As physicians, in the broadest sense of the term, we are concerned not only with the alleviation of pain and the cure of disease, but also with the upbuilding of health and the improvement of bodily efficiency. To obtain satisfactory results in this work it is necessary to begin with the child, and we are thus called upon to solve problems and deal with conditions that are closely related to the field of education. The most important problem to be met in this connection is that of the development and training of the motor and sensory apparatus.
In perfectly normal and healthy children this development may without great harm be left to itself, for motor activity and co-ordinate control come spontaneously with the common games and plays of childhood, and sensory development is unconsciously brought about by contact with the childs environment. But even if this be true, systematic training of these activities during childhood is of the highest benefit in after life. We are accustomed to educate the voluntary muscular system; the usefulness of this procedure is universally admitted.
But the sensory apparatus is commonly much neglected. Professor Charles W. Eliot, in discussing Education for Efficiency (Riverside Educational Monographs, 1909, P. 6) says: “The training of sight, hearing, smell, taste and touch has been neglected in education to an extraordinary degree. Quickness and accuracy in all the senses are of high value to the individual throughout life; and in innumerable cases some slight but unusual superiority in one or more of the senses becomes the real basis of success in life.”.
If this training be necessary for the normal child, how much more is it necessary for the child whose physique is impaired by deformity or disease, and whose motor and sensory mechanisms are rendered inefficient by weakness or defect?.
In no class of cases will the physician be called upon to utilize his best knowledge upon this subject more adroitly than in those mental affections of childhood commonly grouped together under the name of mental defect, or, as it is better styled, mental subnormality.
Mental subnormal children very rarely show any spontaneous tendency to clearly co-ordinated muscular or sensory activity, and yet the prognosis of such cases must be based almost wholly upon the possibilities of development of the sensory-motor system. Failure to recognize this fundamental fact has brought about permanent defect in many a subnormal child who might otherwise have been made a useful member of society.
In all forms of mental subnormality it is a familiar axiom that “after treatment comes training.” It is the physicians duty, therefore, when acute symptoms have subsided and chronic conditions have been controlled, to prescribe a suitable and adequate system of training to meet the requirements of the sensory-motor apparatus, and it is the purpose of this paper to outline a series of exercises of this kind that have been found particularly useful in dealing with the class of cases in question.
These exercises are based largely upon the experience of the founder of the Bancroft Training School, who has studied the problems involved in this subject for more than twenty-five years. The exercises have been shown to be of value in all forms of mental defect, whether due to inherited conditions or acquired diseases. They are especially useful in cases of cerebral or cerebrospinal meningitis, encephalitis, intracranial haemorrhage or other conditions accompanied by some form of hemiplegia.
In children of the malnutritional type, also, where rachitis or marasmus has occurred in early life, much can be accomplished. Cases belonging to the hypothyroideal group, such as mild cretinism, mongolianism, certain forms of obesity, etc., are all greatly improved by these systematized motor and sensory exercises.
One of the fundamental principles of this system of training is that all motor and sensory activities are, for the purposes of development considered to be purely physical. They are treated simply as physical exercises. We are accustomed to think of muscular activity in this way, but the connection between the senses and such psychologic faculties as attention, association, memory, etc., and their close correlation in text-books on psychology, has led us commonly to regard sensory phenomena as being psychologic rather than physiologic, and as involving mental rather than physical states.
While it is true that this relation between mental faculties and physical functions is remarkably intimate, so intimate, in fact, that the latter may be exercised and developed by training the former (the method usually followed in our kindergartens), nevertheless in mentally subnormal children this connection must be temporarily lost sight of if the best results in motor and sensory training are to be gained.
The organs of special sense, the afferent nerve-pathways, and even the sensory centers of the cerebral cortex, may be exercised by appropriate means, although the child may be totally unconscious of their nature and significance. The nutrition of the structures involved may thus be improved, their tissues developed and their functional efficiency raised, exactly as we are accustomed to see done with the muscular system in the gymnasium.
Motor training by means of graded and systematized floor and apparatus work in the gymnasium is of the greatest value in the development of subnormal children. Many of them are able to do only light work, but this can be carefully selected and applied, so that the structures in need of particular attention may receive it without overtaxing the nervous, circulatory or other systems.
