The Classification of Clinic Cases
- Author:
Arthur Holmes,, Ph.D.,
University of Pennsylvania, Philadelphia, Pa.
An important function of the Psychological Clinic is diagnosis. The word “diagnosis” in its general signification may refer to two aspects of the same procedure. In one, it is applied to the act or process of enumerating, examining and studying symptoms, i. e. mental defects, to discover their cause or causes. The method of doing this is to secure a history of the child, together with a report and observations of the symptoms, past and present. In another sense, “diagnosis” refers to the designation applied either to the complex of symptoms, or to their underlying cause. When a conclusion is reached as to the causes, the condition is named, the proper treatment recommended, and a prognosis given, based upon the probability of restoration or amelioration. In its general features a mental diagnosis is something like a medical diagnosis. There are superficial resemblances but sharp differences. Briefly, a mental diagnosis may mean the process of recognizing mental defects from their manifestations; or it may refer to the result of such a process. The process is an examination, and the result ends in a classification of the individual according to his mental capacity.
The result or classification claims our attention in this article. Our task is to furnish such a clear and practical scheme of classification for those varieties of mental deviation met with in the ordinary course of practice in a psychological clinic, that children can be quickly classified for proper remedial or ameliorative measures. With this end in view, theoretical refinements may be waived in favor of workable definitions and lucid classifications. First of all, it must be noted that those who come to the clinic are already partially classified. Something in their character to conduct has led those who have them in charge, to select them as the objects of scientific investigation. The reasons for their selection are manifold, but all can be summed up under two heads of “mental deviation” and “moral deviation”. We adopt the term “deviation” because it is the broadest and most inclusive one that can be applied to those who come to the clinic. It denotes a great class, but connotes one attribute only, that of difference or diversity. The children who are brought are not normal, or usual, or typical. They represent those who are advanced in any way beyond tlieir years, or those who are retarded or defective mentally, or those who have fallen below the standard of moral conduct; in short, all those who deviate in any way from the normal.
Here the question arises as to what is the normal. This question, which is the most difficult in the whole problem of backward and mentally defective children, must be answered by saying that each class of mental or moral deviates has its own norm or standard by which it is measured. At this time the statement of Tredgold might be quoted, that “Our best definition of the ‘normal’ mind must be a degree of intellectual capacity sufficient to enable its possessor to perform his duties as a member or associate in that position of life to which he is born.” However, waiving for the time being the difficulties attached to the definition of normal, which we can fairly do because the mere fact that a child is brought to the clinic is presumptive evidence that it has deviated more or less from the vague standard of normality existing in its home community, we will turn again to search for some practical, and as far as possible, definite, clear and universal principle of classification of the cases.
It ought always to be kept in mind that no classifications appear in nature, that all individuals differ from all others, and yet each individual is like all others, that in classifying individuals ^e are dividing them into groups which represent types, and the individuals assigned to these groups all differ more or less from the average or typical. Classifications are, therefore, made for convenience; for the sake of easily dealing with large numbers of individuals by, in a sense, reducing them to a smaller number. The class stands for the unit.
Again it must be remembered that classifications depend upon the principle of classification selected. One may classify by causes, by purposes or ends, by differences or similarities, or a host of other principles. What principle is selected depends largely upon the individual classifier; so in any classification of the children dealt with in the psychological clinic. In the classification we offer here, it must be remembered that we are looking at the children from the point of view of the psychological clinic and specifically from the point of view of diagnosis. We can best meet these demands bv answering the practical question on the lips of every visitor to the clinic, whose first and foremost thought for the child is, “Can his condition bo cured or not ?”
This is the first question every mental diagnostician must meet, and his answer will place the child under examination in one great class or the other. Either it is curable or not. Curable or incurable are all the cases of mental deviation, no matter what their causes, nor how obscure they may be, nor into what a wilderness of complexity their symptoms may run. There are many objections to such a classification, but the fundamental question here proposed may still be asked and it will still have its practical significance. At present, its insistence upon an answer, as well as the far-reaching effects of that answer, lead us to accept it as a principle of primary classification. Whatever may be the correlates, causes or occasions of any case of mental deviation presented, whether lodged in an ancestral taint or in an immediate cerebral lesion, and however difficult in practice it may be to apply this principle, in theory at least, it makes the problem of diagnosis thoroughly definite.
