Sterilization
Born in Lithuania, DR. ABRAHAM MEYERSON came to the United States as a young boy. He was educated in the Boston public schools and later worked as a streetcar conductor while studying in the College of Physicians and Surgeons at Columbia. He transferred to Tufts Medical School in 1906 and there came under the dynamic influence of Dr. Morton Prince. So began the study and research in neuropsychiatry which were to make him a leading psychiatrist in this country. His books, The Inheritance of Mental Diseases and Social Pyschology, were standard works, and in 1936 he wrote the first definitive report on eugenical sterilization. The Atlantic has drawn the following article from his posthumous book, Speaking of Man, to be published by Knopf in November.
I
THERE are, in America alone, millions of individuals markedly unfit 1o live in society. Many of them cannot care for themselves or their children and are a burden to their families or communities. Because of the possibility that their defects are hereditary, and that allowing these people to have children will result in spreading their disabilities more widely through future generations, we must consider the question of eugenical sterilization.
Sterilization is a very simple operation. But it is much simpler to perform the operation of sterilization than it is to decide on whom the operation shall be done. There are those who advocate sterilizing all individuals who are “socially inadequate by reason of heredity,” and here they include all the insane, the feeble-minded, the epileptic, and certain chronic criminals. They assume that all these defects are hereditary and that individuals in these classifications are potentially the parents of defective offspring. They believe that such a program is needed if we are to prevent the unfit of our race from swamping the fit. Thanks mainly to their efforts and to the celebrated dictum of Justice Oliver Wendell Holmes that three generations of imbeciles are enough, in this country there now are twenty-nine states that have laws providing in some way for the sterilization of the socially inadequate. In some states these laws are “voluntary,” in other states “compulsory.”
The first sterilization law in America was passed by the Pennsylvania legislature in 1905, but it was vetoed by the Governor. ’The first sterilization laws still in effect were introduced in 1909 in California, Washington, and Connecticut. Following this, sterilization statutes wore ado pled in rapid succession by a number of states. Many of these laws were enacted without any definite program. They were frequently revised or amended, sometimes vetoed, and in many instances fell into disuse. Some of them have never really been put into effect, and the number of operations performed is so small as to be negligible. In Connecticut, for example, where the law is “compulsory,” in the course of all these years the number sterilized each year averages thirteen. California has almost as many sterilizations on record as the rest of the United States put together, and is the only state in the country that to any extent really enforces its sterilization law. Yet even in this state, with an average of about four hundred cases a year, the application of the law is limited when compared with the extent of the problem.
Those who consider these sterilization laws wise may ask why the enforcement is so lax. The answer is that in the United States there is formidable opposition to eugenical sterilization. In a democracy, only those laws which have their bases in folkways or the approval of the strong groups have a chance of being enforced. The fate of prohibition demonstrates the futility of trying to make a drastic change in deeply embedded traditions. As for meddling with the sexual organs, there is a deepseated repugnance which is socially instinctive and could be overcome only by great force or very intensive social education.
Before we reach any conclusions about whether these laws should be enforced and whether similar laws should be enacted in other states, we should consider separately each of the conditions for which sterilization is advocated and see in which of them the hereditary factors are of importance.
The tragedy of menial illness crushes not only the sick but also the members of their families. Nothing so breaks into the lives of the well as the mental diseases of those with whom they live: nothing so hurts the pride or arouses such devastating inner conflict. Accompanying the sympathy is the recoil of incomprehension and horror, and underneath the surface loyalty there is often deep, impatient disaffection. To love and care for the mentally disturbed is the final test of endurance, and so deep a drain on emotional reserve as to be beyond the powers of most normal people. There is a grim reason for the old term “alienist” to denote the man who looks after those felt to be aliens on the human scene.
2
INSANITY or mental disease is no unified thing. Mental diseases vary in biological nature, in cause, course, and possibilities for treatment, and have totally different relationships to heredity.
