In

Exceptional in the idiot, when it occurs it is always in the impulsive form, unprovoked and without motive. It is a delirium of acts. imbeciles there are attacks of maniacal excitement, with impulsion to kill, to set on fire, or to break.

With respect to the production of ideas, there is little or none in the inferior types of idiocy, and in the higher grades the imagination is inchoate, of no utility, and often directed to things that are evil.

Will, Personality, and Responsibility. The elder Seguin looked upon defect of will as the basis of idiocy, but the will is rather a diffuse than a local function of the brain. It has no definite seat in the encephalon, lesion of which would impair or destroy it. As Sollier

will in its simplest form is manifested by actions accomplished for the satisfaction of natural needs, appetites, and desires. Accordingly, the individual must have a consciousness of those needs. Such a consciousness may be very much blunted in profound idiots, and consequently the will will be almost entirely lacking. Such an idiot is a spinal being, and his movements may be compared to the reflex phenomena seen in decapitated frogs. In higher idiots, the will is manifested by more complex movements, which are, however, capable of becoming secondarily automatic. Voluntary control of the sphincters occurs only in idiots who learn to walk, and not until they have learned. Volitions do not exist in the lowest order of idiots. The most natural desires and the most primitive instincts are absent. The first to appear is desire for food, but it may manifest itself simply by a stretching out of the hand or a cry. In idiots in whom the will is more developed, and also in imbeciles, it finds its expression more easily in actions than in inhibitions.

Self-respect, very little developed in the idiot, plays a very important rôle in the psychology of the imbecile, and by catering to it he can often be made to do things which would otherwise be impossible to obtain.

Intellectual movements, or acts accomplished under the influence of judgment or reason, are infrequent in the idiot, and not common in the higher grades. Many idiots are incapable of choice. When the power of choice is present, it is often exercised with difficulty. He does not quickly understand that of two things he must take one and leave the other he wants to take them both. It is the same with ideas. Between two desirable objects, the superior type does not hesitate, but takes without reflection the one he sees first, which he may wish to exchange when he sees the second.

In idiots, whose will and motor volitions are so feeble, suggestion produces little or no results. It is the contrary in many imbeciles, except in those whose voluntary impulsiveness is too great. Ordinarily the higher grades are very susceptible to suggestion, as is seen by the facility with which mischief is done by a band of imbeciles which has been led on by one of their number. If suggestion is possible in imbeciles, it shows that the ideas which they already possess are very unstable, and are easily replaced by new ones. It has a great analogy with the suggestibility of the hysterical.

Consciousness and Personality. As consciousness is but a phenomenon added to psychic processes, and not producing them, and as the personality is the coordination of psychic acts, it is necessary to form by deduction our conclusions as to these two attributes in the class of people we are studying. In absolute idiots it is not probable that any act is accompanied by consciousness. In higher idiots, in whom life is but little more than a succession of disconnected moments, it is not possible to say whether they have consciousness or not; but the personality, if present, must be very rudimentary, since an essential of its existence is a proper appreciation of the continuity of events.

For an individual to have consciousness of a psychic act, it is necessary that the exciting stimulus have a certain duration and intensity. Such factors in the stimuli are generally wanting in idiots; and so it is probable that most of their psychic phenomena occur without consciousness; and if there is consciousness, it must be very feeble. The distinction between the ego and the non-ego is not made by absolute idiots, and is but feebly present in the higher idiots.

In many imbeciles consciousness may be wanting or feeble, but in some it is clearly present, together with a perfect idea of their personality. Further, sometimes in delirium they have ideas of grandeur, showing an exaggerated conception of personality.

Responsibility.-All lower types of idiots are unable to manage their own affairs or to enjoy their civil or political rights, but those of a higher degree, who are at liberty, may have these rights.

Psychological Evolution.-In every degree of idiocy there comes a time, as Sollier well says, when the education stops and further mental progress ceases, and when the only hope is to retain the results which have been gained. This acme of development varies for the different psychic functions, so that one faculty may still improve, while another has already reached its cessation point. The senses continue to develop for the longest time, then the sentiments, and the intelligence the shortest. This is true of all classes, though the periods are longer in the higher grades, where all of the faculties are more equally and proportionally developed. Thus, in inferior types intellectual progress may cease at the age of six or seven, and the sentiments and senses continue their development to eighteen or twenty, while in superior grades the improvement of senses, sentiments, and intellect may cease about the same time-viz., at puberty.

