CHAPTER IV
THE MEDICAL EXAMINATION OF DEFECTIVES
Hitherto we have been studying the defective from the point of view of his school relations. This point of view is incomplete, and should not make us forget that there is another--the medical. It is quite certain that in the organisation and the practical working of the special schools the doctor has a role, and an important role, to fill. All foreign countries recognise this, and give him a large place. It is even regretted in some countries that doctors detach themselves too much from such questions, and are content to make a rapid and superficial examination of children on their entrance to school, instead of collaborating actively in the important work of the teacher.
After this declaration of principles, it may not be without interest to fix precisely the role which belongs to the doctor and the services which he can render. It seems to us, in fact, that there is often some confusion as to his attributes, and two opposite tendencies may be recognised. According to one, the more widespread, the defective are often, if not always, invalids, and belong to him by right. It would be an encroachment upon his privileges to concern oneself with them. The opposite opinion consists in not committing to him any particular authority in the matter. This is the case in Germany, where there are schoolmasters who carry things with a high hand in the special schools. Let us add that the doctors themselves have done nothing to bring about an entente. Speak of defectives before them, and they say, "That is our business," and they are perfectly right; but having affirmed their right, they pay very little attention to the territory they defend.
It seems to us that the field is sufficiently great for everyone to glean, and the efforts of all will not be too great to clear it. There are some questions which escape the doctor, unless he is also an educationist and a psychologist. But there are also some, in our opinion, for which he has special competence, and where no one can take his place. To define his role is not to lessen it; on the contrary, it is to assure him an authoritative position. It is not his business to select the abnormal from the normal. But from the children picked out as abnormal he will differentiate certain types and prescribe certain measures with regard to their care and treatment.
THE DOCTOR NOT TO PICK OUT THE DETECTIVES FROM AMONGST THE CHILDREN IN SCHOOL.
There is a general misunderstanding with regard to the special knowledge and aptitude of the doctor. One tends to credit him with a kind of omnipotence and infallibility against which he protests in vain. He is made to judge questions which do not belong to his special province--namely, the medical, and upon which he expresses opinions which are neither more nor less valuable than those of any other intelligent person. Recently, at various congresses, we have seen doctors with the best intentions laying down educational programmes, comparing the educative value of science with that of letters, and expressing a variety of opinions, no doubt very sensible, but with which the medical art had nothing whatever to do. As regards the selection of defectives, one is influenced by the same prejudice. We have discussed this with many people, and especially with educationists, and when we have insisted on the difficulties of examination, they usually reply, "That is the doctor's business!" The prejudice we have noted is very tenacious, and will doubtless be difficult to overcome, for there are many people who have interests to maintain of a pecuniary nature. Let us consider this question from two points of view--the estimation of educational retardation, and the physical examination of defectives.
=Estimation of the Degree of Mental Inferiority.=--We have seen how easily, in spite of the commonly accepted opinion, experienced teachers and inspectors accomplish this part of their task. If a doctor were charged with it his embarrassment would be great. Just imagine a doctor introduced into a school of 300 children in order to pick out the defectives by strictly medical methods. No doubt every doctor, especially if he is an alienist, is called upon to estimate the intellectual level of children, and to sign certificates of idiocy, imbecility, and feeble-mindedness. But just consider how things are managed at the consultation. The parents bring the child. They know very well that he is "not like others." They bring him for that very reason, and consequently the doctor does not require to distinguish the child from a normal one. He only requires to sit and listen to the parents, who give him a crowd of particulars. When he questions and examines the child, it is only to verify what he has learned, and to add his own personal impression. As a general rule the case is a severe one; the deficiency is so evident that any sensible person would notice it. The task of the doctor is therefore narrowed. He has only to certify the mental deficiency of the patient, stating in technical terms the diagnosis which the parents have brought to him ready made. Even his estimation of the gravity of the case, apart from special investigations on his part, is not very different from that of ordinary people who readily distinguish between the idiot who cannot speak; the imbecile, who can make himself understood, though he cannot be educated; and the feeble-minded, who can do some work, but is not able to provide for his wants, or to behave himself sensibly.
When the doctor thus certifies the intellectual level of the patient, does he try to do so with precision? By no means, for it is not expected of him. The parents do not come to him in order to ask him, "Is my child backward in his mental development?" Alas they see it only too well, and little it matters to them whether his backwardness amounts to six months or a year. But they do come to ask, "Why does this child not make the usual progress? Is there not some medicine, doctor, which can help his development?" When they come to the doctor, it is not even with the hope that some medico-pedagogical treatment will cure their child. They know very well that the devoted care which they have always bestowed upon him from his infancy is superior to anything which can be given to him at a dispensary for children; but their indomitable hope leads them to seek chimerical measures. In all this, let us repeat, the doctor does not require to estimate the degree of mental deficiency with any delicacy. But if he should try to do so, what methods would he use?
