John Langdon Down: The Man and the Message
John Langdon Down was the son of a village grocer. Born in Torpoint, Cornwall, in 1828, he was the 6th child of religious parents. He worked in the family business until he was 18 years old and he then qualified as a pharmacist before ultimately entering medical school at the London Hospital. He won numerous medals and prizes and immediately after taking his medical degree he was appointed medical superintendent of the Royal Earlswood Asylum for Idiots in Surrey. He reformed the institution and his efforts at classification resulted in his description of what he called Mongolian idiocy. His findings were based on measurements of the diameters of the head and of the palate and on his series of clinical photographs. He was a pioneer of the use of photography in hospitals. Mongolian idiocy became a widely used term but in 1961 a group of genetic experts wrote to the Lancet suggesting four alternatives. The editor chose Down's syndrome. WHO endorsed this later. Langdon Down was a supporter of liberal causes. He made important contributions to medical science, developed a large practice and he died a wealthy man in 1896. Normansfield, his private training and educational centre, had an international reputation. Only recently has his place in medical history been recognized.
Ward OC. John Langdon Down: The Man and the Message. Down Syndrome Research and Practice. 1999;6(1);19-24.
John Langdon Down was born in 1828 in an upstairs room above his father's
grocery shop in Torpoint. His father, Thomas Joseph Almond Down had failed
in business on three occasions but he prospered in Torpoint. Torpoint was
a working class village and the Down family lived among the artisans who
worked in the naval base in Devonport. Langdon Down was taken out of school
at the age of 14 and he spent the next four years behind the counter of
his father's shop. He had no higher education. At the age of 18 he had what
might be described as a mystical experience. A heavy summer shower drove
the family to take shelter in a cottage. "I was brought into contact with
a feeble minded girl, who waited on our party and for whom the question
haunted me - could nothing for her be done? I had then not entered on a
medical student's career but ever and anon... the remembrance of that hapless
girl presented itself to me and I longed to do something for her kind."
(J Down, 1879)
His first step on the road to a medical career was to go to London and to
be apprenticed to a surgeon practitioner in the East End, where he learned
the basic skills of blood letting, applying blisters, extracting teeth,
and dispensing simple medicines. He quickly realised that without some knowledge
of the sciences the medical qualifying examinations would prove to be too
difficult for him.
One of the best basic science courses in London was offered by the Royal
Pharmaceutical Society. He registered as a student and he quickly distinguished
himself, taking the two professional examinations of the Society in one
year. It was not his intention to practice as a pharmacist and he never
registered as a member of the Pharmaceutical Society. He went back to Torpoint
and with his newly acquired knowledge and skills he developed a very successful
series of over the counter products which boosted the turnover of his father's
shop. Local directories described the enterprise as that of "grocers, chymysts,
druggists, linen and woollen drapers."
The Royal Pharmaceutical Society needed a new laboratory assistant. Langdon
Down was headhunted and he went back to the laboratories of the Pharmaceutical
Society where his main duty was to assist students with their bench work.
This diversion was short lived. He became ill, probably with tuberculosis,
and he returned to Torpoint, where with rest, leisure, and fresh air he
gradually recovered. His father died in 1853 and Langdon Down returned to
the career of his choice. He entered the medical school of the London Hospital.
He was a brilliant student and in his final year he took gold medals in
medicine, surgery and obstetrics and the medal for the best student of the
Before leaving Torpoint he had written a prize essay on "Nature's Balance"
with the title "The Wisdom and Beneficence of the Creator, as displayed
in the compensation between the animal the vegetable kingdoms." He presented
a copy to Mary Crellin. They were both very religious people. She read it,
underlined it and kept it. The relationship flourished and they married
in due course. When he took the qualifying examinations of the Royal College
of Surgeons and of the Worshipful Society of Apothecaries he was appointed
resident accoucheur. This gave him free board and lodgings and he combined
his obstetric duties with further study, taking the London MB two years
later, again with great distinction. The ink on his university parchment
was scarcely dry when he was appointed Medical Superintendent of the Royal
Earlswood Asylum for Idiots. He had no specific experience to equip him
for the supervision of a very large institution for handicapped people of
all ages. Earlswood had lost credibility in the years immediately preceding
1858. It had been criticised by the Commissioners in Lunacy and also in
the press. A new broom was needed. John Conolly, the reformer of the psychiatric
institutions was Visitor to Earlswood and he was the one to steer Langdon
Down through the rough seas of his new venture.
