BOUGHT WITH THE INCOME FROM THE SAGE ENDOWMENT FUND THE GIFT OF Hetirg HI. Sage 1891 Au;^.SA.^...^ ^Y/^..(f.a4.. 5474 Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924031422839 MENTALLY-DEFICIENT CHILDREN MENTALLY-DEFICIENT CHILDREN: THEIR TEEATMENT AND TEAINING. of EfSHUTTLEWORTH, B.A„ M.D., &c. MEDICAL EXAMINER DEFECTIVE CHILDREN, SCHOOL BOARD FOR LONDON; CONSULTING MEDICAL OFFICER, NATIONAL ASSOCIATION FOR PROMOTING THB WELFARE OF THE FEEBLE-MINDED ; LAT'fe MEDICAL SUPERINTENDENT, ROYAL ALBERT ASYLUM FOR IDIOTS AND IMBECILES OF THE NORTHERN COUNTIES, LANCASTER; FORMERLY ASSISTANT MEDICAL OFFICER, EARLSWOOD ASYLUM, Fellow of the Royal Medical and Chtrurgical Society, and of the Medical Society of London ; Member of the Medico-Psychological Association, Neurological, Harveian, and West London Medico-Chirurgical Societies ; Corresponding Member of the Medico-Legal Society of New York, and of the Association of Medical Oncers of American Institutions for Idiotic and Feeble-minded Persons ; Foreign Member Neurological Society of Moscow, SECOND EDITION LONDON H. K. LEWIS, 136 GOWER STREET, W.C. Philadelphia: P. BLAKISTON'S SON AND CO. igoo PRINTED BY M. K. LEWIS, 136 GOWER STREET LONDON, W.C. TO THE MEMORY OF THE TRULY ILLUSTRIOUS EDOUARD SEGUIN, M.D. WHO FOR FORTY-TWO YEARS, BOTH IN THE OLD WORLD AND THE NEW, PRACTICALLY AND WITH HIS PEN LABOURED TO IMPROVE THE CONDITION OF MENTALLY-DEFICIENT CHILDREN BY THE APPLICATION OF PHYSIOLOGY TO EDUCATION; THIS BOOK IS INSCRIBED. ' He loved others better than himself." PREFACE TO SECOND EDITION. This book having been for some time out of print and being still in demand, the author ventures to issue a new edition, and takes the opportunity of adding two additional chapters, giving some account of the inquiry undertaken for the Education Department by a Committee of which he had the honour to be a member (the recommendations of which have now been embodied in a statute), and also of the practical measures adopted for special instruction by several school authorities, and notably by the School Board for London. Ancaster House, Richmond Hill. October, iSgg. PREFACE TO FIRST EDITION. In offering this little Manual to the Medical Profession, and to the increasing number of the Public who take an interest in the special educa- tion of mentally-deficient children, the author trusts that the experience acquired by the pro- verbial " quarter-of-a-century's " successive resi- dence in two of the largest Training Institutions for Imbeciles, may aid him in setting forth both the salient peculiarities of the class, and the ameliorative measures found most useful. He does not profess to bring forward much that is new, but rather to collect and mould into book- form, various papers published by him during the last twenty years in Medical Journals and the Proceedings of Societies. In the present volume, the pathology of the subject is only touched on to supply a few practical hints which may be of service to the medical man in his diagnosis, prognosis, and Preface to First Edition. recommendations, when consulted in the case of a mentally-feeble or deficient child. Though his standpoint is that of the physician, and not of the teacher, the author hopes that his observations upon special educational methods, based as they are upon physiological principles, may not be without value to those engaged in the practical work of instruction. For the successful training of the mentally-deficient child the "physician and the teacher must go hand in hand ; and it will be a satisfaction to the author if in some slight degree this book realises the aspirations of S6guin — who was both. " Let us physicians," he says (in the course of an address to a New York medical society), "help to build the programme of physiological educa- tion, already sketched in the School for Idiots . . The demonstration therein given is that the physiological education of the senses is the royal road to the education of the intellect ; experience, not memory, the mother of ideas." May, 1895. CONTENTS. CHAPTER I. Historical Retrospect. PAGE The work of Seguin, Saegert and Guggenbiihl. Early efforts in Great Britain aided by the writings of Gaskell and Conolly. Investigations as to prevalence of Idiocy in America, and establishment of " experimental schools " there. State Institutions. Public provision for men- tally-defective children in the United Kingdom, the United States, and various European countries . . i CHAPTER n. The "Feeble-Minded" or Mentally-Feeble Child. American use of term " Feeble-minded " as including Idiocy and Imbecility. Special application in England of the term to the slighter grades of mental defect (mental feebleness). Committees on mental and physical condi- tion of school children : investigations of Dr. F. Warner. Criticisms. Official investigations in Switzerland . . 12 CHAPTER HI. Defective and Epileptic Children. Investigation and Report by Departmental Committee ap- pointed by Education Department for England and Wales. The Elementary Education (Defective and Epi- leptic Children) Act, 1899 21 xii Contents. CHAPTER IV. Special Instruction o^ Defective Children. '"* PAGE Hilfsklassen and Hilfschiilen in Germany. Arrangements in Scandinavian countries, in Belgium, Switzerland and Italy. Special classes and special schools in England. Arrangements under School Board for London. Selec- tion of pupils. Private educational homes for children of higher social class. Working homes for feeble- minded adolescents. National Association for promo- tion of the welfare of the feeble-minded. Illustrative cases 31 CHAPTEE V. Pathological Classification of Forms of Mental Deficiency. Congenital, non-congenital and developmental cases. Microcephalus. Defects of corpus callusum and partial atrophies. Hydrocephalus. Mongol type. Scrofulous cases. Birth-palsies. Cretinism. Primarily neurotic cases. Eclampsic and epileptic cases. Syphilitic cases. Traumatic and post-febrile cases. Cases from emotional and toxic causes. Infantile cerebral degeneration . . 48 CHAPTER VI. Etiology, Diagnosis and Prognosis. Etiology. — Family history of phthisis ; of hereditary mental weakness ; of epileptic or neurotic inheritance. Parental intemperance. Inherited syphilis. Consanguineous marriages. Maternal ill-health, accident or shock. (The above causes act before birth). Causes acting at birth : Contents. xiii PAGE prolonged parturition ; question of influence of forceps delivery and of unassisted protracted pressure. Prema- ture birth. Causes coming into play after birth : eclampsia; epilepsy; infantile paralysis; traumatism; fright or shock ; severe febrile illnesses. Diagnosis. — Cranial abnormalities ; formative and develop- mental defects ; abnormality of nervous action ; defects in nutrition. Prognosis of the several types. Distinction between idiocy, imbecility and mental feebleness (" feeble-mindedness "). Connection between criminality and mental deficiency . 6i CHAPTER VII. The Treatment of Mentally-Deficient Children. (a). Qeneral. — Maternal care. Proper feeding. Hygiene of skin. Muscular activity to be encouraged. Cleanly habits to be inculcated. Clothing. Exercise. Care at puberty. (6). Medical. — Depressing treatment inadmis- sible. Tuberculosis. Epilepsy. Sporadic cretinism. Parasitic and other skin diseases, (c). Surgical opera- tions in bone and joint disease. Craniectomy . . 85 CHAPTER VIII. Educational Training. Culture of the external senses. Co-ordination of muscular movement. Promotion of manual and mental activities. (i). Dull and apathetic : (2). Nervous children. Devices for fixing attention and for exercising adjustments of fingers (illustrated). Training of touch, sight, taste, smell, hearing, speech. Drill and dressing lessons. Object lessons. Drawing, writing, reading and cal- culation. Influence of music -99 xiv Contents. CHAPTER IX. Industrial Training; and Recreation. PAGE Kindergarten occupations. Out-door work. Handicrafts. Recreations. Games of ball; marbles; skipping; battle- dore and shuttlecock ; dancing ; bagatelle. Concerts and theatrical performances 117 CHAPTER X. Moral Training. Specially essential in education of mentally-deficient children. Moral discipline ; " force no remedy ; " rewards and pun- ishments. The " moral imbecile." Religious feeling in mentally-deficient children 123 CHAPTER XI. Results and Conclusions. Pessimistic views as to possibility of improving idiot children. Experience of Seguin, of English and of American Insti tutions. Relief to parents. Examples. Need for super- vision after training. Trained cases earning their living. Question of marriage and of permanent sequestration. Duty of County Councils to provide for pauper imbeciles. Special classes under London School Board. Results. Working homes for feeble-minded adolescents. Argu- ments against efforts to educate mentally-deficient chil- dren. The Christian aspect of the subject. . . . 130 Contents. xv APPENDIX A. PAGE (i) Defective, tee., Ctalldren's Act ; (2) Note on Idiots Act 153 APPENDIX B. Iiist of Institutions and Homes for Mentally-Deficient Children 160 APPENDIX C. Special Classes for Defective Children ■ 163 APPENDIX D. American and Colonial Institutions for " Feeble-Minded " 164 APPENDIX E. Spea]£lng Exercise 166 APPENDIX F. Bibliography 168 xvi Contents. LIST OF ILLUSTRATIONS. PLATES. Plate I. — (ComparatlTe Cranial Contours).' [facing p. 49/ Fig. 1. — Microcephalic Contours. „ 2. — " Mongol "'-Type Contours. „ 3. — Hydrocephalic Contours. Flate H.— (AbnormalitleB of Brain development). [between pp. 52 and 53. Fig. I. — Microcephalic Brain (convexity). „ 2. „ „ (profile). Flates m. — (AbnormalitleB of Brain development). [between pp. 52 and 53. Fig. I. — Mongol Brain (from pen and ink sketch). „ 2. — Porencephalus. Flate IV. — (Portraits of typical eases), [between pp. 56 and 57. Fig. I. — Microcephalus. „ 2. — Hydrocephalus. „ 3. — Double athetosis. „ 4. — Sporadic Cretinism. Plate V. — (Portraits of typical cases), [between pp. 56 and 57. Fig. 1. —" Mongol "-Type. ,, 2. — Inherited Syphilis. Plate VI. — (Sporadic Cretinism). [facing p. g6. Fig. I.- — Before Treatment. „ 2. — After Treatment. ILLUSTRATIONS IN THE TEXT. PAGE Fig. I. — Peg-board ■ - . 103 „ 2. — Size-board 106 „ 3. — Form-board . . 106 „ 4. — Graduated wooden rods - - 108 ,, 5. — Domino boards - . 109 MENTALLY-DEFICIENT CHILDREN: THEIR TREATMENT AND TRAINING. CHAPTER I. Historical Retrospect. But little more than fifty years have passed since serious and systematic efforts were first made to improve the condition of the mentally-deficient child. The labours of S6guin, at the Bicdtre Hospital in Paris, gave the earliest impetus to scientific work having for its object (in the words of Esquirol) " the removal of the mark of the beast from the forehead of the idiot." It is true that some essays had been previously made in , France by Itard, Voisin, Esquirol, and others ; and the experiments of Itard on the boy found running wild in the woods of Aveyron (le sauvage de I' Aveyron), of which he published an account in 1801, doubtless contributed materially to a rational understanding of congenital defects of in- tellect. In 1837 S6guin, an old pupil of Itard and Esquirol,, commenced to instruct an idiot child, and after 'gaining some experience at the Hospital for Incurables, he was appointed in 1842 to apply Mentally-Deficient Children. his method to the education of the idiot children of the Bic6tre. About the same date, Dr. Saegert, in BerHn, and Dr. Guggenbiihl, in Switzerland, independently took in hand the ameliorative treat- ment of mentally-feeble children. The conspicu- ous success of the work of Guggenbiihl in improv- ing the condition of cretins by removing them from sequestered and shadowed alpine valleys to the sunshine of the summit of the Abendberg, made a great impression on philanthropists both in Europe and America, and demonstrated, as by an object lesson, the interdependence of physical and mental amelioration. Saegert seems to have laboured somewhat upon the lines of the instruc- tion he had been accustomed to give to deaf-mutes, with such adaptations as were necessary to the case of imbecile children. The school established by him is still carried on at Berlin, though with the disadvantage of being organized as a depart- ment of a lunatic asylum. It was a curious coin- cidence that almost simultaneously in France, Switzerland, and Germany, independent efforts were inaugurated for the benefit of the mentally defective class ; and the year 1842 must be looked upon as an epoch memorable in this matter. Al- though Seguin is entitled to the credit of priority, he himself modestly avers that " at certain times and eras, the whole race of man as regards the discovery of truth, seems to arrive at once at a certain point, so that it is hard to say who is the discoverer." In 1843, however, the merits of Historical Retrospect. S6guin were publicly recognised by the illustrious Voisin, in a paper read by him beifore the French Royal Academy of Medicine. "Already in 1838," says he, " S6guin had published the result of his efforts on behalf of a certain number of pupils, whose condition he has favourably modified. His studies during a later period are entirely unique ; and I do not doubt that the time is not far distant when he will be entitled by his psychological con- tributions to take a distinguished place amongst his contemporaries." Voisin's prognostications were fully justified by the publication, in 1846, of S6guin's magnum opus entitled "Traitement moral. Hygiene et Education des Idiots et des autres Enfants Arrierfis." This book may indeed be regarded as the magna charta of the mental emancipation of the imbecile class. Defining idiocy as "an infirmity of the nervous system, which has for its effect the abstraction of the whole or part of the organs and the faculties of the child from the normal action of the will," he proceeds to divide all cases into two principal classes, those of profound, and those of superficial idiocy. The basis of the treatment which he pro- poses is in the main identical with that which in later works he described under the designation of physiological education. Starting with the axiom that " The education of the senses must precede the education of the mind," he argues that the true phj'siological method of tuition for persons whose nervous system is imperfectly de- B2 Mentally -Deficient Children. velopeil is (i) "to exercise the imperfect organs so as to develop their functions," and (2) "to train the functions so as to develop the imperfect organs." Ingenious devices are described whereby the organs of the senses may be methodically exer- cised, and cases are given in minute detail in which such exercises have been adapted to special incapacities. S6guin himself defines his system as an "adaptation of the principles of physiology, through physiological means and instruments, to the development of the dynamic, perceptive, reflective, and spontaneous functions of youth." In Great Britain some interest had been aroused by the publication, in 1843, of an account by Dr. William Twining of what he had witnessed at Guggenbiihl's institution on the Abendberg. This, indeed, seems to have led to the establish- ment, in 1846, of a small school for imbeciles at Bath, under the management of the Misses White. Articles by Mr. Gaskell (afterwards a Lunacy Commissioner) and Dr. Conolly (the enlightened Superintendent of Hanwell Asylum) upon the work of S6guin at the BicStre, which appeared in 1847, lead to a further practical development in England, and in 1848, Park House, Highgate, the mother institution of Earlswood and of the Eastern Counties Asylum at Colchester, opened its doors for the treatment and training of the imbecile. Dr. Conolly and Dr. Reed acting as its gratuitous secretaries. Meanwhile the New World was closely treacling Historical Retrospect. upon the heels of the Old in the onward march of progress in the education of imbeciles. Early efforts had indeed been made in the most pro- gressive of the United States to benefit idiots by training them in connection with special schools for the deaf, and for the blind ; but Massachusetts was the first to move in specific provision for this class by appointing "Commissioners to inquire into the condition of idiots in the Commonwealth, to ascertain their number, and whether anything can be done for their relief." Dr. S. G. Howe, well known as the successful instructor of the blind deaf-mute, Laura Bridgman, was the Chair- man of this Commission. Their report, issued in 1848, with elaborate statistical tables, led to a grant by the Legislature of 2500 dollars for the establishment of an " experimental school for feeble-minded children ;" and about the same time a private school was opened at Barre, Mass., by Dr. H. B. Wilbur, being " designed for the education and management of all children who by reason of mental infirmity are not fit subjects for ordinary school instruction." In 1851 an " experimental school " was started by the State of New York ; and this subsequently developed into the State Asylum at Syracuse, over which Dr. H. B. Wilbur long and ably pre- sided. The first report of the Trustees so well sets forth the aims and hmitations of training that we are tempted to quote a few lines as follows : — Mentally-Deficient Children. "We do not propose to create or supply facul- ties absolutely wanting ; nor to bring all grades of idiocy to the same standard of development and discipline ; nor to make them all capable of sus- taining creditably all the relations of a social and moral life ; but rather to give to dormant faculties the greatest possible development, and to apply these awakened faculties to a useful purpose under the control of an aroused and disciplined will. At the base of all our efforts lies the prin- ciple that, as a rule, none of the faculties are absolutely wanting, but dormant, undeveloped, and imperfect." Pennsylvania was next in order in establishing a "Training School for Feeble-minded Children." Taking up the private enterprise of Mr. J. B. Richards, a state-aided charity was formed, which under the fostering care of its late Superintendent, Dr. Isaac Kerlin, has become, at Elwyn, a model village for the feeble-minded. The State of Ohio provided for her feeble- minded children in 1857, and the Institution at Columbus, with its splendid stock-farm, is ap- pointed on the most liberal scale, and contains over 800 inmates under the care of Dr. Doren. Connecticut, Kentucky, and Illinois, were also early in the field, having established State Insti- tutions for the feeble-minded between 1855 and 1865. It is noteworthy that all the early Ameri- can Schools were organised on strictly educational lines, the imbecile institution being regarded (in Historical Retrospect. the words of Dr. Howe) " as a link in the chain of common schools — the last indeed, but still a necessary link to embrace all the children in the State." Several additional State Institutions have been founded during more recent years, the most con- siderable being that in the far west for the State of California. No less than 1670 acres of fertile land have been appropriated to this institution, an estate naively described as having " everything on it that the Garden of Eden had, except per- haps the forbidden fruit ! " Western Pennsyl- vania, Winconsin, and North Dakota, have lately established institutions, and many of the older institutions have increased their accommodation. From a report presented in 1898 to the Na- tional Conference of Charities and Correction by Dr. F. M. Powell, we learn that nineteen States now maintain twenty-four public institutions for the feeble-minded (including under this term idiots and imbeciles), and that care is provided for 8492 persons of this class. Of these 2854 are classified in school departments, and 2983 in cus- todial departments, and the number of epileptics is 1208. The estimate that at least 3736 are capable of reproduction emphasizes the necessity of life-long provision for a considerable proportion of the inmates. The State of New York has a special Custodial Asylum at Rome, N.Y., con- taining 327 inmates; and most of the State Institutions have custodial departments apart Mentally -Deficient Children. from the educational, the most complete organ- isation being that at Elwyn (Eastern Pennsyl- vania), which may be described as a village or colony for the various grades of feeble-minded. The present may be a convenient place for comparing the public provision for the education of mentally defective children in the United Kingdom with that in the United States. For many years there was in England only one rate- supported institution — the Metropolitan District Schools for Imbeciles at Darenth, Kent — besides iive charitable foundations (also receiving pay- ment cases), the most considerable being Earls- wood and the Royal Albert Asylum at Lancaster, each accommodating some 600 patients. The present aggregate provision by the charitable institutions is for about 1700 cases ; while the schools at Darenth accommodate 1000. There is also in connexion with the County Lunatic Asylum at Northampton, a separate block for 50 imbecile children ; and special wards for idiots have been set apart at the Hants, Kent and Durham County Asylums, and at the Birmingham City Asylum at Rubery Hill, giving in the aggre- gate accommodation for about 200 patients. At the Middlesex County Asylum there exists a well equipped annex, distinct in all respects from the older buildings for the insane, for 200 patients of the imbecile class. In Lancashire, Winwick Hall has been set apart by the Asylums Committee for 50 idiot boys. Thus the total public provision Historical Retrospect. for young imbeciles as distinguished from the insane may be set down about 3200. In addition the MetropoHtan Asylums Board has accommoda- tion for about 3000 adults — -imbeciles and "harm- less lunatics." It would seem that at present there is public provision in the United States for 8492* of the feeble-minded class. It is stated that the United States Census of i8go, showed a total of 95,609 " idiotic and feeble-minded persons " ; in the 1881 Census for England and Wales, the householder's schedules returned a total of 32,717 "idiots and imbeciles." Unfor- tunately our own census of 1 891 did not furnish any information on the subject, the Commis- sioners having concluded, from the experience of 1881, that the returns as to idiocy and imbe- cility were so defective as not to be worth col- lecting. They calculated in fact that the returns as to persons under 20 years of age ought to be doubled, and on this basis the aggregate number at all ages would amount to 41,940. Special care was exercised in the United States enumeration of " feeble-minded " for the Census, but Dr. Fernaldf estimates some deficiency, and suggests that "taking the country as a whole there are two feeble-minded persons to every 1000 per- sons," and that six per cent, are cared for in * " Care of the Feeble-minded," by F. M. Powell, M.D., Boston, i8g8. t " History of Treatment of Feeble-minded," Boston, 1893, p. 20. 10 Mentally-Deficient Children. special institutions. If we allow for an increase in the number of idiots and imbeciles in propor- tion to the increase of population of England and Wales, we shall have in round numbers 46,000 idiots and imbeciles, and we have seen that the institution provision is for 3200, that is for about 6'9 per cent. But we must remember that whereas in America the majority of the insti- tutions have been built and maintained by State funds, in England the provision is to the extent of more than half voluntary. There is, moreover, reason to believe that the deficiencies as regards the enumeration of idiots and imbeciles is less considerable in the United States' than in the English census, so that much remains to be done, especially by the Poor Law authorities, to bring our own country up to the American standard of state-aided provision for imbecile children. We reserve for a subsequent chapter the consideration of the special instruction for deficient children of late years instituted by the School Boards of London, Leicester, and other large towns. In Scotland accommodation is provided in special institutions for about 400 children, whilst in Ireland there is specific provision only for 80, though no less than 6243 Irish idiots were re- ported in the 1891 census. From an official report by Dr. Bourneville it would appear that in France special provision is made for nearly 1000 " idiot, imbecile, backward, and epileptic children" in the Department of the Historical Retrospect. ii Seine, the establishment at the Bic^tre being the most notable. At a few of the provincial asylums isolated arrangements are made for idiot chil- dren ; but there seems to be no separate educa- tional institution. In the German Empire there are not less than 29 public institutions for men- tally-defective children, besides 15 in private hands. In Switzerland there are 14, public and private; in Denmark* 3, in Sweden 11, and in Norway, 4 containing an aggregate of 450 children. That comparatively poor countries like the latter should do so much for their defective children — and it should be remembered there are in addi- tion special "auxiliary" classes for abnormal pupils in connexion with the public elementary schools — is somewhat of a reproach to ourselves. At any rate the example they set us should be an incitement to further efforts to help those who, without kindly aid, cannot possibly help them- selves. • This enumeration computes as only one the several " Keller Institutions." A list of the more important establishments for mentally-deficient children on the Continent and in America will be found in Appendix. 12 Mentally -Deficient Children. CHAPTER II. The "Feeble-Minded" or Mentally- Feeble Child. Having traced the progress of educational efforts on behalf of' children with mental defect so ob- vious as to mark them as idiots or imbeciles, we must now refer to those less definite cases of men- tal infirmity which, in later years, have been de- scribed under the specific designation of " Feeble- minded." It may be well to explain that according to American usage, this term has long been em- ployed* "to include all degrees and types of con- genital defect, from that of the simply backward boy or girl, but little below the normal standard of intelligence, to the profound idiot, a helpless, speechless, disgusting burden ; with every degree of deficiency between these extremes." Consider- ation for the feelings of relatives has doubtless been the motive for this euphemism, which, how- ever, has not obtained in our own country, where "idiocy" has been used officially to cover the lower grades, and " imbecility " the higher grades of certifiable mental defect. Of late years, how- ever, public attention has been drawn to a class * Fernald, op. at., p. 13. The Feehle-Minded Child. 13 of children who, while not imbecile, present a certain amount of mental deficiency disqualifying them from profiting by the ordinary educational curriculum, and consequently require special modes of instruction. Such children were re- ferred to in the Report (in 1889) of the " Royal Commission on the blind, deaf, and other classes requiring exceptional modes of education," under the designation of "feeble-minded," and this term has thus acquired in this country a special signifi- cance. Under the auspices of the British Medi- cal Association, the Charity Organisation Society, the British Association for the Advancement of Science, the International Congress of Hygiene and Demography, and other public bodies, la- borious investigations have been undertaken by several committees niore or less connected, Dr. Francis Warner being the active conductor of the inquiry. After several preliminary publications a comprehensive " Report on the Scientific Study of the Mental and Physical Conditions of Child- hood ; with particular reference to children of defective constitution ; and with recommenda- tions as to Education and Training," was issued in 1895 by the Committee, Parkes Museum, Margaret Street, W. This Report is stated to be based upon the examination of 50,000 children seen in 1888-91, and of another 50,000 seen in 1892-94. It would appear, however, that whilst 100,027 children passed in groups under the eye of the medical examiner, the number of children 14 Mentally -Deficient Children. individually noted and registered was 18,127, no note being taken of the 81,900 children not pre- senting obvious physical defect, or not reported by teachers as mentally dull. Defects in develop- ment, such as abnormalities of cranium, of ex- ternal ear, of eyelids, of palate, of nasal bones, and of stature, v^'ere noticed in 9777 cases : abnor- mal nerve signs, such as defect in general balance, overacting frontals, corrugation, defective eye movements, defects of balance of head or hand, finger-twitches and lordosis, together with deaf- ness, defective speech, slow response, &c., were observed in 10,355 cases ; low nutrition was regis- tered against 3522 children who were pale, thin, or delicate; and 7391 children were, on report of teachers, entered as mentally dull. Obvious eye- defects were noted in 2929 cases : evidence of rickets (other than cranial) were registered in 244; 811 children were put down as " exceptional," includ- ing 2 idiots, 51 imbeciles, 275 children feebly- gifted mentally, 19 "mentally exceptional" (moral imbeciles, &c.), no epileptics, 5 deaf-mutes, 374 children crippled, maimed and paralysed. Very elaborate tables are given showing the coinci- dence and co-relation of the various classes of defects ; but we must content ourselves with quoting the following estimate from the body of the Report (p. 28) of the co-relation of binary defects in development {two malformations coincident in the same case) in percentages, thus : — The Feeble-Minded Child. " With mental dulness . . 45*7 With low nutrition . . . 3i"o With nerve signs . . . 60*3. " This co-relation is higher than for single defects, and it is remarkable that the number of combined defects was much higher in the case of boys than of girls, i.e., in the proportion of 1240 to 683.* With the exception of " low nutrition " defective conditions are more common in boys than in girls ; though when defects occur they are usually of more serious character in the case of the latter. The general conclusion arrived at with regard to children that require special care and training is that the proportion varies from i*6 per cent, of the first series of 50,000 cases to o'S8 of the second series of 50,000. Putting both series to- gether we get for the 100,000 cases observed a percentage of i'26i as requiring special instruc- tion, but it must be remembered that this propor- tion includes 278 children on the score of physical defects only without signs of mental dulness. Without subscribing to all the conclusions set forth in the Report, it must be admitted that it contains much that is of interest to the physio- logist, psychologist, and educator. Dr. Warner's methods, on which this inquiry was based, were well set forth in an interim report, published in 1893, and from this we extract a few particulars which may interest our readers. The basis of the method is the principle that * 26,287 boys and 23,713 girls were seen in this series of cases. i6 Mentally-Deficient Children. " all expression of nerve states and of mental action, is by movements and results of move- ment,"* and consequently abnormal movements, and even attitudes, may be taken to denote abnormal nerve states or mental action. Cor- related with these are frequently found defects in development and in nutrition ; combinations of the three factors, defects in development, nerve signs, and low nutrition, being constantly met with. Mental dulness is found associated in greater or less degree with these physical abnor- malities, which may consequently be regarded as, at any rate, warning notes of intellectual defect. " It appears that about seven per cent, (of children seen in schools) are mentally dull, and sixteen per looo require special care and train- ing."t Dr. Warner's method of inspecting a school is as follows: — "The pupils are observed as they stand in rank, usually a standard, or a smaller section at a time. The inspector, standing in front of each child, in turn holds a shilling for him to look at, so as to fix his eyes and thus obtain a full face, as well as a profile, view of each side, noting the features separately, the cranium, the expression and muscular action of the parts of the face, the eye movements and other points. The trained observer can read off the points in * " Milroy Lectures," 1892. t Sir Douglas Galton, Times, March ig, 1894. (Estimate based on first series of 50,000 cases). The Feeble-Minded Child. 