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‘A disease that makes criminals’: encephalitis lethargica (EL) in children, mental deficiency, and the 1927 Mental Deficiency Act Violeta Ruiz* Centre for the History of Science, Technology and Medicine, University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom
Encephalitis lethargica (EL) was an epidemic that spread throughout Europe and North America during the 1920s. Although it could affect both children and adults alike, there were a strange series of chronic symptoms that exclusively affected its younger victims: behavioural disorders which could include criminal propensities. In Britain, which had passed the Mental Deficiency Act in 1913, the concept of mental deficiency was well understood when EL appeared. However, EL defied some of the basic precepts of mental deficiency to such an extent that amendments were made to the Mental Deficiency Act in 1927. I examine how clinicians approached the sequelae of EL in children during the 1920s, and how their work and the social problem that these children posed eventually led to changes in the legal definition of mental deficiency. EL serves as an example of how diseases are not only framed by the society they emerge in, but can also help to frame and change existing concepts within that same society. Introduction: ‘A disease that makes criminals’ ‘It is quite a common thing for children of tender years to be sent to mental institutions, but it is somewhat unusual for mental disorder of such a degree as to require certification to occur in a boy æt. 10 who had previously been of sound mind’.1 With this statement, Hugh D. Macphail, Medical Superintendent at Newcastle Mental Hospital, first introduced the case of a previously ‘perfectly normal’ child who, on the 29th of December 1920, was admitted to the hospital after developing sudden, radical changes in behaviour. The boy’s medical certificate declared that he was ‘irresponsible, subject to frequent and sudden periods of excitement’, becoming so unmanageable that he had tried to jump through a window, put his head in the fire and stab his mother with a knife. Two months after returning home, he developed an uncontrollable temper and became restless *Correspondence to: Institute of History, Centre for the Human and Social Sciences, Spanish National Research Council, c/ Albasanz, 24-26, 28037 Madrid, Spain. Tel.: +34 622 323563. Available online 13 February 2015 www.sciencedirect.com
and violent, once again taking ‘a knife to his mother, and threaten[ing] to cut his brother up.’ After a month at a workhouse, he then returned home only to attack his sister with a hatchet and find himself sent back to the workhouse on the 20th of December 1921, where he stayed until his lunacy certification. However, it was not the child’s abhorrent actions that had caught Macphail’s attention. For the clinician, the case stood out because the patient had previously been ‘regarded as perfectly normal in every way until he had an acute illness in the summer of 1920’. This acute illness was encephalitis lethargica (EL), popularly known as the sleepy sickness, a mysterious disease that appeared suddenly and spread endemically throughout North America and Europe between 1918 and 1929. During the 1920s, EL became a key area of focus in medical research and governmental policy. In England and Wales, EL was made compulsorily notifiable on the 1st of January 1919, and in 1924, the year of greatest national incidence, a total of 5,979 cases were registered in the British Isles, with case mortality at an estimated 26%. These figures placed Britain as the second most affected country in the world that year, topped only by Japan which recorded some 6949 cases.2,3 Although simultaneously identified as a new disease by different medical practitioners in several European countries – examples include Arthur Hall in the UK, Jean-Re´ne´ Cruchet in France and, most famously, Constantin von Economo in Austria – it was the latter’s term of ‘encephalitis lethargica’ that became formally adopted to refer to the mysterious complex of acute and chronic symptoms that formed the disease (Figure 1). Usually, EL would provoke respiratory disturbances, alterations of the motor system, obesity, Parkinson’s symptoms, and, especially in children and young adults, serious mental and behavioural disorders. In fact, the initial after-effects of EL in children were almost always mental rather than physical. At a time when Britain was already highly attuned to the social and political issues of mental deficiency, these children were readily classified as feeble-minded and moral degenerates.
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intellectual and institutional history, an occasion of and potential legitimation for public policy, an aspect of social role and individual – intrapsychic – identity, a sanction for cultural values, and a structuring element in doctor and patient interactions’.5 Even though the chronic sequelae of behavioural issues that seemed to exclusively affect children have been historically reviewed,6 the wider implications of these sequelae in society at large have not been analysed. Although historically the 1920s EL epidemic has been understood as a medical milestone and analysed in an attempt to identify the underlying pathogen that caused the disease,a an investigation of the identity of a disease cannot be limited to questions of its biological cause, but must also take into account the medical, social and political frameworks it emerged in – a true intertwining of factors that are not independent of each other. Thus far, and despite serving as a particularly illustrative example of Rosenberg’s approach to the history of disease, EL has not been subjected to such an analysis. In line with this well-established method, this article aims to demonstrate how British clinicians used existing ideas of mental deficiency and juvenile delinquency to understand the epidemic and how the epidemic itself – a disease that made criminals – posed a medical and political challenge that forced a change in the legal definition of mental deficiency. The article will offer a base from which to continue the historical study of the impact of the EL epidemic as a medical and social phenomenon.
Figure 1. Constantin Von Economo first published his work describing encephalitis lethargica in 1917. His detailed monograph on the topic, Die Encephalitis lethargica, ihre Nachkrankheiten und ihre Behandlung was published in 1929 and quickly translated into other languages. The English translation first appeared in 1931, when the epidemic was starting to wane. Wellcome Library, London.
These labels not only identified a medical condition in these children, but also recognised them as a problem for British society. Estimates from the late 1920s indicate that over 70% of children who contracted EL in Britain suffered psychological disturbances after recovering from the acute stages of the disease, with more than a third showing behavioural disorders and even criminal propensities.4 These cases not only made for sensational newspaper headlines, but also served to illustrate just how these children posed a social problem. ‘The Boy Who Has ‘‘Lost Control’’’, ‘A Disease that Makes Criminals’, ‘Children Who Grow Vicious’, ‘Stealing and Begging’, and ‘Girl’s Thefts from People Who Befriended Her’ are just some of the many reports that appeared in the mainstream national press between 1920 and 1927. Therefore, the EL epidemic not only posed the usual threats of a disease, but could also alter behaviour to such an extent that it affected the social order of the nation. In other words, the epidemic was not just a medical problem, but a social and political issue as well. The social historian of medicine Charles Rosenberg stated that ‘disease is at once a biological event, a generationspecific repertoire of verbal constructs reflecting medicine’s www.sciencedirect.com
Mental deficiency and Juvenile delinquency When EL began to spread endemically throughout Britain in the 1920s, the disease appeared in a society that was already well aware of mental deficiency. Interest in the concepts of intelligence and subnormalityb had flourished in Europe and North America at the turn of the twentieth century. In Britain, this provided fertile ground for the theory of eugenics, a term coined in 1884 by Francis Galton. Developed within the framework of social Darwinism, proponents of eugenics argued that social problems were a result of ‘bad genes’ and could, therefore, be solved by stopping mentally defective individuals from reproducing. Significantly, there grew a belief that these ‘subnormal’ individuals posed a serious threat to the economic, moral and social order, with particular attention paid to the classification of mental states as well as the measurement of intelligence with the newly-invented intelligence test. These ideas shaped the concept of mental deficiency and led to the establishment of multiple political bodies and organisations to address these issues, including the Idiots Act in 1886, the Royal Commission on the Care and Control of the Feeble Minded in 1904, and the Eugenics Education Society in 1907 and its journal, the Eugenics Review, published from 1909. As the historian Mark Jackson explained, these a For the impact that EL had on sleep research, see K. Kroker, 2007, The sleep of others and the transformations of sleep research, University of Toronto Press; Toronto, and L.C. Triarhou, 2006, The percipient observations of Constantin von Economo on encephalitis lethargica and sleep disruption and their lasting impact on contemporary sleep research, Brain research bulletin, 69(3), 244–258. For medical analyses of the epidemic, see J.A. Vilensky (Eds.), 2011, Encephalitis Lethargica: During and After the Epidemic, Oxford and New York: Oxford University Press.; and R.R. Dourmashkin, 1997, What caused the 1918–30 epidemic of encephalitis lethargica? Journal of the Royal Society of Medicine, 90(9), 515. b I use the terms ‘subnormality’ and ‘subnormal’ as they were used in the contemporary medical and political contexts of the period covered in this essay.
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organisations reflected the interest of ‘middle-class reformers to locate the source of urban degeneration and declining imperial strength’.c 7 Along with the work of degeneration theorists, like Galton and Henry Maudsley, these bodies contributed to the growing claims that science supported the hereditarian argument and the social policies derived from it to deal with mental and moral degeneration. As new categories for the mentally unsound appeared, so did new legislation to deal with them. In 1913, the British government introduced legislation designed to specifically target the problem of mental deficiency: the Mental Deficiency Act. The Act was viewed as a humanitarian measure, created for the benefit of both the defectives and the community, and was based on two key assumptions: that specialised care had to be provided for the welfare of mental defectives; and that responsibility of care lay with the state as the sufferers were too irresponsible to exert their own civil rights. The state therefore committed to providing suitable institutions for individuals who were ‘neglected, abandoned, or without visible means of support, or cruelly treated’, where they could be looked after or ‘trained’ to become independent (Figure 2). The Act identified four types of mentally defective individuals: idiots, imbeciles, feeble-minded persons, and moral imbeciles. Although each subcategory identified a different series of problems, they were all defined in hereditary terms, as illustrated by the condition that all the categories had to share: ‘from birth or an early age’.8 At that point, the establishment of the Mental Deficiency Act met with little criticism from either the medical or the wider community, as the two assumptions on which it was based were strongly representative of social and cultural attitudes in early twentieth-century Britain to subnormal individuals.d Mental deficiency was not the only perceived threat to the wellbeing of British society. The identification of adolescence during the early years of the twentieth century as a distinct period of growth in an individual’s life and the difficult time it supposed for the nation’s youth rendered juvenile crime a serious cause for concern.e In 1908 the Children and Young Persons Act was passed, which set up juvenile courts in order to separate children and adolescents from adults in the penal system. In 1910, the number of children under the age of 16 that appeared in front of c The classification of mental deficiency is a prominent topic in the history of psychology and there is an extensive amount of literature on the subject. See for example M. Thomson, 1998, The problem of mental deficiency: eugenics, democracy, and social policy in Britain c. 1870–1959, Oxford University Press; M. Jackson, 2000, The borderland of imbecility: medicine, society and the fabrication of the feeble mind in late Victorian and Edwardian England, Manchester University Press; M. Thomson, 2006, Psychological subjects: identity, culture, and health in twentieth-century Britain, Oxford University Press; A. Digby, & D. Wright (Eds.), 2013, From idiocy to mental deficiency: historical perspectives on people with learning disabilities;Routledge. d For the opposition the Act faced from a political angle, see M. Thomson, 1998, The problem of mental deficiency: eugenics, democracy, and social policy in Britain c. 1870–1959, Oxford University Press. e For more on juvenile delinquency in Britain during this period, see A. Digby & D. Wright (Eds.), 2013, From idiocy to mental deficiency: historical perspectives on people with learning disabilities, London and New York; Routledge, particularly Chapter 9, P. Cox, ‘Girls, Deficiency and Delinquency’ and Chapter 10, M. Thomson, ‘Family, community, and state: The micro-politics of mental deficiency’; B. Evans, S. Rahman, & E. Jones, 2008, ‘Managing the Unmanageable: Interwar child psychiatry at the Maudsely Hospital, London’, History of Psychiatry, 19: 454–475; and V. Bailey, 1987, Delinquency and Citizenship: Reclaiming the Young Offender, 1914–1948. Oxford; Clarendon Press.