Here is a child of nine years of age, who has been selected for a class for defectives because he cannot follow the usual lessons in the elementary school. You, however, doctor, put to him some of your usual questions. You ask the child his name, his age, the occupation and address of his parents; the date, day, month, year; some details about his life; you even ask him to read or count. The replies are given to you quietly and correctly. Are you going to refuse to admit him to the special school, and by what right? You have the notes of one, of two, or of three teachers. He cannot follow; he is still with children of seven years of age, in spite of having been at school for three years. It is evident that he is not an idiot, nor an imbecile, nor even feeble-minded to any great extent. But you have been notified that he is behind other children of his age. There is therefore something peculiar about him. It is not a medical question whether he ought to remain in the ordinary school. The doctor cannot go against the opinions which have been given to him, in order to verify whether the retardation is genuine. To do so, it would be necessary for him to make a comparison with the normal condition. Now this varies according to age. The doctor does not know exactly, to two or three years, the normal condition of the mental faculties; nor, after such and such a period of school attendance, the habitual level of instruction reached. That, however, in such special conditions, is the very problem which faces him. We do not hesitate to express the opinion that, in such circumstances, the doctor would be incapable of estimating the intellectual level of the child. He has no more experience in this matter than any other person. Let a doctor seek to pick out a feeble-minded child from a number of normal ones, and he will find how little he is prepared to make the selection.
=Physical Examination of Defectives.=--But it may be asked: "Is not mental debility associated with physical signs which the doctor alone is able to appreciate?" About this question three kinds of facts may be considered: those pertaining to anthropometry, the stigmata of degeneration, and physiognomy. Let us consider in order what help may be derived from these.
_Height and Head Measurements._--Numerous papers have been published upon height and cephalometry. The object of some has been to compare the less intelligent school children with those who are better endowed. Other authors have taken as their subject the study of asylum or hospital cases. The absence or paucity of results of the earlier studies seems to be due to a cause which we have referred to elsewhere (p. 39). The mistake has been made of judging the intelligence of the children by sole reference to the opinion of the teachers, although account should have been taken of the relationship between the age and the stage of instruction. The comparison between the height and head measurements of the hospital cases and those of school children is not subject to the same risk of error, and striking differences between the two have been noticed. But there is yet another factor which must be taken into account if the figures so obtained are to yield all they are capable of teaching. If one confines oneself to comparing the averages of the two sets of children, one finds them almost identical. We have shown that the only suitable method to use here is the method of arranging the figures in series. This proceeding has suggested to one of us a better method still, that of "frontiers." There is for each age a height limit below which the defectives become clearly more numerous. There are limits in the head diameters, upon each side of which are grouped the abnormally small and the hypertrophied heads, which are frequently associated with mental deficiency. We give here the table which one of us has published of the provisional frontiers for height and for the two cephalic diameters.
THE FRONTIERS OF ABNORMALITY (BOYS).
------+--------------+-----------------+--------------+-------------- Age. | Height. | Antero-Posterior| Transverse | Sum of | | Diameter. | Diameter. | Diameters. ------+--------------+-----------------+--------------+-------------- | Centimetres. | Millimetres. | Millimetres. | Millimetres. 6 | 100 | 164 | 134 | 298 7 | 105 | 166 | 135 | 8 | 110 | 169 | 136 | 305 9 | 111 | 171 | 137 | 10 | 120 | 172 | 138 | 310 11 | 124 | 173 | 139 | 12 | 130 | 174 | 140 | 314 13 | 135 | 176 | 141 | 14 | 140 | 178 | 142 | 320 15 | 142.5 | 179 | 143.5 | 16 | 154 | 180 | 145 | 325 17 | 147.5 | 181 | 146 | 18 | 150 | 182 | 147 | 329 ------+--------------+-----------------+--------------+--------------
What this table means is this: If we measure 100 children in an elementary school, we find only a small number (at most 10 per cent.) whose measurements are less than those indicated; if, on the other hand, we measure idiots and imbeciles, the proportion of those whose measurements are inferior is greater, amounting to over 25 per cent. Amongst 120 abnormal children we found not a single one who was below these frontiers in two measurements, whilst 10 per cent. of defectives were below. Certain measurements, therefore, are distinctly suggestive, although, no doubt, not absolutely diagnostic without reference to the subject examined.
_The Stigmata of Degeneration._--Everyone has heard of the physical malformations which are called the stigmata of degeneration. Some of these are very apparent, such as a sixth finger on the hand, or a hare-lip, or those deformities of the head, which are called _plagiocephalus_ (obliquely oval cranium), _scaphocephalus_ (boat-shaped cranium), etc. Other stigmata are less apparent, such as abnormal shapes of the ear, irregular growth of hair, of the teeth, alterations in the eye, etc. Some doctors, not all, have made a study of these various stigmata. But school directors and teachers know nothing about them except what the present-day widespread popularisation of medical knowledge has permitted them to know. Evidently it is no part of their business to take up the study, although no State diploma will prevent their doing so if it is their good pleasure. There is no law against it. But they would expose themselves to grave risks of erroneous interpretations owing to their ignorance of the manner in which stigmata are produced, and the ignorance of doctors on this subject is still great. The determination of the stigmata, their enumeration, and their description, belong, therefore, at any rate by preference, to the doctor. God save us from wanting to dispossess him!
