Ireland ‘On the diagnosis and prognosis of idiocy’

On the Diagnosis and Prognosis of Idiocy and Imbecility

 

William W. Ireland

Edinburgh Medical Journal

June 1882, pp. 1072-85

 

The object of this paper is to point out those features of idiocy and imbecility which it is most important that the physician in ordinary practice should know. I have, therefore, no intention of going deeper into the pathology of the subject than what seems useful in illustrating my remarks or removing the possibility of erroneous ideas arising in the mind of the reader.

I. DIAGNOSIS

When an idiot or imbecile occurs in a family, the ordinary medical attendant is generally the first consulted. Perhaps he is already aware of the nature of the case, having attended the child from infancy, or treated it for some nervous disorder, of which he has now to consider the results. In some cases there is very little difficulty in the diagnosis: in others there is room for doubt. In any case the situation requires tact and management. The parents in general are extremely slow to recognize idiocy in their family, and apt to take offence should their medical adviser arise at the truth too far in advance of their own suspicions; and even when their suspicions are fairly awakened, they are more anxious to get them allayed than confirmed, and sometimes do not bear well the unpleasant intimation that their child has such a serious deficiency. Very frequently the first symptom which startles them is that the child does not speak, though considerably past the usual time when children begin to utter words.

Here, of course, one should be on his guard not to confound an idiotic with a deaf child or with a simply backward or stupid one. The diagnosis between a deaf child and an idiot is generally easy, and need not detain us. There may, however, be additional complications which render it perplexing. Some idiots are deaf, many of them dull of hearing (often from otorrhoea), others are very inattentive to sounds.

I was once consulted about a child five years of age who had partial hemiplegia of the left side. One leg was shorter than the other. There was more power in the arm, which seemed to be gaining strength. She was known to have had three fits. The head was rather small, and she had not attained the ordinary size of a child of her age. These symptoms indicated a cerebral disease, and as she never spoke, the question arose, Was she deaf, or was she imbecile? or was imbecility added to deafness? At first I was unable to give an opinion, as the child was timid and resisted all my attempts to gain her attention. After she became more familiar with me, I could make out that the little girl was insensible save to very loud noises. She could not be awakened by a bell rung over her head, though she could hear it after she was awake. She was too lively, sharp, and noticing to be imbecile, though it was impossible so to probe her intelligence as to determine whether a certain amount of simplicity might not appear after her education was commenced. On this account, and taking the paralysis into consideration, I could not advise that she be taught to speak in the German manner, but thought that she should be educated in the ordinary way in deaf and dumb schools by figurative signs, writing, and the finger alphabet. In teaching the deaf to speak after the German manner, the instructors generally manage to eliminate the slower children, and the results which are exhibited to the public are gained from persevering instruction bestowed on the sharpest children in the school.

It seems strange that an imbecile child could be mistaken for one simply slow in speaking; but apparently this is frequently done: at least many parents have assured me that when they have consulted the doctor about their child he told them that it would all come right. “Only wait for a year, wait for two years, wait til he is seven. He possesses all his faculties.” The parents often give misleading information about the child’s capacity. They will say, “He is very clever, only he does not speak; but he can understand everything that is said to him”; and when this statement is tested it will be found that the child can only execute some very simple command, such as to shut the door, or to pick up his hat. Sometimes the words have to be eked out with pantomimic signs, so that often the child is found not to understand more than a score of words. This, however, does not prevent the parents making remarks disparaging to the doctor’s skill when, after waiting for years, they apply to some other medical adviser, from whom the sad truth comes out that they have been feeding themselves on false hopes.

On being consulted about a possible case of idiocy, the physician should make careful inquiries about the following points:-the existence of neurosis in the family, such as insanity, idiocy, epilepsy (1), or other nervous diseases, and the existence of constitutional maladies, such as consumption or scrofula. Of all known diseases, perhaps idiocy is most frequently propagated by heredity. As the admission of a constitutional disorder in the family is thought humiliating, it is not uncommon to get incorrect or evasive answers. Educated people are much less likely to lead a medical man astray, not only because they are in general more truthful, but also because they generally understand that anything which they reveal will not be repeated by a respectable practitioner. In asking about the health of the grandparents of the child, it should not be forgotten to ask about the collateral relations.