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Figure 2. From Tredgold, A.F. (1929), Mental Deficiency (Aementia) (London: Bailler, Tinder and Cox). The image shows a group of mentally defective girl guides at the Royal Eastern Counties Institution. The Institution was set up in 1850 as an asylum hospital for idiot children. By 1918, the centre could accommodate up to 630 mentally deficient girls. These types of institutions were common around Great Britain as a place where mental defectives could be cared for and taught new skills. Wellcome Library, London.
these courts in England and Wales neared 34,000, with numbers rising closer to 50,000 during the First World War. The start of interwar period saw an unusually high number of incidences of juvenile delinquency, which was initially put down to the struggles of adolescence and the idea that children had lacked role models and guidance at a key stage in their childhood, as fathers left to fight in the war and mothers were forced to leave their homes in search of jobs. Unemployment, poor living conditions and lack of proper upbringing exacerbated the issue, as children took to the streets in order to find excitement and entertainment. As Charles Russell, Chief Inspector of the Departmental Committee on Reformatory and Industrial Schools, bemoaned in his 1917 book The Problem of Juvenile Crime, at the heart of the issue lay ‘the national disgrace of the slum with its overcrowding and all the concomitant conditions we have allowed to exist like a cancer at the heart of the community’ (p. 5).9 However, over the course of the interwar years, understandings of juvenile delinquency shifted. As developmental psychology gained momentum in Britain, the relationship that a child had with their friends and family became more important in determining their delinquent behaviour (or lack thereof). This view was largely shaped through the work of Britain’s foremost expert on child delinquency at the time, Cyril Burt, Psychologist to the Education Department of the London County Council. Burt published his most influential study in 1926, titled The Young Delinquent. The three-volume series used case studies, clinical insights and detailed statistics to evaluate existing theories of child delinquency and offer important suggestions on how to deal with the problem and treat the juvenile delinquents, including the setting up of specialised institutions where discipline and medical treatments were combined to instil the youths with socially acceptable behaviour. Therefore, at the peak of the EL epidemic, understandings of mental deficiency and juvenile delinquency had flourished and were well established concepts that proved key in shaping how clinicians dealt with the cases of EL in children.
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‘The living picture of moral degeneracy’ The mental sequelae of EL that specifically affected sufferers’ behaviour consisted of two conditions: excitable insomnia – also known as nocturnal restlessness or nocturnal excitement – and behavioural disturbances. Excitable insomnia rendered children extremely restless at night and unable to fall asleep until the early hours of the morning. The initial appearance of excitable insomnia was usually ten weeks from the onset of acute EL, although it could appear as early as three weeks.10 A typical case would start with the child being unable to find a comfortable position, tossing and turning in bed until they resigned themselves to wakefulness. At this point, they would devise any number of means for entertainment: whistling, talking to themselves, singing, running about the room, climbing over furniture, spitting on the floor, soiling the bed, and even smearing their faeces over nearby objects, until reaching a state of acute mania around midnight.11 By the early hours of the morning, having reached the point of exhaustion, they would eventually fall soundly asleep, impervious to attempts to wake them. Usually, this restlessness led to the re-hospitalisation of the children, and those who exhibited this type of sequelae normally fell under the ‘feeble-minded’ category of mental deficiency. Far worse than the behaviours caused by excitable insomnia, however, was the sudden, dramatic ‘change in disposition’ of normal children who had previously been well-adjusted to their school and home life, provoking delinquent and even psychopathic behaviour which turned them into moral imbeciles.11 According to reports, these children would fight with classmates and family, leave home and school to wander the streets with strangers, steal, beg, display inappropriate sexual behaviours and in certain extreme cases, even become homicidal or suicidal, all whilst retaining a relatively high level of intelligence, wit and memory (Figure 3).11–13 Therefore, although it was straight-forward to label them as moral imbeciles, the fact that the majority of patients had no previous history of mental illness and their intellect seemed to remain intact made EL particularly remarkable in the eyes of clinicians, and particularly troublesome in the eyes of the law. In an attempt to explain these radical changes in behaviour, doctors turned to the brain. During the second half of the nineteenth-century, medical approaches to psychiatric disorders in Europe were framed by neurobiological understandings of the brain that linked organic lesions to behavioural disorders. Although the optimism surrounding neurobiological explanations had started to fade by the turn of the century, post-war studies of war neuroses and shell-shock had, nevertheless, largely concentrated on the search for an organic brain lesion to explain behavioural changes.f Similarly, medical theories developed to explain the change of behaviour produced by EL were highly influenced by a biological approach to mental disf The topic of shell-shock and the state of interwar psychiatry in Britain has been extensively explored. For an introduction into Shell-shock, see for example T. Loughran, 2009, Shell-shock and psychological medicine in First World War Britain, Social History of Medicine, 22, 79–95; and P. Leese, 2002, Shell shock: Traumatic neurosis and the British soldiers of the First World War, Palgrave. For an introduction into British psychiatry during the interwar years, see W.F. Bynum, R. Porter & M. Shepherd, Eds.), 2004, The anatomy of madness: Essays in the history of psychiatry (Vol. 3), Taylor & Francis.
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Figure 3. After suriviving an acute episode of EL, which left him with a fixed left eye, this boy suffered a permanent change in character. ‘Plate IX. Angelic-looking boy with encephalitis lethargica showing a masked face’. From Hall (1924), Epidemic encephalitis (Encephalits Lethargica) (Bristol: John Wright & Sons). Copyright of the University of Manchester.
