It goes without saying that if a child does not profit from the school work, an examination of his sight and hearing should be made as a matter of course. Perhaps that may have been done already by the teacher himself by such methods as he is able to use. But this first examination is not sufficient. The doctor must correct, as far as possible, the want of acuity noticed. No doubt the defect may not explain the mental deficiency of the child, but one must take care that in the school for defectives a pronounced myopia or catarrh of the middle ear does not prove an obstacle to the efforts which are to be made to bring about development.
In the same way it must be considered whether the condition of the muscular system is such as to permit the manual work which one wants to teach the child, and whether there exists any paralysis or tremor which would prove an obstacle to work of this kind. One must consider whether any symptoms present are transitory, like chorea; or permanent, like infantile hemiplegia; and what kind of efforts may be made without risk to the health of the child. Such are the problems which the doctor has to solve.
In the last place, it is necessary to take into account the coexistence with the mental deficiency of other affections.
Epilepsy.—Epilepsy frequently coexists with mental deficiency. Now, epilepsy does not always reveal itself by severe fits with crying, falling down, loss of consciousness, convulsions, stiffness followed by jerking of the limbs, foaming at the mouth, biting of the tongue, and involuntary passage of urine. It is revealed also by symptoms of a less striking nature, which have been described under the name of petit mal. Such are loss of consciousness, vertigo, or simply mental perturbations. Loss of consciousness occurs without the tremor of a muscle, the child suddenly turns pale, loses consciousness for a moment, and then continues whatever he was doing—for example, walking or writing. There is nothing more impressive to notice when the fit occurs as one is talking to the little patient. One sees, as it were, the passing of a veil. But nothing could be more fugitive, nothing could more easily escape the notice of anyone who was not a good observer. Often the parents know nothing about it. The attacks are so short, the consequences apparently so slight, that even if the parents have chanced to notice them, they do not always think of mentioning the fact. The teacher of defective children ought to be instructed in the characteristics of this affection. He is going to spend several hours daily with the children. He will have the best opportunities for noticing the occurrence of attacks, which may be rare, but which, when they occur, are very significant.
Although the symptoms are a little more marked, vertigo also is of brief duration. To the pallor and the loss of consciousness of the preceding condition there is added a little muscular relaxation. The child totters, supports himself by anything in his neighbourhood, slips down in his seat, or drops his pen. Sometimes there is a slight spasm of the muscles of the face, the mouth is drawn to one side by slight jerks, or performs some movements of mastication or deglutition. And that is all—no convulsions of the limbs, no passage of urine, scarcely an interruption to the work which is being done.
Whether the doctor discovers these symptoms by interrogation of the parents, or whether the teacher some time afterwards describes them to him with sufficient detail to permit of a certain diagnosis, a double gain results. In the first place, there is an indication for treatment; and in the second, the possibility of supervision. As a matter of fact, it too frequently happens that these symptoms, little dramatic as they are, reveal the existence of epilepsy, which will ultimately result in progressive mental decadence.
And yet this is not all. A few days or a few hours before such symptoms occur, or immediately after them, or, lastly, according to some authorities, entirely independently of them, the patient may develop a peculiar condition of irritability, in which he will transgress against discipline, make insolent remarks, or even give way to violence. Such actions ought not to be suppressed by punishment, because they are of morbid origin.
All such symptoms possess this characteristic, that they leave no trace on the memory of the child. He himself knows nothing about them, or knows them only by what he has heard from other people. There can now be no need to insist with what care inquiries must be made, especially of the parents.
Are epileptics to be admitted into the special class? On principle they are refused admission to the ordinary school. They are, however, to be found there. There are those whose attacks occur very rarely, or are so slight as to cause no disturbance. There are probably also unrecognised cases of epilepsy in which the symptoms occur during the night, or on awakening, but never in class. Only the severe forms are turned away. Probably the same state of affairs will recur in the classes for the abnormal—at any rate until the time when provision for epileptics is more extensive than it is at present. It will therefore be necessary to recognise these cases, to supervise them with special care during certain kinds of manual work, and, if possible, to treat the nervous symptoms suitably while the patients are receiving instruction.