Some mental diseases are comparatively easy to classify. There are identifiable physical signs and changes in the body during life, and finally autopsy reveals changes in the brain and other structures. Those conditions account for more than half of the population in our mental institutions, yet they exemplify no hereditary process. The two most important are arteriosclerotic dementia and senile dementia, diseases consequent upon the changes of old age and due to alteration in the brain. General paresis, which develops ten to twenty years after the patient has contracted syphilis, is of environmental origin only, at least for any practical purposes. Most alcoholism, also, is created by social rather than individual heredity. While it is true that a good many alcoholics are neurotic and that some suffer from depression, the main trouble with the alcoholic is that society not only permits him to buy without restriction a drug that he cannot handle, but even applies an extraordinarily potent social pressure to encourage its use.
We come next to schizophrenia and the manicdepressive states, the two great mental diseases still without any known physical signs and without any differentiating pathology and chemistry.
Generally speaking, schizophrenia tends to start early in life as a personality type that develops into disease. The past history of the schizophrenic is usually that of a shut-in, overmeticulous, overscrupulous personality. He has a certain still shyness that marks him off from other men. He (or she) has little successful sexual urge of an outer type; he may and does brood about sex, and is often in what I have called a sexual stew, but frequently nothing comes of this except masturbation. He may have peculiarities of conduct, rigidities and mannerisms of extreme type.
From this schizoid personality, the sick man descends gradually or suddenly into a retreat from life. This retreat is based on a falsification of his relationship with others, he may believe that he is being persecuted. He misinterprets the irrelevant acts of other people and believes that a stranger, who looks at him as he passes will make an adverse criticism and communicate this unfavorable opinion to others, perhaps will consider him homosexual or vile in some other way, or even will follow him to do him damage. While the normal person takes refuge in the certainty that what goes on inside his head is known only to himself, unless he communicates it, the schizophrenic loses this feeling of safety and thinks that others know and read his mind. He feels that he is no longer able to do what he could before: to think consecutively, feel vividly, and act without constraint. He may then develop a “delusion of influence,” a belief that somehow an influence of mysterious and potent nature is being used on him by others — The Others. For he is now an alien in the world.
It is interesting that the nature of this influence changes with each cultural level and scientific achievement. In the days when men believed in “possession” by demons and witches, the schizophrenic claimed that he was bewitched and possessed. Later, when hypnosis was widely discussed and its powers were greatly exaggerated, hypnotism was the instrument of influence. As physical scientific devices developed and it became possible to talk and see at a distance, the radio and television became the means by which others influenced the schizophrenic. The mechanism of projection, which creates scapegoats for us all, is strongly evident in this disease. The schizophrenic finds that his difficulties are created by others, either concretely as coming from one person or group, or vaguely as coming from “Them.”
So the schizophrenic lives his life in a brooding, silly, grimacing, retreated fashion. Either he becomes overpassive or he becomes senselessly resistive. And there also appears as part of the symptomatology of this disease the transformation of one’s own thoughts into voices or hallucinations of one type or another.
The disability inherent in this disease is enormous. The course may run from a short episode that never recurs to a chronic progressive disorder that only grows worse as life goes on, although there may be sharp remission, in which the individual seems much better.
No pathology, no specific altered physiology, has been discovered, although the patients as a whole become inferior in physique and disordered in physiology as time goes on. This is no wonder, since they live aloof from all the invigorating recreative activities of man. In the institutions many of them work, but since they have no spontaneity and little initiative, they need constant spurring and guidance. Too many of them slip into a state that can only be described as vegetating; they may sit or stand all day in some fixed posture, absorbed in a sort of vacuum; or they may groove their activities in a senseless, stereotyped succession.
3
THE other great mental disorder of unknown physiology and pathology is the manic-depressive state. The term “manic-depressive” means that, the individual alternates between a state in which he is overexcited, elated, overactive, and usually over joyous and one in which he shows the opposite mood of grim depression. In the manic state he may be merely overgay, overtalkative, superficial in his speech, and given to punning. He may even he the life of the party, highly amusing when the condition is still under control. In fact, many individuals go through life in what is known as the hypomanic state; that is, they are manic, but never completely lose control. They never feel fatigue and are indomitable; while they tend to pass from one interest and excitement to another, they may even achieve great things and be notable in their lifework. One may even envy the individual in a hypomanic state, since his emotions are all charged with champagne and his energies are almost inexhaustible. But unfortunately the full manic stage often supervenes, and then the fantastic euphoric conduct, the recklessness, and the complete breakdown of inhibition force society to incarcerate the patient in a hospital, to save himself and others from disaster.