orders. This was supported further by the discovery of damage to the brain’s midsection in post-mortem examinations of EL victims and animals inoculated with infected brain tissue.14 According to Hall, evidence had shown that EL damaged ‘the upper and upper-middle nerve centres in their primitive and underdeveloped state’, and, once damaged, these areas – believed to be important for controlling impulses – remained in an impaired state. This impairment rendered victims subnormal which consequently turned them into a social burden, becoming part of the degeneration and mental deficiency issue that was so prominent at the time.15 Following on from this, G.A. Auden, School Medical Officer in Birmingham, argued that the children’s intellectual impairment arose as ‘an inhibition of volition and a failure of the exercise of self-criticism’, suggesting that the drop in attention also bore a correlation to the changes in intelligence and intellect. Auden drew on the work of Henry Head and William H. Rivers, renowned British clinicians and alienists in the 1920s, who had concluded that there were two distinct stages in the evolution of the nervous system. These were the ‘primitive protopathic stage’ involving desires and impulses that developed during the early years of infancy, and the ‘later-developed epicritic stage’ which allowed the control of these impulses according to social norms as the person grew older and developed throughout childhood and adolescence. If the development of these stages was impaired, impulse control would not develop and the individual would behave in a way that was socially unacceptable, becoming a social and economic burden. The extent to which an individual was intellectually and socially sound depended on the stage of development that was impaired. Burt’s theory of juvenile delinquency also explained child crime in these terms. For the psychologist, ‘the chief concomitants of the prime physiological change may be broadly summed up under
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two heads: there are, first, a gradual retardation and an ultimate arrest in the growth of inborn intelligence; there is, secondly, a temporary increase of temperamental instability, arising from or leading to a corresponding reinforcement of all the primary instincts and emotions’ (p. 223).15,16 Although historians have warned about establishing too tight a link between delinquency and mental deficiency, it is evident that there was a definite overlap between the two in the case of EL. For both Auden and Burt, the gravity of the EL episode and the age at which it struck the victim dictated the severity of the impairment. In a particularly grave case of EL there was no hope of recovery or normal growth. Children up to the age of five would develop into cases of idiocy, whereas older children showed less evidence of mental deterioration because they had already begun to develop higher faculties by the time the disease struck. Instead, it was believed that many of the behavioural changes demonstrated by the EL delinquents were a regression to the period of childhood before the epicritic stage had fully developed – a form of ‘slavery of the children to primitive and instinctive tendencies.’ As a result of this ‘‘slavery to impulses’’, children developed the symptoms of restless and destructive behaviour. These biological explanations therefore served a dual purpose; not only did they account for how and why EL could affect their behaviour, but they also made a tight connection between disease, delinquency and mental deficiency.8,15,16 Due to the severity of the sequelae, finding a remedy was an urgent task. But despite the theories that were developed to explain the sudden change in personality, intelligence and moral and social conduct, treatment for these changes was virtually impossible to find. Indeed, the sheer range of suggestions is a strong indicator of the lack of any kind of successful treatment. Physicians agreed that, due to the organic nature of the illness, psychological treatments aimed at understanding and changing behaviour were useless. Instead, treatments directly targeting the symptoms were used. Many of these included some variety of injection: soporifics or sedatives like bulbocapnine, chlorarl or bromide, and even milk were administered through intramuscular injections; sterile water or normal saline solutions, coupled with suggestion, through hypodermic injections. Others attempted to change the patients’ surroundings (some patients with night restlessness were able to sleep soundly for the first few nights of their stay at hospital and in some cases for the full length of their stay), induce sleep through hot packs and hot baths and even tried hypnotism. A change of environment – to the countryside or the seaside for those who could afford it, to specialised institutions for those who could not – coupled with discipline, exercise, training and supervision were also recommended (treatments that were also regularly applied to juvenile delinquents).11,16,17 Some of these treatments would work for periods of time, but they were never reliable nor did they provide a real solution to the problem. The children would often show ‘spontaneous regret for [their actions] and evidence of trying to control themselves, weeping or giving signs of the most genuine repentance and complaining that they ‘‘could not help it’’’ (pp. 3–4).4 Nevertheless, despite promises to improve their behaviour, www.sciencedirect.com
they would soon repeat their crimes and, as such, confirmed EL as an epidemic of real social concern. Furthermore, the medical community now considered them to be ‘the living picture of moral degeneracy’ and, by the mid1920s, the most pressing issue was no longer how to cure the disease, but rather who should take responsibility for these children.18 Loopholes in the Mental Deficiency Act, 1913 The annual rise in incidence of EL and the terrible effects it left in children imbued the disease with what Auden described as a ‘sinister importance’.15 By the time the EL epidemic began to wane in the late 1920s, there was still no consensus over a suitable treatment. For many parents, the domestic and social control of children with EL was virtually impossible. One nine-year-old girl would ‘cut up the sheets and curtains to make her doll’s clothes. . .[and] set the baby’s head alight with a candle’; another 14-year-old boy was repeatedly charged at the Children’s Court for stealing fruit, flowers and harmonicas from shops and gardens; and a father was reluctant to leave his nine-year-old son at home for fear that he would set the house on fire as the boy was ‘wildly excited and up to all sorts of tricks’, including locking his father out of the house for an entire night on his return home from work.12 Destructive behaviour and stealing were sources of constant distress for the parents of the children, who turned to medical practitioners in the hope that they could do something to help. However, although it was agreed that changing the patient’s environment appeared to have the most positive effect, particularly if they were sent to a specialised institution for the mentally defective that could train and readjust their behaviour, not all families could afford to send the children away. Furthermore, the Mental Deficiency Act of 1913 only made provisions for those who could not afford it if the children were abandoned, neglected or cruelly treated. In some cases, the Defective and Epileptic Children Act and the Poor Law could accommodate and make provisions for children with EL. However, these pieces of legislation were only designed to deal with specific problems and, as such, providing for a child with EL was only possible in exceptional circumstances and did not really offer suitable treatment. Consequently, appropriate care was unobtainable for most of these children, with many of them ending up in asylums or prison rather than specialised institutions.12 As Alan F. Tredgold, physician at Bethlem Hospital, observed, these children were clear cases of mental deficiency and were a social concern; thus, the Mental Deficiency Act should have been ultimately responsible for the provision of adequate care and treatment for them – especially as clinicians had failed to find a means of reversing behaviour.19 In September 1926, the Manchester Guardian reported that the North-western District of Poor Law Unions’ annual conference discussed the ‘difficulties of finding suitable accommodation’ for the cases of EL who could not be administered under the Poor Law. G.W. Coster of the West Derby Union in Liverpool ‘called attention to the inaction of local authorities in discharging the duties specially allocated to them under the Mental Deficiency Act’, which consequently passed the problem on to the Union’s Board
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of Guardians who simply did not have the resources to deal with the scope of the problem. According to the article, Coster also pointed out that ‘local authorities, in fact, were in a position to deal only with those cases they saw fit to consider, and that was a good example of the farce of permitting dual responsibility for the same cases’, concluding that ‘some form of sympathetic treatment would have to be found for mentally defective persons under the Act that could be administered by one body who had the facilities and knowledge necessary to do so’.20 Medical practitioners who encountered the disease were equally disturbed by the changes in behaviour, which challenged existing beliefs about inheritance and intelligence. In one report that discussed a series of forty cases, Grace H. Anderson, clinician at the Royal Hospital for Sick Children in Glasgow, wrote: ‘I am not aware of any other disease which, in a hitherto healthy child, is known to produce the peculiar and striking type of night-restlessness one has seen in this series of cases’.11 As such, although these children were clear examples of feeble-mindedness and moral imbecility as defined under the Mental Deficiency Act, clinicians found the cases particularly remarkable because most of the patients had no history of mental problems, nor had they developed the behaviour from birth or an early age, as the Act stipulated must be the case. Furthermore, although studies had been carried out into the IQ of these children, results were contradictory: whilst some asserted that there was indeed a clear drop in intelligence, others did not present such definite findings.21 A further complication was the Act’s definition of mental deficiency in hereditary terms that did not apply to EL victims. This definition, coupled with studies which had shown that intelligence did not always drop in children who suffered from EL, provoked a disagreement amongst clinicians and mental health officers over whether or not an individual could be considered mentally deficient. For instance, in January of 1926, the Manchester Guardian reported the case of an eleven-year-old boy who ‘lost control’ and committed multiple thefts in his neighbourhood after he was discharged from hospital following a bout of EL. His case caused a dispute in court after ‘the superintendent school attendance officer said the boy seemed to have lost self-control, but the school medical officer had certified that he was not mentally defective’.22 In another case, a 21-year-old man who had broken into a house was sentenced to nine months’ hard labour, despite the fact that he had suffered from EL at the age of 13. During his trial, the judge lamented that because he ‘could not be certified to be insane, and he was, in fact, above the average in intelligence’, the law could not provide the victim with suitable treatment as ‘there was not enough to justify the Court in trying him as an insane person’.23 These examples demonstrate the different types of problems that emerged from the loopholes in the Mental Deficiency Act – issues that were recognised and voiced by clinicians and political groups alike from the early 1920s. Clearly, the question of who had the authority to certify children was problematic, since differences in opinion over what constituted mental deficiency meant that a single diagnosis by a clinician could overrule the opinion of a school officer in court. In the meantime, the number of www.sciencedirect.com
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defective patients in county and borough mental hospitals continued to increase by an average of 2,529 every ear, without sufficient institutions to take care of these individuals.24 The problem extended to prisons, as many defectives were kept there because they could not be relocated to an adequate institution, contributing to the problem of persistent relocation of individuals within the educational, penal and medical welfare states.g By 1926, the cries for a reform of the 1913 Mental Deficiency Act were loud enough to bring about action, as the ever-growing impact of this strange disease continued to take its toll on a society that held a deeply-rooted collective fear of lunacy and its perceived heritability.h The 1927 Amendment of the Mental Deficiency Act On the 1st September 1926, an article published in The Times, titled ‘Sleepy Sickness: Plans for treatment and study’, quoted Neville Chamberlain’s (then Minister of Health) intentions to deal with the problem of the long term treatment and certification of EL victims. These intentions included the development of an experimental unit for the treatment of 100 cases in the Metropolitan Asylums Board at Winchmore Hill, and the introduction of a measure ‘into Parliament to amend the Mental Deficiency Act so as to facilitate the admission into mental deficiency institutions of cases suitable for treatment therein’.25 And indeed, amendments were finally made to the original act in 1927. The changes were circulated in February 1928 in a letter issued by the Board of Control to all Local Authorities, stating that, ‘the object of the act is to remove certain defects in the Mental Deficiency Act of 1913 (. . .) which experience has brought to light, and also to enlarge the powers, and to some extent the duties, of the Local Authority.’ The first of these changes eliminated the categorical definition of mental deficiency as appearing ‘from birth or from an early age’, a divisive phrase which had given rise to differences of opinion and unnecessarily complicated cases of EL. Additionally, mental defectiveness was redefined as ‘a condition of arrested or incomplete development of mind existing before the age of 18 years, whether arising from inherent causes or induced by disease or injury’. Attention was also drawn to the fact that a mental defect could exist in individuals with ‘considerable intellectual capacity’ and that criteria for institutionalisation should keep in mind whether the affected person was so mentally defective that they required constant care, supervision and control, and was unable to fend for themselves.26 Further amendments to the Act made it possible to send imprisoned mentally deficient individuals to specialist institutions where they could be ‘trained’ to be independent in the outside world by learning the skills to complete basic tasks. Moreover, the new Act went as far as to ‘impose on Local Authorities the duty of providing training or occupation for defectives, whether under supervision or g Lowman, Menzies and Palys use the term ‘transcarceration’ to refer to this problem. J. Lowman, R.J. Menzies and T.S. Palys, ‘Introduction’, in Transcarceration: Essays in the Sociology of Social Control., Cambridge, 1987, pp 9–11. h In 1927, the Board of Control estimated that just under 20 000 ‘defectives’ required institutional care but could not have it. Anon, ‘Mental Disorders and Deficiency in 1927: The Shortage of Accommodation’, Lancet, 1928, 212, 773.
