y 1 ^♦^ Backward Children IN THE Public Schools With a Preliminary Study on THE RELATION OF PHYSICAL TO MENTAL DEFECTS IN SCHOOL CHILDREN BY WALTER S. CORNELL, M.D. PHILADELPHIA. PENNA. Dbmonstkator of Osteology, University of Pennsylvania; Physician to the Dispensary FOR Nervous Diseases, Presbyterian Hospital; Assistant Medical Inspector, Bureau of Health irilUBtrateO Mitb malMone plates PHILADELPHIA F. A. DAVIS COMPANY PUBLISHERS Price, 25cts., Net, Postpaid BACKWARD CHILDREN PUBLIC SCHOOLS With a Preliminary Study on THE RELATION OF PHYSICAL TO MENTAL DEFECTS IN SCHOOL CHILDREN By WALTER S. CORNELL, M.D. PHILADELPHIA, PENNA. Demonstrator of Osteology. University of Pennsylvania; Physician to the Dispensary FOR Nervous Diseases, Presbyterian Hospital; Assistant Medical Inspector, Bureau of Health PHILADELPHIA F. A. DAVIS COMPANY PUBLISHERS I LC-^for. ^; '|irBKARY of OOMsiElsl i Two Copies Ketiiivat! MAR t!l 1308 \ sioj/ycigiii ciUT.v (CUSS A m&. Mo. COPY 8. Copyright 1908 BY F. A. Davis Company \'. THE RELATION OF PHYSICAL TO MENTAL DEFECT IN SCHOOL CHILDREN. The age of our race between 6 and 15 years is a distinctive one, from the fact that the problem of diet, so important in infancy, decreases with the corresponding increase in bodily activity. So, also, the prevalence and effect of contagious disease suffer a reduction. For these reasons the mortality rate decreases progressively, and the probability of survival becomes steadily brighter. The age of development, however, is one in which the subsequent physical and mental welfare is largely prede- termined. Though the child's life be fairly safe, his for- tune still lies largely in the hands of his parents, his envi- ronment, his teacher, and his physician. First must be met the burdens of heredity, producing thousands of sickly, deformed, and neurotic children. A perpetually (or rather, life-long) acting force is here to be combatted and reck- oned with. Second to heredity is a poor city environment, with its lack of fresh air and its improper diet of canned foods. Exposed to these influences healthy infants succumb, and join the ranks of those already suffering from rickets, anaemia, and adenoid nasal obstruction. Finally, the igno- rance of parents causes indifference to the damage already done, and adds premature decay of the teeth to the existing list of evident physical imperfections. " Are these injuries to the health of the child also harm- ful to his mind? Will he ultimately pass through their (1) 2 The Medical Inspection of School Children. pale of influence more or less scarred, but possessing the same knowledge and mental faculty that make for power, as his more vigorous neighbor? The physical basis of mental defect becomes more and more evident as our psychopathic investigations increase in accuracy. Among the imbecile and idiotic class in children, the agencies producing the mental condition, such as cerebral haemorrhage and paralysis, or hydrocephalus, are very ap- parent to any observer. Feeble-minded children, the result of vicious, drunken, or imbecilic ancestry, show physical defects less evident to gross observation, but demonstrable, nevertheless, by super- ficial examination, by autopsy, and by subsequent brain examination. Backward and subnormal children approach so nearly the ordinary child that the connection between physical defect and brain defect is often not demonstrable at all in individual cases. In these the acting influences are of minor degree, being principally poor eyesight, deafness, and poor nutrition (adenoid growths are included in the latter two). We may either assume that the rule of a sound mind in a sound body is a natural law, and so reason by analogy that it operates in these cases, or by a study of a large series of cases draw positive original conclusions from this very class itself. The latter is well worth proving, if it be pos- sible to do so. That the mentally defective show physical defect is overwhelmingly proven by the statistics of asylums and training schools, by the writings of Shuttleworth, Barr, and Ireland, and by the most superficial observation on the part of any one who visits custodial institutions for these cases. Juvenile criminals usually show mental and physical de- Relation of Physical to Mental Defect. feet, as has been shown by MacDonald (Medical Record, July 20, 1907). Even in the special classes for backward children con- ducted by our large cities, the reports show that almost every backward child shows physical defect of some sort. In these classes the proportion of such children is given by one authority as 95 per cent, of the whole number. Dr. John J. Cronin, of New York, tells me that of 150 back- ward children examined, 81 were actually operated upon subsequently for adenoid growths. In regard to the backward children in the Boston schools, the Massachusetts Health Report (April, 1907) states : — "Certain facts concerning some of the so-called un- graded classes in Boston are significant. These classes are composed of children who have failed to keep up with the work in the lower grades. They are grouped in small classes, and given chiefly individual work. "Of 43 girls of this class in one school, but 2 were found normal in vision and hearing. "Of 66 boys in another school, 64 per cent, were found defective in vision ; while the rest of the school, 473 boys, 36 per cent, were defective. "In another school, boys and girls, of 40 children in ungraded classes, 65 per cent, were found defective in vision or hearing, or both ; while of the remaining 707 children, 36 per cent, were defective." The writer personally visited a special class in New York City in which the whole number of children (18) had nasal obstruction or catarrh ; 8 were also defective in vision, and 3 of the latter suffered from deafness. Numerous other defects and malformations were evident. That the physically defective among ordinary school- 4 The Medical Inspection of School Children. children show subnormal mentality is the converse of the last proposition and should be capable of demonstration. In the following investigation I have endeavored to clearly establish this relationship. The children studied were those of three Philadelphia public schools who had previously been physically examined by myself in conjunc- tion with the official work of medical school inspection. The first step was the recording, in each school, of the name, physical record, and scholarship of each child. The latter was obtained by using the previous term-marks in three of the school studies, from which an average mark was easily