions) in 8 per cent., and suspected phthisis in 5 per cent. A large n u m b e r (16 per cent.) show evidence of w a n t of muscular tone, such as scoliosis, kyphosis, flat feet, etc.
Fcrmily History.--In 34 out of 61 cases there is a family history of insanity, m e n t a l deficiency, epilepsy, or alcoholism. A s in 19 out of the 6I cases no family history has been obtained, this proportion, in all probability, should be considerably higher. Mental Chcrracteristics.- E s t i m a t e d
b y the B i n e t - S i m o n tests the a v e r a g e a m o u n t of retardation at the special school is 5} years. T h i s shows a m a r k e d difference between the m e n t a l deficient and the b a c k w a r d child, whose r e t a r d a t i o n is seldom,
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I think, m o r e than 2 y e a r s by these tests. I was inclined to think, from general impressions, t h a t our children at the special school m a d e v e r y little mental growth. I find, however, in plotting out the mental ages for the whole school with their a c t u a l age, that the resulting curve shows a very fair mental growth. I t shows in p a s s i n g from the age of 7 years to that of 16 years a growth of between 4 and 5 years. T h i s curve is steepest between the ages of 7 and 11. T h i s agrees a l m o s t e x a c t l y with w h a t Burt, the P s y c h o l o g i s t to the L o n d o n County Council, found in the special schools which he investigated, t { e found that the a v e r a g e retardation was 5 years, and that on an a v e r a g e mental defectives m a d e half a y e a r ' s progress mentally during each y e a r of physical growth. H e also points out that this mental growth slows down towards t h e end of school life, and, in m a n y cases, seems to reach its l i m i t a t about 13 or 14 years of age. A word with r e g a r d to the B i n e t - S i r n o n tests. T h e y give, of course, b y no m e a n s a diagnosis of mental deficiency, though they are a useful help t o w a r d s such diagnosis. W h e n used by the s a m e e x a m i n e r on the s a m e child or set of children a t intervals t h e y are, I think, most useful as an index of mental growth. I s a y when used b y the s a m e e x a m i n e r because the questions allow such latitude in the a m o u n t of hint or help which m a y be given to t h e child that I do not think one m a n ' s results m a y be c o m p a r e d with another's. T h e y are t e s t s of intelligence a n d not of educational ability ; two things w h i c h are not synonomous. I h a v e e x a m i n e d our children, therefore, in an a t t e m p t to estimate their educational ability and progress. F o r this the two s u b j e c t s reading a n d n u m b e r were investigated. F o r reading I have divided t h e m into 5 grades, starting from a knowledge of some of the letters as G r a d e I., and w o r k i n g up to ability to read simple story books as G r a d e V.; this last being the highest point t o w h i c h even the most a d v a n c e d children h a v e reached. T h e resulting curve shows a steady rise throughout school life, but at the age of 16 shows that the a v e r a g e has only reached a position m i d w a y b e t w e e n G r a d e s I V . and V. T h i s position is p r a c t i c a l l y that of S t a n d a r d I. in the o r d i n a r y infants' school where it would be the work of children of 7 y e a r s of age. T h a t is to say, that w h e r e a s the child a t the special school a g e d 15 or 16 shows in general intelligence a retardation of 5 years, in reading he shows a r e t a r d a t i o n of 8 or 9 years.
HEALTH.
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F o r n u m b e r I have divided them into three grades, s t a r t i n g from those with no knowledge of n u m b e r and ending with those who can do simple money sums, this a g a i n being the highest level to which any of our children have reached. T h e resulting curve does not start to rise at all until we come to children of 9 years of age. I t then rises slowly, but in the end only reached nay G r a d e I I . (ability to do simple addition and subtraction) at the age of 15 or 16. T h i s is practically the position of children of 6 years of age in the ordinary infants' school. T h u s in number mental deficients are even more behindhand than in reading. I would like to enlarge s o m e w h a t on this matter of the difference b e t w e e n general intelligence and educational ability. F i v e y e a r s ago when I first started to use the B l u e t - S i m o n tests I was inclined to use them as a mechanical method of diagnosis : so m u c h r e t a r d a t i o n - - s o much mental deficiency. I t soon b e c a m e obvious, however, that this would not work. W h e r e one found 4 or 5 years retardation there were usually other indications, such as irrelevency, inattention, or some characteristic described by the p a r e n t which left one in no doubt as to the diagnosis. T h e difficulty was where one found a retardation of about 2 or even 3 y e a r s and no other signs. I confess that at that time I invaria b l y sent such children back to the ordinary school as being merely dull and b a c k w a r d . D u r i n g the last 18 months, however, I have seen several such cases, and have become impressed with the reiterated s t a t e m e n t s of their teachers that the children in question s e e m e d quite ineducable as far as reading, writing, or n u m b e r were concerned. I began to consider, therefore, whether this inability to read might not, even when a c c o m p a n i e d by a fair m e a s u r e of general intelligence, be a definite sign of mental deficiency. One boy of 11 years with a retardation of iess than 2 years, but unable to read words of m o r e than 2 or three letters, and with only the most e l e m e n t a r y knowledge of number, I have, after w a t c h i n g fot several months, certified for the S p e c i a l School. T h e case had to be t a k e n to court before the parents could be pers u a d e d to send him there, but since admission his conduct has fully justified m y diagnosis ; incidentally he has told us sufficient a b o u t his sister for us to consider t h a t she is also m e n t a l l y deficient. I a m keeping under observation s e v e r a l children of 8 or 9 years old with the s a m e inability to learn the
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ordinary school subjects, coupled with only a small retardation in general intelligence, and am strongly of opinion now that they will prove to be really m e n t a l l y deficient. Of course in such cases I have e x c l u d e d such conditions as i r r e g u l a r i t y of attendance at school, defective sight or hearing, word-blindness, or word-deafness. M a y I quote what B u r t found on this m a t t e r of educational a t t a i n m e n t s ; he says : " I t is obvious that the a m o u n t of retardation in educational a t t a i n m e n t s is far g r e a t e r than t h a t in general ability ; children in special schools are eharacterised more by b a c k w a r d n e s s in school w o r k t h a n by defective intelligence. D e f e c t i v e intelligehce is usually a c c o m p a n i e d b y extremeIy defective attainnlents ; but defective a t t a i n m e n t s are by no m e a n s an i n v a r i a b l e index of equal defect in intelligence." I think in the p a s t too much attention has been given to the question of generaI intelligence ; as far as I k n o w all the published tests deal solely with this a s p e c t of deficiency. I t