The Hospital School
- Author:
Lightnek Witmee
In an article on clinical psychology in the first number of this journal, I described the beginnings of the psychological clinic at the University of Pennsylvania in the year 1896 and the general character of the work during the subsequent ten years. During the past year, the demand upon the resources of the clinic for the mental examination and educational treatment of children has greatly increased. Last summer I organized a daily clinic at which I saw, from the first of July to the middle of August, an average of from three to four new cases a day. These children were given a psychological examination by me and a neurological examination by Dr SD IT Ludlum. Mr Stevenson Smith, a former student of the psychological department of the University of Pennsylvania, and now professor of psychology at the Hampden-Sidney College, took charge of the examination and treatment of speech defects, especially stuttering. In the psychological examination of such children as were brought to the clinic, I was assisted by Mr. Edward II. Huntington, principal of special school No. 3, who is one of the first members of the teaching profession of Philadelphia to devote himself to the scientific study of these cases and to the removal of such physical defects as are found to interfere with school progress. I was also assisted by Mr. J. D. McCallie, a supervising principal in Trenton, K J., who has given much time during the last year to the study of defects of vision and audition in school children, and who has devised a clinical audiometer that promises to be of service in examining rapidly the hearing capacity of large numbers of children. Another assistant in this examination was Mr. J. D. Ileilman, a student of psychology and pedagogy at the University, who is engaged on a special investigation of the causes of retardation in school progress. In many cases it is impossible to make a satisfactory diagnosis of the mental status of a child after seeing him once or indeed after several visits. The child’s capacities and failings only become apparent after an attempt is made to teach him something beyond his known acquirements. For this reason no psychologist would risk, in many cases, a statement of the child’s mental status with suggestions for treatment, nor would he risk a prognosis, unless he is able to place the child for observation and instruction in the hands of one or more competent teachers. For many years I have had in mind the establishment of a training school in the nature of a hospital school for the temporary treatment of all classes of children suffering from retardation or physical defects which interfere with their school progress. Such a training school, if properly conducted, is an expensive experiment, but it is an experiment which must be made if we are to understand these children, classify them, and. prescribe efficient methods of treatment. The hospital school must provide a home for the children where food, baths, sleep, massage, open-air life and physical training may be adequately supervised. The best of medical care must also be supplied, not only for the examination and treatment of eyes, ears and naso-pharyngeal obstruction, but also for intestinal disorders, malnutrition, etc., which in some cases seriously interfere with a child’s mental progress. The school mustbeprovided, therefore, with one or more trained nurses. There must be one or more teachers especially fitted for the training of young children and interested in helping children of deficient capacity.
The hospital school, or experimental training school, has not only its raison d’etre as an independent institution; it is a necessity for diagnosis and prognosis. In many cases, I desire to keep children under training for several days, in some cases a month, in others six months, and in a few cases, perhaps a year, before the child is classified and before it can be determined just where the child had best be sent, and what methods of instruction are best adapted for its individual treatment. Since the establishment of the hospital school in July of this year, I have found it extremely serviceable in doubtful cases in making my diagnoses. Several cases taken into the training school for purposes of diagnosis during the summer were still doubtful cases after two or three weeks of examination. The work of the psychologist differentiates itself from that of the neurologist in this respect. It is true that in many branches of medicine to-day a diagnosis is avoided, especially in chronic cases, until after the patient has been kept for some time under observation. This is absolutely essential in most cases of retardation. The more carefully I study these cases, the more surprises I encounter, not only in uncovering unrecognized deficiencies and hindrances to normal progress, but also in discovering unsuspected capacities. Through the liberality of Mrs. J. Lewis Crozer, the Univer140 THE
sity of Pennsylvania was provided with a fund which enabled the department of psychology to make the experiment in establishing a hospital school. I obtained a house in West Philadelphia near the University where I was able to board ten children and two trained nurses. The chief nurse whom I employed for this work was Miss Anna L. Stanley, who obtained leave of absence for the purpose from the Visiting Nurse Society, and who had been employed by that society during the past winter as a school nurse. Miss Stanley shows unusual devotion to this kind of work, and if the school nurse becomes an accepted institution in the Philadelphia schools it will be largely owing to her pioneer work and to the support given the work by the Visiting Nurse Society.