But what help could their study render us in the question whether a particular child ought or ought not to be admitted into a class for defectives? There is an opinion which is very widespread, especially amongst teachers and ordinary people, a souvenir of the doctrines of Gall, that the physical stigmata are signs of the original character, and that the possessor of a certain shape of head is certainly defective. "I have taken my son," a worthy mother said to us, "to consult Dr. P., because he was learning nothing in his class. He was sent away from every school I sent him to, and he is unbearable at home. The doctor felt all over his head. He evidently saw that there was something particular wrong with the boy." We do not smile at this good mother. Plenty of other intelligent people hold her opinions, if they are not so naive in their language. They expect that the moment defective children are brought before them, they will find something peculiar, something ugly, in their physiognomy. And there are plenty of doctors, let us say frankly, who are equally naive, and, more serious still, allow themselves to be influenced by unconscious suggestions. If, like our worthy mother, we present to the doctor a child as defective, the doctor will, as a general rule, have no difficulty in demonstrating that he must be so. How many of us are there without stigmata? None of us is built upon the model of the ideal man. It is always possible to discover some anatomical detail which will give support to a preconceived opinion. But the same doctor who, on seeing a defective child with adherent ear lobes, will say that that was just what he expected, will abruptly change his opinion if he discovers a whorl of frontal hair on a child who is presented to him as normal, and will refuse to attach to the fact any importance whatever. As a matter of fact, these questions have not yet been studied as they ought to be, by a comparison without _parti pris_ between normal and abnormal children of the same age and in the same environment, and we do not yet know how stigmata should be interpreted. We can only suggest some provisional conclusions.
The first of these conclusions is that the presence or absence of a definite stigma has no exact significance for the individual who bears it; for on the one hand one meets with all kinds of malformations in average normal children, and on the other hand, some who are definitely abnormal are quite normal in their conformation. The stigma, therefore, has not the value of a definitely pathognomonic sign like the crepitating rale of pneumonia, or the transient unconsciousness of epilepsy; but if we compare a group of normal children with a group of abnormal, the total number of the stigmata will be much greater in the second group; and, moreover, the multiplicity of stigmata in a single individual constitutes a strong probability that that individual is abnormal. Here are some facts which support these two propositions:
Recently we made a rapid examination of the heads of fifty-eight school children, and noticed that eighteen of them had some stigma, especially an abnormal shape of the ear. We therefore find stigmata amongst children at the average school level. But of these fifty-eight school children only one had four abnormalities--malformed ears, strabismus, prognathism, and slight scaphocephaly. The others had a maximum of two. The first child alone is certainly defective.
In a class of nine defective children subjected to a similar examination, we found only one who had but one stigma, another had two, four had three, and three had five. Of the three last, one had a very high degree of retardation; another was mentally ill-balanced to no less a degree. Let us compare these two groups, the one of fifty-eight average children, the other of nine defectives, and group to group, the difference is very clear. The stigmata are usually more numerous when the children are mentally defective. The existence of stigmata is a presumption of deficiency, and this presumption is greater, the greater the number of stigmata.
If we consider which are the stigmata that are most commonly met with, we find that asymmetry of the face is almost constant, but we also find it sometimes in normal children. Malformations of the ear come next. We are often struck by the frequency of badly defective speech--three times in nine defectives, whilst we did not find a single example in the fifty-eight school children taken by chance.
Here, then, is a "group fact" which is of interest from a scientific point of view. But what use can be made of it for individual diagnosis? This is much more delicate, for even if one could state it as a general rule that defectives have more stigmata than the normal, this rule is subject to important exceptions.
One of our abnormal cases had only one stigma, another had two, and in both cases the anomalies were of a very ordinary kind--slight want of symmetry of the face and sticking out ears. Children with stigmata few in number, and little marked (though as a rule we note the presence of stigmata without measuring them), may therefore not be of normal intelligence. The same is true sometimes of children with no stigma at all.
We may therefore conclude that stigmata may be taken into account when we are making an examination, but they should never be regarded as of fundamental importance in diagnosis.
_Physiognomy._--In addition to stigmata, we have to note another feature which is of more definite significance. Methodical studies made by means of a collection of sixty photographs of children, normal and abnormal, photographs taken by M. Bertillon in conditions comparable in all cases, have shown us that an intelligent teacher can scarcely go wrong in judging physiognomy. The photographs were beautifully taken, and the expression of the faces appeared extremely lifelike to anyone who was used to observing children. We asked various teachers to examine these portraits, and to express their opinion as to the mental capacity revealed. Mistakes were made, as was to be expected; but the correct estimations were always in the majority, and some teachers exhibited a truly remarkable talent for observation; they were practically never deceived. Let us say in passing that our list included a number of doctors amongst the teachers. They were far from distinguishing themselves. Their percentage was not so good as that of the schoolmasters. This difference in competence, which perhaps may appear surprising, suggests the following anecdote: One day, at the meeting of a commission, we had thrown upon the cloth a collection of photographs of children, the very one which we had been using for our methodical experiments. Everyone looked at the portraits and expressed his opinion. By way of a joke we tackled a medical alienist who had a seat on the commission. He was mistaken in his opinion as often as his colleagues who were most ignorant of medicine.
