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600
[MEDICAL AND GENERAL
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 be 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 considerable. 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 appear to 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 incapacities 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 cases 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 1 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. Ireland estimates that there is 1 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  5,216 117
  France (including cretins) (1872)  20,456 14,677 35,133  97
 Germany (1871) 33,739  82
 Sweden (1870)  1,632  38
 Norway (1891)  1,357  1,074  2,431 121
 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 1904 (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 Württemberg, which gives the number of idiots to 100 lunatics:—

Prussia 158
Bavaria 154
Saxony 162
Austria  53
Hungary 140
Canton of Bern  117
America  79
France  66
Denmark  58
Sweden  22
Norway  65
England and Wales   74
Scotland  68
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.