Imbecility with Insanity. 
BY 
HENKY M. jHURD. M. D., 
Pontiac, Mich. 
3£teprint 
FROM 
The American Journal of Insanity, 
Utica, October, 1888. IMBECILITY WITH INSANITY.* 
BY HENRY M. HURD, M. D., 
Superintendent of the Eastern Michigan Asylum, Pontiac, Michigan. 
Idiocy is a mental defect depending upon malnutrition or disease 
of the nervous centres, occurring before birth, or before the 
evolution of the mental faculties in childhood. Imbecility is an 
arrest of mental development at a subsequent period prior to the 
full maturity of the mental faculties. In this paper it is my design 
to exclude idiocy and epileptic imbecility, the latter being due to 
a constantly acting exciting cause, and a condition more nearly 
allied to dementia than to imbecility. In my experience many 
grades of imbecility come under our notice in asylums, some of 
which are nearly allied to idiocy and others are associated with 
such a degree of mental development as to render it difficult to 
detect at first glance any glaring mental defect. Some imbeciles 
are defective physically as well as mentally. They have coarse 
features, large-lobed, misshapen ears, defective teeth and badly 
shaped heads. They speak a few simple words, but are unable to 
frame sentences or to express the simplest abstract idea. They 
often acquire habits of industry and an ability to do rough routine 
work satisfactorily, but cannot acquire a trade and rarely if ever 
possess any mechanical skill. If carefully guarded at home from 
the persecutions of vicious and unfeeling persons, they frequently 
go through life quiet, harmless and not unuseful members of 
society. If plagued by their companions they become irritable 
and violent and often require the seclusion and restraint of an 
asylum, for no other reason than the fact that they have at- 
tempted to live among semi-savages. They are not capable of 
much education. As far as I now recollect, no case of undoubted 
insanity in an imbecile of this class has come under my observa- 
tion. A second class can converse correctly and formulate 
simple ideas readily. In some instances in fact they converse 
quite well and often display much shrewdness in their remarks. 
They are vain, quarrelsome, irritable, not very teachable, and are 
usually unable to read or write. They are generally free from 
delusions, but are perverted and disagreeable and a cause of dis- 
comfort to those with whom they come in contact. They have 
* Read at the annual meeting of the Association of Medical Superintendents of 
American Institutions for the Insane, held at Old Point Comfort, Va., May 15-18,1888. 2 
little manual dexterity, and no ability to learn how to do work. 
Their perceptive faculties are good; their reasoning powers and 
applied faculties are nil. The following case will serve as an 
example of this form of disease. A. S., seventeen years of age at 
admission, and now twenty-five, a female, a native of Michigan, of 
American parentage, was admitted to the Eastern Michigan 
Asylum in December, 1879, and is still an inmate. She is unable 
to read beyond a few letters, and has never learned to write. She 
has never been bright. Her head is small and misshapen, her 
figure unsymmetrical, and her expression of countenance indicative 
of low cunning. She lived at home until the age of sixteen, when 
she became unmanageable, and was transferred to the county 
almshouse for custodial care. There she consorted with vicious 
paupers of the other sex, and was so disorderly as to be sent to 
the house of correction. At the house of correction her insanity 
was soon recognized and she was sent back to the county to be 
lodged in jail as the only place of refuge left for her. Her mental 
disorder has been characterized by restlessness, violence, lewdness 
and insane impulses. She has frequently attempted suicide without 
being depressed, or without any adequate reason. She is exces- 
sively loquacious, and her conduct is lacking in sense of propriety. 
She is fond of dress and display, and many of her outbursts of 
excitement seem due to a perverted desire to make a sensation. 
If she is associated with a patient suffering from extreme mental 
disturbance she is usually interested and helpful. If, however, 
she resides in a quiet hall, she usually improves the occasion to 
render it as disturbed as possible. As a rule she goes to work as 
methodically and painstakingly to create a disturbance as a 
Chinaman prepares for his annual debauch. In the commencement 
of a period of mental disturbance it is sometimes possible by 
conversation, active exercise, or suitable medication to avert the 
storm. Generally, however, the mental storm is only temporarily 
averted by any measures, and eventually breaks with increased 
fury at last. She is excessively noisy, violent, destructive— 
especially to glass, and inclined to injure herself recklessly. After 
eight years of asylum residence her mental condition is in little 
degree more comfortable than when she came. She has never 
manifested any delusions. 
