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 a.s.sure 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 apt.i.tude 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 r.e.t.a.r.dation, 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 embarra.s.sment 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 cla.s.s 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 r.e.t.a.r.dation 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 circ.u.mstances, 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 a.s.sociated 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 a.s.sociated 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. G.o.d 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 cla.s.s 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 cla.s.s. 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 nave 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 nave, 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 const.i.tutes 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 cla.s.s 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 r.e.t.a.r.dation; 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 pa.s.sing 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 const.i.tutes 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 coa.r.s.eness 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 a.n.a.lyse, 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 a.n.a.lyse, 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 a.s.sistance of the teacher, we have better means. In cases on the border-line they might help to incline the balance. Their princ.i.p.al use is not to a.s.sist in selecting children for special cla.s.ses 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 pract.i.tioners 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 att.i.tude, 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 pa.s.sing 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 cla.s.s 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 r.e.t.a.r.dation 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 circ.u.mstances 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 prec.o.x," 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 cla.s.s. 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 a.n.a.logous 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 cla.s.s 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.