17 the physiognomy of the individual features and their parts, noting the proportion and form of each. " Having inspected each child in the line, as described, the children are asked to hold out their hands in front of them, and for a moment the action is done before them. The balance of the hand, spine, shoulders, as vs^ell as the arms, hands and fingers, are noted in each case ; finally the observer places his hand on the head, noting the size, form, bosses, &c., and the palate is in- spected in each case. "At each of these stages in the inquiry, chil- dren presenting deviations from the normal, in any particular, are asked to stand aside. The teachers are then asked to present any exceptional or dull children not picked out by the observer. " Each selected child is examined individually, and noted on a schedule form* in which the defect or abnormal size is verbally described, and the teacher's report of the child's mental status is added. The name, age, and standard, of each child is entered, and the number of children seen in each standard is recorded." The systematic application of physical observa- tion to large masses of school children is no doubt capable of shedding much light upon educational problems which have hitherto been regarded too exclusively from the psychological standpoint. To Dr. Warner and his colleagues is therefore * Recording Card now used. See " Report," p. 17. C i8 Mentally-Deficient Children. due much credit for the conscientious labour ex- pended on the inquiry; and it is much to be desired in the interests of national education that Government aid should be accorded to a similar but more comprehensive investigation. It has long been the practice in dealing with imbe- cile children to note in the Institution Case- books the physical as well as mental abnormalities of each case. Seguin, indeed, more than 50 years ago drew attention to the co-relation of such abnormalities, and in 1883 the present writer pubhshed in the Liverpool Medico-Chirurgical Journal, a paper on the Physical Features of Idiocy, tracing the characteristic physical abnor- malities coincident with certain special types of mental defect. These consisted mainly of what are termed by Dr. Warner developmental defects, but which it must be remembered are for the most part congenital, and usually of permanent significance. As -regards the other conditions noted in the report, it must be borne in mind that abnormal nerve signs, low nutrition and mental dulness may be of a more or less tem- porary character, and to a large extent influenced by surroundings, and consequently alterable by training. This consideration, whilst pointing to the utility from the practical standpoint of such observations, also discloses a source of possible fallacy. A class of children accustomed to phy- sical drill will show fewer " nerve-signs " than a class not so exercised, but it would be wrong The Feehle-Minded Child. ig to conclude that the intellectual standard of the former is necessarily superior to that of the latter. So again " low nutrition " may be the result of ill-feeding, or it may be due to constitutional defect. In both cases there may be diminished intellectual activity; but the latter condition is of much more serious import than the former. " Mental dulness " as reported by the Teacher, will be found to be a very varying quantity in proportion to the educational standard aimed at in the particular school, and also in view of the pupil's state of health at the particular period. The prudent medical examiner of children alleged to be defective will not allow himself to be swayed too much by any one class of observations, for it is only by comparing the signs of physical abnor- mality with those of mental defect, educational attainments being well ascertained and weighed in the balance with those of similarly placed normal children of corresponding age, that a right judgment can be arrived at. A comprehensive statistical inquiry, conducted on different lines, was instituted by the Swiss Government in 1897, to determine the number of children of school age weak in mind (faibles d'esprit) either in greater or less degree, those afflicted with physical infirmities, idiots, deaf mutes, and blind ; and finally those morally unfit for tuition in ordinary schools. This investiga- tion, prompted by the Teachers' Associations of Switzerland, seems to have proceeded upon peda- c 2 20 Mentally -Deficient Children. gogical rather than physiological lines, but it is remarkable that in the aggregate the results tally very closely with those obtained in England by a more purely physical method. Out of 490,252 children of school age in Switzerland, 7667 were returned as more or less mentally-feeble, which is equivalent to a percentage of i"5. This does not include the other categories mentioned above, one of which includes "idiots," of the number of whom, however, we have not exact informa- tion. Altogether 13,155 children were returned as suffering from some degree of mental, physical, or moral infirmity. Of the 7667 children returned as' feeble-minded it is stated that 567 already receive instruction in special classes, that 411 are in special establishments, that 104 are in orphan- ages or similar institutions and do not require special treatment ; whilst for 5585 is demanded individual care in a special class or special insti- tution, leaving 534 for whom this is not deemed necessary, and 466 in which no opinion is given.* * " Kesultats du Denombrement des enfants faibles d'esprit en age de frequenter I'ecole," (ime panic). Statisque de la Suisse, 114 livraison, Berne, 1897. Defective and Epileptic Children. 21 CHAPTER III. Defective and Epileptic Children. Public attention having been called, largely through the non-official investigations referred to in the previous chapter, to the existence of a considerable class of children incapable of re- ceiving education on conventional lines, the Lord President of Council (as chief of the Education Department) appointed in December, 1896, a Departmental Committee for the purpose of in- quiring into the existing systems for the educa- tion of feeble-minded and defective children, "not idiots or imbeciles." The reference required them to report "upon the best practical means for dis- criminating on the one hand between the edu- cable and non-educable classes of feeble-minded and defective children, and on the other hand between those children who may properly be taught in ordinary elementary schools by ordinary methods and those who should be taught in special schools," and also "to inquire and report as to the provision of suitable elementary educa- tion for epileptic children, and to advise as to any changes that may be desirable." The Committee consisted of the Rev. T. W. Sharpe, C.B., then Her Majesty's Senior Chief Inspector of Schools; 22 Mentally -Deficient Children. of Messrs. Pooley and Newton of the Education Department ; of Mrs. Burgwin and Miss Douglas Townsend ; and of Prof. Wm. Smith and Dr. Shuttleworth ; Mr. H. W. Orange acting as Secretary. The Committee, under the presidency of Mr. Sharpe, held 28 meetings and examined 46 wit- nesses, in the lists of whom we find the names of Drs. Fletcher Beach, W. S. Colman, Ferrier, Harris, Holm, Kerr, Shuttleworth, Tait, Walmsley and Warner. Information as to the Darenth Schools for Imbecile Children was given by the Clerk to the Metropolitan Asylums Board, by the present and the late Medical Superintendent, and by the Head Schoolmistress. The officers of the other English institutions for idiots and imbeciles furnished a conjoint memorandum in reply to questions sent to them, but did not attend as witnesses. Dr. Alexander of Liverpool also fur- nished a memorandum with regard to the treat- ment of epileptics .at the Maghull Institution. Amongst other witnesses were Sir Douglas Galton, Mr. C. S. Loch, Mr. Penn Gaskell, Mr. Van Praagh, Mr. Knollys, of the Local Government Board, Mr. Scott Lidgett, Miss F. A. Cooper, Miss Sewell and Miss Margaret Hodge. Full information as to the special classes then in exis- tence in London, Leicester, Bradford, Brighton, and Bristol, was derived from personal inspec- tions, and also given both viva voce and in writing by the managers and teachers attached. Several Defective and Epileptic Children. 23 of Her Majesty's inspectors stated their views with regard to these classes. The topics discussed in the report include de- finitions of terms, the descrirition and number of the children referred for inquiry, and the state of the law affecting these. Proposals are submitted with regard to modes of discrimination of defec- tive children ; an examination of the present system of dealing with such children is made, and certain desirable changes are pointed out. The cases of physically defective and of epileptic children are considered. It is remarked that the term " feeble-minded " (used in the reference) is open to the objection that it has come to be applied to all classes of mentally-defective children, including imbeciles ; and it is explained that, as the reference expressly excludes the cases of idiots and imbeciles, "the word ' feeble-minded ' as used in the report de- notes only those children who are not imbecile, and who cannot properly be taught in ordinary elementary schools by ordinary methods." Of such children the Committee approximately estimates the number at i per cent, of the school population. In arriving at this estimate, the experience of the German auxiliary classes, the observations of Dr. Warner in London, and of Dr. Kerr at Bradford, the evidence of managers of certain provincial centres for special instruction, and local inquiries made by several of Her Majesty's inspectors are taken into account. 24 Mentally-Deficient Children. With regard to the state of the law aifecting feeble-minded children, it is pointed out that " if children are not legally provided for as idiots or imbeciles, they are in the same position as any other children during their school life." They are subject to the same laws arid bye-laws relating to school life, but cannot be compelled qua feeble- mindedness to attend special classes rather than an ordinary school. The law relating to imbeciles is briefly stated so far as it affects school authorities in their rela- tions with mentally-deficient children. The public provision for the training of imbeciles in institu- tions being very inadequate, there is a tendency for children of this grade to be sent to special classes where such exist, and it is important that the boundary line between imbecility and mere " feeble-mindedness " be so drawn as to exclude from the classes children so deficient as to be incapable of receiving proper benefit from instruc- tion therein. It is pointed out that there is an essential difference between the modes of training pursued in imbecile institutions and those prac- ticable in public elementary schools worked under the Education Acts. With regard to the discrimination of " feeble- minded " from non-educable children, the Com- mittee recommend that each school authority should appoint a medical officer whose duty it should be to examine every child who, by reason of any mental or physical defect, is not sent to Defective and Epileptic Children. 25 school (as well as those in attendance at ordinary schools, represented by their Teachers as unfit for ordinary instruction) ; and that his certificate should be in the form that the child is either (i) capable, or (2) incapable of receiving proper benefit from instruction (a) in ordinary schools, or (6) in special classes for feeble-minded chil- dren. If incapable of benefit from the latter, the certificate should be in such a form as to render it available for the child's admission (if desired by the parents) to an imbecile institution. Special Classes for Feeble-minded Children. — After reviewing the modes of admission to special classes at present constituted, it is recom- mended that the medical officer of the school authority should receive from the teacher pre- senting the child alleged to be "feeble-minded" a form, duly filled up, containing a statement of the child's attainments, and that after conference with Her Majesty's inspector and the teachers of the child and of the special class, he should make his recommendation to the school authority in the form : — I certify that A. B., not being imbecile, is, by reason of (i) physical, or (2) mental defect, incapable of receiving proper benefit from the instruction in ordinary schools, but capable of receiving instruction in special classes. It is anticipated that with all these safeguards there would be no great difficulty in arriving at or in enforcing a decision ; but in doubtful cases there should be an appeal to the Education De- 26 Mentally-Deficient Children. partment, which " should have at their disposal the services of a medical adviser." It is also recommended that, besides other school records, medical records should be kept of the cases selected for special instruction, and that a regular medical examination should be held of every class, every twelve months, by the medical officer. With regard to school age it is not proposed to admit children younger than 7 to the special classes, as it is thought that infant school teach- ing is in such cases sufficient. But pupils should be retained in the classes up to 14 years of age, school managers having discretionary power, on the recommendation of their medical officer, to provide for suitable cases being kept at school up to 16. Some hints are given as to the special training of teachers, and as to the school hours and time table appropriate to special classes. It is pointed out that, while it is not desired to thrust the "three R's" into the background,, manual in- struction is of special importance in the case of feeble-minded children, and this may partake of the Kindergarten character for younger pupils and of technical instruction for the oldest. The choice of suitable physical exercises adapted to feeble-minded children, especially with a view to their physical defects, is commented on. Such forms as breathing drill and eye movements are particularly referred to. With regard to feeble-minded children residing Defective and Epileptic Children. 27 in districts where, owing to paucity of population, or otherwise, special classes have not been estab- lished, it is proposed to give school authorities powers of boarding-out near centres of instruction — -with the consent of the parents — as in the case of blind and deaf children, one defective child only being as a rule lodged in the same house. In certain cases it is considered desirable to pro- vide for maintenance at institutions, which must be exclusively confined to children under 16 and not contain more than 20 inmates. It is thought that such training-homes might be specially ser- viceable in the case of feeble-minded girls leaving school at 14 and requiring careful preparation for work in the outer world. As regards rural schools, it is suggested that voluntary aid in the special instruction of the one or two feeble- minded children therein should be, as far as practicable, utilised. Children Physically Defective. — With respect to physically defective children, it is recom- mended that they should be admitted to special classes only when chronic ill-health renders them incapable of receiving proper benefit from instruc- tion in the ordinary school. It is not thought right that children of normal intellect should be educated with mentally-defective children simply because of a physical defect which renders their care amongst ordinary scholars a matter of diffi- culty. Epileptic Children.— The number of epileptic 28 Menially-Deficient Children. children is estimated at i per looo, of whom one- sixth are severely afflicted. It is recommended that epileptic children of normal intellect should be left in ordinary schools if the fits are not fre- quent or violent fits do not occur in school, and that teachers be provided with instructions as to the treatment of children known to be epileptic. Feeble-minded epileptics may be received into special classes when the epilepsy is not severe ; and for such cases it may be necessary to pro- vide guides or conveyance between the home and the school. With regard to severe cases, whether mentally feeble or otherwise, treatment in resi- dential homes seems essential, proper classifica- tion being provided. Each house of residence should consist of one floor only, and should not contain more than twenty inmates ; but there may be an aggregation of such homes round an educational centre, as in the colony plan. It is recommended that school authorities should have power both to provide homes and to contribute to voluntary homes which conform to the conditions laid down. Summary of Recommendations — Legislation is suggested so as to provide for the education of feeble-minded children under similar conditions to those laid down in the Blind and Deaf Act, 1893, which is printed as an appendix. School authorities are to be required to appoint medical officers to advise them as to the discrimination of defective and epileptic children ; and, as a Defective and Epileptic Children. corollary, it is recommended that the Education Department, as the supervising authority, " should consider whether a medical adviser should be appointed, whose duty it should be to advise the department on all matters arising out of the education of defective and epileptic children, and to inspect homes and classes for such children when required." The minutes of evidence extend to 283 pages. Although valuable evidence was taken on the financial aspects of the proposed changes, no reference is made to this in the report, which states that with regard to grants, it was under- stood to be no part of the duty of the Committee "to make specific recommendations on this head." It is satisfactory to find that the recommenda- tions of the Departmental Committee have been embodied in an Act of Parliament which re- ceived the Royal assent in August, 1899. The Act (known as the "Elementary Education [Defective and Epileptic Children] Act, 1899,") is permis- sive only, but it will enable school authorities to obtain grants from public money towards the education of defective and epileptic children, subject to " such conditions as may be directed by or in pursuance of the minutes of the Educa- tion Department in force for the time being." The period of education for such children is ex- tended until the age of sixteen years, and pro- visions are made for boarding out when necessary 30 Mentally -Deficient Children. either in families, or in certified schools, and for the school authority supplying, in cases requiring them, guides or' conveyance. As we propose to print the text of the Act as an appendix,* it is unnecessary here to refer to its clauses in detail, but we may briefly mention some of the points in which its provisions differ from the recommenda- tions of the Committee. No requirement is made as to the appointment of Medical Officers either by school authorities or the Education Depart- ment, but it is enacted (Sect, i., 3) that to bring a child within the purview of the Act " a certificate by a duly qualified practitioner, approved by the Education Department shall be required in each case." Parents may demand the examination of children with a view to their admission to special classes, and also to their transfer to ordinary classes in public elementary schools. Resident schools are limited to four buildings, each build- ing to contain not more than fifteen children. • See Appendix A. special Instruction. 31 CHAPTER IV. Special Instruction. Though much attention has been given in Eng- land of late years to the class of defective children who may be called sub-normal, rather than im- becile or idiotic, (and might with advantage be called " mentally- feeble," rather than "feeble- minded," in order to avoid the ambiguity attach- ing to the comprehensive use of the latter term in America), German and Scandinavian countries have been in advance of us in organising prac- tical arrangements for their training. So far back as 1863 there seems to have been established, at Halle, an auxiliary class (Hilfsklasse) for pupils found incapable of following the ordinary ele- mentary school curriculum ; and in 1867 a similar class was established at Dresden. Leipsic and Brunswick followed; and gradually auxiliary schools (Hilfschiilen) grew out of the classes. Herr Kielhorn, well known as the director of the Brunswick auxiliary school (established in 1881), gave an account in 1894 of 32 auxiliary schools, consisting of no classes, with a teaching staff of 115, established in various parts of Germany. Herr Wintermann,* of Bremen, was able to sup- • " Berichten uber den ersten Verbandstag der Hiilfschulen Deutschlands," 1898. 32 Mentally-Deficient Children. plement this statement in 1898 by the informa- tion that at that date auxihary schools existed in 52 German towns, consisting of 202 classes, and containing 4281 children (2400 boys, 1881 girls) under instruction by 225 teachers. A later esti- mate states that there are probably not less than 6000 children receiving special instruction within the limits of the German Empire. It is claimed that many children considered hopeless in the ordinary schools have been enabled by the special instruction given them to follow useful practical careers ; and the large extension of the auxiliary schools above noted is, in a practical country like Germany, perhaps the best testimony to their success. In the Scandinavian countries also, in addition to the boarding establishments for imbeciles pre- viously referred to, day classes for the instruction of "abnormal children" have for more than 20 years been established. In Christiania and in Bergen they are under the direction respectively of Herr Karl Lippestad and of Herr Soethre, both experienced in the methods used at the neighbouring imbecile institutions. In addition separate classes for merely backward (not neces- sarily defective) children are organised in con- nection with two of the largest elementary schools in Bergen. In Copenhagen various grades of. defectives are received either in day classes or in residential institutions, as may be necessary, in the chain of establishments organised and special Instruction. 33 supervised by Dr. Keller, which are now in course of being adopted by the State. The arrange- ments for the instruction of teachable cases are very complete, and the ratio of teachers to taught very liberal, the classes usually consisting of not more than 8 or 10 pupils. Stress is laid upon physical and manual exercises, and the pupils not fit to return home after school training are drafted to working institutions, of which there are several grades. Farm work and other occupations such as brush, broom, and basket making are followed by the older boys. The older girls are employed in dairy and laundry work, as well as in a variety of home industries, such as weaving cloth for dresses, curtain material, &c. For some, situa- tions in domestic and dairy service are found, and it is said of the girls whose career is carefully watched that " very few turn out badly." Before describing in some detail what has been done in our own country, we may note with satis- faction that the movement in favour of " special schools " for sub-normal children is spreading to Belgium — (Brussels has set apart a Communal School for this purpose)— to Austria, to Switzer- land, and (if the advocacy of Dr. Bourneville has the success it deserves) to Paris and France. In Italy there has lately sprung into existence a " National League for the protection of deficient children," under the presidency of Signor Guido Baccelli, Minister of Public Instruction, and one of the first fruits is the opening in Rome of a Day D 34 Mentally-Deficient Children. School for such. In America the matter is under discussion, and a beginning seems to have been made in connexion with the pubHc school system of Springfield, Massachusetts. In England, priority in the actual opening of a Special Class belongs to Leicester, that having been started by the School Board in April, 1892. On March 5th, 189 1, the School Board for London instructed a committee to consider the advisability of carrying out the recommendation of the Royal Commission previously alluded to, which ran as follows: — "That with regard to feeble-minded children, they should be separated from ordinary scholars in public elementary schools, in order that they may receive special instruction." The result was the establishment, in the following year, of " Schools for Special Instruction " of children who, by reason of phy- sical or mental defects, could not be properly taught in the ordinary standards or by ordinary methods ; and Mrs. Burgwin was appointed or- ganising Superintendent. Under her able direc- tion upwards of 50 centres of special instruction have up to the present time been established, chiefly in the poorer districts of the metropolis, and there are now more than 2000 children on the roll — a number constantly increasing. The Board have wisely ordained that no more than 20 children be assigned to each teacher; and in practice the classes are even smaller than this. The ratio of pupils is, indeed, much larger special Instruction. 35 than that which obtains in the Scandinavian schools, where one teacher is provided for every ten pupils ; but the Superintendent utilises to the utmost the teaching force at her command by a well-devised time table. It may be remarked with regard to this that though the ordinary school nomenclature of studies is retained (as in the case of the so-called "3 R's") much more than the ordinary instruction is included, sen- sorial and manual training and objective methods of demonstration being much resorted to. The " occupations," which form an important part of each day's work, are especially adapted to the varying capacities or incapacities of individual pupils ; and the results, as evidenced at annual . exhibitions of the products of manual training in the London Board Schools generally, are most encouraging, and in some cases surprising. It may be stated, indeed, that at these exhibitions the array of work by children in the special classes creditably holds its own, side by side with that of the normal children. The selection of pupils for these classes is now made by Medical Officers appointed for the pur- pose in conjunction with the Superintendent of Special Instruction. Candidates are periodically presented by the Head Teachers of elementary schools around a centre, a schedule being fur- nished with each child, setting forth its school attainments, observed peculiarities, and other par- ticulars ; and each group of children is usually D2 35 Mentally-Deficient Children. accompanied to the centre by a teacher capable of supplying supplementary information. The child being placed as much as possible at its ease, the examination usually begins by a study of its physical characteristics. Observation is made of the general bodily conformation and development in relation to constitutional conditions and nutri- tion, of the form and size of the head, of the shape of the palate, of any abnormalities of the features (open-mouthedness being specially noticed in re- lation to adenoid growths), of the form, flexibility and pose of the hands, and of the presence or absence of nervous movements, whether of the face, forehead or fingers. Such physical abnor- malities as are observed should be carefully noted, for they have their significance, but the diagnosis is not to be based on these alone. In con- junction with them comes the consideration of the schedule of school attainments which it is desirable in many instances to verify, not so much to test its accuracy as to ascertain the rate of response and the mode of mental action of the child. Experience shows that a certain set of physical characteristics are usually asso- ciated with a certain corresponding set of mental manifestations. As we shall see later when study- ing the more pronounced types of imbecility, cer- tain physical features, such as those of cretinism, of microcephaly, and of the so-called "Mongol" conformation go pretty constantly with distinct varieties of mental abnormality; and so it is. special Instruction. 37 though of course in a less striking manner, with varieties of " feeble-mindedness " which differ rather in degree, than in kind, from the graver abnormalities. In many cases, indeed, the types may be mixed — e.g., there may be a blend of the characters of rickets and of scrofula — but the landmarks of each may be discerned. Given a marked departure from the normal in formation or development, or in the action of the nervous system, some irregularity of mental action may be predicated, and the teacher's record of educa- tional failings is thus confirmed and accounted for. Without such physical confirmation — and it is not pretended that it is met with in every case . — closer scrutiny must be given to the heredity, circumstances, and surroundings of the child. Parental neglect is unfortunately a frequent factor of mental dulness,: defective or injudicious feed- ing, unwholesome home surroundings and moral mismanagement all tend thereto. This may be termed acquired, as distinguished from original, mental deficiency, but the educational result, inability to keep up with average children of similar age, is the same. Such cases, indeed, would seem to fall under the category contem- plated in the new Act* of children who "by reason of mental or physical defect are incapable of receiving proper benefit from the instruction in the ordinary public elementary schools." As the result of medical examination the candi- * 62 and 63 Vic, c. 32, cl. 1. 38 Mentally -Deficient Children. dates presented are divided into three classes, viz : — 1. Those requiring special instruction. 2. Those capable of continuing in the ordinary school. 3. Those whose mental condition is too low for instruction even in special classes. These last are excluded with a recommendation to their friends to obtain admission for them into an institution for imbeciles. There is unfortunately sometimes prejudice in the minds of parents against the attendance of their children at the special schools, as stamping them with inferiority. The new Act recognises parental rights in sub-section 5 of section 2 which compels school authorities to "make provision for the examination from time to time of any child dealt with under this section in order to ascer- tain whether such child has attained such a mental and physical condition as to be fit to attend the ordinary classes of public elementary schools," and if the parent so request this re- examination must be made at intervals of not less than six months. The London School Board has already made provision for the periodical examination by the medical officers of all children attending the special classes ; on their report, which is of course based to a large extent on information as to progress furnished by the " special " teachers, improved cases are sent back to the Mentally-Feeble Children. 39 ordinary elementary schools. Degenerating cases have from time to time to be excluded as imbe- ciles ; and, in such cases, it would seem very desirable that some easier way should be devised for admission into rate-supported institutions than is at present provided by the Poor Law. The imbecile, rejected by the special school, has practically to pass through the procedure pre- scribed for the pauper lunatic before he gains admission to an institution like Darenth ; and parents are thus deterred from placing their un- fortunate offspring in a place of safety. A few private educational homes, in which are received children of the better social class who are so far deficient or irregular in mental develop- ment as to require special modes of education, have of late years been instituted ; and as, in many cases, the mental dehciency or irregularity is intimately connected with physical abnor- mality, skilled medical supervision of such edu- cation is an advantage. It is obvious that a child whose mental deficiency or nervous pecu- liarity is but slight, will have a better chance of improvement when educated with those of similar mental calibre, than if subjected to hopeless competition with normal children at an ordinary school, or on the other hand, exposed to the de- pressing influences of an institution where idiots are received. In addition to special arrangements organised by school boards, certain philanthropic agencies 40 Mentally -Deficient Children. have since i8go established small in^iustrial homes in various parts of the country tor the em- ployment, under judicious supervision, of feeble- minded adolescents. In i8g6 the National Association for Promoting the Welfare of the Feeble-Minded was formed with the object of co-ordinating the scattered efforts that had already been made, and arousing a larger share of public interest in the necessities of the case. It has also established in the neighbourhood of the metropolis four homes, two for girls and one for boys beyond school age, and a school home for younger children. Altogether there are now in England no less than fifteen homes of this class particulars of which will be found in an appendix. A few illustrative cases giving an idea of the class of children to whom the designation of " feeble-minded " or " mentally-feeble " may ap- propriately be applied, may help to elucidate the subject. Such children are also described as " backward," or of " retarded mental develop- ment " — terms corresponding to the " Enfants arri6r6s" of French writers, the " geistig-Zuriick- gebhebene" of the Germans, and the "Tardivi" of the Italians. Case I. — A child of highly intellectual parents is noted to be somewhat delicate in babyhood, but no suspicion of mental abnormality is enter- tained by his parents, until at two years of age it is found he uses only a few monosyllabic words, Mentally -Feeble Children. 