We must now define the active rôle 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, fromour 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.
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.
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 givea 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 whorequire 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 résumé 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 fœtus 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 thedevelopment 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; therough, 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? Lasègue 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.
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 thelimbs, 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 ofpetit 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 timeafterwards 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.
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 sequelæ 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 mouthin 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 willdecide 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.
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.
We shall conclude here what we have to say about the rôle of the doctor, since in this volume we are specially concerned with the recognition and segregation of the children. To discuss the rôle 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 ofthe 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 râles, 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 rôle 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 onlyof 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.
Date of examination:Height:Name and date of birth of child:Weight:Part 1. Obligatory.(i.) Has the child any mental symptoms other than mental deficiency? Signs of alcoholism, etc.?(ii.) Is there reason to think the child has any weakness, congenital or acquired? Cretinism?(iii.) Are there any(a) Sensory defects—sight?hearing?(b) Motor defects—paralysis?tremor, etc.?(iv.) Is the child epileptic? What symptoms are present—convulsions, vertigo, loss of consciousness? Their frequency, etc.?(v.) Has the child adenoids?(vi.) Is the child hysterical?(vii.) Any other ailments?(viii.) What directions are to be given to the schoolmaster?Part II. Optional.A. Cephalometry and stigmata of degeneration.B. History:Birth.Convulsions.Age at commencement of dentition.Age at commencement of control of bladderAge at commencement of and bowel.Age at commencement of walking.Age at commencement of speech.Infantile diseases.C. Heredity.Father—Name:Date of birth:Place of birth:{ syphilis.Illnesses { alcoholism.{ insanity.Mother:Ibid.Brothers and Sisters—Number:Age:Mortality:Health of survivors:Etc.
Date of examination:Height:
Name and date of birth of child:Weight:
Part 1. Obligatory.
(i.) Has the child any mental symptoms other than mental deficiency? Signs of alcoholism, etc.?
(ii.) Is there reason to think the child has any weakness, congenital or acquired? Cretinism?
(iii.) Are there any
(a) Sensory defects—sight?hearing?
(b) Motor defects—paralysis?tremor, etc.?
(iv.) Is the child epileptic? What symptoms are present—convulsions, vertigo, loss of consciousness? Their frequency, etc.?
(v.) Has the child adenoids?
(vi.) Is the child hysterical?
(vii.) Any other ailments?
(viii.) What directions are to be given to the schoolmaster?
Part II. Optional.
A. Cephalometry and stigmata of degeneration.
B. History:
Birth.
Convulsions.
Age at commencement of dentition.
Age at commencement of control of bladder
Age at commencement of and bowel.
Age at commencement of walking.
Age at commencement of speech.
Infantile diseases.
C. Heredity.
Father—
Name:
Date of birth:
Place of birth:
{ syphilis.
Illnesses { alcoholism.
{ insanity.
Mother:Ibid.
Brothers and Sisters—
Number:
Age:
Mortality:
Health of survivors:
Etc.
To sum up, we do not think that the doctor will often have to reject a child, but he will often furnish indications which will help to direct the efforts of the teacher. He will proclaim the opinion, at once so just and so humane, that the symptoms of mental deficiency and want of balance in abnormal children do not arise from laziness or naughtiness, but require no methods of treatment except such as are likely to relieve them. And this conviction which animates him he will impress little by little on the teacher. He will accustom the latter not to regard a defective child at fault like a normal, responsible child, whom he is sometimes tempted to punish in anger, but rather as a patient whose faults should be overcome by persevering patience.
[13]For the sake of greater completeness, let us refer to a type of imbecile with very characteristic features—namely, theMongol. A little round head, chubby cheeks, rosy as if painted with rouge, oblique eyes, a nose broad at the base and with a tip like a little ball, skin slightly yellow—the whole appearance of the child is such that one doubts his European origin, and thinks of a Chinese doll, with limbs of india-rubber, so great is the looseness of the joints. During his first year the Mongol is rather drowsy and quiet—too "old-fashioned," as the mothers say. In the second or third year he becomes lively. His countenance acquires a comic and jolly expression, and his imitative instincts become curiously developed, and as a general rule he is very sweet-tempered. They all resemble one another, and all "promise much and achieve little," for they never cease to be imbeciles.