is just where we need so much help, however, i.e., with the difficult borderline cases, that such tests fail to assist ; b u t it is just here that tests of educational ability s e e m to promise us some of the help we need. A t present there are no standarised tests for such examination, but I g a t h e r from B u r t ' s book that it is a question on which he is at present engaged. LASTLY, MORAL S T A T I S T I C S . ~ T h e s e at p r e s e n t cannot be measured, but there is no doubt of the fact that the morals of children in a special school are on a lower plane than those of the normal child. I t is seldom that I go into the special school without h e a r i n g of some such fault as that of a child has been s y s t e m a t i c a l l y t o r m e n t i n g or even m a l t r e a t i n g another. O n l y recently two boys set oil another on his way home, tore his collar to bits and tore his coat into t w o ; s o m e t i m e s a case of stealing ; sometimes of ill-temper ; sometimes that for d a y s a whole class has been quarrelling a m o n g t h e m s e l v e s . T u r n i n g to more detailed n u m b e r s I find that 25 out of our 61 children are noted as having in a m a r k e d degree some characteristic showing i m p a i r m e n t of moral sense. T h e most common of these are untruthfulness and stealing. U n t r u t h f u l n e s s seems to be almost a characteristic of mental deficients. I a m told there are only two children in the whole school who could be depended on to tell the truth where a lie would a p p a r e n t l y be to their a d v a n t a g e ; but in this e s t i m a t e I have only counted those as untruthful where the lying seems
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to be a m a r k e d and deliberate characteristic. Other defects are spitefullness, bad temper, cruelty to a n i m a l s and immorality. T h i s last is a p p a r e n t l y open a n d troublesome in character. T h i s i m p a i r m e n t of moral sense b e c o m e s more m a r k e d as the children become older. I t shows itself about the time of puberty. D u r i n g the last y e a r we have had two boys a n d a girl at our special school who, until the age of 14, had been docile and not m a r k e d l y below the a v e r a g e intelligence of their fellow scholars, but who at about that age began to deteriorate m a r k e d t y in intelligence, which in each case b e c a m e so low t h a t t h e y could not be given a mental age b y the B i n e t - S i m o n tests, while their conduct b e c a m e such that they had to be excluded from school as d e t r i m e n t a l to the other children. F r o m being docile and obedient in school they b e c a m e agressive and d i s o b e d i e n t ; at home they were u n m a n a g e a b l e , both the b o y s s t r u c k their p a r e n t s and one of them s t a y e d out all night. In the case of the girl there was a probable syphilectic family history and I even thought that she was possibly a case of G . P . I . ; this suggestion, however, was not a c c e p t e d b y the Medicat Officer of the P o o r L a w I n f i r m a r y to which she was admitted. I n the case of the two boys there was a p p a r e n t l y nothing physical to explain this c h a n g e i n behaviour. H e r e , in this question of conduct, I think we have another aid to diagnosis in the borderline cases, F o r i n s t a n c e : a short time ago I certified a boy of nine y e a r s of age, only two y e a r s retarded, and able to read words of one or two syllables, chiefly on account of his conduct. H e was s u b j e c t to fits of uncontrollable t e m p e r at home, such that he tore his clothes and beat his head against the w a l l when thwarted, he also had the habit of occasionally straying a w a y from home for the whole day. O n more than one occasion his m o t h e r had had to a p p l y to the police to find him. H i s t e a c h e r , and curiously enough his mother, also, was convinced of his mental deficiency. I admit, however, that his admission was of the n a t u r e of an experim e n t and I have really a d m i t t e d him for observation ; there being at present no special class for b a c k w a r d children in Coventry. O u r great aid, however, to diagnosis in these difficult borderline cases should come from the formation of special classes for dull and b a c k w a r d children, here not only could children be more frequently and fully observed, but being segregated it would be much easier to get defects of vision
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and hearing attended to, and so ruIe them out of court as possible causes of the backwardness. One point is, I think, important with regard to these classes. The teachers must in some way have special training. I confess that t find even the best head teachers of very little help in deciding on a child's mentality. Either they regard backwardness pure and simple as mental deficiency or else they consider that they can spot a deficient by something in his appearance, by a peculiar expression of the eyes, for instance. To summarise briefly, mental deficients while at school are, as a class, characterised by physical defects, by a deviation of about 5 years from the normal standard of intelligence, by a more marked inability to assimilate the ordinary subjects of elementary education and by impairment of moral sense. Dull and backward children, as far as I know, are characterised by a deviation below the normal intelligence of from 1½ to 2} years and by defects of the sense organs. I would like to say rather more on the question of conduct. If one compares the writing of say Binet and Simon with the papers which were read at the C.A.M.D. Conference in November last, one cannot help being struck by a change of attitude towards the question of mental deficiency. The earlier ~ r i t e r s apparently regarded the actual retardation in mental ability as the essential deficiency and thought that if suitable methods of teaching and training could be devised this defect could to a large extent be remedied so that at any rate a certain number of defectives could b e turned out into the world as fairly normal citizens. Dr. Eichholz in his evidence before the Royal Commission stated that from 40 to 50 per cent. could be sufficiently educated to return to the ordinary elementary school. It is interesting to note that in a paper which he read before the London H e a d Teachers early in 1919 he had reduced this number to 25 per cent. The view taken at the Conference, however, was that the mental defect was really only an index of the real defect, which was one of conduct. Dr. Auden in his paper compared the mental defect with the estimation of CO2 in the atmosphere in which case, although a danger in itself, its chief value is as an index of the more dangerous organic matters present. H e further stated that if he found a child in the special school who had become fit to return