From this overcharged condition he may and usually does pass into the opposite state of depression. He experiences deep melancholy and complete failure of enthusiasm and energy, and loses his sense of reality and his feeling of the worthwhileness of life. From time to time, as we uneasily scan our lives, all of us suffer from a sense of guilt; but the melancholiac feels this in so magnified a form that he accuses himself not only of complete unworthiness but of unforgivable sin, of having created the disasters of the world. He believes that because of his guilt those whom he loves will be punished in one way or another by man or by God. The bluest blue mood of the normal person is a bright rainbow compared with the hopeless darkness of the manic-depressive patient. Losing the will to live, he may have only the desire to die. Suicide often ends the career of the manic-depressive patient.
The milder depressive cases are the bane and the perplexity of those who deal with them. They are adjured from morning to night to “snap out of it” and are given all kinds of banal advice. If they are overactive, they are told to rest more. If they show a tendency not to meet others, they are exhorted to be more social, when the very will to be social has been paralyzed. The patent fact that the “good advice” is impossible to follow does not lessen the stream of irritating importunity.
There is a very strong tendency to recover spontaneously from the manic-depressive state. The attacks may be long and violent, or short and not too greatly disturbing. The patient may need incarceration in an institution or, on the other hand, may even continue at work.
The Metrazol and later the electric-shock method have become of great use, especially for the depressive state. They produce really miraculous recoveries, but recoveries only in the sense of cutting short the individual attack, for unfortunately the disease tends to recur.
Disease knows no favorites. Schizophrenia and the manic-depressive state occur among the rich and poor, the bright and dull, Jew and gentile, black and white. Despite all that has been done, no substantial physiology or pathology has been established for these illnesses. The prevailing opinion is that they are mainly constitutional and hereditary.
This is borne out by a study of those touchstones of the operation of heredity and environment, identical twins. When one twin has schizophrenia or a manic-depressive state, the liability of the other to have the same disease is enormously greater than mere chance, although there are cases where one such person has the disease and his twin does not develop it. The term “concordance” has been invented to express similarity of fate in identical twins. The concordance of schizophrenia and the manic-depressive state in identical twins, while not 100 per cent, is so great as to leave almost no doubt that a hereditary factor is involved.
It is worth while considering the statement that the insane are increasing in our population. For several generations the commitment rate to institutions increased, as would naturally be expected. If a community has no hospitals and then starts building them, the commitment rate goes up as each hospital is built and as there are more facilities to take care of the insane and the defective. Communities that are backward in other ways do not feel the need for institutions. Thus the paradox: Low-grade communities have few hospitals and a low commitment rate. High-grade communities, sensitive to hospital needs, build hospitals and have a high commitment rate. In a community that has as many institutions as it needs and desires, the commitment rate remains stationary or even drops. This is true in many countries and in Massachusetts and New York, the two most carefully studied states in this country. In this type of community the only increase in commitment rate has been in the senile and arteriosclerotic diseases. As the age of the population increases owing to the lowered birth rate and the prolongation of life, more people live to become demented, more people outlive their brains. Then too, as people become urbanized, it becomes more difficult to care for their demented elders in apartment houses and tenements; so instead of caring for them at home, they pack them off to institutions.
All in all, the rate of mental disease is not increasing. The fact that there are more institutions and that more money is being spent for them indicates a more humane attitude toward mental disease and, perhaps more importantly, a realistic social effort to understand and to cure it.
4
IF WE turn our attention to the inheritance of feeble-mindedness, we are confronted at once by the studies of the ardent eugenists. In order to frighten the normal members of the community into stern and sterilizing action against the low-grade people of the community, these pointers-with-alarm have created a propaganda that is selective and biased. It assumes what it wishes whenever there are no facts. It takes exceptional cases and makes them typical. It neglects a whole world of contradictory statistics and facts.
