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 COLLEGE OF PHYSICIANS 
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MENTAL AFFECTIONS 
 
 CHILDHOOD AND YOUTH 
 
ON SOME OF THE 
 
 MENTAL AFFECTIONS 
 
 CHILDHOOD AND YOUTH 
 
 THE LETTSOMIAN LECTURES 
 
 DELIVERED BEFORE THE MEDICAL SOCIETY OF LONDON 
 IN 1887 
 
 TOGETHER WITH OTHER PAPERS 
 
 J. LANGDON DOWN, M.D.Lond. 
 
 riLLOW OF THE EOYAL COLLKGE OF PHYSICIANS OP LONDON; SENIOR PHYSICIAN TO, AND 
 
 LBCTUKKE ON CLINICAL MEDICINE AT, THE LONDON HOSPITAL ; FOKMEKLY LECTUEER 
 
 ON MEDICINE, MATERIA MEDICA, AND COMPAEATIVE ANATOMY AT THE LONDON 
 
 HOSPITAL; AND PHYSICIAN TO THE EAELSWOOD ASYLUM 
 
 LONDON 
 J. & A. CHURCHILL 
 
 11, NEW BURLINGTON STREET 
 
 1887 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/onsomeofmentalafOOdown 
 
PEEFACE 
 
 When the Medical Society of London 
 honoured me with the request to pubhsh 
 these Lectures, I felt, in complying with the 
 wish so kindly expressed, that I should add 
 to the value of the contribution by reprinting 
 fugitive papers relating to the same subject, 
 to some of which I have referred in the 
 Lectures themselves. These papers I have 
 printed in chronological order as the most 
 convenient form. 
 
 J. LANGDON DOWN. 
 
 81, Harley Street, W. ; 
 
 May, 1887. 
 
CONTENTS 
 
 MENTAL AFFECTIONS OF CHILDHOOD 
 AND YOUTH. 
 
 LECTURE I. 
 
 PAfiES 
 
 History of the Subject. — Nomenclature. — Ethnic 01a;8- 
 sification. — Etiological Classification. — Physioal 
 Characteristics. — Intellectual Characteristics 1—42 
 
 LECTURE II. 
 
 Causes of Idiocy. — Accidental Origin. — Developmental 
 Origin. — Congenital Origin. — Influence of Maternal 
 Health ; of Alcoholism ; of Malignant Disease and 
 Syphilis; of Neurotic or Phthisical Inheritance; 
 of Trades and Professions; of Marriages of Con- 
 sanguinity ; of Illegitimacy ; Idiocy from Depriva- 
 tion of Senses; Cretinism; Influence of "Over- 
 Education " of Women . . . 43—90 
 
 LECTURE III. 
 
 Infantile Mania. — Melancholia and Delueions. — Moral 
 Insanity. — " Idiots Savants." — Yariations in the 
 Mental Condition. — Epilepsy and Catalepsy. — Phy- 
 sical Deformities. — Associated Diseases. — Rate of 
 Growth. — Diagnosis of Idiocy. — *' Backward Child- 
 ren."— Deferred or Absent Speech. — Morbid Ana- 
 tomy. — Treatment of Feeble-mindedness . 91 — 142 
 
Vlll CONTENTS. 
 
 PAGES 
 Account of a Case in which the Corpus Callosum and 
 Fornix were imperfectly formed and the Septum 
 Lucidum and Commissura were Absent . 143 — 153 
 
 On the Condition of the Mouth in Idiocy . 154 — 166 
 
 On Polysarcia and its Treatment . . 167 — 180 
 
 An Account of a Second Case in which the Corpus 
 
 Callosum was defective . . . 181—184 
 
 Marriages of Consanguinity in relation to Degenera- 
 tion of Race .... 185—209 
 
 Observations on an Ethnic Classification of Idiots 210 — 217 
 
 On Idiocy and its Relation to Tuberculosis . 218 — 230 
 
 A Case of Asymmetrically Developed Brain . 231 — 235 
 
 A Case of Microcephalic Skull . . . 236—238 
 
 A Case of Microcephalic Skull . . . 239—241 
 
 A Case of Arrested Development . . 242 — 244 
 
 A Case of Paralysis with apparent Muscular Hyper- 
 trophy ..... 245—^6 
 
 A Case of Pseudo-hypertrophic Paralysis . 257 — 267 
 
 On the Relation of the Teeth and Mouth to Mental 
 
 Development . . . 268—288 
 
 The Obstetrical Aspects of Idiocy . 289—307 
 
MENTAL AFFECTIONS OF CHILDHOOD 
 AND YOUTH. 
 
 LECTURE I. 
 
 History of the Subject. — Nomenclature. — Ethnic Classification. 
 — Etiological Classification. — Physical Characteristics. — 
 Intellectual Characteristics. 
 
 When you, sir, and your colleagues on the 
 Council of the Medical Society of London, did 
 me the honour to request me to deliver the 
 Lettsomian Lectures on Medicine for this year, 
 I bethought myself that mental deviations in 
 childhood and youth had never been the subject 
 of a disquisition from this chair, and that pro- 
 bably a period of nearly thirty years spent 
 among children with various phases of mental 
 affection might entitle me to bring before the 
 members of this Society material which, from 
 the nature of the subject, can only be accumu- 
 lated by a few. 
 
 There is not much to be found on this subject 
 in the early records of medicine. Children who 
 were afflicted by mental aUenation or mental 
 
 1 
 
MENTAL AFFECTIONS OF 
 
 incapacity of any kind were placed in tlie cate- 
 gory of idiots and regarded as beyond tlie pale 
 of help. Formerly no attempt was made to 
 ameliorate their condition, and a Spartan-like 
 policy was rife, which troubled itself only with 
 the survival of the fittest. It has been reserved 
 for the medicine of modern times to occupy itself 
 about the waifs of humanity who come under 
 the category of the feeble in mind. The earliest 
 attempts at the education of idiots took place in 
 France some years since, but they were at first 
 isolated efforts under the direction of M. Seguin 
 at the Bicetre. It was, however, in 1842 that 
 attention was more particularly directed to the 
 subject by the establishment of a school on the 
 Abendberg, in Switzerland, which was opened 
 by Dr. Guggenbiihl, who entered on his work 
 with true enthusiasm, — an enthusiasm which one 
 regrets was quenched by the flattery of English 
 drawing-rooms. I shall never forget the feel- 
 ings of disappointment and chagrin when, on 
 reaching the summit of the Abendberg, which 
 I had mounted as a pilgrim to a shrine, I found 
 the pupils in a state of physical and mental 
 neglect while the patron saint was being ener- 
 vated by the Capua-like influence of the West 
 
CHILDHOOD AND YOUTH. 
 
 End of London. Fortunately for the pupils the 
 Commune stepped in and closed what had 
 become a parody on philanthropic effort. 
 
 About the same time M. Saegert, at Berlin, 
 who had been engaged in the instruction of 
 deaf mutes, extended his efforts for the benefit 
 of a class whose mutism was not the outcome 
 of deafness. His school is still carried on with 
 much skill in the neighbourhood of Berlin, but 
 with the immense disadvantage of being located 
 in, and associated with, a large lunatic asylum. 
 On a recent visit which I paid it I found excel- 
 lent work was being done there although handi- 
 capped by the association to which I have 
 referred. It was in the year 1846 that a general 
 movement took place in efforts for ameliorating 
 this afflicted class. Germany took the lead by 
 the establishment of a school at Leipzig. Dis- 
 cussions in the periodical press were initiated 
 by Mrs. Plumbe, of London, whose personal 
 interest in the matter forced the subject on the 
 attention of such philanthropists as Dr. Conolly 
 and Dr. Andrew Reed. Synchronously, public 
 attention was being given to the subject in the 
 United States of America, where, while poli- 
 ticians were delaying action in the matter, the 
 
MENTAL AFFECTIONS OF 
 
 private enterprise of tlae late Dr. Wilbur brought 
 it to a practical issue. England meanwhile 
 commenced the work by the establishment of a 
 small school at Bath. It was not, however, 
 till 1847 that the great effort was made which 
 resulted in starting a small institution at High- 
 gate in 1848 and subsequently another at 
 Colchester. These grew into the large institution 
 at Earlswood, of which in 1858, at tbe mingling 
 of the inmates from these homes at Highgate and 
 Colchester, I undertook the superintendence. 
 In recent years other institutions have been 
 created both in England, Ireland, Scotland, the 
 United States, and on the Continent of Europe. 
 Schools have been established at Darenth for 
 the feeble-minded paupers of London. One 
 hopes that the time may not be far distant when 
 suitable provision may lie within the reach of 
 the afBicted poor who live beyond the metro- 
 politan area. 
 
 It is not uncommon to class all cases of 
 mental lesion occurring in the young under the 
 category of idiocy, or to speak of those ajQBicted 
 with the graver forms of the malady as idiots, 
 while the subjects of the milder or less grave 
 manifestations are called imbeciles. This no- 
 
CHILDHOOD AND YOUTH. 
 
 menclature is open to grave objection. The 
 term imbecile is very often applied to that class 
 of mental infirmity which is the outcome of 
 deteriorating organic causes, often senile. Men 
 or women who may have been in their time 
 capable citizens become the subjects of senile 
 changes of nutrition and lapse into a condition 
 of childishness. It is people of this class who 
 are rightly termed imbeciles, and to whom in my 
 opinion the designation should be thoroughly 
 restricted. I know of no defining limitation be- 
 tween so-called idiocy and so-called imbecility. 
 The gradations of mental incapacity are as nu- 
 merous and delicate as are those of mental capa- 
 city among those who are doing the world's work. 
 The division, therefore, into imbeciles and idiots 
 is thoroughly wrong and misleading. I have 
 no great liking for the term idiot. It is so fre- 
 quently a name of reproach. Moreover, in most 
 cases it does not fairly represent the conditions 
 which exist. The word idiot means " solitary," 
 and the typical idiot knows nothing, sees nothing, 
 does nothing, and this typical idiot is scarcely 
 ever met with except in anencephalous monsters. 
 This objection to the term idiot is not a mere 
 sentimental one on my part. No one likes the 
 
6 MENTAL AFFECTIONS OF 
 
 name, and no mother will admit that her child 
 deserves the title. The constant introduction 
 of a case from medical men is, " I send you a 
 little child for your opinion, but it is not an 
 idiot ;" or the mother brings her child to one, 
 saying, " I have come to consult you about my 
 boy, but he is not an idiot." This is the regular 
 formula. A great impediment is thereby intro- 
 duced to the early appreciation of the lesion 
 and to its early treatment. The term idiot 
 might be advantageously replaced by that of 
 feeble-minded, idiocy being in fact mental 
 feebleness depending on malnutrition or disease 
 of the nervous centres taking place anterior to 
 birth or during the developmental years of 
 childhood and youth. Idiocy is therefore readily 
 differentiated from other forms of mental alie- 
 nation. The term imbecile should be applied 
 to the cases of dementia which crowd our lunatic 
 asylums and who are in an entirely different 
 category from the feeble-minded; they are 
 gradually deteriorating in physical, mental, and 
 moral condition ; they are in the position of 
 spendthrifts who have dissipated their fortune, 
 while idiots for the most part have never entered 
 on a fortune to dissipate. 
 
CHILDHOOD AND YOUTH. 
 
 Some years since I was struck by the remark- 
 able resemblance of feeble-minded children to 
 the various ethnic types of the human family, 
 and showed, in a paper which I contributed to 
 the ' London Hospital Reports ' in 1866, in how 
 many instances one could refer them to one or 
 other of the ethnological families. I have had 
 under my care typical examples of the negroid 
 family, with characteristic malar bones, the 
 prominent eyes, the pufiy lips and retreating 
 chin. They have had the woolly hair, although 
 not black, nor has the skin acquired pigmentary 
 deposit. They have been examples of white 
 negroes, but of European descent. Several, 
 again, have arranged themselves around the 
 Malay variety, with soft, black, curly hair, pro- 
 minent upper jaws and capacious mouths, types 
 of the South Sea Islands. I have also met with 
 a few instances of the North American Indian 
 type, with shortened forehead, prominent cheeks, 
 deep-set eyes and slightly apish nose. A con- 
 siderable number range themselves under the 
 Mongolian type. More than 10 per cent, of 
 congenital, feeble-minded children are typical 
 Mongols. They present characteristics so 
 marked that when the members of this type are 
 
8 MENTAL AFFECTIONS OF 
 
 placed in proximity it is diflScult to believe 
 that they are not brothers and sisters. In fact 
 their resemblance is infinitely greater to one 
 another than to the members of their own 
 families. They rarely have black hair, as in the 
 real Mongol, bnt it is of a brownish colour, 
 straight and sparse. The face is flat and broad 
 and destitute of prominence. The cheeks are 
 roundish and widened laterally. The eyes are 
 obliquely placed and the internal canthi more 
 than normally separated. The palpebral fissure 
 is very narrow, the forehead is wrinkled trans- 
 versely from the constant use of the occipito- 
 frontalis muscle in opening the eyes. The lips 
 are large and thick, with transverse fissures. 
 The tongue is long and thick and very rugous. 
 The nose is small. The skin has a tawny colour, 
 and is deficient in elasticity, giving on the hands 
 the appearance of being larger than is necessary. 
 The ethnic classification of idiocy which I 
 indicated is of extreme interest philosophically 
 as well as of value practically. Philosophically 
 because it throws light on a question which 
 very much agitated public opinion about the 
 time of the American Civil "War. The work of 
 Nott and Gliddon laboured to prove that the 
 
CHILDHOOD AND YOUTH. 9 
 
 various ethnic families were distinct species, 
 and a strong argument was based on this to 
 justify a certain domestic institution. If, how- 
 ever, it can be shown that from some dete- 
 riorating influence the children of Caucasian 
 parents can be removed into another ethnic 
 type, it is a strong corroborative argument that 
 the difference is a variable and not a specific 
 one. The classification is also a practical one. 
 We are able to say, with the greatest possible 
 certainty, that the members of these ethnic 
 types date the origin of their mental feebleness 
 to congenital causes. 
 
 It is often of great importance to determine 
 the question as to whether the affliction has had 
 an accidental beginning. The medical attendant 
 may be charged with malpraxis. The nurse 
 may be suspected of having allowed the infant 
 to fall or of having drugged it with opiates. 
 The being able to refer the child to an ethnic 
 type other than Caucasian settles beyond ques- 
 tion that the cause of the malady, whatever it 
 may be, was antecedent to birth. Again and 
 again has this process of reasoning come to my 
 assistance in determining questions of the 
 gravest possible import, and enabled me to 
 
10 MENTAL AFFECTIONS OF 
 
 assure anxious friends tliat innocent people 
 have been unjustly blamed. Not only so, by a 
 recognition of type we are able to determine 
 the physical as well as mental and moral charac- 
 teristics of the child in a way which astonishes 
 the mother, who finds one is able to anticipate 
 all she has to relate. This is especially the 
 case with the Mongolian type, the numerous 
 instances of which coming under one's notice 
 enables one to become familiar with its leading 
 characteristics. These children have always 
 great power of imitation and become extremely 
 good mimics. Several patients who have been 
 under my care have been wont to convert their 
 pillow-slips into surplices and to imitate, in tone 
 and gesture, the clergyman or chaplain they 
 have recently heard. Their power of imitation 
 is moreover not limited to things clerical. I 
 have known a ventriloquist to be convulsed 
 with laughter between the first and second 
 parts of his entertainment on seeing a Mongolian 
 patient mount the platform, and hearing him 
 grotesquely imitate the performance with which 
 the audience had been entertained. They 
 have a strong sense of the ridiculous ; this is 
 indicated by their humorous remarks and the 
 
CHILDHOOD AND YOUTH. 11 
 
 laughter with which they hail accidental falls, 
 even of those to whom they are most attached. 
 Another feature is their great obstinacy, — they 
 can only be guided by consummate tact. No 
 amount of coercion will induce them to do that 
 which they have made up their minds not to 
 do. Sometimes they initiate a struggle for 
 mastery, and the day previous will determine 
 what they will or will not do on the next day. 
 Often they will talk to themselves, and they may 
 be heard rehearsing the disputes which they 
 think will be the feature of the following day. 
 They in fact, go through a play in which the 
 patient, doctor, governess, and nurses are the 
 dramatis personas, — a play in which the patient 
 is represented as defying and contravening the 
 wishes of those in authority. Whether it be 
 the question of going to church, to school, or 
 for a walk, discretion will often be the better 
 part of valour, by not giving orders which will 
 run counter to the intended disobedience, and 
 thus maintaining the appearance of authority 
 while being virtually beaten. They are always 
 amiable both to their companions and to animals. 
 They are not passionate nor strongly affection- 
 ate. They are usually able to be taught to 
 
12 MENTAL AFFECTIONS OF 
 
 speak ; the speech, however, is somewhat thick 
 and indistinct, and destitute of musical cadence. 
 The co-ordinating faculty is abnormal, but may 
 be greatly improved by training. The circula- 
 tion is usually feeble, and whatever advance is 
 made intellectually in the summer some amount 
 of retrogression may be expected in the winter. 
 They undergo, in fact, a species of hibernation ; 
 not only are they prone to chilblains and frost- 
 bite, they are but little tolerant of excessive 
 heat, and proximity to a fire which to many 
 would be only agreeable would, to patients of 
 this class, be attended by serious blistering of 
 the legs, even when protected by stockings or 
 other articles of clothing. The resemblance to 
 one another is so great in members of this 
 family, both in their physical, moral, and 
 intellectual natures, that the probability was 
 forced on one that there was some unity 
 of cause for their malady. Further investi- 
 gation pointed out that phthisis was very fre- 
 quently met with in the history of their pro- 
 genitors. It is noticeable also that these 
 children have not a long career, very few 
 reaching adult life, being prone to succumb to 
 serious illness or to become phthisical like their 
 
CHILDHOOD AND YOUTH. 13 
 
 ancestors. Their crania have a marked simi- 
 larity, they are all brachycephalic and the pos- 
 terior part is ill-developed. 
 
 Latterly I have been accustomed to adopt a 
 classification based on the etiology of the cases. 
 This is valuable from its practical bearing, and 
 because it brings into prominence a class which 
 was formerly not considered, or at all events 
 had not the attention given to it which it 
 merited. 
 
 It was very early presented to my notice that 
 a large number of feeble-minded children were 
 capable of being referred to one or other of two 
 great groups — the one where there was a com- 
 plete history of the congenital origin of the 
 malady, with the physical proofs, which I shall 
 presently refer to, and the other where it was 
 no less clear that the asseverations of the 
 mother that her child was born with ordinary 
 intelligence was quite correct, but that some 
 accident or some extension of disease equiva- 
 lent to an accident had wrought on the cerebral 
 centres disastrous changes, interfering with 
 intellectual manifestations. Parents always 
 prefer to refer the case to a post-uterine 
 or non-congenital origin, partly because they 
 
14 MENTAL AFPEOTIONS OF 
 
 think it frees them from the suspicion of here- 
 ditary influence, and partly from a notion that 
 the child is more likely to be restored to 
 its pristine state. We have these two well- 
 defined classes : (1) The congenital, and (2) 
 the accidental. On investigating, however, a 
 large number of cases I became familiar with 
 many instances which it was impossible to 
 include in either of these categories. There 
 was no history of accident nor of any illness 
 akin to accident ; the examination, however 
 thorough, revealed nothing which would war- 
 rant the opinion that the origin was accidental. 
 There was, moreover, in these cases, no reason 
 to regard them as congenital. On the contrary, 
 all the historical evidence, as well as all the 
 physical evidence, positively refuted any such 
 idea. 
 
 Under what head, therefore, were they to be 
 placed ? I found that the history was some- 
 what of the following. Their early months 
 of babyhood were perfectly uneventful ; there 
 had been nothing to cause the slightest anxiety ; 
 intelligence had dawned in the accustomed way, 
 when, first dentition proceeding, a change had 
 come over the aspect of the child. Its look had 
 
CHILDHOOD AND YOUTH. 15 
 
 lost its wonted brightness ; it took less notice 
 of those around it ; many of its movements 
 became rhythmical and automatic, and with or 
 without convulsions there was a cessation of 
 the increasing intelligence which had marked its 
 early career ; anxiety was felt on account of the 
 deferred speech, still more from the lessened 
 responsiveness to all the endearments of its 
 friends. In others the crisis at first dentition 
 is not so marked. Speech may be a little de- 
 ferred, but it comes, and with it more mental 
 power ; at second dentition, however, they are 
 prone to crises in which the intelligence be- 
 comes altered, they have night terrors, and not 
 unfrequently loss of speech. I have had many 
 examples of children who had spoken well and 
 with understanding, but who lost speech at the 
 period of second dentition, and had also a 
 suspension of mental growth. 
 
 I have now under my observation a boy who, 
 except that he was a little backward in speaking, 
 not talking till he was two years of age, attracted 
 no particular attention during the first six years 
 of his life. During the period of second dentition, 
 without any fit or convulsion, he suddenly lost 
 speech. He heard everything that was said, 
 
16 MENTAL AFFECTIONS OF 
 
 but never replied to a question. He would 
 caress and coax, but never asked for what he 
 wanted. It was not a case of aphonia ; he 
 appeared to have no power to convert ideas into 
 words. He would cry peevishly if there was 
 something he wanted that he could not have. 
 This condition of things continued for eighteen 
 months, when, suspecting masturbation, he was 
 circumcised by Mr. Heath. Grradually, after 
 two years' absence, speech returned. He had 
 to be taught anew, first the names of objects, and 
 then to build up sentences until, at the end of 
 six months, my notebook says, " Speaks several 
 sentences voluntarily." However, he afterwards 
 always spoke of himself in the third person. 
 He is now passing through the evolutionary 
 period of puberty without any recurrence of the 
 loss of speech faculty, but he has never regained 
 active mental power. There is reason to regard 
 it as a case of developmental feeble-mindedness 
 resulting from illness of his mother at the 
 seventh month of pregnancy. 
 
 I have had under my care two brothers who 
 had spoken with discrimination and understood 
 well two languages, but who both lost speech 
 at the period of second dentition. As the 
 
CHILDHOOD AND YOUTH. 17 
 
 elder one approached, that period, gradually, 
 without any paroxysmal event, he lost speech, 
 and when the younger one arrived at the 
 same age, gradually, but entirely, did he lose 
 speech also. It may be, however, that the 
 periods of first and second dentition are passed 
 harmlessly and the breakdown is reserved for 
 the time of puberty. Many at this time become 
 suspicious and reserved, some become hyper- 
 conscientious, are always practising a process 
 of introspection, are disturbed in their mind 
 lest they should not have rightly stated any 
 circumstance, or, if they have correctly stated 
 it, whether they have put the facts in such a 
 way as to have produced the right impression ; 
 many become epileptic, with rapid declension 
 of intellectual power. These cases have usually 
 characteristic crania ; they are dolichocephalic 
 and are prow-shaped anteriorly, — the line cor- 
 responding to the medio-frontal suture being 
 a prominent ridge. There is reason to believe 
 that in these cases there has been an arrest 
 of the synostosis of the medio-frontal suture 
 which should have taken place during intra- 
 uterine life, so that the lateral pressure on 
 the separated frontal bones determines, when 
 
18 MENTAL AFFECTIONS OF 
 
 the deferred ossification takes place, a pro- 
 minence where there should have been a 
 plane or slightly concave surface between 
 the frontal eminences. In the great bulk of 
 these cases well-marked evidence can be obtained 
 of some disturbing cause towards the later 
 months of pregnancy, which has led to this con- 
 dition; and although the deferred synostosis and 
 its consequent deformity is of no consequence, 
 it is reasonable to believe that the same cause 
 which arrested the bony union has also arrested 
 the development of the cerebral centres and 
 rendered them more unstable. Certain it is 
 that children with such a conformation are 
 almost sure to break down at one or other of the 
 developmental epochs. Their nervous system 
 would appear to be equal to the requirements of 
 growth but not of development. They form 
 a class of cases which I have suggested 
 should be called the " Developmental," as con- 
 tradistinguished from the " Congenital " on the 
 one hand, and the " Accidental" on the other. 
 They are a very important class, because, fore- 
 warned, catastrophes may be avoided. They 
 are the cases which break down by over-excite- 
 ment in babyhood and by " over-pressure " in 
 
CHILDHOOD AND YOUTH. 19 
 
 schools at second dentition and puberty. So 
 frequent is tlie association of this condition of 
 the cranium with neuroses that I have been 
 accustomed for many years to point this out to 
 my students at the London Hospital, and to 
 show them that the prow-shaped skull is an 
 outward and visible sign of an unstable nervous 
 system, not of itself a cause, but indicating, like 
 the seaweeds on the seashore, how far the tide 
 has come. The members of this class do not 
 give evidence of mental defect before their 
 breakdown ; they furnish, however, a number of 
 those who become petulant, wayward vagrants 
 from the elementary school, runaways from the 
 public school, sometimes interesting and with 
 flashes of precocious genius, they become the 
 subjects of headache under continuous intel- 
 lectual strain, a headache which, if not regarded, 
 leads on infallibly to disastrous neuroses or 
 developmental idiocy. 
 
 A large number of boys and girls come under 
 my notice who are not feeble-minded, who have 
 in a high degree the prow-sha]3ed forehead, 
 and who have their nervous system in such 
 an unstable equilibrium that the least intellectual 
 pressure at developmental epochs is attended 
 
20 MENTAL AFFECTIONS OF 
 
 by disastrous results. They are brought to me 
 on account of severe frontal headache, or of 
 wayward petulance, or incapacity for sustained 
 mental exertion. I cannot better illustrate the 
 kind of case which so frequently comes under 
 my observation, and the serious character of 
 which it is of the first importance early and 
 clearly to recognise, than by quoting from the 
 letter of the mother of one such patient. 
 She says, " I have a boy eight and a half years 
 old who is continually suffering with headache 
 from temple to temple, and over the front half 
 of head. He is a child of fine physique, capable, 
 practical, clever, so far as the head permits of 
 lessons, which means but a short amount and 
 often missed altogether, for the same reason — 
 * headache,' — apparently the picture of health, 
 high spirits, active, bright, yet done up with so 
 little. The child is not a rickety creature — 
 more is the puzzle. We shall bring him to see 
 you on Tuesday next, and I think it better to 
 give you all particulars before our visit that 
 you may form an opinion on the whole. In the 
 Spring after a certain pressure of the usual 
 morning work, he would turn grey, gasp for 
 air, and, with windows all open, say he was 
 
CHILDHOOD AND YOUTH. 21 
 
 choked. These attacks were frequent, and the 
 sensations in the throat seemed to frighten him 
 greatly. Lately I have heard less of this ; now 
 it seems ' head ' affecting him ' all over ' as he 
 expresses it. 
 
 " Since then he has grown tall and much 
 stronger, crickets fairly well, can handle any tool 
 ' properly,' has good sense, good memory, a 
 bad or rather tempestuous temper, quickly over, 
 strong will, and ought to be a boy well to the 
 front ; but, alas for such hopes, there is ever a 
 something cropping up which knocks it all over. 
 Then fatigue, long journeys, lessons, and all is 
 depression and pain, and a heavy dulness of 
 power (never of intellect) which is heart- 
 grieving to me. Writing tires him, yet he 
 works his Latin sentences with ease aloud, only 
 two a day. Two hours' work has become half an 
 hour, sometimes lately five minutes. He remains 
 still over-full of life and go, at times, with no real 
 strength, irritable, open, upright, self-willed, 
 loving, very true, still all wrong, and why ?" 
 
 When the boy presented himself to me 
 he displayed a typical neurotic forehead, and 
 there was a very complete history of severe 
 emotional disturbance on the part of the mother 
 
22 MENTAL AFFECTIONS OF 
 
 between the sixth and seventh month of preg- 
 nancy. I counselled complete abstention from 
 intellectual work during the remaining period of 
 second dentition. It was very clear to my mind 
 that any continued pressure would lead, through 
 convulsions, to developmental idiocy. 
 
 Dr. West has pointed out how stammering 
 never occurs among young childreu, and says, 
 " I never knew a child stammer before the 
 commencement of the second dentition." My 
 own experience would lead me to confirm the 
 observations of that distinguished physician, 
 and I would further say that I have never met 
 with a case of stammering at that period which 
 did not bear evidence of its being a develop- 
 mental neurosis, and that its origin could be 
 traced back to a period anterior to birth, to an 
 arrest of development which begat a proclivity 
 to nervous breakdown. In these cases the 
 approach of puberty is a period of grave 
 anxiety. It is at that time that masturbation 
 is so liable to lead to disastrous results, and that 
 epilepsy is so prone to occur. The nervous 
 system may have been stable through the 
 developmental periods of first and second 
 dentition and yet break down at the evolution 
 
CHILDHOOD AND YOUTH. 23 
 
 of puberty, and there is much sagacity in Dr. 
 West's observation : " It is usually with the 
 evolution of the sexual system that hysteria 
 shows itself, and with the pressure of life's cares 
 that the mind is thrown off its balance, and 
 then it is with regard to both that the ancestral 
 taint first displays itself ; so too, is it, I believe, 
 to a great degree with the hereditary tendency 
 to epilepsy." It is, I would venture to say, the 
 influence of the neurotic mother on the embryo 
 during the later months of development that 
 begets the proclivity which is here referred to. 
 I have alluded already to a group which I 
 have ventured to describe as "accidental." I 
 wish thereby to refer to a class of cases which 
 differ from the " developmental " in the date of 
 the origin of their calamity. They are children 
 who are born, or ready to be born, with all the 
 potentiality of intelligence, but whose brain 
 becomes damaged by traumatic lesions, by medi- 
 cations, or by inflammatory disease. There is 
 this one character running through the class, — a 
 character on which I wish to lay as great stress 
 as I have on the prow-shaped cranium of the 
 developmental class, viz. the absence of any of 
 the physical aspects of f eeble-mindedness . They 
 
24 MENTAL AFFECTIONS OP 
 
 are bright in their expression, often active in 
 their movements, agile to a degree, mobile in 
 their temperament, fearless as to danger, perse- 
 vering in mischief, petulant to have their own 
 v^ay. Their language is one of gesture only ; 
 living in a world of their own they are regard- 
 less of the ordinary circumstances around them, 
 and yield only to the counter-fascination of 
 music. 
 
 These are the cases in which mothers enter- 
 tain the strongest hope, and in which the doctor 
 endorses the hope with confidence based on 
 the pretty waywardness of the child. I cannot 
 enforce too strongly grave caution in the pro- 
 gnosis which should be given in such cases ; 
 they are the most disappointing which one is 
 called upon to treat. A period of nearly thirty 
 years has enabled me to study not only the 
 present but the future of such children, to make 
 a forecast, based on experience as to results, 
 and to correct the notions of sanguine hopeful- 
 ness. So interesting are they in appearance 
 that it is diflficult to realise that they will not 
 be perfectly responsive to training, and that 
 speech will not be speedily gained. I know 
 nothing more painful than the long motherly 
 
CHILDHOOD AND YOUTH. 25 
 
 expectancy of speech. ; how, month after month, 
 the hopes are kept at high tension, waiting for 
 the prattle which never comes. How the self- 
 contained and self-absorbed little one cares not 
 to be entertained other than in his own dream- 
 land, and by automatic movements of his fingers 
 or rhythmical movements of his body. I 
 cannot recommend too strongly that caution 
 should be used in giving a hopeful prognosis 
 concerning children of this class. They have 
 well-formed heads, finely-textured skins, well- 
 chiselled mouths, sparkling eyes, features when 
 in repose leading one to augur only bright- 
 ness and intelligence. Surely, it may be 
 thought, the mind is ready to be developed 
 from such a casket, and time only is required 
 to ensure the thorough realisation of all one's 
 wishes. Opinions based on such a theory will 
 prove utterly fallacious. In these cases there 
 is no outward sign of mental vacuity, for 
 there has been nothing during the period of 
 intra-uterine life to arrest the evolutionary 
 stages, and stamp its impress on the bodily or 
 facial formation. The cause of the mental de- 
 ficiency has been something occurring during 
 post-ufcerine life, — some catastrophe notinherent 
 
26 MENTAL AFFECTIONS OF 
 
 in the cliild, no hereditary taint to mar the 
 beauty of his visage or the grace of his cranial 
 contour ; yet there is something more potent 
 for evil than in the case of many a malformed 
 face and many a distorted skull. He runs to 
 you when called, but makes no response in 
 words. He returns your kiss by a bite, and 
 runs away with agile steps, rolling his head 
 with a horizontal swaying motion, or with 
 fingers in ears or at eyeballs producing distorted 
 sounds or double vision, and as he goes, rushing 
 to knock down objects in order to produce an 
 unharmonious noise. They are cases with a 
 vast amount of surplus nervous energy, and 
 although much may be done by training to 
 divert the energy into better channels, the im- 
 provement will be smaller than what may be ob- 
 tained from apparently less promising children, 
 because, as I have elsewhere said, there is more 
 improvement to be obtained from an ill- 
 developed than from a damaged brain. 
 
 The late Professor Griesinger, with whom I 
 have frequently had opportunities of discus- 
 sing this and kindred subjects, describes two 
 varieties of idiots — the apathetic and the ex- 
 cited. The apathetic class he describes as 
 
CHILDHOOD AND YOUTH. 27 
 
 awkward, clumsy, and disproportioned, with 
 repulsive old-looking features. From their 
 torpor and impassiveness thej seem to be in a 
 dreamj state. Their expression is either brood- 
 ing and molancholj, or vacuous and indifferent. 
 The excited or agitated class he describes as 
 just as stupid as the other, but quick in 
 movement and irritable, passing rapidly from 
 one impression to another, and quite incapable 
 of fixing anything on their minds. I have no 
 doubt Griesinger had in view, in describing the 
 latter class, some of the accidental cases whose 
 manifestations I have been discussing. There 
 is no attempt, however, in this classification to 
 refer them to their cause, nor can I admit that 
 the division is true to nature or practically 
 useful. 
 
 Having thus discussed two of the great 
 classes, the accidental and the developmental, 
 there remains for me to describe the character- 
 istics of the remaining one, viz. the congenital. 
 This contains by far the largest number of 
 subjects, and presents characters which are 
 of great value in determining the origin and 
 future of its members. They are less in- 
 teresting in appearance but more amenable 
 
28 MENTAL AFFECTIONS OF 
 
 to training, other things being equal, than 
 either of the other two classes, and especially 
 than the members of the accidental class. The 
 origin of their malady dates from earlier in 
 intra-uterine life than does that of the members 
 of the developmental class, and in many 
 cases the proclivity resides in the germ-cell or 
 sperm-cell, as the result of gradual degenera- 
 tion. That being so, it is not surprising that 
 members of this class should bear in their 
 bodily formation marks of physical change. 
 They for the most part have a tendency to fall 
 under one or other of the ethnic groups which I 
 referred to in the early part of this lecture. 
 Some years since I gave great attention to this 
 subject, and prepared much material for a 
 paper on the physical aspects of idiocy. A 
 great many descriptions had been written, by 
 no means precise, on the intellectual condition 
 of idiots, but none, so far as I know, on their 
 physical attributes. It is now several years 
 since that this city was excited by the trial 
 before a Master in Lunacy of a young man 
 whose ability to manage his affairs was doubted. 
 The author of ' Ten Thousand a Year ' presided 
 at the trial. Experts on both sides gave evi- 
 
CHILDHOOD AND YOUTH. 29 
 
 dence on the psydaological condition. The late 
 Lord Cairns (then Sir Hugh) was the advocate 
 for the youth, and he argued strongly that the 
 error had been fallen into of supposing this 
 young man was feeble-minded because he had 
 a high arched palate, and in other ways a de- 
 formed mouth, so that his defective utterances 
 had given rise to the opinion that he was de- 
 ficient in mental power. From the material I 
 had collected I wrote a paper for the ' Lancet ' to 
 show that, granted any suspicion of defective 
 mental power, the deformation of the mouth, 
 with its vaulted palate, was the strongest corro- 
 borative proof, a proof too of the congenital 
 origin of his condition. My paper was too late 
 to enable the opposite side to call me, and it 
 could only be made use of in the opposing 
 counsel's final address. The jury supported 
 the doctrine of the liberty of the subject, and 
 the poor congenital imbecile was allowed to go 
 his own way to destruction, with the result of 
 becoming speedily bankrupt in fortune, ruined 
 in health, and a scandal to an honoured 
 ancestral name. 
 
 Still more recently, a youth on coming of age 
 sought to obtain possession of his property. 
 
30 MENTAL AFFECTIONS OF 
 
 There was strong evidence brought as to his 
 conduct being incompatible with mental capa- 
 city, and the physical deviations were confirma- 
 tory of the congenital character of the feeble- 
 mindedness. The jury, however, decided by a 
 small majority that he was capable of managing 
 his own affairs, although they were equally 
 divided as to his mental soundness. Within 
 forty-eight hours he was in prison for gross 
 criminal conduct, and he speedily terminated a 
 career of infamy from want of legal protection, 
 which the poor feeble-minded youth could not 
 give to himself. In the cases I am describing 
 the cranium is usually smaller than normal, 
 dolichocephalic in many but brachycephalic in 
 the Mongolian type. Occasionally the head is 
 scaphocephalic, the line of the sagittal suture 
 giving a keel-like feature to what resembles an 
 inverted boat. A very common character is a 
 rapid shelving from the vertex posteriorly, cor- 
 responding to what is so frequently to be 
 noticed, an arrest of development of the occi- 
 pital lobe of the cerebrum. Not unfrequently 
 the cranium is extremely small, reverting to the 
 Aztec type. These examples of extreme micro- 
 cephalism have been attributed by Virchow to 
 
CHILDHOOD AND YOUTH. 31 
 
 premature synostosis of the cranial sutures. I 
 have found, however, that in some of the most 
 marked members of the microcephalic group the 
 sutures are well marked and every indication 
 that the cranium had adapted itself to the cere- 
 brum rather than that the cerebral mass had 
 been dominated by the cranium. They are 
 cases in which the brain and bony covering are 
 both in miniature, the arrest having had an 
 early intra-uterine date. It would be a grave 
 error to imagine that there is an inverse rela- 
 tion between the size of the cranium- and the 
 intellectual capabilities of its possessor. I 
 have known children with the most complete 
 Aztec- like heads susceptible of some amount of 
 education ; they have been taught to talk, to 
 discriminate, to take a real pleasure in the 
 world around them, appreciate the jokes in a 
 dramatic entertainment, and play intelligently 
 with toys. I have under my care now one 
 who has been taught to speak with discrimi- 
 nation, to say the conventional thing, to play 
 on the piano simple airs, to read story books 
 with enjoyment, and to have a practical appre- 
 ciation of right and wrong. They are usually 
 mobile in temperament, sometimes very active 
 
32 MENTAL AFFECTIONS OF 
 
 physically, and always tractable, amiable, and 
 appreciative of kindness. They illustrate the 
 fact that there is such a thing as quality in brain- 
 matter as well as quantity, and that the relative 
 intelligence among feeble-minded children can- 
 not be estimated simply by the tape and calipers. 
 Macrocephalic crania are not unfrequently met 
 with, some being due to hydrocephalus, and 
 others to an increase of the neuroglia of the 
 cerebral mass. I have had patients under my 
 care whose brains were within an ounce of the 
 weight of that of Ouvier, who, nevertheless, were 
 slow in their movements and slower in thought, 
 and were perfect contrasts in intellectual slug- 
 gishness to the volatile microcephalic Aztecs 
 with brains only one fourth the weight. An 
 inspection in these cases revealed the fact that 
 the cineritious portion was pale and that the 
 increased weight was due to the increase of the 
 white substance, and especially of its connec- 
 tive-tissue elements. Another deformation 
 met with in congenital feeble-mindedness is 
 a marked asymmetricality of the two sides 
 of the cranium. There is also in many an 
 increase of the facial development as com- 
 pared with the cranial. The ears are im- 
 
CHILDHOOD AND YOUTH. 33 
 
 planted farther back relatively than in normal 
 heads. The eyes have their canthi too closely 
 approximated in the dolichocephahc cases and 
 too widely separated in the brachycephalic. The 
 palpebral fissures are often narrow and obliquely 
 placed, and the forehead is, not unfrequently, 
 corrugated in consequence of the employment 
 of the occipito-frontalis muscle to raise the lid. 
 At the inner canthi the integument often forms 
 semilunar folds as if the skin were too scanty, 
 which I have proposed to call epi-canthic 
 folds. These are met with in people who are 
 not feeble-minded, but they are more frequent 
 in the latter and are, I believe, signs of degene- 
 racy. 
 
 I have already referred to, and have else- 
 where described in detail, the deformations of 
 the mouth, which I regard as very important in 
 the diagnosis of congenital idiocy. These views 
 have been very generally adopted since I brought 
 them under the notice of the profession. They 
 have, however, been taken exception to in two 
 different quarters and for different reasons. 
 Dr. Kingsley, a distinguished dentist of New 
 York, did me the honour to say that he had 
 come to England mainly to discuss with me the 
 
 3 
 
34 MENTAL AFFECTIONS OF 
 
 question and to see my cases. It was evident 
 to me that he had not had an opportunity of 
 studying the same kind of cases, and he stated 
 that he had met with the palates I have de- 
 scribed in people not feeble-minded. I am not 
 the less convinced that they are signs of degene- 
 racy which, sooner or later, culminate in feeble- 
 mindedness in the offspring, unless intermixed 
 with a stronger strain. This view was con- 
 firmed by many members of the Odontological 
 Society of London when I brought the subject 
 before them. Mr. Keeling said " he had been 
 induced to attend that meeting by the announce- 
 ment of the paper to be read by Dr. Langdon 
 Down. He had understood Dr. Down to ask for 
 information respecting the gradual degenera- 
 tion which might have taken place in the succes- 
 sive generations of the parents of imbecile chil- 
 dren. He was in a position to afford such infor- 
 mation. He knew the grandfather and mother 
 of an imbecile child (the latter, he had reason to 
 know, had been under the care of Dr. Down), and 
 if the discussion were postponed he should be 
 happy to produce the models of the mouths of 
 the grandfather and the mother, and, perhaps, 
 of the imbecile child's mouth also ; and the 
 
CHILDHOOD AND YOUTH. 35 
 
 models would sliow that a very marked and 
 gradual deterioration of the palates and teeth 
 had taken place in the mouths of the individuals 
 referred to, from the grandfather to the imbecile 
 child." Mr. Oakley Coles said that he "for 
 some two years past had experimented upon 
 the anatomy and physiology of the palate, and 
 seemed to have been working side by side with 
 Dr. Down. His results to a great extent con- 
 firmed those of that gentleman." The late Mr» 
 Sercombe said, " Dr. Down's remarks about the 
 high vaulted palate and lunacy being commonly 
 associated had much struck him, and brought 
 to his mind the conditions of one of the oldest 
 families in the realm, who were patients of his, 
 in whom every branch of the family had re- 
 markably high V-shaped palates, and at least 
 two members of the family had been in con- 
 finement." The President of the Odontological 
 Society, the late Mr. Mummery, said " that he 
 had occasionally noticed, in cases where the 
 mental power was deficient, the front teeth 
 were not on the same plane as the molars," an 
 observation I am able to confirm. I am the 
 more desirous of placing these opinions of 
 members of the dental profession on record 
 
36 MENTAL AFFECTIONS OF 
 
 here because Dr. Kingsley, since his return to 
 America, has read a paper " On the Develop- 
 ment of the Teeth " before the Odontological 
 Society of New York in which he reopens the 
 question and makes statements which are not 
 in harmony with my own experience. He says, 
 " In meditating some time since upon the sub- 
 ject I came to the conclusion that, if my 
 deductions were correct, I should find proof of 
 it in an examination of sluggish or feeble 
 intellect, and at that time I wrote this sen- 
 tence : ' In an examination of idiots we shall 
 be likely to find capacious jaws and teeth not 
 crowded.' If a precocious or stimulated brain 
 in infancy urges on and crowds the dental 
 organs in advance of the growth of the jaws, 
 then a brain of low calibre or power will be 
 likely to have associated with it a retarded 
 dentition, but with abundance of room. After 
 this conclusion of my own," he says, " I came 
 across a paper by Dr. Langdon Down. Dr. 
 Down's statements, founded upon his observa- 
 tions of nearly a thousand feeble-minded 
 patients, were so astounding, and so at variance 
 with my theory, that the picture which I had 
 painted seemed to vanish like a vision." Dr. 
 
