During the prenatal or natal period children may be handicapped physically through a sensory defect, a motor defect, or a cerebral defect. Sensory defects would include functional variations, diseases, or deformity of the special senses, as sight and hearing. Motor defects, interfering with the normal development of the neuromuscular system would include paralyses, amputations, and special deformities. Cerebral defects are represented by the agenetic type, in which a failure of brain-cell development occurs; the dysgenetic form, in which the cellular development is imperfect in form; and the paragenetic variations, where originally normal brain cells are vitiated in activity through superposed disease.

Heredity and Environment. It is needless in this special discussion to dwell upon the relative importance of defects due to heredity and those occasioned by environmental maladjustments. It is probably safe to state that heredity, with its various potentialities, requires a favorable environment for its maximum evolution and most favorable developments.

Redemption of Childhood.-With the development of a social consciousness, child nurture has received a relatively more important position than during previous centuries. The disabilities due to prenatal or natal agencies no longer necessarily lead to death, or to a concealed vegetative existence. Society is seeking to redeem childhood and to preserve for itself all children, regardless of their handicaps. Life thus being retained, an obligation rests upon communities to afford the fullest opportunity to such children for the development of their physical, mental, and moral possibilities into actualities productive of good character, capable citizenship, and vital service. The limitations of children arriving at the school age merely increase the responsibilities of educational authorities to afford them every opportunity of receiving the best type of education for which each child is adapted.

Special Defects. In a consideration of defects incidental to prenatal influences, one is immediately confronted with an exceedingly large variety of conditions interfering with normal educational development. Just as the racial factors in heredity may be determinative of the size of individuals, and as family relationship may influence physical and mental resemblances, so there may be inherent in the germ-plasm, either because of

the presence of special determiners or the absence of particular determiners, intrinsic variations which predetermine the necessity of special education. Illustrative of this, one immediately thinks of such conditions as juvenile cataract, glaucoma, and polydactylism. Similarly, a lack of special determiners may cause the development of children suffering from albinism, nyctalopia, hemophilia, deaf-mutism, cleft palate, color-blindness, imbecility, idiocy, and epilepsy. Psychoses and neuroses result from neuropathic inheritance. Migraine may develop from the same cause. On the other hand, the nervous instability may eventuate in precocity or genius. Speech defects may be inherent in hereditary factors latent in the germ-plasm, and not counterbalanced by favoring environment and training.

Racial Immunities.-From another standpoint one must consider even the inheritance of racial immunities, as, for example, the lower susceptibility of the negro to yellow fever, or compared with the negro the lower susceptibility of the whites to tuberculosis. The negro is less liable to acne, lupus, and irritation by animal parasites. Favus is more likely to occur among Italians and Hungarians. Amaurotic family idiocy is almost exclusively found among Jews.

Equally vital from the standpoint of inheritance is the relative degree of resistance or immunity to disease. Even among the skin diseases one may enumerate the inheritance of ichthyosis and psoriasis, exanthema multiplex, and predispositions to In passing, one must also recall the existence of hereditary cerebellar and hereditary spinal ataxia, particularly Friedreich's ataxia.

eczema.

These various conditions all result in the birth of children physically or mentally handicapped who, if they reach the school age, require special adaptations of education in order to receive their proper development.

Other Intrauterine Anomalies.-The conditions which are prenatal though not germ-plastic in origin are due to faulty development or injuries during intrauterine life. They also present types of exceptional children who later merit special consideration. Among the numerous anomalies of development one need only think of intrauterine amputations, congenital heart-disease, cretinism, spina bifida, chondrodystrophy, dwarf

ism, clubfeet, hydrocephalus, hernia, microtia, and congenital absence of the middle and internal ear.

Many of the speech defects, because of the intimate relation between disorders of speech with the development of the organs of speech and the cerebral centres of intelligence, are to be regarded as results of developmental anomalies. Such types of speech defects may be due, for example, to a congenital occlusion of the posterior nares, or to the shortness of the geniohyoglossus muscle, or to tongue tie.

Care of the Prospective Mother.-In order to safeguard the child during the period of prenatal life, in so far as may be possible, it is essential that the prospective mother place herself under the direction, supervision, and guidance of a physician carefully selected because of his ability. The longer the pregnant woman is under medical care, the greater is the likelihood of her escaping miscarriage, and a greater advantage appears to accrue to the unborn child. Prenatal care thus far has indicated that the mortality rate during the first month of life may be cut in half, and those disabilities not due to inherent defects of the germ-plasm decreased to a remarkable extent.