When a child is brought to the clinic for diagnosis, it is already decided that he is a mental or moral deviate. This merely means that he is different from others, but he may be different in many ways.
For example, a boy six years old was brought to the clinic by his mother and an adult sister. The boy lived at home with his sister and parents, the latter being middle-aged people. He had been going to school for about six months. During that time he had given no trouble as far as his conduct went. His teacher reported, however, that mentally he had been doing practically nothing. This was true in spite of the fact that his sister spent a large part of every evening endeavoring to teach him his lessons for the following day. The boy did not take kindly to this coaching and usually the sisterly attempts to improve his scholarship ended in a domestic storm. The sister said he was stupid; the father said he was all right; the mother simply folded her hands in resignation and said nothing.
Outside the house the boy was counted a baby by some, and by others said to possess a wisdom beyond his years. He would talk very gravely on topics which are ordinarily discussed by grown people. When, however, ho attempted to play with the other boys and in one of the usual quarrels that arise in boyvillc, another youngster struck him, instead of fighting back he would immediately set up a cry for his mother and run home. He attempted to play occasionally by himself with his automobile, but if he happened to upset it and fall out the same lachrymose result followed. This happened in spite of the fact that he was never out of sight of his sister or mother.
In the evening he spent part of his time in the cellar working with his father, who was interested in mechanical contrivances. The boy could assemble the parts of electric apparatus, arranging the cells, wire, and bells so that they would ring. He could connect an incandescent lamp so that it could be lighted; he could start a gas engine in the cellar all by himself and operate it. For a six-year-old boy of rather light build, this was a good record. In fact it presaged what was revealed by the Binet tests, namely, that the boy was about one year beyond the mental attainment of the average boy of his age. In school, however, he was counted backward; at home, by his sister, he was counted stupid. The fact is, that he was mentally advanced, and the difficulty which he encountered arose from the fact that he was original. He happened to have a father who had accidentally started to give him the proper kind of education by proceeding from the concrete to the abstract. The boy’s perceptions were being trained as they should be for his age. He was not only allowed, but encouraged; to vent all the healthy curiosity of a six-year-old boy in seeing things, handling things and working with things. During his association with things, which to him were throbbing with living and vital interest, he was storing up memory images of inestimable value to his future intellectual development. The foundations of a true and permanent education were being laid, and laid so deeply and solidly that they would be able to bear any future intellectual edifice.
On the other hand, there were grave defects in his all-around development. His adult gravity was due to his association with grown people, and his babyishness was due to the lack of that robust and vigorous masculine development, which could come to him only by associating with and taking his part among boys of his own age.
With these three characteristics, infantilism, adultism and originality, all developing quite naturally from his environment and from his innate impulses, the ordinary public school had no method of dealing. Formed and fitted, as it is, for the average child, it has no room in its system for the one who either lags behind or pushes ahead, and is especially confused and confounded by any pupil who is so original and self-expressive as to refuse to Is 40 TilE PSYCHOLO GICAL CLINIC. fit himself into its traditional molds. Hence, this boy gave trouble in school, but the trouble that he gave was due to a very admirable trait, which in later life may make him one of the famous men of his time. In short, here was a mental deviate, but one who was distinctly not retarded, unless it was in his ability to play with boys of his own age.
Having decided upon our principle of universal classification, we will proceed to test its utility and applicability to cases brought to the clinic. Usually the children brought to the clinic are either bad or backward. At the present time we will take up the problem of backwardness, and first, let us be clear about the meaning of backwardness in order that we may escape the common fallacy of confusing the symptoms with the disease.
Just at this point we begin to reap the advantages of our simple classification of all mental deviation. We are not led into confusing definitions or bewildering statements concerning this very common and prevalent associate of mental defectiveness, out of which, because of this very association, some writers have been led to form a species of mental deviation absolutely distinct in quality and expression from that of any other species. This would be very helpful if it were only true. Unfortunately, the clinical pictures and general reactions of those counted “simply backward” and those adjudged mentally defective are often so much alike that it is impossible to distinguish the two.