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to the ordinary elementary school he should consider that he had made a mistake in diagnosis. This, I may say, is a conclusion I had come to before hearing his address. This question of conduct has been brought home to us in Coventry during the last year by several cases who have been brought up by Police Court Missioners, rescue workers, &c., or who have appeared in the police court and been referred t o the Mental Deficiency Committee. Some of them had passed through the Special School, but being superficially intelligent it had not been considered necessary to notify them to the Mental Deficiency Committee. I may say that in view of these cases we have now made it a routine measure in Coventry to notify to the Mental Deficiency Committee all children as they leave the Special School. In the Coventry School Report for 1918 I analysed the after histories of the 115 children who had passed through our special school. I found that 36 only of them were doing satisfactory work. Some of the others could not work of course because they had not the ability. Many of them, however, were not working because they would not, at any rate without more supervision than could be given. W i t h regard to these numbers it must be remembered that at that time war conditions stilt existed, under which it was much easier for a defective to obtain employment. Another point too should be mentioned. It has been stated that as they grow older the work of defectives becomes more unreliable, they tend more and more to become casual rather than continuous workers. As evidence of this view that the thing that matters in mental defectives is the conduct of the person affected rather than the limitation in intelligence or educational attainments, we have the Birmingham scheme for dealing with criminals. This scheme has been initiated on the grounds that a very large percentage of crime is due primarily to mental deficiency for which treatment rather than punishment is required. All persons therefore committing crimes who in themselves or their acts suggest the possibility of mental deficiency as the cause are now examined by a medical expert. So far more than 18 per cent. have been found to be mentally deficient and have been dealt with under the Mental Deficiency Act, while over 12 per cent. have been found of unsound mind. If this view of the importance of conduct be accepted I think two things follow. First, that all
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special schools be residential ; and Secondly, that all M.D.'s for some years at least after leaving the special school should be maintained in an institution. With regard to the residential school. _At the day school school children are only under discipline for 4 or 5 hours a day ; for the rest of the time they either wander about uncontrolled or are under the unwise discipline of their parents. Unfortunately, the parents, who feel their resPonsibility, very frequently take the view that corporal punishment is the form of discipline required, but since, in many cases, these children are unable to associate cause and effect the result of such methods is merely to make them sullen and sly. It is at any rate reasonable, I think, to hope that if these children could constantly be under trained disciplinarians from the age of 7 to 16, some of these irregularities of conduct might be expected to be minimised. Briefly, the special school should be regarded, primarily, as a training centre rather than an educational one. I understand that at Bradford the authorities are contemplating converting their day schools into residential ones. The question of sending all children who have passed through a special school to an institution is equally important. Firstly, they would not be able to harm either themselves or others; they would not be able to give rise to illegitimate children, or to contract and disseminate venereal disease ; they would not appear in the police courts or the casual wards of workhouses and would thus save national expense. Secondly, their labour could be made of use to the community. Many of these defectives can work if under adequate supervision. Where their work is casual and intermittent their value to th e community is small or even a minus quantity, but were it utilised in a well directed colony or community it may well be that such a community could be more than self-supporting. Third!y, and most importantly, they would not be able to propagate their species and ipso facto their defect. I suppose we are all agreed beyond a shadow of doubt that mental deficiency is hereditary, and probably most of us consider that in all probability this hereditary follows mendelian linesThis being so, the defect can never be wiped o u t by any form of training. In fact, to this extent the special school is even a danger from the fact that it gives the impression to the public and to educational and other authorities, that the child, having gained a certain amount of education, has
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become fit (with or without a biennial visit to the home of some kind of inspector) to be allowed to take his place as a free citizen. N o matter how highly trained a mental deficient may become, his gametes apparently will remain unaltered, and among his descendants there is almost bound to be one or more who will suffer from some mental defect, even imbecility or idiocy should the other progenitor be of a n equally bad strain, or should his environment be particularly bad. Even were all mental defectives segregated in this way, it would necessarily take generations to stamp out the defect. For it must be remembered that w e are only thus dealing with those in whom mental deficiency is dominant; true they are those who possibly have a double dose of defect, but still there are those in whom the defect is recessive, who are superficially normal but in whose descendants mental weakness is likely crop out. The City of Bradford has already started such colonies; one for men and one for women. All. children are notified to the Mental Deficiency Committee on leaving the special school and practically all go straightway to one of these colonies. Only under very special circumstances is a child placed under guardianship. The men do gardening, fowl keeping, basket and mat making ; the women laundry work and sewing. I understand that these colonies have been running for about two years, and their school medical officer told me that in five years' time he thought they would be self-supporting. I think this plan might be followed with great advantage all over the country. It would probably not be necessary to keep all defectives in such colonies permanently, but at any rate it would be a wise proceeding to send them there as a routine measure for say five or six years. This would not only give them a much longer training in manual work, but would carry them through the period of adolescence, which would, in the great majority of cases, enable a definite decision to be made as to whether or not there was sufficient moral impairment to render it advisable for them to be detained permanently at that or some other institution. It should be remembered that it has been slated that between fifteen and twenty is the age for recruiting into the criminal classes. The Mental Deficiency Act of 1913 makes provision, or at any rate gives instructions, for sending certain defectives to institutions. My point is that
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it should be the rule that defectives go to an institution, and only under special circumstances should exceptions be made. It seems to me that in starting with special schools we kave started at the wrong end. Segregation should come first, it being by far the most important factor in the elimination of these strains of defect which exist in such large numbers throughout the country. Having segregated them, then by ait means train and educate them as highly as possible, both for their own happiness and for the sake of their value to the community at large.
SOCIETY OF MEDICAL OFFICERS HEALTH.
