and
Primary By
Secondary
Amentia
L. S. PENROSE, M.A., M.D.,
Research Medical
Officer, Royal Eastern Counties' Institution
The tradition of classifying all mental defectives into the two categories of primary and secondary amentia has been very widely known and followed. Different names have been applied to the two classes in different countries and by different people but the dichotomy is in each case essentially the same, the fundamental idea behind it being that the mental impairment of every defective is either due to hereditary (germinal) abnormality or else acquired in the course of the life of the individual either before, during or after birth. It was not unnatural that the earliest attempts at classifying defectives employed the same terms which are in general use in medicine and disThat is to say, they tinguished between congenital and acquired idiocy. between birth and those those cases who were affected before distinguished who acquired a disease afterwards. The position was complicated by certain French physicians who used the term idiocy to signify congenital and imbecility to signify acquired defect. In 1877 Ireland C) proposed a grouping based on pathological considerations and gave the name genetous idiocy to the cases which he considered to be determined by heredity, among which "
(x) Idiocy
and
Imbecility.
"
MENTAL WELFARE
58
he included mongolism The of different headings such as "
remaining patients were microcephalic idiocy,"
"
named under "
epileptic
number idiocy," and a
paralytic idiocy." Tredgold, (2)
in 1920, revised this classification, calling those cases be of hereditary or germinal origin, Primary and the remainder, Secondary. At the same time he retained the descriptions of the various different types such as microcephalics, epileptics, mongols, but he left it to be decided by further analysis whether the patient belonging to any of these groups was a primary or secondary anient. Fie gave his opinion, however, that 80% of all cases were primary, but other authorities differ on the question of the correctness of this figure. The varying estimates depend partly on the type and grade of cases studied and partly on the theories of the observer. Where large groups are analysed, the first of these influences will The estimate of Shrubsall and Williams (") in 10,000 not apply so much. cases was 71% primary. Larsen (4), in a series of" 1,000 examinations, gave defectives?a group conthe value 76% for what he termed endogenous which he deemed
to
"
forming closely, by definition, to Tredgold's primary group. Let us now consider the question from the critical point of view. Imagine we are faced with the problem of deciding whether a given patient is to be placed in the group of Primary or Secondary defectives. We are to consider every relevant fact in the personal and family history and make up our minds one way or the other. I will illustrate this by describing a case. There is a female patient in the R.E.C.I., aged 19, who shows a very characteristic post-encephalitic condition. She is much retarded in all her actions and in speech. She drags her feet when walking and does not swing her arms. The face is expressionless and the power of convergence of the
eyes is lost. As far as it can be ascertained, the disease came on at about the age of 11, after or during an attack of what was diagnosed as mumps at the time. She subsequently learnt little at school, partly owing to her being awake at night and sleepy by day. Soon after, her behaviour with men began to attract attention. After leaving school, she was tried in one or two situations but was dismissed as incapable. Then she was found to be pregnant and had a miscarriage. This led to her institutional detention, first as a place-of-safety Fler mental age, as judged case and later on she was certified feeble-minded. by the Stanford-Binet scale, is ten years and she scored nine years six months on the Porteus Maze Tests. One's first impulse in a case of this kind is to say that it is clearly an example of purely secondary amentia, if indeed one would call it amentia But there is another side to the picture. By careful investigation, we at all. found evidence of mental retardation previous to the attack of encephalitis. (2) Mental Deficiency, 1st Edition. (3) Mental Deficiency Practice. (4) A Neurologic-Etiologic Study. Fac. 1.)
(Acta Psychiatrica
et
Neurologica,
Vol.