41 and does not try to construct sentences for him- self, though he can perfectly well repeat what is said to him. He frequently, indeed, repeats ques- tions put to him instead of replying to them, thus showing that the defect is not of hearing, but of understanding. Much care and patience is exer- cised by an intelligent mother, with the result that at four he speaks fairly well, though with thick utterance. Home education is carried on till he is seven years of age, but a brother two years younger is almost two years in advance of him in elementary studies. He is then sent to a kindergarten for morning lessons ; he takes in- terest in. the songs and in simple musical drill, does paper-folding, stick-laying, mat-weaving, and bead threading in series of number and colour. His interest, however, soon flags, and he is apt to repeat the same question again and again, as if not attending to the answer. In calculation he makes but little progress, and with difficulty masters the simple rules of arithmetic. By dint of individual instruction, he attains, by the time he is ten years of age, the power of reading, though in a monotonous style, easy stories in a primer, writes copies in texthand, and plays simple exercises on the piano. There is, how- ever, still a marked childishness of manner, a thick articulation and staccato utterance, and a tendency to repeat questions in a meaningless way. His bodily development has improved, and his only sensory defect is an error of refraction 42 Mentally-Deficient Children. corrected by spectacles. Some twitching move- ment is noticeable in the muscles of the fingers, especially under excitement ; but otherwise mus- cular control is fairly good. Under drill, regu- lated muscular exercise, manual training and varied but brief school lessons, considerable im- provement is proceeding, and he is a steady worker in garden and good at Sloyd work. Case II. — A fairly well-grown, well-nourished girl of thirteen. Head 21 inches, forehead " bossy." Palate high and narrow. On extend- ing hands fingers assume a nervous pose, and there are occasional finger-twitches. Twitching also occurs about the corners of the mouth, and there is a tendency to frontal corrugation. History. — Mother nervous and in ill-health during pregnancy. Child used to start up un- easily when infant, and from seven to eight had "night terrors." Now sleeps uneasily at times. Has never had fits. The habits have not always been clean but are so now. Was carefully taught at home and for a time sent to boarding-school, which however she had to leave in consequence of threatening of chorea. Can read from primer fairly. Writes from dictation shakily. Adds and subtracts imperfectly and with effort. Is fond of needlework. At times shows destructive tenden- cies. Under special instruction for three years has lost many of her nervous movements, with the aid of regulated drill. Has improved in read- ing and writing, but it is found unwise to press special Instruction. 43 her in arithmetic as this brings on twitching and restlessness at night. She has made considerable progress in a variety of manual work, including Sloyd and gardening, and does much useful sewing and fancy work. Case III.— A bright looking gentlemanly little boy of nine ; parents had financial anxieties which worried mother before his birth. As an infant showed weakness of back, and was long in learn- ing to walk. Had whooping-cough when fourteen months old, and was worse after this, having occasional "falling attacks" {■pvohahly petit mal). Speech retarded, but now fairly good, and when not deterred by shyness, chatters volubly on a variety of subjects. The head circumference measured nineteen inches ; the frontal region tapering to a median ridge, the left side of head smaller than the right. The occipital region fairly well developed. There seems to be some slight want of power on right side of body, as compared with left, and he cannot hop on right leg. Hands when held out droop, and there are some twitching movements of fingers. He is thin, though his appetite is good and he is judiciously fed. Had attended a kindergarten class for two years, but had learned very little ; could not count at all. For two years subse- quently he was in an institution for imbeciles, where he made but little progress, and seemed very nervous when with children worse than him- self. During the last year has had special 44 Mentally -Deficient Children. instruction with a few other mentally-feeble children, under medical supervision, and is now beginning to read, write, count, model in clay, and work usefully in the garden.^ His cranial circumference has increased ij inches during the last four years, and the forehead has developed notably. (The following are examples of cases presented for " Special Instruction " from London Board Schools). Case IV. (Microcephalic type). — F. D., aged seven years, seven months. Small for age, fairly nourished, well-limbed. Senses perfect. Head small with narrow forehead, tapers towards ver- tex, circumference ig inches. Palate high and narrow. Epicanthis. Mouth breather. Hands well extended. Has attended infant school three years. Knows letters, and can form O, A, I, T. Cannot count correctly, and says that he has three eyes, a dog six legs, &c. Requires special instruction, but should have more manual than mental work, as he seems subject to headaches. Should be examined for adenoids. Case V. (Hydrocephahc type).— A. M., aged eight and a half. A feeble looking boy with large globular head, measuring 2i\ inches, and right internal squint. Had fits up to five years of age and consequently did not attend infant school. Now free from fits, but unsteady in gait and has finger twitches. No educational attainments, but answers questions with fair intelligence. special Instruction. 45 Knows number and names of brothers and sisters, address of home, his own age, &c. Re- quires special instruction. Case VI. (Scrofulous type). — E. M., aged ten. A pleasing looking girl with long dark eyelashes and nice hair. Head 20 inches. Has scars on neck from glandular abscesses, and minute cor- neal opacities from old phlyctenular inflamma- tion. Has had hiprjoint trouble but no active symptoms now. Owing to delicacy has been irregular in school attendance, and is very back- ward for her age, being able to read only small words, to write her name, and to work simple addition sums. Requires extra care, physical and mental, and would benefit by special instruction for a period. Case VH. (Syphilitic taint). — M. O., aged twelve. A dull looking girl with dusky com- plexion. Head 21 inches. Radiating lines around mouth. Teeth " peggy." Sight of right eye destroyed by interstitial keratitis, some opa- city of left, but fair vision. Slightly deaf. Seems to have been almost stationary the last two years. Is excitable at times, but generally slow in reaction. Reads from primer in drawling way. Writes untidily. Can add and subtract a little. Unfit for ordinary standards, but may learn some manual work in special instruction class. Case VIII. (Neurotic type).— K. R., a bright- looking but restless girl of 9. Head igf inches in circumference. Tendency to epicanthis. Palate de- 46 Mentally-Deficient Children. formed by alveolar hypertrophy. Hands extended in nervous pose, with semi-flexed wrists, and semi bent fingers with difficulty kept still. Has been several years at school, but still in preparatory standard. Knows most of the letters and some small words and guesses others : forms O, A, T, &c., but fails in writing simple words (At, to, &c.) : adds units very much at random. Speaks hur- riedly. Attention wandering. Requires special instruction. (The following have been under special instruc- tion for a time). Case IX. (Paralytic type). — L. O., aged 13, 3 years in special school. Head igf inches in circum- ference, palate saddle-shaped ; some want of power of left side, with athetosis of left fingers. Articu- lation poor. No school attainments when ad- mitted, but has learned to read small words, to write fairly well in the lines of a copy-book, and to add a little. Does good macram6, and is working well in the laundry class. Case X. (Mongoloid type). — P. W., a fairly grown girl of 12, with obliquely-set eyes, rough and ruddy skin, tongue with shallow transverse fissures and broad short-fingered hand and in- curved little fingers. After 3 years' special in- struction has learned to read in second standard book, to work addition and subtraction sums and to write from dictation. She is also progressing at laundry and cookery classes. When admitted at age of 9, incapable of standard work in girls' school : now fit to join second standard. special Instruction. 47 Case XI. (Sporadic cretin). — A. S., aged 14, admitted 4 years ago to special school, being unfit for ordinary school in consequence of physical and mental abnormalities characteristic of cretin- ism. During the last three years has had thyroid treatment at Children's Hospital, and has nota- bly improved. From being an inert dwarf with baggy cheeks and protuberant abdomen, he has become an active (somewhat mischievous) boy of bright expression and slender figure, and has grown 8 inches (from 393- to 473-) in last two years. Now knows the letters and figures : can write his name and add a little ; having originally been absolutely incapable of educational attain- ment. Case XII. (Choreic type). — G. W., aged 13, 3 years in special school. When admitted, vacant in expression and school attainments almost nil. Twitches noticeable in extended fingers and about angles of mouth. Though his mental condition is still variable, dull at times and bright at others, has made considerable progress, and draws and paints in oil admirably. 48 Mentally -Deficient Children. CHAPTER V. Pathological Classification of Forms of Mental Deficiency. As has been stated in the preface, it is not in- tended in the present work to do more than glance at the pathological aspects of the subject. Those interested in these aspects will find in the well known textbook by Ireland,* in the various volumes of "Recherches" by Bourneville,t and in an article by Fletcher Beach, in Hack Tuke'sJ " Dictionary of Psychological Medicine," much that is valuable. We must content ourselves by stating facts in pathology which will be service- able in classifying cases. And first we remark, that in connection with mental deficiency we find two main divisions of cerebral abnormality, (a) that arising from formative or developmental defect, and (6) that resulting from inflammatory or degenerative processes. Each class of abnor- mality corresponds of course to the broad primary classification of cases of mental deficiency into {a) • " Mental Affections of Children," W. W. Ireland, 1898. f " Recherches sur I'Epilepsie, I'Hyst^rie, et I'ldiotie," Paris. l8go, et seq. J See also article on " Idiocy " in Clifford AUbutt's " New System of Medicine," vol. viii. PLATE I. Comparative Cranial Contours. FiQ. 1. Microcephalic Contours. Fiq. 2. Mongol" Type Contours. Fig. 3. Hydrocephalic Contours. Pathological Classification. 49 Congenital, and (6) Non-congenital. There is, however, a mixed class of cases, in which the actual lesion supervenes upon a brain originally imperfect in development, and to such cases, occurring at a crisis of early life, has been given the name of developmental. The extent of the cerebral abnormality, whether original or ac- quired, may a priori be expected to bear some proportion to the degree of mental defect, and this is usually the case, though it is necessary to bear in mind that microscopical as well as macro- scopical constitution of brain tissue must be taken into account, and that certain portions of the brain are of more importance {qua intelligence) than others. Of congenital abnormalities the most striking is microcephalus. In its extreme form it is cha- racteristic of a low type of idiocy, in which have been traced simian and even theroid resemblances. There are a series of gradations rising through idiocy and imbecility to simple " feeble-minded- ness," which is not unfrequently associated with small-headedness. Microcephalus, however, does not depend solely upon diminutive size of head, as ascertained by measurement ; and in our opinion* the limitation of the term proposed by some to cases in which the cranial circumference does not exceed seventeen inches, is scarcely scientific. There is a characteristic form,t as * Ireland, op. cit., p. 8g. t See Plate I., fig. i 50 Mentally -Deficient Children. well as size, of microcephalic heads ; such, for example, as a narrow, rapidly receding forehead, a somewhat pointed vertex, and a flat occiput. Though of course the frontal and parietal lobes are on a small scale, it is in the occipital and temporo-sphenoidal that we usually find the most striking evidence of arrest in development. This is well shown in the case of a microcephalic girl of fifteen, formerly under the care of the author at the Royal Albert Asylum, whose brain was fully described by him in the "Journal of Mental Science," for October, 1878. A view of the con- vexity of the brain, and a diagrammatic sketch of the convolutions, is appended (Plate II., figs, i and 2).* A still more remarkable case ("Freddy"), for twenty years under the author's observation at Lancaster, has recently been anatomically reviewed by Dr. Telford Smith and Professor Cunningham, of Dublin. t His brain, when recent, weighed only 12^ ounces ; the convolutions were simple, though fairly distinguishable in the anterior lobes, but became rudimentary poster- * Description of Plate II. — Fio. i. — General view of Micro- cephalic Brain seen from above. A. Paiieto-occipital fissure. B. Horizontal fissure. C. Ascending limb of Sylvian fissure. D. Fissure of Rolando. Fio. 2. — Semi diagrammatic view of Microcephalic Brain, showing general arrangement of convolutions (light side). F.R. Fissure of Rolando. P.O. Parieto-occipital fissure. F.S. Fissure of Sylvius : i. Horizontal limb ; 2. Ascending limb. I.R. Island of Reil. f Trans. Roy. Dublin Society, vol. v., ser. 2, part viii. Pathological Classification. 51 iorly, the occipital and temporo-sphenoidal lobes being indeed very imperfectly developed. This "Aztec "-like youth,* who had large bright eyes, an aquiline nose, and somewhat receding chin, manifested good powers of observation, but was only able to express himself in a few monosyllabic words. He had considerable will power, and though it was found impossible to train him to much that was useful, he was in no sense a low grade idiot. We have repeatedly seen boys and girls with heads measuring only ig inches, taught to read and write, and to do industrial work. Quality of brain is an important factor, as well as quantity, and in cases of microcephalus what little there is is usually fairly active. Defects of the corpus callosum and partial atrophies affecting only portions of the brain, are occasionally met with. Thus in the autopsy of a hemiplegic imbecile, who died at twenty-one years of age, a gap four inches in length was found extending from the anterior part of the right frontal lobe nearly to the occipital, leaving the orbital plate uncovered, and disclosing part of the cavity of the lateral sinus (see Plate III., fig. 2). Internally, a narrow ridge, marked by convolu- tions, separated this gap from the longitudinal sinus; and between it and the temporo-sphenoidal lobe was seen standing out, quite uncovered by convolutions, part of the caudal nucleus. The brain weighed 325- ounces. This defect was pro- » See Plate IV., fig. i. E 2 52 Mentally -Deficient Children. bably in the nature of an arrest of development, as there was no cicatricial tissue to be made out, and no descending sclerosis of the spinal cord. The mother gave an account of fright and injury in consequence of being knocked down by a cow about the sixth month of pregnancy. The patient had his left arm and hand smaller than the right ; his senses were normal, his speech indistinct, but he was able to use ordinary sentences. He made himself very useful, and could clean shoes well. A rare case of atrophy of the cerebellum was discovered at the autopsy of an imbecile girl of 15, who died at the Royal Albert Asylum of phthisis. As no marked ataxia or inco-ordination had been noticed during life, it was with some surprise that a merely rudimentary condition of the left lobe of the cerebellum was observed (see Plate II., figs. 3 and 4). This was represented by a papilla no larger than the nail of one's little finger, and the vermiform process was a minute nodule obscurely marked with laminae ; whilst the right lobe which constituted the main portion of the cerebellum was only half a square inch in superficial area, and only a quarter of an inch in thickness at its base. This lilliputian lobule had, however, the normal laminated appearance and structure. The pons was indicated by only a few transverse fibres. With the exception of the cerebellum and its peduncles, the rest of the encephalon (which weighed 42 ounces) and the cranial nerves appeared to be normal. In this PLATE II. Fig. 1. Microcephalic Brain. 'Convexity) Fig. 2. Microcephalic Brain. (Profile). Defect of Cerebellum PLATE III. FiG. 1. Mongol Brain. (From Pen and Ink Sketch}. . -4 t "X, '~^'- '■^ \/ ) ^ ."■ "S Fig. 2. PORENCEPHALUS. Pathological Classification. 53 case there was considerable feebleness of body as well as of mind, as the girl suffered from a pro- tracted illness (phthisis), but the gait was by no means characteristic of cerebellar abnormality. Congenital cases of hydrocephalus are not in- frequently met with ; though of course the condi- tion is also non-congenital. Very different degrees of mental enfeeblement are met with in this type, and it is remarkable that a considerable amount of intelligence may subsist with a very watery brain, as in the case of a girl of eleven, peculiar but only slightly imbecile, who continued to con- verse rationally till within an hour of her death, when it was found that her large globular skull* contained 20 ounces of fluid to 36 of cerebral matter ! In other cases optic neuritis and signs of ■ pressure occur, and convulsions usher in a fatal termination. As a rule, indeed, it is only in cases where active symptoms have subsided that educational methods are admissible, and Plate IV., fig. 2, is that of a hydrocephalic youth, with head circumference of twenty-three inches, in whose case the chief residual indication of defect was in the direction of moral imbecility. Another frequent congenital type, obtaining perhaps in nearly five per cent, of mentally- defective children in greater or less degree, is that which has been designated "mongol" or "kalmuc," owing to physiognomical resem- blances to those races. In these cases the skull * See Plate I., fig. 3. 54 Mentally -Deficient Children. is a short oval,* the transverse and longitudinal diameters approximating, and there being a tendency to parallelism of the frontal and occipi- tal planes. Children of this type have a skin coarse in epidermis, if not furfuraceous ; many have sore eyelids ; some fissured lips ; but one of the most striking peculiarities is the state of the tongue, which is transversely fissured, and has hypertrophied papillae. t Many of them have almond-shaped eyes, obliquely set ; and this fea- ture, with the squat nose and wiry hair, gives the Mongol aspect from which they derive their name. The hands are usually broad and the fingers short, and often the little finger is incurved. The feet also are characteristically clumsy. There is reason to believe that they are essentially un- finished children, and that their peculiar appear- ance is really that of a phase of foetal life. Some defect of formative force may usually be traced in connection with the intra-uterine life of these cases, not uncommonly ill-health or mental depression of the mother ; and it is remarkable that nearly half of these children are the last born of a long family, when the procreative powers are at a low ebb. In many there is a family history of phthisis ; and the majority die, before reaching adult life, of tubercular disease. In children of this type the brain is not necessarily small, but it is characterised by great simplicity of develop- * See Plate I., fig. ^. t See Plate V., fig. i. Pathological Classification. 55 ment, and by paucity of multipolar cells. The convolutions are large and coarse, and there are no secondary convolutions.* " Perhaps two-thirds, or even more, of all idiots are of the scrofulous constitution," says Dr. Ireland ; and consequently we are not sur- prised to find various scrofulous lesions in the majority. In some, indeed, the history, personal and hereditary, of scrofula points to the consti- tutional taint as the main cause of the mental condition. Strumous glands and ulcers ; tuber- cular affections of joints and serous membranes are of course frequent accompaniments of this variety. Amongst other pathological conditions some- times met with, dating from birth, are those resulting from meningeal haemorrhage occurring from undue pressure during parturition. In these cases atrophic changes take place in the Rolandic area, and as a consequence ensue spastic contra- tions of the limbs, with inco-ordination and athe- toid movements. The intellectual deficiencies of children suffering from " birth-palsies " are more apparent than real, the intelligence which they possess being masked by their physical infirmities. Cretinism may here be alluded to as a congeni- tal taint, though its full development in many cases takes place after birth, producing mental deficiency. Intra-uterine cretinism fully developed results usually in the death of the foetus, which • See Plate III., fig x. 56 Mentally-Deficient Children. displays a curious stunted conformation of body, with redundant skin, thickened cranial bones, and imperfectly formed face. The essential lesion is absence or atrophy of the thyroid gland, and there are often found fatty tumours in the supra- clavicular regions. Cases of sporadic cretinism usually met with in this country differ from the above in the fact that the child appears normal at birth, but the characteristic conformation and mental hebetude are gradually developed. Pro- gressive atrophy of the thyroid brings about a dwarfing of the physical growth and of the mental powers, and if the patient arrives at adult life he still retains the bodily and mental stature of the child (see Plate IV., fig. 4). The satisfactory results of thyroid treatment in these cases will be hereafter set forth. In addition there remain a group of cases in which mental deficiency dating from birth may be said to depend upon a highly neurotic here- dity. It is probable that in such cases there is a tendency to minute discharging lesions, and an imperfection of those inhibitory arrangements which in the normal child are gradually evolved. This, however, is perhaps a matter of psycho- logical rather than of pathological interest. We have now traced the prominent patholo- gical conditions of the several typical varieties of Congenital Mental Deficiency, viz. : — I. MicrocephaluS; and other formative cere- bral defects. PLATE IV. FlQ. 1, MrCROCEPHA Fig. 2. Hydrocephalus FlQ. 3. Double Athetosis Fig. 4. Sporadic Cretinism. Girl, age 20. PLATE V. 1. " Mongol" Type, Fig. 2. Inherited Syphilis. Pathological Classification. . 57 2. Hydrocephalus (congenital). 3. "Mongol" or "Kalmuc" type. 4. Scrofulous cases. 5. Birth-palsies with athetosis. 6. Cretinism (congenital). 7. Primarily neurotic. In the intermediate group of cases, which we have referred to as developmental, we include those forms of mental weakness which evidence themselves at some crisis of development, such as the first or second dentition, or the epoch of puberty, though traceable to an original defect of nervous constitution. Eclampsic, epileptic, syphilitic, and some post-febrile cases, may be thus classified. A large number of cases of mental deficiency are attributed by parents to convulsions during dentition. Thickened cerebral membranes, some- times thickened skulls, are seen in many of these cases, with consequent atrophic changes in the brain substance. In cases of persistent epilepsy, with mental weakness, the same class of lesions is sometimes met with, though of course the fans et origo mali is to be looked for in the minute structure of the nervous tissue. Syphilitic cases are comparatively rare, and mental deterioration does not usually show itself until the period of second dentition. The stig- mata of inherited syphilitic taint may, however, generally be detected ; such as specific skin af- fections in infancy, radiating scars around the 58 Mentally -Deficient Children. mouth, and in a certain number of^cases, Hutchin- sonian teeth, or at any rate teeth of the " cork- screw " type. Death usually occurs in a few years after the onset of the symptoms, which pro- gress much in the manner of general paralysis of the insane, and at the autopsy we find thickening of the cerebral arteries (from endoarteritis), and of the meninges, with marked atrophy of the con- volutions. (Plate v., fig. 2, represents this type). Of clearly non-congenital cases the main divisions are traumatic and post-febrile, and in each the characteristic lesions are the products of inflammatory processes. Dr. Wilmarth,* for- merly the pathologist of the large Pennsylvania Institution for Feeble-minded Children, states that in 100 consecutive autopsies made by him, he found in 54 conditions " constituting the resi- dual effects of former disease or traumatism." In a large number of cases sclerosis with atrophy was observed ; in a few the sclerose tuhereuse of French writers. Thickened and adherent mem- branes, following meningeal inflammations and interfering with the. due supply of blood to the cerebral cortex were noticed in a considerable number of cases ; whilst porencephalus, which may be considered in some instances to be the terminal condition of acute inflammatory lesion, existed not unfrequently. Emotional shock, such as fright to a young * " Causation and early Treatment of Mental Disease in Chil- dren." yournal American Medical Association, August, 1894. Pathological Classification. 59 child confined in a dark cellar, or from the bite of a dog, is sometimes assigned as a cause of mental defect. How the nervous tissue is affected by shock is not easy to explain, but trophic changes, brought about by the sympathetic system, are probably important factors. At any rate cerebral atrophy, as if from arrested development, is found in some of these cases. Toxic cases, such as those of infants drenched with alcohol or nar- cotics, are also produced by an interference with a due nutrition of the nerve-elements. In conclusion, we may briefly sum up the vari- ous non-congenital types of mental weakness, the pathological circumstances of which we have re- ferred to, as follows* : — A. Developmental cases : 1. Eclampsic. 2. Epileptic. 3. Syphilitic (inherited). B. Accidental or acquired : 1. Traumatic ) 2. Post-febriler"*^^'°'"^*°'^ ^^^'°°^- 3. Emotional. 4. Toxic. * Under the title of Amaurotic Idiocy some curious and hopeless cases of infantile cerebral degeneration, with sym- metrical changes at the macula, commencing about three months after birth, and observed chiefly among Jewish children, have been described by Sachs of New York and other American authorities, and by Mr. Waren Tay, and Drs. Kingdon and Risien Russell in this country. See Med. Chlr. Trans., vol. Ixxx., p. 87, et seq. 6o Mentally -Deficient Children. We shall find that these divisions, together with those of the congenital types previously given (pp. 56 and 57) will be serviceable in con- sidering points in the etiology, diagnosis and prognosis of mental deficiency, which we shall proceed to discuss in the next chapter. Etiology. 6i CHAPTER VI. EnoLOGY, Diagnosis and Prognosis. In treating the subject of the etiology of cases of mental deficiency, we must consider the various factors of causation in the light of clinical experi- ence. The present writer has already recorded his statistics (in conjunction with those of Dr. Fletcher Beach) in an article in Hack Tuke's "Dictionary of Psychological Medicine," in which 1200 cases observed at the Royal Albert Asylum, .and 1180 cases at Darenth Asylum, are collated. It is not logical to attribute to a single specific cause the majority of cases met with, inasmuch as on investigation we shall discover several contributory factors. So strong indeed is the tendency of nature to revert to a healthy type, that the solitary infraction of physiological law is not often visited with the penalty of mental abnormality ; and if we only look back far enough we shall probably find that such a culmination is reached by the gradations of repeated trans- gressions. Not every drunken parent procreates an idiot ; but when inherited nervous instability from this or other causes is intensified in the next generation by injudicious marriage, or by 62 Mentally-Deficient Children. unfavourable environment, instances of mental degeneracy are apt to occur. In our experience physical factors play an important role in the production of mental defects. A phthisical family history is, indeed, the predominant factor traceable in our cases, the percentage in which this was found being 28'3i, against 2i'38, in which hereditary mental weakness (insanity or imbecility) was recorded. It is true, however, that in addition epileptic or neurotic inheri- tance showed a percentage of 20. Parental intemperance was noted in i6"38 per cent, of our cases, ranging from i3"25 at the Royal Albert Asylum, where the large majority of cases were above — some considerably above — the pauper class, to I9"57, at the pauper asylum at Darenth. Clear evidences of inherited syphilis were found in only I'ly of our cases, though the taint was suspected in others. Consanguinity of parents or grand-parents appeared in less than five per cent, of the cases noted; and this factor would appear to be potent for harm in proportion to the risk entailed in intensifying " family weaknesses." Almost 30 per cent, were attributed to maternal ill-health, accident, or shock during gestation. These factors sometimes occurring in combina- tion, exhaust the principal causes acting be- fore BIRTH. Among CAUSES acting at birth that to which undoubtedly most importance attaches is pro- longed parturition. It has been alleged by Drs. Etiology. 63 Winkler, Bollaan, and others, that the use of forceps is accountable for a considerable amount of cerebral injury and consequent mental impair- ment. So far from this being the case, it would appear from our statistics that protracted pres- sure without instrumental interference is a much more potent cause both of mental and nervous defect, the latter factor figuring more than four times as often as the former {i.e., I4'24 per cent, as compared with 3"3i) in our combined etio- logical table, whilst in addition the occurrence of asphyxia neonatorum is noted in I2'g6 per cent, of Dr. Beach's cases. Dr. Langdon-Down* has indeed estimated the frequency of this condition at 20 per cent, amongst imbecile children gener- ally, and at 40 per cent, amongst those who were first-born. It is unquestionable that the asphyxia neonatorum, so often due to protracted unassisted labours, is in some cases followed by birth-palsies, and enfeeblement more or less severe of the intel- lectual powers. It is probably accountable for not a few of the milder types of mental feebleness. Premature birth was noticed as a factor in 3"52 per cent, of our cases. Causes which come into play after birth are commonly heard of, as parents readily put these forward rather than the prsenatal cause of a congenital defect, which they are loth to recognise. Consequently such assigned causes as a fall, a fit, * "The Obstetric Aspects of Idiocy.'' Trans. Obstet. Society, 1876. 