OF
SPECIAL COUNCIL MEETING. A Special Meeting of the Council was held at the homse of the Society on Friday, J u n e 4th, 1920, The P r e s i d e n t (Prof. H. R. Kenwood) took the chair, and there were present Drs. Snell, Cates, G. F. Buchan, Kaye, P o r t e r , Kirkhope, Stevens, E v a n s , H e r b e r t Jones, Kerr, Hislop, Ridley Bailey, L y s t e r , H o w a r t h , Joseph, Sanders, and Prof. A. Bostock Hill. T h e Minutes of the last Council Meeting having been read and approved, apologies for a b s e n c e were r e p o r t e d from D r s . A . K . C h a l m e r s , N a y l o r Barlow, and Caldwelt Smith. Correspondence.--(1) A l e t t e r was read from the F o r e i g n O N c e , conveying the wish of the Austrian D e p a r t m e n t of Public Health to be supplied with e x c h a n g e copies of tl~e Society's journal, and asldng for any reply to the proposal to be r e t u r n e d t h r o u g h the S e c r e t a r y of State for Foreign Affairs. Agreed : T h a t the exchange be sanctioned. (2) F r o m the British Medical Association inviting the Society to n o m i n a t e two representatives on a deputation which may shortly be received by the Minister of H e a l t h in reference to S u p e r a n n u a t i o n of Medical Officers of Health. Agreed: T h a t the P r e s i d e n t and Dr. B u c h a n be n o m i n a t e d to r e p r e s e n t the Society. (3) F r o m Dr. E. H. Snell, Hon. Sec. Midland Branch, enclosing a letter f r o m Dr. Philip B o o b b y e r , in r e f e r e n c e to the r e c e n t decision of the National Association of Local Government Officers to become a T r a d e Union.
HEALTH.
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Agreed: T o d e f e r consideration of the points raised by Dr. B o o b b y e r until f u r t h e r information is available. (4) F r o m Dr. E. H. M a r c u s Milligan, school medical officer for Bath, asking the Society to watch the i n t e r e s t s of public health officials in r e g a r d to the new taxation of m o t o r cars, and, if possible, to s e c u r e relief for those medical officers who provide their own means of locomotion in consideration of a fixed allowance. Agreed : T h a t the E x e c u t i v e S e c r e t a r y should bring this letter to the notice of the B.M.A. c o m m i t t e e now negotiating with the Ministry of T r a n s p o r t , on behalf of the whole profession. T h e Council then p r o c e e d e d to c o n s i d e r the Interim R e p o r t r e c e n t l y submitted to the Ministry of H e a l t h by the Consultative Council on Medical and Allied Services. After a prolonged discussion it was decided to r e f e r the r e p o r t to a Special C q m m i t t e e consisting of the President, the E d i t o r (Dr. Lyster), and Drs. P o r t e r , Ridley Bailey, Joseph, G. F. Buchan, Cates, Snell, and Herbert Jones, with instructions to consider the r e c o m m e n d a t i o n s in detail, and to r e p o r t t h e r e o n to the Council of the Society. It was a g r e e d that the Special C o m m i t t e e should meet on J u n e 18th, at 2.30 p.m., and that, if necessary, a f u r t h e r meeting should be held the following day. T h e Council then a d j o u r n e d . ORDINARY MEETING. An O r d i n a r y Meeting was held at the house of the Society, on Friday, May 28th, 1920. The P r e s i d e n t (Prof. H. R. Kenwood) was in the chair, and a m o n g s t those present w e r e : D r s . T u b b - T h o m ~ s , Ash ken ny, Bygott, Kirkhope, Ellis, Veitch Clark, Shinnie, Sanders, F e n t o n , E w a r t , and Mr. W. Whitake.r, F.R.S. T h e minutes of the last o r d i n a r y meeting having been read and adopted, the following c a n d i d a t e s were elected to m e m b e r s h i p :-Beggs, Samuel ThomaS, Major RA.M.C., M.D.Belf,, D.P.H. ; Blake, Mabel Nellie. M.B., Ch.B:Glasg. ; Borland, Vynne, M.B., Ch.B., B.Sc.Glasg., D.P.H. ; Bunting, Dora Elizabeth Lidgett, M.DLond. (State Med,), B.S,, D.P.H.Camb. ; Craig, James, M.D., C.M.Edin., M.R.C.S. ; Crowe, John Tabuteau, L.M.S., S,A. ; Crnickshank, Mary Walker (Mrs.), M B., Ch.B.Aberd. ; Dean, Henry _]ames, L.R.G,P. & S.I,, L.S.A.; Delmege,James Anthony, O.B.E.,
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SOME OBSERVATIONS ON MENTAL DEFICIENTS. BY
A. H . NEWTON, M.B., Ch.B., A s s i s t a n t School Medical Officer for the City of Coventry.* L i k e p r o b a b l y m a n y other school medical officers I have tried to find some certain m e t h o d of differentiating b e t w e e n m e n t a l deficients, dull and b a c k w a r d , and n o r m a l children. P a r t l y with this o b j e c t and p a r t l y b e c a u s e it is of interest to see h o w local results c o m p a r e with those in other centres and w i t h those for the country at large, I have a n a l y s e d m y experiences with our C o v e n t r y children from various aspects. T a k i n g first physical conditions : N u t r i t i o n (as e s t i m a t e d by height a n d weight) shows a m a r k e d deterioration a m o n g mental deficients as a whole. A t seven y e a r s of age the a v e r a g e weight is 4 Ibs. below that of the normal child in C o v e n t r y ; this defect steadily increases until at 14 years the a v e r a g e is 13 lbs. below the same normal. In height the distinction is not so marked. T h e curve for the whole special school shows that the average is a b o u t }-in. below the normal. D u l l and b a c k w a r d children, on the other hand, show no such defect. Curiously enough, in C o v e n t r y the curve of a v e r a g e weights for these children shows a b o u t 2 lbs. to the good for all ages. T h e curve for their heights is p r a c t i c a l l y the s a m e as that for n o r m a l children. W i t h r e g a r d to defective vision : 33 per cent. of the children in our special school have a defect of 6/12 or worse. This compares v e r y unfavourably with the 7.5 p e r cent. found among n o r m a l children. I n only 2 cases out of 20 cases of defective sight are there corneal opacities to account for it. T h e most c o m m o n defect is astigmatism, with or without other errors of refraction. D e f e c t i v e hearing is present in 6"5 per cent. as c o m p a r e d with 2 per cent. among n o r m a l children. All these cases are due to otitis m e d i a or intra p h a r y n g e a l obstruction of some s o r t ; there being no cases of int. auditory deafness. Comparing dull a n d b a c k w a r d children with these, I find 25 per cent. with defective vision and a high percentage, viz., 13 per cent. with defectivehearing. One m a y note here a r e m a r k b y Dr. H a m e r in the A n n u a l R e p o r t of the Chief M e d i c a l Officer for * A paper read before the Midland Branch of the Society of Medical Officers of Health--29th January, 1920.