John Conolly was an ardent ethnologist, one of a declining number. Ethnology
attempted to correlate a relationship between the external contours of the
skull and the degree of development of underlying areas of the brain. Each
area of the brain was assigned a specific psychic or intellectual function.
In parallel anthropology was in fashion and the classification of head shapes
in different races was thought to correlate with different potential learning
skills. Blumenbach's Latin and German papers were translated into English
by Bendyshe in 1865 (Bendyshe,
1865). Blumenbach's classification of the races of the world into Mongolians,
Aztecs, Caucasians, Malayans and Ethiopians was highly popular. Langdon
Down read Bendyshe's book and he immediately set about endeavouring to assign
all the Earlswood residents to one or other of Blumenbach's racial groups.
This was how he came to publish his ethnic classification. The basis of
his ethnic classification was the measurement of the diameters of the head
and the identification of specific facial features from photographs which
he took himself. Over 200 of his photographs have survived, making the collection
the largest known archive of clinical photography of the Victorian era.
His ethnic classification never came to be widely accepted and indeed he
himself abandoned it in due course. All that is now remembered of it is
his description of what he described as the Mongolian type. He is sometimes
criticised as a racist. His opening statement in which he sets out the predominance
of Caucasian types is overlooked. He said: "of course there are numerous
representatives of the great Caucasian family". His description of the Mongolian
group led to the specific recognition of these residents as a distinct category
and in due course to the designation of those whom he had described as Mongolian
as having Down's syndrome. He published his paper in the London Hospital
Reports (J Down, 1862)
and he published it again verbatim in the Journal of Medical Science the
following year. It was to be reprinted yet again in 1887, when, in association
with the text of his three Lettsomian Lectures at the Medical Society of
London he presented once again the papers which he had previously written
on neurological subjects. (J
Down, 1887). His papers frequently refer to idiots, and imbeciles. These
were descriptive terms then commonly used but now abandoned by consent.
Of the Mongolian group he wrote: "the great Mongolian family has numerous
representatives and it is to this division I wish, in this paper, to call
special attention. A very large number of congenital idiots are typical
Mongols. So marked is this that, when placed side by side, it is difficult
to believe the specimens compared are not children of the same parents.
The number of idiots who arrange themselves around the Mongolian type is
so great, and they present such a close resemblance to one another in mental
power, I shall describe an idiot member of this racial division, selected
from the large number that have fallen under my observation.
The hair is not black, as in the real Mongol, but of a brownish colour,
straight and scanty. The face is flat and broad, and destitute of prominence.
The cheeks are roundish and extended laterally. The eyes are obliquely placed,
and the internal canthi more than normally distant from one another. The
palpebral fissure is very narrow. The forehead is wrinkled transversely
from the constant assistance which the levatores palpebrarum derive from
the occipito-frontalis muscle in the opening of the eyes. The lips are large
and thick with transverse fissures. The tongue is long, thick and much roughened.
The nose is small. The skin has a slight dirty yellowish tinge, and is deficient
in elasticity, giving the appearance of being too large for the body.
The boy's aspect is such that it is difficult to realise that he is the
child of Europeans, but so frequently are these characters presented that
there can be no doubt that these ethnic features are the result of degeneration.
The Mongolian type of idiocy occurs in more than ten per cent of the cases
which are presented to me. They are always congenital idiots and never result
from accidents after uterine life. They are, for the most part instances
of degeneracy arising from tuberculosis in the parents. They have considerable
power of imitation, even bordering on being mimics. They are humorous and
a lively sense of the ridiculous often colours their mimicry. This faculty
of imitation can be cultivated to a very great extent and a practical direction
given to the results obtained. They are usually able to speak; the speech
is thick and indistinct, but may be improved very greatly by a well directed
scheme of tongue gymnastics. The co-ordinating faculty is abnormal, but
not so defective that it cannot be strengthened. By systemic training, considerable
manipulative power may be obtained.
The circulation is feeble and however much advance is made intellectually
in the summer, some amount of retrogression may be expected in the winter.
Mental and physical capabilities are, in fact, directly as the temperature.