The nurses brought the children to school every morning, supervised their daily life when not in school, their diet, their sleep, gave baths and massage, and carried out such medical treatment as was prescribed by the physicians in attendance. The hospital school enjoyed the assistance of a number of physicians, to whose clinics children needing the services of a specialist were taken by a nurse. For the general medical care of the children, the school was indebted to Dr Alfred Stengel, who has taken a great interest in the work and was kind enough to put at the disposal of the school the facilities of the Pepper Clinical Laboratory, where examinations of urine, blood, etc., were made. In the afternoons those children who were not needed for special work, or were not to be sent to a clinic for special treatment, were taken to Fairmount Park, where they were taught to play and were able to enjoy the open air.
Every morning from 9 to 12 the children spent at school. During the six weeks of the summer session the school was held in the College Ilall of the University, where three rooms were set aside for the purpose. Miss Town had charge of the regular school work, in which she was assisted from time to time by several teachers of Philadelphia and other schools, who were students of psychology at the summer school of the University. Children suffering from speech defects and children who show easy distraction of attention must, in the beginning at least, be treated individually for part of the time. This work with individuals or small groups, these student assistants are quite able to carry out satisfactorily under direction, and thus the instructor was able to devote her efforts to the more difficult cases. Miss Edith Boughton, a sloyd teacher in one of the special schools of Philadelphia, had charge of the sloyd room, where children were given work with carpenters’ tools, raphia and other light manual work, and gymnastic exercises. This is an extremely important department of an experimental training school. One would undoubtedly obtain a false impression of the capacities of many children, if they were seen only in intellectual work. Children who are totally indifferent, uninterested, and apparently without sufficient visual memory, attention or mental energy, to learn to read and cipher, become keenly interested, develop considerable effort, and improve mentally when given manual work. Important as it may be, to advance such children as are backward, and appear to be subnormal, to a stage of intellectual development where they become capable of making normal progress, and to improve the condition of such children as are trainable only within circumscribed limits, still the chief benefit that will accrue to society from this kind of work will come from the scientific results that are obtained from the study of these children. In all work of this kind it is, therefore, the first consideration to see that the work is done under such conditions that the results are permanently recorded and the records published. For this reason, I have felt that if the work is to be established on a satisfactory basis, some such journal as The Psychological Clinic should be brought into existence, where the results of the work may be presented and discussed for the benefit of those directly interested?physicians, teachers, social workers, and parents. The development of the work also requires that competent persons shall be trained to observe and work with these children. I consider the efficient teaching of the methods and results of clinical pliycliology as important as the actual prosecution of the work. During the summer session of the University of Pennsylvania, the psychological department offered lecture and laboratory courses, furnishing a foundation for this work in the science of psychology. In addition, a psychological clinic was given daily, where children were shown to the students, their deficiencies and capacities demonstrated, the causes and methods of treatment commented upon. This method of instruction in psychology, which I introduced at first with some misgivings, has proved very helpful to my students, and I now feel that the psychological clinic is as important a department of practical work in psychology as is the regular laboratory instruction. About the middle of August the summer session closed, and the work of the training school at the University of Pennsylvania ceased. Most of the children were sent to their homes, but a small group of four children (later five) were sent to Dr Ludlum’s house in Merion, where they were placed in his care and under the direct training of Miss Hose Tierney, a teacher of thirteen years’ standing, who has had the training of a nurse in mental cases. On the first of October the children were installed under the care of Miss Tiemey in the house in West Philadelphia, where the training school will be continued as long as the department of psychology is able to obtain the funds to carry on the work. From the cases that came under our care and training in the hospital school, I select that of a girl of Russian Jewish parentage, eight years of age, whose history will serve to illustrate in an admirable fashion the co-operation that is coming to exist between school authorities and various special agencies for the amelioration of the condition of many school children. This child had been for two years in the first grade of a Philadelphia school and had made in that time so little progress that there was no possibility of promoting her to the next grade at the end of the school year. She was brought to the psychological clinic by Miss Stanley, a school nurse whose work was supported by a private organization, the Visiting Nurse Society of Philadelphia, in the hope of stimulating the city to undertake this most important work on behalf of children. The medical instructor for the district, Dr Newmayer, had also taken an interest in her and had consulted me concerning her physical and mental condition. When I first examined her she appeared to be a child who took very little interest in her surroundings. She was poorly nourished, dull and sullen, unwilling or unable to answer simple questions. I soon discovered that she was deaf and that this was one cause of her retardation. The tonsils were much enlarged, adenoids were suspected; the eyesight was defective; she had strabismus. I recommended that she be taken to Dr Packard’s clinic at the Polyclinic Hospital to be examined for nasopharyngeal obstruction and operated upon if this appeared necessary. Dr Newmayer refracted her eyes and prescribed glasses, which she has since worn. Dr Packard operated upon her for adenoids and enlarged tonsils.