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1918. On page 109 he says " T h e special incidence upon the children classed as mental deficients of defects of the sense organs raises the question whether, if these defects could be prevented, fewer children would need to be relegated to the special schools." I think the a n s w e r is in the negative. C e r t a i n l y in our own schools, where atl but one or two with defective v i s i o n have had their refraction corrected with glasses, although there has been some i m p r o v e m e n t in their work afterwards, not one of t h e m has proved to be less obviously m e n t a l l y deficient. T h e a n s w e r to a similar question a s k e d with regard to dull and b a c k w a r d children would, I think, be in the affirmative. I have no evidence of this, however, as m y work a m o n g these children has been too recent to show any results. A m o n g other physical defects in our m e n t a l deficients I do not find s t i g m a t a of degeneration at all c o m m o n with the exception of the high a r c h e d palate with irregular t e e t h ; this occurs in very m a n y cases. I mention this because I think it is a c o m m o n idea that s t i g m a t a of d e g e n e r a t i o n are common among mental deficients. I t is certainly not so in Coventry, and Burt states that it is not so in L o n d o n except in such cases as Mongols, Cretins, H y d r o c e p h a l i c s , etc. I a m inclined to consider the n a r r o w palate, &c., coupled with a copious flow of saliva, as a point to be considered in weighing evidence for mental deficiency. Malnutrition is a v e r y c o m m o n and m a r k e d feature, 14 out of 61 cases (23 per cent.) being m a r k e d as puny. D e f e c t i v e articulation occurs in 16 per cent., m a r k e d nervousness (such that, although I a m frequently a m o n g them, I find it difficult to get t h e m to a n s w e r questions) in 8 per cent., and suspected phthisis in 5 per cent. A large n u m b e r (16 per cent.) show evidence of w a n t of muscular tone, such as scoliosis, kyphosis, flat feet, etc.
Fcrmily History.--In 34 out of 61 cases there is a family history of insanity, m e n t a l deficiency, epilepsy, or alcoholism. A s in 19 out of the 6I cases no family history has been obtained, this proportion, in all probability, should be considerably higher. Mental Chcrracteristics.- E s t i m a t e d
b y the B i n e t - S i m o n tests the a v e r a g e a m o u n t of retardation at the special school is 5} years. T h i s shows a m a r k e d difference between the m e n t a l deficient and the b a c k w a r d child, whose r e t a r d a t i o n is seldom,
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I think, m o r e than 2 y e a r s by these tests. I was inclined to think, from general impressions, t h a t our children at the special school m a d e v e r y little mental growth. I find, however, in plotting out the mental ages for the whole school with their a c t u a l age, that the resulting curve shows a very fair mental growth. I t shows in p a s s i n g from the age of 7 years to that of 16 years a growth of between 4 and 5 years. T h i s curve is steepest between the ages of 7 and 11. T h i s agrees a l m o s t e x a c t l y with w h a t Burt, the P s y c h o l o g i s t to the L o n d o n County Council, found in the special schools which he investigated, t { e found that the a v e r a g e retardation was 5 years, and that on an a v e r a g e mental defectives m a d e half a y e a r ' s progress mentally during each y e a r of physical growth. H e also points out that this mental growth slows down towards t h e end of school life, and, in m a n y cases, seems to reach its l i m i t a t about 13 or 14 years of age. A word with r e g a r d to the B i n e t - S i r n o n tests. T h e y give, of course, b y no m e a n s a diagnosis of mental deficiency, though they are a useful help t o w a r d s such diagnosis. W h e n used by the s a m e e x a m i n e r on the s a m e child or set of children a t intervals t h e y are, I think, most useful as an index of mental growth. I s a y when used b y the s a m e e x a m i n e r because the questions allow such latitude in the a m o u n t of hint or help which m a y be given to t h e child that I do not think one m a n ' s results m a y be c o m p a r e d with another's. T h e y are t e s t s of intelligence a n d not of educational ability ; two things w h i c h are not synonomous. I h a v e e x a m i n e d our children, therefore, in an a t t e m p t to estimate their educational ability and progress. F o r this the two s u b j e c t s reading a n d n u m b e r were investigated. F o r reading I have divided t h e m into 5 grades, starting from a knowledge of some of the letters as G r a d e I., and w o r k i n g up to ability to read simple story books as G r a d e V.; this last being the highest point t o w h i c h even the most a d v a n c e d children h a v e reached. T h e resulting curve shows a steady rise throughout school life, but at the age of 16 shows that the a v e r a g e has only reached a position m i d w a y b e t w e e n G r a d e s I V . and V. T h i s position is p r a c t i c a l l y that of S t a n d a r d I. in the o r d i n a r y infants' school where it would be the work of children of 7 y e a r s of age. T h a t is to say, that w h e r e a s the child a t the special school a g e d 15 or 16 shows in general intelligence a retardation of 5 years, in reading he shows a r e t a r d a t i o n of 8 or 9 years.