[13]For the sake of greater completeness, let us refer to a type of imbecile with very characteristic features—namely, theMongol. A little round head, chubby cheeks, rosy as if painted with rouge, oblique eyes, a nose broad at the base and with a tip like a little ball, skin slightly yellow—the whole appearance of the child is such that one doubts his European origin, and thinks of a Chinese doll, with limbs of india-rubber, so great is the looseness of the joints. During his first year the Mongol is rather drowsy and quiet—too "old-fashioned," as the mothers say. In the second or third year he becomes lively. His countenance acquires a comic and jolly expression, and his imitative instincts become curiously developed, and as a general rule he is very sweet-tempered. They all resemble one another, and all "promise much and achieve little," for they never cease to be imbeciles.
An Inquiry in the Hospitals.—Two years ago one of us betook himself to M. X., an important official in one of our ministries, in order to ask him to join a Ministerial Commission which was going to pay a visit to one of our asylum-schools. M. X. shrugged his shoulders, and replied energetically: "No, no, no! I have had enough of such visits. I will go neither to the Salpêtrière nor to Bicêtre. What would I see there? An idiot who allows his saliva to collect in his open mouth; another who has epileptic fits; a third who can say nothing but 'Ba, ba!' What would that prove? The only way in which one can find out whether a school for bad cases of mental deficiency is good for anything, is to find out the mental condition of those who leave. How many defective subjects are there who, after having been treated at the Salpêtrière or at Bicêtre, are able to gain their own livelihood? That is what one would like to know, and that is what no one ever tells us!"
The listener to these incisive and sensible remarks replied, after a moment's reflection: "I entirely agree with you. The information which you desire is of the greatest importance for judging the value of a school. I imagine that such information would be difficult to obtain. But one can try. I am willing to make the attempt."
A few days later the two authors of the present worktook the field. The long preliminary conversations which they had had together about this subject had convinced them that they would encounter opposition. But they decided to treat the question as one treats a scientific matter—with perseverance, with courage, and withoutparti prisof any kind.
Let us subdivide the question to make it more plain. We proposed to discover the value of a school. To make such an inquiry really complete, it would be necessary to consider the question from two points of view—the one educational, the other social.
The educational return consists in the degree of instruction which the institution succeeds in giving to its pupils, after so much time, and with so much expense. In the case of an institution for the sick, the return will take the medical form of a cure or improvement of health. In order to estimate such various returns, it would evidently be necessary to be in possession of various data: (1) A knowledge of the state of instruction or the state of health of the subjects on their admission to the school; (2) a knowledge of their state of instruction or of health on leaving, so that one would be able to estimate by comparison what they owe to the school; (3) a knowledge of the cost for each pupil, whether for instruction or for medical expenses.
The social return consists in the place taken by the pupils in society. This depends in part, it is clear, upon the educational return, but only in part. One could imagine a school, and there are some of the kind, which only cares about producing graduates, without thinking of what will become of them in life, even if they go to the dogs. Every class, every school, for defectives ought to aim at rendering its pupils socially useful. It is not a question of enriching their minds, but of giving them the means of working for their living. This is an important question. Upon this depends our complete and final judgment of the utility of special education.
And be it understood this is not a simple question. Nothing is simple in the sphere of sociological phenomena, and one cannot get hold of an atom of truth except by inquiries bristling with difficulties of all kinds—inquiries whose rules, moreover, are not yet known, but which will certainly be known some day. It is quite necessary.
In order to discover the social return of an institution, school, or hospital, there are many data to be brought together. Here are some of them. What is the number of those who are ultimately able to look after themselves? For how long a time are they able to do so? To what extent have they been assisted by what they acquired at school? And, lastly, what becomes of the failures?
But whatever the social or educational return may be, it would be most important to know what would have become of similar cases who had received no such instruction, or, rather, who had been instructed or treated by different methods.
A single example will show the importance of these reservations. Recently an alienist wanted to prove that all the idiots, without exception, who had been treated in his asylum had been improved. He published copious notes upon these children, which had been taken during several years by different people—the physician, resident doctor, attendant, teacher, etc. On reading these observations one learned that one child, who on admission was unable to walk, by-and-by began to do so. He had grown; he had also begun to speak, etc. In all this there was nothing surprising, and we imagine that, in spite of his optimism, the doctor, who is the author of these observations, would not pretend to credit an increase in size to his medico-pedagogical treatment. As to the rest of the development of the faculties we know nothing. It is possible that an idiot who has ceased to be dirty, or who has learned to dress himself, would have done so in any case without object-lessons. It would be necessary tounderstand the natural development of idiocy in order to estimate exactly the service which had been rendered by the medico-pedagogical treatment. Otherwise sceptics will suspect that three-quarters of what is claimed to be the result of treatment is really due to nature.
After these preliminaries, let us now turn to our inquiry.