calculated. The average term-mark of the whole school was first obtained by the simple process of adding the term-marks of all the children together, and dividing by the number of children. For instance, in the Claghorn School this was 73-I- Relation of all Physical Defects to Scholarship. The record-cards of the children were then divided into two collections : one of the healthy or normal children, the other of the general group showing some noteworthy physical defect. The average term-mark (the scholarship index) was then calculated for each group separately, and the two compared, first with each other, and then with the term-mark of all the children previously calculated. The results showed that in each school, and in each individual branch of study in each school, the healthy or normal children stood higher in their classes than the aver- age children, and the physical defectives, taken as a class, stood lower than the average children. Relation of Physical to Mental Defect, Allison School — 219 Children, Both Sexes, 6 to 12 Years Old. Average Normal child 75 Average child i 74 General defectives 72.6 Adenoids and enlarged tonsils 72 Deaf 67.2 Ninth Street Primary School — 84 Children, Both Sexes, 6 to 10 Yeaks Old. Language Arithmetic Spelling Average 63 cases normal children 72.9 75.5 75.4 74.6 84 cases average child 70.5 74 72.8 72.4 21 cases general defectives 63.3 70 64.8 66 8 cases adenoids 60 66.7 65 63.9 No cases deaf. Claghorn School — 252 Children, Both Sexes, 12 to 15 Years Old. Geography- Language Arithmetic and Average History 179 cases normal children.... 74.4 72 76.6 74.3 252 cases average child 72.7 70 76.5 73.1 73 cases general defectives 71.4 65.1 76.2 70.8 An investigation on slightly different lines was afforded by the existence in the Claghorn School of four classes of the same grammar grade, which had been so made up at the beginning of the year that the brighter children consti- tuted two classes, and the duller children the other two classes. The latter were smaller, so as to afford more op- portunity for individual instruction. A comparison of the physical condition of the children is interesting and instruc- tive : — Class 1 Class 15 Class 9 Class 11 Dullest Bright Children Dull Children Children Number of children 50 39 32 29 Proportion of normal to defective children: — Normal 36 32 20 13 Defective 14 7 12 16 Percentage of normal children, 72% 82% 62.5% 44.8% 6 The Medical Inspection of School Children. In June, 1906, the school medical inspection corps of Philadelphia was directed by its chief, Dr. Thomas J. Beatty, to make a comparative study of those bright chil- dren exempted from their annual examinations, and those children whose lower scholastic standard necessitated their examination for promotion. The proportion of physical defects recorded in the two groups was made the basis of comparison. I am indebted to Dr. Beatty for permission to publish the figures which I submitted to him at that time. It will be observed that, on averaging the five schools, the brighter children showed the less percentage of physical defect. Exempt Children. Non-Exempt Children. Normal. Defective. Normal. Defective. Ninth St. Primary School . . 56 28 39 38 Rutledge School 87 35 75 34 Allison School 128 65 81 49 Camac School 183 71 103 75 Claghorn School 193 61 127 66 647 260 425 262 Percentage defective, Percentage defective, 28.8 per cent. 38.1 per cent. The Massachusetts Health Report above quoted also demonstrates the close relation of physical and mental de- fect by an independent investigation. In part it states : — "Of 420 children examined, 40 per cent, had perfect vision, 30 per cent, had mild defects, and 23 per cent, had serious defects. "Of scholars ranked as 'excellent,' 50 per cent, had normal eyes, and 14 per cent, had serious defects. "Of scholars ranked as 'unsatisfactory,' 40 per cent, had serious eye defects. "Of the 'excellent' scholars, 17 per cent, had dimin- ished hearing. "Of the 'good' scholars, 20 per cent, had diminished hearing. Relation of Physical to Mental Defect. "Of the 'unsatisfactory' scholars, 52 per cent, had diminished hearing. "Of the 'poor' scholars, 42 per cent, had diminished hearing." The standard of normal hearing in these tests was evidently placed higher than is usually the custom in routine school inspection. Relation of Poor Eyesight to Scholarship. A separate study was made to show the single influ- ence of poor eyesight on the scholarship of the children (New York Medical Journal, June i, 1907). The records of the Allison School were used. A series list was made of 219 children, their visual acuity, and their term-marks in arithmetic, geography, and spelling. For convenience vision was designated as normal if it exceeded three- fourths, fair if it exceeded one-half, and bad if it was one- half or less. The children were first grouped according to their acuity of vision with the following result: — Arithmetic Geography Spelling Average Normal vision 79 69 76 75 — Fair vision 70 71 77 73-}- Bad vision 66 70 71 69 This difference of six points is often the difference between promotion and failure in a child's work. It is in- teresting also to note the great difference in the arithmetic marking and the slight difference in the geography mark- ing, the latter being acquired largely by oral instruction rather than blackboard work. Relation of Nose and Throat Defects to Scholarship. An effort was made to determine the exact degree of influence of defect of the nose and throat. The harmful The Medical Inspection of School Children. results of these are well recognized in late years. In the Claghorn School the four classes of bright and dull chil- dren were examined again. Their eyesight proved to be about the same (averaging '-^, ^, ^g', '-f). En- larged tonsils, adenoids, deafness, and nasal catarrh oc- curred much more frequently, however, among the two classes of duller children. In many the adenoid expression was written only too plainly on their faces (see illustra- tions). The following table shows the findings: — Class 1 Class 15 Class 9 Class 11 Dullest Bright Children Dull Children Children Number of children 50 .39 32 29 Nose and throat conditions: — Number defective 6 4 9 9 With single or combined defects, viz.: — Tonsils 3 4 3 3 Adenoids 2 1 5 6 Deaf 2 — 5 1 Catarrh — — 2 3 Percentage of children with nose and throat defects 12% 10.2% 28.1% 31% The conclusions to be drawn from the foregoing facts are very apparent. The educational result in our public schools suffers a discount of about 6 per cent, in the case of the physically defective