If clinical pictures or complexes of symptoms are adopted as principles of classification, it would be perfectly proper to group some curably backward children and some incurably backward children together, for the time being at least, until a remedy was affected. However, upon the principle that we have already laid down, such a proceeding would not bo admissible, our chief problem being the differentiation of those retarded permanently and those retarded temporarily.
Upon this basis, to say that a child is “backward” or “retarded” is merely to state a fact of observation. The statement, does not allege or imply the existence of a physical or mental disease. It may, and nearly always does, imply some defect or some lack, and carries with it a condemnation or commendation according to the kind of retardation indicated. This can readily be seen in the pronouncement that “Mary is not forward in company,” or that “Johnny is backward in swearing.” Backwardness in some kinds of sophistication, therefore, is not deemed an unmixed evil. In some physiological functions, too, like pubescence, late maturity is, in the minds of many, beneficial to the individual rather than detrimental. Even in mental development, retardation is no more of an evil than precociousness. The former may lead to mere slowness of progress in life, while the latter may develop into insanity or extreme dulness.
Retardation, then, is merely the name of a relation; a relation, too, having meaning only after some standard of normal progress is recognized. It means that the backward one is behind someone else; he does not go as fast as others; he does not keep up with his companions. In every case, a standard of normal progress is more or less clearly implied. If the ordinary observer is asked to define the standard by which he measures retarded children, he immediately replies, “Why, the standard is the normal child, meaning by that the usual, average or typical child. In comparison with him all others are abnormal, unusual or atypical.” Such a classification has the merit of simplicity at least. The difficulty arises over the fact that we never have a real, live, average, normal or typical child to set up before us for examination and comparison. Exactly what the term means, however, is hard to say. It does have a meaning, though an indefinite one, in the minds of all those dealing with numbers of children. From the quota contributed by each child, there gradually grows up in the expert’s mind a composite mental picture of the normal or typical child. Those children diverging from this picture, in certain characteristics, are called abnormal or atypical. But, just how to define or accurately describe either the normal or the abnormal, is difficult in the extreme. There are a multitude of minute and individually insignificant characteristics to be taken into consideration. In all but extreme and striking diversions from type, it is the cumulative effect of these characteristics which determines the experienced observer in his judgment, and gives that judgment more the quality of an intuition than of a reasoned conclusion. Because of this fact, in the examination of children, experience on the part of the examiner will probably always count for more than either the methods or the tests used.
To overcome the effects of such a vague norm, students ha%e given much time and attention to the formulation of a standard at once practicable, objective and precise. Many standards hae been suggested, and several systems of mental measurements based upon these have been developed. Three of them have received sufficient endorsement to merit some notice. They may be called for convenience the individual, the social, and the pedagogic respectively.
The first or individual standard is an imaginary norm. It is an attempt to measure the child by himself, or by what he ought to be; the fullest all-around development possible for each individual is accepted as the standard for that individual, and anything short of this is called retardation. Prima facie, the measure has claims to consideration, but what one ought to be or would be under right conditions, mentally, physically or morally, is purely imaginary or problematical. No one, probably, feels that he has had the fullest and fairest chance, or that with another environment and other training he would not have been far more advanced intellectually. The acceptance of such a judgment, therefore, would make us all “backward” or “retarded”. Even if the standard of fullest development is rendered more precise, and to some extent objective, by saying it consists in the most perfect possible development of each individual cortical cell and cerebral tract, it comes no nearer to a feasible application. The perfection of cerebral systems?to say nothing of reflex centers and peripheral organs?is as remotely unimaginable as the possible perfection of psychic powers. The second or social standard develops quite naturally. It represents the judgment of the community upon any one’s mental ability, by comparing him with others in their daily lives of work and play. The every-dav observation that a certain child does not learn common things like dressing, washing, eating and playing games as rapidly as his brothers and sisters did at his age, or as readily as his companions do, may be of value and significance in so far as it calls attention to the need of fuller investigation, but the social standard expressed in the opinion of parents, friends or teachers, is altogether too biased and too crude to serve as a scientific measurement. To invest this indeterminate standard with the necessary precision, Binet made tests upon some thousands of normal children, and from his experiments, developed a set of questions and tasks which he believes have the desired qualifications for accurately and absolutely determining the degree of backwardness of any child, independent of any pedagogical training which it may have had. The essentials of his standard are contained in the following quotation:
“The intellectual faculty appears to us to be independent not only of instruction, but of that which we might call the academic faculty; that is to say, the faculty to learn at school, the faculty of assimilating the instructions given at school with the method used at school. “In our former researches concerning the recruiting of the abnormal, feebleness of the academic faculty was the sole criterion of abnormality employed. We said: Every scholar is abnormal who is retarded three years in his studies, if that retardation is not excusable on account of insufficient time spent at school. It seems to us wise and prudent to admit that this academic aptitude does not in all cases necessarily accompany the intellectual faculty which we measure by our method. From the first, theoretical reasons have induced us to avoid this confusion. It seems to us that the academic aptitude depends upon something else than intelligence. For success in study certain qualities are necessary which depend above all upon attention, upon the will, upon the character, for example, a certain docility, a regularity of habits, and above all a continuity of effort. Even an intelligent child would learn little in class if he never listened, if he passed his time in making notches in his desk, chuckling, and in ‘cutting’ as a bad soldier. The insufficiency of attention, of character, and of will 6how themselves not at all, or very slightly in our examination of intelligence; the test is too short and the child is not left enough to himself. In fact, we have never encountered in our examinations any inattentive children except among those between three and four years of age. All of them made great effort; they were with us and our presence alone would have sufficed to prevent inattention. There is nothing in the conditions of the test by which one is able to measure the ordinary distractions of attention of the child such as occur when he is left to himself.”1
The third measure of retardation is the pedagogical. It is limited to a rather narrow field, but within that field it is perfectly definite and objective. Since, also, a large number of the cases coming to the psychological clinic are children whose difficulty is backwardness in tlieir school work, it would seem justifiable to give a somewhat lengthy consideration to this method of measurement. Since retardation is a school phenomenon and since the first attempts to give it anything like scientific attention originated in tlie public schools, class-grades were turned to for aid. Assuming that a normal pupil was promoted from one grade to another each year, early investigators adopted for their first standard the correspondence between grade-standing and age. Thus, the children “who began school at the legal age and were promoted every year, were counted normal; those in the same grade, who were older by at least one year than these normal children, were considered backI’sycholoRique, Tome XIV. 100S, I,e Pevcloppeinent de k’melllgence p 57 190-fant8’ p- 7C- Scc alflu T’es Enfants Anormaux, A. Bluet et Th. Slmou, ward or retarded. However, it was soon discovered that in the school under investigation such a standard would throw nearly three-quarters of the pupils into the backward class. Therefore, the normal was changed and only those who were two years or more behind the grade corresponding to their age were considered retarded.
Dr Witmer writes of his first attempts to define retardation. “I undertook,” he says, “to define as pedagogical retardation the number of years that a child was behind the grade for his age. If we wish to ascertain the causes of retardation in school children we must first obtain the whole number of retarded children irrespective of any preconceptions we may have as to the causes. Pedagogical retardation follows from the supposition that a child enters upon the first year of school work before he has passed his seventh birthday. If he advances one grade each year, he will complete the eight years of the elementary course before he has passed his fifteenth birthday. This establishes a theoretical age limit for each grade, apparently not excessive in its educational requirements, for the child that leaves the elementary schools in his fifteenth year cannot complete the high school before his nineteenth year, nor graduate from college before his twenty-third year, and yet in the elementary schools in Camden, 72 per cent of the children exceeded this theoretical age limit. It seemed absurd to assert that 72 per cent of a city school system were retarded and moreover the group of children obtained in this way was too large to be studied for the purpose of discovering the causes of their retardation. It was therefore determined to allow one or more years in excess of this theoretic age limit. In the city of Camden 47 per cent were found to exceed the age limit by one year or more, 26 per cent by two years or more, 13 per cent by three years or more, and 5 per cent by four years or more. It was determined to call all those children pedagogically retarded who exceeded the age limit by two years or more. This definition of retardation has been generally accepted in subsequent investigations and retardation statistics in other cities.”2o The latest considerations have not materially altered the standard first suggested by Dr Witmer, as is shown in Mr. Ay res’ statement.