The creation of the royal families of the feebleminded, the Nams, the Kallikaks, the Jukes, the tribes of Ishmael, the Virginians, and so on, is based on these serious errors of research. The typical technique is represented by the history of the Kallikaks. According to the legend, a certain Martin Kallikak, a Revolutionary soldier, had a liaison sub rasa with a “nameless feeble-minded girl" whom he met in a tavern. All the descendants of the Martin Kallikak union with this anonymous moron were “studied,” so the story goes, for four generations, and, lo and behold, they were all monsters; there were no normal people among them! All were alcoholics, feeble-minded, criminals, or vagrants. This family is in sharp contrast to that which followed the union of Martin Kallikak’s germ plasm with that of a presumably good girl. All the descendants of this public and approved union were fine, upstanding people — doctors, lawyers, judges, businessmen of repute. None of them were villains, shiftless alcoholics, insane, or feeble-minded.
Since such a partition of germ-plasmic fate has never occurred in this world, we have the right to raise two pertinent questions about this study. First, we might ask for assurance that Martin Kallikak actually fathered the child of the nameless feeble-minded girl. And then, since it is often difficult even for the experienced psychiatrist to diagnose feeble-mindedness in a patient he sees, we might question the mental disability of this Revolutionary maid. Unless these two basic queries can be answered with facts, the entire study of the Kallikaks is completely without value.
We find that all our information about the nameless girl and her child comes from an elderly lady who was questioned in 1910. This informant said that she had personally known the girl. If the feeble-minded girl was born in 1760 and reached the age of eighty and the informant was eighty years of age in 1910, the paths of these two people would have crossed between 1830 and 1840, at which time the heroine of the Kallikak saga was seventy to eighty years of age and our informant was something under ten. Any other ages would make the thing entirely impossible. And so we are asked to believe that a woman of eighty in 1910 could recall from her childhood authentic information of scientific value about a person whose mental state is alleged to have profoundly influenced four generations of descendants.
No scientific study of any family of feebleminded people reveals a 100 per cent set of failures. Studies such as one we did in Massachusetts reveal no counterparts to the Kallikaks. In many groups we found feeble-mindedness for one or two generations, but, we also found collaterals who reached distinction and were respected in the community. On the other hand, we found no family tree, however distinguished, which did not have hanging from its branches the mentally sick, the defective, the alcoholic, the failure, the ne’er-do-well, and the social misfit.
What often is mistaken for feeble-minded ness is low cultural level. Groups sequestered in the hills of Kentucky or in lonely sections of New Hampshire and Vermont breed low-grade people generation after generation, just as peasant communities throughout Europe are illiterate, superstitious, and low-grade. The cultural milieu is low-grade, and the social factors are so important that it is impossible to call this germ-plasm hereditary rather than cultural. This dependence of mental development on cultural level has been well shown by the study that Freeman and his associates made of foster children moved from a low-grade environment to a better one. They found, for instance, that children who were tested before they were placed in foster homes, and then retested several years later, showed great improvement in their intelligence ratings, and also that the children in the better foster homes gained considerably more than those in the poorer ones.
When we regard the facts about feeble-mindedness, we find that there are various types that are radically different biologically. Mongolian idiocy is certainly not related to feeble-mindedness in general and arises in perfectly normal families. Cretinism is definitely a thyroid disturbance and may have some hereditary basis, but more likely is due either to spontaneous defect in the development of the thyroid gland or to the amount of iodine present in the drinking water and plants of the locality, as in Switzerland. A third type of feeble-mindedness is due to injury at birth, when the brain is damaged because the head of the child is too large for the mother’s pelvis.
It may, nevertheless, be stated that most feeble-mindedness is related in some way to heredity. The concordance of identical twins is almost 100 per cent. This heredity, however, need not be a direct one. A great deal of feeble-mindedness arises by some unknown hereditary combination in what appear to be normal families, and, in fact, a study done by Popenoe, himself one of the leading eugenists, shows that the majority of the feeble-minded in California had about the same kind of ancestry as the normal population, so that there vas no real evidence of huge groups breeding feeble-mindedness generation after generation.