Dr. Kerlin,(2) the medical superintendent of the Pennsylvania Institution for Feeble-minded Children, has found that consumption appeared in 56 per cent in one or both families ancestral of the idiot child. Dr. Grabham, of Earlswood Asylum, has found a history of pthisis in 22 per cent of the parents or near relatives. Dr. Shuttleworth, the medical superintendent of the Royal Albert Asylum at Lancaster, who has paid much attention to the question of drunkenness as a cause of idiocy, holds that it is not so common a cause as has been represented by Dr. Howe and by the sensational writers who quote him. Dr. Fletcher Beach, who has principally studied the cases drawn from the poorer classes in London received into the Darenth Asylum, is disposed to give a greater force to drunkenness in the parent as a cause. Before the examining the question, it would be useful to know in what percentage drunkenness occurs in the population overhead. I certainly know villages where it is very common, and where there are few or no idiots; and I am disposed to believe that when it does appear as a cause, intemperance in drink does so by exciting other nervous diseases in the parents or grandparents. Should there be a record of some neurosis in the family, one must still be careful, as parents who are actually insane have not infrequently had unhealthy children.

An examination of the head of the child often fails to help the diagnosis. Hydrocephaly and microcephaly will, of course, be recognised. The latter is a very rare form of idiocy, which is in the great majority of cases owing to disease, not to want of development, of the brain. In the most common forms there is often nothing peculiar either about the size or conformation of the head, and when irregularities exist, the same irregularities may be found with people who have all their faculties. Flatness of the occiput is one of the commonest deformities. Attempts to guess the amount of intelligence from the physiognomy are often unsuccessful. The countenance expresses the moral disposition better than the mental power.

The most distinctive accompaniment of genetous idiocy or imbecility is a deformed condition of the palate and irregular teeth. The distance between the molars and bicuspids on each side is narrow, and the roof of the palate is high, so as to invade upon the nasal cavity. This deformity has been variously named the vaulted, keel-shaped, or V-shaped palate. The irregularity is not always of the same form; but those who know the shape of the normal palate at different ages will hardly fail to recognise the abnormal form when their attention is aroused. The teeth are of irregular forms and sizes, or growing out of the usual places, or set at diverging planes to one another. Sometimes the palate may be normal and the teeth irregular. Sometimes the enamel is dotted with small holes. A good set of teeth is rare with idiots. They generally decay early, though with little pain. According to Dr. Magitot (3) of Paris, erosions of the teeth similar to those met with in idiocy have been observed to follow convulsions in infancy. This deformity of the jaw and irregularity of the teeth seem often associated with a want of symmetry of the bones of the base of the skull.

Mr. Oakley Coles has devised a scheme for giving greater precision to observations and descriptions deformities of the upper jaw. With a pair of compasses he takes the base of a triangle from the distal surface of the second molar on each side, as near to the level of the alveolus as the third molar will allow. From this as a base the triangle is completed by drawing converging lines to the surface of the gum between the two central incisors. He notes especially the breadth at the base between the second molars, and the breadth between the second bicuspids. The measurement between the centre of the basal line and the apex, between the incisors, of course gives the length; and the height of the palate is determined by a vertical line drawn from the middle plane between the bicuspids up to the palatal arch.

He compares the relative distances in different cases between these several points in the triangle, and notes whether the bicuspids fall within or without the converging lines, for Mr. Coles has discovered “that the best type of well-developed English jaw will give an equilateral triangle as the result of measurements taken in this way.”

The deviations from this standard figure are duly classified, defined, and named; but for further particulars we must refer to Mr. Coles’s pamphlet. (4) To the form known to dentists as the V-shaped palate he gives the name of the lambdoid palate, from the Greek L. It is, he remarks, a class alone, without normal parallel. After noting the prominent markings of the mucous membrane of the mouth, Mr. Coles tells us that “in a typical case we have a base line of 56 m., a length of 43 m. from base to apex of triangle, and an interbicuspid measurement of only 28 m., falling within the sides of the triangle; the central and lateral incisors seem rotated, and the palate presenting the typical wedge-shaped outline, the vertex being above the normal plane, and the soft palate too short to touch the posterior wall of the pharynx. Although it is not essential to idiocy that this deformity should exist, still it is tolerably certain that the lambdoid arch is rarely seen except in connexion with low mental development, and especially where the idiot is microcephalic.”