Sometimes the faculties remain stationary, at others they retrograde when the limit of development is reached. Retrogression follows the same law as dementia-namely, progressive enfeeblement of will, intelligence, sentiments, and sensations, in the order named. When retrogression begins in the simpler forms it is very rapid, but in the higher types goes more slowly and more irregularly. Purely intellectual gifts which they have acquired (reading and writing) disappear very rapidly. In the intellectual downfall of the superior types one sees from time to time flashes of intelligence, like reflections from their weakening minds, but such are not observed in the lower forms.

General Pathological Anatomy.-There has been accumulated in

literature of late years a great deal of valuable matter relating to the pathology and morbid anatomy of idiocy, so that much new light has been shed upon a somewhat obscure subject. The investigations of Sachs and myself1 into the causation of the cerebral paralyses of children, which are so frequently associated with the various degrees of mental impairment, from feeble-mindedness to profound idiocy, and in which we found meningeal hemorrhage to be so commonly the primary lesion, might well give rise to the belief that in a majority of cases of idiocy without paralysis and in idiocy associated with epilepsy we are confronted with the same initial lesion. The site of the meningeal hemorrhage is the determining factor in the establishment of the symptoms. If the Rolandic area be mainly implicated, either on one or on both sides, we have a hemiplegia or diplegia as the result, and these paralyses may be severe or light according to extent of the hemorrhage, and may be associated with idiocy or epilepsy, depending also upon the extent of the lesion and upon the amount of irritation. Again, I have seen a case in which there was left hemianopia, epilepsy, and very slight mental impairment, pointing to a meningeal hemorrhage over the right occipital lobe. Probably, too, some of the cases of arrested development of the speech, with or without enfeebled mind, are due to the same cause. It may be assumed also that meningeal hemorrhage often occurs as the initial lesion in what appears to be idiopathic epilepsy. The symptom or syndrome produced then will depend upon the location and extent of the initial lesion. Asphyxia at birth and convulsions shortly after birth are in themselves significant of meningeal hemorrhage, and in our study of etiology we observe the great frequency of these symptoms in the history of idiocy. At our autopsies, which are nearly always made years after the initial lesion, we find only terminal pathological states, such as atrophy, general sclerosis, and cysts, and, unfortunately, these conditions are not pathognomonic of antecedent hemorrhage, for they also are the terminal states for embolism, thrombosis, cerebral hemorrhage, meningitis, and meningoencephalitis. What other evidence have we that proves the enormous preponderance of meningeal hemorrhage in the etiology of the terminal pathological conditions? It is in the testimony of the investigators of the causes of still-birth. For instance, Litzmann2 examined 161 stillborn children, finding in them 35 cases of meningeal hemorrhage. Parrot, 3 in 34 autopsies on the new-born, found 5 with blood in the arachnoid cavity and 26 with hemorrhage into the subarachnoid space.

The study of Sarah J. McNutt, of New York, in 1885, of 10 similar cases added valuable testimony to that already given, and showed the relation between meningeal hemorrhage and asphyxia and convulsions in the new-born in a manner not to be gainsaid.

"The Cerebral Palsies of Early Life, Based on a Study of One Hundred and Forty Cases," "Jour. Nerv. and Ment. Dis.," May, 1890. See also paper on same subject by author, Louis Starr's "Text-book of Diseases of Children," Phila., 1894, and Sachs' Nervous Diseases of Children," New York, 1895.

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2 Archiv für Gyn.," Bd. xvi, 1880.

3" Clinique des Nouveau-nés," Paris, 1877.

4"Amer. Jour. of Obstetrics."

Allusion is elsewhere made to Herbert R. Spencer's 130 autopsies in still-born children, in which there were 53 instances of hemorrhage from the pia and arachnoid.