The child had been brought to my psychological clinic for the first time on March 23d. On May 4th I saw her again. Her adenoids and tonsils had been removed about two weeks previous. The child already showed a marvelous improvement in appearance. Her skin was in much better condition and she appeared stronger. Her expression had improved likewise; the mouth was still open as it had been before, bnt she looked more alert and took greater interest in her surroundings. Miss Stanley, it seems, had been advising the family as to proper diet, in consequence of which she had been given more nourishing food.
The examination showed that she was very deaf both for words and sounds, but especially for spoken language. We found in her case, as in that of most children suffering from deafness due to adenoids, that it was difficult to ascertain the degree of deafness, owing to her inability to give attention. She was wearing the glasses that had been prescribed; her eyes were still somewhat crossed. May 29th she appeared at the psychological clinic looking mentally much brighter and physically improved. Examination showed her hearing to be about one-fourth what normal hearing should be. Her speech had much improved. Her teacher reported that she was now able to understand almost everything that the child said, whereas, before the tonsils and adenoids had been removed, it was quite impossible to understand her on certain days. Examination showed that slie was able to write a few words, but she had made very little progress in mastering the work of the first grade.
I determined that she was a satisfactory case for the hospital school. She was under special care and training for six weeks in the hospital school on Walnut Street, and subsequently was sent to Merion, whence she returned to the Walnut Street house about the first of October.
Good food and air alone would have accomplished a great deal for this child. She is one of seven children living with their parents in an alley, in two small rooms about 9 x 14. The living room, which has one window, contains a table, a few chairs, a stove and lounge, no carpet, dirty clothes piled in one corner, many flies and a barking dog. The table is covered with a piece of black oilcloth on which there are usually to be found pieces of brown bread and glasses of tea. The family never sit down to table; no meals are prepared. Their diet consists chiefly of bread and tea and sometimes fish. Bread is always on the table and the children take it up when they feel like eating. The front of the house looks out on a board fence which divides a double alley; in the rear is a small brick yard; one hydrant at the entrance suffices for the differeiit families; there is underground drainage, but an offensive odor comes from the water closets.
Although removal to a more favorable environment, good food and medical treatment, even without mental training, would have made some improvement in this child’s physical and mental condition, she showed mental characteristics which at the start made it difficult for her to progress. . She was not only deaf and subject to a speech defect,?both the direct result of adenoids,? but she manifested also inefficient attention and appeared to be subject to fits of sullenness, both of which may have been directly due to the adenoids, but were probably also causally related to insufficient nourishment, bad air, and poor home training. The fits of sullenness were of special interest. They came on frequently and even now she is subject to them, although she is greatly improved in this respect. It is somewhat difficult to distinguish between inability to give attention, sullenness, deafness, and a temperamental shyness. She often refuses to answer a question which she will sometimes answer readily and intelligently if the question is repeated in a louder tone of voice. At other times she refuses to answer even though it is thus repeated, unless the question is put to her by her teacher or some one with whom she is quite familiar. At other times she will even refuse to answer the trainer. In the school room during the summer work, Miss Town found that in the first minutes of the school session it was often quite impossible to obtain the child’s attention or co-operation in any school work. If the child were let alone for from fifteen minutes to half an hour, she appeared to become ready to take up her co-operation in the work of the class. If Miss Town insisted on her taking part in the class work at the beginning of the day,~ the child refused, and the time of her ultimate submission to school work would be more or less postponed. This peculiarity alone would have made her a difficult case to handle in the ordinary first grade of a public school. She was, therefore, pre-eminently a child for special work. Toward the end of the first six weeks, under our care, she began to take more interest in her work, and would often begin the work of the day without the preliminary period of mental dulness.