children, as well as a waste of the time rightfully belonging to the normal children. The drain on the teacher's energies is more than proportionately increased by the presence of such children, because of their associated nervousness or stupidity. To remedy these conditions, educators turn to the med- ical profession as their only source of relief, and the trusted family physician is largely responsible for the condition of affairs which exists, whether good or evil. In many cases he not only guards the health of his charges, but by his alertness or indifference determines their intellectual growth, their scholastic career, and their subsequent life's work. New York school boy, before and after removal of adenoid growths from the naso-pharynx. Relation of Physical to Mental Defect. In this connection it is well to note that a laborious statistical study of the relation of nutrition to scholarship showed practically nega- tive results. This investigation was made by Mr. Albert E. Dudley, principal of the Claghorn Grammar School, Philadelphia, in collabora- tion with the author. Three hundred and fifty-eight boys, whose ages ranged from nine to sixteen years, were weighed and classified in three groups. The middle group (class B) comprised those boys whose weight per age corresponded to the standard figures of the Metropolitan Life Insurance Company, or within one year's variation of the same. The boys of heavier weight per age constituted class A, and the boys of less weight per age (supposed to be poor nutrition cases) constituted class C. The same procedure was followed in the case of the girls. The scholastic standing of the individual in each group was then obtained and averaged, so that the groups could be compared. The results fol- low:— Boys (358). School term Average. Class A, heavy weight for age ( 120 boys) 71.6 Class B, medium weight for age ( 168 boys) 71.2 Class C, light weight for age (70 boys) 72. Girls (225). ■ Class A, hea^'y weight for age (97 girls) 73.7 Class B, medium weight for age (100 girls) 72.1 Class C, light weight for age (28 girls) 70.6 Since an accurate estimate of nutrition can be made only by taking the height as well as the age into account, the omission of the former procedure may possibly have introduced a factor of error in the above conclusion. For this reason it is our intention to revise this paper. There is no doubt, however, that numerous individual cases exist in which anaemia and poor nutrition not only retard school progress, but prevent it altogether. BACKWARD CHILDREN IN THE PUBLIC SCHOOLS* The subject of mentally deficient school children is at the present time attracting the interest of educators to an extraordinary degree, and very naturally so, since the institution of classes for the special instruction of such backward children acts both as a benefit to them, and as an educational economy to the regular-grade teacher and to the great mass of normal children. Consideration of this aspect of special education, which may be called the pedagogical aspect, is given in the general chapter bearing on administration. In this connection the medical and psychological features will be considered. Those who are especially interested in mental defec- tives should not content themselves with a mere book pre- sentation of this subject. A clear, confident comprehension of it can be best obtained by actual observation of defective children in such institutions as the New Jersey Training School at Vineland, the Massachusetts School for the Feeble-minded at Waverly, the Pennsylvania Training School at Elwyn, and the special public school classes for backward children in New York City, London, and Berlin, I. CLASSIFICATION Children with mentality below the average may be divided into two great classes. The first group consists of those children who are (10) Backward Children. 11 but slightly below the normal standard. Their mind proc- esses are sluggish, or of slower growth than normal, or perhaps they are peculiar emotionally or lacking in gen- eral nervous tone. These children are often termed back- ward, or "atypical," or "exceptional." Backward children, such as may be found in the public schools, may be again classified into two groups. They are truly backzvard when the chief defect is in the brain itself, and apparently backzvard (or pseudo-backward) when de- fect of some other part of the body, or the child's home environment, is the cause. The causes producing apparent backwardness are largely removable by proper medical care and by improvement in the child's surroundings; and this would lead us to hope that a child placed in a good home, and perhaps fitted with proper eye-glasses or cured of deaf- ness, is enabled thereby to resume his normal mental devel- opment, and cease to be a backward child. This is usually the case, but unfortunately not always so. A youthful brain arrested too long in its development suffers the same blighting effects as do the bound feet of the Chinese woman or the distorted, suppressed vision of a child's squinting eye. The brain may ultimately be given its opportunity, the bandage may ultimately be removed from the feet, and the crossed eye be made straight by operation, but lack of early exercise results in each case in permanent functional weakness. Therefore a child originally apparently backward may become truly backward from lack of the brain exercise nec- essary to brain development. The second group includes all these children below those of the first group, and generally termed "feeble- minded." They range from the highest grade of such children (classified as feeble-minded in its restricted sense) 12 The Medical Inspection of School Children. through the various grades of imbecihty down to idiocy. In them there is some inherent brain defect precluding the possibiHty of their attaining normal mentality, and often lirniting their possibility of improvement. Their defect is usually evident to any one. They require institution care and training, and are not properly considered here. II. THE CAUSES OF BACKWARDNESS. Children of such mental development that their parents consider them capable of entering the public schools are usually normal, sometimes backward, and rarely actually feeble-minded. Occasionally feeble-minded and imbecile children creep in and lodge for a while. The minor grade cases, which make up the majority of public school defec- tives, are logically caused by the minor grade physical defects, such as deafness, malnutrition, adenoids, and poor eyesight. Gross deformities and diseases of the brain are more likely to produce imbecility or even idiocy, and con- demn their possessors to asylums or training institutions. The relation of physical to mental defect has been already discussed in the chapter devoted to that subject, and the demonstration made that normal children always attain higher school averages than physically defective ones, and further that the individual factors of poor eyesight, ade- noids, deafness, and poor nutrition have each been shown to lower the scholastic average. The physical signs, as well as the child's words and actions, are therefore the criterion by which mental defect is diagnosed. In the lower social strata, among the poor and igno- rant, the active causes producing backward school children are frequently environmental, including evil home sur- roundings, poor nourishment, and the inherited taints of syphilis and alcohol. Backward Children. 