“The method of determining the number of retarded children in a given school system which has received most general acceptsWhnt is meant by Retardation? Lightner Witmer, Tnc Psyciiolooicai, Clinic, Vol. IV, No. 5, October 15, 1910, pp. 128-129.
ance on the part of school-men, is tlie method which enumerates the children by ages and grades and puts all of the children who are older than a determined age in each grade into a group designated ‘Above Normal Age’. These children who are older than they should be for the grade they are in are considered ‘retarded’. Thus used, the term designates a condition, and it is applied with equal propriety to those children who are over age on account of slow progress, and those who have progressed normally but entered school late.
“The method has come into general acceptance because, all things considered, it is the most satisfactory standard by which to measure retardation. Statistics based on the time pupils have spent in each grade are exceedingly rare, often unreliable, and usually are non-cumulative. That is, they deal with each grade as a separate unit and fail to tell us how much time the pupil has gained or lost in the entire course.
“Statistics giving us the figures as to grade and age distribution on the other hand, are simple, certain, easy to gather, and embody valuable information as to many conditions and results of school work. Their application to the problem of retardation so easy that the process may be developed by anyone, however unversed in statistical procedure.”3
Once having determined upon our standard, we may turn again to our problem of diagnosis, for obviously, retardation as defined above may be associated with a multitude of factors. A late start to school, irregular attendance, poor teaching, innutritious ^iet, bad country roads, defective eyesight, dull hearing, pharyngeal obstructions, natural stupidity, mental deficiency?the list unght be continued almost ad infinitum.
All of thein, however, can be roughly classified under those external to the child and those within the child. If the cause of aily particular case of retardation appears to lie in the environment, the problem is a pedagogical or sociological one; if the cause seems to lie within the child himself, the problem is physiological or psychological. In any case the psychological clinic is the proper place to take the child. The clinician is then confronted with this situation. Here is a backward child. With “tthat is the backwardness associated? Is it an environmental or a mere physical defect, amenable to reformation, to surgical or Medical treatment ? Or is it some irremovable defect like an I’fiKKards in Our Schools, Leonard 1’. Ayros, pp. 30, 37. organic defect of tlie central or peripheral nervous system? If the former is true, the child is temporarily backward and may bo restored to his normal position in life and expected to progress steadily. If the latter is true, the child is mentally deficient, and can be trained only within the limits of his capacity and there must stop in life-long imbecility or idiocy. The vital distinction, then, between classes of retarded children, is not in the fundamental differences or causes, but in the curability or incurability of the causes. All the correlates involved are, in a sense, physical, whether classed as brain defects or bad neighborhood. Some are removable; some are not. Therein lies the insurmountable difference and the basis for sharp differentiation. A mental diagnosis is really a classification plus a pedagogical prognosis or prophecy, that is, the judgment pronounced at the end of an examination upon a certain case does not at all state the present intellectual attainments of the child. “What the child now knows is an indication of its mentality, but not a final one. What it will learn or can know under certain conditions and with proper methods of training is the all important and decisive question. Therefore, it may happen that of two children of the same age, one may show marked superiority in intellectual attainments as measured by public school standards and yet be judged an imbecile, while the other is considered normal. The first child has had training, the latter has not. The diagnosis predicts that the former can learn only so much, will then reach his full mental capacity, and from that time remain stationary or recede from his highest attainment. On the other hand, the capacity of the normal child is an unknown quantity or quality and its progress has no present assignable limits. Furthermore, it may even happen that of two children, the one giving the brighter answers and more normal reactions may be pronounced the imbecile. Tho more stupid child may be made so temporarily by the presence of some physical or mental defect, which when remedied, will restore tho sufferer to normality.
All curably backward children do not by any means present the same mental capacities, the same degree of retardation, nor the same speed of recovery. Some may be exceedingly backward, and yet from what is known of the recovery made by similar cases under the best educational training, it may be predicted that they will eventually gain all the lost ground and become normally efficient. This does not mean, however, that they will necessarily become bright or brilliant persons. They may always remain in the class of slow, dull individuals, who are yet able to advance indefinitely in intellectual attainments, and are capable of maintaining their position in the society to which they were born, and of handling their personal aifairs with ordinary prudence. For the purposes which we have in view, probably the best principle of sub-classification for curably backward children is the speed with which they recover their normal position in society or in school. According to this method they may be divided into three classes. First, those who are immediately curable, that is to say, as soon as the physical defects within the child himself, or in his surroundings, are corrected or removed, he immediately takes his proper place in school and in society.