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guardianship, or in certified institutions’, assigning the responsibility of treatment to the state. Consequently, children from poor families whose parents could not afford to pay for specialist institutions, or those who simply could not be cared for at home, were now supported by the law and Local Authorities and represented by their parents or guardians.27 Additionally, mentally defective individuals from all over the country could now be moved to certified institutions, even if it was not under the control of their Local Authority. It also enabled the Local Education Authority and the Mental Deficiency Authority to collaborate and provide an institution that allowed for certification as well as schooling of children with mental deficiency.26 These amendments were welcomed by the medical community, the government and laypeople alike. The new Mental Deficiency Act appeared to have eliminated the issues surrounding patients with EL, epilepsy and meningitis who suffered changes in behaviour as a result of organic lesions, but did not necessarily demonstrate changes in intelligence. Certifying EL victims under the Mental Deficiency Act rather than the Lunacy Act gave the youngest victims a better chance of being re-incorporated into society, as institutions for mentally deficient individuals offered training in all sorts of different trades with the eventual promise that they would be able to earn their own living, unlike lunatics who were locked away in asylums and had no hope for an independent life. For Brooks Crompton Wood – a British Conservative Party politician who sat in the House of Commons at the time – this was the most significant effect of the amended Act, as he explained to the House of Commons during the second reading of the Mental Deficiency Bill on the 18th of March 1927: ‘I went after [visiting the Manor Institution for mental deficients] to the West Park Mental Hospital, which is under the Lunacy Act, and again the most improved of its kind, and there everything was being done for those lunatics, but among them were a lot of cases of encephalitis lethargica, which could not be included under the Mental Deficiency Act, 1913. These young sufferers from encephalitis were among the elderly people, and they had no great provision made for their training. There were not enough of them to be classified. There were just a few of them dotted about among all these middle-aged and elderly people, and I am sure the House will agree that it is not good for young people to be put among middle-aged people in a mental hospital, who probably would teach all sorts of perverted moral teaching to them. I am certain that, if any hon. Member had been there and seen his child there, and had also seen what could be done across the road at the Mental Deficiency Institution, he would have said: ‘‘For goodness’ sake, remove my child from here and put it over there.’’ It is that power to put such children suffering from encephalitis into mental deficiency homes that this Bill is really directed at securing.’ (Emphasis added; HC Deb 18 March 1927 Vol 203, c2326) 27 Wood was not the only one to be happy with the amendments, nor were the youngest EL victims the only ones to benefit from the Act: as a Lancet article published a year www.sciencedirect.com
after the amendment of the Act triumphantly stated, ‘not only have various difficulties been removed which were inherent in the Act of 1913, but the new Act defines mental defect and, by the changes which it introduces into the definition of the four categories of defectives, enables provision to be made for post-encephalitic and other similar cases’.24 Local authorities were now compelled to provide centres for treatment and rehabilitation for individuals suffering from EL and other diseases, including epilepsy and meningitis, whilst doctors with official positions were encouraged to take instruction courses by the London University Extension Board in cooperation with the Central Association for Mental Welfare. However, for all the optimism the amendments helped to initially bring about, the 1927 Mental Deficiency Act did not provide a happy ending for the victims of EL. For them, the opportunity to recover from the mental effects of the illness and be welcomed back into society was never truly there. The degenerative effects of the disease meant that the young patients’ bodies slowly shut down with respiratory difficulties, oculogyric crises and motor dysfunction, eventually developing post-encephalitic Parkinsonism and requiring constant medical care. In these cases, not even the law could save them from their awful fate.i Conclusion This article has applied Rosenberg’s historical approach to epidemics to the previously under-examined case of the chronic sequelae EL had in children. By focussing on the specific sequelae it produced in children, this article has shown that understandings of and approaches to EL developed as a result of an intricate interplay between the preexisting medical, cultural, and governmental conditions that shaped early twentieth-century British society. EL’s high incidence rates meant that British society was changed as much as, if not more than, any other in terms of medical research. EL appeared in a society that had identified and defined mental deficiency and was a disease that affected victims, families and society alike. Additionally, existing theories of degeneracy and the then newly-developed intelligence test, coupled with understandings of juvenile delinquency, gave the behaviours demonstrated by the younger victims of the disease a suitable biological explanation. EL, therefore, developed its legitimacy in the hospital within existing frameworks that tied the mind and body together through biology, reflecting Rosenberg’s category of disease as constituting ‘a generation-specific repertoire of verbal constructs reflect[ing] medicine’s intellectual and institutional history’. Beyond this, EL defied the accepted definitions of mental deficiency as enshrined in the Mental Deficiency Act of 1913. The case of a 15-year-old boy with EL who committed suicide after strangling a 17-year-old girl for laughing at him perfectly exemplifies the full extremity of the behavioural disorders observed in children and young adults which meant that EL was not confined to personal tragedy, i In his book Awakenings, Oliver Sacks gives a chilling account of a group of PEP victims in the Beth Abraham Hospital in New York and the terrible effects that drug L-DOPA had on them. The book was turned into a film by the same name starring Robert de Niro and the late Robin Williams. O. Sacks, 1991, Awakenings, Pan Macmillan.
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but also a cause for real social concern.1 Aside from confounding previous understandings of mental deficiency, it also proved completely incurable and undermined the previously robust confidence of the medical establishment in its approach to mental deficiency. As a result of the EL experience, not only did medical concepts of what constituted mental deficiency change, but so did the legislation that dealt directly with the problem. As such, EL was also ‘an occasion of and potential legitimation for public policy, an aspect of social role and individual – intraphsychic – identity [and] a sanction for cultural values’. These particular amendments might never have been implemented had the EL epidemic not occurred. Similarly, medical and lay opinion which called for adequate legislation to provide the best possible care for childhood victims of EL may never have gained the necessary momentum had theories of intelligence and inheritance not gained such notoriety by the time the disease appeared. By analysing the impact that disease has in society, historians of medicine can use it as a tool to explore how social, political and economic aspects of contemporaneous societies intertwine with the experience of disease. This article has only touched upon one part of the EL epidemic experience, but in doing so it has recognised the significance of the epidemic and the historical potential it has for shedding further light on medical and social understandings of mental deficiency. Furthermore, it can now serve as a stepping stone into further analysis of the patient experience of EL, the institutionalisation of EL patients and the impact of the 1927 Mental Deficiency Act. The EL epidemic in Britain, with the criminal propensities and behavioural disorders it could produce in children and the social problem that these children then posed, serves to perfectly illustrate how disease is at once framed by society and frames society itself. Acknowledgements I am extremely grateful to Elizabeth Toon for supervising this project, Ian Burney for his very useful comments and suggestions on earlier drafts, and Daniel Harper for his help with editing. I would also like to thank the anonymous reviewers for their comments on an earlier version of this
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essay, John Waller from Endeavour for his help in the publication process, and Mathew Thomson for answering my queries.
References 1. Macphail HD. Mental disorder resulting from encephalitis lethargica. Br J Psychiatry. 1922;68:169–171. 2. Matheson Commission Report. Epidemic Encephalitis: Etiology, Epidemiology, Treatment. New York: Columbia University Press; 1929. 3. Hall AJ. Encephalitis lethargic: some clinical observations on thirty cases. Lancet. 1922;199:526–528. 4. Hill TR. The problem of juvenile behaviour disorders in chronic epidemic encephalitis. J Neurol Psychopathol. 1928;4:1–10. 5. Rosenberg CE. Introduction: framing disease; illness, society and history. In: Rosenberg CE, Golden J, eds. Framing Disease: Studies in Cultural History. New Brunswick: Rutgers University Press; 1997:xiii–xxvi. 6. Vilensky JA, Foley P, Gilman S. Children and encephalitis lethargica: a historical review. Pediatr Neurol. 2007;37(2):79–84. 7. Jackson M. The Borderland of Imbecility: Medicine, Society and the Fabrication of the Feeble Mind in Late. Victorian and Edwardian England: Manchester University Press; 2000. 8. Mental Deficiency Bill. A Bill [as amended by Standing Committee B] to make further and better provision with respect to feeble-minded and other mentally defective persons. 1912. HC330, cc. 1033–1041. 9. Russell C. The Problem of Juvenile Crime. London: Oxford University Press; 1917:5. 10. Stevenson MM. The life history of epidemic encephalitis in the child. Arch Dis Childh. 1928;3:57–80. 11. Anderson GH. The sequelae of epidemic encephalitis in childhood, with notes on the prognosis as regards complete recovery. Q J Med. 1923;16:173–192. 12. Auden GA. Behaviour changes supervening upon encephalitis in children. Lancet. 1922;200:901–904. 13. McIntosh J, Turnbull HM. The experimental transmission of encephalitis lethargica to a monkey. Br J Exp Pathol. 1920;1(2). 89–102.7. 14. Hall AJ. The mental sequelae of epidemic encephalitis in children. Br Med J. 1925;1:110–111. 15. Auden GA. Encephalitis lethargica: its psychological implications. Br J Psychiatry. 1925;71:647–658. 16. Burt C. The Subnormal School Child, Vol. 1. The Young Delinquent. London: University of London Press; 1926. 17. Hill TR. Juvenile behaviour disorders in epidemic encephalitis: their treatment by bulbocapnine. Lancet. 1929;213:968–971. 18. von Economo C. Encephalitis Lethargica, Its Sequelae and Treatment [Newman KO, Trans.; 1931]. London: Oxford University Press; 1928 19. Tredgold AF. Section of diseases of children: discussion on the prevention of mental deficiency. Br Med J. 1924;2(3321):316–322. 20. Anon.. The Manchester Guardian. 1926, September 27;10. 21. Dawson S, Conn JCM. Effects of encephalitis lethargica on the intelligence of children. Arch Dis Childh. 1926;1(6):357–368. 22. Anon.. The Manchester Guardian. 1926, January 23;15. 23. Anon.. The Times. 1927, April 29;11. 24. Anon.. Mental disorders and deficiency in 1927: the shortage of accommodation. Lancet. 1928;212(5485):773–774. 25. Anon.. The Times. 1926, September 1;14. 26. Willis FJ. Mental Deficiency Act (England and Wales), 1927. Br Med J. 1928;71:360–362. 27. Commons Sitting. Mental Deficiency Bill, 18 March 1927. 1927. HC 203 cc. 2319–2393.