At the Salpêtrière.—Here we were received most kindly. The superintendent of the hospital introduced us to a most excellent woman, Mme. Meusy, who was at that time head-mistress of the school for defectives at the Salpêtrière. This is a little school with about 140 girl pupils. It is part of the clinique of Dr. Voisin. The school is divided into four classes, each of which is under a lady teacher. It is a modest school, and, we think, little known. Elementary education is given there, and, be it understood, the teachers make a point of object-lessons and the training of the senses. But this education has no original feature. It simply follows what is done elsewhere. There is a workshop where the patients skilfully manufacture artificial flowers. Dr. Voisin has for a long time been asking for a laundry, for the sake of the patients who require physical exercise, but he has not been able to get it.
Mme. Meusy had prepared us to some extent for the work which she had done in the school by intelligent organisation. It was a pleasure to us to see with our own eyes the notes she had kept regarding each of her pupils. All the schedules were in perfect order, regularly filled up to the day. They contained all the medical information, as to diagnosis and treatment, which Mme. Meusy had been able to procure from the doctor by reiterated requests. They contained also full particulars as to the state of instruction of the child, her character, her aptitudes, and the amount of her school attendance. Such notes were repeated periodically, so that it was easy to find out approximately whether or not the child had progressed during her stay in the school. Finally, her history after dischargewas noted. It is only just that we should here express once more to Mme. Meusy how much we admired the care, the order, and the intelligence with which she had kept these individual histories. It is an example to be followed.
Mme. Meusy readily placed before us one after another all these documents, and allowed us to extract from them the notes which seemed of most value for our work. While one of us was taking the notes, she contributed much valuable information in a lively voice; for she knew her pupils admirably, she followed them after they left school, and often received visits from them. But, although she clearly understood the importance of our inquiry, she could not keep to herself a distressing thought, which was that a large number of these unfortunate girls had obtained no benefit from the instruction received at the school during a long series of years. The majority, on leaving school, had been transferred to asylums for adults. It saddened her to acknowledge such impotence officially. However, neither she nor her devoted staff of teachers was responsible, for if their educational success was restricted, that was due to the fact that the administration had for some time been sending her the epileptic defectives, while reserving for the Fondation Vallée the privilege of having the non-epileptic defectives. Now, everyone knows that when epilepsy, with repeated fits, is present, it produces a mental decadence against which the best teacher is powerless.
The information which we have collected about the work of the school of the Salpêtrière bears upon 117 children, who had left the school during the period of four years. Now, this is how these children are distributed, if they are classified according to their condition on leaving:
1. Children who hadimproved. Some of these had returned to their families; they lived at home, and were employed, more or less, and the directress states that theyhad improved in their mental condition. These numbered eight. Others had become capable of following a calling, either in the asylum as attendants, or outside as seamstresses, ironers, laundresses, domestic servants, etc. These numbered twelve. (None was employed in making artificial flowers, for which there was a workshop in the school.) The total number who had improved, therefore, was twenty.
2.Doubtfulcases—children who had returned to their families, but concerning whose mental state and employment precise information was lacking. These numbered twenty.
3. Those who had gotworse. These are the cases who had been marked "transferred." They are to be found in the lunatic asylums, where they are destined to pass the rest of their existence. Of these there is a formidable number—namely, sixty.
4. Those who haddied, of whom there were seventeen.
From all these calculations we obtained a figure to remember, and also an opinion.
The figure is that the school for defectives at the Salpêtrière returns to active life 12 per cent. of its pupils.
The opinion is what one might have known in advance, that in the majority of these cases the education given was a waste of effort, for none of the pupils who had acquired a calling had been affected by the worst degree of mental deficiency, idiocy, or imbecility. Moreover, none of these was epileptic as well as mentally defective. In other words, the two worst degrees of mental deficiency do not permit any hope that the child will be made capable of following any calling; and even a lesser degree of deficiency—that is to say, feeble-mindedness—is equally cut off from hope when the feeble-mindedness is complicated by epilepsy.
Before drawing from this first inquiry any practical conclusions, we should like to reach a comprehensive view of the question. We shall give our conclusions after we have synthetised all our results.
After the Salpêtrière, Bicêtre.
Bicêtre.—The reader would be wrong to imagine that in these visits to the hospitals we are forgetting the school cases of mental deficiency; we are at the heart of the question. Whether we are dealing with hospital cases or school cases, there are details of organisation which are the same for all, and there are similar mistakes which we must try to avoid.