It seems to us, and the facts mentioned support us, that stigmata are only one part of the complicated whole which constitutes a physiognomy. A physiognomy includes many other things, especially the expression,--lively or sluggish, strong or weak, intelligent or lacking in intelligence; there is the fineness or coarseness of the features, the beauty or ugliness of the countenance, the ordinary or unusual appearance of the face. All this forms an _ensemble_ which the eye does not analyse, but judges _en bloc_ by instinct, without considering the elements separately, and, above all, without being able to give reasons for its judgment. Will it be possible some day to analyse, to dissociate, and to describe all these very various elements? We do not know. In the meantime we think that every examiner, as a matter of fact, allows himself to be influenced by the general appearance of the subject, and that the impression so formed is not entirely without value.
Let us sum up regarding the physiognomy. There does exist between the intellectual level of a subject and his physical development a real correlation, but, unfortunately, it is slight. With regard to the stigmata our knowledge of their significance is still very slight. We have no figures which allow us to place any definite value upon them either singly or in combination. There still remains the general appearance, whose significance is apparently indubitable, but which, at present, is too dependent upon individual estimate to be utilisable. Let us add that these relations between the mental and the physical appear to be of greater significance the lower the mental condition. Now, in a school it is the feeble-minded who are in the majority, and it is they who have to be recognised much more frequently than the idiot or the imbecile, and this lessens the importance of the physical examination. We may therefore conclude with this practical rule: a physical examination can never allow us to dispense with a direct examination of the intelligence. Anthropometry, stigmata, and physical appearance must take a second place as means for discovering in school the feeble-minded and the ill-balanced. Failing direct recourse to the teacher, these methods could, and ought, to be made use of. But in most cases, thanks to the assistance of the teacher, we have better means. In cases on the border-line they might help to incline the balance. Their principal use is not to assist in selecting children for special classes for defectives; their significance is quite different, as we shall see immediately.
MEDICAL EXAMINATION OF THE CHILDREN PRESENTED.
We must now define the active role of the doctor. In many foreign countries a scheme has been drawn up for the medical examination, which is often extremely comprehensive, almost interminable. We give an example of this kind, though questioning the appropriateness, from our point of view, of certain questions. If one does not simplify the work, the practitioners will simplify it in their own way--by neglecting it. If you ask them to do too much, they will do nothing.
SCHEME FOR MEDICAL EXAMINATION
_Heredity of the Child._--Note the name, the date, and the place of the birth of the father and the mother, and find out, by direct interrogation, whether the parents have a pathological heredity. Consider first the two great hereditary influences--alcoholism and insanity. Next inquire concerning nervous ailments, tuberculosis, etc. Make inquiries concerning the direct ascendents and their collaterals. Note the number of brothers and sisters, their illnesses, their mortality, and the position of the child in the family.
_Previous History of the Child._--This is the second part of the medical examination. It includes many questions. Has the child had convulsions? At what age did it begin to cut its teeth? At what age did it begin to walk? When did it show habits of cleanliness? When did it speak? What illnesses had it in infancy? Has the child always appeared different from others, or did it only become so at some definite time, or, in other words, is the mental deficiency congenital or acquired?
_Present Condition._--Under this heading are included the general appearance of the subject, his attitude, the form and size of his head, etc.
We have no objection on principle to medical investigations of this kind, and if a doctor desires to collect such information, he ought to be encouraged. We recall in passing that Dr. Ley, of Antwerp, who was for some time medical specialist to a school for defectives, has made a very complete study of the heredity and personal antecedents of hundreds of defective children. But before compelling doctors to fill up conscientiously a schedule containing all these questions, one should consider without prejudice what use the work is going to be when it is done.
Let us distinguish between pure science and what is of immediate practical utility. No doubt one ought to give a warm welcome to everything which helps us to understand the child better; but the above observations upon his heredity do not bear upon the question of whether he is a defective, and throw only the dimmest light upon his character and the manner in which one should treat him. If he is to be counted abnormal, he must be either ill-balanced or of deficient intelligence. Even if he should have an alcoholic heredity, that would be of no importance if he were able to follow his class and to profit by the ordinary instruction. At most, the discovery of a pathological heredity might incline one in a doubtful case towards a diagnosis of mental deficiency; but yet one should be extremely cautious about permitting oneself to be influenced in this way, for we are ignorant to a most incredible degree concerning the heredity and antecedents of normal children, and as our ignorance in this respect is so complete, we are unable to say precisely what is really pathological in the heredity and the antecedents of those who are abnormal. Information of this kind, therefore, is not directly useful.
What, then, are the first problems to be solved? Let us consider just exactly where we are in the examination. Here are the children picked out by the teachers. The inspectors themselves have checked the selection and referred back some of those selected, but very few, if they have carefully directed the methods of choice from the beginning. The children presented are backward in their studies. Inquiries regarding their school attendance have shown that the retardation is not due to irregular attendance. The examination of their intelligence has confirmed this judgment.