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F o r n u m b e r I have divided them into three grades, s t a r t i n g from those with no knowledge of n u m b e r and ending with those who can do simple money sums, this a g a i n being the highest level to which any of our children have reached. T h e resulting curve does not start to rise at all until we come to children of 9 years of age. I t then rises slowly, but in the end only reached nay G r a d e I I . (ability to do simple addition and subtraction) at the age of 15 or 16. T h i s is practically the position of children of 6 years of age in the ordinary infants' school. T h u s in number mental deficients are even more behindhand than in reading. I would like to enlarge s o m e w h a t on this matter of the difference b e t w e e n general intelligence and educational ability. F i v e y e a r s ago when I first started to use the B l u e t - S i m o n tests I was inclined to use them as a mechanical method of diagnosis : so m u c h r e t a r d a t i o n - - s o much mental deficiency. I t soon b e c a m e obvious, however, that this would not work. W h e r e one found 4 or 5 years retardation there were usually other indications, such as irrelevency, inattention, or some characteristic described by the p a r e n t which left one in no doubt as to the diagnosis. T h e difficulty was where one found a retardation of about 2 or even 3 y e a r s and no other signs. I confess that at that time I invaria b l y sent such children back to the ordinary school as being merely dull and b a c k w a r d . D u r i n g the last 18 months, however, I have seen several such cases, and have become impressed with the reiterated s t a t e m e n t s of their teachers that the children in question s e e m e d quite ineducable as far as reading, writing, or n u m b e r were concerned. I began to consider, therefore, whether this inability to read might not, even when a c c o m p a n i e d by a fair m e a s u r e of general intelligence, be a definite sign of mental deficiency. One boy of 11 years with a retardation of iess than 2 years, but unable to read words of m o r e than 2 or three letters, and with only the most e l e m e n t a r y knowledge of number, I have, after w a t c h i n g fot several months, certified for the S p e c i a l School. T h e case had to be t a k e n to court before the parents could be pers u a d e d to send him there, but since admission his conduct has fully justified m y diagnosis ; incidentally he has told us sufficient a b o u t his sister for us to consider t h a t she is also m e n t a l l y deficient. I a m keeping under observation s e v e r a l children of 8 or 9 years old with the s a m e inability to learn the
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ordinary school subjects, coupled with only a small retardation in general intelligence, and am strongly of opinion now that they will prove to be really m e n t a l l y deficient. Of course in such cases I have e x c l u d e d such conditions as i r r e g u l a r i t y of attendance at school, defective sight or hearing, word-blindness, or word-deafness. M a y I quote what B u r t found on this m a t t e r of educational a t t a i n m e n t s ; he says : " I t is obvious that the a m o u n t of retardation in educational a t t a i n m e n t s is far g r e a t e r than t h a t in general ability ; children in special schools are eharacterised more by b a c k w a r d n e s s in school w o r k t h a n by defective intelligence. D e f e c t i v e intelligehce is usually a c c o m p a n i e d b y extremeIy defective attainnlents ; but defective a t t a i n m e n t s are by no m e a n s an i n v a r i a b l e index of equal defect in intelligence." I think in the p a s t too much attention has been given to the question of generaI intelligence ; as far as I k n o w all the published tests deal solely with this a s p e c t of deficiency. I t is just where we need so much help, however, i.e., with the difficult borderline cases, that such tests fail to assist ; b u t it is just here that tests of educational ability s e e m to promise us some of the help we need. A t present there are no standarised tests for such examination, but I g a t h e r from B u r t ' s book that it is a question on which he is at present engaged. LASTLY, MORAL S T A T I S T I C S . ~ T h e s e at p r e s e n t cannot be measured, but there is no doubt of the fact that the morals of children in a special school are on a lower plane than those of the normal child. I t is seldom that I go into the special school without h e a r i n g of some such fault as that of a child has been s y s t e m a t i c a l l y t o r m e n t i n g or even m a l t r e a t i n g another. O n l y recently two boys set oil another on his way home, tore his collar to bits and tore his coat into t w o ; s o m e t i m e s a case of stealing ; sometimes of ill-temper ; sometimes that for d a y s a whole class has been quarrelling a m o n g t h e m s e l v e s . T u r n i n g to more detailed n u m b e r s I find that 25 out of our 61 children are noted as having in a m a r k e d degree some characteristic showing i m p a i r m e n t of moral sense. T h e most common of these are untruthfulness and stealing. U n t r u t h f u l n e s s seems to be almost a characteristic of mental deficients. I a m told there are only two children in the whole school who could be depended on to tell the truth where a lie would a p p a r e n t l y be to their a d v a n t a g e ; but in this e s t i m a t e I have only counted those as untruthful where the lying seems
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to be a m a r k e d and deliberate characteristic. Other defects are spitefullness, bad temper, cruelty to a n i m a l s and immorality. T h i s last is a p p a r e n t l y open a n d troublesome in character. T h i s i m p a i r m e n t of moral sense b e c o m e s more m a r k e d as the children become older. I t shows itself about the time of puberty. D u r i n g the last y e a r we have had two boys a n d a girl at our special school who, until the age of 14, had been docile and not m a r k e d l y below the a v e r a g e intelligence of their fellow scholars, but who at about that age began to deteriorate m a r k e d t y in intelligence, which in each case b e c a m e so low t h a t t h e y could not be given a mental age b y the B i n e t - S i m o n tests, while their conduct b e c a m e such that they had to be excluded from school as d e t r i m e n t a l to the other children. F r o m being docile and obedient in school they b e c a m e agressive and d i s o b e d i e n t ; at home they were u n m a n a g e a b l e , both the b o y s s t r u c k their p a r e n t s and one of them s t a y e d out all night. In the case of the girl there was a probable syphilectic family history and I even thought that she was possibly a case of G . P . I . ; this suggestion, however, was not a c c e p t e d b y the Medicat Officer of the P o o r L a w I n f i r m a r y to which she was admitted. I n the case of the two boys there was a p p a r e n t l y nothing physical to explain this c h a n g e i n behaviour. H e r e , in this question of conduct, I think we have another aid to diagnosis in the borderline cases, F o r i n s t a n c e : a short time ago I certified a boy of nine y e a r s of age, only two y e a r s retarded, and able to read words of one or two syllables, chiefly on account of his conduct. H e was s u b j e c t to fits of uncontrollable t e m p e r at home, such that he tore his clothes and beat his head against the w a l l when thwarted, he also had the habit of occasionally straying a w a y from home for the whole day. O n more than one occasion his m o t h e r had had to a p p l y to the police to find him. H i s t e a c h e r , and curiously enough his mother, also, was convinced of his mental deficiency. I admit, however, that his admission was of the n a t u r e of an experim e n t and I have really a d m i t t e d him for observation ; there being at present no special class for b a c k w a r d children in Coventry. O u r great aid, however, to diagnosis in these difficult borderline cases should come from the formation of special classes for dull and b a c k w a r d children, here not only could children be more frequently and fully observed, but being segregated it would be much easier to get defects of vision