Miss Town reports on her six weeks’ work with the child as follows:
“F. is the natural result of the combined poverty and ignorance of her parents. Her impoverished physical condition, the result of improper nourishment, led to a sluggish mental development. The parents had no understanding of her condition, or the means of alleviating it, even if they had known what to do for her.
“Her faults lay chiefly in the emotional field. She was sluggish and difficult to interest and approach. She appeared obstinate, but the obstinacy I judged was not so much a wilful one, which could be met by strict discipline, as an uncontrollable psychic state, a temporary clouding of the consciousness, which it was best to ignore. When so treated, she would gradually brighten up and be ready to receive instruction quite easily. She did not evince rapid fatigue. Her dullest period was the first of the day, before her interest was aroused. “The strabismus almost disappeared while her attention was centered on an object. The deafness also varied in degree with her attention. The difficulty in articulation is partially due to the labored breathing, resulting from adenoids, and partly to her difficulty in hearing. Not hearing sounds clearly, it is impossible to reproduce them correctly. She is capable of repeating most of the sounds that she really hears, though her mouth breathing has resulted in a habitual slurring of many sounds. She has a good visual memory and very readily learns words as symbols of objects.
“In reality F. was bewildered for some time after she came to us, by the absolute change in her environment. She passed through a period of gradual unfolding of her emotional nature. She did not seem to understand affection, and when another little girl, who was homesick and needed a petting, grew demonstrative, she sat and laughed in surprise and absolute lack of understanding. She learned, however, and before the term of six weeks was over she had grown demonstratively affectionate herself.
“In conclusion, Fanny’s chief faults were a general slowness and lack of ambition, and a defect of articulation. The educational methods used were, first, an effort to win the child’s good will and interest, and, secondly, to make her hear clearly every sound combination she was required to pronounce.”
During the six weeks at Merion, under Miss Tierney’s instruction and Dr Ludlum’s medical care, the child made more rapid improvement. The adenoids, which had been removed early in the spring, again developed, and the child was operated upon in the early part of July and again in August. The association f of mental dulness with adenoids was easily traced in her case. In the latter part of August the child became extremely dull and heavy mentally; her breathing showed increased obstruction, the mouth was again held widely open. These unfavorable conditions wrere all removed through an operation. The obstructed breathing did not disappear more quickly than the obstructed intellectual processes. The operation made her again a fairly bright child. By the first of October I felt convinced that the child was capable of making normal progress in the first grade of a public school. I am not convinced, howrever, that the child is free from some permanent reduction in mental capacity. She lias a permanent reduction in hearing, due to the adenoids, and she may have a similar reduction in mental capacity due to the same cause. I am inclined to the belief that she is a normally bright child, and that if she is kept in a healthful environment and properly instructed, she will grow into the average young woman with no other handicap than a considerable degree of deafness. Even the deafness will diminish as her powers of attention and her capacity to apprehend language increase. Lessons in articulation will improve her hearing, as well as lessons in training the attention. If she should be returned to her home at the present time, and placed in the ordinary first grade, she will have to contend against her deafness and also against the depressing home environment and its insufficient support. I cannot regard my experiment as completed at the present time. I have therefore determined to keep her under observation in my hospital school for at least another period of six months. We can control her diet, give her adequate medical care, watch for a possible recurrence of adenoids, see that nose breathing is firmly established, train her in articulation, improve her voice, and assist her in her school work. To determine whether such a child can maintain herself in an ordinary class in the public schools, I have entered her in the first grade of a neighboring school, where she will be taught with other children. It is our hope that we shall enable her to complete the work of the first two grades in one year. If we succeed in accomplishing this result, the problem will then confront us as to what ultimate disposition is to be made of her case. But the problem will then have become a social problem, as medical care and psychological training will have done their full work in restoring her to health and normal mentality. She will be discharged from the hospital school cured. But will society see to it that she does not again become the victim of lier environment ?
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