Natal Causes.-The natal causes may be infections with gonorrhea, producing the blindness of the new-born, or syphilitic infection at birth, with its later evidences of interstitial keratitis, progressive deafness, large lymph-glands, and ulcerations of the throat. There may be paralysis from blood-clots on the brain, or obstetrical paralysis, particularly those of the upper arm (Erb's paralysis) or the lower arm (Klumpke's paralysis).

The. importance of excellent obstetrical and nursing care at the time of childbirth cannot be overstressed, in order to obviate diseases and deformities incident to the forces operating in childbirth, such forces being either internal or external.

Adjustment to Individual Needs.-Even this brief résumé is indicative of the large variety of conditions among children of school age that are due to prenatal or natal factors. The various conditions mentioned may be productive of various school types of exceptional children. They may be characterized by a varied group of symptoms which are discouraging to pupil, parent, and teacher in connection with educational development. The children may be nervous, irritable, restless, quiet, inattentive, sensitive, diffident, shy, self-conscious, apathetic, retiring,

hysterical, uncommunicative, headstrong, explosive, emotional, passive, vegetative, unsocial, antisocial, quick or dull in sensory or motor reactions, incapable in some special work involving a sensory or motor mechanism, suspicious, fearful, fatigued, backward, and disinterested. They may be blind, deaf, mute, with speech defect, with skin eruptions, faulty dentition, cutaneous disease, or some evident physical impairment or disability in gait or with inco-ordinate muscular movements.

It is not necessary to specify the particular physical and mental conditions arising in connection with each specific handicap. It is patent that children of all these types require special attention. Educational methods must be adjusted to individual needs. Auxiliary classes are essential so that the children from these groups may be attended to. There should

be classes for the blind, the crippled, the deaf, for children with cardiac diseases, speech defects, etc.

In order to secure the maximum educational results, the curriculum must be sufficiently elastic to permit of the widest modifications, while adequate pedagogical methods must be constantly devised for the manifold needs of these no less than other classes of exceptional children. There is a wealth of socially constructive thought bound up in the fact that this handicapped element of the school population is the victim not so much of the failure of a postnatal environment as of dysgenic factors existent before or at the time of actual birth.

IV. MEDICOEDUCATIONAL METHODS IN THE TREATMENT OF ATYPICAL CHILDREN

By DOCTOR C. HUDSON-MAKUEN, Philadelphia

Medicoeducational Methods.-The term "medicoeducational" is one that is frequently used and it explains itself, but its successful application as a system of treatment depends entirely upon the judgment of the physician.

Medicoeducational methods are applicable in a measure to all classes of patients, but they are especially indicated in the treatment of so-called atypical children, and as Doctor Oliver Wendell Holmes has suggested, to be curative in every instance

they should be instituted several generations before the birth of the child.

Medicoeducational methods, therefore, have a twofold function: namely, the prevention of disease and the cure of it.

Principle of Eugenics.-The principle of eugenics has been advocated as a means of preventing disease, and but for the difficulties of establishing or enforcing the principle it would doubtless be of great value. The chief obstacle also to the successful practice of any medicoeducational methods, whether for the prevention or cure of disease, is the difficulty arising, first, in outlining a suitable course of procedure, and second, in seeing that the course is properly carried out.

The Medicoeducationalist.—To successfully meet these difficulties the medicoeducationalist must be a specialist in the true sense of the term. He must be a medical man and an educational man; he must be at once a physiologist and a psychologist, a physician and a teacher; he must know his medicine well, and he must know the workings of the human mind equally well. He must know not only what should be done for the prevention and cure of certain abnormal conditions, but he must know how to do it, and how to teach others to do it. "To do" is not as easy as "to know what to do," and the great medicoeducational problem is to make men do the things that are good for them, and leave undone the things that are not good for them.

Psychological Conditions.-Failure in the successful application of medicoeducational methods of treatment is often due to the physician's own lack of belief in them. If we would convince another of the error of his ways, we must ourselves be keenly alive to the error; and when we have once really convinced our patient of his error, we have him in the true psychological condition for the adoption of means which make for its complete eradication.

Physicians are constantly making the mistake of separating the mind from the body in their diagnosis and treatment of disease, and this is especially true in the diagnosis and treatment of diseases of childhood.

Mind and Brain.-The mind of the child is always a product or function of the child's brain, and defective mentality always suggests a defective action in some of the cerebral structures.