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IDIOCY (from Gr. iblwrrls, in its sec...

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Originally appearing in Volume V14, Page 602 of the 1911 Encyclopedia Britannica.
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IDIOCY (from Gr. iblwrrls, in its secondary meaning of a deprived person). In treating of idiocy it must be carefully599 borne in mind that we are dealing with mental phenomena dissociated for the most part from active bodily disease, and that, in whatever degree it may exist, we have to deal with Idly a brain condition fixed by the pathological circum- stances under which its possessor came into the world or by such as had been present before full cerebral activity could be developed, and the symptoms of which are not dependent on the intervention of any subsequent morbid process. From the earliest ages the term Amentia has been applied to this condition, in contradistinction to Dementia, the mental weakness following on acquired insanity. The causes of congenital idiocy may be divided into four classes: (I) hereditary predisposition, (2) constitutional conditions of one or both parents affecting the constitution of the infant, (3) injuries of the infant prior to or at birth, and (4) injuries or diseases affecting the infant head during infancy. All these classes of causes may act in two directions: they may produce either non-development or abnormal development of the cranial bones as evidenced by microcephalism, or by deformity of the head; or they may induce a more subtle morbid condition of the constituent elements of the brain. As a rule, the pathological process is more easily traceable in the case of the last three classes than in the first. For instance, in the case of constitutional conditions of the parents we may have a history of syphilis, a disease which often leaves its traces on the bones of the skull; and in the third case congenital malformation of the brain may be produced by mechanical causes acting on the child in utero, such as an attempt to procure abortion, or deformities of the maternal pelvis rendering labour difficult and instrumental interference necessary. In such cases the bones of the skull may be injured; it is only fair, however, to say that more brains are saved than injured by instrumental interference. With regard to the fourth class, it is evident that the term congenital is not strictly applicable; but, as the period of life implicated is that prior to the potentiality of the manifestation of the intellectual powers, and as the result is identical with that of the other classes of causes, it is warrantable to connect it with them, on pathological principles more than as a mere matter of convenience. Dr Ireland, in his work On Idiocy and Imbecility (1877), classifies idiots from the standpoint of pathology as follows: (1) Genetous idiocy: in this form, which he holds to be complete before birth, he believes the presumption of heredity to be stronger than in other forms; the vitality of the general system is stated to be lower than normal; the palate is arched and narrow, the teeth misshapen, irregular and prone to decay and the patient dwarfish in appearance; the head is generally unsymmetrical and the commissures occasionally atrophied; (2) Microcephalic idiocy, a term which explains itself; (3) Eclampsic idiocy, due to the effects of infantile convulsions; (4) Epileptic idiocy; (5) Hydrocephalic idiocy, a term which explains itself; (6) Paralytic idiocy, a rare form, due to the brain injury causing the paralysis; (7) Traumatic idiocy, a form produced by the third class of causes above mentioned; (8) Inflammatory idiocy; (9) Idiocy by deprivation of one or more of the special senses. The general conformation of the idiot is generally imperfect; he is sometimes deformed, but more frequently the frame is merely awkwardly put together, and he is usually of short stature. Only about one-fourth of all idiots have heads smaller than the average. Many cases are on record in which the cranial measurements exceed the average. It is the irregularity of development of the bones of the skull, especially at the bast, which marks the condition. Cases, however, often present themselves in which the skull is perfect in form and size. In such the mischief has begun in the brain matter. The palate is often highly arched; hare-lip is not uncommon; in fact congenital defect or malformation of other organs than the brain is more commonly met with among idiots than in the general community. Of the special senses, hearing is most frequently affected. Sight is good, although co-ordination may be defective. Many are mute. On account of the mental dullness it is difficult to determine whether the senses of touch, taste and smell suffer Forms of Insanity. impairment; but the impression is that their acuteness is below the average. It is needless to attempt a description of the mental phenomena of idiots, which range between utter want of intelligence and mere weakness of intellect. The term Imbecility has been conventionally employed to indicate the less profound degrees of idiocy, but in point