Mental deficiency (amentia)

Front matter

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Preface

During the past few years the subject of mental deficiency has evoked a large amount of attention from many prominent persons interested in social and philanthropic questions. To members of the medical profession in particular it is one of much importance, on account of their responsible duties connected with its diagnosis, with the treatment and training of these patients, and their examination and certification as to fitness for special classes and schools, training-homes, and asylums. And there is no doubt that with new legislation, which cannot now long be delayed, these duties and responsibilities will be considerably increased.

For these reasons I venture to hope that the account which I have attempted to give in these pages regarding the incidence, causation, pathology, mental and physical characteristics, social relationship, diagnosis, prognosis, and treatment of persons suffering from mental deficiency, will be found to justify its publication.

To a great extent this account is based upon observations and researches which I have been making for close on ten years, but I have also made full use of, and frequent reference to, the writings of many other workers in this field. Valuable help, permission to examine cases and make use of notes and illustrations, has been generously accorded me from many quarters. In particular I would like to take this opportunity of gratefully acknowledging my indebtedness to the members of the Asylums Committee of the London County Council ; also to Dr. Francis Warner, London ; Dr. G. A. Sutherland, London ; Dr. John Thomson, Edinburgh ; Dr. F. W. Mott, F.R.S., Pathologist to viii Preface

the London County Asylums and Director of the Pathological Laboratory ; Dr. R. R. Alexander and Dr. P. BaiJy, Hanwell Asylum ; Dr. W. J. Seward, Colney Hatch Asylum ; Dr. J. M. Moody, Cane Hill Asylum ; Dr. Robert Jones, Clay bury Asylum ; Dr. T. W. McDowall, Morpeth Asylum ; Dr. F. R. P. Taylor and Dr. C. A. Marsh, formerly of Darenth Asylum ; Dr. C. Caldecott, Earlswood Training Institution ; and Dr. R. Langdon Down, Normansfield Training Institution.

The greater portion of the microscopical work was carried out in the Claybury Pathological Laboratory, during my two years' tenure of the London County Council Research Scholarship in Insanity and Neuropathology ; and to the unequalled advantages which this scholarship afforded for clinical and pathological research in these fields of medicine I desire to pay a grateful tribute.

Finally, I wish to express my indebtedness to the recently issued voluminous Reports of the Royal Commission on the Care and Control of the Feeble-Minded. Of the mass of information contained in these, regarding the number and condition of the mentally deficient population of this country, I have made full use. It is necessary, however, to add a word of explanation with regard to statistics. Under the term " mentally defective " the Commissioners include sane epileptics. Since, in my opinion, these should not rightly be classed as aments, I have considered it advisable to make independent calculations from the original returns — hence the slight discrepancy between the two sets of figures.

A. F. TREDGOLD.

6, Dapdune Crescent,

Guildford, Surrey,

September, 1908.

Table Of Contents

PAGES

PREFACE ------- vii, viii

I. INTRODUCTION ------ 1-3

Section II. Amentia due to Defective Cerebral Nutrition

1. Cretinism : Endemic, sporadic.

2. Amentia due to other nutritional defects.

3. Amentia due to isolation and sense deprivation.

XIV. IDIOTS SAVANTS ----- 270-280

""^^/Description, with illustrative examples. The mechanical Genius of Earlswood Asylum.

XV. THE AMENT AND SOCIETY— PAUPER AMENTS 281-292 Location of the mentally deficient. The number of aments supported at the public expense. Feeble-minded in receipt of parish relief. Idiots and imbeciles. Vagrants. Aments under inadequate care. Propagation by aments.

XVft MORAL DEFICIENCY AND CRIMINAL AMENTS 293-309 \ "^^-^Moral Deficiency :

Latent moral defect. Its relation to amentia and to ' criminality. Habitual criminals and aments.

Criminal Aments :

Number. Facile type. Impulsive type. Morally defective or habitual criminal type. Illustrative cases.

Criminal Responsibility of Aments :

Conditions of responsibility : Defective knowledge, defective control, delusions. Civil incapacity.

Table of Contents xiii

CHAPTER PAGES

XVII. INSANE AMENTS 310-323

Sane and insane aments. Predisposition to insanity in aments. Borderland of amentia and insanity. Relative importance of predisposing and exciting factors. Insanity in the mild aments. Mania. Melancholia. Stupor. Alternating insanity. Delusional insanity. Recurrences. Dementia. General paralysis. Epileptic insanity. Insanity in imbeciles and idiots. Illustrative cases.

XVIII. DIAGNOSIS AND PROGNOSIS - - - 324-331

Diagnosis :

In infancy. In childhood. In later years.

Prognosis :

Of the forms, varieties and degrees.

XIXyTREATMENT AND TRAINING - - - 332-3 5 6

y^medical and surgical treatment.

Education :

The general principles of education. Home training. School training. The senses, movement, intelligence, speech and scholastic. Industrial training. Moral training.

(xW. CONCLUSION 357-362

The necessity for training. Supervision and after-care. Prevention of propagation. Sterilization. Marriage. Eradication.