64 Mentally -Deficient Children. or a fright, must be received with caution, and it must be borne in mind that such may be at most the exciting cause, sometimes merely the conse- quence or coincidence, of a nervous catastrophe to which the child is congenitally predisposed. In the last chapter we referred to the pathology of developmental cases, and under this head many of those produced by causes acting after birth would properly fall. This remark especially ap- plies to the cause most commonly assigned of all others for mental deficiency in children, viz., con- vulsions during teething (eclampsia) , which fig- ured in the statistics of the Royal Albert Asylum to the extent of 32'58 per cent, (nearly one-third of the admissions). There is no doubt that infantile convulsions frequently occur without producing any subsequent mental impairment, and when it follows it is safe to. assume, except when inflam- matory lesions have been set up, that there has been some inherited brain abnormality. Epilepsy, which occurs probably in about 25 per cent, of all mentally-deficient children, is also a commonly assigned cause. There are no doubt cases in which a previously bright child, afflicted with epilepsy, falls into a state of mental hebetude ; but in the majority of cases, both the epilepsy and the mental abnormality are common conse- quences of inherited nervous instability. A simi- lar statement may be made with regard to the role of infantile paralysis as a factor of mental deficiency. Though slight injuries are often set Etiology. 65 forth as causes when quite inadequate, there is no doubt that traumatism (chiefly in the form of injury to the head) is a bona fide cause in a large number of cases — e.g., in 8"25 per cent, of the admissions to the Royal Albert Asylum. Fright or shock (mental) shows as a factor in about three per cent, of our cases; and in such instances as that of a child cruelly locked up in a dark cup- board for several hours, or scared and bitten by a fierce dog, these are likely to be efficient causes. Severe febrile illnesses, such as whooping cough, scarlatina, measles, and small-pox, were assigned as causes in nearly 10 per cent, of the admissions to the Royal Albert Asylum, and where menin- gitis had supervened, probably with truth. It is remarkable that our statistics, both at Lancaster and Darenth, gathered at a time when the worst features of our elementary school system were in vogue, give but little prominence to " over-pres- sure " as a factor, being noted in only "16 per cent, of our 2,380 cases ! While the above statistics have been gathered from cases of recognised idiots and imbeciles, there is no doubt that the same sort of causes, acting, however, with less force, are accountable for those milder cases of mental infirmity which we designate feeble-mindedness. Mentally-feeble children are often the offspring of highly neurotic parents, sometimes of highly cultured persons, exceptionally gifted in a particular direction. It would seem indeed in some cases that the parents F 66 Mentally -Deficient Children. have themselves expended so much of their ner- vous energy that they have httle left to transmit to their offspring : and familiar instances will occur to every one, of distinguished men and women afflicted with children whose mental en- dowments are below the average. Bearing in mind the aphorism that ■" Great wits are sure to madness near allied," and that a neurotic temperament is sometimes associated with intellectual brilliancy, this need not surprise us, though parents naturally consider it as extraordinary. Mental feebleness is in some few cases merely a consequence of feeble health, and with improved physical conditions the mental impairment may gradually disappear. Diagnosis. — The practical question often arises, how shall we recognise mental abnormality in a young infant ? And the further enquiry may follow, is the mental abnormality congenital or acquired ? Mothers are proverbially blind to im- perfections in their own offspring, and in many cases it falls to the medical attendant to point out the painful fact that the poor baby is not " all there." It behoves him, therefore, to be well up in the diagnostic marks of infantile feeble-minded- ness. We may group these under four heads viz : — ■ 1. Cranial abnormalities. 2. Formative and developmental defects. 3. Abnormality of nervous action. 4. Defects in nutrition. Diagnosis. 67 I. Cranial abnormalities. — The most signifi- cant is of course microcephalus. As has been previously stated not only deficient size but also characteristic form of head is indicative of this abnormality (see p. 49, ante). Taking the average head circumference at nine months as I7'5 inches, and at tvi^elve months as ig inches, any notable deficiency in head measurement in a child other- wise of normal size, may be taken to betoken microcephalus. It has been alleged that in some cases there exist absence of soft fontanelles and other signs of premature synostosis, but this is the exception and not the rule in microcephalus, in vi'hich the small skull is simply the diminished envelope of the brain of which the normal de- velopment has been arrested, probably about the fifth month of gestation. We must refer to our previous description of the characteristics of microcephalus (see p. 49) ; here we need only observe that there is commonly but little sen- sorial deficiency or muscular weakness, so that the power of grasping, sucking, &c., is not im- paired. The palate will be found high and narrow ; in form, like a V or a Gothic arch ; and such abnormality of palate may be taken as commonly indicative of congenital defect. Intra-uterine hydrocephalus will probably have given rise to a difficult labour, and the cranial abnormality in the child is not likely to escape notice. In some cases sensorial deficiencies, as of sight or hearing, are associated with this variety. F2 68 Mentally -Deficient Children. The so-called "Mongol" type leaves its im- press not only on the physiognomy, but on the form of the head, as has been already described ; and there can be no difficulty in recognising it even in very early life. Marked asymmetry of skull is met with in hemiplegic cases ; and other distortions some- times occur especially after a difficult labour. Occasionally injuries from forceps leave a per- manent mark ; but in our experience these are not more common with defective than with nor- mal children. Asymmetry must not be taken as of itself a sign of mental defect ; indeed in adult life it is said to be a mark of culture ! Prolonged (dolichocephalic) crania with a median longitu- dinal ridge, especially over the sagittal suture, are met with both in normal and abnormal children, and consequently the scaphocephalic form cannot be called diagnostic. But the persistence of medio-frontal suture, or the existence of a medio- frontal ridge towards which a narrow forehead tapers, may be accepted as signs of imperfect development of the frontal lobes. 2. Formative and developmental defects. — As signs of imperfection of physical development are often associated with mental defect, we should look for such abnormalities of formation as hare- lip, cleft, high and misshapen palates, deficient ear-lobes, sometimes adherent to face and unduly set back, supernumerary auricles represented by tags of projecting skin, epicanthic folds extending Diagnosis. 6g across the caruncle, opacity of ocular media, coloboma iridis, nose unusually indented at bridge or depressed, hairy growths or moles on forehead or face, nsevi, rough and scaly condition of skin, imperfections of nails, general blueness of face, lips, &c., from cardiac malformation, blueness and coldness of hands and feet. None of these stigmata of physical failure necessarily imply mental deficiency, but their occurrence will lead at any rate to suspicion on the subject. 3. Abnormality of nervous action. — Sponta- neous muscular activity, though with movements minute in character (the " microkinesis " of Dr. F. Warner), incessant during waking hours, is the characteristic of healthy infant life. If these movements be absent or excessive, we may rea- sonably suspect something wrong with the ner- vous system, and predicate mental irregularities. In the former case we shall find a dull, vacant expression, sometimes associated with imperfect reflex so that even the function of sucking is not properly accomplished. In the latter, there is over- mobility, perhaps nystagmus, and twitching movements of the muscles of the face. A general tremor is also sometimes met with. As indica- tions of mental deficiency we must of course be guided by the extent of the departure from the normal in one direction or the other. As the age of the child increases we must carefully watch the evolution of its senses, and mark deficiencies of touch, sight, hearing, &c. At a later stage, the 70 Mentally -Deficient Children. absence of attempts at speech, when the hearing is not affected, will of course be of much value as a diagnostic sign. So also will be lack of mus- cular co-ordination and consequent inability to walk, independent of paralytic affection. 4. Defects in nutrition. — The emaciated wizened features of the slum baby, so often seen in the children's wards of East-end hospitals, furnish an extreme example of these defects. This may to some extent arise from injudicious feeding, but there is undoubtedly a congenital state of malnutrition, evidenced for instance in cases of inherited syphilis. Persistent defects of nutrition, in spite of good feeding, are sympto- matic of defect of original constitution and are not unfrequently associated with mental deficiency. This fact was remarked by Dr. Warner in his inspection of Poor Law Schools, where, not- withstanding good feeding, the tendency to low nutrition was in greater ratio than with ordinary school children. To sum up, we shall find aid in diagnosing the CONGENITAL character of mental deficiency by noting abnormalities in the form and shape of head, and the condition of the cranial sutures ; by looking for the physical stigmata, if not of degeneration, at any rate of arrested develop- ment ; and by marking signs of abnormal nervous action and a constitutional tendency to imperfect nutrition. The occurrence of asphyxia neonatorum, the absence of a healthy cry, defect of reflex Diagnosis and Prognosis. 71 action and of grasping power, imperfect reaction to light and sound, absence or excess of sponta- neous movement, and (as time goes on) inability to notice objects or to fix the attention, with tardiness of attempts at speech and at walking, are some of the symptoms marking the child as diiferent from other children. Non-congenital cases are differentiated by the absence of such signs of original defect : by a history of normal condition in infancy until the occurrence of some serious accident, illness, or shock, which was followed by mental enfeeblement. Caution is needful in accepting the statements of parents on these matters, but it must be remembered that a certain number of cases, not obviously suffering from congenital defect, are born with brains so unstable as not to be able to withstand the stress of life, and these may break down at a crisis of child development, or after a comparatively slight injury which would leave a normal child un- harmed. The DIAGNOSIS and prognosis of the various types of mental deficiency are so closely connected that it will be convenient to consider them in com- mon. First, we may remark with regard to the broad division into congenital and non-congenital cases, that the prognosis in the former is, as a rule — (contrary to the popular idea on the sub- ject) — better than in the latter. The fact is that in the one there is simple defective development, and this under favourable circumstances may be Mentally -Deficient Children. fostered and promoted ; in the other there is actual lesion of brain tissue, more or less irreme- diable. Superficial appearances are in favour of non-congenital cases, for the others are handi- capped by ill-formed and sometimes repulsive physical features ; yet our experience is quite in accord with that of the late Dr. Langdon-Down,* that "the prognosis is, contrary to what is so often thought, inversely as the child is comely, fair to look upon and winsome." There are, however, a few cases of mild traumatism, and even of post-inflammatory lesion, in which a more cheerful view may be taken, especially in these days of brain surgery. Passing now to some of the typical groups, let us first take the small heads, those with greater or less degree of microceptaalus. The prognosis may be said to be (generally speaking) favourable or otherwise, in -proportion to the size of the head. With heads under i8 inches in circum- ference, the manifestation of mental power is usually so small as to come under the category of idiocy ; between i8 and 19 inches the cases may be designated as imbecile ; and from ig to 20 inches is not an uncommon measurement in cases of mere " feeble-mindedness." There is hope of improvement under training, especially for the higher grades of this type, and the writer has had under training for four years a mentally-feeble boy whose head circumference has increased * Obstet. Trans., vol. xviii. Diagnosis and Prognosis. 73 during that time from ig to 2o|- inches. As the sensorial and muscular powers are usually good in microcephalic cases, the better class of such patients may be taught useful industrial work, and we have known a girl with a head of 18 inches employed as an assistant dormitory maid, and a boy with a head of 19 inches helping in- telligently in a bakehouse. The physical health of microcephals is usually not amiss, and under favourable circumstances they may live to adult, and even advanced, years. Some simple occupa- tion, not requiring head work, is the goal for such, the mental being limited by the cranial capacity. But as old Fuller quaintly puts it, though " heads are sometimes so little that there is no room for wit, they are sometimes so long that there is no wit for so much room." We have already remarked that long heads do not at all necessarily go with mental deficiency — sometimes the reverse ; and if Fuller had written large heads instead of long, it would have been more in accord with our experience. We refer of course to the hydrocephalic type, the features of which have been already referred to.* Here we may add that some diagnostic care is necessary to distinguish this type from that of the hypertrophic heads occasionally met withl In hypertrophy the cir- cumference is less than that in hydrocephalus, and the increase in size is most marked just above the superciliary ridges, not at the temples. * See Plate IV., fig. 2. 74 Mentally-Deficient Children. The general form of the head is not so globular, but rather piled up towards the vertex. Hypertro- phic change is sometimes associated with rickets ; there is often complaint of headache ; sometimes encephalitis and acute mania. The prognosis of hypertrophy of brain is consequently unfavour- able ; whereas in hydrocephalus, after the acute symptoms have subsided, the prospects of im- provement under judicious training are consider- able. With regard to the so-called Mongol type,* the physiognomy, the form of the head, the furrowed tongue with hypertrophied papillae, the fissured lips and the harsh condition of skin and mucous membrane, are quite charac- teristic ; and the mental condition is equally so. The powers possessed by such children of mimicry are often extraordinary ; their love of music great ; their idea of time as well as tune remarkable ; so that they are apt at drill and dancing. Varied gradations of this type are met with, from the mentally-feeble child with the slight " Mongol " taint to the idiot whose ob- liquely-set almond-shaped eyes are very suggestive of the " heathen Chinee." So far as mental training is concerned, the results, especially amongst the higher grades, are fairly satisfactory, and we know youths of the mildly Mongol type who, after appropriate education, pass muster with their brothers and sisters. Simple imitative * See Plate v., fig. i. Diagnosis and Prognosis. 73 arts, such as writing and drawing, are acquired without much difficulty, but . the coarsely-convo- luted brain is unequal to higher intellectual operations, and calculation is a stumbling block. Simple industrial occupation, such as that of the garden and farm, may be followed, but the clumsy ill-formed fingers militate against success in mechanical work requiring fine adjustment. From the physical side, however, the prognosis of such cases is not good. They are generally delicate and very susceptible to cold, being apt to suffer from chilblains.* They are prone, moreover, to mucous catarrhs of the digestive and respiratory tracts, and the majority die from phthisis before arriving at maturity. Of the cases in which the stigmata of scrofula are strongly marked, we may say that the prog- nosis varies with the intensity of the taint. Much depends upon favourable environment, and it is remarkable how such cases improve, both men- tally and physically, when withdrawn from in- sanitary slums and placed under good hygienic conditions, especially when employed in out-door work in pure country air. In cases of mental deficiency associated with birth-palsy,t the history of the case, the occur- * Dr. Archibald Garrod, in a communication to the Clinical Society, described five cases in which congenital cardiac lesions were met with in idiots of this type. See Brit. Med. journal, Oct. 22, 1898, p. 1255. t See Plate IV., fig. 3. 76 Mentally-Deficient Children. rence of convulsions during the first few days after birth, the liabihty to athetotic movement, distinguish this form from that associated with infantile hemiplegia. In the latter there is a history of convulsions later in infancy, with power * suddenly lost on one side ; and when the paralysis begins to improve, spastic contractures are left and there is the characteristic hemiplegic gait. In the first class of cases, those following birth- palsy, the mental deficiency is often more apparent than real, and the patients improve wonderfully under appropriate training. The athetotic move- ments disqualifying them from ordinary use of the hands, may be overcome by suitable finger exer- cises (such as will be hereafter described), and as considerable power of will exists, the patient will often be able to co-operate with the doctor in trying to combat his infirmities. We have re- peatedly seen children of this type, at first unable to hold a pencil, develop into admirable draughts- men ; indeed the graphic faculty seems to be common with these cases. Intricate Macram6 patterns have also been worked out by such, and delicate wood-carving done. Various grades of mental defect from simple feebleness to crass idiocy are associated with infantile hemiplegia, and the prognosis varies with the degree. Such cases have usually to be attacked from the physical side, muscular atrophies and contrac- tions being subjected to electrical treatment and massage ; and in the milder instances consider- Diagnosis and Prognosis. jy able improvement both physical and mental may be anticipated. The features of sporadic cretinism are so characteristic as when once seen to leave no doubt as to diagnosis.* Dwarfing, both of body and mind, with slow reaction and response, a loose baggy skin, tumid belly, bowed legs, broad squat hands and feet, are some of the general characters. Then there is the square head, the broad flushed cheeks, the indented "pug-nose," the pouting lips, and the protruding tongue, which make up a physiognomy when once seen never forgotten. Investigation shows deficiency or absence of the thyroid gland, and in many cases supra-clavicular fatty tumours. The prog- nosis of such cases was, till within recent years, most unfavourable. Now, thanks to the experi- mental researches of Victor Horsley, Schiff, and others, their successful treatment by adminis- tration of the thyroid gland is an everyday occurrence. Physical and functional develop- ment proceed at a rapid rate, and the mental hebetude and slowness, characteristic of such cases, are transformed into a vivacity and activity strangely contrasting with the previous condition. It would seem, however, that to secure lasting benefit the treatment must be permanent ; and to the question, can cretinism early diagnosed and treated be eradicated, we cannot at present reply hopefully. • See Plate IV., fig. 4, and Plate VI., fig. i. 78 Mentally-Deficient Children. Cases primarily neurotic do better when with- drawn from home influences which are preju- dicial (the common neurotic taint of parent and child often interacting injuriously). Placed under judicious management, much good may be done by suitable drill and manual exercises in over- coming the twitchings and nervous movements common in these cases. With regard to eclampsic cases (the history of which will help us to a diagnosis) the prognosis varies with the severity of the consequences of the fits, but as a rule is not very favourable, The same may be said with regard to epileptic cases ; but where epilepsy is associated with the lower grades of idiocy, the probability of organic lesions renders the prognosis unpromising. In milder cases of mental enfeeblement associated with epi- lepsy, the successful treatment of the epilepsy is followed by considerable mental improve- ment, and should the cessation of fits be per- manent, the mental deficiency may gradually dis- appear. Syphilitic cases* may be distinguished by the history and signs of inherited syphilis ; though the taint is probably a factor in many cases of mental deficiency where its external manifesta- tions are not obvious. In syphilitic cases devel- oping symptoms of mental enfeeblement at the age of second dentition the prognosis is grave ; progressive juvenile dementia, with paralytic and * See Plate V., fig. 2. Diagnosis and Prognosis. 79 epileptoid seizures, usually leading to a fatal issue in the course of three or four years.* In the diagnosis of traumatic cases, the history of a fall or injury to the head must be critically accepted; but falls from careless nurses' arms, from an overturned perambulator, down stone steps, and severe blows on the head, are not improbable causes. The presence of external swelling or haemorrhage, or the occurrence of fits, soon after the accident, will be confirmatory evidence. The prognosis varies with the severity of the injuries and their consequences ; and the influence of heredity to nervous disease must not be overlooked. We have seen mild traumatic imbecility entirely recovered from in the processes of growth and development ; and the modern re- sources of cranial surgery make the prognosis of this class of cases more favourable than formerly. Of emotional cases, caused by shock and fright, there are many degrees. The history, of course, serves for their recognition, and the absence of the features of congenital abnormality, with per- sistent nervousness, and sometimes a peculiar scared expression, will help us in the diagnosis. Much good may be done by placing such a patient in a good environment with suitable training, which m.ay gradually give him confidence in him- * See paper by Drs. Macdonald and Davidson on " Congenital General Paralysis," and remarks by author in Brit. Med. Jour., Sept. 16, 1899, pp. 706-709. See also Clouston's " Neuroses of Development," pp. 74-go. 8o Mentally -Deficient Children. self ; and we have known children, who have been victims of shock, become after special education fairly useful members of society. Exposed to the rugged ways of public schools, where they will be jeered and scoffed at, there is much risk of mental deterioration. Post-febrile or inflammatory cases are simi- larly diagnosed by the history, and the absence of congenital defect. Speaking generally, the prog- nosis is not favourable in this class of cases, though, of course depending upon the amount of damage the brain has sustained, or the degree of atrophy consequent on meningeal thickening. In some cases irremediable lesion may have been left ; in others, the arrest of development from failing nutrition may under favourable circum- stances be averted. Toxic cases are recognised by ill-effects occur- ring in a previously normal child, dosed with alcohol or opium. The lesions are of an atrophic character, and good results may follow withdrawal of the poisons and the substitution of nourishment appropriate to the child's age. It is not pretended that we can refer all cases of mental deficiency to a single type. The ma- jority, indeed, are of mixed types; but experience aids us in distinguishing and assessing the value of one factor and another in their combinations. Thus traumatism combined with a neurotic family history is less hopeful as regards mental improvement, than when the history is good ; Diagnosis and Prognosis. and the physical prognosis of " Mongol " imbe- cility with marked phthisical heredity is most unfavourable. The difference between idiocy and imbecility being one of degree and not of kind, it will suffice to say that the former designation is applied to the lower grades, the latter to the higher grades of marked mental defect, whether congenital or acquired. Mental feebleness (" feeble-minded- ness " in the modern English sense) is distin- guished by departures from the normal mental de- velopment less marked than the above. Retarded mental development may amount to no more than mere "backwardness," and is best estimated by comparing the patient with a normal child of similar age. Thus tested, a boy of ten will some- times be found on an intellectual level with the ordinary child of five ; and if he has had equal advantages with the latter, we may fairly con- clude he is " mentally-feeble." The physical accompaniments of -this state, previously alluded to, such as developmental defects, nerve signs and low nutrition, will also aid in the diagnosis. There may often be detected in these cases by the practised eye, indications of the typical forms • — such as the microcephalic, hydrocephalic, mon- gpl, &c., which are more pronounced in cases of actual imbecility; while scrofulous, neurotic and, we may add, rachitic affections are noticeable in a large number of children whose mental condi- tion is merely sub-normal. These signs, in con- G 82 Mentally -Deficient Children. junction with considerations of heredity, are of great value in the diagnosis of constitutional defect of intelligence of a minor kind, and also in the prognosis. Unfortunately there is sometimes associated with mental defect, particularly when not early subjected to proper training, moral weakness, apt to give much trouble in after life. As Dr. Blandford has well stated in his Lumleian Lectures at the Royal College of Physicians : — "And first, of those who, through congenital defect, or as the result of disease in early life, are mentally deficient — not idiots, but weak-minded imbeciles — children in mind throughout life. They come before us in various ways. Though children in mind, they are very often men and women in wickedness and vice ; and it may be necessary to place them under restraint, or to protect their property from being squandered and themselves from being robbed. I know no class over whom controversy is so' likely to arise, or where we may have greater difficulty in forming a diagnosis. They are not idiots ; many of them have acquired a fair amount of education, can construe a Greek play, or master a proposition of Euclid. Their memory is excellent, and we cannot compare their condition with a former one ; for they have never been any better, so that this test fails us. They have no delusions or hallucinations, and are not insane in the ordinary sense of the word. With regard to many there Diagnosis and Prognosis. 83 is no difficulty. When a man or woman of forty submits to be treated like a child of ten — to be taken out and amused, and to have a sixpence a week pocket money, we have not much difficulty in forming an opinion. But the development of others is not so low ; yet they are deficient in reason and judgment, and often in conduct. There is a tendency to low and depraved habits, to brutish and sensual enjoyment, to low com- pany amongst whom they are of more import- ance, and if remonstrated with they show an absolute disregard for truth or for right behaviour. Lawyers will defend these patients and say that they are not insane, and the celebrated Wyndham case shows what can be done by their aid. In examining any such individual we must consider his conduct in regard to his environment and bringing up. What might be passed over in the lower walks of life is in the higher evidence of a degraded mental state. Every case must be judged by itself, and the question must be asked. Is this person able to take care of himself and his affairs ? But to sign a certificate is often very difficult, as we may not ourselves witness the insane conduct, all of which we arrive at only by hearsay. It is not to be forgotten, however, that imbeciles are very prone to display violent ex- plosiveness of their nerve centres, and this is specially likely to happen as they advance from the period of puberty to adolescent life."* * Lancet, April 6, 1895, p. 857. G2 84 Mentally -Deficient Children. The connection between criminality and mental deficiency is a subject of vast social importance, but presents problems of practical difficulty too extensive for us to grapple with here. To those interested in the subject, we would commend the works of W. D. Morrison, Letchworth, Talbot, and others, and the reports by Macdonald to the United States Bureau of Education. Many valu- able papers — notably one by Dr. Barr — are to be found in the Proceedings of the American State Committees on Charities and Corrections. Treatment. S5 CHAPTER VII. The Treatment of Mentally-Deficient Children. {a) General, {b) Medical, (c) Surgical. The treatment of mentally-deficient children is essentially (to borrow a term from the French) medico-pedagogic. The physician the teacher and the nurse must all co-operate in the ameliorative process, and the judicious parent will best secure the interests of his afflicted child by placing him where the efforts of the three can be co-ordinated. As a matter of convenience, however, we shalll consider in order, first the general treatment, including nursing and domestic management, and after that such treatment as belongs to the domain of medicine and surgery, reserving for a subsequent chapter matters educational. Congenital defect in the young infant having been diagnosed, are there any means available for modifying its accompanying abnormalities ? Much indeed may be done by a loving mother, who will be patient enough to persevere, in spite of apparently slight results, to promote sensorial development and co-ordinate movement, and, as months go on, to foster habits of cleanhness. 86 Mentally -Deficient Children. The faculty of attention, too, may be cultivated, the child being coaxed to fix its gaze on one thing at a time. The aid of music is serviceable in many cases, and even idiots will respond re- markably to congenial sounds, which they at length try to imitate, so that music is sometimes the stepping-stone to speech. S6guin well lays down the principles on which to proceed, in the following paragraph.* " As soon as any function is set down as de- ficient at its due time of development, the cause must be sought and combated ; if external, re- moved ; if seated in the nervous apparatus, counteracted by the earliest course of training and hygienic measures. The arm of the mother becomes a swing or a supporter ; her hand, a monitor or a compressor ; her eye, a stimulant or a director of the distracted look ; the cradle is converted into a class-room or gymnasium." It must, howevex, be remembered that the mother, if of neurotic temperament, is not the best person to conduct these infantile exercises ; a judicious nurse, sympathetic, but not emotional, will have a better chance of success. Amongst hygienic measures, of the first import- ance is proper feeding. An emotional mother should not, as a rule, suckle her child ; in her place a healthy, strong-minded, wet-nurse should be employed, or judicious artificial feeding should be used. The risk of scurvy-rickets from the * " Idiocy," New York, 1866, p. 88. Treatment. 