13 A systematic classification of the causes of backward- ness may be made as follows : — A. True Backwardness. 1. An inherent functional weakness of the brain and nerv- ous system. This is often hereditary. It may be due to injury or illness of the mother previous to the birth of the child, to poverty, or to parental dis- sipation. 2. Serious defects of the special senses. This is especially true of deafness, for blind children are saved in this respect because of their early institutional training. Defects of the external sense organs prevent the ex- ercise and development of their corresponding brain centres. 3. Any of the physical causes of feeble-mindedness, but acting to a less degree. This is but simple mention of numerous accidents, diseases, and deformities enu- merated in detail in the chapter devoted to that sub- ject. They consist mainly in organic defects and lesions of the brain. B. Apparent or Pseudo-backwardness. 1. Children with slower rate of mental development, or un- even rate of development. These children may sub- sequently show great ability. It is said that Haw- thorne, Sir Walter Scott, Napoleon, Clive, Welling- • ton, Froebel, Linnaeus, Webster, Chatterton, Leigh Hunt, and Sir Isaac Newton were dull boys at school. 2. Lesser defects of eyesight and hearing. 3. Poor nourishment, anaemia, and physical weakness. This may be due to poverty, or to yery rapid growth, or to illness, such as scarlet fever, or to Bright's disease. 14 The Medical Inspection of School Children. 4. Adenoid growths. These act by producing deafness and poor nutrition, and possibly by inducing a slug- gish circulation at the base of the brain. 5. Troublesome, spoiled, unhappy, and neglected children. This classification is partly based on the admirable one of Dr. M. P. Groszmann, of Plainfield, New Jersey. III. THE SYMPTOMS AND DIAGNOSIS OF BACKWARDNESS. The preliminary diagnosis is made by the teacher. The final official diagnosis should be made by the medical inspector or consulting physician. A. Teacher's Preliminary Diagnosis. A very helpful knowledge of the diagnostic signs of mental incompetency may be obtained from a book descrip- tion, and certainly enough may be obtained for an intelli- gent teacher to tentatively select such cases in her class and set them aside for expert examination. A thorough and practical knowledge, which gives the power of confi- dent and accurate diagnosis, is only acquired, however, by actual contact with numbers of such children in classes or institutions. The latter, containing feeble-minded children of all degrees, whose physical and nervous defects are pro- nounced enough to admit of study and comparison, fur- nish practical instruction in diagnosis that cannot be ob- tained elsewhere. The student or teacher who derives his knowledge solely from text-books is apt to assume that their classifi- cations of mental deficiency are exactly illustrated in life by the subjects, whereas such classifications are entirely artificial and devised simply for the sake of convenience. In a graded series, the mentality of the lowest member of one group is exactly that of the highest member in the Case of nasal obstruction from adenoids, showing characteristic dull facial expression. (Courtesy of Dr. B. C. Gile.) Group of New York school children who had previously suffered from adenoid growths. These children were operated upon and sent to the country for two weeks, and are now returning improved in health. The cases marked with a cross + also show, when smiling, the broad bridge of the nose and sunken vacant mouth often resulting from adenoids. (Courtesy of Dr. Thomas Darlington and Dr. John J. Cronin. ) Backward Children. 15 group below. The complexity of the various manifesta- tions of the mind, such as the emotions and intellect, and of the moral sense make even an exact gradation impossible. Text-book statements of the physical defects often accompanying feeble-mindedness in its various degrees of existence are also apt to cause the inexperienced teacher to form the hasty conclusion that every mentally defective child bears a sort of label or tag, such as adenoids, or pro- truding ears, or a peculiarly shaped head, by which obvious ph5^sical defect it can be readily distinguished from its fel- lows. As a matter of fact, these signs are simply sug- gestive and corroborative; and there exist idiot children of perfect physical development, as well as extremely bright children with all sorts of unfortunate physical characteris- tics. The occurrence of these physical defects should sim- ply be regarded as ground for suspicion, but nothing more. The diagnosis of a poorly developed mind should be based entirely on the child's thoughts as expressed by its words and actions. The grade teacher herself should make the preliminary observations and diagnosis of backwardness in a child. The evidence, both direct and corroborative, should be carefully recorded on an appropriate official card. The teacher's diagnosis should rest upon : — 1. Observation of Obvious Physical Defects, or knowl- edge of the existence of such defects from the offi- cial physical record. 2. Observation of Symptoms indicative of nervous dis- order. 3. Observation of Psychic Symptoms indicative of men- tal deficiency. 4. Knowledge of such Mental Defect gained by sys- tematic routine testing of the whole number of children. 16 The Medical Inspection of School Children. 1. Physical Defects Frequently Associated with (and Often Causative of) Backwardness: — Very poor eyesight, including squint cases. Deafness, with or without discharging ears. Poor general health. Peculiar shape or size of the skull. Low forehead, peculiar ears, high palate. Vacant facial expression. Adenoid growths, causing nasal obstruction. 