CHILDHOOD AND YOUTH. 37 
 
 Kingsley, however, visited an asylum for idiots 
 upon Rundall's Island in America, numbering 
 about two hundred, and did not see a single 
 pronounced case of V-shaped dental arch. 
 On visiting my patients he says that " there 
 was no mistaking the fact that there was a 
 larger percentage of the kind of deformities 
 which Dr. Down had described than I had 
 found in any other collection of feeble-minded." 
 Dr. Kingsley attributes the exceptional condi- 
 tion of the patients to their being members of 
 the higher orders of society, but the fact is 
 that my first observations were made on poorer 
 children at Earlswood. 
 
 An able physician in England, Dr. T. Claye 
 Shaw, has tried to show that there are many 
 idiots with well-formed mouths and palates, 
 and with this I agree if he includes acci- 
 dental and developmental cases. My contest 
 is that they are typical of the congenital class, 
 and one value attaching to these observa- 
 tions is that they often afibrd a means of 
 differentiating the latter from the two former 
 classes. Dr. Bourneville, of Paris, has car- 
 ried on investigations on the same subject in 
 France, and in a memoir has generally con- 
 
38 MENTAL A T'P MOTIONS OF 
 
 firmed my views. Dr. Ireland, in his treatise 
 of ' Idiocy and Imbecility,' says, " Dr. T. Claye 
 Shaw took the trouble to write a paper to 
 prove that a highly arched palate is not a sign 
 of the existence of idiocy and imbecility ; that a 
 palatal investigation cannot afford a clue to 
 the mental faculties. Dr. T. Claye Shaw's 
 paper illustrates the confusion of mind one 
 must fall into who studies the physical aspects 
 of idiocy, while he persists in regarding it as a 
 class incapable of further subdivision." 
 
 The feeble-minded have a tendency to become 
 stout, with great development of adipose tissue ; 
 an example of this I related in the ' London Hos- 
 pital Reports ' with the results of medication 
 and diet. 
 
 Common sensation is generally much less 
 acute than in ordinary persons. Pain is borne 
 with wonderful callousness. It is not uncom- 
 mon for children of this class to allow a thecal 
 abscess to be opened with a scalpel without 
 a grimace or without uttering a word. The 
 same thing also applies to the extraction of 
 teeth. This is quite in harmony with what 
 may be expected ; the hyper-sensitiveness of 
 the cultured gentleman, as compared with the 
 
CHILDHOOD AND YODTH. 39 
 
 untutored ploughman, is matter of everj-day 
 observation, well illustrated in the case of the 
 great Sir Eobert Peel, whose sensitiveness cost 
 him his life. Special sensation is also obtuse. 
 Hearing is generally less acute, and this is often 
 an important element in cases of delayed speech. 
 We all know that absence of speech is often the 
 outcome of complete deafness, but it is not 
 sufficiently recognised that a very slight con- 
 genital defect of hearing, is sufficient to cause 
 deferred and defective speech. 
 
 Lesions of sight are very frequent. Conge- 
 nital cataract is very commonly associated with 
 congenital feeble-mindedness. Several cases 
 have also come under my notice of blindness 
 the result of arrested development of the globe. 
 Strabismus is very common, and nystagmus, 
 though less common, is not infrequent. Myopia, 
 but especially hypermetropia, is a frequent 
 accompaniment of congenital mental lesions. 
 Colour-blindness is occasionally met with, but 
 it is difficult to say in how many cases it is from 
 a want of mental power. The sense of smell is 
 ill-developed in a great many and that of taste 
 keeps company therewith. The most nauseous 
 medicines are taken without question, and in 
 
40 MENTAL AFFECTIONS OP 
 
 fact with many its administration is regarded 
 as a mark of attention and appreciated accord- 
 ingly. 
 
 The muscular system is weak. N"ot only are 
 physical efforts feeble, there is no power of 
 sustained endurance. Co-ordination is defec- 
 tive and finely adjusted movements are excep- 
 tional. There is a great tendency to automa- 
 tism and rhythmical actions. Salaams, hori- 
 zontal swayings, and rotations of the head and 
 body are often met with. The lack of muscu- 
 lar power makes itself painfully manifest in a 
 number of instances by the postponement of 
 walking or even of standing. This is a symp- 
 tom which brings children of this class under 
 the notice of the physician or sm^geon. The 
 mother mag:nifies all the little manifestions of 
 intelhgence, but she cannot understand why the 
 child does not walk. There may be no spastic 
 rigidity, no contractures, and yet the little legs 
 are powerless ; they would seem to be unable to 
 obey the behests of the will even were there any 
 will exercising its proper domain. In the large 
 number of notes which I possess of congenital 
 feeble-minded children, walking delayed to the 
 third or fourth year is a very common occur- 
 
CHILDHOOD AND YOUTH. 41 
 
 rence. Imperfect prehension with the upper 
 extremities is also a frequent characteristic, and 
 often the vertical position is rendered impos- 
 sible by virtue of muscular weakness long after 
 children of a similar age are running about. 
 
 There is still one important character with 
 children of this class, which is a great cause of 
 anxiety, viz. postponed or absent speech. I 
 have, in describing the accidental forms of 
 feeble-mindedness, referred to speech as a 
 faculty which is frequently absent, and in the 
 " developmental " class as a faculty which, 
 having been once possessed, sometimes vanishes 
 at special epochs. 
 
 In the class we are now considering delayed 
 speech is universal, permanent absence less 
 common. The lesion of speech in these cases 
 is the outcome of several factors. The form 
 of the mouth is, as I have shown, often 
 abnormal. The high, narrow-vaulted palate 
 presents a formidable difficulty ; this is apt to 
 be intensified by the ill-development of the 
 lower jaw, the horizontal ramus forming too 
 obtuse an angle with the ascending ramus, so 
 that labials are expressed with difficulty. In 
 addition to this the tongue is large, flabby, and 
 
42 MENTAL AFFECTIONS JN 
 
 defective in its muscular movementSj and these 
 are ill-co-ordinated. Again, the congenital 
 defective hearing I have referred to is often 
 another factor. Still further, there is too fre- 
 quently the potent cause of having no power to 
 convert ideas into words, and, alas, the still 
 more potent one of having no ideas to com- 
 municate. 
 
 I have thus, in the limited time at my dis- 
 posal, endeavoured to bring before you the 
 prominent features of what I regard as the 
 three great natural divisions of the sufferers 
 from a grave calamity. Some of the causes 
 which have produced it will occupy our time 
 at our next meeting. 
 
CHILDHOOD AND YOUTH. 43 
 
 LECTURE II. 
 
 Causes of Idiocy. — Accidental Origin. — Developmental Origin. 
 — Congenital Origin. — Influence of Maternal Health ; of 
 Alcoholism ; of Malignant Disease and Syphilis ; of Neu- 
 rotic or Phthisical Inheritance ; of Trades and Professions ; 
 of Marriages of Consanguinity ; of Illegitimacy ; Idiocy 
 from, Deprivation of Senses ; Cretinism ; Influence of " Over- 
 Education " of Women. 
 
 The causes of idiocy or feeble-mindedness 
 will always attract a good deal of attention, 
 and will doubtless, as heretofore, lead to mucli 
 speculative opinion. It will be obvious from 
 tbe classification on which I have insisted that 
 the causes vary in their nature and their 
 date, in the three great divisions to which I 
 have referred. In the " accidental " variety 
 there is usually not much diflBculty in arriving 
 at the cause. The history, as a rule, elucidates 
 the matter. Some are from injury received at 
 birth by necessary instrumental interference, 
 but it is very remarkable how few are sacrificed 
 from this cause. Many years ago, when I was 
 
44 MENTAL AFFECTIONS IN 
 
 assistant to the late Dr. Ramsbotham, I remem- 
 ber bis telling me that tbe cases were very few 
 in wbicb be could trace any cerebral lesion as 
 resulting from tbe employment of tbe forceps, 
 and be must bave known many instances wbere 
 tbe forceps, and especially tbe long forceps, bad 
 been applied less dexterously tban tbey would 
 bave been by bis marvellously accomplisbed 
 bands. During tbe later years of Dr. Ramsbo- 
 tbam's life I took great pains to investigate tbe 
 subject, and my results were greatly in accord 
 witb bis assertion. 
 
 I found tbat among tbe great number of 
 feeble-minded cbildren about wbom I could get 
 tborougbly reliable accounts, in only 3 per cent., 
 including members of tbe tbree great classes, 
 bad tbe forceps or any otber instrument been 
 employed. It is probable, tberefore, tbat in 9 
 per cent, of purely accidental cases instrumental 
 interference migbt bave been tbe principal 
 factor. Far more important, bowever, in tbe 
 production of accidental cases, is tbe prolonged 
 transmission of tbe cbild in tbe maternal pas- 
 sages. In tbe preparation of a paper for tbe 
 Obstetrical Society of London I called attention 
 to tbe fact tbat in so large a proportion as 20 
 
CHILDHOOD AND YOUTH. 45 
 
 per cent, of all idiots whose history I had in- 
 vestigated, there was an undoubted account of 
 suspended animation at birth — a suspension 
 requiring active efforts to bring about resusci- 
 tation. I believe that the members of our pro- 
 fession who have given attention to deformities 
 among children could say how very frequently 
 suspended animation at birth is associated with 
 the contractures and other lesions which they 
 are called upon to treat. 
 
 This cause is more frequently met with in 
 first-born children, for the very obvious reason 
 that the transit of the child is more likely to be 
 delayed to a perilous extent by the smallness of 
 the internal passages and the rigidity of the 
 peringeum usually associated with a primiparous 
 birth. Ergot of rye, when administered to the 
 mother during the parturient hours, has been 
 thought to be a cause of accidental idiocy, but 
 the result of my inquiries has been to establish 
 in my mind a verdict of " not proven." In 
 many of the cases in which ergot has been 
 employed, the very condition for which it was 
 used, viz. delayed transit of the child, has been 
 the cause of the evil rather than the agent 
 which was intended to hasten the birth. More- 
 
46 MENTAL AFi<'ECT[ONS IN 
 
 over, it is extremely difficult to obtain from the 
 mother any information of what was or what 
 was not administered during the period of her 
 peril. The outcome of these remarks is, I 
 think, to show that, independently of what 
 concerns the safety of the mother, mental and 
 physical evil to the child is more likely to be 
 induced by prolonged pressure and a delayed 
 use of instruments than by the early and 
 adroit employment of agents likely to hasten 
 the birth. 
 
 Insolation in infancy is certainly a cause of 
 accidental idiocy. It has fallen to my lot to 
 see a notable number of feeble-minded children 
 who owe their disaster to sunstroke while making 
 the passage of the Red Sea and Suez Canal en 
 route from India, or from exposure in that 
 country. I have at the present time under my 
 care a very good example. There is every 
 reason to regard the case as an accidental one, 
 having reference to the history and the physical 
 configuration of the child, while the mental 
 decadence dates without question from the 
 period when exposure was unavoidable. 
 
 The administration of opium by nurses to 
 keep their charges quiet is often regarded by 
 
CHILDHOOD AND YOUTH. 47 
 
 parents as a possible cause of their little one's 
 defect. From the nature of the case it is very 
 difficult to prove the administration of the 
 drug, and even if that be proved, to associate it 
 with the lesion. I am led to regard this as a 
 very infrequent cause of accidental idiocy, 
 inasmuch as the majority of the cases, where 
 strong assertions have been made as to the 
 furtive administration of the medicament, have 
 in their persons indubitable evidence of the 
 congenital nature of the malady, and, moreover, 
 evidence usually that the cause must be traced 
 far back in intra-uterine life. Much more tan- 
 gible as a cause is morbid sexual erethism, too 
 often induced by nurses who procure the quiet- 
 ness of their charge by means which, even if 
 the mental health is not sacrificed, lead even- 
 tually to grave moral delinquencies. A not in- 
 significant portion, however, break down, and 
 mental hebetude becomes their lot. I would 
 impress on you strongly my conviction that 
 this evil has a very early significance, and the 
 probability of the occurrence must always be 
 kept in view. 
 
 Traumatic injury to the cranium from falls 
 may be, and doubtless is, a cause of accidental 
 
48 MENTAL AFFECTIONS IN 
 
 idiocy. It is readily conceivable that injuries 
 of this kind may prove harmful immediately by 
 concussion or later on by secondary lesions of 
 the brain and its membranes. I am persuaded, 
 however, that it is not so common as a cursory 
 consideration might lead one to believe. A 
 large number of cases are referred by the 
 mothers to falls or suspected falls, the objective 
 evidence of which is entirely opposed to such a 
 theory, cases in which the congenital nature of 
 the affection is beyond dispute. Traumatic 
 causes like opium drugging are, I am con- 
 vinced, but rarely factors in the production of 
 feeblemindedness. 
 
 Meningitis, on the other hand, very fre- 
 quently leads to this variety of idiocy. A large 
 number of cases of accidental idiocy have 
 somewhat of this history. They have been 
 born with nndoubted intelligence ; they have 
 contracted scarlatina, measles, or smallpox ; this 
 has been followed by inflammation of the ear 
 with extension to the membranes of the brain, 
 or the otitis may be set up by catarrh, the 
 inflammatory action extending from the outer 
 to the middle ear or from the pharynx by means 
 of the Eustachian tube. Whatever the origin 
 
CHILDHOOD AND YOUTH. 49 
 
 death does not always take place, tlie little 
 sufferer undergoes a perilous illness with violent 
 convulsions, and, escaping with life, is not unfre- 
 quently left in a condition of mental feebleness. 
 I have made many autopsies in which there was 
 evidence of a long past inflammatory process 
 and in which there was a probability that the 
 anaemic condition of the cerebral convolutions 
 had for a cause the constringing effect on the 
 vessels, of organised lymph at the base of the 
 brain. 
 
 Epileptiform convulsions, whether eclampsio 
 or not, frequently cause accidental idiocy. 
 These may be induced by peripheral irritation 
 of any kind, and, as Dr. West has pointed out 
 in his suggestive and elegant Lumleian lectures, 
 " be the cause what it may by which the fit is first 
 excited, a paroxysm of whooping-cough or the 
 irritation of thread-worms,^ — something which 
 would seem most temporary in its character 
 and furthest removed from any abiding influence 
 on the higher endowments of the nervous 
 system, it yet leaves behind a mark, a stamp, a 
 stain, not unlike what theologians tell us of the 
 flaw which our first parents' sin has left upon 
 our moral nature, — a predisposition in short to 
 
 4 
 
50 MENTAL AFFECTIONS IN 
 
 a great evil." It is, however, in the kind of 
 idiocy which I have termed " developmental " 
 that the results of epileptiform convulsions are 
 the most manifest. 
 
 Hydrocephalus is also an occasional cause of 
 accidental idiocy, more frequently, however, 
 of the congenital variety. I have had under my 
 care a few cases where the hydrocephalus 
 became developed after birth and lessened or 
 destroyed the intellectual faculties of the child. 
 
 Paralysis arising from cerebral haemorrhage 
 occurs as a cause of accidental as well as con- 
 genital idiocy. The amount of intellectual 
 defect varies greatly, some cases are very 
 amenable to instruction while others fail to 
 respond to the efforts made for their benefit. 
 In one case under my care the patient has been 
 taught to play the violin fairly well, well enough 
 to give him great pleasure, using the right 
 hand instead of the left for fingering. 
 
 We now come to the causes of developmental 
 idiocy, and I would first mention the maternal 
 health during pregnancy, which is, I am con- 
 vinced, a very potent factor in the production 
 of that kind of idiocy which I have named 
 " developmental," especially is it so if the devia- 
 
CHILDHOOD AND YOUTH. 51 
 
 tion takes place during the sixth or seventh 
 month. 
 
 The causes which, occurring early in the 
 embryonic life of the child produce congenital, 
 operating later produce developmental idiocy, 
 by which I mean, as I explained in my first 
 lecture, children born with intelligence but 
 whose nervous and intellectual system breaks 
 down at one or other of the developmental 
 epochs. 
 
 The health deviations which lead up to this 
 kind of idiocy are sickness, whether produced 
 by the sea or other causes, uterine haemorrhage, 
 great emotional disturbance or grave febrile 
 disease. The members of this class are very 
 prone to eclampsia at first dentition, to epilepsy 
 or chorea at second dentition, and to epilepsy 
 or chorea, and moral deviations at the period 
 of puberty. At any of these epochs there may 
 be intellectual lesion varying in gravity with 
 the nature of the malady. It is of the greatest 
 importance that cases of this nature should be 
 kept free from all exciting causes of nerve dis- 
 turbance at the epochs referred to, and that 
 intellectual pressure should be disallowed if we 
 wish to avoid a greater catastrophe. With 
 
52 MENTAL AFFECTIONS IN 
 
 care in tlie directions referred to many of this 
 class may escape the perils which want of 
 caution will certainly induce. This is especially 
 the class which breaks down from disturbing 
 causes during the early period of puberty, and 
 whose safety is only secured by frank exposi- 
 tion of the danger which results from moral 
 delinquency. 
 
 The majority, however, of the children about 
 whom opinion is desired falls properly under 
 the head of the congenital class, and if it be 
 asked, What is the cause of congenital idiocy ? 
 my reply is, that in a large number of cases one 
 must seek for several factors. The more one 
 inquires into the history of these cases the more 
 one is convinced that the simple causation 
 which has been referred to by several writers 
 is fallacious, and that in one case to attribute 
 It to intemperance only, in others to marriage 
 of consanguinity, is to take a narrow view of the 
 cause of the condition. I cannot but feel that the 
 inquiry really becomes an inquiry into the pre- 
 efficients or all that has gone to the making of 
 idiocy. There can, I think, be no doubt that 
 one of the great causes is heredity. It is im- 
 possible to devote much time to the elucidation 
 
CHILDHOOD AND YOUTH. 53 
 
 of this subject without obtaining overwhelming 
 proof of the transmissible nature of neurotic 
 disease. If there are, as I am convinced, 
 physical indications of the congenital trouble, 
 there are also to be found in many of the pro- 
 genitors indications of decadence. In the in- 
 vestigation into the antecedent history of 2000 
 cases, in 36 per cent, of the fathers I failed to 
 get any history which could throw light upon 
 the affliction, and the same failure occurred 
 in 38 per cent, of the mothers, but in only 16 
 per cent, did I fail in obtaining a grave history 
 of physical or psychical decadence from one or 
 other of the progenitors. But even where there 
 was no evidence of gross departure from a 
 normal standard, one could not fail to notice 
 frequently cranial and other signs of racial 
 degeneration, such as narrow palates, rabbit 
 mouths, bad foreheads and facial exaggerations. 
 The causes of idiocy are not always operative 
 in a single generation, and it is only by having 
 the opportunity of examining into the physical 
 conformation of parents and grandparents that 
 one can see that idiocy in many cases is the 
 culmination in the individual of a gradual 
 degenerative process. Even with all the care 
 
64 MENTAL AJi^PECTIONS IN 
 
 I have taken in the investigation I can 
 only hope that my results are approximately 
 correct. There is much difficulty in getting 
 the information one needs on account of mis- 
 takes respecting the import of one's questions, 
 and there are still further difficulties among 
 those whose education would enable them to 
 appreciate the inquiries made, owing to a desire 
 on their part to keep in the background many 
 points which would have a very important 
 bearing on the problem. I have often found it 
 useful to interrogate the parents separately, 
 and have in this way obtained very useful data, 
 each one in turn being not unwilling to supply 
 all the facts which would appear to point to 
 something in the opposite family as the potential 
 cause of the affliction. I have endeavoured 
 in such investigations to keep myself free from 
 the bias of former statistics, especially those of 
 the late Dr. Howe, of Massachusetts. 
 
 It had been a matter of speculation with me 
 whether great disparity of age of the parents 
 was not likely to be a cause, and strength was 
 given to this supposition by a few remarkable 
 cases which came under my observation — cases 
 where the disparity was very great and where 
 
CHILDHOOD AND YOUTH. 65 
 
 fhere was feeble-mindedness in tlie offspring. 
 On making inquiries, however, over a large 
 field, I was led to results whicli, though, in- 
 teresting, did not tend to confirm the specu- 
 lative opinions I at first entertained. I found 
 that the average age of the fathers of feeble- 
 minded children at their birth was 35i\, and 
 that of the mothers Sl-fi^- ; a disparity of only 
 4^2 years. On looking about for some standard 
 of comparison I met with Mr. Galton's statistics 
 on the ages of the parents of men of scientific 
 attainments at the period of their children's 
 birth. Mr. Oalton states that their father's 
 average 36, and their mothers 30 years. With 
 reference to the ages of the fathers in whose 
 case we should naturally look for the potential 
 cause there is a remarkable similarity, the 
 advantage being on the side of the procreator 
 of feeble-minded children to the extent of -5^2" 
 of a year, while there is less disparity of age 
 among the parents of the feeble-minded than 
 among the parents of men of prominent ability. 
 The difference being six years in the case of 
 Mr. Galton's selected men's parents as against 
 4y2 in the case of the parents of afilicted ones. 
 It is clear, therefore, that disparity of age of 
 
56 MENTAL AFFECTIONS IN 
 
 the parents, although doubtless having an im- 
 portant influence on the wellbeing of the off- 
 spring, does not rank as an important factor in 
 the production of idiocy. 
 
 It is worthy of remark that only 20 per cent, of 
 the mothers gave birth to idiots at the age which 
 Aristotle regarded as the most suitable one 
 for a vigorous progeny, viz. between thirty and 
 thirty-four. "Whereas, according to Mr. Gralton, 
 no less than 34 per cent, of men of eminence 
 are given birth to by their mothers at that age. 
 
 In a paper contributed to the Obstetrical 
 Society of London I have indicated that there is 
 a greater liability to idiocy among primiparous 
 children; 24 per cent, of the 2000 idiots exa- 
 mined by me being first-born children. I found 
 that seven was the average number of living 
 children born to those parents who have had an 
 idiot child, prolific child-bearing rather than the 
 opposite appearing to be the characteristic of 
 people begetting feeble-minded children. I 
 ventured to suggest that the preponderance of 
 idiocy in first-born children might be due to 
 the exalted emotional life of the father and 
 mother as well as to the increased difficulties 
 of parturition, and to the attendant greater risk 
 
CHILDHOOD AND YOUTH. 57 
 
 of suspended animation to wMcIl I have already 
 referred. Curiously enough, while 24 per cent, 
 of idiots generally are primiparae no less than 
 40 per cent, of resuscitated idiots come under 
 this category. I have long held and taught the 
 opinion that suspension of animation must be 
 regarded as one of the pre-efficients of idiocy. 
 
 I do not find that the production of twins is 
 a very appreciable cause of idiocy. 2 per cent, 
 only of my collection were twins, while, on the 
 other hand, in 2 per cent, of my cases the 
 mothers had given birth to twins who were not 
 afflicted in any way. 
 
 I am aware that this opinion is rather differ- 
 ent from that entertained by Dr. Arthur Mit- 
 chell, C.B. His statistics on the subject are 
 somewhat different from mine. His observa- 
 tions were made in Scotland, and while I find 
 that one in fifty idiots is one of twins, he found 
 one in forty to come under this category. 
 Having regard to the greater tendency to 
 abnormal presentations, to the increased neces- 
 sity for instrumental interference, and the 
 greater liability to premature birth, I was pre- 
 pared to expect a much larger number of idiots 
 to have been twin children. 
 
68 MENTAL AFFECTIONS IN 
 
 From what I have previously said it will be 
 seen that I attach immense importance to the 
 emotional life of the mother during the period 
 of pregnancy, and I feel convinced it is one of 
 the most potent of all the pre-efl&cients of 
 idiocy. In 32 per cent, of my cases there was 
 a well-ascertained history of great mental dis- 
 turbance on the part of the mother at that 
 time. My ever- to-be-revered teacher, the late 
 Dr. W. B. Carpenter, relates how at the Siege 
 of Landau in the year 1793, in addition to a 
 violent cannonading, which kept the women in 
 a constant state of alarm, the arsenal blew up 
 with a terrific explosion, which few could bear 
 with unshaken nerves. Out of 92 children 
 born in that district within a few months after- 
 wards 16 died at the time of birth, 33 languished 
 from eight to ten months and then died, 8 
 became idiots and died before the age of five 
 years, and 2 came into the world with numerous 
 fractures of the bones of the limbs, probably 
 caused by irregular uterine contractions. I 
 can from my own experience refer to the 
 number of cases of feeble-mindedness which 
 were the outcome of the Siege of Lucknow, 
 and in many others the result of sudden shocks 
 
CHILDHOOD AND YOUTH. 59 
 
 from the receipt of distressing tidings of death 
 or other calamities. 
 
 Another element in the etiology of idiocy is 
 the physical health of the mother duriug the 
 period of pregnancy. In 20 per cent, of my cases 
 there was marked physical disturbance. In 4 per 
 cent, of these there was a history of serious falls, 
 falls from which uterine haemorrhage followed ; 
 the other cases were those in which there was 
 prolonged ill-health and in which vomiting 
 was a prominent symptom. They were all 
 such events or ailments as would be likely to 
 interfere with the nutritive life of the embryo. 
 
 By far the most potent influence in the pro- 
 duction of idiocy is the general physical and 
 mental health of the progenitors. This I have 
 already touched upon in speaking of heredity. 
 One cannot fail to be struck by the nature of 
 the stock from which such patients have sprung, 
 and one has not far to seek for most potent 
 causes. If, after a perusal of Mr. Glalton's 
 statistics of the antecedents of men of science, 
 we compare the antecedents of my 2000 cases, 
 the contrast is so great that all wonder at the 
 production of mental feebleness vanishes. With 
 fathers phthisical and irascible, with mothers 
 
60 MENTAL AFFECTIONS IN 
 
 feeble in judgment and so emotional that every- 
 tliing is a cause of fright, one is astonished 
 that they should have procreated any sane 
 child at all, and, indeed, in some cases the 
 whole progeny of these parents is puny and 
 feeble, failing to perform social duties. I find 
 that in 16 per cent, of the cases there was 
 insanity or marked feeble-mindedness on the 
 father's side of the family, and in 15 per cent, 
 there was the same condition on the mother's 
 side. Severe emotional disturbance, bordering 
 on insanity, occurred in 4 per cent, of the 
 fathers, while a like affection in the mothers 
 occurred in 13 per cent. These cases of emo- 
 tional disturbance were very marked. Some of 
 uncontrollable passion, ill-regulated grief, or 
 morbid sentiment ; others where clergymen 
 had given up their cures through needless fear 
 of stopping in the middle of their sermons ; 
 others, again, where ruin had been brought 
 about by alienation of friends or ill-regulated 
 lives. 
 
 I have found it very difficult to get at reliable 
 statements with regard to the influence of alco- 
 holic intemperance. There is not only a desire 
 to conceal the fact, but there is evidently such an 
 
CHILDHOOD AND YOUTH. CI 
 
 elastic gauge as to what constitutes intemper- 
 ance that my numbers must be regarded as 
 much within the truth. There was, however, 
 avowed and notorious intemperance in 12 per 
 cent, of the fathers and 2 per cent, of the 
 mothers. I found, however, that the propor- 
 tion varied extremely with the stratum of 
 society from which my records were taken. In 
 the members of the upper ranks in the social 
 scale it was an insignificant factor, while when 
 the inquiries related to the lower social class it 
 became a factor of great importance, and in 
 fact there appeared to be a gradually increasing 
 percentage as the lowest stratum was reached. 
 
 I feel quite sure that drunkenness must be 
 placed among the factors in the production of 
 idiocy. I have had under my observation several 
 families in which the majority of the children 
 were mentally feeble, and the whole more or 
 less fatuous, whose fathers were never very 
 drunk yet never perfectly sober, and in these 
 cases the chronic alcoholism had produced a 
 condition of mental hebetude from the slow 
 poisoning to which they were subjected. 
 
 Some of the cases are the result of slow 
 deterioration of the father's mental and physical 
 
62 MENTAL AFFECTIONS IN 
 
 powers, others are the result of procreation 
 having taken place during a debauch. I have 
 elsewhere called attention to cases of idiocy 
 resulting from well-authenticated instances, 
 where procreation could only have occurred 
 under such a condition. Such cases have a 
 close family likeness to each other. Dr. Elam 
 states in ' A Physician's Problem,' that on 
 the removal of the spirit duty in Norway 
 insanity increased 50 per cent, and congenital 
 idiocy 150 per cent. Mr. Huth quotes from 
 Dr. Lannurien, of Morlaix in Bretagne, where 
 he says : "I do not hesitate to attribute the 
 greater number of cases of idiocy in this esta- 
 blishment to that cause," viz. alcoholism. I 
 certainly cannot bear that out by my experience 
 in England. Some years since, when I ex- 
 pressed my conviction that acute alcoholism 
 produced a distinct form of idiocy, it was 
 received with some questioning. I had, how- 
 ever, found, from conversation with M. Morel, 
 of Pouen, that he had noticed similar facts. 
 Dr. Puez has observed that idiocy was very 
 common among the miners of Westphalia, who, 
 living apart from their wives, only came home, 
 and generally got drunk, on their holidays. 
 
CHILDHOOD AND YOUTH. 68 
 
 M. Demeaux lias also recorded parallel cases. 
 Dr. Delasiauve says that in the village of Careme, 
 whose riches were its vineyards, the inhabitants 
 were forced to be a little more sober in conse- 
 quence of ten years' vine disease. This, he says, 
 had a sensible effect in diminishing the cases of 
 idiocy. Demeaux assured himself that of thirty- 
 six epileptic patients he bad under his observa- 
 tion for twelve years, and whose history he was 
 able to trace, five were conceived in drunkenness. 
 He observed two children of the same family 
 suffering from congenital paraplegia whose 
 conception also took place while the father 
 was drunk. 
 
 I am not aware that any observations have 
 been made with reference to the relation of 
 malignant disease to idiocy, nor do I wish to 
 attach more importance to it than it deserves. 
 Nevertheless it is interesting to notice that 3 
 per cent, of the fathers and 5 per cent, of the 
 mothers, in all 8 per cent, of the progenitors, 
 died from cancer. Goitre occurred in 2 per 
 cent, of the mothers, but not once in a father. 
 
 I have made a very careful examination as 
 to the relation of syphilis to idiocy, and my 
 later inquiries have confirmed the opinion 1 
 
64 MENTAL AFFECTIONS IN 
 
 have long taught, that syphilis is not an impor- 
 tant factor in the production of idiocy. In not 
 more than 2 per cent, are there signs of in- 
 herited syphilis. In making my investigations 
 I have availed myself of the valuable observa- 
 tions made some years since by my friend and 
 colleague Mr. Hutchinson, to whom the profes- 
 sion of medicine owes so much for his original 
 researches. Dr. Shuttleworth confirms my 
 opinion from investigation in another field. 
 
 I met with a history of epilepsy in 3 per cent, 
 of the fathers and in 6 per cent, of the mothers. 
 Phthisis exercises a very important influence 
 among the progenitors. Several years ago I 
 called the attention of the profession to this 
 circumstance, and endeavoured to show that 
 the peculiar form of idiocy to which I referred 
 in my previous lecture as the Mongolian type 
 was the outcome of a predominance of phthisis, 
 and that it included about 10 per cent, of all 
 idiots. I find that there is a marked history of 
 this disease in 25 per cent, of the fathers or 
 their immediate relatives, and the same thing 
 occurs in 20 per cent, of the mothers. 
 
 In 23 per cent, of the cases there was a 
 history of idiocy, mental feebleness, insanity, or 
 
CHILDHOOD AND YOUTH. 65 
 
 other grave neurosis in one or several of the 
 brothers and sisters. 
 
 I have already alluded to the influence of the 
 emotional life of the mother on the embryo, but 
 I have also a large mass of evidence tending to 
 show that just as intemperance at the time of 
 procreation may eventuate in degenerate off- 
 spring, so various kinds of mental perturbation 
 of the father at that time may so result. I have, 
 for example, several instances of the father be- 
 getting healthy children, except when he was 
 the subject of recurrent mania, when idiocy 
 resulted to the children conceived at that time. 
 In like manner I have examples of healthy chil- 
 dren being produced except when the mer- 
 chant's business speculations have been hazard- 
 ous, when the clergyman's parish has been 
 disturbed, or the dissenting minister's church 
 meetings have been stormy. 
 
 There are many facts which tend to indicate 
 that the mental condition of the embryo takes 
 its impression from the mental condition of the 
 father at conception, and that there is a 
 markedly varying potentiality in the sperm- 
 cell. 
 
 It would be a very interesting question to 
 
66 MENTAL AFFECTIONS IN 
 
 determine how far various trades and profes- 
 sions were allied with idiot offspring. I have 
 carefully investigated the matter but have 
 arrived at the conviction that I could not, from 
 my cases, although very numerous, draw any 
 very safe deductions. My patients have come 
 from all parts of the British dominions, and 
 include every variety of social rank, but still 
 I am conscious that a very unfair proportion 
 must have been drawn from this great city, that 
 although I may have accumulated a fair number 
 of histories from agricultural, I am sure there 
 is a deficiency of a due proportion of cases 
 from manufacturing districts, the great bulk 
 having come from the southern counties of 
 England and only a small proportion having 
 come to me from the great manufacturing 
 centres. I therefore feel I am unable to draw 
 any very safe deductions with regard to the 
 influence of employments generally in the pro- 
 duction of, or alliance with, feeble-mindedness. 
 Still there is a possibility of comparing the 
 relative association of this affliction with the 
 different professional classes, and especially with 
 what are termed the three learned professions. 
 I have collected from my notes four hundred 
 
CHILDHOOD AND YOUTH. 67 
 
 cases with fair social antecedents, and I find that 
 75 per cent, are the children of merchants, coun- 
 try gentlemen, officers in the army and navy, 
 gentlemen of independent means and liberal 
 education, and members of the titled aristocracy. 
 No less a proportion than 25 per cent, are the 
 children of members of one or other of the 
 three learned professions, a proportion which 
 I take to be extremely large. On analysing 
 still further the cases supplied by these three 
 professions, I find that 3 per cent, are the chil- 
 dren of lawyers while 4 per cent, are the chil- 
 dren of members of my own profession. The 
 remarkable circumstance, however, in the in- 
 vestigation is that no less than 18 per cent, are 
 the children of members of the clerical profes- 
 sion. Mr. Galton has made some interesting 
 investigations from an opposite standpoint. 
 He takes the members of the councils of some 
 of the prominent scientific societies of London, 
 such as the Royal, the Linnsean, the Greological, 
 &c, and makes the very fair inference that the 
 100 Members of the Councils of such Societies 
 may be taken to be men of marked scientific 
 attainments and of intellectual prowess. He 
 inquires into the various professions of the men 
 
68 MENTAL AFFECTIONS IN 
 
 who have had such representative offshoots. 
 He finds that the legal profession, which, accord- 
 to my statistics, procreates fewest idiots, gives 
 birth to 11 per cent, of the foremost men of 
 eminence ; that the medical profession with its 
 4 per cent, of idiots, gives origin to only 9 per 
 cent, of scientific men, while the clergy, who 
 have the maximum amount of idiocy, give birth 
 to only 6 per cent, of men of science. In other 
 words, while lawyers give origin to nearly three 
 times as many scientific men as do the clergy, 
 the clergy, on the other hand, beget six times as 
 many feeble-minded children as do lawyers. 
 Now, I venture to suggest that there is more 
 than a mere accident in this. I bring it for- 
 ward because, interesting in itself, it is also 
 interesting in the support it gives to the theory 
 that a process of natural selection has been 
 taking place. 
 
 The life of the lawyer is such as to aggregate 
 to that profession men of strong resolve, of 
 mental and physical vigour, men who must be 
 conscious that it is an avocation in which they 
 must bring to their aid an imperturbable will 
 and a good digestion. In the medical profes- 
 sion there is a larger average of moderate 
 
CHILDHOOD AND YOUTH. 69 
 
 success. The race is not so urgent and the 
 claims not so imperious; an aggregation of 
 feebler elements is likely to ensue. But in the 
 clerical profession a moderate success is still 
 more ensured, and there is less claim among 
 the rank and file for great mental and physical 
 exertion. It is a profession which draws to- 
 wards it many good men, but whose goodness 
 need not be the outcome of great mental or 
 physical power. Moreover, when once within 
 the boundary of the Church, their usefulness 
 and success may be in direct proportion to their 
 retirement from intellectual turmoil, and to 
 their assiduous cultivation of the amenities of 
 life. It is a profession which, by its very gentle- 
 ness, is likely to draw to its enclosure less the 
 powerful will, the vigorous thought, and the 
 ratiocinative brain, than those with bodies weak 
 and emotions strong ; men who may be classed 
 as gently good rather than as grandly great. 
 
 The influence of marriage of consanguinity 
 on the production of idiocy has engaged much 
 consideration. There is a strong popular bias 
 in favour of the theory that marriages of consan- 
 guinity are an unmixed evil, and that they are 
 always subversive of physical and mental per- 
 
70 MENTAL AFFECTIONS IN 
 
 fection. Mr. Huth has, however, in his classical 
 work on the marriages of near kin, brought an 
 amount of evidence on the other side of the 
 question which should make us hesitate before 
 we dogmatise on the subject. 
 
 About twenty years since I investigated the 
 matter, and have ever since kept it prominently 
 before me. I must confess that I approached 
 the question with a strong bias in favour of the 
 popular opinion. My inquiries, however, led 
 me to see that the whole subject was worthy of 
 reconsideration. The data on which accurate 
 calculations can be made are unfortunately 
 wanting, inasmuch as there is great uncertainty 
 as to the number of people born who are the 
 children of first cousins. I hope that at the 
 next census this may be remedied, and that we 
 may have reliable information on which to 
 build more conclusive arguments. We want 
 to know how many healthy and capable people, 
 men and women who are doing the world's 
 work, are the children of cousins, before we 
 can determine what, if any, influence the mar- 
 riage of cousins has in producing mental 
 feebleness. In the absence of such data I made 
 inquiries among the out-patients at the London 
 
CHILDHOOD AND YOUTH. 71 
 
 Hospital, and found "5 per cent only were the 
 children of cousins. It is true that my area 
 was a limited one, and it is possible that the 
 percentage is a low one. However, the people 
 I did meet with who claimed to be the product 
 of consanguineous marriages were wonderfully 
 fine specimens of humanity. They were, as a 
 whole, really above the average in physique and 
 vigour. I made similar investigations among 
 the employes in an institution, and found ap- 
 proximately the same result. Other inquirers, 
 however, have made their results rather higher, 
 and have, therefore, in like proportion weakened 
 the argument against consanguineous unions. 
 Thus, M. Boudin, using the French of&cial re- 
 turns from 1853 to 1859 inclusive, says that of 
 every 100 mixed marriages, there were 9 con- 
 sanguineous, while from another official return 
 of marriages in France in the years 1863 to 
 1865, of every 100 mixed marriages 1'28 were 
 consanguineous. M. Dalby has shown that 
 having regard to the records obtained in the 
 offices of the Mairie at Paris, that the results 
 obtained both by M. Boudin and myself are 
 probably too low, and that 1*4 per cent, is the 
 proportion of consanguineous marriages in 
 
72 MENTAL AFFECTIONS IN 
 
 Paris, a larger percentage than that derived 
 from the official returns of France generally. 
 Mr. George Darwin, in a paper read before 
 the Statistical Society, endeavours to arrive at 
 approximate results by a calculation based on 
 the number of same name marriages, and comes 
 to the conclusion that the ratio of consan- 
 guineous marriages in London is 1"5 per cent, 
 and in country districts 2*75 per cent. Having 
 regard, therefore, to results arrived at by dif- 
 ferent observers, I think that until we have 
 more authoritative data, 1 per cent, may be 
 taken as the percentage of marriage of first 
 cousins. Dr. Arthur Mitchell, C.B., estimates 
 them, at a rough guess, on the basis of his 
 inquiries in Scotland at 1'5 per cent. 
 
 Mr. Huth marshals a great many facts to 
 prove the position which he takes. He has no 
 difficulty in appealing to the early history of 
 the world to show that consanguineous mar- 
 riages were the rule. Close intermarriage was 
 practised by the great founders of the Hebrew 
 race. Among the Ancient Egyptians and 
 Persians he indicates that incestuous marriages 
 were common in the kings and people of high 
 rank without apparently any evil result, and he 
 
CHILDHOOD AND YOUTH. 73 
 
 shows bj numberless appeals to Athenian and 
 Spartan history how frequent, and yet how 
 harmless, was marriage of near-of-kin. The 
 whole question has been discussed with an 
 amount of partisanship, which is very remark- 
 able. One disputant goes so far as to attribute 
 hydatids in the liver to consanguineous unions, 
 others again charge to marriages of near kin 
 '' organic degeneration fatal to the propagation 
 of the species." 
 