Hemiplegic cases may be given special exercises for the affected side, foot, leg, trunk, hand, arm and face exercises being included. In addition, these cases may have corrective work in the form of passive movements, massage, and if possible vibratory and electrical treatment. Series of simple exercises may be worked out, adapted to the peculiar needs of each child, and these may be so selected that they may be carried on in the home with only the simplest possible apparatus.
All of these methods of motor training are so familiar to the physician that they need not be dwelt upon here. There are, however, a few special exercise that deserve mention. In diplegic or marked hemiplegic cases it may be necessary to spend much time in training the child to walk.
This has been accomplished with good success in our school by a device composed of head and shoulder straps attached to a tackle running upon an overhead bar or track. After placing the child in this apparatus so that the feet rest fully upon the floor, it may be necessary for the instructor to move the feet and limbs, imitating the movements of walking. This should be persisted in daily until the movement becomes spontaneous. It is remarkable what may be accomplished in this way if time enough is allowed.
Another walking device consists of a platform about fifteen feet long and two feet wide, raised five or six inches from the floor. At appropriate intervals in this platform oblong holes are cut through to the floor in such manner that they are adapted to the angle of eversion of the foot and the length of the step while walking. They are lined on the sides with wood, and look much like footsteps in deep snow. The child is required to walk over this platform, placing the feet in the holes.
The exercise requires the feet to be lifted several inches at each step, and helps to overcome the dragging of the lower limbs, so common in paralytic cases. Still another apparatus is composed of a plank two inches thick and ten feet long supported on edge about a foot from the floor. The child is required to walk along the edge of this plank with little or no assistance, and is thus encouraged to co-ordinate the muscle-groups involved in the maintenance of equilibrium.
Spontaneous hand, arm and shoulder movements, particularly of the co-ordinative type, are often difficult to develop. Even the simple act of apprehension is sometimes wanting. The muscles involved in the grasping movement may be developed by a special form of glove containing stiff rubber elastic bands attached to the back of each finger and fixed firmly by a wrist- band. These bands act a little like the extensor muscles of the fingers and wrist, the flexors being required to contract against resistance. Grasping may be elicited by offering the child an object that arouses interest, such as an apple or a toy.
Lifting and carrying heavy objects, if systematically performed, is a most useful form of elementary motor training. The best objects for this purpose are some round cobblestones about six inches in diameter, some Roman bricks and a few wooden cylinders measuring six by ten inches. These are all heavy enough to necessitate the use of two hands. With these objects a series of exercises consisting of simple lifting, lifting and placing, carrying to a definite spot, piling, building, etc., may be worked out that can be taught to any subnormal child who is able to walk. This training lays a foundation for the finer co-ordinative exercises of block- building, clay modeling, etc.
The more complex motor activities may be developed even where physical stigmata are marked, by careful attention to suitable apparatus and by persistence in regular exercise. Simple and complex peg-boards, swelling-boards, etc., are all of great value. All of these objects should be very large. The common apparatus used in the kindergarten is too small even for the normal child, and is quite useless in the hands of the subnormal.
The pegs for peg-board work should measure not less than 22 inches in length and 2 inch in diameter. The child should be able to grasp them with the whole hand. The sewing-board consists of a light pine board 14 inches square, in which are several rows of 12 inch holes well reamed out on both sides. The child is taught to pass an 8 inch wooden needle, “threaded” with soft 3/8 inch rope, in and out of these holes, imitating various stitches. A child who would find it impossible to take a single stitch with an ordinary needle will learn to use this board in a few weeks and by changing to smaller apparatus will eventually be able to sew very well.
The weaving-board is a 20 inch frame covered with 1 1/4 inch webbing, stretched tightly across in one direction only. The child is taught to weave a long flat needle in and out across the bands of webbing, drawing through detached strips of webbing, the final result being much like a very large kindergarten mat. The webbing may be dyed to form appropriate combinations of color.
The value of these forms of co-ordinative motor training lies not alone in the fact that they develop the motor apparatus, and help the child to acquire facility in the complex movements necessary in daily life. They are also important because of the relation between motor activity and mental growth. They stimulate nutrition in the motor areas of the cerebral cortex, wake up the gray cells of the cerebellum, and encourage the formation and active functioning of association fibres.
