Inherited syphilis may act in two ways: either by giving rise to a congenital anomaly through intrauterine disorders or by causing the appearance of meningeal and cerebral lesions during the first years of life of which arrest of development is the consequence.1

First Manifestations. According to Sollier, who has made an extensive study of these anomalies, the principal early manifestations are:

(a) Difficulty in taking the breast; it seems each time that the act is a new one to the child;

(b) Violent, continued, and unprovoked crying; (c) Impossibility of fixing the child's gaze; (d) Lack of expression in the physiognomy. Later on, at the age when intelligence becomes manifest in normal children, the signs of psychic insufficiency become more and more evident. The child is sad, surly, or, on the contrary, extraordinarily noisy and turbulent. It does not speak or it may be able to say only a few words at an age when other children already dispose of quite a vocabulary. More important than the language of transmission is that of reception. The chief characteristic of the congenital imbecile is the restricted number of words, not which he can pronounce, but which he can understand.

Physically arrest of development manifests itself in retardation of growth, of development of the hairy system, and especially of learning to walk.

1 F. Plaut. The Wassermann Sero-Diagnosis of Syphilis in its Application to Psychiatry. (English translation by Jelliffe and Casamajor.) New York, 1911.

Symptoms. — As with the growth of the child the psychic functions become of greater importance, their insufficiency becomes more apparent and manifests itself in the impossibility of the subject's deriving any benefit from education.

This incapacity is due to absence or weakness of attention (Sollier), so that the degree of atrophy of this faculty can serve as a basis for the classification of arrests of development. Sollier distinguishes:

(1) Absolute idiocy: complete absence and impossibility of attention;

(2) Simple idiocy: weakness and difficulty of attention;

(3) Imbecility: instability of attention.

We may add also feeble-mindedness, in which, as in imbecility, the attention is unstable, though to a less marked degree.

Atrophy of attention is, therefore, the most important symptom of arrest of psychic development.1

Around this is grouped a certain number of other symptoms which I shall mention briefly:

(a) Sluggishness and lack of variety in the psychic processes, entailing insufficiency of judgment and absence or rarity of generalized ideas. The latter two symptoms are most striking in the feebleminded.

(b) Weakness and inaccuracy of the memory. An idiot or an imbecile is seldom able to relate correctly an event that he has witnessed. The details and

1 Sollier. Psychologie de l'idiot et de l'imbécile. Paris, F. Alcan.

even the facts themselves are altered. Quite frequently imbeciles relate pseudo-reminiscences which indicate by their monotonous and childish character a very poor imagination.

(c) Moral indifference associated with morbid irritability (this symptom is to be looked upon as an expression of a disorder of the moral sense), impulsive reactions and extreme suggestibility; this latter disorder, together with the weak memory, insufficient judgment, and atrophied moral sense, renders the testimony of an idiot or an imbecile acceptable only with extreme caution.

(d) Disorders of language. In the lowest grade of idiocy language is absent. In simple idiocy and in imbecility we usually find:

(1) A vocabulary that is more restricted than in normal individuals of the same age and under the same conditions.

(2) Errors of syntax which are at times very curious. Some idiots make use of faulty construction: "Me no sick," etc. Others never use the pronouns, I, you, he, etc., referring to themselves and to others by their proper names. One imbecile, Elsie B., used to say, "Elsie B. is going to bed." The substitution of a pronoun for a proper name is an intellectual operation impossible for these patients. In the pronunciation we often notice lisping, stammering, and stuttering. Written language, necessitating very complex associations, is still less developed than spoken language. Many imbeciles are unable to read, and only few are able to write properly. Writing necessitates delicate movements in

addition to the difficulties of reading. Language of gesture and expression, the most elementary of all forms of language, is least affected. Usually, however, it has not the same liveliness as in the normal individual. A single glance suffices to distinguish the idiot who does not speak from the intelligent deaf-mute.

These are the essential and fundamental features of idiocy and imbecility. They may present all degrees, from complete idiocy, in which the mentality of the individual is inferior to that of an animal, to slight feeble-mindedness, which is compatible with a normal social existence. These extremes are connected by an infinity of intermediate degrees, so that no distinct lines of demarcation can be drawn between idiocy, imbecility, and feeble-mindedness.

All the mental faculties are not always atrophied to the same extent. The memory is sometimes very good, occasionally even exceptionally so. "Forbes Winslow (quoted by Sollier) reports a case of an idiot who could recall the dates of death of all those who died in his town during thirty-five years, giving correctly their names and ages. Some imbeciles present relatively remarkable aptitudes for the arts, especially for music. They retain with surprising facility complicated pieces of music, and are able to reproduce them passably well on an instrument. Still they never acquire a true talent, for they lack the attention which is necessary for the development of their natural aptitudes.

Physically all the anatomical stigmata of degeneration may be met with in idiots and imbeciles.

The sexual instinct is absent (lowest type of idiocy) or abnormally developed, or perverted. Many idiots and imbeciles are addicted to masturbation, to pederasty, or have a tendency to commit acts of rape, exhibitionism, sadism, etc.

Filthy habits are frequent: the patients soil and wet themselves. Often this symptom is only nocturnal and can be combated by constant supervision.

Complications. These are somatic and psychic. The former arise from defects of development or from a low resistance of the organism. They are, on the one hand, the malformations constituting the physical signs of degeneration, and, on the other hand, various infections occurring upon a basis of poor nutrition of the tissues.

Among the sequelæ left behind by the infections a prominent place belongs to permanent lesions of the brain and cord, which give rise to phenomena of paralysis, atrophy, etc. (infantile hemiplegia, infantile palsy, strabismus). These disorders are often coincident in time with the mental disorders and are dependent upon the same causes.

Epilepsy forms a transition between the somatic and the psychic complications. The frequency of infantile convulsions in the histories of cases of arrested development in itself shows the close relationship existing between epilepsy and arrested development. Epileptic seizures are frequent in idiots and imbeciles. The commotion which the seizures exercise upon the psychic functions leads to an accentuation of the mental debility. The imbecile becomes, in addition, an epileptic dement.