 Dr. Shuttleworth has recently published a 
 paper on the subject, in which he discusses the 
 question with marked moderation. His statis- 
 tics, gathered in the North of England, are 
 slightly different frora mine, gathered in the 
 South, and are on the surface less significant of 
 the danger of the unions we are discussing 
 than were mine. Although I have no doubt of 
 the care with which Dr. Shuttleworth's cases 
 were taken, there is always a danger of the 
 friends not appreciating the question, or of 
 desiring to conceal the relationship, and so 
 making the percentage of births from the union 
 of cousins too low. They are not so likely to 
 exaggerate the percentage by the assertion of 
 a relationship which does not exist. In a 
 
74 MENTAL AFFECTIONS IN 
 
 careful examination of 852 cases of known 
 parentage I found tliat 60 were cliildren of 
 consanguineous marriages, or at tlie rate of 7 
 per cent., wliile among these 46 or 5 '4, per cent., 
 were first cousins. Dr. Shuttleworth, in ana- 
 lysing 900 cases, found tliat 5*1 per cent, were 
 consanguineous marriages, and of these 2*9 per 
 cent, first cousin marriages. While Dr. Shuttle- 
 worth finds that 5 is the average number of chil- 
 dren born to relatives who have intermarried, I 
 find that the average number of children born 
 under like circumstances is 6*9. It will be 
 observed that the latter figures are not far 
 removed from the average of my 2000 cases, 
 which is 7, so that there is not much to be said 
 as to consanguineous marriages being less pro- 
 lific than others. I am conscious, moreover, 
 in considering my statistics and those of Dr. 
 Shuttleworth, that I am comparing things 
 which are not the same ; his cases do not include 
 epileptic children, whereas mine do. This 
 may account in some measure for the disparity. 
 Since I wrote on the subject twenty years ago 
 I have continued making observations, and have 
 no reason to materially alter the percentages at 
 which I then arrived. I have recently gone 
 
CHILDHOOD AND YOUTH. 75 
 
 over tlie notes of 400 fresh cases ; tliey have 
 been taken v^ith great care, and I am certain 
 that no error has crept in. Of the 400, 26 
 were children of consanguineous unions, or 6^ 
 per cent., a difference so small as rather to con- 
 firm the value of my statistics on the larger 
 number. Nineteen of these were the children 
 of j&rst cousins, or 4*75 per cent. ; 6 were chil- 
 dren of second cousins, and 1 of third. When 
 1 came to analyse my cases further I was 
 struck with the obvious causes of their feeble- 
 mindedness, other than the marriage of near 
 kin, which the notes of my cases brought to 
 light. I took out of my portfolio 20 unselected 
 cases, and on examining the Hfe-history of their 
 progenitors, I found that in 1 only was the 
 consanguinity of the parents the only discover- 
 able factor. I am convinced that frequently the 
 absence of investigation into the other possible 
 factors has led to such contradictory opinions 
 on this subject. Take an illustration from my 
 notes culled by chance from my portfolio. 
 
 J. T. W — , born in the parish of St. Luke's, 
 1866. His father is a lever escapement maker, 
 his mother worked as a tailoress before her 
 marriage. Father always subject to headache 
 
*?Q MENTAL AFFECTIONS IN 
 
 and to dizziness, frequently to fainting. Mother 
 dreadfully nervous ; her uncle died insane ; had 
 a cousin imbecile; the grandmother also was 
 extremely nervous. 
 
 He is the first-born child and had five brothers; 
 two have died, one from a fit during whooping- 
 cough, and the other from bronchitis ; one of 
 those living is paralysed ; another, three years 
 and five months old, cannot talk. His father fell 
 down in a fainting fit (epilepsy ?) which fright- 
 ened his mother very much when five months 
 advanced in pregnancy and brought on uterine 
 haemorrhage. We read further that the father 
 and mother were first cousins, but it is absurd 
 to suppose that this was the most important 
 factor in the production of the child's idiocy. 
 No one could contemplate the union of two 
 such persons, whether related or not, without 
 predicting disastrous results to their progeny. 
 Although looked at superficially my statistics 
 are rather less favorable to the marriage of first 
 cousins than are those of many other observers, 
 I am strongly of opinion that, having regard to 
 the remarkable antecedent neurotic history of 
 the first cousins who have married and pro- 
 created feeble-minded children, the evil appa- 
 
CPIILDHOOD AND YOUTH. 11 
 
 rently resulting is that where there is hereditary 
 predisposition the intermarriage of relations 
 determines the concurrence of two morbid 
 factors, and this may account for the undoubted 
 greater frequency of feeble-minded children 
 among the progeny of cousins than among those 
 of mixed marriages. My views are quite in 
 harmony with those of Dr. Charles Withington, 
 who regards morbid inheritance rather than 
 specific degenerative tendencies as accounting 
 for all infirmities met with in the offspring of 
 cousins. 
 
 It is interesting to note that Dr. Kerlin, of 
 Pennsylvania, a remarkably accurate observer, 
 arrives at precisely the same conclusion as I 
 have, that 7 per cent, of feeble-minded people 
 are the children of consanguineous marriages. 
 
 Dr. Voisin made a careful examination of 
 1077 of his patients at Bicetre and Salpetriere, 
 and in no instance could healthy consanguinity 
 be regarded as the cause of idiocy, epilepsy, or 
 insanity. 
 
 I have thus endeavoured to show that while 
 the marriage of cousins insures a degenerate 
 offspring where there is something morbid in 
 the family history — where phthisis, scrofula. 
 
78 MENTAL AFFECTIONS IN 
 
 and especially the neuroses exist, I am by no 
 means sure tliat by a judicious selection of 
 cousins the race might not be improved. Dr. 
 Olouston thinks there seems to be a special 
 tendency for members of neurotic families to 
 intermarry, and that an afifective afi&nity 
 amongst such tends to love and marriage. I 
 must say that my experience, on the contrary, 
 would rather lead me to agree with Mr. Grant 
 Allen that "what we each fall in love with 
 individually, is our moral, mental, and physical 
 complement." The intermarriage of cousins 
 arises in all probability from their seeing and 
 knowing more of one another, without com- 
 mitting themselves to an engagement, than can 
 be possible in ordinary life. Other things 
 being equal, I cannot but believe that the 
 physiological law is more usually followed, 
 seeking our unlike and our opposite. However 
 that may be, there is no strong argument, in 
 my opinion, to be based on an inquiry into the 
 etiology of idiocy in favour of the doctrine that 
 consanguinity per se is an important factor in 
 the production of the evil, and that this doctrine 
 is held is shown by the writings of Devay, of 
 Lyons, who asserted '^that in pure consan- 
 
CHILDHOOD AND YOUTH. 79 
 
 guinity, isolated from all circumstances of 
 hereditary disease, resides, i]}so facto, a principle 
 of organic vitiation." Commencing the inves- 
 tigation twenty years ago, and continuing it 
 up to the present time, I am able to agree with 
 Dr. Shuttleworth, that if a close scrutiny does 
 not reveal any hereditary weakness, neurotic or 
 otherwise, that the facts and figures alone will 
 not in all instances justify us in " forbidding 
 the banns." 
 
 Illegitimacy has been regarded as a cause of 
 idiocy. Dr. Arthur Mitchell, from statistics 
 taken in Scotland, where illegitimacy appears to 
 be frequent, came to the conclusion that it is a 
 very common cause. He supports the proba- 
 bility of this by reference to the superior viability 
 of legitimate as compared with illegitimate 
 children. Thus at Berlin every twenty-fifth 
 child of the legitimate and every twelfth child 
 of the illegitimate were stillborn, and after 
 birth the mortality of the legitimate before the 
 age of five years is to that of the illegitimate as 
 6 to 3. 
 
 I cannot but think that these statistics are 
 open to another explanation. My own inves- 
 tigations do not throw much light on the sub- 
 
80 MENTAL AFFIiCTIONS IN 
 
 ject, because my 2000 cases are mainly from 
 children born in wedlock, the illegitimate cases 
 finding their way into the workhouses. Among 
 the few that have come under my notice where 
 there was reason to suspect their legitimacy, 
 there has been enough in the anxieties of the 
 mother's position to account for the disaster. 
 With the prospect of giving birth to a child 
 with a compromised position one cannot wonder 
 that the agony of mind incident to it, should 
 arrest the development of the embryo and give 
 rise either to congenital or developmental idiocy. 
 I am quite prepared, therefore, to expect that in 
 a different class than that from which my sta- 
 tistics are drawn illegitimacy may be a potent 
 emotional factor. 
 
 Attempts to produce abortion have been 
 also regarded as a cause, and it is possible that 
 this may be one among others to add to the 
 numbers of feeble-minded children the outcome 
 of illegitimacy. I am, however, not able from 
 my personal experience to confirm or negative 
 the statement. 
 
 Idiocy is occasionally induced by deprivation 
 of the senses. The case of Laura Bridgman 
 (although not an idiot) has become known 
 
CHILDHOOD AND YOUTH. 81 
 
 wherever the English language is spoken, as a 
 triumph of the perseverance of the late Dr. Howe 
 over difficulties which seemed insurmountable. 
 I have had one such example under my care. 
 The subject of the deprivation was a boy who 
 could neither see, hear, nor speak, and this de- 
 privation was from birth. He had a very acute 
 sense of touch and that of smell was equally 
 good. He knew by their odour all those who 
 were brought into daily relation with him, and 
 caressed lovingly those who ministered to his 
 wants in the way of food and warmth. Attempts 
 were made to teach him to associate actions with 
 things, especially articles of food. I tried to 
 teach him a sign for sugar (of which he was 
 very fond) by the movement of the hand in a 
 vertical direction, but without success, although 
 it was repeated again and again with most 
 persevering efforts. It was, unfortunately, a 
 case in which there was a damaged cerebrum, 
 and he became epileptic. It was most remark- 
 able, however, how at once he smelled out his 
 friends and manifested by a smile his conscious- 
 ness of their proximity. That smile was always 
 a reproof to us, who had full possession of our 
 senses, for our occasional petulence at things of 
 
 6 
 
82 MENTAL AFFECTIONS IN 
 
 minor import, wliile this deprived boy never 
 whined but appeared delighted at the most 
 insignificant creature comforts. 
 
 There is a very important class of cases which 
 owes its origin to malaria or other endemic 
 causes, and which is called Cretinism. A great 
 deal of attention has been given to this disease, 
 and I have had the opportunity of studying it 
 myself in the Italian Valley of Aosta. Here I 
 found it in greater profusion than in any of the 
 valleys of the Bavarian or Swiss Alps. The 
 fact that cretinism is not confined to the valleys 
 of mountainous regions but is found also along 
 the course of the great rivers, suggests the pro- 
 bability of its having a malarial origin. Every 
 variety of theory has been resorted to^ from the 
 presence of iron in the water to the presence of 
 magnesia. Cretinism is not unknown in Eng- 
 land, and has been found in Derbyshire and 
 some parts of Yorkshire, I have seen several 
 cases coming from one part of Somersetshire, 
 not to be distinguished in their general features 
 from those met with in the Swiss and Italian 
 valleys. Virchow and Zillner both trace a con- 
 nexion between marsh fever and acute affections 
 of the thyroid gland. Certain it is that, while 
 
CHILDHOOD AND YOUTH. 83 
 
 the goitrous people are not necessarily cretins, 
 the race tends by a process of gradual deterior- 
 ation to cretinism. A large number of cretins 
 met with in the Yalley of Aosta were not goitrous 
 in the least degree, but their grandparents, who 
 were not cretins, had enormous thyroid glands 
 and the peculiar tawny look which is charac- 
 teristic of cretinism as well as of palludal poison- 
 ing. Cretinism is, however, met with in Eng- 
 land sporadically. My colleague, Mr. T. B. 
 Curling, was the first to call the attention of 
 the profession to these cases, in the year 1850. 
 Without having been aware of his paper I 
 brought a case before the Pathological Society 
 in 1869, having had cases under my observation 
 from the year 1860. I have now had altogether 
 twelve sporadic cretins under my care, and in 
 the majority there was reason to believe that 
 they were procreated during the intemperance 
 of the father, some of the later ones could not 
 have been procreated under any other condition. 
 They all had a very great resemblance to each 
 other, most of them had their growth arrested 
 at the period of first dentition, in three of the 
 number, however, growth was not arrested 
 until the period of second dentition. They all 
 
84 MENTAL AFFECTIONS IN 
 
 had two characteristics ; there was no evidence 
 of the presence of a thyroid gland, and they all 
 had puffy swellings, which Mr. Curling showed 
 to be fatty, in the supraclavicular spaces. In 
 a case I have recently had under my care, and 
 who died a few months since from tubercular 
 meningitis, the supraclavicular swellings en- 
 tirely disappeared before death. Apparently it 
 was a reserve stock of fatty material, which 
 vanished with the general emaciation. The cha- 
 racteristics of these children are their extreme 
 placidity, they are unruffled in temper, seldom 
 cry, never shed tears. They are imitative and 
 have a strong sense of humour. Their speech 
 is usually deferred, and when acquired is mono- 
 syllabic. They are orderly and precise, dis- 
 turbed by anything out of the usual routine. 
 Their skin has a wrinkled appearance, as if too 
 large for their diminutive bodies. Their faces 
 have an earthy colour. The hair is com- 
 monly sparse, and they suffer from pityriasis of 
 the scalp. They have usually a large develop- 
 ment of areolar tissue, and two of my cases 
 were characterised by polysarcia, one weighing 
 210 lbs. 
 
 Three of my twelve cases were males, nine 
 
CHILDHOOD AND YOUTH. 85 
 
 were females. Tliey all had brachyceplialic 
 crania, flattened noses, and tlie distances of 
 the inner canthi exaggerated. Their tongues 
 were large for their mouths, and their lips were 
 thick. There was in the majority a tendency 
 to suck their tongues. In three only was there 
 much intellectual response to teaching. They 
 were all, however, with one exception, readily 
 taught to be clean in their habits, making signs 
 to indicate their natural wants. Menstruation 
 had not appeared even in those who had 
 reached the years of womanhood, and the 
 external organs of generation were infantile in 
 appearance, and apparently there was complete 
 absence of sexual instinct. 
 
 In the year 1857, M. Baillarger presented a 
 case of sporadic cretinism before the Societe 
 Medico-Psychologique of Paris, and described 
 it as a very remarkable one. It is a girl, he 
 said, born at Melun, of healthy and well-formed 
 parents. The first dentition was completed at 
 three years of age, and it was then that general 
 development was arrested. The girl is now 
 about twenty-seven, and she has the intelligence 
 and tastes of a child of four or five ; she plays 
 with a doll, and has no sentiments of modesty. 
 
86 MENTAL AFFECTIONS IN 
 
 After describing the characteristics of the case, 
 which resemble very closely those which I have 
 detailed as being common to mine, he goes on 
 to say that the body is fat, the limbs thick and 
 short and sufficiently regular ; the second denti- 
 tion only commenced at eighteen, and has not 
 yet terminated. The pubis is smooth, the 
 mammary glands rudimentary ; menstruation 
 has not been established, and there has never 
 been any sexual sensation. M. Baillarger 
 throws out the suggestion that the condition of 
 this case, and of another that he had seen in 
 Paris with M. Rayer, arose from inactivity of 
 the generative organs. 
 
 The relation between goitre and cretinism is 
 of extreme interest. The late Dr. Hilton Fagge 
 in 1871 regarded goitre and cretinism to be 
 antagonistic effects of the same cause. He sug- 
 gested that when the cause acts with little inten- 
 sity the sole effect is goitre, but if it acts with 
 great intensity or upon successive generations 
 it at length produces cretinism as well as goitre. 
 The not infrequent absence of goitre in cretins, 
 when not dependent upon congenital deficiency 
 of the thyroid body, must, he thought, be attri- 
 butable to some local morbid change in it, by 
 
CHILDHOOD AND YOUTH. 87 
 
 ■wMcli it is prevented from undergoing enlarge- 
 ment under the operation of the morbific agent. 
 He suggested that when goitre has existed in a 
 family for two or three generations, the struc- 
 ture of the thyroid body may undergo deteriora- 
 tion in members of the succeeding generation. 
 When we have regard to the remarkable cases 
 of cretinoid changes in adult women described 
 so well by Sir William Grull, and the many 
 examples which have been since accumulated by 
 many observers, and especially by Dr. Ord and 
 Sir Dyce Duckworth, we cannot fail to see the 
 close relation between cretinism and degenera- 
 tive changes in the thyroid. This is further 
 strengthened by the fact made known to us by 
 Professor Kocher, of Berne, that after the 
 removal of the thyroid for goitre, a condition 
 gradually supervenes which much resembles 
 adult cretinism, while Professor Horsley, opera- 
 ting on monkeys by removal of their thyroids, 
 has produced symptoms resembhng myxoedema 
 which, by virtue of the increase of mucin in the 
 tissues, is the name which has been proposed to 
 be given to the cretinoid condition described by 
 Sir WilHam Gull. It is very noticeable that 
 many of the physical as well as mental and 
 
88 MENTAL AFFECTIONS IN 
 
 moral cliaracteristics of myxoedema resemble 
 those of sporadic cretinism, and, like it, occur 
 mostly in women. The only exception I have 
 seen was a cabdriver brought by Dr. Fenn, of 
 Richmond, before a meeting of the Thames 
 Valley branch of the British Medical Associa- 
 tion. I cannot but feel that the inquiries 
 which are being made with regard to myxoedema 
 will eventually throw light on the etiology of 
 endemic and sporadic cretinism. 
 
 There is one subject of great interest at the 
 present time which is made the topic of 
 addresses from presidential chairs as well as 
 of numerous articles in periodical literature. I 
 mean the higher education of women. The 
 doctrine which has been promulgated of late is, 
 that the higher culture of the faculties of women 
 will make them less capable of becoming 
 "mothers of men." There has been hitherto 
 no objection to their being taught everything 
 relating to art, music, or their emotional life, 
 but directly there are attempts made to cultivate 
 their judgment, to teach them how to reason, 
 to inculcate habits of self-control, we are met 
 by clamours which, in my opinion, are not based 
 on experience, and, so far as the etiology of 
 
CHILDHOOD AND YOUTH. 89 
 
 feeble-mindedness is concerned, are likely to be 
 prejudicial. If there is one thing more certain 
 than another about the production of idiocy it 
 is the danger which arises from the culture of 
 only one side of a woman's nature ; so long as 
 only the emotional side of their nature is culti- 
 vated and they are responsive to the least un- 
 expected sound, unreasoning as to the world of 
 nature about them, and thrown into emotional 
 paroxysms by the sights and trials which will 
 be sure to cross their path, they will, from my 
 point of view, be liable to become the mothers 
 of idiots. Without advocating over-pressure, 
 which is as bad for the neurotic boy as for the 
 neurotic girl, and which is to be avoided during 
 the developmental life of the one as well as 
 during the developmental life of the other, there 
 can be no reason why the faculties which they 
 possess should not be cultivated so as to make 
 them not only fit to be " mothers of men " but 
 also companions and helpers of men. At all 
 events, let the trial be made without prejudice, 
 and let us welcome the advent of a time when 
 women shall not be the mere frivolous toys of 
 the hour but have and enjoy the privileges and 
 rights of which it is absurd to deprive them. 
 
90 MENTAL AFFECTIONS IN 
 
 My statistics show that we must look mainly 
 to the health and mental life of the parents. 
 They point to the importance of training our 
 sons to be temperate and our daughters to be 
 self-possessed. They indicate that we should 
 seek alliances for our daughters with men from 
 a healthy stock, that our sons should avoid 
 women whose emotions are developed at the 
 sacrifice of their judgment and self-control. 
 They show that idiocy is often the natural out- 
 come of a gradual process in which the strain 
 becomes more and more degenerate, requiring 
 only an insignificant factor to produce the direst 
 results. 
 
CHILDHOOD AND YOUTH. 91 
 
 LECTURE III. 
 
 Infantile Mania. — Melancholia and Delusions. — Moral Insanity. 
 — " Idiots Savants." — Variations in the Mental Condition. 
 — Epilepsy and Catalepsy. — Physical Deformities. — Asso- 
 ciated Diseases. — Bate of Growth. — Diagnosis of Idiocy. — 
 " BacJcward Children." — Deferred or Absent Speech. — 
 Morbid Anatomy. — Treatment of Feeble-mindedness. 
 
 Infantile mania is not of frequent occurrence 
 and has not been the subject of much comment, 
 Nevertheless very well-marked examples have 
 come under my notice in quite young children ; 
 cases where the various phases of insanity in the 
 adult have been well represented; acute maniacal 
 attacks, in which the patient tears and destroys 
 everything within reach, or creeps under tables 
 and sofas to hide, screaming with undisguised 
 rage and biting and scratching anyone who 
 approaches. This attack subsides and the 
 boy behaves as nicely and intelligently as pos- 
 sible, but in a few days has a recurrence with 
 as great violence as before. Some few years 
 
92 MENTAL AFFECTIONS IN 
 
 since a little boy of this class was sent to me. 
 He was by no means deficient in mental acute- 
 ness, in many respects was precocious ; he was 
 an only child, and having lived a good deal with 
 adult people he talked rather sagely, but he 
 was liable to attacks of acute mania of a very 
 marked kind. There were no bounds to his 
 petulance and violence. He would attack his 
 father in the street and behave in all respects 
 in an insane manner, regardless of any injury 
 he might inflict, even on those for whom he 
 ordinarily entertained affection. In the inter- 
 vals of the paroxysms he manifested traits which 
 made him much liked by those about him. 
 
 Occasionally I have met with cases having 
 well-marked delusions of suspicion. The ordi- 
 nary trust and unsuspiciousness of childhood 
 has been replaced by painful mistrust. In one 
 case the child imagined that he was watched 
 and that someone was listening at the key-hole. 
 Another had delusions that things were mixed 
 with his food and had evident fear of being 
 poisoned. I have seen some cases of melan- 
 cholia associated with manifest delusions, one 
 boy believing that he resembled an animal and 
 frequently looking into the mirror to confirm 
 
CHILDHOOD AND YOUTH. 93 
 
 or dissipate tlie conviction; another believed 
 that she would break if you touched her, and 
 the fear of falliug to pieces like a fragile piece 
 of glass was a real terror to her. I had some 
 years since under my observation a girl who, 
 when eight years of age, put her baby brother 
 on the fire so that he was dreadfully burnt. 
 The girl herself was ill-favoured in appearance 
 and she had been accustomed to hear the beauty 
 of her brother injudiciously praised. In a 
 maniacal attack she attempted to get rid of 
 the subject of so much laudation. About three 
 years subsequently she became epileptic and 
 again later on the subject of epileptic dementia. 
 It is highly probable that the maniacal paroxysm 
 which manifested itself in homicidal mania was 
 really masked epilepsy. 
 
 As puberty approaches attacks of mental 
 aberration assume a special character ; there is 
 frequently unnatural introspection and a critical 
 hyper-conscientiousness becomes prominent. I 
 have recently had five cases under my care 
 three boys and two girls. They have all had 
 characters much in common, they have all been 
 very good and studious children, but between 
 eleven and thirteen years of age have become 
 
94 MENTAL AFFECTIONS IN 
 
 moody, have had conscientious scruples as to 
 their motives, have been anxious not only as to 
 whether they have told the truth, but whether 
 when having told it, they have done so in such 
 a way as to convey to others the precise idea 
 in their minds. They have had morbid views 
 as to the standard of right and wrong ; some- 
 times they have detailed things in a non- 
 sequential way. One boy was troubled when 
 he saw a dirty beggar-man or boy lest he should 
 contaminate his mother by thinking of her imme- 
 diately afterwards. I saw him greatly perturbed 
 one day from having seen an errand-boy come 
 to the school-house, and his thoughts flitting 
 to his mother he was rendered inexpressibly 
 miserable lest he had lowered, injured, and 
 contaminated her by unwittingly thinking at 
 the same time of her and the dirty boy. I have 
 sometimes known an avoidance of anything 
 positive in assertion lest the exact truth should 
 not be spoken, so that all the replies are, " Per- 
 haps it was," " It may have been," " I may 
 have done so and so," about things in which 
 no principle was involved, but from a morbid 
 fear of not saying what was true. These cases 
 cause great anxiety at the time and occasionally 
 
CHILDHOOD AND YOUTH. 95 
 
 lead to a permanent breakdown. Many, how- 
 ever, by careful management may be tided over 
 the climacteric period of puberty and then all 
 may go well. It is important, however, to be on 
 guard against any concealed suicidal impulse, 
 and to note its slightest indication, as the ten- 
 dency in such cases is to melancholia and in some 
 instances temptation to self-inflicted injury. 
 Care should also be taken to be quite sure that 
 there is no sexual deviation, and if there be, to 
 treat it, not as moral wrong, which would 
 inevitably lead to further mental disquietude and 
 peril, but as a physical evil which, for the good 
 of the body, it is important should be corrected. 
 These deviations are readily recognised by the 
 aggregation of a group of symptoms which 
 rarely leads one astray. They are, supra-orbital 
 headache, dilated pupils, a brown-umber areola 
 surrounding the eyes, an averted look and a 
 statuesque bearing. This last symptom alone is 
 often very conclusive and may be regarded as 
 certain if associated with the preceding ; occa- 
 sionally the statuesqueness is so marked as to 
 resemble a minor cataleptic state. 
 
 Moral insanity is met with in childhood and 
 youth. It has fallen to my lot to have had a 
 
96 MENTAL AFFECTIONS IN 
 
 great many illustrations brought under my 
 notice — cases of purposeless theft, purposeless 
 lying, and purposeless miscMef. They are 
 difficult cases to treat, and make great demands 
 on one's resources. The subjects of this condi- 
 tion are sometimes intellectually bright, and 
 have an amount of address which makes them 
 extremely troublesome to their friends and 
 those who have to guide them. I was consulted 
 some years since about a boy who displayed 
 such destructive energies on toys and every 
 household appliance that he could get into his 
 possession, that his friends thought it indicated 
 a latent mechanical talent, and as he had also 
 manifested mathematical ability he was appren- 
 ticed to a firm of engineers. Here his pleasure 
 in creating astonishment led him to introduce 
 sand into the mechanism of the machinery he 
 had to overlook, apparently getting amusement 
 out of the consternation and inquiry which his 
 evil deeds induced. He managed for some time 
 to conceal his delinquency by clever lies ; but at 
 length the mischief was fastened on him from 
 his having allowed a traversing machine to go 
 beyond its support in order that he might see 
 the mischief that would ensue. He had good 
 
CHILDHOOD AND YOUTH. 97 
 
 musical talent, and acquiring some skill as an 
 organ player, he would play occasionally in 
 cliurcli, and suddenly stop to enjoy the discom- 
 fiture his irregularity produced. Eventually 
 he became a thief and was several times in 
 danger of being brought under the criminal law. 
 All his delinquencies were conceived and carried 
 out with great skill ; there was no intellectual 
 lesion, but his moral and affective faculties were 
 thoroughly dormant. He saw no wrong in what 
 he did and he entertained no affection for his 
 parents, who were in a state of perpetual agony. 
 Had he been a member of a lower stratum of 
 society he would have become a jail-bird. 
 Great pains were taken to prevent his getting 
 into the hands of the police, and, the period 
 of puberty passed, he has reached manhood 
 with improved moral sense, and is now getting 
 his living by his musical talent in a respectable 
 and honorable way. 
 
 More frequently moral insanity is associated 
 in children and youths with some amount of 
 mental backwardness. The backwardness may 
 be very slight, but yet sufficient to prevent 
 their taking appropriate place in form or in the 
 playground. The manifestations of moral 
 
 7 
 
98 MENTAL AFFECTIONS IN 
 
 insanity in sucli cases are multiform. I have 
 seen a boy who had brought from school 
 sixteen watches without being discovered by 
 the sufferers or the principal of the school, and 
 this so cleverly done as for a long time to 
 elude detection. Another was dismissed from 
 school because he persisted in getting on the 
 roof and putting pillows and other articles 
 of bedding down the chimneys of neighbouring 
 houses in the terrace, or in filling the pillar 
 boxes with stones. Another would beg suffi- 
 cient money during the morning in the streets 
 to enable him to travel backward and forward 
 by the Underground Eailway the whole of 
 the remainder of the day. A still more 
 dangerous form is a tendency sometimes met 
 with of setting fire to articles of furniture, 
 often where it would be perilous to themselves 
 as well as others. Many forms of low cunning 
 are developed in backward boys by associating 
 them with others with more wit, who are also 
 bullies, the feebler one calling to his aid lying, 
 theft, and deceit, to compensate for his lessened 
 intellectual vigour. Again and again I have 
 seen the moral sense developed in boys of this 
 class when they have been removed from the 
 
CHILDHOOD AND YOUTH. 99 
 
 bullying to which they had been subjected and 
 submitted to appropriate training. In all the 
 cases I have met with of moral insanity there 
 has been marked antecedent neurotic history. 
 
 This is a convenient place to treat of an in- 
 teresting class of cases for which the term 
 "idiots savants" has been given, and of which 
 a considerable number have come under my 
 observation. This name has been applied to 
 children who, while feeble-minded, exhibit special 
 faculties which are capable of being cultivated 
 to a very great extent. One youth was under 
 my care who could build exquisite model ships 
 from drawings, and carve with a great deal of 
 skill, who yet could not understand a sentence 
 — who had to have it dissected for him, and who, 
 when writing to his mother copied verbatim a 
 letter from ' The Life of Captain Hedley Yicars,' 
 by Miss Marsh, although it had not the slightest 
 appropriateness in word or sentiment. Another 
 has been under my care who can draw in crayons 
 with marvellous skill and feeling, in whom 
 nevertheless there was a comparative blank in 
 all the higher faculties of mind. 
 
 Extraordinary memory is often met with 
 associated with very great defect of reasoning 
 
100 MENTAL AFFECTIONS IN 
 
 power. A boy came under my observation who, 
 having once read a book, could ever more 
 remember it. He would recite all the answers 
 in ' Magnall's Questions ' without an error, 
 giving in detail the numbers in the astronomical 
 division with the greatest accuracy. I dis- 
 covered, however, that it was simply a process 
 of verbal adhesion. I once gave him Gibbon's 
 ' Rise and Fall of the Eoman Empire ' to read. 
 This he did, and on reading the third page he 
 skipped a line, found out his mistake and 
 retraced his steps ; ever after, when reciting 
 from memory the stately periods of Gribbon, he 
 would, on coming to the third page, skip the line 
 and go back and correct the error with as much 
 regularity as if it had been part of the regular 
 text. Later on his memory for recent reading 
 became less tenacious, but his recollection of 
 his earlier readings never failed him. Another 
 boy can tell the tune, words, and number 
 of nearly every hymn in * Hymns Ancient and 
 Modern.' Often the memory takes the form of 
 remembering dates and past events. Several 
 children under my observation have had this 
 faculty in an extraordinary degree. One boy 
 never fails to be able to tell the name and 
 
CHILDHOOD AND YOUTH. 101 
 
 address of every confectioner's shop that he 
 has visited in London — and they have been 
 numerous — and can as readily tell the date of 
 every visit. Another can tell the time of arrival 
 of all the children at an institution, and could 
 supply accurate records in relation to it if 
 needed. Another knows the home address of 
 every resident who comes under his observation, 
 and they are by no means few. The faculty 
 of number is usually slightly developed with 
 feeble-minded children while memory is fairly 
 well developed, and yet I have had under my 
 observation cases where the power of mental 
 arithmetic existed to an astonishing extent. 
 One boy, about twelve years of age, could 
 multiply any three figures by three figures 
 with perfect accuracy, and as quickly as I could 
 write the six figures on paper, and yet, so low 
 mentally was he, that although having been for 
 two and a half years in almost the daily habit 
 of seeing me and talking to me, could not tell 
 my name. Another boy who has recently been 
 under my observation can multiply two figures 
 by two figures, while another can multiply 
 rapidly two figures by two, and a short time 
 since could multiply three figures by three 
 
102 MENTAL AFFECTIONS IN 
 
 figures, but since an epileptiform attack has 
 lost this faculty to some extent. None of them 
 can explain how they do it, I mean, by what 
 mental process. When by rare chance they 
 have made a mistake, and some hesitation 
 has arisen, it has appeared to me, the plan 
 has been, to clear off the multiplication of 
 the higher figures first. Improvisation is an 
 occasional faculty. I had a boy under my care 
 who could take up a book, pretending to read, 
 an art he had not acquired, and improvise 
 stories of all kinds with a great deal of skill, 
 and in any variety, to suit the supposed tastes 
 of his auditors. 
 
 Memory of tune is a very common faculty 
 among the feeble-minded ; they readily acquire 
 simple airs, and rarely forget them. I have 
 had one boy under my observation who, if he 
 went to an opera, would carry away a recollec- 
 tion of all the airs, and would hum or sing 
 them correctly. In none of the cases of 
 "idiot savant" have I been able to trace any 
 history of a like faculty in the parents or in the 
 brothers and sisters, nor have I had any op- 
 portunity of making an autopsy, except in one 
 instance. This was in the case of a boy who 
 
CHILDHOOD AND YOUTH. 103 
 
 had a very unusual faculty, of which I have 
 never since met another example, viz. the per- 
 fect appreciation of past or passing time. He 
 was seventeen years of age, and although not 
 understanding, so far as I could gather, the use 
 of a clock-face, could tell the time to a minute at 
 any part of the day, and in any situation. I 
 tried him on numberless occasions, and he always 
 answered with an amount of precision truly 
 remarkable. Grradually his response became less 
 ready, and he would not or could not reply unless 
 he was a little excited. He had to be shaken like 
 an old watch, and then the time would be truly 
 given. Gradually his health became enfeebled 
 and the faculty departed. At an autopsy I 
 found that there was no difference in his cere- 
 brum from an ordinary brain, except that he had 
 two well-marked and distinct soft commissures. 
 My explanation of the phenomenon was that 
 as every movement in the house was absolutely 
 punctual he had data from which he could esti- 
 mate the time by accurate appreciation of its 
 flux. All these cases of " idiots savants " were 
 males ; I have never met with a female. 
 
 It happens to the congenitally feeble-minded 
 as to the strong-minded to have deviations from 
 
104 MENTAL AFFECTIONS IN 
 
 their normal standard. There is therefore 
 every form, of mental aberration to be met with 
 among them. They become the subjects of 
 acute and chronic mania, of acute and chronic 
 melancholia, and of dementia. It is curious to 
 witness the change which may take place in the 
 mental and moral condition of one deprived to 
 a great extent of intellectual power. Feeble- 
 minded children are not naturally suicidal ; they 
 are liable to meet with accidents from their not 
 having any sense of fear, or from not being able 
 to work out the logical sequence of any act, 
 but, under the influence of a melancholic state, 
 they do sometimes become suicidal. Occa- 
 sionally, under the influence of acute mania, the 
 feeble intellect of the youth becomes fanned 
 into a brighter flame, and he may say things 
 which are quite in advance of his ordinary 
 powers, becoming for the time quick in repartee 
 or pertly rude. The taciturn may become lo- 
 quacious, the timid and respectful proud and 
 defiant, and the amiable and tractable abusive 
 and destructive. Occasionally, too, a remark- 
 able change takes place in those who are tem- 
 porarily the subject of the delirium of fever. 
 Three remarkable instances have occurred to 
 
CHILDHOOD AND YOUTH. 105 
 
 me of boys wlio had never been beard to speak, 
 making use of well-formed sentences during the 
 high febrile state of acute pneumonia in two 
 instances, and of scarlatina in another. In the 
 case of one, who was the subject of pneumonia, 
 the other boys who were in the Infirmary at 
 the time were frightened by the febrile ejacula- 
 tion of their usually speechless companion. 
 
 There are two ailments from which, according 
 to my experience, the congenitally feeble-minded 
 are remarkably free, viz. chorea and hysteria. 
 I cannot call to mind, among the large number 
 of cases that have come under my notice, a 
 single case of acute chorea. I have met with 
 cases of chronic and persistent inco-ordinated 
 movements, but not with the acute cases so 
 common in a general hospital or in a hospital 
 for children. I have assumed that it is partly 
 owing to the lessened emotional life of my 
 patients. The same reason may account for 
 the rare occurrence of hysteria. This defective 
 emotional element in the feeble-minded spares 
 them much grief. Although very afiectionate, 
 they will hear of the loss of beloved relations 
 or friends without emotional disturbance and 
 with a remarkable philosophy. They live very 
 
106 MENTAL AFFECTIONS IN 
 
 mucli in tlie present, and are not perturbed by 
 the troubles of the past or the unexperienced 
 future. 
 
 Epilepsy is a very common complication of 
 feeble-mindedness. Of the whole number that 
 have come under my observation, 24 per cent, 
 have been at some period of their lives epileptic. 
 This appears to be a very large average and 
 indicates to what a great extent the treatment 
 of idiocy is the treatment of epilepsy. Dr. 
 Kerlin, of Pennsylvania, states that " from an 
 examination of the history of 300 imbecile 
 children between the ages of five and sixteen, 
 I find that 66, or 22 per cent., are now epilep- 
 tics." The percentage is so near my own as 
 to confirm very materially my observations. 
 My cases, however, are not within equally narrow 
 limits as to age, but range from two years to 
 forty. Dr. Kerlin further confirms my observa- 
 tions as to the important neurotic antecedents 
 of feeble-minded children, when he states that 
 62 per cent, have in their antecedents the 
 history of the epileptoid family of diseases. A 
 large number fall under the developmental 
 class and are often associated with a history of 
 eclampsia at first dentition. I have frequently 
 
CHILDHOOD AND YOUTH. 107 
 
 observed attacks come on during second denti- 
 tion, followed by an interval of freedom until 
 tbe evolution of puberty. Epilepsy often 
 appears for tbe first time at puberty and subse- 
 quently ceases. Occasionally the status epi- 
 lepticus supervenes with the worst possible 
 results. 
 
 Catalepsy is met with among the feeble- 
 minded, but always in my experience asso- 
 ciated with impure habits. 
 
 The physical deviations of the feeble-minded 
 are very important. I have already referred to 
 the lessened common sensation and defective 
 co-ordination to which they are prone, to their 
 diminished sense of taste and smell, and to their 
 sight. Hearing is often obtuse, and is, as I have 
 said, frequently a cause of deferred speech. 
 They are very prone to eczematous eruptions 
 in the flexures of the joints and behind the ears. 
 The skin gives evidence of degeneration in its 
 tendency to unnatural unions ; just as the petals 
 of a corollifloral exogen indicate a lower grade 
 than the distinct petals of a thalamifloral so do 
 webbing of the fingers and toes and adhesions 
 of the lobules of the ear suggest marked in- 
 feriority. Dr. Laycock many years ago called 
 
108 MENTAL AFFECTIONS IN 
 
 attention to the prevalence of ear abnormalities 
 in people of a degenerate type, and my own ob- 
 servations coincide with his. Lobules absent, 
 lobules adherent, helices defective, and the entire 
 pinnge misshapen or shrunken, are very common 
 among the congenital feeble-minded. The im- 
 plantation of the ear is often too far back, 
 giving an exaggerated facial development. I 
 have had under my observation very remark- 
 able examples of webbing, both of toes and 
 fingers, in all cases associated with adherent 
 lobules of the ears. The development of the hair 
 offers some anomalies ; some are hirsute over 
 their entire bodies, and 11 per cent, have the 
 eyebrows continuous over the nose. I have 
 before referred to the deformations of the mouth 
 and the importance I attach to these in dia- 
 gnosis. The tongue as a muscular organ is very 
 ill co-ordinated, and this is one factor in the 
 absence or defect of speech which is so charac- 
 teristic of the feeble-minded. In a number of 
 cases, taken without selection, of an age when 
 speech would be expected, 36 per cent, may be 
 regarded as being entirely dumb, and 30 per 
 cent, with speech indistinct, while not more 
 than 28 per cent, speak fluently ; the remaining 
 
CHILDHOOD AND YOUTH. 109 
 
 6 per cent, speak a little and distinctly but 
 with a small vocabulary. Witli such retarded 
 development it is not astonishing to find 
 that puberty is postponed on an average two 
 years. 
 
 Mastication is often defective, partly from 
 carious teeth, and partly from a want of persis- 
 tent voluntary effort. Deglutition is often hur- 
 ried, and ill-masticated food is bolted. Rumina- 
 tion occasionally occurs. Three well-marked 
 examples have come under my notice ; in one of 
 the cases I found the oesophagus distinctly 
 pouched. They all eructated their food and 
 then placidly remasticated the mass. Excepting 
 when asleep, these were the quietest times of 
 their lives, being ordinarily restless and im- 
 patient. The whole process of feeding very 
 closely resembled that of the ruminants. 
 
 There is a great tendency to swallow unusual 
 things, such as pebbles and neckties, which gene- 
 rally prove quite inert. Occasionally, however, 
 the swallowed morsels are not so innocuous, and 
 there are now two or three deaths on record 
 from intestinal obstruction caused by the slow 
 accumulation of hair either bitten from their 
 own head or extracted from mattresses or from 
 
110 MENTAL AFFECTIONS IN 
 
 swallowing a fibre at a time, picked out of cocoa- 
 nut matting. As might be supposed from tlie 
 defective innervation which characterises feeble- 
 minded children they are neither fleet nor per- 
 sistent in endurance. They are deficient in 
 muscular power as they are also deficient in 
 mental tension. The organs of reproduction 
 are ill developed ; among females I have found 
 a great prevalence of small ovaries, and in the 
 males 8 per cent, of those who have reached the 
 age of fourteen have either undeveloped or un- 
 descended testes. In recording this estimate 
 it is worthy of remark that both accidental, 
 developmental, and congenital feeble-minded 
 youths are included, and I have no doubt that 
 if the investigation had been confined to con- 
 genital cases the percentage of defective gene- 
 rative organs would have been much greater. 
 
 I have omitted to speak of one very marked 
 characteristic of the nervous system, viz. defec- 
 tive reflex functions. The feeble-minded are 
 very prone to constipation, and it is extremely 
 difiScult to produce emesis ; they resist any ordi- 
 nary dose of an emetic nature. On the occasion 
 of several children who had returned from a 
 day's holiday complaining of similar pains in 
 
CHILDHOOD AND YOUTH. Ill 
 
 their stomachs, which gave rise to the suspicion 
 that some article of food had been unwholesome, 
 attempts were made to induce vomiting by the 
 administration of twenty grains of sulphate of 
 zinc to each, but in not a single case was it 
 successful, although the fauces were also irri- 
 tated by a feather. The same thing applies to 
 the absence of cough and expectoration when 
 they are the subjects of phthisis. It is not un- 
 common for a feeble-minded patient to pass 
 through all the stages of this disease without 
 the slightest cough. Their vaso-motor system, 
 on the other hand, is very sensitive ; they are 
 prone to gastric intestinal trouble from sudden 
 change of weather, from bolting their food, from 
 taking too much food at a meal, and from too 
 great predominance of meat as an article of diet, 
 or from the presence of electrical disturbance. 
 Occasionally, but not frequently, feeble-minded- 
 ness is associated with disseminated sclerosis, 
 with its characteristic gait and scanning speech ; 
 more frequently, however, with pseudo-hyper- 
 trophic paralysis, two well-marked cases of 
 which I have published in the 'Pathological 
 Transactions,' and several others have been 
 under my observation. In fact, I have seen but 
 
112 MENTAL AFFECTIONS IN 
 
 few examples of that disease which have not 
 been also characterised by some amount of 
 intellectual lesion. Diseases of the kidneys 
 and liver are extremely rare, on account of 
 the discreet and temperate habits which such, 
 patients are accustomed to lead under medical 
 guidance. Rheumatism is very exceptional, 
 probably from the non-exposure to bad weather 
 which the nature of their lives induces. Put- 
 ting aside the diseases of childhood, diseases of 
 the brain and of the lungs are the chief causes 
 of death. Having regard to the frequency of 
 epilepsy as a complication, it is not surprising 
 that it should be a cause of considerable mor- 
 tality among the feeble-minded. I find, from 
 the returns of Dr. Fletcher Beach, that about 
 2^ per cent, of the average daily number of 
 inmates of the schools at Darenth. die from 
 epilepsy, or more than the mortality of London 
 from all causes whatever. 
 