Thus, the evidence before us in favor of meningeal hemorrhage as the initial lesion in a large proportion of cases of idiocy is most convincing. Some idea of the character of the terminal states found in idiocy may be derived from the studies of Wilmarth1 and Bourneville.2 The former communicates the results of 100 autopsies, which he summarizes as follows:

Sclerosis with atrophy, 12; sclérose tubereuse, 6; diffuse sclerotic change, 7; degenerative changes in vessels, ganglionic cells, or medullary substance, not constituting true sclerosis, 15; hydrocephalic, 5; general cerebral atrophy, 2; non-development in various forms, 16; infantile hemorrhage, 1; extensive adhesion of membranes from old

Fig. 303.-Brain of a diplegic idiot, showing atrophy of the convolutions over large symmetrical areas -not a true parencephalia. (See history of case," Proc. N. Y. Path. Soc.," 1894, p. 94.)

meningitis, 3; angiomatous condition of cerebral vessels (with degenerative changes), 1; glioma (with sclerosis), 1; porencephalia (with non-development), 1; of 31 cases where actual disease or imperfect development of the brain proper was not demonstrated, there was hypertrophy of the skull, 6; acute softening (recent), 2; demimicrocephalic, 2; when the brain was above usual weight, but the convolutions large and very simple in their arrangement, 2.

Our examination of this summary discloses the fact that atrophies and diffuse sclerosis were demonstrated in 21 of the cases and tuberous sclerosis in 6. It is probable that the tuberous form of sclerosis has a pathology different from that of the diffuse form and more resembling the disseminated sclerosis of neuropathologists. Fifteen of Wilmarth's cases are recorded as presenting degenerative changes in vessels, ganProceedings Ass'n Amer. Inst. Idiots and Feeble-minded," 1891.

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glionic cells, or medullary substance, "not constituting true sclerosis." There was evidently some resemblance to sclerosis, or this author would not have qualified his description thus; and it is more than probable that the condition would have been pronounced one of genuine diffuse sclerosis by experts at the present day. Wilmarth notes 16 cases of non-development in various forms. He writes, in this connection :

"Non-development is found in several forms. A portion of the cortical substance may be thin, and, instead of following the typical arrangement of the fully developed brain, form a number of irregular folds, which may be so small and numerous as to resemble a mass of angle-worms."

This is evidently the condition which we know as microgyria, a true pathological process probably due to a vascular lesion (thrombosis or embolism), and not, therefore, a fault of development. Wilmarth's observations were made, many of them, years ago, before neuropathology had attained its present precision, and hence have not the value of later researches, such as those undertaken at Bicêtre and Upsala.

Hammarberg 1 has made one of the most valuable contributions to the study of the pathology of idiocy in literature. His study enters into the details of the examination of the brains of nine cases of idiocy, imbecility, and feeble-mindedness. Several of these were epileptic and paralytic idiots. His pathological investigations were controlled by the microscopic examination of twelve normal brains. The results were briefly as follows: In all of the cases of idiocy a more or less large part of the cortex showed arrest of development at a stage corresponding to either an embryonal period or the period of early infancy. Only a small number of cells reached their higher development or were destroyed during the growth of the cortex. The mental defects were in direct proportion to the defects of the development of the cells, and were greater the earlier the period of arrest of development.

As regards hydrocephalic idiocy, the true pathogeny of hydrocephalus is unknown. It is generally explained as being due to a chronic intraventricular meningitis, a congestion of the ependyma. But in many of these cases nothing abnormal is observed about the ependyma save thickening. It is possible that a careful study of the manner of secretion of the cerebrospinal fluid and of the relations existing between the ependyma and the external serous membrane of the brain may help to elucidate the origin of the disorder; for there is some reason for believing that a sort of current of fluid flows from the ventricles into the exterior serous cavity through the foramen of Magendie, the foramina of Mierzejewsky, and two other foramina which have been described, but are of uncertain existence. The ventricular walls secrete the cerebrospinal fluid and the exterior serous cavity absorbs it, according to this theory. Thus, then, there may be three processes by which primary hydrocephalus may be induced hypersecretion in the ventricular spaces, occlusion of the foramina mentioned, and disorder of the absorbent apparatus. An interesting study of the subject along this line might be made.

1 "Studien über Klinik und Pathologie der Idiotie," by C. Hammarberg, Upsala, 1895.