In another place Mr. Coles remarks, “After carefull examining the work of various writers on the subject of microcephalic idiocy, there seems sufficient evidence to justify the belief that premature ossification of the sutures is the rule in the majority of these cases (of microcephaly); and we may therefore assume, if we cannot absolutely conclude, that this influence operates powerfully in the production of the dental deformity known as the lambdoid jaw; and this view is held by Virchow, but it is combated by Dr. Langdon Down and Dr. Ireland.”

It is about twenty years since Virchow gave out the theory that premature ossification of the upper sutures of the cranium was, in many cases, the cause of microcephaly, though he admitted that microcephaly also occurred where the sutures were open. Since then, so many cases of microcephaly with open sutures have been published, that it does not seem too bold to hope that the veteran pathologist has modified his views. This does not seem a fit place either for citing arguments or authorities on the question, so it may enough to remark that I cannot see what causal connexion there is between closed sutures and a lambdoid palate, and that the instances of vaulted palates studied by me have not been associated with microcephaly, but with heads of moderate size. As far as I know, though this deformity does occur in the microcephales, as in the so-called Aztecs, it does not occur in the majority of cases. Let Mr. Coles look at the plates in the monographs of Vogt and Bischoff, and he will see that the palates are all flat. The subject of the connexion of degeneracy of race with irregularities in the jaw and decay of teeth is one of great interest both to the physician and the anthropologist. It is gratifying to see that Mr. Coles and other eminent dentists (5) are busy making observations which may in the end lead to important results.

It has been observed that though congenital idiocy and congenital deafness are not commonly met with together, the causes are often similar. I venture to call the attention of those medical men who have to do with the latter deficiency to the appearance of the palate. I once examined the mouths of a number of pupils in a school for the deaf and dumb, and found an unusual number of high palates in those who were stated by the teacher to be borne deaf, but since then I have had no opportunity of extending the inquiry. The vaulted palate occurs, though rarely, with people who are not at all imbecile, and is wanting in many cases of born idiocy. Still it is a very frequent accompaniment of idiocy. Other peculiarities met with in idiots much oftener than with ordinary people are deformities of the toes and fingers, one or two toes often being smaller than the rest, strange shapes of the ears, wad-shaped fingers, hernia, nystagmus, squinting, and coloboma iridis.

It has been found, by exact observation, that the idiot child is on the average about two years behind an ordinary child in bodily growth; and puberty comes on several years later; sometimes it does not appear at all. In some cases, especially belonging to the lower grades of idiocy, the temperature is below the normal; the pulse is so weak that it is difficult to count, and the respirations are irregular. It is strange to see these blighted children live on year after year with the ordinary functions of vitality going on in so feeble a manner. Dr. W. Bechterew, (6) of St. Petersburg, who has made some careful observations on the loss of temperature in idiots, finds that the increased generation of internal heat which occurs with healthy people immersed in a cold bath does not follow with the weak-minded. He is disposed to think that this deficiency in the thermogenic mechanism of the body is owing to a lesion of that portion of the brain which presides over the regulation of the bodily heat, placed by some physiologists close to the median cerebral convolutions. However this may be, idiots lose heat more rapidly, and do not generate it so quickly. Their power of resisting cold is feeble, like that of infants, but they .have not the same rapid reaction, and are not nearly so subject to acute inflammations of the air-passages. It seemed to me that the approach of phthisis was not so well indicated by a rise of temperature as in normal children. There are cases, as in traumatic idiocy, where the brain alone is diseased; but in most cases of genetous idiocy, and in many apparently resulting from nervous disease in infancy, the whole bodily machinery seems out of gear. Not only are the wheels of being slow, but they work out of harmony with one another. The strumous diathesis is very common, manifesting itself in glandular enlargements, abscesses, or sores, and in ophthalmia, otorrhoea, and skin eruptions.