 The prevalence of phthisis as a cause of death 
 among the feeble-minded varies very much with, 
 the nature of the soil on which they reside. 
 Through the admirable researches of Dr. G. 
 Buchanan we now know how much associated a 
 damp clay soil is with the existence of phthisis. 
 
CHILDHOOD AND YOUTH. 113 
 
 He has taught us that measures which have been 
 taken in some towns and cities for their drainage 
 in consequence of the prevalence of zymotic dis- 
 ease, have resulted in diminishing the mortality 
 from pulmonary consumption in a remarkable 
 degree. 
 
 My own experience lends support, if support 
 were needed, to Dr. Buchanan's view. In the 
 year 1867 I wrote a paper in the * Lancet ' " On 
 the Relation of Idiocy to Tuberculosis," in 
 which I showed how prevalent phthisis was 
 among idiots, amounting to 39' 8 per cent, of 
 the general mortality. My experience since 
 that time has suo^ffested that I oua-ht rather to 
 have headed my paper, " On the Relation of 
 Tuberculosis to a Clay Soil." My observations 
 were made on 1000 feet of Wealden Clay, and I 
 did not know at that time what a relationship 
 existed between the two. My more recent ex- 
 perience on a gravel soil shows the deaths from 
 phthisis to be only 12 per cent, of the general 
 jnortahty. I concluded my paper with this 
 paragraph : " It is no less clear to me that 
 idiocy of a non-tubercular origin leads to tuber- 
 culosis. Whether this arises through the in- 
 fluence of the pneumogastric nerve, mal-assimi- 
 
114 MENTAL AFFECTIONS IN 
 
 lation of food, or defective innervation, it cannot 
 but be regarded that the connection between 
 these maladies is by no means accidental, and 
 that a due appreciation of this relation is neces- 
 sary to those who would treat effectively con- 
 genital mental lesions." I feel it my duty to add 
 to this that the question of soil is an important 
 matter which I then overlooked. When we 
 have regard to the number of days in which 
 outdoor exercise is impossible on a clay soil in 
 a climate like that of England, the difficulty of 
 draining it effectively, and the damp exhalations 
 which the clay gives out in warm, and the mist 
 which is condensed in cold weather, we can 
 appreciate the effect it is likely to have on 
 children and youths whose ordinary mortality is 
 greater than that of those with normal nervous 
 power and nutritive energy. 
 
 Nothing is more remarkable than the readi- 
 ness with which feeble-minded children succumb 
 to acute disease of any form, or the way in which 
 they are injuriously affected by climatic changes. 
 The incidence of illness should be narrowly 
 looked for and promptly treated ; the thermo- 
 meter is of great value in indicating the need 
 of early precautionary measures. Before the 
 
CHILDHOOD AND YOUTH. 115 
 
 introduction of the clinical thermometer the 
 principal indication of deviation from health 
 was loss of appetite. I have known a boy in 
 whose case the first suggestion of illness con- 
 sisted of a face sufiused with tears, because, 
 as he said, the boy who had sat next him at 
 tea had eaten three slices of bread and butter 
 and he could not eat any. This was the pre- 
 lude to one of the most serious ailments to 
 which the feeble-minded are subject, namely, 
 broncho-pneumonia. 
 
 My own observations as regards the height 
 and weight of idiots are very much in harmony 
 with those of Dr. Shuttle worth, and Dr. Tarbell 
 of America. I find that feeble-minded children 
 are shorter and lighter than the normal stan- 
 dard, and agree with Mr. Charles Roberts, 
 " that the relative rate of growth of the two 
 sexes of idiot children follows the same rule as 
 that of normal children, and is subject to the 
 same variations at the age of puberty." " It 
 was found by Dr. Bowditch," so writes Dr. 
 Tarbell, " in his investigation of normal chil- 
 dren, that until the age of eleven or twelve 
 years boys are both taller and heavier than girls 
 of the same age. At this period of life girls 
 
116 MENTAL AFFECTIONS IN 
 
 begin to grow very rapidly, and for the next two 
 or three years surpass boys of the same age 
 both in height and weight. Boys then acquire 
 and retain a size superior to that of girls, who 
 have now nearly completed their full growth." 
 The diagnosis of idiocy is of importance, both 
 in order that the child may early be put under 
 proper training and for medico-legal purposes. 
 The profound cases are not difficult to diagnose, 
 especially if associated with microcephalism or 
 with marked asymmetry of cranium. The con- 
 genital class is that which has to be consid- 
 ered in early life. There is a marked want of 
 muscular power, as indicated by the inability to 
 support the head and to use the hands for pre- 
 hension. The eyes look out as if on an object- 
 less world, and the attention is not arrested by 
 the usual expedients to excite recognition in 
 infants. To the most loving endearments there 
 is no responsive smile, and the infantile cooing 
 is replaced by a wailing cry. The instinctive 
 process of feeding is often acquired with diffi- 
 culty and indicates, what I have long observed, 
 that there is no predominance of instinct in 
 idiocy. On the contrary, so far as instinct 
 itself is concerned, the young animal is on a 
 
CHILDHOOD AND YOUTH. 117 
 
 higher platform than an idiot baby. Tho latter 
 would not search out the source of the maternal 
 supply nor make successful efforts to regain the 
 nipple if once out of the mouth. Later on there 
 is a marked indisposition to make muscular effort, 
 there is no responsive leap when the feet are 
 allowed to touch the ground, and when taken 
 in the hands the scapular muscles offer no resist- 
 ance, and the arms helplessly extend themselves 
 over the head. There is no disposition to 
 crawl but rather to lie on the back in an irreso- 
 lute way. Still later the power of standing is 
 deferred, and walking is an accomplishment 
 which may never be attained. 
 
 I have already referred to the physical devia- 
 tions in congenital idiots, such as the deformed 
 cranium, the vaulted palate, and ill-developed 
 ears, and these come to our aid in a remarkable 
 way in the question of diagnosis. The same 
 may be said of the ethnic characteristics, espe- 
 cially the Mongolian type, which is so signifi- 
 cant of congenital mental incapacity. In the 
 developmental class I have already referred to 
 the prow-shaped frontal bone as being highly 
 typical and an aid to diagnosis, certainly helping 
 us to assign a case to this division where there 
 
118 MENTAL AFFECTIONS IN 
 
 are psycliological grounds for apprehending 
 mental dej&ciency. Witli regard to the acci- 
 dental class, physical deviations do not come to 
 our aid. They have usually none of the grave 
 deviations of conformation which we meet with 
 in the congenital class. They have, as I have 
 said, nothing in their look which would indicate 
 their mental decadence. On the contrary, they 
 in most cases during their childhood present 
 physical features but little indicative of the 
 terrible disaster which has bfefallen them; 
 except in the paralysed sub-class they are fleet 
 and mobile, and mischievous to a degree. 
 They are irritated by constraint, are intolerant 
 of having their heads examined, and try to 
 escape from one's ken, they pull open every 
 drawer that is unlocked, shake the handle of 
 the room door to procure its opening, and 
 sweep with their hand the ornaments off one's 
 table that they may enjoy the rattle. They 
 alternate their mischievous pranks with shrill 
 and unmeaning cries. They rarely speak, are 
 fond of feeling things with their tongues, and 
 run about to get some fresh object on which to 
 indulge this freak. They too frequently return 
 a preferred kiss by a bite, and fill up the 
 
CHILDHOOD AND YOUTH. 119 
 
 intervals of their mobile mischievousness by 
 blowing bubbles with saliva on their lips. 
 They have this important diagnostic feature, 
 that they live entirely in a world of their own ; 
 they do not listen with a childlike curiosity to 
 the conversation which is going on in their 
 presence, — a conversation which is all-important 
 to them, and in the outcome of which they are 
 the most interested parties. They hear what 
 is said, but they do not attend, nor can their 
 attention be arrested, except by diverting them 
 into new channels by a more attractive trail. 
 They have usually great intensity of purpose, 
 and succeed in having their own way, the 
 mothers giving up the contest for the sake 
 of peace. Slavering is a very common sign 
 among the members of the three classes, arising 
 sometimes from inattention, or from hypersemic 
 condition of the salivary glands, from pro- 
 gnathous form of jaw and inadequate size, or 
 want of muscular power of lip, from inco-ordi- 
 nate movements of the tongue, and sometimes 
 from a combination of two or more of these 
 conditions. Automatic movements are also 
 very common ; these may consist of rotatory 
 movements of the head on its axis, of the body 
 
120 MENTAL AFFECTIONS IN 
 
 from side to side, or from back to front, or rhytt- 
 mical movements of tlie fingers before the eyes. 
 There are a large number of boys and girls 
 wbo are dull and backward and who develop 
 tardily, but do arrive at last at a fair amount 
 of intellectual power. They are the enfants 
 arrieres of the French writers. It is very 
 important that their condition should be diffe- 
 rentiated from that of idiots. Their state 
 gives rise to much solicitude, and the pro- 
 gnosis depends very much on a right apprecia- 
 tion of their condition, as they respond very 
 much to proper training. The test which I 
 have found most useful is one suggested in the 
 first instance by Dr. Charles West. In any 
 given case we have to ask ourselves, — Can we in 
 imagination put back the age two or more years, 
 and arrive thus at a time perfectly consistent 
 with the mental condition of our patient ? If 
 he be a backward child we shall have no diffi- 
 culty in saying what period of life would be in 
 harmony with his state. If, however, he be an 
 idiot there is no amount of imaginary antedated 
 age to which the present condition of the child 
 corresponds. 
 
 I have already referred to the frequency with 
 
CHILDHOOD AND YOUTH. 121 
 
 whicli lesions of speech occur among tlie feeble- 
 minded. They often constitute a basis of great 
 interest and importance for a diagnosis. The 
 absence of speech when a child arrives at five 
 or six years of age is in itself a matter for grave 
 anxiety. It will be usually possible to refer 
 the condition to one of three causes : (1) The 
 child is completely deaf or has some shght con- 
 genital defect of hearing ; or (2) there is some 
 defect of conformation in the tongue, palate, or 
 lips which prevents language being acquired; 
 or (3) the child is defective in mental power, and 
 either does not require speech from the absence 
 of ideas or has an inability to convert ideas into 
 words. Even when speech does exist it is often 
 echo-like. I have had several children under 
 my observation, in whom this kind of talking is 
 characteristic— To my question, " How are you 
 to-day ? " came the immediate reply, " To-day." 
 I ask another, " Are you a good girl ? " the re- 
 sponse is simply" Girl." Many such cases, how- 
 ever, maybe gradually led to intelligent response. 
 Sometimes the whole question is repeated, and 
 the echo is not simply that of the last word. 
 Often the absence of speech is associated with, 
 a perfect understanding of what is said, the 
 
122 MENTAL AFFECTIONS IN 
 
 speecli faculty being a later development than 
 the capacity for understanding spoken words. 
 Gesture language frequently takes tlie place of 
 spoken language in the feeble-minded. The 
 want of speech is scarcely ever recognised by 
 friends or relations as the outcome of feeble- 
 mindededness. " My child," says almost invari- 
 ably the mother or father, " has no deficiency 
 except that he does not talk." When the child is 
 being trained the parents regard the acquisition 
 of, or improvement in, speech as the touchstone 
 of progress, disregarding a number of other 
 faculties which have been developed, or evil 
 propensities which have been effaced. In many 
 cases they are right, the absence of speech 
 without deafness or deformity being a very im- 
 portant indication of a grave mental lesion. 
 
 A fertile field for the investigation of the 
 morbid anatomy of idiocy is opened up by 
 the enquiries of Hitzig, Jackson, and Terrier 
 into the localisation of function, and by im- 
 proved microscopy aided by the use of staining 
 agents. A very prominent characteristic is the 
 diminished weight of the encephalon. Some- 
 times the diminution is very great, as in the 
 
CHILDHOOD AND YOUTH. 123 
 
 microceptialic or Aztec variety. I have had the 
 opportunity of examining several, but the most 
 complete example was the brother of the boy 
 described by Professor Marshall in the ' Trans- 
 actions ' of the Royal Society. The brother in 
 question was for some years under my care, and 
 was an extremely good example of the suscepti- 
 bihty to education of even most unpromising 
 cases. He acquired language, read books with 
 simple words, amused himself with pictures, 
 and much enjoyed life. He was very agile, 
 but always rested himself by placing his hands 
 upon his knees, and when he ran he did so with 
 his head far in advance of his body in a simian- 
 like manner. He had a copious gesture lan- 
 guage, which he had adopted before he acquired 
 speech, and when he spoke he opened and shut 
 his eyes and shook his head in a manner very 
 suggestive of one of the quadrumana. He died 
 at the age of eighteen. His mother had only 
 given birth to two children, and they were both, 
 as I have said, microcephalic. There was a 
 history of extreme alcoholic intemperance on 
 the part of the father, who died prematurely 
 therefrom. The boy was 56 inches in height 
 and weighed only 89 lbs . He died from phthisis 
 
124 MENTAL AFFECTIONS IN 
 
 with caseous deposit in his lungs and with more 
 recent disseminated tubercle. 
 
 His head measured 15 inches in circum- 
 ference. Its antero-posterior curve was 8 inches. 
 Its bilateral curve 8 inches. Its antero-pos- 
 terior diameter 5 inches, and its bilateral 
 diameter 3 "9 inches. The encephalon with its 
 membranes weighed 15 ounces. The cerebrum 
 was 4*2 inches long, 3"9 inches wide, and 1*8 
 inches high. It was attenuated in the occipital 
 region in length, width and depth. 
 
 The departure from the ordinary course 
 of development arose in all probability at an 
 early period in the history of the germ. The 
 convolutions which were best developed were 
 those of the frontal, parietal, and temporal 
 regions, while those less so were the orbital, 
 but especially the occipital region. The central 
 lobe, or Island of Reil, was represented only 
 by a slightly elevated prominence. Gratiolet 
 laid great stress on the supra-marginal lobule 
 as characteristic of man ; in this brain, how- 
 ever, the whole was reduced to the smallest 
 possible size, while the bent fold was dispro- 
 portionately large. Certainly the conformation 
 is not explicable by reference merely to re- 
 
CHILDHOOD AND YODTH. 125 
 
 tarded growth, and lends, therefore, no coun- 
 tenance to the arguments of those who regard 
 microcephalic brains as due simply to syn- 
 ostosis. In this case the sutures of the cranium 
 remained with remarkable distinctness. The 
 defect was one of development, and not of 
 growth merely. The evidence of this is derived 
 from the modification of the cerebral convolu- 
 tions and the simplicity of their form. While 
 all the parts of the perfect human cerebrum 
 were represented, they, in a large number of 
 cases, rivalled in simplicity the quadrumauous 
 type. Like the brain described by Professor 
 Marshall, the simplicity of arrangement was not 
 equal throughout the whole of the convolutions, 
 and here again some additional proof was 
 oflPered of the arrest in development not having 
 taken place at a definite period of embryonic 
 existence. 
 
 On comparing this brain with that of his 
 brother, it was noticed that while the parietal 
 reo-ion remained the same, the frontal exceeded 
 it in size. How far this was the result of the 
 physical training to which he had been submitted 
 one can only surmise. Certain it is that it is 
 the only part of the brain which was proper- 
 
126 MEi^TAL APFEOTIONS IN 
 
 tionately larger than that of his brother, while 
 the occipital lobe appeared to have undergone 
 but little developmental change. Comparing 
 his convolutions with those of the orang and 
 chimpanzee they appeared to be less complex, 
 the convolutions being smoother and less dis- 
 turbed by secondary sulci. The absence of a 
 well-defined supra-marginal lobule, the absence 
 of the second connecting convolution, the sim- 
 plicity of the bent convolution, the presence of 
 the calcarine lobule, the absence of the acces- 
 sory fold which unites the lobule of the second 
 ascending fold to the superior marginal lobule, 
 were all characters which approximated it to 
 the quadrumanous brain. On the other hand, 
 the want of symmetry, the presence of several 
 of the external connecting folds, the absence of 
 an operculum, the position from which the bent 
 fold took its rise in reference to the fissure of 
 Sylvius, the complete absence of the two inter- 
 nal connecting convolutions, and, lastly, the 
 complete junction between the calloso-marginal 
 and the middle temporal or uncinate convolu- 
 tions were characters essentially human. 
 
 Cases of extreme asymmetrically developed 
 brains are not infrequent ; a very characteristic 
 
CHILDHOOD AND YOUTH. 
 
 127 
 
 example I published in vol. xx of the " Patho- 
 logical Transactions,' and many similar ones 
 have come under my observation. The most 
 frequent want of development is that of the 
 occipital lobe. Where there is any approach 
 to smallness of the brain this lobe is the 
 part which shows greatest want of develop- 
 ment. This condition has been noted in a case 
 reported by Dr. Shuttleworth, in which the 
 frontal and parietal lobes were fairly well deve- 
 loped but the occipital lobe was quite rudimen- 
 tary. Dr. Fletcher Beach has also pubhshed 
 some cases of microcephahsm where the defec- 
 tive development of the occipital lobe was very 
 marked. 
 
 Hypertrophy of the brain is not infre- 
 quently met with. In one very remarkable case 
 that came under my observation there was the 
 co-existence of a huge cranium with all the 
 sutures completely ossified. So thoroughly was 
 this the case that if it had occurred with a 
 microcephalic cranium it would have been a 
 strong argument in favour of the causal influ- 
 ence of premature synostosis in microcephahsm. 
 In another case the cranium was remarkably 
 and uniformly thickened, and the brain weighed 
 
128 MENTAL AFFECTIONS IN 
 
 sixty-two ounces. On removing tlie dura mater 
 tlie entire surface of tlie encephalon presented 
 a blanc-mange appearance, in great measure 
 obscuring the outline of the convolutions, which 
 had great simplicity. The opacity appeared to 
 be due to the presence of lymph, in the sub- 
 arachnoid space, in the meshes of which lymph, 
 limpid serum was contained. The substance 
 of the brain was very tough and the cineritious 
 portion pale. The subject was only fifteen years 
 of age, and was remarkably stolid and irre- 
 sponsive to all external impressions. Dr. 
 Fletcher Beach has published a collection of 
 cases which well illustrate hypertrophic condi- 
 tions of the brain. 
 
 Absence, more or less complete, of the com- 
 missures is met with. In 2 per cent, of the 
 cases I have examined there has been almost 
 entire absence of the corpus callosum, and in 8 
 per cent, absence of the soft commissure. 
 
 Pallor of the grey portion of the encephalon 
 is very frequently met with in the brains of 
 feeble-minded children. Looking back over my 
 post-mortem notes, nothing is more striking 
 than the frequency with which extreme pallor is 
 mentioned. I cannot but think that this affords 
 
CHILDHOOD AND YOUTH. 129 
 
 indications for treatment as well as a basis for 
 hopefulness in the possible functional improve- 
 ment of the cerebrum. 
 
 The treatment of the various phases of feeble- 
 mindedness resolves itself into medical and 
 physical; and training, both moral and intel- 
 lectual. The importance of commencing this 
 betimes cannot be too much insisted on. Early 
 training is of importance in preventing the 
 growth of bad habits which become engrafted 
 on the child. Constantly one meets with chil- 
 dren who grow up a trouble to themselves and 
 to those around them, from the injudicious 
 treatment of some ignorant nurse who tyrannises 
 over the family by her supposed essential rela- 
 tion to the child. Much time is often required 
 to undo the evil — even if it be capable of being 
 counteracted. 
 
 There are two great hindrances to the early 
 and successful training of feeble-minded chil- 
 dren arising from misconceptions on the part 
 of many members of the medical profession. 
 It is constantly said to the anxious parents of 
 these children, "Do not be troubled, the child 
 will grow out of it; wait till he reaches seven 
 years," or, if the child has reached that age, 
 
 9 
 
130 MENTAL AFFECTIONS OF 
 
 then wait till he has reached fourteen. I know 
 nothing of cataclysmal improvements, such as 
 are here indicated. The opinion and advice 
 have no bases in experience. The septennial 
 periods referred to are periods of anxiety and 
 peril ; they are not periods of sudden leaps 
 from mental feebleness to mental vigour; they 
 are, on the contrary, developmental crises full 
 of danger, periods when wreck of what mental 
 power exists is liable to take place. How often 
 one has cause to lament the precious time lost 
 by the parents being thus lured into a fool's 
 paradise ! It should be remembered that the 
 increments of intelligence are slow ; that every 
 proper habit has to be implanted; that many 
 things which are thought instinctive and appear 
 to come naturally, have, with painstaking soli- 
 citude, to be taught. Bad habits of the most 
 serious kind spring up which militate against 
 the progress of the child while waiting for the 
 sudden change which never comes. 
 
 The other great mistake in the medical advice 
 which is often given is the insistance to the 
 mother that her child should not mix or be 
 trained with children like himself, but with more 
 intelligent children. Now, flattering as this 
 
CHILDHOOD AND YODTH. 131 
 
 may be to tlie parents, it is thorouglily baneful 
 to tbe interest of the feeble-minded little one. 
 The most successful training is effected with 
 the child's equals ; in this way a healthy emu- 
 lation is established. Intelligent children will 
 not take part in the amusements and games 
 of feeble-minded ones, moreover, there is no 
 community of feeling or of interest. The out- 
 come of an attempt to train the feeble-minded 
 child with others more intelligent than himself 
 is infallibly to make his life solitary and to 
 accentuate the condition which it is of the 
 greatest importance to correct. I have seen 
 the relative of a nobleman, living in all the 
 luxury of a well-appointed country house, so 
 put aside by her sisters, junior as well as senior, 
 that she never ventured on a remark, and at 
 length lost speech. I have seen the same girl 
 transferred to a class of children like herself, 
 pass from monosyllables to thorough conversa- 
 tional language, amid the sympathy and com- 
 panionship of her compeers. Mothers of feeble- 
 minded children invariably think their children 
 more intelligent than any others of a like cate- 
 gory, and they only need the bias of medical 
 opinion to put off proper and effective aid until 
 
132 MENTAL AFFECTIONS OF 
 
 it is too late. Being afraid of their association 
 with others of the same class, the parents either 
 send them to schools where their lives are made 
 wretched by teasing, and where they fall hope- 
 lessly behind, without the benefit of individual 
 skill, or the helpfulness of collective emulation ; 
 or the boy is relegated to a country vicarage 
 or Welsh farm, without any of the appliances 
 or agencies which can develop his best possi- 
 bilities. The first thing to be done is to rescue 
 the feeble one from this solitary life, to give 
 him suitable companionship, to place him in 
 a condition where all the machinery shall move 
 for his benefit, and where he shall be surrounded 
 by influences of art and nature calculated to 
 make his life joyous, to arouse his observation, 
 and quicken his power of thought. No one who 
 can speak from experience in the matter would 
 hesitate in saying that the companionship of 
 their equals in intellectual power provides just 
 the attrition which is desirable, — that the associ- 
 ation with their superiors condemns them to a 
 life of isolation which renders nugatory all 
 efforts for their improvement. The fear that 
 the association of a feeble-minded child with 
 feeble-minded children will exercise an injurious 
 
CHILDHOOD AND YOUTH. 133 
 
 effect upon the growth of his intelligence is in- 
 correct and not based upon experience. 
 
 Dr. Ireland has very well said that " imbe- 
 cile children are no more injured by the 
 presence of others of inferior intelligence than 
 ordinary boys and girls are made childish by 
 the appearance of a baby in the house, — that 
 it is often, indeed, a great advantage for chil- 
 dren to get rid of the uniform and hopeless 
 inferiority in which they have hitherto lived, 
 and to find that they have equals with whom 
 they can interchange their simple ideas, and 
 who give them a ready sympathy, and even to 
 find that they have inferiors." How well I 
 remember one feeble-minded boy coming to me 
 and expressing his interest for another who 
 was crippled, and saying to me, " Doctor, what 
 a pity it is that that boy is lame, although he is 
 not quite right." If there was any effect from 
 the association it was that it begat a pharisaical 
 spirit rather than exercised a depressing influ- 
 ence. The position of the feeble-minded is 
 not always a very desirable one in the houses 
 of the wealthy. Too often his claims are lost 
 sight of, and the great aim is to keep his 
 existence a secret, while no kind of com- 
 
134 MENTAL AFFEOTJONS OF 
 
 panionsliip is established between him and the 
 other members of the household. Moreover, 
 the claims of society and the presence of visitors 
 tend to make what little training there is desul- 
 tory and futile, and lead to his being consigned 
 to the care of servants in the less frequented 
 portions of the house, where his life must 
 necessarily be monotonous, uneventful, and 
 uninteresting. If such are the difiBculties 
 among the wealthy, how much more are they 
 intensified in the houses of the poor, where the 
 parents are making a desperate struggle for 
 existence, — where the afflicted little one uses 
 up the time and energy of one sane life ! How 
 can it be possible, with the arrangements of a 
 cottage, that anything tangible can be done to 
 rescue the child from a condition which is 
 deplorable in every aspect ? Is it not probable 
 that the mother, with her attention always 
 directed to this object of care and anxiety, 
 will propagate a neurotic race? Those who 
 have witnessed the transformation in chil- 
 dren who have been removed from squalid 
 cottages to a well-regulated institution, or have 
 seen their joyous return from luxurious homes 
 to their companions and their training, will be 
 
CHILDHOOD AND YOUTH. 135 
 
 able to realise how trutliful is a motlier's ac- 
 count of her boy that : " When putting him to 
 bed the last night he was here he was smiles all 
 oyer, saying, ' Groing back to school to-morrow, 
 mother,' and he packed his own bag before I 
 could get to him in the morning, and could 
 hardly finish breakfast he was in such a hurry 
 to be off, and went away all smiles and delight." 
 It must always be kept in mind that the basis 
 of all treatment should be medical. Medical, 
 I mean, in an enlarged sense. Success can only 
 be secured by maintaining the patient in the 
 highest possible health. This is very well in- 
 dicated by the intellectual torpor which follows 
 or accompanies declension of health, and the 
 lessened intellectual vigour which is met with 
 in cold weather. I have referred to the hiber- 
 nation which occurs among many feeble-minded 
 children, and which has led me to notice that 
 their intellectual vigour is directly as their 
 external temperature. The pallor of the cine- 
 ritious portions of their brains, which is so 
 frequently met with, is suggestive of the neces- 
 sity of vigorously maintaining their nutritive 
 life. A very liberal dietary is of great import- 
 ance. It should contain a fair quantity of 
 
136 MENTAL AFFECTIONS OF 
 
 nitrogenous elements, and be rich also in phos- 
 pliatic and oleaginous constituents. Green 
 vegetables are very essential, as in their absence 
 there is a great tendency to become scorbutic. 
 Care should be taken that farinaceous food, as 
 represented by the so-called corn flours, should 
 give way to the more plastic elements of nutri- 
 tion found in semolina, entire wheat flour, or 
 macaroni. Not only must the diet be sufficient 
 in amount and good in quality, it should be 
 exhibited in a form suited to their power of 
 mastication. Their bedrooms and sitting-rooms 
 should be spacious and well ventilated, and 
 especially well warmed. 
 
 The skin should be kept in healthy function 
 by frequent sponge and other baths, both 
 for the sake of the individual health, and for 
 the health and comfort of their associates. 
 The exhalation from the skin of feeble minded 
 children is something sui generis. It is of 
 great importance that their residence should be 
 on gravel soil, and with well-made walks, that 
 no opportunity may be lost for outdoor exer- 
 cise. Warm clothing is essential, to prevent as 
 much as possible the disastrous effects of 
 climatic changes. 1 have before referred to 
 
CHILDHOOD AND YOUTff. 137 
 
 the relative frequency of phthisis to the ordi- 
 nary mortality. Dr. Fitch, of Elwyn, Pennsyl- 
 vania, in a very interesting paper, relates his 
 experience that over 50 per cent, of his deaths 
 were from disease of the lungs and air passages. 
 My own experience is that on a clay soil 64 
 per cent., while on a gravel soil 44 per cent. 
 of the mortality was from that cause. He also 
 relates, what is in conformity with my experience, 
 and in harmony with what I have been insist- 
 ing on, that there is always a remarkable immu- 
 nity from disease during the summer months. 
 Having placed our patient under the most favor- 
 able hygienic conditions, the special training 
 should be carried out with great enthusiasm. 
 Physical training must form an important part 
 of the education. The feeble muscles must be 
 nourished by calling into exercise their func- 
 tions, as well as by massage and by galvanism. 
 Simple automatic movements, which I have 
 referred to as being so common with the feeble- 
 minded, should be replaced by others which are 
 the product of will. We have to commence 
 with very simple ones, gradually making them 
 more complex. The want of co-ordination in 
 the muscular system is very characteristic of 
 
138 MENTAL AFFECTIONS OF 
 
 the feeble-minded, and it is only by judicious 
 physical training that the mutiny of the muscles 
 can be overcome, and that purposeless acts can 
 be converted into voluntary efforts suited for 
 the wants of daily life. This training has to 
 be carried out in great detail so that every 
 voluntary muscle and every system of muscles 
 may be called eventually into action. In this 
 way the various acts of prehension, locomotion, 
 and mastication are taught, the tongue becomes 
 a willing agent, and the lips learn to retain the 
 saliva which before gave our patient a repulsive 
 look. I cannot enforce too strongly that little 
 progress is made in speech until we first attain 
 co-ordinated movements in the limbs. Finger 
 lessons are to precede tongue lessons. I always 
 remember the pinioned Frenchman who en- 
 treated that his arms might be freed because 
 he wanted to speak. Unless we succeed in 
 unpinioning the arms of our patients they do 
 not speak. It is to be remembered too that we 
 cannot bring into harmonious relation the 
 muscles and the will without improving the 
 physical quality of the brain and the other 
 nervous centres. By these means, too, we shall 
 have placed our patient in practical relation 
 
CHILDHOOD AND YOUTH. 139 
 
 witli the external world and initiated reasoning 
 power. 
 
 The moral training is of great importance. 
 While his physical and mental powers are being 
 developed by hygienic and physiological pro- 
 cesses, he has to be taught to subordinate his 
 will to that of another. He has to learn obe- 
 dience; that right-doing brings pleasure, and 
 that wrong-doing is followed by its deprivation. 
 The affective faculties should be so cultivated 
 that the deprivation of the love of the teacher 
 should be the greatest punishment and its mani- 
 festation the highest reward. In this way in- 
 dications of untruthfulness, selfishness, obsti- 
 nacy, sensuality, theft, and unMndness to com- 
 panions are checked. Corporal punishment 
 should be strictly forbidden. The tact of the 
 teacher will be called into exercise in devising 
 the suitable reward or punishment. I have 
 seen a girl exhibiting violent obstinacy melted 
 into contrition and obedience by the threat of 
 the teacher that she would wipe from her face 
 the kisses she had given her the previous day. 
 In no case should the punishment interfere with 
 the hygienic treatment. Nothing is worse than 
 the deprivation of food for an offence. I have 
 
140 ' MENTAL AFFECTIONS OF 
 
 seen a case of violent and uncontrollable temper 
 reduced to calm obedience by the administra- 
 tion of a basin of bread and milk. The moral 
 delinquency was the result of mental excitement 
 the outcome of defective nutrition. 
 
 The intellectual training must be based on a 
 cultivation of the senses. They should be 
 taught the qualities of form and the relation of 
 objects by their sense of touch ; to appreciate 
 colour, size, shape, and relation by sight; to 
 understand the varieties of sound when ad- 
 dressed to the ear ; the qualities of objects by 
 their taste and smell. The lessons should be 
 of the simplest kind at first and gradually cumu- 
 lative. Nothing is to be left to the imagination. 
 The concrete must be taught, not the abstract. 
 In this way we give them the basis from which 
 their reasoning and reflective powers can be 
 developed. Synchronously with this we make 
 use of the physical powers we have cultivated. 
 They should be taught to dress and undress. 
 They should be trained to acquire habits of 
 order and neatness, to use deftly the spoon or 
 the knife and fork; to walk with precision and 
 to handle with tact. The defective speech is best 
 overcome by a well-arranged plan of tongue 
 
CHILDHOOD AND YODTH. 141 
 
 gymnastics, followed by a cultivation of the 
 purely imitative powers, teaching at first mono- 
 syllabic sounds wbicb have concrete representa- 
 tives. The use and value of money where shops 
 are not accessible is best taught by a plan I 
 devised of instituting a shop furnished with the 
 usual appliances of sale. One patient acted as 
 the customer and another as the trader. In this 
 way a purchase was effected and the whole 
 transaction of buying, weighing, calculating, 
 and paying, with the reception of change, was 
 made under the criticism of the assembled class. 
 All these belong to school instruction. 
 
 It is desirable, however, to supplement the 
 house and school by gardening and farming 
 operations ; by the lathe, the fretwork machine, 
 the carpenter's bench, and, for the more advanced 
 in education, the printer's shop. For girls. 
 Kindergarten occupations and the various 
 elegancies of needlework may be the outcome 
 of persevering endeavours, while music and 
 dancing may for all alternate with dramatic 
 entertainments, which are most useful in appeal- 
 ing both to the eye and the ear. Care should 
 be taken that the physical should interchange 
 with the intellectual training. It is of the 
 
142 MENTAL AFFECTIONS OF CHILDHOOD. 
 
 greatest importance that the teacher should keep 
 clearly in view that his primary object is to make 
 the pupil self-helpful, and, as far as possible, a 
 useful member of the community ; in this way 
 more is done than by any other means. Mere 
 memoriter knowledge is of little value ; every- 
 thing which makes him practically useful makes 
 him proportionately happy. 
 
 But I am warned that my allotted time has 
 expired. Methinks medicine of these later days, 
 which has signalised her march by numerous 
 victories, has had no more beneficent result than 
 has been achieved by the enthusiasm of such 
 men as Howe, Seguin, Wilbur, Knight, and 
 Oonolly of the past, and by those still living 
 who are followers, it may be at a reverential 
 distance, in the work of rescuing from oblivion 
 and neglect a class who appeal to our tenderest 
 sympathies and our most affectionate regards. 
 
. ACCOUNT OP A CASE 
 
 IN WHICH THE 
 
 CORPUS CALLOSUM AND FORNIX 
 WERE IMPERFECTLY FORMED 
 
 AND THE 
 
 SEPTUM LUCIDUM AND COMMISSURA 
 WEEE ABSENT. 
 
 ' Trans, of Eoy. Med. and Chir. Soc./ 1861. 
 
 The medical literature of examples of defective 
 commissures of tlie brain comprises so few- 
 cases, and of these the life-history is so imper- 
 fect, that I need no apology in placing the 
 records of another before the members of this 
 Society. The question has often been proposed 
 to me, what relation idiocy bears to these arrests 
 of development. At an early stage of my 
 inquiry into the pathology of idiocy, I was pre- 
 pared to meet with many cases characterised by 
 the heading of this paper, but on further investi- 
 gation found that, with the exception of deficient 
 
144 DEFECTIVE CORPUS CALLOSUM. 
 
 commissura mollis, absence or defect of the 
 larger commissures of tlie brain occurred but 
 seldom. Among fifty brains of idiots which I 
 have dissected , the following is the only example 
 of this nature. 
 
 That idiocy frequently depends on defective 
 commissural connection my present experience 
 does not support ; but, on the other hand, that 
 the absence of such connection may not occa- 
 sionally be a cause of this calamity is, I appre- 
 hend, a question suh judice. 
 
 Mr. Paget, in the twenty-ninth volume of 
 your ' Transactions,' has so ably generalised on 
 the cases at that time on record, that there is 
 little to be done beyond adding to the facts illus- 
 trating this interesting subject. 
 
 The case to which I beg leave to call your 
 attention, is that of A. B — , a boy aged nine 
 years at the time of his death. He had pre- 
 viously been under my daily observation for 
 two and a half years. He was the first-born of 
 three children ; the second, a boy, is also 
 idiotic ; while the third and youngest, a girl, is 
 healthy and intelligent. The respective ages 
 of his father and mother, at the time of his 
 birth, were twenty- six and twenty- seven years ; 
 
DEFECTIVE CORPUS OALLOSUM. 145 
 
 there was no consanguinity between them. 
 There is no history of mental disease, or of any 
 such defects as club-foot, hare-lip, cleft palate, 
 &c., in either branch of the family. The 
 mother's brother died of phthisis, but it was 
 not thought to be owing in any way to consti- 
 tutional predisposition. The mother, anteriorly 
 to her marriage, had suffered intense pain in 
 the left side, accompanied by hysteria ; subse- 
 quently to her marriage, and during the preg- 
 nancy which speedily followed, there was no 
 diminution, but rather an increase, of these 
 sufferings. The pregnancy was attended by 
 violent vomiting; and the pain in the side 
 becoming more and more insupportable, opiates 
 were largely resorted to for its relief. About 
 this time Sir Benjamin Brodie was consulted, 
 and his written opinion expresses the belief that 
 she was suffering from renal oxalate-of-lime 
 calculus. There were no unusual circumstances 
 during parturition. 
 
 At five years of age the boy was received into 
 the Asylum for Idiots at Earlswood. He was 
 then a fair and delicate child, three feet three 
 inches in height, fifty-three pounds and a half 
 in weight ; the shape of his bead was oval, the 
 
 10 
 
146 DEFECTIVE COE.PUS CALLOSUM. 
 
 circumference above tlie eyebrows eighteen 
 inches and five eighths, length between the 
 eyebrows and occipital protuberance eleven 
 inches and three quarters, width of forehead 
 four inches and a half. At this time he could 
 stand alone, but was unable to walk ; he was 
 fed with a spoon, as he had no notion of mastica- 
 ting, and it was necessary for his nurse to con- 
 vey the food to the fauces in order to excite 
 the reflex act of deglutition. He could not 
 speak, and was very spiteful. His habits were 
 dirty, and this was augmented by frequent 
 diarrhoea. When seven years old he was able to 
 walk, though feebly, and was placed in the 
 infant class for training and instruction. At 
 nine, the period of his death, he could walk and 
 run, his spiteful habits had been overcome, he 
 was mild and tractable, and exhibited much 
 fondness for his younger brother. He was 
 timid, and afraid of certain toys, did not play 
 with other children, and found most amusement 
 in looking at a picture scrap-book. He was 
 fond of listening to music ; had little or no 
 power of imitation. Although great pains were 
 taken to instruct him, he could scarcely be said 
 to have learned anything. He would in some 
 
DEFECTIVE COEPDS CALLOSUM, 147 
 
 measure go through simple exercises in drilling 
 at command, but could not be taught to throw 
 a ball with any aim. There was no want of 
 co-ordination in his movements, and no dimi- 
 nution of sensation ; his habits had become 
 moderately correct ; he was able to feed him- 
 self with a spoon, the meat having been pre- 
 viously minced, and with much difficulty he was 
 taught to raise a cup to his mouth. He remem- 
 bered his father and mother ; on seeing any lady 
 in black, the colour usually worn by his mother, 
 he would approach, and after examination would 
 say, " No, mamma ! no !" which, with the word 
 " me " when he wanted anything, was the full 
 extent of his powers of utterance. He had no 
 vivacity, and his extreme pallor was remarkable. 
 
 His physical health was far from good ; he 
 was never long free from either strumous oph- 
 thalmia, eruptions at the nasal and oral orifices, 
 thecal abscesses, or diarrhoea ; but he had never 
 been subject to convulsions or epileptic fits. He 
 died from pneumonia on the right side. 
 
 A post-mortem examination was made thirty- 
 three hours after death. The right lung was 
 hepatized throughout, except at its anterior 
 margin. Several of Peyer's glands in the ileum 
 
148 DEFECTIVE CORPUS CALLOSUM. 
 
 were enlarged and congested. The large intes- 
 tine extremely congested throughout. The 
 testes had descended into the scrotum, but were 
 small ; the pubes was sparsely covered with hair. 
 The other organs were healthy. 
 
 The calvarium was of normal thickness, but 
 somewhat unsymmetrical ; there were granular 
 patches in the arachnoid on both sides of the 
 longitudinal fissure, and between these and the 
 dura mater slight adhesions. The encephalon 
 weighed two pounds eight ounces avoirdupois ; 
 the cavity of the arachnoid contained about two 
 ounces of straw-coloured serum; the membranes 
 and sinuses normal. The antero-posterior 
 diameter of the cerebrum was six and a half, 
 its width five and a half inches ; the width of 
 each hemisphere measured across the anterior 
 lobe, in front of the remnant of the corpus 
 callosum, two and a quarter inches. The antero- 
 posterior diameter of each hemisphere of the 
 cerebellum was two and a quarter, its entire 
 width three and a half inches. 
 
 On making sections of the cerebrum and cere- 
 bellum, there was nothing noticeable respecting 
 the size, form, arrangement, or colour of the 
 convolutions. On the first removal of the 
 
DEFECTIVE CORPUS CALLOSTJM. 149 
 
 enceplialon from tlie cranium, it was noticed 
 that, on being placed in its natural position, 
 the hemisplieres separated to an unusual extent, 
 without bringing into view the great commissure 
 of the brain, but displaying, instead, the velum 
 interpositum. Anterior to the velum, and on the 
 same plane, was exposed, on forcibly separating 
 the hemispheres, a narrow band of medullary 
 structure. A horizontal section of both hemis- 
 pheres, so as to display the interior of the lateral 
 ventricles, was then made, and the velum inter- 
 positum removed. The brain was in no part of 
 its structure deficient in cohesion ; the posterior 
 cornu of each of the lateral ventricles was 
 enlarged, and contained about half an ounce of 
 straw-coloured serum each. The small hippo- 
 campus on each side was rather large ; the 
 taenia semicircularis very fully developed. At 
 this stage of the dissection no remnant of the 
 fornix could be discerned ; there was positive 
 absence of any septum lucidum. The third 
 ventricle was exposed, but no middle commis- 
 sure could be discovered ; the pineal gland occu- 
 pied its usual position between the lobes of the 
 corpora quadrigemina, all which structures were 
 of normal size and appearance. At the ante- 
 
150 DEFECTIVE CORPUS CALLOSUM. 
 
 rior boundary of the third ventricle there was 
 the before-mentioned medullary band, which 
 was regarded as the representative of the corpus 
 callosum, but occupying a much lower plane 
 than the normal position of the commissure. 
 It presented, both anteriorly and posteriorly, 
 crescentic, thinned margins, and measured at 
 its narrowest part, which was slightly to the 
 left of the mesial line, one third of an inch. A 
 section was then made through both hemi- 
 spheres on a level with the transverse band. 
 The optic thalami were unusually flattened, and 
 their inner surfaces indicated that the soft com- 
 missure had never been present. There was a 
 marked absence of the peduncles of the pineal 
 gland. The third ventricle presented on its 
 floor the usual structures, and at its anterior 
 part could now be seen the anterior pillars of 
 the fornix ascending at slight angles, but widely 
 separated throughout. Beneath the posterior 
 margin of the transverse band they made a 
 sudden bend, and, passing outward and back- 
 ward over the upper surface of the optic thalami, 
 terminated in the descending cornua of the 
 lateral ventricles as the teenise hippocampi, the 
 tsenise, however, being narrower than usual. 
 