87 exclusive use of preserved food (as demonstrated by Dr. Thomas Barlow, in his 1894 Bradshaw Lecture) must not be forgotten ; and fresh milk in some form should come into the dietary. As the child gets older, well-boiled oatmeal porridge {par excellence the food for bone and brain build- ing), should be given it; and careful attention must be paid to the action of the bowels, which are apt to be sluggish, though sometimes there is a tendency to mucous flux. The hygiene of the skin is of importance, and frequent baths, with friction, are beneficial in promoting cutaneous exhalation, otherwise often offensive, and in aiding the sluggish circulation. Muscular ac- tivity should be encouraged, and the child fre- quently laid on the "kicking- rug," and encouraged, by playful methods, to exercise its limbs. Cleanly habits must be promoted by every possible means. It is a mistake to condemn the deficient infant to perpetual swaddling clothes ; the aim should be to approximate as near as is practicable to the normal child, in costume as well as other matters. We have seen children of six swathed in napkins round their loins, reeking with offensive filth, to the great discomfort of all concerned, whereas methodical personal attention would have obviated the need of such expedients. Regularity in the rehef of the bowels and the bladder should be early inculcated, and of course more frequent facilities are required than for ordinary children ; but, except in the case of Mentally-Deficient Children. degraded idiots, there is every prospect of cleanli- ness being attained by patient perseverance. The practice of wetting the bed is a common one with weak-minded people of all degrees, and sometimes there is a physical weakness of the urinary apparatus, which may be corrected by appropriate treatment. More frequently, how- ever, these laches are the result of inattention, and then moral methods, in the way of simple rewards and punishments, may advantageously be tried. One very simple remedy, partaking both of the physical and moral, is the restriction of the amount of fluid imbibed towards bed-time ; and mentally-feeble children are often "thirsty souls." We do not approve of india-rubber urinals, and other mechanical arrangements, which only tend to perpetuate bad habits, any more than we do of the ingenious (?) method proposed by an Idiot Asylum Superintendent, of keeping his beds clean by the nightly administration of enemata to all dirty patients 1 The clothing of mentally-deficient children re- quires consideration. As with others, it should be warm yet light, and free from constricting bands. Woollen undergarments should be worn in all cases where this is practicable ; but with wet cases there may be a difficulty as regards the nether garments, and where frequent washing is necessary, swansdown or some such material may be substituted. Jaeger's natural wool in winter, and cellular cloth (the so-called " Aertex") in Treatment. 8g summer, form appropriate gradations as to warmth. With regard to the cut of clothes, this should conform as nearly as may be to the ordinary fashion ; it is wrong to accentuate per- sonal peculiarities by peculiar clothing. There is no good reason why boys of eight or more should continue to be dressed like girls, when kilted costumes or sailor's suits would be quite as convenient, and moreover, promote a sense of self-respect. Weak-minded children are often not devoid of all pride of appearance ; and this, judiciously cultivated, may be made a powerful lever in the upraising of good habits. We have known a case in which a tendency to destroy clothing has been overcome, not by attiring the child in sackcloth, but by providing for it a fashionable suit ! Appropriate exercise occupies an important place in the management of the rnentally-deficient child. From the first, plenty of pure outdoor air is essential to the child whose brain activity is diminished by the imperfect aeration of its blood, and as time goes on, such muscular exercise as it is capable of should by every method be pro- moted. From a false sense of shame the defi- cient member of the family is too often carefully concealed from the public gaze, and when this entails, as we have known to occur, the segrega- tion of the poor child to the limited area of its nursery, or at most to the seclusion of its " own back yard," it is a question whether the Society go Mentally -Deficient Children. for the Prevention of Cruelty to Children might not advantageously intervene ! Teaching to walk will of course be a more tedious process than with ordinary children, but the faith which works by love will accomplish miracles, whereas neglect will too often entail permanent disability. Con- tractures of limbs, consequent on bad postures allowed to become permanent, are sometimes met with in the case of the mentally-feeble; and we have a vivid recollection of a poor boy of twelve, who having spent his childhood, like a modern Diogenes, in a tub (a sugar hogshead), was brought to us with his legs so hopelessly deformed by his constrained posture, that he was a complete cripple, though we afterwards succeeded in get- ting him to use a tricycle specially built for him. But we must not linger on methods of exercise, which will be treated later ; nor can we now en- force the importance of moral training, from the earliest age, in the formation of good habits, for this forms the subject of a future chapter. It must suffice to say that early home influences are specially potent for good or harm, in the case of the mentally-deficient child, and it behoves the parents of such to promptly obtain expert advice on the subject, as well as the aid of a well quali- fied and intelligent nurse or nursery-governess. Dr. Langdon-Down in his Lettsomian Lec- tures,* for 1887, laid stress on the prevalence of " morbid sexual erethism " in mentally-deficient * " Mental Affections in Childhood and Youth," p. 47. Treatment. gi children of tender years, due oftentimes to the nefarious practices of an unworthy nurse. Whilst happily our own experience does not point to this condition as a frequent one, yet the contingency must be borne in mind, and proper measures of precaution taken. The approach of puberty is of necessity an anxious epoch as regards- domestic management, and too much care cannot be exercised by those in charge of " feeble-minded youths " (of both sexes) to guard against abuses of the animal in- stincts then awakened. Employment in the open air will at this period be of special value ; and for obvious reasons, sending to bed in the daytime, as a punishment, must not be thought of. We now pass to methods in the treatment of the mentally-deficient child, which we may more especially designate medical. It has been already stated that such children are as a rule physically as well as mentally deficient ; at any rate they are feeble in body as well as in mind ; sometimes (as was said of one of our kings) " not only weak in the head, but also weak in the understandings." The limbs, as well as the brain, are imperfectly developed ; and of course nervous defects and disorders are frequently met with. There is in many cases, moreover, a tendency to mal- nutrition, and a want of tone which renders its subjects specially liable to the inroads of infec- tious disease, and to parasitic skin affections. We have already stated that a phthisical family g2 Mentally -Deficient Children. history is extremely common with mentally- deficient children. We shall not therefore be surprised to find in them a marked predisposition to tubercular disease, sometimes affecting the joints, more often the lungs, and occasionally — though perhaps less frequently than would be anticipated — the meninges of the brain. These causes account for from 50 to 75 per cent, of the mortality of Institutions for Imbeciles ; whether or not the conditions of Institution-life contribute to this excessive mortality might be fairly argued. In all cases, however, it behoves the medical at- tendant to watch for, and guard against, the in- cipent symptoms of tubercular disease, fortifying the constitution against it by hygienic surround- ings, judicious feeding, including a sufficiency of carbonaceous elements, and the administration of cod-liver oil, malt-extract, and Parrish's chemical food. Children of the Mongol type are specially liable to break down from exposure, and in cold weather are apt to suffer not only from chills externally but from internal congestions favour- able to the development of tubercle bacilli. Scro- fulous affections of glands, eyelids, bones and joints frequently occur, but of these the treatment will be considered under the head of surgical. Mucous diarrhoea is an extremely common symptom, especially with " Mongols," and calls for care as regards feeding, and for suitable medi- cation. We have found much benefit in these cases from the administration of a mucilaginous Treatment. 93 mixture of castor-oil, with the addition of minute doses of opium. Sometimes small and repeated doses of grey powder or calomel are of service. Astringents, pure and simple, given too early, are apt to add to the intestinal irritation. Epilepsy has been stated to occur in at least 25 per cent, of all weak-minded children. Its dietetic and medical treatment is consequently of much importance in the amelioration of the mental affections of youth, which it is sometimes the cause of, and always tends to aggravate. Our experience leads us to favour an exclusively milk diet in these cases, or at any rate a diet containing but little meat, and that well cooked and minced, so as to avoid the risk of peripheral irritation from large morsels being " bolted." A highly nitrogenous diet probably conduces to an explosive condition of nerve-cells, and is on that account to be avoided, but a restricted diet may at the same time be amply nutritious. As regards drug treatment the idiosyncrasies of each case must be studied, and whilst some are beneficially influenced by bromides, others will do best with borax, or a mixture of the two. Dr. William Alexander, of Liverpool, records* considerable suc- cess in cases treated by the following mixture: — ■ I^ Sodse Biborat. gr. 200 Sodii Bromid. gr. 50 Syr. Simp. Jj. Aquam ad Jx. M. Ft. Mist. gj. t. d. s. ex aqua p. cib. • Liverpool Medico-Chirurgical jfournal, July, 1893, P- 280. 94 Mentally-Deficient Children. Dr. E. C. S6guin, of New York, speaks highly of persevering treatment, extended over some years, by the following combination : — IJ> Chloral Hydrat. 5ij. Sodii Bromid. 5X. Aquae gvij. M. I or 2 teaspoonfuls largely diluted to be taken three times a day. In some cases a simple solution of bromide (sodium in preference to potassium), or a com- bination of several bromides, suffices; but care must be taken that depressing effects are not produced, and when acne occurs, the temporary administration of arsenic is useful. Strontium bromide has recently come into vogue as preferable to the potassium salt ; and Dr. Andriezen* speaks highly of a combination of antipyrin (5 gr.) with ammonium bromide (15 gr.) as " promoting a degree of mental brightness." If there be a syphilitic element in the causation of the epilepsy, bichloride of mercury combined with bark may be of benefit. In petit mal, which is perhaps more often associated with mental enfeeblement than grand mal, and has a less hopeful prognosis, S6guin speaks well of " combining with a very moderate bromide course the free use of strych- nine and atropine or belladonna, "t More important than drug treatment is what one may call the " out-door occupation cure." The experience of the Royal Albert Asylum, and * British Medical journal, Sept. i6, iSgg, p. 713. t " Treatment and Management of Neuroses," New York Medical journal, May, 1890, p. 31. Treatment. 95 more recently of the Epileptic Colony, at Chalfont St. Peter's, is quite emphatic in this direction. Mere loafing in the open air is to very little pur- pose ; the occupation is the predominant factor for good. The most striking advance in the medical treat- ment of mental, in conjunction with bodily, defect is that of sporadic cretinism. Up to the year i8go, this was justly thought to be a hopeless form of idiocy; but the experimental researches of Victor Horsley and others encouraged the view that benefit might be derived from the im- plantation of the thyroid gland of the sheep in such cases. Subsequently it was found that the injection of thyroid juice was of equal efficacy; and later, that the ingestion by the mouth of the gland itself (or its preparations) was the best and most efficient mode of treatment. Numerous cases have been published recording successful results, mental awakening proceeding pari passu with physical development in a manner almost startling ; and those interested in the subject are referred to an article by the author in Wright's Medical Annual, for 1894, p. 324 rfs^^. The ad- justment and regulation of the dose appropriate to each case, so as to avoid stomach irritation, excessive temperature, and undue emaciation, are the points calling for attention ; and so far as we can judge from present experience, the treatment (though in modified doses) must be permanent. Starting in children (according to age) with gS Mentally -Deficient Children. one or more 2|^-^rain tabloids daily, the dose may be cautiously increased up to six tabloids, and when improvement has been achieved, one 5-grain tabloid daily will usually suffice to maintain it. The annexed Plate VI., for which we are indebted to the courtesy of Drs. Railton and Telford-Smith, shows the condition before and after treatment of two brothers, one of whom was formerly under the author's care at Lancaster.* The majority of mentally-deficient children being of feeble constitution, the prognosis of the exanthemata, and of acute disease generally occurring in such, must be guarded, and any depressing treatment is inadmissible. Cerebral complications are frequent and convulsions not uncommon. Troublesome sequelae affecting mu- cous membranes (in the eyelids and elsewhere) are apt to occur after measles, which in our experience is a disease almost as formidable as scarlatina with the imbecile class. The irritability of mucous membranes is at all times a source of trouble with mentally-deiicient children, and catarrhal discharges from the eyes, nose and ears, have to be treated with astringent lotions. Spongy gums are frequently found, especially when the hygiene of the mouth is not attended to, and chlorate of potash washes are useful in these cases. Aphthous patches and parasitic diseases of the skin must be treated by appro- ' For discussion on thyroid treatment, see Brit. Med. your., Sept. 12, i8g6. PLATE VI. Sporadic Cretins. ^H^^^i 4.. ■■■ ^H^' J ^1^1 ^^^ in ^^C-!!r' ^B^^^hH^^I ^^ ^ Treatment. 97 priate remedies. Curious skin afiections of neu- rotic origin are sometimes met with in cases of mental feebleness, such as that described by Dr. Pringle, and others, under the name of "Adenoma sebaceum."* Phthiriasis is occasionally met with. A few remarks as to surgical treatment in relation to mentally-deficient children must close this chapter. The contractures of limbs may sometimes be remedied by tenotomy, but the deficiency of reparative power, and the difficulty found, at any rate with lower grade cases, as to keeping appliances in position and free from filth, must be borne in mind before undertaking a surgical operation. For the relief of constitu- tional irritation, such as that caused by bone or joint disease in scrofulous cases, operative interference is quite justifiable and is generally successful. We have repeatedly seen consider- able benefit to mental activity from the clearing away of post-nasal adenoid vegetations in feeble- minded children. Since 1890 the operation of craniectomy {i.e., the cutting of strips of bone from the cranium) has been recommended and practised in cases of microcephalus. " In a case of congenital micro- cephalus, when the small skull is simply moulded to the brain, which has been arrested in its de- velopment at a stage corresponding to that of the fifth month of intra-uterine life, it would seem * British Jotirnal of Dermatology, Jan., i8go. H gS Mentally-Deficient Children. futile to expect that cerebral development would be fostered by cutting chinks in the skull, which after a short period would be filled up by bony matter apt to encroach upon the cranial cavity... In the light of numerous autopsies, described by Bourneville and others, the theory of premature synostosis, as a common cause of microcephalus, must be given up, and operations based on this theory abandoned."* Whenever signs of pressure present themselves, however, and in the rare cases in which there is a history of prematurely ossified fontanelles, operative interference is justifiable ; and now-a-days the mortality of craniectomy is but small. There is no doubt that beneficial results have been frequently obtained by cranial operations in cases of mental deficiency associated with traumatism, epilepsy, and paralysis : and in such cases surgery should not be deferred until after the establishment of serious atrophic changes and degenerations. * See article by Author, Medical Annual, 1895, p. 327, (Wright, Bristol). Dr. Telford-Smith has described and illustrated in the American journal of Psycho-Asthenics for June, 1897, ^^^ cases of two microcephalic boys whom he had the opportunity of closely observing during four years after craniectomy had been performed, his conclusion being that in the light of results the operation is unjustifiable. Educational Training. 99 CHAPTER VIII. Educational Training. We now pass to the consideration of means, which, as distinguished from general treatment, we may designate Educational. Under this term we include all those methodical and specific exercises, whether physical or mental, which naturally fall into the school routine, and need for their direction a skilled teacher, acting in concert with the physician. The kind and amount of educational exercise appropriate to a particular case of mental deficiency or feebleness should indeed be prescribed by the latter, and consequently a cursory sketch of the teaching technique adapted to characteristic varieties may not be out of place in what aspires to be essenti- ally a medical work. As a matter of convenience, industrial and moral training, though forming integral portions of the educational system, will be considered in subsequent chapters. In dividing educational means into (a) physical (those more particularly addressed to the body), and (b) mental (those more particularly addressed to the intelhgence), we must bear in mind that the two are not independent of each other, and H 2 100 Mentally -Deficient Children. that with regard to mentally-deficient children especially, "the physiological education of the senses must precede the psychical education of the mind."* We may add that the training of the muscular system to ready and regulated re- sponse is merely an extension of sensorial train- ing ; and both these processes naturally precede, and prepare the way for, more purely intellectual training. It has been well remarked by Froebel that, "in primary education, the Doing, the Thing Done, the Teaching and the Learning must, in every case, rest on actual fact and on real ex- istence, so that the mental intelligence incessantly striving upwards in single things, as in its general career, may thereby expand and develop the life- giving creative powers of the pupils, according to the measure of their strength and ability, their talents and desires. "t The mentally-feeble child is specially incapable of comprehending abstrac- tions : all instruction, therefore, must be presented to it in a concrete form, which it can not only see, but when possible grasp in the hand as well as in the mind. Many of the " games " and "occupations" of the kindergarten are conse- quently of service, but whereas the normal child exercises its own spontaneous activity through these occupations, those who are mentally-defici- ent, especially those of the apathetic type, have to * Seguin, " New Facts, &c.,'' p. 41. New York, 1870. f Froebel's " Letters on the Kindergarten." Swan Sonnen- schein & Co., 1891. Educational Training. loi be stimulated to action by the force of imitation. Our system of education, then, starts on physio- logical lines, first addressing itself to the culture of the external senses, then to the co-ordination of muscular movement, and finally to the pro- motion,' by imitative and other exercises, both of the manual and mental activities. In thus laying down these general principles of procedure it must not be imagined that all cases can be treated in the same way. On the con- trary, it is essential to success that the teacher should study the individual peculiarities of each case, and adapt the educational methods em- ployed to the peculiarities. Mentally-abnormal children may be broadly divided into two main groups ; (i) those who are dull and apathetic ; (2) those whose nervous and mental action is irregular. It is obvious that the rousing, stimu- lating regime suitable for the former, is not that most appropriate to the latter, in which the in- hibitory and co-ordinating functions require to be strengthened by exercise. As extreme examples of the first group we may instance the " impassive, low grade idiot, whose education begins with a bombardment of bean- bags. Such a child is so inert as not at first to put up its hands to protect its face from the bean- bag thrown at it by the teacher ; gradually, how- ever, the instinct of self preservation asserts itself so far as to ward off the missile. The second step, to catch the bag, and the third, to throw it back 102 Mentally -Deficient Children. to the teacher, mark successive steps of improving mental activity ; and from these progress is made in the direction of simple drill, aided by music."* The bean-bags referred to are about five inches square, made of bright coloured flannel, and loosely filled with beans or maize, so that their impact is not hurtful. The same sort of exercise, varied by aiming the bags so as to pass through round or square holes in a board, or into the mouth of a grotesque figure, is excellent for pro- moting alertness of the eye and hand, as well as concentrating attention, in higher grade children. Amongst children of the second group we in- clude those with evidences of an over mobile nervous system, or with uniform repetitive move- ments, such as those designated athetosis. The golden rule in these cases is — try to substitute in place of purposeless, irregular movements, motor exercises with a definite purpose, and calling for will-power. In this way inability to fix the atten- tion (aprosexia as it has been called) is gradually overcome, and the moral satisfaction resulting from " something attempted, something done," encourages to fresh efforts. In cases where nervous irritability is so great as to give rise to destructive tendencies, the irregular energy should be turned into constructive channels ; thus a child of this temperament may be coaxed to build up * See paper by Author, " On points connected with the Edu- cation of Feeble-minded Children," British Medical yournal, Sept. 8, 1894. Educational Training. 103 wooden bricks into some definite form for the pleasure of knocking them down with a crash ! Gradually he may be led on to practice building for its own sake. The child with incessant movements of his fingers (athetosis) is usually not greatly wanting in will-power, and it is marvellous how much may be achieved by appropriate finger exercises (such as those of the peg-board, see fig. i), or the more interesting kindergarten occu- FiG. I. — Peg-board. pation of " picture perforating." The intelligent teacher will know how to adopt, and adapt to the use of the deficient child, the various educational means now in vogue in our infant schools. It must, however, be borne in mind that much that the normal child learns intuitively needs to be taught specifically to the former. The external senses are often functionally inactive, if not struc- turally defective, and it will be necessary to open up, by a series of sensorial exercises, these ob- 104 Mentally-Deficient Children. structed avenues of approach to the central intel- ligence. Then the due co-ordination of muscular movement must be strengthened and regulated by judicious drill. Finally, the general intelligence must be cultivated by interesting the child in its surroundings, and breaking down the isolation in which the solitary idiot, and to a lesser extent the mentally-feeble child, carry on their existence. All this preliminary work of necessity precedes instruction in the " three R's," and what we are accustomed to regard as ordinary school work. We rejoice, however, to find that the physiolo- gical sequence we have indicated, and which was laid down by S6guin half a century ago as the educational mode for defective children (as well as for others) is gradually being recognised in the curriculum of elementary schools. We do not venture to trespass upon the domain of psedagogy further than to point out the special methods of instruction indicated to meet the special require- ments of pupils, who by reason of mental defect (often associated with physical) cannot "properly be taught in the ordinary standards, or by ordin- ary methods." And first with regard to sensorial training, it will be convenient to consider separately the several senses, though in practice the training will be of a combined character. The tactile function is not only the most general, but in some respects the most important of our senses, and in the normal baby its evolu- Educational Training. 105 tion takes precedence of the rest. Impressions through the eye and ear are criticised through the sense of touch, and this natural development, so serviceable in the spontaneous education of all healthy young animals, must be imitated in our endeavours to bring up towards the normal standard the sensorial training of imperfect chil- dren. In some cases we shall find coarse insen- sitive hands, which must be drilled into sensibility by grasping hard and soft objects, and discrimin- ating the resistance and surface impressions of such varying substances as polished marble, sand paper, velvet, silk, &c. Sensibility to heat and cold may be gauged and cultivated by the handling of bottles filled with water of varying degrees of temperature. Such lessons will of course form incidents of the object lessons which play so important a part in early education. In some exceptional cases there is a morbid sensi- bility {hyperesthesia), which' is best counteracted by friction against hard substances, and the employment of the fingers in coarsish work. The use bf the peg-board (fig. i) has already been mentioned as serviceable in cases of athetosis (spasmodic finger movements) : it is also valuable in cultivating the tactile sense. Similarly size and form-boards (figs. 2 and 3) promote accu- racy of grasping movements, and a pin-cushion covered with spotted material, into the spots of which the child sticks pins, is useful in exercising minute sensation, as well as fine adjustment of io6 Mentally -Deficient Children. the muscles. Stringing beads and buttons serve not only as exercises of the tactile sense, but as will afterwards be pointed out, of the arithmetical faculty. Fig. 2. — Size-board. Fig. 3. — Form-board. The sense of sight comes next in importance to that of touch, as regards training. Ocular defects must of course be treated by the surgeon : Educational Training. 107 the teacher's function is to concentrate the wan- dering gaze, to specialise the vacant stare of the defective pupil. To quote a quaint Gallicism of S^guin's, "the main instrument in fixing the re- gard is the regard;" that is to say, the vagrant eye of the pupil may be brought to attention by the fixed gaze of the instructor. Glittering objects, such as the silvered globes used for Christmas trees, are serviceable also for this purpose, especially with very young children, and the kaleidoscope is an attractive toy of distinct educational value for older ones. The indepen- dent movement of the eyeball, apart from that of the head, should be made a point of; the training of the ocular muscles is too often neglected, with the result that the child's lateral range of vision is unduly restricted. Discrimination of colour is a later exercise of the visual organ ; and for this purpose discs of various colours for the child to match, cubes, the sides of which are vari-coloured and are successively turned uppermost, follow- ing the lead of the teacher, and a series of cups and balls, to be fitted together in corre- sponding colours, are useful aids. But perhaps more interesting to the juvenile mind is the matching of coloured ribbons and articles of clothing, or pointing out corresponding hues in coloured pictures. Exercises in colour perception naturally lead to the distinguishing of colours by name, but the former take precedence in sensorial training. The teacher or nurse should not there- io8 Mentally-Deficient Children. fore commence by asking the child which is red, blue, &c., but the colour sense should be exercised by getting the child to sort into separate heaps the several discs or pieces of coloured cardboard. Matching coloured wools, and finding cards cor- responding in colour to the squares on the colour chart, are other useful exercises. The forming of pictures from picture cubes in a more advanced form of eye training, and the use of size and Fig. 4. — Graduated wooden rods. form-boards (figs. 2 and 3), and of the gradu- ated wooden rods, to be arranged in step-like series (fig. 4), exercises both hand and eye, and imparts ideas of form and dimension. Ideas of relation are similarly imparted by exercises with domino boards (fig. 5), two of which are placed (a) flat together, one at right angles (6) to the side, (c) to the end of the other, following the leader. Educational Training. 109 Taste and smell, being essentially animal rather than intellectual senses, do not as a rule require much culture in the mentally-deficient class.* But discrimination must be exercised by offering to the pupil substances of similar appear- Fig. 5. — Domino boards. ance such as salt and white sugar to be distin- guished by taste, ground coffee and snuff to be distinguished by smell. Hearing is sometimes apparently deficient when the real deficiency is that of attention. Mentally-feeble children often hear perfectly well, * Perverted and abnormal states of these senses are occasion- ally met witli in idiots ; we have knovifn one whose peculiar " taste for literature " was manifested by his " devouring his book," cover and all ; and another who distinguished his own and his comrades' clothes solely by the sense of smell ! no Mentally -Deficient Children. but do not take the trouble to listen ; they may, however, be coaxed to do so by presenting to them agreeable sounds. Fortunately music has for this class special charms ; and a simple song will often enlist attention when mere speech is disregarded. Nursery ditties are consequently not without educational value, and, as we shall see later, often form stepping-stones to speech. Tone-deafness is sometimes met with, and if low pitched sounds are not apprehended, those that are more shrill (such as those produced by the whistle) should be tried. At a later stage the discrimination by pupils of the different quality of sounds produced by different instruments is a good exercise. Speech is a complex function, having import- ant relations to auditory perceptions on the one side, and on the other being dependent upon the integrity of nerve centres and tracts, and the due co-ordination of the muscular apparatus con- cerned in vocalization and articulation. More or less imperfection of speech is extremely common with mentally-deficient children, and when not the result of want of development or lesion of the cerebral speech centre, much may be done in the way of amelioration by appropriate training. Excluding cases dependent on deafness — (in which lip-imitation methods are of much value, and the " oral method " has a literature of its own) — we may say that, as a rule, such children require to be taught to speak much as a baby learns to Educational Training. iii speak. In some cases, however, a course of lip and tongue gymnastics is an essential prelimin- ary. The pupil may be unable to bring the lips together, to bring the teeth together, or to direct the tongue as required for the formation of a sound. In such cases special exercises adapted to the special infirmity are requisite. To im- prove the power of closing the lips, a flat piece of boxwood, or an ordinary penholder stick may be held by the child between his lips for a few minutes at a time ; and this is an exercise useful in repressing slavering. Blowing a whistle is also of service. Opening and closing the mouth so as to bring the teeth together; putting out the tongue, deviating it to the right and to the left, and touching with it the teeth of the upper and the lower jaw respectively, also the roof of the mouth, are other forms of oral exercises service- able in overcoming defects of co-ordination inter- fering with clear articulation. As a rule consonant sounds are more readily acquired than vowel sounds. The normal infant starts its attempts at speech by repeating the simplest labials or Unguals : " bab-ba," " mam- ma," and later " dad-da," are among its earliest efforts. Following these lines, the child deficient in speech should be exercised in simple re-dupli- cated consonant sounds followed by the open vowel a {ah). A schedule of speaking exercises based on these principles was published by the author in an article on the " Educational, &c.. 112 Mentally -Deficient Children. Training of Idiots and Imbeciles," in Hack Tuke's " Dictionary of Psychological Medicine,"* In this the repetitive phonetic (as "mam-ma") is coupled with name of a common object ("mat," "man"), of a part of the body ("mouth"), and of part of dress ("muff," "mitten"), beginning with the consonant sound (m) ; and so on through the series of labials. Unguals, labio-dentals, gutturals and nasals. There is also a table of vowel sounds and examples. But for the present-work it must suffice to say that with mentally-deficient children half the battle is to sustain their interest, and mechanical exercises in speaking, however well devised, must be brightened up by illustration. The naming of objects in well chosen pictures, t and of the child's own surroundings, and the imitation of the characteristic cries of animals, are some of the best means of making a start with speech. A child will demur to repeat sounds read by a teacher from a table, though he will cheerfully respond to the questions, "What does the cow say?" ('Moo'), or, "What does pussy say?" ('Mew'), Similarly he will imitate the "Ba-ba" of the sheep, or the "Bow-wow" of the dog, and thus unconsciously learn both con- sonant and vowel sounds without an effort. It has already been reniarked that with the feeble-minded, music is often a stepping-stone to speech. Such children will frequently hum tunes * Churchill, 1892, vol. ii., p. 673, (See Appendix E). •)• Dean's " Book of Objects " is recommended. Educational Training. 