A system of practical medicine. By American authors. Vol. 5

by Unknown

B. Non-Congenital, Acquired, or Accidental.—1, Traumatic; 2, post-febrile; 3, hydrocephalic; 4, hypertrophic, with large square-built heads; 5, eclampsic; 6, epileptic; 7, paralytic; 8, idiocy by deprivation: loss of two or more senses in infancy (e.g. sight and hearing); 9, emotional idiocy, with no bodily deformity: shrinking, scared expression; 10, toxic idiocy, with no bodily deformity: malnutrition.¹⁴

¹⁴ “The Physical Features of Idiocy,” Liverpool Medico-Chirurgical Journal, July, 1883.

From the creature of deformed limbs and ape-like movements, incapable of articulate speech, even in monosyllables, or systematized ideas, leading a purely vegetative life, unclean, and with the instincts of a wild beast, up to moderate mental or moral imbecility, there are endless varieties of defects and monstrosities in mind, character, morals, and instincts, differing according to the profoundness of the disorder of the brain (hydrocephalus, atrophy, sclerosis, inflammation of the brain substance or membranes, injury from compression, blows, falls, convulsions, etc.), the extent of the defect in the brain development, the amount of the degenerative hereditary taint, or, in the case of cretinism, the importance of the endemic as well as the congenital influences.

In some of the higher planes of imbecility a considerable degree of intellectual brightness, or even talent, is often observed, and every variety of mental and moral perversion or simple reckless brutality. Training often does a great deal to bring many of these unfortunate creatures within the bounds of good behavior, but their care oftener falls within the province of the medical superintendent in an asylum or the teacher than to the physician in general practice. They are easily led astray by others, and commit all sorts of motiveless crimes or with a trivial or disproportionate motive, and with blind disregard of consequences or inability to comprehend them. In the gallery, at Washington, of photographs of counterfeiters and of passers of counterfeit money, the faces of the latter show conclusively that they belong to the intellectually weak-minded or imbecile class. Their own amusement, gratification, or impulse is so far the basis of their conduct that only a minority are harmless if not more or less constantly watched. Fortunately, a great portion—unfortunately, not all—of the idiots are sterile, but many of the mentally and morally weak-minded, with striking congenital defects which no training can fully remedy, propagate their species indefinitely for the benefit of our prisons and asylums.

Intellectual idiocy and marked intellectual imbecility are so common as to constitute 1 in 650 of our population. Less noticeable intellectual imbecility is quite frequent in the large class of troublesome and perverse children and youth of both sexes, commonly called weak-minded.

Moral imbecility, which cannot be corrected by education, is less common.

Moral idiocy is rare. It consists in such an absence of the moral sense that it cannot be aroused. It is sometimes associated with sufficient intellectual powers to make deliberate action and premeditation quite possible. Such persons are monstrosities, who, for the safety of the community, must be kept shut up for life like wild beasts.

The fact should be remembered, from a medico-legal point of view, that the defective in mind are quite liable to short attacks of simple mania and mental depression and to epilepsy, both of the obvious type and of the obscure or masked form, so that their degrees of responsibility, or rather of irresponsibility, vary from time to time. As a rule, a good physical organization and a general condition denoting healthy circulation and nutrition mark the better brains, and constitute important elements in forming a prognosis in regard to the possibility of educating imbecile and feeble-minded children up to the point of reasonably good behavior and ability to at least partly take care of themselves. The simpler their lives and the more purely routine or imitative their work, the less their defect is noticed. Many can wheel a barrow as well as any one.