The improvement which training affects in them is greatly in excess of what
would be predicated if one did not know the characteristics of the type.
The life expectancy, however, is far below the average, and the tendency
is to the tuberculosis which I believe to be the hereditary origin of the
Apart from the practical bearing of this attempt at an ethnic classification,
considerable philosophical interest attaches to it. The tendency in the
present day is to reject the opinion that the various races are merely varieties
of the human family having a common origin, and to insist that climatic,
or other influences are insufficient to account for the different types
of man. Here however we have examples of retrogression or, at all events
of departure from one type and the assumption of the characteristics of
another. If these great racial divisions are fixed and definite, how comes
it that disease is able to break down the barrier, and to simulate so closely
the features of the members of another division? I cannot but think that
the observations which I have recorded are indications that the differences
in the races are not specific but variable. These examples of the results
of degeneracy among mankind, appear to me to furnish some arguments in favour
of the unity of the human species."
His description covers the most important features of Down syndrome, with
the exception of the flattening of the back of the head. He added this observation
to his description in his first Lettsomian Lecture. He was undoubtedly aware
of the skull shape. The admission examination in Earlswood included specific
skull measurements. The practice of measuring the diameters of the head
had probably been introduced by John Conolly as part of the examination
required under the Lunacy Act which governed the operation of Earlswood.
Langdon Down retained one typical skull vault for future demonstration.
This is now in the museum of the Royal London Hospital. He also endeavoured
to photograph the brain but the picture is not well focused.
His son Reginald made a further important observation. Reginald did not
make any formal contributions to the medical literature but in 1909 in contributing
to discussion of a paper by Shuttleworth he passed around hand prints of
a number of patients with Down syndrome showing that "the bones of the palm
differed from the normal in their extreme irregularity, and the tendency
of the principal fold-lines to be two in number only, instead of three as
was most commonly the case." Reginald may have identified this peculiarity
himself or his father may have shown it to him. A sketch of the palmar crease
pattern dated 1908 survives in the family papers (R
Down, 1909). Regrettably his philosophical views were not those of his
father. Speaking at a meeting of the Medico-Psychological Society he said
that the Mongolian features were accidental and superficial and that as
there were other features which were in no way characteristic of the Mongolian
race the abnormality "must be a reversion to a type even further back than
the Mongol stock, from which some ethnologists believe all the various races
of men have sprung." (R
Down, 1905) This statement was to be quoted later by Crookshank whose
"A Mongol in our Midst" postulated that Mongolian imbecility as he described
it, represented regression to the characteristics of the Orang Utan (Crookshank,
1924). His father would have disapproved. Reginald's suggestion may
have been to some degree related to his reaction to a personal problem.
He was a disappointed father, his first son, born in 1905, having Down syndrome.
At the time of Reginald's communication his son was aged three years old
and the long term implications must have just then begun to become apparent
to his father. Reginald's wife Jane never came to terms with their son's
problems. The boy however grew to manhood in the Langdon Down home and he
came to be a well-loved member of the family, living a happy life to the
ripe old age of 65.
It took some time for Langdon Down's identification of the syndrome to make
an impact. In 1876, ten years after Down's publication, Mitchell and Fraser
published an account of what they described as Kalmuc idiocy, noting at
the time that they had searched the medical literature and they had found
no previous account of the condition. What they described was indeed Down's
syndrome and they had failed to note his earlier publication in the same
journal in which their paper later appeared. The first reference to Langdon
Down's ethnic classification was probably in 1877 (Ireland). Two years later
Tanner and Meadows also referred to it. (Tanner
and Meadows, 1879). Shuttleworth in 1886 referred to Langdon Down's
ethnic classification and he included the "Mongol type" in is tabulation.
1886). Following on the publication of the Lettsomian Lectures references
became more frequent, beginning with Goodheart in 1888 (Goodheart,
1888). In the United States Brush contributed a section to the Cyclopaedia
of Diseases of Children in 1891 in which he quoted Down's description at
length. (Brush, 1891).