113 that take their fancy before they are able to arti- culate words ; but if attractive tunes set to words containing repetitions of simple sounds (such as the " Ba-ba black sheep " of our old Nursery Rhymes*) are constantly repeated to them, the probability is that after a time, first one word and then another will be taken up by the pupil, till the rhyme as well as the tune is known. We pass from the cultivation of speech, which occupies an intermediate place between sensorial training and the co-ordination of muscular move- ment, to a consideration of the exercises more especially addressed to the latter, which we in- clude under the comprehensive designation of drill. With children of deficient bodily as well as mental development, physical training is serviceable not only for muscular growth and co-ordination, but, inasmuch as it demands prompt obedience, for strengthening the faculty of attention. The movements must be gentle and adapted to individual capacities and even incapacities ; mere " tours de force " are inadmis- sible. Musical drill is to be preferred whenever practicable, and there are now many excellent manuals on this subject, such as Gill's " Physical Exercises," Alexander's " Musical Drill for In- fants," &c.,t which may be advantageously used * Elliott's " National Nursery Rhymes " is recommended for this purpose. f See also " Physical Education," by Lennox and Sturrock. (Blackwood). I 114 Mentally-Deficient Children. for exceptional as well as ordinary children. Light wooden dumb-bells, wands and rings, are the simple apparatus required. For special in- firmities, however, such as we frequently meet with in the mentally-feeble, special exercises have to be devised for particular cases ; and the want of balancing power many show is overcome by "toeing the line," by walking the plank, by step- ping first between the broad bars of a ladder laid horizontally on the ground, and then from bar to bar. Deficient grasping power is strengthened first by the bean-bag exercises previously referred to, then by bar-bells, and finally by supporting the weight of the body on parallel bars, or from the bridge-ladder. Though scarcely gymnastic, dressing lessons may be given with advantage as class exercises to children inexpert in putting on their clothes. Buttoning, lacing and tying bows and knots bring into play fine adjustments of the fingers frequently deficient with the mentally-feeble. With regard to the more ordinary school exercises we can only indicate a few points in which special stress should be laid in the case of mentally-feeble children. " Facta non verba" should be the guid- ing principle ; things done will make much more impression than things merely said ; and when- ever practicable, lessons should be illustrated by objects, for as was remarked by Horace : " Segnius irritant animos demissa per aurem Quam quae sunt oculis subjecta fidelibus." Educational Training. 115 Mere parrot-like repetitions of matters committed to memory should be discouraged ; nothing should be learned by rote which is not understood, other- wise much labour may be lost, and at length we may find (with Longfellow) that " In an idiot's brain remembered words Hang empty mid the cobwebs of his dreams." Object lessonEj must start from the simplest facts within the child's observation. The names and uses of the sense-organs, of the limbs, of articles of clothing, of the furniture of the room, are some of the subjects upon which the child's intelligence should be exercised. Drawing and writing are best taught in the elementary stage by large scale exercises on the black-board chequer. Drawing lines vertically, horizontally and obliquely, between points marked by the teacher, and afterwards delineating com- mon objects, under which the names may, with help, be printed and written,* pleasantly lead the child on both to writing and reading, and with regard to the latter it may be remarked that the " word-method " is to be preferred to the old- fashioned plan of beginning with the drudgery of the alphabet, t Of course the names of letters are learned at a later stage, words being dissected for this purpose with the aid of the letter-box. Calculation is the crux in educating the * See " Reading Made Easy," Anna Snell. Philip and Son, London. f Gill's " Regina Reading Sheets " are useful. 12 ii6 Mentally -Deficient Children. mentally-deficient.* Counting (so-called) may be glibly done without any apprehension of the meaning of figures ; consequently the concrete must always elucidate the abstract. Many excel- lent aids are published for this purpose, pictorial and otherwise ; but the ingenious teacher will not be dependent on these, as the child's own fingers, the pupils in class, &c., are always available for demonstration. Shells, beads and the abacus are also convenient objects for counting. To eluci- date the value of weights, money, and to teach simple calculation, there is nothing better than the " shop lesson," an elaboration of the nursery game of shop, in which common groceries are weighed out and paid for by the pupils, problems in change being practically tackled. Industrial training is intimately interwoven with educational processes, but we specially treat of it in the next chapter. * It is remarkable that in the case of candidates for admission to the London Special Classes, there is often a certain ability to malce small calculations as to pennyworths such as they have been accustomed to in errands for their parents. With them reading seems to be the crux. Industrial Training. 117 CHAPTER IX. Industrial Training; and Recreation. To complete the educational fabric appropriate to mentally-deficient children, the woof of indus- trial training must be closely interwoven with the warp of scholastic exercises, and a whole- some moral influence must be the pattern per- vading the whole. In the present chapter we offer some hints as to special modes of industrial training found useful. The "occupations" of the Kindergarten form attractive and serviceable preliminaries to handi- crafts. " Paper - weaving, " for instance, is an excellent preparation for the more prosaic in- dustry of stocking darning, and the "pricker" used for perforated pictures will serve as an in- troduction to the cobbler's awl. Useful as are Kindergarten occupations for training the fingers, and, through them, the intelligence, the actual products of child-labour in the way of bead neck- laces, variegated paper mats, pretty models, &c., have a distinct value in stimulating further effort, as the principle of achieving a tangible result is specially satisfactory to the mentally-feeble child. In this respect, industrial training has an advan- tage over mere book learning, and it has been ii8 Mentally -Deficient Children. well remarked that feeble-minded children learn more with their hands than with their head. The kind of employment most suitable differs with the particular characteristics of each case. With the majority, out-door work is the best whenever practicable, and we have repeatedly seen both physical and mental development set going by such healthy occupation, when indoor teaching and employment had proved unavailing. Careful supervision is of course needed ; other- wise, if put to weed a garden the child may ruth- lessly root up plants as well ! The love of seeing things grow, however, should be fostered, and the child will soon watch with interest how the seedling gradually becomes the plant. Growing mustard and cress on moistened flannel is one of the demonstrations which delight the pupils of the London School Board special classes. Kindness to animals should be inculcated ; and, when this exists, occupation at a farm is often beneficial, much interest being taken in the stock. To town-bred children, unfortunately, such occupations as these are not open. There are, however, many varieties of manual training now commonly practised in connexion with our public elementary schools (and in some private classes) in which the mentally-feeble may participate. Cloth and cane weaving, simple hand-basket making, rococo work, sash-line plaiting, are some of the arts easily acquired, which furnish a very pleasing result ; and the same may be said of Industrial Training. iig Macram6 work, which in our experience is an excellent exercise for those subject to finger twitches. We have elsewhere remarked that these athetotic patients frequently possess gra- phic and artistic ability; and for such, wood- work and even wood-carving form congenial em- ployments. It is marvellous how by persevering exercise of will-power, such pupils gradually over- come their spasmodic movements, and are at length able to execute quite fine work with the chisel and graving tool. Girls with athetoid affection often become, under training, good needle-women, putting in their stitches with great regularity. The mysteries of knitting, crochet and other fancy work are also mastered by them ; and we have seen a mentally-feeble girl, crippled as to her right hand by spastic contractures, do fine-art needle-work with her left. The practical needs of after-hfe must of course be borne in mind in selecting a particular employ- ment. The gentleman's son, though comfortably provided for, will be all the happier for having an occupation to turn to ; and for such, carpentry, wood-carving, and even turning are good indoor pursuits, whilst gardening and farming are spe- cially appropriate. Young ladies who by reason of their feeble-mindedness will be to some extent debarred from the ordinary pursuits of society, should be encouraged to take an interest in domestic matters and to assist in the still-room. 120 Mentally -Deficient Children. They may also employ themselves in a variety of fancy work ; and if they possess any artistic or musical tastes these should be cultivated. For children of the working class some occupa- tion which they can carry on under the eye of their parents is desirable. If they live in the country they should be trained for agricultural labour, or to assist in garden work. If in town, some work which they can practise at home, or in small establishments, such as cobbling or tailoring, basket or door-mat making, should be taught them ; for obvious reasons they are unfit for factory work. Girls should be trained to work in the house and the laundry, and to make gar- ments. Many imbeciles who have been brought up in Institutions are quite capable of earn- ing their living under favourable circumstances, but the "res angusta domi," and (too frequently also) parental incapacity, are not favourable cir- cumstances, and, consequently, if discharged to their own homes, there is much risk of training being thrown away. This is one of the argu- ments in favour of custodial working-homes being instituted by the County Councils for mentally- deficient children capable of useful industry. Recreation. — For mentally-feeble, as well as other children, the maxim " ne quid nimis " is especially appropriate. Study and occupation must be varied ; and relaxation is essential. But care must be taken that relaxation does not de- generate into loafing ; suitable recreation must be Recreation. 121 supplied. Mentally-deficient children, particu- larly those of lower grade, are apt to be solitary ; they have no idea of combination, even for games. Games of ball may, indeed, be practised alone, but they are much more useful when played with others in the form of rounders, cricket, hockey, or tennis. Football can only be played under special conditions — neither Rugby nor Association Rules ; it forms a valuable exercise for the lower limbs. Even golf maj' be played by feeble-minded people. Games at marbles are good for finger training. Trundling hoops, playing horses, &c., should also be encouraged. Skipping is an excel- lent exercise for boys as well as girls, so long as the heart is all right. The game of battledore and shuttlecock is good training both for hand and eye. Of indoor recreations, dancing is to be specially commended as tending to improve carriage and diminish the tricks of gait which often mark the mentally-deficient. " Musical Chairs," " Post " and other similar games pro- mote both activity and intelligence. Bagatelle is a good indoor diversion, the scoring being of educational value ; and dominoes give ideas of number. The " children's hour," so valuable an institution in normal nurseries, is specially useful with the mentally-feeble, who often require to be taught to play, and sleep better for the romp before retiring. The love for music which is common with the mentally-feeble, suggests attendance at concerts 122 Mentally-Deficient Children. and at musical services as appropriate modes of enjoyment. With some a considerable sense of humour exists, and theatrical performances, especially when abounding in comic situations, are much appreciated. It is of importance that entertainments, at which mentally-deficient chil- dren are present, should be of a refined character. Coarse buffoonery and scenes of violence — provo- cative to some weak minds of imitation — should be carefully avoided. Even our old friend " Punch " is not altogether unexceptionable for a feeble-minded audience ! Moral Training. 123 CHAPTER X. Moral Training. If good moral training be a prime essential in every system of education, it is specially so in the case of mentally-deficient children. Not that the mentally-feeble child is by nature morally worse than the ordinary child, but his weakness makes him more pliable, and an evil example — not to say precept— may in his case be specially in- jurious. It is a curious and lamentable fact that when the inhibitive nerve power is weakened, either from disease or from original defect, the lower nature is apt to assert itself, both in deed and word ; and it is sometimes a matter of sur- prise how mentally-feeble persons, notwithstand- ing good surroundings, give vent to the most evil language, profane or obscene. Even the hasty word, carelessly uttered, may be taken up by the weak-minded child, and reproduced on some in- convenient occasion. Great care therefore should be taken by all in charge of such cases to be choice in their language, as well as correct in their conduct ; for imitation is characteristic of the class. On the other hand a good moral in- fluence is insensibly exercised by those who are J 24 Mentally -Deficient Children. judicious, and the choice of a teacher or attendant is a matter of supreme importance, moral as well as mental qualifications calling for considera- tion. As regards moral discipline, coaxing, not coercion, must be the guiding principle. With the mentally-deficient especially, "force is no remedy," the "cowed" child will be a cowardly child, with no pluck or spirit to advance itself. As Roger Ascham remarks with regard to the ordinary pupil, he must in no wise be " beaten into the hatred of learning;" and not only in the scholastic but in the general management of the mentally- deficient child, love must be the all-pervading principle. At the same time judicious firmness must be exercised ; and consistency in word and deed, combined with tact, are essential to moral influence. The mentally-feeble, like the ordinary child, soon finds out to whom he must render prompt obedience. A system of rewards and punishments, modified of course to meet individual peculiarities, is effica- cious with this class as with others. Mentally- deficient children are frequently eager to obtain the commendation of their superiors ; and sometimes withholding commendation will make sufficient impression, at other times words of reproof are necessary. Corporal punishment is rarely bene- ficial ; yet there are cases where pain wantonly inflicted on others is appropriately visited by pain inflicted on the offender. Sometimes an appeal Moral Training. 125 to the mind is best made through the stomach ; thus the cutting off of some favourite article of food {e.g., pudding or sugar) from the day's dietary, will mark disapproval better than any other mode. The deprivation of some looked-for pleasure, such as attending an entertainment or going to church, will be efficacious in many cases; as with younger children will be the temporary forfeiture of some favourite toy. Older cases occasionally (perhaps exceptionally) develop a keen interest in the value of money, and such are best touched by an abate- ment of their allowance, or the enforcement of a fine. With the growth of intelligence it must be pointed out that harm, followed by punishment, inevitably results from evil-doing, and that "Though the mills of God grind slowly, yet they grind exceeding small ; Though with patience He stands waiting, with exact- ness grinds he all." The weak-minded person is not to be encouraged in the notion — but too easily taken up with dangerous consequences —that, because he is not quite like other men, he is less responsible for his actions. From foibles he should of course be guarded ; and he should learn to respect his neighbour, and act on the legal maxim, " Sic utere tuo, ut alienum non laedas." It would be out of place here to discuss the question of the legal re- sponsibility of the mentally-deficient ; the author has elsewhere argued that moral responsibility, at 126 Mentally-Deficient Children. any rate, varies with the kind and the degree of the deficiency.* Perhaps the most trying case we are called on to deal with amongst children mentally-abnormal — there is in this instance often but little intel- lectual deficiency — is that of the moral imbecile. ■ The despair of his parents, the hete noir of the institution, the perplexing puzzle of the jurist — he seems to be the ill-fated product of inherited nervous instability and ancestral criminal in- stincts. He (or she) may combine the most innocent, sometimes engaging, external appear- ance, with an inner depth of cunning and iniquity which requires to be experienced to be appreci- ated. The sudden impulses to mischief occurring in these cases are probably of an epileptoid character, and paroxysms may sometimes be cut short by bromides. But as a rule moral dis- cipline is of little avail ; punishment may be administered, and professions of penitence called forth, only to be forgotten as soon as the mental disturbance again recurs. The author has a vivid recollection of three nice looking children, sisters and brother, formerly under his care, who at times would appear models of propriety, while at others they had all the characteristics of little demons. With innocent expression they would furtively accomplish the most abominable mis- chief, and after meekly acknowledging the error * "Legal Responsibility of Educated Imbeciles," journal of Menial Science, vol. xxix., p. 467. Moral Training. 127 of their ways would emphasize their apology by a missile flung at the head of the person who had attempted to bring them to repentance ! Such children would in old time have been called "possessed;" now they are classified as cases of moral imbecility, or juvenile insanity. Dr. Samuel J. Fort has described similar cases under the title of " Psychical Epilepsy."* In other disappointing cases we find consider- able improvement in intelligence and manual skill with actual deterioration of the moral sense. In- telligence and skill which have been acquired are, indeed, used for evil purposes ; and the late Dr. Kerlin, the able Superintendent of the Penn- sylvania Institution, who paid much attention to this class, came to the conclusion "that to edu- cate them often gave them added power for evil, and that they should not be allowed to prey upon society." He claimed that moral imbeciles " should be treated in a class apart in buildings by themselves, as they affect the methods of living and training of the rest."t Dr. Jules Morel has, in an able communication to the Medico-Psycho- logical Association, J advocated the establishment of special institutions, intermediate between Re- formatories and Asylums, wherein " such per- * Proc. Association Amer. Institution for Idiotic and Feeble- minded Persons, 1894, p. 400. t Forty-first Annual Report Pennsylvania Training School, Philadelphia, 1893. \ journal of Mental Science, vol. xl., p. 599. 128 Mentally-Deficient Children. sons should be objects of prophylactic treatment against crime." There is need for caution in the charitable provision for the mentally-feeble class that egoism, which often springs from the solitary instincts of this class, be not pandered to, but rather that altruistic views should be enforced. The golden rule that even the feeble-minded should " do unto others as they would be done by" should be in- culcated ; and happily such persons are often susceptible not only to moral but to religious influences. Their very simplicity leads them to accept without hesitation ideas of a Universal Father, who is at the same time an all-seeing God, of a loving Saviour, and of a sanctifying Spirit ; and however imperfect may be their com- prehension of these mysteries, there is no doubt that such notions tend to exert a wholesome re- straining influence upon conduct. It is not our intention here to discuss the importance of reli- gious teaching as the foundation of moral train- ing ; but no one who has had large and intimate experience of mentally-deficient children will deny- that in many the religious sense is not wanting. In this connexion we are tempted to quote from the letter to his sister of an athetotic imbecile formerly in the Royal Albert Asylum, a letter written unprompted and unassisted. Referring to the Sunday Service the poor lad writes : — " How beautiful it is to think of our dear, Saviour who loved us all. He knows that I could not do anything for our dear Lord, Moral Training. 129 and it makes me happy to think about Him and to sing about Him as well. We must pray to God to make people happy in our dear Lord and Saviour, and the Holy Spirit." .... We venture also in conclusion to quote from the testimony of a former Teacher describing the closing scene of the life of a pupil who verged upon the type of moral imbecility. She says : — " The dear little fellow, once all life and mischief, the torment- ing pupil of my first school, was dying of consumption. Almost every night he called the Chief Attendant to ' hear his prayers,' giving as his reason that ' his Papa told him not to forget them.' At last, through increasing weakness, he could but lay his feeble hands within those of Mr. M. and listen while he repeated the Lord's Prayer One Sunday, as we were watching by hig bedside, there came a sudden change ; the end was evidently near, as we sent to the doctor to inform him. Turning towards us with placid face, though with fast glazing eyes, the poor boy tried to raise himself in bed, then he stretched forth his wasted fins;ers, as if feeling for something. ' Where is God ? ' he ex- claimed, ' I want to find God ! I \vant to go to God.' Soon he fell back upon his pillow, and in a few minutes his Spirit returned to God who gave it." 130 Mentally -Deficient Children. CHAPTER XI. Results and Conclusions. In this closing chapter we propose to discuss the results which have accrued from the system of treatment and training we have endeavoured to describe, and to formulate some conclusions as to the value of the work. " Once an idiot always an idiot " was for many ages the received doctrine on the subject, and we need not be surprised to find that this view still lingers with many otherwise well-informed people, who are not conversant with what has been done during the last fifty years to amelior- ate the condition of mentally-deficient children. Even Esquii'ol himself had, previous to S^guin's triumphant labours, penned these desponding words : — " Idiots are what they must remain for the rest of their life ; everything in them betrays an organisation imperfect or arrested in its deve- lopment. We do not entertain the idea of its being possible to change this condition. No means are known by which a large amount of reason and intelligence, even for the briefest period, can be bestowed upon the unhappy idiot." Such pessimism, applied as it was to all grades of congenital defect — at that time comprehended in Results and Conclusions. 131 the French term idiotie — was happily soon proved to be quite uncalled for. In 1843 we find the elder Voisin, in a paper read before the French Academy of Medicine, referring in terms of warm appreciation to S6guin's studies and successes. " While we are speaking," says he, " of the men who have occupied themselves with idiots, we should not fail to mention here with some dis- tinction, M. Seguin appointed director of our idiot asylum at Bicfetre .... Already in 1838, and since, he has published the result of his efforts on behalf of a certain number of pupils, whose condition he has favourably modified." And S6guin himself writing, after thirty years' experience of this special work, says* : — " Idiots have been improved, educated, and even cured ; not one in a thousand has been entirely refractory to treatment ; not one in a hundred who has not been made more happy and healthy ; more than thirty per cent, have been taught to conform to moral and social law, and rendered capable of order, of good feeling, and of working like the third of a man : more than forty per cent, have become capable of the ordinary transactions of life under friendly control, of understanding moral and social abstractions, of working like two-thirds of a man, and twenty-five to thirty per cent, have come nearer and nearer the standard of manhood, till some of them will defy the scrutiny of good * " Idiocy and its Treatment by the Physiological Method," New York, 1866. K2 132 Mentally-Deficient Children. judges when compared with ordinary young men and women." The experience of institutions for training youthful idiots and imbeciles both in this country and in America (so far as it extends) goes to con- firm the accuracy of S6guin's view on this subject. The statistics of the Royal Albert Asylum, Lan- caster, with regard to the after-career of pupils discharged on completion of their seven years' training, showed that ten per cent, were, or had been,- earning wages ; that five per cent, were remuneratively employed at home ; and that 3'5 per cent., in addition, were capable of earning wages if suitable situations could be found for them. About twenty-two per cent, were reported to be more or less useful to their friends at home, while another twenty-two per cent, were said to be of little or no use ; twenty-nine per cent, had gravitated to workhouses and lunatic asylums ; the remainder (8"5 per cent.) had died. It must not, however, be imagined that even the best of the above were in all respects equal to persons of average intelligence. Some residual peculiarity usually remains to handicap the feeble-minded in the race of life. "It is not indeed to be expected that without some form of tutelage even the trained imbecile can hold his own in the outside world, and in the majority of cases it may be appropriately said ; — 'Tis not enough to help the feeble up, But to support him after."' • " 2yth Annual Refort, Royal Albert Asylum," p. 40. Results and Conclusions. 133 There is no doubt, however, that such support is rendered infinitely easier by methodical trainiug, and the burden to the friends much lighter. With regard to American experiences we will quote from the paper of Dr. Walter E. Fernald, previously cited. He says* : — " Each year a cer- tain number of persons (trained in industrial work) go out from these institutions [for the feeble-minded] and lead useful, harmless lives. Some of the institutions where only the brightest class of imbeciles are received, and where the system of industrial training has been very care- fully carried out, report that from twenty to thirty per cent, of the pupils are discharged as absolutely self-supporting. In other institutions, where the lower grade cases are received, the percentage of cases so discharged is considerably less. It is safe to say that not over ten to fifteen per cent, of our inmates can be made self-support- ing, in the sense of going out into the community and securing and retaining a situation, and pru- dently spending their earnings. With all our training we cannot give our pupils that indispen- sable something known as good, plain common sense. The amount and value of their labour depend upon the amount of oversight and super- vision practicable. But it is safe to say that over fifty per cent, of the adults of the higher grade who have been under training from childhood are capable, under intelligent supervision, of doing a * op. cii., p. 17. 134 Mentally -Deficient Children. sufficient amount of work to pay for the actual cost of their support, whether in an institution or at home."* We must not, however, conclude that the bene- fits of training are merely to be measured by appraising the proportion of those able to earn their own living. This of course is a positive gain, but there are many which we may call negative, hardly less appreciated by those on whom the care of the mentally-deficient falls. That a child should no longer be uncleanly, mis- chievous or destructive in habits ; that it should cease to disturb the peace of the household by discordant cries, and by untimely wanderings, are points which parents thankfully recognise ; and if in addition it can be taught to undress and dress itself, to feed itself, and to behave with propriety, these results are by no rtieans despicable, even from the economical point of view. It must not be forgotten that the charge of an untrained idiot at home usually monopolises the time of one of the older members of the family, who is thus pre- vented from earning wages ; and without judicious training and discipline deterioration is pretty sure to occur. Even in the best regulated families the care of a defective child is a constant anxiety ; * A more recent American writer (Dr. Powell, Superintendent of the Iowa. Institution) advocates " permanent " sequestration as the most efificient and humane manner of reducing the number of the feeble-minded. Another method proposed and actually prac- tised in, at any rate, one of the States, is the surgical unsexing of imbeciles of an age for procreation. Restdts and Conclusions. 135 how much more in the labourer's cottage, where oftentimes only casual attention can be given it ? The relief to parents afforded by Institution treat- ment is well illustrated in the Report for 1894 of the Superintendent of the Eastern Counties Asylum. He gives a striking example of a mis- chievous imbecile, who "describes with great glee how (before admission) he was left to mind the baby, and blacked its face all over with soot, so that when his mother returned she might think she had a black baby; how his little sister wanted some water and he told her to drink out of the kettle on the fire, by which she nearly lost her life ; and how he was turned out of the Parish Church, during service, for pricking a boy with a pin, so that he yelled out and disturbed the whole congregation ! " In the same Report* reference is made to the desirability of continued kindly supervision even of cases discharged capable of earning their own living. "On sending them out into the world," (says Mr. Turner) " they are looked on as fully responsible for their actions, although their power of reasoning is undoubtedly defective. One of our old boys who had been steadily earning his living for the last two years, and against whom there had been no complaint, was sent by his master to take up potatoes in his shepherd's garden. The shepherd's wife gave him some * Eastern Counties Asylum for Idiots, 36th Annual Report, 189s, P- 45- 1^6 Mentally-Deficient Children. home-made wine early in the morning and after- wards locked the door and hung up the key within reach, teUing him that she was going out for the day. Knowing him as I did, it seemed to me the most natural thing in the world for him to take the key, and help himself to more wine, and afterwards to some money lying in a drawer. When the woman returned at night and was told by her neighbours what had occurred, the lad was charged with house-breaking, and no considera- tion was shown to him, although it was known that he had been for six years the inmate of an idiot asylum. Fortunately the magistrates dis- missed the case, and his master was kind enough to take him back, saying that he was as good a workman as he wanted." For improved cases, able to take situations on leaving Training Insti- tutions, it seems very desirable that there should be some organisation of philanthropic persons willing to keep a friendly eye on such, some- thing after the plan pursued by the Girl's Friendly Society with regard to servants, or the "Fiirsorge" system exercised in Saxony with regard to those discharged from training institutions for the blind. It having been found that many of the pupils of the latter who had been taught a trade were still so far handicapped by their affliction as to be incapable of competing in the open market, an organisation was arranged whereby a trustworthy person resident in the place of employment of the pupil, undertook to Results and Conclusions. 