DEFECTIVE OOEPUS OALLOSUM. 151 
 
 The optic commissure at the floor of the third 
 ventricle was strongly marked, and the lamina 
 cinerea interleaved between it and the anterior 
 commissure, where it terminated. The ante- 
 rior commissure was well defined, and above it 
 an interval of two lines occurred between it and 
 the transverse band. The inner surfaces of the 
 anterior lobes of the cerebrum were separated 
 inferiorly as far as the anterior commissure ; 
 and the parts of them into which the knee and 
 reflected portion or rostrum of the corpus callo- 
 sum are usually inserted were covered with 
 convolutions such as are common to other parts 
 of the cerebral surface. The band or rudiment 
 of corpus callosum was situated opposite the 
 widest portion of the corpora striata; its anterior 
 edge being two and one twelfth inches from the 
 anterior margin of the cerebral hemispheres, 
 and its posterior border being four and one 
 twelfth inches from the posterior margin of the 
 hemispheres. It did not exceed one sixteenth 
 of an inch in thickness at any part of it, and its 
 fibres spread out anteriorly and posteriorly on 
 reaching the hemispheres. It will follow from 
 this description that there was no representative 
 of the genu or of the reflexed portion of the 
 
152 DEFECTIVE CORPUS OALLOSUM. 
 
 corpus callosum ; that the body of the fornix, 
 septum lucidum, and its fifth ventricle, and the 
 soft or middle commissure, were entirely absent ; 
 and that there existed no communication 
 between the lateral representatives of the 
 fornix ; moreover, that these had no connection 
 with the posterior diverging fibres of the trans- 
 verse band, and consequently that not even the 
 analogue of a septum lucidum was present. 
 
 Mr. Paget, in the twenty-ninth volume of 
 your ' Transactions,' has grouped together with 
 his own case others related by Eeil, Mr. Solly, 
 and Mr. Chatto, and has made some important 
 physiological deductions. The case related by 
 him was " not remarkable for any excellence or 
 great defect of mind." In Mr. Solly's, the boy, 
 although *' boobyfied," could read, and selected 
 as his favourite reading religious books. Reil's 
 case, a woman, was of dull intellect, but could 
 go errands in the village. Mr. Ohatto's patient 
 lived only twelve months. 
 
 In comparing the case which has been here 
 detailed with those referred to by Mr. Paget, it 
 would, at first sight, appear to stand opposed 
 to the conclusions at which he arrived, and to 
 support the view that the corpus callosum is 
 
DEFECTIVE OOEPUS OALLOSUM. 153 
 
 necessary to the possession of the average 
 power of tlie human mind. But this opposition 
 may be only apparent ; for it is a circumstance 
 worthy of special regard in instituting a com- 
 parison, that while in the three above-named 
 examples the soft commissure was present, in 
 the one which I have brought forward it was 
 entirely absent. Moreover, in Mr. Solly's case, 
 the soft commissure was " wide and thick," and 
 in Mr. Paget' s it was inordinately large, measur- 
 ing six tenths of an inch from before backwards, 
 and being also thicker than usual. 
 
 How far the presence of extra large, middle 
 commissures compensated for other deficiencies 
 in the former cases, and how far its absence 
 was the cause of the extreme mental deficiency 
 in the present instance, I shall not now discuss. 
 I will only say that my researches hitherto lead 
 me to attach a physiological importance to the 
 soft commissure which previous observers have 
 not recorded. 
 
ON THE 
 
 CONDITION OP THE MOUTH IN IDIOCY. 
 
 The ' Lancet/ vol. i, 1862. 
 
 The opinion wliicli has been formed, both in 
 and out of the profession, in reference to idiocy, 
 has arisen more from the representations of 
 poets and romance- writers than from the deduc- 
 tions of rigid observation. The popular novelist, 
 in this as in other cases, seizes on the charac- 
 teristics of some exaggerated specimen, pour- 
 trays them by the aid of a vivid imagination, 
 and henceforth the exaggeration becomes the 
 type of a species in the minds of men. The 
 term idiot has thus become synonymous with 
 the most degraded condition of humanity only 
 — with a creature incapable of being influenced 
 by moral or physical treatment, and. separated 
 by an immense gulf from the remainder of man- 
 kind. It has arisen, in no small degree, from 
 the existence of this opinion, that until within 
 
CONDITION OP THE MOUTH IN IDIOCY. 155 
 
 a comparatively recent period, so few efforts 
 liave been made to ameliorate the condition of 
 idiots. In too many cases they have been 
 neglected or allowed to be influenced for evil, 
 regardless of the fact that they might be equally 
 impressed for good. Independently of the 
 benefit that can be effected for these unfortu- 
 nate sufferers, the benevolent efforts on their 
 behalf have furnished an opportunity for an 
 investigation into their physical and psychical 
 life before unattainable. 
 
 The condition of the idiot is not simply one 
 of mental alienation. It frequently presents 
 also grave physical deterioration; and this 
 physical alteration is as much a test of idiocy 
 as is the low condition of mental power. In a 
 community such as that of the Earlswood 
 Asylum, there is to be found every variety of 
 imbecile mind. In fact, just as in the outer 
 world there is a graduated series from the most 
 commonplace intellects, — who are " the hewers 
 of wood and drawers of water," — up to the 
 giant minds that leave their impress on the age 
 in which they live ; so is there amongst an 
 imbecile population a gradual shading in an 
 inverse direction — from the youth who might. 
 
156 CONDITION OP THE MOUTH IN IDIOCY. 
 
 if lie tad property, become tlie subject of 
 inquiry before a Master in Lunacy, to one who, 
 with every means of communication with the 
 external world, except feeling, closed, vegetates 
 in impenetrable mist. In such a community 
 one can perceive the grades of physical condi- 
 tion accompanying the mental phases ; and a 
 study of the physical anomalies becomes as 
 interesting and important as that of the psycho- 
 logical state. When contemplating so large a 
 number as that which Earlswood shelters, one 
 is able to set some of the members aside into 
 natural groups, by simple reference to their 
 physical state, and to predicate from that state 
 what will be their probable future mental 
 improvement. 
 
 There is scarcely an organ in the body but 
 may be found gravely altered in idiots : the 
 circulation and respiration are abnormal; the 
 skin exhibits perturbed functions ; defective 
 innervation, lesions of motility and nutrition, 
 are abundantly met with ; the bodily conform- 
 ation is often of an aberrant kind. Regard 
 therefore should be paid, in all cases of dia- 
 gnosis of idiocy, to the physical condition as 
 confirmatory of any opinion based on purely 
 
CONDITION OF THE MOUTH IN IDIOCY. 157 
 
 psychological data. It is in this way one is 
 enabled to differentiate an idiot from a simply 
 backward or ill- regulated child. 
 
 It is from the conviction of the importance 
 of a study of the physiological manifestations 
 of idiocy, that I have been induced to devote 
 no small portion of time to an investigation 
 into the structure and functions of the various 
 organs seriatim amongst idiots and imbeciles. 
 I purpose in the present paper giving some of 
 the results of my observations of the feeble- 
 minded, in reference to the condition and con- 
 formation of their mouths. Characteristic as 
 is this region of various transitory mental phases 
 amongst the sane, does it bear the permanent 
 impress of a state in which the mind has failed 
 in attaining its normal condition ? If so, what 
 is the nature of the impress ? Does any value 
 attach to the conformation of the mouth as 
 confirmatory or otherwise of a state of mental 
 incapacity ? These are some of the questions 
 we have to solve. 
 
 I may premise that these observations have 
 been made during the past year, without refer- 
 ence to any recent legal inquiry, and extend 
 over 200 cases, Avhich have been taken, with- 
 
158 CONDITION OF THE MOUTH IN IDIOCY. 
 
 out any special selection, from a larger number. 
 Not one on the list would in his present con- 
 dition be able to manage his own afiairs, or be 
 legally held to be responsible. Many of them, 
 however, are susceptible of considerable culture, 
 are affected by the amenities of life, write letters 
 to their friends, make small purchases, and form 
 friendships. Several perform mechanical work 
 with system and order. One, although posses- 
 sing very little judgment, has been taught 
 French and Latin, and reads these languages as 
 well as ordinary schoolboys. Some few possess 
 extraordinary memories and special aptitudes. 
 146 were males, and 54 females. Their ages 
 ranged from seven to thirty-six, and the follow- 
 ing table gives the numbers at each age last 
 birthday : — 
 
 No. 
 
 Age. 
 
 No. 
 
 Age. 
 
 No. 
 
 Age. 
 
 2 
 
 at 7 . 
 
 . 14 
 
 at 16 
 
 .. 5 
 
 at 25 
 
 4 
 
 „ 8 . 
 
 . 18 
 
 „ 17 
 
 .. 1 
 
 „ 26 
 
 2 
 
 „ 9 . 
 
 .. 10 
 
 „ 18 
 
 .. 3 
 
 „ 27 
 
 4 
 
 „ 10 . 
 
 . 14 
 
 „ 19 
 
 .. 2 
 
 „ 28 
 
 10 
 
 „ 11 
 
 . 18 
 
 „ 20 
 
 .. 1 
 
 „ 29 
 
 13 
 
 „ 12 . 
 
 . 7 
 
 ,. 21 
 
 .. 3 
 
 „ 30 
 
 11 
 
 „ 13 . 
 
 . 12 
 
 „ 22 
 
 .. 2 
 
 „ 33 
 
 12 
 
 „ 14 . 
 
 .. 9 
 
 „ 23 
 
 . 1 
 
 „ 34 
 
 17 
 
 „ 15 . 
 
 .. 3 
 
 „ 24 
 
 .. 2 
 
 » 36 
 
CONDITION OP THE MOUTH IN IDIOCY. 159 
 
 Or ranged in decennial periods — below 10 
 years, 8 ; from 10 to 19 inclusive, 123 ; from 20 
 to 29, 61 ; from 30 to 39, 8. 
 
 Palate. — Amongst tlie 200 cases included in 
 this inquiry, 82 possessed palates inordinately 
 arched, and with this increased arching were 
 noticed various abnormalities. In some the 
 palate was unsymmetrical, the two sides having 
 different degrees of concavity, or one side 
 plane, and the other concave. In 34 the 
 palates were excessively arched, approximating 
 to the appearance of the roof of a house, and, 
 with this extreme angularity, was great narrow- 
 ness. Excessive arching of the palate occurred, 
 therefore, in 58 per cent. Excessive flattening 
 of the palate was observed in 4 cases. In 34 
 cases, or 17 per cent., the palate had a very 
 prominent antero-posterior ridge or keel, corre- 
 sponding to the line of approximation of the 
 palatal bones. In 7 the palate bones did not 
 meet, leaving a sulcus between them, the 
 mucous membrane being, however, continuous. 
 There was no instance of the ordinary cleft 
 palate, and I may remark that in an exami- 
 nation of nearly 600 idiots, I have failed in 
 meeting with an example of that deformity. In 
 
160 CONDITION OF THE MOUTH IN IDIOCY. 
 
 several the hard palate extended but a short 
 distance posteriorly, from defect of the palatal 
 process of the superior maxillary bone and 
 entire absence of the palatal process of the 
 palate bone, and in all these cases the velum 
 palati was unusually flaccid. In the majority 
 of cases there was marked narrowness of the 
 palate. The following table represents the 
 measurements in 24ths of an inch of the space 
 between the posterior bicuspid teeth of opposite 
 sides : — 
 
 No. 
 
 2 
 1 
 3 
 2 
 
 13 
 10 
 
 Distance. 
 
 No. 
 
 Distance. 
 
 No. 
 
 Distance 
 
 In. 
 
 
 In. 
 
 
 
 In. 
 
 
 . 11 
 
 n+ 2 3 
 
 13 
 
 at 
 
 l2\ 
 
 18 
 
 )) -^4 
 
 . 24 
 
 „ 1 .. 
 
 9 
 
 
 l2\ 
 
 19 
 
 » 2¥ •• 
 
 . 37 
 
 » hk ■■ 
 
 1 
 
 
 1/4 
 
 SO 
 
 . 25 
 
 1 2 
 
 >> -'■24 •• 
 
 6 
 
 
 1^ 
 
 21 
 »> 24 
 
 . 23 
 
 M lA .. 
 
 . 3 
 
 
 HI 
 
 2 2 
 '> '24 ■ 
 
 . 17 
 
 1 ■* 
 
 3> -'■2 4 ■• 
 
 . 1 
 
 
 Iff 
 
 It will be observed that 33 per cent, do not 
 exceed 1 inch, and that 62 per cent., while being 
 more than 1 inch, do not exceed 1^ inch ; 
 whereas the normal average has been stated to 
 be IJ inch. It is worthy of notice that these 
 numbers hold no direct relation to the age or 
 stature of the patients examined. Thus, in a 
 
CONDITION Of THE MOUTH IN IDIOCY. 161 
 
 youth 22 years of age and 6 ft. 1 in. in height, 
 SO narrow is the palate that there is only 1-^^ 
 inch between the bicuspids, and only ^ inch 
 between the opposite gums at their widest 
 interval. The lowest measurements occurred 
 in a boy and girl, the boy 12 and the girl 13 
 years of age. Neither is there a direct relation 
 between the width of the palate and the cranial 
 capacity ; for in a microcephal, whose palate 
 was If inch wide, the internal canthi of the eyes 
 were f f inch distant from one another ; while 
 in a macrocephal whose palate was ff inch 
 wide, the distance between the internal canthi 
 amounted to 2 inches. 
 
 Teeth. — The principal characteristics of the 
 teeth in idiots are, that the period of the first 
 dentition is delayed, the second dentition con- 
 siderably postponed, and that they undergo 
 very general and rapid decay. In many cases 
 the anterior surface of the incisors presents a 
 honeycombed appearance, but in no one instance 
 have I observed those special characters which 
 have been well shown by Mr. Hutchinson to be 
 significant of congenital syphilis. In a large 
 number of cases they are developed irregularly, 
 are crowded, and the canine occupy a different 
 
 11 
 
162 CONDITION OF THE MOUTH IN IDIOCY. 
 
 plane from the otlier teeth, — all these irregu- 
 larities resulting from the imperfect develop- 
 ment of the superior maxillary bone. In 6 
 cases, or 3 per cent., the upper incisors pro- 
 jected to such an extreme degree as to produce 
 grave deformity. In 7 cases the teeth of the 
 lower jaw were in advance of those of the 
 upper. 
 
 Tongue. — The most prevailing character no- 
 ticeable in the tongue of idiots is the hypertrophy 
 of the fungiform papillae. Undue prominence 
 of the papillae was observed in 101 instances. 
 In several there is a marked want of co-ordina- 
 tion in the movements of the tongue, so that 
 the patient, although endeavouring to comply 
 with the request, is unable to protrude it. This 
 condition is usually associated with an absence 
 of general co-ordinated movements, and in the 
 improvement which is effected by treatment it 
 is usually the most persistent derangement of 
 motility. In 16 cases the tongue presented a 
 soddened appearance and exhibited deep trans- 
 verse furrows on its dorsal surface ; in all these 
 patients one is able to trace a marked physio- 
 logical and psychological agreement, and so 
 much do they resemble one another in these 
 
CONDITION OP THE MOUTH IN IDIOCY. 163 
 
 respects that they might readily be taken for 
 members of the same family. Inordinate size 
 occurred in 12 instances, and in almost every 
 case was associated with defective power of 
 articulation. In 2 the tongue was unusually 
 lonsr ; 33 were mute : 16 semi-mute. In 83 
 the speech was indistinct. In 62 the speech 
 was fair. Stammering was observed in 4. 
 
 Tonsils. — One cause of the peculiar speech 
 prevailing among idiots is the condition of the 
 tonsils. These observations for the most part 
 were made in the summer, when the tonsils 
 were not likely to be rendered worse than their 
 usual condition by climatic influences. In 30 
 instances they were injected, in 17 slightly 
 enlarged, in 79 considerably enlarged, and in 5 
 so much increased in size as to interfere with 
 deglutition and respiration. 
 
 Mucous membrane, ^c. — Besides the injection 
 of the mucous membrane of the tonsils which 
 has been noticed, other regions of the oral 
 cavity are liable to this condition. The velum 
 palati, uvula, and pillars of the pharynx were 
 found to be thus characterised in 27 instances. 
 The posterior wall of the pharynx was observed 
 to be marked by considerable vas<5ular injection 
 
164 CONDITION OF THE MOUTH IN IDIOCY. 
 
 in 33 cases, and in 6 the mucous membrane 
 had assumed a granular appearance. The 
 buccal and labial glands were generally hyper- 
 trophied, and the salivary glands were fre- 
 quently enlarged. In 11 instances the sub- 
 lingual gland was greatly enlarged. The uvula 
 was elongated in 14 cases, bifid in 2, very short 
 in 1, and entirely absent in 1. The lips were 
 hypertrophied in 2. Owing probably to the 
 abundant supply of fresh vegetables with which 
 the patients are provided, I only found one 
 case in which the gums were swollen and 
 tumid. 
 
 Slavering, — The flow of saliva from the mouth 
 is universally associated in the popular mind 
 with the condition of idiocy. The slavering 
 may vary in degree. It may occur only at 
 periods of excitement, and at meal times, or 
 with scarcely any intermission throughout the 
 day, producing in severe cases excoriation of 
 the chin. Amongst 325 cases which I have 
 examined, I find 72, or 22 per cent., in which 
 this habit was noticed. Of these, 28 slaver to 
 a slight extent, 17 rather more so, and 26 in an 
 aggravated degree. This peculiarity depends, 
 I believe, on two or three causes — 1st, the in- 
 
CONDITION OP THE MOUTH IN IDIOCY. 165 
 
 creased secretion of saliva ; 2nd, the deformed 
 condition of the mouth ; 3rd, the want of co- 
 ordinated movements in the muscles of the 
 tongue ; and 4th, the absence of tonicity in the 
 labial muscles. Seeing that slavering exists in 
 22 per cent, of imbeciles, the question may- 
 arise — Is it confined to this section of the com- 
 munity ? I am not prepared to say that it is 
 never associated vsrith mental vigour; but I 
 believe that, excluding childhood, old age, dis- 
 ease of the mouth and neural lesions, slavering 
 is very rarely unconnected with mental imbe- 
 cility. Moreover, I have examined with refer- 
 ence to this question 1000 persons, who are 
 doing the everyday work of the world, without 
 meeting with a single example. 
 
 Summary. — We have thus seen that idiocy is 
 not simply a cerebral lesion ; that it carries 
 with it marked physical deviations, of which I 
 have shown conspicuous examples in the mouth ; 
 narrowed, arched, and unsymmetrical palates ; 
 tardily developed, irregular, and rapidly decay- 
 ing teeth ; a hypersemic condition of the mucous 
 membrane and glands; elongated uvulas and 
 hypertrophied tonsils ; large, enervated, and 
 rugous tongues, deficient in co-ordinated move- 
 
166 CONDITION OF THE MOUTH IN IDIOCY. 
 
 ments and in their special function ; saliva 
 secreted inordinately, and retained inconti- 
 nently. Such, are some of the characteristics 
 of a class, in which mental vigour is in abeyance, 
 which should be taken in connection with the 
 psychological state in diagnosis, and inculcate 
 the doctrine that the psychical condition of 
 these unfortunates should be specially sought 
 to be ameliorated by an improvement of their 
 physical condition. 
 
ON 
 
 POLYSARCIA AND ITS TREATMENT. 
 
 « London Hospital Reports,' 1864. * 
 
 The term polysarcia has been so long accepted 
 as a designation of that condition of the body, in 
 which the purely adipose constituents are devel- 
 oped in excess, that I am induced to employ it, 
 although its Hteral significance is not strictly 
 in accordance with the pathological state. 
 
 The history of Medicine contains numerous 
 instances of extraordinary obesity, and an im- 
 mortality attaches to some names, solely on 
 account of special aptitude for the development 
 of fat. It is not in reference to such excep- 
 tional examples as some of the earlier records 
 of medicine unfold, that the practitioner is 
 likely to be consulted, but the cases are not 
 infrequent in which his aid may be solicited in 
 mitigating the inconveniences which excessive 
 adipose development entails. 
 
168 POLYSAROIA AND ITS TREATMENT. 
 
 The sufferers from this disease are found 
 more frequently among those on whom fortune 
 has smiled, whose incentives to physical exertion 
 are in abeyance, while the inducements of the 
 table are in excess. Nevertheless among the 
 out-patients of the hospital, I have noticed 
 several cases, in which polysarcia has been the 
 cause of a variety of subjective symptoms which 
 have made life wretched. The subjects have 
 been for the most part women who had passed 
 the climacteric period. They have resorted to 
 the mental solace which alcoholic potations 
 could afford, and their diet, though poor, has 
 been of the kind calculated to induce this 
 state. 
 
 Dr. Flemyng, in a paper read before the Royal 
 Society in 1757, regarded corpulency as caused 
 either by the introduction of too much oil in 
 the food, or by the over-largeness of the cells, 
 in which it is deposited — or by a crasis of the 
 blood allowing the oily particles to be strained 
 off too easily — or, lastly, by a deficient evacu- 
 ation of oil already taken in and separated from 
 the blood. 
 
 His remedies were addressed either to increas- 
 ing the evacuation by the bowels, the sweat- 
 
POLYSAHGIA AND ITS TREATMENT. 169 
 
 glands, or the renal organs. Diuresis was his 
 principal hope, inasmuch, he said, as " the 
 animal oil is carried out of the body in the 
 urine." The diuretic he selected was soap, from 
 his supposing it to have the property of " besides 
 increasing the quantity of urine, at the same 
 time rendering the animal oil more mixible with 
 the watery vehicle of the blood." 
 
 Darwin, in his ' Zoonomia,' recommends 
 aerated alkaline water, from an idea of its render- 
 ing fat more fluid. Dr. Cullen was of opinion 
 that " the diet must be sparing, or rather, what 
 is more admissible, it must be such as affords 
 little nutritious matter ; it must, therefore," he 
 said, " be chiefly or almost only of vegetable 
 matter, and, at the very utmost, milk." 
 
 Dr. Brown argues "that as animal food is 
 the principal noxious power, the quantity should 
 be reduced, and more exercise taken." 
 
 Dr. Fothergill states that " a strict vege- 
 table diet produces exuberant fat more certainly 
 than any other means I know." He enjoins, 
 moreover, " an abstinence from animal food, so 
 far as the patient's health, situation, and man- 
 ner of life, will admit of it." Dr. Bright has 
 advised iodide of potassium with the view of 
 
170 POLTSAEOIA AND ITS TEEATMENT. 
 
 giving tone to tlie absorbents. Alkalies, from 
 their power of saponifying fats, and thus rend- 
 ering them more miscible, have had their advo- 
 cates. 
 
 More recently, Dr. Duchesne-Duparc has 
 spoken highly of the effect of the extract of the 
 fucus vesiculosus, stating that it increases the 
 appetite, diuresis, and emaciation. 
 
 The following case of polysarcia, which has 
 been for some time under my observation, has 
 given me an opportunity of testing the value 
 of some of these remedies which have been 
 recommended, and of proving the superior effi- 
 cacy of that which I believe to be the true 
 physiological mode of treatment. 
 
 E. — , a girl of healthy parentage, and born 
 in the county of Norfolk, became an inmate of 
 the Asylum for Idiots at Earlswood, in the year 
 1850, at the age of thirteen years. From notes 
 taken by Dr. Foreman at the time of her admis- 
 sion, I learn that she was congenitally of feeble 
 mind, was four feet four inches in height, and 
 weighed in her clothes 113 lbs. ; her size at that 
 time attracted observation, as it is noted, " she 
 is enormously stout, cellular tissue everywhere 
 more than usual." Her diet was not much 
 
POLTSAEOIA AND ITS TEBATMENT. 
 
 171 
 
 restricted, and slie always appears to have been 
 voracious in appetite. In January, 1857, Dr. 
 Maxwell added to the above notes that she was 
 still the same height, but weighed 151 lbs., and 
 up to. that time had not menstruated. She came 
 under my treatment in November, 1858, when 
 I found her indulging in a large mixed diet, 
 with excess of vegetables, and taking very little 
 exercise, and her size was steadily increasing. 
 Her height was still the same, and her weight 
 196 lbs. Her unwieldy size rendered exercise 
 difficult. From inquiries made of her friends, 
 I found there had been no such instance of 
 obesity among the relatives of her progenitors 
 — that she had been delicate and thin up to 
 seven years of age. 
 
 Her diet was restricted to the following scale, 
 which was accurately weighed for each meal : — 
 Breakfast, six ounces of bread; one third 
 ounce of butter ; half-pint of milk-and-water. 
 Dinner — four ounces of meat (weighed, when 
 cooked, and free from bone) ; eight ounces of 
 potatoes ; two ounces of green vegetables ; six 
 ounces of pudding ; half-pint of water. Supper 
 —six ounces of bread; one third ounce of 
 butter ; half -pint of milk-and-water. (The milk- 
 
172 POLYSARCIA AND ITS TEEATMENT. 
 
 and-water was a mixture of one third new milk 
 and two thirds water.) "Walking exercise was 
 enforced, and she was required to turn the 
 handle of a large mincing-machine one hour 
 a day. 
 
 My note-book states that in January, 1862, 
 she remained the same height (four feet four 
 inches), but had increased in weight. She was 
 then 210 lbs. when weighed in her night-dress, 
 and measured, round her waist, fifty-five inches. 
 Her feet and hands remained small, and con- 
 trasted remarkably with the appendages they 
 terminated. She had no hair in the axillse, and 
 scarcely any on the pubis. Although twenty - 
 five years of age she had never menstruated, nor 
 did she exhibit the slightest sexual instinct. She 
 was now able to walk slowly, but with difficulty, 
 and when she fell, was unable without assistance 
 to regain the vertical position. She suffered from 
 dyspnoea, and her breathing at night was 
 attended by so much noise that the occupants 
 of the same room were much disturbed thereby. 
 Moreover, the difficulty she had in moving from 
 her bed bad induced dirty habits, which added 
 much to the wretchedness of her life. It was now 
 difficult to induce her to take any exercise, and 
 
POLYSAKOIA AND ITS TREATMENT. 173 
 
 she was scarcely seated in a chair for a minute 
 without falling asleep. Although imbecile in 
 mind, her obesity was a mental trouble to her, 
 and she was ready to enter into any plan for 
 diminishing her size. 
 
 Being desirous of ascertaining the effect of 
 medication simply, the same diet was continued, 
 and iodide of potassium, in doses of two and a 
 half grains, given three times a day, for a period 
 of six months, without any diminution of size. 
 Her health continued unaltered. The only effect 
 produced was a cessation of the development of 
 fat, which had been constant for the past twelve 
 years. 
 
 The diet remaining the same, solution of 
 potash was given three times a day in doses of 
 ten drops, gradually increased to half a drachm, 
 over a period of seven months. Under this 
 treatment her health became deteriorated, pre- 
 senting symptoms of anasmia, and her weight 
 oscillated around fifteen stone, sometimes a few 
 pounds more, sometimes as many less. 
 
 When the alkali was discontinued, on Feb- 
 ruary 13th, 1863, she weighed in her night- 
 dress 206 lbs. A diminution was thus eftected 
 of 4 lbs. after seven months' exhibition of 
 
174 POLTSAECIA AND ITS TREATMENT. 
 
 caustic potash. Still continuing the same 
 mixed diet, the extract of fucus vesiculosus 
 (prepared by Messrs. Kew and Co., of Regent 
 Street) was given in doses of half a drachm 
 three times a day until April 30th, when she 
 weighed 203 lbs. 
 
 The effect of the fucus was to promote 
 diuresis, as indicated by an increased number 
 of wet beds, and a diminution of weight at the 
 rate of four ounces and one third per week. 
 Her general health had improved, and she was 
 much less anaemic than when she discontinued 
 the potash. 
 
 On April 30th, in conformity with a pre- 
 viously arranged plan, I discontinued all medica- 
 ments, and placed her on very rigid animal diet. 
 Her breakfast consisted of five ounces of cold 
 roast meat, free from fat, and half a pint of tea, 
 with very little milk, and no sugar (no bread). 
 Dinner — six ounces of hot roast meat, free from 
 fat, two ounces green vegetables (no potatoes 
 or bread), half a pint of water. Supper the 
 same as breakfast. In order to induce her 
 compliance, she had one ounce of sherry wine, 
 and occasionally a baked apple with her dinner, 
 and to prevent the possibility of her obtaining 
 
POLTSAEOIA iLND ITS TEEATMENT. 175 
 
 any food from others, strict supervision was 
 exercised. 
 
 After slie laad been subjected to tbis diet for 
 a week sbe bad sbgbt febrile disturbance, and 
 for three days took one quart of beef -tea a 
 day, made from one pound of beef. Sbe then 
 returned to ber meat diet, which was continued 
 without intermission until August 29th, when 
 she weighed 175 lbs. The effect of this diet 
 was to improve her general health and physical 
 power. She was enabled to run, and she took 
 walks with pleasure. The dyspnoea had dis- 
 appeared, and her clothes had to be altered to 
 suit her diminished form. Her loss of weight 
 had been at the rate of one pound and three- 
 quarters per week. 
 
 Wishing to ascertain whether thefucus vesicu- 
 losus would influence the system when a purely 
 animal diet was used, half a drachm of the 
 extract was now given three times a day, while 
 the diet was restricted to sixteen ounces of 
 meat. This was continued until November 
 14th, when she was attacked by scarlet fever ; 
 her weight had receded to 153 lbs., the diminu- 
 tion having been at the rate of one pound 
 thirteen ounces one third per week, or one 
 
176 POLYSAROIA AND ITS TREATMENT. 
 
 ounce one third per week more than when the 
 meat was given without the fucus. During the 
 attack of scarlet fever and the subsequent con- 
 valescence, the diet was beef -tea with bread ; 
 and on this diet, at the end of four weeks, her 
 weight remained without alteration. On Decem- 
 ber 12th she returned to meat diet, substituting, 
 however, fifteen ounces for sixteen ounces per 
 diem. This has been continued to the present 
 time (January 15th, 1864) ; her weight is now 
 147 lbs., and the measurement round the waist 
 has diminished from fifty-five inches to thirty- 
 seven inches. Her general health is good, and 
 the restricted diet has not been attended by 
 any inconvenience. The following tables will 
 give, in a condensed form, the results : — 
 
 Mixed diet, unrestricted in 
 
 amount 
 Mixed diet, restricted 
 
 amount 
 Mixed, restricted diet, 
 
 Iodide of Potassium . 
 Mixed, restricted diet, 
 
 Liquor Potassse . . . — . . 2^ oz. 
 Mixed, restricted diet, and 
 
 Fucus Vesiculosus . . — . • 41- oz. 
 Purely meat diet, witliout 
 
 medicine . . . . — , . 28 oz. 
 Purely meat diet, with Fucus 
 
 Vesiculosus . . . — . . 29i oz. 
 
 Weekly Increase 
 
 Weekly Decrease 
 
 
 in weight. 
 
 ill weight. 
 
 in 
 
 7i OZ. 
 
 
 m 
 
 1| oz. 
 
 
 and 
 
 
 
 
 nil 
 
 nil. 
 
 and 
 
 
 
POLYSAECIA AND 
 
 ITS TREATMENT. 177 
 
 Date. 
 
 Age. 
 
 Weight. 
 
 28tli Feb., 1850 . 
 
 13 . 
 
 . 113 lbs. 
 
 Jan., 1857 . 
 
 20 
 
 . 151 „ 
 
 Nov.. 1858 . 
 
 2U 
 
 . 196 „ 
 
 Jan., 1862 . 
 
 25 
 
 . 210 „ 
 
 ISth Feb., 1863 . 
 
 . 26 
 
 . 206 „ 
 
 30tli April — 
 
 . — 
 
 . 203 „ 
 
 22nd Aug. — 
 
 . 26i 
 
 . 175 „ 
 
 14th Nov. — . 
 
 — 
 
 . 153 „ 
 
 15th Jan., 1864 . 
 
 27 
 
 . 147 „ 
 
 It is only by returning to the views and 
 opinions of medical authorities a century ago 
 that we can duly appreciate the vast service 
 chemistry has rendered physiology, and, m- 
 directly, practical medicine. The influence of 
 respiration in removing carbonaceous materials 
 from the blood, and the possibility of the pro- 
 duction of fat from farinaceous and saccharine 
 bodies, are so familiar to us that we wonder at 
 the absence of knowledge on these subjects 
 displayed by the older writers. They all insist 
 on a non-nutritious diet for the cure of obesity, 
 meaning thereby an expurgation of meat and an 
 indulgence in milk and farina. A great mis- 
 take was also made in supposing that the urine 
 was the outlet for fatty matters, while they 
 ignored the outlet by the lungs. 
 
 12 
 
178 POLYSAROIA AND ITS TEEATMENT. 
 
 On a review of the foregoing case, it is worthy 
 of notice that the young woman has never men- 
 struated, and this, together with the absence of 
 sexual instinct, suggests the idea that the 
 ovaries are undeveloped, and that she may be 
 in the condition of a pig which has been spayed 
 for the purpose of fattening. Her voracious 
 appetite, and a diet in which farinaceous matters 
 largely entered, were doubtless factors in the 
 production of the result. When the diet, how- 
 ever, was restricted to the amount on which 
 her companions were only fairly nourished, still 
 she made fat in excess, to the amount of one 
 ounce and two fifths per week. 
 
 The exhibition of iodide of potassium failed 
 to be of value, other than preventing a continu- 
 ation of the morbid increase, while liquor 
 potassse, by interfering with digestion and 
 undermining her general health, produced slight 
 positive diminution. The results obtained from 
 the fucus vesiculosus were such as to justify its 
 being regarded as a safe and, to a certain extent, 
 effectual plan for diminishing obesity. It falls, 
 however, far behind what it is possible to effect 
 by a purely animal diet, and while to many the 
 latter remedy may appear as bad as the disease. 
 
POLYSAECIA AND ITS TKEATMENT. 179 
 
 it should be remembered that a diet so purely 
 animal need not be insisted upon, a com- 
 promise may be made, keeping in view the 
 typical diet which should be approached as 
 nearly as possible in the treatment of these 
 cases. 
 
 It has been shown by Ranke that even when 
 large quantities of meat are taken, a decrease 
 in the weight of the body takes place, but that 
 the quantity of meat theoretically requisite to 
 maintain the system produces dyspepsia. In 
 the treatment of polysarcia, this difficulty is 
 avoided^ the quantity of meat is regulated to 
 supply the want induced by the tissue-changes 
 of the body, trusting to the superabundant 
 fatty matters of the system to supply the 
 demand of the respiratory process. In the case 
 I have detailed, the patient has continued the 
 meat diet for nine months without any dys- 
 pepsia, with improved tone, with a power of 
 resisting such a disease as scarlet fever, making 
 a speedy convalescence therefrom, and with 
 the positive advantages of diminished size and 
 increased enjoyment of life. 
 
 April 7th. — The patient has continued on a 
 diet of 15 oz. of meat daily, and her present 
 
180 POLYS AECIA AND ITS TREATMENT. 
 
 weight is 133 lbs., indicating a continued 
 diminution at the rate of one pound two ounces 
 and a half a week. Her total loss in weight 
 has been 11 lbs. ; her decrease during the last 
 year, 70 lbs. 
 
AN ACCOUNT OF A SECOND CASE 
 
 IN WHICH THE 
 
 CORPUS CALL08UM WAS DEFECTIVE, 
 
 ' Trans, of Roy. Med. & Chir. Soc.,' 1866. 
 
 In the forty-fourth volume of the ' Trans- 
 actions ' of this Society I furnished the details 
 of a case in which there was a marked defect 
 in the great commissural connections of the 
 brain, associated with grave defect of the intel- 
 lectual faculties. I, at the same time, com- 
 pared the case under review with all others of 
 a similar nature which I could find recorded. 
 
 Another instance having come under my 
 notice which illustrates, in a characteristic 
 way, this rare abnormality, I am desirous of 
 placing it on record in the ' Transactions ' of 
 the same Society, which already contains 
 descriptions of the best marked examples. 
 
 A. B. came under my observation in the 
 
182 DEFECTIVE CORPUS CALLOSUM. 
 
 autumn of 1858. He was the son of a clergy- 
 man, and had been submitted to tlie ordinary 
 process of education with but trifling results. 
 He had been taught to write a little, but he 
 never exercised the art. He had learned to 
 read easy words, and could answer simple 
 questions. His power of calculation was almost 
 nil. He was fond of music, had slight power 
 of imitation, and his memory, although defec- 
 tive, was good in relation to persons and 
 things. He was five feet four and three quarter 
 inches in height, and weighed ten stone one 
 pound. His trunk was well formed, and his 
 facial expression that of an imbecile. He was 
 shy, undemonstrative, fond of children (some 
 of whom he petted), while towards persons of 
 his own age and to the opposite sex he was 
 violent and passionate. His friends were very 
 desirous of asserting the non-congenital nature 
 of the mental condition, and attributed it to 
 masturbation. The diagnosis formed, however, 
 was that it was congenital, and that the mas- 
 turbation was an accidental circumstance. 
 This diagnosis was strengthened by reference 
 to the other members of the family, who, 
 although occupying good positions in the 
 
DEFECTIVE COEPUS CALLOSUM. 183 
 
 world, were manifestly not of average intellec- 
 tual power. The habit of masturbation became 
 entirely broken, and he gave himself up to 
 simple employments, such as wheeling invalids 
 in a Bath chair, and otherwise aiding those 
 whom he petted. 
 
 He lived to forty years of age, when he died 
 from pleuro-pneumonia. An autopsy was made 
 thirty hours after death. The circumference 
 of the head was 21 j in.; the bilateral curve 
 11^ in. ; the antero-posterior curve 12 in. ; 
 the bilateral diameter b-^o in. ; the antero-pos- 
 terior diameter 6-j^ in. The calvarium was 
 unsymmetrical and dense, shelving anteriorly; 
 the posterior clinoid processes were converted 
 into sharp needle-like points ; the encephalon 
 weighed 2 lb. 14 oz. On separating the two 
 hemispheres the almost entire absence of the 
 corpus callosum was apparent, and the velum 
 interpositum exposed to view. A small carti- 
 laginous-like band, -^\ in. in breadth and 2-4- in. 
 in thickness, situated opposite the corpora 
 striata, was the only representative of the great 
 commissure. The fornix was represented by 
 two thin posterior pillars ; the body of the 
 fornix and its anterior pillars were absent. 
 
184 DEFECTIVE CORPUS OALLOSUM. 
 
 The right optic thalamus was very much larger 
 than the left. The cineritious portion of the 
 brain was pale, the posterior cornua of the 
 lateral ventricles were distended with straw- 
 coloured serum, and the Pineal gland was the 
 size of a wild cherry. The middle commissure 
 was absent. The rarity of this abnormality 
 may be indicated by the circumstance that it is 
 only the second time I have met with it in the 
 dissection of 150 brains of idiots. 
 
MARRIAGES OF CONSANGUINITY 
 
 IN EELATION TO 
 
 DEGENERATION OF RACE, 
 
 ' London Hospital Eeports,' 1866. 
 
 Peobably no subject which has engaged the 
 attention of the medical statist has given rise to 
 more widely divergent views, certainly no in- 
 quiry on the part of the physiologist, has been 
 productive of less practical results, than the 
 one which heads this paper. There is a class, 
 and probably a large one, which looks upon 
 consanguineous unions as universally productive 
 of evil, and where the worst consequences are 
 not met with, regard them as mere exceptions 
 to an all but universal rule. To some extent 
 this opinion has permeated society, and although 
 it has failed in preventing such unions, the 
 popular view has of late years been tending to 
 
186 ON THE EESULT OF 
 
 a conviction that degeneracy of race is to be 
 largely attributed to the union of blood-relations. 
 Thus Duvay, of Lyons, asserts " that in pure 
 consanguinity, isolated from all circumstances 
 of hereditary disease, resides, ipso facto, a prin- 
 ciple of organic vitiation." 
 
 On the other hand, a not inconsiderable 
 section regard this conclusion with doubt, and 
 teach that consanguineous unions may be 
 effected with impunity. We may place, as re- 
 presenting this party, and in antithetical rela- 
 tion to that of Duvay, the assertion of Dr. 
 Gilbert Child, that " the marriages of blood- 
 relations have no tendency, per se, to produce 
 degeneration of race." 
 
 The arguments of the former are drawn from 
 examples of a somewhat isolated character, and, 
 in the language of their opponents, "attempt 
 often to prove too much." No one, I think, 
 with a previously unbiassed mind, can read the 
 numerous examples which are cited to prove as 
 the result of such unions sterility, deaf-mutism, 
 idiocy, and other characteristics of degeneration, 
 without coming to the conclusion that the cases 
 from which they argue are selected ones, and 
 that the cause they advocate is damaged by 
 
MAEEIAGES OF CONSANGUINITY. 187 
 
 special pleading wliere there should have been 
 judicial deliberation. Writing from a stand- 
 point of observation which enables me to give 
 an opinion on the subject, and having regard 
 to a great deal that has been written, I cannot 
 but join Dr. Child in his very just remark, " to 
 say that all but half the children of the mar- 
 riages of cousins are idiotic, is simply to say 
 the cases from which the statistics were drawn 
 are not fair cases." 
 
