Scheme for Medical Examination
Heredity of the Child.—Note the name, the date, and the place of the birth of the father and the mother, and find out, by direct interrogation, whether the parents have a pathological heredity. Consider first the two great hereditary influences—alcoholism and insanity. Next inquire concerning nervous ailments, tuberculosis, etc. Make inquiries concerning the direct ascendents and their collaterals. Note the number of brothers and sisters, their illnesses, their mortality, and the position of the child in the family.
Previous History of the Child.—This is the second part of the medical examination. It includes many questions. Has the child had convulsions? At what age did it begin to cut its teeth? At what age did it begin to walk? When did it show habits of cleanliness? When did it speak? What illnesses had it in infancy? Has the child always appeared different from others, or did it only become so at some definite time, or, in other words, is the mental deficiency congenital or acquired?
Present Condition.—Under this heading are included the general appearance of the subject, his attitude, the form and size of his head, etc.
We have no objection on principle to medical investigations of this kind, and if a doctor desires to collect such information, he ought to be encouraged. We recall in passing that Dr. Ley, of Antwerp, who was for some time medical specialist to a school for defectives, has made a very complete study of the heredity and personal antecedents of hundreds of defective children. But before compelling doctors to fill up conscientiously a schedule containing all these questions, one should consider without prejudice what use the work is going to be when it is done.
Let us distinguish between pure science and what is of immediate practical utility. No doubt one ought to give a warm welcome to everything which helps us to understand the child better; but the above observations upon his heredity do not bear upon the question of whether he is a defective, and throw only the dimmest light upon his character and the manner in which one should treat him. If he is to be counted abnormal, he must be either ill-balanced or of deficient intelligence. Even if he should have an alcoholic heredity, that would be of no importance if he were able to follow his class and to profit by the ordinary instruction. At most, the discovery of a pathological heredity might incline one in a doubtful case towards a diagnosis of mental deficiency; but yet one should be extremely cautious about permitting oneself to be influenced in this way, for we are ignorant to a most incredible degree concerning the heredity and antecedents of normal children, and as our ignorance in this respect is so complete, we are unable to say precisely what is really pathological in the heredity and the antecedents of those who are abnormal. Information of this kind, therefore, is not directly useful.
What, then, are the first problems to be solved? Let us consider just exactly where we are in the examination. Here are the children picked out by the teachers. The inspectors themselves have checked the selection and referred back some of those selected, but very few, if they have carefully directed the methods of choice from the beginning. The children presented are backward in their studies. Inquiries regarding their school attendance have shown that the retardation is not due to irregular attendance. The examination of their intelligence has confirmed this judgment.
It still remains to discover whether, amongst all these children who are unable to follow the ordinary school curriculum, there do not exist some who are not, properly speaking, mentally deficient, but who are suffering from some illness. May we not find amongst them some who require medical treatment rather than special teaching—e.g., cretins? And, lastly, may there not be some children whose mental deficiency complicates some other disease, such as epilepsy? These are problems which are essentially medical, and which it is necessary to solve before admitting a child to a special school. Let us consider them in order.
1. Is the Case one of Mental Deficiency, or of an Intercurrent Mental Affection?—To tell the truth, there is not often any doubt. However, there are two circumstances in which doubt may arise. In the first place, an arrest in a child's mental development may be the expression of a state of depression which indicates a psychosis in the course of evolution, or it may be the first sign of decadence in one of those degenerates of whom Morel speaks, who seem to have "a limited mental existence." Such cases, which some authors describe under the name of "dementia precox," require a medical regimen.
In the second place, it is possible that the etiological factor is alcohol. Alcoholism in the parents is frequently the cause of mental deficiency. But the effects of drinking do not always stop there. The child itself may be made to drink, and consequently the doctor may sometimes find symptoms resulting from direct intoxication—nightmares, or tremor of the hands. Such intoxication may be responsible partly, if not entirely, for the want of progress at school, and also for the irritable temper which the child shows in class. It would be necessary in such cases to see the parents, and to advise a different hygiene for their child at any rate, if they themselves cannot be persuaded to give up their bad habits. In this way one may be able to avoid sending the child to a school for defectives. It is apparent that even if the child were sent to such a school, it would be necessary to put a stop to the administration of alcohol. The rarity of such cases makes their exposition of almost theoretical interest.