Lord Derby has remarked, with his usual philosophic insight, when speaking of the work to be done in an institution for imbeciles, that “the greater part of the value of an asylum or an hospital consists in its usefulness as a school where the particular complaints there treated may be studied”; and the close study which such establishments have enabled the resident medical officers to make has been useful in adding much knowledge to an obscure subject, and promises yet to add more. In this unfortunate but interesting class there are many peculiar manifestations of perverted nutrition and disordered nervous action. There is a tendency to convulsions, manifested by fits occurring now and then, sometimes at intervals of many years. There is a great variety of nervous disorders, such as obtuseness of special senses, or anaesthesia of different points of the surface, profuse salivation, automatic motions, athetosis, or paralysis agitans. The tendency to insanity with imbeciles is much greater than with the same number of ordinary people. It generally takes the form of periodical outbursts of sleeplessness, irascibility, or maniacal fury. When put into asylums, imbeciles often take on or imitate the manners of the lunatics by whom they are surrounded.

A medical witness, if examined about a pauper idiot, will likely be asked whether he thinks the case to be a congenital one; for if this can be held, it generally fixes the settlement to the parish in which the idiot was born. Unless there is a very complete medical history, it is difficult to answer this question with anything like certainty; but should there be the characteristic deformity of the palate and teeth, the probability would be strong, and this would be much increased by the existence of hereditary neurosis in the parents, and by the occurrence of the rarer concomitant deformities, and by the absence of all history of nervous diseases known to be causes of idiocy in early life.

The only kinds of idiots in this country which could safely be put down at first sight as certainly congenital are the microcephalic and the Mongolian. The first class would, of course, be recognised by the unusual smallness of the head; the second by the characteristic appearance. The head is obtusely rounded; the eyebrows have the outward slanting turn characteristic of Chinese drawings, owing to obliquity of the outer superciliary margin of the orbit. The nose is low at the bridge and short; the tongue hacked and rough, owing to the abnormal size of the fungiform papillae. The vaulted palate is common with this variety. The stature is short, the figure squat, the fingers and toes stunted. The general appearance recalls the Mongolian. In the mental character there is a deal of passive obstinacy; the intelligence is generally very low. In the male the testicles are wanting or rudimentary, or there is only one. They generally die of phthisis, so that it is very rare to see a grown-up Mongolian idiot. In Scotland about three per cent seem to belong to this variety.

Idiocy is very often caused by nervous disorders in early childhood. The most common of these are fits, mostly occurring at teething, but sometimes before it. In this case there is generally a pretty clear history. The child has been seized with fits rapidly succeeding one another, so as to place its life in great danger. It recovers, with permanent injury to the functions of the brain. The fits may pass away, or the child may remain epileptic for life; but it must be remembered that though the occurrence of eclampsia, epilepsy, hydrocephalus, or paralysis may explain the causation of existing idiocy, they do not actually prove its existence, for we may have all these diseases without idiocy necessarily following: hence one ought to be cautious about the diagnosis of idiocy in early life. Prolonged illness becomes a cause of mental weakness even in adults, and the brain, like other organs, has got wonderful recuperative power. In those few cases seen by me where idiocy was recognised very early, the child was dull and inanimate, let its head fail to one side or other, and if put on the ground, it did not cry or try to right itself. It was not noticing, and was slow of learning to grasp. Slavering is very common with such children. The statements sometimes met with in books about instinct being more powerful in idiots are quite erroneous; on the contrary, it is weaker, as was long ago noted by Esquirol. Idiots are late in walking as well as in speaking; but it is only in cases of extreme fatuity that they fail to learn to walk, if the spinal cord be not involved. Dr. Mierzejewski of St. Petersburg, who has deeply studied the pathology of idiocy, says that where the median convolutions are deficient or isolated from birth, the child is unable to use the limbs, no motor impulse, even if conceived, being able to reach the terminal motor apparatus. He describes a case of the kind, and refers to others. (7) Mr. Hutchinson lately brought the Pathological Society of London (8) a child seven years of age, with an idiotic expression, who could only move slightly all the muscles of the face and limbs. Dr. Hughlings Jackson had diagnosed double hemiplegia, the conditions being .quite symmetrical on both sides. Dr. Jackson believed that it was due to a cyst situated in the motor zone on each side, and that the cysts were probably secondary to an earlier thrombosis. Dr. Warner reported that he had seen two cases of double hemiplegia in children which appeared to be congenital. He had made a post-mortem examination of a child in whom there was bilateral defective development of the convolutions behind the fissure of Rolando. Double hemiplegia had existed from birth. These interesting eases are of very rare occurrence, and I have not observed any cases in which motor deficiencies could be traced to localized cerebral lesions, save one of paraplegia supervening upon an abscess in the centre of the right hemisphere. The ordinary motor deficiencies of idiots seem to be owing to mental incapacity.