They thus indirectly aid in the development of memory, thought, will and other mental faculties, Dr. Boris Sidis is of the opinion that motor elements form the nucleus of consciousness. He says in this connection: “Motor consciousness forms the main body of our mental activity. The great majority of mankind still leads a life closely allied to animal sensory-motor states. Instances the delight of children in their play, and the all-absorbing interest of college students in their baseball and football games.
Even in the highest and most developed forms of mental activity, motor ideas and representations are by far the most predominant. Without motor elements ideational life is arrested. It is these sensory-motor and ideo-motor elements that constitute the stream, the flow, the current of our mental life. Motor elements enter freely into combinations with all other elements of mental life.” (“Analysis of Sleep.” Boris Sidis, Boston, 109.).
The training of the special senses is best carried on by drilling one sensory mechanism at a time. Keeping in mind that the chief aim is development of physical structures, the exercises and apparatus are to be selected with a view to excluding as far as possible every apperception, association or memory concept, except those related specifically to the sense under training.
In training the visual sense the aim should be to develop speed and accuracy in the recognition of form, color and arrangement. For this purpose the following objects are selected: A sphere, a cube, a cylinder, a pyramid and a cone. These objects should be of good size (not less than three inches in the smallest dimension). They should be of one color, and if color- training is associated with exercises in form, a set of models in each color should be provided.
A square of dull black felt should be at hand as a background for the objects. Geometric forms are selected for these exercises because they are almost entirely without associational relations in the childs mind. The results of the training are thus due to the exercises only, and not to associated memories, and the progress of the work can hence be safely measured.
In the first exercise a white sphere is placed upon the square of black felt, hidden beneath an appropriate cover. The pupil is seated about 30 inches from the object, and is required to name it after it has been uncovered a short time and then re- covered. The other forms are treated in like manner, the period of exposure being shortened as the pupil becomes familiar with the exercise.
The color of the objects may be varied, and several models may be used in a group, the order of their arrangement being changed. When these exercises can be readily performed, correlation with familiar objects may be introduced, and similar exercises with other objects may be introduced, and similar exercises with other objects attempted.
These exercises afford an efficient training for the visual apparatus, not only as regards the retinal and central structures, but also the mechanism of accommodation. Children who can not even talk will in time learn to recognize the objects, and will show their recognition by pointing out a similar object in a group of forms.
In training the color-sense the hypothesis of Hering has been adopted as a provisional basis for the exercises, this being the theory that comes nearest to covering the facts. The accuracy of all of Herings conclusions may perhaps be disputed.
Nevertheless, in practice the application of his general theory certainly appears to accomplish results. Herings three chromochemical substances are accordingly made the basis of the color-training, and the exercises are planned to develop their quantity, activity and distribution. The color pairs, green-red, blue-yellow and black-white, are used at first separately, the anabolic and catabolic colors being alternated.
Later they are used in combination, and the training carried on to a series of the six fundamental spectral colors, and the differentiation of their respective hues, tints and shades. In these exercises the old color theory of Brewster, involving primary, secondary and tertiary colors, is discarded for the more rational classification based upon the spectrum.
The auditory sense is developed by systematizing various sounds. Different instruments, such as the bell, rattle, horn, drum, triangle, etc., are utilized. The child is first taught to make the sounds himself. He is next required to listen while they are repeated without his being able to see their source, and he is then directed to indicate upon which instrument the sound was made. Many exercises may be introduced in this way. The chief points aimed at in the training are the accurate recognition of quality, intensity and pitch.
Gustatory and olfactory training are carried on together. The four gustatory fundamentals, sweet, bitter, salt and sour, are first developed; then a large number of stimuli are introduced, the vivid and striking being used first. A surprising degree of skill in detecting shades of difference may thus be obtained. The child is, of course, to be blind-folded during the exercises, and is required to depend entirely upon the sense under training for his conclusions. In gustatory exercises it is well to select stimuli that are non-volatile, as the possibility of recognizing the substances by simple olfaction is thus minimized.