VI, 1931,
MENTAL WELFARE
59
The mistress of the school she attended up to the age of ten remembered her well and informed us that she was rather restless and backward in her work, definitely above the special school standard but two or three years retarded in some subjects, for example, she was very bad at arithmetic and " altogether a C child." She further said that, although the child was sensible and likeshe seemed a bit able, naughtier than the other children. Now it seems clear that this girl was below the normal standard of intelligence and would have come into the group of dull or backward children in any circumstances. An organic disease was sufficient to produce mental deficiency on this foundation, possibly the same disease would have had less effect on a cleverer or more stable individual. If dullness is due to heritable factors it seems there must be an element of primary amentia in this case. Let us look into it further. The parents are healthy, working-class people and come from average families. The patient, however, is the result of one of ten pregnancies, two of which were miscarriages. Two children died in infancy of convulsions and one died of meningitis at the age of fourteen months. The rest are healthy and of average intelligence. Is it possible now that there is a familial disposition here to cerebral infection possibly inherited as a recessive factor? If this were the case we should have to presuppose an additional cause of the patient's deficiency. Encephalitis lethargica is a disease which is probably disseminated to a great extent by carriers who are themselves immune and it is likely that this immunity is, in part, determined genetically- If this is so, it is impossible to classify post-encephalitics either as primary or secondary amenta. They must belong to a class which is primary in the sense of susceptibility which is genetically determined, and secondary in the sense that the condition would not have come about but for the accidental presence of the infective agent. I have described this one case because it shows the difficulty of classification fairly freely, but I could have described almost any case in the institution to illustrate the same difficulty. Very often the more one knows about a case the more difficult it is to classify it correctly and, usually, to classify patients as primary aments is equivalent to the assertion that we are completely ignorant of the cause. It is true that there are certain well-marked examples of heritable characters which cause mental deficiency. The best established example being amaurotic family idiocy. It is quite likely that there are a number of commoner conditions than this which also could be classified as purely primary, but they have not yet been adequately described. Many, but not by any means all, of the class of defectives known as the sub-cultural group may turn out to be of purely hereditary origin: we cannot be sure of these until we have excluded the possible environmental effects. The class of purely secondary defectives is not large, but is equally difficult to define. We can never tell for certain that there is not a hereditary disposition present in infective conditions. In mongolism and some other definite types we have strong indications that both and environmental adverse factors work together to form the final
hereditary
product.
60
MENTAL WELFARE
It is curious that the belief that all defectives can be divided into the two groups of primary or secondary or similar classes should be so widely accepted. If we take a case at random and examine it carefully we are extremely likely to find that it cannot be put into either category. The only way is to judge, in each case, the probable effects of heredity and environment, manifested in various ways, and assess their relative importance.
Primary By
Secondary
Amentia
L. S. PENROSE, M.A., M.D.,
Research Medical
Officer, Royal Eastern Counties' Institution
The tradition of classifying all mental defectives into the two categories of primary and secondary amentia has been very widely known and followed. Different names have been applied to the two classes in different countries and by different people but the dichotomy is in each case essentially the same, the fundamental idea behind it being that the mental impairment of every defective is either due to hereditary (germinal) abnormality or else acquired in the course of the life of the individual either before, during or after birth. It was not unnatural that the earliest attempts at classifying defectives employed the same terms which are in general use in medicine and disThat is to say, they tinguished between congenital and acquired idiocy. between birth and those those cases who were affected before distinguished who acquired a disease afterwards. The position was complicated by certain French physicians who used the term idiocy to signify congenital and imbecility to signify acquired defect. In 1877 Ireland C) proposed a grouping based on pathological considerations and gave the name genetous idiocy to the cases which he considered to be determined by heredity, among which "
(x) Idiocy
and
Imbecility.