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‘A disease that makes criminals’: encephalitis lethargica (EL) in children, mental deficiency, and the 1927 Mental Deficiency Act Violeta Ruiz* Centre for the History of Science, Technology and Medicine, University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom
Encephalitis lethargica (EL) was an epidemic that spread throughout Europe and North America during the 1920s. Although it could affect both children and adults alike, there were a strange series of chronic symptoms that exclusively affected its younger victims: behavioural disorders which could include criminal propensities. In Britain, which had passed the Mental Deficiency Act in 1913, the concept of mental deficiency was well understood when EL appeared. However, EL defied some of the basic precepts of mental deficiency to such an extent that amendments were made to the Mental Deficiency Act in 1927. I examine how clinicians approached the sequelae of EL in children during the 1920s, and how their work and the social problem that these children posed eventually led to changes in the legal definition of mental deficiency. EL serves as an example of how diseases are not only framed by the society they emerge in, but can also help to frame and change existing concepts within that same society. Introduction: ‘A disease that makes criminals’ ‘It is quite a common thing for children of tender years to be sent to mental institutions, but it is somewhat unusual for mental disorder of such a degree as to require certification to occur in a boy æt. 10 who had previously been of sound mind’.1 With this statement, Hugh D. Macphail, Medical Superintendent at Newcastle Mental Hospital, first introduced the case of a previously ‘perfectly normal’ child who, on the 29th of December 1920, was admitted to the hospital after developing sudden, radical changes in behaviour. The boy’s medical certificate declared that he was ‘irresponsible, subject to frequent and sudden periods of excitement’, becoming so unmanageable that he had tried to jump through a window, put his head in the fire and stab his mother with a knife. Two months after returning home, he developed an uncontrollable temper and became restless *Correspondence to: Institute of History, Centre for the Human and Social Sciences, Spanish National Research Council, c/ Albasanz, 24-26, 28037 Madrid, Spain. Tel.: +34 622 323563. Available online 13 February 2015 www.sciencedirect.com
and violent, once again taking ‘a knife to his mother, and threaten[ing] to cut his brother up.’ After a month at a workhouse, he then returned home only to attack his sister with a hatchet and find himself sent back to the workhouse on the 20th of December 1921, where he stayed until his lunacy certification. However, it was not the child’s abhorrent actions that had caught Macphail’s attention. For the clinician, the case stood out because the patient had previously been ‘regarded as perfectly normal in every way until he had an acute illness in the summer of 1920’. This acute illness was encephalitis lethargica (EL), popularly known as the sleepy sickness, a mysterious disease that appeared suddenly and spread endemically throughout North America and Europe between 1918 and 1929. During the 1920s, EL became a key area of focus in medical research and governmental policy. In England and Wales, EL was made compulsorily notifiable on the 1st of January 1919, and in 1924, the year of greatest national incidence, a total of 5,979 cases were registered in the British Isles, with case mortality at an estimated 26%. These figures placed Britain as the second most affected country in the world that year, topped only by Japan which recorded some 6949 cases.2,3 Although simultaneously identified as a new disease by different medical practitioners in several European countries – examples include Arthur Hall in the UK, Jean-Re´ne´ Cruchet in France and, most famously, Constantin von Economo in Austria – it was the latter’s term of ‘encephalitis lethargica’ that became formally adopted to refer to the mysterious complex of acute and chronic symptoms that formed the disease (Figure 1). Usually, EL would provoke respiratory disturbances, alterations of the motor system, obesity, Parkinson’s symptoms, and, especially in children and young adults, serious mental and behavioural disorders. In fact, the initial after-effects of EL in children were almost always mental rather than physical. At a time when Britain was already highly attuned to the social and political issues of mental deficiency, these children were readily classified as feeble-minded and moral degenerates.
0160-9327/ß 2015 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.endeavour.2015.01.001
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intellectual and institutional history, an occasion of and potential legitimation for public policy, an aspect of social role and individual – intrapsychic – identity, a sanction for cultural values, and a structuring element in doctor and patient interactions’.5 Even though the chronic sequelae of behavioural issues that seemed to exclusively affect children have been historically reviewed,6 the wider implications of these sequelae in society at large have not been analysed. Although historically the 1920s EL epidemic has been understood as a medical milestone and analysed in an attempt to identify the underlying pathogen that caused the disease,a an investigation of the identity of a disease cannot be limited to questions of its biological cause, but must also take into account the medical, social and political frameworks it emerged in – a true intertwining of factors that are not independent of each other. Thus far, and despite serving as a particularly illustrative example of Rosenberg’s approach to the history of disease, EL has not been subjected to such an analysis. In line with this well-established method, this article aims to demonstrate how British clinicians used existing ideas of mental deficiency and juvenile delinquency to understand the epidemic and how the epidemic itself – a disease that made criminals – posed a medical and political challenge that forced a change in the legal definition of mental deficiency. The article will offer a base from which to continue the historical study of the impact of the EL epidemic as a medical and social phenomenon.
Figure 1. Constantin Von Economo first published his work describing encephalitis lethargica in 1917. His detailed monograph on the topic, Die Encephalitis lethargica, ihre Nachkrankheiten und ihre Behandlung was published in 1929 and quickly translated into other languages. The English translation first appeared in 1931, when the epidemic was starting to wane. Wellcome Library, London.
These labels not only identified a medical condition in these children, but also recognised them as a problem for British society. Estimates from the late 1920s indicate that over 70% of children who contracted EL in Britain suffered psychological disturbances after recovering from the acute stages of the disease, with more than a third showing behavioural disorders and even criminal propensities.4 These cases not only made for sensational newspaper headlines, but also served to illustrate just how these children posed a social problem. ‘The Boy Who Has ‘‘Lost Control’’’, ‘A Disease that Makes Criminals’, ‘Children Who Grow Vicious’, ‘Stealing and Begging’, and ‘Girl’s Thefts from People Who Befriended Her’ are just some of the many reports that appeared in the mainstream national press between 1920 and 1927. Therefore, the EL epidemic not only posed the usual threats of a disease, but could also alter behaviour to such an extent that it affected the social order of the nation. In other words, the epidemic was not just a medical problem, but a social and political issue as well. The social historian of medicine Charles Rosenberg stated that ‘disease is at once a biological event, a generationspecific repertoire of verbal constructs reflecting medicine’s www.sciencedirect.com
Mental deficiency and Juvenile delinquency When EL began to spread endemically throughout Britain in the 1920s, the disease appeared in a society that was already well aware of mental deficiency. Interest in the concepts of intelligence and subnormalityb had flourished in Europe and North America at the turn of the twentieth century. In Britain, this provided fertile ground for the theory of eugenics, a term coined in 1884 by Francis Galton. Developed within the framework of social Darwinism, proponents of eugenics argued that social problems were a result of ‘bad genes’ and could, therefore, be solved by stopping mentally defective individuals from reproducing. Significantly, there grew a belief that these ‘subnormal’ individuals posed a serious threat to the economic, moral and social order, with particular attention paid to the classification of mental states as well as the measurement of intelligence with the newly-invented intelligence test. These ideas shaped the concept of mental deficiency and led to the establishment of multiple political bodies and organisations to address these issues, including the Idiots Act in 1886, the Royal Commission on the Care and Control of the Feeble Minded in 1904, and the Eugenics Education Society in 1907 and its journal, the Eugenics Review, published from 1909. As the historian Mark Jackson explained, these a For the impact that EL had on sleep research, see K. Kroker, 2007, The sleep of others and the transformations of sleep research, University of Toronto Press; Toronto, and L.C. Triarhou, 2006, The percipient observations of Constantin von Economo on encephalitis lethargica and sleep disruption and their lasting impact on contemporary sleep research, Brain research bulletin, 69(3), 244–258. For medical analyses of the epidemic, see J.A. Vilensky (Eds.), 2011, Encephalitis Lethargica: During and After the Epidemic, Oxford and New York: Oxford University Press.; and R.R. Dourmashkin, 1997, What caused the 1918–30 epidemic of encephalitis lethargica? Journal of the Royal Society of Medicine, 90(9), 515. b I use the terms ‘subnormality’ and ‘subnormal’ as they were used in the contemporary medical and political contexts of the period covered in this essay.
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organisations reflected the interest of ‘middle-class reformers to locate the source of urban degeneration and declining imperial strength’.c 7 Along with the work of degeneration theorists, like Galton and Henry Maudsley, these bodies contributed to the growing claims that science supported the hereditarian argument and the social policies derived from it to deal with mental and moral degeneration. As new categories for the mentally unsound appeared, so did new legislation to deal with them. In 1913, the British government introduced legislation designed to specifically target the problem of mental deficiency: the Mental Deficiency Act. The Act was viewed as a humanitarian measure, created for the benefit of both the defectives and the community, and was based on two key assumptions: that specialised care had to be provided for the welfare of mental defectives; and that responsibility of care lay with the state as the sufferers were too irresponsible to exert their own civil rights. The state therefore committed to providing suitable institutions for individuals who were ‘neglected, abandoned, or without visible means of support, or cruelly treated’, where they could be looked after or ‘trained’ to become independent (Figure 2). The Act identified four types of mentally defective individuals: idiots, imbeciles, feeble-minded persons, and moral imbeciles. Although each subcategory identified a different series of problems, they were all defined in hereditary terms, as illustrated by the condition that all the categories had to share: ‘from birth or an early age’.8 At that point, the establishment of the Mental Deficiency Act met with little criticism from either the medical or the wider community, as the two assumptions on which it was based were strongly representative of social and cultural attitudes in early twentieth-century Britain to subnormal individuals.d Mental deficiency was not the only perceived threat to the wellbeing of British society. The identification of adolescence during the early years of the twentieth century as a distinct period of growth in an individual’s life and the difficult time it supposed for the nation’s youth rendered juvenile crime a serious cause for concern.e In 1908 the Children and Young Persons Act was passed, which set up juvenile courts in order to separate children and adolescents from adults in the penal system. In 1910, the number of children under the age of 16 that appeared in front of c The classification of mental deficiency is a prominent topic in the history of psychology and there is an extensive amount of literature on the subject. See for example M. Thomson, 1998, The problem of mental deficiency: eugenics, democracy, and social policy in Britain c. 1870–1959, Oxford University Press; M. Jackson, 2000, The borderland of imbecility: medicine, society and the fabrication of the feeble mind in late Victorian and Edwardian England, Manchester University Press; M. Thomson, 2006, Psychological subjects: identity, culture, and health in twentieth-century Britain, Oxford University Press; A. Digby, & D. Wright (Eds.), 2013, From idiocy to mental deficiency: historical perspectives on people with learning disabilities;Routledge. d For the opposition the Act faced from a political angle, see M. Thomson, 1998, The problem of mental deficiency: eugenics, democracy, and social policy in Britain c. 1870–1959, Oxford University Press. e For more on juvenile delinquency in Britain during this period, see A. Digby & D. Wright (Eds.), 2013, From idiocy to mental deficiency: historical perspectives on people with learning disabilities, London and New York; Routledge, particularly Chapter 9, P. Cox, ‘Girls, Deficiency and Delinquency’ and Chapter 10, M. Thomson, ‘Family, community, and state: The micro-politics of mental deficiency’; B. Evans, S. Rahman, & E. Jones, 2008, ‘Managing the Unmanageable: Interwar child psychiatry at the Maudsely Hospital, London’, History of Psychiatry, 19: 454–475; and V. Bailey, 1987, Delinquency and Citizenship: Reclaiming the Young Offender, 1914–1948. Oxford; Clarendon Press.