A second class is composed of those who might be called rapidly recoverable. This includes all those who require a period of pedagogical training after the removal of their physical defects. During that time they make rapid progress, and in a comparatively short time have regained the lost ground.
A third class may be called the slowly recoverable, including all those children who require a long, careful and persistent course of education after the removal of the physical defects, before they are again able to take their place with other normal children. It can be immediately seen that this last class forms a difficult group to diagnose, because the clinical picture they present and the time they require to show improvement seems to ally them with the class of permanent mental defectives. Their recovery is so very slow and tedious, and so often only possible under the best environment and training, that judgment as to the final classification must frequently be held in suspense for a long time. That great class of children who must be classified as irremediably backward belongs to the group technically known as mental defectives, dements or aments. To define dementia or amentia exactly is one of the most difficult problems. The difficulties encountered by Seguin in 18G6 are still present. He undertook to define idiocy and give the synonym named by Savage, ‘Amentia”; by Segar, “Imbecilitas ingenii”; by Vogel, “Fatuitas ingenii”; by Linnaeus, “Morosis”; by Cullon and Fodere, Demence innee”; by Willis, “Stupiditas”; by Pinel, “Idiotism”;. by some English writers, Esquirol and the majority of encyclopaedias and dictionaries, “Tdiocy”. “Wo shall use this latter term,” he continues, “to express the physiological infirmity, and would like to see the name given to it by Pinel, ‘Idiotism,’ preserved to express the specific condition of mind pertaining to idiocy. “Its definitions have been so numerous, they are so different one from the other, and they have so little bearing on the treatment, that their omission cannot be much felt in a practical treatise. Our own, if objectionable, will be found at least to correspond to a plan of treatment, both supporting each other; and may suffice until a better definition and a better treatment can be devised.” He then offers his definition in the following terms:
“Idiocy is a specific infirmity of the cranio-spinal axis, produced by deficiency of nutrition in utero and in neo-nati. It incapacitates mostly the functions which give rise to the reflex, instinctive, and conscious phenomena of life; consequently, the idiot moves, feels, understands, wills, but imperfectly; does nothing, thinks of nothing, cares for nothing (extreme cases), he is a minor legally irresponsible; isolated, without associations; a soul shut up in imperfect organs, an innocent.”4
However, what we practically mean by the words is clear enough. As Dr Tredgold says, “The essence of mental defect is that it is incurable, and by no ‘special’ education, however, elaborate, can a case of amentia be raised to the normal standard. Some defect must always remain, and upon this fact all authorities agree.”5 In a previous portion of the same work, between “dementia” and “amentia” he has made a distinction, dependent upon the previous mental development. He says, “Mental defect occurring subsequently to mental development may be compared to a state of bankruptcy, and is more fittingly described as dementia (de, down, from; mens, mind) ; whilst the person whose mind has never attained normal development may bo looked upon as never having had a bank account, and this state is designated amentia (a, without; mens, mind). In both of these, of course, there is literally mental deficiency; but in view of the convenient and growing tendency to restrict this term to the latter class, I shall in this book use it in a specific sense as synonymous with ‘amentia’.”0
He then proceeds to define amentia as “a state of mental defect from birth, or from an early age, due to incomplete cerebral development, in consequence of which the person affected is unable to perform his duties as a member of society in the position of life to which he is born.”
<Idlocy and its Treatment. Edward Sequin, I860. ‘Mental Deficiency, A. F. Tredgold, p. 127. ‘Ibid., p. 2.