137 give kindly aid and supervision, and to report to the Institution in the event of arrangements not proving satisfactory. This plan works so v^^ell that the Royal Commissioners on the Blind, &c., remark as a practical result that " during their tour they saw no blind beggars in Saxony, and were informed that begging on the part of the blind had practically ceased to exist." Notwithstanding all drawbacks, we have known some remarkable instances of permanent improve- ment resulting from training. One of our former pupils, an example of the class now designated "mentally-feeble" as distinguished from imbecile, though for a period an inmate of the Royal Albert Asylum, became, under instruction, an expert joiner, and (what was even more remarkable) from being a very imp of mischief grew up into a well-conducted, self-reliant youth, and ultimately emigrated to one of our colonies. When we last heard of him he was practising his trade in a leading city, and in a letter home reported him- self as doing well, business being brisk in conse- quence of a conflagration which had recently occurred ! In another instance, we encountered in the streets of a northern town a young woman of "considerable personal attractions," whom we did not at first recognise as an old patient — (her's had been a case of mild traumatic imbecility) — but who informed us that she was happily married to a respectable artisan; and certainly she had quite the appearance of a tidy housewife, for 138 Mentally-Deficient Children. which she would be well qualified by her insti- tution training. It is remarkable that of near a thousand discharged patients who had passed under obser- vation, the two just mentioned are the only instances in which we have known marriages occur. It has indeed been urged as an objec- tion to educating mentally-deficient children, and fitting them for work in the world, that they would be thereby encouraged to marry, and in consequence there would be a risk of multiplying mental defect in the progeny. Our experience, however, lends no support to this view. In one case, that of a youth who, after a term of institution training, had become an in- dustrious labourer, and was earning eighteen shillings a week, we ventured to ventilate the subject. The young man had been telling us how, in addition to paying for his board, he had been able to accumulate a fair amount in the Post Ofiice Savings Bank. "Well," we suggested, tentatively, "perhaps you are saving up against getting married." "Nay, nay, doc- tor," was the reply, "it's hard enough for a feller to keep hisself, let alone bothering with a girl!" Such philosophy as this is rarely met with in the social class to which this youth belongs, or we should hear less of improvident marriages. The effect of judicious training seems to be to impress upon the improved imbecile that he is not quite like other men, and must not undertake the Results and Conclusions. 139 responsibilities of married life. Certainly, the net result of training is to diminish the risk of transmitting the evil to another generation, inas- much as moral principles are instilled which have a restraining influence on conduct. Moreover the very fact of healthy occupation tends to keep in check the animal passions, which are apt to run riot when the adolescent imbecile is unemployed. This is one, amongst other reasons, for the estab- lishment of small industrial homes like those affiliated to the National Association for Promot- ing the Welfare of the Feeble-Minded, or the proposed permanent refuges of the Lancashire and Cheshire Society. We have elsewhere* insisted upon the duty incumbent on our County Councils to make specific provision — apart from lunatic asylums — for young imbeciles; and we do this not only from the philanthropic, but also from the econom- ical, point of view. Miss Louisa Twining, from her experience as a guardian, urges that they should establish "asylums sufficient for the needs, not only of pauper children, but of others who by timely training might be saved from becoming life long burdens on the rates." t Dr. Rhodes, Chairman of the Chorlton Board of Guardians (Manchester), points out that J "the want of proper provision for these cases throws a very * Lancet, 1895, v'- ••' PP- 838, 893, et seq. f Lancet, 1895, vol. i., p. 1017. J Lancet, 1895, p. 1082. 140 Mentally-Deficient Children. heavy burden upon the poor-rate. Returns ob- tained from the various boards of guardians show that in one year 715 weak-minded women passed through 105 workhouses, and at 56 workhouses it was stated that 366 of these women were living immoral lives ! "* The appropriate treatment of the mentally- feeble (or feeble-minded) class as distinguished from idiots and imbeciles is a question which has of late years been much discussed from several points of view. It is, however, only fair to recall the fact that so long ago as 1846, Seguin included in his book (to which reference has previously been made) the treatment not only of idiots, but of backward children (Enfants arrieres, ou retardes dans leur developpement, agites de mouvements involontaires, debiles, muets, non-sourds, &c.) : and that some of the cases, the successful training of which he records, are of the mentally-feeble type. It is not always recognised that the so-called " Idiot Asylums" have also served the purpose of board- ing-schools for children merely weak in mind — a department of their work which has been facil- itated by the passing, in 1886, of a special Act, taking them out of the category of lunatic asylums, and giving facilities for the admission of pupils by substituting a simple form of certif- * A " colony " for Epileptics and Imbeciles is shortly to be established in Lancashire by the co-operation of the Manchester and Chorlton Unions. Results and Conclusions. 141 icate for those previously required under the Lunacy Acts. Inasmuch, however, as this cer- tificate is to the effect that a child is an idiot, or has been imbecile from birth, or from an early age, it would seem doubtful how far legislative sanction is given to the admission into " idiot establishments " of the higher grade of child who is " incapable, by reason of mental weakness, of benefiting by the ordinary school curriculum," as was suggested by those who promoted the changes in the law which led to the passing of the " Idiots' Act." The question of providing special instruction ( for exceptional children in elementary day-schools came to the surface in a discussion on a paper by the author read before the School Conference of the International Health Exhibition of 1884,* when he advocated the "establishment in every large centre of a school for the backward chil- dren, who were not able to bear the strain of the ordinary schooling." In January, and again in April, i888,t reference was made in the Journal of Mental Science to the so-called "auxiliary classes " in Germany and elsewhere ; and it was urged that the example should be followed in England for "intermediate cases of mental feeble- ness." After seven years' practical experience * " Health Exhibition Literature," vol. xi., p. 560. Clowes and Sons, 1884. f See remarks by author in yournal of Mental Science, vol. xxxiv., p. 80. 142 Mentally -Deficient Children. in this country, we think we may claim that the School Board Special Classes (where tried) have filled up a lacuna in the scheme of national education. Mrs. Burgwin, reporting in March, 1894, with reference to the progress of her classes (which were established in July, 1892), states that they supply a long-felt want, "and one of the most encouraging aids in the work is the growing confidence of the parents." She refers to some scholars, who, after the examination, have re- turned to the senior departments ; and one of the Inspectors states that the success and progress of the work far surpassed his most sanguine antici- pations. Even where marked progress had not been made in the "three R's," the result of manual training had frequently been satisfactory, and at the least many of the children had made notable improvement physically, especially as regards cleanliness of person and habits. As was well remarked in a communication to the Times,"* — "To the outsider, to whom a large proportion of these children appear hopelessly feeble, the expertness and skill with which they do various kinds of needlework, caning, and other industries, is not less striking than the skill and patience manifested by the teachers, and the gratifying result in the shape of visible improve- ment, both mentally and physically, that is achieved by the exercise of these qualities." The * " A new branch of School Board Work," p. go. Times, April 28, 1895. Results and Conclusions. 143 judicious selection of teachers has no doubt been a most important element of success, and the Superintendent is to be congratulated on having gathered around her an efficient band of helpers, who take a real interest in their charges. It is satisfactory to learn that the School Board have recognised the arduous character of the work by offering a somewhat higher rate of payment for these than for the ordinary teachers. We are glad also to record that, in order further to pro- mote the scientific study of the pecuharities of their pupils, facilities have been afforded them to attend lectures on points of physiology and psy- chology specially helpful to them. By the kindness of Mrs. Burgwin, we are enabled to give some account of recent progress. In her Report to the Board for the year ended Lady-day, 1899, she says : — " Eleven new Centres have been opened during the past year. " The number of pupils on the roll is 1,682, and 139 have been promoted to the senior departments, where they continue to make satisfactory progress. " Of the children rejected as too imbecile for our centres thirty-five have entered asylums, and 55 remain at home, as some parents will take no action to bring the child before the Guardians, and some that do, have the child rejected by the Guardians. This is a very unsatisfactory method of dealing with this question of leaving the ' unfit ' liberty until they injure some- one or become quite unmanageable at home. " There are cases where the mother is worn out with the care of one such child. Few working men's homes can provide proper care for an imbecile child, who requires constant attention and training. "Ninety-two children have left, being over 14 years of age, and have found some kind of employment, e.g., 15 girls as 144 Mentally -Deficient Children. general servants (with an average weekly wage of 2s. 6rf.), 6 work as laundresses, 12 work at home, i is a dressmaker's apprentice (doing well) ; 8 boys are regularly employed as errand boys, 6 flower or fruit sellers, 2 van boys, 8 in factories, i cabinet maker, 2 harness makers, i wood carver, i in brick field, 2 in iron works, 1 printer, 1 cigarette maker, i milkman, i farm labourer. The highest wage is 8s. per week, and the lowest 2j. fid. " Of course, there are some failures, but the general result is satisfactory, as shewing that these children repay the money expended upon them during their School life, for without it they would have been unable to help themselves on leaving School. " The Epileptic children still remain without sufficient accom- modation, as in nearly every case they need permanent ' Homes.' A new experiment has been started for the Poor Law Feeble- Minded Children. A Home has been provided for the accom- modation of 20 girls near one of the Centres where they attend daily, and where by their regular attendance, perfect cleanliness, and well-fed and well-dressed appearance, they often present a strong contrast to the other children in the class, whom it would vastly improve to live under similar conditions. "At 'The Passmore Edwards Settlement,' Tavistock place, two classes have been opened for the education of cripple children only — the Board providing the Teachers and apparatus, and the Settlement a Nurse and an ambulance in which to bring the children to School. These pupils have a hot dinner daily for which they pay i^. Already the accommodation is insufficient to meet the demands made upon it. " Children who come to the classes needing food have some supplied by the Teachers, who receive a grant from the ' Referee Children's Free Breakfast and Dinner Fund ' for this purpose. In some cases a drink of fresh milk is given at the morning recess or at the commencement of morning school About 560 children have been given food during the winter months. " Through ' The Country Holidays Fund ' 180 children have been sent to the country or seaside homes for two weeks, and it would be well if every child could enjoy the same privilege, as all are needing it. " Fifteen schools had a day's holiday for an excursion to the country, and 6 went to the Royal Zoological Society's Gardens, Results and Conclusions. 145 the funds for which were generously supplied from ' Pearson's Country Holiday Fund,' through the Secretary of the R.S.U. "A child on entering the class is generally given something to ' do,' so that its attention and interest may be secured, if only for a few minutes, and when this has been repeated many days, then it may begin to listen to ' instruction.' The mornings are devoted to the 3 R's and Object Lessons, and the afternoons to varied occupations. The girls who are sufficiently capable attend Laundry and Cookery Classes, and take great delight in their work. The boys attend the Manual Training Classes, and many of them show specimens of good work. A few are taught Swim- ming, and an experiment has been tried of giving some boys Cookery lessons. " All such lessons train the faculties of observation and so greatly assist the dull child in its struggle for a living. Physical exercises are part of the daily routine. Singing lessons are a source of pleasure to all, especially if accompanied by the piano. " The Teacher is constantly reminded that pupils have no will power, and the aim must be in all the teaching to strengthen the child's weakness, mentally and physically. From this report will be seen that the Teachers have responded well to the calls upon their skill as Teachers, and to their patience and intelligence which these weaklings make upon them. In every class there appears a great bond of sympathy between them and their pupils, and it is gratifying to find that Her Majesty's Inspectors have noted these points in their Annual Reports. The Managers have shown during the past year much interest in the Schools ; and it is worthy of note that a closer and longer acquaintance seems always to increase their sympathetic assistance. One lady Man- ager is staying in town to take i6 children to the seaside, and provided a mail-cart so that a very delicate cripple child could attend School. Another gives ' her children ' a garden party each year and is pleased with the good manners and general natural behaviour of the children. " The Schools are comparatively costly,* for each child must * It has been recently stated that the cost of instruction in the London Special Classes is on the average about £g for each child per annum. I, 146 Mentally -Deficient Children. have individual instruction, and it follows the number in each class must be small, but looking at the results, whether from the altruistic or economic point of view, it is certain that value for money will be received in the future." The increasing attention paid to secondary education, beneficial as it may be for clever chil- dren, is probably not without its disadvantages to the " dullards," who are apt to be regarded not only as a drag on progress, but also (from the mere commercial point of view) as a drug in the market. At either end of some of our more am- bitious elementary schools, we see two groups of children between whom there is a great gulf fixed : those in the extra standard (" Ex 7 ") at the head ; those in standard " O " (or the equi- valent under another name) at the tail. For the former, money is lavished in apparatus and teaching power : for the latter, it would seem too often thought that anything is good enough. So we sometimes come across, in an otherwise well- appointed school, the melancholy spectacle of a concourse of children of very varying age and of very different mental and physical condition con- gregated in a common class-room, branded as failures. Instead of extra teaching-power being assigned to cope with the difficulties of the situa- tion, we have seen a single teacher in charge of about 60 pupils, struggling manfully with this unpromising mass.* Educational progress was of * The Education Department has recently recognised the necessity of a special organisation in elementary schools for the instruction of children backward from neglect. Revised instruc- tions, i8g8, p. 13. Results and Conclusions. 147 course under such circumstances out of the ques- tion ; and considering that there are notable in- stances of dull boys and girls growing up into bright men and women, and that slow mental de- velopment sometimes even blossoms into genius (as in the cases of Sir Walter Scott and Dr. Darwin), such a false economy cannot be too severely reprehended. Dr. Warner has, indeed, proposed (and the recommendation is one that has commanded the assent of the Committee who with him have conducted the enquiry on the mental and physical condition of school children), that whenever a special grant of public money is made for the purpose of promoting higher educa- tion in elementary schools, a proportionate sum should also be set aside for the additional expense of trying to elevate the lowest stratum. The time is happily past for accepting the doctrine that because the standard attainable by mentally- inferior children is a low one, the attainments and teaching-powers of their instructors need be but low ; the fact being that, in order to pene- trate the dark recesses of the feeble (or even dull) mind, singularly lucid teaching is requisite, and a philosophical power of simplification of instruc- tion, and of adaptation of methods to the in- dividual peculiarities of pupils. Of the results attained in the working-homes for feeble-minded adolescent girls, it must suffice to say that they have fully justified their estab- lishment, and that in some of those longest L2 148 Mentally -Deficient Children. established a considerable portion of income is derived from payments for the work of the in- mates. Thus it has been calculated that at the Homes of Industry, established near Birmingham in 1892 by Miss Stacey, for Feeble-minded Girls, as much as 2s. 5i. per head per week is on the average made by the labour of the 45 inmates in aid of maintenance, the weekly rate for which is about 8s. 6d. It was stated in the last Report that although these Homes are mainly custodial, (one being for innocent, and the other for girls of feeble mind who have had a " first fall,") 11 (out of 46 discharged for various reasons) were in domestic service. The industries carried on in the Homes consist principally of laundry work and of mat and rug making. The aggregate in- dustrial profits of the two Homes amounted last year to ^£"312 out of an aggregate income of £974. The results obtained by the newer homes, if less successful financially, are distinctly encouraging. Thus the National Association report of Alexander House (a working home for 12 girls over 14 at Shepherd's Bush), that after 2 years' working " 6 girls have already gone out to service and are doing well, while 3 have been passed on to the Hendon Home, where (although not men- tally strong enough to stand alone in the world) they are practically earning their living in the laundry." For a long time no provision had been made other than in Imbecile Asylums, for adolescent Results and Conclusions. 149 males of feeble mind, but in 1897 the National Association opened a small farm for the employ- ment of 15 boys. Coming late under training their progress is comparatively slow, but it is stated that several of the boys have been sent out to day-work on farms near the Home. Did space permit it would be easy to give proofs of individual improvement resulting from these and similar Homes (of which a list will be found in Appendix B) ; but for particulars the reader is referred to the Reports of the Homes, and to the publications of the National Associa- tion for the welfare of the Feeble-minded, to be obtained at the offices, 53 Victoria Street, S.W. The question of legal detention in such volun- tary homes as we have described has been dis- cussed, but the difficulties in this land of freedom of abridging the liberty of the subject are so great that it seems to us that voluntary homes — as dis- tinguished from registered Imbecile Institutions — will do well to trust to the spirit of content and attachment which a well-ordered establishment and kind treatment will foster rather than to in- voke the terrors of the law. There is no doubt that in the interests of society a permanent Home, apart from the ordinary population, is in the majority of feeble-minded cases a desideratum. It must never be forgotten that mental feebleness is as a rule hereditary, and consequently transmissible to another generation. The movement set on foot in the north of England by the " Lancashire and 150 Mentally-Deficient Children. Cheshire Society for the Permanent Care of the Feeble-minded " is, therefore, to be commended from this point of view. To quote the words of Miss Dendy (the founder of this Society) : — " Per- manence in the care of the feeble-minded would be ultimately a great saving to the community. As things are now, the boys for the most part become criminals and are convicted over and over again. Sometimes in gaol and sometimes out, they grow up through a wretched and de- graded . youth to an equally wretched and de- graded manhood, and die leaving behind them offspring to carry on the miserable tradition. The story of the girls is better known than that of the boys, but it is not really more terrible except so far as physical suffering is concerned, and physical suffering is the least part of the evil " {Educational Journal, Sept. 1899). In the Metropolitan District it was some years ago found necessary to supplement the school establishment at Darenth by a custodial branch intermediate between that and the adult asylum for imbeciles, with the view that the inmates might have the opportunity of carrying on the industries which they had been taught.* Custodial departments have been established in connexion with several of the American * At Darenth there appears to have gathered, in the course of years, a large accumulation of unimprovable and unproductive cases, and some revision of classification is now rendered neces- sary. Results and Conclusions. 151 Schools for Feeble-minded ; the protection of adolescent women being specially provided for. With regard to the Custodial Department of the Massachusetts Institution, Dr. Fernald, the Superintendent, reported some 7 years ago that "Many of these large girls are perfectly capable of self-support under competent direction, who would be utterly incapable and useless without it."* It is satisfactory to find that the authorities of this asylum have been encouraged to try the Colony plan on a large scale ; and they have recently purchased 1700 acres of land for this purpose in a beautiful part of the State. Thus whether we look at the matter from the point of view of philanthropy, or from that of social economy, we think the movement for providing working-homes for feeble-minded young people well worthy of support. An objection has, indeed, been taken to the several measures that have during the last half century been devised in the interests of the mentally-deficient, that they are antagonistic to Nature's own law which is expressed in the formula " the survival of the fittest." We have already stated facts (page 138) which militate against this theory, and the benevolent schemes just referred to are additional safe-guards against the transmission of inherited mental defect to another generation. It is not denied that indivi- * " Forty-fourth Annual Report, Mass. School for Feeble- minded." 152 Mentally -Deficient Children. dual lives, which, if left to themselves, would probably be extinguished in the struggle for exis- tence, are by fostering care prolonged, perhaps contrary to the rigid principles of social economy. After all; much that has been done for the idiot and imbecile, and even for the feeble-minded, can only be justified on the ground of that quality of mercy which is " nobility's true badge," and " blesseth him that gives and him that takes." May we not indeed in this, as in much other philanthropic work which tends to soften the asperities of Nature's laws, endeavour humbly to follow in the footsteps of Him of whom it was foretold that "A bruised reed shall He not break, and smoking flax shall He not quench " ? Lateat Scintillula forsan ! Bibliography. 153 Appendix A. An Act* to make better provision for the Elementary Education of Defective and Epileptic Children in England and Wales. [62 & 63 Vict., Ch. 32, August 9th, 1899]. (This Act is now in force, but Regulations of Education Department have not yet been issued. December, 1899). "De it enacted by the Queen's most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Tem- poral, and Commons, in this present Parliament assembled, and by the authority of the same, as follows : — Power to Sebool Antbority to determine wbat children axe Defective or Bpileptic. (56 and 57 Vict. c. 42.) i.^(i.) A school authority, as defined by the Elementary Education (Blind and Deaf Children) Act, 1893, may, with the approval of the Education Department, make such arrangements as they think fit for ascertaining — (a) What children in their district, not being imbecile, and not being merely dull or backward, are defective, that is to say, what children by reason of mental or physical defect are incapable of receiving proper benefit from the instruction in the ordinary public elementary schools, but are not incapable by reason of such defect of receiving benefit from instruction in such special classes or schools as are in this Act mentioned ; and (b) What children in their district are epileptic children, that is to say, what children, not being idiots or imbeciles, are unfit by reason of severe epilepsy to attend the ordinary public elemen- tary schools. * Reprinted by permission. 154 Menially -Deficient Children. (ii.) The school authority, in making their arrangements under this section, shall provide facilities for enabling any parent, who is of opinion that his child ought to be dealt with under this Act, to present such child to the school authority to be examined, although he may not have been required so to do by that authority ; and any school authorities failing to provide such facilities shall be deemed to have acted in contravention of this Act. (iii.) For the purpose of ascertaining whether a child is defec- tive or epileptic within the meaning of this section, a certificate to that effect by a duly qualified practitioner approved by the Education Department shall be required in each case. The certificate shall be in such form as may be prescribed by the Education Department. (iv.) For the purpose of the exercise of the powers conferred by this section, it shall be the duty of the parent of any child who may be required by the school authority to be examined to cause the child to attend such examination, and any parent who fails to comply with such requirement shall be liable on summary con- viction to a fine not exceeding five pounds. Fover to Provide for Education of Defective and Epileptic Cbildren. 2. — (i.) Where a school authority have ascertained that there are in their district defective children, they may make provision for the education of such children by all or any of the following means: — (a) By classes in public elementary schools certified by the Education Department as special classes ; or (6) By boarding out, subject to the regulations of the Education Department, any such child in a house conveniently near to a certified special class or school ; or {c) By establishing schools, certified by the Education Depart- ment, for defective children. (ii.) Where a school authority have ascertained that there are in their district epileptic children, they may make provision for the education of such children by establishing schools, certified by the Education Department, for epileptic children. Defective and Epileptic Children's Act. 155 (iii.) The power conferred by this section shall include power to establish or acquire and to maintain certified schools, and to contribute, on such terms and to such extent as may be approved by the Education Department, towards the establishment, en- largement, or alteration, and towards the maintenance of certi- fied schools. (iv.) A school authority may in respect of children resident in or whose permanent home is in their district and attending certi- fied special classes or schools in the district of another school authority, contribute to that other authority the proportionate cost of the provision and maintenance of such special classes or schools. (v.) The school authority, acting under this section, shall make provision for the examination from time to time of any child dealt with under this section, in order to ascertain whether such child has attained such a mental and physical condition as to be fit to attend the ordinary classes of public elementary schools ; and the school authority shall make provision for such examina- tion in the case of any child whose parent claims such examina- tion of his child, provided that the parent shall not make such claim within less than six months after his child has been exa- mined ; and any school authority failing to make such provision as this subsection requires shall be deemed to have acted in contravention of this Act. (vi.) The Education Department shall not certify any establish- ment established after the commencement of this Act for boarding and lodging more than fifteen defective or epileptic children in one building or comprising more than four such buildings. FroviBion of euides or Conveyances, 3. A school authority may provide guides or conveyances for children who, in the opinion of the school authority, are by reason of any physical or mental defect, unable to attend school without guides or conveyances. Obligation of Petzent as to Defective and Epileptic Cbildren. (39 and 40 Vict. c. 79.) 4. — (i.) The duty of a parent under section four of the Elemen- ry Education Act, 1876, to provide elementary instruction for 156 Mentally-Deficient Children. his child shall, in the case of a defective or epileptic child over seven years of age in any place where a certified special class or school is within reach of the child's residence, include the duty to cause the child to attend such a class or school, and a parent shall not be excused from this duty by reason only that a guide or conveyance for the child is necessary. (ii.) In the case of an epileptic child whose age exceeds seven years, the school authority may, if they think fit, apply to a court of summary jurisdiction for an order requiring the child to be sent to a certified school for epileptics, and if any parent fails to comply with the order, he shall be deemed to have failed to perform the duty prescribed by section four of the Elementary Education Act, 1876, and may be proceeded against accordingly. Conditions and Effect of Grant of Certificate to Scbool for Defective or Epileptic Children. 5. The provisions of section seven of the Elementary Educa- tion (Blind and Deaf Children) Act, 1893, respecting the condi- tions and effect of the grant of certificates to schools for blind or deaf children shall apply, with the necessary modifications to schools for defective or epileptic children established or proposed to be established under this Act, except that no requirement need be made as to the proportion of the expenses to be defrayed out of private sources. Fewer and Expenses of Scbool Autborlty. (56 and 57 Vict, c. 42). 