MENTALLY DEFICIENT CHILDREN .MENTALLY DEFICIENT CHILDREN THEIR TREATMENT AND TRAINING G. E. SHUTTLEWORTH, B.A., M.D., &c. FELLOW OF KING'S COLLEGE, LONDON; HON. CONSULTING PHYSICIAN (FORMERLY MEDICAL SUPERINTENDENT), ROYAL ALBERT INSTITUTION, LANCASTER, FOR THE FEEBLE-MINDED OF THE NORTHERN COUNTIES ; "SPECIAL SCHOOLS" MEDICAL OFFICER, WILLESDEN EDUCATION COMMITTEE; FORMERLY ASSISTANT MEDICAL OFFICER, ROYAL EARLSWOOD INSTITUTION FOR MENTAL DEFECTIVES ; MEDICAL EXAMINER OF DEFECTIVE CHILDREN TO THE (LATE) SCHOOL BOARD FOR LONDON J AND MEDICAL EXPERT, M. A. B, INSTITUTION FOR IMPROVABLE IMBECILES, BALING AND W. A. POTTS, M.A., M.D., &c. MEDICAL OFFICER TO THE BIRMINGHAM COMMITTEE FOR THE CARE OF THE MENTALLY DEFECTIVE ; LATE MEDICAL INVESTIGATOR TO THE ROYAL COMMISSION ON THE CARE AND CONTROL OF THE FEEBLE-MINDED, AND CHAIRMAN OF THE AFTER-CARE (SPECIAL SCHOOLS) COMMITTEE, BIRMINGHAM FORMERLY RESIDENT MEDICAL OFFICER, YORKSHIRE EAST RIDING LUNATIC ASYLUM FOURTH EDITION PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1916 H i PRINTED IN ENGLAND. TO THE MEMORY OF THE TRULY ILLUSTRIOUS EDOUARD SEGUIN, M.D. WHO FOR FORTY-TWO YEARS, BOTH IN THE OLD WORLD AND THE NEW, PRACTICALLY AND WITH HIS PEN LABOURED TO IMPROVE THE CONDITION OF MENTALLY DEFICIENT CHILDREN BY THE APPLICATION OF PHYSIOLOGY TO EDUCATION; THIS BOOK IS INSCRIBED. " He loved others better than himself." 372363 PREFACE TO FOURTH EDITION THE Third Edition having some time ago been ex- hausted, and frequent inquiries for copies continuing, the authors have gladly availed themselves of the opportunity of thoroughly revising this work in the preparation of a new edition. During the last five years increasing public attention has been given to the Mentally Defective Class, culminating in the pas- sage through the Legislature of the Mental Deficiency Acts for England and Wales, and for Scotland, re- spectively. An Act amending the " Elementary Education (Defective and Epileptic Children) Act" of 1899 has also been passed. Consequent administra- tive and educational changes have had to be set forth, involving some condensation of matter in the last edition. Much, indeed, has been rearranged and re- written. Chapter VI., dealing with the mental troubles of youth, has been added, and the illustra- tions have been rearranged and supplemented by one or two fresh plates. Thanks are due to several professional friends for the loan of blocks, and to Miss Ethel Dixon for kind assistance in preparing the index. It is hoped that the present edition may enjoy a viii PREFACE TO FOURTH EDITION share of the favour which has been so liberally ac- corded to its predecessors; and it is encouraging to its authors that not only a French version of the work has been published,* but that permission to trans- late it into Japanese has recently been requested. G. E. S. W. A. P. May, 1916. * " Les Enfants Anormaux au point de vue mental." J. Lebegue et C ie , Libraires-]diteurs, 46, Rue de la Madeleine, Bruxelles. Traduite par le Docteur Ley. 1904. PREFACE TO FIRST EDITION IN offering this little Manual to the Medical Profes- sion, and to the increasing number of the Public who take an interest in the special education of mentally deficient children, the author trusts that the experi- ence acquired by the proverbial " quarter-of-a-cen- tury's " successive residence in two of the largest Training Institutions for Imbeciles may aid him in setting forth both the salient peculiarities of the class and the ameliorative measures found most useful. He does not profess to bring forward much that is new, but rather to collect and mould into book form various papers published by him during the last twenty years in Medical Journals and the Proceedings of Societies. In the present volume, the pathology of the subject is only touched on to supply a few practical hints which may be of service to the medical man in his diagnosis, prognosis, and recommendations, when consulted in the case of a mentally feeble or deficient child. Though his standpoint is that of the physician, and not of the teacher, the author hopes that his observations upon special educational methods, based as they are upon physiological principles, may not be x PREFACE TO FIRST EDITION without value to those engaged in the practical work of instruction. For the successful training of the mentally deficient child, the physician and the teacher must go hand in hand ; and it will be a satisfaction to the author if in some slight degree this book realizes the aspirations of Seguin, who was both. " Let us physicians," he says (in the course of an address to a New York Medical society), " help to build the programme of physiological education already sketched in the School for Idiots. . . . The demonstration therein given is that the physiological education of the senses is the royal road to the educa- tion of the intellect; experience, not memory, the mother of ideas." G. E. S. May, 1895. / ' r CONTENTS CHAPTER I HISTORICAL RETROSPECT PAGE The work of Seguin, Saegert, Guggenbiihl, Itard, Voisin, and Esquirol. The writings of Twining, Gaskell, and Conolly lead to the establishment in Great Britain of Training Schools for mentally deficient children. Recent development of Institutions for Defectives. Early scientific investigations. Swiss statistics - I CHAPTER II DEFECTIVE AND EPILEPTIC CHILDREN Official investigations by English Education Department as to above, and consequent legislation. Special Schools: their merits and shortcomings. Royal Commission on the Care and Control of the Feeble- minded: their Report and Recommendations. Mental Deficiency Acts (England and Scotland) : their leading provisions. Regulations issued by Home Secretary - 18 CHAPTER III SPECIAL INSTRUCTION Definitions in Mental Deficiency Act, and in the Educa- tion Acts (1899 and 1914). Special Schools on the Continent and in America. Their arrangements and developments in England. Illustrative cases - 35 xi xii CONTENTS CHAPTER IV PATHOLOGICAL CLASSIFICATION OF FORMS OF MENTAL DEFICIENCY PAGE General pathology. Primary and secondary amentia. Microscopic and macroscopic appearances. Primary Types. Defects of the corpus callosum and partial atrophies. Word -deaf ness and word -blind ness. Mind-blindness. Microcephalus. Hydrocephalus. Hypertrophic cases. " Mongol " type. Neurotic (scaphocephalic). Simple congenital. Developmental Types. Epiloia, or tuberous sclerosis : Eclampsic. Epileptic. Syphilitic (juvenile general paralysis of the insane). Birth-palsies, etc. Secondary Types. Traumatic. Post-febrile (oxycephaly) . Emotional. Trophic and toxic cases (amaurotic family idiocy ; cerebral degeneration with symmetrical changes in the maculae. Glandular inadequacy (cretinism, infantilism). Sense-deprivation - - 51 CHAPTER V ETIOLOGY, DIAGNOSIS, AND PROGNOSIS Etiology. Hereditary mental weakness epileptic, neurotic, etc. Statistics. Mendelian doctrines. In- fluence of environment. Inherited syphilis. Was- sermann reaction. Phthisical family history. Par- ental intemperance. Maternal ill-health, accident or shock. Prolonged parturition use of forceps. Premature birth. Convulsions of teething. Epi- lepsy. Traumatism. Fright or shock. Severe febrile illnesses. Diagnosis. Cranial abnormalities: (microcephalus; hydrocephalus ; hypertrophic cases ; oxycephaly ; scaphocephaly) . Formative and developmental de- fects. Abnormality of nervous action. Defects in nutrition. Primary and secondary amentia. Tests CONTENTS xiii PAGE of intelligence. Binet-Simon scale, etc. Achondro- plasia. Mixed types. Moral defectiveness . Prognosis in various types. Mongol, Cretin and other definite types - - 83 CHAPTER VI THE PSYCHOPATHIES OF PUBERTY AND ADOLESCENCE Juvenile general paralysis of the insane. Dementia prae- cox. Developmental epilepsy and epileptic mental degeneration. Pubertal perversion of moral sense. Hysterical affections. Insanity in childhood. Minor mental and moral changes - - 142 CHAPTER VII ^VIEDICAL EXAMINATION OF MENTALLY DEFECTIVE CHILDREN UNDER THE REGULA- TIONS OF THE BOARD OF EDUCATION 'Model arrangements." Forms and certificates. Binet- Simon and other tests. Pasmore's " Flag " Chart of Heredity. Backward classes. Print of Schedule F 153 CHAPTER VIII THE TREATMENT OF MENTALLY DEFICIENT CHILDREN (a) General. Maternal care. Proper feeding. Hygiene of skin. Muscular activity to be encouraged. Cleanly habits to be inculcated. Clothing. Exer- cise. Care at puberty. (b) Medical. Coexistence of physical and mental defects. Tuberculosis. Mu- cous diarrhoea. Epilepsy. Sporadic cretinism. Parasitic and other skin diseases, (c) Surgical opera- tions in bone and joint disease. Craniectomy - 170 CONTENTS CHAPTER IX EDUCATIONAL TRAINING PAGE Culture of the external senses. Co-ordination of mus- cular movement. Promotion of manual and mental activities, (i) Dull and apathetic, (2) Nervous children. Devices for fixing attention and for exer- cising adjustments of fingers (illustrated). Montes- sori " didactic material." Training of touch, sight, taste, smell, hearing, speech. Echolalia. Idioglossia. Drill and dressing lessons. Object-lessons. Draw- ing, writing, reading, and calculation. Influence of music ------- 186 ^_^ . CHAPTER X INDUSTRIAL TRAINING AND RECREATION Kindergarten occupations. Outdoor work. Handi- crafts. Recreations. Games of ball; marbles; skipping; battledore and shuttlecock; dancing; baga- telle. Concerts and theatrical performances. Speci- men curricula of L.C.C. Special Schools - 207 CHAPTER XI MORAL TRAINING Specially essential in education of mentally deficient children. Moral discipline; "force no remedy"; rewards and punishments. The morally defective child. Sequestration and sterilisation. Religious feeling in mentally deficient children - 216 CONTENTS CHAPTER XII RESULTS AND CONCLUSIONS Pessimistic views as to possibility of improving defec- tive children. Experience of Seguin, of English, of American Institutions, and of Special Schools. Necessity of " after-care." Statistics. Proportion fit for employment. Earning capacity. Relief to parents. Examples. Question of marriage and of permanent sequestration. Special school education and its results and shortcomings. Working homes and colonies for mental defectives. Objections to efforts to educate mentally deficient children. The humanitarian and Christian aspects of the subject -226 APPENDICES A. LIST OF INSTITUTIONS RECOGNISED UNDER MENTAL DEFICIENCY ACTS, AND OF M. A. B. INSTITUTIONS, INSTITUTIONS IN IRELAND AND BRITISH DOMIN- IONS - 244 B. LIST OF PUBLIC AND PRIVATE INSTITUTIONS IN UNITED STATES OF AMERICA - - 256 C. TABLE OF SPEAKING EXERCISES - - 260 D. TIME TABLE L.C.C. SPECIAL SCHOOL FOR ELDER BOYS - - - 262 E. FORM OF MEDICAL CERTIFICATE UNDER MENTAL DEFICIENCY ACT .... - 264 BIBLIOGRAPHY - - - - 265 INDEX OF SUBJECTS - . - 274 INDEX OF NAMES . 283 LIST OF ILLUSTRATIONS PLATES. Plate I.- Defects in Development. [facing p. 12 FIG. i. Misshapen " Morel " Ears. ,, 2. Convoluted Scalp. ,, 3. Ear showing Darwinian Tubercle. ,, 4. Frontal Corrugation in Mongolian Imbecile. Plate II. Abnormalities in Brain Structure. [facing p. 55 FIG. i. Porencephalus. ,, 2. Cerebellar Defect. Plate III. Microcephalic Brains. [facing p. 59 FIG. i. Convexity (half natural size). 2. ,, " ' " Freddy " (natural size). Plate IV. Microcephalic Cases. [facing p. 60 FIG. i." Freddy " (R. A. A.) ,, 2. Special School (boy). ,. 3- M (girl). Plate V. Hydrocephalic Cases. [facing p. 61 FIGS, i and 2. Portraits. Plate VI. Mongol Brain. [facing p. 62 FIG. i. Convexity. ,, 2. Base. 3. Left Lateral View, xvii LIST OF ILLUSTRATIONS Plate VII. From Journal of Psycho- Asthenics. [facing p. 63 FIG. i. American Imbecile with Leptocephalic Cranium. ,, 2. American Imbecile with Scaphocephalic Cranium. Plate VIII. Inherited Syphilis. [facing p. 70 Plate IX. Birth Palsy. [facing p. 72 FIG. i. Girl (R. A. A.). 2. Boy, showing Athetosis (R. A. A.). Plate X. Oxycephalic Case. [facing p. 73 FIG. i. Front. 2. Profile. Plate XI. Sporadic Cretins. [facing p. 79 -pic. i. Female Cretin. 2. " Sarah," aged twenty-two years. Plate XII. Cranial Contours. [facing p. 105 Plate XIII. Reduced Cranial Skiagram (anterior view) [facing p. 108 Plate XIII .A. Reduced Cranial Skiagram (adjoining- lateral view) [ following Plate XIII. Plate XIV. Mongolian Type. [facing p. 119 FIG. i. " Mongol " Profile. 2. " Mongol " Tongue. Plate XV. (FIGS, i and 2)." Mongol " Hands. [facing p. 120 Plate XVI. Wood-Carving by J. B. (R. A. A.) [facing p. 127 Plate XVII. Heredity Chart (Dr. Pasmore). [facing p. 163 LIST OF ILLUSTRATIONS xix Plate XVIII. J. L. (" Diogenes ") (R. A. A.) \facingp. 175 Plate XIX. Sporadic Cretins. [facing p. 182 FIG. i. Before Treatment. 2. After Treatment. Plate XX. The Same after Ten Years' Continued Treat- ment, [facing p. 183 ILLUSTRATIONS IN THE TEXT FIG. i. American Cretins - 80 ,, 2. -Microcephalic Idiot, aged twenty - 105 ,, 3. Contours of Scaphocephalic Cranium - - 108 ,, 4. Peg-Board - 189 ,, 5. Size-Board - 193 ,, 6. Form-Board - - 193 ,, 7. Graduated Wooden Rods - 194 ,, 8. Domino-Bcfards - 194 MENTALLY DEFICIENT CHILDREN THEIR TREATMENT AND TRAINING CHAPTER I HISTORICAL RETROSPECT NEARLY eighty years have now passed since serious and systematic efforts were first made to improve the condition of the mentally deficient child. The labours of Seguin, at the Bicetre Hospital in Paris, gave the first impetus to scientific work having for its object (in the words of Esquirol) " the removal of the mark of the beast from the forehead of the idiot." Some such efforts had indeed been previously made in France by Itard, Voisin, Esquirol, and others; and the ex- periments of Itard on the boy found running wild in the woods of Aveyron (le sauvage de I'Aveyron), of which he published an account in 1801, doubtless con- tributed to a rational understanding of congenital defects of intellect. In 1837 Seguin, an old pupil of Itard and Esquirol, essayed to instruct an idiot child, and after gaining experience and successful results at the Hospital for Incurables, he was appointed in 1842 to. apply his method to the education of the idiot children of the Bicetre. About the same date, MENTALLY DEFICIENT CHILDREN Dr. Saegert, in Berlin, and Dr. Guggenbiihl, in Switzerland, independently took in hand the ameliora- tive treatment of mentally feeble children. The conspicuous success of the work of Guggenbiihl in improving the condition of cretins by removing them from sequestered and shadowed Alpine valleys to the sunshine of the summit of the Abendberg, made a great impression on philanthropists in Europe and America, and demonstrated, as by an object-lesson, the interdependence of physical and mental ameliora- tion. Saegert seems to have laboured somewhat on the lines of the instruction he had been accustomed to give to deaf-mutes, with such adaptations as were necessary to the case of imbecile children. The school he established is still carried on in Berlin, though with the disadvantage of being organised as a department of a lunatic asylum. It was a curious coincidence that almost simultaneously in France, Switzerland, and Germany, independent efforts were inaugurated for the benefit of the mentally defective class; and the year 1842 must be looked upon as an epoch memorable in this matter. Although Seguin is entitled to the credit of priority, he himself modestly avers that " at certain times and eras, the whole race of man as regards the discovery of truth, seems to arrive at once at a certain point, so that it is hard to say who is the discoverer." In 1843, however, the illustrious Voisin publicly recognised the work and merits of Seguin. His prognostications that Seguin would " be entitled by his psychological contributions to take a distinguished place among his contem- poraries " were justified by the publication, in 1846, of Seguin's magnum opus entitled ff Traitement moral, Hygiene et Education des Idiots et des autr.es Enfants Arrieres." This book may indeed be re- HISTORICAL RETROSPECT 3 garded as the magna charta of the mental emancipa- tion of the imbecile class.* Defining idiocy as an " infirmity of the nervous system, which has for its effect the abstraction of the whole or part of the organs and the faculties of the child from the normal action of the will," he . proceeds to divide all cases into two principal classes, those of profound, and those of superficial idiocy. The basis of the treatment he proposes is almost identical with that described in later works as physio- logical education. Starting with the axiom that " The education of the senses must precede the education of the mind/' he argues that the true physiological method of tuition for persons whose nervous system is imperfectly developed is (i) " to exercise the imperfect organs so as to develop their functions/' and (2) ' to train the functions so as to develop the imperfect organs." Ingenious devices are described whereby the sense-organs may be methodically exercised, and cases are given in minute detail in which such exercises have been adapted to special incapacities. \In Great Britain interest had been aroused by the publication, in 1843, of an account by Dr. William Twining of what he had witnessed at Guggenbuhl's Institution on the Abendberg. This, indeed, led to the establishment, in 1846, of a small school for imbeciles at Bath, under the management of the Misses White, subsequently carried on as a benevolent establishment by Miss Heritage. This has now developed into the Magdalen Hospital School, Combe * For further particulars as to Seguin, the reader is referred to a recent excellent work, Seguin and his Physiological Method of Education, by Henry Holman, M. A. London : Sir Isaac Pitman and Co., 1914. MENTALLY DEFICIENT CHILDREN Down, under the management of the Trustees of the Municipal Charities ol Bath. It is a matter of archaeological interest to note that this Institution owes its establishment in 1891 to an Order of the Charity Commissioners amalgamating the school above referred to with an ancient charity founded in the twelfth century as a leper hospital in connec- . tion with the Priory Chapel of St. Mary Magdalen, Bath. It seems probable that as the demand for the accommodation of lepers diminished, lunatics and idiots took their place. Thus the Bath Institution may claim, by right of succession, to be the most ancient foundation in Great Britain for this class of cases, and it is on record that " idiots " were in residence at the Magdalen Hospital early in the eighteenth century. Articles by Mr. Gaskell (after- wards a Lunacy Commissioner) and Dr. Conolly (the enlightened Superintendent of Hanwell Asylum) upon the work of Seguin at the Bicetre, which ap- peared in 1847, ted to a further practical development in England, and in 1848, Park House, Highgate, the mother institution of Earlswood and of the Eastern Counties Asylum at Colchester, opened its doors for the treatment and training of idiots and imbeciles, Dr. Conolly and Dr. Reed acting as its gratuitous secretaries. yL Meanwhile the New World was closely treading upon the heels of the Old in the march of progress in the education of imbeciles. Early efforts had been made in the most progressive of the United States to benefit idiots by training them in con- nection with special schools for the deaf, and for the blind; but Massachusetts was the first to move in specific provision for this class by appointing " Commissioners to inquire into the condition of HISTORICAL RETROSPECT idiots in the Commonwealth, to ascertain their number, and whether anything can be done for their relief/' Dr. S. G. Howe, well known as the successful instructor of the blind deaf-mute, Laura Bridgman, was the Chairman of this- Commission. Their Report, issued in 1848, with elaborate statistical tables, led to a grant by the Legislature of 2,500 dollars for the establishment of an " experimental school for feeble- minded children"; and about the same time a private school was opened at Barre, Mass., by Dr. H. B. Wilbur, being " designed for the education and management of all children who by reason of mental infirmity are not fit subjects for ordinary school instruction." In 1851 an " experimental school " was started by the State of New York; this subse- quently developed into the State Asylum at Syracuse, over which Dr. H. B. Wilbur long and ably presided. The first Report of the Trustees so well sets forth the aims and limitations of training that we are tempted to quote a few lines as follows: 11 We do not propose to create or supply faculties absolutely wanting; nor to bring all grades of idiocy to the same standard of development and discipline; nor to make them all capable of sustaining creditably all the relations of a social and moral life ; but rather to give to dormant faculties the greatest possible development, and to apply these awakened faculties to a useful purpose under the control of an aroused and disciplined will. At the base of all our efforts lies the principle that, as a rule, none of the faculties are absolutely wanting, but dormant, undeveloped, and imperfect/' After the decease of Dr. Wilbur, in 1883, the " Syracuse State Institution for Feeble- minded Children " (as it is now designated) was directed by Dr. J. C. Carson, who resigned in 1912 6 MENTALLY DEFICIENT CHILDREN " after twenty-seven years of diligent and efficient service/' and was succeeded by Dr. O. H. Cobb; the Institution now has 626 inmates. Pennsylvania was the next to establish a " Train- ing School for Feeble-minded Children." Taking up the private enterprise of Mr. J. B. Richards, a State- aided charity was formed, in 1853, which, under its late Superintendent, Dr. Isaac Kerlin, and his assistant and successor, Dr. Martin Barr, has become (at Elwyn) a model village for the feeble-minded. The State of Ohio provided for her feeble-minded children in 1857; the Institution at Columbus, with its splendid stock-farm, is appointed on a liberal scale, and contains about 1,500 inmates under the care of Dr. Emerick, the successor of Dr. Doren, who for over thirty years wisely directed its development. Connecticut, Kentucky, and Illinois, were also early in the field, having established State Institu- tions for the feeble-minded between 1855 an d 1865. It is noteworthy that all the early American Schools were organised on strictly educational lines, the im- becile institution being regarded (in the words of Dr. Howe) " as a link in the chain of common schools the last indeed, but still a necessary link to embrace all the children in the State." The influence of Dr. Seguin, who, after migrating from Paris to the United States in 1850, was asso- ciated with the organisation of several of the early American Institutions, inspired enthusiasm in the educational work, and perhaps a somewhat exag- gerated belief in its possibilities. The sanguine views, however, put forth in some of the early Reports gradually sobered down with experience, and in 1872 Dr. Wilbur set forth to his Trustees in clear language the limitations inevitable in cases of original defect. HISTORICAL RETROSPECT 11 The same limitations " (he writes) " hold here as in any other system of education. These depend upon the individual capacities of the pupil. Now and then one of the pupils absolutely passes from the condition of idiocy, and leaves the Institution capable of caring for himself thereafter. These are the exceptions; the rule is otherwise. Ordinarily, the highest aim of the training is to send out the. sub- ject of it, at the end of the course, so improved as to be capable of some useful occupation, under intelli- gent direction." He pointed out that these conditions involve the necessity of supplementary custodial insti- tutions, and from this time forward such a considera- tion seems to have been more of 4 less kept in mind in the provision of State care for the feeble-minded. In 1898, according to Dr. F. M. Powell's Report to the National Conference of Charities and Correction, there existed twenty-four public Institutions for this class, maintained by nineteen States, and one by the city of New York. From a statement which appeared in an American philanthropic journal, The Survey, in 1912 one gathers that in all but eighteen of the States of the Union some public provision of a residential character has now been made for the mentally de- ficient class, and that about 25,000 in the aggregate are thus accommodated, as compared with 8,492 in 1898. This statement does not include private schools or the special (day) classes established in some of the cities. It would appear, from the Bulletin for 1911 of the United States Bureau of Education, that 99 cities have established special classes for mentally defective children, while 220 classes for mentally backward children have also been organised./ In our own country comparatively little progress has been made in recent years in providing out of MENTALLY DEFICIENT CHILDREN public funds Institutions exclusively for the mentally defective class. Those of the Metropolitan Asylums Board, affording accommodation for about 7,000 adult imbeciles and harmless lunatics and 1,500 children, have been in existence for upwards of forty years under the Metropolitan Poor Act of 1867. But else- where only sporadic attempts have been made by Guardians of the Poor to form special establishments apart from workhouse accommodation for imbeciles and feeble-minded falling under their charge. The most notable example of a provincial Poor Law Institution is that originally provided by a combina- tion of the Birmingham, Aston, and King's Norton Guardians at Monyhull in 1908; the present estab- lishment, now under " the Greater Birmingham " Board of Guardians, is known as the Monyhull Colony for sane epileptics and feeble-minded persons charge- able to the Board. On an estate of 185 acres 252 adult inmates were originally provided for in several separate houses; extensions are in progress to bring up the accommodation to 12 homes for an aggregate of 504 adults, and 8 homes for 76 epileptic and 270 feeble-minded children, 230 of the latter to be main- tained by the Education Committee of Birmingham. A school with 300 places, workshops and laundry, is also to be provided. At the colony 100 beds are required for cases sent under certificate by the Bir- mingham Committee for the care of the Mentally Defective. Stimulated by the passing of the Mental Deficiency Act, other Poor Law Guardians are also moving in the matter; in Wiltshire an Institution is projected at Devizes for 200 feeble-minded cases, and the Joint Committee of Glamorgan Unions is about to establish a Colony for Feeble-minded on the side of the Drymma Mountain, near Neath. A HISTORICAL RETROSPECT g combination of West Riding Guardians contemplate the provision of a colony for feeble-minded near Pontefract; and 24 Unions in the North-East of England are contributing to the establishment of an Institution for Feeble-minded, and have purchased Prudhoe Hall, with its estate of 125 acres, in Nor- thumberland, for the purpose. In connection with County Lunatic Asylums, annexes or special wards for young imbeciles have been provided at Northampton, Wandsworth (Mid- dlesex), Fareham (Hants), Chartham (Kent), Durham, Winwick (Lanes), Stanley Hall (Yorks), Burnt- wood (Staffs), Rubery Hill (Birmingham), and Hel- lingly (East Sussex), the aggregate accommodation being about 1,000 beds. It is probable -that under the Mental Deficiency Act some rearrangement will be effected. Plans have recently been adopted by the Kent County Council for a special Institution for Defectives near Charing. In recent years greater charitable enterprise has been shown in the provision of residential establish- ments for the mentally defective. In addition to the six English voluntary Institutions for Idiots and Imbeciles at Earlswood, Lancaster, Starcross, Col- chester, Knowle, and Bath, which have been doing good work during the last half-century and now accommodate some 2,000 patients the Sandlebridge Colony of the Lancashire and Cheshire Association for Permanent Care has some 300 residents, children and adults, and the Princess Christian Farm Colony near Tonbridge about no. A colony recently estab- lished by the Notts and Nottingham Association ,at Hopwell Hall, Derbyshire, accommodates 50 boys, and will also admit 50 girls later on. In Somerset it is hoped shortly to establish a Permanent Home io MENTALLY DEFICIENT CHILDREN for the feeble-minded of that county and Bristol, a site of 100 acres having been offered for the purpose by Mr. H. H. Wills. Several establishments (The National Institutions for Persons requiring Care and Control), including those at Sandwell Hall and Stoke Park, have been provided, mainly through the activity of the Rev. H. N. Burden, for about 1,700 mentally defective children and adults. About 600 cases, chiefly older feeble-minded girls, are in small voluntary Industrial Homes founded by benevolent associations in various parts of the country. The first homes of this kind were established by the late Miss Agatha Stacey in 1892 near Birmingham. If we also take into account the 14,000 children attend- ing special schools in England and Wales shortly, we trust, to be doubled when the Elementary Educa- tion (Defective and Epileptic Children) Act comes into full operation it may be said that there is, in one way or another, provision for about 25,000 mental defectives in England and Wales. In Scot- land the Institutions at Larbert and Baldovan pro- vide for 6 io inmates,* while many of the imbecile and feeble-minded class are boarded out under super- vision. Special schools for defective children also exist in the larger cities with places for upwards of 800 pupils. In Ireland about 120 imbeciles are accommodated at the Stewart Institution, near Dublin. The Board of Control have acquired, under the powers of the Act, premises at Maghull, near Liverpool, for a State Institution for defectives of dangerous or violent propensities. * Quite recently the Glasgow Association for the Feeble- minded has opened an Institution for Juvenile Female Defec- tives, and three Institutions for Adult Defectives have been organised . HISTORICAL RETROSPECT n In the cursory survey of the provision made for mental defectives in Great Britain and in the United States it has proved impracticable satisfactorily to differentiate between that for children and for adults, or definitely to state the grade of mental defect of the inmates of the respective Institutions. For the most part those in America have been designated Institutions for " Feeble-minded/' and in Great Britain (until recently) "Asylums for Idiots and Imbeciles," though both have ministered to the wants of similar classes of patients. In America, how- ever, the designation " Feeble-minded " has long been used as a euphemism for all grades of mental defect, including idiots, imbeciles, and the higher type to which the appellation Moron (from ^w/>os = a foolish person) has of late years been applied by Dr. Goddard of the Vineland Institution, U.S.A. Though the English Education (Defective and Epi- leptic Children) Act of 1899 recognised a grade of children higher than imbeciles as " mentally defec- tive " so as to require special education, it was not until 1908 that the Royal Commission on the Care and Control of the Feeble-minded gave precision to the term by denning as feeble-minded " persons who may be capable of earning a living under favourable circumstances, but are incapable from mental defect existing from birth or from an early age (a) of com- peting on equal terms with their normal fellows; or (b) of managing themselves and their affairs with ordinary prudence." It will be seen later that this definition, with certain modifications, has been adopted in the Mental Deficiency Act, 1913. Under the auspices of the British Medical Associa- tion, the Charity Organisation Society, the British Association for the Advancement of Science, the In- 12 MENTALLY DEFICIENT CHILDREN ternational Congress of Hygiene and Demography, and other public bodies, laborious investigations were undertaken nearly thirty years ago, Dr. Francis Warner being the active conductor of the inquiry. A " Report on the Scientific Study of the Mental and Physical Conditions of Childhood; with particular reference to children of defective constitution; and with recommendations as to Education and Train- ing," was issued in 1895 by the Committee, Parkes Museum, Margaret Street, W., based on the examina- tion of 50,000 children seen in 1888-91, and of another 50,000 seen in 1892-94. Whilst 100,027 children passed in groups under the eye of the medical examiner, the number of children individually noted and registered was 18,127, no note being taken of the 81,900 children not presenting obvious physical defect, or not reported by teachers as mentally dull. Defects in development* such as abnormalities of cranium, of external ear, of eyelids, of palate, of nasal bones, and of stature, were noticed in 9,777 cases; abnormal nerve signs, such as defect in general balance, overacting f rentals, corrugation, f defective eye movements, defects of balance of head or hand, finger-twitches and lordosis, together with deafness, defective speech, slow response, etc., were observed in 10,355 cases; low nutrition was registered against 3,522 children, who were pale, thin, or delicate; and 7,391 children were, on report of teachers, entered as mentally dull. Obvious eye-defects were noted in 2,929 cases: evidences of rickets (other than cran ; al) were registered in 244; 811 children were put down as " exceptional/' including 2 idiots, 51 imbeciles, 275 children feebly gifted mentally, 19 " mentally exceptional " (moral imbeciles, etc.), no epileptics, 5 deaf-mutes, 374 children crippled, maimed, and * See Plate I., Figs, i, 2, 3, 4. f See Plate I., Fig. 4. [ PLATE I. IG L. MISSHAPEN " MOREL " EARS: CONGENITAL IMBECILE. FIG. 2. CONGENITAL IMBECILE WITH CONVOLUTED SCALP. 1/iG. 3. EAR SHOWING DAR- WINIAN TUBERCLE. FIG. 4. MONGOLIAN IMBECILP:, SHOWING FRONTAL CORRUGATION. DEFECTS IN DEVELOPMENT. From Journal oj Psycho- A sthenics, vol. xi. (by kind permission of Drs. Moorhead Murdoch and A. C. Rogers). 'o face p partie). Statistique de la Suisse, ii4 e livraison, Berne, 1897. t V evhandlungen der VI. Schweize. Konferenz fur das Idiotenwesen, p. 32, J Kelynack's Medical Examination of Schools and Scholars, p. 414. 2 CHAPTER II DEFECTIVE AND EPILEPTIC CHILDREN PUBLIC attention having been called, largely through the non-official investigations referred to in the previous chapter, to the existence of a considerable class of children incapable of receiving education on conventional lines, the Lord President of Council (as chief of the Education Department) appointed in 1896 a Departmental Committee to inquire into the existing systems for the education of feeble- minded and defective children, " not idiots or im- beciles." The Committee consisted of the Rev. T. W. Sharpe, C.B., then Her Majesty's Senior Chief Inspector of Schools ; of Messrs. Pooley and Newton, of the Educa- tion Department ; of Mrs. Burgwin and Miss Douglas Townsend; and of Prof. Wm. Smith and Dr. Shuttle- worth; Mr. H. W. Orange acting as Secretary. They obtained information about the English Institutions for idiots and imbeciles, and also with regard to the treatment of epileptics at the Maghull Institution. They personally inspected the special classes in Leicester, London, Bradford, Brighton, and Bristol. In consequence of their Report, an Act of Parlia- ment, known as the ''Elementary Education (Defec- tive and Epileptic Children) Act," received the Royal Assent in 1899. This Act, which is permissive only, enables school authorities to obtain grants from public 18 DEFECTIVE AND EPILEPTIC CHILDREN 19 money towards the education of defective and epi- leptic children, subject to " such conditions as may be directed by or in pursuance of the minutes of the Education Department in force for the time being/' Under the Regulations issued in 1907, children are not admitted to the special classes till five years . of age, but the period of education for such children is extended until the age of sixteen years, and pro- visions are made for boarding out, when necessary, either in families or in certified schools, and for the school authority supplying, in cases requiring them, guides or conveyance. No requirement is made in the Act of 1899 as to the appointment of Medical Officers either by school authorities or the Education Department, but it is enacted that to bring a child within the purview of the Act " a certificate by a duly qualified practitioner, approved by the Education Department, shall be required in each case." The Education Act of 1907 has, however, since laid an obligation on all school authorities to " provide for the medical inspection of children immediately before, or at the time of, or as soon as possible after, their admission to a public elementary school." Parents may demand the examination of children with a view to their admission to special classes, and re-examination with a view to their transfer to ordi- nary classes in public elementary schools. Thanks to the Elementary Education (Defective and Epi- leptic Children) Amendment Act, 1903, the only ^restriction on boarding-schools is that the school must obtain the approval of the Board of Education. The Departmental Committee estimated the num- ber of " feeble-minded " children at I per cent, of the school population, an estimate which was shown by the investigations of the more recent Royal Com- 20 MENTALLY DEFICIENT CHILDREN mission on the Care and Control of the Feeble-minded to be fairly near the mark when taken over the whole country. This later Commission appointed medical investigators to conduct inquiries in nine selected areas, each with a total population of not less than 150,000. Their Reports showed that " the northerly districts of the Durham County and Hull stand best," and " the large urban areas come last." Thus, in a mining district in Durham County the proportion of mentally defective children to the total registered school population was 0*28, and in Hull and Scul- coates 0-40. The rural areas show a higher per- centage, the figures being wonderfully uniform, with the exception of the Lincolnshire Unions, which, though rural, stand with the urban districts. Thus in Wiltshire the figure was 0-47, in Somerset 0-58, and in Nottinghamshire (partly rural) 0-60. With these rural areas stands Stoke-on-Trent, where the medical investigator, Dr. Potts, reported well of the school population, in spite of many drawbacks. In Lincolnshire the figure was i-io, leading up to the higher figures of 1-12 and 1-24 in Birmingham and Manchester respectively. Epileptic Children. The Departmental Committee estimated the number of epileptic children at i per i ,000, of whom one-sixth might be classed as severely afflicted. They recommended that epileptic children of normal intellect should be left in ordinary schools if the fits are not frequent, or violent fits do not occur in school, and that teachers be provided with instruc- tions as to the treatment of children known to be epileptic. Feeble-minded epileptics may be received into special classes when the epilepsy is not severe; and for such cases it may be necessary to provide guides or conveyance between the home and the DEFECTIVE AND EPILEPTIC CHILDREN 2! school. With regard to severe cases, whether men- tally feeble or otherwise, treatment in residential homes seems essential, proper classification being provided. Each house of residence should consist of one floor only, and should not contain more than twenty inmates ; but there may be an aggregation of such homes round an educational centre, as in the colony plan. It was recommended that school authorities should have power both to provide homes and to contribute to voluntary homes which conform to the conditions laid down. The result of these recommendations was that the Act of 1899 gave power to school authorities to estab- lish residential schools for epileptics. It did not, however, give power to board out or to establish special day-schools for epileptics. For epileptics the Board of Education certify boarding-schools only. The Defective and Epileptic Children Act of 1899 showed the number of feeble-minded children in our big towns, and drew public attention to them. It kept many out of mischief and under control for some hours of the day. It was the means of training some feeble-minded persons to be self-supporting, and of educating a number up to the point of contributing materially to their own support. At the Conference of After-care Committees held in London on Octo- ber 23, 1913, a statement was presented by Sir William Chance, Chairman of the National Associa- tion for the Feeble-minded, dealing with the Reports of the After-care Committees of Berkshire, Birming- ham, Bolton, Bradford, Brighton, Bristol, Bromley and Beckenham, Leicester, London, Northampton, Oldham, Plymouth, Willesden, and Wolverhampton. The combined statistics from these centres showed that nearly 50 per cent, of those who had attended 22 MENTALLY DEFICIENT CHILDREN special schools for the mentally defective were doing remunerative work, the average wages earned being 8s. 6d. per week for boys, and 6s. gd. for girls. Such encouraging reports must, however, be qualified by the consideration that in some of these centres a number of the successful cases were children who had been merely dull and backward, and not really defec- tive, and also by the further consideration that these figures refer largely to cases who have only recently left school. The Birmingham After-care Committee, which v/as the first to be formed, showed repeatedly, after ten years' work, that many of the situations were held for a time only, periods of work often alter- nating with longer periods of idleness, and that young persons who had just left school were frequently the most successful, and gradually deteriorated as they got further away from the time of training and super- vision. This aspect of the subject will, however, be dealt with more fully in the last chapter. Two drawbacks attending the Act were the fact that no legislative action was taken on the Com- mittee's suggestion that the certificate excluding a child from a special class on account of imbecility should admit such child to an institution for imbecile children, and the fact that no provision was made for " after-care " on leaving school. This latter omis- sion did much to nullify the good effected by special classes, even if it did not do worse. In the opinion of many, education for a few years, without subse- quent control, is a dangerous experiment, increasing as it does the capacity, and in the case of some girls the attractiveness, of ill balanced and regulated natures, who ought to be always under supervision. The great disadvantage, however, of the 1899 Act was that it was merely permissive, but by the pro- DEFECTIVE AND EPILEPTIC CHILDREN 23 visions of the Amending Act of 1914 the provision of suitable special education, by means either of day- schools or residential establishments, will become the duty of all education authorities. As all investigations demonstrated more and more clearly that the feeble-minded constitute an impor- tant section of the community, and that many of them require care during the greater part, if not the whole, of their lives, a Royal Commission was ap- pointed, in September, 1904, to investigate the whole problem. The reference required them " to consider the existing methods of dealing with idiots and epi- leptics, and with imbecile, feeble-minded, or defective persons not certified under the Lunacy Laws; and in view of the hardship or danger resulting to such persons and the community from insufficient pro- vision for their care, training, and control, to report as to the amendments in the law and other measures which should be adopted in the matter, due regard being had to the expense involved in any such pro- posals and to the best means of securing economy therein." The original reference was extended in November, 1906, " to inquire into the constitution, jurisdiction, and working of the Commission in Lunacy and of other Lunacy Authorities in England and Wales, and into the expediency of amending the same, or adopting some other system of supervising the care of lunatics and mental defectives; and to report as to any amendments in the law which should, in their opinion, be adopted/' The Commission originally consisted of the Marquis of Bath, Chairman; W. P. Byrne, C.B., of the Home Office; C. E. H. Hobhouse; Dr. Needham, one of the Commissioners in Lunacy; H. D. Greene, K.C. ; C. E. H. Chadwyck-Healey, K.C.; the Rev. H. N. 2 4 MENTALLY DEFICIENT CHILDREN - Burden, Manager of Certified Inebriate Reformatories ; W. H. Dickinson, at that time Chairman of the National Association for Promoting the Welfare of the Feeble-minded; C. S. Loch, Secretary of the Charity Organisation Society; and Mrs. Hume Pin- sent, Chairman of the Birmingham Special Schools Committee. Subsequently Dr. Donkin, one of H.M. Prison Commissioners, and Dr. J. C. Dunlop, Super- intendent of Statistics in the Office of the Registrar- General for Scotland, were added to the Commission ; and in February, 1905, the Marquis of Bath having resigned, Lord Radnor was appointed Chairman. The Commission commenced hearing evidence on November 14, 1904, and published its Report on July 31, 1908. The 248 witnesses examined included inspectors and medical officers of special schools, reformatories, prisons, lunatic and idiot asylums, and inebriate homes, and, indeed, " representatives of all classes of persons who could give information on the subject of inquiry." " Full particulars " were also obtained "of the manner in which foreign countries and the colonies are dealing with the ques- tions submitted in the original reference." Visits were paid to " various institutions in which pro- vision is made for the classes of persons named in the reference in England and Wales, Scotland and Ireland, and on the .Continent." In addition, five members visited the United States of America, and issued a special Report of their observations. Almost at the outset it was found that " there were no avail- able statistics from which any trustworthy estimate could be made as to the number of persons who might be said to fall within one or other of the categories named in our reference. We decided, therefore, that an expert investigation of the question was indis- DEFECTIVE AND EPILEPTIC CHILDREN 25 pensable, and having obtained the authority of the Treasury for the expenditure, which was necessarily considerable, we appointed medical investigators to make a thorough inquiry in regard to the number of mentally defective persons (including epileptics) in sixteen separate typical districts, both urban and rural, in England and Wales, Scotland and Ireland, in the hope that, from the particulars thus ascertained, we might be able to form at least a rough estimate of the whole number, and of the provision that it would be necessary to make for their proper treat- ment." These inquiries by medical experts were a most important part of the work of the Commission, and gave their conclusions and recommendations a precision and authority which could not have been obtained in any other way. The Commissioners published their Report and evidence in eight Blue-Books, of which the first three contain the .evidence on the original reference, and the fourth that on the extended reference. The fifth volume consists of appendix papers; the sixth contains the reports of the medical investigators ; the seventh the report on the visit of certain Commis- sioners to America; while the eighth contains the Commissioners' own Reports and Recommendations. It was stated in the Report that " of the gravity of the present state of things there is no doubt. The mass of facts that we have collected, the statements of our witnesses, and our own personal visits and investigations, compel the conclusion that there are numbers of mentally defective persons whose train- ing is neglected, over whom no sufficient control is exercised, and whose wayward and irresponsible lives are productive of crime and misery, of much injury and mischief to themselves and to others, and of much 26 MENTALLY DEFICIENT CHILDREN continuous expenditure wasteful to the community and to individual families. " We find a local and ' permissive ' system of public education which is available here and there for a limited section of mentally defective children, and which, even if it be useful during the years of training, is supplemented by no subsequent super- vision and control, and is in consequence often mis- directed and unserviceable. We find large numbers of persons who are committed to prisons for repeated offences, which, being the manifestations of a per- manent defect of mind, there is no hope of repressing, much less of stopping, by short punitive sentences. We find lunatic asylums crowded with patients who do not require the careful hospital treatment that well-equipped asylums now afford, and who might be treated in many other ways more economically, and as efficiently. We find, also, at large in the population many mentally defective persons, adults, young persons, and children, who are, some in one way, some in another, incapable of self-control, and who are therefore exposed to constant moral danger themselves, and become the source of lasting injury to the community." The fundamental recommendations of the Commis- sion were that the Lunacy Commissioners for Eng- land and Wales should be replaced by a larger body, with extended powers and a wider purview, to be called " The Board of Control/' which should be responsible for the proper care of all mentally defec- tive persons. This central authority should super- vise local administration. The Local Authority should be the Council of each County and County Borough, and they should be required by Statute to make suitable and sufficient provision for the men- DEFECTIVE AND EPILEPTIC CHILDREN 27 tally defective. They should exercise their powers through a Statutory Committee, to be called the " Committee for the Care of the Mentally Defective," which should take over the duties of the Visiting Committee, or as it is sometimes called, the Asylums Committee, of the County Council. The Report of the Royal Commission excited wide- spread interest among public authorities and social workers throughout Great Britain, but it was not until considerable pressure had been put upon the Government, and two private Bills on the subject had been introduced, that the Home Secretary brought in (on May 16, 1912) a measure to give* effect to its recommendations. This Bill did not get beyond the Committee stage in the Session of 1912, but was re- introduced in 1913, and received the Royal Assent on August 15. In England and Wales it came into opera- tion on April i, 1914; the corresponding Act for Scot- land, which comprised also amendments of the Scottish Lunacy Law, came into operation on May 15, 1914. Those who desire full information are referred to the Mental Deficiency Acts themselves, prints of which may be obtained from Parliamentary pub- lishers for a few pence. Our space will permit only a brief resume of the principal provisions, more especially those relating to children. Taking the English Act first, four classes of persons who are mentally defective are defined to be defec- tives within the meaning of the Act, as follows : " (a) Idiots that is to say, persons so deeply de- fective in mind from birth or from an early age as to be unable to guard themselves against common physical dangers. " (b) Imbeciles -that is to say, persons in whose case there exists from birth or from an early age 28 MENTALLY DEFICIENT CtiiLbREN mental defectiveness not amounting to idiocy, yet so pronounced that they are incapable of managing themselves or their affairs, or, in the case of children, of being taught to do so. " (c) Feeble-minded persons that is to say, per- sons in whose case there exists from birth or from an early age mental defectiveness not amounting to im- becility, yet so pronounced that they require care, supervision, and control for their own protection or for the protection of others, or, in the case of children, that they by reason of such defectiveness appear to be permanently incapable of receiving proper benefit from the instruction in ordinary schools. " (d) Moral imbeciles that is to say, persons who from an early age display some permanent mental defect coupled with strong vicious or criminal pro- pensities on which punishment has had little or no deterrent effect/' Though all persons falling under the above cate- gories are deemed to be " defectives within the mean- ing of the Act," it would appear from Section 2 that they only become subject to be dealt with under the Act, (a) if under twenty-one, at the instance of the parent or guardian, or (6) at any age if found neg- lected, abandoned, destitute, or cruelly treated, criminal or inebriate, or being the pauper mother of an illegitimate child. Defective children over seven, notified by local Education Authorities as incapable of receiving benefit or further benefit in special schools or classes, or detrimental to other pupils in such schools, or certified by the Board of Education on account of special circumstances for supervision or guardianship, are also liable to be dealt with undei the Act, as are also those leaving special schools or classes " in whose case the local Education Authority DEFECTIVE AND EPILEPTIC CHILDREN 29 are of opinion that it would be to their benefit that they should be sent to an institution or placed under guardianship/' This latter provision gives valuable powers for securing permanent protection for those whose home conditions would militate against the improvement effected by special school training being retained and turned to account in after-life. It will be seen that to be dealt with compulsorily under this Act the subject, if adult, must in some way have been brought into contact with existing law. In the case of children they must have at least been found liable to be ordered to be sent to a certified Industrial School, or have proved unfit for instruction in a special school, or at the end of their term there have proved that they require permanent care. The duty of ascertaining what children over the age of seven and under the age of sixteen are defectives devolves on the local Education Authorities, all of whom under the amended Elementary Educa- tion (Defective and Epileptic Children) Act will be called on to notify to their Local Authorities not only the names of those passed as fit subjects for educa- tion in special schools, and their condition when about to leave these schools, but also the names of those whom idiocy or imbecility renders uneducable, and consequently requiring to be dealt with under the Mental Deficiency Act by way of supervision, in an institution, or under guardianship. Doubtful cases are to be referred for the decision of the Board of Education. The efficiency of the Mental Deficiency Act, so far as children are concerned, depends largely upon the efficient working of the Education Act referred to. Those passed for special schools as " mentally defective " will generally fall under the definition given above of " feeble-minded," but will 30 MENTALLY DEFICIENT CHILDREN only become " defectives " to be dealt with under the Mental Deficiency Act when reported as such at the end of their school career. Thereupon it becomes the duty of the Local Authority to deal with them as may seem desirable, either by supervision at their own homes, or by sending them to suitable institu- tions, or by placing them under guardianship. The Board of Control, which now consists of the eight former paid Commissioners in Lunacy, with two additional Commissioners specially appointed under the Mental Deficiency Act, and a paid Chairman, together, with three unpaid Commissioners, is the Central Authority on which devolves the general supervision, protection, and control of all types of defectives, the supervision of the administration by the Local Authorities of their powers and duties under the Act, the licensing, regulation, and inspection of homes and institutions of all classes for defectives, and visitation of those under guardianship or under private care, and the provision and maintenance of institutions for dangerous defectives. The Local Authority under the Act is the County or County Borough Council, which will act through a specially appointed Committee for the care of the mentally defective, consisting either of (i) members of the Council (who must form the majority), together with non-Council members chosen by the Council for their special knowledge and experience of the sub- ject, of whom some must be women; or (2) alterna- tively (at the discretion of the Council) the Visiting or Asylums Committees under the Lunacy Acts, with the addition of at least two women. In certain cases approved by the Home Secretary and the Local Government Board two or more Local Authorities may combine to form a joint Mental Deficiency Com- DEFECTIVE AND EPILEPTIC CHILDREN 31 . mittee. Their duties and powers include the ascer- taining, except in the case of those dealt with at the instance of their parents or guardians under Sec- tion 2 (i) (a), of what persons within their area are defectives subject to be dealt with under the Act, to provide suitable supervision for such persons, and, when necessary, to place them in institutions or under guardianship ; to provide suitable and sufficient accommodation for such persons when sent to certi- fied institutions by orders under the Act ; to maintain them wholly or in part in institutions, approved homes, or under guardianship; to employ the officers necessary for carrying out the Act; and to make annual and such other Reports as may be required by the Board of Control. Local Authorities are not, however, bound to expend money upon the above objects, excepting the first, unless the contribution by Parliament in aid amounts to 50 per cent, of the total expenditure. In addition to the Local Authorities, Poor Law Authorities are to retain the same powers as they previously possessed under the Poor Law to deal with pauper defectives, and will receive the same grants as they were entitled to under the Idiots Act, 1886, notwithstanding its repeal. Four classes of institutions, etc., are contemplated under the Act, in addition to approved homes -viz. : 1. State Institutions for defectives of dangerous or violent propensities, to be established and managed by the Board of Control. 2. Certified Institutions, established by Local Authorities, benevolent societies (incorporated or otherwise), or disinterested individuals, to be certi- fied, regulated, and inspected by the Board, and to possess powers of detention under conditions laid 32 MENTALLY DEFICIENT CHILDREN down in the Act, and regulations framed by the Home Secretary. 