Pressure, muscle, stereognostic and temperature-senses, which, in combination with pain sense, are commonly grouped together as “touch” should be trained separately.
Pressure-sense is developed by teaching the pupil to recognise such differences in objects as rough, smooth, hard, soft, elastic, etc. The exercises are performed by introducing two or more objects into a small cloth bag and requiring the child to insert one hand and select, by means of pressure-sense only, the rough, or smooth, or hard object, as the case may be.
These objects should be alike in every respect, except the particular quality to be studied. In this way the pupil may finally be taught to make comparatively fine distinctions, such as recognizing raw cotton, raw silk, wool, hair and fur, and differentiating cotton, woollen, linen and silk fabrics of various kinds.
Muscle-sense may be readily trained by using pairs of objects, each pair being of different weight. The best results have been obtained by using large cubes and pyramids (with square bases), colored white and carefully loaded with lead, so that a cube and a pyramid constitute a pair, each object of the pair equal in weight to the other, but differing noticeably from the other pairs. Bottles painted white on the inside and loaded with shot set in paraffin, or, in fact, any other suitable objects, can be employed.
The chief points to be remembered are that the objects must be so constructed that they form equally weighted pairs, each pair differing from the others in weight, but resembling them in every other respect. All the objects are set before the child, and he is required to separate those of equal weight into their respective pairs. This he can do only by lifting the objects and measuring their weight by his muscle-sense. The exercises may be multiplied indefinitely. If cubes and pyramids are used, the pyramids should be set upon the cubes of like weight; the pupil may then be taught to arrange the pairs in a row, the heaviest at one end, the lightest at the other.
These blocks or bottles may be utilized in developing the appreciation of weight by pressure-sense. The exercises should be the same as those above mentioned, except that instead of grasping and lifting the objects, they should be placed upon the upturned palm. In these exercises the back of the hand should rest upon the table, in order to eliminate as far as possible muscle-sense, which under ordinary circumstances is combined with pressure- sense in the estimation of weight.
For training more extensive muscle-groups with heavier weights, tightly covered baskets, alike in every respect, but differently weighted with pebbles, may be employed. For example, the pupil may be directed to select the heaviest basket from a group of three and carry it to the teacher.
Stereognostic-sense may be brought to an excellent degree of development by placing in the black bag above mentioned several small objects which the pupil is required to recognize by introducing the hand into the bag and examining the shape of the object with the fingers. It is best at first to select geometric forms, such as the sphere, cube, cylinder, etc., using only three or four at a time. Later common objects of many kinds may be employed with advantage. The game in which the children are blindfolded and made to name various large objects, such as the furniture in the room. etc., is also a useful exercise in stereognosis.
The apparatus for the exercise of temperature-sense consists of six or eight vessels of similar form and color. Ordinary white enamel pint cups serve the purpose well. These vessels are to be filled with water of different temperature. Two vessels should be used at first, one containing hot water, the other cold. When these have been made familiar to the pupil a third may be introduced containing lukewarm water, and finally the cups may be filled in pairs and the child directed to group them properly according to their temperature.
The possibility of the pupil recognizing the difference in the vessels by their appearance, position or the amount of water in them should be carefully guarded against, so that temperature-sense will be the only sense available.
It is to be understood that in all the exercises described above, where the hand is employed, first one hand and then the other is to be exercised. When possible both hands may be brought into play.
The exercises here described afford but an imperfect idea of the scope and varied usefulness of motor and sensor training in the development of the mentally subnormal child. Some physicians have thought such training a foolish waste of time and energy; but this has been because they were not in a position to observe results. It is difficult to believe that a years persistent and systematic application of the exercises here described can so fully arouse the sluggish and uncertain mental faculties of almost any one of these children.
Interest awakens, perception becomes sharpened, memory grows active, association broadens, voluntary control on every plane begins to assert itself. The impulse to make something, to perform some deed, to win some goal, to accomplish something worth while–the great push and urge toward constructive activity–all these may be seen stirring into life under the hand of thorough training. Nor is the training difficult. The application of a few general principles, if properly made, will enable any physician to work out exercises, applicable to his case, that can be performed under his direction by a teacher or relative in any home not actually poverty-stricken.