A third class comprehends imbeciles of a better grade of mental 
development, who have palpable delusions and are influenced in 
their conduct by them. Among males the characteristic delusions 
are generally those of apprehension, due possibly to the persecu- 3 
tions which the feeble-minded usually encounter, and undoubtedly 
in many cases to vicious personal habits. G. P., male, aged 33, 
single, native of Pennsylvania, common laborer, no religion, no 
education, an intemperate father, addicted to masturbation and the 
use of liquors and tobacco. He has always been feeble-minded, 
slow of speech, and quick-tempered. His head is ill-shapen. His 
attack of insanity, which is of one year’s duration, is ascribed to 
an injury to the head. About a year ago he returned home 
bearing a scalp-wound over the left parietal bone, which he said 
had been inflicted with a club. His insanity was first noticed 
after the accident, but his friends ascribe the attack to drink. 
He first destroyed furniture, assaulted his friends and attempted 
suicide. After this outbreak he was quieter, but remained for 
many months excitable and dangerous. He finally attempted to 
throw himself in front of a moving train and was taken to jail for 
safe-keeping. When brought to the asylum he was moody and 
irritable and very apprehensive of personal injury. He was afraid 
to take his meals in the dining-room, and required to be urged to 
go, or was taken by force. Under asylum treatment he remained 
moody and apprehensive for many months. He had frequent 
collisions with his fellow patients, and displayed many causeless 
aversions to his attendants. He was unwilling to speak except in 
a whisper. After the lapse of four years he began to employ 
himself usefully, and for a year past has been able to work regu- 
larly in the laundry, and is now probably as well as he has ever 
been. His delusions of apprehension undoubtedly originated from 
the persecutions which he had been subjected to for many years 
on the part of thoughtless and unfeeling boys. He now dis- 
charges his duties punctiliously and faithfully, and is fond of 
approbation. He seeks the society of others and seems pleased to 
meet strangers. 
Among females the delusions of imbeciles are often of a 
religious or sexual character and generally of both combined. 
The following case illustrates imbecility with religious and sexual 
delusions: 
A. L. M , female, age 55, single, native of Michigan, merchant’s 
daugher; father, mother and paternal aunt insane, the father com- 
mitted suicide and the'mother had delusions of coming to poverty; 
a cousin, C. J. Guiteau, murdered President Garfield. As a child 
she was bright, but possessed an impressible organization, which 
unfortunately was taken advantage of by her father to conduct 
some experiments in mesmerism. She was an excellent subject, 4 
but the effect was to arrest her growth, and she has not developed 
mentally since she was twelve years old. She became feeble in 
mind, unduly religious and deeply emotional. While at church 
she was invariably moved to tears at some stage of the service 
and sobbed so loudly as always to require to be quieted by a com- 
panion. Until the grand climacteric she showed no active 
delusions, but was simply feeble of intellect and silly. At the 
age of forty years however she began to develop erotic delusions. 
She fancied that the clergyman in the pulpit—a married man by 
the way—made her an offer of marriage, that a literary gentleman 
of excellent reputation—also a married man—had broken his 
plighted troth, and that several others desired to marry her. She 
finally conceived an impression that she has been married and was 
to give birth to a child, and at last became so disgusting in con- 
versation as to require asylum custody. For fourteen years past 
she has been an inmate of an asylum, and during all this time has 
been the victim of active delusions. She has had hallucinations 
of hearing and vision; has been quarrelsome and irritable and lack- 
ing in self-control. Her assaults upon her fellow patients, which 
have been frequent, have been due to delusions. There has been, 
in short, an active form of mental disease developed in a person 
of defective intellect. 
In some instances, however, imbeciles suffer from well-marked 
acute and recurrent mania. In this connection an extract from a 
letter written by Dr. Carson, of the New York Asylum for Idiots, 
will be of interest: “ Since I came here three years ago we have 
had two imbeciles of the micro-cephalic type become insane. 
They were brother and sister. The sister had acute mania and 
was sent to the Hudson River Hospital for the Insane. The 
brother had an attack two years ago, was insane for two or three 
months and then recovered. He remained well for nearly a year, 
then became insane again, and the last time had well-marked 
delusions. He thought his blood was all running away from him, 
and that he was receiving electric shocks. He is now at the 
Willard Asylum.” 
C. B., age 24, was admitted to the Eastern Michigan Asylum 
nearly six years ago. There is no history of any convulsive 
seizure. It is stated that she was a person of normal mental 
development up to the age of seven years, but this is doubtful. 
Her general appearance indicates that she had rickets as a child. 
Her body is short, but stout (her weight being 126 pounds, her 
height 4 feet 10£ inches,) and she is stooped-shouldered and 5 
narrow-chested, with a head disproportionately large for her body. 
Her gait is shuffling and her muscular movements clumsy. She 
is able to read and to follow a copy in writing. She also dresses 
and feeds herself and does some routine household work. She 
began to menstruate at the age of ten years, and has since per- 
formed this function regularly. At the age of fifteen her 
admission to the New York Asylum for Idiots, then under the 
charge of Dr. H. B. Wilbur, was sought on account of the 
development of “ mad fits ” which her physician was sure could 
not be mania because she controlled herself well when in the 
presence of strangers. She was retained there two or three years, 
but her removal was finally ordered on the ground that she was 
an insane imbecile, and not amenable to educational advantages. 