6. The provisions of section five of the Elementary Education (Blind and Deaf Children) Act, 1893 (relating to the powers and expenses of a school authority under that Act) shall apply, with the necessary modifications, to school authorities acting under this Act. Provided that a parish in which there is a school board shall be exempt from contributing to the expenses incurred by any district council acting as a school authority under this Act, and where a school authority are an urban district council their expenses a s tuch authority shall be paid out of the fund to be raised in the area for which they are a school authority in the sam6^ manner as Defective and Epileptic Children's Act, 157 the fund out of which their general expenses are payable is raised in the urban district. Qrants trota Public money Towards Education of Defective and Epileptic Children. 7. Nothing in any Act of Parliament shall prevent the Educa- tion Department from giving aid from the parliamentary grant to a school in respect of education given to defective or epileptic children to such amount and on such conditions as may be directed by or in pursuance of the minutes of the Education Department in force for the time being. Contribution by Parent. 8. — (i.) The parent of a defective or epileptic child shall be liable to contribute towards the expenses of the child incurred by a school authority under this Act in like manner and to the like extent as the parent of a blind or deaf child is liable to contribute under section nine of the Elementary Education (Blind and Deaf Children) Act, 1893, and the provisions of that section shall apply accordingly, (ii.) The parent of a defective or epileptic child shall not, by reason of any payment made under this Act in respect of the child be deprived of any franchise, right, or privilege, or be sub- ject to any disability or disqualification. (iii.) Payments under this Act shall not be made on condition of a child attending any certified school other than such as may be reasonably selected by the parent,- nor refused because the child attends or does not attend any particular certified school. Contribution by Guardians of tbc Poor. g. The board of guardians of any poor law union may contri- bute such of the expenses of providing, enlarging, or maintaining any certified special class or school under this Act as are certified by the Education Department to have been incurred wholly or partly in respect of scholars taught at the class or school who are either resident in a workhouse or in an institution to which they have been sent by the guardians from a workhouse or boarded out by the guardians. 158 Mentally-Deficient Children. Limitation on Liability of School Authority. 10. Nothing in this Act shall be construed as imposing a duty on a school authority to receive in a special class or school established by them any child — (a) Who is resident in, or whose permanent home in their opinion is in, the district of another school authority ; or (b) Who is resident in a workhouse, or in any institution to which he has been sent by the guardians, from a workhouse, or boarded out by the guardians, unless that other school authority, or, as the case may be, the guardians are willing to contribute towards the expenses of the education and maintenance of the child such sum as may be agreed on between the authorities concerned. Feriod of Education for Defective and Epileptic Children. 11. For the purposes of the Elementary Education Acts, 1870 to 1893, and of this Act, a defective or epileptic boy or girl shall be deemed to be a child until the age of sixteen years, and the period of compulsory education shall, in the case of such a child, extend to sixteen years, and the attendance of such a child at school may be enforced as if it were required by byelaws made under the Elementary Education Acts, 1870 to 1893, and any such child shall not, in accordance with such byelaws, be entitled to total or partial exemption from the obligation to attend school. Religious Instruction. (56 and 57 Vict. c. 42.) 12. The provisions regulating religious instruction in certified schools for defective and epileptic children shall be the same as those enacted by section eight of the Elementary Education (Blind and Deaf Children) Act, 1893. Report to Farllament. 13. Every school authority shall make to the Education Depart- ment such returns as the Department may require ; and the Department shall annually lay before both Houses of Parliament a report of their proceedings under this Act during the preceding year, and in that report shall give lists of the schools and classes to which they have granted or refused certificates under this Act during the year, with their reasons for each such refusal. Note on Idiots Act. 159 Interpretation of Terms. 14. In this Act — The expression " school " includes any institution in which defective or epileptic children are boarded or lodged as well as taught, and any establishment for boarding or lodging children taught in a certified special class or school : Other expressions have, unless the contrary intention appears the same meaning as in the Elementary Education (Blind and Deaf Children) Act, 1893. Short Title. 15. This Act may be cited as the Elementary Education (Defective and Epileptic Children) Act, i8gg, and may be cited with the Elementar;y Education Acts, 1870 to 1893. (To be obtained from Eyre and Spottiswoode, East Harding Street, Fleet Street, London, E.C.) The Idiots Act, 1886 {49 & 50 Vict., Ch. 25). Gives facilities for the care, education and training of idiots and imbeciles in hospitals, institutions, or licensed houses speci- ally registered for the purpose. These are exempted by section eleven from certain provisions of the Lunacy Acts which formerly applied to them, but are inspected annually by the Lunacy Com- missioners. The form of medical certificate prescribed by the Act is as follows : — I, the undersigned A.B., a person registered under the Medical Act, 1858, and in the actual practice of the medical profession, certify that I have carefully examined CD., an infant [or of full age) now residing at and that I am of opinion that the said CD. is an idiot (or has been imbecile from birth, or for years past or from an early age), and is capable of receiving benefit from [the institution (describing it)] , registered under the Idiots Act, 1886. Dated (Signed) (Full postal address). (The above Act does not apply to Darenth or other poor-law establishments). i6o Mentally -Deficient Children. Appendix B. Training Institutions in Great Britain and Ireland for Mentally -Deficient Children. IDJOTS AND IMBECILES. A. For Pauper Children : — 1. Metropolitan Asylums Board. Darenth Schools, Dartford, Kent. 2. Middlesex County Asylum. (Annex for Imbeciles). 3. Separate Department at Northampton County Asylum, Berrywood. 4. Winwick Hall, Lancashire. (Boys only). 5. Western Counties Idiot Asylum, Starcross, Devon. (Also receives cases on payment, and aided by charity). A limited number of pauper patients (from their own districts) are also received at the Royal Albert and Eastern Counties Asylums. There are also special wards for Idiots at the Hants, Kent, Durham and Rubery Hill Asylums. B. For Children above Pauper Class : — I. Charitable Institutions receiving also paying cases. 1. Earlswood Asylum, Red Hill, Surrey. 2. Royal Albert Asylum, Brunton House Branch, and Storey Home for Feeble-minded Girls, Lancaster. 3. Eastern Counties Asylum, Colchester. 4. Western Counties Idiot Asylum, Starcross. 5. Midland Counties Idiot Asylum, Knowle, Birmingham. 6. Magdalen Hospital, Bath. 7. Scottish National Institution for the Education of Imbe- cile Children, Larbert, Stirlingshire. 8. Baldovan Asylum for Imbecile Children, near Dundee, g. Stewart Institution for Idiotic and Imbecile Children, Palmerston, Dublin. Training Institutions. i6i n. Private Establishments, registered under "Idiots' Act, 1886." X. Normansfield, Hampton Wick, Middlesex. ^. Downside Lodge, Chilcompton, Bath. FEEBLE-MINDED CASES ONLY. in. Private Establislinients (not so registered) for the Education of Backward and IMCentaUy-Peeble Chil- dren (notified in Wright's Medical Annual, 1899). Kingston on Thames. Conifers and Trematon, Hampton Wick. Kingston on Thames. Winchester House, Kingston Hill. Maidstone (Kent). Bearsted House. Polton (Midlothian). Mavisbush. Richmond (Surrey). Ancaster House. Southgate (Middlesex). Brook House. There is also a "Little School" for such children recently opened at 16 Barons Court Road, West Kensington. C. For Pauper Adolescents and Others. Charitable Establishments for the Feeble-lYEinded (cer- tified or approved by I>ocal Government Board). 1. St. Mary's Home, Painswick, Glos. 2. Laundry and Homes of Industry, Birmingham ; — Home No. i. — Arrowfield Top, Alvechurch. Home No. 2. — Enniskerry, Knowle. 3. Scott House, Hitchin, Herts. 4. Adcote, Knotty Ash, Liverpool. 5. Chasejields, Fishponds, Bristol. 6. Laundry and Home of Industry, Morpeth. 7. Mary Carpenter Home, 10 Bishop Street, Bristol. 8. Springfield Home and Laundry, Shebden, Halifax. M 1 62 Mentally-Deficient Children. g. The Alexander Home,* Shepherd's Bush, London. 10. Girls' Home, 15 Clapton Square, London, N.E. 11. Girls' Home, 1 Handford Villas, Ipswich. 12. Boys' Home,* Upshirebury, Essex. 13. St. Saviour's Home,* Hendon, Middlesex. 14. " Elizabeth Barclay Home," Bodmin. 15. Ashton Home, Parkgate, Chester. * The above are under the management of the National Association for promoting the Welfare of the Feeble-minded, 53 Victoria Street, S.W., where a detailed list of all the Homes may be obtained. School Board Special Classes. 163 Appendix C. School Board Special Classes for Defective Children {1899). Iiondon, Chelsea. Ackmar Road, Kingwood Road, Lancaster Road, Langford Road, Park Walk, St. Clement's Road, and St. Dunstan's Road. Finsbury. Ambler Road, Barrett's Grove, Bath Street, Ecclesbourne Road, and " Hugh Myddelton." Greenwich. Edward Street, and Render Street. Hackney. Abbey Street, Cranbrook Road, Maidstone Street, Virginia Road, St. John's Road, Windsor Road, Lamb Lane, Eniield Road, and Mare Street. East Lambeth. Boundary Lane, Choumert Road, Gloucester Road, and Sayer Street. West Lambeth. Priory Grove, Shillington Street, and Worple Way. Marylebone. The Brecknock, Brondesbury Hall, Camden Hall, Capland Street (Junior), the " Moberly," and Tavi- stock Place. Southivark. Galleywall Road, Kipling Street, and Pocock Street. Tower Hamlets. British Street, CuUoden Street, Deal Street, Old Ford Road, Portman Place, St. James', Trafalgar Square, Cable Street, and Smith Street. Westminster. Crown Court. FroTlnces. Birmingham, Bolton, Bradford, Brighton, Bristol, Burnley, Bury, Leicester, Nottingham, Plymouth. Classes also arranged for at Liverpool and Manchester, M 2 i64 Mentally -Deficient Children. Appendix D. american institutions for "feeble-minded/ (From Paper by Dr. Powell, Proceedings National Conference Charities and Correction, 1898.) STATE. CITY. NO. OF INMATES.. C£(lifornia Eldridge 470 Connecticut Lakeviile 170 Illinois Lincoln 642 Indiana Fort Wayne 554 Iowa Glenwood 6go Kansas Winfield 118 Kentucky Frankfort 123 ' ■Maryland Owings Mills 56 . Massachusetts Waltham 423 Michigan Lapeer 200 Minnesota Faribault 574 Nebraska Beatrice 220 New York Children Syracuse 53* , Women Newark 386 Custodial Rome 327 Raridall's I. New York 364 New Jersey Children Vineland 217 Women Vineland 94 North Dakota Jamestown 45 Ohio Columbus 973 ' Pennsylvania Eastern Elwyn 1028 „ Western Polk 225 Washington Vancouver 41 Winconsin Chippewa Falls 20 COLONIAL INSTITUTIONS, &c. Dominion of Canada, Orillia, Ontario, 610 inmates. There are also Institutions for Imbeciles in several of the British Colonies,.Cig-.,. in Australia in connection with the ,Kew Continental Institutions, 165 Asylum, Melbourne, and at Adelaide ; and in South Africa in connection with the Grahamstown Asylum. There is a private Institution at Moonee Ponds, Melbourne. Mr. R. Osuga has recently opened a small Institution for Feeble-minded at Tokio, Japan. SOME OF THE PRINCIPAL CONTINENTAL INSTITUTIONS FOR IMBECILES. France. Bicetre, Paris. Germany. Dalldorf, Berlin. ,, Gladbach, Diisseldorf. ,, Langenhagen, Hanover. ,, Alsterdorf, Hamburg. ,, Oppellstrasse, Dresden. ,, Alice-stift, Darmstadt. ,, Neu-Erkerode, Brunswick. ,, Grosshennersdorf, Saxony. ,, Kiichenmuhle, Stetten. ,, Niedermarsberg, Westphalia. ,, Scheuern, Nassau. „ Stetten, Wurtemberg. Norway. Thorshaug, Christiania. ,, Linden, Christiania. „ Hop, Bergen. Sweden. Stockholm, Lund, Upsala, &c. Denmark. Gamle Bakkehus, Copenhagen. „ Ebberodgaard, near Copenhagen. „ Keller Institutes, Borkof and Copenhagen. Switzerland. Bremgarten Aargau. „ Regensberg, Zurich. ,, Kriegstetten, Solothurn. ,, Biberstein, bei Aarau. Italy. Vercurago, Bergamo. SPEAKING EXERCISE I. Consonants. Sound. Phonetic. Common Object. M. Mam-ma Mat, Man, Miss P. Pa-pa Pen, Pin, Pipe B. Bab-ba Bell, Box, Book T. Tat-ta Table, Top, Tea D. Dad-da Door, Doll, Desk V. Va-va Velvet, View, Violet F. Fa-fa Fan, Fire, Fish L. La-la Lad, Lady, Lock R. Ra-ree Rag, Reel, Rail-road S. See-saw Soap, Slate, Seat Z. Za-zel Zinc, Scissors Th. The Thimble, Thing Sh. She Shell, Shilling Ch. Chick Child, Chair J- Jig Ju-jube, Jug G Gig Girl, Gas, Gate (hard). K. Cake Cat, Kite, Colour N. Nanny Net, Nut, (K)not II. Simple Vowel Sound. Examples. A (open = (Ah) Father A (broad) = (Aw) All (^wful) A (short) = A Cap, Tap A (long) = A Cape, Tape O (short) = O Cot, Knot O (long) = O Coat, Note OO (short) = (00) Foot, Wood OO (long) = (00) Boot, Food Arranged by Dr. Shuttleworth for use at Royal Albert Asylum. Reprinted of Psychological Medicine, by kind [Appendix E. Part of Body, &c. Part of Dress, &c. Mouth, Muscle Muff, Muffler, Mitten Palm (of hand) Pin, Pocket Bone, Bust, Brains Bib, Bow Toe, Tooth Tie, Tape, Trousers Dimple Dress, Diadem Vein, Voice Veil, Vest Foot, Face, Finger Fur, Frock, Flannel Lip, Limb, Leg Lace, (E)lastic Rib, (W)rist Ribbon, Ring Sole, Skin Sock, Sash, Stocking Hazel (Eyes) Stays, Zone Thumb, Throat Thread Shoulders, Shin Shoe, Shawl, Shirt Chin, Chest, Cheek Chain (of Watch) Jaw, Joint Jacket, Jewel Gum, Gullet Garter, Gait6r Calf, Cough Coat, Cap, Collar Nose, Nail, Neck Necktie, (Knot) Vowel Sounds. Vowel Sound. Examples. U (short) = U Tun, Fun U (long) = u Tune, Fume E (short) = E Bed, Fed E (long) = E Bead, Feed I (short) = I Bit, Fit I (long) = i Bite, Fight Aspirate H Double Letters W, Y Diphthongs, 6l, OW Hat, Hall Wall, You Oil, Owl from his article on Education of Imbeciles in Dr. Hack Tuke's Dictionary permission of Messrs. Churchill). 1 68 Mentally-Deficient Children. Appendix F. BIBLIOGRAPHY. I. De I'6ducation d' un Homme Sauvage, Itard. Paris, 1801. £. Observations pour servir a I'histoire de I'Idiotie, Esquirol, (Maladies Mentales). Paris, 1828. 3. Die Heilung und verhiitung des Cretinismus, &c., Guggen- lriib.1. Bern, 1835. 4. Resume de ce que nous avons fait pendant quatorze mois, Esquirol et S6guin. Paris, 1839. 5. Traitement Moral, Hygiene et Education des Idiots, &c., B. S6guin. Paris, 1846.* 6. Articles on Idiocy in Chambers' Edinburgh journal, by Mr. Oaskell. Jan. and Feb., 1847. 7. Remarks on the Education of Idiots and Children of Weak Intellect, W. R. Scott, Fb.S. London, 1847. 8. Article by Dr. Conolly in British and Foreign Medico-Chirnr- gical Review. London, 1847. g. Causes and Prevention of Idiocy {Report to Mass. Legislature), Dr. S. G. Howe. Boston, Mass., 1848. TO. Report of Commission created by King of Sardinia for Study of Cretinism. Turin, 1850. 11. Researches on Idiocy and Cretinism in Norway, Dr. Stalst. Christiania, 1851. 12. On the possibility of Educating Idiot Children, Dr. Elir- chricht, Copenhagen, 1854. 13. Cretinism and Idiocy, Dr. Blackie. Edinburgh, 1855. 14. Idiot Training, Bev. Edwin Sidney. London, 1853. 15. Idiots and the Efforts for their Improvement, Dr. !•. P. Brockett. Hartford, Conn., 1856. * Reprinted by Dr. Bourneville in Publications du Progres Medical. Paris, i8g8. Bibliography. i6g i6. Report of Commissioners on Idiocy in Connecticut (Knight and Brockett;. Dorchester, Conn., 1856. 17. Handbook of Idiocy, James Abbott. London, 1857. 18. The Mind Unveiled, Dr. Isaac N. Kerlin. Philadelphia, 1858, ig. Method of Drill, Manner of teaching Speaking, &c., used at Essex Hall, E. martin Duncan, va. B. London, 1861. 20. Visit to Earlswood, and Second Visit, Rev. E. Sidney, K.A., May, 1859, June 1861. London 1861. 21. Suggestions on Principles and Methods of Elementary In- struction, Dr. vr. B. Wilbur. Albany, New York, 1862. 22. The Idiot and his Helpers, W. Millard. Colchester, 1864. 23. Idiocy : its Diagnosis and Treatment by the Physiological Method, E. S6guin, M.D. Albany, 1864. 24. The Training of Idiotic and Feeble-minded Children, Cbeyne Brady. Dublin, 1864. 25. Idiot Asylums. Edinburgh Review, No. ccxlix., July 1865. 26. Manual for the Classificatiori, Trainihg, &c., of the Feeble- minded, Imbecile, and Idiotic, Duncan and Millard. Lon- don, i856. 27. Idiocy and its Treatment by the Physiological Method, Ed. SSguin, M.D. New York, 1866. 28. Remarks on Sluggish Mental Development educationally considered, VT. H. Mortimer. London, 1868. 29. On the Education of the Imbecile, Dora Greenwell. London, 1869. 30. A Day at Earlswood, J. C. Parkinson. London, 1869. 31. New Facts and Remarks concerning Idiocy, E. Sdguin, M.D. New York, 1870. 32. Two Cases of Microcephalic Idiocy, G. E. Stauttlewortb, M.D. British Medical Journal, August, 1875. 33. Remarks on the Origin, Varieties and Termination of Idiocy, e. W. Grabham, M.D. Earlswood, 1875. 34. Education and Training of the Feeble in Mind, J. Langdon- Down, M.D. London, 1876. 170 Mentally -Deficient Children, 35. Notes of Visit to American Institutions for Idiots and Im- beciles, Q. E. ShutUeworth, K.D. Lancaster, 1877. 36. Case of Microcephalic Imbecility, G. E. Sbuttleworth, M.D. jfournal Mental Science, October, 1878. 37. Some of the Cranial Characteristics of Idiocy. Id, Trans. International Medical Congress, 1881. 38. The Idiot ; His place in Creation, Sir Frederick Bateman, IH.B. London, 1882. 39. Types of Imbecility, Fletcber Beacb, M.B. (Medical Times and Gazette). London, 1882, 40. An address on the Education of Idiots, George Fycroft. Exeter, 1882. 41. The Physical Features of Idiocy, G. E. ShutUewortli, BI.D. Liverpool Med.-Chir. jfournal, July, 1883. 42. Is Legal Responsibility acquired by Educated Imbeciles ? Id. journal Mental Science, January, 1884. 43. The Health and Development of Idiots as compared with Mentally-sound Children. Id. International Health Ex- hibition Literature, vol. xi., p. 526, London, 1884. 44. Clinical Lecture on Idiocy and Imbecility. G. E. SbutUe- wortb, M.D. British Medical jfournal, January 30, 1886. 45. The Relations of Marriages of Consanguinity to Mental Un- soundness. Id. yournal of Mental Science, October, 18S6. 46. Mental Affections of Childhood and Youth. J. I.angdon- Down, ni.D. London, 1887. 47. Idiocy and Imbecility due to Inherited Syphilis, G. E. Shuttlewortli, ni.D. Amer, journal of Insanity, January, 1888. 48. Weak-minded Children. Id. journal Mental Science, April, 1888. 49. The Royal Albert Asylum and its Work, Henry Hutton, M.A., la.B. Lancaster, 1888. 50. A Course of Lectures on the Growth and Means of Training the Mental Faculty, P. vraruer, M.B. Cambridge, i8go. 51. The Care of the " Mentally-feeble " Child (as distinguished from the " Imbecile "), G..E. Shuttlewortli, M.D. London, 1891. Bibliography. 171 52. Neuroses of Development, T. S. Clouston, IH.D. London, 1891. 53. Report on Physical and Mental Condition of 50,000 School Children. F, vrarner and others. Parkas Museum, 1892. 54. Hack Tuke's Dictionary of Psychological Medicine. Articles on Idiocy, &c. (Pathology, F. Beaeb, Etiology, Sbuttle- worth Etnd Beaeb. Treatment and Education, Sbuttle- wortb). London, 1892. 55. The Feeble-minded Child and Adult. (Charity Organization Series). London, 1893. 56. Interim Report of Committee on Mental and Physical Con- dition of Children. Farkes Museum, London, 1893. 57. The History of the Treatment of the Feeble-minded, VTalter B, Fernald, M.S. Boston, 1893. 58. Causation and Early Treatment of Mertal Disease in Chil- dren. A. W. Wilmartb, M.B. Chicago, 1894. 59. Rapport sur I'assistance des enfants idiots et d^gineres, BoumevUIe. Lyon, 1S94. 60. Mentally-feeble Children : Treatment and Education of, Fletcber Beach, in.B. London, 1895. 61. New Medical and Surgical Methods in the Treatment of Mental Defects, G. E. SbutUeworth, nx.D. Bristol, 1895. (In Wright's Medical Annual). 62. Cases of Sporadic Cretinism treated by Thyroid Extract, T. Telford-Smith, ni.D. your. Mental Science, April, 1893. 63. Idiotophilus, Fastor H. Sengelmann, Dr. Norden, 1885. 64. Der unterricht und die erziehung nicht voUsinniger Kmder, Bilcker. Trier, 1885. 65. Psychopatische Minderwertigkeiten im Kindesalter. Trilper. Giitersloh, 1893. 65. Dell' Educazione dei Fanciulli Frenastenici, Prof. A. Oon- nelll Cloni. Lecco, 1893. 67. Pathogenesis of Epileptic Idiocy and Epileptic Imbecility, W. Ii. Andrlezen, nS.D. Brit. Med. your., May i, 1897. 68. Influence of Heredity on Idiocy, Martin Barr, M.D. Jour. Mental and Nervous Diseases, New York, 1895. 172 Mentally -Deficient Children. 69. The Mentally-Feeble Child and How to train him. rietcber Beacb, M.D. Pediatrics, December, 1897. 70. Amaurotic Idiocy, Sacbs. New York Med. jfour., May 30, 1896. 71. Infantile Cerebral Degeneration with Symmetrical Changes at the Macula, E. C. Kingdon, Iffi.B., and J. S. Rislen BusseU, IM.D. Med. Chir. Trans., vol. Ixxx., p. 86. 72. The Paralytic Type of Idiocy and Imbecility, Telford- Smlth, BI.O. Pediatrics, vol. v.. No. 12, 1898. 73. Diagnosis and Prognosis of certain forms of Imbecility, Jobn Thomson, M.b. Scottish Medical and Surgical Journal, March, i8g8. 74. The Mental Affections of Children, Idiocy, Imbecility and Insanity, vrilllam W. Ireland, M.D. London and Edin- burgh, i8g8. 75. Clifford AUbutt's System of Medicine, vol. viii.. Article on Idiocy and Imbecility, by Fletcber Beacb, m.B., and G. E. Sbuttleworth, M.D. London, i8gg. 76. Studien iiber Klinik und Pathologic der Idiotie, Karl Ham- marberg. Upsaja, 1895. 77. The Brain of the Microcephalic Idiot, D. J. Cunningbam, Sa.D. and T. Telford- Smitb, JM.D, Scientific Trans. Roy. Dublin Society, 1895. 78. Kliniske og Aetiologiske Studien over Psykiske Udviklins- manger hos Born, Ceirl Iiooft. Bergen, 1897. 79. The Study of Children, F. Warner, IM.D. New York and. London, 1897. 80. Degeneracy, Eugene Talbot, ia.D. London, 1898. REPORTS AND SBRIAIiS : — Report of a Special Committee of the Charity Organisation Soeifety on the Education and Care of Idiots, &c. London, 1877. Report of the Royal Commission on the Blind, the Deaf, &c; London, 1889, Reports and Serials. 173 Report of the Departmental Committee on Defective and Epileptic Children. London, 1898. Report on Scientific Study of the Mental and Physical Con- ditions of Childhood. Committee, Parkes Museum. London, 1895. Proceedings of the Association of Medical Officers of Ameri- can Institutions for Idiotic and Feeble-minded Persons, 1876-99. Recherches Cliniques, &c., sur I'Epilepsie, I'Hysterie, et ridiot^e. Paris, 1890-99. Zeitschrift fur die Behandlung Schwachsinniger und Epi- leptischer. Dresden, 1882-gg. L'Ortofrenia (Rivista Mensile Medico-pedagogica). Lecco, 1894-95. Institution Bulletin (Quarterly Journal California Institution for Feeble-minded). Sacramento, 1890-95. Journal of Psycho-Asthenics, Faribault, U.S.A., 1896-99. Nordisk Tidskrift for Aandsvage, &c. Copenhagen, 1899. (And Reports of British, Irish, American, and Continental Insti- tutions for Mentally-deficient Children). INDEX OF SUBJECTS. Accidental or acquired cases, 59 After-care, necessity for, 132, 13s Amaurotic idiocy, 59 American experience of re- sults, 133 American institutions for feeble-minded {Appendix D) Athetotic cases, 55, 76, 103, 119 Atrophic cerebral conditions, 51. 52 Bacltward children, 40 Backward children (cases), 40-47 Backward children, educa- tional homes for [Appen- dix B) Barre (Mass.) Institution, 5 Bean- bags (school appliance), lOI Bibliography {Appendix F) Birth-palsies, 55, 75 Bath school. Miss White's, 4 Bath Institution (Magdalen Hospital), {Appendix B) Calculation, cultivation of, 116 Calculation, aids to, 116 California Institution, 7 Causes acting after birth, 63 Causes acting at birth, 62 Causes acting before birth, 62 Childhood, Report on, 13 Christian aspect of work, 152 Classes for special instruc- tion, 31 {Appendix C) Classification, pathological, 48 et seq. Cleanly habits, promotion of, 87 Clothing, 88 Colonial institutions {Appen- dix D) Committee on Children, 13 Conclusions, 130 et seq. Continental institutions {Ap- pendix D) Congenital cases, 48, 56, 70 Connecticut Institution, 6 Consanguinity of parents, 62 Convulsions during dentition, 64 County Councils, duties of, 139 Cranial abnormalities, 66 Craniectomy, 97 Cretinism, sporadic, 55, 77 95 Custodial institutions, 150 175 Index. Darenth Schools, 8 (Appen- dix B) Defective and jspileptic chil- dren, 21'30 Defective and Epileptic Chil- dren Elementary Education Act (Appendix A) Defects of brain, 51 Denmark, institutions in, ■ 32-33 Denmark, provision in, 11 Departmental Report (Defec- tive and Epileptic Children) 21 et seq. Developmental cases, 49, 59 Developmental defects, 68 Diagnosis, 66, 84 Diarrhoea, treatment of, 92 cDomino-boards (school appli- ances), 109 Dravvfing, 115 Dressing lessons, 114 Drill, 113 Dull children, 16, loi " Dullards," 146 Earlswood Asylum, Redhill, ' 4 (Appendix B) Eastern Counties Asylum, Colchester, 4 (Appendix B) . Eclampsic cases, 57, 64, 78 Educational homes, 39 (Ap- cj pendix B)- ■■ - Educational training, 99-116 Emotional cases, 58, 59, 79 England and Wales (number \ of mentally-defipient), 9 England and Wales, provi- sion in, 10 ■ Epileptic ca'ses, 28, 57, 64, 78 Epileptic inheritance, 62 Epilepsy, psychical, 127 Epilepsy, treatment of, 93, 94 Etiology, 61, 66 Exanthemata, prognosis in, 96 Exercise, 89 Experience as to success ot training, 131-133. M^, 147. 148, 151 Feeble-minded adolescents, 40, 147 Feeble-minded, American use of term, 12 Feeb'e-rainded (cases), 40-47 Feeble-minded child, the, 12- 20, 40 Feeble-minded, English use of term, 13 Feeding, 86 ■ Forceps delivery, 63 Formative defects, 66 Foi;m-lpoard (school appli- ances), 106 Forms of mental-deficiency, ■ 48. 49 France, provision in, 10 . General treatment, 85-91 German Etnpire, provision in, II Graduated ' ' woOden rods (school appliance), 108 Gums spongy, treatment of, 96 Index. 177 Habits, improvement of, 87 Hearing, training of, log Hereditary mental weakness, 62 Heredity, phthisical, syphili- tic, &c., 62 Highgate, Park House Insti- tution, 4 " Hilfsklasse" in Germany, 31 Historical retrospect, i-ii Homes, educational (private), list of (Appendix B) Homes, educational (private), uses of, 39 Homes, industrial, for ado- lescent girls, 19, 148 Homes, industrial, for ado- lescent girls, list of (Ap- pendix B) Hydrocephalus, 53, 57, 73 Hypersesthesia, 103 Hypertrophy of brain, 73 Idiocy, 12 Idiots Act, 141 (Appendix A) Illinois Institution, 6 Imbecility, 12 Industrial training, 117, 122 Infantile paralysis, 64, 76 Institutions, list of (Appen- dix B) Intemperance, parental, 62 Ireland, provision in, 10 Kalmuc cases, 53 Keller Institutions (Copen- hagen), 32 Kentucky Institution, 6 Kindergarten system and oc- cupations, 100, 117 Leicester School-board spe- cial classes, 34 (Appen- dix C) London School-board special classes, 3^, 142145 London School-board special classes, list of (Appendix C) Macrame work, 119 Manual training, 118-119 Marriage, question of, 138 Massachusetts Report, 5 Maternal ill-health, shock, &c., 62 Medical examination of, and for, special classes, 35-39 Medical treatment, 91-97 Mentally- feeble adolescents, 40 Mentally-feeble adolescents, industrial homes for, 40-148 Mentally-feeble adolescents, &c., industrial homes for, list of (Appendix B) Mentally- feeble child, 12-20, 81 Mentally-feeble child, educa- tional homes for, 39 Mentally-feeble chill, educa- tional homes for, list of, (Appendix B) Microcephalus, 49, 67, 72 Midland Counties Institution, Knowle (Appendix B) Mongol cases, 53, 74 Moral discipline, 97 N 178 Index. Moral imbecile, 126 Moral training, 123-129 Muscular activity, promotion of, 87 Muscular co-ordination, pro- motion of, lOI Music, influence of, 110-112 Musical drill, 113 National Association for Pro- moting Welfare of Feeble- minded, 40, 149 Need for supervision after training, 132, 135 Nervous abnormality, 6g Nervous children, .teaching of, loi Neurotic cases, primarily, 57, 78 Neurotic inheritance, 62 Non-congenital cases, 49, 71 Northampton Co. Asylum (Idiot Block), 8, (Appen- dix B) Norway, provision in, 11, 32 Nutrition, defective, 70 Object lessons, 1 15 Objections to training, 151 Ohio Institution, 6 Outdoor occupation, g^, 118 Parental intemperance, 62 Pathological classification, 48-60 Peg-board (school appliance), 103 Pennsylvania Institution, 6 Permanent care of feeble- minded, 150 Pessimistic views, 130 Phthisical family history, 62 Physical training, 99, 113 Physically-deficient children, 27 Physiological education, 3 Post-febrile or post-inflamma- tory cases, 58, 80 Premature birth, 63 Prognosis, 71-84 Protracted pressure at birth, 63 Provision for mentally-defi- cient, 8-10, 149 Puberty, care at, 91 Punishments, 124 Reading, 115 Recommendations of Depart- mental Committee, 28 Recreation, 120-122 Relief to parents, by training, 13s Religious feeling, 128, 129 Report on Scientific Study of Childhood, 13 Report on Swiss Schools, 19 Results (percentages, &c.), 130 et seq. Rewards and punishments, 124 Royal Albert Asylum, Lan- caster, 8, 61, 65, 132 {Ap- pendix B) Royal Commission on blind and other defectives, 13 Index 179 Sauvage de VAveyron, 1 Scandinavian Institutions, 32 Scotland, provision in, 10 Scrofulous cases, 55 Secondary education, grants for, 147 Selection of pupils for special classes, 35 et seq. Sensorial training, 104 Sexual erethism, 90 Sight, training of, 106 Size-board (school appliance), 106 Skin affections, g6, 97 Skin, hygiene of, 87 Slavering, repression of, iii Smell, training of, 109 Special classes, 25 Special classes, cost of in London, 145 Special classes, list of (Ap- pendix C) Special Instruction, 31-47 Speech-exercise (Appendix E) Speech, training of, no Sporadic cretinism, 55, 95, g6 Surgical treatment, 97, 98 Syphilitic cases, 57, 78 Syphilitic inheritance, 62 Tactile function, training of, 104 Taste and smell, training of, log Thyroid treatment of cretin- ism, 95, 96 Toxic cases, 59, 80 Trained cases earning living, 133, 137, 144 Trained cases, responsibility of, 125 Traumatic cases, 58, 59, yg Treatment, 85 -g8 Tubercular disease, 92 United States census of im- beciles, &c., 9 United States, provision in, 7, g (Appendix D) Western Counties Asylum, Starcross (Appendix B) Wood-carving by athetotic patients, iig Working homes for adoles- cents, 40, 148, I4g Working homes for adoles- cents, list of (Appendix B) Writing, 115 i8o Index. INDEX OF NAMES. Alexander, Dr. William, 93 Andriezen, Dr., 94 Barlow, Dr., 87 Barr, Dr., 84. Beach, Dr. Fletcher, 48, 61 Blanilford, Dr., 82 Bourneville, Dr., 10, 33, 48, 98 Burgwin, Mrs., 34, 142, 143 Clouston, Dr., 79 Conolly, Dr., 4 Cunningham, Prof., 50 Dendy, Miss, 150 Doren, Dr., 6 Davidson, Dr., 79 Fernald, Dr., g, 12, 133, 151 Fort, Dr. J., 127 Froebel, 100 Garrod, Dr. A., 75 Gaskell, Mr., 4 Guggenbuhl, Dr., 2 Horsley, Prof. Victor, 77, 95 Howe, Dr. S. G., 5 Ireland, Dr. W. W., 48, 55 Keller, Dr., 33 Kerlin, Dr. Isaac, 6, 127 Kielhorn, Herr, 31 Langdon-Down, Dr., 63, go Lippestad, Herr K., 6, 32 Macdonald, Dr., 79 Morel, Dr. Jules, 127 Powell, Dr. F. M., 7, 134 Railton, Dr., g6 Reed, Dr. Andrew, 4 Rhodes, Dr. Milson, 139 Richards, Mr. J. B., 6 Saegert, Dr., 2 Seguin, Dr. E., i, 3, 107, 131 Seguin, Dr. E. C, 94 Scethie, Herr, 32 Telford-Smith, Dr., 50, 96, 98 Tuke, Dr. D. Hack, 61 Turner, Mr. J. J. C, 135 Twining, Dr. W., 4 Twining, Miss Louisa, 139 Voisin, Dr., 3, 131 Warner, Dr. Francis, 13, 15, 16, 17, 18, 69, 147 White, Misses (Bath), 4 Wilbur, Dr. H. B., 5 Wilmarth, Dr., 58 Wintermann, Herr, 31 SELECTED LIST OF NEW AND RECENT WORKS PUBLISHED BY H. K. LEW^IS, 136 GOWER STREET, LONDON, W.C. (Established 1844). *,* For full list of works in Medicine and Surgery published by H. K. Lewis see complete Catalogue sent post free on application. LOUIS C. PARKES, M.D., D.P.H. LOND. Lecturer on Public Health at St. George's Hospital, AND H. R. KENWOOD, M.B., D.P.H., F.C.8. Assistant Professor of Public Health at University College, London. tlYGIENE AND PUBLIC HEALTH. Second Edition, "■^ with illustrations. 12s. ly^t published. ALFRED H. CARTER, M.D. LOND., F.R.O.P. Professor of Medicine, University of Birmingham ; Senior Physician to the Queen's Hospital, Birmingham, &c. CLEMENTS OF PRACTICAL MEDICINE. ^ Eighth Edition, revised throughout, crown 8vo, los. 6d. \yust published. W. 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