3. Certified Institutions provided by Poor Law Guardians, and approved by the Board of Control, subject to the same conditions as above. 4. Certified Houses, established by individuals for private profit, approved by the Board of Control, but not eligible for defectives towards whose expenses there is a Parliamentary grant. These also have powers of detention. Under the title of " Approved Homes/' premises wherein defectives are received and supported wholly or partly by voluntary contributions, or by applying the excess of payments of some patients for or towards the support of other patients, and any similar establishment run for private profit, may be approved by the Board under such conditions as they may think fit. Such homes cannot receive defectives legally committed to an institution, and have no legal power of detention. Elaborate Regulations, which are already in force, have been issued by the Home Secretary in pursuance of the Act under the title of " Provisional Regula- tions/'* These describe in detail the duties of Local Authorities, the procedure on petitions, and the grant- ing, transfer, renewal, revocation, and resignation of certificates for certified institutions and- certified houses. They give rules for approvals of homes, and the management of certified institutions, certified houses, and approved homes, and also for the inspec- tion of these institutions and houses. Forms of peti- tions, statutory declarations, orders, certificates, etc., * To be obtained from Wyman and Sons, 29, Bream's Buildings, Fetter Lane, E.G., and other Parliamentary pub- lishers, price^Jd. DEFECTIVE AND EPILEPTIC CHILDREN 33 are appended. Space does not permit even a brief summary of these. It must suffice to state that ample precautions are taken to insure the suitability for their respective purposes of the various types of institutions, and by means of reports, records, and frequent official inspections, to safeguard the suitable and humane treatment of the inmates, and to prevent detention when not justified by the mental condition. For admission to all the establishments, other than approved homes, -two medical certificates,* one of which must be by a practitioner approved by the Local Authority or the Board of Control for the pur- pose, are required, and in addition a judicial order in the case of any person not certified either as idiot or imbecile. It is only in the latter cases that a state- ment of particulars can be signed by other persons than the father or mother -i.e., by a person under- taking the duties of guardian towards the patient. It must be remembered that the Idiots Act,. 1886, having been repealed, the simple procedure by one medical certificate is no longer available, even in the case of idiots and imbeciles. As regards approved homes (presumably for border-line cases), though ad- mission certificates are not prescribed, it seems likely that full particulars of the bodily and mental condi- tion of inmates will have to be reported by the Medical Officer. The Mental Deficiency and Lunacy (Scotland) Act, 1913,1 is a counterpart of the English Act, with cer- tain modifications adapting it to Scottish administra- tion, and a few amendments of Scottish Lunacy Law. * Form of Medical Certificate is printed in Appendix E, p. 264. t To be obtained from Wyman and Sons, Ltd., Fetter Lane, E.G.; or H.M. Stationery Office, 23, Forth Street, Edinburgh. 3 34 MENTALLY DEFICIENT CHILDREN In Part I. the expression " School Board " takes the place of " Education Committee " so far as ascertain- ing what children are defectives, and which of such children are educable in special schools, and making suitable provision for the education or proper care of such children between five and sixteen years of age when the parents or guardians are unable to do so; they must notify to the Parish Council and the General Board of Control the names of such children as are incapable of receiving benefit or further benefit from, or are otherwise unsuitable for, special schools or classes. The Parish Council is the Local Authority responsible for the care and supervision of such reported children, and also for ascertaining what persons of sixteen years or over are defectives subject to be dealt with under the Act, otherwise than at the instance of their parents or guardians, and for taking steps that they shall be dealt with by being sent to institutions or placed under guardianship. Upon the Sheriff devolves the duty of making judicial orders when these are required. The General Board of Control for Scotland now consists of three paid Medical Commissioners (in- cluding the two formerly known as Lunacy Commis- sioners), in addition to the Chairman and two legal members, and of four Medical Deputy-Commissioners, one of the latter being a woman. Two others may, if necessary, be appointed. A District Lunacy Board will in future be known as the District Board of Control. If it comprises six elected women members, not more than two women must be co-opted. Their duties will be similar as regards carrying out this Act to those of County and County Borough Councils in England. CHAPTER III SPECIAL INSTRUCTION FROM the preceding chapter it will be seen that con- siderable attention has been given in England of late years to the class of subnormal persons who are called in this country feeble-minded, in distinction to the imbecile and idiot groups. Recent legislation has taken account of them from the sociological stand point in the Mental Deficiency Act, and from the scholastic in the 1899 and 1914 Acts for the Education of Defective and Epileptic Children. In the first they are referred to, under the definition of feeble-minded persons, as children who by reason of mental defec- tiveness, not amounting to imbecility, existing from birth or from an early age, " appear to be permanently incapable of receiving proper benefit from the instruc- tion in ordinary schools/' In the latter they are referred to as " children not being imbecile, and not being merely dull or backward that is to say, chil- dren, by reason of mental or physical defect, incapable of receiving proper benefit from the instruction in the ordinary public elementary schools, but not incapable by reason of such defect of receiving benefit from instruction in special classes or schools." It is to be remarked that the element of permanence appears in the first definition, but not in the second; and it may be argued therefrom that the special schools can reasonably be regarded as means of determining such 35 36 MENTALLY DEFICIENT CHILDREN permanence, especially in relation to the need for segregation. It will also be noted that the term " mental defect/' as used in the Mental Deficiency Act, has a wider connotation than in the Education Acts, where it embraces only one of the four classes covered by the former viz., that of " feeble-minded. " With the judicious administration of the new Acts it is hoped that Great Britain will stand ahead of all other countries in its treatment of the mentally defec- tive class. It must, however, be admitted that in the past German and Scandinavian countries have been in advance of us in organising practical arrange- ments for the training of exceptional children. So far back as 1863 there was established at Halle an auxiliary class (Hilfsklasse) for pupils found incapable of following the ordinary elementary school curricu- lum; in 1867 a similar class was established at Dres- den. Leipsic and Brunswick followed, and gradually auxiliary schools (Hilfschulen) grew out of these classes. Herr Kielhorn, the director of the Bruns- wick auxiliary school (established in 1881), gave an account in 1894 of 32 auxiliary schools, consisting of no classes, with a teaching staff of 115, established in various parts of Germany. Herr Wintermann,* of Bremen, supplemented this statement in 1898 by the information that at that date auxiliary schools existed in 52 German towns, consisting of 202 classes, and containing 4,281 children (2,400 boys, 1,881 girls) under instruction by 225 teachers. So rapid was the development that at the end of 1905 Fraulein Dora Weinrich, of the Centrale fiir Private Fursorge, Frank- fort-on-Main, in her paper at the After-care Confer- ence at Nottingham, said there were 230 special * Berichten uber den ersten Verbandstag der Hulfschulen Deutschlands, 1898. SPECIAL INSTRUCTION 37 schools, with 15,000 pupils, and that the aim was to have at least one in every town of 15,000 inhabitants. It is claimed that many children considered hopeless in the ordinary schools have been enabled by the special instruction given them to follow useful prac- tical careers. The large extension of the auxiliary schools above noted is, in a practical country like Germany, perhaps the best testimony to their success. In the Scandinavian countries also, in addition to the boarding establishments for imbeciles previously described, day classes for the instruction of " abnormal children " have been established for more than thirty years. In Christiania and Bergen they were started under the direction of Herr Karl Lippestad and of Herr Soethre respectively. In addition, separate classes for merely backward (not necessarily defec- tive) children were organised in connection with two of the largest elementary schools in Bergen. In Den- mark various grades of defectives are received either in day classes or in residential institutions, as may be necessary, in the chain of establishments organised and supervised by Dr. Keller, which have now been adopted by the State. The arrangements for instruc- tion are very complete, and the ratio of teachers to taught liberal, the classes usually consisting of not more than eight or ten pupils. Stress is laid upon physical and manual exercises. The pupils not fit to return home after school training are drafted to working institutions, of which there are several grades. Farm work and other occupations, such as brush, broom, and basket making, are followed by the older boys. The older girls are employed in dairy and laundry work, as well as in a variety of home in- dustries, such as weaving cloth for dresses, curtain material, etc. For some, situations in domestic and 38 MENTALLY DEFICIENT CHILDREN dairy service are found, and it is said of the girls, whose careers are carefully watched, that " very few turn out badly/' Professor Keller has kindly sup- plied us with a list of institutions, public and private, existing in Denmark, Norway, Sweden, and Finland, from which it appears that no less than forty-three establishments for the care of mental defectives have been established in these countries, with an aggregate accommodation for about 1,500 improvable and 600 unimprovable cases. In Belgium special schools for the mentally defec- tive were in existence for some years previous to the war, and in Brussels, Antwerp, and Ghent, there were also After-care Societies, which originated from the " Societe Protectrice de FEnfance Anormale." The movement in favour of " special schools " for sub- normal children has also spread to Austria, to Switzer- land, to France, and even to Spain. In Italy there exists a " National League for the Protection of De- ficient Children," under the presidency of Signer Guido Baccelli, formerly Minister of Public Instruc- tion, one of the first-fruits being the opening in Rome of a day-school. In America much important work has been done. The members of the Commission on the Care and Control of the Feeble-minded who visited that country were favourably impressed by what they saw in some of the States, for it must be remembered that each State has its own regulations and institutions. Our Commissioners were struck by the excellent practical work they saw being done by the feeble-minded, and also by the economical char- acter of the buildings and arrangements generally. There are in America several industrial colonies for permanent care. These have been recognised as essential. Work in the special schools is regulated SPECIAL INSTRUCTION 39 with this view, and to the continuous training and supervision is no doubt largely due the excellent work done by some of the adult feeble-minded. Our Com- missioners gave a specially interesting account of what they saw at the Templeton Colony for Feeble- minded Males, ninety miles from Boston. The colonists " are all required to do manual work, and many of them do nearly the full work of a free labourer. We saw a group of four, with heavy sledges and hammers, breaking rock and drilling it for blasting with explosives. They were working steadily and without supervision. Farther on was another group of five men working in a field. They were bringing in stocks of corn, which they were loading upon a cart. Others in the shed were un- loading and storing the corn. A further group was hauling brick in wheelbarrows. At a little distance there was a row of about a dozen, who, under the supervision of one man only, were working a field with sharp pickaxes. An imbecile was ploughing with a pair of horses, his daily task. All of these men had come from Dr. Fernald's schools for the feeble- minded, and a large proportion of those who were busily and happily engaged in useful work could never be taught to read and write; some had not human speech. The previous training was, of course, essential ; idiots and low-grade imbeciles could not be employed in this way without preliminary training/' In England priority in the opening of a Special Class belongs to Leicester, where the School Board started one in April, 1892. In the same year were established in London " Schools for Special Instruc- tion " qf children who, by reason of physical or mental defects, could not be properly taught in the ordinary standards or by ordinary methods, Mrs. 40 MENTALLY DEFICIENT CHILDREN Burg win being appointed organising superintendent. Under her able direction, ninety-five centres of special instruction for mentally defective children have up to the present time been established, chiefly in the poorer districts of the Metropolis, with an attendance roll of 7,848 pupils a number constantly increasing. The Board have wisely ordained that no more than twenty children be assigned to each teacher; in prac- tice the classes are even smaller. The ratio of pupils is, however, much larger than that which obtains in the Scandinavian schools, where one teacher is pro- vided for every ten pupils; but the superintendent utilises to the utmost the teaching force at her com- mand by well-devised time-tables.* It may be re- marked with regard to this that, though the ordinary school nomenclature of studies is retained (as in the case of the so-called " three R's "), much more than the ordinary instruction is included, sensorial and manual training and objective methods of demonstra- tion being freely employed. The "occupations/' which form an important part of each day's work, are specially adapted to the varying capacities of individual pupils. The results, as evidenced at annual exhibitions of the products of manual training in the London Council Schools generally, are most encouraging, and in some cases surprising. It may be stated, indeed, that at these exhibitions the array of work by children in the special classes creditably holds its own, side by side with that of the normal children. During the last ten years an advance has been made by the establishment of twelve centres for about 1,300 " Elder Boys/' in which instruction is given in manual arts by male teachers. Four centres for 360 " Elder Girls " have also been established. * See specimen time-table, Appendix D, p. 262-3. SPECIAL INSTRUCTION 41 The selection of pupils for these classes is made by medical officers appointed for the purpose in conjunc- tion with the Superintendent of Special Instruction. The parents, and also the family doctor, may attend the examination; but we shall not discuss here the mode of procedure, as we have devoted a special chapter (Chapter VII.) to this subject. The Report of the Chief Medical Officer of the Board of Education for 1915 states that up to July 31, 1914, the number of certified schools for mentally defective children in England and Wales was 184, with accommodation for 14,555 children, and a total average of 13,563 on the register. These include eleven residential schools, providing accommodation for 902 children on the register. The present Report stated that 177 out of 317 education authorities had taken action under the Act, and upwards of fifty authorities had themselves established schools. The Royal Commission estimated the number of children in England and Wales needing provision at 35,662. About two-fifths of this number are being dealt with at the present time in certified special schools, and the Chief Medical Officer of the Board of Education considers that the aggregate accommodation necessary for educable mental defectives, excluding idiots and imbeciles, amounts to about 25,000 school places. There is, unfortunately, sometimes prejudice in the minds of parents against the attendance of their children at special schools, as stamping them with inferiority. The Act of 1899 recognises parental rights in Subsection 5 of Section 2, which compels school authorities to " make provision for the ex- amination from time to time of any child dealt with under this section, in order to ascertain whether such child has attained such a mental and physical con- 42 MENTALLY DEFICIENT CHILDREN dition as to be fit to attend the ordinary classes of public elementary schools," and, if the parents so request, re-examination must be made at intervals of not less than six months. The amending Act of 1914 further provides for the parents being consulted by the Local Education Authority on the subject of suitable provision for the mentally defective child, which, if not made by the parents, must be provided by the authority either in a special day school or class, or in a special residential school. The parents are to have a certain choice in the selection of the former, and the'r written consent, which must not be unreasonably withheld, is necessary before sending the child to a boarding-school. Education Committees have made provision for the periodical examination by the medical officers of ajl children attending the special classes. On their report, which is based to a large extent on informa- tion as to progress furnished by the " special " teachers, improved cases are sent back to the ordinary elementary schools. In view of the fact that under the Mental Deficiency Act (Section 2, 2) notice will have to be given by the Education Authority to the Local Authority of all defective children over the age of seven, (i) who have been ascertained to be in- capable of receiving benefit or further benefit in special schools or classes, or who are detrimental to the other children in those classes, or (2) who on or before attaining the age of sixteen are about to be withdrawn or discharged from such classes, and re- quire care in an institution or under guardianship, it is important that the first and subsequent examina- tions should be conducted with precision on a definite plan. An elaborate scheme for this has therefore been drawn up by the Board of Education. SPECIAL INSTRUCTION 43 There are a few educational homes which receive children of the better social class who are so far deficient or irregular in mental development as to require special education. As the mental deficiency or irregularity is often intimately connected with physical abnormality, skilled medical supervision is an advantage. It is obvious that a child whose mental deficiency or nervous peculiarity is but slight will have a better chance of improvement, when educated with those of similar mental calibre, than if subjected to hopeless competition with normal children at an ordinary school, or, on the other hand, exposed to the depressing influences of an institution where idiots are received. Such private establishments are now sub- ject to the approval and visitation of the Board of Control. In addition to arrangements organised by Educa- tion Committees, certain philanthropic agencies have, since 1890, established industrial homes in various parts of the country for the employment, under judicious supervision, of feeble-minded adolescents. In a few instances there have also been established institutions for the training of younger children for whom a boarding-school is essential, either on account of immoral, vicious, or truant tendencies, or because they come from very bad homes. In 1896 the National Association for Promoting the Welfare of the Feeble-minded was formed, with the object of co-ordinating the scattered efforts that had already been made, and arousing a larger share of public interest. It has under its immediate control in the neighbourhood of the Metropolis three homes, two for girls beyond school age, and one for feeble-minded mothers and their children, and has established, under the patronage of H.R.H. the Princess Christian, an 44 MENTALLV DEFICIENT CHILDREN Endustrial Colony in Kent, where over 200 boys and girls and adults are at present resident. They are accommodated in scattered buildings on various parts of the estate of 170 acres, the males being employed principally in farm work, and also in carpentering, shoemaking, etc., and the females in domestic, dairy, and laundry work. In May, 1902, the Incorporated Lancashire and Cheshire Society for the Permanent Care of the Feeble-minded opened a boarding-school for boys at Sandlebridge, near Manchester, and in September of the same year a home for girls, all under the manage- ment of Miss Mary Dendy. In the first instance, 12 boys and 8 girls were admitted. In September, 1914, there were 161 boys under care, 102 of them being under sixteen, and 59 over sixteen, years of age; and 104 girls, of whom 53 were under, and 51 over, sixteen. Children are not admitted over thirteen, and as far as possible are kept for life; 42 boys work on the farm and garden, and 52 girls are employed in the laundry and the various houses. In May, 1907, the Sandwell Hall Boarding-school for the Feeble-minded was opened near Birmingham by the generous efforts of the Rev. H. N. Burden, one of the members of the Royal Commission on the Care and Control of the Feeble-minded. Sandwell Hall was formerly the family seat of the Earls of Dartmouth, and stands in the midst of a spacious park a few miles north of Birmingham. In this institution special arrangements were made for training in prac- tical work gardening, carpentry, boot-making, brush- making, laundry work, carpet-weaving, and tailoring. The full complement of 200 was soon received. At first both boys and girls were admitted, but the girls have since been transferred, and Sandwell is now SPECIAL INSTRUCTION 45 reserved for boys only. No cases are retained after sixteen, but whenever possible they are drafted on to other institutions. Mr. Burden's energy and enter- prise have, however, extended far beyond the limits of Sandwell Hall, with the result that Sandwell is now merely one of a group of institutions, called the " National Institutions for Persons requiring Care and Control/' The central offices of the Incorporation are at 14, Howick Place, Westminster. The institu- tions are intended for "permanent as distinct from temporary care, and no case is knowingly received as a temporary measure." They include Stoke Park Colony, near Bristol, opened in 1908, and now cer- tified by the Board of Control as an " institution " for 750 male and female cases, under the Mental Deficiency Act, and also certified by the Home Office under the Children Act as a Special School for mentally defective children; the Midland Counties Institution, Whittington Hall, Chesterfield, certified by the Board of Control for 320 female cases; and the Eastern Counties Institution, East Harling, Norfolk, certified by the Board of Control for 330 male cases. The Royal Victoria Home near Bristol and Clevedon Hall in Somersetshire are registered as " ancillary" to Stoke Park, and the latter is intended partly for the use of those members of the staff and inmates of the other houses who require change and special treatment, and partly for the training of specially selected girls with very slight mental defect, who may ultimately become fit for domestic service in better-class situations. In May, 1908, the three Boards of Guardians then responsible for the city of Birmingham namely, the Aston, Birmingham, and King's Norton Boards opened the Monyhull Colony near Birmingham for 46 MENTALLY DEFICIENT CHILDREN* Epileptic and Feeble-minded Persons, which has been described in Chapter I. Altogether there are now in England a considerable number of homes of this class, particulars of which will be found in Appendix A. The accommodation so far available, however, is inadequate to deal with the large number of cases in need of provision. All such institutions have a long waiting list, and many Com- mittees for the Care of the Mentally Defective who have taken up their duties under the Mental Deficiency Act have found that they must establish institutions of their own to provide the accommoda- tion they require. A few illustrative cases, giving an idea of the class of children to whom the designation of " feeble- minded " may appropriately be applied, will help to elucidate the subject: PRIVATE CASES. CASE I. A child of highly intellectual parents is noted to be somewhat delicate in babyhood, but no suspicion of mental abnormality is entertained by his parents until, at two years of age, it is found he uses only a few monosyllabic words, and does not try to construct sentences for himself, though he can perfectly well repeat what is said to him. He frequently, indeed, repeats questions put to him instead of replying to them, thus showing that the defect is not one of hearing, but of understanding. Much care and patience is exercised by an intelligent mother, with the result that at four he speaks fairly well, though with thick utterance. Home education is carried on till he is seven years of age, but a brother two years younger is almost two SPECIAL INSTRUCTION 47 years in advance of him in elementary studies. He is then sent to a kindergarten for morning lessons; he takes interest in the songs and in simple musical drill, does paper-folding, stick-laying, mat -weaving, and bead- threading in series of number and colour. His interest, however, soon flags, and he is apt to repeat the same question again and again, as if not attending to the answer. In calculation he makes but little progress, and with difficulty masters the simple rules of arith- metic. By dint of individual instruction he attains, by the time he is ten years of age, the power of reading, though in a monotonous style, easy stories in a primer, writes copies in text-hand, and plays simple exercises on the piano. There is, however, still a marked childish- ness of manner, a thick articulation and staccato utter- ance, and a tendency to repeat questions in a meaningless way. His bodily development has improved, and his only sensory defect is an error of refraction corrected by spectacles. Some twitching movement is noticeable in the muscles of the fingers, especially under excite- ment; but otherwise muscular control is fairly good. Under drill, regulated muscular exercise, manual training, and varied but brief school lessons, considerable im- provement is proceeding, and he is a steady worker in garden, and good at Sloyd work. (He is now learning practical farming.) CASE II. A pretty, well-nourished little girl of five, the third child of healthy, intelligent parents. Type. Mongolian . The family history records nothing unfavourable. History. As a baby she was not able to suck, and was therefore brought up with great difficulty on a bottle. She could not walk or talk till four years of age. On examination, she is able to count to 20, and has a good memory. She has some hypermetropic astig- matism, for which glasses are prescribed. On examination at eight years of age, she reads easy words and writes a little; she recognises animals in 48 MENTALLY DEFICIENT CHILDREN pictures, and can count up to 100, but cannot calculate at all. She can almost dress herself, and is useful in the house. The only trouble is weak powe of attention . A year later she was able to write a short letter from dictation, and was improving in every way. CASE III. A stupid -looking youth of eighteen ; height, 5 feet loj inches. Family History. The father died at forty-five of pneu- monia. The paternal grandfather, who had been in the army, was a heavy drinker; he died at seventy-two, having done no work for the last twenty-five years of his life. On examination, he is found to be a high-grade defec- tive of no special type. He has a small forehead and a defective occiput; the little ringers are abnormally short, and he is flat-footed. He reads the newspaper, can write and perform simple calculations. He knows the day of the week and the year, but not what month it is; he does not know the name of the King, though he can say who the last King was. The History is that he was precocious as a child, and not considered abnormal till he left the infant school, when he was found to be dull at learning. He was, however, very mischievous and imaginative. At thir- teen years of age he was only in Standard IV. The parents were advised that work would bring him out, so he was sent to a cabinet-maker's. After a few months he was sent home as having no adaptability. He got another place as an errand-boy, but nothing could be made of him, and the same tale was told at other places. His condition remained much the same till eighteen years of age, when it was noticed that he was getting more lazy and otherwise deteriorating. The following are examples of cases presented for ' Special Instruction " from Council Schools; SPECIAL INSTRUCTION 49 NOTES ON ADMISSION. Ci : sE IV. (Microcephalic type). F. D., aged seven years seven months. Small for age, fairly nourished, well limbed. Senses perfect. Head small with narrow forehead, tapers towards vertex, circumference 19 inches. Palate high and narrow. Epicanthus. Mouth breather. Hands well extended. Has attended infant school three years. Knows letters, and can form O, A, I, T. Cannot count correctly, and says that he has three eyes, a dog six legs, etc. Requires special instruction, but should have more manual than mental work, as he seems subject to headaches. Should be examined for adenoids. CASE V. (Syphilitic taint). M. O., aged twelve. A dull-looking girl with dusky complexion. Head 21 inches. Radiating lines around mouth. Teeth " P e gy" Sight of right eye destroyed by interstitial keratitis, some opacity of left, but fair vision. Slightly deaf. Seems to have been almost stationary the last two years. Is excitable at times, but generally slow in reaction . Reads from primer in drawling way. Writes untidily. Can add and subtract a little. Unfit for ordinary standards, but may learn some manual work in special instruction class, but will probably retrograde. CASE VI. (Mongolian type). S. B., a delicate boy of ten, with a stoop. He cannot quite dress himself, and is very restless; little power of concentration. He can count to 20, but does not know what twice 3 is. He can interpret simple pictures, and recognises a penny and a halfpenny, but said a sixpence was a shilling. Unfit for an ordinary school, but will improve in a special class, especially when doing manual work, which will provide an outlet for his restlessness and strengthen his power of concentration. The following have been under special instruction for a time: 50 MENTALLY DEFICIENT CHILDREN CASE VII. (Mongoloid type). P. W., a fairly grown girl of twelve, with obliquely-set eyes, rough and ruddy skin, tongue with shallow transverse fissures, broad, short-fingered hand, and incurved little fingers. After three years' special instruction has learned to read in second-standard book, to work addition and subtraction sums, and to write from dictation. She is also progressing at laundry and cookery classes. When admitted at age of nine, incapable of standard work in girls' school ; now fit to join second standard. CASE VIII. (Sporadic cretin). A. S., aged fourteen, admitted four years ago to special school, being unfit for ordinary school in consequence of physical and mental abnormalities characteristic of cretinism. During the last three yea#s has had thyroid treatment at Children's Hospital, and has notably improved. From being an inert dwarf, with baggy cheeks and protuberant abdomen, he has become an active (somewhat mischievous) boy of bright expression and slender figure, and has grown 8 inches (from 39^ to 47^) in last two years. Now knows the letters and figures; can write his name and add a little, although originally absolutely incapable of any educational attainment. CHAPTER IV PATHOLOGICAL CLASSIFICATION OF FORMS OF MENTAL DEFICIENCY As stated in the preface to the first edition, it is not intended in the present work to do more than glance at the pathological aspects of the subject. Those interested in these aspects will find much that is valuable in the well-known textbook by Ireland,* in successive volumes of " Recherches " by Bourne- ville,f in an article by Fletcher Beach in Hack Tuke's | " Dictionary of Psychological Medicine," in the publications of Hammarberg, and particularly of J. S. Bolton,|| and in the writings of Tredgold^ff and Sherlock.** The most important facts in pathology from the clinical point of view are those that are serviceable in classifying cases. Before describing these, however, a short account of the general pathology may be interesting. And first * Mental Affections of Children, W. W. Ireland, 1898. f Recherches sur I'Epilepsie, I'Hysterie, et I'ldiotie, Paris, 1890 et seq. t See also article 'on " Idiocy and Imbecility " in Clifford Allbutt's System of Medicine, vol. viii. Hammarberg, Studien iiber* Klinik iind Pathologic der Idiotie," Upsala, 1895. || " Amentia and Dementia," Journal of Mental Science, 1905 and 1906. Also various contributions to Brain on "The Brain in Health and Disease," London, 1914, etc. D Mental Deficiency, A. F. Tredgold (second edition), 1914. "* The Feebleminded, E. B. Sherlock, 1911. 52 MENTALLY DEFICIENT CHILDREN we remark that in connection with mental deficiency there are two main divisions of cerebral abnormality : (a] that arising from formative or developmental defect, and (b) that resulting from inflammatory or degenerative processes. These two classes are now usually spoken of as Primary and Secondary Amentia, terms suggested by Dr. Tredgold, who states that prob- ably about 90 per cent, of all cases may be assigned to the first group. Primary Amentia denotes mental defect due to an intrinsic cause (morbid heredity), Secondary Amentia that due to an extrinsic cause (traumatism, disease or other unfavourable environ- ment). It is important to realise that the second group includes a mixed class of cases, in which the actual lesion supervenes upon a brain originally imperfect in development; to such cases, occurring at a crisis of early life, the name DEVELOPMENTAL is often applied. The extent of the cerebral abnor- mality, whether original or acquired, may a priori be expected to bear some proportion to the degree of mental defect; this is usually the case, though it is necessary to bear in mind that microscopic as well as macroscopic constitution of brain tissue must be taken into account, and that certain portions of the brain are of more importance (qua intelligence) than others. Recent microscopical investigations have yielded a rich harvest of facts. In primary amentia cellular changes have been found in all regions of the brain. The prefrontal and, to a less extent, the parietal lobes, are, however, the two situations in which they most frequently occur.* Dr. Bolton states that ' ' the regions of under-development in cases of mental deficiency and of wasting in cases of dementia (or * See also Goulstonian Lectures, R.C.P., by J. S. Bolton, February and March, 1910. PATHOLOGICAL CLASSIFICATION 53 permanent psychic disability due to neuronic degen- eration) were satisfactorily determined to have their chief focus in the pref rental region." According to Dr. Tredgold, " As compared with the nerve cells of the healthy brain, those of the ament are char- acterised by the following conditions: (i) Numerical deficiency; (2) irregular arrangement; (3) imperfect development of individual cells/'* He further states " that the amount of change discoverable by the microscope is distinctly proportionate to the degree of mental deficiency present during life." Among other changes a paucity of dendrons and gemmules and pigmentation are noticeable. The pyramidal layer of the cortex shows the most obvious abnor- malities; it is in its deeper layer that pigmentation is most frequently observed. At the same time " the bands of tangentially coursing fibres comprising the association systems show a very definite diminu- tion in cases of severe amentia, so great, indeed, as often to be apparent to the naked eye. Generally speaking, the most marked alteration occurs in the fibres composing the outer line of Baillarger, next in the super- and inter-radial bundles, whilst the superficial tangential fibres are somewhat less affected. ' ' f There is often also sclerosis, or overgrowth of neuroglia, usually in the form of localised patches. These are found chiefly in three situations: (i) the grey matter of the cerebral cortex; (2) the floor of the lateral ventricles; (3) the surface of the hemi- sphere under the pia, closely applied to the cortex. These histological changes are the essentials in mental defect, rather than the gross lesions we shall presently describe. * A. F. Tredgold, Mental Deficiency, 1914, p. 75. f Ibid., p. 79. 54 MENTALLY DEFICIENT CHILDREN Localised signs of disease in an otherwise well- developed brain are suggestive of secondary amentia as distinguished from primary. In the absence of a reliable history, however, the distinction is difficult, and often impossible, especially as the dementia that frequently supervenes is characterised by histological signs that obscure the issue. As regards macroscopic appearances, we find that frequently, and especially in the more extreme cases of mental defect, there are definite changes visible to the naked eye. The skull in primary amentia is often thick and dense, and the diploe frequently non-existent. The sutures are sometimes prematurely united, a condition, however, in no way the cause of poor cerebral development, as was at one time thought. As a rule, in primary amentia the brain weighs less than the normal. It may be peculiar in configuration, and the convolutions may be irregular or unusually simply arranged. There may be gross malforma- tions of development connected with the fissures, basal ganglia, and other parts. Defects of the Corpus Callosum and partial atrophies affecting portions only of the brain are occasionally seen. Such gross lesions, however, although more common in the mentally defective and epileptic, have been found in individuals who appeared to be normal. They do not, therefore, predicate mental defect unless associated with the histological changes already described, or involving an area essential to the normal intellectual or psychic processes. Among some remarkable abnormalities the following are specially interesting. In the autopsy of a hemiplegic imbecile, who died at twenty-one years of age, a gap 4 inches in length was found extending from the f> ' PLATE II. I. PORENCEPHALUS. (R.A.A. 1884.) FIG. 2. FIG. 3 DEFECT OF CEREBELLUM. (R.A.A. 1884.) ABNORMALITIES IN BRAIN STRUCTURE. PATHOLOGICAL CLASSIFICATION 55 anterior part of the right frontal lobe nearly to the occipital, leaving the orbital plate uncovered, and disclosing part of the cavity of the lateral sinus (see Plate II., Fig. i). Internally, a narrow ridge, marked by convolutions, separated this gap from the longitudinal sinus; between it and the temporo- sphenoidal lobe was seen standing out, quite un- covered by convolutions, part of the caudate nucleus. The brain weighed 32 J ounces. This defect was due to an arrest of development, as there was no cica- tricial tissue to be made out, and no descending sclerosis of the spinal cord. The mother gave an account of fright and injury in consequence of being knocked down by a cow during the sixth month of pregnancy. The patient's left arm and hand were smaller than the right; his speech was indistinct, but he was able to frame ordinary sentences ; while his senses were normal. He made himself useful, and could clean shoes well. A rare case of atrophy of the cerebellum was dis- covered at the autopsy of an imbecile girl of fifteen, who died at the Royal Albert Asylum of phthisis. As no marked ataxia or inco-ordination had been noticed during life, it was with some surprise that a merely rudimentary condition of the left lobe of the cerebellum was observed (see Plate II., Figs. 2 and 3). This was represented by a papilla no larger than the nail of one's little finger, while the vermiform process was a minute nodule showing faint signs of lamination on the surface; the right lobe, which constituted the main portion of the cere- bellum, was only half a square inch in superficial area, and only a quarter of an inch thick at its base. This lilliputian lobule had, however, the normal laminated appearance and structure, The pons was 5 6 MENTALLY DEFICIENT CHILDREN indicated by a few transverse fibres. With the ex- ception of the cerebellum and its peduncles, the rest of the encephalon (which weighed 42 ounces) and the cranial nerves appeared to be normal. In this case there had been considerable feebleness of body as well as of mind, the girl having suf- fered from a protracted illness (phthisis), but the gait \\as by no means characteristic of cerebellar abnormality. We may appropriately refer here to the two inter- esting groups of cases spoken of as word-deaf and word-blind, which are due to absence or imperfect development of special portions of the brain. These conditions are not uncommon, occurring, according to Dr. C. J. Thomas,* about once in every 2,000 children, and probably at least once in every twenty mentally defective children. In our experience word-deafness is a very rare condition, while slight degrees of word-blindness are not infrequent, even amongst ordinary school - children. Just as with the condition of oxycephaly to be presently described, the first accounts were written by ophthalmic sur- geons, and to Dr. Hinshelwoodf in particular we are indebted for some instructive clinical cases. Dr. Kerr,J late medical officer to the London County Council Education Committee, and others have since described the condition. Those who are specially interested will find his papers, and also those of Dr. Thomas, well worthy of study. * Some Forms of Congenital Aphasia in their Educational Aspects, 1905. f Lancet, May 26, 1900; Ophthalmic Review, 1902. t Lancet, 1900, i., p. 1446; Report of Medical Officer of School Board for London, 1904. C. J. Thomas, op. cit., The Aphasias of Childhood and Educational Hygiene, London, 1908. PATHOLOGICAL CLASSIFICATION 57 A typical WORD-DEAF child, though he does not appear to be as intelligent as one whose only defect is word-blindness, is superior to the ordinary mental defective. He may be able to write from a copy, to draw well, and use his fingers ; his vision is normal, and he is not really deaf, for he can respond by raising his head to sounds of all kinds, even when faint. It is not the actual hearing centre which is at fault, but the centre which interprets the sound of words heard. He can reproduce many words without understanding them, though the meaning of an occasional word may dawn upon him when his lips move to pronounce it. Some of these children keep their eyes on a speaker's lips, and recognise a few nouns by lip- reading. The only chance of training is to teach them to understand language by lip-reading, and so " connote the mechanism employed in uttering words with their meaning."* This must be done at what- ever cost of time and patience, because the under- standing of language is a necessity for all human beings. The typical WORD- BLIND child is apparently intelli- gent, often clever at hand-work and drawing, with good powers of observation and reasoning; in calcu- lation and manipulation of Arabic numerals he may be equal to the normal. He is, however, quite unable to read even words of one syllable, and the most painstaking attempts to teach him reading are an absolute failure. Vision is normal. Although he cannot recognise words, yet if a word is spelt out to him he is often able to respond with the correct one. Occasionally he is able to arrive at the meanings of * Dr. Leonard Guthrie, " Functional Diseases of the Nervous System," Diseases of Children, edited by Garrod > Batten, and Thursfield, p. 691. 58 MENTALLY DEFICIENT CHILDREN words by spelling them aloud. It is not the actual centre for vision which is to blame, but, according to Dr. Thomas, the defect is due to "a congenital poverty of structural elements " of the visual word- centre, which is situated in the supramarginal and angular gyri of the left side, which results in word- blindness. In the case of word-blind children the auditory centre can be trained to supplement the visual, and also much may be done to develop a kinsesthetic memory of word-meanings by making the pupil move his lips as he reads, or trace the words on paper, or by the use of the Braille raised type. The process is, however, so laborious and slow, and the ultimate result so far from being really satisfactory, that with working-class children, at any rate, time should not be wasted in any attempts of the kind, but the child should be put at once to tasks for which he has more natural capacity. The condition designated Mind-Blindness is one essentially of the receiving rather than the storing visual centre ; for this " a lesion of the posterior part of the corpus callosum is generally considered, at least partly, responsible . " * We have often thought that a similar explanation may be given for some at least of the cases spoken of as MORAL DEFECTIVES, an account of which we have included in the next chapter. Moral sense must depend on* the integrity of more than a single area of the brain ; a lesion of one of the areas involved, or of some of the connecting fibres, can scarcely fail to have serious consequences. * Brain, Vol. 36, p. 119, "Experimental and Patho- logico-Anatomical Researches on the Corpus Callosum/' by Dr. C. T. Van Valkenburg, Amsterdam. PLATE III. FlG. I. MlCROCEPHALIC BRAIN (CONVEXITY). (Half natural size.) A -D FIG. 2. BRAIN OF "FREDDY" (CONVEXITY). (Natural size, after preservation in spirit.) MlCROCEPHALIC BRAINS. PATHOLOGICAL CLASSIFICATION 59 Of the obvious primary abnormalities, no condition is more striking than that of Microcephalus. Charac- teristic in its extreme form of a low type of idiocy, in which have been traced simian and even theroid resemblances, it may be 'traced through a series of gradations of head measurement from idiocy and imbecility to simple " feeble-mindedness." Micro- cephalus, however, does not depend solely upon diminutive size of the head, as ascertained by measurement. In our opinion the limitation of the term proposed by some * to cases in which the cranial circumference does not exceed 17 inches is scarcely scientific. There is a characteristic form,f as well as size, indicative of microcephaly, consisting of a narrow, rapidly receding forehead, a somewhat pointed vertex, and a flat occiput. The frontal and parietal lobes are on a small scale, but it is in the occipital and temporo-sphenoidal that we usually find the most striking evidence of arrest in develop- ment. This is well shown in the case of a micro- cephalic girl of fifteen, formerly under the care of Dr. Shuttleworth, at the Royal Albert Asylum, whose brain was fully described by him in the Journal of Mental Science for October, 1878. A view of the con- vexity of the brain, which weighed, when removed, only 2i| oz., is appended (Plate III., Fig. i, half size.)J A still more remarkable case ("Freddy"), for twenty years under Dr. Shuttleworth's observa- * Ireland, op. cit., p. 89. f See Plate IV., Fig. i, p. 60. J DESCRIPTION OF PLATE III. FIG. i. General view of Microcephalic Brain seen from above. A. Parieto-occipital fissure. B. Horizontal fissure. C. Ascending limb of Sylvian fissure. D. Fissure of Rolando. FIG. 2. Lettering as in Fig. i. See also Trans. Roy Dublin Society, new ser., vol. v., plate xxxvi. MENTALLY DEFICIENT CHILDREN tion at Lancaster, was anatomically reviewed by Dr. Telford Smith and the late Professor Cunningham.* His brain, when recent, weighed only 12^ ounces. The convolutions were simple; fairly distinguishable in the anterior lobes, they became rudimentary posteriorly, the occipital and temporo-sphenoidal lobes being, indeed, very imperfectly developed. This " Aztec "-like youth, J \ who had large bright eyes, an aquiline nose, and somewhat receding chin, manifested good powers of observation, but was only able to make use of a few monosyllabic words He had considerable will power, and was in no sense a low-grade idiot, though but little amenable to training. We have repeatedly seen boys and girls with heads measuring only 19 inches taught to read and write, and do industrial work. Quality of brain is an important factor, as well as quantity; in cases of microcephalus what little there is, is usually fairly active. The condition of infantilism, which is described in the next chapter in connection with cretinism, is sometimes, however, a prominent factor. Many microcephalies are dwarfs. Primary cases of Hydroeephalus are not infrequent, though the condition is also secondary. In both conditions the hydrocephalus may be either internal or external, the latter being much the rarer form. Very different degrees of mental enfeeblement are met with in this type, and it is remarkable that a considerable amount of intelligence may subsist with a very watery brain, as in the case of a girl of eleven, peculiar, but only slightly imbecile, who continued to converse rationally till within an hour of her death, * Trans. Roy. Dublin Society, vol. v., ser. 2, part viii. f See Plate IV., Fig. i, and Plate III., Fig. 2, p. 59. PLATE IV. FIG. i. "FREDDY" (ROYAL ALBERT ASYLUM). FIG. 2 (SPECIAL SCHOOL). FIG. 3 (SPECIAL SCHOOL). MICROCEPHALIC CASES. w H PH 6 H O i-J w o o P4 Q >H tu PATHOLOGICAL CLASSIFICATION 61 when it was found that her large globular skull* contained 20 ounces of fluid to 36 of cerebral matter. In some cases optic neuritis and signs of pressure occur, and convulsions usher in a fatal termination. As a rule, indeed, it is only in cases where active symptoms have subsided that educational methods are admissible. Plate V., Fig. 2, portrays a hydro- cephalic youth, with a head circumference of 23 inches, in whose case the chief residual indication of defect was in the direction of moral imbecility. In some cases syphilitic or tubercular lesions have been found ; these would suggest that the case belongs to the secondary class, as does also the finding of a positive Wassermann reaction. In Hypertrophie cases the head is also enlarged, though not to the same extent as in hydrocephalus, no record, existing of one over 25 inches; nor is the enlargement in the same directions, the shape being square rather than round. There is no excess of fluid, but an enlargement of the brain substance; the hypertrophy, however, affects the interstitial tissue only, and is a diffuse gliosis. The distinction between these cases and hydrocephalus is not diffi- cult, as will be shown in the next chapter. A frequent congenital type, obtaining (in England, at least)! in nearly 5 per cent, of mentally defective children, in greater or less degree, is that which has been designated " Mongol " or " Kalmue," owing to the physiognomical resemblance to those races. In these cases the skull is a short oval,J the transverse and longitudinal diameters approximating, while * See Plate XII., Fig. 3, p. 105. f See paper on " Mongolian Imbecility/' by G. E. Shuttle- worth, British Medical Journal, September n, 1909. t See Plate XII., Fig. 2, p. 105; Plate XIV., Fig. i, p. 119. 62 MEN TALLY DEFICIENT CHILDREN there is a tendency to parallelism of the frontal and occipital planes. In children of this type the brain is not necessarily small, but, according to Dr. A. W. Wilmarth,* whose observations are confirmed by Dr. Tredgold, there is a notable diminution in the size of the pons, medulla, and cerebellum. It has been suggested that the imperfect development of these parts may result in a deficient expansion of the base of the skull, and that this leads to the characteristic physiognomy. The brain is characterised by great simplicity of development, and by paucity of multi- polar cells. The convolutions are large and coarse, and there are few secondary convolutions, f Babon- neix,J Fromm, Bernheim-Karrer,|| Lange,^ and others, have found abnormalities, such as hypo- plasia, sclerosis, atrophy, and haemorrhages, in the thyroid gland in some cases of Mongolism. So many other cases have, however, been examined and found to possess a normal thyroid that we are justified in assuming that when a lesion of the thyroid does occur it is an accidental complication, and not necessarily associated. The characteristic features of the Mongolian type will be further discussed in the next chapter, which treats of diagnosis. There is a large group of cases in which mental * A. W. Wilmarth, " Report on the Examination of One Hundred Brains of Feeble-Minded Children," Alienist and Neurologist, October, 1890. f See Plate VI., Figs, i, 2, and 3. { Babonneix, " Contribution a l']tude anatomique de I'ldiotie Mongolienne," Archives de Medecine des Enfants, July, 1909. Fromm, Jahrb. fur Kinderheilk., November, 1905. || Bernheim-Karrer, Jahrb. fur Kinderheilk., 1906, p. 26, 'If Lange, Jahrb. fiir Kinderheilk., 1906, p. 753. PLATE, -VI, .'.* FIG. i. (CONVEXITY.) FIG. 3. (LEFT LATERAL VIEW.) "MONGOL" BRAIN. PLATE VII. FIG. i. AMERICAN IMBECILE WITH " LEPTOCEPHALIC " CRANIUM. FIG. 2. AMERICAN HIGH-GRADE IMBECILE WITH SCAPHOCEPHALIC CRANIUM. (J. Moorhead Murdoch, M.D.) From Journal of Psycho- Asthenias, vol. xi. (by kind permission). To face page 63. PA TUOLOG1CAL CLA SStfitCA TtON _j* deficiency dating from birth may be said to depend upon a highly neurotic heredity. It is probable in such cases there is original defect in constitution of neurones with a tendency to irregular discharge, and an imperfection of those inhibitory arrangements which are gradually evolved in the normal child. Dr J. Langdon-Down long ago pointed out quent association with the neurotic type of a prow- shaped skull "-i.e., a cranium tapering anteriorly to a prominent ridge marking the position of the medio-frontal suture, synostosis of which has bee, deferred, owing to some intra-uterine check, which has also arrested the development of the cerebral centres, and rendered them unstable. Such cases have been designated Scaphocephalic,\ and even i they show no marked intellectual defect in early childhood, are apt to break down from the strain o second dentition or of puberty. Cases which do not conform to any of the above types, but still show abnormal configuration, are spoken of by some authorities as Simple Congenital. This group has been well described by Dr. Fletcher Beach i They show no marked deformity of skull or limbs, but are usually below the average height. The expression of the face is vacant, are several obvious anatomical peculiarities, the so-called stigmata of degeneration. These are usually multiple, instead of occurring singly, as may happen in normal individuals. Found in the face, head, and hand, they take the form of obliteration or exaggera- * Mental Affections of Childhood and. Youth, J, Langdon- Down, 1887. t See Plate VII., Fig- 2. < Types of Mental Deficiency, Report of tirst National Conference of Special School Teachers, held in Manches (Tinling and Co., Liverpool), 1904- 64 MENTALLY DEFICIENT CHILDREN tion of normal markings, such as those of the anti- helix or other parts of the ear, or consist in marked diminution in size of the mouth, orbital fissures, or lower jaw. The teeth are often irregular, and may be arranged in two rows, while the ear may be im- planted too far back. At the present time, however, the custom of most authorities is to classify together under the term Simple Primary Amentia both this group and the larger one, which shows no abnormal configuration at all. Although there is no external abnormality, the brain, when examined, usually shows some of the pathological conditions we described in the first instance. This class, although placed last on our list, includes much the greater proportion of all cases of primary mental defect. Both Epilepsy and Paralysis may occur as a com- plication of primary amentia. These cases must be distinguished from cases of secondary amentia, which are due to epilepsy, or to traumatism or disease occurring at or after birth, and affecting both the motor and intellectual areas of the brain. We have now traced the prominent pathological conditions of the several typical varieties of primary mental deficiency viz. : 1 . Defects of Special Areas and Partial Atrophies (including Word-deafness and Word-blindness). 2. Microcephalus. 3. Hydrocephalus (primary). 4. Hypertrophie. 5. " Mongol " or " Kalmuc " typj. 6. Primarily neurotic (including Seaphoeephaly), 7. Simple Primary Amentia. In the intermediate group of cases, which we have referred to as DEVELOPMENTAL, we include those PATHOLOGICAL CLASSIFICATION 65 forms of mental weakness which evidence them- selves at some crisis of development, such as the first or second dentition, or the epoch of puberty, but are traceable to an original defect of nervous constitution. Epiloia or tuberous sclerosis, and some eclampsic, epileptic, syphilitic, and post-febrile cases, may be thus classified. Epiloia or Tuberous Sclerosis. As long ago as 1880* Bourneville drew attention to a case which, at the autopsy, showed tumours in the kidney, in addition to rounded areas of sclerosis in the brain. Subsequently he and others described similar cases, and in 1908 H. Voght reviewed thirty cases, including three of his own. These were called " tuberose " or " hyper- trophic " sclerosis. Till recently it was difficult, if not impossible, to separate this group as a clinical entity. The knowledge, however, that sometimes the cerebral and renal changes coexist with the skin affection known as " adenoma sebaceum " may enable us to diagnose the condition during life Hence the group designated by some " Tuberous Sclerosis," and by Sherlock "Epiloia," which we now place among the clinical types. Epiloia is a rare levelopmental disease, characterised by numerous rounded tumours scattered throughout the cortex of the brain; they may form projections on the sur- face, and also extend into the subjacent tissue. In addition to the tumours in the kidney, tumours may also be found in the heart (rhabdomyomata), and in the breast, thyroid, thymus, pancreas, and duo- denum. The skin tumours (designated by derma- tologists adenoma sebaceum) are seen chiefly on the face, round the nose and mouth, and on the fore- head; they are " composed of little red nodules of * Archives de Neurologie, 1880. 66 MENTALLY DEFICIENT CHILDREN sebaceous gland tissue embedded in a vascular matrix/' Dr. John Thomson,* to whom we are largely indebted for our description, says that the brain condition probably dates from the seventh month of fcetal life, or soon after it. The convulsions which generally occur may begin in very early life, but are often deferred till late child- hood. The child may show no sign of mental defect till after the convulsions have continued for some time. Eclampsic and Epileptic Cases. A large number of cases of mental deficiency are attributed by parents to convulsions during dentition. Thickened cerebral membranes, sometimes thickened skulls, are seen in many of these cases, with consequent atrophic changes in the brain substance. In cases of persistent epilepsy, with mental weakness, the same class of lesions is sometimes met with, though, of course, the fons et origo mali is to be looked for in the minute structure of the nervous tissue. As a matter of fact, there is no clear distinction between infantile convulsions and epilepsy. Most infants who have teething fits are of neurotic heredity, and a number of them are the victims later on of " idiopathic " epilepsy. When epilepsy does exist from an early age in mentally deficient children, it should be regarded as a complication; it is a complication to which many defectives, especially lower grade cases, are liable. It is often associated with hydrocephalus, and is fre- quently noticed in syphilitic cases. In Mongolians it is comparatively uncommon. Sometimes epileptic seizures, occurring for the first time in children, are followed by signs of mental deficiency, although pre- * John Thomson, M.D., " Congenital Mental Defect it Childhood," Diseases of Children, edited by Garrod, Batten, and Thursfield, London, 1913, p. 882. PATHOLOGICAL CLASSIFICATION 67 viously the child was known to be of normal intelli- gence. These cases should be described as cases of secondary amentia, due to epilepsy. The exact classification of a particular case is often difficult. Idiopathic epilepsy cannot as a rule be diagnosed till after the primary dentition is complete, while it is sometimes impossible to differentiate slight mental defect from mere dulness or backwardness till six or even seven years of age. In cases of epilepsy, as in some other cases of mental defect, especially if there is any history of traumatism, a careful X-ray examina- tion may show an injury to the skull or other patho- logical condition amenable to surgical treatment.* It is important to examine the Sella Turcica and its immediate neighbourhood to see if there is any indica- tion of an abnormal condition of the pituitary gland. Epilepsy sometimes follows bursting fractures of the base of the skull; in such cases the pituitary body is liable to be injured. \ There is, however, another class of patient, according to Dr. George C. Johnston, J who, with an uneventful history, no injury, and previous good health, between fifteen and twenty- live years of age, begin to suffer from attacks of petit-mal, gradually increasing in severity and fre- quency. In such cases there are often changes in the Sella lurcica viz., " for the most part an over- growth of the anterior and posterior clinoidal pro- cesses, which, in addition to an increase in area and length, are slowly folded over and down upon the pituitary gland, enclosing it within a bony basket. * See Plates XIII. and XIIlA., p. 108. f Harvey Gushing, M.D., The Pituitary Body and its Dis- orders, p. 272. J. B. Lippincott Company. J George C. Johnston, M.D., " The Pituitary Gland in its Relation to Epilepsy/' Surgery, Gynaecology, and Obstetrics, April, 1914. 68 MENTALLY DEFICIENT CHILDREN In addition to this process, which evidently is one requiring a considerable length of time for its accom- plishment, there is very often noticeable a decided difference in the size of the pituitary fossa, and there- fore of the gland itself. The fossa is thus largely or completely roofed over in some cases in which the shadows of the anterior and posterior clinoidal pro- cesses not only meet, but overlap. The frequency with which this condition has been found is quite striking. " In addition to this overgrowth of the clinoidal process, a large proportion of the cases show distinct increase in density in the bony tissues forming the roof of the orbit, the sphenoidal sinus, and the eth- moidal cells. In quite a number of cases the sphe- noidal cells are decidedly blocked with newly formed bony tissue. This condition resembles, to a marked degree, the appearance of the skull in general acrome- galy, and has been interpreted by us as a local- ised acromegaly." Dr. Johnston goes on to say that if in the skiagrams of cases in this class the clinoidal processes do not show, it is probably hypopituitarism, due to hypophysial struma with enlargement of the gland and pressure atrophy of the processes. He suggests that we want an operation for the removal of one or both processes in choked pituitary before the gland has suffered too long. Surgical treatment is sometimes useful in cases of Status Epilepticus, which may be due to a localised ' meningitis serosa externa. Dr. Leonard Guthrie* states that " a number of such cases in which the subarachnoid cisterns have been opened and drained, with great relief to the patient, have recently been recorded." * Diseases of Children, edited by Garrod, Batten, and Thursfield, 1913, p. 714. PATHOLOGICAL CLASSIFICATION 69 In connection with the pathology of epilepsy, refer- ence must be made to the work of Dr. Alfred Gordon,* of Philadelphia. Dr. Gordon assumes that " the pathogenesis of the malady presupposes a constant, or at least a frequent, formation in the organism of the epileptic individual of unusually severe or of specially toxic elements, which cause cerebral irrita- tion, manifesting itself in convulsive seizures/' After referring to Ceni's and Donath's investigations upon the chemical constitution of the blood-serum and the cerebro-spinal fluid in epilepsy, he states that other writers have shown that there is a marked toxicity of the cerebro-spinal fluid in epilepsy. Dr. Gordon himself noticed that the blood accidentally in the cerebro-spinal fluid drawn from an epileptic under- went haemolysis; he also noticed that, when the patient improved and the seizures became very mild and rare, this phenomenon disappeared. He found, further, that one drop of blood from the finger of one patient in fifteen drops of cerebro-spinal fluid from another undergoes haemolysis, and vice versa ; but one drop of blood from the finger of a patient in that patient's own cerebro-spinal fluid remains coagulated for days. This meant that the cerebro-spinal fluid of each patient contained elements antagonistic to the other's blood, but not to that from the same subject. He therefore withdrew 30 c.c. of cerebro-spinal fluid from each of two epileptics, and injected into the arm of each 3 c.c. of the other's fluid. Dr. Gordon treated four cases in this way, and in all there was a great improvement ; yet all of them had had bromide before without benefit. The fact that in one of the four cases no cerebro-spinal fluid was withdrawn proved * Alfred Gordon, M.D., New York Medical Journal, 1914, xcix., p. 10. yo MENTALLY DEFICIENT CHILDREN that the improvement could not be attributed to the withdrawal of cerebro-spinal fluid. As will be fully explained in the next chapter when discussing etiology, although one investigation* sets forth that in nearly 50 per cent, of cases of epilepsy in children the Wassermann reaction showed a syphilitic infection, and that when the investiga- tion is extended to the families giving a negative or doubtful reaction the percentage is higher still, we do not consider that it has yet been proved that syphilis is the most frequent cause of epilepsy. In regard to Syphilitic cases, our ideas have been modified in recent years by the careful investigations of Dr. Mott, and by the help of the Wassermann reaction. In our last edition we suggested that the number of cases of mental defect due to syphilis was larger than was generally realised. Now, as will be explained in discussing the etiology in the next chapter, we know that syphilis is responsible for a considerable percentage of cases, many of which show neither the ordinary syphilitic stigmata, nor any evidence of a gross lesion in the central nervous system. This is not surprising, considering that the ''gross changes in the brain which are known to be due to congenital syphilis are not compatible as a rule with a continuance of life/'f Cases of mental defect in which the causal relation with syphilis is deter- mined only by the Wassermann reaction or by an * Kate Fraser, M.B., and H. Ferguson Watson, M.B., " The Role of Syphilis in Mental Deficiency and Epilepsy: a Review of 205 Cases," The Journal of Mental Science, October, 1913. | H. R. Dean, M.B., " An Examination of the Blood-Serum of Idiots by the Wassermann Reaction," Proceedings of the Royal Society of Medicine, Neurological Section, vol. iii., June, 1910, p. 117. PLATE VIII. INHERITED SYPHILIS. To face page 70. PATHOLOGICAL CLASSIFICATION 71 investigation of other members of the family may be classed as parasyphilitic. It is important to remember that congenital syphilis affecting the nervous system of infants and young children may " give rise to a meningitis, a hydrocephalus, to an endarteritis, to gummata, to a juvenile tabes, and to a juvenile general paralysis of the insane."* As regards the particular type of mental defect that may result from congenital syphilis, Dr. Plaut,t working in Kraepelin's clinique, showed that in cases of imbecility with motor paralysis, syphilis played an important, though previously unsuspected, part. This has since been confirmed by Dr. Leslie Gordon, J among others. The relation of syphilis to hydro- cephalus is well known. Apart from these types, congenital syphilis, according to Dr. Gordon, " is as likely to cause a simple, uncomplicated form of con- genital mental defect as it is to cause any particular type " a statement which is in accordance with our own experience. There is one type of mental defect universally admitted to be due to syphilis in every case viz., Juvenile General Paralysis of the Insane. In these cases mental deterioration does not usually show itself until the period of the second dentition, though Dr. Mott says the mental deficiency may date from birth. These cases progress in much the same manner" * F. E. Batten, M.D., Diseases of Children, edited by Garrod, Batten, and Thursfield, 1913, p. 850. f Plant, Die Wassermannsche Serodiagnostik der Syphilis, Jena, 1909. { J. Leslie Gordon, M.D., " The Incidence of Inherited Syphilis in Congenital Mental Deficiency," Lancet, Sep- tember 20, 1913. F. W. Mott, M.D., Archives of Neurology, 1898, i. 250. 72 MENTALLY DEFICIENT CHILDREN as general paralysis of the insane in the adult, death occurring in a few years after the onset of the symp- toms. A full description of these cases will be found in the next chapter. At the autopsy we find thicken- ing of the cerebral arteries (from endarteritis) and of the meninges, with marked atrophy of the con- volutions; the sulci are wide, the ventricles dilated, the ependyma granular, and the brain wasted as a whole (Plate VIII. represents this type). " On microscopical examination, the fibres of the cortex have to a large extent disappeared, and there is almost complete absence of the tangential fibres of the cortex. The cells of the cortex show various stages of chromatolysis; many have already dis- appeared or been replaced by calcareous deposits. The pyramidal tracts, and in some cases the pos- terior columns of the cord, show degeneration/'* Amongst other pathological conditions sometimes met with, dating from early life, are those resulting from meningeal haemorrhage occurring from undue pressure during parturition, the injurious element being, however, prolonged pressure rather than in- strumental interference. In these cases atrophic changes take place in the Rolandic area, and as a consequence ensue spastic contractions of the limbs (bilateral or unilateral), with inco-ordination and often "athetoid," " choreic," or "perverse" move- ments. The intellectual deficiencies of children suffering from "Birth-palsies" are more apparent than real, the intelligence which they possess being masked by their physical infirmities, f Of clearly SECONDARY cases two main divisions * F. E. Batten, M.D., Diseases of Children, edited by Garrod, Batten, and Thursfield, 1913, p. 851. f See Plate IX., Figs, i and 2. o H W w H o PQ H s 3 X w o W o PATHOLOGICAL CLASSIFICATION 73 are Traumatic and Post-febrile, and in each the characteristic lesions are the products of inflam- matory processes . Thickened and adherent mem- branes, following meningeal inflammations and inter- fering with the due supply of blood to the cerebral cortex, have been noticed in a considerable number of cases; whilst porencephalus,* which may be con- sidered in some instances to be the terminal con- dition of an acute inflammatory lesion, has not in- frequently been observed. It must be noted, how- ever, that some of the cases in which sclerosis is found are not strictly secondary, as was at one time supposed, but belong to the " Tuberous Sclerosis " group, a developmental type. Among the cases probably due to meningitis is a peculiar form of enlargement, in one direction at least, of the skull, known as Oxycephaly, or Tower skull (French, Tete a tour ; German, ThurmscMdel). This type is not frequently met with, and has seldom been described from the mental aspect. It has sometimes been confused with other types. For most of the descriptions we are indebted to ophthal- mic surgeons, as the ocular defects, which are usually the most marked, have attracted more attention than the mental. Indeed, Patry states that the in- telligence is usually normal. In some cases, how- ever, there has been marked mental defect. It is probable that slight mental defect would be found in most cases if the investigations were made by an expert. A fairly typical case was shown by Dr. Potts at the meeting of the Society for the Study of Disease in Children in Birmingham, in June, 1908, two illustrations of which we now reproduce, f This boy required education in a special school, though * See Plate II., Fig. i, p. 55. f See P late X, 74 MENTALLY DEFICIENT CHILDREN he was not very weak mentally. Contrary to what is usual, he had no ocular defect. The case described by Dr. Rosa Ford in the Ophthalmoscope, April, 1907, was also mentally defective. The condition has been well described by Patry* in a monograph published in 1905, which dealt with ten cases of his own, and, in addition, with the records of fifty-eight published cases. Typical cases are very striking. There is a dome-shaped mound rising up from the forehead, separated from the temples by shallow furrows; the supra-orbital ridges are absent, and the eyes prop- tosed and large. At the same time there is an atrophy of the optic nerve, post-neuritic in type. The exophthalmos is due to malformation of the orbit, the upper wall of which slopes down towards the floor at a more acute angle than in the normal. Many of these patients suffer greatly from headache; some also from fits during childhood. Patry states that the cranial deformity commences in the first year of life, and is due to premature synostosis of the coronal and frontal sutures. This theory receives consider- able confirmation from the deep convolution markings found in the vault, the expanding brain being driven up into the vertex. Hence the suggestion that these cases would be benefited by craniectomy. Patry endorses Virchow's view that the primary cause both of the cranial deformity and the optic neuritis is a meningitis. Emotional shock, such as fright to a young child confined in a dark cellar, or from the bite of a dog, is sometimes assigned as a cause of mental defect. * Contribution d I' Etude des Lesions Oculaires dans les Malformations Craniennes sp&cialement dans l'Oxyc6phalie, par Andre Patry. Paris, 1905. PATHOLOGICAL CLASSIFICATION 75 The experimental investigations of Dr. G. W. Crile* have shown us that shock and fright are followed by definite changes in the brain cells, as shown by swell- ing and rupture of the nuclei, the cells being hyper- chromatic during fright, and exhausted after. It is not unreasonable to suppose that certain cases never return to their normal state. Possibly, too, trophic changes, brought about by the sympathetic system, are important factors. At any rate, cerebral atrophy, as if from arrested development, is found in some of these cases. We recognise also Toxic cases, such as those of infants drenched with alcohol or narcotics, in which the interference with the proper nutrition of the nerve elements, and the poison introduced, may have far-reaching effects. The dangers to infants from alcohol are very real and very frequent, as all readers of Mr. George R. Sims' spirited article, "The Cry of the Children/' reprinted from the Tribune, must admit. Fortunately, the Children Act now excludes infants and children from public- houses, but much of the evil still remains. There is complete ignorance in some classes of the harm done to nursing mothers by the taking of alcohol. The time, too, is more than ripe for some legislation which will make it impossible to advertise as safe for children proprietary medicines which contain morphia and other narcotics. Under the title of Amaurotic Family Idiocy some curious and hopeless cases of infantile cerebral de- generation, with symmetrical changes at the macula lutea, commencing about three months after birth, and observed almost exclusively among Jewish children, have been described by Sachs of New York and other * George W. Crile, M.D., " Anaesthesia and Anoci- Associa- tion," Surgery, Gynaecology, and Obstetrics, June, 1913. 76 MENTALLY DEFICIENT CHILDREN American authorities, and by Mr. Waren Tay and Drs. Kingdon and Risien Russell* in this country. The first abnormalities noticed are weakness of the muscles of the back and neck, and imperfection of sight. With the ophthalmoscope there is seen in the macula an oval whitish-grey patch, with softened edges slightly raised above the general surface of the retina. The fovea centralis appears as a dark cherry-red spot in the centre of the patch. Later on there is optic atrophy, and complete blindness. The senses of taste and hearing are preserved, the latter being par- ticularly acute. The muscles become weaker and weaker, the whole body becoming involved. There is marked emaciation, and, in the final stages, rigidity of the extremities, with retraction of the head. There is no fever. The thoracic and abdominal organs are normal. The cerebro-spiaal fluid shows practically no change. Death usually occurs in less than two years, from pneumonia or cardiac failure. The cause is possibly a toxin, causing degeneration of the cortical neurones, the optic nerves, and the pyramidal tracts throughout their whole course. Dr. Poynton,f who has also written on the subject, after seeing four cases and studying one by modern neurological methods, ascribes the condition to " some inherent bio-chemical property of the protoplasm of the cells." He states that the disease is primarily one of the interfibrillar protoplasm of the cells, and describes the changes in the nerve cells as " swelling of the cell body with frequently gross alteration in shape; disappearance of Nissl bodies; excentric position of nuclei; vacuolisation of the protoplasm/' * Med. Chir. Trans., vol. Ixxx., p. 87. f " Amaurotic Family Idiocy," Brit, Med. Journal, May 8 , X909, p. 1106. PATHOLOGICAL CLASSIFICATION 77 In one case Dr. Mott had the blood and cerebro- spinal fluid examined for the Wasserrhann reaction, with a negative result, thus confirming the clinical experience that the disease is not a result of syphilis. The condition just described must not be confused with another form of cerebral degeneration seen in older children, known as Cerebral Degeneration with Symmetrical Changes in the Maculae. This also is a familial disease, and is thought to be partly due to consanguinity of the parents. In some cases syphilis has been a factor, but has not been in evidence in typical cases of the disease. Children who are affected are normal in early life, and make a good start at school. At the age of six or seven they begin to be difficult, fail to advance, and lose the power of reading ; they do not see well, and it is noticed that the head is turned to the side, presumably in an effort to see in spite of the central scotoma which is believed to be present. There is obvious mental deterioration, with the development of dirty habits, but no muscular weakness in the early stages. The distinguishing feature is the association of mental failure with a curious pigment ed condition round the maculae. The disease slowly progresses, the child dying in seven or eight years, usually from some inter- current disease. Glandular Inadequacy. The cases just considered are due to the presence of toxins. We now pass to an important group which are due to the absence of a necessary element from the economy. Inade- quacy of the thyroid and other glandular secretions are frequent causes of serious maldevelopment, often associated with mental defect. The best known of these conditions is Cretinism, the full development of 78 MENTALLY DEFICIENT which usually takes place after birth, producing mental deficiency. Cretins are divided into two classes endemic and sporadic. Endemic cretins are met with in goitrous districts, .and in affected families; in this class the thyroid is often enlarged, though functionally inactive. Sporadic cretins are met with in all parts of the world; the thyroid is atrophied or altogether absent. Intra-uterine Cretinism fully developed results usually in the death of the foetus, which displays a FIG. i. AMERICAN CRETINS, AGED 34 AND 24 YEARS. (J. Moorhead Murdoch, M.D.) curious stunted conformation of the body, with re- dundant skin, thickened cranial bones, and imper- fectly formed face. The essential lesion is absence or atrophy of the thyroid gland, and there are often found fatty tumours in the supraclavicular regions. Cases of sporadic cretinism usually met with in this country differ from the above in the fact that the child appears normal at birth, but the characteristic PATHOLOGICAL CLASSIFICATION 7 g conformation and mental hebetude are gradually developed. The condition can usually be recognised at six months, though in rare instances it is not possible to do so till much later, sometimes not even till the child is six or seven years of age. Pro- gressive atrophy of the thyroid brings about a dwarfing of the physical growth and of the mental powers; if the patient arrives at adult life, he still retains the bodily and mental stature of a child (see ! Plate XL, Figs, i and 2). At this stage we may consider the condition of Infantilism, some varieties of which are due to dis- turbances of the functions of glands of internal : secretion, and which may be associated with men.tal defect. The term merely denotes a group of symp- toms. The essential feature is that the genital organs remain immature, while just as the primary sexual characteristics of adult life fail to appear at the proper time, so also do the secondary sexual charac- teristics of body and mind. In some cases the intelli- gence is fairly normal, but generally it is weak and childish. Infantilism is not as a rule a prominent feature of the mentally defective, except in some cases of microcephalus, mongolism, and severe spastic diplegia. Dr. John Thomson* classifies the cases under three headings. The first group, which he calls the Jdiopathic, shows no serious general or local disease. In the second, or Cachectic, serious general disease or poisoning exists. The most common disease is chronic tuberculosis, next syphilis ; malaria, leprosy, and some of the common infective diseases, have also been blamed, as has also any form of heart disease that begins early in life, and causes * " Infantilism," System of Medicine, Allbuttand Rolleston, vol. iv., part i., p. 486. 8o MENTALLY DBFlCtEMf CHILDREN much interference with the general circulation. One type, now well known owing to the writings of Dr. Herter,* is associated with intestinal disorder, usually with coeliac disease. In many cases of infantilism polyuria has been noticed; sometimes this has been due to diabetes insipidus; in other cases, however, as Dr. Leonard Parsonsj and others have shown, the primary lesion is interstitial disease of the kidneys. The third group depends on gross lesions or defects of important internal organs. The organ most often at fault is the thyroid gland, and Dr. Thomson points out that one type of the condition constitutes the mildest degree of cretinism, with symptoms so slight that the real cause is often overlooked. He brings forward evidence, however, to show that defective action of other internal organs may produce the same symptoms. The account of two cases in which the pancreatic secretion was proved to be in abeyance, and in which development resumed its normal course on the regular administration of pancreatic substance, is particularly interesting. Dr. Sajous has recently called attention to the frequent association of aplasia of the thymus with defects of development, and its absence in cases of amentia, as recorded by Bourneville, Morel, and others. J Pituitary Infantilism is now a well-defined variety; the possible connection between hypopituitarism and some forms of epilepsy has already been discussed. It has also been suggested that sometimes the supra- * C. Herter, Trans. Assoc. Amev. Phys., 1908, xxiii., p. 260. f Leonard Parsons, M.D., " Infantilism associated with Chronic Interstitial Nephritis," Lancet, September 2, 1911. J New York Med. Journ., Jan. to Nov., 1915 (" Hema- denology "). PATHOLOGICAL CLASSIFICATION 81 renal glands are at fault. Dr. A. E. Garrod* refers to a case in which a marked advance in development followed the administration of suprarenal tablets. In some cases, such as those described by Dr. Hastings Gilford,f under the name of " ateleiosis," the under- lying cause is quite obscure. Another kind of defect which may have serious consequences is Sense-deprivation. When this is associated with primary mental defect, as not in- frequently happens, the difficulties of training are greatly increased; if both sight and hearing are absent, attempts at education must inevitably end in failure. If, however, the mental defect is due to the sense- deprivation, then proper education will remove that defect, provided it is begun at an early age. Should it be unduly delayed or altogether neglected, permanent secondary amentia may be the result. In conclusion, we may briefly sum up the various secondary types of mental weakness, the pathological circumstances of which we have described, as follows : A. DEVELOPMENTAL CASES: 1. Epiloia, or Tuberous Sclerosis. 2. Eclampsic. | 3. Epileptic. 4. Syphilitic (inherited). 5. Paralyse (spastic, etc.). B. ACCIDENTAL OR ACQUIRED: 1. Traumatic. 2. Post-febrile (including Oxycephaly). * A. E. Garrod, Diseases of Children, edited by Garrod, Batten, and Thursfield, p. 583. f Hastings Gilford, The Disorders of Postnatal Groivth and Development, 1911, 6 82 MENTALLY DEFICIENT CHILDREN 3. Emotional. 4. Toxic (including Amaurotic Family Idiocy and Cerebral Degeneration with Sym- metrical Changes in the Maculae). 5. Due to Nutritional Defect (including Cretinism and Infantilism). 6. Due to Sense-deprivation. We shall find that these divisions, together with those of the primary types previously given (p. 64), will be serviceable in considering points in tt etiology, diagnosis, and prognosis of mental de ficiency, which We shall proceed to discuss in the next chapter. CHAPTER V ETIOLOGY, DIAGNOSIS, AND PROGNOSIS IN connection with mental defect in children there is no more interesting or important subject than its ETIOLOGY. At one time this was an obscure and difficult problem, but such considerable 'advance has been made in our knowledge in recent years that we are now in a position to express a more decided opinion than heretofore, and to say that in primary amentia a neuropathic inheritance is the most effec- tive factor. In a limited number of cases other in- fluences are undoubtedly accountable, but the large majority of cases of primary amentia originate in this way, and even in secondary amentia a morbid heredity sometimes has an important influence in deciding the issue. These views were foreshadowed in 1892 by Dr. Shuttleworth, who then recorded his statistics (in conjunction with those of Dr. Fletcher Beach) in an article in Hack Tuke's " Dictionary of Psychological Medicine/' in which 1,200 cases observed at the Royal Albert Asylum, and 1.180 cases at Darenth Asylum, were collated. Hereditary mental weakness (insanity or imbecility) was recorded in 21-38 per cent, of cases, but in addition epileptic or neurotic inheritance showed a percentage of 20, making a total of 41-38 per cent, of cases which could be tabulated as having a neuropathic inheritance, a proportion which tends to increase with further knowledge of the antecedents. 83 84 MENTALLY DEFICIENT CHILDREN Dr. Caldecott of Earlswood Asylum found that over 70 per cent, of his patients have neuropathic ante- cedents. " In Germany, Koch came to the con- clusion that it accounted for 60 per cent, of cases. In Switzerland (Canton of Berne), the census of 1893 showed that heredity was present in 55 per cent, of idiots; whilst in Norway, Ludwig Dahl found it to occur in 50 per cent, of cases."* It is important to remember that in Dr. Shuttleworth's inquiry, as in. most of the earlier ones, no house-to-house visitation was made in order to elicit additional information, and to examine both the parents. When this pro- cedure has* been adopted, and searching inquiries made into the family records, convincing evidence of the effects of a morbid heredity has always been obtained. One of the most careful inquiries on these lines was conducted by Dr. Tredgold, f who studied a large number of cases in the pauper asylums of London, and in 150 obtained " full particulars of the family for at least three, and sometimes four, genera- tions." He traced a neuropathic inheritance in 82-5 per cent. All those who have conducted an inquiry of this kind will agree with Dr. Tredgold that the reason why he obtained a considerably higher per- centage than most other observers is " entirely a question of the method adopted." " Again and again," he says, " have I discovered by a little ques- tioning a well-marked history of insanity, of which no record whatever existed in the case-books. The taking of a reliable family history involves much time and trouble. Several members of the family must be * A. F. Tredgold, Mental Deficiency, 1914, p. 40. j A. F. Tredgold, Report and Evidence of the Royal Com- mission on the Care and Control of the Feeble-minded, 1908, vol. i., p. 396. DIAGNOSIS. AND PROGNOSIS 8 5 seen, and their confidence must be gained before any- thing like the true state of affairs can be elicited. It is not only that the relatives are averse from giving information upon what they regard as their private affairs to a complete stranger, but that very often they do not really know until they have talked the matter over amongst themselves." We may add that it is extraordinary how ignorant even well- educated people often are as to the records of illness and causes of death of their forbears. In the case of insanity and consumption, in particular, it is a com- mon practice to gloss over the real nature of the trouble, and keep many members of the family in complete ignorance. Dr. Tredgold's statistics have been amply confirmed by the inquiries in America of Dr. Goddard, the Director of the Research Laboratory of the Training School at Vineland, New Jersey, for Feeble-minded Girls and Boys. At this institution a laboratory and Department of Research for the study of feeble- mindedness was opened in September, 1906; since 1910 it has employed field-workers. " These are women highly trained, of broad human experience, and interested in social problems. As a result of weeks of residence at the Training School, they be- come acquainted with the condition of the feeble- minded. They study all the grades, note their pecu- liarities, and acquaint themselves with the methods of testing and recognising them. They then go out with an introduction from the Superintendent to the homes of the children, and there ask that ah 1 the facts which are available may be furnished, in order that we can know more about the child and be better able to care for him, and more wisely train him. "Sometimes all necessary information is obtained 86 MENTALLY DEFICIENT CHILDREN from the one central source, but more often, especially where the parents are themselves defective, many visits to other homes must be made. Parents often send the field-worker to visit near and distant rela- tives, as well as neighbours, employers, teachers, physicians, ministers, overseers of the poor, alms- house directors, etc. These must be interviewed, and all the information thus obtained must be weighed and much of it verified by repeated visits to the same locality, before an accurate chart of the par- ticular child's heredity can be made/' * As a result of this work, Dr. Goddard has been able to study more than 300 families. His conclusions are that " Feeble-mindedness is hereditary, and trans- mitted as surely as any other character." Dr. God- dard's researches have, however, gone further than this, for he claims to have shown that, putting mon- golianism on one side, mental defect is a Mendelian recessive character. As a consequence, not every person who carries the taint shows it, as would happen if mental defect were a Mendelian dominant charac- teristic; many people unconsciously carry the taint in their germ-cells without showing any sign; it only becomes evident in certain members of the families where both parents have a mentally defective heredity. " According to a recent calculation, made in one of the bulletins of the Eugenics Record Office, about one-third of the population in the United States is thus capable of conveying mental deficiency, the 1 insane tendency/ epilepsy, or some other defect/' f * H. H. Goddard, Ph.D., The Kallikak Family : a Study in the Heredity of Feeble-mindedness. New York: The Mac- millan Company, 1912. Also Feeble-mindedness : Its Causes and Consequences. New York: The Macmillan Company 1914- f C. W. Saleeby, M.D., The Progress of Eugenics, p. 181. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 87 It is not necessary for us to elaborate the details of Mendelism, as there are now so many excellent treatises on the subject; for the benefit, however, of those of our readers who are not thoroughly familiar with its principles, we may briefly state how it works out as regards mental defect in various sets of cases : 1. If two normal parents, both of whose families are free from mental defect, have children, all those children will be normal; and, in addition, the children will be incapable of transmitting mental defect to their offspring. 2. If a normal person whose family is quite free marries either a mentally defective person or one who, though normal, is a carrier of the defect, then, al- though all the children will be normal, a certain number will be carriers of the taint. If the second parent is actually defective, half the children will carry it; but if the second parent merely carries it, without showing it, only one in every four of the children will carry the defect in its germ- cells. 3. If both parents are apparently normal, and yet both carry the taint, then one in every four of their children will be defective, and, in addition, two out of every three of the normal children will carry the defect, while one only will be entirely free. 4. If both parents are defective, every one of the children will be defective. In human families, which are limited in size, the numbers of those who are defective and those who are not seldom corresponds exactly with the table just given; the results of Mendelian inheritance can only be exact when the families are large, as happens in the vegetable kingdom. Yet many of Dr. God- dard's records approximate closely to the condi- tions of a Mendelian recessive. MENTALLY DEFICIENT CHILDREN Further confirmation from other workers is re- quired before this theory can be accepted uncondition- ally; still, the work of Dr. Goddard has been so thorough and extensive, and the explanation fits in so well with generally observed phenomena, that authority is attached to his conclusions. The work done in the Galton Laboratory by Pro- fessor Karl Pearson and his collaborators, the writings of Whetham and many others, have established the importance of heredity in regard to mental defect. One argument of which much was made by the school who attributed everything to environment was the results of matings in the class of cases described in heading 3 in the table above that is, those instances when two normal parents have a certain proportion of defective children. At one time it was difficult to reconcile this with the hereditary principle, but, ac- cording to Goddard's theory that mental defect is a recessive Mendelian quality, this, so far from dis- proving thelmportance of heredity, goes a long way to establish it. The most important evidence, how- ever, of the powerful effect of heredity is afforded by the fourth condition described above ; this is abso- lutely true. In the year 1909 the statement was first made that two mentally defective parents never have any but defective offspring; in the six years that have since elapsed this statement has never been contradicted. It is necessary to point out that if mental defect is a Mendelian recessive character, segregation cannot stamp it out in a generation ; the good effect of segre- gation will only gradually become apparent. The Mendelian theory explains the deep-rooted objection to cousin marriages, the danger being that if one parent carries mental defect in his germ-cells, the ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 8g other parent will very likely do so too ; the results of such a union are sometimes disastrous. The Men- delian theory enables us also to understand how a parent may have only normal children after one marriage, and defective children after a second marriage; the writer has recently seen a normal woman who had four normal children by her first husband, but after a second marriage four children, of whom only one was normal, while one was defective and two died in infancy. The explanation is that the mother is a carrier of mental defect, and that the first husband was free, while the second is a carrier. The history of the Kallikak family, unearthed by the energy of Dr. Goddard, shows how a man by different matings may found two entirely different types of family. We must not, however, pursue this interesting aspect of the subject further, but must proceed to say that, although we attach the greatest importance to heredity, we believe that the environment does exert an influence; in considering various factors that one sometimes finds to be precursors of mental defect, we shall later on give specific examples where the en- vironment was undoubtedly to blame. Speaking generally, we accept the doctrine that " like breeds like/' and admit that the germ-cells are wonderfully protected from injurious influences. There are, how- ever, many observations as regards both the vegetable and animal kingdoms which show that external influ- ences may leave a mark. For instance, Macdougal,* experimenting with the evening primrose, showed that by injecting certain chemical substances into the immature ovaries, he got seeds which afforded plants * Report of the Department o Botanical Research, Fifth Year-Book, Carnegie Institute, Washington, 1907, p. 119. 90 MENTALLY DEFICIENT CHILDREN some of which departed widely from type; in this way he was able to establish new varieties. Tower,* experimenting with a certain species of beetle, ob- served that if shortly before maturation of the germ- cells he subjected the beetles to intense environmental change (cold and humidity), he obtained offspring widely different from the parents, and the results appeared to be permanent, or at least heritable through further generations. The wing-cases of the normal beetle showed one pattern, those of the progeny of the cooled beetles showed another. When crossed, these altered forms bred true, nor did they lose their acquired characters in subsequent genera- tions. Sumnerf also proved that influences primarily affecting the body can secondarily affect the germ- cells. He found that similar broods of young mice brought up, one in a warm temperature (21 C.), and the other in a cold temperature (5 C.), differ consider- ably; the mean length of tail, feet, and ears of those brought up in the warm atmosphere is greater, and the young of these two groups, though reared in a common room, subsequently present the greater or lesser length of tail, foot, and ear acquired by the parent. Again, Carriere J inoculated guinea-pigs, both male and female, with the toxins and soluble products of tubercle bacilli, and found that the num- bers of the litters were reduced and the number of the stillborn increased. Lustig showed similar re- sults with chickens; there was diminished fertility, * An Investigation of Evolution in Chrysomelid Beetles oj the Genus Leptinotana (publication of the Carnegie Institute), Washington, 1906. f Archiv fur Entwickelungsmechanik , 30, 1910. J Archives de Medecine Experimental, 12, 1900, p. 782. Centralblatt fur Pathologic, xv., 1904, p. 210. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS gi an increased number of monstrous births, and poor vitality of the surviving offspring. Such observations as these justify the contention of Dr. Beard,* in his " Study of the Morphological Con- tinuity of Germ-Cells as the Basis of Heredity and Variation/' that food, climate, toxins, disease, natural phenomena of all kinds, can affect the corresponding characters of any germ-cell. Dr. Beard demonstrated that at the time at which the determiners separate out of the germ-cells, the reaction to the influences of the environment is a cause of variation and varieties ; healthy influences promote variation of a good type, unfavourable ones tend towards a bad type. More than half a century ago records were published proving that poisons such as lead, mercury, alcohol, malaria, smallpox, or tubercle, in very concentrated doses are possible causes of mental defect in the human family. Constantin Paulf stated that of 32 pregnancies in which the husband alone was ex- posed to lead in his work, there were 12 abortions; and of the 20 children born, 8 did not survive the first year, 4 died in the second, and 5 in the third, so that only 3 out of 32 lived beyond the third year. He also showed, as Roque, Sir Thomas Oliver, and others have done since, that epilepsy, idiocy, and imbecility frequently occur in the children of workers in lead. LizeJ supplied identical data regarding workers exposed to the fumes of mercury. We could quote many more facts such as these, which prove * J. Beard, " A Morphological Continuity of Germ-Cells as the Basis of Heredity and Variation," Review of Neurology and Psychiatry, vol. ii , 1904. f Constantin Paul, Archives Generates de Medecine, 15. 1860, p. 513. % Lize, Union Medicale, 1862, p. 106. 92 MENTALLY DEFICIENT CHILDREN that variation is sometimes due to the environment and mode of life of the parent, and that variation may take the form of mental defect. When investigating at Stoke-upon-Trent for the Royal Commission on the Care and Control of the Feeble-minded, Dr. Potts found several cases of ab- normally backward children. In several instances these children, after being almost hopeless at school for many months, unexpectedly improved, and sub- sequently developed as well as their normal fellows. He attributed the condition partly to the mothers going out to work and leaving the children shut up for many hours, ill supplied with food, and with no one to talk to or play with. When such children come to school, they sometimes actually have to be taught to talk, and much else that a child should learn at home. It is time now to discuss certain special factors which are sometimes accountable, in whole or in part, for mental defect. We must first point out, however, that it is not logical to attribute to a single specific cause, other than a direct hereditary tendency, the majority of cases met with, inasmuch as on investiga- tion we olten discover several contributory factors. So strong, indeed, is the tendency of Nature to revert to a healthy type, that the solitary infraction of physiological law is not often visited with the penalty of mental abnormality; if we only look back far enough, we shall probably find that such a culmina- tion is reached by the gradations of repeated trans- gressions. Not every drunken parent procreates an idiot; but when inherited nervous instability from this or other causes is intensified in the next genera- tion by injudicious marriage, or by unfavourable environment, or by a very severe infectious illness ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 93 shortly before conception, instances of mental de- generacy are apt to occur. We shall first consider Inherited Syphilis. This has recently been shown to act more frequently as a cause than was suggested by the earlier records. Dr. Mott has studied for several years the effects of syphilis, acquired and congenital, on the nervous system, and arrived at the conclusion that it is an active agent in the production of congenital weakness and the degeneracy that accompanies it. He has demonstrated that " the measure of the effects of syphilis in the production of feeble-mindedness and epilepsy should not be estimated only by the cases in which there are visible and characteristic signs of syphilis on the body, for he has observed one member of a family with syphilitic notched teeth, another without any external sign, but with severe visceral and brain disease, while a third was an imbecile. He has also seen many other examples pointing to the same conclusion/' Dr. Mott* further states that " it may be thought that because syphilis of the parents produces sterility, miscarriage, and abortion, its dangers are greatly minimised, but it cannot be doubted that if the poison is sufficiently strong to kill the embryo either before or shortly after birth, it must have a devitalising effect on the offspring that survives. Though hereditary neurosis or psychosis greatly increases the liability of the syphilitic poison to affect the nervous system, yet in numbers of the cases there was no pre-existing neuropathic family history in fact, sometimes the syphilitic poison appeared to induce a neuropathic condition in the offspring/' Dr. Mott has also shown that in some cases * F. W. Mott, Minutes of Evidence taken before the Royal Commission on the Care and Control of the Feeble-minded, vol.ju p., 453- 94 MENTALLY DEFICIENT CHILDREN the blindness, deafness, mental deficiency or disease does not manifest itself till between eight and puberty. More recently confirmatory evidence of the pro- duction of mental defect by inherited syphilis has been obtained by means of the Wassermann reaction. The results obtained, however, by different investiga- tors differ so much that we cannot regard any of them as final. The table on p. 95, showing the percentage of cases of congenital mental defect, found to give a positive Wassermann reaction by some of the workers, justifies this statement. Well might Sir H. Bryan Donkin say that, " even assuming that the Wassermann process may be regarded as an absolute scientific test for the presence of syphilitic infection, it is clear that at present no positive conclusion as to the relations of mental defect to syphilis can be drawn from any accounts hitherto published "* The discrepancies in the results obtained are partly due to the different antigens and degrees of dilution employed by different investigators. The age of the mentally defective person also affects the result, a larger number of positive reactions being obtained in early life. But even if the largest percentage yet obtained were proved to be correct, it would not shake our belief in the outstanding importance of a morbid heredity. It need prove nothing more than that the mentally defective, including, of course, slight cases, are singu- larly lacking in moral control and ability to take care of themselves. Our verdict at the present time is that, as regards the causation of mental defect, syphilis is a sufficient factor in itself, and often has a deciding influence when there is a morbid heredity or other unfavourable factors. * Sir H, Bryan Donkin, M.D., Lancet, March 14, 1914. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 95 PERCENTAGE OF POSITIVE REACTIONS TO THE WASSERMANN TEST OBTAINED BY VARIOUS WORKERS. Thomsen, Boas, Hort, and Leschly 1 . . 1*5 per cent. Dawson 2 ..4-0 Kellner, Clemenz, Bruckner, and Rauten- burg 3 .... . . 7*4 Lippmann (first series) 4 . . . . . . 8-9 Rees Thomas 5 10-0 Lippmann (second series) .. .. 13-2 Atwood 6 .... . . 14*6 Dean 7 . . i5'4 Gordon 8 . . 16*5 Krober 9 21-3 Raviart, Breton, Petit, Gayet, and Cannae 10 3'8 Scholberg and Goodall 11 32-6 Chislett 12 50-0 Fraser and Watson 13 . . . . . . 6oo ,, 1 Thomsen, Boas, Hort, and Leschly, Berliner Klinische Wochenschrift, 1911, Band xlviii., p. 891. 2 Dawson, Journal of Psycho- Asthenics, Faribault, Minne- sota, December, 1912. :{ Kellner, Clemenz, Bruckner, and Rautenburg, Deutsche Medicinische Wochenschrift (Leipzig und Berlin), 1909, p. 1827. 4 Lippmann, Munchener Medicinische Wochenschrift, 1909, Band Ivi., p. 2417. 5 Rees Thomas, Lancet, April 4, 1914. 6 Atwood, Journal of American Medical Association, Chi- cago, vol. lv., p. 464. 7 Dean, Proceedings of the Royal Society of Medicine, Neuro- logical Section, vol. in'., No. 9, July, 1910. 8 Gordon, Lancet, September 20, 1913. 9 Krober, Medicinische Klinik, Vienna, 1911, Band vii., P- I2 39- 10 Raviart, Breton, Petit, Gayet, and Cannae, Revue de Medecim, Paris, 1909, an. xxviii., p. 840. 11 Scholberg and Goodall, Journal of Mental Science, vol. Iviii., No. 237, April, 1911, p. 247. 12 Chislett, Ibid., vol. Ivii., No. 238, July, 1911, p. 499. 13 Fraser and Watson, Ibid., vol. lix., No. 247, October, 1913, p. 640, 96 MENTALLY DEFICIENT CHILDREN A phthisical family history has often been blamed in the past for mental defect; at the present time there is a difference of opinion as to how far tuber- cular disease acts in its causation, some authorities believing that it acts directly, while others regard it rather as a concomitant of degeneracy to be found along with various degrees of amentia in families on the racial down-grade. Thus, Sir James Crichton- Browne, when giving evidence before the Royal Com- mission on the Care and Control of the Feeble- minded, said: " The true connection between tuber- culosis and mental defect is to be found in the fact that they are both apt to fasten on a particular kind of human soil, weakly and little resistant to morbific agents."* While giving due weight to this idea, we are probably justified in concluding with Dr. Tredgoldf that " in the absence of neuropathic in- heritance, consumption and alcoholism, if very strongly marked, may produce mental defect." How far parental intemperance is accountable has given rise to much controversy. In a paper read before the Society for the Study of Inebriety (London) in October, 1908, Dr. PottsJ made a careful review of the evidence as to how far alcoholism in a pre- vious generation was accountable. He cited many authenticated cases where it appeared to be a direct cause, and, in particular, one quoted by the late Dr. * Sir James Crichton-Browne, M.D., Report and Evidence of the Royal Commission on the Care and Control of the Feeble- minded, 1908, vol. i., p. 329. y f A. F. Tredgold, Report and Evidence of the Royal Com- mission on the Care and Control of the Feeble-minded, 1908, vol. i., p. 396. J W. A. Potts, "The Relation of Alcohol to Feeble- mindedness," British Journal of Inebriety, January, 1909. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 97 Andriezen* of a man aged twenty-two, the second child of a family of six. This individual was begotten by his father while in a state of " alcoholic intoxica- tion and exaltation. The child was neurotic, and at twenty-two had to be admitted to an asylum suffering from dementia prcecox. The father, a well-to-do man, had several mistresses, and was the father of several other children. Though given to occasional alcoholic indulgence, he abstained from cohabiting when in a state of intoxication, and his other children, born of his sober moments, were not afflicted mentally or bodily like the patient referred to." Attention was directed in this paper to the important comparative statistics of Dr. Sullivan and others, and especially to the investigation of Dr. MacNicholl in New York. This inquiry, undertaken for the New York Academy of Medicine in 1901, recorded, among other observa- tions, the results of tracing the family histories of 3,711 children through three generations, with great detail in regard to the taking of alcohol. Dividing them into two classes viz., those free from hereditary alcoholic taint and those with that taint it was found that of those free from hereditary alcoholic taint, 96 per cent, were proficient, 4 per cent, were dullards, and 18 per cent, suffered from some neurosis or organic disease. On the other hand, of those with hereditary alcoholic taint, 23 per cent, were proficient, 77 per cent, were dullards (and of these more than one-third were very deficient), and 76 per cent, suf- fered from some neurosis or organic disease. The conclusions drawn at the end of the paper are that " the evidence is not clear that alcoholism by * W. Lloyd Andriezen, " The Problem of Heredity, with Special Reference to the Pre-Embryonic Life/' Journal of Mental Science, January, 1905. 7 98 MENTALLy DEFICIENT itself in the father will produce amentia, but it is quite plain that in combination with other bad factors it is a most unfavourable element, while maternal drinking, and drinking continued through more than one generation, are potent influences in mental degeneracy." In many cases in which alcoholism appears at first sight to be the determining factor, the alcoholism is really a neurosis, and is simply evidence of a morbid heredity. Sometimes, however, excessive drinking is deliberate self-indulgence, the consequences of which may be very serious to the offspring. There is no gainsaying this fact, although Professor Karl Pearson* claims to have proved that alcoholic in- dulgence in the mass has no deteriorating influence on the physique and ability of the following generation ; his statistics and conclusions have, however, been sub- jected to much criticism. The problem is beset with difficulties ; to settle the question finally, we require in statistics very careful investigation as to whether there was any sign of morbid heredity before the drinking began, and, of course, a statement as to whether the drinking preceded the birth of the child. The only comparisons of real value, are between total abstainers and drinkers; any arbitrary division be- tween moderate and excessive drinkers begs the question. Dr. Shuttleworth 'and others have fre- quently pointed out that it is also necessary to go back more than one generation; it is no uncommon experience to find that the child of a heavy drinker shows no abnormality beyond a want of nervous tone * A First Study of the Influence of Parental A Icoholism on the Physique and Ability of the Offspring, by Ethel M. Elderton, with the assistance of Karl Pearson, F.R.S. Eugenic Lab-* oratory Memoirs. London: Dulau and Co., 1910. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS and tendency to eccentricity when he grows up; his eccentricity may take the form of being a rabid tem- perance advocate, but when one of his children ex- hibits mental defect, that does not indicate that tem- perance is no benefit, but rather that the grand- father's indulgence has had far-reaching effects. Dr. Shuttleworth's statistics, published in 1892, showed that a number of cases, almost 30 per cent., are attributed by the parents to maternal ill-health, accident, or shock during gestation. More recent investigations, such as those of Dr. Tredgold and Dr. Goddard, have shown that when a house-to-house visitation is made, and inquiries as regards all mem- bers of the family, there are often in these cases clear evidences of a morbid heredity. We have, however, already cited experiments in both the vegetable and animal kingdoms, and special histories of human beings, which show that it is only reasonable to suppose that these conditions may exact their toll. Dr. Mercier and others, when giving evidence before the Royal Commission on the Care and Control of the Feeble- minded, gave it as their opinion that bad nutrition of the mother during pregnancy, or poisoning by such agents as alcohol and morphia, were sometimes to blame. Sir James Crichton-Browne referred to an idiot he had seen, whose mother during pregnancy had Asiatic cholera. Her children born both before and after this were healthy. Dr. Potts* has recorded a single case of mental defect in the middle of a large family, probably due to the mother sustaining a com- plicated fracture of the arm during pregnancy. He ascertained, however, that the mother was a con- firmed alcoholic, and expressed the opinion that such * " Causation of Mental Defect in Children/' Brit. Med t Journal, October 14, 1905. loo MENTALLY DEFICIENT CHILDREN unfortunate developments only occurred when some other factor was also present. Such was the case in an instance he recorded of feeble-mindedness ascribed by the parents to the father having a severe attack of smallpox some twelve months before the child was born. There is reason to think that severe attacks of malaria and other infectious fevers shortly before conception may have serious effects on the mental capacity of the child. While dealing with this aspect of the subject, we may refer to the possible conse- quences of artificial restriction of families, and also of attempts to procure abortion. Sir James Crichton- Browne, in his evidence to the Royal Commission, said: "One cause productive of idiocy or feeble- mindedness operating during utero-gestation, and deserving of careful attention at this time, is attempts to procure abortion. When that is instrumentally attempted without success, injury may be done to the head of the foetus, and when drugs are used these may disastrously interfere with its nutrition and growth. . . . These attempts at abortion, and also the practices employed to prevent pregnancy, with a view to the restriction of the family, are said by all the physicians who gave evidence before the New South Wales Commission to have a detrimental effect on the nervous system of the woman, pro- ducing hysteria, neurasthenia, and mental disturb- ance, and thus acting unfavourably on the health of any children who may be subsequently born."* Mentally feeble children are often the offspring of highly neurotic parents, sometimes of highly cul- tured persons exceptionally gifted in a particular direction. It would seem, indeed, in some cases that * Report of the Royal Commission on the Feeble-Minded, 1908, vol. i., p 330. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 101 the parents have themselves expended so much of their nervous energy that they have little left to trans- mit to their offspring; familiar instances will occur to everyone of distinguished men and women afflicted with children whose mental endowments are below the average. Bearing in mind the aphorism that " Great wits are sure to madness near allied," and that a neurotic temperament is sometimes associated with intellectual brilliancy, this need not surprise us, though parents usually consider it as extraordinary. Mental feebleness is in some cases merely a consequence of feeble health ; with improved physical conditions the mental impairment may gradually disappear. Among CAUSES ACTING AT BIRTH, that to which most importance attaches is prolonged parturition. It has been alleged by Drs. Winkler, Bollaan, and others, that the use of forceps is accountable for a considerable amount of cerebral injury and conse- quent mental impairment. So far from this being the case, it appears from Shuttleworth's and Fletcher Beach's statistics that protracted pressure without instrumental interference is a more potent cause both of mental and nervous defect, the latter factor figuring more than four times as often as the former (i.e., 14-24 per cent., as compared with 3-31) in their combined etiological table, whilst in addition the occurrence of asphyxia neonatorum is noted in 12-96 per cent, of Dr. Beach's cases. The late Dr.Langdon- Down,* indeed, estimated the frequency of the latter condition at 20 per cent, amongst imbecile children generally, and at 40 per cent, amongst those who * " The Obstetric Aspects of Idiocy/' Trans. Obstet. Society, 1876. loa MENTALLY DEFICIENT CHILDREN were first-born. It is unquestionable that the asphyxia neonatorum so often due to protracted un- assisted labours is in some cases followed by paralysis, and enfeeblement more or less severe of the intellec- tual powers. It probably accounts for some of the milder types of mental feebleness, although some- times the asphyxia is the first indication of mental and physical weakness. Premature birth was noticed as a factor in 3-52 per cent, of the cases recorded by Dr. Shuttle worth. Although insufficient in itself to determine mental defect, this accident may just turn the scale when there are other predisposing influences. CAUSES WHICH COME INTO PLAY AFTER BIRTH are commonly heard of, as parents readily put these forward rather than the praenatal cause of a con- genital defect, which they are loth to recognise, Coasequently such assigned causes as a fall, a fit, or a fright, must be received with caution, and it must be borne in mind that such may be at most the exciting cause, sometimes merely the consequence or coincidence, of a nervous catastrophe to which the child is congenitally predisposed. In the last chapter we referred to the pathology of developmental cases, and under this head many of those produced by causes acting after birth would properly fall. This remark applies especially to the cause most com- monly assigned of all others for mental deficiency in children -viz., Convulsions during teething (eclampsia) which figured in the statistics of the Royal Albert Asylum to the extent of 32-58 per cent, (nearly one-third of the admissions). There is no doubt that infantile convulsions frequently occur without producing any subsequent mental im- pairment ; when it follows it is safe to assume, except ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 103 when inflammatory lesions have been set up, that there has been some inherited brain abnormality. Epilepsy is also a commonly assigned cause. Accord- ing to Dr. Tredgold,* a special examination with regard to convulsions in over 500 mentally defective patients showed that in cases presenting no paralysis or other indication of gross cerebral lesions, and in whom, therefore, the attacks were idiopathic epilepsy, convulsions occurred in 37 per cent. ; whilst in patients presenting signs of gross lesions they occurred in 70 per cent. There are cases in which a previously bright child, afflicted with epilepsy, falls into a state of mental hebetude; but in the majority of cases both the epilepsy and the mental abnormality are con- sequences of inherited nervous instability. Though slight injuries are often set forth as causes when quite inadequate, Traumatism (chiefly in the form of injury to the head) is a bond-fide cause in a number of cases e.g., in 8-25 per cent, of the admissions to the Royal Albert Asylum. Fright or shock (mental) showed as a factor in about 3 per cent, of the cases ; and in such instances as that of a child cruelly locked up in a dark cupboard for several hours, or scared and bitten by a fierce dog, these shocks may be contributing causes. Severe febrile illnesses, such as whooping-cough, scar- latina, measles, and smallpox, were assigned as causes in nearly 10 per cent, of the admissions to the Royal Albert Asylum, and, where meningitis had supervened, probably with truth. It is remarkable that the statistics, both at Lancaster and Darenth, gathered at a time when the worst features of our elemen- tary school system were in vogue, give but little prominence to " over-pressure as a factor, being noted in only 0-16 per cent, of the 2,380 cases, * Mental Deficiency, 1914, p. 22 T. io 4 MENTALLY DEFICIENT CHILDREN DIAGNOSIS. The practical question often arises: How shall we recognise mental abnormality in a young infant ? And the further inquiry may follow Is the mental abnormality primary or secondary? Mothers are proverbially blind to imperfections in their offspring, and in many cases it falls to the medical attendant to point out the painful fact that the poor baby is not " all there." It behoves him, therefore, to be well posted in the diagnostic marks of infantile feeble-mindedness. As regards the question of the earliest age at which mental deficiency can be recognised, we may say that in well-marked cases a diagnosis is possible during the early months of life. If there is great difficulty in getting the baby to suck, and careful examination shows no physical condition in either mother or child to account for this, mental weakness may be sus- pected. It would be confirmed by the child's con- figuration conforming to one of the definite types described in the last chapter, such as the Micro - cephalic or Mongolian. Discrimination must be exercised in deciding that there is an approximation to the type as a whole, and not merely an exhibition of one of its more prominent features, such as an epicanthic fold, which is not very uncommon in normal individuals. On the other hand, we cannot expect to find the transverse furrows on the tongue in an infant mongolian, for they develop later. Cretins have been diagnosed at the third month, but when no definite type is recognised, judgment must be postponed and the progress of development carefully watched. In the slighter cases sometimes no definite opinion can be given till seven years of age, or even a little later. PLATE XII. ANTKRO-FOSTERIOB CIRCUMFERENCE. TRANSVERSE Fig. ?. Fig. 3. COMPARATIVE CRANIAL CONTOURS. Fig. i. Microcephalic Contours. Fig. 2. "Mongolian" Contours. Fig. 3. Hydrocephalic Contours. To face page 105* ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 105 The DIAGNOSTIC marks of infantile mental defect may be grouped under four heads -viz. : 1. Cranial Abnormalities. 2. Formative and Developmental Defects. 3. Abnormality of Nervous Action. 4. Defects in Nutrition. i. Cranial Abnormalities. The most significant is, of course, Microcephalus. As previously stated, not only deficient size, but also a characteristic form of F IG- 2 . MlCROCEPHALIC IDIOT, AGED 2O. (From Journal of Psycho- Asthenias.) head, is indicative of this abnormality (see p. 59, ante). Taking the average head circumference at nine months as 17 inches, and at twelve months as 18 inches, any notable deficiency in head measure- ment in a child otherwise of normal size may be taken to suggest microcephalus. The typical form, which confirms the diagnosis, comprises a narrow, rapidly receding forehead, a flat occiput, and a pointed vertex, thus exhibiting two marked angles, at the centre of 106 MENTALLY DEFICIENT CHILDREN the face and the top of the head. We have seen typical microcephalic adults whose head circumfer- ence exceeded 20 inches, and Dr. Tredgold* refers to one whose measurement was 21 inches. The palate is high and narrow ; in form, like a V or a Gothic arch. Such abnormality of palate, though more frequent in mentally defective children, is, however, by no means a definite indication in these days of teats and feeding- bottles. Intra-uterine Hydrocephalus generally gives rise to a difficult labour, and the cranial abnormality in the child is not likely to escape notice. The head is globular, and the greatest enlargement is in the cir- cumference at the level of the temples, giving the typical top-heavy appearance; there is some bulging at the fontanelles and along the sutures. Though the diagnosis is usually self-evident, there are cases without marked enlargement of the head; in such cases the diagnosis is based on periodic attacks of headache and vomiting associated with physical signs dependent on an increase of pressure. Hypertrophic cases, although less striking, attract attention in much the same way. A diagnosis from Hydrocephalus can be made by noticing that the skull looks square rather than round, and that the increase in size is most marked just above the super- ciliary ridges instead of at the temples, while there is no bulging of the fontanelles or sutures. The enlarge- ment is more even and general than in rickets, which is the commonest cause of a large head; in doubtful cases careful examination of other parts of the body should establish a diagnosis, and prevent any con- fusion with cretinism, achondroplasia, cleido-cranial dysostosis, or congenital syphilis. Bossy enlarge- * A. F. Tredgold, Mental Deficiency, 1914, p. 207, ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 107 ments of the skull are characteristic of the two latter, but are also found in rickets, which may be associated with hypertrophic cases. In hypertrophy the circum- ference is less than in hydrocephaly, there being no record of one over 25 inches. For purposes of com- parison, it is useful to remember that the average circumference of the normal head at five years of age is 20 to 2O-J- inches, and at ten 21 inches, while in the female adult it is 21 J inches, and in the male adult 22 inches. Oxycephaly, with its great increase in the vertical measurement of the cranium, and the shallow furrows above the temples, can scarcely be mistaken, nor can Scaphocephaly. The configuration of the head in both these conditions has been fully described in the last chapter (see pp. 63, 73 and 74, also Plates VII. and X., and Fig. 3, p. 108). The so-called " Mongol " type leaves its impress not only on the physiognomy, but on the form of the head, as has already been described; and there should be no difficulty in recognising it even in early life. The brachycephalic skull, and the " almond-shaped," obliquely set palpebral fissures, are quite character- istic; the other physical features will be described a little later, and also the differential diagnosis from Cretinism, to which it often bears a superficial re- semblance. Marked asymmetry of the skull is met with in HEMIPLEGIC cases; other distortions sometimes occur, especially after a difficult labour. Occasionally in- juries from forceps leave a permanent mark, but in our experience these are not more common with defective than with normal children. Asymmetry must not be taken as of itself a sign of mental defect; indeed, in adult life it is said to be a mark of culture. io8 MENTALLY DEFICIENT CHILDREN Prolonged (dolichocephalic) crania with a median longitudinal ridge, especially over the sagittal suture, are met with both in normal and abnormal children, and consequently the scaphocephalic form cannot be called diagnostic. But the persistence of a medio- frontal suture, or the existence of a medio-frontal ridge towards which a narrow forehead tapers, may be accepted as signs of imperfect development of the frontal lobes. FIG. 3. ANTERO-POSTERIOR AND CIRCUMFERENTIAL CONTOURS OF SCAPHOCEPHALIC CRANIUM. In cases where there is any possibility of an injury at birth or later, the X rays may give much assistance in the diagnosis. For instance, in a case seen recently by Dr. Shuttleworth, a skiagram showed thinning of the bone near vertex, with a shadow below, probably due to an organised clot.* There had been a definite injury at birth. 2. Formative and Developmental Defects. As signs of imperfection of physical development are often as- sociated with mental defect, we should look for such abnormalities of formation as hare-lip; delayed or irregular dentition; cleft, high, and misshapen palates; * See Plates XIII. and XIII (A). PLATE XIII.- 1 1 mEm m I DEDUCED FROM SKIAGRAM (BY DR. N. S. FlNZl) OF CHILD THREE YEARS OLD SUFFERING FROM EPILEPSY. ANTERIOR VlEW OF HEAD. (Arrow indicates irregularity of cranial contour.) ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 109 small, rudimentary, or misshapen auricles, sometimes set too far back, or at different levels on the two sides, or outstanding; supernumerary auricles represented by tags of projecting skin; epicanthic folds extending across the caruncle ; opacity of ocular media; coloboma iridis ; nose unusually indented at bridge or depressed ; nostrils looking forward, or shaved off at the sides; hairy growths or moles on forehead or face; naevi; rough and scaly condition of skin; imperfections of nails; general blueness of face, lips, etc., from cardiac malformation; blueness and coldness of hands and feet. None of these stigmata of physical failure neces- sarily imply mental deficiency, but their occurrence will lead, especially if several be observed, to suspicion on the subject.* 3. Abnormality of Nervous Action. Spontaneous muscular activity, though with movements minute in character (the " microkinesis " of Dr. F. Warner), incessant during waking hours, is the characteristic of healthy infant life. If these movements be absent or excessive, we may reasonably suspect something wrong with the nervous system, and predicate mental irregularities. In the former case we shall find a dull, vacant expression, sometimes associated with imperfect reflexes, so that even the function of sucking is not properly accomplished. In the latter there is over-mobility, perhaps nystagmus, and twitching movements of the muscles of the face. A general tremor is also sometimes met with. As indications of mental deficiency, we must, of course, be guided by the extent of the departure from the normal in one direction or the other. As the age of the child increases, we must carefully watch the evolution of its senses, and note deficiencies of touch, See Plate I., facing p. 12. no MENTALLY DEFICIENT CHILDREN sight, hearing, etc. At a later stage, the absence of attempts at speech, when the hearing is not affected, will be of much value as a diagnostic sign. So also will be lack of muscular co-ordination and consequent inability to walk, independent of paralytic affection. 4. Defects in Nutrition. The emaciated, wizened features of the slum baby, so often seen in the children's wards of East-End hospitals, furnish an extreme example of these defects. These may arise from injudicious feeding; but there is undoubtedly a congenital state of malnutrition, evidenced, for instance, in cases of inherited syphilis. Persistent defects of nutrition, in spite of good feeding, are symptomatic of defect of original constitution, and are not infrequently associated with mental deficiency. This fact was remarked by Dr. Warner in his inspec- tion of Poor Law Schools, where, notwithstanding good feeding, the tendency to low nutrition was in greater ratio than with ordinary school children. To sum up, we shall find aid in diagnosing the PRIMARY character of mental deficiency by noting abnormalities in the form and shape of head, and the condition of the cranial sutures; by looking for the physical stigmata, if not of degeneration, at any rate of arrested development; and by seeing signs of abnormal nervous action and a constitutional ten- dency to imperfect nutrition. The occurrence of asphyxia neonatorum, the absence of a healthy cry, defect of reflex action and of grasping power, im- perfect reaction to light and sound, absence or excess of spontaneous movement, and (as time goes on) inability to notice objects or to fix the attention, with tardiness of attempts at speech and at walking, are some of the symptoms marking the child as- different from other children. As a definite guide we &fiOLO'Gy. DIAGNOSIS, AND PROGNOSIS ni may state the time at which certain functions develop in a normal child; there are, however, great varia- tions even in healthy children, so that considerable latitude must be allowed. Touch, taste, and probably smell, are more or less developed at birth, at which time the infant should present a developed voice, and cry vigorously. The power of hearing is soon established; the eyes are sensitive to light from the first, but there is a lack of power to interpret the images received. By the fifth or sixth week ob- jects are followed by the eye, and at the same time the child, whose features have previously been more or less passive, begins to smile. From two to three months is the time at which it can sustain its head without assistance, but this is done in a vacillating way till the fourth or fifth month. By the sixth month it can sit up with ease, and accomplish many movements with its arms, hands, and fingers, and enjoy playthings. Between the seventh and ninth months it may be put on the floor alone, and can amuse itself. When from ten to twelve months old, it begins to crawl, and is generally able to walk at some time between the twelfth and sixteenth months. When twelve months old, the child begins to enunciate single words, and when eighteen months or two years learns to form short sentences. In SECONDARY AMENTIA there is a history of normal development till the occurrence of a definite injury or disease followed by deterioration. Tests of Intelligence. Having explained the dia- gnosis as far as it can be based on anatomical and physical grounds, or abnormality of nervous action, it will be useful to indicate how the intelligence may be tested both in older children and adults. In the first place, the personal history and information as to ii2 MENTALLY DEFICIENT CHILDREN habits and conduct must be obtained from parents or others in charge of the patient, knowledge as to which is, indeed, essential before certificates can be made out under the Mental Deficiency Act.* No better illustrations of the kind of facts required can be given than by quoting extracts from the " Facts communicated by Others " in the medical certificates of cases already dealt with under the Act. Among others we have the/ following statements: " Has always been dull and backward," " Has never been like other children," " Has never grown up/' " Can do no useful work," " Never works except under supervision," " Loses his way," " Cannot take care of himself," " Cannot go any errands," " Cannot be trusted with money," " Has never been able to earn anything," " Cannot keep a situation," " Abnormally passionate," " Extraordinarily obstinate," " Open to any suggestion," " Will never wash himself," " Has no memory." The Birmingham After-Care (Special Schools) Committee found that, among the high- grade feeble-minded who were able to get work after leaving school, mental defect often made itself plain by a constant change of situation (seven or eight in a year), and inability to ever earn a living wage. As regards the observations at the time, it may be said that there is no examination and no set of tests which provide an absolute standard; the opinion of an expert after a few minutes' conversation is of much greater value than the records of a series of tests conducted by a tyro, who judges by their result only. Sometimes numerous scars of cuts and burns will be seen, suggestive of the patient's inability to take care of himself. In others the slovenly dress and torn clothes give a useful clue. The manner of * Form of certificate will be found in Appendix E. p. 264. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 113 the patient is of the utmost importance. How does he enter the room ? How does he meet a stranger ? Gait and carriage must be carefully observed. How does he conduct himself during the examination ? Does he take an intelligent interest, or is he quite in- different ? What is his capacity for attention and concentration ? If he cannot read or write, or tell the time, or perform simple calculations, in spite of training, the diagnosis is usually clear. If he has such elementary knowledge, he may still fail in very simple tests. Of course, in all of these allowance must be made for age, and also for any lack of educa- tion. Here, again, we can give our readers no more practical assistance than by quoting from actual certificates for detention. " Does not know the date/' " Does not know when Christmas Day is," " Does not know when his birthday is," " Does not know how long he has been in this institution/' " Told me that a penny was a halfpenny, and a shil- ling a threepenny bit/' " Says a horse has two legs," " Does not know which is his right hand," " Told me that a horse has feathers on its head," " Does not see any necessity for earning his own living," " Does not know how many brothers he has," " Cannot say what he had for dinner," " Cannot describe how he came here," " Says the word insensible means ' Are you sens- ible ? ' ' ' ' Says the opposite of ugly is ' Are you ugly ? ' ' Special tests, sometimes useful, are on the follow- ing lines: 1. Turn patient's coat-sleeves inside out, and tell him to put it on. 2. Give him a knotted cord to untie. 3. Give him a match to strike. 4. Saying which feature is missing in an imperfectly drawn human figure. H4 MENTALLY DEFICIENT CHILDREN 5. Crossing-out test (letters or groups of different numbers of dots). 6. Distinguishing the ugly from the beautiful in pairs of face illustrations. 7. Tell him to repeat as many words (names of objects, etc.) as he can in three minutes (a child of eleven should be able to give at least sixty; an adult ought to give nearly sixty per minute) . The most important point often is, not whether the correct solution is obtained, but how the prob- lem is approached and carried out. The interpreta- tion of pictures is a valuable form of test. SECONDARY cases are differentiated by the absence of signs of original defect: by a history of a normal condition in infancy until the occurrence of some serious accident, illness, or shock, which was fol- lowed by mental enfeeblement. Caution is necessary in accepting the statements of parents on these matters, and it must be remembered that a certain number of cases, not obviously suffering from con- genital defect, are born with brains so unstable as to be unable to withstand the stress of life, and these may break down at a crisis of child development, or after a comparatively slight injury which would leave a normal child unharmed. Before discussing any special types, a few general remarks on PROGNOSIS will be useful. This is an aspect of the subject to which parents and guardians not unnaturally attach the greatest importance. First we may remark, with regard to the broad division into primary and secondary cases, that the prognosis in the former is, as a rule contrary to the popular idea on the subject better than in the latter. The fact is that in the one there is merely defective development, and this, under favourable ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 115 circumstances, may be fostered and promoted; in the other there is actual lesion of brain tissue, more or less irremediable. Superficial appearances are in favour of secondary cases, for the others are often handicapped by ill-formed and sometimes repulsive features; yet our experience is quite in accord with that of the late J. Langdon-Down,* that " the prog- nosis is, contrary to what is so often thought, in- versely as the child is comely, fair to look upon, and winsome." There are, however, a few cases of mild traumatism, and even of post-inflammatory lesion, in which a more cheerful view may be taken, especi- ally in these days of brilliant brain surgery. In primary cases Dr. Lapage has shown that the greater the mental deficiency the later is the child in learning to walk and talk, as a rule. The age, therefore, at which these accomplishments were acquired are facts of considerable importance in prognosis. A comparison with the facts of the development of infants we have just given (p. in) will often be useful. In the first instance the PROGNOSIS must be guarded ; as shown in our concluding chapter, the number of defectives who are capable of holding their own in the world is limited, while the number who find their way into institutions is large. When working at Stoke-upon-Trent for the Royal Commission on the Care and Control of the Feeble-minded, Dr. Potts showed that the highest grade of the feeble-minded can sometimes work, and keep themselves for a time, yet drift into the workhouse at an early age. Half of all the cases were in the workhouse by the time they were thirty. Some have to be placed in lunatic asylums; the last annual report of the Birmingham. * Obstet. Trans., vol. xviii. n6 MENTALLY DEFICIENT CHILDREN After-Care Committee, published in June, 1915, shows that nearly 10 per cent, of their cases have met with this fate. It is important to look for any signs of dementia praecox, which affects more particularly the higher grades. The condition often develops soon after puberty; first will be noticed failure to improve; later peripheral anaesthesia, exaggerated tendon reflexes, and signs of negativism or other disorder of action characteristic of some forms of dementia prsecox, settle the case. Periodical testing by the Binet-Simon scale often helps; the child who improves year by year may achieve something after leaving school; the child who fails to advance after eleven or twelve never will. Further hints on prognosis will be given under the special types. Special defects such as word-deafness and word- blindness are not recognised till the child is of school age ; these conditions have been fully discussed in the last chapter, and only require to be mentioned here. Passing now to some of the typical groups, let us first take the small heads, those with greater or less degree of Microeephalus. The theories that this is an atavistic variation or the result of premature synostosis have both been disproved ; the small skull is simply the envelope of the brain of which the normal development has been arrested, probably about the fifth month of gestation. " Microcephalies usually come of a pronounced neuropathic stock, their brothers and sisters are often typical degenerates, and frequently one or more of them suffer from the same condition/'* The diagnosis, as has been explained in the last chapter, and also under the heading of Cranial Abnormalities, depends not only on diminu- * A. F. Tredgold, Mental Deficiency, p. 175. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 117 tive size, but also on a characteristic shape of the head. The prognosis may be said to be, generally speaking, favourable or otherwise, in proportion to the size of the head. With heads under 18 inches in circumference the manifestation of mental power is usually so small as to come under the category of idiocy; between 18 and 19 inches the cases may be designated as imbecile; and from 19 to 20 inches is not an uncommon measurement in cases of mere " feeble-mindedness." There is hope of improvement under training, especially for the higher grades of this type. Dr. Shuttleworth had under training for four years a mentally feeble boy whose head circum- ference increased during that time from 19 to 2oJ inches. As the sensorial and muscular powers are usually good in microcephalic cases, the powers of sucking, grasping, etc., are not impaired, while the best of them may be taught industrial work. We have known a girl with a head of 18 inches employed as an assistant dormitory maid, and a boy with a head of 19 inches helping intelligently in a bake- house. The physical health of microcephalic children is usually not amiss, and under favourable circum- stances they may live to adult, and even advanced, years. Some simple occupation, not requiring head- work, is their role, the mental being limited by the cranial capacity. But, as old Fuller quaintly puts it, though " heads are sometimes so little that there is no room for wit, they are sometimes so long that there is no wit for so much room/' We have already remarked that long heads do not at all necessarily go with mental deficiency sometimes the reverse; if Fuller had written large heads instead of long, it would have been more in accord with our experience. We refer, n8 MENTALLY DEFICIENT CHILDREN of course, to the Hydrocephalie type.* In hydro- cephalus the degree of mental defect varies greatly, and is not proportionate to the deformity. The prognosis is usually bad, but much depends on the cause and age at which it occurs, and whether the condition is stationary or slowly progressive. To determine the cause, an examination of the fluid with- drawn by lumbar puncture may be useful; this is often also the best form of treatment. The distinc- tions previously indicated differentiate this type from that of the Hypertrophic heads occasionally met with. Hypertrophic change is sometimes asso- ciated with rickets. In many hypertrophic cases there is considerable muscular weakness, even when the bodily health is fairly good ; manual work in con- sequence is done with difficulty, and the speech may also be affected. There is often complaint of headache ; sometimes encephalitis and acute mania supervene. Epilepsy is often a complication; sometimes the fits gradually subside, sometimes they get steadily worse, and may be the cause of death. The prognosis of hypertrophy of brain is consequently unfavourable, whereas in hydrocephalus, after the acute symptoms have subsided, the prospects of improvement under judicious training are considerable. Cases of Oxycephaly,f or, as it is better called, " Tower skull," are readily recognised by the large proptosed eyes, absence of supra-orbital ridges, and the dome-shaped mound rising up from the forehead and separated from the temples by shallow furrows. This rare condition has been fully described in the preceding chapter (p. 73). The chief characteristic of cases Primarily Neurotic * See Plate V. (opposite p. 61). f See Plate X. (opposite p. 73). PLATE XIV. FIG. i. " MONGOL " PROFILE. FIG. 2. " MONGOL " TONGUE. MONGOLIAN TYPR ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 119 is the impression they give of weakness, mental and physical; there is little power of attention. Asked to look at a fixed object held up in front of them, the eyes will quickly wander. Children of this typ'j are slackness personified. If told to extend the arms in front, their response is feeble; the arms are not straight nor raised to the shoulder-level. Warner's " weak hand balance " is noticed. c ' The wrist droops, the bones of the palm of the hand are some- what folded together, while the thumb drops and all the fingers are slightly bent." Often the right hand is kept at a lower level than the left. The " prow- shaped skull " sometimes associated with this con- dition has been fully described in the last chapter. This type is not infrequently blended with others. Cases of this class always do better when withdrawn from home influences, which are prejudicial (the common neurotic taint of parent and child often interacting injuriously). Placed under judicious management in healthy surroundings, much good may be done by suitable drill and manual exercises in overcoming the twitchings and nervous movements common in these cases. It must be remembered that such individuals are weak all through, and that self-control is with difficulty established and maintained. There is a special danger of their be- coming inebriate, if not carefully guarded. Slight cases of this group are not uncommon, and are often a source of continual anxiety and distress to their relatives and friends. With regard to the so-called " Mongol " type,* the form of the head, the almond-shaped eyes, obliquely set, the epicanthic folds, and the squat nose, are quite characteristic. The hands are usually broad, * See Plates XIV., XV. (opposite pp. 119, 120). 120 MENTALLY DEFICIENT CHILDREN and the fingers short, the little finger often being curved inwards. The feet also are characteristically clumsy, with a marked cleft between the big and second toes. Laxity of the joints is a marked feature. The skin is usually coarse in epidermis, if \not furfuraceous ; many have sore eyelids, some fissured lips; the hair is usually wiry. One of the most striking peculiarities is the state of the tongue, which is transversely fissured and has hypertrophied papillae.* Dr. John Thomson^ states that in the early weeks of life the tongue is normal; between the third and ninth months the papillae get enlarged, while during the third and fourth years the trans- verse fissures appear. This latter peculiarity is possibly due to tongue-sucking, which is so common in this type of defective, acting on an abnormally vulnerable mucous membrane. The mental condition of defectives of this type is almost as characteristic as the physical ; the powers possessed by such children of mimicry are often extraordinary; their love of music great; their idea of time as well as tune remarkable, so that they are apt at drill and dancing. In some ways, therefore, they are full of promise, but they seldom accomplish much, and the ultimate outlook, both on the mental and physical sides, is unsatisfactory. Something may, however, be expected from a favourable en- vironment, and cases are to be seen, sheltered in institutions, of mongolians over forty years of age. In adult life there is still peculiarity of appearance, but the physical characteristics of the type tend to be less marked as age advances. Varied gradations are * See Plate XIV., Fig. 2, p. 119. f John Thomson, " Notes on the Peculiarities of the in Mongolism," Brit. Med. Journ., May 4, 1907. PLATE XV. FIG. i. FIG. 2. " MONGOL " HANDS. To face page 120. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 121 met with, from the mentally feeble child with the slight " mongol " taint, to the idiot whose obliquely- set almond-shaped eyes are very suggestive of the " heathen Chinee/' Amongst the higher grades fairly satisfactory results of mental training are sometimes obtained. Indeed, we know youths of the mildly " mongol " type who, after appropriate education, pas's muster with their brothers and sisters. Simple imitative arts, such as writing and drawing, are acquired without much difficulty, but the coarsely convoluted brain is unequal to higher intellectual operations, and calculation is a stumbling-block. Simple industrial occupation, such as that of the garden and farm, may be followed, but the clumsy, ill-formed fingers militate against success in mechan- ical work requiring fine adjustment. From the physical side the prognosis is not good. They are generally delicate and very susceptible to cold, being apt to suffer much from chilblains. They are prone, moreover, to mucous catarrhs of the digestive and respiratory tracts, and the majority die of phthisis before arriving at maturity. Many of these cases suffer from cataract, probably of a progressive nature, for it is not observed before nine years of age. Dr. A. W. Ormond* found opacities of the lens in nine- teen of a series of twenty-eight cases. They are liable also to congenital heart disease, and some die young from this cause. On post-mortem examina- tion in such a case, the foramen ovale is usually patent, and there may be in addition some defect in the interventricular septum, as described by Dr. Guthrie in the discussion on Dr. Archibald Garrod's communication to the Clinical Society, f Cases with * A. W. Ormond, Brit. Med. Journ., November 18, 1911. f See Brit. Med. Journ., October 22, 1898, p. 1255. 122 MENTALLY DEFICIENT CHILDREN this defect are not often seen in institutions, as they usually die before the age for admission. We have suggested in the past that they are essen- tially unfinished children, and that their peculiar appearance is really that of a phase of foetal life. Dr. John Thomson* has, however, improved upon our description by the use of the term " ill-finished," pointing out that, although something goes wrong in their growth in very early intra-uterine Hfe, probably in the second month, yet their later development goes on continuously, though badly. Some defect of formative force may usually be traced in connection with the intra-uterine life of these cases, not uncom- monly ill-health or mental depression of the mother; and it is remarkable that nearly half of these children are the last born of a long family, when the procreative powers are at a low ebb. Dr. G. A. Sutherland! nas concluded that mon-v golism is probably parasyphilis, because he- found syphilis in eleven of his series of twenty-five cases, and strongly suspected it in three others. We have, however, already pointed out that the claim that syphilis is responsible for a large percentage of cases of mental defect is far from established as yet. Like Dr. Tredgold, { we have seen many cases of mongolism in which syphilis was not even to be thought of. As evidence in favour of this, we can state that, when Dr. Gordon subjected eight cases to the Wasser- mann reaction, not one gave a positive result. * John Thomson, in Diseases of Children, edited by Garrod, Batten, and Thursfield, p. 882. f G. A. Sutherland, " Mongolian Imbecility in Infants," Practitioner, December, 1899. J A. F. Tredgold, Mental Deficiency, second edition, p. 213. J. L. Gordon, Lancet, September 20, 1913. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 123 We have already pointed out that mongolians are not instances of hereditary mental defect; they are frequently, however, found in families with a neurotic taint. With regard to Eclampsic cases (the history of which will help us to a diagnosis), the prognosis varies with the severity of the consequences of the fits. A certain number of fits of doubtful origin in infancy, even when they recur frequently, leave no permanent bad effect, although for a time after they have ceased the child is dull and apathetic. Nor does any serious result follow the so-called " rickety fits/' often asso- ciated with tetany and laryngismus stridulus. Still, the prognosis must always be guarded, as, according to Dr. Leonard Guthrie, " about 10 per cent, of infants who suffer from convulsions become epileptic in after-life."* The possibility of the case being one of Tuberous Sclerosis must be kept in mind ; a diagnosis can only be made when there is a palpable renal tumour or peculiar cells in the urine, or the condition of adenoma sebaceum can be seen. In tuberous sclerosis the prognosis is always bad, death taking place in child- hood or early adult life. As regards Epileptic cases, Dr. W. Aldren Turnerf has shown that mental impairment is more likely to be present when there is an hereditary neuropathic tendency. His records from the Chalfont St: Peter colony also show that, while some epileptics show no mental enfeeblement after thirty years or more, the majority, as time goes on, develop a bad memory or more serious sign of failure, 29-1 per cent, becoming * Diseases of Children, edited by Garrod, Batten, and Thursfield, 1913, p. 710. | Epilepsy, Aldren Turner, 1907. I2 4 MENTALLY DEFICIENT CHILDREN actually demented. Where epilepsy is associated with the lower grades of idiocy, the probability of organic lesions renders the prognosis specially un- promising. In milder cases of mental enfeeblement associated with epilepsy, the successful treatment of the epilepsy is followed by considerable mental im- provement, and should the cessation of fits be per- manent, the mental deficiency may gradually dis- appear. Epileptic children must be educated according to their individual mental capacity. Dr. Shuttleworth found that of the 470 epileptic children in London submitted to him by the educational officers for examination and report (1) 17 per cent, were cases of mild epilepsy, with no obvious mental impairment, and were suitable to continue in the ordinary schools. (2) 27-5 per cent, showed some degree of mental impairment, and were preferably educated in special classes, as, owing to their defective memory and the lesser degrees of mental deficiency, they were un- suited to compete with normal children. (3) 40 per cent, were capable of being educated along special lines, but, owing to the frequency and severity of the seizures, additional supervision was necessary. This group was suitable for education in residential schools or colonies. (4) 15-5 per cent, were epileptic imbeciles or dements, and were incapable of education. These required care in an idiot asylum. According to Dr. W. A. Turner, a " cure of epilepsy may be defined as arrest of the seizures for a period of eight or nine years, when it will be found that from 10 to 12 per cent, of cures may be expected." Jn the last chapter we have described the important ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 125 group of cases associated with some abnormality of the Sella Turcica, in which pituitary extract may be given with beneficial results. Syphilitic cases* can be distinguished by the history and signs of inherited syphilis. As we have already pointed out, the taint is undoubtedly a factor in many cases of mental deficiency where its external manifestations are not obvious; in some of these careful examination of the rest of the family may give an important clue, while the Wassermann reaction, as explained when discussing etiology, is a useful but not infallible guide. Degenerative changes due to this cause may, indeed, manifest themselves early in life, and give rise to cranial osteitis, meningeal inflammations, and eclampsic, epileptic and paralytic symptoms, so often associated with mental defect in children, and frequently assigned as its cause, though more correctly to be regarded as links in the chain of causation. While discussing cases associated with paralysis, we referred to the important work both Dr. Plaut and Dr. Gordon had done in establishing the close relationship of syphilis with cases of mental defect associated with motor paralysis. The most characteristic type of mental degeneration in the young associated with hereditary syphilis is that designated by Dr. Clouston in 1877 " juvenile general paralysis " (or by Dr. Judson Bury as " juvenile dementia "), in which a breakdown (mental and physical) occurs at the period of second dentition or advent of puberty, leading to a fatal issue in a few years. The first sign of mental weakness is the loss of the most recently acquired accomplishments e.g., writing or arithmetic. The hesitating, indistinct * See paper by G. E. Shuttleworth. British Journal of Chil- dren's Diseases, April, 1908. 126 MENTALLY DEFICIENT CHILDREN articulation and Argyll-Robertson pupil which develop a little later, together with the general feebleness of the limbs, leave no doubt as to the diagnosis. Such cases are found not to be so rare in asylums as was formerly thought, and Dr. Mott has tabulated the histories of twenty-two in volume i. of the Archives of Neurology. It would appear from this table, as well as from a paper in the Practitioner, January, 1908 in which an aggregate of forty cases are dealt with by the same author, that in at least 80 per cent, of these cases there was evidence either of a syphilitic family history or of the presence of syphilitic stigmata (in several instances, of both), .and he states his opinion that, " though there may be many exciting causes, the predisposing cause of this disease (juvenile general paralysis) is nearly always hereditary syphilis," thus agreeing with the conclusions of Thiry, Alzheimer, Mendel, and other Continental pathologists, that inherited syphilis plays a predominant role in its etiology. In our experience, syphilitic cases do not respond much to education. Even if they survive the second dentition and puberty without changing for the worse, they do not as a rule improve in any way. In cases of mental deficiency associated with Paralysis,* the history of the case, and the occurrence of convulsions during the first few days after birth, distinguish the form due to injury at birth from that associated with paralysis developing later on as a result of some toxic condition or defective vital en- durance, or a vascular lesion. In the latter there is generally a history of convulsions later in infancy, with power suddenly lost on one side; when the paralysis begins to improve, spastic contractures are * See Plate IX. (opposite p. 72). WOOD-CARVING, DESIGNED AND EXECUTED BY J. B., ROYAL ALBERT ASYLUM. To fa.cc 6ae l*7 ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 127 left, and there is the characteristic hemiplegic gait. In the first class of cases,, which used to be spoken of as birth-palsy, the mental deficiency is often more apparent than real, and the patients improve wonder- fully under appropriate training. The paralysis may be either hemiplegic or diplegic, the latter being the more common ; the amentia is less in the former than in the latter. The athetotic movements sometimes disqualifying them from ordinary use of the hands may be overcome by suitable finger exercises (such as will be hereafter described) ; as considerable power of will exists, the patient will often be able to co- operate with the doctor in trying to combat his infirmities. We have repeatedly seen children of this type, at first unable to hold a pencil, develop into admirable draughtsmen; indeed, the graphic faculty frequently seems to be good in these cases. Intricate macrame patterns have also been worked out*by them, and delicate wood-carving done. Dr. Shuttleworth once had under his care a patient of this type, J. B., who at twelve years of age could not read or write, and could do nothing beyond washing and dressing himself, which he accomplished with difficulty, owing to athetosis. Two years later he was able to read, write, and draw a little, and could make simple articles in the joiners' shop. After ten years' training he was an excellent joiner, and gained prizes for wood-carving in Arts and Crafts Exhibitions. Five years later he had become the instructor in wood-carving. A recent report states that " he is able to explain his methods; is an accu- rate and artistic wood-carver himself ; makes his own designs for panels/'* It must be remembered, however, that many cases of cerebral diplegia in * See Plate XV i. 128 MENTALLY DEFICIENT CHILDREN infants die either from inanition or some intercurrent disease. Various grades of mental defect from simple feeble- ness to crass idiocy are associated with paralysis de- veloped after birth, and the prognosis varies with the degree; the prognosis is, however, worse than in the cases due to injury at birth. In those cases speech is often bad, and this fact may be misleading. It must be remembered that they have considerable will-power, and will persevere to overcome their defects. Attention must be directed mainly to the physical side, muscular atrophies and contractions being subjected to electrical treatment and massage; in the milder cases considerable improvement, both physical and mental, may be anticipated. The postnatal cases are particularly liable to epilepsy; should this develop, the prognosis is bad. There are undoubtedly cases of cerebral paralysis in children with no intellectual weakness, but they are rare. Whatever the parents may think, we usually find a degree of mental irritability, or a ten- dency to epileptic fits, or emotional weakness, or some other slight mental peculiarity. When discussing etiology, we referred to the fre- quent association of syphilis with plegic cases of mental defect, which has been suggested by the results obtained with the Wassermann reaction both by Dr. Plaut and Dr. Gordon. Dr. Gordon,* after exam- ining 400 cases of congenital mental deficiency, of which 105 were plegic and 295 non-plegic, found the percentage of positive reactions to the Wassermann test in plegic cases almost treble the percentage in non-plegic cases viz., 31-4 in the plegic as com- * J. Leslie Gordon, M.D., " The Incidence of Inherited Syphilis in Congenital Mental Deficiency," Lancet, September 20, 1913. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 129 pared with 11-2 in the others. As regards the par- 1 ticular types of paralysis, excluding juvenile general paralysis of the insane, in which, as might be expected, i every case gave a positive result, Dr. Gordon obtained i positive results in chorea and paralysis in every case, in ocular cases in 50-0 per cent., in diplegia in 48-3 per cent., in paraplegia in 20-4 per cent., and in hemi- plegia in 13-6 per cent. In the diagnosis of Traumatic cases the history of a fall or injury to the head must be accepted with dis- crimination; but falls from careless nurses' arms, from an overturned perambulator, down stone steps, and severe blows on the head, are not improbable causes. The presence of external swelling or haemorrhage, or the occurrence of fits soon after the accident, will be confirmatory evidence. Sometimes careful exam- ination with the X rays will reveal some localized thickening of the bone or membranes. The prognosis varies with the severity of the injuries and their con- sequences ; the influence of an hereditary tendency to nervous disease may be an important factor. We have seen mild traumatic imbecility entirely recovered from in the process of growth and development ; the resources of modern cranial surgery make the prog- nosis more favourable than formerly. Of the cases in which the stigmata of Tubercle are strongly marked, we may say that the prognosis varies with the intensity of the taint. Much depends upon favourable environment, and it is remarkable how such cases improve, both mentally and physi- cally, when withdrawn from insanitary slums and placed under good hygienic conditions, especially when employed in outdoor work in pure country air. Post-febrile or Inflammatory cases are also diag- nosed by the history, and the absence of congenital 130 MENTALLY DEFICIENT CHILDREN defect. Here, again, a radiograph may help. Speak- ing generally, the prognosis is not favourable in these cases, though, of course, it depends upon the amount of damage the brain has sustained and the degree of atrophy consequent on meningeal thickening. In some cases irremediable lesions are left; in others the arrest of development from failing nutrition may, tinder favourable circumstances, be averted. In this group should be included the cases that occur after Polioencephalo-myelitis (infantile paralysis). Of Emotional cases, caused by shock and fright, there are many degrees. The history usually serves for their recognition, while the absence of the features of congenital abnormality, with persistent nervous- ness, and sometimes a peculiar scared expression, will help in the diagnosis. Much good may be done by placing such a patient in a favourable environ- ment with suitable training, and so gradually giving him confidence in himself; we have known children who have been victims of shock become, after special education, fairly useful members of society. Exposed to the rugged ways of public schools, where they may be jeered and scoffed at, there is considerable risk of mental deterioration. Toxic cases are recognised by signs of failure in a child, previously normal, who has been dosed with alcohol or opium. The possibility of the presence of these and other powerful drugs in patent medicines must not be overlooked. The lesions are of an atrophic character; good results will follow with- drawal of the poisons, and the substitution of nourishment appropriate to the child's age. In the last chapter we gave a full account of the pathology of the family type of infantile cerebral degeneration designated Amaurotic Idiocy. Here we ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 131 need only say that the diagnosis depends on the onset during the fourth month, or thereabout, of weakness of the muscles and back in a previously healthy Jewish infant, with difficulty of vision. The ophthalmoscope reveals changes in the macula lutea, whi^e later there is optic atrophy and total amaurosis. As the disease progresses, the child is unable to sit up. All the muscles become weak. At a later stage there is muscular atrophy and emaciation. The senses of hearing and taste are preserved, and the thoracic and abdominal viscera remain healthy. The prog- nosis is at present hopeless, the patients always suc- cumbing within two years, and often much sooner. The condition occurring in older children, known as Cerebral Degeneration with Symmetrical Changes in the Maculae, has also been fully described in the last chapter. The features of Sporadic Cretinism are so charac- teristic that there is usually little doubt as to the diagnosis, which can often be made by the third month. Dwarfing, both of body and mind, with slow reaction and response, a loose baggy skin, tumid belly, bowed legs, broad, squat hands and feet, are 3me of the general characters.* Then there is the ^uare, expanded head, the sallow complexion, the Droad, flushed cheeks, the indented " pug-nose," the Duting lips, and the protruding tongue, making up a physiognomy which once seen is never forgotten. f Investigation shows deficiency or absence of the thyroid gland, and in many cases supraclavicular fatty tumours. The prognosis was, till a few years ago, most unfavourable. Now, thanks to the experi- * See Plate XI., p. 79, and Fig. i on p. 78. f For table of characteristic differences between Cretinism and Mongolism, see pp. 133-134 132 MENTALLY DEFICIENT CHILDREN mental researches of Victor Horsley, Schiff, and others, successful treatment by administration of the thyroid gland is an everyday occurrence. Physical and functional development then proceed at a rapid rate, and the mental hebetude and slowness charac- teristic of these cases are usually transformed into a vivacity and activity strangely contrasting with the previous condition. In rare cases, however, while the bodily symp- toms disappear under treatment, the mental con- dition does not improve. Dr. Tredgold has an interesting account of two such cases in his book "Mental Deficiency." Some observers think that, if a normal condition is to be attained, treatment must be begun early at any rate, not later than the age of twelve months. Less marked improvement may, how- ever, be looked for even when thyroid medication is resorted to only in later years. Indeed, Dr. Shuttle- worth has treated with considerable benefit a man of forty-two, who at that age was only 3 feet I inch high, was quite imbecile, and suffered from lateral curvature of the spine. After three years' thyroid treatment Dr. Shuttleworth was able to report that he " has been transformed from an inert mass of unin- telligent matter to an individual taking some interest in his surroundings, and able to move about and investigate them for himself. His general health has improved, and his capacity for happiness and enjoy- ment of life has notably increased." It would seem, however, that to secure lasting bene- fit the treatment must be permanent ; relapse is apt to ensue if the thyroid administration is discontinued. There is a superficial resemblance in many cases between Cretins and Mongolians, both being back- ward in bodily development, with misshapen hands ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 133 and feet, squat noses, large tongues, and peculiarities of the integument. On careful examination, how- ever, the difference is considerable. The annexed table, setting forth the characteristic differences, may be serviceable, for correct diagnosis is of importance to save parents the disappointment of expecting marked improvement from thyroid medication when the case is one of mongolism. MONGOLISM. i. Characteristics able from birth. notice- 2. Skull brachycephalic : contour rounded or short oval : longitudinal and trans- verse diameters nearly corre- spond . 3. Forehead usually smooth. 4. Palpebral fissures " al- mond-shaped," and more or less oblique upwards and outwards. Frequent epi- canthus. Strabismus com- mon. Ciliary blepharitis fre- quent. 5. Cheeks chubby, often florid. Complexion mottled. 6. Lips often transversely fissured. Lower lip may be pursed up over upper. 7. Tongue large and coarsely papillated if not fis- sured. Tongue frequently protruded and drawn back. CRETINISM. 1. Characteristics often not noticeable till sixth or seventh month. 2. Skull dolichocephalic : flat at top (fontanelles close late) , expanded laterally ; broad behind, often asym- metrical. 3. Forehead usually wrinkled. 4. Palpebral fissures hori- zontal, but appear small ow- ing to pseudo-oedema of eye- lids. Strabismus and ciliary blepharitis less common. 5. Often circumscribed ma- lar flush; complexion ashy or waxy. 6. Lower lip often everted. Mouth open. Drivelling com- mon. 7. Tongue large, but not coarsely papillated or fis- sured. Tip of tongue thick- ened, and constantly pro- truding. 134 MENTALLY DEFICIENT CHILDREN MONGOLISM. 8. Skin smooth in infancy, but furfuraceous later; not redundant or " baggy." 9. Hair " wiry," often " mouse-colour," but some- times blonde. Downy growth common on forehead, cheeks, and neck. 10. Thyroid gland pal- pable to greater or less ex- tent. 11. No fatty tumours (pseudo-lipomata)in posterior triangle of neck. 12. Long bones somewhat shorter than usual, but slen- der. 13. Hands broad; thumb and little finger short, the latter often curved towards ring finger. Fingers taper at ends. 14. Feet large and flat. Fissure between great and second toe often seen. 15. Abdomen often dis-l tended; occasional umbilical/ hernia ; often inguinal hernia. 1 6. Expression more or less vivacious and mobile; observant and imitative. CRETINISM. 8. Skin dry and scaly; forms folds here and there, be- ing redundant and " baggy." 9. Hair harsh, coarse, and scanty. Usually of darkish tint (Bourn eville says brown) ; scalp often eczematous. 10. Thyroid gland impal- pable to most thorough ex- amination. 11. Fatty tumours (pseu- do-lipomata) frequently found in posterior triangle of neck, etc. 12. Long bones shortened and thickened, in some cases bowed. 13. Hands broad, thick, and stumpy, with wrinkled skin. Fingers square at tips. 14. Feet squat; skin re- dundant about ankles and dorsum of foot. 15. Abdomen very bulky and prominent with folds of skin; umbilical hernia com- mon. 1 6. Expression dull and immobile ; unobservant and apathetic. Similarities in Each Variety. Deficient stature, flattened bridge of nose, with expanded alse, late and irregular dentition, deferred closure of fontanelles, retarded puberty (the last most marked in cretins) . ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 135 A passing reference must be made to the rare class of Achondroplasiaes, mistaken sometimes for cretins, but not necessarily mentally deficient. These are usually intelligent but short-limbed dwarfs, dis- tinguished from cretins by their " trident hands," healthy skin and copious growth of hair, and also by the absence of " fat pads," swollen eyelids, and characteristic mouth and tongue. Whilst setting forth the leading characters of these several groups as an aid to diagnosis and prognosis, it is not pretended that we can refer all cases of mental deficiency to a single type. The majority, indeed, are of Mixed Types or of no particular type at all. One of the most unusual combinations we have seen was a well-marked epileptic microcephalic mongolian. Experience aids us in distinguishing and assessing the value of one factor and another in their combinations. Thus traumatism combined with a neurotic family tendency is less hopeful as regards mental improvement than when the history is good. A syphilitic element makes the outlook bad, and the physical prognosis of the mongolian with marked phthisical heredity or a cardiac lesion is most un- favourable. Considerable care must be exercised at an early age in discriminating feeble-mindedness from retarded mental development amounting to nothing more than " backwardness." In doubtful cases a definite opinion must be withheld, and the child's develop- ment carefully watched. The best estimate will be obtained by comparing the patient with a normal child of similar age. Thus tested, a boy of ten will sometimes be found on an intellectual level with the ordinary child of five; if he has had equal advantages with the latter, we may fairly conclude that he is 136 MENTALLY DEFICIENT CHILDREN " mentally feeble." M. Binet and Dr. Simon regard as defective in intelligence a child of nine or more who shows an intellectual retardation of three years.* The physical accompaniments previously alluded to, such as developmental defects, nerve signs, and low nutrition, may aid in the diagnosis. There may often be detected by the practised eye indications of the typical forms such as the Microcephalic, Hydro- cephalic, Mongol, etc. which are more pronounced in cases of actual imbecility; while tubercular, neu- rotic, and, we may add, rachitic, affections are notice- able in a large number of children whose mental con- dition is merely subnormal. These signs, in conjunc- tion with considerations of heredity, are of great value in the diagnosis of constitutional defect of intelligence of a minor degree, and also in the prognosis. Unfortunately, there is sometimes associated with mental defect, particularly when not early subjected to proper training, moral weakness, apt to give much trouble in after-life. As Dr. Blandford has well stated in his Lumleian Lectures at the Royal College of Physicians: " And first, of those who, through congenital defect, or as the result Of disease in early life, are mentally deficient not idiots, but weak-minded imbeciles children in mind throughout life. They come before us in various ways. Though children in mind, they are very often men and women in wickedness and vice; and it may be necessary to place them under restraint, or to protect their property from being squandered and themselves from being robbed. I * Mentally Defective Children, by Alfred Binet and Th. Simon, M.D. Authorised translation by W. B. Drummond, M.B., C.M., F.R.C.P. (Edin.). London, Edward Arnold, 1914, P 1 6, ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 137 know no class over whom controversy is so likely to arise, or where we may have greater difficulty in forming a diagnosis. They are not idiots; many of them have acquired a fair amount of education, can construe a Greek play, or master a proposition of Euclid. Their memory is excellent, and we cannot compare their condition with a former one, for they have never been any better, so that this test fails us. They have no delusions or hallucinations, and are not insane in the ordinary sense of the word. With regard to many there is no difficulty. When a man or woman of forty submits to be treated like a child of ten to be taken out and amused, and to have sixpence a week pocket-money we have not much difficulty in forming an opinion. But the develop- ment of others is not so low ; yet they are deficient in reason and judgment, and often in conduct. There is a tendency to low and depraved habits, to brutish and sensual enjoyment, to low company amongst whom they are of more importance, and if remon- strated with they show an absolute disregard for truth or for right behaviour. Lawyers will defend these patients and say that they are not insane, and the celebrated Wyndham case shows what can be done by their aid. In examining any such individual we must consider his conduct in regard to his environ- ment and bringing up. What might be passed over in the lower walks of life is in the higher evidence of a degraded mental state. Every case must be judged by itself, and the question must be asked, Is this person able to take care of himself and his affairs ? But to sign a certificate is often very difficult, as we may not ourselves witness the insane conduct, all of which we arrive at only by hearsay. It is not to be forgotten, however, that imbeciles are very prone to 138 MENTALLY DEFICIENT CHILDREN display violent explosiveness of their nerve centres, and this is specially likely to happen as they advance from the period of puberty to adolescent life."* The connection between criminality and mental de- ficiency is a subject of vast social importance. It is discussed in an important section, " Mental Defect and Crime," of the Report of the Royal Commission on the Care and Control of the Feeble-minded. To those interested in the subject we would commend the works of W. D. Morrison, Letchworth, Talbot, Havelock Ellis, G. H. Savage, and others, and the reports by Macdonald to the United States Bureau of Education. Lydston's " Diseases of Society " and Mercier's " Criminal Responsibility " are two excel- lent text-books. Many valuable papers notably one by Dr. Barr are to be found in the Proceedings of the American State Committees on Charities and Corrections. We cannot go into the whole of this difficult sub- ject, but must explain that, while very many of the feeble-minded gravitate towards immoral and antisocial conduct, only a small proportion of them are really " moral imbeciles." Take the ordinary feeble-minded child or youth away from the bad environment into which he so readily drifts, and place him in healthy and proper surroundings with good discipline; in a short time he will be quite a different creature. Such has been the experience at the Sandlebridge Schools of the Lancashire and Cheshire Society for the Permanent Care of the Feeble-minded. Miss Dendy, who was the Honorary Secretary of that Society before becoming a member of the Board of Control, in answer to inquiries before the publication pf our third edition, kindly wrote to say: " I am, * Cancel, April 6, 1895, p. 857. ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 139 however, as you say, sure that in the majority of cases children who have been supposed to be moral defec- tives do not merit that title at all, and do very well as soon as they are removed from the surroundings which have prompted their evil doings;" adding: " Many children have been sent to us at Sandlebridge as incurably wicked, but we have had to discharge only one youth. He was more lunatic than feeble- minded, or, rather, I should say lunacy supervened on weakness of mind. Occasionally we have to iso- late a child for a time, so that it may not contaminate the other children; but, luckily, bad habits are as soon forgotten as good ones/' The true moral im- becile is, however, a difficult type. According to the Mental Deficiency Act, Moral Imbeciles are " persons who from an early age display some permanent mental defect coupled with strong vicious or criminal propensities on which punishment has had little or no deterrent effect." As an illustrative case, we will refe.r to a " youth aged nineteen, the son of respectable people. He was educated at an ordinary school, and subse- quently at a technical school, where he exhibited special talent, especially for drawing. He writes an exquisite hand, and is an expert in photography. He has had several situations, usually as a clerk, but if he has not been summarily dismissed, he has always given them up after a few weeks' work. He was a thief from an early age, and has frequently been caught in the act at school and elsewhere. He has several, times been in the hands of the police, and has served a term of imprisonment. He is utterly de- praved ; he lies in bed in the morning, and spends all the money he can get on drink and vice. He steals from his own family, and pawns the clothes with 140 MENTALLY DEFICIENT CHILDREN which he is provided. Although he will not do ordinary work, he spends hours in his favourite hobby of enlarging photographs. This he does, not in the usual way, but in a manner suggestive of a mental twist, for he makes a large pencil-drawing of a small photograph, and then photographs the large drawing. So accurately is this done that people believe the en- largement to be effected in the usual way. He is certainly abnormal, for he has a narrow forehead, suffers from an extreme degree of myopia, and has a slightly dilated heart." Essential features in the diagnosis are the con- sideration that the crime is out of all proportion to the temptation, that the moral shortcomings are not to be explained by training and environment, and are not influenced by ordinary discipline and punish- ment. There is usually some other sign of defect, but this is not necessarily of an intellectual nature. Often there is a certain eccentricity of character and a dislike of family habits; there is frequently a constant tendency to lying, together with bad sexual habits and cruelty towards companions and animals. The crime of arson is sometimes an overpowering temptation. These cases are very difficult to deal with, though something may be accomplished by prolonged training in favourable surroundings. For- tunately, real moral imbeciles are not common. It is certain that they form a very small proportion of the inmates of prisons and other places of correc- tion. When Dr. Potts conducted an investigation for the Royal Commission on the Care and Control of the Feeble-minded into the number of the mentally defective in the parish of Birmingham, he reported, after examining 403 prisoners, of whom 44, or 10-9 per cent., were defective, that " not a single moral defec- ETIOLOGY, DIAGNOSIS, AND PROGNOSIS 141 live was encountered/' After regularly visiting the Stafford prison in connection with a similar inquiry at Stoke-upon-Trent, he stated: " It was particularly noticed that there were but few moral imbeciles." We are not acquainted with any statistics showing the proportion of moral imbeciles in a large group of feeble-minded. Dr. Potts* carefully studied during a series of years ninety-seven consecutive cases ad- mitted to a Magdalen Home. He found that thirty- seven were defective in some way, and that, of these, seven might be fairly described as moral imbeciles. These seven morally defective girls were sharp and intelligent, but without any sense of honour or modesty, and were insusceptible to moral and re- ligious training, thereby differing markedly from the majority. Nothing could restrain them from lying and from stealing from their companions. As we have already indicated, the prognosis in these cases is bad. Short terms of training are useless, but when firm and judicious training can be continued for a long time in proper surroundings, improvement is some- times effected. It is not impossible that there is a kind of moral centre in the brain, and so these cases, r some of them, have been compared with cases of raphia or aphasia. We have, indeed, seen moral r eakness develop after a head injury. If a portion f the brain is poorly developed at birth, or destroyed at a later date, it is not likely to be replaced by healthy tissue; after a long interval other portions may be educated to assume its functions. For instance, the child without a conscience may be taught that dis- honesty is unpopular, and does not pay. * " The Problem of the Morally Defective/' Lancet, Oc- tober 29, 1904. CHAPTER VI THE PSYCHOPATHIES OF PUBERTY AND ADOLESCENCE THOUGH this work deals primarily with mentally de- ficient children, it has been thought desirable to intro- duce into this edition a brief chapter dealing with the abnormalities showing themselves during puberty and adolescence a period in general extending from thirteen to twenty-five years of age. These are ofttimes closely connected with states of congenital unfitness, and, consequently, may be regarded as complementary to the more juvenile defects previously described. We are indebted to the acumen of Sir Thomas Clouston (whose recent death psychiatry de- plores) for the earliest and most comprehensive in- vestigations respecting the above, his classic work on the Neuroses of Development* dating as far back as 189!. In Germany, Kraepelin has grouped the signs of juvenile progressive mental deterioration observed at adolescence (other than those of juvenile general paralysis) under the comprehensive designation of " dementia praecox "; and Ziehen, Fischer, Jung, and others, have dealt more especially with the educational aspects of the subject. Juvenile General Paralysis of the Insane has been referred to in previous chapters,! and it will suffice to * Published by Oliver and Boyd, Edinburgh, and by Simp- kin, Marshall and Co., London, 1891. f See chap, iv., p. 71, and chap. V., p. 125, etc. 142 THE PSYCHOPATHIES OP PUBERTY 143 mention here that Clouston fully describes under the designation of " developmental general paralysis " the cases of two girls, aged seventeen and nineteen respectively, the study of which convinced him that symptoms similar to those familiar to him in the general paralysis of insane adults were " due to hereditary syphilis as the predisposing cause, and to puberty as the exciting cause, with a neurotic heredity as an extra-predisposing cause."* The degenerative symptoms showed themselves in each case at about the age of fifteen by a slow and gradual process of enfeeblement and mental " disso- lution/' with motor disabilities progressively advanc- ing/ In the first case the sixth standard had been reached at school; in the second, the fourth; and in each the knowledge attained was gradually lost. Mental hebetude, indolence, irritability of temper, with occasional fits of passion, and a tendency to uncleanly habits, were amongst the early symptoms noticed; and, later, melancholic symptoms and fixed delusions. In both cases there had been arrest of bodily growth and of the evolution of puberty, with absence of menstruation and of mammary develop- ment; the physiognomy remained childlike, with a vacant and listless expression. There was careless- ness as to personal appearance and no sense of shame or feelings of modesty. The speech was high in pitch and monotonous, with tendency to wavy, sing-song enunciation, though not markedly tremulous. Fibril- lary twitchings of the lingual and facial muscles were observed during utterance, and there was con- siderable hesitation in protruding the tongue. The hands and arms were awkward and shaky in the coarser manipulations and tremulous in the finer * The Neuroses of Development, pp. 74-90. I 4 4 MENTALLY DEFICIENT CHILDREN movements. Grasping power was much impaired, but not notably unequal on the two sides. The muscular power and co-ordination of the lower limbs were also diminished, and the gait was slovenly. There was, however, no marked ataxia, and in the younger case the knee-jerks were found exaggerated; in the older and more advanced one completely absent. Common sensibility seemed to be impaired. In both cases the pupils were dilated and unequal, with sluggish reaction to light, and there were " Hutchin- sonian " teeth. The older patient, whose degenera- tion had been going on for five years previous to her admission to the asylum, died from gangrene of the lower extremities six months after her admission, her mental enfeeblement and muscular weakness having slowly but steadily progressed. At the autopsy slight adhesion of the dura mater to the skull-cap was found along the coronal suture. " On reflecting the dura mater, there were numerous fine threads of adhesion between it and the arachnoid along the line of the pial veins, especially between the falx and the arachnoid. The arachnoid was milky and the pia mater tough and thickened. On removing the brain, it was found to weigh 34^ ounces. Of this there were 4! ounces of fluid, and the cerebellum, pons, and medulla weighed 5| ounces. The convolutions were very well marked and numerous, and there was only slight atrophy anteriorly." Adhesions of pia mater were marked over the convolutions on the under sur- face of the frontal lobe, and existed slightly on the under surface of the temporo-sphenoidal, but nowhere else. The two hemispheres were adherent anteriorly, and the nerves of the base bound down by thickened membrane. The lateral ventricles were much dilated, with thickened lining membrane showing a few THE PSYCHOPATHIES OF PUBERTY 145 granulations, which were also well marked on the surface of the fourth ventricle. There were also adhesions and' thickening of the membranes of the spinal cord. On microscopic examination of fresh sections of the brain, there was found considerable thickening of the pia mater, with a close network of fine fibres in the layer just below. A little deeper there were seen a considerable number of spider cells of various sizes, and in the deeper layers the nerve cells proper were very much degenerated, the apical pro- cesses of many being absent or truncated, and most of the basal processes also gone. The nucleus in many of the cells was not to be seen, whilst in others it was vacuolated. In the spinal cord the pia mater was much thickened, and degeneration of the large cells of the anterior cornua noted, and the epithelial cells lining the central canal were found largely increased. We have ventured to draw thus copiously from Dr Clouston's observations both on account of their historical interest and because they serve to mark the pathological character of the changes found in juvenile general paralysis, the incipient symptoms of which (especially in the absence of an authentic his- tory) are sometimes confused with those of original defect. It is noteworthy that in each of the two cases described stress was laid in the admission certifi- cates on the idiotic aspect of the patients, though, of course, the history negatived the existence of amentia. It is no uncommon experience for similar cases to be recommended for admission into training institutions for imbeciles, for which, of course, they are utterly unfit. Even apart from a knowledge of the family and personal history, a correct diagnosis may be arrived at by an observation of the sluggish, dilated, 10 J 4 6 MENTALLY DEFICIENT CHILDREN unequal pupils, sometimes irregular in outline, and of the existence of fibrillar tremors in the muscles about the mouth and of the tongue. Stigmata of inherited syphilis found in adolescence will also furnish a warning note. It is almost unnecessary to add that the course of juvenile general paralysis is' slowly but surely towards a fatal termination. As Tredgold remarks, " Primary dementia in young aments is of such rare occurrence that its presence, without antecedent insanity or epilepsy, is nearly always indicative of juvenile general paralysis/'* Dementia praecox is the term used by Kraepelin to designate certain forms of mental derangement and degeneration occurring during the period of adoles- cence in persons not necessarily recognised as defective in their earlier years. Clouston, who had described a similar train of symptoms under the name of " ado- lescent insanity " more than twenty years previously, lays great stress upon its hereditary character, tracing neuropathic inheritance in 65 per cent, of his cases;| and a neuropathic family history to the extent of from 80 to 90 per cent, in cases of dementia prsecox is alleged by German writers. Clouston calls adolescent insanity " the most hereditary of all insanities/' and considers that the 30 per cent, of such cases who die demented were " doomed to this ending from the first by their original hereditary defect." Yet up to about eighteen no evidence of bodily or mental defect may be apparent, though the affection may be looked upon as a con- dition of " postponed idiocy/' evolved only just before maturity. Whether or not dementia praecox is (as Kraepelin considers) a pathological entity has been * Mental Deficiency, second edition, p. 358. f The Neuroses of Development, p. 116. THE PSYCHOPATHIES OF PUBERTY keenly contested; and Shaw Bolt on* refers to the term as loosely applied to many types of insanity originating between puberty and maturity. Accord- ing to Kraepelin,f the early symptoms are (i) list- lessness and seeming apathy; (2) sensory sphere affected, as evidenced by dream perceptions and rare hallucinations; (3) morbid curiosity and inability to sustain attention and connected conversation; and (4) memory good for events and acquirements previous to onset of affection. Later, however, the mental processes undergo deterioration, the judgment is affected, and delusions occur. Verbigeration and stereotypism are in evidence. Kraepelin groups cases into three varieties, of which the predominant features are . 1. Hebephrenia, in which there is a condition of mental weakness developing into subacute disturb- ance. 2. Katatonia, in which stupor or excitement occurs, with stages of auto-suggestibility. 3. Paranoia, in which the demented condition is slowly progressive, attended with delusions and hallu- cinations in an otherwise clear mind, with marked tendency to negativism. The progress of the disease often extends over many years, and intermissions of considerable length may occur, giving rise to fallacious hopes of recovery. The prognosis is, however, un- favourable : Kraepelin states that not more than 3 per cent, of the hebephrenics recover, but about 20 per cent, of the katatonics. In certain stages the re- semblance to primary amentia, as regards weak will and judgment, childish conversation with tiresome * Brain in Health and Disease, Joseph Shaw Bolton, p. 320. f Lectures on Clinical Psychiatry, Kraepelin, translated by Johnstone. London, 1904. 148 MENTALLY DEFICIENT CHILDREN iteration of phrases, may lead to confusion in diagnosis; but the statuesque postures, muscular rigidity, increased reflexes, hallucinations, and un- emotional tendencies, will serve to differentiate true cases of dementia praecox, which, however, may occasionally supervene in the subject of primary amentia. A knowledge of the mental history in childhood and the existence of educational acquire- ment, which is not abrogated in the early stages of the dementia, will, of course, clear up the diagnosis. Developmental Epilepsy and Epileptic Mental De- generation. Clouston lays down as an axiom that " almost all cases of true epilepsy first arise during the growth and development of the brain/'* From birth up to the age of seven Gowersf found that out of 1,450 cases investigated, 340 (or 23 per cent.) arose during this period, 77 (or 5 per cent.) during the first year of life. From thirteen to eighteen, the period of puberty and early adolescence, 444 cases first occurred, about one-third of the whole. In the last seven years of adolescence (eighteen to twenty-five) 195 (or only 13 per cent, of all the cases) occurred. Infancy, puberty, and early adolescence thus figure as the markedly epilepto -genetic periods, respect- ively those of faster brain growth and most rapid development. Gowers and others have traced neuro- pathic heredity in from 28 to 35 per cent, of the cases noted. The " discharging lesion " of the motor cortex which Hughlings Jackson pointed out as the essential cause of epilepsy implies imperfect evolu- tion of co-ordinating and inhibitory apparatus in the highest cortical levels, which we may consider in most cases to be an innate pathological condition. * Op. cit., p. 97. t Gowers' Epilepsy, first edition, p. 12. ?# PSYCHOPATHIES Of PUBERTY 149 Epileptic nerve-storms frequently occurring produce more or less mental wreckage. The effect of epilepsy in childhood has been already considered (see pp. 123-124). It remains to add that in puberty and adolescence mental enfeeblement of various degrees is frequently produced in those who begin to suffer at this period from oft-repeated convulsions or from the minor attacks known as " petit mal." There are, however, exceptions, for such men as Julius Caesar, Mahomet, Peter the Great, and Napoleon, are reputed to have been epileptics; but there is ample evidence that impairment of memory, judgment, and of mental activity generally, is apt to follow such attacks, and in extreme cases the previously intelli- gent youth may sink into a condition of progressive dementia, or develop the more active symptoms of epileptic insanity. The diagnosis of such cases is readily determined by the history; the prognosis is, with few exceptions, most unfavourable, especially when neuropathic heredity is traceable. It has been suggested, with a considerable degree of probability, that in some cases of so-called " moral imbecility " the periodical (and at first sight inex- plicable) outbursts of evil conduct are due to epilepti- form impulses, and cases have been recorded in which convulsions and criminality seemed to alternate with each other. Pubertal Perversion of Moral Sense. Apart from the more permanent forms of moral imbecility previously referred to, * one occasionally meets with cases in which the strain of puberty in its initial period produces, especially in those of neurotic antecedents, a tempor- ary lapse or perversion of moral sense. A well-brought- up youth of previous average intelligence and in- * See pp. 136-141. 150 MENTALLY DEFICIENT CHILDREN tegrity, during the access of puberty may begin to disregard the " proprieties/' evolve hazy ideas of the distinctions between ,meum and tuum, and go on to appropriate other people's goods, which possibly are of no service whatever to himself. From his own family his depredations may extend to outsiders, and a public exposure may follow, greatly to the dis- may of his relatives. If in the lower ranks of society, he gets into the hands of the police, and his appro- priate penal treatment puzzles the magistrate, who probably commits him to a reformatory or industrial school. If of the " upper classes," a doctor is called in, who diagnoses kleptomania, and the youth remains in his friends' care, probably to relapse into similar peccadillos from time to time. If, however, with- drawn from his old surroundings and placed under the judicious care of a tactful tutor, able to secure his pupil's confidence and affection, and to interest him in outdoor employments and sports, a gradual rehabilitation of moral balance may be looked for as the initial stress of puberty subsides. We have, indeed, met with such cases in widely differing social ranks. Youths who have caused scandals at public schools, not only by pilfering from their school- fellows, but in one instance by appropriating articles from the masters' common room, and in another by forging his house-master's signature to a demand for money from his father's agent, have proved amenable to influences such as are suggested above, and have eventually become useful and upright citizens. Girls, also, who in the general perturbation of budding womanhood have temporarily lost moral balance, descending, perhaps, to degraded habits and language, untruthfulness, and pilfering e.g., in one case from a servant's savings-box have, under good THE PSYCHOPATHIES OF PUBERTY 151 management, retrieved their characters and grown up self-respecting and respected members of society. The prognosis of cases displaying moral delinquency for the first time at puberty is not necessarily un- favourable, but discrimination is needed as regards family and personal history, not always correctly given. If instability can be traced from childhood, especially when there is a neurotic family history, the prospect of recovering a proper moral tone is, of course, less hopeful. It will be observed that to certify a person as a moral imbecile under the Mental Deficiency Act some evidence of permanent mental defect existing " from an early age " is required. Space does not permit us to enlarge upon the hysterical affections which may be taken as signs of mental weakness in the adolescent period, more especially of females. In such cases whimsical fancies and perverted emotional impulses, which may, perhaps, be regarded as reflex symptoms of inchoate uterine function, give rise to eccentricities of conduct which it may be difficult to differentiate from adolescent insanity save by their more transient character. In a case recorded by Clouston a young woman of twenty complained of " jumpings " all over her body, " cracklings " in the nerves of the abdominal region, and " emptinesses " in many places ! Withal there was an exuberant religiosity, with an insensitiveness to ordinary moral obligations, such as dutiful behaviour towards her parents.* Insanity in Childhood. Under this head we may very briefly consider symptoms which are sometimes passed over in early life until accentuated at puberty, but which point to something more than the ordinary negative characteristics of mental defect. Con- * The Neuroses of Development, p. 107. 152 MENTALLY DEFICIENT CHILDREN ditions indistinguishable from those of mania and of melancholia sometimes occur in the offspring of insane parents or grandparents long before puberty, though in some of these it is probable that there is a premature development of the reproductive system. The nerve-storms to which some children of unstable brain action are periodically subject may be properly classed as of the nature of maniacal insanity; and in other cases states of depression of which instances are recorded at as early an age as six deserve the name of melancholia. The prognosis is invariably grave, such cases often deteriorating under the stress of puberty and eventually gravitating into asylums for the insane. Amongst minor mental and moral changes not infre- quently noticed at this period may be mentioned lethargic conditions, asociability, causeless aver- sions, ill-temper, hyper-conscientiousness, religiosity, and perverted sexual trains of thought with evil practices. These may pass away as the constitutional upheaval subsides, though in cases of neuropathic inheritance there is risk of permanent mental de- terioration. CHAPTER VII MEDICAL EXAMINATION OF MENTALLY DEFEC- TIVE CHILDREN UNDER THE REGULATIONS OF THE BOARD OF EDUCATION IN view of the relations subsisting between the Mental Deficiency Act Sections i (i), 2 (2), and 31 (i) and the Elementary Education Acts relating to defective and epileptic children, the Board of Edu- cation have issued a circular to Local Education Authorities, accompanying a scheme of model ar- rangements for ascertaining the existence of mental defect and its degree in children between the ages of seven and sixteen. The principal provisions are as follows : 1. The School Medical Officer, and such other duly qualified medical practitioners approved by the Board of Education as the Local Education Authority may approve for that purpose, will be Certifying Officers under the sections of both Acts above referred to. 2. Head- teachers and School Medical Officers are to report to the Local Education Authority all chil- dren appearing properly to fall under any of the sections cited of either of the Acts. 3. School Attendance Officers are also required to report the names and addresses of all children not in attendance at school who appear, or are alleged to be, defective within the meaning of the Mental Deficiency Act, 1913. I 5 4 MENTALLY DEFICIENT CHILDREN 4. The Certifying Officer is to examine, under the direction of the Education Authority, all such children so reported, and any child presented by its parent as requiring to be dealt with under the Elementary Education (Defective and Epileptic Children) Act, 1899. The child is to be examined within three months of his attaining the age of seven years, and at such other times as the Authority may deem desirable. 5. A certificate in the prescribed form, together with a full report of the child on the lines of the schedule printed on pages 168 and 169, is to be furnished to the Local Education Authority. 6. In the case of children of seven years or upwards certified to be unfit for special schools in consequence of their being idiots or imbeciles, copies of such certifi- cate and report are to be furnished to the Local Authority under the Mental Deficiency Act, 1913. In any case of proposed notification to the Local Authority of a child not certified to be an idiot or imbecile, the Board of Education is to be furnished with a copy of the report, and the question whether or not the child shall be notified will, if they think fit, be determined by the Board. 7. In any case in which a defective child is certified as unfit to be instructed in a special school or class without detriment to the interests of the other chil- dren, otherwise than on the ground of being a moral imbecile (in which case he is to be notified to the Local Authority), a copy of the report of the Certify- ing Officer is to be furnished to the Board of Educa- tion, who will determine, if they think fit, whether or not the retention of the child in the special school or class is practicable. 8 The Local Education Authority is to arrange for MEDICAL EXAMINATION 155 re-examinations annually (at the least) of all pupils being educated in special schools or classes with a view of ascertaining (a) fitness for transfer to ordinary ele- mentary school; (b) incapability of further benefit from special instruction; (c) fitness for special school, without detriment to the interests of the other chil- dren. 9. Similar arrangements to apply to children main- tained in special schools not belonging to the Authority. 10. If a child be certified as incapable of receiving further benefit from special instruction, the Local Education Authority will notify such child to the Local Authority under the Mental Deficiency Act, 1913, and send copy of certificate; but if the child be not certified as an idiot or imbecile, it will be neces- sary to furnish a copy of the report to the Board of Education, who will determine, if they think fit, as to notification to the Local Authority. n. If the Local Education Authority decide that it is desirable that a child over seven years of age who is certified as capable of receiving benefit from special instruction should be dealt with by way of super- vision or guardianship under the Mental Deficiency Act, 1913, they will notify the case and the circum- stances thereof to the Board of Education; and if the Board certify that it is desirable that the child be placed under supervision or guardianship, the Local Education Authority will notify the child to the Local Authority under the Mental Deficiency Act, 12. The Local Education Authority will notify to the Local Authority under the Mental Deficiency Act, 1913, any child about to be withdrawn or discharged on or before attaining the age of sixteen, in whose 156 MENTALLY DEFICIENT CHILDREN case they are of opinion that it would be for his benefit that he should be sent to an institution or placed under guardianship under the Mental Deficiency Act, 13. In any cases under Clauses 6, 7, or 10, in which the Local Education Authority, notwithstanding the certificate of the Certifying Officer, are opposed to the child being notified to the Local Authority, they may refer to the Board of Education to determine the question. Similarly with regard to notifying a child who has not been certified by the Medical Officer. 14. Where the Local Education Authority propose to notify to the Local Authority under the Mental Deficiency Act blind or deaf children, reports both from the Certifying Officer and the head-teacher of the blind or deaf school attended must be sent to the Board of Education, who, if they think fit, will deter- mine as to notification. From a consideration of the scheme above detailed, it will be seen that increased responsibility will be thrown upon the Medical Officers of special schools, and that the time occupied by their examinations will be considerably extended by the necessity of their filling up voluminous reports, not only on chil- dren presented for admission, but also on those about to be withdrawn or discharged, or considered to be incapable of benefiting by further instruction. The suggested form of report is substantially the same as that printed in Appendix C of the Annual Report of the Chief Medical Officer to the Board of Education for 1913.* The headings for inquiry therein relate to circumstances of environment, * See Annual Report, Chief Medical Officer, Board of Educa- tion, for 1913, Appendix C, p. 321. MEDICAL EXAMINATION 157 family and personal history, physical and mental conditions, and assessment of general intelligence in relation to age by means of the Binet-Simon tests. These tests, formulated by Binet and Simon after much experimental work, largely among normal children, admittedly rest upon a more or less empirical basis; but experience with them in France, Belgium, Germany, Denmark, and in America (where Dr. God- dard has published an edition of them specially re- vised for English-speaking children*), has shown that the results obtained in measuring the mental develop- ment of normal children at various ages are surpris- ingly accurate, and that their application to abnormal children reveals the degree of defect in them as com- pared with normal children of corresponding age. If a child fails to pass the tests appropriate to his own age, but passes those for a child not more than three years younger than himself, he is, in Goddard's view, backward by one, two, or three years ; but if he is more than three years backward he is mentally defective. These tests do not, like ordinary educational tests, depend upon acquired attainment, nor even upon knowledge merely, but, in the words of Binet, " upon the ability to use knowledge in meeting a situation created by the standardised conditions of the test." They do not pretend to measure the entire mentality of the child, including the volitional and emotional elements, though information as to these may be incidentally gathered from the way in which the examination is faced. It is, of course, essential that the examiner should by his manner place the child at ease before applying the tests, and gain his con- * The Binet-Simon Measuring Scale for Intelligence, re- vised edition, 1911, by Henry H. Goddard, Ph.D. The Train- ing School, Vineland, NJ. Price i I 5 8 MENTALLY DEFICIENT CHILDREN fidence by pleasurable suggestions, such as offering to show attractive pictures and asking what he sees in them, rather than by plying him at once with a formal questionnaire. In fact, the less formality that is compatible with a complete examination, the more satisfactory will be the results. Replies, how- ever wide of the mark, must not be openly stigmatised as wrong: only words of encouragement should be used. Whilst the " standardised " form of questions presented should be strictly adhered to, in some cases it may require such explanation as may render it intelligible to the child e.g., in Question i for age eight it may be necessary to explain that the difference between two things means the points in which they are not alike. But no hints as to answers must be given by word or sign. Preconceived ideas of the child's abilities must be excluded from the mind of the examiner, whose correct attitude is, in Goddard's view, " to regard him as an unknown quantity, an x which is to be determined/' This dictum cannot, however, be intended to imply that distracting bodily conditions (e.g., toothache or headache) can be ignored; and in the case of mentally defective chil- dren it must be borne in mind that mental fatigue may be speedily induced by continuous questioning, so that it may be advisable in certain cases not to take the whole examination at one sitting. The tests of Binet and Simon grouped according to age (as revised in 1911) are printed in Appendix C of the Chief Medical Officer's Report for 1913, pp. 323, 324, and will be found to differ slightly from the arrangement by Dr. Goddard previously referred to. As the Chief Medical Officer judiciously remarks (p. 214, note) : " There is need for much research and co-operation in order to revise our mental tests and MEDICAL EXAMINATION 150 standardise them on various types of children. The Binet tests, which are recommended in the Board's schedule, are, it should be remembered, tentative, and not yet standardised for English use." Dr. Kate Fraser, formerly Assistant Medical Officer, Govan School Board, and now Deputy Commissioner of the Scottish Board of Control, has published a valuable paper (School Hygiene, May, 1913) on the use of the tests in determining the suitability of a child for ad- mission to a special school; and there is no doubt that these tests, judiciously employed, in conjunction with the results of clinical examination, and a con- sideration of environment and family history, to- gether with the experience of the teacher as to the child's educational capacity, will prove to be of con- siderable aid in the diagnosis and differentiation of mental defect. The competence of the examiner rightly to administer the tests is of course a sine qua non, and, though any intelligent teacher may easily attain the needful technique, any bias from knowledge of a child's educational acquirements must be guarded against. The medical examiner must therefore be personally familiar with the procedure and with the inferences to be drawn from the results obtained. It has been pointed out by Dr. Kuhlmann, in an inter- esting contribution to the Journal of Psycho- Asthenics (June, 1912), that the Binet-Simon tests are valuable, not only in differentiating mentally defective children, but in grading them for class instruction, and also in gauging their capability of improvement. Space will not permit of a detailed description of the Binet-Simon system of tests, but those desiring a more complete knowledge of the subject are referred to Goddard's pamphlet previously referred to; to Binet 's papers to be found in successive numbers of 160 MENTALLY DEFICIENT CHILDREN L'Annee Psychologique, from 1905 to 1911; and to Dr. DrummoncTs authorised translation of Binet and Simon's Mentally Defective Children, which has recently appeared (London: Edward Arnold, 1914). Whilst recognising the value of the Binet-Simon system judiciously used in conjunction with clinical methods and scientific scrutiny of the family history, we fully agree with the dictum of Dr. Walter E. Fernald, the experienced superintendent of the Massachusetts Institution, that " the determination of mental defect cannot be made by automatic appli- cation of any method and scale/'* In the suggested form of report on children examined for mental deficiency, appended to the " Model Arrangements " issued by the Board of Education, information is required as to social surroundings, family and per- sonal history, general physical conditions, including also the efficiency or otherwise of the special senses, the state of the nose and throat and of spinal re- flexes, the existence of physical stigmata, etc. " In assessing mental conditions, the tests designed by Binet and Simon are recommended," and in the course of their application observations may be made with regard to the activity or otherwise of such reactions of motor mechanism as are involved in the (i) forma- tion and (2) storage of motor ideas; in (3) power of control, initiative, purpose, and concentration; (4) motor incompetence, as shown by attitude, gait, and general balance; (5) motor instability, as evi- denced in uncouth habits; and (6) motor disturbance, under which are included tremors (such as Dr. Warner designates " abnormal nerve signs "), chorea, epilepsy, aphasia, and hemiplegia. Then come " reactions resulting from sensory stimulation/' in- * Journal of Psycho- A sthenics, vol. xviii., No. 2, p. 80.. MEDICAL EXAMINATION 161 eluding (i) Attention, as ascertained by the dis- crimination of colours, shape, size, and odours; (2) formation of memory images, as ascertained by (a) recognition, (b) recollection, of objects and sounds; (c) association of ideas; (d) judgment, as tested by appreciation of length, size, and distance ; (e) relation- ship, in comprehension of similarity, contrast, sym- bolism. Emotional conditions, as demonstrated by interest, excitement, aggression, co-operation, affec- tion, etc., are to be observed and noted. Then follows a list of tests of intelligence based upon edu- cational capacity, and finally an estimation of the will-power and moral characteristics. Upon the data so obtained a diagnosis is founded under nine cate- gories, some of which may be correlated. Finally, " recommendations as to treatment " are to be made under the following headings of the class of instruction desirable : 1. An ordinary public elementary school. 2. A special class for dull and backward children. 3. A special school (day or residential). 4. Unsuitable for a special school. Forms of certificate to meet the needs of the various classes diagnosed are prescribed by the Board as follows : A. u I certify that this child is not incapable, by reason of mental defect, of receiving benefit from the instruction in an ordinary public elementary school/' B. "I certify that this child, not being merely dull or backward, and not being an idiot, an imbecile, or a moral imbecile, is feeble-minded within the meaning of the Mental Deficiency Act, 1913, but is not incapable, by reason of mental defect, of receiving benefit from instruction in a special school or class ii 1 62 MENTALLY DEFICIENT CHILDREN under the Elementary Education (Defective and Epileptic Children) Act, 1899." C. " I certify that this child is incapable, by reason of mental defect, of receiving benefit from instruction in a special school or class under the Elementary Education (Defective and Epileptic Children) Act, 1899." "Note. Under the last-named Act, idiots and imbeciles are excluded from special schools and classes certified under that Act." D. " I certify that this child is incapable, by reason of mental defect, of receiving further benefit from instruction in a special school or class under the Elementary Education (Defective and Epileptic Children) Act, 1899." E. " I certify that this child cannot be instructed in a special school or class under the Elementary Educa- tion (Defective and Epileptic Children) Act, 1899, with- out detriment to the interests of the other children." Other forms of certificate are prescribed for epi- leptic, physically defective, blind, and deaf children ; and there are also forms of recommendation to be employed by the Medical Officer when he is of opinion that a child in a special school should be dealt with under the Mental Deficiency Act, 1913, by way of supervision or guardianship, or, when about to be withdrawn or discharged, should be sent to an insti- tution or placed under guardianship, in each case the reasons for such opinion being fully set forth. The summary just given of the procedure offi- cially prescribed renders superfluous much that appeared in the last edition of this work as to the medical examination of children requiring special instruction. With regard to the technique, it may be noted that, in addition to appliances such as are needed in the medical inspection of ordinary schools PLATE XVII. Dr. E. S. Pasmore's "Flag" Chart of Heredity (Report, Royal Commission on Care and Control of Feeble-minded, Vol. II., p. 531. Reproduced by kind permission.) Name Date... EXPLANATORY NOTES FOR USING CHART. 1. Each flag denotes particular class of relative (e.g. Grandparents, Aunts, etc.): male rela ndicated by shading ; female, plain. 2. Number of relatives in each class noted by figure in corner of flag next pole. Those affected leritable maladies denoted by line, having name of malady, drawn through flag appropriate elationship. To face 1>age 163. MEDICAL EXAMINATION 163 e.g., weighing machine, height standard, and various instruments for ascertaining the general conditions, physical and sensorial, of the patient it will be necessary to be provided with material for the Binet- Simon tests, which can be readily constructed or may be obtained in sets (as arranged by Dr. Goddard) from the C. H. Stoelting Company, 121, North Green Street, Chicago, 111., U.S.A. In the Report for 1913 of the Chief Medical Officer, Board of Education (p. 214) , the outfit of the psychiatric clinic of the school service at Stoke, as arranged by Dr. Robert Hughes, is noted as a model for Medical Officers engaged in similar work elsewhere. With regard to special points in the model schedule, the following remarks may be found serviceable : II. Home Conditions should be stated, if practicable, in terms of the rooms occupied and number in family. School attendance should be definitely ascertained as to date of commencement, regularity or otherwise of attendance, and type of school. III. Family History. As the statements of rela- tives are apt to be vague and diffuse, particularly with regard to mental and nervous defects, the em- ployment of some such scheme* as that suggested by Dr. Pasmore (set forth opposite) is serviceable in giving precision to information collected. In the flag cor- responding to each member of the family may be written alive (a.) or dead (d.) ; in the latter case the age and cause of death should be noted. The question of alcoholism is always a difficult one to deal with, and, unless notorious drunkenness exists, this factor in its less conspicuous manifestations is apt to be overlooked. Even present teetotalism is I not always a guarantee against the existence of alco- C'ic excess in the past. The examiner must needs * Plate XVII. 1 64 MENTALLY DEFICIENT CHILDREN be content with recording such information as the relative in attendance usually the mother deigns to give, and she is not likely to give evidence against herself. Such questions as, "Are you a beer or spirit drinker; and if so, when do you take your drink ?" may sometimes elicit suggestive information about drinking habits, but excess must not be too hastily assumed without reliable evidence ; and caution in stating in a document such as that prescribed by the Board of Education that alcoholism exists in a par- ticular relative seems specially necessary unless con- clusive proof is available. The points to be noted under IV. Personal History, and under V. Physical Conditions, are so fully de- tailed in the schedule as to require no comment ; but with regard to VI. Mental Conditions a few remarks may be hazarded. What, for instance, is meant (under VI. a. 3) by " execution of familiar complex movements " ? The seven-years-old test in the Binet Simon scheme would seem to supply an answer in i instruction to a child, which runs as follows: and put this key on that chair. Then close the dc Then take the key which is lying on the chair ne the door, and bring it to me. First put the key the chair, then close the door, then bring the key to me." Goddard places this test amongst those for six years of age, stating that at five years of age about half the number of (normal) children tested succeed: " at six all, or nearly all," can accomplish this triple commission. Most of the " reactions resulting from sensory stimulation " mentioned under VI. (I) are also ascertained in the course of applying Binet 's tests; and consequently it is a good plan to submit the child to these tests previous to filling up the items headed VI. Mental Conditions. MEDICAL EXAMINATION 165 It cannot be denied that up to the present time children have found their way into special schools for defectives who are not the subjects of essential mental defect, though displaying a certain amount of mental abnormality as compared with ordinary school-children. In some cases, especially in young children, it is difficult to determine with any degree of certainty how far incapacity to benefit by the ordinary school curriculum is due to retarded de- velopment rather than to actual initial defect. In the differentiation between cases of " spurious " and real defectiveness, the Binet-Simon tests are service- able, and, conventionally, a child of nine or upwards whose mental age is not more than three years behind his actual age may be considered backward, but a greater difference shows mental defect* Apart from this, retarding causes may be usually discovered, such as bad environment, irregular school attendance, physical defects especially adenoids, defective vision or hearing and sometimes partial incapacities, such as inferior power of calculation with fair ability in other directions. In consequence of one or more of these conditions, those affected prove incapable of bene- fiting by elementary school instruction suitable for the average child, and lag behind the educational standards appropriate to their age. In fact, ordinary school methods prove ineffectual for their improve- ment, and the question arises, especially when beyond the age for infant departments, What steps can be taken for their advancement ? For such children the general establishment of backward classes or intermediate schools (as in the Mannheim educational system) becomes an urgent desideratum, the essential * Mentally Defective Children, Binetand Simon (Drummond's translation), p. 16. 1 66 MENTALLY DEFICIENT CHILDREN conditions being small classes, a larger proportion physical and manual training in the curriculum, and such individual attention as the peculiarities of ea case may require. In cases mentally backward owing to physical weakness, open-air schools, wit their comparatively restful arrangements, often pro\ very beneficial. Unfortunately, " backward classes : are only to be found at present in about a dozen edu- cational areas in England and Wales ; and the result of want of appropriate provision elsewhere is that backward children are apt to gravitate to specia schools (where they exist), as these are the only ones available by which they can benefit, though it is mani- festly unjust to such children that they should be stamped with the stigma of mental defect. It would seem to be the duty of medical examiners to report, with regard to children of proved incapacity benefit by instruction in the ordinary school fron causes such as are mentioned above, that they need a modified curriculum, in the hope that educationa authorities may see the desirability of establishk special classes for the dull and backward, in addition to those for the mentally defective. Dr. Kerr pointed out (L.C.C. Educational Reports, 1905-1906) ten ye ago that a large percentage of children attendir elementary schools in London, " although not actually ' mentally defective/ are yet of such a low grad mentally that they are neither capable nor worth tt effort of being raised to the ordinary elementa school standard/' and that for such simpler school; the " intermediate schools " of the Mannheim educa- tional system were required, in which, so far ordinary scholastic attainment is concerned, Stan- dard IV. should be deemed sufficient; while objective teaching, with physical and manual training, should MEDICAL EXAMINATION 167 be the predominant element. The Chief Medical Officer of the Board of Education has consistently advocated in his Annual Reports the formation of " backward classes/' and in his Report for 1913 con- siderable space is devoted to the discussion of the question. Pending the more general establishment of classes or centres for " intermediate " instruction, it seems inevitable that the resources of the " special school " should be utilised for certain " probationary " cases, with the safeguard of systematic scrutiny as to their fitness or otherwise for an ordinary school at successive annual examinations. Under the operation of the Elementary Education (Defective and Epileptic Children) Act of 1914, Local Education Authorities generally will be charged with provision for the education of all mentally defective children, belonging to their area, over seven years of age, subject to consultation with the parents in each case as to their wishes and ability to make suitable provision. It remains to be seen how this proviso will work in practice, but it will be an additional reason for increased care in classification, and will call for much tact as well as accuracy on the part of the medical examiner. As Section 6 makes it com- pulsory on the latter, if the parents so request, to consult with the head-teacher of the school previously attended by the child, it seems desirable that, in all cases in which the child has attended an elementary school, a careful written report by the head-teacher should be available at the examination and be duly considered. Overleaf will be found print of "Model Arrangements" (Schedule F), previously alluded to in this chapter. 168 MENTALLY DEFICIENT CHILDREN " MODEL ARRANGEMENTS " (BOARD OF EDUCATION CIRCULAR 829). SCHEDULE F. SUGGESTED FORM OF REPORT ON CHILD EXAMINED FOR MENTAL DEFICIENCY. I. Name of Child (in full). Address. Date of Birth. School (if any). Local Education Authority. II. Particulars of Home Conditions, Environment, School Attendance, and other Factors. . III. Family History (in regard to history of mental defect, epilepsy, alcoholism, etc.). IV. Personal History : (a) Constitutional Defects, Injury at Birth, Malnutrition, Rickets, Congenital Syphilis, etc. (b) Diseases of Childhood, (c) Commencement of Teething, (d) Walking, (e] Speech. V. Physical Conditions: (d) General (results of routine medical inspection), (b) Special: (i) Speech: De- fective articulation. (2) Sight: Blindness, total or partial, errors of refraction. (3) Hearing: Deaf- mutism, partial deafness, partial mutism. (4) Nose and throat: Enlarged tonsils, adenoids, mouth breathing. (5) Control of spinal reflexes and of sali- vation, (c) Stigmata: (i) General retardation Cretinoid development. (2) Cranium Microce- phaly, hydrocephaly , asymmetry, rickets, imperfect closure of fontanelles, simple head measurement. (3) Hair Double and treble vortices, wiry or supple. (4) Face Irregularity of features. (5) Lower jaw Protruding or receding. (6) Eyes Mongoloid, presence of epicanthic fold. (7) Ears Size, setting, conformation, lateral symmetry, size of lobes, attach- ment of lobe to the cheek, supernumerary lobules. (8) Tongue Enlarged, furrowed, papillae enlarged. (9) Teeth Irregular, absent, enlarged incisors. (10) Palate Arched, narrow. (n) Fingers Webbed, clubbed, defective in number or shape, supernumer- ary digits. (12) Limbs Excessive length of upper limbs. VI. Mental Conditions: [N.B. In assessing mental conditions, the tests designed by Binet and Simon are recommended.] (a) Reactions of Motor Mechanism: (i) Forma- tion of Motor Ideas. (Execution of simple move- ments from imitation.) (2) Storage of Motor Ideas. MEDICAL EXAMINATION 169 (Execution of simple familiar command by word of mouth.) (3) Power of control, initiative, purpose, and concentration. Success of motor output. (Exe- cution of familiar complex movement.) (4) Motor Incompetence. Attitude in standing position of head, spine, knees. Gait. Position of arms, hands, fingers, in horizontal extension. General balance, (5) Motor Instability. (Habits.) Rocking of body, rubbing hands, spitting, biting nails, or licking lips. (6) Motor Disturbance. Tremors (face, hand, tongue), Chorea, Epilepsy, Aphasia, Hemiplegia. (b) Reactions resulting from Sensory Stimulation: (i) Attention colour, shape, size, smell. (2) For- mation of Memory Images : (a) Recognition; ob- jects, sounds, (b) Recollection. (3) Association of Ideas. (4) Judgment (for example length, size, distance). (5) Relationship (similarity, contrast, symbolism). (6) General concepts (possession, self- protection, purpose, concentration, initiative), (c) Emotional Conditions: Interest, excitement, aggres- sion, co-operation, affection, etc. (positive or negative phases), (d) Tests of Intelligence: (i) Description of pictures, models, objects, familiar events. (2) Letters, words, reading (word blindness) . (3) Count- ing, manipulation of simple numbers, simple money values. (4) Writing. (5) Manual Tests, (e) Will Power as tested under the above headings. (/) Moral characteristics not recorded in (a) to (e) . VII. Diagnosis: (a) Physically defective stating defect. (b) Blind or partially blind, (c) Deaf-mute or semi- mute or semi-deaf, (d) Epileptic, (e} Merely dull or backward. (/) Mentally defective (feeble-minded). (g) Imbecile, (h) Moral Imbecile, (i) Idiot. [In this group the symbols (a) to (i) are intended to be correlated when necessary.] VIII. Treatment recommended. (With any necessary notes as to after-care, custody, and the degree and char- acter of manual training and ordinary school teach- ing likely to be advisable.) (i) An ordinary public elementary school. (With or without particular supervision or modification of curriculum.) (2) A special class for dull or backward children. (3) A special school (state whether day or residential is recommended). (4) Unsuitable for a special school. Signature of the Medical Officer Date CHAPTER VIII THE TREATMENT OF MENTALLY DEFICIENT CHILDREN (a) GENERAL. (6) MEDICAL, (c) SURGICAL. THE treatment of mentally deficie'nt children is essentially (to borrow a term from the French) medico-pedagogic. The physician, the teacher, and the nurse, must all co-operate in the ameliorative process, and the judicious parent will best secure the interests of his afflicted child by placing hir where the efforts of the three can be co-ordinated. As a matter of convenience, however, we shall con- sider in order, first the general treatment, including nursing and domestic management, and after that such treatment as belongs to the domain of medicine and surgery, reserving for a subsequent chapter matters educational. Congenital defect in the young infant having been diagnosed, are there any means available for modify- ing its accompanying abnormalities ? Much, indeed, may be done by a loving mother, who will be patient enough to persevere, in spite of apparently slight results, to promote sensorial development and co- ordinate movement, and, as months go on, to foster habits of cleanliness. The faculty of attention, too, may be cultivated, the child being coaxed to fix its gaze on one thing at a time. The aid of music is 170 TREATMENT OP MENTALLY DEFICIENT 171 often serviceable, and even idiots will respond in a remarkable way to congenial sounds, which they at length try to imitate, so that music is sometimes the stepping-stone to speech. Seguin has laid down the principles on which to proceed in the following para- graph: " As soon as any function is set down as deficient at its due time of development, the cause must be sought and combated ; if external, removed ; if seated in the nervous apparatus, counteracted by the earliest course of training and hygienic measures. The arm of the mother becomes a swing or a supporter; her hand a monitor or a compressor; her eye a stimulant or a director of the distracted look; the cradle is converted into a class-room or gymnasium/'* It must, however, be remembered that the mother, if of neurotic temperament, is not the best person to conduct* these infantile exercises. A judicious nurse, sympathetic, but not emotional, will have a better chance of success. (A) GENERAL. Proper Feeding is of the first im- portance. An emotional mother should not, as a rule, suckle her child. In her place a healthy, strong-minded wet-nurse should be employed, or judicious artificial feeding used. The risk of scurvy-rickets from the exclusive use of preserved foods (as demonstrated by Sir Thomas Barlow in his 1894 Bradshaw Lecture) must not be forgotten, and fresh milk in some form should come into the dietary. Frequently we find that infants who must be fed artificially do best with fresh cows' milk, unsterilised, but diluted with a little water or barley-water. In the case of infants who give evidence of their mental weakness by in- ability to suck, a spoon must be used, and great * Idiocy, p. 88. New York, 1866. 172 MENTALLY DEFICIENT CHILDREN patience exercised. As the child gets older, well- boiled oatmeal porridge (par excellence the food for bone and brain building) should be given. Careful attention must be paid to the action of the bowels, which are apt to be sluggish, though sometimes there is a tendency to mucous flux. The hygiene of the skin must be studied, and frequent baths, with fric- tion, are beneficial in promoting cutaneous exhalation, otherwise often offensive, and in aiding the sluggish circulation. Muscular activity should be encouraged, and the child frequently laid on the "kicking-rug," and encouraged by playful methods to exercise its limbs. Fresh air is absolutely essential, and we unhesitatingly recommend the modern vogue of keeping the baby out of doors for a considerable part of every day, asleep and awake, care, of course, being taken to see that he is properly protected from the weather, and kept warm by hot-water bottles, if necessary. Cleanly habits must be promoted by every possible means. It is a mistake to condemn the defective infant to perpetual swaddling-clothes. The aim should be to approximate as near as is practicable to the normal child, in costume as well as other matters. We have seen children of six swathed in napkins round their loins, reeking with offensive filth, to the great discomfort of all concerned, whereas methodical personal attention would have obviated the need of such expedients. Regularity in the relief of the bowels and the bladder should be inculcated early, and, of course, more frequent facilities are required than for ordinary children ; but, except in the case of degraded idiots, there is every prospect of cleanliness being attained by perseverance. The practice of wetting the bed is a common one with weak-minded people of all degrees, and sometimes there is a physical TREA TMENT GENERA L 1 73 weakness of the urinary apparatus, which may be corrected by appropriate treatment. More frequently, however, these laches are the result of inattention, and then moral methods, in the way of simple rewards and punishments, may be tried. One very simple remedy, partaking both of the physical and moral, is the restriction of the amount of fluid imbibed towards bed-time, and mentally feeble chil- dren are often " thirsty souls/' Raising the foot of the bed, and ensuring that the child does not sleep on his back, are two other household remedies^ often efficacious. We do not approve of india-rubber urinals, and other mechanical arrangements, which only tend to perpetuate bad habits, any more than we do of the ingenious (?) method proposed by an Idiot Asylum Superintendent of keeping his beds clean by the nightly administration of enemata to all dirty patients. Belladonna is the drug on which most reliance is placed; sometimes small doses of thyroid are beneficial. If the child has a tendency to dribble, efforts must be made to strengthen the muscles of the lips. Such exercises as holding a pencil transversely between the lips for a given time, and blowing whistles and trumpets, may be useful for this purpose. The clothing requires consideration. As with other children, it should be warm, yet light, and free from constricting bands. Woollen under- garments should be worn in all cases where this is practicable, but with wet cases there may be a difficulty as regards the nether garments, and where frequent washing is necessary, swansdown or some such material may be used. Jaeger's natural wool in winter, and cellular cloth (the so-called " Aertex ") in summer, form appropriate gradations 174 MENTALLY DEFICIENT CHILDREN as to warmth. With regard to the cut of the clothes, this should conform as nearly as may be to the ordinary fashion. It is wrong to accentuate per- sonal peculiarities by peculiar clothing. There is no good reason why boys of eight or more should con- tinue to be dressed like girls, when kilted costumes or sailor suits would be quite as convenient, and, moreover, promote a sense of self-respect. Weak- minded children are often not devoid of all pride of appearance ; this, judiciously cultivated, may be made a powerful level in the upraising of good habits. We have known a case in which a tendency to destroy clothing has been overcome, not by attiring the child in sackcloth, but by providing for her a pretty costume. Appropriate exercise occupies an important place in the general management. From the first, plenty of pure outdoor air is essential to the child whose brain activity is diminished by the imperfect aeration of its blood; and as time goes on, such muscular exercise as it is capable of should by every method be promoted. From a false sense of shame the deficient member of the family is too often carefully concealed from the public gaze; when this entails, as we have known to occur, the segregation of the poor child to the limited area of its nursery, or at most to the seclusion of its " own back- yard/' it is a question whether the Society for the Prevention of Cruelty to Children might not advantageously intervene. Teaching to walk will, of course, be a more tedious process than with ordinary children, but the faith which works by love will accomplish miracles, whereas neglect will too often entail permanent dis- ability. Contractures of limbs, consequent on bad postures allowed to become permanent, are sometimes PLATE XVIII. J. L. f " DIOGENES "). (R.A.A.) To face page 175. TREA TMENT GENERA L 1 75 met with in the mentally feeble ; and we have a vivid recollection of a poor boy of twelve who, having spent his childhood, like a modern Diogenes,* in a tub (a sugar-hogshead), was brought to us with his legs so hopelessly deformed by his constrained posture that he was a complete cripple, though we afterwards succeeded in getting him to use a tricycle specially built for him. But we must not linger on methods of exercise, which will be treated later; nor can we now enforce the importance of moral training from the earliest age in the formation of good habits, for this forms the subject of a future chapter. It must suffice to say that early home influences are specially potent for good or harm in the case of the mentally deficient child, and it behoves the parents of such to promptly obtain expert advice on the subject, as well as the aid of a well-qualified and intelligent nurse or nursery- governess. The late J. Langdon-Down, in his Lettsomian Lecturesf for 1887, laid stress on the prevalence of " morbid sexual erethism " in mentally deficient children of tender years, due oftentimes to the nefarious practices of an unworthy nurse. Whilst, happily, in our own experience this condition has not proved as frequent as some allege, yet the con- tingency must be borne in mind, and proper precau- tions taken. The approach of puberty is of necessity an anxious epoch as regards domestic management, and too much care cannot be exercised by those in charge of "feeble-minded youths" (of both sexes) to guard against abuses of the animal instincts then awakened. * See Plate XVIII. | Mental Affections in Childhood and Youth, p. 47 176 MENTALLY DEFICIENT CHILDREN Employment in the open air at this period will be special value; for obvious reasons, sending to bed ir the day-time as a punishment must not be thought of (B) We now pass to methods in the treatment of the mentally deficient child, which we may more especially designate MEDICAL. It has been already stated that such children are as a rule physically as well mentally deficient. At any rate, they are feeble body as well as in mind; sometimes (as was said one of our Kings) " not only weak in the head, but also weak in the understandings." The limbs, as wel as the brain, are imperfectly developed, and, ot course, nervous defects and disorders are frequently met with. There is in many cases, moreover, tendency to malnutrition, and a want of tone whicl: renders its subjects specially liable to the inroads infectious disease, and to parasitic skin affections. We have already stated that a phthisical family history is common with mentally deficient children We shall not, therefore, be surprised to find in the a marked predisposition to tubercular disease, some times affecting the joints, more often the lungs, and occasionally though perhaps less frequently tt would be anticipated the meninges of the brair Such causes of death formerly loomed large in the principal English institutions for defectives, account ing for at least 50 per cent, of the mortality of the inmates. Improved sanitary conditions, better ven- tilation and heating, and, above all, an increas open-air regime, have brought about a striking diminution in the tubercular death-rate. Thus, in his Annual Report on the Royal Eastern Counties Institution for 1912, Dr. Douglas Turner states that during the seven preceding years it had averaged only 9-2 per thousand, less by 35 per thousand than the TREA TMENT MEDICAL 177 average prevailing previous to that period. It must, however, be borne in mind that mental defectives as a class are unusually prone to the infection of tubercle. In all cases, therefore, it behoves the medical attendant to watch for, and guard against, the incipient symptoms of tubercular disease, fortify-l ing the constitution against it by open air, hygienic surroundings, judicious feeding, including a suffi- ciency of carbonaceous elements, and the adminis-'^ tration of such medicaments as cod-liver oil, malt extract, and Parrish's chemical food. \ Children of the " Mongol " type are specially liable to break down from exposure, and in cold weather are apt to suffer- not only from chills externally, but from internal congestions favourable to the development of tubercle! bacilli. Tubercular affections of glands, eyelids, \ bones, and joints, frequently occur. s The treatment of these will be considered under the head of Surgical. Mucous diarrhoea is a frequent ailment, especially with " Mongols/' and calls for care as regards feeding, and for suitable medication. We have found much 1 benefit in these cases from the administration of a mucilaginous mixture of castor-oil, with the addition ; of minute doses of opium. Sometimes small and re- peated doses of grey powder or calomel are of service. Astringents, pure and simple, given too early, are apt to add to the intestinal irritation. Epilepsy has been stated to occur in at least 25 per cent, of all weak-minded children. Its dietetic and medical treatment is, consequently, of much im- portance in the amelioration of the mental affections of youth, which it sometimes causes, and always tends to aggravate. Our experience leads us to lay stress upon the importance of a carefully regulated diet free from stimulating elements, milk food being a 12 178 MENTALLY DEFICIENT CHILDREN leading ingredient, with a restricted allowance ot meat. All food must be thoroughly cooked anc well masticated. To insure the latter condition, services of a dentist are often required. Spratling* condemns the eating of pastry or cake in any form, also of small fruits containing hard seeds. All ale holic drinks must be avoided, and only cocoa or weal tea and coffee be given. Cucumber and cabbage should be avoided. When bromide is administere table salt should be abstained from. As regards drug treatment, while there is no ques tion of the value of bromides in certain cases, there is considerable difference of opinion as to whether they should be adopted as a routine treatment for ; and sundry, and also as to the amount of the dose. Dr. McCallum, f the Medical Officer of the School for Epileptic Boys at Starnthwaite, in Westmorland, an enthusiastic advocate of the routine administra- tion of bromide, and often in large doses. He gives 20 grains night and^ morning, and increases bj 10 grains per day as long as fits occur. If necessary, he administers 100 or even 300 grains daily, but 80 grains is the average. His experience is that boys take 80 or 100 grains quite well, but that wit! 150 grains or more equilibrium is interfered with, and the patient must be kept in bed. He has excellent results to show in support of his system. At Ling- field, J where most of the children are said to have more or less mental defect, bromide is given in selectee cases, and pushed if necessary. The results in thes cases are very good, and in almost every instance the * Epilepsy and its Treatment, by William P. Spratling. Philadelphia, N.Y. London: W. B. Saunders and Co., 1904. f British Medical Journal, March 14, 1908. J Ibid. t June i, 1907. TtlEA TMENTMEblCA L i 79 child's work and mental capacity has improved. The statistics quoted by Dr. Aldren Turner in his book on epilepsy show that 50 per cent, of the cases treated with bromide derive benefit facts which, as he points out, go to disprove Dr. Spratling's contention that, if recovery takes place under the use of the bromides, it is in spite of, and not on account of, the drug. In our opinion, the idiosyncrasies of each case must be studied, and while some are beneficially influenced by bromides, others will do best with borax or a mixture of the two. Dr. E. C. Seguin, of New York, advo- cated the addition of a small dose of chloral. It is well to remember the value sometimes of a combina- tion of the bromides. Care, of course, must be taken that depressing effects are not produced. If acne occurs, the temporary administration of arsenic is useful. Bromide rashes are, however, relatively un- common in persons of cleanly habits, and Dr. McCallum, of Starnthwaite, says there need be no fear of a rash if the best English bromide is used. He says that the only treatment ever necessary, if it does occur, is a soothing ointment, and that the bromide can be continued. Strontium bromide has been recommended as preferable to the potassium salt, but Dr. Aldren Turner states that he has not found it more valuable than the other bromides. He refers to favourable results obtained by the use of the combination of potassium bromide, arseniate of antimony, and picrotoxin, known as Gelineau's Dragees. Among other preparations of bromide, we have had favourable experience of bromipin (bromide and sesame-oil). It is quite as efficacious as the ordinary bromides, and is now made in special tablets, which children take readily. It is also useful for excitable children. Bromipin can be given hypo- i8o MENTALLY DEFICIENT CHILDREN dermically in the status epilepticus without fear of abscess, and is not a gastro-intestinal irritant, the sesame -oil with which it is made up being a simple emollient. The late Dr. Andriezen* spoke highly of a combination of antipyrin (5 grains) with ammonium bromide (15 grains) as " promoting a degree of mental brightness. " In debilitated cases, the glycero- phosphates form a valuable combination with the bromides. If there be a syphilitic element in the causation of the epilepsy, bichloride of mercury, com- bined with bark, may be of benefit, or the ordinary grey powder, or else treatment by inunction. Sal- varsan has been satisfactorily employed, but in the light of our present experience should be reserved for those grave cases showing symptoms at birth. Its injection is difficult and dangerous in babies; it should be remembered that they are very liable to choroiditis, and as a rule respond well to mercury. As regards organotherapy it is disappointing, in view of the frequent association of glandular with mental defect, that so far little benefit has followed the use of organic extracts, beyond that of thyroid in cretinism. Recently good results have been ob- tained with pituitary extract in cases in which the hypophysis cerebri has been involved when the base of the skull has been fractured, or has had its function impaired by other pathological changes in the Sella Turcica. The pathology of these cases and the method of recognising them by an X-ray ex- amination have been described in Chapter IV. Serotherapy, or the treatment of epilepsy by in- jections of blood-serum from another epileptic, as introduced by Ceni, has recently been carried out by * British Medical Journal, September 16, 1899, p. 713. TREA TMENT MEDICAL 181 Dr. Alfred Gordon,* of Philadelphia, in a small group of cases, with beneficial results, as described in Chapter IV. The auto-intoxication theory of the origin of epileptic seizures has not been proved, but may hold good in a small minority of cases, and, at any rate, often aggravates the condition, even when the real cause is to be sought elsewhere. Attention to the eliminating channels is, therefore, essential. The periodical administration of calomel and other intestinal antiseptics is often beneficial. It is to this view of the origin of epilepsy that the drugs bromaline (bromine and formaldehyde derivatives) and bromo- carpine (bromine and pilocarpine) owe their intro- duction. In petit mal, which is, perhaps, more often asso- ciated with mental enfeeblement than grand mal, and has a less hopeful prognosis, E. C. Seguin speaks well of " combining with a very moderate bromide course the free use of strychnine and atropine or bella- donna, "f More important than drug treatment is what one may call the " outdoor occupation cure." The ex- perience of the Royal Albert Asylum, and more recently of the various epileptic colonies, is quite emphatic in this direction. Mere loafing in the open air is to very little purpose. Occupation is the pre- dominant factor for good. The most striking advance in the medical treat- ment of mental in conjunction with bodily defect is that of sporadic cretinism. Up to the year 1890, this was thought to be a hopeless form of idiocy; * Alfred Gordon, M.D., New York Medical Journal, 1914, xcix. 10. f " Treatment and Management of Neuroses/' New York Medical Journal, May, 1890, p. 31. 1 82 MENTALLY DEFICIENT CHILDREN but the experimental researches of Victor Horsley and others encouraged the view that benefit might be derived from the implantation of the thyroid gland of the sheep in such cases. Subsequently it was found that the injection of thyroid juice was of equal efficacy, and later that the ingestion by the mouth of the gland itself, or its preparations, was the best and most efficient mode of treatment. Thyroid grafting a method of treatment which went out of vogue has recently been suggested afresh by Sir Victor Horsley as the most desirable method, because it is permanent and avoids the continued administra- tion of thyroid extract. His views on this subject will be found in the discussion on Dr. McGarrison's paper on " Endemic Cretinism in Chitral and Gilgit " (published in the Proceedings of the Royal Society of Medicine, vol. ii., No. i, Medical Section, p. i). When thyroid extract is administered, mental awakening proceeds pari passu with physical development in a manner almost startling. Those interested in the sub- ject are referred to an article by Dr. Shuttleworth in Wright's Medical Annual for 1894, p. 324 et seq. The adjustment and regulation of the dose appropriate to each case, so as to avoid stomach irritation, excessive temperature, and undue emaciation, are the points calling for attention. So far as we can judge from present experience, this treatment (though in modified doses) must be permanent. Starting in children (ac- cording to age) with one or more 2i-grain tabloids daily, the dose may be cautiously increased up to six tabloids, and when improvement has been achieved one or two 5-grain tabloids daily will usually suffice to maintain it. The annexed Plate XIX., for which we are indebted to the courtesy of Drs. Railton and Telford-Smith, shows the condition before and after TREA TMENTS URGICA L 1 83 treatment of two brothers, one of whom was formerly under Dr. Shuttleworth's care at Lancaster, while Plate XX. depicts their ultimate condition. The majority of mentally deficient children being of feeble constitution, the prognosis of the exanthe- mata, and of acute disease generally, must be guarded, while depressing treatment is inadmissible. Cerebral complications are frequent, and convulsions not un- common. Troublesome sequelae affecting mucous membranes (in the eyelids and elsewhere) are apt to occur after measles, which, in our experience, is a disease almost as formidable as scarlatina with defec- tives. The irritability of mucous membranes is at all times a source of trouble with mentally deficient children, andcatarrhal discharges from the eyes, nose, and ears have to be treated with astringent lotions. Spongy gums are frequently found, especially when the hygiene of the mouth is not attended to, and chlorate of potash washes are useful in these cases. Aphthous patches and parasitic diseases of the skin must be treated by appropriate remedies. Curious skin affections of neurotic origin are sometimes met with in cases of mental feebleness, such as that described by Dr. Pringle and others under the name of " Adenoma sebaceum,"* and now recognised, as we have described in Chapter IV., as part of a clinical entity designated " tuberous sclerosis " or " epiloia." (C) A few remarks as to SURGICAL treatment in relation to mentally deficient children must close this chapter. The contractures of limbs may sometimes be remedied by tenotomy, but the deficiency of reparative power, and the difficulty found -at any rate, with low-grade cases. in keeping appliances in position and free from filth, must be borne in * British Journal of Dermatology, January, 1890. 1 84 MENTALLY DEFICIENT CHILDREN mind before undertaking a surgical operation. We cannot, therefore, give mentally deficient childre the full benefit of all modern surgery has achieved in the treatment of paralysis, especially as, to ensure success, the after-treatment must be prolonged. Indeed, Mr. Robert Jones,* of Liverpool, has placed many of these unfortunate children " in a group out- side remedial art." For the relief of constitutional disturbance, however, such as that caused by bone or joint disease in tubercular cases, operative inter- ference is justifiable, and is generally successful. We have repeatedly seen considerable benefit to mental activity from the clearing away of post-nasal adenoid vegetations in feeble-minded children. About 1890 the operation of cranieetomy i.e., the cutting of strips of bone from the cranium was recommended in cases of microcephalus. This prac- tice has, however, been abandoned, owing to the disappointing results, and the knowledge that the small skull is simply moulded to the brain, the development of which has been arrested at the fifth month of intra-uterine life, f When signs of pressure are seen, however, as in oxycephaly, and in the rare cases in which there is a history of prematurely ossified fontanelles, operative interference may be justifiable. In Chapter IV. we have explained the advantage of draining the subarachnoid cisterns in * On Certain Principles and Methods in the Surgical Treat- ment of the Paralysis of Children, by Robert Jones, 1902. t See article by Dr. Shuttleworth, Medical Annual, 1895, p. 327. Dr. Telford-Smith has described and illustrated in the American Journal of Psycho- A sthenics for June, 1897, the cases of two microcephalic boys whom he had the oppor- tunity of closely observing during four years after cranieetomy had been performed, his conclusion being that in the light of results the operation is unjustifiable. TREATMENT OF MENTALLY DEFICIENT 185 cases of status epilepticus due to a localised meningitis serosa externa. Beneficial results have been fre- quently obtained by cranial operations in cases of mental deficiency associated with traumatism, epilepsy, and paralysis; in such cases surgery should not be deferred until after the establish- ment of serious atrophic changes and degenera- tions. The diagnosis of abnormal cranial condi- tions, which may give rise to prejudicial irritation of subjacent tissues, is facilitated by the progress of radiography, skiagrams demonstrating with fair clearness the cranial outlines being now available. CHAPTER IX EDUCATIONAL TRAINING WE now pass to the consideration of means which, as distinguished from general treatment, we maj designate Educational. Under this term we include all those methodical and specific exercises, whether physical or mental, which naturally fall into the school routine, and need for their direction a skilled teacher, acting in concert with the physician. The kind and amount of educational exercise appropriate to a par- ticular case of mental deficiency or feebleness should indeed be prescribed by the latter, and consequently a cursory sketch of the teaching technique adapted to characteristic varieties may not be out of place in what aspires to be essentially a medical work. As a matter of convenience, industrial and moral training, though forming integral portions of the educational system, will be considered in subsequent chapters. In dividing educational means into (a) physical (those more particularly addressed to the body), and (b) mental (those more particularly addressed to the intelligence), we must bear in mind that the two are not independent of each other, and that, with regard to mentally deficient children especially, " the physi- ological education of the senses must precede the psychical education of the mind."* We may add that the training of the muscular system to ready * Seguin, New Facts, etc., p. 41. New York, 1870. 1 86 EDUCATIONAL TRAINING 187 and regulated response is merely an extension of sen- sorial training; and both these processes naturally precede, and prepare the way for, more purely intellec- tual training. It has been well remarked by Froebel that, " in primary education, the Doing, the Thing Done, the Teaching and the Learning, must, in every case, rest on actual fact and on real existence, so that the mental intelligence, incessantly striving upwards in single things, as in its general career, may thereby expand and develop the life-giving creative powers of the pupils, according to the measure of their strength and ability, their talents and desires."* The mentally feeble child is specially incapable of comprehending abstractions: all instruction, there- fore, must be presented to it in a concrete form, which it can* not only see, but, when possible, grasp in the hand as well as in the mind. Many of the " games " and " occupations " of the kindergarten are conse- quently of service, but whereas the normal child exer- cises its own spontaneous activity through these occupations, those who are mentally deficient, especi- ally those of the apathetic type, have to be stimu- lated to action by the force of imitation. Our system of education, then, starts on physiological lines, first addressing itself to the culture of the external senses, then to the co-ordination of muscular movement, and finally to the promotion, by imitative and other exercises, both of the manual and mental activities. In thus laying down these general principles of procedure, it must not be imagined that all cases can be treated in the same way. On the contrary, it is essential to success that the teacher should study the individual peculiarities of each case, and adapt the * Froebel' s Letters on the Kindergarten. Swan Sonnen- schein and Co., 1891. i88 MENTALLY DEFICIENT CHILDREN educational methods employed to those peculiaritie Mentally abnormal children may be broadly divide into two main groups: (i) those who are dull and apathetic; (2) those whose nervous and mental action is irregular. It is obvious that the rousing, stimu- lating regime suitable for the former is not that most appropriate to the latter, in whom the inhibitory and co-ordinating functions require to be strengthene by exercise. As extreme examples of the first group we ma} instance the " impassive, low-grade idiot, whos education begins with a bombardment of bean-bags. Such a child is so inert as not at first to put up its hands to protect its face from the bean-bag thrown at it by the teacher; gradually, however, the instinct of self-preservation asserts itself so far as to ward of the missile. The second step, to catch the bag, anc the third, to throw it back to the teacher, mark successive steps of improving mental activity; and from these progress is made in the direction of simple drill, aided by music/'* The bean-bags referred to are about 5 inches square, .made of bright-coloured flannel, and loosely filled with beans or rice, so that their impact is not hurtful. The same sort of exercise, varied by aiming the bags so as to pass through round or square holes in a board, or into the mouth of a grotesque figure, is exceUent for promoting alertness of the eye and hand, as well as concentrating atten- tion, in higher-grade children. Amongst children of the second group we include those with evidences of an over-mobile nervous system, or with uniform repetitive movements, such * See paper by Shuttleworth, "On Points Connected with the Education of Feeble-minded Children," British Medical Journal, September 8, 1894. EDUCATIONAL TRAINING 189 as those designated athetosis. The golden rule in these cases is try to substitute, in place of purpose- less, irregular movements, motor exercises with a definite purpose, and calling for will-power. In this way inability to fix the attention (aprosexia, as it has been called) is gradually overcome, and the moral satisfaction resulting from " something attempted, something done," encourages to fresh efforts. In cases where nervous irritability is so great as to give rise to destructive tendencies, the irregular energy FIG. 4. PEG-BOARD. should be turned into constructive channels; thus a child of this temperament may be coaxed to build up wooden bricks into some definite form for the pleasure of knocking them down with a crash ! Gradually he may be led on to practise building for its own sake. The child with incessant movements of his fingers (athetosis) is usually not greatly wanting in will- power, and it is marvellous how much may be achieved by appropriate finger exercises (such as those of the peg-board, see Fig. 4), or the more interesting kinder- garten occupation of "picture perforating." The 190 MENTALLY DEFICIENT CHILDREN intelligent teacher will know how to adopt, and adapt to the use of the deficient child, the various educa- tional means now in vogue in our infant schools. It must, however, be borne in mind that much that the normal child learns intuitively needs to be taught specifically to the abnormal. The external senses are often functionally inactive, if not structurally defec- tive, and it will be necessary to open up, by a serie of sensorial exercises, these obstructed avenues of approach to the central intelligence. Then the due co-ordination of muscular movement must strengthened and regulated by judicious drill. Finally, the general intelligence must be cultivated by inter- esting the child in its surroundings, and breaking dowr the isolation in which the solitary idiot, and to less extent the mentally feeble child, carry on their existence. All this preliminary work of necessit} precedes instruction in the three " R's " and what we are accustomed to regard as ordinary school- work. We rejoice, however, to find that the physiological sequence we have indicated, and which was laid down by Seguin seventy years ago as the educational mode for defective children (as well as for others), is gradually being recognised in the curriculum of elementary schools. We do not ven- ture to trespass upon the domain of pedagogy farther than to point out the special methods of in- struction indicated to meet the special requirements of pupils who, by reason of mental defect (often associated with physical), cannot " properly be taught in the ordinary standards or by ordinary methods." And first with regard to sensorial training, it will be convenient to consider separately the several senses, though in practice the training will be of a combined character. EDUCATIONAL TRAINING 191 The tactile function is not only the most general, but in some respects the most important of our senses, and in the normal baby its evolution takes precedence of the rest. Impressions through the eye and ear are criticised through the sense of touch, and this natural development, so serviceable in the spontaneous educa- tion of all healthy young animals, must be imitated in our endeavours to bring up towards the normal standard the sensorial training of imperfect children. In some cases we shall find coarse, insensitive hands which must be drilled into sensibility by grasping hard and soft objects, and discriminating the resistance and surface impressions of such varying substances as polished marble, sand-paper, velvet, silk, etc. Sensibility to heat and cold may be gauged and culti- vated by the handling of bottles filled with water of varying degrees of temperature. Such lessons will, of course, form incidents of the object-lessons which play so important a part in early education. In some exceptional cases there is a morbid sensibility (hyper- cesthesia), which is best counteracted by friction against hard substances, and the employment of the fingers in coarse work. In order to test and exercise tactual impressions apart from those derived from the sense of sight, Seguin recommended that the patient should be placed in a darkened room. The same object is ac- complished in the Montessori method by blindfolding the child engaged in tactual discrimination of sur- faces and objects. In the case of mentally deficient children, however, there is risk, as Dr. Montessori remarks, that the attention may be diverted to the bandage itself, or that the darkened room may pro- duce a condition of lethargy or disorder interfering with the tactual exercise. 192 MENTALLY DEFICIENT CHILDREN The use of the peg-board (Fig. 4) has already been mentioned as serviceable in cases of athetosis (spas- modic finger movements) : it is also valuable in culti- vating the tactile sense. Similarly, size and form boards (Figs. 5 and 6) promote accuracy not only of grasping movements, but of capacity for adjustment of insets to their appropriate cavities; and a pin- cushion covered with spotted material, into the spots of which the child sticks pins, is useful in exercising minute sensation, as well as fine adjustment of the muscles. Threading coloured beads and buttons serves not only as an exercise of tactile sense, but, as will afterwards be pointed out, of the arithmetical faculty. The appliances illustrated on pp. 193-194 were de- signed some sixty years ago by Seguin for use in American institutions for the feeble-minded, and with slight modifications have formed part of the school equipment for such institutions on both Continents ever since. Of recent years similar, but more elaborate, appliances have been devised by Dr. Maria Montessori for use, not only by defective children, but as aids to the auto-education of normal infants, and are on sale under the designation of the " Didactic Apparatus for use with the Montessori System of Education."* The Dottoressa acknowledges in her classic work (" The Montessori Method "), published in English in 1912, her obligations to Seguin and his .didactic apparatus, which she has skilfully systematised and extended. She justly lays stress upon the spirit- uality (or intelligent spirit) in which the apparatus needs to be used, which is, indeed, of more importance than the precise form of its construction. It may * A list of these appliances may be obtained from Messrs. Philip and Tacey, Ltd., Norwich Street, E.G. EDUCATIONAL TRAINING 193 perhaps be open to question whether some of the modifications introduced by her are improvements FIG. 5. SIZE-BOARD. on Seguin's devices. Thus the little knobs added for lifting the " geometrical insets " detract from FIG. 6. FORM-BOARD. their utility as a grasping exercise afforded by the size and form boards above illustrated. The grooves in Seguin's "graduated rods" (Fig. 7) have ad van - 194 MENTALLY DEFICIENT CHILDREN FIG. 7. GRADUATED WOODEN RODS. 2 (&) FIG. 8. DOMINO-BOARDS. (Cl tages as compared with the " long -stair " of the Montessori system, inasmuch as the former exercise the tactual as well as the visual sense. EDUCATIONAL TRAINING 195 The sense of sight comes next in importance to that of touch, as regards training. Ocular defects must, of course, be treated by the ophthalmic sur- geon, and in errors of refraction correcting glasses supplied; the teacher's function is to concentrate the wandering gaze, to specialise the vacant stare of the defective pupil. To quote a quaint Gallicism of Seguin's, " the main instrument in fixing the regard is the regard "; that is to say, the vagrant eye of the pupil may be brought to attention by the fixed gaze of the instructor. Glittering objects, such as the sil- vered globes used for Christmas-trees, are serviceable also for this purpose, especially with very young children, and the kaleidoscope is an attractive toy of distinct educational value for older ones. The in- dependent movements of the eyeball, apart from I. those of the head, should be called into play; the \ training of the ocular muscles is too often neglected, with the result that the child's lateral range of vision is unduly restricted. Discrimination of colour is a \ later exercise of the visual organ; and for this pur- pose discs of various colours for the child to match, cubes, the sides of which are vari-coloured and are successively turned uppermost, following the lead of the teacher, and a series of cups and balls, to be fitted together in corresponding colours, are useful aids. But perhaps more interesting to the juvenile mind is the matching of coloured ribbons and articles of clothing, or pointing out corresponding hues in coloured pictures. Exercises in colour perception naturally lead to the distinguishing of colours by name, but the former take precedence in sensorial training. The teacher or nurse should not therefore commence by asking the child which is red, blue, etc., but the colour sense should be exercised by getting 196 MENTALLY DEFICIENT CHILDREN the child to sort into separate heaps the severa discs or pieces of coloured cardboard. Matching coloured wools, and finding cards corresponding colour to the squares on the colour chart, are other useful exercises. Forming pictures from picture cubes is a more advanced form of eye training, and the use of size and form boards (Figs. 5 and 6), anc of the graduated wooden rods, to be arranged in step- like series (Fig. 7), exercises both hand and eye, anc imparts ideas of form and dimension. Ideas of rela- tion are similarly imparted by exercises with dominc boards (Fig. 8), two of which are placed (a) flat, side by side ; (b) at right angles laterally ; and (c) at right angles end to end, following the lead of the teacher. Taste and smell, being essentially animal rather than intellectual senses, do not as a rule require much stimulation in the mentally deficient class. * But discrimination may be exercised by offering tc the pupil substances of similar appearance, such salt and white sugar, to be distinguished by taste; ground coffee and snuff, to be distinguished by smell. Hearing is sometimes apparently deficient when the real deficiency is that of attention. Mentally feeble children often hear perfectly well, but do not take the trouble to listen; they may, however, be coaxed to do so by presenting to them agreeable sounds. Fortunately, music has for this class specia charms, and a simple song will often enlist attentior when mere speech is disregarded. Nursery dittie * Perverted and abnormal states of these senses are occa- sionally met with in idiots; we have known one whose peculiar " taste for literature " was manifested by his " de- vouring his book," cover and all; and another who tinguished his own and his comrades' clothes solely by sense of smeliv TRAINING 197 are consequently not without educational value, and, as we shall see later, often form stepping-stones to speech. Tone-deafness is sometimes met with, and if low-pitched sounds are not apprehended, those that are more shrill (such as those produced by the whistle) should be tried. At a later stage the discrim- ination by pupils ol the different quality of sounds produced by different instruments is a good exercise. Speech is a complex function, having important relations to auditory perceptions on the one side, and on the other being dependent upon the integrity of nerve centres and tracts, and the due co-ordination of the muscular apparatus concerned in vocalisation and articulation. More or less imperfection of speech is extremely common with mentally deficient children, and when not the result of want of development or lesion of the cerebral speech-centres, much may be done in the way of amelioration by appropriate training. Excluding cases dependent on deafness in which lip-imitation methods are of much value, and the " oral method " has a literature of its own* we may say that as a rule such children require to be taught to speak much as a baby learns to speak. In some cases, however, a course of lip and tongue gymnastics is an essential preliminary. The pupil may be unable to bring the lips together, to bring the teeth together, or to direct the tongue as required for the formation of a sound. In such cases special exercises adapted to the particular infirmity are requisite. To improve the power of closing the lips, a flat piece of boxwood, an ordinary penholder-stick, or a bone ring, may be held by the child between his lips for a few minutes at a time; and this is an exer- cise useful in repressing slavering. Blowing a whistle * E.g., Lip-Reading, by Edward B. Nitchie (London: Methuen and Co.) . ig8 MENTALLY DEFICIENT CHILDREN is also of service, and puffing into motion a pellet paper or a flake of cotton-wool helps in the power pursing up the lips necessary for labial sound Opening and closing the mouth, so as to bring the teeth together; putting out the tongue, deviating it to the right and to the left, and touching with it the teeth of the upper and the lower jaw respectively also the roof of the mouth, are other forms of or exercises serviceable in overcoming defects of cc ordination interfering with clear articulation. Exer cises in deep breathing are also important.* In most cases, though not in all, consonant sounc are more readily acquired than vowel sounds. Tr. normal infant starts its attempt at speech by repeatir the simplest labials or linguals: " bab-ba," "mam- ma/' and later " dad-da, " are among its earlies efforts. Following these lines, the child deficient in speech should be exercised in simple reduplicate consonant sounds, followed by the open vowel a (ah}. A schedule of speaking exercises based on these prir ciples was published by the author in an article on the " Educational, etc., Training of Idiots and Im- beciles," in Hack Tuke's " Dictionary of Psyche logical Medicine."! In this the repetitive phonetic (e.g., " mam-ma ") is coupled with the name of a cor mon object (" mat," " man "}, of a part of the bod} (" mouth "), and of part of dress (" muff," " mitten "), beginning with the consonant sound (m) ; and so on through the series of labials, linguals, labio-dentali gutturals, and nasals. There is also a f table of vowe sounds and examples. But for the present work it must suffice to say that for mentally deficient children * Breathing Exercises, by Duncan Matheson Mackay, M.D. (London: J. Bale, Sons and Danielsson), price id. t Churchill, 1892, vol. ii., p. 673 (see Appendix C, p, 261) EDUCATIONAL TRAINING 199 half the battle is to sustain their interest, and mechanical exercises in speaking, however well de- vised, must be brightened up by illustration. The naming of objects in well-chosen pictures,* and of the child's own surroundings, and the imitation of the characteristic cries of animals, are some of the best means of making a start with speech. A child will demur to repeat sounds read by a teacher from a table, though he will cheerfully respond to the ques- tions, "What does the cow say?" ("Moo"), or, " What does pussy say ?" (" Mew "). Similarly he will imitate the " Ba-ba " of the sheep, or the " Bow- wow " of the dog, and thus learn both consonant and vowel sounds without conscious effort. Slovenly pronunciation, with slurring of final consonants, especially if doubled, is a frequent failing with the child of inert temperament, and needs to be dealt with by vigilance in reading and recitation exercises. Stammering, and especially stuttering, is common with those of neurotic type, and slow and deliberate utterance should be encouraged in such, exercises in deep and diaphragmatic breathing being an essential preliminary, with practice in controlling the exit of the breath. Intonation of vowels, and the gradual introduction of preceding consonants, special atten- tion being given to those over which there is tendency to stumble, are amongst the expedients found service- able, but these methods are best applied by skilled teachers capable of appreciating the physiological disabilities of the pupil. For those following up the subject valuable hints will be found in such treatises as Dr. Wyllie's on " The Disorders of Speech," Dr. W. S. Colman's article on " Impediments of Speech," in Allbutt's " System of Medicine," vol. viii., and * Tuck's Book of Objects is recommended. 200 MENTALLY DEFICIENT CHILDREN Dr. Leonard Guthrie's " Functional Nervous Dis- orders in Childhood/' There are two peculiar modes of speech, occurring, indeed, at a certain stage of development in normal children, but apt to persist in what Dr. Guthrie well designates the " crystallised infancy " of imbeciles, which call for special notice here Eeholalia and Idioglossia. By Eeholalia we mean the parrot-like imitation of heard sounds and words without any definite connotation of their meaning in the mind of the imitator. All children begin to talk in this way, but the bright child soon associates the sound " Mam- ma " with his mother, " Nan-na " with his nurse, and so on. In due time he attains a rational vocabulary, which he is able to apply in naming familiar objects, and subsequently in replying to questions. But with some low-grade imbeciles this stage is never attained. Hearing being, however, good, and the commissural connections between the auditory centres and the organs of speech being fairly developed, a kind of reflex action is set up without the intervention of thought, and what is merely the echo of spoken words is the result. In some cases only the last words of a phrase are repeated, in others the whole phrase. Thus an imbecile, when asked " What is your name ?" may reply simply, " Name "; or another may vacantly repeat the whole question without giving an answer. Yet the fond parent will stoutly maintain his child can " speak," and will be much discouraged, if not indignant, when told that such speech is nothing worth, and, if persistent at an age beyond infancy, denotes a low grade of mental defect. Of course, with a quite young child the prognosis is more hope- ful, as there is a chance, under persevering training of the powers of observation, of his attaining the EDUCATIONAL TRAINING 201 indispensable association between the name and the thing. Idioglossia (described by some authors as a severe form of " lalling " or lisping) is a term applied to a species of " baby language " persistent beyond the period of babyhood. Up to three or four years of age the normal child is apt to substitute sounds easy of articulation for more difficult ones: thus, " muvver " is substituted for " mother "; " tahee " for " father "; and so on. Further, when phrases are formed, the pronunciation of the words may be grotesquely varied, as in such a sentence as " Ditty is dood 'ittle boy " Dicky is good little boy. Fond and foolish parents and nurses sometimes allow themselves to fall into similar modes of language in conversing with their children, and so correct pronunciation is delayed. A child, indeed, sometimes builds up a fancy language of his own, unintelligible to any but his intimates, which may, in fact, seriously handicap him in the early years of education. In some of these cases there seems to be partial auditory or visual defect: in others, however, there may be some degree of mental defect, and imbeciles are occasionally met with who have constructed a sort of language of their ov/n, requiring a glossary for its comprehension. Such a girl of ten, formerly under Dr. Shuttleworth's care, habitually called him " Fish," because her family medical attendant had been a Dr. Fisher; his wife she designated " Fish-mamma," and his daughter " Fish-dolly "J An old man glazing the greenhouse was promptly christened by her " Pa-putty "! In this case the " idioglossia " (using this term in its etymological rather than strictly scientific sense) seems to have had a philological basis. Interesting as these deviations from normal speech may be, they 202 MENTALLY DEFICIENT CHILDREN are not, however, to be encouraged; and in the case of imbecile children especially, every effort should be used to promote correct pronunciation. Training ir speech is, indeed, a valuable means of fixing the attention and cultivating muscular co-ordination, and in these respects, as well as for its specific effect, may be regarded as a valuable adjuvant to other educational measures. It has already been remarked that, with the feeble- minded, music is often a stepping-stone to speech. Such children will frequently hum tunes that take their fancy before they are able to articulate words; but if attractive tunes set to words containing repeti- tions of simple sounds (such as the " Ba-ba, black sheep " of our old Nursery Rhymes*) are constantly repeated to them, the probability is that, after a time, first one word and then another will be taken by the pupil, till the rhyme as well as the tune is known. We pass from the cultivation of speech, whicl occupies an intermediate place between sensorial training and the co-ordination of muscular move- ment, to a consideration of the exercises more especi- ally addressed to the latter, which we include under the comprehensive designation of drill. With chil- dren of deficient bodily as well as mental develop- ment, physical training is serviceable not only for muscular growth and co-ordination, but, inasmuch as it demands prompt obedience, for strengthening the faculty of attention. The movements must be gentle and adapted to individual capacities, and even in- capacities ; mere " tours de force " are inadmissible. Musical drill is to be preferred at any rate, in the * Elliott's National Nursery Rhymes is recommended for this purpose. EDUCATIONAL TRAINING 203 first instance whenever practicable, and there are now many excellent manuals on this subject, such as GnTs " Physical Exercises," Alexander's " Musical Drill for Infants," etc. , * which may be advantageously used for exceptional as well as ordinary children. Light wooden dumb-bells, wands and rings, are the simple apparatus required. The Syllabus of Physical Exercises issued by the Inter-Departmental Com- mittee for use in Public Elementary Schools contains many that are also appropriate for special schools, including some for deep breathing. " Swedish " drill under a judicious instructor is of much value. For special infirmities, however, such as we frequently meet with in the mentally feeble, special exercises have to be devised for particular cases ; and the want of balancing power many show is overcome by " toe- ing the line," by walking the plank, by stepping first between the broad bars of a ladder laid hori- zontally on the ground, and then from bar to bar. Deficient grasping power is strengthened first by the bean-bag exercises previously referred to, then by bar-bells, and finally by supporting the weight of the body on parallel bars or from the bridge- ladder. Seguin speaks highly of the beneficial effect of a swing worked by the child's feet from a spring- board in developing the lower limbs and strengthening weak knees. Though scarcely gymnastic, dressing lessons may be given with advantage as class exercises to children inexpert in putting on their clothes. Buttoning, lacing, and tying bows and knots bring into play fine adjustments of the fingers frequently deficient in the mentally feeble. For practice in this frames for * See also Physical Education, by Lennox and Sturrock (Blackwood). 204 MENTALLY DEFICIENT buttoning, lacing, and bow-tying, etc., have been patented as part of the Montessori method, though similar arrangements (e.g., the fastening of clothes on a mannikin) have been in use in training institu- tions for defectives from time immemorial. With regard to the more ordinary school exercises, we can only indicate a few points on which special stress should be laid in the case of mentally feeble children. " Facia non verba " should be the guiding principle; things done will make much more impres- sion than things merely said; and whenever prac- ticable, lessons should be illustrated by objects, for, as was remarked by Horace : " Segnius irritant animos demissa per aurem Quam quae sunt oculis subjecta fidelibus." Mere parrot-like repetitions of matters committed to memory should be discouraged; nothing should be learned by rote which is not understood, otherwise much labour may be lost, and at length we may find (with Longfellow) that " In an idiot's brain remembered words Hang empty mid the cobwebs of his dreams." In this connection we may lay stress on the im- portance of simple conversational examination, in which the pupil is encouraged to take a full part, the teacher thus ascertaining how much the child has understood of a lesson, and encouraging the latter to add to his vocabulary and powers of language. Object-lessons must start from the simplest facts within the child's observation. The names and uses of the sense-organs, of the limbs, of articles of clothing, of the furniture of the room, are some of the subjects upon which the child's intelligence should be exer- cised. Nature-study is attractive to many, and is most EDUCATIONAL TRAINING 205 useful in educing and cultivating powers of observa- tion. Drawing and writing are best taught in the ele- mentary stage by free-arm and large scale exercises on the blackboard chequer. Drawing lines vertically, horizontally, and obliquely, between points marked by the teacher, and afterwards delineating common objects under which the names may, with help, be printed and written,* pleasantly lead the children on both to writing and reading, and with regard to the latter it may be remarked that the " look and say " or " word " method is to be preferred to the old-fashioned plan of beginning with the drudgery of the alphabet, f Of course, the sounds and names of letters are learned at a later stage, words being dissected for this pur- pose with the aid of the letter-box. Madame Mon- tessori has an ingenious system of cards upon which script letters of the alphabet cut in sandpaper are mounted, and over those forms the index-finger is passed in the direction in which the letter is formed in writing, as a preliminary exercise of the muscular, tactile, and visual sensations. These sensations are associated with the letter-sound, and writing, and subsequently reading, both of script and printed letters and words, are by this means acquired with more facility than by the ordinary method. % Calculation is the crux in educating the mentally deficient. Counting (so-called) may be glibly done * See Reading Made Easy, Anna Snell. Philip and Son, London. f Gill's " Regina Reading Sheets " are useful. J Montessori Method, pp. 275, 303. It is remarkable that in the case of candidates for admis- sion to the London Special Classes there is often a certain ability to make small calculations as to pennyworths, such as they have been accustomed to in errands for their parents. With them reading seems to be the crux. 206 MENTALLY DEFICIENT CHILDREN without any apprehension of the meaning of figures; consequently the concrete must always elucidate the abstract. Many excellent aids are published for this purpose, pictorial and otherwise; but the ingenious teacher will not be dependent on these, as the child's own fingers, the pupils in class, etc., are always avail- able for demonstration. Shells, beads, and the abacus are also convenient objects for counting. To elucidate the value of weights, money, and to teach simple calculation, there is nothing better than the " shop lesson/' an elaboration of the nursery game of shop, in which common groceries are weighed out and paid for by the pupils, problems in change being tackled practically. Industrial training is intimately interwoven with educational processes, but will be specially treated in the next chapter. CHAPTER X INDUSTRIAL TRAINING AND RECREATION To complete the educational fabric appropriate to mentally deficient children, the woof of industrial training must be closely interwoven with the warp of scholastic exercises, and a wholesome moral influ- ence must be the pattern pervading the whole. In the present chapter we offer some hints as to special modes of industrial training found useful. The " occupations " of the Kindergarten, selected so as to avoid too minute work, form attractive and serviceable preliminaries to handicraft. " Paper- weaving," for instance, is an excellent preparation for the more prosaic industry of stocking-darning, and the " pricker " used for perforated pictures will serve as an introduction to the cobbler's awl. Useful as are Kindergarten occupations for training the fingers, and, through them, the intelligence, the actual pro- ducts of child-labour in the way of bead necklaces, variegated paper mats, clay and cardboard models, etc., have a distinct value in developing continuity of attention and stimulating further effort, as the principle of achieving a tangible result is specially satisfactory to the mentally feeble child. In this respect, industrial training has an advantage over mere book-learning, and it has been well remarked that feeble-minded children learn more with their hands than with their head. A judicious industrial 207 208 MENTALLY DEFICIENT CHILDREN trainer, in fact, develops the child's intelligence par passu with the use of his fingers. The kind of employment most suitable differs wit the particular characteristics of each case. With the majority, outdoor work is the best whenever pra ticable, and we have repeatedly seen both physica and mental development set going by such healthy occupation, when indoor teaching and employmen had proved unavailing. Wherever and wheneve practicable, the regime of an open-air school is tt ideal to be aimed at in the instruction of defective nervous, and backward children. Careful suj vision is, of course, needed; otherwise, if put to wee a garden the child may ruthlessly root up plants well. The love of seeing things grow, howeve should be fostered, and the child will soon watch wit interest how the seedling gradually becomes tl plant. To every special school a children's garden should, if practicable, be attached. The care plants in pots, the growing of bulbs and germination of acorns and chestnuts in glasses, and even grov mustard and cress on moistened flannel, are simpl< forms of Nature-study which delight the pupils the London sp2cial classes. Kindness to anima should be inculcated; and, when this exists, occupa tion at a farm is often beneficial, much interest bein taken in the stock. For town-bred children, unfortunately, outdo occupations are not, as a rule, available. There ar however, many varieties of manual training nov commonly practised in connection with our publi elementary schools and in technical classes in whic the mentally feeble may participate. The ma of woollen and cocoanut fibre mats, cloth and ca weaving, simple brush and basket making, strav plaiting, sashline-making, are some of the arts easil INDUSTRIAL TRAINING AND RECREATION 209 acquired which furnish a very pleasing result; and the same may be said of macrame work, which in our experience is an excellent exercise for those subject to finger twitches. We have elsewhere remarked that these athetotic patients frequently possess graphic and artistic ability; and for such, wood- work and even wood-carving form congenial employments. It is marvellous how, by persevering exercise of will- power, such pupils gradually overcome their spas- modic movements, and are at length able to execute quite fine work with the chisel and graving tool. Girls with athetoid affections often become, under training, good needlewomen, putting in their stitches with great regularity. The mysteries of knitting, crochet, and other fancy work, are also mastered by them; and we have seen a mentally feeble girl, crippled as to her right hand by spastic contractures, do fine-art needlework with her left. At some of the institutions lace-making is carried on with con- siderable success. An excellent handbook for trainers,* entitled " Industries for the Feeble-minded and Imbecile/' has been published by Mr. A. Bick- more, the able Craftsmaster of the Darenth Industrial Colony. Practical advice is therein given as to the various industries found serviceable in a Poor Law institution, amongst which he mentions, in addition to wood- work and building handicrafts, such occupa- tions as printing, book-binding, envelope and paper- bag making, cardboard-box making, tin-ware and metal- plate work, as well as the more ordinary trades of shoemaking, tailoring, and brash and basket making. The practical needs of after-life must, of course, be borne in mind in selecting a particular employment. * " Industries for the Feeble-minded and Imbecile," by A. Bickmore. London: Adlard and Son, 1913. 14 210 MENTALLY DEFICIENT CHILDREN The gentleman's son, though comfortably provided for, will be all the happier for having an occupation to turn to; and for such, carpentry, wood-carving, and even turning, are good indoor pursuits, whilst gardening and farming are specially appropriate. Young ladies who by leason of their feeble-minded- ness will be to some extent debarred from the ordinary pursuits of society should be encouraged to take an interest in domestic matters, and to assist in arranging floral decorations. They may also employ them- selves in a variety of fancy work ; and if they possess any artistic or musical tastes these should be culti- vated. For children of the working class some occupation which they can carry on under the eye of their parents is desirable. If they live in the country, they should be trained for agricultural labour, or to assist in garden work. If in town, some work which they can practise at home, or in small establishments, such as cobblering or tailoring, basket or doormat making, should be taught them; for obvious reasons they are unfit for factory work. It may be interesting to add that recent after-care statistics show a considerable number of ex-pupils of special schools serving with the colours (sixty so reported from Birmingham* and seventy-seven from London) ;| and in the Boer War an ex-patient of the Royal Albert Institution ren- dered creditable service in the I3th Hussars, assisting at the relief of Ladysmith, but ultimately succumb- ing to an illness contracted in his duties. The dis- cipline and outdoor life of the army seem, indeed, beneficially suitable for the more intelligent cases of * .Report of Birmingham Special Schools After-care Sub- committee, June, 1915. f After-care Association for Elder Mentally Defective Children of London, 1914. INDUSTRIAL TRAINING AND RECREATION 21 f good physique. Girls should be trained to work in the house and the laundry, to cook, and to make garments. Many imbeciles who have been brought up in institutions are quite capable of earning their living under favourable circumstances, but the " res angusta domi," and (too frequently also) parental incapacity, are not favourable circumstances, and consequently, if discharged to their own homes, there is much risk of training being thrown away. This is one of the arguments in favour of permanent custodial working-homes and colonies being instituted by private benevolence and public authorities for mentally deficient children capable of useful industry. Recreation. For mentally feeble, as well as other children, the maxim " ne quid nimis " is especially appropriate. Study and occupation must be varied; signs of fatigue watched for and guarded against ; and relaxation is essential. But care must be taken that relaxation does not degenerate into loafing; suitable active recreation must be supplied. Mentally deficient children, particularly those of low grade, are apt to be of solitary habit; they have no idea of combination, even for games. Games of ball may, indeed, be prac- tised alone, but they are much more useful when played with others in the form of rounders, cricket, hockey, or tennis. Football can only be played under special conditions neither Rugby nor Asso- ciation Rules; it forms a valuable exercise not only for the limbs but for the wits. Even golf may be played by feeble-minded people. Games at marbles are good for finger training. Trundling hoops, playing horses, etc., should also be encouraged. Skipping is an excellent exercise, for boys as well as girls, so long as the heart is all right. The game of battledore and shuttlecock is good training both for hand and eye. Of indoor recreations, dancing is to '212 MENTALLY DEFICIENT CHILDREN be specially commended as tending to improve carriage and diminish the tricks of gait which often mark the mentally deficient. " Musical Chairs/' " Post," and similar games, promote both activity and intelligence. Bagatelle is a good indoor diver- sion, the scoring being of educational value ; and the game of dominoes helps in ideas of number. Even card games may be played by the more intelli- gent, and whist is an excellent exercise of memory. The " children's hour," so valuable an institution in normal nurseries, is specially useful with the mentally feeble, who often require to be taught to play, and sleep better for the romp before retiring. The love for music which is common with the mentally feeble suggests attendance at concerts and at musical services as appropriate modes of enjoy- ment. With some a considerable sense of humour exists, and theatrical performances, especially when abounding in comic situations, are much appreciated. It is of importance that entertainments at which mentally deficient children are present should be of a refined character. Coarse buffoonery and scenes of violence provocative to some weak minds of imita- tion should be carefully avoided. In these days the cinema show can hardly be tabooed, but care is necessary as to the character of the pictures. In concluding this chapter we may note with satis- faction the increasing importance which, as the result of experience, has of late years been attached to the place of manual work in the educational curriculum of the mentally deficient child. In his Annual Report for 1909 the Chief Medical Officer of the Board of Education writes as follows: "The intro- duction of manual instruction into the curriculum receives its practical sanction from the certainty that any attempt to train the feeble-minded child INDUSTRIAL TRAINING AND RECREATION 213 through the abstract literary methods of the elemen- tary school must be doomed to failure, and the mentally defective children will never be able to earn their living, entirely or partially, by any other than manual means/' He proceeds to chronicle the developments in industrial instruction that had taken place in the Special Schools of the London, Birmingham, and Liverpool Education authorities, and in an appendix the subjoined " Specimen Cur- ricula for Schools for the Mentally Defective/ 1 which it will be noticed contain a gradually increasing proportion of manual training with advancing age, are set forth. I. A Specimen Curriculum for Junior Schools. LONDON COUNTY COUNCIL KENNINGTON ROAD JUNIOR SCHOOL. Approximate Analysis of Time-Table for One Week. Hrs. Mins. Manual and Sense Training - - - 8 30 Elementary Subjects (including Scripture and Registration) 7 55 Physical Education 120 Voice- training, Singing, and Recitation - 2 15 Recreation - - - - - -230 Total - - - - 22 30 Subjects of Manual Instruction (Three Stages). First Stage. Drawing and Crayon Work, Canvas and Kindergarten, Sewing, easy Cane Weaving, easy Knotting, easy Loom Weaving, Modelling in Plasticine. Second Stage. Scale and Free Drawing, Paper-cutting, Loom Weaving, Straw Weaving, Cane Weaving, easy Rug- making, Canvas Work. Third Stage. Painting, Strip Work, Chair-caning, Basket Work, Rug-making, Knitting, Needlework, Cookery, Laundry. 2i 4 MENTALLY DEFICIENT CHILDREN II. A Specimen Curriculum for Elder Boys. LONDON COUNTY COUNCIL BROOK GREEN SENIOR SCHOOL (ELDER BOYS). Approximate Analysis of Time-Table for One Week. Classes 1,2, Classes 2, 4, and 3. and 6. Hrs. Mins. Hrs. Mins. Manual Work - - - n 20 12 Elementary Subjects (in- cluding Scripture and Registration) - - 6 10 5 30 Physical Education - -30 3 Singing and Recitation - i 10 I 10 Recreation - - 2 30 2 30 Total 24 10 24 10 Subjects of Manual Instruction. Drawing, Clay Modelling, Gardening, Carpentry, Joinery, Wood Carving, Metalwork, Tailoring, Boot Making and Mending. III. A Specimen Curriculum for Elder Girls. LONDON COUNTY COUNCIL PRIORY ROAD SENIOR SCHOOL (ELDER GIRLS). Approximate Analysis of Time-Table for One Week. Classes A andB. Hrs. Mins. Manual Work - 10 50 Elementary Subjects (in- cluding Scripture and Registration) 6 20 Physical Education - i 15 Singing and Recitation I 35 Recreation 2 30 Total - - - 22 30 22 30 Subjects of Manual Instruction. 1. Drawing to Scale, Colour Drawing, Clay Modelling. 2. Needlework, Fancy Sewing, Mending of Garments, Catting-out (paper) Patterns, Use of Sewing Machine. 3. Cookery, Laundry, Housewifery. INDUSTRIAL TRAINING AND RECREATION 215 From returns kindly furnished by Mrs. Burgwin, we learn that in the London County Council Special Schools for Elder Boys the proportion of time now devoted to handicrafts is even greater than that speci- fied above, varying from fifteen hours a week for the more advanced boys to ten for beginners. The balance of the twenty-five hours now forming the school week in Elder Boys' Departments is devoted to ordinary classwork. A typical Time- Table is printed in Appendix D, pp. 262-263. CHAPTER XI MORAL TRAINING IF good moral training be a prime essential in every system of education, it is specially so in the case of mentally deficient children. Not that the mentally feeble child is by nature morally worse than the ordinary child, but his weakness makes him more open to suggestion, so that an evil example not to say precept may in his case be specially injurious. It is a curious and lamentable fact that when the inhibitive nerve power is weakened, either from disease or from original defect, the lower nature is apt to assert itself, both in deed and word; and it is sometimes a matter of surprise how mentally feeble persons, notwithstanding good surroundings, give vent to the most evil language, profane or obscene. Even the hasty word, carelessly uttered, may be taken up by the weak-minded child, and reproduced on some inconvenient occasion. Great care, therefore, should be taken by all in charge of such cases to be choice in their language, as well as correct in their conduct; for imitation is characteristic of the class. On the other hand, a good moral influence is insensibly exercised by those who are judicious, and the choice of a teacher or attendant is a matter of supreme im- portance, moral as well as mental qualifications calling for consideration. As regards moral discipline, coaxing, not coercion; 216 MORAL TRAINING 217 must be the guiding principle. With the mentally deficient especially, "force is no remedy"; the " cowed " child will be a cowardly child, with no pluck or spirit to advance itself. As Roger Ascham remarks with regard to the ordinary pupil, he must in no wise be " beaten into the hatred of learning "; and not only in the scholastic, but in the general management of the mentally deficient child, love must be the all-pervading principle. At the same time judicious firmness must be exercised; and con- sistency in word and deed, combined with tact, are essential to moral influence. The mentally feeble, like the ordinary child, soon finds out to whom he must render prompt obedience. It is specially true of him that he cannot " serve two masters/' and attempts at dual control are apt to result in failure. This should be borne in mind in making arrangements with a governess, whose influence should not be im- paired by unnecessary parental interference. A system of rewards and punishments, modified, of course, to meet individual peculiarities, is effica- cious with this class as with others. Mentally deficient children are frequently eager to obtain the commendation of their superiors, and sometimes withholding commendation will make sufficient im- pression ; at other times words of reproof are necessary. The Regulations of the Board of Control prohibit the administration of corporal punishment to any patient in institutions for mental defectives. It is true that corporal punishment is rarely beneficial; yet there are cases where pain wantonly inflicted on others is appropriately visited by pain inflicted on the offender. Sometimes an appeal to the mind is best made through the stomach: in many instances the cutting off of some favourite article of food (e.g., pudding or sugar) from the day's dietary will mark disapproval better 218 MENTALLY DEFICIENT CHILDREN than any other procedure. The deprivation of some looked-for pleasure, such as attending an entertain- ment or going to church, will be efficacious in many cases; with younger children the temporary for- feiture of a favourite toy is all that is necessary. Older cases occasionally (perhaps exceptionally) develop a keen interest in the value of money, and such are best touched by an abatement of their allow- ance, or the enforcement of a fine. With the growth of intelligence it must be point out that harm, followed by punishment, inevitably results from evil doing, and that " Though the mills of God grind slowly, yet they grind exceeding small; Though with patience He stands waiting, with exactness grinds He all." The weak-minded person is not to be encouraged in the notion but too easily taken up with dangerous consequences that, because he is not quite like other men, he is less responsible for his actions. From foibles he should, of course, be guarded; and he should learn to respect his neighbour, and act on the legal maxim, " Sic utere tuo, ut alienum non Isedas." 1 * Perhaps the most trying case we are called on to deal with amongst children mentally abnormal though, indeed, there may be but little evidence of intellectual deficiency is that of the moral imbecile. The despair of his parents, the bete noir of the institu- tion, the perplexing puzzle of the jurist he seems to be the ill-fated product of inherited nervous instability and ancestral criminal instincts. In the Mental Deficiency Act, 1913, moral imbeciles are defined as " persons who from an early age display some permanent mental defect, coupled with strong vicious pr criminal propensities, on which MORAL TRAINING 219 ment has had little or no deterrent effect/' It must be noted that three conditions qualify this definition : (a) mental defect coupled with the moral infirmity shown, (b) displayed from an early age, and (c) of a permanent character. In practice it will be found that these qualifications materially narrow the appli- cation of the term " moral imbecile " for legal pur- poses. If, however, we may judge from a legal decision given (in 1914) in the case of a highly edu- cated B.Sc. London and Whit worth scholar convicted at the Old Bailey of fraudulent conduct, but subse- quently dealt with by the Judge as a moral imbecile under the Mental Deficiency Act, it would appear that but slight evidence of mental defect may be held sufficient. With regard to the class of moral defectives as found in the London schools, we venture to extract from Dr. Kerr's Report, presented to the London County Council Education Committee in May, 1909, the following apposite paragraphs : " Moral Defectives and Permanent Custodial Treatment. The necessity for compulsory powers of detention in custodial schools till sixteen, and later for the rest of life, of certain moral defectives is a most pressing matter. For instance, just as we find in cases of pure word-blind- ness a defect of a particular region of the brain, some- times as an hereditary failing which may occur in children normal in other respects, or combined with any amount of other defect, from mere dulness to low-grade mental defect, imbecility, or idiocy, so cases are found of morally defective children who vary in mental capacity from some cases which are exceedingly clever in other respects to children who are so bad as to be classed as imbecile. Very commonly, through such individuals being on what might be considered as a lower scale of mental develop- ment than normal, the emotions are much more developed relatively than the intellectual qualities which give re- 220 MENTALLY DEFICIENT CHILDREN straint, so that they are exceedingly plausible in spee< and have a peculiarly attractive gift of adapting the: selves, smiles or tears being available with equal ea according to their environment. There are great difl< ences in the way the defect is manifested. It is aim impossible yet to classify them, but a provisional arrang ment might be made into (i) Passive; (2) Active. " i. PASSIVE CASES (ONLY PASSIVE TROUBLE i SCHOOL CONDUCT). (a) Children who have irregula: but recurrent outbursts, showing moral defect in slight degrees amounting to uncontrollable bad temper, often with a complete heedlessness of all correction or advice, and very often a tendency to roam or wander away. These cases are probably of an epileptic nature, and require detention, and are to be regarded as cases of disease. " (b) Children who seem merely not to be amenable to discipline. This is a large class, and I think a very large proportion would be taught habits of obedience b; regular and inflexible corporal punishment. Most them are subjects for industrial training later on, bu they often present other defects e.g., word-blindness. "2. ACTIVE CASES (ACTIVE TROUBLES TO TH TEACHERS). (a) Children who are only differentiat from the first of the class above by their violence am destructiveness in their outbursts of rage, almost unpro voked at times, and quite irregular. For the greate: part of their time such children are inoffensive, some- times clever, often dull, stupid, or even sullen, but in a rage behave as uncontrollable lunatics. They are, how- ever, comparatively rare. " (b) Murderous tendencies from pure cruelty (quarrel- ling, pinching, biting others, infliction of cruelty on young children, or killing of animals). In particular cases these children are very objectionable in school. Manslaughter has been committed by children of inno- cent, pleasant, and in one case almost angelic appear- ance. There is every grade of mental attainment among these children afflicted with this lust of cruelty. (c) Interference with the opposite sex shows itself in MORAL TRAINING boys, but most objectionably in girls. There is every grade, from the natural attraction of the sexes to the most flagrant and offensive behaviour requiring the attention of the police. Here, again, mental capacity may vary from children who are quite normal in school- work to those who are low-grade mental defectives. This particular type of girl is most difficult to deal with. It is of vital importance to place them in residential schools, and separate them from other children of the same age, because, though numerically few, they con- stitute a most vicious element, a leaven of evil among the girls with whom they are compelled to mix. It is principally for the sake of others that this policy is proposed. * * * * * " A much more humane and scientific idea than mere segregation, and more economical to the State, would be to deprive such individuals of the objectionable powers and capacities, at the same time relieving them of the passions and desires before the time at which these develop/' The last paragraph refers, of course, to methods of surgical sterilisation, which during the last few years have been strongly advocated in some quarters. In America eight of the States of the Union have laws which authorise or require such procedure in certain classes of defectives and degenerates viz., Indiana, Connecticut, Washington, California, Iowa, Nevada, New Jersey, and New York; the first (in Indiana) having been enacted in 1907, the last (in New York) in 1912. In all these enactments the determination of the individual to be operated on is entrusted to a State Commission or Board, and vasectomy (excision of a portion of the vas deferens) in the male, and salpingectomy (excision of the Fallopian tubes) in the female, are the operations usually resorted to. The conclusions arrived at by a committee of well-known 222 MENTALLY DEFICIENT CHILDREN experts, who recently investigated the results attainec under this legislation, are that, while vasectomy is simple innocuous method of procuring sterility in the male, though not always permanently, and not other- wise interfering with sexual function, there is certain risk to life in the case of females, and occa- sionally of serious mental disturbance in both sexes On the whole, American experience does not afford enthusiastic support to the oft-vaunted practice of surgical sterilisation, and it is stated that, " except in Indiana and in California, little or nothing has beer done to carry out the laws authorising it."* The police in many large centres of population know children, members sometimes of respectable families, whom they shrink from prosecuting, but whom they cannot otherwise restrain from crime. Schools of the highest class are not unfrequentl} confronted with the problems that arise from the presence of an undesirable pupil of this type. He, or she, may combine the most innocent, sometimes engaging, external appearance with an inner depth of cunning and iniquity which requires to be ex- perienced to be appreciated. The sudden impulses to mischief occurring in these cases are sometimes of an epileptoid character, and paroxysms may in such cases be cut short by bromides. But as a rule moral discipline is of little avail; punishment may be administered, and professions of penitence called forth, only to be forgotten as soon as the mental dis- turbance again recurs. The original author has a vivid recollection of three nice-looking children, sisters and brother, formerly under his care, who at times would appear models of propriety, while at others they had all the characteristics of little demons. With innocent expression they would furtively accom- * Journal of Psycho-Asthenics, June, 1914. MOKAL TRAINING 223 plish the most abominable mischief, and, after meekly acknowledging the error of their ways, would empha- sise their apology by a missile flung at the head of the person who had attempted to bring them to re- pentance ! Such children would in old time have been called "possessed"; now they are classified as cases of moral imbecility or juvenile insanity. Dr. Samuel J. Fort has described similar cases under the title of " Psychical Epilepsy "*; and in his Goul- stonian Lectures for 1902 Dr. G. F. Still points out that a severe bout of convulsions in infancy is some- times followed by arrest of moral development. Arson is a crime that has a special fascination for these degenerates, and so has the placing of obstruc- tions on railways. The catastrophes that may result in consequence furnish a strong argument for per- manent detention. It occasionally happens, however, that moral aberrations of a more transient character are met with in young people of neurotic heritage, whose unstable mental equilibrium has been upset by the strain of pubescence. Such are the cases in which a propensity to petty peculation develops itself in boys or girls who have previously borne good characters at a high-class school; it is sometimes accompanied by other eccentricities of conduct, and is often apparently motiveless. Our experience has been that on re- moval to an appropriate environment many of these cases improve under tactful management, and when the stress of pubescent development has subsided, there may be a gradual restoration of moral control. In other disappointing cases we find considerable improvement in intelligence and manual skill with actual deterioration of the moral sense. Intelli- gence and skill which have been acquired are, indeed, * Proc. Association Amer. Institution for Idiotic and Feeble- minded Persons, 1894, p. 400. 22 4 MENTALLY DEFICIENT CHILDREN used for evil purposes; and Dr. Kerlin, the former Superintendent of the Pennsylvania Institution, who paid much attention to this class, came to the con- clusion " that to educate them often gave them added power for evil, and that they should not be allowed to prey upon society/' He claimed that mora imbeciles " should be treated in a class apart in buildings by themselves, as they affect the methods of living and training of the rest/'* Dr. Jules Morel has, in an able communication to the Medico-Psycho- logical Association, f advocated the establishment of special institutions, intermediate between re- formatories and asylums, wherein " such persons should be objects of prophylactic treatment against crime/' Similar views have been expressed Dr. Barr, who succeeded Dr. Kerlin in charge of the Pennsylvania Institution. In his communication tc the section of the Royal Commission on the Care anc Control of the Feeble-minded which visited America, he stated, in reference to the patients under his charge at Elwyn: " Many of the children are absolute crimi- nals. Some are the victims of circumstances, but the absolutely bad children we cannot do anything with. We have fifty to seventy-five of them. I think our Government should take up the question of these children. I should have these form a national colony on the bad lands of the West, to be taken care of under military discipline/'! In our own country the Board of Control are dealing with the problem by the pro- * Forty-First Annual Report, Pennsylvania Training School. Philadelphia, 1893. f Journal of Mental Science, vol. xl., p. 599. | Report of the Members of the Royal Commission on the Care and Control of the Feeble-minded upon their Visit to American Institutions (vol. vii.). MORAL TRAINING 225 vision of a State Institution for defectives of marked dangerous or violent propensities. There is need for caution in institution arrange- ments for the mentally feeble class that egoism, which often springs from their solitary instincts, be not pandered to, but rather that altruistic views should be enforced. The golden rule that even the feeble- minded should " do unto others as they would be done by " should be inculcated. Happily, such per- sons are often susceptible, not only to moral, but to religious influences. Their very simplicity leads them to accept without hesitation ideas of a Universal Father, who is at the same time an all-seeing God, of a loving Saviour, and of a sanctifying Spirit ; and however imperfect may be their comprehension of these mysteries, there is no doubt that such notions tend to exert a wholesome restraining influence upon conduct. CHAPTER XII RESULTS AND CONCLUSIONS IN this closing chapter we propose to discuss the results which have accrued from the system of treat- ment and training we have endeavoured to describe, and to formulate some conclusions as to the value of the work. The pessimism of the early part of the nineteenth century has fortunately been put out of court by the results obtained. Nearly every case is amenabli to training, and capable of improving to a certair extent, with the result of rendering existence healthier and happier, and less burdensome to others. A con- siderable proportion can be " taught to conform tc moral and social law, and rendered capable of order/'* and many " become capable of the ordinary trans actions of life under friendly control, of understandir moral and social abstractions " j ; while, in the specia case of cretins and other aments suffering from some glandular deficiency, almost complete amelioratior of the symptoms may be obtained. The experience of institutions for training youthful defectives both in this country and in America goes to confirm the accuracy of Seguin's prognostications. The statistics of the Royal Albert Asylum, Lancaster, * E. Seguin, Idiocy, c:nd its Treatment by the Physiological Method, New York, 1866. t Ibid. 226 RESULTS AND CONCLUSIONS 227 gathered by Dr. Shuttleworth in 1890, with regard to the after-career of pupils discharged on completion of their seven years' training, showed that 10 per cent, were, or had been, earning wages; that 5 per cent, were remuneratively employed at home; and that 3-5 per cent., in addition, were capable of earning wages if suitable situations could be found for them. About 22 per cent, were reported to be more or less useful to their friends at home, while another 22 per cent, were said to be of little or no use; 29 per cent, had gravitated to workhouses and lunatic asylums; the remainder (8*5 per cent.) had died. In the Jubilee Report of the Royal Albert Institution (1914) it is stated that 10 per cent, of the patients discharged (from an aggregate of 3,433 who had been under training) had been rendered self-supporting, while not less than 82 per cent, had shown evidence of noticeable improvement. A case is cited of a boy earning 375. a week in a Yorkshire bakery, and another of a patient, discharged twenty years pre- viously, who gets 3os. a week " at a great dye-works near Leeds, and has never lost a day's work, except on the occasion of a strike, with which he had nothing to do." It must not, however, be imagined that even the best of the above were in all respects equal to persons of average intelligence. Some residual peculiarity usually remains to handicap the feeble- minded in the race of life. " It is not, indeed, to be expected that without some form of tutelage even the trained defective can hold his own in the outside world, and in the majority of cases it may be appropriately said: " 'Tis not enough to help the feeble up, But to support him after."* * Twenty-seventh Annual Report, Royal Albert Asylum, p. 40. 228 MENTALLY DEFICIENT CHILDREN - port is There is no doubt, however, that such support rendered infinitely easier by methodical training, and the burden to the friends much lighter. Before quoting further figures, it is necessary explain that those of different institutions an societies can scarcely be compared; so much depen on the grade and type of mental defect select Till the passing of the Mental Deficiency Act, 191 we had no generally accepted definitions, far less any universal standard. Under these circumstances sta- tistics are chiefly of value as showing the possibilitii and limitations. The necessity for after-care has been establishes on a priori grounds; it is interesting to see the results. For this purpose we will take the records of the Bir- mingham After-care (Education) Committee, which was the first to undertake this work. Founded in 1901 by Mrs. Hume Pinsent, it is now able to formu- late fourteen years' experience. The last annual report (dated June 25, 1915) states, that of the 1,436 cases (876 males, 560 females) observed 495 are doing remunerative work; of these 415 are earning wages which average los. 2d. per week. 279 are males, earning from is. 6d. to 358. per week (aver- age us. 7d.) ; and 136 are females earning from 35. to 2os. per week (average 75. 5d.). 59 youths are soldiers. 18 girls are employed from home in domestic work. 13 (8 m., 5 f.) work with their relations at home in simple trades, without wages. 126 (47 m., 79 f.) are living at home and doing unpaid work. 41 (17 m., 24 f .) were dismissed from special schools as incapable, through physical or mental disability. 121 (76 m., 45 f.) have been transferred to ordinary schools. 5 (4 m., I f.) have been transferred to schools for the deaf; i (m.) to an open-air school; RESULTS AND CONCLUSIONS 229 I (m.) to a private school; 7 (3 m., 4 f.) removed to special schools in other towns; 18 (16 m., 2 f.) are in residential schools for mental defectives; 81 (42 m., 39 f.) are in workhouses; 138 (76 m., 62 f.) are in other institutions, including 91 (54 m., 37 f.) in the Monyhull Colony, and 17 in lunatic asylums. 52 (31 m., 21 f.) have died, and 337 (213 m., 124 f.) lost sight of. The committee have frequently stated in their reports that for a large percentage of the feeble- minded permanent supervision is necessary for the following reasons: " i. To enable them to contribute to their own support. 11 2. To save them from harsh treatment at home and in the streets. "3. To prevent their becoming drunkards, crimi- nals, and prostitutes. "4. To prevent their giving birth to children who can only grow up to be a burden to the community." With these statistics from Birmingham we may compare the following extract from the Report of the After-care Committee of the London County Council for 1915, with reference to those discharged from the London Special Schools during the previous three years. This " shows that from November, 1910, to November, 1914, 1,448 children left the schools for elder mentally defective children and came under the notice of the association. Of these, 812 (55 per cent.) were in work in October, 1914, including 72 males who were serving with His Majesty's forces. In the previous year it was reported that 72 per cent, were in work, while, of the whole 1,198, 103 were out of employment, 133 had been lost sight of, 42 were in institutions, 46 were not reported upon, and 7 dead." 230 MENTALLY DEFICIENT CHILDREN These figures, if somewhat more favourable those from Birmingham, extend over a much briefe period, and, in the long-run, no doubt will suppor the view of the necessity of permanent care for tt majority of cases. As a matter of fact, the Birmir ham committee have pointed out that much mor satisfactory returns are obtained when only the who have recently left school are considered. The said in their 1914 report that " it is important remember that the large majority in employmerj are boys and girls who have recently left school, the 397 in employment, only 54 are over twenty one years of age, and only 16 of these are ove twenty-five; but 343 are of ages varying fror fourteen to twenty-one years. Of the latter group the large majority (240) are of ages vary from fourteen to seventeen years, as compared wit 103 of ages from eighteen to twenty-one. It significant that the age at which there are mos workers is sixteen." Mr. E. W. Locke, Superintendent of the Wester Counties Idiot Asylum at Starcross, when giving ev dence before the Royal Commission on the Care Control of the Feeble-minded, said: " I think tha during the last ten years about forty children ha\ been placed out in the world. I have informatic from about twenty of them ; several of those are earn ing their own living independently, but they we brilliant exceptions; the others were living at hon and making themselves of use, going out to work, instance, in gardens, or doing needlework at home and so on." But he added, with regard to those wt are discharged: " They ought not to go out into tt world, any of them, never mind how competent the are to work." The subsequent comment by tl: RESULTS AND CONCLUSIONS 231 Commissioners was: " This view is held by all our witnesses in regard to this branch of work/'* Dr. E. B. Sherlock has recently published an interesting estimate of the earning capacity of mental defectives employed at the Darenth Indus- trial CxOlony. He points out that the net profit of the patients' work in such an establishment must needs be affected by such considerations as the following : First, teachers and industrial at- tendants command higher salaries than ordinary attendants ; ' secondly, the working patients require better feeding than others; and finally, their hours of labour are necessarily shorter than those current in the various trades, and these he estimates at 35 per week. He proceeds : " In order to obtain information as to the actual earning powers of the patients at Darenth an inquiry has been made into the capacity of each individual over the age of fourteen years, that age being taken as the one at which persons not mentally defective and of the same social class as the patients might be expected to contribute something towards their own maintenance. To arrive at anything like a satis- factory valuation has proved to be a matter of extreme difficulty, and the results obtained are incomplete and probably vitiated by numerous errors. Nevertheless, they appear to have suffi- cient interest to make the publication of them desirable. " For imbeciles, the average earning capacity per week in the following industries was : Males: Mat -making, 35. 2d. ; brush-making, 35. iod.; boot- making, 5s. 8d; tailoring, 6s.; upholstering, 75.; * Report of the Royal Commission on the Care and Control of the Feeble-minded, vol. viii., p. 159. 232 MENTALLY DEFICIENT CHILDREN basket-making, 75. 2d. ; carpentry, 95. 3d. ; painting, 6s.; printing, 75.; book-binding, 45. gd. ; metal- working, 8s. 3d.; wood-chopping, 2s. 6d.; carting, 2s.; school industries, is.; odd jobs, is. " For females the average earning capacity was : Needlework, is. 8d. ; upholstering, 2s. 90!.; bag- making, 9|d. ; machine knitting, 75. id.; brush- making, is. 4d. ; rug-making, 45. ; school industries, is. id. " For the feeble-minded males the average earning capacity was: Farming, 45. 9d. ; boot-making, 6s. 3d.; tailoring, 5s. 4d. ; cord-making, is. 3d.; laundry work, 5s. " For feeble-minded females the average earning capacity was: Needlework, is. 4d.; laundry work, 2s. id.; machine and other knitting, 45. 6d." With regard to American experiences, we will quote from a paper by Dr. Walter E. Fernald, of Waver- ley. He says: "Each year a certain number of persons (trained in industrial work) go out from these institutions [for the feeble-minded], and lead useful, harmless lives. Some of the institutions where only the brightest class of imbeciles are received, and where the system of industrial training has been very carefully carried out, report that from 20 to 30 per cent, of the pupils are discharged as absolutely self- supporting. In other institutions, where the lower- grade cases are received, the percentage of cases so discharged is considerably less. It is safe to say that not over 10 to 15 per cent, of our inmates can be made self-supporting, in the sense of going out into the com- munity and securing and retaining a situation, and prudently spending their earnings. With all our training we cannot give our pupils that indispensable something known as good, plain common-sense. The RESULTS AND CONCLUSIONS 233 amount and value of their labour depend upon the amount of oversight and supervision practicable. But it is safe to say that over 50 per cent, of the adults of the higher grade who have been under training from childhood are capable, under intelligent super- vision, of doing a sufficient amount of work to pay for the actual cost of their support, whether in an insti- tution or at home." In support of the claim for after-care, and as an embodiment of the most recent ideas in America on this question, we cannot do better than quote from the conclusions summarised by the members of the Royal Commisson on the Care and Control of the Feeble-minded who visited that country: . " Most of the American institutions were started as schools for feeble-minded children, under the idea which prevailed that a large number of these could be educated so as to be able to take their place in the world alongside of their normal brothers and sisters. This idea has been modified by experience, and now it is the opinion of those whom we consulted that it is only a very small fraction of the feeble-minded who can stand alone, how- ever excellent their education may have been. Two results flow from this : Firstly, although in some places the system of education still follows on the lines of that given in schools for normal children, in those institutions which appeared to us to be the most scientifically organised there is now a tendency to limit the instruc- tion to such manual work as the feeble-minded are found able to perform, and as will afford them occupation and happiness as inmates of permanent working homes. Secondly, the opinion 'has now become general that the provision of schools for feeble-minded children must be accompanied by permanent homes for adults. The present schools have become congested with adults who have grown up in the school, and whom the managers " ive felt constrained to retain there for fear of the 234 MENTALLY DEFICIENT CHILDREN disasters which would have fallen upon the adolescent if turned adrift into the world. Hence, those interested in the American institutions have induced the State Legislatures to allow of the establishment of depart- ments or branches for adults, into which they can draft the children who have passed school age, and also admit from outside feeble-minded adult men and women whom the Poor Law or other public authority may think require the protection of a home. Expert opinion con- demns as ineffective and wasteful an institution which lacks a custodial department or colony or other annexe for adults." Nevertheless, it is not quite fair to conclude that the benefits of training institutions, as at present organised, are merely to be measured by appraising- the proportion of those sent out able to earn their own living. This, of course, is a positive gain, but there are benefits, which we may call negative, hardly less appreciated by those on whom the care of the mentally deficient falls. That a child should no longer be uncleanly, mischievous, or destructive, in habits; that it should cease to disturb the peace of the household by discordant cries, and by untimely wanderings, are points which parents thankfully recognise; and if, in addition, it can be taught to undress and dress itself, to feed itself, and to behave with propriety, these results are by no means despic- able, even from the economical point of view. It must not be forgotten that the charge of an untrained idiot at home usually monopolises the time of one of the older members of the family, who is thus prevented from earning wages; and without judicious training and discipline deterioration is pretty sure to occur. Even in the best-regulated families the care of a defective child is a constant anxiety; how much more in the labourer's cottage, where oftentimes only RESULTS AND CONCLUSIONS 235 casual attention can be given to it ? The relief to parents afforded by Institution treatment is well illus- trated in the Report for 1894 of the superintendent of the Eastern Counties Asylum. He gives a striking example of a mischievous imbecile, who " describes with great glee how (before admission) he was left to mind the baby, and blacked its face all over with soot, so that when his mother returned she might think she had a black baby; how his little sister wanted some water, and he told her to drink out of the kettle on the fire, by which she nearly lost her life; and how he was turned out of the Parish Church, during service, for pricking a boy with a pin, so that he yelled out and disturbed the whole congrega- tion !" For improved cases, able to take situations on leaving Training Institutions, it seems very desirable that there should be established in all parts of the county some organisation of philanthropic persons willing to exercise a friendly supervision, such as the After-care Committees in London, Birmingham, and other English centres, and certain Continental cities.* Since the passing of the Mental Deficiency Act, much has been accomplished in this direction by the estab- lishment of the Central Association for the Care of the Mentally Defective, under the able chairmanship of Mr. Leslie Scott, K.C., M.P., with Miss Evelyn Fox as Honorary Secretary. This association, which has offices at Queen Anne's Chambers, Tothill Street, Westminster, has co-ordinated several of the existing After-care Societies, and stimulated the formation of others. Through its agency, overlapping in this charitable work will be prevented, new workers * Treatment of Feeble-minded : Question of After-care, Shu ttleworth, 1904. 236 MENTALLY DEFICIENT CHILDREN will have the benefit of the experience that has been gained, and all reports will be kept on similar lines. Recently it has developed other useful activities in the direction of providing training for special teachers. Unfortunately, while the Mental Deficiency Act in Section 48 encourages the formation of After-care Committees, and provides them with money from Parliamentary grant for the purpose of assisting and supervising defectives, it does not make this an obligatory duty. When a defective is withdrawn or discharged from a special school on or before attaining the age of sixteen, without a notice being sent by the local education authority to the local authority under the Act that he is an imbecile or detrimental to the other children in school, or that it would be to his benefit that he should be sent to an institution or placed under guardianship, there is no statutory obligation for his supervision. It is, however, only fair to say that we have known some remarkable instances of permanent improvement resulting from training. A former insti- tution pupil, an example of the class now designated " feeble-minded " as distinguished from imbecile, though for a period an inmate of the Royal Albert Asylum, became, under instruction, an expert joiner, and (what was even more remarkable) from being a very imp of mischief grew up into a well-conducted, self-reliant youth, and ultimately emigrated to one of our colonies. When last heard of, he was practising his trade in a leading city, and in a letter home reported himself as doing well, business being brisk in consequence of a conflagration which had recently occurred ! In another instance of mild defect, the result of an injury in infancy, treated at the Royal Albert Asylum with great benefit, a girl, after dis- RESULTS AND CONCLUSIONS 237 charge, got respectably married, and is said to be an excellent housewife. It is remarkable that of nearly a thousand dis- charged patients who had passed under observation at the Royal Albert Asylum the two just mentioned are the only instances in which we have known mar- riages occur. It has, indeed, been urged as an objec- tion to educating mentally deficient children, and fitting them for work in the world, that they would be thereby encouraged to marry, and, in consequence, there would be a risk of multiplying mental defect in the progeny. Our experience, however, does not altogether support this view. It is quite true that the mentally defective, when left to themselves, do produce, both in and out of wedlock, a considerable number of children, many of whom exhibit the same weakness as their parents. Dr. Potts, when working at Stoke-on-Trent for the Royal Commission on the Care and Control of the Feeble-minded, collected clear evidence on this point. It does not, however, hold good to the same extent in the case of those who have had judicious training in such an institution as the Royal Albert Asylum. In one case, that of a youth who, after a long period of institution training, had become an industrious labourer, and was earning eighteen shillings a week, we ventured to ventilate the subject of marriage. The young man had been telling us how, in addition to paying for his board, he had been able to accumulate a fair amount in the Post- Office Savings Bank. " Well/' we suggested tenta- tively, " perhaps you are saving up against getting married/' " Nay, nay, doctor," was the reply; " it's hard enough for a feller to keep hisself, let alone bothering with a girl !" Such philosophy as this is rarely met with in the social class to which this youth 238 MENTALLY DEFICIENT CHILDREN belongs, or we should hear less of improvident mar- riages. The effect of judicious training seems to be to impress upon the improved imbecile that he is not quite like other men, and must not undertake the responsibilities of married life. Certainly, the net result of training is to diminish the risk of transmit- ting the evil to another generation, inasmuch as moral principles are instilled which have a restraining influ- ence on conduct. Moreover, the very fact of healthy occupation tends to keep in check the animal passions, which are apt to run riot when the adolescent imbecile is unemployed. This is one, amongst other reasons, for the establishment of permanent industrial homes like those belonging and affiliated to the National Association for the Feeble-minded. Considerable experience in the training of mentally peculiar children of the well-to-do class has convinced us of the benefit resulting from appropriate education commenced at an early age, if due care be taken to provide them after school life with occupations suit- able to their capacities under some degree of judicious supervision. We can point to cases in which artistic and musical talents have been developed in such a way as to render subsequent home life resourceful and no longer a burden to the relatives, and to others in which occupation in such pursuits as horticulture and farming has furnished a useful career. The history of legislation for the benefit of educable feeble-minded as distinguished from imbecile children has already been given, and we have now had more than twenty years' practical experience of special classes for exceptional children in elementary day- schools. We think we can fairly claim that, where tried, they have filled up a lacuna in the scheme of national education. In the words of the Report of RESU ITS AND CONCLUSIONS 239 the Royal Commission on the Care and Control of the Feeble-minded : " It [i.e., the establishment of special schools] gave to those interested in education the first opportunity of trying what could be done for these children on day- school lines and under a special curriculum. Whether the number of those who, when they left school, could materially support themselves were few or many, it helped to make the larger number of the children cleaner in person and habits, more orderly and more moral; it did this where the parents cared for their children and wished to do the best for them, and it did it, as far as might be, where the parents were careless and incon- siderate of their children's welfare. The scrutiny of the lives and mental condition of children, made in conse- quence of the investigations of Dr. Francis Warner, Dr. Shuttleworth, and others, led to the passing of the Act; and the Act itself has been instrumental in pro- ducing still further inquiries of the same nature." The Report then goes on to show that it might not be altogether wise to continue simply on the same lines, and merely make the Elementary Education (Defective and Epileptic Children) Act, 1899, com- pulsory. It explains that the demand which the Act first created has assumed larger proportions. " Schooling* in personal habits was found to be the first step in education. Then, more and more, it was made evident that the intelligence was roused through the hands and eyes working together in making or doing some actual thing, rather than by the secondary and more abstract accomplishments of reading, writing, and arithmetic. This suggested great changes in teaching. And now, in the opinion of many, the simple ' occupa- tions ' of the earliest years of schooling should develop into systematic industrial teaching, while the ' scholastic ' * Report of Royal Commission on Care and Control of Feeble- minded, p, 103, par. 338. 