This brings us at once to a collateral question of great importance. The statement is continually made that the feeble-minded breed much faster than do the normal members of the population, and the pointers-with-alarm cite this as evidence of a deterioration of the race that is going on apace and will end in feeble-minded human species. The investigations carried out by the British Royal Commission appointed for this purpose completely contradict this statement. The report says: “Except for a relatively small number of isolated instances, we find that there is no evidence of excessive fertility, and indeed it would be easy to set off against these exceptional cases a much larger number of cases in which the fertility rate was low. The supposed abnormal fertility of defectives is, in our view, largely mythical.”
The birth rate of the feeble-minded is no greater than that of the population as a whole, and their mortality is much higher, as is the mortality of all mentally sick people. Moreover, the marriage rate of the defective individuals is much less than that of the normal population. This would naturally be the case. They are not so attractive. They find a greater difficulty in earning a living. They have less sexual drive or, at any rate, a less normal sexual drive. They tend to be isolated early by the very nature of their illness, and every social factor operates against their reproduction.
Epilepsy has been described from the earliest days of medicine and has been glorified as the sacred disease. Epilepsy is found throughout the whole mammalian kingdom, appears spontaneously in cats, dogs, and guinea pigs as well as man, and can be experimentally produced in practically all animals by the use of drugs.
Nevertheless, the disease remained of almost unknown pathology and cause until a fertile era of experimentation culminated in the marvelous discovery of the brain waves. It was learned that throughout life the brain its an electric organ gives off waves that can be captured, enormously magnified, and recorded on smoked paper. Then, came the application of this discovery to the study of epilepsy. A group of notable Boston investigators demonstrated that in epilepsy disordered brain waves of specific types almost constantly appeared, even when the individual was ostensibly well. Drs. William Gordon Lennox, E. L. Gibbs, and F. A. Gibbs found that the brain waves of the parents, brothers, and sisters of the epileptic patient, even though these relatives themselves showed no evidence of epilepsy, had waves of the epileptic type in a very much larger proportion than those of the normal population.
This demonstrates that there is a constitutional predisposition to epilepsy in the family group, yet it is too early to say that it proves a true heredity. The fact that epilepsy can be reproduced experimentally and that definite environmental agents, such as illness and brain injury, create the disease in otherwise healthy individuals and in animals leads to the conclusion that, in addition to the hereditary factor, some unknown environmental agent cooperates to bring about the actual epileptic attacks.
The epileptic is not necessarily an inferior person. Epilepsy is a very widespread disorder occurring sporadically among all people, regardless of their social status or intelligence. When the attacks are very frequent, mental deterioration takes place as a secondary factor: that is, it is caused by the effects of attacks and the drugs used to control them. Fortunately, there has been great improvement in the treatment of this condition. Drugs now used exercise a very beneficial effect without so much narcosis as was necessary in the past. Further work promises exceedingly well for the future, and undoubtedly the time will come when the epileptic attack will be a rarity.
I do not believe that criminality is a mental disease. Crime is socially defined, and each society has its own criteria of what constitutes crime. Thus, it was a crime to be a Jew in Nazi Germany. The leading crime of the Middle Ages was heresy; in times of war it is a crime not to believe what the majority believes about the enemy.
Statistics showing that members of the same families become criminals do not take into account the fact that members of the same families usually have the same social background as well. There are subnormal characters who come in contact with the law, who become declared criminals. There are just as many , perhaps more, abnormal characters who are zealous defenders of the law and who uphold it with great firmness. I think I have seen as many psychopathic judges, lawyers, police officers, and psychiatrists as psychopathic criminals.
5
WHEN we consider sterilization for schizophrenia, the manic-depressive psychoses, feeble-mindedness, and epilepsy, the four conditions for which it is most widely urged, we find that our present knowledge does not warrant compulsory sterilization of all those who suffer from these conditions. Nevertheless, it seems to me that there is sufficient evidence on hand to legitimatize the sterilization of carefully selected eases, in each case taking into account the assets as well as the liabilities that the individual could transmit to his descendants.