of fact no distinct line of demarcation can be drawn between the conditions. As the scale of imbeciles ascends it is found that the condition is evidenced not so much by obtuseness as by irregularity of intellectual development. This serves to mark the difference between the extreme stupidity of the lowest of the healthy and the highest forms of the morbidly deprived type. The two conditions do not merge gradually one into the other. Absolute stupidity and sottishness mark many cases of idiocy, but only in the lowest type, where no dubiety of opinion can exist as to its nature, and in a manner which can never be mistaken for the dulness of the man who is less talented than the average of mankind. Where in theory the morbid (in the sense of deprivation) and the healthy types might be supposed to approach each other, in practice we find that, in fact, no debatable ground exists. The uniformity of dulness of the former stands in marked opposition to the irregularity of mental conformation in the latter. Comparatively speaking, there are few idiots or imbeciles who are uniformly deprived of mental power; some may he utterly sottish, living a mere vegetable existence, but every one must have heard of the quaint and crafty sayings of manifest idiots, indicating the presence of no mean power of applied observation. In institutions for the treatment of idiots and imbeciles, children are found not only able to read and write, but even capable of applying the simpler rules of arithmetic. A man may possess a very considerable meed of receptive faculty and yet be idiotic in respect of the power of application; he may be physically disabled from relation, and so be manifestly a deprived person, unfit to take a position in the world on the same platform as his fellows. Dr Ireland subdivides idiots, for the purpose of education, into five grades, the first comprising those who can neither speak nor understand speech, the second those who can understand a few easy words, the third those who can speak and can be taught to work, the fourth those who can be taught to read and write, and the fifth those who can read books for themselves. The treatment of idiocy and imbecility consists almost entirely of attention to hygiene and the building up of the enfeebled constitution, along with endeavours to develop what small amount of faculty exists by patiently applied educational influences. The success which has attended this line of treatment in many public and private institutions has been very consider-able. It may be safely stated that most idiotic or imbecile children have a better chance of amelioration in asylums devoted to them than by any amount of care at home. In the class of idiots just spoken of, imperfect development of the intellectual faculties is the prominent feature, so prominent that it masks the arrest of potentiality of development of the moral sense, the absence of which, even if noticed, is regarded as relatively unimportant; but, in conducting the practical study of congenital idiots, a class presents itself in which the moral sense is wanting or deficient, whilst the intellectual powers are apparently up to the average. It is the custom of writers on the subject to speak of " intellectual " and " moral " idiots. The terms are convenient for clinical purposes, but the two conditions cannot be dissociated, and the terms therefore severally only imply a specially marked deprivation of intellect or of moral sense in a given case. The everyday observer has no difficulty in recognizing as a fact that deficiency in receptive capacity is evidence of imperfect cerebral development; but it is not so patent to him that the perception of right or wrong can be compromised through the same cause, or to comprehend that loss of moral sense may result from disease. The same difficulty does not present itself to the pathologist; for, in the case of a child born under circumstances adverse to brain development, and in whom no process of education can develop an appreciation of what is right or wrong, although the intellectual faculties appearto be but slightly blunted, or not blunted at all, he cannot avoid connecting the physical peculiarity with the pathological evidence. The world is apt enough to refer any fault in intellectual development, manifested by imperfect receptivity, to a definite physical cause, and is willing to base opinion on comparatively slight data; but it is not so ready to accept the theory of a pathological implication of the intellectual attributes concerned in the perception of the difference between right and wrong. Were, however, two cases pitted one against another—the first one of so-called intellectual, the second one of so-called moral idiocy—it would be found that, except as regards the psychical manifestations, the cases might be identical. In both there might be a family history of tendency to degeneration, a peculiar cranial conformation, a history of previous symptoms during infancy, and of a series of indications of mental in-capacities during adolescence, differing only in this, that in the first the prominent indication of mental weakness was inability to add