Unfortunately, owing to Dr. Wilbur’s death, I have not been able 
to get any particulars of her conduct while at this school. After 
being at home about a year she was transferred to the Eastern 
Michigan Asylum in the autumn of 1882. Upon her admission 
she was violent and destructive, loquacious, vulgar in language 
and excessively irritable. She had periods of screaming, gasping 
for breath and furious outbreaks of excitement for about seven 
months, when she became quiet and depressed for four months. 
This was followed by a period of mental disturbance of three 
months’ duration, and this in turn by a period of profound mental 
and physical depression of several months’ duration, from which she 
slowly emerged in such a comfortable state of mental health that 
her mother was able to take her home for nearly a year. After 
her return to the asylum she had a period of excitement lasting 
five months, followed by a period of stupidity and mental 
depression lasting nearly four months, from which as before she 
slowly recovered so as to go home with her mother—this time for 
a period of about five months. She was again returned in conse- 
quence of the development of maniacal excitement which lasted 
for four months, and was succeeded by a period of quiet. Similar 
alternations have occurred up to the present time. Perhaps I 
should add that when she is depressed she has a delusion that she 
will die, and talks much of death. Her disease in fact has 
assumed all the characteristics of folie circulaire. The symptoms 
which have characterized her outbreaks suggest the query whether 
after all pubescent insanity, with its alternations of excitement and 
stupidity, or elation and depression, is not in all essential respects 
an allied condition. There are indeed many reasons to think that 
in cases of pubescent insanity an arrest of mental development, 6 
and a consequent condition of imbecility develops at the age of 
puberty. In reviewing those cases of pubescent insanity which 
have come under my attention I am deeply impressed with the 
developmental character of the disorder. 
In other imbeciles systematized delusions of persecution often 
develop in consequence of some untoward event which excites 
their fears or gives rise to a severe mental shock. The following 
will serve as an example: 
J. K., age 29, single, native of Germany, a farm laborer with 
limited education, but able to read and write, of good habits, 
amiable, kind-hearted and industrious, but lacking in judgment, 
easily imposed upon and unsuccessful in business, was admitted 
to the Eastern Michigan Asylum in April, 1887. He had a small, 
badly-shaped [head and disproportionately large ears, and had 
never been considered bright. He has, however, been able to do 
routine farm work successfully, and had been respected and self- 
supporting. For several years previous to his admission he had 
resided with a respectable farmer. During the past few months he 
became impressed with the idea that his employer’s daughter had 
promised to marry him. lie also under a similar impression that 
the wedding day had been set, had purchased a wedding suit and 
made arrangements for the marriage. He subsequently ac- 
knowledged that he had never had any conversation with the girl 
upon the subject of marriage, nor had he ever spoken to her 
parents about it, but he “knew” from his feelings that she 
reciprocated his affection, and that her parents designed to have 
him marry her. He finally became so open in his matrimonial 
intentions that his employer ordered him to leave the house, and 
after much difficulty succeeded in convincing him that his atten- 
tions to the girl were unwelcome. He immediately began to com- 
plain that the girl had “jilted ” him, and conceived the idea that 
her parents had turned against him and were persecuting him. 
In his despair he procured a revolver and started for the woods to 
destroy himself, but his intention was discovered, and he was 
pursued by friends, when in an agony of apprehension and fearing 
immediate personal injury he turned and fired upon them, 
fortunately without effect. He was at once disarmed and trans- 
ferred to the asylum. Upon coming he was thin in flesh, timid 
and apprehensive. He took food irregularly, through fear of 
poison, and slept badly. He had some appreciation of his con- 
dition, and recognized that his mind was unbalanced. His con- 
versation was coherent, but his mind acted slowly. He seemed 7 
grateful for attention, showed much kindness of heart towards the 
sick, and was free from unpleasant traits. Under careful manage- 
ment his apprehensions were allayed, and he improved rapidly in 
bodily health. His delusions also disappeared, and he was able to 
go home with a relative upon trial in about three weeks, apparently 
as well as usual. In this case no cause could be assigned for his 
attack except an attendance upon special religious meetings. 