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Figure 2. From Tredgold, A.F. (1929), Mental Deficiency (Aementia) (London: Bailler, Tinder and Cox). The image shows a group of mentally defective girl guides at the Royal Eastern Counties Institution. The Institution was set up in 1850 as an asylum hospital for idiot children. By 1918, the centre could accommodate up to 630 mentally deficient girls. These types of institutions were common around Great Britain as a place where mental defectives could be cared for and taught new skills. Wellcome Library, London.
these courts in England and Wales neared 34,000, with numbers rising closer to 50,000 during the First World War. The start of interwar period saw an unusually high number of incidences of juvenile delinquency, which was initially put down to the struggles of adolescence and the idea that children had lacked role models and guidance at a key stage in their childhood, as fathers left to fight in the war and mothers were forced to leave their homes in search of jobs. Unemployment, poor living conditions and lack of proper upbringing exacerbated the issue, as children took to the streets in order to find excitement and entertainment. As Charles Russell, Chief Inspector of the Departmental Committee on Reformatory and Industrial Schools, bemoaned in his 1917 book The Problem of Juvenile Crime, at the heart of the issue lay ‘the national disgrace of the slum with its overcrowding and all the concomitant conditions we have allowed to exist like a cancer at the heart of the community’ (p. 5).9 However, over the course of the interwar years, understandings of juvenile delinquency shifted. As developmental psychology gained momentum in Britain, the relationship that a child had with their friends and family became more important in determining their delinquent behaviour (or lack thereof). This view was largely shaped through the work of Britain’s foremost expert on child delinquency at the time, Cyril Burt, Psychologist to the Education Department of the London County Council. Burt published his most influential study in 1926, titled The Young Delinquent. The three-volume series used case studies, clinical insights and detailed statistics to evaluate existing theories of child delinquency and offer important suggestions on how to deal with the problem and treat the juvenile delinquents, including the setting up of specialised institutions where discipline and medical treatments were combined to instil the youths with socially acceptable behaviour. Therefore, at the peak of the EL epidemic, understandings of mental deficiency and juvenile delinquency had flourished and were well established concepts that proved key in shaping how clinicians dealt with the cases of EL in children.
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‘The living picture of moral degeneracy’ The mental sequelae of EL that specifically affected sufferers’ behaviour consisted of two conditions: excitable insomnia – also known as nocturnal restlessness or nocturnal excitement – and behavioural disturbances. Excitable insomnia rendered children extremely restless at night and unable to fall asleep until the early hours of the morning. The initial appearance of excitable insomnia was usually ten weeks from the onset of acute EL, although it could appear as early as three weeks.10 A typical case would start with the child being unable to find a comfortable position, tossing and turning in bed until they resigned themselves to wakefulness. At this point, they would devise any number of means for entertainment: whistling, talking to themselves, singing, running about the room, climbing over furniture, spitting on the floor, soiling the bed, and even smearing their faeces over nearby objects, until reaching a state of acute mania around midnight.11 By the early hours of the morning, having reached the point of exhaustion, they would eventually fall soundly asleep, impervious to attempts to wake them. Usually, this restlessness led to the re-hospitalisation of the children, and those who exhibited this type of sequelae normally fell under the ‘feeble-minded’ category of mental deficiency. Far worse than the behaviours caused by excitable insomnia, however, was the sudden, dramatic ‘change in disposition’ of normal children who had previously been well-adjusted to their school and home life, provoking delinquent and even psychopathic behaviour which turned them into moral imbeciles.11 According to reports, these children would fight with classmates and family, leave home and school to wander the streets with strangers, steal, beg, display inappropriate sexual behaviours and in certain extreme cases, even become homicidal or suicidal, all whilst retaining a relatively high level of intelligence, wit and memory (Figure 3).11–13 Therefore, although it was straight-forward to label them as moral imbeciles, the fact that the majority of patients had no previous history of mental illness and their intellect seemed to remain intact made EL particularly remarkable in the eyes of clinicians, and particularly troublesome in the eyes of the law. In an attempt to explain these radical changes in behaviour, doctors turned to the brain. During the second half of the nineteenth-century, medical approaches to psychiatric disorders in Europe were framed by neurobiological understandings of the brain that linked organic lesions to behavioural disorders. Although the optimism surrounding neurobiological explanations had started to fade by the turn of the century, post-war studies of war neuroses and shell-shock had, nevertheless, largely concentrated on the search for an organic brain lesion to explain behavioural changes.f Similarly, medical theories developed to explain the change of behaviour produced by EL were highly influenced by a biological approach to mental disf The topic of shell-shock and the state of interwar psychiatry in Britain has been extensively explored. For an introduction into Shell-shock, see for example T. Loughran, 2009, Shell-shock and psychological medicine in First World War Britain, Social History of Medicine, 22, 79–95; and P. Leese, 2002, Shell shock: Traumatic neurosis and the British soldiers of the First World War, Palgrave. For an introduction into British psychiatry during the interwar years, see W.F. Bynum, R. Porter & M. Shepherd, Eds.), 2004, The anatomy of madness: Essays in the history of psychiatry (Vol. 3), Taylor & Francis.
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Figure 3. After suriviving an acute episode of EL, which left him with a fixed left eye, this boy suffered a permanent change in character. ‘Plate IX. Angelic-looking boy with encephalitis lethargica showing a masked face’. From Hall (1924), Epidemic encephalitis (Encephalits Lethargica) (Bristol: John Wright & Sons). Copyright of the University of Manchester.