It still remains to discover whether, amongst all these children who are unable to follow the ordinary school curriculum, there do not exist some who are not, properly speaking, mentally deficient, but who are suffering from some illness. May we not find amongst them some who require medical treatment rather than special teaching--_e.g._, cretins? And, lastly, may there not be some children whose mental deficiency complicates some other disease, such as epilepsy? These are problems which are essentially medical, and which it is necessary to solve before admitting a child to a special school. Let us consider them in order.
=1. Is the Case one of Mental Deficiency, or of an Intercurrent Mental Affection?=--To tell the truth, there is not often any doubt. However, there are two circumstances in which doubt may arise. In the first place, an arrest in a child's mental development may be the expression of a state of depression which indicates a psychosis in the course of evolution, or it may be the first sign of decadence in one of those degenerates of whom Morel speaks, who seem to have "a limited mental existence." Such cases, which some authors describe under the name of "dementia precox," require a medical regimen.
In the second place, it is possible that the etiological factor is alcohol. Alcoholism in the parents is frequently the cause of mental deficiency. But the effects of drinking do not always stop there. The child itself may be made to drink, and consequently the doctor may sometimes find symptoms resulting from direct intoxication--nightmares, or tremor of the hands. Such intoxication may be responsible partly, if not entirely, for the want of progress at school, and also for the irritable temper which the child shows in class. It would be necessary in such cases to see the parents, and to advise a different hygiene for their child at any rate, if they themselves cannot be persuaded to give up their bad habits. In this way one may be able to avoid sending the child to a school for defectives. It is apparent that even if the child were sent to such a school, it would be necessary to put a stop to the administration of alcohol. The rarity of such cases makes their exposition of almost theoretical interest.
=2. Would the Mental Deficiency respond to Medical Treatment?=--Cannot the doctor prescribe something to cure the mental deficiency or want of balance? Let us give some consideration to this question. Medicines act either upon the symptoms of a disease, or upon the organic changes which produce them, or, lastly, upon the very causes of such organic changes. Quinine, for example, has a selective action on the parasites of malaria; mercury produces an undoubted effect upon syphilitic growths; treatment by cold baths keeps the temperature of typhoid fever below a certain level during the whole of the illness. Cannot analogous results be hoped for in mental deficiency? A brief resume of what we know concerning the causes of mental deficiency and the anatomical lesions which accompany it will determine our answer.
The dominant etiological feature is that mental deficiency and want of balance depend upon hereditary conditions, or conditions acquired in the earliest stages of development. By hereditary conditions must be understood strictly those which result from alterations in the germ cells of the parents. An intoxication alone seems capable of exercising upon the latter a sufficiently general action to reach the germ cells, and by far the most frequent poison is alcohol. By acquired conditions must be understood the results of diseases of the foetus or of infancy, and especially the cerebral complications of the infectious fevers--_e.g._, meningitis in the course of an eruptive fever. In all such cases, with rare exceptions to be mentioned immediately, by the time the mental deficiency is discovered, its causes are no longer active, and consequently cannot be affected by medical intervention.
The statements we have just made with regard to the causes of mental deficiency lead to some practical conclusions. The ultimate evolution of the congenital cases differs from that of acquired cases, and this renders a study of the early history of the child important. If the development of the child has been normal at first, and has then been abruptly interrupted, for example, by an attack of meningitis, of which we can obtain by inquiry a definite history, the prognosis is not good. For it is a well-recognised fact that cases of acquired mental deficiency are not likely to make a fresh start. If we were hesitating whether to send an imbecile child to an asylum or to put him in a class for mental defectives, a history like the above would lead us to give the preference to the asylum; but let us say once more, we do not find here an indication for treatment.
As to the changes which are found post-mortem, these are manifold and of an unalterable kind. They are as follows:
(1) The results of the rupture of a cerebral vessel--_e.g._, from asphyxia at birth or a delivery by forceps. Blood has been poured out into the nervous tissue. The latter has been destroyed over a greater or less extent, and there is found in its place a cyst filled with sero-sanguineous fluid.
(2) The obstruction of an artery--_e.g._, by septic thrombosis--has prevented the blood from reaching a part of the brain, with similar results to those mentioned.
(3) In other cases are found the more or less extensive changes produced by meningitis or meningo-encephalitis. The inflammation of its envelopes has interfered with the brain, and consequently with its functions.
(4) An increased secretion of cerebro-spinal fluid has led to a compression of the nervous system or a distension of its cavities, notably of the lateral ventricles of the cerebral hemispheres, and has led to a separation of the bones of the cranium, thus producing the large globular head of hydrocephalus.
(5) There may be found simply defects of development whose causes are known (microcephalus, or extreme smallness of the cranium relatively to the face; microgyria, or marked thinness of the convolutions).
(6) Lastly--and this is frequently the case in the worst degrees of deficiency--the post-mortem, and even microscopic examination of the organs may show no change at all.
Let us add that the nature of the lesions just mentioned does not seem to have any relationship to the condition of the mental faculties. An anatomico-pathological grouping of the cases and a grouping according to the mental condition, far from being parallel, are frequently decidedly different. On the other hand, the extent of the lesions is of more importance. Diffuse lesions affect the mind more than those which are circumscribed--that is to say, limited to a certain part of the brain--as if the mental functions required the co-operation of the entire cerebral cortex. One will often find, for example, sound judgment in the subject of a marked paralysis, whilst it is very rare to find that good intelligence co-exists with any degree of microcephalus.