2. Disorders and Defects of the General Nervous System: — These signs may or may not be indicative of men- tal defect. They are suspicious, not conclu- sive. Lack of strength and vigor, manifested by rapid fa- tigue, shambling gait, and slouching position. Low or irritable nerve-tone, manifested by uneasiness, restlessness, and muscle twitchings, particularly of the fingers and jaws. A more severe condi- tion is chorea (St. Vitus dance), characterized by involuntary rolling of the eyeballs, by spas- modic movements of the muscles of the face, jaws or neck, or by shuffling of the feet. Some cases of epilepsy are the result of a highly irri- table nervous system. Epileptic convulsions. Poor coordination, manifested by inability to thread needles, button garments, lace shoes, or perform any but the simplest mechanical acts. 3. Direct Psychic Evidence of Mental Defect by Observa- tion : — Inability to perform regular school work, designed for average pupils of the child's age. Backward Children. 17 Rapid mental fatigue. Dullness and listlessness. Excitability and emotionalism. Stubbornness and bad temper. Demonstrative expression of desire. Lack of judgment. Inattention. Untidy or uncleanly personal habits. Defective speech. 4. Knowledge of Mental Defect by Test: — Defects of Perception (of color, form, size, num- ber). Defects of Concept of Number. Defects of Memory. Defects of Association. Defects of Attention. Defects of Coordination. Defects of Imitation. y It is understood, of course, that the following tests are elementary in character and do not assume to classify the faculties nor to investigate thoroughly those that are touched upon. The first is beyond our power, and the second too complex for our practical purpose. The exact value of psychological tests for the detection of mental defect is as yet undetermined. In the first grade, containing the )^ounger children, the elementary lessons in arithmetic, spelling, and writing are now so scientifically formulated as to call directly upon the simplest faculties of the mind almost as well as any special tests that can be devised. Simple counting of concrete objects, for instance, is the test for the perception of number; spelling and the recognition of words show the power of memory and the 18 The Medical Inspection of School Children. perception of form. Addition or multiplication of abstract numbers is the test of the concept of number. Writing is a test of coordination, not to mention motor power. How- ever, special tests of the simplest character, such as the form board, tests of color and of size, will help much to fix the grade of a small child's intellect. Among the older children, the complexity of their studies makes it difficult for the teacher to accurately per- ceive the particularly defective faculties in the child's men- tal make-up. For this reason attempts have been made by psychologists, with varying degrees of success, to prepare \ mind-charts and systematic tests, and thus obtain the accu- rate insight desired. I am greatly indebted to Dr. Goddard, psychologist to the New Jersey Training School for Feeble-minded Children, for suggestions and material embodied in the test system given below and in the appendix. The tests embodying words and letters are abstracted and condensed from a thesis on this general subject by Dr. Naomi Norsworthy, of Columbia University. Test of Color : — A. Kindergarten Children : Color sense may be tested by the ability to recognize differences of color. A pile of blocks or cards, or some yarns of, say, three different colors, may be used. It should be remembered that a very small number of children are born color-blind, and in these cases red and green cannot be distinguished. It is well, therefore, not to use these colors exclu- sively. B. Primary Children: Test as for "A." After the child demonstrates that he distinguishes differ- Backward Children. 19 ence of color (color-sense), he may be tested, after instruction, for the recognition of simple colors (color perception). Test of Form Perception : — A, Kindergarten Children: The form board is use- ful, the test consisting in the placing of the blocks in their proper places. The facility with which this is done should be noted. A child of six to fifteen years will fill a board of ten blocks in thirty to fifteen seconds. Form Board. B. Primary Children : The recognition of some letter known to the child, as it may happen to occur in a mass of printed matter, is a good test. Thus, on a printed or mimeographed slip the children may be given an exercise to cross out the letter A wherever it may occur, a time limit being ob- served. Such a test, already tried and stand- ardized by Dr. Norsworthy, is given below. 20 The Medical Inspection of School Children. Table Containing: the Letter A One Hundred Times. As many of tliese as possible to be crossed out in one minute. OYKFIUDBHTAGDAACDIXAMRPAGQZTAACV AOWLYXWABBTHJJANEEFAAMEAACBSVSK ALLPHANRNPKAZFYRQAQEAXJUDFOIMWZSA UCGVAOABMAYDYAAZJDALJACINEVBGAOFH ARPVEJCTQZAPJLEIQWNAHRBUIASSNZMWA AAWHACAXHXQAXTDPUTYGSKGRKVLGKIM FUOFAAKYFGTMBLYZIJAAVAUAACXDTVDAC JSIUFMOTXWAMQEAKHAOPXZWCAIRBRZNSO QAQLMDGUSGBAKNAAPLPAAAHYOAEKLNV FARJAEHNPWIBAYAQRKUPDSHAAQGGHTAM ZAQGMTPNURQNXIJEOWYCREJDUOLJCCAKSZ AUAFERFAWAFZAWXBAAAVHAMBATADKVS TVNAPLILAOXYSJUOVYIVPAAPSDNLKRQAAO JLEGAAQYEMPAZNTIBXGAIMRUSAWZAZWXA MXBDXAJZECNABAHGDVSVFTCLAYKUKCWA AFRWHTOYAFAAAOH GiELs Boys A.GE Average Number of A'a Crossed Out Normal Limit of Variation Average Number of A 6 Crossed Out Normal Limit of Variation 9 32.6 4.5 28.4 2.1 12 45.9 7.3 41.3 4.4 15 54.1 7.3 48.6 4.4 16.5 57.0 7.3 51.2 4.4 Test of Size Perception : — A. Kindergarten Children: Marbles of two or three sizes may be used and the child asked to pick out the large ones or the small ones. He may be asked to make big circles or little circles. B. Primary Children: The comparative size of two or three objects, such as books or pencils, or the comparative size of other children may be ques- tions asked. Backward Children. 