 The arguments of the party, of which I have 
 placed Dr. Child as the exponent, are mainly 
 based on observations on the results of the 
 modern system of breeding among the lower 
 animals, and on the examples furnished by the 
 Hebrew race and the North American Indians. 
 The racial degeneracy, which it is the pur- 
 pose of this paper to examine in its relation to 
 consanguineous unions, is that congenital men- 
 tal defect, which, manifesting itself in different 
 varieties as to intensity, has received the name 
 of idiocy. • 
 
 My notes refer to 1138 cases of idiots, 763 
 being males, and 385 females, which I may say 
 en passant is about the ratio, according to my 
 experience, in which the sexes are affected by 
 
188 ON THE EESULTS OF 
 
 idiocy, viz. in the proportion of about two to 
 one. 
 
 I have taken the records with every care as 
 to accuracy, and from the number have excluded 
 all cases in which there was impossibility in 
 obtaining information or elements of doubt 
 when obtained. Influenced only by these cir- 
 cumstances, I have eliminated 196 males and 
 90 females, leaving 557 males and 295 females, 
 or a total of 852, on which the arguments will 
 be based. 
 
 Of the 753 male idiots, 33 were the progeny 
 of first cousins ; in two of these instances there 
 was another element elicited, viz. in one case 
 the mother was also the product of first cousins, 
 and in the other the mother was the product of 
 cousins germain, involving, therefore, in these 
 two cases, an increased intensity of blood- 
 relationship. Three cases were the progeny of 
 second cousins. Four of third cousins. In all, 
 40 cases out of 753, or only rather more than 
 5 per cent., could by any possibility have been 
 due to consanguineous unions. Of the 295 
 females, 13 were the progeny of first cousins, 
 3 were the children of second, and 4 those of 
 third cousins. In all, 20 among 295, or little 
 
M.4.RRIAaES OF CONSANGUINITY. 189 
 
 less than 7 per cent., could have been caused by 
 the marriage of blood-relations. 
 
 The difference in the percentage of idiots, the 
 progeny of cousins, between the male and female 
 sex is remarkable, but may, I think, be explained 
 by the existence of a preponderating cause of 
 idiocy on the part of males over females, in the 
 larger size of the male cranium at birth, and 
 the consequent greater risk. of injury to the 
 cranial contents during parturition. 
 
 I am unable to say with certainty how fre- 
 quently the marriage of blood-relations takes 
 place in an ordinary community, but I have 
 made a careful inquiry into the family history 
 of 200 persons, collected from different dis- 
 tricts, who are sane and healthy, and who belong 
 to different families, and I find only one is 
 the offspring of cousins ; being half per cent., 
 and I learn that in that one instance he is the 
 son of unusually healthy parents. Certainly, 
 in his case, there is no symptom of either phy- 
 sical or mental degeneracy, and he would pro- 
 bably be selected from among the 200 as one 
 of the most robust and vigorous. 
 
 I propose now, further, to inquire into the 
 cases of idiocy from which my statistics are 
 
190 ON THE EESULTS OF 
 
 drawn, and endeavour to discover if there are 
 any other factors, besides that of consanguinity, 
 to account for the manifestation. For this 
 purpose I quote from the notes of 20 cases 
 taken, without selection, from my portfolio, and 
 which may, therefore, be fairly regarded as 
 typical of the whole. 
 
 Case 1. — J. Y. T., male, born in London, 
 father and mother healthy and of sound mind, 
 but first cousins. The father's mother had 
 hemiplegia at 73. Mother was frightened when 
 six weeks advanced in pregnancy by seeing her 
 mother with paralysis, and to this she attributes 
 the idiocy of the son, who is a microcephale. 
 Three sisters, all healthy. J. Y. T. is the fourth, 
 and last born. 
 
 Case 2. — M. M. Y., female, born at Calne, 
 father and mother first cousins. The mother's 
 parents were also distantly related. The father 
 healthy and of sound mind, but his brothers 
 and sisters with consumptive tendencies. The 
 mother died from tumour of the brain, several 
 of her relatives died from consumption. M. 
 M. Y. is the second-born and a twin, the other 
 
MARRIAGES OP CONSANGUINITY. 191 
 
 twin healthy and of sound mind. This child 
 was remarkably small when born, is deaf, and 
 had fits for many years. She has one cousin 
 who is demented from epilepsy. 
 
 Case 3.— A. E. Y. S.,male, born at Walworth. 
 The father and mother were first cousins. The 
 father was dehcate, sound in mind, but intem- 
 perate, his relations healthy. The mother 
 healthy and of sound mind, had given birth to 
 twins twice, her family generally consumptive. 
 A. E. Y. S. io the eighth-born, and one of his 
 brothers died from consumption. The mother 
 was frightened by a cat during the seventh 
 month of her pregnancy, and was ill a week in 
 consequence. She attributes the idiocy to her 
 husband's habitual intemperance. 
 
 Case 4. — M. A. S., female, born in London. 
 Father and mother first cousins. Father of 
 sound mind, died from pulmonary hemorrhage. 
 One of his sisters died from consumption. 
 Mother consumptive, has also lost one sister 
 from consumption. M. A. S. is the fifth-bor-n, 
 and had four brothers and one sister, all have 
 died from consumption. 
 
192 ON THE RESULTS OP 
 
 Case 5. — F. H., female, born in Lancashire. 
 Father and mother were second cousins. The 
 father healthy and of sound mind ; his father 
 lost his sight when a young man (amaurosis ?), 
 two brothers died from consumption. Mother 
 healthy and of sound mind, her aunt on father's 
 side insane. The mother married twice, the 
 first time to a person not I'elated, and had three 
 children, two girls healthy, and one boy who 
 has epileptic fits. She afterwards married her 
 second cousin and had two girls, who are 
 healthy, then a boy, who is decidedly idiotic, 
 and then F. H., who has little or no mental 
 power. F. H. is the seventh-born. Mother 
 states thai? she believes the cause of the idiocy 
 of the first idiot child was from fright, and 
 that of the second from thinking of the idiocy 
 of the former. 
 
 Case 6. — C. E. H., female, born in Leicester- 
 shire. Father and mother first cousins. Father 
 is a clerk in holy orders, healthy now, but was 
 very delicate when at college ; his uncle was 
 imbecile, his father was eccentric, and acquired 
 drinking habits, his aunt died from phthisis. 
 The mother is very deaf, her sister died from 
 
MAERIAGES OF CONSANGUINITY. 193 
 
 cancer. C. E. H. has three brothers and two 
 sisters of average physical and mental power. 
 She was the first-born, and during the preg- 
 nancy the mother had great anxiety about 
 pecuniary matters. The forceps were em- 
 ployed at parturition, and the head was greatly 
 crushed. 
 
 Case 7. — J. C, female, born in Surrey. 
 Father and mother second cousins. Father had 
 fits when a child, is very ailing, and feeble in 
 mind. No family history. The mother not 
 very strong, lost a brother from consumption. 
 J. C. is the sixth-born ; her eldest brother died 
 from acute hydrocephalus; the rest are all bright 
 although not very strong. The mother says 
 she saw, when seven months advanced in preg- 
 nancy, a girl precisely like her daughter both 
 mentally and physically. 
 
 Case 8. — J. T. B., male, born at Wingham. 
 Father and mother third cousins ; father healthy 
 and of sound mind, very deaf; his cousin became 
 blind from study. Mother healthy, but all her 
 relations consumptive. J. T. B. is the seventh- 
 born, and is a twin-child; his twin-sister is 
 
 13 
 
194 ON THE RESULTS OF 
 
 very intelligent, as are also another sister and 
 eight brothers. 
 
 Case 9. — E. P. 0., male, born at Tiverton. 
 Father and mother first cousins ; father died 
 from Bright' s disease after five years' illness; 
 relations healthy. Mother healthy, but ner- 
 vous ; had bad health during her pregnancy, 
 and was much distressed by her eldest child 
 having croup in Paris, and not being able to 
 procure a doctor. She had a very bad labour, 
 owing to the large size of the child. There 
 are two brothers and three sisters, all particu- 
 larly intelligent. E. P. C. is the fourth-born. 
 
 Case 10. — W. G., male, born at Dorking. 
 Father and mother were second cousins. Father 
 healthy, and of sound mind; has lost five 
 brothers and sisters from consumption, and 
 has one sister insane. The mother has had a 
 fistula, is of sound mind. She was very low- 
 spirited during pregnancy at the prospect of 
 another child, with limited means for the support 
 of the family. W. Gr. is the fourth-born, and 
 has had three brothers and two sisters ; one 
 brother died from scarlatina, one is rather deli- 
 cate, the rest are healthy and intelligent. 
 
MAEEIAGES OF OONSANGUIJSIITY. ]95 
 
 Case 11. — W, A. P., male, born at Peckham. 
 Father and mother first cousins. The father 
 was healthy, but below the average in mental 
 power ; his relations were healthy. The mother 
 has always been delicate, and is very nervous, 
 had an aunt insane, all her brothers and sisters 
 died young. W. A. P. is the eleventh-born, 
 and has had four brothers and six sisters. The 
 first-born, a male, is an idiot, one brother died 
 of inflammation of the lungs, one of convulsions 
 at a fortnight old. Four sisters are dead — two 
 were twins, one died at birth, and the other 
 twin-child, when ten days old, of fits, one died 
 from fever; there are two sisters and one 
 brother living, who are all intelligent. 
 
 Case 12. — W. R., male, born in London. 
 Father and mother were first cousins. Father 
 has good health, but is very irritable and de- 
 sponding ; his mother died of consumption, and 
 he lost one sister from congestion of the brain. 
 Mother healthy, has lost one sister from cou- 
 sumption, and has an uncle imbecile. The 
 mother sufl^ered severely from sea-sickness 
 when in the fourth month of pregnancy. The 
 umbilical cord was obliged to be divided before 
 
196 ON THE RESULTS OF 
 
 the birth, animation was suspended and had to 
 be resuscitated by artificial means. W. R. is 
 the eleventh-born, has had eleven brothers and 
 sisters, all of whom had average mental and 
 bodily power. 
 
 Case 13. — R. S., male, born in London. 
 Father and mother first cousins. The father 
 healthy, sober, and steady, family healthy. 
 The mother suffers from chronic bronchitis, 
 sound in mind, and family healthy. The rela- 
 tive ages of father and mother at the birth of 
 R. S. were 41 and 29. The labour was linger- 
 ing, and ergot of rye given twice ; the head was 
 misshapen, and the child made a strange noise 
 when born, R. S. is the fourth-born, and has 
 had one brother and seven sisters. One had 
 no bone on one side of the head, and lived only 
 two days ; four died at birth, but seemed all 
 right. The rest quite healthy children. The 
 first three born are the healthy ones, the rest 
 have all been defective or have died. The 
 mother miscarried with a child with one leg. 
 
 Case 14. — J, B., male, born at Tottenham. 
 The father and mother were first cousins. The 
 
MARRIAGES OF CONSANGUINITY, 197 
 
 father has good health, but is of low intelli- 
 gence: his relations healthy. The mother is 
 delicate, and lost a brother and sister from con- 
 sumption. J. B. was the third-born, and had 
 one brother and four sisters ; one boy had fits 
 and died from consumption, one girl died from 
 epilepsy at seven years, the rest healthy and 
 bright. 
 
 Case 15.— E. P., male, born at Bath. The 
 father and mother are second cousins. The 
 father has average health, but is a drunkard, 
 six of his immediate relatives stammer. The 
 mother has very poor health, and suffers from 
 uterine disease ; two of her sisters died young 
 from consumption. The mother was ill during 
 the whole of her pregnancy, fell downstairs 
 during the seventh month, was nervous, and 
 was disturbed by hallucinations. E. P. was 
 the second-born, and had three brothers and 
 three sisters ; one died of water on the brain, 
 one of scarlet fever, and one of consumption. 
 Three are idiots. 
 
 Case 1G. — J. A. V., male, born in London. 
 Father and mother are first cousins. Father is 
 
198 ON THE RESULTS OF 
 
 healthy, but his father was eight months in an 
 asylum with mania, and recovered ; father's 
 mother very eccentric ; his sister had spinal 
 disease, and died from consumption. Mother 
 healthy, but nearly all her immediate relatives 
 consumptive. She had much trouble and busi- 
 ness difficulties during her pregnancy. J. A. V. 
 is the fourth-born, had two brothers and one 
 sister who were intelligent. 
 
 Case 17. — J. T. W., male, born in London. 
 Father and mother are first cousins. Father is 
 a very weak and nervous man, faints frequently, 
 and his whole bearing is like one suffering from 
 mercurial tremor. The mother has good health, 
 but is very nervous, her mother is also nervous, 
 and bordering on being insane, one uncle died 
 insane, and one cousin is imbecile. She fell 
 downstairs when six months pregnant, and about 
 the same time she was much frightened by her 
 husband falling down in a fainting fit, which 
 induced in her uterine action and a considerable 
 amount of flooding. J. T. W. is the first-born, 
 and has had five brothers ; one died from a fit 
 during an attack of whooping-cough, one died 
 from bronchitis, one is paralysed on one side, 
 
MARRIAGES OF CONSANGUINITY. 199 
 
 and another is three years and a half old, and 
 cannot talk, is only just able to walk, and has 
 a large head. 
 
 Case 18. — B. H. H., male, born at Lewes. 
 Father and mother were first cousins. Father 
 is healthy, but irritable ; one of his sisters died 
 from consumption, and another, who also died 
 from consumption, was subject to delusions. 
 The mother died from consumption, and had 
 an uncle who suffered from dementia, thought 
 to have been induced by drink. She was 
 frightened two months before her confinement 
 by stepping on an adder. The labour was lin- 
 gering, and the child's head much distorted. 
 E. H. H. was the first-born, and was born with 
 animation suspended; he had one sister only, 
 who was prematurely born, and who died three 
 days after her birth. 
 
 Case 19. — Gr. K., male, born at Woolwich. 
 Father and mother were first cousins. Father 
 is healthy, and of sound mind ; his relatives 
 were of average health and mental power. 
 Mother healthy, and of sound mind ; her mother 
 was insane ; her aunt died in an asylum ; and 
 
200 ON THE EESULTS OP 
 
 another aunt's child suffers after every confine- 
 ment from puerperal mania. G-. K. was the 
 second-born, and had one brother and three 
 sisters ; one sister is an idiot, and another was 
 quite helpless, and died at the age of fourteen 
 months. 
 
 Case 20.— T. E., male, born at Thetford, 
 Norfolk. Father and mother were first cousins. 
 Father died from a contraction of the bowel, 
 sound in mind, and steady ; his mother used to 
 stammer ; mother very nervous ; she was 
 frightened during her pregnancy by seeing an 
 idiotic man. Labour lasted twenty-eight hours, 
 and she was delivered with instruments. T. R. 
 is the first-born, and had three brothers and one 
 sister ; one brother died from whooping-cough ; 
 the second and third were twins, and are very 
 healthy ; all sound in mind. 
 
 My own statistics differ so much from those 
 published by Dr. Howe, of the United States, 
 and on which many arguments have been based, 
 that I am induced to place them in contrast : — 
 
 Dr. Howe's 17 marriages produced 95 chil- 
 dren — i. e. 5*58 each. Of the 95 children — 
 
MARRIAGES OP CONSANGUINITY. 201 
 
 37 were of tolerable health. 
 
 1 was a dwarf. 
 
 1 was deaf. 
 12 were scrofulous or puny. 
 44 were idiots. 
 
 Total 95 
 
 Thus more than 46 per cent, were idiots. 
 ' The 20 marriages, relating to my own cases, 
 produced 138 children — i. e. 6*9 each. Of the 
 138 children — 
 
 75 had average health and intellect. 
 11 were consumptive. 
 
 8 were still-born. 
 4 died from convulsions or fits. 
 
 2 were hydrocephalic. 
 
 7 died young from infantile complaints. 
 
 6 were puny and delicate. 
 25 were idiots. 
 
 Total 138 
 
 It will be seen that only a little more than 
 18 per cent, were idiots. 
 
 It will be interesting to place also in contrast 
 the results of 20 marriages, in which there was 
 
202 ox THE RESULTS OF 
 
 no consaDguinity, but in which there were one 
 or more instances of mental defect in the pro- 
 geny of each family, and which have been taken, 
 like the former twenty cases, from a much 
 larger number, without any principle of selec- 
 tion. The 20 non-sanguineous marriages 
 produced 145 children, or 7'25 each. Of the 
 145 children — 
 
 83 had average health. 
 
 1 was consumptive. 
 11 were still-born. 
 
 3 died from convulsions or fits. 
 
 2 were hydrocephalic. 
 
 13 died from infantile complaints- 
 
 6 were puny, or dwarfed. 
 26 were idiots. 
 
 Total 145 
 
 It will be seen that 18 per cent, were idiots. 
 In the case of the consanguineous progeny, 
 55 per cent, were of average health ; in the non- 
 consanguineous, 57 per cent. No one, I think, 
 who has had an opportunity of investigating 
 the subject, or who compares these statistics 
 with Dr. Howe's, can avoid coming to the con- 
 clusion that Dr. Howe's 17 cases were not 
 
MARRIAGES OP CONSANGUINITY. 203 
 
 typical of what is to be met with in this country. 
 Only 39 per cent, of the progeny in his cases 
 had average health. 
 
 I have shown that about 6 per cent, of those 
 suffering from congenital mental defect are 
 the product of consanguineous marriages, 
 wliile, among the healthy and vigorous, only 
 about half per cent, may be placed as the result 
 of such unions. One cannot, therefore, resist 
 the conviction that the union of blood-relations 
 has some influence in the deterioration of our 
 species. What that influence is, however, can 
 only be determined by a further investigation 
 into the etiology of the 20 cases I have cited. 
 
 Out of the 20 cases, among whom the aver- 
 age number of children were 6'9 each, no less 
 than 5, or 25 per cent., were primiparge. This 
 of itself, according to my observation, is some- 
 times a cause of idiocy. It may be explained, 
 I believe, by the greater injury sustained in the 
 birth than at subsequent labours, and is analo- 
 gous to the determining cause of the pre- 
 ponderance of male over female idiots before 
 alluded to.* No less important is the fact, 
 
 * In the statistics of th(3 maternity department of the 
 London Hospital (' London Hospital Reports,' vol. i, 
 
204 ON THE RESULTS OF 
 
 that in two cases the forceps were employed at 
 the birth of the child, or in 10 per cent, of the 
 cases. I find from the statistical report of the 
 maternity department of the London Hospital, 
 by Mr. Heckford, published in the first volume 
 of the ' London Hospital Eeports,' that the 
 forceps were employed only in 8 per cent, of 
 the children alive. It would not be difficult to 
 prove, by reference to all the notes I possess, 
 that instrumental interference is of itself a cause 
 of idiocy. In two of the 20 cases, in which in- 
 struments were not employed, the head of the 
 child was much missphapen by the difficulty of 
 the labour. 
 
 One was a twin-child, and there is reason to 
 believe that this condition may, of itself, be 
 conducive to defective mental development. 
 Suspended animation was reported in two cases, 
 or 10 per cent. ; how far this may influence the 
 future development of the child, I shall inquire 
 into, in a future paper. 
 
 Ergot of rye was given in one case ; but I 
 am not aware of any observations on the use 
 of this drug as a cause of idiocy. 
 
 p. 254), it is stated that the stillborn males exceeded the 
 females by 35 per cent. 
 
MARRIAGES OP CONSANGUINITY. 205 
 
 This disposes of all the possible causes in- 
 fluencing the child at parturition. I have now 
 to inquire into the hereditary influences which 
 might have affected the ovum, and I think it 
 will be readily granted that no breeder of cattle, 
 apart from all question of breeding in and in, 
 would select analogous stock for propagation 
 from, to those which constitute the parents of 
 the twenty cases I have quoted. 
 
 Thus, among the progenitors of the twenty, 
 in no fewer than twelve instances, was phthisis 
 abundantly established in the family history of 
 one or both parents. 
 
 In 12 cases there was well-established 
 history of insanity, epilepsy, or imbecility in 
 the family of one or both progenitors reaching 
 to the large amount of 60 per cent. In 2 
 cases the fathers were habitual drunkards. In 
 one instance the mother was very deaf, and the 
 same case furnished the solitary example of 
 cancer. 
 
 There were only 4 cases in which there 
 did not exist either a history of insanity or 
 phthisis in the family. In the first of these the 
 father's mother stammered when young, the 
 mother stated that she was nervous during her 
 
206 ON THE RESULTS OF 
 
 pregnancy, during whicli she was frightened 
 by an idiotic man. Tlie boy had four brothers 
 and sisters, all of whom were healthy, and he 
 was one of the cases delivered by forceps. In 
 the second case there was no history of here- 
 ditary taint. There was, however, disparity in 
 the ages of the parents : father was 41 and the 
 mother 29. The labour was very lingering, 
 and it was the one case in which ergot of rye 
 was administered.* 
 
 In the third case, the father was suffering 
 from Bright's disease at the time of procreation, 
 from which disease he died. 
 
 The fourth case is the only one in which the 
 consanguinity stands as an isolated cause, and 
 even in this instance there are three sisters 
 perfectly sound, and it is the only example of 
 degeneracy in the family, while the mother 
 asserts that she was frightened by seeing her 
 mother with paralysis at the age of 73. It is 
 worthy of remark that the father's mother also 
 died from paralysis at the age of 70. The boy 
 is a microcephale and the last-born ; the father, 
 about the time of the procreation, grew thrift- 
 
 * Dr. Eamsbotham lias shown that the ergot of rye 
 influences unfavorably the viability of the child. 
 
MARRIAGES OP CONSANGUINITY. 207 
 
 less, ran away to Australia, and has not been 
 heard of. 
 
 It is also noteworthy that these four excep- 
 tional examples are all males. Reviewing the 
 whole of these cases, there is only one, and that 
 the one just mentioned, in which there is not 
 quite sufficient to account for the idiocy apart 
 from consanguineous influences. 
 
 Since writing the foregoing, my attention 
 has been called to a paper of Dr. Mitchell's, 
 read before the Medico -Chirurgical Society of 
 Edinburgh,* in which, making observations 
 from a similar point of view to myself, on a 
 different field, he has arrived at very opposite 
 conclusions. He found in Scotland that more 
 than every sixth idiot born in wedlock was the 
 child of cousins. I am unable to account for 
 such a wide disparity, and in the face of it can 
 only reiterate the care with which my informa- 
 tion has been collected, and the impartiality 
 with which my results are here presented. My 
 own researches conclusively show that in Eng- 
 land, at least, every fourteenth idiot only is the 
 child of cousins. But can it be as certainly 
 
 * ' Edin. Med Journ.,' vol viii, p. 872. 
 
208 ON THE RESULTS OF 
 
 shown that the relationship per se is the cause 
 of the idiocy? I think not, and the analysis I 
 have made clearly shows that in the vast majo- 
 rity of such, so great in fact that it may almost 
 be said to be universal, other causes were 
 operating which were merely intensified by the 
 relationship. Had the same care been exercised 
 in the selection of relations as is displayed by 
 the breeder of race-horses, vastly different 
 results might have ensued ; or were the prac- 
 tice of the coloured races of North America in 
 force, of destroying all the weak, rachitic, and 
 diseased children, the intermarriage of cousins 
 would not have displayed the facts which I 
 have furnished. Consanguinity has doubtless 
 the power of aggravating any morbid tendency, 
 as I believe it has of perfecting any good 
 quality. Any statistics on the results of the 
 marriage of relations are of doubtful value 
 unless they give the life-history of the progeni- 
 tors. What a different aspect the whole matter 
 assumes when this plan is adopted, will be 
 apparent to the readers of this paper. When- 
 ever a similar investigation is made, I believe it 
 will be found, as in the subjects of my own 
 inquiry, that consanguinity is only one of the 
 
MAREIAGBS OF CONSANGUINITY. 209 
 
 factors, and not the most important one, in the 
 production of deterioration. 
 
 If our advice is sought, it will be our duty 
 to inquire into other elements which are less on 
 the surface, but which have equal or even greater 
 potentiality for evil. 
 
 iiUiances, such as I have exhibited, with 
 hereditary disease on both sides, should be dis- 
 countenanced even where there is no element 
 of consanguinity. It would only be a part of 
 a true philosophy to render more forcible our 
 opposition where blood-relationship would have 
 a well-determined tendency to aggravate the 
 wrong. 
 
 14 
 
21 OJBSEKVATIONS ON AN ETHNIC 
 
 OBSERVATIONS 
 
 ETHNIC CLASSIFICATION OF IDIOTS. 
 
 • London Hospital Reports,' 1866. 
 
 Those who have given any attention to con- 
 genital mental lesions must have been fre- 
 quently puzzled how to arrange, in any satis- 
 factory way, the different classes of this defect 
 which have come under their observation. 
 Nor will the difficulty be lessened by an appeal 
 to what has been written on the subject. The 
 systems of classification are generally so vague 
 and artificial that not only do they assist but 
 feebly in any mental arrangement of the pheno- 
 mena which are presented, but they completely 
 fail in exerting any practical influence on the 
 subject. 
 
CLASSIFICATION OP IDIOTS. 211 
 
 The medical practitioner who may be con- 
 sulted in any given case, has, perhaps in a very 
 early condition of the child's life, to give an 
 opinion on points of vital importance as to the 
 present condition and probable future of the 
 little one. Moreover, he may be pressed as to 
 the question, whether the supposed defect dates 
 from any cause subsequent to the birth or not. 
 Has the nurse dosed the child with opium? 
 Has the little one met with any accident ? Has 
 the instrumental interference which maternal 
 safety demanded been the cause of what seems 
 to the anxious parents a vacant future ? Can it 
 be that when away from the family attendant 
 medicine has been injudiciously prescribed? 
 Can, in fact, the strange anomalies which the 
 child presents be attributed to the numerous 
 causes which maternal solicitude conjures 
 to the imagination, in order to account for a 
 condition, for which any cause is sought rather 
 than hereditary taint or parental influence ? 
 Will the systems of classification, either all to- 
 gether, or any one of them, assist the medical 
 adviser in the opinion he is to present, or the 
 suggestions which he is to tender to the anxious 
 parent? I think that they will entirely fail 
 
212 OBSERVATIONS ON AN ETHNIC 
 
 liim in the matter, and that he will have in 
 many cases to make a guarded diagnosis and 
 prognosis, so guarded, in fact as to be almost 
 valueless ; or to venture an authoritative asser- 
 tion which the future may or may not confirm, 
 
 I have for some time had my attention 
 directed to the possibility of making a classifi- 
 cation of the feeble-minded, by arranging them 
 around various ethnic standards, — in other 
 words, framing a natural system to supplement 
 the information to be derived by an inquiry 
 into the history of the case. 
 
 I have been able to find among the large 
 number of idiots and imbeciles which come 
 under my observation, both at Earlswood and 
 the out-patient department of the hospital, 
 that a considerable portion can be fairly referred 
 to one of the great divisions of the human 
 family other than the class from which they 
 have sprung. Of course there are numerous 
 representatives of the great Caucasian family. 
 Several well-marked examples of the Ethiopian 
 variety have come under my notice, presenting 
 the characteristic malar bones, the prominent 
 eyes, the pufi'y lips, and retreating chin. The 
 woolly hair has also been present, although not 
 
CLASSIFICATION OF IDIOTS. 213 
 
 always black, nor has tlie skin acquired pig- 
 mentary deposit. They have been specimens 
 of white negroes, although of European 
 descent. 
 
 Some arrange themselves around the Malay 
 variety, and present in their soft, black, curly 
 hair, their prominent upper jaws and capacious 
 mouths, types of the family which people the 
 South Sea Islands. 
 
 Nor have there been wanting the analogues 
 of the people who, with shortened foreheads, 
 prominent cheeks, deep-set eyes, and slightly 
 apish nose, originally inhabited the American 
 Continent. 
 
 The great Mongolian family has numerous 
 representatives, and it is to this division I wish, 
 in this paper, to call special attention. A very 
 large number of congenital idiots are typical 
 Mongols. So marked is this that, when placed 
 side by side, it is difficult to believe that the 
 specimens compared are not children of the 
 same parents. The number of idiots who 
 arrange themselves around the Mongolian type 
 is so great, and they present such a close 
 resemblance to one another in mental power, 
 that I shall describe an idiot member of tbis 
 
214 OBSERVATIONS ON AN ETHNIC 
 
 racial division, selected from the large number 
 that liave fallen under my observation. 
 
 The hair is not black, as in the real Mongol, 
 but of a brownish colour, straight and scanty. 
 The face is flat and broad, and destitute of pro- 
 minence. The cheeks are roundish, and ex- 
 tended laterally. The eyes are obliquely placed, 
 and the internal canthi more than normally dis- 
 tant from one another. The palpebral fissure 
 is very narrow. The forehead is wrinkled 
 transversely from the constant assistance which 
 the levatores palpebrarum derive from the 
 occipito-frontalis muscle in the opening of the 
 eyes. The lips are large and thick with trans- 
 verse fissures. The tongue is long, thick, and 
 much roughened. The nose is small. The 
 skin has a slight dirty yellowish tinge, and is 
 deficient in elasticity, giving the appearance of 
 being too large for the body. 
 
 The boy's aspect is such that it is difficult to 
 realise that he is the child of Europeans, but so 
 frequently are these characters presented that 
 there can be no doubt that these ethnic features 
 are the result of degeneration. 
 
 The Mongolian type of idiocy occurs in more 
 than 10 per cent, of the cases which are pre- 
 
CLASSIFICATION OF IDIOTS. 215 
 
 sented to me. They are always congenital 
 idiots, and never result from accidents after 
 uterine life. They are, for the most part, in- 
 stances of degeneracy arising from tuberculosis 
 in the parents. They are cases which very 
 much repay judicious treatment. They require 
 highly azotised food with a considerable amount 
 of oleaginous material. They have considerable 
 power of imitation, even bordering on being 
 mimics. They are humorous, and a lively 
 sense of the ridiculous often colours their mimi- 
 cry. This faculty of imitation may be culti- 
 vated to a very great extent, and a practical 
 direction given to the results obtained. They 
 are usually able to speak ; the speech is thick 
 and indistinct, but may be improved very greatly 
 by a well-directed scheme of tongue gymnastics. 
 The co-ordinating faculty is abnormal, but not 
 so defective that it cannot be greatly strength- 
 ened. By systematic training, considerable 
 manipulative power may be obtained. 
 
 The circulation is feeble, and however much 
 advance is made intellectually in the summer, 
 some amount of retrogression may be expected 
 in the winter. Their mental and physical capa- 
 bilities arc, in fact, directly as the temperature. 
 
216 OBSERVATIONS ON AN ETHNIC 
 
 The improvement whicli training effects in 
 them is greatly in excess of what would be pre- 
 dicated if one did not know the characteristics 
 of the type. The hfe expectancy, however, is 
 far below the average, and the tendency is to 
 the tuberculosis which I believe to be the here- 
 ditary origin of the degeneracy. 
 
 Apart from the practical bearing of this 
 attempt at an ethnic classification, considerable 
 philosophical interest attaches to it. The ten- 
 dency in the present day is to reject the opinion 
 that the various races are merely varieties of 
 the human family having a common origin, and 
 to insist that climatic, or other influences, are 
 insufficient to account for the different types of 
 man. Here, however, we have examples of re- 
 trogression, or, at all events, of departure from 
 one type and the assumption of the characteris- 
 tics of another. If these great racial divisions 
 are fixed and definite, how comes it that disease 
 is able to break down the barrier, and to simu- 
 late so closely the features of the members of 
 another division ? I cannot but think that the 
 observations which I have recorded are indica- 
 tions that the differences in the races are not 
 specific but variable. 
 
CLASSIFICATION OF IDIOTS. 217 
 
 These examples of the result of degeneracy 
 among mankind, appear to me to furnish some 
 arguments in favour of the unity of the human 
 species. 
 
218 ON IDIOCY AND ITS 
 
 ON IDIOCY AND ITS RELATION TO 
 TUBEECULOSIS. 
 
 ' The Lancet,' vol. ii, 1867. 
 
 The causes which have been assigned as 
 productive of idiocy are numerous, and some 
 have received special advocacy. Thus we are 
 asked to believe that one of the most profound 
 misfortunes which aflSicts our race — which to 
 a great extent blots out the characteristics of 
 man, and approximates him to the lower animals 
 — arises from sucking the thumb ; and that if 
 we could prevent a " fruitless sucking " idiocy 
 would be immensely diminished, even if it did 
 not cease to exist. Others, with more show of 
 reason, urge the intermarriage of blood rela- 
 tions as the prevailing cause ; and so far does 
 a belief in the potency of this latter element 
 permeate society that I have been often gravely 
 
EBLATION TO TUBERCULOSIS. 219 
 
 asked whether intermarriage of relations is not 
 the cause of the idiocy of three fourths of the 
 cases which come under my observation. 'No 
 one who has had an opportunity of investiga- 
 ting the influences which are at work in the 
 production of congenital mental diseases can 
 fail to be struck with the fact that they are, 
 for the most part, to be traced to some inherent 
 vice of constitution in the progenitors. He will 
 discover in the parents elements of degeneracy 
 which must have had their share in producing 
 the catastrophe. He will notice how by degrees 
 the stock has deteriorated. He will be able to 
 estimate how intemperance or sensuality leads 
 slowly but surely to idiocy — how physical weak- 
 ness of the parents culminates in the mental 
 blight of the child. 
 
 Amongst the influences which have been 
 regarded as connected with idiocy, very little 
 attention has been given to that of tuberculosis, 
 and I am not aware that any observations have 
 been made with reference to the connection of 
 these two maladies. 
 
 Several writers have discussed the relations 
 between insanity and tuberculosis, and have, I 
 think, made it tolerably evident that there is 
 
220 ON IDIOCY AND ITS 
 
 more than an accidental connexion between 
 them. 
 
 At the Earlswood Asylum, where the follow- 
 ing observations have been made, the subjects 
 of the inquiry are not likely to present an unfair 
 proportion of tubercular idiots. Rather would 
 they be likely to be below the average. The 
 inmates are, for the most part, elected after 
 great exertion, and the friends of a phthisical 
 idiot would scarcely be likely to undertake the 
 trouble for a manifestly short-lived child, even 
 if the rules of the institution did not exclude it. 
 
 During the past eight years, from 1859 to 
 1866 inclusive, there have been 201 deaths. 
 During this time there have been two epidemics 
 of measles, one of scarlet fever, and two of 
 whooping-cough, which have all added to the 
 mortality. Moreover, a large proportion of 
 the patients who succumbed to these epidemic 
 diseases were those who would in all probability 
 have eventually died of phthisis but for their 
 intervention. Notwithstanding this circum- 
 stance there remains the fact, which my notes 
 record, that, of the whole mortality, 39*8 is due 
 to phthisis. To appreciate fully the meaning 
 of these figures, it is necessary to consider the 
 
RELATION TO TUBERCULOSIS. 
 
 221 
 
 rate of mortality wliich rules amongst an idiot 
 population. My notes show that, taking the 
 last eight years, in some of which there were 
 epidemics, while others were entirely free 
 therefrom, the mortality presented an average 
 of about 73 "3 per 1000 ; whereas the mortality 
 of the district in which the asylum is situated 
 was about 18 per 1000. 
 
 
 Average 
 
 Gross 
 
 Deaths 
 
 
 Date. 
 
 popula- 
 
 mor- 
 
 from 
 
 — 
 
 1859 
 
 tion. 
 
 tality. 
 
 phthisis. 
 
 
 2851 
 
 13 
 
 7 
 
 
 1860 
 
 3081 
 
 22 
 
 7 
 
 Epidemic of typhoid. 
 
 1861 
 
 318i 
 
 23 
 
 13 
 
 
 1862 
 
 322 
 
 33 
 
 8 
 
 Epidemic of measles. 
 
 1863 
 
 sm 
 
 47 
 
 15 
 
 Epidemic of measles and 
 scarlatina. 
 
 1864 
 
 369f 
 
 19 
 
 10 
 
 
 1865 
 
 4121 
 
 13 
 
 9 
 
 
 1866 
 
 423i 
 
 31 
 
 11 
 
 Epidemic of measles. 
 
 The statistics of London show that the deaths 
 from phthisis constitute 115 per 1000 of the 
 general mortality. My notes of the causes of 
 death at Eiarlswood indicate that phthisis was 
 the actual cause of death in 398 per 1000 of 
 the general mortality. The significance, how- 
 ever, of this, as before observed, can only be 
 
222 ON IDIOCY AND ITS 
 
 rightly estimated by recollecting that the general 
 mortality is four times that of an ordinary com- 
 munity. 
 
 It will be obvious that, in consequence of the 
 greater readiness with which idiots succumb to 
 epidemic or other diseases, the proportional 
 deaths from phthisis are therebymuch decreased. 
 This element may be fully brought out by 
 dividing the eight years ; bringing together the 
 four epidemic years, and comparing them with 
 the four non-epidemic years. It will then be 
 seen that during the epidemic years 1860, 1862, 
 1863, and 1866, the deaths from phthisis num- 
 bered 297 per 1000 of the general mortality, or 
 considerably more than twice the ratio which 
 rules in London ; while in the non-epidemic 
 years 1859, 1861, 1864, and 1865, the deaths 
 from phthisis reached the enormous proportion 
 of 570*58 per thousand of the general mor- 
 tality. I now propose to present a tabular 
 view of the age and sex of those who died from 
 phthisis. 
 
 Age. 
 
 Male. 
 
 Female. 
 
 Total, 
 
 7 
 
 1 
 
 
 
 1 
 
 8 
 
 1 
 
 
 
 1 
 
 9 
 
 1 
 
 2 
 
 3 
 
 10 
 
 3 
 
 
 
 3 
 
EELATION TO TUBERCULOSIS. 
 
 223 
 
 11 
 
 12 
 13 
 14 
 15 
 16 
 17 
 18 
 19 
 20 
 21 
 23 
 27 
 20 
 
 Male. 
 
 Female. 
 
 
 2 
 
 1 
 
 3 
 
 1 
 
 
 6 
 
 2 
 
 
 5 
 
 2 
 
 
 1 
 
 
 
 
 4 
 
 1 
 
 
 2 
 
 6 
 
 
 4 
 
 3 
 
 
 8 
 
 1 
 
 
 7 
 
 1 
 
 
 6 
 
 2 
 
 
 2 
 
 
 
 
 1 
 
 
 
 
 1 
 
 
 
 
 Total. 
 8 
 4 
 8 
 7 
 1 
 5 
 8 
 7 
 9 
 
 58 22 80 
 
 Dividing the ages into quinquennial periods, 
 it will be observed that the greatest mortality 
 from phthisis was from fifteen to twenty years 
 of age. 
 
 From 5 to 10 years ... 8 
 
 „ 10 to 15 „ 23 
 
 „ 15 to 20 „ 38 
 
 „ 20 to 25 „ 10 
 
 „ 25 to 30 „ 2 
 
 The above details have reference solely to 
 ante-mortem diagnosis and have included cases 
 where the death was evidently caused by 
 
224 ON IDIOCY AND ITS 
 
 phthisis. I have, however, made an analysis of 
 the last hundred of my post-mortem records, 
 and I find that no fewer than 62 per cent, were 
 subjects of tubercular deposit. There were 62 
 males, and tubercular deposit was found in 49 
 instances, or 79*03 per cent. There were 38 
 females, and of these 13, or 34 per cent., were 
 tubercular. 
 
 Dr. Clouston, in the ' Journal of Mental 
 Science' for 1863, has analysed the post-mortem 
 records of the insane at the Royal Edinburgh 
 Asylum, and found that 60*9 per cent, had 
 tubercular deposit. It would appear that idiots 
 are slightly more liable to tuberculosis than the 
 insane, but there is a remarkable difference 
 between the proclivity of the two sexes. While 
 among the insane, 51 '7 per cent, of the males 
 were tubercular, 73 per cent, of the females had 
 tubercular deposit. Among idiots, however, 
 while the females have a remarkable immunity, 
 the deposit being found in only 34 per cent., 
 among the males no less than 79*03 per cent., 
 or more than twice the ratio, had tubercle in 
 some of their organs. 
 
 If we inquire into the sex of those whose 
 death resulted from phthisis, and in whom the 
 
EELATION TO TUBERCULOSIS. 
 
 225 
 
 diagnosis was made during life, we shall also find 
 that the females suffered in a less degree than 
 the males. While 31*9 per cent, of the female 
 mortality resulted from phthisis, this disease 
 was the cause of death in 44'6 per cent, of the 
 males. 
 
 The following table will give the distribution 
 of the deposit in the different organs : — 
 
 Total number of cases referred to, 100. 
 
 Males. Females. 
 
 Total number of cases 
 
 tubercular 
 Lungs 
 
 Lungs, much deposit 
 Lungs, slight deposit 
 Deposit in right lung 
 Deposit in left lung 
 Peritoneum 
 Nervous centres 
 Bronchial glands 
 Liver 
 Kidneys 
 Spleen 
 
 found 
 
 
 37 . 
 
 . 25 
 
 
 
 31 . 
 
 . 21 
 
 
 
 24 . 
 
 . 14 
 
 
 
 7 . 
 
 7 
 
 
 
 26 . 
 
 . 17 
 
 
 
 27 . 
 
 . 21 
 
 
 
 4 . 
 
 . 3 
 
 
 
 3 . 
 
 . 3 
 
 
 
 12 . 
 
 6 
 
 
 
 . 5 . 
 
 . 4 
 
 
 
 4 . 
 
 
 
 
 1 
 
 7 . 
 1 1 II 
 
 2 
 
 1 1 
 
 
 Total. 
 
 62 
 52 
 38 
 14 
 43 
 48 
 
 7 
 
 6 
 18 
 
 9 
 
 4 
 
 9 
 
 It is worthy of remark that tubercle is rarely 
 found in the encephalon. In only two cases 
 did this occur ; in one the corpus striatum was 
 the seat of the deposit, and in the other the 
 
 15 
 
226 ON IDIOCY AND ITS 
 
 cerebellum. The most noticeable character 
 observed was the extreme pallor of the cortical 
 substance of the encephalon ; and so frequent 
 was this that it was all but universal. Occa- 
 sional softening of the fornix and the neigh- 
 bouring parts was met with, but not nearly so 
 frequently as paleness of what should be the 
 grey portion of the brain. 
 
 In several of the cases included in the above 
 record, most careful inquiry failed to discover 
 any family history of tuberculosis; and the 
 brothers and sisters were thoroughly vigorous. 
 In these cases the tuberculosis appears to have 
 been the sequence of the idiocy — a condition of 
 idiocy resulting from accidental causes. Defec- 
 tive innervation in all probability led to mal- 
 nutrition, and predisposed to a tubercular con- 
 dition. In some this was doubtless materially 
 assisted by the imperfect mastication and in- 
 salivation to which the food was subjected. 
 The tendency to bolt the food unmixed with 
 saliva often prevents the proper alteration of 
 the starchy element, so as to fit it for speedy 
 assimilation. 
 