Let us emphasise the last fact we mentioned, the absence of any lesion. Some authorities have maintained that all conditions of mental deficiency and want of balance found in children are connected with definite diseases of which they are the symptoms. The question is unsettled. For our own part we adopt the following provisional statement: Mental deficiency and want of balance are peculiar mental conditions which it is often impossible to connect with definite pathological changes.
Thus, we do not know of any medical treatment which is likely to act upon the preceding lesions when they are present, and we do not think it is even possible to act upon them.
An exception must, however, be made of conditions due to insufficient secretion of certain glands. The type of these is cretinism. Marked cases of this condition are easy to recognise. The very appearance of the children is sufficient for an experienced eye--the stunted growth; the rough, wrinkled skin; the swollen eyelids half-concealing the eyes; the prominent belly; and the mental apathy. One also comes across abortive cases, where the above-mentioned characters are less marked; the sluggishness also is less. These latter cases are amenable to the same treatment as the former--namely, the ingestion of thyroid glands from the sheep.
This treatment stimulates growth and makes the child more lively; but what ultimately becomes of the cases so treated? The amelioration usually ceases whenever the treatment is dropped. But how far does this amelioration go? To what extent does the child profit by it? Lasegue has jocularly remarked that the average duration of an attack of typhoid fever (six weeks) represents the maximum time during which medical attention could be brought to bear upon a patient. One feels disposed to think he is right in face of the slight satisfaction one can obtain from the literature regarding a point of such importance.
Other cases of mental deficiency may be due to an alteration in the pituitary gland. It is for the doctor to find out whether there are any symptoms by which mental deficiency of such an origin can be recognised, and whether it is possible to prepare a suitable substance for replacing the absent secretion.
The number of cases amenable to treatment of this kind is, unfortunately, very limited.[13] We may even say that, as a general rule, we did not find amongst the school children we examined any cases of obesity or infantilism such as are sometimes described of a truly remarkable nature. Even children who were abnormally short looked their age. We have still, however, to mention one last influence--namely, poverty. Its part in the production of mental debility is scarcely defined. What are the exact effects upon intelligence of prolonged deficiency of nutrition? How can its action be isolated from that of other agents, such as alcoholism, which too frequently accompanies it? The complexity of such social studies sufficiently explains their present incompleteness. Let us recall the results we obtained from an inquiry of this kind; the children of parents in extreme poverty are retarded in their physical development more frequently than those whose parents are in easy circumstances. It is interesting to add that analogous inquiries with reference to intelligence have furnished similar results.
Apart from the preceding cases, the best that can be done is to treat the symptoms. The two principal agents at the disposal of the doctor are the bromides and hydrotherapy. Unfortunately, if the bromides are undoubtedly efficacious in certain cases of epilepsy, that is far from being the case in simple want of mental balance, in which cases they are at best useful adjuvants. As to hydrotherapy, and especially cold douches, their principal indication is in certain nervous affections, where their effect is to enable the subject to master the emotional reactions which are habitually exaggerated.
Lastly, the doctor can exert his moral influence to assist the educative work of the teacher in the special school. His less frequent intervention, the different motives of his advice, will often give him even more authority than the teacher. The suggestive effects of his intervention should be obtained, in our opinion, without resort to hypnotism.
=3. Does the Mentally Defective suffer from any Definite Illness?=--If the illness such as we have referred to affects those parts of the cerebral cortex which govern the muscles of a limb, one will find, in addition to the mental condition, paralysis with atrophy and contracture. But in addition to such very marked cases, there exist others in which sensory or motor affections, although slight, may hinder the progress of education.
It goes without saying that if a child does not profit from the school work, an examination of his sight and hearing should be made as a matter of course. Perhaps that may have been done already by the teacher himself by such methods as he is able to use. But this first examination is not sufficient. The doctor must correct, as far as possible, the want of acuity noticed. No doubt the defect may not explain the mental deficiency of the child, but one must take care that in the school for defectives a pronounced myopia or catarrh of the middle ear does not prove an obstacle to the efforts which are to be made to bring about development.
In the same way it must be considered whether the condition of the muscular system is such as to permit the manual work which one wants to teach the child, and whether there exists any paralysis or tremor which would prove an obstacle to work of this kind. One must consider whether any symptoms present are transitory, like chorea; or permanent, like infantile hemiplegia; and what kind of efforts may be made without risk to the health of the child. Such are the problems which the doctor has to solve.
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In the last place, it is necessary to take into account the coexistence with the mental deficiency of other affections.