21 Test of Number: — A. Kindergarten Children: The perception of num- ber may be tested by asking the child to count the number of pennies on a table or the marks on the blackboard. The concept of number may be tested by simple abstract processes, such as adding two and three, and multiplying small figures. B. Primary Children : Test as for A, but with larger numbers. Lack of number percept indicates very low mentality. Test of Perception of Weight : — A. This may be omitted with kindergarteners. B. Primary Children : Test by using large pill-boxes of the same size, but filled with substances of different weight. Let the child take a box on the palm of each hand and discover the heavier. Any two objects of about the same size, but of different weight, will answer. Test of Perception of Temperature: — A. Kindergarten Children: This test may be omitted. Children with lack of temperature sense are the victims of serious organic nervous disease, and therefore not encountered in public schools. An endeavor to test the ability to perceive compara- tive temperatures in very small children is diffi- cult and apt to be terrifying to them. B. Primary Children : Take two tumblers of water, one warm and the other cool, and have the child distinguish temperature by dipping the fingers 22 The Medical Examination of School. Children. of the same hand into them. This test need only be apphed to extreme cases of backwardness, where imbecihty or idiocy is suspected. Test of Memory: — A. Kindergarten Children: See if the child remem- bers his name, age, number of brothers and sis- ters, and the names of familiar animals and ob- jects. B. Primary Children: Also the child's address, the names of other boys, other streets, father's name and business, events of the da)'-, etc. Reading of words is a test of the memory, requiring also a normal perception of form in order to first dis- tinguish the letters. Test of Attention : — This is really a matter of observation as much as test, but a test has the advantage of accuracy from being conducted systematically. The children should be told a story or shown a series of colored pictures or unusual articles. The story told should not be too interesting or too dry. Those with poor powers of attention soon betray it by their wandering eyes and vacant facial expression. Test of Coordination : — A. Kindergarten Children : Inability to button clothes, and to do the ordinary kindergarten exercises with blocks, pegs, and paper strips. B. Primary Children: Inability to thread large-eyed needles. Inability to do the simpler physical exercises, such as touching the fingers over the Backward Children. 23 head. A precision test may possibly be useful. It is given in the Appendix. Test of Associations: — The association of ideas may be tested by en- deavoring to elicit from the child prominent charac- teristics of a thing mentioned, or opposite qualities and characteristics may be sought for. The request may be made to name the whole after the exhibition of a part. These may be done informally with each indi- vidual child, or a class test may be made by giving to each pupil a printed list, with a request to set down alongside of each term given its opposite adjective. Such a test, already standardized by Dr. Norsworthy, by experiment on several hundred children, is as fol- lows : — List A given. Pupils (boys or girls) asked to write list B ; 20 words maximum ; no time limit. List B Number of Oppo- site Character- ■*^86 istics Correctly Sttaed 9 12 15 16^ 9 13.5 15 15.5 Normal Limit of Variation 2 2.6 2.3 2.3 List B given. Pupils (boys or girls) asked to write list A ; 20 words maximum ; no time limit. Normal Limit of Variation Number of Oppo- siie Character- Age istics Correctly Stated 9 9.5 12 14.7 15 18.5 \Q\ 19 1.7 3.6 2 2 good outside bad inside quick tall slow short big loud little soft white black light happy false dark sad true like dislike rich sick poor well glad thin sorry thick empty full war many above peace few below friend enemy Test of Imitative Faculty: — This is best shown in physical exercises. Test by facing the class and asking them to imitate the move- 24 The Medical Examination of School Children. ments. After the coarser and easier movements have been tried, Dr. Francis Warner suggests a finger ex- ercise, such as bending certain fingers simuhaneously, and moving one finger from side to side. This idea was first suggested by Seguin ("Idiocy and Its Treat- ment"). Test of Reason : — Reason is in reahty a complex act, involving so many mental factors that it may be safely taken as an index to the intellect itself. The good judgment or reasoning power of the individual is therefore the best criterion of his intellect, and Professor Johnstone, of the New Jersey Backward School, has said that to him the foremost characteristic of feeble-minded children is the lack of good judgment displayed by them in their ordinary activities. Some tests of reasoning power are simple enough in themselves, and yet they should be made carefully, since a timid, confused child will not do himself jus- tice. His confidence should be secured by dealing with him in a gentle, deliberate manner, and by ask- ing him a few easy questions of no particular conse- quence. Such questions as these will test the reasoning power : — "What would happen if I put my finger in the fire?" "What would happen if I went out in the rain?" "What will the dog do if I kick him ?" "Why does the man carry an umbrella?" "Why do you wear an overcoat to-day?" Or (exhibiting a picture of a girl and a broken doll), "Why does the little girl cry?" High-grade feeble-minded girl. Institution case. Backward Children. 25 The general way in which this information is given to the examiner is the best single index of the child's mental capacity. I remember one occasion (not in the public schools) on which a normal child who had been mistakenly sent by a nurse with several feeble-minded children to be examined and committed to an asylum, showed at once, by his prompt, clear answers, his healthy mind. Illustrative Case: — A fair example of what may be ascertained by any intelligent teacher, after reading these instructions as to observation and test, is as folows : — C McC ; age, six years ; good family. Has been in the first grade two months and is so stupid that he does not know a word or a letter, and cannot add two and two. It is difficult to get him to talk. His speech is fair but short, much like that of a quiet three-year-old child. He seems to have no memory, although he imitates well enough. His attention is always wandering, and he ap- pears restless. Frequently he stands up in his place, turns and leans over the desk behind him, with no apparent reason for so doing. He occasionally pinches the other boys around him. He appears to see well enough, but breathes through his mouth. He has a good color and complexion, and is a rather good-looking boy, although his face has very little expression. By test he told his name but not his address, saying that he lived "down there," pointing in any direction. (He knew his way home every day, however. ) He did not know his parents' names, and, on being pressed to name a brother or sister, gave the name of a classmate. On being asked his teacher's name (he had had three, owing to the sickness 26 The Medical Examination of School Children. of first one and then another), he gave the name of his first teacher, last seen two months since. He had little or no perception of color, form, number, or weight, calling a red vase and a green blotter "blue" not recognizing letters, stating that two fingers plus two more fingers were "five." Obsorvatioiis on CMId Proposed for an Uegraded Class RS.. Name X Borough ...7../-L. /- Age. Home con£!