two and two together, in the second the prominent feature was incapacity to distinguish right from wrong. What complicates the question of moral idiocy is that many of its subjects can, when an abstract proposition is placed before them, answer according to the dictates of morality, which they may have learnt by rote. If asked whether it is right or wrong to lie or steal they will say it is wrong; still, when they themselves are detected in either offence, there is an evident non-recognition of its concrete nature. The question of moral idiocy will always be a moot one between the casuist and the pathologist; but, when the whole natural history of such eases is studied, there are points of differentiation between their morbid depravation and mere moral depravity. Family history, individual peculiarities, the general bizarre nature of the phenomena, remove such cases from the category of crime. Statistics.—According to the census returns of 1901 the total number of persons described as idiots and imbeciles in England and. Wales was 48,882, the equality of the sexes being remarkable. namely, 24,480 males and 24,402 females. Compared with the entire population the ratio is T idiot or imbecile to 665 persons, or 15 per 10,000 persons living. Whether the returns are defective, owing to the sensitiveness of persons who would desire to conceal the occurrence of idiocy in their families, we have no means of knowing; but such a feeling is no doubt likely to exist among those who look upon mental infirmity as humiliating, rather than, as one of the many physical evils which afflict humanity. Dr. Ire-land estimates that there is T idiot or imbecile to every 500 persons in countries that have a census. The following table shows the number of idiots according to official returns of the various countries: Males. Females. Total. Proportion to 100,000 of Pop. England and Wales 24,480 24,402 48,882 150 Scotland . . . 3,246 3,377 6,623 148 Ireland . . 2,946 2,270 5,216 I17 France (including . 20,456 14,677 35,133 97 cretin) (1872) Germany (1871) . . — — 33,739 82 Sweden (1870) . .: — — 1,632 38 ~I 1,074 2,431 121 Norway (1891) . 1,357 Denmark (1888–89). 2,106 1,751 3,857 200 For the United States there are no later census figures than 1890 when the feeble-minded or idiotic were recorded as 95,571 (52,940 males and 42,631 females). In 19o¢ (Special Report of Bureau of Census, 1906) the " feeble-minded " were estimated at 150,000. The relative frequency of congenital and acquired insanity in various countries is shown in the following table, taken from Koch's statistics of insanity in Wurttemberg, which gives the number of idiots to Too lunatics: Prussia 158 France . . 66 Bavaria 154 Denmark . 58 Saxony . 162 Sweden . 22 Austria . 53 Norway. . 65 Hungary . . . . 140 England and Wales 74 Canton of Bern . . 117 Scotland . 68 America . . 79 Ireland . . . . 69 It is difficult to understand the wide divergence of these figures, except it be that in certain states, such as Prussia and Bavaria. dements have been taken along with aments and in others cretins. This cannot, however, apply to the case of France, which is stated to have only 66 idiots to every too lunatics. In many districts of France cretinism is common; it is practically unknown in England, here the proportion of idiots is stated as higher than in France; and it is rare in Prussia, which stands at 158 idiots to too lunatics. Manifestly imperfect as this table is, it shows how important an clement idiocy is in social statistics; few are aware that the number of idiots and that of lunatics approach so nearly. II. Acquired Insanity.—So far as the mental symptoms of acquired insanity are concerned, Pinel's ancient classification, into Mania, Melancholia and Dementia, is still applic- able to every case, and although numberless classifica- tions have been advanced they are for the most part merely terminological variations. Classifications of the insanities based on pathology and etiology have been held out as a solution of the difficulty, but, so far, pathological observations have failed to fulfil this ideal, and no thoroughly satisfactory pathological classification has emerged from them. Classifications are after all matters of convenience; the following system admittedly is so: Melancholia. Mania. Delusional Insanity. Katatonia. Hebephrenia. Traumatic Insanity. Insanity following upon arterial degeneration. Insanities associated or caused by: General Paralysis; Epilepsy. Insanities associated with or caused by Alcoholic and Drug intoxi- cation: Delirium Tremens, Chronic Alcoholic Insanity, Dip- somania, Morphinism. Senile Insanity. The general symptoms of acquired insanity group themselves naturally under two heads, the physical and the mental. The physical symptoms of mental disease generally, if not invariably, precede the onset of the mental symptoms, and the patient may complain of indefinite symptoms of General symptoms. malaise for weeks and months before it is suspected that the disorder is about to terminate in mental symptoms. The most general physical disorder common to the onset of all the insanities is the failure of nutrition, i.e. the