The cretin can usually be recognised without difficulty by his stunted growth ; his large head ; his depressed nose, with widely separated eyes ;' his dull, 'heavy expression ; wide mouth, broad lips, and thick tongue ; his shriv elled-looking tawny skin ; his heavy limbs and awkward walk. If the disease is endemic, there is probably a goitre ; if sporadic, we notice the curious fleshy elastic masses above the clavicles and the absence of a thyroid gland.
Pr ognosi s. —The most hopeful cases are those in which the defect is a congenital one ; the worst are those of accidental origin who bear in their faces and persons little trace of their infirmity. Paralysis or epilepsy, or other form of nervous instability, increases the difficulty of the case. So, also, general feebleness of health is a bar to improvement ; and profound scrofulous cachexia, or a weak heart and feeble circulation, render the patient less responsive to systematic training than another whose nutrition is more satisfactory.
Dr. Edward Seguin regards as favourable signs : Steadiness of the walk, which deviates little from the centre of gravity ; a hand firm without stiffness, and not disturbed by automatic movements—one which can take and leave hold at command ; an unimpaired state of the senses, especially a look which is easily called into action ; a command of the words, however imperfect or few, which the child may possess, so that they have a con nected and come out opportunely ; activity without restlessness ; willingness to obey ; sensibility to praise, and capability of returning as well as of receiving caresses.
A. contrary state of things must be looked upon as unfavourable. More over, if some feelings of affection have been developed by kind parents, and are not followed by corresponding intellectual progress ; or if the idiocy is complicated by extensive paralysis, or worse, by epilepsy, the prognosis is very bad.
Treatment.—In the treatment of idiocy our first care should be to attend to the general health of the patient, so that he may be put physically into as good a condition as he is capable of reaching, and afterwards to incul cate volition and co-ordinated voluntary movement by careful physical training ; to attend to his moral education, and do what can be done to develop his intellect.
It is very important that the idiot should be removed from the society of healthy children, whose games he cannot share, and whose companion ship he cannot enjoy, to association with beings afflicted like himself, in the presence of whom he is not oppressed by a painful sense of inferiority. It is indispensable to the due progress of the feeble in mind that they should be received into asylums and establishments especially devoted to the treatment of such cases. In these every means can be adopted to
counteract the scrofulous tendencies of which a large proportion of the patients are the subjects. The building can be erected at a suitable ele vation on a porous soil of sand or gravel. The rooms and passages can be large, well ventilated, and suitably warmed. Moreover, a proper system of bathino. and shampooing can be established to promote the healthy action of the bathing and invigorate the feeble muscles.
The dietary should be liberal, and presented in a form to suit the peculiarities of the patient, for many idiots cannot chew their food. Some, indeed, can only swallow it when it is placed far back on the tongue, so that it may come within the grasp of the pharyngeal muscles.
Residence at a special training school, it is generally held, should begin when the patient is about seven years of age, unless the existence of con stitutional disease, epileptic fits, or other complication requiring constant medical supervision necessitate earlier admission. The system of training can be divided into three branches : physical, moral, and intellectual.
The physical training consists in careful education of the muscles by regular co-ordinated movements which bring the will into exercise, and substitute purposive acts for the aimless automatic motions which are so characteristic of the vacant mind. The exercises are graduated, and pass from the simplest movements to others more complex in character, so that, as Dr. Langdon Down observes, " the idiot builds up a series of co-ordi nated voluntary movements which are applicable to the wants of daily life." Moral education teaches the child obedience, and encourages him to endeavour to win the approval and retain the affection of his teachers by doing what he is told is right, and avoiding what he is told is wrong.
The intellectual education is based on a cultivation of the senses.
Touch and feeling are trained to appreciate differences in the form of objects, beginning with simple things and proceeding gradually to the more complex. Sight is cultivated by making the patient appreciate light and darkness, and accustoming him to match coloured counters or string coloured beads. So on with the other senses. Everything that is taught should be taught in the beginning in the simplest way, and we should make sure that the first fact has been thoroughly grasped before we pass on to the second. In this way the mind is educated through the senses, and in time by patience and perseverance astonishing results may be often obtained.