 On the other hand, in a large number of 
 cases the progenitors had also manifested a 
 
RELATION TO TUBERCULOSIS. 227 
 
 tubercular condition; and in some the tuber- 
 culosis of the parents had been, in my opinion, 
 the prime cause of the idiocy of the offspring. 
 I have elsewhere shown (' Lend. Hosp. Reports,' 
 vol. iii) that a specific phase of idiocy — a phase 
 which, is curiously associated with altered racial 
 characters — arises from tuberculosis of tbe pro- 
 genitors. 
 
 The subjects of this class assume the Mon- 
 golian type ; and while they present a marked 
 similarity in external conformation, they are 
 characterised by the same mental and moral 
 peculiarities ; so that, given a case of the Mon- 
 golian type, we are often able to trace its origin 
 to tuberculosis, and to predicate the extent of 
 response to training that may be expected, and 
 the tendencies it will evince. Moreover, the 
 knowledge that is gained by this racial charac- 
 ter assists in laying down specific rules as to 
 food, medicine, and general hygiene, without 
 which the mental development would be but 
 small. The power of progress is usually much 
 greater than one would judge by an ordinary 
 inspection. Such cases are extremely suscepti- 
 ble to climatic changes, and winter is for them 
 a period of mental and physical developmental 
 
228 ON IDIOCY AND ITS 
 
 rest. In the spring they put forward in- 
 creased imitative and receptive powers, which 
 compensate to some extent for the period of 
 hybernation. 
 
 It will be interesting now to ascertain to 
 what extent tuberculosis exists among the pro- 
 genitors of idiot children generally. I have 
 gone through my records very carefully, dis- 
 regarding all doubtful cases, meaning thereby 
 cases in which, although there has been a death 
 from phthisis in the family, I had reason to 
 believe that it arose from accidental causes, and 
 selecting only those in which the tubercular 
 taint was well impressed. I find that in 31 per 
 cent, of the cases of idiocy which have come 
 under my care, or about whom I have been 
 consulted, tuberculosis existed in an unmistake- 
 able manner, in the family of the progenitors ; 
 in 6 per cent, the tubercular element was found 
 on both sides of the family ; in 10 per cent, it 
 was due to the father ; while in 15 per cent, 
 the tuberculosis belonged to the mother. It is 
 a somewhat singular circumstance that while 
 tuberculosis is more frequent on the maternal 
 side, the male progeny are the most tubercular. 
 
 In the third volume of the ' London Hospital 
 
RELATION TO TUBEEOULOSIS. 229 
 
 Reports,' I have endeavoured to show that 
 idiocy has been too often traced to the inter- 
 marriage of blood relations, without regarding 
 other elements that may be operative. It is 
 readily conceivable that if there be tuberculosis 
 strongly impressed on a family, the members 
 of that family would by intermarriage be 
 taking tolerably effectual steps to ensure the 
 extinction of their race. Certain it is that in a 
 large number of the cases in which marriages 
 of consanguinity are referred to as the cause 
 of idiocy, the tuberculosis of the progenitors 
 is a potent, but often disregarded, element. 
 The Mongolian type, which I have elsewhere 
 described, occurs, according to my observation, 
 in greater degree when the tubercular element 
 is strongly impressed, still more where it exists 
 in both branches of the family, and greatest if 
 consanguinity is added thereto. 
 
 It appears to me that tuberculosis must be 
 accepted as one important cause of idiocy ; that 
 it impresses special characters thereon, charac- 
 ters which impart a strong family likeness to 
 the subjects of this class. 
 
 It is no less clear to me that idiocy of a non- 
 tubercular origin leads to tuberculosis. Whether 
 
230 EBLATION OF IDIOCY TO TUBERCULOSIS. 
 
 this arises througli the influence of the pneumo- 
 gastric nerve, mal-assimilation of food, or defec- 
 tive innervation, it cannot but be regarded that 
 the connection between these two maladies is 
 by no means accidental, and that a due appre- 
 ciation of this relation is necessary to those 
 who would treat effectively congenital mental 
 lesions. 
 
A CASE 
 
 ASYMMETEICALLY DEYELOPED 
 BRAIN. 
 
 * Trans, Path. Soc.,' 1869. 
 
 The brain now exhibited was removed from 
 the cranium of a girl seventeen years of age, 
 who had been idiotic from birth. Her father 
 died insane. Her mother had good bodily and 
 mental health. She was the youngest of six 
 children. The other members of the family 
 had average intellectual powers, but were all 
 delicate as to their physical health ; one brother 
 died from phthisis. At the age of seven months 
 she had epileptic fits, which persisted for some 
 time at short intervals. She never spoke. The 
 cutting of her teeth and her walking were both 
 deferred. She was passionate and self-willed. 
 She was always in motion, full of mischief, and 
 delighted in tearing things up and putting them 
 
232 ASYMMBTEIOALLT DEVELOPED BRAIN. 
 
 on the fire. Her habits were dirty. Under the 
 influence of training she became clean, tract- 
 able, and able to take some part in her own 
 toilet. She was taught to feed herself with 
 propriety at table. She made no attempt to 
 speak, apparently from want of ideas to com- 
 municate. She would come when called, but 
 manifested very little affection. Her demeanour 
 indicated considerable erotic feeling. There 
 was no paralysis either of sensation or motiou, 
 and her powers of prehension and manipulation 
 were susceptible of education. 
 
 Her physical health had been very good for 
 several years, until an attack of scarlet fever 
 led to acute desquamative nephritis, and conse- 
 quent broncho-pneumonia. 
 
 Post-mortem examination. — The body was 
 well nourished, and weighed 6 stones 12 lbs. 
 There was hair on the pubis, but not in the 
 axillae. The heart weighed 7 J oz., the valves 
 competent ; the large vessels filled with clots 
 of blood. The left lung was adherent to the 
 costal pleura, weighing 14| oz. ; interlobular 
 adhesions. The apex was much puckered, 
 corresponding thereto was a calcareous mass 
 the size of a pea, of a hard density ; another 
 
ASYMMETRIOALLY DEVELOPED BRAIN. 233 
 
 part of the apex contained a tubercular nodule 
 the size of a bean. The posterior part of the 
 lung was intensely congested. The right lung 
 was hepatised throughout ^ of its extent. The 
 bronchial glands were enlarged, and the tubes 
 intensely injected. The kidneys presented at 
 the margin of the pyramids a deep red colour. 
 The uterus and ovaries were normal. 
 
 The cranium was slightly unsymmetrical, 
 exhibiting slight flattening on the anterior third 
 of the left side. The circumference was 21f 
 in. ; the antero-posterior diameter 6*5 in. ; the 
 antern-posterior curve lOf in. ; the bilateral 
 diameter 5*3 in.; the bilateral curve 7*5 in. 
 On removing the calvarium the anterior portion, 
 of the left side corresponding to the external 
 flattening was found to be enormously thick- 
 ened. 
 
 The left side of the encephalon was conse- 
 quently much smaller than the right, and on re- 
 moving the brain it was found that this dis- 
 parity was still further increased by a diminu- 
 tion of brain matter on the inferior surface of 
 the anterior lobe, which was replaced by exces- 
 sive thickening and consequent elevation of the 
 orbital plate of the frontal bone. 
 
234 ASYMMETRICALLY DHJVELOPED BRAIN. 
 
 The left hemisphere was not more than two- 
 thirds the size of the right. The occipital lobe 
 was slightly less developed on the left side than 
 on the right, but the great cause of want of 
 symmetry was the absence of development 
 of the frontal lobe. All the convolutions were 
 present, but the middle and inferior frontal 
 gyri were extremely minute in size, although 
 not more simple than usual. The gyri of the 
 orbital lobule were also of small size. 
 
 Bemarhs. — Asymmetrical brains are not un- 
 frequently met with in dissections of idiots, 
 but so great an inequality has never before 
 come under my notice. There was no want 
 of symmetry in the lobes of the cerebellum. 
 In this case it was arrest of growth rather 
 than of development, as indicated by the com- 
 plexity of the defective convolutions. The 
 amount of disparity could not have been pre- 
 dicated before death by external examination 
 of the cranium. The thickened calvarium and 
 orbital plate were sequential to and not ante- 
 cedent to the arrested growth. 
 
 A remarkable case of asymmetrical brain, 
 which came under my notice a few years 
 since, had associated with it an asymmetrical 
 
ASYMMETRICALLY DEVELOPED BRAIN. 235 
 
 cranium, but the larger side of cranium corre- 
 sponded to the diminished hemisphere of the 
 encephalon ; the inner and outer tsibles of the 
 skull had separated widely, so that external 
 examination gave no idea of the size of the 
 skull cavity. 
 
 It is worthy of remark that the region im- 
 plicated was that known as Broca's. Having 
 regard, however, to the frequency of absence of 
 speech in idiocy, I cannot look upon this case 
 as being of much importance in localising the 
 faculty of speech to one half of the hemisphere, 
 or to the frontal lobe in particular. The 
 absence of speech was the result of defect of 
 cerebration generally. There was no power to 
 formulate ideas, and speech was not required. 
 It should also be noticed that she was the 
 youngest child of a father who died insane. 
 There is reason to believe that she was pro- 
 created during the early progress of the mental 
 alienation, and thus suffered in a way different 
 from the others, who were born anterior to the 
 mental change. This is in accordance with 
 many instances which have come under my 
 observation, and what might be theoretically 
 expected. 
 
A CASE 
 
 MICROCEPHALIC SKULL. 
 
 '■ Trans. Path. Soc.,' 1869. 
 
 The cranium exhibited is that of a boy thir- 
 teen years of age, having a height of 45^ inches, 
 and a weight of 26 lbs., who died from tuber- 
 cular disease of the lungs. He was the son of 
 healthy parents, but had been an idiot from 
 birth. The cause of idiocy was attributed to 
 fright of the mother during pregnancy. He 
 was dirty in his habits, did not speak, and was 
 extremely mischievous. The circumference of 
 his head measured 18 inches, the longitudinal 
 curve 11 inches, the longitudinal diameter 6 
 inches, the bilateral curve 10 inches, the bi- 
 lateral diameter 4-8 inches; the brain weighed 
 2^ lbs. ; the fornix was diffluent, the middle 
 commissure absent, the right corpus striatum 
 smaller than the left; the pons Varolii and 
 
MIOROCEPHALIC SKULL. 237 
 
 medulla oblongata weighed together | oz. ; the 
 cerebellum weighed 3| oz., the right lobe being 
 narrower anteriorly than the left. The cal- 
 varium, when deprived of integument, measured 
 17 inches; the longitudinal diameter 5|- inches, 
 the bilateral diameter 4f inches. The calvarium 
 was un symmetrical, being larger on the left side 
 posteriorly, and the left parietal eminence being 
 more prominent than the right. The anterior 
 portion of the cranium had a remarkable prow- 
 shaped prominence, corresponding to the medio- 
 frontal suture which remained unossified ; all 
 the remaining sutures were in the same con- 
 dition. 
 
 Remarks. — The above case is interesting, not 
 as exhibiting a very extreme degree of micro- 
 cephalism, but as evidence that premature 
 synostosis of the cranial sutures cannot be 
 regarded as the cause of the abnormal condition. 
 In this case, not only were the usual sutures 
 in an unossified condition ; but the medio-frontal 
 suture, which usually becomes ossified during 
 the first year of extra-uterine life, was patent, 
 so that deferred rather than premature synos- 
 tosis existed. Moreover, it throws doubt on 
 the view usually entertained, that scapho- 
 
238 MIOEOOEPHALIO SKULL. 
 
 cephalic skulls depend on the premature ossifi- 
 cation of the sagittal suture, as in this case 
 the marked frontal ridge corresponded to a 
 line where synostosis had been remarkably 
 .postponed. 
 
A CASE 
 
 MIOEOCEPHALIC SKULL. 
 
 ' Trans. Path. Soc./ 1869. 
 
 The cause of deformation of the cranium, 
 and especially of that kind known as micro- 
 cephalism, has been so authoritatively stated to 
 be premature synostosis of the cranial sutures, 
 that the tendency has been to acquiesce in this 
 explanation and to accept this as the great 
 determining factor. My own observations on 
 the crania of about 200 idiots — many of them 
 deformed in various ways, and some of them 
 unusually small — have led me to take an entirely 
 different view, and to assume that the devia- 
 tions of the cranium have been rather the 
 sequence of circumstances arresting the deve- 
 lopment and growth of the encephalon, and 
 have not been the result of premature ossifica- 
 tion of the sutures. The only case in which I 
 
240 MICKOOEPHALIO SKULL. 
 
 have met with ossification of the sutures was a 
 case of macro cephaHsm, where certainly the 
 ossification of the sutures could have had no 
 influence in the production of the enlarged 
 cephalic mass. 
 
 The cranium which I now produce is interest- 
 ing, as showing how an extreme degree of 
 microcephalism can exist without any ossifica- 
 tion of the cranial sutures. The cranium is 
 that of a male, eighteen years of age, who had 
 been educated with some slight result. He had 
 acquired speech and correct habits, had learned 
 to be self-helpful, to count, and to make imitative 
 drawings of a simple character on a black-board. 
 The head measured in its circumference 15 
 inches. The antero-posterior curve measured 
 from the glabella of the frontal bone over the 
 vertex to the occipital protuberance 8 inches. 
 The bilateral curve over the vertex from above 
 the implantation of the ears was 8 inches. The 
 antero-posterior diameter of the head was 5 
 inches, the bilateral diameter 3*9 inches. 
 
 The greatest antero-posterior diameter of 
 the interior of the cranium was 4*7 inches ; the 
 greatest bilateral diameter of the interior of 
 the cranium 3 "4 inches. 
 
MIOROOEPHALIO SKULL. 241 
 
 All the sutures which are usually unossified 
 were perfectly free from synostoses, and, in 
 fact, the cranial bones were more than usually 
 freely separable the one from the other. 
 
 It is worthy of remark that more than one 
 foreign observer had predicated during the 
 youth's life that it was a good illustration 
 of premature synostosis. I had been led to 
 doubt this from the result of former autopsies, 
 and I am desirous of placing on record 
 this extreme degree of microcephalism, without 
 any synostosis, as a striking example in which 
 other than mere mechanical causes must be 
 looked for as productive of this and analogous 
 eases. 
 
 U 
 
A CASE 
 
 AEEESTED DEYELOPMENT. 
 
 ♦Trans. Path. Soc.,' 1869. 
 
 J. P., a female, aged five, came under my 
 observation at the London Hospital. She 
 measured twenty-two inches in height, was un- 
 able to walk, but could stand by the help o£ a 
 chair. She could not speak, and gave utter- 
 ance only to a few monosyllabic sounds. There 
 was no deformity of the body or limbs. The 
 face had an earthy complexion, and the integu- 
 ment generally had a wrinkled appearance as 
 if it were too large for the diminutive body. 
 The hair was sparse and coarse, the eyebrows 
 obliquely placed, the tongue large and rugous. 
 There was a SDiall tumour on each side of 
 the neck above the clavicle. She understood 
 what was said to her, and had the mental con- 
 dition of a child about fifteen months old. The 
 
AERESTED DEVELOPMENT. 243 
 
 father and mother had been healthy, and there 
 was no history of mental or physical deviation 
 on either side. The mother stated that her 
 first child was perfectly healthy, until it died 
 from measles. The husband about that time 
 gave himself up to intemperance, and the 
 mother subsequently gave birth to a child, 
 which died at the age of three, having the same 
 physical peculiarities as the subject of these 
 remarks. The third child, now under con- 
 sideration, was procreated like the second, 
 while the husband was suffering from alcoholic 
 intoxication. A miscarriage succeeded. The 
 husband at this time relinquished his habits of 
 intemperance, became as thrifty and prudent 
 as he was formerly the reverse ; and the wife 
 again becoming pregnant, gave birth to a child 
 normally developed, and in good bodily and 
 mental health, now sixteen months old. 
 
 Remarks^ — The above case is of great interest, 
 because, in the author's opinion, it adds another 
 to a group of cases which have come under his 
 observation of arrested development arising 
 from intoxication of one or both of the pro- 
 genitors at the time of the procreative act. 
 The whole group of cases has presented features 
 
244 AEEESTED DEVELOPMENT. 
 
 of such close resemblance that it is difficult to 
 avoid the conclusion that there was some unity 
 of cause, and careful investigation has elicited 
 facts bearing on the etiology of these cases, 
 having a close parallelism to the circumstances, 
 which he believes to have been potential in 
 this. He has known some of these cases to 
 attain the age of twenty, while still preserving 
 infantile characteristics. 
 
 In each case the tumours in the neck have 
 been observed. 
 
A CASE OE PAEALYSIS 
 
 APPAKENT MUSCULAR HYPERTROPHY. 
 
 ♦Path. Soc. Trans.,' 1870, 
 
 Benjamin Round, aged eleven, admitted into 
 tlie London Hospital, September 14tli, 1869. 
 
 History. — His mother states that this disorder 
 has been coming on for five years. The first 
 thing wrong which she noticed was, that when 
 he fell down he could not get up again. About 
 two years ago he began to get unsteady in his 
 gait ; when running, if he tried to stop himself 
 suddenly, he fell down, and even when walking 
 he had difficulty in stopping without tumbling 
 over. Running was easier to him than walking, 
 and walking than standing still. When he stood 
 still, he looked out for something to lean against, 
 getting to the wall if he could. His mother 
 noticed that as he ran he used to stick out his 
 
246 PAEALTSIS WITH APPARENT 
 
 belly and throw back his shoulders. For the 
 past twelve months he has been nnable to walk, 
 and for the past seven months has been gradu- 
 ally losing the use of his arms. 
 
 Family history. — His mother's health has 
 always been good, and so has his father's. No 
 history of any hereditary disease, except that 
 his grandfather died from " consumption," and 
 his father's grandfather was insane. All his 
 brothers and sisters are healthy. 
 
 The only previous illness the boy has had 
 was measles seven years ago. Has never had 
 thrush nor any cutaneous eruption. Has had 
 thread-worms for six years. His mother suckled 
 him for eighteen months. He was not any 
 longer teething or learning to walk than the 
 other children. He has always been very fat ; 
 his belly has always been big, and the calves of 
 his legs have always been large. During the last 
 four years his mother thinks his ankles and 
 thighs have wasted. His head is unusually 
 large. During the past two years he has not 
 been well fed ; the family have only had meat 
 once a week, and then a pound and a half 
 divided among ten. 
 
 Present condition. — He is utterly unable to 
 
MUSCULAR HYPERTEOPHY. 247 
 
 stand. When put upon his legs they sprawl 
 helplessly in every direction. He can sit up, 
 but if he is gently pushed back he falls quite 
 passively upon the floor, and can by no efforts 
 raise himself. As he sits up, he likes to sup- 
 port himself by using his hands as props. When 
 pushed back in bed against the pillow, so that 
 he does not fall quite down, he can manage to 
 raise himself by swinging his head laterally to 
 the front. There is great loss of power over 
 the arms. On being desired to raise his arm 
 slowly, he can move it but a little distance from 
 his side, and that by the aid of his scapular 
 muscles, the shoulder being raised and thrown 
 forward, and the lower angle of the scapula tilted 
 upwards and outwards. By a jerk he can raise 
 it about 60 degrees, and by swinging his arm 
 backwards and forwards, he can get it up nearly 
 horizontally. If his arm be extended in the 
 supine position he can flex it at the elbow-joint, 
 but if a small book be placed in his hand he 
 cannot raise it. If his arm be flexed at the elbow 
 he can extend it, but a weight of three or four 
 ounces prevents his doing so. He can perform 
 any movements with his fingers and thumb, but 
 without much power. When he wishes to raise 
 
248 PAEALYSIS WITH AFPAEENT 
 
 his hand lie does so by the aid of his fingers, 
 jnaking them climb, as it were, over his body 
 and head, and drag his arm after them. He 
 separates his fingers, and places his thumb on a 
 higher point than the rest ; he then approxi- 
 mates his fingers, and resting his little finger on 
 the same level as his thumb, again separates his 
 fingers, and plants his thumb on a higher level 
 still ; in this way he makes his arm travel to the 
 •desired place. He cannot flex the thigh upon 
 the trunk at all in bed ; out of bed ha can do it 
 a little. As he lies in bed he moves his lower 
 extremities about by the movements of his feet, 
 alternately using the heel and toe as a fixed point 
 to advance the rest of the foot. He can rotate 
 the limb at the hip- joint. Out of bed, by 
 swinging his legs, he can get them to an angle 
 of about forty-five degrees from the perpen- 
 dicular, but he cannot keep them in opposition 
 ,to the force of gravity. He can also swing his 
 feet laterally. He can move his feet a little 
 laterally at the ankle-joint, but without much 
 power. He flexes and extends his toes readily. 
 He can adduct the limb slightly, but appears to 
 do so by the action of his quadriceps. 
 
 Muscular system ; loiver extremities. — The 
 
MUSODLAE HYPBRTEOPHY. 249 
 
 muscles supplied by the gluteal and great sciatic 
 nerves are immensely hypertrophied^ On look- 
 ing at the boy the prominence of his gluteal 
 region is very apparent, and on feeling the part 
 the extreme hardness of the. muscle is very 
 striking. The lumbo-sacral curve is greatly 
 exaggerated. The tensor vaginae femoris can 
 be felt as a thick, hard, firm band under the 
 skin. The flexors of the thighs are also much 
 hypertrophied. The muscles of the calves are 
 also very hard and very large. The extensor 
 and peronei muscles on the outside of the tibia 
 appear to share this hypertrophy. The foot is 
 in a state of talipes equino-varus. 
 
 The adductor muscles on the inside of the 
 thigh are very soft, small, and lax. The quadri- 
 ceps extensor appears somewhat hypertrophied, 
 but it is very diiBSicult to estimate its size. The 
 sartorius is wasted. 
 
 Measurements of lower extremities — 
 
 From one iliac spine to the other . = 8 in. 
 Around pelvis, over most prominent 
 
 part of glutsei . . . . = 24J in. 
 From anterior superior iliac spine 
 
 to outer condyle. . . . = 12| in. 
 
250 PARALYSIS WITH APPARENT 
 
 From great troclianter to outer con- 
 dyle = lOf in. 
 
 Circumference at middle of thigH . = 12 in. 
 , Tibia, from inner tuberosity to inner 
 
 malleolus . . . . . = 9J in. 
 
 Circumference of thickest part of 
 
 leg = 11 in. 
 
 Circumference of leg just above 
 
 ankle . . . . . . = 6 in. 
 
 Upper extremities. — The deltoid seems a little 
 hypertrophied, but not so much as the glutsei. 
 The triceps seems also somewhat hypertrophied. 
 The pectorals and scapular muscles almost com- 
 pletely atrophied, and the latissimus dorsi can 
 scarcely be felt. The head of the humerus can 
 be felt with perfect ease, and can be partially 
 dislocated and reduced, the ligaments being very 
 lax ; the bony points around the joint can 
 be very easily felt. The biceps and coraco- 
 brachialis are also very much wasted. The 
 muscles of the forearm and of the thumb and 
 fingers are fairly developed, and of their natural 
 size. 
 
MUSCULAR HYPERTROPHY. 251 
 
 Measurements of upper extremities — 
 
 From acromion to outer condyle . = 8 J in. 
 
 Circumference at middle of arm . = 6 in. 
 
 Length of ulna . , . . = 7 J in. 
 Circumference of forearm just below 
 
 condyles . . . . , = 6f in. 
 
 TruTik. — As before said, the lumbo-sacral 
 curve is greatly exaggerated. The erector 
 spinse is immensely hypertrophied, and can be 
 felt as a thick, hard mass on each side of the 
 spine. The spinous processes of the vertebrae 
 lie in a groove between these masses of muscle. 
 In the space between the crest of the ilium 
 and the last rib the thick hard edge of the 
 erector spinse can be felt distinctly. The belly 
 is big, but the muscles forming its wall do not 
 appear to be either wasted or hypertrophied. 
 The cremasters act readily. The chest is 
 broad and deep, and the costal angle exceed- 
 ingly obtuse ; its conical shape can be very 
 distinctly seen, owing to the wasting of the 
 pectorals. The serratus magnus is large, and 
 its serrations can be seen with great clearness 
 through the skin ; it is not hard, like the 
 erector spinse, but appears to act naturally. 
 
252 PARALYSIS WITH APPARENT 
 
 The action of the diaphragm in respiration 
 was carefully watched, and found to be the 
 same as in a healthy person. The intercostals 
 appear to act fairly. 
 
 Measurements of chest — 
 
 From acromion to acromion . = 10 in. 
 Circumference just below axilla : 
 
 On expiration . . . = 24 in. 
 On inspiration . . . = 25 J in. 
 Circumference on a level with 
 ensif orm cartilage : 
 
 On expiration . . . = 26 in. 
 On inspiration . . . = 274 i^* 
 
 Head and neck. — The sterno-mastoid is 
 rather wasted. The depressors of the oS 
 hyoides are capable of fairly vigorous action. 
 It is doubtful whether there is anything 
 abnormal with the trapezius, and the other 
 muscles of that group ; if anything they are 
 hypertrophied. His temporal muscles are un- 
 doubtedly hypertrophied, and, seen from the 
 front, form a small tumour outside each orbit. 
 His masseters seem somewhat increased in size, 
 but this is difficult to ascertain. The facial 
 
MUSOULAE HYPERTROPHT. 253 
 
 muscles of expression appear sluggisli in 
 their action. His orbiculares are wasted. ; lie 
 can shut his eyes, but cannot screw them up 
 tightly. He cannot frown, and can elevate 
 his eyebrows but little. The muscles acting 
 on the mouth do not seem defective at first 
 sight, but on making him go through various 
 grimaces, it is seen that he has not the com- 
 mand over the upper 'lip that he has over the 
 lower; this, perhaps, is from misapprehension 
 of directions. He puts out his tongue in a 
 peculiar way, it always being concave, and 
 he does not protrude it beyond his lips unless 
 told to put it out further, when he makes an 
 effort J but it is never convex from side to 
 side. No affection of any ocular muscle. 
 
 General appearance, Sfc. — He is a dull, heavy- 
 looking boy, with a stolid, but somewhat 
 cunning expression of countenance. His face 
 is very fat, especially about the lower part ; 
 complexion sallow and pasty ; skin thick, 
 superficial veins cannot be distinctly seen 
 through it. His head is very large (circum- 
 ference where the hat fits twenty-one inches) ; 
 its shape is broad rather than long. Hair 
 thick, brown, and straight. Forehead rather 
 
254 PARALYSIS WITH APPAEENT 
 
 high. Eyes brown, pupils large, eyelashes 
 long, eyebrows thick at outer part, thick 
 towards the median line. Nose flat and broad, 
 especially broad at the bridge ; alse nasi thin, 
 nasal aperture large. Ears small, but well 
 shaped, lobules not ill developed. Lips thick, 
 upper lip thicker than lower, angles of mouth 
 somewhat inclined downwards. Thyroid gland 
 enlarged but not greatly. Yoice natural, clear, 
 low-pitched. Bones of extremities well shaped ; 
 epiphyses not unduly large. 
 
 Mental condition. — He is stupid or dull, but 
 rather cunning. He is generally good tem- 
 pered, but is often passionate, and at times 
 very sulky ; he appears to possess a strong 
 will (he has probably been spoilt at home). 
 He is not timid or bashful in any way. He 
 smiles when spoken to, answers questions 
 readily, and he takes any experiments tried 
 upon him in very good part. He cannot read, 
 but knows his letters. He has an appreciation 
 of music, and amuses the other patients by his 
 singing, whistling, &c. 
 
 Nervous system. — He sleeps well. Has no 
 fits or cramps of any kind. Sight good, 
 ophthalmoscopic appearance normal. Hear- 
 
MUSCULAR HTPEETEOPHY. 255 
 
 ing, taste, and smell good. Sensation, both 
 painful, tactile, and thermic, appears to be very 
 good all over the body. It cannot be estimated 
 with the compasses, because the boy, whether 
 from laziness or any other motive, does not 
 (or perhaps cannot) give consistent answers. 
 The atrophied muscles do not respond at all to 
 electricity. The gastrocnemii and hamstring 
 muscles contract under it. The other hyper- 
 trophied muscles were not tested with it. 
 
 Digestion and appetite good. Bowels regular. 
 
 Urine. — Sp. gr. generally rather high ; acid ; 
 no albumen, no sugar. 
 
 Respirations f 18 per minute, taken minutely ; 
 no cough or dyspnoea. 
 
 Heart. — Cardiac dulness. reaches above to 
 third rib ; on the right to an inch beyond the 
 sternum ; on the left to within half an inch of 
 nipple; apex beat under fifth rib, one inch to 
 right of nipple, 88 per minute. Impulse nor- 
 mal. Sounds sharp and clearly defined, some- 
 what exaggerated. J^o murmur or thrill of 
 any kind. 
 
 Temperature, taken at different times, always 
 normal. 
 
 Remarks. — This case, for the very careful 
 
256 PAEALTSIS, ETC. 
 
 notes of wHcli I am indebted to my clinical 
 clerk, Mr. Herman, is a very typical example 
 of the disease so well described by Dr. Du- 
 cbenne in the ' Transactions ' of this Society. 
 By the aid of the harpoon I extracted speci- 
 mens of the muscle from both gastrocnemii. 
 When examined by the microscope, it was 
 noticed that the transverse striation of the 
 muscular fibre was very indistinct, that there 
 was a, great increase of connective-tissue ele- 
 ments, and that there were numerous fat- 
 globules, but they were distinctly external to 
 the sarcolemma. There was no fatty degene- 
 ration of the muscular structure. 
 
 The treatment has been dietetical with the 
 daily use of the faradic current. No im- 
 provement, however, has resulted. I think the 
 best name for such cases is pseudo-hypertrophic 
 paralysis. 
 
A CASE 
 
 PSEUDO-HYPERTROPHIC PARALYSIS. 
 
 ' Path. Soc. Trans.,' vol. xxi, 1870. 
 
 Samuel Richardson, aged eleven, admitted 
 into the London Hospital 22nd February, 1870. 
 There is no family history of insanity, nor any 
 mental affection. The father appears a man 
 of average intelhgence ; the mother is certainly 
 below the average. She appears a woman of 
 a desponding, irresolute disposition, and of 
 very slow perception; I should think her in- 
 clined to melancholia. She is thirty-seven, 
 and has had six children ; this one is the 
 eldest. It was born at full time, after a 
 tedious labour, lasting two days and a half, 
 and was delivered with instruments. She has 
 had one miscarriage, and one child, her fourth, 
 died aged one year and a half, from " fits," 
 
 17 
 
258 PSEUDO-HYPERTROPHIO PAEALTSIS. 
 
 whicli it had had from a month old : at the 
 time it died it had not cut any of its teeth. 
 All the rest are living. She states that while 
 pregnant with this child she was in very deli- 
 cate health, but she is unable to describe any 
 definite ailment. She has always had plenty 
 of food. The father is a mason, aged thirty- 
 three; has always had good health. During 
 the first two or three years of his marriage he 
 used to be very frequently intoxicated. This 
 child was two years old before he had any teeth, 
 or before he could walk, and he was always very 
 fretful. The mother says that while he was 
 teething, and afterwards, he used to suffer from 
 attacks of " inflammation," but I cannot make 
 out what she means by this. She does not 
 think that in intellectual capacity he is behind 
 the other children. Five years ago he had 
 rheumatic fever; was in bed six months, all 
 his joints being affected. Previous to that was 
 quite well. Since then has suffered at times 
 with rheumatic pains in different joints, and 
 has been weak and delicate. About twelve 
 months ago his parents first noticed that when 
 he walked he used to " bend his back in ;" his 
 stomach sticking out in front and his buttocks 
 
PSEUDO-HTPEETROPfllO PARALYSIS. 259 
 
 behind. About nine months ago it was first 
 observed that when running, his legs would 
 give way, and he would fall with his legs under 
 him. About eight months ago he began to 
 complain of his back hurting him. About this 
 time, his mother says, he began to lose strength 
 in his arms. His walking has since gradually 
 got worse; he began to be unable to run 
 before he was unable to walk. His falls be- 
 came more and more frequent; at last he would 
 fall down about every five or six yards. For 
 the past two months he has been unable to 
 walk without assistance, and for the past fort- 
 night has been unable to walk at all. For 
 some time past, his mother says, he has been 
 losing flesh. She says he has lost flesh in his 
 calves and buttocks as well as in other places. 
 
 He is rather small for his age. His height 
 is 3 ft. lOJ in. His aspect is that of a dull, 
 backward child. He has a vacant, apathetic, 
 timid expression of face. Complexion fair, 
 cheeks fresh-coloured ; hair brown, thick, 
 straight, and fine ; eyelashes long and fine ; 
 eyebrows thin, a wide interval between them 
 in the middle line. Pupils large, irides 
 dark, sclerotics of a bluish tint; eyeballs 
 
260 PSEUDO-HyPEETROPHIO PARALYSIS. 
 
 prominent. Nose broad, especially at tlie 
 bridge, al93 nasi tliick; nasal apertures large. 
 Forehead high, round, protuberant; face fat, 
 especially at lower part ; lips tlaick, upper lip 
 the thicker, and is broad and long. Bones 
 well shaped ; epiphyses not unduly large. 
 Finger ends square. Costal angle acute. 
 Palatal arch contracted; teeth crowded and 
 irregular; skin thick, superficial veins can be 
 seen, but not distinctly. Ears of moderate 
 size, lobules small. Circumference of head 
 where hat fits, 20J inch.es. 
 
 He cannot stand by Mm self. When told to 
 try and. stand by himself, he bends forward, 
 and stands on tiptoe, but he cannot succeed. 
 If he be held up by the arms there is a 
 tendency to bend his body at the hips. If he 
 be made to put his heels to the ground the 
 tendency is greater. If left unsupported, his 
 body bends forward at the hips, and he falls 
 witb his legs under him ; but he can stand if 
 support be given by the hand pressing his 
 buttocks forward, though he does so in a 
 tottering way. He can sit up without assist- 
 ance, but he likes to have one hand behind him 
 as a kind of prop. If he be laid down on his 
 
PSEDDO-HYPERTROPHIO PARALYSIS. 261 
 
 back, he cannot get up by himself without 
 great exertion ; he accomphshes it by turning 
 on his side, and by pulling at the clothes 
 brings his body to the proper angle with his 
 legs, he then clutches at the bedclothes and 
 pulls himself up by them. 
 
 His body is wasted, but not markedly so.. 
 The lumbo-sacral curve is slightly exaggerated ; 
 the gluteeal region is larger and more rounded 
 than is consistent with his wasted condition, 
 and it is very hard. The erector spinas is 
 about as large as it should be for a boy 
 of his age, but is much harder and firmer 
 than it ought to be. The abdomen is large. 
 It is difficult to estimate the size of the abdo- 
 minal muscles, but they are capable of fairly 
 vigorous action; (measurement around pelvis 
 over most prominent part of glutsei, twenty- 
 two inches ; from one iliac spine to the 
 other, eight inches). He moves his legs 
 about badly, and without much power. If 
 asked to cross his legs, he takes hold of one 
 with his hands and lifts it over the other. 
 He can perform this movement without the 
 aid of his hands, but does so slowly, and 
 with apparent exertion. As he lies on the 
 
262 PSKUDO-HYPEBTROPfllO PAEALYSIS. 
 
 bed, if told to draw up his legs, he does this 
 with more force than he can any other move- 
 ment. On sitting him on the edge of the bed 
 he can raise his feet to a right angle with his 
 body, i. e. extend his knees ; but a 1 lb. weight 
 attached to his great toe is suflScient to prevent 
 him. On placing him on his face, he can flex 
 his leg on the thigh, but a 2 lb. weight attached 
 to his great toe prevents him. He can move 
 his feet laterally at the ankle-joint, and does 
 this pretty well. He can extend and flex his 
 foot a little at the ankle, but he does not do 
 this nearly so well as he should. He can 
 move his toes but slightly. 
 
 On examining the muscles, the tensor vaginse 
 femoris is felt enlarged and very hard. The 
 sartorius he can put in action, and it does not 
 seem wasted. The quadriceps extensor seems 
 harder than it should be, but this is diflficult to 
 estimate, as is the size of the muscle. The 
 flexor muscles of the thigh are larger than 
 ordinary. The adductors are small, but con- 
 tract well when he puts them in action. The 
 gastrocnemii are large and very hard ; the 
 extensor muscles and the peronei are also hard, 
 and are certainly not wasted. The foot is in 
 
PSEUDO-HrPERTROPHIO PARALYSIS. 263 
 
 a state of talipes equino -varus : the tendo 
 AcMUis is very tense. The extensor brevis 
 appears wasted, but it is difficult to tell. 
 {Measurements. — From trochanter major to 
 external condyle, lOf inches ; from anterior 
 superior spine of ilium to external condyle 
 12 J in. : circumference at middle of thigh, 
 9^ in. ; length of tibia, from inner tuberosity 
 to inner malleolus, lOJ in. ; circumference at 
 thickest part of calf, 8f in. ; just above ankle, 
 H in.) 
 
 His chest is long and narrow ; costal angle 
 very acute. Breathing mostly abdominal. 
 When told to take a deep breath, he does so 
 with his diaphragm; the chest moves but 
 slightly, and the intercostal spaces sink in. 
 The serratus magnus can be felt, and appears 
 about normal. 
 
 He can move his hands and arms in any 
 direction, but has not much strength in them. 
 He can take a 2 lb. weight and elevate it above 
 his head, but no heavier weight. A boy aged 
 nine, in the same ward, suffering from pul- 
 monary disease, can lift 6 lb. ; on resisting the 
 action of the triceps with a 2 lb. weight, he can 
 just extend his arm. As to the biceps, he 
 
264 PSEUDO-HYPERTROPHIO PARALYSIS. 
 
 cannot flex his arm against 2 lb., but he can 
 against 1 lb. He can move his fingers readily, 
 but has not much strength in them. 
 
 On examination of the muscles, the pectorals, 
 biceps, and coraco-brachialis are most markedly 
 wasted. The deltoid is hypertrophied, also 
 the triceps, in a very noticeable manner. The 
 latissimus dorsi is wasted, also the sterno- 
 mastoid, very decidedly. The scapular muscles 
 are hypertrophied, as is the trapezius. The 
 muscles of the forearm and hand seem neither 
 hypertrophied nor wasted. {Measurements.— 
 Circumference of thorax : just below axillge, 
 on inspiration, 20J inches, on expiration, 
 20J in. ; at level of ensiform cartilage, on 
 inspiration, 23 J in., on expiration, 22^ in. ; 
 from acromion to acromion, 10 in. ; from 
 acromion to outer condyle, 8^ in. ; circumfer- 
 ence at middle of upper arm, right, 5f in. ; 
 left 6|- in. ; length of ulna, 7 j in. ; circumfer- 
 ence of thickest part of forearm, 6 in. ; circum- 
 ference of neck, 10 J in.) 
 
 His facial muscles of expression appear slug- 
 gish in their action. He can screw his eyes 
 up firmly, and can elevate his eyebrows ; but I 
 cannot get him to frown ; whether he can or 
 
PSEDDO-HTPERTEOPHIC PARALYSIS. 265 
 
 cannot I do not know. He seems to have but 
 little power over his lips. His face seems re- 
 markably devoid of expression ; on trying to 
 make him grimace, he either will not or cannot 
 contort his face as told. When he laughs he 
 does so in a feeble sort of way ; I cannot make 
 him laugh aloud, or put on a broad grin, but 
 the other patients say that he does. His tem- 
 porals and masseters seem normal. His thy- 
 roid gland does not seem enlarged. He puts 
 his tongue out in a feeble manner; he puts it 
 out slowly, and a very little distance, but he 
 can put it out far if he likes. 
 
 Mentally he is certainly below the average 
 of a boy of his age. He is very slow in his 
 answers ; seems afraid of everyone, and often 
 cries. The men in the ward remark that the 
 other boy (Round), although more paralysed, 
 is " the best man of the two." He knows his 
 letters, but cannot read. He can do very 
 simple sums in arithmetic, such as that two 
 and two make four, but three and four he says 
 make eight. He is cunning, although stupid. 
 
 He sleeps well. Has no fits or cramps of 
 any kinds. No paralysis of any ocular muscle. 
 Fundus oculi normal. Hearing, taste, and 
 
266 PSEUDO-HYPERTROPHIO PARALYSIS. 
 
 smell good. Sensation of every kind, painful, 
 tactile, thermic, and electric, seems unim- 
 paired : he does not answer properly, so that 
 it is impossible to estimate it for purposes of 
 comparison. Induced electricity applied to 
 muscles does not produce contraction. 
 
 Appetite and digestion good, bowels regular. 
 . Urine. — Sp. gr. about 1020 ; acid, no depo- 
 sit, no albumen, no sugar. 
 
 Pulse 96. Cardiac dulness extends above to 
 third rib; on the right, to right margin of 
 sternum; on the left, to half an inch beyond 
 the nipple ; below, to the sixth rib. Apex-beat 
 under fifth rib, half an inch to the right of the 
 nipple. The impulse is increased, but is not 
 heaving, nor is there a thrill. The first sound 
 is doubled, but there is no decided murmur. 
 
 Respirations 20 per minute. No cough, no 
 dyspnoea. Temperature normal. 
 
 Bemarhs. — This case presents a very good 
 example of pseudo-hypertrophic paralysis in an 
 earlier condition than that of " Eound," pre- 
 viously reported. I am again indebted to my 
 clinical clerk, Mr. Herman, for the very care- 
 ful notes of the case. I did not extract any 
 specimens of muscle, in consequence of rather 
 
PSEUDO-HYPEETEOPHIO PAEALYSIS. 267 
 
 troublesome wounds having been produced in 
 tbe previous case. 
 
 It is worthy of being noted that this is the 
 seventh case of pseudo -hypertrophic paralysis 
 which has come under my observation, and 
 that in each case there has existed more or less 
 mental feebleness. 
 
 The treatment has been dietetical, with the 
 daily employment of faradisation. No per- 
 ceptible improvement of any kind has been 
 observed. 
 
268 EELATION OP THE TEETH AND 
 
 ON THE RELATION 
 
 TEETH AND MOUTH TO MENTAL 
 DEVELOPMENT. 
 
 ' Trana. Odontological Soc.,' vol. iv, 1871-2. 
 
 Gentlemen, — When your President did me 
 the honour of requesting me to read a paper 
 before your Society, I felt at first some reluct- 
 ance, from the consciousness that one of a very 
 practical character was not within the scope of 
 my power. 
 
 It occurred to me, however, that there was a 
 branch of inquiry in which I felt considerable 
 interest, and which had some slight bearing on 
 the department of medical science represented 
 by this Society. I thought, moreover, that I 
 should derive great gain myself in bringing my 
 observations before you, from the fact that 
 
MOUTH TO MENTAL DEVELOPMENT. 269 
 
 while some of my work has been with a some- 
 what special class of humanity, you would be 
 able to correct or confirm my views from obser- 
 vations over a wider and more varied field. It 
 is thus, by the comparison of results obtained 
 from opposite standpoints that broad princi- 
 ples may be elicited, where otherwise narrow, 
 and possibly mistaken, views might be enter- 
 tained. 
 