Subsequently other authors included the description in major publications,
sometimes without attribution. (Tredgold,
By the turn of the century, Mongolism had become a widely used descriptive
term. This was the title used by Bertram Hill in 1908 and by Penrose as
late as 1961 (Hill, 1908;
The term was gradually dropped from 1961, to be superseded by Down syndrome
but it was still used occasionally and the 1967 Ciba Symposium on the disorder
chaired by Lord Russell Brain was entitled Mongolism. In 1961, a very prestigious
group of genetic experts wrote a joint letter to the Lancet which read:
"It has long been recognised that the terms 'Mongolian Idiocy', 'Mongolism',
'Mongoloid', etc as applied to a specific type of mental deficiency have
misleading connotations. The importance of this anomaly among Europeans
and their descendants is not related to the segregation of genes derived
from Asians; its appearance among members of Asian populations suggests
such ambiguous designations as 'Mongol Mongoloid'; increasing participation
of Chinese and Japanese in investigation of the condition imposes on them
the use of an embarrassing term. We urge, therefore, that the expressions
which imply a racial aspect of the condition be no longer used. Some of
the undersigned are inclined to replace the term Mongolism by such designations
as 'Langdon Down Anomaly', or 'Down's Syndrome or Anomaly', or 'Congenital
Acromicria'. Several of us believe that this is an appropriate time to introduce
the term 'Trisomy 21 Anomaly', which would include cases of simple Trisomy
as well as translocations. It is hoped that agreement on a specific phrase
will soon crystallise once the term 'Mongolism' has been abandoned." (Allen
et al, 1961).
The first two signatories were Allen and Bender, the former a world authority
on mental retardation and the latter the author of a book on Mongolism.
Allen had initiated the redesignation project in Bethesda in Maryland. The
signatories represented the cream of the investigators who were active in
the burgeoning field of genetic studies. The UK signatories were Carter,
Ford, Penrose, Polani and Langdon Down. According to Polani, Penrose approached
Norman Langdon Down to ask for the permission of the family in proposing
the new descriptive term. Norman was a grandson of John Langdon Down. As
a matter of interest the Lancet gave him the wrong initials designating
him as W Langdon Down. He was the medical superintendent of Normansfield,
and this responsibility had passed from father to sons to grandson for a
period of 102 years. Normansfield had been opened by Langdon Down in 1868
to cater for the upper classes.
There were only two objections to the proposals and in due course the Editor
of the Lancet issued his ruling: "Down's Syndrome is an appropriate alternative
for Mongoloid Idiocy until the chromosome abnormality in the disorder has
been fully elucidated and a new scientific term has been coined." The redesignation
of the condition was confirmed by the World Health Organisation in 1965.
The People's Republic of Mongolia had approached the Director General and
said that they objected to the use of the descriptive term 'Mongolian Idiot'
as it was derogatory to them. Down's Syndrome was adopted as an official
definition. This decision has never been revoked. (Beighton
& Beighton, 1986).
John Langdon Down was an astute clinical observer. He was the first to describe
Prader-Willi Syndrome (Ward,
1997). He contributed the only autopsy report available to Little when
he described the relationship between perinatal crises and subsequent cerebral
palsy. (Little, 1862)
He carried out the autopsy which makes it possible to say that the index
case of West's syndrome was cryptogenic (Ward,
in press) He wrote papers on pseudohypertrophic muscular dystrophy,
microcephaly and plagiocephaly.
Langdon Down published an almost-forgotten book on the 'Education and Training
of the Feeble in Mind' (Down,
1876). He advocated what he described as a medical model of management,
but in effect the specifically medical content of the programme was very
limited. He did however, stress the importance of diet although the scientific
basis of dietetics was as yet not established. In the Royal Earlswood Asylum,
and later in Normansfield, he set up training systems based on physical
exercise, sensory stimulation, and role-playing in such social activities
as shopping. This involved training and encouraging a team of carers who
would now be classified as play therapists, occupational therapists, speech
therapists and specialist teachers. None of these groups had as yet emerged
as distinct professions.
He recognised that social exclusion and the loneliness of limited social
contact were major problems for all classes of society. Among the well-to-do
children with handicap spent their days isolated in the servants' quarters
of their homes. Those in the middle classes were neglected in school and
were perceived as a poor educational investment. Those in the lower income
groups placed an impossible burden on their struggling parents. He recommended
institutional training as it was only in institutions that the range of
necessary services would be provided. He hoped that many could later be
integrated in useful activity at home. He also emphasised that by putting
children of comparable talents in groups together they could learn more
easily, protected from the pressure of competition. In the conditions of
the time, the social attitudes, the transport problems, and the overall
lack of services his ideas were practical and innovatory. In particular,
although his own Normansfield centre was orientated towards the upper classes,
he laid great emphasis on the importance of the provision of services for
lower income families funded either by single counties or by groups of counties.