This definition which places the essence of amentia upon its incurability is in thorough accord with the problem of classification already laid down in this article as the particular one to be solved by clinical diagnosis. We have said that the cases which come to the clinic are already classified as mental or moral deviates. Of the mental deviates, by far the largest number manifest their deviation from the normal by their mental retardation. Concerning this, the immediate question is whether retardation is permanent or temporary. If it is permanent, by the definition given above, the retarded mental deviate must be classed as an ament. This step in the classification, though rough, imperfect and incomplete, from the point of view of a thoroughgoing diagnosis, is still vital and final,?that is to say, once a child is classified as an ament, he is shut off from the possibility of being classified as a normal person. As to his future career, as has been said more than once before, this step is of the most vital significance, as upon it hinges his training, treatment and final disposal.
To quote Dr Tredgold again,?”It is not, however, to bo assumed that amentia is merely a subtraction in varying degree from the normal. Although the contrary might be thought, nevertheless the two conditions do not merge into one another, and between the lowest normal and the highest ament a great and impassable gulf is fixed. Whilst the former is heavy, stolid, and uniformly dull-witted, he has yet sufficient common sense to look after his interests and hold his own in that environment in which Mature has placed him. The mildest ament, on the other hand, may show no apparent dulness; he may even be bright and vivacious; and in some of his abilities immeasurably superior to the clodhopper. But the other faculties of his mind are not present m like proportion. Instead of harmonious working, there is discord, and in possession of that essential to independent existence common sense?he is lacking, and the want can never be supplied. “The difference hns been well described by Sir J. Batty Tuke, who says: ‘Where in theory the morbid and the healthy types might be supposed to approach each other, we find in practice that no such debatable ground exists. The uniformity of dulness m the former stands in marked opposition to the irregularity of mental conformation in the latter.’ “7 The next step in the classification is the assignment of the pp. o and 3
ament to that particular sub-class of imbeciles or idiots to which he belongs by reason of his degree of mentality, for it must be remembered that up to a certain limit all degrees of mentality are represented amongst the mental defectives.
The most usual sub-classification divides amentia into three divisions or degrees. Beginning with the most normal, Dr Tredgold has assigned to this class the name feeble-minded, or highgrade amentia. This, he says, “is the mildest degree of mental defect, and the feeble-minded person is ‘one who is capable of earning a living under favorable circumstances, but is incapable from mental defect existing from birth, or from an early age, (a) of competing on equal terms with his normal fellows; or (6) of managing himself and his affairs with ordinary prudence(This and the following definitions were suggested by the Royal College of Physicians of London, and adopted by the Royal Commission on the Feeble-minded as the basis of classification in their inquiries.)
“Feeble-minded persons under the age of sixteen years come within the jurisdiction of the education authority by reason of a Special Act of Parliament (Defective and Epileptic Children Act, 1899). On account of this act they are commonly designated mentally defective children, and they are defined as ‘those children who, not being imbecile, and not being merely dull and backward, are, by reason of mental defect, 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 in such special classes or schools as are in this Act mentioned
“It should be remarked that in America the term ‘feeblemindedness’ is not thus used specifically of the mildest degree of amentia. In that country it is applied generally to the whole order of amentia, thus being synonymous with the English term ‘mental deficiency.’ There has been an attempt in this country also to include all grades of defect in this euphemistic description, and to call the mildest degree of all (feeble-minded) ‘mental defectives.’ The attempt has not met with much success, however, and since ‘feeble-mindedness’ is in itself a more specific term than ‘mental defect/ I think it is decidedly better to restrict its use to the mildest degree.
“The imbecile is defined as ‘one who, by reason of mental defect existing from birth, or from an early age, is incapable of earning his own living, but is capable of guarding himself against common physical dangers.’
“It may be remarked that these three terms are occasionally used of varying degrees of dementia, particularly the dotage of old age, just as ‘mental deficiency’ is sometimes used generally for that condition. The practice, however, is to be deprecated as likely to lead to considerable confusion.”
Dr Tredgold’s classification is to a large extent social, in that it rests upon the ability or inability of the affected person to take his place in society.