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and hearing attended to, and so ruIe them out of court as possible causes of the backwardness. One point is, I think, important with regard to these classes. The teachers must in some way have special training. I confess that t find even the best head teachers of very little help in deciding on a child's mentality. Either they regard backwardness pure and simple as mental deficiency or else they consider that they can spot a deficient by something in his appearance, by a peculiar expression of the eyes, for instance. To summarise briefly, mental deficients while at school are, as a class, characterised by physical defects, by a deviation of about 5 years from the normal standard of intelligence, by a more marked inability to assimilate the ordinary subjects of elementary education and by impairment of moral sense. Dull and backward children, as far as I know, are characterised by a deviation below the normal intelligence of from 1½ to 2} years and by defects of the sense organs. I would like to say rather more on the question of conduct. If one compares the writing of say Binet and Simon with the papers which were read at the C.A.M.D. Conference in November last, one cannot help being struck by a change of attitude towards the question of mental deficiency. The earlier ~ r i t e r s apparently regarded the actual retardation in mental ability as the essential deficiency and thought that if suitable methods of teaching and training could be devised this defect could to a large extent be remedied so that at any rate a certain number of defectives could b e turned out into the world as fairly normal citizens. Dr. Eichholz in his evidence before the Royal Commission stated that from 40 to 50 per cent. could be sufficiently educated to return to the ordinary elementary school. It is interesting to note that in a paper which he read before the London H e a d Teachers early in 1919 he had reduced this number to 25 per cent. The view taken at the Conference, however, was that the mental defect was really only an index of the real defect, which was one of conduct. Dr. Auden in his paper compared the mental defect with the estimation of CO2 in the atmosphere in which case, although a danger in itself, its chief value is as an index of the more dangerous organic matters present. H e further stated that if he found a child in the special school who had become fit to return
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to the ordinary elementary school he should consider that he had made a mistake in diagnosis. This, I may say, is a conclusion I had come to before hearing his address. This question of conduct has been brought home to us in Coventry during the last year by several cases who have been brought up by Police Court Missioners, rescue workers, &c., or who have appeared in the police court and been referred t o the Mental Deficiency Committee. Some of them had passed through the Special School, but being superficially intelligent it had not been considered necessary to notify them to the Mental Deficiency Committee. I may say that in view of these cases we have now made it a routine measure in Coventry to notify to the Mental Deficiency Committee all children as they leave the Special School. In the Coventry School Report for 1918 I analysed the after histories of the 115 children who had passed through our special school. I found that 36 only of them were doing satisfactory work. Some of the others could not work of course because they had not the ability. Many of them, however, were not working because they would not, at any rate without more supervision than could be given. W i t h regard to these numbers it must be remembered that at that time war conditions stilt existed, under which it was much easier for a defective to obtain employment. Another point too should be mentioned. It has been stated that as they grow older the work of defectives becomes more unreliable, they tend more and more to become casual rather than continuous workers. As evidence of this view that the thing that matters in mental defectives is the conduct of the person affected rather than the limitation in intelligence or educational attainments, we have the Birmingham scheme for dealing with criminals. This scheme has been initiated on the grounds that a very large percentage of crime is due primarily to mental deficiency for which treatment rather than punishment is required. All persons therefore committing crimes who in themselves or their acts suggest the possibility of mental deficiency as the cause are now examined by a medical expert. So far more than 18 per cent. have been found to be mentally deficient and have been dealt with under the Mental Deficiency Act, while over 12 per cent. have been found of unsound mind. If this view of the importance of conduct be accepted I think two things follow. First, that all
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special schools be residential ; and Secondly, that all M.D.'s for some years at least after leaving the special school should be maintained in an institution. With regard to the residential school. _At the day school school children are only under discipline for 4 or 5 hours a day ; for the rest of the time they either wander about uncontrolled or are under the unwise discipline of their parents. Unfortunately, the parents, who feel their resPonsibility, very frequently take the view that corporal punishment is the form of discipline required, but since, in many cases, these children are unable to associate cause and effect the result of such methods is merely to make them sullen and sly. It is at any rate reasonable, I think, to hope that if these children could constantly be under trained disciplinarians from the age of 7 to 16, some of these irregularities of conduct might be expected to be minimised. Briefly, the special school should be regarded, primarily, as a training centre rather than an educational one. I understand that at Bradford the authorities are contemplating converting their day schools into residential ones. The question of sending all children who have passed through a special school to an institution is equally important. Firstly, they would not be able to harm either themselves or others; they would not be able to give rise to illegitimate children, or to contract and disseminate venereal disease ; they would not appear in the police courts or the casual wards of workhouses and would thus save national expense. Secondly, their labour could be made of use to the community. Many of these defectives can work if under adequate supervision. Where their work is casual and intermittent their value to th e community is small or even a minus quantity, but were it utilised in a well directed colony or community it may well be that such a community could be more than self-supporting. Third!y, and most importantly, they would not be able to propagate their species and ipso facto their defect. I suppose we are all agreed beyond a shadow of doubt that mental deficiency is hereditary, and probably most of us consider that in all probability this hereditary follows mendelian linesThis being so, the defect can never be wiped o u t by any form of training. In fact, to this extent the special school is even a danger from the fact that it gives the impression to the public and to educational and other authorities, that the child, having gained a certain amount of education, has
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become fit (with or without a biennial visit to the home of some kind of inspector) to be allowed to take his place as a free citizen. N o matter how highly trained a mental deficient may become, his gametes apparently will remain unaltered, and among his descendants there is almost bound to be one or more who will suffer from some mental defect, even imbecility or idiocy should the other progenitor be of a n equally bad strain, or should his environment be particularly bad. Even were all mental defectives segregated in this way, it would necessarily take generations to stamp out the defect. For it must be remembered that w e are only thus dealing with those in whom mental deficiency is dominant; true they are those who possibly have a double dose of defect, but still there are those in whom the defect is recessive, who are superficially normal but in whose descendants mental weakness is likely crop out. The City of Bradford has already started such colonies; one for men and one for women. All. children are notified to the Mental Deficiency Committee on leaving the special school and practically all go straightway to one of these colonies. Only under very special circumstances is a child placed under guardianship. The men do gardening, fowl keeping, basket and mat making ; the women laundry work and sewing. I understand that these colonies have been running for about two years, and their school medical officer told me that in five years' time he thought they would be self-supporting. I think this plan might be followed with great advantage all over the country. It would probably not be necessary to keep all defectives in such colonies permanently, but at any rate it would be a wise proceeding to send them there as a routine measure for say five or six years. This would not only give them a much longer training in manual work, but would carry them through the period of adolescence, which would, in the great majority of cases, enable a definite decision to be made as to whether or not there was sufficient moral impairment to render it advisable for them to be detained permanently at that or some other institution. It should be remembered that it has been slated that between fifteen and twenty is the age for recruiting into the criminal classes. The Mental Deficiency Act of 1913 makes provision, or at any rate gives instructions, for sending certain defectives to institutions. My point is that
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it should be the rule that defectives go to an institution, and only under special circumstances should exceptions be made. It seems to me that in starting with special schools we kave started at the wrong end. Segregation should come first, it being by far the most important factor in the elimination of these strains of defect which exist in such large numbers throughout the country. Having segregated them, then by ait means train and educate them as highly as possible, both for their own happiness and for the sake of their value to the community at large.
