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.