patient rapidly and apparently without any apparent cause loses weight. Associated with this nutritional failure it is usual to have disturbances of the alimentary tract, such as loss of appetite, dyspepsia and obstinate constipation. During the prodromal stage of such conditions as mania and melancholia the digestive functions of the stomach and intestine are almost or completely in abeyance. To this implication of other systems consequent on impairment of the trophesial (nourishment-regulating) function of the brain can be traced a large number of the errors which exist as to the causation of idiopathic melancholia and mania. Very frequently this secondary condition is set down as the primary cause; the insanity is referred to derangements of the stomach or bowels, when in fact these are, concomitantly with the mental disturbance, results of the cerebral mischief. Doubtless these functional derangements exercise considerable influence on the progress of the case by assisting to deprave the general economy, and by producing depressing sensations in the region of the stomach. To them may probably be attributed, together with the apprehension of impending insanity, that phase of the disease spoken of by the older writers as the stadium melancholicum, which so frequently presents itself in incipient cases. The skin and its appendages—the hair and the nails—suffer in the general disorder of nutrition which accompanies all insanities. The skin may be abnormally dry and scurfy or moist and offensive. In acute insanities rashes are not uncommon, and in chronic conditions, especially conditions of depression, crops of papules occur on the face, chest and shoulders. The hair is generally dry, loses its lustre and becomes brittle. The nails become deformed and may exhibit either excessive and irregular or diminished growth. Where there are grave nutritional disorders it is to be expected that the chief excretions of the body should show departures from the state of health. In this article it is impossibleto treat this subject fully, but it may suffice to say that in many states of depression there is a great deficiency in the excretion of the solids of the urine, particularly the nitrogenous waste pro-ducts of the body; while in conditions of excitement there is an excessive output of the nitrogenous waste products. It has lately been pointed out that in many forms of insanity indoxyl is present in the urine, a substance only present when putrefactive processes are taking place in the intestinal tract. The nervous system, both on the sensory and motor side, suffers very generally in all conditions of insanity. On the sensory side the special senses are most liable to disorder of their function, whereby false sense impressions arise which the patient from impairment of judgment is unable to correct, and hence arise the psychical symptoms known as hallucinations and delusions. Common sensibility is generally impaired. On the motor side, impairment of the muscular power is present in many cases of depression and in all cases of dementia. The incontinence of urine so frequently seen in dementia and in acute insanity complicated with the mental symptom of con-fusion depends partly on impairment of muscular power and partly on disorder of the sensory apparatus of the brain and spinal cord. The outstanding mental symptom in nearly all insanities, acute and recent or chronic, is the failure of the capacity of judgment and loss of self-control. In early acute insanities, however, the two chief symptoms which are most evident and easily noted are depression on the one hand and excitement or elevation on the other. Some distinction ought to be made between these two terms, excitement and elevation, which at present are used synonymously. Excitement is a mental state which may be and generally is associated with confusion and mental impairment, while elevation is an exaltation of the mental faculties, a condition in which there is no mental confusion, but rather an unrestrained and rapid succession of fleeting mental processes. The symptoms which most strongly appeal to the lay mind as conclusive evidence of mental disorder are hallucinations and delusions. Hallucinations are false sense impressions which occur without normal stimuli. The presence of hallucinations certainly indicates some functional disorder of the higher brain centres, but is not an evidence of insanity so long as the sufferer recognizes that the hallucinations are false sense impressions. So soon, however, at conduct is influenced by hallucinations, then the boundary line between sanity on the one hand and insanity on the other has been crossed. The most common hallucinations are those of sight and hearing. Delusions are not infrequently the result of hallucinations. If the hallucinations of a melancholic patient consist in hearing voices which make accusatory statements, delusions of sin and unworthiness frequently follow. Hallucinations of the senses of taste and smell are almost invariably associated with the delusion that the patient's food is being poisoned or that it consists of objectionable matter. On the other hand, many