Some years ago I was the chairman of a committee that surveyed this question. We favored sterilization for selected cases and believed that it should be voluntary—that is, performed with the consent of the patient or of those responsible for him. Seeing no reason for group or class discrimination, we decided that it should be applicable not only to patients in state institutions but also to those in private institutions and those at large in the community. We felt that the essential machinery for administering such a law should be one or several boards composed chiefly of persons who have had special training and experience in the problems involved and who could evaluate each case on its individual merits. Cases could be brought before such a board by superintendents of institutions, private physicians, parents or guardians, or by the patients themselves. This arrangement would promote elasticity in the application of the law, and permit the utilization of future advances in knowledge.
We recommended sterilization in the case of feeble-mindedness. Though we hesitated to stress any purely social necessity for sterilization, it is obvious that in the case of the feeble-minded there may be a social as well as a biological situation of importance. Since most of the feeble-minded can hardly care for themselves, a family of children may prove an overwhelming burden.
We believed that schizophrenia would need relatively little attention from the surgeon because most cases that are recognized in time to prevent procreation spend their days in hospitals anyway. Moreover, the sexual urge and the marriage and birth rate are low. Sterilization might well be recommended, however, for those patients living in the community, since desirable qualities of other kinds are only incidental to schizophrenia and not part of its make-up.
As for the manic-depressive psychoses, there are problems that would tax the judgment of the wisest board and that must be met with conservatism and caution. The manic-depressive temperament is frequently associated with the highest achievement and ability of which mankind can boast. In this disease particularly, the decision would have to take into account the total assets of the individual character as well as the liabilities incident to the psychosis.
As for epilepsy, we believed that if the individual’s epileptic attacks were infrequent and if the qualities of the personality were intact, there was no reason for recommending sterilization.
In the past, marriage has acted as a selective agency operating in a eugenic way. When there was little efficient treatment for schizophrenia, the malignant manic-depressive state, and severe epilepsy, the commitment rate and the patients’ obvious mental condition kept down their marriage and birth rates. But we are entering an era when the schizophrenic will be improved, the depressive states sharply curtailed without hospital stay, and the fits of the epileptic will be either greatly reduced or entirely prevented. We shall make them more marriageable and more socially efficient, therefore more likely to have offspring. Still, there is no danger that the race will go to the dogs, and we do not have to accept any measures born of panic or of dogma, unjustified by sure facts.
A long-term, carefully carried out research program is the first essential for understanding not only the heredity but the nature of the major inheritable mental conditions. When we shall really study human families carefully and systematically for at least a hundred years, so that we can view three generations in the clear light of well-established facts and records, then we shall have some knowledge of the relationship of heredity to eminence and genius, as well as to mental disease and social difficulty.
Even though we may believe that a condition is hereditary, we must not dismiss the environmental influences as nonrelevant. In our environment there may be evocative factors — social, traditional, cultural, as well as physical — that bring about the inheritance of schizophrenia, manic-depressive state, epilepsy, and possibly, although this is not likely, feeble-mindedness.
It is the duty of any reasonable society to know about the constitution of its members. No such effort has been made even in the most advanced commonwealths. A long-time survey of the potentialities of the members of our society is necessary for a proper, reasonable organization. Every time we go to war and examine the potential fighting members of the group, we are surprised at the amount of defect. No such surprise is warranted. The surprise is that there is not more defect. Man uses his intelligence less in the care of his own species than he does in the care of anything else he owns or governs.
It is a cardinal article of faith with me that it would be good eugenics, as well as good euthenics, to wipe out every slum, to secure for everyone access to sunshine and good food, cultural opportunities, and those things which stimulate the growth of intelligence; to eliminate the infectious diseases and especially those diseases such as syphilis and tuberculosis which may injure more than one generation. A large part of our population, even in the best of our commonwealths, live in circumstances in which we would expect deterioration in plants and animals. At any rate, we can say that while a limited eugenic program is warranted at this time, even more important would be a radical improvement in the environment of civilized man and an organized research into the nature of those mental conditions from which he suffers, so that we can work with understanding and intelligence.