In general, unless imbeciles are subjected to very careful instruction, their gait is awkward; they learn to walk in the easiest manner, which they never try to alter or improve. I have seen imbeciles who were nearly grown up totally unable to perform such simple motions as pronation and supination of the forearm, but who, on being taught, soon learned to do so. The same awkwardness applies to the hand. The best and earliest sign of idiocy is the deficiency of grasp. The hand is flapped or vibrated about instead of being employed to seize or obtain an object. The machinery of the human body, adapted for a being of superior intelligence, is too complicated an apparatus for an inferior one.

A large number of idiots remain mute simply because their ideas are too rudimentary to need expression. In general the intelligence appears somewhat greater than the faculty of speech. You must not expect a word to come to fit every idea: there must be a certain accumulation of ideas before any words are uttered. For example, an imbecile may distinguish colours without being able to name them, desire articles without being able to ask for them, and know all his companions without being able to can them by name. In some rare cases the ideas attain a certain complexity: these I have called aphasic mutes; but the general rule is, that when the storage of ideas is at all considerable, the faculty of language appears. Sometimes it is much retarded, occasionally as late as seven or eight. I have known an instance of an imbecile boy beginning to speak at nine, but never met with one where speech came after ten years of age. On the other hand, I have seen a case where speech was so much impeded by defect of command of the vocal apparatus with hemiplegia, that the patient was erroneously believed to be imbecile. If the child can speak, the degree and manner in which words are used form the best guide of his mental capacity. Esquirol’s psychical classification of idiocy and imbecility is based upon the degree in which speech is exercised. It is true that some imbeciles are more voluble of talk than others of more mental power, and this holds good with many people who deem themselves wise enough to direct others. Still, there is no doubt that when the imbecile can talk freely, it becomes comparatively easy to determine the degree of stupidity. Conversing with a man is one of the best and easiest ways of arriving at an idea of his general ability. Imbeciles are almost always very unskilful in counting, and it requires an enormous deal of trouble to teach them. On the contrary, they are fond of music, and often catch up easy tunes. Their parents often cite this as a proof that their mental powers are not so deficient as might appear.

A new difficulty in the diagnosis turns up when the deficiency is of a slight character. There is sometimes a question whether a young person is imbecile or only grossly stupid. He may present none of these irregularities of conduct or vagaries of reasoning, delusions, or hallucinations which indicate insanity, and nevertheless he may be so unfit to conduct himself in a proper way, adding the passions of youth to the intellect of childhood, that it is necessary to have some legal control over him. The difficulty often appears when the parents are dead and when the young person becomes entitled to property For such cases it would be difficult to lay down any criteria. The medical attendant, if consulted, will perhaps, in addition to his estimate of the mental powers of the individual, be able to point out some physical peculiarity or some nervous disease indicative of imbecility.

The case of Mr. Windham, a good many years ago, caused much discussion in the law courts. He was a young man of distinguished connexions, who was entitled to come into a large estate, but showed great lack of mental and moral guidance. He contracted a marriage with a woman whose conduct seemed quite at variance with such a compact, but who was exacting the matter of settlement. His relations tried to get him declared incapable of managing his affairs. Doctors, of course, appeared on both sides, and those who were inclined to certify the young man as imbecile were abused in some of the newspapers. It was decided that lie was capable of managing his affairs. In tills case there was a vaulted palate. Medical science will probably never be exact enough to prevent such difficult questions from becoming a source of profit to lawyers, a class of men who generally spend money well and invest it prudently; but unless parents and guardians wish that their money should be so spent, it is expedient that they should take timely consideration of coming eventualities, and see that everything is done to avert such issues.