THE INSANE TEMPERAMENT (Insane Diathesis, Neuro-psychopathische Constitution) is an exaggeration of the nervous temperament. It is closely allied to insanity and the neuroses, and at the critical periods of life is very apt to develop into one of them. It is congenital or due to early interference with the normal development of the brain by injury or disease. It shows itself in childhood and infancy by irregular or disturbed sleep, irritability, apprehension, strange ideas, great sensitiveness to external impressions, high temperature, delirium, or convulsions from slight causes, disagreeable dreams and visions, romancing, intense feeling, periodic headache, muscular twitchings, capricious appetite, and great intolerance of stimulants and narcotics. At puberty developmental anomalies are often observed in girls, and not seldom perverted sexual instincts in both sexes. During adolescence there are often excessive shyness or bravado, always introspection and self-consciousness, and sometimes abeyance or absence of the sexual instinct, which, however, is frequently of extraordinary intensity. The imitative and imaginative faculties may be quick. The affections and emotions are strong. Vehement dislikes are formed, and intense personal attachments result in extraordinary friendships, which not seldom swing suddenly around to bitter enmity or indifference. The natural home associations and feelings easily become disturbed or perverted. The passions are unduly a force in the character, which is commonly said to lack will-power. The individual's higher brain-centres are inhibited, and he dashes about like a ship without a rudder, fairly well if the winds are fair and the seas calm, but dependent upon the elements for the character and time of the final wreck. Invention, poetry, music, artistic taste, philanthropy, intensity, and originality are sometimes of a high order among these persons, but desultory, half-finished work and shiftlessness are much more common. With many of them concentrated, sustained effort is impossible, and attempts to keep them to it result disastrously. Their common sense, perception of the relations of life, executive or business faculty, and judgment are seldom well developed. The memory is now and then phenomenal. In later life there is a ready reaction to external circumstances, even to the weather, by which the individual is usually a little exhilarated or somewhat depressed. All sorts of vaso-motor disturbances are common and create distressing symptoms. Such people are said to be on the border-line between sanity and insanity. They are apt to be self-conscious, egoistic, suspicious, and morbidly conscientious; they easily become victims of insomnia, neurasthenic, hypochondriacal, neurotic, hysterical, or insane, and they offend against the proprieties of life or commit crimes with less cause or provocation than other persons. At the same time that many of them are among the most gifted and attractive people in their community, the majority are otherwise, and possess an uncommon capacity of making fools of themselves, being a nuisance to their friends and of little use to the world. Many of them get fairly well through life if their lives are tolerably easy or especially well regulated; if not, even they seldom escape further disturbance during the period of growing old. Their mortality-rate, especially from pulmonary consumption, is high. The prognosis is usually stated as unfavorable, largely, perhaps, because proper treatment is seldom pursued. If such children could be placed in the hands of judicious and experienced physicians from earliest years, much better results would undoubtedly be got and the downward tendency might be stopped. In the critical physiological periods of life, and under the influence of mental worry with physical strain, there is danger of breaking down. At the senile dissolution some of them lose much of their lifelong peculiarities, and as the mind fails in force and activity become more like other people. After the climacteric there may be also great improvement.

TREATMENT should consist in the general principles of mental hygiene, especially in training the mind to self-control and to avoid introspection—in a word, in maintaining health and in having healthy occupation. The earlier in life it begins, the better. It is well for such persons, unless of uncommon gifts in some direction, as many are, to obtain quiet, routine positions in life, and to avoid its wearing responsibilities as much as possible. The question of marriage is a difficult one for the physician if he is called upon for advice. Of course the risk often can be estimated only approximately, even after knowing both parties, who will heed medical counsel implicitly if it happens to coincide with their own notions. The further propagation of the neuro-psychopathic constitution in the world involves much entirely uncompensated misery, as well as genius, enthusiasm, and originality, the compensation for which is estimated by society in one way as regards Burns, Byron, De Quincey, Carlyle, Goldsmith, John Howard, and Frederick the Great's father, and in another when considering the inmates of jails and almshouses and the destroyers of home peace. Maudsley thinks that one such poet as Shelley justifies the risks of marriage in the insane diathesis, and Savage considers the neuro-psychopathic constitution a useful element in society; while Clouston holds that the world would be better off to lose the few ill-balanced geniuses, the hundreds of impracticable, unwise talented men and women, and the thousands of people who cannot get on, shiftless, given to drink, idle, improvident, and unpractical, to get rid of the insane diathesis, especially if we shall find a middle course and learn to apply the laws of heredity so as to save the best and eliminate the unsound. It is to this class probably that Pinel refers in saying that what he calls moral insanity is largely a matter of bad education. It is undoubtedly true that judicious training in very many cases would limit, if not prevent, the further development of the morbid element and strengthen the healthy side, so as to prevent actual insanity.