APPENDIX I. A TABLE OF NORMAL DEVELOPMENTAL

APPENDIX II. METHOD OF ESTIMATING THE TOTAL

NUMBER OF AMENTS IN ENGLAND AND WALES 366-369

APPENDIX III. THE LAW OF ENGLAND CONCERNING AMENTIA, with the Recommendations of the Royal Commission (1904) ----- 370-376

INDEX 377

LIST OF TABLES

TABLE

I. Showing the Total Number of Aments, and of Idiots, Imbeciles, and Feeble -Minded, per 1,000 Population, in Certain Districts of the United Kingdom II. Showing the Relative Incidence of Amentia in Certain Areas of the United Kingdom -

III. Approximate Estimation of the Total Number of Aments,

AND OF THE RESPECTIVE DEGREES, EXISTING IN ENGLAND

and Wales on January i, 1906 -

IV. Showing the Relative Incidence of the Degrees of

Amentia in Certain Districts of the United Kingdom

V. The Location of All Aments in Eleven Selected Areas

of England and Wales -

VI. Showing the Condition of 150 Aments with their

Brothers and Sisters -----

VII. Classification of Amentia -----

VIII. Anatomical and Physiological Anomalies associated

with Amentia - - - - - - 82

IX. Relative Mortality of Aments and Non-Aments - 92

X. Showing Age Periods of 1,000 Consecutive Deaths in

Earlswood Asylum - - - - 92

XL Showing the Percentage of Deaths to the Number of Patients in Residence at Earlswood Asylum over a Period of Seventeen Years - - - 93

XII. Showing the Cause of Death in 1,000 Consecutive

Deaths in Earlswood Asylum - - - - 94

XIII. Consonantal Defects in Amentia - - - 121

XIV. Showing the Percentage of Mentally Deficient Children to the Public Elementary School Population in Certain Districts of the United Kingdom - 126

XV. Showing the Relation of Epilepsy to Amentia - 197

XVI. Showing the Location of Feeble-Minded Persons in

Urban and Rural Areas respectively - - 286

XVII. The Number of Aments inadequately cared for - 287

Appendix I. A Table of Normal Developmental Data - 364 xv

LIST OF FAMILY HISTORY CHARTS

CHART PAGE

I. Showing Good Heredity contaminated by Slight Alcoholic Heredity and Town Life - - - - 41 II. Showing Good Heredity contaminated by Morbid Heredity -- - - - - -41

III. Showing Good Heredity contaminated by Insane He-

IV. Showing the Effect of Insane + Phthisical Heredity - 42 V. Showing the Effect of Alcoholic and Insane Inheritance + Phthisical Inheritance - - - 43

VI. Showing the Effect of Double Morbid Heredity - 43

VII. Showing the Effect of Double Morbid Heredity - 44

VIII. Showing the Effect of a Double Insane Inheritance

IX. Showing the Effect of Consanguinity with a Tendency

to Vascular Lesions of the Brain - - - 45

LIST OF ILLUSTRATIONS

PLATE FIGS. PAGE

I. 1-8. Types of Brain Cells occurring in Amentia

Frontispiece II. 9. Diagrammatic Sections of Frontal Cortex in

Amentia, Dementia, and the Normal Brain - 6$

10. Schema for taking Cranial Measurements - 85

III. 11-16. Mentally Defective School-Children - - 128

IV. 17-18. Primary Amentia, Feeble-Mindedness, Mentally

Stable Type (Males) - - - - 150

V. 19-20. Primary Amentia, Feeble-Mindedness, Mentally

Unstable Type (Females) - - - 154 VI. 21-22. Primary Amentia, Imbecility, Mentally Unstable Type (Males) - - - - 160 VII. 23-24. Primary Amentia, Imbecility (Females) - - 162 VIII. 25-26. Primary Amentia, Imbecility (Males) - - 164 IX. 27. Primary Amentia, Imbecility - - - 166 28. Primary Amentia, Idiocy with Sclerosis - 166 X. 29-30. Primary Amentia, Idiocy, Excitable Type - 168 XL 31-32. Primary Amentia, Microcephalic Variety - 176 XII. 33-34. Primary Amentia, Mongolian Variety - - 184

XIII. 35-36. Primary Amentia, Mongolian Variety, Children 186

XIV. 37-38. Primary Amentia, Mongolian Variety, Children 188 XV. 39. Secondary Amentia due to Epilepsy - - 200

40. Secondary Amentia due to Cerebral Lesion - 200 XVI. 41. Secondary Amentia with Paralysis and Convulsions due to Infantile Lesion - - 214 42. Secondary Amentia with Paraplegia due to

Vascular Lesion at Birth - - - 214 XVII. 43. Secondary Amentia with Epilepsy due to Encephalitis in Infancy - - - - 218