II. PROGNOSIS

It may be asked, Is the whole brain diseased in idiocy, or only a part? I do not think that we are sufficiently advanced in the study of the pathological anatomy of the brain of idiots to give a direct answer to this question. In some brains very extensive lesions or alterations are discovered; in others the lesions seem only partial; but in others, again, nothing abnormal has been made out, though most pathologists will be disposed from analogy to believe that this is only owing to the imperfection of our existing means of investigation. It seems likely enough that in some cases portions of the brain still remain healthy. Goltz (9) found, in his recent investigations, that when he removed a great portion of the hemisphere on one side the animal did not become idiotic or demented; but if he removed portions from either hemisphere, the animal showed a diminution of mental power, with loss of tactile sensibility and awkwardness in its movements. We may therefore suppose that in idiots who improve under instruction, where the whole cerebrum is diseased, it in great part recovers its tone by being brought into healthy exercise, and that where a part still remains sound it is thrown into more vigorous exercise than the rest, attracts a greater supply of blood, and gains a more vigorous nutrition than the surrounding parts. We may fairly infer that the improvement will be influenced by three circumstances,-the nature of the existing lesion, the possibility of ensuring that the brain will receive no further injury, and the propriety of the stimulus applied to the nutrition and function of the organ. To ascertain the extent of the lesion, come and gone, which has robbed the child of the intellectual powers it would otherwise have enjoyed is very difficult; nor would it be easy to formulate the knowledge on which a conclusion should rest. The diagnosis of a disease may be made by seizing upon some recognisable symptom or group of symptoms;but the prognosis in most diseases can only be made from a lengthened experience of the course of many cases carefully studied. It is what Dr. John Brown has called the middle propositions, which every craftsman learns from practice, that here come into request. Thus prognosis is the highest test of medical skill.

One who wishes to know the matter thoroughly will not be content till he has made himself acquainted with all that is known on the pathology of idiocy. In the degree of the mental deficiency we have a fine test of the extent of the lesion; and in our knowledge of the causal disease we have an idea of the probability of its effects being permanent, or whether they maybe expected to pass away, at least in part, or are likely to hinder our efforts at mental improvement.

Thus we know that where the deficiency is congenital the prognosis is often better than where it is traceable to disease s occurring in childhood, that great improvement in the intelligence often follows improvement in the general health, as in the successful treatment of strumous and anaemic conditions. Thus at Larbert the miserable children brought from the closes of the Cowgate and Saltmarket on first admission improved much more than those who came from country villages, whose tone of health was good at entry.

The effects of convulsions at teething are liable to remain, so that eclampsic idiocy has an unfavourable prognosis. Hydrocephalus, when it has ceased to advance, leaves a fair chance for improvement, unless fits occur, which is a bad complication.

Since my book on idiocy and imbecility was written, I have come to set a higher value upon the view of my friend Dr. W. A. F. Browne, that cases of epileptic imbecility, when the epilepsy is successfully treated, form the cases in which there is most improvement. It would take up too much time to give instances at length, but I have had a number of epileptic patients where the fits entirely ceased, and where there was a very remarkable improvement in the mental condition. In other cases the number of fits was clearly diminished by medical treatment and regimen, while in a considerable number no benefit was obtained. In epileptic cases no time should be lost in putting the child under proper medical treatment. Out of fifteen deaths in ten years, two children died of exhaustion from fits, but I never lost any in the status epilepticus, though death sometimes seemed imminent. Many of the epileptics, also made considerable improvement under teaching, though, as a rule, epileptics are eccentric and difficult to manage. In one of the most improving cases I had, a boy afflicted from infancy with chorea, great amelioration took place after the successful treatment of the nervous disorder. The boy was taught to earn his bread at brush-making. In paralytic imbecility there is often a great improvement, especially in the mental symptoms. The individual symptoms of the case require careful study and a variety of knowledge and resource in treatment. It has been proved by the experience of forty years that children of defective intellect are susceptible of very gratifying improvement if subjected to an education consisting in the wise regulation of their whole life and habits, the treatment of their peculiar diseases going along with persistent training on physiological principles, conducted under the direction of persons well versed in hygiene and the educational art. In considering the amount of improvement, one must always remember the grade at which the training commenced. Critics have sharply disputed the assertions of those who claimed to have made cures of imbecility; but if a child whose intelligence was a few degrees below the boundary line between stupidity and imbecility is raised so far as to pass it, such an improvement can fairly be called a cure.

There are a large number of cases in which the mental fatuity is so complete that training will never be of any use; there are others where it can go no further than habit teaching, forming habits of cleanliness-a thing, no doubt, of considerable importance, both for the comfort of the idiot and those who have the care of him, and which, by the way, is a quite different thing from simply keeping him clean. In reading over the works of the late Dr. Seguin, one is struck by the hopeful way in which he approached cases which seemed to promise little or no improvement. A good deal may sometimes be done in the very worst cases; but this requires an amount of effort and attention and the devotion of time which can only be commanded by those parents who are in affluent circumstances.