"
MENTAL WELFARE
58
he included mongolism The of different headings such as "
remaining patients were microcephalic idiocy,"
"
named under "
epileptic
number idiocy," and a
paralytic idiocy." Tredgold, (2)
in 1920, revised this classification, calling those cases be of hereditary or germinal origin, Primary and the remainder, Secondary. At the same time he retained the descriptions of the various different types such as microcephalics, epileptics, mongols, but he left it to be decided by further analysis whether the patient belonging to any of these groups was a primary or secondary anient. Fie gave his opinion, however, that 80% of all cases were primary, but other authorities differ on the question of the correctness of this figure. The varying estimates depend partly on the type and grade of cases studied and partly on the theories of the observer. Where large groups are analysed, the first of these influences will The estimate of Shrubsall and Williams (") in 10,000 not apply so much. cases was 71% primary. Larsen (4), in a series of" 1,000 examinations, gave defectives?a group conthe value 76% for what he termed endogenous which he deemed
to
"
forming closely, by definition, to Tredgold's primary group. Let us now consider the question from the critical point of view. Imagine we are faced with the problem of deciding whether a given patient is to be placed in the group of Primary or Secondary defectives. We are to consider every relevant fact in the personal and family history and make up our minds one way or the other. I will illustrate this by describing a case. There is a female patient in the R.E.C.I., aged 19, who shows a very characteristic post-encephalitic condition. She is much retarded in all her actions and in speech. She drags her feet when walking and does not swing her arms. The face is expressionless and the power of convergence of the
eyes is lost. As far as it can be ascertained, the disease came on at about the age of 11, after or during an attack of what was diagnosed as mumps at the time. She subsequently learnt little at school, partly owing to her being awake at night and sleepy by day. Soon after, her behaviour with men began to attract attention. After leaving school, she was tried in one or two situations but was dismissed as incapable. Then she was found to be pregnant and had a miscarriage. This led to her institutional detention, first as a place-of-safety Fler mental age, as judged case and later on she was certified feeble-minded. by the Stanford-Binet scale, is ten years and she scored nine years six months on the Porteus Maze Tests. One's first impulse in a case of this kind is to say that it is clearly an example of purely secondary amentia, if indeed one would call it amentia But there is another side to the picture. By careful investigation, we at all. found evidence of mental retardation previous to the attack of encephalitis. (2) Mental Deficiency, 1st Edition. (3) Mental Deficiency Practice. (4) A Neurologic-Etiologic Study. Fac. 1.)
(Acta Psychiatrica
et
Neurologica,
Vol.
VI, 1931,
MENTAL WELFARE
59
The mistress of the school she attended up to the age of ten remembered her well and informed us that she was rather restless and backward in her work, definitely above the special school standard but two or three years retarded in some subjects, for example, she was very bad at arithmetic and " altogether a C child." She further said that, although the child was sensible and likeshe seemed a bit able, naughtier than the other children. Now it seems clear that this girl was below the normal standard of intelligence and would have come into the group of dull or backward children in any circumstances. An organic disease was sufficient to produce mental deficiency on this foundation, possibly the same disease would have had less effect on a cleverer or more stable individual. If dullness is due to heritable factors it seems there must be an element of primary amentia in this case. Let us look into it further. The parents are healthy, working-class people and come from average families. The patient, however, is the result of one of ten pregnancies, two of which were miscarriages. Two children died in infancy of convulsions and one died of meningitis at the age of fourteen months. The rest are healthy and of average intelligence. Is it possible now that there is a familial disposition here to cerebral infection possibly inherited as a recessive factor? If this were the case we should have to presuppose an additional cause of the patient's deficiency. Encephalitis lethargica is a disease which is probably disseminated to a great extent by carriers who are themselves immune and it is likely that this immunity is, in part, determined genetically- If this is so, it is impossible to classify post-encephalitics either as primary or secondary amenta. They must belong to a class which is primary in the sense of susceptibility which is genetically determined, and secondary in the sense that the condition would not have come about but for the accidental presence of the infective agent. I have described this one case because it shows the difficulty of classification fairly freely, but I could have described almost any case in the institution to illustrate the same difficulty. Very often the more one knows about a case the more difficult it is to classify it correctly and, usually, to classify patients as primary aments is equivalent to the assertion that we are completely ignorant of the cause. It is true that there are certain well-marked examples of heritable characters which cause mental deficiency. The best established example being amaurotic family idiocy. It is quite likely that there are a number of commoner conditions than this which also could be classified as purely primary, but they have not yet been adequately described. Many, but not by any means all, of the class of defectives known as the sub-cultural group may turn out to be of purely hereditary origin: we cannot be sure of these until we have excluded the possible environmental effects. The class of purely secondary defectives is not large, but is equally difficult to define. We can never tell for certain that there is not a hereditary disposition present in infective conditions. In mongolism and some other definite types we have strong indications that both and environmental adverse factors work together to form the final
hereditary
product.
60
MENTAL WELFARE
It is curious that the belief that all defectives can be divided into the two groups of primary or secondary or similar classes should be so widely accepted. If we take a case at random and examine it carefully we are extremely likely to find that it cannot be put into either category. The only way is to judge, in each case, the probable effects of heredity and environment, manifested in various ways, and assess their relative importance.
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