_Epilepsy._--Epilepsy frequently coexists with mental deficiency. Now, epilepsy does not always reveal itself by severe fits with crying, falling down, loss of consciousness, convulsions, stiffness followed by jerking of the limbs, foaming at the mouth, biting of the tongue, and involuntary passage of urine. It is revealed also by symptoms of a less striking nature, which have been described under the name of _petit mal_. Such are loss of consciousness, vertigo, or simply mental perturbations. Loss of consciousness occurs without the tremor of a muscle, the child suddenly turns pale, loses consciousness for a moment, and then continues whatever he was doing--for example, walking or writing. There is nothing more impressive to notice when the fit occurs as one is talking to the little patient. One sees, as it were, the passing of a veil. But nothing could be more fugitive, nothing could more easily escape the notice of anyone who was not a good observer. Often the parents know nothing about it. The attacks are so short, the consequences apparently so slight, that even if the parents have chanced to notice them, they do not always think of mentioning the fact. The teacher of defective children ought to be instructed in the characteristics of this affection. He is going to spend several hours daily with the children. He will have the best opportunities for noticing the occurrence of attacks, which may be rare, but which, when they occur, are very significant.
Although the symptoms are a little more marked, vertigo also is of brief duration. To the pallor and the loss of consciousness of the preceding condition there is added a little muscular relaxation. The child totters, supports himself by anything in his neighbourhood, slips down in his seat, or drops his pen. Sometimes there is a slight spasm of the muscles of the face, the mouth is drawn to one side by slight jerks, or performs some movements of mastication or deglutition. And that is all--no convulsions of the limbs, no passage of urine, scarcely an interruption to the work which is being done.
Whether the doctor discovers these symptoms by interrogation of the parents, or whether the teacher some time afterwards describes them to him with sufficient detail to permit of a certain diagnosis, a double gain results. In the first place, there is an indication for treatment; and in the second, the possibility of supervision. As a matter of fact, it too frequently happens that these symptoms, little dramatic as they are, reveal the existence of epilepsy, which will ultimately result in progressive mental decadence.
And yet this is not all. A few days or a few hours before such symptoms occur, or immediately after them, or, lastly, according to some authorities, entirely independently of them, the patient may develop a peculiar condition of irritability, in which he will transgress against discipline, make insolent remarks, or even give way to violence. Such actions ought not to be suppressed by punishment, because they are of morbid origin.
All such symptoms possess this characteristic, that they leave no trace on the memory of the child. He himself knows nothing about them, or knows them only by what he has heard from other people. There can now be no need to insist with what care inquiries must be made, especially of the parents.
Are epileptics to be admitted into the special class? On principle they are refused admission to the ordinary school. They are, however, to be found there. There are those whose attacks occur very rarely, or are so slight as to cause no disturbance. There are probably also unrecognised cases of epilepsy in which the symptoms occur during the night, or on awakening, but never in class. Only the severe forms are turned away. Probably the same state of affairs will recur in the classes for the abnormal--at any rate until the time when provision for epileptics is more extensive than it is at present. It will therefore be necessary to recognise these cases, to supervise them with special care during certain kinds of manual work, and, if possible, to treat the nervous symptoms suitably while the patients are receiving instruction.
_Hysteria._--Although hysteria has not the same gravity, it is no less advisable that cases should be tracked out. This neurosis is being discussed to-day as never before. Without setting forth at length what we think should be included under this term, let us point out a characteristic of hysteria which is commonly recognised, and which is of such importance that it indicates the line of treatment to be followed. The two principal manifestations of the affection, hysterical fits and the recital of lying tales, require for their complete development the presence of a public, of a gallery. Inversely, their disappearance is assured by isolation or apparent inattention.
The discovery of such tendencies before entrance to the school will allow the doctor to forewarn the teacher, and point out to him the best way of dealing with such children.
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There are still three affections about which we must say a few words--rickets, adenoid vegetations, and scrofula.
_Rickets._--The chief characteristic of this condition is defective ossification. Instead of possessing their usual rigidity, the bones become curved, and multiple deformities result. The legs become bowed, and the knees cannot be brought into contact when the feet are placed together; the thorax becomes constricted or gibbous, etc. In addition to the nutritive disturbance, which appears to be at the root of all these disorders, there may be, according to some authors, an affection of the entire system, and especially of the nervous centres. Unfortunately, as rickets is a disease of the earliest years of life, one often finds oneself in the presence of the sequelae which have been left, and which simply must be made the best of.
_Adenoid Vegetations._--Everyone has now heard of cases of this kind where the appearance is so characteristic. The lips are always half open, the appearance is sleepy-looking, the respiration is difficult. If one looks at the throat, or if one introduces the finger into the child's mouth in order to explore the pharynx behind the soft palate, one will see or feel the large tonsils or the fleshy masses which obstruct the posterior orifice of the nasal fossa. One would like to find in these vegetations the cause of the habitual torpor of the children, and of their want of progress. It is true that there is a connection between mental backwardness and adenoids. The removal of the swellings by a surgical operation will make more free the respiration, whose obstruction prevented sustained attention, and will also frequently cure the deafness, which was due to an obstruction of the Eustachian tubes. The operation may therefore result in a marked amelioration of the mental condition as well as of the general health. If the amelioration is sufficient, the child can be sent back to the ordinary school.
_Scrofula, Tuberculosis._--A child with a lymphatic appearance, whose tissues are infiltrated with serum, and whose glands readily become enlarged, requires plenty of country air and a nutritious diet. If he is admitted to the special school, it will be advisable to attend to his health before subjecting him to any particular educational methods.