SOCIETY OF MEDICAL OFFICERS HEALTH.
OF
SPECIAL COUNCIL MEETING. A Special Meeting of the Council was held at the homse of the Society on Friday, J u n e 4th, 1920, The P r e s i d e n t (Prof. H. R. Kenwood) took the chair, and there were present Drs. Snell, Cates, G. F. Buchan, Kaye, P o r t e r , Kirkhope, Stevens, E v a n s , H e r b e r t Jones, Kerr, Hislop, Ridley Bailey, L y s t e r , H o w a r t h , Joseph, Sanders, and Prof. A. Bostock Hill. T h e Minutes of the last Council Meeting having been read and approved, apologies for a b s e n c e were r e p o r t e d from D r s . A . K . C h a l m e r s , N a y l o r Barlow, and Caldwelt Smith. Correspondence.--(1) A l e t t e r was read from the F o r e i g n O N c e , conveying the wish of the Austrian D e p a r t m e n t of Public Health to be supplied with e x c h a n g e copies of tl~e Society's journal, and asldng for any reply to the proposal to be r e t u r n e d t h r o u g h the S e c r e t a r y of State for Foreign Affairs. Agreed : T h a t the exchange be sanctioned. (2) F r o m the British Medical Association inviting the Society to n o m i n a t e two representatives on a deputation which may shortly be received by the Minister of H e a l t h in reference to S u p e r a n n u a t i o n of Medical Officers of Health. Agreed: T h a t the P r e s i d e n t and Dr. B u c h a n be n o m i n a t e d to r e p r e s e n t the Society. (3) F r o m Dr. E. H. Snell, Hon. Sec. Midland Branch, enclosing a letter f r o m Dr. Philip B o o b b y e r , in r e f e r e n c e to the r e c e n t decision of the National Association of Local Government Officers to become a T r a d e Union.
HEALTH.
JuLy,
Agreed: T o d e f e r consideration of the points raised by Dr. B o o b b y e r until f u r t h e r information is available. (4) F r o m Dr. E. H. M a r c u s Milligan, school medical officer for Bath, asking the Society to watch the i n t e r e s t s of public health officials in r e g a r d to the new taxation of m o t o r cars, and, if possible, to s e c u r e relief for those medical officers who provide their own means of locomotion in consideration of a fixed allowance. Agreed : T h a t the E x e c u t i v e S e c r e t a r y should bring this letter to the notice of the B.M.A. c o m m i t t e e now negotiating with the Ministry of T r a n s p o r t , on behalf of the whole profession. T h e Council then p r o c e e d e d to c o n s i d e r the Interim R e p o r t r e c e n t l y submitted to the Ministry of H e a l t h by the Consultative Council on Medical and Allied Services. After a prolonged discussion it was decided to r e f e r the r e p o r t to a Special C q m m i t t e e consisting of the President, the E d i t o r (Dr. Lyster), and Drs. P o r t e r , Ridley Bailey, Joseph, G. F. Buchan, Cates, Snell, and Herbert Jones, with instructions to consider the r e c o m m e n d a t i o n s in detail, and to r e p o r t t h e r e o n to the Council of the Society. It was a g r e e d that the Special C o m m i t t e e should meet on J u n e 18th, at 2.30 p.m., and that, if necessary, a f u r t h e r meeting should be held the following day. T h e Council then a d j o u r n e d . ORDINARY MEETING. An O r d i n a r y Meeting was held at the house of the Society, on Friday, May 28th, 1920. The P r e s i d e n t (Prof. H. R. Kenwood) was in the chair, and a m o n g s t those present w e r e : D r s . T u b b - T h o m ~ s , Ash ken ny, Bygott, Kirkhope, Ellis, Veitch Clark, Shinnie, Sanders, F e n t o n , E w a r t , and Mr. W. Whitake.r, F.R.S. T h e minutes of the last o r d i n a r y meeting having been read and adopted, the following c a n d i d a t e s were elected to m e m b e r s h i p :-Beggs, Samuel ThomaS, Major RA.M.C., M.D.Belf,, D.P.H. ; Blake, Mabel Nellie. M.B., Ch.B:Glasg. ; Borland, Vynne, M.B., Ch.B., B.Sc.Glasg., D.P.H. ; Bunting, Dora Elizabeth Lidgett, M.DLond. (State Med,), B.S,, D.P.H.Camb. ; Craig, James, M.D., C.M.Edin., M.R.C.S. ; Crowe, John Tabuteau, L.M.S., S,A. ; Crnickshank, Mary Walker (Mrs.), M B., Ch.B.Aberd. ; Dean, Henry _]ames, L.R.G,P. & S.I,, L.S.A.; Delmege,James Anthony, O.B.E.,