It may be said, as a general rule, that where the fatuity is very deep and the child cannot so interpret the senses as to produce voluntary motions, but is a mere passive recipient of sensation, all training is useless. Where walking is late and the child is mute, where it is passive or given to automatic movements, the grasp not firm, and the attention difficult to fix, the prognosis is unfavourable; but where the child commences to speak before six or seven, where he is active and noticing, and capable of sustained attention, a good deal of improvement can be expected. Where speech is free and the mental manifestations diversified, the prognosis depends upon the degree and character of the intelligence, the bodily health, and the hopes of improvement in casual or concomitant diseases.

In training the imbecile one need not expect success where the conditions, in the opinion of those who are acquainted with the subject, promise at least a partial failure. To gain a full measure of success, the training should be begun when the need of it appears, and carried on as long as the need exists, and not for five years, beginning at one age or other and ending abruptly. The training must include a regulation of the whole life and habits and the evolution of the whole intellectual and moral being, not the narrow circle of the ordinary schoolmaster. The teaching must be no make-believe, but earnest and painstaking, and carried on in an enthusiastic and hopeful spirit. One has to combat with a gross notion, that because the capacity of the pupils is low, or rather, perhaps, because the results can never be very high, any make-shift of a teacher obtained at poor wages will suffice. If the thing is not worth doing well, it had better not be attempted at all. The art of the teacher must augment with the obtuseness of the pupil. A very clever man will teach himself. In universities, where the highest minds resort, teaching is at its minimum. Within two generations the art of the educator has made great strides towards improvement; and the physiological training devised for idiots by Dr. Seguin is the result of consummate study and practice of the art. People of the Gradgrind stamp will always ask, Cui bono? but, in reality, imbeciles are much better and happier when their intellectual power is increased by exercise, and when they have acquired habits of manual dexterity. This is to be done by teaching them sometimes one trade, sometimes another; for they are not all fit for one occupation. It by no means follows that the trouble of teaching is thrown away because, in an overpeopled country where hundreds of skilled artisans are idle, the feeble-minded often fail in getting remunerative employment. One of the main reasons for teaching imbeciles to work is the formation of habits of attention and industry. Work with them must become a habit till idleness ceases to be agreeable, and a pleasant occupation is given to them for life; and this remark applies as much to the children of the rich as of the poor.

============================

Footnotes

1. In an interesting lecture, delivered before the section of Menal Diseases at the Medical Congress, Dr. Lasègue described a form of epilepsy dependent upon malformation of the base of the cranium, which is indicated int he living by irregular or unsymmetrical form of the face. It appears about puberty. The professor had been often consulted whether there was danger of the disease being transmitted to the children. He believed there was no danger of this occurring; and where such marraiges took place, which sometimes occurred (the lady being rich), he never found that they gave birth to an epileptic child.

2. See his excellent pamphlet on the Enumeration, Classification, and Causation of Idiocy, Philadelphia, 1880.

3. See his elaborate paper in the Transactions of the International Medical Congress. London, 1881. Vol. iv. p. 128.

4. Deformities of the Upper Jaw: an attempted Classification of them. By Oakley Coles, Lecturer on Dental Surgery and Deformities of the Mouth to the National Dental College, etc. Reprinted from the Transactions of the Odontological Society.

5. See the paper of Dr. Norma Kingsley on “Civilisation in its Relation to the Decay of the Teeth,” and the discussion thereupon; and the inquiry of Mr. Mummery “On the Causes of Mental Decay,” in the Transactions of the International Medical Congress, Vol. iii. pp. 553-541.

6. W. Bechtereu, “Calorimetrie bei Geisteskranken,” St. Petersburger Medicinische Wochenschrift, Nos. 38 and 39, 1879.

7. Contributions à l’Etude des Localisations Cérébrales Observation de Porencephaliefausse Double, par Professeur Mierjewski, Paris, 1881.

8. British Medical Journal, 11th March 1882.

9. Ueber die Verrichtungen des Grosshirns, von Friedrich Goltz, Bonn, 1881.

© Murray K. Simpson, 1997

 

Leave a reply