orders. This was supported further by the discovery of damage to the brain’s midsection in post-mortem examinations of EL victims and animals inoculated with infected brain tissue.14 According to Hall, evidence had shown that EL damaged ‘the upper and upper-middle nerve centres in their primitive and underdeveloped state’, and, once damaged, these areas – believed to be important for controlling impulses – remained in an impaired state. This impairment rendered victims subnormal which consequently turned them into a social burden, becoming part of the degeneration and mental deficiency issue that was so prominent at the time.15 Following on from this, G.A. Auden, School Medical Officer in Birmingham, argued that the children’s intellectual impairment arose as ‘an inhibition of volition and a failure of the exercise of self-criticism’, suggesting that the drop in attention also bore a correlation to the changes in intelligence and intellect. Auden drew on the work of Henry Head and William H. Rivers, renowned British clinicians and alienists in the 1920s, who had concluded that there were two distinct stages in the evolution of the nervous system. These were the ‘primitive protopathic stage’ involving desires and impulses that developed during the early years of infancy, and the ‘later-developed epicritic stage’ which allowed the control of these impulses according to social norms as the person grew older and developed throughout childhood and adolescence. If the development of these stages was impaired, impulse control would not develop and the individual would behave in a way that was socially unacceptable, becoming a social and economic burden. The extent to which an individual was intellectually and socially sound depended on the stage of development that was impaired. Burt’s theory of juvenile delinquency also explained child crime in these terms. For the psychologist, ‘the chief concomitants of the prime physiological change may be broadly summed up under
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two heads: there are, first, a gradual retardation and an ultimate arrest in the growth of inborn intelligence; there is, secondly, a temporary increase of temperamental instability, arising from or leading to a corresponding reinforcement of all the primary instincts and emotions’ (p. 223).15,16 Although historians have warned about establishing too tight a link between delinquency and mental deficiency, it is evident that there was a definite overlap between the two in the case of EL. For both Auden and Burt, the gravity of the EL episode and the age at which it struck the victim dictated the severity of the impairment. In a particularly grave case of EL there was no hope of recovery or normal growth. Children up to the age of five would develop into cases of idiocy, whereas older children showed less evidence of mental deterioration because they had already begun to develop higher faculties by the time the disease struck. Instead, it was believed that many of the behavioural changes demonstrated by the EL delinquents were a regression to the period of childhood before the epicritic stage had fully developed – a form of ‘slavery of the children to primitive and instinctive tendencies.’ As a result of this ‘‘slavery to impulses’’, children developed the symptoms of restless and destructive behaviour. These biological explanations therefore served a dual purpose; not only did they account for how and why EL could affect their behaviour, but they also made a tight connection between disease, delinquency and mental deficiency.8,15,16 Due to the severity of the sequelae, finding a remedy was an urgent task. But despite the theories that were developed to explain the sudden change in personality, intelligence and moral and social conduct, treatment for these changes was virtually impossible to find. Indeed, the sheer range of suggestions is a strong indicator of the lack of any kind of successful treatment. Physicians agreed that, due to the organic nature of the illness, psychological treatments aimed at understanding and changing behaviour were useless. Instead, treatments directly targeting the symptoms were used. Many of these included some variety of injection: soporifics or sedatives like bulbocapnine, chlorarl or bromide, and even milk were administered through intramuscular injections; sterile water or normal saline solutions, coupled with suggestion, through hypodermic injections. Others attempted to change the patients’ surroundings (some patients with night restlessness were able to sleep soundly for the first few nights of their stay at hospital and in some cases for the full length of their stay), induce sleep through hot packs and hot baths and even tried hypnotism. A change of environment – to the countryside or the seaside for those who could afford it, to specialised institutions for those who could not – coupled with discipline, exercise, training and supervision were also recommended (treatments that were also regularly applied to juvenile delinquents).11,16,17 Some of these treatments would work for periods of time, but they were never reliable nor did they provide a real solution to the problem. The children would often show ‘spontaneous regret for [their actions] and evidence of trying to control themselves, weeping or giving signs of the most genuine repentance and complaining that they ‘‘could not help it’’’ (pp. 3–4).4 Nevertheless, despite promises to improve their behaviour, www.sciencedirect.com
they would soon repeat their crimes and, as such, confirmed EL as an epidemic of real social concern. Furthermore, the medical community now considered them to be ‘the living picture of moral degeneracy’ and, by the mid1920s, the most pressing issue was no longer how to cure the disease, but rather who should take responsibility for these children.18 Loopholes in the Mental Deficiency Act, 1913 The annual rise in incidence of EL and the terrible effects it left in children imbued the disease with what Auden described as a ‘sinister importance’.15 By the time the EL epidemic began to wane in the late 1920s, there was still no consensus over a suitable treatment. For many parents, the domestic and social control of children with EL was virtually impossible. One nine-year-old girl would ‘cut up the sheets and curtains to make her doll’s clothes. . .[and] set the baby’s head alight with a candle’; another 14-year-old boy was repeatedly charged at the Children’s Court for stealing fruit, flowers and harmonicas from shops and gardens; and a father was reluctant to leave his nine-year-old son at home for fear that he would set the house on fire as the boy was ‘wildly excited and up to all sorts of tricks’, including locking his father out of the house for an entire night on his return home from work.12 Destructive behaviour and stealing were sources of constant distress for the parents of the children, who turned to medical practitioners in the hope that they could do something to help. However, although it was agreed that changing the patient’s environment appeared to have the most positive effect, particularly if they were sent to a specialised institution for the mentally defective that could train and readjust their behaviour, not all families could afford to send the children away. Furthermore, the Mental Deficiency Act of 1913 only made provisions for those who could not afford it if the children were abandoned, neglected or cruelly treated. In some cases, the Defective and Epileptic Children Act and the Poor Law could accommodate and make provisions for children with EL. However, these pieces of legislation were only designed to deal with specific problems and, as such, providing for a child with EL was only possible in exceptional circumstances and did not really offer suitable treatment. Consequently, appropriate care was unobtainable for most of these children, with many of them ending up in asylums or prison rather than specialised institutions.12 As Alan F. Tredgold, physician at Bethlem Hospital, observed, these children were clear cases of mental deficiency and were a social concern; thus, the Mental Deficiency Act should have been ultimately responsible for the provision of adequate care and treatment for them – especially as clinicians had failed to find a means of reversing behaviour.19 In September 1926, the Manchester Guardian reported that the North-western District of Poor Law Unions’ annual conference discussed the ‘difficulties of finding suitable accommodation’ for the cases of EL who could not be administered under the Poor Law. G.W. Coster of the West Derby Union in Liverpool ‘called attention to the inaction of local authorities in discharging the duties specially allocated to them under the Mental Deficiency Act’, which consequently passed the problem on to the Union’s Board
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of Guardians who simply did not have the resources to deal with the scope of the problem. According to the article, Coster also pointed out that ‘local authorities, in fact, were in a position to deal only with those cases they saw fit to consider, and that was a good example of the farce of permitting dual responsibility for the same cases’, concluding that ‘some form of sympathetic treatment would have to be found for mentally defective persons under the Act that could be administered by one body who had the facilities and knowledge necessary to do so’.20 Medical practitioners who encountered the disease were equally disturbed by the changes in behaviour, which challenged existing beliefs about inheritance and intelligence. In one report that discussed a series of forty cases, Grace H. Anderson, clinician at the Royal Hospital for Sick Children in Glasgow, wrote: ‘I am not aware of any other disease which, in a hitherto healthy child, is known to produce the peculiar and striking type of night-restlessness one has seen in this series of cases’.11 As such, although these children were clear examples of feeble-mindedness and moral imbecility as defined under the Mental Deficiency Act, clinicians found the cases particularly remarkable because most of the patients had no history of mental problems, nor had they developed the behaviour from birth or an early age, as the Act stipulated must be the case. Furthermore, although studies had been carried out into the IQ of these children, results were contradictory: whilst some asserted that there was indeed a clear drop in intelligence, others did not present such definite findings.21 A further complication was the Act’s definition of mental deficiency in hereditary terms that did not apply to EL victims. This definition, coupled with studies which had shown that intelligence did not always drop in children who suffered from EL, provoked a disagreement amongst clinicians and mental health officers over whether or not an individual could be considered mentally deficient. For instance, in January of 1926, the Manchester Guardian reported the case of an eleven-year-old boy who ‘lost control’ and committed multiple thefts in his neighbourhood after he was discharged from hospital following a bout of EL. His case caused a dispute in court after ‘the superintendent school attendance officer said the boy seemed to have lost self-control, but the school medical officer had certified that he was not mentally defective’.22 In another case, a 21-year-old man who had broken into a house was sentenced to nine months’ hard labour, despite the fact that he had suffered from EL at the age of 13. During his trial, the judge lamented that because he ‘could not be certified to be insane, and he was, in fact, above the average in intelligence’, the law could not provide the victim with suitable treatment as ‘there was not enough to justify the Court in trying him as an insane person’.23 These examples demonstrate the different types of problems that emerged from the loopholes in the Mental Deficiency Act – issues that were recognised and voiced by clinicians and political groups alike from the early 1920s. Clearly, the question of who had the authority to certify children was problematic, since differences in opinion over what constituted mental deficiency meant that a single diagnosis by a clinician could overrule the opinion of a school officer in court. In the meantime, the number of www.sciencedirect.com
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defective patients in county and borough mental hospitals continued to increase by an average of 2,529 every ear, without sufficient institutions to take care of these individuals.24 The problem extended to prisons, as many defectives were kept there because they could not be relocated to an adequate institution, contributing to the problem of persistent relocation of individuals within the educational, penal and medical welfare states.g By 1926, the cries for a reform of the 1913 Mental Deficiency Act were loud enough to bring about action, as the ever-growing impact of this strange disease continued to take its toll on a society that held a deeply-rooted collective fear of lunacy and its perceived heritability.h The 1927 Amendment of the Mental Deficiency Act On the 1st September 1926, an article published in The Times, titled ‘Sleepy Sickness: Plans for treatment and study’, quoted Neville Chamberlain’s (then Minister of Health) intentions to deal with the problem of the long term treatment and certification of EL victims. These intentions included the development of an experimental unit for the treatment of 100 cases in the Metropolitan Asylums Board at Winchmore Hill, and the introduction of a measure ‘into Parliament to amend the Mental Deficiency Act so as to facilitate the admission into mental deficiency institutions of cases suitable for treatment therein’.25 And indeed, amendments were finally made to the original act in 1927. The changes were circulated in February 1928 in a letter issued by the Board of Control to all Local Authorities, stating that, ‘the object of the act is to remove certain defects in the Mental Deficiency Act of 1913 (. . .) which experience has brought to light, and also to enlarge the powers, and to some extent the duties, of the Local Authority.’ The first of these changes eliminated the categorical definition of mental deficiency as appearing ‘from birth or from an early age’, a divisive phrase which had given rise to differences of opinion and unnecessarily complicated cases of EL. Additionally, mental defectiveness was redefined as ‘a condition of arrested or incomplete development of mind existing before the age of 18 years, whether arising from inherent causes or induced by disease or injury’. Attention was also drawn to the fact that a mental defect could exist in individuals with ‘considerable intellectual capacity’ and that criteria for institutionalisation should keep in mind whether the affected person was so mentally defective that they required constant care, supervision and control, and was unable to fend for themselves.26 Further amendments to the Act made it possible to send imprisoned mentally deficient individuals to specialist institutions where they could be ‘trained’ to be independent in the outside world by learning the skills to complete basic tasks. Moreover, the new Act went as far as to ‘impose on Local Authorities the duty of providing training or occupation for defectives, whether under supervision or g Lowman, Menzies and Palys use the term ‘transcarceration’ to refer to this problem. J. Lowman, R.J. Menzies and T.S. Palys, ‘Introduction’, in Transcarceration: Essays in the Sociology of Social Control., Cambridge, 1987, pp 9–11. h In 1927, the Board of Control estimated that just under 20 000 ‘defectives’ required institutional care but could not have it. Anon, ‘Mental Disorders and Deficiency in 1927: The Shortage of Accommodation’, Lancet, 1928, 212, 773.
