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UN GR ADED
Entered as second-class matter March 28, 1918, at the Post Office at Concord, N. H.,
under the Act of March 3, 1879
THREE TYPES OF MENTAL DEFECT
WM. H. HIGGINS, M.D. DIRECTOR, PSYCHOPATHIC CLINIC, MEDICAL COLLEGE OF VIRGINIA; PSYCHOLOGIST OF
SPECIAL CLASSES, RICHMOND PUBLIC SCHOOLS
Whenever medical science can reclaim an individual from the dependent class, it is rendering to the state a distinctly economic service. The problem of the mentally deficient logically falls under this heading, as no type or condition of mankind is more definitely a burden to the community than these unfortunate victims.
There are now listed in the state of Virginia approximately 5,000 feebleminded persons, and there are probably twice that number whose mental retardation has only partially incapacitated them from self sustainment. Certainly no one would venture a hopeful prognosis for the fully developed degenerates, but to what extent the borderline or high grade type can be prevented or relieved will depend in a measure on our efforts.
Formerly, mental deficiency was considered a distinct entity, varying only in degree, but characterized by a uniformly gloomy outlook. We were disposed to look upon the defective as a necessary evil, a by-product, so to speak, of our natural evolution. Recent studies, however, have shown us the gross injustice of this attitude. Obstetricians have demonstrated by reliable statistics, the baneful results of birth traumatisms. The eugenists have clearly established by the Mendelian Law the transmissibility of the defective germplasm. Physiologists have defined the functions of the ductless glands, and their relation to mental and physical development. In a like manner, the rôle of chronic infections in their relation to the cerebral reactions in the young is now a matter of common knowledge.
Thus it seems that the time has come when a classification of mental defect according to degree should be abandoned in favor of an etiological basis for differentiation. We should not be so much concerned as to whether the child is an imbecile or a moron, but whether he belongs to a type amenable to treatment or not. It will then be possible by intelligent individualization to lessen the ever increasing contributions to this class.
The more scientific methods, which are now practiced in the public school systems, have strikingly demonstrated the different grades of mental development in children. Supplemented by the newer psychological tests, they have brought to the medical profession, problems which rightly belong in its domain. The mere diagnosis of mental deficiency or feeble-mindedness is not satisfying, nor is the cloak of heredity acceptable as a cause in all types. A definite etiological basis is required.
The purpose of this paper is to illustrate by case reports three types of mental defect of known origin.
Case 1. White boy, aged 10, was admitted to the psychopathic clinic one year ago, because of general mental deficiency and nervousness. His family record is clear, both in regard to immediate and distant relatives.
“He was healthy as a baby, and weighed 36 pounds at one year of age. Nothing abnormal was noticed in his teething, walking or talking. His mother states that he was bright and manifested the mental activities of other children his age.
“During his fifth year, evidences of backwardness and lack of self-control began to manifest themselves. Attacks of screaming without cause were common. Two years ago he had several fainting or unconscious spells, the exact nature of which could not be ascertained.
“He entered school one year ago, at which time, he was nervous and restless, constantly moving from place to place, spoke very indistinctly and showed absolutely no academic ability.
“On admission to the clinic, his mental examination showed a restless, unstable child with a marked deficiency in all lines. According to the Binet test, he had a mental level of 5.3.'
On physical examination, the chief points of interest were (1) large head, (2) drooping right eyelid, (3) pads of fat over shoulders, (4) breasts and thighs, (5) abnormally fat abdominal walls, (6) small hands with short tapering fingers, (7) negative Wassermann, (8) increased sugar tolerance and (9) lack of perspiration. An X-ray examination of his skull was attempted several times, but he would not submit.
A probable diagnosis of hypo-pituitarism with a possible thyroid deficiency was made.
The treatment has consisted of alternating anterior lobe pituitary extract with thyroid extract throughout the year.
An examination at this time shows that he has lost from 12 to 15 pounds in weight, chiefly from his abdomen, his restless temperament has become markedly lessened, his articulation is better, and the following notes dictated by his teacher describe his further improvements: "Reads well in Primer. Can repeat Mother Goose Rhymes and other verses. Learns songs readily, writes his name well and shows improvement in coördination and self-control. He is eager to work, is quiet and happy."
The vagaries of the ductless glands have held the attention of the ablest workers in medicine today. The functioning of these bodies and their
inter-relation with each other are so complex, and apparently so contradictory at times, that it has been difficult to designate clinical syndromes for each gland. However, out of the maze of clinical and experimental work, sufficient data have crystallized for practical purposes by which the recognition of many of these syndromes may be made.
The pituitary gland, in which for the present we are particularly interested, is composed of two distinct parts, which differ in their structure, in their physiological activities, and their development.
Complete removal of the anterior lobe is usually and probably always followed by death. The posterior lobe, however, may be extirpated without necessarily producing death. The experimental work of Cushing and others have shown that a hypo- or a hyper-activity of either lobe will produce well recognized pictures. When the secretion of the whole gland is over active, glycosuria, loss of body weight, excessive sweating, hypertrichosis, and osseous overgrowth will result. When this overgrowth antedates puberty or ossification of the epipheses, gigantism follows; occurring subsequently, acromegaly develops.
In states of under activity (hypopituitarism) the condition is suggested by an increased carbohydrate tolerance, adiposity, hypotrichosis and reversion to the feminine type of the body as shown by deposits of fat about the shoulders and breasts, and the symmetry of the extremities. Further evidences are dryness of the skin, sexual under development and mental retardation. The hands are short with stubby pointed fingers, and the abdomen is greatly enlarged by deposits of fat.