&oia..^U4k^:'}J6.r-.i::/SAS^. Habits ...fi. ..i^fe5tf,....j»^£2fe5^: — „ Attentk>iis2^^<;^r^]x>n^^§f^iU,>J^J.M^£.^... .190 •/• PrincipaL Backward Children. 27 He recognized a penknife and a pencil, however, called a five-cent piece a ''quarter," and knew that the dog was bigger than the cat. He was reminded that "the doggie barked," and was then asked what the cat did. The cat "jumped over the fence," which was a bright enough an- swer, although a failure in the endeavor to test his asso- ciation sense. A preliminary diagnosis of backwardness was made, the stupidity probably caused by adenoid growths in the pharynx. Systematic observation and test by the teacher having been made, these should be recorded. A printed blank for this purpose is very helpful to the teacher without special knowledge or previous experience. An actual case history on the form provided by New York City is here given. B. Medical Examiner's Official Diagnosis of Backwardness. The medical inspector or consulting psychiatrist should confirm or reject the teacher's preliminary diagnosis by: — 1. A Review of the Teacher's Record. 2. A Careful History of the Case. 3. A Thorough Physical and Mental Examination. 1. Review of Teacher's Record: — The tests and points of observation should be repeated, the object being the confirmation of the pre- liminary diagnosis. If it be the first case passed upon by the teacher in her teaching career, the skill and ex- perience of the physician may lead to an opposite con- clusion. An- experienced teacher is, however, usually correct in her judgment. The official diagnosis of backwardness is largely a matter of expediency. Pronounced cases should be removed at once from the general class, as a relief to 28 The Medical Examination of School Children. their fellows, the teacher, and themselves. Less evi- dent cases should be classed as backward only when the facilities for dealing with these children are satisfac- tory. In an ideal school system, with special classes con- ducted unostentatiously in the regular school buildings, the teacher's diagnosis should be accepted. This in- cludes all doubtful cases with no confirmation of the mental defect from either the history or the physical examination. In the ideal special school the children are given individual instruction under skilled observa- tion. The environmental conditions rendering an ex- act diagnosis possible are obtained, and the public is none the wiser. On the other hand, in cities with no special provision for backward children, or in those where a poorly organized system herds the incorrigi- bles and plain backward children together, or com- pels the backward children to travel long distances to special centres, the diagnosis should be made with cau- tion. Under these conditions the backward child is treated with scant consideration and publicly stigma- tized. Therefore, parents have a right to demand that mental defects in their children shall be certified to by a physician from personal observation and examina- tion. 2. The History of the Case: — This comprises (a) the family history, which may show a record of insanity, idiocy, intemperance in the parents, {h) The personal medical history, such as injury at birth, subsequent accidents, or disease, such as meningitis. (c) The social histor)^ particularly the factors of poverty and neglect, and intemperance. Backward Children. 29 Since intemperance is the most potent of all agencies in producing degeneracy, its existence in the child's parents should always be suspected and inquired for. In this connection I may quote from an admirable paper by Dr. T. Alexander MacNicholl/ of New York City:— "Beer-drinking children are notoriously sluggish in their mental operations, while spirit-drinkers gravi- tate into habits which seriously impair the higher in- tellectual properties and cloud the judgment. "When the drink habit is linked with an heredi- tary alcoholic taint, dullness is perceptibly increased. From 15 to 25 per cent, of drinkers, free from heredi- tary alcoholic taint, are dullards. From 53 per cent, to yy per cent, of the descendants of a drinking an- cestry are dullards. From 4 per cent, to 10 per cent, of the descendants of a total abstinence ancestry are dullards. "drinking habits of children. "Dividing the pupils into two classes {a) pros- perous; (6) poor, we have the following: — "(a) In this class, 32 per cent, have drinking parents; 68 per cent, have abstaining parents, {h) In this class, 85 per cent, have drinking parents; 15 per cent, have abstaining parents. {a) Of 12,919 dullards, 9,689 had drinking parents, {h) Of 3195 dullards, 2715 had drinking parents. "One hundred and two children in twenty-five families of heavy drinking parents show the follow- ing: Seven had tuberculosis, 8 had diseases of the heart, 31 had functional diseases of the nervous sys- '^ "Alcohol and the Disabilities of School Children," Journal of the American Medical Association, February 2, 1907. 30 The Medical Examination of School Children. tern, 41 were drinkers, 6 were degenerates, and 4 were idiots. Only 5 of the entire number were normal. "Tracing ten families of total abstaining parents, we note the following: First generation, 34 children, of whom II per cent, suffered from organic or func- tional diseases; second generation, 38 children, of whom 26 per cent, suffered from organic and func- tional diseases ; third generation, 58 children, of whom 7 per cent, suffered from organic and functional dis- eases. "Ten families of moderate-drinking parents show the following : First generation, 47 children, of whom 59 per cent, suffered from organic and functional dis- eases; second generation, 90 children, of whom 62 per cent, suffered from organic and functional diseases; third generation, 82 children, of whom 95 per cent, suffered from organic or functional diseases." 3. Physical and Mental Examination of Backward Chil- dren : — Briefly, the following characteristics are notice- able in this connection. They may or may not be present: — ' I. Defects of the special senses in greater proportion than is found in average children. 