The asylum-school of Bicêtre, which owes its origin, in 1892, to the General Council of the Seine, and its organisation to Dr. Bourneville, has a world-wide reputation. Dr. Bourneville has set himself to demonstrate, by every possible means, that idiots can be improved if they are treated methodically and progressively. It is thanks to his initiative that the medico-pedagogical treatment of idiocy, a treatment which has been much vaunted by the doctors, is now known everywhere. His clinique has constantly been cited as a model. This model has been imitated in France and more especially abroad. The asylums of Saint-Yon, of La Roche-sur-Yon, of Clermont, of Sainte-Gemme, and of Auxerre, have been inspired by the example of Bicêtre, and have followed its methods. The State supports 440 boys in the asylum-school of Bicêtre, and 230 girls at the Fondation Vallée.
We have no intention of describing here at length the organisation of these establishments. All who are interested may join in the Saturday morning visits, when Dr. Bourneville goes round the whole of his clinique. We shall content ourselves by saying that the children in the asylum-school of Bicêtre are divided into three groups:
1. The group ofinvalids—children who are idiotic, dirty, epileptic, demented. In this group are those who are regarded as incurable, and some who, although completely idiotic, are capable of some slight improvement. By means of aswingorsee-sawtheir limbs are strengthened, by means of ago-cartthey are taught to walk, and by meansof theparallel barsthey are taught to keep themselves upright.
2. Thehealthychildren of thelittle school, all of whom are able to walk alone. These undergo treatment for uncleanly habits. Special chairs are kept for the dirty, who are placed at stated times upon conveniences in order to regularise their functions. Then comestrengthening exercises, which are gymnastics of a very simple kind;toilet lessonsto teach them to wash themselves;table lessons, to teach them to feed themselves, with spoon, fork, and even knife; thetraining of the senses; and, lastly,training in speech.
3. The third group includes children in thebig school. These are less defective than the preceding. They are fit and healthy. But, on the other hand, there are found here a great many abnormal children (perverse and ill-balanced) who are not wanting in intelligence. The big school includes four classes, each under the charge of a professor. The education, especially in the last class, is carried pretty far, and many of the pupils possess their certificate of study.
For reasons upon which we will not insist, we were not so delighted with the hospital of Bicêtre as we had been with the Salpêtrière. We might have dispensed with this visit. The medical superintendent of the school for defectives at Bicêtre has taken the trouble for a long time to publish regularly every year a volume of several hundred pages, which contains the most diverse statistical information about everything that goes on. We have studied the volumes bearing upon four years only—the years 1899, 1901, 1902, and 1903. Moreover, we profess that we have some knowledge of the school at Bicêtre, having not only joined several times in the Saturday visits, but having on several occasions carried on there researches in cephalometry; and, in the last place, we have had the pleasure of following in their inspection two members of the ministerialcommission, who had had the idea of finding out how the teachers in the big school were fulfilling their functions.
It will be remembered that we made a distinction between the educational and the social return. This distinction is not recognised by everyone, and many good people take into account only the social return. There are those who would judge the school of Bicêtre by one thing only—the number of patients who are made useful to society. This is a question of great interest, but it is wrong to think that it is the only one to be considered. It would be unjust to confine oneself to it. The injustice can be understood by supposing that one is considering an institution which receives idiots only. Would one judge such an institution by asking how many of its patients become capable of winning their livelihood? Certainly not. It is possible to be of real service to the patients without raising them to such a level. The cure of dirty habits, for example, is not a thing to be disdained. Not only does it result in an economy of linen and washing, but it makes the patient less disgusting, less difficult to take care of. Here we have material and moral improvement which, even for those who consider expense only, cannot be considered negligible, for in the end the result is pecuniary economy. But, having stated this principle, it would be necessary to find out what is the value, what is the duration, what is the frequency of such improvements. It would be necessary to know what is their cost, and to compare the cost with the results in order to find out where one was. This kind of stock-taking, both financial and medical, has no place in the publications of the Bicêtre, and cannot be replaced by isolated observations on the treatment and improvement of idiot children. There is here, therefore, a first lacuna. We note also with regret the absence of any inspection of the teachers in the schools, who are left to themselves without any supervision but that of the doctor. Now, the doctor is notusually an educationist, and it is to be regretted that he does not himself recognise his incompetency in pedagogy, but that, on the contrary, his nature, often prone to take offence, will not submit to any collaboration in his work. Having said this, we are going to confine ourselves to the social return of the school of Bicêtre, since it is affirmed that such a return exists.
We would like to know exactly how many boys and girls have been able, after their discharge, to work at a trade and to maintain themselves. Upon this point of capital importance the publications of Bicêtre tell us nothing—absolutely nothing. It is, therefore, impossible to find out the real value of this institution, so richly endowed, where the visitor perambulates palatial buildings, is saluted by a fanfare, and admires museums of natural history which would be the envy of many a public educational establishment. The publications give a number of particulars as to the number of dancing lessons, the walks to the Jardin d'Acclimatation, and the cost of laundry, etc.; but we are left in entire ignorance as to what all this is good for, and what is the practical tangible benefit which society receives from it.