Another classification is that used by the New Jersey Training School at Vineland, 1ST. J., which is similar to Dr Tredgold’s with the exception that in the place of “feeble-minded” the word “moron” (from the Greek word meaning fool) is substituted. The Training School Report for 1910s says:
“We presented to the American Association for the Study of the Feeble-minded, at its meeting this year, an industrial classification, which it has tentatively adopted. The feeble-minded are divided into three large groups, very much as has been done in the past,?the lowest grade is called ‘idiots,’ the middle grade ‘imbeciles,’ and the highest grade, who were formerly called ‘feeble-minded,’ we now propose to call by an entirely new term, ‘moron’. This is a Greek word, and means those who are mainly lacking in judgment and good sense. Each of these groups may again be divided into three,?the high, middle and the low, thus making nine degrees of defectiveness, all told, with ten in the scale standing for the normal child, including those who are simply backward. The low-grade idiot is the perfectly helpless child, the middle-grade idiot, the one who is able to feed himself, but who eats almost anything,?the high-grade idiot, the child who eats with some discrimination, discarding that which is not food. The low-grade imbecile, the child who plays a little and tries to help but can do nothing alone; the middle-grade imbecile, he who can do simple tasks, “^ery simple indeed; the high-grade imbecile, the one who can do tasks of short duration and little errands in the house,?washing dishes, scrubbing floors, washing and sweeping, perhaps. The low-grade morons, the boys and girls who can run errands, do light work, make beds, etc., scrub, mend, care for a room, if there is no great complexity of furniture; the middle-grade morons, those who can do institution routine work; and the high-grade morons, who can do fairly complicated work, with only occasional supervision, or no supervision,?can run simple Machinery, take care of animals, only are unable to plan.”
Finally, we offer a third classification made by Dr Barr.9 It sNew Jersey Training School for Feeble-minded Girls and Boys, Twenty-second Annual Report. 1010, pp. 13G-137. ?
. , ? “Mental Defectives,” Martin W. Barr, 1904, P. Blakiston’s Sons & Co., Philadelphia, p. 00. is called educational in that all the characteristics of its several divisions are the degrees or limits to which the mental defectives, included within the class, can he educated. It is therefore practical and useful for the purpose of clinical work, since the problem of future training and education constitutes so large a part of diagnosis.
The scheme of classification comprises three classes with five sub-classes of sub-normals; the imbeciles with the three sub-classes of high-grade, middle grade and low grade; the idio-imbecilea, and the idiots sub-divided into superficial and profound. The idiots are also classified according to their disposition into apathetic and excitable. These various classes, together with their capacities for training and the best ultimate disposal to be made of them are given as follows:
Idiot. Profound (Apathetic) Unimprovable. (Excitable) Superficial (Apathetic) Improvable in selfexcitable) help-only. Asylum Care Custodial Life and Perpetual Guardianship Long Apprenticeship and Colony Life Under Protection .. Idio-imbecile. Improvable in self-help and helpfulness. Trainable in very limited degree to assist others. Moral Imbecile. Mentally and morally deficient. Low Grade: Trainable in industrial occupations; temperament bestial. Middle Grade: Trainable in industrial and manual occupations; a plotter of mischief. High Grade: Trainable in manual and intellectual arts; with a genius for evil. Imbecile. Mentally deficient. Low Grade: Trainable in industrial and simplest manual occupations. Middle Grade: Trainable in manual arts and simplest mental acquirements. High Grade: Trainable in manual and intellectual arts. r r [ Backward or Mentally Feeble. Mental processes normal, but slow and requiring special training and environment to the World prevent deterioration; defect imminent under slightest provocation, such as excitement, overstimulation or illness. Trained for a Place in What will be the final outcome of classification? Which one will be adopted ? At the present time Dr Barr classifies according to educational standards, Binet10 according to speech ability, Dr. Tredgold according to ability to hold one’s place in society, to care for one’s personal affairs with prudence and to escape common dangers; while the Vineland Training School classifies according to industrial capabilities. In general, however, it would seem that all sub-classifications may be made according to pedagogical and sociological principles. The work to be done, therefore, in order to decide finally 011 some one classification and make it as widely acceptable as possible is, first, to find by investigation and experimentation the pedagogical possiblities of each sub-grade of the mental defective and then by the same method to find the industrial or sociological capabilities of each sub-division. These two could then be amalgamated and any individual could be classified and sub-classified according to his intellectual and social possibilities. Such a task calls for greater unity and co-operation among the many workers in this field, who are now proceeding each in his own way according to his own plan, without much regard to what is being done by others. l0Les Anormnux, pp. 111-113.
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