Between these two extreme types there may be found a variety of syndromes, depending on the lobe involved.
It has been shown that there may be in the same individual a lowered activity of one lobe with a compensatory acceleration of functions in the other lobe. Or again, other glands may compensate for altered secretions in the offending one, thus giving rise to an entirely new symptom-complex.
Unfortunately, these so-called polyglandular syndromes are the most frequently encountered, and are the most difficult for diagnosis. Studies, therefore, of the pituitary gland involve the entire field of the endocrine system.
The second type of mental defect is illustrated by the following history.
Case 2. White girl, age 13, was admitted to the clinic because of repeated failures in school and temperamental instability. There was nothing of significance obtainable in her family history, with the exception of a record of poor health in her mother. She was born at full term, weighing 11 pounds. As a baby, she was healthy aside from a history of convulsions at the age of 18 months. She was normal in her walking, talking and teething. During recent years she has had several attacks of rheumatism which she described as aching pains in her muscles, knee joints and back. These attacks were sufficiently severe to keep her in bed.
She was irritable as a baby, and in the past few years has developed a rather quarrelsome disposition with a tendency towards disobedience. Her school record shows that she spent 4 terms in 1A, 3 terms in 1B and 2 terms each in 2A, 2B and 3B.
Her mental examination showed a poor motor coördination, a lack of imaginative and retentive ability, with no initiative. Her mental level was 7.3 (Binet).
Physical examination was entirely negative. The blood gave a positive Wasserman reaction.
Under specific treatment for 8 months, the transformation has been magical. There has been no return of the rheumatic pains, her former sallow complexion is now replaced by a ruddy color, and a definite alertness has taken the place of her usual languid manner. Formerly quarrelsome and irritable, she now is mild-tempered and obedient.
Her school record for the last term showed marked improvement in all subjects. Her mental level now is 9.2 in comparison with 7.2 one year ago.
On a former occasion, I made an analytical report of the first 50 children admitted to the psychopathic clinic. A chart was shown giving the age, mental level physical defects temperament and complement fixation tests of this series. Forty-two per cent gave a positive Wasserman reaction. In this report it was pointed out that the positive reactions were found much more frequently in the incorrigible, ill-tempered high grade defectives than in the mild-tempered low grade types. This observation has been verified by our more extended series, and it probably accounts for the low percentages of positive reactions reported from institutions whose enrollment is composed largely of low grade defectives.
In view of the known relationship existing between acquired syphilis and the central nervous system, the frequency of congenital lues manifesting itself in these points of predilection should be of vital interest to us. The method of transmission of spirochete from parent to child is still open to discussion. Suffice it to state that in the light of our present knowledge, the weight of evidence favors maternal transmission. Thus the offspring becomes directly infected with the organisms circulating in the blood.
The pathology differs in no way from that found in acquired infections. The disease may implicate the blood vessels, meninges, or the parenchyma. However, owing to the proximity of these structures, it is not likely that one part would become involved without the others showing the same pathological process.
The third type is represented by the following history:
Case 3. White boy, age 12, was admitted to the clinic in February, 1917. He had made repeated failures in his grades and manifested no interest in his work. At home, sitting down was his chief occupation, although no sickness was complained of. His condition is aptly described by his teacher as follows:
“His head propped in his hands, elbows resting on the table was the only evidence much of the time that Claude, a frail, under-sized boy, was in the room. He seldom responded to any questions, and only then if he knew that he was being watched. He never volunteered any information for the first three months of school. His memory was poor, his spelling was fair, his language showed not only a lack of imagination, but a lack of words as well. He showed no interest in reading, and made no effort to concentrate his attention on a problem. He would not enter into any of the games and he manifested a genuine dislike for physical exercise in any form.
“His mental level (Binet) was 10 years.
“Physical examination was negative with the exception of his blood which had a haemoglobin reading of 50, and an eosinophilia of 27 per cent uncinaria eggs were found in his faeces.
“At the end of the past session, he was showing a keen interest in his work, games became a pleasure-in fact a general awakening had taken place. He was promoted and is now in one of the regular grades.”
The ravages of the hookworm are too well known for discussion. During the past decade, various investigations including the Rockefeller Sanitary Commission, and the United States Public Health Service have absolutely demonstrated the dangers from this source to which the children of the South are subject.
In 1916, the Rockefeller Foundation published the report of an extensive investigation of the effects of hookworm disease on the mental and physical development of children. Quoting from their conclusions:
“Hookworm disease interferes very radically with mental development. Treatment alleviates this condition, to some extent, but it does not immediately at least permit the child to gain as he would if he had not had the infection. The longer the child has the disease, the more will he lose mentally, and the less rapid will be his mental development after he has been treated.”
Our conclusions from a study of these three types of mental defect would seemingly justify us in at least withholding our prognosis for backward children, until an etiological basis has been determined. The unscientific classification of the mentally deficient has doubtless been in part responsible for the indifference manifested towards its logical treatment.
Diagnoses dealing in generalities should no longer be acceptable. The specific cause should be the descriptive term.
The problem is a live one, and calls for our most careful consideration. (1) The Pituitary Body and its Disorders. Philadelphia, 1912.
(2) Relation of Cengenital Syphilis to Mental Deficiency. American Journal Medical Society, 1917. CLIV.
(3) International Health Commission. The Rockefeller Foundation, Pub. No. 3, 1916.