44. Secondary Amentia due to Encephalitis in

XVIII. 45. Secondary Amentia due to Sclerosis (so-called

" Hypertrophy of the Brain ") - - 232 xv ii xviii List of Illustrations

FLATE FIGS. TO FACE PAGE

XVIII. 46. Hydrocephalic and Microcephalic Imbeciles 232 XIX. 47. Secondary Amentia due to Hydrocephalus,

Child i£ Years Old - - - -236

Female Microcephalic Aged 4$ Months - 236

XX. 49-50. Secondary Amentia due to Syphilis - 246

XXI. 51-52. Secondary Amentia, Cretinism - - 254 XXII. 53. Secondary Amentia due to Congenital

Blindness - - 266 54. Secondary Amentia due to Deafness (the

Genius of Earls'syood Asylum) - - 266 XXIII. 55. Diagrammatic Life History of the Genius

of Earlswood Asylum - - - 276 XXI Y. 56. A Crayon Copy of the Picture " Bolton

^;. A Fully Rigged Man-of-War - 278 XX Y. 58. A Page of the Patient's Priyate Memorandum Book - 2S0 59. The " Great Eastern " Steamship - - 2S0 XXYI. 60. Criminal Ament - 296 61. Insane Ament ----- 296

XXVII. 62-63. Insane Aments - - - - -312

XXVIII. 64-65. Insane Aments - - - - - 314

XXIX. 66-67. Insane Aments - - - - - 316

Introduction

Literally, the term " mental deficiency " is just as applicable to a decay as to a non-development of the mental powers, to the dotage of old age or disease as to idiocy from birth; and it is still often used indiscriminately of either of these conditions. There is, however, a great difference between them. Mental defect occurring subsequently to mental development may be compared to a state of bankruptcy, and is more fittingly described as dementia (de, down, from ; mens, mind) ; whilst the person whose mind has never attained normal development may be looked upon as never having had a banking account, and this state is designated amentia (a, without ; mens, mind). In both of these, of course, there is literally mental deficiency ; but in view of the convenient and growing tendency to restrict this term to the latter class, I shall in this book use it in a specific sense as synonymous with " amentia."

Mental deficiency, or amentia, then, is that state in which the mind has failed to attain normal development. But the question at once arises, What is'" normal " mental development ? for there is probably no quality in which human beings differ so much as the degree of their mental capacity. All civilized nations are composed of men of very varying grades of intellect, ranging from the genius of a Bacon, Newton, Kepler, Copernicus, Shakespeare, Plato, or Galileo, to the rustic simplicity of an agricultural Hodge ; and all of these come within the compass of the

I normal Mind. Corresponding differences are present amongst barbarians and savages, and probably have always existed. What, then, is to be considered the standard, and how and where are we to draw a line which shall divide the normal from the abnormal, the least intellectually gifted members of normal mankind from the population which is mentally deficient ?

It is not easy to do this, but I think that our best definition of the " normal " mind must be a degree of intellectual capacity sufficient to enable its possessor to perform his duties as a member of society in that position of life to which he is born.

Fortunately for human progress, the mental capacity of many persons suffices for this, and more ; but where there is any falling short of this irreducible minimum, then I think we must say that the bounds of normal variation have been overstepped, and that a condition of incomplete development, or amentia, is present. We may thus define amentia as a state of mental defect from birth, or from an early age, due to incomplete cerebral development, in consequence of which the person affected is unable to perform his duties as a member of society in the position of life to which he is bom.

It is not, however, to be assumed that amentia is merely a subtraction in varying degree from the normal. Although the contrary might be thought, nevertheless the two conditions do not merge into one another, and between the lowest normal and the highest ament a great and impassable gulf is fixed. Whilst the former is heavy, stolid, and uniformly dull-witted, he has yet sufficient common sense to look after his interests and hold his own in that environment in which Nature has placed him. The mildest ament, on the other hand, may show no apparent dullness ; he may even be bright and vivacious, and in some of his abilities immeasurably superior to the clodhopper. But the other faculties of his mind are not present in like proportion. Instead of harmonious working there is discord, and in the possession of that essential to independent existence — common sense — he is lacking, and the want can never be supplied.

The difference has been well described by Sir J. Batty Tuke,* who says : " Where in theory the morbid and the healthy tvpes might be supposed to approach each other, we find in practice

* Article " Insanity," " Encyclopaedia Britannica."

Introduction 3

that no such debatable ground exists. The uniformity of dullness in the former stands in marked opposition to the irregularity of mental conformation in the latter."

The fact is that amentia is not merely a mental subtraction, but a distinct pathological condition which is produced by disease. The cerebral tissues concerned in Mind do not suffer from a uniform arrest of their development at a point which is inadequate for the needs of everyday life, but their whole growth and development is irregular. Even the function of the parts laid down is often imperfect and perverted, the total result being not only mental defect, but mental discord.

The two other chief forms of mental disease are dementia and insanity. The fcrmer of these has already been referred to, and is the result of neuronic degeneration ; whilst " insanity " is the clinical manifestation of a disturbance or perversion of neuronic function, which may or may not terminate in degeneration, and which, as we shall subsequently see, is by no means incompatible with neuronic deficiency or amentia.

The subject of amentia, therefore, whilst presenting many interesting problems to the physician, the pathologist, and the psychologist, has also a much wider interest and importance. Since in Man the predominant feature is Mind, and since it is by the development of this faculty that human progress has taken, and must take, place, it is clear that the question of its disease, and particularly of its defect, is one of supreme importance to the statesman, the sociologist, and the philosopher.

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