Everyone knows, however, that the director of the school for defectives at Bicêtre is an enlightened philanthropist, who has devoted himself with remarkable zeal and activity to procuring for his old pupils situations which they are capable of filling. He has understood, and was one of the first to do so, that the question of the education of defectives will never be settled until one has settled that of the social usefulness of these children.
We have even learned indirectly that he has made many endeavours to induce employers to engage his defectives as workmen; but it is likely that these suggestions have not met with the success they deserved, for the employers, threatened by the new law regarding accidents at work, hesitate to saddle themselves with workers who, beingliable to attacks of epilepsy, or affected by motor inability, would lay upon them a very heavy responsibility. On the other hand, the school education has had a good deal of success since it has happened, as we have already remarked, that several of the pupils obtained their certificates of study.[14]But the only publications which we have consulted say no more about these certificates of study than about the trades followed by the defectives after leaving school. This silence is very significant. In spite of oneself, one puts a bad interpretation upon it. One has an irresistible tendency to believe, not that all the effort at Bicêtre has been in vain, but that it has been disproportionate in relation to the result achieved.
We have no difficulty in admitting that idiots have been improved, but to what an extent this amelioration loses in importance if the majority of these idiots are destined to pass the rest of their life in an asylum, where they will be nourished in absolute idleness, and where, consequently, the heedless administration will gain nothing for what has been taught them at the price of such great efforts!
Let us try, however, to interpret the silence of the text. In four years 240 boys have left the school at Bicêtre. In studying the school of the Salpêtrière we distinguished three classes of children—theimproved, thestationaryordoubtful, and those who have gotworse. We have consulted the statistical tables of Bicêtre, and we have not found a single one markedworse, although one-third of the entire contingent are epileptic. Now, this is very surprising, since we know that epilepsy with repeated fits inexorably results in mental decadence. It is an enigma, which we explain in the following manner: Those who are really decadent have been markedstationaryby medicalor pedagogical optimism. If our interpretation is correct, it recoils forcibly upon the expressionimproved, which is applied frequently to those discharged. To the interpretation of this wordimprovedwe are, therefore, obliged to turn our attention.
What, then, must be understood byimprovedwhen this word is found in the publications of Bicêtre? First of all we must subtract a certain number of subjects who have been markedtransferred. We know what is meant by this little wordtransferredwhen it is applied to the children. It is lugubrious. It amounts to a sentence for life. A subjecttransferredis one who, his time at school come to an end, is removed to an asylum for the insane, where, in all probability, he will stay to the end of his useless existence. If we eliminate the transferred, and if we keep amongst the improved only those who, having been so designated, have returned to their families, we get a proportion of 58 in 290—that is, 20 per cent. of boys.
This proportion seems to us too large, on account of the optimism which these documents exhibit. It is to be noticed, however, that children are sometimes markedvery much improved, ornotably improved. If, for the sake of prudence, we consider as improved only those who are designated in this way, we have only eighteen, or 7 per cent.
This new proportion, if small in absolute value, still seems to us an exaggeration, because it is reached only by including a certain number of children affected with epilepsy. It must, therefore, be believed that their epilepsy has improved. But the amelioration or cure of epilepsy is not a matter of education; it cannot be considered as a success to be credited to active medico-pedagogical treatment. Let us therefore put the cured epileptics aside. There will then remain only seven who have undergone a notable amelioration and have returned to their families. What percentage is this? The total contingent upon which we have been making our calculations numbered 290, but it is right toexclude all the epileptics, for the reasons we have mentioned. This brings the number down to 216, and the number of children really improved, calculated upon 216, amounts, for the boys, to from 3 to 4 per cent.
By similar calculations, into the details of which we will not enter, we have shown that the improved amongst the girls are more numerous—namely, 20 per cent. But Vallée contains relatively far fewer epileptics than Bicêtre. We do not know, also, how many of them have become capable of working at a trade.
We therefore conclude with the following propositions:
1.At the school of the Salpêtrière, 20 per cent. of defective girls improved, and 12 per cent. are able to work at a trade.
2.At the Fondation Vallée, also, 20 per cent. of defective girls have improved. No return has been furnished as to their future employment.
3.In the case of Bicêtre, the number of defective boys improved is from 3 to 4 per cent. It is not known how many of these defectives are employed after leaving school.