2. Certain special physical markings (a) indicative of injury to the brain {e.g., depressions on the skull, paralyses), or {h) indicative of possible degen- eracy {e.g., asymmetrical ears or skull, faulty de- velopment of anatomical organs or members). 3. Words and actions of a crude or purposeless or immoral character {e.g., grinning, uttering of uncouth sounds, and the commission of crime). Backward Children. 31 4. Poor nutrition. 5. Nervous disorders. By these various means the medical inspector should arrive at a fairly exact diagnosis of the grade of the mental defect and the cause of the mental defect. He should make his classification as scientific and ex- act as possible, giving consideration to the age of the person examined, the grade of intelligence existing, and whether it is improvable or not. For this purpose it is most convenient to state primarily whether the patient be a child, youth, or adult, and by qualifying adjectives to further state whether he is progressing, stationary, or retrogress- ing, and the grade of mental defect at the time. Thus the diagnosis may be "male, improvable imbecile child," "male, retrogressive idiotic youth," etc. The cause of the defect may be "alcoholism," "syphilis," "injury at birth," "deaf- ness," "hydrocephalus," etc. Eecord of Case. It is obviously important that systematic record be made of these cases while in the special classes. For this purpose a large individual record-card should be kept, con- taining full information contributed both by the teacher of the class, and by the medical examiner. Such a card is here presented. On the reverse side is a list of detailed points to be considered in every case. Furthermore, a child trans- ferred to a special class should have sent with it all the helpful information possible ; and a blank space is reserved on the reverse side of the card for such notes received. To facilitate this, blank cards should be kept on hand in every school. A child re-transferred to a regular grade should take a duplicate of his special record-card with him. ^ to Ow H Q z o < z i < X hi J f< UJ Q. (0 3 .t; O ^ X £ O (S H o O tn O CS .5 1=1 o ^ s 1' P 0^ S Xrc^ Sad ft S .- X fa H : o o •5 (A UJ 4> Id S> I 1- S: o li. u a u 4) Q X n ^^ u .■,°«caCi:-!fa-MS O J3 "O Bii'o 3 O 5 O J3 -a O _j3 ^-3 a S c S _; 5>H S >. - ^ * fl 5 -g -g .O i D. © a 03 3 "S 2S£. — eS cS <» o W ^— „5x33~^g3HQ ""•-OS ^-S^So S ^ S ^ 3 o S 5,7^ g 3 3 a 'l.cs 2 ^ o g -3 > ^'3 3 SL) 01 >• 3 « ^03 -e •- H .c3 CO ■ "3 gao^s»>>g-3 S^ s " S S-S^?* «■« a> o ■ i^ 2:^^-S 2"= § S^-2 o == g o S i2 cT:: "S =« 5 J~^^'" a -^ g § » 1 1 a a '^ * " ^vS® -a "s 2 m^ .2 S •= 13 .2 -^3 a c3 li u o. o JS ■*-» 3 > 2 '■3 "42 fl O f^ H O < Z cu S H rl O ^ ^ S «3 ><: • l-H o a, CO z o H z o o o >> r a iHi Specimens of basket and mat work done by pupils of one of the New York special classes for backward children. (Loaned by Miss M. H. Leech.) Backward Children. 45 a lesser number do not improve at all, and in very rare in- stances mental deterioration may be proceeding in spite of all efforts. These discouraging cases with the intellectual limit apparent should not distract our attention from the evidence of great improvement in the majority. The classes are es- tablished for the backward rather than the feeble-minded and imbecile, and the latter, at least, should be weeded out at once when detected by their failure to progress, and sent to proper institutions. Evidence of improvement is shown by speech, facial expression, and actions. The motor side, therefore, is the index of progress. The better articulation and use of words, the better ability to play the games, follow the drills, and perform tasks requiring coordination, are infallible signs of improvement in those cases where the regular school studies have been so recently begun that improve- ment is uncertain. Mental and Physical Equilibrium to be Sought and Maintained. Individual instruction and the fitting of the studies to the child's necessities are also most important from the standpoint of the child's future health. Exercise should be along the broadest lines, and every part of the body and of the nervous system should be called upon for action. A healthy circulation and equilibrium are thus maintained, or at least striven for. It is a well-known physiological fact that persistent exercise of one part, with neglect of another, results in actual decrease in vitality of the latter by distraction of the circulation from it. Recognizing the lack of spontaneous action in these children, and the defect resulting from disuse, a constant \\\ 46 The Medical Examination of School C. 020 730 576 5 ( endeavor should be made to exercise and develop each part in turn, and to subsequently prevent degeneration from the same negative causes. On the other hand, while increased stimulation of any part increases its power of response to the stimulus, if per- sisted in too far a diseased condition of irritability may re- sult. This is particularly true in the neurotic, with their functionally weak and unstable nerve centres; in the epi- leptic, where some focus indicative of previous accident or brain disease often already exists ; or in those children who have had meningitis or other inflammatory brain diseases. In these cases over-excitation may cause nervous explosions, resulting in epileptic convulsions, hysterical attacks, or other emotional outbreaks. In cases of feeble mind or of moral imbecility deserving of institution custody, an outbreak of insanity or the sudden commission of crime may result. The first consideration in the care of these children is free- dom from nervous strain, the scholastic education of the child being unhesitatingly sacrificed wherever necessary. Short school hours and country life among congenial sur- roundings constitute the ideal environment. If this same wise balance between neglect and over- stimulation had been sought after by the parents of these unfortunate children, the majority of the latter would not exist as mute testimony to the violation of Nature's laws. The disposition of the truly backward children, espe- cially of the low-grade cases among the poor, is a most im- portant subject, which is, however, outside the province of this paper. Most of them possess such mixed powers and weaknesses that the)'- are capable of self-support if given home or institution supervision, but prone, if neglected, to sink to the lowest depths of physical, moral, and mental depravity. LIBRARY OF CONGRESS 020 730 576 5