The doctor, then, will notice in passing the existence of such conditions as rickets, adenoids, and scrofula in the children who are submitted to him. Affections of the lungs and tuberculosis of the bones will also attract his attention. But such affections in abnormal children have no other significance than in the case of children of average intelligence. They furnish no special indication regarding the admission or non-admission of the child into a special class. Their severity alone determines the course to follow with respect to their treatment.
We shall, however, say a few words about another infirmity--incontinence of urine. If there is presented for a class for defectives a subject, eleven years of age, who cannot control himself in this respect, the course to follow is: submit the child to examination by a specialist, who will decide the nature of the incontinence. If it is curable, give the condition the necessary attention, or give instructions at the school for training the child properly; but if there is an incurable weakness of the sphincters, supply the child with the same kind of apparatus as is used in such cases by ordinary people.
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Here, then, are a number of important points upon which the doctor may be called to give his opinion. It is he alone who is able, by his special knowledge, to enlighten the other members of the jury. If the mental condition is doubtful and requires further observation, it is for him to point it out. One will thus avoid the mistake of placing in a class for defectives a lunatic, or a child poisoned by alcohol, who would not find there the kind of care required. If the bodily condition discovered complicates or aggravates the mental deficiency, as adenoid vegetations may do, he will prescribe the proper treatment. If he suspects the coexistence of some neurosis, he will give directions by which the condition may be recognised, and consequently treated. The doctor therefore has to recognise the physical and mental ailments by which the defective may be affected. He makes this diagnosis for two reasons. In the first place, in order that mental deficiency may not be confounded with conditions of illness of a different kind; and, secondly, in order to relieve or cure if possible coexisting affections which may aggravate the condition of the children and interfere with the work of the school.
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We shall conclude here what we have to say about the role of the doctor, since in this volume we are specially concerned with the recognition and segregation of the children. To discuss the role of the doctor quite fully would take us too far.
The details we have given show that the part of the doctor with regard to defectives is quite different from that of the teacher. It is not so much to determine the child's precise mental level as to diagnose the condition of his brain, and to discover, by analysis of all the symptoms, the original responsible agent. That, however, is the second part of the doctor's work, and is of scientific interest; whereas the first part, which consists in diagnosing the ailments which co-exist with the mental deficiency, is of immediate practical utility.
Let us note, in conclusion, the scientific trend of the present day. A large proportion of medical work is of scientific interest rather than of direct utility for the patient. A concrete example will explain our meaning. A severe shivering, a sudden elevation of the temperature, a dulness on one side of the chest, the presence in the same position of crepitant rales, a rusty, sticky expectoration--such is the syndrome by which a practitioner recognises an attack of acute pneumonia. He knows its duration; he knows the relief which will be produced by the application of poultices. To ideas such as these may be reduced all that is indispensable for the doctor to know in order to exercise his art. The post-mortem examination of the hepatised lung, its increase in density, the histological study of the engorged air cells and bronchioles, the researches upon the pneumococcus, its culture, its vitality--all this constitutes a search into etiology and pathogenesis, whose aim is quite different.
The same distinction may be made in the medical study of defective children. And from this point of view the results which at first seem of secondary importance reappear in the foreground. This is the case, for example, with the stigmata of degeneration. It would be unreasonable to attribute to them an individual value, and to utilise them for arranging children serially in the order of their mental deficiency; but in the work of synthesis they are decidedly significant, since their study leads one to consider them either as the effects of, and therefore as witnesses to, alterations in the nervous system, or as the consequences of causes sufficiently powerful to have modified that system.
One would not deny all practical bearing to such investigations of pathogenesis. It is a mistake of Tolstoy to regard them as the pastime of refined dilettantes. When the biological study of defectives leads to this idea, that the mental weakness of the defectives, like the peculiarities in the character of the ill-balanced, is the result of degeneration--the result, for instance, of the alcoholisation of a people--it will quickly result in measures of social hygiene.
The point is, however, that this second part of the work cannot, in our opinion, be carried out under the same conditions as the first. One would like to believe that, in making observations upon heredity and stigmata, the doctors are collecting, in their daily work, materials for a great scientific work which will be produced by degrees. No doubt all their schedules may some day be extracted from the drawers in the office where they will sleep for a long time; but with what object will they be taken out, if not to compile statistics of doubtful value? The truth is that scientific investigation cannot be carried on automatically and collectively. There is always a personal element which is independent of all administrative prescription. What use can be made of observations which are often merely a collection of paper? If we are some day to understand the role of heredity, of alcoholism, of insanity, of poverty, in the production of defective children, it will be necessary for someone, who wants to do a really good piece of work, to set aside all these equivocal documents, and go straight to the facts, collecting his information at first hand and in a critical spirit. Scientific work can be done in no other way. When it is done otherwise it is worth nothing.
We therefore suggest the following schedule for the medical examination of defective children. The schedule includes two parts--one part optional, because it is only of indirect interest; another part which is obligatory. None of the questions in this part should be left unanswered, and the doctor will also give the instructions which he thinks ought to be followed.
MEDICAL SCHEDULE.
Date of examination: Height: Name and date of birth of child: Weight: