Name. | Age. | Grade of Reading. | Retardation.
-------+--------------+-----------------------+---------------
Coch | 14 years | _Hesitating_-fluent | 6 years
Grio | 10-1/2 " | Hesitating-fluent | 2-1/2 "
Sev | 13-1/2 " | Hesitating-fluent | 5 "
Coff | 11 " | Syllabic-hesitating | 4 "
Ro | 12 " | Syllabic-_hesitating_ | 5 "
Ostro | 12-1/2 " | Hesitating-_fluent_ | 4 "
-------+--------------+-----------------------+---------------
It will be noticed that in spite of their advanced age none of these
children have attained the fluent grade of reading.
In marking the reading one is sometimes at a loss owing to the absence
on the scale of an exact description. Thus little Coff is judged
syllabic-hesitating. The scale does not contain such a combination,
which ought to figure between the syllabic reading of the infant class
and the hesitating reading of the elementary class, first year. One
may calculate the retardation either by admitting the existence of
this intermediate term, or by marking Coff's reading "hesitating."
The choice is of little practical importance, since its effect is a
variation in the amount of retardation of only six months.
=Arithmetic.=--Although arithmetical ability depends upon special
aptitude, and a child may be quite intelligent though backward in
arithmetic, the tests here chosen are so elementary, and the ignorance
one tolerates is so great, that failure is of serious significance. We
follow here the directions of M. Vaney, who has taken the trouble to
simplify them at our request. All the questions in arithmetic ought to
be dictated. This may even be done collectively. It is essential not
to interpose to ask the child what operation is to be done. Such help
would make the work much too easy, and indeed that is the very problem
which has to be solved in the very exact and carefully considered form
in which it has been stated. It is the problem rather than the
operation which requires intelligence. Moreover, it will be noted that
the difficulty of our mode of expression is calculated. The words
_subtract_, _take away_, _remain_, ought not to be replaced by
synonyms, and still less should they be explained. Even when, as often
happens, the child makes a mistake in the first problem (for example,
19-6 = 12), he must not be allowed to stop there; his mistake might be
due to carelessness. One must always try the higher problems until one
obtains a clear demonstration that the child is incapable of solving
them. M. Vaney has suggested a scale of marking for these sums. It
enables one to take into account slight differences by the aid of a
system of points. Here it is:
_Correction of Sums._
_First Sum_ (1 point).--1 point for correct answer (_vide_ p.
54).
_Second Sum_ (2 points).--1 point for subtraction; 1 point for
correct answer.
_Third Sum_ (3 points).--1 point for 604 correctly written; 1
point for subtraction; 1 point for correct answer.
_Fourth Sum_ (4 points).--2 points for correct division (1 if
wrong); 2 points for the remainder (1 if obtained by long
division).
_Fifth Sum_ (5 points).--2 points for the subtraction (1 if
answer wrong); 3 points for correct division (2 if it is wrong).
_Sixth Sum_ (6 points).--A dressmaker buys 8 yards of velvet at
9s. 6d. a yard and 25 yards of cloth; she pays for the whole L6.
Find the price of the cloth per yard. 2 points for the price of
the velvet; 2 points for the price of the cloth (1 for
subtraction, if answer wrong); 2 points for price of cloth per
yard (1 for division if answer wrong).
_Seventh Sum_ (7 points).--A merchant mixed 25 pints of wine at
2s. a pint with 60 pints at 2s. 6d. a pint; at how much per pint
must he sell the mixture in order to gain 55s.? etc.
This scale enables us to determine by the total number of points
obtained the level of the child in arithmetic, and at the same time we
find out what sums can be done by the pupils of each age. This is
shown in the table.
RESULTS OF ARITHMETIC TESTS IN AN ELEMENTARY SCHOOL IN PARIS.
--------+-------+---------+-------+--------------------------+-------
All the |Average|Children |Average| |Average
Children|Points.|in Proper|Points.| All Children in Class-- |Points.
of-- | | Class. | | |
--------+-------+---------+-------+--------------------------+-------
6 years| 1.45 | 6 years | 1 |Infant | 1.5
7 " | 3.93 | 7 " | 6 |Junior (first year) | 6.5
8 " | 7.00 | 8 " | 7 | " (second year) | 6.83
9 " | 9.65 | 9 " | 14 |Intermediate (first year) |16.00
10 " | 15.47 |10 " | 23 |Intermediate (second year)|22.42
11 " | 21.47 |11 " | 29 |Senior |28.45
12 " | 22.50 | | | |
13 " | 24.75 | | | |
--------+-------+---------+-------+--------------------------+-------
It will be noticed in the table that the averages are a little less
when calculated on _all_ the children. We have indicated this
difference already, and have explained the reason for it. We have
based our scale upon the marks obtained by all the children.
In practice we consider that M. Vaney's system of points is not
indispensable. It is sufficient to find out whether or not the pupil
can do the sum set. If he can, he is at that level; if not, he must
be placed in the grade below. Some examples will show how we use these
results. We select them from a class of defectives.
_Roger B----_, age ten and a half years, is asked orally, for he
cannot write: "If I had 19 apples and ate 6, how many would be
left?" He replies first 9, then 6. One then tries easier sums.
_Q._ "I have 4 apples, and eat 1?" _R._ "Three are left." _Q._
"I have 12 apples, and eat 2?" _R._ "There are 9 left." _Q._ "I
have 8 apples, and eat 2?" _R._ "There are 7 left." Evidently
this child does not clear even the first step. He has therefore
four years and a half of retardation.
In this connection let us remark that as Roger is a child whose
attendance has been regular, it follows that in his four and a
half years at school he has scarcely learned more than a normal
child learns in two months. We recently met with a similar case
at Bicetre. This was a child of twelve, who had begun to learn
his letters at the age of four, and who did not yet know how to
spell! In presence of such cases one may well ask whether the
teacher who has not managed in four and a half years or in eight
years to teach a defective child what a normal child learns in a
month has not wasted his own time and that of the defective. At
this point let us call attention to a defect in the mechanical
calculation of retardation. Little Roger, who is ten and a half
years, and cannot yet read by syllables, has only four and a
half years of retardation, if we apply to him the usual rule. It
would therefore appear that he is at the same level of
intelligence as a child of thirteen and a half, who belongs to
the intermediate course, first year, for the latter has also a
retardation of four years and a half. The error of this method
of calculation is at once apparent. The real significance of
retardation is proportionate to the class and course which the
pupil has reached. We shall return presently to the exact
estimation of retardation.
Let us quote another example to show the application of the
arithmetical test.
_Ostrow_, twelve and a half years, replies correctly to
questions 1, 2, and 3. At the fourth he hesitates and begins by
multiplying 7 by 89, and obtains as answer 783, which is doubly
inexact, because he ought not to have multiplied, and the
multiplication is incorrect. Then he draws back, and tries a
division of 89 by 7; he obtains an incorrect answer (11), which
does not satisfy him. Finally, he tries a multiplication: says 7
times 10 makes 70. He next adds 7 several times to reach 89, but
he becomes confused, and finishes by finding the number 13,
which is almost correct. This child is therefore at stage 4; he
does not clear it, but he attempts it. Look at the scale. We
give him full points for Problems 1, 2, and 3, plus 2 points for
Problem 4, or a total of 8, which puts him at the level of
children of eight and a half years, which amounts to a
retardation of four years.
=Spelling.=--The test of spelling is a piece of dictation given
individually or collectively. The scale contains the first phrases of
the dictation. We reproduce them all here, pointing out the
grammatical difficulties which they contain, and the scale for marking
faults which seemed to us most fair. [We quote the phrases in French,
as a translation would not indicate the real difficulties. It will be
observed that in many cases correct spelling implies grammatical
knowledge.--TR.]
_Phrase 1._--To write phonetically, without liaison, a phrase
dictated in the ordinary vocabulary of the child.
_Example._--Emile est un petit eleve bien sage; il ecoute son
papa et sa maman; il va a l'ecole.
_Phrase 2._--To put the _s's_ of the plural to words chosen from
the vocabulary of the child.
_Example._--J'ai une tete, deux bras, deux jambes, une bouche,
vingt dents, une langue, et dix doigts.
_Phrase 3._--Plural of qualifying adjectives in simple cases;
verbs to the third person plural, present indicative.
_Example._--Le soleil brille deja de ses plus _gais_ rayons. Les
hommes _partent_ en chantant. Les bergers sont _heureux_ de la
belle journee qui se _prepare_: ils suivent au paturage le
_grand_ troupeau des vaches _pesantes_.
_Phrase 4._--Feminine of the qualifying adjectives without
phonetic indication; verbs with the plural endings _ons_, _ont_,
_ez_, _aient_.
_Exercise._--Le garcon de ferme, de son pas lourd, _entrait_
dans la grange encore _obscure_, ou nous _reposions_. Les boeufs
_mugissaient_ tout bas. Dans la cour le coq, les poules, le
chien, _allaient_ et _venaient_.
_Phrases 5, 6, and 7._--Finals of verbs in the singular of the
different tenses of the four conjugations. Past participle with
or without _avoir_. Infinitive in _er_, and past participle in
_e_.
_Example._--Joyeux merle, ne _viens_ pas dans le bocage.
_Prends_ garde a ce mechant qui _veut_ te saisir et
t'_enfermer_. Pendant que je te _parle_, tu _viens picorer_ les
raisins que l'oiseleur a _disposes_ comme un piege. Ils sont
_garnis_ de glu: si tu y _touches_, c'en est fait de ta liberte.
_Method of Marking Mistakes._
One mistake for a letter omitted.
One mistake for a letter too much.
One mistake for a letter substituted for another.
There may therefore be several mistakes in the same word, but
the number of mistakes for any word cannot be greater than the
number of letters in the word. A word omitted counts as many
mistakes as it has letters.
The liaison of two words counts for one mistake. Failure to join
the two parts of a word also counts one mistake.
It is to be noticed that we do not speak of grades of spelling--that
is to say, of different phrases which the children of each age should
be able to write without mistake. No doubt such could be found. But we
have been content to count the mistakes; it is by the number of
mistakes that the children of each age are distinguished.
The dictation given in February by M. Vaney in his school and
corrected by the teachers there has enabled us to draw up the
following table, which shows the number of mistakes committed, counted
by the method indicated above:[8]
---------------+------+---------------------+------------------------
| | | Phrases.
| | +----+----+----+----+----
Children. |Class.| Course. |1st |2nd |3rd |4th |5th
---------------+------+---------------------+----+----+----+----+----
6 to 7 years | 1 | Preparatory |13 |22 | -- | -- |--
7 to 8 years | 2 | Elementary (first | 6 |15 | 32 | -- |--
| | year) | | | | |
8 to 9 years | 3 | Elementary (second | 2 |10 | 19 | 20 |--
| | year) | | | | |
9 to 10 years | 4 | Intermediate (first | 0 | 2 |6.6 |6.9 |17
| | year) | | | | |
10 to 11 years | 5 | Intermediate (second| 0 | 0 | 4 | 4 |12
| | year) | | | | |
11 to 12 years | 6 | Senior | 0 | 0 |0.6 |0.7 | 5
---------------+------+---------------------+----+----+----+----+----
To show how we classify a child from the point of view of spelling,
let us take an example. We shall choose _Ostrow_, the defective whom
we have already tested in arithmetic. He writes the first phrase with
one mistake, the second with one mistake, the third with eight
mistakes; he is at the level of a child of nine to ten (_vide_ Table,
p. 54). He has therefore a retardation of three years. He must be
reckoned as slightly feeble-minded.[9]
We now understand the manner of judging the capacity of a child in
arithmetic, reading, and spelling. Which of all these tests is of the
greatest value? We shall reply to this question by giving a summary
in a few words of the tests we applied to twenty children in a special
class. The amount of retardation varied considerably from one child to
another, and for the same child from one test to another. On the
average, the amount of retardation was 3.3 years for spelling, 4 years
for reading, and 4.5 years for arithmetic. These children did not do
so badly in spelling; there was even one who was at the normal level.
It was especially in the problems that their deficiency was
noticeable, because the problem requires not only memory, but some
understanding. They have great difficulty in defining what is the
proper arithmetical operation. When addition is necessary they have a
tendency to subtract, and if they ought to divide they will more
readily multiply. These mistakes lead to absurd results, which usually
do not put them about, unless their attention is drawn to the
absurdity. A defective will admit quite readily that if I have 604
apples, and sell 58, I shall have 662 left. These results show that in
the ordinary school they do, we will not say too much spelling, but
too little arithmetic in comparison to the amount of spelling.
Finally, we again insist upon the evidential value of methodical
tests. We demand that the elementary school inspector should have
these tests carried out without assistance to the pupils, without
intervention to indicate the solution or the step to take. He must
neither assist nor do the lesson, but simply note the result achieved.
He must therefore reduce himself to the easy role of a benevolent
spectator.
=Retardation and Knowledge Percentage.=--We said above, in estimating
retardation, account should be taken of the course to which the pupil
belongs--that is to say, the grade of instruction to which he has
already attained. A child of nine years of age who has a retardation
of three years has learned absolutely nothing; on the other hand, a
child of twelve years who has a retardation of three years has learned
something, since he has reached the intermediate course, first year.
The difference between the two pupils is apparent; probably it will
increase still more as years go on. To understand the matter clearly,
it is necessary to compare the amount of retardation with the period
of school attendance. The latter may be represented by the figure 100.
Thus, our child of nine, who has learned nothing, has a retardation of
three years in three years at school--that is to say, a percentage of
0; our child of twelve, who is in the "intermediate course, first
year," has made in six years half the normal progress; he has
therefore a "knowledge percentage" of 50. Such figures have evidently
a quite different significance from those of the amount of
retardation. Our opinion is that it suffices to make use of the simple
calculation of retardation in selecting the defectives, for it is an
easy and useful method; but when one is in the presence of a child,
and desires to estimate his knowledge, not only for the actual moment,
but with reference to his future and his capacity for learning, it is
necessary to note also, and more especially, his "knowledge
percentage."
We suggest the following schedule to be filled up after the
examination of the child:
=Examination of Instruction of a Child proposed for Special Class.=
Date of examination:
Place of examination:
Full name of pupil:
Date of birth of pupil:
This child has attended .......... school, ...... class.
Attendance regular or irregular?
Has he been able to follow his class?
What is the amount of his retardation?
_Reading._
(Syllabic, hesitating, fluent, expressive, intermediate--_e.g._,
fluent-expressive.)
Observations on reading:
_Arithmetic._
The pupil can do the problems noted without mistake:
(Refer to scale.)
Observations on arithmetic:
_Spelling._
Phrase dictated:
Number of mistakes:
_Conclusion._
Retardation in reading (taking account of school attendance):
Retardation in arithmetic (_ibid._):
Retardation in spelling (_ibid._):
Knowledge percentage:
Name and position of examiner:
In spite of the lengthy details into which we enter, it is evident
that all this work of examination can be done pretty rapidly. The
arithmetic alone is a little long, because it is necessary to allow
time to put the child at his ease. We may put the total examination at
fifteen minutes. Often it will be possible to abridge the time. The
inspector is now in a position to estimate the retardation of the
pupil and his knowledge percentage. He has several means at his
disposal--the evidence of the teachers, the notes concerning the
pupil, the examination of his copybook, observation of the attitude of
the child, his physiognomy, etc., and, above all, the exact and
personal test which he has made.
Is this enough? When the inspector has established the retardation and
determined its causes, may he, should he, give his opinion
immediately? In most cases, without doubt, a further inquiry is not
necessary. But in other cases the need of further inquiry is felt.
Instruction is not everything, and there are some children who have
difficulty in assimilating school knowledge owing to want of aptitude,
to inattention, to laziness, who are yet quite intelligent. It is the
intelligence of these children that one would like to determine, and
for this it is necessary to make use of some tests of intelligence. We
propose, therefore, for the inspectors a last examination, a
psychological one. Let no one accuse us of complicating the
examinations. We do not impose them, we do not even advise them in
all cases. But these tests are none the less very valuable tools to
which one is very happy to have recourse when one feels embarrassed.
PSYCHOLOGICAL EXAMINATION.
This consists in putting the following questions,[10] which have been
grouped in such a manner that the four first can be answered by normal
children at seven years of age, the five following by normal children
at nine years of age, and the four last by normal children at eleven
years of age.
Tests of Intelligence.
_Seven Years._
1. If you were late for school, what would you do?
2. If you lost a train, what would you do?
3. If one is lazy and does not want to work, what happens?
4. If you were tired and had not enough money to take an
omnibus, what would you do?
_Nine Years._
5. If one needed sixpence, how could one get it?
6. Why should we not spend all our money, but put a little past?
7. If you break an object that does not belong to you, what
should you do?
8. If a companion should strike you without meaning it, what
should you do?
9. If you require some good advice, what should you do?
_Eleven Years._
10. Before taking part in anything important, what should you
do?
11. Why do we forgive a bad deed done in anger more readily than
a bad deed done without anger?
12. If anyone asks your opinion about a person whom you know
very little, what would you do?
13. Why should one judge a person by his acts rather than by his
words?
These questions present various difficulties, both in thought and in
vocabulary. We have tried them upon a great number of school children,
and they correspond pretty exactly to the level of children at the
ages indicated.
The answers of the children may be good, passable, mediocre, or
negative (the child makes no reply), or even absurd or unintelligible.
In marking the replies one does not take account of a wrong word or an
awkward phrase, but considers the meaning and whether the child has
really understood. It may seem that marking these replies would be
rather delicate and arbitrary, but in practice the difficulty is not
great. Here are some examples:
(10) The reply, "Ask some capable person, a master, a parent," is a
good reply. "Ask it," "Listen for it," are passable replies.
(7) The reply, "Pay and apologize," is good. "Pay for it," is
passable.
(8) The reply, "Forgive him," is better than the reply, "Don't tell
tales."
(1) The reply, "Hurry up," is better than, "Ring the bell," "Hurry
to-morrow," "One is kept in."
(3) The reply, "One remains ignorant," is better than, "One is
punished."
(4) The reply, "Take a rest, then walk," is better, being more
explicit, than simply, "Walk."
We mark the good replies 3, the passable 2, the mediocre 1, the absurd
and silence 0. Silence sometimes makes one hesitate. It may result
from timidity, or even from prolonged reflection. It is necessary,
without changing the form of the question, to encourage the child and
to press him to reply. With a little practice one can easily see who
is trying to find an answer and who does not understand.
We have stated that normal children of eleven years of age replied to
the questions 10 to 13. It must be understood that by this we mean
that the majority replied. There are no tests which can characterise
all the subjects without exception of a given group. There are always
failures. By way of example, we shall quote the observations we made
in an elementary school with our questions 10 to 13, which we put to
all the children of eleven, who were distributed, according to their
ability, in the different classes. There were thirty-six of these
pupils. The maximum of marks obtainable was 12, since there were four
questions, and a good reply was worth 3. We then obtained the
following averages:
Tests of Intelligence put to Normal Children of Eleven Years of Age.
Average Marks.
Senior, first year 11
Intermediate, second year 6
Intermediate, first year 4.7
In the "intermediate course, second year," there were two children who
obtained 0 and 1. In the "intermediate course, first year," there were
four who got 0, and one who got only 1. What were these pupils, who
had certainly not reached the average intellectual level of eleven
years? Two are said to be defectives by the head-master. Let us
subtract them, and there remain five; and these work sufficiently well
to remain in their class and to follow the lessons. Their success is a
very important fact. A child may not have very much intelligence, but
if he has a good memory, application, and will, he is regular in his
studies, and this compensates for the mental feebleness. We have often
noticed this. If a child is regular in his school work, the question
whether he is a defective does not present itself. It only presents
itself if the case is reversed. Supposing he is very clearly backward,
by two years, by three years, with a sufficient school attendance. If,
in spite of this retardation, the psychological examination shows that
he is all the same quite intelligent, this is a favourable
circumstance of which he should have the advantage. In other terms,
the psychological examination is capable of showing that he is normal,
even when he is behindhand in his studies. This examination cannot, in
any case, serve to make him be regarded as defective if he is regular
in his studies. This is why we place this examination last.
Here are some very good replies from normal children:
_G. R----_:
10. It would be necessary to consider where the affair would
lead us.
11. Because when a bad action is done without anger one knows
what one is doing, while when one is angry one does not know
what one is doing.
12. One should say nothing. If one does not know the person one
cannot tell what he is.
13. By his words he may deceive us. By his acts we can tell what
he is.
_G----_:
10. It is necessary to think what one is going to do.
11. Because when one acts without anger one has thought
beforehand, and is more to blame; while, on the other hand, it
is an act of passion, and afterwards one regrets what one has
done.
12. I would say that it would be necessary to know him first and
then afterwards to judge him, not to say anything bad or good
about him without knowing him.
13. Because there are people who say words and often do not do
them.
Here are some replies which are mediocre or absurd:
12. You should try to ask the particulars of the person you do
not know. (Mediocre.)
13. Because his acts are more terrible while his words are less
threatening. (Mediocre.)
11. Because the action which has been done in anger is not so
violent. (Mediocre.)
13. Because you must not speak after the person who speaks.
(Absurd.)
In a class of defectives of eleven years of age we obtained from seven
children an average of replies equal to 1.3. This figure, therefore,
is considerably less than that of the normal children regular in
their studies, and even than that of the normal with a retardation of
two years. Let us note in passing a very curious fact. We had had to
examine these defectives before their admission into the special
class. Now, the teachers sent us as defective two children who were
clearly intelligent, for one of them obtained five marks and the other
eight. Let us give the replies of the latter, whose name was Cler, age
eleven years:
10. You would have to think. (Good.)
11. Because anger is less serious. (Absurd.)
12. Say nothing bad about him, because I do not know him well.
(Good.)
13. Because words are not correct. It is not certain that he
will do it. (Passable.)
These replies are evidently not very brilliant, but they are so
superior to the level of a defective that we have sent this child back
to the ordinary school. We have since learned a fact which was not
originally communicated to us. This child came from the country, and
he did not begin to go to school until the age of ten.
To sum up, we offer the psychological examination as a means of
rehabilitating a child who has a marked degree of retardation. That is
its sole utility. Never, in any case, must this examination be used to
label as defective a child who keeps up with his lessons.
* * * * *
A last word regarding the necessity of these examinations.
We know that, after having read the preceding pages, more than one
inspector, more than one teacher, will exclaim, "What is the use of
all this? I am quite accustomed to questioning children, and I don't
require such precautions in order to distinguish between those who are
intelligent and those who are not. By two or three questions which are
quite familiar to me I can judge the state of instruction."
We have paid homage to the ability of the teachers and inspectors
sufficiently often to be permitted to maintain here against those who
would contradict us the necessity of our methods or of others of a
similar kind. In order to determine the degree of intelligence or the
state of instruction of a child one would require to have in mind the
normal levels. Now, frankly, who knows what these are? Let any
inspector, any teacher, glance over our test questions. He will be
very much at a difficulty to say whether it is at nine years or at
seven years that a child ought to be able to reply suitably to a
particular question. We will go even farther. Let an inspector look at
our scale, and say at what age reading is "fluent," at what age a
child should write the third phrase with less than ten mistakes. Just
let him try, and he will find the result. Let us add that people who
are neither inspectors nor teachers will be still more embarrassed. We
recollect that at the recent opening of a special class some eminent
people appeared much astonished at the intelligence of the pupils.
They were surprised at children of twelve years who made replies of
which in reality normal children of eight should have been capable. It
is impossible to form a correct judgment about matters so delicate
unless one makes use of exact tests. We insist upon this because we
foresee that all who visit the class for defectives will be subject to
this illusion. All the more will they have an optimistic tendency to
overestimate the intelligence and instruction of the children since
they know in advance that they are going to see defectives, and
consequently have a preconceived expectation of seeing degraded
imbeciles with low foreheads and dirty habits. They will be quite
surprised to find that the great majority of defectives do not answer
to this description, and seeing that they have fallen into an error,
they will correct themselves as usual by falling into the opposite
mistake.
=Estimation of Want of Balance.=--If it is easy to determine
backwardness by a direct examination of a child's state of
instruction, the difficulty of establishing a lack of mental balance
is, on the other hand, very great. Such want of balance is indicated
by breaches of discipline, inattention, naughtiness, lying, violence,
brutality, etc. But it would be a very unruly child who would not
behave quietly when taken apart by the inspector. Isolated in the
examination room, surrounded by strange, grave people, the child
shrinks into himself. He has little occasion or desire for a display
of rebellion or naughtiness when his comrades are not there to admire
him. Possibly an exact estimation of his reactions, of his motor
ability, of his power of attention, would indicate the presence of
some anomalies; but this is not certain, and is not to be relied upon.
There may be some hope in that direction for the pedagogy of the
future, but scientific investigations cannot help us to-day. In short,
mental want of balance cannot, in the majority of cases, be the object
of direct examination.
How, then, can it be estimated? Indirectly, by the evidence of others.
The inspector, then, must be content to accept the facts which are
given to him by the teacher, but he must not accept them altogether on
trust. Are these facts correct? Are they probable? Is any evidence of
them to be found? Have they been altered in the telling? Such will be
the first queries to awaken the critical spirit of the inspector. Then
it must not be forgotten that he can question the parents, and hear
their replies before letting them know the opinion of the teacher, and
that everything they say will help him to judge not only the child,
but the family circumstances in which he lives. The ill-balanced are
often spoiled, or only children, or children not looked after, or
children whose father has disappeared. The sons of widows form a
considerable contingent. Now, the inspector will gain a good deal of
information from the school history of the child. The ill-balanced is
a nomad. He has attended several schools. It is important to find out
what impression he has left behind him. The proof of want of balance
is not to be taken from a single teacher. If three teachers, at least,
whose pedagogic reputation is good, agree about a child, the chances
are that their estimate is correct. The inspector will resort to such
controls, and if he is not satisfied, and if the alleged facts are not
very serious, he will remove the child to another class or another
school rather than send him to a class for defectives.
=Elimination of Hospital or Asylum Cases.=--Only defectives likely to
improve are to be admitted to the special schools. That is only common
sense. Everyone knows that the epithet "defective" does not belong to
a single type. There are various categories which extend between two
extremes: the purely _vegetative idiot_ who cannot speak, or walk, or
even feed himself; and the slightly _feeble-minded_, who may easily be
taken for normal. In spite of all our sympathy for these poor
creatures whom Nature has treated so cruelly, we could not think of
supplying them without distinction with all the benefits of education.
It is certain that the worst affected would not profit much thereby.
It is pure folly to devote six or eight years to teaching the letters
to a child who will never be able to read, or who, if he should manage
to read a little, will not understand what he reads. To such an
unfortunate it is quite enough to give lessons in walking, feeding,
dressing himself, and in simple occupations, such as dusting or
sweeping. Such cases do not require schools so much as places where
they can be taken care of. These will cost less to establish,
especially in the country. Educational efforts should be concentrated
on the defectives who are less profoundly affected. It is they alone
whom one should try to instruct. This is the practice which is rightly
followed abroad. For administrative purposes the defectives of
different grades may be divided into two groups, medical cases and
educational cases, or preferably, in order to obviate the use of the
equivocal term "medical," we may speak simply of hospice cases and
school cases to show the difference in their destination. The exact
terms employed matter little so long as we understand what we mean by
the words.
We have just pointed out the importance of reserving the schools for
defectives for improvable cases. But it is necessary to correct this
word "improvable," because all defectives can be improved more or
less. Their asserted _arrest_ of development is not complete, and the
expression is equivocal. It would be better to replace the word
"improvable" by the following more precise phrase: "Capable of being
taught to gain, in part, their own living." Which of them are in this
position? Unfortunately, we do not know. All such questions should
have been solved long ago, since thousands of defectives have passed
into the hospices. It would have been enough to have followed them up,
to have found out what became of them, and to have drawn conclusions.
But this has never been done methodically, and for the present we are
reduced to conjecture. The nearest estimate we can form is that the
social value of any individual case, not epileptic, is in inverse
proportion to the degree of deficiency; the imbecile would seem to be
more improvable than the idiot, and the feeble-minded than the
imbecile. But this is simply hypothesis, and we accept it quite
provisionally, until exact investigations have been made which will
permit us to replace conjecture by demonstrated truth. Consequently we
shall open wide the doors of the school to the feeble-minded and close
them to the idiots, while as to the imbeciles, we shall have to find
out whether the proper place for them is the school or the hospice. It
will be necessary to find out in what measure, and at the price of
what effort, an imbecile can be instructed to the point, say of being
able to read. There are two other indications which may help us. Cases
of _acquired_ mental deficiency--that is to say, cases who have
become defective as the result of something which affected them after
birth--are usually less improvable than _congenital_ cases, or cases
where the deficiency is due to some cause acting before birth. And,
secondly, cases affected by epilepsy, with fits or frequent attacks of
vertigo, usually undergo a progressive mental deterioration.
What distinctions can we draw between the different degrees of mental
deficiency? Such a question, we think, might be asked with regard to
the ill-balanced as well as the defective. With respect to the former,
we have no criterion at present to offer. It will be enough to pick
out and send to the hospices _the most ill-balanced_, those whose
presence among normal children would be a danger owing to the
perversion of their instincts or the brutality of their impulses.
With regard to mental deficiency, we think it possible to formulate
precise definitions which will enable all competent persons to agree
as to the diagnosis of idiocy, imbecility, and feeble-mindedness. We
are aware that in making this statement we are running counter to the
general practice of medical alienists. When these, in an admission
certificate, call a child "idiot," "feeble-minded," or "imbecile,"
they are rarely in agreement with the confrere who, a few days later,
examines the same child, and makes a new diagnosis. We have made a
methodical comparison between the admission certificates filled up for
the same children with a few days' interval by the doctors of
Sainte-Anne, Bicetre, the Salpetriere, and Vaucluse. We have compared
several hundreds of these certificates, and we think we may say
without exaggeration that they looked as if they had been drawn by
chance out of a sack. This is a fact which many alienists have already
suspected, and Dr. Blin[11] has expressed himself frankly on the
subject.
What is the cause of such contradictions? They result, in great
measure from the use of ill-defined terms. To the majority of
alienists, the idiot is one who is _profoundly_ affected in his mental
faculties, the imbecile is _a little less_, and the feeble-minded
_less still_. What mean those words: "profoundly," "a little less,"
"less still"? No one defines them. They are taken to be indefinable.
It is no wonder they are understood so differently. All this trouble
would disappear if the following definitions were adopted:
DEFINITION OF AN IDIOT.
_An idiot is any child who never learns to communicate with his kind
by speech--that is to say, one who can neither express his thoughts
verbally nor understand the verbally expressed thoughts of others,
this inability being due solely to defective intelligence, and not to
any disturbance of hearing, nor to any affection of the organs of
phonation._ Since a normal child of two years of age can understand
the speech of others, and can make itself understood by others, so far
as its simple wants are concerned, it is evident that the distinction
between an idiot and a normal child is easily made.
DEFINITION OF AN IMBECILE.
_An imbecile is any child who fails to learn how to communicate with
his kind by means of writing--that is to say, one who can neither
express his thoughts in writing, nor read writing or print, or, more
correctly, understand what he reads, this failure being due to
defective intelligence, and not to any defect of vision or any
paralysis of the arm which would explain his inability._ One will not
count a child an imbecile until he has had much more than the normal
time to learn to read and write. The normal time in schools is six
months. A child who does not yet know his letters after being at
school for two years is likely to be an imbecile.
Spontaneous writing or writing from dictation must not be confounded
with mere transcription from a copy. The latter is a kind of drawing,
and may be acquired by some who are incapable, from defective
intelligence, of writing from dictation. Nor must real reading be
confused with reading which consists in transforming graphic signs
into sounds without meaning to the reader. The distinction can easily
be made by giving the child in writing some simple order which he is
to carry out, such as "Shut the door," "Knock three times on the
table."
DEFINITION OF A FEEBLE-MINDED CHILD.
_A feeble-minded child is one who can communicate with his kind by
speech or writing, but who shows a retardation of two or three years
(according to the rules already indicated) in his school studies, this
retardation not being due to insufficient or irregular attendance._
These distinctions are pedagogical. The inspector will make them
easily. If he is ever in doubt, he has a doctor at hand who will
advise him.
Obviously the idiot is a case for the asylum or hospice. Obviously
also the feeble-minded is a case for the school. There remains the
imbecile, about whom we may hesitate. From the moment the imbecile
proves himself unable to learn to read or write, his place is in the
workshop. We must find out to what extent he can profit by special
education.
=True and False Defectives.=--We shall formulate a rule which will
surely meet with no objection. It is that _none but defectives should
be admitted to schools for defectives_.
The moment we begin to apply this rule in practice, however, we meet
with difficulties. There are normal children who are very backward in
their studies. They cannot profitably follow the proper class for
their age. Such children are numerous, and of great interest
socially. As they are really intelligent they can certainly be helped
to make up for lost time. Various terms have been applied to them, but
it will be simplest to call them "backward" or "ignorant." In Belgium
many such "ignorant" children were admitted to the first school for
defectives. In fact, they formed the majority, and one can understand
how easily the teachers collected them. These are the cases which give
such grand results, and are sometimes exhibited as genuine defectives
who have been improved by teaching. In France it has been agreed that
the ignorant are not to be admitted to the classes for defectives. The
principle is sound. But let us not confuse the questions by
approaching them both at once. Let us consider the defectives first,
the ignorant or backward next. Even when we are agreed as to the
principle, we find difficulties in practice. In the first place, there
are the doubtful cases, children of whom we cannot say, even after
prolonged examination, whether they are defective or backward. Demoor,
in the return he published concerning the pupils of the first school
for defectives at Brussels, noted a considerable number of these
doubtful cases.[12] What should be done with such cases? The best
thing to do is to admit them to the classes for defectives, writing on
their schedule a large mark of interrogation in order to guard against
future deception. Again, it is not always easy to establish irregular
or insufficient attendance when this is the cause of the backwardness.
The child may have been at several schools, and at some the teaching
may have been faulty. There are some schools which practically produce
mediocrity. In the next place, it is necessary to discover the causes
of defective attendance. Sometimes these causes are completely
extrinsic to the nature of the child--frequent removals, constant
domestic disturbances, laxity of the parents, an infirm parent to be
taken care of, etc. In such cases the interpretation presents no
difficulty. But sometimes the case is more embarrassing. It may be a
thin child, who has been out of sorts for a long time. Without being,
properly speaking, of defective intelligence, he is weakly, anaemic,
and consequently incapable of sustained attention. Would it not be
advisable to admit such a case, at least as a temporary measure, into
the class for defectives, until his system had recovered tone? Should
we not also open the door to cases retarded by adenoids? And if we
enter upon this work of charity, shall we not also accept some of
those physically abnormal children who, affected by Little's disease
or Pott's disease, are so little at their ease among their more robust
companions? And what, lastly, is to be done with children retarded in
their studies by an unrecognised myopia? It is evident that the
question ceases to seem simple and easy when regarded closely. We may
rigorously exclude from the class of defectives the child who is
simply ignorant, but there is a whole series of complex cases
intermediate between the ignorant and the defective. The inspector,
let us say in anticipation, will consult his colleague the doctor with
advantage about all these border-line cases. No breach of principle is
involved here. It is necessary to be guided by circumstances. _The
essential point is to mark distinctly upon the child's schedule the
special reasons for his admission, in order to prevent ultimate
deception in the shape of presenting the child as an average defective
who has been improved by tuition in the special class._
* * * * *
We now come to the normal, the really normal cases. There can
evidently be no doubt as to what is to be done with them. They are
provided for. They have only to remain in the ordinary school. We hope
they will be kept there. We hope it; we even demand it with all our
power. But we are not certain that it will be possible to save them
from the special schools. How many vital interests are leagued
against the keeping of that rule! And interests, when they are not
looked after, are like the millions of ship-worms which slowly and
silently corrode the most solid barriers.
In the first place, there is the interest of the parents. When it is a
question of secondary education, of rich or middle-class parents,
there is nothing to fear. The bourgeois do not love their defectives;
they are ashamed of them. They send them to a distance, to some
private institution. They never speak of them to anyone; they do not
visit them; they abandon them. But the common people have more heart
or less prejudice. They will not be afraid of the special school for
defectives any more than they are of the hospice. When they have a
really defective child in the hospice, they never cease to visit him.
We can imagine the results which such a state of mind will bring
about. If these fathers and mothers of the working class were to hear
of the existence of a boarding-school where children receive board,
lodging, and clothing, they would flock to obtain admission even for
their normal children, although it were well known that the school
admitted only the feeble-minded, defectives, and fools. If necessary,
they would get municipal councillors to back up their demands. This
abuse was practised recently in the case of a reformatory, which was
rapidly filled with ordinary children, whose sole characteristic was
this--that their parents had political backing.
This fraud--for it is one--will not be perpetrated in the case of the
special schools and classes where no greater material advantages are
given to the pupils than is the case in the public schools, but it is to
be feared that it will recur in the case of special boarding-schools for
defectives. Such schools, if they are not carefully looked after, will
turn out plenty of normal young people!
And this is not all. It is not only the parents who will try to
deceive. Think also of the heads of the schools for defectives. What
is their interest? Take note of it, for it is important. One should
always try to foresee the results of human frailty. In every new
school which is started one should watch that part of the organisation
which gives most scope for charlatanism.
The head-masters and the teachers of the defectives will certainly
have a tendency to show off before visitors children who have never
been mentally defective, or who have been so to a very slight degree.
They will take good care to say nothing about the condition of the
child on admission. Or, if necessary, they will tell lies--pious lies,
told in a good cause, and for the honour of the school! These children
will be shown off as advertisements, which will be just as
illegitimate as if the schools for deaf-mutes were to present to
visitors the semi-deaf-mutes, or the deaf who had formerly been able
to hear, and to claim the entire credit for the facility with which
these pupils could read the lips or pronounce words.
All such impositions will continue to be practised as long as those
who visit such institutions are content to look about and docilely
question the children presented to them by the teachers, instead of
personally selecting the pupils to interrogate.
There is another reason why the heads of schools for defectives will
keep their doors wide open to normal cases. This is, that in some
cases a dearth of pupils may arise. A school is opened; it begins its
work; the staff signs on. There is not much to do; there is no gossip
about the matter; everyone is happy. But the number of admissions
slowly decreases. It begins to be feared that the inspector will in
his report notice the decrease, and that the school will be closed as
of no public utility. Pupils, therefore, must be found, and if they
must be found, found they will be. Recollect those evening classes
held in the elementary schools, where the teacher, fearing he will
have to speak to empty benches, begs the head-master to send him some
school children as an audience. Think of those libraries, where the
staff, uneasy at the desertion of the public, pays a gratuity to an
industrious reader for show!
We strongly insist that the inspectors should be alive to this danger.
They will be seated by the side of the manager of the special school.
Let them take note that this manager has a direct vital interest to
admit normal children. It is upon the inspectors that we rely to see
that everything is done honestly and correctly.
=Schedules of Particulars.=--Full and detailed particulars regarding
every child admitted to a class for defectives should be furnished by
the head-master and teachers of the school from which he came. They
will do this easily, for when a child is a little peculiar he attracts
attention. Abnormal children never escape unnoticed. It is of the
greatest importance that the future teacher of the child in the
special class should be correctly informed, and that what has already
been observed should not be lost. Let it be remembered that the
education of defectives should be individual, _made to measure_, as
has been said with picturesque exaggeration. Now, if the child is to
be individualised, he must be well known, well studied.
The necessity of some definite method of collecting particulars has
been experienced abroad. A scheme of questions has been prepared, to
be answered by the teacher who sends the child. The plan is a good
one. It avoids the worry of lapses of memory. We suggest the following
questionnaire:
PARTICULARS.
SUPPLIED BY THE ORIGINAL SCHOOL.
_Concerning_ .......... _Admitted_ ..........
_to the special class at .......... school._
GENERAL PARTICULARS.
Original school:
Full name of child:
Date of birth:
Standard to which he belongs:
Is the child considered mentally defective?
Is the child considered ill-balanced?
FAMILY HISTORY.
Names of father and mother:
Address of parents:
Occupation of parents:
Particulars of family which it would be useful to know:
SCHOOL ATTENDANCE.
How long has the child attended school?
What standards has he passed through, and how long was he in
each?
Regularity of school attendance: How many days was he absent
each year?
What were the most frequent reasons for absence, if any?
What other schools has he attended, and at what periods?
INSTRUCTION.
What amount of intelligence has he (count from 0 to 20)?
What do you know of his memory?
In which subjects does he do least badly?
In which subjects is he weakest?
How many years behindhand do you consider him in school
instruction compared with average children of the same age?
Annex to the present sheet one of his exercise-books and samples
of his drawing and manual work.
CHARACTER AND DISCIPLINE.
Conduct in class. Does the child keep his place? Is he sleepy,
unruly, talkative? Does he laugh without apparent cause? Does he
disturb the class?
Application. Is he attentive in class? Does he do his exercises?
Does he learn his lessons? To what extent does his family assist
him with the school work?
What is his attitude towards the teacher? How does he receive
remarks? Does he pay attention to them? How often? Is he
indifferent? Is he restive?
What are his relations with his companions? Is he kind, docile,
compliant? Does he make himself liked? Is he the object of
marked attention? Or is he indifferent? Does he keep apart from
others? Is he bullying, brutal, irascible, untruthful,
dishonest, wicked? Has he any special vices?
PEDAGOGY.
What moral influences are most successful for guiding him?
What is the effect of punishment? Of severity?
What is the effect of rewards? Of praise?
Do you require to take any special measures with regard to him
in class or in the playground?
What are the most successful methods for advancing his
instruction?
STATE OF HEALTH.
What do you know of his state of health? Has he incontinence of
urine? Any motor affection? Any defect of speech? Fits? Has he
been examined by a doctor, and do you know the doctor's opinion?
Was any medicine prescribed? What?
_Date_ ........ _Signature_ .................
_Position_ ..................
All the terms of this schedule are readily intelligible to the
teachers. They have filled up a hundred samples in a very satisfactory
manner, and we thus have in our possession a veritable mine of
valuable information. It is to be hoped that the teachers in the
special school may enjoy the same advantage. The plan has been found
of value in other countries. The bulletins which are used in
Rotterdam, for example, scarcely differ from ours except that they are
more laconic. We have included in our questionnaire all that is likely
to interest not only the inspector, but the doctor and the
psychologist.
* * * * *
And now to sum up, here are the steps we advise to be taken in
collecting the defectives:
_First._--The inspector has the pupils of each age in the schools
arranged according to the "standard" or "course" they are in.
_Second._--By examining the tabulated results, the inspector picks out
the backward, and demands particulars regarding the school attendance
of those who have a retardation of two years (when they are under nine
years of age), and of three years (when they have passed their ninth
birthday). In the same circular the inspector asks the teachers to
name any of their pupils who appear to be mentally ill-balanced--that
is to say, who, according to the testimony of at least two teachers,
are rebellious to discipline and an annoyance in the class. The
particulars with regard to want of discipline should be stated in each
case.
_Third._--After examining the returns relating to school attendance
and to the faults alleged against the children supposed to be wanting
in balance, the inspector will make his first choice.
_Fourth._--The direct examination of the child bears specially upon
his state of instruction and degree of intelligence. The inspector
comes to a positive decision with regard to each child, and asks the
opinion of the doctor, as well as of the head of the special school,
who assists.
_Fifth._--The inspector has a schedule of particulars regarding the
children finally accepted for the special school filled up by their
teachers in the schools from which they came.
The medical examination will be considered in the next chapter.
Let us add, in conclusion, that all the decisions arrived at are to be
regarded as provisional; the children are to be admitted to the class
for defectives on trial, to be kept under observation.
FOOTNOTES:
[6] See _Annee Psychologique_, vol. xii., p. 1, and vol. x., p. 116.
The method sometimes adopted, for other purposes, of asking the
teacher to classify the children according to their intelligence is
quite fallacious. Teachers make no allowance for age. Recently an
excellent teacher pointed out to us, as the most intelligent in the
class, a child who had really, when his age was taken into account, a
retardation of two years; but in a class of younger children his age
gave him an appearance of mental superiority. [Such facts vitiate much
statistical work on the correlation of "brightness" in school-children
with other qualities.--TR.]
[7] Teachers have a troublesome habit of saying simply "attendance
regular" or "irregular." The inspector should demand an exact return
of the absences.
[8] There are two methods of stating the representative value of a
group, the _average_ and the _median_. Everyone knows the average. The
median is obtained by arranging the values in linear series from the
smallest to the greatest and taking the middle one. When should one
use the average, and when the median? It is not easy to give a general
rule, but in this case of spelling, we have a good example. If we wish
to calculate the number of mistakes for each age, to take the average
might be a disastrous proceeding. A single child who made a hundred or
so mistakes would obviously make the average unfairly high. The median
is affected much less by such aberrant cases, and consequently is more
suitable for very heterogeneous series, in which the difference
between the maximum and the minimum is very great.
[9] By way of comparison, the following dictation was given to
ninety-two children in an Edinburgh school. The progressive
difficulties depend upon the non-phonetic spelling and the lesser
familiarity of words. Most of the children came to school in their
sixth year.
1. Tom is a good boy. He has a book and a bat. He can run fast.
2. The dog is bigger than the cat, but he cannot climb so well. He
would if he could.
3. The farmer walked through the wood till he came to the field. It
was a fine day for sowing the corn. He hoped it would not rain till he
had finished his work.
4. The weather was very stormy. The boughs of the trees were blowing
to and fro in the wind. Clouds were chasing each other across the sky.
The crows were watching the ploughman in the field.
Mistakes were marked according to the directions in the text. Thus
"bows" for "boughs" counted three mistakes. The results were as
follows:
-----------------+------------------------------------
|Average Mistakes in Test Sentences.
Age of Children.+--------+--------+--------+---------
| 1. | 2. | 3. | 4.
-----------------+--------+--------+--------+---------
6 to 7 years | 0.32 | 2.64 | -- | --
7 " 8 " | 0.22 | 1.77 | 3.45 | 6.18
8 " 9 " | 0.2 | 0.36 | 1.68 | 5.91
-----------------+--------+--------+--------+---------
[10] The complete set of tests as revised in 1911 is given in the
Appendix, with notes regarding their subsequent use in Britain and
America.
[11] "Les Debilites Mentales," _Rev. de Psychiatrie_, 1902.
[12] _Annee Psychologique_, vol. vii., 1901, p. 296.
CHAPTER IV
THE MEDICAL EXAMINATION OF DEFECTIVES
Hitherto we have been studying the defective from the point of view of
his school relations. This point of view is incomplete, and should not
make us forget that there is another--the medical. It is quite certain
that in the organisation and the practical working of the special
schools the doctor has a role, and an important role, to fill. All
foreign countries recognise this, and give him a large place. It is
even regretted in some countries that doctors detach themselves too
much from such questions, and are content to make a rapid and
superficial examination of children on their entrance to school,
instead of collaborating actively in the important work of the
teacher.
After this declaration of principles, it may not be without interest
to fix precisely the role which belongs to the doctor and the services
which he can render. It seems to us, in fact, that there is often some
confusion as to his attributes, and two opposite tendencies may be
recognised. According to one, the more widespread, the defective are
often, if not always, invalids, and belong to him by right. It would
be an encroachment upon his privileges to concern oneself with them.
The opposite opinion consists in not committing to him any particular
authority in the matter. This is the case in Germany, where there are
schoolmasters who carry things with a high hand in the special
schools. Let us add that the doctors themselves have done nothing to
bring about an entente. Speak of defectives before them, and they
say, "That is our business," and they are perfectly right; but having
affirmed their right, they pay very little attention to the territory
they defend.
It seems to us that the field is sufficiently great for everyone to
glean, and the efforts of all will not be too great to clear it. There
are some questions which escape the doctor, unless he is also an
educationist and a psychologist. But there are also some, in our
opinion, for which he has special competence, and where no one can
take his place. To define his role is not to lessen it; on the
contrary, it is to assure him an authoritative position. It is not his
business to select the abnormal from the normal. But from the children
picked out as abnormal he will differentiate certain types and
prescribe certain measures with regard to their care and treatment.
THE DOCTOR NOT TO PICK OUT THE DETECTIVES FROM AMONGST THE CHILDREN IN
SCHOOL.
There is a general misunderstanding with regard to the special
knowledge and aptitude of the doctor. One tends to credit him with a
kind of omnipotence and infallibility against which he protests in
vain. He is made to judge questions which do not belong to his special
province--namely, the medical, and upon which he expresses opinions
which are neither more nor less valuable than those of any other
intelligent person. Recently, at various congresses, we have seen
doctors with the best intentions laying down educational programmes,
comparing the educative value of science with that of letters, and
expressing a variety of opinions, no doubt very sensible, but with
which the medical art had nothing whatever to do. As regards the
selection of defectives, one is influenced by the same prejudice. We
have discussed this with many people, and especially with
educationists, and when we have insisted on the difficulties of
examination, they usually reply, "That is the doctor's business!" The
prejudice we have noted is very tenacious, and will doubtless be
difficult to overcome, for there are many people who have interests to
maintain of a pecuniary nature. Let us consider this question from two
points of view--the estimation of educational retardation, and the
physical examination of defectives.
=Estimation of the Degree of Mental Inferiority.=--We have seen how
easily, in spite of the commonly accepted opinion, experienced
teachers and inspectors accomplish this part of their task. If a
doctor were charged with it his embarrassment would be great. Just
imagine a doctor introduced into a school of 300 children in order to
pick out the defectives by strictly medical methods. No doubt every
doctor, especially if he is an alienist, is called upon to estimate
the intellectual level of children, and to sign certificates of
idiocy, imbecility, and feeble-mindedness. But just consider how
things are managed at the consultation. The parents bring the child.
They know very well that he is "not like others." They bring him for
that very reason, and consequently the doctor does not require to
distinguish the child from a normal one. He only requires to sit and
listen to the parents, who give him a crowd of particulars. When he
questions and examines the child, it is only to verify what he has
learned, and to add his own personal impression. As a general rule the
case is a severe one; the deficiency is so evident that any sensible
person would notice it. The task of the doctor is therefore narrowed.
He has only to certify the mental deficiency of the patient, stating
in technical terms the diagnosis which the parents have brought to him
ready made. Even his estimation of the gravity of the case, apart from
special investigations on his part, is not very different from that of
ordinary people who readily distinguish between the idiot who cannot
speak; the imbecile, who can make himself understood, though he cannot
be educated; and the feeble-minded, who can do some work, but is not
able to provide for his wants, or to behave himself sensibly.
When the doctor thus certifies the intellectual level of the patient,
does he try to do so with precision? By no means, for it is not
expected of him. The parents do not come to him in order to ask him,
"Is my child backward in his mental development?" Alas they see it
only too well, and little it matters to them whether his backwardness
amounts to six months or a year. But they do come to ask, "Why does
this child not make the usual progress? Is there not some medicine,
doctor, which can help his development?" When they come to the doctor,
it is not even with the hope that some medico-pedagogical treatment
will cure their child. They know very well that the devoted care which
they have always bestowed upon him from his infancy is superior to
anything which can be given to him at a dispensary for children; but
their indomitable hope leads them to seek chimerical measures. In all
this, let us repeat, the doctor does not require to estimate the
degree of mental deficiency with any delicacy. But if he should try to
do so, what methods would he use?
Here is a child of nine years of age, who has been selected for a
class for defectives because he cannot follow the usual lessons in the
elementary school. You, however, doctor, put to him some of your usual
questions. You ask the child his name, his age, the occupation and
address of his parents; the date, day, month, year; some details about
his life; you even ask him to read or count. The replies are given to
you quietly and correctly. Are you going to refuse to admit him to the
special school, and by what right? You have the notes of one, of two,
or of three teachers. He cannot follow; he is still with children of
seven years of age, in spite of having been at school for three years.
It is evident that he is not an idiot, nor an imbecile, nor even
feeble-minded to any great extent. But you have been notified that he
is behind other children of his age. There is therefore something
peculiar about him. It is not a medical question whether he ought to
remain in the ordinary school. The doctor cannot go against the
opinions which have been given to him, in order to verify whether the
retardation is genuine. To do so, it would be necessary for him to
make a comparison with the normal condition. Now this varies according
to age. The doctor does not know exactly, to two or three years, the
normal condition of the mental faculties; nor, after such and such a
period of school attendance, the habitual level of instruction
reached. That, however, in such special conditions, is the very
problem which faces him. We do not hesitate to express the opinion
that, in such circumstances, the doctor would be incapable of
estimating the intellectual level of the child. He has no more
experience in this matter than any other person. Let a doctor seek to
pick out a feeble-minded child from a number of normal ones, and he
will find how little he is prepared to make the selection.
=Physical Examination of Defectives.=--But it may be asked: "Is not
mental debility associated with physical signs which the doctor alone
is able to appreciate?" About this question three kinds of facts may
be considered: those pertaining to anthropometry, the stigmata of
degeneration, and physiognomy. Let us consider in order what help may
be derived from these.
_Height and Head Measurements._--Numerous papers have been published
upon height and cephalometry. The object of some has been to compare
the less intelligent school children with those who are better
endowed. Other authors have taken as their subject the study of asylum
or hospital cases. The absence or paucity of results of the earlier
studies seems to be due to a cause which we have referred to elsewhere
(p. 39). The mistake has been made of judging the intelligence of the
children by sole reference to the opinion of the teachers, although
account should have been taken of the relationship between the age
and the stage of instruction. The comparison between the height and
head measurements of the hospital cases and those of school children
is not subject to the same risk of error, and striking differences
between the two have been noticed. But there is yet another factor
which must be taken into account if the figures so obtained are to
yield all they are capable of teaching. If one confines oneself to
comparing the averages of the two sets of children, one finds them
almost identical. We have shown that the only suitable method to use
here is the method of arranging the figures in series. This proceeding
has suggested to one of us a better method still, that of "frontiers."
There is for each age a height limit below which the defectives become
clearly more numerous. There are limits in the head diameters, upon
each side of which are grouped the abnormally small and the
hypertrophied heads, which are frequently associated with mental
deficiency. We give here the table which one of us has published of
the provisional frontiers for height and for the two cephalic
diameters.
THE FRONTIERS OF ABNORMALITY (BOYS).
------+--------------+-----------------+--------------+--------------
Age. | Height. | Antero-Posterior| Transverse | Sum of
| | Diameter. | Diameter. | Diameters.
------+--------------+-----------------+--------------+--------------
| Centimetres. | Millimetres. | Millimetres. | Millimetres.
6 | 100 | 164 | 134 | 298
7 | 105 | 166 | 135 |
8 | 110 | 169 | 136 | 305
9 | 111 | 171 | 137 |
10 | 120 | 172 | 138 | 310
11 | 124 | 173 | 139 |
12 | 130 | 174 | 140 | 314
13 | 135 | 176 | 141 |
14 | 140 | 178 | 142 | 320
15 | 142.5 | 179 | 143.5 |
16 | 154 | 180 | 145 | 325
17 | 147.5 | 181 | 146 |
18 | 150 | 182 | 147 | 329
------+--------------+-----------------+--------------+--------------
What this table means is this: If we measure 100 children in an
elementary school, we find only a small number (at most 10 per cent.)
whose measurements are less than those indicated; if, on the other
hand, we measure idiots and imbeciles, the proportion of those whose
measurements are inferior is greater, amounting to over 25 per cent.
Amongst 120 abnormal children we found not a single one who was below
these frontiers in two measurements, whilst 10 per cent. of defectives
were below. Certain measurements, therefore, are distinctly
suggestive, although, no doubt, not absolutely diagnostic without
reference to the subject examined.
_The Stigmata of Degeneration._--Everyone has heard of the physical
malformations which are called the stigmata of degeneration. Some of
these are very apparent, such as a sixth finger on the hand, or a
hare-lip, or those deformities of the head, which are called
_plagiocephalus_ (obliquely oval cranium), _scaphocephalus_
(boat-shaped cranium), etc. Other stigmata are less apparent, such as
abnormal shapes of the ear, irregular growth of hair, of the teeth,
alterations in the eye, etc. Some doctors, not all, have made a study
of these various stigmata. But school directors and teachers know
nothing about them except what the present-day widespread
popularisation of medical knowledge has permitted them to know.
Evidently it is no part of their business to take up the study,
although no State diploma will prevent their doing so if it is their
good pleasure. There is no law against it. But they would expose
themselves to grave risks of erroneous interpretations owing to their
ignorance of the manner in which stigmata are produced, and the
ignorance of doctors on this subject is still great. The determination
of the stigmata, their enumeration, and their description, belong,
therefore, at any rate by preference, to the doctor. God save us from
wanting to dispossess him!
But what help could their study render us in the question whether a
particular child ought or ought not to be admitted into a class for
defectives? There is an opinion which is very widespread, especially
amongst teachers and ordinary people, a souvenir of the doctrines of
Gall, that the physical stigmata are signs of the original character,
and that the possessor of a certain shape of head is certainly
defective. "I have taken my son," a worthy mother said to us, "to
consult Dr. P., because he was learning nothing in his class. He was
sent away from every school I sent him to, and he is unbearable at
home. The doctor felt all over his head. He evidently saw that there
was something particular wrong with the boy." We do not smile at this
good mother. Plenty of other intelligent people hold her opinions, if
they are not so naive in their language. They expect that the moment
defective children are brought before them, they will find something
peculiar, something ugly, in their physiognomy. And there are plenty
of doctors, let us say frankly, who are equally naive, and, more
serious still, allow themselves to be influenced by unconscious
suggestions. If, like our worthy mother, we present to the doctor a
child as defective, the doctor will, as a general rule, have no
difficulty in demonstrating that he must be so. How many of us are
there without stigmata? None of us is built upon the model of the
ideal man. It is always possible to discover some anatomical detail
which will give support to a preconceived opinion. But the same doctor
who, on seeing a defective child with adherent ear lobes, will say
that that was just what he expected, will abruptly change his opinion
if he discovers a whorl of frontal hair on a child who is presented to
him as normal, and will refuse to attach to the fact any importance
whatever. As a matter of fact, these questions have not yet been
studied as they ought to be, by a comparison without _parti pris_
between normal and abnormal children of the same age and in the same
environment, and we do not yet know how stigmata should be
interpreted. We can only suggest some provisional conclusions.
The first of these conclusions is that the presence or absence of a
definite stigma has no exact significance for the individual who bears
it; for on the one hand one meets with all kinds of malformations in
average normal children, and on the other hand, some who are
definitely abnormal are quite normal in their conformation. The
stigma, therefore, has not the value of a definitely pathognomonic
sign like the crepitating rale of pneumonia, or the transient
unconsciousness of epilepsy; but if we compare a group of normal
children with a group of abnormal, the total number of the stigmata
will be much greater in the second group; and, moreover, the
multiplicity of stigmata in a single individual constitutes a strong
probability that that individual is abnormal. Here are some facts
which support these two propositions:
Recently we made a rapid examination of the heads of fifty-eight
school children, and noticed that eighteen of them had some stigma,
especially an abnormal shape of the ear. We therefore find stigmata
amongst children at the average school level. But of these fifty-eight
school children only one had four abnormalities--malformed ears,
strabismus, prognathism, and slight scaphocephaly. The others had a
maximum of two. The first child alone is certainly defective.
In a class of nine defective children subjected to a similar
examination, we found only one who had but one stigma, another had
two, four had three, and three had five. Of the three last, one had a
very high degree of retardation; another was mentally ill-balanced to
no less a degree. Let us compare these two groups, the one of
fifty-eight average children, the other of nine defectives, and group
to group, the difference is very clear. The stigmata are usually more
numerous when the children are mentally defective. The existence of
stigmata is a presumption of deficiency, and this presumption is
greater, the greater the number of stigmata.
If we consider which are the stigmata that are most commonly met with,
we find that asymmetry of the face is almost constant, but we also
find it sometimes in normal children. Malformations of the ear come
next. We are often struck by the frequency of badly defective
speech--three times in nine defectives, whilst we did not find a
single example in the fifty-eight school children taken by chance.
Here, then, is a "group fact" which is of interest from a scientific
point of view. But what use can be made of it for individual
diagnosis? This is much more delicate, for even if one could state it
as a general rule that defectives have more stigmata than the normal,
this rule is subject to important exceptions.
One of our abnormal cases had only one stigma, another had two, and in
both cases the anomalies were of a very ordinary kind--slight want of
symmetry of the face and sticking out ears. Children with stigmata few
in number, and little marked (though as a rule we note the presence of
stigmata without measuring them), may therefore not be of normal
intelligence. The same is true sometimes of children with no stigma at
all.
We may therefore conclude that stigmata may be taken into account when
we are making an examination, but they should never be regarded as of
fundamental importance in diagnosis.
_Physiognomy._--In addition to stigmata, we have to note another
feature which is of more definite significance. Methodical studies
made by means of a collection of sixty photographs of children, normal
and abnormal, photographs taken by M. Bertillon in conditions
comparable in all cases, have shown us that an intelligent teacher can
scarcely go wrong in judging physiognomy. The photographs were
beautifully taken, and the expression of the faces appeared extremely
lifelike to anyone who was used to observing children. We asked
various teachers to examine these portraits, and to express their
opinion as to the mental capacity revealed. Mistakes were made, as
was to be expected; but the correct estimations were always in the
majority, and some teachers exhibited a truly remarkable talent for
observation; they were practically never deceived. Let us say in
passing that our list included a number of doctors amongst the
teachers. They were far from distinguishing themselves. Their
percentage was not so good as that of the schoolmasters. This
difference in competence, which perhaps may appear surprising,
suggests the following anecdote: One day, at the meeting of a
commission, we had thrown upon the cloth a collection of photographs
of children, the very one which we had been using for our methodical
experiments. Everyone looked at the portraits and expressed his
opinion. By way of a joke we tackled a medical alienist who had a seat
on the commission. He was mistaken in his opinion as often as his
colleagues who were most ignorant of medicine.
It seems to us, and the facts mentioned support us, that stigmata are
only one part of the complicated whole which constitutes a
physiognomy. A physiognomy includes many other things, especially the
expression,--lively or sluggish, strong or weak, intelligent or
lacking in intelligence; there is the fineness or coarseness of the
features, the beauty or ugliness of the countenance, the ordinary or
unusual appearance of the face. All this forms an _ensemble_ which the
eye does not analyse, but judges _en bloc_ by instinct, without
considering the elements separately, and, above all, without being
able to give reasons for its judgment. Will it be possible some day to
analyse, to dissociate, and to describe all these very various
elements? We do not know. In the meantime we think that every
examiner, as a matter of fact, allows himself to be influenced by the
general appearance of the subject, and that the impression so formed
is not entirely without value.
Let us sum up regarding the physiognomy. There does exist between the
intellectual level of a subject and his physical development a real
correlation, but, unfortunately, it is slight. With regard to the
stigmata our knowledge of their significance is still very slight. We
have no figures which allow us to place any definite value upon them
either singly or in combination. There still remains the general
appearance, whose significance is apparently indubitable, but which,
at present, is too dependent upon individual estimate to be
utilisable. Let us add that these relations between the mental and the
physical appear to be of greater significance the lower the mental
condition. Now, in a school it is the feeble-minded who are in the
majority, and it is they who have to be recognised much more
frequently than the idiot or the imbecile, and this lessens the
importance of the physical examination. We may therefore conclude with
this practical rule: a physical examination can never allow us to
dispense with a direct examination of the intelligence. Anthropometry,
stigmata, and physical appearance must take a second place as means
for discovering in school the feeble-minded and the ill-balanced.
Failing direct recourse to the teacher, these methods could, and
ought, to be made use of. But in most cases, thanks to the assistance
of the teacher, we have better means. In cases on the border-line they
might help to incline the balance. Their principal use is not to
assist in selecting children for special classes for defectives; their
significance is quite different, as we shall see immediately.
MEDICAL EXAMINATION OF THE CHILDREN PRESENTED.
We must now define the active role of the doctor. In many foreign
countries a scheme has been drawn up for the medical examination,
which is often extremely comprehensive, almost interminable. We give
an example of this kind, though questioning the appropriateness, from
our point of view, of certain questions. If one does not simplify the
work, the practitioners will simplify it in their own way--by
neglecting it. If you ask them to do too much, they will do nothing.
SCHEME FOR MEDICAL EXAMINATION
_Heredity of the Child._--Note the name, the date, and the place
of the birth of the father and the mother, and find out, by
direct interrogation, whether the parents have a pathological
heredity. Consider first the two great hereditary
influences--alcoholism and insanity. Next inquire concerning
nervous ailments, tuberculosis, etc. Make inquiries concerning
the direct ascendents and their collaterals. Note the number of
brothers and sisters, their illnesses, their mortality, and the
position of the child in the family.
_Previous History of the Child._--This is the second part of the
medical examination. It includes many questions. Has the child
had convulsions? At what age did it begin to cut its teeth? At
what age did it begin to walk? When did it show habits of
cleanliness? When did it speak? What illnesses had it in
infancy? Has the child always appeared different from others, or
did it only become so at some definite time, or, in other words,
is the mental deficiency congenital or acquired?
_Present Condition._--Under this heading are included the
general appearance of the subject, his attitude, the form and
size of his head, etc.
We have no objection on principle to medical investigations of this
kind, and if a doctor desires to collect such information, he ought to
be encouraged. We recall in passing that Dr. Ley, of Antwerp, who was
for some time medical specialist to a school for defectives, has made
a very complete study of the heredity and personal antecedents of
hundreds of defective children. But before compelling doctors to fill
up conscientiously a schedule containing all these questions, one
should consider without prejudice what use the work is going to be
when it is done.
Let us distinguish between pure science and what is of immediate
practical utility. No doubt one ought to give a warm welcome to
everything which helps us to understand the child better; but the
above observations upon his heredity do not bear upon the question of
whether he is a defective, and throw only the dimmest light upon his
character and the manner in which one should treat him. If he is to be
counted abnormal, he must be either ill-balanced or of deficient
intelligence. Even if he should have an alcoholic heredity, that would
be of no importance if he were able to follow his class and to profit
by the ordinary instruction. At most, the discovery of a pathological
heredity might incline one in a doubtful case towards a diagnosis of
mental deficiency; but yet one should be extremely cautious about
permitting oneself to be influenced in this way, for we are ignorant
to a most incredible degree concerning the heredity and antecedents of
normal children, and as our ignorance in this respect is so complete,
we are unable to say precisely what is really pathological in the
heredity and the antecedents of those who are abnormal. Information of
this kind, therefore, is not directly useful.
What, then, are the first problems to be solved? Let us consider just
exactly where we are in the examination. Here are the children picked
out by the teachers. The inspectors themselves have checked the
selection and referred back some of those selected, but very few, if
they have carefully directed the methods of choice from the beginning.
The children presented are backward in their studies. Inquiries
regarding their school attendance have shown that the retardation is
not due to irregular attendance. The examination of their intelligence
has confirmed this judgment.
It still remains to discover whether, amongst all these children who
are unable to follow the ordinary school curriculum, there do not
exist some who are not, properly speaking, mentally deficient, but who
are suffering from some illness. May we not find amongst them some
who require medical treatment rather than special teaching--_e.g._,
cretins? And, lastly, may there not be some children whose mental
deficiency complicates some other disease, such as epilepsy? These are
problems which are essentially medical, and which it is necessary to
solve before admitting a child to a special school. Let us consider
them in order.
=1. Is the Case one of Mental Deficiency, or of an Intercurrent Mental
Affection?=--To tell the truth, there is not often any doubt. However,
there are two circumstances in which doubt may arise. In the first
place, an arrest in a child's mental development may be the expression
of a state of depression which indicates a psychosis in the course of
evolution, or it may be the first sign of decadence in one of those
degenerates of whom Morel speaks, who seem to have "a limited mental
existence." Such cases, which some authors describe under the name of
"dementia precox," require a medical regimen.
In the second place, it is possible that the etiological factor is
alcohol. Alcoholism in the parents is frequently the cause of mental
deficiency. But the effects of drinking do not always stop there. The
child itself may be made to drink, and consequently the doctor may
sometimes find symptoms resulting from direct intoxication--nightmares,
or tremor of the hands. Such intoxication may be responsible partly, if
not entirely, for the want of progress at school, and also for the
irritable temper which the child shows in class. It would be necessary
in such cases to see the parents, and to advise a different hygiene for
their child at any rate, if they themselves cannot be persuaded to give
up their bad habits. In this way one may be able to avoid sending the
child to a school for defectives. It is apparent that even if the child
were sent to such a school, it would be necessary to put a stop to the
administration of alcohol. The rarity of such cases makes their
exposition of almost theoretical interest.
=2. Would the Mental Deficiency respond to Medical Treatment?=--Cannot
the doctor prescribe something to cure the mental deficiency or want
of balance? Let us give some consideration to this question. Medicines
act either upon the symptoms of a disease, or upon the organic changes
which produce them, or, lastly, upon the very causes of such organic
changes. Quinine, for example, has a selective action on the parasites
of malaria; mercury produces an undoubted effect upon syphilitic
growths; treatment by cold baths keeps the temperature of typhoid
fever below a certain level during the whole of the illness. Cannot
analogous results be hoped for in mental deficiency? A brief resume of
what we know concerning the causes of mental deficiency and the
anatomical lesions which accompany it will determine our answer.
The dominant etiological feature is that mental deficiency and want of
balance depend upon hereditary conditions, or conditions acquired in
the earliest stages of development. By hereditary conditions must be
understood strictly those which result from alterations in the germ
cells of the parents. An intoxication alone seems capable of
exercising upon the latter a sufficiently general action to reach the
germ cells, and by far the most frequent poison is alcohol. By
acquired conditions must be understood the results of diseases of the
foetus or of infancy, and especially the cerebral complications of the
infectious fevers--_e.g._, meningitis in the course of an eruptive
fever. In all such cases, with rare exceptions to be mentioned
immediately, by the time the mental deficiency is discovered, its
causes are no longer active, and consequently cannot be affected by
medical intervention.
The statements we have just made with regard to the causes of mental
deficiency lead to some practical conclusions. The ultimate evolution
of the congenital cases differs from that of acquired cases, and this
renders a study of the early history of the child important. If the
development of the child has been normal at first, and has then been
abruptly interrupted, for example, by an attack of meningitis, of
which we can obtain by inquiry a definite history, the prognosis is
not good. For it is a well-recognised fact that cases of acquired
mental deficiency are not likely to make a fresh start. If we were
hesitating whether to send an imbecile child to an asylum or to put
him in a class for mental defectives, a history like the above would
lead us to give the preference to the asylum; but let us say once
more, we do not find here an indication for treatment.
As to the changes which are found post-mortem, these are manifold and
of an unalterable kind. They are as follows:
(1) The results of the rupture of a cerebral vessel--_e.g._, from
asphyxia at birth or a delivery by forceps. Blood has been poured out
into the nervous tissue. The latter has been destroyed over a greater
or less extent, and there is found in its place a cyst filled with
sero-sanguineous fluid.
(2) The obstruction of an artery--_e.g._, by septic thrombosis--has
prevented the blood from reaching a part of the brain, with similar
results to those mentioned.
(3) In other cases are found the more or less extensive changes
produced by meningitis or meningo-encephalitis. The inflammation of
its envelopes has interfered with the brain, and consequently with its
functions.
(4) An increased secretion of cerebro-spinal fluid has led to a
compression of the nervous system or a distension of its cavities,
notably of the lateral ventricles of the cerebral hemispheres, and has
led to a separation of the bones of the cranium, thus producing the
large globular head of hydrocephalus.
(5) There may be found simply defects of development whose causes are
known (microcephalus, or extreme smallness of the cranium relatively
to the face; microgyria, or marked thinness of the convolutions).
(6) Lastly--and this is frequently the case in the worst degrees of
deficiency--the post-mortem, and even microscopic examination of the
organs may show no change at all.
Let us add that the nature of the lesions just mentioned does not seem
to have any relationship to the condition of the mental faculties. An
anatomico-pathological grouping of the cases and a grouping according
to the mental condition, far from being parallel, are frequently
decidedly different. On the other hand, the extent of the lesions is
of more importance. Diffuse lesions affect the mind more than those
which are circumscribed--that is to say, limited to a certain part of
the brain--as if the mental functions required the co-operation of the
entire cerebral cortex. One will often find, for example, sound
judgment in the subject of a marked paralysis, whilst it is very rare
to find that good intelligence co-exists with any degree of
microcephalus.
Let us emphasise the last fact we mentioned, the absence of any
lesion. Some authorities have maintained that all conditions of mental
deficiency and want of balance found in children are connected with
definite diseases of which they are the symptoms. The question is
unsettled. For our own part we adopt the following provisional
statement: Mental deficiency and want of balance are peculiar mental
conditions which it is often impossible to connect with definite
pathological changes.
Thus, we do not know of any medical treatment which is likely to act
upon the preceding lesions when they are present, and we do not think
it is even possible to act upon them.
An exception must, however, be made of conditions due to insufficient
secretion of certain glands. The type of these is cretinism. Marked
cases of this condition are easy to recognise. The very appearance of
the children is sufficient for an experienced eye--the stunted growth;
the rough, wrinkled skin; the swollen eyelids half-concealing the
eyes; the prominent belly; and the mental apathy. One also comes
across abortive cases, where the above-mentioned characters are less
marked; the sluggishness also is less. These latter cases are amenable
to the same treatment as the former--namely, the ingestion of thyroid
glands from the sheep.
This treatment stimulates growth and makes the child more lively; but
what ultimately becomes of the cases so treated? The amelioration
usually ceases whenever the treatment is dropped. But how far does
this amelioration go? To what extent does the child profit by it?
Lasegue has jocularly remarked that the average duration of an attack
of typhoid fever (six weeks) represents the maximum time during which
medical attention could be brought to bear upon a patient. One feels
disposed to think he is right in face of the slight satisfaction one
can obtain from the literature regarding a point of such importance.
Other cases of mental deficiency may be due to an alteration in the
pituitary gland. It is for the doctor to find out whether there are
any symptoms by which mental deficiency of such an origin can be
recognised, and whether it is possible to prepare a suitable substance
for replacing the absent secretion.
The number of cases amenable to treatment of this kind is,
unfortunately, very limited.[13] We may even say that, as a general
rule, we did not find amongst the school children we examined any
cases of obesity or infantilism such as are sometimes described of a
truly remarkable nature. Even children who were abnormally short
looked their age. We have still, however, to mention one last
influence--namely, poverty. Its part in the production of mental
debility is scarcely defined. What are the exact effects upon
intelligence of prolonged deficiency of nutrition? How can its action
be isolated from that of other agents, such as alcoholism, which too
frequently accompanies it? The complexity of such social studies
sufficiently explains their present incompleteness. Let us recall the
results we obtained from an inquiry of this kind; the children of
parents in extreme poverty are retarded in their physical development
more frequently than those whose parents are in easy circumstances. It
is interesting to add that analogous inquiries with reference to
intelligence have furnished similar results.
Apart from the preceding cases, the best that can be done is to treat
the symptoms. The two principal agents at the disposal of the doctor
are the bromides and hydrotherapy. Unfortunately, if the bromides are
undoubtedly efficacious in certain cases of epilepsy, that is far from
being the case in simple want of mental balance, in which cases they
are at best useful adjuvants. As to hydrotherapy, and especially cold
douches, their principal indication is in certain nervous affections,
where their effect is to enable the subject to master the emotional
reactions which are habitually exaggerated.
Lastly, the doctor can exert his moral influence to assist the
educative work of the teacher in the special school. His less frequent
intervention, the different motives of his advice, will often give him
even more authority than the teacher. The suggestive effects of his
intervention should be obtained, in our opinion, without resort to
hypnotism.
=3. Does the Mentally Defective suffer from any Definite Illness?=--If
the illness such as we have referred to affects those parts of the
cerebral cortex which govern the muscles of a limb, one will find, in
addition to the mental condition, paralysis with atrophy and
contracture. But in addition to such very marked cases, there exist
others in which sensory or motor affections, although slight, may
hinder the progress of education.
It goes without saying that if a child does not profit from the school
work, an examination of his sight and hearing should be made as a
matter of course. Perhaps that may have been done already by the
teacher himself by such methods as he is able to use. But this first
examination is not sufficient. The doctor must correct, as far as
possible, the want of acuity noticed. No doubt the defect may not
explain the mental deficiency of the child, but one must take care
that in the school for defectives a pronounced myopia or catarrh of
the middle ear does not prove an obstacle to the efforts which are to
be made to bring about development.
In the same way it must be considered whether the condition of the
muscular system is such as to permit the manual work which one wants
to teach the child, and whether there exists any paralysis or tremor
which would prove an obstacle to work of this kind. One must consider
whether any symptoms present are transitory, like chorea; or
permanent, like infantile hemiplegia; and what kind of efforts may be
made without risk to the health of the child. Such are the problems
which the doctor has to solve.
* * * * *
In the last place, it is necessary to take into account the
coexistence with the mental deficiency of other affections.
_Epilepsy._--Epilepsy frequently coexists with mental deficiency. Now,
epilepsy does not always reveal itself by severe fits with crying,
falling down, loss of consciousness, convulsions, stiffness followed
by jerking of the limbs, foaming at the mouth, biting of the tongue,
and involuntary passage of urine. It is revealed also by symptoms of a
less striking nature, which have been described under the name of
_petit mal_. Such are loss of consciousness, vertigo, or simply mental
perturbations. Loss of consciousness occurs without the tremor of a
muscle, the child suddenly turns pale, loses consciousness for a
moment, and then continues whatever he was doing--for example, walking
or writing. There is nothing more impressive to notice when the fit
occurs as one is talking to the little patient. One sees, as it were,
the passing of a veil. But nothing could be more fugitive, nothing
could more easily escape the notice of anyone who was not a good
observer. Often the parents know nothing about it. The attacks are so
short, the consequences apparently so slight, that even if the parents
have chanced to notice them, they do not always think of mentioning
the fact. The teacher of defective children ought to be instructed in
the characteristics of this affection. He is going to spend several
hours daily with the children. He will have the best opportunities for
noticing the occurrence of attacks, which may be rare, but which, when
they occur, are very significant.
Although the symptoms are a little more marked, vertigo also is of
brief duration. To the pallor and the loss of consciousness of the
preceding condition there is added a little muscular relaxation. The
child totters, supports himself by anything in his neighbourhood,
slips down in his seat, or drops his pen. Sometimes there is a slight
spasm of the muscles of the face, the mouth is drawn to one side by
slight jerks, or performs some movements of mastication or
deglutition. And that is all--no convulsions of the limbs, no passage
of urine, scarcely an interruption to the work which is being done.
Whether the doctor discovers these symptoms by interrogation of the
parents, or whether the teacher some time afterwards describes them
to him with sufficient detail to permit of a certain diagnosis, a
double gain results. In the first place, there is an indication for
treatment; and in the second, the possibility of supervision. As a
matter of fact, it too frequently happens that these symptoms, little
dramatic as they are, reveal the existence of epilepsy, which will
ultimately result in progressive mental decadence.
And yet this is not all. A few days or a few hours before such
symptoms occur, or immediately after them, or, lastly, according to
some authorities, entirely independently of them, the patient may
develop a peculiar condition of irritability, in which he will
transgress against discipline, make insolent remarks, or even give way
to violence. Such actions ought not to be suppressed by punishment,
because they are of morbid origin.
All such symptoms possess this characteristic, that they leave no
trace on the memory of the child. He himself knows nothing about them,
or knows them only by what he has heard from other people. There can
now be no need to insist with what care inquiries must be made,
especially of the parents.
Are epileptics to be admitted into the special class? On principle
they are refused admission to the ordinary school. They are, however,
to be found there. There are those whose attacks occur very rarely, or
are so slight as to cause no disturbance. There are probably also
unrecognised cases of epilepsy in which the symptoms occur during the
night, or on awakening, but never in class. Only the severe forms are
turned away. Probably the same state of affairs will recur in the
classes for the abnormal--at any rate until the time when provision
for epileptics is more extensive than it is at present. It will
therefore be necessary to recognise these cases, to supervise them
with special care during certain kinds of manual work, and, if
possible, to treat the nervous symptoms suitably while the patients
are receiving instruction.
_Hysteria._--Although hysteria has not the same gravity, it is no less
advisable that cases should be tracked out. This neurosis is being
discussed to-day as never before. Without setting forth at length what
we think should be included under this term, let us point out a
characteristic of hysteria which is commonly recognised, and which is
of such importance that it indicates the line of treatment to be
followed. The two principal manifestations of the affection,
hysterical fits and the recital of lying tales, require for their
complete development the presence of a public, of a gallery.
Inversely, their disappearance is assured by isolation or apparent
inattention.
The discovery of such tendencies before entrance to the school will
allow the doctor to forewarn the teacher, and point out to him the
best way of dealing with such children.
* * * * *
There are still three affections about which we must say a few
words--rickets, adenoid vegetations, and scrofula.
_Rickets._--The chief characteristic of this condition is defective
ossification. Instead of possessing their usual rigidity, the bones
become curved, and multiple deformities result. The legs become bowed,
and the knees cannot be brought into contact when the feet are placed
together; the thorax becomes constricted or gibbous, etc. In addition
to the nutritive disturbance, which appears to be at the root of all
these disorders, there may be, according to some authors, an affection
of the entire system, and especially of the nervous centres.
Unfortunately, as rickets is a disease of the earliest years of life,
one often finds oneself in the presence of the sequelae which have been
left, and which simply must be made the best of.
_Adenoid Vegetations._--Everyone has now heard of cases of this kind
where the appearance is so characteristic. The lips are always half
open, the appearance is sleepy-looking, the respiration is difficult.
If one looks at the throat, or if one introduces the finger into the
child's mouth in order to explore the pharynx behind the soft palate,
one will see or feel the large tonsils or the fleshy masses which
obstruct the posterior orifice of the nasal fossa. One would like to
find in these vegetations the cause of the habitual torpor of the
children, and of their want of progress. It is true that there is a
connection between mental backwardness and adenoids. The removal of
the swellings by a surgical operation will make more free the
respiration, whose obstruction prevented sustained attention, and will
also frequently cure the deafness, which was due to an obstruction of
the Eustachian tubes. The operation may therefore result in a marked
amelioration of the mental condition as well as of the general health.
If the amelioration is sufficient, the child can be sent back to the
ordinary school.
_Scrofula, Tuberculosis._--A child with a lymphatic appearance, whose
tissues are infiltrated with serum, and whose glands readily become
enlarged, requires plenty of country air and a nutritious diet. If he
is admitted to the special school, it will be advisable to attend to
his health before subjecting him to any particular educational
methods.
The doctor, then, will notice in passing the existence of such
conditions as rickets, adenoids, and scrofula in the children who are
submitted to him. Affections of the lungs and tuberculosis of the
bones will also attract his attention. But such affections in abnormal
children have no other significance than in the case of children of
average intelligence. They furnish no special indication regarding the
admission or non-admission of the child into a special class. Their
severity alone determines the course to follow with respect to their
treatment.
We shall, however, say a few words about another
infirmity--incontinence of urine. If there is presented for a class
for defectives a subject, eleven years of age, who cannot control
himself in this respect, the course to follow is: submit the child to
examination by a specialist, who will decide the nature of the
incontinence. If it is curable, give the condition the necessary
attention, or give instructions at the school for training the child
properly; but if there is an incurable weakness of the sphincters,
supply the child with the same kind of apparatus as is used in such
cases by ordinary people.
* * * * *
Here, then, are a number of important points upon which the doctor may
be called to give his opinion. It is he alone who is able, by his
special knowledge, to enlighten the other members of the jury. If the
mental condition is doubtful and requires further observation, it is
for him to point it out. One will thus avoid the mistake of placing in
a class for defectives a lunatic, or a child poisoned by alcohol, who
would not find there the kind of care required. If the bodily
condition discovered complicates or aggravates the mental deficiency,
as adenoid vegetations may do, he will prescribe the proper treatment.
If he suspects the coexistence of some neurosis, he will give
directions by which the condition may be recognised, and consequently
treated. The doctor therefore has to recognise the physical and mental
ailments by which the defective may be affected. He makes this
diagnosis for two reasons. In the first place, in order that mental
deficiency may not be confounded with conditions of illness of a
different kind; and, secondly, in order to relieve or cure if possible
coexisting affections which may aggravate the condition of the
children and interfere with the work of the school.
* * * * *
We shall conclude here what we have to say about the role of the
doctor, since in this volume we are specially concerned with the
recognition and segregation of the children. To discuss the role of
the doctor quite fully would take us too far.