In the Royal Earlswood Asylum, the charitable institution which he served
for ten years, his sweeping reforms had established for it a world-wide
reputation as a centre of excellence.
Aside from his contribution to medicine he was in advance of his time in
being prepared to accept the advancement of women in medicine, the law and
the church. His Harley Street consulting rooms were used for fundraising
for the suffragette movement. When he died shops closed and members of the
public stood on the pavement in silent tribute as his cortege passed by.
A street was named in his honour in Teddington and another in Torpoint.
Surprisingly his life story has not attracted the attention it deserves.
More than one hundred years after his death Langdon Down's contributions
to medicine have been commemorated at the Mansell Symposium in the Medical
Society of London (Ward,
in press) and a biography has been published by the Royal Society of
O Conor Ward, MD FRCPI FRCP (G) FRCP (L) FRCPCH (Hon). Department of Paediatrics,
University College Dublin, Our Lady's Hospital for Sick Children, Dublin
- Allen, G. Benda C.J. et
al (1961). Lancet corr. 1, 775.
- Beighton, P. & Beighton,
G. (1986). The man behind the syndrome. Springer Verlag.
- Bendyshe, T. (1865). The Anthropological
Treatises of Johan Frederich Blumenbach. Longman Roberts and Green.
- Brain, R. (1967). In Woltstenholme, G.E.W.,
Porter, R. (Eds.). Mongolism. CIBA Foundation.
- Brush, E. (1891). In Keating, J. M. &
Young, J. (Eds.) Cyclopaedia of Diseases of Children. Pentland
- Crookshank, F. G. The Mongol in Our
Midst 1924, Keagan Paul, Trench Traubner Company, London.
- Down, J. Langdon (1879*). Address
Christian Union, June 27.
- Down, J.L. (1862). Observations on an
Ethnic Classification of Idiots. Lond Hosp. Rep. 3, 259 - 262*
- Down, J. Langdon. (1876). The Education and Training of the Feeble in Mind*. London: HK Lewis
- Down, J. Langdon (1887). Mental
Afflictions of Childhood and Youth. J& A Churchill, London.
- Down, R. (1909). Discussion of Paper by
G Shuttleworth BMJ, 2, 665*
- Down, R. (1905). Notes and News. J
Ment Sc, 52, 188 - 9.*
- Goodheart, J.F. (1888). The
Diseases of Children. JA Churchill
- Hill W Bertram. Mongolism and its Pathology
Quart J Med (1908). 2, 49-68. Lancet. Editorial comment
1961, 2, 935.
- Ireland, W.W. (1887). On idiocy
and imbecility. D&A Churchill.
- Little, W.G. (1862). On the Influence
of Abnormal Parturition Difficult Labours, Premature Birth and Asphyxia
Neonatorum on the Mental and Physical Conditions of the Child, Especially
in Relation to Deformities. Trans. Obst. Soc, 3, 293-347.
- Penrose L S. (1961). Mongolism.
Brit. Med. Bull, 17, 184-189.
- Shuttleworth, G.E. (1886). Clinical
Lecture on Idiocy and Imbecility. BMJ, 1, 183-6.
- Tanner, T.H. & Meadows,
A. (1879). Diseases of Infancy and Childhood. Renshaw, London.
- Treadgold, A. (1903). Amentia
Practitioner, 2, 354-382.
- Ward, O. Conor. (1997). Langdon
Down's 1864 Case of Prader Willi Syndrome. J. Roy. Soc. Med, 90,
- Ward, O. Conor. (1998). John
Langdon Down, a caring pioneer. Royal Society of Medicine Press, London.
- Ward, O. Conor. (in press).
John Langdon Down (1828 - 1896). In F. Clifford Rose (Ed.). A Short
History of Neurology, Butterworth.
*John Langdon Haydon Down changed his name by deed poll in 1868 to John
Langdon Haydon Langdon-Down.