I now approach another class of imbeciles with considerable 
hesitation because a consideration of their characteristics brings 
up immediately the question of moral insanity, so-called. I refer 
to cases of imbecility with moral perversions. In these unfor- 
tunate persons there seems to be a normal and, in fact often an 
undue development of the perceptive faculties, emotions and 
organic impulses, and a corresponding deficiency of reasoning and 
inhibitory powers. In all persons of this class with whom I have 
come in contact the degree of mental development is about equal 
to that of a person of average mental capacity at puberty, and 
beyond this point the unfortunate moral imbecile never seems to 
go. Up to the age of puberty, for obvious reasons, their mental 
deficiencies are not apparent, but when they pass this age and 
begin to feel the stirring of physiological impulses their mental 
deficiency becomes patent to all. The more their characteristics are 
studied the more evident it becomes that the apparent moral defect 
is really a mental deficiency. They are incapable as a rule of 
reasoning or of taking the “sober second thought” which is so 
essential to sound and correct action, but are the creatures of 
wayward impulses and go wrong because they have no will-power 
to go right. The immorality of their lives and the depravity of 
their conduct do not spring from deliberate choice or a settled 
action of the will, but from organic impulses which they have not 
the will to control or the reasoning powers to understand that 
such control is essential to future happiness and well-being. In 
my experience they are not wantonly cruel or utterly depraved. 
They have some good impulses, but mox-e bad ones, and are wicked 
because they have not will-power enough to be good. The proof 
of these statements is largely found in the fact that they go on 
from bad to worse, and invariably, in the asylum or out of it, 
become hopelessly demented. They generally come from neurotic, 
depraved or insane families. A single case will serve as an 
example: I. D. V., a female, seventeen years of age, had an 
intemperate, dissolute and depraved father, an insane mother and 
sister, and a “ ne’er-do-well ” brother who was an inmate of a 8 
reformatory. She graduated from a county poorhouse to the 
State Public School, where many ineffectual efforts were made to 
“bind her out”—ineffectual because of her bad conduct—and 
from the State Public School to the Girl’s Reform School, and 
finally after three years in the latter, became an inmate of the 
Eastern Michigan Asylum because of the development of suicidal 
and violent impulses. She was neat in dress, attractive in appear- 
ance, and had considerable taste and ability in dress-making and 
fancy work. She was free from delusions, but was seemingly 
destitute of any self-regulating power. She was childish in her 
relations with physicians, attendants or fellow patients, and wholly 
unreasonable in conversation and conduct. She was jealous, sus- 
picious, irritable and depraved. She had a great craving for 
approbation, and if petted, praised and made much of, was amiable 
and pleasant, but if for any reason she imagined herself to be 
slighted she yielded to sudden and most violent impulses. She 
attempted to dash out her brains, to destroy glass, pictures and 
furniture. She was frequently able, when everything was favora- 
ble, to avoid an outbreak for several months, but the storm sooner 
or later came with disastrous fury. She usually assigned some 
trivial cause for her conduct, and seemed incapable of reasoning 
in a manner to combat her destructive impulses. Her last period 
of fury, which followed eight months of composure, was of a 
year’s duration and resulted in a confirmed state of chronic mania 
with great incoherence. 
A word as to causation. The causes of the development of 
insanity among imbeciles are not as complex as those of ordinary 
insanity, owing to the limited mental range of the imbecile. 
Cases have been reported where attacks of melancholia or mania 
have developed in imbeciles in consequence of a severe mental 
shock, like the sight of a sudden death, a fright, or some over- 
whelming calamity, but such causation seems rare. In the great 
majority of insane imbeciles, heredity undoubtedly plays a most 
important part. The insane imbecile, in almost every instance, 
inherits an unstable nervous organization from an insane ancestor, 
which is liable to take on diseased action at the various physiologi- 
cal epochs of life. The great majority of those who become insane 
develop mental trouble at puberty, some at the beginning of adult 
life, and a few at the grand climacteric. I am also of the opinion 
that masturbation or sexual vices are most important aetiological 
factors of insanity in these defective organizations. 9 
As a result of the above inquiry into the insanity of imbeciles 
the following conclusions may be given: 
1. As a rule the lowest grade of imbeciles are irritable and 
impulsive, especially when annoyed, but they do not have delu- 
sions nor can they properly be considered insane. 
2. In the next higher grade of imbecility an actual insanity is 
developed, which assumes the form of impulsive acts, morbid 
propensities and even acts of suicidal or homicidal intent, without 
delusions and without sustained mental disturbance. 
3. A still higher grade of imbecility exists in which attacks of 
acute and recurrent mania, simple melancholia, and malancholia 
with systematized delusions may be present. These attacks run 
about the same course as in persons who possess a normal brain. 
4. In cases of moral insanity, so called, or of imbecility with 
moral perversion, there is always present from the age of puberty 
a well marked mental deficiency of a progressive character, which 
goes on to confirmed dementia. The apparent moral defect is in 
reality a mental one. 
5. The determining causes of the development of insanity 
among imbeciles are generally physiological epochs or crises, or 
vicious practices or indulgences acting upon a neurotic organiza- 
tion which has been directly inherited from an insane or dissolute 
parent.