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guardianship, or in certified institutions’, assigning the responsibility of treatment to the state. Consequently, children from poor families whose parents could not afford to pay for specialist institutions, or those who simply could not be cared for at home, were now supported by the law and Local Authorities and represented by their parents or guardians.27 Additionally, mentally defective individuals from all over the country could now be moved to certified institutions, even if it was not under the control of their Local Authority. It also enabled the Local Education Authority and the Mental Deficiency Authority to collaborate and provide an institution that allowed for certification as well as schooling of children with mental deficiency.26 These amendments were welcomed by the medical community, the government and laypeople alike. The new Mental Deficiency Act appeared to have eliminated the issues surrounding patients with EL, epilepsy and meningitis who suffered changes in behaviour as a result of organic lesions, but did not necessarily demonstrate changes in intelligence. Certifying EL victims under the Mental Deficiency Act rather than the Lunacy Act gave the youngest victims a better chance of being re-incorporated into society, as institutions for mentally deficient individuals offered training in all sorts of different trades with the eventual promise that they would be able to earn their own living, unlike lunatics who were locked away in asylums and had no hope for an independent life. For Brooks Crompton Wood – a British Conservative Party politician who sat in the House of Commons at the time – this was the most significant effect of the amended Act, as he explained to the House of Commons during the second reading of the Mental Deficiency Bill on the 18th of March 1927: ‘I went after [visiting the Manor Institution for mental deficients] to the West Park Mental Hospital, which is under the Lunacy Act, and again the most improved of its kind, and there everything was being done for those lunatics, but among them were a lot of cases of encephalitis lethargica, which could not be included under the Mental Deficiency Act, 1913. These young sufferers from encephalitis were among the elderly people, and they had no great provision made for their training. There were not enough of them to be classified. There were just a few of them dotted about among all these middle-aged and elderly people, and I am sure the House will agree that it is not good for young people to be put among middle-aged people in a mental hospital, who probably would teach all sorts of perverted moral teaching to them. I am certain that, if any hon. Member had been there and seen his child there, and had also seen what could be done across the road at the Mental Deficiency Institution, he would have said: ‘‘For goodness’ sake, remove my child from here and put it over there.’’ It is that power to put such children suffering from encephalitis into mental deficiency homes that this Bill is really directed at securing.’ (Emphasis added; HC Deb 18 March 1927 Vol 203, c2326) 27 Wood was not the only one to be happy with the amendments, nor were the youngest EL victims the only ones to benefit from the Act: as a Lancet article published a year www.sciencedirect.com
after the amendment of the Act triumphantly stated, ‘not only have various difficulties been removed which were inherent in the Act of 1913, but the new Act defines mental defect and, by the changes which it introduces into the definition of the four categories of defectives, enables provision to be made for post-encephalitic and other similar cases’.24 Local authorities were now compelled to provide centres for treatment and rehabilitation for individuals suffering from EL and other diseases, including epilepsy and meningitis, whilst doctors with official positions were encouraged to take instruction courses by the London University Extension Board in cooperation with the Central Association for Mental Welfare. However, for all the optimism the amendments helped to initially bring about, the 1927 Mental Deficiency Act did not provide a happy ending for the victims of EL. For them, the opportunity to recover from the mental effects of the illness and be welcomed back into society was never truly there. The degenerative effects of the disease meant that the young patients’ bodies slowly shut down with respiratory difficulties, oculogyric crises and motor dysfunction, eventually developing post-encephalitic Parkinsonism and requiring constant medical care. In these cases, not even the law could save them from their awful fate.i Conclusion This article has applied Rosenberg’s historical approach to epidemics to the previously under-examined case of the chronic sequelae EL had in children. By focussing on the specific sequelae it produced in children, this article has shown that understandings of and approaches to EL developed as a result of an intricate interplay between the preexisting medical, cultural, and governmental conditions that shaped early twentieth-century British society. EL’s high incidence rates meant that British society was changed as much as, if not more than, any other in terms of medical research. EL appeared in a society that had identified and defined mental deficiency and was a disease that affected victims, families and society alike. Additionally, existing theories of degeneracy and the then newly-developed intelligence test, coupled with understandings of juvenile delinquency, gave the behaviours demonstrated by the younger victims of the disease a suitable biological explanation. EL, therefore, developed its legitimacy in the hospital within existing frameworks that tied the mind and body together through biology, reflecting Rosenberg’s category of disease as constituting ‘a generation-specific repertoire of verbal constructs reflect[ing] medicine’s intellectual and institutional history’. Beyond this, EL defied the accepted definitions of mental deficiency as enshrined in the Mental Deficiency Act of 1913. The case of a 15-year-old boy with EL who committed suicide after strangling a 17-year-old girl for laughing at him perfectly exemplifies the full extremity of the behavioural disorders observed in children and young adults which meant that EL was not confined to personal tragedy, i In his book Awakenings, Oliver Sacks gives a chilling account of a group of PEP victims in the Beth Abraham Hospital in New York and the terrible effects that drug L-DOPA had on them. The book was turned into a film by the same name starring Robert de Niro and the late Robin Williams. O. Sacks, 1991, Awakenings, Pan Macmillan.
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but also a cause for real social concern.1 Aside from confounding previous understandings of mental deficiency, it also proved completely incurable and undermined the previously robust confidence of the medical establishment in its approach to mental deficiency. As a result of the EL experience, not only did medical concepts of what constituted mental deficiency change, but so did the legislation that dealt directly with the problem. As such, EL was also ‘an occasion of and potential legitimation for public policy, an aspect of social role and individual – intraphsychic – identity [and] a sanction for cultural values’. These particular amendments might never have been implemented had the EL epidemic not occurred. Similarly, medical and lay opinion which called for adequate legislation to provide the best possible care for childhood victims of EL may never have gained the necessary momentum had theories of intelligence and inheritance not gained such notoriety by the time the disease appeared. By analysing the impact that disease has in society, historians of medicine can use it as a tool to explore how social, political and economic aspects of contemporaneous societies intertwine with the experience of disease. This article has only touched upon one part of the EL epidemic experience, but in doing so it has recognised the significance of the epidemic and the historical potential it has for shedding further light on medical and social understandings of mental deficiency. Furthermore, it can now serve as a stepping stone into further analysis of the patient experience of EL, the institutionalisation of EL patients and the impact of the 1927 Mental Deficiency Act. The EL epidemic in Britain, with the criminal propensities and behavioural disorders it could produce in children and the social problem that these children then posed, serves to perfectly illustrate how disease is at once framed by society and frames society itself. Acknowledgements I am extremely grateful to Elizabeth Toon for supervising this project, Ian Burney for his very useful comments and suggestions on earlier drafts, and Daniel Harper for his help with editing. I would also like to thank the anonymous reviewers for their comments on an earlier version of this
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essay, John Waller from Endeavour for his help in the publication process, and Mathew Thomson for answering my queries.
References 1. Macphail HD. Mental disorder resulting from encephalitis lethargica. Br J Psychiatry. 1922;68:169–171. 2. Matheson Commission Report. Epidemic Encephalitis: Etiology, Epidemiology, Treatment. New York: Columbia University Press; 1929. 3. Hall AJ. Encephalitis lethargic: some clinical observations on thirty cases. Lancet. 1922;199:526–528. 4. Hill TR. The problem of juvenile behaviour disorders in chronic epidemic encephalitis. J Neurol Psychopathol. 1928;4:1–10. 5. Rosenberg CE. Introduction: framing disease; illness, society and history. In: Rosenberg CE, Golden J, eds. Framing Disease: Studies in Cultural History. New Brunswick: Rutgers University Press; 1997:xiii–xxvi. 6. Vilensky JA, Foley P, Gilman S. Children and encephalitis lethargica: a historical review. Pediatr Neurol. 2007;37(2):79–84. 7. Jackson M. The Borderland of Imbecility: Medicine, Society and the Fabrication of the Feeble Mind in Late. Victorian and Edwardian England: Manchester University Press; 2000. 8. Mental Deficiency Bill. A Bill [as amended by Standing Committee B] to make further and better provision with respect to feeble-minded and other mentally defective persons. 1912. HC330, cc. 1033–1041. 9. Russell C. The Problem of Juvenile Crime. London: Oxford University Press; 1917:5. 10. Stevenson MM. The life history of epidemic encephalitis in the child. Arch Dis Childh. 1928;3:57–80. 11. Anderson GH. The sequelae of epidemic encephalitis in childhood, with notes on the prognosis as regards complete recovery. Q J Med. 1923;16:173–192. 12. Auden GA. Behaviour changes supervening upon encephalitis in children. Lancet. 1922;200:901–904. 13. McIntosh J, Turnbull HM. The experimental transmission of encephalitis lethargica to a monkey. Br J Exp Pathol. 1920;1(2). 89–102.7. 14. Hall AJ. The mental sequelae of epidemic encephalitis in children. Br Med J. 1925;1:110–111. 15. Auden GA. Encephalitis lethargica: its psychological implications. Br J Psychiatry. 1925;71:647–658. 16. Burt C. The Subnormal School Child, Vol. 1. The Young Delinquent. London: University of London Press; 1926. 17. Hill TR. Juvenile behaviour disorders in epidemic encephalitis: their treatment by bulbocapnine. Lancet. 1929;213:968–971. 18. von Economo C. Encephalitis Lethargica, Its Sequelae and Treatment [Newman KO, Trans.; 1931]. London: Oxford University Press; 1928 19. Tredgold AF. Section of diseases of children: discussion on the prevention of mental deficiency. Br Med J. 1924;2(3321):316–322. 20. Anon.. The Manchester Guardian. 1926, September 27;10. 21. Dawson S, Conn JCM. Effects of encephalitis lethargica on the intelligence of children. Arch Dis Childh. 1926;1(6):357–368. 22. Anon.. The Manchester Guardian. 1926, January 23;15. 23. Anon.. The Times. 1927, April 29;11. 24. Anon.. Mental disorders and deficiency in 1927: the shortage of accommodation. Lancet. 1928;212(5485):773–774. 25. Anon.. The Times. 1926, September 1;14. 26. Willis FJ. Mental Deficiency Act (England and Wales), 1927. Br Med J. 1928;71:360–362. 27. Commons Sitting. Mental Deficiency Bill, 18 March 1927. 1927. HC 203 cc. 2319–2393.