240 MENTALLY DEFICIENT CHILDREN teaching should become entirely subordinate, and, indeed, in some cases should be discontinued. But, as we have seen, criticism has gone farther still. Analysis has shown that the special school by itself is largely unserviceable, from the point of view of the after-life of the child. The feeble-minded child can, in the main, become only a feeble-minded adult, edu- cated into a rather better routine of thought and habit. If special education is required on his behalf in his school- days, special care will probably be necessary for him when he has left school; and, moreover, later on in life. All this, by degrees, the Act of 1899 has enabled many to learn." Hence the idea that " either the special classes will become classes for the dull and backward, from which the feeble-minded, except, possibly, those who are of the very highest type, will, by degrees, be excluded; or, as at Leicester, new classes for the backward will be started, and the present classes for the feeble-minded will be continued as a kind of lowest class of all, and will be supplemented to a much larger extent by institutional care of some kind. According to our judgment, this ' backward ' class should remain under the direct control of the education authorities, for the children in them could not be certified; while the children who are or may become certifiable as mentally defective should fall within the province of the Committee for the Care of the Mentally Defective, who, either directly or by contract with the education author- ities, should provide for them/' In a paper on the Result of Special School Educa- tion read at the Conference of the National Special Schools Union in Birmingham in 1910, Mrs. Hume Pinsent said, in regard to the children who remain in special, schools, that " it is quite exceptional for any of them to reach a higher educational position than that attained in Standard II. This means that at RESULTS AND CONCLUSIONS 241 sixteen the best of them will be able to read and calculate to about the same extent as a normal child of eight or nine. The numbers who attain to Standard II. are variously stated by witnesses as from 40 to 58 per cent., at the best only about half the total number." " If it is a question of pleasure or profit to be obtained from reading, I am afraid we cannot flatter ourselves that special school teaching confers this benefit on the mentally defective ; for to read for pleasure after school age a far greater ease and fluency must be obtained than is represented by Standard II. Only about half get even as far as this." After pleading for more manual work, Mrs. Pinsent goes on to say that, " Just as their manual work, though fair in its results when done under supervision, has no value in the open market, so their frail morality, when severed from the ever-present sanction of the teacher, falls to pieces on contact with the outside world, and succumbs to every temptation/' As regards the results attained in the Residential Homes charitably founded for feeble-minded girls beyond school age, it must suffice to say that in some of those longest established an appreciable portion of income is derived from payments for the work of the inmates. Thus it has been calculated that at the Homes of Industry, established near Birmingham in 1892 by the late Miss Stacey, for feeble-minded girls, more than 2s. per head per week is on the average made by the labour of the 45 inmates in aid of maintenance, the weekly rate for which is about 8s. gd. It was stated, however, in the evidence before the Royal Commission, that, although these Homes are mainly custodial, out of 101 discharged for various reasons, not more than 3 were really fit to return to ordinary life. The industries carried on in the Homes consist 16 242 MENTALLY DEFICIENT CHILDREN principally of laundry work and of mat and rug making. The results obtained by more recent homes, if less successful financially, are distinctly encouraging. Thus the National Association Report of Alexander House (a working home for 19 girls over fourteen at Hammersmith), after eight years' working, stated: " There are now 8 girls in service, who are regularly visited. Of these, 4 are going on well ; the others leave their situations frequently, their mental deficiencies making them unable to work steadily for any length of time." Further experience has, however, proved the need for permanent care in the majority of cases. Did space permit, it would be easy to give proofs of individual improvement resulting from these and similar homes (of which a list will be found in Appendix A) ; but for particulars the reader is referred to the Reports of the Homes, and to the publications on After-care of the National Associa- tion for the Feeble-minded, to be obtained at their offices, 72, Denison House, Vauxhall Bridge Road, S.W. As the result of the passing of the Mental Deficiency Act, it is to be hoped that all defectives over sixteen who are without proper provision, and are a source of danger to themselves or the community, will be kindly taken care of in such institutions as we have described. Objection has sometimes been taken to the benevo- lent efforts of the last seventy or eighty years in favour of the mentally deficient, that they are an- tagonistic to Nature's law, expressed in the formula, " The survival of the fittest." We would submit, however, that the reclamation of these outcasts, and more especially the " setting of the solitary in families " (i.e., in institutions and colonies), has not RESULTS AND CONCLUSIONS 243 necessarily been inconsistent with our duties towards posterity, for it has aroused a scientific interest in questions of heredity previously imperfectly under- stood. As Dr. Saleeby well puts it in his work on " Parenthood and Race Culture/' " the ideal of eugenics is to abolish the brutal elements of the struggle for existence, whilst gaining its great end." Let us by all means adopt every reasonable measure to prevent the perpetuation of the evil, but in the meantime we are responsible for those weaklings we have allowed to be born as fellow-members of the human family. It is not denied that individual lives, which, if left to themselves, would probably be extinguished in the struggle for existence, are by fostering care prolonged, perhaps contrary to the rigid principles of social economy. It may, indeed, be admitted that much that has been done for the idiot and imbecile, and even for the feeble-minded, can only be justified on the ground of that quality of mercy which is " nobility's true badge," and " blesseth him that gives and him that takes." May we not indeed in this, as in much other philanthropic work which tends to soften the asperities of Nature's laws, endeavour humbly to follow in the footsteps of Him of whom it was foretold that " A bruised reed shall He not break, and the smoking flax shall He not quench " ? LATEAT SCINTILLULA FORSAN ! APPENDIX A MENTAL DEFICIENCY ACTS, 1913. (List kindly supplied by Board of Control, February, 1916.) ENGLAND AND WALES. Certified Institutions. Figures indicate number admissible, m., Males only; /., Females only; m.f., Males and Females. BERKSHIRE. /. CUMNOR RISE, CUMNOR Hon. Sec., Hon. Pamela Bruce. Radcliffe House, St. Giles, Oxford; Supt., Miss Haigh. (22) CHESHIRE. m.f. SANDLEBRIDGE, ALDERLEY EDGE Hon. Sec., ]. S. Walker, 54, Kenwood Road, Stretford, Manchester. Supt., Miss Grace Wyatt. (275) /. ASHTON HOUSE (SEASIDE LAUNDRY HOME), PARKGATE- Hon. Sec., Miss J. M. Grayson, 29 Ullett Road, Liverpool; Supt., Mrs. Dennis. (20 CUMBERLAND. m.f. DURRAN HILL HOUSE, CARLISLE Sec., T. W. Hunter, Archbishop's House, Victoria Street, London, S.W. ; Supt., Sister Ethelburga Ring. (65 244 APPENDIX A 245 DERBY. /. WHITTINGTON HALL (MIDLAND COUNTIES INSTITUTION), CHESTERFIELD Warden, Rev. H. N. Burden, 14, Howick Place, Victoria Street, London, S.W.; Supt., Miss Smith. (320) m. HOPWELL HALL COLONY, NEAR DERBY Hon. Sec., Mrs. Kipping, 40, Magdala Road, Nottingham; Supt., Mrs. H. Swinburne. (50) DEVON. m.f. WESTERN COUNTIES INSTITUTION, STARCROSS, NEAR EXETER Supt. and Sec., E. W. Locke. (336) DURHAM. m. MONKTON HALL HOME FOR LADS, MONKTON, JARROW-ON- TYNE Hon. Sec., Dr. Ethel Williams, 3, Osborne Terrace, Newcastle-upon-Tyne ; Supt., Mr. Piggott. (42) ESSEX m.f. ROYAL EASTERN COUNTIES INSTITUTION FOR IDIOTS, COLCHESTER Supt., F. Douglas Turner, M.B. Sec., A. Turner. (512) m. THURLBY HOUSE SCHOOL, WOODFORD BRIDGE Sec., T. W. Hunter, Archbishop's House, Westminster, London, S.W. ; Supt., Miss Mary Ryan. (40) /. ETLOE HOUSE, CHURCH ROAD, LEYTON, N.E. Supt., Sister Susan O'Reilly. (122) m. CO-OPERATIVE SANATORIUM (NEW LODGE, LEON HOUSE, THE HOMESTEAD AND ST. KEVERNE), BILLERICAY Sec., Thos. Wm. Edwards, New Lodge, Billericay; Supt., T. W. Edv/ards. (56) GLOUCESTER. /. ST. MARY'S HOME, PAINSWICK, NEAR STROUD Hon. Sec., Miss Wemyss, Washwell House, Painswick ; Supt., Mrs. Oddy. (26) 246 MENTALLY DEFICIENT CHILDREN m.f. STOKE PARK, BRISTOL (with ancillary premises), ROYAL VICTORIA HOME, HORFIELD, BRISTOL ; CLEVEDON HALL, CLEVEDON ; and BEECH HOUSE Warden, Rev. H. N. Burden, 14, Howick Place, Victoria Street, London, S.W.; Supt., Miss Gladys Williams. (940) /. CHASEFIELD LAUNDRY HOME, 874, FISHPONDS ROAD, FISHPONDS, BRISTOL Hon. Sees., Miss Alice Mary Laving- ton and Miss Clara E. Sheppard, Stoberry Lodge, 1 8, Ash- grove Road, Redland, Bristol; Supt., Miss Ada Brett. (38) HAMPSHIRE. /. ST. MARY'S HOME, ALTON (Wantage Sisters) Supt., Sister Rachel. t45) HERTS. m.f. ST. ELIZABETH'S HOME FOR EPILEPTICS, MUCH HADHAM Sec., T. W. Hunter, Archbishop's House, Westminster, S.W.; Supt., Sister Mary Edmund. (136) KENT. m.f. PRINCESS CHRISTIAN'S FARM COLONY, HILDENBORO' Part certified. Part approved. Applications to Miss Kirby, Secretary National Association for Feeble-minded, Denison House, Vauxhall Bridge Road, S.W.Supt., Miss E. J. Price. (102) LANCASHIRE. m.f. ROYAL ALBERT INSTITUTION, LANCASTER Supt., Dr. W. H. Coupland; Sec., S. Keir. (750) /. 45, WEBSTER STREET, GREENHEYS, MANCHESTER Hon. Sec., Miss A. H. Macalpine, 164, Denmark Road, Moss Side, Manchester; Supt., Mrs. Collier. (16) m.f. PONTVILLE SPECIAL SCHOOL, AUGHTON, ORMSKIRK Hon. Sec., Very Rev. W. Canon Pinnington, The Presbytery, Great Mersey Street, Liverpool; Supt., Sister M. A. Driscoll. APPENDIX A 247 /. DOVECOT (HORTICULTURAL SCHOOL), KNOTTY ASH, LIVER- POOL Hon. Sec., Miss J. M. Gray son, 29, Ullett Road, Liverpool; Supt., Miss F, C. Eyre. (55) /. ADCOTE (LAUNDRY AND TRAINING HOME), PILCH LANE, KNOTTY ASH, LIVERPOOL Hon. Sec., Miss J. M. Grayson, 29, Ullett Road, Liverpool; Supt., Miss L. Foster. (19) /. BROCKHALL, LANGHO, NEAR BLACKBURN Clerk, Lancashire Asylums Board, Sir Harcourt E. Clare; Supt., Dr. F. Gill. LONDON. /. 41, DOWNS ROAD, CLAPTON, N.E. Sec., Miss C. Tozer, 39, Downs Road, Clapton, N.E.; Supt., Miss Main. (Girls over 16.) (25) /. 46-48, PEMBURY ROAD, CLAPTON, N.E. Sec., Miss C. Tozer, 39, Downs Road, Clapton, N.E. Supt., Miss E. Allen. (Girls over 16.) (30) /. 39, DOWNS ROAD, CLAPTON, N.E. Sec., Miss C. Tozer, 39, Downs Road, Clapton, N.E. Supt., Miss Aubery. (Girls over 8.) (25) /. CLIFTON HOUSE, 127, UXBRIDGE ROAD, SHEPHERD'S BUSH, W. Sec., Miss Pierce, Church Army Rescue Homes; Supt., Miss Margaret Fanny Pearne. (40) /. SPRINGFIELD LODGE, GROVE HILL ROAD, DENMARK HILL, S.E. Sec., Miss J. A. Cox, Salvation Army Social Work, 280, Mare Street, N.E.; Supt., Miss Annie Salt. (28) MIDDLESEX. /. CRATHORNE, OAK LANE, EAST FINCHLEY, N. Hon. Sec., Mrs. Moss-Blundell, 7, North Grove, Highgate, N.; Supt., Mrs. Morfee. Including mothers and children. (32) m. BRAMLEY HOUSE, GORDON HILL, ENFIELD. Clerk, H. S. Freeman. (Middlesex County Council.) (44) 248 MENTALLY DEFICIENT CHILDREN NORFOLK. m. GUILTCROSS (EASTERN COUNTIES INSTITUTION), EAST MARLING. Warden, Rev. H. N. Burden, 14, Howick Place, Victoria Street, London, S.W. Supt., Dr. Manning. (410) OXFORD. /. ST. PETER LE BAILEY RECTORY, NEW INN, HALL STREET, OXFORD (BRANCH OF CUMNOR RISE, CUMNOR). Sec., Hon. Pamela Bruce; Supt., Miss Haigh. (24) SOMERSET. m.f. ROCK HALL HOUSE (MAGDALEN HOSPITAL SCHOOL), COMBE DOWN, BATH (Bath County Borough). Clerk, Bath Municipal Charity Trustees, E. Newton Fuller, i, Queen Square, Bath. Supt., Miss J. Quinton. (34) SUFFOLK. /. ST. JOSEPH'S HOME, THE CROFT, SUDBURY. Supt., Sister M. Murray. (15) SURREY. m.f. THE ROYAL EARLSWOOD INSTITUTION FOR MENTAL DP- FECTIVES, REDHILL. Supt., C.Caldecott, M.B. Sec., Henry Howard, 15/16 Ludgate Hill, E.C. (600) WARWICK. m.f. MIDLAND COUNTIES INSTITUTION, KNOWLE, NEAR BIR- MINGHAM. Sec. and Supt., H. Williams. (129) /. AGATHA STACEY HOME, REDNAL, NEAR BIRMINGHAM (Birmingham County Borough). Financial Sec., Miss C. P. Fleetwood, 158, Broad Street, Birmingham; Supt., Miss Smith. (35) /. AGATHA STACEY HOME, ENNISKERRY, KNOWLE. Financial Sec., Miss C. P. Fleetwood, 158, Broad Street, Birmingham; Supt., Miss Davis. (24) APPENDIX A 249 Institutions Approved under Section 37. (Poor Law Cases.) CHESHIRE. m.f. CHESTER WORKHOUSE IMBECILE WARDS, HOOLE. Supts., Medical Officer and Master of Workhouse. (25) ESSEX. m.f. TENDRING UNION WORKHOUSE, TENDRING, HARWICH. S'ltpt., Henry James Burden. (46) HAMPSHIRE. m. PARISH INFIRMARY BUILDINGS, SHIRLEY WARREN, SOUTHAMPTON (Southampton County Borough) Supt., J. C. Young, M.R.C.S., L.R.C.P. (54) KENT. m.f. CROYDON UNION WORKHOUSE. Supt., Dr. R. W. Wilson. (6) LANCASHIRE. m.f. SEAFIELD HOUSE, SEAFORTH, LIVERPOOL. Supt., S. J. Towill. (269) NORTHUMBERLAND. m.f. PRUDHOE HALL COLONY, and BURN HOUSE, PRUDHOE (Newcastle County Borough). Matron, Miss N. M. Hawkes. (105) STAFFORD. m.f. GUARDIANS INSTITUTION, LONDON ROAD, STOKE-ON- TRENT (Stoke-on-Trent County Borough). Supt., C. Gray son. (20) 2 50 MENTALLY DEFICIENT CHILDREN m.f. MENTAL WARDS, UNION WORKHOUSE, HEATH TOWN, WOLVERHAMPTON (Wolverhampton County Borough). Supt., T. D. Rollinson. (31) m.f- WALSALL UNION POOR LAW INSTITUTION, PLECK ROAD, WALSALL (Walsall County Borough). Supts., W. J. Humphries and Mrs. Humphries. (12) m.f. BURTON-ON-TRENT UNION WORKHOUSE. Sttpt., Robert Barcham. (20) WILTS. /. PEWSEY UNION WORKHOUSE. Supt., H. England. (4) /. UNION WORKHOUSE, ST. JAMES, DEVIZES. Supt., W. Fear. (16) m.f. CHIPPENHAM UNION WORKHOUSE. Supt., Jas. B. Pierce. (21) /. TROWBRIDGE UNION WORKHOUSE. Supt., Chas. H. Taylor. (24) WORCESTERSHIRE. m.f. EVESHAM UNION WORKHOUSE INFIRMARY. Supt., J. H. Damen. (8) m.f. MONYHULL COLONY, KING'S HEATH, BIRMINGHAM (Bir- mingham County Borough). Supt., Miss Carse. (io) YORKSHIRE. m.f. POOR-LAW INSTITUTION, 75, HARTINGTON ROAD, YORK. Sup'., w. E. Jenner. (30) APPENDIX A 251 Certified Houses. (Proprietary Homes for Private Cases, etc.) * Houses thus marked for private cases only. DERBYSHIRE. *m.f. RYDAL HOUSE, TENNYSON AVENUE, CHESTERFIELD. Supt., Miss Augusta Mole. (6) LANCASHIRE. /. LIN WOOD AND YORK VILLA, CROMPTON ROAD, FORMBY, NEAR LIVERPOOL. Supt., Miss Ethel Hobday. (44) m. LINTHAL, BARKFIELD AVENUE, FORMBY, NEAR LIVERPOOL. Supt., Miss K. Bowyer. (32) MIDDLESEX. *m.f. FERNHURST, 8, MATTOCK LANE, EALING, W. Supt., Miss S. M. Macdowall. (19) *Wl.f. NORMANSFIELD, HAMPTON WlCK, KlNGSTON-ON-THAMES. Supts., R. L. Langdon-Down, M.B., and P. L. Langdon- Down, M.B. (14) *m.f. THE GABLES, UPPER TEDDINGTON ROAD, HAMPTON WICK, KINGSTON-ON-THAMES. Supt., Miss F. H. Deck. (18) *m.f. ARNISTON, THE GROVE, ISLEWORTH. Supts., Miss J. M. and Miss M. D. Isbister. (12) SOMERSET. */. DOWNSIDE LODGE, CHILCOMPTON, BATH. Supt. 9 Miss C. E. Short. (7) SUSSEX. m.f. 12, UPPER MAZE HILL, ST. LEONARDS-ON-SEA. Supt., Mrs. J. Meiklejon. (38) YORKSHIRE. */. THE GRANGE, ALTOFTS, NORMANTON. Supt., Mrs. E. A. Howard. (15) 2 5 2 MENTALLY DEFiCiEtfT CHILDREN Approved Homes. (Training Schools for Uncertified Improvable Cases.) * Homes thus marked are proprietary Training Schools for private patients. CORNWALL. /. ELIZABETH BARCLAY HOME OF INDUSTRY, BODMIN. Hon. Sec., Miss E. M. S. Shaw; Supt., Miss Emily Hunt. (26) DERBY. /. MAGDALENE HOUSE, CROMWELL ROAD, CHESTERFIELD (Managed by Committee). Supt., Miss Root. (6) DORSET. /. KING'S GATE, AND FRITKSTOW, WEST MOORS. Manager, Miss B. James, 10, Bolton Court, London, S.W. ; Supt., Miss A. H. Egan. (12) ESSEX. m. GAY BOWERS, WEST HANNINGFIELD, CHELMSFORD. Supts., P. Chennells and Mrs. G. Chennells. (7) GLOUCESTERSHIRE. /. MARY CARPENTER HOME, 598 AND 600, FISHPONDS ROAD, BRISTOL, and BRANCH HOME AT WESTRA, YATE (Bristol County Borough and Gloucester County Council). Hon. Sec., Mrs. Gilmore Barnett; Supt., Miss Edwards; 18 female defectives at Fishponds Home and 7 at Branch Home, Westra, Yate. (25) /. ROYAL FORT HOME, BRISTOL (Bristol Preventive Mission). Supt., Miss Blanche Whiteaway. (15) *m.f. SOUTHEND HOUSE SCHOOL, PITVILLE, CHELTENHAM. Supt., Miss A. King-Turner. (16) KENT. m. UPPER HOLLANDEN FARM, PRINCESS CHRISTIAN FARM COLONY, HILDENBORO' (Application to Miss Kirby, Sec., N.A.F.M., Denison House, Vauxhall Bridge Road, S.W.) Supt., Miss E. J. Price. (See also Certified Institutions.) (8) LEICF;STER. /. SUNNYHOLME, 155, KING RICHARD'S ROAD (Leicester County Borough, managed by After-Care Committee). Hon. Sec., Miss A. E. Clephan, no, Regents Road, Leicester. Supt., Miss Gertrude Annie Ladkin. (12) APPENDIX A 253 MIDDLESEX. /. ALEXANDER HOUSE, 117, HIGH STREET, UXBRIDGE (Application to Miss Kirby, Sec., N.A.F.M., Denison House, Vauxhall Bridge Road, S.W.)Supt., Miss Ellen Collyer. (24) *m.f. BROOK HOUSE, SOUTHGATE, N. Supt., Dr. H. Corner. (37) *m.f. ST. CHRISTOPHER'S (SCHOOL), AMHERST ROAD, EALING, W. Supt., Miss M. C. B. Foster. (22) *m.f. CONIFERS, KINGSTON ROAD, HAMPTON WICK. Supt., Miss Florence Eddolls. (Drs. Langdon-Down.) (10) *m. TREMATON, BROOM ROAD, HAMPTON WICK. Supt., Miss A. G. Mackay. (Drs. Langdon-Down.) (12) NORTHUMBERLAND. /. HOME OF INDUSTRY, Bow VILLA, MORPETH (Managed by Committee). Supt., Miss A. A. Pawsey. (16) SOMERSET. /. HOUSE OF HELP FOR WOMEN AND GIRLS, 112, WALCOT STREET, BATH (Bath County Borough). Sec., Miss Twiss; Supt., Miss Alice Lilian Walker. (50) SUSSEX. (Mrs. Meiklejon's Homes.) *m.f. BROOKLANDS, 23, UPPER MAZE HILL, ST. LEONARDS- ON-SEA. Supt., Miss A. Lavers. (10) */. TlPPERARY, 22, UPPER MAZE HlLL, ST. LEONARDS-ON-SEA. Supt., Miss A. Lavers. (35) SUFFOLK. /. HANDFORD HOME FOR FEEBLE-MINDED GIRLS, RANELAGH ROAD, IPSWICH. Hon. Sec., Mrs. Alan Turner, Crane Hall, Ipswich; Supt., Miss Florence Church. (20) YORKSHIRE (N.R.). *m.f. THE MOUNT, WHITBY. Supt., Mrs. Annie E. Priestly. (12) FLINTSHIRE. m.f. " WALMER " SCHOOL FOR BLIND AND DEAF, RHYL. Supt., Mrs. Elizabeth Roberts. (13) 254 MENTALLY DEFICIENT CHILDREN (List kindly furnished by Clerk, June, 1915.) METROPOLITAN ASYLUMS BOARD. INSTITUTIONS FOR IMBECILES AND FEEBLE-MINDED, ETC. (From London Parishes.) A ccommodation . Males. Females. Total Asylums for unimprovable imbeciles (certified) : Leavesden 1,007 1,188 2,195 Caterham 1,017 1,092 2,109 Tooting Bee: (i) Asylum* 486 57<3 1,062 (2) Receiving-home for children 28 24 52 Fountain (temporary) 363 303 666 Industrial Colonies for improvable imbeciles (certified) and for feeble-minded (uncertified) : Daren th : Improvable imbeciles 884 784 1,668 Feeble-minded .. 320 310 630 Bridge : Feeble-minded 210 200 4>3i5 4> 2 77 8,592 * This asylum is now being extended. When finished, it will contain 942 male, 1,226 female, and 52 beds for chil- dren Total, 2,220. APPENDIX A 255 (List kindly supplied by General Board of Control, Scotland, 1915.) SCOTLAND. CERTIFIED INSTITUTIONS. Licensed for Name of Institution. Pri- vate. Aided. Class of Defectives to be Accommodated. M.| F. M. F. BALDOVAN, near Dundee. 2 60 Imbecile and mentally Med. Supt., Dr. W. B. defective children Drummond GRIERSON HALL, Dum- 50 50 Private and aided de- fries fectives over 1 6 LARBERT, Stirlingshire. 350 Imbecile and mentally Med. Supt., Dr. R. D. defective children Clarkson MIDDLETON HALL, Lin- 65 Males of Edinburgh lithgowshire parish OUARRIER'S HOMES, 68 m. 44 f. Epileptics of school age, Bridge of Weir, Ren- Protestants frewshire STONEYETTS, Chryston, 174 T7I Adults and ineducable near Glasgow juveniles of Glasgow parish WAVERLEY PARK, Kir- QO Educable girls be- kintilloch, nr. Glasgow tween 5 and 16 years IRELAND. (Not included under Mental Deficiency Acts.) STEWART INSTITUTION FOR IDIOTIC AND IMBECILE CHILDREN. Palmerston House, Chapelizod, Co. Dublin. no boys and girls. Med. Supt., Dr. Rainsford; Sec.,W. M'c. O'Neill. BRITISH DOMINIONS. Canada : Orillia, ONTARIO HOSPITAL FOR FEEBLE-MINDED (800). Med. Supt., Dr. A. M. Beaton. Australia : KEW ASYLUM ANNEXE FOR IDIOTS, near Mel- bourne; ADELAIDE INSTITUTION, S. Australia. New Zealand : STATE INSTITUTION FOR MENTALLY DEFECTIVE BOYS, Otckaike, Oamaru. South Africa : DEPARTMENT FOR DEFECTIVE CHILDREN: GRAHAMSTOWN ASYLUM. 256 MENTALLY DEFICIENT CHILDREN Q W Q W O ff H *r i ^ H f I I u * Q 3 q >^ PQ e g t s ^ | X < < H < a w a 5J !75 g H C/5 Q S I-H Jz; P ro M H M ro^ i-T i-T ' ^Q 6 OHOOfeffi * d S | > o <3 W W g S ou ^ S IgS'S-S I a 6^ 0f | & I I _ 'O-in S .7? **lJig*fl ^^MHftfe ^ o S ^ ^ S fe S O -S S r^^^ i|Iii|!| |l||i I l en w ^ APPENDIX B 257 w , l||l|3|l|l|!||!f|l!l|l|||| 111 C bo rj D L_i O C4 S3~ Crj " ^ S3 - ' o M '55 ^|^ I al| 0.2^ O ll .8, 258 MENTALLY DEFICIENT CHILDREN o o 00 f; Offi Ex f 1 ! 1 1 11 i .3 82 S Nam t/3 I a fe 1 - _ v ' l ll a < ^s r rg w coSJJJi S |83H 66 APPENDIX B 259 O Tt- H vQ N 04 O M Ps a O a 1 *(K Go 1 ft JZJ fc 260 MENTALLY DEFICIENT CHILDREN IT) w I s x I 3 S S I X M S OH O, K < W ft S i L-. 2g to J " a? g *dt> - _ _ .- - -C flj tD .S K^ frfH -!> n ^ Jj-j _ C/3 _ .- flj J-J M -C fe .t; ^-1 -1-) r^ ! ^ ft pq H Q > ft >4 J c/5 sj H ^^ APPENDIX C 261 II. SIMPLE VOWEL SOUNDS. Vowel Sound. Examples. A (open) =(Ah) Father A (broad) = (Aw) All (Awtul) A (short) =A Cap, Tap A (long) =A Cape, Tape O (short) =6 Cot, Knot O (long) =0 Coat, Note 56 (short) =(66) Foot, Wood OO (long) = (OO) Boot, Food U (short) -U Tun, Fun U (long) =U Tune, Fume E (short) = Bed, Fed E (long) =E Bead, Feed I (short =1 Bit, Fit I (long) =1 Bite, Fight Aspirate H Hat, Hall Double Letters W, Y Wall, You Diphthongs, 6t, OW Oil, Owl [Arranged by Dr. Shuttleworth for use at Royal Albert Asylum. Reprinted from his article on " Education of Imbeciles " in Dr. Hack Tuke's " Dictionary of Psychological Medicine," by kind permission of Messrs. Churchill.] The following phonetic phrases (from Dr. Wyllie's book) are serviceable for speech testing : 1. (Labials) " Peter Brown made white wax." 2. (Labio-dentals) " Fine villages." 3. (Linguo-dentals) " Thinkest thou so, Zealot ?" 4. (Anterior linguo-palatals) " She leisurely took down nine large roses." 5. (Posterior linguo-palatals) " Can Gilbert bring Loch Hourn youths ?" 262 APPENDIX D. L.C.C. "SPECIAL" MENTAL! ELDER BOy (Staff: i Head Master, 4 Assistant Maste 1 6 9-30 to 9.40 to 10.0 to 10.35 to 10.55 to II. IO to II. 2O to 11.40 to i ^ IO.O. 10.35. 11.40. 12. 0. O 9.40. 10.55- II. IO. 11.20. i Scripture Arithmc. Readg. Recitation Writing K| 2 d Q 3 4 " Hand work 11 f 1 1 '; O *a Woodwork Wood work o Wood work b Bootmaking Boot making PH (3 P^ Boot making c Tailoring Tailor ing Tailor ing i Hymns Arithmc. Readg. Oral Comp. Writing Q 2 3 Scripture J 3 j> C/) 4 Hand work 11 rt i a g Woodwork Wood work OJ "Wood work H b Mj Bootmaking Boot making ^ w Boot making c Tailoring Tailor ing Tailor ing ^ , 1 Scripture Basket work Basket work Q C/3 W 2 3 4 1 Arithmc. Readg. || cS .2 Recitation Geograpb Z a (/) Woodwork Wood work A K "Wood work b | Bootmaking Boot making Pn pq Pn Boot making s c * Tailoring Tailor irig Tailor ing i 1 Scripture Arithmc. Readg. Wordbuildg Geograpl < 2 ,, ,, ,, F ( & ,, ,, p 3 o> Hymns Hand work o . ' Object Le: f3 4 }) Arithmc. Readg. "0 " cJ i ,, a Woodwork Wood work g 8 : Wood work n b Bootmaking Boot making ^ & Boot making H c ; Tailoring Tailor ing Tailor ing i Scripture Arithmc. Readg. Oral Comp. Dictatio ;* 2 _< t/5 ^3 ? d .2 3 o .ty Q 4 Hand work *co ft cd CL) tt ,, 5 a Woodwork Wood work A o Wood work & b iBootmaking Boot making PH pq ft Bootmaking c Tailoring Tailor ing Tailoring * Classes a, b, c, are section: ' EFECTIVE SCHOOL TIME fcTABLE, 1914-15. EPARTMENT. Manual Instructors ; Accommodation 126.) 30 to 35- 1.35 to 2.IO. 2.10 to 2.35. 2-35 to 3-5- 3-5 to 3.20. 3.20 to 3.55. 3-55 to 4.0. | : co 'd 03 3 Arithmetic Handwork Arithmetic Woodwork Bootmaking Tailoring Reading Handwork Reading Wood Boot Tailor Drawing (pattern) Handwork Drawing (colour) work making ing 03 1 Singing Geography Woodwork Bootmaking Tailoring 'rt C/) 5 03 1 Arithmetic Handwork Arithmetic Woodwork Bootmaking Tailoring Reading Handwork Reading Wood Boot Tailor Phys. Ex. & Games Singing work making ing i History Woodwork Bootmaking Tailoring Arithmetic Basketwork Arithmetic Woodwork Bootmaking Tailoring Reading Basket Reading " Wood Boot Tailor Drawing (woodwk.) work Drawing (colour) (pattern) work making mg )_i Singing Story-telling Woodwork Bootmaking Tailoring Arithmetic Handwork Woodwork Bootmaking Tailoring Reading Handwork Wood Boot Tailor Drawing (colour) ,, (pattern) Handwork work making ing Recreation Story-telling >> Singing Woodwork Bootmaking Tailoring Arithmetic Woodwork Bootmaking Tailoring Reading " Wood Boot Tailor Drawing ,, (memory) Phys. Ex. & Games work making ing Recreation Object Lesson Woodwork Bootmaking Tailoring 264 MENTALLY DEFICIENT CHILDREN APPENDIX E MENTAL DEFICIENCY ACT, 1913, S. 3, 5, ETC. [Form P4-] MEDICAL CERTIFICATE. In the matter of A.B. , of in the County (*) of , an alleged defective. I, the undersigned, K.L. , do hereby certify as follows : 1. I am a person registered under the Medical Acts and I am in the actual practice of the medical profession [and approved by the Local Authority for the County (*) of or by the Board of Control, for the purpose of giving medical certificates under the above Act] [and the usual medical attendant of the said A.B. ] 2. On the day of , (f) at , in the County (*) of separately from any other practitioner, I personally examined the said A.B. and satisfied myself that he was .(J) 3. I formed this conclusion on the following grounds, viz. : (a) Facts observed by myself (i.) at the time of examination ; (ii.) previously to examination. () (b) Facts communicated by others. 4. The said A.B. appeared to me to be [or not to be] in a fit condition of bodily health to be removed. Dated Signed * Or County Borough. t The examination must have taken place not more than seven clear days before the date of the presentation of the petition or admission of patient. { State whether an idiot, an imbecile, a feeble-minded person, or a moral imbecile. If the defective be certified otherwise than as an idiot or imbecile, the sanction of a judicial Authority is also required (S. 3). Give date when observed. || Insert postal address. BIBLIOGRAPHY 1. De 1' education d'un Homme Sauvage, Itard. Paris, 1801. 2. Observations pour servir a 1'histoire de 1' Idiotic, Esquirol (Maladies Mentales) . Paris, 1828. 3. Die Heilung und verhiitung des Cretinismus, etc., Gug- genbuhl. Bern, 1835. 4. Resume de ce que nous avons fait pendant quatorze mois, Esquirol et SSguin. Paris, 1839. 5. Traitement Moral, Hygiene et Education des Idiots, etc., E. S6guin. Paris, 1846.* 6. Articles on Idiocy in Chambers' Edinburgh Journal, by Mr. Gaskell. January and February, 1847. 7. Remarks on the Education of Idiots and Children of Weak Intellect, W. R. Scott, Ph.D. London, 1847. 8. Article by Dr. Conolly in British and Foreign Medico- Chirurgical Review. London, 1847. 9. Causes and Prevention of Idiocy (Report to Mass. Legisla- ture), Dr. S. G. Howe. Boston, Mass., 1848. 10. Report of Commission created by King of Sardinia for Study of Cretinism. Turin, 1850. 11. Researches on Idiocy and Cretinism in Norway, Dr. Stalst. Christiania, 1851. 12. On the Possibility of Educating Idiot Children, Dr. Ehr- chricht. Copenhagen, 1854. 13. Cretinism and Idiocy, Dr. Blackie. Edinburgh, 1855. 14. Idiot Training, Rev. Edwin Sidney. London, 1855. 15. Idiots and the Efforts for their Improvement, Dr. L. P. Brockett. Hartford, Conn., 1856. 1 6. Report of Commissioners on Idiocy in Connecticut (Knight and Brockett). Dorchester, Conn., 1856. * Reprinted by Dr. Bourneville in Publications du Progrls Medical. Bibliotheque d' Education Speciale, III. bis. Paris, 1906. 265 266 MENTALLY DEFICIENT CHILDREN 17. Handbook of Idiocy, James Abbott. London, 1857. \. 1 8. The Mind Unveiled, Dr. Isaac N. Kerlin. Philadelphia/^ 1858. 19. Suggestions on Principles and Methods of Elementary In- struction, Dr. W. B. Wilbur. Albany, New York, 1862. 20. The Idiot and his Helpers, W. Millard. Colchester, 1864. 21. Idiocy : its Diagnosis and Treatment by the Physiological Method, E. SSguin, M.D. Albany, 1864. 22. Manual for the Classification, Training, etc., of the Feeble- minded, Imbecile, and Idiotic, Duncan and Millard. London, 1866. 23. Idiocy and its Treatment by the Physiological Method, E. S6guin, M.D. New York, 1866.* 24. New Facts and Remarks concerning Idiocy, E. S6guin, M.D. -New York, 1870. 25. Two Cases of Microcephalic Idiocy, G. E. Shuttleworth, M.D. British Medical Journal, August, 1875. \ 26. Education and Training of the Feeble in Mind, J. Langdon- Down, M.I). London, 1876. 27. Notes of Visit to American Institutions for Idiots and Imbeciles, G. E. Shuttleworth, M.D. Lancaster, 1877. 28. Case of Microcephalic Imbecility, G. E. Shuttleworth, M.D. Journal Mental Science, October, 1878. x> *9. Some ofj;he Cranial Characteristics of Idiocy. Id. Trans. International Medical Congress, 1881. 30. The Idiot : his place in Creation, Sir Frederick Bateman, M.D. London, 1882. ^ 31. Types of Imbecility, Fletcher Beach, M.B. Medical Times and Gazette. London, 1882. ^32. The Physical Features of Idiocy, G. E. Shuttleworth, M.D. Liverpool Med.-Chir. Journal, July, 1883. 33. Is Legal Responsibility acquired by Educated Imbeciles ? Id. Journal Mental Science, January, 1884. 34. The Health and Development of Idiots as compared with Mentally Sound Children. Id. International Health Exhibition Literature, vol. xi. t p. 526. London, 1884. * Reprinted by Teachers' College, Columbia University, New York, 1907. BIBLIOGRAPHY 267 35. Idiotophilus, Pastor H. Sengelmann, Dr. Norden, 1885. 36. Clinical Lecture on Idiocy and Imbecility, G. E. Shuttie- ^ worth, M.D. British Medical Journal, January 30, 1886. 37. The Relations of Marriages of Consanguinity to Mental Unsoundness. Id. Journal of Mental Science, October, 1886. K 38. Mental Affections of Childhood and Youth, J. Langd on- Down, M.D. London, 1887. 39. Idiocy and Imbecility due to Inherited Syphilis, G. E. Shuttleworth, M.D. Amer. Journal of Insanity, January, 1888. ^40. Weak-minded Children. Id. Journal Mental Science, April, 1888. 41. A Course of Lectures on the Growth and Means of Training the Mental Faculty, F. Warner, M.D. Cambridge, 1890. 42. The Care of the " Mentally-feeble " Child (as distinguished from the "Imbecile"), G. E. Shuttleworth, M.D. London, 1891. 43. Neuroses of Development, T. S. Clouston, M.D. London, 1891. 44. Report on Physical and Mental Condition of 50,000 School Children, F. Warner and others. Parkes Museum, 1 892 . 45. Hack Tuke's Dictionary of Psychological Medicine. Articles on Idiocy, etc. (Pathology, F. Beach. Etiology, Shuttleworth and Beach. Treatment and Education, Shuttleworth). London, 1892. 46. The Feeble-minded Child and Adult. (Charity Organiza- tion Series.) London, 1893. 47. L' Idiotic, Dr. Jules Voisin. Paris, 1893. 48. The History of the Treatment of the Feeble-minded, Walter E. Fernald, M.D. Boston, 1893. 49. Psychopatische Minderwertigkeiten im Kindesalter, Triiper. Giitersloh, 1893. 50. Dell* Educazione dei Fanciulli Frenastenici, Prof. A. Gon- nelli Cioni. Lecco, 1893. \. 51. Causation and Early Treatment of Mental Disease in Chil- dren, A. W. Wilmarth, M.D. Chicago, 1894. 268 MENTALLY DEFICIENT CHILDREN 52. The Disorders of Speech, John Wyllie, M.D. Edinburgh, 1894. 53. Rapport sur 1'assistance des enfants idiots et degeneres, Bourneville. Lyon, 1894. 54. Mentally-feeble Children : Treatment and Education of, Fletcher Beach, M.B. London, 1895. 55. Cases of Sporadic Cretinism treated by Thyroid Extract, T. Telford-Smith, M.D. Jour. Mental Science, April, 1895. 56. Stndien iiber Klinik und Pathologic der Idiotic, Karl Hammarberg. Upsala, 1895. 57. The Brain of the Microcephalic Idiot, D. J. Cunningham, M.D., and T. Telford-Smith, M.D. Scientific Trans. Roy. Dublin Society, 1895. S 58. Report on Scientific Study of the Mental and Physical Conditions of Childhood. London, 1895. 59. Amaurotic Idiocy, Sachs. New York Med. Jour., May 30, 1896. 60. Pathogenesis of Epileptic Idiocy and Epileptic Imbecility, W. L. Andriezen, M.D. Brit. Med. Jour., May i, 1897. 61. The Mentally-feeble Child and How to Train him, Fletcher Beach, M.D. Pediatrics, December, 1897. 62. Kliniske og Aetiologiske Stndien over Psykiske Udviklins- manger hos Born, Carl Looft. Bergen, 1897. 63. The Study of Children, F. Warner, M.D. New York and v London, 1897. 64. Diagnosis and Prognosis of Certain Forms of Imbecility, John Thomson, M.D. Scottish Medical and Surgical Journal, March, 1898. \J35. The Mental Affections of Children, Idiocy, Imbecility, and Insanity, William W. Ireland, M.D. London and Edinburgh, 1898. 66. Clifford Allbutt's System of Medicine, vol. viii. Article on Idiocy and Imbecility, by Fletcher Beach, M.B., and G. E. Shuttleworth, M.D. London, 1899. 67. Letter-, Word-, and Mind-Blindness, James Hinshelwood, , M.A., M.D. London, 1900. ^68. Pathological Anatomy of Idiocy, Beach, Bourneville, Mierzejewski, Shuttleworth. Transactions Paris Inter- national Medical Congress, 1900. BIBLIOGRAPHY 269 Mentally Deficient Children, W. A. Potts, M.D. Bir- mingham Medical Review, October, 1901. 70. Insanity in Imbeciles, A. F. Tredgold, M.R.C.S. Journal of Mental Science, January, 1903. Amentia, A. F. Tredgold, M.R.C.S. Practitioner, Sep- tember, 1903. ^72. The Responsibility of the State for the Feeble-minded, W. H. Dickinson. National Association for the Feeble- minded. London, 1904. 73. On the Relations of Epilepsy to Amentia, A. F. Tredgold, M.R.C.S. British Journal of Children's Diseases, July, 1904. 74. The Problem of the Morally Defective, W. A. Potts, M.D. Lancet, October 29, 1904. ^5. Mental Defectives : their History, Treatment, and Train- ing, Martin W. Barr, M.D. Philadelphia, 1904. ^76. The Causation of Mental Defect in Children, W. A. Potts, M.D. British Medical Journal, October 14, 1905. 77. Traitement Medico -Pedagogique de 1'Idiotie, Dr. Bourne- ville. Paris, 1905. 78. Functional Nervous Disorders in Childhood, Leonard G. Guthrie, M.A., M.D. London, 1907. \79. The Burden of Feeble-mindedness, Amos W. Butler. National Conference of Charities and Correction, 1907. 80. The Recognition and Training of Congenital Mental Defectives, W. A. Potts, M.D. British Medical Journal, May 9, 1908. Some Types of Congenital Mental Defect and their Significance, W. A. Potts, M.D. Transactions of the Society for the Study of Disease in Children, 1908. 82. The Differentiation of Mentally Deficient Children, G. E. Shuttleworth, M.D. Transactions of the International Congress School Hygiene, 1908, p. 742 et seq. 83. The Problem of the Feeble-minded, Mary Dendy. Man- chester Statistical Society, March, 1908. 84. Inherited Syphilis as a Factor in the Etiology of Mental Defect in Children, G. E. Shuttleworth, M.D. British Journal of Children's Diseases, April, 1908. y 270 MENTALLY DEFICIENT CHILDREN 85. The Relation of Alcoholism to Feeble-mind edness, W. A. Potts, M.D. British Journal of Inebriety, London, 1908. ^86. Mongolism and its Pathology, W. Bertram Hill, M.B. Quarterly Journal of Medicine, October, 1908. 87. The Aphasias of Childhood and Educational Hygiene, C. J. Thomas, M.B. London, 1908. 88. Guide to the Clinical Examination and Treatment of Sick Children, John Thomson, M.D. Edinburgh and London, 1908. 89. fitud'e Anatomique de 1'Idiotie Mongolienne, M. L. Babonneix. Archives de Medecine des Enfants, July, 1909. 90. Common Disorders and Diseases of Childhood, G. F. Still, M.A., M.D. London, 1909. 91. Physiological Variations in Children, James Kerr, M.A., M.D. Medical Chronicle, July, 1909. 92. Mongolian Imbecility, G. E. Shuttle worth, M.D. British Medical Journal, September n, 1909. 93. Mendel's Principles of Heredity, W. Bateson. Cambridge University Press, 1909. 94. Feeble-mind edness and Juvenile Crime, G. A. Auden, M.D. Birmingham Medical Review, 1910. 95. Care and Training of the Feeble-minded, A. R. Douglas, L.R.C.P. and S. Journal of Mental Science, 1910. 96. Allbutt and Rolleston's System of Medicine, vol. viii. (Idiocy and Imbecility, by G. E. Shuttleworth, M.D., and Fletcher Beach, M.B., F.R.C.P.). London, 1910. 97. Care and Control of the Feeble-minded, Ellen F. Pinsent. Nineteenth Century and After, July, 1910. 98. Mental and Physical Tests, G. M. Whipple. Warwick and Yorke, Baltimore, 1910. 99- Oxycephaly, W. A. Potts, M.A., M.D. The Child, Novem- ber, 1910. 100. Prevention of Feeble-mindedness, E. R. Johnstone. Journal American Public Health Association, 1911. 10 1. The Feeble-minded, E. B. Sherlock, M.D. Macmillan, London, 1911. 102. Our Provision for the Mentally Defective, Ellen F. Pinsent. Nineteenth Century and After, October, 1911. BIBLIOGRAPHY 271 103. Training of the Mentally Defective in Special Schools, W. A. Potts, M.A., M.D. Papers and Proceedings of the National Conference on the Prevention of Destitution. London, 1911. 104. The Deaf Child, James Kerr Love, M.D. Wright, Bristol, 1911. 105. Feeble-mindedness in Children of School Age, C. Paget Lapage, M.D. University Press, Manchester, 1911. 106. Measurement of Mental Ability of Backward Children, A. R. Abelson, D-fcs-L. British Journal of Psychology, 1911. 107. The Binet-Simon Measuring Scale for Intelligence, H. H. Goddard, Ph.D. The Training School, 1911. Vineland Training School, N.J., U.S.A. 108. Tests of Intelligence, W. A. Potts. M.A., M.D. British Medical Journal, April, 1912. 109. The Kallikak Family, a Study in the Heredity of Feeble- mindedness, H. H. Goddard, Ph.D. Macmillan Co., New York, 1912. no. The Conservation of the Child, Arthur Holmes, Ph.D, J. B. Lippincott Co., Philadelphia, 1912. in. Experimental Studies of Mental Defectives, J. E. Wallace Wallin, Ph.D. Warwick and Yorke, Baltimore, 1912. 112. Some of the Methods employed in the Care and Training of Feeble-minded Children of the Lower Grades, W. E. Fernald, M.D. G. H. Ellis Co., Boston, 1912. 113. What is a Feeble-minded Child? Helen MacMurchy, M.D. Annual Report, Ontario Women's Institutes, Toronto, 1913- 114. The Brain in Health and Disease, Joseph Shaw Bolton, M.D., D.Sc. E.Arnold, 1914. 115. Feeble-mindedness, its Causes and Consequences, H. H. Goddard, Ph.D. Macmillan and Co., 1914. 116. Mental Deficiency, A. F. Tredgold, L.R.C.P., M.R.C.S. 2nd edition, Bailliere, London, 1914. 117. Mental Health of the School Child, J. E. Wallace Wallin, Ph.D. Yale University Press, 1914. 1 1 8. Mentally Defective Children, Alfred Binet and Th. Simon, M.D. Translation by W. B. Drummond, M.B. E. Arnold, London, 1914. 272 MENTALLY DEFICIENT CHILDREN ng. Industries for the Feeble-minded, A. Bickmore. Adlard and Son, London, 1914. 1 20. Seguin and his Physiological Method of Education, Henry Holman, M.A. Sir Isaac Pitman and Sons, Ltd. London, 1914. 121. What Tests in Childhood are best calculated to throw Light upon the Capacities of Mental Defectives for Future Work, W. A. Potts, M.D. Lancet, July, 1915. 122. Dementia Praecox and Some Neuroses of Adolescence, G. E. Shuttle worth, M.D. School Hygiene, November, 123. Organization and Management of Auxiliary Classes, Helen MacMurchy, M.D. L. K. Cameron, Toronto, 1915- 124. Nature and Nurture in Mental Development, F. W. Mott, M.D. John Murray, London, 1915. 125. Criminal Imbecility, H. H. Goddard, Ph.D. Vineland Training School, N.J., U.S.A., 1915. 126. Kelynack's Defective Children (article on Idiots and Imbeciles, by Dr. D. Hunter). London, 1915. REPORTS AND SERIALS. 1. Report of a Special Committee of the Charity Organiza- tion Society on the Education and Care of Idiots, etc. London, 1877. 2. Report of the Royal Commission on the Blind, the Deaf, etc. London, 1889. 3. Report of the Departmental Committee on Defective and Epileptic Children. London, 1898. 4. Report of Royal Commission on the Care and Control" of the Feeble-minded (8 vols.). London, 1908. 5. Reports of Conferences of the National Association for Promoting the Welfare of the Feeble-minded. 6. Reports of Conferences of After-Care Committees, Bir- mingham, Leicester, and Nottingham, 1903-1905. Sub- sequently After-Care Conferences of the National Association for Promoting the Welfare of the Feeble- minded. BIBLIOGRAPHY 273 7. Reports on the Feeble-minded in Ontario, Toronto, 1906- 1914. Cameron, Toronto. 8. Report of the Commission to Investigate the Question of the Increase of Criminals, Mental Defectives, Epileptics and Degenerates in Massachusetts, 1911. 9. Annual Reports of the Chief Medical Officer of the Board of Education, 1910-1915. Eyie and Spottiswoode. 10. Publications of the Gal ton and Biometric Laboratories, University of London. Cambridge University Press. 11. Journal of Mental Science. Churchill, London, 1858-1915. 12. The Psychological Clinic, Philadelphia, U.S.A., 1900-1915. 13. Journal of Psycho-Asthenics, Faribault, Minn., U.S.A., 1900-1915. 14. The Training School Bulletin. Vineland, N. J., U.S.A., 1904-1915. 15. The Special Schools Quarterly, Morris and Yeaman. Manchester, 1910-1915. 16. L'Enfance Anormale. Paris, A. Maloine, 1911-1915. 17. Nyt Tidskrift for Abnormvaesenet i Norden. Copenhagen, 1899-1915. 1 8. The British Journal of Children's Diseases. London, 1901-1915. 19. Reports, National Association for Feeble-minded. Lon- don, 1900-1915. 20. First Report, Central Association for the Care of the Mentally Defective. London, 1915. (And Reports of British, Irish, American, and Continental Institutions for Defectives.) Publications re Mental Deficiency Act. 1. The Mental Deficiency Act, 1913, R. A. Leach. London, L.G.B. Press, 27, Furnival Street, E.G. 2s. 6d. 2. A Guide to the Mental Deficiency Act, 1913, J. and S. Wormald. London, P. S. King. 53. 3. The Law relating to the Mentally Defective, Herbert Davey. Second Edition, 1914. London, Stevens and Son. los. 18 INDEX OF SUBJECTS ABNORMALITIES of cranium, 59, 105-8, 116-19 of nervous action, 12, 16, 109-10, 160 Abortion, etc., attempts at, 100 Accidental or acquired defect, 73, 8 1 Accidents (maternal) during gestation, 99 Achondroplasia, 135 Acts of Parliament. Elementary Education (Defective and Epileptic Children) Act (1899), n, 18, 19, 21, 22, 41, 153, 162, 239; (1903), 19; (1914). I0 > 2 3> 35, 42 Mental Deficiency Act (1913), n, 27-33, 151, 153, 161-2. Mental Deficiency and Lunacy (Scotland) Act (1913)* 27, 33-4 Adenoids, 184 Adenoma sebaceum, 65, 183 Adolescence, psychopathies of, 142-52 After-care, need for, 228-9, 235 committees, 21-2, 235 Alcoholism, 75, 96-9, 130, 163-4 Amaurotic family idiocy, 75-6, 82, 130-1 Amentia, primary, 52, 64, 104, uo-n secondary, 52, 104, in, 114 American Institutions, 4-7, 38-9, Appendix B, 256-9 results, 232-4. Approved Homes, 32, Appendix A, 252-3 .Articulation (speech), 197-202, Appendix C, 260-1 Asphyxia neonatorum, 101, no Asymmetry of cranium, 107-8 Athetosis, 127, 189 Attention, defects of (aprosexia), 170, 189 Backward (or intermediate) classes, 165-7, 240 Backwardness, 135, 165 Bean-bags (school appliance), 188 Belgium, provision in, 38 Bibliography, 265-73 Bicetre Hospital, Paris, I 274 INDEX OF SUBJECTS 275 Binet and Simon tests, 116, 157-60, 163-5 Birmingham After-care (Special Schools) Committee, 112, 116, 228-9 Birth, causes acting at, 101-2; previous to, 99, 100 Premature, 102 Injury at, 101 Palsies, 72, 127 Causes acting after, 102-4 Board of Control, 26, 30 Provisional regulations, 32 General, for Scotland, 34 District, in Scotland, 34 Board of Education : Departmental Committee, 18-21 " Model arrangements " (Special Schools), 153-69 Chief Medical Officer's Annual Reports, 41, 156, 163, 167, 212-14 Brains of defectives, 54-63 Breathing exercises, 198-9 British Dominions, Institutions in, 255 Calculation, cultivation of, 205-6 Causes of mental deficiency. See Etiology Central Association for Mentally Defective, 235 Cerebellum, defect of, 55 Certificates under Mental Deficiency Act, 112-14 Form of medical certificate, 264 Under Elementary Education (Defective and Epi- leptic Children) Act, 19, 154, 161-2 Certified Houses, 32, 251 Certified Institutions (England and Wales), 31, 244-8 (Scotland), 255 Classification, pathological, ^z&z Cleanly habits, promotion of, 172-3 Clothing, 173-4 Colour perception, exercises in, 195-6 Committee on Children (Dr. Warner's), 11-13 Conclusions (and results), 226-43 Congenital (simple) types, 63-4 Consanguinity of parents (cousin marriages), 88-9 . Consumption and mental defect, 96 Convulsions during dentition, 66, 102, 123 Co-ordination, exercises to promote, 187 seq. Corpus callosum, defects of, 54 Cranial abnormalities, 105-9, 116-19 Craniectomy, 184 Cretinism, 77-8 Sporadic, 78-9, 131-2, Table of differences from mongolism, 133-4 276 MENTALLY DEFICIENT CHILDREN Criminality and mental defect, 26, 138-40, 219-21 Curricula (specimen) for Mentally Defective Schools, 213-14, 262-3 Custodial treatment, 211, 219, 224, 230 Dancing as recreation, 211-12 Defective and epileptic children, 34 Acts, 21-3 Estimated number, 19-20 Defects of special areas of brain, 64 Definitions : Idiots, 27 Imbeciles, 27 Feeble-minded, 28, 35 Moral imbeciles, 28, 218-9 Degeneration, stigmata of, 63-4 Degenerative changes in eyes, 76, 77, 121 in epilepsy, 148 Dementia praecox, 146-8 Denmark, provision in, 37-8 Departmental Report (defective and epileptic children), 18-21 Development of function in normal infancy, in Developmental cases, 64-72, 81, 102 defects, 12, 108-9 Diagnosis, 104-41 Diarrhoea, treatment of, 177 Drawing, instruction in, 205 Dressing lessons, 203-4 Dribbling, repression of, 173 Drill, 202-3 Dull children, 165. See also Backward Earnings of defectives, 227-8, 231-2, 241 Echolalia, 200 Eclampsic cases, 66, 81, 102, 123 Educational training, 186-206 Elder boys and girls, special schools (L.C.C.), 40 Time tables, 214, 262-3 England and Wales, provision in, 3-4, 8-10, 244-54 Enuresis, 172-3 Environment and mental defect, 89-92 Epilepsy : Associated with primary amentia, 64 As cause of secondary amentia, 67, 81 Developmental, mental degeneration in, 148-9 Pathology, 69 Psychical, 223 Status epilepticus, 68 Treatment, 177-81, 185 INDEX OF SUBJECTS 277 Epiloia (tuberous sclerosis), 65-6, 81, 183 Etiology (causation), 83-105 Attempts at abortion, 100 Environment, 89-92, 103 Epilepsy, 67, 81, 103, 148 Febrile illnesses, 103 Formative defects, 12, 54 Heredity, 83-9 Infantile convulsions, 102 Instrumental delivery, 101 Maternal conditions, 99 Parental intemperance, 96-9 Phthisical family history, 96 Premature birth, 102 Prolonged birth, 101 Shock (emotional), 74, 103 Syphilis (inherited), 93-5 Traumatism, 73, 103 Exanthemata, prognosis in, 183 Exercise, importance of, 174-5 Eye defects, 12, 74-5, 77, 121 Eye training, 195-6 Family, artificial restriction of, 100 Family history, 83-9, 159, 163-4 Pasmore's Chart for, opposite p. 163 Febrile diseases, 103 Feeble-minded, use of the term, 1 1 Definition of, 28, 35 Illustrative cases, 46-50 Finger training, 189-94, 207-11 Forceps delivery, 101, 107 Form and size boards, 192-3 Formative and developmental defects, 108-9 Forms of mental defect (pathological classification), 51-82 France, special instruction in, 2, 38 " Freddy," case of, 59-60 Fresh air and exercise, 174, 208 Fright (or shock), 103 Functions, normal, development of, uo-n Games, 211-12 Gardening, 208, 210 General paralysis (juvenile), 71-2, 142-6 General treatment, 171-6 Germ cells, 86-7, 89 Germany, provision of special instruction in, 2, 36 Glandular deficiency, 80 278 MENTALLY DEFICIENT CHILDREN Guardianship, 155-6, 236 Gums, spongy, 183 Habits, improvement of, 172-3 Hair in mongols and cretins, 134 Hands in mongols, 120, 134 Cretins, 131, 134 Hearing, 196-7 Heart, anomalies of, in mongols, 121 Hebephrenia, 147 Hemiplegia. See Paralysis Heredity in mental defect, 83-89 Chart for recording, 163 " Hilfsklasse " and " Hilf schiilen, " 36-7 Histological changes in mental defect, 52-3 Homes, " Approved," 32 List of, 252-3 Educational, for better class children, 43 Residential, list of, 244-51. See also Certified Homes and Institutions Hydrocephalus, 60-1, 64, 106, 118 Hypertrophy of brain, 61, 64, 106-7, 118 Hysterical affections in youth, 151 Idiocy, Seguin's definition, 3 Idiots, statutory definition, 27 Idioglossia, 200-1 Imbeciles, statutory definition, 27-8 Moral, statutory definition, 28 Moral, 218-25 Inco-ordination (muscular), 188 Industrial training, 207-15 Inflammatory (post-febrile) cases, 129-30 Inheritance. See Heredity, 83-9 Inherited syphilis, 70-2, 81, 93-5, 125 Insanity in children, 151, 223 Institutions, Colonies, Homes, Schools, etc. : England and Wales, 244-54 Scotland, 255 Ireland, 255 British (oversea) Dominions, 255 United States of America, 4-7, 256-9 Special Schools, 39, 40-1 Continental Institutions, 36-9 Intelligence, tests of, 111-14 Binet and Simon's, 157-60 Intemperance, parental, 96-9 Intermediate schools and classes, 165-7, 2 4 INDEX OF SUBJECTS 279 Ireland, provision in, 10, 255 Italy, provision in, 38 Juvenile general paralysis, 71, 142-6 Joints, laxity of, in mongols, 120 Kallikak family, 89 Kalmuc. See Mongol, 61-2, 119-122 Katatonia, 147 Kindergarten methods, 187, 207 Kleptomania, 150 Lip exercises, 173, 197-8 Limbs, contractions of, 183-4 Local authorities (England and Wales), 30-1, 33, 42, 153-167 (Scotland), 34 Lunacy Commission and Board of Control, 30 Macrame work, 209 Manual training, 207-15, 241 Marriage, question of, 237 Masturbation, 175 Maternal conditions during gestation, 99-100 Medical examination (Special Schools), 154-169 treatment, 176-83 Melancholia, 152 Mertdelism (applied to mental defect), 86-9 Meningitis, 73-4 Mental Deficiency Acts. See Acts of Parliament Mental retardation (Binet and Simon's tests), 157, 165 Microcephalus, 59-60, 105-6, 116-7 Microkinesis, 109 Mind-blindness, 58 Mixed types, 135 ^ Model arrangements," Board of Education, 153 seq., 168-9 " Mongol " cases, 61-27^4, 107, 119-22, 177 Diagnosis from cretinism, 133-4 Montessori method, 191-4 Moral defects, 136-41, 149-51. See also Moral training, 216-25 Moral defectives and imbeciles, 58, 139-41, 149-51, 218-25 Moron, the term, u Mortality from tubercle, 176-7 Muscular activity, promotion of, 172 Music, value of, in training, 196-7, 202, 212 National Association for Feeble-minded, 43, 238, 242 Nature -study, 204, 208 Nerve-storms, 152 Nervous action, abnormality of, 109-10 280 MENTALLY DEFICIENT CHILDREN Neurotic (primarily), 63, 64, 118-9 Nomenclature, n Norway, provision in, 37 Nutritional defect (glandular), 77, 82 (general), no Object-lessons, 204 Objections to training, 242-3 Occupations, 207-15 Operations on defectives, 183-4 Optic changes in maculae: In amaurotic family idiocy, 76 In central degeneration, 77 Organotherapy, 180 Outdoor occupation in epilepsy, 181 Overpressure in education, 103 Oxycephaly, 73-4, 81, 107, 118 Palate, anomalies of, 12, 108, 168 Paralytic cases: Birth palsies, 72, 101, 126-7 Complications of primary amentia, 64 Diplegia, 129; Hemiplegia, 107, 129; Paraplegia, 129 Infantile (polioencephalo-myelitis) , 130 Juvenile general paralysis, 71, 142-6 Parental intemperance, 96-9 Parturitional difficulties, 72 Pathological classification, 51-82 Peg-board (school appliance), 189, 192 Permanent improvement (cases), 227, 236 supervision, need of, 219, 229-30 Phthisical family history, 96 Physical and mental defect, correlation of, 1 3 Physiological education, 3 Pictures in education, 196 Pituitary gland abnormalities, 67, 80 Porencephalus, 55, 73 Post-febrile cases, 73, 81, 103, 129-30 Premature birth, 102 Primary amentia. See Amentia Prognosis, general, 114-16 special types, 118, 119, 123, 124, 126, 127, 129-32, 141 Provision made in special schools, and needed, 41 Psychical epilepsy, 223 Pubertal perversion of moral sense, 149-51 Puberty and adolescence, psychopathies of, 142-52 special care at, 175, 223 Punishments, 217-8. INDEX OF SUBJECTS 281 Radiography, 67, 108,. 129, 185 Reading, instruction in, 205, 241 Recreations, 211-12 Relief to parents by training, 234 Religious feeling, 225 Reports : Royal Commission on Feeble-minded, n, 13, 23-7, 38, 39, 96, 100, 115, 138, 140, 224, 233, 239 Scientific study of childhood/ 12-15 Chief Medical Officer's Board of Education, 41, 156, 163, 167, 212-14 Results and conclusions, 226-43 Rewards and punishments, 217-8 Sauvage de I'Aveyron, i Scandinavian countries, provision in, 37-8, 40 Scaphocephalic cases, 63, 64,' 107-8 Sclerosis of brain, 53, 62 ; tuberose, 65 Scotland, provision in, 10 Certified Institutions, 255 Scurvy-rickets, 171 Secondary amentia. See Amentia Selection of children for special schools, 153-69 Sense-deprivation, cases due to, 81, 82 Sensorial training, 190-7 Serotherapy, 180-1 Sexual erethism, 175 Shock (emotional), 74, 82 Sight, training of, 195-6 Simple congenital cases, 63-4 Size and form boards, 192-3 Skiagrams (radiograms), 108 Skin, affections of, 183 hygiene of, 172 Slavering, repression of, 173 Smell, training of, 196 Spain, provision in, 38 Speaking exercises, 260-1 Special brain areas, defects of, 54-8 classes and schools, 17, 37-46 instruction, 35-50, 239-40 Speech, disorders of, 197-202 instruction in, 197-9 Stammering and stuttering, 199 Sterilization, 221-2 Stigmata of degeneration, 63-4 Surgical treatment, 183-5 Switzerland, statistical inquiry in, 16, 17 Syphilis, See Inherited Syphilis 282 MENTALLY DEFICIENT CHILDREN Syphilitic cases, 70-2, 93-5, 125-6, 142-6 lesions in hydrocephalus, 61 Tactile function, training of, 191-4 Taste and smell, training of, 196 Tests of intelligence, 111-4 Binet-Simon, 116, 157-60, 163-165 Thymus aplasia, 80 Thyroid gland, abnormalities of, 79, 80 treatment, 132, 182 Timetables, specimen, 213-4, 262-3 Toxic cases, 75, 82, 91, 93, 130 Training, educational, 186-206 Industrial (and recreation), 207-215 Moral, 216-225 Treatment, 170-85 General, 171-76 Medical, 176-83 Surgical, 183-5 Traumatic cases, 73, 81, 103, 129, 141 Tubercular predisposition, 96, 129, 176-7 mortality, 176 United States of America: Provision in, 4-7 Institutions, list of, 256-9 Royal Commissioners' visit to, 25 Results recorded, 223, 232-4 Urinary troubles, I72 : 3 Volitional weakness, 216 Wassermann reaction, 61, 70, 77, 94-5 Wood-carving by athetotic patient, 127 Word-blindness and word-deafness, 56-8 Writing, instruction in, 205 X-ray examinations, 67, 108, 129, 185 INDEX OF NAMES ALZHEIMER, Dr., 126 Andriezen, W. L., 180 Babonneix, M. L., 62 Barlow, Sir T., 171 Barr, Martin, 6, 138, 224 Batten, F. E., 71, 72 Beach, Fletcher, 51, 63, 83, 101 Beard, J., 91 Bernheim-Karrer, Dr., 62 Bickmore, A., 209 Binet, A., 136 Blandford, G. F., 136-8 Bollaan, Dr., 101 Bolton, J. S., 51, 52-3, 147 Bourneville, Dr., 51, 80 Burden, Rev. H. N., 44-5 Burgwin, Mrs., 18, 40, 215 Caldecott, C., 84 Carson, J. C., 5 Chance, Sir W., 21 Clouston, SirT., 125, 141-5 Cobb, O. H., 6 Conolly, J., 4 Crichton-Browne, Sir J., 96, 100 Crile, G. W., 75 Cunningham, Professor D. J., 60 Gushing, Harvey, 67 Dahl, Ludwig, 84 Dean, H. R., 70 Dendy, Miss M., 44, 138-9 Donkin, Sir B., 94 Doren, G. A., 6 Drummond, W. B., 136, 160 283 Elderton, Ethel M., 98 Ellis, Havelock, 138 Emerick, E. J., 6 Esquirol, E., i Fernald, W. E., 39, 160, 232-3 Finzi, N. S., 108 (opp.) Ford, Rosa, 74 Fort, S. J., 223 Fraser, Kate, 70 Froebel, 187 Fromm, Dr., 62 Garrod, A. E., 81, 121 Gaskell, S., 4 Gilford, Hastings, 81 Goddard, H. H., n, 85-7, 99, 157-60 Gordon, Alfred, 69, 181 Gordon, J. Leslie, 71, 122, 125, 128 Gowers, Sir W. R., 148 Guggenbiihl, Dr., 3 Guthrie, Leonard, 57, 121, 123, 200 Hammarberg, Karl, 51 Herter, C., 80 Hinshelwood, J., 56 Holman, H., 3 Horsley, Sir V., 182 Howe, S. G., 5-6 Ireland, W. W., 51 Itard, Dr., i Johnston, G. C., 67-8 Jones, Robert, 184 284 MENTALLY DEFICIENT CHILDREN Keller, Christian, 37 Kerlin, Isaac, 6, 224 Kerr, Jas-, 56, 166, 219-21 Kielhorn, Herr, 36 *Kingdon, E. C., 76 Koch, Dr., 84 Kraepelin, Emil, 147 Langdon-Down, J., 63, 101, ii5, 175 Lange, Dr., 62 Lapage, C. P., 115 Letchworth, W. P., 138 Lippestad, Karl, 37 Lize, Dr., 91 Locke, E. W., 230 Macdonald, A. C., 138 McCallum, A. J., 178 McGarrison, R., 182 Mendel, G., 126 Mercier, C. A., 138 Mott, F. W., 70, 71, 77, 93, 126 Ormond, A. W., 121 Parsons, L., 80 Pasmore, E. S., 163 Patry, 73, 74 Pearson, Karl, 88, 98 Pinsent, Mrs. Hume, 228, 240-1 Plaut, Dr., 71 Potts, W. A., 20, 73-4, 92, 96-7, 115-6, 141, 237 Powell, F. M., 7 Poynton, F. J., 76 Railton, J. C., 182 Richards, J. B., 6 Russell, J. S. Risien, 76 Sachs, Dr., 75 Saegert, Dr., 2 Sajous, Dr., 80 Saleeby, C. W., 243 Savage, Sir G. H., 138 Schwab, Rudolf, 17 Seguin, E., i, 2, 3, 6, 15, 171, 190 Seguin, E. C., 179, 181 Sherlock, E. B., 51, 231-2 Shuttleworth, G. E., 15, 18, 59-60, 84, 98, 102, 108, 124, 182, 188 Simon, Th., 136 Sims, G. R., 75 Soethre, Jacob, 37 Spratling, W. P., 179 Still, G. F., 223 Sutherland, G. A., 122 Talbot, Eugene, 138 Tay, Waren, 76 Telford-Smith, T., 60, 182 Thomas, E. J., 56, 58 Thomson, John, 66, 79, 122 Tredgold, A. F., 51, 52, 53, 62, 84, 85, 96, 99 Tuke, D. Hack, 51 Turner, F. D., 176 Turner, W. Aldren, 123, 179 Twining, W., 3 Van Valkenberg, C. T., 58 Voght, H., 65 Voisin, Felix, i, 2 Warner, F., 12, 14-15/109-10, 160, 239 Watson, H. Ferguson, 70 Weinrich, Dora, 36 Whetham, W. C. D., 88 Wilbur, H. B., 5, 6 Wilmarth, A. W., 62 Wintermann, H., 36 H. K. LEWIS AND CO. LTD., 136 GOWER STREET, LONDON, W.C. 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