delusions are apparently the outcome of the patient's mental state. They may be pleasant or disattreeable according as the condition is one of elevation or depression. The intensity and quality of the delusions are largely influenced by the intelligence and education of the patient. An educated man, for instance, who suffers from sensory disturbances is much more ingenious in his explanations as to how these sensory disturbances result from electricity, marconigrams, X-rays, &c., which he believes are used by his enemies to annoy him, than an ignorant man suffering from the same abnormal sensations. Loss of self-control is characteristic of all forms of insanity. Normal self-control is so much a matter of race, age, the state of health, moral and physical up-bringing, that it is impossible to lay down any law whereby this mental quality can be gauged, or to determine when deficiency has passed from a normal to an abnormal state. In many cases of in-sanity there is no difficulty in appreciating the pathological nature of the deficiency, but there are others in which the conduct is other-wise so rational that one is apt to attribute the deficiency to physiological rather than to pathological causes. Perversion of the moral sense is common to all the insanities, but is often the only symptom to be noticed in cases of imbecility and idiocy, and it as a rule may be the earliest symptom noticed in the early stages of the excitement of manic-depressive insanity and general paralysis. The tendency to commit suicide, which is so common among the insane and those predisposed to insanity, is especially prevalent in patients who suffer from depression, sleeplessness and delusions of persecution. Suicidal acts may be divided into accidental, impulsive and premeditated. The accidental suicides occur in patients who are partially or totally unconscious of their surroundings, and are generally the result of terrifying hallucinations, to escape Acquired Insanity. from which the patient jumps through a window or runs blindly into water or some other danger. Impulsive suicides may be prompted by suddenly presented opportunities or means of self-destruction, such as the sight of water, fire, a knife, cord or poison. Premeditated suicides most frequently occur in states of long continued depression. Such patients frequently devote their attention to only one method of destruction and fail to avail them-selves of others equally practicable. As a rule the more educated the patient, the more ingenious and varied are the methods adopted to attain the desired result. The faculty of attention is variously affected in the subjects of insanity. In some the attention is entirely subjective, being occupied by sensations of misery, depression or sensory disturbances. In others the attention is objective, and attracted by every accidental sound or movement. In most of the early acute insanities the capacity of attention is wholly abolished, while in hebephrenia the stage of exhaustion which follows acute excitement, and the condition known as secondary dementia, loss of the power of attention is one of the most prominent symptoms. The memory for both recent and remote events is impaired or abolished in all acute insanities which are characterized by confusion and loss or impairment of consciousness. In the excited stage of manic-depressive insanity it is not uncommon to find that the memory is abnormally active. Loss of memory for recent but net remote events is characteristic of chronic alcoholism and senility and even the early stage of general paralysis. Of all the functions of the brain that of sleep is the most liable to disorder in the insane. Sleeplessness is the earliest symptom in the onset of Insanity; it is universally present in all the acute forms, and the return of natural sleep is generally the first symptom of recovery. The causes of sleeplessness are very numerous, but in the majority of acute cases the sleeplessness is due to a state of toxaemia. The toxins act either directly on the brain cells producing a state of irritability incompatible with sleep, or indirectly, producing physical symptoms which of themselves alone are capable of preventing the condition of sleep These symptoms are high arterial tension and a rapid pulse-rate. The arterial tension of health ranges between no and 120 millimetres of mercury, and when sleep occurs the arterial tension falls and is rarely above too millimetres. In observations conducted by Bruce (Scottish Medical and Surgical Journal, August 1900) on cases of insanity suffering from sleepless. ness the arterial tension was found to be as high as 140 and 150 millimetres. When such sleep was obtained the tension always sank at once to no millimetres or even lower. In a few cases suffering from sleeplessness the arterial tension was found to be below Too millimetres, accompanied by a rapid pulse-rate. When sleep set in, in these cases, no alteration was noted in the arterial tension, but the pulse was markedly diminished.
End of Article: IDIOCY (from Gr. iblwrrls, in its secondary meaning of a deprived person)
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