 At an early period of my study of the mental 
 affections of childhood and youth, I became 
 convinced that the question involved a far 
 larger region of inquiry than the mere psycho- 
 logical phenomena which were presented before 
 me, — that, interesting as were the examples of 
 mental deviations which were the every-day 
 object of one's contemplation, they were really 
 only a part of the great subject ; and one be- 
 came convinced, from observation, that the 
 physical deviations were as interesting and 
 important as the psychical, in relation to the 
 study of mental alienation, and especially to 
 that form of it which had a congenital origin 
 or proclivity. It became clear to me that idiocy 
 and imbecility were not simply disturbances of 
 brain-power, — were not simply nerve-lesions in 
 
270 EELATION OP THE TEETH AND 
 
 the narrowed acceptation of the term, — but 
 were profound diseases involving almost every 
 organ and system of organs in the body. True, 
 the encephalic ganglia were found altered, 
 either in quality or quantity, or both ; the con- 
 volutions of the brain might be reduced to 
 quadrumanous simplicity in one case, or pre- 
 sent remarkable symmetricality in another; 
 but these were conditions that could only be 
 ascertained on post-mortem inspection. The 
 question that presented itself to me was, — 
 Were there any outward and visible signs of 
 inward mental disturbance? If idiocy were 
 something more than brain alteration, it followed 
 that an inquiry into the condition of the other 
 organs might establish some correlative change 
 in them. With this object in view, I made a 
 careful investigation into the bodily condition 
 of nearly a thousand feeble-minded youths — 
 their height, weight, and bodily conformation ; 
 into the condition of their muscular develop- 
 ment, the state of their eyes, the shape of their 
 ears ; and last, but not least, into the structure 
 of their mouths and the contents of the oral 
 cavity. It was in my inquiry into the condi- 
 tion of the teeth and mouth especially that I 
 
MOUTH TO MENTAL DEVELOPMENT. 271 
 
 arrived at the conclusion that, in by far the 
 larger number of instances, I was able to indi- 
 cate the period at which the depressed condi- 
 tion commenced and to predicate in some degree 
 the amount of improvement which physical, 
 intellectual, and moral training might possibly 
 effect. 
 
 Thus an examination of the mouth afforded 
 me a valuable guide both as to diagnosis and 
 prognosis in cases which, without such guide, 
 would be surrounded with insurmountable 
 difficulty. 
 
 In consultations one is often pressed by the 
 friends of the patient for an opinion as to the 
 date at which the affection commenced. It is 
 always a relief if an opinion can be given that 
 the child was born intelligent ; that the calamity 
 is the result of some after-birth catastrophe. 
 Curiously enough, there is often a degree of 
 wounded pride if it is decided that the child was 
 defective from birth. It is by an appeal to the 
 physical conformation only that the decision can 
 be justly made. In children whose idiocy is 
 accidental, arising from causes operating after 
 uterine life, there is but slight deviation from 
 normal condition in the state of the mouth and 
 
272 RELATION OF THE TEETH AND 
 
 teeth while it is in those whose malady is con- 
 genital, especially where arising from causes 
 operating at a very early period of embryonic 
 life, that the deviation of the mouth and its 
 appendages from the normal condition is most 
 pronounced. 
 
 It often happens to me to see children, about 
 whom the only anxiety is that they do not speak. 
 The parents seek for an explanation in the con- 
 dition of the palate, little suspecting that the 
 palatal deformity is only one of the manifesta- 
 tions of a congenital mental defect, in which 
 ideas are so little formulated that language is 
 not needed. 
 
 I could occupy a large portion of the time 
 of this meeting in illustrating the value of an 
 appeal to the condition of the mouth as an aid 
 to diagnosis in such cases ; a few cases must 
 suffice. 
 
 A year or two since a very intelligent medical 
 practitioner in the country was called in to treat 
 a case of infantile convulsions. The condition 
 of the child was desperate. He poured from an 
 ewer a stream of cold water over the occiput of 
 the child; the convulsions ceased, the patient 
 was rescued from impending death, but grew up 
 
MOUTH TO MENTAL DBVELOl'MENT. 273 
 
 to be an idiot. The friends of the child took up 
 a position which involved a trial in a court of 
 law, equivalent to an action for malpraxis 
 against the medical man. By a judge's order, 
 I, with other medical men, saw the child ; and 
 we were ahle to say not only that the child 
 was an idiot then, but, by an examination of 
 the mouth, to assert that the idiocy was em- 
 bryonic as to date, that the convulsion was an 
 epiphenomenon, and that the medical man was 
 in no way responsible for the mental condition 
 of the child whose life he had rescued. Thus, 
 by an appeal to physical conformation, we were 
 able to date the mental defect, and to save the 
 reputation of a medical brother from undeserved 
 opprobrium. 
 
 It will be within your remembrance that this 
 town was some years since greatly moved by a 
 sensational trial before a Master in Lunacy, in 
 which an attempt was made to save from himself 
 a youth with an honoured name. " Liberty of the 
 Subject " was the popular cry, and after conflict- 
 ing evidence, the popular will prevailed, and the 
 free agent went rapidly to his doom. The 
 counsel for the defence, in specious terms sug- 
 gested that the mistake about this young man's 
 
 ]8 
 
274 DELATION OP THE TEETH AND 
 
 imbecility arose f roiQ a defect in his mouth, from 
 which imperfect speech resulted. I showed at 
 that time — too late, however, to influence the 
 verdict — that that was the most important 
 admission that could be made, — that, given any 
 amount of mental obliquity, no stronger con- 
 firmatory proof could have been adduced of his 
 imbecility than the physical defects of mouth 
 to which this lisping speech was due. The 
 sequel proved the true nature of the case. 
 
 No less valuable, however, is a study of the 
 condition of the mouth as a means of prognosis 
 in any given case. In children who exhibit any 
 want of mental power, or present anomalous 
 moral or intellectual symptoms, no more anxious 
 question is suggested than that relating to 
 their probable future. The disposition of pro- 
 perty, and other family arrangements, depend a 
 good deal on the answer which is given. We 
 have learned by experience this important fact, 
 that the child who has been born with defective 
 intellect is more susceptible of improvement 
 by physical and intellectual training than the 
 child who has been born with full possession 
 of his brain-power, and has afterwards lost it. 
 It follows, that of two children who are the 
 
MOUTH TO MENTAL DEVELOPMENT. 275 
 
 subjects of solicitude, other things being equal, 
 there is greater probability of improvement 
 for the patient with an ill-developed, than 
 the one with a damaged brain. Often it hap- 
 pens that a microcephalic idiot, about whom 
 the inexperienced would entertain no sort of 
 hope, will far outshine, under intellectual train- 
 ing, the fine, well-developed boy the mem- 
 branes of whose brain have been the subject 
 of inflammatory lesion, and about whose capil- 
 laries lymph has been inextricably effused. An 
 appeal to the condition of the mouth is an 
 important aid in determining whether the 
 lesion on which the mental weakness depends is 
 of intra-uterine or of post-uterine origin. In the 
 event of the mouth being abnormal, it indicates 
 a congenital origin ; while if the mouth be well 
 formed, and the teeth in a healthy condition, 
 it would lead to the opinion that the calamity 
 had occurred subsequently to embryonic life. 
 
 Of course, our judgment would be formed 
 after a physical examination of every organ — 
 of the condition of the ears and eyes — of the 
 shape of the cranium; but what I want to 
 enforce is, that most important information is 
 derived from an examination of the mouth. 
 
276 RELATION OP THE TEETH AND 
 
 I have had this day brought to me a young 
 girl of manifestly defective power, and the 
 parents were extremely anxious to know 
 whether it was a congenital case. Their anxiety 
 was based partly on an unwillingness for 
 either branch of the family to allow that 
 there was on their side any hereditary tendency 
 to mental disease — a sort of rivalry as to the 
 purity of the two antecedent sources ; but 
 mainly also to ascertain with what degree of 
 fear they must watch the development of their 
 other children, and how it might affect the 
 education of their sons, or the marriage pros- 
 pects of their daughters. JSTo study of the 
 mental phenomena themselves would have en- 
 abled me to venture an opinion ; but an exami- 
 nation into the totality of the physical confor- 
 mation in general, and of the mouth in particular, 
 enabled me to refer the calamity, with a con- 
 siderable degree of certainty, to an accidental 
 cause, probably a sunstroke in the tropics ; to 
 clear the other members of the family from the 
 suspicion of insane proclivity, and to defend the 
 purity of the rival stocks. 
 
 Let us now consider what are the conditions 
 of the mouth associated with mental defect. 
 
MOUTH TO MENTAL DEVELOPMENT. 277 
 
 The lips are usually thick, the thickness being 
 greatly more marked in the lower than in the 
 upper one. In addition to the thickening, they 
 are often striated, marked by transverse fissures; 
 this character is more generally seen in a class 
 of congenital idiots, which I have elsewhere 
 described as Mongolian idiots, from their resem- 
 blance in physical character to the Mongolian 
 race. Often the lips are deficient in muscular 
 power, which interferes with their prehensile 
 function, and which also induces a tendency for 
 the saliva to run over the chin. The mucous 
 membrane is extremely liable to chronic inflam- 
 mation, and ulceration is induced by the slightest 
 pressure against prominent or uneven teeth. 
 The glands of the mucous membrane of the 
 mouth generally, as well as the salivary glands, 
 are usually hypertrophied ; and this is another 
 factor in the production of stammering. 
 
 There is a marked postponement in the evolu- 
 tion of the first teeth. Looking over my notes 
 of a very large number of cases, I find that the 
 first dentition is almost invariably postponed. 
 The ease with which dentition is effected varies ; 
 sometimes the teeth are cut so easily that no 
 disturbance of the general health is observed ; 
 
278 RELATION OF THE TEETH AND 
 
 in others it is tlie period at wliich. violent 
 convulsive attacks are developed, imperilling 
 greatly tlie feeble mental endowment of the 
 child. Contrary to the law that tissues which 
 are slowly formed are the most persistent, 
 these primary teeth have a more temporary 
 existence than usual. They are frequently 
 dark, speedily become carious, and their stunted 
 growth often aggravated by the incessant 
 grinding of the teeth, which is so frequent 
 during the infantile life of such children. I have 
 been curious to ascertain the cause of this 
 grinding. In most cases it appears to be a 
 kind of automatic movement, not depending on 
 the direct influence of the will ; one of those 
 rhythmic movements of which there are several 
 amongst children of this class. In others it 
 would appear to be purposely developed to 
 produce a monotonous sound, which imparts 
 pleasure to the feeble-minded. Not only, how- 
 ever, are the primary teeth ill developed ; they 
 are often irregularly developed as to sequence. 
 Nothing but disorder is noticed in their succes- 
 sion. 
 
 Just as the evolution of the temporary teeth is 
 accompanied by cataclysmic effects, like pheno- 
 
MOUTH TO MENTAL DEVELOPMENT. 279 
 
 mena not unfrequently accompany the evolution 
 of the permanent teeth. The epileptiform con- 
 vulsions which accompany the first, not nnfre- 
 quently after a long interlude, reappear at the 
 cutting of the second, to be followed by another 
 interlude, and a recurrence at puberty. I have 
 now under my observation a boy whose first 
 teething was marked by paroxysmal phenomena 
 of the most violent kind, which ceased when the 
 physiological effort was over. He has now 
 arrived at the period of second dentition, and 
 the evolution of every tooth is accompanied by 
 well-marked epileptic attacks and by a corre- 
 sponding decadence in his stunted mental 
 development. 
 
 The evolution of the second teeth is also fre- 
 quently postponed, and there is slight irregu- 
 larity in the sequence of their development. A 
 marked character of the teeth is their irregu- 
 larity as to position. They are often crowded — 
 so crowded as to present their sides instead of 
 their anterior surfaces. They are often arranged 
 on different planes. The canine teeth are fre- 
 quently unduly prominent, and a marked sulcus 
 is sometimes seen between the incisors and 
 canines, with prominence of the incisors. The 
 
280 RELATION OF THi<] TEETH AND 
 
 teeth themselves . present very frequently a 
 honeycombed appearance, from an absence of 
 continuity in the enamel, and they undergo 
 speedy decay. Nothing is more marked than 
 the temporary nature of the so-called perma- 
 nent teeth. 
 
 It has been a matter of considerable interest 
 to me to ascertain how frequently the syphilitic 
 teeth, so well described by my friend and col- 
 league Mr. Hutchinson, were to be met with 
 among the feeble-minded; but the result of 
 my inquiry has been to discover very few 
 among them who were in this way indicated 
 to be the subjects of congenital syphilis. Yery 
 few have had syphilitic teeth ; but where I did 
 discover them, I always had confirmatory evi- 
 dence of the syphilitic history of the case, 
 and the condition of the teeth was always 
 associated with the chronic inflammation of 
 the cornea to which Mr. Hutchinson has called 
 attention. I have therefore been led to the 
 conclusion that syphilis is not by any means 
 an important factor in the production of con- 
 genital mental disease. The honeycombed teeth 
 are, I am persuaded, perfectly distinct from the 
 syphilitic, and are manifestations of that grave 
 
MOUTH TO MENTAL DEVELOPMENT. 281 
 
 perversion of nutrition which implicates, in 
 these cases, every tissue in the body. 
 
 The tongue presents peculiarities worthy of 
 notice. It is frequently unusually large. Its 
 inordinate size generally arises from increase in 
 length, and also from an absence of muscular 
 tonicity. The surface is often curiously corru- 
 gated, presenting numerous fissures. The sur- 
 face is rendered still more rough from hyper- 
 trophy of the papillse. Not only is the tongue 
 inconveniently large, it is but feebly under the 
 influence of the will. There is a want of co-ordi- 
 nation in its muscles ; so that not only is the 
 more intelligential act of speaking performed 
 awkwardly even when there are ideas to be 
 communicated, but the simple voluntary act of 
 conveying the food to the posterior part of the 
 mouth, where the reflex act of deglutition is 
 excited, is eff"ected with difiQculty, and thus an 
 almost instinctive act is rendered to some extent 
 abortive. 
 
 Of most significant value, however, is the con- 
 dition of the palate. I have made a very large 
 number of careful measurements of the mouths 
 of the congenitally feeble-minded and of intelli- 
 gent persons of the same age, with the result of 
 
282 EELATION OF THE TEETH AND 
 
 iDclicating, with some few exceptions, a mark- 
 edly-diminislied width between the posterior 
 bicuspids of the two sides. The exceptions 
 were some few cases of macrocephahc idiots, 
 who had inordinately large crania, depending 
 in some cases on hypertrophy of the brain, or 
 more frequently on chronic hydrocephalus. In 
 these exceptional cases the palates were as 
 widely in excess, as in others they are less than 
 the normal width. One result, or rather one 
 accompaniment, of this narrowing is the in- 
 ordinate vaulting of the palate, which assumes 
 a roof-like form. The vaulting is not simply 
 apparent from the approximation of the teeth 
 of the two sides, it is absolute — the line of junc- 
 tion between the palatal bones occupying a 
 higher plane. Often there is an antero-poste- 
 rior sulcus corresponding to the line of approxi- 
 mation of the two bones. 
 
 There is very frequently a deficiency in the 
 posterior part of the hard palate, from a want 
 of development of the palatal process of the 
 maxillary bone, as well as absence of the palatal 
 process of the palate bone. As a result of this 
 defect, the false palate hangs down abnormally, 
 and interferes with clear phonation. At an 
 
MOUTH TO MENTAL DEVELOPMENT. 283 
 
 early period of my investigations I was prepared 
 to find a large number of cases of cleft palate. 
 This does not appear, however, to be a frequent 
 defect — not more, according to my statistics, 
 than 5 in 1000 cases. Bisection of the uvula 
 occurred 4 times in 1000, and absence of the 
 uvula twice. The cause of the frequent exces- 
 sive vaulting of the palate is not quite clear; 
 it may possibly arise, as has been suggested, 
 from arrest of development of the sphenoid 
 bone, or defective growth of the bone. It has 
 been attributed by one writer to a cause which 
 I think cannot be allowed, viz. sucking the 
 thumb. This gentleman attributes idiocy 
 entirely, or almost entirely, to " fruitless suck- 
 ing." The chain of events, according to his 
 theory, is this : — The fruitless sucking gives 
 rise to secretion of gastric juice in the stomach 
 when it has no physiological use, — that this 
 acts as an irritant on the intestinal mucous 
 membrane, giving rise to diarrhoea and dis- 
 turbed nutrition, eventuating in convulsions and 
 idiocy; and that the roofed palate I have 
 described is the physical result of the pressure 
 of the child's thumb against the palate. Banish 
 fruitless sucking, he says, and idiocy would be 
 
284 EELATION OF THE TEETH AND 
 
 unknown. I believe this to be a tborougbly 
 mistaken notion. Idiots are not much more 
 prone to fruitless sucking than other children, 
 and I have examined the palates of several fruit- 
 less suckers among the sane without finding the 
 palatal defects I have described. I think it will 
 require no argument to prove that the defects 
 I have referred to are developmental defects, and 
 that they betoken a cause long anterior to the 
 time when sucking the thumb is practised, unless 
 that habit be an intra-uterine one. The theory 
 overlooks the whole bearing of hereditary influ- 
 ence, and of nervous shocks and physical illness 
 to the pregnant woman, as potent causes of 
 imbecility in the offspring, and negatives the 
 idea of the congenital nature of the ailment. 
 
 There is one practical point with reference 
 to the palatal defect which has some interest to 
 me. One of the greatest difliculties we have, 
 but one which, when overcome, brings the 
 greatest kudos, is the teaching an idiot or imbe- 
 cile to speak. We have to furnish him with a 
 vocabulary, to practise him in tongue gymnas- 
 tics, to build up for him a language, and to 
 lessen the mutiny of the muscles of his tongue. 
 When all this is in part accomplished, the 
 
MOUTH TO MENTAL DEVELOPMENT. 285 
 
 arcTied roof of the palate is a great trouble. 
 Imperfect speech still remains. Can nothing 
 be done mechanically in this direction ? Can 
 the members of this Society tell us of any 
 success they have had by diminishing the palatal 
 cavity among the sane that may augur hope for 
 us with the insane ? Often cases are met with 
 where the palatal difficulty is just the hindrance 
 to an improved imbecile mixing with the world, 
 and taking his place with his fellows. 
 
 Among idiobs and imbeciles there is often 
 discovered a want of symmetry in the cranium. 
 The plan which I adopt of taking the shape 
 with a strip of lead shows this defect admirably, 
 and enables me to sketch the precise deformity 
 on paper. This want of symmetry also affects 
 the bones of the jaw, leading to a great differ- 
 ence between the two halves of the maxillary 
 bones. A very marked example of this kind 
 was seen with me a short time since by my 
 friend Mr. Ramsay, who advised the removal 
 of some teeth to make room for the movements 
 of the tongue. It was an excellent example 
 also of the obtuseness to pain which is common 
 among the feeble-minded. Often they are 
 anxious to have their teeth extracted, as if it 
 
286 EELATION OF THE TEETH AND 
 
 were a personal favour ; tliey are flattered by 
 the attention, — rarely do they care for the pain 
 which is inflicted, — chloroform is for them a 
 superfluity. 
 
 A want of symmetry is occasionally noticed 
 in the palate when there is no very marked 
 absence of symmetry elsewhere. 
 
 I might also mention anomalies of the tonsils 
 and of the fauces, but these would have but little 
 interest to you. 
 
 The gums are extremely prone to recede from 
 the teeth, and to become tumid, as in the scor- 
 butic condition. 
 
 The masticatory process is always performed 
 with diflBculty. The carious condition of the 
 teeth is one cause of this, but it is principally 
 due to the imperfection with which any volun- 
 tary act is performed. The sense of taste is 
 obtuse, no medicine, however nauseous, is re- 
 fused, and without care many will eat with indif- 
 ference the most offensive garbage. 
 
 To sum up, we have in the condition of the 
 mouths of idiots important data for distinguish- 
 ing between idiocy of a congenital and that of 
 a non-congenital origin, and to base thereon 
 a prognosis as to relative improvement by 
 
MOUTH TO MENTAL DEVELOPMENT. 287 
 
 treatment. They are, tlie tliickness of the 
 lower lip, the delay of dentition, premature 
 caries of the teeth, the irregularity of dentition, 
 the chronic inflammation of the gums and buccal 
 mucous membrane ; the height, angularity, and 
 want of symmetry of the palatal vault ; the long, 
 corrugated, and coarsely-papulated tongue, and 
 the hyper-secretion of saliva. Common to the 
 congenital and non-congenital cases we meet with 
 defect of mastication, a want of co-ordination 
 of the muscles of the tongue, and the slight 
 development of the faculty of speech. 
 
 I am anxious to hear from the members of 
 this Society their own experience with regard 
 to any feeble-minded patients that may have 
 come under their observation, and how far the 
 picture I have drawn from nature contrasts 
 with what they meet with in members of a 
 sane community. It is quite possible that 
 some of the characters I have noted may be 
 met with sometimes among those who are 
 doing their work in the world, and are among 
 the bread-winners of society. My own expe- 
 rience leads me to consider that they are ex- 
 ceptional cases. May not palatal deformities 
 be indicative of a slightly degenerative process ? 
 
288 EELATION OF THE TEETH, ETC. 
 
 When investigating cretinism in the valleys of 
 Piedmont, one is struck with the very gradual 
 deterioration of the race. Some of the typical 
 features of cretinism are met with among the 
 grandparents, and we have been able to trace 
 the increased degenerative stages through the 
 children to the effete grandchildren. 
 
 I have often had a wish to measure and 
 note the condition of the mouths of some of 
 the progenitors of my patients, and trace — as 
 I believe in some instances one could trace 
 — the gradual deterioration of the species till 
 it culminated in congenital imbecility. 
 
 That is just the link that I have not been 
 able to forge. I know no men more likely 
 than those I have the honour to address to- 
 night, to be able to fill up, from their experience, 
 the shortcomings of my own. 
 
THE 
 
 OESTETEICAL ASPECTS OF IDIOCY. 
 
 ' Trans. Obstet. Soc.,' 1876. 
 
 If one regards tlie large number of children 
 in our community wlio grow up with defective 
 mental power, children who, although not all 
 fairly to be ranked among decided idiots, yet 
 have such lesion of the faculties of perception 
 and reasoning as to bring them under the cate- 
 gory of the feeble-minded, and if one has 
 reference to the terrible anxieties such children 
 entail on their parents, and the burden they 
 often are to the struggling members of our race, 
 one cannot fail to be impressed with the import- 
 ance of anything connected with the circum- 
 stances of such a condition. 
 
 I had therefore no diflBculty in responding 
 to an invitation to bring before this Society 
 some of the opinions which have been im- 
 
 19 
 
290 OBSTETRICAL ASPECTS OF IDIOCY. 
 
 pressed upon me, having relation to facts 
 which come under the immediate regard of 
 gentlemen practising the obstetrical ^^branch of 
 our profession. 
 
 The data on which these remarks are based 
 have been collected over a space of more than 
 eighteen years, and relate to two thousand 
 children who during that time have come under 
 my observation, and about whom I have been 
 able to gather information. They have been 
 collected with great care and with an anxious 
 desire to exclude all doubtful matter. 
 
 One very interesting and important point 
 suggested by my inquiries is that of primogeni- 
 ture. We know how much our political system 
 hangs on the laws of primogeniture, how the 
 first-born inherits property and inherits too the 
 power to rule over his fellows, and how much 
 our whole social structure is built thereon. 
 Nevertheless, the result of my statistics shows 
 that no less than 24 per cent, of all the 
 idiot children I have seen are primiparous 
 ofi'spring. How many primiparse there are 
 who, although not coming under the category 
 of idiots are yet somewhat incapable, my 
 statistics, of course, do not reveal. 
 
OBSTETRICAL ASPECTS OF IDIOCY. 291 
 
 It will be obvious, however, tliat before any- 
 real value can be assigned to this statement it 
 will be necessary to inquire into the average 
 number of children belonging to these fami- 
 lies. This I have been at great pains to ascer- 
 tain, and I find that up to the time I had "been 
 consulted in each case 6'91, or nearly seven, 
 was the average number of living children 
 born to the parents who have had an idiot 
 child. Fourteen per cent, were second born, 9 
 per cent, fourth, 5 per cent, fifth, 7 per cent, 
 sixth, 10 per cent, seventh, 2 per cent, eighth, 
 9 per cent, ninth, 2 per cent, tenth, 2 per cent, 
 eleventh, 1 per cent, twelfth, 3 per cent, thir- 
 teenth, and 1 per cent, fourteenth. The 
 question naturally presents itself as to what 
 should give this undue preponderance of idiocy 
 to primiparse. I have no doubt that it may be 
 largely attributed to the exalted emotional life 
 of the mother ; her life is one of exaggerated 
 hopes and fears ; she is prone to live in an 
 unnaturally expectant atmosphere. She is 
 going through an experience altogether new, 
 with untried responsibilities both social and 
 domestic. She is more than usually responsive 
 to external impressions and influences, cer- 
 
292 OBSTETEICAL ASPECTS OP IDIOOr. 
 
 tainly more to subjective feelings and wliims. 
 But, as I have elsewhere observed, it would 
 betoken a narrow view of the matter if we 
 restricted our attention to the emotional life 
 of the mother and kept out of sight the emo- 
 tional tendencies of the father. No one who 
 has seen much of private practice is unaware 
 how much men are frequently influenced by 
 the responsibilities of the matrimonial state, 
 how the doubts as to their own virility, of their 
 being able to make a position in the world 
 after having given hostages to fortune, the 
 disturbing elements of a new social position 
 both with regard to their immediate circle of 
 friends and to the new relationships formed. 
 All these and some others are perturbing in- 
 fluences to many men, and while, therefore, 
 the emotional life of the incubating mother is 
 an important element, the emotional tendencies 
 of the procreating father must be regarded too 
 as a cause of the increased frequency of primi- 
 parous idiots. 
 
 But there is another cause which will natu- 
 rally occur to the Fellows of this Society as ob- 
 stetricians. I refer to the increased difficulties 
 of parturition. No one can have regard to the 
 
OBSTETETOAL ASPECTS OE IDIOCY. 293 
 
 smallness of tlie maternal passages, to their 
 undilated characterj to the rigidity of the peri- 
 naeum, and to the tediousness of the labour, 
 ■without being impressed with the influence 
 they must have in interfering with the integrity 
 of the cranial contents, and to their inducing 
 a condition perilous to the future mental 
 health of the little one. They are conditions 
 which frequently give rise to instrumental in- 
 terference, but above all to a state of suspended 
 animation which in my opinion it should be 
 the earnest desire of the obstetrician to avoid. 
 
 I think it cannot fail to strike the Fellows of 
 the Society as a very important fact that no 
 fewer than 20 per cent, of the idiots of my 
 investigation were born with well-marked sym- 
 ptoms of suspended animation — symptoms 
 which required judicious and strenuous efforts 
 to overcome in order to effect resuscitation. 
 Moreover, it is specially interesting that while, 
 as we have said, 24 per cent, of idiots gene- 
 rally are primiparous, as many as 40 per cent, 
 of resuscitated idiots come under this category. 
 Clearly, then, suspended animation is a condi- 
 tion as far as possible to be avoided by the 
 practical obstetrician. 
 
294 OBSTETRICAL ASPECTS OF IDIOCY. 
 
 Bearing on this part of the subject is the 
 question of instrumental interference. I have 
 made a careful inquiry on this subject over a 
 very large area, and with the expectation I 
 should find a large amount of idiocy to be the 
 result of " meddlesome midwifery," but I am 
 bound to say that my statistics falsify my anti- 
 cipations, and redound to the care with which 
 instruments are employed in parturition. I 
 find from an examination of all my cases about 
 which positive information could be obtained 
 that in only 3 per cent, were the forceps em- 
 ployed. In every case, however, where they 
 had been employed the friends of the child 
 believed that the instrument alone was the 
 cause of the disaster, while in nearly every 
 case I could discover quite suflBcient to account 
 for the mental defect in the neurotic history of 
 the progenitors. In a very few cases, only a 
 small fractional percentage, could I arrive at 
 the conclusion that the use of the forceps was 
 the principal cause of the calamity. 
 
 I find in a very large number of my cases 
 that the labour was stated to be unusually 
 tedious and prolonged. Dr. Playfair has 
 shown that the employment of the forceps 
 
OBSTETETOAL ASPECTS OP IDIOCY. 295 
 
 does not interfere with the viability of the off- 
 spring, and that a prolonged labour is more 
 compromising to the life-prospects of the child 
 than a judicious and timely application of the 
 forceps. Certainly my statistics make clear to 
 me, contrary to what some years since was 
 advanced by Dr. Arthur Mitchell, and in har- 
 mony with Dr. Ramsbotham's experience, that 
 the use of the forceps is not an important 
 factor in the production of brain disease. 
 When, however, it is borne in mind how fre- 
 quent is the association of suspended anima- 
 tion with idiocy, it cannot, I think, be too 
 strongly enforced that the mental integrity of 
 the child is more likely to be compromised by 
 a prolonged pressure in the maternal passages 
 than by skilled employment of artificial assist- 
 ance. The accoucheur who postpones instru- 
 mental help often does so at the risk of terrible 
 consequences to the nervous system of the 
 little one he is solicitous to protect. 
 
 I have collected a good deal of information 
 as to the influence of twin births. There is a 
 general prejudice that the individuals of twin 
 births are not strong physically. Mr. Galton 
 has been collecting materials on this and 
 
296 OBSTETRICAL ASPECTS OF IDIOCY. 
 
 cognate subjects, but I am not aware of 
 bis results. Taking my last tbousand cases, 
 only 2 per cent, were twins, while, singularly 
 enough, the same thousand show that in 2 per 
 cent, of the cases the mothers had given birth 
 to twins who were not afflicted in any way. 
 This would appear to indicate that the exist- 
 ence of twins does exercise some prejudicial 
 influence, seeing that among one thousand 
 mothers who have borne an idiot child, where 
 they have happened to be twins, no fewer than 
 a quarter of them were idiots. 
 
 A very potential cause in the production of 
 idiocy is the physical health of the mother 
 during gestation. In 20 per cent, of my cases 
 there was a history of marked physical dis- 
 turbance. In 4 per cent, there was a history 
 of serious falls — falls which were followed by 
 alarming uterine hsemorrhage. In 6 per cent, 
 there was an account of prolonged ill health, 
 and in no fewer than 10 per cent, was there a 
 history of sickness — cases in which the vomit- 
 ing had been marked and persistent, and had 
 given rise to anxiety on account thereof. 
 I feel quite sure that sickness during pregnancy 
 is an important producer of idiocy and is a 
 
OBSTETEICAL ASPECTS OF TDIOOT. 297 
 
 symptom whicii, from tliis grave aspect of it, 
 claims the earliest attention of the obstetrician. 
 It will be readily understood that any cause 
 which would render the mother anaemic would 
 be a source of peril to the mental health of the 
 child. 
 
 From what I have already said it will have 
 been gathered that I lay great stress on the 
 emotional life of the child-bearing woman as a 
 potential cause of idiocy. I cannot, however, 
 attach greater importance to this aspect of the 
 subject than it deserves. It is one of most 
 serious importance and bespeaks one's careful 
 regard. In no fewer than in 32 per cent, of 
 my cases was there a well-founded history of 
 great physical disturbance in the mother by 
 fright, intense anxiety, or great emotional 
 excitement. They were all cases in which a 
 strong impression had been made on the mind. 
 In a large number of instances the fright was 
 attended by syncope. They were cases of 
 fright arising from threatened outrage to the 
 person, or where they had seen their own 
 children in great peril or killed, or where 
 intense anxiety had existed in consequence 
 of the fatal illness of their husband or the loss 
 
298 OBSTETRTOAL ASPECTS OF IDIOCY. 
 
 of several of tlaeir children. No doubt they 
 were troubles in many cases which might have 
 been borne with equanimity by a philosopher, 
 but the mothers possibly were more than 
 usually responsive, and with an unstable equi- 
 librium required only the stimulus of fear op 
 anxiety to exercise a morbid influence on the 
 development of their children. 'No doubt the 
 emotional tendency of the mother, as depend- 
 ing on the same neurosis, may be regarded as 
 a cause, but the actively potential cause in all 
 the cases I have referred to was mainly the 
 undue response to some external impression. 
 The lesson to be gathered from such data is 
 a very important one, viz. to maintain the 
 child-beariug woman in the most equable state, 
 to shield her as much as possible from all 
 causes whicb would disturb unduly her 
 emotional life, and to maintain in her tliat 
 hopeful spirit and placid calm which is so much 
 to be desired both for the woman herself as well 
 as for the infant she is incubating. These 
 data teacb us how important it is that for 
 women generally the emotions should not be 
 cultivated at the sacrifice of their judgment 
 and self-control. 
 
OBSTETEIOAL ASPECTS OF IBIOOT. 299 
 
 The relation of sex to idiocy presents some 
 matters of interest ; there is a marked prepon- 
 derance in the number of male over femaJe 
 idiots, The proportion among the two 
 thousand I have noted stands in the ratio of 
 2*1 to '9, or rather more than twice as many 
 male as female. It is, I think, a very fair 
 conclusion to arrive at that one very important 
 factor is the increased dimension of the male 
 over the female infantile cranium. This would 
 be likely to give rise to prolonged and difficult 
 parturition, to that continued pressure and that 
 suspended animation which I regard as so 
 disastrous to the cerebral functions. Another 
 reason is the greater tendency, according to my 
 notes, to infantile convulsions among males who 
 have become idiots than among females who 
 have become idiots, a circumstance which gives 
 rise to a larger amount of what I call accidental 
 idiocy among males. These statistics are, 
 moreover, in harmony with what we know of 
 the greater viability of female over male 
 children. The question of sex opens up many 
 interesting problems in relation to idiocy. I 
 can only here intimate that where the origin is 
 purely of a neurotic character my notes show 
 
300 OBSTETRICAL ASPECTS OE IDIOCY. 
 
 that when the neurosis is paternal the male 
 progeny are liable to suffer and the female to 
 escape ; where, on the contrary, the neurosis 
 is maternal the female progeny are likely to 
 bear the stress. 
 
 I have been at some pains to ascertain 
 whether there is any relation between the 
 administration of ergot of rye and idiocy. I 
 have found, however, the answers so vague and 
 the knowledge of my informants so uncertain 
 that it has proved quite hopeless to arrive at 
 any results which would have a scientific basis. 
 Often the mothers have imagined that ergot 
 had been used when there had been no such 
 administration, and it is obvious that in many 
 cases the medicine may have been taken with- 
 out the mother being conscious that any drug 
 had been made use of. 
 
 The diagnosis and prognosis of idiocy are 
 both matters which perforce fall to the lot of 
 the obstetrician, and it is of no small import- 
 ance that he should have definite bases on 
 which to form and give an opinion. An error 
 in diagnosis would lead in all probability to 
 unpleasant lessening of professional confi- 
 dence. 
 
OBSTETRICAL ASPECTS OF IDIOCY. 301 
 
 The earliest observations, on the part of those 
 in attendance on the child, of defect of sight, 
 of unusual fretfulness or peculiarity as to 
 taking food, should lead to very careful investi- 
 gation of the structural formation of the child. 
 
 In cases which have a congenital origin 
 you may find very early physical signs of 
 serious trouble. The cranium must be ex- 
 amined as to its configuration, giving special 
 heed to want of symmetry, to extreme dolico- 
 cephalism, to extreme brachycephalism, to 
 rapid shelving at the occipital region, to the 
 condition of the sutures, their premature or 
 deferred synostosis, and especially to the 
 frontal region which often displays the medio- 
 frontal suture still existing, whereas there 
 should have been complete coalescence of the 
 two halves of the frontal bone during intra- 
 uterine life. 
 
 Examination of the ocular media and retina 
 will remove the notion of blindness, and 
 indicate that the defect in taking notice of 
 external objects is rather one of cerebral than 
 optical defect. The presence of strabismus 
 should be noted, and the integument about the 
 eye should be examined especially for semi- 
 
302 OBSTETRICAL ASPECTS OF IDIOCY. 
 
 lunar folds of skin at the inner canthus — folds 
 which are more frequently present in feeble- 
 minded children than in others, and which I 
 have been accustomed to describe as epicanthic 
 folds. They are according to my experience 
 marks of developmental degeneracy, and 
 should be looked for. The position of the 
 eyes is worthy of note, whether the inner 
 canthi are too nearly approximated, as met with 
 in microcephalic or scaphocephalic idiots, or 
 too widely separated, as obtains in macro- 
 cephalic and hydrocephalic idiots. Observation 
 should also be made as to any obhque position 
 of the eyes as well as their wide separation, 
 such as is met with in that ethnical variety 
 which I have elsewhere described as Mongolian 
 idiocy, a variety of great clinical as well as 
 biological interest, showing that degenerative 
 causes may and often do remove children into 
 a different ethnic type from that of their 
 progenitors. Particular observation should be 
 made as to that peculiar oscillation of the balls 
 called nystagmus, which is very frequently met 
 with in children of the feeble-minded class. 
 
 The appearance of the external ear should 
 be noticed, the condition of the pinna, the 
 
OBSTETEIOAL ASPECTS OF IDIOCY. 303 
 
 absence of a helix, and whether the lobule be 
 absent. Observation should also be made as 
 to the seat of implantation of the ear, which in 
 idiots is usually placed further back in relation 
 to the head and face than in normal children. 
 No feature is more worthy of regard than the 
 configuration and position of the external ear. 
 
 The mouth should be examined as to its 
 palate, whether it be arched or Grothic-shaped ; 
 the tongue, whether it be too large, rugous, 
 fissured, and with its papillae enlarged ; the 
 jaw, as to the angle formed by the ascending 
 and horizontal rami, which in idiots is more 
 obtuse than usual. 
 
 Examination should be made of the surface 
 of the body as to the condition of the skin — 
 noting whether it has a lax and soddened 
 appearance, especially on the extremities, and 
 whether there be any defective coalescence at 
 the bottom of the spine. The muscular system 
 should be examined, special observation being 
 made as to the existence of any automatic 
 movements, contractures, or spastic rigidity. 
 In early childhood as well as in more advanced 
 life too much attention cannot be given to 
 these physical signs of cerebral disease. They 
 
304 OBSTETRICAL ASPECTS OP IDIOCY. • 
 
 are, many of them, the marks of that kind 
 of idiocy which is inherited or congenital in 
 its origin, of that kind which is so often met 
 with as the outcome of a gradually degenerating 
 race. 
 
 Idiocy, however, is not always strictly con- 
 yenital ; in a large number of cases it is 
 acquired or accidental. This includes those 
 cases which occur from inflammation, often of 
 a slow and insidious character, of the meninges 
 whereby products are thrown out which after- 
 wards interfere with the nutritive supply to 
 the encephalon. It includes also the recoveries, 
 although very rare, from tubercular meningitis, 
 from infantile convulsions, and from acute 
 diseases of various kinds, also those arising 
 from traumatic injury as well as those where 
 narcotics have been injudiciously and probably 
 furtively given. 
 
 It is of great importance to be able to 
 differentiate these accidental cases from the 
 congenital ones, and this can only be done by 
 having regard to the physical diagnosis I have 
 before referred to. Often the friends of the 
 children refer the origin of the disaster to a 
 careless nurse who has let the child fall, to 
 
OBSTETRICAL ASPECTS OE IDIOCY. 305 
 
 some remembered fright, or to an accoucheur 
 who has used instruments unadvisedly ; but a 
 reference to the physical condition of the child 
 may tell one that the cause was long antecedent 
 to the one suggested, and that far back in 
 intra-uterine life, or possibly before, in the 
 history of the progenitors, must the real cause 
 be traced. 
 
 Not only is physical examination important 
 in a diagnostic point of view; it is of no less 
 value, as we shall see, in prognosis. What 
 is to be the future of our child ? is a ques- 
 tion which will be put with more or less 
 earnestness, usually with an earnestness from 
 which there is no escape, and the reply will be 
 treasured for years to come. I j&nd that a large 
 number of replies are given, apparently based 
 on some sort of belief in periodic leaps. The 
 favourite epoch is seven years. The friends 
 are often lulled into a false security under the 
 notion that at seven, fourteen, or twenty-one 
 years of age all will come right. I know 
 nothing of such cataclysmal improvements. 
 The misfortune is that such opinions prevent 
 all active means being employed, and when the 
 longed-for time arrives it is found that precious 
 
 20 
 
306 OBSTETRICAL ASPECTS OP IDIOCY. 
 
 opportunities have been lost, that with in- 
 creased physical development there has come a 
 stronger will, more resolute disobedience, and 
 an absence of intellectual and moral growth 
 which proper training might have effected. 
 
 But a no less fallacious opinion is often 
 based on the good looks of the patient. The 
 child probably does not speak at the proper 
 time, rolls its head in a rhythmical way, looks 
 into space, or makes monotonous noises with its 
 lips. " Oh !" it is often said, " have no anxiety, 
 all will come right ; he is so bright-looking, so 
 comely, he has no deformity of head, no lesion 
 of limb." The friends have no difficulty in 
 falling in with such a doctrine, and they await 
 in full reliance the future which is predicated, 
 but it is a future which never comes. It is 
 experience alone that tells one that the pro- 
 gnosis in such a case is far less hopeful than 
 in the case of one whose misplaced eyes, ill- 
 shaped cranium, and distorted face gives ready 
 indication of his feeble mind. 
 
 The case we have been considering is one of 
 accidental origin. Something since birth has 
 given rise to the disaster and has left no trace 
 on his exterior. With such an one we are able 
 
OBSTETRICAL ASPECTS OF IDIOCY. 307 
 
 to predict much less response to training than 
 in the case of one whose defects have had an 
 origin anterior to birth. It may be taken as a 
 rule which has but few exceptions, that con- 
 genital idiocy is more amenable to training 
 than post-congenital, that, in fact, it is more 
 hopeful to have to do with an ill-developed than 
 with a damaged brain, and having regard to 
 what I have laid down as to the physical 
 signs and configuration of congenital idiocy, 
 that the prognosis is, contrary to what is so 
 often thought, inversely as the child is comely, 
 fair to look upon, and winsome. 
 
 It will be readily conceived how many 
 interesting points of departure are suggested 
 by the topics I have touched on. I have 
 endeavoured, however, not to wander into 
 simply philosophical paths, but to confine 
 myself to what I considered had most direct 
 bearing on " the obstetrical aspect of idiocy." 
 
 PRINTED BY ADLAED AND SON, BAETHOLOMEW CLOSE. 
 

 
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